Amendments from Version 1

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10.12688/f1000research.126690.2

Research Article

Articles

Reliability of the 44-question Home Fall Hazard Assessment Tool and personal characteristics associated with home hazards among the Thai elderly

[version 2; peer review: 1 approved, 1 approved with reservations]

Wittayapun

Yuwadee

Data Curation Investigation Methodology Writing – Review & Editing 1 2 Nawarat

Jiraphat

Investigation Methodology Supervision Writing – Review & Editing https://orcid.org/0000-0001-7121-2519 1 2 Lapmanee

Sarawut

Investigation Supervision Writing – Original Draft Preparation Writing – Review & Editing https://orcid.org/0000-0002-8890-9109 3 Mackenzie

Lynette

Investigation Methodology Supervision Writing – Review & Editing https://orcid.org/0000-0002-1597-2051 4 Lektip

Charupa

Conceptualization Data Curation Methodology Project Administration Writing – Original Draft Preparation Writing – Review & Editing https://orcid.org/0000-0002-8348-3399 a 1 2 1Department of Physical Therapy, School of Allied Health Sciences, Walailak University, Nakhon Si Thammarat, 8016, Thailand 2Movement Science and Exercise Research Center, Walailak University, Nakhon Si Thammarat, 80160, Thailand 3Department of Basic Medical Sciences, Faculty of Medicine, Siam University, Bangkok, 10160, Thailand 4Discipline of Occupational Therapy, School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, 2141, Australia

a charupa.le@wu.ac.th

No competing interests were disclosed.

9 3 2023

2023

2 3 2023

2023

This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background: The 44-question Thai Home Fall Hazard Assessment Tool (Thai-HFHAT) was developed to assist healthcare professionals in identifying the risk of falls among community-dwelling elderly from their home environment. However, the reliability of this tool has not been studied. This study aimed to examine reliability of the 44-question Thai-HFHAT and determine the person characteristics associated with home hazards.

Methods: A descriptive cross-sectional study design was used for this research. The participants in this study were 51 elderly people from various types of Thai houses: a one-story elevated house, a one-story non-elevated house, and a house with two or more floors, 51 caregivers of elderly patients and 5 village health volunteers (VHV). All participants answered 44 Thai-HFHAT questions to determine inter-rater and test-retest reliabilities. The reliabilities were analyzed using an intra-class correlation coefficient (ICC). Personal characteristics including sex, occupation, and education were used to identify the factors affecting home hazard and linear regression was used to analyze.

Results: The ICC of inter-rater reliability of the 44-question Thai-HFHAT was 0.74 (95% CI: 0.57-0.84) and the test-retest reliability was 0.80 (95% CI: 0.64-0.88) for the elderly, 0.80 (95% CI: 0.65-0.89) for the caregivers and 0.70 (95% CI: 0.477-0.83) for the VHV. Personal business career and education level grade 1-3 are less than 0.05, which showed these factors had a significant relationship with the 44-question Thai-HFHAT score as dependent variable.

Conclusions: The 44-question Thai-HFHAT is suitable for the home hazards assessment among the elderly in Thailand. Further studies are needed to investigate changes in the house environment after using the 44-question Thai-HFHAT to determine which changes can reduce the risk of fall.

elderly falling hazard control prevention reliability

Walailak University

WU-IRG-63-079

This study was granted by Walailak University (Grant Number: WU-IRG-63-079).

The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Revised Amendments from Version 1

- I added the inclusion criteria using the Barthel ADLs Index and the Mini-Mental State Examination-Thai 2002 to be more precise. - I used the word "participants" rather than "subjects". - In Table 1, I used only descriptive statistics to describe the table. - I used Tomita MR et al, 2014 to analyze and compare with my research written in the discussion part.

Introduction

Falls among the elderly are considered a major public health problem, becoming the second leading cause of death and unintentional injuries ¹ ( https://www.who.int/news-room/fact-sheets/detail/falls). Thailand’s Department of Disease Control has predicted that during 2017-2021, falls among the Thai elderly will account for 27.0% of deaths in the elderly, resulting in a death rate due to falls among Thais of 50 per 100,000 populations https://www.dop.go.th/th/know/side/1/1/1159.

The precipitating cause for falls in the elderly involved the interaction of various risk factors categorized as intrinsic or extrinsic. ² Muscle weakness of the lower extremities and balance impairment were the most important intrinsic factors for the fall. ³ In addition, extrinsic factors such as poor housing conditions, inadequate lighting, or slippery floors were also considered mediators in precipitating falls. ⁴ However, most of the evidence comes from high-income countries. Despite the significant burden of falls, prevention strategies are not prioritized in the policy agendas of government in low- and middle-income countries. ⁵ Therefore, identifying potential hazards in Thai houses with an appropriate home hazard screening tool is an effective measure to prevent falls and reduce the risk of falls among the elderly. ⁶

In Thailand, Thai Fall Risk Assessment Test (Thai-FRAT) is a widely used tool to screen risks of fall. ⁷ ^– ⁹ Of a total of 6 items of Thai-FRAT, there is only one item to evaluate home environmental risk: “Do you live in a traditional Thai house built with an elevated ground floor exceeding 1.5 meters?”. Therefore, the 69-question Thai Home Falls Hazards Assessment Tool (Thai-HFHAT) was designed as a self-reported screening tool to assess the risk of falls at home and is considered suitable for use in Thailand. Psychometric properties of the 69-question Thai-HFHAT were acceptable. ¹⁰ However, it is time-consuming and difficult for elderly users to precisely complete all questions.

