Knowledge, attitudes, and beliefs about balance among adults in the United States

Abstract

Objectives:

We conducted a cross-sectional survey among young, middle-aged, and older adults to assess knowledge, attitudes, and beliefs about balance in the United States.

Methods:

A community-based online cross-sectional survey was administered to a nationally representative sample of United States adults. Respondents were categorized into three age groups (young, middle-aged, older adults). Chi-square tests were used to assess differences in categorical variables, and analysis of variance was applied for continuous variables to examine differences in responses between age groups.

Results:

All age groups demonstrated knowledge of balance, had a positive attitude toward improving their balance, and agreed with beliefs about the balance importance with age. While most respondents reported their balance was good, 25%–51% could not stand on one leg for more than 30 s, and one-third were not sure if they could. Regardless of age group, 34%–38% of respondents reported falling in the past year.

Conclusions:

Balance is important across all age groups, yet most respondents do not report visiting a medical provider due to concerns about balance. A history of falls in the past year among younger and middle-aged adults may be higher than previously reported. Thus, balance education and balance practice should ideally begin well before the age of 65.

Introduction

Falls among older adults present a major public health concern often resulting in injury, disability, and mortality, globally.^1–4 In the United States, unintentional falls are the leading cause of injury-related deaths among adults over 65 with 38,742 fall-related deaths in this age group, corresponding to an age-adjusted rate of 78.0 deaths/100,000 population and $50 billion in annual costs. ⁵ A fall and repeated falls come with substantial medical costs, leading to consequences such as fractures, head injuries, and hospitalization.^5–7 Beyond direct medical costs, falls often lead to a fear of falling, which can cause severely restricted mobility and independence, loss of productivity, diminished quality of life, and increased reliance on informal caregivers, placing significant emotional, physical, and financial strain on families.^7–9 While 30% of those over age 65 experience a fall annually in the United States,^5,10 fall risk may start increasing well before then. One study reported a tripling of annual fall incidence from 9% among those 40–44 years old to 28% among those 60–64 years old among community-dwelling adults, ¹¹ highlighting mid-life as a potentially critical time period to initiate fall prevention strategies.

While there has been a substantial investment in fall and injury prevention strategies, including multiple large, well-conducted randomized trials of balance exercises, environmental modifications, and multifactorial interventions, some of which have shown strong evidence for benefit,^12–14 fall death rates have continued to rise through 2021. ⁵ This may be partly due to poor participation in fall prevention programs stemming from (1) a lack of awareness that exercise can reduce fall risk, (2) the assumption that engaging in fall prevention programs means restricting activity or using walking aids, (3) because individuals do not view themselves at risk for falls, and/or (4) are not willing to engage despite knowing about the programs and their potential benefits.^15–17 Further, current fall prevention guidelines target individuals over age 65, which may not address the fall risk factors and prevention needs of middle-aged adults. ¹¹

A key component of all fall prevention programs is balance exercise training, which is the most effective single intervention for fall reduction, lowering the rate of falls by 23%.^18,19 Balance training includes exercises that challenge stability and improve postural control, such as tai chi, single-leg stance, heel-to-toe walking, and multidirectional stepping. These activities enhance sensory integration, neuromuscular coordination, and lower-extremity strength, thereby improving the body’s ability to respond to perturbations and prevent falls. ¹⁹ Given that balance starts to decline as early as the fourth decade,^20–22 initiating training earlier rather than later in life may help slow the rate of balance decline and reduce fall risk. Although their annual fall risk is substantial, the majority of older adults do not engage in routine balance exercise training. ²³ While previous research has identified potential barriers to older adult engagement in balance exercise training, ²⁴ there is a gap in understanding of how adults think about balance more generally, including how much they know about balance, their views of its importance, and their desire to improve their balance. In this study, knowledge refers to the factual information or awareness individuals have about balance, including its causes, risks, and strategies for improvement. ²⁵ Attitudes are the evaluative feelings or emotional predispositions that influence an individual’s perceptions and reactions toward balance and their willingness to engage in balance-promoting activities. ²⁶ Beliefs are the personal convictions or perceptions that individuals hold about the nature, causes, and consequences of poor balance, which can shape their engagement in balance training. ²⁷ We conducted a national survey of U.S. young (aged 30–50 years), middle-aged (aged 51–65 years), and older (aged 66 years or older) adults to gain a better understanding of the public’s knowledge, attitudes, and beliefs about balance, and their personal experience of the consequences of poor balance. We hypothesized that knowledge, attitudes, and beliefs about balance and falls would vary by age, with older adults expressing greater concerns about their balance and falls than young and middle-aged adults.

