Home and environmental hazards modification for fall prevention among the elderly
預防長者跌倒的居家與環境危害改造

Italian Ministry of Education, University and Research (MIUR) program “Departments of Excellence 2018-2022,” AGING Project- Department of Translational Medicine, Università del Piemonte Orientale.
義大利教育、大學與研究部 (MIUR) 計畫「2018-2022 年卓越學系」，東方皮埃蒙特大學 AGING 計畫 - 轉化醫學系。

Aging is a challenge for the global public health because it increases fall risk, disabilities, cognitive impairment, and comorbidities (Chang et al., 2019; The Lancet Public Health, 2017). Worldwide people aged 65+ who fall at home are $28\mathrm{\%}-35\mathrm{\%}$$28\mathrm{\%}-35\mathrm{\%}$28%-35%28 \%-35 \% per year, people aged $70+$$70+$70+70+ are 32%-42% (Bilik et al., 2017; CDC, 2017; Stevens et al., 2012; WHO, 2008).
老齡化是全球公共衛生所面臨的挑戰，因為它會增加跌倒風險、殘障、認知障礙和併發症（Chang 等人，2019；The Lancet Public Health，2017）。全世界 65 歲以上的人每年在家跌倒的比例為 $28\mathrm{\%}-35\mathrm{\%}$$28\mathrm{\%}-35\mathrm{\%}$28%-35%28 \%-35 \% ， $70+$$70+$70+70+ 歲的人為 32%-42% (Bilik 等人，2017；CDC，2017；Stevens 等人，2012；WHO，2008)。

Falls are defined as unexpected events in which participants come to rest on a lower level (Lamb et al., 2005). In adults, they are complex and feature multifactorial phenomena (Gazibara et al., 2017), related to environmental factors (31%), lack of physical exercise (17%), and dizziness (13%) (Rubenstein, 2006).
跌倒被定義為參與者在較低處休息的意外事件（Lamb 等人，2005）。在成人中，它們是複雜的多因素現象 (Gazibara 等人，2017)，與環境因素 (31%)、缺乏運動 (17%) 和頭暈 (13%) 有關 (Rubenstein，2006)。

Falls represent a major public health problem (Heinrich et al., 2010): they are consequences for people both physical (e.g., fractures or loss of mobility) and psychological (increasing fear of falling, loss of self-confidence, and social participation; Gunn et al., 2014; Pin & Spini, 2016). Older adults lose autonomy (Milat et al., 2011), experience a decrease in quality of life (Stenhagen et al., 2014), and have increased nursing home admissions (Gill et al., 2013).
跌倒是一個重大的公共衛生問題（Heinrich等人，2010年）：它們對人體造成生理（例如骨折或失去行動能力）和心理（增加對跌倒的恐懼、失去自信心和社會參與；Gunn等人，2014年；Pin和Spini，2016年）兩方面的後果。老年人會失去自主性（Milat等人，2011年）、生活品質下降（Stenhagen等人，2014年）、入住療養院的人數增加（Gill等人，2013年）。

Falls can have significant outcomes for the elderly population. According to the Centers for Disease Control and Prevention (CDC, 2020), in 2018, falls were the 11th leading cause of death and
跌倒會對老年人群造成重大後果。根據美國疾病控制與預防中心（CDC，2020）的資料，在 2018 年，跌倒是導致死亡的第 11 個主要原因，而且
the first cause of fatal or non-fatal injury in people aged 65+ in the United States of America. Moreover, falls are the primary cause of emergency department admission and hospitalization.
是美國 65 歲以上人口致命或非致命傷害的首要原因。此外，跌倒也是急診室入院和住院的主要原因。

Falls incur both direct and indirect costs for society (Piscitelli et al., 2010). For instance, according to the National Institute for Health and Care Excellence (NICE), in 2011, falls in the United Kingdom cost the NHS $\pounds 2.3$$\pounds 2.3$£2.3£ 2.3 billion per year (National Institute for Health & Clinical Excellence, 2013).
跌倒會為社會帶來直接和間接的成本（Piscitelli et al.）例如，根據英國國家健康與醫療卓越研究所 (National Institute for Health and Care Excellence, NICE) 的資料，2011 年英國每年因跌倒造成的 NHS 成本為 $\pounds 2.3$$\pounds 2.3$£2.3£ 2.3 億英鎊（National Institute for Health & Clinical Excellence, 2013）。

Italy’s elderly population is the largest in Europe and one of the largest in the world (United Nations Population & Division, 2019). Preventive activities, interventions, and strategies should be implemented to reduce the age-related disease burden and save money (National Prevention Council, 2016; WHO, 2017a).
意大利的老年人口是歐洲最大的，也是世界上最大的老年人口之一（聯合國人口與司，2019年）。应实施预防活动、干预措施和战略，以减少与年龄相关的疾病负担并节省资金（国家预防委员会，2016年；世卫组织，2017年a）。

