Barriers and Facilitators to Older Adults Participating in Fall-Prevention Strategies After Transitioning Home from Acute Hospitalization: A Scoping Review

Figures & data

Figure 1 PRISMA flowchart showing selection of articles for scoping review.

Table 1 General and Methodological Characteristics of All Included Articles (n=17)

Publication Year	n (%)	Article Citations
2009–2014	10 (58.8)	[^Citation5,Citation38–Citation46]
2015–2019	7 (41.2)	[^Citation19,Citation36,Citation37,Citation47–Citation50]
Country/Setting	n (%)	Article Citations
Australia	6 (35.3)	[^Citation5,Citation19,Citation41–Citation43,Citation45]
Hong Kong	1 (5.9)	[^Citation46]
Israel	1 (5.9)	[^Citation47]
Sweden	1 (5.9)	[^Citation37]
UK	3 (17.6)	[^Citation36,Citation40,Citation44]
USA	5 (29.4)	[^Citation38,Citation39,Citation48–Citation50]
Study Type	n (%)	Article Citations
Quantitative	5 (29.4)	[^Citation5,Citation39,Citation45,Citation47,Citation48]
Qualitative	6 (35.35)	[^Citation36,Citation38,Citation40,Citation44,Citation49,Citation50]
Mixed methods	6 (35.3)	[^Citation19,Citation37,Citation41–Citation43,Citation46]
Study Design	n (%)	Article Citations
Case studies	2 (11.8)	[^Citation38,Citation40]
Cross-sectional	1 (5.9)	[^Citation48]
Prospective, excluding randomized clinical trials	4 (23.5)	[^Citation39,Citation46,Citation49,Citation50]
Randomized clinical trials	4 (23.5)	[^Citation5,Citation41,Citation42,Citation45]
Prospective, with a nested retrospective study	1 (5.9)	[^Citation47]
Grounded theory	1 (5.9)	[^Citation44]
Systematic review	4 (23.5)	[^Citation19,Citation36,Citation37,Citation43]
Data Collection Methods	n (%)	Article Citations
Structure/semi-structured interviews	4 (23.5)	[^Citation38,Citation44,Citation49,Citation50]
Focus group discussions	1 (5.9)	[^Citation40]
Survey questionnaires	5 (29.4)	[^Citation5,Citation39,Citation45,Citation47,Citation48]
Mixed methods	3 (17.6)	[^Citation41,Citation42,Citation46]
Secondary data (eg, review studies)	4 (23.5)	[^Citation19,Citation36,Citation37,Citation43]
Stage in the Continuum on Which the Study Focused	n (%)	Article Citations
After acute hospitalization, but recruited from the community	3 (17.6)	[^Citation38,Citation40,Citation48]
Post-hospital discharge for up to 8 days	1 (5.9)	[^Citation49]
Post-hospital discharge for up to 1 month	5 (29.4)	[^Citation5,Citation39,Citation43,Citation47,Citation50]
Post-hospital discharge for up to 3 months	1 (5.9)	[^Citation44]
Post-hospital discharge for up to 6 months	3 (17.6)	[^Citation19,Citation41,Citation42]
Post-hospital discharge for up to 12 months	2 (11.8)	[^Citation45,Citation46]
Not applicable (eg, review studies)	2 (11.8)	[^Citation36,Citation37]
Point of Patient Recruitment to Study	n (%)	Article Citations
Prior to hospitalization	0 (0)	–
In hospital prior to discharge	10 (58.8)	[^Citation5,Citation19,Citation39,Citation41–Citation44,Citation47,Citation49,Citation50]
Within a week after discharge following recent acute hospitalization	1 (5.9)	[^Citation45]
From the community, more than 1 month to a year following hospital discharge for previous fall-related hospitalization	4 (23.5)	[^Citation38,Citation40,Citation46,Citation48]
Not applicable (eg, review studies)	2 (11.8)	[^Citation36,Citation37]
Primary Person Who Delivered the Fall-prevention Intervention	n (%)	Article Citations
Physicians	0 (0)
Hospital nurses	0 (0)
Medical assistants	0 (0)	–
Physical therapist	3 (17.6)	[^Citation5,Citation38,Citation48]
Occupational therapist	0 (0)	–
Personal trainer	0 (0)	–
Community health workers	0 (0)	–
Interdisciplinary team (clinicians, health professionals, and researchers)	10 (58.8)	[^Citation39–Citation42,Citation44–Citation47,Citation49,Citation50]
Not applicable (eg, review studies)	4 (23.5)	[^Citation19,Citation36,Citation37,Citation43]
Person Receiving the Fall-Prevention Intervention	n (%)	Article Citations
Patient only	13 (76.5)	[^Citation5,Citation38–Citation42,Citation44–Citation50]
Patient and family member or caregiver	0 (0)	–
Family member or caregiver only	0 (0)	–
Not applicable (eg, review studies)	4 (23.5)	[^Citation19,Citation36,Citation37,Citation43]
Mode of the Fall-Prevention Intervention	n (%)*	Article Citations
Group-based intervention	5 (29.4)	[^Citation5,Citation41,Citation42,Citation45,Citation47]
Individual-based intervention	7 (41.2)	[^Citation38–Citation40,Citation44,Citation48–Citation50]
Follow-up events (by telephone, mail, e-mail)	9 (52.9)	[^Citation5,Citation38,Citation39,Citation41,Citation42,Citation46,Citation47,Citation49,Citation50]
Social network (eg, Facebook)	0 (0)	–
Self-monitoring devices (eg, Smartphone, Fitbit, Apple Watch)	0 (0)	–
Home technologies or internet-of-things (eg, blood pressure cuff, weight scale)	0 (0)	–
Not applicable (eg, review studies)	4 (23.5)	[^Citation19,Citation36,Citation37,Citation43]

