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FACTORS RELATED TO FEAR OF FALLING AMONG COMMUNITY-
DWELLING OLDER ADULTS IN DANANG, VIETNAM
TRAN THI HOANG OANH
A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE
REQUIREMENTS FOR THE MASTER DEGREE OF NURSING SCIENCE
(INTERNATIONAL PROGRAM)
FACULTY OF NURSING
BURAPHA UNIVERSITY
AUGUST 2015
COPYRIGHT OF BURAPHA UNIVERSITY
This mater thesis has been supported by
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.
Tran Thi Hoang Oanh
v
56910328: MAJOR: NURSING SCIENCE; M.N.S
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
ABSTRACT ........................................................................................................... v
CONTENTS ........................................................................................................... vi
LIST OF TABLES ................................................................................................ viii
LIST OF FIGURES ............................................................................................... ix
CHAPTER
1 INTRODUCTION ......................................................................................... 1
Background and significance ............................................................... 1
Research questions ............................................................................... 8
Research objectives .............................................................................. 8
Research hypotheses ............................................................................. 8
Scope of the study ................................................................................ 8
Conceptual framework ......................................................................... 8
Operational definitions ......................................................................... 11
2 LITERATURE REVIEWS ........................................................................... 13
Overview of Vietnamese older adults .................................................. 13
Fear of falling ....................................................................................... 15
Self-efficacy theory .............................................................................. 22
Factors related to fear of falling in community-dwelling older adults. 24
Summary .............................................................................................. 32
3 RESEARCH METHODOLOGY .................................................................. 34
Research design ................................................................................... 34
Setting of the study ............................................................................... 34
Population and sample .......................................................................... 34
Research instruments ............................................................................ 36
Instrument translation ........................................................................... 41
Validity and reliability of instruments .................................................. 42
Ethical consideration ............................................................................ 43
Data collection procedures ................................................................... 43
Data analysis procedures ...................................................................... 45
vii
CONTENTS (CONT.)
CHAPTER Page
4 RESULTS ...................................................................................................... 46
Descriptions of community-dwelling older adults’demographic
characteristics, general health perception, balance and gait status,
ADLs and depression ........................................................................... 46
Findings related to research questions .................................................. 49
5 CONCLUSION AND DISCUSSION ........................................................... 54
Conclusion ............................................................................................ 54
Discussion ............................................................................................ 55
Nursing implications ............................................................................ 65
Limitation of the study ......................................................................... 66
Recommendation for further researches ............................................... 66
REFERENCES ....................................................................................................... 67
APPENDICES ........................................................................................................ 83
APPENDIX 1 ................................................................................................ 84
APPENDIX 2 ................................................................................................ 88
APPENDIX 3 ................................................................................................ 95
APPENDIX 4 ................................................................................................ 102
APPENDIX 5 ................................................................................................ 106
APPENDIX 6 ................................................................................................ 109
APPENDIX 7 ................................................................................................ 112
BIOGRAPHY ......................................................................................................... 122
LIST OF FIGURES
Figures Page
1 Research framework of the study ................................................................ 11
2 Sampling procedure ..................................................................................... 36
LIST OF TABLES
Tables Page
1 Frequency, percentage, mean, and standard deviations of demographic
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
INTRODUCTION
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
as performing any activities without falling. Considerably, general health perception is
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
According to self-efficacy theory, mastery experience or performance
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
Figure 1 Research framework of the study
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).
Balance and gait status
Activities of daily living
General health perception
Fear of falling
Depression
History of falls
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.
1. Overview of Vietnamese older adults
2. Fear of falling
2.1. Fall in older adults
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
4.3. History of falls
4.4. Balance and gait status
4.5. Activities of daily living
4.6. General health perception
4.7. Depression
5. Summary
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
Fear of falling
Fall in older adults
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.
16
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 –
18
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.
Besides these abovementioned physical consequences, fear of falling also
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.
Activities-Specific Balance Confidence Scale (ABC Scale)
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).
History of fall
Mastery experience is the strongest determinant of self-efficacy (Bandura,
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
28
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,
29
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
32
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
33
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.
CHAPTER 3
RESEARCH METHODOLOGY
This chapter presented the research methodology including research design,
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.
Population and sample
Population
The population was the older adults who have been living in community in
Danang city, Vietnam.
Sample
Sample was recruited through a multistage random sampling from the target
population with the following criteria:
1. Be 60 years old or over
2. Be able to communicate in Vietnamese
35
3. Have the stable health status enough to participate in the whole study
4. Have normal cognitive status measured by Mini-Mental State
Examination (MMSE) Vietnamese version ≥ 23
5. Have no movement limitation and balance problem regarding illnesses
due to some illnesses such as Parkinson, stroke, and osteoporosis.
6. Willing to participate in the study
Sample size
The sample size of this study was calculated by using a power analysis with
G*Power 3.1.9.2 program (Faul, Erdfelder, Buchner, & Lang, 2009). Firstly, the
design of this study was correlation and the researcher test the relationship between
the fear of falling and each independent variable. Therefore, the correlation-bivariate
normal model was chose as type of statistical test in G*Power program. The level of
significant (α) was set at .05 and the standard power was at .80 as usual in most of
nursing studies (Grove, Burns, & Gray, 2013). From literature review, many
researchers have examined the relationship between demographic (gender, age),
history of fall, balance and gait status, perceived health status, activities of daily
living, depression and fear of falling. The correlation coefficients were from .20 to
.97. Thus, in order to have good validity, the effect size estimated of .20 was used in
this study. From G*Power programs, the sample size was calculated at 153.
Sampling technique
The participants were selected by multistage random sampling technique
following step. Danang city is classified into seven districts. Depending on the total
population, each district is divided into 4 - 13 communes.
Step 1. The researcher randomly selected one commune from each district.
Thus, 7 communes from 7 different districts were selected.
Step 2. In each commune, the number of participants was calculated by
using the proportional formula as follows (Cochran, 1977).
nh Number of participants in each commune
Nh Number of older adults in each commune
N Total older adults in seven selected communes
n Sample size (n = 153)
36
Step 3. In each commune, the participants were selected by using simple
random sampling technique. Researcher met the head of primary health care center in
each commune to get the name list of older adults. In the list, older adults have already
been assigned numbers based on their names. After that, the researcher used computer
(SPSS 17.0 program) to select 153 numbers randomly to obtain the sample after
checking for sampling criteria except for health status (Figure 2.). The health status
and MMSE were assessed on the date of data collection. If the older adults could not
meet these two inclusion criteria, the simple random sampling technique was repeated
performed for selecting the new sample.
Figure 2 Sampling procedure
Research instruments
Screening instrument
The MMSE was used as screening tool for assessing cognitive status of the
participants for sample inclusion. The MMSE is a well-known, widely-used as the
screening and assessment of cognition instrument in older adults. It measures
orientation, registration, attention and calculation, recall, language, and construct
ability. The score ranges from a minimum of 0 to a maximum of 30. The higher score
the older adults get the better cognitive status they have. It takes about 10 minutes to
Thanh
Khe
District
Lien
Chieu
District
Son Tra
District
Ngu
Hanh Son
District
Cam Le
District
Hoa Vang
District
Danang City, Vietnam
Hai Chau II
1196
older adults
28
subjects
26
subjects
26
subjects
19 subjects
20
subjects
17 subjects
17 subjects
Tan Chinh
1095 older adults
Hoa Minh
1094 older adults
Phuoc My
835 older adults
Khue My
865 older adults
Hoa Phat
740 older adults
Hoa Phuoc
719 older dults
Hai Chau
District
37
complete this test (Folstein, Folstein, & McHugh, 1975). In the original research, the
MMSE demonstrated single examiner test-retest reliability Pearson coefficient of .88
and multiple examiner test-retest reliability Pearson coefficient of .83 (Folstein et al.,
1975). It has also been validated and used extensively in research and clinical practice
in various settings. In this study, it was used for screening for the inclusion criteria.
Those participants scoring more than 23 out of 30 were included to ensure the
reliability of interview responses.
Data collection instruments
Data was collected by face-to-face interview via available questionnaires and
one balance and gait test was measured by researcher. The questionnaires comprise of
6 parts including demographic questionnaire, the first item of the MOS SF-20, the
barthel activities of daily living, the geriatric depression scale, the fall efficacy scale-
international. The balance and gait test was conducted with the timed up and go test
by researcher and one supporter, who had already been described about this test
clearly. The details of questionnaires and test are as follows:
1. Demographic questionnaire
This questionnaire was developed by the researcher. It included age, gender,
educational level, marital status, living arrangement, morbidity and history of fall.
2. The Fall Efficacy Scale-International (FES-I)
This scale was used to measure the level of concern about falling of older
adults when they perform daily activities. It was first developed as The Fall Efficacy
Scale (FES) by Tinetti and colleagues in 1990 with measuring the confidence of older
adults when they perform 10 physical activities within their house (Tinetti et al.,
1990). The FES-I was then modified by expanding on the initial 10-item FES to
include 6 items about 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. Additionally, the word
was change to ask “how concerned”, not “how confident” respondents were in
carrying out activities. Completely, the FES-I comprises 16 items with “how
concerned” as the respondent.
Each item measures on a 4-point Likert-type scale ranging as following:
1 = not at all concerned, 2 = somewhat concerned, 3 = fairly concerned, 4 = very
38
concerned. The total score was sum up and ranges from a low score of 16 to a high
score of 64. The higher score elderly have, the higher they concern about falling
(Yardley et al., 2005). Based on the total score, participants were classified as follow
(Delbaere et al., 2010):
Low fear of falling: 16 - 19
Moderate fear of falling: 20 - 27
High fear of falling: 28 - 64
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). The FES-I has
demonstrated excellent internal validity (Cronbach’s α=.96) and test-retest reliability
(ICC=.96). The FES-I was validated with factor analysis with all variables loading on
a single factor. The FES-I has superior psychometric properties in comparison to the
original FES (Yardley et al., 2005).
3. General health perception questionnaire
It is the first single item of medical outcomes study (MOS) SF20. The MOS
SF20 was developed by Stewart and colleagues in 1988 to measure the subjective
well-being in a Medical Outcomes Study. It consists of 20 items to measure six
components of health including physical functioning, role functioning, social
functioning, mental health, health perception, and pain. In this study, the researcher
used only the first items of health perception component which there were five items
to measure the perception of individuals about their general health status. It is a simple
question with 1 - 5 Likert scale asking participants to rate their general health as
excellent (1), very good (2), good (3), fair (4) or poor (5). In this study the score of
this instrument was reversed. The higher the individuals score, the better general
health perception they have (Stewart et al., 1988).
4. The Timed Up and Go test
This test was used for assessing the balance and gait status of older adults by
measuring the time it takes a participant to complete it. It was developed at first as a
clinical measure of balance in elderly people and was scored on an ordinal scale of 1
to 5 based on an observer's evaluation of the performer's risk of falling during the “Get
39
Up and Go” test (Mathias, Nayak, & Isaacs, 1986). Then it is modified by Podsiadlo
and Richardson in 1991 by timing the task and became a short, reliable and valid test
for quantifying balance, gait and functional mobility for frail community-dwelling
older adults (Podsiadlo & Richardson, 1991). It takes approximately 1-2 minutes to
complete. It will be more objective and accurate compared to self-report functional
assessment tools that are potentially less reliable (Podsiadlo & Richardson, 1991).
4.1 Required equipment and condition
4.1.1 Three meters of distance with even surface and no obstructions
4.1.2 Armchair with 45 cm approximate seat height and 65 cm arm
height
4.1.3 Measuring tape to measure 3 meters distance
4.1.4 A bright color ruler to mark the 3 meters away from chair position
4.1.5 A stopwatch: A mobile phone Samsung I 8190 was used as a
stopwatch
4.2 Test procedure
4.2.1 Researcher: Start timer on the word “Go” and stop it when the
elderly sits down.
