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Background: Falls among older adults are a significant public health issue due to their high incidence, severe consequences, and substantial economic impact. Exercise programs incorporating balance and functional exercises have been shown to reduce fall rates, but adherence and scaling up the interventions remain challenges. Digital technology offers a promising avenue to deliver this type of exercise, potentially improving exercise adherence and enabling self-management of exercise in the aging population.

Objective: This study aims to assess the effectiveness of the Safe Step app, a self-managed, unsupervised, home-based digital exercise program, in reducing fall rates or fall risk in community-dwelling older adults. Additional aims were to describe fall-related injuries in both the exercise and control groups, study attrition, and adherence to the Safe Step exercise program.

Methods: Community-dwelling individuals, aged 70 years or older, who had experienced falls or a decline in balance in the past year were randomized to either an exercise group using the Safe Step app combined with educational videos, or a control group receiving educational videos alone. Both interventions lasted for 1 year. Information regarding fall events was self-reported monthly through questionnaires. Exercise adherence was monitored through questionnaires every third month. Negative binomial and logistic regression estimated the incidence rate ratio of fall rate and the risk ratio (RR) of experiencing falls, respectively. Fall-related injuries, study attrition, and exercise adherence were reported descriptively. Results: In total, 1628 people were enrolled in the study, 79% were women, and the mean age was 75.8 (SD 4.4) years (range 70-94 years). The intention-to-treat analysis showed no significant difference in fall rates between the exercise and control groups after 12 months (2.21 falls per person-year in the exercise group and 2.41 in the control group; incidence rate ratio 0.92, 95% CI 0.76-1.11; P=.37). The risk of experiencing at least 1 fall was significantly lower (11%) in the exercise group compared to the control group (53% vs 59.6%; RR 0.89, 95% CI 0.80-0.99; P=.03). No differences were observed regarding the risk of 2 or more falls (34.1% in the exercise group, 37.1% in the control group; RR 0.92, 95% CI 0.79-1.06; P=.23). Injurious fall rates were similar between the exercise and control group. During the trial, 161 (20%) participants from the exercise group and 63 (8%) from the control group formally withdrew. The proportion of exercise group participants meeting the 90-minute weekly exercise goal was 12.7%, 13.4%, 8.6%, and 9.1% at 3, 6, 9, and 12 months, respectively.

Conclusions: Access to a self-managed unsupervised digital exercise program can be an effective component of a primary fall prevention strategy for community-dwelling older adults. Further research is needed to explore the mediating factors that influence the outcomes and develop strategies that enhance adherence for optimal impact in this population.

Aim: To formulate strategic recommendations for enhancing the implementation of the World Falls Guidelines among community-dwelling older adults and improve falls prevention efforts across Europe.

Findings: Effective fall prevention policies require a comprehensive multifaceted approach, which includes the integration of falls prevention strategies into broader healthcare policies, public health messaging and the development of a comprehensive curriculum in healthcare education. Design and delivery of services should include community participation involving older adults with lived falls experience and the application of implementation science. Establishing a standardized, locally adaptable European toolkit for falls prevention plans along with tailored implementation tactics, could effectively address barriers to the successful implementation.

Message: A collaborative commitment of relevant stakeholders to European initiatives—such as developing a standardized falls prevention strategy, promoting evidence-based implementation plans, establishing a European-wide research agenda, and creating an under- and postgraduate curriculum—is essential for advancing falls prevention efforts across Europe.

Background: Falls among community-dwelling older adults can be significantly reduced through exercises for balance and strength. Digital solutions show promise in increasing the reach and promote adherence to fall prevention exercises among older adults. However, research on long-term engagement in self-managed fall prevention programs is lacking. The Safe Step application is designed, in collaboration with older adults, to motivate and support them in independently engaging in balance and strength exercises. The aim of this study was to explore longitudinal patterns of older adults’ engagement in self-managed fall prevention exercise supported by the Safe Step digital application.

Methods: A qualitative longitudinal study was nested within a randomized controlled trial that evaluated the effectiveness of the Safe Step application in reducing falls among community-living older adults. A selection of participants who maintained an exercise dose of ≥ 60 min each week was invited to the study. Fifteen participants were included. Each participant was interviewed twice, first at the end of a twelve-month trial period and then after an additional six months. The analysis followed the Pattern-Oriented Longitudinal Analysis approach, analyzing patterns of change over time.