Preventive and multifactorial interventions should be implemented and focus on the individualized risk factors. They should not limit individuals’ freedom, dignity, or quality of people’s life (Vance, 2012). Research has long shown that home assessment and modification is an effective intervention to prevent falls and fall-related injuries: a well-designed environment protects people from home injuries and hidden fall hazards in daily activities (WHO, 2017a). Aging decreases people’s abilities, so home design must accommodate their characteristics, minimizing barriers and increasing participation in activities of daily living (National Research Council, 2010).
應該實施預防性和多因素的介入措施，並將重點放在個人化的風險因素上。這些干預不應該限制個人的自由、尊嚴或生活品質（Vance，2012）。研究早已表明，家庭評估和改造是預防跌倒和跌倒相關傷害的有效干預措施：設計良好的環境可保護人們免受家庭傷害和日常活動中隱藏的跌倒危險（WHO，2017a）。老化會降低人們的能力，因此居家設計必須符合他們的特點，盡量減少障礙，增加日常生活活動的參與 (National Research Council, 2010)。

International literature suggests installing zero-step entrances, short hallways, motion-sensor lightening, as well as removing rugs, adding grab bars or ramps, reorganizing furnishings, and similar interventions (Pynoos et al., 2010). According to a Cochrane review, the range of modifications and their costs are wide, and literatures are often inconclusive about the most cost-effective interventions and the best ways to implement them (Hopewell et al., 2018).
國際文獻建議安裝零階梯入口、短走廊、動作感應照明，以及移除地毯、加裝扶手或斜坡、重新整理陳設，以及類似的干預措施 (Pynoos et al., 2010)。根據 Cochrane 的一項文獻回顧，改裝的範圍及其成本很廣，而文獻中對於最具成本效益的干預及實施干預的最佳方法往往沒有定論（Hopewell 等人，2018 年）。

A prevention tool should be developed to guide local health authorities in delivering evidence-based interventions that improve the quality and the safety of care. The evidence-based manual should also support professionals in promoting healthy aging programs. This sets up the following framework: Effective, Sustainable, and Transferable Preventive Interventions (IPEST; Faggiano et al., 2018).
應發展一套預防工具，以指導地方衛生當局提供以實證為基礎的干預措施，改善照護的品質和安全性。循證手冊也應支援專業人員推廣健康老齡化方案。這就建立了以下的架構：有效、可持續、可轉移的預防干預（IPEST；Faggiano 等人，2018）。

The aim of this study is to develop an implementation tool for effective, sustainable, and transferable home assessments and modification interventions to prevent falls and fall-related injuries in community-dwelling older people.
本研究的目的是針對有效、可持續且可轉移的居家評估與修正干預開發一套執行工具，以預防社區居住的老年人跌倒及跌倒相關傷害。

The research questions (see Appendix S1 for further details), which were formulated according to the population, intervention, comparison, outcome (PICO) methodology (Richardson et al., 1995), are as follows:
研究問題（詳見附錄 S1）是根據人口、干預、比較、結果 (PICO) 方法 (Richardson et al., 1995) 所制定的：

The IPEST framework (Figure 1) that can be used to develop effective, sustainable, and transferable preventive interventions was applied in this study (Faggiano et al., 2018). The framework has two main components.
IPEST 框架（圖 1）可用於開發有效、可持續和可轉移的預防干預措施，本研究採用了 IPEST 框架（Faggiano 等人，2018 年）。該框架有兩個主要組成部分。

The first is a review of the scientific literature (guidelines, systematic reviews, and randomized controlled trials), including ev-idence-based activities, actions, interventions, programs, and strategies about home assessment and modification interventions to prevent falls and fall-related injuries in community-dwelling older
首先是對科學文獻（指導方針、系統性評論和隨機控制試驗）的回顧，包括以實證為基礎的活動、行動、干預、計畫和策略，這些活動、行動、干預、計畫和策略是關於居家評估和修改干預措施，以預防社區居住的老年人跌倒和與跌倒相關的傷害。
people. This step includes research of previous studies, review of inclusion and exclusion criteria, study selection, quality assessment, data extraction, and analyses. The extracted data have been summarized in a narrative way in the draft manual.
人。此步驟包括研究先前的研究、檢視納入與排除標準、研究選擇、品質評估、資料萃取與分析。擷取的資料已在手冊草稿中以敘述方式進行總結。

The second is to submit the draft manual to achieve a consensus among clinical experts about (1) sustainability in social terms (the intervention must not increase social inequalities related to gender, socioeconomic aspects, and cultural differences, among others), economic terms (e.g., cost efficacy), and in terms of time (positive effects should continue after the intervention has stopped), and (2) transferability in the local context given the barriers and resources. The draft manual has been modified according to the expert opinions, and the final manual has been created.
其次是提交手冊草案，以便在臨床專家之間就以下方面達成共識：(1) 在社會方面（干預不得增加與性別、社會經濟方面和文化差異等有關的社會不平等）、經濟方面（例如成本效益）和時間方面（在干預停止後，正面效果應持續）的可持續性，以及 (2) 鑒於障礙和資源，在當地環境中的可轉移性。手冊草稿已根據專家意見進行修改，最終手冊已經完成。