4.2.2 Participant: From sitting in the chair, the participant stands up
after the word “Go” from researcher, walks a distance of 3 meters (to the marked
position), turn, walks back to the chair and sits down. During this test, the participant
was required to wear the regular and comfortable footwear. He/ she should use the
usual walking aid.
4.2.3 The supporter: During the test, there was one supporter following
beside the participant independently and closely to help the participant in case he/ she
is unstable and likely to have a fall.
4.3 Test evaluation: The time during participant completes this test was
scored. The result can be interpreted as follows (Podsiadlo & Richardson, 1991):
< 20 seconds: Mostly independent mobility
20 - 29 seconds: Moderate independent mobility
≥ 30 seconds: Dependent mobility
40
This test was performed twice and the mean score was used for analysis
(Herman, Giladi & Hausdorff, 2011). The lesser times the participants needed to
perform this test, the better balance and gait status they had.
Test-retest reliability of measurements obtained with the TUG in a group of
mainly community-dwelling older adults was excellent (ICC = .97) (Schenkman,
Cutson, Kuchibhatla, Scott, & Cress, 2002). It is demonstrated that had excellent
intra-rater reliability and inter-rater reliability, .98 and .99 respectively (Podsiadlo &
Richardson, 1991). Construct validity has been supported through correlation of TUG
scores with measurements obtained for Berg Balance scale (r = -.72), gait speed
(r = .75), postural sway (r = -.48), step length (r = -.74), Barthel Index (r = -.79),
Functional Stair Test (r = .59), and step frequency (r = -.59) (Mathias et al., 1986;
Podsiadlo & Richardson, 1991; Shumway-Cook, Brauer, & Woollacott, 2000). The
TUG had a sensitivity and specificity of 87 % and an overall prediction of 87 % for
those who had a fall (Shumway-Cook et al., 2000).
5. The Barthel Activities of Daily Living
This instrument was used to measure the functional disability of older adults
by assessing the independence in activities of daily living including grooming,
walking, bladder and bowel control, dressing, climbing stairs, feeding, and bathing. This
scale was first developed by Mahoney and Barthel (1965) and then it was modified into
several versions. In this study, the modified 10-items version was used (Wade &
Collin, 1988).
In the modified 10-items version, the scored may be gotten from 0 to 1, 0 to
2, or 0 to 3 depending on the each activity (Collin, Wade, Davies, & Home, 1988).
The total score ranges from 0 to 20. The higher score participants get, the higher
independence they have. For the participants who reach a total of 20 points are
sufficiently independent to carry out ADL. Based on the total scores, the participants
were categorized as follows (Wade & Hewer, 1987):
0 - 4 = very severely dependence
5 - 9 = severely dependence
10 - 14 = moderately dependence
15 - 19 = minor dependence
20 = independence
41
It has good validity including content validity, concurrent, predictive validity
and the construct validity also. Moreover, it is demonstrated that its reliability is
acceptable (Collins et al., 1988).
6. Geriatric Depression Scale: Short Form
This scale is a self-report measurement used to assess depression in older
adults. It was shortened and modified from the first version with 30-item by Sheikh
and Yesavage (1986). It consists of 15 yes/ no items that ask the subject to answer
how they felt over the last week.
For each item, one point was given for each depressive response for a total
15 possible points. The lesser score the participant gets the better he/ she is. A score of
7 or greater may be an indication of depression in elderly (Sheikh & Yesavage, 1986).
Depending upon the cut-off score and the population, the GDS-15 has
acceptable sensitivity and specificity that ranges from 79 % - 88 % and 64.2 % - 80%,
respectively (Herrmann et al., 1996), and has been reported to demonstrate respectable
criterion validity in cognitively mixed populations of older adults (Lesher & Berryhill,
1994).
Instrument translation
The questionnaires of this study including FES-I, GDS, TUG, Barthel ADLs,
and first item of MOS SF20 were translated in Vietnamese language for data
collection. The recommended method was translation and back-translation. This cycle
was continued until the culturally equivalent meaning is achieved between the source,
and target language versions of the instrument. This translation method was
recommended by Brislin (1970). The translation procedure was used in this study as
follows:
1. The original instruments in English version were independently translated
into Vietnamese language by two bilingual experts in both English and Vietnamese
language who uses simple and relevant with Vietnamese culture, and maintain the
meaning of the original versions in English. These two translators were the gerontological
nursing lecturers in Danang University of Medical Technology and Pharmacy.
2. Those two Vietnamese versions were compared and combined in one
Vietnamese version by researcher based on content of individual item agreement.
42
3. The third translator who was not only Vietnamese speaker but also expert
in English language translated the Vietnamese versions back into English.
4. The researcher and one English native speaker checked the back-
translated English version for language accuracy and comparability of the contents,
culture and meaning between the English back-translated and the English original
versions.
Validity and reliability of instruments
Validity
All of instruments used in this study were original instruments, including the
FES-I, first item of MOS SF-20, Barthel ADLs, GDS, TUG. Most of instruments
were assessed validity which was acceptable to use in older adults. Additionally, all
the instruments were translated into Vietnamese by Back-Translation technique
(Brislin, 1970) which maintains the validity of the original ones.
Reliability
The reliability of the instruments (FES-I, GDS, Bathel ADLs, general health
perception questionnaire, TUG test) were tested by a pilot test. The pilot test was
conducted in Danang community, which included 30 community-dwelling older
adults who had same characteristics with the participants of the study.
1. For the falls efficacy scale-international and barthel ADLs, the internal
consistency was tested with the Cronbach’s alpha. The Cronbach‘s alpha were .98 and
.95 respectively. These levels of internal consistency coefficient were acceptable
because they were higher than .80 (Grove et al., 2013).
2. Kuder-Richardson 20 (KR 20) formula was used to calculate the internal
consistency of the geriatric depression scale. The calculation yielded a KR-20 of .81
3. Test-retest reliability was used to test the stability of the Timed Up and
Go test with stopwatch. Coefficient of stability of time up and go test (Test-retest
reliability) was .98.
43
Ethical consideration
The researcher has been aware of research ethics of human subjects. This
proposal was submitted to grant approval for ethical consideration for the institutional
review board (IRB), Faculty of Nursing, Burapha University, Thailand before data
collection.
The researcher asked for permission from participants after clearly
explaining the aims and the objectives of the study as well as data collection
procedure to participants. Then if participants volunteer to participate in the study, the
consent form was completed before data collection and they were able to withdraw
whenever they want without prejudice. The data collection and result representation
were done with thoughtful concern for the dignity, value, and consequence to the older
adults. It was assured that the participants’ anonymity and confidentiality were
respected.
The participants’ personal information will not be revealed to any other
persons. All completed forms was put into envelop to maintain confidentially by a
secure place. All the data was stored safely and accessed by the researcher only. It was
utilized for research purposes only will be destroyed after finishing research and
publication.
There was no harm for participants during the study. However, there was
risk of falling during perform TUG test, so the researcher prepared one supporter and
a first aid bag in case there are any emergency problems that happen to participant.
Data collection procedures
Data were collected by researcher from February 2015 until April 2015 in
seven districts of Danang City, Vietnam after the proposal was approved by IRB of
Faculty of Nursing, Burapha University and the permission letter from the dean of
Faculty of Nursing was sent to the head of each health care center of seven commune
of Danang city, Vietnam.
Then, the researcher contacted with the head of primary health care center of
each commune to explain the purposes of the study as well as data collection
procedure and got the name list of older adults, their phone number and address.
44
The researcher contacted with older adults via telephone to check for
inclusion criteria except for health status and cognitive status which were checked on
the data collection day. The older adults who met the inclusion criteria were selected
by using simple random sampling technique. The older adults who were selected to be
the participants of the study were asked for an appointment for data collection.
Based on participants’ address, the researcher did home visit for data
collection. Firstly, the researcher greeted and introduced about the researcher to create a
good relationship with participants before inviting them to participate in the study.
Then, the participants were explained clearly about the study purposes, study procedure,
human protection and their right to participate or withdraw from the study. If the
participants expressed their willing to participate in the study, they were checked with
vital signs for health status and MMSE test for cognitive status. If they met these two
criteria, they were asked to sign in the consent form to participate in the study.
Firstly, demographic questionnaire, the first item of MOS SF 20 about
general health perception, the barthel ADL index. Then, the participant was instructed
to perform the timed up and go test. The timed up and go test was performed twice
and the mean score was used for analysis. For this test, if there was no enough space
inside the participant‘s house, the researcher asked he/ she to come to closest place for
doing this test. After this test, the older adults had a break for 10 - 15 minutes. Next,
the geriatric depression scale and the fall efficacy scale-international were used for
interviewing. All the instruments were used orderly and independently in order to
prevent the bias of the answer received from the participants.
After finishing each questionnaire, the researcher reviewed and checked for
the data completion. When the entire questionnaires were finished, the whole
information was checked again. Before finishing the interview, research said good bye
and thanked participants for their kind cooperation.
It took about 60 minutes to 90 minutes for each participant. The researcher
started at 9 am until 11 am every morning and from 2 pm until 5 pm every afternoon.
There were 4 - 5 participants were performed each day.
In this study, the supporter did not involve in the study. She just
independently went beside the participant during timed up and go test in case the
45
participant was unstable and likely to fall. She was trained about the timed up and go
test procedure clearly before the data collection.
Data analysis procedures
After all the data were completely collected, the data were entered into a
statistic program and then they were analyzed by this program to describe and
examine the relationships between variables. The alpha level for significance was set
at .05. The data were analyzed by using the following statistics:
1. Descriptive statistics
Descriptive statistics including frequency, percentage, range, mean, and
standard deviation were used to describe demographic characteristics, fear of falling,
balance and gait, general health perception, activities of daily living and depression.
2. Point biserial correlation
Point Bisieral Correlation test was used to examine the association between
gender (male and female) and fear of falling.
3. Spearman’s rho correlation
Spearman’s rho Correlation test was used to examine the relationship
between general health perception and fear of falling.
4. Pearson product moment correlation
Pearson’s was computed to explore the relationship between age, history of
falls, balance and gait status, ADLs, depression and fear of falling.
The strength of correlations is generally classified according to the following
criteria applying to positive or negative correlation (Grove et al., 2013):
r > .50 is strong relationship
r ≥ .30 to .50 is moderate relationship
r > 0 to.30 is weak relationship
CHAPTER 4
RESULTS
This chapter presented findings from data analyses that describe community-
dwelling older adults’ demographic characteristics, fear of falling and the relationship
between factors (age, gender, history of falls, balance and gait status, general health
perception, activities of daily living, depression) and fear of falling among
community-dwelling older adults. The data were collected from 153 older adults who
lived in community from 7 different communes of 7 districts of Danang city, Vietnam
during February until April, 2015.
The findings were presented as followings:
1. Description of community-dwelling older adults’ demographic
characteristics, balance and gait status, general health perception, activities of daily
living, depression.
2. Findings related to research questions
2.1 Descriptions of community-dwelling older adults’ fear of falling
2.2 Examinations of the relationships between age, gender, history of
falls, balance and gait status, general health perception, activities of daily living,
depression and fear of falling among community-dwelling older adults.
Descriptions of community-dwelling older adults’ demographic
characteristics, general health perception, balance and gait status,
ADLs and depression
The study used descriptive statistics to examine the frequency, percentage,
mean, standard deviations, and range of demographic characteristics, general health
perception, balance and gait status, ADLs and depression of community-dwelling
older adults. The results are shown in Table 1, Table 2, and Table 3.
47
Table 1 Frequency, percentage, mean and standard deviations of demographic
characteristics of community-dwelling older adults (n = 153)
Community-dwelling older adults’
characteristics n %
Age (years old)
60 - 69 65 42.50
70 - 79 53 34.6
80 - 89 31 20.3
≥ 90 4 2.6
M = 72.00 SD = 8.47
Gender
Female 85 55.60
Male 68 44.40
Marital status
Married 96 62.70
Widowed 49 32.00
Divorced 4 2.60
Single 4 2.60
Living condition
With family 104 68.00
Couple only 36 23.50
Alone 13 8.50
Education level
No school 4 2.60
Primary school 53 34.60
Secondary school 56 36.60
High school 34 22.20
Undergraduate 6 3.90
48
Table 1 (cont.)
