“A manageable and challenging fall prevention intervention with impact on society” - older women’s perspectives on participation in the stayBalanced training programme

ABSTRACT

Introduction

Efficient and effective evidence-based practice (EBP) strategies for managing fall prevention in primary health care are of great importance. To ensure that EBP methods have the potential to be implemented and maintained in clinical practice, patient perspective must be ensured. Novel programs need to be perceived as meaningful and feasible, and in line with the patients’ values, preferences and needs.

Purpose

To describe how older women with osteoporosis experience participation in the StayBalanced Programme.

Methods

Individual semi-structured interviews with 39 women aged 67–86 with osteoporosis, impaired balance and fear of falling. Data were analyzed with thematic analysis.

Results

The analysis resulted in three main themes; “Managing and challenging training through support and enjoyment,” “Structured training leads to safety and self-awareness” and “Lack of structured balance training means missed benefits, for both the individual and society.” The participants experienced that the increased safety and self-awareness achieved through the challenging and motivating training, were transferred to daily life, thus, leaving them less exposed to falls, fall injuries and fear of falling. They expressed concerns about lack of knowledge translation regarding the positive effects of structured and challenging balance training, which left older adults and society without the benefits of evidence-based intervention.

Conclusions

The StayBalanced Programme was appreciated and acceptable from the perspective of the participants, and in line with their values and preferences, one of three key components of EPB. The results of this study may support the uptake of the evidence-based StayBalanced Programme for fall prevention in clinical practice.

KEYWORDS:

• Balance training
• physiotherapy
• thematic analysis
• osteoporosis
• evidence-based practice

INTRODUCTION

Efficient and effective evidence-based practice (EBP) strategies for managing fall prevention in primary health care are of great importance. EBP aims to integrate the best available evidence, clinical expertise, and patient values into clinical practice to ensure the best quality of care (Sackett et al., 1996) and to guarantee that clinicians use effective interventions to achieve positive patient outcomes.

Fall-related injuries are the second leading external cause of unintentional injury and death worldwide (World Health Organization, 2018). In the European Union, one-third of community-dwelling people over the age of 65 years fall each year, and about 30% of all falls require medical treatment, often at emergency departments, and hospitalization (European Network for Action on Ageing and Physical Activity, 2015). There is strong evidence that exercise programs can reduce the rate of falls by at least 24% among community dwelling older adults, and reduce the risk of fall-related injuries by 32–40%, including severe falls requiring medical care or hospitalization (DiPietro et al., 2018; Sherrington et al., 2019). There is also convincing evidence on the efficacy and effectiveness of fall prevention interventions, including multicomponent training programs with various combinations of balance, endurance, strength, gait, flexibility, and physical function training (Campbell and Robertson, 2007; DiPietro et al., 2018; Goodwin et al., 2014).

Despite the fact that falls are preventable and the clear benefits of EBP in fall prevention (DiPietro et al., 2018; Sherrington et al., 2019), translating evidence into clinical practice has been challenging (Curtis, Fry, Shaba, and Considine, 2017) and the uptake rates of evidence-based interventions in community settings are low (Markle-Reid et al., 2015).

A balance training program for community-dwelling older adults, StayBalanced, was developed at the Karolinska Institutet from 2008 to 2011 (Halvarsson, Dohrn, and Ståhle, 2015). The program has been evaluated in both healthy older adults and older adults with osteoporosis, with self-perceived balance deficits and fall-related concerns. Participants in the program improved their gait speed (preferred speed > 0.08 m/s; p < .08 and fast speed 0.11 m/s; p < .008), dual-task step execution (0.08s; p < .012), physical function (LLFDI >3.7p; p < .034), and physical activity level (OR 6.17 for ≥ 5 000) and also reduced their fall-related concerns (FES-I > 4p; p < .034) (Dohrn, Hagströmer, Hellenius, and Ståhle, 2017; Halvarsson et al., 2013; Halvarsson, Franzen, and Ståhle, 2015; Halvarsson, Oddsson, Franzen, and Ståhle, 2016; Halvarsson et al., 2011).

