Archives of Gerontology and Geriatrics 99 (2022) 104610

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Archives of Gerontology and Geriatrics

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A qualitative study of older adults’ facilitators, barriers, and cues to action

to engage in falls prevention using health belief model constructs
Jennifer L. Vincenzo a, *, Susan Kane Patton b, Leanne L. Lefler c, Pearl A. McElfish d,
Jeanne Wei e, Geoffrey M. Curran f
a
University of Arkansas for Medical Sciences, Department of Physical Therapy, College of Health Professions, United States
b
University of Arkansas, Department of Nursing, College of Education and Health Professions, United States
c
University of Arkansas for Medical Sciences, College of Nursing, United States
d
University of Arkansas for Medical Sciences, Office of Community Health and Research, United States
e
University of Arkansas for Medical Sciences, Department of Geriatrics, College of Medicine, Reynolds Institute on Aging, United States
f
University of Arkansas for Medical Sciences, Departments of Pharmacy Practice and Psychiatry, Central Arkansas Veterans Healthcare System, United States

A R T I C L E I N F O A B S T R A C T

Keywords: Background and Objectives: Falls are the leading cause of fatal and nonfatal injuries among older adults.
Accidental injury Decreasing falls is highly dependent on engagement in fall prevention activities. The Health Belief Model (HBM)
Implementation science theoretical framework was used to explore older adults’ perceptions about falls prevention.
Research Design and Methods: An informed grounded theory approach was applied. Four focus groups were
conducted using semi-structured interview guides based on the HBM with 27 community-dwelling older adults
(average age = 78 years). Deductive content analysis was used to apply constructs of the HBM to the data and
explain the findings.
Results: Potential reasons for not engaging in falls prevention included lack of self-perceived severity, suscepti­
bility, and self-efficacy with a subtheme of lack of information about falls prevention from medical providers.
Potential facilitators included older adults’ knowledge and current engagement in falls prevention and social­
izing while engaging in falls prevention. Participants recommended cues to action to improve engagement in falls
prevention from family, friends, physicians, pharmacists, and insurance companies; and using various modes to
deliver cues to action, including print, audiovisual, online, and reminders.
Discussion and Implications: In this study, the HBM was used to understand older adults’ potential barriers, fa­
cilitators, and cues to action to support engagement in falls prevention. Engagement in fall prevention behaviors
could be improved by addressing barriers such as lack of knowledge, and lack of self-perceived severity and
susceptibility to falls. Reinforcing the benefits of fall prevention, and promoting cues to action to engage in falls
prevention may also support engagement.

1. Background and objectives foot impairments, environment, and some medications (Ganz &
Latham, 2020; Gillespie et al., 2012). Systematic reviews demonstrate
Falls are the leading cause of fatal and nonfatal injuries among adults that several interventions addressing modifiable factors can reduce falls
65 years and older (Centers for Disease Control and Prevention, 2021). (Gillespie et al., 2012; Hopewell et al., 2018), yet mortality rates
Twenty-eight percent of older adults fall annually, resulting in $50 continue to rise (Hartholt, Lee, Burns, & Van Beeck, 2019).
billion in medical costs (Florence et al., 2018). Direct costs do not ac­ Evidence-based interventions include, but are not limited to, exercise,
count for long term effects of falls such as disability, loss of indepen­ management of visual and foot issues, medication management, phys­
dence, and decreased quality of life. ical therapy, and home modifications (Grossman et al., 2018). At least
Modifiable factors increase an older adults’ risk of falling, such as 22 interventions, investigated in randomized control trials, demon­
fear of falling, decreased strength or balance, unsteady gait, visual and strated that implementing even a single intervention could decrease falls

* Corresponding author at: Physical Therapy, University of Arkansas for Medical Sciences, 1125 N. College Ave, Fayetteville, AR 72703, United States.
E-mail addresses: JLVincenzo@uams.edu (J.L. Vincenzo), SKPatton@uark.edu (S.K. Patton), LeflerLeanne@uams.edu (L.L. Lefler), PAMcelfish@uams.edu
(P.A. McElfish), WeiJeanne@uams.edu (J. Wei), CurranGeoffreym@uams.edu (G.M. Curran).

https://doi.org/10.1016/j.archger.2021.104610
Received 9 August 2021; Received in revised form 15 November 2021; Accepted 12 December 2021
Available online 13 December 2021
0167-4943/© 2021 Elsevier B.V. All rights reserved.
J.L. Vincenzo et al. Archives of Gerontology and Geriatrics 99 (2022) 104610

and save $94-$442 million in medical costs (Stevens & Lee, 2018). convenience, proximity, socializing, and group exercise (Howard et al.,
Although interventions are efficacious, barriers to older adults’ 2018; Kiami, Sky, & Goodgold, 2019), but not in the context of
engagement in falls prevention still exists (Farrance, Tsofliou, & Clark, engagement in falls prevention not included in a formal program nor the
2016; Stevens, Sleet, & Rubenstein, 2018). Strategies for increasing context of a behavior change model. Although the HBM has been used to
older adults’ engagement in falls prevention are imperative to address develop and implement falls prevention programs, it has not been used
these public health issues. Employing constructs from a behavioral to identify themes and index meaning units from primary qualitative
change model, such as the health belief model (HBM), to identify older data in an effort to understand older adults’ attitudes and beliefs on
adults’ barriers, facilitators, and recommended cues to action for engaging in falls prevention. Given that the aim of preventing falls is
engagement in falls prevention may be helpful to target behavior highly dependent on adherence to fall prevention behaviors, it is
change. important to understand older adults’ perceptions of their susceptibility
to falling, perceived severity of falling as having serious medical and
1.1. Health belief model social consequences, perceived benefits of taking action to reduce the
risk of falling, perceived barriers in taking the action, and recommended
The HBM is a theoretical framework developed to explain in­ cues to action to engage in falls prevention. Therefore, the purpose of
dividuals’ engagement in preventive health behavior based on the this study was to explore older adults’ perceptions about engagement in
following constructs; (1) perceived susceptibility of the health condi­ falls prevention behaviors using constructs from the HBM.
tion, (2) perceived severity of the health condition, (3) perceived ben­
efits to taking the recommended action, (4) perceived barriers to taking 2. Research design and methods
the recommended action, (5) cues to action to engage in the preventive-
health behavior, and (6) self-efficacy to engage in the prevention-health 2.1. Ethical considerations
behavior (Janz & Becker, 1984). There are several modifying factors in
the HBM as well; such as knowledge about the health condition The institutional review board approved the study.
(Davidhizar, 1983). The HBM is one of the most widely used theoretical
frameworks used to explain the health intervention uptake and behavior
and has been useful in planning and designing fall prevention strategies. 2.2. Design
For example, an expanded HBM, adding habits and intention as con­
structs, was used to identify determinants of physical activity among An informed grounded theory approach was used to explore older
older adults who have and have not experienced a fall. The authors adults’ perceptions of falls, falls prevention, and strategies to improve
found that perceived barriers to physical activity significantly predicted engagement in falls prevention using constructs from the HBM (Thorn­
intention to participate among people with a history of falls (Kaushal, berg, 2012). Informed grounded theory supports using existing litera­
Preissner, Charles, & Knäuper, 2021). Another study found that older ture and theories to inform the approach to qualitative research. The
females participating in an osteoporosis and falls prevention program, HBM and additional modifying factors related to fall prevention
which included 4 sessions of education and counseling based on the engagement (Fig. 1) informed the approach to the semi-structured
HBM constructs, demonstrated greater knowledge and adoption of interview guide (Table 1; (Janz & Becker, 1984; Vincenzo & Patton,
preventive behaviors compared to a group education only program that 2021). Three one-on-one interviews were conducted to assess and
was not based on the HBM (Ahn & Oh, 2021). Huang, Tzeng, and Chen
(2021) used the HBM to develop a prediction model for the likelihood of
community dwelling older adults to engage in fall prevention activities.
Results showed that self-efficacy had the largest influence on engage­
ment followed by cues to action. Perceived barriers did not directly
affect the likelihood of taking fall prevention action.