A subsequent study investigated the development of the 44-question Thai-HFHAT based on the instrument design and methodology of the original Thai-HFHAT. The Cox proportional hazard model using stepwise variable selection methods was used to re-design the 69-question Thai-HFHAT. ¹¹ There was a report of psychometric properties of 44-question Thai-HFHAT as the adjusted hazards ratio (HR) was 1.26 (95% CI: 1.20-1.33), a cut-off was 18 points, the sensitivity and specificity were 0.93 and 0.72, and the area under the receiver operating characteristic curve (AuROC) was 0.90. ¹² In addition, the study also found that the 44-question Thai-HFHAT requires only 30 minutes for elderly users to complete all the questions. Occasionally, due to the inability to answer all the elders' questions in practice, the remaining questions were answered by a caregiver or a village health volunteer for the elders. However, the reliability of this tool has not been studied. In order for the 44-question Thai-HFHAT to have psychometric properties in all aspects, a reliability study is required.

Studies on home hazards frequently investigate the area where the hazards are present, the numbers of hazards in the home and how these hazards could contribute to falls. ¹³ ^, ¹⁴ Such a unilateral approach does not take into account the characteristics of elderly and how these might make the home environment more hazardous. Romli et al., 2018 was to investigate the elderly’s characteristics that contribute to home hazards. Lower educational attainment, greater number of home occupants, lower monthly expenditure, traditional housing, Chinese ethnicity and younger age were the factors associated with home hazards. ¹⁵ The researcher proposes that elderly Thai participants’ characteristic will correlate with the number of home hazards Therefore, this study also aimed to determine the Thai elderly’s characteristic factors contributing to home hazards.

Methods Ethical approval statement

This study was approved by Institutional Review Board of Walailak University (approval number WUEC-20-302-01) on September 16, 2020.

Informed consent

Written informed consent was obtained from each of the participants.

Study design

A descriptive cross-sectional study design was used to study the area at risk of falling, personal factors, and reliability of the 44-question Thai-HFHAT. This study was conducted in Tha Khuen Sub-District, Tha Sala District, Nakhon Si Thammarat.

Participants

The target population consisted of Thai elderly aged 60 years or over, with a total number of 2,552 adults residing in Tha Khun Subdistrict, Tha Sala District, Nakhon Si Thammarat Province ( https://www.dop.go.th/th/know/1). Inclusion criteria were those who achieved fluency in the Thai language. Exclusion criteria were those who could not perform activities of daily living (ADLs) according to Barthel ADLs Index, those who were completely dependent or disabled (ADL scores: 0-4), and had dementia determined by the Mini Mental State Examination-Thai 2002 those who received no formal education had MMSE-Thai scores of ≤14, when the elderly who received only upper secondary education had scores of ≤17, and when the elderly who continued their education received a score of ≤22. ¹⁶ Researchers approached the particicpants at their homes to explain the study. 51 elderly people, who passed the exclusion and exclusion criteria as above, were chosen because this number was adequate for examining inter-rater reliability and test-retest reliability. ¹⁷ Participants were selected by stratified and quota sampling and categorized according to three types of Thai houses: one-story elevated house, one-story non-elevated house, and a two or more-story house. In addition, 51 caregivers who spend the most time caring for the elderly and five village health volunteers (VHV) with more than five years of experience were also recruited to examine inter-rater reliability for the level of reliability of the 44-question Thai-HFHAT. These different groups were chosen to help identify whether each group of participants can be replaced by other groups when assessing the hazards in the event the elderly paticipant cannot complete the instrument by themselves in real life.

Research instruments

The 44-question Thai-HFHAT

The Thai-HFHAT is composed of 44 questions grouped into 7 sections/rooms. 4 items were used to assess hazards in a living room, 4 in a kitchen room, 5 in a garage, 6 for house curtilage, 7 in stairs, 8 in a bedroom, and 10 in a bathroom. Also, the instrument contained a drawing for each room to help the elderly to identify hazards more easily.

The Barthel Activities of Daily Living Index

This is an assessment tool for evaluating ADLs for the performance of daily activities by elderly in 10 activities. ¹⁶ The elderly participants were then classified into three groups according to the scores received: those who were completely independent and able to help others (ADL scores: ≥12), those who were moderately dependent and spent most of their time in their home (ADL scores: 5-11), and those who were completely dependent or disabled (ADL scores: 0-4).

The Mini Mental State Examination-Thai 2002 (MMSE-Thai 2002)

This is a Thai version of the cognitive impairment assessment tool for the Thai elderly. ¹⁶ The cognitive impairment of the elderly can be preliminarily determined when the elderly who received no formal education had MMSE-Thai scores of ≤14, when the elderly who received only upper secondary education had scores of ≤17, and when the elderly who continued their education received a score of ≤22.

Data collection

Data on demographic characteristics of the elderly, caregivers, and VHVs were collected. Three groups of study participants were asked to fill out the 44-question Thai-HFHAT. They were instructed to enter each room in their home and answer a list of questions for assessing fall hazards in each room using a guided drawing. Scoring of potential hazards from the screening tool was performed. High scores have been associated with an increased risk of falls. The study participants were informed to complete the screening tool within 30 minutes. The hazard areas, the participant’s characteristic factors, and inter-rater reliability were conducted after obtaining data from all participants.

All three groups were instructed to perform the second assessment a week later ¹⁵ so that researchers could collect more data for examining test-retest reliability. During the assessment, the elderly, caregivers, and VHV participants had to independently answer assessment questions, and no conversation was permitted. We considered the intraclass correlation coefficient (ICC) with values ranging from 0 to 1 suitable for the evaluation of inter-rater and test-retest reliability. The ICC results were classified as follows: values between 0.00-0.49 were classified as poor reliability, values between 0.50-0.74 as moderate, values between 0.75-0.90 as good, and 0.91-1.00 as excellent. ¹⁸ Data collection started in July 2021 and ended in August 2021.

