Views, experiences and attitudes of community-living older people towards the FIT-at-Home fall prevention programme: A qualitative interview study / Sichtweisen, Erfahrungswerte und Einstellungen von sturzgefährdeten Menschen im höheren Lebensalter zum FIT-at-Home-Sturzpräventionsprogramm: Eine qualitative Interviewstudie
Publié en ligne: 18 juin 2021
Pages: 37 - 47
Reçu: 12 févr. 2021
Accepté: 07 mai 2021
DOI: https://doi.org/10.2478/ijhp-2021-0004
Mots clés
© 2021 Christian Müller et al., published by Sciendo
This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
The risk of falling among the community-living older people increases with advancing age. Each year, more than one third of older people aged ≥65 sustain a fall (Rubinstein, 2006). In this population, falls usually occur during the day in the older people's home or home surrounding, usually at times of the day when older people with risk of falling are most active (Soriano et al., 2007; Keall et al., 2008). Falls in older people are negatively associated with physical, psychological and even social impacts on people's life (Burns et al., 2016), e.g. inactivity, loss of individual autonomy, loss of confidence, fear of falling, restrictions in mobility and everyday activities and even social isolation (Davis et al., 2010; Murphy et al., 2002; Delbaere et al., 2004). Furthermore, fall-related injuries also imply a considerable financial burden on families and increase associated healthcare costs.
Falls are caused by a number of interrelated intrinsic and extrinsic fall risk factors (Lord et al., 2007). Key risk factors for falls include balance deficits, gait disorder, lower limb weakness and a history of falls (Rubenstein & Josephson, 2006; Deandrea et al., 2010). In addition, the prevalence of environmental hazards in the homes of older people increases the risk of falls through a dynamic interaction between environmental conditions and risk factors in an individual that can precipitate falls (Feldman & Chaudhury, 2008; Ambrose et al., 2013). In addition, age-related neuromuscular changes play a role (McKinnon et al., 2017), since the loss of muscle strength and motor coordination in older people increase the risk of falling. It has been shown that regular exercise can improve or maintain motor task performance even at an advanced age (Benichou & Lord, 2016). Therefore, interventions for preventing falls in older people have become an important healthcare topic (Church et al., 2012). There is increasingly strong evidence that fall prevention programmes that include muscle strength and balance exercises can significantly reduce the risk and rate of falls. Cochrane meta-analysis showed that home-based interventions which comprise balance and muscle strengthening training exercises reduced rate of falls (RaR 0.68, 95% CI 0.58–0.80) and risk of falling (RR 0.78, 95% CI 0.64–0.94) in community-living older people. Moreover, home safety assessment and home modification were also effective in reducing rate of falls (RaR 0.81, 95% CI 0.68–0.97) and risk of falling (RR 0.88, 95% CI 0.80–0.96) (Gillespie et al., 2012), especially when home modification was delivered by occupational therapists (OTs) in comparison with other health professionals.
Home-visiting programmes are often used to provide support to older people who are in poor health, have fallen multiple times in the past, are afraid of falling, avoid physical activity, have difficulty leaving their home and have limited mobility (Dorresteijn et al., 2012). It has been reported that particularly older people at risk of falling with limited mobility prefer exercising at home instead of frequenting exercise training sessions outside their homes (McInnes & Askie, 2004; Robinson et al., 2014). These home-visiting programmes are a strategy to provide a tailored approach to high-risk populations. An understanding of contextual (personal, environmental) factors that affect programme uptake as well as attitudes and experiences of older people towards fall prevention programmes is crucial when designing interventions. Prior to the uptake of a fall prevention programme, it is meaningful for participants to obtain information about the programme and its benefit, as well as adequate information about what awaits them in the programme, so they can make an informed decision about their participating (Dickinson et al., 2011; Robinson et al., 2014; Gardiner et al., 2017). Other factors that encourage older people to participate are high self-efficacy; involvement in decision-making processes; preservation of independence in everyday activities; no cost; social support from spouse, family or friends; previous programme participation; and exercises that are fun, that take into account individual abilities and that are of moderate intensity (McInnes & Askie, 2004; Bunn et al., 2008). Barriers that prevent older people from participating in a programme are physical impairments, underestimation of one's own fall risk, low expectations of improvements to one's own situation, low self-confidence, not taking into consideration their individual abilities and personality characteristics (e.g. apathy, laziness, inadequate intrinsic motivation) (McInnes & Askie, 2004; Bunn et al., 2008). Research shows that healthcare professionals should consider the experiences and views of older people to trigger their willingness to participate in fall prevention programmes (Yardley et al., 2006,; Yardley et al., 2007).
