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Yang Y, Gao Y, An R, Wan Q. Barriers and facilitators to exercise adherence in community-dwelling older adults: A mixed-methods systematic review using the COM-B model and Theoretical Domains Framework. Int J Nurs Stud 2024; 157:104808. [PMID: 38823146 DOI: 10.1016/j.ijnurstu.2024.104808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 04/26/2024] [Accepted: 05/10/2024] [Indexed: 06/03/2024]
Abstract
BACKGROUND Although the health benefits of exercise for older adults are widely recognized, physical inactivity is still common among older adults. Further clarification of the factors affecting exercise adherence is needed to develop more effective exercise interventions in community-dwelling older adults. OBJECTIVE The purposes of this study were to identify (1) barriers and facilitators of exercise adherence in community-dwelling older adults and (2) behavior change techniques (BCTs) and implementation strategies that are potentially effective in improving adherence. METHODS A total of eight databases were searched: PubMed, Web of Science, EMBASE, CENTRAL, PsycINFO, SPORTDiscus, MEDLINE, and Scopus. Studies published from database inception to April 2023 were searched. The quality of the included studies was assessed using the Mixed Methods Appraisal Tool (MMAT). The Capabilities, Opportunities, Motivations, Behavior (COM-B) model and the Theoretical Domain Framework (TDF) were used to identify potential barriers and facilitators. The BCTs were used to identify potential intervention implementation strategies. RESULTS A total of 64 studies were included, including 30 qualitative studies, 12 randomized controlled trials, 12 mixed methods studies, 6 quantitative descriptive studies, and 5 non-randomized trials. 54 factors influencing adherence and 38 potentially effective BCTs were identified from the included studies. The 38 BCTs were further categorized into 8 areas of implementation strategies (tailored exercise program, appropriate exercise environment, multidimensional social support, monitoring and feedback, managing emotional experiences and issues, participants education, enhancing self-efficacy, and exerting participants' autonomy). CONCLUSION This study identified 54 influential factors affecting exercise adherence and identified 8 areas of intervention strategies (containing 38 BCTs). Further refinement, evaluation, and validation of these factors and strategies are needed in future studies.
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Affiliation(s)
- Yi Yang
- School of Nursing, Peking University, Beijing, China
| | - Yajing Gao
- School of Nursing, Peking University, Beijing, China
| | - Ran An
- School of Nursing, Peking University, Beijing, China
| | - Qiaoqin Wan
- School of Nursing, Peking University, Beijing, China.
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Steckhan GM, Warner LM, Fleig L. Falls prevention is more than just promoting physical health: evaluation of the group-based, out-patient prevention program 'Staying safe and active in old age - falls prevention'. Health Psychol Behav Med 2024; 12:2358915. [PMID: 38831976 PMCID: PMC11146244 DOI: 10.1080/21642850.2024.2358915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 05/14/2024] [Indexed: 06/05/2024] Open
Abstract
Introduction The aim of this study was to evaluate the German falls prevention program 'Staying safe and active in old age - falls prevention', which is already established in practice. Methods The single-arm intervention study consisted of two time points, 6 months apart, to evaluate the multifactorial falls prevention program (n = 125 at Time 2). We observed the groups and their trainers and assessed which behavior change techniques (BCTs) were used. According to our evaluation framework, changes in the following three domains were assessed: (a) fall-related variables (i.e. number of falls, fear of falling), (b) physical functioning (i.e. performance-based gait speed, coordination, self-reported leg strength, balance, as well as habitual execution of the exercises), and (c) psychosocial functioning (i.e. quality of life, activities of daily living, mobility, and loneliness). Linear mixed models were used to determine changes in each variable. Results Demonstration of behavior was the most frequently used BCT. The program showed significant benefits for fear of falling, balance, coordination, habitual execution, and loneliness over time (Cohen's d between -0.59 and 1.73). Number of falls, gait speed, coordination (dual task), activities of daily living, and quality of life were maintained (Cohen's d between -0.26 and 0.30), whereas leg strength and mobility decreased significantly at Time 2 (Cohen's d = -0.55 and -0.36). Discussion Group-based falls prevention programs may facilitate social integration among older adults and may also enhance and maintain physical functioning in old age.Trial registration: German Clinical Trials Register identifier: DRKS00012321.
