Older adults are vulnerable to falls and fall-related injuries. The US Census Bureau reported that the number of Americans aged 65 and over in 2016 was 49.2 million and more than half (28.7 million) were aged 65 to 74. All older population age groups (65 and over) struggle with serious difficulty walking or climbing stairs (Roberts et al., 2018). There is ample evidence to suggest that falls are a leading cause of both fatal and non-fatal injuries among older adults in the USA (National Council on Aging, 2018). In 2014, 30% of older Americans (age 65 and over) experienced a fall at least once, which is equivalent to approximately 29 million falls, causing 7 million injuries and 27,000 deaths (Bergen et al., 2016). A fall often leads to serious injuries, physical deterioration, and often institutionalisation (Iglesias et al., 2009;Keene et al., 1993), which would be more often observed in older adults as they tend to have greater bone fragility and poorer protective reflexes (Dhital et al., 2010). Hip fracture is the most serious injury in that more than 95% of hip fractures are caused by falling (Hayes et al., 1993). In general, the majority of fallers with a hip fracture could not return to the level of activity of daily living where they used to show before the fracture (Abdelhafiz and Austin, 2003). Over 20% of fallers with a hip fracture are relocated from their own home to a nursing home while only 24% remain as mobile as they used to be before the fracture (March et al., 1999). There are accumulating evidence to suggest that hip fractures are linked to poor vision (e.g., reduced visual acuity, contrast sensitivity, and visual field) (de Boer et al., 2004;Ivers et al., 2000;Loriaut et al., 2014;Coleman et al., 2009).
As a fall-related injury is considered as one of the most expensive medical conditions in the aging population (Centers for Disease Control and Prevention, 2016a), older adults at an increased risk of having a fall are concerned about financial burden for treating fall-related injuries and loss of independence (Bailly et al., 2014;Tan et al., 2016;Black et al., 2011). A recent report indicates that the medical costs for falls among older adults totalled $35 billion in 2012, which is projected to increase to over $101 billion by 2030 (Houry et al., 2016). There is a detailed report (Florence et al., 2018) that provides medical costs of fatal and non-fatal falls in older adults (aged 65 and older during 2015) in the USA. For fatal falls, overall medical spending was approximately $754 million while for non-fatal falls, Medicare paid $28.9 billion, Medicaid paid $8.7 billion, and private and other payers paid $12 billion. Medical costs of non-fatal falls among older adults in 2015 consist of $12.9 billion for hospital expenditures (i.e., 4.4%), $10.8 billion for health professional's expenditures (i.e., 5.7%), $2.1 billion for prescription drug expenditures (i.e., 2%). Medical spending by older adults vary depending on treatment settings; for example, they spent mostly on hospitalised injuries ($12 billions), followed by injuries treated in emergency rooms and outpatient clinics and doctor's offices ($3 billions) (Stevens et al., 2006). There were individual differences between elderly groups, e.g., the highest percentage of hospitalisation costs was observed in people aged 75-84 while the highest percentage of emergency room costs was observed in people aged 85 and over (Stevens et al., 2006).
