Falls, especially in older adults, is a significant problem, the solutions to which are still being researched. In this paper, a synthesis of the literature that is relevant to education-based fall prevention is presented (see Appendices A and B). Since recent articles that consider fall education in isolation is not very numerous, some of them review similar or adjacent topics. The synthesis of their key concepts demonstrates that high-quality studies have been dedicated to the topic, but their limitations imply that a new project could cover multiple research gaps.
Concept 1: The Problem of Falls
The topic of fall prevention is naturally connected to the concept of falls, which, in the reviewed literature, is typically problematized. It is mentioned or directly addressed in every of the thirty reviewed articles, including quantitative ones. The first subtheme in this literature review is the issue of falls and their consequences. While few of the studies pose a research question about the consequences of falls, all of them justify their attention to the topic by pointing out the dangers of falls.
As an illustration, the study by Gazibara et al. (2017) incorporated an epidemiological question about injuries after falls in older persons in Serbia; for that sample, almost 50% of the falls led to injuries. The sample was sufficient for the setting, which was one center (n=354), but not for more direct generalizations. However, the authors pointed out the similarities in their findings with other studies, and future research may consider other, understudied populations.
Furthermore, some studies incorporate outcome measures (fall-related injuries) in their research questions. An example is an article by Hill et al. (2015), which is a multi-site randomized controlled trial (RCT) with a large sample (3,606 inpatients in two groups). Its findings may be specific to Australia and inpatients from rehabilitation units, which is a limitation. Also, the results are only applicable to a particular intervention, and other interventions may need more research. Still, the fact that the consequences of falls make them important to address is a common theme in the literature.
As is required for determining appropriate solutions for a problem, a second subtheme is the causes of falls. An article by Haines, Lee, O’Connell, McDermott and Hoffmann (2015) proposed a question about the reasons for falls with a focus on risky behaviors. It is a qualitative study with interview data from 16 inpatients (older adults), eight caregivers, and 33 staff members. Other qualitative studies have also demonstrated that some of the potential causes for falls (or fall-prone behaviors) include overconfidence, the lack of knowledge about fall prevention, and difficulties with performing fall prevention activities (Lim et al., 2018; Mamani et al., 2019).
All these articles suffer from sample size issues; their findings may not apply to populations that are different from their samples. Still, the findings indicate that the motivations for taking risks vary, and they include the lack of information.
Quantitative articles that cover this subtheme also exist. Their questions are generally concerned with the epidemiology of risk factors in different populations. For example, Yoo, Kim, Yim, and Jeon (2016) conducted a quantitative assessment to determine the factors that may be more important in rural and urban areas (with a sample of 534 South Korean people). Similarly, Gale, Cooper, and Sayer (2016), with a sample of 4,301 people, demonstrate that fall risks for women and men tend to differ. The additional investigation of this topic is justified since both studies have sample-related limitations and do not cover all conceivable subgroups in patient populations. Still, the literature demonstrates that attention is paid to the causes of falls, one of which is the lack of knowledge.
The importance of addressing falls, which is the third subtheme, appears to be the rationale of most presented articles. Some articles pose questions about the perspectives of patients and caregivers, as well as staff members (Haines et al., 2015; Hill et al., 2016; Lim et al., 2018; Mamani et al., 2019; Meyer, Dow, Hill, Tinney, & Hill, 2016; Radecki, Reynolds, & Kara, 2018; Schoberer, Breimaier, Mandl, Halfens, & Lohrmann, 2016; Xu et al., 2017).
Such articles are typically qualitative, which affects the size of their samples and means that generalizing their findings is impossible, which is a limitation. An exception is an article by Mamani et al. (2019), in which the authors determined the prevalence of good knowledge and helpful attitudes in participants. The authors focused on elderly caregivers, and with a small sample of 97 people, their findings are not supposed to be generalized, but they demonstrate that most caregivers understand the significance of falls.
