Association between fear of falling and self‐care behaviours of older people with hypertension

Abstract Aim This study investigated the association between fear of falling and self‐care behaviours of older people with hypertension. Design A cross‐sectional study. Methods This study was conducted in 2019 on 301 older people with hypertension above the age of 60 years in Tehran, Iran. Data were collected using a demographic questionnaire, the Persian Falls Efficacy Scale‐International, and a hypertension‐related self‐care behaviour questionnaire. Results Analyses revealed that gender, educational level and history of falling were significant factors associated with fear of falling; and marital status, educational level and income source were significant factors associated with self‐care behaviours (p < 0.05). Partial correlations controlling for education revealed a significant positive correlation showing that high fear of falling is associated with worse health promotion self‐care behaviours and significant inverse correlations with psycho‐emotional, social and daily self‐care behaviours (p < 0.05), meaning that high fear of falling is associated with better self‐care for these dimensions. Patient or Public Contribution This study involved patients in order to evaluate the validity and reliability of the questionnaires. The study was conducted on older people with hypertension referred to hypertension clinics in hospitals.

cardiovascular chronic illnesses (DeWald et al., 2018). Antihypertensive and diuretic medications, polypharmacy and age-related physiological changes have been associated with an increased risk for falls and consequently fear of falling (FOF) particularly among older adults with hypertension (Kahlaee et al., 2018;Montero-Odasso et al., 2019). Ozaldemir et al. (2019) showed that hypertensive individuals have higher FOF and decreased functional mobility in comparison with normotensive individuals. This study included participants with a mean age of less than 60 years who had not identified comorbidities. Therefore, it expects FOF to be a more important issue in older adults with hypertension that usually have one or more chronic diseases and more risk factors for falls.

| BACKG ROU N D
Fear of falling (FOF) has influence on ability of older adults to carry out activities of daily living (Brustio et al., 2018;Hoang et al., 2017;Oh et al., 2017). The restriction of activities caused by fear is also barrier to older adult's presence in society and leads to activity avoidance (Bertera & Bertera, 2008;Mohammadi et al., 2018). Auais et al. (2017) found that FOF was associated negatively with life-space mobility and social participation of older adults in Canada, Albania, Colombia, and Brazil and is associated with higher levels of loneliness, lower life satisfaction, as well as lower levels of optimism, self-efficacy, selfesteem and more perceived stress (Hajek et al., 2018). Mahler and Sarvimaki (2012) found that Finnish older women cope with FOF by managing daily life with a strict daily regime and planning what to do next. Therefore, FOF can influence one's ability to be independent, including the self-care that is crucial to maintaining health and preventing complications in older adults with hypertension.
Self-care is the essential component for successful treatment of hypertension (Gholamnejad et al., 2019;Lee & Park, 2017).
Self-care is the personal care that individuals require on a daily basis to regulate their own functioning and development, and is affected by age, developmental stage, environmental conditions and effects of medical care (Orem, 2001). Fundamental principles for self-care include self-reliance, autonomy, personal responsibility, self-efficacy, community participation, community involvement and community empowerment (World Health Organization, 2020). In patients with hypertension, self-care behaviours encompass smoking cessation, weight management, physical activity and adherence to the diet and medication regimen that is recommended by hypertension guidelines (DeWald et al., 2018).
The association between FOF and ability to engage in self-care behaviours of older adults with hypertension is not clear, and studies are not asking this question. The aim of our study was to examine the association between FOF and self-care behaviours of older adults with hypertension.
The content validity of the Persian version of FESI and the hypertension-related self-care behaviour questionnaire was assessed by ten experts in the field of hypertension and ageing.
Moreover, the items' clarity and simplicity were assessed by ten older adults with hypertension. Necessary amendments were made based on the experts' and the older adult's comments. The reliability of the Persian version of FESI and the hypertension-related self-care behaviour questionnaire was assessed through internal consistency statistics. Cronbach's alpha values were calculated to be 0.9 and 0.8, respectively. Cronbach's alpha for the domains of hypertension-related self-care behaviour were 0.9 for physical, 0.9 for psycho-emotional, 0.9 for social, 0.5 for spiritual and 0.9 for daily self-care behaviours. Therefore, the reliability of the questionnaires was adequate.

