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Fall prevention exercise for older adults: self-management with support of digital technology
Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Section of Physiotherapy.ORCID iD: 0000-0002-5147-9715
2021 (English)Doctoral thesis, comprehensive summary (Other academic)Alternative title
Digital fallprevention – egenträning för äldre personer (Swedish)
Abstract [en]

Background: Falls are a major public health issue, which can cause physical and psychological suffering for the individual as well as large costs for the society. To increase access and adherence to evidence-based fall prevention exercise, utilisation of older adults’ own capabilities and digital health offers promising solutions. The aim of this thesis was to explore a digital programme as support for self-management of fall preventive exercises in community-dwelling older adults with a focus on participant experiences, behaviour change, and intervention reach.

Methods: This thesis comprises four papers, of which Papers I and II report from a feasibility study comparing two self-managed fall prevention exercise programmes, a paper booklet and the digital Safe Step programme. Papers III and IV describes a randomised controlled trial, which evaluates the effectiveness of the Safe Step programme in combination with educational videos, to reduce falls in comparison with educational videos alone. In Paper I, individual interviews were analysed with inductive qualitative content analysis to explore older adults’ experiences of self-managing their fall prevention exercise. In Paper II, a deductive and inductive approach was utilised for the analysis of comments in questionnaires, individual, and focus group interviews to explore experiences of self-determination when using the Safe Step programme. The classification system of motivational and behaviour change strategies based on Self-determination theory was utilised as a categorisation matrix. An additional analysis of behavioural regulation for exercise according to the Self-determination theory was performed in this thesis. Paper III is a protocol for a randomised controlled trial, and Paper IV describes the recruitment strategies, and reach of this trial through comparison with another representative sample of adults 70 years or older by descriptive statistics.

Results: Results from Papers I and II show that the older adults appreciated the autonomy of a self-managed exercise programme. They expressed a capability to independently select exercises and manage their progression with support from the programme. However, some wanted the support of others in their training. The behaviour change support in the Safe Step programme was voiced as motivating and supportive, and the diversity of behaviour change strategies was emphasized as important to suit many older adults’ preferences. In Paper II, the behaviour change support were found supportive for the basic human psychological needs according to the Self-determination theory, although, support for autonomy and competence were more clearly stated than for relatedness. An additional category was formed and proposed as an amendment to the classification system used as an analytical matrix. In the thesis, expressions of intrinsic and extrinsic motivations for doing the exercise from participants in Paper I were triangulated with results from the Behavioural Regulations in Exercise Questionnaire-2. The results confirmed the trend found in the qualitative analysis of more intrinsically motivated expressions in the group using the Safe Step programme. A study protocol was written that described the design of the Safe Step randomised controlled trial, including the aims, methodology and overall organisation of the research (Paper III). In Paper IV, the most successful recruitment strategy to the randomised controlled trial was identified as advertisement in social media. The recruited participants were predominantly women, highly educated, and frequently used applications or internet on mobile devices.

Conclusion: Finding of this thesis support implementation of fall prevention strategies through increased utilisation of older adults' self-management capabilities. Older adults’ experiences of exercising with a self-managed digital exercise program can be understood as managing pieces of a personal puzzle and was shaped more by the sum of the features and behaviour change support in the programme than by parts of the programme. The Safe step programme seems to provide support for more self-determined exercise motivation, than a paper booklet, which can support maintenance of the new exercise routines. The older adults’ experiences, as well as the characteristics of the participants reached, highlight the necessity for a variety of fall prevention strategies that reflect the diversified needs and preferences of older adults.

Abstract [sv]

Fallolyckor bland äldre personer är ett av vår tids största folkhälsoproblem. Fallen orsakar psykiskt och fysiskt lidande för individen och ger upphov till stora kostnader för samhället. Ungefär en tredjedel av alla personer som är minst 65 år och bor i sitt ordinarie boende faller varje år. Den äldre befolkningen växer och det är därför av stor vikt att arbeta fallförebyggande. Det finns stort vetenskapligt underlag för träningens effekter för att förhindra fallolyckor, därtill finns också kunskap om vilken typ av övningar som bör genomföras. Dock har det visat sig att hälften av alla som påbörjar fallpreventiv träning slutar inom ett år.

