Measurement instruments for falls efficacy
Summary
Selecting the right measurement instrument for a latent construct is not easy. To ensure consistency with the measurement, the unobservable construct needs to be well-defined and precisely demarcated as a subject of measurement. A multi-item instrument needs an explicit and clear conceptual framework that describes the relationship between the items and the construct to be measured.
Previously, falls efficacy has been used to assess fear of falling. However, falls efficacy and fear of falling are distinct concepts and should be measured using different measurement instruments. Falls efficacy encompasses multiple domains of self-efficacies, including balance confidence, balance recovery confidence, safe-landing confidence, and post-fall recovery confidence. Falls efficacy is not synonymous to balance confidence. This perspective aligns with the self-efficacy concept that the efficacy belief system is a differentiated set of self-beliefs linked to distinct realms of functioning. In this context, the perceived capabilities to overcome different situational demands across various fall-related scenarios.
Professor Albert Bandura has offered similar arguments for the role of self-regulatory efficacy in managing one’s weight. He proposed that there are at least three separable aspects to this endeavour,:
(1) self-efficacy to regulate the type of food products that are purchased and brought home,
(2) one’s eating habits that determine daily caloric intake, and
(3) the level of physical activity that burns calories and affects the body’s metabolic rate.
Focusing solely on self-efficacy to regulate eating habits provides a narrow view of the contribution of self-efficacy to weight self-management.
New measurement instruments have been developed for falls efficacy, balance confidence, balance recovery confidence, safe-landing confidence, and post-fall recovery confidence. They should be distinguished from fear of falling measurement instruments. This research aims to advance the understanding of the use and psychometrics of various measurement instruments for various fall-related psychological concerns.
Appropriate measurement instruments must be used for the targeted construct of interest. If not, interpreting results from inaccurately used PROMs risks researchers and clinicians making incorrect conclusions, be it of interventions’ efficacy or the individual being cared for.
For Pre-Fall Domain: On the perceived ability to perform different activities without losing balance or falling
| Name | Developer | Number of items | Scoring | Conceptualisation method | Remarks |
| Falls Efficacy Scale (FES) | Tinetti et al., 1990 | 10 | A 10-point continuum scale. Represented by 1 (very confident) to 10 (not confident at all). A higher score equivalent to lower confidence or efficacy | Items were constructed by experts to identify the most important activities essential to independent living for most elderly persons. | Find it on Pubmed. |
| Modified Falls Efficacy Scale | Edwards & Lockett, 2008 | 11 | A 3-point scale. Represented by 1 (not at all confident) to 3 (completely confident). | Constructed by modifying the original FES. Additional items were introduced by scale developers. | Find it on Pubmed. |
| Modified Falls Efficacy Scale | Tennstedt et al., 1998 | 12 | A 1-4 point scale. Represented by 1 (not at all sure) to 4 (very sure). A higher score indicates greater confidence. | Constructed for a randomised controlled trial. Items were constructed based on the original FES. Two additional items were introduced by the study authors. Scoring was revised. | Find it on Pubmed. |
| Modified Falls Efficacy Scale | Hellstrom & Lindmark, 1999 | 13 | An 11-point visual analogue scale. Marked from 0 to 10 with a higher score depicting higher confidence. | Constructed by modifying the original FES. Additional items were introduced by scale developers. Scoring options have been reversed. | Find it on Pubmed. |
| Modified Falls Efficacy Scale | Hill et al., 1996 | 14 | An 11-point visual analogue scale. Marked from 0 to 10 with a higher score depicting higher confidence. | Constructed by modifying the original FES. Additional items were introduced by the study authors. Scoring options have been reversed. | Find it on Pubmed. |
| Perceived Ability to Prevent and Manage Fall Risks (PAPMFR) | Yoshikawa & Smith, 2019 | 6 | A 1 to 5 point scale. Represented by 1 (excellent) and 5 (poor). | Constructed for an interventional study attempting to address falls efficacy, and its mediating role between fear of falling and functional mobility. Reference against other falls efficacy scales, e.g., PAMF, MFES, FES-I, and ABC. | Find it on Pubmed. |