Data analysis

All data were recorded and entered using the statistical package software version 22 (SPSS Inc. Chicago, IL, USA). Mean and standard deviation (SD) were used to analyze the participants’ characteristics. Frequency and percentage were used show the data of home hazard areas. Inter-rater and test-retest reliabilities were evaluated using an intra-class correlation coefficient (ICC), that is, ICC (2, k) and ICC (3, k), respectively. Mean score differences between the elderly, caregivers, and VHV participants were evaluated using a One-Way ANOVA. Differences in mean scores from the first and the second visits (1 week apart) were analyzed using an independent-samples t-test. We used multiple linear regression to predict the independent factors, consisting of sex, occupation, and education level, affecting the 44-question Thai-HFHAT score. ¹⁹ ^, ²⁰ Information bias may arise from the use of the 44-question Thai-HFHAT. The researcher explained the assessment tool to the participants to help them understand the objectives, and that the presentation of the results that will be anonymized. So, nobody knows how each participant will be evaluated, so that participants are confident that there will be no impact from the actual assessment.

Results

This study included 107 study participants, and the demographic characteristics of all participants and fall history of the elderly participants are shown in Tables 1 and 2, respectively. 59% of the elderly lived in a one-story non-elevated house, 55.8% had blurred vision, and 86.5% demonstrated normal balance ability (≥10 seconds of tandem standing). The underlying diseases of the elderly participants included hypertension (46.2%) and hyperlipidemia (44.2%). Most caregivers had a close relationship with the elderly participants (53.9%). The mean (±SD) duration of caregiving in the caregiver group was 21.73 (±5.71) hours/day or 6.88 (±0.83) days/week. The mean (±SD) working experience of the VHV participants was 12.96 (±6.63) years.

Table 1. Demographic characteristics of study participants.

Characteristics	Elderly (n = 51)	Caregiver (n = 51)	VHV (n = 5)
Characteristics	n (%)	n (%)	n (%)
Sex
Men	20 (39.2)	23 (45.1)	0 (0.0)
Women	31 (60.8)	28 (54.9)	5 (100.0)
Mean ± SD age in years	73.40 (7.21)	58.12 (15.82)	45.5 (6.24)
Mean ± SD BMI in kg/m ²	25.67 (1.23)	22.71 (3.81)	22.33 (4.45)
Education level
Grades 1-3	44 (86.3)	19 (37.3)	1 (20.0)
Grades 4-6	3 (5.9)	12 (23.5)	3 (60.0)
Above grade 6	4 (7.8)	20 (39.2)	1 (20.0)
Marital status
No partner	6 (11.8)	6 (11.8)	1 (20.0)
Have a partner	45 (88.2)	45 (88.2)	4 (80.0)
Occupations
Housekeeper	30 (58.8)	19 (37.3)	2 (40.0)
Agriculture	12 (23.5)	23 (45.1)	2 (40.0)
Personal business	9 (17.7)	9 (17.7)	1 (20.0)

VHV, village health volunteers.

Table 2. Fall history of the elderly participants (n = 51).

Falling history	n (%)
History of falling in the previous 6 months
Yes	14 (27.5)
No	37 (72.6)
The cause of falling
Tripping	8 (57.1)
Loss of balance	5 (35.7)
Slip	1 (7.1)
Fall injury
No	7 (13.5)
Sprain	3 (5.8)
Scratch	3 (5.8)
Fracture	3 (5.8)

The areas at the most risk of fall risk are the bathroom (94.1%), bedroom (74.5%), living room (56.9%), kitchen room (37.3%), around the home (35.3%), garage (25.5%), and stair in the home (7.8%), respectively. The risk of falling in each room is shown in Figure 1.

Figure 1. The areas at risk of fall in home. Inter-rater reliability

The ICC for the 44-question Thai-HFHAT was 0.74 (95% CI: 0.57-0.84). The mean (±SD) scores of the elderly, caregiver, and VHV groups were 6.65 (±3.29), 5.37 (±3.22), and 4.88 (±2.65), respectively. The mean difference in scores for all three groups was statistically significant ( p = 0.012), as shown in Figure 2.

Figure 2. The average scores of Thai-HFHAT for the 1 st and 2 nd time of the participants. Test-retest reliability

The ICC for the 44-question Thai-HFHAT was 0.80 (95% CI: 0.64-0.88) for the elderly group, 0.80 (95% CI: 0.65-0.89) for the caregiver group, and 0.70 (95% CI: 0.48-0.83) for the VHV group. The mean difference in scores obtained before and after one week of the assessment of the elderly ( p = 0.283), caregiver ( p = 0.604), and VHV ( p = 0.984) groups was not statistically significant. The average scores of the 1 ^st and 2 ^nd time of the elderly, caregivers, and VHV are shown in Figure 2.

Personal characteristics associated with home hazards

As shown in Table 3, the values of variance inflation factor (VIF) are all less than 5 and all the tolerance values are more than 0.10. ¹⁹ The p-value for all independent variables, that is, personal business career and education level grade 1-3 are less than 0.05, which shows they have a significant relationship with the dependent variable, 44-question Thai-HFHAT score.

Table 3. Regression analysis for predicting 44-question Thai-HFHAT score <xref ref-type="table-fn" rid="tfn1"> a </xref>.

Variable	Unstandardized coefficients		Standardized coefficients			Collinearity statistics
Variable	B	SE	Beta	T	Sig.	Tolerance	VIF
(Constant)	3.13	1.72		1.82	0.071
Sex	-0.34	0.64	-0.05	-0.54	0.593	0.82	1.22
Agriculture	-0.12	0.73	-0.02	-0.17	0.865	0.68	1.48
Personal business	-2.05	0.95	-0.23	-2.15	0.034	0.89	1.12
Education grade 1-3	3.99	1.64	0.59	2.43	0.017	0.51	1.96
Education grade 4-6	2.43	1.66	0.35	1.47	0.146	0.55	1.81

SE: Standard Error; VIF: Variance Inflation Factor.

Dependent variable: 44-question Thai-HFHAT score (r = 0.41, r ² = 0.17, Adj. r ² = 0.12).

