Background
Falls efficacy is often mistaken for fear of falling, but they’re not the same. Understanding this difference is crucial for improving how we prevent and manage falls among older adults.
Since the late 1990s, researchers have recognised that falls efficacy and fear of falling are related but distinct psychological constructs.
Lawrence et al. (1998) were among the first to make this distinction. They introduced two scales — the Perceived Control Over Falling and the Perceived Ability to Manage Falls and Falling — to assess falls efficacy. In contrast, they used a simple 4-point scale item to gauge fear of falling, reflecting the individual’s perceived likelihood of falling and sustaining injury.
Tinetti et al. (1994) further clarified these concepts following the development of the original Falls Efficacy Scale (FES). Their study revealed a strong, independent relationship between falls efficacy and functional performance, whereas fear of falling was not a significant predictor of social or physical function. The authors concluded that falls efficacy, a cognitive construct grounded in Bandura’s self-efficacy theory, is a determinant of functional ability. They advocated for interventions that integrate efficacy training with physical skill training to optimise outcomes—an approach that continues to underpin efforts to help older adults age well despite comorbidities.
Further evidence came from Li et al. (2002), who found that older adults who were fearful of falling but still possessed high falls efficacy maintained good functional outcomes. In a follow-up study, Li et al. (2005) demonstrated that a six-month Tai Chi intervention significantly reduced fear of falling by enhancing falls efficacy, highlighting efficacy as a mediator of psychological change.
More recently, Müller et al. (2025), in the FEARFALL Study, explored how concern about falling (CaF) and perceived control over falling relate to biological markers of stress and inflammation in community-dwelling older adults. While CaF was not linked to inflammatory markers, perceived control over falling was associated with physiological stress system activity (HPA axis). Older adults who felt more in control exhibited more adaptive cortisol responses to fall-related stress.
Together, these findings reinforce that psychological factors such as falls efficacy and perceived control are central to the mind–body connection, influencing both psychological resilience and physiological regulation in ageing.
Despite growing evidence differentiating the two constructs, contemporary literature still frequently treats falls efficacy and fear of falling as synonymous. This conflation remains concerning. Are we drawing accurate conclusions when these constructs are viewed as tautological? Are current interventions truly designed to address fear, or are they inadvertently targeting efficacy? And which underlying mechanisms are genuinely responsible for improvements in functional status and quality of life?
Systematic reviews by Jorstad (2005), Moore (2008), and Soh (2021) have each highlighted this persistent conceptual ambiguity, noting that researchers often use measurement tools interchangeably—even when these tools were originally developed to assess either fear of falling or falls efficacy, but not both.
Conceptually, falls efficacy and concerns about falling should work together like the accelerator and brake pedals of a car. Both essential for safe, adaptive movement. To enable confident mobility and independence, it is important to enhance and calibrate falls efficacy while appropriately managing fear.
After all, focusing only on the brake pads does not get the car moving. Falls efficacy offers a more empowering psychological mechanism that strengthens an individual’s sense of agency, while ensuring safety in older adults.
Continued research is needed to unravel the dynamic interplay between falls efficacy and fear of falling, and to better understand how these psychological factors jointly influence functional independence and healthy ageing.
Together, we can shape the future of falls prevention and healthy ageing.
Let’s switch gears and explore how modern research is reshaping our understanding of falls efficacy and fear of falling!
Check out this video clip
References
1. Fuzhong, L., McAuley, E., Fisher, K.J., Harmer, P., Chaumeton, N., Wilson, N.L. (2002). Self-efficacy as a mediator between fear of falling and functional ability in the elderly. J Aging Health. 14(4):452-66.
2. Li, F., Fisher, K. J., Harmer, P., McAuley, E. (2005). Falls self-efficacy as a mediator of fear of falling in an exercise intervention for older adults. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 60(1), P34-P40.
3. Bandura, A. (1977). Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev. 84(2):191-215.
4. Hughes, C., Kneebone, I., Jones, F., Brady, B. (2015). A theoretical and empirical review of psychological factors associated with falls-related psychological concerns in community-dwelling older people. International Psychogeriatrics, 27(7), 1071-1087.
5. McKenna, S.P., Heaney, A., Wilburn, J. (2019). Measurement of patient-reported outcomes. 2: Are current measures failing us? J Med Econ. 22(6):523-530.
6. Moore, D.S., Ellis, R. (2008). Measurement of fall-related psychological constructs among independent-living older adults: a review of the research literature. Aging Ment Health. 12(6):684-99.
7. Jørstad, E.C., Hauer, K., Becker, C., Lamb, S.E., ProFaNE Group. (2005) Measuring the psychological outcomes of falling: a systematic review. J Am Geriatr Soc. 53(3):501-10. doi: 10.1111/j.1532-5415.2005.53172.x. PMID: 15743297.
8. Soh, S.LH., Lane, J., Xu, T., Gleeson, N., Tan, C.W. (2021). T Falls efficacy instruments for community-dwelling older adults: a COSMIN-based systematic review. BMC Geriatr 21, 21.
9. Image in the website by Freepik
10. Lawrence, R.H., Tennstedt, S.L., Kasten, L.E., Shih, J., Howland, J., Jette, A.M. (1998). Intensity and correlates of fear of falling and hurting oneself in the next year: baseline findings from a Roybal Center fear of falling intervention. J Aging Health. 10(3):267-86.
Falls efficacy
As a perceived ability to prevent and manage falls
Balance Confidence | Balance Recovery Confidence | Safe-landing Confidence | Post-Fall Recovery Confidence
For more information, read “Falls efficacy: The self-efficacy concept for falls prevention and management”. Click here.
