The Influence of Gynecological Malignancies and Patient Characteristics on Fall Risk Perception

Background : The ability to predict how patient characteristics influence vulnerability for other potential health hazards would lead to more effective clinical preventions and better outcomes. In this study, we examined how gynecological malignancies and patient traits influence fall risk perception. Methods : Patients with gynecological cancers aged > 18 years were surveyed using 5 tools: a predesigned questionnaire to collect general information (demographic characteristics and disease characteristics), the fall risk perception scale, the Morse fall risk assessment scale (Chinese), the Chinese Big Five Personality Inventory, and a medical coping strategy questionnaire. Results : Fall risk perception among patients with gynecological malignancies was scored 16.51 ± 17.647 (mean ± standard deviation (SD)) by the fall risk perception survey and 11.28 ± 15.270 (mean ± SD) by the Morse fall risk assessment scale. Multivariate linear regression analysis revealed that additional comorbidities, specific personality traits, and coping methods are positively correlated with patient perception of fall risk ( p < 0.05). Conclusions : Patients with gynecological cancers have low perceived risk to fall, which is decreased further in specific subgroupings of patients lacking other chronic comorbidities, with neurotic personality traits, and who exhibit avoidant or submissive coping methods. These subgroups are good candidates for additional education designed to raise awareness of falling risk. This methodology can be applied to study the relationships between patient traits and other health hazards.


Introduction
The falling of hospitalized patients is a prevalent issue [1], with incidences reaching as many as 1.4% to 18.2% [2] of hospitalized patients in China per day.Fall risk has been shown to be positively associated with patient age, with greater than 35% of falls resulting in serious injuries including fractures, head trauma, physiological trauma, soft tissue damage, and even potentially death, adding to the economic and human toll of treatment [3].There are more predictors of falls including cancer [4], fatigue [5], cognitive performance [6], acute mental fatigue [7], and neurological diseases.Patients with gynecological malignancies (GM) are at greater risk of falling due to factors such as surgery and cancer-related pain [8].However, it remains unclear if GM patients perceive that they have an increased fall risk.
Accurately assessing the risk of falling has been shown to be essential for preventing falls [9], and depends on both the assessment of fall risk by healthcare workers as well as the patients' self-perception of fall risk.Selfperceived fall risk is defined as both the patients' awareness of the possibility of falling, as well as the severity of fall outcomes.Research [10] demonstrates that patient-initiated prevention, governed by their awareness of fall risk, can reduce the incidence of falls by as much as 50%.Therefore, helping patients to accurately estimate their risk of falling, so that their perceived risk is more reflective of their actual risk, is a critical first step in fall prevention [11].However, efforts to improve patient self-assessment are often sidelined by current clinical practices focusing more on the assessments of healthcare workers, impeding the ability of patients to participate in fall prevention.This study examines fall risk perception in patients with gynecological malignancies to uncover factors influencing the accurate estimation of fall risk, offering new insights for clinical fall prevention.

Object
From January to March 2023, a convenience sampling method was used to select patients with gynecological tumors (cervical cancer, endometrial cancer and ovarian cancer) inpatients preparing for surgery from three top-tier general hospitals.Inclusion criteria were: (i) over 18 years of age; (ii) informed consent and voluntary participation and (iii) clear thinking with the ability to accurately express personal thoughts.Exclusion criteria included: (i) previously diagnosed cognitive impairment and (ii) impaired consciousness.

Survey Research Tools
2.2.1.1General Information Questionnaire.This questionnaire collects demographic data such as age, education level, disease diagnosis, marital status, primary caregiver, presence of chronic diseases, residence, family annual income, and history of falls in the past year.
2.2.1.2Fall Risk Perception Questionnaire for Patients (in Chinese) (FRPQ).This tool, developed by Choi et al. [12] and translated into Chinese by Bao et al. [13], assesses the patients' perception of fall risk during hospitalization.It consists of 26 items representing three categories: environmental factors (13 items), personal activity factors (8 items), and physical condition factors (5 items).Scores range from 0 (no risk) to 3 (extreme risk), with higher scores indicating greater perceived fall risk.The maximum score of the survey is 78, and the Cronbach's α coefficient for the scale is 0.942, with coefficients for the three dimensions being 0.902, 0.883, and 0.853, respectively.The split-half reliability of the scale is 0.808.