A combination of aging and poor vision is likely to put older adults with visual disabilities at an increased risk of falls. In 2014, an estimated 2.8 million older Americans (aged 65 and over) reported severe visual impairments (Centers for Disease Control and Prevention, 2016b). The prevalence of visual impairments becomes more significant as aging proceeds further -e.g., 4.5% for those aged 65 to 74 has visual impairments; 7.2% for those 75 to 84; and 15.8% for those 85 and older (Roberts et al., 2018). It is well documented that vision plays a critical role in stabilisation of human posture, and poor vision is likely to increase the risk of falls (Lin and Lee, 2019;Dhital et al., 2010). There is ample evidence to suggest that there is a strong correlation between visual disability and falls, especially among community-dwelling older adults (Ivers et al., 1998;Lord and Dayhew, 2001;Ramrattan et al., 2001;Coleman et al., 2004). Impaired vision would more than double the risk for falls (National Academies of Sciences, Engineering and Medicine, 2017). For instance, a state-based, telephone survey of community-dwelling older adults (aged ≥ 65 years) in the USA reported that nearly half (46.7%) of the respondents with visual disabilities experienced a fall in the previous year as compared to 27.7 % of those without visual disabilities (Crews et al., 2016). A systematic review study (Legood et al., 2002) argued that as compared to older adults without visual impairments, their peers with visual impairments are 1.7 times more likely to fall and 1.9 times more likely to have multiple falls. Vision can be impaired for a variety of reasons including age-related macular degeneration, glaucoma, and cataracts, all of which are associated with falls. For example, age-related macular degeneration affects central and reading vision, leading to a distorted view and difficulty recognising one's face (Dhital et al., 2010). An empirical study (Radvay et al., 2007) found that two thirds of older participants with age-related macular degeneration showed visuomotor and balance deficits, resulting in an increased risk of falls. Older women with age-related macular degeneration showed a combination of impaired balance and slower reaction time as compared to their peers without age-related macular degeneration, which would contribute to a higher risk of falling, e.g., a fall risk index score (3.20) of those with age-related macular degeneration was significantly greater than that (1.21; p < .001) of their peers without age-related macular degeneration (Szabo et al., 2008). Visual field refers to how wide of an area an individual can see, which is measured in degrees. A visual field test is typically conducted when glaucoma is suspected. When visual acuity, contrast sensitivity, visual field, and stereoacuity were tested after adjustment for demographic and health variables, visual field loss was found to be the primary determinant increasing the risk of falls (Freeman et al., 2007). Haymes et al. (2007) revealed that older patients with glaucoma and mid field defects were over three times more likely to have fallen in the previous year than the control group of people without glaucoma. People with cataracts have cloudy areas in the lens of the eye. A number of studies (Ivers et al., 1998;McCarty et al., 2002) reported a higher risk of falls among people with cataract as compared to their peers without cataract. The World Health Organization (2007) views low visual acuity as one of significant risk factors for falls and fall-related injuries.
Fear of falling has substantial impacts on the quality of life. Fear of falling is defined as an individual's cautious concern about falling (Tinetti and Powell, 1993). Both people with and without a history of falls experience fear of falling (Lee et al., 2018). Fear of falling is viewed as a risk factor for a fall and a leading cause of injury, morbidity, and mortality (Hadjistavropoulos et al., 2011). For example, fear of falling can lead to reductions in various activities on a daily basis (Tinetti and Powell, 1993); an increased risk of falling especially among older populations (Wijlhuizen et al., 2007;Lee et al., 2019;Smith et al., 2016); and poor emotional health (e.g., depression and anxiety) (Painter et al., 2012;van Haastregt et al., 2008). It is well documented that the aging population is likely to develop fear of falling (Legters, 2002;Murphy et al., 2003), which would be influenced by various factors including chronic dizziness, impaired balance and gait, a sedentary lifestyle, anxiety, lack of emotional support, and a history of falls (Murphy et al., 2003). The adverse effects of fear of falling on falls and fall-related injuries have received much attention in the gerontology and safety research area; yet, there is still lack of understanding of fear of falling among older adults who have visual disabilities. The primary aim of this study is to advance understanding of the degree to which older adults with visual disabilities develop fear of falling and to explore facilitators and barriers to reducing fear of falling and fall risk.
A convenience sampling method helped to invite 19 older adults with visual disabilities across North Carolina in the USA (see Table 1). It is recommended that sample sizes for qualitative studies generally run at least 15 participants (Marshall et al., 2013), 5 to 50 participants (Dworkin, 2012), 10 participants (Sandelowski, 1995), and 12 participants (Boddy, 2016). The sample size of this research is believed to be adequate for the data analysis. Research participants should speak English, be 65 years old or older, and have visual disabilities [i.e., visual acuity level worse than 20/70 (World Health Organization, 2008)]. Approval for this study was obtained from the Institutional Review Board (IRB). By referring to the study by Voss et al. (2004), participants who lost their sight before they reached 11 years of age were considered as people with early-onset visual disabilities. The majority of participants were female (79%), European-American (63%), retired (68%), and visually impaired after 11 years of age (79%).
