Fall prevention education among older hospital inpatients: a systematic review

Abstract

Background:

Hospitalized older adults are at high risk of falls. Although fall prevention education is recommended in hospital settings, the efficacy of different education programs remains inconsistent. This study aimed to systematically review the effectiveness of fall prevention education interventions among older inpatients.

Methods:

We conducted a systematic review of randomized or trial-linked evaluations of fall prevention education programs for inpatients aged ≥60 years. A comprehensive search was performed across PubMed, Embase, Web of Science, Scopus, and Cochrane Library databases from inception to January 7, 2026. Risk of bias was assessed for all included evaluations. Intervention characteristics, including format, content, duration, providers, and theoretical frameworks, were extracted and analyzed.

Results:

Twelve reports describing 11 trial-based evaluations were included, with risk of bias ranging from low to high. Most reports described session-level or initial education contact of ≤1 h, whereas six reports incorporated protocol-specified repeated education, reinforcement, or post-education contact. Interventions varied considerably in format, content, duration, and providers, including physiotherapists, an occupational therapist, nurses or nurse investigators, a trained MSc sport science student, allied health assistants, and investigators with unspecified professional background. Five evaluations reported reductions in at least one fall-related measure, and one evaluation reported benefit only among cognitively intact patients. Six evaluations reported favorable education-related outcomes where measured. Behavior-related outcomes were mixed: three reports showed improvements in selected risk-reducing behaviors, whereas two reports found no significant behavior-related between-group differences. The 11 assessed programs used several theoretical or design approaches and demonstrated high educational-design quality, with scores ranging from 15 to 17 on a 17-point scale.

Conclusion:

Fall prevention education may help reduce falls and improve related outcomes among older inpatients; however, substantial heterogeneity in study design, intervention characteristics, and outcome measures limits generalizability. The use of explicit theoretical or design approaches may support more structured educational intervention design, but further comparative evaluation is needed to determine which delivery models and components are most effective.

Systematic review registration:

https://www.crd.york.ac.uk/PROSPERO/view/CRD420251238711.

Highlights

What is already known?

• Fall prevention education is recommended for hospitalized older adults at risk of falls.

• Individualized or tailored education has been evaluated as a strategy to improve fall-risk awareness, engagement in prevention strategies, and fall-related outcomes.

• The effects of fall prevention education on fall-event outcomes have been inconsistently reported.

What this paper adds?

• Trial-based evidence on theory-informed fall prevention education for hospitalized older adults remains limited and heterogeneous.

• The Health Belief Model was the most frequently used theoretical framework among the included fall prevention education programs.

• Evidence remains limited on how theoretical constructs, education content, and delivery features translate into sustained behaviour change and fall-event reduction.

1 Introduction

A fall is an event that occurs when a person inadvertently encounters the floor, ground, or another lower level during displacement. Falls are a significant public health concern worldwide. It is estimated that 684,000 fatal falls occur globally each year, representing the second leading cause of unintentional injury deaths. Although the majority of falls are not deadly, falls account for approximately 37.3 million annual incidents that are serious enough to require medical attention. Globally, more than 38 million disability-adjusted life years (DALYs) are lost each year because of falls, resulting in more DALYs lost than traffic injuries, drowning, burns, and poisoning combined (1). Older adults are at the greatest risk of death or serious injury from falls, with the risk increasing with age. The mortality rate in cases of fatal falls is highest among people over 60. In the United States, 20–30% of older adults who fall suffer moderate to severe injuries, including bruises, hip fractures, and head trauma. The financial costs of fall-related injuries are considerable, with average health system costs per fall injury for people aged 65 years or older being $3,611 and $1,049 in Finland and Australia, respectively (1).

Inpatient fall rates, typically measured per 1,000 bed days, generally fall within the range of 2 to 8 in acute hospitals, geriatric wards, and emergency settings (2, 3). However, among older inpatients, studies have shown a notably higher incidence of falls, reaching 12.6 per 1,000 bed days (4). Hill observed that in eight rehabilitation and geriatric wards in Australia, there were 10.9 patient falls per 1,000 bed days (5). In 2004, a significant incidence of 18.0 falls per 1,000 bed days was documented in a geriatric care unit at a regional general hospital in the United Kingdom (6). Two systematic reviews have shown that risk factors for falls in hospitalized patients include a history of falls, use of walking aids, and disability, advanced age, cognitive impairment, the use of sedatives and antidepressants, gait instability, agitated psychosis, and urinary incontinence (7, 8). Advanced age is a prominent intrinsic risk factor for inpatient falls, with fall-related injury incidence rates spanning from 6.8 to 72.1% (9). As a result, hospitalized older patients, particularly those with a fall history, are frequently at an increased risk of experiencing falls during their hospital stay.