Community-dwelling older
adults’ characteristics
n %
Morbidity
No 44 28.80
Yes 109 71.20
Hypertension 78 71.56
Diabetes 10 9.17
COPD 3 2.75
Hypertension and diabetes 2 1.84
Others 16 14.68
History of fall
Number of fall
0 75 49.00
1 46 30.10
2 22 14.40
≥ 3 10 6.50
Table 1 showed that the age of older adults who participated in the study
varied between 60 and over 90 with the average of 72.00 (SD = 8.47). The majority of
older adults’ age fell down in the 60 - 69 years olds group, accounted for 42.50 %.
There was a higher percentage of female compared with male, 55.60 % and 44.40 %
respectively. About marital status, the married group was the biggest one with 96
subjects (62.70 %) and 32.00 % of older adults were widower. Most of respondents
were living with their family (68.00 %), and 8.50 % older adults were living alone
however. The most common educational levels of older adults were secondary and
primary, 36.60 % and 34.60 % respectively. There were still 2.60 % of participants
were illiterate. There were 71.20 % of participants got at least one disease and the
most popular diseases were hypertension and diabetes. About history of falls, 75 older
adults (49.00 %) had no falls while there were 10 ones (6.50 %) had more than two
falls during last year.
49
Table 2 The frequency and percentage of general health perception of community-
dwelling older adults (n = 153)
General health perception n %
Very good 26 17.00
Good 65 42.50
Fair 45 29.40
Poor 17 11.10
Table 2 revealed that about half of number of participants perceived that
their general health was good (42.50 %) while 29.40 % stated that their health was fair
and 11.10% said that their health was poor.
Tabe 3 The mean, standard deviations, range of balance and gait status, ADLs and
depression of community-dwelling older adults (n = 153)
Variables M SD Actual
range
Possible
range Interpretation
Balance and gait
status (TUG) 16.24 3.83 8.50 - 24.50
Independent
mobility
ADLs 17.61 1.70 14 - 20 1 - 20 Minor dependence
Depression 6.85 3.42 0 - 15 0 - 15 Non-depressed
The results from Table 3 explored that the mean time of TUG test was 16.24
seconds (SD = 3.83). The participants were minor dependence in performing daily
living activities (M = 17.62, SD = 1.70). The mean score of depression status was not
high at 6.85 (SD = 3.42).
Findings related to research questions
This part presented the results of statistical analyses which addressed the
questions of the study. Firstly, the levels of fear of falling among community-dwelling
older adults were described. Secondly, the existence associations between between
50
age, gender, history of falls, balance and gait status, general health perception,
activities of daily living, depression and fear of falling were also statistically
confirmed.
1. Descriptions of community-dwelling older adults’ fear of falling
The descriptive statistics were used to examine the mean, standard deviation,
range, and level of fear of falling among community-dwelling older adults. Fear of
falling was assessed by the FES-I which has sixteen items with 16 - 64 total scores.
The higher score the participants had, the more fear of falling they were. The findings
were presented in detail in Table 4 and Table 5.
Table 4 Frequency, percentage, range, mean and standard deviation of each level of
fear of falling (n = 153)
Level of fear of
falling n %
Possible
range
Actual
range M SD
Interpre-
tation
Fear of falling 153 100.00 16 - 64 16 - 61 34.95 11.36 High level
Low
fear of falling 13 8.50 16 - 19 16 - 19 18.08 1.19
Moderate
fear of falling 42 27.50 20 - 27 20 - 27 24.76 2.22
High
fear of falling 98 64.00 28 - 64 28 - 61 41.55 8.53
Table 4 showed that the fear of falling of participants varied between 16 and
61 scores with average score was 34.95 (SD = 11.36). The percentage of older adults
who had high fear of falling was highest with 64.00 % (M = 41.55, SD = 8.53 ) while
the percentage of older adults who had moderate and low fear of falling were lower,
27.50 % and 8.50 % respectively.
51
Table 5 Mean and standard deviation of each item of FES-I about fear of falling
(n = 153)
Items M SD
Walking on a slippery surface (e.g. wet or icy) 3.29 .78
Walking on an uneven surface (e.g. rocky ground, poorly
maintained pavement) 2.87 .92
Walking up or down a slope 2.71 .98
Reaching for something above your head or on the ground 2.62 .98
Going up or down stairs 2.41 1.03
Walking in a place with crowds 2.35 .88
Going to answer the telephone before it stops ringing 2.22 .94
Cleaning the house (e.g. sweep, vacuum, dust) 2.08 .92
Taking a bath or shower 2.05 .93
Going to the shop 1.98 .90
Preparing simple meals 1.95 .99
Going out to a social event (e.g. religious service, family
gathering, or club meeting) 1.82 .96
Visiting a friend or relative 1.69 .82
Getting in or out of a chair 1.67 .85
Getting dressed or undressed 1.62 .79
Walking around in the neighborhood 1.61 .79
From the results presented in Table 5, older adults had the third highest fear
of falling when they performed the following activities including walking on a
slippery surface (M = 3.29, SD = .78), walking on an uneven surface (e.g. rocky
ground, poorly maintained pavement) (M = 2.87, SD = .92), walking up or down a
slope (M = 2.71, SD = .98).
52
2. Examinations of the relationships between age, gender, history of
falls, balance and gait status, general health perception, activities of daily living,
depression and fear of falling among community-dwelling older adults
This section presented the second research question of this study which were
about the relationships between age, gender, history of falls, balance and gait status,
general health perception, activities of daily living, depression and fear of falling
(Table 6). Depending on level of each instrument, different correlation tests were used
to examine the relationship between each selected variables and fear of falling.
Point biseral correlation test was used to explore the relationship between
gender and fear of falling. The relationships between history of falls, general health
perception and fear of falling were tested with the Spearman’s rho Correlation test.
Pearson’s product moment correlation were used to examine the
relationships between age, balance and gait status, activities of daily living, depression
and fear of falling after all assumptions including normality of each variable,
homoscedasticity and linearity were tested. Firstly, the normality of each variable
were described in Table 7 (Appendix 4) with fisher coefficient of skewnesses fall
between ± 1.96 (Munro, 2005). Next, from all scatter plots, the variance of fear of
falling across all variance of each independent variables, it was constant variance
(Homoscedasticity) (Appendix 4). Also, in the scatter plots group of data had shape as
a straight line. It means linearity.
Table 6 Relationship between age, gender, history of falls, ADLs, depression, balance
and gait status and fear of falling (n = 153)
Variable FOF
r p-value
ADLs -.80 p < .001
General health perception -.77 s < .001
Balance and gait status (TUG) .75 p < .001
Age .54p
< .001
Depression .45 p < .001
History of falls .39 s < .001
Gender (female) .28 pb
< .001
p Pearson’s test;
pb Point biserial correlation test;
s Spearman’s rho Correlation test
53
Table 6 revealed that there were significant relationships between age,
gender, history of falls, ADLs, balance and gait status, general health perception,
depression and fear of falling among community-dwelling older adults. However, the
strength and direction of relationships were different. The relationship between female
gender and fear of falling was weak (r = .28, p < .001) and the relationship between
history of falls, depression and fear of falling was moderate (r = .39 and r = .45,
p < .001 respectively) while the relationship between ADLs, general health perception,
TUG, age and fear of falling were quite high, r = -.80, r = -.77, r = .75 and r = .54, p
< .001 respectively.
In summary, the level of fear of falling among Danang community-dwelling
older adults were notably high and the relationships between age, gender, history of
falls, balance and gait status, general health perception, activities of daily living,
depression and fear of falling among community-dwelling older adults were
significant. There were high and negative relationships between general health
perception, activities of daily living, balance and gait status and fear of falling among
community-dwelling older adults. Also, there were moderate and positive relationship
between age, depression, history of falls and fear of falling. Additionally, the
relationship between female gender and fear of falling was weak and positive.
CHAPTER 5
CONCLUSION AND DISCUSSION
This study aimed to investigate the level of fear of falling and 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. This chapter presented the summary of
the research findings and discussion those findings as well as the nursing implications
and the recommendation for further research.
Conclusion
This descriptive correlational study was conducted to describe the level of
fear of falling and examine factors related to fear of falling among community-
dwelling older adults in Danang, Vietnam. A multistage random sampling was used to
recruit the sample of 153 older adults who have been living in seven randomized
communes from seven different districts of Danang city, Vietnam and met the eligible
criteria. Data were collected using five interviewed questionnaires including
demographic questionnaire, the first item of MOS SF 20, the barthel ADL index, the
geriatric depression scale and the fall efficacy scale-international and timed up and go
test (Vietnamese versions) during February to April in 2015. All of above instruments
were translated into Vietnamese versions by back-translation technique (Cha et al.,
2007). The reliabilities of instruments were tested with 30 community-dwelling older
adults in Chinh Giang commune, Thanh Khe district, Danang city, Vietnam. The
Cronbach’s alpha coefficients of the FES-I and Barthel ADLs were .98, .95,
respectively. The K-R 20 reliability score of the GDS was .81 and coefficient of
stability of TUG test (Test-retest reliability) was .98. Data were analyzed with
descriptive statistics and correlation tests including Point biseral correlation, Spearman
‘rho correlation and Pearson’s. Findings were summarized as follows.
Firstly, about demographic information, the average age of participants was
72.00 (SD = 8.47) with 42.50 % of them falls down in the 60 - 69 years old group.
Male and female had equal distribution in this study, 44.40 % and 55.60 %
55
respectively. 62.70 % of participants were married and 32.00 % of participants were
widowers. There were 68.00 % of samples were living with their family. Most of older
adults finished primary or secondary school, 36.60 % and 34.60 % respectively.
71.20 % of participants got at least one disease. 49.00 % of older adults had no falls
while there were 6.50 % having more than two falls during last year.
Overall, the older adults in Danang community had high fear of falling (M
= 34.95, SD = 11.36). Particularly, 64.00 % of them were at high level of fear of
falling (M = 41.55, SD = 8.53), 27.50 % and 8.50 % of them were at moderate and low
level of fear of falling, respectively. The activities that older adults had the highest
concern about falling when performed them were as follows walking on a slippery
surface (M = 3.29, SD = .78), walking on an uneven surface (e.g. rocky ground, poorly
maintained pavement) (M = 2.87, SD = .92), walking up or down a slope (M = 2.71,
SD = .98).
Finally, the relationships between age, gender, history of falls, balance and
gait status, activities of daily living, general health perception, depression and fear of
falling were statistically significant. There were high and negative relationships
between balance and gait status, general health perception, activities of daily living
and fear of falling among community-dwelling older adults, r = -.75, rs = -.77 and
r = -.80, p < .001 respectively. Also, there were moderate and positive relationship
between history of falls, depression and fear of falling, rs = .39 and r = .45, p < .001
respectively. The relationship between age and fear of falling was quite high and
positive (r = .54, p < . 001) while the relationship between female gender and fear of
falling was low and positive (rpb = .28, p < .001).
Discussion
Based on the previous literature reviews, this section presented the
discussion of findings that addressed the research questions. First, the level of fear of
falling among community-dwelling older adults was discussed and then the
relationships between fear of falling and researching factors were explained.
