Barriers Encountered When Implementing a Community Evidence-Based Fall Prevention Program

Brandi M. Crowe ^1,*, Karen Kemper ², Marieke Van Puymbroeck ³

1. Department of Parks, Recreation and Tourism Management, Clemson University, Clemson, SC 29634, USA

2. Department of Public Health Sciences, Clemson University, Clemson, SC 29634, USA

3. Graduate School, University of Tennessee, Knoxville, Knoxville, TN 37996, USA

* Correspondence: Brandi M. Crowe

Academic Editor: Hanna S. Schroeder

Special Issue: Falls and Fractures in Older Adults: Causes and Prevention

Received: June 11, 2025 | Accepted: October 29, 2025 | Published: November 05, 2025

OBM Geriatrics 2025, Volume 9, Issue 4, doi:10.21926/obm.geriatr.2504330

Recommended citation: Crowe BM, Kemper K, Van Puymbroeck M. Barriers Encountered When Implementing a Community Evidence-Based Fall Prevention Program. OBM Geriatrics 2025; 9(4): 330; doi:10.21926/obm.geriatr.2504330.

© 2025 by the authors. This is an open access article distributed under the conditions of the Creative Commons by Attribution License, which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is correctly cited.

1. Introduction

One in four older adults in the U.S. experience a fall each year [1] with approximately 37% experiencing injury or limited activity [2]. Individuals who experience a fall-related injury are likely to decrease their activity level, which can contribute to functional decline and increased fall risk [3]. Falls are the leading cause of nonfatal and fatal injuries among Americans aged 65+ [1]. Risk of falls and fall-related injuries increase with age [4]. Fall risk factors include pre-existing health conditions, environmental barriers (e.g., uneven surfaces, lack of railings), residual impacts of medication, age-related physical and cognitive changes (e.g., change in vision, hearing, muscle mass), limited physical activity, fear of falling, and recurrent falls [4,5,6,7,8]. By 2050, the U.S. population of individuals older than 65 is expected to reach 82 million, a 47% increase from 2022 [9]. As the U.S. aging population increases, it is imperative that sustainable community-based, evidence-based fall prevention programs (EBFPP) are offered in conjunction with clinical services to decrease fall risk and falls/fall-related injuries [10,11].

While several fall prevention initiatives (e.g., fall risk screenings, physical activity and balance exercise programs, and educational programs) have been found effective in increasing older adults' awareness of fall risk and prevention [12,13], more research identifying strategies for sustained implementation of these initiatives is needed [14]. For example, A Matter of Balance (AMOB) [15] is an EBFPP shown to improve participant fall-risk outcomes related to number of falls, fear of falling, physical risks of falling, falls self-efficacy, falls management, exercise frequency, and overall health status [16,17,18,19,20]. However, few studies discuss lessons learned regarding the planning and implementation of AMOB with community-dwelling older adults, nor provide recommendations regarding sustained implementation. This multi-method descriptive study aimed to (1) assess whether AMOB participation decreased fear of falling or concerns about falls, and increased confidence to manage falls among community-dwelling older adults, (2) examine stakeholders' perspectives regarding their AMOB engagement, and (3) identify barriers to sustained AMOB implementation.

2. Methods

2.1 Ethics Statement

As part of a three-year grant-funded project, AMOB was implemented with community-dwelling older adults aged 60+ in South Carolina. Following Institutional Review Board approval and receipt of participant consent, quantitative and qualitative data were obtained from stakeholders to determine AMOB participant outcomes and better understand factors that influence successful AMOB implementation. A one year no-cost extension was granted to the project team to complete data analysis, interpretation, and final reports.

2.2 Intervention

The intervention utilized in this study was AMOB [15], an EBFPP curriculum focused on decreasing participants' fear of falling, increasing activity levels, and improving participants' confidence to manage falls through education about fall risks and prevention, cognitive restructuring strategies, lectures, class activities, and physical exercises. The recommended cohort size is 8-12 participants aged 60+, who meet once a week for 120 minutes for eight weeks [21]. AMOB was facilitated at various community-based organizations including senior centers, public libraries, faith-based organizations, and college campuses. Prior to implementation, AMOB facilitators received standardized training to implement the curriculum. There are two levels of facilitator training available: "Master Trainer" and "Coach". Master Trainers (MTs) are allowed to facilitate workshops as a single facilitator; coaches are required to co-facilitate workshops with another trained coach.

