Health behaviour change theory meets falls prevention- Feasibility of a habit-based balance and strength exercise intervention for older adults

Health behaviour change theory meets falls prevention: Feasibility of ahabit-based balance and strength exercise intervention for older adults Lena Fleiga,b,c,*, Megan M.. Therefore, we

Health behaviour change theory meets falls prevention: Feasibility of a

habit-based balance and strength exercise intervention for older

adults

Lena Fleiga,b,c,*, Megan M McAllistera,b, Peggy Chena,b, Julie Iversond, Kate Milnee,

a Centre for Hip Health and Mobility, Vancouver, Canada

b Department of Family Practice, The University of British Columbia, Vancouver, Canada

c Health Psychology, Freie Universit€at Berlin, Berlin, Germany

d Parks & Recreation Vancouver, Vancouver, Canada

e Cardea Health Consulting, Vancouver, Canada

f Faculty of Health Sciences, The University of Sydney, Sydney, Australia

a r t i c l e i n f o

Article history:

Received 20 May 2015

Received in revised form

30 June 2015

Accepted 1 July 2015

Available online 17 July 2015

Keywords:

Habit formation

Balance and strength exercises

Older adults

Falls prevention

Mixed methods

Feasibility

a b s t r a c t

Objectives: Habit formation is a proposed mechanism for behaviour maintenance Very few falls pre-vention studies have adopted this as an interpre-vention framework and outcome Therefore, we tested feasibility of a theory-based behaviour change intervention that encouraged women to embed balance and strength exercises into daily life routines (e.g., eating, self-care routines)

Design: The EASY LiFE study was a mixed-methods, 4-month feasibility intervention that included seven group-based sessions and two telephone calls

Main outcome measures: We obtained performance-based (i.e., Short-Physical-Performance-Battery) and psychological self-report measures (i.e., intention, self-efficacy, planning, action control, habit strength, quality of life) from 13 women at baseline (T1) and 4-month follow-up (T2) We applied the Framework-Method to post-intervention, semi-structured interviews to evaluate program content and delivery Results: In total, 10 of 13 women completed the program (Mage¼ 66.23, SD ¼ 3.98) and showed changes

in their level of action control [mean differenceT1T2¼ 1.7, 95% CI (2.2 to 0.8)], action planning [mean differenceT1T2¼ 0.8, 95% CI (1.1 to 0.2)], automaticity [mean differenceT1T2¼ 2.5, 95% CI (3.7

to 1.2)], and exercise identity [mean differenceT1T2¼ 2.0, 95% CI (3.2 to 0.8)] Based on the Theoretical Domains Framework we identified knowledge, behavioural regulation, and social factors as important themes For program delivery, dominant themes were engagement, session facilitators and group format

Conclusion: The theory-based framework showed feasibility for promoting lifestyle integrated balance and strength exercise habits Using activity and object-based cues may be particularly effective in generating action and automaticity

© 2015 Elsevier Ltd All rights reserved

Introduction

Health behaviours, such as regular physical activity, are well

known to positively affect the health of individuals (Warburton,

Nicol, & Bredin, 2006) There are several evidence-based

guide-lines for regular physical activity across the lifespan that include a

number of recommended components; aerobic, muscle-strengthening, flexibility, and balance exercises (Nelson et al.,

2007) In particular, for older adults, balance and strength training programs are an effective way to reduce the risk of falling (Sherrington, Tiedemann, Fairhall, Close,& Lord, 2011), maintain mobility and retain autonomy However despite substantial knowledge regarding the benefits of regular physical activity, many older adults are not meeting the guidelines for physical activity (Ashe, Miller, Eng,& Noreau, 2009) Importantly even fewer older adults partake of recommended balance and/or strength regimens

on a regular basis (Kraschnewski et al., 2014; Vezina, DerAnanian,

* Corresponding author Department of Family Practice, University of British

Columbia, Centre for Hip Health and Mobility, 6F e 2635 Laurel St., Vancouver, V5Z

1M9, Canada Tel.: þ1 604 675 2574; fax: þ1 604 675 2576.

E-mail address: lena.fleig@fu-berlin.de (L Fleig).

Contents lists available atScienceDirect Psychology of Sport and Exercise

j o u r n a l h o m e p a g e : w w w e l s e v i e r c o m / l o c a t e / p s y c h s p o r t

http://dx.doi.org/10.1016/j.psychsport.2015.07.002

1469-0292/© 2015 Elsevier Ltd All rights reserved.

Psychology of Sport and Exercise 22 (2016) 114e122

Greenberg,& Kurka, 2014) Therefore, comprehensive yet feasible,

effective programs need to be developed to increase the uptake

Strategies to sustain participation over the longer term also need to

be devised if these programs are to benefit older adult health (e.g.,

improve quality of life, prevent falls etc.)

New pathways to physical activity promotion among older adults: is

less the key to more?