Strategies for preventing inpatient falls encompass patient and staff education, environmental enhancements, assistive devices, therapeutic exercise, medication review, nutritional interventions, cognitive-care protocols, and continuous multidisciplinary quality improvement and effective leadership (10–12). The World Guidelines strongly recommend tailored fall prevention education for all inpatients aged ≥ 65 years and other high-risk groups (recommendation 1A) (13). Well-designed programs significantly improve older patients’ awareness of fall risk and motivate them to adopt protective behaviors (14). A systematic review indicates that educating patients and staff effectively reduces inpatient falls (11). An updated Cochrane review of fall-prevention interventions in hospitals reported that tailored education probably reduces both the rate of falls and the risk of falling among older hospital patients (12). Hospitalized older adults are at higher risk of falling and often sustain more severe injuries, resulting in prolonged length of stay and increased medical and financial burden. Health education can mitigate this problem by raising awareness of fall risk and providing specific prevention strategies during hospitalization (13). Advancing age is accompanied by declining auditory, visual and cognitive function, which reduces the effectiveness of conventional educational interventions and underscores the need for tailored approaches. This systematic review was therefore undertaken to evaluate the efficacy of different fall prevention education methods for older inpatients and to generate evidence-based recommendations for hospital managers.

2 Method

2.1 Aim

The aims of this review are threefold: (i) to identify existing fall prevention education (FPE) programs and evaluate their efficacy among older inpatients; (ii) to identify the theoretical models underlying the educational designs utilized in these programs; (iii) to assess the quality of these FPE programs.

2.2 Design

This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (15). The protocol was registered with the PROSPERO database on 27 November 2025 (registration number: CRD420251238711).

2.3 Inclusion and exclusion criteria

The PICO framework guided the research question: (p) hospital inpatients aged 60 years or older; (i) fall prevention education (FPE); (c) usual care or alternative education formats; (o) fall prevention-related outcomes, including fall-related, education-related, and behavior-related outcomes.

Inclusion criteria are: (a) studies with a target population aged 60 years or above; (b) participants are hospital inpatients; (c) research studies on fall prevention education (FPE); (d) studies using an individually randomized or cluster-randomized controlled trial design, or reports providing additional data linked to an eligible randomized controlled trial (16). Exclusion criteria are: (a) studies on outpatients; (b) studies lacking a definitive outcome for evaluating the efficacy of a fall prevention education program; (c) interventions where education is only a part of the program rather than the sole component; (d) abstracts, reports, conference posters, or non-English publications.

2.4 Search strategy

Five electronic databases (PubMed, Embase, Web of Science, Scopus, and Cochrane Library) were searched from their inception to January 07, 2026. Two researchers (YW and XW) searched independently and concurrently using the consistent strategy. Different strategies were employed to achieve comprehensive search, tailored to the characteristics of each database. Details of the search strategies were reported in the Appendix I.

2.5 Search selection

Study selection followed the PRISMA 2020 flow diagram and was conducted independently by two reviewers (YW, XW) in two sequential steps (15):

• Title/abstract screening: all retrieved records were screened to exclude obviously ineligible studies; potentially relevant records were advanced to full-text review.

• Full-text assessment: potentially eligible studies were evaluated against predefined inclusion and exclusion criteria. Discrepancies were resolved by discussion or, if necessary, by adjudication of the corresponding author.

After full-text assessment, 12 reports describing 11 trial-based evaluations were included in the review. The detailed selection process and reasons for full-text exclusion are presented in (Figure 1).

Figure 1

2.6 Data extraction

Two researchers (Y. Y and Y. W) independently extracted data from the included reports and entered the data into a standardized extraction table. The extracted characteristics included participants, interventions, comparators, follow-up durations, outcomes measures main findings, and other relevant details, which are summarized in Table 1. Outcomes were extracted as reported and grouped narratively into fall-related outcomes, education-related outcomes, behavior-related outcomes, and, where reported, related health-service outcomes such as readmission and length of stay.

The quality of the educational programs was assessed using the metric tool developed by Heng et al. (17). This instrument evaluates the educational-design quality of interventions by focusing on pedagogical elements rather than on methodological rigor alone. The tool comprises 17 items that identify flaws in educational content and delivery that may influence participants’ learning, thereby providing a more relevant assessment for studies evaluating educational programs regardless of design. Each item is scored 1 for a positive response and 0 for a negative or uncertain response. The scores ranging from 0 to 6 indicate low quality, 7 to 12 indicate moderate quality, and 13 to 17 indicate high quality. Two researchers (Y. Y and Y. W) independently assessed the quality of the health-education programs reported in the 12 included reports; the results are presented in Table 2.

2.7 The risk of bias assessment

Two researchers (Y. Y, and Y. W) independently assessed the risk of bias using the Cochrane Risk of Bias tool (ROB 2), which was developed specifically for randomized trials (18, 19). The tool comprises five domains, each covering distinct aspects of trial design. Every domain contains signaling questions intended to elicit information pertinent to bias risk. An algorithm converts the responses into domain-level judgments, classifying each as “low risk,” “some concerns,” or “high risk.”