Following the hierarchy of the evidence pyramid, we looked for guidelines, systematic reviews, and randomized controlled trials (RCTs) that answered our research questions. We searched for guidelines on the websites of scientific societies, institutions, organizations, and associations. The MEDLINE, Embase, and Cumulative Index of Nursing and Allied Health Literature (CINAHL) databases were screened for systematic reviews and RCTs (see Appendix S1 for the search strategy).
依照證據金字塔的層級，我們尋找能回答研究問題的指導方針、系統性評論及隨機對照實驗 (RCT)。我們在各科學學會、機構、組織和協會的網站上搜尋指導方針。我們在 MEDLINE、Embase 和 Cumulative Index of Nursing and Allied Health Literature (CINAHL) 資料庫中篩選系統性文獻回顧和 RCT (檢索策略請參閱附錄 S1)。

We included guidelines, systematic reviews, and RCTs in Italian and/or English published between January 1, 2015 and July 15, 2019. We excluded studies with narrative or observational approaches, grey literature, editorials, expert opinions, reports, studies with inconclusive results, studies that were cited in already included papers, and studies that focused on populations with severe cognitive impairment or populations that were not self-sufficient.
我們納入了 2015 年 1 月 1 日至 2019 年 7 月 15 日期間發表的義大利語和/或英語的指引、系統性評論和 RCT。我們排除了採用敘事或觀察方法的研究、灰色文獻、社論、專家意見、報告、結果無定論的研究、已被收錄論文引用的研究，以及針對嚴重認知障礙族群或無法自給自足族群的研究。

Guidelines were searched independently by four reviewers (D.C., A.A., L.I.F., S.P.). Two reviewers (L.I.F., S.P.) independently looked for reviews and RCTs. First, they read the titles and abstracts of the identified papers and eliminated irrelevant studies. Second, they read the papers in their entirety to identify those eligible for
四位審查員 (D.C.、A.A.、L.I.F.、S.P.) 獨立搜尋指南。兩位審查員 (L.I.F., S.P.) 獨立尋找文獻回顧和 RCT。首先，他們閱讀已識別論文的標題和摘要，並剔除不相關的研究。其次，他們閱讀論文全文，以找出符合條件的研究。

FIGURE 1 IPEST framework process [Color figure can be viewed at wileyonlinelibrary.com]
圖 1 IPEST 架構流程 [彩圖可於 wileyonlinelibrary.com 觀看]

TABLE 1 Quality assessment rating. The table shows the percentages applied to classify the studies according to quality, and related graphic representation
表 1 品質評估等級。本表顯示根據品質將研究分類時所應用的百分比，以及相關的圖表表示方式

inclusion. The reviewers managed disagreements by reaching a consensus or consulting a third reviewer (D.C.).
納入。審查員透過達成共識或諮詢第三位審查員 (D.C.) 來處理分歧。

Studies were selected following the hierarchy of evidence of effectiveness, and then were excluded according to the following criteria:
研究依據有效性證據的層級進行篩選，然後依據下列標準排除研究：

Guidelines were assessed with the Appraisal of Guidelines for Research & Evaluation II (AGREE II; Brouwers et al., 2012), a tool that evaluates scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, and editorial independence and provides an overall guideline assessment. The final score was calculated as the arithmetic mean of the results from each domain.
指南使用研究與評估指南評鑑 II (AGREE II; Brouwers 等人，2012) 進行評估，此工具可評估範圍與目的、利害關係人的參與程度、開發的嚴謹性、表達的清晰度、適用性及編輯的獨立性，並提供整體指南評估。最終分數以各領域結果的算術平均值計算。

Systematic reviews were assessed with the following tools:
使用下列工具對系統性文獻回顧進行評估：

First, we calculated the AMSTAR score. Reviews were given one point if each items received a “Yes” on an AMSTAR item and obtained the maximum rating (if the method was correct) on PRISMA. Second, the score was integrated based on the criteria for the strength of evidence. We added a point if there was a low reporting bias or if the review was done with RCTs. We removed a point if the results were influenced by bias, if the results were inconsistent, or if the outcome was indirect or subjective.
首先，我們計算 AMSTAR 分數。如果每項評論在 AMSTAR 項目上獲得「是」，並在 PRISMA 上獲得最高評分（如果方法正確），則給予一分。其次，根據證據強度的標準整合評分。如果報告偏差較低，或是以 RCT 進行評論，我們會加上一分。如果結果受到偏差影響、結果不一致、結果是間接或主觀的，我們就會去掉一分。

RCTs were assessed with the Cochrane Risk of Bias Tool (Jüni et al., 2001).
使用 Cochrane 偏見風險工具 (Jüni 等人，2001 年) 評估 RCT。