One promising pathway to promote the uptake and maintenance

of physical activity among older adults is to embed activities into daily

life A decline in physical functioning can limit older adults'

engage-ment in physical activity Thus, it seems imperative to shift attention

away from a singular focus on moderate to vigorous physical activity

(MVPA) towards acknowledging the potential benefits of simple, low

intensity, short-lived activities (i.e., short duration bouts) that can be

easily integrated into the lives of older people (e.g., in convenient

settings such as at home or immediate neighbourhoods) This may be

key to increased uptake and maintenance of physical activity

be-haviours for older people (Sparling, Howard, Dunstan,& Owen, 2015;

White, Ransdell, Vener,& Flohr, 2005) Beginning with“non-exercise

activity” (Manns, Dunstan, Owen,& Healy, 2012) and encouraging

small, incremental changes (Ashe et al., 2015) can increase

experi-ences of mastery which, in turn, contributes to continuous behaviour

engagement and long-term maintenance

Daily routines as cues to action: putting habit into older adults'

health promotion practice

Habit formation is a proposed mechanism that supports

main-tenance of health behaviours It is particularly desirable for older

adults, as it relaxes the demands imposed on memory processes and

attention (Danner, Aarts,& de Vries, 2007) In essence, a behaviour is

habitual if it is exhibits features of automaticity That is, it is

per-formed efficiently, without awareness, control, and potentially

without intention (Bargh, 1994) Similar to other

motivational-volitional theories of health behaviour change (e.g., integrated

behaviour change model,Hagger& Chatzisarantis, 2014; health

ac-tion process approach, Schwarzer, 2008), the habit formation

framework (Lally& Gardner, 2013) proposes that health practitioners

should initially focus on motivating individuals, then support them

to translate this intention into action (e.g., through use of action

planning, (Hagger& Luszczynska, 2014)) Once motivated, habitual

behaviour gradually develops if a person repeats that same

behav-iour (e.g., one-leg stand) in an unvarying context over and over again

(e.g., while brushing teeth) thereby strengthening a mental

repre-sentation of that cue-behaviour association Ultimately, a person can

rely on contextual cues rather than conscious self-regulation to

initiate a behaviour (i.e., automatic process;Lally& Gardner, 2013;

Neal, Wood, & Quinn, 2006; Verplanken & Melkevik, 2008)

Encountering the environmental cue then becomes sufficient to

trigger the previously established cue-behaviour chain

A novel practical contribution of the lifestyle integrated physical

activity approach is that motivated individuals are explicitly

encouraged to anchor their physical activities around existing, daily

events (e.g., seeing a kettle, being at the grocery store) or activities

such as household, eating (Lally, Van Jaarsveld, Potts,& Wardle,

2010) or self-care activities (Judah, Gardner, & Aunger, 2013)

rather than specific times (e.g., Fleig, Kerschreiter, Schwarzer,

Pomp,& Lippke, 2014; Sniehotta, Scholz, & Schwarzer, 2005)

In-dividuals are encouraged to do so by consistent and repeated

practice (i.e., behaviour change strategy habit formation), and also

by means of action planning to obtain a clear mental representation

of the cue-response link Theoretically, event and activity cues

should be particularly beneficial for promoting context-consistent

behaviour repetitions as individuals encounter them very frequently (i.e., every day) and in close proximity (i.e., in home-based environment or close neighbourhood) Most importantly, in comparison to time-based cues, such external cues do not require

‘self-initiated constant monitoring’ (Judah et al., 2013, p 3; McDaniel& Einstein, 2000)

We previously tested feasibility for this lifestyle-integrated, habit-based approach within the Everyday Activity Supports You (EASY) intervention in women at retirement age (Ashe et al., 2015) Our group-based program focused on establishing daily routines (e.g., shopping, household activities) as cues to physical activity (e.g., utilitarian activities of daily living and walking) to maximize habit formation In our feasibility study, we noted a significant difference between groups in daily activity (steps/day), and selected health outcomes (weight and diastolic blood pressure) at six months that favoured the intervention group (Ashe et al., 2015) Recently, Clemson et al (2012) tested a similar approach to assist older adults to engage in more balance and strength exercises for falls prevention The program called Lifestyle integrated Func-tional Exercise (LiFE), employs an individually delivered program for older adults that concentrates on using everyday activities as triggers to engage in simple balance and strength exercises, with downstream benefits of falls prevention (Clemson et al., 2012) The original LiFE study was conducted with community-dwelling adults aged 70 yearsþ who sustained one or more falls in the previous 12 months.Clemson et al (2012)reported a 31% reduction

in the rate of falls However, the LiFE program has not been tested in

a younger group of adults (i.e., lower risk of falls) or delivered within a group setting, to determine outcomes For example, whether exercises and behaviour change techniques are feasible to deliver and will result in changes in balance and strength, habit strength and related psychosocial determinants

Aims Therefore, we tested feasibility of this novel behaviour change intervention that encouraged middle aged and older women to embed balance and strength exercises into daily life routines To our knowledge this is the first mixed-methods study to apply habit formation as an intervention outcome and behaviour change technique to the promotion of lifestyle integrated, functional bal-ance and strength exercises (LiFE) in this age group Specifically, our objective was to test feasibility of the EASY-LiFE program delivery, and acceptance and utilization of the program content (e.g., uptake

of behaviour change techniques) by study participants

Method Procedure and participants

We invited study participants who took part in our previous EASY study (Ashe et al., 2015), and who provided written permis-sion for us to contact them about future studies, to enrol All study participants completed a PAR-Qþ questionnaire (Warburton, Jamnik, Bredin,& Gledhill, 2011) administered by a certified exer-cise physiologist Based on their responses, some participants were asked to obtain approval from their family physician prior to commencing this study Participants received no monetary in-centives for study participation

Intervention The EASY-LiFE program duration was four months We followed the LiFE protocol established byClemson et al (2012) Specifically, the intervention consisted of seven two-hour group sessions, and

