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Meiho University Graduate Institute of Health Care

Thesis

PREVALENCE OF FALLS AND RELATED FACTORS AMONG ELDERLY ADMITTED IN HOCMON HOSPITAL

Graduate student： Dang Duong Thuy

Supervisor: Dr Chou, Huei-Yin

July 2015

PREVALENCE OF FALLS AND RELATED FACTORS AMONG ELDERLY ADMITTED IN HOCMON HOSPITAL

Graduate student: DANG DUONG THUY

Supervisor: Dr CHOU, HUEI-YIN

Meiho University Graduate Institute of Healthcare

Thesis

A thesis submitted to the Graduate Institute of Health Care of

Meiho University

In partial fulfillment of the requirement for the degree of

Master of Health Care

July 2015

Abstract

With the rapid ageing of the world’s populations, falls in older adultsare a significant public health issue Falls cause serious consequences toelder’s health and quality of life and shoulder heavier costs of health careonto their family as well Although recognized as a young population,Vietnam is now enter the “aging phase” in its population growth Vietnameseelderly have to suffer not only physical impairment due to their old age butalso illnesses, especially non-communicable diseases It could be said thatfalls may be a common health problem among Vietnamese elderly, but dataabout this type of health issue is incomprehensive explored Therefore, toprovide more data on fall prevalence and associated factors for falls amongolder adults, this study was conducted

A cross-sectional study design was employed in this study Threehundred and six older patients visiting Hoc Mon General Hospital from 15April 2015 to 15 May 2015 were recruited in the study A structuredquestionnaire was used to investigate frequency of falls and four groups offactor including biological, behavioral, environmental, and socioeconomicalfactors The statistic package SPSS v16 was applied to entry and analyzedata in this study Frequency tables and mean and standard deviation were

used for descriptive statistic and Chi square test was applied to check therelationships between falls and potential factors A p-value of 0.05 wasconsidered as statistical significance in the present study

The proportion of falling of elderly in this study was 25.49% Forbiological factors, diasystolic, percentage of eosinophile, serumconcentration of cholesterol, serum concentration of HDL-C and LDL-C,balance and gait score significant related to falls in older adults Forbehavioral factors, only sleep disorders had strong association with falls Forenvironmental factors, materials of floor, walking problem in home andwalking problems outside home had strong associations with falls Finally,only educational level was associated with falls

This thesis was carried out at Nguyen Tat Thanh University and MeihoUniversity under the guidance of my supervisor, Dr Chou, Huei-Yin Iwould like to express my deep gratitude to my supervisor and otherprofessors who had spent their precious time to instruct and facilitate mecomplete this thesis I would like to send my thanks to all authors ofpublished works cited in the thesis for providing valuable resources andrelated knowledge during my studying

I would like to give my special thanks to the Director Board, ScienceCouncil, Ethical Council, doctors and nurses of the Hoc Mon GeneralHospital for their endless supports in helping me fufill the thesis My thanksalso gave to officers of the International and Postgraduate TrainingDepartment of Nguyen Tat Thanh University, scientists from the MeihoUniversity, and my classmates who had provided administrative supports andencouragement during my studying

There is no success without supports, more or less or directly orindirectly, from others individuals From the beginning to the end of mystudying, I had received lots of concerns and supports from my best friendsand colleagues I would like to be grateful to participants in the study who

although suffered physical and mental pains as well as numerous concerns indaily life had spent their valuable time to provide important informationthose will be used to help other patients receive better health care All ofthose made a strong motivation to me in completion of the study

Finally, my deep gratitude was sent to my beloved husband and twodaughters, my close friends and colleagues who always encourage, concernand share many aspects of life to me and those made myself more confident

to finish my thesis

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List of Figures

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List of tables

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Chapter 1: Introduction

1.1. Statement of the Problem

With the rapid ageing of the world’s populations, falls in older adultsare a significant public health issue More than one third of persons 65 years

of age or older fall each year, and in half of such cases the falls are recurrent(Nevitt, Cummings, Kidd, & Black, 1989; Tinetti, Speechley, & Ginter,

1988) The risk of falling and fall-related injury proportionately increases asolder adults age Indeed, it is estimated that about 28-35% of people aged of

65 and over fall each year (Blake et al., 1988), whereas 32-42% of olderover 70 years of age experience falling in their life (Downton & Andrews,