Morse Fall Risk Assessment Scale (Chinese).
Originally developed in 1989 by Professor Janice Morse of the University of Pennsylvania, this tool predicts the risk of falling [14].It includes six items: the patients' history of falls in the past three months, number of medical diagnoses greater than one, the use of walking aids, the use of medication, gait, and cognitive status.The total score ranges from 0 to 125, with higher scores indicating greater fall risk: 0-24 points indicate low fall risk, 25-44 points indicate moderate fall risk, and 45 or more points indicate high fall risk [15].The Cronbach's α coefficient of the scale is 0.960, and the content validity index is 0.780, indicating good reliability and validity.

Chinese Big Five Personality Inventory
(CBF-PI-B).Developed by Wang et al. [16][17][18] from the Institute of Medical Psychology at Xiangya Hospital, Central South University, the inventory covers five dimensions: extraversion, neuroticism, conscientiousness, openness, and agreeableness, with 8 items per dimension, totaling 40 items.Each item is scored using a 6-point Likert scale, from 1 (strongly disagree) to 6 (strongly agree).First, reverse scoring items (5, 8, 13, 15, 18, 32, 36) are calculated, followed by direct scoring items.The sum of the scores for each dimension is calculated, with the maximum score per dimension being 48, and higher scores indicating more pronounced personality traits in that dimension.All five dimensions have a Cronbach's coefficient above 0.75, demonstrating good reliability and validity, suitable for this study.In this study, the Cronbach's coefficient of the questionnaire is 0.811.

Medical Coping Modes Questionnaire (MCMQ).
Revised by Shen et al. [19], the survey includes 20 items across three categories: confrontation (8 items), acceptance resignation (5 items), and avoidance (7 items).Each item is scored on a 4-point scale, with scores from 1 to 4 determined from the responses.Higher scores on given subscale indicate a greater tendency to adopt that coping tactic.The Cronbach's coefficients for the three dimensions are 0.733, 0.602, and 0.712, respectively.

Data Collection Methods
Two nurses with unified training were selected as investigators.A questionnaire survey was conducted within 24 hours of admission.Adopt uniform guidelines to explain the purpose and significance of the survey, inform that the survey follows the principles of voluntariousness and confidentiality, and sign the informed consent after obtaining consent.The questionnaire was filled out by the respondents themselves.For the patients with low vision, illiteracy, and the elderly and infirm, the investigators asked them one by one according to the contents of the questionnaire.When the patients encountered items with doubts, the investigators explained them clearly in person to make them understand, and recovered them on the spot after filling in.The Chinese version of the Morse Fall Risk Assessment Scale was completed by investigators.A total of 236 questionnaires were sent out in this study, and 230 were effectively collected, with an effective questionnaire recovery rate of 97.46%.

Statistical Methods
Data analysis was performed using SPSS 26.0 software (IBM SPSS statistics, Chicago, IL, USA).For data conforming to a normal distribution, the mean ± standard deviation was used, applying t-tests, analysis of variance (ANOVA), and multivariate linear regression analysis, with a significance level of α = 0.05.Questionnaires with missing data were excluded in the statistical analyses.Data were analyzed using SPSS 26.0 software.All p values are two-sided, with a statistical level of significance set at p < 0.05.Frequencies and proportions were summarized for demographic characteristics and each survey item.t-tests and ANOVA were used to compare the fall risk perception scores in GM patients with different demographic characteristics and disease characteristics.Multivariate linear regression analysis was conducted with the fall risk perception Scores as the dependent variable and meaningful variables in the univariate analysis as the independent variable, with a significance level of α = 0.05.

Fall Risk Perception Scores in GM patients
A total of 230 valid surveys were conducted, with ages ranging from 18 to 86 (48.01 ± 14.097) years.We first examined the self-perceived fall risk of patients from the results of the FRPQ survey.The mean total fall risk perception score calculated for the 230 patients was 16.51 ± 17.647 (Table 1) out of 78.Environmental factors (7.81 ± 8.990) and personal activity factors (5.55 ± 6.066) were the categories that most contributed to the score, followed by physical condition factors (3.15 ± 3.662).Each FRPQ item had a similar contribution to the total score for each category (Table 1).

Comparing Fall Risk Perception Scores among GM Patients with Different Demographic and Disease Characteristics
Significant statistical differences were noted in fall risk perception scores regarding marital status, presence of chronic diseases, falls in the past year, residence, primary caregiver, personality traits, and coping methods.The score on the Chinese version of the Morse Fall Risk Assessment Scale was (11.28 ± 15.270), among them, 20.43% were at moderate or high risk of falling (Table 2).

