Archives of

1. Introduction
he population aged ≥60 years is growing
faster than any age group. In 2019, the number
of individuals aged ≥60 years was equal
to 1 billion. This number will increase to 1.4
billion by 2030. This process of change will
accelerate in the coming decades, especially in developing
countries. According to the World Health Organization
(WHO), the population aged ≥60 years in Iran will
increase to 21.7% in 2050 [1, 2]. Aging is a risk factor
for cardiovascular disease; the prevalence of cardiovascular
disease is higher in the elderly, compared to the
general population [3]. A report by the WHO suggested
that 31% of the world’s deaths are due to cardiovascular
disease and 75% of deaths due to cardiovascular disease
occur in low- and middle-income countries [4]. Cardiovascular
disease is among the main causes of disability
in the elderly and is the most common factor for their
referral to healthcare centers [5]. Cardiovascular disease
also elevates the risk of falls in the elderly [6]. In a study
by Elsamahy et al., heart problems and hypertension increased
the risk of falls in the elderly by 7.4% and 76.8%,
respectively [7]. A fall can be considered as a sudden and
unintended change in an individual’s posture, causing
them to be on a lower surface, on an object, or on the
floor [8]. Every year, one-third of individuals aged over
65 years and a half those aged ≥80 years, experience a
fall [9, 10].
Fear of falling is considered a mental state; in different
societies, 25%-55% of the elderly express it even without
a history of falling [9, 11]. Fear of falling is defined as
a constant concern about falling, leading to the Activities
of Daily Living (ADL) avoidance and physical problems
[12]. The causes of falls are multifaceted. In addition to
physical injuries, psychological harms are also associated
with and affect the fear of falls [13-15]. Various
studies revealed that older people are more vulnerable
to decreased happiness. Accordingly, such conditions
predispose them to various mental health disorders, such
as depression and anxiety [16]. The elderly with a high
sense of wellbeing experience greater positive emotions.
They also present a positive assessment of the past and
the events and happenings around them. As a result, the
individual has further psychological resources to prevent
and cope with problems. However, the elderly with low
wellbeing experience more depression and anxiety [16].
In the study by Painter et al., fear of falling was significantly
associated with problems, such as depression,
anxiety, and decreased physical activity. These factors affect
the fall and fear of it and are among its predictors
[9]. Additionally, depression increases the odds of falls
in the elderly. Salarvand et al. identified depression as a
risk factor for falls in the elderly [17]. Findings from a
review by Theodos also revealed that patients who are
depressed are >30 times more prone to fall, compared to
the patients without such conditions [13].
Considering the above-mentioned points and that no
study has been conducted in Tabriz City on the fear of
falling among the elderly with heart disease, this study
aimed to determine the relationship between fear of falling,
mental wellbeing, and depression in the elderly with
cardiovascular disease.
2. Materials and Methods
This descriptive-analytical study was performed on
283 elderly with cardiovascular disease in Tabriz City,
Iran. The study population included all individuals, aged
≥60 years living in the urban and rural areas of Tabriz
who were covered by urban and rural health centers. The
convenience sampling method was used to select the desired
sample per the inclusion and exclusion criteria as
well as the necessary sample size. The inclusion criteria
included the following: an age of ≥60 years, literacy or
ability to speak, no memory impairment, having a health
record in urban and rural healthcare centers, willingness
to participate in the study, and having cardiovascular diseases.
Moreover, the exclusion criteria were the lack of
health records in the relevant healthcare centers, presenting
no cardiovascular disease, and discontinuing participation
in the study. After obtaining written informed
consent forms from the participating elderly, the required
data were collected using the Center of Epidemiological
Studies-Depression Scale (CES-D), the Falls Efficacy
Scale International (FES-I), and the World Health Organization-
Five Well-Being Index (WHO-5).
The CES-D is an international tool for measuring depression;
it is among the most frequently applied tools
for measuring depression among the elderly. This scale
primarily focuses on the psychological and cognitive
symptoms of depression. The questionnaire includes 3
subscales addressing depression, 4 subscales for physical
complaints, 2 subscales for happiness, and one subscale
for irritability. Each question has a two-part answer (yes/
no) and is scored as 0 or 1. Therefore, the total score of
the questionnaire ranges between 0 and 10. This questionnaire
has been validated in Iran by Malakouti and associates.
