International Journal of

Environmental Research
and Public Health

Article
Older Adults’ Perceptions and Recommendations Regarding a
Falls Prevention Self-Management Plan Template Based on the
Health Belief Model: A Mixed-Methods Study
Jennifer L. Vincenzo 1, * , Susan K. Patton 2 , Leanne L. Lefler 3 , Pearl A. McElfish 4 , Jeanne Wei 5
and Geoffrey M. Curran 6,7

1 Department of Physical Therapy, College of Health Professions, University of Arkansas for Medical Sciences,
Fayetteville, AR 72703, USA
2 Department of Nursing, College of Education and Health Professions, University of Arkansas,
Fayetteville, AR 72703, USA; skpatton@uark.edu
3 College of Nursing, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA;
leflerleanne@uams.edu
4 Office of Community Health and Research, University of Arkansas for Medical Sciences,
Fayetteville, AR 72703, USA; pamcelfish@uams.edu
5 Department of Geriatrics, Reynolds Institute on Aging, College of Medicine, University of Arkansas for
Medical Sciences, Little Rock, AR 72205, USA; weijeanne@uams.edu
6 Departments of Pharmacy Practice and Psychiatry, University of Arkansas for Medical Sciences,



Little Rock, AR 72205, USA; currangeoffreym@uams.edu

 7 Central Arkansas Veterans Healthcare System, North Little Rock, AR 72114, USA
Citation: Vincenzo, J.L.; Patton, S.K.; * Correspondence: jlvincenzo@uams.edu
Lefler, L.L.; McElfish, P.A.; Wei, J.;
Curran, G.M. Older Adults’ Abstract: Falls are the leading cause of fatal and non-fatal injuries among older adults. Self-
Perceptions and Recommendations management plans have been used in different contexts to promote healthy behaviors, but older
Regarding a Falls Prevention adults’ perceptions of a falls prevention self-management plan template have not been investigated.
Self-Management Plan Template Using mixed methods, we investigated older adults’ perceptions and recommendations of a falls
Based on the Health Belief Model: A prevention self-management plan template aligned with the Health Belief Model. Four focus groups
Mixed-Methods Study. Int. J. Environ.
(n = 27, average age 78 years) were conducted using semi-structured interview guides. Participants
Res. Public Health 2022, 19, 1938.
also ranked the written plan on paper with respect to each item by the level of importance, where
https://doi.org/10.3390/
item 1 was the most important, and 10 was the least important. Focus groups were transcribed
ijerph19041938
and analyzed. Descriptive statistics were calculated for item rankings. Older adults felt that the
Academic Editors: Harish Chander, plan would raise awareness and help them to engage in falls prevention behaviors. Participants
Jennifer C. Reneker and Paul recommended adding graphics and using red to highlight the risk of falling. Participants opined that
B. Tchounwou
ranking the items by level of importance was challenging because they felt all items were important.
Received: 29 November 2021 ‘What might happen to me if I fall’ was ranked as the most important item (average 2.6), while ‘How
Accepted: 30 January 2022 will I monitor progress’ was the least important (average = 6.6). Considering that older adults need
Published: 9 February 2022 support to engage in falls prevention, future research should investigate the impact of implementing
Publisher’s Note: MDPI stays neutral
an individually tailored falls prevention self-management plan on older adults’ engagement in falls
with regard to jurisdictional claims in prevention behaviors and outcomes of falls and injuries.
published maps and institutional affil-
iations. Keywords: adherence; patient-centered design; behavioral change; health belief model; patient
engagement; shared decision-making

Copyright: © 2022 by the authors.

