The Association between Falls and Attitudes toward Aging among Older Adults in China: The Moderating Role of Age-Friendly Community Renovations

The Association between Falls and Attitudes toward Aging among Older Adults in China: The Moderating Role of Age-Friendly Community Renovations | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Association between Falls and Attitudes toward Aging among Older Adults in China: The Moderating Role of Age-Friendly Community Renovations Hang Liang, Boyu Wang, Xigang Qin, Jia Meng, Erpeng Liu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7319199/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Positive attitudes toward aging (ATA) constitute a key factor for healthy aging and well-being among older adults. This study aimed to examine the association between falls and ATA among older adults in China and to investigate the moderating effects of age-friendly community renovations on this association. Methods Data were derived from the China Longitudinal Ageing Social Survey (CLASS). The sample included 11,398 participants; 7.6% of the participants experienced falls in the previous year. Multiple linear regression models were applied to analyze the data, and propensity score matching (PSM) was used to address endogeneity. Results Falls were significantly and negatively associated with ATA ( β = -0.581, 95% CI: -0.877, -0.284). Age-friendly community renovations positively moderated the association between falls and ATA ( β = 0.659, 95% CI: 0.037, 1.202). Conclusion Policymakers should devote more attention to the negative association between falls and ATA. Increasing the implementation of age-friendly community renovations can reduce the probability of falls and enhance ATA among older adults. Attitudes toward aging Falls Age-friendly community renovations Older adults Figures Figure 1 Introduction Due to the rapid aging of the global population, older adults in China “live a long time”, but their “quality of life” has not significantly improved [ 1 , 2 ]. China’s average life expectancy is 79 years, but the healthy life expectancy is only 68.7 years, thus presenting a challenge for healthy aging [ 3 ]. Healthy aging refers not only to individual health and good social adaptability among older adults but also to the health of the entire elderly population and the extension of healthy life expectancy; this concept emphasizes a good social atmosphere as well as an orderly and healthy humanistic environment for aging [ 4 ]. At a micro level, attitudes toward aging (ATA) are the basis of the healthy aging among individuals [ 5 , 6 ]. Individual ATA have important impacts on physical and psychological health, and positive ATA improve health and well-being, thus promoting healthy aging; on the other hand, negative ATA accelerate the aging process and exert adverse effects on health, even leading to maladjustment in later stages of life among older adults [ 7 , 8 ]. ATA refer to individuals’ perceptions of the aging process with respect to oneself or others [ 9 ]. ATA can be divided into self ATA and general ATA [ 10 ]. Self ATA refer to an individual’s perception of their own aging process, while general ATA refer to an individual’s attitudes toward holistic perceptions of the body aging process among older adults [ 11 ]. Previous studies have identified three broad categories of factors that influence ATA. The first category includes demographic and health factors (e.g., older age, female gender, more chronic diseases, poorer self-rated health, and greater levels of functional dependence) [ 8 , 9 ]. The second category comprises indicators of the social environment (e.g., humid or cold living conditions, dim light, activity places with obstacles, and noisy and unfriendly neighborhood atmospheres) [ 6 , 11 , 12 ]. The third category includes major life events (e.g., retirement, bereavement of spouses or children, falls, and cancer) [ 13 , 14 , 15 ], which can exert considerable impacts on the physical and psychological health of older adults and accelerate their perception of aging [ 16 ]. Among the factors that affect ATA of older adults, falls are important risk factors. The global incidence of falls among people aged 60 years and above is as high as 30%, with more than 75% of life-threatening falls among older adults occurring in low- and middle-income countries [ 17 ]. Falls have become the second leading cause of accidental death among older adults. A total of 52.6% of older adults who experience falls subsequently suffer from physical injuries such as soft tissue contusions, fractures, and concussions, as well as psychological trauma, including fear of falling, anxiety, depression, and social isolation [ 18 , 19 ]. Despite the potentially significant implications of falls for older adults’ well-being, the association between falls and ATA have rarely been examined in previous studies. Falls cause physical or psychological damage, thereby potentially affecting the daily lives of individuals. For example, falls affect people’s activities of daily living; reduce the frequency of social interaction; and aggravate psychological trauma, fear of falling, loneliness and anxiety [ 20 , 21 ]. Thus, further research on the potential association between falls and ATA could elucidate the psychological damage caused by falls and help health care professionals more actively engage in health-promoting activities among older adults. To further improve quality of life among older adults – especially by reducing the risk of falls and restrictions on daily activities – the World Health Organization (WHO) has recognized the importance of the environment and proposed the concept of the “Ageing-Friendly Community” [ 22 ]. The construction of an age-friendly community emphasizes the promotion of greater social interaction, more meaningful activities, and better health opportunities for older persons through improvements in the community environment [ 23 ]. Aging-friendly communities are associated with better self-perceived health [ 24 ], lower levels of depression [ 25 ], higher levels of subjective well-being [ 26 ], and better quality of life [ 27 ]. Over the years, the Chinese government has formulated a series of policies concerning age-friendly community renovations. In October 2016, the National Aging Population Office published guidelines promoting aging-friendly environments by developing appropriate facilities, implementing barrier-free access designs and increasing elderly care services [ 28 ]. Therefore, it is necessary to examine the relationship between age-friendly community renovations and ATA. Furthermore, it is necessary to determine whether age-friendly community renovations can reduce the probability of falls and enhance positive ATA among older adults. This study aimed to examine the association between falls and ATA among older adults in China, to explore the potential mediating roles of activities of daily living (ADLs) and depression, and to investigate the moderating role of age-friendly community renovations. The major contributions of this study are as follows. First, the association between falls and ATA and the underlying mechanism of this relationship have rarely been studied. This study aims to determine whether falls, as important life events, exacerbate negative ATA. Second, this study aims to assesses the moderating effect of age-friendly community renovations on the association between falls and ATA, which will be helpful for objectively evaluating the direct impact of age-friendly community renovations on ATA and disentangling its role in mitigating the negative impact of falls on ATA. Methods Data sources The data were derived from the China Longitudinal Ageing Social Survey (CLASS), which is a large-scale national and continuous social survey project. The survey was conducted using a stratified multistage probabilistic sampling method. The county/district was the primary sampling unit, the village/neighborhood committee was the secondary sampling unit, and individuals aged 60 years and above were sampled from each village/neighborhood committee. The survey content is comprehensive and assesses health status and related services for older adults, socioeconomic status, pension planning and arrangement, cognition and ATA, generational support and other dimensions. The overall aim of the CLASS is to comprehensively elucidate the quality of life and health status of older adults in China [29, 30]. The CLASS was ethically reviewed and approved by the Biomedical Ethics Review Committee of Renmin University of China (No. 20221226025). The investigator explained the purpose of the study to all participants, and they were notified of their right to withdraw at any time. All the participants provided informed consent. The CLASS was first administered in 2014; the data in this study were drawn from the 2020 wave of the survey, which is the most recent dataset. After excluding observations with missing, rejected and obviously wrong data, a total of 11,398 valid observations were ultimately included for analysis. Measures Dependent variable: ATA The dependent variable was ATA, which was evaluated by the Attitudes to Ageing Questionnaire (AAQ, [31]). The questionnaire measures ATA in three domains: physical functioning, psychological growth and psychological loss [31]. Example items include “I feel like I’m getting old”, “In my opinion, growing old is a process of constant loss”, “As I get older, I find it harder to make new friends”, “Because of my age, I feel like I’m being pushed aside”, “The older people get, the better they are at dealing with life’s problems?”, and “Does wisdom come with age?”. The responses to these questions were aggregated or weighted to obtain a score of ATA for each respondent. In this study, the psychological loss item was reverse scored. Higher scores indicated more positive ATA. The total score of ATA ranged from 1 to 35. The AAQ has been found to reliably assess older adults’ AAT [32] and is aimed to be used with older adults [15, 33]. Independent variable: falls The independent variable was falls, which was assessed by the following item: “Have you fallen in the past 12 months?” A value of 0 represents “no falls”, and a value of 1 represents “one fall” or “at least two falls”. This item was used to quantify and capture the fall experiences of older adults within a certain period (i.e., the past year). Mediating variables: ADLs and depression The mediating variables included ADLs and depression. ADLs consists of six domains, i.e., bathing, dressing, toilet behavior, indoor transfer, continence and eating. Based on the independence of individuals in terms of engaging in each of the above mentioned actions, they were given a score of 1 (complete dependence on others), 2 (partial independence) or 3 (complete independence). The scores on the six items were summed, and thus, the total ADLs score ranged from 6 to 18. Higher scores indicated more independent functional ability of the respondent. Depression was measured by two items: “Have you felt in a good mood in the past week?” and “Have you felt sad in the past week?” The response options for each item ranged from 1 to 3 (1 = none, 2 = sometimes, 3 = often). The positive psychology item was reverse scored. The total depression score ranged from 2 to 6, with higher scores indicating more severe depression. Moderating variable: age-friendly community renovations The moderating variable was age-friendly community renovations, which consists of two categories (hardware facility renovations and cultural atmosphere construction). Age-friendly community hardware facility renovations were measured by respondents’ satisfaction with community roads, street or road lighting, and barrier-free facility construction. Age-friendly community cultural atmosphere construction was measured by respondents’ satisfaction with the atmosphere of respecting and loving older adults and the pleasant environment. The response options for each item ranged from 1 to 5 (1 = very dissatisfied, 2 = less satisfied, 3 = generally, 4 = more satisfied, and 5 = very satisfied). The overall age-friendly community renovations were obtained by adding the scores of the five options (ranging from 5 to 25). Higher scores reflect better age-friendly community renovations. Covariates To accurately analyze the association between falls and ATA, this study measured a series of control variables to rule out other potential influencing factors based on findings from previous studies [34, 35]. These control variables included sociodemographic characteristics such as gender (1 = female, 0 = male), age, education (years of schooling), marital status (1= married, 0 = widower/divorced/unmarried), ethnicity (1 = Han ethnicity, 0 = minority