Methods

Study sample

This study is a retrospective analysis of data collected for the purposes of informing the design of an intervention to enhance balance. A formal power analysis was not conducted because the data were originally collected to inform the development of a balance intervention rather than to test-specific hypotheses. We worked with ACUPOLL Precision Research survey firm, a U.S.-based market research firm that conducts consumer and professional surveys using a proprietary, opt-in research panel (Loveland, OH, USA), to obtain a sample of adults over the age of 30 spread geographically across the United States. This involved stratifying the sample by age, gender, self-identified race, and geographical region. Inclusion criteria included adults aged 30 years or older who were English-speaking and members of the ACUPOLL research panel. Exclusion criteria included individuals who did not complete the full survey; however, the survey platform required completion of all questions prior to submission, so no partial responses were recorded. Respondents were eligible to receive a small honorarium (<$1 U.S. dollar) upon completion of the survey. Participants were recruited through email invitations and accessed the survey via a secure online link. Recruitment followed a convenience sampling approach, and all eligible individuals who received an invitation were encouraged to participate. Data were collected over 2 days, from May 23 to 24, 2023. All survey responses were complete, as the survey design required participants to answer all questions before submission. Data were reviewed for duplicate entries, and none were identified. Participant anonymity was maintained by not collecting any personally identifying information (e.g. names, email addresses, IP addresses). All survey responses were stored securely on a password-protected server, accessible only to authorized study personnel. We used the STROBE cross-sectional checklist when writing our report. The Ethics Committee of the Institutional Review Board waived the need for ethics approval and patient consent for the collection, analysis and publication of the retrospectively obtained and anonymized data for this noninterventional study. Although no formal power analysis was performed, the final sample size was selected to ensure representation across key demographic groups. Recruitment continued until broad coverage across age, gender, race, and region was achieved, supporting meaningful descriptive comparisons.

Survey development

Survey items were developed from six semistructured interviews discussing balance in order to inform an intervention (Supplemental Appendix). The survey assessed the following: knowledge, attitudes, and beliefs about balance, self-assessed balance ability, consequences of impaired balance including prior falls, and the desire for knowledge and tools to monitor and improve balance. Balance importance relative to maintaining a healthy lifestyle was scored between 0 (not at all important) to 10 (very important). The importance of balance in 5 years compared to today was scored on a scale of 0 (much less important) to 10 (much more important), with five indicating equal importance. Balance ability and consequences of impaired balance questions were scored categorically. Consequences queried included falls, tripping, fear of falling and being injured, and visiting a medical provider. For the item consequences of impaired balance (“check all that apply”), participants could select multiple options. Each response option was analyzed separately, and percentages reflect the proportion of participants within each age group who endorsed that specific experience. Percentages do not sum to 100% because participants could select more than one response. Items pertaining to beliefs about balance and desire for knowledge and tools to monitor and improve balance involved eight items, each of which was rated on a scale of 0 (disagree) to 10 (agree). Falls were classified as minor or major. Minor falls were defined as falls resulting in no or minor injuries not requiring medical attention. Major falls were defined as falls requiring medical attention. The total number of minor or major falls was pooled for reporting purposes. The final questionnaire was not previously validated, as no standardized instrument assessing knowledge, attitudes, and beliefs about balance across adult age groups was available. To ensure content clarity and face validity, the survey was pilot-tested with 10 English-speaking adults (~1% of the final sample) prior to fielding.

Participants were asked to self-report their general health using a 0–10 scale (0 = poor, 10 = excellent). To assess health-related values, participants ranked their top three most important attributes for maintaining a healthy lifestyle, choosing from six options: balance, hydration, healthy diet, weight-bearing exercise, weightlifting, and adequate sleep. They also rated the importance of each of these six behaviors on a scale from 0 (not at all important) to 10 (very important). Additionally, participants reported how often they engaged in eight common health behaviors (e.g. sleep, types of physical activity, health monitoring) using a six-point scale ranging from 1 (never) to 6 (once a day or more often). All responses were summarized by age group: young adults (30–50 years), middle-aged adults (51–65 years), and older adults (⩾66 years).