1991; Stalenhoef, Diederiks, Knottnerus, Kester, & Crebolder, 2002) Therate of falling is vary from 20% in Japanese older (Yoshida & Kim, 2006) to21.6% in Barbados and 34% in Chile (Reyes-Ortiz, Al-Snih, & Markides,

Doucette, Claus, & Marottoli, 1995) Falls account for approximately 10percent of visits to the emergency department and 6 percent of urgenthospitalizations among elderly persons (Runge, 1993; Sattin, 1992) Manylongitudinal studies indicated that elderly with fall-relate hospitalization have

to pay higher health care cost than nonfallers (Bohl et al., 2010 ; Craig et.al., 2013 ; Dubey, Koval, & Zuckerman, 1998; Finkelstein & Miller, 2006;

Hartholt et al., 2011 )

1.2. Problem: Background and Significance

Although recognized as a young population, Vietnam is now enter the

“aging phase” in its population growth Historically, only 3.71 million olderadults over 60 years was reported in 1979, but the number increased by thetime from 4.64 million in 1989 to 7.8 million in 2006 (General StatisticsOffice, 2007) The projected number of elderly in 2020 will be more than 12million and the proportion of older population is estimated to be 26.1% by

2050 (United Nations, 2007b)

Like any older individual in other countries, Vietnamese elderly have

to suffer not only physical impairment due to their old age but also illnesses,especially non-communicable diseases Most of the elderly have to cope withnon-contagious and chronic diseases such as joint degradation, cardiacproblems and blood pressure, prostate, and urination disorders (United

Nations, 2007a) In addition, risks of disability are also high for theVietnamese elderly, particularly in terms of vision and hearing.

It could be said that falls may be a common health problem amongVietnamese elderly, but data about this type of health issue isincomprehensive explored Several studies showed that the elderly havehighest injury incidence rate compared with other age-group and falls, whichtook place in the home, represented a major proportion of injuries among theelderly (Chuan et al., 2001; Hanh, 1999; M H Hoang, 2004) A recent studyfound that falls are common injuries among older adults and account for thehighest proportion of economic costs for their family (H Nguyen, Ivers, Jan,Martiniuk, & Pham, 2013) However, no study on associated factors for fallswithin older population has been conducted recently (To et al., 2014)

1.3. Aim of this research

To provide more data on fall prevalence and associated factors for fallsamong older adults, I conduct this study There are two objectives must beachieved in this study:

1. Evaluating the fall prevalence among institutionalized older adults

2. Identifying associated factors involving to falls among institutionalizedolder adults

1.4. Research questions

What is the prevalence of falls among elderly visiting Hoc MonGeneral Hospital? What are factors likely to have influence onto falloccurrence among participants?

1.5. Chapter summary

Besides chronic illnesses and physical and mental impairments,elderly population also engage high possibility of falls in their daily life InVietnam, elderly may also have high prevalence of falls; however there arefew studies on fall prevalence among Vietnamese studies Thus, this studyfocus on investigating the prevalence of falls and related factors those couldhave impacts on falls among older adults visiting Hoc Mon General Hospital

Chapter 2: Literature Review

2.1 Introduction

In this chapter, definition of falls was described the first Second part

of the chapter described about epidemiology of falls in elderly in which theprevalence, incidence and consequences of falls in older adults werereviewed comprehensively Additionally, main factors that have impacts onfalls in elderly were mentioned as well Finally, a glance of older population

in Vietnam including health status and fall frequency was added in the finalpart

2.2 Definition of fall

Falls are commonly defined as inadvertently coming to rest on theground, floor or other lower level, excluding intentional change in position torest in furniture, wall or other objects The adoption of a definition is animportant requirement when studying falls as many studies fail to specify anoperational definition, leaving room for interpretation to study participants.This results in many different interpretations of falls (Zecevic, Salmoni,Speechley, & Vandervoort, 2006) For example, older people tend to describe

a fall as a loss of balance, whereas health care professionals generally refer

to events leading to injuries and ill health Therefore, the operationaldefinition of a fall with explicit inclusion and exclusion criteria is highlyimportant

