CONCEPTUAL DEVELOPMENT
From Fear of Falling to Falls Efficacy
Falls efficacy and fear of falling are closely related, but they are not the same psychological construct. Research over the past three decades has progressively clarified this distinction and highlighted the importance of understanding what individuals believe they are capable of doing when faced with fall-related situations.
Recognising two distinct constructs
Early falls research frequently operationalised fear of falling through self-efficacy. The original Falls Efficacy Scale, introduced by Tinetti, Richman and Powell (1990), assessed confidence in performing everyday activities without falling. Subsequent research, however, demonstrated that fear and efficacy could be differentiated.
Tinetti and colleagues (1994) examined fear of falling and fall-related efficacy in 1,103 community-dwelling older adults. Fall-related efficacy showed independent associations with activities of daily living, physical activity and social functioning after adjustment for multiple covariates. In contrast, fear of falling was only marginally associated with ADL-IADL functioning and was not associated with higher-level physical or social functioning.
These findings suggested that physical capability and perceived capability should be considered together. The authors consequently proposed that rehabilitation and falls-prevention programmes should attend to both physical skills and confidence rather than treating psychological responses to falling as secondary concerns.
Perceived control and the ability to manage falls
Lawrence and colleagues (1998) extended this perspective by examining fear of falling alongside perceived ability to manage falls and perceived control over falling. Their work helped shift attention from fear alone towards how capable and in control older adults perceived themselves to be when confronted with fall-related situations.
Fall-related self-efficacy as a potential psychological pathway
Li and colleagues (2002) subsequently examined relationships between fear of falling, falls self-efficacy and functional ability. Their structural modelling indicated that higher fear was associated with lower falls self-efficacy, while greater self-efficacy was associated with better functional outcomes. Falls self-efficacy statistically mediated the relationship between fear of falling and functional outcomes.
In a later exercise study, Li and colleagues (2005) examined older adults participating in six months of Tai Chi or a stretching control programme. Improvements in falls self-efficacy among Tai Chi participants were associated with greater reductions in fear of falling, supporting falls self-efficacy as a potential mediator of intervention-related psychological change.
A contemporary mind–body perspective
More recent research has begun to examine whether fall-related psychological constructs are also associated with physiological stress regulation. In the FEARFALL Study, Müller and colleagues (2025) examined concern about falling, perceived control over falling, endocrine stress-system activity and inflammatory markers in community-dwelling older adults.
Greater perceived control over falling was associated with cortisol dynamics, including higher individual cortisol values and a trend towards a steeper diurnal cortisol decline. No significant associations were observed between concern-about-falling measures and inflammatory markers. These findings suggest that perceived control may be relevant to physiological stress regulation, although the observational associations do not establish causality.
Collectively, this body of research supports a view in which physical capability, perceived capability, fear, concern and perceived control interact within the broader experience of mobility and ageing. Distinguishing these constructs is therefore important for both research and practice.
WATCH
Understanding Falls Efficacy
This short video introduces the Falls Efficacy perspective and why confidence across different fall-related situations matters.
A MULTIDIMENSIONAL PERSPECTIVE
Falls Efficacy Across Different Fall Stages
Falls efficacy can be considered across four confidence domains corresponding to different stages of a fall-related situation. This broader perspective extends beyond maintaining balance alone towards confidence in responding to and managing a potential fall.
PRE-FALL
Balance confidence
Confidence in maintaining balance during activities.
NEAR-FALL
Balance recovery confidence
Confidence to arrest a fall following a loss of balance, slip, or trip.
FALL-LANDING
Safe-landing confidence
Confidence in protecting oneself during a fall.
COMPLETED FALL
Post-fall recovery confidence
Confidence to get up or get help after a fall.
Fall Prevention and Fall Management
The four domains can be organised into two complementary areas: confidence relating to preventing a fall and confidence relating to managing a fall when prevention is no longer possible.
FALL PREVENTION
Pre-fall + Near-fall
Confidence in maintaining balance and responding to instability before a fall is completed.
FALL MANAGEMENT
Fall-landing + Completed fall
Confidence in protecting oneself during a fall and managing recovery after the fall has occurred.
Fall Prevention and Fall Management are used here as this research programme’s organising framework for the four falls-efficacy domains, rather than as a universally established taxonomy.
FROM CONCEPT TO PRACTICE
Therapeutic Falls Efficacy
Within this research programme, Therapeutic Falls Efficacy is an applied, person-centred approach to building an individual’s confidence and capability to engage safely in meaningful activities that may involve fall-related challenge.
Building capability, not simply avoiding risk
Therapeutic Falls Efficacy brings together the individual, clinicians and other relevant stakeholders to develop confidence within appropriately supervised therapeutic boundaries. The emphasis is not on encouraging unnecessary risk, but on supporting informed, adaptive engagement in meaningful activities.
