Exploring Optometrists’ Practice Patterns in Falls Prevention Management

Abstract

Introduction

Optometrists, as primary eye care professionals working in the community, routinely provide consultations for older adults. Impaired vision significantly increases falls risk, positioning optometrists as important health service providers to address primary falls prevention. However, there is scarce evidence for how optometrists implement evidence-based falls prevention management. This study explored Australian community optometrists’ understanding of falls prevention management and their perspectives on the barriers and enablers for implementing falls prevention management in their clinical practice.

Methods

The study employed a qualitative descriptive design, using purposeful sampling to recruit Western Australian optometrists across metropolitan and rural primary eye care settings. Focus group discussions explored participants’ knowledge of falls prevention, implementation experiences, and educational opportunities to improve implementation. Data were analyzed using inductive content analysis.

Results

Four focus groups were conducted (N = 23, females = 12 and males = 11). Participants were predominantly early career optometrists (52% with 1–5 years of experience), 87% were aged under 40 and primarily practicing in metropolitan areas. The main category identified a substantial evidence-to-practice gap in optometrists’ falls prevention management for older adults within primary eye care settings. Four generic categories contributed; perceived low levels of knowledge and awareness about falls prevention, sporadic integration into clinical practice, the need for an improved approach to collaboration within multidisciplinary teams, and hesitancy to undertake falls prevention management.

Conclusion

Community optometrists had perceived low levels of knowledge about falls prevention and identified limited opportunities to implement falls prevention management. Suggestions to bridge this implementation gap included providing further education and promoting optometrists’ engagement in multidisciplinary teams. Further research investigating how community optometrists can translate falls prevention evidence into practice is required.

Introduction

Accidental falls are the leading cause of injury hospitalization, and death in Australia [1] and are a global burden for healthcare [2]. Within Australia, falls-related hospitalizations cost an estimated 5 billion AUD (USD 3.2 billion) in 2022–23 [1]. Vision impairment is a key risk factor for falls in community-dwelling older adults [3, 4]. A national USA survey found falls are more prevalent in adults with visual impairment, with 27.6% reporting more than one fall compared to 13.2% without self-reported visual impairment [5]. Leading causes of age-related vision loss such as cataracts, age-related macular degeneration, and glaucoma, significantly predict increased risk of both falls and fractures in older adults [4].

There is strong evidence that effective multidisciplinary interventions that reduce falls among community-dwelling older adults incorporate vision management [6, 7]. World Falls Guidelines (WFG) recommend that older adults receive vision assessment and treatment to effectively manage falls risk [7]. Furthermore, WFG recommends that using a primary preventative approach, all older adults presenting to health services for any reason should be asked if they have fallen and received individual advice regarding falls prevention [7]. In Australia, the Department of Health and Aged Care provides an annual rebate that allows older adults (≥65 years) to receive annual eye examinations from optometrists who can assess and manage their eye health [8]. This potentially positions optometrists as a first point of contact for older community-dwelling adults, particularly those with visual impairment to discuss falls prevention.

Australian optometry guidelines for falls prevention recommend that optometrists; adapt case histories to identify falls risk factors, manage falls risk through eye examinations, engage in conservative prescribing practices to minimize falls risk, avoid monovision glasses and restrict the use of progressive lenses unless needed, follow the guidelines for cataract treatment, and educate patients on correct glasses use and seek home modifications [9]. These guidelines have been adapted across multiple countries where optometry is a regulated profession [10, 11]. However, these recommendations are not currently embedded within formal optometry competency frameworks, which remain primarily focused on visual assessment and ocular disease management [12, 13]. As a result, falls prevention management may not be widely recognized as part of optometrists’ practice and limited research has investigated if these guidelines are being implemented into clinical practice [14]. Furthermore, a report by the Australian Healthcare and Hospitals Association found limited evidence that optometrists were delivering falls prevention strategies [15]. A previous Delphi study assessed the feasibility of implementing optometry falls guidelines into practice. While the majority of recommendations reached consensus among the optometrist panelists, they found low uptake of actual clinical practice [16]. These findings contrast with the WFG, which states all health professionals should screen older adults for falls risk and those at high risk of falls should be offered comprehensive multidisciplinary care for falls prevention. Hence, it suggests that knowledge, awareness and implementation of falls prevention may be low.

