Outdoor Falls Prevention Strategy Use and Neighborhood Walkability Among Naturally Occurring Retirement Community Residents

Abstract

Background

Outdoor falls present a significant challenge to the health and well-being of older adults. Safe strategy use is an important component of falls prevention, yet little is known regarding use of outdoor falls prevention strategies.

Aims

To examine outdoor falls prevention strategy use among naturally occurring retirement community residents at risk for falls, and to examine associations with neighborhood walkability.

Methods

Descriptive analyses of pretest data from an intervention study (N = 97) were conducted to examine frequency of outdoor falls prevention strategy use. Walk Score^® data were added to the dataset, and chi-square tests of independence were used to examine associations between walkability categories and outdoor falls prevention strategy use.

Results

Some strategies, such as visual scanning and holding rails on stairs, were used by 70% or more of participants while others, such as route planning, were infrequently or inconsistently used. With the exception of avoiding cell phone use while walking outdoors, no significant associations were found between walkability categories and outdoor falls prevention strategy use.

Conclusion

Study findings serve as a needs assessment for health education and behavioral training.

Keywords

aging and older adults community health promotion health education neighborhood

Close to 80% of adults age 50 and older prefer to remain active and engaged in their own homes and communities as they age (American Association of Retired Persons, 2018). “Aging in place” can be defined as the ability to live in one’s own home and community, comfortably, safely, and independently regardless of income, age, or ability level (Centers for Disease Control and Prevention, 2009). Promoting the ability of older adults to age in place is part of the mission of naturally occurring retirement communities (NORCs), and their associated community-based programs and services help facilitate this client-centered goal. NORC programs offer case management, community connection, health and wellness programing, and opportunities for social participation. NORC staff members are key to effective programs and services. However, supportive exchanges among NORC program members, that is, members helping members, and fruitful partnerships with other community organizations also help facilitate effective program outcomes (Elbert & Neufeld, 2010; Greenfield, 2016). NORC program success is manifest in a number of ways including better health and a lower rate of nursing home admissions among program participants (Elbert & Neufeld, 2010).

In addition to organized programs and services that promote a physically and socially active lifestyle, characteristics of NORC neighborhoods also play a key role in the ability to successfully age in place. Examples include a safe and crime-free environment, senior friendly policies, adequate public transportation, and walking access (Masotti et al., 2006).

The neighborhood environment contributes to healthy and productive aging and the ability to age in place. However, the neighborhood environment’s features can also result in detrimental consequences, such as falls. Neighborhood walkability is one component of the risk profile for fallers (Satariano et al., 2017) as the physical and social environment can increase both fear of falling and the risk for falls (Lee et al., 2019; Nicklett et al., 2017). Walkability can be defined as the extent to which a neighborhood is conducive to walking. Examples of walkability features include aesthetics, user friendliness of street crossings, behavior of drivers, and availability of amenities (National Highway Traffic Safety Administration, 2020). Examples of environmental hazards that affect walkability and that have been associated with outdoor falls and/or fear of falling include uneven and poorly maintained streets and sidewalks, stairs, litter, drainage ditches, traffic speed, slippery surfaces, objects (e.g., stones, sticks), lack of social cohesion, the social environment, and loud noises (Chippendale & Raveis, 2017; Lee et al., 2018; Nicklett et al., 2017; Nyman et al., 2013).

Outdoor falls can be defined as coming to rest on the ground or a lower level in an outdoor setting as a result of a trip, slip, being pushed or struck. Outdoor falls are often caused by a combination of risk factors rather than a single contributing factor. A person’s behavior is an independent risk factor, but can also interact with an environmental hazard to precipitate an outdoor fall (Chippendale & Raveis, 2017). Examples of behaviors that contribute to outdoor falls include rushing, inattention to environmental hazards, unsafe strategies for carrying items, not using a prescribed mobility aid, overexertion, use of multifocal lenses, and improper footwear (Chippendale & Raveis, 2017; Clemson et al., 2003a; Nyman et al., 2013). Although using falls prevention strategies can mitigate the risk of a fall, some studies indicate that little to no action or behavior change is initiated by older adults after a fall, even among those who have sustained injuries (Shankar et al., 2017). Reasons for behaviors associated with increased fall risk and barriers to implementing outdoor falls prevention strategies are not well understood, but may include the demands of caregiving and resulting focus of attention on a spouse or family member with a mobility disability, knowledge gaps, and perceived stigma associated with use of a mobility aid (Chippendale & Raveis, 2017; Resnik et al., 2009).