In addition to offering AMOB workshops, facilitators were tasked with participant recruitment, identification of host facilities, pre-post-participant data collection, and workshop documentation (e.g., attendance log, host facility information). MTs were also tasked with recruiting and training coaches. Several MTs delivered AMOB workshops as part of their professional job responsibilities. Neither MTs nor coaches received compensation for planning or implementing the EBFPP from the university-led project team.

2.3 Quantitative Data Collection

To address the study's first aim, quantitative data were collected to assess change in AMOB participants' fall risk.

2.3.1 Sampling

Purposive sampling was used to recruit community-dwelling adults aged 60+ willing to enroll in an eight-week AMOB workshop, consent to study participation, and complete either the pre- and/or post-AMOB survey. No exclusion criteria was utilized as AMOB is designed for community-dwelling adults [15], without restriction based on individuals' cognitive function, educational level, physical ability, or history of falls. Also, AMOB focuses on primary and secondary fall prevention, preventing a first fall for individuals who have not yet experienced a fall (i.e., primary prevention) and preventing subsequent falls among individuals who have experienced a fall (i.e., secondary prevention) [22]. As such, AMOB was implemented as originally designed in a community environment [15] with older adults with and without a history of falls. Individuals who did not consent to the study were not excluded from attending the AMOB workshop, however, their data were excluded from analysis.

2.3.2 Data Collection

Prior to and immediately following participation in the eight-week AMOB workshop, participants were asked to complete a survey. The 26-item pre-AMOB survey included questions about demographics, health history, history of falls/fall-related injuries, fear of falling, perceived impact of fall concerns, and confidence to manage falls. The 27-item post-AMOB survey included the same questions as the pre-survey as well as items about any changes participants had made because of AMOB participation and their opinions about their AMOB experience. Additional data collected included AMOB workshop data (e.g., participants' attendance, workshop location, and classes taught per MT and coach). Survey data reflective of four fall-related outcomes were assessed to address the first aim of this study (see Table 1).

Table 1 Description of Quantitative Fall-related Survey Items.

2.3.3 Data Analysis

Using SPSS 27, descriptive statistics were used to summarize demographics. A nonparametric Wilcoxon Signed Rank Test was used to analyze pre-post outcome data. P-value thresholds of <0.05 were used to determine statistically significant differences between pre-post-data. Frequency counts were used to summarize AMOB attendance and AMOB completers (i.e., participants who completed at least five of eight AMOB sessions).

2.4 Qualitative Data Collection

A qualitative descriptive research design was used to address the second and third aims of the study. Qualitative data were collected to examine stakeholders' perspectives regarding their AMOB engagement and identify barriers to sustained AMOB implementation.

2.4.1 Sampling

At the end of the project's first year, purposive sampling was used to recruit stakeholders, including the project manager, steering committee members, and AMOB facilitators, to participate in semi-structured interviews. In addition to interview data, responses to open-ended questions were extracted from participants' post-surveys submitted throughout the three-year project. The open-ended questions asked participants to comment on what they enjoyed, or recommended in the future, regarding AMOB.

2.4.2 Data Collection

Four semi-structured interviews were co-facilitated with the team's project manager and three MTs. Four group interviews were also conducted with steering committee members (n = 5), university students serving as coaches (n = 8), and two groups of lay leader coaches (n = 4). Interviews were audio recorded and occurred in person or via Zoom. The project manager was asked to provide their insights regarding (a) the structure and interactions of steering committee members, community partners, and the project team; (b) marketing AMOB to participants and potential facilitators; and (c) sustained AMOB implementation. MTs and coaches were asked about facilitator training, AMOB planning and implementation, participant interactions, and communications with the project team. Steering committee members were asked to provide feedback related to their understanding of the purpose of the steering committee, their experience as a committee member, and recommendations for increased engagement moving forward.

2.4.3 Data Analysis

Data were transcribed verbatim using Rev.com transcription services. Prior to analysis, a researcher listened to each interview while reviewing the transcript to ensure accurate transcription. Conventional content analysis [23] was used to analyze data collected via stakeholder interviews and open-ended survey responses. The researcher read through each transcript, creating codes based on common insights or experiences shared across stakeholder data. Codes were assessed and grouped based on related and interconnecting ideas. Final qualitative themes were identified based on overarching topics repeated across stakeholder data. A second researcher reviewed the qualitative themes and transcripts to confirm agreement with data interpretation and final qualitative themes.