1. The level of fear of falling among community-dwelling older adults
56
Generally, the results revealed that older adults in Danang community was at
high level with average score of FES-I of 34.95 (SD = 11.36) and the total score varied
from 16 and 61 out of possible of maximum score of 64. It can be explained by several
points. Firstly, the average age of the participants of current study was quite high (M =
72.00, SD = 8.47) and 2.60 % of samples were 90 years old and over. From literature,
it was showed that being aged was one of the most important risk factors of fear of
falling because of numerous age-related problems (Kumar et al., 2014; Scheffer et al.,
2008). Therefore, this might be one of the reasonable explanations for the high level of
fear of falling among Danang community-dwelling older adults. Secondly, from the
demographics characteristics, it could be revealed that most of correspondents of this
study had morbidity (71.20 %). This might impact on fall self-efficacy of older
adults and particularly lower their fall related self-efficacy. Additionally, among
morbidities, hypertension was the most common disease that 71.56 % older adults
have gotten. Significantly, the balance and gait status of hypertensive participants
were worse because of effects of hypertension (Hausdorff, Herman, Baltadjieva,
Gurevich, & Giladi, 2003).
Moreover, in this study, researcher found that up to 51 % of samples had at
least one fall during the last 12 months and among them 10 older adults had three falls
and over. Because of having failing experience, the older adults might lose their fall
self-efficacy. Therefore, this might be one important reasons of high level of fear of
falling among older adults.
On the other hand, the high level of fear of falling can be explained by socio-
economic as well as cultural characteristics. Particularly, most of older adults were
living with their family (68.00 %) or their spouse (23.50 %). In Vietnamese culture,
they are not encouraged to do so much of things if they have their children, their
caregivers beside. Many family members, healthcare provider or relatives worry that
their beloved older adults might fall so that they often unintentionally discourage
independence and encourage dependence of their loved one. This can be an important
factor contributing to the low self-efficacy about fall prevention or the increased fear
of falling (Tinetti & Powell, 1993).
Additionally, being different from elderly of developed countries,
Vietnamese elderly do not have many chances to take part in many activities,
57
especially social activities and some of health promotion programs, so they might be
less active and that might be one of the important reasons that their self-efficacy are
not high. Specifically, Vietnam especially Danang city is the developing area with
heavy traffics. There is so much traffic on the streets so the older adults felt fear to
going out for any activities because they thought that it was not safe and they will get
fall easily. This explanation was corresponding with the result of the study about fear
of falling among high-risk, urban community elderly with 38.02 of mean FES-I score
(SD = 14.75) (Greenbegn, 2014).
From literature review, this result was quite high comparing with the results
of several previous studies including the study of Patil et al. (2013) with 23.30 mean
of FES-I (SD = 6.20), and study about fear of falling in older adults from urban
community of Londrida, Brazil with 26.20 of mean score of FES-I (SD = 8.50)
(Fucahori et al., 2014).
Particularly, for each activity on the FES-I, minimum score was one as “not
at all concerned” and the maximum was four as “very concerned”. The study explored
that the older adults had different level of concern about falling when performed
different activities. They felt the highest fear of falling with following activities:
Walking on a slippery surface (M = 3.29, SD = .78), walking on an uneven surface
(M = 2.87, SD = .92), walking up or down a slope (M = 2.71, SD = .98). However,
walking around in the neighborhood (M = 1.61, SD = .79), getting dressed or
undressed (M = 1.62, SD = .79), getting in or out of chair (M = 1.67, SD = .85),
visiting a friend or relative (M = 1.69, SD = .82) were the activities that participants
had lower concern about falling. This result was correspondent with the results of
study about fear of falling among Thai elderly in the study of Wongpanitkul et al.
(2012) and also Brazil elderly in study of Fucahori et al. (2014).
2. Factors related to fear of falling among community-dwelling older
adults
2.1 Relationship between age and fear of falling
The result of this study showed that age was a significant related factor of
fear of falling in community-dwelling elderly. This relationship was positively high
with r = .54 (p < .001). It meant the more age individuals are, the more fear of falling
they had. Obviously, as becoming aged, people are more susceptible to falls because
58
of numerous age-related changes including neuromuscular and cardiac homeostatic
mechanisms (Edelberg, 2001), physical frailty, immobility and reduced functional
capacity (Miller, 2009) and contribution of disease (WHO, 2007). Perceived those
changes, older adults seemed to be fearful of falls. They think that their body is not
strong enough to perform the activities without fall. Moreover, because of ageing,
they also worry that it will be the worst problem if they have fall. Additionally,
phobias are common in elderly; they tend to worry about their health and fear of
specific things and specific situations, especially fall (Linton & Lach, 2007).
This result was consistent with the results of a plenty of previous studies
(Bertera & Bertera, 2008; Cho et al., 2013; Scheffer et al., 2008) that the older
participants were, the higher fear of falling they had. Particularly, in the systemic
review from relevant studies about fear of falling among community-dwelling older
adults, Scheffer et al. (2008) found that being aged was one of the main risk factors of
fear of falling. Significantly, one study about the disparity in the fear of falling
between urban and rural residents in Korea explored that the correspondents who
were 70 years old and over were 22.83 times likely to be perceptive fear of falling
which was measured by single question “Do you fear of falling?” compare with those
who were aged from 40 to 50 (OR = 22.83; 95 % CI = 14.34 - 36.34; p < .001).
Similarly, they were 55.85 times likely to be higher level of concern over falling
which was assessed by FES-I (OR = 55.85; 95 % CI = 20.10 - 155.17, p < .001)
(Cho et al., 2013). Finally, getting older, individual did lose their perceived self-
efficacy in avoiding fall during essential and nonhazardous activities of daily living.
2.2 Relationship between gender and fear of falling
The result of present study showed that female had higher fear of falling
compared with male older adults. The relationship between female gender and fear of
falling was significantly positive and weak (rpb = .28, p < .001). This difference can be
due to the degree of concern with health in which female gender are more concerned
in health than male (Gochman, 1997). In the other words, women are more concerned
about fall and fall related consequences than men. Furthermore, women may tend to
over-estimate their risk while men may underestimate the risk of falling. According to
socio-cultural perspective, especially, in Vietnamese culture, males are always the
strong individuals; they are the pillar of the family and society. That might be the
59
socio-cultural perspective, especially, in Vietnamese culture, males are always the
strong individuals; they are the pillar of the family and society. That might be the
reason why they do not want to complain and talk about any fear including fear of
falling. They worry that the others will think about them as the bad men. In the other
words, males simply underreported fear of falling in order to avoid potential
stigmatization (Tinetti et al., 1994). Additionally, female older adults have more
susceptibility of falls and this experience, in turn, increased their fear of falling.
This result corresponded with the result of a study about prevalence and
correlates of fear of falling in Korean community elderly (Kim & So, 2013). In that
study, researchers explored that females were significantly more likely than males to
be afraid of falling (83.30 % vs. 65.70 %) (Kim & So, 2013) and they also revealed
significantly that female were 1.68 times likely to be fear of falling compared with
male (95 % CI = 1.447 - 1.858; p < .001). Similarly, an exploratory study of individual
and environment correlates of fear of falling among 350 community-dwelling seniors
in the province of Quebec (Canada) pointed out that fear of falling was significantly
more frequent among women elderly. The logistic regression model indicated that
female were approximately four times likely to have fear of falling compared with
male (OR = 3.44; 95 % CI = 1.22 - 9.74; p < .001) (Filiatrault et al., 2009). More
significant, one prospective cohort study about the fear of falling among 380
participants who was 70 years old and over in New York also indicated that female
was twice likely to be fearful of falling (Oh-Park et al., 2011). A systematic review
about factors associated with fear of falling significantly stated that female gender was
one of four parameters robustly associated with fear of falling (Denkinger et al., 2014).
This result of current study was also consistent with several previous researches
(Bertera & Bertera, 2008; Cho et al., 2013; Kumar et al., 2014; Sawa et al., 2014; Sharaf
& Ibrahim, 2008) which indicated that there was a significant relationship between
older adults’ gender and their fear of falling and the female older adults were more
likely to have higher fear of falling than male.
2.3 Relationship between history of falls and fear of falling
The result of this study significantly explored that there was a significant
relationship between history of falls and fear of falling. This relationship was positive
and moderate with correlation coefficient rs = .39 (p < .001). The more number of falls
60
elderly had in the past, the higher fear of falling they had. In this study, researcher
found that up to 51 % of samples had at least one fall during the last 12 months and
among them 10 older adults had three falls and over. This was one of the most
important reasons of high fear of falling among older adults. Consistently, according
self-efficacy theory, mastery experience or performance accomplishment is the most
influential source of self- efficacy. Conversely, negative experience will reduce the
self-efficacy. In the other words, it can lead to low fall related self-efficacy (Bandura,
1997). Practically, the individuals who have fall experience are more likely to be
fearful of falls. Oh-Park et al.(2011) suggested that it was the long lasting negative
effect of falls on emotional function of previous falls.
The result of this study was consistent with a study about fear of falling
among 180 community-dwelling older adults in Kanchanaburi province (Thailand) of
Wongpanitkul et al. (2012) who found that there was a significantly positive
relationship between history of falls and fear of falling(r = .15, p < .05). Similarly,
Zijlstra et al. (2007) robustly stated that the number of previous falls was the important
determinants of fear of falling in older adults. They showed that the older adults who
experienced more than one falls were approximately six times likely to be fearful of
falling and those who experienced 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. Significantly, one systematic review from the studies examining fear of
falling in community-dwelling older adults between 2006 and October 2013 clearly
indicated that history of falls was the associated factor of fear of falling (Denkinger et
al., 2014). Moreover, from literature review, the present finding was also consistent
with many studies about fear of falling among community-dwelling older adults (Cho
et al., 2013; Costa et al., 2012; Kim & So, 2013; Oh-Park et al., 2011). In short, there
was the significant positive correlation between the number of previous falls and fear
of falling among Danang community-dwelling older adults.
2.4 Relationship between balance and gait status and fear of falling
Agreeing with the previous literature, the result of the current study
indicated that there was a high significant correlation between TUG with fear
of falling among community-dwelling older adults (r = .75, p < .001). This
61
meant that the better balance and gait status older adults had, the lesser fearful of
falling they were. According to Bandura (1997), individuals rely partly on their
somatic states in judging their capabilities. The age-related changes in balance and gait
status as well as some clinical balance and gait abnormalities which reflect the effects
of different disease processes on various components of the balance and gait status
might reduce the older adults’ level of confidence in avoiding fall. On the other hand,
from previous literature review, Sharaf and Ibrahim (2008) and Bertera and Bertera
(2008) showed that the two main contributing factors to fear of falling in the older
adult were frailty and psychological factors. It was also described that fear of falling
was worse in older adults when they had weakness in their lower bodies and/ or they
had balance problems (CDC, 2007). More significantly, Oh-Park et al. (2011) revealed
that the mobility impairment which associated with gait abnormalities may be more
important in the pathogenesis of fear of falling than the specific disease processes.
Additionally, Murphy et al. (2003) also identified having unsteady balance, and gait
deficits as risk factors for the fear of falling.
The finding of current study was similar to the results of numerous previous
studies including the studies of Wongpanitkul et al. (2012), Lopes et al. (2009), Kumar
et al. (2008), with r = -.23 (p < .001), r = -.46 (p < .001) and r = -.95 (p =.05)
respectively. Additionally, in a cross-sectional study in 1,088 community-dwelling
older people aged ≥ 65 years, Kumar et al. (2014) described that taking more than 13.5
seconds to complete the timed up and go test was the associated factor with a
significant higher odds of fear of falling. Firstly, univariate analysis showed that older
participants who needed more than 13.5 seconds to complete the timed up and go test
were 13-folds more likely to have high concern about falling (OR = 13.08, 95 % CI =
8.43 - 20.29, p < .001). In multivariable models for factors associated with fear of
falling, 82 % of observations were correctly classified by the model, with a sensitivity
of 70 % and a specificity of 84 %, with significantly raised odds of fear of falling in
those with taking at least 13.5 seconds to complete the timed up and go test (OR =
2.50, 95 % CI = 1.41 - 4.45, p < .05) (Kumar et al., 2014). Similarly, another study
found that the prevalence of elderly who had fear of falling was manifold higher in
those with balance and gait impairment or functional mobility impairment, OR = 16.4
(95 % CI = 5.9 - 45.6) and OR = 28.2 (95 % CI = 9.1 - 87.1) respectively (Andersson
62
et al., 2008). Similarly, there were also numerous studies indicated that individuals
with balance and gait impairment were more likely to have fear of falling (Austin et
al., 2007; Deshpande et al., 2008; Fletcher & Hirdes, 2002; Gaxatte et al., 2011; Guthrie
et al., 2012; Rochat et al., 2010).
