The Clinimetric Properties of Instruments Measuring Home Hazards for Older People at Risk of Falling: A Systematic Review

Abstract

Home hazards are associated with falls among older people living in the community. However, evaluating home hazards is a complex process as environmental factors vary according to geography, culture, and architectural design. As a result, many health practitioners commonly use nonstandardized assessment methods that may lead to inaccurate findings. Thus, the aim of this systematic review was to identify standardized instruments for evaluating home hazards related to falls and evaluate the clinimetric properties of these instruments for use by health practitioners. A systematic search was conducted in the Medline, CINAHL, AgeLine, Web of Science databases, and the University of Sydney Library CrossSearch Engine. Study screening, assessment, and quality ratings were conducted independently. Thirty-six studies were identified describing 19 instruments and three assessment techniques. The clinimetric properties varied between instruments. The Home Falls and Accidents Screening Tool, Home Safety Self-Assessment Tool, In-Home Occupational Performance Evaluation, and Westmead Home Safety Assessment were the instruments with high potential for evaluating home hazards associated with falls. Health practitioners can choose the most appropriate instruments for their practice, as a range of standardized instruments with established clinimetric properties are available.

Keywords

home hazards accidental falls assessment tool evaluation psychometric clinical utility older people

By the age of 65 years, over a third of older individuals report at least one fall in the previous year, with half of them reporting frequent falls (World Health Organization, 2007). The impact of falls can be severe including the psychological impact of fear of falling, cost of health care, development of physical and functional impairments, increased risk of developing other medical conditions such as fracture and stroke, and even death (Boye et al., 2012; Frith & Davison, 2013; Siracuse et al., 2012). Over time, researchers have tried to reduce the frequency of falls among older people living in the community by investigating factors contributing to the risk of falls and developing interventions and prevention programs addressing those risk factors. Home hazards are accepted as one of the contributing factor to the risk of falls (Clemson, Mackenzie, Ballinger, Close, & Cumming, 2008; Gillespie et al., 2012; Lord, Menz, & Sherrington, 2006; Tse, 2005).

Studies have shown that many falls among older people occur in the home (Milat et al., 2011; Muangpaisan et al., 2015; Rizawati & Mas Ayu, 2008). However, the association between environmental hazards and falls is not fully understood. A study by Lord, Menz, and Sherrington (2006) showed home hazards were not associated with an increasing risk of falls among older people. This finding was supported by other studies in other countries (Chin, Wang, Ong, Lee, & Kong, 2013; Letts et al., 2010; Pattaramongkolrit, Sindhu, Thosigha, & Somboontanot, 2013; Rizawati & Mas Ayu, 2008; Stalenhoef, Diederiks, Knottnerus, Witte, & Crebolder, 1998). However, other studies report that home hazards are significantly associated with falls (Carter, Campbell, Sanson-Fisher, Redman, & Gillespie, 1997; Sophonratanapokin, Sawangdee, & Soonthorndhada, 2012). A study by Northridge, Nevitt, Kesley, and Link (1995) found that active older people with a higher number of hazards in their home fell more. Home assessment and modifications to reduce the number of hazards in the homes of older people have been shown to be effective in reducing the number of falls, and the risk of falls, either as a single intervention (Clemson et al., 2008) or part of a multifactorial intervention (Chase, Mann, Wasek, & Arbesman, 2012; Gillespie et al., 2012; Lord et al., 2006).

The measurement of home hazards is fundamental to investigating the association of home hazards with falls. It has been argued that investigating home hazards by observing the physical features of the home environment alone may be inappropriate, as home hazards are better viewed as a product of the interaction between an individual and their home environment when undertaking functional activities (Gitlin, 2003). Therefore, the difficulty in functioning safely in the home is what is considered hazardous rather than only the physical structure of the house. Many of the studies that found that home hazards were not a significant factor for falls (Letts et al., 2010; Lord et al., 2006) were conducted by evaluating the physical features of the home environment alone.

A systematic review by Barras (2005) evaluating the effectiveness of home assessments showed that the majority of studies evaluating home hazards used nonstandardized instruments such as generic instruments developed by the authors. Using nonstandardized instruments or instruments without established psychometric properties may result in inaccurate or misleading findings. Such instruments may also be inappropriate for the population under study and not measure what they purport to measure (Stapleton & McBrearty, 2009). The tendency to use nonstandardized instruments may be related to the absence of a universal home hazards instrument used in standard health-care practice (Hill, Smith, & Schwartz, 2001). Furthermore, standardized instruments may be viewed by practitioners as having limited clinical value and being too narrow by focusing on one type of hazard only such as lighting for low vision or on a specific health condition such as dementia. Practitioners may also have a lack of exposure to and knowledge of available instruments and be unfamiliar with available standardized instruments and how to use them (Hill et al., 2001; Stapleton & McBrearty, 2009). Therefore, practitioners may find nonstandardized assessments more convenient to use as they are readily available and accepted in local practice.

Clinimetrics refers to the combination of psychometric properties and clinical utility of a standardized instrument to provide meaningful and valuable information for decision-making and intervention planning (Djikers, 2003). Psychometric properties focus on the evidence of validity and reliability of an instrument established using robust research study designs (Cohen et al., 2008). According to Law and MacDermid (2014), types of validity include descriptive, predictive, evaluative, content, criterion-related (including concurrent), and construct (including convergent and discriminant) validity. Types of reliability include internal consistency, inter-rater, and test–retest reliability. Complementing psychometric properties, clinical utility focuses on the appropriateness, accessibility, practicability, and acceptability of an instrument in terms of ease of use, duration, training requirement, format of the instrument, and meaningful interpretation on the data gathered by the instrument (Smart, 2006). Acceptable instruments are characterized by the ease of administration, a short administration and completion time, minimal training for the administrator, low cost, and having a small number of items yet still able to capture the desired information (Stapleton & McBrearty, 2009). Psychometric properties and clinical utility are important elements to consider when choosing an instrument for use in clinical practice.

Currently, there is no comprehensive summary of the research literature to guide the selection of instruments most suited to evaluate home hazards in relation to falls risk. While Ainsworth and de Jonge (2011) have suggested several instruments suitable for assessing the home, there is limited discussion in relation to their psychometric properties and clinical utility. Reviews conducted by Fabre, Ellis, Kosma, and Wood (2010) and Tzingounakis (2012) suggest the Westmead Safety Home Assessment (WeHSA) and the Home Falls and Accidents Screening Tool (HOME FAST) as suitable instruments for measuring fall-related home hazards. However, neither review included other instruments which may be relevant to fall prevention practice.

