Abstract
Introduction
Unintentional falls are a leading cause of injury and mortality among older adults, with a growing burden in rapidly ageing regions like the Middle East and North Africa. Despite this, the availability, scope and geographical distribution of epidemiological evidence on fall-related outcomes in the region remain poorly characterised, limiting policy and prevention efforts. This evidence gap map systematically identifies, categorises and maps existing observational research on fall-related outcomes among older adults in the Middle East and North Africa.
Methods
We searched PubMed, Web of Science, Google Scholar and Google (up to November 2025) without time restrictions to identify primary studies and systematic reviews reporting on fall prevalence, frequency, risk and fear of falling, self-reported perceived reasons for falling and postfall consequences in older adults (aged ≥60) in the Middle East and North Africa. Two reviewers independently conducted screening, data extraction and quality assessment.
Results
We included 203 primary studies, representing data from 424 112 older adults. Evidence from low-income countries was scarce (one national health survey from Sudan, one retrospective study from Yemen, no study for Syria). Upper-middle-income countries (Iraq, Jordan and Libya) contributed limited evidence (4.9%; 10/203). High-income countries contributed registry-based and national-level data. Most studies were conducted in lower-middle-income countries (113/203; 55.7%); in both genders (96.6%; 196/203) and in urban settings (157/203; 77.3%). The most frequently studied populations were the general population and outpatients (each 45/203; 22.6%). Under-researched outcomes were fear of falling and self-perceived reasons of fall.
Conclusion
This evidence gap map highlights substantial data gaps across several countries, with marked underrepresentation of rural, low-income and conflict-affected settings, and limited evidence on key fall-related outcomes across the Middle East and North Africa. Strengthened surveillance using validated context-adapted tools, hospital-based registries and integrated national survey fall indicators are essential to inform effective and equitable fall prevention strategies in the region.
Keywords: Aging, Global Health
WHAT IS ALREADY KNOWN ON THIS TOPIC
Existing evidence gap maps in healthy ageing and fall prevention primarily focus on interventions, with limited attention to the availability and distribution of observational epidemiological data, particularly in the Middle East and North Africa.
WHAT THIS STUDY ADDS
This study provides the first comprehensive mapping of observational epidemiological evidence on fall-related outcomes across the Middle East and North Africa, identifying an absence of data in several countries, under-representation of rural, low-income and conflict-affected settings, and limited evidence on key outcomes such as fear of falling and self-reported perceived reasons for falling.
WHAT THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
The findings highlight the need to strengthen regional data systems through standardised context-specific surveillance, including the integration of fall indicators into national surveys, and hospital-based registries. Data should be collected in regional languages to improve accessibility and comparability. Addressing these gaps will support effective, equitable and locally relevant fall prevention policies across the Middle East and North Africa.
Introduction
Unintentional falls are a major cause of injury and death among older adults worldwide,1 contributing to disability,2 reduced independence and poor quality of life.3 Health systems face a significant burden, with 172 million falls each year resulting in short- or long-term disability.2 Falls occur across community and healthcare settings, including among the community-dwelling and clinical older populations, and require context-specific measurement to inform prevention strategies that differ by population and setting.4 5 A striking 82% of fall-related deaths occur in low- and middle-income countries.6 Fall-related outcomes in older adults remain under-represented in the Middle East and North Africa—particularly in the low- and middle-income countries7—where rapid demographic transitions are undergoing8 and falls among older adults are expected to increase in the coming decades.6
While existing evidence gap maps address interventions to promote healthy ageing,9 10 this is, to our knowledge, the first to focus on fall-related observational epidemiological outcomes in the region. This evidence gap map is aligned with the United Nations Decade of Healthy Ageing (2021–2030), which calls for strengthening data systems.11 12 In this context, we aim to systematically identify and map research gaps related to fall outcomes among older adults in the Middle East and North Africa. The objectives are to: (1) explore available evidence on prevalence of fallers among older adults (aged ≥60), frequency of falls, fall risk, fear of falling, self-reported perceived reasons for falling and postfall consequences; (2) identify existing systematic reviews and primary studies and (3) highlight areas lacking primary or secondary research.
Method
The protocol was pre-registered on the Open Science Framework (https://osf.io/3cu4q). Our evidence gap map follows the Campbell Collaboration guidelines for producing a Campbell evidence gap map13 and adheres to the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR)14 guidelines (online supplemental table S1). We applied the Population, Intervention, Comparison, Outcome, Timing and Setting (PICOTS) framework to develop the evidence gap map methodology.15
Eligibility criteria
The population of interest includes approximately 57 million16 17 older adults (aged ≥60), as defined by the United Nations,18 across 20 countries in the Middle East and North Africa. Country list is based on definitions by the WHO, Joint United Nations Programme on HIV/AIDS (UNAIDS), the World Bank and Global Burden of Disease initiative, consistent with prior published systematic reviews on population health in the region.19 The region includes low-income countries (Sudan, Syria and Yemen); lower-middle-income countries (Algeria, Djibouti, Egypt, Lebanon, Morocco, Pakistan, Palestine and Tunisia), upper-middle-income countries (Iraq, Jordan and Libya) and high-income countries (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia and United Arab Emirates (UAE)).20
We included primary studies and systematic reviews reporting fall-related outcomes among older adults. Falls were defined using the WHO definition: ‘an event, which results in a person coming to rest inadvertently on the ground or floor or other lower level’,21 excluding falls caused by assault, self-harm, animals, burning buildings, transport vehicles, fire, water and machinery.21 The outcomes of interest included prevalence of fallers among older adults (one or more falls), frequency of falls, fall risk, fear of falling, self-reported perceived reasons for falling and postfall negative health consequences.
