Measurement of Fall-Related Psychological Constructs Among Independent-Living Older Adults A Review of The Research Literature

Aging & Mental Health
Vol. 12, No. 6, November 2008, 684699

Measurement of fall-related psychological constructs among independent-living older
adults: A review of the research literature
Delilah S. Moore
a
and Rebecca Ellis
b
*
a
Louisiana State University, Baton Rouge, LA, USA;
b
Department of Kinesiology and Health, Georgia State University,
Atlanta, GA, USA
(Received 19 November 2007; final version received 5 March 2008)
Objectives: Falls and the fall-related psychological concerns associated with these events pose a serious public
health problem among aging adults. The measurement of fall-related psychological concerns can serve as
important endpoints for fall prevention programs, yet there is some confusion regarding the best method of
defining and measuring fall-related psychological constructs. Consequently, greater attention should be devoted
to investigating fall-related psychological constructs and their measurement. Therefore, the purpose of this paper
was to review the published research literature on the measurement of fall-related psychological constructs
among independent-living older adults.
Method: Electronic searches of PubMed, EBSCO, Academic Search Premier, PsycINFO, CINAHL and online
library catalogs were conducted using search terms including but not limited to fear of falling, falls efficacy,
fall-related self-efficacy, balance confidence, fall-related psychological outcome(s) and independent-living.
Results: Each of these constructs is unique, yet instruments are often employed to measure constructs other than
those the instruments were designed to assess. Inconsistencies were also revealed both within and across studies in
terms of providing evidence of validity for these instruments.
Conclusion: Fall-related psychological constructs, although similar in nature, are unique constructs and should be
measured as such.
Keywords: falls; self-efficacy; balance confidence; older adults; psychometric
Falls constitute a common health problem in aging
adults. Specifically, 3540% of adults over 65 years of
age and at least 40% of adults aged 80 years and older
fall annually (American Geriatrics Society, 2001).
Of all older adults that fall, between 10 and 20% fall
again within the same year (Stalenhoef, Diederiks,
Knottnerus, Kester, & Crebolder, 2002). However, the
prevalence of falls is likely to be underestimated, as
only falls that lead to injury or require hospitalization
tend to be reported (Tideiksaar, 1988). Regardless,
falls are a common threat among older adults that can
jeopardize independence and daily functioning, and
lead to premature nursing home admission (Jette,
Branch, & Berlin, 1990; Rubenstein, 2006). In addition
to the individual suffering that falls and fall-related
injuries create for the victim, these events are costly in
terms of health care service utilization. The direct
health care cost of falls and fall-related injuries in the
United States is currently more than $20 billion per
year (Centers for Disease Control and Prevention,
2005). With the aging baby boomer generation,
fall-related costs are expected to exceed $43.8 billion
per year by 2020 (Englander, Hodson, & Terregrossa,
1996).
In addition to the physical and socioeconomic
consequences of falls, falls can also be associated with
various psychological difficulties that can compromise
quality of life (Walker & Howland, 1991). Regardless
of whether a fall causes physical trauma, falls often
create a loss of confidence in mobility in older adults
(Yardley & Smith, 2002). Moreover, fall-related
psychological difficulties can potentially be more
debilitating than sustaining a fall when a loss of
confidence in mobility leads to self-imposed reductions
in physical activity. Activity restriction can further lead
to decreased muscle strength, flexibility, coordination
and progressive functional decline that may cause
a loss of independence and damage to identity, thereby
increasing the risk for future falls (Cumming, Salkeld,
Thomas, & Szonyi, 2000; Lach, 2002; Quigley, Hann,
& Evitt, 2003; Yardley & Smith, 2002). Consequently,
psychological issues are not only important conse-
quences of falls, but determinants of falls.
Early in the study of psychological issues related to
falls, ptophobia (Bhala, ODonnell, & Thoppil, 1982)
and post fall syndrome (Murphy & Isaacs, 1982) were
used to describe a loss of confidence, voluntary
restriction of activity and loss of independence that
occurred as a result of a fall. More recently, researchers
have used terms such as fall-related psychological
traumas (Tinetti, Richman, & Powell, 1990), the fear
of falling syndrome (Chandler, Duncan, Sanders, &
Studenski, 1996) and fall-related psychological
morbidities (Buchner et al., 1993). Today, the most
common and best-studied fall-related psychological
issues are fear of falling, fall-related self-efficacy or
falls efficacy (Tinetti et al., 1990), and balance
confidence (Powell & Myers, 1995). Although these
*Corresponding author. Email: rellis@gsu.edu
ISSN 13607863 print/ISSN 13646915 online
2008 Taylor & Francis
DOI: 10.1080/13607860802148855
http://www.informaworld.com
constructs are the most common fall-related psycho-
logical issues, other related constructs including feared
consequences of falling (Yardley & Smith, 2002),
perceived control over falling (Lawrence et al., 1998)
and perceived ability to manage falls (Lawrence et al.,
1998) have been identified.
Fall-related psychological issues are an important
endpoint for clinical fall prevention trials in older
adults (Jorstad, Hauer, Becker, & Lamb, 2005).
Unfortunately, while the physical and socioeconomic
consequences of falls are easy to identify and measure,
the subsequent psychological effects on confidence
and independence are more ambiguous and harder to
quantify. Consequently, greater attention needs to be
devoted to investigating fall-related psychological
factors vs fall-related physical factors (Myers et al.,
1996). In reviewing the constructs of falls efficacy, fear
of falling and balance confidence, it becomes notice-
able that these constructs are quite similar in nature.
