Self-perception of health, balance, and fear of falling as predictors of gait speed decline among community-dwelling older women: a longitudinal study

Abstract

Objective  To investigate the association between self-perceptions of general health status, balance, and fear of falling with the decline in usual gait speed (UGS) over 12 months in a prospective study of community-dwelling older women in Ribeirão Preto, São Paulo, Brazil.

Methods  This was an epidemiological, observational, analytical, and prospective study. A total of 94 independent older women were assessed. They were interviewed about their self-perceptions of general health status and balance, using the following response options: very good, good, fair, poor, and very poor. Additionally, the presence of fear of falling (FoF) was assessed through a dichotomous question (yes or no). UGS was measured at baseline and again after 12 months. Binary logistic regression, adjusted for confounding variables, was used to examine the associations between self-perceptions and gait speed decline over the period.

Results  After 12 months, 24.47% of the participants experienced falls, and 37.24% showed a decline in UGS, with a mean baseline gait speed of 1.19 (±0.24) m/s. In intergroup comparisons, no significant differences were found in age, height, weight, physical activity level, or complications during the follow-up period between the groups with and without UGS decline. Similarly, no significant intragroup differences were observed between baseline and 12-month data for FoF or self-perceptions of general health and balance. Logistic regression analysis revealed no significant associations between self-perceptions and UGS decline.

Conclusion  Negative self-perceptions were not predictive of usual gait speed decline in community-dwelling older women.

Keywords
Risk Factors; Health of Older Adults; Aging; Self-Image; Active Mobility.

Resumo

Objetivo  Investigar a associação entre as autopercepções de condição de saúde geral, equilíbrio e de medo de quedas com o declínio da velocidade de marcha habitual (VMH) ao longo de 12 meses em um estudo prospectivo com mulheres idosas da comunidade em Ribeirão Preto, SP, Brasil.

Método  Trata-se de um estudo epidemiológico, observacional, analítico e prospectivo. Foram avaliadas 94 mulheres idosas independentes, as quais foram questionadas por um entrevistador sobre suas autopercepções de condição de saúde geral e de equilíbrio. Além disso, foi investigado a presença de medo de quedas (MQ). A VMH foi mensurada, tanto na linha de base quanto após 12 meses. A regressão logística binária, ajustada para variáveis de confusão, foi utilizada para examinar as associações entre as autopercepções e o declínio da VMH ao longo do período.

Resultados  Após 12 meses, 24,47% das mulheres idosas caíram, 37,24% das participantes apresentaram declínio da VMH, com velocidade média de marcha na linha de base de 1,19 (±0,24) m/s. Nas comparações intergrupos, não houve diferenças significativas nas variáveis de idade, altura, peso, nível de atividade física e complicações no período de seguimento entre os grupos que apresentaram e não apresentaram declínio de VMH. Também não foram observadas diferenças intragrupos entre os dados da linha de base e após 12 meses para MQ e autopercepções de condição de saúde geral e equilíbrio. A regressão logística não demonstrou associação significativa entre autopercepções e VMH.

Conclusão  Autopercepções negativas não se mostraram preditoras do declínio da VMH em mulheres idosas residentes na comunidade.

Palavras-chave
Fatores de Risco; Saúde do Idoso; Envelhecimento; Autoimagem; Mobilidade Ativa.

INTRODUCTION

Fear of falling (FOF) is associated with reduced physical performance, as demonstrated by tests such as the 30-second chair stand test, balance assessments, and the Timed Up and Go test¹-⁴. This fear can impair basic activities of daily living⁵, as older adults often avoid certain tasks when their confidence in balance is compromised⁶,⁷. Additionally, FOF has been linked to poorer quality of life, reduced social interactions, depression, and increased mortality among older individuals⁸,⁹. Evidence also suggests that self-perception issues—such as fear of falling, perceived balance, and general health status—are associated with adverse health outcomes, including higher hospitalization rates, depression, increased fall risk, activity restriction, negative impacts on quality of life, and gait alterations¹⁰.

