研究背景：

我国作为世界上老龄化进程最快的人口大国，60岁及以上人口比例已从2000年的10%倍增至2022年的20%（2.8亿）。值得关注的是，跌倒作为老年人群体伤害的首位致死原因，其疾病负担将随着老龄化的加深而加重。目前基于全国调查数据的老年人跌倒状况研究证据较少，其报告跌倒率和跌伤率的变化趋势及地区差异尚不明确。与此同时，无障碍设施和居家适老化改造是许多发达国家伤害预防的有效策略和减少健康不平等的重点举措，而我国在该方面的尝试和研究仍处于早期阶段，对于本土住房环境风险识别不充分且跌倒居家环境干预评价证据匮乏。深圳市罗湖区“老人防跌倒项目”是在医保支付制度改革背景下由公立医疗机构牵头并较早一批开展的小型居家适老化改造工程，其试点经验的总结对于我国其它地区积极应对人口老龄化并推动伤害防控关口前移具有重要实践和借鉴意义。

研究目的：

本研究旨在揭示我国社区老人跌倒报告的地区差异和变化趋势；此外，为探究居家环境改善作为我国老年人跌倒预防策略的可行性，本研究聚焦现阶段我国政策较关注的老旧住宅无障碍设施建设和居家环境适老化改造两方面：一是探究城镇住宅楼房无障碍特征（电梯配置）与老年人跌倒报告的关联；二是选取深圳罗湖区为案例，评估该地福利性小型居家环境改造项目开展的效果、总结其阶段性工作经验，以期为明确跌倒环境干预策略的受益群体、优化资源配置、促进多部门协同等相关政策的制订提供循证支持。

研究方法：

本研究在文献研究和理论学习的基础上，以全国或地方调查数据中的跌倒报告情况为结局指标，从地区差异和趋势描述、住宅楼房建筑特征关联探究、试点地区居家适老化改造项目效果评价三个方面展开。

1. 利用中国健康与养老追踪调查（CHARLS）2011、2013、2015和2018四次调查的老年人数据开展回顾性描述分析，依次调整个体社会人口学特征、健康状况和躯体功能水平后，采用二元Logistic回归边际效应估计描绘四次调查中跌倒和跌伤的的全国报告率和地区报告率变化，以上模型均考虑复杂抽样单位间的随机效应和校正无应答后的个体权重。

2. 在“人-环境契合理论”的指导下，考虑我国住宅建筑规范要求，纳入CHARLS四次调查中居住在城镇楼房2-7层的老年人作为研究样本，探究居住楼层、电梯配置、建筑年限、厕所和洗澡设施类型等住房特征与跌倒发生的关联，同时纳入室内温度、整洁度等室内环境评估变量，模型估计采用混合效应估计的Logistic回归及广义估计方程。

3. 在真实世界视角下，本研究将2016年8月至2019年10月申请罗湖区居家环境改造项目（“老人防跌倒项目”）的老年人纳入为“项目组”调查对象，并基于“安德森医疗服务利用模型”采用倾向性评分匹配设计（PSM）为其在罗湖区基本公共卫生服务老年人健康档案中找寻“对照组”调查对象。随后开展横断面电话调查补充收集以上两组共2170名调查对象的跌倒情况、健康和功能状况、居家环境情况、“项目组”的满意度和依从性及“对照组”参与项目的意愿和阻碍。本研究最终共纳入2098位社区老人（其中“项目组”709例，“对照组”1389例），采用负二项回归比较两组老年人室内跌倒事件发生率的差异，分年龄组开展亚组分析。电话调查收集的定性资料文本采用主题分析。

研究结果：

1. 老年人跌倒报告率从2011年的18.6%增长至2018年的21.9%，调整老年人健康状态和躯体功能后，该趋势变得不显著；东部地区跌倒率较中部和西部地区更低。2018年跌伤报告率为8.5%，2011至2018年调整后的跌伤报告率呈显著下降趋势；东北部地区较其它地区更低。跌倒和跌伤回归模型均发现，年龄因素在调整了健康状态和躯体功能后变为不显著；中风、肾脏疾病、关节炎或风湿病等多种慢性病和下肢功能受限相关条目是跌倒和跌伤的共同预测因素。

2. 2011至2018年城镇楼房2-7层老年受访者住宅设施不断完善，但电梯配置比例依旧较低，2018年受访者报告率为11.1%。城镇楼房内电梯的配置与跌倒发生呈显著负相关（OR=0.519，95%CI [0.294 - 0.916]），且该保护效应在二层老年住户中更显著（OR=0.195 [0.051 - 0.747]）；事后分析发现住在二层的老年人相对于其他楼层的老年人躯体功能和日常生活活动能力更差。此外，房屋内整洁度高、室内温度适宜也与跌倒的减少有关。