1.2. Barriers and facilitators to engaging in falls prevention

Addressing the public health issue of falls in older adults is highly

dependent on sustained adherence to fall prevention strategies (Sjosten
et al., 2007). A meta-analysis of older adults’ adherence to home exer­
cise programs to prevent falls found only 21% of older adults were
adherent (Simek, McPhate, & Haines, 2012), while a systematic review
found that ~50% adhered to falls prevention interventions at 12 months
(Nyman & Victor, 2011). Barriers to engagement and adherence iden­
tified in the literature include lack of knowledge, low self-efficacy,
perceptions that falls are not preventable, being unaware of the risk
for falling, feeling limited by health, not feeling supported by medical
providers and family, and lack of access to programs (Bunn, Dickinson,
Barnett-Page, Mcinnes, & Horton, 2008; McMahon, Talley, & Wyman,
2011; Pin, Spini, Bodard, & Arwidson, 2015; Stevens et al., 2018). Fa­
cilitators, which affect perceived benefits and barriers, to adopting falls
prevention recommendations include personal relevance and appropri­
ateness of programs, self-efficacy, participation in decision making,
convenience, and encouragement by medical providers or social sup­
ports (Bunn et al., 2008; Pin et al., 2015; Stevens et al., 2018). Strategies
to address barriers are sparse and are recommended as a priority by the
Centers for Disease Control (CDC) and imperative to effective falls pre­
vention (Bergen & Eckstrom, 2018). Literature identified strategies to
improve engagement in falls prevention programs, including Fig. 1. Health Belief Model Adapted to Falls Prevention.

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Table 1 Meaning units were extracted from the focus groups and assigned a code
Semi-Structured Interview Guide about Perceptions and Strategies for Falls which was placed under a pre-determined HBM category. The steps
Prevention. involved in the data analysis process are listed below:
Tell me what you know about older people having a fall or multiple falls.
• Prompt: What do you think most older adults know about their risk of falling? Step 1: Identification of relevant behavior change theory and a priori
Tell me about how falls have or have not personally affected you? themes: core constructs of the HBM were listed and used as codes.
• Prompts: Have you fallen? If yes, were you injured? Describe how the fall affected
Step 2: Deductive analysis: data was analyzed to identify and sort
you. Do you know someone who has suffered a fall? How did it affect them? Tell me
your understanding of the consequences of falling. meaning units. The a priori themes were applied and used to index
Tell me about information, if any, you have gotten about falls and preventing them? the meaning units from the data.
• Prompts: Where did you get this information and/or who gave you the information? Step 3: During the final step, researchers reached a consensus on
How was it provided to you? How was it helpful? What were the difficulties with
interrelationships between the research questions, codes, and core
using the information? Did you do or change anything due to the information; why
or why not? themes (Bingham & Witkowsky, 2021). Researchers agreed that data
Tell me about how habits may help or hurt you or others to prevent falls.Tell me about saturation, when no new information or themes emerge, was ob­
how you feel about your control or lack of control over preventing a fall? tained with the four focus groups (Bailey & Bailey, 2017).
1 What would help an older adult to engage in falls prevention behaviors?