3 Results

3.1 Description of included reports and risk of bias

Twelve reports describing 11 trial-based evaluations of fall prevention education were included. Of these evaluations, seven were conducted in Australia (5, 14, 20–25), two in Iran (26, 27), one in the USA (28), and one in France (29). By design, six evaluations were individually randomized RCTs (23, 25–29), one was a pilot RCT (21), one was a feasibility RCT (22), and one was a stepped-wedge cluster-randomized trial (5). Two evaluations required design qualification: Haines was an education-component subgroup report (14) from the Haines targeted multifactorial RCT (30); the analyzed subgroup received one-to-one bedside education in addition to usual care and could also receive other targeted components when indicated. Hill was a DVD–workbook randomized comparison with an added non-randomized no-education control group (20). Naseri was treated as a companion behavior/process report of Hill and was not counted separately (24, 25). Among individually randomized evaluations, randomized sample sizes ranged from 30 to 1,206 participants; Hill additionally included 122 non-randomized control participants. The stepped-wedge cluster-randomized trial included 3,606 admissions.

Risk of bias was assessed across the 11 trial-based evaluations using the revised Cochrane Risk of Bias tool (RoB 2), with Hill and Naseri treated as one evaluation. The risk-of-bias results are summarized in (Figures 2, 3) Overall, six evaluations (54.5%) were judged to have low risk of bias, three (27.3%) raised some concerns, and two (18.2%) were at high risk. Domain-level analysis showed that concerns were concentrated in three domains. For D1, the randomization process was rated low risk in nine evaluations (81.8%), whereas Perrot was rated high risk and Dadgari raised some concerns. D2, deviations from intended interventions, was rated low risk across all evaluations. For D3, missing outcome data were adequately addressed in 10 evaluations (90.9%), although Valieiny was rated high risk because of attrition. For D4, measurement of the outcome was rated low risk in 10 evaluations (90.9%), but Hill was rated high risk because unblinded assessors evaluated subjective outcomes. D5, selection of the reported result, was rated low risk across all evaluations.

Figure 2

Figure 3

3.2 Characteristics of the fall prevention education programs

3.2.1 Health education approaches

Among the 11 FPE programs, Perrot et al. used group-based education, whereas the remaining 10 evaluations used individual-level or one-to-one education (5, 14, 20–29).

3.2.2 Health education methods

Education methods included group therapeutic patient education sessions, simulated home-environment education, print materials, videos or DVDs, tailored bedside discussions or interviews, home visits, and telephone reinforcement/follow-up; the specific combinations used in each report are summarized in Table 1 (5, 14, 20–29).

3.2.3 Fall prevention education content

Most reports incorporated educational material that defined falls and addressed their risk factors, causes, consequences and preventive strategies. Hill et al. incorporated modules aimed at enhancing personal beliefs related to fall prevention (20). Hill et al. included fall risk and prevention strategies for individuals discharged from the hospital with decreased physical functioning (21). In a subsequent trial, Hill et al. expanded the content to include the nature of falls, benefits of adherence, and self-efficacy enhancement, goal setting, and action planning (5). Valieiny et al. used video sequences to explain the importance, outcomes, risk factors, preventability, and prevention of falls (26). Perrot et al. devoted the first of four 1-h sessions to understanding falls, including fall history, fall definition, intrinsic and extrinsic risk factors, and describing immediate and long-term physical, psychological, social and behavioral consequences, and prevention strategies (29). Dadgari et al. opened the program with a definition of falls in older adults, emphasized prevention relevance, and differentiated intrinsic from extrinsic causes (27). Morris et al. centered on fall-risk awareness and preventive behaviors, and goal-oriented action planning (22). In the education-recommended subgroup reported by Haines et al., the program covered risk factors, mechanisms and preventive measures (14); in a subsequent RCT, Haines et al. added epidemiological data, self-reflection of individual risk, preventive strategy development, goal setting, and goal review (23).

Six reports explicitly addressed environmental safety: four focused on home or post-discharge environments and two on the hospital setting. DeWalt et al. simulated a home environment in the hospital to teach patients to recognize 14 environmental fall hazards (28). Hill et al. targeted home modification as part of individualized post-discharge fall prevention education (25). Hill et al. provided ward-based education and incorporated patient feedback about ward environmental hazards into staff support (5). Valieiny et al. used a brief video to deliver hospital-based environmental education, covering the nurses’ station, emergency exits, toilets, wall-mounted and toilet handrails, the call-bell system and bedside lighting (26). Perrot et al. dedicated one of four 1-h sessions to environmental factors, including home hazard identification and countermeasures (29). Dadgari et al. conducted a home-visit session to assess each participant’s living environment and recommend modifications (27).

3.2.4 Follow-up and reinforcement of fall prevention education

Among the included reports, six described protocol-specified repeated education, reinforcement, or post-education contact. In-hospital reinforcement or repeated educational contact was reported by Haines et al. (2006), Haines et al. (2011), Hill et al. (2015), and Morris et al. (2024), whereas post-discharge telephone reinforcement was used by Hill et al. (2013) and Hill et al. (2019). Haines et al. delivered repeated bedside education sessions during hospitalization (14), and Haines et al. employed individualized bedside follow-up during the first study week, delivered by trained physical therapists (23). Hill et al. used individually tailored follow-up sessions with ward visits and staff feedback during the intervention period (5). Hill et al. carried out a single telephone call 2 weeks after discharge to reinforce the education (21). Hill et al. provided three monthly coaching calls after discharge from the same therapist to reinforce behavior change, provide feedback, identify barriers, and revise fall prevention action plans (25). Morris et al. scheduled brief conversations during admission and an individual bedside follow-up on day 5 after initial in-hospital education (22). Valieiny et al. assessed patients with the Falls Efficacy Scale-International at discharge and at 1 and 3 months after discharge; this represented outcome follow-up rather than additional education reinforcement (26).