L Fleig et al / Psychology of Sport and Exercise 22 (2016) 114e122

two 30 min follow-up phone calls (up to 9 contact sessions) During

each of the group sessions a certified exercise physiologist,

accompanied by a personal trainer, introduced and reviewed

bal-ance and strength exercises with participants in a group setting

They added two new exercises at each subsequent session To

determine level of difficulty for the individual exercises,

partici-pants completed the Life Assessment Tool (LAT) with an exercise

professional (Clemson et al., 2012) We deviated in two ways from

the original protocol byClemson et al (2012) First, we asked

par-ticipants to complete the Life Assessment Tool (LAT) individually at

the beginning of each group session, rather than only once at the

beginning of the program (Clemson et al., 2012) Second, we added

a health psychologist to the team that delivered the program The

psychologist attended each session to assist participants with

setting goals, to facilitate the generation of action plans, encourage

self-monitoring, and promote consistent and context-dependent

practice of balance and strength exercises At the end of each

ses-sion participants had the opportunity to write down their action

plans, and use the ‘take-home recording sheets’ to self-monitor

their balance and strength exercises until the next group session

Table 1describes the content of sessions classified according to the

CALO-RE taxonomy of behaviour change techniques (Michie et al.,

2011) At the end of the final group session, participants were

invited to write and post‘a letter-to-themselves’ with their future

exercise goals

In addition to the group sessions, the exercise physiologist made

up to two phone calls per participant near the end of the program

to provide support, ascertain program maintenance and brainstorm

solutions for any problems encountered (seeTable 1)

Measures

Quantitative measures

Objective physical measures A registered physiotherapist assessed

mobility before (T1) and after the four month intervention (T2)

using the Short Physical Performance Battery (Guralnik et al., 1994)

Self-reported psychosocial measures We measured intention to

engage in balance and strength exercises with one item from

Sniehotta, Schwarzer, Scholz, and Schuz (2005),“I intend to engage

in regular balance and strength exercises at leastfive times a week.”

Self-efficacy was measured with two items adapted fromSniehotta,

Scholz, et al (2005), namely‘I am sure that I can engage in balance and strength exercises at leastfive times a week, even if I feel a strong temptation not to exercise,’ and ‘ … even if I don't see suc-cess immediately’ Action planning was measured with 5 items and coping planning with 4 items as perSniehotta, Scholz, et al (2005) andSniehotta, Schwarzer, et al (2005) General use of action plan-ning as self-regulatory strategy was measured with one additional item,“Usually, I make specific plans for my physical activities.” (Fleig, Lippke, Pomp, & Schwarzer, 2011b) Action control was assessed by four items which addressed the subcomponents of awareness of standards, self-monitoring, and self-regulatory effort (Sniehotta, Scholz, et al., 2005; Sniehotta, Schwarzer, et al., 2005) Satisfaction with exercise experience was assessed at T2 with two items that asked participants“To date, how satisfied are you with your results from the EASY LiFE balance and strength training program?” and “Given your effort with the EASY LiFE balance and strength training program, how satisfied are you with your prog-ress?” (Baldwin, Rothman, Hertel, Keenan,& Jeffrey, 2006; Fleig, Lippke, Pomp, & Schwarzer, 2011a) As part of the semi-structured interviews (described below) we also asked partici-pants to rate their overall experience with the EASY LiFE Study, ranging from“did not enjoy at all” (1) to “it was exceptional” (10)

We used nine items of the Self-Report Habit Index (Verplanken& Orbell, 2003) adapted to balance and strength exercises to assess the degree to which participants integrated the exercises into their self-concept (i.e self-identity) and to assess the degree to which behaviour became habitual (i.e automaticity) We measured quality

of life with the EQ5D-5L (Rabin& de Charro, 2001) Unless other-wise stated, response formats for psychosocial measures were 5-point Likert scales, ranging from completely disagree (1) to totally agree (5)

Qualitative measures

We also requested that participants take part in a semi-structured exit interview one week after the final intervention contact The researcher who conducted the interviews was also a group facilitator Our topic guide was based on previous studies (Ashe et al., 2015) and the Theoretical Domains Framework (TDF; (Francis, O'Connor,& Curran, 2012)) To ensure that participants considered behaviour change techniques (Michie et al., 2011) based

on our framework of volitional behaviour regulation (i.e., HAPA, (Schwarzer, 2008)), we included prompts regarding the behaviour

Table 1

Content of intervention by session based on the CALO-RE taxonomy ( Michie et al., 2011 ).

Behaviour change technique Week 1 Week 2 Week 3 Week 4 Week 6 Week 9 Week 11 a Week 13 Week 15 a

Shaping knowledge (i.e., information on antecedents

of habit formation)

Shaping knowledge (i.e., instruction on how to

perform the behaviour)

Feedback on behaviour (i.e., form) x x x x x x x

Barrier identification/problem-solving x x x x x x

a

L Fleig et al / Psychology of Sport and Exercise 22 (2016) 114e122

change techniques of action planning and self-monitoring We

conducted eight interviews at the research centre where

partici-pants attended exercise intervention sessions Two additional

in-terviews were conducted via telephone All inin-terviews were

recorded in writing

Data analysis

Quantitative

We provide descriptives using means and standard deviations

for continuous data We used medians and 10th and 90th

percen-tiles if data were skewed Given the small sample size and the

feasibility character of the study we refrained from using signi

fi-cance testing (Arain, Campbell, Cooper,& Lancaster, 2010) All

an-alyses were run with SPSS 19 (IBM Corp, New York)

