Preplanned Studies: Effectiveness of Group-Based Interventions for Fall Prevention Among Community-Dwelling Older Adults — 7 Regions, 6 PLADs, China, 2019–2020

In 2020, China’s population aged 60 or older reached 264 million individuals, comprising 18.70% of the nation’s total population (1). The swift increase in the aging demographic intensifies the prevalence of fall-related incidents. Falls represent the primary reason for injury-related medical consultations, the leading cause of injury-related fatalities, and the predominant cause of hip fractures among individuals aged 65 and older (2–4). Evidence suggests that group-based fall prevention programs that combine exercise initiatives with health education can effectively reduce the incidence of falls (5). Nonetheless, data on the efficacy of such interventions in preventing falls among the elderly in China remain scarce.

This investigation evaluated the efficacy of a community-based fall prevention program through a multicenter, cluster-randomized controlled trial conducted from August 2019 to December 2020 across six provincial-level administrative divisions (PLADs) in China. We enrolled 60 communities, randomly assigning them to either the intervention or the control group. Of the initially screened 954 senior adults from community health service centers (CHSCs), all met the eligibility criteria. These participants were monitored for a period of 12 months by means of telephone or in-person follow-ups. The results indicated that, in comparison to the control group, the intervention group exhibited a substantial reduction in fall risk [odds ratio (OR): 0.36; 95% confidence interval (CI): 0.24–0.52].

This cluster randomized controlled trial was carried out across 60 communities in 7 Chinese regions: Suzhou City in Jiangsu Province, Ningbo City in Zhejiang Province, Hefei City in Anhui Province, as well as Pudong and Songjiang districts in Shanghai Municipality, Shenzhen City in Guangdong Province, and Shijiazhuang City in Hebei Province. Under simple random sampling methods, communities were allocated equally into either the intervention group (30 communities) or the control group (30 communities). Eligible participants were selected following preliminary screenings conducted by CHSCs. Enrollment criteria included: age between 65 and 84, a history of at least one fall within the previous 12 months, independent ambulatory capabilities, normal communication abilities, and residency within the study area (excluding those in care facilities) for the upcoming 14 months. Exclusion criteria consisted of psychological or neurological disorders, an intolerance for exercise, or diseases affecting balance, such as vertigo or Meniere’s disease. Individuals in the intervention group partook in a six-month group-based fall prevention program that included health education lectures and the cultivation of exercise skills aimed at enhancing balance, endurance, and lower limb strength. The program was facilitated by two trained physicians from the CHSCs, employing aid materials such as slides, an exercise demonstration video, and an intervention manual. Additionally, CHSC staff conducted home-fall hazard assessments for the intervention group during the third month, providing feedback and suggestions for improvements post-assessment. Further details regarding the interventions can be found in Supplementary Table S1. On the contrary, participants in the control group received a total of three health education lectures that covered the same topics. Each session lasted approximately 40 minutes and was conducted monthly by trained CHSC physicians.

In this study, the primary outcome measured was the incidence of falls. Following the initial baseline survey, participants were required to maintain a monthly diary documenting any falls experienced throughout the duration of the follow-up period. A fall is characterized as an unintentional event where an individual comes to rest on the ground, floor, or another lower surface. Fall-related self-efficacy was evaluated using the Fall Efficacy Scale, which comprises 16 items. Each item is scored on a scale from 1 to 4 — where a score of 1 signifies no fear of falling, and a score of 4 indicates a high level of fear regarding potential falls. Balance function was assessed by the Short Physical Performance Battery (SPPB), which incorporates three distinct tests: the Side-by-Side Stand, the Semi-Tandem Stand, and the Tandem Stand. For the Side-by-Side Stand and Semi-Tandem Stand tests, participants received a score of 1 point if they could maintain the stance for 10 seconds and 0 points if they could not, or if the attempt was not made. The Tandem Stand was scored with 2 points for maintaining the position for 10 seconds, 1 point for holding it between 3 and 9.99 seconds, and 0 points for holding it for less than 3 seconds or if the stance was not attempted. The cumulative score, with a possible range of 0 to 4 points, represents the sum of points from all three tests.

Data analysis was conducted using SAS software (version 9.4; SAS Institute, Inc., Cary, NC, USA). We performed a descriptive analysis of the demographic characteristics, disease status, balance function, and other related factors of the study participants. To compare baseline characteristics between the two groups, we employed the t-test or Mann-Whitney U test for continuous variables and the chi-square test or Fisher’s exact test for categorical variables. We used logistic regression models to evaluate the impact of the intervention on the occurrence of falls, calculating the ORs with 95% CI accordingly. The inclusion criteria for the analysis stipulated that participants in the intervention group must have engaged in the intervention activities at least twice. Similarly, subjects in the control group who did not attend any educational lectures were excluded from the analysis. We considered a two-tailed P-value less than 0.05 as statistically significant. The Ethical Review Committee of the National Center for Chronic and Noncommunicable Disease Control and Prevention, part of the China CDC, has approved this study under the protocol (201907).

Participant flowchart showing 488 participants in the intervention group and 487 in the control group with a total of 21 dropouts, including withdrawn consents (n=18) and deaths (n=3), leaving 954 participants for the final analysis with 477 from each group (Figure 1). Baseline characteristics of the 954 individuals analyzed, comprising 698 (73.17%) females with an average age of 71.71±4.50 years, and showing no significant differences between the intervention and control groups (Table 1).

Figure 1. 

Flowchart of participants recruitment, screening, and participation — six PLADs, China, 2019–2020.

Abbreviation: PLADs=provincial-level administrative divisions.

During the 12-month follow-up, falls occurred in 53 out of 477 participants (an 11.11% fall rate) in the intervention group. In contrast, the control group saw 114 out of 477 participants experience falls, representing a 23.90% fall rate. A multivariate logistic regression analysis was conducted, employing two models. The basic Model 1 included only the independent variable, while Model 2 was adjusted for variables showing statistically significant differences, such as education level and disease status (i.e., osteoporosis, arthritis, cervical spondylopathy, lumbar herniated disc, depression, and cataract). The analysis revealed that in comparison to the control group, the intervention group had a 60% reduced risk of falling according to Model 1 (OR: 0.40, 95% CI: 0.28–0.56) and a 64% reduced risk in Model 2 (OR: 0.36, 95% CI: 0.24–0.52), (Table 2). Subgroup analyses based on gender, age group, and fall efficacy scores [with 35 points chosen as the cutoff value, informed by prior literature (6)] showed no statistically significant differences in the efficacy of the intervention strategies among the subgroups, even after adjusting for confounding factors (all P for interaction >0.05), (Supplementary Table S2).