We designed a two-component intervention based on the “Lifestyle-integrated Functional strength and balance Exercise” (LiFE) intervention and “Community Aging in Place, Advancing Better Living for Elders” (CAPABLE) intervention (Clemson et al., 2010; Clemson et al., 2012; Szanton et al., 2011; Szanton et al., 2014a; Szanton et al., 2014b) comprising a physical exercise training and home modification adapted to the German healthcare setting, namely the FIT-at-Home intervention. Prior to the implementation of the FIT-at-Home intervention in the German healthcare setting, it is important to understand older people's as well as OT's views concerning the feasibility, acceptance and satisfaction with the intervention. A report of the feasibility of the intervention from the OT's perspectives is reported elsewhere (Müller et al., 2019a). In our article, we only report findings of a qualitative study that explored older people's perspectives on the intervention.
The aim of this study was to gain an understanding of older people's perceptions, experiences and attitudes towards the FIT-at-Home fall prevention programme in order to further develop the intervention.
The objectives were as follows:
To capture expectations and requests of older people regarding the intervention To identify the factors associated with the programme uptake To explore older people's perception of the physical exercise training and home modification To explore older people's perspective of barriers and facilitators to exercise To assess the benefits and expenses of the intervention
This qualitative study was a part of a feasibility study of the research project “Aging in Place” focusing on falls prevention. A descriptive qualitative research approach was applied and data were obtained by face-to-face interviews from community-living older people with risk of falling who participated in a feasibility study (Müller et al., 2019a), and data analysis was done following the qualitative content analysis (Mayring, 2010). Reporting is in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) (Tong et al., 2007).
The study targeted community-living older people in southwest Germany. The inclusion criteria were as follows: (1) aged 60 years and older, (2) independently living in their own home, (3) able to walk 5 m independently, (4) history of falls within the last 12 months, (5) having self-perceived balance problems, (6) able to understand the study requirements and (7) willingness to participate in the study. We excluded those who were (1) admitted to a hospital or another institution, (2) permanently wheelchair-dependent or bedridden, (3) unable to understand verbal instructions due to cognitive difficulties, (4) terminally ill or had unstable diseases and (5) did not give informed consent. The same aforementioned criteria were also applied in the feasibility study by Müller et al. (2019a). We worked with local OTs from the FIT-at-Home programme to promote recruitment for the interviews. Seventeen potential participants were contacted via invitation letters to participate in interviews after the intervention was completed. They received written details of the study and a phone number to call for further information or to schedule an interview.
The FIT-at-Home programme is a home-based progressive physical exercise training and home modification intervention designed to improve strength, balance and home safety. Details of the intervention development are reported elsewhere (Müller et al., 2019b). The intervention included nine sessions over 12 weeks and two aftercare follow-up sessions delivered by trained OTs. Aftercare sessions intended to support behaviour change, to maintain initial improvements and to prevent relapse according to a treatment manual (Voigt-Radloff et al., 2016).
Based on exercises principles, the lifestyle-integrated approach embedded lower-limb strength and balance exercises into daily life activities (Clemson et al., 2010; Clemson et al., 2012). Exercises were connected with daily routines to strengthen behavioural change. Exercises were individually tailored to the participant's abilities based on the LiFE Assessment Tool (Clemson et al., 2012; Clemson et al., 2014). The exercise activities were linked to daily tasks by using situational cues as prompts to action. For example, training of plantar flexion can be performed through toe raises while putting the dishes into a tall cupboard.