Statistical analysis

Respondents were divided into one of three age groups: young adults (aged 30–50 years), middle-aged adults (aged 51–65 years), and older adults (aged 66 years or older). We calculated descriptive statistics of respondent characteristics and responses to questions pertaining to balance and falls for the three age groups. Between-group differences were tested with the chi-square test for categorical measurements and one-way analysis of variance (ANOVA) for continuous measurements. Group comparisons for continuous outcomes were conducted using ANOVA, given the approximate normal distribution of the outcome variables. Assumptions of normality and homogeneity of variance were assessed using residual plots, Shapiro–Wilk tests, and Levene’s test. Assumptions were sufficiently met, and thus nonparametric tests were not required. Bonferroni corrections were applied to all questions to control for multiple comparisons and ensure the overall type I error rate remains below the predetermined alpha level of 0.05, thereby reducing the likelihood of false positive results. All tests were two-sided and the alpha level set at 0.05. Statistical analyses were conducted using R software with the tidyverse, stats, and car packages. (version 4.3.1; Vienna, Austria).

Results

Respondent demographics

The survey was administered to 1142 individuals and 1009 (50% female, median age 42 years, Interquartile Range [IQR]: 30–55 years) completed the survey, representing an 88% complete response rate. Six hundred sixty (65%) were young adults (aged 30–50 years), 212 (21%) middle-aged adults (aged 51–65 years), and 137 (14%) older adults (aged 66 years or older; Table 1).

Table 1.

Demographics of the study sample.

Demographic information	Young adults (n = 660)	Middle-aged adults (n = 212)	Older adults (n = 137)
Female, n (%)	316 (48)	99 (47)	70 (51)
Income, n (%)
Under $29,999	189 (29)	67 (32)	29 (21)
$30,000–$124,999	377 (57)	119 (56)	97 (71)
$125,000 or more	94 (14)	26 (12)	11 (8)
Race, n (%)
White	468 (71)	176 (83)	120 (88)
Black	103 (16)	23 (11)	11 (8)
Asian	36 (5)	4 (2)	3 (2)
Native Hawaiian or other Pacific Islander	5 (1)	0 (0)	0 (0)
American Indian	10 (2)	2 (1)	1 (1)
Other race	38 (6)	7 (3)	2 (1)
Employment, n (%)
Unemployed	138 (21) a	37 (17)	3 (2)
Employed	504 (76)	131 (62)	25 (18)
Retired	18 (3)	44 (21)	109 (80)
Education, n (%)
High school or less	212 (32)	74 (35)	33 (25)
Some college	210 (32)	67 (32)	49 (36)
Bachelor’s degree	145 (22)	49 (23)	28 (20)
Graduate degree	93 (14)	22 (10)	27 (20)
Marital status, n (%)
Married	338 (51)	97 (46)	81 (59)
Unmarried/widowed	322 (49)	115 (54)	56 (41)
Region, n (%)
Northeast	124 (19)	48 (23)	21 (15)
Midwest	142 (22)	39 (18)	34 (25)
South	303 (46)	86 (41)	47 (34)
West	91 (14)	39 (18)	35 (26)

^aTwelve students reported being unemployed.

Knowledge, attitudes, and beliefs about balance

All groups rated balance as important, with the older group giving it the highest rating (young adults: 7.9 ± 2.0; middle-aged adults: 7.8 ± 2.1; older adults: 8.5 ± 1.6, p = 0.001 for young versus older). All groups reported that balance would be more important to them in 5 years, with older adults endorsing this statement most highly (young adults: 7.5 ± 2.1; middle-aged adults: 7.3 ± 2.1; older adults: 8.3 ± 2.1, p < 0.001 for young versus older). All age groups demonstrated high agreement that maintaining good balance would enable them to stay independent and reduce their risk of falls and ankle injuries, with older adults reporting a significantly higher level of agreement with the statement than the younger and middle-age groups (means: 8.4–8.6/10 across groups; Table 2). Further, all groups agreed that hip fractures can be life-changing, although young adults were less convinced about how life-changing (young adults: 8.7 ± 1.9; middle-aged adults: 9.1 ± 1.6; older adults: 9.2 ± 1.4, p = 0.007 for young versus and p = 0.008 for young versus older. Notably, across all age groups, the expectation that balance would decline with age had the lowest average agreement (young adults: 6.9 ± 2.6; middle-aged adults: 6.8 ± 2.8; older adults: 6.8 ± 2.7) compared to the other statements about balance. Furthermore, there was a comparable level of agreement across the age groups regarding a desire for more knowledge about how to maintain their balance, improve it, and how to monitor their progress over time.