Trustworthiness in our study was ensured by engaging in member

modify the interview guides, which are not included in this study. Par­ checking and investigator triangulation (Wilson, 2014). The two re­
ticipants completed a questionnaire on demographics and medical his­ searchers held regular meetings throughout the process of analysis.
tory before participation in a focus group. Investigator triangulation was applied by having two researchers with
expertise in fall prevention and qualitative research (Removed for
blinded review) read and code the data separately, followed by discus­
2.3. Participant sampling
sion and agreement on codes, themes, and exemplary quotes. Investi­
gator triangulation also lessoned potential bias when applying data to
Individuals who participated in a prior, unrelated study at the Uni­
the HBM codes.
versity and were interested in participating in future studies were
recruited. The inclusion criteria were adults >65 years of age,
3. Results
community-dwelling, and able to understand and answer the study
questions. Guided by evidence that gender differences in attitudes and
3.1. Sample description
beliefs regarding falls prevention exists (Sandlund et al., 2017), two
focus groups consisted solely of women, and two focus groups consisted
Participants (n = 27) averaged 78 years old with an approximately
solely of men.
even distribution of males and females (Table 2). Ten participants (37%)
experienced at least one fall in the last year and 26% suffered an injury.
2.4. Data collection Participants in the focus groups were engaged and collectively accepting
of others’ experiences and ideas.
Before conducting the focus groups, informed consent, de­
mographics, and health history were collected. Krueger and Casey’s 3.1.1. Potential barriers to engaging in falls prevention
(2014) guide to designing and conducting focus group interviews was Participants identified barriers to engaging in falls prevention which
followed. Four focus groups of six to eight participants were conducted fit within the pre-determined HBM constructs and included lack of self-
between December 2019 and February 2020. The primary researcher, a perceived severity, susceptibility, and self-efficacy and lack of infor­
physical therapist with 20 years of experience and a trained qualitative mation from medical providers regarding how to prevent falls.
researcher, served as the moderator for three focus groups, and a
research assistant trained by the primary investigator who took field 3.1.1.1. Lack of self-perceived severity of falls. Although most partici­
notes in the first three focus groups, moderated the fourth focus group. pants felt that falls resulted in severe consequences, they related the
Ground rules were established at the start of each session (speak one at a severity and consequences of falls to anecdotal experiences of friends
time, be respectful, engage and share opinions and experiences). Two and family rather than how a fall would affect themselves, "you’ve seen
focus groups were conducted in a conference room at a university, one the consequences of what can happen with other people." Participants
was in a conference room at a senior center, and one was hosted at the shared examples, "My dad broke a hip and that was the beginning of the
house of a participant per their request. Focus groups were recorded on a end," and "I had a great aunt who fell… she spiral fractured both her
digital voice recorder (Olympus WS-853, Pennsylvania). Before arms," and "I have a neighbor who recently slipped off a stool and her hip
concluding the focus groups, the interviewer summarized themes broke and she fell." Some participants who experienced a fall minimized
regarding group and participants’ perspectives for confirmability. Focus the health consequence; stating for example, "I don’t fall that much,"
groups lasted between 1.25 – 1.5 h. Participants received a $30 gift card. and, "I haven’t gotten hurt. I usually have some bruises." Only one
participant addressed the severe consequences of falls; however, from
2.5. Data analysis their friend’s perspective, "My friend said…you realize we’re just one
fall away from the nursing home."
Data from the demographic questionnaires were entered into excel.
Descriptive statistics were calculated. Interviews were uploaded to 3.1.1.2. Lack of self -Perceived susceptibility of experiencing a fall. Older
computerized software (Descript, San Francisco, CA) for initial tran­ adults’ perceived susceptibility of experiencing a fall did not reflect their
scription and edited for accuracy. Data from focus groups were analyzed expressed general knowledge about falls and prevention described in the
using deductive content analysis to identify, analyze, and interpret facilitators theme below. Some who had not experienced a fall did not
meaning and themes in the data. In the deductive (directed) approach, believe that they were at risk for falling. "The threat is not there indi­
analysis starts with a theory as guidance for initial codes (Hsieh & vidually," and, "I think I’m just fine, I don’t have any problems," and, "I
Shannon, 2005). The HBM served as the framework for the analysis. A hadn’t worried about falling … I don’t have a balance problem." Other
deductive approach was applied whereby key categories were participants suggested that older adults do not feel susceptible until they
pre-determined according to the HBM (perceived susceptibility, experience a fall, "You don’t think about it until you have a problem,"
perceived severity, perceived barriers, cues to action, and self-efficacy).

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Table 2 3.1.1.3. Lack of self-efficacy to prevent a fall. Some participants recog­