In summary, service providers need to consider the psychometric evidence and the clinical utility of an instrument when choosing one for practice. Moreover, the instruments should incorporate the person–environment interaction by evaluating functional activities. The instruments should have multiple purposes as an evaluation and an outcome measure. This systematic review aimed to identify instruments measuring home hazards that can be used with older people living in the community at risk of falls and determine their clinimetric properties.

Material and Method

Study Identification

The identification of instruments was based on a systematic search of the literature for relevant studies (Wales, Clemson, Lannin, & Cameron, 2012). A systematic search was conducted in electronic databases including Medline, CINAHL, AgeLine, and Web of Science. An additional search was conducted through The University of Sydney Library’s CrossSearch Engine to ensure that relevant studies were unlikely to be missed. Relevant review studies were read to identify relevant key words for use in the search strategies (Clemson et al., 2008; Terwee, Jansma, Riphagen, & de Vet, 2009; Tse, 2005). Using the person, exposure, comparison, outcome (PECO) format (Prasad, 2013), the databases were searched to identify articles published in academic journals containing the following search terms:

Person: “older,” “aged,” “elderly,” “senior.”

Exposure: “home safety,” “home hazards,” “home modification,” “environment modification,” “housing for the elderly,” “home assessment,” “home evaluation,” “home intervention,” “home visit,” “accident,” “home.”

Comparison: reproducibility, methods, validity, reliability, “internal consistency,” “coefficient of variation,” “observer variation,” psychometrics, precisions, discriminative.

Outcome: falls, fall prevention, fall intervention, accidental fall, risk of fall.

The search strategies used in each database varied depending on the availability of Medical Subject Headings (MeSH) terms, the ability to combine terms using Boolean operators and use of truncations. The final search strategy was tailored to each database and was designed to maximize the retrieval of relevant studies. As well, the reference lists of eligible studies were scanned to identify additional relevant studies. The “cited by” option in Google Scholar was also used for citation tracking to identify relevant studies cited in the eligible studies identified from the database searches (Wright, Golder, & Rodriguez-Lopez, 2014). The initial searches were conducted in August 2014. Top-up searches were conducted in May 2016 to ensure that more recently published studies and instruments were included.

Study Eligibility Criteria

Each article retrieved from the searches was screened for eligibility. To be included, studies had to (i) involve community-dwelling older people, (ii) include an instrument or evaluation method relevant to fall prevention, (iii) focus specifically on the assessment of home hazards related to risk of falls, (iv) be relevant to health rehabilitation practice, and (v) investigate the psychometric properties and clinical utility of the instrument. Studies were excluded if they were (i) not published in English; (ii) conducted in hospitals, clinics, or residential care environments; (iii) books, conference proceedings, dissertations, or theses; and (iv) not the primary study.

Study Selection

Duplicate studies were removed prior to the screening process. Two authors (MHR with either LM or ML) independently screened each study by title and abstract for eligibility. Assessment of the full text article for each study was then conducted independently by two authors for those studies retained after the screening process. Any disagreements in relation to study inclusion were resolved through discussions among the authors until consensus was achieved.

Data Extraction and Analysis

Relevant data were first extracted from each study. These data included the study objective, study design, instrument investigated, number and characteristics of raters (for reliability studies), number and characteristics of participants, country of the study, and results. The data for each study were then summarized in tables.

Assessment of Study Quality

Quality appraisal for clinical measurement research reports evaluation form

The form was used to assess the quality of each study (Law & MacDermid, 2014). The form was developed by rehabilitation experts from occupational therapy and physiotherapy backgrounds and has excellent inter-rater reliability (Flamand, Massé-Alarie, & Schneider, 2013; Forhan, Vrkljan, & MacDermid, 2010; MacDermid et al., 2009; Rouleau, Faber, & MacDermid, 2010; Roy, Desmeules, & MacDermid, 2011; Roy, MacDermid, & Woodhouse, 2009, 2010). It consists of a 12-item checklist evaluating the quality of the research question, design, measurements, analyses, and the recommendations from the study. Each item on the form is assigned a score of 0–2, with 2 representing best practice, 1 representing acceptable but suboptimal practice, and 0 representing substantially inadequate or inappropriate practice. A total score is calculated and then converted to a percentage. The quality assessments were conducted independently by two authors with disagreements resolved using consensus. If needed, a third author was consulted to determine the final rating.

The Terwee Checklist

The Terwee Checklist was used to determine the quality of the psychometric properties of each instrument (Terwee et al., 2007). For that purpose, the studies were grouped based on the instrument described and a summary of the psychometric properties of each instrument was then prepared according to eight categories, namely, (i) content validity, (ii) internal consistency, (iii) criterion validity, (iv) construct validity, (v) reproducibility (agreement and reliability), (vi) responsiveness, (vii) floor or ceiling effect, and (viii) interpretability. Each instrument was then assessed against quality criteria and rated according to four categories: positive (having desired outcome with robust methodology), intermediate (having desired outcome with less robust methodology), poor (having undesired outcome or having poor methodology), or no information available. Where two or more studies investigated the same property, the highest quality score for that item was recorded.

Results

Our comprehensive search for all articles published from the year 1971 yielded 1,335 articles combined. The initial preselection agreement rate was 68.8% (33/48), and the selected articles were resolved by discussion between three authors (MHR, LM, and ML). Ultimately, 36 articles were selected for data extraction (Figure 1). Excluded articles with reason of exclusion were listed in the Appendix.

Figure 1.

Study identification process.

Study Inclusion and Characteristics

Thirty-six studies were included in the review (Figure 1). Key characteristics of the included studies are provided in Table 1 according to the Garrad’s (2014) matrix method. Publication year ranged from 1995 to 2015. Nineteen instruments—COUGAR, the Home Environmental Assessment Protocol (HEAP), the HOME FAST, the Home Safety Self-Assessment Tool (HSSAT), the In-Home Occupational Performance Evaluation (I-HOPE), the Safety Assessment of Function and the Environment for Rehabilitation–Health Outcome Measurement and Evaluation (SAFER-HOME), the Enabler, The Safe Living Guide, the Usability in My Home (UIMH), the WeHSA, the Home Environment Survey (HES), the Home-Screen Scale (HSS), the Safety Housecheck, Assessment of Home Hazards, the Ritchey Home Assessment, the Home Safety Checklist of Indoor Fall Risk, the Home Assessment Profile (HAP), the HEROS Environmental Safety Check, and the Comprehensive Assessment and Solution Process for Aging Residents (CASPAR)—and three alternative assessment techniques (photography, video, and robot-assisted video) were identified from the 36 studies. Ten instruments were developed by occupational therapists (COUGAR, HEAP, HOME FAST, HSSAT, I-HOPE, SAFER-HOME, Enabler, The Safe Living Guide, UIMH, WeHSA). Three instruments were developed by nurses (HES, HSS, Safety Housecheck). Three instruments were developed by doctors (Assessment of Home Hazards, the Ritchey Home Assessment, the Home Safety Checklist of Indoor Fall Risk), with one each by a physiotherapist (HAP), a public health officer (HEROS Environmental Safety Check), and an architect (CASPAR). Most studies were conducted in North America (n = 18) followed by Australia (n = 10) and Europe (n = 7). Only one study was conducted in Asia. The quality score of all included studies ranged from 14% to 86% (Table 2).