Discussion

37 elderly participants in this study (72.6%) had no history of falls. This may be attributed to regular exercise of the participants, as the 34 participants (66.6%) performed a regular exercise routine. Our results are consistent with the study by Hopewell S. et al. (2018) who reported that the practice of regular exercise would decrease fall rates and reduce the risk of falls in the elderly. ²¹ Of all elderly surveyed participants, 27.5% reported a fall. This number is close to that predicted by the Thailand Department of Disease Control report on the prevalence of falls during 2017-2021, in which falls among Thai elderly account for 27.0% ( https://www.dop.go.th/th/know/side/1/1/1159). The area of the home with the most falls was the bathroom at 94.1 %, consistent with several studies on both Thais and in other countries. ²² ^– ²⁵ The bathrooms are areas where water is trapped with no separation between wet and dry areas. In addition, the present step in the room, no toilet or seat with hanging legs, and no shower seat/shower chair are causes of most falls in the bathroom.

The inter-rater reliability of the study participants using the 44-question Thai-HFHAT was moderate (ICC = 0.74) and the test-retest reliability among the elderly was good (ICC = 0.80). Our results indicated that the 44-question Thai-HFHAT is as reliable as the 69-question Thai-HFHAT, whose inter-rater reliability was good (ICC = 0.87) and the test-retest reliability was good (ICC = 0.87). In our study, the 44-question Thai-HFHAT had lower ICC than the 69-question Thai-HFHAT. This is probably because the study was conducted with 30 elderly and caregiver participants and 1 VHV participant, resulting in the moderate level of inter-rater reliability. ¹⁰ The smaller sample size of the 69-question Thai-HFHAT slightly affected the evaluation of reliability, causing minor errors. The same is accurate for the Tomita MR et al., 2014 study, where testing interrater reliability between two occupational therapists who were trained for home safety assessment using older adults' homes resulted in a higher ICC value of inter-rater reliability (ICC = 0.89) than that of the recent study (ICC = 0.74). This makes it more reliable than tests conducted in a recent study on older adults, VHV, and their caregivers. ²⁶

The inter-rater reliability of the 44-question version was higher than the Modified HOME FAST-SR (Thai version) (ICC = 0.64). ¹² This is probably because the Thai-HFHAT was designed to have questions listed in an organized manner with drawings to help illustrate each room in a house, allowing participants to identify home hazards at ease. However, the text in the HOME FAST-SR may have been confusing. For instance, in the HOME FAST-SR question 8b asks “Does it take you several attempts to get up out from your sitting chair?”, and question 8c asks “When you lower yourself into the chair, can you do it without falling back on the chair?”. These two statements may have caused confusion that could lead to medical measurement errors. ²⁷

We found that the elderly participants had a higher mean home hazard rating, followed by caregivers and VHV participants. This is likely because most of our elderly participants had a health issue and considered falling one of the health issues that cause the most damage, ²⁸ prompting the elderly to pay more attention to risk factors that contribute to falls than caregiver and VHV groups. Also, the difference in mean home hazard ratings between the elderly and VHV participants was statistically significant ( p = 0.012). Our results are consistent with the previous study by Morgan et al. (2005) who investigated the reliability of a self-report home hazard screening tool and found some questions, i.e. “Is lighting suitable for activities?”, could not be precisely answered by looking around the home environment. Such questions were viewed by the elderly participants as increasing the risk of falls, whereas the VHV participants may not. ²⁹ Thus, the self-report 44-question home hazard screening tool was preferred for the home hazards assessment among the elderly. In our study, the mean ratings of the 44-question Thai-HFHAT among the elderly, caregivers, and VHV groups were varied in the first and second assessments. We found a slight decrease in the mean rating of the elderly participants on the second visit. This may be due to changes in the behavior of the elderly participants and in the home environment between the first and the second visits. The study participants may have removed obstacles like power cords from walkways before the second home visit. This phenomenon is called “reactivity” and can occur as a result of administering an instrument to the study participants multiple times. Participants become sensitized with the instrument and “learn” to respond when they perceive how they are expected to respond. ³⁰

Elderly participants with higher education levels had lower number of home hazards. These elderly participants might have greater awareness and more access information to assist with improving the safety of their home environment. Higher educational attainments are likely to be associated with better income and socioeconomic status, and therefore greater affordability for safer housing and home modification. ³¹ Moreover, home hazards appeared to be associated with occupation. This study found that the group of people those who served as housewives in their own homes had a higher risk of falling, which may be related to the amount of clutter in the home.

The main limitation of our study was the small number of the sample size. To achieve the valid generalization that covers most types of Thai houses, this study should have been conducted with a larger sample size to ensure the applicability of the screening tool. Further studies are needed to investigate the changes in house environment after using the 44-question Thai-HFHAT to determine what particular changes could reduce fall risk. Finally, the 44-question Thai-HFHAT was developed in the Thai version. Therefore, cross-cultural translation of 44-question Thai-HFHAT is important for widespread use.

Conclusions

Our study confirmed that the 44-question Thai-HFHAT is suitable for the home hazards assessment among the elderly in Thailand.

Author contribution

Conceptualization, CL; Data curation, CL, YW; Investigation, CL, YW, JN, SL, LM; Methodology, CL, YW, JN, LM; Project administration, CL; Supervision, JN, SL, LM; Writing-original draft, CL, SL; Writing-review & editing, CL, RP, JN, SL, LM.

Data availability Underlying data

figshare: Underlying data and extended data of Reliability on the 44-question Home Fall Hazard Assessment Tool and Personal Characteristics Associated with Home Hazards among thein Thai Elderly. https://doi.org/10.6084/m9.figshare.c.6239961.v1 ³² ‐

General information of elderly. https://doi.org/10.6084/m9.figshare.21382278

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General information of caregiver. https://doi.org/10.6084/m9.figshare.21343374

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General information of village health volunteer. https://doi.org/10.6084/m9.figshare.21343380

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1st test done by elderly. https://doi.org/10.6084/m9.figshare.21343383

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1st test done by caregiver. https://doi.org/10.6084/m9.figshare.21343413

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1st test dons by VHV. https://doi.org/10.6084/m9.figshare.21343431

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2nd test done by elderly. https://doi.org/10.6084/m9.figshare.21343464

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2nd test done by caregiver. https://doi.org/10.6084/m9.figshare.21343470

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2nd test done by VHV. https://doi.org/10.6084/m9.figshare.21343476

Extended data

Supplementary Table 1. https://doi.org/10.6084/m9.figshare.21304887

Inform consent. https://doi.org/10.6084/m9.figshare.21304920

Data are available under the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Public domain dedication).

