Optimizing and Implementing a Community-Based Group Fall Prevention Program: A Mixed Methods Study

3.3.1. Recruiting and Motivating Older Adults to Participate

To optimally benefit from the FPP, it is important that the target group consists of community-dwelling older adults with a fall history or fear of falling. This is the group that is intrinsically motivated to participate in the program:

“The people who most recognize themselves in things are the people who have had a fall once or twice and very often they say: they didn’t know how that happened, but are still a bit in that shock of: oh, I fell and I have to do something with it. And I think that group is the best to train with.”

[therapist]

Although most eligible participants already experienced a fall, therapists describe that the participants of the In Balance FPP should not be too vulnerable. The appropriate target group can be identified using screening tools that focus on frailty status and fall risk. These screening tools are not generally available yet, but therapists noticed that there is a need for them.

Trial participants in the current study, but also participants who follow the In Balance FPP outside this research, were mostly well-educated older adults with a higher socioeconomic status and without a migration background. Therefore, according to the therapists, most FPP participants are not a reflection of society. To have a more representative group of participants, recruitment should be carried out using a personal approach in the local environment of potential participants: for example, via health professionals, at community centres, or via local newspapers. When recruiting, the social element and the person-centred approach of the program are important to focus on. Also, positive labelling is helpful for recruitment: for example, not using the term ‘fall prevention’ but ‘remaining your balance’ and using language at the ECRL-B1 level to enhance clarity.

3.3.2. Structure and Content of the Program

Overall, FPP participants, therapists and stakeholders were positive about the structure and content of the FPP. Positive aspects were the combination of education and exercises, interdisciplinarity, having the same therapist(s) during the program, and a tailor-made approach:

“Everyone could do the exercises on their own occasion, at their own pace. I quite liked that.”

[older male participant]

However, several barriers were mentioned. With respect to content, the high number of training sessions was mentioned as a barrier for FPP participants to participate, according to therapists and stakeholders. Second, some FPP participants noticed that more attention should be focused on the mental component after a fall: for example, when fear of falling increases. Such fears may negatively affect self-confidence, and they could be more thoroughly addressed. Furthermore, exercises should focus more on activities of daily living and real situations in practice, and there could be more variations in exercises according to therapists:

“I notice that I think it’s too bad that: okay, we are practicing this now, but what is it good for in everyday life. Or people, for example, are afraid to ride a bicycle or do certain activities and I also miss the link with that.”

[therapist]

With respect to structure, a consistent and continuous schedule of training sessions is important. Therapists noticed that it is confusing when in the first four weeks, there is one training session per week while the last ten weeks include two training sessions per week. Some therapists mentioned that the number of information meetings is too high. There should also be a regular start of the program, for example, every three months, so potential participants do not have to wait too long before the program starts:

“You lose a lot of people because for In Balance, you can’t enroll during the course. Then you have organized one and then people have to wait a long time if they are just too late, so that you lose a lot of people again. So actually, you would like some continuity really just every 2 weeks, month, whatever, something somewhere.”

[stakeholder, working at a municipality]

3.3.3. Awareness, Confidence and Physical Effects

A crucial factor for adherence is that FPP participants perceive some degree of training effects. Specific effects that were addressed are more self-consciousness: physical effects, such as balance and strength, and mental effects.

Awareness of fall risk in daily life activities was important according to participants, therapists and stakeholders. Awareness can affect multiple domains: for example, the physical domain, such as being aware of the manner of moving and walking and being aware of one’s own body, strength and posture. But it is also important to be more aware and pay more attention to what someone is doing (e.g., walking the stairs), or that someone is not able to do things as fast as before, and regarding one’s own fall risk and physical activity (e.g., do not walk or do daily tasks in a hurry, but pay attention to it, and plan actions). Moreover, FPP participants also noticed their increased awareness of the environment: for example, making adaptations within and outside of the house and being more attentive to the surroundings:

“I was even picking things up off the floor in someone else’s house at one point. That is not the intention either, but you’re much more aware of: that can be dangerous.”

[female participant]

FPP participants felt that they had a better physical condition and increased balance and strength, and most participants indicated that they increased their physical activity level after following the FPP. Some FPP participants continued their exercises after the program: for example, standing on their toes when making coffee or brushing their teeth:

“And I enjoyed doing it, but it actually pushed me to exercise a bit more. I am not the natural gym rat. And this has pushed me to become more of one now and I’m in better shape in that regard.”

[male participant]

Self-perceived confidence increased and fear of falling decreased due to the program:

“Also when it was a bit slippery and normally you would think like I’m going to be very careful again and now you think I just have to do it like I learned it, that you think, you know, actually it’s going fine.”

[female participant]

3.3.4. Training with Peers

Sharing experiences with peers and learning from each other were perceived as helpful for adherence and wellbeing. FPP participants and therapists indicated that there is a lot of personal attention and participants are willing to help each other. In most groups, social interaction is supported by drinking a cup of coffee together after the training session. Team spirit and its social component were important and provided motivation to come to the training sessions:

“And I also had a very positive experience. All the things we did. I really liked it and I made some friends, proper lasting friends.”

[female participant]

The therapist played an important role in creating group cohesion and maintaining a good atmosphere. This makes the program more enjoyable and increases adherence. Some FPP participants and therapists mentioned that after the program finished, the group kept seeing each other:

“I think you suddenly come to the conclusion that you’re 80 years old and within a week so to speak, I almost make new friends.”

[female participant]

Although some of the training sessions took place during a period of COVID-19 with restrictions, the COVID-19 situation did not have noteworthy consequences for the FPP participants.

3.3.5. Funding and Costs

Stakeholders and therapists indicated that paying a contribution increased the motivation and commitment to keep participating in the program. Adherence benefits most from paying for the whole program rather than paying per attended session. However, paying a contribution should not be a barrier to participating in the program. Therefore, it is important that the contribution is not too high so that it remains affordable:

“We ask for a contribution of 10 euros for the course, which is very little, but is still a difference compared to nothing and we do not want to make a distinction in contributions.”

[stakeholder, innovation and development wellbeing organisation]

A feasible individual contribution for FPP participants should be between EUR 45 and 150 for the complete program according to FPP participants, therapists and stakeholders. The funding differed per municipality where the program was provided, and the contributions also differed between locations. As municipalities are responsible for the funding of local FPPs in the Netherlands, the manner and amount differ between locations. It would be better, according to the FPP participants and therapists, to harmonize their own contributions across the country so that their own financial contributions do not differ between locations.

Also, healthcare insurance companies sometimes financially contributed to the program: for example, when there was an underlying medical condition. It should be made more clear which insurance company contributes which amount of money for FPPs.

3.3.6. Long-Term Continuation

There was little offer in sports or follow-up programs after finishing the 14-week FPP. If there were any, it was locally arranged, and the offer differed per location. There was also a need for the continuation of exercising with the same group as in the FPP:

“I’ve also had it happen that a dining club was found after the program, where they kept seeing each other. That’s fun too. And this time there was a whole group that wanted to continue training together.”

[therapist]

Securing and trying to pursue a regular start of the In Balance program was suggested:

“Otherwise, the assurance is of course that you can offer the program regularly so that people also know that: oh yes, you can do that every autumn or every spring and that you know that, with the partners involved: this is a continuous offer here. Just a basic facility that we want to realize.”

[stakeholder, innovation and development wellbeing organisation]

FPP participants noticed that booster sessions should be organized to refresh the information and exercises of the program and determine if more follow-up actions are needed for the FPP participants.