Fear of falling was measured using the widely-used scale developed by Tinetti et al. (1990). The scale includes 10-items measuring one's fear of falling associated with activities of daily living: reach into cabinets or closets, walk around the house, prepare meals not requiring carrying heavy or hot objects, get in and out of bed, answer the door or telephone, get in and out of a chair, getting dressed and undressed, personal grooming, and getting on and off of the toilet. The scale has adequate internal consistency (Cronbach's α = .91). A participant was asked to rate fear of falling on a 10-point Likert type scale. Higher rating indicates higher fear (i.e., lower fall-related self-efficacy).
The research team visited each participant at home and administered the fear of falling scale by reading out loud for the participant. After participants have completed the scale, they were instructed to elaborate on their ratings. The interview was audio-recorded for content analysis. The interview lasted no longer than 60 minutes.
The data were analysed using the descriptive statistics, the Cronbach's α for internal consistency of the fear of falling scale, and the Spearman's rho test to measure the strength of association between fear of falling and participants' demographic characteristics (e.g., length of time period living in the current home). Statistical analyses were performed using the IBM SPSS Statistics for Macintosh, version 24 (IBM Corp., 2016). The interview data were analysed using inductive content analysis (i.e., open coding, axial coding, and selective coding) (Strauss and Corbin, 1990) via QSR International's NVivo 11 software (QSR International Pty Ltd, 2015). Another coder helped to assess the inter-rater reliability using Cohen's kappa statistic, which resulted in substantial agreement among the raters as the inter-rater reliability was found to be k = 0.88 (95% CI: 0.64 to 1.12), p < 0.05.
The fear of falling scale showed adequate internal consistency (Cronbach's α = 0.89).
Spearman's rho testing found that fear of falling (M = 34, SD = 21.58) was negatively correlated with length of residence (years) in the current home (M = 15.63, SD = 18.42), r(17) = -.547, p < .05. There was no significant correlation between fear of falling and the other demographic variables.
Participants shared their experience developing fear of falling, ultimately increasing risk of falling and getting injured inside and outside the home on a daily basis under the circumstance of being severely visually impaired and blind. The content analysis resulted in 14 themes that were associated with home environment (i.e., slippery rugs, objects on the floor, reaching into cabinets, rearrangement of household goods, taking shower, knee stiffness, vertigo, walls, hand grab bars, additional indoor-lighting, cognitive map of the house, one story house, a high toilet seat, and hand use); 6 themes for outside the home (i.e., visiting an unfamiliar place, going outside by myself, walking around the neighbourhood, walking a dog, walking through a crowd, and inadequate balance support by a white cane); and 6 themes for general cases including inside and outside the home (i.e., age-related muscle weakness, exercise, health issues, falling safely, vicarious learning from the failures and near-failures of other people, and changes in walking characteristics to protect themselves from falling). Table 2 shows a full list of themes in which older adults with severe visual impairments and blindness develop fear of falling on a daily basis. Those themes were also sorted to identify whether they were barriers or facilitators to reducing fear of falling, contributing to mitigating the risk of falling. I would much rather be on one level.
As they are afraid of stairs, a home environment without stairs would contribute to reducing fear of falling, leading to mitigating the risk of falling.
Recommend a one-story home environment to avoid stairs Getting on and off a toilet -High toilet seat Facilitator I have no problem with getting on and off a toilet because I had high toilets put in.
The high toilet seat may contribute to safety as it makes rising easier, helping people to reduce the risk of slips and falls.
Install a high toilet seat as the raised toilet is expected to contribute to relieving the knee joints from any added pressure, which will help to reduce fear of falling and mitigate the fall risk For those who have a dog and tend to walk with their dog, the fear of falling could be elevated as his/her dog may be stronger to pull him/her down the street and cause him/her to fall.
Walk the dog by taking proper precautions, e.g., using an appropriate leash for the dog's size and physical strength; avoiding allowing the dog to run long distances from the owner, otherwise, he/she can easily lose control, leading to falls Participants lived in home environments that included multiple factors causing them to develop fear of falling. For example, they have shared their experiences or concerns about tripping over objects on the floor or bump into household goods (e.g., furniture), and slipping on slippery rugs and a wet surface during taking a shower. As they have lost their vision (or have severely impaired vision), they are more likely to fail to detect those hazardous conditions as compared to their sighted peers, ultimately increasing further the risk of falling. Their fear of falling was also associated with losing balance when reaching into cabinets or when getting on and off a toilet as they feel vertigo or have knee stiffness. On the other hand, they have shared their strategies implemented in the home to overcome the fear of falling and protect themselves from falls and fall-related injuries. They, for instance, installed a safety bar, placed additional lights in the home, spent time developing a clear cognitive map of their house via a sense of touch, relocated household goods in the first floor to avoid stairs, and installed a high toilet seat.