On Therapeutic Falls Efficacy
Therapeutic falls efficacy refers to an multidisciplinary team approach where stakeholders come together to empower and build the individual’s confidence in their ability to safely engage in meaningful, ‘high-risk’ activities, including the capacity to anticipate, manage, and recover from a potential fall within a supervised therapeutic boundaries.
References
1. Soh, S.L., Tan, C.W., Thomas, J.I., Tan, G., Xu, T., Ng, Y.L., Lane, J. (2021) Falls efficacy: Extending the understanding of self-efficacy in older adults towards managing falls. J Frailty Sarcopenia Falls. 1;6(3):131-138.
2. Soh, S.L.H., Lane, J., Xu, T., Gleeson, N., Tan, C.W. (2021). Falls efficacy instruments for community-dwelling older adults: a COSMIN-based systematic review. BMC Geriatr 21, 21
3. Lawrence, R.H., Tennstedt, S.L., Kasten, L.E., Shih, J., Howland, J., Jette, A.M. (1998). Intensity and correlates of fear of falling and hurting oneself in the next year: baseline findings from a Roybal Center fear of falling intervention. J Aging Health. 10(3):267-86.
4. Yoshikawa, A., Smith, M.L. (2019). Mediating Role of Fall-related Efficacy in a Fall Prevention Program. Am J Health Behav. 1;43(2):393-405.
5. Tinetti, M.E., Richman, D., Powell, L. (1990). Falls efficacy as a measure of fear of falling. J Gerontol. (6):239-243.
6. Powell, L.E., Myers, A.M. (1995). The Activities-specific Balance Confidence (ABC) Scale. J Gerontol A Biol Sci Med Sci. 50A(1):M28-34.
7. Hadjistavropoulos, T., Delbaere, K., Fitzgerald, T.D. (2011). Reconceptualizing the role of fear of falling and balance confidence in fall risk. J Aging Health. 23(1):3-23.
8. Soh, S.L.H, Tan, C.W., Xu, T., Yeh, T.T., Bte Abdul Rahman, F., Soon, B., Gleeson, N., Lane, J. (2022). The Balance Recovery Confidence (BRC) Scale. Physiother Theory Pract. 19:1-12.
9. Soh, S.L.H. (2022). Falls efficacy: The self-efficacy concept for falls prevention and management. Front Psychol. 9;13:1011285.
Fear of falling
Fear of Falling
Refers to a persistent concern about falling (Lee and Tak, 2023).
Manifested in four distinct aspects:
(1) Apprehension arising from the unpredictability of falls,
(2) Unease related to personal vulnerability,
(3) Heightened vigilance concerning the environment,
(4) Concern about potential harm following fall events.
Worries about falling which could be protective or harmful to individuals (Ellmers et al., 2022).
References
1. Bhala, R., O’Donnell, J., Thoppil, E. (1982) Ptophobia: phobic fear of falling and its clinical management. Phys Ther. (62)187-190.
2. Tinetti, M.E., Richman, D., Powell, L. (1990). Falls efficacy as a measure of fear of falling. J Gerontol. 45(6):239-243.
3. McGarrigle, L., Yang, Y., Lasrado, R., Gittins, M., Todd, C. (2023). A systematic review and meta-analysis of the measurement properties of concerns-about-falling instruments in older people and people at increased risk of falls. Age Ageing. 1;52(5):afad055.
4. Montero-Odasso, M., van der Velde, N., Martin, F.C., Petrovic, M., Tan, M.P., Ryg, J., Aguilar-Navarro, S., Alexander, N.B., Becker, C., …, Task Force on Global Guidelines for Falls in Older Adults. (2022). World guidelines for falls prevention and management for older adults: a global initiative. Age Ageing. 2;51(9):afac205.
5. Tinetti, M. and Powell, L. (1993). Fear of falling and low self-efficacy: a cause of dependence in elderly persons. Journals of Gerontology, 48, 35–38.
6. Hughes, C.C., Kneebone, I.I., Jones, F., Brady, B. (2015). A theoretical and empirical review of psychological factors associated with falls-related psychological concerns in community-dwelling older people. Int Psychogeriatr. 27(7):1071-87.
7. https://sites.manchester.ac.uk/fes-i/
8. Yardley, L., Beyer, N., Hauer, K., Kempen, G., Piot-Ziegler, C., Todd, C. (2005). Development and initial validation of the Falls Efficacy Scale-International (FES-I). Age Ageing. 34(6):614-9.
9. Lee, D., Tak, S.H. (2023). A concept analysis of fear of falling in older adults: insights from qualitative research studies. BMC Geriatr 23, 651.
10. Ellmers, T.J., Wilson, M.R., Norris, M., Young, W.R. (2022). Protective or harmful? A qualitative exploration of older people’s perceptions of worries about falling. Age Ageing. 1;51(4):afac067.
11. Adamczewska, N., Nyman, S.R. (2018). A New Approach to Fear of Falls From Connections With the Posttraumatic Stress Disorder Literature. Gerontol Geriatr Med. 27;4:2333721418796238.
12. MacKay, S., Ebert, P., Harbidge, C., Hogan, D.B. (2021). Fear of Falling in Older Adults: A Scoping Review of Recent Literature. Can Geriatr J. 1;24(4):379-394.
13. Lachman, M.E., Howland, J., Tennstedt, S., Jette, A., Assmann, S., Peterson, E.W. (1998). Fear of falling and activity restriction: the survey of activities and fear of falling in the elderly (SAFE) J Gerontol B Psychol Sci Soc Sci. 53(1):P43–P50.
14. Waddell, G., Newton, M., Henderson, I., Somerville, D., Main, C.J. (1993). A Fear-Avoidance Beliefs Questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain. 52(2):157-168.