DWELLING OLDER ADULTS IN DANANG, VIETNAM
TRAN THI HOANG OANH
(INTERNATIONAL PROGRAM)
the master and doctoral thesis support grant from Burapha University,
fiscal year 2015
ACKNOWLEDGEMENT
The success of this thesis was a result of the collaborative and supportive
effort from many people. I would like to take this opportunity to express my deep
appreciation and sincere gratitude to people who have contributed not only to the
completion of this study, but also to my pursuit of the degree.
Firstly, my sincere appreciation would like to give to my major advisor,
Assistant Professor Dr. Pornchai Jullamate – the person who has always been by my
side throughout my thesis completion. I am forever mindful his kindness,
thoughtfulness and encouragement which inspired me to do the best I could.
My special thank also would like to send to Assistant Professor Dr. Naiyana
Piphatvanitcha, my co-advisor, for her invaluable encouragement and kindness
guidance from my first time of practicing in community until I finished this thesis.
I wish to extend my thankfulness to the committee for their valuable
comments which help this study much better.
My deep gratitude goes to all lecturers and the staffs in the Faculty of
Nursing, Burapha University for their support and contribution during my study in
Burapha University as well as the thesis completion.
I would like to thank the head of Danang Unversity of Medical Technology
and Pharmacy and the head of health care centers as well as the participants in seven
selected communes in Danang city for their kind cooperation and help for me to
collect data successfully.
I would like to send my deep gratitude to The Project Program Health
Human Resource Development under Ministry of Health of Vietnam for their finance
support during two years of my study in Thailand.
I wish to express the deep thank to my beloved family, friends and
colleagues for their endless love, valuable supports and encouragements during my
study.
KEYWORDS: OLDER ADULTS/ COMMUNITY-DWELLING/ FEAR OF FALLING
TRAN THI HOANG OANH: FACTORS RELATED TO FEAR OF
FALLING AMONG COMMUNITY-DWELLING OLDER ADULTS IN DANANG,
VIETNAM. ADVISORY COMMITTEE: PORNCHAI JULLAMATE, Ph.D.,
NAIYANA PIPHATVANITCHA, Ph.D. 122 P. 2015.
Fear of falling is a common psychological problem of older adults. It can
lead to numerous long-term adverse effects on physical, and psychosocial function
and consequently affects the quality of life of older adults. This descriptive
correlational study aimed to investigate the level of fear of falling and to examine the
relationships between age, gender, history of fall, balance and gait status, general
health perception, activities of daily living (ADLs), depression and fear of falling in
community-dwelling older adults in Danang, Vietnam. 153 older adults who lived in
seven communes of districts in Danang, Vietnam were randomly selected to
participate in the study. Data were collected from February to May 2015 by using 6
structured interview questionnaires including a demographic questionnaire, the Fall
Efficacy Scale-International (FES-I), General Health Perception questionnaire, Barthel
Activities of Daily Living, Geriatric Depression Scale (GDS), and one of
performance-related test (the Timed Up and Go test [TUG]). The Cronbach’s alphas
of FES-I and Barthel ADLs were .98 and .95 respectively. Kuder-Richardson 20 of
GDS was .81 and the coefficient of stability of TUG was .98. Data were analyzed
using descriptive statistics, Pearson product-moment correlation coefficients,
Spearman’s rho correlation and point biserial correlation coefficient.
It was found that there was a high level of fear of falling among Danang
community-dwelling older adults (M = 34.95, SD = 11.36). Fear of falling was
significantly negatively related to ADLs, general health perception (rp = -.80, rsp = -.77,
respectively); but was significantly positively related to balance and gait status (TUG)
age, depression, history of falls and being female (rp = .75, rp =.54, rp =.45, rs =.39,
rpb = .28, respectively).
Fear of falling is more common in older adults who are old age, female, have
a history of fall, have poor balance and gait status, have poor health perception, have
greater ADLs dependency, and have depression. Future research on identifying the
predictors of fear of falling and examining intervention strategies for reducing the fear
of falling among community-dwelling older adults is recommended.
CONTENTS
Page
Conceptual framework ......................................................................... 8
Operational definitions ......................................................................... 11
Fear of falling ....................................................................................... 15
Self-efficacy theory .............................................................................. 22
Factors related to fear of falling in community-dwelling older adults. 24
Summary .............................................................................................. 32
Population and sample .......................................................................... 34
Ethical consideration ............................................................................ 43
characteristics, general health perception, balance and gait status,
ADLs and depression ........................................................................... 46
5 CONCLUSION AND DISCUSSION ........................................................... 54
Conclusion ............................................................................................ 54
Discussion ............................................................................................ 55
REFERENCES ....................................................................................................... 67
APPENDICES ........................................................................................................ 83
2 Sampling procedure ..................................................................................... 36
characteristics of community-dwelling older adults ................................ 47
2 The frequency and percentage of general health perception of
community-dwelling older adults ............................................................. 49
3 The mean, standard deviations, range of balance and gait status, ADLs
and depression of community-dwelling older adults .............................. 49
4 Frequency, percentage, range, mean and standard deviation of each level
of fear of falling ...................................................................................... 50
5 Mean and standard deviation of each item of FES-I about fear of falling 51
6 Relationship between age, gender, history of falls, ADLs, depression,
balance and gait status and fear of falling ................................................ 52
7 Normal distribution of age, Barthel ADLs, depression, balance and gait
status and fear of falling .......................................................................... 103
CHAPTER 1
Background and significance
The world has experienced a dramatic increase in the number of aging
population. It has become one of the most important considered problems of many
countries during the past few decades. Especially, national health care systems have
been coping with numerous health problems of older adults. Among them, fall is one
of the most common and problematic issues that we have to concern when taking care
of elderly. Globally, it is a major public health problem (World Health Organization
[WHO], 2012 b). According to WHO (2007) global report on falls prevention in older
age, there are approximately 28 - 35 % of people 65 years of age and over fall each
year. This number significantly increases to 32 - 42 % for those over 70 years old. It is
the second leading cause of accidental or unintentional injury deaths worldwide
(WHO, 2012 b) and the fifth leading cause of death in older persons (Rubenstein,
2006). In Vietnam, it is the sixth leading cause of death (Nguyen, 2011). As the
consequence, fall is serious threat to patient safety and results in disability, morbidity,
and mortality (Davis et al., 2010). Besides these physical consequences, falls also
result in many negative psychological impacts such as fear of falling, anxiety,
depression, loss of autonomy, dependence, emotional trauma, loss of self-confidence
in the ability to perform routine daily tasks, loss of self-efficacy and social isolation
(Scheffer, Schuurmans, van Dijk, Hooft, & De Rooij, 2008; WHO, 2007). Among
them, fear of falling is considered as an important and potentially serious problem in
older persons (Denkinger, Lukas, Nikolaus, & Hauer, 2014; Murphy, Williams, &
Gill, 2002).
Fear of falling is defined as a lasting concern about falling that can lead to an
individual avoiding activities that he/ she remains capable of performing (Tinetti &
Powell, 1993). It is also defined as “low perceived self-efficacy in avoiding falls
during essential, nonhazardous activities of daily living” (Tinetti, Richman, & Powell,
1990). This definition of fear of falling is partly based on Bandura’s theory of
self-efficacy that posits that a person’s beliefs about his/ her capabilities affect how
2
they behave in specific situations (Bandura, 1997). Particularly, elderly tend to avoid
the various activities if they belief that they will fall when they perform those
activities. Evidence suggests that fear of falling may develop as a result of these four
sources; enactive mastery experience, vicarious experience, verbal persuasion,
physiological and affective states (Tinetti & Powell, 1993).
Fear of falling is one of the most common and important psychological
consequences of falls (Evitt & Quigley, 2004; Murphy, Dubin, & Gill, 2003). With
many age-related changes including the reduced physical and psychosocial
functioning, high risk of fall and high phobias about their health, fear of falling have
high prevalence and numerous negative effects to older adults. It is common in
community-dwelling older adults, ranging from 3 % to 85 % (Scheffer et al., 2008;
Zijlstra et al., 2011). A higher prevalence of fear of falling has been described in 29 %
to 92 % of those who have fallen (Legters, 2002). However, it has also been reported
that up to half of the older adults who have never fallen have a fear of falling (Murphy
et al., 2003). Fear of falling can lead the elderly to be cautious, and contribute to fall
prevention through careful choices about physical activity due to a fear of further falls
(Murphy et al., 2003). Conversely, if older adults are fearful of falling when they
perform the non-hazardous activities, they tend to restrict many activities. This will
result in a plenty of negative consequences, not only the physical changes but also
psychosocial function and finally it might reduce the quality of life of older adults.