| Gait Efficacy Scale | Rosengren et al., 1998 | 8 | A10-point Likert scale. Represented by 10 (complete confidence) and 1 (no confidence) | Constructed for a study attending to gait adjustments in older adults. Items were based on modifying the original GES. New items were constructed by study authors. | Find it on Pubmed. |
| Modified Gait Efficacy Scale | McAuley et al., 1997 | 10 | A 10-point Likert scale. Represented by 10 (complete confidence) and 1 (no confidence) | Constructed for a study examining self-efficacy, balance and fear of falling in older adults. Items were constructed by the study authors. | Find it in Journal. |
| Perceived Control over Falling | Tennstedt et al., 1998 | 4 | A 1-4-point scale. Represented by 1 (strongly disagree) to 4 (strongly agree) A higher score depicting a greater sense of control | Constructed for a randomised controlled trial. Items were constructed based on the control inventories. | Find it on Pubmed. |
| Perceived Ability to Manage Risk of Falls or Actual Falls (PAMF) | Tennstedt et al., 1998 | 5 | A 1-4 point scale Represented by 1 (being not at all sure) to 4 (very sure) A higher score depicting a greater sense of ability to manage | Constructed for a randomised controlled trial. Items constructed were based on the original FES. Items were introduced by the study authors. | Find it on Pubmed. |
| Balance Self-perceptions Test | Shumway-Cook et al., 1997 | 20 | A 1-5 point scale. Represented by 1 (no confidence) to 5 (extreme confidence). | Constructed for a study investigating the effect of multidimensional exercises on balance, mobility and fall risk in community-dwelling older adults. Items constructed were based on modifying the FES by the study authors. | Find it on Pubmed. |
| Activities-specific Balance Confidence Scale | Powell & Myers, 1995 | 16 | A 0-100% response continuum. Represented by 0% depicting no confidence and 100% represent complete confidence. | Constructed by involving clinicians and older adults. A similar question used to construct FES’s items was applied. An additional question relating to fear of falling was asked to older adults. | Find it on Pubmed. |
| Modified Activities-specific Balance Confidence Scale | Filiatrault et al., 2007 | 15 | A 4-category response score. Represented by 0 (not at all confident), 1 (slightly confident), 2 (moderately confident), and 3 (very confident). | Constructed using the original ABC scale. Instructions were revised. Response options were amended. | Find it on Pubmed. |
| Short Activities-specific Balance Confidence Scale | Peretz et al., 2006 | 6 | A 0-100% response continuum. Represented by 0% (no confidence) and 100% (complete confidence). | Constructed using original ABC scale. Based on lowest scores (highest fear) obtained from individuals with higher-level gait disorders (HLGD), and those with Parkinson’s. | Find it on Pubmed. |
| CONFBal Scale of Balance Confidence | Simpson et al., 2009 | 10 | A 3-point scale. Represented by 1 (being confident), 2 (being slightly confident), 3 (being not confident). | Items were derived from the ‘Confidence in everyday activities’ instrument developed for use with older adults. | Find it on Pubmed. |
For Near-Fall Domain: On the perceived ability to recover the balance following perturbations
| Name | Developer | Number of items | Scoring | Conceptualisation method | Remarks |
| Balance Recovery Confidence Scale | Soh et al., 2022 | 19 | A 0-10 scoring options. Represented by 0 (cannot do) to 10 (certain can do) | Constructed by involving community-dwelling older adults. Reference against previous conducted systematic reviews of falls efficacy scales. | Find it on Pubmed. |
For Fall-Landing Domain: The perceived ability to fall safely on the floor or lower ground.
| Name | Developer | Number of items | Scoring | Conceptualisation method | Remarks |
| Perceived ability to manage risks of falls or actual falls (PAMF) | Tennstedt et al., 1998 | 5 | A 1-4 point scale. A higher score depicting a greater sense of ability to manage | Constructed for a randomised controlled trial of an intervention designed to reduce the fear of falling among community-dwelling older adults. Items constructed were based on the original FES. Items were introduced by the study authors. | Find it on Pubmed. |
For Completed-Fall Domain: On the perceived ability to get up or get help after a fall.