Qualitative

We used the Framework approach (Gale, Heath, Cameron,

Rashid,& Redwood, 2013) to analyse all exit interviews Two

au-thors (LF, PC) individually familiarized with the interviews, together

developed an early conceptual model with“barrier” and “strengths”

codes for two broad categories Category 1 referred to how

partici-pants perceived the program content; category 2 referred to

par-ticipants' perceptions of program delivery After coding thefirst few

interviews, they compared applied labels, and agreed on a set of

codes to apply to all subsequent manuscripts We drew on the TDF

(Gale et al., 2013) and the list of minimal intervention details

(Davidson et al., 2003) to derive more specific themes and subdivide

each of the two broad categories Based on this working analytical

framework both raters independently coded the interviews

gener-ating a matrix in an excel spreadsheet The authors discussed the

spreadsheets, compared and agreed upon coding allocations

Results

There were 13 participants who initially consented to take part in

the study Retention rate at thefinal assessment was 77% (10/13)

The reasons for withdrawal were flair up of a previous health

problem (n¼ 2) and a family emergency (n ¼ 1) Participants were

highly educated (85% with at least post-secondary education, n¼ 11) with a mean age of 66 years (SD¼ 4.0, 59e71) More than half of all participants (70%, n¼ 9) reported being retired At four months, participants reported being very satisfied with their experience with the balance and strength exercises (Mdn ¼ 9.5, Q10 ¼ 8,

Q90¼ 10) and their overall experience with the program (Mdn ¼ 4.8,

Q10¼ 3.5, Q90¼ 5) Participants who dropped out reported lower quality of life at baseline (Mdn¼ 0.64) compared with those who completed the program (Mdn¼ 0.84) Attendance for the 7 group sessions ranged from n¼ 8 (62%) to n ¼ 13 (100%) participants; median was nine participants/session Individual attendance rate across all seven group sessions ranged from three (43%) to seven (100%) sessions per participant (Mdn¼ 6) Ten participants (77%) took part in thefirst follow-up phone call, 4 (31%) participants chose

to take part in the second follow-up phone call

Quantitative analysis Table 2provides baseline and follow-up values for physical and psychosocial outcomes

At T2, participants reported higher use of action control and action planning compared with baseline Similarly, participants showed an increase in general use of action planning, overall habit strength, as well as automaticity and self-identity For the different action plan components (e.g., when, where, how), participants scored higher on the“how”-component at T2 compared with T1 scores There were no mean differences between T1 and T2 for SPPB, intention, self-efficacy, and coping planning

Qualitative analysis

We conducted 10 semi-structured interviews which lasted be-tween 18 and 35 (M¼ 23.0, SD ¼ 0.1) minutes

Participants' perceptions about program content: what motivates individuals and which strategies do they use for behaviour change? Within the TDF we identified and analysed the following themes

of individual behaviour change: knowledge, skills, beliefs about consequences, beliefs about capabilities (including mastery),

Table 2

Characteristics of study participants across the two time points of the study a

Characteristics Baseline (N ¼ 13) Final-6 months (n ¼ 10) Psychological variables

Mean (SD, range) Intention 4.2 (0.6, 3.0e5.0) 4.3 (0.6, 3.0e5.0)

Mean (SD, range) Action planning 3.3 (1.0, 2.0e5.0) 4.1 (0.9, 1.8e5.0)

Where 3.3 (1.0, 2.0e5.0) 4.0 (1.2, 1.0e5.0)

How often 3.4 (1.2, 2.0e5.0) 4.0 (1.3, 1.0e5.0)

With whom 3.2 (1.1, 2.0e5.0) 4.0 (1.3, 1.0e5.0)

Mean (SD, range) General use of action planning 2.9 (1.8, 1.0e5.0) 3.7 (1.6, 1.0e5.0)

Mean (SD, range) Coping planning 3.4 (1.0, 1.5e5.0) 3.7 (1.0, 1.0e4.3)

Mean (SD, range) Action control 2.3 (1.1, 1.0e4.0) 4.0 (0.9, 2.0e5.0)

Mean (SD, range) Habit strength 2.4 (1.9, 1.0e6.3) 5.2 (1.3, 3.6e7.0)

Automaticity 2.8 (2.1, 1.0e6.4) 5.3 (1.2, 3.6e7.0)

Self-identity 2.7 (2.3, 1.0e7.0) 4.7 (1.8, 2.0e7.0)

Short physical performance battery

Mean (SD, range) Gait speed, (distance/s) 1.1 (0.2, 0.8e1.3) 1.1 (0.2, 0.8e1.3)

Subjective health

Mean (SD, range) EQ5D-5L VAS score 86.1 (11.1, 65e98) 89.1 (7.0, 75e95)

Mean (SD, range) EQ5D-5L 0.8 (0.2, 0.4e1.0) 0.9 (0.2, 0.8e1.0)

a ¼ EuroQol quality of life questionnaire 5 Dimensions; VAS ¼ Visual Analogous Scale.

L Fleig et al / Psychology of Sport and Exercise 22 (2016) 114e122

intentions, memory and attention, behavioural regulation,

rein-forcement (including direct experience), social influences, and

so-cial role We added a further theme of “barriers” to capture

challenges that participants anticipated would impede their

exer-cise goal pursuit beyond the program We expand on these themes

below Table 3provides an overview of the theoretical domains

with exemplar quotes from the interviews

Knowledge Many participants valued the procedural knowledge on

how to correctly and safely do the different balance and strength

exercises, the nuts and bolts of doing the exercises (Jane, age 66) In

particular, participants liked the demonstrations (Mary, age 66) that complemented the explanations on how to do the exercises (Maria, age 64) Whereas the exercise professionals focussed on providing procedural knowledge during group sessions, the health psychol-ogist presented information on the psychological mechanisms of habit formation Participants appreciated the interdisciplinary character of the sessions (seeTable 3)

In particular, participants found information on stuff on what's gonna motivate me, to learn how to get motivated (Ruth, age 70) and the habit forming stuff (Pat, age 62) valuable Participants empha-sized that they enjoyed learning about the scientific evidence on

Table 3

Participants' perceptions about program content: Motivation and strategies to change behaviour.