More particular, older adults with fear of falling may enter a debilitating spiral of loss
of confidence, restriction of physical activities, immobility with numerous serve
consequences such as osteoporosis, constipation (Li, Fisher, Harmer, McAuley, &
Wilson, 2003; Scheffer et al., 2008), increased physical frailty (Brouwer, Musselman,
& Culham, 2004), increased falls (Scheffer et al., 2008), loss of independence and
decreased social participation (Dias et al., 2011; Hellstrom, Vahlberg, Urell, &
Emtner, 2009). These negative consequences will lead to decreased quality of life and
life satisfaction (Kato et al., 2008; Scheffer et al., 2008). Additionally, it will lead to
increased medication use, care utilization cost, and institutionalized care (Cumming,
Salkeld, Thomas, & Szonyi, 2000; Deshpande et al., 2008; Yardley, Donovan-Hall,
Francis, & Todd, 2007). Thus, the impact of fear of falling may be as significant a
health problem as falls themselves.
3
Many researchers has studied about this phenomenon and they showed that
fear of falling in older adults are influenced with plenty of factors. From the results of
numerous previous studies, the most common and important associated factors of fear
of falling were age, gender, history of fall, balance and gait status, activities of daily
living, general health perception, and depression (Denkinger et al., 2014; Jorstad,
Hauer , Becker, & Lamb, 2005; Jung, 2008; Scheffer et al., 2008; Wongpanitkul,
Piphatvanitcha, & Paokunha, 2012). Consistently, according to self-efficacy theory, if
individuals had a prior history of fall that means they got a negative performance
experience; their self-efficacy about fall avoiding will be decreased. Furthermore,
another factors including balance and gait status, general health perception, activities
daily living and depression belongs to the fourth source of self-efficacy, physiological
and affective states.
Although age and gender have been related to fear of falling, findings from
previous studies have been inconsistent. Generally, fear of falling is associated with
increased age because of a range of age-related health problem such as reduced
physical and psychosocial functions, high risk of fall, and so on (Kumar, Carpenter,
Morris, Liffe, & Kendrick, 2014; Scheffer et al., 2008). In six studies from a systemic
review (Scheffer et al., 2008), age remained significant in multiple logistic regression
analyses. According to a study about factors associated with fear of falling in
community-dwelling elderly, 26.80 % older adult aged 65 - 69 have high concern
about falling and this percentage is highest with elderly 80 years old and over, 32.10 %.
The study also significantly revealed that the older adults who were 80 years old or
older were three times more likely to be fearful of falling (OR = 3.35, 95 % CI = 2.22
- 5.07) (Kumar et al., 2014). Conversely, several studies demonstrated that no
significant correlation was found between age and fear of falling (Gaxatte et al., 2011;
Sawa et al., 2014; Shin et al., 2010). In addition, with higher degree of health concern
(Gochman, 1997) and more frequent falls, female were consistently more likely have a
fear of falling than male in many studies (Kim & So, 2013; Kumar et al., 2014; Lach,
2005; Sawa et al., 2014). Considerably, one systematic review showed that 19 of 22
studies since 2006 and 25 of 31 studies before 2006 described the significant
relationship between female gender and fear of falling (Denkinger et al., 2014). On the
other hands, an exploratory study showed that male were more likely be fearful of
4
falling than female (Filiatrault, Desrosiers, & Trottier, 2009) and other studies found
that there is no association between fear of falling and gender (Deshpande et al., 2008;
Guthrie et al., 2012).
Having history of fall is one of the most terrible experiences of elderly.
According to self-efficacy, with this negative experience, elderly will be reduced their
self-efficacy about avoiding falling. In the other word, having history of fall can lead
to low fall efficacy or fear of falling. Consistently, it is also demonstrated as an
influencing factor of fear of falling with several previous studies (Cho et al., 2013;
Chu et al., 2011; Costa et al., 2012; Kim & So, 2013; Oh-Park, Xue, Holtzer, &
Verghese, 2011). Kim and So (2013) found that 95.9% older adults who have fallen
before had fear of falling and this group was six times more likely to have fear of
falling compared with the group of individual who have never fallen before
(OR = 6.41, 95 % CI = 4.93 - 8.32). Another study showed that people with higher
number of falls had more fear of falling. Particularly, there was 35.6 % of older adults
who had fall experience for one time and 38 % of older adults had more than one fall
within the past 12 months had fear of falling. Significantly, while the group of
individual who had one fall were 1.58 times more likely to have fear of falling
(OR = 1.58, 95 % CI = .77 - 3.24), the group of individual who had more than one
falls were about four times more likely to be fearful of falling (OR = 3.96,
95 % CI = 2.20 - 7.13) (Costa et al., 2012). It should be recognized, however,
individuals who have not fallen, also report fear of falling (Cho et al., 2013;
Kim & So, 2013; Lach, 2005; Murphy et al., 2003).
Balance and gait disturbances are the most common symptoms of older
adults and they are the important risk factors of fall among this population.
From several previous studies, they are also the important factors that relate to fear of
falling because with balance and gait disturbances, elderly will lose their confidence to
perform the activities without concern about falling (Gaxatte et al., 2011; Guthrie
et al., 2012; Kumar et al., 2014; Oh-Park et al., 2011). While Lopes et al. found that
fear of falling was moderately associated with balance and gait status (r = .46) (Lopes,
Costa, Santos, Castro, & Bastone, 2009), another study showed that the relationship
between fear of falling and functional mobility and balance is very high, r = .95 and r
= -.97 respectively (Kumar, Vendhan, Awasthi, Tiwari, & Sharma, 2008).
5
Significantly, one study about fear of falling in community older adults indicated that
those who had problem with functional ability (balance and gait disorder) were
thirteen times more likely to have fear of falling (OR = 13.08, 95 % CI = 8.43 - 20.29)
(Kumar et al., 2014). Similarly, another study about fear of falling of stroke patients
showed that elderly with impaired functional mobility and impaired balance were
more likely to have low fall self-efficacy (OR = 28.2, 95 % CI = 9.1 - 87.1 and
OR = 16.4, 95 % CI = 5.9 - 45.6 respectively) Andersson, Kamwendo, & Appelros,
2008). Furthermore, numerous studies indicated that older adults who had fear of
falling are more likely to have balance and gait disorders (Austin et al., 2007; Gaxatte
et al., 2011; Oh-Park et al., 2011).
Activities of daily living (ADLs) are basic daily self-care activities (Wade &
Collin, 1988). Dependent ADLs are also indicated as a related factor of fear of falling
in older adults based on results of several studies (Kim & So, 2013; Lawson &
Gonzalez, 2014; Patil, Rasi, Kannus, Karinkantan, & Sievanen, 2014). According to
Kim and So (2013), 92.40 % elderly with dependent ADLs feared of falling while there
was only 75.00 % of elderly independent ADLs that had fear of falling (OR = 1.44;
95 % CI = 1.06 - 1.95). Similarly, the study of Kempen, Van Haastregt, Zijlstra, Beyer,
& Freiberger (2009) found the same result. Several studies indicated that the older
adults who have difficulty with ADLs were approximately 2.5-fold more likely to be
fearful of falling compared with those who were independent in ADLs (OR = 2.48
[Chu et al., 2011]; OR = 2.51 [Curcio, Gomez, & Reyes-Ortiz, 2009]). Another study
found that the relationship between ADLs and fear of falling was significantly
moderate (r = -.46) (Shin et al., 2010). Notably, a study about fear of falling in women
with history of fall showed that the risk for having a high concern about falling was
increased many times with greater dependence in ADLs (OR = 38.30; 95 % CI = 11.10
- 131.50) (Patil et al., 2014).
General health perception is described as the subjective rating by the affected
individual of his or her general health status and it may be decreased in older adults
(Wilson & Cleary, 1995). It has been shown that general health perception has an
association with physical and mental health status of individual (Hennessy, Moriarty,
Zack, Scherr, & Brackbill, 1994). Therefore, older adults with lower general health
perception may have lower health status, lower confidence about their health as well
6
strongly associated with fear of falling among community-dwelling elderly. Those
with lower general health perception were more likely to be fearful of falls (Denkinger
et al., 2014; Kim & So, 2013; Kumar et al., 2014; Tiernan, Lysack, Neufeld,
Goldberg, & Lichtenberg, 2014). A range of previous studies significantly found that
older adults who had lower general health perception were more likely to be fearful of
falling (OR = 2.85 [Kumar et al., 2014]; OR = 1.82 [Kim & So, 2013]; OR = 6.93
[Zijlstra et al., 2007]). Additionally, two systematic reviews about fear of falling in
community-dwelling elderly stated that general health perception is one of the
potentially modifiable risk factors of fear of falling (Denkinger et al., 2014; Scheffer
et al., 2008). However, the other study differently showed that the relationship
between fear of falling and general health perception was not significant (Filiatrault et
al., 2009).