Notes: *Multiple modes of fall-prevention overlap for cited studies. The frequency is the number of cited articles per category. The percentage is the percentage of the 17 articles included in the review.

Table 2 Characteristics of the Included Studies (n=17)

Article	Aim/Study Outcome	Participants/Inclusion Criteria	Methods	Findings
Agmon et al, 2016^Citation47	To determine the association between pre-diagnosed anxiety during hospitalization and falls 1-month post-discharge.	Older adults aged ≥70 years pre-diagnosed with anxiety, no loss of cognitive function and no disabling diagnosis (N=556).	Post-discharge data collected retrospectively by telephone interviews/surveys. Data analyzed using logistic regression studies.	Older adults ≥70 years with prediagnosed anxiety were twice as likely to fall 30 days post-discharge after acute hospitalization than were older adults without prehospitalization anxiety (adjusted odds ratio=1.89; 95% CI: 1.04–3.48).
Calhoun et al, 2011^Citation38	To investigate barriers and facilitators to participating in fall-risk assessment programs among older adults who had fallen.	Older adults aged ≥75 years recruited from a list of fall-risk assessment programs (N=39).	Interview guide with open-ended questions to stimulate conversations around facilitators and barriers to participation. Data analyzed using thematic analysis.	Study findings under facilitators and barriers to participation included: 1) Perception of need: differentiated between participators and non-participators. Participants expressed that they “needed” the program, while nonparticipants expressed a lack of need for the fall-prevention programs because they prevented falling themselves by being more careful. 2) Transportation: Lack of transportation was a barrier to participating as it affected older adults who were assigned to programs in community clinics.
Davenport et al, 2009^Citation39	To investigate the fall rate of in-hospital fallers post-discharge and explore their risk factors for falling during the period immediately after hospital discharge.	Younger and older adults who had fallen during hospitalization, English-speaking, had not been to a nursing home before hospitalization, would not be discharged to a nursing home, life expectancy ≥3 months, discharged home, had a phone, and were cognitive to give consent (N=65).	Data regarding fall frequency and factors enabling falls at home were collected 4 weeks post-discharge through telephone surveys and analyzed quantitatively and qualitatively.	Self or caregiver reported falls at home 4 weeks post-discharge; 19 participants suffered 38 falls with a fall rate estimated as 25.4/1000 person-days (95% CI= 17.3–33.4) for adult participants aged 22–97 years (mean 65.5 years ± 13). However, fall rates between age groups <64 years and ≥65 years were 25.5 falls/1000 person-days and 25.2 falls/1000 person-days, respectively. The study also recorded 3 mortalities and 4 nursing home referrals for rehabilitation therapy. Risk factors for falls post-discharge did not statistically significantly differ between fallers and non-fallers controlled for all categories (age, use of mobility aids, previous hospitalizations, previous fall histories, fall injuries during hospitalization, and duration of hospitalization). However, after controlling for sex, fall rates post-discharge were higher among adults who fell more than once during hospitalization (p=0.001).
Dickinson et al, 2011^Citation40	To investigate older adults’ perceptions of facilitators and barriers to participating in fall-prevention interventions	Older adults aged ≥60 years living within a community setting and had experienced at least one fall-prevention intervention (eg, fall clinics, postural stability classes, Tai-Chi, and exercise classes). Participants were recruited by letters and personal invitations (N=187).	Seventeen focus groups with 122 participants and individual interviews for the rest (n=65). Data were analyzed for content and themes.	Major findings included: Health professional response: Participants felt health professionals lacked interest in talking about falls; therefore, they failed to refer them to the right interventions. Inadequate assessment from health-care professionals who failed to assess the extent of older adult fall risks and fall injuries, only to be picked up at a later date from complications in other body systems. Poor access to healthcare when needed: lack of doctors in the community when patients had emergencies. Doctors acting as barriers by showing disinterest and delinquency. Language barriers: Some non-English-speaking doctors deterred patients because of poor communication.
Finnegan et al, 2019^Citation36	A systematic review of qualitative studies to explore the barriers and facilitators to continued participation in fall-prevention exercise programs	Community-dwelling older adults aged ≥65 years who had participated in a fall-prevention exercise program.	Data extracted from identified articles included aim, participant characteristics, method of data collection, methodology, and analysis. All data extracted were thematically analyzed and used to integrate findings.	