3. Results

3.1 Quantitative Results

Of the 491 AMOB participants, 481 (98%) met inclusion criteria and completed either a pre-survey (n = 139, 29%) or both pre- and post-surveys (n = 342, 71%). Participants averaged age 77 (range 60-95 years; SD = 7.28) and reported having an average 3.55 (SD = 2.30) chronic health conditions (see Table 2 for additional demographics).

Table 2 AMOB Participant Demographics.

Four outcome measures were compared for participants who completed both pre- and post-surveys (n = 342; see Table 3). Variations in sample size per question are due to missing data. Fear of falling, fall concerns restricting social activity, and average number of falls decreased in post-survey measures (p ≤ 0.05). Confidence to manage falls also increased in post-survey measures (p ≤ 0.05).

Table 3 AMOB Participant Outcomes.

3.2 Qualitative Results

Twenty-one individuals participated in qualitative data collection, including AMOB facilitators (n = 15; eight university students, four lay leaders, three health educators/injury prevention coordinators), steering committee members (n = 5), and a project manager (n = 1). At the time of data collection, 15 of 21 (71%) participants completed either the MT or Coach training. Eleven of the 15 (73%) trained facilitators interviewed had implemented AMOB at least once. At the conclusion of the three-year project, 59 AMOB workshops were implemented by 15 MTs and 32 coaches. During the three-year project, all 15 MTs facilitated at least one AMOB workshop; with MTs facilitating 61% of the workshops offered. Ten MTs facilitated one or two AMOB workshops throughout the three-year project. Six of the 15 MTs trained coaches.

Of the 342 participants who consented to study participation and completed the post-survey, 209 provided open-ended comments regarding their AMOB experience. Qualitative analysis resulted in six themes: 1) time-intensive program, 2) marketing AMOB, 3) curriculum implementation feedback, 4) AMOB facilitator training and mentorship, 5) need for community-based participatory planning, and 6) need for improved communications network.

3.2.1 Time Intensive Program

While AMOB was perceived to positively benefit participants, facilitators were challenged by the time required for AMOB implementation. Lay Leader Coach #2 indicated losing a co-facilitator because of the time commitment, sharing "… we even lost one of our coaches the first day in training because of that [16-hr, 8-wk program]… She's like, I don't have time to do this." MT #1 said,

… with all the other duties that I have… [it's] been a challenge for me to create the time to have classes… and what is my reach?… to devote that much time, and I have 12…15 people… [I can do] a webinar and reach 100 people in an hour.

The time-intensive nature of AMOB resulted in several facilitators having limited capacity to offer the program. Lay Leader Coach #4 shared "I personally would not commit to more than once a year…". Lay Leader Coaches #1 and #2 reflected on what they felt would be feasible moving forward, after co-facilitating for the first time, stating:

… if it [EBFPP] was half the time, we could probably offer it once a year… maybe even twice a year… But given… [we] were either part-time or not getting paid at all, it was a lot of our time to do the 16 hours, and prep…

Facilitators also indicated that AMOB's duration was a barrier for participants and a potential deterrent regarding participant recruitment. MT #1 said "the two-hour class for some… participants, it's really long… they have other stuff to do." MT #2 shared, "they [participants] did not like the fact that it [AMOB] was long… they would be like, 'Can we get the exercises and kind of do a quick rundown of the information we want to go to this other thing'." Lay Leader Coach #1 stated, "I think you're going to be hard-pressed to find participants that will give you 16 hours." Participants also recommended decreasing AMOB's duration. One participant wrote "shorten the sessions to less than two hours." Another said, "the material could be presented in fewer sessions."

3.2.2 Marketing AMOB

Stakeholders emphasized it was essential to communicate that AMOB was focused on problem-solving and cognitive reframing rather than it being a physical activity or balance class. When marketing AMOB, MT #3 found it important to say to potential participants that "… there's exercise involved, but this is not an exercise program." Likewise, Student Coach #3 advised,

… when you're advertising [AMOB]… have a part of it where it's like, 'how do you know this class is right for you?' Be like 'this is going to be about fear of falling and confidence. Do you think that relates to you? It's not going to be super activity-based as in exercise.' Just letting them know exactly what the class is about.

AMOB participants echoed the importance of proper marketing suggesting that the premise of AMOB was not clearly communicated when they initially registered. One participant said, "[I] was expecting more physical training; class description should clearly state this is a psychological approach to falling, not a physical course."

