Introduction
Aging is a natural process that starts from the conception of the embryo and continues until death. Aging is naturally associated with a gradual decline in the function of most body organs until the end of life [1]. The number and proportion of older people in the world population are increasing, and this rising trend will continue at an unprecedented rate in all societies in the coming decades, especially in developing societies [2].
Falling is one of the most prevalent and significant problems that older people face [2]. However, the risk of falling increases with age, causing disability, numerous physical and psychological complications, and death. Mental complications related to falling are debilitating, and like physical complications can affect daily life activities, health, and well-being [3].
Appropriate physical activities are essential in reducing morbidity and mortality in old age and are considered one of the main factors of healthy aging [7]. Physical activity improves mental health, delays the onset of dementia, and improves the quality of life and feeling well-being [8]. Physical activity and old age are in a vicious circle. With increasing age, people’s physical activity decreases because chronic diseases limit the physical activity of the elderly. On the other hand, reducing these activities causes an increase in old age diseases [9]. 
Fear of falling is also an obstacle to proper physical activities [7]. Due to the fear of falling, older people refrain from doing a series of activities that they used to do, such as preparing food, walking, etc. [10-12]. The fear of falling is an independent risk factor for reducing the quality of life, mobility limitation, loss of independence, and the risk of falling (which is the cause of injury, illness, and death) [6]. Previous studies show that people afraid of falling limit their activities more than others. It seems that in older adults, the fear of falling leads to a decrease in self-confidence and self-efficacy of the elderly and is an obstacle to proper physical activities [3].
In previous studies, the fear of falling and physical activities have been investigated in certain populations, such as stroke sufferers, referrals to rehabilitation clinics, urban health centers, or urban populations. However, despite the existence of differences between urban and rural elderly in the underlying causes of fear of falling and the amount and type of physical activities, based on the knowledge of the research team, there has been no research in this field in Iran so far. Therefore, this study investigates and compares the fear of falling and physical activity in older people covered by comprehensive rural and urban health service centers in Konarak City, Sistan and Baluchistan Province, Iran, as one of the least privileged areas of the country. 

Materials and Methods
This analytical cross-sectional study with a non-probability sampling method. The inclusion criteria comprised people aged ≥60 years, covered by comprehensive urban and rural health service centers in Konarak City, able to understand and repeat required functional concepts, walk independently with or without aids (cane and walker), absence of debilitating diseases such as Alzheimer disease, Parkinson disease, and so on as recorded in their electronic health file [3]. The exclusion criteria included lack of satisfaction to continue cooperation, change of residence location, and death [13].
According to the 64% to 36% ratio of rural to urban elderly in the study population, 224 rural elderly (covered by 3 rural health centers) and 126 urban elderly (covered by 1 comprehensive urban health service center) were included. Due to the climate and living conditions of the region, the number of visits of older people to health homes is low, and most of the elderly health care is done at home. Therefore, a list of eligible elderly was obtained from the electronic health system (SIB system) of health homes in 2021. Then, those older people who volunteered to participate in the research were selected when visiting the health center or the research team at their door. After that, the research objectives and procedures were thoroughly explained, and their written informed consent was obtained. Since most elderly participants in the research were illiterate and some did not have official identity documents (identity card and national card), first, the individual characteristics, including name and surname, age, contact number, and accommodation address, as well as anthropometry indicators, including height, weight, and body mass index (BMI) of the participating elderly were extracted from the SIB system. It is noteworthy that health workers and healthcare providers periodically update this information. Then, the rest of the demographic information, including the level of education, marital status, and living conditions (alone or with family), was collected from older adults. If the older person could not read and write, the questions were read by the examiner, and the answer of the subject to each question was written accurately and completely.
In addition to assessing the demographic information of the studied sample, we used the Persian version of the falling efficacy scale-international (FES-I) [14, 15], rapid assessment of physical activity (RAPA) [19, 20], activities of daily living (ADL) [22], and instrumental activities of daily living (IADL) [22] to evaluate the fear of falling and physical activity. A native person, fluent in the culture and language of the region, was also present with the examiner to understand better the expressions raised in the questionnaires and to clear all the doubts of the elderly participants.
In this research, following the normal distribution of the study samples, the independent t-test and the chi-square test were used to compare the quantitative and the qualitative research variables between the two groups, respectively. Also, the Pearson correlation coefficient was used to assess the relationship between study variables. The research data analysis was done using SPSS software, version 25, and 95% confidence intervals and values <0.05 were considered statistically significant.