Little is known regarding the frequency of outdoor falls prevention strategies used by older adults to prevent outdoor falls. In order to effectively meet the health and wellness needs of NORC residents, a better understanding of outdoor falls prevention strategy use and the association with neighborhood walkability is warranted. NORC neighborhoods have large concentrations of older adults. Furthermore, the aim of NORC programs is to promote aging in place. Therefore, NORCs are an important context for examining outdoor falls prevention strategy use and for addressing outdoor falls.

Although there are a number of existing evidence-based falls prevention programs available (National Council on Aging, 2020), none were specifically designed to target outdoor falls. Consequently, NORCs have not been able to offer evidence-based outdoor falls prevention programs to their members. Therefore, a needs assessment of gaps in outdoor falls prevention strategy use is warranted to help inform prevention programs. The Ecological Model highlights the impact of the physical environment on health behaviors (National Cancer Institute, 2005). Therefore, with program planning in mind, one aspect of the physical environment, namely, neighborhood walkability, also warrants study with regard to its impact on outdoor falls prevention strategy use.

In order to help fill knowledge gaps, the primary purpose of this study is to examine the frequency of outdoor falls prevention strategy use among NORC residents who are at risk for outdoor falls. Given that the use of outdoor falls prevention strategies may be influenced by the neighborhood environment, the secondary purpose of this study was to examine associations between Walk Score categories and the use of such strategies.

Method

Research Design

A cross-sectional, descriptive study was conducted. Pretest data from a multisite intervention study was used. Components of the intervention study data used for the purpose of this study are described in the measures section. A total of 97 participants met the inclusion criteria, consented to participate in the study, and completed pretests. Walkability data from a publically available data source (i.e., Walk Score) was also obtained for each participant’s home address. The study was approved by the institutional review board at the principal investigator’s institution.

Measures

The Falls Behavioral Scale for the Older Person (FaB) is a valid and robust measure of protective behavior used by older adults to prevent falls. Response choices for each question range from “never” to “always” for each falls prevention strategy (Clemson et al., 2003b). The FaB includes falls prevention strategies that pertain to both indoor and outdoor falls. Questions that pertain to outdoor falls prevention strategies were the focus of this study. For descriptive purposes, the average score for the 24-item version of the FaB was also reported.

The Outdoor Falls Questionnaire (OFQ) is a measure of perceived outdoor fall risks and outdoor falls prevention strategy use. It has strong content and face validity, and test–retest reliability (Chippendale, 2015). It includes demographic (e.g., age, education level, race, ethnicity) and background questions regarding functional status (e.g., number of activities of daily living/instrumental activities of daily living [ADLs/IADLs] requiring assistance, use of a mobility aid), use of psychotropic medications, depressive symptoms, walking speed, and alcohol use. The OFQ also includes outdoor falls prevention strategy use, where each strategy is rated as “I don’t use,” “I use sometimes,” or “I use most of the time.” Responses to demographic and functional status questions, and frequency of outdoor falls prevention strategy use were used in this study. For descriptive purposes, the total score for the outdoor falls prevention strategy use subscale is also reported.

The Falls Efficacy Scale–International (FES-I) is a valid and reliable measure of concern about falling while performing daily activities. Scores range from 16 to 64 with a higher score indicating a greater level of concern about falls (Yardley et al., 2005). For descriptive purposes, and to characterize the sample, total score on the FES-I was reported in this study.