3.2.3 Curriculum Implementation

Overall, participants seemed pleased with the AMOB curriculum, as indicated by open-ended survey responses: "classes are very informative, and [I] have loved the exercises can be done anytime and anywhere;" and "I think the exercises were so good. I'd loved to share them with… a friend… who [doesn't] go out a lot." MT #2 said participants "loved having the books. They liked to… look at it at home… read ahead… so they would be prepared when they came to class." Another participant wrote that they "like[d] the combination of lectures and exercises." However, participants also provided several recommended revisions to AMOB. One participant said, "information can be condensed and not be so repetitive." Others encouraged increased exercises, writing "Would like more exercise/balance practice, ideally some starting with the first class." Another participant voiced the need to offer modifications for exercises such that participants could adjust the difficulty based on comfort or ability, stating, "have two sections of exercises or alternatives for hard ones."

After completing AMOB training or facilitating AMOB, some MTs and coaches shared that the program was different than they originally understood when they agreed to serve as a facilitator. Lay Leader #2 said "Initially, I was thinking it was going to be all physical activity… more of a gym class… versus more lecture." Student Coach #1 also indicated having the impression that AMOB was "more exercise-based… I didn't realize how much was going into it on the fear-based prevention side." MTs and coaches were also dissatisfied with redundant information in the curriculum. MT #3 said:

I feel like I'm beating a dead horse… I don't want them to feel like, 'Hey, you guys are old so you're slow. You don't understand what I'm saying.' Because a lot of them get it, especially by the second or third time. By the time I've said it, four or five [times], I feel like I'm almost insulting them…

For Lay Leader Coach #2, covering redundant material created a sense of fatigue among facilitators and participants, saying, "I know from experience you have to repeat things several times for people to get it… But for me as a… it got repetitive… I sensed with the participants it got repetitive, and then it just got long." In addition to the redundant curriculum, MTs and coaches found the facilitator workbooks were not user-friendly due to the layout, lack of examples to accompany main curriculum points, and outdated references. Lay Leader #1 said "I had difficulty following this lesson plan… I know… [another facilitator]… wrote hers on a totally different paper. Because she's like, 'I can't follow this.'" Lay Leader Coach #2 also shared several inconveniences:

… it would've been nice in the [coach's] book to have examples… if you didn't have your own examples… You were like, 'Okay. How are we going to say this?… you want to make sure your example does go with what [curriculum is] trying to teach… [Also,] I would like to know that when I'm looking at the [facilitator] handout, what page it's in the participant's manual… Because I would have to go through there and find… They're page 33-34, but on mine it's 95… [And] References… they're outdated… the curriculum… need to have newer supporting documents… at this point, 30 years old, it's misinformation…

3.2.4 AMOB Facilitator Training & Mentorship

MTs and coaches with previous experience teaching or facilitating groups indicated using those skills when facilitating AMOB. MT #1 shared that their "… previous jobs and knowing some of those facilitation techniques and how adults learn… was helpful… I… relied a lot on the skills that I had learned in professional development." However, MT #1 suggested facilitator training include more support and feedback regarding their AMOB facilitation:

… modeling… not a whole lesson, but maybe a content-heavy part of a lesson… what are the most important pieces that we could share with the participants? And how would somebody [facilitator] that has been doing this for a while, what would they say? How would they say it?

The Project Manager, who served as a MT, also recommended improved mentorship of facilitators as the AMOB facilitator training did not include content to assist MTs in how to train coaches. If the facilitator training could not be revised to include more mentorship regarding the train-the-trainer model, the Project Manager suggested recruiting MTs and coaches that had a background in teaching or facilitation, saying, "We… have to help MTs know how to… train coaches… I don't know that we [project team] have time to develop those skills in the MTs… we need to have coaches developed by people who… have that experience [training or teaching others]."

Similarly, university students who served as coaches suggested more support during training and when facilitating AMOB for the first time. For example, Student Coach #4 stated,

… [in AMOB training] we were learning more how to be a teacher and how to stand up and talk… most of us already know we can get up and talk to people if we know what we're talking about… we needed to know more about the content.