Results: Four engagement patterns were identified that began to emerge during the first year and were consolidated over time: (i) Coherent and sustained pattern, (ii) Coherent and episodic pattern, (iii) Integrated and sustained pattern, and (iv) Integrated and episodic pattern. The long-term engagement in self-managed digital fall prevention was characterized by the degree of cohesion and regularity in training. Initially, all participants followed the exercise recommendations provided by the application. With time they developed different strategies to maintain the exercises that resonated with their own preferences and daily activities. Conclusions: The digital program played a meaningful role in initiating and establishing exercise routines, while other determinants also influenced long-term engagement strategies. Support for self-management of fall preventive exercise needs to evolve over time to meet the changing needs of individuals and their different patterns of exercise engagement. Further research is needed to inform digital interventions aimed at supporting long-term engagement in fall prevention programs.

Background: Regular physical activity is essential for healthy aging, yet sustaining long-term engagement remains a challenge for many older adults. Emerging research highlights habit formation as a promising mechanism for maintaining physical activity, particularly when supported by contextual cues and digital technology.

Objective: This qualitative study explores how community-dwelling older adults incorporate physical activity into their daily lives, focusing on the processes of habit formation and maintenance, and the role of technology in supporting these behaviours.

Methods: Data were collected through three focus group interviews, one dyadic interview, and two workshop sessions conducted in Umeå, Sweden. Fifteen participants (mean age 73.3 years) with previous experience with regular physical activity contributed to the study. Reflexive thematic analysis was used to interpret the data, following Braun and Clarke’s six-phase approach.

Results: The analysis generated one overarching theme “Staying active through life’s shifting seasons” which captures how participants adapted their physical activity routines in response to aging, health changes, and life transitions. Two interwoven subthemes were identified: “Building the habit scaffold” and “Cultivating a movement mindset”. The first describes how participants constructed supportive frameworks for activity through routines, environmental adjustments, social contracts, and digital technology. The second highlights internal strategies such as emotional reframing, identity alignment, and the development of a personal philosophy around physical activity. Participants emphasized the importance of flexibility, self-awareness, and emotional engagement in sustaining activity. Technology, including smartwatches and fitness apps, was described as both a motivational aid and a feedback system, reinforcing routines and providing a sense of accountability. Seasonal variation and life events were common disruptions, requiring participants to renegotiate their habits and find new forms of physical activity.

Conclusions: Sustaining physical activity in later life is a multifaceted and adaptive process, maintained through the interplay of external scaffolding such as routines, cues, and supportive structures and internal orientations rooted in identity, emotion and meaning. Interventions that are practical, motivational, and flexible are likely to be most supportive. Digital technology can offer valuable support if embedded into personally meaningful and adaptable routines.

Trial registration: NA

Background: Supramaximal high-intensity interval training (HIT) programmes can be challenging to replicate outside research settings. This study aimed to explore its feasibility for older adults in a community setting, incorporating perspectives from exercise participants and instructors.

Methods: A pragmatic feasibility study using a convergent mixed- methods design involving four exercise instructors from one training facility and 21 older adult exercise participants (14 women, age-range 65–78). The previously used HIT programme consisted of 20-minute sessions that included a warm-up, ten 6-second intervals, and cool-down. Instructors first adapted the programme around these core components to their setting and then conducted 25 sessions. Both qualitative (individual interviews) and quantitative (estimated maximal oxygen consumption, estimated 6-second power, exercise- related motivation, and self-efficacy) data were collected and analysed (content analysis and descriptive statistics) in parallel. A taxonomy for implementation outcomes was used as an analytical matrix.

Results: Experiences of both participants and instructors revealed that the structure of the training was regarded as engaging, enjoyable, and supportive for establishing routines and promoting ownership of training progression. Participants found personalised and motivating approaches to engage with the programme and confidence in their abilities grew. Changes in exercise-related motivation and self-efficacy showed individual variation without a group trend. Participants who completed the intervention showed a positive median change in estimated 6-second power and maximal oxygen consumption, although individual responses varied. Experienced challenges included coordinating tasks during intervals and confidence in managing the programme. Barriers to fidelity and to scale-up were related to the practical complexity and fixed structure.