As a result, researchers use several related constructs
interchangeably to measure another construct. For
example, the Falls Efficacy Scale (FES), which was
designed to measure the construct of falls efficacy, has
been used extensively to measure fear of falling (Tinetti
et al., 1990), and the Activities-specific Balance
Confidence (ABC) Scale, which was designed to
measure the construct of balance confidence, has
been used to measure fear of falling (Brouwer,
Musselman, & Culham, 2004) and fall-related self-
efficacy (Davison, Bond, Dawson, Steen, & Kenny,
2005; Li et al., 2002). Needless to say, there is some
confusion regarding the best method of defining and
measuring these fall-related psychological constructs.
In a 2005 systematic review of the measurement of
psychological outcomes of falling, Jorstad and collea-
gues mirrored the sentiment of confusion, and they
noted that researchers must ensure that the construct
they are measuring, as well as the instrument used to
measure it, are in fact the same as the construct that is
being researched.
Another problem in the falls literature lies in the
lack of consistency and quality across studies in
providing psychometric evidence for fall-related psy-
chological instruments. The two most common
methods for examining the psychometric properties
of an instrument are by testing their reliability and
validity. Reliability refers to the consistency, stability
or repeatability of an instrument across repeated
observations or measurements, and it can be exam-
ined using testretest, inter-rater or internal consis-
tency reliability methods. Testretest is used to
determine the stability of an instrument given to the
same individuals at two different points in time, inter-
rater reliability is the extent to which different testers
can yield similar scores for the same individual at the
same time, and internal consistency is an estimate of
the extent to which a set of items on a test measure
the same trait or construct. Validity refers to the
extent to which a test is measuring what it purports to
measure. Recently, there has been a shift towards
providing evidence for the construct validation of an
instrument or using one unifying concept for all
validity evidence (American Educational Research
Association, American Psychological Association, &
National Council on Measurement in Education,
1999) instead of testing instruments using several
different types of validity (e.g. content, concurrent,
convergent, discriminant). Construct validation,
defined as a judgment about the appropriateness of
inferences drawn from test scores regarding individual
standings on a variable called a construct (Cohen &
Swerdlik, 2005; p. 175), is used when there is no gold
standard available to assess the validity of an
instrument (McDowell, & Newell, 1996). One way
to provide evidence of construct validity of an
instrument is to formulate a hypothesis based on
the research literature, then test whether the instru-
ment can accurately discriminate the higher scorers
and lower scorers on the construct. Another less
frequently reported measurement property is sensitiv-
ity (i.e. responsiveness), which is the ability of an
instrument to detect differences between two points
in time (changes over time) within groups (Middel &
van Sonderen, 2002). Evidence of sensitivity is
needed to aid in the selection of an instrument that
will be sensitive to change in a specific context, for
example when evaluating the efficacy of an
intervention.
Therefore, the purpose of this paper was to review
the published research literature on the measurement
of fall-related psychological constructs among inde-
pendent-living older adults. Specifically, this review
focused on examining the measurement properties (i.e.
reliability, validity, sensitivity) of the most common
fear of falling, falls efficacy and balance confidence
instruments.
Method
Studies were included in the review if they utilized an
independent-living older adult population, a fall-
related psychological outcome measure, and were
published between 1966 and 2006. Electronic literature
searches of PubMed, EBSCO, Academic Search
Premier, PsycINFO, CINAHL and the LSU library
online catalog were conducted using search terms
including fear of falling, falls efficacy, fall-
related self-efficacy, balance confidence, fall-related
psychological outcome(s), falls, psychological, con-
sequence of falls, community-dwelling and indepen-
dent-living, as well as all combinations of these terms.
Studies were excluded from the review if they were not
published in a scholarly outlet or if they were not
written in English. Instruments are classified into
fear of falling, falls efficacy and balance confidence
categories based on the title of each scale. Instruments
not falling under one of the three categories are
classified as other fall-related psychological
instruments.
Aging & Mental Health 685
Results
In their review, Jorstad et al. (2005) identified 18 multi-
item measures and eight single-item fall-related
psychological measures. Although the researchers
indicate that a number of measures are available to
assess fall-related psychological outcomes, their results
highlight that many of these measures are merely
variations of the same instrument, but with different
response formats or with several items omitted.
In addition, Jorstad and colleagues found that few of
these instruments demonstrate acceptable measure-
ment properties. Furthermore, not all of the instru-
ments identified in the Jorstad et al. review paper were
designed for use in an independent-living older adult
population. Since the 2005 review, several new fall-
related psychological instruments have been developed
(Huang, 2006; Peretz, Herman, Hausdorff, & Giladi,
2006; Williams, Hadjistavropoulos, & Asmundson,
2005; Yardley et al., 2005) and these were included in
this review. Based on the inclusion criteria for this
review, 19 fall-related psychological measures for
independent-living older adults were identified.
Fear of falling
Fear of falling, defined as a lasting concern about
falling that leads to an individual avoiding activities
that he/she remains capable of performing (Tinetti &
Powell, 1993, p. 36), has been operationalized using
generic, single-item questions as well as multi-item
measures. Single-item measures have been, and still
are, useful in research studies where participants are
categorized into afraid of falling and not afraid of
falling groups. Researchers have argued that measur-
ing fear of falling this way was not effectively capturing
the full psychological impact of falls, thus several
multi-item measures have been developed to assess fear
of falling (see Table 1). Unlike single-item measures,
multi-item measures can differentiate between varying
degrees of fear across a variety of situations (Hatch,
Gill-Body, & Portney, 2003; Howland et al., 1993).
In addition to measuring fear of falling, several of these
instruments also measure other constructs. For exam-
ple, the SAFFE and the mSAFFE also measure
activity restriction.
Survey of Activities and Fear of Falling in the Elderly
(SAFFE)
The SAFFE instrument was developed to assess the
role of fear of falling in activity restriction in a face-to-
face interview format, and it was designed to improve
upon previous fear of falling measures by providing the
capability to distinguish fear of falling that leads to
restriction of activity from fear of falling that
accompanies activity (Lachman et al., 1998). The
SAFFE, also referred to as the SAFE, includes
subdomains of activity level, fear of falling and activity
restriction. Although Lachman et al. (1998) reported
mean scores for the activity level scale (M7.98,
SD2.37) and the activity restriction scale
(M3.98, SD3), many researchers utilizing the
SAFFE have only used or validated the worry scale.