The quality of evidence was summarized with a qualitative four-position scale (low, sufficient, good, and excellent), which
證據的品質以四個定性等級（低、足夠、良好和優異）來總結，其中
represents the percentage of excellent quality evidence to the total evaluated evidence (Table 1; Faggiano et al., 2018).
代表優質證據佔總評估證據的百分比（表 1；Faggiano 等人，2018）。

Only studies rated “excellent” were included. Five authors (D.C., A.A., S.P., L.I.F., S.B.) independently assessed the quality and managed disagreements by reaching a consensus.
只有被評為「優秀」的研究才會被納入。五位作者 (D.C.、A.A.、S.P.、L.I.F.、S.B.) 獨立評估品質，並達成共識以處理分歧。

Three authors independently (A.A., L.I.F., S.P.) extracted the data. For guidelines, the society and year of publication, recommendations, strength of evidence, and references were extracted. For systematic reviews, the author and year of publication, the typology and number of included studies, the objectives and target population, and the outcomes and effect size were extracted. For RCTs, the author and year of publication, the type of study, the objectives and target population, and the outcomes and effect size were extracted.
三位作者（A.A.、L.I.F.、S.P.）獨立萃取資料。對於指南，則萃取出版社團和年份、建議、證據強度和參考資料。對於系統性文獻回顧，則萃取作者與出版年份、研究類型與納入研究的數目、目標與目標人口、結果與效應大小。對於 RCT，則會擷取作者和發表年份、研究類型、目標和目標人口，以及結果和效果大小。

Data on the sustainability and transferability of each intervention were also obtained. See Appendix S3 for the data extraction of the included guidelines. Analyses and narrative syntheses of the data obtained were carried out in order to create the draft manual.
此外，也取得了每項干預的持續性和可轉移性的資料。關於所納入指南的資料萃取，請參閱附錄 S3。對取得的資料進行分析和敘述性綜合，以建立手冊草稿。

A draft of the user manual for implementing effective home assessment and modification interventions was developed based on the IPEST method (Faggiano et al., 2018). The manual was then discussed with an expert panel (IPEST Working Group) to assess the local transferability and sustainability.
根據 IPEST 方法（Faggiano 等人，2018 年），制定了實施有效家庭評估和改造干預的用戶手冊草案。之後與專家小組（IPEST工作小組）討論手冊，以評估其在當地的可轉移性和可持續性。

The panel included the following health care professionals:
小組成員包括以下醫療照護專業人員：

All individuals participating in the consensus gave their verbal consent. Two authors (S.C., D.C.) informed all the participants about the study aim and that the results would be anonymous. The data were accessible only to the research team members (The Italian Data Protection Authority, 2018).
所有參與共識的個人都口頭同意。兩位作者（S.C.、D.C.）告知所有參與者研究目的，並告知研究結果將匿名。資料僅供研究團隊成員存取 (The Italian Data Protection Authority, 2018)。

A semistructured interview as developed. The interview session lasted one hour and was audio recorded and transcribed (A.A.). Two authors (A.A., D.C.) repeatedly read the transcript and identified the categories, followed by the themes (Mason, 2018; Patton, 2014).
制定了一個半結構式訪談。訪談歷時一小時，並進行了錄音和謄寫 (A.A.)。兩位作者（A.A.、D.C.）反覆閱讀謄本並確認類別，接著是主題（Mason，2018；Patton，2014）。

The authors organized the data by bracketing the information (Fischer, 2009). Two authors (A.A., D.C.) made additions to the manual (see the Appendix S4) before submitting it back to the experts’ judgment.
作者以括號標示資訊來組織資料 (Fischer，2009)。兩位作者（A.A.、D.C.）對手冊進行了補充（見附錄 S4），然後再交回專家判斷。

On February 1, 2019, we identified 14 scientific societies, institutions, and associations that had published guidelines on fall prevention. Only two met the eligibility criteria and passed the quality assessment and therefore included in the study (Figure 2). On July 23, 2019, we identified 591 systematic reviews and RCTs. None of the reviews met the eligibility criteria (Figure 3), and none of the RCTs passed the quality assessment (Figure 4).
2019 年 2 月 1 日，我們識別出 14 個科學學會、機構和協會曾發表預防跌倒的指引。只有兩個符合資格標準，並通過品質評估，因此納入研究（圖 2）。2019 年 7 月 23 日，我們識別出 591 篇系統性文獻回顧和 RCT。沒有一篇文獻符合資格標準（圖 3），也沒有一篇 RCT 通過品質評估（圖 4）。