ethnicity), residence (1 = urban area, 0 = rural area), self-rated health (1 = unhealthy to 5 = very healthy) and chronic diseases (1 = one or more, 0 = none). The control variables also included family/social characteristics such as co-residence with children (1 = yes, 0 = no), pension insurance (1 = yes. 0 = no), number of children (ranging from 0 to 12) and household income. Statistical analysis This study first conducted descriptive statistics for the total sample. Differences in covariates between participants who experienced falls and those who had not experienced falls were tested by unpaired t tests and chi-square tests for quantitative and categorical variables, respectively. Second, we examined the association between falls and ATA among older adults by a multiple linear regression model. Propensity score matching (PSM) was applied to address endogeneity. Third, we examined the differences in the association between falls and ATA among three groups of older adults: gender (male vs. female), residence (urban area vs. rural area), and chronic disease (yes vs. none). Fourth, we assessed the mediating effect of ADLs and depression on the association between falls and ATA. The mediating effects of ADLs and depression were determined by bootstrapping with 5000 resamples. Finally, we explored the moderating role of age-friendly community renovations. The moderating effect of age-friendly community renovations was analyzed by constructing a regression model with interaction terms. The results are presented as β coefficients with 95% confidence intervals (CIs). Statistical analyses were performed by using STATA, version 15 (StataCorp, TX, USA). Results Sample characteristics The Cronbach alpha coefficient for the ATA measure was 0.81, which indicated a moderate level of internal consistency. A total of 11,398 observations were included in the study, and 866 older adults experienced falls in the past year (7.6%). Older adults who experienced falls had more negative ATA than did participants who had not experienced falls (17.56 vs. 18.95, p < 0.001), a lower level of ADLs (15.35 vs. 17.53, p < 0.001), a lower level of depression (3.75 vs. 3.44, p < 0.001), and received more age-friendly community renovations (1.16 vs. 0.98, p < 0.001). Compared with those who had not experienced falls, those who had experienced falls were more likely to be older, married, live in urban areas, have more kinds of chronic diseases, be of Han ethnicity, not reside with family members, have a lower level of education and self-rated health, and have more children (Table 1 ). Table 1 Descriptive statistics of the study population (N = 11,398) Variables Falls (N = 866) No falls (N = 10,532) P value N % N % Gender Female 448 51.73 5202 49.39 0.186 Male 418 48.27 5330 50.61 Age 60 ~ 69 254 29.33 4779 45.38 < 0.001 70 ~ 79 383 44.23 4362 41.42 ≥ 80 229 26.44 1391 13.21 Marital status Married 567 65.47 8024 76.19 < 0.001 Widower/divorced/unmarried 299 34.53 2508 23.81 Residence Urban area 442 51.04 5830 55.36 0.014 Rural area 424 48.96 4702 44.64 Chronic diseases Yes 780 90.07 8159 77.47 < 0.001 None 86 9.93 2373 22.53 Nation Han ethnicity 837 96.65 9879 93.8 < 0.001 Minority ethnicity 29 3.35 653 6.2 Co-residence with children Yes 428 49.42 3880 36.84 < 0.001 No 438 50.58 6652 63.16 Pension insurance Yes 275 31.76 3394 32.23 0.776 No 591 68.24 7138 67.77 Mean S.D. Mean S.D. Age 71.35 6.48 74.53 7.34 < 0.001 Attitudes toward aging 17.56 3.95 18.95 3.53 < 0.001 Age-friendly community renovations 1.16 2.20 0.98 2.11 < 0.001 Education (years of schooling) 4.89 4.21 5.99 3.94 < 0.001 Self-rated health 2.78 1.02 3.42 0.87 < 0.001 Household income 4.14 5.25 4.35 5.31 0.1303 Numbers of children 2.84 1.53 2.43 1.32 < 0.001 ADLs 15.35 3.27 17.53 1.64 < 0.001 Depression 3.75 0.04 3.44 1.07 < 0.001 Note. S.D., standard deviation. P values were calculated via t tests (continuous variables) or chi-square tests (categorical variables). Association between falls and ATA Baseline regression Model 1 (Table 2 ) revealed that falls were significantly and negatively associated with ATA ( β = -0.937, 95% CI: -1.229, -0.645). However, there were no control variables in Model 1, which may have led to biased results. Model 2 was adjusted for a series of sociodemographic and family/social characteristics; the results showed that age, ethnicity, chronic diseases, co-residence with family members, and pension insurance were significantly associated with ATA. Falls were significantly and negatively associated with ATA ( β = -0.581, 95% CI: -0.877, -0.284). These findings suggest that falls are key risk factors for negative ATA among older adults. Table 2 The association between falls and ATA Model 1 Model 2 Falls -0.937 *** -0.581 *** (-1.229, -0.645) (-0.877, -0.284) Male (ref: female) -0.063 (-0.221, 0.094) Age 70 ~ 79 (ref: age 60 ~ 69) -0.230 ** (-0.404, -0.056) Age ≥ 80 (ref: age 60 ~ 69) -0.364 ** (-0.631, -0.097) Education -0.008 (-0.031, 0.015) Married (ref: widower/divorced/unmarried) -0.037 (-0.230, 0.158) Han ethnicity (ref: minority ethnicity) -0.916 *** (-1.242, -0.589) Urban area (ref: rural area) -0.008 (-0.196, 0.181) Self-rated health 0.513 *** (0.423, 0.603) Chronic diseases (ref: none) 0.765 *** (0.572, 0.959) Numbers of children 0.005 (-0.060, 0.070) Co-residence with children (ref: no) -0.404 *** (-0.569, -0.239) Pension insurance (ref: no) 0.408 ** (0.143, 0.673) Household income -0.015 (-0.039, 0.008) Note: * p < 0.05, ** p < 0.01, *** p < 0.001. Endogeneity To more accurately explore the association between falls and ATA, PSM was applied. Table 3 shows that the association between falls and ATA passed three tests. The test of nearest neighbor matching yielded an effect − 0.492 ( t = -3.43, p < 0.001); the test of radius matching yielded an effect of -0.408 ( t = -2.63, p < 0.001); and the test of kernel matching yielded an effect was − 0.471 ( t = -3.07, p < 0.001). The t values of the above three tests passed the significance requirements, which indicated that there was a significant association between falls and ATA. The results further emphasized that falls are risk factors for ATA. Table 3 PSM test on the association between falls and ATA Treated (Falls) Untreated (No fall) Average treatment effect on the Treated (ATT) Standard error t tests Nearest neighbor matching 17.814 18.307 -0.492 0.144 -3.43 *** Radius matching 17.818 18.226 -0.408 0.155 -2.63 *** Kernel matching 17.815 18.285 -0.471 0.153 -3.07 *** Note: * p < 0.05, ** p < 0.01, *** p < 0.001. Heterogeneity analysis Table 4 shows the differences in the associations between falls and ATA between genders, residence and chronic disease. The results of Model 3 and Model 4 indicated that falls had a greater effect on ATA among female older adults than among male older adults ( β = -0.646 vs. β = -0.486). The results of Model 5 and Model 6 showed that falls were significantly associated with ATA among older adults from rural areas ( β = -0.975, 95% CI: -1.219, -0.372). The results of Model 7 and Model 8 revealed that falls were significantly associated with ATA among older adults who had chronic diseases ( β = -0.543, 95% CI: -0.854, -0.233). Table 4 Differences in the associations between falls and ATA between genders, residence and chronic disease. Model 3 Model 4 Model 5 Model 6 Model 7 Model 8 Female Male Rural area Urban area Chronic diseases No chronic diseases Falls -0.646 *** -0.486 * -0.795 *** -0.372 -0.543 *** -0.796 (-1.059, -0.233) (-0.913, -0.057) (-1.219, -0.372) (-0.789, 0.045) (-0.854, -0.233) (-1.749, 0.157) Note: All covariates were controlled when we conducted the analyses. * p < 0.05, ** p < 0.01, *** p < 0.001. The mediating effects of ADLs and depression To further determine whether the association between falls and ATA among older adults was affected by mediating variables, ADLs and depression entered into the regression models. Table 5 shows the results concerning the mediating effects of ADLs and depression. Bootstrapping was conducted with 5000 resamples to test the significance of the mediating effects. A 95% bootstrap CI that does not include zero indicates a significant mediating effect. The results revealed that falls were negatively associated with ADLs ( β = -1.532, 95% bootstrap CI: -1.650, -1.416), and ADLs were positively associated with ATA ( β = 0.142, 95% bootstrap CI: 0.093, 0.190). The mediating effect of ADLs on the association between falls and ATA was − 0.217 (95% bootstrap CI: -0.301, -0.138), and the relative effect size was 37.61%. Additionally, falls were significantly associated with depression ( β = 0.117, 95% bootstrap CI: 0.041, 0.193), and depression was negatively associated with ATA ( β = -0.246, 95% bootstrap CI: -0.320, -0.172). The mediating effect of depression on the association between falls and ATA was − 0.029 (95% bootstrap CI: -0.055, -0.010), and the relative effect size was 5.03%. The path of the association between falls and ATA is shown in Fig. 1 a. And the findings indicated that falls among older adults adversely affected ATA through ADLs and depression. Table 5 The mediating effects of ADLs and depression Path β 95% bootstrap CI P value Proportion of effect (%) Total effect -0.577 (-0.881, -0.273) < 0.001 100 Direct effect -0.331 (-0.643, -0.019) 0.034 57.37 a1 -1.532 (-1.650, -1.416) < 0.001 - a2 0.117 (0.041, 0.193) 0.002 - b1 0.142 (0.093, 0.190) < 0.001 - b2 -0.246 (-0.320, -0.172) < 0.001 - Total indirect effect -0.246 (-0.334, -0.164) < 0.001 42.63 Indirect effect 1 (a1 × b1) -0.217 (-0.301, -0.138) < 0.001 37.61 Indirect effect 2 (a2 × b2) -0.029 (-0.055, -0.010) 0.007 5.03 Note. All covariates were controlled when we conducted the mediating analyses. Indirect effect 1, falls → ADLs → ATA; Indirect effect 2, falls → depression → ATA. β , standardized regression coefficient. 95% bootstrap CI, 95% bootstrap confidence interval. The Moderating effect of age-friendly community renovations Table 6 shows the moderating effect of age-friendly community renovations on the association between falls and ATA. First, age-friendly community hardware facility renovations were included in Model 9, and the results indicated that age-friendly community hardware facility renovations were associated with ATA ( β = 0.265, 95% CI: 0.193, 0.336). Second, age-friendly community cultural atmosphere renovations were included in Model 10, and the results indicated that the construction of an age-friendly community cultural atmosphere was associated with ATA ( β = 0.329, 95% CI: 0.167, 0.490). Third, age-friendly community hardware facility renovations and age-friendly community cultural atmosphere renovations were combined to generate total age-friendly community aging renovations. Age-friendly community renovations were included in Model 11, and the results indicated that age-friendly community renovations were significantly and positively associated with ATA ( β = 0.202, 95% CI: 0.146, 0.258). In Model 12, the interaction between falls and age-friendly community renovations was included in the regression model. The results showed that age-friendly community renovations positively moderate the association between falls and ATA ( β = 0.659, 95% CI: 0.037, 1.202). These findings suggest that both age-friendly community hardware facility renovations and age-friendly community cultural atmosphere renovations could significantly improve ATA and further reduce the degree of psychological trauma caused by falls for older adults. The regulatory pathway of age-friendly community renovations on the association between falls and ATA is shown in Fig. 1 b. Table 6 The moderating effect of age-friendly community renovations. Model 9 Model 10 Model 11 Model 12 Falls -0.542 *** -0.547 *** -0.530 *** -0.797 *** (-0.838, -0.245) (-0.844, -0.250) (-0.827, -0.234) (-1.154, -0.440) Age-friendly community hardware facilities renovations 0.265 *** (0.193, 0.336) Age-friendly community cultural atmosphere construction 0.329 *** (0.167, 0.490) Age-friendly community renovations 0.202 *** 0.136 (0.146, 0.258) (-0.049, 0.320) Falls × age-friendly community renovations 0.659 ** (0.037, 1.202) Note: The effects of the control variables were omitted. * p < 0.05, ** p < 0.01, *** p < 0.001. The above mentioned results indicated that falls had a negative effect on ATA by reducing the level of ADLs and increasing the severity of depression. However, age-friendly community renovations could effectively mitigate the adverse effects of falls on ATA. The mechanisms underlying the association between falls and ATA are shown in Fig. 1 . Discussion The findings of this study show that falls are key risk factors for ATA among older adults. Falls were found to be associated with ATA through reducing the levels of ADLs and increasing depression severity. Furthermore, age-friendly community