Results of the SAFFE have shown that participants
with higher fear scores engage in fewer activities
(r 0.57) and are more likely to have reduced their
activities over the last five years (r 0.57; Lachman
et al., 1998). The SAFFE may be more useful than the
Falls Efficacy Scale (FES; Tinetti et al., 1990) because
it can differentiate fear of falling that leads to activity
restriction from fear of falling that accompanies
activity (Lachman et al., 1998), but researchers have
criticized it for being too long and burdensome for
use in clinical trials (Lamb, Jorstad-Stein, Hauer, &
Becker, 2005).
Modified version of the Survey of Activities and Fear
of Falling in the Elderly (mSAFFE)
In 2002, Yardley and Smith developed a modified
version of the SAFFE instrument (Lachman et al.,
1998), which was constructed to assess fear of falling
and activity avoidance using a self-report format.
In modifying the scale, several activities were omitted
from the original instrument to improve the discrimi-
nant validity in a higher-functioning sample of com-
munity dwelling older adults (Yardley & Smith, 2002).
The mSAFFE requires participants to view a list of 17
activities and determine whether they would never
avoid, sometimes avoid or always avoid the activity
because they are afraid they might fall over. Mean
scores for the mSAFFE have ranged from 22.8
(Delbaere, Crombez, Vanderstraeten, Willems, &
Cambier, 2004) to 24.0 (Yardley & Smith, 2002). As
of December 2006, no other published studies have
utilized the mSAFFE instrument.
University of Illinois at Chicago Fear of Falling
Measure (UIC FFM)
The UICFFM(Velozo &Peterson, 2001) measures fear
of falling among community-dwelling older adults using
a face-to-face interview format. The development of the
UIC FFM expands on the work of Lusardi and Smith
(1997) by using a Rasch analytic approach to create
a new fear of falling measure. The authors used focus
group interviews to create a list of activities in which
participants were concerned about falling (e.g. step off
a curb, carry a full plate, climb up poorly lit stairs;
Velozo & Peterson, 2001). After initial testing of the
instrument using Rasch analysis, the authors deter-
mined that participants could not discriminate moder-
ately worried fromvery worried or a little worried on
a four-point rating scale (i.e. 1 very worried,
2 moderately worried, 3 a little worried, and
4 not at all worried). Therefore, the final version of
the UIC FFM consists of 16 items scored using a three-
point Likert rating scale (i.e. 1 very worried, 2 mode-
rately worried/a little worried, 3 not worried at all;
686 D.S. Moore and R. Ellis
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Velozo & Peterson, 2001), with raw scores converted to
a logit scale for interpretation (i.e. log-odds metric;
range 3 to 3). The authors found a mean UIC FFM
score of 0.52 logits in their sample (Velozo & Peterson,
2001). One of the strengths of the UIC FFM is that the
items were developed entirely by older adults. As of
December 2006, no other published articles have used
the UIC FFM instrument in an independent-living
older adult population.
Geriatric Fear of Falling Measure (GFFM)
The GFFM (Huang, 2006) was designed to be
a culturally relevant fear of falling instrument for
community-dwelling older adults in Taiwan. More
specifically, the GFFM serves as an outcome measure
to evaluate research interventions and as a quick (i.e.
5 min) screening tool for health care providers (Huang,
2006). The GFFM consists of three subscales that
include psychosomatic symptoms (PS), adopting an
attitude of risk prevention (RP) and modifying
behavior (MB). Using samples of 100 (M age 73.4
years, SD6.7; 55% female) and 384 (M age 74.4
years, SD6.8; 51% female) independent-living
Taiwanese older adults, Huang provided evidence of
the reliability and validity of the GFFM (see Table 1).
The author suggests that this instrument is suitable to
measure fear of falling among rural, urban and
suburban Taiwanese older adults, but more research
is needed to determine the suitability of the GFFM for
community-dwelling older adults in other countries.
One-item instruments
Single-item fall-related psychological measures are
commonly used as a screening tool to determine
whether participants can be categorized into a group
depending on if they possess a fear of falling.
Consequently, the most commonly used single-item
measures include Are you afraid of falling? (Tinetti
et al., 1990), How afraid are you that you will fall in the
coming year? (Howland et al., 1993), How afraid are
you that you will fall and hurt yourself in the next year?
(Lachman et al., 1998), and In general, are you afraid of
falling over? (Yardley &Smith, 2002). Out of the single-
item measures identified, only the Lachman and
colleagues single-item measure has been validated
(Jorstad et al., 2005). Although single-item measures
are widely used, especially in determining the prevalence
of fear of falling, these measures have been criticized.
Specifically, because fear of falling is considered
a multidimensional construct that is made up of
a number of partially independent components, oper-
ationalizing it in terms of a single item can under-
estimate the incidence of fear of falling (Howland et al.,
1993; Lachman et al., 1998; Yardley, 1998).
Falls efficacy
Falls efficacy, or fall-related self-efficacy, refers to the
confidence in ones ability to perform activities of daily
living (ADL) without falling (Tinetti et al., 1990).
Several multi-item measures assess falls efficacy (see
Table 2). Commonly referred to as the gold standard
(Skelton, 2004), the Falls Efficacy Scale (FES; Tinetti
et al., 1990) is the most widely used fall-related
psychological instrument. As a result of its widespread
use, several researchers have modified it to improve its
measurement properties (Buchner et al., 1993; Hill,
Schwarz, Kalogeropoulos, & Gibson, 1996; Tinetti,
Mendes de Leon, Doucette, & Baker, 1994). Almost all
of these authors assert that their version of the
instrument is a modified version of the FES. For
the purpose of this review, all modified versions of the
FES are discussed using the names identified by
Jorstad et al. (2005). Because there are numerous
adaptations of the FES for use in other countries, the
only international adaptation of the FES included in
this review is the FES-I, which is a universal adapta-
tion that is suitable for use in a wide range of cultural
contexts and languages.