En möjlig lösning för att det ska vara lättare att träna under längre tid är att äldre personer är mer delaktiga i beslut om sin egen träning. Allt fler digitala lösningar utvecklas och utvärderas för att ge stöd för träning till fler äldre personer och ge möjlighet att vara delaktiga i att förebygga fall. Digital teknik kan stödja träningen i det egna hemmet och ger möjligheten att inkludera stöd för beteendeförändring, också över tid. Dock behövs mer forskning om vilket stöd som behövs för att äldre personer, med olika förutsättningar och förmågor, ska kunna vara mer självständiga i utformandet och utförandet av fallpreventionsträning. Syftet med denna avhandling var att utforska självständig fallförebyggande träning med stöd av digital teknologi.

Avhandlingen innehåller fyra delstudier. De två första delstudierna baseras på en genomförbarhetsstudie där deltagarna själva valt om de vill träna med ett digitalt program (Säkra steg) eller med ett pappersbaserat program under fyra månader. Den första delstudien utforskar deltagarnas upplevelser och erfarenheter av självständig träning genom individuella intervjuer med äldre personer i båda träningsgrupperna. Den andra delstudien utforskar deltagarnas erfarenheter av stöd för beteendeförändring i det digitala Säkra steg-programmet. Intervjuer genomfördes både individuellt och i fokusgrupper. Vid analysen inkluderades även kommentarer från enkäter. Båda delstudierna analyserades med kvalitativ innehållsanalys. I den andra delstudien relaterades deltagarnas upplevelser också till ett klassifikationssystem av motivations- och beteendeförändringstekniker baserat på självbestämmandeteorin. En tilläggsanalys i kappan beskriver deltagarnas motivation enligt denna teori före och efter studiens genomförande. De sista två delstudierna beskriver utformning av en nationell randomiserad kontrollerad studie och undersöker rekryteringen till denna samt vilka äldre personer som visat intresse för att delta. I den sista delstudien beskrivs och jämförs bakgrundsdata från de deltagare som inkluderats med data från personer 70 år och äldre som besvarat Folkhälsoenkäten utgiven av Folkhälsomyndigheten.

Resultaten från denna avhandling ger insikter om äldre personers erfarenheter och förmågor att självständigt genomföra fallförebyggande träning i hemmet. Deltagarnas erfarenheter byggde på ett dynamiskt samspel mellan personens egna drivkrafter och motivation, stödet från programmet samt hur man utformar sina träningsrutiner. Det digitala Säkra steg-programmet verkar ha bidragit med ett större stöd för deltagarna att bibehålla sin träning. Detta stöds både av intervjuerna men också av tilläggsanalyser i avhandlingen baserat på enkäten gällande motivation enligt självbestämmandeteorin. Rekryteringen till den nationella randomiserade kontrollerade studien var mer framgångsrik via annonser i sociala medier än via andra rekryteringsstrategier. Äldre personer intresserade av att delta studien var till största delen kvinnor, de hade hög utbildning och använde ofta internet eller applikationer på sin mobiltelefon eller surfplatta dagligen. Andelen kvinnor och utbildningsnivå var också högre i studien än i jämförelse med äldre personer som besvarat Folkhälsoenkäten.

En mängd olika insatser för fallprevention behövs, både när ett fall har skett men också innan. Äldre personer bildar inte en homogen grupp när det gäller förutsättningar, preferenser och motivation och därför kan inte ett enskilt fallpreventivt program passa alla. Resultatet från denna avhandling visar att ett digitalt träningsprogram med stöd för beteendeförändring är en sådan möjlighet. Deltagarnas uttryckta förmåga till att vara aktiva deltagare i sin fallpreventionsträning kan bidra till vägledning i fortsatt utformning av fallpreventionsinsatser för äldre personer.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2021. , p. 78
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 2122
Keywords [en]
eHealth, digital health, fall prevention, self-management, smartphone, digital technology, behavioural change support, Self-determination theory
Keywords [sv]
Fallprevention, eHälsa, egenvård, digital teknik, beteendeförändring, självbestämmandeteorin
National Category
Physiotherapy
Research subject
physiotherapy; Public health
Identifiers
URN: urn:nbn:se:umu:diva-183077ISBN: 978-91-7855-537-6 (electronic)ISBN: 978-91-7855-536-9 (print)OAI: oai:DiVA.org:umu-183077DiVA, id: diva2:1554633
Public defence
2021-06-10, Aula Biologica, Umeå, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2021-05-20 Created: 2021-05-17 Last updated: 2022-04-29Bibliographically approved
List of papers
1. "Managing pieces of a personal puzzle': Older people's experiences of self-management falls prevention exercise guided by a digital program or a booklet
Open this publication in new window or tab >>"Managing pieces of a personal puzzle': Older people's experiences of self-management falls prevention exercise guided by a digital program or a booklet
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2019 (English)In: BMC Geriatrics, ISSN 1471-2318, E-ISSN 1471-2318, Vol. 19, article id 43Article in journal (Refereed) Published
Abstract [en]

Background: Exercise is effective in order to prevent falls in community-dwelling older people. Self-management programs have the potential to increase access and reduce costs related to exercise-based fall prevention. However, information regarding older people's views of participating in such programs is needed to support implementation. The aim of this study was to explore older people's experiences of a self-management fall prevention exercise routine guided either by a digital program (web-based or mobile) or a paper booklet.