Depression is one of the most common psychosocial problems of older
adults. Based on self-efficacy, depression can influence the elderly judgments of their
personal efficacy (Bandura, 1997). It has been demonstrated to be significantly
associated with a fear of falling among community dwelling older adults (Chu et al.,
2011; Denkinger et al., 2014; Kim & So, 2013; Oh-Park et al., 2011; Painter et al.,
2012; Tiernan et al., 2014). The depression may be a result in their lack of activity,
reduced social support, loneliness and fear of falling. It has also been hypothesized
that depression and/ or the medication being take to treat depression contributes to
falls and associated fear of falling (Gagnon, Flint, Naglie, & Devins, 2005). After
reviewing literature, Denkinger et al. (2014) significantly stated that depression was
an important modifiable risk factor of older adults with fear of falling. Several studies
indicated the significant relationship between depression and fear of falling among
community-dwelling elderly and they stated that depressed individuals were
approximately twice or over twice more likely to have fear of falling compared with
non-depressed elderly (Austin et al., 2007; Kempen et al., 2009; Kim & So, 2013;
Kressig et al., 2001; van Haastregt, Zijlstra, van Rossum, van Eijk, & Kempen, 2008).
Notably, in a study about psychosocial and physical factors showed that the
prevalence of depressed elderly with fear of falling is very high compared with those
without depressive symptoms (OR = 6.73, 95 % CI = 3.03 - 14.93) (Chu et al., 2011).
7
On the other hand, some studies stated that there is no significant relationship between
depression and fear of falling (Hull, Kneebone, & Farquharson, 2013; Painter et al.,
2012).
Vietnam is a Southeast Asian country with the rapid increasing numbers of
older adults. In 1999, 8.1 % of overall population was older adults and this percentage
increased to 9.9 % in 2009. It is also estimated to 11.4 % in 2020 and 26 % in 2050
(Nguyen, 2009). Similar to the other countries, Vietnamese older adults have to face
with a plenty of age-related health problems. Among them, fall is a quite common
one. To, Huynh, Nguyen, Truong, & Dinh (2015) found that there are 12.10 % of
Vietnamese older adults had fall experience. They also showed that one of the
important consequences of fall in older adults was fear of falling which can lead to the
physical restriction, reduced the confidence and increased dependence.
Danang is an important and developing city which located in the middle of
Vietnam. It is also recognized as aging city with increasing numbers of older adults.
According to the survey of Le (2014), there are over 8 % of populations being older
adults. Most of them are living with their family within their homes. In Vietnamese
culture, older adults are highly respected and beloved person in their families. They
are likely not to be encouraged to do many activities, because their children prefer
taking care of them and also preventing them from falls. This will decrease the
confidence of older adults and increase their fear of falling when they perform any
activity (Tinetti & Powell, 1993). Additionally, Danang is an industrial and
commercial developing city with traffics jams. There are not many social activities as
well as the health promotion programs especially for older adults. These might be the
reason why most of older adults normally stay at their homes and in turn, they will
lose their fall related self-efficacy. Thus, it is necessary to better understand the fear of
falling among older adults in order to reach for further interventions of reducing fear
of falling to improve the older adults’ quality of life.
In conclusion, fear of falling is one of the most common and adverse problem
of older adults. Many studies have been identifying a variety of factors affecting fear of
falling. Among them, age, gender, history of fall, balance and gait status, activities of
daily living, general health perception, and depression were found to be reliable factors
and they were demonstrated with many research findings. It is also consistent with self-
efficacy theory. However, most of those studies were conducted in the Western
8
countries and developed countries. Vietnam has different characteristics, not only the
natural conditions, but also the socioeconomic as well as culture. So, it is not absolutely
appropriate to apply those results in Vietnamese older adults. Based on published
literature review, there is no study about fear of falling in Vietnam, especially in Danang
city. Therefore, this study was conducted in order to better understand about fear of
falling and its related factors among Vietnamese community-dwelling older adults and
filled the gap of knowledge of Vietnamese older adults’ fear of falling. Once the factors
associated with fear of falling are clarified, it can provide guidance for identifying older
adults who are at risk of fear of falling. More significantly, it is the basic knowledge and
the evidence for further researches that can promise an effective nursing strategy to
prevent and reduce the excessive fear of falling, promote health and enhance the quality
of life among this population.
Research questions
Specifically, the research was conducted to answer two questions:
1. What was level of fear of falling among community-dwelling older adults
in Danang city, Vietnam?
2. Did age, gender, history of fall, balance and gait status, activities of daily
living, general health perception, and depression relate to fear of falling among
community-dwelling older adults in Danang city, Vietnam?
Research objectives
The objectives of this study were as follows:
1. To investigate the level of fear of falling in community-dwelling older
adults in Danang city, Vietnam.
2. To examine the relationships between age, gender, history of fall, balance
and gait status, activities of daily living, general health perception, depression and fear
of falling in community-dwelling older adults in Danang city, Vietnam.
Research hypotheses
1. Age, gender (female), history of fall and depression were positively
related with fear of falling among community-dwelling older adults in Danang,
Vietnam.
9
2. Balance and gait status, activities of daily living, and general health
perception were negatively related with fear of falling among community-dwelling
older adults in Danang, Vietnam.
Scope of the study
This correlational descriptive study aimed to investigate the level of fear of
falling and the relationship between age, gender, history of falls, balance and gait,
activities of daily living, general health perception, depression and fear of falling
among community-dwelling older adults in Danang city, Vietnam. The data was
collected during February to April 2015 in 153 older adults who have been living in
7 communes of Danang city, Vietnam.
Conceptual framework
Fear of falling is an emerging concept with many different definitions and
measurements. It has been broadly defined as “low perceived self-efficacy in avoiding
falls during essential, nonhazardous activities of daily living” (Tinetti et al., 1990).
Within this broad definition it has been conceptualized as fall-related self-efficacy,
balance confidence, fear, activity avoidance, and concern about falling (Jorstad et al.,
2005). In this study, it is used as the broad conceptualization as low fall-related self-
efficacy that leads to an individual avoiding activities that older adult remains capable
of performing. These activities are not only physical activities in his/ her house but
also the social activities within his/ her community.
Bandura’s theory of self-efficacy served as the conceptual framework for
this study based on the conceptualization of fear of falling as fall-related self-efficacy.
Bandura (1997) stated that self-efficacy is an individual’s judgment about being able
to perform a specific behavior and whether it is accurate or faulty, and based on four
principle sources of information: enactive mastery experience, vicarious experience,
verbal persuasion, physiological and affective states. This study focuses on the first
source, enactive mastery experience which is history of fall and the fourth source,
physiological and affective states which are balance and gait status, general health
perception, activities of daily living and depression.
10
accomplishment is the most influential source of efficacy information. It generally
leads to increased self-efficacy expectations better than the other informational
resources (Bandura, 1997). Conversely, negative experience will reduce the self-
efficacy. In the other words, it can lead to low self-efficacy (Bandura, 1997).
Practically, elderly who experienced previous fall will be likely to have fear of falling.
Bandura (1997) also stated that physiological states affected the judgment of
individual’s capabilities. Older adults often rely on their physical health to judge their
own abilities to perform any activities without falling. The thoughts on age related
changes as well as clinical abnormality on their balance and gait status, their
dependent abilities to perform daily activities and their general health perception
might reduce older adults’ level of concerning about falling when they do some
activities.
Theoretically, mood can affect individual’s judgments of their personal
efficacy (Bandura, 1997). While the positive mood activates the thoughts of
accomplishments, the negative mood activates thoughts of the past failings.
Depression is one of the negative moods, often occurred in older adults. It might
influence the fall related self-efficacy of older adults because of recalling of failures
about fall avoiding.
Consistently, numerous previous studies have shown that fear of falling in
community-dwelling older adults related to history of falls (Hull et al., 2013; Kumar
et al., 2014; Oh-Park et al., 2011), balance and gait status (Gaxatte et al., 2011;
Guthrie et al., 2012; Lopes at al., 2009; Rochat et al., 2010), activities of daily living
(Lawson & Gonzalez, 2014; Kim & So, 2013; Patil et al., 2014), general health
perception (Kim & So, 2013; Kumar et al., 2014; Tiernan et al., 2014; Zijlstra et al.,
2007) and depression (Denkinger et al., 2014; Painter et al., 2012; Tiernan et al., 2014).
Additionally, based on literature review with many significant results from a
range of previous studies, age and gender were described to have significant
relationships with fear of falling among older adults (Hull et al., 2013; Kempen et al.,
2009; Kumar et al., 2014; Oh-Park et al., 2011; Scheffer et al., 2008).
The relationships between all variables with fear of falling were depicted as
the research framework in figure 1.