Licensee MDPI, Basel, Switzerland. 1. Introduction
This article is an open access article
Falls are the leading cause of emergency department visits, injuries, and hip frac-
distributed under the terms and
tures, resulting in significant morbidity and mortality among older adults over the age of
conditions of the Creative Commons
Attribution (CC BY) license (https://
65 years [1] and costing upwards of $50 billion in direct medical costs annually [2]. Many
creativecommons.org/licenses/by/
falls are preventable [3,4], yet approximately 27% of older adults report falling each year [1].
4.0/).
Successful interventions for falls prevention are comprised of single and multifactorial

Int. J. Environ. Res. Public Health 2022, 19, 1938. https://doi.org/10.3390/ijerph19041938 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2022, 19, 1938 2 of 13

approaches to modify individual risk factors. Evidence-based interventions include, but are
not limited to, participation in programs to improve fear of falling, physical function, and
balance; management of visual and foot issues, medication management, physical therapy,
and home modifications as directed by an occupational therapist [3–5]. Implementing even
a single intervention could save up to $442 million in direct medical costs [6].
Although falls prevention screening, assessment, and intervention can decrease falls,
older adults’ poor adherence to interventions is a significant barrier to addressing the public
health issue of falls [7]. Results after community-based falls screenings [8] and a systematic
review on fall prevention [9] indicate that at 6 or 12 months, approximately 50% of community-
dwelling older adults are likely to adhere to recommended falls prevention interventions.
Notably, adherence to health behavior interventions can be improved. For example, supported
self-management improves adherence to disease management interventions [10].
Self-management is one of the most frequently used interventions for chronic dis-
ease management, especially among people with chronic conditions such as diabetes and
heart disease [11]. The concept of self-management refers to the daily management of
one’s chronic health conditions [10,11]. Contrary to the implications of the word self-
management, it is centered around an individual being an active partner in their healthcare
with providers supporting shared decision making, health behavior change, and goal
setting. According to the Royal College of Physicians, ‘shared decision-making and support
for self-management refer to a set of attitudes, roles, and skills supported by tools and or-
ganizational systems, which put patients and caregivers into a full partnership relationship
with clinicians in all clinical interactions’ [12]. Shared decision making among older adults
and healthcare providers to improve patient engagement in falls prevention has resulted
in fewer falls in hospital settings [13–15]. However, few studies have investigated shared
decision making, patient engagement, or other components of self-management in falls
prevention for community-dwelling older adults. Directing efforts of self-management for
falls prevention in the community setting is necessary to support an older adult’s choice
to age in place [16]. Szanton et al. utilized strategies to engage low-income older adults
on chronic disease and physical function self-management in the home-based CAPABLE
(Community Aging in Place: Advancing Better Living for Elders) program studies [17,18].
An occupational therapist and nurse worked with the older adult over 5 months using
motivational interviewing, shared decision making, goal setting, and individually tailored
strategies to assist the older adult in achieving their goals. In one of their many studies,
Szanton et al. found that 51% of the older adults chose fall prevention as a goal; of those,
46% fully achieved their goal, and 40% partially achieved this goal [17].
However, studies show that community-dwelling older adults have had challenges
with goal setting and achievement. Haas et al. found that Australian older adults who par-
ticipated in a 15-week home-based or group-based falls prevention program had difficulties
setting and achieving goals to facilitate behavior change to prevent falls [19]. Furthermore,
healthcare practitioners that supported the older adults had difficulty assisting older adults
with goal setting. The STRIDE study (Strategies to Reduce Injuries and Develop Confi-
dence in Elders), the largest pragmatic randomized control trial (RCT) of multifactorial
fall prevention in primary care, utilized shared decision making and a fall care plan [20] to
promote older adults’ uptake of recommendations but did not follow-up with or support
older adults to engage in the fall care plan. As a result, the study results were mixed;
older adults’ self-reported injuries from a fall were significantly lower in the intervention
group than the control group that received information only, but there were no differences
between groups in confirmed fall-related injury [21]. These results highlight the importance
of support for self-management, which was also noted in an observational study across
four physical therapy practices in New Zealand conducted by Peek et al. [22]. The authors
found that physical therapist-supported self-management interventions (e.g., exercise, ice,
education) resulted in older adults adhering to recommendations most frequently when the
older adults repeated the interventions and when print materials were included with the
Int. J. Environ. Res. Public Health 2022, 19, 1938 3 of 13

prescribed interventions. However, there was no patient engagement or shared decision