In addition, two qualitative evaluations showed that the participating older women perceived that physical activity and adapted exercise therapy was an important tool to maintain health and that safety precautions and fall-prevention strategies were used to handle the fragile body in a way that made it possible for them to stay physically active. However, to stay active over time it was important for the older women to be guided by skilled physical therapists. (Dohrn, Ståhle, and Roaldsen, 2016; Halvarsson, Ståhle, Halén, and Roaldsen, 2015).

The perspective of the participants is fundamental in evidence-based fall prevention practice, as they have individual rationale for participating in fall prevention, based on experience, knowledge and habits. To ensure that novel training programs are efficient and effective and are likely to be implemented and maintained in clinical practice, it is therefore necessary to check for patient acceptability and ensure that the program is perceived as meaningful and feasible in line with patients’ values, preferences and needs (Altin et al., 2015). The aim of the present study was, therefore, to explore and describe the complexity of factors that influence experiences of and reflections on participation in the balance training program StayBalanced in older women with osteoporosis.

METHODS

The stayBalanced programme

StayBalanced is a progressive balance training program for older adults with a focus on divided attention. (Halvarsson, Dohrn, and Ståhle, 2015) Between 2009 and 2011 a randomized controlled trial (RCT) (BETA study; NCT01417598, ClinicalTrials.gov) was carried out to evaluate the effects of the program on older adults with osteoporosis with an increased risk of falling. Participants were recruited through advertisements in local newspapers. The aim was to evaluate the effects on fall-related concerns, gait and balance performance, physical function, health related quality of life and physical activity (Dohrn, Hagströmer, Hellenius, and Ståhle, 2017; Halvarsson, Franzen, and Ståhle, 2015). To be included in the RCT the participants had to be community-dwelling older adults, ≥ 65 years, with diagnosed osteoporosis, who had a fear of falling and/or had experienced at least one fall in the last 12 months, and were independent in ambulation. Participants were excluded if they had experienced fractures during the last year, had a Mini-Mental State Examination (MMSE) score < 24 (Folstein, Folstein, and McHugh, 1975), severely decreased vision, or other diseases or constraints that might interfere with participation in the exercise program. Enrollment to group allocation was performed in blocks of nine divided into three different groups: two intervention groups (Training, and Training + Nordic Walking), or a Control group, using Web-based software.

The balance training was performed at two different locations in Karolinska University Hospital in groups of 4–9 participants, 3 times per week for 12 weeks, and each session lasted 45 minutes. Every session started with a warm up for 5 minutes and ended with stretching for 5 minutes. The exercises were performed sitting, standing and walking with the addition of motor and/or cognitive tasks. The exercises were individually adjusted allowing everybody to challenge their balance ability. The participants were informed to always try to exercise on a challenging level to trigger balance reactions. To ensure safety for the participants and to enable progression of the exercises, 2–3 physiotherapists were present at every session.

Informants

The 39 informants in this study were purposively sampled from participants in the RCT intervention groups. All informants had completed the balance training during one of three semesters, 2010–2011. They were approached after the follow-up testing by the test leaders and asked to participate in the interview study. None of them declined to participate. The study was approved by the Regional Board of Ethics in Stockholm and all informants gave their written informed consent to participate (2006/151-31, 2009/819-32, 2012/1829-32, 2013/1810-32).

Data collection

Individual face-to-face interviews were performed by two of the authors (I-MD and CH) one to five months after participation in the balance training. Semi-structured interview guides with open-ended questions covering three main domains were used during the interviews; i.e. physical activity and health-related quality of life, balance and fear of falling in daily life, and experience of the balance training program. Results from the two former domains have been published elsewhere (Dohrn, Ståhle, and Roaldsen, 2016; Halvarsson, Ståhle, Halén, and Roaldsen, 2015), thus the latter domain (i.e. experience of the balance training program) constitutes the analysis unit for the present study.

Both interviewers conducted pilot interviews to test the interview guides and to practice the technique. Two pilot interviews were included in this study. Both interviewers had long experience as physiotherapists working with older adults, and with balance training in hospital care and primary care.

