INTRODUCTION
1. Background and Significance
South Korea has already entered a super-aged society, with the proportion of adults aged 65 years and older increasing from 18.6% in 2023 to 20.6% in 2025 because of rapid population aging [1]. In addition, 23% of older adults in Korea live alone, of whom 81.9% are women [2,3]. According to the 2023 national survey of older people conducted by the Ministry of Health and Welfare [4], older women living alone tend to have lower educational attainment, are often unemployed, and have limited social functioning, making them physically and psychologically vulnerable. Although health problems in older adults appear in various forms, falls are among the most frequently occurring problems. A community-based survey conducted in an urban area found that a substantial proportion of health-related problems among older adults were fall-related [2]. Older adults who experience falls may require assistance with daily living because of functional decline, and falls may lead to chronic diseases requiring long-term clinical treatment, thereby increasing social costs. Costs associated with prolonged hospitalization and outpatient care, rehabilitation, and continuous caregiving are representative examples of this social and economic burden [5]. In addition to physical injury, falls cause a fear of falling, loss of self-efficacy, and gait limitation, which interfere with daily life, lead to social isolation, and ultimately worsen health status [2].
In particular, the fear of falling and post-fall syndrome can accelerate functional decline and are associated with increased mortality, causing older adults to limit their functioning and avoid daily activities [6]. Prior studies have reported that higher fear of falling is associated with depression and decreased quality of life [2,6-8]. The fear of falling has also been identified as a factor that directly affects the ability of community-dwelling older women to perform activities of daily living (ADL), thereby lowering their quality of life [6]. Therefore, attention should be paid not only to falls themselves but also to the fear of falling, which is relatively easy to overlook.
Above all, this study is particularly necessary because community-dwelling older women living alone are more active than older adults residing in facilities. Prior studies have reported that the prevalence and incidence of falls are higher among older women than among older men [9]. Moreover, older women are more susceptible to the perceived risk of falls and fear of falling [7,9]. In a European study [7], older women’s fear of falling was approximately 3.8 times higher than that of older men. The fear of falling is closely related not only to sociodemographic factors such as educational level and economic status but also to health-related factors such as the number of chronic diseases and ADL [10]. In addition, the fear of falling is reportedly related not only to women-specific issues such as fall experiences and pain but also to various environmental factors [3,9,10]. Ultimately, the fear of falling can limit basic ADL and physical activity ability [11]. In summary, prior studies have shown that the fear of falling increases with older age, living alone, being a woman, lower educational and income levels, more fall experiences, higher depression, and lower social participation [3,12-14].
Another notable issue in aging is change in sleep patterns. Sleep quality, which greatly affects human health and quality of life, has been reported to decline with age, as age is a predisposing factor in older adult sleep models [15,16]. In addition, Yoon [17] reported that nocturia or daytime sleepiness caused by sleep apnea may increase the risk of falls. Other prior studies on sleep quality reported that chronic illness and health-related problems, which are precipitating factors, and social isolation or loneliness, which are perpetuating factors, lower sleep quality [18]. As such, sleep quality, which is influenced by physical, psychological, social, and behavioral factors, is highly likely to affect older adults’ daily lives and cause health-related problems, leading to risk perceptions of falls and the fear of falling [12,13,16,17].
The senescent sleep model [19] classifies personal, physical, and psychosocial problems affecting sleep in older adults into predisposing, precipitating, and perpetuating factors, which lead to falls and negative health outcomes. Consistent with this theory, chronic sleep problems in community-dwelling older women living alone are likely to cause daytime fatigue and reduced activity, gradually leading to increased risk perception of falls or the fear of falling [17]. Therefore, it is necessary not only to identify the interrelationship between sleep quality and the fear of falling in community-dwelling older women living alone but also to systematically explain the complex factors influencing the fear of falling.
Although many studies have analyzed the causative factors for falls or the fear of falling, few have examined their relationship with sleep by applying the senescent sleep model. Studies addressing the complex issues faced by older women living alone, particularly those living in the community rather than in hospitals or facilities, and analyzing the correlation between sleep quality and the fear of falling and the factors influencing the fear of falling are also rare.