Walk Score (www.walkscore.com) is a publically available tool that provides a measure of walkability for any given address. The score is calculated by examining the distance to amenities such as food, retail, entertainment, and recreational facilities. Amenities within a 0.25 mile walk are given the greatest points, and no points are given if the amenity is further than 1 mile away. Walk Score also incorporates pedestrian friendliness by examining features such as block length, intersection, and population density. Data sources used to inform the measure include Google, U.S. Census, Open Street Map, and places added by the Walk Score user community. Categories of walkability proposed by Walk Score were used in the current study, that is, Walker’s Paradise = 90 to 99, Very Walkable = 70 to 89, Somewhat Walkable = 50 to 69, and Car-Dependent = 25 to 49.

Participants

Eligibility criteria for the original study included the following: age 60 and older, English speaking, able to ambulate outdoors independently with or without a mobility aid, and must answer “yes” to one of more of the following questions: (1) Have you fallen outdoors and hurt yourself in the last year? (2) Have you fallen two or more times in the past year? (3) Have you had two or more stumbles or trips outdoors in the last month? (4) Are you afraid that you might fall outdoors? NORC program sites were selected by the leadership team of the partnering community service agency based on perceived need for the program among their affiliated community sites. At each site, participants were recruited using fliers, and by making announcements after regularly scheduled programs. A nonrandom sample of older adults who met the inclusion criteria and expressed interest in the program/study were enrolled. Ninety-seven participants from eight NORC program sites in New York City consented to participate in the study, with 12 to 13 participants at each site.

Analysis

SPSS version 25 was used to analyze the data. Descriptive analyses were conducted to examine participant characteristics and the frequency of outdoor falls prevention strategies used. This allowed for an exploration of gaps in falls prevention practices among NORC residents. Chi-square tests of independence at a p < .05 significance level were used to determine any significant relationships between Walk Score categories and outdoor falls prevention strategy use. Subgroup analysis was also conducted for participants who use any type of mobility aid (N = 43), for those age 80 and older (N = 33), and for those with any ADL/IADL disability (N = 32).

Results

Descriptive analyses of participant characteristics reveal that study participants were mostly female, and independent with regard to most activities of daily living and instrumental activities of daily living (Table 1). Educational attainment ranged from less than high school to a graduate degree. Close to half (44%) of participants used some form of mobility aid (e.g., cane or rollator). Walking outdoors was the primary source of physical activity for over 75% of study participants. According to Walk Score categories, the neighborhood of residence of the NORC program participants ranged from “Car-Dependent” to a “Walker’s Paradise.”

Table 1.

Participants’ and Associated Neighborhood Characteristics, N = 97.

Variable	Value	Range
Age, M (SD)	76.72 (7.36)	60–94
Sex: Female, n (%)	92 (94.8)
Education, n (%)
Less than high school	12 (12.4)
High school	28 (28.9)
Some college	27 (27.8)
College degree	21 (21.6)
Graduate degree	9 (9.3)
Race, n (%)
Black	57 (58.8)
White	40 (41.2)
Asian	0 (0)
Ethnicity, n (%)
Hispanic	14 (14.1)
Number of ADL and IADLs requiring assistance, M (SD)	0.72 (1.28)	0–6
Use of mobility aid, n (%)	43 (44.3)
Primary source of physical activity, n (%)
Walking outdoors	75 (77.3)
Exercise class	17 (17.5)
Other	5 (5.2)
Patient Health Questionniare-2, M (SD)	0.63 (0.94)	0–6
Outdoor Falls Questionnaire: Strategy use subscale, M (SD)	22.7 (3.6)	16–33
Falls Behavioral Scale (FaB) for the Older Person–24 item version, M (SD)	2.9 (0.5)	1.8–3.8
Falls Efficacy Scale–International, M (SD)	32.6 (10.3)	9–61
Walk Score category, n (%)
Walkers paradise	42 (43.3)
Very walkable	34 (35.1)
Somewhat walkable	20 (20.6)
Car dependent	1 (1.0)

Note. ADL = activity of daily living; IADL = instrumental activity of daily living.