There is strong evidence for health professionals such as physiotherapists, occupational therapists, and nurses implementing evidence-based falls prevention into practice [17–19]. However, recently published reviews found scant published evidence on how, or if, optometrists are implementing falls prevention management for older adults in primary eye care settings [14, 20]. A scoping review found eye care professionals are well-positioned to contribute to falls prevention for older adults but there appeared to be substantial gaps in their awareness and implementation of falls prevention guidelines [14]. Additionally, a narrative review highlighted inconsistent implementation of ocular assessments, such as obtaining a thorough visual history and uniocular visual acuity assessment, due to a lack of guidance on which visual functions to assess and an overall uncertainty about eye care professionals’ role in falls prevention [20]. A Delphi study evaluated the feasibility of optometrists incorporating falls guideline recommendations into their routine practice [16]. The recommendations for assessing falls risk history and advising patients about addressing home modifications with occupational therapists reached a consensus, despite a low uptake in practice [16]. A survey conducted among community optometrists in Texas revealed low implementation of falls prevention practices within routine eye examinations. Perceived barriers to implementation included a lack of awareness among optometrists concerning the benefits for older adults participating in community-based exercise programs and program availability [21]. However, neither of these studies directly explored optometrists’ practice patterns about their clinical practice regarding falls prevention management. Engaging with stakeholders allows an understanding of their capability, opportunity and motivation to implement programs and their perspectives about potential barriers and enablers to implementation [22]. Consequently, there is a need to explore what are optometrists’ current practice of falls prevention such as screening (e.g., ask about previous history of falls), assessment (e.g., reviewing glasses prescriptions) and management (e.g., providing falls prevention advice), as well as their understanding of falls prevention and how they incorporate falls prevention into their clinical practice within primary eye care settings. The objectives of the study were to explore optometrists’: (i) understanding of falls prevention management and (ii) perspectives about the barriers and enablers to implementing falls prevention management in primary eye care settings.

Methods

Design

A qualitative descriptive study using focus groups was conducted [23]. There is limited research that has investigated implementation of falls prevention within optometry practice [24]. Therefore, this approach offered a comprehensive and direct account of what optometrists understand about falls prevention and how they implement falls prevention strategies [25]. Given the exploration of a novel topic, focus groups were viewed as appropriate for data collection and several roundtable discussions were used to encourage active participation [26]. This enabled the researchers to explore the topic in depth with the participants, encouraging them to describe their current experiences and viewpoints while promoting group interactions to build upon ideas [27].

Ethics

The study received approval from the Human Research Ethics Committee of The University of Western Australia (UWA) (2024/ET000664). All participants provided written informed consent.

Participants and Setting

Optometrists practicing either in metropolitan area according to the Modified Monash Model 1 or rural areas including regional centers and large rural towns according to the Modified Monash Model 2 and 3 [28] of Western Australia (WA) participated in this study. The Modified Monash Model is a geographical classification that defines the location according to remoteness and population size [28]. Optometrists practicing in rural areas may receive targeted government support and need to have high levels of clinical knowledge and referral options to manage diverse patient needs [29]. Focus groups were held in a quiet, private room at the Department of Optometry and Vision Sciences at UWA, Perth. The focus groups utilized a hybrid format, allowing for in-person attendance at the Department while also enabling online participation via Microsoft Teams (version 1.7.0.19353, Microsoft Corporation). The focus groups were held from December 2024 to February 2025.

Recruitment

A purposeful sampling method was used to include the most suitable participants to assist in answering the research questions [30]. Inclusion criteria were optometrists who examined older adults regularly in their practice (≥16 older adults seen per week), worked in community practices, either corporate practices or independent practices, and were registered with the Australian Health Practitioner Regulation Agency. Optometrists working exclusively in hospitals, ophthalmology clinics, or aged care facilities were excluded since these optometry staff provide specialized care that may differ from primary eye care settings. Optometrists not practicing in WA or those not examining older adults in their clinics were also excluded. No restrictions were placed on eligibility based on the number of years of practice or the number of hours of practice per week.

The research team reached out to industry organizations and networks that aided in distributing the advertisement flyers to WA optometrists. All potential participants were required to complete an eligibility screening survey before admission to the study. Once deemed eligible, written informed consent was obtained, and a short demographic survey (age, university qualifications, years of clinical experience, employment arrangement) was provided to participants via RedCap (hosted at UWA) [31].

Topic Guide

A focus group discussion guide was developed with expert input from members of the research team, three of whom were practicing community (primary care) optometrists and one an expert in falls prevention for older adults. The guide was structured around the concept of an optometrist’s practice in a primary eye care setting (see online suppl. File 1; for all online suppl. material, see https://doi.org/10.1159/000551621). The discussion guide points addressed prior expertise and professional knowledge regarding falls, practice patterns in assessing and treating older individuals for falls risk or management and providing falls prevention advice. A five-step process was used to develop the focus group guide [32]. This consisted of: (1) identifying the prerequisites to use a focus group guide; (2) reviewing the literature to critically appraise previous knowledge; (3) developing a preliminary guide; (4) pilot testing the focus group guide and prompts prior to use; (5) presenting the completed focus group guide for use [32].

Data Collection

The primary researcher (S.Y.L.) acted as the facilitator and was supported by senior qualitative researchers (A.M.H., K.A., H.N.), who assisted with moderating the focus groups. The moderators assisted with the session by ensuring the discussion remained on topic and encouraging participants to feel comfortable to share their opinions openly. Due to the time constraints and nature of work as optometrists, flexibility in attendance allowed participants to choose their preferred in-person or online attendance. Each focus group consisted of 5–7 participants and ran for approximately 60–90 min. The senior researchers documented their observations during the focus group, noting participants’ body language, gestures and nonverbal cues. The group was audio-recorded, and recordings were transcribed verbatim using transcription software (Temi, 2025). Transcriptions were checked by the primary researcher who reread the transcripts several times, to verify the accuracy of the content.

