Relationship between fall experience and fear of falling, health literacy, and self-efficacy among community-dwelling older adults

Abstract

[Purpose] This study aimed to examine the relationship between fall experience and fear of falling, exercise-related health literacy, and self-efficacy in community-dwelling older adults. [Participants and Methods] A total of 360 community-dwelling older adults participated in the study. Surveys assessed fall experience, fear of falling, exercise-related health literacy, and exercise self-efficacy. Mean scores for these variables were compared between groups with and without fall experiences and between those with and without fear of falling. [Results] No significant differences in health literacy or self-efficacy were observed between the groups with and without fall experiences. However, self-efficacy was significantly higher among those without fear of falling than among those with fear of falling. [Conclusion] Lower self-efficacy was observed among individuals with fear of falling, indicating that fall prevention strategies should address both fear reduction and self-efficacy improvement to promote continued physical activity.

INTRODUCTION

Falls in old age lead to a decline in both activities of daily living (ADLs) and quality of life (QOL) among older adults. In Japan, nearly 10,000 people die each year from accidents, such as tripping or falling. This figure exceeds the annual number of fatalities caused by traffic accidents. As the population continues to age, the number of deaths resulting from such accidents is gradually increasing¹⁾. Falls and related fractures are among the leading causes of the requirement of assistance in daily living among older adults²⁾. The social consequences of fall-related injuries are profound, including increased medical and long-term care costs and a greater need for support from families and communities. As Japan’s population continues to age, the prevention of falls among older adults has become a pressing issue.

Although numerous studies on fall prevention exist, exercise interventions that combine strength and balance training are considered more effective compared with interventions focusing on either approach alone³⁾. In contrast, comprehensive interventions, including exercise, environmental modifications, education, and psychological strategies, are believed to have greater effectiveness regarding fall prevention⁴⁾. Falls in old age also have psychological consequences, regardless of whether an injury results in musculoskeletal impairment. The fear of falling can reduce physical activity levels, increasing vulnerability to frailty and dependency^{5, 6)}. These experiences are collectively known as post-fall syndrome. Therefore, preventing falls and reducing the fear of falling are critical priorities not only for reducing musculoskeletal disorders but also for addressing the psychological effects associated with the syndrome.

In recent years, health literacy and self-efficacy have gained attention as key factors for promoting healthy aging and preventing falls^7,8,9). Health literacy refers to the ability to comprehend, assess, and apply health-related information^{10, 11)}, while self-efficacy is confidence in one’s ability to perform actions required to reach a goal or manage a task in specific situations^{12, 13)}. However, the relationship between fall experiences and the fear of falling and the roles of health literacy and self-efficacy in older adults remain unclear. Examining these connections will provide valuable insights into the design of comprehensive fall prevention strategies. Hence, this pilot study aimed to cross-sectionally explore the relationship between fall experiences and the fear of falling and health literacy and self-efficacy among community-dwelling older adults participating in a local exercise program in Japan.

PARTICIPANTS AND METHODS

The study participants were 380 community-dwelling older individuals residing in “A” Ward, Tokyo. The participants were enrolled in 13 voluntary community exercise classes within the ward. The participants consisted of 120 men and 260 women, mean age was 75.0 years. These exercise classes were locally developed with support from the “A” Ward Office, the “A” Ward Community Comprehensive Support Center, and university faculty, who contributed to the design and content of the exercise programs. However, the classes were primarily conducted by the participating elderly residents themselves, following a resident-led mutual aid model. This approach, called “Kayoinoba”, is recommended nationwide by the Japanese Ministry of Health, Labour and Welfare and is widely implemented across Japan¹⁴⁾.

The initial participants were recruited through outreach by staff from the aforementioned local government agencies. Subsequent enrollment occurred through word-of-mouth among stakeholders and existing participants. As the initiative emphasizes the cultivation of social capital, known as interpersonal connections, no inclusion or exclusion criteria were applied for participation. As demographic items, age, sex, body mass index (BMI) were investigated. And also fall experience within the past year, presence or absence of the fear of falling, exercise-related health literacy, and exercise self-efficacy were evaluated. Fall experiences and the fear of falling were assessed using the Kihon Checklist developed by the Japanese Ministry of Health, Labour and Welfare, which serves as a screening tool for frailty¹⁵⁾. The checklist comprises 25 yes/no questions covering domains such as daily living function, musculoskeletal function, nutritional status, oral function, cognitive function, and depressive tendencies. Frailty and prefrailty were determined based on the number of affirmative responses. This questionnaire is routinely administered in community settings and is familiar to the older residents. By using the Kihon Checklist, we hope to prevent variation in wording and make our research suitable for long-term longitudinal studies.