Falls Efficacy Scale
The FES (Tinetti et al., 1990) assesses the perceived
efficacy or confidence of avoiding a fall during ADL.
The authors, who originally intended the FES to
measure fear of falling, operationalized a fear of falling
as a low perceived self-efficacy for performing
a specific activity (Tinetti et al., 1990). The FES,
which was the first instrument to expand on the
conceptualization of fear as a dichotomous entity
(Tinetti et al., 1990, p. P239), was based upon
Banduras concept of self-efficacy (Bandura, 1986).
The FES consists of 10 relatively nonhazardous
activities that are rated on a 10-point scale. Tinetti
and colleagues used the FES with two samples of
cognitively intact, independent-living older adult
volunteers and observed mean FES scores of 18.56
(SD9.04; n 18; M age 79 years; 78% female) and
25.11 (SD12.26; n 56; M age 78 years; 75%
female). In addition to the extensive reliability and
validity evidence (see Table 2), the FES can predict
future falls and decline in functional capacity
(Cumming et al., 2000; Hill et al., 1996; Mendes de
Leon, Seeman, Baker, Richardson, & Tinetti, 1996;
Tinetti et al., 1994). Moreover, many studies have used
the FES in clinical interventions and have found it to
be sensitive to change (Cameron et al., 2000; Petrella,
Payne, Myers, Overend, & Chesworth, 2000;
Tennstedt, Howland, Lachman, Peterson, Kasten, &
Jette, 1998; Wolf et al., 1996).
Since the development of the FES, several authors
have demonstrated that fear of falling and falls efficacy
are two separate constructs (Li et al., 2002; McAuley,
Mihalko, & Rosengren, 1997; Tinetti et al., 1994), and
therefore, the FES should be used to measure a more
specific confidence in ability to perform activities
without falling (i.e. falls efficacy), not fear of falling.
However, researchers have continued to use the FES to
measure fear of falling, and have used fear of falling as
T
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a general term to represent a low fall-related self-
efficacy (Wolf et al., 1996; Zhang, Ishikawa-Takata,
Yamazaki, Morita, & Ohta, 2006). Inappropriate use
of the instrument as a jack of all fall-related
psychological trades has created widespread confusion
about the true meaning of, and difference between,
these constructs. This has made it very difficult to
interpret and compare studies that have used the FES.
In addition, researchers have criticized the FES for
its 10-point numerical response format and its inclu-
sion of a narrow scope of simple daily activities
(Lachman et al., 1998; Powell & Myers, 1995).
Although the FES may be better suited for lower
functioning, frail older adults in which this range of
activities is appropriate, the FES fails to accurately
capture the fall-related concerns of more active, higher-
functioning older adults who score at the higher ends
of the self-efficacy continuum (Lusardi & Smith, 1997).
For this reason, several researchers have attempted to
solve this problem by creating their own instrument to
measure fear of falling or falls efficacy by adding or
omitting items from the original version (Buchner
et al., 1993; Hill et al., 1996; Lusardi & Smith, 1997;
Parry, Steen, Galloway, Kenny, & Bond, 2001; Powell
& Myers, 1995; Tinetti et al., 1994; Velozo & Peterson,
2001). Consequently, there are several variations of the
FES available.
Amended FES (amFES)
The amFES (Buchner et al., 1993) is a modified version
of the original FES (Tinetti et al., 1990) that assesses
falls-related self-efficacy among older adults partici-
pating in the Frailty and Injuries: Cooperative Studies
of Intervention Techniques (FICSIT) trials. The
authors of the amFES modified the wording of the
FES from how confident to how concerned partici-
pants are about the possibility of falling when
performing 10 mainly indoor, home-based activities
such as getting in and out of a chair and preparing
simple meals (Buchner et al., 1993). A four-point
Likert scale (range 14) was also adopted to alleviate
difficulties that many older adults faced when using the
10 levels of response categories of the original FES
(1 not at all concerned, 2 somewhat concerned,
3 fairly concerned, 4 very concerned; Buchner
et al., 1993).
In addition to the evidence of validity (see Table 2),
the amFES is sensitive to change as evidenced by mean
amFES scores that were significantly lower for a Tai
Chi group (vs a control group) after 8 months (18.4 vs
20.5, p 0.01) and 12 months of training (17.6 vs
21.2, p50.001; Sattin, Easley, Wolf, Ying, & Kutner,
2005). Although the amFES is a modified version of
the FES and the authors of the amFES contend that it
measures falls efficacy, in a review comparing fall-
related psychological outcome measures, Jorstad et al.
(2005) indicate that it may more appropriately relate to
fear of falling because of the change from confidence
to concern in the scale anchors, therefore making it
difficult to discern if the amFES is a measure of falls
efficacy or fear of falling. As of December 2006, no
other published studies were found using the amFES in
an independent-living older adult population.
Revised FES (rFES)
Tinetti et al. (1994) slightly modified the original FES
(Tinetti et al., 1990) so that, when participants were
asked how confident they felt in performing each
activity without falling, high scores would correspond
with high confidence and low scores would correspond
with low confidence (0 not at all confident,
10 completely confident). The rFES, which is admi-
nistered in an interview format, includes 10 relatively
nonhazardous activities rated on a 10-point scale. The
authors observed mean rFES scores of 84.9
(SD20.5) with approximately 7.8 items (SD2.9)
in which participants reported a confidence level of
seven or higher (N1103 community-dwelling older
adults; M age 79.6 years, SD5.2; 73% female; 84%
white). Possibly because other variations of the FES
exist, the rFES has not been widely used. Aside from
Tinetti and colleagues, few investigators have reported
evidence for the psychometric properties of the rFES
(Lachman et al., 1998; Rosengren, McAuley, &
Mihalko, 1998).