Table 2.

Knowledge, attitudes, and beliefs about balance.

Survey question	Mean (SD)	Young adults (n = 660)	Middle-aged adults (n = 212)	Older adults (n = 137)	Young versus middle (p value)	Young versus old (p value)	Middle versus old (p value)
How important is your balance? (0: not at all important, 10: very important)	7.9 ± 2.0	7.8 ± 2.1	7.8 ± 2.2	8.5 ± 1.6	1.0	0.001	0.01
Will maintaining your balance be less, equally, or more important to you in 5 years than it is today? (0: much less important, 5: equally important, 10: much more important)	7.5 ± 2.1	7.3 ± 2.1	7.6 ± 2.2	8.3 ± 2.1	0.08	<0.001	0.01
How much do you disagree or agree with each of the following statements? (0: disagree, 10: agree)
Improving my balance could reduce my chances of an ankle injury and falling in the future	8.4 ± 2.0	8.1 ± 2.1	8.4 ± 2.1	8.6 ± 1.9	0.3	0.04	1.0
I am afraid that as my balance gets worse, I could fall and injure myself	7.1 ± 2.9	6.9 ± 2.8	7.0 ± 3.1	7.4 ± 2.8	1.0	0.29	0.78
I believe that good balance will be important to staying healthy as I age	8.4 ± 1.8	8.1 ± 1.9	8.2 ± 2.1	8.8 ± 1.4	1.0	<0.001	0.03
It can be life-changing for an older person to fall and break their hip	9.0 ± 1.6	8.7 ± 1.9	9.1 ± 1.6	9.2 ± 1.4	0.007	0.008	1.0
I expect my balance to decline as I get older	6.8 ± 2.7	6.9 ± 2.6	6.8 ± 2.8	6.8 ± 2.7	1.0	1.0	1.0
I wish I knew more about how to maintain and improve my balance as I age	7.2 ± 2.7	7.2 ± 2.4	7.2 ± 2.8	7.1 ± 2.9	1.0	1.0	1.0
It would be helpful if there was a way for me to monitor and improve my balance as I age	7.5 ± 2.5	7.5 ± 2.3	7.5 ± 2.6	7.4 ± 2.6	1.0	0.923	0.58

Bold text indicates significance (p < 0.05).

Perceived balance ability

The majority of respondents in each group rated their balance as good or very good (young adults: 78%; middle-aged adults: 74.5%; older adults: 78.1%; Table 3). More middle-aged and older adults compared to younger adults reported that their balance had gotten worse in the past 5 years, and between-group differences were highly significant (young adults: 27%; middle-aged adults: 44%; older adults: 54%; p < 0.001 for young versus middle and young versus older). There was no significant difference between the middle-aged and older groups in the percent reporting their balance getting worse over the prior 5 years.

Table 3.

Perceived balance ability.

Survey question	Mean (SD)	Young adults (n = 660)	Middle-aged adults (n = 212)	Older adults (n = 137)	Young versus middle (p value)	Young versus older (p value)	Middle versus older (p value)
How is your balance?, n (%)
Very poor, I struggle to independently walk without falling or stumbling	–	9 (1)	3 (1)	2 (1)	0.77	1.0	1.0
Poor, I fall or stumble very often	–	19 (3)	7 (3)	5 (4)
Fair, I fall or stumble occasionally	–	114 (17)	44 (21)	23 (17)
Good, I rarely fall or stumble	–	323 (49)	102 (48)	66 (48)
Very good, I never fall or stumble	–	195 (30)	56 (27)	41 (30)
Have you seen any change in your balance in the past 5 years?, n (%)
Gotten worse	–	181 (27)	93 (44)	74 (54)	<0.001	<0.001	0.35
Hasn’t changed	–	347 (53)	102 (48)	52 (38)
Improved	–	132 (20)	17 (8)	11 (8)
How long can you stand and balance on one leg?, n (%)
I can’t stand on one leg at all a	–	20 (4)	11 (7)	9 (10)	0.76	0.98	0.92
<30 s a	–	119 (21)	53 (32)	39 (41)
30 s or longer a	–	422 (75)	101 (61)	46 (49)
I’m not sure; I haven’t tried to stand on one leg for 30 s	–	99 (15)	47 (22)	43 (31)

^aCalculated based on those who reported having tried to stand on one leg.