3.2.5 Duration of fall prevention education

Among reports with sufficient duration data, reported education contact ranged from a 14-min DVD or 15-min simulated-video intervention to four 1-h therapeutic education sessions. Most reports described session-level or initial education contact of ≤1 h, whereas multi-session programs could exceed 1 h in total. Home-visit time, post-discharge telephone reinforcement, and outcome follow-up periods were excluded from this duration summary.

3.3 Principles and theoretical framework of fall prevention education design

Four reports used the Health Belief Model (HBM): Hill et al., Haines et al., Hill et al., and Hill et al. (5, 20, 21, 23). Originally developed in the 1950s, the HBM explains health behavior through perceived susceptibility, perceived severity, perceived benefits, perceived barriers, self-efficacy, and cues to action (31, 32).

The post-discharge education program reported by Hill et al. was designed according to the COM-B model, which conceptualizes behavior change as the interaction among capability, opportunity and motivation (25, 33).

Two reports used simulation-based education (SBE), grounded in experiential learning theory, to enhance learner engagement: DeWalt et al. and Valieiny et al. (26, 28, 34). DeWalt et al. implemented SBE incorporating realistic visual displays, demonstrations, repetitive practice, and role-play to improve critical thinking and self-confidence (28). Valieiny et al. provided simulation-based video education that allowed repeated exposure, delivered standardized content delivery, time and cost saving, increased motivation and knowledge retention, and training in scenarios that would be hazardous or impractical in real clinical settings (26).

Two reports used motivationally oriented approaches: Morris et al. used motivational interviewing, and Haines et al. applied Protection Motivation Theory (14, 22). Morris et al. used motivational interviewing (MI), as described by Miller and Rollnick (22, 35). MI emphasizes empathy and non-directive communication, elicits intrinsic motivation, and facilitates change by helping individuals explore discrepancies between their behavior and goals (35). Haines et al. applied the Protection Motivation Theory (PMT), together with threat appraisal and goal setting/review (14). PMT explains how persuasive communication influences behavior through cognitive processes that endorse or resist recommended actions (36). Patient goal setting, goal review, action planning, or goal-oriented strategy planning was reported (5, 14, 21–23, 25).

Perrot et al. introduced therapeutic patient education (TPE), a structured, person-centered learning process that mobilizes patients’ internal resources and supports self-management (29). TPE is delivered by professionally trained healthcare providers and tailored to patient’s circumstances (37). It aims to help patients acquire specific or generic medical knowledge and self-management skills, including preventive service use, healthy lifestyles, and management of illness or accidents at home (37).

Dadgari et al. implemented a discharge-planning program derived from the nursing process (27). This framework comprises assessment, problem identification, care-plan formulation, implementation, and evaluation, and coordinates healthcare resources with patient needs to support transition from hospital to home or community settings (38). Structured discharge education has also been associated with clearer discharge instructions in a quality-improvement study (39).

3.4 Assessment of fall prevention education program quality

The quality of the fall prevention education programs was assessed using the Modified Quality Assessment Scale for Educational Programs (17), after excluding items specific to clinical physician training. The scale evaluates core educational elements, including objectives and implementation environment, characteristics of learners and instructors, learning-activity design, and program effectiveness (17).

The 11 assessed fall prevention education programs were rated as high quality, with scores ranging from 15 to 17 on a 17-point scale. Maximum scores were achieved for objectives, learner characteristics, learning activities, and evaluation. Points were deducted primarily in the instructor-characteristics domain: implementer training was not reported in four reports—Hill et al. (2009), Dadgari et al. (2022), DeWalt et al. (2023), and Valieiny et al. (2023)—and Hill et al. (2009) also did not clearly identify the personnel delivering the education (20, 26–28).

3.5 Evaluation of the efficacy of fall prevention education for older inpatients

3.5.1 Fall-related outcome measures

Nine of the 11 trial-based evaluations assessed fall-related outcomes, including fall rate/incidence, injurious falls, faller proportion, fractures, and injury severity. Reductions in at least one fall-related measure were reported by Haines et al. (2006), Hill et al. (2013), Hill et al. (2015), Dadgari et al. (2022), and Valieiny et al. (2023), whereas Haines et al. (2011) reported a subgroup effect among cognitively intact patients only (5, 14, 21, 23, 26, 27). Haines et al. reported a lower incidence of falls in the intervention group than in the control group (8.2 vs. 16.0 falls/1000 participant-days, p = 0.007), although the proportion of fallers did not differ significantly (14). Hill et al. reported a lower fall rate after discharge in the intervention group than in the control group (5.4 vs. 18.7 falls/1000 person-days, p = 0.05) (21). Hill et al. reported lower rates of falls and injurious falls during the intervention period than during the control period (falls: 7.80 vs. 13.78/1000 patient-days, ARR = 0.60, 95% CI 0.42–0.94, p = 0.003; injurious falls: 2.63 vs. 4.75/1000 patient-days, ARR = 0.65, 95% CI 0.42–0.88, p = 0.006) (5). Dadgari et al. reported lower falls and injury severity in the intervention group than in the control group (p < 0.049 and p < 0.001, respectively) (27). Valieiny et al. reported a lower falling rate in the intervention group than in the control group (IRR = 0.545, 95% CI = 0.307–0.968; p = 0.020) (26).

