student

Details of assignment

Please review an academic article which explicitly examines the current consequences of your social cause. In 500-600 words (single spaced) summarize the findings made in this article. What is the article’s main idea? What evidence or point does it use to support this idea? How does the main idea and these points help you in understanding whether or not your organization is doing a good job?

· Marketing rationale:

This brief piece updates the section in your report where you discuss your social cause. Many of you will need to focus on
one specific aspect
of this social cause and discuss research on why it persists today.

This review should include

-an introductory statement

-a direct citation or paraphrase of the article’s thesis

-your assessment of this thesis

-a recap of the article key evidence or supporting points

-clearly stated idea of what you learned from reading this article

Guest worker programs and

Canada

Towards a foundation for understanding the
complex pedagogies of transnational labour

Peter H. Sawchuk and Arlo Kempf
Ontario Institute for Studies in Education, University of Toronto,

Toronto, Canada

Abstract

Purpose – The purpose of this paper is to contextualise historically transnational labour experiences
within guest worker programs in Canada and to provide a conceptual foundation for analysing work,
learning and living relations with special attention to agricultural workers.

Design/methodology/approach – The research is based on a critical review of the literature as
well as secondary analysis of existing research on agricultural guest workers in Ontario, Canada.

Findings – The authors argue that the structural conditions for these particular forms of work, learning
and living relations have a long historical trajectory that dates back in North America to the nineteenth
century. They outline a long trajectory of convergence of American and Canadian policies in this regard.
In terms of work, learning and living experiences we show how shaped by race, class and citizenship
relations, as well as by the learning that infuses their reproduction, intensification and contestation.

Originality/value – The article sheds light on a system of transnational labour that is emerging in a
wide range of economies around the world, but which has not, to date, been widely analysed in work
and learning literature.

Keywords Migrant workers, Learning, Labour, Agriculture, Race, Canada

Paper type Research paper

Introduction
The subject of guest worker programs (GWPs) has been emerging in diverse scholarly
literatures for some time. By different names, these programs refer to the importation
of temporary labour under specific conditions. In various forms, they are increasingly
prevalent in core capitalist countries. Across North, Central and South America as well
as the Caribbean, the role of GWPs in national economies is poised to explode. Over the
past 40 years, the challenges of immigration and guest work in an evolving European
Union have been fundamental to national and regional understandings of ethno-racial
and class relations. Despite the recent focus of debate around such issues in the
Americas and Europe, however, various forms of labour transnationalism have been
around a long time, producing networks that have touched virtually every region of the
globe.

Although scholarship from the fields of migration studies, international human
geography, international labour market economics, post-colonialism and others have
touched upon discipline specific implications of GWPs in various contexts, the topic
remains virtually invisible within work-based learning literature. For those committed
to the notion that work and learning do not take place in a vacuum, the development of

The current issue and full text archive of this journal is available at

www.emeraldinsight.com/1366-5626.htm

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Journal of Workplace Learning
Vol. 20 No. 7/8, 2008
pp. 492-

502

q Emerald Group Publishing Limited
1366-5626
DOI 10.1108/13665620810900319

an understanding of GWPs from a work-based learning perspective is overdue, and
requires deep and specific efforts at contextualisation.

Superficially, it may be arguable that the work and learning relations of GWPs hold
few mysteries: they simply represent a highly exploited form of labour and learning
which involves little, if any, skill, knowledge or learning of consequence to the evolving
future of work or workers in the twenty-first century. How, it might be asked, can guest
work – with its echoes of the twentieth century (and nineteenth and even eighteenth
centuries) – be considered a relevant topic in the twenty-first century in an epoch
characterised by advanced knowledge work, expansive technologies, globalised
production and trade? In a rapidly globalising yet polarising world, transnational
labour in general, and guest work specifically, are every bit as definitive of the
twenty-first century as they are of any previous time period. As all work and learning
relations are deeply shaped by the cultural, political and economic histories, relations,
realities and struggles of a given context, and as skill, learning and knowledge can
remain very well hidden in the occupational lives that constitute peripheral labour
markets, we are compelled to seek out the learning dynamics within activity and
experience so raw and basely human that it is easily conflated with the sheer act of
surviving.

Below we begin with an historical contextualisation, which reveals a long pattern of
infrastructure building. This long building process has established, in our view, the
virtual inevitability of the – albeit contested – expansion of guest worker programs
across the Americas. Moreover, we claim that the situation in Canada cannot be
adequately understood without a vision of its military, political and economic origins
with regard to hemispheric relations. We then establish some of the relevant
dimensions of transnational work and community and learning relations. Finally, we
undertake a brief secondary analysis of popular education materials based on Mexican
guest workers in Southern Ontario, Canada.

The historical trajectory of guest worker program expansion
By identifying the context and historical trajectory of GWP expansion, we establish a
firm ground for first understanding the nature of this evolving formation, and second
for setting the stage for a deep understanding of the dynamics of the work, learning,
domination, resistance and social reproduction, and their reverberating effects across a
range of economic sectors, as well as host/origin country communities. In Canada,
guest worker programs were originally established with the Caribbean vis-à-vis the
British Commonwealth colonial networks. Since the 1980s, however, Canadian GWPs
have increasingly come within the orbit of US-dominated policy across the Americas
which, as we shall see, has shaped in particular the growth of absolute and
proportionate numbers of Mexican workers. Here we seek to assess the nature of this
long wave of synchronisation.

In many ways, the establishment of the contemporary North American guest
worker program infrastructure begins with US continental action in relation to the
Mexican-American War (1846-1848) (Chacón and Davis, 2006). Massive expropriation
and annexation at the close of this conflict established direct subjugation, a redrawing
of the map of nine US states[1] and the strengthening of US capacity for establishing
peripheral labour market conditions. A pattern soon emerged that would shape the
economic as well as cultural fabric of the USA, Mexico, and more recently Canada. This

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pattern would establish a range of unique methods of overt/covert control over labour
conditions and labour markets.

This patterned trajectory featured active state experimentation throughout the
twentieth century: from the First World War, to the inter-war period, to the Second
World War/Bracero[2] era, and continuing through to the establishment of the North
American Free Trade Agreement (NAFTA)[3] with its resulting Maquiladorisation of
the US-Mexican border (Chacón and Davis, 2006). These latter actions have
increasingly incorporated Canada directly through NAFTA, as well as through
Canada’s support of Mexican debt restructuring via the World Trade Organisation
(WTO) and its ongoing support for the General Agreement on Trade in Services
(GATS).

This historical trajectory demonstrates shifting forms of official and unofficial
policies and public proclamations, including:

. general open-border policies allowing passage of labour from Mexico to the USA;

. official guest worker programming; and

. unofficial policies that actively encourage the growth of undocumented workers.

While the US government has varied its method over time – responding to levels of
unemployment, the strength of the US economy, the strength of the US labour
movement, and the xenophobic and racist backlash – it has not strayed from its
objective of sustaining peripheral labour markets. This notion of nativist racism
cannot be overlooked within these phenomena. Public denunciations of Mexican
workers and increased deportation activity at different points throughout the twentieth
century can be correlated with US citizen outcry in the face of social/economic
conditions at three distinctive points:

(1) the 1930s;

(2) the 1950s; and

(3) at present in the USA.

