Accidental falls are the leading cause of injury-related deaths amongst older adults (National Center for Injury Prevention and Control 2019; i.e. individuals older than 65 years of age). Falls are therefore considered one of the five so-called ‘geriatric giants’, along with dementia, poor mobility, incontinence and polypharmacy (Cumming 2013). Internationally, it is estimated that a third of community-dwelling older adults may experience accidental falls every year, with a potential 35.5% experiencing recurrent falls (Hung et al. 2017). Although research on falls in South Africa is scarce (Kalula et al. 2016), a recent study revealed that falls are the most common injury in older adults for which medical intervention is required (Da Costa 2020). On the African continent, South Africa has one of the highest proportions of older adults, compared with other African countries, such as Angola, Burkina Faso, Gambia and Uganda. This population is expected to grow from 4 million in 2011 to over 10 million in 2030 (Kelly, Mrengqwa & Geffen 2019). Falls in older adults could have severe and far-reaching consequences, not only for the person who falls but also for their family members – as a third-party disability (Hickson & Scarinci 2007) – and for society at large. The International Classification of Functioning, Disability and Health (ICF) describes third-party disability as the disability experienced by significant others as a consequence of their family members’ health condition (in this case falls), and the impact this has on the family members’ life functioning. As such, falls have several financial and environmental consequences, for instance hospitalisation and early nursing home admission, which may result in a socio-economic burden on the person who falls, family members and the healthcare system (Bird et al. 2013; Howcroft, Kofman & Lemaire 2013; Liu et al. 2017).

The majority of the South African population relies on the public healthcare system – public hospitals, clinics and medical facilities – for medical intervention. The public health system in South Africa is an institution under severe restraint, with a shortage of healthcare practitioners (HCPs), poor leadership and often improper allocation and use of the limited resources (Kelly et al. 2019). Healthcare access, in both the public and the private sectors, is shaped by several factors, including the characteristics, financial position, social capital and level of education of the population and the limited availability of equipment, medicine, skilled HCPs and facilities (Kelly et al. 2019). Although the private healthcare system in South Africa is currently better equipped than the public system with both resources and HCPs, older adults nonetheless experience difficulties in navigating their medical aid funds to cover HCP fees. They also struggle to afford medical co-payments and cope with having to wait several weeks to months for specialist appointments. Because community-dwelling older adults face challenges in accessing appropriate care and support from medical facilities, they often under-utilise the healthcare system or receive insufficient care (Kelly et al. 2019). Because early identification of fall risk factors may potentially decrease the rate of falls in older adults, HCPs could assist in reducing older adults’ chances of landing in the healthcare system for falls and fall-related injuries. Healthcare practitioners’ play an important role in relieving not only the burden on the healthcare system but also, more importantly, the burden on older adults who have to live with the negative consequences of fall-related injuries. The latter could lead to reduced functioning and decrease these older persons’ health-related quality of life (HRQoL; Fahlström et al. 2018). By lowering their fear of falling and improving their physical functioning, HCPs could help to reduce fall risks even more, thus creating a positive and upward spiral of health in older adults (Bjerk et al. 2018).

Despite the relatively small percentage of older adults in South Africa (8.6%) – considering a population size of almost 60 million in 2020 – this translates into an actual figure of more than 5.2 million older adults (South African Government 2018). With the expected growth of this population, as well as the burden that falls in older adults could have on the healthcare system and society at large, it is important to determine the perceptions of HCPs on fall-related risk factors. It is also imperative to use this knowledge to potentially increase early identification of fall risk factors in older adults and so reduce falls and fall-related injuries in this population. Literature is abundant with different factors that could potentially increase this population’s risk of falling, although most studies are aimed at hospital settings or at specific medical conditions, e.g. Parkinson’s disease or cancer (Myers 2013; Park 2017; Voss et al. 2012). A recent study (Howland et al. 2018) indicated that although almost all HCPs in their sample (n = 97) believed that older adults should regularly be screened (as this could guide HCPs to implement prevention strategies to reduce fall risk in older adults), only half of them felt confident to perform fall risk screenings in this population. Furthermore, these HCPs did not believe that conducting fall risk screenings currently constitutes the prevailing standard of practice in their profession. Some of the reasons for not screening for fall risk as routine practice could relate to limited time to complete such screenings during routine consultations (Hunderfund et al. 2011), not necessarily being compensated for these screening procedures by the healthcare system or medical aids (Howland et al. 2018) and the sheer amount of available screening fall risk assessment tools (FRATs). Another reason may be the fact that FRATs are currently not well-integrated as routine clinical practice in the majority of HCP practices (Howland et al. 2018). Identifying from a clinical point of view, the factors that are most relevant to fall risk in older adults could help to further develop early identification and screening methods to reduce falls in this population.

