“I don’t know if it makes a difference to safety?” perception vs actuality: A mixed-methods study on older adults’ experiences of home stair falls revealed during COVID-19 lockdown

Emily Wharton; Thomas O’Brien; Richard J. Foster; Clarissa Giebel; Justine Shenton; Asan Akpan; Avril Mills; Mike Roys; Constantinos Maganaris

doi:10.1371/journal.pone.0326850

Peer Review History

Original SubmissionJanuary 9, 2025
9 Jan 2025 Author Response https://doi.org/10.1371/journal.pone.0326850.r001
Decision Letter - Andrew Curtis, Editor PONE-D-24-57759-->-->“I don’t know if it makes a difference to safety?" Perception vs actuality: A mixed-methods study on older adults' experiences of home stair falls revealed during COVID-19 lockdown-->-->PLOS ONE?> Dear Dr. Wharton, --> -->-->I believe the manuscript is close to being accepted. The reviewer's raised some interesting points worthy of consideration. I also would prefer you find an alternative word choice to "significant" on line 50. Also -- while I understand the efforts taken in linking the participants to a socioeconomic measure, it might be interesting to describe the broader geography (your choice, but did they all come from one area?) and even urban / rural source of the subject pool-- not that these have to be included in the analysis, rather just providing some additional context.-->--> -->-->Please consider the comments of Reviewer 2 as I believe some of these observations would strengthen the paper from a readership perspective.?> Please submit your revised manuscript by Apr 07 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols . We look forward to receiving your revised manuscript. Kind regards, Andrew Curtis, Ph.D Academic Editor PLOS ONE Journal Requirements: When submitting your revision, we need you to address these additional requirements. 1.Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. Thank you for stating the following financial disclosure: “Initials of the authors who received each award: EW (NIHR200182) National Institute for Health and Care Research Applied Research Collaboration North West Coast https://arc-nwc.nihr.ac.uk/ This independent research is funded by the National Institute for Health and Care Research Applied Research Collaboration North West Coast (ARC NWC) as part of a” Please state what role the funders took in the study. If the funders had no role, please state: "The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript." If this statement is not correct you must amend it as needed. Please include this amended Role of Funder statement in your cover letter; we will change the online submission form on your behalf. 3. We note that you have indicated that there are restrictions to data sharing for this study. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For more information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. Before we proceed with your manuscript, please address the following prompts: a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information, data are owned by a third-party organization, etc.) and who has imposed them (e.g., a Research Ethics Committee or Institutional Review Board, etc.). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent. b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. For a list of recommended repositories, please see https://journals.plos.org/plosone/s/recommended-repositories. You also have the option of uploading the data as Supporting Information files, but we would recommend depositing data directly to a data repository if possible. We will update your Data Availability statement on your behalf to reflect the information you provide. 4. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information. 5. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? Reviewer #1: Yes Reviewer #2: Partly ******** 2. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: Yes Reviewer #2: N/A ****** 3. Have the authors made all data underlying the findings in their manuscript fully available??> The PLOS Data policy Reviewer #1: Yes Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: Yes ****** Reviewer #1: In the manuscript titled “I Don’t Know If It Makes A Difference To Safety? Perception vs Actuality: A Mixed Methods Study On Older Adults' Experiences of Home Stair Falls During the COVID-19 Lockdown,” the authors conducted a mixed-methods analysis that included semi-structured interviews and quantitative surveys involving 22 adults aged over 60. These participants were asked about their experiences with independent living and stair falls during and after the COVID-19 pandemic, as well as the discrepancies between their perceptions and objective safety assessments of their stairs. Wharton and colleagues also examined, through this mixed-methods nested study, the perception of stair safety, fall causes, behavioral attitudes towards falls, and general concerns regarding independent living with advancing age. Stair falls among older adults in the UK represent a major public health issue with significant societal and financial consequences. This study highlights how the social isolation imposed by the COVID-19 lockdown, coupled with its negative impact on physical health, exacerbated the problem. A key strength of the study is its ability to bring attention to the difficulties in addressing stair fall safety within this vulnerable population. The study found that 40% of stairs examined as part of this study, did not mean safety assessment based on UK guidelines, but no correlation was found between frequency of falls and adherence to code. The challenge in addressing this issue of non-adherence to codes is significant, as the UK has the oldest housing stock in Europe, and most individuals in this group cannot afford the necessary modifications to meet these guidelines. While the authors acknowledge that new homes can better incorporate these guidelines, they stress that a comprehensive approach—including education and targeted interventions—is required to mitigate fall risks among the aging population, enabling them to live independently in their homes. However, there are some missed opportunities in the study, though they do not detract from its value. For example, the authors mention the involvement of occupational therapists but do not specify at which stage(s) such encounters would be most beneficial for the elderly population. Additionally, there