Abstract

Background: Fear of falling (FOF) is a prevalent yet understudied issue among community-dwelling Indian older adults, contributing to increased fall risk and functional decline. The aim of this study was to assess FOF among elders from rural and urban areas of India and to explore the distinctive challenges and factors influencing the perception of FOF. Methods: In this prospective cross-sectional study, 220 community-dwelling Indian older adults participated, representing both rural and urban areas. The score of the Fall Efficacy Scale (FES-I) & its association with age and gender were also explored in both the contexts. Results: Rural participants had significantly higher FES-I scores compared to urban participants (34.13 ± 10.97 vs 19.58 ± 4.07), indicating a greater fear of falling (p < 0.001). Females reported higher FES-I scores than males (28.51 ± 11.38 vs. 25.20 ± 0.42; p < 0.05). Age also showed a significant positive correlation with FES-I scores (r = 0.185, p < 0.01). Conclusion: The Study highlighted varied levels of concern about falling in diverse conditions and the need for context-specific interventions to mitigate FOF and related issues.

Keywords

Community-Dwelling, Fall Efficacy, Falls, Fear of Falling, Older Adults, Self-Efficacy

Introduction

As populations age worldwide, the health and well-being of older adults have become increasingly critical areas of research and public health concern. Among the multi-fold challenges faced by this demographic, fear of falling (FOF) stands out as a significant issue with far-reaching implications on mobility, independence, and overall quality of life.¹ FOF refers to an individual’s perceived risk or anxiety about falling, which can lead to activity restriction, social isolation, and diminished physical function.² It has been defined as a continuing concern characterized by walking anxiety or excessive worry about falling, which may affect older adults by limiting their activities of daily living (ADLs).^3,4 FOF is not only a consequence of previous falls but also a predictor of future falls.⁵ The prevalence of FOF among older adults varies globally, with studies indicating rates ranging from

20% to 85%, depending on the population and assessment methods used.⁶ FOF is reportedly present even among those who have not experienced any history of falls. Therefore, FOF is considered a health problem and needs urgent attention and feasible measures in the immediate future. FOF has been increasingly reported in community-dwelling older adults, with a prevalence ranging from 20 to 85%,^3,7,8 being present even among those who have not experienced any type of fall.^3,8 In India, the population of older adults is rapidly increasing, projected to reach 19% of the total population by 2050.⁹ This transition emphasises the importance of addressing age-related health concerns, including psychological and functional impacts of FOF leading to falls in older adults. The prevalence of falls among the elderly population is 11.43% (N=3282) in India.¹⁰ However, limited empirical research has explored FOF among older adults in India, particularly concerning rural-urban disparities.

In the context of rural and urban environments, older adults may experience unique challenges and risk factors that influence their perception of FOF. Rural and urban environments in India differ significantly in terms of infrastructure, healthcare access, and social support systems, which can influence the risk and perception of falls among older adults.¹¹ Urban areas often offer greater access to healthcare services, recreational facilities, and social support networks, which may mitigate feelings of fear and apprehension among older residents. Conversely, rural areas may present environmental barriers such as uneven terrain, limited access to healthcare, and social isolation, which could exacerbate FOF among older adults. A major portion of older adults continues to reside in rural areas and, therefore, might be closely affected by FOF. However, testing tools and related data are not readily available from rural regions, and it largely remains unknown about the belief and confidence in balance and about FOF.

Understanding the interplay between age, gender, and residential setting in relation to FOF is essential for developing targeted interventions to support older adults in rural and urban communities. Previous research has suggested that older age and female gender are associated with higher levels of FOF, while the influence of residential setting remains less explored. Therefore, investigating FOF among older adults in rural and urban areas of India can provide valuable insights into the factors contributing to FOF and inform the development of context-specific interventions.

The present cross-sectional study aims to assess FOF among adults aged 60 years and above, residing in the community in rural and urban areas in India. By examining age and gender-related differences in FOF scores and exploring the impact of residential setting, this research seeks to contribute to the understanding of the complexities surrounding FOF among older adults in diverse environments. The outcomes of this study could guide focused strategies to reduce FOF and enhance the well-being of older adults in rural and urban areas in India.

Methods

Study design and participants

A cross-sectional study design was employed, targeting community-dwelling older individuals aged 60 years and above living in rural and urban areas of Jaipur, Rajasthan, India. A total of 220 older adult participants were recruited through convenience sampling. A structured interview was conducted to collect demographic information and FES-I scale scores to assess FOF. The study is a part of a PhD project, and the ethical approval was obtained from the Institutional Ethics Committee MGUMST, Jaipur, India. The study was designed and reported in accordance with the STROBE guidelines.

Inclusion and exclusion criteria

Participants were included if they were community-dwelling Indian older adults aged 60 years and above, able to hear and comprehend the administrator’s commands, and ambulant with/without the use of a walking aid. The exclusion criteria included being home-bound, institutionalized, wheelchair bound; inability to ambulate with/without the use of a walking aid or physically related personal assistance, having a history of neurological conditions like stroke, Parkinson’s disease, etc., and those with a history of surgical intervention to the lower extremity or spine.

