Analysis of factors influencing fall risk among elderly people in rural of China

Abstract

Background

Falls can cause serious health problems in the elderly. China is gradually entering a moderately aging society. In rural areas of China, the elderly are at a higher risk of falling.

Methods

M County, Anhui Province, China was selected as the survey site by the typical field sampling method, and the elderly people in rural areas were selected as the research objects. A total of 1187 people were investigated. Mann-Whitney U test and Kruskal-Wallis H test were used for univariate analysis, and multiple linear regression was used for multivariate analysis.

Results

Chronic diseases, number of chronic diseases, daily living ability, mental health, working status and family doctors are the factors that influence falls among elderly people in rural areas of China (P<0.05, Adjusted R²=0.395).

Conclusion

The falls risk of the elderly in rural areas of China is influenced by multiple factors. Therefore, comprehensive measures should be taken to reduce the fall risk by comprehensively evaluating the influencing factors.

Introduction

According to the results of China's seventh census, the total number of the elderly aged 60 and above reached 264 million, accounting for 18.70% of the total population of the country, which increased by 5.44% compared with the China's sixth census. The aging degree of the population will be further deepened and gradually enter a moderately aging society [1]. The rapid increase in the number of the elderly has put forward higher requirements for medical and health institutions and other social institutions, greatly affecting the long-term development of the entire social economy [2–4], and the health problems of the elderly have become increasingly prominent.

The World Health Organization defines a fall as a" sudden, not intentional, and unexpected movement from orthostatic position, from seat to position, or from clinical position " [5]. Currently, falls are recognized as a major public health problem worldwide and the number one global health problem [6]. With the increase of age, the physiological indexes and functions of the elderly population gradually decline, and the gait and balance ability are also affected, resulting in the incidence of fall in the elderly population with the increase of age [7]. One study has shown that injury rates from falls also rise with age [8]. The fall of the elderly is usually characterized by many complications, poor prognosis, high disability rate and fatality rate. Fall will cause serious health problems for the elderly, leading to morbidity, death, mobility inconvenience, hospitalization and premature entry into long-term care institutions to a large extent. It not only brings heavy burden to the family and society, but also increases the consumption of medical resources [9–11]. In addition, fall may also cause a complex chain effect. For example, Elderly people who fall may fear fall and reduce physical activity due to physical injury, which in turn increases the risk of falling. Fall risk factors include physiology, pathology, drugs and environment, etc. Previous studies have shown that multi-factor comprehensive intervention can reduce the fall rate [12]. At present, there have been many studies on the factors affecting the fall risk of the elderly. However, due to the differences in economic and social conditions, medical security services, residents' health awareness and other aspects in different regions, the research results may be different.

In 2019, the National Health Commission of China released Tips on Preventing Falls among the Elderly and related studies pointed out that falls have become the leading cause of injury death among the elderly in China [13]. In China, the elderly who fall at least once a year account for about one-third of the total [14]. Previous studies have shown that the elderly living in rural areas are more likely to fall and are more likely to be at high risk of fall [15, 16]. Liu Yue pointed out in the analysis of the impact of living environment on the fall risk of the elderly that the fall rate of the elderly in China's rural areas was significantly higher than that in urban areas, and the fall rate of the elderly in rural areas was about 1.36 times of that in urban areas [17]. Despite this, many older people living in rural areas believe that falls are normal and that they are not aware of their chances of falling or are unaware of their risk of falling [18]. It is clearly pointed out in the outline of Healthy China 2030 plan that the elderly fall prevention intervention is an important part of the health promotion of the elderly in China [19], and it is urgent to study the factors affecting the risk of falls in rural areas. The purpose of this study is to explore and analyze the factors affecting the fall risk of the elderly in rural areas of China, so as to provide a theoretical basis for carrying out fall prevention intervention for the elderly and reducing the fall risk of the elderly in rural areas.

Methods

A cross-sectional survey was conducted in M County, Anhui Province, central China from July to September 2021. M County is one of the pilot counties for the construction of compact county medical community. Local counties and villages have a sound medical and health service system, which can effectively coordinate the cooperation of relevant departments, providing good external conditions for this research.

Two townships in M County, Anhui Province, China were randomly selected, and 5 villages were randomly selected in each township. The elderly people in these 10 villages were selected as survey objects. At present, the definition of the elderly at home and abroad can be roughly divided into two kinds: one defines the age of the elderly as 60 years old and above, the other defines the age of the elderly as 65 years old and above. Since the World Congress on Aging and the Law of the People's Republic of China on the Protection of the Rights and Interests of the Elderly both define the elderly as those aged 60 and above [20], this study defines the population aged 60 and above as the elderly. In central China, M County is a typical rural area. In terms of economic development level and per capita income level, it is lower than China's average level. In 2022, the per capita disposable income of M County permanent residents was 24,344 yuan, and that of rural permanent residents was 17,221 yuan. The annual per capita disposable income of Chinese residents was 35,128 yuan, and the economic level of the elderly in M County was significantly lower than the national average.

