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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: The proportion of older people is increasing and calls for a shift towards proactive approaches to support healthy ageing. The evidence base on health-promoting and preventive interventions (HPP) is promising in terms of maintaining health in older people, but for such interventions to have an impact on population health, translation of evidence to practice is crucial. To facilitate this process, factors relevant for decision makers are important to consider. One specific public health challenge is fall-related injuries in older people which cause the highest number of injury-related deaths, have many consequences for the individual (physical and psychological) as well as wide-ranging societal costs. Translation of evidence to practice faces challenges with regards to reach, limiting the public health impact of such interventions. Digital interventions have the potential to increase reach and thereby contribute as an innovative proactive approach. The aim with this thesis was twofold. First, to review the scientific literature in the field of health promotion and prevention conducted in Nordic Countries and targeting community-dwelling older people. Secondly, to evaluate reach, self-reported health outcomes and cost-effectiveness of the Safe Step digital fall preventive exercise intervention in an observational study in the municipality of Östersund-Sweden.

Methods: In paper I, a scoping review design was applied to review and summarise a broad field of research focusing on seven factors important for decision-makers such as: context, population, content, feasibility aspects, experiences of participants, intervention effects, and cost-effectiveness. In Paper II, data related to reach including recruitment rate, and participant characteristics (based on self-reported health outcomes and socioeconomic status) were collected. The sample was compared with a representative sample of older people for the purpose of exploring representativeness. In paper III, self-reported health outcomes in relation to balance, leg strength, fear of falling and health-related quality of life were evaluated over the course of the one-year intervention and in relation to exercise time, reported in quarterly questionnaires. In paper IV, the cost effectiveness of the Safe Step intervention was modelled in a Markov model with five states over 12 years to evaluate the potential cost-effectiveness of the intervention in community-dwelling older people at risk of falling.

Results: Paper I showed that all included studies, except one, reported a positive effect in at least one health outcome measured. Most studies did not report on cost-effectiveness, feasibility, or experiences of participants. Based on the summarised evidence, senior meetings, preventive home visits and various forms of fall preventive exercise interventions emerged as most recommendable for implementation. Results from paper II showed that the majority of participants had a better health status, were women, and were more commonly using technology in comparison to a sample population. Paper III showed that participants in the intervention self-reported positive changes in balance and leg strength at different follow-ups. Balance and leg strength indicated a small but positive association with self-reported exercise activity. Paper IV showed the potential of Safe Step being a cost-saving intervention with better health outcomes and lower costs compared to no intervention alternative. Assuming a lower estimated intervention effect and higher recruitment costs still indicated that Safe Step was cost effective.

Conclusion: This thesis provides evidence to support proactive approaches in healthy ageing and recommends increased efforts in research regarding translation of such interventions to practice as to maximize impact on a population level. The Safe Step intervention shows promise in being used independently in community-dwelling older people with good overall health and familiarity with internet and digital technologies. The majority reached were women with higher education, which infers a need for other non-digital interventions or additional support to increase reach in the general population of older people at risk for falling. Preliminary effectiveness results imply that Safe Step can lead to self-rated changes in known fall-risk factors although participants reported exercise time was lower than the recommended levels. Safe Step indicates also to be a cost-effective intervention even with conservative estimates of intervention effects and higher costs.

Andelen äldre i befolkningen ökar. Det är därför av vikt att arbeta proaktivt för att främja hälsosamt åldrande. Det finns idag god evidens för att hälsofrämjande och förebyggande insatser kan bidra till ökad hälsa hos seniorer. Men för att sådana insatser ska nå ut och få en påverkan på hela den äldre befolkningens hälsa så är det avgörande att evidens kan omsättas i praktiken. För att underlätta denna process så är det viktigt att beakta faktorer som är relevanta för beslutsfattare när forskning i området bedrivs. Faktorer som deltagarnas erfarenheter av interventioner, genomförbarheten av interventioner i olika kontexter samt dess kostnader i förhållande till effekter är alla viktiga att ta hänsyn till när man granskar lovande interventioner för en eventuell implementering. Dessa faktorer kan vara avgörande för effektiviteten av sådana interventioner på populationsnivå.