Participant Demographics. nized their susceptibility to falling and described falls as "inevitable",
Characteristic N (27) indicating a lack of self-efficacy to prevent a fall. "You’re going to fall
probably," and "You’re waiting; something is going to happen." Another
Sex
Male 13 participant shared, "The times that I fell; I tried really hard to just fall.
Female 14 There’s no stopping the fall." Other participants talked about preparing
Age themselves for a fall, "practice getting up" from the floor in case they fall.
Male 79.4 One participant shared, "I get down on the floor because … my mom
Female 76.1
Race/Ethnicity
used to fall, and my husband used to fall."
Non-Hispanic - white 21
No response 6 3.1.1.4. Subtheme - Lack of falls prevention information from a healthcare
Educational level provider. Although many older adults in the focus groups were aware of
Less than a high school diploma 2
High school degree or equivalent (GED) 0
and engaged in some falls prevention behaviors described in the facili­
Some college, no degree 11 tators’ theme below, the majority of participants shared that they had
Associate degree 2 not received information about falls prevention from their doctor. One
Bachelor’s degree 5 participant stated, "My doctor always asks… have you had any falls in
Master’s degree 3
the last six months or a year or so? That kind of makes me more aware of
Professional degree (MD, DDS, DVM) 0
Doctorate (PhD, EdD) 2 it, but it’s not really information." Another participant had a similar
No response 2 experience, "It’s always their first question when you have an appoint­
Yearly income ment, have you fallen? But then there’s no follow-ups." One participant
Less than $20,000 3 asked another participant in the group, "You said you’ve had a fall. Have
$20,000 to $34,999 6
$35,000 to $49,999 2
you had a doctor asked you, and you said yes? What happens then?" The
$50,000 to $74,999 5 other participant answered, "Nothing, well they always say, did you hurt
$75,000 to $99,999 7 yourself? No." Some participants were specific regarding the informa­
Over $100,000 3 tion they felt they lacked from their doctor.
No answer 1
Marital Status When I talked to the doctor after I fell, he did not ask me if I had any
Married, or in a domestic partnership 19 throw rugs or anything like that," and "When we go in for a wellness
Widowed 8
Comorbid conditions
visit annually, or just go to see the doc, I never hear a word from
Cardiovascular disease 5 them or even the nurses… how to prevent falls.
Cancer 1
Chronic obstructive pulmonary disease 1
Hyperlipidemia 4 3.1.2. Potential facilitators to engaging in falls prevention
Hypertension 7 We found that participants’ general knowledge and engagement in
Thyroid impairment (hyper/hypothyroidism) 2
falls prevention is a modifying factor from the HBM that serves as a
Enlarged prostate 2
Osteoporosis 1 facilitator. Other facilitators included perceived benefits of socializing
Arthritis 5 with group activities and cues to action. Participants suggested strate­
Vestibular impairment 3 gies to increase awareness of falls prevention, including advice from
Vision impairment (glaucoma, cataracts) 2 family and friends, doctors, and pharmacists; and cues to action via
Musculoskeletal impairments (low back pain, knee pain) 6
print, audiovisual, online modes, and reminders.
Neuromuscular impairments (sciatica, fibromyalgia) 2
Depression 2
Number of Medications 3.1.2.5. Modifying factor - General Knowledge about falls and current
1–2 15 engagement in falls prevention. Focus group participants were generally
3–4 6
aware of falls, consequences, and various interventions for falls pre­
≥5 3
No answer 3 vention,. One participant stated, "There’s a lot of awareness that old
Experienced a fall in the last year people are falling." Another participant suggested, "It’s common … I
Yes 10 would think it’s pretty high for folks over the age of 65 at least or 70 to
No 17
have fallen at least one time in the last 10 years." When asked about how
Number of falls in the last year
1 2 they could prevent falls, participants most frequently related prevention
2 2 to being more "careful." The terms careful or cautious were used 39 times
≥3 3 across all focus groups. Participants described, "As you get older you’re
No answer 3 more careful," and "I am very careful … I never thought about falling
Falls resulting in injury
before." Some older adults described actions they employed to be careful
Yes 7
No 6 to prevent falls. For example, "I take blood pressure medicine, so I have
No answer 14 to be real careful standing up. I have to wait until the dizziness passes so
Injury type from falls I won’t fall," and, "I have been unbalanced occasionally, and I notice it
Fracture 2
sometimes in the shower when I close my eyes I get unbalanced, and I
Musculoskeletal pain or soreness 3
Bruising or scrapes 3
have several hand grips in the shower." Participants also mentioned the
ways that they restricted their activities to be more "careful." For
example, "I don’t walk out here in the garden … that is really dangerous
and "Until you go down, it just doesn’t click," and "when I tripped, I to me," and "I always opt-out of the stairs." Participants also mentioned
wasn’t aware… I didn’t even imagine falling." Only one participant they either are aware of or engage in various forms of exercise that may
seemed to accept and recognize their susceptibility of experiencing a help prevent a fall (21 quotes), that they wear proper footwear
fall, "part of it is, we have to come to grips at some point. We have to (mentioned 9 times), and use rails on the stairs (mentioned 10 times).
accept the reality condition. We have to accept the fact that I am who I
am and where I’m at and make adjustments." 3.1.2.6. Perceived benefit -Socializing with group activities. Socializing