2.3 Epidemiology of falls among elderly

2.3.1 The prevalence and mortality of fall among older age

Among older adults, the risk of falling and fall-related injury is known

to increase with increasing age Approximately 28-35% of people aged of 65and over fall each year (Blake, et al., 1988) increasing to 32-42% for thoseover 70 years of age (Downton & Andrews, 1991; Stalenhoef, et al., 2002).Approximately 30-50% of people living in long-term care institutions falleach year, and 40% of them experienced recurrent falls (Tinetti, 1987)

Given incidence of falls it varies among countries The annualincidence of falls in China was estimated to 6-31% (Gang & Sufang, 2006;

Liang, Y., & X., 2004) while in Japan was 20% (Yoshida & Kim, 2006).Some countries in region of the Americas reported the proportion of elderlyfelt annually ranging from 21.6% in Barbados to 34% in Chile (Reyes-Ortiz,

et al., 2005)

2.3.2 The consequences of falls among elderly

Falls among older adults represent a major public health problemassociated with increased morbidity, mortality, and health care costs.Approximately 10%-15% of falls result in a major injury such as a fracture,serious soft tissue injury, or traumatic brain injury (Orces, 2014; Tinetti &Williams, 1997) Previous studies have demonstrated that fall-relatedfractures treated in hospital emergency departments and hospitalizations forfall-related injuries are increasing among older adults in developed countries(Hartholt, Stevens, Polinder, van Der Cammen, & Patka, 2011; Hartholt et.al., 2010; Orces, 2013) Overall, 44.2% of adults aged 65 years or older withfall-related fractures require hospitalization and hip fractures account for48% of the hospitalizations for fall related injuries among women (Hartholt,

et al., 2010; Orces, 2013) Falls are also associated with restricted mobility;

a decline in the ability to carry out activities such as dressing, bathing,shopping, or housekeeping; and an increased risk of placement in a nursinghome (Kosorok, Omenn, Diehr, Koepsell, & Patrick, 1992; Tinetti &Williams, 1998)

The mortality of falls varies widely among countries Fall fatality ratefor people aged 65 and older in United States is 36.8 per 100,000 population(Stevens, Ryan, & Kresnow, 2007) whereas in Canada mortality rate for thesame age group is 9.4 per 10,000 population (Division of Aging and Seniors

& PHAC Canada, 2005) Rates of fatal falls among men exceed that ofwomen for all age groups and this is attributed to the fact that men sufferfrom more co-morbid conditions than women of the same age (Stevens, et.al., 2007) One study found that men reported poorer health and a greaternumber of underlying conditions than women, which substantially increasedthe impact of hip fracture and consequently increased the risk of mortality(Fransen et al., 2002).

Not only causing injuries and mortality in elderly, falls also cause highhealthcare cost to older patients A longitudinal analysis of total 3-yearhealthcare costs for older adults who experience a fall requiring medical careshowed that fallers are sought resulted in higher costs than for nonfallers for

up to 12 months after a fall, particularly for falls requiring hospitalization(Bohl, et al., 2010 ) A study conducted in Scotland found that the healthcare cost for falling elderly were over £470 million, with 60% incurred bysocial services, mainly providing long-term care Cost per person falling wasover £1720, rising to over £8600 for those seeking medical assistance A hipfracture admission cost £39,490, compared with £21,960 for other falls-related admissions (Craig, et al., 2013 ) In Dutch, falls among older adultsled to a total healthcare cost of €474.4 million, which represents 21% of totalhealthcare expenses due to injuries (Hartholt, et al., 2011 ) In American, the

direct medical costs associated with fall-related injuries were approximately

$19 billion (Finkelstein & Miller, 2006) and are projected to rise as thepopulation ages (Dubey, et al., 1998)

2.3.3 Main risk factors for falls

Although a few falls have a single cause, the majority occur as a result

of a complex interaction of risk factors The risk of falling consistentlyincreases as the number of these risk factors increases (Nevitt, et al., 1989;

Tinetti, et al., 1988) The risk of falling increased in a cohort of elderlypersons living in the community, for example, from 8 percent among thosewith no risk factors to 78 percent among those with four or more risk factors(Tinetti, et al., 1988) Those are categorized into five dimensions: biological,behavioral, environmental, personal and socioeconomic factors (WorldHealth Organization, 2007)

Biological risk factors

Biological factors embrace characteristics of individuals that arepertaining to the human body For instance, age, gender and race are non-modifiable biological factors These are also associated with changes due toageing such as the decline of physical, cognitive and affective capacities, andthe co-morbidity associated with chronic illnesses