Descriptive analyses of outdoor falls prevention strategy use revealed that although more than 70% of participants use strategies such as visual scanning, holding rails on stairs, and avoiding cellular phone use when walking outdoors, other outdoor falls prevention strategies are not as commonly used. These include carrying fewer items, and route planning to avoid problematic streets, sidewalks, and intersections. Some strategies are either not used at all or are not used consistently, such as wearing appropriate footwear and avoiding areas with crowds. More than 50% of participants reported that they never talk with others about ways to prevent a fall. Over 70% of participants never ask others for help (e.g., to hold the door or to procure a seat) and/or have never reported an environmental hazard to the city.

Results of chi-square tests of independence reveal a statistically significant relationship between neighborhood walkability categories and avoiding cell phone use while walking outdoors (p = .04), but no significant relationship for any other outdoor falls prevention strategies, ps. > .05 (Table 2). The results of subgroup analysis for participants who use any type of mobility aid (N = 43), participants age 80 and older (N = 33), and for those with any ADL/IADL disability (N = 32) did not reveal any significant findings (all ps > .05).

Table 2.

Frequency of Outdoor Falls Prevention Strategy Use and Association With Walkability.

Strategy use question	Name of measure	n (%)	Association with Walk Score categories, p
Look ahead for hazards/visual scanning	FaB		.4
Never		4 (4.1)
Sometimes		12 (12.4)
Often		11 (11.3)
Always		70 (72.2)
Holding rails on stairs	FaB		.7
Never		1 (1.0)
Sometimes		5 (5.2)
Often		5 (5.2)
Always		79 (81.4)
Not applicable		7 (7.2)
Avoid cell phone use while walking outdoors	OFQ		.04
I don’t use		7 (7.2)
I use sometimes		13 (13.4)
I use most of the time		76 (78.4)
Not applicable		1 (1.0)
Carry fewer items	OFQ		.8
I don’t use		25 (25.8)
I use sometimes		28 (28.9)
I use most of the time		44 (45.4)
Use of appropriate footwear (e.g., walking shoes, boots with grips during the winter)	OFQ		.4
I don’t use		3 (3.1)
I use sometimes		38 (39.2)
I use most of the time		56 (57.7)
Ask other people for help (e.g., hold the door, give up their seat)	OFQ		.8
I don’t use		72 (74.2)
I use sometimes		24 (24.7)
I use most of the time		1 (1.0)
Contacted the city to report a problem	OFQ		.1
No		70 (72.2)
Avoid places with crowds	FaB		.8
Never		34 (35.1)
Sometimes		35 (36.1)
Often		10 (10.3)
Always		18 (18.6)
Hurry when doing things	FaB		.4
Never		44 (45.4)
Sometimes		42 (43.3)
Often		7 (7.2)
Always		4 (4.1)
Talk with others about falls prevention	FaB		.7
Never		50 (51.5)
Sometimes		36 (37.1)
Often		4 (4.1)
Always		7 (7.2)
Think about how to move around carefully outdoors	FaB		.7
Never		20 (20.6)
Sometimes		13 (13.4)
Often		10 (10.3)
Always		53 (54.6)
Cross at traffic lights/pedestrian crossings whenever possible	FaB		.4
Never		0 (0)
Sometimes		14 (14.4)
Often		18 (18.6)
Always		65 (67.0)
Pause after light turns green to let those who run the light go through	OFQ		.5
I don’t use		15 (15.5)
I use sometimes		27 (27.8)
I use most of the time		55 (56.7)

Note. FaB = Falls Behavioral Scale for the Older Person; OFQ = Outdoor Falls Questionnaire: Strategy subscale.

