Fear of falling and fall circumstances in Thailand
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Numerous Thai older people fall each year. Although it has been shown that only 3.1% of fallers sustained fractures (Nevitt, Cumming, Kidd, & Black, 1989), injuries in older people are often more serious. For example, hospital charges for older adult fall injuries are about US $2,000 per person higher than for young fallers (Ellis & Trent, 2001). Moreover, falling can lead to social isolation, physical restraint, disability and institutionalisation (Donald & Bulpitt, 1999; Tideiksaar, 1994). Therefore falling in old age results in a considerable burden on, not only the individual concerned, but also the whole society. Internationally, a successful falls prevention program usually employs a multidimensional approaches (Alexander & Edelberg, 2002; Mosley, Galindo- Ciocon, Peak, & West, 1998). However, limited information about fall prevention has been reported in Thailand. A survey indicated that Thai elderly fall outside their homes which is different from the findings in Western countries (Jitapunkul et al., 1998). This suggests that adoption of fall prevention strategies from Western countries might not be successful in Thailand. Prior to this study, details of fall circumstances in terms of location, time, associated activity, hazards and type of falls in Thai older people were not available. Moreover, there was no information about fear of falling and activity restriction. These are important fall consequences that impact on quality of life and themselves are risk factors for falls. The purpose of this study was to determine the prevalence of fear of falling, and to describe activity restriction in fallers and non-fallers, and the circumstances associated with falls in Thailand. No fear of falling measurement tools for Thai older people were available prior to the study.Therefore the Survey of Activities and Fear of Falling in the elderly (SAFE) has been modified for use with Thai elderly people. The SAFE was translated to Thai by a certified translator, checked for cultural relevance and back-translated by a second translator; reliability testing then took place in Thailand. Face validity and cultural appropriateness were tested with a sample of convenience of 10 bilingual Thai elderly people living in Perth, Australia. After translation into Thai, 4 items showed less than 80% agreement and required adjustment to capture the equivalent meaning of the original version. The ‘take a show/wash yourself with a basin of water’ was added because the participants reported that taking a tub bath is not common or traditional in Thailand. However, the item ‘take a tub bath’ was retained until the examination in the main study confirmed that less than 1% of Thai older persons had taken a tub bath and inclusion of the item confounded actual fear of falling results. Interrater reliability was tested; nine 4th year occupational therapy students and 15 older persons living in the Chiang Mai community were recruited. The intraclass correlation coefficient of fear of falling of activities done, activities not done and activity restriction scores were .9845, .9236 and .9718 respectively (p < 0.001). Four raters and 50 older community dwellers participated in the intrarater and test-retest reliability tests. The results showed that intrarater reliability of all raters exceed 0.8 in every scores (p < .001).The test-retest also demonstrated good reliability: .9960, .9376 and .9849 (p < 0.0001) for fear of falling of activities done, activities not done and activity restriction scores respectively. Five hundreds and forty six Thai older adults were then recruited by multistage random sampling. Fall history, fall circumstances, fear of falling and activity restriction data were obtained by structured interview and using the Thai version of the SAFE. The results demonstrated that prevalence of falls, fear of falling and activity restriction in Thai older people were 21%, 48% and 18%, respectively. Comparison between fallers and non-faller showed that fallers were more likely to be older (p < .001), female [χ2(1, N = 546) = 6.133; p = .013], not married [χ2 (4,N=546)=61.102;~= .001], living alone[χ2 (l,N=546)=4.313;p= ,041, rated their health as poorer [χ2 (4, N = 546) = 13.232; p < .001], had fear of falling [χ2 (1, N = 546) = 6.265; p = .015] and activity restriction [χ2 (1, N = 546) = 5.488; p = ,0271]. Older persons with a fear of falling tended to be older (p = .005), lower educated (p < .001), female [χ2 (1, N = 546) = 29.602; p = .001], rated their health as poorer [χ2 (4, N = 546) = 69.70; p < .001], had fallen [? (1, N = 546) = 6.265; p = ,0151 and had activity restriction [χ2 (l, N = 546) = 23.267; p < .001]. Older adults who curtailed their activities tended to be married [χ2 (1, N = 546) = 6.188; p = ,0131, rated their health as poorer [χ24, N = 546) = 14.302; p = ,0061, have a fall history [χ2 (1, N = 546) = 5.488; p = ,0271 and have a fear of falling [χ2(1, N = 546) = 23.267; p < .001].Using Chi-square test, the results showed that there were significant associations between falls and fear of falling χ2(l,N=546)=6.265;p=.015], falls and activity restriction [χ2 (l,N= 546) = 5.488; p = ,0271] and fear of falling and activity restriction [χ2 (1, N = 546) = 23.267; p < .001]. Fall circumstances of 114 falls demonstrated that most falls took place outdoors (65%), were associated with work (40%), involved environmental hazards (76%), occurred during the daytime (90%). Moreover most falls were falls on the same level from slipping, tripping or stumbling (61%). Logistic regression analysis indicated that risk factors for fear of falling in Thai older people were age (odds ratio = 1.025), unmarried-female (odds ratio = 5.979), married female (odds ratio = 1.903), poor self perceived health (odds ratio = 3.383) and more than 2 falls experience (odds ratio = 7.202). The protective factors were unmarried marital status for men (odds ratio = 0.344) and level of education (odds ratio = 0.933 2 or less falls and = 0.5625 if more than 2 falls in 12 months). The logistic model also provided a logistic equation for individual prediction of probability of fear of falling. To calculate the probability of having fear of falling, 6 parameters are required: age, gender, marital status, level of education, self-perceived health and number of falls in the past 12 months. The equation predicts with 70% accuracy and can be used for screening fear of falling in Thai elderly people. In conclusion, this study has modified a measurement tool (the SAFE Thai version) and developed a screening tool (logistic equation) for fear of falling. Both of them appear to be appropriate to further examine FOF in Thai elderly. The survey results showed a considerably number of Thai elderly people have fall experiences, fear of falling and activity restriction.The predisposing factors for each problem have been identified. The association between 3 problems implicated that fear of falling and activity restriction interventions are necessary for fall prevention. The fall circumstances data show that conditions of falls in Thai elderly people were similar and dissimilar to those in Western countries. The preventive efforts to reduce falls should consider these distinctive fall circumstances.
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