Modified FES (mFES)
The mFES (Hill et al., 1996), which the authors contend
assesses fear of falling, was expanded to include four
additional activities that induced greater levels of fear
(i.e. using public transport, crossing roads, light
gardening or hanging out the washing and using
front or rear steps at home; Hill et al., 1996). Compared
with the original 10-item version of the FES, the
mFES is an interviewer-administered questionnaire
that consists of 14 items rated on a 10-point visual
analog scale (0 not confident/not sure at all, 5 fairly
confident/fairly sure, and 10 completely confident/
completely sure). Unlike the original FES, higher
scores reflect higher falls efficacy and lower fear of
falling. In a sample of 111 healthy community-dwelling
older adults (M age 74 years) and 68 older adults
referred to a balance clinic (BC; M age 74 years), the
authors observed mean mFES scores of 9.76
(SD0.32) and 7.69 (SD2.21), respectively (Hill
et al., 1996).
The mFES exhibits less skew than the original
version of the FES (2.4 (mFES), 3.3 (FES); Hill
et al., 1996). Moreover, the mFES has been used in
falls prevention programs (Cameron et al., 2000; Cheal
& Clemson, 2001; Zijlstra, van Haastregt, van Eijk, &
Kempen, 2005) and has been recommended as
a standard psychological consequence of falling
measure by the ProFaNE consensus (Lamb et al.,
2005). Further, the authors suggest that the mFES can
be a useful instrument for evaluating fear of falling
among older adults with balance or mobility
dysfunction (Hill et al., 1996). Although the mFES
seems to measure falls efficacy because it is a modified
version of the FES and Jorstad et al. (2005) classify
it as such, the authors of the mFES suggest that it
is better suited to measuring fear of falling (Hill et al.,
1996).
FES-International (FES-I)
The FES-I (Yardley et al., 2005) is the newest version
of the FES scale that was designed for use in a range of
cultural contexts. The FES-I, which can be adminis-
tered in a structured interview or self-report format,
was developed to expand upon the original FES by
including six new items (e.g., walking on slippery,
uneven or sloping surfaces, visiting friends or relati-
ves, going to a place with crowds; Yardley et al.,
2005). According to Yardley and colleagues, neither
the FES nor any of its variations have evaluated the
effect of fear of falling on social life (i.e. fear of the
social consequences of falling, such as embarrassment)
that independently contributes to avoidance of activity
(Yardley & Smith, 2002). The FES-I items are rated on
a four-point scale (1 not at all concerned to 4 very
concerned) that is similar to the format used by Tinetti
et al. (1994). In a sample of 704 community-dwelling
older adults (M age 74.7 years, SD7.1; 72.9%
female), the authors observed mean FES-I scores of
30.92 (SD12.15) and 34.57 (SD14.5) in partici-
pants who received questionnaires by mail and in
interview formats, respectively (Yardley et al., 2005).
Although only one published study as of December
2006 has examined the psychometric properties of the
FES-I, it appears to have close continuity with the
original FES (Yardley et al., 2005; see Table 2 for
reliability and validity evidence). Interestingly, the
FES-I is named the falls efficacy scale, but the
authors contend that it actually measures concern
about falling.
Balance confidence
Balance confidence, which is defined as the confidence
in ones ability to maintain balance and remain steady
(Powell & Myers, 1995), is a situation-specific form of
self-efficacy that relates to perceived balance ability. At
first glance, it appears that measuring balance con-
fidence is less complex than measuring fear of falling or
falls efficacy because there is only one instrument that
has been used extensively to measure the construct (i.e.
Activities-specific Balance Confidence scale, ABC;
Powell & Myers, 1995). In addition to the ABC scale,
several adaptations of the instrument also exist (see
Table 3), including a new six-item version (ABC-6;
Peretz et al., 2006). The original instrument has also
been referred to as the ABC-16 to avoid confusion with
the modified versions (Peretz et al., 2006). As with the
FES, there are also several international adaptations of
the ABC Scale (i.e. ABC United Kingdom version,
ABC-UK; Parry et al., 2001; ABC Canadian French
version, ABC-CF; Salbach, Mayo, Hanley, Richards,
& Wood-Dauphinee, 2006; ABC Chinese version; Hsu
& Miller, 2006). For the purpose of this review, the
adaptations developed for use in specific countries are
not discussed. Another instrument, the Balance Self-
Perceptions Test (Shumway-Cook, Gruber, Baldwin,
& Liao, 1997b), was developed to assess perceived
confidence in balance-related tasks, but has not been
widely used. With fewer instruments available to assess
balance confidence, choosing an instrument to measure
this construct is not as daunting a task as choosing an
instrument to measure falls efficacy or fear of falling.
Nevertheless, balance confidence has been used to
measure fear of falling (Kressig et al., 2001; Peretz
et al., 2006; Williams et al., 2005) and fall-related
efficacy (Li et al., 2002), which only adds to the
complexity of the situation and further blurs the
boundaries between these fall-related psychological
constructs.
Activities-specific Balance Confidence Scale (ABC)
The ABC (Powell & Myers, 1995) is an interviewer-
administered questionnaire that assesses confidence in
balance ability while performing several ADL. The
ABC scale was developed to address several limitations
of the FES and it includes a broader range of
functional activities than the FES that make it more
sensitive to detecting loss of confidence for higher-
functioning individuals (McAuley et al., 1997; Powell
& Myers, 1995). The ABC consists of 16 items, rated
on a 0100% response continuum (Bandura, 1977,
1991), in which participants rate their level of
confidence (0%no confidence; 100%complete
confidence) in maintaining balance and remaining
steady when performing each of the activities. The
authors observed a total mean ABC score of 59.6
(SD27.7), with means of 80.9 and 38.3 for groups of
high (n 30; M age 71.4 years) and low mobility
(n 30; M age 77.7 years) community-dwelling older
adults, respectively (Powell & Myers, 1995). The ABC
has been widely used in fall-related research and
evidence for its measurement properties are displayed
in Table 3.