| Statistical analysis
We first performed descriptive analyses. Kolmogorov-Smirnov tests confirmed the normality of the FOF and self-care behaviours variables (p < 0.05). Independent-sample t-tests, one-way analysis of variance and post hoc tests, and Pearson's correlation coefficient were used to evaluate the associations between sociodemographic, disease factors and FOF and self-care behaviours. After that, we developed multiple linear regression models to investigate the effects of sociodemographic, disease characteristics on FOF and self-care behaviours. Categorical variables were entered into the regression models as dummy/indicator variables in binary form with a reference category for each, for example gender (male = 1 with female = 0 as reference). Finally, partial correlations (partialling out educational level) were calculated between FOF and self-care behaviours. An alpha level of 0.05 was set to evaluate statistical significance. Data were analysed via the IBM SPSS v25.0 (IBM Corp).

| Ethical considerations
Participation in the study was voluntary and anonymous, with the possibility to withdraw at any time or refuse to answer any question without penalty. Participants filled out a written informed consent form and received an orally presented informed consent if they were illiterate. The study protocol was reviewed and ap-

| RE SULTS
The average age of the study participants was 68.6 with a range of 60-86 years. The means of systolic and diastolic blood pressure were 138.9 ± (13.3) and 87.2 ± (10.6) respectively. Other demographic and disease characteristics are shown in Table 1.
Male, and participants with a higher level of education, who were employed, and without a history of falling had higher FOF than those who were female, had lower level of education, had income source from charities, and had a history of falling (  (Table 2). Also, there were no significant correlations be- These variables accounted for 16.1% of the variance in FOF ( Table 3).
The score of self-care behaviours had significant correlations with participants' age (r = 0.2, p < 0.001) and duration of hypertension (r = 0.2, p < 0.001). Married older adults, participants with more education, employment and chronic diseases had on average lower self-care behaviour scores than those who were unmarried, had lower level of education, had income source from charities, and other chronic diseases (Table 2). Gender, living companion and history of falling had no association with self-care behaviours (Table 2).
Also, there were no significant correlations between the rate of systolic (r = 0.07, p = 0.22) and diastolic (r = 0.07, p = 0.20) blood pressure, or BMI (r = 0.02, p = 0.72) and self-care behaviours. When multiple linear regression was conducted to identify the factors that were associated with self-care behaviours, marital status, educational level and income source remained the significant predictors.
These variables accounted for 16% of the variance in self-care behaviours (Table 3).
Partial correlations (partialling out educational level) revealed a significant positive correlation between FOF and the mean score of the health promotion self-care behaviours, meaning that a high fear of falling is associated with worse health promotion self-care behaviours. Also, significant inverse correlations were found between FOF and the mean scores of psycho-emotional, social and daily selfcare behaviours, meaning that high fear of falling is associated with better self-care for these dimensions (Table 4).

| DISCUSS ION
This study aimed to examine the association between FOF and selfcare behaviours among older adults with hypertension.
Among the predictors of FOF, gender, educational level, income source and history of falling were the predictors of FOF. Men experience more FOF than women, which is against the findings of early studies (Hoang et al., 2017;Oh et al., 2017). Probably, age has an important role in these studies as FOF increases in older age (Hoang et al., 2017;Rivasi et al., 2020;Tomita et al., 2018). Our findings showed that participants' average age was less than 70 years and there was no difference between men and women. This age range has been known as 'young old' people, and men because of early retirement in Iran are less active than women, which probably causes more experiences of FOF.
Fear of falling (FOF) in older adults increases as the level of education and awareness of FOF increases. Dierking et al. (2016) and Oh et al. (2017) found that more education is a protective factor for FOF in older Mexican Americans and in Korea respectively. A higher level of education is likely an important factor for older adult's awareness of fall risk (Gholamnejad et al., 2019). An increase in awareness would lead to increased information, use of different sources and better social relationships. Therefore, older adults will know more about falling. Older adults without a history of falling had more FOF than older adults with falls. Gardiner et al. (2017) and Hoang et al. (2017) showed that a history of falls can lead to lower independence and more FOF. In addition to high blood pressure that inherently increases concern for falling, high burden of chronic diseases in this study and as showed in other studies is associated with  Note: In the fear of falling adjusted R 2 = 0.161, R 2 = 0.181 (F = 9.24 p < 0.001), In the self-care adjusted R 2 = 0.160, R 2 = 0.185 (F = 7.36 p < 0.001). programs. The findings of Gholamnejad et al. (2019) and Lee and Park (2017) revealed that education level and family support affected self-care behaviour in older patients with uncontrolled hypertension. Likely education leads to more general health and impetus for doing self-care behaviours. Education could lead to improvement in job status, social and financial matters, better lifestyle, lower psychological distress and consequently well-being and access to health services (Gholamnejad et al., 2019). Married older adults have a better family function than unmarried. They receive family support and help from people who are directly concerned about them, particularly their spouse. Therefore, marriage of older adults is along with improve in self-care behaviours of older adults.