The Level of Fall Risk Perceived in Patients with Gynecological Malignant Tumor was Lower
Postural stability in general is improved by regular exercising and reduces the risk of falling [20].Regarding fall risk assessment, overestimating one's risk of falling can lead to prolonged fear of falling, subsequently reducing physical activity, diminishing muscle strength, and increasing the risk of falls.Conversely, underestimating the risk may lead to patients disregarding potential dangers, thus impacting fall prevention [21].In this survey, the average fall risk perception score among patients with gynecological tumors was a comparatively low level.This indicates that patients often overlook or underestimate their fall risk, which significantly undermines the effectiveness of prevention strategies.Limited physical activity and self-care abilities could further elevate patients' fall risk perception, consistent with findings by Turner et al. [22].Of the three dimensions of fall risk perception, scores for environmental factors scored the lowest, possibly due to patients' insufficient awareness of potential hazards in the hospital environment.Therefore, it is crucial for healthcare workers to implement varied health education methods to improve patients' understanding of environmental risks, thereby enabling them to recognize and implement effective preventive measures.Studies [23,24] demonstrate that video and personalized health education can significantly enhance patients' awareness of fall risks, thereby boosting their confidence in fall prevention and ultimately reducing fall incidence rates.This study has certain limitations; factors such as cancer, possibly fatigue, cognitive performance, acute mental fatigue, and neurological diseases were not considered, and had these factors been considered results may have changed.A second limitation is the use of an exclusively Asian population and as such, the data may not be extrapolatable to other populations.Although the participants were from three hospitals, all were tertiary general hospitals, limiting representativeness.

Chronic Diseases Comorbidity, Big Five Personality Traits and Coping Styles were the Influencing Factors of Fall Risk Perception 4.2.1 Chronic Disease Comorbidity
This survey found that comorbidity with chronic diseases is a crucial factor influencing patients' fall risk perception.Patients with chronic diseases tend to have a higher perception of fall risk.This is likely due to their extended medication use and ongoing medical care, which heightens their familiarity with and concern for their physical condition, as well as their awareness of environmental impacts on their health.This finding emphasizes the need for healthcare workers to offer more comprehensive and specific fallrelated health guidance to patients without chronic diseases, aiming to heighten their awareness and effectively mitigate relevant risk factors.

Big Five Personality Traits
Personality traits are fundamental behavioral characteristics and, as typical individual difference variables, directly affect emotional and stress responses [25].The survey indicates that neuroticism, conscientiousness, openness, and agreeableness have lower fall risk perception compared to extraversion, with neuroticism scoring the lowest.Neuroticism is characterized by anxiety, depression, suspicion, sensitivity, and vulnerability [16].This may be because individuals with high neuroticism react more intensely to external stimuli and are prone to negative emotions such as tension [26].Patients' focus might be more on the anxiety and worry related to their illness, leading to a lack of awareness of fall risks.Additionally, patients' excessive dependence on healthcare workers can impact their perception of fall risk [27].Therefore, in clinical practice, healthcare workers should pay greater attention to high-risk groups, implement effective measures to enhance their proactive involvement in fall prevention, and empower them to become active participants and leaders in preventing falls.

Coping Methods
Coping methods are crucial mediators and regulators in the psychological stress process [28].In this survey, patients employing avoidance and submission as coping methods exhibited lower fall risk perception compared to those using confrontation.This might be because patients who adopt avoidance coping methods are reluctant to acknowledge or confront problems and risks directly.Some scholars argue [29] that avoidance is a behavior that diverts attention, shifting patients' focus to other aspects, thereby alleviating negative psychological emotions.In contrast, others believe [30] that avoidance is a passive coping strategy, characterized by evasion of recognition and self-blame, thereby denying the causes and adverse effects of diseases or problems.For fall risk, such patients may engage in selfdeception, similar to their denial of the disease itself, refusing to acknowledge the existence of fall risk, resulting in low fall risk perception.Suggesting that can work towards life goals was found to be a positive coping technique [31].

Conclusions
Fall risk perception among GM patients is relatively low and is influenced by factors such as chronic diseases, personality traits, and coping methods.Healthcare workers should leverage this information to identify patients who are more likely to underestimate fall risk.Special attention should be given to patients with no chronic comorbidities, with higher neuroticism scores, and those who adopt avoidance coping methods.Supplying more vulnerable patients with educational resources to help them accurately identify fall risk factors would likely lead to decreased falling incidence for hospitalized patients.Future studies should involve multi-center recruitment to expand the sample size and further explore the fall risk perception among GM patients.The study design should be used to explore the relationship between other patient populations and other types of health hazards, in order to bolster clinical prevention and improve patient outcomes.

Table 3 . Multivariate linear regression analysis of factors influencing fall risk perception in patients (n = 230).
β, beta, regression coefficient; SE, standard error.