Barriers to continued participation in fall-prevention exercises were summarized under the following themes: Denial of being at risk to fall: Older adults who had a history of falling did not identify themselves as ‘fallers’ and did not think they needed to continue exercising. Increasing age: Increasing age was a risk factor for falling, yet some participants denied acknowledging themselves as old. Conversely, others did not think of age as a barrier to ongoing exercise but expressed that their population was not the intervention target. Perceived value of the exercise: Older adults chose to participate or not based on perceived benefits. Health issues: such as dizziness, feeling shaky, pain, drowsiness, reduced strength-endurance, and depression. Lack of time: conflicting schedules, and time pressures resulting from caring responsibilities. Perception of self-attainment/self-efficacy: Participants felt that they were already doing enough to prevent falls, and additional fall-prevention exercise programs were unnecessary. Transitioning: Participants expressed difficulty in transitioning from one exercise format to another, which was a barrier to participating in exercises. Facilitators identified were summarized under the following themes: Improved strength, balance and confidence: Perceived benefits such as independence, maintaining health status and improving balance and strength facilitated participants to keep exercising. Health benefits perception: Maintaining health and preventing deterioration of health. Social interaction: Participants saw the social benefits of participating in group exercise as a facilitator to continued participation. Family support as well as encouragement from their exercise instructors: older adults described support and encouragement from others (family members, peers, and instructors) as facilitators to ongoing. Nature of intervention (group vs individual): For some older adults, being part of a group was a facilitator to continue exercising. For other older adults, they preferred individual exercise programs describing that the group events made them feel uncomfortable and uneasy. Signposting: Providing appropriate, up-to-date, and relevant information about other groups or new exercise opportunities when transitioning from one exercise to another.
Hill et al, 2011^Citation41	RCT to examine whether older adults were ready to engage in fall-prevention strategies following hospital discharge The study outcome was to identify what fall-prevention strategy participants perceived would reduce their risk for in the first 6 months following discharge.	Older adults aged ≥60 years discharged following acute hospitalization or subacute rehabilitation for conditions such as orthopedic, pulmonary, stroke, and cardiac conditions. Participants (N=333) were randomized into 3 groups. Two groups received a multimedia package containing fall-prevention education specific to their condition, and the control group received standard care.	Semi-structured interviews were administered 48 hours before discharge. Data analyzed for descriptive outcomes and themes.	Findings were described under the following thematic headings: Behavioral: Participants described behavioral strategies to reduce falls. Quotations included, “being careful”, “getting help” and “not taking risks.” Support while mobilizing: Using supportive equipment or items to remain upright. Approach to movement: Considered movement concepts that cause falls such moving too fast or turning too quickly. Physical environment: Modification of physical home environments such as removing clutter and obstacles. Visual: Being alert about one’s immediate environment (eg, looking where one is going or watching for different surfaces). Medical: Medical suggestions older adult thought might reduce their fall risks. For example, “checking for dizziness and being aware of medication side effects on balance.” Activity and exercise: Participants’ suggestions for improving physical capability such as, “going for walks,” and “doing strength and balance building exercises.”
Hill et al, 2011^Citation42	RCT to identify factors associated with older adults’ exercising 6 months after hospital discharge. Study outcomes were: 1) older adults’ attitudes and beliefs about falls, 2) older adults’ engagement in structured exercises (ie, exercise that increased balance and strength), and 3) Perceived barriers to engaging in structured exercise after discharge.	Older adults ≥60 years old recently discharged from 4 participating wards (medical, surgical, stroke, or rehabilitation wards) in a general hospital. Of these, 343 consented to participate and were randomized to 2 groups. One group received fall-prevention education, and the control group received standard care.	Data were collected 48 hours before discharge. Follow-up data came from semi-structured telephone interviews at 6 months	Barriers to engaging in exercise post-discharge included: 1) attitudes toward exercise, including low self-efficacy, believing that exercise was unnecessary, safety concerns while exercising, insufficient motivation, dislike for exercise, no need for exercise, no cue to actions during exercise, and being fearful of engaging in exercise, 2) medical barriers to exercise: pain from first attempts at exercising extending up to 6 months post-discharge, shortness of breath on exertion, feeling unwell, 3) reduced mobility from surgery, and 4) exercise program delivery, for example, not being assigned to an exercise program, not being able to get to the class, or abrupt exercise therapy cessation.