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with group activities was the only theme that emerged as a perceived A few participants suggested that pharmacists could provide cues to
benefit to falls prevention. Participants made several statements that action. One participant would like to receive "handouts with pre­
exemplified this theme. For example, "getting out and about is a big scriptions because your visits with the doctor are less frequent, but your
thing…encouraging involvement," "doing things with people makes a prescription filling is pretty much ongoing." Another participant sug­
big difference," and that with "classes and things…socialization can gested the information be provided via "a flyer or something that a
improve." One participant felt that group support and socializing helps pharmacist would make available."
with accountability,
3.1.2.9. Cues to action or financial incentives from insurance companies.
"Well, if you go and you can talk about, I had trouble with this, or I
Across all focus groups, insurance companies’ role in supporting falls
did this four times this week, and I feel so much better. Especially too
prevention was a suggested strategy to improve engagement. One
of being older, I mean, the socialization for some people … maybe
participant reported that a nurse practitioner from her insurance com­
some people are like "I don’t want to do it," but I think it’s important
pany comes for a yearly home safety visit. This information resulted in
and it reinforces, you doing it. And plus, there’s some accountability
discussion and interest from others in the same focus group. For
if you do it in a group."
example, "If it was provided to me through the insurance company or
through Medicare… we want to communicate these principles to you. I
3.1.2.7. Cues to action from family and friends. Participants shared how would pay attention, but it’s not something I would go out and seek on
cues to action arose from social influences such as their family or my own." Another participant suggested that home evaluations should
friend’s involvement in falls prevention. One participant stated, "I have a be provided by insurance, "Even with each client [insurance]… some­
close cousin that fell several times. Her family went in and removed all body goes into someone’s home and makes the evaluation." Other par­
of her little throw rugs and everything." Others talked about adult ticipants suggested insurance companies should provide financial
children that check on them regularly, "My daughter checks on me every incentives for older adults to participate in falls prevention. For
day," and "my son fixed the house and I have a lifeline," and "We’ve got a example, "Money… if Medicare or somebody like that decided… pre­
daughter, and she is always questioning both of us about how are you? vention of falls," and "I wonder if insurance companies could be involved
What are you doing? What have you been doing? Be careful." One … [you would get] lower rates if you get a home evaluation."
participant noticed their balance impairment when playing with their
grandkids on a gaming system, 3.1.2.10. Print cues to action. Along with suggestions of print materials
that doctors or pharmacists could provide, participants mentioned other
I came to be aware that my balance was not what it used to be. My print/print materials that would increase older adults’ engagement in
grandkids got a Wii … and it had a deal where you balance on it … it falls prevention. For example, "A newspaper, a visible ad.," and "A
said I was 72 years old according to my balance. magazine or a medical magazine." More specifically, two people
Two participants noted that friends and loved ones can provide mentioned the American Association of Retired Persons (AARP) maga­
valuable action to facilitate engagement in falls prevention. For zine, "AARP magazine, but I haven’t seen anything like that in there,"
example, "A loved one telling you or reminding you that something’s and "I have noted articles in the AARP magazine. They’re pretty good."
wrong and you don’t realize it," and "Friends, those really affect me One man suggested, "From time to time, you read about someone that’s
when someone I know has something that they feel like they need to fallen out of the tree stand. The sports shooting magazines would have
bring to me or make me aware." Finally, one participant indicated that articles." Finally, one participant suggested that a poster or something
going to the wellness center with her spouse helps her with adherence, would be helpful at "Doctor’s appointments…in a waiting room… a
"My husband and I come every day, and if he didn’t go, then I don’t poster or something”.
know if I would come every day."
3.1.2.11. Audiovisual cues to action. Participants suggested different
3.1.2.8. Cues to action from a doctor or pharmacist. The majority of audiovisual modes to increase older adults’ engagement in falls pre­
participants voiced how doctors could provide older adults with infor­ vention. One participant suggested, “The doctor’s office…a little screen
mation to prevent falls and preferred their doctor to discuss falls pre­ in the waiting room… 30-second segments on falls and being careful.”
vention with them. One participant stated, "The doctor would say, this is Another participant suggested that a visual machine like the blood
what you need to do." Another explicitly preferred, pressure screening near the pharmacy would be helpful,