It is instructive, for example, to note that since the discontinuation of the US’s most
ambitious guest worker program – the Bracero Program – government policies have
allowed the expansion of peripheral labour markets through tacitly supported
undocumented economic migration, which until recently was able to meet the
standards of plausible deniability – what Richard Vogel (2007) refers to as “official
grandstanding to cover an unofficial open border policy demanded by American
capitalism” (p. 8).

Economically, the agricultural sector has traditionally been at the centre of these
issues. In both Canada and the USA, GWPs have originated within agricultural sectors.
In Canada specifically, such programs flourished under long-established labour codes
that explicitly excluded farm workers from union organising (codes first legitimised as
a form of protection from “Communist” labour incursions onto the “family farm”).
Despite the virtual extinction of the family farm over the last half-century, these
sections of labour code were until recently, fundamental to establishing viable
agri-business/factory-farms. In June 2007, The Supreme Court of Canada overturned
the old law with a ruling that allows, in principle, the right to organise labour unions
inclusive of farm workers[4].

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Recently, three other sectors have found a home in guest worker policy discussions:

(1) hospitality (e.g. hotels, seasonal resorts);

(2) transportation (i.e. trucking); and

(3) light manufacturing (food processing, plastics and other consumer products).

If expanded significantly into these sectors, the economic effects on broader labour
market conditions would likely multiply, spreading well beyond these sectors (Vogel,
2007). The US government’s recent proposals for guest worker program expansion,
and similarly its attempts to liberalise cross-border trucking, seek to formalise existing
experimentation in these sectors; a move which, in turn, will compel similar
discussions in Canada. The contours of the discussion in Canada, however, will most
likely differ due to differences in union density and issues relating to the
proximity/cost. Absent in Canada for example, is the rapid development of light
industry across a range of Southern, “right to work” (i.e. anti-union) states in the USA,
reflecting an already high level of integration with Mexican border communities and
maquiladora economic zones.

These impending sectoral expansions aside, for now the current phase of this long
history requires the completion of the “clampdown” exercise to dismantle the
unauthorised migrant labour flows of the past 25-30 years[5]. Again, this is in part a
response to US public outcry. According to Vogel (2007), the clampdown phase was
initiated by the US Senate in 2003 and slated for completion by 2012. It is closely linked
to the “War on Terror” and the establishment of the US Department of Homeland
Security (DHS), which allows for the flow of (massive) funding which, justified in terms
of national security, easily eludes public debate. In one form or another, the coming of
an expanded guest worker program initiative to Canada is, by now, virtually
inevitable, in part through US-Canada trade agreement alignment (NAFTA, WTO and
GATS). Paster and Alva (2004) note that even among labour, left and centrist circles in
the USA, there has been a “quiet softening of the progressive opposition” based on a
number of structural “realizations” (p. 92); a trend that is sure to further shape
discussions in Canada as well.

Capitalist economic imperatives drive this process, but build on a solid bedrock of
worker insecurity as well as traditional nativist xenophobia and racism[6]. Its primary
goal, beyond establishing a gateway through which to better control the rich natural
resources of Central and South America, has for some time been to establish a
permanent peripheral labour market from which, first agricultural industry and
eventually other business sectors, could profit based on lower labour costs and
intensified control. With the addition of workers to the list of extractable resources, the
exploitation is near total.

Canadian guest work
Without rights to health and safety, social benefits or freedom of movement, and with
the help of state enforcement and unceremonious cancellations of contracts with few
avenues for appeal, guest workers’ experiences in North America offer perhaps the
closest approximation to the US system of chattel slavery. Moreover, guest worker
programs, according to Burawoy (1976), function as a parasitic phenomenon: families
and communities in origin countries bear the costs of social reproduction while host
countries claim the profits and enjoy unfettered labour control.

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For a long time in Canada, immigration policy revolved around the targeting of
specific national/racial/ethnic groups[7]. However, by the early 1960s, having
experienced increasing wage pressures and against the backdrop of more
generalised pressure to reform its immigration system, Canadian agri-business
demanded changes. Anticipating the initiation of the immigration “point system” in
1967 that would shift the focus of entry criteria to economic and educational
background (and undermine the ethno-racial recruitment), the Canadian government
instituted its Seasonal Agricultural Workers Program (SAWP) in 1966. The SAWP
brings particular foreign workers to the country for periods of six weeks to eight
months. Built on formal agreements with origin countries, it sings from the hymn book
of “labour market complementarity and bilateral co-operation that provides benefits to
all participants” (Preibisch and Binford, 2007, p. 9). Largest in the provinces of Ontario
and Quebec, the SAWP is now established in nine of ten provinces, topping 20,000
workers in 2001 (Weston and Scarpa de Masellis, 2003). As indicated earlier, building
on its roots in the British Commonwealth, SAWP originally targeted Caribbean, and
specifically Jamaican, men to come and work on fixed-term labour contracts on
Canadian farms (Satzewich, 1991). Caribbean men constituted the bulk of these
workers until the late 1980s when the state, alongside eager growers, established
Mexico as the soon-to-be-dominant origin country for SAWP (Preibisch and Binford,
2007). This transformation from Caribbean to Mexican workers has not gone
unnoticed. Binford (2002) argues that fuelling this change is a two-part, racialised
assumption on the part of the employer regarding the docility of Mexican workers on
the one hand and the resistance-orientation of Caribbean workers on the other. Binford
points to a culture of (albeit limited) empowerment developed among the
English-speaking Caribbean workers, who may demand employer adherence to the
contract, and who may be unwilling to work hours not mandated in that contract.
Conversely, Mexicans are relatively new to the terms of work and, facing a substantial
language barrier, come unprepared and unarmed to negotiate the informal cultural
contract that mediates much of the day-to-day life of a guest worker.

Canadian-based scholarship in this area began to emerge about the same time as
this shift, and has developed since (Cecil and Ebanks, 1991; Bolaria, 1992; Smart, 1998;
Basok, 2002; Binford, 2002; United Food and Commercial Workers Union of Canada,
2002; Sharma, 2006). Early research focused on migratory experiences and the dual
social and economic effects on origin and host countries. Joined by both broader
international economic analysis that revealed the contradictory, transnational
economic compulsions and results (e.g. Stasiulis and Bakan, 2005) and analyses
from the field of migrant studies, basic research on guest workers has reached a critical
mass as far as an integrated class/race/gender analysis. The work of Satzewich (1991),
for example, was one of the earliest to highlight the class but most powerfully, the
racial dimensions inherent in the construction of the SAWP program, where the
decision to establish the linkage to Caribbean workers was undertaken out of a deep
concern for the “social problem” and the disruption to “social order” apparently
endemic to Black populations in Canada.

Support for the program is found amongst growers. Local businesses in the host
communities also see economic benefit, with some guest workers noting instances of
price gouging. Activists and organised labour in Canada see a serious organising
challenge, interwoven with concerns for the possibility of general downward pressure

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on wages. The Caribbean and Mexican guest workers themselves are obliged to
embrace the opportunity to work and send remittances homeward to family. Although
they occasionally make sustained community linkages in host communities and
nearby cities, most experience a profound alienation from their surroundings,
employers and work. The notion of obligation is, as noted earlier, a direct artefact of the
subjugation of the Mexican economy that has increasingly produced new and wider
gaps between labour market segments. This has led guest worker activist and scholar
Evelyn Enclada Grez (2005) to identify guest work as a form of “forced labour”. Guest
work is framed by health risks, loneliness, harsh conditions, instances of poor
treatment, lack of citizenship and worker rights as well as pronounced cultural
alienation that, not infrequently, erupts in racial violence in communities.