making in the study mentioned above, which may have negatively impacted adherence.
According to the Standards for Reporting Implementation Studies, the background
and rationale for a health intervention must be supported by a theory, framework, or
model [23]. Implementing health behavior change models to guide interventions can sup-
port behavior change and has been successfully used in chronic disease self-management
interventions [24,25]. The Health Belief Model (HBM) is a theoretical framework devel-
oped to explain engagement in health behaviors using constructs including (1) perceived
susceptibility of getting the health condition, (2) perceived severity of the health condition,
(3) perceived benefits to taking the recommended action to prevent the health condition,
(4) perceived barriers to taking the recommended action to prevent the health condition,
(5) cues to action to engage in the health behavior, and (6) self-efficacy to engage in the
health behavior [26]. There are several modifying factors in the HBM as well, such as
awareness and knowledge regarding the health condition [27]. The HBM is one of the
most widely used theoretical frameworks to explain health behavior change [28]. A system-
atic review found that HBM-based behavior change interventions significantly improve
adherence to healthy behaviors [29]. The HBM has also been used in research to predict
health behaviors in people with a history of falls [30,31] or design fall prevention interven-
tions [32]. However, no studies have reported using the HBM or another health behavior
change framework to specifically support older adults to engage in a falls prevention
self-management plan. For example, Kaushal et al. [30] used an expanded model of the
HBM, including habits and intention, to identify predictors of physical activity among
older adults who have and have not fallen. They found that perceived barriers to physical
activity significantly predicted intention to perform physical activity among only people
with a history of falls and that cues to action were important predictors of habitual physical
activity regardless of fall history. Huang, Tzeng, and Chen [31] used the HBM to predict
determinants of engagement in fall prevention activities among community-dwelling older
adults. They found that the model predicted 39% of engagement. Of the HBM constructs,
self-efficacy had the most significant influence on engagement, which was followed by
cues to action, perceived severity, and perceived benefit. Another study utilized the HBM
to develop a four-session educational and counseling osteoporosis and falls prevention
program for older females. Participants in the HBM-based program demonstrated greater
knowledge and adoption of preventive behaviors than a group education-only program
that was not based on the HBM [32].
Our research was based on the following: (1) chronic disease self-management plans
have been effective in the past, (2) self-management plans need to be refined and tailored
to the needs/perceptions of older adults before they can be implemented, and (3) to our
knowledge, there is no existing literature regarding the development or implementation of a
falls prevention self-management plan, with older adults’ input, based on a behavior change
theory. Therefore, we aimed to identify older adults’ perceptions and recommendations of
an HBM-based falls prevention self-management plan template. Tailoring a falls prevention
self-management plan template for older adults will optimize future studies designed to
examine self-management plan implementation.

2. Materials and Methods

2.1. Design
A mixed-methods approach was used to explore older adults’ perceptions regarding
a falls prevention self-management plan based on the HBM. The falls prevention self-
management plan was adapted from a fall care plan utilized in the STRIDE study, a
published pragmatic clinical trial on fall prevention that used stakeholder input, including
older adults, to develop study materials, but did not report utilizing a health behavior
change theory to inform the plan (Figure 1) [20,33]. For our adaption of the STRIDE fall care
plan (Figure 2), we aligned each of the existing 8 items in the STRIDE plan with constructs
from the HBM. Then, we added 2 items (my risk of falls is, what might happen to me if I
Int. J. Environ. Res. Public Health 2022, 19, x 4 of 14

older adults, to develop study materials, but did not report utilizing a health behavior
Int. J. Environ. Res. Public Health 2022,change
19, 1938 theory to inform the plan (Figure 1) [20,33]. For our adaption of the STRIDE fall
4 of 13
care plan (Figure 2), we aligned each of the existing 8 items in the STRIDE plan with con-
structs from the HBM. Then, we added 2 items (my risk of falls is, what might happen to
me iftoI fall)
fall) to address
address missingmissing constructs
constructs in the of
in the HBM HBM of perceived
perceived susceptibility
susceptibility and per-
and perceived
ceived severity. The plan was in 14-point font for easier
severity. The plan was in 14-point font for easier reading. reading.

Figure 1. STRIDE study fall care plan for one fall risk item [33].
Figure 1. STRIDE study fall care plan for one fall risk item [33].