is no mention or elaboration of the Fall Prevention Team and its role within the British medical and public health sectors. For an international audience, further explanation of this potentially helpful team could enhance the paper’s impact. Given the homogeneity of the interviewees (predominantly White, higher socioeconomic status based on the deprivation index, and mostly homeowners), the findings may not fully capture the disparities present in other populations, such as those in the US, and could limit the generalizability of the results. Other minor points: • The authors do not mention whether the interviewees had any ambulatory impairments or used mobility aids such as canes or walkers. • It is unclear whether the fall experienced by patient 22 occurred at home. • The sentences on page 5, lines 109 and 112 are identical. • Line 182 should state 80%, not 8%. • Lines 309 and 376 may contain small grammatical errors that need correction. • In addition to recall bias, there also appears to be a self-selection bias, which could be noted when discussing the study's limitations. Despite these minor recommendations, this study provides a clever approach to addressing a significant (and costly) public health issue. It warrants further attention, particularly as life expectancy continues to rise and the desire for independent living persists, all while the feasibility of making extensive improvements to older homes remains limited due to both structural age and financial constraints. Notwithstanding these minor critiques, I believe this paper makes a valuable contribution to the field and recommend its publication. Reviewer #2: Broad subject area considering stair safety, falls and the impact of Covid lockdown. Although qualitative information gathered represents the views of participants and suggests areas of future research, the overall subject seems too broad. To my reading the information gathered does not identify established links between covid lock down, risk of falls and stair safety. There are broad themes but some of the narrative of the participants quoted is contradictory. Perhaps including rating scales/ evaluation methods that could be statistically analysed would have been helpful. The authors identify the limitation of the study in terms of ethic origin and socioeconomic status of the participants. The paper does raise awareness of consideration of home safety in an aging population, the views regarding transition to older age and the longer term concerns about the type and expensive of care provision. ****** what does this mean? ). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy Reviewer #1: Yes: Nilanjana Majumdar Reviewer #2: No ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org https://doi.org/10.1371/journal.pone.0326850.r002
Revision 1
7 Apr 2025 Author Response Dear Dr Andrew Curtis, Thank you for the opportunity to revise and resubmit our manuscript titled “I don’t know if it makes a difference to safety?" Perception vs actuality: A mixed-methods study on older adults' experiences of home stair falls revealed during COVID-19 lockdown (PONE-D-24-57759). We are grateful for the constructive feedback provided by both reviewers and the editorial team. We have carefully considered and addressed all comments and suggestions raised during the review process. Below, we provide a detailed point-by-point response to each comment, outlining the changes made to the manuscript where applicable. Editorial Feedback: 1. "I also would prefer you find an alternative word choice to 'significant' on line 50." • Response: We have revised the term "significant" on line 50 to "important" to better reflect the intended meaning without implying statistical significance. 2. "It might be interesting to describe the broader geography (your choice, but did they all come from one area?) and even urban/rural source of the subject pool - not that these have to be included in the analysis, rather just providing some additional context." • Response: We have added a sentence the Results section (demographic characteristics) providing additional context about the geographic distribution of participants, including region and whether they resided in urban or rural areas (line 170). Reviewer #1 Comments: 1. "The authors mention the involvement of occupational therapists but do not specify at which stage(s) such encounters would be most beneficial for the elderly population." • Response: We have clarified in the Discussion section when occupational therapists’ involvement would be most beneficial, particularly during the initial home assessment phase and when implementing fall prevention strategies (lines 475 – 479). 2. "There is no mention or elaboration of the Fall Prevention Team and its role within the British medical and public health sectors." • Response: We have added a brief explanation of the role of the Fall Prevention Team within the UK healthcare system in the Discussion section to provide context for international readers (lines 472 – 475). 3. "The authors do not mention whether the interviewees had any ambulatory impairments or used mobility aids such as canes or walkers." • Response: We captured existing medial conditions and/or long-term illnesses which may include ambulatory impairments. However, we did not probe further and therefore do not have specific details on the medical conditions, any ambulatory impairments and/or if the participants used mobility aids such as canes or walkers. We acknowledge that the use of walking aids is an important factor in understanding mobility and fall risk among older adults. We have added a brief statement in the discussion (limitations section) to acknowledge this as a limitation of the study (lines 483 – 486). 4. "It is unclear whether the fall experienced by patient 22 occurred at home." • Response: There was a typo error and [Faller-Female22, aged 60-69], was in fact [Faller-Female21, aged 60-69]. We have also clarified in the Results section that fall experienced by participant 21 occurred at home, they had two homes at the time, one with their partner and one they previously owned which is why they said “I drove three hours home”. We have removed that for clarity. 5. "The sentences on page 5, lines 109 and 112 are identical." • Response: We have removed the duplicated sentence. 6. "Line 182 should state 80%, not 8%." • Response: We have corrected the value to 80%. 