Falls prevention in Outdoor Public Spaces: An Interdisciplinary Delphi Consensus on Risks, Actions, and Barriers

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These falls are complex, understudied, and insufficiently addressed in current age-friendly cities or walkability frameworks. This study aimed to build interdisciplinary consensus on risks, preventive actions, and barriers to fall prevention in outdoor public spaces through a Delphi process. Methods A three-phase Delphi study was conducted with 64 participants in round 1, 60 in round 2, and 49 in round 3, including four expert groups: older adults who had fallen outdoors, health and research professionals, urban planners, and decision-makers. Phase one collected open responses on risks, preventive actions, and barriers. Responses were synthesized using AI-assisted analysis with systematic human validation. In phases two and three, the relevance of 124 propositions were rated on a 10-point Likert scale. Consensus was defined as ≥ 70% of ratings ≥ 7/10 and interquartile range ≤ 2.5. Results Consensus was reached for key intrinsic factors (e.g., gait and balance impairments, visual and vestibular deficits, cognitive decline, polypharmacy) and environmental factors (e.g., irregular or inappropriate surfaces, obstacles, signage not adapted, crowding). Highly relevant preventive actions included integrating fall prevention into street and sidewalk design, training urban planning professionals, awareness campaigns, systematic maintenance, safer crossings, participatory co-design, and improved data monitoring. Main barriers were insufficient budgets, high costs, limited integration of fall prevention into planning priorities, and lack of evaluation. Conclusions Outdoor fall prevention is a transversal challenge requiring integration of public health and urban planning. This Delphi highlights actionable priorities to embed fall prevention in local and national strategies, in particular in rapidly aging regions. Falls older adults outdoor public spaces Delphi prevention urban planning Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 1. Introduction Falls are the leading cause of accidents in daily life among older adults. The consequences are severe, as falls can result in fractures, loss of independence, hospitalizations, and even death. Beyond the physical consequences, falls also have a profound psychological impact, as they can lead to a loss of confidence in one’s balance, resulting in social isolation and progressive withdrawal [ 1 , 2 ]. With approximately 30% of adults over 65 falling each year and associated healthcare costs exceeding 50 billion dollars in the United States alone [ 3 ], falls represent a major public health challenge, for which the overall impact of current strategies remains limited with fall rates not showing any sign of decline in Europe [ 4 ]. By 2030, one in six people will be over 60 years old, and this population will have doubled by 2050 [ 5 ] making this issue even more pressing. Nearly half of the falls take place outdoors, with about 75% of outdoor falls triggered by environmental factors [ 6 , 7 ], highlighting the crucial role of urban design. For older adults, moving around safely in public space is essential to maintaining social life, autonomy, an active lifestyle, preventing other health risks, accessing healthcare, shops, and public services [ 8 ]. Even though these falls present specificities (involving more active older adults and triggering more severe injuries [ 9 , 10 ]), they remain largely understudied compared to falls indoors [ 6 ]. This is partly due to outdoor environments being more variable, shared among multiple users, and dependent on a wide range of stakeholders: urban planners, local authorities, technical services, equipment designers, health professionals, and citizens themselves. Outdoor falls thus represent a “wicked problem,” at the intersection of multiple domains (health, urban planning, mobility, social policy), with no single stakeholder being exclusively responsible [ 11 ]. International tools and frameworks relating to age-friendly urban environments (such as the AFCCQ questionnaire or the WHO Age-Friendly Cities framework) address accessibility, participation, and mobility broadly, but integrate little to no focus on fall prevention [ 12 , 13 ]. In summary, outdoor falls can still be considered a neglected public health problem [ 6 ]. Very few scientific studies have so far systematically documented the risk factors for falls among older adults in outdoor public spaces, and they have simply relied on fallers’ recollections to identify types of fall risks [ 7 , 9 , 14 ]. This approach can be affected by recall bias and does not provide actionable solutions for fall prevention. Faced with this lack of consolidated data, the Delphi method appears particularly relevant. It is an iterative consensus-building approach among experts, conducted through several anonymous rounds where responses are aggregated, shared, and re-evaluated. This method is especially suited to contexts where knowledge is fragmented but where experiential knowledge, professional expertise, and field observations are diverse and complementary [ 15 – 18 ]. This is the case for fall risks in outdoor public spaces, making such type of studies valuable in generating shared knowledge and priorities from heterogeneous opinions (urban planners, health professionals, local authority representatives, researchers, older adults who have fallen). Moreover, using the Delphi method fits fully within a broader participatory approach: integrating stakeholders and engaging users as co-producers of knowledge, strengthens the legitimacy, relevance, and operational impact of the results. The challenge of preventing falls in outdoor public spaces is both local and global. Normandy, France, is a particularly critical setting, as it is experiencing one of the fastest growth rates of older adults in France [ 19 ]. This makes the region a prototype for demographic transition, where the interplay between rapid aging and diverse territorial structures can be studied in depth. Its urban fabric, comprising medium-sized towns, peri-urban areas, and historic centers, closely mirrors the traditional territorial configurations of many European regions. As such, studying falls in Normandy not only generates knowledge directly applicable to local public policies and stakeholder mobilization, but also provides transferrable insights for other regions navigating similar challenges of aging populations and urban adaptation. In this context, the objective of the present study is to document, using an interdisciplinary classic Delphi method, the intrinsic (person-related) and extrinsic (environment-related) risk factors for outdoor falls among older adults, as well as the preventive actions and barriers to their implementation in public spaces. This approach combines the expertise of urban planners, research and health professionals, local decision makers, and older adults who have themselves fallen in the outside environment, in order to identify a common core set of operational propositions. By bringing together a multidisciplinary stakeholder panel on this still under-researched topic, the study aims to fill a gap in the literature and provide concrete guidance for integrating fall prevention into urban planning and public health policies. 2. Methodology The Delphi method is a qualitative and prospective research method designed to find consensus among experts around a complex subject [ 15 ]. It is used in many fields when knowledge is still partial, fragmented, or dispersed among different stakeholders [ 15 ]. It relies on iterative, anonymous consultation of a panel of experts chosen for the complementarity of their experience and knowledge [ 18 ]. Contributions are then analyzed, synthesized, and redistributed to participants in successive predetermined cycles (usually three), enabling them to revise their views in light of the collective’s arguments [ 18 ]. The classic Delphi method used here is described below and followed current recommendations for health and social sciences [ 15 – 18 , 20 , 21 ]. The number of rounds was defined in advance to be a maximum of three rounds. The checklist associated with the reporting guidelines for Delphi studies in social and health sciences is provided as Supplementary Material 1 [ 17 ]. Participation was anonymous and voluntary. All questionnaire were integrated into an online LimeSurvey. The University of Caen Normandy Research Ethics Committee approved the study protocol (no. 2025030408142400000260000327). Participants The Delphi process relied on a panel of experts concerned in different ways with falls in outdoor public space. In order to retrain some homogeneity, the panelists were all from the Normandy region. The working group (WG) responsible for this study decided was built within a regional “Anti‑Fall Plan” and composed of various stakeholders with experiential or professional knowledge of how outdoor public spaces could contribute to fall in older adults: older users, urban‑planning professionals, physicians and researchers on aging and falls, local decision‑makers, and associations. The WG group was advised by experts from XXX regarding the methodology. They decided to target four categories: (1) older adults aged 65 + who had already fallen outdoors, providing experiential expertise; (2) scientific or technical experts and health professionals, with clinical or research expertise (geriatricians, emergency physicians, GPs, researchers in falls prevention.); (3) planning experts, with professional expertise in the design and management of public space (technical municipal services, urban planners, architects, etc.); and (4) decision‑makers with governance expertise (local authority representatives, elected officials). Names and emails were proposed by WG members and snowball recruitment was also used as recommended to improve Delphi sampling [ 21 ]. A total of 171 contacts were invited even if they had not responded previously. The target was to collect at least 60 responses in phase 1 and not drop below 47 in the final phase with at least 10 participants per expert group [ 18 ]. An invitation letter was emailed in early March, 2025 detailing objectives, confidentiality, schedule, and the survey link. Round 1 remained open for three weeks, with a reminder one week before closing. 2.1. Round 1 The first-round questionnaire was co‑designed within a regional “Anti‑Fall Plan” by the “Outdoor Public Space” WG composed of various stakeholders linked to older adults’ fall risk outdoors: older users, urban‑planning professionals, physicians and researchers on aging and falls, local decision‑makers, and associations. The objective of this first questionnaire was to collect information on risk factors in outdoor public spaces, on possible solutions to reduce these falls, and on potential barriers to these solutions. The WG’s initial meeting was held in March 2024, during which the method was presented, and the working group decided to organize thirteen open questions into three sections: causes of falls; actions to adapt public space; and barriers and facilitators to implementing prevention actions. Each question proposed by the members were then discussed and revised based on others’ feedback. Causes of falls were explored via five open questions related to intrinsic factors (person‑related), extrinsic factors (environment‑related) that could decrease or increase fall risk. Actions to prevent falls were explored by four open questions targeting modifications to physical layout, space management, and behaviors. Barriers and facilitators were explored by two open questions on difficulties in implementing proposed actions and on enablers. Two final open questions captured any information not covered earlier. The questionnaire is provided as Supplementary Material 2. In addition, in all the questionnaire (Round 1 to 3) participants were asked to selected their department and the size of their municipality (village/small town vs. medium/large city) and self‑rated their knowledge of the issue on a 1–5 scale (1 = no knowledge; 5 = perfect knowledge). The questionnaire was tested internally within the WG in September, 2024. A small group of two national experts per stakeholder category then piloted the questionnaire and their feedback led to wording adjustments to enhance accessibility and specification of risks. These experts were not involved thereafter. To ensure accessibility, the questionnaire was adapted to Easy‑to‑Read standards (FALC) in December 2024 by an independent group composed of older adults trained to the Easy-to-Read method. The group unanimously validated the final questionnaire prior to distribution. 2.2. Round 2 Open‑ended responses from the first round were analyzed to synthesize a limited set of propositions to be rated quantitatively in phase two. A mixed approach combining artificial intelligence and human validation was used. Pre‑processing with ChatGPT‑4 (OpenAI) allowed to identified ideas, common themes, and generated a set of propositions for the second round. Then a thorough human check of all responses made by every participant was done in order to ensure that all initial ideas were correctly represented. Starting from AI‑generated drafts, formulations were manually adjusted or reworded, new items created, and others removed or merged to cover all contributions. This approach aligns with recent practice on the use of AI to support qualitative analysis [ 22 – 24 ]. Round 2 allowed for open comments in order for the panelists to indicate if their initial propositions were not appropriately transferred in this round. Propositions were presented to WG members at the end of March 2025 and questions were revised collectively. For each item, perceived relevance was rated on a 10‑point Likert scale (1 = not at all important; 10 = extremely important) [ 16 ]. The survey was emailed in mid‑May and remained open for three weeks, with a reminder one week before closing. At the end of the second round, items were classified as: (a) consensual: at least 70% of participants rated an item ≥ 7 (≥ 70%≥7), and the interquartile range (IQR) was ≤ 2.5 resulting in items beeing selected and not re‑rated in the third round; (b) non‑consensual: 2.5 resulting in items being re‑rated in phase three in light of the results of the second round [ 18 , 20 ] with possible modification if the panelists suggested them in the open comment section. 2.3. Round 3 In addition to the non-consensual items from round 2 (presented to all participants with median scores and reason for not being selected directly in round 2) new items were introduced in phase three based on round‑two comments. The third questionnaire did not allow for open comments. It was emailed in the last week of June. Phase three remained open for three weeks, with a reminder one week before closing. 