Qualitative Content Analysis
Five overarching themes were identified: Program overall, trainer support, content of the program, format of the program, and changing behavior. The results are illustrated by quotes, translated from German to English. Participants are identified by group, gender, and age (e.g., gF73=gLiFE, female, 73 years; oM80=original LiFE, male, 80 years).
Participants reaction to the overall program did not differ much in the two program formats. In both formats, participants were positive about the program: “The LiFE-program is great and I enjoyed it” (gF73); “It seemed […] very well structured” (oM78). Most participants understood and liked the concept of lifestyle-integrated exercise: “And what I found appealing is that these are exercises that can be integrated into daily life” (gF70). Many participants further valued the focus on independent exercising: “Doing my own thing at home alone, not having to join any sports clubs or groups, that is exactly the right thing for me” (oM80).
Participants experienced some troubles with the paperwork for the study. The monthly fall calendar and the set of questions at baseline and follow-up assessments were perceived as “quite annoying” (gF70) by some participants in both formats.
In general, gLiFE and LiFE participants spoke positively about the teaching styles of their trainers: “The guidance and instructions were great […] and well explained” (gM82) and “I think, my impression was entirely positive. He [the trainer] had a very good pedagogical approach. So, it was very clear” (oM80).
Participants in both formats felt individually supported by the trainers during teaching sessions. LiFE participants described how the trainers adapted the programs to their abilities and gave feedback on their performance during activities: “She really catered to my needs and abilities and had another idea, on how to adapt things if I could not do them” (oF72). gLiFE participants described how the trainers approached them individually within the group setting. “They really responded to the individual’s situation” (gF77); “They would correct the execution of activities in a very caring way, I would say. So, when someone did not do it correctly, then they very gently approached you and said, try this or try that.” (gF70).
For gLiFE participants, it seemed important not to feel pressured by trainers or exposed in front of their peers when they were having difficulties with an exercise: “You never had to feel embarrassed. For example, I have a problem with my hip and I cannot step over objects sideways. But nobody gave me a weird look and I could just tell the trainers that I cannot do it […] and never felt pressured (gF72);
LiFE FGs discussed their relationship with the trainers in more detail, by for example praising their personality (e.g. how cheerful or friendly they were, “he [the trainer] always arrived with a big smile on his face and we were always happy to see each other. He was always so cheerful, even in the morning” (oF80). Furthermore, they described the one-on-one supervision as an opportunity for a personal exchange with the trainer, “So I liked that you could talk to them about personal stuff, too. There was an exchange and I really enjoyed that. We had great conversations.” (oF74).
Content of the program
Structure and materials. Participants from both formats liked the “whole structure” (gF84) of sessions and the “well balanced and instructive” (gM82) combination of theory and practice. One gLiFE participant specified that the repetition of activities from the last sessions was helpful: “It really gets stuck in your mind; you don’t hear it just once and then you have to be able to do it and then there’s a different program next time, but instead it was repeated before adding something new” (gF80).
In both formats, participants valued the manual as a helpful tool “especially at the time when the trainer is not there anymore” (oM74).
Activities. gLiFE and LiFE participants indicated strong preferences for activities that are easy to integrate into daily routines, like the one-leg stand. “I think the most beneficial are the activities, that can be successfully implemented in everyday tasks” (oM80). Participants of both formats talked about activities which were difficult to perform or which they perceived as “not natural” (gF73) or “silly” (oM80), like “stepping over objects backwards” (gF91). They often related difficulties with certain activities to personal health conditions or pain. “For me it is difficult, because my knees cause a lot of troubles. I cannot do many of the activities” (oF96).
gLiFE participants reported that they consider safety aspects when practicing at home: “I always make sure, when practicing […], that I am close to the wall” (gF82). LiFE participants did not make specific statements on safety.
Only gLiFE participants suggested to add more activities, like “some kind of coordination” (gF84) or to practice more complex movements like “getting out of a bathtub” (gF82). One LiFE participant wished for more specific fall prevention exercises to learn “how to fall and how to compensate a fall” (oF73).
Intensity and duration. Participants had different opinions on program intensity, with most being satisfied. Few expressed that the intensity “was slightly too little” (oF80) compared to similar exercise programs. Some participants wished for more practice time during sessions, as well as increased difficulty or more challenging exercises, for example “strength could be a little bit more [challenging], to guarantee stability” (oM83).
Format of the program
Group format. When asked about their thoughts on the other format, gLiFE and LiFE participants addressed advantages of group exercising. gLiFE participants reported that the group enhanced their motivation: “[…] it wakes your ambition. You do not want to step down, you want to keep up with the others” (gF88). A good atmosphere in their groups motivated and encouraged them: “[…] in the group it is, I think, a bit funny from time to time. You encourage each other” (gF88). Not all gLiFE participants had the same experience of group cohesion in their groups and had wished for more group interaction: “So, to be honest, I never felt a sense of companionship, unfortunately. (…) I would have liked to experience some team spirit, to have an exchange” (gF84).