Theoretical domain of

behaviour change

Knowledge It was important that you (LF) talked about the psychology, that it was

not only the exercises (Ruth, age 70)

I wish there was more information on safety in the household, like getting rid of rugs and lightning, info on sleep and exercise, and the fatigue factor (Maria, age 64) Skills Start with one and build on it (Maria, age 64)

Do what you can, e.g., hold on to something when I was doing the exercises (Betty, age 70)

Some of us were at different levels (Ruth, age 70)

Beliefs about consequences

(joining program)

Help age with more grace and healthfully (Judy, age 61) Strengthen legs before growing older (Mary, age 66)

To prevent falls which will be good in the long run (Pat, age 62)

I want to ensure my retirement (Amy, age 68),

I wanna be self-sufficient forever (Ruth, age 70) Research was valid and valuable (Pat, age 62) Beliefs about capabilities and

mastery experience

It does not have to be difficult, these are not big changes in your life, just simple exercises (Mary, age 66)

Initially it was difficult, halfway through, I felt it was a lot easier (Susan, age 59)

Some of them very simple, easy to integrate them (Ruth, age 70)

With some [exercises] I'm not sure I'll be able to turn them into a habit (Jane, age 66)

Memory and attention Triggers that remind me of the group exercises (Judy, age 61)

Just the triggers that I put in place, personal reminders (Susan, age 59) It's attention, pay attention as I do them, that I'm out of core (Jane, age 66)

Behavioural regulation Action control

I did it, but didn't check it off (Ruth, age 70)

To be honest, I did it at the end of the week, just thought back to the week and ticked it (Linda, age 70).

Action planning I'm a pretty busy person, I have to make sure I plan how to incorporate

my exercise into the day (Mary, age 66) Associate something with something that you are already doing was super important to me (Pat, age 62)

Habit formation

It became part of my day, it really became an automatic thing (Maria, age 64)

Some of them are just habitual, I do it without thinking (Ruth, age 70) Problem solving

Talk over what I was having difficulties with and what to do (Betty, age 70)

The least fun part of the whole thing and not realistic [to complete] (Judy, age 61)

I like [how] the Fitbit reminded me; everybody should have one; something to measure every day, I like to see

my achievement immediately; we can't see results straight away with balance and strength [exercises] (Judy, age, 61).

I didn't feel I needed the sheets, better for others who still have to think about prompts (Linda, age 70)

Reinforcement My knees aren't so sore, had inflamed knees only twice, being in the

program made the most enormous difference, now it's almost gone (Maria, age 64)

Can't say I enjoyed them [exercises] (Linda, age 70)

Social influences Other peoples feedback, incorporated their ideas into my own routines

(Pat, age 62) Finding out how some of the other women integrated their exercises was inspiring (Ruth, age 70)

Goals Keeping up with all the things I wanna do (Susan, age 59)

Increase some of the balance and strength exercises (Mary, age 66) Environmental context

(including barriers)

If I'm on vacation, it's not my daily routine, everything is somewhat lost (Linda, age 70)

My husband isn't well, I'm a caregiver (Maria, age 64) Social role I will implement my own program, teach people how to make it a

pattern, an automatic piece (Amy, age 68)

L Fleig et al / Psychology of Sport and Exercise 22 (2016) 114e122

habit formation, hearing about research, the studies that you

pre-sented (Pat, age 62) including the different theories (Jane, age 66)

Finally, one participant requested more information on household

safety and interplay between sleep and exercise (seeTable 3)

Skills During every group session (guided by exercise

pro-fessionals), participants were invited to practice up to two new

balance and strength exercises The gradual introduction to doing

the exercises (‘start…with one and build on it’, Maria, age 64) as

well as the individual skill assessment were core features of the

program and much appreciated by participants (‘scrutiny that is put

on you; good to have those checks’, Pat, age 62; ‘making sure that

everything is done properly’, Maria, age 64) Participants described

the feedback by exercise professionals as encouraging and

appre-ciated that they were given exercise options tailored to their

physical capabilities One participant mentioned that the

hetero-geneous group slowed down her individual progress (seeTable 3)

Beliefs about consequences Participants frequently referred to

health-related reasons for joining the program Whereas some

participants described positively framed expectations such as

pre-serving health and physical ability (Linda, age 70), the majority of

participants stated that they wanted to prevent deteriorations of

their health status by joining the program (seeTable 3) In

partic-ular, participants hoped not to fall down and break a hip or wrist, stay

out of hospital as long as possible (Linda, age 70) and avoid mobility

problems later (Amy, age 68) Interestingly, a number of participants

referred to seeing salient persons of their social network suffer

from health concerns (i.e., mother, good friend, colleague) as the

origin of their motivation to be proactive about their own health

Beyond health-related beliefs, there was an understanding that

joining the program is a way to maintain autonomy (seeTable 3)

When talking about their expectations and reasons for joining

the program, participants also mentioned that they enjoyed being

part of studies that are helping (Susan, age 59) and contributed to

research (Amy, age 68)