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Affiliation(s)
| | | | - Lena Fleig
- MSB Medical School Berlin, Berlin, Germany
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3
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Pfledderer CD, von Klinggraeff L, Burkart S, da Silva Bandeira A, Lubans DR, Jago R, Okely AD, van Sluijs EMF, Ioannidis JPA, Thrasher JF, Li X, Beets MW. Consolidated guidance for behavioral intervention pilot and feasibility studies. Pilot Feasibility Stud 2024; 10:57. [PMID: 38582840 PMCID: PMC10998328 DOI: 10.1186/s40814-024-01485-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 03/26/2024] [Indexed: 04/08/2024] Open
Abstract
BACKGROUND In the behavioral sciences, conducting pilot and/or feasibility studies (PFS) is a key step that provides essential information used to inform the design, conduct, and implementation of a larger-scale trial. There are more than 160 published guidelines, reporting checklists, frameworks, and recommendations related to PFS. All of these publications offer some form of guidance on PFS, but many focus on one or a few topics. This makes it difficult for researchers wanting to gain a broader understanding of all the relevant and important aspects of PFS and requires them to seek out multiple sources of information, which increases the risk of missing key considerations to incorporate into their PFS. The purpose of this study was to develop a consolidated set of considerations for the design, conduct, implementation, and reporting of PFS for interventions conducted in the behavioral sciences. METHODS To develop this consolidation, we undertook a review of the published guidance on PFS in combination with expert consensus (via a Delphi study) from the authors who wrote such guidance to inform the identified considerations. A total of 161 PFS-related guidelines, checklists, frameworks, and recommendations were identified via a review of recently published behavioral intervention PFS and backward/forward citation tracking of a well-known PFS literature (e.g., CONSORT Ext. for PFS). Authors of all 161 PFS publications were invited to complete a three-round Delphi survey, which was used to guide the creation of a consolidated list of considerations to guide the design, conduct, and reporting of PFS conducted by researchers in the behavioral sciences. RESULTS A total of 496 authors were invited to take part in the three-round Delphi survey (round 1, N = 46; round 2, N = 24; round 3, N = 22). A set of twenty considerations, broadly categorized into six themes (intervention design, study design, conduct of trial, implementation of intervention, statistical analysis, and reporting) were generated from a review of the 161 PFS-related publications as well as a synthesis of feedback from the three-round Delphi process. These 20 considerations are presented alongside a supporting narrative for each consideration as well as a crosswalk of all 161 publications aligned with each consideration for further reading. CONCLUSION We leveraged expert opinion from researchers who have published PFS-related guidelines, checklists, frameworks, and recommendations on a wide range of topics and distilled this knowledge into a valuable and universal resource for researchers conducting PFS. Researchers may use these considerations alongside the previously published literature to guide decisions about all aspects of PFS, with the hope of creating and disseminating interventions with broad public health impact.
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Affiliation(s)
- Christopher D Pfledderer
- Department of Health Promotion and Behavioral Sciences, The University of Texas Health Science Center at Houston, School of Public Health in Austin, Austin, TX, 78701, USA.
- Michael and Susan Dell Center for Healthy Living, The University of Texas Health Science Center at Houston, School of Public Health in Austin, Austin, TX, 78701, USA.
| | | | - Sarah Burkart
- Arnold School of Public Health, University of South Carolina, Columbia, SC, 29205, USA
| | | | - David R Lubans
- College of Human and Social Futures, The University of Newcastle Australia, Callaghan, NSW, 2308, Australia
| | - Russell Jago
- Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, BS8 1QU, UK
| | - Anthony D Okely
- Faculty of Arts, Social Sciences and Humanities, School of Health and Society, University of Wollongong, Wollongong, NSW, 2522, Australia
| | | | - John P A Ioannidis
- Department of Medicine, Stanford University, Stanford, CA, USA
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA, USA
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
- Department of Statistics, Stanford University, Stanford, CA, USA
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, CA, USA
| | - James F Thrasher
- Arnold School of Public Health, University of South Carolina, Columbia, SC, 29205, USA
| | - Xiaoming Li
- Arnold School of Public Health, University of South Carolina, Columbia, SC, 29205, USA
| | - Michael W Beets
- Arnold School of Public Health, University of South Carolina, Columbia, SC, 29205, USA
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Dams J, Gottschalk S, Schwenk M, Nerz C, Becker C, Klenk J, Jansen CP, König HH. Budget impact analysis of a Lifestyle-integrated Functional Exercise (LiFE) program for older people in Germany: a Markov model based on data from the LiFE-is-LiFE trial. BMC Geriatr 2024; 24:186. [PMID: 38395743 PMCID: PMC10893703 DOI: 10.1186/s12877-024-04802-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 02/11/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Fall prevention is important for healthy ageing, but the economic impact of fall prevention are scarcely investigated. A recent cost-effectiveness analysis compared a group-delivered Lifestyle-integrated Functional Exercise Program (gLiFE) with an individually-delivered program (LiFE) in community-dwelling people (aged ≥ 70 years) at risk of falling. In addition, the current study aimed to analyze the budget impact of LiFE and gLiFE, compared with standard care in Germany. METHODS A Markov model was developed to reflect falls and associated care needs for community-dwelling persons over 5 years. The intervention effects of LiFE and gLiFE were shown to be equivalent in a non-inferiority trial, although the costs differed. Outpatient, inpatient, and intervention costs were assessed from a payer's perspective. The effect of parameter uncertainty was assessed in sensitivity analyses. RESULTS The budget impact due to intervention costs was €510 million for LiFE and €186 million for gLiFE. Over five years, health care expenditures were €35,008 million for those receiving standard care, €35,416 million for those receiving LiFE, and €35,091 million for persons receiving gLiFE. Thereby, LiFE and gLiFE could prevent 2700 deaths and 648,000 falls over 5 years. Parameter uncertainties in the risk of falling, uptake of an intervention offer, and in the intervention effects had a major influence; thus cost savings for LiFE and gLiFE compared with standard care could be achieved for individuals with a high risk of falling. CONCLUSIONS The results revealed that cost savings for LiFE and gLiFE compared with standard care could only be achieved for individuals at high risk of falling, with gLiFE being superior to LiFE. Future research should consider benefits and aspects of fall prevention beyond falls (e.g., physical activity, social aspects, and personal preferences of participants). TRIAL REGISTRATION The study was preregistered under underclinicaltrials.gov (identifier: NCT03462654) on 12th March 2018; https://clinicaltrials.gov/ct2/show/NCT03462654 .