2.4. Final analysis and classification of selected items Levels of knowledge about falls (ordinal scale 1–5) were analyzed using an ordinal logistic regression (cumulative link model). The main predictor was expert group (Seniors, Urban planning, Health and science, Decision-makers), while survey phase was included as a covariate to control for potential variability across rounds. Post-hoc pairwise comparisons between groups were conducted using estimated marginal means with Bonferroni correction for multiple testing. Results were reported as odds ratios (ORs) with 95% confidence intervals (CI). For each selected item, either validated in the second round or sent to the third, the percentage of respondents scoring ≥ 7, the IQR, and the median were calculated for each group and overall. To allow prioritization, items were classified by median into four perceived‑relevance levels: Median < 7: low relevance; Median ≥ 7: moderate relevance; Median ≥ 8: high relevance; Median ≥ 9: very high relevance. Consensus was considered reached if at least 70% of responses were ≥ 7 and if the IQR was ≤ 2.5. Total consensus meant all groups met these thresholds, ; global consensus referred to the overall sample meeting them; partial consensus referred to only some expert groups meeting them. 3. Results The flow of participants and consensus outcomes across the three Delphi rounds is presented in Fig. 1 and Table 1 provides an overview of Delphi panel participation across the three rounds. Table 1 Overview of Delphi panel participation across rounds by expert group (some panelists could belong to several groups) Expert group Round 1 Round 2 Round 3 Older adults 19 13 13 Health & science 19 28 20 Urban planners 19 9 10 Decision-makers 16 13 13 Total 64 60 49 Insert Fig. 1 here Figure 1 : Flow of the three-round Delphi process, showing participant numbers and consensus outcomes. Insert Table 1 here 3.1. Round 1 A total of 117 propositions emerged after combining and refining with AI pre-analysis, research team analysis, and working group comments. The number of items generated in Phase 1 by each group and for each category is presented in Table 2 . Four main categories emerged : person-related factors, environmental factors, proposed actions, and barriers to change. Table 2 Number of items generated in Phase 1 by expert group and category Category Older adults Health & science Urban planners Decision-makers Person-related factors 61 124 75 46 Environmental factors 86 107 129 83 Proposed actions 37 78 82 51 Barriers to change 13 21 13 9 Total 197 330 299 189 Insert Table 2 here 3.2. Round 2 In phase two, consensus was reached for 47 of the 117 propositions. The remaining propositions were carried into phase three. Four items were reformulated following feedback. For example: the statement “Being a woman strongly influences outdoor fall risk” failed to reach consensus; it was reframed as “Sex has no effect on outdoor fall risk.” The statement “Personal fall‑risk factors outdoors are the same as at home” was reframed as “Personal fall‑risk factors outdoors are specific (and differ from those at home or in institutions).” The statement “Develop contextual signage to dynamically alert pedestrians to temporary hazards (e.g., ice, obstacles, construction)” became “Develop contextual signage, including targeted weather alerts for older adults, to prevent temporary hazards such as ice, obstacles, or construction.” Finally, the statement “Design features perceived as reserved for older people or stigmatizing (e.g., ‘senior’ pictograms) may hinder acceptance” was reframed as “Features perceived as reserved for older adults or stigmatizing (e.g., ‘senior’ pictograms) may hinder their use.” In line with participant suggestions, seven new items were also added in phase three. 3.3. Round 3 The final phase included 77 items. Final results are shown in Figs. 1–4, in addition to items that reached consensus in phase two. The analysis of the difference in expertise regarding the issue addressed by this study revealed a significant effect of group on self-reported knowledge levels (χ²(3) = 31.1, p < 0.001), while the effect of survey round was not significant (χ²(2) = 0.85, p = 0.65). Compared to other groups, participants in the Health and science group reported substantially higher expertise. Specifically, they had approximately eight times higher odds of reporting greater knowledge compared to participants in Urban planning (OR = 8.0, 95% CI [3.4–19.0], p < 0.001), 3.4 times higher odds compared to Seniors (OR = 3.4, 95% CI [1.5–8.1], p = 0.027), and 9.2 times higher odds compared to Decision-makers (OR = 9.2, 95% CI [3.7–22.9], p < 0.001). No other between-group differences were statistically significant. Insert Fig. 2 here Figure 2 : Self-reported expertise across Delphi rounds. Presented as median ± interquartile range (IQR) for each stakeholder group (older adults, urban planning, science & care, decision-makers). Intrinsic Factors Figure 3 presents the results for intrinsic factors. In Characteristics and general aspects , 1 item reached total consensus, 1 global consensus, 2 remained partial, and 1 did not reach any consensus in any group. In Physical, sensory, and motor capacities , 5 items obtained total consensus, 1 reached global consensus, and 2 remained partial. In Lifestyle, hygiene, and nutritional status , 2 items reached total consensus, 3 global, and 2 no-consensus. In Cognitive and psychological functioning , 2 items achieved total consensus and 5 global consensus. In Age-related pathologies , 5 items reached total consensus, and 1 did not reach consensus. Finally, in Personal equipment , 2 items obtained total consensus. Insert Fig. 3 here Figure 3 : Bubble heatmap of Delphi consensus across expert groups on intrinsic risk‑factor propositions for outdoor public spaces. Bubble fill color indicates relevance level, bubble size the interquartile range (IQR), and text the percentage of ratings ≥ 7. Red bubble outlines mark high dispersion (IQR > 2.5), and red text indicates lack of consensus (< 70% ≥7). * = item re-rated in round 3; ᵃ = item modified between rounds 2 and 3; ᵇ = item added in round 3. Extrinsic Factors Figure 4 presents the results for extrinsic factors. In Pavement quality and continuity of pathways , 5 items reached total consensus. In Obstacles on pedestrian areas , all 6 items reached total consensus. In Signage and visibility , 5 items reached total consensus, and 1 global consensus. In External conditions and environment , all 5 items reached total consensus. Finally, in Lack of amenities , 5 items reached total consensus and 1 partial consensus. Insert Fig. 4 here Figure 4 : Bubble heatmap of Delphi consensus across expert groups on extrinsic risk‑factor propositions for outdoor public spaces. Bubble fill color indicates relevance level, bubble size the interquartile range (IQR), and text the percentage of ratings ≥ 7. Red bubble outlines mark high dispersion (IQR > 2.5), and red text indicates lack of consensus (< 70% ≥7). * = item re-rated in round 3; ᵃ = item modified between rounds 2 and 3; ᵇ = item added in round 3. Preventive Actions Figure 5 presents the results for action propositions. In Public-space layout, maintenance, and accessibility , 5 items reached total consensus, 1 global consensus, and 2 partial consensus. In Norms, urban and health policies , 6 items achieved total consensus. In Awareness, enforcement, and information , 8 items reached total consensus and 1 global consensus. In Data, monitoring, and steering , 4 items reached total consensus and 1 global consensus. In Financial resources and economic levers , 2 items achieved total consensus and 1 partial consensus. In Individual approach and support for at-risk persons , 6 items reached total consensus. In Research, development, and innovation , 5 items achieved total consensus and 1 global consensus. Finally, in Co-design and public involvement , 6 items reached total consensus. Insert Fig. 5 here Figure 5 : Bubble heatmap of Delphi consensus across expert groups on propositions for preventive actions for falls in outdoor public spaces. Bubble fill color indicates relevance level, bubble size the interquartile range (IQR), and text the percentage of ratings ≥ 7. Red bubble outlines mark high dispersion (IQR > 2.5), and red text indicates lack of consensus (< 70% ≥7). * = item re-rated in round 3; ᵃ = item modified between rounds 2 and 3; ᵇ = item added in round 3. Barriers to Preventive Actions Figure 5 presents the results on barriers to preventive actions. In Financial and budgetary barriers , both items reached total consensus. In Technical, organizational, and steering constraints , 3 items achieved total consensus and 3 reached global consensus. In Social, cultural, and territorial barriers , 3 items reached total consensus, while 2 achieved global consensus. Insert Fig. 6 here Figure 6 : Bubble heatmap of Delphi consensus across expert groups on propositions for barriers to preventive actions. Bubble fill color indicates relevance level, bubble size the interquartile range (IQR), and text the percentage of ratings ≥ 7. Red bubble outlines mark high dispersion (IQR > 2.5), and red text indicates lack of consensus (< 70% ≥7). * = item re-rated in round 3; ᵃ = item modified between rounds 2 and 3; ᵇ = item added in round 3. 4. Discussion This Delphi study aimed to identify risk factors for outdoor falls among older adults, as well as the most relevant preventive actions and the barriers to their implementation. It addresses a context where scientific knowledge remains scarce and fragmented and where outdoor falls are [ 6 ]. The study relies on a rigorous three‑phase Delphi process, characterized by iterative rounds, anonymous expert ratings, controlled feedback, a predefined definition of consensus [ 17 , 18 ], and a multidisciplinary panel to build informed consensus useful for urban and public health strategies. Intrinsic Factors Final results show a strong consensus on intrinsic contributors of older adults to outdoor fall risks, with strong consensus on biomedical but also notable divergences on behavioral, psychosocial, and social factors. The strongest core consensus, rated highly or very highly concerned biomedical factors, including sensory, cognitive, motor, and musculoskeletal declines (gait and balance impairments; visual, vestibular, cognitive, and proprioceptive deficits; and reduced muscular function). These vulnerabilities, documented in the fall literature, form the biomedical core of risk and confirm that biomedical determinants may remain important to explain outdoor falls [ 25 – 27 ]. Pain, chronic disease, locomotor or osteoarticular disorders, as well as polypharmacy also show strong consensus, consistent with prior work [ 25 , 27 ]. Panelists also unanimously identified inadequate use of assistive devices and inappropriate footwear as major factors, highlighting behaviors and equipment often less emphasized in classic prevention strategies [ 28 ]. Some factors were judged relevant by certain groups but not by others. Obesity and thinness divided groups, possibly because they are often approached using BMI, which poorly reflects body composition [ 29 ]. Sex effects is a complicated topic. The initial statement that “being a woman strongly influences risk” was rejected in the second round, and the reformulated “no sex effect” failed to achieve consensus suggesting that panelists do not share a unified view. Epidemiological data often show a higher prevalence of falls among women [ 30 ], but this may reverse when focusing on outdoor falls [ 31 ]. Mobility behaviors, activities, and exposure to urban environments may differ between sexes and help explain these patterns [ 30 ] The relevance of psycho-behavioral factors could differ between groups. It is also noteworthy that older fallers did not perceive fear of falling as a risk factor, even though the literature describes it as both consequence and determinant of fall risk that can foster activity avoidance and alter gait [ 32 – 34 ]. Older adults may see fear as a cautious behavior intended to secure movement rather than increase vulnerability [ 35 ]. While sedentariness was supported by strong global consensus, it was down‑weighted by older adults. The role of physical activity appears complex, and could be both an indirect protective behavior and a direct risk factor, especially since outdoor fallers are often reported to be particularly active [ 36 ]. Of interest, social isolation and deprivation, frequently linked to physical‑activity and cognitive declines, were much less recognized by panelists, who tended to prioritize biomedical dimensions [ 37 ]. These divergences reflect different priorities (urban planners and decision‑makers focus on practical levers, health professionals on clinical vulnerabilities, older adults on lived experience). They call for policies that tailor messages for each group. They also highlight the specificity of outdoor environments, even though a key point concerned the absence of consensus on whether intrinsic factors are distinct between home and outdoors. The initial statement that “personal risk factors outdoors are the same as at home” failed to reach consensus in round two. The reformulated statement that “personal risk factors outdoors are specific” also failed to secure overall agreement in round three, although older adults were more favorable to specificity while scientific/health professionals expressed more caution, likely reflecting the current limits of evidence and calling for further research on the topic. In sum, strong consensus supports sensory, cognitive, motor, and musculoskeletal vulnerabilities, along with polypharmacy and inadequate assistive devices or footwear, as priority targets for outdoor fall prevention. Uncertainties remain regarding the specificity of the context (home vs. outdoor), sex, body composition, activity level, psychosocial vulnerabilities, fear of falling, and cognitive fatigue in outdoor travel. Mixed designs combining epidemiology, real‑world observation, and qualitative analyses are needed. Extrinsic Factors The study reveals broad consensus on most extrinsic factors with 25 out of 27 items reaching total consensus, underscoring the importance of physical obstacles, missing amenities, and the overall sensory environment as determinants of pedestrian safety. The strongest consensus was regarded physical and organizational obstacles that directly affect pedestrian safety: unsuitable, degraded, or irregular surfacing; level changes; risky detours around worksites; absence of sidewalks; debris; temporary or fixed obstacles; and vehicles parked or moving on sidewalks. Adverse weather conditions also stand out when poorly addressed. Another core of consensus concerns missing amenities that support continuous and secure travel (benches, shelters, ramps, continuous wide sidewalks) and signage that is absent or not adapted to older adults (with possible