The study team developed and iteratively refined the semi-structured interview guide
for the focus groups based on factors related to engaging in health behaviors from constructs
in the Health Belief Model (HBM, Table 1; [20,21]). The constructs, perceived susceptibility,
perceived severity, perceived benefits, perceived barriers, cues to action, and self-efficacy
help explain an individual’s perceptions of the threat of a health problem, the benefits of
addressing the threat, and factors that influence the decision to practice a health-promoting
behavior. The plan items’ associations with constructs related to the HBM are depicted in
Table 1. One-on-one pilot interviews were conducted with three older adults to assess and
modify the interview guides. The pilot interview data were not included in the study.

2.2. Participant Sampling

Convenience sampling was used to recruit older adults. Individuals who had partici-
pated in a prior, unrelated study and indicated an interest in participating in future studies
were contacted by telephone. Interested participants were also asked to provide the primary
investigator’s contact information to other older adults who might be interested in the
research. The inclusion criteria were adults 65 years of age and older, community-dwelling,
and ability to attend the focus groups.

2.3. Data Collection

Four focus groups of six to eight participants were conducted between December 2019
and February 2020. The primary researcher served as the moderator for three focus groups.
A research assistant trained by the primary investigator who attended and documented field
notes in the first three focus groups moderated the fourth focus group. Ground rules were
established before each focus group. These included being respectful of differing opinions,
having only one person to speak at a time, and open sharing of participants’ opinions and
experiences [34]. Two focus groups were conducted in a conference room in the primary
Int. J. Environ. Res. Public Health 2022, 19, 1938 5 of 13

investigator’s department at the university, one was conducted in a senior center conference
room,
Int. J. Environ. Res. Public Health 2022, 19, xand one was conducted at the house of a participant per their request. Focus groups
5 of 14
were recorded on a digital voice recorder (Olympus WS-853, Olympus America, Inc., Center
Valley, PA, USA).

Health-beliefmodel-based
Figure2.2.Health-belief
Figure model-basedfalls
fallsprevention
preventionself-management
self-managementplan
plantemplate.
template.

Demographics
The study teamwere collected
developed byiteratively
and written survey. Participants
refined were educated
the semi-structured by the
interview
interviewer on the falls prevention self-management plan and the purpose of
guide for the focus groups based on factors related to engaging in health behaviors fromthe plan,
which was for a healthcare provider to assess the older adult for their fall risk, followed by
constructs in the Health Belief Model (HBM, Table 1; [20,21]). The constructs, perceived
both the provider and older adult completing the individualized plan together to support
susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action,
the older adult to engage in falls prevention behaviors. Before asking participants about
and self-efficacy help explain an individual’s perceptions of the threat of a health problem,
their perceptions of the plan, each participant ranked the 10-item plan on paper with respect
the benefits of addressing the threat, and factors that influence the decision to practice a
to the other items by the level of importance (1–10), where item 1 was the most important,
health-promoting behavior. The plan items’ associations with constructs related to the
and 10 was the least important. Following rankings, older adults’ perspectives of each item
HBM are depicted in Table 1. One-on-one pilot interviews were conducted with three
were investigated using the semi-structured interview guide (Table 1, middle column).
older adults to assess and modify the interview guides. The pilot interview data were not
At the end of the focus groups, the interviewer summarized general themes regarding
included in the study.
the group and participants’ perspectives regarding the appearance and recommendations
to improve the plan. Participants were encouraged to provide any feedback or clarification
of the summary. The focus groups lasted from 1.25 to 1.5 h. Participants received a $30 gift
card for completing the focus group interview.
Int. J. Environ. Res. Public Health 2022, 19, 1938 6 of 13

Table 1. Interview guide for falls prevention plan guided by constructs of the Health Belief Model.