Hill et al, 2013^Citation5	RCT pilot study to evaluate the effects of providing tailored fall-prevention education in hospital on engaging in fall-prevention strategies 1 month after discharge. The study outcomes were a measure of 1) older adults’ engagement in fall-prevention strategies 1 month after discharge and 2) perceived risk about falls and fall-prevention strategies to engage in after discharge.	Hospital older adult patients aged ≥60 years scheduled to be discharged from stroke or rehabilitation wards to home (N=50). Participants were randomized into an intervention group with a tailored multimedia fall-prevention education package, follow-up and additional care, and a control group with usual care.	Data were collected 24 hours prior to discharge and at 1-month post-discharge via telephone using semi-structured survey tools.	The intervention group was significantly more likely to safely restart functional activities (adjusted odds ratio 3.80, 95% CI [1.07, 13.52], p = 0.04) and more likely to complete targeted fall preventive behaviors (adjusted odds ratio 2.76, 95% CI [0.72, 10.50], p = 0.14) than the control group. The intervention group was significantly more knowledgeable, confident, and motivated to engage in fall-prevention strategies post-education intervention compared with the control group.
Kiami et al, 2019^Citation48	To identify factors that increase the likelihood of enrolling in fall-prevention programs among community-dwelling older adults.	Older adults aged ≥60 years, residing in the community who could read and write English.	Semi-structured survey questionnaires used to collect data. Data analyzed using chi-square tests and logistic regression analysis.	Four barriers were associated with less likelihood to enroll in fall-prevention programs: 1) belief will not fall, 2) lack of time, 3) transportation, 4) will not prevent falling, and 5) not offered nearby. Seven facilitators were associated with more likely to enroll in fall-prevention programs: 1) offered near home, 2) free vision screening, 3) friendly leader, 4) coffee hour to socialize, 5) no cost, 6) group exercise, and 7) safe space/place
Lee et al, 2013^Citation43	Systematic review and meta-analyses to assess the effectiveness of patient education in reducing falls, promoting behavioral change, and taking up fall-prevention activities during and after hospitalization. Primary outcome: Proportion of older adults who were hospital or post-hospital fallers. Secondary outcome: Awareness of fall and fall-prevention strategies.	Studies with older adults aged ≥60 years involved in patient education as a single or multifactorial intervention in hospital or post-discharge.	Data were collated from identified library databases, screened for inclusion, and thematically analyzed for facilitators and barriers to fall prevention.	Barriers identified included 1) lack of fall-prevention education, 2) perceiving falls as unpreventable, 3) cluttered environment, 4) chronic diseases, 5) unavailability of walking aids, 6) advancing age, 7) lower educational or literacy levels, 8) lack of social support, and 9) cognitive and communication problems. Facilitators identified included 1) patient education on falls, 2) cues to action: recommendations made by health professionals, 3) self-efficacy using visual learning aids, and 4) location and prolonged engagement: attitudes and beliefs regarding falls and prevention influenced positively by location (eg, hospital-based studies demonstrated positive attitudes to change following fall education due to the intensity of the education provided).
McMillan et al, 2014^Citation44	Used grounded theory to explore the post-discharge concerns of older adults after fall-induced hip fractures.	Older adults aged ≥65 years living at home who had been discharged for up to 3 months (N=19).	Data collected using semi-structured qualitative interview guides and analyzed using a constant comparison method of the Glaserian method.	A theory of ‘taking control’ was developed to explain the coping mechanisms employed after falls post-discharge. The key strategy to this theory was ‘Balancing risk,’ which older adults said helped them take control after discharge. This strategy was explained by key quotes like “protective guarding” and “following orders.”
Naseri et al, 2018^Citation19	Systematic review to synthesize evidence for fall-prevention interventions in older adults discharged from hospital and followed for 6 months.	1) Studies involving older adults aged ≥60 years, 2) studies where older adults were hospitalized and then discharged home or to a community, 30 studies where interventions were delivered in a hospital or within 1 month post-discharge, and studies published globally in English between January 1990 and June 2017.	Data were extracted from identified library databases, appraised for quality using the JBI critical appraisal tool and pooled for meta-analyses using RevMan review manager. Synthesized studies were evaluated and categorized using the summary of evidence.	Selected studies reported synthesized evidence for the following fall interventions shown to reduce falls post-discharge: 1) Home hazard modification (1 study; low-grade evidence), 2) Home exercise (3 studies, moderate GRADE evidence), and 3) Short-term nutritional supplementation (1 study; low-grade evidence).
Sandlund et al, 2017^Citation37	Systematic review to explore underlying gender perspectives or interpretations of older adults’ preferences regarding uptake and adherence to exercise to prevent falls.	Qualitative, quantitative, or mixed-method studies involving older adults aged ≥60 years, community-dwelling or living in residential homes, presenting views on fall-prevention exercise strategies.	Data were collated from identified library databases, screened for inclusion, and analyzed using constant comparison to create themes for facilitators and barriers to fall-prevention.	Barriers to participating in fall-prevention exercise were categorized into six themes: 1) practical issues (transportation, lack of time, bad weather, and lack of a suitable place to exercise at home); 2) concerns about exercise (lack of confidence to exercise, fear of adverse effects, not being able to keep up, dislike for group exercise); 3) unawareness (lack of knowledge about the benefits of exercise to fall prevention, perception of being active enough to need exercise, and denial of fall risk); 4) reduced health status (eg, pain and fatigue); 5) lack of support; and 6) lack of interest (for group versus individual exercise programs). Facilitators included 1) support from professionals or family; 2) social interaction; 3) perceived benefits, 4) supportive exercise context; 5) feelings of commitment; and 6) having fun.