ANTICIPATE
Prepare
Recognise fall-related challenges and develop appropriate strategies before undertaking an activity.
RESPOND
Manage instability
Build confidence in responding when balance is disturbed.
MANAGE
Respond to a fall
Develop capability to protect oneself and manage the consequences if a fall occurs.
RECOVER
Regain agency
Support confidence to recover, obtain assistance and return to meaningful activity following a fall.
Therapeutic Falls Efficacy is presented here as an applied concept within this research programme. Further research is required to develop and evaluate its theoretical and clinical applications.
A RELATED BUT DISTINCT CONSTRUCT
Fear of Falling
Fear of falling is not simply low falls efficacy. Contemporary conceptual work describes it as a persistent fall-related concern characterised by emotional, cognitive and behavioural responses to the possibility or consequences of falling.
APPREHENSION
Unpredictability
Apprehension may arise from the unpredictable nature of falls and uncertainty about when a fall-related threat may occur.
VULNERABILITY
Perceived susceptibility
Fear may reflect awareness of one’s vulnerability and the potential consequences of falling.
VIGILANCE
Environmental awareness
Individuals may become increasingly attentive to environmental features perceived to threaten balance or safety.
POTENTIAL HARM
Consequences of a fall
Concern may extend beyond falling itself to anticipated injury, loss of independence or other consequences.
Fear is not necessarily harmful
Fall-related worry can sometimes promote adaptive caution and safer behaviour. However, when individuals perceive little control over fall-related threats, worry may become maladaptive and contribute to panic, excessive restriction or reduced engagement in valued activities.
The therapeutic goal should therefore not necessarily be to eliminate all fear. A more useful objective may be to calibrate concern, strengthen perceived capability and control, and support safe participation.
Distinguishing Falls-related Psychological Constructs
Precise terminology matters because falls efficacy, balance confidence, fear, concern and perceived control capture different aspects of the individual’s response to fall-related situations.
CAPABILITY
Falls efficacy
How capable do I feel of preventing or managing this fall-related situation?
CONFIDENCE
Balance confidence
How confident am I that I can maintain my balance during this activity?
EMOTIONAL RESPONSE
Fear of falling
How afraid or apprehensive am I about falling and its consequences?
CONCERN
Concern about falling
How concerned am I about the possibility or consequences of falling?
CONTROL
Perceived control over falling
How able do I feel to control a situation that threatens my balance, including my behavioural and emotional response?
BEHAVIOUR
Activity avoidance
Do fall-related perceptions lead me to restrict or avoid activities?
IMPLICATIONS FOR MEASUREMENT
Measure the Construct You Intend to Understand
Measurement should follow conceptualisation. Instruments developed for fear, concern, balance confidence or falls efficacy should not automatically be treated as interchangeable simply because the constructs are related.
BALANCE RECOVERY CONFIDENCE
BRC
Explore measurement of confidence in recovering balance following a loss of balance.
Explore BRC →MULTIDIMENSIONAL FALLS EFFICACY
MdFES
Explore multidimensional assessment across fall-prevention and fall-management situations.
Explore MdFES →MEASUREMENT LIBRARY
Measure List
Compare measures according to the construct and purpose you intend to assess.
View the Measure List →Key References
Selected publications informing the conceptual development of falls efficacy, fear of falling and related constructs.
- Tinetti, M.E., Richman, D., & Powell, L. (1990). Falls efficacy as a measure of fear of falling. Journal of Gerontology, 45(6), P239–P243.
- Tinetti, M.E., Mendes de Leon, C.F., Doucette, J.T., & Baker, D.I. (1994). Fear of falling and fall-related efficacy in relationship to functioning among community-living elders. Journal of Gerontology, 49(3), M140–M147.
- 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. Journal of Aging and Health, 10(3), 267–286.
- Li, F., 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. Journal of Aging and Health, 14(4), 452–466.
- 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. Journals of Gerontology Series B, 60(1), P34–P40.
- Soh, S.L.H., 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. Journal of Frailty, Sarcopenia and Falls, 6(3), 131–138.
- 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 and Ageing, 51(4), afac067.
- Lee, D., & Tak, S.H. (2023). A concept analysis of fear of falling in older adults: insights from qualitative research studies. BMC Geriatrics, 23, 651.
- Müller, A., Kob, R., Sieber, C.C., Freiberger, E., Rohleder, N., & Britting, S. (2025). Relationship between stress systems and inflammation in older adults concerned about falling: Findings from the FEARFALL study. Experimental Gerontology, 211, 112899.
Translate Falls Efficacy into Research and Practice
Explore construct-specific measures and research informed by a broader understanding of confidence around falls.