Introduction
Falls pose significant physical and psychosocial challenges for older adults, highlighting the need for early detection and targeted interventions. Age-related physiological changes across multiple body systems contribute to reduced physical capacity and diminished ability to perform daily activities, thereby increasing fall risk (Milanović et al., 2013). Falls are a leading cause of injury in this population, often resulting in hospitalization, functional decline, and elevated mortality (Vaishya & Vaish, 2020). Beyond physical harm, falling or even the anticipation of falling can lead to a persistent fear of falling —a psychological condition characterized by ongoing concern that often results in the avoidance of physical and social activities. This avoidance can further deteriorate physical function and postural control, thereby creating a cycle of decline and increasing the likelihood of future falls (Hoang et al., 2017). The fear of falling is widespread, affecting 20% to 85% of older adults, with 20% to 55% reporting activity limitations. Notably, 30% to 50% of community-dwelling older individuals experience fear of falling regardless of prior fall history (Liu et al., 2021; Sapmaz & Mujdeci, 2021).
A widely used tool for assessing fear of falling in older adults is the Falls Efficacy Scale-International (FES-I), which evaluates concerns related to daily activities, ranging from basic self-care to complex tasks, and is globally validated for its reliability and ease of use (Yardley et al., 2005). Nevertheless, several important limitations constrain its utility. First, its exclusive reliance on selfreport may introduce response bias: individuals with cognitive impairment or language barriers may underreport or overestimate their fear, while those with limited literacy or differing cultural expressions of anxiety may misinterpret item phrasing (Delbaere et al., 2010; Kempen et al., 2007). Second, the instrument’s 16–item length can impose substantial cognitive and time burdens, potentially leading to respondent fatigue or confusion, particularly among those with diminished concentration or memory capacity. Third, certain subitems reference context–specific activities (e.g., navigating public transport or negotiating uneven terrain) that may not be universally applicable, thereby reducing comparability across settings. Finally, the FES–I omits direct assessment of critical physical domains—such as static and dynamic balance or lower–limb strength—which are essential to a comprehensive appraisal of fall risk and may lead to incomplete evaluations when used in isolation. Collectively, these limitations underscore the need for alternative or supplementary tools that integrate both psychological and physical dimensions of fall risk in diverse older populations.
To address the above limitations, the Timed Up and Go (TUG) test is often used as a complementary tool, objectively measuring functional mobility and balance through a timed task involving rising from a chair, walking three meters, turning, returning, and sitting down (Podsiadlo & Richardson, 1991). While the TUG serves as a valuable complementary measure, it nonetheless demands dedicated time, space, and trained personnel for administration. In large–scale screening programs, these resource requirements can become prohibitive, creating logistical bottlenecks and increasing operational costs. Such constraints highlight the imperative to develop or adopt briefer, selfadministered instruments that maintain acceptable psychometric properties while reducing dependence on examiner time and specialized equipment. Therefore, simpler evaluations requiring minimal equipment may be more appropriate for older adult populations in these contexts.
The Fear of Falling 10–Rating Scale (FOF–10) was specifically engineered to overcome both linguistic and literacy-related barriers by leveraging universally recognized Arabic numerals. The instrument employs a single–item, verbally administered, 10–point ordinal scale ranging from 1 (no fear) to 10 (extreme fear), whereby participants are prompted to self–report their current level of fear of falling. Scores near the lower bound (e.g., 0–1) are indicative of minimal apprehension, whereas values approaching the upper limit (e.g., 9–10) reflect a markedly elevated fear of falling. This scale is particularly suitable for illiterate individuals, speakers of different languages, and older adults who may face greater challenges in language comprehension. The numeric format allows participants to easily express their level of fear of falling, enabling evaluators to obtain more accurate and objective data. Older adults can directly indicate their fear without the complexity of understanding verbal questions or descriptions, facilitating quicker and more efficient assessments in time-constrained contexts. Although the FOF-10 was developed based on principles of simplicity, convenience, and widespread applicability, its psychometric properties have not yet been examined. We hypothesize that, as the first singleitem, numeral–based instrument explicitly designed to surmount both linguistic and literacy barriers, the FOF–10 will yield a valid and sensitive measure of fear of falling and effectively distinguish between fallers and non–fallers in community–dwelling older adult populations. Therefore, this study aims to evaluate the utility of the FOF-10 in assessing fear of falling and predicting falls by comparing its performance with the established FES-I and the TUG test, both standard assessments for fall risk.