The interviews took place between February 2011 and June 2012 at the Physiotherapy Department at the University Hospital or at the Division of Physiotherapy at Karolinska Institutet in Stockholm, Sweden. The informants were familiar with these two locations because the balance training and the baseline and follow-up tests in the randomized controlled trials were performed there. The interviews lasted between 25 and 75 minutes (mean length: 45 minutes) and were taped with a digital voice recorder (Olympus WS-550 M).

Data analysis

The interviews were transcribed verbatim by three of the authors (IMD, CH and AH). The transcripts were not returned to the informants for comments or corrections. The qualitative data analysis used was based on the framework of Braun and Clarke (2006) thematic analysis. This is an analytic approach used to find patterns across data sets, i.e. to identify, analyze, and report patterns in the data. In a thematic analysis, a theme is a thread of meaning that appears in all domains, linking them together and providing a holistic analysis as the basis for the researcher’s interpretations (Baxter, 1991; Braun and Clarke, 2006). An inductive approach was adopted in which themes and codes were identified from the data itself, not from predefined assumptions. Themes were identified at the latent level and examined the underlying assumptions or ideas behind participants’ perceptions about participating in the StayBalanced Training Programme. The analysis was carried out following six steps: 1) familiarization with the data; 2) generating initial codes; 3) searching for themes; 4) reviewing the identified themes; 5) defining and naming the themes; and 6) preparing the report.

To maintain rigor throughout the analysis, features of trustworthiness were established according to Elo et al. (2014) criteria of soundness. The criterion for credibility was met through individual interviews using open-ended questioning, prolonged engagement with the data and by providing a detailed description of the methods. As the interviews were conducted over three semesters, the semi-structured interview guide was used to ensure the uniformity of the interview questions and the stability of the data collection over time. The criterion for transferability was fulfilled through presenting detailed description of the demographic data about the participants, detailed description of the data collection and in-depth descriptive data from the participants’ quotes. To meet the criterion for dependability, each transcription was independently read, checked and coded by the first and second author, SG read the interviews carried out by CH, and CH read the interviews carried out by IMD. To ensure the conformity of coding, three transcripts were also read by the last author. No data were excluded due to the lack of an appropriate theme. Final interpretations were reached via agreement between all five authors who discussed the findings and interpretations several times until consensus was reached and themes were identified, i.e. gathering codes into potential themes, reviewing themes and defining and naming themes. The transcription was carried out after all the interviews had been completed. To reduce the risk of changes in the data over time, the data analysis was completed over a limited time, following the rigorous and systematic process carried out in predefined steps in accordance with the framework of Braun and Clarke (2006).

The criterion of confirmability was fulfilled by providing rich quotes from the participants depicting each emerging theme. Furthermore, the consolidated criteria for reporting qualitative studies (COREQ) were considered for reporting of the current study (Tong, Sainsbury, and Craig, 2007). Both the interviews and the data analysis process were carried out in Swedish. The citations were translated to English by a bilingual professional with experience of the patient group and qualitative research.

RESULTS

All 39 informants were community-dwelling women and had a median attendance rate of 89% (range: 67–100%) for all training sessions. Common diseases or conditions in the group were dizziness (54%), hypertension (41%) and previous cancer (31%), and none of the informants had heart failure. See Table 1 for further background information.

Table 1. Background information for the 39 female informants in the study who participated in the StayBalanced balance training.

Variable	Measurements
Age (years), median (min–max)	75 (67–86)
Body mass index (kg/m^2), median (min–max)	24 (17–35)
University education, n	18
Living alone, n	22
Physical activity level (1/2/3/4/5), n*	0/2/16/21/0
Use walking aid outdoors, n	16
Experienced a fall in the past year, n	30
Falls Efficacy Scale International, median (min–max)** Preferred gait speed, m/s, median (min-max)***	27 (20–47) 1.19 (0.70–1.60)

*Frändin-Grimby activity scale, a six-degree scale, including household activities, ranging from hardly any physical activity (1) to hard exercise several times a week (5) (Frändin and Grimby, 1994).