Gait performance is a key component of individual independence. Slow gait speed is strongly associated with adverse health outcomes in older adults¹¹,¹², and is considered an important factor in the screening for sarcopenia, frailty, fall risk, cognitive decline, hospitalizations, and mortality⁵,¹³,¹⁴. Thus, investigating factors that may predict reduced gait speed is essential for identifying older adults at higher risk of morbidity and mortality. However, most studies published in the scientific literature have employed a cross-sectional design, limiting the ability to determine causative or predictive factors. Therefore, exploring the predictive value of self-perceptions for mobility decline is warranted.

Identifying the association between self-perceptions and gait speed decline over time may contribute to the early detection of older adults at risk of functional impairment. The use of brief, straightforward questions addressing self-perceptions may enhance screening strategies in primary care settings by facilitating the identification of individuals who require more comprehensive assessment and appropriate follow-up. Therefore, the aim of this study was to investigate the association between self-perceptions of general health status, balance, and fear of falling and gait speed decline over a 12-month period in a prospective study of community-dwelling older women in Ribeirão Preto, São Paulo, Brazil.

METHODS

A 12-month prospective, analytical, observational epidemiological study was conducted. The study included 94 independent and autonomous older women, aged 60 to 84 years, residing in Ribeirão Preto, São Paulo, Brazil, and surrounding areas, who agreed to sign the informed consent form. The study was approved by the Research Ethics Committee for Human Subjects at the Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas (approval number: 1.887.384). Assessments were conducted between March 2017 and May 2019.

Participants were recruited through direct contact and health education programs promoted by the Universidade de São Paulo. These programs aimed to promote older adults' health through physical and sports activities (such as dance, aerobic, and functional exercises), as well as educational lectures on various topics related to healthy aging. No prior sample size calculation was performed; instead, a convenience sample was used. To determine whether the study had sufficient power to detect a true effect, a retrospective power analysis was conducted using the sample size (n = 94), R² = 0.03, and effect size = 0.03, resulting in a power of 90%.

Inclusion criteria were women over 60 years of age with functional independence and adequate mobility (i.e., health conditions that allowed the performance of daily activities without assistance), living independently in their communities. Exclusion criteria included musculoskeletal conditions that interfered with functional tests, such as the presence of prostheses, chronic pain, fractures in the year prior to assessment, symptomatic spinal or lower limb disorders, neurological diseases, complaints of vertigo, decompensated cardiovascular disease, low scores on the Cognitive Screening Test (10-CS) according to education level (<8 points)¹⁵, and impaired protective foot sensation (failure to detect 10g pressure using Semmes-Weinstein monofilaments on the plantar surface)¹⁶. Additionally, participants who missed the follow-up assessment were excluded.

Assessments were conducted at the Laboratory of Balance Assessment and Rehabilitation (LARE) of the Universidade de São Paulo, Faculdade de Medicina (FMRP-USP). Participants were initially assessed and then reassessed after one year. All research procedures were conducted by three trained doctoral students in physical therapy. Data collected for participant characterization included age, weight, height, body mass index (BMI), fall history in the 12 months prior to the study, and the short version of the International Physical Activity Questionnaire (IPAQ)¹⁷. A fall was defined as unintentional contact with a support surface¹⁸.

Participants answered interviewer-administered questions regarding self-perceptions of general health status, balance, and fear of falling (FOF). The FOF question was direct: “Are you afraid of falling?” with response options: “1 = No, I am not afraid of falling” or “2 = Yes, I am afraid of falling.”¹⁹,²⁰ Self-perception of balance was assessed using the question: “How would you rate your balance?”, with response options: “1 = Very good,” “2 = Good,” “3 = Fair,” “4 = Poor,” and “5 = Very poor.”²⁰ General health status was assessed with the question: “In general, how would you rate your health?”, using the same five-point scale.²⁰

Following the self-perception questions, the usual gait speed (UGS) test was administered to assess mobility. The test was conducted on an 8-meter walkway, with only the central 5 meters timed to exclude the initial 1.5 meters (acceleration) and final 1.5 meters (deceleration). The test was performed three times, and the average UGS was calculated. The UGS test has demonstrated excellent test-retest reliability (ICC = 0.96–0.98)²¹.