sensory decline). This shapes a set of risk factors that can be assessed in the environment to determine the risk of falls. The ambient sensory environment (visual overload, crowding, excessive noise) also mattered to the panelists, highlighting that prevention must go beyond physical layout to include overall urban quality and users’ capacity to process information. These priorities align with WHO “age‑friendly cities” recommendations. Strong consensus on safe, continuous pathways; public lighting; benches and ramps; and securing worksites and temporary obstacles fits the framework’s key dimensions [ 13 ]. However, while the WHO framework considers public‑space safety broadly, it does not address falls directly. Our study centers falls explicitly and highlights factors of specific relevance. Adding a specific “fall prevention” axis would increase the framework’s operational relevance for this public‑health challenge. Our results also overlap with walkability frameworks. Walkability typically addresses environments that support pedestrian movement and sometimes perceived comfort and safety, but it differs markedly from the topic of fall risks in older age, especially because many classic indices are not adapted to aging [ 38 ]. Even in older‑adult‑oriented studies, the focus is rather on physical activity, social participation, or daily mobility, and “falls” is absent despite their public‑health importance [ 38 ]. This study therefore complements existing frameworks by confirming shared criteria while enlarging evaluation to vulnerabilities specific to older fallers. Preventive Actions This present Delphi study support that effective prevention of outdoor falls should not solely focus on fixing sidewalks and physical environment, but is instead a multiaxial challenge. While walking surfaces and their quality are priorities often cited in participatory studies [ 39 – 41 ], the present study provides broader set of preventive actions. These can be organized into: regulation and governance, awareness and education, monitoring and technology, preventive action targeting intrinsic factors, and social and participatory involvement. A particularly strong consensus concerns embedding fall prevention within regulatory and policy frameworks, beyond clinical settings. Panelists called for dedicated funding via ambitious programs and explicitly integrating fall prevention into planning documents and local health programs. They advised for a better enforcement of existing accessibility norms, and a strengthening the pedestrian’s place relative to cars and bicycles, in line with broader shifts away from car‑centric mobility [ 42 , 43 ]. Awareness, training and information are also seen as highly relevant, with most related items reaching total consensus. Broad public campaigns on outdoor fall risk gained strong support, as did tailored awareness for at‑risk individuals to recognize vulnerabilities and adapt behaviors, in line with research showing the importance of self-efficacy in fall prevention [ 33 ]. A novel, strongly supported point is systematic training of urban‑planning professionals on fall prevention. At the interface of regulation and awareness, stronger controls and sanctions against cluttering sidewalks (with scooters, parking...) are supported, indicating that information alone is insufficient without enforcement. Promoting a culture of respect for vulnerable pedestrians was also consensual among panelists and promotes the need for cultural change in line with previous identified top priority for age friendly cities [ 44 ]. Practical measures such as systematic reporting of obstacles, encouraging users to remove minor obstructions, and priority seating for older adults in transit illustrate a balance between individual, collective, and institutional responsibility proposed by the panelists. Proposals for action involving technological innovations also occupy a notable place. The use of technologies is increasingly considered by experts as a possible solution to address some of the challenges associated with urban aging, but remains underexploited [ 45 ]. Experts propose citizen‑reporting apps to alert municipalities about hazards. Existing initiatives seldom target fall risk specifically and are not widely deployed [ 46 ]. Using urban sensors to detect conditions (degradation, weather, crowding) and deploying adaptive public lighting were also proposed. While older adults are often thought to be wary of technology in relationship with personal, technical and contextual factors [ 47 ] participants in our study, especially older adults, were among the most favorable to such solutions. Strong consensus also supported better structuring of data production and use in relationship with fall prevention. A national observatory to catalog, analyze, and disseminate effective interventions demonstrate the need for evidence‑based steering. Identifying hotspots of emergency responses to falls and maintaining updated risk‑zone databases can also help locate where to act first. This aligns with calls to strengthen data governance in public health and urbanism and with the international trend toward using spatial data to target urban vulnerability [ 48 , 49 ]. Participants also strongly recommended supporting research on environmental contributors to falls. Panelists agreed on the need for individualized, coordinated care for mobility and balance disorders, integrating medical, social, and environmental dimensions. Proposed innovative actions with broad support include enabling at‑risk persons to reappropriate public space (guided walks, training for transit use…), which can reduce anxiety and foster autonomous mobility [ 50 – 52 ]. Social participation and access to group activities, also consensual among panelists, can also reduce isolation and support mental health [ 53 , 54 ] and may indirectly contribute to fall prevention. However, their effectiveness warrants further study. Access to targeted physical activity programs (balance, strength) is rated as highly pertinent and is among the best‑established primary and secondary prevention domains [ 55 ]. Finally, experts emphasize better consideration of cognitive and medication factors, including optimized prescriptions to limit side effects and interactions, in line with guidance on fall‑risk‑increasing drugs [ 56 ]. Finally, a very strong consensus supports embedding fall prevention within co‑construction approaches. Essential dimensions include linking researchers and health professionals with policy‑makers for public‑space decisions, co‑constructing projects with users (especially those at risk), and organizing continuous consultation with residents. This aligns with international movements in citizen science and participatory urbanism, which improve intervention fit to real needs [ 57 ]. Involving diverse publics (older adults, urban planners, local decision‑makers) can be especially effective for promoting environments that support physical activity and social interaction [ 58 ]. Because the present results emerged from a structured, participatory process involving multidisciplinary experts and users, they can be considered particularly legitimate. They illustrate that falls, too often framed as a clinical issue, are a collective challenge requiring novel alliances among public health, urban planning, and civil society [ 59 ]. Panelists also stress the role of local actors of proximity (shops, landlords, municipalities), whose involvement can shift practices toward safer environments for older pedestrians. Training and supporting older adults to participate actively in consultation processes recognizes them not only as beneficiaries but as experts in using public space, consistent with empowerment approaches [ 60 ]. The strong consensus behind these actions is decisive for deployment as initiatives supported across users, professionals, and decision‑makers are better implemented and accepted [ 61 ]. Barriers to Preventive Actions The Delphi results highlight that the relevance of barriers to preventive actions may differ among expert groups, with strong consensus on financial obstacles but more divergence on technical, organizational, and social dimensions. Financial barriers were the most consensual. High costs of design and maintenance and insufficient dedicated public funding were unanimously identified as major obstacles. This convergence reflects a well‑documented reality: adapting urban environments to older populations’ needs is often seen as secondary to other municipal priorities [ 62 – 64 ]. Our results argue for embedding aging needs in urban planning and for stable resources, as promoted in age‑friendly city programs. Technical and organizational constraints were less consensual. The lack of systematic impact evaluation is a key barrier with consensus, echoing prior work showing that many age‑friendly initiatives lack rigorous evaluation, leaving a fragmented evidence base [ 45 ]. Without strong data on effects, sustaining investment is difficult, even when interventions seem promising [ 65 ]. Stakeholders themselves emphasize the need for standardized frameworks and tools to evaluate and compare interventions [ 66 ]. Developing shared instruments and continuous validation cycles appears critical to strengthen legitimacy and facilitate integration into policy [ 67 ]. In the specific context of outdoor falls, although fall risk is sometimes cited as something to assess, there are no specific environmental evaluation tools [ 68 ]. Evaluations could rely on this Delphi’s results and combine quantitative indicators (fall and hospitalization rates), qualitative indicators (sense of safety, avoidance behaviors), environmental indicators (maintenance, lighting, signage), and governance indicators (budgets, citizen‑reporting mechanisms). While participants agreed on the technical complexity of adapting constrained spaces and on long timelines, other aspects are debated. Methodological and organizational hurdles to participatory processes did not reach total consensus. Urban planners may be more familiar with participatory devices (workshops, public inquiries, mandated consultations) than other participants assume, and thus view these as part of routine practice rather than major barriers (in comparison with more structural barriers like financial constraints [ 66 ], whereas others may perceive them as significant obstacles to co‑construction. Panelists broadly agree that territorial (e.g., center vs. periphery) and socioeconomic inequalities between neighborhoods is a barrier to effective prevention. These disparities may reflect unequal distribution of amenities conducive to “aging well” [ 69 ]. Evidence directly linking such inequalities to fall risk is limited, though more favorable neighborhood environments for leisure physical activity may reduce falls among older adults [ 70 ]. Lack of citizen mobilization and public interest was also reported as a pertinent barrier, possibly reflecting limited public awareness of the issue, recognized as a key challenge for implementing age‑friendly environments [ 62 ]. By contrast, the impact of negative social opinion of aging is disputed: older adults often identify ageism as a barrier to active aging, whereas other actors may down‑weight it [ 71 ]. The fact that elected officials and urban planners did not rate this barrier as a priority could reflect lower perceived importance or overestimation by older adults. Recommendations Based on these results and the literature, several recommendations can guide public policies and practices for preventing outdoor falls (Fig. 7). Falls should no longer be considered only a clinical problem; they are a transversal issue of public health and urban planning. Municipalities should explicitly embed fall prevention in urban, mobility, and health plans with stable dedicated funding [ 13 , 62 ]. Strong consensus highlights basic pedestrian safety dimensions as immediate, widely shared levers to reduce fall risk. Investing in systematic maintenance protocols, rapid repairs, and securing risk zones should become standard practice. Multidisciplinary actions (systematic inclusion of fall prevention in planning documents, targeted training for planners and technical agents, and monitoring tools such as observatories and participatory reporting) should also be prioritized. Insert Fig. 7 here Figure 7 : Intrinsic, extrinsic, and governance-related factors identified in the Delphi study on falls in outdoor public spaces and their associated possible preventive actions (red = intrinsic factors, yellow = extrinsic/environmental factors, blue = governance and societal factors; darker boxes indicate identified risks or issues, lighter boxes indicate the associated preventive actions). The results support that prevention requires shared governance mobilizing researchers, professionals, decision‑makers, associations, and citizens. Consultations should be regular, inclusive, and adapted (Easy‑to‑Read, digital tools, exploratory walks), giving older adults their place as expert users while also engaging other citizens so the issue becomes collective [ 57 , 58 ]. Public awareness campaigns should reinforce recognition of falls as a shared concern, not one reserved to older people. Involving local proximity actors (shopkeepers, landlords, associations) could help diffuse a common culture of safety [ 59 ]. Prevention must prioritize peripheral and disadvantaged neighborhoods, where infrastructure is often less developed and risks are increased by social and spatial conditions. A major barrier, beyond funding, is the lack of systematic evaluation. It is crucial to develop standardized instruments specific to outdoor fall risk, combining quantitative indicators (falls, hospitalizations), qualitative indicators (risk perception, sense of safety), environmental indicators (maintenance, lighting, signage), and governance indicators (budgets, participatory mechanisms). Such tools would enable comparisons, objectify progress, and strengthen legitimacy of investments [ 66 , 67 ]. Pilot projects deploying innovative solutions (connected technologies, intelligent signage, participatory platforms) should be encouraged, with attention to accessibility for older users. Strength, limitations and perspectives Beyond the under‑studied topic of outdoor falls, a key originality of the study is the multidisciplinary panel including: older adults who have already fallen outdoors, scientific experts and health professionals, urban planners, and decision‑makers. Delphi studies relatively rarely include populations directly affected (27% according to Schifano & Niederberger, 2025). Their inclusion here allows to benefits from their lived experience as expertise while ensuring knowledge sharing from technical, scientific, and policy views. This diversity yielded complementary and sometimes contrasting results, enabling shared priorities to emerge while identifying areas of