TA B L E 4 Correlations between fear of falling and self-care behaviours
The main finding of this study was that the health promotion aspect of self-care decreased with increasing FOF. Health promotion self-care behaviours include specific self-care behaviours that are necessary to maintain and improve health status of older adults with hypertension. Learning of these behaviours needs capacity to obtain, process and understand necessary health information that is known as health literacy. Clarke et al. (2021) showed fear of recurrence in head and neck cancer survivors is associated with inadequate health literacy. On the other hand, older adults with hypertension must keep adherence to their therapeutic regimen because hypertension is a long-term disease that needs continuous attention. In addition, 82% of the sample had other chronic diseases that increase care burden and we know that cumulative effects of chronic diseases lead to FOF (Thiamwong & Suwanno, 2017). FOF in the long term will be a barrier to learning and using health promotion self-care behaviours.
Therefore, FOF seems to decrease health promotion self-care behaviours among older adults with hypertension.
In contrast to the result for health promotion behaviours, significant inverse associations were found between FOF and the dimensions of psycho-emotional, social and daily self-care behaviours.
Because higher scores on these dimensions indicate poorer selfcare, this means that higher FOF is associated with better functioning in these domains. Although former studies show that FOF is associated with poor activities of daily living (Brustio et al., 2018;Hoang et al., 2017), instrumental activities of daily living (Dierking et al., 2016), depression (Dierking et al., 2016;Hoang et al., 2017;Rivasi et al., 2020), psychological factors (Hajek et al., 2018), and family relationship (Dierking et al., 2016), we found higher FOF associated with a better psycho-emotional, social and daily selfcare behaviours. Highly probably, older adults with hypertension know about the consequences and complications of their disease, including risk of falling. Gardiner et al. (2017) showed that older adult's feeling 'at risk of falling' is a threat to personal identity, independence and social interaction. Dierking et al. (2016)

| Limitations
We had some limitations that may have affected the results our study. Firstly, the study sample was selected from only one of the provinces in Iran and the total sample size was limited. Secondly, we used a newly developed scale for self-care behaviours of older adults with hypertension that can requires further evaluation of reliability (particularly in the spiritual domain) and validity such as construct validity in future studies. A scale to measure specific self-care behaviours for older adults with hypertension was not available at the time of the study. Also, self-reported questionnaires with many items limits interpretation of the results because of problems such as fatigue and precise recall of events and information, particularly in an older population. Lastly, regression models for FOF and self-care did not explain much of the variation [< 20%], which perhaps can be improved in future studies.

| CON CLUS IONS
This study examined the effects of fear of falling from a multidimensional viewpoint in older adults with hypertension. The results of this study showed that FOF is significantly associated with self-care behaviours. Although higher FOF goes along with improved psychoemotional, social, and daily self-care behaviours, the health promotion self-care behaviours that are core for management and control of hypertension in older adults decreased with increasing FOF.

FU N D I N G S TATEM ENT
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors

ACK N O WLE D G E M ENTS
We would like to thank of Professor Judith Hall for English editing and reviewing. Hereby, authors feel obliged to extend their gratitude toward Shahid Beheshti University of Medical Sciences for their support to conduct this research.

E TH I C S S TATEM ENT
Permission to conduct the study was proved by the Ethics

Committee of Shahid Beheshti University of Medical Sciences (ap-
proval number: PHNM.1395.691). The researcher acquired written informed consent form and received an orally presented informed consent from all participants previous to data collection and their contribution in the study was optional and nameless, with the opportunity of backing away at any time or declining to answer any questions without fine.

CO N FLI C T O F I NTE R E S T S TATE M E NT
The author(s) declare that they have no conflict of interests.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request.
15. I consider the advice of the physician for next visit.
16. I forget the physician's recommendations.
17. I take medicines as order by my physician.