| Name | Developer | Number of items | Scoring | Conceptualisation method | Remarks |
| Perceived ability to manage risks of falls or actual falls (PAMF) | Tennstedt et al., 1998 | 5 | A 1-4 point scale A higher score depicting a greater sense of ability to manage | Constructed for a randomised controlled trial of an intervention designed to reduce the fear of falling among community-dwelling older adults. Items constructed were based on the original FES. Items were introduced by the study authors. | Find it on Pubmed. |
| Perceived Ability to Prevent and Manage Fall Risks (PAPMFR) | Yoshikawa & Smith, 2019 | 6 | A 1-5 point scale. Represented by 1 (excellent) and 5 (poor). Higher scores represented a higher perceived ability to prevent and manage fall risks | Constructed for an interventional study attempting to address falls efficacy, and its mediating role between fear of falling and functional mobility. Reference against other falls efficacy scales, e.g., PAMF, MFES, FES-I, and ABC. | Find it on Pubmed. |
| Difficulty scale of rising from the floor | Hofmeyer et al., 2002 | 7 | A 1 to 4 point scale. Represented by 1 (no difficulty) to 4 (unable to rise). | Constructed as part of a floor-rise strategy training for older adults. | Find it on Pubmed. |
For Fear of falling: On the lasting concerns about falling that lead to an individual avoiding activities that one remains capable of performing.
| Name | Developer | Number of items | Scoring | Conceptualisation method | Remarks | |
| Single question on FOF and activity restriction (SQ-FAR). | Belloni et al., 2020 | 2 | Dichotomous scoring of yes or no. | The SQ-FAR was a combination of the answers to the question “Are you afraid of falling?” and “If yes, have you restricted any activities because of this fear?” | Find it on Pubmed. | |
| Appraisal of Harm Outcomes Questionnaire | Noimontree and Lach, 2017 | 6 | 10-point rating scale | Reassess an older measure of fear and appraisal of harm. | Find it on Pubmed. | |
| Geriatric Anxiety Scale | Segal et al., 2010 | 30 | A 4-point Likert-type scale ranging from 0 (not at all) to 3 (all of the time) | To determine anxiety symptoms including somatic, cognitive, and affective domains in older adults. Items also include concern about finances; concern about one’s health; concern about children; fear of dying; and fear of becoming a burden to others. | Find it on Pubmed. | |
| Falls Efficacy Scale-International Activities Avoidance Behaviour (FES-IAB) | Dorresteijn et al., 2011 | 16 | Questions about avoidance behavior are only asked when people indicate that they are at least somewhat concerned (i.e., answer options 2, 3, and 4 of the FES-I). If people are not concerned (i.e., answer option 1 of the FES-I), a score of 1 is assigned to the item. A sum score is obtained ranging from 16 to 64. A higher score indicates a greater activity avoidance level. | The FES-IAB builds upon the internationally used and validated FES-I. The 16-item FES-I will be used. For the FES-IAB, people indicate to what extent they avoid an activity due to their concerns for each item of the FES-I. The answer options of the FES-IAB are 1=no, never, 2=yes, sometimes, 3=yes, regularly, and 4=yes, often. | Find it on Pubmed. | |
| Geriatric Fear of Falling Questionnaire | Sangpring et al., 2012 | 34 | A 6-point Likert scale ranging from 1 (not at all) to 6 (very much) | To assess the level of fear of falling based on physical activities, functional, environmental, and psychosocial aspects. | Find it on Pubmed | |
| Short Falls Efficacy Scale-International Activities Avoidance Behaviour (Short FES-IAB) | Kruisbrink et al. 2021 | 7 | Similar to the scoring format of FES-IAB. A sum score is obtained ranging from 7 to 28. A higher score indicates a greater activity avoidance level. | The Short FES-IAB contains a selection of seven items out of the FES-IAB; the seven items are based on the Short FES-I | Find it on Pubmed. | |