divergence. The methodology followed recent recommendations [ 18 ], maintained a retention rate consistent with standards (− 18.3% from first to last phase), and applied strict consensus criteria (≥ 70% ratings ≥ 7/10 and IQR ≤ 2.5). The combined use of an initial AI‑assisted synthesis with systematic human validation for the open qualitative responses in round one is innovative and aligns with guidance on limiting bias [ 22 , 23 ]. Adapting the questionnaire to Easy‑to‑Read standards broadened inclusion of older profiles, including those less familiar with research, enhancing panel representativeness. This study has several limitations. First, it was conducted in Normandy, France, and although the region is demographically and urbanistically representative of many European regions undergoing advanced demographic transition, priorities and perceptions may vary in other contexts, such as very dense urban areas or countries with different infrastructures and policies. Replication elsewhere is needed to test transferability. Choosing a very broad geographical area (multiple countries) could have led to a consensus emerging only on very general aspects, more widely applicable but less insightful. Second, panel recruitment was voluntary, which may introduce selection bias toward more sensitized stakeholders. Complementary population surveys or random panels could enhance representativeness. Third, as with any Delphi, results reflect perceptions and expertise rather than objective measurement, and they have not yet been matched to field data (epidemiological, sensor‑based, in situ observation). Developing standardized evaluation tools that combine quantitative, qualitative, environmental, and governance indicators would strengthen external validity. Fourth, consensus methods inherently produce compromises. Technical details (e.g., precise surfacing specifications) or very personal issues (e.g., anxiety after a fall) may have been diluted in the final ranking even if recognized as important in the literature. In‑depth qualitative interviews, exploratory walks, and in situ observations could identify latent needs or “blind spots,” refining understanding of still understudied dimensions (e.g., sensory overload, cognitive fatigue, combined environmental conditions). Finally, pilot tests with longitudinal evaluation are needed to test effectiveness and reproducibility across contexts. Embedding these priorities in local public‑health and urban‑planning policies, with shared governance and stronger citizen mobilization, could be decisive in sustainably reducing outdoor fall risk. 5. Conclusions Fall-prevention guidelines mainly address clinical aspects of fall prevention without addressing risks in outdoor public spaces, while age-friendly frameworks promote accessibility without considering falls. Outdoor fall prevention thus remains neglected, and this Delphi study helps fill that gap by documenting risks, actions, and barriers in public spaces, and by showing that effective strategies require bridging clinical and environmental perspectives through shared governance. Building prevention as a transversal issue across health and urban planning is key to safer and more inclusive environments for older adults. Declarations Ethics approval and consent to participate : The University of Caen Normandy Research Ethics Committee approved the study protocol (no. 2025030408142400000260000327). Informed consent was collected at each step of the study, for each questionnaire. All procedures were conducted in accordance with the principles of the Declaration of Helsinki. Consent for publication : NA Availability of data and materials : The data that support the findings of this study are available from the corresponding author upon reasonable request. Competing interests : The authors declare that they have no competing interests Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Authors' contributions : AL, BW, ML and MT contributed to the conceptualization of the study. AL and BW developed the methodology. BW performed the validation. AL conducted the formal analysis, the investigation and the data curation. AL prepared the original draft. All authors contributed to the writing, review and editing of the manuscript. AL created the visualizations. AL and BW supervised the work. AL and ML handled project administration. Acknowledgements : The authors would like to thank all the older adults and professionals who participated in this Delphi study and generously shared their experiences and expertise. We also acknowledge the support of the regional working group Plan antichute – espace extérieur coordinated by the Gérontopôle de Normandie and the Agence Régionale de Santé (ARS) Normandie. The contribution of the Grenelle du Handicap of the city of Évreux in adapting the questionnaire to Facile à Lire et à Comprendre (FALC) standards is gratefully acknowledged. References Salari N, Darvishi N, Ahmadipanah M, Shohaimi S, Mohammadi M. Global prevalence of falls in the older adults: a comprehensive systematic review and meta-analysis. 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Presented as median ± interquartile range (IQR) for each stakeholder group (older adults, urban planning, science \u0026amp; care, decision-makers).\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8114657/v1/178b19762817e3b04dd7e8c5.jpg"},{"id":96915878,"identity":"1c67660a-655e-43c7-bdc8-1772668e604c","added_by":"auto","created_at":"2025-11-27 14:07:43","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1006396,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eBubble heatmap of Delphi consensus across expert groups on intrinsic risk‑factor propositions for outdoor public spaces. Bubble fill color indicates relevance level, bubble size the interquartile range (IQR), and text the percentage of ratings ≥7. Red bubble outlines mark high dispersion (IQR \u0026gt;2.5), and red text indicates lack of consensus (\u0026lt;70% ≥7). * = item re-rated in round 3; ᵃ = item modified between rounds 2 and 3; ᵇ = item added in round 3.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8114657/v1/3241d937783ae44109b1cc6b.jpg"},{"id":96916956,"identity":"09353fe1-3758-4632-ab0e-08c1e6a6f9b3","added_by":"auto","created_at":"2025-11-27 14:09:05","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":988061,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eBubble heatmap of Delphi consensus across expert groups on extrinsic risk‑factor propositions for outdoor public spaces. Bubble fill color indicates relevance level, bubble size the interquartile range (IQR), and text the percentage of ratings ≥7. Red bubble outlines mark high dispersion (IQR \u0026gt;2.5), and red text indicates lack of consensus (\u0026lt;70% ≥7). * = item re-rated in round 3; ᵃ = item modified between rounds 2 and 3; ᵇ = item added in round 3.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Figure4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8114657/v1/5086911cbfaf55a55514ce56.jpg"},{"id":96917547,"identity":"8f0093a5-0f9b-4b80-aa7d-8bf909871c01","added_by":"auto","created_at":"2025-11-27 14:10:03","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":2281576,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eBubble heatmap of Delphi consensus across expert groups on propositions for preventive actions for falls in outdoor public spaces. Bubble fill color indicates relevance level, bubble size the interquartile range (IQR), and text the percentage of ratings ≥7. Red bubble outlines mark high dispersion (IQR \u0026gt;2.5), and red text indicates lack of consensus (\u0026lt;70% ≥7). * = item re-rated in round 3; ᵃ = item modified between rounds 2 and 3; ᵇ = item added in round 3.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Figure5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8114657/v1/1fe2f6f1b938b8a6175a683e.jpg"},{"id":96806346,"identity":"f26d512c-00ce-40d5-89dd-00b8d60e8add","added_by":"auto","created_at":"2025-11-26 09:16:52","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":581260,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eBubble heatmap of Delphi consensus across expert groups on propositions for barriers to preventive actions. Bubble fill color indicates relevance level, bubble size the interquartile range (IQR), and text the percentage of ratings ≥7. Red bubble outlines mark high dispersion (IQR \u0026gt;2.5), and red text indicates lack of consensus (\u0026lt;70% ≥7). * = item re-rated in round 3; ᵃ = item modified between rounds 2 and 3; ᵇ = item added in round 3.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Figure6.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8114657/v1/6b0de1a577b3e47c5913a833.jpg"},{"id":96918519,"identity":"7e6d2ecd-7df7-40fd-a9eb-892d9548d382","added_by":"auto","created_at":"2025-11-27 14:12:04","extension":"jpg","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":133325,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eIntrinsic, extrinsic, and governance-related factors identified in the Delphi study on falls in outdoor public spaces and their associated possible preventive actions (red = intrinsic factors, yellow = extrinsic/environmental factors, blue = governance and societal factors; darker boxes indicate identified risks or issues, lighter boxes indicate the associated preventive actions).\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Figure7.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8114657/v1/64df6a4f219d142759fc1088.jpg"},{"id":108809489,"identity":"bb7ffb32-23de-4b9f-a282-355d44890a7c","added_by":"auto","created_at":"2026-05-08 15:53:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5417099,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8114657/v1/031740e6-db02-4fa3-addd-329d4c533cf3.pdf"},{"id":96806338,"identity":"36df49ac-5293-42a0-8cb4-4e6084f8d3f5","added_by":"auto","created_at":"2025-11-26 09:16:52","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":338185,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterial1.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8114657/v1/77888e68ad8617958d1388c3.pdf"},{"id":96806340,"identity":"874b284a-6db3-43a8-9e47-b006b1a063ba","added_by":"auto","created_at":"2025-11-26 09:16:52","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":223116,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterial2.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8114657/v1/0e3d3a904e4ba15014df0bc5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Falls prevention in Outdoor Public Spaces: An Interdisciplinary Delphi Consensus on Risks, Actions, and Barriers","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eFalls are the leading cause of accidents in daily life among older adults. The consequences are severe, as falls can result in fractures, loss of independence, hospitalizations, and even death. Beyond the physical consequences, falls also have a profound psychological impact, as they can lead to a loss of confidence in one\u0026rsquo;s balance, resulting in social isolation and progressive withdrawal [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. With approximately 30% of adults over 65 falling each year and associated healthcare costs exceeding 50\u0026nbsp;billion dollars in the United States alone [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], falls represent a major public health challenge, for which the overall impact of current strategies remains limited with fall rates not showing any sign of decline in Europe [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. By 2030, one in six people will be over 60 years old, and this population will have doubled by 2050 [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] making this issue even more pressing.\u003c/p\u003e\u003cp\u003eNearly half of the falls take place outdoors, with about 75% of outdoor falls triggered by environmental factors [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], highlighting the crucial role of urban design. For older adults, moving around safely in public space is essential to maintaining social life, autonomy, an active lifestyle, preventing other health risks, accessing healthcare, shops, and public services [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Even though these falls present specificities (involving more active older adults and triggering more severe injuries [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]), they remain largely understudied compared to falls indoors [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. This is partly due to outdoor environments being more variable, shared among multiple users, and dependent on a wide range of stakeholders: urban planners, local authorities, technical services, equipment designers, health professionals, and citizens themselves. Outdoor falls thus represent a \u0026ldquo;wicked problem,\u0026rdquo; at the intersection of multiple domains (health, urban planning, mobility, social policy), with no single stakeholder being exclusively responsible [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. International tools and frameworks relating to age-friendly urban environments (such as the AFCCQ questionnaire or the WHO Age-Friendly Cities framework) address accessibility, participation, and mobility broadly, but integrate little to no focus on fall prevention [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In summary, outdoor falls can still be considered a neglected public health problem [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eVery few scientific studies have so far systematically documented the risk factors for falls among older adults in outdoor public spaces, and they have simply relied on fallers\u0026rsquo; recollections to identify types of fall risks [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. This approach can be affected by recall bias and does not provide actionable solutions for fall prevention. Faced with this lack of consolidated data, the Delphi method appears particularly relevant. It is an iterative consensus-building approach among experts, conducted through several anonymous rounds where responses are aggregated, shared, and re-evaluated. This method is especially suited to contexts where knowledge is fragmented but where experiential knowledge, professional expertise, and field observations are diverse and complementary [\u003cspan additionalcitationids=\"CR16 CR17\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. This is the case for fall risks in outdoor public spaces, making such type of studies valuable in generating shared knowledge and priorities from heterogeneous opinions (urban planners, health professionals, local authority representatives, researchers, older adults who have fallen). Moreover, using the Delphi method fits fully within a broader participatory approach: integrating stakeholders and engaging users as co-producers of knowledge, strengthens the legitimacy, relevance, and operational impact of the results.