Table 1.

Study Characteristics.

Author	Year	Purpose	Instrument	Study Design	Country	Participant	Rater	Result
Daniel et al.	2013	To evaluate the validity and feasibility of a photography-based home assessment as an alternative for on-site home assessment	No specific instrument Photography	Cross sectional	Switzerland	20 Confidantes of older people	—	Sensitivity: 78.9% Specificity: 84.9% Concurrent validity: r = .87 Convergent validity: moderate (k = .52) and very good (ICC = 0.86)
Northridge, Nevitt, Kesley, and Link	1995	To observe the inter-rater and potential of home hazards to predict falls among older people	Assessments of Home Hazards	Cohort study	United States	Older people: 72 (inter-rater) 323 (cohort)	Older people A nurse	Inter-rater: moderate (k = 0.07–0.81) Predictive validity: Higher with vigorous older people to frail older people (RR: 2.24, 95% confidence interval: 1.54–3.27)
Sanford and Butterfield	2005	To examine the feasibility of remote assessment using paper-and-pencil and tele-video	CASPAR Video remote	Cross sectional	United States	73 Houses	Older people An inexperienced technician Occupational therapists	Overall inter-rater: good Sensitive enough to detect hazards at home of older people
Sanford, Jones, Daviou, Grogg, and Butterfield	2004	To evaluate the criterion validity of the remote home assessment via teleconference over the traditional in-home assessment	CASPAR Tele-rehabilitation	Case study	United States	3 Houses	An inexperienced technician 2 Occupational therapists	Criterion validity: high (86.4–90%)
Sanford, Pynoos, Tejral, and Browne	2002	To develop the assessment tool To investigate the validity and examine the inter-rater reliability of the tool	CASPAR	Expert panel (development) Cross sectional (inter-rater)	United States	70 Houses	15 Health professionals	Overall inter-rater: fair (27–100%) Criterion validity: fair
Fisher, Baker, Koval, Lishok, and Maisto	2007	To determine the assessment tool’s face validity	COUGAR	Cross sectional	United States	44 Older people 13 Occupational therapists	—	Face validity: good
Fisher, Coolbaugh, and Rhodes	2006	To determine the assessment tool’s inter-rater reliability and content validity	COUGAR	Cross sectional (reliability and validity)	United States	35 Occupational therapists (content validity) 14 Older people (inter-rater)	3 Occupational therapists	Overall inter-rater: k = 0.506 Content validity: acceptable level
Iwarsson, Horstmann, Carlsson, Oswald, and Wahl	2009	To test the hypothesis that person-environment fit is a better predictor than environmental barriers for falls	UIMH Enabler	Cohort study	Sweden, Germany, Latvia	834 Older people	—	Predictive validity: strong (or: 1.025, p = .037)
Iwarsson, Nygren, and Slaug	2005	To investigate the cross-national inter-rater reliability with multiprofessionals	Enabler	Cross sectional	Sweden, Germany, Latvia, Hungary, United Kingdom	64 Older people	—	Overall inter-rater: moderate (k = 0.43–0.50).
Carlsson et al.	2009	To develop a reduced version of The Enabler for screening tool, practice, and research use	Enabler	Mixed method	Sweden, Germany, Latvia	264 Community-dwelling older people (quantitative) 6 Occupational therapists (qualitative)	—	Reduction: 61-Items (original 188 items) Validity: strongly correlated with original version: r = .99–.97
Helle et al.	2010	To develop a content validity and to investigate the inter-rater reliability of cross-Nordic version	Enabler	Expert panel (validity) Cross sectional (inter-rater)	Sweden, Finland, Denmark, Iceland	Multiprofessionals (expert panel) 106 adults and older adults with disabilities (inter-rater)	20 Occupational therapists	Content validity: satisfactory preferability Overall inter-rater: fair (k = 0.1–1.00)
Barstow, Bennett, and Vogtle	2011	To examine the SAFER Tool, WeHSA and The Enabler suitability with older people with vision loss	Enabler WeHSA	Qualitative in-depth interview	United States	22 Older people with low vision problem	—	Validity: WeHSA (19/29 items addressing low vision problem) Enabler (7/29 items addressing low vision problem)
Clemson, Roland, and Cumming	1992	To compare the inter-rater reliability of the current and previous WeHSA	WeHSA	Cross sectional	Australia	21 Older people and a young adult	15 Occupational therapists	Overall inter-rater: fair to good (range from 0.00 to 1.00)
Clemson, Fitzgerald, and Heard	1999a	To demonstrate the content validity of the assessment tool	WeHSA	Delphi technique	Australia and overseas	14 Occupational therapists	—	Content validity: CVI = .80
Clemson, Fitzgerald, Heard and Cumming	1999b	To investigate the inter-rater reliability of the tool	WeHSA	Cross sectional	Australia	20 Older people house	Occupational therapists	Overall inter-rater: fair to good (range from 0.48 to 1.00)
Chandler, Duncan, Weiner, and Studenski	2001	To examine the test–retest and inter-rater reliability and predictive validity of the assessment tool	HAP	Cross-sectional survey (inter-rater) Cohort (test–retest, validity)	United States	Community-dwelling older people 24 (inter-rater) 7 (test–retest) 159 (validity)	5 (physiotherapists and physicians)	Inter-rater: ICC = .92 (.73–.94) Test–retest: ICC = .92. Predictive validity: using multivariate logistic regression was p = .03
Gitlin et al.	2002	To evaluate the inter-rater reliability and validity of the tool with older people with dementia	HEAP	Cross sectional (inter-rater and validity)	United States	22 Family caregiver of dementia person	2 Occupational therapists 2 Social science research assistants	Overall inter-rater: inconclusive and varied (k = 0.01–0.95) (ICC = 0.09–0.93) Convergent validity: satisfactory
Sadasivam et al.	2014	To investigate the feasibility of using robot-assisted video to evaluate home hazards	HEROS Environmental Safety Check Robotic video	Mixed method	United States	9 Older people	3 Trained research assistants	Overall inter-rater: poor (mean: 31.5%; range: 0–89%)
Morgan et al.	2005	To examine the inter-rater reliability of self-rated assessment	HES	Cross sectional	United States	52 Community-dwelling older women	Older women 2 Observers	Overall inter-rater: good (k = 0.87)
Rodriguez et al.	1995	To determine the inter-rater reliability of the tool	HES	Cross sectional	United States	11 Model of dwelling units (apartments and houses)	3 (researcher and field supervisors)	Overall inter-rater: fair (k = 0.18–0.92).
Mackenzie, Byles, and D’Este	2009	To evaluate the predictive validity and responsiveness of the tool	HOME FAST	Cohort study	Australia	727 Community-dwelling veterans	—	Predictive validity: strong (OR: 1.016, p = .006) Responsiveness: 1–2% (OR: 0.984, p = .02)