If somebody’s on a visit, the doctor says, after age … the statistics In a pharmacy where you’re having to stand and wait for your pre­
show that you are more apt to have a fall and here are some of the scription. If there was a line on the floor, walk this line, how difficult
things that can happen at that age or as you get older. or easy is it? Or some visual things like the little machine where you
can take your blood pressure.
Some preferred receiving falls prevention information from a
brochure provided by their doctor. One participant stated, "If he (your Some participants suggested audiovisual options for broader
doctor) could discuss some of it with you, just a verbal discussion would dissemination. For example, a “Public service announcement… if you’re
be more lasting than handing you a brochure, but then we would look at a senior citizen, listen to this about falls and give tips periodically,” and
the brochure." Another stated, "If the doctor doesn’t have time to talk “State public television… half-hour snippets,” and “CNN and fox news…
about it … a brochure or something, at least that’s a start." Finally, one stations that a lot of seniors listen to.”
participant suggested there should be a policy for doctors to include falls
prevention education as part of the Medicare well examination: 3.1.2.12. Online cues to action. Participants mentioned using the
internet to look up or provide information on falls prevention. State­
We’re probably all seeing doctors on some regular basis, and I think ments exemplified this, “My wife would go on the internet and learn all
those practitioners or those physicians need to have some policy. about it,” and that to find out about falls prevention, another participant
Maybe at some point, when a person reaches a certain age, the risk would “look at some information on the internet.” Another participant
becomes greater. That it needs to be a part of their well examination suggested that there should be a falls prevention knowledge test on the
to educate us in those areas rather than waiting until we fall and internet because, “Popular things on the internet or quizzes…people like
break a hip and then say, Hey, you know, you shouldn’t be doing to answer questions about things, particularly if it has to do with their
that. intelligence.” Finally, another participant indicated they would like to

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receive falls prevention information from their health system or insur­ adults should be provided information about falls prevention to facili­
ance, “an email that you knew was coming from a place you recognize.” tate older adults’ engagement. Engaging both older adults and their
families improves falls prevention behaviors among hospitalized older
3.1.2.13. Reminders cue to action. Numerous participants felt that they adults (Opsahl et al., 2017), and community-dwelling adults with cancer
needed reminders to engage in falls prevention, “Because we forget (Potter, Pion, Klinkenberg, Kuhrik, & Kuhrik, 2014).
things, we need to be reminded.” They suggested forms of reminders An unexpected finding in our study was that some older adults
such as, “A ring, like a bell,” or “A ding on your phone every day.” shared that pharmacies or pharmacists could improve engagement in
However, only one participant suggested using a virtual assistant, for falls prevention by providing information, scripts, or having information
example, Amazon’s Alexa, asking, “Have you walked today?” readily available. Pharmacists’s roles in falls prevention are primarily
focused on medication management (Blalock et al., 2020; Robinson
4. Discussion and implications et al., 2019). Future research would be beneficial to explore expanding
the pharmacist’s role beyond medication management for falls
This study is the first, to our knowledge, to use qualitative methods prevention.
to apply constructs from the HBM to identify older adults’ barriers, fa­ Another novel finding in each of our focus groups included that in­
cilitators, and recommended cues to action to increase awareness and surance companies and financial incentives could facilitate older adults
engagement in falls prevention. The older adults in our focus groups to engage in falls prevention. Participants suggested insurances provide
were generally knowledgeable about falls, the consequences of falling, information, support, annual home safety evaluations, or lower rates for
and falls prevention, but had barriers to engaging in falls prevention, people that engaged in falls prevention. Indeed, falls are costly to health
including lack of perceived self-susceptibility, severity, and self-efficacy insurance, with the most recent data indicating falls result in over $50
and felt they did not receive falls prevention information from health­ billion in direct medical costs annually (Florence et al., 2018).
care providers. The participants mentioned multiple facilitators that Numerous studies indicate that investing in falls prevention saves
would increase their engagement in falls prevention, including social­ money. For example, a study analyzing three different evidence-based
izing with group activities for falls prevention and cues to action. Ours is falls prevention programs (Otago Exercise Program, Tai Chi: Moving
the first study to identify older adults’ recommended cues to action to for Better Balance, and Stepping On) found that the return on investment
increase engagement in falls prevention; receiving personalized infor­ for averting direct medical costs from falls ranged from 36% to 491%
mation from their doctor or pharmacist, cues from family and friends, (Carande-Kulis, Stevens, Florence, Beattie, & Arias, 2015). Individual
cues or financial incentives from insurance companies, and modes of interventions such as home safety modifications (Pega, Kvizhinadze,
cues including print, audiovisual, online, and reminder. Blakely, Atkinson, & Wilson, 2016) and cataract surgery are also
Barriers to engagement in falls prevention that emerged align with cost-effective (Boyd, Kvizhinadze, Kho, Wilson, & Wilson, 2020).
barriers previously identified in the research, including lack of knowl­ To our knowledge, ours is the first study to identify older adults’
edge, perceptions that falls are not preventable, being unaware of the recommended modes for cues to action to support engagement in falls
risk for falling, and not feeling supported by health care providers (Bunn prevention. Participants recommended print, audiovisual, online, and
et al., 2008; McMahon et al., 2011; Pin et al., 2015; Stevens et al., 2018). reminder cues to action. Falls prevention articles were recommended in
In an observational study of older adults with a history of falls, Jansen a newspaper or a magazine that an older adult would be likely to read,
and colleagues found that only 16% who experienced a fall recognized for example, AARP magazine or a sports magazine for older men. Par­
their risk, and only 10% prioritized fall prevention. Older adults who ticipants recommended brochures, flyers, or prescriptions as an adjunct
prioritized falls prevention were more likely to have recurrent falls, to education provided by a physician or pharmacist. Non-tailored falls
severe fear of falling, and use an assistive device for walking (Jansen prevention advice appears to affect older adults’ rate of falls. Hopewell
et al., 2015). It is not surprising that our study sample did not prioritize et al. (2018) found that the rate of falls for multifactorial interventions
falls prevention considering only three focus group participants in our compared to usual care favored multifactorial interventions; however,
study had recurrent falls, and none came to the interview with an as­ when usual care included non-tailored advice like a brochure or
sistive device. Our data supports the existing literature that many older handout, there were no group differences. Another study compared the
adults do not receive fall prevention information from their healthcare effects of a 1-hour fall prevention class with a pamphlet to a pamphlet
providers (Shubert, Smith, Prizer, & Ory, 2013). Although a only on immediate fall prevention knowledge and 2-week uptake of fall
cross-sectional survey found that physician advice did not facilitate prevention among community-dwelling older adults and found no dif­
older adults to enroll in a fall prevention program (Kiami et al., 2019), ferences between groups (Hakim, Roginski, & Walker, 2007). Although
participants in our study felt that if they received individualized rec­ some research indicates that adults infrequently read handouts (Shaw,
ommendations from their physician, they would engage in falls pre­ Ibrahim, Reid, Ussher, & Rowlands, 2009), print materials can supple­
vention. Differences in the results of our study may be due to the survey ment healthcare providers’ education, resulting in increased knowledge
included two multiple answer questions regarding what would make and uptake of preventive health behaviors (Coulter & Ellins, 2007).
older adults more likely and less likely to participate in a falls prevention Audiovisual cues to action were recommend, including information
program, including an option of ‘doctor’s advice to attend’. In contrast, on a screen in the doctor’s office or pharmacy, a public service
our qualitative study had open-ended questions to identify barriers and announcement, or the news. Khong and colleagues (2017) found that
facilitators to engagement in falls prevention, not a program. older adults preferred falls prevention information be disseminated by a
Our research aligns with the literature regarding facilitators to health professional and provided to the broader community. A fall
engagement in falls prevention, including increased knowledge and prevention campaign in Australia increased older adults’ attitudes that
awareness, personal relevance, socializing, and encouragement by falls are preventable and high priority; however, did not change
medical providers or other social supports (Bunn et al., 2008; Pin et al., self-perceived risk (Hughes et al., 2008). De Jong and colleagues (2019)
2015; Stevens et al., 2018). To our knowledge, ours is the first study to conducted a study that included older adults collaboratively designing
identify older adults’ recommended cues to action to support engage­ audiovisual fall prevention messages. They found that some older
ment in falls prevention. We found that cues to action from family and adults’ awareness and knowledge increased; however, perceptions
friends served as facilitators to engage in falls prevention behaviors. about the messaging’s negative or positive perspectives was interpreted
Participants mentioned that family members performed home modifi­ by each individual differently.
cations to prevent falls, and participants value friends or family mem­ Participants recommended online sources to find information
ber’s concerns. These findings suggest that family and friends of older regarding falls prevention or receive an email from a reputable and
familiar source. One suggestion was to provide a quiz about falls as a cue