\u003c/p\u003e\u003cp\u003eThe challenge of preventing falls in outdoor public spaces is both local and global. Normandy, France, is a particularly critical setting, as it is experiencing one of the fastest growth rates of older adults in France [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. This makes the region a prototype for demographic transition, where the interplay between rapid aging and diverse territorial structures can be studied in depth. Its urban fabric, comprising medium-sized towns, peri-urban areas, and historic centers, closely mirrors the traditional territorial configurations of many European regions. As such, studying falls in Normandy not only generates knowledge directly applicable to local public policies and stakeholder mobilization, but also provides transferrable insights for other regions navigating similar challenges of aging populations and urban adaptation.\u003c/p\u003e\u003cp\u003eIn this context, the objective of the present study is to document, using an interdisciplinary classic Delphi method, the intrinsic (person-related) and extrinsic (environment-related) risk factors for outdoor falls among older adults, as well as the preventive actions and barriers to their implementation in public spaces. This approach combines the expertise of urban planners, research and health professionals, local decision makers, and older adults who have themselves fallen in the outside environment, in order to identify a common core set of operational propositions. By bringing together a multidisciplinary stakeholder panel on this still under-researched topic, the study aims to fill a gap in the literature and provide concrete guidance for integrating fall prevention into urban planning and public health policies.\u003c/p\u003e"},{"header":"2. Methodology","content":"\u003cp\u003eThe Delphi method is a qualitative and prospective research method designed to find consensus among experts around a complex subject [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. It is used in many fields when knowledge is still partial, fragmented, or dispersed among different stakeholders [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. It relies on iterative, anonymous consultation of a panel of experts chosen for the complementarity of their experience and knowledge [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Contributions are then analyzed, synthesized, and redistributed to participants in successive predetermined cycles (usually three), enabling them to revise their views in light of the collective\u0026rsquo;s arguments [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The classic Delphi method used here is described below and followed current recommendations for health and social sciences [\u003cspan additionalcitationids=\"CR16 CR17\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The number of rounds was defined in advance to be a maximum of three rounds. The checklist associated with the reporting guidelines for Delphi studies in social and health sciences is provided as Supplementary Material 1 [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Participation was anonymous and voluntary. All questionnaire were integrated into an online LimeSurvey. The University of Caen Normandy Research Ethics Committee approved the study protocol (no. 2025030408142400000260000327).\u003c/p\u003e\u003cp\u003e\u003cb\u003eParticipants\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe Delphi process relied on a panel of experts concerned in different ways with falls in outdoor public space. In order to retrain some homogeneity, the panelists were all from the Normandy region. The working group (WG) responsible for this study decided was built within a regional \u0026ldquo;Anti‑Fall Plan\u0026rdquo; and composed of various stakeholders with experiential or professional knowledge of how outdoor public spaces could contribute to fall in older adults: older users, urban‑planning professionals, physicians and researchers on aging and falls, local decision‑makers, and associations. The WG group was advised by experts from XXX regarding the methodology. They decided to target four categories: (1) older adults aged 65\u0026thinsp;+\u0026thinsp;who had already fallen outdoors, providing experiential expertise; (2) scientific or technical experts and health professionals, with clinical or research expertise (geriatricians, emergency physicians, GPs, researchers in falls prevention.); (3) planning experts, with professional expertise in the design and management of public space (technical municipal services, urban planners, architects, etc.); and (4) decision‑makers with governance expertise (local authority representatives, elected officials). Names and emails were proposed by WG members and snowball recruitment was also used as recommended to improve Delphi sampling [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. A total of 171 contacts were invited even if they had not responded previously. The target was to collect at least 60 responses in phase 1 and not drop below 47 in the final phase with at least 10 participants per expert group [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAn invitation letter was emailed in early March, 2025 detailing objectives, confidentiality, schedule, and the survey link. Round 1 remained open for three weeks, with a reminder one week before closing.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1. Round 1\u003c/h2\u003e\u003cp\u003eThe first-round questionnaire was co‑designed within a regional \u0026ldquo;Anti‑Fall Plan\u0026rdquo; by the \u0026ldquo;Outdoor Public Space\u0026rdquo; WG composed of various stakeholders linked to older adults\u0026rsquo; fall risk outdoors: older users, urban‑planning professionals, physicians and researchers on aging and falls, local decision‑makers, and associations. The objective of this first questionnaire was to collect information on risk factors in outdoor public spaces, on possible solutions to reduce these falls, and on potential barriers to these solutions. The WG\u0026rsquo;s initial meeting was held in March 2024, during which the method was presented, and the working group decided to organize thirteen open questions into three sections: causes of falls; actions to adapt public space; and barriers and facilitators to implementing prevention actions. Each question proposed by the members were then discussed and revised based on others\u0026rsquo; feedback. Causes of falls were explored via five open questions related to intrinsic factors (person‑related), extrinsic factors (environment‑related) that could decrease or increase fall risk. Actions to prevent falls were explored by four open questions targeting modifications to physical layout, space management, and behaviors. Barriers and facilitators were explored by two open questions on difficulties in implementing proposed actions and on enablers. Two final open questions captured any information not covered earlier. The questionnaire is provided as Supplementary Material 2.\u003c/p\u003e\u003cp\u003eIn addition, in all the questionnaire (Round 1 to 3) participants were asked to selected their department and the size of their municipality (village/small town vs. medium/large city) and self‑rated their knowledge of the issue on a 1\u0026ndash;5 scale (1\u0026thinsp;=\u0026thinsp;no knowledge; 5\u0026thinsp;=\u0026thinsp;perfect knowledge). The questionnaire was tested internally within the WG in September, 2024. A small group of two national experts per stakeholder category then piloted the questionnaire and their feedback led to wording adjustments to enhance accessibility and specification of risks. These experts were not involved thereafter. To ensure accessibility, the questionnaire was adapted to Easy‑to‑Read standards (FALC) in December 2024 by an independent group composed of older adults trained to the Easy-to-Read method. The group unanimously validated the final questionnaire prior to distribution.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2. Round 2\u003c/h2\u003e\u003cp\u003eOpen‑ended responses from the first round were analyzed to synthesize a limited set of propositions to be rated quantitatively in phase two. A mixed approach combining artificial intelligence and human validation was used. Pre‑processing with ChatGPT‑4 (OpenAI) allowed to identified ideas, common themes, and generated a set of propositions for the second round. Then a thorough human check of all responses made by every participant was done in order to ensure that all initial ideas were correctly represented. Starting from AI‑generated drafts, formulations were manually adjusted or reworded, new items created, and others removed or merged to cover all contributions. This approach aligns with recent practice on the use of AI to support qualitative analysis [\u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Round 2 allowed for open comments in order for the panelists to indicate if their initial propositions were not appropriately transferred in this round. Propositions were presented to WG members at the end of March 2025 and questions were revised collectively. For each item, perceived relevance was rated on a 10‑point Likert scale (1\u0026thinsp;=\u0026thinsp;not at all important; 10\u0026thinsp;=\u0026thinsp;extremely important) [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The survey was emailed in mid‑May and remained open for three weeks, with a reminder one week before closing.\u003c/p\u003e\u003cp\u003eAt the end of the second round, items were classified as: (a) consensual: at least 70% of participants rated an item\u0026thinsp;\u0026ge;\u0026thinsp;7 (\u0026ge;\u0026thinsp;70%\u0026ge;7), and the interquartile range (IQR) was \u0026le;\u0026thinsp;2.5 resulting in items beeing selected and not re‑rated in the third round; (b) non‑consensual: \u0026lt;70% \u0026ge;7 and/or IQR\u0026thinsp;\u0026gt;\u0026thinsp;2.5 resulting in items being re‑rated in phase three in light of the results of the second round [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] with possible modification if the panelists suggested them in the open comment section.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.3. Round 3\u003c/h2\u003e\u003cp\u003eIn addition to the non-consensual items from round 2 (presented to all participants with median scores and reason for not being selected directly in round 2) new items were introduced in phase three based on round‑two comments. The third questionnaire did not allow for open comments. It was emailed in the last week of June. Phase three remained open for three weeks, with a reminder one week before closing.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.4. Final analysis and classification of selected items\u003c/h2\u003e\u003cp\u003eLevels of knowledge about falls (ordinal scale 1\u0026ndash;5) were analyzed using an ordinal logistic regression (cumulative link model). The main predictor was expert group (Seniors, Urban planning, Health and science, Decision-makers), while survey phase was included as a covariate to control for potential variability across rounds. Post-hoc pairwise comparisons between groups were conducted using estimated marginal means with Bonferroni correction for multiple testing. Results were reported as odds ratios (ORs) with 95% confidence intervals (CI).\u003c/p\u003e\u003cp\u003eFor each selected item, either validated in the second round or sent to the third, the percentage of respondents scoring\u0026thinsp;\u0026ge;\u0026thinsp;7, the IQR, and the median were calculated for each group and overall. To allow prioritization, items were classified by median into four perceived‑relevance levels: Median\u0026thinsp;\u0026lt;\u0026thinsp;7: low relevance; Median\u0026thinsp;\u0026ge;\u0026thinsp;7: moderate relevance; Median\u0026thinsp;\u0026ge;\u0026thinsp;8: high relevance; Median\u0026thinsp;\u0026ge;\u0026thinsp;9: very high relevance. Consensus was considered reached if at least 70% of responses were \u0026ge;\u0026thinsp;7 and if the IQR was \u0026le;\u0026thinsp;2.5. Total consensus meant all groups met these thresholds, ; global consensus referred to the overall sample meeting them; partial consensus referred to only some expert groups meeting them.\u003c/p\u003e\u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eThe flow of participants and consensus outcomes across the three Delphi rounds is presented in Fig.\u0026nbsp;1 and Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e provides an overview of Delphi panel participation across the three rounds.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003eOverview of Delphi panel participation across rounds by expert group\u003c/b\u003e (some panelists could belong to several groups)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eExpert group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRound 1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRound 2\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRound 3\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOlder adults\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealth \u0026amp; science\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUrban planners\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDecision-makers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e64\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e60\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e49\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eInsert Fig.\u0026nbsp;1 here\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eFigure 1 : Flow of the three-round Delphi process, showing participant numbers and consensus outcomes.\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eInsert\u003c/b\u003e Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e \u003cb\u003ehere\u003c/b\u003e\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e3.1. Round 1\u003c/h2\u003e\u003cp\u003eA total of 117 propositions emerged after combining and refining with AI pre-analysis, research team analysis, and working group comments. The number of items generated in Phase 1 by each group and for each category is presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Four main categories emerged : person-related factors, environmental factors, proposed actions, and barriers to change.