7. "Lines 309 and 376 may contain small grammatical errors that need correction." • Response: We have corrected the grammatical errors in these lines. 8. "In addition to recall bias, there also appears to be a self-selection bias, which could be noted when discussing the study's limitations." • Response: We have added a note in the Limitations section acknowledging the potential for self-selection bias (line 492 – 495). Reviewer #2 Comments: 1. "The overall subject seems too broad… does not identify established links between COVID-19 lockdown, risk of falls, and stair safety." • Response: We appreciate the reviewer’s observation regarding the scope of our study. We are in agreement that the themes identified by our analysis extend beyond the COVID-19 lockdown. While our data collection allowed for comparisons before, during, and after the pandemic, the findings highlight broader concerns related to stair safety and fall risk among older adults. To clarify this point, we have emphasised in the abstract (lines 38 -39), two points discussion section (lines 370 - 372, 461 – 486), and the conclusion (lines 514 -515) that several themes identified were independent of the pandemic and reflect ongoing challenges faced by older adults in navigating their home environments. This broader perspective underscores the importance of staircase safety as a persistent issue rather than one limited to the COVID-19 period. 2. "Some of the narrative of the participants quoted is contradictory." • Response: We have addressed this in the Discussion section, highlighting that contradictory experiences reflect the subjective nature of qualitative research and the diverse responses to aging and fall risk (lines 455 – 464). 3. "Perhaps including rating scales/evaluation methods that could be statistically analysed would have been helpful." • Response: We appreciate the reviewer’s suggestion regarding the use of rating scales and validated questionnaires. As our study followed a mixed-methods design, the qualitative component primarily focused on capturing perspectives of older adults regarding stair safety and fall risk. While a quantitative component was included, our sample size was not sufficient to conduct meaningful statistical analyses, and we did not include structured rating scales as part of our data collection. We acknowledge that the inclusion of standardised assessment tools could have added an additional layer of quantitative insight. However, due to the novelty of the work, a tailored approach was needed and our approach prioritised exploratory qualitative methods to uncover themes that may not have been easily captured through structured measures alone. Additional Journal Requirements: 1. Funding Statement: Initials of the authors who received each award: EW (NIHR200182) National Institute for Health and Care Research Applied Research Collaboration North West Coast https://arc-nwc.nihr.ac.uk/. This independent research is funded by the National Institute for Health and Care Research Applied Research Collaboration North West Coast (ARC NWC) as part of a PhD studentship. The views expressed in this publication are those of the author(s) and not necessarily those of the National Institute for Health and Care Research or the Department of Health and Social Care. The funders had no role in study design, data collection and analysis, decision to publish and preparation of the manuscript. 2. Data Availability: We have provided a detailed explanation in the Data Availability Statement regarding the ethical restrictions on sharing data due to confidentiality and participant privacy. 3. Supporting Information Captions: We have added captions for all Supporting Information files and updated in-text citations accordingly. We believe these revisions have strengthened the manuscript and addressed the reviewers’ and editor’s comments. We appreciate the opportunity to improve our work and hope that the revised manuscript is now suitable for publication in PLOS ONE. Thank you for your consideration. We look forward to hearing from you. Yours sincerely, Emily Wharton, Postgraduate Researcher Liverpool John Moores University, Faculty of Science NIHR ARC NWC, Health and Care Across the Life Course Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0326850.r003
Decision Letter - Andrew Curtis, Editor “I don’t know if it makes a difference to safety?" Perception vs actuality: A mixed-methods study on older adults' experiences of home stair falls revealed during COVID-19 lockdown PONE-D-24-57759R1 Dear Dr. Wharton, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Andrew Curtis, Ph.D Academic Editor PLOS ONE Additional Editor Comments (optional): I appreciate your efforts on addressing each of the reviewer's comments. I have read through the revision and I am happy the manuscript is now suitable for publication. I appreciate the efforts you made in making sure the revisions were easy to follow and clearly (and politely) addressed the reviewer's comments. Both of whom were impressed with the initial version of the paper and the topic in general. Reviewers' comments: https://doi.org/10.1371/journal.pone.0326850.r004
Formally Accepted
Acceptance Letter - Andrew Curtis, Editor PONE-D-24-57759R1 PLOS ONE Dear Dr. Wharton, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset You will receive further instructions from the production team, including instructions on how to review your proof when it is ready. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few days to review your paper and let you know the next and final steps. Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. If we can help with anything else, please email us at customercare@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Andrew Curtis Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0326850.r005

Open letter on the publication of peer review reports

PLOS recognizes the benefits of transparency in the peer review process. Therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. Reviewers remain anonymous, unless they choose to reveal their names.

We encourage other journals to join us in this initiative. We hope that our action inspires the community, including researchers, research funders, and research institutions, to recognize the benefits of published peer review reports for all parts of the research system.

Learn more at ASAPbio .