After the baseline assessment, participants were contacted monthly by telephone over a 12-month period to monitor the occurrence of new falls and health complications. Health complications included acute conditions such as pneumonia, fractures, other illnesses, and/or surgeries. After 12 months, participants returned to LARE at FMRP-USP for follow-up assessments, during which the questionnaires and UGS test were repeated.

Statistical analyses were performed using the free software JASP 18.3 (University of Amsterdam, The Netherlands, JASP Team), with associations considered statistically significant at p ≤ 0.05. For all analyses, the reference category for fear of falling was “presence of fear.” For balance self-perception, the responses “very good” and “good” were grouped into a “positive perception” category. The responses “fair,” “poor,” and “very poor” were grouped as a “negative perception,” which served as the reference category. This categorization was based on the distribution of responses regarding balance self-perception. For general health perception, participants who responded “very good” or “good” were classified as having a positive health perception. Those who responded “fair” were grouped under “negative health perception,” as none of the participants selected the “poor” or “very poor” options.

Participants were initially divided into two groups based on the presence or absence of gait speed decline after one year. A reduction of at least 0.1 m/s at follow-up was considered indicative of decline²². To compare women who experienced gait speed decline with those who did not, independent t-tests were used for continuous variables (weight, height, age, BMI, UGS), and chi-square tests were applied to categorical variables (self-perceptions of balance, general health status, FOF, occurrence of health complications, and fall history). In addition, paired t-tests were used to assess within-group changes between baseline and the 12-month follow-up for variables related to self-perception. Effect sizes were calculated using Cohen’s d, interpreted as small (0.2), medium (0.5), and large (≥0.8). Finally, a multiple binary logistic regression was conducted to examine whether baseline self-perceptions of general health, balance, and FOF predicted UGS decline at 12 months, adjusting for age, history of falls, and physical activity level (IPAQ).

DATA AVAILABILITY

All data supporting the findings of this study are available from the corresponding author upon request.

RESULTS

A total of 127 women were recruited for the study. Of these, 27 declined to participate, two were excluded due to chronic low back pain, and four did not complete the 1-year follow-up (two participants died and two withdrew). Therefore, 94 older women were included in the final analyses. Among them, 37.24% experienced a gait speed decline of ≥0.1 m/s over 12 months, with a baseline mean gait speed of 1.19 (±0.24) m/s.

The baseline characteristics of participants in the groups with and without gait speed decline (e.g., age, height, weight, BMI, and physical activity level assessed by the IPAQ) were similar, with no statistically significant differences between groups (Table 1). Approximately half of the sample reported fear of falling (FOF) and a negative self-perception of balance. Most participants reported a positive self-perception of general health at baseline (74.36%) and after 12 months (Table 1).

Table 1
Characteristics of the study population. Values expressed as mean (standard deviation) and frequency from 2017 to 2019. Ribeirão Preto, SP, Brazil.

Variables	Participants (n=94)	HGS Decline (n=35)	No HGS Decline (n=59)	p	Cohen's d
Age (years), mean (SD)	68.40 (5.37)	68.14 (5.15)	68.86 (5.77)	0.96	0.01
Height (m), mean (SD)	1.54 (0.05)	1.55 (0.50)	1.54 (0.64)	0.72	-0.07
Weight (kg), mean (SD)	66.81 (10.81)	66.59 (11.99)	66.20 (9.29)	0.28	0.23
BMI (kg/m²), mean (SD)	27.90 (4.20)	27.94 (4.78)	27.51 (3.31)	0.17	0.29
Health complications during 12-month follow-up, n (%)	19 (20.2)	8 (42.11)	11 (57.89)	0.10	-0.34
IPAQ (METs), mean (SD)	1261.01 (1001.48)	1382.94 (1090.05)	1188.68 (947.30)	0.36	-0.19
Falls in previous 12 months, n (%)	23 (24.47)	15 (42.85)	8 (13.55)	0.54	-0.13
Fear of falling – baseline, n (%)	52 (55.31)	17 (48.57)	35 (59.32)	0.31	0.21
Fear of falling – 12-month follow-up, n (%)	51 (54.25)	18 (51.42)	33 (55.93)	0.67	0.09
Negative self-perception of balance – baseline, n (%)	49 (52.1)	18 (51.42)	31 (63.26)	0.91	0.02
Negative self-perception of balance – 12-month follow-up, n (%)	47 (50)	17 (48.57)	30 (63.82)	0.83	0.04
Negative self-perception of general health – baseline, (%)	24 (25.53)	8 (22.85)	16 (27.11)	0.41	0.17
Negative self-perception of general health – 12-month follow-up, n (%)	24 (25.53)	8 (22.85)	16 (27.11)	0.94	0.01