2.5 Relationship between activities of daily living and fear of falling
In this study, the mean score of ADLs was 17.61 (SD = 1.70) out of 20. It
meant that the participants were minor dependence in ADLs, most of them could
perform a plenty of daily activities by themselves because they were the healthy older
adults who lived in the community. However, corresponding with the previous
literatures, the finding of this study pointed out that there was a high and negative
relationship between ADLs and fear of falling (r = -.80, p < .001). It meant that the
older adults who were more independent in performing ADLs had lesser fear of
falling. However, dependent ADLs also had impact on fear of falling (Curcio et al.,
2009). The level of dependence of ADLs might relate to the confidence of older adults
to perform activities without concern about falling. The more dependent older adults
were the higher fear of falling they had. This can be explained that the increased need
for assistance with activities of daily living might cause older adults to be less secure
about their physical abilities and therefore more fear of falling (Burker et al., 1995).
The finding of this study was quite similar with the result of the study about
fear of falling in South Korean community-dwelling elderly with r = -.46 (p < .001)
(Shin et al., 2010). In a study about fear of falling among dizzy and non-dizzy elderly,
Burker et al. (1995) also showed that the relationships between ADLs and fear of
falling of dizzy and nondizzy older adults were significant, r = .67 and r = .26
respectively. Additionally, a group of researchers studied about fear of falling and
associated physical and psychosocial factors in 371 older Chinese men (mean age 82.1
± 5.11) living in a veterans home in southern Taiwan.They described that older men in
fear of falling group had poorer activities of daily living and statistically, the logistic
regression showed that ADLs was independent risk factor of fear of falling among
older adults (OR = 2.48, 95 % CI = 1.08 - 5.71, p = .033) (Chu et al., 2011). Another
study of Patil et al. (2014) about associated factors of fear of falling among 409
independently living older women with a history of fall aged 70 - 80 years in Finland
significantly indicated that elderly women with dependent ADLs were significantly
more likely to have both moderate and high concern for falling. Particularly, the risk
63
for moderate and high concern about falling was increased manifold with greater
disabilities in ADLs. The elderly women who had difficulty with more than one task
in ADLs were 5.5 folds more likely to have moderate concern about falling and 38.3
folds greater likely to be high concern about falling (OR = 5.5, 95 % CI = 1.6 - 19.1
and OR = 38.3, 95 % CI = 11.1 - 131.5 respectively) (Patil et al., 2014). It was also
consistent with a range of other previous studies (Kempen et al., 2009; Kim & So,
2013). In a word, the current study could conclude that the correlation between ADLs
and fear of falling among Danang community-dwelling elderly was negatively
significant and high magnitude.
2.6 Relationship between general health perception and fear of falling
From the results of this study, the researcher found that there was a
negative relationship between general health perception and fear of falling (rs = -.77, p
< .001). It meant that if elderly have had better health perception, they had been lesser
fearful of falling. It can be explained with the following theory. According to self-
efficacy theory, 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. Older adults might lose their
confidences to perform activities easily if they thought that their general health was
not good. In this study, only 17.00 % of samples stated that their health was very good
and no one thought that they had excellent health. About half of number of
participants perceived their health was good while 29.40 % stated that their health was
fair and 11.10 % said that their health was poor. This can be the explanation of the
high fear of falling in Danang elderly.
Corresponding with the result of this study, Tiernan et al. (2014)
significantly showed that the relationship between health perception and fear of falling
was negatively high (r = .-51, p < .001) while Wongpanitkul et al. (2012) found that it
was a negatively low relationship (r = -.16, p < .05). More particular, a survey in
Korean older adults indicated that self-rated health of older adults was significantly
correlated with their falls efficacy. They found that 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 (Kim & So, 2013). More significant, in a
systematic review, Denkinger et al. (2014) stated that poor self-rated health was the
important parameter that significantly correlated with fear of falling. Additionally, the
64
finding of present study also significantly corresponded with several studies from the
literature review (Kumar et al., 2014; Zijlstra et al., 2007). In summary, it could be
assured that association between general health perception and fear of falling among
Danang community-dwelling elderly was negatively significant.
2.7 Relationship between depression and fear of falling
Consistent with several previous literature, the present study found that
depression was a significant related factor of fear of falling (r = .45, p < .001). This
meant that the more depressive participants were, the more fear of falling they had.
Firstly, Gagnon et al. (2005) indicated that fear of falling was affected by both
physical and psychosocial factors. Depression is one of the most common
psychosocial disorders in older adults (Miller, 2009). It is assumed that depression
decreases the performance of automatic daily behaviors and in turn decreases the
positive reinforcement that comes to a person. Unfortunately, decreased positive
reinforcement prompt a chain of events that lead to increased focus on the person‘s
self, increased need for assistance, decreased participation on pleasurable activities,
and fear of falling. Moreover, depression always accompanies with tiredness and
decreased energy which may make people less secure about their abilities and
therefore fearful of falling (Burker et al., 1995). In other word, individuals who get
depression are more likely to have fear of falling. Additionally, in self-efficacy theory,
depression belongs to the last source of self-efficacy; it might affect the fall-related
self-efficacy in older adults. Older adults with depression may lose their confidence to
perform the activities.
The finding of the current study significantly corresponded with the result of
a study about the impact of depression on fear of falling (r = .50, p <. 001) (Shin et al.,
2010) and the result of a study about Thai elderly fear of falling (r = .36, p < .05)
(Wongpanitkul et al., 2012). Similarly, a study about fear of falling and depressive
symptom in Chinese elderly living in nursing home pointed out that depression
significantly had a positive correlation with fear of falling and negative correlation
with fall efficacy scale, r = .34 (p < .01) and r = -.37 (p < .01) respectively (Chou et
al., 2005). An another cross-section study about psychosocial and physical factors
of fear of falling in institutionalized elderly men Taiwan showed that participants with
depression were over six times as likely to have fear of falling compared with non-
depressed participants (OR = 6.73; 95 % CI = 3.03 - 14.93; p < .001) (Chu et al.,
65
2011). Additionally, the result of present study also agreed with numerous previous
studies (Denkinger et al., 2014; Kim & So, 2013; Painter et al., 2012; Oh-Park et al.,
2011; Tiernan et al., 2014). Finally, from this study it can be assured that older adults
who have depression are likely to be more fearful of falling.
Nursing implications
According the results from the current study with the high level of fear of
falling and the significant relationships between age, gender, history of falls, balance
and gait status, ADLs, general health perception, depression and fear of falling among
Danang community-dwelling older adults, several implications can be suggested for
nursing profession including nursing practice, nursing education and nursing research.
Nursing practice
Obviously, similar with fall, fear of falling also has numerous negative
consequences and effect to elderly health as well as their quality of life. However, the
level of fear of falling among Danang community-dwelling is quite high. It is the
noteworthy insight for the gerontological nurses and the elderly health care provider as
well. Gerontological nurse as well as the elderly health care provider should focus
more on these related factors of fear of falling when they take care of elderly.
Secondly, with the revealed significant associations between age, gender,
history of falls, balance and gait status, ADLs, general health perception, depression
and fear of falling, gerontological nurses could screen for these factors to detect
effectively the older adults at high risk of fear of falling. From that screening, nurses
should pay more attention to the one who have those related factors and have
appropriate care when taking care of older adults. For instance, the elderly with poor
perception about their general health or recognized signs of depression should be
provided with more proper care which specifies to fear of falling.
From the results of the study, although ADLs and balance and gait status are
the two highest relations with fear of falling, in order to reduce the fear of falling of
older adults, gerontological nurses should try to prevent and limit the depression of
older adults firstly because it may be easier. Secondly, the gerontological nurses also
can apply several evidences to enhance older adults’ ADLs and balance and gait
status, although they often reduce because of functional decline when individuals
66
become old. Enhancing older adults’ ADLs and balance and gait status might be
helpful in reducing the level of fear of falling among older adults.
Limitation of the study
Because FES-I itself just assessed the level of fear of falling and could not
distinguish between “fear” and “no fear”, the researcher could found only the level of
fear of falling among Danang community-dwelling older adults and could not
differentiate between “fear” and “no fear” among older adults.
Recommendation for further researches
During conducting this study, several of recommendations for future
research are suggested:
In order to distinguish between “fear” and “no fear” among community-
dwelling older adults, further researches should use another instruments instead of
FES-I.
The effective nursing intervention for reducing and preventing fear of falling
for older adults by applying the related variables including ADLs, balance and gait
status and depression should be conducted.
A longitudinal and prospective study should be conducted in the future to
explore the ability to explain the variance of fear of falling of age, gender, history of
falls, balance and gait status, ADLs, general health perception, depression. And
furthermore, the experiment studies to find the proper and effective intervention for
reducing and preventing fear of falling for older adults should be conducted then.
There may have some more variables such as frailty, impaired hearing,
impaired vision, cognitive status, medication, economic status and so on might have
the relationship with fear of falling. If it is possible, further researches should include
those variables to enable a more comprehensive assessment of related factors of fear
of falling.
This study should be conducted in other settings including hospital and
nursing home.
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APPENDICES
APPENDIX 1
Instruments’ permission of usage and translation
85
1. Permission of usage and translation of FES-I
2. Permission of usage and translation of the Geriatric Depression Scale
86
3. Permission of usage and translation of the MOS SF-20
4. Permission of usage and translation of the Barthel ADL Index
87
5. Permission of usage and translation of the Timed Up and Go test
APPENDIX 2
English questionnaires
89
Code: ……………..
Date:……………...
Part 1. Demographic questionnaire
Please tell me about your personal information
1. Gender ❑ Male ❑ Female
2. Age: ………………..
3. Marital status
❑ Single ❑ Married
❑ Divorced ❑ Widowed
4. Educational level
❑ No schooling ❑ Primary school
❑ Secondary school ❑ High school
❑ Undergraduate ❑ Graduate
❑ Other: …………………………………
5. Living condition
❑ Alone ❑ Couple only
❑ With family
6. Morbidity
❑ No ❑ Yes. If yes, specify
❑ Hypertension ❑ COPD
❑ Diabetes mellitus ❑ Other ………………
7. History of fall:
How many falls did you have within past year?...............................
Part 2. General health perception
In general, would you say your health is:
1. ❑ Excellent 2. ❑Very good 3. ❑ Good 4. ❑ Fair 5. ❑ Poor
90
Part 3. Barthel Index of Activities of Daily Living
1. Bowels
0 = incontinent (or needs to be given enema)
1 = occasional accident (once/week)
2 = continent
Patient's Score:
2. Bladder
0 = incontinent, or catheterized and unable to manage
1 = occasional accident (max. once per 24 hours)
2 = continent (for over 7 days)
Patient's Score:
3. Grooming (preceding 24 – 48 hours) (Refers to personal hygiene: doing teeth,
fitting false teeth, doing hair, shaving, washing face.)
0 = needs help with personal care
1 = independent face/hair/teeth/shaving (implements provided)
Patient's Score:
4. Toilet use (ability to reach toilet/commode, undress sufficiently, clean self, dress,
and leave)
0 = dependent
1 = needs some help, but can do something alone
2 = independent (on and off, dressing, wiping)
Patient's Score:
5. Feeding (Ability to eat any normal food (not only soft food))
0 = unable
1 = needs help cutting, spreading butter, etc.