Discussion

Given that all of the participants in the study had a history of outdoor falls or were at risk for outdoor falls (i.e., had frequent stumbles or trips and/or a fear of falling), broad and consistent use of outdoor falls prevention strategies are indicated. Noteworthy is that the average score on the Falls Efficacy Scale–International was 32.6, indicating a high level of concern about falls among participants (Yardley et al., 2005). Although some outdoor falls prevention strategies, such as looking ahead and holding rails on stairs, were commonly used, others such as carrying fewer items, avoiding hurrying, and wearing appropriate footwear were inconsistently used by a number of participants. Outdoor falls have numerous causes and can occur at any time (Chippendale & Raveis, 2017; Nyman et al., 2013), therefore consistent use of multiple outdoor falls prevention strategies are warranted to minimize outdoor fall risk. The results of the study highlight gaps in use/consistent use of outdoor falls prevention strategies that should be addressed.

Research findings are consistent with prior studies regarding inconsistent or lack of use of some fall prevention strategies among adults (Chippendale & Raveis, 2017; Girasek & Gielen, 2003; Shankar et al., 2017). In a survey study, participants were least likely to identify prevention strategies for falls as opposed to other unintentional injuries (Girasek & Gielen, 2003). Shankar et al. (2017) found that despite having a fall resulting in an emergency room visit, older adults had a low rate of initiating falls prevention behaviors. Previous studies that examined outdoor falls prevention strategies among community-dwelling older adults revealed similar findings such as inconsistent use of appropriate footwear, and not seeking help from others or reporting environmental hazards (Chippendale & Raveis, 2017). The current study adds new knowledge with regard to outdoor falls prevention strategy use among NORC residents at risk for falls, and their association with neighborhood walkability.

According to the results of this study, the walkability of NORC neighborhoods are variable and range from car dependent to highly walkable. Although close to 80% of participants in this study live in neighborhoods that are “Very Walkable” or a “Walker’s Paradise,” some participants live in areas with lower levels of walkability. Also noteworthy is that although characteristics of the neighborhood environment impact fear of falling and risk for outdoor falls (Chippendale & Boltz, 2015; Satariano et al., 2017), not all of these neighborhood characteristics are captured by Walk Score. Some older adults may age in place in neighborhoods where community-based services are available. However, some NORC neighborhoods may be less than ideal for safe community mobility. For those NORC neighborhoods that do not have high levels of walkability, and where environmental hazards are present, there are implications for urban planning to improve the conditions and design of the neighborhood. In addition to a focus on age friendliness of existing NORC neighborhoods, a focus on neighborhoods with a projected large concentration in older adults in the next decade may be warranted.

Previous studies have shown that the ability to identify environmental hazards, concern about falls, suburban versus urban place of residence, and lower education levels were predictive of outdoor falls prevention strategy use (Chippendale, 2019; Chippendale & Boltz, 2015). Although the neighborhood environment does impact risk for falls (Satariano et al., 2017), according to the results of this study, with the exception of avoiding cell phone use while walking, walkability as calculated by Walk Score is not associated with use of outdoor falls prevention strategies. Avoiding cell phone use while walking outdoors may be particularly relevant to neighborhood walkability given the demands it places on divided attention. Noteworthy is that Walk Score captures intersection and population density, features of walkability which pose a high level of distraction. In this study, there was little variability in neighborhood walkability as 78% of the NORC participant’s neighborhoods were considered a “Walker’s Paradise” or “Very Walkable,” which may have affected the results. Furthermore, although Walk Score includes pedestrian friendliness in terms of distance to amenities, block length, and pedestrian density, it does not incorporate street or sidewalk hazards. Therefore, future research could incorporate neighborhood walkability measures that include these features. One possibility is the Stakeholders Walkability/Wheelability in Neighborhood (SWAN) tool, a checklist that includes function of streets and sidewalks (e.g., level surfaces, width of sidewalk) as well as safety of street features and traffic (e.g., street conditions and appropriate speed limits; Mahmood et al., 2020).

Implications for practice include implementing targeted outdoor falls prevention programs to address gaps in knowledge and consistent use of outdoor falls prevention strategies among NORC residents. Examples include promoting self-advocacy with regard to reporting environmental hazards to the city and/or to local community boards, teaching strategies such as avoiding crowded places, carrying items safely, and route planning to avoid hazardous streets, sidewalks, and intersections. Also needed is instruction and action planning regarding consistent use of appropriate footwear.