Haines et al. (2011) found no significant difference in falls per 1,000 patient-days in the total sample, but reported a significant interaction between intervention and cognitive impairment. Among cognitively intact patients, falls were less frequent in the complete program group than in the materials-only group and usual-care group (4.01 vs. 8.18 and 8.72 falls/1000 patient-days, complete program group vs. materials-only group, adjusted hazard ratio, 0.51, 95% CI, 0.28–0.93, complete program group vs. usual-care group, adjusted hazard ratio, 0.43, 95% CI, 0.24–0.78). Among cognitively impaired patients, injurious falls were higher in the complete program group than in the usual-care group (7.49 vs. 2.89 injurious falls/1000 patient-days) (23).

Several evaluations did not show statistically significant effects on fall-event outcomes. Hill et al. reported no significant between-group differences in 6-month fall rate, injurious fall rate, or faller proportion after discharge (25). DeWalt et al. reported fewer post-discharge fall events numerically, but the between-group difference was not statistically significant (28). Morris et al. found no significant difference in fall rates between groups (IRR = 0.66, 95% CI 0.32–1.36; p = 0.26) (22).

3.5.2 Education-related outcome measures

Education-related outcomes included participants’ perceptions of the education program, fall-prevention knowledge, fall-risk awareness or self-assessment, self-perceived fall risk, confidence and motivation, and fear of falling. These outcomes were reported (14, 20, 21, 26, 28, 29). Haines et al. reported positive program-evaluation responses, including that participants found the materials understandable and gained new information (14). Hill et al. reported higher fall-prevention knowledge in the DVD and workbook groups than in the no-education quasi-control group (p < 0.001), and higher self-perceived risk of falling, confidence, and motivation in the DVD group than in the workbook group (p = 0.04, p = 0.03, and p = 0.04, respectively) (20). Hill et al. reported that the intervention group was significantly more knowledgeable, confident, and motivated to engage in fall-prevention strategies than the control group (21). DeWalt et al. reported higher fall-risk post-assessment scores in the simulation group than in the written-education group (p = 0.022), with greater pre–post changes in fall-risk assessment scores in the simulation group (p = 0.009) (28). Perrot et al. reported a significant group × time interaction for the Falls Efficacy Scale-International, indicating a greater reduction in fear of falling in the therapeutic patient education plus physical activity group (29). Valieiny et al. reported a lower post-test mean fear-of-falling score in the intervention group than in the control group (p < 0.001) (26).

3.5.3 Behavior-related outcome measures

Behavior-related outcomes included risk-reducing actions, seeking or waiting for assistance, identifying environmental hazards, using assistive devices, wearing safe footwear or clothing, increasing physical activity, seeking assistance for ADL/IADL, safely resuming functional activities, participating in a home exercise program, making home modifications, and engagement in post-discharge fall-prevention strategies. These outcomes were reported in Haines et al. (2006), Haines et al. (2011), Hill et al. (2013), DeWalt et al. (2023), and Naseri et al. (2019), the companion behavior report of the Hill et al. (2019) trial (14, 21, 23, 24, 28). Haines et al. reported that participants modified their actions to reduce their risk of falling (14). Haines et al. reported increased use of selected risk-reducing behaviors, including seeking or waiting for assistance, identifying environmental hazards, using assistive devices, wearing safe footwear or clothing, and doing more exercise (23). Hill et al. reported greater engagement in selected post-discharge strategies; participants in the intervention group were more likely to plan how to safely restart functional activities than those in the control group (AOR = 3.80, 95% CI 1.07–13.52; p = 0.04), whereas the difference in completing a home exercise program was not statistically significant (AOR = 2.76, 95% CI 0.72–10.50; p = 0.14) (21). DeWalt et al. found no significant between-group difference in home-environment changes (28), and Naseri et al. reported no significant differences in engagement in ADL/IADL assistance, home-hazard modification, or exercise after discharge (24).

3.5.4 Related health-service outcome measures

Related health-service outcomes were reported in three trial-based evaluations and included readmission or rehospitalization and length of stay. Dadgari et al. reported a lower readmission rate (p = 0.014) and shorter length of hospital stay (p = 0.018) in the intervention group than in the control group (27). DeWalt et al. found no statistically significant between-group difference in rehospitalization (28). Hill et al. also found no significant difference in length of stay between the intervention and control periods (5).