• BMI: Body Mass Index; IPAQ: International Physical Activity Questionnaire; UGS: usual gait speed; HGS: Hand grip strength; p-value comparing those who showed decline during follow-up with the baseline usual gait speed. Source: Data from the present study, 2019.

Among the health complications reported during monthly telephone follow-ups, two women were diagnosed with pneumonia (2.12%), one sustained a knee fracture (1.06%), one was diagnosed with anemia (1.06%), and two developed herpes zoster (2.12%). Additionally, five participants underwent surgeries (5.31%), and six reported pain (6.38%) in the hip (n = 1), spine (n = 2), and knee (n = 3). One woman experienced facial paralysis (1.06%), and another was struck by a vehicle (1.06%). After 12 months of follow-up, 24.47% of participants (n = 23) reported experiencing a fall.

No significant within-group differences were observed between baseline and 12-month follow-up for FOF (p = 0.84; Cohen’s d = 0.04), self-perception of balance (p = 0.65; Cohen’s d = 0.26), or self-perception of general health (p = 1.00; Cohen’s d < 0.001).

The multiple binary logistic regression, adjusted for age, history of falls, and physical activity level (IPAQ), showed no significant association between self-perception of balance (χ²(89) = 1.43, p = 0.83; Nagelkerke R² = 0.02), general health status (χ²(89) = 1.50, p = 0.82; Nagelkerke R² = 0.02), and fear of falling (χ²(89) = 2.33, p = 0.67; Nagelkerke R² = 0.03). None of the self-perception variables were predictive of gait speed decline over the 12-month follow-up period (p > 0.05) (Table 2).

Table 2
Association between baseline self-perceptions and gait speed decline after 12 months, from 2017 to 2019. Ribeirão Preto, SP, Brazil.

Multiple binary logistic regression
Independent variables (predictors)	β	Wald	p-value	OR (95% CI)
Fear of falling	-0.41	0.89	0.34	0.43 (–1.25 to 0.44)
Self-perception of balance	-0.01	0.001	0.97	0.44 (–0.88 to 0.85)
Self-perception of general health	-0.13	0.07	0.79	0.51 (–1.14 to 0.87)

• Source: Data from the present study, 2019.

DISCUSSION

In this study, among the 94 women, 24.47% reported falls during the follow-up period. No significant within-group differences were observed between baseline and 12-month follow-up data for self-perceived health status, balance, or fear of falling. Regarding between-group comparisons—i.e., those with and without gait speed decline after 12 months—there were no significant differences in height, weight, or BMI. In the logistic regression analysis, self-perception variables were not significant predictors of habitual gait speed decline at 12 months.

Gait speed is a widely used indicator for assessing mobility and functional health in older adults, influenced by various biomechanical, neuromuscular, and contextual factors (e.g., socioeconomic status, clinical conditions, access to healthcare services, cognitive function, lifestyle, and anthropometric characteristics)²². Studies have shown that higher habitual gait speed is associated with better health status, reduced risk of hospitalization, and greater independence in daily activities²³,²⁴. Conversely, a reduction in habitual gait speed may reflect functional decline, cognitive impairment, increased fall risk, frailty, and higher mortality²⁵.