Beliefs about capabilities and mastery experience Throughout the

program, participants learned 12 different balance and strength

exercises, and overall, participants were confident about their

ability to do the exercises (seeTable 3) Participants appreciated the

gradual progression of exercises and described that with increased

practice they were more comfortable doing the exercises and were

very pleased with the progress With regard to the full set of

rec-ommended exercises, participants reported gaining mastery, but

also mentioned that at the end of the program, they still faced some

challenges (seeTable 3)

Memory and attention Remembering to do the planned balance

and strengths exercises was perceived as a major challenge by some

women: for me doing them wasn't that much of an issue but

remembering them [was] (Jane, age 66) Some participants

mentioned that specifying the triggers as part of their action plan

helped them to remember the exercises (see Table 3) Others

mentioned using additional visual reminders such as a sticky [note]

that reminds me to do it (Mary, age 66) or a list of balance and

strength exercises to put on the kitchen table (Ruth, age 70) Although

it was not addressed in the program, electronic wearable devices

were cited as a help to remind participants to do the activities,

getting it on your iPhone, really helped to remember triggers (Pat, age

62) Another participant described how her Fitbit [wearable,

elec-tronic activity monitor] served as a memory aid to engage in daily

physical activities, I like [how] the Fitbit reminded me (Judy, age 61)

Many participants also described that they became more aware of

their posture and paid more attention to executing the exercises (seeTable 3)

Behavioural regulation To promote habit formation of the balance and strength exercises, participants were encouraged to use paper-based self-monitoring and action planning sheets, and to engage in repeated rehearsal of the behaviour in the same context Although participants mentioned that the check part of the charts [self-monitoring sheets] was good (Mary, age 66) and that they would leave them on the kitchen table [as a prompt] (Ruth, age 70), some women engaged in the exercises but did not consciously monitor their behaviour on a daily basis or at all (seeTable 3) One woman described her experience with the weekly self-monitoring sheets as the worst part of the program (Pat, age 62) Another woman remarked that she preferred a self-monitoring method with im-mediate and ‘outsourced’ self-monitoring and feedback options (seeTable 3)

The general principle and use of making action plans to anchor the recommended balance and strength exercises around other daily routine activities (e.g., brushing teeth) was frequently mentioned as being important and useful (seeTable 3) Although the usefulness of prompts to action was generally valued, completing the weekly planning sheets was frequently cited as repetitious, irritating, and annoying tofill in all the time (Jane, age 66) Participants described their experience withfilling in the sheets as helpful in the beginning but believed that the novelty wore off (Amy, age 68) and that they got a little tired of it by the end (Pat, age 62) Similarly, one participant questioned thefit between the planning-sheet strategy and her needs (see Table 3) Participants very frequently referred to their established balance and strength ex-ercise habits With regard to developing these habits, many women repeatedly referred to their daily-routine contextual cues with which they successfully linked the recommended exercises In more detail, participants most frequently referred to household tasks or chores (e.g., washing dishes), to personal hygiene and self-care activities (e.g., in the bathroom while brushing teeth, combing hair, choosing clothes from closet), to occasions when they waited for something (e.g., during commercial breaks, when I waited for light to change or the bus) or to meal times as their cues to action One woman also referred to the consistency and low complexity of behavioural patterns as being instrumental for habit formation, it's the little things that make you stronger, make them consistent (Mary, age 66) There were also several references to the awareness of the duration of the habit formation process as a facilitator for contin-uous practice, I always kept that 88e82 days in mind, the end goal that helped, I was curious (Susan, age 59) Finally, one participant described how restructuring her physical environment helped with engaging in strength exercises, I have a tall skinny chest of drawers, I moved it all down, so I have to bend down (Ruth, age 70), and another referred to addressing barriers and coming up with problem-solving strategies as helpful (seeTable 3)

Reinforcement Participants described different experiences with practicing balance and strength exercises Whereas some in-terviewees emphasized the enjoyment they felt by doing the self-directed exercises, for others exercises did not seem to have the same self-rewarding character (see Table 2) In addition, some participants talked about specific health-related outcomes which they attributed to the exercise program (see Table 2) Another woman described how her posture really improved, like shoulders and chest (Linda, age 70)

Social influences The group setting, and the opportunity this offered participants to exchange perspectives and ideas facilitated engagement in the self-directed exercises Participants also

L Fleig et al / Psychology of Sport and Exercise 22 (2016) 114e122

mentioned thatfinding out how other group members managed to

embed the exercises into their daily routines was very motivating

(seeTable 3)

Goals Health-related exercise outcomes were frequently cited as

goals, including physical, spiritual and emotional health (Susan, 59)

When talking about their self-set goals, many participants

mentioned that they wished to stay healthy rather than referring to

improved health Similarly, some participants said their goal was to

maintain autonomy With regard to behaviour goals, many women

mentioned that they intended to increase their current exercise

levels (seeTable 3)

Environmental context (including barriers) Participants anticipated

very different barriers that could potentially interfere with their

exercise goals These ranged from change in context, taking care of

a family member to time and health limitations (seeTable 3)

Social role In relation to the EASY LiFE program, participants

mentioned how they tried to encourage others to pursue program

principles (‘got my mum to do it, I could see it really helped her’, Pat,

age 62) Participants also planned to facilitate their own program

(seeTable 3)

Participants' perceptions about program delivery: which features of

the program encouraged and engaged participants?