At the level of the labour process specifically, traditional divide-and-conquer
strategies are virtually universal in the agricultural GWPs in Canada. Roots of these
strategies are found in both personal (grower’s) racism, pseudo-genetic, common-sense
ideologies which become intertwined with a basic capital accumulation calculus that
play out in complex relationships between growers, workers (both new and returning),
workers’ families and the local communities of both the host and origin countries. A
core feature of divide-and-conquer strategies in practice is spatial-linguistic
organisation of production. Workers are separated by virtue of culture and
language, which combine with local traditions revolving around the working of
specific crop types. Pseudo-genetic formulae are invoked: for example, Caribbean
workers for the tree-picking and sustained ditch work versus Mexican workers for
weeding and planting and low crop harvesting. Workers are also separated based on
their ability to understand and work well with one another. Language use is regularly
the object of control in guest work (i.e. employer-controlled “back-chat”), but in general
has a long history of manipulation in relation to labour control and worker resistance
(cf. Chacón and Davis, 2006; in Canada, see Palmer, 2004; Livingstone and Sawchuk,
2004; Sawchuk, n.d.).

The structures and resources of control in guest work are powerful. However, we
can also see that groups of guest workers can and do generate and maintain cultures of
solidarity on a local scale, with some dispersed instances of open revolt, as have been
seen in each of the core receiver provinces in Canada (British Columbia, Ontario and
Quebec). Moreover, with the aid of local community groups and activist organisations
such as “Justicia/Justice for Migrant Workers” (J4MW[8]) as well as with the support of
organised labour (e.g. the United Food and Commercial Workers Union, or UFCW),
there is a developing but still latent potential for expanding cultural alignment and
struggle. Although cultural alignment with host certain segments of host communities
appears weak, it is increasing in places. This is seen, for example, in relations between
the various Caribbean communities in the city of Toronto and Caribbean guest
workers.

Deepening the analysis of the labour/learning processes of guest working
in Canada
We begin by outlining programmatically the basic dimensions of a complex circuit of
communication, participation and learning that shape Canadian guest work as a
transnational labour process. Organised training in guest worker production is
virtually non-existent. Thus, we can begin by noting that ongoing worker-to-worker

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on-the-job training and direct supervisory edict provide the most prominent basis of
immediate, production-based learning. The degree to which guest workers are skilled
(and to which they become skilled on the job despite the absence of formal training) is
recognised concretely by the employers who re-call experienced workers, by name, at a
rate of 70 per cent each year (Binford, 2002). But these practices represent merely the
tip of the learning iceberg. Intertwined with immediate production learning, there is a
second dimension in the form of the dense fabric of “inter-cultural learning”
surrounding guest work. This learning is multi-dimensional: it takes place across
relations between workers and growers, and also implicates bureaucrats (from both
Canadian officials and origin country consulates). It also involves residents of host and
origin communities. Each example features some moments of cross-cultural benefit[9],
but is more often characterised as conflictual. Third, and again closely intertwined,
there is the inter-cultural learning that takes place between different workers within
and between ethno-linguistic/national groups (e.g. Mexican and Caribbean workers) as
well as learning and communication between those from different regions of the same
country. Fourth is the learning and exchanges between host country activists (such as
those from J4MW or the UFCW) as well as community and university-based
organisations. Finally, and perhaps one of the least understood dimensions of this
complex circuit of learning, is the extended, transnational lines of development
constituted vis-à-vis family and community units across borders and, with the passage
of time, generations. Together, across these five dimensions we see a “curriculum of
experience” generated, redeveloped, stored, taught and learned.

Having outlined a basic program for addressing the dimensions of labour/learning in
guest work, we now turn toward a brief, secondary analysis of these dynamics based on
popular education work carried out by J4MW (Hinnenkamp, 2004)[10]. To understand
the work and learning dimensions of guest work, it is vital to first address the role of
material conditions. Although the materiality of traditional industrial control is in full
force here (including divisions of labour, as well as divide-and-conquer/control labour
process organisation); additional physical conditions shaped the experiences, interests
and learning needs at the centre of guest work – factors absent in a vast majority of
work and learning literature. Guest worker programs in Canada are infused through and
through with a pedagogy of cold, hot, wet, outdated – a pedagogy informed by
sub-standard equipment, clothing, boots, transportation and pesticide protections.
Workers in Hinnenkamp’s discussion groups clearly articulate how acute injuries and
chronic health dangers stand as a central theme around which their thinking, reaction
and strategising revolves. Summarised under a broad notion of health and safety
concerns, these challenges deeply shape the directions of learning amidst agricultural
production and sub-standard on-site living conditions. Moreover, necessarily implicated
in these conditions are underlying relations with the state and citizenship vis-à-vis the
virtual absence of legal rights to protection under legislation.

Hinnenkamp’s (2004) Freirean method involved the workers’ selection of images
(from magazines, etc.) to facilitate dialogue. One example was the selection of a picture
of a marathon runner. This formed the basis for dialogue about the labour process.
Gazing upon the picture, one worker commented: “This also represents a job. Some
people work in this way and others – the Mexicans – that come here, we do it in a
different way, helping Canada to progress”. This statement, Hinnenkamp reports,
touches off at least two important work/learning themes for consideration.

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The first theme revolves around the thesis that Mexican workers bring with them
specific patterns, orientations and cultural constructions of work-life that are likely
distinct from Euro-American labour processes and workers. One way to understand
this may be to pursue the notion that in an era of concern over “over-worked workers”,
“work/life balance” and so on, Mexican workers have sustained a different orientation
that, while clearly not eschewing hard work, nevertheless may subsume hard work
within an orientation that sees paid work as only part of the fulfilment of individual
and collective needs. Hinnenkamp’s focus groups also reveals a specific understanding
that difference among workers in terms of skills, abilities and work interests should be
taken into account in the design and execution of the labour process. This challenges
the tried-and-true technical and social divisions of labour held sacrosanct in North
American industrial design. This orientation, if it exists, would in principle stand as an
alternative to the manic, economically conditioned neurosis of segments of North
American workers, and would be, assuredly, more complex than it might seem at first
blush. It would likely require an elaborate figuring of the relations between self, work,
family and society – orientations that must be actively reproduced and learned and
which increasingly elude major segments of North American society[11]. Another layer
of this first line of inquiry is that there are likely specific forms of work-based
knowledge and skill – to this point hidden from academic research – concerning guest
agricultural work and the social relations that shape it that are distinct from, if not in
conflict with, from what now constitutes Euro-American, industrial-capitalist farming.

