Self-Reported Fall-Related Injury and Its Associated Factors among Adults with Visual Impairment Attending St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia

Background Falls account for vast majority of fractures and are a significant reason for trauma related hospital admissions. The main aim of this study is to determine the prevalence of self-reported fall, related injuries, and associated factors among adult patients with visual impairment. Methods Hospital-based cross-sectional study was conducted from July to August 2021. Systematic random sampling technique was used. The data were entered into Epi-data version 3.1 and exported to SPPS version 26 for analysis. Frequency, mean, and percentage, were used to summarize the descriptive data. The association between the outcome variable and explanatory variables was assessed using binary and multivariate logistic regressions. The adjusted odds ratio was calculated, and variables with a p-value below 0.05 at the 95% confidence interval (CI) were considered statistically significant. Result A total of 487 study participants were involved in this study with a response rate of 93.83%. The mean age of the study participants was 52 ± 16.26 years. The overall prevalence of self-reported fall was 36.1 %. Being female, being older than 64 years of age, rural residence, fear of falling, and blind stage of visual impairment were significantly associated with falling. Conclusion The prevalence of self-reported fall was high among visually impaired individuals. Female sex, age more than 64 years, rural residence, fear of falling, and blind stage of visual impairment were significantly associated with falling. Reducing patients' chances of suffering from falling-related injuries and consequences requires raising awareness about the burden, danger, and effects of falling on persons who are visually impaired.


INTRODUCTION
Fall is defined as "a sudden and unintentional change of posture to the ground or a lower level, onto an object, floor, pavement, ground, or any other type of surface" (1). It is a significant issue for public health and medicine. Falling significantly lowers quality of life and can cause fear of falls, decreased physical activity, performance decline, loss of daily living activities, social isolation, depression, and an elevated risk of subsequent falling (2).
Falls are one of the main sources of injury because they expose the body to excessive energy, which results in physical harm (3). Serious injuries, such as acute head trauma, significant lacerations, or fractures, occur in five to ten percent of falls (4). Falls account for about 90% of fractures and are a significant reason for trauma related hospital admissions (5). It also accounts for 40% of all injury deaths (6) likewise injury is among the top 10 causes of death and Approximately, 90% of injury-related mortality occurred in low and middle-income countries (7,8). Falls-related injuries cost money for medical professionals, social services, patients, and their families (9). The anticipated annual medical expenditures for falling in 2015 were 50 billion US dollars (10).
People with visual impairment have an increased risk of falling (11)(12)(13). Visual impairment (VI) is a severe health issue that significantly affects a person's personal, professional, and social life (14). The World Health Organization estimates that there are over 314 million visually impaired persons worldwide, whereas the prevalence of low vision is 3.7% in Ethiopia (14,15). Individuals with VI are about two to three times more likely to fall, experience recurrent falls, and sustain fractures than people without VI (16,17).
Numerous research conducted worldwide shown that the percentage of visually impaired people who fall ranges from 10% to 46% (17)(18)(19)(20)(21). Age, gender, the degree of vision impairment, psychosocial variables, the physical surroundings, fall anxiety, depression, concurrent medical conditions, poly-medications, and pre-existing medical comorbidities are just a few of the many associated factors for falling (1,22,23). In order to create preventive measures that can be incorporated into prevention programs, it may be helpful to examine modifiable associated factors like Visual impairment (12,24).
There were few pieces of evidence about the frequency of falls among visually impaired people in Ethiopia. The prevalence of selfreported falls, related injuries, and associated factors among people with visual impairment is thus estimated in part by the findings of this study. Finally, the ultimate objective of this research is to determine the prevalence, related injury, and associated factors of self-reported fall among adult patients with visual impairment attending St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia, 2021.

METHODS AND MATERIALS
Study design and setting: The study was carried out at St. Paul's Hospital Millennium Medical College (SPHMMC) from July to August 2021 utilizing a hospital-based cross-sectional study design. The facility has sub-specialty clinics with the tools necessary to examine a patient with eye problems. For the approximately 6 million residents of Addis Ababa and the surrounding areas, it acts as the last point of referral.
In the city, there are two hospitals with tertiary eye care facilities and six hospitals with secondary eye care centers. Secondary eye care facilities refer patients with eye disorders to such tertiary facilities; SPHMMC is one of those tertiary facilities and sees roughly 4000 outpatient patients a month.