Literature search
We conducted searches for grey and non-grey literature on PubMed, Web of Science and Google Scholar, and Google in English, Arabic and French on 13 November 2025. Search terms combined free-text and controlled vocabulary related to falls, older adults and countries of the Middle East and North Africa (details reported in online supplemental boxes S1 and S2). The search strategy was developed with an information scientist and has been published.22 We applied no language or time restrictions. We also screened reference lists of included studies and relevant systematic reviews.
Multistage screening and data extraction
Two reviewers independently screened title/abstracts and full texts using Rayyan software (Rayyan Systems Inc, Cambridge, MA, USA, https://www.rayyan.ai/)23 with disagreements resolved with a third reviewer (online supplemental figure S1). Two reviewers independently extracted data using a predesigned form in Microsoft Excel, capturing (1) study characteristics (eg, study design, sampling method, data collection time, sample size); (2) setting; (3) sociodemographic information (eg, population type, age, sex and residence); (4) details of the diagnosis tool and (5) outcome. A third reviewer verified all extracted data and discrepancies were resolved through discussions.
Assessment of quality and strength of evidence
Two reviewers independently assessed study quality (ie, the external and internal validity assessment) using the Risk of Bias in Prevalence Studies tool,24 applying a conservative approach when information was insufficient. This tool facilitated the assessment of reporting biases in the included studies. Risk of bias was categorised as high if studies lacked validated diagnostic tools or sufficient data for judgement. Conflicts of interest were examined following Cochrane Collaboration recommendations.25 In line with the guidance on conducting systematic reviews and meta-analyses of observational studies of etiology (COSMOS-E), no summary quality score was calculated.26 We resolved discrepancies through discussions.
Synthesis
Studies were categorised by income level and outcomes. Quantitative synthesis summarised the number of studies per outcome, while qualitative synthesis assessed heterogeneity in study design, settings, populations and study-level quality. Evidence was visually mapped to identify research gaps.
Sex and Gender Equity in Research (SAGER) guidelines statement
Not applicable.
Patient and public involvement
This research involved secondary data analysis with the primary studies serving as the unit of analysis. No patients were involved in this systematic review.
Ethics statement
Ethical approval was not required for this evidence gap mapping study as it involved analysis of published literature only.
Results
Characteristics of the included studies
A total of 203 primary studies met the inclusion criteria representing 424 112 older adults (figure 1). Included studies showed substantial heterogeneity in outcome measures, settings and populations. Overall, 135 studies (66.5%) reported the prevalence of fallers among the older adults, 39 (19.2%) examined the frequency of falls, 91 (44.8%) assessed the fall risk of which 59 studies (29.1%) reported fall risk mean scores (figure 2, table 1 and online supplemental tables S2 and S3). Prevalence of fear of falling was reported in 47 (23.2%) studies with 23 studies (11.3%) providing fear of falling mean scores. Additionally, 23 studies (11.3%) explored self-reported perceived reasons for falling, and 65 studies (32.0%) reported postfall consequences. The detailed evidence gap map is provided in online supplemental table S2.
Figure 1. Primary study selection flow diagram.
Figure 2. Distribution of primary studies and systematic reviews by fall-related outcomes among older adults in the Middle East and North Africa.
Table 1. Summary evidence gap mapping of fall-related outcomes among older adults in the Middle East and North Africa.
| Countries | Data geographical coverage | Populations | Prevalence of fallers among the older adults (aged ≥60) | Frequency of falls | Self-reported perceived reasons for falling | Postfall consequences among older adults | Prevalence of older adults with a fall risk | Prevalence of older adults with a fear of falling | |
|---|---|---|---|---|---|---|---|---|---|
| (N) | Type | (N) | (N) | (N) | (N) | (N) | (N) | ||
| Low-income countries | |||||||||
| Sudan | National: | 16 | General | 1 | – | – | – | – | – |
| Syria | – | – | – | – | – | – | – | – | |
| Yemen | Urban (non-national): 1 | Trauma patients | 1 | – | – | – | – | – | |
| Lower-middle-income countries | |||||||||
| Algeria | – | – | – | – | – | – | – | – | |
| Djibouti | – | – | – | – | – | – | – | – | |
| Egypt | Non-national | Nursing home residents | 10 | 6 | 3 | 3 | 7 | 4 | |
| Urban: 49 | Patients with fall history | – | 2 | 1 | 2 | 1 | 2 | ||
| Rural: 10 | Trauma patients | 4 | 1 | 2 | 4 | 1 | – | ||
| Mixed: 4 | Patients with cardiac disease | 1 | – | – | – | 1 | – | ||