6
J.L. Vincenzo et al. Archives of Gerontology and Geriatrics 99 (2022) 104610

to action. Only one person mentioned the use of a smartphone/appli­ CRediT authorship contribution statement
cation as a cue to action. Surprisingly, these suggestions did not lead to
group discussion, possibly because older adults over 75 years of age are Jennifer L. Vincenzo: Conceptualization, Methodology, Formal
less likely to own digital devices and use the internet to obtain health analysis, Investigation, Resources, Data curation, Writing – original
information (Gordon & Hornbrook, 2016) and the average age of our draft, Writing – review & editing, Project administration, Funding
sample was 78 years. Future studies should investigate older adults’ acquisition. Susan Kane Patton: Conceptualization, Formal analysis,
health literacy and digital technology use for falls prevention, especially Data curation, Writing – original draft. Leanne L. Lefler: Conceptuali­
considering that several internet and smartphone applications target zation, Methodology, Funding acquisition. Pearl A. McElfish: Concep­
older adults for falls prevention. tualization, Methodology, Funding acquisition. Jeanne Wei:
There are other contextual cultural, societal, and healthcare factors Conceptualization, Methodology, Funding acquisition. Geoffrey M.
that may affect older adults’ engagement in falls prevention behaviors. A Curran: Conceptualization, Methodology, Resources, Writing – review
systematic review of cultural influences on participation in exercise and & editing, Funding acquisition.
fall prevention programs conducted in numerous countries and cultures
revealed that societal and cultural norms greatly impacted older adults’ Declaration of Competing Interest
perceptions and engagement in falls prevention (Jang et al., 2016).
Cultural and family perceptions of aging, family roles, and the inevita­ The authors declare that they have no known competing financial
bility of frailty with aging negatively impacted engagement in falls interests or personal relationships that could have appeared to influence
prevention. Language barriers compounded lack of engagement among the work reported in this paper.
migrants. Conversely, positive reinforcement from family and health­
care providers positively influenced engagement in falls prevention,
similar to our study. A qualitative study was conducted with 30 Chinese Funding
older adults living in England. In contrast to our study, the authors found
that Chinese older adults were reluctant to talk about falls, had fatalistic This work and Dr. Vincenzo were supported by the Translational
views about falls, and lacked knowledge regarding falls prevention in­ Research Institute (TRI), grant [KL2 TR003108] and [UL1 TR003107]
terventions and availability (Horton & Dickinson, 2011). In addition, through the National Center for Advancing Translational Sciences
fall prevention programs in Asian countries have not shown the same (NCATS) of the National Institutes of Health (NIH). Dr. Curran is sup­
level of effectiveness as fall prevention programs in Western countries. A ported by TRI [UL1 TR003107], through NCATS of the NIH. Dr. McEl­
recent systematic review and meta-analysis, although limited in the fish is supported by TRI [UL1TR000039] through NCATS of the NIH.
number of studies, found that only exercise was consistently preventive The funders played no role in the design, conduct, or reporting of this
of falls and that other interventions such as footwear modifications and study. The content is solely the authors’ responsibility and does not
home modifications did not prevent future falls among older Asian necessarily represent the official views of the NIH.
adults (Hill et al., 2018). The authors postulate that the differences in
fall prevention intervention effectiveness between Western and Asian Acknowledgments
countries are due to different cultures and other factors such as different
indoor and outdoor environments, footwear, lifestyles, and health ser­ The authors would like to thank the participants for their valuable
vices. Because our study did not address culture, healthcare systems input in this study. We would also like to thank Holly Bennett, PT, DPT
factors, and/or social context, the ability to generalize findings to for assisting with data collection and formating the manuscript.
different countries and cultures is a limitation.
Our study has strengths. Using constructs from a theory-based health References
behavior change model to identify older adults’ barriers, facilitators,
and cues to action to engage in falls prevention can assist future efforts Ahn, S., & Oh, J. (2021). Effects of a health-belief-model-based osteoporosis-and fall-
prevention program on women at early old age. Applied Nursing Research, 59, Article
towards targeted behavior change. Identified cues to action provide
151430.
various modes to deliver falls prevention messages. Although our study Bailey, C. R., & Bailey, C. A. (2017). A guide to qualitative field research. Sage Publications.
offers insight, it has limitations that warrant consideration. First, cues to Bergen, G., & Eckstrom, E. (2018). Building the evidence base for falls prevention: The
action were not specific to different falls prevention interventions. cdc’s steadi initiative. Innovation in Aging, 2(suppl_1), 237.
Bingham, A., & Witkowsky, P. (2021). Deductive and inductive approaches to qualitative
Future research should identify which cues to action work for different data analysis. In C. Vanover, P. Mihas, & J. Saldana (Eds.), Analyzing and interpreting
interventions, such as exercise or home modifications. Second, the qualitative research: After the interview (pp. 133–148). Thousand Oaks, California:
sample was not representative of all community-dwelling older adults. Sage.
Blalock, S. J., Ferreri, S. P., Renfro, C. P., Robinson, J. M., Farley, J. F., Ray, N., et al.
Our sample was independent without any assistive devices and lacked (2020). Impact of STEADI-rx: A community pharmacy-based fall prevention
diversity. In addition, most of our sample had at least some college intervention. Journal of the American Geriatrics Society, 68(8), 1778–1786. https://
experience, which may affect their perceptions, preferences, and health doi.org/10.1111/jgs.16459
Boyd, M., Kvizhinadze, G., Kho, A., Wilson, G., & Wilson, N. (2020). Cataract surgery for
literacy. Therefore, it would be beneficial to conduct this study with falls prevention and improving vision: Modelling the health gain, health system costs
older adults from diverse backgrounds and education to determine if and cost-effectiveness in a high-income country. Injury Prevention, 26(4), 302–309.
they have different barriers, facilitators, and cues to action to engage in Bunn, F., Dickinson, A., Barnett-Page, E., Mcinnes, E., & Horton, K. (2008). A systematic
review of older people’s perceptions of facilitators and barriers to participation in
falls prevention.
falls-prevention interventions. Ageing & Society, 28(4), 449–472.
Our study provides insights into older adults’ potential barriers, fa­ Carande-Kulis, V., Stevens, J. A., Florence, C. S., Beattie, B. L., & Arias, I. (2015).
cilitators, and cues to action to engage in falls prevention using the HBM. A cost–benefit analysis of three older adult fall prevention interventions. Journal of
Safety Research, 52, 65–70.
Healthcare providers, public health practitioners, and researchers can
Centers for Disease Control and Prevention. (2021). WISQARS (web-based injury
apply these findings to improve older adults’ engagement in falls pre­ statistics query and reporting system) Injury Center CDC. Retrieved from https:
vention. Future studies would be beneficial to investigate the impact of //www.cdc.gov/injury/wisqars/index.html.
family engagement, insurance or financial incentives, and cues to action Coulter, A., & Ellins, J. (2007). Effectiveness of strategies for informing, educating, and
involving patients. Bmj, 335(7609), 24–27.
for specific falls prevention interventions in order to improve older Davidhizar, R. (1983). Critique of the health-belief model. Journal of Advanced Nursing, 8
adults’ engagement in falls prevention. (6), 467–472.
De Jong, L., Lavendar, A., Wortham, C., Skelton, D., Haines, T., & Hill, A.-M. (2019).
Exploring purpose-designed audio-visual falls prevention message on older people’s
capability and motivation to prevent falls. Health and Social Care in the Community,
27, e471–e482. https://doi.org/10.1111/hsc.12747

