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Background Falls are the leading cause for non-fatal injuries in older community-dwelling people. Compared to men, women fall more often, experience more fall-related injuries, and report fear of falling (FoF) more often. Falls may be prevented with specific exercises, but adherence is often low in long-term. One aim of the thesis was to gain a deeper understanding of the risk factors previous falls, FoF, and gender. Another aim was to explore safety strategies in older community-dwelling people in terms of fall risk awareness and actions taken to protect from falls, and to identify motives for exercising and preferred exercise properties. A gender perspective was used throughout the thesis.

Methods To determine the impact of the risk factors on future falls and injurious falls, a cross-sectional design was used combined with longitudinal data. Baseline data from 230 community-dwelling people over 75 years were collected with questionnaires and performance-based tests. FoF was measured with the single item question “Are you afraid of falling?”. Monthly fall calendars were collected for one year (monitoring year). Based on status on falls, participants were classified as those with i) no falls (n=119), ii) 1 non-injurious fall (n=51), iii) ≥2 non-injurious falls (n=40), and iv) ≥1 injurious fall (n=20). These data were linked to data from an injury database (IDB) with respect to registered injurious falls for a period of about 5 years (long term follow-up). Andersen-Gill method of Cox regression for multiple events was used to estimate the risk of future injurious fall events. To find relationships between FoF, gender, and falls (defined as two or more falls), a general log-linear analysis was performed. Associations between FoF and the components of the International Classification of Functioning (ICF) were explored with a structural equation model. To explore fall risk awareness and safety strategies, and to identify motives and preferred exercise properties, qualitative study design was used. Multistage focus groups were held with 18 community-dwelling people (10 women and 8 men) between 70 and 80 years. Transcriptions were analysed with qualitative content analysis.

Results Fourty-eight per cent of the 230 participants fell at least once during the monitoring year, and 23% experienced recurrent falls. Compared to men, women reported FoF more often, but did not experience more recurrent falls, and no more injurious falls. FoF was significantly associated with the ICF components Activity/Participation and Personal Factors in women and men both; but in opposite directions for women and men on Personal Factors. During the long-term follow-up, 91 injurious falls were registered in 70 participants (30%). Those with injurious falls during the monitoring year were at significant risk of experiencing new injurious falls in long-term (HR 2.78; 95% CI 1.40-5.50), compared to those with no falls. Women experienced a higher rate of fractures than did men. Analyses from the multistage focus groups resulted in three categories: Facing various feelings; Recognizing one’s fall risk; and Taking precautions. A comprehensive theme tied them together: Safety precautions through fall risk awareness. Analyses also resulted in six categories identifying preferred exercise properties in the context of falls prevention: Motives to start exercise; Barriers to start exercise; Exercise characteristics; Confirmation; Spirit lifters; and Maintenance tricks. All categories included sub-categories. Both studies revealed greater variations among women and among men than between women and men.

Conclusion Community-dwelling people over 75 years who have experienced an injurious fall are at high risk of sustaining new injurious falls the forthcoming five years, and should be offered multifactorial fall risk assessments with targeted interventions to optimize the prevention of future falls. The single item question “Are you afraid of falling?” has no predictive value for future falls, and the answer may be strongly gendered. The questions should therefore be avoided in clinical practice and research in community settings. The participants of the qualitative studies implicity and explicitly described how they had become aware of fall risks in everyday life, and both women and men took precautionary actions. Raised fall risk awareness was achieved by several channels including the media, and by meeting with peers and professionals with expertise in falls prevention. A wide variety of preferred exercise properties in the context of falls prevention were identified among the older community-dwelling people. The variations of the requests were greater among women and among men than between women and men. The results should be taken into consideration when offering exercise-based falls prevention interventions to older people. The results from this thesis indicated that measures can be taken on a broad front in order to reduce the damage from injurious falls in older community-dwelling people. A gender perspective is warranted for in clinical practice and future research. Adopting a gender perspective may broaden the understanding of gender differences and similarities when implementing falls prevention activities.