**Falls Efficacy Scale International consisting of 16 questions about how concerned a person is about the possibility of falling, with four alternatives from not at all concerned to very concerned. Total score ranging from 16 to 64; high scores indicate high concern (Yardley et al., 2005).

***Preferred gait speed collected with GAITRite® system (CIR Systems, Inc., Haverton, PA, USA) (Menz et al., 2004; Webster, Wittwer, and Feller, 2005)

The analysis resulted in three main themes and ten subthemes (Table 2). The results are illustrated with citations from the informants with the informants’ age and FES-I score in parentheses.

Table 2. Subthemes and main themes show the perception and experience of participating in the StayBalanced Balance Training Programme by older women with osteoporosis, self-reported balance deficits and fear of falling.

Subthemes	Main themes
Design and structure of the program	Managing challenging training through support and enjoyment
Social context and group dynamics
Improvement suggestions
Effects after participation	Structured training leads to safety and self-awareness
Self-awareness of ability
Strategies obtained for moving more safely
Transfer abilities to daily life
Benefits to society	Lack of structured balance training means missed benefits both for the individual and the society
Challenges for continued training
Knowledge transfer

Managing challenging training through support and enjoyment

The balance training was found to be time-consuming and challenging. Despite that, the informants found the training rewarding and enjoyable due to the nature of the training, for example group size, type of exercises, and the support from other informants in the group and the physiotherapists.

I thought that everything was so enjoyable and positive. And I thought that you had so much variation in those movements and exercises, that you never watched the clock to see when it was over. No, it was more like, “oh is it already over?”! (age: 76, FES-I: 28)

Design and structure of the program

The overall experience was that the exercises were good, demanding, fun and varied. Exercises with dual tasks were perceived as both fun and difficult. The physiotherapists contributed to a good atmosphere and were considered to be educational, nice and knowledgeable even though someone thought some of the physiotherapists were a bit too young.

Mm … and we swayed around and while we were trying to call out names of lakes and countries and all of a sudden I just blanked about where my feet were supposed to be. (age: 78, FES-I: 24)

The level of difficulty was experienced as adequate and was adjusted to the individual, even though some exercises were perceived as too easy and others too difficult. The informants felt safe during the training because of the relatively small group size, making it possible for the physiotherapists to be close by and to pay attention to everyone.

And we were all at different levels of balance, you could say, but everyone made such progress, each according to what they were capable of doing. (age: 71, FES-I: 21)

There were different opinions about the timing of the training sessions. Most of the participants found the time of the day and the frequency (three times a week) good or acceptable because they were taking part in a research study. According to some of the informants, the morning start time was too early. At the beginning of the training period, three times a week was considered too much. However, after a while most of the informants were satisfied with how it was.

Social context and group dynamics

The overall experience was that it was fun being in a group. They learned while watching the others, they encouraged each other, they laughed a lot together, and reported that it was sad when the balance training was finished. The importance of being a part of a context and belonging to a group with others with similar experiences was expressed. A few mentioned that they kept social contact after the training period. For example, they met to have lunch together.

You see that there are people in the same situation as you, who actually have the same type of problems; even if we don’t have the same problems, we have the same type of symptoms. So when you came together and realized that you couldn’t just sit and feel sorry for yourself but that you could actually laugh at your own inabilities. I think that is really good, a good experience. You should have much more of that. (age: 76, FES-I: 28)

Improvement suggestions

The informants had different suggestions about the frequency of the training sessions per week and how long a training session should last. Most of them suggested twice per week with longer sessions. More individual support and treatment was requested, such as an individual session instead of or in between the group training sessions, for example, every second week. Some wanted to continue the training at home and asked for written instructions to be able to perform the exercises on their own. They also requested some sort of training support in the osteoporosis clinic or other facility, such as open training sessions.

I can’t understand why an osteoporosis department can’t have time for these balance exercises two times a week, that you can come and go as you please. I don’t get that. When you know that you can prevent falls from happening. (age:68, FES-I: 20)

Structured training leads to safety and self-awareness

The informants experienced positive effects on body and mind that resulted in increased body and self-awareness. They found new strategies for moving more safely and resumed physical activities in daily life. Some even reported a change in quality of life.