Reducing and even preventing fall risk in older adults firstly hinges on effective documentation of risk factors, which could then be used to guide further intervention and mitigate fall risk (Reinoso, Mccaffrey & Taylor 2018). One of the key strategies for compiling a list of relevant ICF codes involves determining the perspectives of HCPs on fall risk factors in older adults. Practitioners have an important role to play in identifying fall risk (Liddle et al. 2018), yet their perspectives are not routinely included in research on the topic (Burgon et al. 2019). Currently, no universal tool exists for HCPs to comprehensively document fall risk factors in older adults, and this possibly contributes to the ineffective management of the problem (De Clercq, Naude & Bornman 2020). One strategy towards creating an early identification documentation system is to develop a holistic, universal classification of fall risk in older adults. This can be done by incorporating the ICF as a framework for determining functioning in older adults who have a risk of falling and using this framework to guide the early identification of fall risk by HCPs of these patients. The World Health Organization’s ICF uses a universal language to ensure that the functioning of a person of any age, participating in any activity, can be documented in any healthcare setting by HCPs from different professional disciplines. Built on such a multidimensional view of functioning, the ICF is especially suitable to obtain health information because it recognises the individual (consisting of a body participating in specific activities) as being influenced by different contextual factors. As such, the ICF consists of three domains, namely Body Functions and Structures, Activities and Participation and Contextual Factors (which are divided into Environmental and Personal Factors). Several codes describe each domain, save for Personal Factors, which are not coded in the ICF. The complete ICF consists of more than 1400 codes, presenting a challenge in using it in clinical practice (Aiachini et al. 2010). Therefore, researchers and clinicians alike have recommended that the most relevant and typical codes should be determined for a specific condition – termed a ‘code set’ – as that would enable HCPs to utilise the ICF more effectively in clinical practice. Currently, a code set does not exist to describe and document fall risk in older adults.

Based on their clinical experience, HCPs could offer new insights into the current knowledge on fall risk factors in older adults, thereby identifying potential risk factors not previously documented. Healthcare practitioners are also able to influence patients’ opinions on falls and to reduce fall risk (Burgon et al. 2019). Obtaining qualitative data on their perspectives on fall risk factors in older adults and linking these factors to the ICF as a universal framework could give insight into the clinical manifestation of fall risk in this population. The data could also be used to move towards incorporating the perspectives of HCPs into future fall risk guidelines for clinical practice. This could also help to identify areas to be considered in the compilation of a list of ICF codes, as well as to develop improved strategies to manage (Loganathan et al. 2015) and ultimately have a positive impact on older adults’ HRQoL. Healthcare practitioners are key stakeholders in the process of translating findings from literature and research into clinical practice and policies (Van Rhyn & Barwick 2019). By gathering their insights, researchers could develop more user-friendly and appropriate clinical tools for HCPs for use in their routine screening of these patients.

This study aims to fulfil two distinct objectives: firstly, to provide insight into the perspectives of HCPs in the South African context regarding risk factors associated with falls in older adults, and secondly, to link these factors to the ICF as a universal framework for describing functioning. The researchers hoped to move towards incorporating the perspectives of HCPs as key stakeholders into future fall risk guidelines for clinical practice.

Following a qualitative design, two focus group discussions were conducted, as these allowed the gathering of in-depth, detailed information on a novel topic – the perspectives of HCPs in South Africa on fall risk factors in older adults. This method ensured that all voices in the discussion were heard, thereby enhancing contemporary knowledge (Carey & Asbury 2012).

The focus group participants provided rich insights into their perspectives with regard to the fall risk factors that they considered relevant in older adults. Table 1 lists the points that emerged from these discussions as well as how frequently each of the themes was mentioned, as per the first objective of the study.

A total of 42 themes emerged from the data, and the most prominent themes were identified as ‘medical history/conditions’ (n = 14), followed by ‘floor surfaces’ (n = 10) and ‘balance/instability’ (n = 8). One theme, ‘medication’, was mentioned six times and ‘dizziness and vertigo’ five times, followed by ‘vision’ four times. Five fall risk factors were mentioned three times each, 10 factors were mentioned twice and the remaining factors (n = 21) were only mentioned once during the discussions. Of the identified themes, four themes could not be linked to the ICF as they were classified as Personal Factors, namely ‘age’, ‘fall history’, ‘gender’ and ‘medical history/conditions’. The remaining 38 themes could be linked to the ICF, resulting in a total of 142 ICF codes, as depicted in Table 2, to satisfy the second objective of the study.

As depicted in Table 2, of the 142 ICF codes identified from the 38 themes mentioned in the discussions, 43% (n = 61) were in the Body Function category, 23% (n = 32) in the Environmental Factors category, 18% (n = 26) in the Body Structure category and 16% (n = 23) in the Activities and Participation category.

Differences were calculated between all four categories, and statistically significant differences were found for the comparison between Body Function (n = 61) vs Body Structure (n = 26) – p < 0.0001; Body Function (n = 61) vs Activities and Participation (n = 23) – p < 0.0001; and Body Function (n = 61) vs Environmental Factors (n = 32) – p = 0.0003. No statistically significant differences were reported for any of the other comparisons (p > 0.05).