The second work/learning theme that emerges from this section of Hinnenkamp’s
work deals with the conflict between newer, often younger workers, who in classic
industrial sociology would be termed “rate-busters” – working particularly fast to
garner supervisory approval. Hinnenkamp (2004) specifically comments on this, noting
that workers were hesitant to articulate these dynamics fully. Although the learning of
how fast to work, and of how to subtly resist and control production speed, is by no
means new to industrial sociology, unique aspects of guest work in Canada further
shape and sharpen these dynamics. Growers exercise the right to hand-select workers
for return work in following seasons. Were collective resistance to be identified by the
grower, she or he may also choose to country “surf” for whole new intake communities.
Further shaping and sharpening these relations of course, is the poverty of Mexico,
constructed, as we saw earlier, across an almost two-century trajectory of concerted
political and military actions in which in the last decades the Canadian state has been
both tacitly and actively complicit. Here we see a structure that sets specific dynamics
of labour and learning, at once familiar, but also archaic; a work system of the
twenty-first century that requires a look back more than a century, to chattel slavery,
to understand.

Still too often ignored elements in work and learning research are the skill,
knowledge and learning that begin from and with workers’ needs and interests, rather
than those of management and production (see Sawchuk, 2006, 2007). The most intense
and obvious examples of these are the structures and moments of resistance (both
organised and spontaneous). Further fuelling conflict and resistance is the culturally
mediated experience of working life for guest workers. One group of workers in
Hinnenkamp (2004) argued: “[i]n Canada they like dogs better than they like
Mexicans”. Others went on to describe their treatment as “animals”, as “machines”, and
so on. Outright racism shapes many of the experiences, both within the production

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process and within the experiences in the surrounding communities. The
ethno-linguistic differences – revolving around the absence of Spanish-language
capacity of the supervisory staff and the ethno-centric presumptions that continue to
replicate this inadequacy – produce a degenerative feedback loop of events where
English-only instructions, half-understood, ineffectively direct work. This is followed
by supervisory criticism (and not infrequently racialised claims of laziness and
neglect). Workers, meanwhile, become increasingly frustrated, and on it goes. The
resulting forms and ruminations on resistance amongst guest workers in Canada,
however, appear to express distinct dynamics. Reflecting on poor conditions, a worker
comments: “[I wonder] if this is really what the Canadian people or the bosses we have
want us to do – hold a demonstration . . . to express what’s wrong with our houses,
how we are treated, and the benefits that we should have a right to?” (quoted in
Hinnenkamp, 2004). This statement, and the question it poses, express the entirely
unique intercultural dislocation and labour subordination so powerfully at play within
Canadian guest work. It is instructive to consider where else in the Canadian economy
this question might be asked, for surely it is relevant in every sector.

Conclusions
Guest worker programs are poised to undergo significant expansion, implicating a host
of countries across the Americas. In this paper we have sought to establish a historical
foundation for understanding the labour/learning process dynamics that shape these
programs in Canada. These dynamics have radiant causes and effects on workers,
employers, origin and host communities, and will undoubtedly reverberate across
labour markets more broadly in the short and long term.

We have sought to develop a preliminary articulation of the complex circuits of
learning as well as the cultural, political, economic forces at play within the core
“curriculum of experience” that is contemporary guest work. We have offered a basic
program of investigation for such circuits, and have put forth a brief (secondary)
analysis of related themes based on previously published, popular education work.

We maintain that these dynamics are as central to the future of work under
advanced capitalism as those forms of work/learning that garner the lion’s share of
research attention. Although reflective of the labour processes of previous centuries,
the implications for the twenty-first century are paramount, particularly as far as these
dynamics are shaped by a powerful confluence of race, class and citizenship relations
from which reproduction, intensification and contestation flow.

Notes

1. For the low price of troop withdrawal and $15m, this treaty established, redefined and/or
enlarged the territories of California, Arizona, New Mexico, Nevada, Utah, Colorado,
Wyoming and Oklahoma – as well as settled contestation over the Texas border (Chacón
and Davis, 2006).

2. The Bracero Program (rooted in the Spanish word “brazo”, meaning “arm(s)” – as in manual
labour) was the first large-scale, overtly supported, guest worker program in the USA,
operating between 1942 and 1964.

3. Indeed, the Central America Free Trade Agreement (CAFTA) is designed to recreate and
extend the basic pattern further.

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4. At the time of writing, the Canadian province of Manitoba, under New Democratic Party
governance, has been the first provincial jurisdiction to apply this to their own labour code,
explicitly extending rights to migrant/guest workers. With a range of court challenges pending,
the United Food and Commercial Workers Union (UFCW Canada) has been particularly active
in these terms. In Ontario, which is home to the largest proportion of migrant farm labourers,
the Agricultural Employees Protection Act 2002 (Bill 187) was passed on November 18, 2002. It
allows farm workers to form associations, though not the right to unionise or the right to strike.
Farm workers remain excluded from provincial health and safety legislation.

5. Whip-sawing the American public, it is likely that the current media tour of Mexican
ex-President Fox is aimed at precisely this accomplishment in his call for a “rationalised
immigration” strategy – an idea entirely in line with the Bush guest worker proposal.

6. In Canada, these dimensions are particularly well laid out in Sharma (2001, 2006), wherein
she examines Bill C-11 – Canada’s border security and citizenship law that was actively
debated and which laid bare the active racialised and gendered construction of “preferred
citizens” and their others.

7. See Sawchuk (2008) for discussion of union perspectives on immigration and underemployment.

8. For more information on the important work of J4MW, see their website at: www.
justicia4migrantworkers.org

9. According to Hinnenkamp (2004), learning about Anglo-Canadian culture is one of the
enjoyable features of guest work for workers. There are similar examples of enjoyment for
host community members. These instances are largely overshadowed, however, by
ethno-racial-class conflict.

10. Sessions were held in Southern Ontario and involved Sunday meetings held over the course
of four weeks. They involved 18 male and three female farm workers, aged 20 to 60. All were
citizens of Mexico and part of the Canadian government’s SAWP. The project eventually
produced not simply data but striking artwork, dramatic scripts, and highly informative
interpretation.

11. Whether these orientations are link-able to a process of exporting/enforcing the obsessive
residues of the “spirit of capitalism” articulated a century ago by Max Weber, is open to debate.

References

Basok, T. (2002), Tortillas and Tomatoes, McGill-Queen’s University Press, Montreal.

Binford, L. (2002), “Social and economic contradictions of rural migrant contract labor between
Tlaxcala, Mexico, and Canada”, Cultural and Agriculture, Vol. 24 No. 2, pp. 1-19.

Bolaria, B. (1992), “Farm labour, work conditions, and health risk”, Rural Sociology in Canada,
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About the authors
Peter H. Sawchuk is a Professor of Sociology and Equity Studies in Education at the University
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JWL
20,7/8
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Journal of Cemnlology: MEDtCAL SCtENCES
2002, Vol. 57A. No. 8,

M504

-M510

Copyriglu 2002 hy The Gcromohsical Society of America

Risk Factors for Falling Among Community-Based
Seniors Using Home Care Services

Paula C. Fletcheri and John P. Hirdes^

‘Department of Kinesiology & Physical Education, Wilfrid Laurier University, Waterloo, Ontario, Canada.
^Department of Health Studies & Gerontology, University of Waterloo, and Canadian Collaborating Centre—interRAI,

Homewood Research Institute, Guelph, Ontario, Canada.

Background. Despite the plethora of information concerning risk factors for falls, limited research efforts have fo-
cused on the issue of the differences in risk factors for falls based on fall status, or more specifically one-time versus
chronic/recurrent fallers. Given that multiple falls have been found to be associated with negative outcomes, such as an
increased risk of institutionalization, more research in this area is warranted.