When participants went outside, their fear of falling was associated with various environmental hazards. For example, they avoided going outside if they had no one to go together; were reluctant to visit unfamiliar places even if their caregivers (e.g., sighted family members or friends) could go together; and were less likely to walk their dogs who could be stronger than the owner to pull down the street leading to falling. Participants were more likely to use a white cane outdoor than indoor, and often used it outdoor even if they had a sighted caregiver near them. They typically used a white cane for two purposes:
1 the white cane helped those with visual disabilities to scan their surroundings for obstacles or orientation marks 2 the white cane helped sighted people to recognise those who carry a white cane as a person who is visually impaired.
People who are visually impaired but keep somewhat residual vision may appear to be sighted people; thus, they believed that a white cane would be helpful for sighted people in identifying them as a person with a visual disability and taking appropriate care before bumping into them and falling down. Regardless of indoors and outdoors, their fear of falling would also be elevated or reduced by several other factors. In addition to their poor visual status, the aging effects contribute to increasing the fear of falling. They were concerned about an age-related loss of muscle mass, muscle strength, and physical function. Participants who were diagnosed with chronic diseases such as diabetes and low blood pressure shared their concerns that those diseases could cause them to pass out, resulting in a fall. Participants implemented their own interventions to prevent them from developing fear of falling, falling and getting injured; for example, they did exercise regularly at home and community centres. As they cannot drive any longer due to vision loss, they tended to obtain transportation supports from family, friends or community organisations in order to attend exercise programs at community centres. They also took hazard mitigations into consideration in order to reduce or minimise fall injuries. For example, they were interested in learning how to minimise fall-related injuries if a fall were to occur. They shared various strategies, e.g., falling forwards (instead of backwards) to protect themselves from hitting the head and fracturing the neck. Other strategies included sideway falling and hand slapping on the ground. They also learned through other persons' experience of falling (i.e., vicarious learning), which helped them maintain or increase awareness of the risk of falls, leading to precautions on a daily basis. Since they lost their vision, they have changed their walking patterns; for example, they greatly relied on a sense of touch while walking (e.g., touching the wall); and those who had residual vision tended to focus on the near point by constantly looking down as they wanted to find a way to walk safely. Other approaches they took included slow walking and shorter stride length.
This study contributed to advancing knowledge about fear of falling associated with various activities of daily living among community-dwelling older adults with visual disabilities. This study found the negative correlation between fear of falling and years of living in the current home -e.g., those who lived longer in their home are likely to have a lower level of fear of falling as compared to those who lived shorter in their home. It is also supported by their exit interview in that after living long enough to develop a cognitive map about their house, they feel comfortable walking around. If the questionnaire was, however, designed to examine fear of falling outside the home, their fear of falling would probably be higher as they would feel uncomfortable walking in unfamiliar places. As there are lack of published reports that compared the fall frequency between indoor and outdoor among community-dwelling older adults with visual disabilities, the results of this study can be further discussed by referring to other studies that involved sighted older adults. For example, a research team by Hoang et al. (2017) examined the fear of falling among community-dwelling sighted older adults by using a scale that considered a combination of indoor and outdoor activities. They reported a slightly higher mean score of fear of falling outside the home than in the home. Gazibara et al. (2017) also reported that sighted older community-dwellers fell more often outdoors (76.8%) than indoors (23.2%). Yet, it does not imply that those with visual disabilities would fall more often outside the home than inside as falls are caused by various risk factors such as intrinsic factors (e.g., fear of falling, aging, muscle weakness, gait and balance problems, and chronic conditions) and extrinsic factors (e.g., lack of stair handrails, poor stair design, dim lighting, obstacles hazards, and slippery surfaces) (Centers for Disease Control andPrevention, 2020a, 2020b). For example, numbers of other research studies on falls among sighted people observed that falls occurred frequently both inside and outside the home (Pynoos et al., 2005;Timsina et al., 2017), e.g., 55% of fall injuries occurred inside the home, 23% occurred outside but near the home, and the remaining 22% occurred away from the home.