As expected, the results of this study revealed that the main focus of HCPs was on Body Function. The way in which the body functions is important to HCPs, as there is no better indication of successful assessment and intervention outcomes than improved functioning. Difficulties in functioning urge patients to seek advice from HCPs so as to improve their health and increase their own functioning (Bickenbach et al. 2012). When considering the ICF, a person’s functioning (on the level of the body) is important for HCPs, as it describes the outcome of four main health strategies, namely prevention, cure, rehabilitation and support. The ICF also offers a common terminology for the improvement of clinical and patient-orientated assessment instruments (Bickenbach et al. 2012; World Health Organization 2012). A comparison between the perspectives of HCPs and a recent systematic review of FRATs (De Clercq et al. 2020) indicated that the majority of perspectives of both the FRATS and the HCPs focussed on Body Function. It also showed that the knowledge of HCPs was in line with contemporary knowledge in the field.

Functioning is furthermore related to the environment, as it essentially captures the functioning of the body in ‘real-life contexts’ and reflects how the body and the environment interact with one another to either increase or decrease older adults’ ability to function. It was not at all surprising that approximately a quarter of the factors mentioned by the HCPs could be categorised under Environmental Factors. Almost all the activities of daily life are complex and require complex and dynamic interaction with the environment (Young & Williams 2015) (e.g. walking along an uneven pavement or stepping over obstacles on the floor). The physical environment poses the most significant environmental risk for older adults, and often home hazards are the most important to consider in understanding and preventing falls, especially for persons who fall repeatedly (Letts et al. 2010). A person’s interaction with the environment is therefore important, as the type of interaction could increase fall risk.

When considering the number of codes in each ICF category, about a third of the second-level codes are in the Activities and Participation category. This category entails three concepts: one is the task being executed (Activities) (World Health Organization 2002) and the others are two Participation concepts, namely attending (physical presence) and involvement in activities (the type of activities the older adult is participating in, whilst being physically present) (Adair et al. 2018; Imms et al. 2017). In the current study, however, the HCPs had a minimal focus on this category and they only discussed Activity-related factors. They did not include any Participation factors, such as domestic life activities, relationship activities and community or social life activities, in this category. One possible reason for this could be that Activities, the execution of a task, is more closely related to Body Functions, and as such, more in line with the role of HCPs in the clinical identification of fall risk factors. Participation codes, on the other hand, are more in line with intervention strategies, which were not discussed by the focus groups.

A comparison between the clinical perspectives of HCPs on fall risk factors in older adults and the systematic review of FRATs (De Clercq et al. 2020) revealed that the HCPs mentioned two relevant factors that were not captured in existing FRATs, namely ‘muscle-power functions’ and ‘mobility-of-joint functions’. Both of these ICF codes are important to consider for fall risk in older adults, as they relate directly to the ability to execute mobility activities. Almost 25% of older adults have mobility limitations, and both muscle-power functions and (to a degree) mobility functions are modifiable impairment limitations on the mobility of older adults (Bean et al. 2007). Studies have shown a link between lack of mobility and flexibility, and poor walking ability and balance in older adults (Martínez-López et al. 2014). Healthcare practitioners were clearly aware of the importance of these two aspects and included them in the discussions, thus revealing the importance of these clinical perspectives in the discussion of fall risk in older adults.

Healthcare practitioners have a crucial role to play in identifying fall risk factors in older adults and also in assisting older adults to understand the importance of reducing their own risk, not only in terms of their medical conditions but also with regard to their environment and how they engage and participate in activities. Early identification of fall risk factors, combined with appropriate referrals to other HCPs when needed, could reduce older adults’ fall rate by up to 24% (Howcroft et al. 2013; Phelan et al. 2015). Our findings revealed that HCPs’ knowledge is in line with current literature and they were well aware of the importance of including aspects not only related to Body Function, even though the latter was their main focus. By gathering the perspectives of HCPs on the topic at hand, we were able to add the necessary clinical evidence to support the development (in future research) of a holistic instrument to identify fall risk in older adults. Such an instrument could guide intervention strategies for this population, as well as be used by HCPs, in different settings, with ease and consistency. It could ultimately assist HCPs in guiding older adults on how to reduce their own risk of falling.

All data was collected from HCPs in urban Gauteng, although they represented both public and private facilities. The clinical knowledge, skills and experience of these HCPs may, however, differ from those of their peers in smaller towns or rural areas. Furthermore, this research only focussed on the perspectives of one stakeholder group, namely HCPs. Only one general question and a follow-up question were asked to elicit information about the participants’ perspectives. Further studies could consider asking more specific questions regarding each ICF category to elicit more detailed ICF-focussed as well as intervention-related responses.

Whilst this article provided insight into the perspectives of HCPs on factors contributing to fall risk in older adults, it also demonstrated that HCPs are not only aware of current literature on the topic but also have knowledge of factors not specifically related to the body (i.e. the environment and the older adults’ ability to perform physical activities).

By comparing the perspectives of HCPs on fall risk in older adults to current literature as well as to the perspectives of the older adults themselves, future research could pursue a twofold aim: it could provide a holistic picture of fall risk factors in older adults, and it could use this information to further develop ICF tools to guide the comprehensive management of fall risk in this population. Future research could also identify factors that are focussed on intervention in fall risk management in older adults and determine if the perspectives of HCPs are translated into clinical practice.