Methods. The purpose of this investigation was to determine the risk factors for nonfallers versus fallers (1 + falls),
and for nonfallers/one-time fallers versus recurrent fallers (2+ falls). All participants {N = 2304) in this study were re-
ceiving home care services from 10 community-based agencies (Community Care Access Centres) in Ontario, Canada.
The Minimum Data Set-Home Care (MDS-HC) is an assessment instrument that covers several key domains, such as
service use, function, health, and social support. Nurses trained to administer the MDS-HC assessed each of the partici-
pants within their homes.

Results. Of the 2304 participants in the study, 27% fell one or more times, and 10% experienced multiple falls (2 +
falls). In the two final logistic regression models for risk of falling (0 falls vs 1 + falls) and multiple falling (0 falls/1 fall
vs 2 + falls), the independent variables that remained significant included gender, gait, environmental hazards, and the
Changes in Health, End Stage Disease and Signs and Symptoms of Medical Problems Scale. Also significant in the
model for multiple falls was the Cognitive Performance Scale, Parkinson’s disease, and perceived health status.

Conctusions. Overall, distinguishing individuals into different fall status classifications is important from a clinical
perspective, as it is the recurrent faller who would benefit to the greatest extent from fall prevention efforts and from the
negative outcomes associated with multiple falls (i.e., mortality). One of the most significant barriers in determining risk
factors for falls is the lack of consistency in the variables/tools used in the research. As such, utilizing a standardized
tool, such as the MDS-HC, would assist researchers in making comparisons between different settings.

FALLING results in substantial disability, morbidity, andmortality among seniors. For example, falling is the
leading cause of injury admissions to acute care hospitals
and in-hospital deaths (1,2). Each year, approximately one
third of seniors experience a fall, (3-5), although the major-
ity of falls do not lead to serious injury, hospitalization, or
death (6,7). However, many elderly individuals experience
complications, including restricted activity, soft tissue inju-
ries, or fractures (8-11) as a direct result of the fall event.

The literature consistendy identifies multiple risk factors
for falling among the community-based elderly population,
including having a history of previous falls (4,12), being
functionally impaired (3,7,11,13), being of advanced age
(3,4,13), being female (4,14-16), using various medications
or multiple medications (4,17-22), having specific condi-
tions, diseases, or physiological limitations (3-5,23,24) and
comorbidity (16), having cognitive impairments (4,16,25),
having factors contributing to postural instability and gait
impairments (7,16,26,27), performing activities such as bed
transfers (3), climbing stairs (28,29), and night urination
(24,30), and environmental influences or engaging in rou-
tine activities (i.e., walking on stairs) (13,3f ,32).

Despite the volume of information concerning these risk
factors, few studies have dealt with the issue of the differ-
ences in risk factors for falls based on fall status, or more

specifically one-time versus chronic/recurrent fallers. Nevitt
and colleagues (25) suggested that risk factors for one-time
fallers appeared to be less robust than for chronic fallers.
Further, single falls were generally less predictable and may
have been the result of an accident (e.g., environmental haz-
ard) or an overwhelming incident (e.g., myocardial infarc-
tion), whereas multiple falls may have been more indicative
of intrinsic factors (e.g., physiological predisposition to fall-
ing, chronic disease, physiological disability) (25,33). After
completing a one-year prospective study to determine the
risk factors for falling using a sample of community-based
seniors, Tinetti and colleagues (5) concluded that the risk
factors for multiple fallers as compared to one-time fallers
were the same; however, the magnitude of the associations
were stronger for recurrent fallers. Use of sedatives, cogni-
tive impairments, lower-extremity disability, palmomental
reflex, i’oot problems, and number of balance-and-gait ab-
normalities were significant predictors of falls, and the risk
of falling increased linearly with the number of these risk
factors present (5).

Graafmans and colleagues (34) found that mobility im-
pairments and dizziness were associated with falls (1 +
i’alls) and recurrent falls (2+ falls); however, history of
stroke, poor mental state, and postural hypotension were as-
sociated with being a recurrent faller only. Lord and col-

M504

RISK FACTORS FOR FALLING M505

leagues (27) found five factors that significantly distin-
guished recurrent fallers from nonfallers/one-time fallers:
sway, proprioception in the lower limbs, visual contrast sen-
sitivity, quadriceps strength, and reaction time. However,
this analysis was restricted to physiological factors associ-
ated with falls. Other studies of different patterns of falls fo-
cused only on certain types of variables (e.g., balance [35]
or medications 119|) or failed to examine multivariate mod-
els (36). Therefore, they failed to provide comprehensive
information about risk factors for recurrent fallers from a
multifactorial perspective.

Based on information to date, one-time fallers and multi-
ple/recurrent fallers appear to represent two distinct groups.
For example, it would appear that single falls are often
chance events that may not be modifiable through interven-
tion, whereas multiple falls would seem to be characteristic
of a group of older and more frail seniors with a greater
number of comorbid conditions or physiological impair-
ments. Given that multiple falls have been found to be asso-
ciated with negative outcomes, such as an increased risk of
institutionalization (37), more research in this area is war-
ranted. This investigation aims to determine the risk factors
for nonfallers versus fallers (1-t- falls) and for nonfallers/
one-time fallers versus recurrent fallers (2+ falls) using
data from a comprehensive assessment completed by home
care professionals.

METHODS

Subjects and Data Collection Measure
All participants (A’ = 2304) in this study were receiving

home care services from 10 community-based agencies
(Community Care Access Centres [CCACs]) in Ontario,
Canada. Each of the CCACs utilized the home care version
of the Resident Assessment Instrument on a pilot basis. The
Resident Assessment Instrument-Home Care (RAI-HC) is a
comprehensive and standardized assessment tool used to
evaluate the needs and ability levels of older adults utilizing
home care services. The RAI-HC consists of two core ele-
ments: the Minimum Data Set-Home Care (MDS-HC) and
the Clinical Assessment Protocols (CAPs). The MDS-HC is
the screening portion of the instrument, which serves as a
brief assessment instrument covering several key domains,
such as service use, function, health, and social support (Ta-
ble 1). In addition, the MDS-HC identifies individuals who

Table I. Domain Areas Assessed in the MDS-HC

Table 2. Clinical As.sessment Protocols (CAPs) Triggered by
the MDS-HC

Demographics
Rclerral
Cognilion
Coniiminicalion
Vision
Mood and behavior
Social t’unclioning
Inlorniai support
ADLs and IADLs

Continence

Disease diagnoses
Health conditions
Preventive health measures
Nutrition/hydration
Dental .status
Skin condition
Environmental assessment
Service utilization
Medications

Functional Performance
ADL rehabilitation potential

Health promotion
IADLs
Institutional risk

Sensory Performance
Communication disorders
Visual function

Health Problems/Syndromes
Cardiorespiratory

Falls

Oral health

Skin and foot conditions
Dehydration
Nutrition
Pressure ulcers
Pain

Continence

Bowel management
Urinary incontinence and

indwelling catheters
Service Oversight

Adherence
Medication tiianagement
Preventive health care measures
Reduction in formal .services
Brittle support system
Palliative care
Psychotropic drugs
Environmental assessment

Note: MDS-HC = Minimum Data Set-Home Care; ADLs = activities of
daily living; IADLs = instrumental activities of daily living.