As the study of Tinetti et al. (1990) used the same scale in measuring fear of falling as this study did, the mean value of each item of the fear of falling scale in this study was compared with that in the study of Tinetti et al. (1990) that included sighted people. All items in this study indicated higher mean values; in other words, fear of falling of participants with visual disabilities in this study was greater than that of sighted people in the study by Tinetti et al. (1990). Thus, it could hypothetically be argued that those with visual disabilities tend to show greater fear of falling as compared to sighted people, associated with activities of daily living in the home; however, other sociodemographic factors that were not covered by this study may lead to different results. As this study did not include sighted older adults to directly compare with their peers with visual disabilities, further research is required to examine empirically the effect of vision loss on fear of falling between sighted and visually impaired community-dwelling older adults inside and outside the home by controlling other sociodemographic factors to be constant.
Although there are a few published studies focusing on fall risk factors for older adults with visual disabilities, they did not focus on fear of falling (Dhital et al., 2010;Brundle et al., 2015). This study contributed to:
1 advancing knowledge of fear of falling among older adults with visual disabilities both inside and outside the home 2 identifying a set of facilitators and barriers to reducing fear of falling and mitigating the risk of falling.
In the home, their fear of falling was influenced by various barriers and facilitators; for example, the barriers included slippery rugs, objects on the floor, reaching into cabinets, rearranged household goods, shower, knee stiffness, vertigo and walls, while the facilitators included hand grab bars, additional indoor-lighting, cognitive mapping of the house, one story house, a high toilet seat, and hand use. There is evidence suggesting that at least one-third of all falls among older adults are caused by environmental hazards in the home (Tremblay and Barber, 2005;Guimarães et al., 2014;Josephson et al., 1991). The environmental hazards in the home typically refer to slippery surfaces, poor lighting and loose rugs, and the most common environmental hazard for falls in the home is tripping over objects on the floor (Tremblay and Barber, 2005). It is well documented that there are positive relationships between the presence of environmental hazards in the home and falls; for example, Isberner et al. (1998) found that older adults who had a history of falls tended to live in the home where handrails were not equipped and floors were uneven. Older adults living in the home with environmental hazards were more likely to have reported a fall incident in the past three months (Fletcher and Hirdes, 2002). Carter et al. (1997) conducted a home inspection for 425 older adults and uncovered that 80% (n = 542) of homes were exposed to at least one hazard and 39% (n = 164) had more than five hazards (e.g., absence of appropriate grabs and handrails). As older adults with visual disabilities have poor vision (or no light perception at all), it could be argued that older adults with visual disabilities are more likely to be vulnerable to environmental hazards in the home as compared to their peers without visual disabilities.
Outside the home, fear of falling among older adults with visual disabilities was affected by various variables, e.g., visiting an unfamiliar place, going outside alone, walking around the neighbourhood, going out with a dog, walking through a crowd, and inadequate support by a white cane. Carter et al. (1997) contended that the risk factors for outdoor falls would be different from that for indoor falls due to different environmental conditions. Kelsey et al. (2012) also observed different characteristics of falling between indoors and outdoors as indoor falls were more likely to occur among individuals with poor health conditions while outdoor falls were among healthy, active individuals. When older adults with visual disabilities in this study go outside, they were to rely on assistive devices (e.g., a white cane), a service dog, or personal assistance (e.g., holding on to a sighted person's elbow), which are what they are less likely to rely on inside the home. Therefore, their fear of falling outside the home were likely to be induced by a dog and assistive equipment inferred with external environmental conditions (e.g., a failure to detect objects on the ground) or visiting unfamiliar and crowded places (e.g., excessive anxiety due to sighted people ignoring the white cane, overstepping, or inferencing with manoeuvring a white cane). As this study did not observe older adults with visual impairments while they were outside in the midst of working at their workplace, walking nearby the home, or walking around the community, this study's interview might cause the participants to rely on their retrospective memories about walking outside; thus, actual observations may lead to different results (e.g., different sets of factors leading to fear of falling).