Sample size determination:
The sample size was determined by using single population proportion formula taking the prevalence of falling was taken from a prevalence study conducted in Gondar, Ethiopia,(26) which was 26.8% (0.268); 1 − P = 0.732; d, a margin of error 4% = 0.04, and the sample size was 471. Using Epi-info software, the sample size was estimated with associated factors in mind. Taking systemic comorbidity and medication use as the two primary consistent predictors for fall, the results were 178 and 61, respectively. As a result, the sample size chosen for the prevalence was sufficiently bigger than the two, and when the 10% non-response rate was taken into account, the final sample size was 519.
Sampling technique and procedure: The samples were selected using systematic random sampling from all patients attending St. Paul's Hospital Millennium Medical College at the Department of Ophthalmology. According to information from triage offices, every day, 200 individuals receive ocular medical care, of which 175 are visually impaired.
As a result, there are 1400 study participants overall during the research time. The k value for systematic random sampling was 3 (1400/519). The first sample was chosen at random from a group of one to three participants, and then each subsequent sample was amused.

Data collection tool, procedures, and Analysis:
Three trained optometrists who participated in the study used a self-administered structured questionnaire, a clinical examination, and a data extraction checklist to collect the data. Data on the socio-demography and fall experience of the study participants were gathered using the selfadministered questionnaire. While the scope of the clinical examination ranges from determining the monocular distance visual acuity of study participants using a projected Snellen chart calibrated for the distance of the examination room at three meters to weight and height measurements using a digital balance and meter, respectively. The remaining data including primary diagnosis confirmed by a physician (as primary causes for visual impairment) were extracted from medical charts using a data extraction checklist. Falling was considered when a patient is coming to rest unintentionally on the ground or another lower-level one or more times during the past 12 months (27) whereas the severity of visual impairment was measured based on presenting visual acuity in the better eye (28).
After being entered into Epi-data version 3.1, the acquired data was exported to SPPS version 26, where it was then analyzed. Descriptive statistics such as frequency, mean, percentage, and standard deviation were used to summarize the descriptive part of the data. The relationship between falling and various independent factors was determined using binary logistic regression, and the model's fitness was assessed using Hosmer and Lemeshow's goodness of fit test. To find statistically significant factors, variables having a p-value of less than 0.2 at bivariable logistic regression were included to a multivariable logistic regression. With multivariable binary logistic regression, a Pvalue of 0.05 or less was deemed significant.
Ethical consideration: The University of Gondar, College of Medicine and Health Sciences ethics review committee granted ethical clearance prior to the study's execution with the reference number (684/06/21). Additionally, SPHMMC gave approval for the data gathering to continue. Each participant was given the opportunity to give their oral consent after being informed of the study's goals and their complete ability to stop or decline participation. The World Medical Association Declaration of Helsinki was followed in conducting the study. By eliminating identifiers from the data gathering process, protecting their privacy, and storing the data securely, the confidentiality of the information was carefully maintained.   Table 2). Behavioral and general health-related conditions of the study participants: Among study participants, almost two-thirds of them, 323(66.1%) were non-alcoholic, only a few  than half (58.5) thought that a loss of vision was the reason they did so. Twenty one (11.9%) thought of muscle weakness they had, while 25 (14.2%) thought of an uncomfortable road, and the remaining thought of other causes for falling (Table 3). Factors associated with falling among visually impaired: According to bivariable logistic regression, a number of factors, including sex, age, body mass index, education level, place of residence, monthly income, drinking behavior, fear of falling, and degree of vision impairment, were associated with self-reported falls. Sex, age, place of residence, fear of falling, and degree of visual impairment were, nonetheless, significantly associated with falling according to multivariable logistic regression analysis. Female study subjects were 2 times (AOR=2, 95% CI: 1.19-3.38) more likely to fall in comparison to male subjects. Those older than 64 years were 3 times (AOR=3.03, 95% CI: 1.43-6.43) more likely to experience falling than those whose ages were between 18 and 44 years. The odds of fall among participants lived in rural areas were 1.69 times (AOR=1.69, 95% CI: 1.03-2.77) more than those who live in urban areas. Those participants who had a concern about falling were 5.17 times (AOR=5.17, 95% CI: 2.70-9.90) more likely to fall as compared to participants not concerned about falling. The odds of fall was 4.20 times (AOR= 4.20, 95% CI: 2.70-9.90) higher in study subjects with blind stage of visual impairment than mildly visual impaired (see Table 4).
