Background

China has the largest elderly population in the world. The seventh census [1] showed that at the beginning of November 2020, the number of people aged 60 years and above in China was 264 million, accounting for 18.70% of the total population. Falls are common among adults aged 60 years and above due to physiological changes [2, 3]. Thus, the incidence of falls increases with age. Approximately one-third of individuals above 65 years fall each year, and the incidence of falls in persons above 80 years is as high as 50% [4]. In addition, 71.20% of older adults will experience contusion, abrasion, sprain, fracture, and even death after falling [5]. Falls have become the leading cause of injury among older adults and the second leading cause of death due to injury in older adults [6]. The most common place where falls occur for older adults is at home. Jiayuan [7] conducted a survey on the status of falls among 561 older adults in urban communities and found that falls were more likely to occur at home than anywhere else, accounting for 45.6%. Tolulope [8] reviewed and analyzed the case data of elderly patients in the U.S. National Trauma Database from 2003 to 2006 and found that more than 42% of older adults fell at home. Therefore, to reduce the overall incidence of falls in the elderly, it is required to start by preventing falls at home.

According to the China Health and Retirement Longitudinal Study [9] that screened 4736 eligible older adults, the incidence of falls in rural areas (22.00%) is higher than that of urban areas (18.70%), even the incidence of severe falls in both urban and rural areas are comparable. Rural older adults are engaged in long-term agricultural work and have a low awareness of fall prevention [11] and has received extensive attention due to its cost-effectiveness, simplicity, and ease of implementation [12]. Minglong [25]. Baduan** could effectively improve balance, leg muscle strength, mobility, and fall prevention [26]. The TBHE intervention process was as follows: (a) The gaps in theoretical knowledge and practical skills in the fall-related lifestyle of older adults was assessed. FA informed participants that they needed to enter the WeChat mini-program every Tuesday to watch 5 min and 14 s of lifestyle animation videos and complete five practice questions related to lifestyle. After completing the questions, FA immediately reported errors to participants. According to a standard answer, FA explained the correct content to the participants and rightly guided them. Participants needed to record a video of themselves completing Baduan** before the coming Friday and send it to FA in advance through WeChat. FA combined the participants’ previous practice questions and recorded exercise videos to manually analyze whether the participants fully mastered the theoretical knowledge and sports skills according to the correct answers and standard exercise movements. Finally, FA scanned and evaluated the total distribution of wrong questions and each person’s sports practices in the WeChat mini-program background, which recorded weak points in each person’s theory and practice. (b) Feedback on weak points in theory and practice were given to the older adults, and they were educated to re-examine gaps to improve. FA asked the participants to watch the Baduan** animation video on Friday and complete the same five exercises again. Then, FA corrected the weak points of each person’s theoretical knowledge and practical skills one-to-one through pictures, voice, and videos. Participants recited the health education content in their language in voice format, gave feedback on sports skills to be mastered in video format, and sent them to FA again. (c) Re-evaluation and re-education: FA re-evaluated participants’ retelling voice and sports video, corrected them again according to the unified standard, and repeated the above process. The TBHE intervention ended only when the participants could correctly repeat all the right knowledge points taught to them during the health education and complete the whole set of Baduan** movements skillfully and standardly, which indicated that they mastered the theoretical knowledge and sports skills. Finally, participants rated their satisfaction after learning the entire health education content on the topic of lifestyle on Friday.

Control group

Traditional health education was used for participants in the control group. Participants were reminded to enter the WeChat mini-program at 8 am every Tuesday to learn health education content on the topic of preventing falls at home and completed the same five exercises as the intervention group. During this research, FA did not perform any active interventions and only responded to participants who had questions, which was also ethical. On Friday, FA urged them to re-enter the WeChat mini-program to learn the health education content on fall prevention at home consistent with the theme of Tuesday. Finally, participants rated their satisfaction after learning the entire health education content on the topic of lifestyle on Friday. After 8 weeks, participants finished learning eight topics content, and traditional health education ended.

Instruments

Socio-demographic questionnaire

A self-designed questionnaire was used to collect sociodemographic information about older adults. Older adults’ sociodemographic data included age, gender, marital status, children number, education, having chronic diseases or not, living with children or not, public officials or not, primary caregiver, monthly income, self-care ability, and smoking, drinking, and exercise frequency.