The underlying principle of home modification is to assess the individual's functional limitations, the demands of the environment and the evaluation of accessibility problems (Oswald et al., 2007; Iwarsson et al., 2012). The strategy is to offer solutions for home safety problems and to enhance the individual's knowledge about home safety hazards and skills about falls prevention. The OTs examined the interior and exterior of the older people's home environment according to the Housing Enabler instrument (Iwarsson et al., 2007; Iwarsson et al., 2012) to identify accessibility problems and physical environmental hazards. The OTs discussed strategies for reducing home hazards or accessibility problems with the individual and proposed recommendations for change.
All interviews were conducted face-to-face using an interview guide (Table 1). The interview guide (Patton, 2002) was designed according to the study objectives and covered predetermined topics to explore older people's experiences, attitudes and perceptions regarding the FIT-at-Home intervention. It was also used to ensure consistency across the interviews. The interview guide was piloted with two persons not involved in the study (Creswell, 2009) and refined to adequately cover the scope and context of our research objectives. All interviews were audio recorded and carried out at participants’ homes. We used the problem-centred interview method (Witzel, 2012). Each interview started with an open-ended question to bring up topics and to give respondents the opportunity to freely talk about their experiences. Probing questions were used to clarify responses and elicit supplementary information (Silverman, 2014). The interviews lasted between 30 and 55 minutes. Field notes were made after the interviews recording the context of the interview and the researcher's personal reflections. Written informed consent and socio-demographic information was obtained from all participants interviewed in-person. No incentive was provided for participation.
List of topics covered in the interview guide.
| Block A | Topic: Reasons for participation in the FIT-at-Home intervention |
| Block B | Topic: Practicability and acceptability of the home assessment and modification |
| Block C | Topic: Practicability and acceptability of the physical exercise training |
| Block D | Topic: Facilitators and barriers to the implementation of the FIT-at-Home intervention |
| Block E | Topic: Benefits and expenses of the FIT-at-Home intervention |
| Block F | Topic: Sustainability of the FIT-at-Home intervention |
| Block G | Topic: Overall satisfaction with the FIT-at-Home intervention |
The interviews were evaluated with qualitative structured content analysis method as described by Mayring (2010). A deductive-inductive analysis approach was used in order to identify themes across the data with regard to the research objectives through comparisons for similarities and differences described in categories and subcategories (Mayring, 2015). The interviews were transcribed verbatim by CM and SL using the transcription software F4, checked for accuracy by listening to the audio recording and checked against the transcript before being imported into MAXQDA® 12. Subsequently, all transcripts were re-read systematically line-by-line by CM and SL to identify the meaning units of the text that were relevant to the research objectives. A set of seven categories was initially predetermined (deductive approach) based on the interview guide, and a list of subcategories representing more specific themes evolved based on the inductive coding process (Mayring, 2015). All coding was completed by two coders (CM and SL) working independently. Meaningful units of the text were condensed, abstracted and labelled with codes within each interview (Elo & Kyngäs, 2008). Each transcript was thoroughly analysed for new meanings that emerged until there was no new code arising from the transcript. Finally, a list of themes was obtained. Credibility was enhanced through interactive discussions among the researchers (CM, SL) to clarify accurate interpretation of the data (Silverman, 2017). A co-examiner (CD) was assigned to test the intersubjective agreement of categories and subcategories to strengthen the findings of the study. Coding discrepancies were reviewed with the research team until consensus on final codes was reached.
A total of 17 older persons (7 women and 10 men) participated in the feasibility study. The mean age of individuals enrolled in the study was 72.2 years (SD = 9.18). At the end of study, 16 of 17 individuals completed the 3-month intervention period. Within 4 weeks after completing the intervention, 16 individuals were contacted by letter and requested for an interview. Ten persons refused to participate. Due to confidentiality, we do not know why they refused. Seven participants who agreed to take part in the interviews were between 60 and 78 years with a mean age of 71.3 (SD = 6.2) years, four of them being male and three female. Four interview participants lived with their spouse in a household (P1, P3, P5, P7) and three participants were widowed and lived alone (P2, P4, P6).
