Falls are a common event among older adults and a leading cause of fatal and nonfatal injury associated with a decline in functional status and disability [1, 2]. Fall rates differ widely between states, and variations in falls have been noted between urban and rural environments [3]. In addition, weather and the built environment (e.g. poor walking surfaces, traffic, and inadequate light) vary by location and may affect fall risk and physical activity behavior in those areas [4]. Research has identified several key individual risk factors for fall risk that include age, female gender, visual impairments, cognitive decline, gait limitations, chronic diseases, non-Hispanic white race, and a history of previous falls [5-7].

Many minority groups experience worse health outcomes due to limited healthcare access, discrimination, socioeconomic status, and other factors [8]. Geriatric conditions which affect fall risk, such as greater disease burden [9] and osteoporosis [10], differ by racial/ethnic status. Body mass index, may also influence risk of falling [11] and differs by group, as Asian Americans on average have lower BMIs [12]. Among older age groups, blacks, Hispanics and Asians have greater rates of poverty (18.0%, 18.0%, and 14.6%) compared to whites (7.7%) and blacks and whites tend to have a greater percentage of individuals living alone (44.0% and 43.0%) than Hispanics and Asians (33.9% and 30.4%) [10]. Furthermore, differences in cultural factors, such as perceptions of frailty, and lifestyle factors, such as living with a relative, may also influence susceptibility to falling [13].

Several studies have suggested that variations in fall risk exists among different racial/ethnic groups [14]. For example, older African Americans and blacks, even with a higher risk profile, are less likely or not as likely to fall when compared to whites [9, 15, 16], but for unclear reasons. Few studies have examined falls among Hispanics and Asian Americans [14]; however, one study found similar fall rates between Hispanics and non-Hispanic whites [9] and evidence from other countries indicates a decreased fall risk among Asians living in their home country compared to Asian immigrants and whites [13]. New York City mortality data has shown that death due to falls is higher among whites and Asians, and lower among blacks and Hispanics [17].

Acculturation may influence health risks among immigrant populations [18, 19]. It has previously been proposed that immigrants migrate with favorable health behaviors that may change with increased time in the U.S. [20, 21] and that immigrant populations, even those with lower socioeconomic backgrounds and less access to healthcare, experience better health [22]. The ‘healthy immigrant effect,’ which suggests that healthy individuals migrate from home, has been cited to explain why individuals within recent migration groups may initially appear healthier and have better health outcomes compared to those born within their host country [21, 23, 24]. Furthermore, recent immigrants tend to have better health profiles compared to individuals born in the U.S., such as lower rates of smoking and obesity [20], which get worse the longer they stay in the U.S. [20, 21, 24], and stronger social-networks [20]. It is not clear, however, how acculturation may affect common conditions of older adults, such as falls and gait disorders. It can be hypothesized that specific, culturally-embedded behaviors, such as living with relatives, using walking sticks, or engaging in low risk strengthening exercise like Tai Chi or squatting, may contribute to a decrease in fall risk [13, 25] among specific immigrant populations. These advantages may be lost the longer an individual lives outside their home country. The acculturation model, which posits “the gradual adoption of the norms and behaviors of the dominant culture” [26] helps to explain how positive traditional health behaviors may be lost once an individual has become immersed in a new culture. Previous studies have not focused on older Asian and Hispanic immigrants or on understanding how acculturation and its related changes in health behaviors may influence the risks of falls for older adults in the U.S.

Thus, there is a great need to address this knowledge gap, as the older adult population in the U.S. is rapidly growing and substantial demographic shifts by race/ethnicity are projected— racial/ethnic minority communities will comprise the new majority in the near future, with the largest increases projected for immigrant groups such as Hispanics (141.7%) and Asian Americans (116.4%) [27]. Given the rapidly increasing racial/ethnic older adult population and the limited information regarding the impact of falls in these groups, the objective of this study was to examine whether there is an association between race/ethnicity and falling ≥2 times in the past year; in addition, we further examine if the relationship between race/ethnicity and English proficiency is associated with falling ≥2 times in the past year among Asian Americans and Hispanics as compared to non-Hispanic whites.

The findings from this study add important insight to the current literature regarding fall risks among different racial/ethnic groups. Race/ethnicity was a significant predictor for the risk of falling ≥2 times in the past year among older individuals, and Asian Americans were significantly less likely to have fallen ≥2 times in the past year compared to non-Hispanic whites. Further analysis found that this risk was significant for the LEP Asian American group. No significant differences in the risk of falling were found among African Americans or Hispanics when compared to non-Hispanic whites. Our final model also found several traditional individual level risk factors for falling to be significant within our diverse study population, including marital status, chronic disease status and functional limitations. Previous research indicates that females are more likely to fall than males; our gender findings were not significant.

While several studies have examined falls among African Americans or blacks and non-Hispanic whites [9, 14-16, 41], fewer studies, with mixed results, have examined falls among Hispanics [9]. The Health and Retirement Survey, a longitudinal population-based survey from 2000-2010 found that African Americans had a significantly lower risk of falls and the Hispanic population saw no difference compared to non-Hispanic whites [9]. A recent study using the National Health and Aging Trends longitudinal survey found that blacks had a 30% decreased risk for falls and a 40% decreased risk for recurrent falls compared to whites. Reasons for such a large difference were unclear when accounting for physical performance level, disability, and physical activity [16]. Other large cohort studies have not shown significant differences in fall rates between whites and African Americans or blacks [9, 14, 15], which are consistent with our findings. As far as the authors are aware, no current studies have examined fall risks among Asian Americans as compared to other groups.