Two guidelines were selected, Registered Nurses’ Association of Ontario (RNAO) and WHO. Either were rated “excellent,” with overall scores $85\mathrm{\%}$$85\mathrm{\%}$85%85 \% and $87\mathrm{\%}$$87\mathrm{\%}$87%87 \%, respectively. The RCT was assessed as “good” (Pey June Tan 66.7%) and was therefore excluded from the analysis (see Appendix S 2 for the quality assessment).
選擇了兩份指引，分別是安大略省註冊護士協會 (RNAO) 和世界衛生組織 (WHO)。兩者皆被評為「優」，總分分別為 $85\mathrm{\%}$$85\mathrm{\%}$85%85 \% 和 $87\mathrm{\%}$$87\mathrm{\%}$87%87 \% 。RCT 被評為「良好」（Pey June Tan 66.7%），因此被排除在分析之外（品質評估請參閱附錄 S 2）。

Home modification is an effective strategy for reducing the number of falls and fallers in community-dwelling older adults, mostly among those who are classified as having a high risk of falling. However, little evidence was found about the most effective combinations of interventions. Interventions should be tailored to individuals’ needs. Individual risks must be identified before starting the program to
居家改裝是一種有效的策略，可減少居住在社區的老年人跌倒的次數和跌倒者的人數，主要是針對那些被歸類為有高跌倒風險的老年人。然而，關於最有效的干預組合，卻沒有找到什麼證據。干預應該根據個人的需求量身打造。在開始計劃之前，必須確認個人風險，以便

FIGURE 2 Guidelines selection. The diagram illustrates the selection process of the guidelines
圖 2 指南選擇。該圖說明了指南的選擇過程

FIGURE 3 Systematic reviews selection. The diagram illustrates the selection process of the reviews
圖表 3 系統性評論的選擇。此圖說明評論的篩選過程

produce targeted interventions and maximize their efficacy (RNAO, 2017; WHO, 2017b).
產生有針對性的干預並發揮最大功效（RNAO，2017；WHO，2017b）。

Home modification interventions should consider the following factors in the physical environment:
居家改造干預應該考慮物理環境中的下列因素：

The effectiveness of home modification is enhanced in multifactorial interventions that include risk evaluation, health education, environmental modification, the promotion of proper footwear, multifaceted podiatry care, medication reconciliation, and continence management (RNAO, 2017; WHO, 2017b).
在多因素干預措施中，包括風險評估、健康教育、環境改變、推廣適當的鞋類、多方面的足科照護、藥物調和及尿失禁管理，可加強居家改裝的成效 (RNAO, 2017; WHO, 2017b)。

In terms of sustainability, we found both barriers to and facilitators of successful implementation. Health professionals must address individuals’ lack of a sense of urgency or motivation to change behaviors in order to raise their awareness of being at risk of falling. Every home modification must be discussed and approved by individuals and their caregivers to produce targeted and lasting change. Furthermore, the lack of financial resources could be a major barrier for both individuals and society (RNAO, 2017).
就持續性而言，我們發現成功實施的障礙與促進因素。健康專業人員必須解決個人缺乏改變行為的迫切感或動機的問題，以提高他們對跌倒風險的意識。每一項居家改裝都必須經過個人及其照護者的討論與同意，才能產生有針對性的持久改變。此外，缺乏財務資源可能會成為個人和社會的主要障礙（RNAO，2017）。

Regarding transferability, we found that trained professional (including doctors, occupational therapists, nurses, and physiotherapists) can carry out home hazard assessments and modifications (WHO, 2017b).
關於可轉移性，我們發現受過訓練的專業人員 (包括醫師、職業治療師、護士和物理治療師) 可以進行居家危險評估和改裝 (WHO, 2017b)。

A draft version of the user manual was created from a summary of evidence, and submitted to the expert panel to discuss the transferability, sustainability, and implementation of the intervention in the Italian context. The following findings and suggestions emerged from the consensus: First, fall-risk assessment tools are useful in completing clinical judgment. Second, interventions must be delivered by trained health professionals (e.g., nurses, doctors, occupational therapists, and physiotherapists) who should create a therapeutic alliance with people
根據證據摘要建立了使用者手冊的草案版本，並提交給專家小組討論在義大利環境下干預的可轉移性、持續性和實施性。在達成共識後，我們得出了以下的發現和建議：第一，跌倒風險評估工具有助於完成臨床判斷。第二，干預措施必須由受過訓練的健康專業人員 (例如護士、醫生、職業治療師及物理治療師) 執行，他們應與人們建立治療聯盟。

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FIGURE 4 RCTs selection. The diagram illustrates the selection process of the RCTs
圖 4 RCTs 的選擇。本圖說明 RCT 的選擇過程
under their care. Third, it may be useful to deliver simpler and cheaper interventions first to make the environmental change more acceptable. Finally, local institutions (e.g., municipalities and social services) must be involved to ensure economic sustainability.
在他們的照顧下。第三，先提供較簡單、較便宜的介入措施，使環境改變更容易被接受，這可能是有用的。最後，當地機構 (例如市政府和社會服務機構) 必須參與其中，以確保經濟的可持續性。