En stor samhällsutmaning och särskilt fokus i den här avhandlingen är fall hos seniorer och fallförebyggande arbete för att motverka fall. Seniorer faller ofta och en del fall kan leda till skador med omfattande konsekvenser för funktionen för individen samt tillför stora samhällskostnader. Det finns god evidens för att fallpreventiv träning kan minska fall bland äldre personer men det behövs nya metoder för att nå ut med träningsinsatser till flera i befolkningen. Digitala insatser har potential för att med mindre insatser nå ut till många med stöd och råd för träning och kan därmed bidra som ett innovativt och proaktivt tillvägagångssätt.

Denna avhandling har två syften. Första syftet var att granska den vetenskapliga litteraturen inom området hälsofrämjande och förebyggande åtgärder som genomförts i de nordiska länderna med målgrupp seniorer. Målet med litteraturöversikten var att utforska tillgången av evidens-baserade interventioner som skulle kunna rekommenderas för implementering i en kommunal kontext. Andra syftet var att analysera utfall av rekryteringen, deltagarnas självrapporterade utfall och en modellerad kostnadseffektivitetsanalys av en digital fallförebyggande intervention som innehåller balans och styrketräning. Interventionen innefattade applikationen Säkra steg och stödjande strategier för att komma i gång med träningen. Applikationen har tidigare utvecklats i vår forskningsgrupp i samarbete med seniorer och ett multidisciplinärt team av forskare. Appen utvecklades för att kunna användas helt självständigt. Alla övningar i appen visades in ett videoformat där man kunde se seniorer utföra övningarna i en hemmiljö.

Utvärderingen av interventionen Säkra steg gjordes in en observationsstudie där omfattande arbete genomfördes med att informera och nå ut till seniorer. Alla deltagare som bedömde sig uppfylla urvalskriterierna kunde anmäla sig till studien genom att ange sin epost på studiens hemsida. Rekrytering pågick över 6 månader och omfattade olika strategier som genomarbetats delvis i samarbete med seniorer. Totalt deltog 173 personer i åldern 70+ som var ett av urvalskriterierna. Deltagare tränade med appen under ett år. Vi samlade in självrapporterade data på olika utfallsmått genom digitala enkäter som skickades till deltagarnas epost kvartalsvis.

Resultat från litteraturöversikten har rapporterats i en artikel medan resultat av utvärderingen av Säkra steg har rapporterats i tre olika artiklar i den här avhandlingen. För artikel I har en scoping review design använts som är en form av litteraturöversikt. Enbart RCT studier har inkluderats och analyserats utifrån sju faktorer: sammanhang, population, innehåll, genomförbarhetsaspekter, deltagarnas erfarenheter, interventions-effekter och kostnads-effektivitet. I artikel II rapporterades data relaterat till rekryteringsfrekvens och deltagarnas egenskaper (baserat på självrapporterade resultat på hälsa och socioekonomisk status). Urvalet jämfördes med ett representativt urval av seniorer i syfte att undersöka representativitet. I artikel III utvärderades självskattade resultat av balans, benstyrka, rädsla för att falla och hälsorelaterad livskvalitet vid upprepade mätningar under den ett år långa interventionen. Resultaten analyserades även i relation till träningsaktivitet, rapporterad i kvartalsvisa frågeformulär. I artikel IV modellerades kostnads-effektiviteten för interventionen Säkra steg i en Markov-modell med fem tillstånd över 12 år för att utvärdera den potentiella kostnadseffektiviteten av interventionen för hemma-boende seniorer med benägenhet att falla.

Artikel I visade att alla inkluderade interventionsstudier förutom en rapporterade en positiv effekt på minst ett utfallsmått på hälsa. De flesta studier rapporterade inte om kostnadseffektivitet, genomförbarhet eller deltagarnas erfarenheter med de utvärderade interventionerna. Baserat på den sammanfattade evidensen framstod seniormöten, förebyggande hembesök och olika former av fallförebyggande träningsinsatser som mest lämpade för implementering. Resultat från artikel II visade att majoriteten av deltagarna skattade ett bättre hälsotillstånd, var kvinnor och använde digital teknik oftare i jämförelse med en urvalspopulation. Artikel III visade att deltagandet i interventionen förbättrade självrapporterad balans, benstyrka och uppresning mätt med 30 sekunder Chair Stand Test (30CST) vid olika uppföljningar. Inga positiva förändringar sågs i skattningar av rädsla för att falla eller hälsorelaterad livskvalitet. Benstyrka och 30CST indikerade ett litet men positivt samband med självrapporterad träningsaktivitet. Artikel IV visade potentialen i Säkra steg som en kostnadsbesparande intervention med bättre hälsoresultat och lägre kostnader jämfört med ingen intervention. En lägre uppskattad interventionseffekt och högre rekryteringskostnader visade fortfarande att Säkra steg var kostnadseffektivt.

