Concepts of falls efficacy and fear of falling

Concepts of Falls Efficacy and Fear of Falling

Up to today, the concepts of falls efficacy and fear of falling remain enigmatic.

But still, it is important for researchers and clinicians to distinguish these two concepts. There are several evidence demonstrating that these two concepts are distinct, even though they are closely related.

Some evidence

In the 1994 study, “Fear of Falling and Fall-Related Efficacy in Relationship to Functioning Among Community-Living Elders”, Tinetti and colleagues identified 43% seniors from a sample of 1,103 acknowledged fear but majority remained confident in their ability to perform activities without falling. Fear of falling was not significant factor in the social and physical functioning models, but rather, falls efficacy was a critical factor determining the function score.

In the 2002 paper, “Self-Efficacy as a Mediator Between Fear of Falling and Functional Ability in the Elderly”, Li and colleagues showed that falls efficacy (i.e., balance confidence) act as a mediator between fear of falling and functional ability.

Several more papers across the years have identified the significance of fall efficacy.

A more recent paper, “Mediating Role of Fall-related Efficacy in a Fall Prevention Program”, Yoshikawa and Smith (2019) show that by enhancing falls efficacy (i.e., balance confidence, safe falling confidence, and post fall recovery confidence) via exercise training, fear of falling was reduced and seniors had greater level of daily activity.

Falls efficacy refers to the perceived ability to prevent and manage falls

Falls efficacy has been posited to encompasses several domains of self-efficacies including:

Balance confidence – perceived ability to maintain balance whilst performing activities of daily living.
Balance recovery confidence – perceived ability to arrest a fall in response to a loss of balance due to slip, trip, or from volitional movement.
Safe-falling confidence – perceived ability to fall safely onto the ground.
Post-fall recovery confidence – perceived ability to get up or help from the ground.

Evolution of concept

In the late 80s and early 90s, there was an imperative need to understand fear of falling. Fear of falling was viewed dissimilar to phobias, such as agoraphobia (fear of entering open or crowded places), ptophobia (fear of walking), or acrophobia (fear of falling from heights). Tinetti et al (1990) developed the first falls efficacy measure, operationalising it that fear of falling was low perceived self-efficacy or confidence at avoiding falls.

In 1995, Powell and Myers developed the first balance confidence scale, the Activities-specific Balance Confidence scale, extending the Falls Efficacy Scale with a wider continuum of activity difficulty and more detailed item descriptors.

In 1998, Lawrence and colleagues expanded the conceptual understanding of falls efficacy and developed the scales to measure perceived control over falling and perceived ability to manage falls and falling. Unfortunately, the importance of highlighting the falls efficacy concept was undermined by the focus towards advocating the use of multicomponent interventions to address risk of falls and fear of falling.

The ubiquitous interchangeable use between fear of falling and balance confidence led to Hadjistavropoulos et al (2011) to reconceptualise the role of fear of falling and balance confidence in fall risk. The authors posited that balance confidence was synonmous to falls efficacy.

In 2021, Soh and colleagues reaffirmed the extended understanding of falls efficacy that there are several domains of self-efficacy (i.e. Balance confidence, balance recovery confidence, safe-landing confidence, and post-fall recovery confidence) to inform fall efficacy.

This was supported by a COSMIN systematic review conducted by Soh et al (2021) to evaluate the content validity of various falls efficacy-related measures.