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Affiliation(s)
- Judith Dams
- Department of Health Economics and Health Services Research, University Medical Center Hamburg- Eppendorf, Hamburg Center for Health Economics, Hamburg, Germany.
| | - Sophie Gottschalk
- Department of Health Economics and Health Services Research, University Medical Center Hamburg- Eppendorf, Hamburg Center for Health Economics, Hamburg, Germany
| | - Michael Schwenk
- Department of Sport Science, Human Performance Research Centre, University of Konstanz, Constance, Germany
| | - Corinna Nerz
- Department of Clinical Gerontology and Geriatric Rehabilitation, Robert Bosch Hospital, Stuttgart, Germany
| | - Clemens Becker
- Department of Clinical Gerontology and Geriatric Rehabilitation, Robert Bosch Hospital, Stuttgart, Germany
| | - Jochen Klenk
- Department of Clinical Gerontology and Geriatric Rehabilitation, Robert Bosch Hospital, Stuttgart, Germany
- Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany
- IB University of Applied Health and Social Sciences, Study Centre Stuttgart, Stuttgart, Germany
| | - Carl-Philipp Jansen
- Department of Clinical Gerontology and Geriatric Rehabilitation, Robert Bosch Hospital, Stuttgart, Germany
- Center for Geriatric Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Hans-Helmut König
- Department of Health Economics and Health Services Research, University Medical Center Hamburg- Eppendorf, Hamburg Center for Health Economics, Hamburg, Germany
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Pfledderer CD, von Klinggraeff L, Burkart S, da Silva Bandeira A, Lubans DR, Jago R, Okely AD, van Sluijs EM, Ioannidis JP, Thrasher JF, Li X, Beets MW. Expert Perspectives on Pilot and Feasibility Studies: A Delphi Study and Consolidation of Considerations for Behavioral Interventions. RESEARCH SQUARE 2023:rs.3.rs-3370077. [PMID: 38168263 PMCID: PMC10760234 DOI: 10.21203/rs.3.rs-3370077/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
Background In the behavioral sciences, conducting pilot and/or feasibility studies (PFS) is a key step that provides essential information used to inform the design, conduct, and implementation of a larger-scale trial. There are more than 160 published guidelines, reporting checklists, frameworks, and recommendations related to PFS. All of these publications offer some form of guidance on PFS, but many focus on one or a few topics. This makes it difficult for researchers wanting to gain a broader understanding of all the relevant and important aspects of PFS and requires them to seek out multiple sources of information, which increases the risk of missing key considerations to incorporate into their PFS. The purpose of this study was to develop a consolidated set of considerations for the design, conduct, implementation, and reporting of PFS for interventions conducted in the behavioral sciences. Methods To develop this consolidation, we undertook a review of the published guidance on PFS in combination with expert consensus (via a Delphi study) from the authors who wrote such guidance to inform the identified considerations. A total of 161 PFS-related guidelines, checklists, frameworks, and recommendations were identified via a review of recently published behavioral intervention PFS and backward/forward citation tracking of well-know PFS literature (e.g., CONSORT Ext. for PFS). Authors of all 161 PFS publications were invited to complete a three-round Delphi survey, which was used to guide the creation of a consolidated list of considerations to guide the design, conduct, and reporting of PFS conducted by researchers in the behavioral sciences. Results A total of 496 authors were invited to take part in the Delphi survey, 50 (10.1%) of which completed all three rounds, representing 60 (37.3%) of the 161 identified PFS-related guidelines, checklists, frameworks, and recommendations. A set of twenty considerations, broadly categorized into six themes (Intervention Design, Study Design, Conduct of Trial, Implementation of Intervention, Statistical Analysis and Reporting) were generated from a review of the 161 PFS-related publications as well as a synthesis of feedback from the three-round Delphi process. These 20 considerations are presented alongside a supporting narrative for each consideration as well as a crosswalk of all 161 publications aligned with each consideration for further reading. Conclusion We leveraged expert opinion from researchers who have published PFS-related guidelines, checklists, frameworks, and recommendations on a wide range of topics and distilled this knowledge into a valuable and universal resource for researchers conducting PFS. Researchers may use these considerations alongside the previously published literature to guide decisions about all aspects of PFS, with the hope of creating and disseminating interventions with broad public health impact.
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Affiliation(s)
| | | | - Sarah Burkart
- University of South Carolina Arnold School of Public Health
| | | | | | - Russ Jago
- University of Bristol Population Health Sciences
| | | | | | | | | | - Xiaoming Li
- University of South Carolina Arnold School of Public Health
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Endress C, Schwenk M, Werner C, Becker C, Jansen CP. [Lifestyle-integrated functional exercise for fall prevention : How and why do walking characteristics change?]. Z Gerontol Geriatr 2023; 56:464-469. [PMID: 37676321 DOI: 10.1007/s00391-023-02230-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 08/01/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND The lifestyle-integrated functional exercise (LiFE) program has been shown to increase physical activity. It remains unclear, however, how these changes translate into long vs. short walking episodes. OBJECTIVE The aim of this work was to investigate changes in short vs. long walking episodes between baseline and 6‑month follow-up and to determine which factors are associated with these changes. MATERIAL AND METHODS This was a two-arm randomized noninferiority study with 309 older adults (mean age 78.7 ± 0.3 years; 73.5% female) at risk of falling who exercised either in a group (gLiFE; n = 153) or individually (LiFE; n = 156). Walking episodes were measured using activPAL 4micro sensors: a distinction was made between walking episodes < 10s, < 20s, and > 60 s. Changes in walking episodes between baseline and 6‑month follow-up were analyzed, including calculation of effect sizes (Cohen's d). Determinants of changes in the walking episodes were analyzed using multiple regression. RESULTS The walking episodes < 10s and < 20 s showed a significant increase in both intervention groups but not for > 60 s. The overall daily walking duration and average steps per day had an influence on changes in the walking episodes between baseline and 6 months. Parameters of objective and subjective function explained a very small but significant amount of the variance. CONCLUSION The LiFE program seems to work on a behavioral rather than on a functional level. By accumulating short walking episodes, large gains in physical activity can potentially be achieved. This can be of health-promoting benefit especially for persons living in institutional settings or for those who are cautious or even anxious to undertake longer walking episodes (e.g., outdoors).