2 = independent (food provided within reach)
Patient's Score:
6. Transfer (From bed to chair and back)
0 = unable – no sitting balance
1 = major help (one or two people, physical), can sit
2 = minor help (verbal or physical)
3 = independent
Patient's Score:
91
7. Mobility (Refers to mobility about house or ward, indoors, may use aid. If in
wheelchair, must negotiate corners/doors unaided)
0 = immobile
1 = wheelchair independent, including corners, etc.
2 = walks with help of one person (verbal or physical)
3 = independent (but may use any aid, e.g., stick)
Patient's Score:
8. Dressing (ability to select and put on all clothes, which may be adapted)
0 = dependent
1 = needs help, but can do about half unaided
2 = independent (including buttons, zips, laces, etc.)
Patient's Score:
9. Stairs
0 = unable
1 = needs help (verbal, physical, carrying aid)
2 = independent up and down
Patient's Score:
10. Bathing
0 = dependent
1 = independent (Must get in and out unsupervised, and wash self)
Patient's Score:
Total Score:
92
Part 4. Timed Get Up and Go Test
Instructions:
The person may wear their usual footwear and can use any assistive device they
normally use.
1. Have the person sit in the chair with their back to the chair and their arms resting on the
arm rests.
2. Ask the person to stand up from a standard chair and walk a distance of 3 meters
3. Have the person turn around, walk back to the chair and sit down again.
Timing begins when the person starts to rise from the chair and ends when he or she
returns to the chair and sits down.
Time to complete: First time________________seconds
Second time______________seconds
93
Part 5. Geriatric Depression Scale: Short Form
Choose the best answer for how you felt over the past week.
No. Question Answer Score
1. Are you basically satisfied with your life? Yes/No
2. ……………………………………………………………. Yes/No
3. Do you feel that your life is empty? Yes/No
4. Do you often get bored? Yes/No
5. Are you in good spirits most of the time? Yes/No
6. ……………………………………………………………. Yes/No
7. Do you feel happy most of the time? Yes/No
8. Do you often feel helpless? Yes/No
9. Do you prefer to stay at home, rather than going out and
doing new things? Yes/No
10. ……………………………………………………………. Yes/No
11. Do you think it is wonderful to be alive? Yes/No
12. Do you feel pretty worthless the way you are now? Yes/No
13. Do you feel full of energy? Yes/No
14. ……………………………………………………………. Yes/No
15. Do you think that most people are better off than you are? Yes/No
Total
94
Part 6. Falls Efficacy Scale-International
I would like to ask some questions about how concerned you are about the possibility
of falling. For each of the following activities, please choose the opinion closest to
your own to show how concerned you are that you might fall if you did this activity.
Please reply thinking about how you usually do the activity. If you currently don’t do
the activity (example: if someone does your shopping for you), please answer to show
whether you think you would be concerned about falling IF you did the activity.
No
.
Activities Not at all
concerned
1
Somewhat
concerned
2
Fairly
concerned
3
Very
concerned
4
1. ……………………………
2. Getting dressed or
undressed
3. Preparing simple meals
4. Taking a bath or shower
5. Going to the shop
6. ……………………………
.
7. Going up or down stairs
8. Walking around in the
neighborhood
9. Reaching for something
above your head or on the
ground
10. ……………………………
...
11. Walking on a slippery
surface (e.g. wet or icy)
12. Visiting a friend or relative
13. Walking in a place with
crowds
14. ……………………………
15. Walking up or down a
slope
16. ……………………………
TOTAL /64
APPENDIX 3
Vietnamese questionnaires
96
Mã số: ……………..
Ngày………………..
Phần 1. Thông tin chung
1. Giới ❑ Nam ❑ Nữ
2. Tuổi: ………………..
3. Tình trạng hôn nhân
❑ Không có vợ/chồng ❑ Có vợ/chồng
❑ Ly dị ❑ Góa vợ/chồng
4. Trình độ học vấn
❑ Mù chữ ❑ Cấp 1
❑ Cấp 2 ❑ Cấp 3
❑ Đại học, cao đẳng ❑ Sau Đại học
❑ Khác: …………………………………
5. Điều kiện sống
❑ Sống một mình ❑ Sống với vợ/ chồng
❑ Sống với gia đình
6. Bệnh kèm theo
❑ Không ❑ Có
❑ Tăng huyết áp ❑ COPD
❑ Đái tháo đường ❑ Khác………………
7. Tiền sử ngã:
7. Trong vòng 1 năm vừa qua, ông/bà đã bị ngã bao nhiêu lần? ………..
Phần 2. Nhận thức về tình trạng sức khỏe
Về tổng quan, ông/bà cho rằng sức khỏe của mình như thế nào?
1. ❑ Tuyệt vời 2. ❑ Rất tốt 3. ❑ Tốt 4. ❑ Khá 5. ❑ Xấu
97
Phần 3. Chỉ số Barthel về các hoạt động sống hàng ngày
Hướng dẫn: đối với mỗi mục trong 10 mục sau đây, xin hãy chọn một lựa chọn đúng
với tình trạng của ông bà nhất. Vui lòng thuật lại thực tế mà ông bà đang găp phải.
1. Tình trạng đại tiện
0 = không tự chủ (hoặc cần phải thụt tháo)
1 = thỉnh thoảng có vấn đề (một lần/tuần)
2 = tự chủ
Điểm của người bệnh:
2. Tình trạng tiểu tiện
0 = không tự chủ, hoặc phải đặt thông tiểu và không thể kiểm soát
1 = thỉnh thoảng có vấn đề (tối đa một lần/một ngày)
2 = tự chủ (trên 7 ngày)
Điểm của người bệnh:
3. Chăm sóc (trước 24-48 giờ) (đề cập đến vệ sinh cá nhân: đánh răng, lắp răng
giả, chải tóc, cạo râu, rửa mặt)
0 = cần sự trợ giúp của người chăm sóc
1 = tự làm một cách độc lập (dụng cụ được cung cấp)
Điểm của người bệnh:
4. Đi vệ sinh (khả năng với tới nhà vệ sinh/ghế vệ sinh, cởi quần áo, tự lau chùi, mặc
quần áo và rời đi)
0 = phụ thuộc hoàn toàn vào người khác
1 = cần có sự trợ giúp của người khác nhưng có thể tự làm một mình một vài việc nào đó
2 = tự làm một cách độc lập (mặc và cởi quần áo, lau chùi)
Điểm của người bệnh::
5. Ăn uống (khả năng ăn bất cứ loại thức ăn bình thường nào, không chỉ mỗi thức ăn
mềm)
0 = không thể ăn
1 = cần có sự trợ giúp để cắt nhỏ thức ăn, quết bơ, ….
2 = tự làm một cách độc lập (thức ăn được để trong tầm tay)
Điểm của người bệnh:
98
6. Di chuyển (Từ giường qua ghế và ngược lại)
0 = không thể - không ngồi vững
1 = trợ giúp là chủ yếu (một hoặc hai người, trợ giúp về thể chất), có thể ngồi
2 = trợ giúp một phần (trợ giúp về ngôn ngữ hoặc thể chất)
3 = tự làm một cách độc lập
Điểm của người bệnh:
7. Sự chuyển động
0 = bất động
1 = sử dụng xe lăn một cách độc lập, kể cả ở những góc
2 = đi lại với sự trợ giúp của một người khác (trợ giúp về ngôn ngữ hoặc thể chất)
3 = tự đi lại một cách độc lập (nhưng có thể phải sử dụng vật trợ giúp ví dụ như gậy)
Điểm của người bệnh:
8. Mặc quần áo (khả năng lựa chọn và mặc tất cả các loại quần áo phù hợp)
0 = hoàn toàn phụ thuộc vào người khác
1 = cần có sự trợ giúp của người khác, nhưng có thể tự mặc được một nửa người
2 = tự làm một cách độc lập (kể cả cài nút, kéo khóa, thắt dây, ….)
Điểm của người bệnh:
9. Lên xuống bậc thang
0 = không thể lên xuống bậc thang
1 = cần có sự trợ giúp (trợ giúp về lời nói, thể chất hoặc có người bế lên xuống)
2 = đi lên và đi xuống một cách độc lập
Điểm của người bệnh:
10. Tắm rửa
0 = hoàn toàn phụ thuộc
1 = tự làm độc lập (tự đi vào và đi ra mà không có sự giám sát, tự lau rửa)
Điểm của người bệnh:
Tổng điểm:
99
Phần 4. Kiểm tra thời gian đứng dậy và di chuyển
Hướng dẫn:
Một người có thể mang đôi giày bình thường vẫn mang và có thể sử dụng bất kỳ thiết
bị trợ giúp nào mà bình thường vẫn sử dụng (nạn, gậy,…)
1. Một người ngồi lên ghế, vai của họ tựa vào ghế, hai cánh tay đặt lên trên hai bên
2. Yêu cầu người này đứng dậy và bước đi một đoạn khoảng 3m
3. Cho người này quay lại, đi bộ trở về ghế và ngồi xuống ghế.
Thời gian tính từ lúc người này bắt đầu đứng dậy từ ghế và kết thúc khi người này
quay trở lại và ngồi xuống ghế.
Thời gian hoàn thành Lần 1:________________giây
Lần 2:________________giây
100
Phần 5. Thang điểm đánh giá mức độ trầm cảm ở người cao tuổi
Họ tên người bệnh: _______________________________ Ngày, tháng: _________
Chọn một câu trả lời thích hợp nhất nói về tâm trạng của ông (bà) trong những tuần qua.
STT CÂU HỎI Câu trả
lời Điểm
1. Nhìn chung, ông (bà) có hài lòng với cuộc sống của
mình không? Có/không
2. ……………………………………………………… Có/không
3. Ông (bà) có cảm thấy cuộc sống của mình vô
vị/trống rỗng không?
Có/không
4. Ông (bà) có thường xuyên cảm thấy chán nản
không?
Có/không
5. Ông (bà) có thường xuyên cảm thấy tinh thần mình
thoải mái không?
Có/không
6. ……………………………………………………… Có/không
7. Ông (bà) có thường xuyên cảm thấy vui vẻ, hạnh
phúc không?
Có/không
8. Ông (bà) có thường xuyên cảm thấy vô dụng không? Có/không
9. Ông (bà) có cảm thấy thích ở nhà hơn là đi ra ngoài
và làm việc gì đó mới mẻ không?
Có/không
10. ……………………………………………………… Có/không
11. Ông (bà) có cảm thấy hiện tại được sống là điều
tuyệt vời không?
Có/không
12. Ông/bà có cảm thấy cách sống của ông/bà hiện nay
hơi kém ý nghĩa không?
Có/không
13. Ông (bà) có cảm thấy mình khoẻ mạnh, nhiều sinh
lực không?
Có/không
14. ……………………………………………………… Có/không
15. Ông (bà) có nghĩ rằng đa số mọi người chung quanh
đều có cuộc sống tốt hơn mình không?
Có/không
TỔNG CỘNG
101
Phần 6. Thang đo quốc tế về khả năng té ngã
Tôi xin được hỏi ông (bà) một số câu hỏi về việc ông (bà) quan tâm như thế nào đến
khả năng té ngã. Đối với mỗi hoạt động sau đây, xin ông (bà) hãy khoanh tròn vào ý
kiến nào cho thấy mức độ quan tâm của ông (bà) đến khả năng bị té ngã nếu ông (bà)
thực hiện hoạt động đó. Nếu hiện tại ông (bà) không thực hiện một hoạt động nào đấy
(ví dụ có người đi chợ, đi siêu thị thay cho ông (bà)), ông bà làm ơn thể hiện sự lo lắng
của mình về khả năng té ngã của mình NẾU giả sử ông bà thực hiện hoạt động đó.
Lưu ý: Nếu lo lắng được chia làm 4 mức độ (Mức 1:hoàn toàn không lo lắng; Mức 4: rất lo
lắng), ông/bà ở mức nào?
TT HOẠT ĐỘNG
Mức độ quan ngại
1
Hoàn
toàn
không
quan
ngại
2
Quan
ngại
một ít
3
Khá
quan
ngại
4
Rất
quan
ngại
1. ………………………………………..