Questions: We Are Seeking Your

Items Included in Written Health Belief
Opinion on the Following: How Does
Model-Informed Falls Prevention Constructs of the Health Belief Model
or Does Not This Sample Falls
Self-Management Plan
Prevention Plan Help Older Adults:
Understand and acknowledge their falls
My risk of falls is_____ Knowledge, perceived susceptibility
risk?
Understand what may happen if they
What might happen to me if I fall? Perceived threat, perceived severity
suffer a fall?
My goal for the next month: Promote engagement and goals? Self-efficacy, cues to action
See the personal benefit to
Why it matters to me: Benefit, personal relevance
falls prevention?
Perceived facilitators and barriers,
How will I do this? Promote engagement and goals?
self-efficacy
When will I do this? Make a plan? Cues to action, likelihood to take action
Address barriers to undergoing
Things that could make it difficult to do: Perceived barriers
falls prevention?
Provide facilitators to undergoing
My plan for overcoming difficulties: Perceived facilitators, self-efficacy
falls prevention?
The support/resources I have to achieve Provide resources and social support to Cues to action, self-efficacy,
these goals include: achieve goals? social support
Cues to action, self-efficacy,
How will I monitor progress Provide accountability to goals?
social support

2.4. Data Analysis

Data from the demographic questionnaires and rankings of the falls-prevention self-
management plans were entered into Excel, and descriptive statistics were calculated.
Audio-taped interviews were uploaded to computerized software (Descript, San Fran-
cisco, CA, USA) for initial transcription and edited for accuracy. Data from the focus
groups were analyzed to identify, analyze, and interpret meaning based on the focus of the
semi-structured interview questions using thematic analysis [35]. Analysis began with a
thorough reading and rereading of all transcripts. Two experienced qualitative investiga-
tors (JV and SKP) separately read and coded the data. A line-by-line analysis of the data
was completed individually to identify important words or phrases regarding the targeted
questions, and narratives were applied. Then, investigators met to discuss and agree on
the themes, which were perceptions regarding the falls prevention self-management plan
and recommendations regarding the falls prevention self-management plan. Perceptions
were data and quotes surrounding older adults’ understanding, feelings, attitudes, and
interpretation about the plan. Recommendations were data and quotes regarding revisions
to the plan. During the final step of the analysis, the investigators reached a consensus on
the representative quotes. There were no disagreements among investigators regarding the
themes or representative quotes during the analysis phase. Data saturation was obtained
when the coders agreed no new information emerged after completing the analysis of the
four focus groups [36].

3. Results
3.1. Sample Description
Table 2 summarizes the participant characteristics. The focus groups consisted of
27 adults with an average age of 78 years and an approximately even distribution of males
and females. Participants in the focus groups were engaged and collectively accepting of
others’ ideas.
Int. J. Environ. Res. Public Health 2022, 19, 1938 7 of 13

Table 2. Participant demographics.

Characteristic n (27)
Sex
Male 13
Female 14
Age a
Male 79.4
Female 76.1
Race/Ethnicity
Non-Hispanic—white 21
Did not state 6
Educational level
Less than a high school diploma 2
High school degree or equivalent (GED) 0
Some college, no degree 11
Associate’s degree 2
Bachelor’s degree 5
Master’s degree 3
Professional degree (MD, DDS, DVM) 0
Doctorate (PhD, EdD) 2
No answer 2
Yearly income
Less than $20,000 3
$20,000 to $34,999 6
$35,000 to $49,999 2
$50,000 to $74,999 5
$75,000 to $99,999 7
Over $100,000 3
No answer 1
Marital Status
Married, or in a domestic partnership 19
Widowed 8
Experienced a fall in the last year
Yes 10
No 17
Number of falls in the last year
None 17
1 2
2 2
≥3 3
No answer 3
Falls resulting in injury
Yes 7
No 6
No answer 14
a average age.

3.2. Perceptions Regarding the Falls-Prevention Self-Management Plan

Despite the introduction and description of the plan and how it would be used in
practice during the interview, older adults in the focus groups largely did not understand
the plan or how it was supposed to be implemented. Participants thought they were
supposed to complete the plan based on their current perceived falls risk and what they
needed to do to prevent falls while being questioned about the plan. The interviewers
reiterated that both the older adult and their healthcare provider would complete the plan
after the provider screens them for fall risk. The interviewers’ clarifications assisted the
Int. J. Environ. Res. Public Health 2022, 19, 1938 8 of 13