Shuman et al, 2016^Citation49	To describe hospitalized older adults’ perceptions about 1) their fall risks while hospitalized; 2) interventions they received to prevent falls while hospitalized; and 3) the instructions received at discharge to prevent falls at home.	Older adults aged ≥60 years, hospitalized in the study unit for at least 48 hours, classified as at-risk-for-falls patients based on Morse fall score, have a phone number, English-speaking, and medically stable (N=18).	Data collected in-hospital and post-discharge interviews by telephone. Data analyzed using constant comparative methods to delineate and resolve conflicting themes.	Barriers identified in the thematic analysis were 1) fear of falling for those at risk of falling, 2) misunderstanding or non-acknowledgment of fall-prevention procedures by healthcare staff causing patients not to pay attention to their fall risk or adopt/comply with interventions, 3) generalized fall-prevention interventions not fitting for outlying patients, 4) perception of fall-related discharge instructions (some forget they were told what to do post-discharge), and 5) mobility issues and compliance especially for those using walking aids without support or assistance. Facilitators identified included 1) tailored fall-prevention interventions, 2) satisfaction with fall-prevention interventions, 3) reminders of fall-prevention interventions, 4) family support and assistance, 5) effectiveness of fall prevention (as defined by research evidence) of the fall-prevention intervention, and 6) verbal and written discharge prescriptions
Shuman et al, 2019^Citation50	To describe 1) the risks for falls, factors contributing to fall risks and actions to prevent falls at home, 2) information received at discharge to prevent falls at home; and 3) awareness and perceptions regarding the usefulness of CDC STEADI fall-prevention brochures in recently hospitalized older adults	a) Older adults aged ≥60 years, b) identified as moderate-to-high risk for falls by Morse fall score, during recent hospitalization, c) discharged home after acute hospitalization, d) English-speaking, and e) able to participate in interview 4 weeks post-hospital discharge (N=9).	Data were collected via face-to-face interviews lasting 45–60 minutes 4 weeks after discharge. Audio was recorded and analyzed using inductive thematic analysis for the key question: ‘What can you do to prevent falls?’ Data analyzed using constant comparative methods.	Findings summarized in five major themes included 1) sedentary behaviors and limited functioning, 2) prioritization of social involvement, 3) low perceived fall risk and attribution of risk to external factors, 4) avoidance and caution as fall-prevention and 5) limited fall-prevention information when transitioning home from hospitalization.
Vogler et al, 2009^Citation45	RCT to compare the efficacy of seated exercises compared with weighted exercises and social visits, on fall-risk factors in older people recently discharged from hospital. Study outcome: Physiological profile assessment (PPA) composite fall risk score and test of ability to lean or stand.	Older adults aged ≥65 years, not cognitively impaired and with no contraindications to exercise Participants (N=180) were randomized into 3 groups; seated exercises (n=60); weight-bearing exercises (n=60) and social visits (n=60).	Data collected a few days after participants reached home and completed 3 months post-discharge, using self-reported questionnaires.	Participants in the weight-bearing group had significantly better performance than did the social visit group for PPA score, coordinated stability, maximal balance range body sway on the floor with eyes closed, and finger-press reaction time. Similarly, the seated exercise group scored significantly better than did the social visit group on PPA score only. Conversely, the seated group had the highest rate of musculoskeletal soreness.
Wong et al, 2011^Citation46	To evaluate the uptake rate of a fall-prevention exercise program among older fallers discharged more than 12 months from acute hospitalization due to related falls.	Older adults aged ≥60 years hospitalized in accident and emergency regional hospital in Hong Kong for fall-related events between August 2006 and August 2007.	Data were collected by telephone from all previous fallers using a structured telephone survey tool. Data were analyzed using logistic regression to examine relationships between the associated factors and participation in the fall exercise program.	Barriers included 1) lack of fall-prevention education, 2) perceiving falls as being unpreventable, 3) cluttered environment, 4) presence of chronic diseases, 5) unavailability of walking aids, 6) advancing age, 7) lower educational or literacy levels, and 8) lack of social support. Facilitators were considered the reverse of the barriers identified in this study.