Six-item version of the Activities-specific Balance
Confidence Scale (ABC-6)
The ABC-6 (Peretz et al., 2006) includes only the most
challenging activities from the original version, and it
was intended to be a shorter questionnaire that can be
used as a quick screening tool in applied settings
(Peretz et al., 2006). In developing this instrument,
Peretz and colleagues used a sample of 19 older adults
with Parkinsons disease (PD; M age 72 years,
SD6; 63% male), 70 older adults with higher-level
gait disorders (HLGD; M age 78 years, SD5; 74%
female), and 68 healthy independent-living older adults
(M age 75 years, SD6; 54% female). The original
16-item version of the ABC was reduced by identifying
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.
the scale items in which patient groups rated highest
levels of fear (i.e. items in which HLGD and PD
groups exhibited lowest scores). The final version of
the ABC-6, which was designed to be administered in
a face-to-face interview format, asks participants to
rate his or her level of confidence lost in the course of
the following daily activities . . . (e.g. standing
on a chair to reach, walking on icy sidewalks) on
a 0100% scale. Observed mean scores were 92.7 for
healthy older adult participants, and 45.5 and 68.9 for
the HLGD and PD groups, respectively (Peretz et al.,
2006).
The authors of the ABC-6 concluded that the ABC-
6 is comparable to the original ABC and it is useful in
assessing fear of falling among healthy and patient
populations. Although the ABC-6 purports to measure
balance confidence, the authors who developed it refer
only to its use for measuring fear of falling. They
conclude that it can be useful for measuring fear of
falling in research and applied or clinical settings, but
they do not provide any information or discuss the
implications of using it to measure balance confidence.
As of December 2006, no other authors have examined
the ABC-6 for the purpose of measuring balance
confidence in an independent-living older adult
population.
Modified version of the Activities-specific Balance
Confidence Scale
The modified version of the Activities-Specific Balance
Confidence Scale (Williams et al., 2005) is a newer
version of the ABC (Powell & Myers, 1995) that
assesses balance confidence and fear of falling.
Williams and colleagues modified the original ABC
by replacing the 0100% rating scale with a 21-point
horizontal box scale (Jensen, Miller, & Fisher, 1998).
Using the 21-point scale, the 16 items from the
original ABC were rated using a continuum with 21
numbers ranging from 0 to 100 (0 no confidence,
100 complete confidence). Mean scores for a group
of 128 older participants (M age 73.6 years,
SD5.9; 66% female) and a group of 122 participants
who were 55 years and younger (M age 34.3 years,
SD12.5; 67% female) were 1226.22 (SD337.12)
and 1449.64 (SD244.93), respectively. As of
December 2006, no other published studies have
utilized the ABC-6.
Williams and colleagues used fear of falling and
low balance confidence interchangeably. The authors
argued it was reasonable to assume that both would
lead to avoidance of activities, and thus decondition-
ing (Williams et al., 2005, p. 64). After reviewing the
available instruments used to measure balance con-
fidence, it appears that balance confidence, or at least
the measurement of balance confidence, may not be
a construct in its own right. For instance, it could be
argued that all of the balance confidence instruments
should be placed under an umbrella fear of falling
category or possibly under the falls efficacy category
because they were developed or used to measure fear of
falling or fall-related efficacy. Similarly, Powell and
Myers (1995) developed the ABC to create an
instrument that had better properties and assessed
a wider range of activities than the FES. In fact, other
researchers have referred to the ABC as an extended
version of the FES (Li et al., 2002). Therefore, it is
possible that a distinct balance confidence construct
may not be necessary. More research is needed to
determine the exact relationship between these
constructs.
Balance Self-perceptions Test
The Balance Self-perceptions Test (Shumway-Cook
et al., 1997b) is a modification of the rFES (Tinetti
et al., 1994) that consists of 20 items in which
participants are asked to self-report their degree of
confidence on a scale of 15 (1 no confidence,
5 extreme confidence) for performing ADL and
instrumental ADL without experiencing fear or loss
of balance. A 12-item version has also been utilized
(Shumway-Cook, Baldwin, Polissar, & Gruber, 1997a),
and scores from this version of the instrument range
from 0 to 60. The 20-item instrument has assessed the
effects of a multidimensional exercise program on
balance, mobility, and falls risk in 105 community-
dwelling older adults with a history of two or more
falls in the past six months (control: n 21, M age
78 years, 67% female; partially adherent exercise
group: n 32, M age 80 years, 78% female; fully
adherent exercise group: n 52, M age 79 years, 73%
female). Shumway-Cook et al. (1997b) reported mean
scores on pre- and post-tests for the control group of
64.1 (SD16.7) and 59.8 (SD15.7), respectively, for
the partially adherent group of 54.8 (SD12.6)
and 61.1 (SD14.7), respectively, and mean scores
for the fully adherent group of 57 (SD12.9) and
70.4 (SD13.2), respectively. Additional evidence of
validity is presented in Table 3.