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Affiliation(s)
- Christoph Endress
- Klinik für Geriatrische Rehabilitation, Robert-Bosch-Krankenhaus, Auerbachstraße 110, 70376, Stuttgart, Deutschland
- Geriatrisches Zentrum, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Michael Schwenk
- Human Performance Research Centre, Abteilung für Sportwissenschaft, Universität Konstanz, Konstanz, Deutschland
| | - Christian Werner
- Geriatrisches Zentrum, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Clemens Becker
- Klinik für Geriatrische Rehabilitation, Robert-Bosch-Krankenhaus, Auerbachstraße 110, 70376, Stuttgart, Deutschland
- Unit Digitale Geriatrie, Geriatrisches Zentrum, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Carl-Philipp Jansen
- Klinik für Geriatrische Rehabilitation, Robert-Bosch-Krankenhaus, Auerbachstraße 110, 70376, Stuttgart, Deutschland.
- Geriatrisches Zentrum, Universitätsklinikum Heidelberg, Heidelberg, Deutschland.
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Adams M, Carrascosa L, Jansen CP, Ritter Y, Schwenk M. "Can Do" vs. "Do Do" in Older Adults: A Cross-Sectional Analysis of Sensor-Derived Physical Activity Patterns. SENSORS (BASEL, SWITZERLAND) 2023; 23:1879. [PMID: 36850476 PMCID: PMC9959454 DOI: 10.3390/s23041879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 02/02/2023] [Accepted: 02/02/2023] [Indexed: 06/18/2023]
Abstract
(1) Background: Identifying groups with a misaligned physical capacity (PC) and physical activity (PA) is potentially relevant for health promotion. Although an important health determinant, deeper knowledge of underlying walking behavior patterns in older adults is currently missing. We aim to identify specific PA signatures of misaligned groups and determine PA variables discriminating between groups. (2) Methods: In total, 294 community-dwelling older adults (≥70 years) were divided into four quadrants based on thresholds for PA (≥ or <5000 steps/day) and PC (≤ or >12 s, Timed Up and Go test). Kruskal-Wallis and effect sizes were calculated to compare quadrants' PA variables and to determine the discriminative power of PA parameters on walking duration, frequency, and intensity. (3) Results: We identified quadrant-specific PA signatures. Compared with "can do-do do", the "cannot do-do do" group performs shorter continuous and lower-intensity walks; the "can do-do not do" group takes fewer steps and walks with less intensity. The "cannot do-do not do" group presents lower values in all PA variables. "Walking duration greater or equal 3 METs" was the strongest discriminative PA variable. (4) Conclusion: We provide distinct PA signatures for four clinically different groups of older adults. Walking intensity is most useful to distinguish community-dwelling older adults, which is relevant for developing improved customized health promotion interventions.
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Affiliation(s)
- Michael Adams
- Institute of Sports and Sports Sciences, Heidelberg University, 69120 Heidelberg, Germany
| | - Lara Carrascosa
- Human Performance Research Centre, Department of Sport Science, University of Konstanz, 78464 Konstanz, Germany
| | - Carl-Philipp Jansen
- Institute of Sports and Sports Sciences, Heidelberg University, 69120 Heidelberg, Germany
- Department of Clinical Gerontology and Geriatric Rehabilitation, Robert Bosch Hospital, 70376 Stuttgart, Germany
| | - Yvonne Ritter
- Human Performance Research Centre, Department of Sport Science, University of Konstanz, 78464 Konstanz, Germany
| | - Michael Schwenk
- Institute of Sports and Sports Sciences, Heidelberg University, 69120 Heidelberg, Germany
- Human Performance Research Centre, Department of Sport Science, University of Konstanz, 78464 Konstanz, Germany
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Jansen CP, Gottschalk S, Nerz C, Labudek S, Kramer-Gmeiner F, Klenk J, Clemson L, Todd C, Dams J, König HH, Becker C, Schwenk M. Comparison of falls and cost-effectiveness of the group versus individually delivered Lifestyle-integrated Functional Exercise (LiFE) program: final results from the LiFE-is-LiFE non-inferiority trial. Age Ageing 2023; 52:6998047. [PMID: 36702515 DOI: 10.1093/ageing/afac331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND the individually delivered Lifestyle-integrated Functional Exercise (LiFE) was shown to improve physical activity (PA) and reduce fall incidence, however being rather resource-consuming due to one-to-one delivery. A potentially less resource-intensive group format (gLiFE) was developed and compared against the original program, considering higher risk of falling due to possible PA enhancement. OBJECTIVE to investigate non-inferiority in terms of PA-adjusted fall risk and cost-effectiveness of gLiFE at 12-month follow-up. DESIGN single-blinded, randomised, multi-centre non-inferiority trial. SETTING community. SUBJECTS in total, 309 adults aged 70+ years at risk of or with history of falling; n = 153 in gLiFE, n = 156 in LiFE. METHODS LiFE was delivered one-to-one at the participants' homes, gLiFE in a group. PA-adjusted fall risk was analysed using negative binomial regression to compare incidence rate ratios (IRR). Cost-effectiveness was presented by incremental cost-effectiveness ratios and cost-effectiveness acceptability curves, considering quality-adjusted life years, PA and falls as effect measures. Secondary analyses included PA (steps/day) and fall outcomes. RESULTS non-inferiority was inconclusive (IRR 0.96; 95% confidence interval, CI 0.67; 1.37); intervention costs were lower for gLiFE, but cost-effectiveness was uncertain. gLiFE participants significantly increased PA (+1,090 steps/day; 95% CI 345 and 1.835) versus insignificant increase in LiFE (+569, 95% CI -31; 1,168). Number of falls and fallers were reduced in both formats. CONCLUSION non-inferiority of gLiFE compared with LiFE was inconclusive after 12 months. Increases in PA were clinically relevant in both groups, although nearly twice as high in gLiFE. Despite lower intervention costs of gLiFE, it was not clearly superior in terms of cost-effectiveness.