Student Coach #2 shared that the limited portion of AMOB training that involved mock facilitation was helpful, and proposed increased opportunities for receiving feedback regarding content delivery, saying, "I think one part of training that was beneficial was when we led our [mock] session… We could do more of those and then get good critiques from the instructor…"

3.2.5 Need for Community-Based Participatory Planning

Once the grant project was underway, several stakeholders recognized the project team's oversight in selecting to implement AMOB without having heard directly from community stakeholders, including community-dwelling older adults, about what the perceived needs or interests regarding fall prevention were. The Project Manager highlighted this, saying:

I don't know that any of them [stakeholders] heard about [AMOB/grant project] and said, 'This fills a need for me, sign me up.' That might've been the challenge is that it was a little bit one-directional, us [project team] saying 'we need this. Please give this to us.' … I don't know that they [stakeholders] saw the value in it… to come to a community and say 'hey, we found a problem in your community, we're going to fix it.' That's a little bit different from a community realizing there's a problem and saying 'who can we partner with to fix this?' It's a very top-down approach rather than a bottom-up approach.

Steering committee members also voiced the importance of conducting a needs assessment to ensure selected EBFPPs appropriately address stakeholders' needs and confirm there are adequate resources to support selected EBFPPs. Steering Committee Member #1 shared:

"… to get buy-in… surveying the staff and then the seniors themselves, what kinds of fall prevention program would appeal to them… I think that would be helpful… survey to find out what individuals want because then you're designing programming that fits what the community is interested in… might be helpful if there was some options… getting input from the aging network… our AAAs and senior centers and meal site staff about what programming makes sense for their structure as far as how many staff need to be involved in the actual classes, how long is the class… because if the older adult is only with them for 3 hours and a [EBFPP] is an extent, it starts to become… not the right kind of environment for some of the [EBFPP]."

Had this level of community-based participatory planning occurred, the project team may have recognized the need to offer more than one EBFPP, or the need to adjust the timing of AMOB implementation. For example, Steering Committee Member #2 said:

It was not the best time to start something like this [AMOB] because so many of our senior centers across… South Carolina… are just trying to get seniors back in and active [post-COVID]… to coordinate a class of this magnitude, it is hard… a lot of senior centers rely on volunteers… Some have paid staff and they have experienced a huge turnover…

3.2.6 Need for Improved Communications Network

Steering committee members also discussed difficulties in recruiting AMOB host facilities, MTs, coaches, and participants. Steering Committee Member #1 shared "I made so many calls… I just felt like I wasn't getting anywhere even when looking for alternate partners… I just did not realize it was going to be this tricky." Recruitment challenges could be attributed to the lack of stakeholder buy-in as discussed in the previous theme, or difficulties explaining AMOB due to lack of understanding of what the program was about. For example, the Project Manager said:

They came into the steering committee with [AMOB] being, I think very foreign to a lot of them… and we were asking them to talk about it, and promote it, and recruit individuals to be MTs, when they probably didn't know much about it, and only what we [project team] were telling them. But it [AMOB] was new to us too.

Recruitment challenges were also attributed to a lack of communication between the project team and stakeholders, and the need for a more established fall prevention network. For example, steering committee members commented that their being made aware of other stakeholders' successes would have been encouraging, recommending the project team utilize frequent visuals to update stakeholders on successes and areas needing additional focus. Steering Committee Member #1:

… there's just so much going on and I have to be kind of prompted sometimes, especially when I'm not getting a lot of movement on my end. Then it kind of trailed off for me… because I wasn't making any progress. I kind of got deflated…and then I just felt like I was very disconnected to what was going on, even if it wasn't my successes, what were the other successes that were going on… I think that might've helped inspire me, try again.

Steering Committee Member #2 voiced the importance of project team updates, saying "I think it would be good to have some feedback on… we connected a lot of people initially [re: AMOB partners], and I kind of lost touch with how that was going…" Steering Committee Member #4 echoed their sentiments regarding improved project communications, saying "… being prompted about not just successes but where we're still struggling… I kind of lost track and I love the idea of something visual. Say, 'hey, here's a giant gap we still have here, but we're doing well in this area.'"