Table 3 Barriers to Older Adults Participating in Fall-Prevention Strategies After Transitioning Home from Hospitalization (n=17 Articles)

Capability-Related Themes	Frequency (%)*	Article Citation
C1: Frailty due to advanced age	4 (23.5)	[^Citation36,Citation39,Citation43,Citation46]
C2: Language and communication barriers	4 (23.5)	[^Citation40,Citation41,Citation43,Citation46]
C2.1: Not understanding the fall-prevention program due to limitations in reading, speaking or comprehension of English	1 (5.9)	[^Citation40]
C2.2: Lack of communicative channels such as visual aids, pamphlets, and reminders	1 (5.9)	[^Citation41]
C2.3: Use of medical jargon during communication	2 (11.8)	[^Citation43,Citation46]
C3: Literacy or educational levels associated with poor comprehension	2 (11.8)	[^Citation43,Citation46]
C4: Health-related issues limiting participation	7 (41.2)	[^Citation36,Citation37,Citation40,Citation42,Citation46,Citation47,Citation49]
C4.1: Physical health issues (eg, joint pain, chest pain on exertion, vision)	3 (17.6)	[^Citation37,Citation42,Citation46]
C4.2: Health issues (physical, mental, psychosocial, etc.) limiting participation	4 (23.5)	[^Citation36,Citation40,Citation47,Citation49]
Opportunity-Related Themes	Frequency (%)*	Article Citation
O1: Lack of institutional support (eg, health, medical, and social service systems) for fall-prevention program	8 (47.1)	[^Citation37,Citation38,Citation40–Citation43,Citation46,Citation49]
O1.1: Disinterest/discouragement from health staff (ie, physicians, nurses, and healthcare systems) due to heavy clinical workload, not understanding the program, or other reasons	5 (29.4)	[^Citation37,Citation38,Citation40,Citation42,Citation49]
O1.2: Lack of financial incentives for nurses, doctors or fall-prevention educators to encourage active delivery and sustainability of fall-prevention programs	1 (5.9)	[^Citation38]
O1.3: Poor organization and resources to carry out the planned activities (eg, fall-prevention programs not implemented consistently to continue to engage patients in outpatient settings)	3 (17.6)	[^Citation38,Citation42,Citation43]
O1.4: Lack of patient safety equipment (glides, floor anti-slip mats), mobility adaptation (ramps for wheelchair mobility) and mobility aids (crutches, walkers, strollers) needed to participate in fall-prevention programs	3 (17.6)	[^Citation41,Citation46,Citation49]
O2: Lack of social support from community, family, spouse, and peers to support fall prevention (eg, older adults in the community not participating in the group exercise programs discourages other older adults from participating)	1 (5.9)	[^Citation37]
O3: Fall-prevention program requires additional design (eg, more engaging in including older adults, having older adults buy in; more encompassing for all ages, genders and older adults with chronic disease or disabilities)	4 (23.5)	[^Citation19,Citation41,Citation42,Citation49]
O3.1: Fall-prevention programs are not comprehensive or inclusive (eg, older adults felt the interventions were not patient-centered; researchers should consider older adults’ preferences in types of fall-prevention activities).	1 (5.9)	[^Citation49]
O3.2: Program incompatible with older adults because it was too complex to execute (eg, virtual reality exercise games)	2 (11.8)	[^Citation41,Citation42]
O3.3: Program lacking in organization, delivery and technical support (eg, programs lacked contacts to provide support or answer questions when needed)	2 (11.8)	[^Citation41,Citation42]
O3.4: Program did not send reminders, follow-up or visual aids (eg, pamphlets)	2 (11.8)	[^Citation19,Citation50]
O4: Lack of access to intervention deters willingness to participate	4 (23.5)	[^Citation36,Citation40,Citation48,Citation49]
O4.1: Transport unavailable (eg, no roads to that area, no access to transport to the venue)	2 (11.8)	[^Citation48,Citation49]
O4.2: Long distance (eg, too long a distance or commute makes older adults too tired to participate)	2 (11.8)	[^Citation48,Citation49]
O4.3: Cost (personal financial cost and time cost)	2 (11.8)	[^Citation36,Citation48]
O4.4: Difficulty in accessing healthcare directions or technical support (eg, older adults cannot access technical support for virtual reality exercises)	1 (5.9)	[^Citation40]
Motivation-Related Themes	Frequency (%)*	Article Citation
M1: Lack of motivation to carry out or sustain fall-prevention intervention following hospital discharge or during hospitalization	8 (47.1)	[^Citation36,Citation37,Citation41–Citation44,Citation48,Citation49]
M1.1: Lack of motivation to participate because of emotional/mental-related issues (eg, sad or not in the mood to participate)	2 (11.8)	[^Citation43,Citation49]
M1.2: Unwilling to participate because of spiritual beliefs conflicting with fall-prevention practice (eg, practicing Tai-Chi may interfere with spiritual beliefs)	1 (5.9)	[^Citation37]
M1.3: Behavior and attitudes towards fall-prevention hindering participation (eg, overconfident in their own ability to prevent falls)	6 (35.2)	[^Citation36,Citation37,Citation41,Citation42,Citation44,Citation48]
M1.4: Older adults lacking confidence to prevent falls	2 (11.8)	[^Citation48,Citation49]
M2: Self-denial of being at risk for falls	2 (11.8)	[^Citation36,Citation50]
M3: Difficulty transitioning between activities of daily living and fall-prevention interventions	1 (5.9)	[^Citation36]
M4: Enthusiasm fatigue	1 (5.9)	[^Citation37]