3. 在深圳罗湖区“项目组”中，老人群体对以卫生间内安装扶手、赠送防滑垫和小夜灯为主要环境改善措施的“老人防跌倒项目”满意度较高。模型结果显示，项目参与可能会非显著性地减少26.3%的室内跌倒发生（IRR=0.737，95%CI [0.431 - 1.259]），在75岁以下低龄老年群体中的保护效应（IRR=0.619，95%CI [0.175 – 2.186]）可能大于75岁及以上老年群体（IRR=0.815，95%CI [0.459 - 1.446]），但无统计学差异。

研究发现，高龄、离婚/丧偶、有医保覆盖、社会地位较高、有跌倒史或跌倒恐惧心理、自评健康不良、残疾、视力受限、伴有多种慢病（如高血压、糖尿病、心脏病、骨关节炎等）、日常生活活动受限是老年人申请参与“老人防跌倒项目”的预测因素，社区医务人员建议也是老年人项目参与的重要促进因素。“对照组”少数家庭报告已自行开展居家环境改造，项目参与的阻碍因素包括项目信息不可及，跌倒风险认知不足，家庭空间有限以及城市老人住房流动性问题。此外，项目组老人也反馈了项目维护问题、其他个性化改造需求和公共空间改造诉求。

研究结论与建议：

我国社区老年人的跌倒率和跌伤率存在地区间“不平衡”，我国老龄结构的变化及其伴随的共病、失能问题的增加是老年人跌倒趋势变化的重要驱动因素，应积极推广跌倒防控措施，并进一步加强中西部地区资源配置。此外，可探索既有慢性病防控措施与跌倒风险人群管理的结合路径。

楼房电梯等无障碍设施配置对于预防跌倒乃至居家养老生活质量具有重要意义，建议加快我国《住宅设计规范》的标准更新，各地方政府全面推进老旧小区和既有多层楼房住宅区的适老化建设。

罗湖区居家改造试点项目取得了初步成效，居民满意度和获得感有所提升。本研究提示尽早开展居家环境改造可能获益更多，并强调后期维护；“老人防跌倒项目”需进一步加强项目宣传和健康教育，并调整和优化项目内容及人群策略，在充分了解群众参与意愿的基础上提质扩容增效，鼓励探索以基层卫生服务和家庭医生签约服务为载体的伤害防控策略，进一步促进老年福祉提升。

Background:

As the world’s most populous nation in the midst of a rapid aging process, the proportion of China’s total population aged 60 and above has doubled from 10% in 2000 to 20% in 2022 (280 million people). Falls are the leading cause of injury-related deaths among the elderly, and the associated disease burden is expected to escalate as the aging process deepens. Despite this, there has been a lack of comprehensive understanding regarding fall prevalence and potential regional disparities in China based on national survey data analysis. Although accessible facilities and home modifications constitute effective strategies for injury prevention and key initiatives to reduce health inequalities in many developed countries, the attempts and research in this regard in China are still in early stages. There is limited exploration of domestic housing environmental risks, and insufficient evidence to evaluate home environmental interventions in China. The “Fall Prevention Project” in Luohu District, Shenzhen, represents an exemplary, albeit small-scale, home adaptation pilot initiated by a healthcare group, which had undergone payment reform from fee-for-service to global budgeting. 

Objectives:

The study aimed to establish a comprehensive understanding of regional and temporal trends in self-reported falls among community-dwelling older adults in China and to explore two policies related to home environmental aspects that could potentially be developed as a fall prevention strategy. Firstly, the study explored the association between the accessibility features of urban residential buildings, particularly elevator installations, and the occurrence of falls among older adults. Additionally, using both outcome and satisfaction measures, an evaluation of a pilot home adaptation project in Luohu District, Shenzhen City, was conducted. Based on the study’s major findings, we discussed policy implications related to targeting strategies, resource allocation and multisector cooperation, among other aspects.

Methods:

Aided by literature review and relevant theoretical framework, our empirical research is consisted of three parts:

1. Descriptive analyses on regional disparities and trends of falls and injurious falls:

Retrospective descriptive analyses were performed using data from four waves of the China Health and Retirement Longitudinal Study (CHARLS) conducted in 2011, 2013, 2015, and 2018 among older adults. After sequentially adjusting for individual sociodemographic characteristics, health status, and physical functional limitations, binary logistic regression models with marginal effects were employed to depict the national and regional trends in falls and injurious falls reported in the four surveys. All models accounted for random effects between CHARLS sampling units, and incorporated individual weights adjusted for non-response.

2. Associations between housing characteristics and falls:

Following Lawton’s Person-Environment Fit Theory and considering Residential Building Codes in China, we included in our sample older adults living on the 2nd-7th floors of urban residential buildings from four CHARLS waves to investigate the associations between falls and building characteristics (such as floor level, elevator accessibility, age of the building, the type of toilets and bathing facilities) as well as indoor environment assessment (including cleanliness and room temperature etc.). The models were estimated using mixed-effects logistic regression and generalized estimating equations.