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eNumber of items generated in Phase 1 by expert group and category\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOlder\u003c/p\u003e\u003cp\u003eadults\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHealth \u0026amp; science\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eUrban planners\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eDecision-makers\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePerson-related factors\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e124\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e46\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEnvironmental factors\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e107\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e129\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e83\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProposed actions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e51\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBarriers to change\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e197\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e330\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e299\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e189\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eInsert\u003c/b\u003e Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e \u003cb\u003ehere\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003e3.2. Round 2\u003c/h2\u003e\u003cp\u003eIn phase two, consensus was reached for 47 of the 117 propositions. The remaining propositions were carried into phase three. Four items were reformulated following feedback. For example: the statement \u0026ldquo;Being a woman strongly influences outdoor fall risk\u0026rdquo; failed to reach consensus; it was reframed as \u0026ldquo;Sex has no effect on outdoor fall risk.\u0026rdquo; The statement \u0026ldquo;Personal fall‑risk factors outdoors are the same as at home\u0026rdquo; was reframed as \u0026ldquo;Personal fall‑risk factors outdoors are specific (and differ from those at home or in institutions).\u0026rdquo; The statement \u0026ldquo;Develop contextual signage to dynamically alert pedestrians to temporary hazards (e.g., ice, obstacles, construction)\u0026rdquo; became \u0026ldquo;Develop contextual signage, including targeted weather alerts for older adults, to prevent temporary hazards such as ice, obstacles, or construction.\u0026rdquo; Finally, the statement \u0026ldquo;Design features perceived as reserved for older people or stigmatizing (e.g., \u0026lsquo;senior\u0026rsquo; pictograms) may hinder acceptance\u0026rdquo; was reframed as \u0026ldquo;Features perceived as reserved for older adults or stigmatizing (e.g., \u0026lsquo;senior\u0026rsquo; pictograms) may hinder their use.\u0026rdquo; In line with participant suggestions, seven new items were also added in phase three.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003e3.3. Round 3\u003c/h2\u003e\u003cp\u003eThe final phase included 77 items. Final results are shown in Figs.\u0026nbsp;1\u0026ndash;4, in addition to items that reached consensus in phase two.\u003c/p\u003e\u003cp\u003eThe analysis of the difference in expertise regarding the issue addressed by this study revealed a significant effect of group on self-reported knowledge levels (χ\u0026sup2;(3)\u0026thinsp;=\u0026thinsp;31.1, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), while the effect of survey round was not significant (χ\u0026sup2;(2)\u0026thinsp;=\u0026thinsp;0.85, p\u0026thinsp;=\u0026thinsp;0.65). Compared to other groups, participants in the Health and science group reported substantially higher expertise. Specifically, they had approximately eight times higher odds of reporting greater knowledge compared to participants in Urban planning (OR\u0026thinsp;=\u0026thinsp;8.0, 95% CI [3.4\u0026ndash;19.0], p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), 3.4 times higher odds compared to Seniors (OR\u0026thinsp;=\u0026thinsp;3.4, 95% CI [1.5\u0026ndash;8.1], p\u0026thinsp;=\u0026thinsp;0.027), and 9.2 times higher odds compared to Decision-makers (OR\u0026thinsp;=\u0026thinsp;9.2, 95% CI [3.7\u0026ndash;22.9], p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). No other between-group differences were statistically significant.\u003c/p\u003e\u003cp\u003e\u003cb\u003eInsert Fig.\u0026nbsp;2 here\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eFigure 2 : Self-reported expertise across Delphi rounds.\u003c/b\u003e \u003cem\u003ePresented as median\u0026thinsp;\u0026plusmn;\u0026thinsp;interquartile range (IQR) for each stakeholder group (older adults, urban planning, science \u0026amp; care, decision-makers).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eIntrinsic Factors\u003c/b\u003e\u003c/p\u003e\u003cp\u003eFigure 3 presents the results for intrinsic factors. In \u003cem\u003eCharacteristics and general aspects\u003c/em\u003e, 1 item reached total consensus, 1 global consensus, 2 remained partial, and 1 did not reach any consensus in any group. In \u003cem\u003ePhysical, sensory, and motor capacities\u003c/em\u003e, 5 items obtained total consensus, 1 reached global consensus, and 2 remained partial. In \u003cem\u003eLifestyle, hygiene, and nutritional status\u003c/em\u003e, 2 items reached total consensus, 3 global, and 2 no-consensus. In \u003cem\u003eCognitive and psychological functioning\u003c/em\u003e, 2 items achieved total consensus and 5 global consensus. In \u003cem\u003eAge-related pathologies\u003c/em\u003e, 5 items reached total consensus, and 1 did not reach consensus. Finally, in \u003cem\u003ePersonal equipment\u003c/em\u003e, 2 items obtained total consensus.\u003c/p\u003e\u003cp\u003e\u003cb\u003eInsert Fig.\u0026nbsp;3 here\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eFigure 3 : Bubble heatmap of Delphi consensus across expert groups on intrinsic risk‑factor propositions for outdoor public spaces.\u003c/b\u003e \u003cem\u003eBubble fill color indicates relevance level, bubble size the interquartile range (IQR), and text the percentage of ratings\u0026thinsp;\u0026ge;\u0026thinsp;7. Red bubble outlines mark high dispersion (IQR\u0026thinsp;\u0026gt;\u0026thinsp;2.5), and red text indicates lack of consensus (\u0026lt;\u0026thinsp;70% \u0026ge;7). * = item re-rated in round 3; ᵃ = item modified between rounds 2 and 3; ᵇ = item added in round 3.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eExtrinsic Factors\u003c/b\u003e\u003c/p\u003e\u003cp\u003eFigure 4 presents the results for extrinsic factors. In \u003cem\u003ePavement quality and continuity of pathways\u003c/em\u003e, 5 items reached total consensus. In \u003cem\u003eObstacles on pedestrian areas\u003c/em\u003e, all 6 items reached total consensus. In \u003cem\u003eSignage and visibility\u003c/em\u003e, 5 items reached total consensus, and 1 global consensus. In \u003cem\u003eExternal conditions and environment\u003c/em\u003e, all 5 items reached total consensus. Finally, in \u003cem\u003eLack of amenities\u003c/em\u003e, 5 items reached total consensus and 1 partial consensus.\u003c/p\u003e\u003cp\u003e\u003cb\u003eInsert Fig.\u0026nbsp;4 here\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eFigure 4 : Bubble heatmap of Delphi consensus across expert groups on extrinsic risk‑factor propositions for outdoor public spaces.\u003c/b\u003e \u003cem\u003eBubble fill color indicates relevance level, bubble size the interquartile range (IQR), and text the percentage of ratings\u0026thinsp;\u0026ge;\u0026thinsp;7. Red bubble outlines mark high dispersion (IQR\u0026thinsp;\u0026gt;\u0026thinsp;2.5), and red text indicates lack of consensus (\u0026lt;\u0026thinsp;70% \u0026ge;7). * = item re-rated in round 3; ᵃ = item modified between rounds 2 and 3; ᵇ = item added in round 3.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003ePreventive Actions\u003c/b\u003e\u003c/p\u003e\u003cp\u003eFigure 5 presents the results for action propositions. In \u003cem\u003ePublic-space layout, maintenance, and accessibility\u003c/em\u003e, 5 items reached total consensus, 1 global consensus, and 2 partial consensus. In \u003cem\u003eNorms, urban and health policies\u003c/em\u003e, 6 items achieved total consensus. In \u003cem\u003eAwareness, enforcement, and information\u003c/em\u003e, 8 items reached total consensus and 1 global consensus. In \u003cem\u003eData, monitoring, and steering\u003c/em\u003e, 4 items reached total consensus and 1 global consensus. In \u003cem\u003eFinancial resources and economic levers\u003c/em\u003e, 2 items achieved total consensus and 1 partial consensus. In \u003cem\u003eIndividual approach and support for at-risk persons\u003c/em\u003e, 6 items reached total consensus. In \u003cem\u003eResearch, development, and innovation\u003c/em\u003e, 5 items achieved total consensus and 1 global consensus. Finally, in \u003cem\u003eCo-design and public involvement\u003c/em\u003e, 6 items reached total consensus.\u003c/p\u003e\u003cp\u003e\u003cb\u003eInsert Fig.\u0026nbsp;5 here\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eFigure 5 : Bubble heatmap of Delphi consensus across expert groups on propositions for preventive actions for falls in outdoor public spaces.\u003c/b\u003e \u003cem\u003eBubble fill color indicates relevance level, bubble size the interquartile range (IQR), and text the percentage of ratings\u0026thinsp;\u0026ge;\u0026thinsp;7. Red bubble outlines mark high dispersion (IQR\u0026thinsp;\u0026gt;\u0026thinsp;2.5), and red text indicates lack of consensus (\u0026lt;\u0026thinsp;70% \u0026ge;7). * = item re-rated in round 3; ᵃ = item modified between rounds 2 and 3; ᵇ = item added in round 3.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eBarriers to Preventive Actions\u003c/b\u003e\u003c/p\u003e\u003cp\u003eFigure 5 presents the results on barriers to preventive actions. In \u003cem\u003eFinancial and budgetary barriers\u003c/em\u003e, both items reached total consensus. In \u003cem\u003eTechnical, organizational, and steering constraints\u003c/em\u003e, 3 items achieved total consensus and 3 reached global consensus. In \u003cem\u003eSocial, cultural, and territorial barriers\u003c/em\u003e, 3 items reached total consensus, while 2 achieved global consensus.\u003c/p\u003e\u003cp\u003e\u003cb\u003eInsert Fig.\u0026nbsp;6 here\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eFigure 6 : Bubble heatmap of Delphi consensus across expert groups on propositions for barriers to preventive actions.\u003c/b\u003e \u003cem\u003eBubble fill color indicates relevance level, bubble size the interquartile range (IQR), and text the percentage of ratings\u0026thinsp;\u0026ge;\u0026thinsp;7. Red bubble outlines mark high dispersion (IQR\u0026thinsp;\u0026gt;\u0026thinsp;2.5), and red text indicates lack of consensus (\u0026lt;\u0026thinsp;70% \u0026ge;7). * = item re-rated in round 3; ᵃ = item modified between rounds 2 and 3; ᵇ = item added in round 3.\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis Delphi study aimed to identify risk factors for outdoor falls among older adults, as well as the most relevant preventive actions and the barriers to their implementation. It addresses a context where scientific knowledge remains scarce and fragmented and where outdoor falls are [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The study relies on a rigorous three‑phase Delphi process, characterized by iterative rounds, anonymous expert ratings, controlled feedback, a predefined definition of consensus [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], and a multidisciplinary panel to build informed consensus useful for urban and public health strategies.\u003c/p\u003e\u003cp\u003e\u003cb\u003eIntrinsic Factors\u003c/b\u003e\u003c/p\u003e\u003cp\u003eFinal results show a strong consensus on intrinsic contributors of older adults to outdoor fall risks, with strong consensus on biomedical but also notable divergences on behavioral, psychosocial, and social factors.\u003c/p\u003e\u003cp\u003eThe strongest core consensus, rated highly or very highly concerned biomedical factors, including sensory, cognitive, motor, and musculoskeletal declines (gait and balance impairments; visual, vestibular, cognitive, and proprioceptive deficits; and reduced muscular function). These vulnerabilities, documented in the fall literature, form the biomedical core of risk and confirm that biomedical determinants may remain important to explain outdoor falls [\u003cspan additionalcitationids=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Pain, chronic disease, locomotor or osteoarticular disorders, as well as polypharmacy also show strong consensus, consistent with prior work [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Panelists also unanimously identified inadequate use of assistive devices and inappropriate footwear as major factors, highlighting behaviors and equipment often less emphasized in classic prevention strategies [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Some factors were judged relevant by certain groups but not by others. Obesity and thinness divided groups, possibly because they are often approached using BMI, which poorly reflects body composition [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Sex effects is a complicated topic. The initial statement that \u0026ldquo;being a woman strongly influences risk\u0026rdquo; was rejected in the second round, and the reformulated \u0026ldquo;no sex effect\u0026rdquo; failed to achieve consensus suggesting that panelists do not share a unified view. Epidemiological data often show a higher prevalence of falls among women [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], but this may reverse when focusing on outdoor falls [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Mobility behaviors, activities, and exposure to urban environments may differ between sexes and help explain these patterns [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eThe relevance of psycho-behavioral factors could differ between groups. It is also noteworthy that older fallers did not perceive fear of falling as a risk factor, even though the literature describes it as both consequence and determinant of fall risk that can foster activity avoidance and alter gait [\u003cspan additionalcitationids=\"CR33\" citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Older adults may see fear as a cautious behavior intended to secure movement rather than increase vulnerability [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. While sedentariness was supported by strong global consensus, it was down‑weighted by older adults. The role of physical activity appears complex, and could be both an indirect protective behavior and a direct risk factor, especially since outdoor fallers are often reported to be particularly active [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Of interest, social isolation and deprivation, frequently linked to physical‑activity and cognitive declines, were much less recognized by panelists, who tended to prioritize biomedical dimensions [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThese divergences reflect different priorities (urban planners and decision‑makers focus on practical levers, health professionals on clinical vulnerabilities, older adults on lived experience). They call for policies that tailor messages for each group. They also highlight the specificity of outdoor environments, even though a key point concerned the absence of consensus on whether intrinsic factors are distinct between home and outdoors. The initial statement that \u0026ldquo;personal risk factors outdoors are the same as at home\u0026rdquo; failed to reach consensus in round two. The reformulated statement that \u0026ldquo;personal risk factors outdoors are specific\u0026rdquo; also failed to secure overall agreement in round three, although older adults were more favorable to specificity while scientific/health professionals expressed more caution, likely reflecting the current limits of evidence and calling for further research on the topic.