Bold text indicates significance (p < 0.05).

Regarding their ability to stand on one leg for 30 s, 31% of older adults reported not having tried, compared to 15% of the young adult group and 22% of the middle-aged group. Among those who had tried to stand on one leg, more than half in each age group reported being able to stand on one leg for 30 s or longer; however, fewer middle-aged and older adults reported being able to do so compared to younger adults. Additionally, 4% of young adults, 7% of middle-aged adults, and 10% of older adults reported being unable to stand on one leg at all.

Consequences of impaired balance

The percent of respondents who had experienced a fall was comparable across age groups, ranging from 34% to 38% (p > 0.05; Table 4). Slightly lower percentages reported falling or stumbling in response to a separate question (young adults: 21%; middle-aged adults: 25%; older adults: 22%). This discrepancy may reflect the differences in how participants interpreted the two questions—where “fall or stumble” may have been perceived more broadly and “fall in the past 12 months” more narrowly, potentially limited to serious or reportable events. Fear of falling was more frequent among middle-aged and older adults versus young adults (young adults: 17%; middle-aged adults: 26%; older adults: 25% (p = 0.016 for young versus middle). The proportion of respondents who reported seeing a medical provider due to balance concerns was low and did not differ significantly by age group young adults: 7%; middle-aged: 8%; older adults: 2%; p > 0.05.

Table 4.

Consequences of impaired balance.

Which of the following, if any, have you personally suffered from due to lack of balance in the past 12 months? Check all that apply.	Young adults (n = 660)	Middle-aged adults (n = 212)	Older adults (n = 137)	Young versus middle (p value)	Young versus old (p value)	Middle versus old (p value)
A minor or major fall, n (%)	247 (37)	73 (34)	52 (38)	0.83	0.66	0.94
Fear of falling and getting injured, n (%)	114 (17)	55 (26)	34 (25)	0.016	0.1	0.96
Visited a medical provider due to balance concerns, n (%)	47 (7)	17 (8)	3 (2)	0.89	0.08	0.08

Participants could select multiple responses. Percentages reflect the proportion of participants endorsing each option and may not total 100%. Minor and major falls category is the sum of the three questions related to falls.

Bold text indicates significance (p < 0.05).

General health and health behaviors

Self-rated physical health was similar across age groups (young adults: 6.7 ± 2.0; middle-aged adults: 6.1 ± 2.1; older adults: 6.6 ± 2.0; p > 0.05; Table 5). Hydration was rated as more important among older adults (8.9 ± 1.4) compared to young (8.3 ± 1.8) and middle-aged adults (8.5 ± 1.8), with statistically significant differences between young and older (p < 0.0001) and middle-aged and older adults (p = 0.0013). Healthy diet followed a similar pattern, with older adults rating it more highly (8.9 ± 1.8) than both younger (7.6 ± 2.2) and middle-aged adults (7.8 ± 2.1; p = 0.0002 and p = 0.0439, respectively).

Table 5.

General health and health behaviors.