Regarding the rest of the studies in this subtheme, they are qualitative because they attempt to produce insights into participants’ views. They may involve patients and caregivers (Meyer et al., 2016; Schoberer et al., 2016; Xu et al., 2017), as well as staff members (Haines et al., 2015; Hill et al., 2016). The articles indicate the studied populations’ interest in solutions to fall problems, including those that are achieved through education. Therefore, this finding, which is reflected in different studies, can be considered relatively well-established, even though the attitudes toward specific interventions may require individual research.
To summarize, the concept of falls is made to incorporate the subthemes of the negative features of falls, their risks, and the importance of addressing them. Based on these studies, falls are connected, among other things, to the lack of knowledge, and addressing falls is important, partially because of their consequences and the perspectives of falls-prone people.
Concept 2: Factors to Consider in Prevention Intervention Development
Many of the studied articles consider the development of interventions that are supposed to prevent falls. They are predominantly quantitative; they discuss the process of an intervention’s creation and test or pilot it with quantitative outcomes as the common measurements (Hill et al., 2019; Ueda et al., 2017). However, qualitative studies are also present for patient-focused interventions (Hill et al., 2016; Meyer et al., 2016). A primary subtheme to this concept is the consideration of the opinions and perspectives of the people who are targeted by an intervention. Multiple qualitative studies pose the questions or state goals and purposes that require investigating such views (Hill et al., 2016; Lim et al., 2018; Meyer et al., 2016; Radecki et al., 2018; Schoberer et al., 2016; Xu et al., 2017).
Such articles have small samples, and they are typically concerned with fall-prone patients (Hill et al., 2016; Lim et al., 2018; Radecki et al., 2018), informal caregivers (Meyer et al., 2016; Xu et al., 2017), and formal caregivers (that is, hospital staff) (Hill et al., 2016). Qualitative methodology implies limitations for the findings’ application outside of a specific population that the sample represents. However, they show that the feedback of the people who are targeted by the interventions is valuable and needs to be researched for each intervention.
The second subtheme is customization; some articles set questions about testing tailored (customized) programs, including the articles by Hill et al. (2015) and Ueda et al. (2017). Certain studies, for example, those by Carlucci et al. (2018) and Jie and Deng (2019), mention that their trials incorporated customized elements, but they do not focus on this topic.
Three RCTs (Hill et al., 2015; Jie & Deng, 2019; Ueda et al., 2017), as well as a pre-test post-test study (Carlucci et al., 2018), use reliable methods, but only one of them has a sample that can be considered large (Hill et al., 2015). As a result, most of these articles have limited generalizability, especially since each of them investigates a specific intervention. These studies imply that customized programs could be effective, but more research on individual interventions, especially that by Ueda et al. (2017), is needed.
The final subtheme is concerned with involving specialists in the process of intervention development. Many studies state research questions about the effectiveness of interventions that are developed by physicians, nurses, or other experts (Lohman et al., 2017; Nakagami-Yamaguchi et al., 2016; Vonnes & Wolf, 2017). Each of those articles has its intervention and approach to studying it, but they tend to have relatively large sample sizes (269 people and more). Their quantitative methodologies, while not free of limitations (for example, those associated with pre-test post-test design), produce reliable findings. The results suggest that professional-developed interventions are effective. To summarize, the reviewed literature suggests that intervention development should be patient-centered, customized, and performed by professionals.
Concept 3: Different Approaches to Prevention Interventions
The approaches to fall prevention are rarely limited to education, but the first subtheme to be considered is education and educational elements in fall prevention. Some of the reviewed articles consider more comprehensive interventions, which incorporate education as their part (Casey et al., 2017; Johnston et al., 2018; Lohman et al., 2017; Szewieczek, Mazur, & Wilczyński, 2016). However, many of the reviewed studies ask questions about the effectiveness and outcomes of specifically education-related interventions. The main limitation of these studies is that they are most often dedicated to a specific program that is not investigated again; the only exception is a series of articles by Hill et al. (2016), in which one educational project was studied from multiple perspectives in several sites.
