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- Bajraktari, Saranda, 1989-
(författare)
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Health promotion and fall prevention for older people : impact, relevance and economic justification for decision making in a municipality context
- 2023
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: The proportion of older people is increasing and calls for a shift towards proactive approaches to support healthy ageing. The evidence base on health-promoting and preventive interventions (HPP) is promising in terms of maintaining health in older people, but for such interventions to have an impact on population health, translation of evidence to practice is crucial. To facilitate this process, factors relevant for decision makers are important to consider. One specific public health challenge is fall-related injuries in older people which cause the highest number of injury-related deaths, have many consequences for the individual (physical and psychological) as well as wide-ranging societal costs. Translation of evidence to practice faces challenges with regards to reach, limiting the public health impact of such interventions. Digital interventions have the potential to increase reach and thereby contribute as an innovative proactive approach. The aim with this thesis was twofold. First, to review the scientific literature in the field of health promotion and prevention conducted in Nordic Countries and targeting community-dwelling older people. Secondly, to evaluate reach, self-reported health outcomes and cost-effectiveness of the Safe Step digital fall preventive exercise intervention in an observational study in the municipality of Östersund-Sweden.Methods: In paper I, a scoping review design was applied to review and summarise a broad field of research focusing on seven factors important for decision-makers such as: context, population, content, feasibility aspects, experiences of participants, intervention effects, and cost-effectiveness. In Paper II, data related to reach including recruitment rate, and participant characteristics (based on self-reported health outcomes and socioeconomic status) were collected. The sample was compared with a representative sample of older people for the purpose of exploring representativeness. In paper III, self-reported health outcomes in relation to balance, leg strength, fear of falling and health-related quality of life were evaluated over the course of the one-year intervention and in relation to exercise time, reported in quarterly questionnaires. In paper IV, the cost effectiveness of the Safe Step intervention was modelled in a Markov model with five states over 12 years to evaluate the potential cost-effectiveness of the intervention in community-dwelling older people at risk of falling.Results: Paper I showed that all included studies, except one, reported a positive effect in at least one health outcome measured. Most studies did not report on cost-effectiveness, feasibility, or experiences of participants. Based on the summarised evidence, senior meetings, preventive home visits and various forms of fall preventive exercise interventions emerged as most recommendable for implementation. Results from paper II showed that the majority of participants had a better health status, were women, and were more commonly using technology in comparison to a sample population. Paper III showed that participants in the intervention self-reported positive changes in balance and leg strength at different follow-ups. Balance and leg strength indicated a small but positive association with self-reported exercise activity. Paper IV showed the potential of Safe Step being a cost-saving intervention with better health outcomes and lower costs compared to no intervention alternative. Assuming a lower estimated intervention effect and higher recruitment costs still indicated that Safe Step was cost effective.Conclusion: This thesis provides evidence to support proactive approaches in healthy ageing and recommends increased efforts in research regarding translation of such interventions to practice as to maximize impact on a population level. The Safe Step intervention shows promise in being used independently in community-dwelling older people with good overall health and familiarity with internet and digital technologies. The majority reached were women with higher education, which infers a need for other non-digital interventions or additional support to increase reach in the general population of older people at risk for falling. Preliminary effectiveness results imply that Safe Step can lead to self-rated changes in known fall-risk factors although participants reported exercise time was lower than the recommended levels. Safe Step indicates also to be a cost-effective intervention even with conservative estimates of intervention effects and higher costs.
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| 2. |
- Pettersson, Beatrice, 1987-
(författare)
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Fall prevention exercise for older adults : self-management with support of digital technology
- 2021
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Falls are a major public health issue, which can cause physical and psychological suffering for the individual as well as large costs for the society. To increase access and adherence to evidence-based fall prevention exercise, utilisation of older adults’ own capabilities and digital health offers promising solutions. The aim of this thesis was to explore a digital programme as support for self-management of fall preventive exercises in community-dwelling older adults with a focus on participant experiences, behaviour change, and intervention reach.Methods: This thesis comprises four papers, of which Papers I and II report from a feasibility study comparing two self-managed fall prevention exercise programmes, a paper booklet and the digital Safe Step programme. Papers III and IV describes a randomised controlled trial, which evaluates the effectiveness of the Safe Step programme in combination with educational videos, to reduce falls in comparison with educational videos alone. In Paper I, individual interviews were analysed with inductive qualitative content analysis to explore older adults’ experiences of self-managing their fall prevention exercise. In Paper II, a deductive and inductive approach was utilised for the analysis of comments in questionnaires, individual, and focus group interviews to explore experiences of self-determination when using the Safe Step programme. The classification system of motivational and behaviour change strategies based on Self-determination theory was utilised as a categorisation matrix. An additional analysis of behavioural regulation for exercise according to the Self-determination theory was performed in this thesis. Paper III is a protocol for a randomised controlled trial, and Paper IV describes the recruitment strategies, and reach of this trial through comparison with another representative sample of adults 70 years or older by descriptive statistics.Results: Results from Papers I and II show that the older adults appreciated the autonomy of a self-managed exercise programme. They expressed a capability to independently select exercises and manage their progression with support from the programme. However, some wanted the support of others in their training. The behaviour change support in the Safe Step programme was voiced as motivating and supportive, and the diversity of behaviour change strategies was emphasized as important to suit many older adults’ preferences. In Paper II, the behaviour change support were found supportive for the basic human psychological needs according to the Self-determination theory, although, support for autonomy and competence were more clearly stated than for relatedness. An additional category was formed and proposed as an amendment to the classification system used as an analytical matrix. In the thesis, expressions of intrinsic and extrinsic motivations for doing the exercise from participants in Paper I were triangulated with results from the Behavioural Regulations in Exercise Questionnaire-2. The results confirmed the trend found in the qualitative analysis of more intrinsically motivated expressions in the group using the Safe Step programme. A study protocol was written that described the design of the Safe Step randomised controlled trial, including the aims, methodology and overall organisation of the research (Paper III). In Paper IV, the most successful recruitment strategy to the randomised controlled trial was identified as advertisement in social media. The recruited participants were predominantly women, highly educated, and frequently used applications or internet on mobile devices.Conclusion: Finding of this thesis support implementation of fall prevention strategies through increased utilisation of older adults' self-management capabilities. Older adults’ experiences of exercising with a self-managed digital exercise program can be understood as managing pieces of a personal puzzle and was shaped more by the sum of the features and behaviour change support in the programme than by parts of the programme. The Safe step programme seems to provide support for more self-determined exercise motivation, than a paper booklet, which can support maintenance of the new exercise routines. The older adults’ experiences, as well as the characteristics of the participants reached, highlight the necessity for a variety of fall prevention strategies that reflect the diversified needs and preferences of older adults.
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