Methods: This qualitative study was part of a feasibility study exploring two completely self-managed exercise interventions in which the participants tailored their own program, guided either by a digital program or a paper booklet. Individual face-to-face semi-structured interviews were conducted with a purposeful sample of 28 participants (18 women), mean age 76yrs. Qualitative content analysis was used to analyse the data.

Results: Self-managing and self-tailoring these exercise programs was experienced as Managing pieces of a personal puzzle'. To independently being able to create a program and manage exercise was described in the categories Finding my own level' and Programming it into my life'. The participants experienced the flexibility and independence provided by completely self-managed exercise as positive and constructive although it required discipline. Furthermore, different needs and preferences when managing their exercise were described, as well as varying sources of motivation for doing the exercise, as highlighted in the category Defining my source of motivation'. The category Evolving my acquired knowledge' captures the participants' views of building their competence and strategies for maintenance of the exercise. It describes a combined process of learning the program and developing reflection, which was more clearly articulated by participants using the digital program.

Conclusions: This study provides new knowledge regarding experiences, preferences and motivations of older people to engage in home-based self-managed fall prevention exercise. They expressed both a capability and willingness to independently manage their exercise. A digital program seems to have strengthened the feeling of support while creating their own exercise program and tailoring it to their preferences and circumstances, which might therefore create better opportunities for adoption and adherence in the long term.

Place, publisher, year, edition, pages
BioMed Central, 2019
Keywords
Accidental falls, Aged, Exercise, Qualitative research, eHealth, Digital health, Self-management, Falls prevention, Intervention, Behaviour change
National Category
Geriatrics Nursing
Identifiers
urn:nbn:se:umu:diva-157209 (URN)10.1186/s12877-019-1063-9 (DOI)000459122200003 ()30777026 (PubMedID)2-s2.0-85061861155 (Scopus ID)
Available from: 2019-03-26 Created: 2019-03-26 Last updated: 2023-03-24Bibliographically approved
2. Older adults’ experiences of behavior change support in a digital fall prevention exercise program: A qualitative study framed by the self-determination theory
Open this publication in new window or tab >>Older adults’ experiences of behavior change support in a digital fall prevention exercise program: A qualitative study framed by the self-determination theory
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2021 (English)In: Journal of Medical Internet Research, E-ISSN 1438-8871, Vol. 23, no 7, article id e26235Article in journal (Refereed) Published
Abstract [en]

Background: Exercise is an effective intervention to prevent falls in older adults; however, long-term adherence is often poor. To increase adherence, additional support for behavior change has been advocated. However, consistency in the reporting of interventions using behavior change techniques is lacking. Recently, a classification system has been developed to increase consistency in studies using behavior change techniques within the self-determination theory.

Objective: This study aimed to explore expressions of self-determination among community-dwelling older adults using a self-managed digital fall prevention exercise program comprising behavior change support (the Safe Step program), which was developed in co-creation with intended users.

Methods: The qualitative study design was based on open-ended responses to questionnaires, and individual and focus group interviews. A deductive qualitative content analysis was applied using the classification system of motivation and behavior change techniques as an analytical matrix, followed by an inductive analysis. Twenty-five participants took part in a feasibility study and exercised in their homes with the Safe Step program for 4 months. The exercise program was available on computers, smartphones, and tablets, and was fully self-managed.

Results: In the deductive analysis, expressions of support were demonstrated for all three basic human psychological needs, namely, autonomy, competence, and relatedness. These expressions were related to 11 of the 21 motivation and behavior change techniques in the classification system. The inductive analysis indicated that autonomy (to be in control) was valued and enabled individual adaptations according to different rationales for realizing exercise goals. However, the experience of autonomy was also two-sided and depended on the participants’ competence in exercise and the use of technology. The clarity of the program and exercise videos was seen as key for support in performance and competent choices. Although augmented techniques for social support were requested, support through relatedness was found within the program.

Conclusions: In this study, the Safe Step program supported the establishment of new exercise routines, as well as the three basic human psychological needs, with autonomy and competence being expressed as central in this context. Based on the participants’ experiences, a proposed addition to the classification system used as an analytical matrix has been presented.