Women are more likely than men to fall and sustain fracture (Stevens,Ryan, & Kresnow, 2006), resulting in twice more hospitalizations andemergency department visits than men (Hendrie, Hall, Legge, & Arena,

2003) The reasons for these differences may come from gender-relatedfactors such as women being inclined to make greater use of multiplemedications and living alone (Ebrahim & Kalache, 1996), women's musclemass declines faster than that of men, especially in the immediate few yearsafter menopause, and to some extent women are less likely to engage into thepractice of muscular building physical activities (e.g sports, exercises)though the life course

On the other hand, fall-related mortality disproportionately affectsmen more than women That is attributed from health seeking behaviordiffers according to gender Generally, men are not try to seek medical careuntil a condition becomes severe, resulting in substantial delay to the access

to prevention and management of diseases In addition, men are more likely

to be engaged in intense and dangerous physical activity and risky behaviors– such as climbing high ladders, cleaning roofs or ignoring the limits of theirphysical capacity

Although the relationship between falls and ethnicity and race remainswidely open for research, Caucasians living in the USA have higher risk of

falling In addition, the rate of hospitalization for fall-related injuries is two

to four times higher among the Whites than Hispanics and Asians/PacificIslanders, and about 20% higher than African-Americans (Ellis & Trent,

2001) It is also clear differences observed between Singaporeans of Chinese,Malay and Indian ethnic origins, and between native Japanese oldercommunity dwellers and Japanese-Americans and Caucasians NativeJapanese people have much lower rates of falls than Japanese-Americans andCaucasians

Behavioral risk factors

Behavioral risk factors include those concerning human actions,emotions or daily choices They are potentially modifiable For example,risky behavior such as the intake of multiple medications, excess alcohol use,and sedentary behavior can be modified through strategic interventions forbehavioral change

Medications may be appropriately recommended for the treatment of adisease, but they also have adverse effects; falling is one of the mostcommon adverse events related to drugs (Field et al., 2001; Gray, Mahoney,

& Blough, 1999; Hanlon et al., 1997) Many elderly patients have severalchronic conditions for which multiple medications are prescribed, furtherincreasing the associated risks, including falling Although there is a clear

relation between falling and the use of a higher number of medications, therisks associated with individual classes of drugs have been more variable(Leipzig, Cumming, & Tinetti, 1999) To date, serotonin-reuptake inhibitors,tricyclic antidepressants, neuroleptic agents, benzodiazapines,anticonvulsants, and class IA antiarrhythmic medications have been shown tohave the strongest link to an increased risk of falling (Leipzig, et al., 1999;

Thapa, Gideon, Cost, Milam, & Ray, 1998)

It is believed that moderate physical activities and exercises lowersrisk of falls and fall-related injuries in older age based on the evidence thatthese activities could control weight and contribute to healthy bones,muscles, and joints (Gardner, Robertson, & Campbell, 2000) One studyshowed that regular participation in moderate physical activities couldincrease bone mineral density of postmenopausal women and individualsaged 70 years and over (Day et al., 2002) Activities such as outdoorwalking or mall walking indoors is the most feasible and accessible way ofexercising that improves strength, balance and flexibility leading to areduction on the risk of falling

Eating is a behavioral risk factor that could be contributable for fallingamong older population Deficiencies in consumption of protein, calcium,essential vitamins and water could result in weakness, poor fall recovery and

increase risk of injuries Numerous evidence supports dietary calcium andvitamin D intake improves bone mass among persons with low bone densityand that it reduces the risk of osteoporosis and falling (Tuck & Francis,

2002) Older persons with low dietary intake of calcium and vitamin D may

be at risk for falls and therefore fractures resulting from them (Division ofAging and Seniors & PHAC Canada, 2005) No dairy and fish consumptionwere also associated with a higher risk of falling Use of excessive alcoholhas been shown to be a risk factor of falls Consumption of14 or more drinksper week is associated with an increased risk of falls in older adults (Division

of Aging and Seniors & PHAC Canada, 2005)

Non-adherence or not taking medication is now considered as a riskfactor of falling Effects of uncontrolled medical conditions and ofmedication because of non-adherence can provoke or generate alteringalertness, judgment, and coordination; dizziness; altering the balancemechanism and the ability to recognize and adapt to obstacles; and increasedstiffness or weakness (Division of Aging and Seniors & PHAC Canada,

2005)

Some other risk-taking behaviors increase the risk of falling in olderage as well Those behaviors include climbing ladders, standing on unsteadychairs or bending while performing activities of daily living, rushing with

little attention to the environment or not using mobility devices prescribed tothem such as a cane or walker (Gallagher & Brunt, 1996) Wearing poorfitting shoes or walking in socks without shoes or in slippers without a soleincrease the risk of slipping indoor.