The analysis produced seven themes and subthemes that described different facets of older people's experiences regarding the feasibility of the FIT-at-Home intervention. The qualitative findings are presented in summaries, using illustrative excerpts with quotes in italics using a pseudonymised code.
The interviewed persons emphasise that one's own motivation, the goals and positive expectations were essential to participation. They decided to participate in the programme because they consider mobility to be beneficial for their illness: “Yes, of course I’m interested in things that help me, that are beneficial for my illness … because I must make sure I really move around a lot” (P4_L:12–14). To be mobile is the crucial goal for the participants so they are able to take an active part in life. In this context, they develop an ambition that drives them and has motivated them to participate. This ambition is to help themselves and not to be dependent on help from others. It is also the hope to improve their own mobility or at least keep it at a consistent level. For example, a participant reported: “…So I want to help myself as long as I still can, so this programme is beneficial” (P4_L:76–81).
However, the participants evaluate the programme in advance and carefully weigh the potential benefit against the possible harm. The prevailing of the potential benefit is crucial for participation. One participant mentioned: “Well, I like to try anything. I’m open to anything. Even any treatment. As long as I can say: Well, it can’t hurt. But let's see what happens” (P1_L:19–22).
In order to identify barriers, the participants were also asked under what conditions they would have turned down taking up the programme. For them, it was important that the exercises in the physical training programme were practical and not too tiring. This was connoted as follows: “If it would have been too much effort. I mean, if, say, there would have been things in it that would have been physically or even mentally exhausting, I would have said: No, that's too much for me” (P6_L:79–81). Participation would also have been out of the question if they would have been unable to perform any of the FIT-at-Home exercises, e.g. due to poor health. However, if it is possible at least to omit individual exercises that are not practical, participation is definitely conceivable, as illustrated by the following example: “The programme had some exercises that I cannot do on account of my health. But since I could just skip them, it wasn’t a problem” (P1_L:34–37).
Prior to the intervention, home safety assessments were conducted. For four individuals, home modifications were recommended by their OTs (P2, P3, P6, P4), which had been implemented for three of the participants at the time of the interview (P3, P6, P4). In the homes of the other three older people, no barriers in their homes were identified. The recommended home modifications included removing rugs (P3, P6, P4), reorganising the kitchen cabinets so that infrequently used items were placed in the upper cabinets and frequently used items in the lower cabinets (P6), raising the height of the toilet seat and placing a shower chair (P3), grab rails in the bathroom (P2), a wood railing for the stairs (P3) and a height-adjustable bed (P3). The following experiences were reported: “…Because the therapist has an eye for it. Cleaning up, not putting the chair like that, rather to the side so it's no longer in the way, or not setting the flower pot so you can get caught on it and that the path is also wide enough so if you trip, you may not hit something that has a sharp edge” (P6_L:141–148).
The participants who made modifications to their home subsequently felt safer, since they no longer needed to be so concerned with getting caught on something. However, they also make it clear that there must be a willingness to make room. As one person said: “There needn’t be a cabinet here and a cabinet there where you can trip over them and such” (P1_L:113–115).
The total duration of the programme was acceptable for all surveyed participants. None of those surveyed wished the programme had been longer or shorter. The participants also considered the intensity of the exercises reasonable. Whilst participants also reported that quick breaks were needed when repeating the exercises multiple times and they felt physical exertion, overall it was not perceived as overexertion. The participants had vastly different approaches to taking days off from the exercises. There were participants who purposely did not integrate any exercises into their daily routine on Sundays and holidays which were considered rest days for these people, whilst other participants performed the physical exercises on these days, as well: “I wasn’t overextended. I was able to space it all out” (P2_L:62). Furthermore, participants were able to increase the exercises, for example, by increasing the frequency, extending the duration or reducing the support area with consideration of safety aspects (P1, P3, P4, P5, P6, P7), and one participant was also able to add more exercises from unit to unit; however, she was unable to increase the exercises due to her state of health during the period (P2).