Lastly, steering committee members discussed the absence of a well-established fall prevention network, which negatively impacted AMOB recruitment. Steering Committee Member #4 said "I thought that I would be a conduit for identifying potential trainers and organizations to connect with… [that] was challenging because we were a little slow in… figuring out who all those people were…" Steering Committee Member #5 also shared having limited contacts specific to fall prevention when discussing the identification of potential MTs and coaches "… where we only know a few folks… in those counties…" This resulted in the recommendation to develop a more formal fall prevention network within South Carolina to help connect stakeholders. Steering Committee Member #5 referenced benefits of their participation in an unrelated statewide coalition, saying:

I know this group [grant team] was working to get that initiative [fall prevention]… off the ground… I don't know if there's a space for a broader… group… we have [a coalition] quarterly and it's just a good touch point for folks… doing stuff across the state… it's been a real opportunity for… 'oh, I didn't know that,' or 'I didn't know about this.' So that's been a great group…

4. Discussion

This multi-method study assessed AMOB participant outcomes and sought to understand stakeholders' perspectives regarding their AMOB involvement and challenges to sustained AMOB implementation. Study findings reflective of participant outcomes align with previous AMOB research [16,17,18,19,20] indicating AMOB participation decreases participants' fear of falling and increases falls self-efficacy. Regarding curriculum, participants appreciated that AMOB involved educational content and physical exercises. This supports previous research showing multicomponent fall prevention initiatives are an effective modality for decreasing community-dwelling older adults' fall risk [24,25]. However, participants recommended that more exercises be incorporated into the AMOB curriculum and that exercises be introduced earlier than week three. Participants also requested modifiable exercises where the challenge level could be adjusted based on functional ability. This recommendation coincides with literature focused on home- and group-based fall prevention activities for older adults that reference the value of offering adaptable exercises, as well as exercises that progress in challenge, to ensure safe and effective participation [12,26,27].

While AMOB resulted in positive participant outcomes, stakeholders highlighted several challenges to sustained implementation. Facilitators considered AMOB to be time intensive, which deterred them from committing to offering AMOB more than once or twice a year. The time required for planning and implementing AMOB (16+ hours) was also disincentivizing as the cohort size required for program fidelity (8-12 participants) limited participant reach compared to other EBFPPs with shorter duration that allow for larger cohorts. Limited time and staff turnover is a frequently reported challenge among EBFPPs [28,29,30], as many community-based programs rely on volunteers who have responsibilities beyond their EBFPP facilitator duties. In response to these challenges, researchers emphasize the importance of assessing a community's capacity regarding the staff and time required of different EBFPPs when deciding on which to adopt. Once an EBFPP is selected, researchers recommend developing a strategic plan for long-term recruitment and training of new EBFPP facilitators to account for inevitable attrition [16,29]. It is also imperative that organizing committees communicate with facilitators, as well as facilitators' employers (if applicable), the value and impact of their work to encourage their investment in serving as an EBFPP facilitator [31]. It is also possible that AMOB facilitators in this study decreased or discontinued program implementation because of the burden associated with their being asked to collect pre-post data, and assist with participant and facilitator recruitment, in addition to planning and implementing AMOB. Research advocates for EBFPPs to offer continued support to facilitators beyond their initial facilitator training to establish connection among facilitators while discussing successes, challenges, and implementation fidelity issues [16,32]. Dattalo and colleagues [29] also advocate for organizational tasks being assigned to paid project staff rather than volunteer lay leaders.

Another challenge confronted during this project was the residual impact of not having a sufficient community-based participatory planning period prior to selecting and implementing an EBFPP. More time should have been dedicated to hearing from community stakeholders prior to adopting AMOB as the EBFPP. For example, the Project Manager spoke about our using a top-down approach, focused on an initiative the project team had not confirmed corresponded with service providers' needs or resources. AMOB facilitators shared that conducting fall risk assessments with older adults heightened their fall risk awareness and motivated them to register for an EBFPP. This suggests community members may have benefited from a fall prevention awareness campaign prior to EBFPP implementation. Relatedly, AMOB participants shared they initially thought they were enrolling in a physically engaging balance program, and recommended follow-up programs inclusive of more exercise. This suggests community-dwelling older adults had needs and interests not fulfilled solely by AMOB. EBFPP research supports the use of multiple complementary services, and follow-up programs, to address fall prevention long-term [18,33]. The project team should have offered multimodal fall prevention initiatives (i.e., fall risk assessments, educational curriculums, and physical exercise programs) to better address the needs of older adults at varying levels of fall prevention readiness and awareness.

In hindsight, steering committee members identified that AMOB may not have been the best fit for senior centers as they rely on volunteer staff for everyday operations and were working to recover staff post-COVID pandemic. Steering committee members also shared that many older adults engage in, or have access to, senior center programs and services for a few hours at a time. Thus, AMOB's two-hour duration per session was a constraint and limited older adults' engagement in other programming. Diligence in conducting a needs assessment prior to EBFPP selection and implementation would have allowed the project team to develop a strategic plan regarding sustainability and substantiate that the selected modality addressed a community perceived need and could be integrated into existing community services [30,34].