| NR or online: 2 | Patients with diabetes | – | – | – | – | 0 | – | ||
| Patients with rheumatoid arthritis | 1 | – | – | – | 1 | – | |||
| Outpatients | 11 | 5 | 4 | 6 | 4 | 5 | |||
| Inpatients | 4 | 1 | – | 0 | 3 | – | |||
| Mixed outpatients and nursing home residents | 1 | – | – | 1 | 1 | 0 | |||
| General | 8 | 4 | 3 | 5 | 4 | 4 | |||
| Lebanon | Non-national | Nursing home residents | 1 | – | 1 | 1 | 1 | – | |
| Urban: 5 | Fallers | 1 | – | – | 1 | – | – | ||
| Mixed: 1 | Trauma patients | 1 | – | – | 1 | – | – | ||
| Morocco | Urban (non-national): 2 | Trauma patients | 1 | – | – | 1 | – | – | |
| Rheumatoid arthritis patients | 1 | – | – | 1 | – | 1 | |||
| Pakistan | National: | 1 | Nursing home residents | 1 | – | – | – | – | – |
| Non-national | Mixed outpatients and nursing home residents | – | – | – | – | 1 | 1 | ||
| Urban: 26 | Trauma patients | 2 | – | – | 1 | – | – | ||
| Mixed: 3 | Patients with history of falls | 2 | 1 | 2 | 1 | 1 | – | ||
| Patients with musculoskeletal pain | – | – | – | – | 1 | – | |||
| Outpatients | 2 | 1 | – | 1 | 1 | 1 | |||
| General | 7 | 1 | – | 2 | 4 | 1 | |||
| Community-dwelling elderly with hypertension | – | – | – | – | – | – | |||
| Palestine | Non-national | Trauma patients | 1 | – | – | 1 | – | – | |
| Urban: 1 | |||||||||
| Mixed: 2 | General | 2 | – | – | 2 | – | – | ||
| Tunisia | National: | 1 | Accidental deaths | 1 | – | – | 1 | – | – |
| Non-national | Trauma patients | – | – | – | 1 | – | – | ||
| Urban: 1 | Fallers | – | – | – | 1 | – | – | ||
| Mixed: 1 | Outpatients | – | – | – | – | – | – | ||
| Upper-middle-income countries | |||||||||
| Iraq | Non-national | Trauma patients | – | – | 1 | 1 | – | – | |
| Urban: 4 | Diabetic patients | – | 1 | – | 1 | 1 | – | ||
| Rural: 1 | General | 1 | – | – | – | – | 1 | ||
| Jordan | Urban (non-national): 4 | Trauma patients | 1 | – | – | 2 | – | – | |
| Mixed outpatients and GP | 1 | – | – | – | – | 1 | |||
| General | – | – | – | – | – | – | |||
| Libya | Mixed (non-nationals): 1 | General | 1 | 1 | – | – | – | – | |
| High-income countries | |||||||||
| Bahrain | – | – | – | – | – | – | – | – | |
| Kuwait | National: | 1 | Fallers | – | – | – | 2 | – | – |
| Non-national (urban): 1 | |||||||||
| Oman | Non-national | Trauma patients | 1 | – | – | – | – | – | |
| Urban: 1 | |||||||||
| Rural: 1 | Outpatients | 1 | – | – | – | – | – | ||
| Qatar | National: 2 | Trauma patients | 6 | – | – | 9 | – | – | |
| Non-national | Fallers | – | – | – | 1 | – | – | ||
| Urban: 16 | Patients with history of falls | – | – | – | 1 | – | – | ||
| Saudi Arabia | National: | 4 | Nursing home residents | – | – | – | – | 1 | – |
| Non-national | Trauma patients | 3 | – | – | 2 | – | – | ||
| Urban: 40 | Frail or prefrail older adults | 1 | – | – | – | – | – | ||
| Mixed: 4 | Patients with history of falls | – | 1 | – | – | – | – | ||
| NR: 2 | Fallers | 1 | – | – | 1 | – | – | ||
| Outpatients | 15 | 5 | 2 | 2 | 4 | 5 | |||
| Patients with stroke | 1 | – | 1 | – | – | – | |||
| ICU patients | – | – | – | – | 1 | – | |||
| Mixed outpatients and GP | 2 | 1 | – | – | 1 | – | |||
| Patients with diabetes | 1 | 1 | – | – | – | – | |||
| General | 14 | 5 | 2 | 2 | 4 | 5 | |||
| United Arab Emirates | Urban (non-national): | 6 | Trauma patients | 3 | – | – | 2 | – | – |
| Haemodialysis patients | – | – | – | – | – | – | |||
| General | 2 | 1 | 1 | 1 | – | – | |||
Detailed evidence gap map is provided in online supplemental table S2.
N indicates the number of studies reporting each outcome. ‘–’ indicates no available data. GP indicates general population. ICU indicates intensive care unit. Data geographical coverage is categorized as national (representative at country level) or non-national (subnational), including urban, rural, mixed or not reported (NR) settings. Population types include low-risk population (general population), clinical populations (eg, outpatients, inpatients) and at-risk groups (patients with history of falls, frail or prefrail older adults). Outcomes include prevalence of fallers, frequency of falls, perceived reasons for falling (self-reported), postfall consequences, prevalence of older adults with fall risk and fear of falling.
No data 
Low risk population 
Clinical population 
At risk population
Most evidence came from Egypt (65/203; 32.0%), Saudi Arabia (50/203; 24.6%) and Pakistan (30/203; 14.8%), with studies using a wide range of validated tools to assess fall risk and fear of falling. No relevant studies were identified from Algeria, Bahrain, Djibouti or Syria (online supplemental table S4). Twenty-six studies (12.8%) were national or included both rural and urban populations, 12 (5.9%) were exclusively rural and 157 (77.3%) were urban. One study was online, and seven did not report study location.
The most frequently studied populations were the general older adult population (45/203; 22.6%), outpatients (45/203; 22.6%) and patients admitted to trauma services (32/203; 15.8%). Most studies included both men and women (96.6%; 196/203); three focused exclusively on men and four exclusively on women.