This study aimed to provide basic data for developing an age-friendly intervention program that can improve sleep quality, prevent the fear of falling, and ultimately promote the physical, psychological, and social health of community-dwelling older women living alone by analyzing sleep problems, which strongly influence fear of falling, through the application of the senescent sleep model.
2. Research Purpose
This study aimed to identify the factors influencing the fear of falling among community-dwelling older women living alone and, in particular, to examine its relationship with sleep quality by applying the senescent sleep model [19]. The specific aims were as follows:
1) To identify the general characteristics, sleep quality, and level of the fear of falling among community-dwelling older women living alone.
2) To identify differences in the fear of falling according to the general characteristics of community-dwelling older women living alone.
3) To identify the correlation between sleep quality and the fear of falling among community-dwelling older women living alone.
4) To identify the factors influencing the fear of falling among community-dwelling older women living alone.
3. Theoretical Framework
The conceptual framework of this study was based on the senescent sleep model, which was modified and applied to fit the purpose of the study by reflecting key factors related to the fear of falling, identified through a literature review. In particular, sleep quality was set as the primary independent variable, and the factors proposed in the senescent sleep model were expanded as variables influencing the fear of falling (Figure 1).
The senescent sleep model [19] classifies factors affecting sleep into predisposing, precipitating, and perpetuating factors. Predisposing factors refer to physiological changes associated with normal aging that lead to intrinsic changes in sleep, whereas precipitating factors refer to physical factors such as deteriorating health status or reduced physical function. Perpetuating factors refer to psychosocial factors such as social isolation, and the model explains that these factors interact to cause sleep disturbances and may further lead to various negative health outcomes, including falls, cognitive decline, depression, and reduced ADL function [19].
According to this theoretical framework, age and sex [15] were included as predisposing factors, and subjective health status [16] was set as a precipitating factor. In addition, social participation and depression were included as perpetuating factors to reflect psychosocial influences [20]. These factors were considered not only to influence sleep quality but also to ultimately affect the fear of falling. Therefore, this study sought to structurally examine how various factors influence the fear of falling together with sleep quality based on the senescent sleep model and to clarify the association between sleep quality and the fear of falling.
METHODS
Ethic statement: This study was approved by the Institutional Review Board (IRB) of the Hanyang University (IRB-HYUIRB-202401-007). Informed consent was obtained from the participants.
1. Study Design
This study was a descriptive correlational study based on the senescent sleep model [19] to identify the factors influencing the fear of falling among community-dwelling older women living alone. The study was reported in accordance with the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines (https://www.strobe-statement.org/).
2. Participants
The participants were women aged 65 years or older living alone in Seoul and Incheon. Using convenience sampling, older women registered at senior colleges, home-based care centers, and senior welfare centers who had no cognitive impairment, were able to communicate, and voluntarily agreed to participate were recruited.
The required sample size for regression analysis was calculated using G*Power 3.1.9.6. Based on the adjusted coefficient of determination (R2) reported in a previous study, an effect size of 0.107 was applied. With a significance level of .05, a power of .80, and predictors, the minimum required sample size was 157.
Considering the dropout rate, 190 participants were initially recruited. After excluding 12 questionnaires with insufficient responses, 178 questionnaires were included in the final analysis, yielding a response rate of 94%. Thus, the sample size was considered sufficient for regression analysis.
3. Study Instruments
1) General Characteristics
General characteristics included age, educational level, employment status, duration of living alone, participation in community activities, subjective health status, subjective economic status, and monthly income.
2) Fear of Falling
Fear of falling was measured using the tool developed by Yardley et al. [21] and translated by Heo et al. [22]. This instrument consists of 16 items rated on a 4-point scale ranging from 1 (very confident) to 4 (not confident at all). Total scores range from 16 to 64, with higher scores indicating greater fear of falling. A score of 24 or higher indicates high fear of falling, whereas a score of 23 or lower indicates low fear of falling. The coefficients of reliability (Cronbach’s α) were .96 at the time of development and .84 in this study.