Other fall-related psychological instruments
In addition to the three constructs discussed in the
previous sections, several other less common fall-
related psychological instruments exist that are
intended for use in an independent-living older adult
population (see Table 4). Fall-related psychological
instruments that do not fall within the categories of
fear of falling, falls efficacy or balance confidence
include the Consequences of Falling Scale (CoF;
Yardley & Smith, 2002), the Gait Efficacy Scale
(GES; McAuley et al., 1997), the Mobility Efficacy
Scale (MES; Lusardi & Smtih, 1997), the Perceived
Control Over Falling scale (PCOF; Lawrence et al.,
1998), and the Perceived Ability to Manage Falls scale
(Lawrence et al., 1998). Although all five of these scales
have demonstrated adequate reliability, as of
December 2006 only the MES has been validated.
T
a
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4
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Discussion
Evidence from the published research literature (from
1966 to 2006) does not point to one unanimous
solution to the measurement issue among the fall-
related psychological constructs. Several of the issues
that make deciphering the literature so challenging
include inappropriate operationalization and mea-
surement of constructs, inconsistencies in evidence of
validity across studies and different recommendations
as to which instrument, if any, should serve as
a criterion or gold standard fall-related psycholo-
gical measure. The research findings indicate that
several fall-related psychological instruments are
being employed to measure constructs other than
those the instruments were designed to assess. Before
it can be determined what the most important
constructs are to measure and which instruments
are the best to use in falls prevention efforts, it is
first necessary to determine and quantify the under-
lying relationship between fear of falling, falls
efficacy, and balance confidence and other fall-
related psychological constructs. Several studies
have attempted to clarify the relationship between
fear of falling and falls efficacy. Results from studies
collectively indicate that each of these constructs are
unique, yet related constructs, and evidence for this
are consistent moderate correlations observed
between instruments (Hotchkiss et al., 2004;
Lachman et al., 1998; Li et al., 2002). Although
the findings from these studies have helped us to
understand the relationship between fear of falling
and falls efficacy, researchers have continued to use
falls efficacy instruments to measure fear of falling
(e.g., using the FES, amFES, or mFES to measure
fear of falling; Buchner et al., 1993; Hill et al., 1996;
Wolf et al., 1996; Zhang et al., 2006).
One way to make sense of the confusion is to use
Banduras Self-Efficacy Theory (SET; Bandura, 1986)
as a framework to better understand how constructs
such as self-efficacy and fear of falling are related. Self-
efficacy, which is a component of the SET, refers to an
individuals belief or confidence in his or her own
capabilities to perform a specific activity successfully
(Bandura, 1986) and is important for maintaining
physical activity levels and preventing functional
decline (Myers, Fletcher, Myers, & Sherk, 1998).
Because it has been argued that self-report global
states such as fear are often poor predictors of actual
behavior (Bandura, 1982), and because researchers
suspected that fear of falling was not effectively
capturing the full psychological impact of falls,
Tinetti et al. (1990) came up with an instrument that
assessed a specific fall-related form of self-efficacy (i.e.
falls efficacy) that was based on the SET (Tinetti et al.,
1990). Originally, fear of falling and falls efficacy were
considered isomorphic constructs (Tinetti & Powell,
1993; Tinetti et al., 1990), and according to this school
of thought, fear of falling could be measured using falls
efficacy measures, and consequently a high fear of
falling was synonymous with a low falls self-efficacy.
Tinetti and colleagues and other researchers later
found that, although there were significant associa-
tions between fear of falling and falls efficacy, both
measures essentially tapped into different constructs
(Li et al., 2002; McAuley et al., 1997; Tinetti et al.,
1994). Furthermore, Li and colleagues found that fall-
related self-efficacy plays a mediational role in the
relationships between fear of falling and functional
outcomes (Li et al., 2002) and fear of falling and
exercise (Li, Fisher, Harmer, & McAuley, 2005).
Despite these attempts to clarify the relationship
between falls efficacy and fear of falling, the confusion
among the fall-related psychological literature persists.
In line with Banduras SET (1986), measures of
efficacy should be composed of items that are specific
to the situation or task of interest in the investigation.
Future research efforts utilizing fall- or balance-related
efficacy measures need to follow this SET principle
instead of using one fall-related psychological measure
as a broad, overarching measure to assess all efficacy-
related constructs. Because efficacy measures are
situation specific, it seems that the best approach to
measuring fall-related psychological outcomes is to
include items in our studies that examine a specific
dimension of fall-related efficacy such as falls efficacy,
balance confidence, gait efficacy, perceived control
over falling, consequences of falling, and so on.
Another issue that has created confusion in the
literature lies in the lack of consistency across studies in
providing evidence of validity of fall-related psycholo-
gical instruments. One of the inconsistencies across
studies can be attributed to the determination of an
appropriate criterion measure, if one exists. For
example, in some cases researchers have used the
FES as a criterion measure (Huang, 2006; Powell &
Myers, 1995), and in other cases, quality of life
variables have been used as a criterion (Lachman
et al., 1998).
This review of the literature revealed inconsisten-
cies within and across studies in providing evidence of
validity of fall-related psychological instruments. For
example, some researchers reported examining the
criterion validity of an instrument in their abstract, but
indicated in the manuscript that it was construct
validation (see Lachman et al., 1998). Studies have also
compared the same or similar instruments, while one
study labels the evidence for validity as concurrent,
and the other labels it convergent. For example, in
correlating a newer instrument (i.e. ABC, SAFFE,
GFFM) with the FES, some studies claim to provide
evidence of the convergent validity of the instrument
(Hotchkiss et al., 2004), while other studies have
identified it as concurrent (empirical) validity
(Huang, 2006; Powell & Myers, 1995). Perhaps even
more distressing is that the only review article on fall-
related psychological measures (Jorstad et al., 2005) is
not consistent in its classification of different types of
validity. Part of the confusion arises as Jorstad and
colleagues attempt to identify which type of validation
a study provided when the study did not state they
were providing evidence of validity (Jorstad et al.,
2005). Although this is not necessarily a problem in its
own right, Jorstad and colleagues incorrectly refer-
enced many types of validity as convergent when, with
the movement to a more unified concept of providing
validity evidence (American Educational Research
Association, American Psychological Association, &
National Council on Measurement in Education,
1999), the type of validity should more appropriately
have been referred to as construct. For example, when
Li et al. (2002) correlated the SAFFE with the SF-12,
ADL, physical performance and balance measures
(r 0.190.04), Jorstad and colleagues identified
these correlations as providing evidence of the con-
vergent validity of the SAFFE. According to the
definition, convergent validity would be evidenced if
these variables were measuring the same or a similar
construct as the SAFFE instrument, which measures
fear of falling. Clearly, health-related quality of life,
ADL, and physical and balance measures are not
measures designed to assess fear of falling or a similar
construct. Therefore, this example should more appro-
priately be identified as construct validity in the broad
sense. This also becomes a problem and further plagues
the literature because many researchers look to review
articles as a frame of reference. Regardless of whether
studies have incorrectly identified the type of validity
they are claiming to report, many are not clear in
indicating the methodology used to provide evidence of
a certain type of validity. When the validity evidence
presented is not clearly stated or is not consistent with
the literature, more confusion results and it is
impossible to replicate findings and determine what
still needs to be investigated.