Participants in this study implemented their own strategies to deal with fear of falling and mitigate the risk of falls, e.g., exercise, falling safely, and vicarious learning from the failures (or near-failures) of other people. In the literature, various fall prevention interventions have been introduced for sighted people, including environmental assessment and modification such as placement of additional lighting and handrails; vision assessment and treatment; exercise training; and calcium and vitamin D supplementation (Tricco et al., 2017;Guirguis-Blake et al., 2018). Among those different interventions, exercise is reported to be the most effective approach for sighted people; for example, a meta-analysis study (Guo et al., 2014) incorporating 111 studies (n = 51,551 participants in total) evaluated a number of different fall-prevention interventions (e.g., multiple-and single-component interventions) and found that single exercise interventions contributed to effectively reducing risk of falls among older adults with and without cognitive impairments in institutional or non-institutional settings. However, as previous studies did not test the efficacy of the fall prevention interventions by including older adults with visual disabilities, further research is needed to investigate the effectiveness of those interventions for those with visual disabilities both inside and outside the home. Furthermore, the conventional fall prevention exercise programs were merely designed under the assumption that learners can see the instructional manuals (or the instructors) such that those conventional programs would be challenging for those with visual disabilities to understand and practice exercise. Further research is essential to determine the effectiveness of exercise interventions and to design them to be accessible to those with visual disabilities. Besides exercise interventions, other conventional interventions would also need to be modified, based on evidence, to better accommodate people with visual disabilities at risk of falls because the one-size-fits-all approach would be inadequate. For example, the research team by Foster et al. (2014) tested the effectiveness of a high-contrast highlighter that was placed on the edge of stair threads to improve safety on stairs for people with visual impairments. They found that the highlighter led to a decrease in the number of accidental foot contacts (from 15% to 3%); however, their study was conducted via a simulated vision condition, i.e., younger sighted participants (average of 24.0 ± 4.3 years old) wore cataract simulation goggles and experienced the highlighter. In user studies, blindfolded sighted participants often evaluate assistive technology applications on behalf of their peers with visual disabilities; however, such simulation approach is likely to fail to address needs of those with visual disabilities (Silverman et al., 2015). A fall prevention intervention designed for sighted people should, thus, be tested by people with visual disabilities and/or redesigned to fit those with visual disabilities, as necessary. Pundlik et al. (2015) developed a portable collision warning device for people with peripheral vision loss and observed that the device could reduce the number of collisions (i.e., approximately 37%) in an obstacle course. However, they did not test the device in home environments as they tested it under highly controlled conditions using a 41-metre-long loop-shared course. Their device, as a fall prevention intervention, would still be questionable as to whether people with visual impairments in the home could benefit.
A few limitations may affect this study. This study used the fear of falling scale that was developed by Tinetti et al. (1990), and the scale covered only 10 different activities of daily living in the home. As this study found multiple barriers leading to increases in fear of falling, the inclusion of more various activities of daily living in the scale would result in different results. The fear of falling scale in this study focused on home environments while the participants felt fear of falling both inside and outside the home, and furthermore the correlation analysis indicated that the participants living longer in their home were more likely to show lower fear of falling as compared to those living shorter in their home. As they would be unfamiliar with places outside, their fear of falling outside would be different than inside. Further research is needed to obtain a deeper understanding of fear of falling among older adults with visual disabilities under various contexts. Future research will also be conducted with a larger sample size to examine the recommendations for reducing fear of falling (as presented in Table 2) and to construct a statistical model via regression analysis in order to investigate the relationship between the recommendations and the fear of falling (and/or actual falls) via a longitudinal study (e.g., repeated observations of participants over long periods of time).
The present study contributed to advancing knowledge about facilitators and barriers to reducing fear of falling that were associated with aging issues, visual disabilities, or both. Those facilitators and barriers were identified by comprehensively reviewing internal and external environments (e.g., indoor and outdoor), tools that they used on a daily basis (e.g., assistive devices for people with visual disabilities and general household goods), humans (e.g., limitations, capabilities, and preferences), and tasks (e.g., activities of daily living). This study suggested adequate recommendations to handle their fear of falling, eventually leading to mitigating the risk of falls.