3) Sleep Quality
Sleep quality was measured using the Pittsburgh Sleep Quality Index (PSQI), developed by Buysse et al. [23] and translated by Shin and Kim [24]. The total score ranges from 0 to 21, with higher scores indicating poorer sleep quality. Generally, scores of 0~4 indicate normal sleep, scores of 5~10 indicate poor sleep quality, and scores of 11~21 indicate sleep disturbance; a score of 5 or higher indicates sleep disturbance. The coefficients of reliability (Cronbach’s α) were .83 at the time of development and .84 in this study.
4) Depression
Depression was measured using the Korean version of the Geriatric Depression Scale, Short Form (GDSSF-K), adopted into Korean by Bae and Cho MJ [25] from the 15-item Geriatric Depression Scale (short form) developed by Sheikh and Yesavage [26]. This 15-item scale has a maximum score of 15 (the higher the score, the greater the depression); a score of 5 or higher is indicative of depression. The coefficient of reliability (Cronbach’s α) at the time of development by Sheikh and Yesavage was .88. Cronbach’s α in this study was .87 [26].
5) Social Participation
Social participation was measured using the social participation items from the national survey of older people [4]. Participants were asked to indicate whether they had participated in six social activities (leisure activities, fellowship group activities, political activities, volunteer activities, religious activities, and educational activities) during the past month. The scores for each item (yes=1, no=0) were summed to obtain a total score, with higher scores indicating greater social participation. The reliability coefficient of the tool in this study was Kuder-Richardson Formula 20 (KR-20)=.87.
4. Data Collection
With the cooperation of the heads of each institution, data were collected from December 10, 2023, to February 29, 2024, at senior colleges, home-based care centers, and senior welfare centers in Seoul and Incheon by recruiting participants who met the study criteria and administering questionnaires.
After explaining the purpose and content of the study and obtaining informed consent, data were collected using a structured questionnaire in a one-on-one interview format, with the researcher reading each item aloud and recording the participant’s responses. The survey took approximately 20–30 minutes on average.
5. Data Analysis
The collected data were analyzed using SPSS WIN 28.0 (IBM Corp.) following the following procedure.
(1) The participants’ general characteristics, depression, social participation, sleep quality, and fear of falling were analyzed using frequencies, percentages, means, and standard deviations.
(2) The fear of falling was analyzed in terms of general characteristics using t-tests and ANOVA, and post hoc testing was conducted according to Scheffé’s procedure.
(3) The relationships among variables related to the fear of falling, including social participation, depression, and sleep quality, were analyzed using Pearson correlation coefficients.
(4) Factors influencing the fear of falling were analyzed using hierarchical multiple regression.
6. Ethical Considerations
This study was conducted after approval from the Institutional Review Board (IRB) of Hanyang University (IRB-HYUIRB-202401-007). Before data collection, the participants were fully informed about the purpose and methods of the study, and were assured of confidentiality, anonymity, and that the data would not be used for any purpose other than the study. In addition, they were informed that participation was voluntary and that they could withdraw at any time during the survey. Written informed consent was obtained from participants who agreed to take part in the study.
RESULTS
1. General Characteristics
The general characteristics of the participants are as shown in Table 1.
By age, participants aged 70~79 years formed the largest group (n=68, 38.2%). They were followed by participants aged 80~84 years (n=56, 31.5%), 85 years and older (n=41, 23.0%), and 60~69 years (n=13, 7.3%) in that order. Regarding educational level, 134 participants (75.3%) had a middle school education or lower education, whereas 44 (24.7%) had a high school or higher education. For duration of living alone, 71 participants (39.9%) had lived alone for 5 years or less, 52 (29.2%) for 16 years or more, and 30 (16.9%) for 6~10 years.