Outcome measure

FOF was assessed using the Falls Efficacy Scale-International (FES-I), a validated tool that measures the level of concern about falling during various activities of daily living.¹² The FES-I consists of 16 items, each scored on a 4-point scale, with total scores ranging from 16 (no concern) to 64 (severe concern). The Hindi version of the FES-I, validated for use among Indian older adults,¹³ was utilized in this study to ensure cultural relevance and ease of comprehension among participants, enhancing the reliability of the findings.

Procedure

The participants were first informed about the study objectives, and written informed consent was obtained. Information about demographic details (age, locality, and sex), and response to the questions of the Falls Efficacy

Scale- International (FES-I). The FES-I was administered via face-to-face structured interview among the participants.

Statistical analysis

Data was analysed using IBM SPSS Statistics version

27.0. Results for descriptive statistics were reported using mean and standard deviation. The independent t-test was used for comparison of FOF scores between male & female participants belonging to rural and urban areas. The correlation between age and FES-I score was determined using the Pearson correlation test. A p-value of ≤ 0.05 was considered statistically significant.

Results

Participant characteristics

The study involved a total of 220 participants, comprising

119 male participants and 101 female participants. Information regarding the locality of participants (urban or rural) and gender (males or females) for age, FES-I score is depicted in Table 1. This table also mentions the number of participants in each subgroup (urban males, rural males, urban females, rural females).

Descriptive data show rural participants (n=108) consisted of 63 females (mean age 69.05 ± 7.50 years; mean FES-I score 34.08 ± 10.70) and 45 males (mean age: 70.73 ± 6.50 years; mean FES-I score: 34.20 ± 11.48). Urban participants (n=112) consisted of 38 females (mean age 65.79 ± 5.16; mean FES-I 19.29 ± 4.25) and 74 males (mean age 68.09 ± 5.71; mean FES-I

19.73 ± 3.99) (Table 1).

FOF scores

The study revealed significant differences in FOF between rural and urban participants, with higher mean FES-I scores observed in the rural group (34.13 ± 10.97) compared to the urban group (19.58 ± 4.07). This difference was statistically significant, t: 13.13, df: 218, p

< 0.01, with a mean difference of 14.55 (Tables 2 & 3).

When analysed by gender, females (28.51 ± 11.38) reported higher FES-I scores than males (25.20 ± 10.42). An independent t-test confirmed this difference as statistically significant, t: 2.25, df: 218, p < 0.05, with a mean difference of –3.13 (Table 3). Further, independent t-tests examining rural–urban differences within gender groups revealed that rural males scored significantly higher than urban males (mean difference = 14.47; t: 9.92, df: 108, p < 0.001), and rural females scored significantly higher than urban females (mean difference = 14.79; t: 8.13, df: 108, p <0.01) (Table 3).

Comparison of age between gender and locality

A one-way ANOVA was conducted to compare the mean age of respondents across groups based on gender and locality. The results revealed a statistically significant difference in mean age between groups, F(3,216): 4.418, p< 0.01, indicating that at least one group differed from the others.

To identify the source of this difference, Tukey HSD post-hoc comparisons were performed. The analysis showed that urban women had a significantly higher mean age compared to rural men (Mean Difference: 4.94, p<0.005, 95% CI: 1.31 to 8.57). No other pairwise comparisons were found to be statistically significant, although the difference between rural women and urban women approached significance (Mean Difference: 3.26, p = 0.063). These findings suggest that age distribution differed primarily between rural men and urban women, while other group comparisons did not show significant variation.

Association of age and FES-I scores

Pearson correlation coefficients were computed to assess the relationship between age and FES-I scores for all older adults in the study, as well as within both the gender groups. The values of the Pearson correlation coefficient, its significance value, and interpretation are mentioned in Table 5.

Overall (n=220), age showed a weak but significant positive correlation with FES-I scores (r = 0.185, p < 0.01). In gender-specific analyses, correlations were positive for both males (r = 0.194, p = 0.34) and females (r = 0.213, p = 0.33), but not statistically significant.

Discussion

Rural-urban disparities in FOF

Various international and Indian studies indicate higher FOF among those residing in less resource-rich environments.^6,11 This current study also investigated the impact of residential setting on FOF among older adults. Interestingly, while FES-I scores were higher in participants from the rural areas compared to their counterparts, the difference was statistically significant, indicating greater concern about falling. This finding aligns with previous research suggesting that older adults from rural areas face a unique set of environmental and systemic challenges that can exacerbate FOF.^6,11,14 The FOF in rural areas may be shaped by uneven terrain, limited infrastructure, poor lighting, lack of paved walkways, and restricted access to assistive devices or rehabilitation services.¹¹^,¹⁴ Rural residents may also face limited healthcare access,¹⁵ lower health literacy,¹⁶ and greater social isolation due to geographical barriers.¹¹^,¹⁷

Currently, around 71% of Indian older people live in rural areas.¹⁸ With a large proportion of older adults already experiencing difficulties accessing healthcare due to health or geographic factors, and with this number set to increase with the ageing population, it is imperative to identify methods to bridge inequities in healthcare access for older adults and to alleviate rising costs to the healthcare systems.¹⁹ Concurrently, the incidence of falls is higher among rural than urban older people.^20,21 The prevalence of perceptive fear of falling was significantly higher in the rural population than that in the urban one and increased with aging in both rural and urban areas.²²

Age-related differences in FOF

Consistent with previous research, our study showed a modest association between age and FOF, with scores increasing as age advanced, reflecting greater fall-related fear among older adults. Although this relationship was not statistically significant when males and females were analysed separately, likely due to smaller subgroup sizes or variability, the trend supports the concept of age-related declines in physical function, balance, and sensory perception. These findings highlight the trajectory of FOF across the lifespan and emphasize the importance of age-sensitive, cohort-specific interventions to address fall-related fears.