Environmental risk factors

Physical environment plays a significant role in many falls in olderage Factors related to the physical environment are the most common cause

of falls in older people, responsible for between 30 to 50% of them(Rubenstein, 2006) A number of hazards in the home and publicenvironment that interact with other risk factors contribute to falls and fall-related injuries A high particular risk to falls was found in homes includingirregular sidewalks to the residence, loose carpets on the kitchen andbathroom floors, loose electrical wires, and inconvenient doorsteps Poorsurroundings around home such as garden paths and walks that are cracked

or slippery from rain, snow or moss are also dangerous Entrance stairs andpoor night lighting can also pose risks Factors related to the publicenvironment are also frequent causes of fall in older age Most problematicfactors are cracked or uneven sidewalks, unmarked obstacles, slipperysurfaces, poor lighting and lengthy distances to sitting areas and publicrestrooms

Socioeconomic risk factors

Culturally driven expectations affect how people view older personsand falls in older age In some cultures, social participation in older age isnot seen as a virtue: the perception is that old people are meant “to rest” Inpractice, this results in some older people adopting sedentary life often inisolation due to the resignation from social, economic and culturalparticipation, with a resulting increase in the risk of falling Furthermore, inmany societies, falls in older age are perceived as "an inevitable natural part

of ageing" or "unavoidable accidents" All these contribute to fallsprevention not to be considered as a matter of priority on governmentalagendas-leading to a loss of financial provisions required to developsurveillance systems, appropriate interventions and clinical diagnostictechniques, as well as treatment regimens for falls and fall-related injuries

Cultural preferences are also reflected in the design of public andprivate spaces–such as shining floors and steps or staircases withoutappropriate railings Culture also contributes to the stigma of requesting helpwhere that is needed or even unavoidable–for instance, where negotiatingarchitectonic barriers that should not be there in the first place but, if theyare, asking for help should come naturally rather than a reason forembarrassment

Falls in older age has been a neglected public health problem in manysocieties, particularly in the developing world Many health and socialservices providers are unprepared to prevent and manage falls in older age asthey lack sufficient knowledge to treat the conditions that predispose theirconsequences and complications Falls in older age are often iatrogenicconditions – that is, induced by incorrect diagnoses and treatments.Examples include over-prescription of medications that cause side effectsand interactions among the drugs, inadequate dosage and lack of warning tomake older people aware about their effects.

Appropriate training programmes covering knowledge and skills infalls prevention and management should be a priority in primary health care(PHC) settings, where increasing number of patients are older people PHCpractitioners should be well versed in the diagnosis and management of fallsand fall-related injuries In addition, social services that ensure theaccessibility of older people to falls prevention programmes are critical

Isolation and loneliness are commonly experiences by older peopleparticularly among those who lose their spouse or live alone They are muchmore likely than other groups to experience disability and the physical,cognitive, and sensory limitations that increase the risk of falls Isolation anddepression triggered by lack of social participation increase fear of falling,

and vice versa Fear of falling can increase the risk of falls through areduction in social participation and loss of personal contact - which in turnincrease isolation and depression Providing social support and opportunitiesfor older people to participate in social activities to help maintain activeinteraction with others may decrease their risk of falls.

Studies have shown that there is a relationship between socioeconomicstatus and falls Lower income is associated with increased risk of falling(Reyes, Al Snih, Loera, Ray, & Markides, 2004) Older people, especiallythose who are female, live alone or in rural areas with unreliable andinsufficient incomes face an increased risk of falls Poor environment inwhich they live, their poor diet and the fact of not being able to access healthcare services even when they have acute or chronic illness exacerbates therisk of falling The negative cycle of poverty and falls in older age isparticularly evident in rural areas and in developing countries The fallrelated burden to health system will keep increasing unless resources andmoney are allocated in order to provide proper PHC and opportunities toolder people for social participation It is never too late to break this viciouscycle