Mackenzie, Byles, and Higginbotham	2000	To design and develop a home hazard screening tool on falls for the use with a community-based older population	HOME FAST	Literature review Cross sectional Expert panel survey	Australia	83 Older veterans and war widows(cross-sectional) 10 health professionals (expert panel)	—	25 Items established (out of 142 items)
Mackenzie, Byles, and Higginbotham	2002a	To observe the transferability and translability of the tool from one country context to another country context	HOME FAST	Cross sectional	United Kingdom	149 Occupational therapists, physiotherapists, nurses	—	Validity: excellent (≥0.30 factor loading) Internal consistency: α = .95
Mackenzie, Byles, and Higginbotham	2002b	To observe the inter-rater reliability of the assessment tool with health professionals	HOME FAST	Cross sectional	Australia	40 Community-dwelling older people	9 (occupational therapists, occupational therapy assistants, social worker)	Overall inter-rater: k = 0.62.
Maghfouri, Mehraban, Taghizade, Aminian, and Jafari	2013b	To determine the inter-rater and test–retest reliability of the Persian version of the tool	HOME FAST	Cross sectional	Iran	60 Healthy community-dwelling older people	Available but not mentioned	Overall test–retest: k = 0.93. Overall inter-rater: k = 0.85
Mehraban, Mackenzie, and Byles	2011	To develop and evaluate the validity and reliability of self-reported version of the tool	HOME FAST	Expert panel (content validity) Cross sectional (pilot, reliability, convergent validity)	Australia	4 Occupational therapists (expert panel) Older women: 17 (pilot) 39 (inter-rater) 568 (cross sectional)	Older women 9 Occupational therapists	Content validity: satisfactory association of the 87-items (self-reported) with 25-items (original) Overall inter-rater: moderate (k = 0.01–0.8)
Vu and Mackenzie	2012	To further establish inter-rater and test–retest reliability of the tool	HOME FAST	Cohort	Australia	Older people 31 (inter-rater) 29 (test–retest)	9 Occupational therapists	Overall inter-rater: ICC = 0.82 Overall test–retest: ICC = 0.77)
Stalenhoef, Diederiks, Knottnerus, Witte, and Crebolder	1998	To develop the assessment tool for home environment hazards evaluation use	Home Safety Checklist of Indoor Fall Risk	Delphi technique Cohort study	the Netherland	7 (Occupational therapists, a nurse, a social insurance expert; Delphi study) 311 older people (cohort)	2 Physicians	Development: 23-items tool developed Overall inter-rater: k = 0.66 Predictive validity: poor
Johnson, Cusick, and Chang	2001	To examine the construct validity and reliability of the assessment tool	HSS	Cross sectional	Australia	1,165 Community-dwelling veterans	—	Construct validity: adequate level (60%) Cutoff score: 74 (p = .047) Internal consistency: α = .86
Horowitz, Nochajski, and Schweitzer	2013	To develop a self-completed home environment assessment tool	HSSAT	Focus group (validity) Case-study (feasibility)	United States	Community-dwelling older people 22 (focus group) 1 (case study)	—	Face and content validity: satisfactory
Tomita, Saharan, Rajendran, Nochajski, and Schweitzer	2014	To test the reliability (inter-rater and test–retest), validity (content, construct, convergent, discriminant) and responsiveness to change of the tool	HSSAT	Expert panels (content validity Cohort (test–retest) Cross sectional (inter-rater, other validities) Pretest–posttest (responsiveness)	United States	5 Occupational therapists (content validity) Older people: 26 (test–retest) 5 (inter-rater) 34 (construct, convergent, discriminant validity) 104 (responsiveness)	2 Occupational therapists	Content validity: satisfactory (I-CVI = 0.98). Overall test–retest: ICC = 0.97. Overall inter-rater: ICC = 0.89 Convergent validity: very high (r = .65) Discriminant and construct validity: fear of falling was very low (r = .10) Responsiveness: moderate (SRM = 0.57).
Stark, Somerville, and Morris	2010	To develop an occupation-based home environment tool To examine the inter-rater, internal consistency, and convergent validity of the tool	I-HOPE	Phase 1: Case control Cross sectional Phase 2: Cross sectional	United States	Phase 1: >200 clinical records (case control) 458 (cross sectional) Phase 2: 10 Older people (cross sectional)	2 Occupational therapists	Development: containing 44 items. Internal consistency: α = .77–.85. Overall inter-rater: excellent (ICC: 0.94–1.00) Convergent validity: Functional independency (r = .53, p = .00) Chronic conditions (r = −.41, p = .00)
Ritchey, Meyer, and Ice	2015	To investigate the feasibility of using digital photography to evaluate home hazards on the Ritchey home assessment	Ritchey Home Assessment Photography	Cross sectional	United States	10 Simulated environment (original instrument) 10 Older people (photography)	3 Medical students	Validity: was not thoroughly reported Overall inter-rater reliability of the original instrument: substantial (k = 0.68) Overall inter-rater reliability for photography: substantial (k = 0.61)
Chiu and Oliver	2006	To examine the factor analysis, reliability, and validity of the development of SAFER HOME	SAFER-HOME	Mixed method (validity) Cross sectional (factor analysis and reliability) Cross-sectional survey (convergent validity)	Canada	First study: Occupational therapists 70 (Quantitative) 7 (Qualitative) Second study 1,173 older people Third study 133 Older people	—	Acceptability: 76–96% resulted to 93-items accepted Internal consistency: α = .859 Divergent validity: α = −.206 (p = .018)
Carter, Campbell, Sanson-Fisher, Redman, and Gillespie	1997	To investigate the inter-rater reliability of the tool	Safety Housecheck	Cross-sectional survey	Australia	Older people: 425 (prevalence) 58 (inter-rater)	Not reported	Inter-rater incorrectly reported
Sorcinelli, Shaw, Freeman, and Cooper	2007	To establish inter-rater reliability on administrators and self-reported version	The Safe Living Guide	Cross sectional	Canada	Phase: 42 Older people Phase 2: 34 Older people	5 Occupational therapy graduate students (Phase 1) 76 Older people (Phase 2)	Overall inter-rater: Good (k = 0.73) for expert raters Moderate (k = 0.51) for older raters Content validity: good

Note. CASPAR = Comprehensive Assessment and Solution Process for Aging Residents; CVI = Content Validity Index; UIMH = Usability in My Home; WeHSA = Westmead Home Safety Assessment; HAP = Home Assessment Profile; HEAP = Home Environmental Assessment Protocol; HES = Home Environment Survey ; HOME FAST = Home Falls and Accidents Screening Tool; HSS = Home Screen Scale; HSSAT = Home Safety Self-Assessment Tool; I-CVI = Item Content Validity Index; ICC = Intraclass Correlation Coefficient; I-HOPE = In-Home Occupational Performance Evaluation; k = kappa; RR = Relative Risk; SAFER-HOME = Safety Assessment of Function and the Environment for Rehabilitation–Health Outcome Measurement and Evaluation; SRM = standardized response mean.