It [confidence] is much better now. The fact that I’m not as afraid of falling, because I know that I have better control over my body now. (age: 71, FES-I: 21)

Physical effects after participation

Most informants experienced better balance and felt more secure in their body and in all movements; for example, they were more alert and more secure when walking on icy and slippery ground outside. They felt more self-confident in activities in daily life and in more challenging situations.

The informants were less afraid of falling and less tense in their body. They experienced better and faster body reactions in demanding balance situations (the right muscles reacted quicker to maintain balance).

When I’m out walking and things like that, I notice that having been here (the balance training) that when I trip up I can get my bearings now. Yes! I have been about to trip and fall several times, and I’m not sure what I did, but I don’t fall now. (age: 68, FES-I: 39)

They also started to worry about how to keep their improved balance. Worries about losing the psychological part of being in a group when the training ended were also mentioned. Better balance and ability to move made them feel in a better mood, with improved self-esteem and made them happier. Better quality of life, less pain and improved sleep were also mentioned.

Awareness about own ability

The informants described an improved awareness of their own body; for example, their foot placement when walking, how they used their muscles, and difficulties in performing dual tasks.

I think a lot about what we have learned. I am conscious about how I walk, I haven’t been like that before. I haven’t thought about how I placed my feet, for example. (age: 78, FES-I: 23)

They noticed how their own balance had improved and described increased knowledge of the importance of physical activity, and insight into improving their balance. The women mentioned an increased awareness of their own fragility, which raised concerns about how easy it could be to lose their balance. They were also more aware of how other people move or walk.

Strategies obtained for moving more safely

The informants described new strategies to avoid falls and move more safely, such as observing the surroundings and planning the best way to walk and, if needed, lifting the feet higher or taking shorter steps. They had become more structured and aware of their limitations.

It’s like that I have gotten more structured. That has helped me become braver. I try to solve the situation so that I can do it, whereas beforehand I maybe said to myself ‘I can’t do that’. Like walking in a forest trail that I haven’t walked before, and I say to myself ‘if I look carefully at how the ground looks and don’t rush, then I can probably walk that way’. (age: 73, FES-I: 30)

Transfer abilities to daily life

The participants were inspired to find ways of continuing the balance training at home with exercises from the group training, self-composed exercises or through activities in daily life. They mentioned that they had started with physical activities such as dancing or working out outside the home or resumed activities they had not dared to do for a long time, such as traveling by bus, using an escalator and walking outside when it is icy or slippery.

I have become braver … I don’t think that it is as unpleasant to go out now, I dare to take the bus and even local busses, not just long-distance coaches … It used to be that I feel safe at home. That was why I wasn’t so keen on going outside. But it’s easier to go out now. (age:78, FES-I: 39)

Lack of structured balance training means missed benefits both for the individual and society

In this theme the informants reflected on the consequences for society. They perceived that the benefits of the training were so important that they wanted the concept to be available for other older people. After the program, they had become aware of barriers in society for balance training and lack of opportunities for older people. The lack of available structured balance training was expressed as a missed opportunity for the society to save money.

The balance project and those movements that I learned, they were so worthwhile, so all older people should get the chance to train with them, these exercises and become more aware of them. Imagine how much the health care system would gain from it, health care costs and people’s suffering. (age: 70, FES-I: 30)

Benefits to society

The informants could see the benefits to society, both economic and for each individual, if the balance training was made available to more people. Suggestions were made about the responsibility of municipalities and primary care doctors to provide information about and arrange similar balance training.

I think that this is something that everyone needs, I wish that everyone got the opportunity to go. Imagine how much the health care system would save. Imagine all the broken bones and slipping accidents. (age: 70, FES-I: 22)

Challenges for continued training

The informants wished to continue the training and asked for suggestions on how to continue with balance training, either in the same group or in community organizations, such as patient associations or municipal facilities. One informant criticized the concept for not having arranged continued training for the informants. Barriers for continued training also included economic issues and nowhere for themselves and others to go.