Conclusions: Supramaximal HIT can be implemented for older adults in a community setting with appropriate support, including individualised watt-based intensity and structured progression. The findings highlight how participants took ownership of their intensity progression, enabling them to challenge their limits. However, the fixed structure and complexity in managing short intervals may pose barriers to broader adoption. To enhance feasibility and scalability, simplifying interval management and providing clear, structured guidance are recommended. These insights help refine and optimize supramaximal HIT implementation for older adults in community settings.

Trial registration: Open Science Framework 31 January 2023 (https://doi.org/10.17605/OSF.IO/B7T2G).

Falls are the most common cause of injury in older people, with consequences for the individual and society. With an increasing population of older people, falls and related costs are expected to increase. It is crucial to identify scalable and cost-effective interventions and subsequently reduce fall-related costs. The aim was to evaluate the cost-effectiveness of the Safe Step digital fall preventive exercise intervention over a period of 12 years and, in addition, to evaluate the impact of increased recruitment cost and decreased intervention effect. The intervention was evaluated in an observational study in a municipality context targeting community-dwelling older people of age 70 +. A Markov model with five states was used to model the cost-effectiveness of the Safe Step intervention and evaluate quality-adjusted life years (QALYs) and fall-related costs from a societal perspective. By using data from a meta-analysis as basis for the estimated intervention effect, the Safe Step intervention was compared with a no-intervention alternative. The results showed that the Safe Step intervention dominated no intervention. In the sensitivity analysis with the most conservative estimate of intervention effect, the ICER was €7 616 per QALY gained. Hence, Safe Step showed to be a cost-saving fall preventive intervention in older people at risk of falling and potentially cost-effective even with a low estimated intervention effect. Future studies on efficacy of fall preventive digital interventions will contribute in precising effect estimates and enhance the validity of these cost-effectiveness results.

Background: Accidental falls are one of the greatest threats to older adults’ health and well-being. The risk of falling can be significantly reduced with strength and balance interventions. However, there needs to be further knowledge into how older adults can be supported to achieve a maintained exercise behaviour. Therefore, the aim of this study was to explore factors that enabled older adults to maintain their exercise during a 1-year self-managed digital fall prevention exercise intervention.

Methods: This study used a grounded theory methodology. Semi-structured individual interviews were conducted by phone or conference call. Eighteen community-dwelling older adults aged 70 years or more participated. The participants had a self-reported exercise dose of 60 min or more per week during the last three months of participation in a 12-months intervention of self-managed digital fall prevention exercise, the Safe Step randomized controlled trial. Open, axial, and selective coding, along with constant comparative analysis, was used to analyze the data.

Results: The analysis resulted in a theoretical model. We found that the fall prevention exercise habits of adults were developed through three stages: Acting against threats to one’s own identity, Coordinating strategies to establish a routine, and Forming habits through cues and evaluation. The main category of Maintaining balance in life encases the participants transition through the three stages and reflects balance in both physical aspects and in between activities in daily life. The process of maintaining balance in life and desire to do so were mediated both by intrinsic person-dependent factors and the Safe Step application acting as an external mediator.

Conclusion: This study identified three stages of how older adults developed self-managed fall prevention exercise habits, supported by a digital application. The generated theoretical model can inform future interventions aiming to support long-term engagement in digitally supported and self-managed fall prevention interventions.

BACKGROUND: Little is known about associations between performance-based measurements and self-reported scales, nor about ceiling effects or sensitivity to change to evaluate effects in the target population for self-managed exercise interventions. This study aimed to explore the feasibility of using performance-based outcomes for gait speed, functional leg strength and balance, and self-reported outcomes of falls-efficacy and functional ability in two self-managed falls prevention exercise interventions for community dwelling older adults.

METHODS: Independent living, community-dwelling older adults (n = 67) exercised with one of two self-managed falls prevention exercise programmes, a digital programme (DP) or a paper booklet (PB) in a 4-month participant preference trial. Pre- and post-assessments, by blinded assessors, included Short Physical Performance Battery (SPPB) and 30s Chair stand test (30s CST). Participants completed self-reported questionnaires: Activities-specific and Balance Confidence scale (ABC), Iconographical Falls Efficacy Scale (Icon-FES), Late-Life Function and Disability Instrument Function Component (LLFDI-FC). In addition, improvement in balance and leg strength was also self-rated at post-assessment. Participants' mean age was 76 ± 4 years and 72% were women.

