Recipient and Instructor perspectives of an adapted exercise-based fall prevention program for older adults with vision impairment: a qualitative study nested within a randomised controlled trial

People with vision impairment are at an increased risk of falls compared with their sighted peers, but have very little access to existing community fall prevention programs. The Lifestyle-integrated Functional Exercise (LiFE) program can prevent falls in older people and may be suitable for adults aged ≥50 with vision impairment. The LiFE program was adapted for older adults with vision impairment (v-LiFE) and delivered by Orientation and Mobility Specialists (Instructors), who are experienced with individualised programs for people with vision impairment. Perspectives of older adults with vision impairment (recipients) receiving the v-LiFE program and their Instructors were explored through semi-structured interviews.


Background
In Australia, the population of people aged ≥65 years is projected to increase from 14% in 2012 to 18.3-19.4% in 2031. 1 Over 80% of injury-related hospital admissions of people ≥65 years are a result of falls, representing the leading cause of injury-related morbidity and mortality in older Australians. 2 Older adults with vision impairment experience deteriorated postural stability at a younger age (<60 years) 3 and have higher risk of falls and fall-related injuries, compared with their sighted peers. 4,5 A recent systematic review showed that exercise alone can reduce falls by up to 39% in high-risk populations for programs which include 3+ hours of exercise per week and focus on balance. 6 To date, however, there are no proven exercise-based falls prevention programs for older adults with vision impairment. 7 The Lifestyle-integrated Functional Exercise (LiFE) program has been shown to decrease falls by 31% in community-dwelling older adults. 8 The LiFE program requires participants to integrate strength and balance activities into their everyday routines, to enhance adoption and adherence of the program through habit formation. 8,9 Following pilot testing in adults ≥50 years with vision impairment 10 , an adapted program for this population (v-LiFE) was proposed for state-wide evaluation throughout New South Wales (NSW) and the Australian Capital Territory (ACT), Australia. The program was delivered by Orientation and Mobility Specialists (Instructors) from a community organisation (Guide Dogs NSW/ACT) 11 , with experience delivering individualised programs that enhance safe, confident and independent travel of people with vision impairment in their home or community environment. 12 Little is known about the perspectives of Instructors delivering falls prevention programs to their clients, as these programs are usually outside Instructors' scope of practice. 13 Similar professions (e.g. occupational therapy) routinely investigate professionals' perspectives to inform clinical practice as part of their evidence-based models. 14 Positive findings in the general community, not replicated in those with vision impairment, warrant further investigation of how programs can be adapted to improve accessibility and adherence of people with vision impairment. This study documents the adaptation and implementation of the v-LiFE program from the perspectives of Instructors involved in delivery, as well as the older adults with vision impairment receiving the program.

Methods
Instructor and recipient perspectives were triangulated to systematically investigate delivery of an exercise-based falls prevention program in people with vision impairment (v-LiFE). This aim was addressed through a range of data sources:

Older adults with vision impairment
Older adults with vision impairment were recruited from the intervention group of a randomised controlled trial (RCT). 11 Eligibility included community-dwelling adults ≥50 years with vision impairment severe enough to interfere with daily living, and no diagnosis of dementia. A total of 294 participants were allocated to receive the v-LiFE program, of which 172 had finished the program at the time of interviews for the present study.

Orientation and Mobility Specialists (Instructors)
Instructors from Guide Dogs NSW/ACT, trained in the v-LiFE program, who delivered at least one v-LiFE program session to an older adult with vision impairment were eligible to participate in the present study. A random sample of Instructors were invited for interview, which were conducted until data saturation was reached.

Program
The original LiFE program was designed using habit formation theory 8,9 , and aligns with the ethos of the behaviour change wheel. 15

Training the Orientation and Mobility Specialists (Instructors)
Instructors were trained in the v-LiFE program in a two-day workshop, by the designer of LiFE (LC) and a physiotherapist involved in program development. Instructors were provided ongoing support by the physiotherapist and an experienced colleague (LD).
Email or phone support was recorded, as well as any time the physiotherapist or experienced colleague attended a session with Instructors.

Older adults with vision impairment perspectives
After completion of the v-LiFE program, recipients were invited to complete a postintervention semi-structured telephone interview with an independent researcher (HN).
Although the v-LiFE program typically took three months, recipients were contacted four months' post-baseline to allow for any breaks within programs that may have occurred, or  15 , since previous studies called into question the adherence of older adults with vision impairment to exercise-based falls prevention programs. 17 Questions were asked about reducing barriers and increasing delivery of the v-LiFE program to older adults with vision impairment.