We identified three relevant systematic reviews: two global7 27 and one focused on the Gulf Cooperation Council countries.28 The global reviews addressed prevalence of fallers and the frequency of falls,7 27 and the Gulf Cooperation Council review reported on fall risk28 (figure 2).
Figure 3 and online supplemental table S5 provide a summary and detailed analysis of the study-level quality. Overall, internal validity was strong. All studies applied consistent data collection methods across participants, used appropriate time frame for measuring falls, accurately used numerators and denominators, and directly collected data from participants or medical records. However, while all studies focused on unintentional falls, only 54.7% (111/203) provided a clear definition of the outcome. Approximately 57.8% of studies (78/135) reporting the prevalence of fallers relied on single-item questionnaire about fall history, potentially introducing recall bias. In contrast, fear of falling and fall risk were assessed using validated tools in 74.5% (35/47) and 98.9% (90/91) of the studies, respectively. Assessing external validity was challenging, as 77.8% (158/203) of studies did not report response rates. While 98.5% (200/203) of studies included population samples closely representative of the target population, national representativeness was limited in many countries. None of the studies that disclosed conflicts of interest reported any significant concerns.
Figure 3. Summary of the quality assessment of the included primary studies.
We identified 23 validated assessment tools, either performance-based or questionnaire-based, for measuring fall-related outcomes in the Middle East and North Africa: 19 for fall risk and four for fear of falling (table 2). Most validated tools were administered in English. Berg Balance Scale (BBS), Fall Efficacy Scale—International (FES-I) and Modified Falls Efficacy Scale (MFES) were also used in Arabic, while only MFES was also used in French. Additionally, five non-validated questionnaires were used for assessing fear of falling. Most studies assessing fall risk (97.8%; 89/91) used English versions of performance-based tools (eg, Timed up and go test, BBS and Five Times Sit-to-Stand test score) or English-language questionnaires. Similarly, most studies assessing fear of falling (93.6%; 44/47) administered questionnaires in English, with minimal use of Arabic versions including FES-I (4.3%; 2/47). Tool use was highest in Egypt, followed by Saudi Arabia and Pakistan, highlighting a critical shortage of validated instruments in regional languages.
Table 2. Falls risk assessment tools validation status and use in Middle East and North Africa.
| Assessment tool | Tool type | Validated | Language of validation* | Countries where it was used in the included studies | Languages used in the included studies | Number of studies using the tools |
|---|---|---|---|---|---|---|
| Fall risk | ||||||
| Timed up and go test (TUGT)31 | Performance-based | Y | English† | Egypt, Iraq, Jordan, Lebanon, Pakistan, Palestine, Qatar, Saudi Arabia, Sudan, Tunisia, UAE | English | 43 |
| Berg Balance Scale (BBS)32 | Performance-based | Y | English† Arabic† | Egypt, Jordan, Kuwait, Oman, Pakistan, Qatar, Saudi Arabia, UAE, Yemen | English | 34 |
| Five Times Sit-to-Stand test score (5TSST)33 | Performance-based | Y | English† | Egypt, Saudi Arabia | English | 4 |
| Functional Reach Quotient (FRQ) | Performance-based | Y | English† | Egypt, Saudi Arabia | Arabic English | 1 2 |
| Functional Reach Test (FRT) | Performance-based | Y | English† | Jordan | English | 1 |
| Y Balance Test (YBT) | Performance-based | Y | English† | Jordan | English | 1 |
| Functional Gait Assessment (FGA) | Performance-based | Y | English† | Egypt | English | 1 |
| Romberg’s Balance Test | Performance-based | Y | English† | Egypt, UAE | English | 2 |
| Modified Romberg Balance Test | Performance-based | Y | English† | Egypt | English | 1 |
| Hendrich II Fall Risk Model (HFRM)34 | Questionnaire | Y | English‡ | Pakistan, Palestine | English | 3 |
| The Falls Risk for Older People in the Community (FROP-COM)35 | Questionnaire | Y | English‡ | Egypt, Lebanon | English | 2 |
| Morse Fall Scale (MFS)36 | Questionnaire | Y | English‡ | Egypt, Pakistan, Palestine, Saudi Arabia, | English | 6 |
| John Hopkins-Fall Risk Assessment Tool (JHFRAT)37 | Questionnaire | Y | English‡ | Egypt, Palestine | English | 2 |
| Tinetti assessment tool (TIT)38 | Questionnaire | Y | English‡ | Jordan, Pakistan, Palestine, Saudi Arabia, Tunisia | English | 6 |
| Schmid Fall Risk Assessment (Schmidt-FRAT)39 | Questionnaire | Y | English‡ | Palestine | English | 1 |
| Elderly fall screening test (EFST)40 | Questionnaire | Y | English‡ | Pakistan | English | 1 |
| Single Leg Stance (SLS) | Questionnaire | Y | English‡ | Egypt | English | 1 |
| Falls Risk Assessment Scale | Questionnaire | Y | English‡ | Pakistan, Saudi Arabia, Tunisia | English | 4 |
| Missouri Alliance for Homecare (MAHC-10)41 | Questionnaire | Y | English‡ | Saudi Arabia | Arabic, English | 1 3 |
| Fear of falling | ||||||
| Fall Efficacy Scale—International (FES-I)42 43 | Questionnaire | Y | English‡ Arabic‡ | Egypt, Pakistan | English | 13 |
| Palestine | Arabic | 1 | ||||
| Modified Falls Efficacy Scale (MFES)44,46 | Questionnaire | Y | English‡ Arabic‡ French‡ | Egypt, Pakistan | English | 6 |
| Egypt | Arabic | |||||
| Short Fall Efficacy Scale (SFES-I)47 | Questionnaire | Y | English‡ | Egypt | English | 1 |
| Visual analogue scale (VAS)48 | Questionnaire | Y | English‡ | Egypt, UAE | English | 2 |
| Subjective questionnaire | Questionnaire | N | NA | Egypt, Jordan, Pakistan, Saudi Arabia | NR | 9 |
Languages spoken in the 20 countries of the Middle East and North Africa.