renovations positively moderated this association. Older adults who experienced falls had more negative ATA, especially those who were female, from rural areas and had chronic diseases. The models constructed herein were adjusted for sociodemographic and family/social support characteristics. The results revealed a significant association between falls and ATA among older adults. This finding is consistent with previous research that also demonstrated that falls are key risk factors for ATA [ 21 , 36 , 37 ]. Negative ATA (i.e., the association of aging with physical and social losses and the perception of older adults as frail and dependent) are becoming increasingly popular and are influenced by physical functions and social roles [ 16 ]. Recent research has indicated that falls not only cause physical damage to older adults but also reduce their ADLs, thus increasing their sense of isolation and powerlessness [ 18 , 19 ]. Therefore, when older adults fall, a decline in physical function and a loss of social participation significantly affect their ADLs and increase their level of depression, which negatively affects their ATA and their quality of life. Notably, falls have a greater negative impact on ATA among older adults who are female, those from rural areas and those with chronic diseases. Women’s position and the role of the housewife in the family are affected by falls, which aggravates their negative ATA [ 38 ]. Some older adults in rural areas may experience more serious physical injuries and face the dilemma of not providing care at home after falls [ 39 ]. Falls are equivalent to a worsening agent for older adults with chronic diseases, aggravating their condition, and their ATA become more negative. Moreover, our analysis revealed that falls are associated with ATA through reduced ADLs and increased depression. These findings suggest that falls have negative effects on physical and psychological health. The physical harm and pain perception caused by falls tend to be more pronounced in older adults. Furthermore, when older adults fall, their ADLs is restricted, and their roles in the family and society are affected, thereby promoting negative ATA among older women [ 38 , 40 ]. Falls have significant physical, psychological and psychosocial consequences, as they can predict future functional disability; restrict mobility with a significant threat to autonomy; and are associated with social isolation, depression, anxiety, cognitive impairment, poor quality of life, and mortality [ 21 ]. The literature emphasizes that physical impairments caused by falls result in a series of adverse consequences, i.e., limiting individuals’ social interaction and participation in social activities [ 36 , 41 ]. The decrease in social participation caused by physical impairments reduces the frequency of information exchange and emotional catharsis, thereby increasing negative ATA [ 42 ]. The loss of social roles can cause severe loneliness; aggravate depression, anxiety and other negative emotions; and eventually accelerate the perception of aging and reduce the quality of life among older adults [ 21 , 37 ]. The key finding of this study is that age-friendly community renovations play a positive moderating role in the association between falls and ATA. These findings indicate that age-friendly community renovations make a difference in preventing falls; relieving loneliness, tension, anxiety, depression and other negative emotions in older adults; and especially reducing negative ATA [ 43 , 44 ]. Previous studies have noted that in the process of age-friendly community renovations, measures such as the improvement of dim environments, nonslip ground, and the construction of barrier-free facilities can increase the safety of older adults’ environments and increase their pleasant and familiar atmosphere [ 45 ]. This study indicated that the positive influence of age-friendly community cultural atmosphere construction on ATA is greater than that of age-friendly community hardware facility renovations, which is consistent with the findings of the literature [ 23 , 26 ]. The cultural atmosphere of respecting and caring for older adults could enhance their sense of identity, delay negative ATA, and promote their participation in community activities [ 25 , 46 ]. Therefore, interventions aimed at decreasing the risk of falls among older adults through age-friendly community renovations could be a mechanism for enhancing positive perceptions of aging, thereby increasing happiness and comfort and decreasing negative ATA. This study had several limitations. First, owing to data availability limitations, only cross-sectional data were used in this study. The causal relationship between falls and ATA needs to be further examined by using panel data or looking for appropriate instrumental variables. Second, although this study tries to control the factors affecting ATA among older adults, the regression results may have been affected by missing variables. Generally, studies have included cognition as an important control variable when analyzing the association between falls and ATA. However, variables related to cognition were not available in the CLASS, thus potentially introducing some biases in the analysis. Additionally, owing to space constraints, this study explored only the moderating role of age-friendly community renovations on the association between falls and ATA among older adults. However, with respect to the intensity and coverage of age-friendly community renovations, there may be different moderating effects that should be studied in the next step of an in-depth investigation. Conclusion This study found that falls were significantly and negatively associated with ATA among older adults in China. This association was mediated by lower ADLs and more severe depression, and it was positively moderated by age-friendly community renovations. Our findings emphasize that falls are risk factors for ATA, thus emphasizing the importance of post-fall interventions and psychological counseling among older adults. This research highlights that age-friendly community renovations could reduce the negative effects of falls and promote psychological health among older adults. Policymakers should formulate valuable targets to promote individual psychological health through age-friendly community renovations and other forms of social support (e.g., visiting and accompanying chats) and to integrate into social life, which could help older adults reduce the rate of aging and the negative psychological effects of falls. These findings have implications for understanding the behavior of falls and social support factors that affect psychological health and resilient aging. Abbreviations AAQ, Attitudes to Ageing Questionnaire; AAT, attitudes toward ageing; ADLs, activities of daily living; β , β -coefficient; CI, Confidence interval; CLASS, China Longitudinal Ageing Social Survey; PSM, propensity score matching; SD, standard deviation; WHO, World Health Organization. Declarations Acknowledgments The authors acknowledge the support of the Institute of Gerontology and the National Survey Research Center at Renmin University of China for providing the China Longitudinal Aging Social Survey (CLASS) data. Authors’ contributions E.L. conceived the study and coordinated the research conduct. H.L. conducted statistical analyses and wrote the manuscript. B.W. assisted with statistical analyses and interpretation of results. X.Q. prepared the literature review. J.M. made critical revisions of the final manuscript. All the authors have read and approved the final submission of the study. Funding This study was supported by the Post-funding Program of National Social Science Foundation of China (23FRKB005), the Early-funding Program of Social Science Foundation of Hubei Province (23ZD191), the Soft Science Project of the Ministry of Agriculture and Rural Affairs of China (RKX2025017), the Project of Research on the Social Integration in Guangdong-Hong Kong-Macao Greater Bay Area (RP/FCHS-04/2022). Availability of data and materials CLASS data are available at http://class.ruc.edu.cn/ (requiring a simple application). Ethics approval and consent to participate This study is a secondary analysis of the data from the CLASS. The CLASS study was ethically reviewed and approved by the Biomedical Ethics Review Committee of Renmin University of China (No. 20221226025). The participants provided their written informed consent to participate in this study. Clinical trial number Not applicable. Consent for publication Not applicable. Competing interests The authors declare no competing interests. Author details 1 School of Economics and Management, Hubei University of Technology, Wuhan, 430068, China. 2 Hubei Innovation Research Center of Rural Social Management, Hubei University of Technology, Wuhan, 430068, China. 3 School of Public Administration, Zhongnan University of Economics and Law, Wuhan, 430073, China. 4 Economy & Management School, Wuhan Sports University, Wuhan, 430079, China. 5 Institute of Income Distribution and Public Finance, Zhongnan University of Economics and Law, Wuhan, 430073, China. References United Nations. World population prospects 2024. 2024. https://www.un.org/development/desa/pd/world-population-prospects-2024. Accessed 18 Mar 2025. Wu H, Wang Y, Zhang H, Yin X, Wang L, Wang L, et al. An investigation into the health status of the elderly population in China and the obstacles to achieving healthy aging. Sci Rep. 2024;14(1):31123. National Health Commission of the People’s Republic of China. The average life expectancy in China reach 79 years old in 2024. 2025. https://www.nhc.gov.cn/wjw/mtbd/202503/3bfb889a16c6499dba0e6c0eb2b70887.shtml. Accessed 18 Mar 2025. World Health Organization. Ageing and health. 2022. https://www.who.int/news-room/fact-sheets/detail/ageing-and-health. Accessed 18 Mar 2025. World Health Organization. Decade of healthy ageing: baseline report. 2021. https://www.who.int/publications/i/item/9789240017900. Accessed 18 Mar 2025. Manzi C, Adorni R, Giannella VA, Steca P. How to age more positively? Analyzing determinants that shape attitudes towards ageing. J Adult Dev. 2024;31(1):53-64. Santini ZI, Koyanagi AI, Tyrovolas S, Haro JM, Koushede V. The association of social support networks and loneliness with negative perceptions of ageing: Evidence from the Irish Longitudinal Study on Ageing (TILDA). Ageing Soc. 2019;39(5):1070-90. Faudzi FNM, Armitage CJ, Bryant C, Brown LJ. Moderating effects of age on relationships between attitudes to aging and well-being outcomes. Aging Ment Health. 2020;24(10):1620-26. Choi EY, Franco Y, Zelinski E. Gender differences in attitudes toward aging and its longitudinal impact on psychological health. Innov Aging. 2020;4(Suppl 1):324. Diehl M, Wahl HW, Barrett AE, Brothers AF, Miche M, Montepare JM, et al. Awareness of ageing: Theoretical considerations on an emerging concept. Dev Rev. 2014;34(2):93-113. Cadmus EO, Adebusoye LA, Owoaje ET. Attitude towards ageing and perceived health status of community-dwelling older persons in a low resource setting: a rural-urban comparison. BMC Geriatr. 2021;21(1):454. Kato K, Zweig R, Schechter CB, Barzilai N, Atzmon G. Positive attitude toward life, emotional expression, self-rated health, and depressive symptoms among centenarians and near-centenarians. Aging Ment Health. 2016;20(9):930-39. Kite ME, Stockdale GD, Whitley BE Jr, Johnson BT. Attitudes toward younger and older adults: an updated meta-analytic review. J Soc Issues. 2005;61(2):241-66. Lindwall M, Berg AI, Bjälkebring P, Buratti S, Hansson I, Hassing L, et al. Psychological health in the retirement transition: Rationale and first findings in the Health, Ageing and Retirement Transitions in Sweden (HEARTS) study. Front Psychol. 2017;8:1634. Shenkin SD, Laidlaw K, Allerhand M, Mead GE, Starr JM, Deary IJ. Life course influences of physical and cognitive function and personality on attitudes to aging in the Lothian Birth Cohort 1936. Int Psychogeriatr. 2014;26(9):1417-30. Schönstein A, Dallmeier D, Denkinger M, Rothenbacher D, Klenk J, Bahrmann A, et al. Health and subjective views on ageing: Longitudinal findings from the ActiFE Ulm Study. J Gerontol B Psychol Sci Soc Sci. 2021;76(7):1349-59. World Health Organization. Injuries and violence. 2024. https://www.who.int/news-room/fact-sheets/detail/injuries-and-violence. Accessed 18 Mar 2025. You Y, Zheng H, Lei X, Zhou H, Huang L, Zhang Y, et al. Development of a falls risk assessment scale for middle-aged and elderly patients with cardiovascular diseases in Chinese community based on AutoScore: A CHARLS study. Public Health. 2025;240:167-73. Towne SD, Smith ML, Li Y, Dowdy D, Ahn S, Lee S, et al. A multi-level analyses of charges and cost of fall-related hospitalizations among older adults: individual, hospital, and geospatial variation. J Aging Soc Policy. 