Survey questions	Young adults (n = 660)	Middle-aged adults (n = 212)	Older adults (n = 137)	Young versus middle (p value)	Young versus old (p value)	Middle versus old (p value)
How would you describe your health (0: poor, 10: excellent)	6.7 ± 2.0	6.1 ± 2.1	6.6 ± 2.0	0.979	0.431	0.425
Rank the top three attributes that are most important to you for maintaining a healthy lifestyle, with (1) being the most important, (2) the second-most important, (3) the third-most important (balance, hydration, healthy diet, weight-bearing exercise, weight lifting, adequate sleep)
Most important	Adequate sleep	Hydration	Adequate sleep	0.15	0.0	0.001
Second important	Hydration	Adequate sleep	Healthy diet	0.025	0.0	0.044
Third important	Healthy diet/balance	Healthy diet	Balance	0.3	0.109	0.427
How important is each of the following to you to maintain a healthy lifestyle with the life you are leading now? (0: not at all important and 10: very important)
Hydration	8.3 ± 1.8	8.5 ± 1.8	8.9 ± 1.4	0.15	0.0	0.001
Healthy diet	7.6 ± 2.2	7.8 ± 2.1	8.9 ± 1.8	0.025	0.002	0.044
Weight-bearing exercise	7.5 ± 2.3	7.4 ± 2.5	7.8 ± 2.3	0.3	0.109	0.427
Weight lifting	5.6 ± 3.6	4.2 ± 3.1	3.9 ± 3.0	0.058	0.0	0.002
Adequate sleep	8.2 ± 1.9	8.4 ± 1.9	8.7 ± 1.6	0.121	0.003	0.022
How often do you do each of the following? (1) Never, (2) less than once a month, (3) once every few weeks, (4) once a week, (5) a few times a week, (6) once a day or more often
Do exercises such as yoga, Pilates, aerobics.	2.88 ± 1.84	2.46 ± 1.8	2.94 ± 1.69	0.624	0.002	0.008
Exercise indoors on a treadmill, elliptical, etc.	3.01 ± 1.83	2.54 ± 1.77	3.14 ± 1.72	0.305	0.001	0.003
Exercise outdoors by walking, running, hiking, etc.	4.2 ± 1.59	4.08 ± 1.72	4.2 ± 1.43	0.979	0.421	0.42
Get a good night’s rest	4.64 ± 1.27	4.97 ± 1.02	4.51 ± 1.25	0.143	0.0	0.001
Lift weights	2.68 ± 1.74	2.21 ± 1.66	2.88 ± 1.75	0.102	0.0	0.001
Participate in team sports such as tennis, pickleball, swimming, basketball.	2.07 ± 1.51	1.41 ± 0.91	2.45 ± 1.6	0.001	0.0	0.0
Track sleep, heart rate, activity, or steps through an app	3.35 ± 2.09	2.58 ± 2.08	3.4 ± 2.0	0.729	0.0	0.0
Wear a health monitoring device such as an Apple watch, Fitbit	3.15 ± 2.26	2.3 ± 2.06	3.28 ± 2.13	0.4	0.0	0.0

Bold text indicates significance (p < 0.05).

Weightlifting was considered less important among older adults (3.9 ± 3.0) compared to younger (5.6 ± 3.6) and middle-aged adults (4.2 ± 3.1; p = 0.0000 and p = 0.0002, respectively; Table 5). Despite these differences in perceived importance, frequency of engaging in weightlifting was higher among older adults (2.88 ± 1.75) and young adults (2.68 ± 1.74) than among middle-aged adults (2.21 ± 1.66; p = 0.0022 for young versus middle). Participation in team sports was lowest among middle-aged adults (1.41 ± 0.91) compared to young (2.07 ± 1.51) and older adults (2.45 ± 1.60; p < 0.0001 and p = 0.0207, respectively). Engagement with digital health tools also differed by age. Middle-aged adults were less likely to use apps to track health (2.58 ± 2.08) or wearables such as an Apple Watch or Fitbit (2.30 ± 2.06) compared to young (3.35 ± 2.09 and 3.15 ± 2.26) and older adults (3.40 ± 2.00 and 3.28 ± 2.13; p < 0.01 for both comparisons).

Discussion

In this cross-sectional study, we observed that while older adults placed greater importance on balance compared to their younger and middle-aged counterparts, all adults uniformly regarded balance as important. Declining balance begins in the late 40s–50s and is the number one cause of falls often leading to a loss of independence and early mortality.^21,28–30 Thus, perhaps not surprisingly, each age group rated maintaining balance over 5 years as becoming more important over time. The rating of balance as being highly important observed among young and middle-aged adults was unexpected. Despite recognizing balance as important, all groups demonstrated a lack of understanding of age-related balance decline as evidenced by lower agreement that they expected balance to decline with age. If there were higher awareness that balance declines with age, there might be more interest in balance exercise programs earlier in life. Taken together, these survey findings highlight the need for education about balance and balance training beginning in early to mid-life and periodic evaluation of balance as persons age.