Methods
Participation
This retrospective diagnostic study was conducted among adults aged 60 years and older residing in various rural and suburban communities in Phayao Province, Thailand. Eligible participants needed to be able to stand independently, walk at least six meters with or without assistive devices, and understand the study commands. Exclusion criteria included neurological diseases affecting walking ability or balance, significant lower extremity pain that could impact study outcomes, active infection, cancer diagnosis, recent injury, uncorrected visual impairments, and extremity amputation. The study was approved by the Institutional Ethics Committee for Human Research (Ethics Committee reference number: UP-HEC1.2/013/65), and all participants provided written informed consent before participating.
The minimum required sample size for this study was estimated based on the primary objective of determining the optimal cut-off score of the FOF-10 for identifying individuals at risk of falling. As this is the first study to develop and evaluate the FOF-10, no prior data on the sensitivity of the instrument were available to inform the sample size calculation using conventional formulas for diagnostic accuracy studies. Therefore, a minimum acceptable sensitivity of 50% was conservatively assumed, with an allowable margin of error of 10% and a significance level (α) set at 0.05. Based on these parameters, the estimated minimum required sample size was 97 participants. To account for potential attrition or withdrawal during the study, an additional 10% was added to the target sample size. As a result, the final required number of participants for this study was set at no fewer than 107 individuals.
Measurements
The 107 eligible participants were interviewed and evaluated for their demographics, and none used a walking device. Fall data were recorded concerning the number of falls in the previous six months, and then the participants were divided into faller (positive) and non-faller (negative). Following the completion of the interview and medical history-taking, all participants underwent the assessments in a standardized order to ensure procedural consistency. The evaluation began with the FOF-10, followed by the FES-I, and concluded with the Timed Up and Go (TUG) test. The details of the test protocols are as follows:
The FOF-10: The assessment was conducted verbally, using the question: “To what extent do you fear falling?” Participants responded using a numerical rating scale from 1 to 10. A score of 1 indicated no fear of falling, characterized by the ability to walk or move freely in daily life without concern. In contrast, a score of 10 represented the highest possible level of fear, to the extent that the individual avoids walking or independent movement without close supervision. Participants were free to select a score that best reflected their personal experience, based on the score definitions provided by the researcher at the outset. The scores obtained were subsequently subjected to statistical analysis to generate meaningful insights.
The FES-I: The tool is widely recognized as a standard for assessing fear of falling, self-efficacy, and balance confidence across diverse cultural and linguistic contexts. The questionnaire consists of 16 items, covering both basic and instrumental daily activities. Responses are rated on a scale from one (not at all concerned) to four (very concerned), with a total score ranging from 16 to 64, reflecting the level of concern (from no concern to extreme concern) (Yardley et al., 2005). It has demonstrated reliability and validity in older adults living in the community in various countries. Regarding the Thai language, research on the psychometric properties of the Thai version of the FES-I (Thai FES-I) indicates good internal consistency and construct validity in Thai older adults residing in the community (Thiamwong, 2011).
The TUG: The test is widely used to assess complex mobility and dynamic balance control in daily activities and specific tool for identifying fall risk in community-dwelling adults (Alexandre et al., 2012). For the test, the participants stood up from a standard chair with armrests, walked around a cone positioned three meters from the chair’s edge, and then returned to sit back down. The time, recorded in seconds from the “Go” command until the participant’s back contacts the backrest, was measured with a stopwatch (Thaweewannakij et al., 2013). The participants performed the test three times, and the average time across the three trials was calculated and used for subsequent statistical analysis.
Statistical analysis
Descriptive statistics were used to summarize the participants’ characteristics and the study outcomes. To compare demographic data and the scores of the FES-I, TUG, and FOF-10 between fallers and non-fallers, the independent samples t-test, Mann-Whitney U test, and Chi-square test were conducted. The Pearson correlation coefficient (r) was applied to assess the relationships between the FOF-10 and the FES-I and TUG, supporting concurrent validity. Correlation levels were categorized as negligible correlation (0.00 to 0.3), low correlation (0.30 to 0.50), moderate correlation (0.50 to 0.70), high correlation (0.70 to 0.90) and very high (at least 0.90) (Mukaka, 2012). Accordingly, a correlation coefficient closer to one, regardless of its direction, signifies a stronger association, reflecting a linear relationship between FOF-10 scores and the standard measures. Additionally, a receiver operating characteristic (ROC) curve analysis was performed to determine the optimal cut-off scores for the FOF-10 and standard measures (FES-I and TUG) for identifying falls, based on sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under the curve (AUC). The level of statistical significance was set at p < 0.05.