Our study is consistent with previous international studies that indicate a lower fall rate among Asians compared to a range of white populations [13, 14]. A study by Kwan et al. examining fall rates among Chinese in Taiwan, Hong Kong, and Australia and whites in Australia found that fall rates were significantly lower for all Asian groups when compared to the white cohort; the lowest fall rates were seen in the Taiwan and Hong Kong Chinese cohorts, followed by the Australian Chinese cohort [13]. The authors suggest that decreased falls risk among the Chinese cohorts may be due to increased concerns with falling and the subsequent adoption of protective behaviors against falls; behaviors which may be lost with migration per the higher falls risk found with the Chinese immigrant Australian cohort. The results of our secondary analyses suggest that LEP and EP Asian Americans both demonstrated decreased risk; however, this decreased risk was stronger in the LEP group. This association, however, was not seen within the Hispanic population. Specific culturally-imbedded health behaviors that may affect fall risk are unclear from our data, and it is possible that they may change with level of acculturation. For example Tai Chi, an ancient Chinese martial art, has been shown to be effective at reducing falls in certain populations [42, 43]. A systematic review of falls risk among Chinese older adults in Asia found that the overall decreased incidence in falls within this population may be due to a variety of factors, including a high incidence of squatting, less risk taking behaviors, and specific activity patterns [25]. Moreover, within certain populations, perceptions of frailty may differ. In Kwan et al.'s study, each Chinese cohort, compared to the white cohort, had high scores on the Falls Efficacy Scale-International (FES-I), which measures concerns about falling. The authors suggest that due to a heightened concern for falling, Chinese cohorts may be more likely to engage in ‘cautious behaviors,’ such as the use of walking sticks (especially in Hong Kong)—a behavior negatively associated with frailty in western cultures and therefore used less often [13].

Language-isolated or less-acculturated older adults may report lower levels of neighborhood social cohesion and may spend less time outside in the built environment, which could contribute to a slightly decreased fall risk [44-46]. Within the Asian American community, less acculturated immigrants may experience fewer falls because they are healthier when they arrive in the United States, as suggested by the healthy immigrant effect [20]. Furthermore, Asian Americans are less likely to live alone and therefore may be able to request assistance from household members thus avoiding activities that may increase their general likelihood of a fall. No differences were seen among Hispanics by acculturation level, however, even though they too are more likely to not live alone. Thus, further studies are needed to clarify the specific health behaviors among older Asian Americans and Hispanics and how they may be influenced by level of acculturation.

Additionally, data from New York City has shown that Asian Americans have a high falls mortality rate [17], suggesting that even if Asian Americans are falling less frequently, once they fall they are more likely to die. In their systematic review, Kwan et al. also reported a similar phenomenon between Chinese and white older adults, whereby Chinese older adults were less likely to fall, but when they fell, they sustained more serious injuries than their white counterparts. The authors postulated that this may be due to Chinese older adults being more likely to fall on the street or sidewalk, rather than on a softer surface [25], therefore increasing the risk of serious fracture [47]. The mechanisms underlying these complexities also require further examination

This study was subject to several limitations. First, the results may not be applicable to individuals who live in other areas of the country with different environmental influences on fall risk and/or different racial/ethnic heterogeneity. Moreover, heterogeneity within each racial/ethnic group may differ greatly based on location and immigration patterns [48]. Second, the CHIS only assesses more than one fall and does not specify the location of the fall (indoors versus outdoors), which may have different clinical and social implications [15]. Third, only a subset of risk factors for falls could be examined, and some key risk factors, including fear of falling [49], medication use, frailty, gait, and history of falls, could not be ascertained from the data [5, 6, 50]. Fourth, a discrepancy may exist between the decreased fall risk among Asian Americans in our study and increased mortality due to falls among Asian Americans as reported in NYC mortality data. This discrepancy could be due to the limitations of self-reported data in our study, in which certain groups may under-report falls. Finally, acculturation is a complex process, which is difficult to define and measure. While language is one of the strongest predictors of acculturation [51, 52], there are many other measures and scales that are used as proxies for acculturation, including survey language, years lived in the U.S., and validated acculturation scales [39]. Use of other scales or proxies for acculturation may result in different study outcomes, and should be further examined in future studies.

Our study also has important implications. These findings, as well as future study findings, could be used by health providers and public health officials to inform programs and policies and to allocate additional resources on falls prevention. As the diversity in the U.S. continues to grow, especially among older racial and minority populations including Asian Americans, it is important to understand why and how specific groups fall, in order to identify those most at risk.

To our knowledge, this is the first study to examine fall risk among a racially and ethnically diverse sample of older individuals, and to examine the association of English language proficiency in relation to race/ethnicity on fall risk. Race/ethnicity may play an important role in many health behaviors, and it is important to understand the relationship between race/ethnicity and the risk of falling. Careful attention is needed to understand how migration and acculturation, environmental factors, and social support affect falls in older adults. Our findings inform this evolving body of research and underscore the need for further research to understand the risk of falls across diverse racial/ethnic populations. Culturally relevant and targeted interventions are needed to prevent falls and subsequent injuries in the increasingly diverse aging population in the U.S.