Multiple stakeholders reported miscommunication or a lack of communication regarding the project. For example, steering committee members identified that communication with community partners about recruitment of AMOB host sites, facilitators, and participants was more challenging than expected. They recommended having more project team led communication regarding successes, and discussions related to what strategies others were finding effective in obtaining buy-in from community partners. Communication is well-established as a challenge with EBFPP [28,33]. Community-participatory planning before EBFPP dissemination would have permitted time for the cultivation of a statewide network (e.g., coalition or consortium) to streamline inter-agency collaboration among clinical and community partners, AMOB marketing and referral processes, and resource sharing [16,28,29,30,31,33].

4.1 Implications for Practice

Using an EBFPP that provides positive participant outcomes does not ensure that the program will be easily adopted and disseminated. This project was developed based on the structure and outcomes of a small, single-site pilot study [35] that did not translate easily to a larger scale. Based on study findings, there were several barriers that hindered sustained AMOB implementation. Table 4 provides a summary of strategies organizing committees should consider when navigating these barriers to sustained EBFPP implementation.

Table 4 Strategies for Navigating Barriers to Sustained EBFPP Implementation.

4.2 Future Research Recommendations

Limited research addresses the long-term impact of AMOB participation. Further research assessing whether AMOB outcomes are sustained beyond the eight-week program is recommended. Findings suggest offering multiple, complementary fall prevention initiatives to community-dwelling older adults and follow-up programming that allows older adults to progress from one EBFPP to the next. Future research should explore which combination of EBFPP, or initiatives are recommended for simultaneous use, and which EBFPP should be offered in what order for scaffolded education and exercise training related to fall prevention. Also, given that many EBFPP are volunteer led, it is imperative to acknowledge that volunteer facilitators have competing demands on their time. To evolve fall prevention initiatives, future research focused on strategies for developing more time efficient EBFPP is necessary.

4.3 Limitations

Quantitative data reflective of changes in participants' functional outcomes post-AMOB are self-reported. Standardized performance measures were not utilized to evaluate changes in participant outcomes. Social desirability could have influenced participants' survey responses. Also, terminology used within survey items were not defined for participants; participants' interpretations of the terms may have impacted their responses. For example, an operational definition for what constitutes a "fall" was not provided in the survey. Participants' perception of what they consider a fall to be may have differed within the sample and resulted in inaccurate reporting among participants.

Qualitative data collected from the project manager, steering committee members, and AMOB facilitators were collected in the first 12-18 months of the three-year project. At this time, most facilitators had only facilitated one AMOB workshop. It is possible that their perspective regarding supports and challenges to implementing the EBFPP differed in years two and three of the project, after facilitating more than one workshop. However, most (n = 10, 66.7%) MTs and coaches only taught one or two workshops throughout the three-year project.

5. Conclusion

While AMOB participation resulted in positive participant outcomes, stakeholders identified several challenges to sustained AMOB implementation. Organizations should consider what evidence supports the EBFPP producing positive participant outcomes, as well as the time and resources required when selecting which EBFPP can be effectively, efficiently, and sustainably implemented among older adults in their community. Organizations are also encouraged to offer multiple, simultaneous and complimentary fall prevention initiatives to best address the needs and interests of community-dwelling older adults in their area.

Acknowledgments

The program and research reflected in this manuscript were funded by the Administration for Community Living.

Author Contributions

Brandi Crowe: Conceptualization, methodology, resources, investigation, data curation, formal analysis (qualitative), writing – original draft. Karen Kemper: Conceptualization, methodology, resources, investigation, data curation, formal analysis (quantitative), validation (qualitative), writing – original draft. Marieke Van Puymbroeck: Conceptualization, funding acquisition, project administration, supervision, methodology, resources, investigation, writing – review and editing. All authors have read and approved the manuscript.

Competing Interests

Authors have no conflicts of interest to disclose.

Data Availability Statement

Aggregate quantitative and qualitative data are available within the article. Additional data collected during the grant project for program evaluation or research purposes will not be made publicly available.

AI-Assisted Technologies Statement

Authors used Microsoft Word's Spelling and Grammar Check tool when writing the manuscript. No other AI software or AI-assisted tools were used during data collection, data analysis, data interpretation, or the writing of the manuscript.