The internal consistency of this scale per Cronbach’s
alpha coefficient and test-retest method was measured to
be 0.85, 0.65, and 0.49, respectively. Analyzing the factors
of this scale by the Varimax rotation method identified
T
Papi Sh, et al. Fear of Falling, Mental Wellbeing and Depression in the Elderly. Arch Hyg Sci. 2021; 10(2)155-162.
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two factors of depression and interpersonal relationships.
The depression factor (CESD-8) can be considered as a
short form with a Cronbach’s alpha coefficient of 0.87 and
a correlation coefficient of 0.99. By performing the ROC
test, a cut-off point of 5 was obtained for this form with
82% sensitivity and 70% specificity [18]. The WHO-5 is
a one-dimensional scale. Besides, each question provides
unique information about the level of wellbeing. The tool
was first presented at the WHO meeting in Stockholm, in
February 1998, as a project to measure wellbeing in the
primary care of patients. This index is the most widely
used tool among psychological welfare assessment questionnaires
[19]. This 5-question tool was developed with
factors, including the feeling of cheerfulness and good
mood; feeling calm; the feeling of being active; the feeling
of vitality and comfort after waking up, and the feeling
of interest in ADL. This is a one-dimensional scale
index. Moreover, each question provides unique information
about the level of wellbeing and measures the rate of
positive wellbeing over the past two weeks on a 6-point
Likert-type scale, ranging from 0 (never) to 5 (always).
The responsive raw score theoretically ranges from 0 (no
welfare) to 25 (maximum welfare).
It is also possible to multiply the total score by 4 to
convert the score range to a 0-100 scale. Higher scores
indicate greater welfare and lower scores reflect depression.
The 5 points of the WHO-5 have been validated in
Iran by Dehshiri and colleagues. Accordingly, the internal
consistency of the questions in this index is high and its
Cronbach’s alpha coefficient equals 0.89. Furthermore, its
test-retest coefficient was equal to 0.82 [20]. The FES-I
measures the fear of falling in the elderly during ADL in
two dimensions; indoor activities and outdoor activities.
The questionnaire measures 16 questions in the form of a
self-administered questionnaire. Moreover, the questions
are answered on a four-point Likert-type scale, as follows:
I am not worried at all, I am a little worried, I am relatively
worried, and I am very worried. Accordingly, the minimum
possible score is 16 (no worries & fear of falling)
and the maximum score is 64 (very severe anxiety & fear
of falling). This tool was first developed and validated by
Tinetti et al. in 1990 [21]. The validity and reliability of
this questionnaire have been evaluated and confirmed in
various studies, in Iran [22, 23].
To complete the questionnaires, after selecting the elderly,
the purpose of the study was explained to them.
We also observed the confidentiality of personal data in
recording the data and presenting the results. Besides, the
questionnaires were completed by a trained questioner by
asking the elderly and marking their answer on the questionnaire.
This research was approved with design code
62468 and ethics code IR.TBZMED.REC.1398.221. The
necessary data were analyzed in SPSS v. 25 using descriptive
statistics, including mean and frequency as well as
the regression analysis method. The significance level
was considered 0.05.
3. Results
The present study findings suggested that 167(59%)
study subjects were male and 116(41%) were female.
Moreover, 208(73.5%) of the studied elderly lived in
cities and 75(26.5%) lived in villages. Most of the research
subjects, i.e., 279(98.6%) were married. Besides,
86(30.4%) of the explored elderly were literate,
168(59.4%) of them reported under secondary school
education, and 29(10.2%) had secondary and higher education.
The Mean±SD age of the research subjects was
68.47±8.19 years. The Mean±SD score of fear of falling
in the studied elderly was 36.42±7.46. The Mean±SD
score of mental wellbeing in the examined elderly was
measured as 57.7±24.22 (Table 1).
The results of descriptive statistics for qualitative variables
presented in Table 2 highlighted that fear of falling
was low, moderate, and high in 48, 133, and 102 subjects.
In the present study, 108(38.2%) patients presented
depression.
The correlation coefficient data of the fear of falling
concerning the studied variables are reported in Table 3.