Several gLiFE participants described the exchange and comparison with peers as “comforting” (gF91) because they “all face difficulties with walking and climbing stairs, and they are all troubled by their knee pain” (gF91).
LiFE FGs discussed “group pressure” and peer exchange as positive effects of exercise groups, based on previous experiences or preconceptions: “The group pressure, […] yields more than fumbling around alone with the trainer” (oM74). Some said they would have preferred “being part of a group of like-minded people” (oF96) for the social aspects, and to have an exchange with peers because “you always have this one person [the trainer], who you of course can always have an exchange with, and who gives good advice, but in everyday life it’s different. We’re all elderly people and you [research team] can’t really understand how we feel” (oF82).
Individual format LiFE participants agreed that it was helpful to receive individual support to identify situations and locations suitable for the implementation of activities directly in one’s home: “The advantage of him [trainer] being in my home was that we could choose situations together in which it [activities] can be implemented” (oM80). LiFE participants appreciated the flexibility of home visits (e.g., individual scheduling, no travel time) and the individual supervision by a trainer “That’s why I was really glad to have my own trainer. Who could tell me, that I was doing it correctly. Who corrected me” (oF80).
gLiFE participants suggested that receiving one home visit in addition to the group sessions, “to have one’s attention directly drawn to where in the house, when in the household, you could do this”, would be “an enhancement” (gF84).
In LiFE, the transition from being supervised by a trainer at home to practicing alone might have been more difficult; one LiFE participant recalled the two booster phone calls as important: “First you have the regular supervision and suddenly it stops. And then you have to see how to get on alone. And I found it [phone call] quite good” (oF72).
Forming habits. Participants from all FGs identified opportunities to integrate activities into daily routines, and some activities became habitual: “For me, it became a habit – I don’t want to say that I do everything. But now I tend to remember it and then I do it” (gF82) and “[…] it’s like learning a new language. In the beginning you’re studying two, three hours every day and then at one point you know the basics and can just use them without thinking” (oM78). gLiFE and LiFE participants described activities being connected to situational, object-related, or activity-based cues: “It did indeed remind me, when in a certain course of action, AHA!, now you could integrate this” (gF84).
Planning actions. One key psychological strategy of both interventions is action planning. One gLiFE participant described that the activity planning helped her: “It [activity planner] was really good to get started […] because it provides an incentive […] to actually do it” (gF70). However, a few gLiFE participants felt like the action plans they made during the group sessions were not applicable in a home environment: “how I was doing it in the beginning, doing this and that while brushing teeth, that just did not work” (gF78). Some LiFE participants found the activity planner tedious and “too silly” (oM80). One LiFE participant specifically stated: “I would like to do it spontaneously […] I could never say, so now when I brush my teeth I do this forward and backward thing, only when it comes to my mind I do it” (oF82).
Outcome experiences. The majority of gLiFE and LiFE participants shared positive outcome experiences, like improvements in physical functions or mobility (“Since I walk the stairs so often, […] my knee became better”, gF70) or a more active daily life (“I use the car less often”, oF74). A few participants reported improvements in their fear of falling: “For me it took away the fear of falling” (oF92). Others stated that their fear of falling was persistent:” Despite participating in this program, I am always afraid of falling again” (gF78).
Confidence in doing. gLiFE and LiFE participants were confident about their capability of performing the activities and saw practicing LiFE as their responsibility: “If I don’t have the discipline myself, then another meeting is not going to help me […]” (oF72). A few participants in gLiFE reported adopting a role as a motivator for others to be more physically active: “So you can [teach] others, if you want to of course and if they accept it. You can motivate them and say, simply integrate this into your daily life. And that does, it does help really (oF82)”. Some LiFE participants anticipated that their exercise routine might fade without regular home visits over time. One of the LiFE focus group participant stated that not seeing the personal relevance for themselves, or more important things on their agenda, kept them from implementing activities into their lives: “As I have already said, I don’t take this [LiFE] so seriously. I have a lot of other things to do in my life, I have a house, I have a garden to take care of and then I also have a lot of hobbies (oF80)”. Both LiFE participants and gLiFE participants describe their confidence being influenced by what others might think about them exercising: “So I live on the ground floor and many people pass by outside and then if I for example walk on my heels I watch and make sure that nobody thinks, ‘oh god, what is she doing, how is she walking around so stupidly.’ It looks so foolish (oF74)”.