On the basis of referring to relevant literature, a questionnaire was developed based on the characteristics and living conditions of the elderly population in rural areas of China. After obtaining the informed consent and signature of the survey subjects, data was collected through household survey to investigate their fall risk. The questionnaire included socio-demographic characteristics (name, sex, age, education, marital status, residence, etc.), living habits (use of a walker, smoking, alcohol, etc.), past history (chronic history and drug use, etc.), and living conditions (sleep quality, mental health, ability to perform activities of daily living, etc.). Before each survey, investigators composed of uniformly trained graduate students from Anhui Medical University and doctors from local township health centers visited the survey subjects to dictate the research objectives and procedures, and then conducted face-to-face interviews. A total of 1200 questionnaires were distributed in this survey, and 13 questionnaires that could not be used due to multiple selection and missing selection were excluded. A total of 1187 effective questionnaires were collected, with effective recovery of 98.92% (1187/1200).

Measurement of fall risk

Morse Fall Risk Assessment Scale (MFS): Developed by American scholar Janice Morse [21] in 1989, this scale was adapted by Chinese scholar Zhou Jungui [22] and applied to the assessment of fall risk of hospitalized elderly patients. Studies have shown that this scale has good use value for elderly patients [23]. The scale consisted of six items, including history of falls, diagnosis of more than one disease, use of assistive devices while walking, use of intravenous fluids or medication, gait/movement and mental state. Each item was scored on a scale ranging from 0 to 25 points, with a total score of 125. The higher the score, the greater the risk of falls.

Results

Linear regression analysis of fall risk among elderly people in rural areas

Taking fall risk as dependent variable, statistically significant variables in univariate analysis are introduced into multiple linear regression equation as independent variables. The assignments are shown in Table 3.

Table 4 describes the results of multiple linear regression. The results show that chronic disease, number of chronic diseases, ability to live daily, mental health, work status and family doctor are associated with fall risk.

Discussion

In this survey, the incidence of falls among the elderly in rural areas of China is 16.88%, which is lower than the result of the analysis of Mate Wang Xiaojun et al in 2020 (the incidence of falls among the elderly in rural communities is 21.5%) [24]. The incidence of falls among the elderly aged 60 and above in rural areas was 8.6% higher than that of Qi Shige et al in 2011 [25], which was similar to the results of Zhang L et al in 2019 on 8,840 elderly in urban areas and 7,953 elderly in rural areas in 20 provinces (urban: 14% and rural: 17%) [26]. The results of each study may be different due to different factors such as sample size, survey time, population characteristics and region. Multiple linear regression analysis indicated that family doctor, chronic disease, number of chronic diseases, daily living ability, working status and mental health were the factors affecting the fall risk, which could affect 39.5% of the fall risk. The degree of influence was in descending order of chronic disease, number of chronic diseases, daily living ability, working status, mental health and family doctor.

Older people in poorer health are at higher risk of falling

Studies have shown that rural elderly people with chronic diseases, more types of chronic diseases and mental health problems have a higher risk of falling, which is consistent with previous studies [27–32]. Chronic diseases will cause damage to the health of the elderly. As chronic diseases have the characteristics of long course and persistent disease, the elderly with one chronic disease will often cause complications due to long-term disease, and then develop a variety of chronic diseases. The damage to the health of the elderly is usually accompanied by product effect, which leads to further decline of the health status of the elderly and higher risk of falling [33, 34]. For older people with mental health problems, loneliness and negative emotions such as anxiety and depression all increase the risk of falling. Studies have shown that loneliness can increase the risk of cardiovascular disease in the elderly [35], which may cause symptoms such as fainting and thus increase the risk of falls. In addition, due to inner loneliness, the elderly will reject the outside world, leading to a decline in mental health, and long-term negative emotions such as anxiety and depression, which further increase the risk of falling [36].

These factors are also related to the aging of the elderly body. In the aging process, the body structure will undergo degenerative changes. Due to the growth of age, the body's various systems and organs will appear different degrees of aging, resulting in the elderly's vision, hearing and balance gradually decline, more prone to loneliness, anxiety, depression and other negative emotions. The risk of chronic diseases is also increased. These factors may cause and effect each other when affecting health status, thereby directly or indirectly increasing the risk of falls.

Older people who don’t have to rely on or work in their daily lives have a lower risk of falling

Studies have shown that elderly people who are not dependent in daily living activities have a lower risk of falling, which is consistent with previous studies [37]. In terms of working status, working elderly people have a lower risk of falling than those who do not work. In China, farming civilization determines the characteristics of Chinese culture, and farming is the main feature in China's rural areas. The survey shows that there are more left-behind elderly people in China's rural areas, and more than half of them need to rely on their own labor to support themselves [38]. Elderly people who work are exposed to high risk of falling and theoretically have a higher risk of falling.