11
Operational definitions
Fear of falling refers to lasting concern about fall when the older adults
perform the essential and non-hazard activities. It was measured by the Falls Efficacy
Scale-International (FES-I) (Yardley et al., 2005).
Community-dwelling older adult is any individual aged 60 years old or
older who lives in their home within the community either with a spouse, family,
relatives, other adults or alone in Danang city.
Age refers to the numbers of years that older adults have lived from the date
of birth until the date the data collection.
History of fall refers to the number(s) of falls that older adults experienced
within last year.
Balance and gait status refers to independent mobility which is the ability
of individual to get in and out of bed and chair, get on and off a toilet and walking a
few feet. It is measured by the time that individual need to get out the chair, walk for 3
meters, come back and get in the chair. It was measured by the Timed Up and Go test
(Podsiadlo & Richardson, 1991).
Gender
Age
12
General health perception is subjective rating by the affected individual of
their health status. It was measured with item one of the MOS SF-20 (Stewart, Hays,
& Ware, 1988).
Activities of daily living refers to dependence level of individual to perform
the basic daily activities including bowels, bladder, grooming, toilet use, feeding,
transfer, mobility, dressing, stairs, and bathing. It was measured by the Barthel Index
of ADL (Wade & Collin, 1988).
Depression refers to feelings of guilt, feelings of tiredness, low self-worth,
sadness, loss of interest or pleasure of individuals. It was measured by the Geriatric
Depression Scale: Short Form (Sheikh & Yesavage, 1986).
CHAPTER 2
LITERATURE REVIEWS
In this chapter, the reviews about issues related to the study were presented.
It began with overview about Vietnamese older adults. Then, an overview about fear
of falling including definition, prevalence, consequence and measurement; and the
perceived self-efficacy concept were reviewed. Finally, the relationship between
related factors and fear of falling among community-dwelling older adults were
focused.
2. Fear of falling
2.2. Definition of fear of falling
2.3. Prevalence of fear of falling in older adults
2.4. Consequences of fear of falling in older adults
2.5. Measurements of fear of falling
3. Self-efficacy theory
4. Factors related to fear of falling in community-dwelling older adults
4.1. Age
4.2. Gender
4.6. General health perception
Overview of Vietnamese older adults
The definition of elderly or older adults is different among each country due
to the difference of predominance of chronological time or social, cultural or
functional markers. In most developed countries, elderly are considered as people who
are over 65 years old. In 2013, United Nations agreed that elderly are people with 60
14
years of age and over. Similarly, in Vietnamese’s law about older adults, the older
adult is defined as an individual who is full 60 years of age or over (Nguyen, 2009).
According to United Nation Population Fund [UNFPA], Vietnamese
population is ageing with a historical unprecedented rate (UNFPA, 2013). Following
the sharp reductions in fertility and mortality and increased life expectancy, the elderly
population is increasing rapidly. In particular, as result of achievements in health care
and family plan projects, the fertility rate is decreased strongly from an average as
4.8 children in each family in 1979 to 2.07 children in 2007 and life expectancy is
increased significantly from 68.6 in 1999 to 72.2 in 2005 and predictively 75 years old
in 2020 (Thang & Hy, 2009).
Following age-related changes, the proportion of people with self-reported
poor health increases from 50 % at ages of 65 - 74 years to 81 % among those over 85.
A national report showed that 65.4 % of older adults rated that their general health was
very poor/ poor whereas the percentage of elderly thought that their health was fair
and good or very good were very low, 29.8 % and 4.8 % respectively. In fact, they
have to face with several health problems. Most of them have to withstand some of
impairments such as vision, hearing, and memory. Over one-third suffer acute diseases
while more than one-fourth suffers chronic diseases [Ministry of health (MOH), 2011].
According to the national report about older adults, blood pressure, arthritis, chronic
lung diseases, heart disease and cataract were the most common and important
diseases that older adults had to resist. Consequently, older adults have many
difficulties in mobility and performing activities of daily living. The older individuals
are, the more prevalence of them have problem with mobility and ADL performance.
According to the national survey about Vietnamese older adults, 89.70 % of older
adults aged 80 and over, 75 % of individual with ages from 70 to 79 had at least one
difficulty about mobility (MOH, 2011).
Among several health problems that Vietnamese older adults have to face
with, fall is one of the considerable issues as the first cause of injury and the first
leading cause of dead because of its related complications (Tran & Tran, 2014).
However, there are also numerous programs and solutions are published and applied
for fall prevention. Conversely, fear of falling, the common consequence of fall, also
one of the problematic health problems of older adults is still uncovered.
15
Definition of fall
In 1987, the Kellogg international working group on the prevention of falls in
the elderly defined a fall as ‘unintentionally coming to the ground or some lower level
and other than as a consequence of sustaining a violent blow, loss of consciousness,
sudden onset of paralysis as in stroke or an epileptic seizure’ (Gibson, Andres, Isaacs,
Radebaugh, & Wormpetersen, 1987). Since then, many researchers have used this or
very similar definitions of a fall.
Risk factors of fall in older adults
Frequency of falling in older adults is sometimes attributed to “multisystem
stability disorder” that arising from the accumulated effect of multiple disorders
superimposed on age-related changes. These multiple disorders or risk factors have
been studied extensively in order to predict and reduce falls and their sequelae.
Numerous retrospective and prospective studies have identified characteristics related
to falls. Risk factors for falls are usually categorized as biological factors, behavioral
factors socioeconomic factors and environmental factors. Firstly, biological factors are
the most important risk factors of fall including age, chronic illness and aged-related
changes such as muscle weakness, impaired balance, gait deficit, sensory impairment,
limited mobility, cognitive impairment, etc. Behavioral factors including those
concerning human actions, emotions or daily choices such as lack of exercise, multiple
medications use, unsafe activity performance and so on can affect negatively to fall in
older adults. However, they are potentially modifiable factors. Besides these two
important risk factors, the socioeconomic status including low income and education
levels, inadequate housing, lack of social interaction, limited access to health and
social services and the bad environmental conditions including home hazards and
hazardous features in public environment are associated with increased risk of falling
among elderly (WHO, 2007).
Consequences of fall in older adults
Falls heavily influence the quality of life of older adults, and they place a
burden on health care providers and the families of older adults. The negative
influences of falls can be categorized as physical consequences, psychological
consequences and economic consequences.
Physical consequences
Falls are a major cause of severe non-fatal injuries and are the second leading
cause of spinal cord and brain injury among older adults (WHO, n.d.). Approximately
30 - 50 % of falls result in minor soft tissue injuries. Overall, 20 - 30 % of those who
fall sustain moderate to severe injuries that limit mobility and independence and may
result in death. Nearly 30 % of older people experiences injuries to the hip, thigh,
knee, lower leg, ankle, or foot; 17 % experience injuries to the wrist and hand, and 14
% to the back and spine (Division of Aging and Seniors; Public Health Agency of
Canada, 2005), 46 % of elders sustained minor injuries such as bruises, sprain, and
abrasions (Kallin, Gustafson, Sandman, & Karlsson, 2004). According to WHO, fall-
related injuries is the third leading cause of disability (Pluijm et al., 2006).
Psychological consequences
Even non-injurious falls could cause psychological difficulties for the
elderly, including fear of falling, emotional trauma, loss of self-confidence in the
ability to perform routine daily tasks, loss of self-efficacy, self-imposed activity
restrictions, social withdrawal, and depression (O'Loughlin, Robitaille, Boivin,
& Suissa, 1993).
One of the most common psychological symptoms of falls is the fear of
falling (Evitt & Quigley, 2004). A higher prevalence of fear of falling has been
reported in 42 % to 73 % of those who have fallen (Lach, 2005; Murphy et al., 2003),
and the fear of falling reduced physical activity, activity of daily living, physical health
status, and quality of life in the elderly (Fletcher & Hirdes, 2002). Also, older adults
who have fallen report feeling helpless, depressed, anxious, powerless, fearful and
experienced low self-esteem, and tend to seek help from health care providers more
frequently than those who have not experienced a fall (Evitt & Quigley, 2004; Means,
Rodell, & O’Sullivan, 2005).
Economic consequences
Falls create a large cost burden for both the public and private purse,
regardless of how health and social care is funded. These were not only direct costs
of treatment and care, but also indirect costs of cost productivity from caregivers of
those who fell and opportunity costs associated with use of resources, which could
17
otherwise have been effectively used in another way. The largest components of this
cost are: mortality, lost quality of life, long-stay care costs and hospital inpatient costs
(Gannon, O'Shea, & Hudson, 2008).
Fear of falling
For better understanding toward fear of falling, its definition, the prevalence
and consequences of fear of falling are described.