Notes: *The frequency is the number of cited articles per category. The percentage is the percent out of the 17 articles included in the review. Bold font denotes a main theme.

Table 4 Facilitators to Older Adults Participating in Fall-Prevention Strategies After Transitioning Home from Hospitalization (n=17 Articles)

Capability-Related Themes	Frequency (%)*	Article Citation
C1: Younger older adults more inclined to participate in fall-prevention because they consider themselves fit	1 (5.9)	[^Citation46]
C2: Language and communication aids (eg, language interpreter, visual aids, pamphlets, audiovisual tools help better communicate program aims to older adults)	5 (29.4)	[^Citation36,Citation41,Citation43,Citation46,Citation49]
C3: Personal preferences and nature of the fall-prevention intervention (eg, one-on-one, or group-based intervention)	2 (11.8)	[^Citation5,Citation48]
C4: Adopting a different approach to mobilize (adapting to new norm after a spinal injury or paralysis, eg, resiliency in an adverse situation)	3 (17.6)	[^Citation41,Citation46,Citation50]
Opportunity-Related Themes	Frequency (%)*	Article Citation
O1: Organizational/institutional support in assisting with fall-prevention programs	8 (47.1)	[^Citation36,Citation37,Citation40–Citation43,Citation49,Citation50]
O1.1: Providing funding and organizational structure for fall-prevention programs	2 (11.8)	[^Citation37,Citation42]
O1.2: Providing financial or other incentives for health staff (doctors, nurses, occupational therapists, exercise facilitators) who educate older adults on participating in fall prevention	1 (5.9)	[^Citation40]
O1.3: Making mobility supports available (eg, ramps for wheelchairs, clutches, non-slip bathroom mats, gliders, visual aids for slippery surfaces)	2 (11.8)	[^Citation41,Citation46]
O1.4: Providing communication aids (eg, translators, signposts, visual aids, pamphlets) to facilitate understanding/comprehension when consulting with patients about falls and how to prevent them	4 (23.5)	[^Citation36,Citation43,Citation49,Citation50]
O2: Prolonged community engagement by health care practitioners and health institutions, and relationship building with older adults to learn to mitigate barriers to participation	4 (23.5)	[^Citation5,Citation36,Citation41,Citation48]
O2.1: Engaging older adults in designing fall-prevention programs collaboratively and inclusively (ie, listening to them to determine needs and learning how to meet their needs regarding preventing falls)	2 (11.8)	[^Citation5,Citation41]
O2.2: Engaging older adults respectfully and with sensitivity (eg, considering their time/schedules, physical limitations)	2 (11.8)	[^Citation36,Citation48]
O3: Improving access to fall-prevention programs	3 (17.6)	[^Citation40,Citation48,Citation50]
O3.1: Bringing fall-prevention programs closer to participants’ homes (eg, through home visits, consistent follow-up programs post-discharge, using centralized, accessible venues closer to older participants)	2 (11.8)	[^Citation48,Citation50]
O3.2: Creating free/reasonable cost for fall programs	1 (5.9)	[^Citation48]