Personal factors

Older people's attitudes greatly influence whether they will avoid related risk taking behaviors when they participate in activities of dailyliving If older people perceive falls as a normal consequence of ageingexpressed as "seniors will always fall" their attitudes may halt preventivemeasures.

fall-Attitudes of policy-makers determine to a large extent the amount ofresources allocated to falls prevention and development and enforcement ofrelated policies Awareness and attitudes of health professionals to falls areessential to increased incentive in providing appropriate services forpreventing and managing falls in older age

Professionals who design public transportations, such as buses andsubway systems, often do not make them age-friendly, neglecting the risk offalls for older people For example, in some developing countries, buses aredesigned with not enough seats and rails and the steps to climb into them aretoo high As a consequence, older people incur the risk of falling becausethey have to stand or do not have the strength to climb into the buses in thefirst place and cannot properly hold on for support Moreover, the steps onthe public buses are often too high to older people and they might fall whengetting into the bus

Fear of falling is frequently reported by older persons Older peopleare usually under the fear of falling again, being hurt or hospitalized, notbeing able to get up after a fall, social embarrassment, loss of independence,and having to move from their homes Fear can positively motivate someseniors to take precautions against falls and can lead to gait adaptations thatincrease stability For others, fear can lead to a decline in overall quality oflife and increase the risk of falls through a reduction in the activities needed

to maintain self-esteem, confidence, strength and balance In addition, fearcan lead to maladaptive changes in balance control that may increase the risk

of falling People who are fearful of falling also tend to lack confidence intheir ability to prevent or manage falls, which increases the risk of fallingagain (Division of Aging and Seniors & PHAC Canada, 2005)

The ability of coping with falls of both older people and healthprofessionals can lower the risk and consequences of falling Falls areparticularly difficult to manage in PHC settings because health professionalslack enough knowledge and skills Building coping skills of healthprofessionals to prevent and manage falls needs to be emphasized Forexample, health professionals are recommended to teach patients at risk offalling how to get up from the floor; unfortunately clinical experiencesuggests that this is rarely done (Simpson & Salkin, 1993) Physical and

mental management of falls by older people and their family members is alsoimportant Therefore, training programs for older people at high risk offalling need to be encouraged.

2.4 Older population in Vietnam

2.4.1 Health status of Vietnamese elderly

Over time, thanks to improved living standards and a better healthcaresystem, the health status of the Vietnamese elderly has improved, and thusthe percentage of the elderly with fair/good health has increased, while thepercentage of those with ill health has subsequently diminished However,there continue to be a number of serious health challenges for the elderly inVietnam The elderly have to live with the burden of disease due to thenatural occurrence of such at an advanced age; on the other hand, they alsoare exposed to new diseases resulting from socio-economic change.According to United Nation country statement (2007a) there were about 95%

of elderly people suffer from a disease with an average of 2.6 diseasessuffered per elderly person

Most of the elderly have to cope with non-contagious and chronicdiseases such as joint degradation, cardiac problems and blood pressure,prostate, and urination disorders (United Nations, 2007a) There are 53.1%

of the participants reported a bone and joint related disease, making it the

most common disease The second most common disease was cardiovasculardisease (38.5%) and the third most common disease was blood pressure(23.2%) Other diseases had much lower rates of occurrence, with fewdifferences across regions In terms of marriage status, single elderly hadhigher disease rates than the married couples For example, cardiovasculardisease was found in 33.3% of legally separated elderly, 32.0% of widowedelderly, and 21.7% of still married elderly

Risks of becoming disabled are also high for the Vietnamese elderly,particularly in terms of vision and hearing Disabilities make the elderlyuncomfortable, unconfident, and less socially interactive Data from thePopulation and Housing Census 2009 indicate that the percentage of elderlysuffering from disabilities increases with age

2.4.2 Fall prevalence and associated factors among Vietnamese elderly

It could be said that falls may be a common health problem amongVietnamese elderly, but data about this type of health issue isincomprehensive explored Several studies showed that the elderly havehighest injury incidence rate compared with other age-group and falls, whichtook place in the home, represented a major proportion of injuries among theelderly (Chuan, et al., 2001; Hanh, 1999; M H Hoang, 2004) A recent

study found that falls are common injuries among older adults and accountfor the highest proportion of economic costs for their family (H Nguyen, et.al., 2013) However, no study on associated factors for falls within olderpopulation has been conducted recently (To, et al., 2014).