| Falls Behavioural (FaB) Scale | Clemson et al., 2008 | 29 | A 4-point scale: never (1), sometimes (2), often (3), always (4) and does not apply (no score). | To provide a profile of level of risk related to falling by evaluating both safety strategies and risky behaviours. | Find it on Pubmed. | |
| Survey of activities and fear of falling in the elderly (SAFE) | Lachman et al., 1998 | 22 | A 0-4 point scale. A higher score indicates a greater fear of falling. | Constructed using disability instruments administered in large-scale survey. Judgement to identify items were based on three experts. | Find it on Pubmed. | |
| Modified Survey of activities and fear of falling in the elderly (mSAFFE) | Yardley & Smith, 2002 | 17 | A 3-point scale. Represented by 1 (never avoid), 2 (sometimes avoid), and 3 (always avoid). | Constructed for a prospective study. Five items from the original SAFE was omitted for a likelihood of poor discriminant validity of high-functioning community individuals. | Find it on Pubmed. | |
| Consequences of Falling Scale | Yardley and Smith, 2002 | 16 | A 4-point response scale including disagree strongly, disagree, agree, agree strongly) | To determine the level of worries about the consequences of falling. Focus on two dimensions: Loss of functional independence and social consequence of falling. | Find it on Pubmed. | |
| University of Illinois at Chicago fear of falling measure (UIC-FFM) | Velozo & Peterson, 2001 | 16 | A 0–4 point scale Represented by 1 (very worried), 2 (moderately worried), 3 (a little worried) and 4 (not at all worried). | Items were generated from focus groups sessions with older adults. Part of a larger study to compare the prevalence, intensity, and impact of fear of falling among white and African-American older adults living independently. | Find it on Pubmed. | |
| Geriatric fear of falling measure (GFFM) | Huang, 2006 | 15 | A 1-5 point scale Represented by 1 (never) and 5 (always). | Conceptualised using a qualitative study of Taiwanese community-dwelling older adults. Items were identified by the study authors. | Find it on Pubmed. | |
| Short Falls-efficacy scale-International (Short FES-I) | Kempen et al., 2008 | 7 | A 1-4-point scale Represented by 1 (not at all concerned) and 4 (very concerned). | Constructed using the original FES-I administered via postal survey and face-to-face structured interviews. Items were selected based on face validity and psychometric criteria. | Find it on Pubmed. | |
| Falls efficacy scale – International (FES-I) | Yardley et al., 2005 | 16 | A 1-4-point scale Represented by 1 (not at all concerned) and 4 (very concerned). | Constructed by modifying the original Falls Efficacy Scale. Items were constructed by falls experts (members of the Prevention of Falls Network Europe). | Find it on Pubmed. | |
| Short Iconographical Falls Efficacy Scale (Short Icon-FES) | Delbaere et al., 2011 | 10 | A 1-4-point scale Represented by 1 (not at all concerned) and 4 (very concerned). | Constructed using the original Icon FES. Items were selected based on face validity and psychometric criteria. | Find it on Pubmed. | |
| Iconographical Falls Efficacy Scale (Icon-FES) | Delbaere et al., 2011 | 30 | A 1-4-point scale Represented by 1 (not at all concerned) and 4 (very concerned). | Constructed using the literature – FES-I, SAFE, ABC, and Falls Behavioral Scale. Items were constructed by the scale developers. | Find it on Pubmed. | |
| Fear of Falling Avoidance Behaviour Questionnaire (FFABQ) | Landers et al., 2011 | 14 | A 0-5-point scale Represented by 0 (completely disagree) to 4 (completely agree). | Based on the fear-avoidance model of exaggerated pain perception. Constructed items were based on inputs from 13 experts (11 physical therapists and 2 patients with a history of falling). | Find it on Pubmed. | |
| Fear of Falling Questionnaire (FFQ) | Dayhoff et al., 1994 | 21 | A 1-4 point scale Represented by 1 (strongly disagree) to 4 (strongly agree). Higher scores indicating greater fear of falling. | Based on the cognitive appraisal model of emotion. Fear of falling is a function of the emotion of fear and appraisals of the potential outcome of harm from a fall, seriousness of harm from a fall, and coping potential to prevent harm. | Find it on Google Scholar. | |