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Affiliation(s)
- Carl-Philipp Jansen
- Department of Clinical Gerontology and Geriatric Rehabilitation, Robert Bosch Hospital, Stuttgart, Germany.,Institute of Sports and Sports Sciences, Heidelberg University, Heidelberg, Germany
| | - Sophie Gottschalk
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Corinna Nerz
- Department of Clinical Gerontology and Geriatric Rehabilitation, Robert Bosch Hospital, Stuttgart, Germany
| | - Sarah Labudek
- Network Aging Research, Heidelberg University, Heidelberg, Germany
| | | | - Jochen Klenk
- Department of Clinical Gerontology and Geriatric Rehabilitation, Robert Bosch Hospital, Stuttgart, Germany.,Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany.,IB University of Health and Social Sciences, Study Centre Stuttgart, Stuttgart, Germany
| | - Lindy Clemson
- Faculty of Health Sciences, University of Sydney, Sydney, Australia
| | - Chris Todd
- School of Health Sciences, Faculty of Biology, Medicine & Health, The University of Manchester, Manchester M13 9PL, UK.,Manchester University NHS Foundation Trust, Manchester, UK.,Manchester Academic Health Science Centre, Manchester, UK
| | - Judith Dams
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hans-Helmut König
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Clemens Becker
- Department of Clinical Gerontology and Geriatric Rehabilitation, Robert Bosch Hospital, Stuttgart, Germany
| | - Michael Schwenk
- Network Aging Research, Heidelberg University, Heidelberg, Germany.,Human Performance Research Centre, Department of Sport Science, University of Konstanz, Konstanz, Germany
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Gottschalk S, König HH, Schwenk M, Nerz C, Becker C, Klenk J, Jansen CP, Dams J. Willingness to pay for a group and an individual version of the Lifestyle-integrated Functional Exercise program from a participant perspective. BMC Public Health 2022; 22:1934. [PMID: 36258179 PMCID: PMC9580107 DOI: 10.1186/s12889-022-14322-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 09/23/2022] [Accepted: 10/05/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Perceived benefits of intervention programs from a participant perspective can be examined by assessing their willingness to pay (WTP). Aiming to support decision-makers in their decision to implement a fall prevention program, this study examined (1) the WTP for a group-based and an individually delivered fall prevention program, (2) which factors influence WTP, and (3) whether the WTP exceeds the intervention costs. METHODS WTP was elicited using Payment Cards from 237 individuals who participated in a randomized non-inferiority trial (LiFE-is-LiFE) comparing a group version of the Lifestyle-integrated Functional Exercise program (gLiFE) with the individually delivered version (LiFE). Linear regression models were used to examine factors associated with WTP. The net benefit for (g)LiFE was calculated as the difference between WTP and intervention costs, assuming different scenarios of intervention costs (varying group sizes of gLiFE) and hypothetical subsidy levels by a payer (€0, €50, or €75). RESULTS The mean WTP was €196 (95% CI [172, 221]) for gLiFE and €228 (95% CI [204, 251]) for LiFE. In the linear regression model, WTP was significantly associated with delivery format (-€32, 95% CI [- 65, - 0.2], for gLiFE) and net household income (+ 68€, 95% CI [23, 113], for ≥€3000 compared to <€2000). The net benefit for gLiFE was positive in most cases. Due to higher intervention costs of LiFE compared to gLiFE (€298 vs. €113), the net benefit for LiFE was negative for the majority of the sample, even at a subsidy of €75. CONCLUSION The results provide insight into how valuable the interventions are perceived by the participants and thereby may be used by decision-makers as complement to cost-effectiveness analyses. WTP for both programs was generally high, probably indicating that participants perceived the intervention as quite valuable. However, further research is needed on the WTP and net benefit of fall prevention programs, as results relied on the specific context of the LiFE-is-LiFE trial.