Regarding samples, inpatients (Perrot, Ayad, Gernigon, & Maillot, 2019), as well as outpatients (Carlucci et al., 2018; Hill et al., 2019; Jie & Deng, 2019; Kuhirunyaratn, Prasomrak, & Jindawong, 2019; Lyons & Hall, 2016; Ott, 2018; Ueda et al., 2017), are involved in such studies. Typically, older patients are a part of the sample (Nakagami-Yamaguchi et al., 2016; Perrot et al., 2019; Uymaz & Nahcivan, 2016). In addition, caregivers are occasionally considered (Vonnes & Wolf, 2017).
The limitations can be connected to the specifics of the methodology, including, for example, the lack of a comparison group (Perrot et al., 2019; Uymaz & Nahcivan, 2016) or randomization (Kuhirunyaratn et al., 2019), but the most common issue is a small sample. As an example, Perrot et al. (2019) involved only 30 people during the pre-intervention period, and in the study by Ott (2018), only eight people were subjected to the intervention. Large samples can also be encountered with the maximum number amounting to over 3,000 people (Hill et al., 2015). Still, small or specific (non-generalizable) samples remain an issue for these studies, which warrants individual research for specific interventions.
The target of the interventions varies across the literature, and it is the second subtheme of this concept. Thus, several studies posed research questions that required determining the effectiveness of an intervention that was aimed directly at patients (inpatients and outpatients) (Johnston et al., 2018; Uymaz & Nahcivan, 2016). However, some of the interventions were targeting caregivers and patients (Nakagami-Yamaguchi et al., 2016; Vonnes & Wolf, 2017), as well as staff (Hill et al., 2015).
The primary limitations of such studies are connected to their sample sizes; mostly, they are relatively small. In addition, not all studies are RCTs (Uymaz & Nahcivan, 2016; Vonnes & Wolf, 2017). Most studies demonstrate different positive outcomes associated with their interventions, although they consider individual interventions that can benefit from additional research.
As a third theme, the different new approaches to the modes of education can be noted. Such studies ask a question about the effectiveness of unusual interventions, for example, educational movies, floor plans, or robotic coaches (Maneeprom, Taneepanichskul, Panza, & Suputtitada, 2019; Nakagami-Yamaguchi et al., 2016; Ueda et al., 2017).
Outpatients (Maneeprom et al., 2019; Ueda et al., 2017), as well as inpatients (Nakagami-Yamaguchi et al., 2016), have been involved, and the methodologies included an RCT by Ueda et al. (2017) and quasi-experiments. All the studies demonstrated the effectiveness of the novel interventions with older patients, but with the limited amount of data for each of those interventions, which were mostly studied with small samples, more research for each of them should be recommended. To summarize, the approaches to interventions incorporate novel and older ones, including education, which may target different groups.
Concept 4: Studying Prevention Interventions
Few articles are directly dedicated to the methods of studying and evaluating the interventions. However, they are important since they can direct future studies (Hill et al., 2019; Meyer et al., 2016). First, the subtheme and research question of investigating the effectiveness was found (Carlucci et al., 2018; Hill et al., 2019; Jie & Deng, 2019; Kuhirunyaratn et al., 2019; Lyons & Hall, 2016; Ott, 2018; Perrot et al., 2019; Ueda et al., 2017).
As mentioned, the populations are typically older adults who are in or outpatients; the samples are rather small and typically restricted to one facility with few exceptions (Hill et al., 2015). The findings usually suggest effectiveness in some respect; it is rather rare for a study to find no effect at all. Out of the reviewed literature, only an article by Hill et al. (2019) reports that an RCT with 382 discharged patients did not demonstrate any positive effects of their education as related to fall rates. Therefore, individual programs require individual studies to prove or disprove their effectiveness. Also, with pilot studies and small samples (Ueda et al., 2017), additional research may be required.
The subtheme of gathering feedback from participants is represented rather extensively. Some articles dedicate their inquiry to the questions related to the perspectives of patients, caregivers, and staff (Carlucci et al., 2018; Hill et al., 2016; Meyer et al., 2016; Schoberer et al., 2016; Xu et al., 2017). Such articles focused on qualitative methodologies, and their findings should be applied to a relatively small population. However, new populations can be studied in future research.