Although a few falls have a single cause, the majority occur as a result

of a complex interaction of risk factors According to the WHO model, riskfactors for falls of elderly are categorized into five dimensions: biological,behavioral, environmental, personal and socioeconomic factors Biologicalfactors embrace characteristics of individuals that are pertaining to thehuman body such as age, gender, and ethnicity Behavioral risk factorsinclude those concerning human actions, emotions or daily choices such aspolypharmacy, smoking, high physical activities Environmental factorsinclude a number of hazards in the home such as irregular sidewalks to the

residence, loose carpets on the kitchen and bathroom floors, and looseelectrical wires; and public environment hazards such as garden paths andwalks that are cracked or slippery from rain, snow or moss.Sociaoeconomical factors such as income, living arrangement, socialsupport, also play an important role in the risk of falls in elderly population.Finally, personal factors including attitudes of elderly, fear of falling,knowledge of falling are often neglected in intervention programs, but theycould be contributable significantly to falls in elderly.

In Vietnam, elderly population is increasing and they have to suffers alots of communicable diseases, chronic health conditions, disabilities andmental impairment as well Falls may be a common health a problem amongelderly, but it is not received much concerns Therefore, lack of data andstudies on falls among this subgroup of population does exist

Chapter 3 Research Methodology

3.1 Introduction

In this chapter all aspects of research methodology are discussed in adetail manner The research design and research framework that are the basefrom which the author develop ideas for the study are mentioned firstly.Sample issues are the next topics that need to be described to outline steps ofsampling and ways of collecting data Data management discussing aboutsystematic error reduction and data analysis highlighting statistic methodsapplied in the study are crucial parts in this chapter Finally a description ofethical issues is also included at the end of the study

3.2 Research design

A descriptive cross-sectional design was used in the study to examinethe prevalence of falls and related factors among elderly who visited HocMon General Hospital from 15 April 2015 to 15 May 2015

3.3 Research framework

According to 2007 WHO report, falls occur as a result of a complexinteraction of risk factors The main risk factors reflect the multitude of

health determinants that directly or indirectly affect well-being (WorldHealth Organization, 2007) Those are categorized into four dimensions:biological, behavioral, environmental and socioeconomic factors Biologicalfactors such as age, gender and race embrace characteristics of individualsthat are pertaining to the human body Behavioral risk factors include thoseconcerning human actions, emotions or daily choices Several behavioralfactors that could be listed here are polypharmacy, alcohol abuse, smokingand regular physical activity Environmental factors encapsulate the interplay

of individuals' physical conditions and the surrounding environment,including home hazards such as narrow steps, slippery surfaces of stairs,looser rugs and insufficient lighting and hazardous public environment such

as poor building design, slippery floor, cracked or uneven sidewalks, andpoor lightening in public places Socioeconomic risk factors are those related

to influence social conditions and economic status of individuals as well asthe capacity of the community to challenge them These factors include: lowincome, low education, inadequate housing, lack of social interaction,limited access to health and social care especially in remote areas, and lack

of community resources (World Health Organization, 2007)

However, 2007 WHO report also mentioned to determinants related topersonal factors (World Health Organization, 2007) Older people's attitudes

greatly influence whether they will avoid fall-related risk-taking behaviorswhen they participate in activities of daily living In addition, attitudes ofpolicy-makers, health professionals, and transportation stakeholders alsodetermine to a large extent the amount of resources allocated to fallsprevention and development and enforcement of related policies Apart fromattitudes, fear of falling and knowledge of management of falls play animportant role in preventing falls among older adults (Division of Aging andSeniors & PHAC Canada, 2005; Simpson & Salkin, 1993)

Based on 2007 WHO report and numerous studies on falls amongelderly (Blake, et al., 1988; Reyes-Ortiz, et al., 2005; Reyes, et al., 2004;

Rubenstein, 2006; World Health Organization, 2007; Yoshida & Kim, 2006),

I build up a study framework for this study There are four groups of factorsrelated to falls will be explore in the study They include biological,behavioral, environmental and socioeconomic factors

For biological factors, six selected factors would be examinedincluding age, sex, balance and gait status, comorbidities, self-reportedgeneral health, and biological indexes Although race or ethnicity is animportant factor that influences fall likelihood of elderly (Blake, et al., 1988;