Underscoring their opinions of balance importance, the majority of respondents across all age groups rated their balance as good or very good. However, between 15% and 31% had never attempted standing on one leg for 30 s, a common clinical test, and 25%–50% who had attempted it reported being unable to do so. One possible explanation is that single-leg stance is not perceived as a functional daily task, and individuals may not be aware of its relevance as a balance assessment. Further, our findings are similar to previous estimates that 20%–50% of adults over 65 are unable to hold single-leg stance for at least 10 s. ³¹ The percent of older adults who reported having a fall was slightly higher than the national average (25%–33%).^5,32 However, over 30% of both younger and middle-aged adults reported having fallen which is higher than previous estimates (18% and 21%, respectively). ³³ Our finding that younger and middle-aged adults reported higher fall rates than typically observed in prior studies may reflect several factors. Younger populations may engage more frequently in higher-risk physical activities, encounter environmental hazards such as uneven workspaces, or experience occupational risks that increase fall likelihood. Additionally, increased health awareness or willingness to report falls in survey-based studies may have contributed to these findings. ³³ Additionally, survey-based self-report may contribute to higher observed rates due to recall bias or increased willingness to report falls compared to prospective studies.^33,34 Previous research also suggests that longer recall intervals can inflate reported fall rates. ³⁴ The observed discrepancy between responses to the general question about falling or stumbling and the more specific question about falls in the past 12 months may reflect differences in participant interpretation. Respondents may have viewed “falling or stumbling” as including minor or brief balance losses, while “fall in the past 12 months” may have been interpreted more narrowly as a medically significant or injurious event. This highlights the importance of precise language when assessing fall history in both research and clinical contexts. As fall prevention is typically targeted to older adults, this finding highlights the need to consider interventions for people in earlier life. The discrepancy between balance self-assessment and performance may be explained by a poor understanding of balance among the general public and/or by never having undergone a balance assessment by a healthcare professional. ³⁵ Other research has found that older adults often attribute falls to external events and circumstances. ³³ For example, an individual who falls may ascribe the event to an issue with the environment (e.g. a step that was not clearly marked). Overall, there may be a lack of awareness of the connection between poor balance and falls. Although evidence-based interventions for fall prevention and balance training are well-established, real-world uptake remains limited.^18,19 Barriers include lack of awareness, low perceived need among younger populations, and limited access to tailored programs. These findings reinforce the urgent need for accessible, scalable, and engaging interventions to promote balance training earlier in life. ³⁶ Our results also align with the 2022 World Guidelines for Falls Prevention and Management, which emphasize early screening, balance training, and scalable exercise-based interventions as key fall prevention strategies. ¹² Yet, our data highlight that many adults—even those who value balance—may be unaware of or unengaged in balance-related assessments or training, indicating a gap between guideline recommendations and public awareness.

Exercise habits varied notably by age group, with the middle-aged group engaging in exercise the least. This aligns with prior research showing that physical activity levels often decline during middle age, driven by time constraints, shifting priorities, and increasing responsibilities—despite rising health risk during this life stage. ³⁷ Although weightlifting was rated as least important across age groups, younger and older adults reported engaging in it more frequently than middle-aged adults. Middle-aged adults also demonstrated the lowest engagement in team sports and digital health tools (e.g. wearables, tracking apps), suggesting that midlife may represent a critical window of under-recognized opportunity for preventive health interventions. Conversely, activities like outdoor walking and sleep were more uniformly practiced across age groups and rated as highly important. These results highlight that while balance and health are generally valued, there are discrepancies between perceived importance and behavioral follow-through, particularly for strength-based and technology-supported strategies. Engagement in mind-body or flexibility-focused exercises such as yoga and Pilates was also low across all groups, further reinforcing the need to encourage a wider variety of exercise modalities earlier in life. Given that these types of exercises can play a meaningful role in improving balance, coordination, and fall prevention, their low adoption underscores the importance of earlier, targeted education and promotion efforts. As such, these findings underscore the need for age-tailored interventions to close gaps between awareness and action, especially among middle-aged adults.

Implications for clinical practice

Although fear of falling and self-reported falls were commonly reported, few participants across age groups sought medical advice for balance issues, suggesting a potential under recognition of fall risk. Previous research has reported that even among older adults with recent falls, the frequency of clinical discussions surrounding fall risk and fall prevention is relatively low. ³⁸ One reason for this observation might be both the patient’s and treating provider’s assumptions that declining balance is an inevitability with aging rather than a trainable skill. There may also be insufficient time for discussing and evaluating balance during brief primary care visits and multiple health concerns. Lastly, many healthcare providers may be ill-prepared to provide recommendations due to low levels of education about balance and fall prevention as part of their medical training. ³⁹

Current fall prevention guidelines target adults aged 65 and older who generally are at a higher risk for falls compared to younger individuals. ⁴⁰ While this strategy may help those most at risk for falls, it fails to address the role of early intervention to reduce the chances of falling among middle-aged adults. Since balance ability starts to decline from ages 40 to 50,^21,28 middle-aged adults may benefit from initiating a routine balance training to mitigate age-related balance decline. Indeed, there is strong rationale for initiating fall prevention practices in earlier life, with other research demonstrating a sharp increase in the incidence of falls in middle-age. ¹ Given that a history of a prior fall is the strongest predictor of future falls, ³⁴ focusing on primary fall prevention among middle-aged as well as older adults is a pressing public health need.