Definition of fear of falling
One of the most common consequence and inversely also the common risk
factors of fall is fear of falling. The concept fear of falling has evolved over many
years. It has been defined in a range of different ways. Firstly, it is described as
“ptophobia”, which means a phobic reaction to standing or walking (Bhala,
O’Donnell, & Thoppil, 1982) and was subsequently classified as a “Post fall
syndrome” (Murphy & Isaacs, 1982). Other authors have mentioned that fear
of falling means a patient’s loss of confidence in his or her balance abilities (Maki,
Holliday, & Topper, 1991; Tinetti, Speechley, & Ginter, 1988). Based on Bandura’s
theory of self-efficacy, fear of falling is defined as “low perceived self-efficacy in
avoiding falls during essential, nonhazardous activities of daily living” (Tinetti et al.,
1990). Tinetti and Powell (1993) also described fear of falling as a lasting concern
about falling that can lead to an individual avoiding activities that he/ she remains
capable of. Fear of falling is also a psychological barrier to performing activities of
daily living and participating in physical activities (Bruce, Devine, & Prince, 2002).
For this study, the definition for fear of falling as “low perceived self-efficacy in
avoiding falls during essential, nonhazardous activities of daily living” was used.
Prevalence of fear of falling in older adults
Similar with fall, fear of falling is another common problem of older adults
with high prevalence. It is one of the most prevalence fears in older adults with the
highest rate among other common fears such as criminal violence, financial crisis, or
an adverse health event, being robbed on the street, forgetting an important
appointment or losing a cherished item (Deshpande et al., 2008). It is not only reported
by elderly who had fall experiences but also presented remarkably in others who have
never fallen before. In 1994, Tinetti et al. stated that there was 43 - 70 % of recent
falling elderly persons have acknowledged fear of falling compared to 20 –
46 % among elderly persons without recent fall. Likewise, Legters described that the
percentage of older adults who have not had fall history was 12 % to 65 % and this
number is higher in persons who have experienced fall, 29 % to 92 % (Legters, 2002).
Another updated systemic review from 21 studies focused on the prevalence of fear of
falling found that fear of falling was prevalent among 3 % of non-dizzy community-
dwelling older adults in one study, while the other studies reported a fear of falling
between 20.80 and 87 % (Scheffer et al., 2008). This prevalence is higher in older
women, those with physical frailty, those who have fallen before, those who perceive
they are in poor health, those with psychosocial problems, and in persons with certain
comorbidities such as rheumatoid arthritis and stroke (Deshpande et al., 2008; Sharaf &
Ibrahim, 2008). Furthermore, the prevalence of fear of falling in elderly in the other
settings is also reported highly. It was found up to 50 % to 65 % of residents of a
nursing home (Gillespie & Friedman, 2007; Kressig et al., 2001), 47 % of persons
attending a dizziness clinic (Burker et al., 1995), 66 % of patients on a rehabilitation
ward (Clague, Petrie & Horan, 2000), and 30 % of hospitalized elderly patients
without a specific diagnosis (40 % of those who had fallen and 23 % of those who had
not fallen) (Cumming et al., 2000).
Despite the variability in the prevalence of fear of falling which is likely due
to the various definitions, instruments used to measure fear of falling and sampling
differences (Legters, 2002; Scheffer et al., 2008), it is clear that fear of falling is a
pervasive health problem in the elderly.
Consequences of fear of falling
Fear of falling in elderly may results from previous fall and also occurs with
the elderly who are non-faller. It can be considered as a protective response to a real
threat, preventing the elderly from performing activities with high risk of falling
(Murphy et al., 2003). On the contrary, it can also lead to a restriction of the activities
that will result in a long-term adverse effect on physical, psychosocial functions of
elderly and lastly, reduce their quality of life.
Previously, fear of falling is described as “ptophobia” which means the
phobic reaction to standing or walking. Hence, restriction and avoidance of activities
is the major consequence of fear of falling (Boyd & Stevens, 2009; Deshpande et al.,
2008). Consequently, this can result in negative physical functions changes. Firstly,
19
demonstrating marked deficits in physical function. Particularly, it results in reduced
muscle mass, reduced flexibility (Lachman et al., 1998), reduced muscle strength
(Brouwer et al., 2004), gait changes, decreased stride length, and speed (Maki, 1997).
Accordingly, because of the abovementioned declines, fear of falling can be the risk
factor of future fall (Brouwer et al., 2004; Friedman, Munoz, West, Rubin, & Fried
2002; Fucahori, Correia, Lopes, Silva, & Trelha, 2014). Furthermore, activity
restriction can lead older adults to decrease their physical activities (Deshpande et al.,
2008; Scheffer et al., 2008) and their activities of daily living (Martin, Hart, Spector,
Doyle, & Harari, 2005; Scheffer et al., 2008). One study from Sydney, Australia
showed that individuals with poorer fall-related self-efficacy had greater declines in
ability to perform activities of daily living (p < .001) (Cumming et al., 2000). Another
study about the relationship between fear of falling and avoidance of nine everyday
activities critical to independence among community-dwelling older adults showed
that there was a positive association between fear of falling and activities avoidance
such as lifting, bending, walking, reaching, and going outside (Bertera & Bertera,
2008). Similarly, Suzuki, Ohyama, Yamada, & Kanamori, (2002) found that with
elderly females, walking and bathing had a highly significant relationship with fear of
falling, and the need for assistance with dressing and toileting tended to be
significantly associated with fear of falling. Significantly, a meta-analytic review of 20
cross-sectional and prospective studies showed that there was a strong positive
relationship between fall-related efficacy and activity engagement (r = .53; 95 % CI =
.47- .58) (Schepens, Sen, Painter, & Murphy, 2012). Furthermore, there is increasing
evidence of the role of physical activity in maintaining overall health status. Because
older adults who are afraid of falling may limit participation in physical activities,
fear of falling may result in some chronic conditions (e.g., cardiovascular disease,
diabetes). In the other words, by restricting and avoiding these activities because of
fear of falling, older adults may decrease their physical functions, increase risk of falls,
decrease ADLs and the less mobility they do, the lower their physical capacity they
becomes and their risk of falling increases. These impacts describe a downward spiral
of functioning.
affects the psychosocial functions of older persons adversely. Firstly, because of fear
20
of falling, older adults decrease their movements; they seem likely to be safe within
their home and their communities. They refuse to participate in any social activities
and this can lead them to social isolation (Clague et al., 2000). Secondly, several
studies showed that fear of falling might result in depression and anxiety because of
loss of confidence and increased social isolation (Dias et al., 2011; Hellstrom et al.,
2009). Finally, by declining physical functions, reducing social interactions, increasing
depression and anxiety, fear of falling can lead to reduced quality of life of elderly
(Brouwer et al., 2004; Suzuki et al., 2002).
Measurement of fear of falling
Based on the definition of fear of falling as the low self-efficacy about fall
avoiding, there are numerous different measurements have been developed to measure
individual’s confidence or belief in their ability to perform specific activities without
losing balance or falling.
Another scale developed by Canadian researchers, Powell and Myers, (1995)
is the Activities-Specific Balance scale. According to authors of ABC Scale
perspective fear of falling was defined as “balance confidence,” or confidence in the
ability to maintain one’s balance while completing certain selected activities (Talley,
Wyman, & Gross, 2008). This scale measures an individual’s confidence in doing
more specific tasks like, sweeping the floor, going up and down stairs and picking a
slipper off the floor (Powell & Myers, 1995). It includes 16 items, and each item starts
with “How confident are you that you will not lose your balance or become unsteady
while…?” in order to ask older adults to rate their balance confidence on a visual
analog scale (0 - 100, 0 point = no confidence; 100 point = complete confidence),
which are then totaled and divided by 16 to get the score. Any score 80 per cent or
greater demonstrates a high level of physical functioning; any score below 50 per cent
shows a low level of physical ability (Myers, Fletcher, Myers, & Sherk, 1998). This
measurement may be self-reported or administered by personal or telephone interview
(Powell & Myers, 1995). Comparable to FES, the ABC scale was found to be
internally consistent and demonstrated good test-retest reliability, and convergent and
criterion validity (Powell & Myers, 1995). Nevertheless, some activities in this scale
are quite difficult to all older adults to perform. Additionally, it is common used in
21
Western and developed countries so it is not absolutely appropriate for the setting of
this study. For instance, many items mention about car, car park, icy ground, mall,
elevator and so on, which are not common in Vietnamese country.