Notes: MDS-HC = Minimum Data Set-Home Care; ADL = activity of
daily living; IADLs = instrumental activities of daily living.

may benefit from more extensive evaluation and care plan-
ning through 30 problem-oriented Clinical Assessment Pro-
tocols or CAPs (Table 2) (38,39). Prior to data collection,
the nurses were trained to administer the MDS-HC and sub-
sequently assessed each of the participants in his or her
home.

The MDS-HC was developed by investigators from Can-
ada, France, Italy, Japan, Netherlands, Switzerland, the
United Kingdom, and the United States. The reliability and
validity of the instrument were established through a five-
country study that included Canada and the United States
(39). Studies of the use of the MDS-HC for preventive
home screening are currently underway in Canada and in 10
European countries. In short, the MDS-HC provides a com-
prehensive assessment of the full range of client needs, and
it directly supports the development of person-specific care-
plans. The MDS-HC takes approximately 45 to 60 minutes
to complete.

The independent variables representing the risk factors
for falls have been grouped into the following sections:
(i) sociodemographic and social relationship variables
(age, gender, marital status, education, living arrangements,
change in social activities, amount of time alone during the
day); (ii) measures of frailty (various chronic diseases, per-
ceived health status, cognition or Cognitive Performance
Scale [CPS] or Changes in Health, End Stage Disease and
Signs and Symptoms of Medical Problems [CHESS] Scale);
and (iii) exposure to risk variables (gait, environmental haz-
ards, various medications). The Cognitive Performance
Scale, a measure that describes cognitive status, is based on
four items from the MDS-HC: short-term memory, cogni-
tive decision making, making self understood, and depen-
dent eating. The CHESS Scale, which is indicative of the
degree of frailty or medical instability, utilizes a combina-
tion of the following items dealing with changes in health
(activities of daily living and cognitive decline), end-stage
disease, and signs and symptoms of medical conditions (i.e..

M506 FLETCHER AND HIRDES

edema, shortness of breath, weight loss, dehydration, loss of
appetite, diarrhea, vomiting). Scores range Ürom 0 (indicat-
ing no instability) to a high of 5.

The dependent variable was fall status. Specifically, indi-
viduals were asked whether they had fallen in the past 90
days. The outcome variable was dichotomized in two ways,
as two analyses were completed: (i) 0 falls versus 1 or more
falls and (ii) 0 falls/1 fall versus 2 or more falls.

Data Analysis
Logistic regression was utilized to analyze the data with

fall status as the dependent variable and other MDS-HC
variables as the independent variables. Stepwise methods
were not used in the logistic regression analyses. Rather, a
variety of models were examined in order to rule out order
effects prior to specification of the final model. Only the in-
dependent measures found to be significant at the bivariate
level {p < .05) were examined in multivariate models. The final logistic regression models were used to estimate the adjusted odds ratios for the main and interactive effects for the measures investigated.

Table 3. Percentage (Frequency) Distributions of
Sociodemographic Variables and Social Relationship Variables

Utilizing the MDS-HC

Variable , •

Age

65-69 years of age
70-74 years of age
75-79 years of age
80-84 years of age
85 years of age and older

Gender
Women
Men

Marital Status
Never married
Married
Widowed
Other

Education
Elementary/no schooling
Secondary/some secondary
Technical/trade or some post secondary
Diploma/university/graduate degree

Living Arrangements (at Referral)
Lived alone
Lived with spouse only
Other

Change in Social Activities
No decline
Decline, not distre.ssed
Decline, distressed

Amount of Time Alone During Day
Never or hardly ever
About one hour
Long periods of time (i.e.. all morning)
All of the time

Percentage (Frequency)

7.8(179)
13.9(321)
23.1 (531)
25.7(591)
29.6 (682)

71.8(1653)
28.3(651)

6.0(138)
33.2 (762)
55.6(1276)
5.1 (118)

33.8 (773)
43.4 (992)
16.6 (379)
6.2(141)

47.7(1048)
28.8 (634)
23.5(517)

69.7(1598)
20.8 (476)
9.6 (220)

33.3 (766)
11.3(261)
30.6 (703)
24.8(571)

Note: MDS-HC = Minimum Data Set-Home Care.

Table 4. Percentage (Frequency) Distributions of Measures of
Frailty Utilizing the MDS-HC

Variable Percentage (Frequency)

Stroke
No stroke 84.9(1952)
Stroke 15.1(347)

Heart Disease
No heart disease 82.3 ( 1893)
Heart disease 17.7(406)

Hypertension
No hypertension 62.9 ( 1447)
Hypertension 37.1 (852)

Parkinson’s Disease
No Parkinson’s disease 95.6 (2200)
Parkinson’s disease 4.4(101)

Alzheimer’s Disease
No Alzheimer’s disease 93.9(2158)
Alzheimer’s disease 6.1(141)

Arthritis
No arthritis 52.5(1208)
Arthritis 47.5(1091)

Osteoporosis
No osteoporosis 88.4 (2032)
Osteoporosis 11.6 (267)

Hip Fracture
No hip fracture 95.7 (2201 )
Hip fracture 4.3 (987)

Glaucoma or Cataracts
No glaucoma or cataracts 78.0 ( 1798)
Glaucoma or cataracts 22.0 (506)

Vision
Adequate vision 71.9 ( 1656)
Impaired moderately 24.4 (562)
Severely impaired 3.7 (86)

Perceived Health Status
Perceived good health 69.2 ( 1594)
Perceived poor health 30.8(710)

Note: MDS-HC = Minimum Data Set-Home Care.

RESULTS

Univariate Results
The univariate distributions have been summarized in Ta-

bles 3 through 6. Table 3 provides results for the sociode-
mographic and social variables. The majority of the 2304
participants sampled were between the ages of 75 and 79
years of age (23%), 80 to 84 years of age (26%), or 80 years
of age and older (30%) (Table 3). Women comprised 72%
of the sample, while 28% were men. With respect to marital
status, 56% and 33% were widowed and married, respec-
tively. Approximately 77% of the sample had obtained a sec-
ondary education or less. Forty-eight percent of the sample
lived alone, while 29% lived with their spouses. Seventy
percent of the participants had not had a change in their so-
cial activities during the past 90 days, while 21% reported a
decline in their social activities but they were not distressed
by the change. An additional 10% were distressed by the
changes that had occurred in their social activities (Table 3).