With guidance, the participants were able to work the exercises into everyday life and doing them was not perceived as time-consuming. The participants described how they themselves increasingly discovered everyday actions in their daily routine that they were able to combine with the exercises, as explained: “Those are all things you do standing. Where you can properly shift your weight and so on or when doing dishes or cutting vegetables. That I thought: Oh, you could try it out now. It also moved elsewhere in the flat, for example, just standing differently when brushing my teeth in the bathroom. And after I had memorised this exercise, it was easy” (P1_L:275–287).
Overall, the participants found the activity planner helpful. The participants perceived the routine checking off of the exercises to be performed each day as a reminder to perform the exercises and as a review of what they had already done. At the same time, the activity planner was used by the OTs as a means of monitoring, making the activity planner a common instrument of communication as part of the treatment: “It was perfect. If I had not been forced to write it down, I wouldn’t have done it all. And the occupational therapist always checked it. … If I don’t do it and check it off, I’m only cheating myself. I won’t do that” (P7_L:229–233).
The participants were asked what factors were conducive to performing the physical exercises and how hindering factors made it more difficult. The participants found the constructive, interpersonal relationship with their therapist to be especially important. It was also helpful when they were motivated, encouraged and praised by the therapist. One person reported that his wife supported him greatly and reminded and motivated him to perform the exercises: “These are all little things that help me, that also tell me we’ve accomplished something. (…) For me, it's the interpersonal, namely the therapist, the patient, it must fit somehow” (P6_L:341–346; 478–479). Intrinsic motivation was another aspect that was pivotal for participating in the FIT-at-Home intervention and also contributed to continuity in performing the exercises. Formulating goals was also a trigger for motivating the participants to work on the focal points of their treatment. If the participants noticed initial success and subjectively perceived improvements over time, this was perceived as a further boost to motivation: “Yes, that I stay independent, as I said. … That I can achieve what I want … That's an example of something I wasn’t able to do years ago and now I notice a bit of progress, and I’m really chuffed about it” (P6_L:65–71).
To regularly perform the exercises, it was important to the participants that the exercises were fun, but that their own safety was always ensured when performing them. One participant explained that the exercises were easy to perform because they were integrated into the daily routine and could be performed at any time without any aids or sportswear: “… That one didn’t need special training equipment. … One can actually do it anywhere. Without standing out. … So, it's not tied to any sort of conditions. One doesn’t need any sportswear (…) and I thought that was very positive” (P1_L:250–262). Some participants encountered barriers that made it difficult for them to perform the physical exercise programme, such as their own laziness, falling out of the exercise rhythm or not exercising as regularly and then it being difficult to find a regular rhythm again. However, overall health, the illness itself, how participants felt on a given day and weather sensitivity also affect the regular performance of the exercises. As stated by one participant: “Sometimes it depends on the weather for me. If it's storming, raining, and wet outside, it's much, much different for me than with this weather” (P5_L:241–243).
Overall, the participants deemed the effort whilst participating in the intervention as minimal and assessed the benefit compared to the effort as positive. A majority of participants noticed improvements in their mobility and some at least maintained their current level: “The benefit for me is that I notice I can change a bit with small things. That my awareness of tripping hazards or falling risks was increased further. (…) The effort was minimal … so, it has been very helpful to me” (P1_L:329–336).
All interviewees continued the exercises after the end of the project. However, some participants no longer performed all the exercises as prescribed in the activity planner. They selected specific exercises, and they did not always perform them with the same regularity as during the study. This was described as follows: “Yes, I’m still doing it, some of them, the exercises. The occupational therapist gave the materials to me. But I don’t need them. Everything we did I have in my head. … I like doing it. And it's good for me” (P5_L:211–217). Another participant noted: “Yes, I still do it now and then … for example walking sideways and after getting up in front of the bed, I still do that” (P3_L:370; 378–379).
All those interviewed were overall satisfied with the FIT-at-Home intervention and were able to integrate it well into their daily routine. They thought the programme was structured and did not limit them in their recreational activities, since they were always able to integrate the exercises into everyday situations when it suited them best. Another benefit was that the exercises could be done at any time. They were not required to make a separate trip to the OT's office, use exercise equipment or put on sportswear. One person said: “It's simple and structured. Basically, anyone can do it. There's something for everyone. It trains one's perception, which is very important. One can easily integrate it into one's daily routine. And that's always important. (…) I could do it whenever I wanted, and that was very convenient for me. I didn’t need to make a special trip into the city or leave the house” (P1_L:414–425).