Rigor

This study’s design and reporting were guided by the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist to improve trustworthiness and methodological rigor (see online suppl. Table S.1) [33]. The COREQ checklist provides a comprehensive and transparent framework of reporting qualitative studies involving interviews and focus groups [33]. Two researchers were present at all focus groups to assist in moderating and observing the group dynamic, aiming to enhance the completeness of the data and reduce bias. The primary researcher, who is a current practicing community optometrist, engaged in reflexivity, recognizing their prior professional connections with some participants. To facilitate this, they employed a bracketing process, deliberately setting aside any biases and preconceived notions to understand the topic of interest fully [34]. Two researchers (S.Y.L., J.A.H.) independently coded the transcripts, with ongoing discussion of the analysis with a third senior researcher (A.M.H.) as a means of researcher triangulation throughout the analysis [35]. An audit trail was kept with reflexive notes taken after the focus groups to increase dependability of the results [35].

Data Analysis

The cleaned transcripts were deidentified, and then two independent researchers (S.Y.L. and J.A.H.) coded the transcripts using NVivo software (Lumivero, US, Ver 14, 2024). The transcriptions were reviewed multiple times to discern the topics discussed during the focus groups. The primary researcher is an optometrist with 3.5 years of clinical experience within community settings. The second researcher is a physiotherapist with 10 years of clinical gerontology community practice, with strong focus on falls prevention and concurrent research experience. The researchers convened regularly to deliberate on how their individual experiences and perspectives could potentially influence data interpretation. Any differences were settled with discussion to reach a consensus or by a third senior researcher (A.M.H.).

Inductive content analysis was employed to ensure the analysis remained authentic and accurately reflected participants’ statements, deriving direct insights from the focus group discussions [36]. A systematic coding process was employed, involving open coding, creating categories, and abstraction. This process first identified keywords and phrases, resulting in written notes and headings, and generating an initial list of categories. Subsequently, similar categories were grouped under higher order headings, allowing for the comparison and contrast of data and observations for assignment to particular groups. The categories facilitated a description of the phenomenon to enhance understanding. Finally, abstraction was performed to formulate a general description of the research topic through categories creation [37]. This resulted in the creation of subcategories, generic categories, and a final main category in accordance with an inductive content analysis [37]. A summary of the participants’ characteristics was presented using descriptive statistics [38].

Results

Participants’ Characteristics

Data saturation was achieved after analyzing data from the four focus groups. The focus groups comprised of 23 participants (n = 12 female, n = 11 male). Two focus groups were held online, one was held face-to-face, and one held as a hybrid meeting. Participant characteristics are presented in (see Table 1). Nineteen optometrists were from the Perth metropolitan area, and there were four rural/regional optometrists. The years of experience varied widely, ranging from 1 year to over 40 years of experience. Participants practiced across a diverse range of settings, including corporate practice as either employees or owners, independent practice as either employees or owners, or locum positions.

Table 1.

Participant demographic characteristics

Sample characteristics	Total, n = 23
Gender, n (%)
Female	12 (52.2)
Male	11 (47.8)
Age range, n (%)
20–29 years	11 (47.8)
30–39 years	9 (39.1)
40–49 years	1 (4.3)
50 and above, years	2 (8.7)
Years of clinical experience range, n (%)
1–5 years	12 (52.2)
6–10 years	6 (26.1)
11–15 years	2 (8.7)
16 and above, years	3 (13.0)
Scheduled medicines endorsementa, n (%)
I have medicines endorsement of my registration	19 (82.6)
I intend to study for a medicines endorsement in the future	2 (8.7)
I am currently studying for medicines endorsement	0 (0)
I have no intention of becoming medicines endorsed	2 (8.7)
Current employment arrangement, n (%)
Employee corporate owned practice	6 (26.1)
Employee independent owned practice	1 (4.3)
Employee franchise owned practice	0 (0)
Owner independent practice	4 (17.4)
Owner corporate practice	6 (26.1)
Owner independent franchise	0 (0)
Locum	3 (13.0)
Other	3 (13.0)
Location of principal practice, n (%)
Metropolitan (within 50 km of Perth)	18 (78.3)
Regional (50–600 km from Perth, e.g., Bunbury)	4 (17.4)
Rural (more than 600 km from Perth, e.g., Kalgoorlie)	1 (4.3)

Participants’ characteristics were gathered from the demographic survey provided.

^aScheduled medicines endorsement is a formal registration under Australian law that permits optometrists to obtain, possess, administer, prescribe, or supply schedule 2, 3, and 4 medicines for eye care.