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Affiliation(s)
- Sophie Gottschalk
- Department of Health Economics and Health Services Research, Hamburg Center for Health Economics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Hans-Helmut König
- Department of Health Economics and Health Services Research, Hamburg Center for Health Economics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Schwenk
- Network Aging Research, Heidelberg University, Heidelberg, Germany.,Human Performance Research Centre, Department of Sport Science, University of Konstanz, Konstanz, Germany
| | - Corinna Nerz
- Department of Clinical Gerontology and Geriatric Rehabilitation, Robert Bosch Hospital, Stuttgart, Germany
| | - Clemens Becker
- Department of Clinical Gerontology and Geriatric Rehabilitation, Robert Bosch Hospital, Stuttgart, Germany
| | - Jochen Klenk
- Department of Clinical Gerontology and Geriatric Rehabilitation, Robert Bosch Hospital, Stuttgart, Germany.,Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany.,IB University of Applied Health and Social Sciences, Study Centre Stuttgart, Stuttgart, Germany
| | - Carl-Philipp Jansen
- Department of Clinical Gerontology and Geriatric Rehabilitation, Robert Bosch Hospital, Stuttgart, Germany.,Institute of Sports and Sports Sciences, Heidelberg University, Heidelberg, Germany
| | - Judith Dams
- Department of Health Economics and Health Services Research, Hamburg Center for Health Economics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Nerz C, Kramer-Gmeiner F, Jansen CP, Labudek S, Klenk J, Becker C, Schwenk M. Group-Based and Individually Delivered LiFE: Content Evaluation and Predictors of Training Response – A Dose-Response Analysis. Clin Interv Aging 2022; 17:637-652. [PMID: 35509348 PMCID: PMC9057901 DOI: 10.2147/cia.s359150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 03/12/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Material and Methods Results Discussion and Conclusion Trial Registration
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Affiliation(s)
- Corinna Nerz
- Department for Clinical Gerontology, Robert-Bosch-Hospital, Stuttgart, Germany
- Correspondence: Corinna Nerz, Department for Clinical Gerontology, Robert-Bosch-Hospital, Auerbachstr. 110, Stuttgart, 70376, Germany, Tel +49 711-81010 6070, Fax +49 711 8101 3194, Email
| | | | - Carl-Philipp Jansen
- Department for Clinical Gerontology, Robert-Bosch-Hospital, Stuttgart, Germany
- Institute of Sports and Sports Sciences, Heidelberg University, Heidelberg, Germany
| | - Sarah Labudek
- Network Aging Research (NAR), Heidelberg University, Heidelberg, Germany
| | - Jochen Klenk
- Department for Clinical Gerontology, Robert-Bosch-Hospital, Stuttgart, Germany
- Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany
- IB University of Health and Social Sciences, Study Centre Stuttgart, Stuttgart, Germany
| | - Clemens Becker
- Department for Clinical Gerontology, Robert-Bosch-Hospital, Stuttgart, Germany
- Unit Digitale Geriatrie, Medical Faculty of the University Heidelberg, Heidelberg, Germany
| | - Michael Schwenk
- Network Aging Research (NAR), Heidelberg University, Heidelberg, Germany
- Human Performance Research Centre, Department of Sport Science, University of Konstanz, Konstanz, Germany
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Associations Between Planned Exercise, Walking, Incidental Physical Activity, and Habit Strength in Older People: A Cross-Sectional Study. J Aging Phys Act 2021; 30:813-823. [PMID: 34929661 DOI: 10.1123/japa.2021-0284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 11/22/2021] [Accepted: 11/23/2021] [Indexed: 11/18/2022]
Abstract
Habits play an important role in physical activity (PA) engagement; however, these associations in older people are not well understood. The present study aimed to investigate the relationship between engagement in types of PA and their automaticity in older people, using an observational, cross-sectional design. Current hours engaged in planned exercise (excluding walking), planned walking, and incidental activities and the automaticity of those PA behaviors were measured in 127 community-dwelling Australians aged 65 years and older via an online questionnaire. After controlling for demographic and health factors (age, gender, education level, body mass index, history of falls, and anxiety and depression symptoms), higher automaticity scores were associated with more hours undertaking planned walking and incidental activity but not planned exercise. Although preliminary, these findings indicate that the role of habit in maintaining PA in older people may, therefore, differ depending on the type of activity.
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The Lifestyle-integrated Functional Exercise (LiFE) program and its modifications: a narrative review. GERMAN JOURNAL OF EXERCISE AND SPORT RESEARCH 2021. [DOI: 10.1007/s12662-021-00770-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
AbstractLifestyle-integrated exercise is a promising approach to increase adherence levels of older adults compared to structured exercise programs as it saves time and effort and supports older adults in preventing falls and functional decline. The Lifestyle-integrated Functional Exercise (LiFE) program embodies this approach by integrating physical activity, balance, and strength activities into daily tasks of community-dwelling older adults aged 70+. A randomized controlled trial shows strong effectiveness of the original, resource-intensive one-on-one format of the LiFE program in terms of reducing falls, improving motor performance, and increasing physical activity. The positive effects of the original LiFE program have yet stimulated adaptions to group-based and information and communications technology-based formats, to younger seniors, for multicomponent interventions, and to populations with disabilities which resulted in 16 known studies about LiFE modifications. Evidence for the effectiveness of specific LiFE modifications exists for four programs, while seven adaptions are in the feasibility stage and one is still in the early development phase. A decade of existing LiFE research is summarized in this narrative review that, to the best of our knowledge, does not exist until now. The aim of this article is (1) to provide an overview of the number of LiFE modifications and their specifications, (2) to describe the current evidence regarding feasibility and effectiveness, and (3) to present challenges and potential of the different LiFE modifications. All adaptions of the LiFE program embody the benefits of the lifestyle-integrated approach and enable an enhancement of the successful LiFE concept.