Limitations of the study include a focus on one geographical area and the use of self-report measures, which may have resulted in recall bias. Also, the sample was small, not randomly selected, and was predominantly women, which may impact the generalizability of findings. Furthermore, the analysis that examined the association between Walk Score categories and strategy use did not include control variables. However, despite limitations the study adds new knowledge regarding the outdoor falls prevention strategies used by older adults in NORCs who are at risk for outdoor falls. The results also highlight lower walkability of some NORC neighborhoods and reveal that, with the exception of avoiding cell phone use, walkability levels as per Walk Score categories do not appear to influence outdoor falls prevention strategy use. Directions for future research include expanding research about outdoor falls prevention strategy use and walkability to other locations, and the implementation of outdoor falls prevention programs and services to fill the gap in safe community mobility practices. Research is also warranted to explore reasons behind a lack of use of some outdoor falls prevention strategies, such as the demands of caregiving and the perception of stigma. Finally, given that perceived walkability as opposed to objectively measured walkability has been shown to effect changes in walking behavior (Merom et al., 2015), incorporating this type of measure may also be warranted in future research.

In conclusion, study results reveal some gaps in outdoor falls prevention strategy use among NORC members at risk for outdoor falls. Furthermore, the study builds on existing knowledge regarding factors that influence outdoor falls prevention strategy use. Specifically, in this study with the exception of avoiding cell phone use outdoors, neighborhood walkability was not associated with use of outdoor falls prevention strategies. Although further research is warranted, including studies using additional measures of walkability, preliminary results from this study may help inform outdoor falls prevention programming.

Footnotes

Acknowledgements

Walk Score data provided by Redfin Real Estate in New York City: .

Declaration of Conflicting Interests

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

Funding

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

ORCID iD

Tracy Chippendale

References

American Association of Retired Persons. (2018). 2018 Home and Community Preferences Survey: A national survey of adults age 18-plus. https://www.aarp.org/content/dam/aarp/research/surveys_statistics/liv-com/2018/home-community-preferences-survey.doi.10.26419-2Fres.00231.001.pdf

Centers for Disease Control and Prevention. (2009). Healthy places terminology. https://www.cdc.gov/healthyplaces/terminology.htm#:~:text=aging%20in%20place,%2C%20income%2C%20or%20ability%20level

Chippendale

(2015). Development and validity of the Outdoor Falls Questionnaire. International Journal of Rehabilitation Research, 38(3), 263–269. https://doi.org/10.1097/MRR.0000000000000115

Chippendale

(2019). Predicting use of outdoor falls prevention strategies: Considerations for prevention practices. Journal of Applied Gerontology, 38(6), 775–790. https://doi.org/10.1177/0733464817751199

Chippendale

Boltz

(2015). The neighborhood environment: Perceived fall risk, resources, and strategies for fall prevention. The Gerontologist, 55(4), 575–583. https://doi.org/10.1093/geront/gnu019

Chippendale

Raveis

(2017, September). Knowledge, behavioral practices, and experiences of outdoor falls: Implications for prevention programs. Archives of Gerontology and Geriatrics, 72, 19–24. https://doi.org/10.1016/j.archger.2017.04.008

Clemson

Cumming

R. G.

Heard

(2003a). The development of an assessment to evaluate behavioral factors associated with falling. American Journal of Occupational Therapy, 57, 380–388. https://doi.org/10.5014/ajot.57.4.380

Clemson

Cumming

R. G.

Heard

(2003b). The Falls Behavioral (FaB) Scale for the Older Person: Instruction manual. https://doi.org/10.1037/t40503-000

Elbert

K. B.

Neufeld

P. S.

(2010). Indicators of a successful naturally occurring retirement community: A case study. Journal of Housing for the Elderly, 24(3–4), 322–334. https://doi.org/10.1080/02763893.2010.522440

10.