Place, publisher, year, edition, pages
JMIR Publications, 2021
Keywords
Accidental falls, Aged, Behavior change, Behavior change techniques, Classification of motivation, EHealth, Exercise, Fall prevention, Qualitative research, Self-determination theory, Self-management
National Category
Physiotherapy
Identifiers
urn:nbn:se:umu:diva-183075 (URN)10.2196/26235 (DOI)000680402200002 ()34328438 (PubMedID)2-s2.0-85111690599 (Scopus ID)
Note

Originally included in thesis in manuscript form.

Available from: 2021-05-17 Created: 2021-05-17 Last updated: 2024-01-17Bibliographically approved
3. Effectiveness of a self-managed digital exercise programme to prevent falls in older community-dwelling adults: study protocol for the Safe Step randomised controlled trial
Open this publication in new window or tab >>Effectiveness of a self-managed digital exercise programme to prevent falls in older community-dwelling adults: study protocol for the Safe Step randomised controlled trial
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2020 (English)In: BMJ Open, E-ISSN 2044-6055, Vol. 10, no 5, article id e036194Article in journal (Refereed) Published
Abstract [en]

Introduction: Exercise interventions have a strong evidence base for falls prevention. However, exercise can be challenging to implement and often has limited reach and poor adherence. Digital technology provides opportunities for both increased access to the intervention and support over time. Further knowledge needs to be gained regarding the effectiveness of completely self-managed digital exercise interventions. The main objective of this study is to compare the effectiveness of a self-managed digital exercise programme, Safe Step, in combination with monthly educational videos with educational videos alone, on falls over 1 year in older community-dwelling adults.

Methods and analysis: A two-arm parallel randomised controlled trial will be conducted with at least 1400 community-living older adults (70+ years) who experience impaired balance. Participants will be recruited throughout Sweden with enrolment through the project website. They will be randomly allocated to either the Safe Step exercise programme with additional monthly educational videos about healthy ageing and fall prevention, or the monthly education videos alone. Participants receiving the exercise intervention will be asked to exercise at home for at least 30 min, 3 times/week with support of the Safe Step application. The primary outcome will be rate of falls (fall per person year). Participants will keep a fall calendar and report falls at the end of each month through a digital questionnaire. Further assessments of secondary outcomes will be made through self-reported questionnaires and a self-test of 30 s chair stand test at baseline and 3, 6, 9 and 12 months after study start. Data will be analysed according to the intention-to-treat principle.

Ethics and dissemination: Ethical approval was obtained by The Regional Ethical Review Board in Umeå (Dnr 2018/433-31). Findings will be disseminated through the project web-site, peer-reviewed journals, national and international conferences and through senior citizen organisations’ newsletters.

Trial registration number: NCT03963570.

Place, publisher, year, edition, pages
BMJ Publishing Group Ltd, 2020
Keywords
geriatric medicine, preventive medicine, public health, statistics & research methods
National Category
Public Health, Global Health, Social Medicine and Epidemiology Physiotherapy Geriatrics
Identifiers
urn:nbn:se:umu:diva-177628 (URN)10.1136/bmjopen-2019-036194 (DOI)000738373200077 ()32423936 (PubMedID)2-s2.0-85084786663 (Scopus ID)
Available from: 2020-12-15 Created: 2020-12-15 Last updated: 2023-09-05Bibliographically approved
4. Recruitment strategies and reach of a digital fall-prevention intervention for community-dwelling older adults
Open this publication in new window or tab >>Recruitment strategies and reach of a digital fall-prevention intervention for community-dwelling older adults
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2022 (English)In: Digital health, Vol. 8, article id 20552076221126050Article in journal (Refereed) Published
Abstract [en]

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.

Place, publisher, year, edition, pages
Sage Publications, 2022
Keywords
accidental falls, aged, eHealth, exercise, fall prevention, Geriatric medicine, preventive medicine, reach, recruitment, self-management
National Category
Physiotherapy
Identifiers
urn:nbn:se:umu:diva-183076 (URN)10.1177/20552076221126050 (DOI)000855672000001 ()36118253 (PubMedID)2-s2.0-85138745998 (Scopus ID)
Funder
Swedish Research Council, 2015-03481Forte, Swedish Research Council for Health, Working Life and Welfare, 2020-00589Umeå UniversityKarolinska Institute
Note

Originally included in thesis in manuscript form.

Available from: 2021-05-17 Created: 2021-05-17 Last updated: 2022-10-12Bibliographically approved

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