The research findings have also attempted to direct
our focus to the use of one instrument over another.
Unfortunately, there has been no agreement among
these studies, and each recommendation has been
different from the previous recommendation. Some
researchers have considered the FES to be the gold
standard fall-related psychological measure (Skelton,
2004), although others are quick to call attention to its
limitations (Lusardi & Smith, 1997; Parry et al., 2001;
Yardley et al., 2005). Some researchers have concluded
that the best approach to handling this measurement
issue is to develop a new instrument that addresses the
limitations of previous instruments (FES, ABC,
SAFFE, etc.). Although this appears to be
a satisfactory solution to the problem, developing
a new instrument only creates more confusion in the
literature because now, instead of choosing between
two or three instruments, researchers have to choose
between five or more. Further, if researchers are
modifying the FES and not coming up with a unique
name for their instrument (i.e. all studies calling their
version the modified FES) or they are not referencing
the questions they use, there will be inconsistencies
when researchers attempt to replicate their instrumen-
tation for future studies. More problems arise when
new instruments are developed because validation
studies are slow to appear, if they ever appear, to
quantify the appropriateness of the new instrument for
measuring the intended construct.
While studies have compared the psychometric
properties of several fall-related psychological mea-
sures, they have focused primarily on the most widely
used instruments (i.e. FES, ABC and SAFFE). To
determine which instrument or instruments perform
the most favorably against all of the available
instruments, it is imperative to know how the newer
instruments compare with the older measures. In an
attempt to identify a standardized, outcome data set of
fall-related measures for fall prevention trials, the
ProFaNE consensus recommended conceptualizing
psychological consequences of falls in terms of a fall-
related self-efficacy measure (Lamb et al., 2005).
Because they felt that an appropriate fall-related
psychological measure should be a self-efficacy-based
measure with a solid theoretical foundation in the SET,
they recommended using the mFES (Hill et al., 1996)
as a standard against which new measures can be tested
(Lamb et al., 2005). Since the 2005 ProFaNE
consensus, other researchers have supported the use
of self-efficacy measures based on the SET, and have
recommended the FES and the FES-I as universal fall-
related self-efficacy measures (Yardley & Kempen,
2006).
More recently, researchers have suggested the
incorporation of an outcome expectancy measure as
a supplement to self-efficacy measures for evaluating
fall prevention interventions (Lach, 2006).
Consequently, the CoF scale (Yardley & Smith, 2002)
was identified as a potential outcome expectancy
measure. Although the ProFaNE consensus attempted
to move researchers towards using a standardized fall-
related psychological measure for all fall-prevention
trials, it is too soon to tell whether their recommenda-
tions will be followed. In line with the ProFaNE
consensus, future research efforts need to identify
a standardized outcome measure(s) for each specific
fall-related psychological construct to facilitate com-
parisons between studies. Based on the collective
results from published fall-related psychological stu-
dies, the mFES or the FES-I, pending more research
support, and the ABC could be recommended to
measure falls efficacy and balance confidence con-
structs, respectively. To date, the available evidence
relating to fear of falling measures does not indicate
one measure as being superior to another. Although
there is more evidence to support the validity of the
SAFFE instrument as compared with the other fear of
falling measures, it is cumbersome to administer and
therefore would not be recommended for use in many
situations, such as in a community-based falls risk
screening. Alternatively, the mSAFFE could be
recommended as a measure of fear of falling-related
activity restriction, pending more research support.
Because the instruments identified in the other
category of fall-related measures encompass a wider
range of efficacy-related constructs, an instrument
from this category should be selected based on the
specific goal and purpose of the intended research. As
only one of these measures has been validated, more
research is needed in this area. Another potential
direction for future research could be to combine
several questions from each of the constructs into
a solitary questionnaire in which researchers could
measure all fall-related psychological constructs at one
time.
By employing measures that can accurately char-
acterize which fall-related psychological issues older
adults face, appropriate socialcognitive intervention
strategies can be used to enhance participants sense of
efficacy for falls, balance, gait, etc., while reducing fear
of falling and other negative consequences of falls.
In so doing, falls prevention interventions can be
tailored to meet not only the physical, but also the
psychological needs of the participants.
Acknowledgements
This manuscript is a modified version of the first authors
General Examination document. The General Examination
document was completed in partial fulfillment of the
requirements for the degree of Doctor of Philosophy in the
Department of Kinesiology at Louisiana State University
under the advisement of the second author. We would like
to thank the General Examination committee members,
Drs Maria Kosma, Amelia Lee, Melinda Solmon, Kevin
McCarter and Susanne Lauer for their helpful comments on
a previous version of this document.
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Aging & Mental Health

Vol. 12, No. 6, November 2008, 684699

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