Performance-based tools require only translation of administration instructions.
For questionnaire-based tools, full linguistic and cultural validation is required.
N, no; NA, not applicable; NR, not reported; UAE, United Arab Emirates; Y, yes.
Fall-related outcomes across high-income countries of the Middle East and North Africa
We identified data from five high-income countries: Saudi Arabia, Oman, Qatar, Kuwait and the UAE, accounting for 78/203 studies (38.4%). Studies were conducted in urban areas, except in Saudi Arabia where four were conducted in both urban and rural settings. Saudi Arabia provided the most data, including four national population-based surveys focused on community-dwelling older adults and outpatients, as well as 43 cross-sectional studies and three randomised clinical trials conducted across clinical populations. Qatar and the UAE contributed primarily through national registries and cross-sectional studies, often in trauma patients. Kuwait provided one national registry-based study and one cross-sectional study both among fallers, while Oman contributed two cross-sectional studies—one among outpatients and one among trauma patients. No relevant study was found for Bahrain. The most frequently reported outcomes were the prevalence of fallers among older adults (50 studies), fall risk (29 studies) and postfall consequences (22 studies). Fall risk was predominantly assessed in Saudi Arabia (21 studies), using a variety of validated tools. Prevalence of fear of falling was reported in 10 studies from Saudi Arabia using FES-I, MFES or a non-validated tool. No data on fear of falling (prevalence or mean scores) were available for Bahrain, Kuwait and UAE. Data for postfall consequences were available only for Saudi Arabia. No data on self-reported perceived reasons for falling were available for Bahrain, Kuwait, Oman or Qatar.
Fall-related outcomes in upper-middle-income countries of the Middle East and North Africa
Jordan, Iraq and Libya contributed data, accounted for 10 studies (4.9%). These studies were non-national and focused on the general population, trauma patients and diabetic patients. Reported outcomes were largely limited to prevalence of fallers and fear of falling.
Fall-related outcomes in lower-middle-income countries of the Middle East and North Africa
Most studies (113/203; 55.7%) were conducted in lower-middle-income countries, specifically Egypt, Lebanon, Morocco, Pakistan, Palestine and Tunisia. Egypt and Pakistan contributed substantially through non-national and community-based studies, with one nationwide survey identified for Pakistan. All countries with data included studies conducted in both urban and rural areas. Only Egypt had studies conducted exclusively in rural areas. Few studies were identified from Lebanon, Morocco, Palestine and Tunisia primarily addressing prevalence of fallers and postfall consequences. Egypt and Pakistan reported a broader range of outcomes, including the prevalence of fallers, fall frequency, fall risk, fear of falling, self-reported perceived reasons for falling and postfall consequences. This made them the most data-rich countries despite persistent gaps in national representativeness. No data were identified for Algeria and Djibouti.
Fall-related outcomes in low-income countries of the Middle East and North Africa
Evidence from low-income countries was extremely limited. Sudan contributed with one national health survey (1/203; 0.5%) reporting prevalence of fallers among older adults while one study from Yemen focused on trauma patients. No studies were identified for Syria.
Discussion
This evidence gap map represents the first systematic effort to map observational epidemiological evidence on fall-related outcomes among older adults in the Middle East and North Africa. Unlike most evidence gap maps from the WHO’s United Nations Decade of Healthy Ageing and all those developed by the Cochrane-Campbell Ageing Coordinating Group, which focus on interventions (eg, effectiveness of treatments), this study shifts attention to the availability and distribution of observational data required to inform interventions. By identifying where observational data is absent or limited across countries, populations and outcomes, it highlights critical evidence gaps that constrain effective policy and fall prevention strategies in the region.
Substantial disparities in research output were observed across income levels. Evidence from low-income countries was particularly scarce, limited to a single national health survey from Sudan and one retrospective study from Yemen, with no studies identified for Syria, resulting in substantial gaps in understanding fall-related risks among older adults in these settings. Upper-middle-income countries (Iraq, Jordan and Libya) contributed limited evidence, often focused on specific subpopulations such as diabetic patients. Among lower-middle-income countries, Algeria and Djibouti had no published data. Lebanon and Palestine had limited studies, mostly reporting on prevalence of fallers, with no large-scale national surveys. Egypt and Pakistan provided the largest volume of data and used a range of validated tools to assess fall risk and fear of falling. Pakistan also contributed one national survey. Among high-income countries, Saudi Arabia provided the second largest volume of data in the region. Kuwait, Qatar, Saudi Arabia and the UAE contributed registry-based and national-level data, yet longitudinal population-based studies and standardised data collection remain limited across these countries.