Main Category: There Is an Evidence-to-Practice Gap in Optometrists’ Falls Prevention Management

Participants described their current optometric clinical practices and understanding of falls prevention management as primary eye care professionals in a community setting. The main category identified an “evidence-to-practice gap in optometrists’ falls prevention management.” This gap was exemplified by one participant who mentioned that before the focus group discussion, falls prevention management had never crossed their mind.

“It was so funny’ cause you sent the topic and I went, oh my gosh, why did I never think about falls and optometry before this as much as now we’re discussing it all.” (P17, age 30 to 39)

Generic Categories

Four generic categories that contributed to this main category (see Table 2) were identified. (1) Participants identified they had perceived low levels of knowledge and awareness about falls prevention and scant comprehension about the implications of falls beyond the ocular domain. (2) Participants identified there was only sporadic integration of falls prevention within their current clinical practices. (3) Participants reflected that they required an improved approach to collaborate within a multidisciplinary team, if they were to effectively implement falls prevention strategies. (4) Most participants were hesitant to undertake falls prevention management within their clinical practice.

Table 2.

Categorization of optometrists’ understanding of falls prevention management

Subcategory	Generic category	Main category
Knowledge of falls prevention practice	Perceived low levels of awareness and knowledge of falls prevention	There is an evidence-to-practice gap in optometrists’ falls prevention management
Optometry education
Disease focused practice patterns
Optometry training
Awareness of guidelines
Targeted history taking	Sporadic integration of falls prevention management within current practice
Current approach to falls prevention
Patient led
Identification of falls risk
Remuneration
Inter-professional association	Required an improved approach to collaborate within a multidisciplinary team
Multidisciplinary collaboration
Access to multidisciplinary care
Conveying the message
Sporadic services
Patient perceptions	Hesitancy to undertake falls prevention management
Understanding of optometrists’ role
Liability/concern
Level of confidence

Category 1: Perceived Low Levels of Awareness and Knowledge about Falls Prevention

Knowledge of Falls Prevention Practice. During the focus group discussions, it became clear that many participants were unaware of falls prevention management and lacked clinical knowledge about falls prevention.

“I don’t think I’ve ever really come across anything directly addressing falls prevention.” (P8, age 30 to 39)

This was further supported by discussions in another focus group, where one participant stated they had poor knowledge of the associations between vision and falls. The other group members concurred with this point.

“Not very strong. (unanimous agreement by the participants).” (P17, age 30 to 39)

Participants further noted that their current knowledge of falls prevention was often based on patient anecdotes.

“I would say most of my knowledge on the topic [falls prevention management] is assumption more than anything and feedback from patients.” (P6, age 20 to 29)

Optometrists consistently described that they had a very limited understanding about what falls prevention strategies were required within their scope of practice. Some participants extended this description and indicated they had not realized that falls prevention was even within their scope of practice. As a result, their confidence to implement falls prevention strategies in their practices varied.

“If somebody comes in with [risk or history of] falls, I’m not gonna be that comfortable [to manage].” (P18, age 50 and above)

Awareness of Guidelines. Additionally, nearly all participants concurred that they were not aware of falls prevention guidelines relevant for optometry. This gap in guideline knowledge was a recurring topic in all focus groups.

“[I am] not even aware that there’s any optometry-related falls guidelines.” (P1, age 20 to 29)

Although one participant among the focus groups possessed an understanding of falls prevention guidelines in optometry, this participant indicated limited awareness of other potentially available information about falls prevention.

“I think there are actually a few guidelines out there…one’s written by Optometry Australia…I sometimes look at those, but it’s not really much else there’s out there.” (P7, age 20 to 29)

Regarding glasses prescription, some participants were aware of the need to avoid making dramatic changes to the prescription to appropriately manage falls risk.

“I think our university taught us two studies…centred around the amount that you change when you prescribe and things to watch out for. If you are prescribing more than a 0.50 change or if you’re prescribing more than a 5-degree cylinder change, then that can actually affect the outcomes of falls.” (P7, age 20 to 29)

Optometry Training. Participants frequently described their personal experiences regarding the training and education obtained to achieve their optometry qualifications. Several participants noted that their previous training lacked sufficient focus on falls prevention management, resulting in a limited understanding.

“Even just coming back to our own education and what optometrists learn about the topic too…we’re probably not so educated in how we can prevent falls or what our role is in that.” (P6, age 20 to 29)

Some participants proposed potential enablers to improve their knowledge about falls prevention within the optometry field. When discussing training needs, participants sought guidance to extend their practice in falls prevention.

“Probably just some online reading material or some CPD through Optometry Australia would be good, like even some short training modules…[maybe] CPD modules to be distributed to optometrists online. I think it's just taking key points so the message gets across more effectively.” (P19, age 30 to 39)

Disease Focused Practice Patterns. To maintain their registration, optometrists are required to fulfil Continuing Professional Development (CPD) through attendance at conferences and training programs. Numerous participants emphasized that there was an almost complete absence of CPD training addressing topics such as falls prevention, which were not within the direct scope of eye disease, ocular assessments, and prescribing practices.