7
J.L. Vincenzo et al. Archives of Gerontology and Geriatrics 99 (2022) 104610

Farrance, C., Tsofliou, F., & Clark, C. (2016). Adherence to community based group Khong, L., Bulsara, C., Hill, K., & Hill, A.-M. (2017). How older adults would like falls
exercise interventions for older people: A mixed-methods systematic review. prevention information delivered: Fresh insights from a World Cafe forum. Ageing
Preventive Medicine, 87, 155–166. and Society, 37(6), 1179–1196. https://doi.org/10.1017/S0144686X16000192
Florence, C. S., Bergen, G., Atherly, A., Burns, E., Stevens, J., & Drake, C. (2018). Medical Kiami, S. R., Sky, R., & Goodgold, S. (2019). Facilitators and barriers to enrolling in falls
costs of fatal and nonfatal falls in older adults. Journal of the American Geriatrics prevention programming among community dwelling older adults. Archives of
Society, 66(4), 693–698. https://doi.org/10.1111/jgs.15304 Gerontology and Geriatrics, 82, 106–113.
Ganz, D. A., & Latham, N. K. (2020). Prevention of falls in community-dwelling older Krueger, R. A., & Casey, M. A. (2014). Focus groups: A practical guide for applied research
adults. New England Journal of Medicine, 382(8), 734–743. https://doi.org/10.1056/ (5th ed.). Thousand Oaks, CA: Sage publications.
NEJMcp1903252 McMahon, S., Talley, K. M., & Wyman, J. F. (2011). Older people’s perspectives on fall
Gillespie, L. D., Robertson, M. C., Gillespie, W. J., Sherrington, C., Gates, S., risk and fall prevention programs: A literature review. International Journal of Older
Clemson, L. M., et al. (2012). Interventions for preventing falls in older people living People Nursing, 6(4), 289–298.
in the community. Cochrane Database Syst Rev, 9(11). Nyman, S. R., & Victor, C. R. (2011). Older people’s participation in and engagement
Gordon, N. P., & Hornbrook, M. C. (2016). Differences in access to and preferences for with falls prevention interventions in community settings: An augment to the
using patient portals and other eHealth technologies based on race, ethnicity, and cochrane systematic review. Age and Ageing, 41(1), 16–23.
age: A database and survey study of seniors in a large health plan. Journal of Medical Opsahl, A. G., Ebright, P., Cangany, M., Lowder, M., Scott, D., & Shaner, T. (2017).
Internet Research, 18(3), e50. Outcomes of adding patient and family engagement education to fall prevention
Grossman, D. C., Curry, S. J., Owens, D. K., Barry, M. J., Caughey, A. B., Davidson, K. W., bundled interventions. Journal of Nursing Care Quality, 32(3), 252–258. https://doi.
et al. (2018). Interventions to prevent falls in community-dwelling older adults: US org/10.1097/NCQ.0000000000000232
preventive services task force recommendation statement. Jama, 319(16), Pega, F., Kvizhinadze, G., Blakely, T., Atkinson, J., & Wilson, N. (2016). Home safety
1696–1704. https://doi.org/10.1001/jama.2018.3097 assessment and modification to reduce injurious falls in community-dwelling older
Hakim, R. M., Roginski, A., & Walker, J. (2007). Comparison of fall risk education adults: Cost-utility and equity analysis. Injury Prevention, 22(6), 420–426.
methods for primary prevention with community-dwelling older adults in a senior Pin, S., Spini, D., Bodard, J., & Arwidson, P. (2015). Facilitators and barriers for older
center setting. Journal of Geriatric Physical Therapy, 30(2), 60–68. people to take part in fall prevention programs: A review of literature. [Facteurs
Hartholt, K. A., Lee, R., Burns, E. R., & Van Beeck, E. F. (2019). Mortality from falls facilitant et entravant la participation des personnes agees a des programmes de
among US adults aged 75 years or older, 2000-2016. Jama, 321(21), 2131–2133. prevention des chutes: Une revue de la litterature]. Revue D’Epidemiologie Et De Sante
Hill, K. D., Suttanon, P., Lin, S., Tsang, W. W., Ashari, A., Abd Hamid, T. A., et al. (2018). Publique, 63(2), 105–118. https://doi.org/10.1016/j.respe.2014.10.008 [doi].
What works in falls prevention in Asia: A systematic review and meta-analysis of Potter, P., Pion, S., Klinkenberg, D., Kuhrik, M., & Kuhrik, N. (2014). An instructional
randomized controlled trials. BMC Geriatrics, 18(1), 1–21. DVD fall-prevention program for patients with cancer and family caregivers.
Hopewell, S., Adedire, O., Copsey, B. J., Boniface, G. J., Sherrington, C., Clemson, L., Oncology Nursing Forum, 41(5), 486–494. https://doi.org/10.1188/14.ONF.486-494
et al. (2018). Multifactorial and multiple component interventions for preventing Robinson, J. M., Renfro, C. P., Shockley, S. J., Blalock, S. J., Watkins, A. K., &
falls in older people living in the community. Cochrane Database of Systematic Ferreri, S. P. (2019). Training and toolkit resources to support implementation of a
Reviews, 7(7), Article CD012221. https://doi.org/10.1002/14651858.CD012221. community pharmacy fall prevention service. Pharmacy, 7(3), 113.
pub2 Sandlund, M., Skelton, D. A., Pohl, P., Ahlgren, C., Melander-Wikman, A., & Lundin-
Horton, K., & Dickinson, A. (2011). The role of culture and diversity in the prevention of Olsson, L. (2017). Gender perspectives on views and preferences of older people on
falls among older chinese people. Canadian Journal on Aging/La Revue Canadienne Du exercise to prevent falls: A systematic mixed studies review. BMC Geriatrics, 17(1),
Vieillissement, 30(1), 57–66. 1–14.
Howard, B., Baca, R., Bilger, M., Cali, S., Kotarski, A., Parrett, K., et al. (2018). Shaw, A., Ibrahim, S., Reid, F., Ussher, M., & Rowlands, G. (2009). Patients’ perspectives
Investigating older adults’ expressed needs regarding falls prevention. Physical & of the doctor–patient relationship and information giving across a range of literacy
Occupational Therapy in Geriatrics, 36(2–3), 201–220. levels. Patient Education and Counseling, 75(1), 114–120. https://doi.org/10.1016/j.
Hsieh, H., & Shannon, S. E. (2005). Three approaches to qualitative content analysis. pec.2008.09.026
Qualitative Health Research, 15(9), 1277–1288. Shubert, T. E., Smith, M. L., Prizer, L. P., & Ory, M. G. (2013). Complexities of fall
Huang, S.-F., Tzeng, Y.-M., & Chen, S.-F. (2021). Validation of a prediction model for prevention in clinical settings: A commentary. The Gerontologist, 54(4), 550–558.
likelihood of fall prevention actions in community-dwelling older adults: Application https://doi.org/10.1093/geront/gnt079
of the health belief model. International Journal of Gerontology, 15(1), 34–38. https:// Simek, E. M., McPhate, L., & Haines, T. P. (2012). Adherence to and efficacy of home
doi.org/10.1016/j.imr.2020.100642 exercise programs to prevent falls: A systematic review and meta-analysis of the
Hughes, K., van Beurden, E., Eakin, E. G., Barnett, L. M., Patterson, E., Backhouse, J., impact of exercise program characteristics. Preventive Medicine, 55(4), 262–275.
et al. (2008). Older persons’ perception of risk of falling: Implications for fall- Sjosten, N. M., Salonoja, M., Piirtola, M., Vahlberg, T. J., Isoaho, R., Hyttinen, H. K., et al.
prevention campaigns. American Journal of Public Health, 98(2), 351–357. https:// (2007). A multifactorial fall prevention programme in the community-dwelling
doi.org/10.2105/AJPH.2007.115055 aged: Predictors of adherence. European Journal of Public Health, 17(5), 464–470.
Jang, H., Clemson, L., Lovarini, M., Willis, K., Lord, S. R., & Sherrington, C. (2016). CKl272 [pii].
Cultural influences on exercise participation and fall prevention: A systematic review Stevens, J. A., & Lee, R. (2018). The potential to reduce falls and avert costs by clinically
and narrative synthesis. Disability and Rehabilitation, 38(8), 724–732. managing fall risk. American Journal of Preventive Medicine, 55(3), 290–297. https://
Jansen, S., Schoe, J., van Rijn, M., Abu-Hanna, A., van Charante, E. P. M., van der doi.org/10.1016/j.amepre.2018.04.035
Velde, N., et al. (2015). Factors associated with recognition and prioritization for Stevens, J. A., Sleet, D. A., & Rubenstein, L. Z. (2018). The influence of older adults’
falling, and the effect on fall incidence in community dwelling older adults. BMC beliefs and attitudes on adopting fall prevention behaviors. American Journal of
Geriatrics, 15(1), 169. Lifestyle Medicine, 12(4), 324–330. https://doi.org/10.1177/1559827616687263
Janz, N. K., & Becker, M. H. (1984). The health belief model: A decade later. Health Thornberg, R. (2012). Informed grounded theory. Scandinavian Journal of Educational
Education Quarterly, 11(1), 1–47. Research, 5v6(3), 243–259.
Kaushal, N., Preissner, C., Charles, K., & Knäuper, B. (2021). Differences and similarities Vincenzo, J. L., & Patton, S. K. (2021). Older adults’ experience with fall prevention
of physical activity determinants between older adults who have and have not recommendations derived from the STEADI. Health Promotion Practice, 22(2).
experienced a fall: Testing an extended health belief model. Archives of Gerontology https://doi.org/10.1177/1524839919861967
and Geriatrics, 92, Article 104247. Wilson, V. (2014). Research methods: Triangulation. Evidence Based Library and Information
Practice, 9(1), 74–75.