Falls Efficacy Scale (FES)
The FES was one of the first developed by Tinetti et al. (1990) and becomme
most frequently used measures of fear of falling reported in the literature (Evitt &
Quigley, 2004; Tinetti et al., 1990). This original scale examined the degree of self-
efficacy or self-perception an individual has for completing ten activities of daily
living without falling (uses a 10-point confidence rating, 0 = no confidence, 10 =
completely confident). Older adults are asked global questions that relate to the
confidence level an individual has about performing tasks. All of the questions start
with the phrase, “How confident are you that you can . . .?” and ends with the phrase,
“without falling” (Tinetti et al., 1990). In between these two phrases are ten tasks, “get
out of bed, take a shower, reach into cabinets, prepare meals, walk around the house,
light housekeeping, get dressed and undressed, answer the door or telephone, get in and
out of a chair and simple shopping" (Tinetti et al., 1990). Participants answer the
questions with a 10-point Likert scale with a score of 0 - 10 (Tinetti & Powell, 1993).
The total score is 0 - 100 and the higher FES the higher person's feelings of confidence
in performing household tasks without fear of falling. The internal consistency for the
FES is r = .92 (McAuley, Mihalko, & Rosengren, 1997) and the test-retest reliability
of r = .71 (Cumming et al., 2000).
Falls Efficacy Scale-International (FES-I)
Although the FES scale was found to be internally consistent and
demonstrated good test-retest reliability, and convergent and criterion validity (Powell
& Myers, 1995), it was criticized for some weaknesses. Firstly, it is likely to be
influenced by general estimations of functional capability and less closely associated
with fear and anxiety (Mckee et al., 2002). Secondly, the items on the original FES
refer almost exclusively to very basic activities of daily living that only frail or
disabled people would be likely to have difficulty with, and do not include the more
demanding activities which may be the principal cause for concern among higher
functioning older people (Yardley et al., 2005). Thirdly, none of the items of the
original FES directly concern about the relationship between fear of falling and social
22
life (Lachman et al., 1998). Hence, several of modified versions of original FES were
developed. Among them, FES-I was demonstrated as the most common usage in
clinical practice and research (Kempen et al., 2007; Yardley et al., 2005).
The FES-I was created to expand on the initial 10-item FES to include
instrumental and social activities that may be considered more challenging among
more active, functional people, potentially causing more fear of falling than the basic
activities presented in the initial FES. These additional activities correspond to items
11 - 16 on the FES-I. The Prevention of Falls Network Europe (ProFaNE) Committee
tested the FES-I using different samples of older adults in different countries (Kempen
et al., 2007). Additionally, the wording of the items was updated to account for cross-
cultural differences (Kempen et al., 2007; Yardley et al., 2005). According to
numerous above advantages, FES-I will be used in this study to examine the fear of
falling in community-dwelling older adults.
Self-efficacy theory
Perceived self-efficacy theory is developed based on the basic concept of
social learning theory proposed by Bandura (1997).
In social cognitive theory, Bandura points out that individuals’ behaviors do
not result from environmental factors alone but they also result from individual’s
internal factors including affective factors, cognitive factors, and biological factors.
Thus, individuals’ behaviors result from a causal structure, which consists of three
components of 1) the internal personal factor, 2) representing behavior, and 3) the
external environment. These three factors have reciprocal determination and are
dynamically interrelated. However, their influence depends on the situation or the
behaviors individuals intend to carry out (Bandura, 1997).
A major component of this theory is a construct referred to as self-efficacy; an
individual’s judgment about being able to perform a specific behavior. Self-efficacy is
thought to mediate between knowledge and behavior. In the other words, it is defined as
a decision made by each individual to or not to carry out a certain behavior. It can
control peoples’ desires, selection of behavioral courses, maintenance of attempt, and
affective reactions (Bandura, 1997). According to Bandura, in carrying out general
behaviors and healthcare behaviors, if individuals have low perceived self-efficacy,
23
they will not able to successfully do difficult behaviors. It is also possible that low
perceived self-efficacy makes individuals have no attention to behave and thus not
succeed in do the behavior. They shy away from difficult tasks, lack effort, give up
easily when faced with difficult tasks, are distracted by thought of personal deficiencies,
and attribute success to luck or ease of task and failure to lack of ability. In the other
words, if people believe that they have no power and ability to do something (e.g., do
not believe they can perform activities without falling), they will not attempt
performance to achieve (e.g., they do not perform those activities; Bandura, 1997).
In social learning theory, self-efficacy, whether accurate or faulty, are based
on four principle sources of information (Bandura, 1997) as follows:
1. Enactive mastery experience: This is an important and most influential
source of information for individuals’ perceived self-efficacy because it is based on
authentic mastery experiences. Success heightens perceived self-efficacy; repeated
failures lower it, especially if the mishaps occur early in the course of events. In the
other words, repeated success will create perceived self-efficacy. If not succeed,
individuals’ perceived self-efficacy will be low, thus affecting their confidence in their
perceived self-efficacy to subsequently carry out the behavior. With perceived self-
efficacy, individuals will try to behave for success even though they encounter
problems and obstacles, but they will persist without any discouragement.
2. Vicarious experience: Whether an experience is successful or not will
have an impact on perceived self-efficacy. By seeing similar others perform successfully
can raise efficacy expectations in observers who judge that they too possess the
capabilities to master comparable activities. By the same situation, observing others who
are perceived to be of similar competence fail despite high effort lowers observers’
judgments of their own capabilities. Competent models can also teach observers
effective strategies for dealing with challenging or threatening situations.
3. Verbal persuasion: Verbal persuasion can help to the extent that
persuasive boosts in self-efficacy lead people to try hard enough to succeed. Such
positive influences promote development of skills and a sense of personal efficacy.
Particularly, when significant or respected persons of individuals use verbal
persuasions or compliments to motivate individuals to carry out certain behavior,
24
individuals will be encouraged and try to carry out such behaviors. Conversely,
negative verbal persuasion can increase fear and decrease motivation.
4. Physiological and affective states: When individuals are stressed,
exhausted, or painful, they will feel disheartened and think that they cannot carry out a
behavior successfully. This is because individuals tend to believe that stress is a result
of lack of ability to carry out a behavior. In general, self-evaluation on the ability to
carry out a behavior does not occur automatically after learning from these four
sources of information. The information gained from cognitive process will be
selected as individuals decide which information is most reliable or important for
them. They will also combine the information to make their efficacy judgment.
Factors related to fear of falling in community-dwelling older adults
Age
As the consequence of aging, a range of age-related changes put older adults
at high risk for falling. This can be explained with the changes in neuromuscular and
cardiac homeostatic mechanisms (Edelberg, 2001), physical frailty, immobility and
reduced functional capacity (Miller, 2009). Unfortunately, by perceiving the high risk
of falling, older adults feel fear and always concern about it. They will lose their
perceived self-efficacy in avoiding fall during essential and nonhazardous activities of
daily living. Similarly, in 2010 Chen stated that “As individuals age, they encounter
many obstacles that undermine their abilities, confidence and desire in conducting
physical activity”. This relationship has been demonstrated by many researchers who
have been studying about this area in older adults.
Particularly, after the systematic review from 28 relevant studies among the
community-dwelling elderly, Scheffer et al. (2008) showed that being older was one of
the main risk factors in developing a fear of falling (Scheffer et al., 2008). Similarly,
in several studies, age greater than eighty years has been shown to be a factor in
developing a fear of falling ( Centers for Disease Control [CDC], 2007; Murphy et al.,
2003). Bertera and Bertera (2008) discovered that the oldest group of participants
(over 85 years old) was four times more likely to have a fear of falling than the
youngest one (65 to 74 years old). Interestingly, Cho et al., (2013) demonstrated that
participants who were over 70 years old were 22.83 times likely to be perceptive fear
of falling compare with those who were aged from 40 to 50 (OR = 22.83; 95 % CI =
25
14.34 - 36.34; p < .001). Similarly, they were 55.85 times likely to be higher level of
concern over falling (OR = 55.85; 95 % CI = 20.10 - 155.17,
p < .001) (Cho et al., 2013).
Gender
Gender belongs to concept of biological properties in personal factors within
social cognitive theory. According to Bandura, personal factors can influence human
belief about their capacity (Bandura, 1997). Particularly, female gender is
demonstrated as determinant of fear of falling in many researches (Bertera & Bertera,
2008; Cho et al., 2013; Costa et al., 2012; Filiatrault et al., 2009; Kim & So, 2013;
Sharaf & Ibrahim, 2008). A secondary analysis of a cross-sectional survey about fear
of falling in older people in Belgian town found that fear of falling was significantly
more frequent among women elderly. The logistic regression model showed that
female was approximately twice likely to have fear of falling (adjusted OR = 1.92,
95 % CI = 1.18 - 3.14; p = .009) (Costa et al., 2012). Similarly, the 2008 National
Elderly Survey of the Korea Ministry of Health & Welfare pointed out females were
significantly more likely than males to be afraid of falling (83.3 % vs. 65.7 %)
(Kim & So, 2013). Significantly, an exploratory study of individual and
environmental correlates of fear of falling among community-dwelling elderly
indicated that female elderly were four times likely to be fearful of falling compared
with male (OR = 3.44; 95 % CI = 1.22 - 9.74; p < .001) (Filiatrault et al., 2009) . In
addition, a prospective cohort study from 380 participants at baseline in the Einstein
Aging Study aged 70 and older in New York also implied the same association
between female and fear of falling (OR = 2.01; 95 % CI = 1.12 - 3.60; p < .05) (Oh-
Park et al. , 2011).