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

Acknowledgments

The authors thank all of the elderly who participated in the study.

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Pynoos

Steinman

Nguyen

: Environmental assessment and modification as fall-prevention strategies for older adults. Clin. Geriatr. Med. 2010;26(4):633–644. 20934614

10.1016/j.cger.2010.07.001

PMC6036911

Kwan

Straus

: Assessment and management of falls in older people. CMAJ. 2014;186(16):E610–E621. 24982291

10.1503/cmaj.131330

PMC4216276

Lök

Akin

: Domestic environmental risk factors associated with falling in elderly. Iran. J. Public Health. 2013;42(2):120–128. 23515204

Leclerc

Bégin

Cadieux

: Relationship between home hazards and falling among community-dwelling seniors using home-care services. Rev. Epidemiol. Sante Publique. 2010;58(1):3–11. 20097025

10.1016/j.respe.2009.10.008

Tomita

Saharan

Rajendran

: Psychometrics of the Home Safety Self-Assessment Tool (HSSAT) to prevent falls in community-dwelling older adults. Am. J. Occup. Ther. 2014;68(6):711–718. 10.5014/ajot.2014.010801

Lilford

Mohammed

Braunholtz

: The measurement of active errors: methodological issues. Qual. Saf. Health Care. 2003;12:8ii–812ii. 14645889

10.1136/qhc.12.suppl_2.ii8

PMC1765778

Dionyssiotis

: Analyzing the problem of falls among older people. Int. J. Gen. Med. 2012;5:805–813. 23055770

10.2147/IJGM.S32651

PMC3468115

Morgan

De Vito

Stevens

: A self-assessment tool was reliable in identifying hazards in the homes of elders. J. Clin. Epidemiol. 2005;58:1252.e1–1252.e21. 16291469

10.1016/j.jclinepi.2005.04.001

Hendrickson

Massey

Cronan

: On the test-retest reliability of perceived usefulness and perceived ease of use scales. MIS Q. 1993;17:227–230. 10.2307/249803

Romli

Tan

Mackenzie

: Factors associated with home hazards: Findings from the Malaysian elders longitudinal research study. Geriatr. Gerontol. Int. 2018;18(3):387–395. 29139186

10.1111/ggi.13189

Lektip

: Underlying data and extended data of Reliability on the 44-question Home Fall Hazard Assessment Tool and Personal Characteristics Associated with Home Hazards among thein Thai Elderly. figshare.[Dataset]. Collection. 2022. 10.6084/m9.figshare.c.6239961.v1

10.5256/f1000research.144999.r165889

Reviewer response for version 2

Tomita

Machiko R

1 Referee 1Department of Rehabilitations Science, University at Buffalo, Buffalo, NY, USA

Competing interests: No competing interests were disclosed.

18 5 2023

2023

This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

recommendation

approve-with-reservations

This article has been improved, but being viewed with fresh eyes, there are some issues that need to be addressed by authors.

Major issue: What was the reason that fall related personal characteristics were not included in the study using regression? Age, past falls, past fall injuries, physical and cognitive function, balance/dizziness, foot problems, alcohol intake, incontinence, vision and hearing problems, high bald pressure, etc. It looks like you have information about some of them. If you are interested in demographic factors only, you should have controlled for these fall risk factors that are known to cause a fall. To do so, you need more than 51 participants to use a regression analysis.

Minor issues: These are mainly for writing clarifications and are easy to fix.

Abstract

1. In Background, use the word “demographic” rather than “personal” characteristic because in Methods, only sex, occupation, and education are mentioned. Why was age not included?

2. Choose either “interrater” or “inter-rater”.

3. In Results, the p-value should be less than .05. If it is significantly related, it should be p≤.05; therefore, it is not necessary to talk about it. Revise the sentence to something such as “In demographic variables, business career and education level (grades 1-3) had significant relations with the total number of home hazards in the 44-questions Thai-HFHAT.”

Introduction

4. Words such as “the elderly” and “elderly” are not preferred terms. Use “older adults”, instead. This is for the whole manuscript.

5. Can you be a little more specific about poor housing conditions?

6. How many minutes does it take to complete the 69-question Thai HFHAT while 44-quesitons take 30 minutes?

Methods

7. In Study design, a description is only for interrater reliability. Write one for test-retest reliability. They are written in the Abstract.

8. Start a new sentence for determination of dementia using MMSE-Thai 2002 or follow my suggestion for # 12 below.

9. 51 should be spelled out. Same for 4 items in Research and 37, the beginning in Discussion when a sentence starts with a number.

10. The word “passed” should be replaced with “met”.

11. After “this number was adequate” it is better to say, “for our primary purpose – examining interrater and test-retest reliability.” It is because if you used only 51 participants for regression, it is not enough. The parts talking about the sample sizes are a bit confusing. Please clarify the sample size for each of three analyses. You had these 3 groups for interrater reliability study, which was one of the study strengths.

12. The information about MMSE-Thai 2002 is redundant with that in Participants. This part is easier to understand than in Participants section. It may be better to leave it something like “ had dementia determined by the Mini Mental State Examination-Thai 2002. Do you have the information about psychometric properties of MMSE-Thai 2002?

13. In Data collection, if participants were instructed to complete the assessment within 30 minutes, you have to revise the sentence In the Introduction, “requires only 30 minutes for elderly users to complete”. It is because we read the sentence that “older participants took 30 minutes to complete” and you are reporting the fact. The revised sentence should be “…was designed for older participants to complete it within 30 minutes.”

14. Were 51 older participants’ houses used for reliability tests?

15. Provide one or two examples of instructions or questions to identify a home hazard. Were they asked, “Isthis room lighted well?” “Does thisroom light well not to fall?”, etc.?