RESULTS: Ceiling effects were evident for the balance sub-component of the SPPB, and also indicated for ABC and Icon-FES in this high functioning population. In SPPB, gait speed, 30s CST, and LLFDI-FC, 21-56% of participants did not change their scores beyond the Minimal Clinically Important Difference (MCID). At pre-assessment all performance-based tests correlated significantly with the self-reported scales, however, no such significant correlations were seen with change-scores. Improvement of performance-based functional leg strength with substantial effect sizes and significant correlations with self-reported exercise time was shown. There were no differences in outcomes between the exercise programmes except that DP users reported improved change of leg strength to a higher degree than PB users.

CONCLUSION: The LLFDI-FC and sit-to-stand tests were feasible and sensitive to change in this specific population. The balance sub-component of SPPB and self-reported measures ABC and Icon-FES indicated ceiling effects and might not be suitable as outcome measures for use in a high functioning older population. Development and evaluation of new outcome measures are needed for self-managed fall-preventive interventions with high functioning community-dwelling older adults.

Background: Despite the significant value of physical activity for the health of older adults, this population often fails to achieve recommended activity levels. Digital interventions show promise in providing support for self-managed physical activity. However, more information is needed about older adults' preferences for digital support to change physical activity behaviors as well as the process of designing them. The aim of this paper was to describe the participatory design process in which older adults were involved in the co-creation of digitally supported behavioral change strategies to support self-managed physical activity, and how the results were integrated in a prototype.

Methods: The participatory design process involved with nine older adults and two researchers. The participants were divided in two groups, and each group participated in three workshops and completed home tasks in between workshops. Following an iterative design process influenced by theories of behavior change, the workshops and home tasks were continuously analyzed, and the content and process were developed between groups and the next set of workshops. Prototypes of a mobile health (mHealth) solution for fall preventive exercise for older adults were developed in which the conceptualized strategies were integrated. To support coherence in reporting and evaluation, the developed techniques were mapped to the Behavior Change Technique Taxonomy v1 and the basic human psychosocial needs according to the Self-determination Theory.

Results: The results highlight different preferences of older adults for feedback on physical activity performance, as well as the importance of transparency regarding the identification of the sender of feedback. Preferences for content and wording of feedback varied greatly. Subsequently, the design process resulted in a virtual health coach with three different motivational profiles and tools for goal setting and self-monitoring. These behavior change strategies were integrated in the exercise application Safe Step v1. The conformity of the design concepts with the needs of Self-determination Theory and Behavior Change Technique Taxonomy v1 are presented.

Conclusion: The participatory design process exemplifies how older adults successfully contributed to the design of theory-based digital behavior change support, from idea to finished solution. Tailoring feedback with a transparent sender is important to support and not undermine motivation.

Background: There is robust evidence that falls in old age can be prevented by exercise programs that include balance training, functional exercises, and strength training. For the interventions to have a population health impact, outreach to the population of focus with suitable interventions is needed. While digital interventions are promising there is limited knowledge on the characteristics of who is reached. The aim of this study was to describe the recruitment process, estimate reach rate at the population level and to describe participants characteristics and representativeness in a digital fall prevention intervention study.

Methods: In a municipality-based observational study, reach of a digital fall prevention intervention was evaluated. The intervention included a digital exercise programme (Safe Step) and optional supportive strategies, complemented with a range of recruitment strategies to optimize reach. Recruitment during a period of 6 months was open to people 70 years or older who had experienced a fall or a decline in balance the past year. Reach was based on data from the baseline questionnaire including health and demographic characteristics of participants. Representativeness was estimated by comparing participants to a sample of older people from the Swedish National Public Health Survey.

Results: The recruitment rate was 4.7% (n = 173) in relation to the estimated population of focus (n = 3,706). Most participants signed up within the first month of the intervention (n = 131). The intervention attracted primarily women, older people with high education, individuals who used the internet or digital applications almost every day and those perceiving their balance as fair or poor. Safe step participants lived more commonly alone and had higher education and better walking ability in comparison to the Swedish National Public Health Survey.

Conclusions: With a range of recruitment strategies most participants were recruited to a digital fall intervention during the first month. The intervention attracted primarily highly educated women who frequently used the internet or smart technologies. In addition to digital fall prevention interventions, a higher diversity of intervention types (digital and non-digital) is more likely to reach a larger group of older people with different needs.