Our results showed that more than half of the older women reported fear of falling (FOF) at the initial assessment (55.31%), and nearly one-third (37.24%) experienced a decline in habitual gait speed. The FOF rate observed in this study is higher than average compared to previous research. For instance, Eckert et al.³ reported a rate of 44.6%, while Lavedàn et al.²⁶ found a rate of 41.⁵%²⁶. One possible explanation for the higher FOF rate in our study may be the exclusively female sample. Previous studies have suggested that being female is associated with a higher risk of falls, potentially due to factors such as lower muscle mass, higher prevalence of osteoporosis, and a greater tendency to report health-related events. However, these studies included mixed-gender samples, with Eckert et al.³ including 76% women and Lavedàn et al.²⁶ including 60%. Nonetheless, our findings are consistent with previous research indicating that self-perceived balance does not predict negative outcomes. Specifically, balance self-perception did not predict falls after one year of follow-up in older adults²⁰.

In our sample, only 25.53% of the older women reported a negative perception of their general health status. The literature suggests that a negative self-perception of general health may predict falls among older women after one year of follow-up²⁰. However, such perceptions are less common in younger segments of the older population²⁷,²⁸, and are more frequently observed in very old adults, i.e., those over 80 years of age. The low percentage of negative health perception in our sample may therefore be related to the participants’ relatively younger age.

Physical activity level and health education are modifiable factors that can influence habitual gait speed²⁸, and are strongly recommended as preventive strategies against gait decline²⁹. Additionally, other factors such as muscle strength and adequate postural balance can help improve or prevent declines in habitual gait speed³⁰,³¹. Given that our statistical model also included physical activity level as a confounding variable, other unmeasured factors—such as muscle strength and postural balance—may have influenced the reduction in gait speed over the 12-month period.

This longitudinal study did not identify an association between fear of falling and habitual gait speed decline over 12 months, in contrast with cross-sectional studies that have found an association between fear of falling and slower gait speed³²,³³. A possible explanation for this discrepancy could lie in the duration or intensity of fear of falling, which may affect the restriction of daily activities in different ways and, consequently, influence gait speed variably. In a five-year longitudinal study—although habitual gait speed was not specifically assessed—independent older adults with fear of falling showed a progressive decline in functionality, including motor tasks, self-care, and domestic activities³⁴,³⁵.

Another variable analyzed was self-perception of balance: more than half of the sample (51.42%) reported a negative perception, although most of these individuals (63.26%) did not show a decline in habitual gait speed. This finding is not well documented in the current scientific literature, which limits the possibility of comparative analysis.

The 12-month follow-up period was a limitation of the study, as it prevented the assessment of whether the observed results would become more significant over time. Another limitation was that some participants were members of a health education group, which may have influenced their self-perceptions. Future research comparing groups of older adults who do and do not participate in health education programs could help clarify the impact of such programs on self-perception. It is also recommended that future studies include both sexes to analyze whether the interactions among self-perceptions of balance, general health status, and fear of falling occur similarly in men.

Although the Falls Efficacy Scale (FES-I) and the Activities-Specific Balance Confidence (ABC) scale are widely used, it is important to consider the feasibility of using more direct questions—such as those applied in this study—to assess self-perceptions of balance and health in clinical settings. In time-constrained scenarios, identifying quick and effective strategies to detect mobility-related risk factors may help optimize screening and early intervention.

CONCLUSION

Based on the results of this study, self-perceptions of fear of falling, general health status, and balance were not associated with a decline in habitual gait speed after one year of follow-up in community-dwelling older women. These findings highlight the importance of incorporating objective assessments—such as evaluations of muscle strength and neuromotor function—to identify older adults at risk of functional decline, thereby complementing subjective information. The longitudinal design strengthens the study by capturing functional changes over time, supporting the development of more effective interventions aimed at maintaining mobility in older adults.

• Funding
  Fundação Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES). Process Number: 88887.509001/2020-00, Process Code: 001. Masters scholarship.

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Edited by

• Edited by
  Larissa Neves Quadros

Publication Dates

• Publication in this collection
  11 Aug 2025
• Date of issue
  2025

History

• Received
  25 Nov 2024
• Accepted
  06 May 2025