16. “So that reserachers could collect more data for examining test-rest reliability,” should be “for test-retest reliability.”

17. In Data analysis, citation (SPSS Inc., Chicago, IL, USA) should be replaced with (IBM Corp. Armonk, NY, USA). IBM bought SPSS in 2009.

18. Was the test-retest performed for the three groups separately or altogether? Later I understood but it should be written here also.

19. Sentences starting with “Information bias” are not necessary. It should be covered by IRB. If you must write it for some reason, it should be placed in the Data collection section.

Results

20. Caregivers provided care about 22 hours/day on average. The hour seems extremely high even if care recipients have dementia.

21. In Table 2, 14 participants fell but in fall injury, 16 participants answered. The total should be 14. Also, the percentage should be calculated out of 14.

22. The result section should be written in past tense.

23. Is the sentence starting with “the area at the most risk of fall risk are…” 94.1% of 107? Revise the sentence, such as “The most home hazards that may cause a fall was found for the bathroom (94.1% of 107), then bedroom…” Did 94.1% of participants identify at least one of 4 items in the bathroom is a fall risk?

24. “The risk of falling in each room” and the title of Figure 1 should be replaced by for example “Percentage of identified home hazards that may cause a fall in each room.”

25. Who are participants for personal characteristics associated with home hazards? 51 older adults?

26. Why was age not included in independent variables? Please read a major concern.

27. In Table 3, all r should be R. Discussion 28. I would use (91.9% of 37 non-fallers) rather than (66.6%).

29. I would state “This figure supports the study by Hopewell….” rather than “Our results are consistent..” because this was not the purpose of the study and happened to find it.

30. Remove the last sentence of the first paragraph on page 8, staring “This makes it more reliable than….”. When raters are homogeneous, they tend to rate in a similar manner. In your study, the raters are diverse. Accordingly, the reference 26 should move after (ICC=0.74)” When we use 1 vs. K, the use of ICC(2,k) produces a larger ICC value than ICC (2,1). It is not always that a lager sample size produces a lower ICC value than a small sample size. When there is little variation among raters given to each item, then the ICC v values become high. Revision of these paragraphs related to the sample size and ICC values is recommended or if the statement is true, put citations.

31. You discussed a lot about interrater reliability but not much about test-retest reliability.

32. Finally, if you do have answers for my major concern, please state them and if not, you should state lack of control for known fall risks in the limitation.

Is the work clearly and accurately presented and does it cite the current literature?

Partly

If applicable, is the statistical analysis and its interpretation appropriate?

Partly

Are all the source data underlying the results available to ensure full reproducibility?

Partly

Is the study design appropriate and is the work technically sound?

Partly

Are the conclusions drawn adequately supported by the results?

Yes

Are sufficient details of methods and analysis provided to allow replication by others?

Partly

Reviewer Expertise:

Fall prevention, smart house, e-health in gerontological population.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

Lektip

Charupa

Walailak University, Thailand

Competing interests: No competing interests

23 5 2023

Response

The main objective of this study was to study home hazards associated with falls using a developed assessment form. Home hazards were classified as extrinsic factors affecting falls that were also important to reduce the risk of falls from home hazard. Romli et al., 2018 reported that older adult characteristics consist of education, number of home occupants, monthly expenditure, traditional housing, ethnicity, and age were correlated with home hazard, but were not reported for the Thai older adult.

Therefore, in this study, which was conducted in a Thai population, so interested in the educations, sex, and income-generating occupation, but there is also a limitation on the age variable since the study was conducted in an elderly population that 75 % was middle elderly (70-79 years) and 15% was the late elderly (80-89 years) of the Thai population tended to be low survivors. This is a limitation in the analysis of regression data. The researchers will write a limitation in the next study for clarity.

The other variables recommended by the reviewer are good recommendations as they are intrinsic factors that affect falls as well. But with the main objective of focusing on home hazards, the researchers did not collect data on these variables. However, inclusion criteria were used by the investigators to attempt to control for intrinsic factors as much as possible. For this reason, I would like to adjust the title to only demographic characteristics and would like to take the reviewer's advice as a limitation and suggestion next time.

Minor issues: These are mainly for writing clarifications and are easy to fix.

Abstract

1. In Background, use the word “demographic” rather than “personal” characteristic because in Methods, only sex, occupation, and education are mentioned. Why was age not included?

Response

I have changed personal to demographic characteristic.

Because the study was conducted in an elderly population that 75 % was middle elderly (70-79 years) and 15% was the late elderly (80-89 years) of the Thai population tended to be low survivors. The researchers assumed that the irrelevant age of the subjects would not affect the home hazard.

2. Choose either “interrater” or “inter-rater”.

Response I have changed interrater to inter-rater.

Response I have fixed as you suggest.

Introduction

4. Words such as “the elderly” and “elderly” are not preferred terms. Use “older adults”, instead. This is for the whole manuscript.

Response I have change elderly to older adults as you suggest.

5. Can you be a little more specific about poor housing conditions?

Response I have described poor housing in the line 12.

6. How many minutes does it take to complete the 69-question Thai HFHAT while 44-quesitons take 30 minutes?

Response 45 minutes.

Methods

7. In Study design, a description is only for interrater reliability. Write one for test-retest reliability. They are written in the Abstract.

Response I have described about test-retest in the line 67.

8. Start a new sentence for determination of dementia using MMSE-Thai 2002 or follow my suggestion for # 12 below.

Response I follow as you suggest in item 12.

9. 51 should be spelled out. Same for 4 items in Research and 37, the beginning in Discussion when a sentence starts with a number.

Response I have already change as you suggest in line 82, 98 and 202.

10. The word “passed” should be replaced with “met”.

Response I have already change as you suggest in line 83.

Response I already clarify as you suggest about sample size for inter-rater reliability and test-retest reliability as our primary purpose in line 84-89.

12. The information about MMSE-Thai 2002 is redundant with that in Participants. This part is easier to understand than in Participants section. It may be better to leave it something like “had dementia determined by the Mini Mental State Examination-Thai 2002. Do you have the information about psychometric properties of MMSE-Thai 2002?