Results
The present study found that the older adult participants had a mean age of 74 years. Among them, 49 individuals (45.79%) reported experiencing at least one fall in the preceding six months. Additionally, two-thirds of the participants were female (67.30%). Baseline characteristics, including age, gender, and BMI, showed no significant differences between the faller and non-faller groups. The FOF-10 assessment revealed distinct score distributions between the groups. In the faller group, the most frequently observed score was six (11 participants, 22.45%), while in the non-faller group, the most common score was two (25 participants, 43.10%) (Table 2). Furthermore, statistically significant differences were observed in the average time taken for the TUG and the mean FES-I scores between fallers and non-fallers (p < 0.001). Additional data are detailed in Table 1.
Table 1
The demographics and of the participants.
| VARIABLES | TOTAL (n = 107) | FALLER (n = 49) | NON-FALLER (n = 58) | p VALUE |
|---|---|---|---|---|
| Age: years (mean ± SD) | 74.63 ± 6.73 | 74.82 ± 7.14 | 74.47 ± 6.41 | 0.790a |
| Gender: n of female (%) | 72 (67.30) | 36 (73.47) | 36 (62.07) | 0.210b |
| BMI: kg/m2 (mean ± SD) | 23.27 ± 3.39 | 23.61 ± 3.47 | 22.30 ± 3.32 | 0.346a |
| FOF-10: score (mean ± SD) | 4.21 ± 2.18 | 5.76 ± 2.04 | 2.90 ± 2.18 | <0.001a |
| TUG: s (mean ± SD) | 15.16 ± 5.49 | 18.16 ± 6.70 | 12.62 ± 1.99 | <0.001a |
| FES-I: scores (mean ± SD) | 33.29 ± 13.20 | 41.96 ± 11.49 | 25.97 ± 9.68 | <0.001a |
[i] Note: BMI, Body mass index; FOF-10, fear of falling 10-rating scale; TUG, time up and go test; FES-I; Falls Efficacy Scale International. a p-values were analyzed using the independent samples t –test, b using the Chi square test.
Table 2
Frequency and percentage of self-reported FOF-10 scores among participants.
| VARIABLES | TOTAL (n = 107) | FALLER (n = 49) | NON-FALLER (n = 58) | p VALUE |
|---|---|---|---|---|
| FOF-10 score: n (%) | ||||
| 1 | 1 (0.90) | 0 (0.00) | 1 (1.72) | <0.001a |
| 2 | 28 (26.20) | 3 (6.12) | 25 (43.10) | |
| 3 | 24 (22.40) | 3 (6.12) | 21 (36.21) | |
| 4 | 16 (1.50) | 10 (20.41) | 6 (10.34) | |
| 5 | 8 (7.50) | 5 (10.20) | 3 (5.17) | |
| 6 | 11 (10.30) | 11 (22.45) | 0 (0.00) | |
| 7 | 6 (5.60) | 5 (10.20) | 1 (1.72) | |
| 8 | 10 (9.30) | 9 (18.37) | 1 (1.72) | |
| 9 | 1 (0.90) | 1 (2.04) | 0 (0.00) | |
| 10 | 2 (1.90) | 2 (4.08) | 0 (0.00) |
[i] Note: a using the Chi square test.
Table 3 presents the correlation analysis between the primary study variable, the FOF-10 score, and other key variables, including TUG, FES-I, and the number of falls. The findings indicate a very strong correlation between FOF-10 and standard measures such as FES-I (rho = 0.929, p < 0.001). Additionally, statistically significant correlations were observed between FOF-10 and both TUG and the number of falls. The results of correlations with other relevant variables are detailed in Table 3.
Table 3
The correlation between the outcomes of FOF-10, FES-I, TUG, and number of falls.
| VARIABLES | FES-I (Score) | TUG (s) | NUMBER OF FALLS (Times) |
|---|---|---|---|
| (95%CI) | (95%CI) | (95%CI) | |
| FOF-10 (score) | 0.929** (0.885–0.953) | 0.738** (0.619–0.831) | 0.648** (0.499–0.754) |
| Number of falls (times) | 0.573** (0.412–0.712) | 0.502** (0.317–0.640) | |
| TUG (s) | 0.830** (0.732–0.894) |
[i] Note: FOF-10, fear of falling 10-rating scale; TUG, time up and go test; FES-I; Falls Efficacy Scale International.
