Perceived Fall Risk versus Actual Preventive Behaviors among Community-Dwelling Older Adults: A Cross-Sectional Study

Abstract

Objective: To investigate the consistency between older adults’ subjective perception of fall-related environmental risk factors at home and their actual preventive behaviors, and to analyze the influencing factors of the knowledge-behavior gap, providing evidence for developing precision fall prevention interventions. Methods: A cross-sectional survey was conducted from September 2025 to March 2026, recruiting 350 community-dwelling older adults in a city in East China. Based on a systematic review of international home fall risk assessment tools and the Health Belief Model, the “Home Environment Fall Risk Perception Scale” (6 dimensions, 24 items) was developed through literature review, semi-structured interviews, and expert consultation, and validated through a pilot study (n=68) before formal use. Standardized home environment visits were conducted to evaluate actual preventive behaviors. Participants were classified into four types using the quartile method. The Kappa consistency test was used to evaluate the knowledge-behavior consistency, and binary Logistic regression was used to analyze influencing factors. Sensitivity analysis using the theoretical median (3.0/5.0) was performed to verify classification robustness. Results: A total of 327 valid samples were included, with an effective response rate of 93.4%. The perception scale had a Cronbach’s α of 0.89, a test-retest ICC of 0.86, and an EFA extracted 6 factors explaining 62.35% of variance. The mean score of fall risk perception was (3.42±0.68), and the mean score of actual preventive behavior was (2.15±0.79). The Kappa value for knowledge-behavior consistency was 0.28 (P<0.001), indicating weak consistency. The proportions of the four types were: Knowledge-Behavior Consistent 24.5% (80/327), Knowledge without Action 38.2% (125/327), Action without Knowledge 15.3% (50/327), and Double Low 22.0% (72/327). Sensitivity analysis showed that using the theoretical median (3.0/5.0) as a cut-off point yielded proportions of 23.2%, 36.7%, 17.1%, and 23.0%, highly consistent with median-based classification (Kappa=0.89, P<0.001). Multivariate Logistic regression showed that age ≥75 years (OR=2.34, 95%CI: 1.42-3.86), living alone (OR=1.89, 95%CI: 1.12-3.19), monthly income <3000 yuan (OR=2.67, 95%CI: 1.58-4.51), no fall history (OR=2.15, 95%CI: 1.28-3.62), inadequate health literacy (OR=3.12, 95%CI: 1.84-5.29), and low social support (OR=2.48, 95%CI: 1.46-4.21) were independently associated with “Knowledge without Action”. Female gender (OR=0.62, 95%CI: 0.38-1.01) and living with a caregiver (OR=0.45, 95%CI: 0.26-0.78) were protective factors. Conclusion: The consistency between perception and behavior of fall-related environmental risk factors among community-dwelling older adults is poor, with a prominent phenomenon of “Knowledge without Action”. Personalized intervention strategies should be implemented for older adults who are advanced in age, living alone, with low income, no fall history, and inadequate health literacy, to strengthen behavioral activation and social support, bridging the gap between cognition and behavior. However, causal directions remain to be verified by longitudinal studies, given the cross-sectional design.