2022;34(4):515-36. Liu Y, Kabba JA, Xu S, Gu H, Su X, Liu Y, et al. Regional and temporal trends of falls and injurious falls among Chinese older adults: results from China Health and Retirement Longitudinal Study, 2011-2018. Inj Prev. 2023;29(5):389-98. Arkkukangas M. Involvement of older adults, the golden resources, as a primary measure for fall prevention. Clin. Interv Aging. 2023;18:2165-70. World Health Organization. Global age-friendly cities: A guide. 2007. https://www.who.int/publications/i/item/9789241547307. Accessed 18 Mar 2025. Levasseur M, Dubois M, Généreux M, Menec V, Raina P, Roy M, et al. Capturing how age-friendly communities foster positive health, social participation and health equity: A study protocol of key components and processes that promote population health in aging Canadians. BMC Public Health. 2017;17(1):502. Chen X, Lee C, Huang H. Neighborhood built environment associated with cognition and dementia risk among older adults: a systematic literature review. Soc Sci Med. 2022;292:114560. Lei P, Feng Z. Age-friendly neighborhoods and depression among older people in China: Evidence from China Family Panel Studies. J Affect Disord. 2021;286:187-96. Nieboer AP, Cramm JM. Age-friendly communities matter for older People’s well-being. J Happiness Stud. 2018;19(8):2405-20. Aung MN, Koyanagi Y, Ueno S, Tiraphat S, Yuasa M. A contemporary insight into an age-friendly environment contributing to the social network, active ageing and quality of life of community resident seniors in Japan. J Aging Envi. 2021;35(2):145-60. National Aging Population Office of China. Guidelines on promoting aging-friendly environment. 2016. www.gov.cn/xinwen/2016-11/25/content_5137617.htm. Accessed 18 Mar 2025. Tang D, Lin Z, Chen F. Moving beyond living arrangements: the role of family and friendship ties in promoting mental health for urban and rural older adults in China. Aging Ment Health. 2020;24(9):1523-32. Zhang D. Pain and the risk of social isolation and loneliness in older Chinese adults: Do gender, age, and education make a difference? Soc Sci Med. 2024;363:117486. Laidlaw K, Power MJ, Schmidt S. The attitudes to ageing questionnaire (AAQ): development and psychometric properties. Int J Geriatr Psychiatry. 2007;22(4):367-79. Kalfoss MH, Low G, Molzahn AE. Reliability and validity of the attitudes to ageing questionnaire for Canadian and Norwegian older adults. Scand J Caring Sci. 2010;24:75-85. Thelu M, Webster B, Jones K, Orrell M. A cross sectional survey on UK older adult's attitudes to ageing, dementia and positive psychology attributes. BMC Geriatr. 2022 Nov 5;22(1):837. Park J, Hess TM. The effects of personality and aging attitudes on well-being in different life domains. Aging Ment Health. 2020;24(12):2063-72. Kisvetrová H, Mandysová P, Tomanová J, Steven A. Dignity and attitudes to aging: A cross-sectional study of older adults. Nurs Ethics. 2022;29(2):413-24. Petersen N, König HH, Hajek A. The link between falls, social isolation and loneliness: a systematic review. Arch Gerontol Geriatr. 2020;88:104020. Sherrington C, Fairhall N, Kwok W, Wallbank G, Tiedemann A, Michaleff ZA, et al. Evidence on physical activities and falls prevention for people aged 65+ years: systematic review to inform the WHO guidelines on physical activities and sedentary behaviour. Int J Behav Nutr Phys Act. 2020;17(1):144. Bryant C, Bei B, Gilson K, Komiti A, Jackson H, Judd F. The relationship between attitudes to ageing and physical and mental health in older adults. Int Psychogeriatr. 2012;24(10):1674-83. Zhang L, Ding Z, Qiu L, Li A. Falls and risk factors of falls for urban and rural community-dwelling older adults in China. BMC Geriatr. 2019;19(1):379. Yue Z, Liang H, Gao X, Qin X, Li H, Xiang N, et al. The association between falls and anxiety among elderly Chinese individuals: the mediating roles of functional ability and social participation. J Affect Disord. 2022;301:300-306. Hajek A, König HH. The association of falls with loneliness and social exclusion: evidence from the DEAS German Ageing Survey. BMC Geriatr. 2017;17(1):204. Wagner-Gutiérrez N, Gonzalez SA, Rubio MA, Sánchez-Franco S, Palencia-Pérez L, Blanco M, et al. Quality of life, mental health and social relationships among older adults participating in the Recreovía physical activity community program. Int J Equity Health. 2025;24(1):145. Gibney S, Zhang M, Brennan C. Age-friendly environments and psychosocial wellbeing: A study of older urban residents in Ireland. Aging Ment Health. 2020;24(12):2022-33. Wang R, Xue D, Liu Y, Chen H, Qiu Y. The relationship between urbanization and depression in China: the mediating role of neighborhood social capital. Int J Equity Health. 2018;17(1):105. Coyle CE, Gleason SR, Mutchler JE. Spillover benefits and achieving sustainability of age-friendly communities. Gerontologist. 2022;62(1):29-35. Cheng Y, Chen ZL, Wei Y, Gu N, Tang SL. Examining dynamic developmental trends: the interrelationship between age-friendly environments and healthy aging in the Chinese population-evidence from China Health and Retirement Longitudinal Study, 2011-2018. BMC Geriatr. 2024;24(1):429. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7319199","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":512194988,"identity":"13227e7d-bccc-415f-b49a-68df99b3f569","order_by":0,"name":"Hang Liang","email":"","orcid":"","institution":"Hubei University of Technology","correspondingAuthor":false,"prefix":"","firstName":"Hang","middleName":"","lastName":"Liang","suffix":""},{"id":512194989,"identity":"6a650755-ea81-451e-922c-b4324be5d1ec","order_by":1,"name":"Boyu Wang","email":"","orcid":"","institution":"Zhongnan University of Economics and Law","correspondingAuthor":false,"prefix":"","firstName":"Boyu","middleName":"","lastName":"Wang","suffix":""},{"id":512194990,"identity":"49aee1f8-2d76-4c53-b84c-b3c0bdc22f7f","order_by":2,"name":"Xigang Qin","email":"","orcid":"","institution":"Zhongnan University of Economics and Law","correspondingAuthor":false,"prefix":"","firstName":"Xigang","middleName":"","lastName":"Qin","suffix":""},{"id":512194991,"identity":"4f7c0faa-8d5a-479b-b516-0da267690351","order_by":3,"name":"Jia Meng","email":"","orcid":"","institution":"Wuhan Sports University","correspondingAuthor":false,"prefix":"","firstName":"Jia","middleName":"","lastName":"Meng","suffix":""},{"id":512194992,"identity":"512cede8-a7c5-4dd9-9c29-df2b58122d39","order_by":4,"name":"Erpeng Liu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAqElEQVRIiWNgGAWjYDACCQY2ECXHxt5+gCQtBsZ8PGcSSNOSOE/CwYA4HQa3e8wefPjzJ71NgiGB4UfFNiK03DljbjizzSC3TbrxAGPPmduEtZjdyDGT5m0AapE5kMDM2Easlj9/DNLZJBIMSNDCwGaQQLwW+xtp5Ya9bcaGbcBAPkiUXyRnJG978OOPnLx8e/vBBz8qiNCCAg6QqH4UjIJRMApGAS4AAGycOl4MmpTbAAAAAElFTkSuQmCC","orcid":"","institution":"Zhongnan University of Economics and Law","correspondingAuthor":true,"prefix":"","firstName":"Erpeng","middleName":"","lastName":"Liu","suffix":""}],"badges":[],"createdAt":"2025-08-07 13:23:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7319199/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7319199/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":91104183,"identity":"d4c4f213-511b-4d18-b881-42ab6d101b77","added_by":"auto","created_at":"2025-09-11 15:13:04","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":43672,"visible":true,"origin":"","legend":"\u003cp\u003eThe mechanisms underlying the association between falls and ATA\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7319199/v1/0bb4045b8658689275720b02.png"},{"id":109613942,"identity":"072d56ed-41d5-4e48-b320-8b77f546659f","added_by":"auto","created_at":"2026-05-20 08:11:39","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":459336,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7319199/v1/da7bc241-0aae-4fb4-9792-85e0487d591a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Association between Falls and Attitudes toward Aging among Older Adults in China: The Moderating Role of Age-Friendly Community Renovations","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDue to the rapid aging of the global population, older adults in China \u0026ldquo;live a long time\u0026rdquo;, but their \u0026ldquo;quality of life\u0026rdquo; has not significantly improved [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. China\u0026rsquo;s average life expectancy is 79 years, but the healthy life expectancy is only 68.7 years, thus presenting a challenge for healthy aging [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Healthy aging refers not only to individual health and good social adaptability among older adults but also to the health of the entire elderly population and the extension of healthy life expectancy; this concept emphasizes a good social atmosphere as well as an orderly and healthy humanistic environment for aging [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. At a micro level, attitudes toward aging (ATA) are the basis of the healthy aging among individuals [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Individual ATA have important impacts on physical and psychological health, and positive ATA improve health and well-being, thus promoting healthy aging; on the other hand, negative ATA accelerate the aging process and exert adverse effects on health, even leading to maladjustment in later stages of life among older adults [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eATA refer to individuals\u0026rsquo; perceptions of the aging process with respect to oneself or others [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. ATA can be divided into self ATA and general ATA [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Self ATA refer to an individual\u0026rsquo;s perception of their own aging process, while general ATA refer to an individual\u0026rsquo;s attitudes toward holistic perceptions of the body aging process among older adults [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Previous studies have identified three broad categories of factors that influence ATA. The first category includes demographic and health factors (e.g., older age, female gender, more chronic diseases, poorer self-rated health, and greater levels of functional dependence) [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The second category comprises indicators of the social environment (e.g., humid or cold living conditions, dim light, activity places with obstacles, and noisy and unfriendly neighborhood atmospheres) [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The third category includes major life events (e.g., retirement, bereavement of spouses or children, falls, and cancer) [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], which can exert considerable impacts on the physical and psychological health of older adults and accelerate their perception of aging [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAmong the factors that affect ATA of older adults, falls are important risk factors. The global incidence of falls among people aged 60 years and above is as high as 30%, with more than 75% of life-threatening falls among older adults occurring in low- and middle-income countries [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Falls have become the second leading cause of accidental death among older adults. A total of 52.6% of older adults who experience falls subsequently suffer from physical injuries such as soft tissue contusions, fractures, and concussions, as well as psychological trauma, including fear of falling, anxiety, depression, and social isolation [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Despite the potentially significant implications of falls for older adults\u0026rsquo; well-being, the association between falls and ATA have rarely been examined in previous studies. Falls cause physical or psychological damage, thereby potentially affecting the daily lives of individuals. For example, falls affect people\u0026rsquo;s activities of daily living; reduce the frequency of social interaction; and aggravate psychological trauma, fear of falling, loneliness and anxiety [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Thus, further research on the potential association between falls and ATA could elucidate the psychological damage caused by falls and help health care professionals more actively engage in health-promoting activities among older adults.