“I don't think I have come across any fall prevention information during the CPD talks over the years… I guess low vision is common [as a topic] but not particularly the topic of falls prevention.” (P12, age 30 to 39)

Category 2: Sporadic Integration of Falls Prevention Management within Current Practice

Current Approach to Falls Prevention. Participants expressed a range of perspectives about how falls prevention was included within their current practice. Differing opinions on optometrists’ roles in falls prevention were evident and multiple participants stated they were uncertain about how to integrate falls prevention management into their current practice.

“I think it starts with, kind of clarifying among ourselves, like what can we do? What can a primary care general optometrists do? Like how can we screen for this and how can we actually make a difference? I'm willing to do more in this realm.” (P5, age 50 and above)

Some participants described a potential enabler to uptake falls prevention in their clinical practices by diversifying their practice beyond general eye care to focus on care of the older adult population.

“I think it’s interesting that we have in optometry, we’ve got behavioural optometry, we’ve got paediatric optometry, we’ve got glaucoma, all those things. But we don’t have geriatric optometry (affirmative agreement by the participants).” (P18, age 50 and above)

Targeted History Taking. When discussing current falls prevention practices, many participants highlighted the importance of paying attention to the visual cues provided by patients when they arrive at the clinic. Examples given were observing mobility and walking aids, and these topics also arose as relevant during case history taking. It was noted that occasionally, patients willingly shared their falls history during the history-taking process.

“I’m more likely to discuss it [falls risk] if … they come in and they’re holding onto everything, walking in. 'cause I find, a lot of my patients anyway will tell me if they’ve had a fall.” (P17, age 30 to 39)

However, the discussion of current practice most clearly illustrated that most optometrists were not integrating falls screening into their routine case histories. One participant (with confirmation offered by the rest of the group) mentioned their case history focused specifically on ocular and vision-related questions. Falls risk questions were not usually incorporated into this initial history taking.

“Our case history at [the clinic (anonymised)] asks about blood pressure, all those kinds of things…there's no question, have you had a fall recently, or have you had a fall? [agreed to by all participants at the group in-person and online]” (P18, age 50 and above)

The discussion also highlighted that participants felt less confident asking screening questions when there were no obvious visual cues, such as the use of specific optical aids or the lack of diagnosed eye conditions.

“If it doesn’t naturally follow…if they’re not wearing multifocal. If they don’t have any overt eye conditions, then I think that reduces my confidence in asking that and expecting a positive response from the patient.” (P3, age 20 to 29)

In contrast, a few participants mentioned that as part of their screening process, they sometimes felt confident in their own ability to distinguish those who they deemed might be at risk of falls.

“I think I feel confident enough to be able to identify someone who might be at falls risk.” (P19, age 30 to 39)

Identification of Falls Risk. Despite identifying gaps in current practice overall, some participants felt falls prevention strategies could be specifically integrated as part of assessments for low vision patients. They suggested that falls prevention assessments could potentially be added to their scope of practice to complement current optometry-specific assessments and treatments.

“I think a lot of it has to do with also low vision patients that have these eye conditions, and as optometrists, I guess we do make decisions on their refractive correction, and we also detect any conditions, and just assessing if falls are actually ocular related.” (P7, age 20 to 29)

Participants indicated that the discussion highlighted their lack of understanding of how to integrate falls prevention evidence into their clinical practice. This was exemplified by one participant who expressed a desire for more advice regarding the best practices for prescribing glasses to improve their falls prevention management.

“I think there is an opportunity to educate optometrists on the things we shouldn’t do because, we may inadvertently be causing more falls when we’re not aware of things…which may increase their risk of falls…a reminder of things not to do would be important because it’s not just about seeing the patient and prescribing their refraction for example, but it's also about the decision making around that in the context of falls evidence.” (P3, 20 to 29)

Category 3: Required an Improved Approach to Collaborate within a Multidisciplinary Team

Multidisciplinary Collaboration. Numerous participants perceived that optometrists were isolated from other allied health professionals, complicating the potential initiation of referrals to members of the multidisciplinary team (e.g., physiotherapist, occupational therapist) to support a comprehensive falls care plan for patients. Participants conveyed that their referrals were predominantly directed toward general practitioners (GPs) or ophthalmologists, while engagement with other health professionals was minimal.

“I think the closest thing [referral] would be if you’re writing something to the General Practitioner (GP)…that would be the closest thing but no. I don’t think I’ve ever written a letter to a physio or to another healthcare provider specifically about falls.” (P4, age 20 to 29)

Inter-Professional Association. Another participant pointed out the limited collaboration across disciplines, highlighting minimal engagement with other allied health professionals beyond GPs and ophthalmologists.