3.6 Providers of fall prevention education for older inpatients

Across the 11 trial-based evaluations, fall prevention education was delivered by therapists in five evaluations, including physiotherapists in Haines et al. (2011), Hill et al. (2013), Hill et al. (2015), and Hill et al. (2019)/Naseri et al. (2019), and an occupational therapist in Haines et al. (2006) (5, 14, 21, 23–25). Three evaluations involved nurses or a nurse investigator as providers (26–28). The remaining evaluations were delivered by a trained MSc sport science student (Perrot et al., 2019), allied health assistants (Morris et al., 2024), or investigators whose professional background was not specified (Hill et al., 2009) (20, 22, 29). Overall, therapists—particularly physiotherapists—were the most frequently reported providers, while nurses also delivered fall prevention education in several evaluations.

4 Discussion

4.1 Principal findings across outcome domains

Across the 12 reports describing 11 trial-based evaluations, fall prevention education was assessed primarily through fall-related outcomes, including falls, fall rates, faller proportion, injurious falls, fractures, and injury severity, with fewer evaluations measuring education-related, behavior-related, and related health-service outcomes. Haines et al. (2006), Hill et al. (2013), Hill et al. (2015), Dadgari et al. (2022), and Valieiny et al. (2023) reported reductions in at least one fall-related measure, while Haines et al. (2011) reported benefit only among cognitively intact patients and a potential adverse signal for injurious falls among cognitively impaired patients (5, 14, 21, 23, 26, 27). By contrast, Hill et al. (2019), DeWalt et al. (2023), and Morris et al. (2024) did not show statistically significant fall-event effects (22, 25, 28). Education-related outcomes generally moved in a favorable direction when measured, as reported by Haines et al. (2006), Hill et al. (2009), Hill et al. (2013), Perrot et al. (2019), DeWalt et al. (2023), and Valieiny et al. (2023), but these intermediate outcomes were not consistently linked to sustained behavior change or fall reduction (14, 20, 21, 26, 28, 29). Behavior-related findings were also mixed: selected risk-reducing actions improved in Haines et al. (2006), Haines et al. (2011), and Hill et al. (2013), whereas DeWalt et al. (2023) and Naseri et al. (2019), as the companion behavior report of the Hill et al. (2019) trial, found no significant between-group differences in home-environment changes or post-discharge strategy engagement (14, 21, 23, 24, 28). Health-service outcomes were reported in only a small number of evaluations and showed mixed findings: Dadgari et al. (2022) reported reductions in readmission and length of stay, whereas DeWalt et al. (2023) and Hill et al. (2015) found no significant differences in rehospitalization or length of stay (5, 27, 28). Future trials should pre-specify linked education, behavior, fall-event, and health-service outcomes to clarify whether gains in knowledge, awareness, or motivation translate into sustained risk-reducing behavior and clinically meaningful reductions in falls.

4.2 Interpretation of outcome inconsistency

The inconsistent effects on fall-related outcomes may partly reflect differences in prevention targets, education settings, and follow-up periods across the included evaluations. In-hospital programs such as Haines et al. (2006), Haines et al. (2011), Hill et al. (2015), Valieiny et al. (2023), and Morris et al. (2024) were delivered during admission, whereas Hill et al. (2013), Hill et al. (2019), Dadgari et al. (2022), and DeWalt et al. (2023) focused partly or mainly on post-discharge or home-related fall prevention (5, 14, 21–23, 25–28). These settings differ in the degree to which patients can translate education into action, because inpatient behavior is shaped by ward routines, staff responsiveness, and environmental controls, whereas post-discharge behavior depends more on functional recovery, home support, and sustained self-management.

Intervention intensity and reinforcement may also have contributed to the mixed findings. Programs with repeated contact, tailored discussion, goal setting, or staff feedback, such as Haines et al. (2006), Haines et al. (2011), Hill et al. (2015), Hill et al. (2019), and Morris et al. (2024), differed from one-off or brief education approaches, making it difficult to separate the effect of educational content from the effect of delivery intensity and implementation support (5, 14, 22, 23, 25). Patient characteristics are another likely source of heterogeneity, particularly cognitive status. Haines et al. found no significant effect in the total sample but reported fewer falls among cognitively intact patients and a potential adverse signal for injurious falls among cognitively impaired patients, suggesting that fall prevention education may require adaptation for patients with impaired cognition rather than uniform delivery across all older inpatients (23).

The pathway from education-related outcomes to behavior change and fall reduction also remains uncertain. Improvements in knowledge, confidence, motivation, fall-risk awareness, or fear of falling were reported in several evaluations, but behavior-related outcomes were measured less consistently, and the companion behavior report by Naseri et al. did not show greater post-discharge engagement in fall prevention strategies in the Hill et al. trial (20, 21, 24, 26, 28, 29). This suggests that fall prevention education may improve proximal cognitive or affective outcomes without necessarily producing sustained behavior change or fall-event reductions, especially after discharge.