Univariate distributions for measures of frailty have been
summarized in Table 4. The majority of the sample (69%)
reported perceiving their health to be good. With respect

RISK FACTORS FOR FALLING M507

Table 5, Percentage (Frequency) Distributions of Exposure to Risk
Measures tJtilizing the MDS-HC

Table 6, Percentage (Frequency) of Fall Status, Utilizing
the MDS-HC

Variable Percenlage (Frequency) Variable

Gail*
Nol impaired
Impaired

Environmenlal Hazards*

0 environmenlal bazards
1 environmental bazard
2 or more environmental bazards

Antipsychotic/Neuroleptie Medications

Non use
Use

Anxiolytic Medications

Non use
Use

Antidepressant Medications

Non use
Use

Hypnotic Medications
Non use
U.se

46.5 (1070)
53.5(1232)

88.4 (2046)
7.69(177)
3.47 (80)

95.0(2184)
5.0(114)

83.1 ( 1913)
16.9(388)

81.8(1880)
18.2(418)

96.0 (2204)
4.0 (92)

Note: MDS-HC = Minimum Data Set-Hotne Care.
*ln tbe MDS-HC Section on unsteady gait, tbe following information is pro-

vided: “A gait tbat places tbe client at risk of falling. Unsteady gaits take many
forms. Tbe client tiiay appear unbalanced or walk witb a sway. Otber gaits may
bave tnicoordinated or jerking movements. Exatnples of unsteady gaits tTiay in-
clude fast gaits witb large, careless movements; abnormally slow gaits witb
small sbul’lling steps; or wide-based gaits witb balling, tentative steps.”

t|n tbe section on “Environmental Hazards,” tbe assessor is asked to check
any of tbe following tbal make the home environment bazardous: lighting in
evening (including inadequate ur no lighting in living room, sleeping rootn,
kilcben, toilet, corridors); flooring and carpeting (e.g., boles in floor, electric
wires where client walks, scatter rugs); batbroom and toilet room (e.g., nonoper-
ating toilet, leaking pipes, no rails tbougb needed, slippery batbtub, outside toi-
let); kitcben (e.g., dangerous stove, inoperative refrigerator, infestation by rats
or bugs); beatitig and cooling (e.g., too bot in summer, too cold in winter, wood
stove in a bome witb an astbtnatic); access to bome (e.g., difftculty entering/
leaving bome); access to rooms in house (e.g., unable to climb stairs).

to medical conditions, the most frequently reported con-
sisted of arthritis (48%), hypertension (37%), glaucoma or
cataracts (22%), heart di.sease (18%), and stroke (15%),
Less frequently occurring conditions included osteoporo-
sis (12%), Alzheimer’s disease (6%), Parkinson’s disease
(4%), fractures of the hip (4%), and impaired (24%) or se-
verely impaired (4%) vision.

Measures of exposure to risk variables are summarized in
Table 5, About 54% of the sample were categorized as hav-
ing a gait impairment, while 12% had one or more environ-
mental hazards within their homes. With respect to medica-
tion, anxiolytics (17%) and antidepressants (18%) were
used more frequently than hypnotics (4%) and neuroleptics
(5%).

The distribution for the dependent variables employed
within the logistic regression analyses is summarized in
Table 6. For the analysis of nonfallers versus fallers (1 +
falls), 73% of the sample were classified as nonfallers,
while 27% were deemed fallers. For the second logistic
analysis, 90% of the sample experienced no falls or one fall,
while 10% experienced multiple falls (2+ falls).

Frequency (Percentage)

Falls

No falls
I or more falls

Falls
0 or 1 falls
Multiple falls (2 or more falls)

73.0(1679)
27.0(621)

89.7 (2063)
10.3(237)

Notes: The MDS-HC defines a fall as “an unintentional ebatige in position
wbere tbe elder ends up on tbe floor or ground. A fall tiiay result frotn intrinsic
or extrinsic causes or botb.” MDS-HC = Minimutii Data Set-Home Care.

Multivariate Results
In the final logistic regression model for risk of falling (0

falls vs 1+ falls), the independent variables that remained
significant included gender, gait, environmental hazards,
and the CHESS Scale (Table 7). No interaction terms were
significant in the final model. Specifically, being male was
associated with an increased risk of falling as indicated by
an odds ratios of 1.31. Individuals with impaired gait were
also more likely to experience falling (odds ratio [OR] =
2.50). Seniors who had one or more environmental hazards
within their homes were 1.20 times more likely to experi-
ence a fall, and those with higher scores on the CHESS
Scale (OR = 1,20) were at greater risk of falling, a differ-
ence of 5 points on the CHESS, representing the highest and
lowest possible scores, resulting in an OR of about 2,50.

The risk factors significant in the second logistic model,
namely nonfallers/one-time fallers versus recurrent fallers
(2+ falls), included the same four variables in the first
model (Table 7), Also significant in this model were CPS,

Table 7. Multiple Logistic Regression Models for Risk of Falling

Independent Variables

Gender
Female
Male

Gait
Not impaired
Impaired

Count of
Environtiiental Hazards

CHESS Scale
(single-point increment)

Cognitive Perfortnance Scale
(single-point incretiient)

Parkinson’s Disease (PD)
Do not bave PD
Have PD

Healtb Status
Good bealtb
Poor bealtb

Model One
Odds Ratios

(Confidence Intervals)
for Fallers ( 1 + falls)

1.00
1.31 (1.07, 1.62)*

1.00
2.50 (2.05, 3.07)t

1.20(1.01, 1.43)*

1.20(1.11, l.3l)t

Model Two
Odds Ratios

(Confidence Intervals)
for Multiple Fallers

1.00
1.45(1.08, 1.95)*

1.00
2.80 (2.01, 3.89)t

1.35(1.04, 1.59)*

1.29(1.15, l.47)t

1.13(1.02, 1.25)*

1.00
2.47 (1.50, 4.07)t

1.00
1.35(1.01, 1.82)*

Note: CHESS = Changes in Health, End Stage Disease and Signs and

Sytnptoms of Medical Problems.

*/)< .05;V< .01; V<.OOI.

M508 FLETCHER AND HIRDES

Parkinson’s disease, and perceived health status. Men were
1.45 times more likely to be at risk for multiple falls than
women. Individuals with impaired gait were also more
likely to experience 2+ fall events (OR = 2.80). Having en-
vironmental hazards within the home increased risk of re-
current falls by 1.35 times, whereas higher scores on the
CHESS Scale increased fall risk by 1.29 per single unit in-
crement. Clients with Parkinson’s disease and impaired
cognition scores were also more likely to fall two or more
times, as indicated by odds ratios of 2.47 and 1.13, respec-
tively. A six-point differential on the CPS, again represent-
ing extreme scores, results in a 2.08 increase in the odds of
multiple falls. Lastly, those with poor self-rated health had
an increased risk of multiple falls by 1.35 times. There were
no significant interaction terms in either of the final logistic
regression models.

DISCUSSION

This study examined two different outcome measures for
fall events among home care clients: no falls versus one or
more falls, and no falls/less than one fall versus recurrent
falls (2+ falls) (Table 7). Categorization and analyses of
falls in this manner is consistent with the literature (34,40).
Differentiating “one-time fallers” and “recurrent fallers” is
important from a clinical viewpoint as the latter group is
more likely to be targeted and to benefit from preventive ef-
forts (34). Analyses revealed four variables that were signif-
icant in both models, namely gender (males), impaired gait,
presence of environmental hazards within the home, and
higher scores on the CHESS Scale for medical instability.
However, three other factors were significant predictors of
multiple falls: impaired cognition, Parkinson’s disease, and
poor self-rated health.

