Are population-based interventions (those aimed at entire communities rather than individuals) helpful in preventing falls and fall-related injuries in older people?

Key messages:

• We are unsure whether approaches to falls prevention that target the whole community reduce falls and fall-related injuries.

• Future studies should be well-designed and use up-to-date descriptions of their interventions. Ideally, studies should be carried out in several communities (rather than just two study communities), each with large populations, and types of older people living in the study communities should be representative of the country in which the study took place.

Why is it important to try to prevent falls?

Falls in older people are very common. Approximately one-third of people 65 years of age or older fall each year, and some older people may have several falls each year. Falls in older people can be very serious and may lead to broken bones and treatment in hospital. A bad fall may seriously affect someone's quality of life and possibly lead to a long recovery. Because falls in older people may need treatment in hospital, including surgery for broken bones, they also cost healthcare services large amounts of money. Finding ways to prevent falls will benefit older people as well as reduce the burden of falls in healthcare services.

What are population-based approaches to falls prevention?

Approaches to prevent falls in older adults are usually aimed at people who are at an increased risk of falling. People at increased risk may have already had at least one fall or may have other conditions that increase their risk of falling (such as problems with walking or moving around or balance). Population-based approaches are different because they are aimed at entire communities rather than individuals. Examples of population-based fall prevention approaches include public health initiatives aimed at informing the public about the benefits of physical activities (e.g. strength and balance exercises); visiting all older people at home to help them identify and reduce fall risks; or local councils improving public walkways and lighting in towns or cities.

What did we want to find out?

We wanted to find out how effective population-based approaches are in preventing falls or fall-related injuries in older adults.

What did we do?

We searched for studies that compared falls and fall-related injuries in communities that used falls prevention approaches in their whole community (i.e. population-based approaches) compared to communities that received no intervention. We compared and summarised the results of these studies, and rated our confidence in the evidence based on factors such as study methods and sizes.

What did we find?

We found nine studies targeting participants aged at least 60 years of age from communities across eight different countries. Study communities ranged in size. Most studies reported the number of older residents, which ranged from 1200 to nearly 137,000 older residents. Other studies only reported the size of the whole population in the study communities, which ranged from 67,300 to 172,500 residents. Studies lasted between 14 months and eight years. Approaches generally involved multiple components such as exercise, education, or reducing fall hazards in the home (such as adding grab rails or non-slip mats) or reducing fall hazards in the community (improving pavements and street lighting). One study also looked at the benefit of a free-of-charge daily supplement of calcium and vitamin D.

Main results

We are unsure whether offering calcium or vitamin D supplements to all older people in the community reduces the number of people who need hospital treatment for falls.

We are also unsure whether population-based approaches that have multiple components reduce the number of falls or the number of people who have one or more falls. We are also unsure whether these approaches make any difference to the number of people with fall-related broken bones, or if they reduce the number of people with fall-related injuries or fall-related hospital admissions. Furthermore, we are uncertain whether these approaches provided savings to the healthcare service.

What are the limitations of the evidence?

We are not confident in the evidence because in some of the included studies communities were not randomly chosen to receive the falls prevention approaches. This is a common design for population-based studies, but it can mean that there are differences between communities that might affect the results. Studies did not provide enough information to judge whether they were well-conducted. In addition, the findings often differed between studies, and we could not identify the reason for this.

How up-to-date is this evidence?

The evidence is current to January 2023.

Authors' conclusions: 

Given the very low-certainty evidence, we are unsure whether population-based multicomponent or nutrition and medication interventions are effective at reducing falls and fall-related injuries in older adults. Methodologically robust cluster RCTs with sufficiently large communities and numbers of clusters are needed. Establishing a rate of sampling for population-based studies would help in determining the size of communities to include. Interventions should be described in detail to allow investigation of effectiveness of individual components of multicomponent interventions; using the ProFaNE taxonomy for this would improve consistency between studies.

Read the full abstract...

Around one-third of older adults aged 65 years or older who live in the community fall each year. Interventions to prevent falls can be designed to target the whole community, rather than selected individuals. These population-level interventions may be facilitated by different healthcare, social care, and community-level agencies. They aim to tackle the determinants that lead to risk of falling in older people, and include components such as community-wide polices for vitamin D supplementation for older adults, reducing fall hazards in the community or people's homes, or providing public health information or implementation of public health programmes that reduce fall risk (e.g. low-cost or free gym membership for older adults to encourage increased physical activity).