Den här avhandlingen ger stöd för fortsatt främjande av proaktiva tillvägagångssätt för hälsosamt åldrande och rekommenderar ökade forskningsinsatser som bidrar till översättningen av evidensbaserade interventioner i praktiken. Interventionen Säkra steg visar sig lovande att användas självständigt av hemmaboende seniorer med god allmän hälsa och god vana med internet och digital teknik. Majoriteten som nåddes var kvinnor med högre utbildning vilket tyder på ett behov av andra icke-digitala insatser eller ytterligare stöd för att nå flera seniorer i risk att fall i den allmänna befolkningen.

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.

Background: To have an impact on the population's health, preventive interventions have to reach a large proportion of the intended population. Digital solutions show potential for providing wider access to fall preventive exercise. However, there is a lack of knowledge about how to reach the target group. The aim of this study was to describe the recruitment process used in the Safe Step randomised controlled trial and the characteristics of the participants reached.

Methods: Several recruitment methods, both digital and non-digital, were adopted to reach the intended sample size. Sociodemographic parameters from the baseline questionnaire were used to describe participant characteristics. The characteristics were also compared to a representative sample of older adults in the Swedish population.

Results: In total, 1628 older adults were recruited. Social media proved to be the most successful recruitment strategy, through which 76% of the participants were recruited. The participants reached had a mean age of 75.9 years, lived in both urban and rural locations, were already frequent users of the Internet and applications (smartphone/tablet) (79.9%), had higher education (71.9%), and a large proportion were women (79.4%). In comparison with the general population participants in the Safe Step study were more highly educated (p < 0.001), women in the study more frequently lived alone (p < 0.001) and men more often reported poorer self-rated health (p = 0.04). Within the study, men reported a faster deteriorating balance (p = 0.003) and more prescribed medication (p < 0.001) than women.

Conclusion: Recruitment via social media is a useful strategy for reaching older adults, especially women and frequent users of the Internet, for a fully self-managed and digital fall prevention exercise intervention. This study underlines that a range of interventions must be available to attract and suit older adults with different functional statuses and digital skills.

Background: Despite the promising evidence of health-promoting and preventive interventions for maintaining health among older people, not all interventions can be implemented due to limited resources. Due to the variation of content in the interventions and the breadth of outcomes used to evaluate effects in such interventions, comparisons are difficult and the choice of which interventions to implement is challenging. Therefore, more information, beyond effects, is needed to guide decision-makers. The aim of this review was to investigate, to what degree factors important for decision-making have been reported in the existing health-promoting and preventive interventions literature for community-dwelling older people in the Nordic countries.

Methods: This review was guided by the PRISMA-ScR checklist (Preferred Reporting Items for Systematic reviews and Meta-Analysis extension for Scoping Reviews), the methodological steps for scoping reviews described in the Arksey and O ' Malley's framework, and the Medical Research Council's (MRC) guidance on complex interventions. Eligible studies for inclusion were randomised controlled trials (RCTs) concerning health promotion or primary prevention for community-dwelling older people implemented in the Nordic countries. Additionally, all included RCTs were searched for related papers that were reporting on additional factors. Eligible studies were searched in seven databases: PubMed, SCOPUS, CINAHL, Academic Search Elite, PsycINFO, SocINDEX, and SPORTDiscus.

Results: Eighty-two studies met the inclusion criteria (twenty-seven unique studies and fifty-five related studies). Twelve studies focused on fall prevention, eleven had a health-promoting approach, and four studies focused on preventing disability. All interventions, besides one, reported positive effects on at least one health outcome. Three studies reported data on cost-effectiveness, three on experiences of participants and two conducted feasibility studies. Only one intervention, reported information on all seven factors.

Conclusions: All identified studies on health-promoting and preventive interventions for older people evaluated in the Nordic countries report positive effects although the magnitude of effects and number of follow-ups differed substantially. Overall, there was a general lack of studies on feasibility, cost-effectiveness, and experiences of participants, thus, limiting the basis for decision making. Considering all reported factors, promising candidates to be recommended for implementation in a Nordic municipality context are 'Senior meetings', 'preventive home visits' and 'exercise interventions' on its own or combined with other components.