Gender disparities in FOF

Another significant finding of our study was the gender disparity in FOF, with females consistently reporting higher scores than males across both areas. Rural females emerged as the most affected group, highlighting their vulnerability and the need for targeted interventions. This gender difference in FOF, widely documented in the literature^23,24,25,26 and may be attributed to numerous factors, including differences in physical strength, balance confidence, and perception of risk. Additionally, societal expectations and cultural norms may influence gender-specific attitudes towards falls and fear avoidance behaviours. Recognizing these gender disparities is crucial for tailoring interventions that address the unique needs and concerns of older women, thereby empowering them to maintain independence and engagement in daily activities. The higher FOF among females is consistent with global trends, where women often report greater concern about falling, potentially due to higher rates of osteoporosis and lower muscle strength.⁶ Kumari and Dsouza in 2015, ²⁷ concluded that the rural and urban elderly differ in intrinsic risk factors, circumstances and consequences of fall, and in socioeconomic and environmental risk factors. A fall prevention programme should be tailored specifically for the two populations for optimum results²⁸. The interaction effect observed suggests that rural females are particularly vulnerable, necessitating targeted interventions.

Implications for public health interventions

This cross-sectional study sheds light on the intricate relationship between age, gender, and residential setting in shaping fear of falling among older adults living in the community. By identifying vulnerable subgroups, particularly older women in rural areas- the findings emphasise the urgent need for targeted fall prevention strategies that are sensitive to both the demographic profile and environmental context of the population. The insights gained from this study have important implications for public health strategies aimed at reducing FOF and promoting the well-being of older adults in rural and urban areas in India. Interventions targeted at older adults should incorporate multifaceted approaches that address physical, psychological, and environmental factors contributing to FOF. Programs designed to enhance strength and balance, improve confidence in mobility, and provide education on fall prevention can empower older adults to mitigate their fear of falls and maintain active, independent lifestyles. In rural areas, where access to healthcare and rehabilitation services may be limited, community-based initiatives are particularly critical. Moreover, community-based initiatives that foster social connectivity and support networks can help alleviate feelings of isolation and anxiety among older adults, particularly in rural areas where resources may be limited. Culturally sensitive and locality-adapted strategies are essential to ensure equitable access and effectiveness across diverse residential environments²⁹.

Risk factors for falls in older people vary according to the characteristics  of  their  living  areas,  and  relevant interventions should be targeted according to the characteristics of falls occurring in different residential areas.³⁰ The association of increasing age with higher FOF emphasizes the importance of tailored interventions to address FOF, particularly in rural areas and among ageing females. Taken together, these findings highlight the complex interplay between environmental, social, and demographic factors in shaping capital FOF among older adults. Addressing these disparities will require multifaceted interventions that go beyond modifying the physical environment to include community engagement, access to healthcare, and education on fall prevention.

Limitations and future directions

While this study provides valuable insights into FOF among older adults in rural and urban areas in Jaipur, Rajasthan, India, several limitations should be acknowledged. The cross-sectional design precludes causal inference, and longitudinal studies are needed to explore the temporal relationship between age, gender, residential setting, and FOF. Additionally, the convenient sampling method may limit the generalizability of the findings, and future research with randomization and larger sample sizes is warranted to confirm and extend our results. Furthermore, qualitative investigations may provide deeper insights into the lived experiences and perceptions of FOF among older adults, complementing quantitative assessments.

Conclusion

 This cross-sectional study provides insights into the prevalence of higher FOF among older adults in rural than urban areas in India, and significantly higher FOF is observed in females in both rural and urban areas. Outcomes of the study highlight the need for customized interventions to address FOF and address the unique challenges faced by older individuals in distinct environments, and enhance the well-being of older adults in diverse settings. Timely screening, specific need identification, and education on fall prevention and monitoring diverse mechanisms underneath FOF in rural and urban areas may contribute to reducing the burden of falls and enhancing quality of life and healthy ageing at large.

Acknowledgements

 The authors sincerely thank all the older adults who generously participated in this study. Their time, openness, and insights made this research possible. We are also grateful to Dr Sebestina Anita Dsouza, Professor, Department of Occupational Therapy, MCHP, MAHE, Manipal for her valuable inputs throughout the study.

Ethical statement

Ethical approval was obtained from the Institutional Ethics Committee MGUMST, Jaipur, India (EC/NEW/INST/2022/RJ/0097). Informed consent was obtained from all participants.

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