Girasek

D. C.

Gielen

A. C.

(2003). The effectiveness of injury prevention strategies: What does the public believe? Health Education & Behavior, 30(3), 287–304. https://doi.org/10.1177/1090198103030003005

11.

Greenfield

E. A.

(2016). Support from neighbors and aging in place: Can NORC programs make a difference? The Gerontologist, 56(4), 651–659. https://doi.org/10.1093/geront/gnu162

12.

Lee

Ory

M. G.

(2019). Association between recent falls and changes in outdoor environments near community-dwelling older adults’ homes over time: Findings from the NHATS study. International Journal of Environmental Research and Public Health, 16(18), 3230. https://doi.org/10.3390/ijerph16183230

13.

Mahmood

O’Dea

Bigonnesse

Labbe

Mahal

Qureshi

Mortenson

W. B.

(2020). Stakeholders Walkability/Wheelability Audit in Neighbourhoods (SWAN): User-led audit and photographic documentation in Canada. Disability & Society, 35(6), 902–925. https://doi.org/10.1080/09687599.2019.1649127

14.

Masotti

P. J.

Fick

Johnson-Masotti

MacLeod

(2006, July). Healthy naturally occurring retirement communities: A low cost approach to facilitating aging in place. American Journal of Public Health, 96, 1164–1170. https://doi.org/10.2105/AJPH.2005.068262

15.

Merom

Gebel

Fahey

Astell-Burt

Voukelatos

Rissel

Sherrington

(2015). Neighborhood walkability, fear and risk of falling and response to walking promotion: The Easy Steps to Health 12-month randomized controlled trial. Preventive Medicine Reports, 2, 704–710. https://doi.org/10.1016/j.pmedr.2015.08.011

16.

National Cancer Institute. (2005). Theory at a glance: A guide for health promotion practice. https://cancercontrol.cancer.gov/brp/research/theories_project/theory.pdf

17.

National Council on Aging. (2020). Evidence-based falls prevention programs. https://www.ncoa.org/healthy-aging/falls-prevention/falls-prevention-programs-for-older-adults-2/

18.

National Highway Traffic Safety Administration. (2020). How walkable is your community? https://www.nhtsa.gov/pedestrian-safety/how-walkable-your-community

19.

Nicklett

E. J.

Lohman

M. C.

Smith

M. L.

(2017). Neighborhood environment and falls among community dwelling older adults. International Journal of Environmental Research and Public Health, 14(2), 175. https://doi.org/10.3390/ijerph14020175

20.

Nyman

S. R.

Ballinger

Phillips

J. E.

Newton

(2013). Characteristics of outdoor falls among older people: A qualitative study. BMC Geriatrics, 13, Article 125. http://www.biomedcentral.com/1471-2318/13/125. https://doi.org/10.1186/1471-2318-13-125

21.

Resnik

Allen

Isenstadt

Wasserman

Iezzoni

(2009). Perspectives on use of mobility aids in a diverse population of seniors: Implications for intervention. Disability and Health Journal, 2(2), 77–85. https://doi.org/10.1016/j.dhjo.2008.12.002

22.

Satariano

W. A.

Wang

Kealey

M. E.

Kurtovich

Phelan

E. A.

(2017). Risk profiles for falls among older adults: New directions for prevention. Frontiers in Public Health, 5, Article 142. https://doi.org/10.3389/fpubh.2017.00142

23.

Shankar

K. N.

Treadway

N. J.

Taylor

A. A.

Breaud

A. H.

Peterson

E. W.

Howland

(2017). Older adult falls prevention behaviors 60 days post-discharge from an urban emergency department after treatment for a fall. Injury Epidemiology, 4, Article 18. https://doi.org/10.1186/s40621-017-0114-y

24.

Yardley

Beyer

Kempen

Piot-Ziegler

Todd

(2005). Development and initial validation of the Falls Efficacy Scale–International (FES-I). Age and Ageing, 34(6), 614–619. https://doi.org/10.1093/ageing/afi196