2. Mặc áo quần, cởi áo quần
3. Chuẩn bị những bữa ăn đơn giản
4. Tắm rửa hoặc gội đầu
5. Đi mua sắm ở các quầy hàng
6. …………………………………………
7. Lên hoặc xuống bậc thang/ bậc cấp
8. Đi bộ xung quanh khu dân cư sinh sống
9. Với lấy những vật ở cao phía trên đầu
hoặc ở dưới sàn/mặt đất
10. …………………………………………
11. Đi bộ trên bề mặt trơn (ví dụ bề mặt bị
ướt)
12. Đi thăm bạn bè, người thân, họ hàng
13. Đi bộ nơi đông đúc
14. …………………………………………
15. Đi bộ lên hoặc xuống dốc
16. …………………………………………
TỔNG ĐIỂM
/64
APPENDIX 4
Pearson’s assumption test results
103
1. Normality
Table 7 Normal distribution of age, Barthel ADLs, depression, balance and gait status
and fear of falling (n = 153)
Variables Skewness Std. Error of
Skewness
Fisher skewness
coefficient
Age .378 .196 1.93
Barthel ADLs -.277 .196 -1.41
Depression .350 .196 1.79
Balance and gait status .113 .196 0.57
Fear of falling .352 .196 1.79
Table 7 showed that the Fisher skewness coefficient of all variables fall
between ± 1.96. It meant that all variables have normal distribution.
2. Homoscedasticity and linearity
104
105
APPENDIX 5
Ethical form and the letter for asking permission for data collection
107
108
APPENDIX 6
Consent form
110
INFORMATION SHEET
Dear Sir/Madam,
My name is Tran Thi Hoang Oanh, a student of Master of Gerontological Nursing,
Faculty of Nursing, Burapha University, Thailand. I am conducting a study entitled
“Factors related to fear of falling among community-dwelling older adults in Danang,
Vietnam”. This study will be conducted in order to investigate the fear of falling in
community-dwelling older adults and examine the relationships between age, gender,
history of fall, balance and gait status, general health perception, activities of daily living,
depression and fear of falling in community-dwelling older adults in Danang, Vietnam.
The findings of the study will provide the basic knowledge for gerontological nurses to
assess fear of falling and further researches for developing the interventions in order to
prevent and reduce fear of falling to prevent fall and improve quality of life in older adults.
If you agree to participate in this study, the researcher will interview you six
questionnaires within about 60 minutes and you will be asked to take a simple test for
balance and gait status within 1-2 minutes by standing up, walking for 3 meters, returning
and sitting. There are no identified risks with participating in this study.
Participation is voluntary. You have the right to refuse to answer any questions
and may withdraw at any time without any penalty. Anonymity and confidentiality will be
assured, and no personal information will be revealed to any other person. All data will be
stored in a secure place and will be only utilized for the purposes of the study. You will
receive a complete explanation of the nature of the study if you wish to.
If you agree to join this study, please sign your name below to indicate that you are
informed, and you understand all necessary information related to the study, and to prove
your consent to participate in this study as well.
The study will be conducted by me. If you have any questions, please contact me
at +84 903 52 52 69 or by e-mail: [email protected] or my major adviser
Assist. Prof. Dr.Pornchai Jullamate, e-mail: [email protected].
Thank you very much for your cooperation.
Tran Thi Hoang Oanh
111
INFORMED CONSENT
Title: “Factors related to fear of falling among community-dwelling older
adults in Danang, Vietnam”.
IRB approval number: 22 – 01 – 2558
Date of collection data ……………Month ………….Years………………
Before I give signature in below, I already be informed and explained by the
researcher, Ms Tran Thi Hoang Oanh about purposes, method, procedures, and
benefits of this study, and I understood all of that explanation. I agree to be as a
participant of this study.
I’m Ms Tran Thi Hoang Oanh, as a researcher has explained all of explanation
about purposes, method, procedures, and benefits of this study to the participant with
honestly; then, all of information of the participants will only be used for purpose of
this research study.
___________________________ ___________________________
Name and Signature of the Participant Date
___________________________ ___________________________
Name and Signature of witness Name and Signature of the researcher
APPENDIX 7
Other relevant documents
113
PHIẾU THÔNG TIN
Kính thưa Ông/ Bà
Tôi tên là Trần Thị Hoàng Oanh, là sinh viên thạc sỹ Điều dưỡng Lão khoa tại
trường đại học Burapha, Thái Lan. Hiện nay tôi đang tiến hành một đề tài tốt nghiệp với
tên là “ Các yếu tố liên quan đến sự sợ ngã của người cao tuổi tại cộng đồng thành phố Đà
Nẵng, Việt Nam” với hai mục tiêu là đánh giá sự sợ ngã và xác định các yếu tố liên quan
đến sự sợ ngã của người cao tuổi ở cộng đồng thành phố Đà Nẵng. Kết quả nghiên cứu sẽ
có giá trị ứng dụng vào chương trình giảng dạy Điều dưỡng lão khoa cũng như công tác
chăm sóc sức khỏe người cao tuổi. Nó là tiền đề để làm các nghiên cứu sâu hơn nhằm phát
triển các chương trình can thiệp nhằm hạn chế và dự phòng sự sợ ngã của người cao tuổi
để đề phòng nguy cơ té ngã và cải thiện chất lượng cuộc sống của người cao tuổi.
Nếu ông bà đồng ý tham gia nghiên cứu, người nghiên cứu sẽ phỏng vấn ông bà
thông qua 5 bộ câu hỏi ngắn gọn cùng với 1 kiểm tra đơn giản về khả năng cân bằng của
ông/bà bằng cách ông bà sẽ đứng lên và đi lại 3 mét sau đó quay lại. Tôi xin đảm bảo
không có bất cứ nguy hiểm nào cho ông/bà khi tham gia nghiên cứu này.
Sự tham gia của ông/bà là hoàn toàn tự nguyện. Ông/ bà có quyền từ chối không
trả lời bất cứ câu hỏi nào cũng như kết thúc sự tham gia bất cứ lúc nào. Tất cả những
thông tin về cá nhân của ông/ bà sẽ được giữ bí mật. Các dữ liệu sẽ được cất giữ ở nơi an
toàn và chỉ được truy cập, sử dụng bởi người nghiên cứu với mục đích nghiên cứu. Ông,
bà sẽ được giải thích rõ ràng những thông tin liên quan đến nghiên cứu mà ông/ bà muốn.
Nếu ông/bà đồng ý tham gia nghiên cứu, kính mong ông/ bà vui lòng ký tên bên
dưới để xác nhận rằng ông/ bà đã được thông báo và hiểu tất các những thông tin cần thiết
liên quan đến nghiên cứu cũng như chứng minh sự đồng ý tham gia nghiên cứu của ông, bà.
Nghiên cứu này được tiến hành bởi chính tôi. Nếu cần bất cứ thông tin gì,
ông, vui lòng liên hệ với tôi thông qua số điện thoại +84 903 52 52 69 hoặc e-mail:
[email protected] hoặc thầy giáo hướng dẫn của tôi PGS TS.
Pornchai Jullamate, e-mail: [email protected].
Tôi xin chân thành cám ơn sự hợp tác giúp đỡ của ông, bà!
Trần Thị Hoàng Oanh
114
GIẤY ĐỒNG Ý
Tên đề tài: “Các yếu tố liên quan đến sự sợ ngã của người cao tuổi ở cộng
đồng thành phố Đà Nẵng, Việt Nam”.
Mã số IRB: 22-01-2558
Ngày thu thập số liệu: …………
Trước khi ký tên bên dưới, tôi đã được thông báo và giải thích kỹ bởi người
nghiên cứu, cô Trần Thị Hoàng Oanh về mục tiêu, phương pháp, quy trình và lợi ích
của nghiên cứu. Tôi đã hiểu rõ những điều nói trên. Tôi đồng ý trở thành người tham
gia nghiên cứu của nghiên cứu này.
Tôi là Trần Thị Hoàng Oanh, người tiến hành nghiên cứu, đã giải thích rõ
mục tiêu, phương pháp, quy trình và lợi ích của nghiên cứu cho người tham gia nghiên
cứu một cách chân thành; sau đó tất cả những thông tin của người tham gia nghiên cứu
sẽ chỉ được sử dụng duy nhất với mục đích nghiên cứu.
___________________________ ________________________
Họ, tên và chữ ký của người tham gia Ngày
___________________________ ___________________________
Họ, tên và chữ ký của người làm chứng Họ, tên và chữ ký của người nghiên cứu
115
Cộng hòa xã hội chủ nghĩa Việt Nam
Độc lập – Tự do – Hạnh phúc
ĐƠN XIN THU THẬP SỐ LIỆU
Kính gửi: Trạm y tế Phường Hải Châu II, Quận Hải Châu, Thành phố Đà Nẵng
Tôi tên là Trần Thị Hoàng Oanh, giảng viên khoa Điều dưỡng, trường ĐH
Kỹ thuật Y Dược – Đà Nẵng. Hiện tôi đang theo học Cao học Điều Dưỡng tại trường
ĐH Burapha, Thái Lan, chuyên ngành Lão khoa.
Hiện nay tôi đang trong quá trình tiến hành thực hiện luận văn thạc sỹ với
tên đề tài “Các yếu tố liên quan đến sự sợ ngã ở người cao tuổi tại cộng đồng thành
phố Đà Nẵng, Việt Nam” dưới sự hướng dẫn của PGS TS Pornchai Jullamate.
Liên quan đến vấn đề này, tôi viết đơn này kính xin trạm Y tế cho phép tôi
được thu thập số liệu từ 28 người cao tuổi tại phường trong thời gian từ tháng 2 tới
tháng 5 năm 2015. Người tham gia nghiên cứu sẽ được phỏng vấn thông qua bộ câu
hỏi từ người nghiên cứu. Đề cương nghiên cứu đã được thông qua hội đồng đạo đức
nghiên cứu của trường ĐH Burapha, Thái Lan. Quá trình thu thập không gây bất cứ
ảnh hưởng xấu nào đến người tham gia nghiên cứu và người tham gia nghiên cứu
được phổ biến rõ mục tiêu, nội dung và quy trình nghiên cứu cũng như cách thức thu
thập số liệu. Nếu người nghiên cứu đồng ý tham gia, quá trình thu thập số liệu sẽ được
tiến hành.
Rất mong nhận được sự giúp đỡ, hợp tác của quý trạm.
Trong lúc chờ đợi sự đồng ý của quý trạm tôi xin chân thành cám ơn.
Đà Nẵng, ngày 02 tháng 3 năm 2015
Ý kiến của trưởng trạm Y tế Kính đơn
Trần Thị Hoàng Oanh
116
Cộng hòa xã hội chủ nghĩa Việt Nam
Độc lập – Tự do – Hạnh phúc
ĐƠN XIN THU THẬP SỐ LIỆU
Kính gửi: Trạm y tế Phường Tân Chính, Quận Thanh Khê, Thành phố Đà
Nẵng
Tôi tên là Trần Thị Hoàng Oanh, giảng viên khoa Điều dưỡng, trường ĐH
Kỹ thuật Y Dược – Đà Nẵng. Hiện tôi đang theo học Cao học Điều Dưỡng tại trường
ĐH Burapha, Thái Lan, chuyên ngành Lão khoa.
Hiện nay tôi đang trong quá trình tiến hành thực hiện luận văn thạc sỹ với
tên đề tài “Các yếu tố liên quan đến sự sợ ngã ở người cao tuổi tại cộng đồng thành
phố Đà Nẵng, Việt Nam” dưới sự hướng dẫn của PGS TS Pornchai Jullamate.