To review and synthesise the current evidence on the effects of population-based interventions for preventing falls and fall-related injuries in older people. We defined population-based interventions as community-wide initiatives to change the underlying societal, cultural, or environmental conditions increasing the risk of falling.

Search strategy: 

We searched CENTRAL, MEDLINE, Embase, three other databases, and two trials registers in December 2020, and conducted a top-up search of CENTRAL, MEDLINE, and Embase in January 2023.

Selection criteria: 

We included randomised controlled trials (RCTs), cluster RCTs, trials with stepped-wedge designs, and controlled non-randomised studies evaluating population-level interventions for preventing falls and fall-related injuries in adults ≥ 60 years of age. Population-based interventions target entire communities. We excluded studies only targeting people at high risk of falling or with specific comorbidities, or residents living in institutionalised settings.

Data collection and analysis: 

We used standard methodological procedures expected by Cochrane, and used GRADE to assess the certainty of the evidence. We prioritised seven outcomes: rate of falls, number of fallers, number of people experiencing one or more fall-related injuries, number of people experiencing one or more fall-related fracture, number of people requiring hospital admission for one or more falls, adverse events, and economic analysis of interventions. Other outcomes of interest were: number of people experiencing one or more falls requiring medical attention, health-related quality of life, fall-related mortality, and concerns about falling.

Main results: 

We included nine studies: two cluster RCTs and seven non-randomised trials (of which five were controlled before-and-after studies (CBAs), and two were controlled interrupted time series (CITS)). The numbers of older adults in intervention and control regions ranged from 1200 to 137,000 older residents in seven studies. The other two studies reported only total population size rather than numbers of older adults (67,300 and 172,500 residents). Most studies used hospital record systems to collect outcome data, but three only used questionnaire data in a random sample of residents; one study used both methods of data collection. The studies lasted between 14 months and eight years.

We used Prevention of Falls Network Europe (ProFaNE) taxonomy to classify the types of interventions. All studies evaluated multicomponent falls prevention interventions. One study (n = 4542) also included a medication and nutrition intervention. We did not pool data owing to lack of consistency in study designs.

Medication or nutrition

Older people in the intervention area were offered free-of-charge daily supplements of calcium carbonate and vitamin D3. Although female residents exposed to this falls prevention programme had fewer fall-related hospital admissions (with no evidence of a difference for male residents) compared to a control area, we were unsure of this finding because the certainty of evidence was very low. This cluster RCT included high and unclear risks of bias in several domains, and we could not determine levels of imprecision in the effect estimate reported by study authors. Because this evidence is of very low certainty, we have not included quantitative results here. This study reported none of our other review outcomes.

Multicomponent interventions

Types of interventions included components of exercise, environment modification (home; community; public spaces), staff training, and knowledge and education. Studies included some or all of these components in their programme design.

The effectiveness of multicomponent falls prevention interventions for all reported outcomes is uncertain. The two cluster RCTs included high or unclear risk of bias, and we had no reasons to upgrade the certainty of evidence from the non-randomised trial designs (which started as low-certainty evidence). We also noted possible imprecision in some effect estimates and inconsistent findings between studies. Given the very low-certainty evidence for all outcomes, we have not reported quantitative findings here.

One cluster RCT reported lower rates of falls in the intervention area than the control area, with fewer people in the intervention area having one or more falls and fall-related injuries, but with little or no difference in the number of people having one or more fall-related fractures. In another cluster RCT (a multi-arm study), study authors reported no evidence of a difference in the number of female or male residents with falls leading to hospital admission after either a multicomponent intervention ("environmental and health programme") or a combination of this programme and the calcium and vitamin D3 programme (above).

One CBA reported no difference in rate of falls between intervention and control group areas, and another CBA reported no difference in rate of falls inside or outside the home. Two CBAs found no evidence of a difference in the number of fallers, and another CBA found no evidence of a difference in fall-related injuries. One CITS found no evidence of a difference in the number of people having one or more fall-related fractures.

No studies reported adverse events.