Based on the list of minimal intervention details (Davidson et al.,

2003) our framework comprised the following“delivery” themes:

intervention format (i.e., methods of intervention administration),

intensity and duration, provider (i.e., characteristics of the persons

delivering the intervention), and elements of intervention/delivery

mode (i.e., how content of the intervention was delivered) We

added a further theme labelled intervention engagement to refer to

participants' overall engagement and compliance to the program

Format Overall, the delivery model of our program included seven

group sessions, and up to two individual follow-up phone calls

Many women valued the support from the group and described the

interaction with the group as encouragement (Judy, age 61) Similarly,

some participants reflected that being in a group program was a

way of staying connected: building community cause I tend to isolate

myself (Jane, age 66) Women also appreciated this specific group of

participants (‘nice group of people’, Betty, age 70) Whereas one

person cited the lack of opportunity to the group to exist beyond

program as a shortcoming of the program, another participant

expressed her preference for having individual sessions only With

regard to the individual face-to-face sessions with an exercise

pro-fessional, participants valued the focus, scrutiny, and attention that

was put on them as a person, 1-on-1 really helpful, really focus on me

(Mary, age 66) When talking about the follow-up phone calls,

in-terviewees frequently mentioned that they did not need further

support (‘didn't really feel I needed them; didn't need to check in’,

Susan, age 59) and saw no benefits in having had the phone calls

(‘wasn't useful for me or for her’, Mary, age 66) However,

partici-pants acknowledged that follow-up phone calls may be useful and

beneficial if implemented at a later time during the program (‘If we

are still in the session we don't really need the phone call, but

after-wards’, Judy, age 61) and offered to people who are isolated as it may

be really nice for them to feel that there is a connection out there (Amy,

age 68) Finally, many participants appreciated the

‘letter-to-myself’-feature of the program In particular, interviewees

high-lighted the unexpectedness, fun, and memory-aid function of the

letter: It was quite funny, I opened it up, forgot all about it, really good

reminder, really good thing to have to get back to the exercises (Mary,

age 66)

Intensity and duration The well-managed timing and organisation

of the single sessions as well as the convenient spacing of the multiple group sessions were valued by participants (‘sessions spaced well, was not overly demanding, I didn't feel inconvenience’, Susan, age 59)

Element of intervention/delivery mode A good balance of informa-tion and exchange, as well as exercise demonstrainforma-tions were much emphasized themes As described by one participant, being shown how to do the exercises, something just don't translate from paper (Ruth, age 70)

Provider It was evident that participants valued the passion, approachability, expertise and diversity of team members As described by participants: I enjoyed the passion of staff, they worked well with us (Jane, age 66) Have the whole group: physios, doctors [researchers] and you (Pat, age 62)

Intervention engagement (including commitment and compliance) Although participants received no monetary or other incentives for their participation, the women frequently expressed their commitment to the program and their motivation to comply with all requirements of the program: I made a commitment to do it, signed an obligation, didn't occur to me not to come I signed up for the program, like I paid for a class at afitness club (Linda, age 70) Discussion

In this mixed-methods study, we aimed to evaluate the feasi-bility of an interdisciplinary, theory-based behaviour change pro-gram designed to encourage women at retirement age to embed balance and strength exercises into their daily routines In partic-ular, we explored acceptability of intervention characteristics (e.g., delivery mode), as well as acceptance and utilization of the inter-vention content (e.g., behaviour change techniques) Overall, our results suggest that the group-based adaptation of the original protocol (Clemson et al., 2012) was highly feasible with regard to both delivery and content of the intervention Delivery of the adapted model resulted in changes for automaticity, identity, action planning, action control, and quality of life Thesefindings under-score the program's potential to be tested in larger trials While gains in these psychosocial variables were pronounced, interven-tion recipients seemed to maintain baseline level of inteninterven-tion,

self-efficacy and physical performance (i.e., SPPB), possibly due to a ceiling effect (e.g., high scores at baseline assessment) Ourfindings extend what was currently reported about the LiFE program (Clemson et al., 2012) and speak to its adaptability We note that it has potential to achieve changes in assumed psychological pro-cesses of behaviour maintenance In particular, our quantitative results suggest that behaviour change strategies such as self-monitoring, action planning (Fleig, Pomp, Parschau, et al., 2013; Fleig, Pomp, Schwarzer, & Lippke, 2013; Orbell &Verplanken.,

2010, study 3; Judah et al., 2013), and habit formation (i.e., prompt rehearsal and repetition of behaviour in the same context; Gardner, Sheals, Wardle,& McGowan, 2014) are instrumental to promote automaticity and exercise-related self-identity With repeated rehearsal of balance and strength exercises, participants also seemed to integrate these routines into their self-concept (Gardner, de Bruijn,& Lally, 2012)

Qualitative analyses of theoretical domains of behavioural change added depth to what we learned from our quantitative analyses and served to inform how best to optimize the program Our results also provided further evidence into the type of cues that trigger auto-matic processes Analyses emphasized the acceptability and uptake

of anchoring recommended balance and strength exercises around

L Fleig et al / Psychology of Sport and Exercise 22 (2016) 114e122

event- and activity-based cues This supports previous research in

the dietary (Gardner et al., 2014), dental hygiene (Judah et al., 2013),

and physical activity domain (e.g., after breakfast;Pimm et al., in

press) In particular, some participants reported that specific

trig-gers (e.g., daily activities of self-care) helped them to remember the

exercises This suggests that habit formation and action planning

could alleviate demands imposed on memory (Danner et al., 2007)