For this study, question no. 9 (“Have you fallen in the past year?”) was used to assess fall experience, and question no. 10 (“Are you very anxious about falling?”) was used to assess the fear of falling. Health literacy regarding exercise was evaluated through questions related to the exercises regularly performed in the classes. These questions addressed exercise techniques, expected effects, and muscle groups involved, as explained in the instructional DVD materials used during the sessions. Twelve multiple-choice questions were developed: four on correct exercise techniques (e.g., “When lifting your thighs while standing, should you ‘bend your upper body backward’ or ‘avoid bending it backward’?”), four on exercise effects (e.g., “What is the effect of sitting and straightening the knee joints?”), and four on identifying muscle groups by using anatomical illustrations. The total health literacy score was calculated by summing the number of correct responses. Exercise self-efficacy was assessed using four statements: 1. “I am confident that I can exercise even when the weather is unfavorable”; 2. “I am confident that I can exercise even when I feel slightly tired”; 3. “I am confident that I can exercise even when I am not in the mood”; and 4. “I am confident that I can exercise even when I am busy and short on time”. Participants rated each statement on a 5-point Likert scale ranging from 1 (“Not at all true”) to 5 (“Very true”). The total self-efficacy score was calculated by summing the responses to the four items.

Statistical analyses began with normality tests for health literacy and self-efficacy scores across groups categorized according to fall experiences and fear of falling. If normality was not confirmed, the Mann–Whitney U test and Kruskal–Wallis test were used to compare the mean values between groups. If normality was confirmed, an independent sample t-test and one-way analysis of variance were applied. Statistical significance was set at p<0.05. All analyses were performed using SPSS version 24 (IBM Corp., Armonk, NY, USA).

The study was conducted in accordance with the principles of the Declaration of Helsinki. The researchers provided both oral and written explanations to the participants who signed an informed consent form. The study protocol was approved by the Ethics Review Board of Mejiro University (approval no. 23-I 046).

RESULTS

Of the 380 study participants, 362 responded to question 9 regarding their fall experience. Among them, 82 reported having experienced a fall in the past year, whereas 280 reported having no such experience. Regarding question 10, 360 participants responded, with 147 reporting a fear of falling and 213 reporting no fear. In the assessment of health literacy, unanswered items were treated as incorrect responses. Regarding self-efficacy, non-responses were considered missing data and were excluded from the analysis. The number of valid responses differed between literacy and efficacy evaluations. The mean health literacy scores were 5.68 ± 2.7 and 5.85 ± 2.3, respectively, for participants with and without fall experiences. Regarding with or without the fear of falling, the mean literacy scores were 5.82 ± 2.4 and 5.81 ± 2.4, respectively. Intergroup differences in literacy scores were not significant (Table 1). In contrast, self-efficacy scores were 12.26 ± 3.6 and 13.06 ± 4.0, respectively, for participants with and without fall experiences. Regarding with or without the fear of falling, the efficacy scores were 12.19 ± 3.9 and 13.99 ± 3.8, respectively. While no significant difference was found between those with and without a fall experience, a significant difference was observed between those with and without the fear of falling (p<0.01) (Table 2).

Table 1. Differences between fall experiences.

			Fall experience
	Total		None		Yes
Items	n	Mean ± SD	N	Mean ± SD	n	Mean ± SD
HL	362	5.82 ± 2.4	280	5.85 ± 2.3	82	5.86 ± 2.7
SE	327	12.91 ± 3.9	259	13.06 ± 4.0	68	12.26 ± 3.6

HL: health literacy; SE: self-efficacy.

Table 2. Differences between the fear of falling.

			Fear of falling
	Total		None		Yes
Items	n	Mean ± SD	n	Mean ± SD	n	Mean ± SD
HL	360	5.82 ± 2.4	147	5.81 ± 2.4	213	5.82 ± 2.4
SE	324	12.94 ± 3.9	132	13.99 ± 3.8	192	12.26 ± 3.6*

*p<0.01. HL: health literacy; SE: self-efficacy.