Limitations and strengths

Our study has several limitations. First, the survey was not previously validated. A standardized questionnaire assessing knowledge, attitudes, and beliefs about balance was not readily available, and thus, the survey questions were developed by the study authors (P.C., A.G., A.K., K.B.) and pilot-tested with a representative sample of 10 English-speaking adults (~1% of the final sample) release on ACUPOLL. Because the survey was designed to inform the development of a balance intervention rather than to test specific hypotheses, we prioritized breadth of concept coverage over psychometric evaluation. As a result, internal consistency and construct validity were not formally assessed. Without established psychometric properties, there is a possibility that some items may not have accurately captured the intended constructs, potentially introducing measurement error. This limitation may have attenuated observed associations or limited the generalizability of our findings. Future studies should include the development and formal validation of a standardized instrument to assess balance-related knowledge, attitudes, and beliefs across diverse populations. Specifically, we recommend rigorous psychometric evaluation—including assessments of reliability, internal consistency, and construct validity—using independent cohorts. This will strengthen methodological rigor and support the use of these tools in both research and clinical practice. Second, our recruitment strategy, which relied on the ACUPOLL database and convenience sampling methods, introduces the potential for selection bias. Participants who choose to complete online surveys may differ systematically from the general population in ways that influence their knowledge, attitudes, and beliefs about balance, such as being more health-conscious or more technologically literate. This selection bias could limit the generalizability of our findings to the broader U.S. adult population. Third, although we achieved a large sample size with national representation, the cross-sectional design precludes any causal interpretations. Furthermore, we were unable to adjust for physical function, comorbidities, or socioeconomic status, which may influence balance-related knowledge, attitudes, and beliefs. As this study was exploratory, our focus was descriptive rather than causal. Future studies should account for these factors to better understand their impact. Fourth, while we assessed general physical activity, we did not ask about participation in balance-specific exercises (e.g. tai chi, tandem walking). This limits our ability to interpret how targeted balance training may relate to falls or perceived balance ability. Future studies should explicitly assess balance-focused exercise behaviors. This study also had notable strengths. First, it is the first to explore in depth the knowledge, attitudes, and beliefs about balance in adults across a spectrum of ages starting at age 30. Second, to the authors’ knowledge, only one prior study has explored perceptions of balance which was measured as a binary (yes/no) response to the question, “do you think your balance is poor?” ⁴¹ Third, this study has a large sample size with national representation, suggesting reasonable generalizability of findings to the U.S. population.

Conclusion

Younger and older U.S. adults alike endorse the importance of balance, especially as one ages. Similar to previous studies, the self-reported history of falling in the past year was estimated to affect about one-third of the study sample, but this study differed from previous reports in that the prevalence of falls was the same among younger age groups. In addition, while most respondents rated their balance as good or very good, their balance performance assessed by self-reported one leg stance was suboptimal with about 25% of those age 30–50, 39% of those age 51–65, and 51% of those >65 years of age, being unable to stand on one leg for more than 30 s. Since it is well established that poor balance and past falls are strong predictors of future falls, public health efforts targeting balance performance starting well before the age 65 are warranted. Specific strategies to address the gaps identified in this study include (1) expanding public health education campaigns to emphasize that balance decline begins in midlife and is modifiable through exercise; (2) integrating brief balance assessments (e.g. one-leg standing tests) into routine primary care visits starting in midlife; and (3) promoting balance training exercises as a core component of physical activity guidelines for adults of all ages. Importantly, qualifying educational programs for nurses, allied health professionals, and medical practitioners should incorporate training on early identification and intervention for balance decline, to better equip clinicians with the knowledge to support fall prevention across the lifespan. Increasing access to preventive diagnostics and balance-focused interventions for middle-aged and older adults could reduce future fall risk, maintain independence, and improve healthcare system efficiency.