older adults in understanding the purpose of the plan, as evidenced by the feedback older
adults provided.
All but one participant liked the plan. Only one participant stated, “It was confusing to
me,” while others stated, “I love it,” and, “I liked the questions; they’re simple, the terminology is
clear to understand.” Participants felt that all of the items on the plan were “all important,”
and another stated, “I saw it as a chronological listing.”
Participants mentioned how the plan would help with awareness. This was exempli-
fied by statements such as, “it helps staying aware of it,” and “keeping it up . . . and scheduling
it.” One participant felt that awareness would help with initiating falls prevention behav-
iors, stating, “The awareness is the beginning of all action, first [you] have to be aware, and this
would help bring awareness to the fact that you need to be sensitive to those possibilities and, and it
would get you thinking. And so, it would initiate it, I think.” Another participant implied that
the falls prevention plan increased awareness, “If you get our attention, you get everybody’s
attention. I would think.”
All participants felt that every item in the plan would help an older adult to implement
the plan. Participants felt that no items should be omitted. Participants stated that some
of the items might be challenging to answer. This was exemplified by comments such as,
“Why it matters to me. You know? It could be because I want to live a long time and be healthy . . .
maybe a couple of examples might clarify it,” and, “Things that would make it difficult- because
I’m a caregiver and I don’t have time, or because I’m in pain and it’s so broad that you had to think
about it, but you might look at it and say, like, ‘How will I do this?’ You know? How is really big?”

3.3. Discrete Rankings of Items in the Falls Prevention Self-Management Plan

Participants’ discrete rankings of each item on the plan by level of importance (1–10); 1
being the most important item and 10 being the least important are depicted in Table 3. The
participants voiced that it was challenging to rank items in the plan by importance because
they felt that all items were equally important. Item ranking means ranged from 2.6 to 6.6.
Participants ranked the item ‘What might happen to me if I fall?’ as the most important
item (ranked 2.6) based on means. Participants ranked ‘How will I monitor progress’ as the
least important item on the plan (ranked 6.6). The item, ‘My risk of falls is____’ was most
frequently ranked 1, while ‘How will I monitor progress’ was most frequently ranked 10.

3.4. Recommend Revisions to the Plan

Participants suggested a few revisions to the plan. Two participants suggested that
examples of items would be helpful, specifically for ‘why it matters to me’ and ‘things
that could make it difficult to do.’ Another participant felt it should be a bit shorter, “I
think something maybe not as comprehensive . . . but more of an abbreviated, maybe three or four
questions that the doctor went over with you and your visit, I think would make me more aware
of possibilities that may happen. Some accidental fall and then prevent that, and the consequences
of it.” Participants felt that the plan “needs graphics” or “pictures.” One participant stated
emphatically, “I’m a great believer in graphics.” Another participant felt graphics would help
participants grasp concepts.
“a lot of times, a personality is something people cannot grasp on their own unless they
see something that really points it out. And if you had a graphic showing how many,
what the risk of falls were on an age line or something like that, to where they would see
that there’s an urgency here, they can place themselves within this data.”
Participants also had suggestions with regard to colors. One participant felt that “the
separation with the color helps.” Two others recommended including the color red; “Well,
I think red is always a high alert. So maybe if there was one question that was more important,
probably a red color would catch your attention,” and “In my case, I would say that number one,
risk of falling is red certainly if it’s 10% is still a red.”
Int. J. Environ. Res. Public Health 2022, 19, 1938 9 of 13

Table 3. Discrete rankings of items in falls prevention self-management plan.

Ranking Each Item on the Plan with Respect to One

Falls Prevention Self-Management
Another with a Discrete Number (1–10); 1 Being the
Plan Item
Most Important Item and 10 Being the Least (n = 27)
Range = 1–9
My risk of falls is_____ Mean = 3.0 ± 2.8
Mode = 1
Range = 1–10
What might happen to me if I fall? Mean = 2.6 ± 1.0
Mode = 2
Range = 1–10
My goal for the next month: Mean = 5.7 ± 3.0
Mode = 8
Range = 1–9
Why it matters to me: Mean = 4.3 ± 2.2
Mode = 3
Range = 1–10
How will I do this? Mean = 4.6 ± 2.5
Mode = 4
Range = 2–10
When will I do this? Mean = 5.1 ± 2.3
Mode = 5
Range = 1–10
Things that could make it difficult to do: Mean = 5.5 ± 3.1
Mode = 9
Range = 1–10
My plan for overcoming difficulties: Mean = 5.4 ± 2.9
Mode = 5
Range = 1–10
The support/resources I have to
Mean = 5.3 ± 3.4
achieve these goals include:
Mode = 3
Range = 1–10
How will I monitor progress Mean = 6.6 ± 3.8
Mode = 10