\u003c/p\u003e\u003cp\u003eIn sum, strong consensus supports sensory, cognitive, motor, and musculoskeletal vulnerabilities, along with polypharmacy and inadequate assistive devices or footwear, as priority targets for outdoor fall prevention. Uncertainties remain regarding the specificity of the context (home vs. outdoor), sex, body composition, activity level, psychosocial vulnerabilities, fear of falling, and cognitive fatigue in outdoor travel. Mixed designs combining epidemiology, real‑world observation, and qualitative analyses are needed.\u003c/p\u003e\u003cp\u003e\u003cb\u003eExtrinsic Factors\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe study reveals broad consensus on most extrinsic factors with 25 out of 27 items reaching total consensus, underscoring the importance of physical obstacles, missing amenities, and the overall sensory environment as determinants of pedestrian safety.\u003c/p\u003e\u003cp\u003eThe strongest consensus was regarded physical and organizational obstacles that directly affect pedestrian safety: unsuitable, degraded, or irregular surfacing; level changes; risky detours around worksites; absence of sidewalks; debris; temporary or fixed obstacles; and vehicles parked or moving on sidewalks. Adverse weather conditions also stand out when poorly addressed. Another core of consensus concerns missing amenities that support continuous and secure travel (benches, shelters, ramps, continuous wide sidewalks) and signage that is absent or not adapted to older adults (with possible sensory decline). This shapes a set of risk factors that can be assessed in the environment to determine the risk of falls. The ambient sensory environment (visual overload, crowding, excessive noise) also mattered to the panelists, highlighting that prevention must go beyond physical layout to include overall urban quality and users\u0026rsquo; capacity to process information.\u003c/p\u003e\u003cp\u003eThese priorities align with WHO \u0026ldquo;age‑friendly cities\u0026rdquo; recommendations. Strong consensus on safe, continuous pathways; public lighting; benches and ramps; and securing worksites and temporary obstacles fits the framework\u0026rsquo;s key dimensions [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. However, while the WHO framework considers public‑space safety broadly, it does not address falls directly. Our study centers falls explicitly and highlights factors of specific relevance. Adding a specific \u0026ldquo;fall prevention\u0026rdquo; axis would increase the framework\u0026rsquo;s operational relevance for this public‑health challenge.\u003c/p\u003e\u003cp\u003eOur results also overlap with walkability frameworks. Walkability typically addresses environments that support pedestrian movement and sometimes perceived comfort and safety, but it differs markedly from the topic of fall risks in older age, especially because many classic indices are not adapted to aging [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Even in older‑adult‑oriented studies, the focus is rather on physical activity, social participation, or daily mobility, and \u0026ldquo;falls\u0026rdquo; is absent despite their public‑health importance [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. This study therefore complements existing frameworks by confirming shared criteria while enlarging evaluation to vulnerabilities specific to older fallers.\u003c/p\u003e\u003cp\u003e\u003cb\u003ePreventive Actions\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis present Delphi study support that effective prevention of outdoor falls should not solely focus on fixing sidewalks and physical environment, but is instead a multiaxial challenge. While walking surfaces and their quality are priorities often cited in participatory studies [\u003cspan additionalcitationids=\"CR40\" citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e], the present study provides broader set of preventive actions. These can be organized into: regulation and governance, awareness and education, monitoring and technology, preventive action targeting intrinsic factors, and social and participatory involvement.\u003c/p\u003e\u003cp\u003eA particularly strong consensus concerns embedding fall prevention within regulatory and policy frameworks, beyond clinical settings. Panelists called for dedicated funding via ambitious programs and explicitly integrating fall prevention into planning documents and local health programs. They advised for a better enforcement of existing accessibility norms, and a strengthening the pedestrian\u0026rsquo;s place relative to cars and bicycles, in line with broader shifts away from car‑centric mobility [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAwareness, training and information are also seen as highly relevant, with most related items reaching total consensus. Broad public campaigns on outdoor fall risk gained strong support, as did tailored awareness for at‑risk individuals to recognize vulnerabilities and adapt behaviors, in line with research showing the importance of self-efficacy in fall prevention [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. A novel, strongly supported point is systematic training of urban‑planning professionals on fall prevention. At the interface of regulation and awareness, stronger controls and sanctions against cluttering sidewalks (with scooters, parking...) are supported, indicating that information alone is insufficient without enforcement. Promoting a culture of respect for vulnerable pedestrians was also consensual among panelists and promotes the need for cultural change in line with previous identified top priority for age friendly cities [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Practical measures such as systematic reporting of obstacles, encouraging users to remove minor obstructions, and priority seating for older adults in transit illustrate a balance between individual, collective, and institutional responsibility proposed by the panelists.\u003c/p\u003e\u003cp\u003eProposals for action involving technological innovations also occupy a notable place. The use of technologies is increasingly considered by experts as a possible solution to address some of the challenges associated with urban aging, but remains underexploited [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Experts propose citizen‑reporting apps to alert municipalities about hazards. Existing initiatives seldom target fall risk specifically and are not widely deployed [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Using urban sensors to detect conditions (degradation, weather, crowding) and deploying adaptive public lighting were also proposed. While older adults are often thought to be wary of technology in relationship with personal, technical and contextual factors [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e] participants in our study, especially older adults, were among the most favorable to such solutions. Strong consensus also supported better structuring of data production and use in relationship with fall prevention. A national observatory to catalog, analyze, and disseminate effective interventions demonstrate the need for evidence‑based steering. Identifying hotspots of emergency responses to falls and maintaining updated risk‑zone databases can also help locate where to act first. This aligns with calls to strengthen data governance in public health and urbanism and with the international trend toward using spatial data to target urban vulnerability [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. Participants also strongly recommended supporting research on environmental contributors to falls.\u003c/p\u003e\u003cp\u003ePanelists agreed on the need for individualized, coordinated care for mobility and balance disorders, integrating medical, social, and environmental dimensions. Proposed innovative actions with broad support include enabling at‑risk persons to reappropriate public space (guided walks, training for transit use\u0026hellip;), which can reduce anxiety and foster autonomous mobility [\u003cspan additionalcitationids=\"CR51\" citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. Social participation and access to group activities, also consensual among panelists, can also reduce isolation and support mental health [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e] and may indirectly contribute to fall prevention. However, their effectiveness warrants further study. Access to targeted physical activity programs (balance, strength) is rated as highly pertinent and is among the best‑established primary and secondary prevention domains [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. Finally, experts emphasize better consideration of cognitive and medication factors, including optimized prescriptions to limit side effects and interactions, in line with guidance on fall‑risk‑increasing drugs [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFinally, a very strong consensus supports embedding fall prevention within co‑construction approaches. Essential dimensions include linking researchers and health professionals with policy‑makers for public‑space decisions, co‑constructing projects with users (especially those at risk), and organizing continuous consultation with residents. This aligns with international movements in citizen science and participatory urbanism, which improve intervention fit to real needs [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]. Involving diverse publics (older adults, urban planners, local decision‑makers) can be especially effective for promoting environments that support physical activity and social interaction [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. Because the present results emerged from a structured, participatory process involving multidisciplinary experts and users, they can be considered particularly legitimate. They illustrate that falls, too often framed as a clinical issue, are a collective challenge requiring novel alliances among public health, urban planning, and civil society [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. Panelists also stress the role of local actors of proximity (shops, landlords, municipalities), whose involvement can shift practices toward safer environments for older pedestrians. Training and supporting older adults to participate actively in consultation processes recognizes them not only as beneficiaries but as experts in using public space, consistent with empowerment approaches [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e]. The strong consensus behind these actions is decisive for deployment as initiatives supported across users, professionals, and decision‑makers are better implemented and accepted [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cb\u003eBarriers to Preventive Actions\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe Delphi results highlight that the relevance of barriers to preventive actions may differ among expert groups, with strong consensus on financial obstacles but more divergence on technical, organizational, and social dimensions.\u003c/p\u003e\u003cp\u003eFinancial barriers were the most consensual. High costs of design and maintenance and insufficient dedicated public funding were unanimously identified as major obstacles. This convergence reflects a well‑documented reality: adapting urban environments to older populations\u0026rsquo; needs is often seen as secondary to other municipal priorities [\u003cspan additionalcitationids=\"CR63\" citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e]. Our results argue for embedding aging needs in urban planning and for stable resources, as promoted in age‑friendly city programs.\u003c/p\u003e\u003cp\u003eTechnical and organizational constraints were less consensual. The lack of systematic impact evaluation is a key barrier with consensus, echoing prior work showing that many age‑friendly initiatives lack rigorous evaluation, leaving a fragmented evidence base [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Without strong data on effects, sustaining investment is difficult, even when interventions seem promising [\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e]. Stakeholders themselves emphasize the need for standardized frameworks and tools to evaluate and compare interventions [\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e]. Developing shared instruments and continuous validation cycles appears critical to strengthen legitimacy and facilitate integration into policy [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e]. In the specific context of outdoor falls, although fall risk is sometimes cited as something to assess, there are no specific environmental evaluation tools [\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e]. Evaluations could rely on this Delphi\u0026rsquo;s results and combine quantitative indicators (fall and hospitalization rates), qualitative indicators (sense of safety, avoidance behaviors), environmental indicators (maintenance, lighting, signage), and governance indicators (budgets, citizen‑reporting mechanisms).\u003c/p\u003e\u003cp\u003eWhile participants agreed on the technical complexity of adapting constrained spaces and on long timelines, other aspects are debated. Methodological and organizational hurdles to participatory processes did not reach total consensus. Urban planners may be more familiar with participatory devices (workshops, public inquiries, mandated consultations) than other participants assume, and thus view these as part of routine practice rather than major barriers (in comparison with more structural barriers like financial constraints [\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e], whereas others may perceive them as significant obstacles to co‑construction.