Results 
Table 1 presents the Mean±SD and compares quantitative demographic variables. Table 2 presents the frequency distribution of qualitative research variables, and Table 3 lists the history of falling in participants. 



The results showed that the Mean±SD of the FES-I score was 20.74±6.67 in all older people, 21.59±7.25 in rural older people, and 19.5±17.5 in urban older people, and this difference was statistically significant (P<0.001). In examining the severity of fear of falling based on the FES-I test score, 74.9% of all elderly (71% of rural and 81.7% of urban elderly) had low fear. Also, the prevalence of high fear was 25.1% in all elderly, 29% in the rural elderly, and 18.3% in the urban elderly. This difference was statistically significant (P=0.02). In this research, the range of FES-I was 16-22 for low fear and 23-64 for high fear [16].



In the current study, the frequency of having a history of falling in the last 6 months was 4.57% in all older people, 6.2% in rural, and 1.6% in urban older people.



Table 4 reports the Mean±SD of physical activity assessment.



The results of the Pearson correlation test showed a statistically significant positive relationship between the FES-I test score and the history of falling in the past 6 months in rural elderly, urban elderly, and all older people (P<0.001) (Table 5).




Discussion 
This research showed that the mean score of the fear of falling test was higher in the rural elderly than the urban elderly, and this difference was statistically significant. Also, the prevalence of high fear of falling in older people in rural areas was significantly higher than in urban areas. Previous studies investigating the factors affecting the fear of falling indicate that heightened fear of falling is related to older age, female gender, living alone, and inappropriate physical activity [23-25]. The findings of our study, in line with previous studies, showed that a higher fear of falling is related to a lower level of physical activity. Also, in the present study, the average age of older people in rural areas was higher than in urban areas, the frequency of women in rural areas was higher than in urban areas, and a higher percentage of older people in rural areas lived alone. A less active lifestyle, due to the difference in the livelihood and cultural conditions of rural and urban areas, evidenced by the lower average score of the ADL test in older people in rural areas, is one factor causing this difference. Other causes of high fear of falling among rural elderly include the dangerous and less safe physical environment, the lack of safe infrastructures related to urban development (pavement and paved streets), and the unsafe physical spaces of rural houses, which may create a greater risk of falling in older adults. 
In the present study, 39.1% of all older adults did not report the fear of falling. In the Birhanie et al. study conducted in Ethiopia, 27.2% of older adults were not afraid of falling [23]. The prevalence of high fear in all older adults was 25.1%. It was  reported the prevalence of fear of falling between 21% and 85% among older people. Among the domestic studies, Zarepour et al. reported a low fear rate of 20%, a medium fear rate of 52.5%, and a high fear rate of 27.5% [25]. In their study, Najafi Qazalcheh also reported a low fear in 20.6% of older adults, a moderate fear in 60%, and a high fear in 14.4% [12]. Bastani et al. reported a high level of fear of falling (about 19%) among 1088 older people over 65 years of age [26]. Therefore, based on this research, the fear of falling is a significant health problem in the elderly living in Konarak, especially the elderly living in rural areas, which requires further recognition and investigation of the underlying factors that cause falling and the implementation of interventions to reduce the fear of falling. 
Also, daily life activities and aerobic activities during free time were more in urban areas than in rural areas, while the amount of instrumental daily activities and physical activities related to muscle strength and flexibility did not differ between the two groups of older people in rural and urban areas. According to the research findings, the fear of falling is related to the level of daily life activities, instrumental daily activities, and aerobic physical activities in all older people. So, reducing the fear of falling can increase physical activity in older adults and, as a result, reduce complications caused by immobility and help create an active lifestyle to improve physical and mental health and ultimately increase the number of active elderly. Also, the presence of a higher fear of falling in the rural elderly, along with the lower level of physical activity among them, indicates the need to pay more attention to the rural elderly population and to carry out more research, design executive interventions, and improve the physical environment in the villages.
One of the hypotheses examined in this research was the relationship between the fear of falling and physical activity in older adults. In the review of existing studies, including Sawa et al. in America, a negative statistical relationship was found between the intensity of physical activity and the fear of falling [31]. The study’s results by Bjerk et al. showed that the fear of falling has a negative statistical relationship with physical performance. In this research, IADL activities of the daily living questionnaire were used to measure physical performance [32]. Therefore, based on the research conducted and the evidence in previous studies, the fear of falling has a statistically significant negative relationship with physical activity, denoting that the fear of falling has a greater relationship with high scores on physical activity tests and, as a result, a lower relationship with low scores of physical activities.
Regarding the history of falling in the studied sample, based on the available studies, more than 30% of older adults living in the community experienced falling once or more [3]. In the study of Nabavi et al. in Bojnord City in 2015, the frequency of older people falling to the ground was 30.9%. The prevalence of falls in older people was investigated in different countries, and the frequency of falls was reported as 28.5% in Turkey, 26.4% in China, 33.3% in the Netherlands, 31% in Switzerland, 27.1% in Brazil, and 28.5% in Argentina [33]. Also, in Iran, in the study of Borhaninejad et al., the prevalence of falls in older adults has been reported at 33.8% [7]. All the available findings confirm the result of our research, indicating a very low falling history (4.75%). The reasons for this finding can be attributed to the specific lifestyle of this region, which includes living together in large families, doing most of the chores inside and outside the home by the younger family members, and accompanying the elderly who are frail in all activities even in doing personal things, which can reduce the risk of falling. Also, environmental factors reduce the risk of falling, such as houses on the ground floor, which often include one room, and the placement of toilets and bathrooms on the same level with cement flooring providing a non-slip surface, reducing the possibility of falling. Among other possible reasons for the low history of falling in this study is the age of the participants, that is, the young elderly group [34]. 