Response I have added the information about psychometric properties in the line 116.

Response I have already changed the sentence in the Introduction as you suggest in line 39-40.

14. Were 51 older participants’ houses used for reliability tests?

Response Yes, of course.

15. Provide one or two examples of instructions or questions to identify a home hazard. Were they asked, “Isthis room lighted well?” “Does thisroom light well not to fall?”, etc.?

Response I have already added the example of questions in line 126-128.

16. “So that reserachers could collect more data for examining test-rest reliability,” should be “for test-retest reliability.”

Response I have already edited in line 134.

17. In Data analysis, citation (SPSS Inc., Chicago, IL, USA) should be replaced with (IBM Corp. Armonk, NY, USA). IBM bought SPSS in 2009.

Response I have already change as you suggest in line 145.

18. Was the test-retest performed for the three groups separately or altogether? Later I understood but it should be written here also.

Response I have already added “the test-retest performed for the three groups separately” in line 150.

19. Sentences starting with “Information bias” are not necessary. It should be covered by IRB. If you must write it for some reason, it should be placed in the Data collection section.

Response I have already deleted “Information bias” out of data analysis part.

Results

20. Caregivers provided care about 22 hours/day on average. The hour seems extremely high even if care recipients have dementia.

Response Most caregivers are family members such as husbands, daughter or son who live in the same house. Each person's care period is almost 24 hours.

21. In Table 2, 14 participants fell but in fall injury, 16 participants answered. The total should be 14. Also, the percentage should be calculated out of 14.

Response I apologize for adding the wrong numbers. I have done the fix as you suggested.

22. The result section should be written in past tense.

Response I have written the result section in the past tense.

Response I have rewritten the sentence as you suggest. Participants who identify at least one of all questions in each room assume that the fall risk.

24. “The risk of falling in each room” and the title of Figure 1 should be replaced by for example “Percentage of identified home hazards that may cause a fall in each room.”

Response I have rewritten as suggest in line 179-180 and the title of Figure 1.

25. Who are participants for personal characteristics associated with home hazards? 51 older adults?

Response Yes, the demographic characteristics of 51 older adults. I have added word “older adults” in the topic for easy to understand.

26. Why was age not included in independent variables? Please read a major concern.

Response Because the study was conducted in an elderly population that 75 % was middle elderly (70-79 years) and 15% was the late elderly (80-89 years) of the Thai population tended to be low survivors. The researchers assumed that the irrelevant age of the subjects would not affect the home hazard.

27. In Table 3, all r should be R.

Response I have replaced r by R as you suggest.

Discussion

28. I would use (91.9% of 37 non-fallers) rather than (66.6%).

Response I have changed from 66.6% to 91.9%.

29. I would state “This figure supports the study by Hopewell….” rather than “Our results are consistent.” because this was not the purpose of the study and happened to find it.

Response I have edited as you suggest in line 213-214.

Response I have moved references 26 to after (ICC=0.74). I've changed the reason for this study's ICC being less than the previous study without justifying the sample size in the line 235-238.

31. You discussed a lot about interrater reliability but not much about test-retest reliability.

Response I added the discussion on test-retest reliability in the same section as the discussion on inter-rater reliability.

32. Finally, if you do have answers for my major concern, please state them and if not, you should state lack of control for known fall risks in the limitation.

Response I have already explained the major concern in the first part of your question. It will be put in the limitation section in line 295-300.

10.5256/f1000research.144999.r165888

Reviewer response for version 2

Ashari

Asmidawati

1 Referee 1Department of Human Development and Family Studies, Faculty of Human Ecology, University Putra Malaysia, Serdang, Malaysia

Competing interests: No competing interests were disclosed.

21 3 2023

2023

recommendation

approve

Thank you for your kind responses toward my comments. I am agreed with the revised version.

Is the work clearly and accurately presented and does it cite the current literature?

Yes

If applicable, is the statistical analysis and its interpretation appropriate?

Yes

Are all the source data underlying the results available to ensure full reproducibility?

Partly

Is the study design appropriate and is the work technically sound?

Yes

Are the conclusions drawn adequately supported by the results?

Partly

Are sufficient details of methods and analysis provided to allow replication by others?

Yes

Reviewer Expertise:

Fall prevention and aged care research.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

10.5256/f1000research.139124.r158960

Reviewer response for version 1

Ashari

Asmidawati

1 Referee 1Department of Human Development and Family Studies, Faculty of Human Ecology, University Putra Malaysia, Serdang, Malaysia

Competing interests: No competing interests were disclosed.

28 2 2023

2023

recommendation

approve-with-reservations

The paper by Lektip et al. analysed the reliability of the 44-question Thai Home Fall Hazard Assessment Tool (Thai-HFHAT) and determine the person characteristics associated with home hazards. This is an interesting study and the authors have collected a unique dataset using cutting edge methodology.

Overall, the information presented represents valuable information regarding the feasibility of using (Thai-HFHAT). The main strength of this paper is that it addresses an interesting question and finds a novel solution based on a carefully selected set of rules and provides a clear answer in culturally context. The paper is generally well written and structured. The title and abstract are appropriate for the content of the text.

However, in my opinion the paper has some shortcomings regarding some data analyses and discussion. The number of subjects for VHV group is too small (5) as compared to other groups. This number is too small which may affect the analysis. I also suggested to add further information on caregiver and VHF personal characteristic to explain any important aspects contributing to the variation in (Thai-HFHAT) score.

Is the work clearly and accurately presented and does it cite the current literature?

Yes

If applicable, is the statistical analysis and its interpretation appropriate?

Yes

Are all the source data underlying the results available to ensure full reproducibility?

Partly

Is the study design appropriate and is the work technically sound?

Yes

Are the conclusions drawn adequately supported by the results?

Partly

Are sufficient details of methods and analysis provided to allow replication by others?