\u003c/p\u003e\u003cp\u003ePanelists broadly agree that territorial (e.g., center vs. periphery) and socioeconomic inequalities between neighborhoods is a barrier to effective prevention. These disparities may reflect unequal distribution of amenities conducive to \u0026ldquo;aging well\u0026rdquo; [\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e]. Evidence directly linking such inequalities to fall risk is limited, though more favorable neighborhood environments for leisure physical activity may reduce falls among older adults [\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e]. Lack of citizen mobilization and public interest was also reported as a pertinent barrier, possibly reflecting limited public awareness of the issue, recognized as a key challenge for implementing age‑friendly environments [\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e]. By contrast, the impact of negative social opinion of aging is disputed: older adults often identify ageism as a barrier to active aging, whereas other actors may down‑weight it [\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e]. The fact that elected officials and urban planners did not rate this barrier as a priority could reflect lower perceived importance or overestimation by older adults.\u003c/p\u003e\u003cp\u003e\u003cb\u003eRecommendations\u003c/b\u003e\u003c/p\u003e\u003cp\u003eBased on these results and the literature, several recommendations can guide public policies and practices for preventing outdoor falls (Fig.\u0026nbsp;7). Falls should no longer be considered only a clinical problem; they are a transversal issue of public health and urban planning. Municipalities should explicitly embed fall prevention in urban, mobility, and health plans with stable dedicated funding [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e]. Strong consensus highlights basic pedestrian safety dimensions as immediate, widely shared levers to reduce fall risk. Investing in systematic maintenance protocols, rapid repairs, and securing risk zones should become standard practice. Multidisciplinary actions (systematic inclusion of fall prevention in planning documents, targeted training for planners and technical agents, and monitoring tools such as observatories and participatory reporting) should also be prioritized.\u003c/p\u003e\u003cp\u003e\u003cb\u003eInsert Fig.\u0026nbsp;7 here\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eFigure 7 : Intrinsic, extrinsic, and governance-related factors identified in the Delphi study on falls in outdoor public spaces and their associated possible preventive actions\u003c/b\u003e \u003cem\u003e(red\u0026thinsp;=\u0026thinsp;intrinsic factors, yellow\u0026thinsp;=\u0026thinsp;extrinsic/environmental factors, blue\u0026thinsp;=\u0026thinsp;governance and societal factors; darker boxes indicate identified risks or issues, lighter boxes indicate the associated preventive actions).\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe results support that prevention requires shared governance mobilizing researchers, professionals, decision‑makers, associations, and citizens. Consultations should be regular, inclusive, and adapted (Easy‑to‑Read, digital tools, exploratory walks), giving older adults their place as expert users while also engaging other citizens so the issue becomes collective [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. Public awareness campaigns should reinforce recognition of falls as a shared concern, not one reserved to older people. Involving local proximity actors (shopkeepers, landlords, associations) could help diffuse a common culture of safety [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. Prevention must prioritize peripheral and disadvantaged neighborhoods, where infrastructure is often less developed and risks are increased by social and spatial conditions.\u003c/p\u003e\u003cp\u003eA major barrier, beyond funding, is the lack of systematic evaluation. It is crucial to develop standardized instruments specific to outdoor fall risk, combining quantitative indicators (falls, hospitalizations), qualitative indicators (risk perception, sense of safety), environmental indicators (maintenance, lighting, signage), and governance indicators (budgets, participatory mechanisms). Such tools would enable comparisons, objectify progress, and strengthen legitimacy of investments [\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e]. Pilot projects deploying innovative solutions (connected technologies, intelligent signage, participatory platforms) should be encouraged, with attention to accessibility for older users.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStrength, limitations and perspectives\u003c/b\u003e\u003c/p\u003e\u003cp\u003eBeyond the under‑studied topic of outdoor falls, a key originality of the study is the multidisciplinary panel including: older adults who have already fallen outdoors, scientific experts and health professionals, urban planners, and decision‑makers. Delphi studies relatively rarely include populations directly affected (27% according to Schifano \u0026amp; Niederberger, 2025). Their inclusion here allows to benefits from their lived experience as expertise while ensuring knowledge sharing from technical, scientific, and policy views. This diversity yielded complementary and sometimes contrasting results, enabling shared priorities to emerge while identifying areas of divergence. The methodology followed recent recommendations [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], maintained a retention rate consistent with standards (\u0026minus;\u0026thinsp;18.3% from first to last phase), and applied strict consensus criteria (\u0026ge;\u0026thinsp;70% ratings\u0026thinsp;\u0026ge;\u0026thinsp;7/10 and IQR\u0026thinsp;\u0026le;\u0026thinsp;2.5). The combined use of an initial AI‑assisted synthesis with systematic human validation for the open qualitative responses in round one is innovative and aligns with guidance on limiting bias [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Adapting the questionnaire to Easy‑to‑Read standards broadened inclusion of older profiles, including those less familiar with research, enhancing panel representativeness.\u003c/p\u003e\u003cp\u003eThis study has several limitations. First, it was conducted in Normandy, France, and although the region is demographically and urbanistically representative of many European regions undergoing advanced demographic transition, priorities and perceptions may vary in other contexts, such as very dense urban areas or countries with different infrastructures and policies. Replication elsewhere is needed to test transferability. Choosing a very broad geographical area (multiple countries) could have led to a consensus emerging only on very general aspects, more widely applicable but less insightful. Second, panel recruitment was voluntary, which may introduce selection bias toward more sensitized stakeholders. Complementary population surveys or random panels could enhance representativeness. Third, as with any Delphi, results reflect perceptions and expertise rather than objective measurement, and they have not yet been matched to field data (epidemiological, sensor‑based, in situ observation). Developing standardized evaluation tools that combine quantitative, qualitative, environmental, and governance indicators would strengthen external validity. Fourth, consensus methods inherently produce compromises. Technical details (e.g., precise surfacing specifications) or very personal issues (e.g., anxiety after a fall) may have been diluted in the final ranking even if recognized as important in the literature. In‑depth qualitative interviews, exploratory walks, and in situ observations could identify latent needs or \u0026ldquo;blind spots,\u0026rdquo; refining understanding of still understudied dimensions (e.g., sensory overload, cognitive fatigue, combined environmental conditions). Finally, pilot tests with longitudinal evaluation are needed to test effectiveness and reproducibility across contexts. Embedding these priorities in local public‑health and urban‑planning policies, with shared governance and stronger citizen mobilization, could be decisive in sustainably reducing outdoor fall risk.\u003c/p\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003e Fall-prevention guidelines mainly address clinical aspects of fall prevention without addressing risks in outdoor public spaces, while age-friendly frameworks promote accessibility without considering falls. Outdoor fall prevention thus remains neglected, and this Delphi study helps fill that gap by documenting risks, actions, and barriers in public spaces, and by showing that effective strategies require bridging clinical and environmental perspectives through shared governance. Building prevention as a transversal issue across health and urban planning is key to safer and more inclusive environments for older adults.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate : The University of Caen Normandy Research Ethics Committee approved the study protocol (no. 2025030408142400000260000327). Informed consent was collected at each step of the study, for each questionnaire. All procedures were conducted in accordance with the principles of the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003eConsent for publication : NA\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials : The data that support the findings of this study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests : The authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003eFunding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions : AL, BW, ML and MT contributed to the conceptualization of the study. AL and BW developed the methodology. BW performed the validation. AL conducted the formal analysis, the investigation and the data curation. AL prepared the original draft. All authors contributed to the writing, review and editing of the manuscript. AL created the visualizations. AL and BW supervised the work. AL and ML handled project administration.\u003c/p\u003e\n\u003cp\u003eAcknowledgements : The authors would like to thank all the older adults and professionals who participated in this Delphi study and generously shared their experiences and expertise. We also acknowledge the support of the regional working group Plan antichute \u0026ndash; espace ext\u0026eacute;rieur coordinated by the G\u0026eacute;rontop\u0026ocirc;le de Normandie and the Agence R\u0026eacute;gionale de Sant\u0026eacute; (ARS) Normandie. The contribution of the Grenelle du Handicap of the city of \u0026Eacute;vreux in adapting the questionnaire to Facile \u0026agrave; Lire et \u0026agrave; Comprendre (FALC) standards is gratefully acknowledged.\u003cbr\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSalari N, Darvishi N, Ahmadipanah M, Shohaimi S, Mohammadi M. 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Active and healthy ageing in urban environments: laying the groundwork for solution-building through citizen science. Health Promot Int. 2022;37:daac126. https://doi.org/10.1093/heapro/daac126.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Falls, older adults, outdoor public spaces, Delphi, prevention, urban planning","lastPublishedDoi":"10.21203/rs.3.rs-8114657/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8114657/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eFalls are the leading cause of accidental injury among older adults, with nearly half occurring outdoors. These falls are complex, understudied, and insufficiently addressed in current age-friendly cities or walkability frameworks. This study aimed to build interdisciplinary consensus on risks, preventive actions, and barriers to fall prevention in outdoor public spaces through a Delphi process.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA three-phase Delphi study was conducted with 64 participants in round 1, 60 in round 2, and 49 in round 3, including four expert groups: older adults who had fallen outdoors, health and research professionals, urban planners, and decision-makers. Phase one collected open responses on risks, preventive actions, and barriers. Responses were synthesized using AI-assisted analysis with systematic human validation. In phases two and three, the relevance of 124 propositions were rated on a 10-point Likert scale. Consensus was defined as \u0026ge;\u0026thinsp;70% of ratings\u0026thinsp;\u0026ge;\u0026thinsp;7/10 and interquartile range\u0026thinsp;\u0026le;\u0026thinsp;2.5.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eConsensus was reached for key intrinsic factors (e.g., gait and balance impairments, visual and vestibular deficits, cognitive decline, polypharmacy) and environmental factors (e.g., irregular or inappropriate surfaces, obstacles, signage not adapted, crowding). Highly relevant preventive actions included integrating fall prevention into street and sidewalk design, training urban planning professionals, awareness campaigns, systematic maintenance, safer crossings, participatory co-design, and improved data monitoring. Main barriers were insufficient budgets, high costs, limited integration of fall prevention into planning priorities, and lack of evaluation.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eOutdoor fall prevention is a transversal challenge requiring integration of public health and urban planning. This Delphi highlights actionable priorities to embed fall prevention in local and national strategies, in particular in rapidly aging regions.\u003c/p\u003e","manuscriptTitle":"Falls prevention in Outdoor Public Spaces: An Interdisciplinary Delphi Consensus on Risks, Actions, and Barriers","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-26 09:16:47","doi":"10.21203/rs.3.rs-8114657/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-05T08:11:54+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-31T17:09:35+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-22T11:13:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"284664752897053770609088956044900749185","date":"2026-01-18T08:25:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"67181220297712214151907122307292560225","date":"2026-01-17T19:16:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"100485148452532063344652166473248949003","date":"2026-01-05T11:29:48+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-03T19:11:03+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-02T05:55:09+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-19T11:18:35+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-18T22:11:23+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-11-18T22:07:50+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a0eadf8f-e3a9-412c-ac76-17e0b37ce91f","owner":[],"postedDate":"November 26th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-05-08T15:16:25+00:00","versionOfRecord":{"articleIdentity":"rs-8114657","link":"https://doi.org/10.1186/s12889-026-27548-1","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2026-05-02 15:58:26","publishedOnDateReadable":"May 2nd, 2026"},"versionCreatedAt":"2025-11-26 09:16:47","video":"","vorDoi":"10.1186/s12889-026-27548-1","vorDoiUrl":"https://doi.org/10.1186/s12889-026-27548-1","workflowStages":[]},"version":"v1","identity":"rs-8114657","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8114657","identity":"rs-8114657","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}