O3.3: Experts (eg, health care professionals/fall experts) knowledgeable about fall programs	1 (5.9)	[^Citation40]
O4: Feasibility and practicability of fall-prevention strategy	1 (5.9)	[^Citation49]
O5: Adapting the physical environment to facilitate mobility	1 (5.9)	[^Citation41]
O6: Encouragement and social support	8 (47.0)	[^Citation5,Citation36,Citation37,Citation41,Citation44,Citation46,Citation48,Citation49]
O6.1: Family support	5 (29.4)	[^Citation5,Citation36,Citation37,Citation46,Citation49]
O6.2: Community support	2 (11.8)	[^Citation36,Citation37]
O6.3: Peer-to-peer support	2 (11.8)	[^Citation37,Citation44]
O6.4: Healthcare provider support and empathy	3 (17.6)	[^Citation37,Citation41,Citation48]
O6.5: Fall-prevention program facilitator support	3 (17.6)	[^Citation36,Citation37,Citation48]
O7: Eye exams and vision screening tests	1 (5.9)	[^Citation48]
O8: Incentivizing fall-prevention programs with opportunities for social participation and fun	2 (11.8)	[^Citation37,Citation48]
O9: Creating a safe and inclusive agenda in fall-prevention strategies	3 (17.6)	[^Citation37,Citation46,Citation48]
O10: Tailoring fall-prevention strategies to participants’ needs	2 (11.8)	[^Citation48,Citation49]
O11: Creating fall-prevention strategies that are participatory, educational and empowering	1 (5.9)	[^Citation43]
O12: Creating fall-prevention strategies that consider personal time conflicts	2 (11.8)	[^Citation41,Citation50]
Motivation-Related Themes	Frequency (%)*	Article Citation
M1: Following up with older adults (eg, by phone, e-mail or mail) to clarify their understanding of the fall-prevention program via pamphlets or communicated during hospitalization	2 (11.8)	[^Citation49,Citation50]
M2: Changing inaccurate perceptions of falls and fall-prevention programs	5 (29.4)	[^Citation36–Citation38,Citation46,Citation50]
M2.1: Perception of need for fall-prevention program	1 (5.9)	[^Citation38]
M2.2: Perception of benefits of a fall-prevention program	4 (23.5)	[^Citation36,Citation37,Citation46,Citation50]
M3: Seeing personal gain, benefits, and improvements in gait and balance	1 (5.9)	[^Citation36]

Notes: *The frequency is the number of cited articles per category. The percentage is the percent out of the 17 articles included in the review. Bold font denotes a main theme.

Box 1 Keyword Search Syntax and Search Strategy for the PubMed/MEDLINE, ERIC, CINAHL, Cochrane Library, Scopus, PsycINFO, and Web of Science Databases

1. Fall prevention/ 2. (fall adj1 prevention).ti.ab 3. (fall adj1 (control or reduction or prevention)) adj2 strateg$.ti.ab 4. (fall adj1 (control or reduction or prevention)) adj2 program$.ti.ab 5. #2 AND #3 AND #4 6. Older adult$/ 7. Older adj1 adult$ or seniors$ or the adj2 elderly or the adj2 aged or geriatr$.ti.ab 8. Post discharge/ 9. Post adj3 discharge or post adj3 hospital adj3 discharge or after adj3 discharge or after adj3 hospital discharge or transition$ adj3 care.ti.ab 10. #5 AND #7 11. #9 AND #10

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