“Optometry…it’s felt very separated from other multidisciplinary care models. So, our interaction with other health professionals is quite limited. I can’t say I’ve spoken with a physiotherapist since I graduated and similar with pharmacy [or] GP.” (P3, age 20 to 29)

Suggested enablers for improvement within the multidisciplinary care team were that other allied health professionals give presentations or conference lectures to optometrists. This was suggested as a means of slowly bridging the gap in optometrist participation within a multidisciplinary care team for falls prevention.

“If we have the opportunity to improve the interprofessional relationships as well with other allied health to learn from. Especially because while we can all attend CPD events or take further training, learning from a fellow colleague is really helpful.” (P6, age 20 to 29)

Sporadic Services. Discussions conducted with participants practicing in rural and regional areas indicated that geographical remoteness from urban centers could potentially influence the quality of service they were capable of providing to their patients. Participants reflected that services that are readily accessible in metropolitan environments were frequently restricted or wholly nonexistent in rural and regional sites.

“When you’re in a rural area access to services like Vision Australia or certain low vision services become so much more limited and like non-existent.” (P22, age 30 to 39)

Some participants described that in rural and regional areas, health professionals may have limited and irregular availability to provide services at their primary practice locations. This, in turn, makes it more challenging to deliver the necessary care or referral for patients seeking these services.

“When they [allied health professionals] only come to town once every two months or so, trying to get them [patients] to organize to see an OT or even to if in some cases bring an OT to their house to show them how to install some things in their home it’s a tough call for them [patients] to make sure to do that.” (P23, age 20 to 29)

While access to services in regional and rural areas was described as challenging, participants conversely reflected that closely-knit communities often create a clearer path for collaborative practices and enhancements in health professional education and training. However, participants reflected that if an optometrist was not integrated into the community, this could impede the implementation of education and training.

“You [health professional] often personally know a lot of the other allied health professionals, so organising in-person talks is sometimes actually easier in a rural area if you have a close-knit community. On the flip side, if you're not part of that close-knit community or [if] you don't know any of the other allied health professionals in the rural area, then obviously online would be the easiest way to deliver a course or have some of that information on education and training.” (P22, age 30 to 39)

Category 4: Hesitancy to Undertake Falls Prevention Management

Understanding of Optometrists’ Role. As optometrists, most participants felt their practices revolved around the assessment and management of ocular conditions. They were hesitant to implement specific falls prevention strategies into their clinical practice, with some participants questioning its relevance to optometry practice. Participants expressed that informing practicing optometrists about the importance of their scope of practice to include falls prevention can act as an enabler for uptake.

“I think if more people knew the importance of optometry in that space and they could actually see that. Then, the eyecare and having the routine annual examination or six or nine months…it [falls prevention] would be prioritized as well.” (P15, age 20 to 29)

Some participants believed that an enabler for engaging in falls prevention would be receiving information from an optometrist with specialized expertise in falls prevention.

“I have to very much agree that I personally feel that if, optometrists want to see, if you want to make optometrists more aware about this issue also and to tell us how important it is. It probably has to come from an optometrist who maybe is a bit more specialised in the field [someone] who has put their foot in the door so that we understand how optometrists can make an impact.” (P2, age 30 to 39)

Liability/Concern. Participants emphasized the need for clear regulation regarding optometrists’ consequences and legal responsibilities to better incorporate falls prevention into their practices. Some expressed this concern to clarify optometrists’ responsibilities concerning falls prevention and their prescribing practices for preventing falls.

“Understanding what that hook is for optometry and is it guidelines on really explicitly saying what our responsibility is here and you could be legally [accountable]. There could be consequences if you aren't prescribing correctly.” (P16, age 40 to 49)

Participants felt there were challenges that could impact on whether they could consistently integrate falls prevention into their clinical practice. They noted possible barriers to initiating falls prevention management. Some participants considered that optometrists would expect adequate compensation for their time and efforts.

“I think you might find that a hard sell for optometrists. Most optometrists would say Medicare doesn’t pay enough for what we do already. I honestly think if you went to a conference full of optometrists and said, “As part of your Medicare 10911, you should all be doing falls management as well.” I think you'll get a lot of pushback…or you have to have a new Medicare code.” (P4, age 20 to 29)

Patient Perceptions. To enable integration of falls prevention practices in optometry, some participants proposed using flyers or brochures to raise public awareness about falls prevention and what to anticipate regarding glasses changes.

“Flyers like this is your first pair of multifocals, here’s what to expect, come back if you have any of these problems might be handy. Similar to what [other participants] said about educating them…how potential eye conditions could affect their risk of falls as well.” (P1, age 20 to 29)

Suggestions were offered not only to encourage optometrists to adopt falls prevention strategies but also to educate and involve patients in enhancing their care, fostering a patient-centered approach.

“Probably like even before a patient’s having a fall, educating them, especially if they’re at higher risk like age category. Just educating that the vision is a big part of falls. Because I think some patients would probably just dismiss vision and assume it’s something else that’s causing the falls. So, it was worth giving them [education] just make them understand that.” (P13, 20 to 29)

In the context of integrating falls prevention into standard practice, a participant consensus was that, as optometrists, they were apprehensive regarding how patients might perceive inquiries related to falls. Some participants expressed concern that such questions could be misinterpreted or perceived as irrelevant to an eye examination.