4. Discussion
We investigated older adults’ perceptions and recommendations of a falls prevention
self-management plan based on constructs from the HBM. This work serves as a first step
toward developing a health behavior change-based falls prevention self-management plan
template, with stakeholder input, for community-dwelling older adults. Participants liked
and had positive feedback regarding the 10-item falls prevention self-management plan.
They felt that the plan would raise awareness and help them engage in falls prevention
behaviors. Older adults had a few recommendations to improve the appearance of items
on the falls prevention plan, suggesting adding graphics and highlighting items such as
the risk of falling.
We investigated older adults’ rankings of the plan’s most and least important items.
The most important item, on average, was, ‘What might happen to me if I fall,’ which aligns
with the HBM construct of perceived severity. The item most frequently ranked at number
one was, ‘My risk of falls is___,’ which aligns with the HBM construct of perceived suscepti-
bility. Studies show that older adults are more likely to engage in falls prevention behaviors
if they perceive they are susceptible to falls or injuries (e.g., perceived severity) [37,38].
Huang et al. found that the perceived severity of suffering a fall predicted engagement
in falls prevention behaviors, among other constructs [31]. Hill et al. [39] found that self-
perceived risk of falls and injury (e.g., HBM constructs of perceived susceptibility and
Int. J. Environ. Res. Public Health 2022, 19, 1938 10 of 13

perceived severity) were predictive of engagement in falls prevention. Taken together, these
results and supporting data support the inclusion of the items ‘My fall risk is,’ and ‘What
might happen to me if I fall’ in the self-management plan.
Participants ranked the three least important items on the plan as, ‘How will I monitor
progress,’ ‘My goal for the next month is,’ and ‘Things that could make it difficult to do.’ ‘How will
I monitor progress’ aligns with the HBM constructs of self-efficacy and cues to action, and
‘My goal for next month is’ aligns with self-efficacy. Despite these being the lowest-ranked
items on our plan, Huang, Tzeng, and Chen [31] found that the HBM construct of self-
efficacy had the most significant influence on falls prevention engagement followed by
cues to action, perceived severity, and perceived benefit. Although we did not measure
self-efficacy, the participants’ perceived self-efficacy may have affected their ranking of
this item on the plan. Indeed, a meta-analysis found that self-efficacy has a medium effect
size (d = 0.47) on health-related behavior change [24]. Considering that goal-setting and
monitoring progress were the lowest ranked items, and self-efficacy plays a significant role
in older adults’ engagement, these results may be due to older adults’ need for support
to set and achieve goals and self-management. Indeed, a systematic review of behavior
change techniques’ effect on older adults’ self-efficacy and physical activity found that
interventions involving unsupported goal-setting and self-monitoring were associated with
lower levels of self-efficacy and physical activity [40]. Haas et al. [19] found that Australian
older adults had difficulties setting and achieving goals to facilitate behavior change to
prevent falls. Conversely, Taylor et al. found that 50% of their CAPABLE participants chose
fall prevention as their goal, and approximately the same percentage achieved that goal
with the goal-setting support, decision-making support, and strategies interventions in
the program [17].
The item, ‘Things that could make it difficult to do’, which aligns with HBM constructs
of perceived barriers, was the 3rd lowest ranked item on the plan. In addition, focus
group participants indicated that this item would be hard to address. Kaushal et al. found
that perceived barriers to physical activity significantly predicted intention to perform
physical activity among people with a history of falls and that cues to action were important
predictors of habitual physical activity regardless of fall history [30]. A scoping review
on the validity of HBM constructs to predict behavior change, of which only four studies
met the inclusion criteria, found that the perceived barriers and benefits were the strongest
predictors of behavior change [41]. It is possible that the utilization of shared decision-
making and self-management support to identify and overcome barriers may make this
item important for the plan. Taken together, these three lowest-ranked items on the plan
are still important to include in the plan. Still, research involving the implementation and
revelation of the plan will be necessary to provide future directions.
Our research study does have strengths and limitations. Strengths of our study
include that it is the first, to our knowledge, to investigate older adults’ perceptions of a
falls prevention self-management plan based on the HBM. Limitations to our study are
that the sample is homogenous and small; therefore, the generalizability of our results to
different cultures and backgrounds may be limited. A small percentage (37%) of our sample
had a history of falls, which may have impacted our findings. People with a history of
falls may be more fearful of doing activities and restrict themselves in an effort to decrease
their risk, which may impact their perceptions of a falls prevention self-management plan
and willingness to participate in falls prevention. Future research should compare the
differences in falls prevention plan perceptions of older adults with and without a history
of falls. It is important to note that the items ranked as the most important on the plan were
the first two in order on the written plan. The item ranked as the least important on the plan
was the last item in the order, although these items were ranked almost a whole point(s),
lower or higher than other items comparatively. In addition, we did not ask participants
why they ranked the items in the order that they did. Considering the order of the rankings
and that the participants felt that all items on the plan were important and challenging to
rank discretely, the rankings should be interpreted with caution.
Int. J. Environ. Res. Public Health 2022, 19, 1938 11 of 13