So I thought that it was a pity actually, that we weren’t able to continue in some way. I really wanted advice about things (continued training). (age: 78, FES-I: 24)

Yes, what you can do is to prevent things by going on walks and such. I would like to go and exercise, but I can’t afford it because I have such a small pension, so I don’t have the money. (age: 76, FES-I: 25)

Knowledge transfer

The informants stated that knowledge about the importance of specific balance training should be transferred to other people, to give them a chance to improve their balance.

I think that it is important that these type of things are available for people when they get older. I think that many people never get around to doing different things, like training. I think that many people won’t do it until they get a push and start to realize that this is really good! I think that it is important that even older ladies and men exercise, that it’s not just younger people doing that spinning or whatever it’s called, but that there are things for the elderly as well. (age: 76, FES-I: 26)

DISCUSSION

We sought to understand the complexity of factors that influence the participants’ experiences of and reflections on participation in the balance training program StayBalanced. The program was appreciated and acceptable from the participants’ perspective and in line with their values and preferences. They perceived increased safety and self-awareness, and this was transferred to their daily life, thus, leaving them with less fear of falling and more capable of handling fall risk situations. They also expressed concerns about lack of knowledge translation regarding the positive effects of balance training, like the StayBalanced Programme, leaving older adults and society without the benefits of evidence-based fall prevention. Together with the previous results from our quantitative studies, showing improved gait speed, dual-task step execution, balance performance, physical function, fall-related self-efficacy and physical activity level (Dohrn, Hagströmer, Hellenius, and Ståhle, 2017; Halvarsson et al., 2013; Halvarsson, Franzen, and Ståhle, 2015; Halvarsson, Oddsson, Franzen, and Ståhle, 2016; Halvarsson et al., 2011) the results of the present study supports the idea that the StayBalanced Programme is an efficient, effective, feasible and acceptable evidence-based balance training intervention suitable in clinical settings for women with osteoporosis. From our previous analysis of the two other domains explored in this study we found that women with osteoporosis perceived that physical activity was an important tool to maintain health with osteoporosis and believed that they had a responsibility to use this tool (Dohrn, Ståhle, and Roaldsen, 2016). Moreover, women with osteoporosis had an internalized risk perception to cope with their fragility and they perceived improved empowerment and self-efficacy after participation in balance training (Halvarsson, Ståhle, Halén, and Roaldsen, 2015). The present study contributed with additional knowledge about the informant’s experience from participation in the StayBalanced Programme in a clinical context.

All this information is of great importance for evidence-based practice (EBP) in physiotherapy (i.e. combining and integrating the different sources of knowledge and experience that are available in the clinical context: 1) the patient values, preferences and experiences; 2) research-based knowledge; and 3) clinical expertise) (Altin et al., 2015), a prerequisite for implementation of evidence-based fall prevention programs in clinical practice (Worum et al., 2019). Further, the present study fills the knowledge gap about the participants’ own experiences of the StayBalanced Programme, valuable knowledge to build evidence-based practice and to transfer this knowledge into clinical practice (i.e. the implementation phase).

Previous research has shown the effects of dual-task training on balance performance, gait speed, fall-related self-efficacy and physical function (Halvarsson, Franzen, and Ståhle, 2015; Konak, Kibar, and Ergin, 2016). Several of these exercises in the StayBalanced Programme are similar to tasks in daily life, such as walking and carrying a big object that obscures the view of the ground or walking and reading a paper or letter at the same time. The informants in this study were women with osteoporosis. Despite their fear of falling and their fragility, they reported that these dual-task exercises were challenging, difficult and useful, and that they had noticed effects on balance, felt safer when they moved and resumed everyday activities. They also reported that they dared to do things they had not done for a long time, for example, taking long bus journeys. It is possible that these effects derive from the many dual-task exercises. To our knowledge, these findings have not been reported in the literature for this population. Interestingly, older people with Parkinson’s disease, who participated in balance training similar to the StayBalanced Programme, have also been interviewed about their experiences of the training and the most frequently discussed components were dual-task exercises. These were experienced as challenging and demanding, but unlike the participants in the present study, the people with Parkinson’s disease could not see how the effect could be transferred into their everyday lives (Leavy et al., 2017).