Furthermore, collaborative planning (e.g., brainstorming cues with

other participants) was perceived to be particularly helpful Even

though perceived as useful, participants identified several

chal-lenges with how we implemented the behaviour change techniques

action planning and self-monitoring Participants critiqued the

fre-quency (i.e., weekly), duration (i.e., over 8 weeks), and redundancy

of generating action plans (i.e., writing down the same plans every

week even if plans had not changed) Once participants are familiar

with the principles of creating action plans and self-monitoring (e.g.,

halfway through the group sessions), it may be more acceptable for

them to explicitly choose whether they want to continue to use of

the recording sheets As a decision-aid, a quick stage-based

self-screener (e.g., stage algorithm,Lippke, Ziegelmann, Schwarzer,&

Velicer, 2009) may be applied to evaluate how far participants

have progressed toward forming a habit Instead offilling in new

sheets every week, it may be more feasible to suggest that

partici-pants reuse their weekly planning sheets throughout the program

and to encourage them to modify planning components as needed

(e.g., change cues or add exercises)

Interestingly, participants often described how some of the

ex-ercises became automatic for them However, they also referred to

their increased awareness and attention while doing the exercises

This is a noteworthy detail, as mindful execution of a specific

behaviour is distinct from ‘automatically’ deciding to initiate a

behaviour in a given situation (i.e., habitual instigation;Maddux,

1997; Phillips& Gardner, in press) Being mindful and aware of

one's ‘doing’ an exercise may ensure that individuals do them

correctly (i.e., based on provided procedural knowledge) Being

mindful may also help participants derive enjoyment from the

‘do-ing’ Ultimately, intrinsically rewarding behaviours will most likely

be repeated; this aids habit formation (Wiedemann, Gardner, Knoll,

& Burkert, 2014) Perceptions of enjoyment with doing the exercises

varied considerably Qualitativefindings suggest that satisfaction

was derived from experiencing positive exercise outcomes rather

than from experiences related to doing the exercises, per se

Finally, participants were highly committed to the program, and

acknowledged the group format and the intervention provider as

most beneficial intervention characteristics However, participants

also suggested changes to improve the program structure and to

optimize recruitment Participant's beliefs about the positive

con-sequences related to them joining the program has implications for

feasibility Specifically, it appears highly feasible to conduct a

larger-scale study with a focus on; a) using balance and strength

exercises as a means to prevent age-related declines in mobility and

autonomy, and b) opportunities to contribute to research With

regard to intervention dose, participants experienced

telephone-based follow-up prompts as superfluous and suggested that these

‘boosters’ be provided once the main intervention is finished

(Fjeldsoe, Neuhaus, Winkler,& Eakin, 2011; Fleig, Pomp, Parschau,

et al., 2013; Fleig, Pomp, Schwarzer, et al., 2013)

Strengths and limitations

We note some limitations of this study While our results

sug-gest that the LiFE program (Clemson et al., 2012) translates from an

individual to a group setting and is well-received by a younger,

more active sample, it remains uncertain to what extent the

suc-cessful implementation can be replicated across different age and

sex groups Qualitative data were collected by the same person who facilitated the intervention and analysed the data Given that par-ticipants identified that the program presented several challenges attests to the fact that interview responses were less biased by social desirability

In addition, the very small sample size and the lack of a control group limits the interpretation of the revealed preepost differences

in psychosocial variables For example, a future RCT could be implemented with a waiting list control group (i.e., intervention only starts after the second follow-up measurement) In terms of measures, we reliably assessed behaviour with an objective per-formance indicator (i.e., SPPB), and behavioural “quality” with a self-report measure of habit strength To assess linkages between context-dependent repetitions, habit formation, and sustainability,

a more rigorous measure of behaviour with indicators of behaviour frequency (e.g., preepost or time-sampling analyses) is needed

In the present delivery model, participants were encouraged to sequentially integrate new behaviours into their repertoire of bal-ance and strength exercises (i.e., on average two new exercises per group session) Although participants increased their overall habit strength by the end of the program, comments indicated that some participants struggled making all of the exercises into a habit How goal behaviour‘dosage’ (i.e., single vs multiple goals;Gardner et al.,

2014) and goal character (e.g., self-set vs other imposed) affect habit formation is an avenue for further research Longer-term data are required to determine whether individuals can sustain in-creases in exercise habit strength Finally, more research is needed

to examine the potential positive consequences of habit formation for other types of physical activity (e.g., higher intensity physical activity), and other health domains such as healthy dietary behaviour (Fleig et al., 2014)

In summary, a group-based, lifestyle-integrated exercise pro-gram that targets balance and strength was well-received, feasible

to deliver, and can potentially achieve uptake of self-regulatory strategies (e.g., event- and activity-based action planning), context-dependent behaviour repetitions, and increases in auto-maticity and self-identity among older women Theory-based principles of habit formation provide an acceptable and prom-ising foundation from which to design larger scale balance and strength exercise programs for this age group, in future To address the challenge of advancing older adults' health promotion and falls prevention practice these principles may be combined with prin-ciples of lifespan psychology (Gellert, Ziegelmann, Krupka, Knoll,& Schwarzer, 2014; Ziegelmann& Knoll, 2015) In later life, promoting physical activity through lifestyle-integrated activities rather than through formal exercise sessions may be more encouraging and effective to sustain activity This may be especially true for those with mobility impairments

Acknowledgements

We gratefully acknowledge the generosity of our study partici-pants and the support of the Centre for Hip Health and Mobility staff We also acknowledge Canadian Institutes of Health Research (CIHR) for operation funds for this project Dr Ashe is supported by career awards from the CIHR and the Michael Smith Foundation for Health Research (MSFHR) The sponsor had no role in the study design; collection, analysis, and interpretation of data; writing the report; and the decision to submit the report for publication References

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