Table 2.

Quality Rating of Each Study Using the Quality Appraisal for Clinical Measurement Research Reports Evaluation Form.

Studies	Instrument	Evaluation Criteria^a (Score: 2 = Good, 1 = Moderate, 0 = Poor, N/A = Not Applicable)												Score (%)
Studies	Instrument	Item 1	Item 2	Item 3	Item 4	Item 5	Item 6	Item 7	Item 8	Item 9	Item 10	Item 11	Item 12	Score (%)
Daniel et al. (2013)	Photography	0	2	1	0	0	N/A	1	1	2	2	1	1	50
Northridge et al. (1995)	Assessment of Home Hazards	0	2	0	0	1	N/A	1	0	1	1	0	0	27
Sanford and Butterfield (2005)	CASPAR	1	1	1	0	1	N/A	1	1	2	2	1	1	55
Sanford et al. (2004)	CASPAR	2	1	1	0	0	N/A	2	2	2	2	1	1	64
Sanford et al. (2002)	CASPAR	2	1	1	1	1	N/A	1	2	2	1	0	1	59
Fisher et al. (2007)	COUGAR	2	1	0	0	0	N/A	0	1	1	0	0	0	23
Fisher et al. (2006)	COUGAR	2	0	1	1	0	N/A	1	1	2	2	0	1	50
Iwarsson et al. (2009)	UIMH, Enabler	2	1	2	0	1	1	2	2	1	2	1	1	67
Carlsson et al. (2009)	Enabler	2	0	1	2	1	N/A	1	1	1	2	2	2	68
Helle et al. (2010)	Enabler	2	0	1	1	1	N/A	2	1	1	2	1	2	64
Iwarsson et al. (2005)	Enabler	1	1	1	1	0	N/A	2	2	1	1	1	1	55
Barstow et al. (2011)	Enabler, WeHSA	1	2	0	0	0	N/A	1	1	1	0	0	1	32
Clemson et al. (1992)	WeHSA	1	1	1	0	0	N/A	1	1	2	2	1	1	50
Clemson et al. (1999a)	WeHSA	2	1	1	0	0	N/A	1	1	2	1	1	1	50
Clemson et al. (1999b)	WeHSA	2	1	2	0	0	N/A	1	1	2	2	1	2	64
Chandler et al. (2001)	HAP	0	1	1	2	1	0	2	1	1	2	0	1	50
Gitlin et al. (2002)	HEAP	2	2	2	1	0	N/A	2	2	2	2	2	2	86
Sadasivam et al. (2014)	HEROS	0	1	0	0	0	N/A	1	1	1	1	0	1	27
Morgan et al. (2005)	HES	1	1	1	1	1	N/A	2	1	2	2	1	1	64
Rodriguez et al. (1995)	HES	2	0	1	0	0	N/A	1	1	1	2	1	1	45
Mackenzie et al. (2009)	HOME FAST	1	1	1	1	1	1	2	2	1	2	1	2	71
Mackenzie et al. (2000)	HOME FAST	1	1	1	0	1	N/A	2	2	2	2	2	1	68
Mackenzie et al. (2002a)	HOME FAST	2	1	2	0	1	N/A	2	2	2	2	2	1	73
Mackenzie et al. (2002b)	HOME FAST	1	1	1	0	1	N/A	2	2	2	2	2	2	68
Maghfouri et al. (2013b)	HOME FAST	1	2	1	1	1	0	1	0	2	2	0	0	50
Mehraban et al. (2011)	HOME FAST	2	2	1	2	1	N/A	2	2	2	2	1	1	82
Vu and Mackenzie (2012)	HOME FAST	2	1	1	1	1	2	2	2	2	2	2	2	83
Stalenhoef et al. (1998)	Home Safety Checklist of Indoor Fall Risk	1	2	1	1	2	2	0	1	1	2	1	1	63
Johnson et al. (2001)	HSS	2	1	1	1	1	N/A	2	1	2	2	1	1	73
Horowitz et al. (2013)	HSSAT	2	0	0	0	0	N/A	1	0	0	0	0	0	14
Tomita et al. (2014)	HSSAT	1	2	1	2	0	2	1	1	2	2	2	1	75
Stark et al. (2010)	I-HOPE	1	2	1	2	0	N/A	2	2	2	2	2	2	82
Ritchey et al. (2015)	Ritchey Home Assessment	2	2	0	1	1	N/A	1	2	2	2	1	2	73
Chiu and Oliver (2006)	SAFER-HOME	2	1	1	2	1	N/A	2	1	2	2	1	2	77
Carter et al. (1997)	Safety Housecheck	1	2	0	0	1	N/A	1	0	1	0	0	1	32
Sorcinelli et al. (2007)	The Safe Living Guide	2	1	1	1	1	N/A	2	2	2	2	1	1	73

^aItem 1: Relevant background on psychometric properties and research question; Item 2: inclusion/exclusion criteria; Item 3: specific psychometric hypothesis; Item 4: appropriate scope of psychometric properties; Item 5: appropriate sample size; Item 6: appropriate retention/follow-up; Item 7: specific descriptions of the measures (administration, scoring, interpretation procedures); Item 8: standardization of methods; Item 9: data presented for each hypothesis or purpose; Item 10: appropriate statistical tests; Item 11: appropriate secondary analyses; and Item 12: conclusions/clinical recommendations supported by analyses and results. CASPAR = Comprehensive Assessment and Solution Process for Aging Residents; UIMH = Usability in My Home; WeHSA= Westmead Home Safety Assessment; HAP = Home Assessment Profile; HEAP = Home Environmental Assessment Protocol; HES = Home Environment Survey ; HOME FAST = Home Falls and Accidents Screening Tool; HSS = Home Screen Scale; HSSAT = Home Safety Self-Assessment Tool; I-SAFER-HOME = Safety Assessment of Function and the Environment for Rehabilitation–Health Outcome Measurement and Evaluation.