We identified a notable lack of evidence from seven countries affected by economic crisis, conflict, population displacement, limited healthcare access and chronic underfunding of public health systems including Iraq, Lebanon, Libya, Palestine, Sudan, Syria and Yemen. In such contexts, ageing-related vulnerability is often intensified in older adults, yet falls remain poorly captured by health surveillance systems.29 Without localised data on fall prevalence, functional impairments and environmental risk factors, the implementation of evidence-based screening and prevention strategies is likely constrained. This is compounded by health system limitations including absent electronic health records, under-resourced primary care and limited geriatric service coverage.
We noted under-researched outcomes, including fear of falling and self-perceived reasons for falls. These outcomes merit dedicated future primary research and systematic reviews. While most studies included both men and women, few explored gender-specific patterns, such as differential risk factors and experiences of fear of falling. Similarly, rural older adults remain under-represented, despite facing distinct environmental hazards and healthcare access barriers. Future research should better address these population and outcome-specific gaps to support equitable, context-sensitive, evidence-informed fall prevention strategies.
The World Guidelines for Falls Prevention and Management strongly recommend the use of standardised and validated assessments to consistently identify risk factors and guide prevention efforts across diverse settings.5 However, our study identified considerable variation in populations studied, settings and outcome measurement tools limiting meaningful comparison across countries. Future research should adopt validated tools for multifactorial fall risk including fear of falling, adapted into regional languages alongside English. Addressing linguistic and cultural validation is essential to advancing health equity and achieving the goals of the UN Decade of Healthy Ageing in the Middle East and North Africa, which calls for collaborative action to optimise older people’s functional ability and enable them to live longer, healthier lives.12
Improved data systems are particularly needed in low-income and conflict-affected countries, where fragile health infrastructures magnify the consequences of falls.11 National surveys and hospital-based registries should be expanded using harmonised methods. Integrating fall-related metrics into existing WHO frameworks such as the STEPwise approach to non-communicable disease surveillance, and prioritising indicators like fall prevalence, functional mobility and fear of falling, could enhance the quality and comparability of regional data. These efforts would help align fall monitoring with broader health system strengthening goals.
Our evidence gap map identifies where data are needed to inform fall prevention planning, complementing existing evidence gap maps focused on intervention effectiveness. In low-resource settings in the Middle East and North Africa, low-cost strategies—including strength and balance training, home hazard modification and community-based fall risk screening—have shown effectiveness globally and could be adapted locally.30 Embedding fall risk assessments into routine primary care or non-communicable disease programmes may enhance reach and sustainability. However, cost-effectiveness and implementation data are lacking in the region, and future research should evaluate the affordability, scalability and sustainability of such interventions within diverse health systems.
This study benefits from a comprehensive and rigorous search strategy across multiple databases, languages and grey literature sources including unindexed journals, theses, conference abstracts and government reports. Though some studies may have been missed due to publication bias or limited access to non-indexed regional publications, this evidence gap map identifies important data and measurement gaps that can guide prioritising future primary studies and secondary research and support monitoring and evaluation of healthy ageing initiatives aligned with the UN Decade of Healthy Ageing (2021–2030).
Conclusion
By moving beyond intervention-focused evidence maps, this study provides a foundation for strengthening observational data systems and guiding research prioritisation in rural, low-income and conflict-affected settings across the Middle East and North Africa. Strengthening surveillance through validated, context-adapted tools, hospital-based registries and the integration of fall indicators into national health surveys is essential to support effective, equitable and locally relevant fall prevention policies for older adults in the region.
Supplementary material
Acknowledgements
We would like to thank Dr Ross MacDonald, Librarian, Scholarly Communications, at Weill Cornell Medicine-Qatar, for his help in developing the search strategy. We also thank Dr Philippe Piccardi, Specialist in Population Health Research for his assistance with manuscript editing, and Mr Hidenori Miyagawa, Visual Design Specialist, for his assistance with visual asset consultation, both at Weill Cornell Medicine-Qatar. Finally, we would like to thank Ms Sarah Baig, medical student at Weill Cornell Medicine-Qatar and Dr Sonia Chaabane, Instructor in Population Health Sciences at Weill Cornell Medicine-Qatar for their assistance in the screening stage.
Footnotes
Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Handling editor: Soumitra S Bhuyan
Patient consent for publication: Not applicable.
Ethics approval: Not applicable.
Provenance and peer review: Not commissioned; externally peer reviewed.
Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting or dissemination plans of this research.
Author note: This research was conducted entirely within a single institution (Institute for Population Health, Weill Cornell Medicine-Qatar).
