Fall Prevalence And The Home Environmental Factors Among Community-Dwelling Older Adults In China

Background:As the world’s most populous nation in the midst of a rapid aging process,the proportion of China’s total population aged 60 and above has doubled from 10%in 2000 to 20%in 2022(280 million people).Falls are the leading cause of injury-related deaths among the elderly,and the associated disease burden is expected to escalate as the aging process deepens.Despite this,there has been a lack of comprehensive understanding regarding fall prevalence and potential regional disparities in China based on national survey data analysis.Although accessible facilities and home modifications constitute effective strategies for injury prevention and key initiatives to reduce health inequalities in many developed countries,the attempts and research in this regard in China are still in early stages.There is limited exploration of domestic housing environmental risks,and insufficient evidence to evaluate home environmental interventions in China.The "Fall Prevention Project" in Luohu District,Shenzhen,represents an exemplary,albeit smallscale,home adaptation pilot initiated by a healthcare group,which had undergone payment reform from fee-for-service to global budgeting.Objectives:The study aimed to establish a comprehensive understanding of regional and temporal trends in self-reported falls among community-dwelling older adults in China and to explore two policies related to home environmental aspects that could potentially be developed as a fall prevention strategy.Firstly,the study explored the association between the accessibility features of urban residential buildings,particularly elevator installations,and the occurrence of falls among older adults.Additionally,using both outcome and satisfaction measures,an evaluation of a pilot home adaptation project in Luohu District,Shenzhen City,was conducted.Based on the study’s major findings,we discussed policy implications related to targeting strategies,resource allocation and multisector cooperation,among other aspects.Methods:Aided by literature review and relevant theoretical framework,our empirical research is consisted of three parts:1.Descriptive analyses on regional disparities and trends of falls and injurious falls:Retrospective descriptive analyses were performed using data from four waves of the China Health and Retirement Longitudinal Study(CHARLS)conducted in 2011,2013,2015,and 2018 among older adults.After sequentially adjusting for individual sociodemographic characteristics,health status,and physical functional limitations,binary logistic regression models with marginal effects were employed to depict the national and regional trends in falls and injurious falls reported in the four surveys.All models accounted for random effects between CHARLS sampling units,and incorporated individual weights adjusted for non-response.2.Associations between housing characteristics and falls:Following Lawton’s Person-Environment Fit Theory and considering Residential Building Codes in China,we included in our sample older adults living on the 2nd-7th floors of urban residential buildings from four CHARLS waves to investigate the associations between falls and building characteristics(such as floor level,elevator accessibility,age of the building,the type of toilets and bathing facilities)as well as indoor environment assessment(including cleanliness and room temperature etc.).The models were estimated using mixed-effects logistic regression and generalized estimating equations.3.Evaluation of "Fall Prevention Project" in Luohu,Shenzhen:In a real-world context,the study included older adults who applied for the "Fall Prevention Project" in Luohu District from August 2016 to October 2019 as the "project group"respondents.Using propensity score matching(PSM)based on the Andersen’s Behavioral Model,a sample of "control group" respondents in the community was established by selecting those elderly who were not enrolled in the pilot from Luohu District elderly health records.A telephone interview survey was administered amongst 2,170 respondents from both the "project group" and "control group" to collect additional information on fall events,health and functional status,home environment,satisfaction/compliance with the project,and willingness and barriers to participation.A total of 2,098 community-dwelling older respondents(709 in the "project group" and 1,3 89 in the "control group")were finally included.The negative binomial regression was employed to compare the differences in indoor fall incidence rates between two groups of older adults,and subgroup analyses were conducted based on age categories.Qualitative textual data recorded from telephone interviews were subjected to thematic analysis.Results:1.The unadjusted fall rate among older adults increased from 18.6%in 2011 to 21.9%in 2018.After adjusting for the functional status of participants,the fall rate changed from an upward trend to an insignificant trend from 2011 to 2018,while significant regional variations in falls existed with higher fall prevalence in the central and western areas,compared with the eastern area,corresponding with the region’s relative levels of socioeconomic development.The unadjusted injurious fall rate was 8.5%in 2018.We depicted a significant descending trend of injurious falls between 2011 and 2018 and identified the northeastern region with the lowest rates of injurious falls.Age turned out to be an insignificant predictor of both falls and injurious falls after controlling for functional,ADL and IADL limitations.Several chronic conditions(ie,stroke,kidney disease,arthritis)and lower limb functional limitations posed significant risks for both falls and injurious falls.2.From 2011 to 2018,facilities in urban residences spanning the 2nd to 7th floors for elderly participants continued to improve.The accessibility of elevators was still reported 11.1%among respondents in 2018,despite an increase from 2011.Elevator accessibility in urban buildings was found negatively associated with falls(OR=0.519,95%CI[0.294-0.916]),with this effect being more significant among elderly residents living on the second floor(0.195[0.051-0.747]).Post-hoc analysis revealed that older adults residing on the second floor had poorer physical function and ability of daily living compared to those on higher floors.Additionally,higher levels of indoor cleanliness and tidiness,and appropriate indoor temperatures were associated with fewer falls.3.The "Fall Prevention Project",which offered primary adaptations such as installing grab bars in bathrooms,providing non-slip mats and nightlights,was considerably favored by participants in the "project group" However,the results indicated an insignificant reduction in indoor fall occurrence in the "project group"(IRR=0.737,95%CI[0.4311.259]).Moreover,participants below 75 years(IRR=0.619,95%CI[0.175-2.186])may gain more benefits compared to those aged 75 and above(IRR=0.815,95%CI[0.4591.446]),although these estimates showed no statistical significance.Factors predicting application for the "Fall Prevention Project" included being older,divorced/widowed,insurance covered,with higher socioeconomic status,a history of falls or fear of falling,poor self-rated health,disability,limited vision,and multiple chronic conditions(e.g.,hypertension,diabetes,heart disease,osteoarthritis)and limitations in activities of daily living.Recommendation from community healthcare workers was identified as a facilitator for the elderly’s participation.A small number of respondents in the "control group" had undertaken home modifications on their own,while barriers to participation included inaccessibility of the project information,insufficient awareness and knowledge of falling,inadequate living space,and mobility issues for urban seniors.Furthermore,respondents of "project group" also provided feedback on maintenance issues and unmet need for personalized home modification and public spaces.Conclusion:Both overall fall rates and injurious fall rates among Chinese older adults displayed significant regional disparities,and the trends can be partly attributed to the deepening aging structure in China,accompanied by an increase in comorbidities and disabilities.It is imperative to proactively implement fall prevention measures,and resources allocation in the central and western regions should be further strengthened through initiatives such as expanding the coverage of barrier-free facilities and home modifications.Additionally,integrated approaches that combine chronic disease prevention with fall risk management should be further explored in China.Accessible facilities such as building elevators are of crucial significance for aging in place as well as fall prevention.It is recommended to expedite the updated revision of China’s Residential Building Codes and encourage local governments to coordinate the promotion of age-friendly construction in both deteriorated neighborhoods and existing multistory residential areas.The pilot home modification project in Luohu District has achieved initial success,with increased residents’ satisfaction.This study advocates for the early adoption and subsequent upkeep of home modifications among older individuals.To achieve active aging,future adjustments and optimizations of home modification projects should include target populations,involvement strategy,a wider range of personalized services,while exploring the incorporation of fall prevention into community healthcare services.