\u003c/p\u003e\u003cp\u003eTo further improve quality of life among older adults \u0026ndash; especially by reducing the risk of falls and restrictions on daily activities \u0026ndash; the World Health Organization (WHO) has recognized the importance of the environment and proposed the concept of the \u0026ldquo;Ageing-Friendly Community\u0026rdquo; [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The construction of an age-friendly community emphasizes the promotion of greater social interaction, more meaningful activities, and better health opportunities for older persons through improvements in the community environment [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Aging-friendly communities are associated with better self-perceived health [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], lower levels of depression [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], higher levels of subjective well-being [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], and better quality of life [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Over the years, the Chinese government has formulated a series of policies concerning age-friendly community renovations. In October 2016, the National Aging Population Office published guidelines promoting aging-friendly environments by developing appropriate facilities, implementing barrier-free access designs and increasing elderly care services [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Therefore, it is necessary to examine the relationship between age-friendly community renovations and ATA. Furthermore, it is necessary to determine whether age-friendly community renovations can reduce the probability of falls and enhance positive ATA among older adults.\u003c/p\u003e\u003cp\u003eThis study aimed to examine the association between falls and ATA among older adults in China, to explore the potential mediating roles of activities of daily living (ADLs) and depression, and to investigate the moderating role of age-friendly community renovations. The major contributions of this study are as follows. First, the association between falls and ATA and the underlying mechanism of this relationship have rarely been studied. This study aims to determine whether falls, as important life events, exacerbate negative ATA. Second, this study aims to assesses the moderating effect of age-friendly community renovations on the association between falls and ATA, which will be helpful for objectively evaluating the direct impact of age-friendly community renovations on ATA and disentangling its role in mitigating the negative impact of falls on ATA.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eData sources\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data were derived from the China Longitudinal Ageing Social Survey (CLASS), which is a large-scale national and continuous social survey project. The survey was conducted using a stratified multistage probabilistic sampling method. The county/district was the primary sampling unit, the village/neighborhood committee was the secondary sampling unit, and individuals aged 60 years and above were sampled from each village/neighborhood committee. The survey content is comprehensive and assesses health status and related services for older adults, socioeconomic status, pension planning and arrangement, cognition and ATA, generational support and other dimensions. The overall aim of the CLASS is to comprehensively elucidate the quality of life and health status of older adults in China [29, 30]. The CLASS was ethically reviewed and approved by the Biomedical Ethics Review Committee of Renmin University of China (No. 20221226025). The investigator explained the purpose of the study to all participants, and they were notified of their right to withdraw at any time. All the participants provided informed consent. The CLASS was first administered in 2014; the data in this study were drawn from the 2020 wave of the survey, which is the most recent dataset. After excluding observations with missing, rejected and obviously wrong data, a total of 11,398 valid observations were ultimately included for analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMeasures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eDependent variable: ATA\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe dependent variable was ATA, which was evaluated by the Attitudes to Ageing Questionnaire (AAQ, [31]). The questionnaire measures ATA in three domains: physical functioning, psychological growth and psychological loss [31]. Example items include \u0026ldquo;I feel like I\u0026rsquo;m getting old\u0026rdquo;, \u0026ldquo;In my opinion, growing old is a process of constant loss\u0026rdquo;, \u0026ldquo;As I get older, I find it harder to make new friends\u0026rdquo;, \u0026ldquo;Because of my age, I feel like I\u0026rsquo;m being pushed aside\u0026rdquo;, \u0026ldquo;The older people get, the better they are at dealing with life\u0026rsquo;s problems?\u0026rdquo;, and \u0026ldquo;Does wisdom come with age?\u0026rdquo;. The responses to these questions were aggregated or weighted to obtain a score of ATA for each respondent. In this study, the psychological loss item was reverse scored. Higher scores indicated more positive ATA. The total score of ATA ranged from 1 to 35. The AAQ has been found to reliably assess older adults\u0026rsquo; AAT [32] and is aimed to be used with older adults [15, 33].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eIndependent\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003evariable:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003efalls\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe independent variable was falls, which was assessed by the following item: \u0026ldquo;Have you fallen in the past 12 months?\u0026rdquo; A value of 0 represents \u0026ldquo;no falls\u0026rdquo;, and a value of 1 represents \u0026ldquo;one fall\u0026rdquo; or \u0026ldquo;at least two falls\u0026rdquo;. This item was used to quantify and capture the fall experiences of older adults within a certain period (i.e., the past year).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eMediating variables: ADLs and depression\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe mediating variables included ADLs and depression. ADLs consists of six domains, i.e., bathing, dressing, toilet behavior, indoor transfer, continence and eating. Based on the independence of individuals in terms of engaging in each of the above mentioned actions, they were given a score of 1 (complete dependence on others), 2 (partial independence) or 3 (complete independence). The scores on the six items were summed, and thus, the total ADLs score ranged from 6 to 18. Higher scores indicated more independent functional ability of the respondent. Depression was measured by two items: \u0026ldquo;Have you felt in a good mood in the past week?\u0026rdquo; and \u0026ldquo;Have you felt sad in the past week?\u0026rdquo; The response options for each item ranged from 1 to 3 (1 = none, 2 = sometimes, 3 = often). The positive psychology item was reverse scored. The total depression score ranged from 2 to 6, with higher scores indicating more severe depression.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eModerating variable: age-friendly community renovations\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe moderating variable was age-friendly community renovations, which consists of two categories (hardware facility renovations and cultural atmosphere construction). Age-friendly community hardware facility renovations were measured by respondents\u0026rsquo; satisfaction with community roads, street or road lighting, and barrier-free facility construction. Age-friendly community cultural atmosphere construction was measured by respondents\u0026rsquo; satisfaction with the atmosphere of respecting and loving older adults and the pleasant environment. The response options for each item ranged from 1 to 5 (1 = very dissatisfied, 2 = less satisfied, 3 = generally, 4 = more satisfied, and 5 = very satisfied). The overall age-friendly community renovations were obtained by adding the scores of the five options (ranging from 5 to 25). Higher scores reflect better age-friendly community renovations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCovariates\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo accurately analyze the association between falls and ATA, this study measured a series of control variables to rule out other potential influencing factors based on findings from previous studies [34, 35]. These control variables included sociodemographic characteristics such as gender (1 = female, 0 = male), age, education (years of schooling), marital status (1= married, 0 = widower/divorced/unmarried), ethnicity (1 = Han ethnicity, 0 = minority ethnicity), residence (1 = urban area, 0 = rural area), self-rated health (1 = unhealthy to 5 = very healthy) and chronic diseases (1 = one or more, 0 = none). The control variables also included family/social characteristics such as co-residence with children (1 = yes, 0 = no), pension insurance (1 = yes. 0 = no), number of children (ranging from 0 to 12) and household income.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study first conducted descriptive statistics for the total sample. Differences in covariates between participants who experienced falls and those who had not experienced falls were tested by unpaired \u003cem\u003et\u003c/em\u003e tests and chi-square tests for quantitative and categorical variables, respectively. Second, we examined the association between falls and ATA among older adults by a multiple linear regression model. Propensity score matching (PSM) was applied to address endogeneity. Third, we examined the differences in the association between falls and ATA among three groups of older adults: gender (male vs. female), residence (urban area vs. rural area), and chronic disease (yes vs. none). Fourth, we assessed the mediating effect of ADLs and depression on the association between falls and ATA. The mediating effects of ADLs and depression were determined by bootstrapping with 5000 resamples. Finally, we explored the moderating role of age-friendly community renovations. The moderating effect of age-friendly community renovations was analyzed by constructing a regression model with interaction terms. The results are presented as\u0026nbsp;\u003cem\u003e\u0026beta;\u003c/em\u003e coefficients with 95% confidence intervals (CIs). Statistical analyses were performed by using STATA, version 15 (StataCorp, TX, USA).\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eSample characteristics\u003c/h2\u003e\u003cp\u003eThe Cronbach alpha coefficient for the ATA measure was 0.81, which indicated a moderate level of internal consistency. A total of 11,398 observations were included in the study, and 866 older adults experienced falls in the past year (7.6%). Older adults who experienced falls had more negative ATA than did participants who had not experienced falls (17.56 vs. 18.95, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), a lower level of ADLs (15.35 vs. 17.53, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), a lower level of depression (3.75 vs. 3.44, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and received more age-friendly community renovations (1.16 vs. 0.98, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Compared with those who had not experienced falls, those who had experienced falls were more likely to be older, married, live in urban areas, have more kinds of chronic diseases, be of Han ethnicity, not reside with family members, have a lower level of education and self-rated health, and have more children (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDescriptive statistics of the study population (N\u0026thinsp;=\u0026thinsp;11,398)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eFalls\u003c/p\u003e\u003cp\u003e(N\u0026thinsp;=\u0026thinsp;866)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eNo falls\u003c/p\u003e\u003cp\u003e(N\u0026thinsp;=\u0026thinsp;10,532)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e448\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e51.73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5202\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e49.39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.186\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e418\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e48.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5330\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e50.61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e60\u0026thinsp;~\u0026thinsp;69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e254\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e29.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4779\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e45.38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e70\u0026thinsp;~\u0026thinsp;79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e383\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e44.