Regarding community activity participation, 106 (59.6%) participated, whereas 72 (40.4%) did not. Most participants were unemployed (n=159, 89.3%), while 19 (10.7%) were employed. For living standard, “moderate” was the most common response (n=101, 56.7%), followed by “difficult” (n=72, 40.4%) and “well-off” (n=5, 2.8%). For monthly income, less than 300,000 KRW (South Korean Won) was reported by 59 participants (33.1%), 300,000~500,000 KRW by 58 (32.6%), and 500,000~700,000 KRW by 24 (13.5%). For subjective health status, the largest group reported “moderate” (n=96, 53.9%), followed by “poor” (n=47, 26.4%) and “good” (n=35, 19.7%).
2. Fear of Falling According to General Characteristics
The fear of falling according to general characteristics is presented in Table 1. The analysis showed significant differences in the fear of falling by age (p<.001). In the post hoc test, participants aged 85 years and older had the highest score (2.36±0.90), whereas those aged 60~69 years had the lowest score (1.38±0.23). Community activity participation also showed a significant difference (p<.001). Older adults who participated in activities at senior colleges and programs at senior welfare centers had a lower score of 1.52±0.29, whereas those who did not participate in community activities had a higher score of 2.03±0.91. Monthly income also showed a significant difference (p<.05). In the post hoc test, the group with a monthly income below 300,000 KRW had a higher score (1.85±0.74), whereas the group with a monthly income between 700,000 and 1,000,000 KRW had a lower score (1.32±0.44). Subjective health status also showed a significant difference (p<.001). In the post hoc test, those who perceived their health as poor had a higher score (2.19±0.84), whereas those who perceived their health as good had a lower score (1.38±0.46).
3. Fear of Falling, Depression, Social Participation, and Sleep Quality
The participants’ degrees of fear of falling, depression, social participation, and sleep quality are shown in Table 2. The fear of falling was 1.73±0.66 on a 1~4 scale, depression was 4.30±3.97 on a 0~15 scale, and social participation was 1.55±1.19 on a 0~6 scale. The degree of sleep quality was 10.91±1.76, close to the degree of sleep disturbance.
4. Correlations Among Depression, Social Participation, Sleep Quality, and the Fear of Falling
The correlations among depression, social participation, sleep quality, and the fear of falling are presented in Table 3. Depression showed a significant positive correlation with the fear of falling (r=.542, p<.001), whereas social participation showed a significant negative correlation with the fear of falling (r=-.309, p<.001). Sleep quality also showed a significant positive correlation with the fear of falling (r=.668, p<.001). These findings indicate that fear of falling increased as depression levels rose, social participation decreased, and sleep quality worsened.
5. Factors Influencing the Fear of Falling
A hierarchical regression analysis was performed to identify the factors influencing the fear of falling, as shown in Table 4. In Step 1, general characteristics and health-related variables that were significant in univariate analysis were included. The model was statistically significant (F=26.20, p<.001), and the explanatory power for the fear of falling was 42%. In Step 2, depression and social participation were additionally included. The model remained statistically significant (F=25.83, p<.001), and the explanatory power increased to 46%, representing a 4% increase compared with Step 1. In Step 3, sleep quality was also included. The model remained statistically significant (F=24.35, p<.001), and the explanatory power increased to 48%, representing a 2% increase compared with Step 2. In the final model, age (β=.29, p<.001), community activity participation (β=-.23, p<.001), depression (β=.29, p<.001), social participation (β=-.18, p=.004), and sleep quality (β=.37, p<.001) were significantly associated with the fear of falling.
The tolerance values ranged from 0.74 to 0.90, all above 0.1, and the variance inflation factor (VIF) values ranged from 1.07 to 1.72, all below 10, indicating no multicollinearity problems. These results indicate that, among the various factors influencing the fear of falling, depression, social participation, and sleep quality were particularly important.
DISCUSSION
This study, which was based on the senescent sleep model [19], aimed to identify factors influencing the fear of falling among community-dwelling older women living alone and, in particular, to examine its relationship with sleep quality. The significant variables influencing the fear of falling among community-dwelling older women living alone were age, community activity participation, depression, social participation, and sleep quality.