The collected results indicated a strong and significant
but inverse relationship between fear of falling and mental
wellbeing, fear of falling, and depression. In addition,
there was a significant and direct relationship between
fear of falling and residential areas.
Using a multiple regression model, the relationship
between fear of fall and depression was investigated respecting
the demographic variables. The relevant results
revealed that gender, place of residence, mental wellbeing,
and depression were significantly associated with
fear of falling (P<0.001) (Table 4). According to Table 4,
for every 10 units of welfare increase, the average fear of
fall decreased in the elderly by 2 units. Moreover, on average,
fear of falling in the female elderly was 1.55 points
higher than that in their male counterparts. The obtained
data suggested that the average fear of falling in the elderly
with depression was 3.37 points higher than that in
those without depression. Additionally, the average fear
of falling in the elderly living in the rural regions was
2.68 points higher than the elderly living in urban areas.
Papi Sh, et al. Fear of Falling, Mental Wellbeing and Depression in the Elderly. Arch Hyg Sci. 2021; 10(2)155-162.
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Using a multiple regression model, the relationship between
fear of fall and depression was investigated without
respecting demographic variables (Table 5). is the
related data signified a significant relationship between
fear of fall, depression, and mental wellbeing (P<0.001).
4. Discussion
The present descriptive-analytical study was performed
on 283 elderly with the cardiovascular disease
living in the urban and rural areas of Tabriz City Iran. We
determined the relationship between fear of falling, depression,
and mental wellbeing in the study sample. The
necessary data were collected using three questionnaires
of the CES-D, the FES-I, and the WHO-5.
The current research results revealed that fear of falling
was significantly associated with mental wellbeing
and depression. In this study, fear of falling was higher
among depressed subjects, compared to their non-depressed
counterparts. This finding was consistent with
the findings of Mishra et al. as well as Mahmoudi et al.
[11, 14]; in these studies, the level of fear of falling was
significantly associated with depression. In other words,
isolation and depression reduce an individual’s activities;
thus, muscle weakness and the odds of falling are
enhanced [11]. Additionally, the explored elderly with
low activity were more prone to depression and mental
health problems [14]. As a result, fear of falling and
depression present a strengthening effect on each other;
therefore, increasing each is effective in enhancing the
Table 1. Frequency distribution of the quantitative variables of the research units
Characteristic Mean±SD Min. Max.
Age, y 66.77±8.19 57 91
Fear of falling 36.42±7.46 26 64
Mental wellbeing 57.7±24.22 0 100
Table 2. Frequency distribution of the qualitative variables of the research units
Characteristic Level No. (%)
Gender
Male (S.M*) 167 (0.59)
Female 116 (0.41)
Depression
No (S.M*) 175 (61.8)
Yes 108 (38.2)
Place of residence
Village (S.M*) 75 (26.5)
City 208 (73.5)
Marital status
Without spouse (S.M*) 4 (1.4)
Married 279 (98.6)
Educational level
Reading and writing (S.M*) 86 (30.4)
Under secondary school 168 (59.4)
Secondary school and higher 29 (10.2)
Fear of falling
Low worry 48 (17)
Moderate worries 133 (47)
Extensive worries 102 (36)
*Reference level.
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incidence and severity of the other. Our study findings
contradict those of Iaboni and associates. In the Iaboni
study, individuals with depressive disorder were more
afraid of falling; however, this fear of falling was not
significantly associated with depression. An Iaboni intervention
highlighted that improving depressive symptoms
was associated with a reduced risk of falls [15].
Austin et al. explored the role of depression in predicting
fear of falling and their data were consistent with
those of our study [24]. In our study, mental wellbeing
was significantly correlated with fear of falling. In other
words, individuals with better mental wellbeing presented
a lower rate of fear of falling. As a result, the examined
elderly with a high sense of wellbeing have more
psychological resources to prevent and cope with problems,
and present a better biopsychological status [25].
The obtained finding demonstrated that fear of falling
was significantly related to gender. Moreover, the rate of
fear of falling was higher among women than men. Our
study findings were consistent with those of Natour et al.