Downton & Andrews, 1991; Hartholt, et al., 2010; Liang, et al., 2004;

Nevitt, et al., 1991), we did not examine it since there are solely two groups

of ethnicity living in Ho Chi Minh City where we were going to conduct thisstudy

Six behavioral factors including multiple medication use(polypharmacy), sleep disorders, smoking habit, alcohol consumption,physical activity, dietary (number of vegetables and fruit servings daily) andhealth care access (routine physical examination) are added in the group ofbehavioral factors Strong evidence showed that these factors play importantrole in preventing and managing falls among older adults (Blake, et al.,

1988; Downton & Andrews, 1991; Hartholt, et al., 2010; Liang, et al., 2004;

Nevitt, et al., 1991) Inappropriate footwear is suggested in WHO model as abehavioral factor, but this behavior is not popular among Vietnamese elderly

so I exclude from the study

In the terms of environmental factors, I selected factors suggested byWHO model including material made of floors, walking problems in homeand walking safety outside home (World Health Organization, 2007).Although there are no data about these hazards involving in fall probabilityamong Vietnamese elderly, I supposed that they may have high impact on theways of falling within older population

Socioeconomic factors those suggested in WHO model included lowincome and education levels, inadequate housing, lack of social interactions,

limited access to health and social services and lack of community resources.Inadequate housing may be a significant factor related to falls in othercountries, but it is not considered as an important issue in Vietnamesesettings where most of elderly live with their children or other relatives(Giang & Pfau, 2007) Instead we choose living arrangement as one ofsocioeconomic factors that needs to be explored in the study Three factorsincluding lack of social interactions, limited to health and social services andlack of community resources are not chosen as interested factors for similarreasons Instead, we choose marital status, area of residence (rural/urban) aretwo factors may have significant impacts on falls likelihood of elderly Thus,five socioeconomic factors exploring in this study are marital status, livingarrangement, education level, area of residence and household income

Personal factors may be contributable to the risk of falling amongelderly (Simpson & Salkin, 1993; Tinetti, et al., 1988; Yoshida & Kim,

2006) However, since the study conducted in hospital setting, therefore thetime of interview for each of participant is relative short As a result,personal factors (eg attitude and knowledge of elderly) those consume a lot

of time for collecting could not be investigated in this study

Four groups of factors as described in WHO model have interactionrelationships and they all contribute to cause falls in older adults (World

Polypharmacy, sleep disorders, smoking habit, alcohol consumption physical activity, physical examination

Health Organization, 2007) With the aim of cross-sectional description offall prevalence and associated factors, I however solely describe theassociations between four groups of factors and falls occurrence amongparticipants Thus, the study framework would be described in the figure 3.1

Figure 3.1 The study of framework for falls prevalence and associated

factors

3.4 Sampling issues

3.4.1 Sample size

All elderly (≥ 60 years of age) who visited Hoc Mon General Hospitalfor physical examination from 15 April 2015 to 15 May 2015 were thetargets for enrolling in the study

3.4.2 Sampling technique

Because the study had a complete sample, the sampling techniqueshould be full sampling method All elderly who met the inclusion andexclusion criteria were recruited to the study

Disabled elderly and those unable to stand unassisted for a minimum

of one minute were excluded from the study Additionally, elderly who hadmental disorders or cognitive impairments so that they could not completethe questionnaire were excluded Finally, elderly who were not willing totake part in the study would be excluded as well

3.4.4 Sampling procedure

Elderly who visited the hospital for physical examination or examination were asked to provided demographic information (eg age,gender, co-mornid diseases) and take all essential examinations includingclinical examinations (eg height, weight, vital signs), and laboratory tests toidentify the status of their health After completing all clinical requirements,they were invited to participate in the study The data collectors described thepurposes of the study and the benefits of participants if involving in thestudy If subjects voluntarily agree to participate in the study, an informedconsent was obtained The Tinetti test then would be applied to measurebalance and gait score of elderly and fall-related questions would be asked tocollect data about frequency of falls

re-3.5 Data management and data analysis strategy

3.5.1 The data collection instrument

A structured questionnaire was designed on the basis of previousstudies (Azidah, Hasniza, & Zunaina, 2012; Downton & Andrews, 1991) andadvices from Ethical Board of Hoc Mon General Hospital The questionnaireincludes following sections: