Introduction
Falling is one of the common problems in old age, as a result of which the elderly may be exposed to many complications, such as fractures, soft tissue destruction, bruises, tears, and subdural hematoma [10]. These complications are more common in the elderly compared to other age groups and cause an increase in the rate and duration of hospitalization and mortality in them [11], leading to the financial burden and potential physical, psychological, and social consequences for the elderly and their families [13]. Hence, fall prevention training is one of the main training of the Ministry of Health’s Elderly Health Department [20]. Considering that precautionary measures caused by the COVID-19 epidemic and technological opportunities have accelerated the replacement of face-to-face educational environments with virtual environments [21], the purpose of this study was to determine the effect of virtual self-care training on the awareness, attitude, and performance of the elderly in preventing falls at home.

Methods
The present semi-experimental interventional study with a before-and-after design was conducted in 2021 on 120 elderly people aged 65 years and older using a random cluster sampling method. The inclusion criteria included the age group of 65 years and older, receiving at least one care from subsidiary bases, access to the Internet by the elderly or one of his/her family members to participate in the virtual training course, the ability to communicate and answer questions, a conscious desire to participation in the study, living at home, and scoring 1 to 5 out of 6 on activities of daily living (ADL) test.
Data collection was done by a researcher-made questionnaire based on the national protocol of the Ministry of Health, Treatment, and Medical Education, integrated care for the elderly for non-physicians [26], the package of modern health services for the elderly for non-physicians [30] and a review of literature and included questions on demographic characteristics, assessment of individual risk against falls, assessment of ADL based on Katz’s standard questionnaire, and examination of awareness, attitude and performance in fall prevention. It should be mentioned that the validity and reliability of this tool were checked and confirmed in three stages, and it was completed by the researcher at baseline, immediately, and 3 months after the intervention over the phone. The content of the virtual educational intervention was based on the provisions of the guidelines for integrated care of old age [26], containing information about the prevalence of falls in the elderly, the major individual and environmental causes of falls, problems and complications after falls, and prevention strategies, which were in the form of text, images, multimedia, movies and presented offline and online during four sessions on WhatsApp and Skype platforms. Data analysis was done by SPSS software, version 26 using descriptive statistics and analytical statistics (independent t-test, Mann-Whitney test, and Chi-square test). 

Results
In this study, 120 elderly people aged 65 years and older participated, of whom those in the age range of 71 to 75 years (42.3%) compared to other age groups, women (57.6%) compared to men, those with primary education (69.2%) compared to other educational groups, elderly who lived with a companion (88.4%) compared to single elderly, married elderly (61.5%) compared to others, and retired elderly (50 %) compared to other occupational groups reported more falls. Also, the highest frequency based on the history of falling was related to vision problems (61.5%) and high blood pressure (50%), and the lowest frequency was related to obesity (11.5%). In general, among the elderly participants in this study, about 22% of them had a history of falling during the past year. The place where most elderly people had experienced a fall was outside the home environment (30.8%) and bedroom or living room (23.1%). Also, the most common causes of falls were related to the unevenness of the ground (26.9%), the use of inappropriate slippers (15.4%), and other causes (15.4%).
As mentioned, the ADL score was evaluated as a criterion for entering the elderly into the study. Based on the findings of this test, 64.2% of the elderly scored 5, 2.5% of them scored 1, and people with ADL scores of 0 and 6 were not selected for the study due to the low probability of falling.
Also, Table 1 shows an analysis of the effect of virtual education intervention on preventing the fall of the elderly by paired sample t-test.


The statistical difference between the scores of the first stage (before the intervention) and the scores of the second stage (immediately after the intervention), and also the difference between the scores in the third stage (three months after the intervention) and the first stage was examined. The average scores of the elderly regarding self-care in preventing falls at home were significantly higher in the second stage compared to the first stage, in the dimensions of awareness (18.39±2.86), attitude (14.99±2.51), and performance (3.1±13.76) (P<0.001). Also, the average scores of the elderly three months after the intervention (third stage) in each dimension of awareness (18.18±1.14), attitude (14.91±1.57), and performance (9.06±2.78) were still significantly higher than the first stage (P<0.001).

Conclusion
Based on the findings of the present study, virtual education on fall prevention for the elderly at home has a significantly positive effect on increasing the knowledge of the elderly about fall prevention strategies, their belief that fall prevention measures are useful, and the intention they had to take measures to reduce the risk of falling. Therefore, it is possible to use the virtual education method on issues related to the health of the elderly, such as preventing falls at home and in situations where it is not possible to participate in face-to-face classes for the elderly. Thus, we can achieve the intended educational goals in addition to benefiting from the side advantages of virtual education classes. It is also necessary to carry out more studies to facilitate virtual education for the elderly so that the effectiveness and quality of this educational method can be further increased by designing the appropriate content and platform to provide self-care virtual educational programs that suit the characteristics of the elderly.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the ethics committee of the School of Medicine, Tehran University of Medical Sciences (Code: IR.TUMS.MEDICINE.REC.1400.132).

Funding
This study was extracted from the master’s thesis of Azar Jahanbani in medical education, funded by Tehran University of Medical Sciences and was done with the financial support of the Research Vice-Chancellor of this University.

Authors' contributions
Study design, and investigation: Maryam Tajvar, Azar Jahanbani and Mahnaz Ashoorkhani; Data analysis: Azar Jahanbani; original draft preparation: Omolbanin Atashbahar and Maryam Tajvar; Review & editing: Omolbanin Atashbahar, Maryam Tajvar and Mahnaz Ashoorkhani.

Conflicts of interest
The authors declared no conflicts of interest.

Acknowledgments
The authors would like to thank all participants in this research for their cooperation.


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