**p-values < 0.001.
The comparative analysis of the discriminatory ability of different measures to predict falls among community-dwelling older adults is summarized in Table 4. The findings indicate that the FOF-10 assessment demonstrated the highest discriminatory performance, followed by FES-I and TUG, respectively. Metrics such as sensitivity, specificity, PPV, NPV, overall classification accuracy, and the AUC for each measure are presented in Table 3 and visualized in Figure 1.
Table 4
The optimal cut-off score and predictive variables of the FOF-10 and standard measures to determine falls in older individuals.
| MEASURES | CUT-OFF SCORE | SENSITIVITY (%) | SPECIFICITY (%) | PPV (%) | NPV (%) | CORRECTLY CLASSIFY (%) | AUC (95%CI) |
|---|---|---|---|---|---|---|---|
| FOF-10 (score) | 4 | 87.66 | 81.03 | 86.84 | 76.81 | 80.37 | 0.8841 (0.8175–0.951) |
| FES-I (score) | 33 | 81.63 | 70.69 | 80.00 | 79.03 | 79.44 | 0.848 (0.771–0.925) |
| TUG (s) | 13.07 | 75.51 | 62.07 | 88.89 | 76.06 | 80.37 | 0.793 (0.701–0.886) |
[i] Note: FOF-10, fear of falling 10-rating scale; TUG, time up and go test; FES-I; Falls Efficacy Scale International; PPV, Positive predictive value; NPV, Negative predictive value; AUC, area under ROC curve.
Figure 1
Area under the ROC curve of the FOF-10 and standard measures.
Discussion
The findings of this study highlight several significant benefits for clinical and research applications. The FOF-10 scale demonstrates superior validity and accuracy in identifying fall among community-dwelling older adults, surpassing traditional tools such as TUG and FES-I. This underscores the FOF-10’s utility as a holistic measure for fall risk assessment. The simplicity and practicality of the FOF-10 make it an accessible tool for integration into routine clinical practice, promoting efficient and effective fall prevention strategies tailored to the needs of the aging population.
The fear of falling and fall incidents are interlinked challenges that become increasingly prevalent in aging societies, particularly as sedentary lifestyles take hold. Fear of falling frequently emerges as a consequence of previous falls in older adults and, in turn, significantly elevates the risk of subsequent falls (Friedman et al., 2002; Murphy & Isaacs, 1982). This bidirectional relationship is further reinforced by their shared predictors, enabling fear of falling and falls to serve as mutual indicators of each other’s likelihood (Schoene et al., 2019). Conceptually, fear of falling can be defined and measured through two distinct approaches. The first focuses on the emotion of fear itself, assessing the anticipatory fear of potential falls, often using single-item questions such as, “At this moment, how fearful are you about the possibility of falling?” The second approach draws on Bandura’s self-efficacy theory, evaluating fall-related efficacy, which refers to an individual’s confidence (or lack thereof) in their ability to perform specific daily tasks (Bandura, 1977; Schoene et al., 2019). The current study demonstrates that the faller group exhibited higher fear of falling scores, as measured by the FES-I, compared to the non-faller group. Additionally, the faller group required significantly more time to complete the TUG than the non-faller group. Furthermore, the FOF-10 assessment showed strong alignment with the two standard tests, with fallers reporting significantly higher self-reported fear of falling scores compared to non-fallers (p < 0.001). These findings are consistent with numerous studies that have shown that fear of falling often leads to a decline in physical function, particularly in mobility and balance. Fear of falling negatively impacts balance performance as assessed by the TUG, with individuals experiencing fear of falling taking significantly longer to complete the TUG test than those without fear (p < 0.05) (Huang et al., 2022; Sapmaz & Mujdeci, 2021).