The attendance rate in this group was high and there are probably several reasons for this. Studies have found that important facilitators and motivators for older people to continue with fall prevention exercises are support from professionals or family, social interaction (i.e. social benefits of being in a group), perceived health benefits, a supportive exercise context and having fun (Claesson, Ståhle, and Johansson, 2020; Finnegan, Bruce, and Seers, 2019; Sandlund et al., 2017).

In cognitive evaluation theory, it is known that enjoyment originating from a particular behavior may lead to maintenance or an increase in a person’s intrinsic motivation for the specific behavior (Vallerand, Deci, and Ryan, 1987). Enjoyment can also serve as a predictor of exercise adherence (White, Ransdell, Vener, and Flohr, 2005). Most of the informants emphasized how much fun they had together in the group. They often laughed and “larked about” during the training.

An important component of group training is the social aspect of being with others with the same problems and thoughts. The atmosphere in the group was described as enjoyable, supportive and encouraging. Similar experiences have been described in previous research. Older people with peripheral neuropathy participating in progressive balance training described a strong sense of camaraderie, “they were not alone,” and enjoyed coming to the training (Powell-Cope, Quigley, Besterman-Dahan, and Lind, 2014). Another study explored how older people perceived balance training. In a similar way, the participants treasured the social benefits of training in a group (Haas and Haines, 2014). In addition to the support from the group, support from the leaders is also important (Yardley et al., 2006).

Another significant factor is that the informants became aware of the possibility of using training as a treatment for better balance. This is an important insight because motivation is fundamental in training and treatment, and increases the possibility that a person continues the balance training on their own outside the study (Maltby and Day, 2001). Importantly, updated evidence has shown that regular physical activity, such as functional balance training, is effective in improving a broad range of functional outcomes in people with osteoporosis (DiPietro et al., 2018).

Research about fall prevention exercise programs has presented barriers for participation. The barriers included: practical issues (i.e. transport, effort and cost); reduced health; no interest (i.e. lazy or does not see the need); or concerns about the exercises (i.e. not able to keep up or not demanding enough) (Sandlund et al., 2017; Yardley et al., 2006). A lack of opportunities for physical activity in the community has also been found (Moschny et al., 2011). In the present study, the informants described barriers to continuing with balance training, mainly involving lack of arranged group training, and a wish for older people to be able to attend a training program such as StayBalanced clearly emerged.

The informants’ reflections about possible beneficial effects of the program, both at a societal and an individual level, are supported by the findings from El-Khoury, Cassou, Charles, and Dargent-Molina (2013) and Sherrington et al. (2019), whereby multiple component group-based exercise were found to reduce the rate of falls by at least 24% in community-dwelling older adults. This is also reflected in updated general physical activity recommendations, stating that older adults should do multicomponent physical activity that includes balance training as well as aerobic and muscle-strengthening activities as part of their weekly physical activity (DiPietro et al., 2018). It is also worth noting that the duration of most of the evidence-based exercise programs is 12 weeks or more, highlighting the importance of ongoing exercise for older adults (Sherrington et al., 2019). Despite this, there are limited opportunities in Sweden for older people to participate in ongoing challenging, secure and enjoyable balance training in a group. This emphasizes the need for future research to transfer and implement this type of research findings into clinical practice.

StayBalanced has been found to be suitable for both older adults and people with osteoporosis with balance deficits and a fear of falling (Conradsson and Halvarsson, 2019; Dohrn, Hagströmer, Hellenius, and Ståhle, 2017; Dohrn, Ståhle, and Roaldsen, 2016; Halvarsson et al., 2013; Halvarsson, Franzen, and Ståhle, 2015; Halvarsson, Oddsson, Franzen, and Ståhle, 2016; Halvarsson et al., 2011; Halvarsson, Ståhle, Halén, and Roaldsen, 2015; Roaldsen, Halvarsson, Sahlström, and Ståhle, 2014). Increased availability of this training might reduce the fall rate and even increase the quality of life for many.