5. Conclusions
Research shows that education alone does not consistently increase engagement in
health behaviors among community-dwelling older adults [26] nor does it decrease falls in
the home post-hospitalization [31]. Falls prevention in hospital settings is most effective
when older adults are engaged in shared decision making [14] and in the community
setting when older adults participate in shared decision making and have support for
engagement [15,18]. Self-management plans facilitate shared decision making and support
for engagement [10]. Our research indicates that a falls prevention self-management plan
based on the HBM is viewed positively by older adults. Older adults also feel this plan
would help increase their awareness and engagement in falls prevention behaviors. Future
studies should investigate the impact of implementing the falls prevention self-management
plan on older adults’ engagement in falls prevention behaviors and outcomes of falls and
fall-related injuries.

Author Contributions: Conceptualization, J.L.V., S.K.P., L.L.L., P.A.M., J.W., G.M.C.; Methodology,
J.L.V., S.K.P., L.L.L., P.A.M., J.W., G.M.C.; Software, J.L.V., G.M.C.; Validation, S.K.P., L.L.L.; Formal
Analysis, J.L.V., S.K.P., L.L.L.; Investigation, J.L.V., S.K.P., L.L.L.; Resources, J.L.V., S.K.P., L.L.L.,
P.A.M., J.W., G.M.C.; Data Curation, J.L.V., S.K.P., L.L.L.; Writing—Original Draft Preparation, J.L.V.,
S.K.P., L.L.L., P.A.M., J.W., G.M.C.; Visualization, J.L.V., S.K.P.; Supervision, J.L.V., S.K.P., L.L.L.,
P.A.M., J.W., G.M.C.; Project Administration, J.L.V.; funding Acquisition, J.L.V., L.L.L., P.A.M., J.W.,
G.M.C. All authors have read and agreed to the published version of the manuscript.
Funding: This work was supported by the Translational Research Institute (TRI), grant [KL2
TR003108], [UL1 TR003107], and TRI [UL1TR000039] through the National Center for Advanc-
ing Translational Sciences (NCATS) of the National Institutes of Health (NIH). The funders played no
role in the design, conduct, or reporting of this study. The content is solely the authors’ responsibility
and does not necessarily represent the official views of the NIH.
Institutional Review Board Statement: The study was conducted according to the guidelines of the
Declaration of Helsinki and determined to be not human subjects research according to the University
of Arkansas for Medical Sciences—Institutional Review Board with code number: IRB 239642.
Informed Consent Statement: Since this was deemed not human subjects research by the IRB,
informed consent was not formally obtained. Participants were informed about the study prior to
their participation and that they may withdraw or choose not to answer questions at any time.
Data Availability Statement: The data are not publicly available due to ethical restrictions.
Acknowledgments: We would like to thank the participants who engaged in this study. We would
also like to thank Dollie Resh, Bassel Chaaban, and Holly B. Bennett, for their assistance.
Conflicts of Interest: The authors declare no relevant conflicts of interest with regards to this study.

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