Numerous studies have been published on the relationship between fear of falling, fall incidents, and physical functioning in community-dwelling older adults. Previous research has demonstrated a statistically significant positive correlation between fear of falling, as assessed by the short version of the FES-I, and fall occurrences (rbp = 0.309, p < 0.01) (Duangsanjun & Poncumhak, 2024). This finding suggests that an increase in fear of falling is associated with a higher incidence of falls. Similarly, impaired balance, a critical component of physical function, may contribute to heightened fear of falling. Past studies have reported a modest positive relationship between balance dysfunction and fear of falling among older adults, with a correlation coefficient of r = 0.35 (p = 0.01) (Ranade et al., 2022). These results highlight the bidirectional nature of the relationship between balance deficits and fear of falling, emphasizing the need for comprehensive interventions to address both aspects. The findings from the current study are consistent with previous literature as shown in Table 3. However, when comparing the strength of correlations for the measures used in this study, the FOF-10 outcomes demonstrate a stronger correlation with both the number of falls and TUG than the standard FES-I measure. This suggests that the FOF-10 may more effectively capture fear of falling and balance abilities. The FOF-10’s distinctive feature lies in its simplicity and ease of use, making it accessible to both assessors and participants. Additionally, it incorporates an individual’s subjective perception of fear, which may be influenced by personal experiences, current self-awareness, and the surrounding environment.
In terms of practical application, another key aspect involves determining the optimal cutoff value based on sensitivity, specificity, PPV, NPV, and AUC. These metrics are crucial indicators of the test’s ability to accurately identify or predict the occurrence of the event under study. The ROC curve is commonly employed for this purpose, and is a graphical representation that plots sensitivity values on the y-axis and 1-specificity values on the x-axis for all possible cutoff scores derived from participant data. A test that perfectly discriminates between fallers and non-fallers would produce a curve that aligns with the upper left corner of the plot. Moreover, the AUC is a summary measure of the test’s overall diagnostic accuracy, with values ranging from zero to one, where zero indicates a perfectly inaccurate test and one denotes perfect accuracy (Fan et al., 2006). In the present study, the results show that all three assessments (FES-I, TUG, and FOF-10) demonstrated similar abilities to discriminate falls, with AUC values ranging between 79.44% and 80.37% (Table 4). Based on ROC curve analysis, the optimal cut-off score for the FOF-10 was determined to be four out of 10. This threshold was identified by maximizing sensitivity, specificity, and the area under the curve (AUC), indicating a high discriminatory ability of the cut-off point in effectively identifying fall risk among participants. However, when considering sensitivity, which represents the True Positive rate (the proportion of patients with the condition correctly diagnosed), the FOF-10 assessment exhibited the highest sensitivity, indicating its superior ability to identify fallers compared to the two standard measures. Furthermore, when considering the potential application in community settings with large populations, where ease of use and simplicity are paramount, the FOF-10 may serve as a valuable alternative tool for identifying fall risk, given its practical nature and effectiveness.
This study highlights several advantages of the FOF-10; however, certain limitations should be acknowledged. First, the retrospective cross-sectional design may have affected the accuracy of fall-related data among older adults. Future research may consider adopting a prospective cohort design to capture real-time fall events and to evaluate the predictive validity of the identified cut-off score for future falls. Second, the study population was limited to a specific geographic area, which may affect the representativeness and generalizability of the findings. Future studies should aim to recruit participants from multiple and more diverse settings, in combination with an improved study design as suggested above, to enhance the external validity of the results. Third, in order to further strengthen the credibility of the FOF-10, future research should also investigate additional psychometric properties, such as reliability.
Conclusion
In terms of practical application, the FOF-10 is not only simple and convenient to administer—requiring no equipment or specialized personnel—but study findings also highlight its superior ability to assess fear of falling and distinguish fall events among older adults. The study suggests that the participants who self-reported a score of four or higher on the FOF-10 were indicative of a higher likelihood of experiencing falls. The FOF-10 can be administered as a self-assessment tool by older adults, or it can be used by healthcare professionals to evaluate fear of falling in community settings. It serves as a preliminary screening instrument that may inform further clinical evaluation and intervention.
Data Accessibility Statement
Data are available in anonymous form upon reasonable request addressed to the corresponding author.
Ethics and Consent
Research protocols of the study were approved by the institutions’ human research ethics committees (Ethics Committee reference number: UP-HEC1.2/013/65). Additionally, all participants provided signed informed consent forms. The study was conducted in compliance with the Declaration of Helsinki and its later amendments.
Written informed consent was obtained from all participants that were screened for eligibility, including consent to use information acquired from the screening phase of the study.
Competing Interests
The authors have no competing interests to declare.
Author contributions
Study conception and design: P.P., W.N., A.S., and W.D.; data collection: P.P., W.D.; analysis: P.P., W.N., W.D.; interpretation of the results: P.P., W.N., A.S., and W.D.; draft manuscript preparation: P.P., and W.D. All authors reviewed the manuscript and approved the final version of the manuscript.