The goal of this study was to examine the feasibility, acceptance and practicality of the FIT-at-Home intervention from the perspective of elderly people with increased risk of falling to refine the intervention and mode of delivery. The results show that the interviewed participants accepted the intervention and consider it feasible and practical. The participants considered the programme both simple and structured, which had a positive effect on the implementation of the intervention. The findings highlight the importance of simplifying exercise prescription to enhance adherence to exercise training. In particular, the physical exercises could be integrated into the daily life routine, and participants could decide themselves at what time of day the exercises could be done.
The participants took part in the intervention with the goal of improving their mobility or at least maintaining it at the same level. In future studies, a greater attention by OTs and other healthcare professionals on the meaning of mobility should be taken into account as older people at risk of falling regard mobility independence as an important theme and essential for their well-being. Furthermore, independence was also considered to be very important, particularly maintaining independence is a crucial motivator for older people's decisions to participate in a fall prevention programme. The participants weighed the potential benefit against the possible harm before deciding to participate in the programme. Similar results were also described by Yardley et al. (2006), who surveyed older people in six different European countries about benefits and barriers with respect to participation in a fall prevention programme. In our study, widowed persons living alone remarked on the importance of the preservation of independence in old age. This observation is also confirmed by Dorreststeijn et al. (2012), who concluded in their study that the willingness to participate in fall prevention programmes increases not just with age, but also when a person lives alone. The fact that the preservation of older people's independence was seen as a central issue is also described by Gardiner et al. (2017) and Robinson et al. (2014), especially independence is often considered to be more important than reducing the rate of falls or the risk of falling (Robinson et al. 2014).
Individuals in our study believed they would have decided against participating if the physical exercise programme had not been individually tailored, had been too strenuous or poor health had prevented them from performing the exercises. This is consistent with other research suggesting that older people are more willing to participate in a fall prevention programme if the exercises are adapted to their individual abilities and are of moderate intensity (Arkkukangas et al., 2017; Dickinson et al., 2011; Bunn et al., 2008; McInnes & Askie, 2004). Compared to the results of other studies, it is surprising that interviewed participants in our study were willing to accept recommendations on home modifications and, all in all, they regard the home assessments and home modifications positive. Corresponding to our study results, the systematic review by Weber et al. (2018) also shows that the LiFE exercise programme which is the physical exercise component of our FIT-at-Home intervention is described as feasible with different populations and settings. Our study also revealed that the exercises were easy to learn. All in all, the duration and intensity of the exercises were deemed acceptable and appropriate by the participants in our study, and furthermore, they found the exercises not too strenuous. As other research findings by Arkkukangas et al. (2017), Dickinson et al. (2011), Bunn et al. (2008) and McInnes & Askie (2004) confirm, participants of fall prevention programmes prefer exercises of moderate intensity and duration. In addition, it must be mentioned that some participants in our study found it difficult to perform all exercises accurately depending on their health status and their daily physical condition. The participants we interviewed reported as positively that they had the opportunity to decide for themselves when and into which everyday activity they could integrate the exercises, and similar results were also found by Weber et al. (2018) and Robinson et al. (2014). As highlighted in our study, the activity planner was considered to be a useful tool for reminding older people to self-monitor the exercises which is consistent with that reported by Yardley et al. (2006). Individual participants stated that they would not have done the exercises so regularly without an activity planner.