Table 5 describes the daily living ability of the elderly in different working states in this study. Among the elderly in working states, 86.55% do not need to rely on their daily living activities, while among the elderly who do not work, 66.23% do not need to rely on their daily living activities. The elderly in working states have stronger ability of daily living activities. Secondly, previous studies have shown that the labor participation rate of residents will increase with the increase of health status [44], and the health status of the elderly working is better than that of the elderly not working. Thirdly, physical exercise is an important factor affecting the physical and mental health of the elderly, moderate physical exercise can play an important role in improving the physical and mental health of the elderly [40–43], while the situation of physical exercise in rural areas is poor [44], labor can replace physical exercise to a certain extent, and contribute to the physical and mental health of the elderly. The health of the working elderly is relatively better. Older people who work are at lower risk of falls due to their greater capacity for activities of daily living and better health.

Older people who signed up with family doctors had a higher risk of falling

Family doctor contract service is a personalized service package with general practitioners as the core, residents' voluntary contract as the basis, and residents' health conditions and needs as the guidance. It provides services in the form of team service, which is one of the important tasks of China's medical and health system reform. Family doctors can provide preventive, health, medical and rehabilitation services to residents, but this study found that elderly people who signed up with family doctors had a higher risk of falling. On the one hand, although family doctors have made preliminary progress in China, there is still a certain gap between urban and rural areas. In rural areas, there are insufficient number of family doctors, low educational and professional level, which greatly affects the quality of family doctor services [45, 46]. On the other hand, the study of Zhang Cuiping et al. shows that in China, the worse the health status of residents, the higher the signing rate of family doctors [52,53], and the elderly with worse health status are more likely to sign up for family doctor services. Therefore, the group of older people who signed up with family doctors in rural areas have poorer health and are not sufficiently improved by family doctor services, leading to a higher risk of falls.

Advantages and Limitations

Advantages: First, the effective response rate of this study is 98.92% (1187/1200), as we all know, studies with higher effective response rates were more reliable. Secondly, an internationally recognized measurement questionnaire was used to measure the objects objectively. In addition, this is the first time to use multiple linear regression to study the factors affecting the fall risk of the elderly in rural Anhui Province, and a new situation has been found that the elderly who work have a lower risk of falling and the elderly who contract with family doctors have a higher risk of falling.

However, this study also has the following limitations: First, there is a lack of investigation into the living environment of the subjects. Housing and some environmental factors may be important factors that influence fall risk, but these factors were not included in this study. Secondly, the survey objects of this study only cover rural areas of Anhui Province. Due to the differences in economic development and cultural background in different regions, the scalability of the results of this study is limited.

Conclusion

To sum up, the fall risk of the elderly in rural areas of China is related to chronic diseases, the number of chronic diseases, grip strength and other factors, and the fall risk of the elderly is the result of multiple influencing factors. When judging the factors affecting the elderly fall risk, it is necessary to evaluate them in various aspects, so that targeted intervention measures can be taken to reduce the fall risk and reduce the occurrence of falls, so as to enhance the happiness of the elderly and help the development strategy of "Healthy China".

Declarations

Ethics approval and consent to participate 

This study was conducted in accordance with the Declaration of Helsinki and was approved by the Research Ethics Committee of Anhui Medical University. All participants were fully informed about the study purpose and methods. Before conducting the survey, explain the purpose and procedures of the research to all interviewees, and ensure that all interviewees have informed consent to this research. For the illiterate interviewees, the informed consent of the guardian was also obtained. 

Consent for publication 

Not applicable. 

Availability of data and materials 

The datasets generated during the study are not publicly available due to an ethical restriction but are available from the corresponding author on reasonable request. 

Conflicts of interest 

The authors declare that they have no conflict of interest.

Funding 

This research was funded by Research Projects of Humanities and Social Sciences in Colleges and Universities of Anhui Province (No. SK2018A0165) and Doctoral Fund Project of Anhui Medical University (No. XJ201545). The funders had no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript. 

Author’s contributions 

YDZ conceptualized the study. DX, CZ, HBW, contributed to the study design, data collection and data processing and statistical analysis. SL and BBZ contributed to the literature review. YDZ wrote the article. YDZ,HD, GMC and ML revised the article. All authors reviewed the manuscript and approved the final manuscript. 

Acknowledgements 

The authors would like to appreciate the involvement of the participants who joined this study. 、

Author details

¹ Department of Health Service Management, School of Health Management, Anhui Medical University, Anhui, China.

² School of Public Health and Health Management, Anhui Medical College, Hefei, Anhui, China

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