[26] and Malini and associates [27]. This may be due to
women generating more chronic diseases, musculoskeletal
problems, as well as anatomical and biopsychological
gender differences [28]. Besides, according to other
studies, aging is significantly associated with increased
fear of falling [12, 29]. Considering the longer life expectancy
of older women than men, the high fear of falling
in older women can be justified. In our study, fear of
falling was not significantly associated r with age, i.e., in
contrast with other studies [29].
We observed that the place of residence was significantly
related to fear of falling; the studied elderly liv-
Table 3. Correlation coefficient of fear of falling and the studied variables
Characteristic Age Rehabilitation Depression Gender Residential
Area
Marital
Status
Educational
Level
Fear of
falling
Coefficient -0.065 -0.814 -0.816 0.007 0.474 0.024 0.089
P 0.275 0.001 0.001 0.889 0.001 0.626 0.054
Table 4. Results of multiple regression analysis respecting the demographic variables
Characteristic Status Coefficient SD P
Width of origin - 43.36 3.14 <0.001
Age - -0.005 0.03 0.86
Rehabilitation - -0.20 0.01 <0.001
Gender
Male (S.M *) - - -
Female 1.55 0.49 <0.001
Depression
No (S.M *) - - -
Has it 3.37 0.61 <0.001
Address
Village (S.M *) - - -
City 2.68 0.64 <0.001
Marital status
Without spouse (S.M *) - - -
Married 0.73 1.99 0.71
Educational level
Reading and writing (S.M *) - - -
Under secondary 0.01 0.55 0.98
Secondary and higher -0.83 0.92 0.36
*Reference level.
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ing in rural areas were less afraid of falling, compared to
their urban-living peers. The reason for the difference in
the level of fear of falling of elderly living in urban and
rural regions could be attributed to differences in their
lifestyle as well as the quality of life [30]. Due to the integrity
of individuals’ culture in rural areas, older people
receive higher social support from family, neighbors, or
friends, i.e., effective in improving their wellbeing and
physical health, resulting in better cognitive function and
mental wellbeing; consequently, such conditions reduce
fear of falling in the elderly living in villages [12]. Arruda
addressed no difference in the risk of falls between
urban- and rural-living elderly [31].
Findings of the present study revealed that fear of
falling in most of the examined elderly was moderate
or high. Besides, a small proportion of the study sample
reported no worries about falling. This finding was
consistent with those of other studies [11, 29]. Falling is
among the most common and problematic issues among
the elderly. The WHO has classified falls as the third
leading cause of chronic disability. Fear of falling is classified
as an essential psychological factor that often leads
to falling [32].
This study had some limitations, including its crosssectional
nature, which prevented understanding the
cause-and-effect relationships between the research
variables. There may also be other variables affecting
the fear of falling in the elderly, i.e., overlooked in our
study. According to the obtained results, it is suggested
that studies be conducted to investigate the causes of fear
of falling in the elderly living in urban and rural areas.
Besides, intervention studies are required to help reduce
the fear of falling in this population.
5. Conclusion
According to the current study findings, depression
and mental wellbeing were predictors of fear of falling.
Therefore, in health promotion interventions in the
elderly, programs can be performed to reduce their depression
and increase mental wellbeing, as a result, improving
these factors can affect fear of falling and the
associated falls in this group.
Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee
of the University of Tbzmed (Code: IR.TBZMED.
REC.1398.221 and 62468).
Funding
This study is the result of a research project with project
code 62468 approved by the Vice-Chancellor for
Research and Technology of Tabriz University of Medical
Sciences and financially supported by the Same
University.
Authors' contributions
Conceptualization and supervision: Shahab Papi and
Zeynab Karimi; Methodology: Azin Barmala; Investigation,
writing – original draft, and writing – review &
editing: All authors; Data collection: Mohammad Reza
Molav; Data analysis: Fatemeh Hosseini.
Conflict of interest
The authors declared no conflicts of interest.
Acknowledgments
The authors appreciate all the study participants, the
officials of healthcare centers, also the Vice-Chancellor
for Research and Technology of Tabriz University of
Medical Sciences for their contribution to this research.
Table 5. Results of multiple regression analysis in the absence of demographic variables
Characteristic Status Coefficient SD P
Width of origin - -46.92 0.91 <0.001
Rehabilitation - -0.20 0.01 <0.001
Depression
No (S.M *) - - -
Has it 3.37 0.62 <0.001
*Reference level; SM.
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