In the hierarchical regression model, sleep quality, added in the final step, was one of the major variables influencing the fear of falling and explained an additional 2% of the variance, compared with the 4% explanatory power of depression and social participation. Sleep hygiene is a basic human need and an important component of health-related quality of life that relieves psychological stress accumulated during the complexity of daily living and promotes psychological stability; it is also an important factor influencing the fear of falling, which can lead to multiple health problems [17,27,28]. These findings are consistent with the results of Stone et al. [27], Kakazu et al. [28], who studied sleep quality and fall causation in community-dwelling older women.
In Yoon’s study [17], with a research context similar to the present study, the mean sleep quality score was 6.24±3.91, which was relatively mild compared with the score of 10.91±1.76 in this study. The difference in sleep quality scores despite similar circumstances may be attributed to the fact that the participants in this study were not older adults in general but community-dwelling older women living alone. In other words, older women living alone are more likely to experience complex and comprehensive physical and psychosocial difficulties, such as loneliness due to prolonged isolation, financial hardship, depressive emotions due to long-term chronic illness, and lowered self-esteem due to low educational attainment [8,18]. Consequently, older women living alone may have relatively poorer sleep quality than older adults in general, and the poor sleep hygiene may be associated with increased fear of falling [18]. Therefore, practical sleep hygiene improvement programs and policy development tailored to the environment and circumstances of community-dwelling older women living alone are urgently needed.
Depression and social participation are perpetuating factors in the senescent sleep model that may adversely affect sleep quality. This study included age, community activities, employment status, monthly income, and subjective health status in Step 1 to identify the relative influence of variables affecting the fear of falling and added depression and social participation in Step 2. The explanatory power increased from 42% in Step 1 to 46% in Step 2, representing a 4% increase, indicating that depression and social participation, together with sleep quality, were major variables with high explanatory power. Seo and Lee [6], who studied the relationship between fall experiences and the fear of falling, found that older women living alone experience depression to varying degrees and that depression increases the fear of falling, leading to anxiety and even psychological fear, which is highly consistent with the findings of the present study. In addition, survey findings have shown that older adults experiencing depression also report sleep disturbances, suggesting that depression not only affects the dependent variable, fear of falling, but also has a considerable effect on the independent variable, sleep quality. Therefore, sleep hygiene management in older adults should be carried out alongside interventions addressing psychological problems such as depression.
Participants’ social participation score was relatively low at 1.55±1.19 on a 0~6 scale, and among the general characteristics, community activity participation showed that older adults who participated in activities had a low fear of falling score of 1.52±0.29, whereas those who did not participate had a higher score of 2.03±0.91. This suggests that participants with low community activity or social participation experienced greater fear of falling. However, Hong et al. [20], who showed a different causal direction compared with the present study, identified the fear of falling as a factor affecting restrictions on social activity among older women. In other words, in the present study, social participation, which was an independent variable influencing the fear of falling, acted as a dependent variable in the opposite direction. As older adults age, complex physical and emotional problems arise, leading to social isolation and restricted social participation, which in turn increases the fear of falling. This suggests that social participation and the fear of falling have a complex relationship in which the two variables strongly influence each other, yet their temporal order is difficult to clearly distinguish.
Among the results related to the fear of falling, age—one of the participants’ general characteristics and a predisposing factor in the senescent sleep model—was highest among those aged 85 years and older, at 2.36±0.90. As in Kim and Hong [29], many prior studies [2,5,10] have also shown that the fear of falling increases with age, leading to reduced participation in social or community activities, which, along with social isolation, decreases muscle strength and adversely affects older adults’ health.