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4362\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e41.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e229\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26.44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1391\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e13.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMarital status\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e567\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e65.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8024\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e76.19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWidower/divorced/unmarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e299\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e34.53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2508\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e23.81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eResidence\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUrban area\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e442\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e51.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5830\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e55.36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.014\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRural area\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e424\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e48.96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4702\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e44.64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eChronic diseases\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e780\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e90.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8159\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e77.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2373\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e22.53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNation\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHan ethnicity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e837\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e96.65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9879\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e93.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMinority ethnicity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e653\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCo-residence with children\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e428\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e49.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3880\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e36.84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e438\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e50.58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6652\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e63.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePension insurance\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e275\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e31.76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3394\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e32.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.776\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e591\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e68.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7138\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e67.77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eMean\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eS.D.\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003eMean\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003eS.D.\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e71.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6.48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e74.53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7.34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAttitudes toward aging\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17.56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18.95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3.53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge-friendly community renovations\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEducation (years of schooling)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5.99\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3.94\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSelf-rated health\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHousehold income\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.1303\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNumbers of children\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eADLs\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e17.53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDepression\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003eNote. S.D., standard deviation. \u003cem\u003eP\u003c/em\u003e values were calculated via \u003cem\u003et\u003c/em\u003e tests (continuous variables) or chi-square tests (categorical variables).\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eAssociation between falls and ATA\u003c/h2\u003e\u003cdiv id=\"Sec14\" class=\"Section3\"\u003e\u003ch2\u003eBaseline regression\u003c/h2\u003e\u003cp\u003eModel 1 (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) revealed that falls were significantly and negatively associated with ATA (\u003cem\u003eβ\u003c/em\u003e = -0.937, 95% CI: -1.229, -0.645). However, there were no control variables in Model 1, which may have led to biased results. Model 2 was adjusted for a series of sociodemographic and family/social characteristics; the results showed that age, ethnicity, chronic diseases, co-residence with family members, and pension insurance were significantly associated with ATA. Falls were significantly and negatively associated with ATA (\u003cem\u003eβ\u003c/em\u003e = -0.581, 95% CI: -0.877, -0.284). These findings suggest that falls are key risk factors for negative ATA among older adults.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eThe association between falls and ATA\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eModel 1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eModel 2\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eFalls\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e-0.937\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e-0.581\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e(-1.229, -0.645)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e(-0.877, -0.284)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eMale (ref: female)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e-0.063\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e(-0.221, 0.094)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eAge 70\u0026thinsp;~\u0026thinsp;79 (ref: age 60\u0026thinsp;~\u0026thinsp;69)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e-0.230\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e(-0.404, -0.056)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eAge\u0026thinsp;\u0026ge;\u0026thinsp;80 (ref: age 60\u0026thinsp;~\u0026thinsp;69)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e-0.364\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e(-0.631, -0.097)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eEducation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e-0.008\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e(-0.031, 0.015)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eMarried (ref: widower/divorced/unmarried)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e-0.037\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e(-0.230, 0.158)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eHan ethnicity (ref: minority ethnicity)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e-0.916\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e(-1.242, -0.589)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eUrban area (ref: rural area)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e-0.008\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e(-0.196, 0.181)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSelf-rated health\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.513\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e(0.423, 0.603)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eChronic diseases (ref: none)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.765\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e(0.572, 0.959)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eNumbers of children\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.005\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e(-0.060, 0.070)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eCo-residence with children (ref: no)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e-0.404\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e(-0.569, -0.239)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ePension insurance (ref: no)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.408\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e(0.143, 0.673)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eHousehold income\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e-0.015\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e(-0.039, 0.008)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003eNote: \u003csup\u003e*\u003c/sup\u003e\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05, \u003csup\u003e**\u003c/sup\u003e\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01, \u003csup\u003e***\u003c/sup\u003e\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eEndogeneity\u003c/h2\u003e\u003cp\u003eTo more accurately explore the association between falls and ATA, PSM was applied. Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows that the association between falls and ATA passed three tests. The test of nearest neighbor matching yielded an effect \u0026minus;\u0026thinsp;0.492 (\u003cem\u003et\u003c/em\u003e = -3.43, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001); the test of radius matching yielded an effect of -0.408 (\u003cem\u003et\u003c/em\u003e = -2.63, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001); and the test of kernel matching yielded an effect was \u0026minus;\u0026thinsp;0.471 (\u003cem\u003et\u003c/em\u003e = -3.07, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The \u003cem\u003et\u003c/em\u003e values of the above three tests passed the significance requirements, which indicated that there was a significant association between falls and ATA. The results further emphasized that falls are risk factors for ATA.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePSM test on the association between falls and ATA\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"9\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTreated (Falls)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eUntreated (No fall)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e\u003cp\u003eAverage treatment effect on the Treated (ATT)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u003cp\u003eStandard error\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u003cem\u003et\u003c/em\u003e tests\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNearest neighbor matching\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17.814\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e18.307\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.492\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e0.144\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e-3.43\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRadius matching\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17.818\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e18.226\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.408\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e0.155\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e-2.63\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKernel matching\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17.815\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e18.285\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.471\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e0.153\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e-3.07\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"9\"\u003eNote: \u003csup\u003e*\u003c/sup\u003e\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05, \u003csup\u003e**\u003c/sup\u003e\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01, \u003csup\u003e***\u003c/sup\u003e\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eHeterogeneity analysis\u003c/h2\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e shows the differences in the associations between falls and ATA between genders, residence and chronic disease. The results of Model 3 and Model 4 indicated that falls had a greater effect on ATA among female older adults than among male older adults (\u003cem\u003eβ\u003c/em\u003e = -0.646 vs. \u003cem\u003eβ\u003c/em\u003e = -0.486). The results of Model 5 and Model 6 showed that falls were significantly associated with ATA among older adults from rural areas (\u003cem\u003eβ\u003c/em\u003e = -0.975, 95% CI: -1.219, -0.372). The results of Model 7 and Model 8 revealed that falls were significantly associated with ATA among older adults who had chronic diseases (\u003cem\u003eβ\u003c/em\u003e = -0.543, 95% CI: -0.854, -0.233).