Methodological differences further limit direct interpretation of between-study inconsistency. The evidence base included conventional individually randomized RCTs, a pilot RCT, a feasibility RCT, a stepped-wedge cluster-randomized trial, an education-component subgroup analysis from a parent multifactorial RCT, and a DVD–workbook randomized comparison with an additional non-randomized control group. Therefore, the direction of findings should be interpreted alongside study design, sample size, risk of bias, intervention fidelity, and outcome follow-up rather than as evidence that fall prevention education has a single uniform effect.

4.3 Program characteristics and delivery features

The educational content of the included fall prevention education programs clustered around three recurring areas. First, fall risk, fall-related consequences, risk factors, preventive strategies, and benefits of adherence were addressed in programs reported (5, 14, 20–23, 26, 27, 29). Second, environmental safety was incorporated in programs targeting either hospital or home hazards (5, 25–29). Third, post-discharge risk management was emphasized in Hill et al. (2013), Hill et al. (2019), Naseri et al. (2019), Dadgari et al. (2022), and DeWalt et al. (2023), including home modification, functional activity, exercise, assistance with daily activities, and safe performance of activities after discharge (21, 24, 25, 27, 28).

These content areas are broadly consistent with guideline recommendations that at-risk patients, and when appropriate their families, should receive information on fall risk, fall prevention, and relevant interventions (40). The same guideline also supports individualized, multi-component exercise and balance training for adults at risk of falls; however, this evidence relates to active fall-prevention interventions rather than to education content alone (40). Medication-related fall risk was not directly evaluated as an education component in the included programs. Given that Jehu et al. reported an association between medication-related factors and recurrent falls in older adults, medication-safety messages may be considered in future fall prevention education programs, particularly when education is integrated with multidisciplinary fall-risk assessment; however, this review does not provide direct evidence that adding medication content improves fall-related outcomes (41).

Among the 11 fall prevention education programs, 10 used individual-level delivery, whereas Perrot et al. used group-based therapeutic patient education. Individual-level delivery was reported (5, 14, 20–29). This pattern supports the relevance of individualized or tailored education for older inpatients, because fall risk, functional limitations, discharge destination, and environmental hazards vary across patients. This delivery orientation is also supported by discharge-planning evidence showing that participation in individualized decision-making and effective information exchange explained 71% of the variance in satisfaction with discharge plans and continuity of care among older inpatients; tailored health education was also reported to improve functional status, including balance and activity safety (42). However, the available fall prevention education studies did not directly compare individual- and group-based delivery for fall-event reduction.

Among programs with sufficient duration information, session-level or initial education contact generally lasted no more than 1 h, although multi-session programs and post-discharge reinforcement could exceed this duration. Brief or one-off education was reported by Hill et al. (2009) and DeWalt et al. (2023), short simulated-video education was used by Valieiny et al. (2023), and repeated sessions, tailored follow-up, home visits, or reinforcement were reported (5, 14, 20–29). These findings highlight a feasibility trade-off: shorter education may be more compatible with inpatient workflow, whereas repeated reinforcement or tailored follow-up may be needed to support behavior change. Duration findings should be interpreted cautiously because studies varied in whether they counted only initial education contact, repeated sessions, home visits, or post-discharge reinforcement. The barriers reported by Pueyo-Garrigues et al., including insufficient training, inadequate time, and excessive workload, further support the need to design concise, trainable, and workflow-compatible fall prevention education programs (43).

4.4 Theoretical basis and program quality

From an ecological perspective, health-education models can be grouped into individual capability, interpersonal relationships, and environmental contexts. Individual-capability models include the Health Belief Model (HBM), Transtheoretical Model of Change, Theory of Planned Behavior, and related cognitive-behavioral models; interpersonal and environmental-context models include Social Cognitive Theory, Communication Theory, and Diffusion of Innovations Theory. Rimer et al. noted that evidence-based, theory-driven interventions are most likely to demonstrate effectiveness in empirical research. Combining theory-based interventions with rigorous evaluation clarifies why programs succeed or fail under specific conditions (44).

In this systematic review, HBM was the most frequently used theoretical model and was applied (5, 20, 21, 23). This predominance is likely related to the way fall prevention education for hospitalized older adults is commonly conceptualized. Such interventions typically target patient-level risk perception and safety behavior, aiming to strengthen awareness of personal susceptibility to falls and the seriousness of fall-related harm, increase perceived benefits of preventive actions, and reduce perceived barriers to seeking assistance, using assistive devices, and adhering to safety advice. In this respect, HBM provides a close conceptual fit for educational interventions designed to improve knowledge, risk awareness, and adherence-related behaviors. However, HBM is primarily centered on individual cognition and pays less attention to contextual determinants, such as ward environment, staff responsiveness, care processes, and post-discharge support. In addition, emphasizing severity without corresponding supportive strategies may risk increasing fear of falling.