1997). Bandura stated that previous successes raised efficacy appraisals and failures
lowered them (Bandura, 1997). Thus, experiencing a fall before will lead the older
adults to lower their perception of their capabilities within avoiding falls. In addition,
there are considerable number of studies indicated that having a history of fall is a
common risk factor for fear of falling in older adults (CDC, 2007; Cho et al., 2013;
Costa et al., 2012; Filiatrault et al., 2009; Kim & So, 2013; Oh-Park et al., 2011;
26
Sharaf & Ibrahim’s, 2008). In a cross-sectional, epidemiological study of all
community-dwelling areas in Korea from 9033 elderly aged ≥ 65 years, 17.8 % of
elderly had an experience of falls (1604 participants). This group of previous fallers
had a statistically significant greater fear of falling than those who had no history of
previous fall, 95.9 % and 72.4 % respectively (p < .001). Multivariate logistic regression
indicated that previous experience of falls affected the risk of fear of falling significantly
(OR = 6.41; 95 % CI = 4.938 - 8.320, p < .001) (Kim & So, 2013). Similarly, another
research among institutionalized older Chinese men in Taiwan showed that elderly
men who had history of fall in the past 6 months were more than twice likely to be
afraid of falling compared with non-fallers (OR = 2.47, 95 % CI = 1.04 - 5.9, p = .041)
(Chu et al., 2011). In 2007, Zijlstra et al. pointed out that history of fall was a
significant factor that affected the fall avoiding belief of older adults. The study results
indicated that the higher number of falls that participants had in the past, the more
susceptibility to fear of falling they likely to be. Statistically, the elderly who had more
than one fall in the past were approximately six times likely to have fear of falling and
those who had only one fall were only over twice compared with non-fallers, OR = 5.72
(95 % CI = 4.40 - 7.43) and OR = 2.28 (95 % CI = 1.89 - 2.75) respectively (Zijlstra
et al., 2007). Notably, a systematic literature review from the studies examining fear of
falling in community-dwelling older adults between 2006 and October 2013 described
that within twenty-one researches studied about the impact of history of fall on fear of
falling there were thirteen study results indicated that the association between history
of one fall and fear of falling is significant. Furthermore, there was only one research
referred to the history of multiple falls and this research study showed that factor is an
important related factor of fear of falling among community-dwelling elderly
(Denkinger et al., 2014).
Balance and gait status
Balance is the condition in which all the forces acting on the body are
balanced such that the center of mass is within the stability limits the boundaries of the
base of support. It involves control of the relative positions of body parts by skeletal
muscle with respect to each other and gravity (O’Sullivan & Schmitz, 2007).
Physiologically, balance is maintained with the integration and coordination of three
body systems: sensory system, motor function and the central coordination of sensory
27
and motor function. The sensory system gathers essential information about the
position and orientation of body segments in space; the central nervous system
integrates, coordinates, and interprets the sensory inputs and then directs the execution
of movements; and the motor system responds to the others provided by the central
nervous system. All these components undergo changes with aging. Particularly,
decreased vibration senses, especially in the feet, decreased vision are the example of
altered sensory function. Postural control is also altered by decreased righting reflex
ability (motor responses to maintain supine posture or recover balance). Additionally,
change in gait, decreased stride, and less height in foot lift are motor function changes
that negatively affect balance of older adults (Millsap, 2007). Beside these age-related
changes, balance also is influenced by chronic diseases such as dementia, stroke,
Parkinson’s disease, arthritis, cardiac arrhythmias, peripheral neuropathies, and
orthostatic hypotension (Millsap, 2007); and medications including psychotropic
drugs, insulin and oral hypoglycemic, antidepressant, antihypertensive, anticholinergic
(Baum, Capezuti, & Driscoll, 2002). Deficits within any single components are not
typically sufficient to cause postural instability, because compensatory mechanisms
from other components prevent that from happening. However, accumulation of
deficits across multiple components may lead to instability (Alghwiri & Whitney,
2012). As the consequence, balance impairment is one of the most important risk
factors of fall (Linton & Lach, 2007) and the most common related factors of fear of
falling in older adults (Denkinger et al. 2014; Scheffer et al., 2008).
After systematically reviewing from a range of articles, which were published
from January, 2006 to October, 2013 about fear of falling in elderly, Denkinger et al.
indicated that there was a robust association between impaired balance and function
and fear of falling among elderly people. In particular, there were four of six studies
and two of three showed the significant relationship between impaired balance and gait
abnormality respectively (Denkinger et al., 2014). Similarly, another systematic
literature review found that various authors identified balance and gait impairment as a
common risk factor of fear of falling (Scheffer et al., 2008).
The relationship between balance and gait abnormality and fear of falling
among older adults is likely to be from moderate to high in many researches. Firstly, a
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cross-sectional study about fear of falling and its correlation with mobility, dynamic
balance was conducted among 253 community-dwelling older adults over 60 without
distinction of sex, race or socioeconomic class. With the Tandem Gait Test (TGT) as
a measurement of the dynamic balance, Timed Up and Go Test (TUG) as a functional
mobility instrument, and FES-I as the fear of falling measurement, the Pearson’s
correlation was statistically significant (p < .001) between FES-I and TGT (r = -.44)
and TUG (r = .46). It means that the more balance impairment participants had, the
more fearful of falling they were and additionally, this positive relationship was
moderate (Lopes et al., 2009). Being comparable to this study, another study showed
that the correlation between balance and fear of falling was absolutely high, r = -.97
(p < .01) (Kumar et al., 2008).
Additionally, many researchers also showed that balance and gait
impairment is the significant factor that associated with fear of falling among elderly
(Guthrie et al., 2012; Wongpanitkul et al., 2012; Oh-Park et al., 2011; Gaxatte et al.,
2011; Rochat et al., 2010; Lopes at al., 2009; Deshpande et al., 2008; Austin et al.,
2007). In order to investigate the association between fear of falling and gait
performance, a group of reseachers conducted a survey among 860 community
living elderly aged 65 - 75 years. The result of survey showed that fear of falling was
associated with reduced gait performance, including increased gait variability (Rochat
et al., 2010). Similarly, another study significantly found that chair standing
performance was negatively associated with fear of falling (p = .001) (Deshpande et
al., 2008).
Activities of daily living
ADLs was referred to the capabilities relating to the maintenance of self and
lifestyle, which often includes self-care, keeping one’s life-space in order, and obtaining
resources (Rodgers & Miller, 1997). It is referred to measure the functional status of an
individual, particularly in persons with disabilities and the elderly. ADLs concept is
included as a dimension of conceptualizations of functional health, functional
limitation, and disability; and is affected by many factors as follow physical factors,
including gait, postural stability, muscle strength, psychological factors including
cognitive impairment, depression, and environmental factors (Roberts, 1999). Aging in
general is associated with a decline in exercise capacity, muscle strength and power,
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lung capacity, balance, and/ or walking ability (Miller, 2009). Ultimately, these changes
in the body can result in a decline of the ability to carry out ADL.
Lower ADLs status was demonstrated as a related factor of fear of falling in a
range of previous studies. Firstly, some studies showed that individuals with dependent
ADLs were significant more likely to be fearful of falling compared with older adults
who were independent in doing daily activities (OR = 1.44, 95 % CI = 1.07 - 1.95,
p = .0017) (Kim & So, 2013). Similar to Kim and So, Kempen et al. found that older
adults who had difficulty with ADLs are 1.17 folds likely have high fear of falling
corresponded to older adults with low fear of falling (OR = 1.17, 95 % CI = 1.11 - 1.23, p
< .05) (Kempen et al., 2009). Correspondently, Curcio et al. showed the difficulty with
ADLs was one of the independent factors of fear of falling in older people (OR = 2.51,
95 % CI = 1.82 - 3.46, p < .001) (Curcio et al., 2009). Particularly, Suzuki et al.
described that two activities of daily living, walking and bathing, were highly related
to fear of falling (p = .001 and p = .009 respectively) (Suzuki et al., 2002).