Liên quan đến vấn đề này, tôi viết đơn này kính xin trạm Y tế cho phép tôi
được thu thập số liệu từ 26 người cao tuổi tại phường trong thời gian từ tháng 2 tới
tháng 5 năm 2015. Người tham gia nghiên cứu sẽ được phỏng vấn thông qua bộ câu
hỏi từ người nghiên cứu. Đề cương nghiên cứu đã được thông qua hội đồng đạo đức
nghiên cứu của trường ĐH Burapha, Thái Lan. Quá trình thu thập không gây bất cứ
ảnh hưởng xấu nào đến người tham gia nghiên cứu và người tham gia nghiên cứu
được phổ biến rõ mục tiêu, nội dung và quy trình nghiên cứu cũng như cách thức thu
thập số liệu. Nếu người nghiên cứu đồng ý tham gia, quá trình thu thập số liệu sẽ được
tiến hành.
Rất mong nhận được sự giúp đỡ, hợp tác của quý trạm.
Trong lúc chờ đợi sự đồng ý của quý trạm tôi xin chân thành cám ơn.
Đà Nẵng, ngày 02 tháng 3 năm 2015
Ý kiến của trưởng trạm Y tế Kính đơn
Trần Thị Hoàng Oanh
117
Cộng hòa xã hội chủ nghĩa Việt Nam
Độc lập – Tự do – Hạnh phúc
ĐƠN XIN THU THẬP SỐ LIỆU
Kính gửi: Trạm y tế Phường Hòa Minh, Quận Liên Chiểu, Thành phố Đà Nẵng
Tôi tên là Trần Thị Hoàng Oanh, giảng viên khoa Điều dưỡng, trường ĐH
Kỹ thuật Y Dược – Đà Nẵng. Hiện tôi đang theo học Cao học Điều Dưỡng tại trường
ĐH Burapha, Thái Lan, chuyên ngành Lão khoa.
Hiện nay tôi đang trong quá trình tiến hành thực hiện luận văn thạc sỹ với
tên đề tài “Các yếu tố liên quan đến sự sợ ngã ở người cao tuổi tại cộng đồng thành
phố Đà Nẵng, Việt Nam” dưới sự hướng dẫn của PGS TS Pornchai Jullamate.
Liên quan đến vấn đề này, tôi viết đơn này kính xin trạm Y tế cho phép tôi
được thu thập số liệu từ 26 người cao tuổi tại phường trong thời gian từ tháng 2 tới
tháng 5 năm 2015. Người tham gia nghiên cứu sẽ được phỏng vấn thông qua bộ câu
hỏi từ người nghiên cứu. Đề cương nghiên cứu đã được thông qua hội đồng đạo đức
nghiên cứu của trường ĐH Burapha, Thái Lan. Quá trình thu thập không gây bất cứ
ảnh hưởng xấu nào đến người tham gia nghiên cứu và người tham gia nghiên cứu
được phổ biến rõ mục tiêu, nội dung và quy trình nghiên cứu cũng như cách thức thu
thập số liệu. Nếu người nghiên cứu đồng ý tham gia, quá trình thu thập số liệu sẽ được
tiến hành.
Rất mong nhận được sự giúp đỡ, hợp tác của quý trạm.
Trong lúc chờ đợi sự đồng ý của quý trạm tôi xin chân thành cám ơn.
Đà Nẵng, ngày 02 tháng 3 năm 2015
Ý kiến của trưởng trạm Y tế Kính đơn
Trần Thị Hoàng Oanh
118
Cộng hòa xã hội chủ nghĩa Việt Nam
Độc lập – Tự do – Hạnh phúc
ĐƠN XIN THU THẬP SỐ LIỆU
Kính gửi: Hội người cao tuổi Phường Phước Mỹ, Quận Sơn Trà, TP Đà Nẵng
Tôi tên là Trần Thị Hoàng Oanh, giảng viên khoa Điều dưỡng, trường ĐH
Kỹ thuật Y Dược – Đà Nẵng. Hiện tôi đang theo học Cao học Điều Dưỡng tại trường
ĐH Burapha, Thái Lan, chuyên ngành Lão khoa.
Hiện nay tôi đang trong quá trình tiến hành thực hiện luận văn thạc sỹ với
tên đề tài “Các yếu tố liên quan đến sự sợ ngã ở người cao tuổi tại cộng đồng thành
phố Đà Nẵng, Việt Nam” dưới sự hướng dẫn của PGS TS Pornchai Jullamate.
Liên quan đến vấn đề này, tôi viết đơn này kính xin trạm Y tế cho phép tôi được thu
thập số liệu từ 19 người cao tuổi tại phường trong thời gian từ tháng 2 tới tháng 5 năm
2015. Người tham gia nghiên cứu sẽ được phỏng vấn thông qua bộ câu hỏi từ người
nghiên cứu. Đề cương nghiên cứu đã được thông qua hội đồng đạo đức nghiên cứu
của trường ĐH Burapha, Thái Lan. Quá trình thu thập không gây bất cứ ảnh hưởng
xấu nào đến người tham gia nghiên cứu và người tham gia nghiên cứu được phổ biến
rõ mục tiêu, nội dung và quy trình nghiên cứu cũng như cách thức thu thập số liệu.
Nếu người nghiên cứu đồng ý tham gia, quá trình thu thập số liệu sẽ được tiến hành.
Rất mong nhận được sự giúp đỡ, hợp tác của quý hội.
Trong lúc chờ đợi sự đồng ý của quý hội tôi xin chân thành cám ơn.
Đà Nẵng, ngày 02 tháng 3 năm 2015
Ý kiến của hội trưởng hội người cao tuổi Kính đơn
Trần Thị Hoàng Oanh
119
Cộng hòa xã hội chủ nghĩa Việt Nam
Độc lập – Tự do – Hạnh phúc
ĐƠN XIN THU THẬP SỐ LIỆU
Kính gửi: Trạm y tế Phường Khuê Mỹ, Quận Ngũ Hành Sơn, TP Đà Nẵng
Tôi tên là Trần Thị Hoàng Oanh, giảng viên khoa Điều dưỡng, trường ĐH
Kỹ thuật Y Dược – Đà Nẵng. Hiện tôi đang theo học Cao học Điều Dưỡng tại trường
ĐH Burapha, Thái Lan, chuyên ngành Lão khoa.
Hiện nay tôi đang trong quá trình tiến hành thực hiện luận văn thạc sỹ với
tên đề tài “Các yếu tố liên quan đến sự sợ ngã ở người cao tuổi tại cộng đồng thành
phố Đà Nẵng, Việt Nam” dưới sự hướng dẫn của PGS TS Pornchai Jullamate.
Liên quan đến vấn đề này, tôi viết đơn này kính xin trạm Y tế cho phép tôi được thu
thập số liệu từ 20 người cao tuổi tại phường trong thời gian từ tháng 2 tới tháng 5 năm
2015. Người tham gia nghiên cứu sẽ được phỏng vấn thông qua bộ câu hỏi từ người
nghiên cứu. Đề cương nghiên cứu đã được thông qua hội đồng đạo đức nghiên cứu
của trường ĐH Burapha, Thái Lan. Quá trình thu thập không gây bất cứ ảnh hưởng
xấu nào đến người tham gia nghiên cứu và người tham gia nghiên cứu được phổ biến
rõ mục tiêu, nội dung và quy trình nghiên cứu cũng như cách thức thu thập số liệu.
Nếu người nghiên cứu đồng ý tham gia, quá trình thu thập số liệu sẽ được tiến hành.
Rất mong nhận được sự giúp đỡ, hợp tác của quý trạm.
Trong lúc chờ đợi sự đồng ý của quý trạm tôi xin chân thành cám ơn.
Đà Nẵng, ngày 02 tháng 3 năm 2015
Ý kiến của trưởng trạm Y tế Kính đơn
Trần Thị Hoàng Oanh
120
Cộng hòa xã hội chủ nghĩa Việt Nam
Độc lập – Tự do – Hạnh phúc
ĐƠN XIN THU THẬP SỐ LIỆU
Kính gửi: Trạm y tế Phường Hòa Phát, Quận Cẩm Lệ, Thành phố Đà Nẵng
Tôi tên là Trần Thị Hoàng Oanh, giảng viên khoa Điều dưỡng, trường ĐH
Kỹ thuật Y Dược – Đà Nẵng. Hiện tôi đang theo học Cao học Điều Dưỡng tại trường
ĐH Burapha, Thái Lan, chuyên ngành Lão khoa.
Hiện nay tôi đang trong quá trình tiến hành thực hiện luận văn thạc sỹ với
tên đề tài “Các yếu tố liên quan đến sự sợ ngã ở người cao tuổi tại cộng đồng thành
phố Đà Nẵng, Việt Nam” dưới sự hướng dẫn của PGS TS Pornchai Jullamate.
Liên quan đến vấn đề này, tôi viết đơn này kính xin trạm Y tế cho phép tôi
được thu thập số liệu từ 17 người cao tuổi tại phường trong thời gian từ tháng 2 tới
tháng 5 năm 2015. Người tham gia nghiên cứu sẽ được phỏng vấn thông qua bộ câu
hỏi từ người nghiên cứu. Đề cương nghiên cứu đã được thông qua hội đồng đạo đức
nghiên cứu của trường ĐH Burapha, Thái Lan. Quá trình thu thập không gây bất cứ
ảnh hưởng xấu nào đến người tham gia nghiên cứu và người tham gia nghiên cứu
được phổ biến rõ mục tiêu, nội dung và quy trình nghiên cứu cũng như cách thức thu
thập số liệu. Nếu người nghiên cứu đồng ý tham gia, quá trình thu thập số liệu sẽ được
tiến hành.
Rất mong nhận được sự giúp đỡ, hợp tác của quý trạm.
Trong lúc chờ đợi sự đồng ý của quý trạm tôi xin chân thành cám ơn.
Đà Nẵng, ngày 02 tháng 3 năm 2015
Ý kiến của trưởng trạm Y tế Kính đơn
Trần Thị Hoàng Oanh
121
Cộng hòa xã hội chủ nghĩa Việt Nam
Độc lập – Tự do – Hạnh phúc
ĐƠN XIN THU THẬP SỐ LIỆU
Kính gửi: Trạm y tế xã Hòa Phước, Huyện Hòa Vang, Thành phố Đà Nẵng
Tôi tên là Trần Thị Hoàng Oanh, giảng viên khoa Điều dưỡng, trường ĐH
Kỹ thuật Y Dược – Đà Nẵng. Hiện tôi đang theo học Cao học Điều Dưỡng tại trường
ĐH Burapha, Thái Lan, chuyên ngành Lão khoa.
Hiện nay tôi đang trong quá trình tiến hành thực hiện luận văn thạc sỹ với
tên đề tài “Các yếu tố liên quan đến sự sợ ngã ở người cao tuổi tại cộng đồng thành
phố Đà Nẵng, Việt Nam” dưới sự hướng dẫn của PGS TS Pornchai Jullamate.
Liên quan đến vấn đề này, tôi viết đơn này kính xin trạm Y tế cho phép tôi
được thu thập số liệu từ 17 người cao tuổi tại phường trong thời gian từ tháng 2 tới
tháng 5 năm 2015. Người tham gia nghiên cứu sẽ được phỏng vấn thông qua bộ câu
hỏi từ người nghiên cứu. Đề cương nghiên cứu đã được thông qua hội đồng đạo đức
nghiên cứu của trường ĐH Burapha, Thái Lan. Quá trình thu thập không gây bất cứ
ảnh hưởng xấu nào đến người tham gia nghiên cứu và người tham gia nghiên cứu
được phổ biến rõ mục tiêu, nội dung và quy trình nghiên cứu cũng như cách thức thu
thập số liệu. Nếu người nghiên cứu đồng ý tham gia, quá trình thu thập số liệu sẽ được
tiến hành.
Rất mong nhận được sự giúp đỡ, hợp tác của quý trạm.
Trong lúc chờ đợi sự đồng ý của quý trạm tôi xin chân thành cám ơn.
Đà Nẵng, ngày 02 tháng 3 năm 2015
Kính đơn
Trần Thị Hoàng Oanh
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