Further analysis divided the participants into four groups based on their fall experiences and fear of falling: (1) “Fall experience: None / Fear of falling: None”, literacy score=5.91 ± 2.3 (n=129) and efficacy score=14.05 ± 3.9 (n=118); (2) “Fall experience: None / Fear of falling: Yes”, literacy score=5.81 ± 2.3 (n=151) and efficacy score=12.24 ± 4.0 (n=140); (3) “Fall experience: Yes / Fear of falling: None”, literacy score=5.11 ± 2.9 (n=18) and efficacy score=13.50 ± 3.1 (n=14); and (4) “Fall experience: Yes / Fear of falling: Yes”, literacy score=5.85 ± 2.7 (n=61) and efficacy score=12.80 ± 3.7 (n=51) (Table 3). Significant differences in the self-efficacy scores were observed among the four groups. Post hoc analysis revealed that the group with no fall experience and no fear of falling had significantly higher self-efficacy scores than both the group with no fall experience but fear of falling and the group with both fall experience and fear of falling.

Table 3. Differences between fall experiences and the fear of falling.

	Fall experience: None		Fall experience: None		Fall experience: Yes		Fall experience: Yes
	Fear of falling: None		Fear of falling: Yes		Fear of falling: None		Fear of falling: Yes
Items	n	Mean ± SD	n	Mean ± SD	n	Mean ± SD	n	Mean ± SD
HL	129	5.91 ± 2.3	151	5.81 ± 2.3	18	5.11 ± 2.9	61	5.85 ± 2.7
SE	118	14.05 ± 3.9†	140	12.24 ± 4.0	14	13.50 ± 3.1§	51	12.80 ± 3.7†§

^†p<0.01, ^§p<0.05. HL: health literacy; SE: self-efficacy.

DISCUSSION

This study explored the relationship between fall experience and the fear of falling with health literacy and self-efficacy among community-dwelling older individuals participating in local exercise classes. It aimed to provide insights that could inform the development of comprehensive fall prevention strategies. The results of this study should be interpreted considering the characteristics of the study population. Although the study participants were general community-dwelling older adults, it is possible that they were relatively health conscious from the outset. Moreover, because these individuals maintained regular social interactions through weekly exercise classes, it is important to recognize that the cohort represents a socially engaged group.

Approximately 22% of the participants reported experiencing a fall within the past year, a figure comparable to or slightly higher than that reported in previous study¹⁶⁾. Additionally, approximately 60% of the participants expressed a fear of falling, indicating a relatively high prevalence. The findings suggest that while fall experiences were not associated with health literacy or self-efficacy, the fear of falling was significantly associated with lower self-efficacy. In other words, the fear of falling may reflect an individual’s perceived ability to engage in activities without falling¹⁷⁾. Although the cross-sectional design of this study precludes conclusions regarding causality, the results imply that individuals who perceive themselves as likely to fall tend to have less confidence in initiating and maintaining their exercise routines. Although actual physical activity levels were not measured, previous research suggests that individuals without the fear of falling may be less physically active than those with this fear⁵⁾. Therefore, when designing interventions to prevent falls or promote physical activity, it is essential to include strategies that enhance self-efficacy, along with efforts to reduce the fear of falling. However, no significant association was found between health literacy and the fear of falling. However, considering training principles such as specificity and awareness, individuals with higher literacy, i.e., those who understand the targeted body parts and purposes of exercises, may achieve better outcomes. Thus, improving health literacy should be considered in interventions aimed at enhancing physical functioning.

As a preliminary survey, this study had several limitations. The primary limitation is its cross-sectional design, which prevents the determination of causal relationships between fall experiences or the fear of falling and levels of literacy or self-efficacy. Follow-up studies have been planned to investigate the changes in these variables over time. Additionally, responses regarding fall experiences were based on subjective recall over a 1 year period, which may not accurately reflect actual fall events. Details such as the number of falls or whether injuries occurred were not collected. Moreover, because the study was conducted in an urban area, the findings may not be generalizable to older adults living in rural settings. Future studies should include participants who do not engage in community activities in order to provide a more comprehensive understanding. Although this was a pilot study, we aim to expand our research and ultimately contribute to the development of effective intervention strategies.

Funding

This study was supported by a Grant-in-Aid for Scientific Research.

Conflict of interest

The authors declare no conflicts of interest.