“If I just routinely ask everyone about falls, maybe there is this concern that they would be like, why are you asking me this? So, I think because typically patients seem to tie in falls perhaps with a different practitioner like their GP, it can seem a bit funny.” (P3, age 20 to 29)

However, some participants additionally suggested that emphasizing patient safety in falls prevention messages could act as an enabler by taking a positive approach and potentially improve receptiveness by the patients.

“What ultimately, we’re all aiming for falls is personal safety. Then it’s very easy to then extend that towards to say well it’s your safety, but also potentially the safety of others like your wife or your partner or so on and so forth.” (P21, age 30 to 39)

Discussion highlighted that optometrists perceived that older adults, even those without prior falls, may unexpectedly learn they are at risk of falls. Participants felt that this information could lead to anxiety, hindering patients’ understanding. Consequently, it might impact on communication with patients.

“If they haven’t had a fall before, they’re usually a bit apprehensive with the idea of being told that they’re at fall risk and I don’t think they like that concept…I find the patients that who’ve had a fall and then you explain it to them they go “oh, okay”. Then they seem to try to do everything they can to prevent that from happening. So, I think unfortunately once they’ve had the fall, they understand how serious it can be, but before [having a fall] making it even harder [to understand].” (P20, age 20 to 29)

Discussion

This study identified that practicing optometrists had perceived low levels of knowledge and awareness regarding falls prevention management and lacked motivation to implement this into their clinical practice. Participants identified strong barriers to undertaking falls prevention assessment and management, such as a lack of confidence to discuss falls with an older adult and an absence of formal training. Possible enablers identified through participant discussion included improving their knowledge of falls prevention practices, learning from falls prevention experts, diversifying their practices to incorporate a greater focus on geriatric care, and strengthening collaboration with members of multidisciplinary teams. Overall, findings identified an evidence-to-practice gap in the implementation of falls prevention into optometry practice. The gaps in knowledge, motivation, and having the opportunity to make change assist to explain why optometrists described limited translation of falls prevention evidence into “real world” optometry settings. Behavior change by relevant stakeholders is vital for effective translation of evidence-based practice into clinical settings and public health [39]. The Capability, Opportunity, and Motivation theory of Behavior change (COM-B) suggested that for any behavior change to occur, such as optometrists implementing falls prevention management, optometrists require the capability (knowledge and awareness about falls prevention and their role in undertaking management), opportunity (clear pathways to enact suitable strategies), and motivation (confidence to take action) [39]. These findings concurred with a systematic review that examined implementing falls prevention interventions in community population [40]. The review identified a persistent gap in detailed description of implementation strategies and the effective use of implementation frameworks [40].

There was strong consensus among the participants that there was currently limited integration of falls prevention assessment in their practices and they did not include specific falls risk questions. This reflected their lack of confidence in conducting falls-related screening and assessments during routine practice. The participants’ reflections diverged from the WFG, which recommended that all health professionals screen older adults for falls risk and provide appropriate advice on falls prevention [7]. However, the participants’ reflections were concordant with a recent narrative review, which underscored a gap in clear guidance regarding the importance of eye care professionals in assessing and identifying visual risk factors for falls [20]. Participants felt there was a need to integrate screening tools and questions into their clinical practice to identify falls risk in older adults. Previous studies have identified that optometrists have low uptake of falls screening [16] and implementation of falls risk assessments [21]. Our study, to authors’ knowledge, is the first to directly ask community optometrists about their understanding and knowledge and experiences of providing falls prevention assessments or treatments, as well as their perspectives as working clinicians, on the barriers and enablers to implementing falls prevention care in their clinical practice.

Further discussions reflected limited collaboration with other allied health professionals in falls prevention management. Many participants felt they were only referring to ophthalmologists or GPs and referrals to other allied health professionals were scarce. However, participants demonstrated a willingness to collaborate with other allied health professionals and suggested enabler to implementing multidisciplinary management was to offer patients appropriate referral pathways. These findings concurred with previous research, whereby Delphi participants [16] and survey respondents [21] shared a similar enthusiasm for collaborating in a multidisciplinary team. Practice location was also described as a challenge for collaboration with other allied health professionals. Healthcare disparities between geographical areas are a well-known challenge in maintaining the quality and availability of healthcare services [41]. However, increased community participation could improve healthcare in these areas, as a strong sense of community has been found to correlate with more positive perceptions of health service quality, supporting better delivery [42].

Participants described limited understanding and knowledge of evidence-based falls prevention practices. The focus of optometry education and CPD has primarily been linked to ocular health assessment and management guidance, leading to limited exploration of topics beyond this scope [13]. Furthermore, current optometry guidelines provide limited implementation strategies to support the incorporation of falls prevention practices into routine clinical care [13, 16]. A common barrier to implementation identified by participants, which has been identified in other studies, was the need for appropriate remuneration if eye examinations were to include additional assessments or management [43].