The manual was modified according to the experts’ recommendations, and a final version was created (see Appendix S4 for the full text of the manual).
根據專家的建議對手冊進行了修改，並形成了最終版本（手冊全文見附錄 S4）。

This study aimed to develop a user manual for the implementation of an effective, sustainable, and transferable home assessment and modification intervention, to prevent falls and fall-related injuries among community-dwelling older people. We reviewed the literature according to the hierarchy of evidence (guidelines-systematic
本研究的目的是針對有效、可持續且可轉移的居家評估與改良干預方 法，開發使用者手冊，以預防社區居住的老年人跌倒及跌倒相關傷害。我們依據證據的層次（指導方針-系統性-實證）檢閱了相關的文獻。
reviews-RCTs) and then filtered the sources through a quality assessment. From the studies included, we extracted recommendations about the efficacy, sustainability, and transferability of home modification programs. We developed an implementation manual draft and discussed it with a panel of experts. After that, a final IPEST version was created.
RCTs），然後透過品質評估篩選資料來源。從納入的研究中，我們擷取了有關家庭改造方案的效能、持續性及可轉移性的建議。我們撰寫了一份實施手冊草案，並與專家小組討論。之後，我們建立了 IPEST 的最終版本。

We found that home/environmental interventions can be effective in reducing the number of individuals who fall and the frequency of falls in community-dwelling people aged 65 and over. The literature suggests using slip-resistant flooring, adequate lightning, appropriate furniture, and an adequate and convenient layout (RNAO, 2017; WHO, 2017b).
我們發現，居家/環境干預可有效減少 65 歲及以上社區居住者跌倒的人數和頻率。文獻建議使用防滑地板、足夠的避雷設備、適當的家具，以及足夠且方便的佈局 (RNAO, 2017; WHO, 2017b)。

Many variables are associated with falls of the elderly in the home environment, such as medical conditions, medications (Lee et al., 2015), and physical inactivity or reduced physical activity (Sherrington et al., 2019).
許多變數都與老年人在居家環境中跌倒有關，例如醫療狀況、藥物（Lee 等人，2015 年），以及缺乏運動或運動量減少（Sherrington 等人，2019 年）。

Elderly patients experience more unstable balance as a result of important cardiovascular therapies that affect blood pressure and heart rate (Pinho-Gomes & Rahimi, 2019).
由於重要的心血管治療會影響血壓和心率，因此老年患者會經歷更不穩定的平衡（Pinho-Gomes & Rahimi, 2019）。

In addition, clothing and footwear also play an essential role in the incidence of falls in the elderly population (Moncada & Mire, 2017).
此外，衣服和鞋類也對老年人群的跌倒發病率起著不可或缺的作用（Moncada & Mire, 2017）。

Home assessment and modification is a low-cost, highly cost-effective, and high-return intervention (Phelan et al., 2016). It produces health gains in terms of the quality of life among older adults. Moreover, a high fall burden is linked to an inadequate home environment; thus, preventive interventions should focus on accurate home modification (Keall et al., 2017). Before any scaling up an intervention, an efficient way to start the program is to target people at high risk of falls (Pega et al., 2016).
居家評估與改造是一種低成本、高成本效益且高回報的介入方式 (Phelan 等人，2016)。它可以提高老年人的生活品質，從而獲得健康收益。此外，高跌倒負擔與不適當的居家環境有關；因此，預防干預措施應著重於準確的居家改造（Keall 等人，2017）。在擴大干預規模之前，有效的方法是針對跌倒高風險人群開展計畫（Pega 等人，2016）。

Such an intervention benefits all people staying in the modified homes, not just those at risk of falls. The effectiveness of the intervention is linked to the compliance of individuals at risk of falls and their caregivers (Lord et al., 2006; Pynoos et al., 2010). Thus, the literature and experts suggest making easy and feasible changes first to make the intervention more acceptable (RNAO, 2017).
這樣的干預對所有住在改良居家的人都有好處，而不只是那些有跌倒風險的人。干預的有效性與有跌倒風險的個人及其照護者的依從性有關（Lord 等人，2006 年；Pynoos 等人，2010 年）。因此，文獻和專家建議先做出簡單可行的改變，讓干預較容易被接受（RNAO，2017）。

A multicomponent program to prevent falls in community-dwelling older adults is recommended to create an intervention focused on individual needs and offer additional benefits (e.g., group exercise programs that provide social contact; Wilson et al., 2017).
建議採用多成分計畫來預防社區居住的老年人跌倒，以建立專注於個人需求的介入方式，並提供額外的好處（例如，提供社交接觸的團體運動計畫；Wilson 等人，2017）。

Similar studies have suggested implementing environmental modification after a comprehensive assessment of individuals’ needs and demands. Education is a key step in creating a therapeutic alliance and successful intervention (Maggi et al., 2018).
類似的研究建議在全面評估個人的需要和需求後實施環境改造。教育是建立治療聯盟和成功介入的關鍵步驟（Maggi 等人，2018）。