Limitations

One limitation is that one of the interviewers (CH) was involved in the training of some of the informants and the other interviewer (IMD) was a test leader in the previous randomized controlled study; this could be a cause of bias. The informants could have felt uncomfortable about sharing negative thoughts about the balance training. But the opposite situation could also have arisen. They could have been more comfortable because they knew the interviewer and were relaxed about voicing their opinions. The data showed both positive and negative aspects of the program and the informants also suggested improvements, which could indicate that they felt comfortable with the interviewers. In addition, the location for the interviews was familiar to the informants, which probably contributed to a positive interview situation.

This study sample was limited to a selected population. The informants were Swedish women with osteoporosis living in an urban area who had chosen to sign up for participation in the StayBalanced training study on their own initiative, and most of them already participated in light to moderate physical activity. Therefore, it is possible that they may have been more positively disposed toward physical activity compared with a general population of the same age, with higher motivation to complete the training.

However, the informants posited the idea that the training program should be available for all older people in society. They also expressed how there is a lack of structured balance training for older adults. Therefore, in future studies we are aiming to implement this type of balance training to make it accessible for older adults.

Because all the informants were women, the results may not be transferable to how men would experience the training program. The absence of men is shared with other studies including participants with osteoporosis (Giangregorio et al., 2013). Possible explanations for this are that more women than men are diagnosed with osteoporosis (Hernlund et al., 2013), and that women have more fall-related concerns (Legters, 2002) and may, therefore, be more conscious about their balance and more interested in taking part in a balance training intervention. Women are also more likely to attend group sessions (Yardley et al., 2008). It has been suggested that older men may not be willing to admit to being afraid of falling or having balance problems (Legters, 2002).

Preunderstanding

Qualitative research creates a unique relationship between participant and researcher and the role of the researcher is important. In contrast to quantitative research, qualitative researchers attempt to interpret, understand, and describe information in a reflexive process (Wilding and Whiteford, 2005). The position and reflexivity of the qualitative researcher are of great importance at all stages of the research process (Berger, 2015). Accordingly, the researchers’ professional background and clinical experience may have affected the data collection and analytic procedures. To avoid this, the researchers maintained a constant sense of awareness about how their preconceived notions may affect the study findings both during the interviews and data analysis. Three of the authors (KSR, IMD, AH) are experienced physical therapy researchers with extensive knowledge of qualitative studies. All the authors have long clinical experience as physical therapists within different fields such as primary care setting (IMD), university hospital (AH, SG, CH) and rehabilitation facility (KSR). Four of the authors (KSR, AH, SG, CH) are experienced physical therapists specialized in neurology or elderly health. As all authors have many years of experience with clinical balance training and patients with balance issues, it is possible that preunderstanding could influence the interpretation of the data and overshadow new meanings. However, the opposite could also be true, that their preunderstanding helps the authors to comprehend nuances. Because all the authors have different backgrounds in the balance field and therefore have different preunderstanding, this could be seen as a strength for a proper analysis.

CONCLUSIONS

The StayBalanced Programme was appreciated and acceptable from the participants’ perspective and in line with their values and preferences, one of three key components of evidence-based practice. The participants felt that the increased safety and awareness achieved through the challenging and motivating training were transferred to daily life, leaving them less exposed to falls, fall injuries and fear of falling. They expressed concerns about lack of knowledge translation regarding the positive effects of structured and challenging balance training, like the StayBalanced Programme, leaving older adults and society without the benefits of evidence-based fall prevention. The results of this study may support the uptake of the evidence-based StayBalanced Programme for fall prevention in clinical practice.

Acknowledgments

The authors would like to thank all the informants in the study. The study was supported by grants through the Regional Agreement on Medical Training and Clinical Research between Stockholm County Council and Karolinska Institutet (ALF) and from the Swedish Research Council (521-2010-2483), (521-2013-255).

Disclosure Statement

The authors report no conflict of interest.

Additional information

Funding

This work was supported by the Regional Agreement on Medical Training and Clinical Research between Stockholm County Council and Karolinska Institutet (ALF) [521-2010-2483,521-2013-255].