The 11 assessed fall prevention education programs received high scores in the quality assessment, with scores ranging from 15 to 17 on a 17-point scale. However, implementer training was not reported in four reports—Hill et al. (2009), Dadgari et al. (2022), DeWalt et al. (2023), and Valieiny et al. (2023)—and Hill et al. (2009) also did not clearly identify the personnel delivering the education (20, 26–28). Equipping education providers with relevant knowledge and skills may enhance health-education efficacy and support more consistent program implementation. In a cross-sectional study, Pueyo-Garrigues et al. reported that nurses directly involved in patient care had insufficient health-education knowledge, with inadequate training being the main barrier (71.4%) (43). Because nurses delivered fall prevention education in several included evaluations and commonly participate in hospital patient education, their training and competencies warrant attention (26–28). Pueyo-Garrigues et al. advocated comprehensive education and training programs, together with a hospital-wide culture and infrastructure for health promotion, to enhance the knowledge, skills, and personal qualities related to health education (43).

4.5 Implications for practice and research

In clinical practice, fall prevention education is likely to be more sustainable when embedded within a multidisciplinary workflow. Nurses’ continuous bedside presence may facilitate repeated risk communication, safety reminders, and discharge preparation, whereas physiotherapists and occupational therapists contribute expertise in mobility, exercise, assistive devices, environmental hazards, and post-discharge functional recovery. The feasibility study by Morris et al. (2024) also suggests that trained allied health assistants, under professional supervision and with clear escalation pathways, may support timely delivery of scripted fall prevention education within 48 h of admission (22). These findings indicate that implementation models should clarify how educational responsibilities are shared across professional groups, how educators are trained and supervised, and how education is reinforced throughout admission, ward care, and discharge.

Further research is needed to evaluate different delivery models as implementation strategies for fall prevention education. Future studies should specify educator selection, training, supervision, fidelity monitoring, and professional role boundaries, and should examine whether nurse-led, therapist-led, assistant-supported, or multidisciplinary delivery influences education-related, behavior-related, fall-event, and related health-service outcomes. Such evidence would help identify scalable models for integrating fall prevention education into routine hospital care.

4.6 Strengths and limitations

A strength of this review is that it examined not only fall-event outcomes but also the theoretical basis, educational content, delivery features, providers, and program quality of fall prevention education programs. This approach allowed a more detailed interpretation of why education-related outcomes, behavior-related outcomes, and fall-event outcomes were not always aligned across the included evaluations.

First, sample size and analytic denominator varied across the 11 trial-based evaluations. Three evaluations enrolled fewer than 100 participants (Hill et al., 2013; Perrot et al., 2019; DeWalt et al., 2023), six enrolled 100 to fewer than 1,000 participants or used comparable trial denominators (Haines et al., 2006; Hill et al., 2009; Hill et al., 2019/Naseri et al., 2019; Dadgari et al., 2022; Valieiny et al., 2023; Morris et al., 2024), and two included at least 1,000 participants or admissions (Haines et al., 2011; Hill et al., 2015). Smaller evaluations may produce less precise and more variable estimates; therefore, positive findings from smaller studies should be interpreted cautiously in the narrative synthesis. Risk-of-bias concerns also reduced confidence in the evidence, with two evaluations rated as high risk of bias and three as having some concerns.

Substantial clinical and methodological heterogeneity also precluded meta-analysis. The included evaluations differed in prevention target, education setting, study design, outcome follow-up, intervention content, delivery method, education duration or reinforcement, provider type, and theoretical or pedagogical basis. These differences indicate that the included programs were not sufficiently comparable for a pooled estimate of effect. Four reports used the Health Belief Model, but the extent to which theoretical constructs were translated into education content, delivery procedures, and outcome measures varied across programs. Similarly, the two simulation-based education programs differed in focus, with DeWalt et al. (2023) emphasizing home-environment hazards and Valieiny et al. emphasizing hospital-based fall prevention scenarios. This heterogeneity made meta-analysis inappropriate, a concern also highlighted by Almas et al. (45).

A further limitation is that the review focused on randomized or trial-based evaluations. This focus may have excluded relevant non-randomized, observational, mixed-methods, and qualitative evidence, thereby narrowing insight into implementation processes, contextual influences, educator perspectives, and patient experiences. Future evidence syntheses could incorporate a broader range of study designs to complement trial-based evidence and provide a more comprehensive understanding of the effectiveness, feasibility, and applicability of fall prevention education for older adults.

5 Conclusion

This systematic review of 12 reports describing 11 trial-based evaluations suggests that fall prevention education for hospitalized older adults and those transitioning home after discharge may improve selected fall-related, education-related, and behavior-related outcomes, but effects were inconsistent across outcome domains. Gains in knowledge, risk awareness, confidence, motivation, or fear of falling were not consistently linked to sustained risk-reducing behavior or fall-event reduction. Many programs were theory-informed and the assessed fall prevention education programs were rated as high quality, but the depth of theoretical application, reporting of provider training, and linkage between theoretical constructs and outcome measures remained uneven. Although nurses or nurse investigators delivered fall prevention education in several evaluations, therapists were the most frequently reported providers, and no included evaluation directly compared outcomes by provider discipline. Future fall prevention education programs should be theory-informed, tailored to patient risk and care setting, and evaluated using rigorous designs with linked education-related, behavior-related, fall-event, and health-service outcomes. Further research should compare nurse-led, therapist-led, assistant-supported, and multidisciplinary delivery models, including nurse-delivered or nurse-reinforced education, to inform role-specific implementation decisions.

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