In Kakazu et al. [28], unlike the present study, falls and the resulting fear of falling were found to be more common among older adults in their 60s and 70s than among those aged 80 years and older. This may be because older adults who are relatively younger are more active and may not have received proper education or awareness about falls, so falls occur more often in the early and middle stages of old age, and fall experiences then lead to fear of falling. These findings suggest that age should be segmented more finely to analyze fall-related issues specific to each age group. However, since age is an uncontrollable demographic factor, managing the major variables that can be adequately adjusted and controlled—depression, social participation, and sleep quality—would be a much more effective approach to preventing the fear of falling and improving quality of life.
Subjective health status, a health-related issue and a precipitating factor, also showed a significant difference. Older adults who perceived their health as poor had a higher fear of falling score of 2.19±0.84, which is consistent with findings from many studies on the fear of falling, including Seo and Lee [6], Um and Hwang [10], and Lee and Lee [3]. In particular, Park and Shin [2] reported that the fear of falling increases with the number of chronic diseases, because prolonged chronic illness leads to negative perceptions of one’s health, which in turn worsens subjective health status and increases the fear of falling.
Notably, although subjective health status was a significant variable for the fear of falling in several previous studies, in Step 1 of the hierarchical regression analysis in this study, it became a non-significant variable after depression, social participation, and sleep quality were considered. This finding again demonstrates that depression, social participation, and sleep quality, which showed high explanatory power among the variables, are key factors influencing the fear of falling.
Among the general characteristics, monthly income, which partially reflects economic status, showed a somewhat higher fear of falling among participants with an income below 300,000 KRW (1.85±0.74). This finding is similar to that of Moon and Hong [14]. Han [12], who examined the relationship between age-friendly housing environments and the fear of falling, also reported an association between the fear of falling and economic status or housing environment. However, the present study did not find that economic factors significantly influenced the fear of falling. Nevertheless, economic factors are related to perpetuating factors such as depression and social participation, and a vulnerable economic status and poor living conditions of older women living alone are expected to indirectly affect the fear of falling by causing health inequalities and psychosocial withdrawal.
Overall, while applying the senescent sleep model [19], this study sought not only to emphasize sleep quality but also to align with the study’s purpose of providing interventions prioritized according to the special circumstances of community-dwelling older women living alone. The study is meaningful in that it focused on stepwise identification of the relative influence of factors affecting the fear of falling. Therefore, sustainable management practices are needed to improve sleep quality, depression, and social participation; reduce the fear of falling; and improve health-related quality of life in older adults.
Um and Hwang [10], Moon and Hong [14], and Kakazu et al [28] have shown that fear of falling can lead to actual falls. Therefore, healthcare researchers should analyze the factors influencing the fear of falling, closely examine the relationship between the fear of falling and actual fall incidence, and establish systematic measures to fundamentally address fall-related problems among community-dwelling older women living alone.
CONCLUSION
This study was conducted to identify the relationship between the fear of falling and sleep quality and to determine factors influencing the fear of falling among community-dwelling older women living alone. The results showed that the explanatory power differed when general and health-related factors influencing the fear of falling were first considered for community-dwelling older women living alone and when depression, social participation, and sleep quality were in turn included subsequently. Consequently, in the final model, the significant variables influencing the fear of falling were age, community activity participation, depression, social participation, and sleep quality; among these, depression and social participation showed the highest explanatory power, and sleep quality, included in the final step, was also a major variable influencing the fear of falling. Therefore, to prevent the fear of falling among community-dwelling older women living alone, management strategies are needed to improve depressive mood and social isolation, which are psychosocial problems, and to enhance sleep quality.
This study is expected to provide basic data for developing social activity participation programs, tailored sleep hygiene management, and fear of falling prevention programs according to the demographic, physical, and psychosocial characteristics of community-dwelling older women living alone.
A limitation of this study is that the data were collected mainly from participants residing in Seoul and Incheon, which limits the generalizability of the findings. Moreover, the use of a structured questionnaire may have insufficiently reflected the diversity of responses. Therefore, future studies should include participants from diverse regions. Follow-up studies using qualitative or mixed-methods research are also needed to gain a deeper understanding of the psychological and emotional characteristics and lived experiences of older women living alone.
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