Yes

Reviewer Expertise:

Fall prevention and aged care research.

Lektip

Charupa

Walailak University, Thailand

Competing interests: No competing interests

1 3 2023

Thanks for the compliment and advice on my research. Allow me to explain the number of 5 VHV, which seems too small for inter-rater and test-retest reliability.

1) The most important target group used by the 44-question Thai-HFHAT was the elderly, followed by caregivers, while VHV was the final target group in cases where the elderly were unable to use the assessment and lacked caregivers.

2) In Thailand, one VHV takes care of people in around 10-15 households. Similarly, this study used one VHV to assess 10 elderly homes. In this study, 51 elderly people were studied, so 5 VHVs were used to assess.

10.5256/f1000research.139124.r161483

Reviewer response for version 1

Tomita

Machiko R

1 Referee 1Department of Rehabilitations Science, University at Buffalo, Buffalo, NY, USA

Competing interests: No competing interests were disclosed.

14 2 2023

2023

recommendation

approve-with-reservations

The purposes of the study are to establish reliability of 44-item home fall hazard assessment tool for Thai older adults and to find personal characteristics associated with the identified number of fall risks. The reliability section is done correctly but can be improved further.

One of the most comprehensive studies about reliability and validity of home hazard to prevent falls in older adults is missing ¹.

This study is a methodological study not cross-sectional.

A study replication cannot be done easily. Explain how the sample size was determined. Fifty-one is enough for inter-rater and test-retest reliability but not enough for a regression analysis. Make inclusion criteria of ADL and MMSE clearer. What are the compositions of 107 participants? Fifty-one older adults, 47 caregivers, and 5 VHS make only 103.

Personal characteristics should include those related to a fall risk, in addition to demographic information. For example, falls in past one year, no falls or no vicarious falls so far, experiences in fall related injury and hospitalization, MMSE and ADL scores, readiness to make home safer, dizziness, balance problems etc. should be included. However, the sample size is too small for a multiple regression.

In Discussion, "...the group who were working in their own homes as housekeepers..." does not make sense. Revise this sentence.

When we deal with human being for research, we use the word "participants" rather than "subjects". In Table 1, the statistical comparisons among these three groups are made; however, it is not the purpose of this study; therefore, they are not necessary. Descriptive statistics is sufficient.

Overall impression of this study is that authors may be able to do more meaningful analyses using existing data for the personal characteristics part, although it has to be based on hypotheses derived from literature review.

Is the work clearly and accurately presented and does it cite the current literature?

Partly

If applicable, is the statistical analysis and its interpretation appropriate?

Partly

Are all the source data underlying the results available to ensure full reproducibility?

Partly

Is the study design appropriate and is the work technically sound?

Partly

Are the conclusions drawn adequately supported by the results?

Yes

Are sufficient details of methods and analysis provided to allow replication by others?

Partly

Reviewer Expertise:

Fall prevention, smart house, e-health in gerontological population.

References 1

: Psychometrics of the Home Safety Self-Assessment Tool (HSSAT) to prevent falls in community-dwelling older adults. Am J Occup Ther .2014;68(6) : 10.5014/ajot.2014.010801 711-8

25397766

10.5014/ajot.2014.010801

Lektip

Charupa

Walailak University, Thailand

Competing interests: We have no competing interests.

19 2 2023

1. One of the most comprehensive studies about the reliability and validity of home hazards to prevent falls in older adults is missing.

Answer: I will include that study in the discussion section of my research to discuss the similarities and differences of reliability and validity.

2. This study is a methodological study not cross-sectional

Answer: This study is a prospective study

3. A study replication cannot be done easily. Explain how the sample size was determined. Fifty-one is enough for inter-rater and test-retest reliability but not enough for a regression analysis. Make inclusion criteria of ADL and MMSE clearer. What are the compositions of 107 participants? Fifty-one older adults, 47 caregivers, and 5 VHS make only 103.

Answer: - 51 elderly people were adequate for examining inter-rater reliability and test-retest reliability following the reference in the article" Rating the methodological quality in systematic reviews of studies on measurement properties: a scoring system for the COSMIN checklist" that recommends 50-99 subjects are Good sample size.

- I think a sample of 51 is sufficient for a regression analysis because correlation statistics will use 10-20 times the variable. And my main objective studies about the reliability and validity of home hazards to prevent falls in older adults.

- I exclude those who were completely dependent or disabled (ADL scores: 0-4) and those who received no formal education had MMSE-Thai scores of ≤14, when the elderly who received only upper secondary education had scores of ≤17, and when the elderly who continued their education received a score of ≤22.

- The compositions of 107 participants - Fifty-one older adults, 51 caregivers, and 5 VHV.

4. Personal characteristics should include those related to fall risk, in addition to demographic information. For example, falls in the past year, no falls or no vicarious falls so far, experiences in fall-related injury and hospitalization, MMSE and ADL scores, readiness to make home safer, dizziness, balance problems, etc. should be included. However, the sample size is too small for multiple regression.

Answer: I think the variables you've suggested are very helpful in regression analysis. But with a small sample size, because the main objective of my work is to find reliability and validity, I only take personal characteristics variables that I show in the demographic table characteristics of study subjects.

5. In Discussion, "...the group who were working in their own homes as housekeepers..." does not make sense. Revise this sentence.

Answer: I revise it to " This research found that the group of people who acted as housekeepers in their own homes had a higher risk of falling, which may be related to the amount of clutter in the home.

6. When we deal with a human being for research, we use the word "participants" rather than "subjects". In Table 1, the statistical comparisons among these three groups are made; however, it is not the purpose of this study; therefore, they are not necessary. Descriptive statistics are sufficient.

Answer: - I will use "participants" rather than "subjects".

- I will only use descriptive statistics to descript the three groups.

7. Overall impression of this study is that authors may be able to do more meaningful analyses using existing data for the personal characteristics part, although it has to be based on hypotheses derived from the literature review.

Answer: Thank you for your impression, I will add the literature review to support the personal characteristics associated with home hazards.