| Fear of Falling Questionnaire Revised (FFQ-R) | Bower et al., 2015 | 6 | A 1-4 point scale Represented by 1 (strongly disagree) to 4 (strongly agree). Higher scores indicating greater fear of falling. | Revision of the FFQ based on inputs given from expert clinicians of face validity. | Find it on Pubmed. | |
| Mobility Efficacy Scale (MES) | Lusardi & Smith, 1997 | 10 | A 1-4-point scale Represented by 1 (not at all concerned) and 4 (very concerned). | Developed by including a variety of activities more challenging to postural control than the activities of daily living in the FES. The content was developed with community-living older adults. | Find it on Pubmed. | |
| Questionnaire on activity restriction | Vellas et al., 1987 | 15 | A 0 to 4 rating scale. A total sum score between 0 and 60. | To investigate the activity level, fall description, interpersonal relationship and the psychological state of the individual. | Find it on Pubmed. | |
| Fear of falling questionnaire | Howland et al., 1993 | 3 | A 3-point rating scale using (a) not afraid of falling; (b) afraid of falling but do not curtail activities; and (c) afraid of falling and curtail activities (don’t do or stopped doing activities). | To assess the level of fear of falling associated with activity curtailment. | Find it on Pubmed. | |
| Single-item measures, e.g. “Are you afraid of falling?”, “Are you concerned about falls?” | Multiple authors | 1 | Dichotomous scoring of yes or no. | Different phrasing of the item is based on the construct of interest to be measured by the researcher. Concerns have been raised whether the different phrasing, e.g. afraid, concern, worry, troubled would affect the validity, i.e., not measuring the constructed as intended. |
For Fall Risk Perception: There are variations in the constructs used to understand individuals’ perceptions of their fall risks.
| Name | Developer | Number of items | Scoring | Conceptualisation method | Remarks | |
| Falls Efficacy measures | ||||||
| Fear of Falling measures | ||||||
| Self-awareness of falls measure (SAFRM) | Mihaljcic et al., 2014 | 35 | Varying scoring options for different domains | Comprises of three domains: intellectual, emergent and anticipatory awareness. | Find it on Pubmed. | |
| Self-awareness of falls in elderly (SAFE) | Shyu et al., 2018 | 21 | A 5-point scale was used to rate awareness levels, ranging from 1 (strongly agree) to 5 (strongly disagree); a higher score indicated a high level of fall risk awareness. | Measures four factors: awareness of activity safety and environment, awareness of physical functions, awareness of medication, and awareness of cognitive behavior | Find it on Pubmed. | |
| Falls risk perception questionnaire (FRPQ) | Choi et al., 2021 | 27 | A 4-point Likert scale ranging from 0 (absolutely not true) to 3 (absolutely true), with higher scores indicating a higher perceived fall risk | Measures three factors: personal-mobility, personal-chronic condition, environmental | Find it on Pubmed |
Others
| Okubo et al., 2021 | Stepping impairment and falls in older adults: A systematic review and meta-analysis of volitional and reactive step tests | This large systematic review demonstrated that both volitional and reactive stepping impairments are significant fall risk factors among older adults. Step tests can identify fallers from non-fallers with moderate accuracy. | Find it on Pubmed. |
| Russell et al., 2009 | FROP-Com Screening tool | The FROP-Com screen has a relatively good capacity to predict falls. The assessment tool involves rating 13 falls risk factors, usually on a scale of 0-3. They include: History of falls, Medications, Medical conditions, Sensory loss, Feet and footwear, Cognitive status, Continence, Nutritional status, Environment, Functional behaviour, Function, Balance, Gait/Physical activity | Find it on Pubmed |
24/1/2024