Home-based fall prevention knowledge (HFPK) questionnaire

The HFPK was developed based on the Health Belief Model (HBM) [27], Expert Consensus on Fall Risk Assessment of Older Adults in China (draft) [28], and Fall Prevention Knowledge, Attitude, and Practice Questionnaire [29, 30]. The HFPK assessed urban older adults’ knowledge of fall prevention, including physiological diseases, application of drugs, psychological cognition and mental status, lifestyle and behavior, and knowledge of the house environment that older adults should be aware of to prevent falls. We emailed 15 community or aged care specialists for comments on the initial questionnaire using Delphi Method. After two rounds of consultation and revision of the questionnaire, we tested the reliability and validity of the HFPK among 374 community-based older adults aged 60 years and above in Fuzhou. The formal HFPK comprises 68 items grouped into five subscales, including physiology & disease (19 items, 0 ~ 19 scores), drug application (8 items, 0 ~ 8 scores), mental, cognitive, and spiritual well-being (12 items, 0 ~ 12 scores), lifestyle (8 items, 0 ~ 8 scores), and house environment (21 items, 0 ~ 21 scores). Its score ranges from 0 to 68. All items are positive, with three answers including yes, uncertain, and no, which are all multiple-choice questions. If answer is Yes, the response is correct and gets 1 point. If answer is unclear or no, the response is incorrect and gets 0. The higher the score, the higher the knowledge level of older adults in preventing falls at home. According to the 100-point scale, 85 ~ 100 is excellent, 75 ~ 84 is good, 60 ~ 74 is medium, and 60 below is poor [31]. Knowledge on preventing falls at home was categorized as follows: 58 ~ 68 as excellent, 51 ~ 57 as good, 41 ~ 50 as medium, and 40 below as poor. After expert evaluations, I-CVI ranged from 0.867 to 1, and S-CVI was 0.985, which achieved the content validity criterion [36] conducted a seven-month teach-back combined with video health education intervention on pulmonary inhalant usage in 163 COPD patients. She found that the teach-back health education could significantly improve participants’ knowledge of pulmonary inhalers usage in the intervention group. Likewise, in our study, a higher knowledge score in the intervention group further confirms the effectiveness of TBHE in drug application knowledge. Before the intervention, two groups had low scores with fall-prevention knowledge regarding their drug application knowledge, which was consistent with the finding of Li** [37] that the awareness rate of drug application knowledge among older adults was lower than 30%. After the intervention, the drug application knowledge score of the intervention group was significantly improved and better than that of the control group. Factually, the meaning of receiving teach-back health education could remind older adults to pay attention to the relationship between drugs and falls when taking various medicines daily so that they are more careful and correct to take pills as directed by their doctors.

In terms of mental, cognitive, and spiritual well-being, the incidence of mental illness, like depression, is increasing year in the elderly population [38]. Compared to other clinical diseases in older adults, depression may be underdiagnosed. People with depression are less likely to seek therapy due to the stigma of mental illness in some areas of China [39]. This study makes older adults realize that they need to attach importance to their mental state by educating them that abnormal psychological states such as emotional stress can easily lead to falls. An interesting finding of this study is that, despite the interaction of time and group on mental, cognitive, and spiritual well-being, the control group scored higher than the intervention group after the intervention. There are two possible reasons as follows. First, the baseline data for mental, cognitive, and spiritual well-being are unbalanced. Before the intervention, the mental, cognitive, and spiritual well-being scores of the intervention group were higher than those of the control group, and the difference was statistically significant (t = 2.410, p = 0.019). After the intervention, the score increase of the intervention group was lower than that of the control group. Second, the intervention in the control group affected the participants. The interventions in the control group were self-learning, and the FA did not engage in any active interventions and responded only to problematic participants. In the satisfaction and feedback, participants mentioned that they thanked the FA for spending time to help them improve their knowledge, patiently answering their questions, and soothing their emotions when they encountered WeChat use obstacles. These measures stimulated their interest in learning and maintained it until the end of the study, creating conditions for participants to learn knowledge, consistent with a comparison within groups results. Self-contrast found that two groups in mental, cognitive, and spiritual well-being were statistically significant (t = − 3.448, p = 0.002; t = − 8.438, p < 0.001), showing that TBHE and traditional health education intervention could increase scores in this dimension. Thus, our project helps to remind participants to value their mental health, maintain a peaceful mind, actively seek psychological treatment, and prevent falls.

In terms of lifestyle and the household environment, participants in the intervention group had significantly higher knowledge scores for fall prevention than those in the control group; however, there was no interaction effect. Zhihong [40] pointed out that a restricted household environment and an unhealthy lifestyle were predisposing factors for falls in older adults and that reducing the per capita housing area and drinking alcohol would increase the incidence of falls. In addition, technical guidelines for fall interventions in older adults [41] pointed out that it is necessary to improve living environments to be suitable for older adults to prevent home-based injuries. Our study suggests that TBHE reinforces older adults’ fall prevention knowledge about their lifestyle and household environment and reminds them to keep healthy living habits and improve their household environment. It is worth mentioning that there was no significant difference in physiology and disease (t = − 0.904, p = 0.370). A study [42] showed that older adults were aware of their decreased physical performance and reduced ability to cope with physical challenges, such as balance, which increased their fear of falling. Fear of falling may cause them to seek out a lot of fall prevention knowledge about physical health. Therefore, learning fall prevention knowledge in physiology and disease is still significant.

Limitations

This study has some limitations. First, the implementation and evaluation process of TBHE were all completed in WeChat without having to meet the participants face-to-face. The authenticity of feedback from participants could not be guaranteed, which was likely to affect the quality of TBHE. Second, we do have not a larger study sample, a higher intervention frequency, and a longer study duration. Scholars in the future can consider increasing the size of the study sample and extending the intervention’s duration to better explore the effect of the intervention. Finally, the WeChat mini-program could only be used on smartphones, which hinders some older adults who use outdated phones from benefiting from such health education. Future researchers need to design more rational health education programs for older adults who do not use smartphones.