3. Evaluation of “Fall Prevention Project” in Luohu, Shenzhen:

In a real-world context, the study included older adults who applied for the "Fall Prevention Project" in Luohu District from August 2016 to October 2019 as the “project group” respondents. Using propensity score matching (PSM) based on the Andersen’s Behavioral Model, a sample of “control group” respondents in the community was established by selecting those elderly who were not enrolled in the pilot from Luohu District elderly health records. A telephone interview survey was administered amongst 2,170 respondents from both the “project group” and “control group” to collect additional information on fall events, health and functional status, home environment, satisfaction/compliance with the project, and willingness and barriers to participation.

A total of 2,098 community-dwelling older respondents (709 in the “project group” and 1,389 in the “control group”) were finally included. The negative binomial regression was employed to compare the differences in indoor fall incidence rates between two groups of older adults, and subgroup analyses were conducted based on age categories. Qualitative textual data recorded from telephone interviews were subjected to thematic analysis.

Results:

1. The unadjusted fall rate among older adults increased from 18.6% in 2011 to 21.9% in 2018. After adjusting for the functional status of participants, the fall rate changed from an upward trend to an insignificant trend from 2011 to 2018, while significant regional variations in falls existed with higher fall prevalence in the central and western areas, compared with the eastern area, corresponding with the region’s relative levels of socioeconomic development. The unadjusted injurious fall rate was 8.5% in 2018. We depicted a significant descending trend of injurious falls between 2011 and 2018 and identified the northeastern region with the lowest rates of injurious falls. Age turned out to be an insignificant predictor of both falls and injurious falls after controlling for functional, ADL and IADL limitations. Several chronic conditions (ie, stroke, kidney disease, arthritis) and lower limb functional limitations posed significant risks for both falls and injurious falls.

2. From 2011 to 2018, facilities in urban residences spanning the 2^nd to 7^th floors for elderly participants continued to improve. The accessibility of elevators was still reported 11.1% among respondents in 2018, despite an increase from 2011. Elevator accessibility in urban buildings was found negatively associated with falls (OR=0.519, 95%CI [0.294-0.916]), with this effect being more significant among elderly residents living on the second floor (0.195 [0.051-0.747]). Post-hoc analysis revealed that older adults residing on the second floor had poorer physical function and ability of daily living compared to those on higher floors. Additionally, higher levels of indoor cleanliness and tidiness, and appropriate indoor temperatures were associated with fewer falls.

3. The “Fall Prevention Project”, which offered primary adaptations such as installing grab bars in bathrooms, providing non-slip mats and nightlights, was considerably favored by participants in the “project group”. However, the results indicated an insignificant reduction in indoor fall occurrence in the "project group" (IRR=0.737, 95% CI [0.431-1.259]). Moreover, participants below 75 years (IRR=0.619, 95%CI [0.175 – 2.186]) may gain more benefits compared to those aged 75 and above (IRR=0.815，95%CI [0.459 - 1.446]), although these estimates showed no statistical significance.

Factors predicting application for the “Fall Prevention Project” included being older, divorced/widowed, insurance covered, with higher socioeconomic status, a history of falls or fear of falling, poor self-rated health, disability, limited vision, and multiple chronic conditions (e.g., hypertension, diabetes, heart disease, osteoarthritis) and limitations in activities of daily living. Recommendation from community healthcare workers was identified as a facilitator for the elderly’s participation. A small number of respondents in the “control group” had undertaken home modifications on their own, while barriers to participation included inaccessibility of the project information, insufficient awareness and knowledge of falling, inadequate living space, and mobility issues for urban seniors. Furthermore, respondents of “project group” also provided feedback on maintenance issues and unmet need for personalized home modification and public spaces.

Conclusion:

Both overall fall rates and injurious fall rates among Chinese older adults displayed significant regional disparities, and the trends can be partly attributed to the deepening aging structure in China, accompanied by an increase in comorbidities and disabilities. It is imperative to proactively implement fall prevention measures, and resources allocation in the central and western regions should be further strengthened through initiatives such as expanding the coverage of barrier-free facilities and home modifications. Additionally, integrated approaches that combine chronic disease prevention with fall risk management should be further explored in China.

Accessible facilities such as building elevators are of crucial significance for aging in place as well as fall prevention. It is recommended to expedite the updated revision of China's Residential Building Codes and encourage local governments to coordinate the promotion of age-friendly construction in both deteriorated neighborhoods and existing multistory residential areas.

The pilot home modification project in Luohu District has achieved initial success, with increased residents’ satisfaction. This study advocates for the early adoption and subsequent upkeep of home modifications among older individuals. To achieve active aging, future adjustments and optimizations of home modification projects should include publicity strategy, target populations, involvement strategy, a wider range of personalized services, while exploring the incorporation of fall prevention into community healthcare services.