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDifferences in the associations between falls and ATA between genders, residence and chronic disease.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eModel 3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eModel 4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eModel 5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eModel 6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eModel 7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eModel 8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRural area\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eUrban area\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eChronic diseases\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eNo chronic diseases\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eFalls\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.646\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.486\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.795\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.372\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-0.543\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-0.796\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e(-1.059, -0.233)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(-0.913, -0.057)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(-1.219, -0.372)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(-0.789, 0.045)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e(-0.854, -0.233)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e(-1.749, 0.157)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003eNote: All covariates were controlled when we conducted the analyses. \u003csup\u003e*\u003c/sup\u003e\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05, \u003csup\u003e**\u003c/sup\u003e\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01, \u003csup\u003e***\u003c/sup\u003e\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eThe mediating effects of ADLs and depression\u003c/h2\u003e\u003cp\u003eTo further determine whether the association between falls and ATA among older adults was affected by mediating variables, ADLs and depression entered into the regression models. Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e shows the results concerning the mediating effects of ADLs and depression. Bootstrapping was conducted with 5000 resamples to test the significance of the mediating effects. A 95% bootstrap CI that does not include zero indicates a significant mediating effect. The results revealed that falls were negatively associated with ADLs (\u003cem\u003eβ\u003c/em\u003e = -1.532, 95% bootstrap CI: -1.650, -1.416), and ADLs were positively associated with ATA (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.142, 95% bootstrap CI: 0.093, 0.190). The mediating effect of ADLs on the association between falls and ATA was \u0026minus;\u0026thinsp;0.217 (95% bootstrap CI: -0.301, -0.138), and the relative effect size was 37.61%. Additionally, falls were significantly associated with depression (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.117, 95% bootstrap CI: 0.041, 0.193), and depression was negatively associated with ATA (\u003cem\u003eβ\u003c/em\u003e = -0.246, 95% bootstrap CI: -0.320, -0.172). The mediating effect of depression on the association between falls and ATA was \u0026minus;\u0026thinsp;0.029 (95% bootstrap CI: -0.055, -0.010), and the relative effect size was 5.03%. The path of the association between falls and ATA is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ea. And the findings indicated that falls among older adults adversely affected ATA through ADLs and depression.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eThe mediating effects of ADLs and depression\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePath\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eβ\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e95% bootstrap CI\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003eProportion of effect (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal effect\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.577\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(-0.881, -0.273)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e100\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDirect effect\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.331\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(-0.643, -0.019)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e0.034\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e57.37\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ea1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-1.532\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(-1.650, -1.416)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ea2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.117\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(0.041, 0.193)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eb1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.142\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(0.093, 0.190)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eb2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.246\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(-0.320, -0.172)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal indirect effect\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.246\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(-0.334, -0.164)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e42.63\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIndirect effect 1 (a1 \u0026times; b1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.217\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(-0.301, -0.138)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e37.61\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIndirect effect 2 (a2 \u0026times; b2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.029\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(-0.055, -0.010)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e0.007\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e5.03\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003eNote. All covariates were controlled when we conducted the mediating analyses. Indirect effect 1, falls \u0026rarr; ADLs \u0026rarr; ATA; Indirect effect 2, falls \u0026rarr; depression \u0026rarr; ATA. \u003cem\u003eβ\u003c/em\u003e, standardized regression coefficient. 95% bootstrap CI, 95% bootstrap confidence interval.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eThe Moderating effect of age-friendly community renovations\u003c/h2\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e shows the moderating effect of age-friendly community renovations on the association between falls and ATA. First, age-friendly community hardware facility renovations were included in Model 9, and the results indicated that age-friendly community hardware facility renovations were associated with ATA (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.265, 95% CI: 0.193, 0.336). Second, age-friendly community cultural atmosphere renovations were included in Model 10, and the results indicated that the construction of an age-friendly community cultural atmosphere was associated with ATA (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.329, 95% CI: 0.167, 0.490). Third, age-friendly community hardware facility renovations and age-friendly community cultural atmosphere renovations were combined to generate total age-friendly community aging renovations. Age-friendly community renovations were included in Model 11, and the results indicated that age-friendly community renovations were significantly and positively associated with ATA (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.202, 95% CI: 0.146, 0.258). In Model 12, the interaction between falls and age-friendly community renovations was included in the regression model. The results showed that age-friendly community renovations positively moderate the association between falls and ATA (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.659, 95% CI: 0.037, 1.202). These findings suggest that both age-friendly community hardware facility renovations and age-friendly community cultural atmosphere renovations could significantly improve ATA and further reduce the degree of psychological trauma caused by falls for older adults. The regulatory pathway of age-friendly community renovations on the association between falls and ATA is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eb.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eThe moderating effect of age-friendly community renovations.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eModel 9\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eModel 10\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eModel 11\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eModel 12\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eFalls\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.542\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.547\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.530\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.797\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e(-0.838, -0.245)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(-0.844, -0.250)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(-0.827, -0.234)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(-1.154, -0.440)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eAge-friendly community hardware facilities renovations\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.265\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e(0.193, 0.336)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eAge-friendly community cultural atmosphere construction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.329\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(0.167, 0.490)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eAge-friendly community renovations\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.202\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.136\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(0.146, 0.258)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(-0.049, 0.320)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eFalls \u0026times; age-friendly community renovations\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.659\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(0.037, 1.202)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003eNote: The effects of the control variables were omitted. \u003csup\u003e*\u003c/sup\u003e\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05, \u003csup\u003e**\u003c/sup\u003e\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01, \u003csup\u003e***\u003c/sup\u003e\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe above mentioned results indicated that falls had a negative effect on ATA by reducing the level of ADLs and increasing the severity of depression. However, age-friendly community renovations could effectively mitigate the adverse effects of falls on ATA. The mechanisms underlying the association between falls and ATA are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe findings of this study show that falls are key risk factors for ATA among older adults. Falls were found to be associated with ATA through reducing the levels of ADLs and increasing depression severity. Furthermore, age-friendly community renovations positively moderated this association. Older adults who experienced falls had more negative ATA, especially those who were female, from rural areas and had chronic diseases. The models constructed herein were adjusted for sociodemographic and family/social support characteristics.