However, the finding of this research was higher than studies from USA (27%) (4), Australia (29.8%) (33), Italy (28.6%) (34), China (10.7%) (21), Nigeria (23%) (35) and Gondar-Ethiopia (26.8%) (26). The discrepancy might be due to differences in the study population characteristics, sample size, or methodology. For instance, USA, Australia, Italy, and China are economically developed and eye care and healthrelated facilities are easily accessible which helps to prevent both visual impairment and falling. The Ethiopian study selected study subjects based on impairment of either eye.
On the other hand, this finding was lower than studies conducted in Australia (42.5%) (27), and USA (46.7%) (36). This difference might be due to the criteria for selecting study subjects. Their study mainly focused on older age groups, in which age is a higher risk for falling and visual impairment (37,38). While this study includes participants whose age is 18 and above.
Regarding associated factors gender, age, residence, fear of fall, and degree of visual impairment were significantly associated with falling. Concerning gender, female study subjects were more likely to fall in comparison to male subjects. Similar results were reported from USA, Australia, Taiwan, and Nigeria (5,20,33,35). It might be because of this commonality that more women than men are affected by blindness and moderate to severe vision impairment (39).
This study also discovered that participants over the age of 64 had a higher odds of fall than participants between the ages of 18 and 44. Studies undertaken in Gondar, Ethiopia, Latin America, and the USA confirm this conclusion (22,26). This could be due to physiological changes in muscle and bone, and greater burden of visual impairment in older age (40).
Those who live in rural areas were more likely to fall as compared to those who resided in urban areas. Similarly, the study conducted in USA and Nigeria revealed that falling was higher in rural residents (35,41). High-risk professions like farming and forestry as well as limited access to medical facilities in rural locations might be the possible reason for the result.
Fear of fall among visually impaired individuals was the other variable associated with falling in the regression model. Study subjects reported somewhat and very high concern about fall during daily living activities were more likely to fall compared to those who had not been concerned about falling. This finding was similar to studies conducted in Australia, USA, and Gondar-Ethiopia (26,42,43). Fear of fall affects 20-50% of old adults and may be a rational psychological response to previous falls (44). Fear of falling may have a direct effect on balance control through psychological factors such as anxiety, which leads to stiffening of joints and gait changes, which in turn, may lead to an increased risk of falling (42).
The severity of visual impairment affects an individual's ability to respond to environmental hazards. Cataract and glaucoma were the most common eye disease that causes visual impairment found in this study. Besides, blind individuals were more likely to fall than those with mild visual impairment. This finding was similar to studies conducted in USA, Australia, Taiwan, and United Kingdom (5,20,27,36,45). Contrary to this study, the degree of visual impairment was not associated with falling for studies conducted in China, Nigeria, and Gondar-Ethiopia (19,26,35). This might be due to methodological difference; in the Nigerian and Ethiopian studies, visual acuity was not measured objectively but rather used self-reported by participants.
The prevalence of self-reported fall was high. Factors such as age more than 64 years, female sex, rural residence, fear of falling, and blind stage of visual impairment were statistically significantly associated with falling. Reducing patients' chances of suffering from falling-related injuries and consequences requires raising awareness about the burden, danger, and effects of falling on persons who are visually impaired.
It would have been better if there was a control group to compare with because it can give better pictures of falling due to visual impairment. The questionnaire used to assess falling was based on the recalling ability of participants so it may be subjected to recall bias and also VA was taken after falling that may not reflect the actual acuity at the time of falling.