Participants highlighted several enablers to uptake falls prevention practices through enhancing optometrists’ knowledge, opportunity, and motivation to improve falls prevention management [39]. Theory-driven frameworks identify that interventions targeting these components can help reach the threshold for change [39]. Providing targeted education and training for optometrists and students can boost their confidence in managing falls risk. Targeted health promotion training can serve as an enabler for health professionals to provide more comprehensive, patient-centered care, improving outcomes [44]. Other means of enabling falls prevention involved reformatting the messaging to underscore patient safety in falls risk. Incorporating these messages into health communication guarantees that patients receive straightforward, actionable information about falls risk and prevention strategies [45]. Lastly, by improving the collaboration pathways, optometrists can significantly contribute to vision interventions that enhance falls prevention management. Previous literature revealed better patient falls risk outcomes when optometrists were part of a multidisciplinary team [46].

Strengths and Limitations

This study is the first to use focus group discussion on optometrists to explore how they conduct falls prevention in their community practice and identify barriers and enablers to implementing falls prevention into practice. By utilizing a qualitative descriptive approach, this study differed from previous research by directly asking participants about their current practices. A diverse set of perspectives was obtained by incorporating optometrists with various levels of experience and geographical locations. However, there are several limitations, as a relatively homogenous sample of WA optometrists may potentially affect the generalizability of the results. The transferability of the results to optometrists practicing in different states or countries should be further investigated. The exclusive use of primary eye care optometrists in community settings may have missed complementary insights from those in hospitals or other clinical settings. The majority of participants in the study were early career optometrists, typically with 1–5 years of clinical experience, which may have influenced the perspectives captured in the study. However, several mid-to-late career optometrists were also included who described similar gaps in knowledge regarding falls prevention management and limited awareness of multidisciplinary care. This consistency suggests that the findings were not solely attributed to the younger participants, although inclusion of a larger cohort of older optometrists could have provided additional insights. The findings provide a novel understanding about optometric practices that could inform future research on falls prevention in optometry.

Conclusion

Vision assessment and treatment are crucial components for effective multifactorial falls prevention interventions for community-dwelling older adults. Optometrists, as primary healthcare providers, are well-positioned to provide falls prevention care for older adults they examine in their clinics. This study explored optometrists’ understanding about falls prevention in primary eye care settings and their perspectives on implementing falls prevention as part of their clinical practice. Participants identified that they had perceived low levels of capability regarding falls prevention management. This led to many participants expressing a lack of confidence and motivation to undertake specific screening and assessments. Several barriers to the optometrists’ opportunity to undertake falls prevention were identified, leading to inconsistent practice in primary eye care clinics. Participants suggested providing relevant education and training to address these challenges and to maximize optometrists’ scope of practice. Shifting the mindset of both optometrists and patients to emphasize falls prevention and establishing clear guidelines could enhance optometrists’ confidence and motivation to improve implementation of falls prevention management. Barriers to implementation included the need for adequate remuneration and the opportunity to collaborate in multidisciplinary team care with other allied health professionals. Further implementation studies are required to address the gap between falls prevention evidence and optometrists’ current practice by evaluating strategies that can improve the adoption and enactment of falls prevention management in primary eye care settings.

Acknowledgments

We extend our sincere appreciation to industry and professional organizations for their assistance in recruiting community optometrists for this study. We extend our gratitude to all participating community optometrists for taking the time to share their experience in the focus groups.

Statement of Ethics

The study received approval from the Human Research Ethics Committee of The University of Western Australia (UWA) (2024/ET000664). All participants provided written informed consent.

Conflict of Interest Statement

We have no conflict of interest to declare.

Funding Sources

S.Y.L. is supported by an Australian Government Research Training Program Fees Offset Scholarship and a Perth Eye Foundation Scholarship. A.M.H. is supported by the Royal Perth Hospital Research Foundation. The funders had no role in the design, analysis, or writing of this article.

Author Contributions

S.Y.L. was primarily responsible for drafting the manuscript with support from A.M.H. and K.A. S.Y.L., A.M.H., and K.A. were responsible for study conception and design with support from J.C. and H.N. S.Y.L., K.A., A.M.H., and H.N. completed the focus group discussion. S.Y.L. and J.A.H. completed the analysis with support from A.M.H. All authors critically reviewed the manuscript for its content and approved the final version of the manuscript for submission.

Funding Statement

S.Y.L. is supported by an Australian Government Research Training Program Fees Offset Scholarship and a Perth Eye Foundation Scholarship. A.M.H. is supported by the Royal Perth Hospital Research Foundation. The funders had no role in the design, analysis, or writing of this article.

Data Availability Statement

All the data are contained in the manuscript. The raw data from the focus group are not available due to ethical considerations regarding preserving the anonymity of the participants. Further enquiries can be directed to the corresponding author. This study was not preregistered.