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Gottschalk S, König HH, Schwenk M, Nerz C, Becker C, Klenk J, Jansen CP, Dams J. Cost-Effectiveness of a Group vs Individually Delivered Exercise Program in Community-Dwelling Persons Aged ≥70 Years. J Am Med Dir Assoc 2021; 23:736-742.e6. [PMID: 34626579 DOI: 10.1016/j.jamda.2021.08.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 08/26/2021] [Accepted: 08/30/2021] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Interventions aimed at reducing falls and physical inactivity could alleviate the economic burden attributable to these factors. The study aimed to analyze the cost-effectiveness of a group-delivered version of the Lifestyle-integrated Functional Exercise Program compared with an individually delivered program version. DESIGN An economic evaluation conducted alongside the LiFE-is-LiFE randomized non-inferiority trial. INTERVENTIONS Group and individually delivered version of a program consisting of strength and balance exercises integrated into everyday activities to prevent falls. SETTING AND PARTICIPANTS 309 community-dwelling older adults (aged ≥70 years) at risk of falling recruited around Heidelberg and Stuttgart (Germany). METHODS Cost-effectiveness of the group program was assessed over 6 months using different effect measures [quality-adjusted life years (QALYs, EQ-5D-5L), physical activity (mean number of steps/day), and falls] and cost perspectives (societal and payer's). Incremental cost-effectiveness ratios were determined, and cost-effectiveness acceptability curves were constructed. RESULTS From a societal perspective, mean costs, the number of falls, and the number of steps/day were somewhat higher in the group program, whereas QALYs were almost identical between the 2 interventions. From the payer's perspective, the incremental cost-effectiveness ratio for the group compared to the individual program were €56,733 per QALY and €4755 per fall prevented. Based on the cost-effectiveness acceptability curves, the cost-effectiveness of the group program had to be rated as uncertain for both effect measures and perspectives. In contrast, it demonstrated cost-effectiveness for increasing physical activity at willingness-to-pay values per additional 1000 steps/day of €1600 (societal perspective) or €600 (payer's perspective). CONCLUSIONS AND IMPLICATIONS Compared to the individual program, the group program might be cost-effective for increasing physical activity in older adults but was unlikely to be cost-effective with regard to QALY or for preventing falls. The cost-effectiveness should be evaluated long-term and compared to a regular care group.
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Affiliation(s)
- Sophie Gottschalk
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Hamburg Center for Health Economics, Hamburg, Germany.
| | - Hans-Helmut König
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Hamburg Center for Health Economics, Hamburg, Germany
| | - Michael Schwenk
- Network Aging Research, Heidelberg University, Heidelberg, Germany
| | - Corinna Nerz
- Department of Clinical Gerontology and Geriatric Rehabilitation, Robert Bosch Hospital, Stuttgart, Germany
| | - Clemens Becker
- Department of Clinical Gerontology and Geriatric Rehabilitation, Robert Bosch Hospital, Stuttgart, Germany
| | - Jochen Klenk
- Department of Clinical Gerontology and Geriatric Rehabilitation, Robert Bosch Hospital, Stuttgart, Germany; Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany; IB University of Applied Health and Social Sciences, Study Centre Stuttgart, Stuttgart, Germany
| | - Carl-Philipp Jansen
- Network Aging Research, Heidelberg University, Heidelberg, Germany; Department of Clinical Gerontology and Geriatric Rehabilitation, Robert Bosch Hospital, Stuttgart, Germany
| | - Judith Dams
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Hamburg Center for Health Economics, Hamburg, Germany
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Jansen CP, Nerz C, Labudek S, Gottschalk S, Kramer-Gmeiner F, Klenk J, Dams J, König HH, Clemson L, Becker C, Schwenk M. Lifestyle-integrated functional exercise to prevent falls and promote physical activity: Results from the LiFE-is-LiFE randomized non-inferiority trial. Int J Behav Nutr Phys Act 2021; 18:115. [PMID: 34479573 PMCID: PMC8414469 DOI: 10.1186/s12966-021-01190-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 08/23/2021] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND The 'Lifestyle-integrated Functional Exercise' (LiFE) program successfully reduced risk of falling via improvements in balance and strength, additionally increasing physical activity (PA) in older adults. Generally being delivered in an individual one-to-one format, downsides of LiFE are considerable human resources and costs which hamper large scale implementability. To address this, a group format (gLiFE) was developed and analyzed for its non-inferiority compared to LiFE in reducing activity-adjusted fall incidence and intervention costs. In addition, PA and further secondary outcomes were evaluated. METHODS Older adults (70 + years) at risk of falling were included in this multi-center, single-blinded, randomized non-inferiority trial. Balance and strength activities and means to enhance PA were delivered in seven intervention sessions, either in a group (gLiFE) or individually at the participant's home (LiFE), followed by two "booster" phone calls. Negative binomial regression was used to analyze non-inferiority of gLiFE compared to LiFE at 6-month follow-up; interventions costs were compared descriptively; secondary outcomes were analyzed using generalized linear models. Analyses were carried out per protocol and intention-to-treat. RESULTS Three hundred nine persons were randomized into gLiFE (n = 153) and LiFE (n = 156). Non-inferiority of the incidence rate ratio of gLiFE was inconclusive after 6 months according to per protocol (mean = 1.27; 95% CI: 0.80; 2.03) and intention-to-treat analysis (mean = 1.18; 95% CI: 0.75; 1.84). Intervention costs were lower for gLiFE compared to LiFE (-€121 under study conditions; -€212€ under "real world" assumption). Falls were reduced between baseline and follow-up in both groups (gLiFE: -37%; LiFE: -55%); increases in PA were significantly higher in gLiFE (+ 880 steps; 95% CI 252; 1,509). Differences in other secondary outcomes were insignificant. CONCLUSIONS Although non-inferiority of gLiFE was inconclusive, gLiFE constitutes a less costly alternative to LiFE and it comes with a significantly larger enhancement of daily PA. The fact that no significant differences were found in any secondary outcome underlines that gLiFE addresses functional outcomes to a comparable degree as LiFE. Advantages of both formats should be evaluated in the light of individual needs and preferences before recommending either format. TRIAL REGISTRATION The study was preregistered under clinicaltrials.gov (identifier: NCT03462654 ) on March 12th 2018.
