Understanding Barriers to Home Safety Assessment Adoption in Older Adults: Qualitative Human-Centered Design Study.

Background: Falls are the leading cause of injury-related death among adults aged 65 and older. The fear of falling can further limit older adults' independence by contributing to activity restriction, social isolation, and physical decline-ironically increasing the risk of mechanical falls. Although home safety assessments have been shown to reduce fall risk by up to 36% and decrease serious injuries such as hip fractures, their adoption remains low. Understanding the barriers to implementing these assessments is critical to improving their uptake and effectiveness.

Objective: This study aimed to (1) identify specific barriers perceived by older adults in implementing home safety assessments and modifications to reduce the risk of mechanical falls, (2) explore the attitudes of health care professionals and other stakeholders toward these assessments, and (3) identify novel design opportunities to guide the development and implementation of more effective home safety assessment techniques and practices to reduce mechanical fall risk.

Methods: This explanatory qualitative study drew on the "inspiration" phase of the human-centered design (HCD) research process. We conducted 35 interviews (28 initial and 7 follow-up) with 28 purposefully sampled participants in the San Francisco Bay Area between February and June 2021. Participants included community-dwelling older adults (n=3), geriatricians (n=4), therapists (n=6), product developers (n=2), older health researchers (n=8), and community program leaders (n=5). Interview notes were analyzed inductively by the research team to extract themes and generate insight statements and design opportunities.

Results: Analysis yielded three key insights: (1) older adults often experience a conflict between maintaining independence and implementing safety modifications. One participant described living with a "repeating mantra in my head throughout the day saying 'above all, don't fall.'" (2) aesthetic and privacy concerns frequently override safety benefits. Participants rejected modifications that made their homes feel "institutional." (3) access to occupational therapy services-already limited in rural areas-was further constrained by the COVID-19 pandemic, with some providers reporting that travel time "took up the majority of their day just assessing one home." These barriers help explain the low adoption of home safety assessments despite strong supporting evidence. The study identified design opportunities to address these challenges, including customizable, user-friendly safety solutions, dignity-preserving approaches to assessment, and technology-enabled remote alternatives.

Conclusions: This study identified specific emotional, aesthetic, logistical, and access-related barriers to the adoption of home safety assessments among older adults. The proposed design solutions offer promising directions to increase uptake, improve user experience, and enhance safety. However, further validation through co-design with a larger and more diverse group of older adults is needed. Future research should pilot test these ideas across varied contexts and evaluate their implementation and impact.