Psychometric Properties of Each Instrument

The psychometric properties of each instrument are presented in Table 3. All instruments had evidence of at least one type of validity or reliability. Five studies conducted predictive validity testing that is considered a key property in predicting falls risk. From these five studies, two studies (Chandler, Duncan, Weiner, & Studenski, 2001; Mackenzie, Byles, & D’Este, 2009) showed positive results on the HOME FAST and the HAP and two studies (Iwarsson et al., 2009; Northridge, Nevitt, Kesley, & Link, 1995) showed mixed results (UIMH, Enabler, Assessments of Home Hazards), while one study (Stalenhoef et al., 1998) showed a negative ability of the Home Safety Checklist of Indoor Fall Risk to predict falls. A summary of the total number of psychometric evidence is also provided in Table 3.

Table 3.

Ranking of the Instruments by Psychometric Properties based on the Terwee Checklist Outcome.

Instrument Tool	Terwee Checklist (Score: + = positive; ? = intermediate; − = poor; 0 = no information available)									Total score rating
	Content Validity	Internal Consistency	Criterion Validity	Construct Validity	Reproducibility		Responsiveness	Floor or Ceiling Effect	Interpretability	Total score rating
	Content Validity	Internal Consistency	Criterion Validity	Construct Validity	Agreement	Reliability	Responsiveness	Floor or Ceiling Effect	Interpretability	+	?	-
HOME FAST	+	+	?(i)	+	+	?,?(i)	?	+	+	6	4	N/A
I-HOPE	+	+	0	+	0	?	?	0	?	3	3	N/A
HEAP	+	0	0	+	0	?	0	0	+	3	1	N/A
SAFER-HOME	+	+	0	+	0	0	0	0	0	3	N/A	N/A
HSSAT	+	0	?	?	+	?	?	0	?	2	5	N/A
UIMH	0	?	0	+	0	0	0	0	+	2	1	N/A
WeHSA	?, +(l),?(j)	0	?(l)	0	0	?	0	0	0	1	4	N/A
HES	?, +(g)	0	0	0	?(g)	?,?(g)	0	0	0	1	4	N/A
The Safe Living Guide	+	0	0	0	0	?	0	0	?	1	2	N/A
Ritchey Home Assessment	?	0	0	0	0	?,?(f)	0	0	0	N/A	3	N/A
HSS	?	+	0	0	0	0	0	−	+	2	1	1
The Enabler	?,?(j),?(k)	0	?(k)	?	0	?	0	+	−	1	6	1
CASPAR	?	0	?, +(a)	0	?(a),?(b)	−,?(a),?(b)	0	0	0	1	6	1
COUGAR	+(c),?(d)	0	0	0	0	−(e)	0	0	0	1	1	1
Safety Housecheck	?	0	0	0	0	−	0	0	+	1	1	1
Assessment of Home Hazard	?	?	0	−	0	?	0	0	?	N/A	4	1
HAP	−	0	0	?	0	?	0	0	?	N/A	3	1
HEROS Environmental Safety Check	0	0	0	0	0	−(h)	0	0	0	N/A	N/A	1
Home Safety Checklist of Indoor Fall Risk	−	0	0	−	0	−	0	+	?	1	1	3

Note. In most, ratings are based on the original instrument, but certain instruments have additional version investigated, where the additional version was mark according to the following: a = CASPAR paper-and-pencil version; b = CASPAR televideo; c = COUGAR version 1.0; d = COUGAR version 2.0; e = COUGAR original paper-and-pencil; f = photography; g = HES self-checklist; h = robotic video; i = HOME FAST self-report version; j = visually impaired older people; k = enabler-reduced version; l = WeHSA short form. N/A = not available. CASPAR = Comprehensive Assessment and Solution Process for Aging Residents; UIMH = Usability in My Home; WeHSA= Westmead Home Safety Assessment; HAP = Home Assessment Profile; HEAP = Home Environmental Assessment Protocol; HES = Home Environment Survey ; HOME FAST = Home Falls and Accidents Screening Tool; HSS = Home Screen Scale; HSSAT = Home Safety Self-Assessment Tool; I-HOPE = In-Home Occupational Performance Evaluation; SAFER-HOME = Safety Assessment of Function and the Environment for Rehabilitation–Health Outcome Measurement and Evaluation.

Clinical Utility

Twelve instruments (HAP, HEAP, HES, HEROS Environmental Safety Check, HOME FAST, HSS, HSSAT, Ritchey Home Assessment, SAFER-HOME, Enabler, The Safe Living Guide, WeHSA) focused on the person–environment interaction when evaluating home hazards. Five instruments (Assessment of Home Hazard, CASPAR, COUGAR, Home Safety Checklist of Indoor Fall Risk, and Safety Housecheck) focused solely on assessment of the physical home environmental hazards. Meanwhile, two instruments (I-HOPE, UIMH) focused on individual functioning within the home with a lesser emphasis on elements of the physical environment. The Assessment of Home Hazards, the HES, the HEROS Environmental Safety Check, the HAP, the HOME FAST, the Home Safety Checklist of Indoor Fall Risk, the HSS, the HSSAT, the Ritchey Home Assessment, and the WeHSA were specifically developed for older fallers, while the other instruments were generic instruments that could be suitable for older fallers. The clinical utility of each instrument is presented in Table 4.

Table 4.

Clinical Utility of the Instruments.