More significant, ADLs was notably stated as an important predictor of fear
of falling in the study about the impact of ADLs on fear of falling among 213 South
Korean community-dwelling elderly (Shin et al., 2010). In this study, fear of falling
was measured by FES and the result showed that the relationship between FES and
ADLs index was slightly high (r = -.46, p < .001). It means that elderly who has lower
ADLs status are more likely to have higher fear of falling. Furthermore, the results of
the hierarchical regression analyses with addition of the ADL in the second step
indicated that ADLs had statistically significant influences on the fear of falling of
elderly (β = -.34, p < .001) and 35.6 % of the variance in fear of falling was explained
totally (F = 23.86, p < .001) (Shin et al., 2010). In short, ADLs was significantly
indicated as the related factors of numerous previous studies (Bertera & Bertera, 2008;
Chu et al., 2010; Curcio et al., 2009; Kempen et al., 2009; Kim & So, 2013; Lawson &
Gonzalez, 2014; Patil et al., 2014; Shin et al., 2010).
General health perception
Health status is an individual's relative level of wellness and illness, taking
into accounts the presence of biological or physiological dysfunction, symptoms, and
functional impairment. General health perception (or perceived health status,
self-rated health) is defined as overall ratings of current health in general (Stewart et
30
al., 1988). It reflects a person’s integrated perception of health, including its
biological, psychological and social dimensions, that is inaccessible to any external
observer (Miilunpalo, Vuori, Oja, Pasanen, & Urponen, 1997). It is one of six
concepts of health which include health perceptions, physical functioning, role
functioning, social functioning, mental health, and pain (Stewart et al., 1988). It is
potent predictor of future health outcomes including mortality and appears to
contribute significant additional independent information to health status indicators
gathered through self-reported health histories or medical examinations (Idler &
Angel, 1990; Idler & Kasl, 1995; Jylha, 2009). Moreover, it is the significant
predictor of change in functional ability (Idler & Kasl, 1995). Significantly, general
health perception is influenced by many factors such as age, gender, employment
status, educational level, smoking status and physical activity (Kaleta et al., 2009).
Among these factors, age is a considerable predictor of health perception. In cross-
sectional age group comparisons, global self-rated health does not decrease with
advancing age to the same extent as chronic conditions and disability increase (Jylha,
Guralnik, Balfour, & Fried, 2001). Many studies showed that controlling for other
health indicators in multivariate analyses usually leads to a negative correlation
between age and poor health (Jylha et al., 2001; Mulsant, Ganguli, & Seaberg, 1997).
For a given level of measured health conditions, older people usually assess their
health more positively than younger people (Ferraro, 1980).
Theoretically, general health perception belongs to fourth source of self-
efficacy, somatic and emotional status. It can affect individuals’ belief about their
capabilities within fall avoiding when they perform daily activities. In addition, many
researchers have studied about this and indicated that the relationship between this
concept and fear of falling is significantly (Lach, 2005; Kim & So, 2013;
Kumar et al., 2014; Tiernan et al., 2014; Zijlstra et al., 2007). Specifically, in 2011 a
cross-sectional study from 449 African American older adults (mean age = 72.3
years) living in Detroit, Michigan, United States was conducted to identify the
relationship between falls efficacy and self-related health. From this study, Tiernan et
al. pointed out that self-rated health of older adults was significantly correlated with
their falls efficacy (r = .51, p < .001) (Tiernan et al., 2014). Similarly, in 2013 from a
survey in Korean older adults, Kim and So also indicated that those who perceived
31
their health as poor were approximately twice likely to have fear of falling compared
with those who rated their general health was good (OR = 1.89, 95 % CI = 1.67 - 2.14,
p < .001) (Kim & So, 2013). Interestingly, a study about fear of falling and associated
avoidance of activity in the general population of community-ling older people
showed that general health perception was significantly associated with fear of falling
and fear of falling related avoidance of activity. The older adults who rated their
health as fair or poor were more susceptible to have fear of falling than those who
thought that their health was good, OR = 3.19 (95 % CI = 2.75 - 3.71) and OR = 6.93
(95 % CI = 4.70 - 10.21) respectively. More seriously, the difference of the
susceptibility to fear of falling related avoidance of activity between those who
perceived their health as fair or poor and good is significantly high, OR = 4.42
(95 % CI = 3.79 - 5.15) and OR = 11.91 (95 % CI = 8.38 - 16.95) (Zijlstra et al., 2007).
Depression
Depression is a common mental disorder that presents with depressed mood,
loss of interest or pleasure, decreased energy, feelings of guilt or low self-worth,
disturbed sleep or appetite, and poor concentration (WHO, 2012 a). It is the most
common impairment of psychosocial function in older adulthood; it has the
unfortunate distinction of being the most undetected and untreated of the treatable
mental disorders in older adults (Miller, 2009). In elderly people, depression mainly
affects those with chronic medical illnesses and cognitive impairment, causes
suffering, family disruption, and disability, worsens the outcomes of many medical
illnesses, and increases mortality (Alexopoulos, 2005). It is a significant source of
concern for families, increases use of medical services and pharmaceutical costs, and
impairs immunologic function (Schleifer, Keller, & Bartlett, 1999). It is also one of
the main predictors of the risk of suicide among older adults. The World Health
Organization indicated in its annual report (WHO, 2006) that depression would be the
second cause of disability by 2020, only below that of cardiopathy and higher than
cancer or acquired immunodeficiency syndrome (AIDS), since older adults as a
population group are particularly vulnerable to disability. In older adults, it is affected
by many risk factors such as female gender, somatic illness, cognitive impairment,
functional impairment, lack or loss of close social contacts, and a history of
depression (Djernes, 2006). Another systematic review categorized predictors of
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depression in elderly into three groups, which are biological, psychological and social
factors (Vink, Aartsen, & Schoevers, 2008).
In self-efficacy theory, depression is categorized as physiological or affective
form, the last source of self-efficacy. Thus, it may affect the fall-related self-efficacy of
older adults negatively. It is noteworthy that depression were found to have
significantly positive relationship with fear of falling in several previous studies (Chou,
Yeung, & Wong, 2005; Chu et al., 2011; Denkinger et al., 2014; Kempen et al., 2009;
Kim & So, 2013; Painter et al., 2012; Oh-Park, 2011; Sharaf & Ibrahim, 2008; Tiernan
et al., 2014; van Haastregt et al., 2008; Wongpanitkul et al., 2012). Significantly, after
reviewing the literatures about fear of falling, Denkinger et al. found that several
studies showed the significant relationship between fear of falling and depression,
seven of sixteen studies since 2006 and eleven of twenty studies before 2006
(Denkinger et al., 2014). After studying about falls efficacy in African American
elderly, Tiernan et al. showed that the relationship between falls efficacy with
depression is significantly negative (r = -.21; p < .001) (Tiernan et al., 2014). A study
about anxiety and depression in older adults who avoid activity for fear of falling
indicated that depression is one of the strongest factors relating to fear of falling
(OR = 2.74; 95 % CI = 1.69 - 4.47; p < .001) (van Haastregt et al., 2008). Another
study about fear of falling in older women showed that elderly women who has
depression were more likely to be fearful of falling than the others, 7.10 % and 15.80
% respectively (OR = 2.47; 95 % CI = 1.71 - 3.57) (Austin et al, 2007). Furthermore,
before 2000, depression was considerably found to have a statistically significant
positive association with fear of falling in many studies that included depression in
multivariate models of fear of falling (Burker et al., 1995; Tinetti et al., 1990).
In addition, presence of depression possibly modulates what factors in addition to fear
of falling affect fear-induced activity restriction (Deshpande et al., 2008).
Summary
Fear of falling has numerous adverse consequences, especially the reduced
quality of life of older adults. Several researches have studied about this issue and its
associated factors. The literature review indicated that age, gender, history of fall,
balance and gait status, activities of daily living, general health perception and
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depression are the most common and important factors associated fear of falling
among community-dwelling older adults. However, these relationships are still
inconclusive. Additionally, the study about fear of falling and these related factors
among Vietnamese community-dwelling is still limited. Hence, this study is needed to
be conducted for the better understanding about fear of falling and its related factors
in order to help gerontogical nurses find the best intervention for improving their
clients’ quality of life.
setting of the study, population and sample, instruments, ethical consideration, data
collection procedures, and data analysis procedures.
Research design
The descriptive correlational design was used to address the research
questions.
Setting of the study
This study was conducted in Danang city, which is located at the center of
Vietnam. Danang is the biggest city in the South Central Coast of Vietnam with seven
districts including Hai Chau, Thanh Khe, Lien Chieu, Son Tra, Ngu Hanh Son, Cam
Le and Hoa Vang. It is the commercial and industrial center of Central Vietnam. It is
also a fast developing city of Vietnam. According to Vietnamese classification, it is
the aging city with 8 % of population are older adults (79, 800 older adults) and the
number of older adults is increasingly.
Almost older adults are taken care at home by their family or relative. There
is only one small nursing home in Danang city but it is usually used for the individual
who need rehabilitation. Normally, older adults are more likely to be at their homes.