The economic situation and social interaction of the older adult also play an essential role in the fall event. A relevant study by Pin and Spini (2016) evaluated the interaction between falls and social participation as well as social support. Falls caused a decrease in social involvement and an increase in social support. This social impact of falls can be mitigated by preventive or rehabilitative interventions (Pin & Spini, 2016).
老年人的經濟狀況和社會互動在跌倒事件中也扮演著不可或缺的角色。Pin 和 Spini（2016 年）的相關研究評估了跌倒與社會參與以及社會支持之間的互動關係。跌倒導致了社會參與的減少以及社會支持的增加。跌倒的這種社會影響可以透過預防或復健干預來減輕（Pin 和 Spini，2016 年）。

In the Italian context, family and community nurses can be the appropriate health professionals to assess the individual risk of falls and deliver targeted interventions. Nurses should first evaluate the individual risk factors and then involve the person in a multifaceted intervention and a support network to deliver appropriate care. A network of primary care health professionals, hospital specialists, local institutions, and caregivers should be created to deliver the appropriate interventions and support people undergoing the change (e.g., home modification). Long-term sustainability of the intervention is linked to the support and trust of caregivers and the family. Local institutions must promote and finance the intervention, which can be costly.
在義大利的環境中，家庭與社區護士可以是評估個人跌倒風險並提供針對性介入的適當醫療專業人員。護士應該先評估個人的風險因素，然後讓患者參與多方面的介入措施和支援網路，以提供適當的照護。應建立一個由基層醫療保健專業人員、醫院專科醫生、當地機構及照護者所組成的網絡，以提供適當的介入措施，並支援正在進行改變（例如居家改裝）的人。介入措施的長期持續性與照護者及家人的支持和信任有關。當地機構必須推廣介入措施並提供資金，而這可能需要很高的成本。

This study has a number of limitations. First, most of the evidence focused on environmental modifications of hospitals or long-term care settings. Nevertheless, some universal precautions may also be
本研究有許多限制。首先，大部分證據都著重於醫院或長期照護環境的環境改造。儘管如此，一些普遍預防措施也可能是
applicable to individual homes. Second, the literature does not specify the types of structural/home modifications that can maximize the effectiveness of the program. It was hard to find papers that studied home modifications as a single intervention and not as part of a multicomponent one. Third, although we included only high-quality sources, the evidence they found was not always of high quality and was often exposed to bias. For instance, we assessed the quality of guidelines with AGREE II, which evaluates the methodological rigor and transparency but not the quality of the recommendations. Fourth, the fall risk of the included populations was assessed with different or unspecified tools, so it was hard to make comparisons. Fifth, the populations of the included studies often excluded persons with specific diseases (e.g., Parkinson’s and Alzheimer’s disease) that are common in older adults. Sixth, the follow-up period used in most of the included studies was too short, making it difficult to evaluate the long-term effectiveness of the interventions. Finally, the studies did not demonstrate that home modifications reduce falls and fall-related injuries.
適用於個別住宅。其次，文獻並沒有具體說明哪些類型的結構/住家改造可以使計畫的成效最大化。我們很難找到將居家改裝作為單一干預來研究，而非作為多成分干預一部分的文獻。第三，儘管我們只收錄了高品質的資料來源，但他們找到的證據並不總是高品質的，而且經常暴露於偏見中。舉例來說，我們以 AGREE II 評估指引的品質，AGREE II 評估方法的嚴謹性與透明度，但不評估建議的品質。第四，我們使用不同或未指定的工具評估納入人群的跌倒風險，因此難以進行比較。第五，所納入研究的人口通常不包括患有特定疾病 (例如帕金森氏症和阿茲海默症) 的老年人，而這些疾病在老年人中很常見。第六，大多數納入研究的追蹤期都太短，因此難以評估干預療法的長期成效。最後，這些研究並未顯示居家改裝可減少跌倒及跌倒相關的傷害。

Further studies may be carried out to assess the impact of home modification on other risk reduction interventions so that an appropriate cost-benefit program can be developed. To the best of our knowledge, no studies have compared the effectiveness of individual interventions related to environmental change, especially in relation to the difficulty in making them applicable in everyday practice. However, some studies comparing the effectiveness of environmental modification with other interventions took into account different aspects of home modification (e.g., removing obstacles and installing handrails).
可進一步進行研究，評估居家環境改造對其他降低風險介入措施的影響，以便制定適當的成本效益方案。據我們所知，沒有任何研究比較與環境改變相關的個別介入措施的有效性，尤其是在使其適用於日常實務的難度方面。不過，一些比較環境改造與其他干預措施有效性的研究，考慮到了居家改造的不同方面（例如，移除障礙物和安裝扶手）。