Factors encouraging the participants to implement the Fit-at-Home intervention are also supported by other research findings. Factors promoting the implementation include the following: (1) support from the therapist (motivates, encourages, provides reassurance when performing the exercises and understands the situation) (Arkkukangas et al., 2017; Yardley et al., 2006), (2) support from the family members (motivate, remind to perform the exercises) (Bunn et al., 2008; Yardley et al., 2006), (3) exercises which can be easy to perform and be integrated into everyday activities (Arkkukangas et al., 2017; Gardiner et al., 2017; Robinson et al., 2014; Yardley et al., 2006), (4) an activity planner as a reminder (Arkkukangas et al., 2017), (5) favourable overall conditions (no need for sportswear, exercises can be performed anywhere and no public transport required), (6) intrinsic motivations and goals as a trigger (Yardley et al., 2006) and (7) exercise success and self-perceived improvements in physical ability (Arkkukangas et al., 2017; Robinson et al., 2014; Dickinson et al., 2011). In addition to factors that motivate participants to implement the intervention, several other factors were also mentioned that prevent participants from implementing the intervention.
Factors influencing the implementation success are (1) personality characteristics (laziness and no motivation) (Bunn et al., 2008; Yardley et al., 2006; Crombie et al., 2004), (2) participant in poor overall health (medical illnesses, allergies and operations) (Dickinson et al., 2011; Yardley et al., 2006; McInnes & Askie, 2004), (3) no support from the therapist (Yardley et al., 2006) and (4) general conditions (poor weather conditions) (Akkunkangas et al., 2017). The sustainability of the FIT-at-Home intervention was confirmed by the participants in our study; however, some reduced the number of exercises or decided to continue only certain exercises or performed the exercises not with the same intensity as during the intervention period. In accordance with Robinson et al. (2014), self-efficacy and adherence can be reinforced, if continuous supervision and support by therapists is provided. Whilst many older people are aware that regular physical activity can improve health and well-being as well as increase independence in daily life, their level of physical activity is often very low (Crombie et al., 2004). Furthermore, the implementation of home-based exercise programmes on falls requires a high level of self-discipline and motivation (Robinson et al., 2014). Consequently, the delivery of an exercise programme needs to be tailored to fit individual preferences, as well as based on motivational and self-control strategies, as older people at risk of falling prefer to exercise at home. In our study, the implementation fidelity was ensured by several procedures. First, the FIT-at-Home intervention was manualised and the treatment manual was provided to all of the therapists. Second, a standardised half-day training workshop for all OTs was conducted before starting the intervention. Third, OTs ensured that participants received and understood the intervention components when applied in the real-life context. Fourth, in vivo observations were also used with the OTs as observers being present at several treatment sessions. Fifth, we monitored implementation fidelity by focusing on the older people's ability to perform exercises through activity calendars.
A specific strength of the study is the fact that we explicitly captured older people's perspectives on feasibility of the FIT-at-Home intervention in order to ensure individuals’ needs and to generate parameters that are needed to refine the intervention. Moreover, the qualitative methodology allowed us to gather views on how older people with risk of falling experienced the intervention that was not achievable from a questionnaire survey. However, the current study has some limitations that should be taken into account when interpreting the results. Member checking was not conducted to obtain participants’ feedback on the study findings for reasons of time. A further limitation is that the retrospective nature of our data collection may have hindered older people's ability to accurately recall their views towards the intervention's procedure and mode of delivery. Consequently, statements about changes in these aspects during the 3-month intervention period may be affected by memory bias. Due to our study design, the interviews only took place only once. It would be preferable to use a qualitative longitudinal study design with multiple time-series measurement, i.e. at the beginning, in the middle and at the end of the intervention to better capture the changes in older people's views in the course of study. Despite the standardised procedure of interviewing using the interview guide, it cannot be ruled out that in the context of data collection, the presumptions of the researchers and their subjectivity may also have influenced the interview process. Nevertheless, this interview study has revealed important insights into factors that may influence the implementation of the complex FIT-at-Home intervention.
The FIT-at-Home intervention comprising a balance and strength exercise training and home modification is feasible and acceptable from the perspectives of older people with increased risk of falling. Findings contribute to the body of research that examines views of and attitudes towards recommended fall prevention practices in community-living older people in Germany. According to the participants, it is worthwhile to further develop the FIT-at-Home intervention, and in the future, the refinement of intervention should target older people's needs and requests. Furthermore, the study results are also informative for OTs as well as for other healthcare practitioners, which may help them to be more informed about factors that serve as barriers and facilitators to the successful implementation of fall prevention programmes.