Knowledge of falls risk factors in older adults among physiotherapy students in Malaysia

1 Introduction

A fall, which is an occurrence resulting in a person coming to rest unintentionally on the floor is the most frequent accident for people aged above 65 years [1–3]. Falls have a significant consequences to older adults that include morbidity, immobility, hospitalisation and even mortality [4]. The World Health Organization reported that about 28% –35% of the older adults experience falls every year, and the number of accidents rapidly increases with age such that 32% –42% of older adults above 70 years of age have had fall episodes [5]. Accordingly, it was reported that about 3.0 million older adults were treated for fall injuries, and 68% of people who fell had injuries that account for the decline of their physical performance [6, 7]. In Malaysia, a recent review found about 45% of the older adults aged 60 years and above have received treatments due to injury from falls [8].

Given the high fall incidence in Malaysia, developing awareness regarding risk factors for falls and establishing prevention guidelines that can be utilised among the Malaysian society is crucial, especially for those involved in caring for older adults with chronic conditions and physical limitations. Singapore, being the nearest country to Malaysia, has developed fall prevention guidelines emphasising the importance of assessing fall risks and thus focusing on prevention intervention such as exercise training, walking aids, home modifications, proper footwear, modification of medication, and prescription of Vitamin D [9]. Guidelines on fall prevention strategies as structured by the Government of South Australia for hospital settings highlight the use of beds with adjustable heights, overhead grab handle and bed rails, belts for preventing falls and ensuring that personal items are within reach for older patients [10, 11]. These guidelines were found to target the common risk factors as reported in various studies [1, 12–16].

A relationship may exist between knowledge and awareness regarding the risk factors for falls and fall incidents. A previous study conducted in Nigeria revealed a significant correlation between the level of knowledge and awareness, in which greater knowledge indicates greater awareness of fall risks and fall prevention strategies [17]. Other studies have found that providing proper education for healthcare practitioners on the conceptualisation of fall prevention programs increases the knowledge, awareness and even confidence to undertake fall prevention strategies [18–21]. On the other hand, low understanding of fall risk and minimal awareness of healthcare-provided fall prevention strategies are hurdles to fall prevention, especially when these strategies fail to tackle some of the major risk factors of falling [22]. This result may be because these individuals lack a sense of urgency and fail to understand the hazards due to fall incidence.

Educating future healthcare providers, especially those involved in the rehabilitation of older adults, is of the utmost importance to prepare them to face the ageing of the population. Previous studies have been conducted among licensed physiotherapists, care staff and even the older adults themselves with their self-perceived knowledge [17, 23–25]. Research that emphasises knowledge of risk factors for falls among physiotherapy students is lacking. This circumstance further advocates the importance of conducting this study to understand better the level of future physiotherapists’ knowledge of risk factors for falls and how they can improve the fall prevention guidelines. Thus, this study aimed to identify the levels of knowledge of the risk factors among physiotherapy students in Malaysia.

2 Methods

A total of 239 physiotherapy students from public and private universities in Malaysia participated in this study. Table 1 presents all the characteristics of the participants. Table 2 describes the responses regarding the knowledge level about the risk factors for falls. Factors deemed by the participants as very important include balance/gait disorders (82.8%), muscle weakness (65.7%), environmental factors (50.2%), sensory/perceptual deficits (56.1%), impaired cognitive (55.2%) and footwear problems (48.5%). Approximately 42.3% and 51.0% of participants deemed postural hypotension and multiple medications, respectively, as somewhat unimportant risk factors for falls.

Table 3 displays the comparisons of the level of knowledge on risk factors for falls according to different participants’ characteristics. Full-time students have significantly higher knowledge (p = 0.010) than part-time counterparts. Additionally, participants who had no working experience have been shown to have significantly higher knowledge (p = 0.009). No significant differences occurred between gender, age, ethnicity, study institution, ageing course completion, field placement experience in service to the older adults, and personal contacts with an older non-family member(s) and with an older family member(s) (all p > 0.05).

This study aimed to determine the levels of knowledge of the risk factors for falls among physiotherapy students in Malaysia. Knowledge levels regarding the risk factors for falls were low for most participants, the worst being the knowledge about postural hypotension and multiple medications as risk factors for falls among the older adults. All factors were deemed important risk factors related to the incidence of falls [7, 26].

The participants scored the highest mean for knowledge in acknowledging balance/gait disorders and muscle weakness as risk factors for falls in this study. Not just physiotherapy students; in fact, most people are aware that physical deterioration comes with age, impair balance and muscle strength. A previous study reported that muscle strength was significantly lower among older adults who experienced fall, affecting their balance and gait [27].

Aside from the physical declines mentioned before, many participants had insufficient knowledge of sensory/perceptive deficits and cognitive impairment as risk factors for falls. Visual impairments can lead to falls due to poor perception of surroundings [28], while cognitive impairment may cause a decline in processing function, leading to impaired balance and fall [29].