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Affiliation(s)
- Carl-Philipp Jansen
- Network Aging Research, Heidelberg University, Bergheimer Strasse 20, 69115 Heidelberg, Germany
- Department of Clinical Gerontology and Geriatric Rehabilitation, Robert Bosch Hospital, Stuttgart, Germany
| | - Corinna Nerz
- Department of Clinical Gerontology and Geriatric Rehabilitation, Robert Bosch Hospital, Stuttgart, Germany
| | - Sarah Labudek
- Network Aging Research, Heidelberg University, Bergheimer Strasse 20, 69115 Heidelberg, Germany
| | - Sophie Gottschalk
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Jochen Klenk
- Department of Clinical Gerontology and Geriatric Rehabilitation, Robert Bosch Hospital, Stuttgart, Germany
- Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany
- IB University of Health and Social Sciences, Study Centre Stuttgart, Stuttgart, Germany
| | - Judith Dams
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hans-Helmut König
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lindy Clemson
- Faculty of Health Sciences, University of Sydney, Sydney, Australia
| | - Clemens Becker
- Department of Clinical Gerontology and Geriatric Rehabilitation, Robert Bosch Hospital, Stuttgart, Germany
| | - Michael Schwenk
- Network Aging Research, Heidelberg University, Bergheimer Strasse 20, 69115 Heidelberg, Germany
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Reicherzer L, Kramer-Gmeiner F, Labudek S, Jansen CP, Nerz C, Nystrand MJ, Becker C, Clemson L, Schwenk M. Group or individual lifestyle-integrated functional exercise (LiFE)? A qualitative analysis of acceptability. BMC Geriatr 2021; 21:93. [PMID: 33522904 PMCID: PMC7852079 DOI: 10.1186/s12877-020-01991-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 12/29/2020] [Indexed: 11/14/2022] Open
Abstract
Background The Lifestyle-integrated Functional Exercise (LiFE) program is an effective but resource-intensive fall prevention program delivered one-to-one in participants’ homes. A recently developed group-based LiFE (gLiFE) could enhance large-scale implementability and decrease resource intensity. The aim of this qualitative focus group study is to compare participants’ experiences regarding acceptability of gLiFE vs LiFE. Methods Programs were delivered in seven group sessions (gLiFE) or seven individual home visits (LiFE) within a multi-center, randomized non-inferiority trial. Four structured focus group discussions (90–100 min duration; one per format and study site) on content, structure, and subjective effects of gLiFE and LiFE were conducted. Qualitative content analysis using the method of inductive category formation by Mayring was applied for data analysis. Coding was managed using NVivo. Results In both formats, participants (N = 30, 22 women, ngLiFE = 15, nLiFE = 15, mean age 78.8 ± 6.6 years) were positive about content, structure, and support received by trainers. Participants reflected on advantages of both formats: the social aspects of learning the program in a peer group (gLiFE), and benefits of learning the program at home (LiFE). In gLiFE, some difficulties with the implementation of activities were reported. In both formats, the majority of participants reported positive outcomes and successful implementation of new movement habits. Conclusion This is the first study to examine participants’ views on and experiences with gLiFE and LiFE, revealing strengths and limitations of both formats that can be used for program refinement. Both formats were highly acceptable to participants, suggesting that gLiFE may have similar potential to be adopted by adults aged 70 years and older compared to LiFE. Trial registration ClinicalTrials.gov, NCT03462654. Registered on March 12, 2018. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-020-01991-0.
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Affiliation(s)
- Leah Reicherzer
- School of Public Health and Community Medicine, University of Gothenburg, Gothenburg, Sweden
| | | | - Sarah Labudek
- Network Aging Research (NAR), Heidelberg University, Heidelberg, Germany
| | | | - Corinna Nerz
- Department of Clinical Gerontology and Geriatric Rehabilitation, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Malin J Nystrand
- School of Public Health and Community Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Clemens Becker
- Department of Clinical Gerontology and Geriatric Rehabilitation, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Lindy Clemson
- Faculty of Medicine and Health Sciences, University of Sydney, Sydney, Australia
| | - Michael Schwenk
- Network Aging Research (NAR), Heidelberg University, Heidelberg, Germany.
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Steckhan GMA, Fleig L, Schwarzer R, Warner LM. Perceived Physical Functioning and Gait Speed as Mediators in the Association Between Fear of Falling and Quality of Life in Old Age. J Appl Gerontol 2020; 41:421-429. [PMID: 33305984 DOI: 10.1177/0733464820979188] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Preserving Quality of Life (QoL) in old age gains in importance, but Fear of Falling (FoF) considerably limits QoL. The aim of our study was to understand how physical mediators may translate FoF to QoL. At Time 1, FoF, subjective leg strength, balance, QoL, and objective gait speed were assessed. QoL was reassessed after 6 months, at Time 2 (n = 125). A sequential mediation analysis examined whether the relationship between FoF and QoL could be mediated by leg strength, balance, and gait speed. FoF was directly associated with QoL (β = -.27; 95% CI [-0.007, -0.001]) as well as indirectly via leg strength, balance, and gait speed (specific sequential indirect effect: β = -.03; 95% CI [-0.06, -0.001]; R2 = .40 in QoL; controlled for age, QoL at Time 1). An intervention approach could be to address FoF and foster physical functioning and gait speed to maintain QoL.
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Affiliation(s)
| | | | - Ralf Schwarzer
- Freie Universität Berlin, Germany.,SWPS University of Social Sciences and Humanities, Warsaw, Poland
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