The incidence of falls among older adult people in Shantou City in the past year was 20.65%, which was higher than the result of a meta-analysis in China (18.3%) [15], lower than that of Cape Town (26.4%) in South Africa[16]and close to that of South Korea (20.95%)[17] and Japan (20.8%) [18]. The fall rate and rate of injury from falls among older adults in urban areas were higher than those among older adults in rural areas. This is consistent with the study by Li[12] but different from the study by He[14]. The discrepancies may be due to the comprehensive influence of regional culture, gender structure, age structure, education level and economic income of older adults, which suggests the need to carry out intervention measures according to specific fall circumstances in different regions.
Similar risk factors for both areas
Incontinence was a risk factor for falls in both urban (OR = 8.792) and rural areas (OR = 11.396). This is consistent with the results from Choi and Kim’s studies [17, 19], indicating that incontinence is a common risk factor across different regions and populations. Incontinence causes a corresponding increase in the frequency of urination in older adults, which itself is increased further due to an increased water intake resulting from the hot climate in Shantou and the rich tea culture in China. This increased frequency of urination, especially at night, greatly increases the risk of falling. Therefore, targeted intervention for older adults with incontinence or urinary system infection may effectively prevent and reduce the risk of falls.
Decreased balance ability was a risk factor for falls in both urban (OR = 3.901) and rural areas (OR = 4.260). Our finding is consistent with the results of Zhao and Hou’s studies[20, 21], in which they found that the balance ability of older adults decreases with age. This is due to the structural and functional impairment and degradation of the bones, joints, ligaments and muscles with age [5]. At the same time, degradation of the central nervous system degeneration and osteoporosis affect older adults’ muscle strength, sensation, coordination, reaction times, and ability to move [5]. All of these factors contribute to the increased risk of falling. Physical exercise has been shown to improve balance in older adults, including Taijiquan [22]. Regular physical exercise helps enhance muscle strength and balance[23]. In addition, group-based exercise helps older adults interact and communicate, which improves their mental health and confidence and reduces their fear of falling [24].
Different risk factors between rural and urban areas
Older adults with lower education levels and who lack fall prevention education have a higher risk of fall. The ORs for these two factors were 3.737 and 11.907 for the urban area, respectively. This is consistent with the findings of Huang[25]. The proportion of older adults who have received fall prevention education in Shantou City is only 16.80%. Older adults with higher education levels generally have a higher standard of living and a greater sense of self-protection[26]. Older adults with low education levels are less aware of the knowledge of fall prevention. Their low level of consciousness may increase their exposure to falls. For older adults in rural areas, due to their overall low level of education and limited access to fall prevention education, the level of education and whether they had received fall prevention education were not significantly associated with the incidence of falling. Our results suggest that more education should be provided to older adults to prevent falls, especially in less educated and underdeveloped areas. More attention should be paid to the popularization and dissemination of fall prevention programs, and targeted health education should be carried out to improve the awareness among older adults to prevent falls.
Taking diabetes medication increased the risk of falling by 4.518 times compared to not taking diabetes medicine, which is consistent with the results of Berlie’s study[27]. Diabetes occurs in older adults after taking too much diabetes medication. Studies have found that patients with diabetes have twice the risk of diabetes than those without diabetes[28]. Older adults with diabetes often have complications and take multiple drugs for many years. One study showed that the side effects of one or more drugs can increase the risk of falls in older adults[29]. Older adults have weakened memory, take more chronic medications daily, and lack correct guidance from a doctor. In the process of taking the medication, they are prone to inappropriate doses and an increased risk of falling. Therefore, we should pay attention to the daily medication of older adults and provide guidance and education on medication management, especially those with diabetes.
Previous occupation as a farmer was a protective factor for falls among rural older adults. One explanation is that past engagement in labor was a protective form of physical exercise, which may have improved their physical fitness over time[12]. However, when we compared and analyzed previous occupation and balance, we did not find an association between older adults who used to be farmers and their balance ability. The possible reason is that the cause of fall is affected by many factors and does not only depend on the level of balance. On the other hand, few older adults in urban areas were previously employed as farmers, which may explain the lack of statistical significance of their occupation on fall risk.
This study found that rural older adults who had more than 3 home environment issues had a 3.457-fold higher risk of falling than those with 1 or no home environment issues. Sophonratanapokin’s study[30] also indicated that a high number of home environment issues was a risk factor for falls among older adults. Our investigation found that the living environment of rural older adults in Shantou City is much worse than that of urban older adults. The living environment of rural older adults (floor and passageways, living room, bedroom, kitchen, and bathroom) is littered with many potential safety hazards. Some households even lack separate toilets, which greatly increases the risk of older adults falling. This study found that 28.2% of rural older adults lived alone, and nearly half of falls occurred at home. Therefore, there is an urgent need to conduct a comprehensive assessment of the home environment of older adults and identify hazards to reduce their risk of falls.
The limitations of this study mainly include the following: First, the questionnaire survey covered falls in the past year, which could be affected by the worsening memory of older adults and therefore recall bias. However, this is a common issue for most survey studies. Considering that older adults of Shantou City are not well educated, especially rural older adults who are mostly illiterate, the questionnaires were filled out by the researchers asking the questions to the older adults. Our investigators have been trained for consistency in data collection to reduce subjectivity. To address the memory problems of older adults, the researchers made multiple inquiries in local dialects to reduce recall bias. Second, falls among older adults are the result of the interaction of multiple factors. However, this study focused on investigating the internal risk factors for older adults but less on external risk factors.