Instrument	Number of Item	Usage	Time Duration	Language	Training Requirement	Administrator	Accessibility
Assessment of Home Hazard	49	Assessment tool	Unknown	English	Self-reading of manual	Nurses Older people	Unable to replicate May need to contact the author
CASPAR	59	Assessment tool Modification intervention	Approximately 30 min	English	No training but requires experience in home evaluation and modification	Occupational therapists Rehabilitation specialists	Free (require registration)
COUGAR	56 (version 1.0) 52 (version 2.0) 66 (version 3.0) 78 (version 4.0)	Assessment tool	Approximately 60 min	English	No training but requires experience in home evaluation and modification	Occupational therapists	Free (internet download)
Ritchey Home Assessment	44	Assessment tool	22–25 min	English	No training required	Nontherapist health practitioners	Unable to replicate. May need to contact the author
HES	73 (HES/HC)	Assessment tool	Unknown	English	One week of training and an on-site practice	Rehabilitation specialists	Unable to replicate. May need to contact the author
HAP	58	Assessment tool	60–120 min	English	Requires training but duration not mentioned	Physiotherapists Physicians	Unable to replicate. May need to contact the author
HOME FAST	25	Screening tool Outcome measure	Approximately 20 min	English Persian Mandarin	Self-reading of manual but brief one-hour introductory workshop is desirable	Occupational therapists Physiotherapists Social worker Older people	Free open Possible to replicate from article
HEAP	192	Assessment tool	Approximately 45 min	English	Three hours of training	Occupational therapists Social science personnel	Require purchase
HEROS Environmental Safety Check	23	Assessment tool	Unknown	English	Requires training but duration not mentioned	Nurse Research assistants	Free (internet download)
Home safety Checklist of Indoor Fall Risk	23	Not suitable to be use	Unknown	English	Requires training but duration not mentioned	Older people	Replicable from the article
Home-Screen Scale	10	Screening tool	Unknown	English Turkish	No training required	Nurses	Might be possible to replicate from article Require permission. Contact the author
HSSAT	64	Assessment tool	Approximately 40 min	English	No formal training but seek professional guidance is desirable	Occupational therapists Older people	Free (internet download from developer site)
I-HOPE	44	Assessment tool	Unknown	English	Requires four hours of training	Occupational therapists	Require purchase
SAFER-HOME	97 (version 1) 93 (version 2) 74 (version 3)	Assessment tool	Between of 60 and 90 min	English French	Requires training but duration not mentioned	Occupational therapists	Require purchase
Safety Housecheck	99	Assessment tool	Unknown	English	Requires training but duration not mentioned	Not known	May need to contact the author to retrieve full instrument
The Enabler	188 (original) 61 (reduced) 161 (2010 version)	Assessment tool	Around 90–120 min	English Swedish German Finnish Danish Latvian Hungarian Portuguese Icelandic	Two days of lecture and a practical training	Occupational therapists Health professionals Real estate employees	Require to purchase the tool
The Safe Living Guide	70	Assessment tool	Approximately 30 min	English French	Requires training but duration not mentioned	Older people	Free downloadable from the Internet
UIMH	23	Assessment tool Outcome measure	Unknown	English Swedish German Hungarian Latvian	Intensive training is required but duration not mentioned	Occupational therapists	Require permission and purchase of the tool
WeHSA	72 (original) 43 (short form)	Assessment tool Outcome measure	Approximately 90 min	English	4-Hr workshop and two in-home self-practice	Occupational therapists	Require purchase or contact the author

Note. CASPAR = Comprehensive Assessment and Solution Process for Aging Residents; UIMH = Usability in My Home; WeHSA= Westmead Home Safety Assessment; HAP = Home Assessment Profile; HEAP = Home Environmental Assessment Protocol; HES = Home Environment Survey ; HOME FAST = Home Falls and Accidents Screening Tool; HSS = Home Screen Scale; HSSAT = Home Safety Self-Assessment Tool; I-HOPE = In-Home Occupational Performance Evaluation; SAFER-HOME = Safety Assessment of Function and the Environment for Rehabilitation–Health Outcome Measurement and Evaluation.

Discussion

This systematic review has identified 19 home hazard instruments for use with older people at risk of falls and has provided comprehensive information on the psychometric properties and clinical utility of these instruments. There is no consensus on the number of studies related to psychometric properties that an instrument should be able to demonstrate to be considered a psychometrically sound instrument. However, Cook and Beckman (2006) suggested that an instrument should at least contain evidence on five psychometric properties—content, construct and criterion validity, inter-rater reliability, and responsiveness. Only the HOME FAST instrument has evidence on all these properties. Predictive validity is among the highest quality and most important type of validity to strengthen the purpose of the instrument and increase the accuracy of the instrument to measure what it is intended to measure (Murphy, 2009). Only a small number of instruments investigated predictive validity. The HOME FAST, HAP, UIMH, the Enabler, and the Assessment of Home Hazards have adequate evidence on predictive validity in relation to falls risk. The Home Safety Checklist for Indoor Fall Risk has poor predictive validity and is not suitable to be used for a falls risk instrument. Many instruments appeared to demonstrate less than robust methods in terms of sample size and analysis.

However, strong psychometric evidence does not mean the instrument will be well accepted for use in practice. For example, although the Enabler is supported by a number of studies investigating its psychometric properties, it has been criticized because of the demands of training requirements to use it and the lengthy administration time. Thus, a shorter version of the Enabler was developed with fewer items requiring less time to complete the instrument while retaining the psychometric strengths of the original version (Carlsson et al., 2009). Similarly, the COUGAR instrument has established psychometric properties but has received low interest by practitioners for use in practice (Fisher et al., 2007, 2008). In contrast, the WeHSA has evidence of content validity and inter-rater reliability only but is considered the “gold standard” home hazards instrument and is accepted for use in practice by occupational therapists (Fabre, Ellis, Kosma, & Wood, 2010; Tzingounakis, 2012).

Only 10 of the 19 instruments in this review were developed specifically in relation to home hazards and falls risk. The remaining nine instruments focused more broadly on environmental hazards with only some studies focusing on falls. However, an understanding of the characteristics of instruments can assist health practitioners to make better choices on which instrument to use in a specific situation for a specific intervention objective and for researchers to further investigate the applicability of the instruments with older fallers.

Recommendations and Implications

This review has offered a good platform for practitioners to choose the most appropriate standardized instrument for practice. Using nonstandardized instruments contributes to health practitioners not being able to explain the relevance and necessity of interventions to clients and other disciplines, according to available evidence. Nonstandardized instruments might over- or underestimate falls risk, and therefore unnecessary, excessive, or inadequate modifications were recommended as a result (Weeks, Lamb, & Pickens, 2010). Selection of an instrument should be based on the reasoning and justification by the health practitioner on the need to conduct a home visit and home evaluation. The reasoning will often be associated with a client’s living arrangement, conditions, and functional level as well as how far the instrument provides meaningful intervention planning, how much time it takes to administer, and the resources needed (Atwal et al., 2014; Weeks et al., 2010).

There are nine instruments with satisfactory evidence about psychometric properties. From these, we recommend the HOME FAST for a screening evaluation, as the HOME FAST has the most psychometric properties, requires minimal training, was designed specifically for older people at risk of falls, has a minimal number of items, and is openly available. For a thorough assessment by an occupational therapist, we recommend the WeHSA as the instrument is widely accepted in occupational therapy practice, is considered the gold standard instrument, and was specifically developed for falls. In addition, we suggest the HSSAT for a thorough self-administered instrument due to its evidence of psychometric properties, and it was also specifically developed for falls and for older people to self-administer. The I-HOPE should be considered for further exploration in relation to detecting risk of falls based on its unique focus on the functionality of the older person in the home environment.

Many instruments implemented manual in-home observation methods either administered by practitioners or clients. However, there are difficulties associated with practitioners undertaking visits to the homes of older people due to other clinical duties and time needed for travel, arranging a visit, and acquiring permission to observe the house (Atwal et al., 2014). Photography was found to be the most cost-effective and plausible technique to substitute the needs for health practitioners to be present in the home to conduct a home assessment. Researchers should conduct future study to evaluate the feasibility of using a photography technique to supplement information available from established standardized instruments to strengthen the use of standardized instrument in practice. It may be possible for researchers to consider affordable and easily available technology such as Skype and FaceTime to evaluate the home environment quickly and in real time rather than using more costly technology. However, only if this is of high quality.