\u003c/p\u003e\u003cp\u003eThe results revealed a significant association between falls and ATA among older adults. This finding is consistent with previous research that also demonstrated that falls are key risk factors for ATA [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Negative ATA (i.e., the association of aging with physical and social losses and the perception of older adults as frail and dependent) are becoming increasingly popular and are influenced by physical functions and social roles [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Recent research has indicated that falls not only cause physical damage to older adults but also reduce their ADLs, thus increasing their sense of isolation and powerlessness [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Therefore, when older adults fall, a decline in physical function and a loss of social participation significantly affect their ADLs and increase their level of depression, which negatively affects their ATA and their quality of life. Notably, falls have a greater negative impact on ATA among older adults who are female, those from rural areas and those with chronic diseases. Women\u0026rsquo;s position and the role of the housewife in the family are affected by falls, which aggravates their negative ATA [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Some older adults in rural areas may experience more serious physical injuries and face the dilemma of not providing care at home after falls [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Falls are equivalent to a worsening agent for older adults with chronic diseases, aggravating their condition, and their ATA become more negative.\u003c/p\u003e\u003cp\u003eMoreover, our analysis revealed that falls are associated with ATA through reduced ADLs and increased depression. These findings suggest that falls have negative effects on physical and psychological health. The physical harm and pain perception caused by falls tend to be more pronounced in older adults. Furthermore, when older adults fall, their ADLs is restricted, and their roles in the family and society are affected, thereby promoting negative ATA among older women [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Falls have significant physical, psychological and psychosocial consequences, as they can predict future functional disability; restrict mobility with a significant threat to autonomy; and are associated with social isolation, depression, anxiety, cognitive impairment, poor quality of life, and mortality [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The literature emphasizes that physical impairments caused by falls result in a series of adverse consequences, i.e., limiting individuals\u0026rsquo; social interaction and participation in social activities [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. The decrease in social participation caused by physical impairments reduces the frequency of information exchange and emotional catharsis, thereby increasing negative ATA [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. The loss of social roles can cause severe loneliness; aggravate depression, anxiety and other negative emotions; and eventually accelerate the perception of aging and reduce the quality of life among older adults [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe key finding of this study is that age-friendly community renovations play a positive moderating role in the association between falls and ATA. These findings indicate that age-friendly community renovations make a difference in preventing falls; relieving loneliness, tension, anxiety, depression and other negative emotions in older adults; and especially reducing negative ATA [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Previous studies have noted that in the process of age-friendly community renovations, measures such as the improvement of dim environments, nonslip ground, and the construction of barrier-free facilities can increase the safety of older adults\u0026rsquo; environments and increase their pleasant and familiar atmosphere [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. This study indicated that the positive influence of age-friendly community cultural atmosphere construction on ATA is greater than that of age-friendly community hardware facility renovations, which is consistent with the findings of the literature [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. The cultural atmosphere of respecting and caring for older adults could enhance their sense of identity, delay negative ATA, and promote their participation in community activities [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Therefore, interventions aimed at decreasing the risk of falls among older adults through age-friendly community renovations could be a mechanism for enhancing positive perceptions of aging, thereby increasing happiness and comfort and decreasing negative ATA.\u003c/p\u003e\u003cp\u003eThis study had several limitations. First, owing to data availability limitations, only cross-sectional data were used in this study. The causal relationship between falls and ATA needs to be further examined by using panel data or looking for appropriate instrumental variables. Second, although this study tries to control the factors affecting ATA among older adults, the regression results may have been affected by missing variables. Generally, studies have included cognition as an important control variable when analyzing the association between falls and ATA. However, variables related to cognition were not available in the CLASS, thus potentially introducing some biases in the analysis. Additionally, owing to space constraints, this study explored only the moderating role of age-friendly community renovations on the association between falls and ATA among older adults. However, with respect to the intensity and coverage of age-friendly community renovations, there may be different moderating effects that should be studied in the next step of an in-depth investigation.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study found that falls were significantly and negatively associated with ATA among older adults in China. This association was mediated by lower ADLs and more severe depression, and it was positively moderated by age-friendly community renovations. Our findings emphasize that falls are risk factors for ATA, thus emphasizing the importance of post-fall interventions and psychological counseling among older adults. This research highlights that age-friendly community renovations could reduce the negative effects of falls and promote psychological health among older adults. Policymakers should formulate valuable targets to promote individual psychological health through age-friendly community renovations and other forms of social support (e.g., visiting and accompanying chats) and to integrate into social life, which could help older adults reduce the rate of aging and the negative psychological effects of falls. These findings have implications for understanding the behavior of falls and social support factors that affect psychological health and resilient aging.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAAQ, Attitudes to Ageing Questionnaire; AAT, attitudes toward ageing; ADLs, activities of daily living; \u003cem\u003e\u0026beta;\u003c/em\u003e, \u003cem\u003e\u0026beta;\u003c/em\u003e-coefficient; CI, Confidence interval; CLASS, China Longitudinal Ageing Social Survey; PSM, propensity score matching; SD, standard deviation; WHO, World Health Organization.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors acknowledge the support of the Institute of Gerontology and the National Survey Research Center at Renmin University of China for providing the China Longitudinal Aging Social Survey (CLASS) data.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eE.L. conceived the study and coordinated the research conduct. H.L. conducted statistical analyses and wrote the manuscript. B.W. assisted with statistical analyses and interpretation of results. X.Q. prepared the literature review. J.M. made critical revisions of the final manuscript. All the authors have read and approved the final submission of the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by the Post-funding Program of National Social Science Foundation of China (23FRKB005), the Early-funding Program of Social Science Foundation of Hubei Province (23ZD191), the Soft Science Project of the Ministry of Agriculture and Rural Affairs of China (RKX2025017), the Project of Research on the Social Integration in Guangdong-Hong Kong-Macao Greater Bay Area (RP/FCHS-04/2022).\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCLASS data are available at http://class.ruc.edu.cn/ (requiring a simple application).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study is a secondary analysis of the data from the CLASS. The CLASS study was ethically reviewed and approved by the Biomedical Ethics Review Committee of Renmin University of China (No. 20221226025). The participants provided their written informed consent to participate in this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003e School of Economics and Management, Hubei University of Technology, Wuhan, 430068, China. \u003csup\u003e2\u003c/sup\u003e Hubei Innovation Research Center of Rural Social Management, Hubei University of Technology, Wuhan, 430068, China. \u003csup\u003e3\u003c/sup\u003e School of Public Administration, Zhongnan University of Economics and Law, Wuhan, 430073, China. \u003csup\u003e4\u003c/sup\u003e Economy \u0026amp; Management School, Wuhan Sports University, Wuhan, 430079, China. \u003csup\u003e5\u003c/sup\u003e Institute of Income Distribution and Public Finance, Zhongnan University of Economics and Law, Wuhan, 430073, China.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eUnited Nations. 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BMC Geriatr. 2024;24(1):429.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Attitudes toward aging, Falls, Age-friendly community renovations, Older adults","lastPublishedDoi":"10.21203/rs.3.rs-7319199/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7319199/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003ePositive attitudes toward aging (ATA) constitute a key factor for healthy aging and well-being among older adults. This study aimed to examine the association between falls and ATA among older adults in China and to investigate the moderating effects of age-friendly community renovations on this association.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eData were derived from the China Longitudinal Ageing Social Survey (CLASS). The sample included 11,398 participants; 7.6% of the participants experienced falls in the previous year. Multiple linear regression models were applied to analyze the data, and propensity score matching (PSM) was used to address endogeneity.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eFalls were significantly and negatively associated with ATA (\u003cem\u003eβ\u003c/em\u003e = -0.581, 95% CI: -0.877, -0.284). Age-friendly community renovations positively moderated the association between falls and ATA (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.659, 95% CI: 0.037, 1.202).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003ePolicymakers should devote more attention to the negative association between falls and ATA. Increasing the implementation of age-friendly community renovations can reduce the probability of falls and enhance ATA among older adults.\u003c/p\u003e","manuscriptTitle":"The Association between Falls and Attitudes toward Aging among Older Adults in China: The Moderating Role of Age-Friendly Community Renovations","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-11 15:13:00","doi":"10.21203/rs.3.rs-7319199/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2b4a4ead-4dec-4e35-82cb-d37aefc07375","owner":[],"postedDate":"September 11th, 2025","published":true,"recentEditorialEvents":[{"type":"decision","content":"Withdrawn","date":"2026-05-20T07:55:38+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-20T08:09:59+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-11 15:13:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7319199","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7319199","identity":"rs-7319199","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}