The participants also had insufficient knowledge about environmental hazards and footwear problems being a risk factor for falls. Falls can occur in an environment with poor lighting and slippery surfaces, especially without proper footwear. A previous study in Thailand reported that home/environmental hazards and improper footwear were associated with a high risk of falls [30].

The results with regards to a very low knowledge about postural hypotension and multiple medications could be because they have received neither ageing nor pharmacology courses to understand the hazard behind experiencing postural hypotension and the side effects from polypharmacy especially for the older adults. Another research reported that the incidence of experiencing a fall among the older adults associated with postural hypotension was significantly high [31]. On the other hand, the incidence of falls caused by multiple medications was mostly associated with anti-depressants for which the older adults will experience side effects such as sedation, dizziness, and postural hypotension [32]. The odds ratio of falls that lead to hospital admissions increased for every additional drug taken (OR 1.47, 95% CI 1.32–1.64 for > 15 drugs in contrast to 0–3 drugs) [33].

Despite not showing any significant difference, the current study indicated that female physiotherapy students had a higher knowledge of risk factors for falls than their male counterparts. A possible explanation for this result is that, on average, female students had a higher likelihood of excelling better than male students on reading and verbal assessments [34]. It is also noted that the majority of the physiotherapy students in Malaysia from public and private institutions were females.

Age differences seem to be not a significant factor in determining knowledge in fall prevention consistent with a previous study [17]. However, older participants might have more experience with older adults and were more mature in handling and preventing issues among older adults. Among the other factors that provide knowledge, the experience that comes with co-existing with older adults who experienced falls with ageing may influence the ability of people to adopt fall prevention strategies [25]. However, merely coexisting with the older adults will provide insufficient information from scientific knowledge regarding the risk factors for falls [25].

Studies that have compared the knowledge of the risk factors for falls and awareness of fall prevention strategies between full-time and part-time students is lacking. For this current work, full-time students showed a higher knowledge compared to part-time counterparts. Full-time students may be assumed to be able to focus more in classes compared to part-time peers who must cram a six-hour worth of lessons at one go. A study in Australia reported that undergraduate students from health professional courses in 43 different universities were taught fall prevention as a core unit that is delivered in two or three hours in both practical sessions or tutorials [35].

Moreover, no significant differences were found between public and private institutions. Even so, public institutions in Malaysia receive more exposure to corporate social responsibility and programs for older adults. For example, a program called the Service Learning Malaysia (also known as SULAM) [36] with older adults is annually conducted by public institutions to provide a learning experience that implements both theory and practical knowledge towards solving a community issue. Both public and private institutions taught similar subjects and contents, and they corresponded to the universities in Australia and New Zealand, where curriculum guidelines regarding fall incidences are implemented [35].

The current findings also reported that physiotherapy students with no working experience had a higher knowledge of the risk factors for falls. A study in India reported that working nurses had low knowledge levels despite receiving fall prevention education [37]. Moreover, health workers reported low knowledge levels regarding fall incidences [37]. The speculation could be made that full-time students had more time to equip themselves with knowledge than part-time counterparts who had other commitments in life.

No significant differences occurred between knowledge in terms of ageing course completion, field placement in service with older adults, employment in service to the older adults and personal contact with older non-family member(s) and family member(s). A previous study suggested that licensed care staff had limited knowledge of the risk factors for falls and low awareness that the older adults they cared for were at risk of falling [24]. However, another research confirmed that the rate of falls declined in eight rehabilitation units in general hospitals located in Australia after implementing a fall education program [20]. This outcome confirmed the need for an evidence-based training program to implement effective fall prevention strategies among healthcare providers. Having knowledge learned theoretically without practical training might explain why some healthcare workers lack knowledge and awareness even after completion of an ageing course. Despite not having significant differences, participants who had frequent personal contact with an older family member(s) had higher knowledge of risk factors for falls. Spending more time with a blood-related, older family members might instil the need for preventing fall incidences, hence driving them to find out what could cause falls. This result is compatible with those of a previous study which indicated that blood-related caregivers were able to identify measures and precautions to prevent fall incidences [25].

The outcomes of this study could be a keystone in providing better physiotherapy updates in future that may assist many healthcare practitioners in producing better courses of action to overcome fall incidences among older adults while considering knowledge and awareness levels. These outcomes could also be impactful in adding more syllabus contents that focus on the risk factors for falls and prevention strategies in older adults in physiotherapy courses.

5 Conclusions

Physiotherapy students in Malaysia generally showed low knowledge of the risk factors for falls among older adults. The results of this study could potentially become a guide in producing and implementing educational programs focusing on fall prevention strategies for older adults that can be offered to physiotherapy students by higher education providers.