An underrepresented theme is the tools that can be used to study the interventions. An article by Lohman et al. (2017) is unique in its research question, which requires determining how effective a STEADI tool is at predicting falls. Similarly, there exists a study of a risk assessment algorithm, which would be useful in reviewing fall prevention (Gomez, Wu, Auais, Vafaei, & Zunzunegui, 2017).
These articles have very large samples of older adults, and their limitations are mostly individual issues, for example, the impossibility of assessing the accuracy of the patients’ self-reports. Still, their results demonstrate that workable tools, which might benefit from some additional investigation, exist and can be used for researching falls. To summarize, the presented literature shows how to investigate a fall prevention program with attention paid to its outcomes, clients’ feedback, and well-researched methods of performing that activity. Despite the limitations, the cited literature also implies that fall prevention can be assessed and tends to have positive effects, although there are some exceptions.
Concept 5: The Effectiveness of Education
Since education is the primary focus of the proposed study, the effectiveness of education is the final concept. It has been evaluated from different perspectives, especially quantitative ones (Carlucci et al., 2018; Hill et al., 2019). The first subtheme is the reduction in fall ratios (Hill et al., 2019; Nakagami-Yamaguchi et al., 2016), falls (Perrot et al., 2019), near-falls (Ueda et al., 2017), injurious falls (Vonnes & Wolf, 2017), and fallers (Hill et al., 2015), which becomes the research question of the cited sources. These studies are quantitative, and some of them have large samples (Hill et al., 2015), although other ones have very small ones (Perrot et al., 2019).
Inpatients and outpatients can be studied (Hill et al., 2019), as well as staff and informal caregivers (Hill et al., 2015). The limitations are mostly the sample and location; also, the interventions are not always tested against a control group or groups. Since each of these articles is about a specific intervention, future ones will need additional research.
As a second subtheme, the reduction in risks of falls is noteworthy. The studies that ask the question of the effectiveness of their intervention at achieving this outcome are quantitative (Carlucci et al., 2018; Jie & Deng, 2019; Kuhirunyaratn et al., 2019; Maneeprom et al., 2019; Perrot et al., 2019; Uymaz & Nahcivan, 2016), but a qualitative study can ask what fall risks are affected by the educational program (Hill et al., 2016). With small and large samples of in- and outpatients (from 43 at post-test to 757), these articles have the limitations of specific samples (for example, only rehabilitation units) and individual interventions.
The articles prove that education can improve knowledge (Maneeprom et al., 2019), reduce the fear of falls (Perrot et al., 2019; Uymaz & Nahcivan, 2016), and enhance awareness and confidence (Hill et al., 2016), as well as balance (Kuhirunyaratn et al., 2019). However, risk factors are more numerous, and their additional research in the areas in which these articles found no statistically significant differences could be helpful.
As a third subtheme, the approval of the target audience can be noted. These articles and their findings are not as generalizable since they are mostly qualitative (Carlucci et al., 2018; Hill et al., 2016; Meyer et al., 2016). Their samples are on the smaller side, which is a limitation, and they also focus on older patients and people who provide them with care. The articles demonstrate the fact that educational interventions can be of importance to target audiences, but to support this thesis for different populations, additional research may be required. To summarize, this concept demonstrates that educational interventions can be effective from different perspectives (from fall reductions to risk factors improvements), and they can also have no effects, which is why investigating new ones is a requirement.
Conclusion
The presented synthesis demonstrates that the articles cover different aspects of fall-related issues, and the topics of older people and educational interventions are represented. Most articles are limited by their samples and by studying individual interventions. Educational interventions are proven to be effective, which may be attributable to them targeting one of the causes of falls. Furthermore, the literature demonstrates that fall prevention interventions need to be studied to ensure their effectiveness, and the presented articles can be used to design or choose an intervention, research it, and justify researching it.
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Appendix A
The Summary of First Articles.
Appendix B
The Summary of New Articles.