Conclusion
One of the limitations of the current research was the non-referral of older people to health homes due to the distance and large dispersion of the covered villages, the lack of private and public vehicles, and the region’s weather conditions. Therefore, to solve this limitation, the research team tried to include a real sample from the studied population by being present at the living place of the studied samples.
According to the living conditions and the climate of the place where the research was carried out, some of the limitations of the study can be attributed to some items related to the fear of falling while walking on slippery surfaces in the FES-I questionnaire, which needed to be fully and accurately understood by participants because they had no previous experience of this concept.
Regarding the mentioned limitations, it is suggested that due to ethnic, cultural, and geographical diversity in different parts of the country, the questionnaires used for each specific region should be more localized. Concerning the present research, more comprehensive studies should be conducted on the elderly population in Konarak. Another suggested solution is to use functional tests in future studies because, in deprived areas, there may not be a correct understanding of the questions in the questionnaires due to low levels of education.

Ethical Considerations

Compliance with ethical guidelines
This research received the ethical code from the Ethics Committee of the University of Social Welfare and Rehabilitation Sciences (Code: IR.USWR.REC.1400.263). All participants were fully aware of the research process and assured of the confidentiality of the information. Participation in the research was completely voluntary, and they were allowed to withdraw at any time. The written informed consent was obtained from them. The selection of samples was random without bias, and the tests were conducted in a safe environment. During the tests, older people were supported by the examiner.

Funding
This research was taken from the master’s thesis of Mohammad Mehdi Mohammadi, approved by Department of Physiotherapy, Faculty of Rehabilitation, University of Social Welfare and Rehabilitation Sciences. 

Authors' contributions
All authors equally contributed to preparing this article.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The research team would like to express its gratitude to the officials of the Health and Treatment Network of Kenarak City for their voluntary cooperation and support for the implementation of the research at the regional level, especially to the respected physician Ebrahim Yarmohammadi, who was actively and effectively present in the implementation phase of the research.