It would be interesting to compare the effectiveness of various types of environmental modification interventions, such as no-cost interventions (e.g., removal of carpets and obstacles or the use of walking aids), low-cost interventions (e.g., reorganizing lighting systems and using handrails and chairs with armrests), and high-cost interventions (e.g., changing the layout and installing elevators). Moreover, it is important for future studies to demonstrate that environmental modification can reduce falls and fall-related injuries.
比較各種環境改造干預措施的效果，例如無成本干預措施（例如移除地毯和障礙物或使用步行輔具）、低成本干預措施（例如重新組織照明系統、使用扶手和有扶手的椅子），以及高成本干預措施（例如改變佈局和加裝電梯），將是非常有趣的。此外，未來的研究必須證明環境改造可以減少跌倒及跌倒相關的傷害。

The manual that we created can be used to implement home modification programs to reduce the number of falls and fallers among community-dwelling older adults. The IPEST methodology is useful in producing user-friendly evidence to support health workers in everyday practice. This IPEST manual has not yet been widely implemented, so there is still little experience in this area. The operating manual needs strategies for transferability and implementation in local contexts.
我們製作的手冊可用於實施居家改裝計畫，以減少社區居住的老年人跌倒及跌倒者的人數。IPEST 方法有助於製作方便使用者的證據，以支援保健工作者的日常實務。這本 IPEST 手冊尚未廣泛實施，因此在這方面的經驗仍不多。操作手冊需要在當地環境中轉移和實施的策略。

Home modification is an effective preventive program in reducing falls and fallers among older community-dwelling adults aged 65 and over. The IPEST user manual can help clinicians, health professionals, and stakeholders to implement environmental change interventions. However, promoting healthy aging remains the most effective strategy for reducing costs and morbidity in the elderly population.
居家環境改造是一項有效的預防方案，可減少 65 歲以上居住在社區的老年人跌倒及跌倒者。IPEST 使用手冊可協助臨床醫師、衛生專業人員及相關人員實施環境改變干預。然而，促進健康老化仍是降低老年人群成本和發病率的最有效策略。

All authors approved the manuscript and publication.
所有作者都批准了手稿和出版。

The authors declare they have no competing interests.
作者聲明他們沒有利益衝突。

Daiana Campani (D) https://orcid.org/0000-0002-4621-9150
Silvia Caristia (iD https://orcid.org/0000-0003-0660-1547
Alex Amariglio (iD https://orcid.org/0000-0003-0766-0629
Michela Barisone (iD https://orcid.org/0000-0003-4224-8779
Sara Bortoluzzi (iD https://orcid.org/0000-0003-1502-9757
Fabrizio Faggiano (iD https://orcid.org/0000-0003-2382-0848
Alberto Dal Molin (D) https://orcid.org/0000-0003-2263-1340

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Additional supporting information may be found online in the Supporting Information section.How to cite this article: Campani D, Caristia S, Amariglio A, et al; IPEST Working Group. Home and environmental hazards modification for fall prevention among the elderly. Public Health Nurs.
其他輔助資訊可在線上的輔助資訊部分找到。如何引用本文：Campani D, Caristia S, Amariglio A, et al; IPEST Working Group.預防老年人跌倒的居家和環境危險改造。Public Health Nurs.
2021;38:493-501. https://doi.org/10.1111/phn. 12852
2021;38:493-501.https://doi.org/10.1111/phn.12852

Ermellina Silvia Zanetti: APRiRE Network, Italian Society of Gerontology and Geriatrics, Italy; Cristina Caldara: Health Professions Direction, ASST Papa Giovanni XXIII, Bergamo, Italy; Aldo Bellora: Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy; Loredana Grantini: Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy; Anna Lombardi: Local health agency ASL, Novara, Italy; Carmen Carimali: Local health agency ASL, Novara, Italy; Miriana Miotto: Local health agency ASL, Biella, Italy, Italian Association Family and Community Nurses (Aifec), Italy; Alessandro Pregnolato: Local health agency ASL, Novara, Italy; Paola Obbia: Italian Association Family and Community Nurses (Aifec), Italy, Local health agency ASL, Cuneo, Italy.
Ermellina Silvia Zanetti：APRiRE Network, Italian Society of Gerontology and Geriatrics, Italy; Cristina Caldara: Health Professions Direction, ASST Papa Giovanni XXIII, Bergamo, Italy; Aldo Bellora：Azienda Ospedaliera SS.Antonio e Biagio e Cesare Arrigo, Alessandria, Italy; Loredana Grantini: Azienda Ospedaliera SS.Antonio e Biagio e Cesare Arrigo, Alessandria, Italy; Anna Lombardi：當地醫療機構 ASL，意大利諾瓦拉；Carmen Carimali：義大利諾瓦拉當地健康機構 ASL；Miriana Miotto：義大利比耶拉當地健康機構 ASL、義大利家庭與社區護士協會 (Aifec)；Alessandro Pregnolato：義大利諾瓦拉當地健康機構 ASL；Paola Obbia：義大利家庭與社區護士協會 (Aifec)、義大利庫內奧地方保健機構 ASL。