Data analysis
Transcripts of the semi-structured interviews from recipients and Instructors were analysed using QSR International NVivo 11 qualitative data analysis software. Using deductive analysis 18

Initial adaptations
The participant manual, activity planner and activity counter all needed to be made accessible to people with vision impairment. 11 The participant manual was modified into large print, electronic (PDF) and audio (CD) versions to suit a variety of vision conditions and preferences. The LiFE manual was also updated to shorten text, and case studies were replaced with examples of people with vision impairment, to ensure participants could identify with the program. The activity planner and activity counter were modified into large print, extra-large print, and electronic (PDF) versions. Participants were encouraged to use whatever device or method of recording they were already familiar with in order to increase compliance. Examples of recording methods included tally counters, voice recorders, counters in a box, marking calendars or electronically recording activities using spreadsheets or word processing software.
Previous pilot testing 10 revealed that the standard number of sessions for LiFE was insufficient to adequately train participants in all program activities. Consequently, Instructors were given the option to include an additional two sessions, if required.
Instructors were encouraged to facilitate participants' learning by using tactile modelling, verbal instructions, and introduce cues to prompt action (behavioural, situational and environmental) and encourage practice, repetition and reinforcement of activities.

Ongoing adaptations
In the interviews, Instructors reported using a person-centred approach to adapting and delivering the program. Overall, the program was tailored to participants' preferences, home environment and health status. Table 1 shows specific adaptations reported by Instructors. Adapted program activities for comorbidities and injuries using performance in the v-LiFE Assessment Tool, professional judgement and advice from the physiotherapist LiFE trainer Program materials Participant manual: Large text, audio, pdf Recording devices: Large text activity planner and activity counter, word processing software document, spreadsheets, voice recorder, beads v-LiFE Assessment Tool: Used at the start to guide level of activities, but also used at the end to reinforce progress Activity frequency Routine-based (as per LiFE) or allowed LiFE activities to be completed as a block based on participant preference Number of sessions Additional sessions for older participants, those with health issues, or those having trouble remembering activities Fewer sessions for younger participants, those without health issues, or those who implemented activities quickly Prompts to perform activities Home item prompts (such as a tissue box out of place, or a tooth brush placed in a lower drawer) Prompts specific to those with low vision: Coloured/big markers/stickers Prompts specific to those who are blind: Tactile markers Family Family assisted in recording and monitoring completion of activities

Training and support required for Orientation and Mobility Specialists (Instructors) to deliver v-LiFE
Seventy-three Instructors received two days of training (approximately 9 hours) in the v-LiFE program. Of these, 51 (69.9%) delivered at least one session to participants between March 2017 and April 2019 ( Table 2). Of these 51 Instructors, the physiotherapist provided phone or email support to seven (13.7%) and two (3.9%) Instructors, respectively. On Instructor request, the experienced colleague attended sessions with two (3.9%) Instructors, and provided phone or email support to 14 (27.5%) and 12 (23.5%) Instructors, respectively.

Older adults with vision impairment
Of the 294 RCT participants randomised to receive v-LiFE, 172 finished the program and were contacted for phone interview between March 2017 and April 2019. Of these, 3 were unreachable or declined interview and 15 had withdrawn from the study. Interviews were ceased at 154 interviews due to thematic saturation, and no more participants invited after this point. Table 3 shows the demographic characteristics of the 154 v-LiFE recipients who completed the post-intervention interview.

Orientation and Mobility Specialists (Instructors)
Twenty Instructors were invited to participate in an interview between June and August 2018; of these, eight were unreachable and one declined following initial interest.
Interviews were ceased at 11 interviews due to thematic saturation, and no more Instructors invited after this point. Table 4 shows characteristics of the 11 Instructors who completed the interview.  Table 5 with illustrative quotes). Program implementation was also interpreted within habit formation theory 20 which was the basis for v-LiFE. Overall, recipients were able to access and engage with the program. However, the program was considered too easy for younger recipients or those already undertaking physical activity or exercise. Instructors generally enjoyed delivering the program and saw it as an extension of their work. Although criticism was scarce, there was some criticism of the high number of activities and difficulty in recording activities for a wide range of participants with different levels of vision or ability to utilise technology.

O&M = Orientation and Mobility, v-LiFE = Lifestyle-integrated Functional Exercise program for people with vision impairment
Older adults with vision impairment perspectives Delivery aptitude. Although not explicitly asked, delivery by Instructors was well-regarded based on a perceived good understanding of how vision influences mobility, and the need to adapt activities accordingly. Recipients also appreciated the regular one-on-one sessions in their home and found the program pace well-suited to them.
Social norms. Recipients reported that they would recommend the program to someone like themselves, including those with or without vision impairment, particularly because the program is individualised and aims to improve strength and balance. Recipients who said they would not recommend the program to someone like themselves were usually younger (≤ 65 years) and stated the program would be more appropriate for someone older or less mobile.
Habit formation. