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Older adults’ experiences of behavior change support in a digital fall prevention exercise program: A qualitative study framed by the self-determination theory
Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Section of Physiotherapy.ORCID iD: 0000-0002-5147-9715
Umeå University, Faculty of Science and Technology, Department of Computing Science. Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Section of Occupational Therapy.
Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Section of Physiotherapy.ORCID iD: 0000-0001-6636-9597
Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Section of Physiotherapy.
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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. Vol. 23, no 7, article id e26235
Keywords [en]
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: urn:nbn:se:umu:diva-183075DOI: 10.2196/26235ISI: 000680402200002PubMedID: 34328438Scopus ID: 2-s2.0-85111690599OAI: oai:DiVA.org:umu-183075DiVA, id: diva2:1554605
Note

Originally included in thesis in manuscript form.

Available from: 2021-05-17 Created: 2021-05-17 Last updated: 2024-01-17Bibliographically approved
In thesis
1. Fall prevention exercise for older adults: self-management with support of digital technology
Open this publication in new window or tab >>Fall prevention exercise for older adults: self-management with support of digital technology
2021 (English)Doctoral thesis, comprehensive summary (Other academic)
Alternative title[sv]
Digital fallprevention – egenträning för äldre personer
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
eHealth, digital health, fall prevention, self-management, smartphone, digital technology, behavioural change support, Self-determination theory, Fallprevention, eHälsa, egenvård, digital teknik, beteendeförändring, självbestämmandeteorin
National Category
Physiotherapy
Research subject
physiotherapy; Public health
Identifiers
urn:nbn:se:umu:diva-183077 (URN)978-91-7855-537-6 (ISBN)978-91-7855-536-9 (ISBN)
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

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Pettersson, BeatriceJanols, RebeckaWiklund, MariaLundin-Olsson, LillemorSandlund, Marlene

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