The present findings differ from the majority of research
concerning gender. Men were 1.31 times and 1.45 times
more likely to be at risk for a fall or recurrent falls, respec-
tively. The bulk of literature suggests that women have an
increased risk of falling in comparison to men (3,4,13-
16,21,41,42); however, there have been speculations that in-
creased falls among women may be the result of the reluc-
tance of men to report falling, the result of variables not
examined (i.e., differences in gait, knee action) (15,42), or
factors associated with being female gender, like osteoporo-
sis (43,44) or medication use (i.e., psychotropic medica-
tions) (15,21). Other research suggests that more women
may be injured by a fall, but more men die from fall-related
injuries (45). This may be related to the fact that men not
only take more risks, but also experience more traumatic in-
juries. It is conceivable that this group of male fallers re-
ceiving home care services may represent a distinct group
as compared to other men in the fall literature. For example,
the men within this study may be receiving home care ser-
vices as a direct result of injurious falls, or this study may
include men who are able to remain in the home with the
support of their spouses and home care services. Similar op-
portunities may not be available to women who experience
injurious falls. Alternatively, unpublished results also using
this data revealed that women were more fearful of falling
than men (Fletcher & Hirdes, unpublished data, 2002). As
such, it is possible that women feared that they may fall so

they restricted their activity and thus experienced fewer
falls. Another possibility is the men in this group were more
severely impaired or widowed and thus required more home
care than the women within this group; however, there were
no significant interaction terms between gender and the
CHESS or marital status. Regardless, more research in this
area is needed to ascertain whether community-based men
receiving home care experience more falls than women,
whether the group in question is distinct from other groups
of community-based seniors, or whether men experienced
more falls than women because women restrict their activity
because of their fear of falling.

Individuals with impaired gait were also found to be as-
sociated with an increased risk of falls and recurrent falls.
For example, individuals with impaired mobility were 1.65
times more likely to experience a fall, as compared to those
with no impairments in mobility (42). Wickham and col-
leagues (46) determined that seniors with impaired mobility
were 2.0 times more likely to experience a fall. Other sup-
port for the relationship between impaired mobility and fall
risk, as measured by impairments in balance and gait, were
found to be associated with falls (3,4,14,18), multiple falls
(25,27), serious injuries resulting from falling (16,28), and
mortality associated with falls (13). Given the significant in-
fluence that impaired gait, balance, and mobility have on el-
derly adults, it would seem essential that preventive inter-
ventions include a component that restores, improves, or
maintains the balance control system.

Environmental hazards may not always be used as pre-
dictors or risk factors in fall research, but rather are defined
as causal agents or contributing factors in the fall event.
Therefore, they may not be entered as risk factors in multi-
variate models. However, the contribution of environmental
hazards is an important consideration related to the need for
environmental modifications in prevention efforts (47-50).
Campbell and colleagues (51), Connell (52), and Hind-
marsh and Estes (53) found that environmental hazards con-
tribute to falls among seniors, which is consistent with the
findings for falls and recurrent falls in this research.

The CHESS Scale, which measures changes in health and
medical signs and symptoms, was also a significant predic-
tor of falls and recurrent falls. This measure is a relatively
new scale and has not been used in other falls research.
However, many of the key components inherent in the scale
itself have been established as risk factors for falls (e.g., in-
continence [24,25,30,42], activities of daily living [54], and
cognition [10]). Future work in the predictive value of the
CHESS Scale is warranted given that it is a standard com-
ponent of the MDS-HC, which is now being adapted by
home care agencies in several U.S. states and Canadian
provinces.

Impaired cognition and Parkinson’s disease were two of
the risk factors that distinguished failers from recurrent fall-
ers. Individuals with impairments in cognitive status as
measured by the CPS were more likely to experience two or
more falls, but not one or more falls. Cognitive impairment
has been linked to increased risk of falling (5,11,55) and re-
current falling (5,34). Graafmans and colleagues (34) re-
ported that individuals with compromised mental status
were 2.4 times more likely to experience recurrent falls. In

RISK FACTORS FOR FALLING M509

addition, impairments in cognition may be indicative of the
early stages of dementia, and, as such, multiple falls may be
a sign that intervention is required. Parkinson’s disease, a
progressive degenerative neurologic disorder, was also pre-
dictive of recurrent falls, but not one or more falls. Lipsitz
and colleagues (40) showed that Parkinsonism was one of
the causes of recurrent falls in frail, community-based se-
niors. Ambulating safely through one’s environment re-
quires physical stability and sound mental capacity to react
to hazardous conditions. As such, the contribution that cog-
nition and Parkinson’s disease have on fall status is not sur-
prising.

Poor self-rated health is the remaining significant vari-
able in the final model for recurrent falls. Studies by Vellas
and colleagues (32) and Stalenhoef and colleagues (56) pro-
vide confirmatory evidence of the predictive value of health
status for falls, injurious falls, or recurrent falls. Perceived
measures of health may be useful in identifying those at risk
of falling, or more specifically recurrent falling, particularly
when clinical assessments may be too expensive or difficult
to conduct (32). More research in determining whether per-
ceived poor health has predictive value in and of itself or is
a surrogate measure of other conditions such as various
chronic conditions, physiological impairments, or use of
certain medication is warranted.

Underreporting of falls is one limitation that may have af-
fected the present results. The number of falls may have
been underreported because of problems with recall (18)
given the retrospective design of the study. Tideiksaar (57)
suggests that reliance on self-reporting may also be prob-
lematic if seniors do not want to admit they have experi-
enced a fall because they (i) attribute the fall to conse-
quences of normal aging; (ii) deny the fall because it
reminded them of increasing frailty and dependency; or (iii)
fear that reporting it would lead to restriction of activities or
to institutionalization. Further, the cross-sectional nature of
the study may also limit the conclusions that can be drawn
from the multivariate analyses, as cross-sectional designs do
not allow researchers to establish a temporal order for fac-
tors associated with the fall event.

The risk factors found to be significant in the final logis-
tic regression models for one or more falls and recurrent
falls (2-1- falls) are consistent with previous falls research
with seniors, with the exception of the two scales inherent in
the MDS-HC and the male gender finding. Distinguishing
individuals into different fall status classifications is impor-
tant from a clinical perspective, as it is the recurrent fallers
that would benefit to the greatest extent from fall prevention
efforts, and from the negative outcomes associated with
multiple falls (i.e., mortality) (58). One of the most signifi-
cant barriers in the area of determining risk factors for falls
is the lack of consistency in the variables/tools used in the
research. As such, utilizing a standardized tool, such as the
MDS-HC, would assist researchers in making comparisons
between different settings. Currently, five Canadian prov-
ince.s/territories, seven states, and Veterans Affairs in the
United States are either in the process of implementing or
are utilizing the MDS-HC as their home care assessment in-
strument. Further, an assessment instrument, like the MDS-
HC, provides thorough comprehensive health information

about clients and indicates those who may benefit from
more extensive evaluation and/or care planning.

ACKNOWLEDGMENTS

We acknowledge the financial contribution from the Health Transition
Fund, Health Canada. The views expressed herein do not necessarily repre-
sent the official policy of Health Canada. The MDS-HC is a comprehensive
assessment instrument developed and owned by interRAI, a not-for-profit
network of researchers and clinicians.

An earlier version of this article was presented at the 17th World Con-
gress of the International Association of Gerontology Conference, Vancou-
ver. British Columbia, Canada, July 2001.

Address correspondence to Paula C. Fletcher, PhD, Department of Ki-
nesiology and Physical Education, Wilfrid Laurier University, Waterloo,
Ontario N2L 3C5 Canada. E-mail: pfletche@wlu.ca

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Received December 10, 2001
Accepted March 11, 2002

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