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
References
- 1.World Health Organization: Switzerland; 2021. Step safely: strategies for preventing and managing falls across the life-course.https://www.who.int/teams/social-determinants-of-health/safety-and-mobility/step-safely2024 Available. [Google Scholar]
- 2.Stanaway JD, Afshin A, Gakidou E, et al. Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. The Lancet. 2018;392:1923–94. doi: 10.1016/S0140-6736(18)32225-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Santos-Lozada AR. Trends in Deaths From Falls Among Adults Aged 65 Years or Older in the US, 1999-2020. JAMA. 2023;329:1605–7. doi: 10.1001/jama.2023.3054. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.McKercher JP, Peiris CL, Hill A-M, et al. Hospital falls clinical practice guidelines: a global analysis and systematic review. Age Ageing. 2024;53:afae149. doi: 10.1093/ageing/afae149. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Montero-Odasso M, van der Velde N, Martin FC, et al. World guidelines for falls prevention and management for older adults: a global initiative. Age Ageing. 2022;51:afac205. doi: 10.1093/ageing/afac205. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Step safely . World Health Organization: Switzwerland; 2021. Strategy for preventing and managing falls across the life-course.https://www.who.int/publications/i/item/978924002191-4 Available. [Google Scholar]
- 7.Salari N, Darvishi N, Ahmadipanah M, et al. Global prevalence of falls in the older adults: a comprehensive systematic review and meta-analysis. J Orthop Surg Res. 2022;17:334. doi: 10.1186/s13018-022-03222-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Abyad A. Ageing in the Middle-East and North Africa: Demographic and Health Trends. Int J Ageing Dev Countries. 2021;6:112–28. [Google Scholar]
- 1.WHO . Switserland: World Health Organization; 2024. Evidence and gap maps for the UN decade of healthy ageing.https://www.who.int/initiatives/decade-of-healthy-ageing/evidence-gap-map/2024 Available. [Google Scholar]
- 10.Cochrane Global Agine Cochrane Campbell global ageing partnership evidence and gap maps: Cochrane. 2024. https://globalageing.cochrane.org/Cochrane%20Campbell%20Global%20Ageing%20Partnership%20Evidence%20and%20Gap%20Maps2024 Available.
- 11.Geneva, Switzerland: World Health Organization; 2021. What is the UN decade of healthy ageing?https://www.who.int/initiatives/decade-of-healthy-ageing#:~:text=Section%20navigation&text=What%20is%20WHO’s%20role%20in,communities%20in%20which%20they%20live Available. [Google Scholar]
- 12.Geneva, Switzerland: 2020. Decade of healthy ageing: baseline report. [Google Scholar]
- 13.White H, Albers B, Gaarder M, et al. Guidance for producing a Campbell evidence and gap map. Campbell Syst Rev . 2020;16:e1125. doi: 10.1002/cl2.1125. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Tricco AC, Lillie E, Zarin W, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Ann Intern Med. 2018;169:467–73. doi: 10.7326/M18-0850. [DOI] [PubMed] [Google Scholar]
- 15.National Health Council, Duke Margolis Center for Health Policy; 2021. What is the PICOTS framewok?https://nationalhealthcouncil.org/wp-content/uploads/2021/04/NHC-PICOTS-Infographic-v10.pdf Available. [Google Scholar]
- 16.United Nations, Department of Economic and Social Affairs, Population Division; 2023. World population prospects: the 2022 revision.https://population.un.org/wpp/Download/Standard/MostUsed Available. [Google Scholar]
- 17.PopulationSizePyramid.ned. 2023. https://www.populationpyramid.net/algeria/2022 Available.
- 18.Older persons: the UN refugee agency. 2023. https://emergency.unhcr.org/protection/persons-risk/older-persons2023 Available.
- 19.Chaabna K, Cheema S, Abraham A, et al. Gray literature in systematic reviews on population health in the Middle East and North Africa: protocol of an overview of systematic reviews and evidence mapping. Syst Rev. 2018;7:94. doi: 10.1186/s13643-018-0751-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.World Bank group country classifications by income level: World Bank. 2023. https://datatopics.worldbank.org/world-development-indicators/the-world-by-income-and-region.html Available.
- 21.World Health Organization: Switzerland; 2023. Falls.https://www.who.int/en/news-room/fact-sheets/detail/falls2023 Available. [Google Scholar]
- 22.Chaabna K, Jithesh A, Khawaja S, et al. The epidemiology of unintentional falls among older people in the Middle East and North Africa: a systematic review and meta-analysis. J Glob Health. 2025;15:04072. doi: 10.7189/jogh.15.04072. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Mourad Ouzzani HH, Fedorowicz Z, Elmagarmid A. Rayyan — a web and mobile app for systematic reviews. Syst Rev. 2016;5 doi: 10.1186/s13643-016-0384-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Hoy D, Brooks P, Woolf A, et al. Assessing risk of bias in prevalence studies: modification of an existing tool and evidence of interrater agreement. J Clin Epidemiol. 2012;65:934–9. doi: 10.1016/j.jclinepi.2011.11.014. [DOI] [PubMed] [Google Scholar]
- 25.Higgins JPT, Thomas J, Chandler J, editors. Cochrane handbook for systematic reviews of interventions version 6.3. Cochrane; 2022. www.training.cochrane.org/handbook Available. [Google Scholar]