Study Strengths and Limitations

The study was strengthened by the additional use of reference searching and citation tracking process beyond the usual searching methods, and almost a quarter of the studies included came from the these additional processes. However, the review was limited by a number of factors. Our review excluded gray literature, non-English articles, and nonprimary studies. Several instruments reported psychometric properties in nonpeer-reviewed publications; for example, the HEROS Environmental Safety Check reported some psychometric properties in its manual. Other instruments reported psychometric properties in foreign language journals; for example, a small number of HOME FAST psychometric properties were reported in Persian and Chinese (Guo et al., 2015; Maghfouri, Mehraban, Taghizade, Aminian, & Jafari, 2012, 2013a) and the Home-Screen Scale was reported in Turkish (Uysal, Ardahan, & Ergu¨, 2006). One review reported valuable information such as the Enabler instrument having been translated into several languages (Iwarsson, Haak, & Slaug, 2012).

Conclusion

This systematic review provides a comprehensive evaluation of home hazards instruments related to falls with older people living in the community. From our review, the I-HOPE, HSSAT, WeHSA, and the HOME FAST have demonstrated evidence of clinimetric properties. We considered photography as a potential technique to be explored in supplementing the traditional in-home assessment conducted by practitioners. However, there is no instrument that is likely to be appropriate to all situations and populations. Researchers and practitioners should provide justification before choosing an instrument to match their intervention planning. The findings from this systematic review will enable practitioners to select appropriate measures of home hazards to use in practice and will allow researchers to better investigate the risk of falls related to home hazards among the community-dwelling older people in future studies.

Footnotes

Appendix

Table A1.

List of Excluded Studies With Reason for Exclusion.

Studies	Reason of Exclusion
Anemaet and Moffa-Trotter (1999)	Not an original study (literature review) Study was not about psychometric property investigation
Barras (2005)	Not an original study (systematic review) Study was not about psychometric property investigation
Brandt et al. (2008)	Instruments not about home hazards but about mobility
Brasset-Latulippe, Al-Hazzouri, Hébert, Bourgault-Coté, and Meilleur (2010)	Study was not about psychometric property investigation
Calys, Gagnon, and Jernigan (2013)	Comprehensive assessment where home hazards items were unclear
*Carignan, Rousseau, Gresset, and Couturier (2008)	Focus of the study was not on falls
*Clemson et al. (1996)	Study was not about psychometric property investigation
*de Courval et al. (2006)	Comprehensive assessment where home hazards items were negligible
Demons et al. (2014)	Study was not about psychometric property investigation
Dove (1999)	Study was not about psychometric property investigation
*Erkal (2010)	Study was not about psychometric property investigation
Fabre, Ellis, Kosma, and Wood (2010)	Not an original study (literature review)
*Fänge and Iwarsson (1999)	Focus of the study was not on falls
*Fänge and Iwarsson (2003)	Focus of the study was not on falls
Fänge, Risser, and Iwarsson (2007)	Study was not about psychometric property investigation
Fisher et al. (2008)	Study was not about psychometric property investigation
Flemming and Ramsay (2012)	Study was not about psychometric property investigation Instrument was unsure about home hazards
Gallagher, Stith, and Southard (2013)	Home hazards not related to falls
Gates, Smith, Fisher, and Lamb (2008)	Study was not about psychometric property investigation Home hazards not related to falls
Greene, Sample, and Fruhauf (2009)	Study was not about psychometric property investigation Home hazards not related to falls
Helle and Brandt (2009)	Gray literature (conference proceeding abstract)
Hnizdo, Archuleta, Taylor, and Son Chae (2013)	Study was not about psychometric property investigation Comprehensive assessment where home hazards items were negligible
Horowitz (2002)	Study was not about psychometric property investigation Home hazards not related to falls
Iwarsson (1999)	Study was not about psychometric property investigation
*Iwarsson and Isacsson (1996)	Focus of the study was not on falls
Iwarsson, Haak, and Slaug (2012)	Not an original study (literature review)
*Iwarsson, Slaug, and Fänge (2012)	Focus of the study was not on falls
Jakovljevic (2009)	Study population not with community older people Instrument not on home hazards
Kara, Yildirim, Genc, and Ekizler (2009)	Full text not in English Study not related to falls
*Keglovits, Somerville, and Stark (2015)	Study population not with community older people Focus of the study was not on falls
Keysor, Jette, and Haley (2005)	Focus of the study was not on falls Instrument not about home hazards
Leclerc et al. (2010)	Study was not about psychometric property investigation
*Letts and Marshall (1996)	Focus of the study was not on falls
*Letts, Scott, Burtney, Marshall, and McKean (1998)	Focus of the study was not on falls
Lowery, Buri, and Ballard (2000)	Study was not about psychometric property investigation
Maghfouri et al. (2012)	Full text not in English
Maghfouri et al. (2013a)	Full text not in English
Morris et al. (1997)	Comprehensive assessment where home hazards items were unclear
Newton (2006)	Not an original study (literature review)
Painter (1996)	Focus of the study was not on falls Study was not about psychometric property investigation
Perlmutter et al. (2013)	Focus of the study was not on falls Instrument limited to lighting aspect
Pynoos, Steinman, and Nguyen (2010)	Study was not about psychometric property investigation
Renfro and Fehrer (2011)	Study was not about psychometric property investigation Not in the home (primary care setting)
Robnett, Hopkins, and Kimball (2002)	Study population not with community older people Focus of the study was not on falls
Rousseau, Potvin, Dutil, and Falta (2001)	Study was not about psychometric property investigation Focus of the study was not on falls
Rousseau, Potvin, Dutil, and Falta (2013)	Study population not with community older people Focus of the study was not on falls
Schulz et al. (2012)	Focus of the study was not on falls
Sim, Barr, and George (2015)	Focus of the study was not on falls
*Tanner (2003)	Study was not about psychometric property investigation
Tomita (2012)	Gray literature (Conference proceeding abstract)
Weeks, Lamb, and Pickens (2010)	Not an original study (literature review)
You, Deans, Liu, Zhang, and Zhang (2004)	Study was not about psychometric property investigation
Yuen and Austin (2014)	Not an original study (systematic review) Not about home hazards instruments for falls

Note. Asterisk (*) indicates articles excluded during full text eligibility.

Authors’ Note

This study is conducted as part of the first author’s PhD project at the University of Sydney. Lynette Mackenzie is the developer of Home Falls and Accidents Screening Tool (HOME FAST) and Lindy Clemson is the developer of Westmead Home Safety Assessment (WeHSA).

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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