- 26.Dekkers OM, Vandenbroucke JP, Cevallos M, et al. COSMOS-E: Guidance on conducting systematic reviews and meta-analyses of observational studies of etiology. PLoS Med. 2019;16:e1002742. doi: 10.1371/journal.pmed.1002742. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Neri S, Oliveira J, Dario A, et al. Does Obesity Increase the Risk and Severity of Falls in People Aged 60 Years and Older? A Systematic Review and Meta-analysis of Observational Studies. J Gerontol A Biol Sci Med Sci. 2020;75:952–60. doi: 10.1093/gerona/glz272. [DOI] [PubMed] [Google Scholar]
- 28.Alqahtani BA, Alshehri MM, Hoover JC, et al. Prevalence of falls among older adults in the Gulf Cooperation Council countries: A systematic review and meta-analysis. Arch Gerontol Geriatr. 2019;83:169–74. doi: 10.1016/j.archger.2019.04.006. [DOI] [PubMed] [Google Scholar]
- 29.Harper S. The Fate of Older Adults in Conflict Zones. Population Ageing. 2025;18:217–9. doi: 10.1007/s12062-025-09493-w. [DOI] [Google Scholar]
- 30.An X, Pan Y, He C, et al. Evidence Based Strategies for Preventing Falls in Community-Dwelling Older Adults. J Multidiscip Healthc. 2025;18:4033–44. doi: 10.2147/JMDH.S535977. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Podsiadlo D, Richardson S. The timed “Up & Go”: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991;39:142–8. doi: 10.1111/j.1532-5415.1991.tb01616.x. [DOI] [PubMed] [Google Scholar]
- 32.Berg KO, Wood-Dauphinee SL, Williams JI, et al. Measuring balance in the elderly: validation of an instrument. Can J Public Health. 1992;83 Suppl 2:S7–11. [PubMed] [Google Scholar]
- 33.Whitney SL, Wrisley DM, Marchetti GF, et al. Clinical measurement of sit-to-stand performance in people with balance disorders: validity of data for the Five-Times-Sit-to-Stand Test. Phys Ther. 2005;85:1034–45. [PubMed] [Google Scholar]
- 34.Hendrich AL, Bender PS, Nyhuis A. Validation of the Hendrich II Fall Risk Model: a large concurrent case/control study of hospitalized patients. Appl Nurs Res. 2003;16:9–21. doi: 10.1053/apnr.2003.YAPNR2. [DOI] [PubMed] [Google Scholar]
- 35.Russell MA, Hill KD, Blackberry I, et al. The reliability and predictive accuracy of the falls risk for older people in the community assessment (FROP-Com) tool. Age Ageing. 2008;37:634–9. doi: 10.1093/ageing/afn129. [DOI] [PubMed] [Google Scholar]
- 36.Morse JM, Morse RM, Tylko SJ. Development of a Scale to Identify the Fall-Prone Patient. Can J Aging. 1989;8:366–77. doi: 10.1017/S0714980800008576. [DOI] [Google Scholar]
- 37.Poe SS, Cvach M, Dawson PB, et al. The Johns Hopkins fall risk assessment tool: postimplementation evaluation. J Nurs Care Qual. 2007;22:293–8. doi: 10.1097/01.NCQ.0000290408.74027.39. [DOI] [PubMed] [Google Scholar]
- 38.Tinetti ME. Performance-oriented assessment of mobility problems in elderly patients. J Am Geriatr Soc. 1986;34:119–26. doi: 10.1111/j.1532-5415.1986.tb05480.x. [DOI] [PubMed] [Google Scholar]
- 39.Schmid NA. Federal Nursing Service Award Winner: Reducing patient falls: A research-based comprehensive fall prevention program. Mil Med. 1989;155:202–7. doi: 10.1093/milmed/155.5.202. [DOI] [PubMed] [Google Scholar]
- 40.Cwikel JG, Fried AV, Biderman A, et al. Validation of a fall-risk screening test, the Elderly Fall Screening Test (EFST), for community-dwelling elderly. Disabil Rehabil. 1998;20:161–7. doi: 10.3109/09638289809166077. [DOI] [PubMed] [Google Scholar]
- 41.Calys M, Gagnon K, Jernigan S. A Validation Study of the Missouri Alliance for Home Care Fall Risk Assessment Tool. Home Health Care Manag Pract. 2013;25:39–44. doi: 10.1177/1084822312457942. [DOI] [Google Scholar]
- 42.Halaweh H, Svantesson U, Rosberg S, et al. Cross-cultural adaptation, validity and reliability of the Arabic version of the Falls Efficacy Scale-International (FES-I) Med Princ Pract. 2015;25:1–7. doi: 10.1159/000441128. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 43.Yardley L, Beyer N, Hauer K, et al. Development and initial validation of the Falls Efficacy Scale-International (FES-I) Age Ageing. 2005;34:614–9. doi: 10.1093/ageing/afi196. [DOI] [PubMed] [Google Scholar]
- 44.Hasan S, Chevidikunnan MF, Khan F. Reliability and validity of the Arabic version of the modified falls efficacy scale. Disabil Rehabil. 2024;46:793–801. doi: 10.1080/09638288.2023.2175045. [DOI] [PubMed] [Google Scholar]
- 45.Perrot A, Castanier C, Maillot P, et al. French validation of the modified-falls efficacy scale (M-FES Fr) Arch Gerontol Geriatr. 2018;78:233–9. doi: 10.1016/j.archger.2018.07.001. [DOI] [PubMed] [Google Scholar]
- 46.Buchner DM, Hornbrook MC, Kutner NG, et al. Development of the common data base for the FICSIT trials. J Am Geriatr Soc. 1993;41:297–308. doi: 10.1111/j.1532-5415.1993.tb06708.x. [DOI] [PubMed] [Google Scholar]
- 47.Kempen GI, Yardley L, Haastregt JC, et al. The Short FES-I: a shortened version of the falls efficacy scale-international to assess fear of falling. Age Ageing. 2008;37:45–50. doi: 10.1093/ageing/afm157. [DOI] [PubMed] [Google Scholar]
- 48.Scheffer AC, Schuurmans MJ, vanDijk N, et al. Reliability and validity of the visual analogue scale for fear of falling in older persons. J Am Geriatr Soc. 2010;58:2228–30. doi: 10.1111/j.1532-5415.2010.03105.x. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
All data relevant to the study are included in the article or uploaded as supplementary information.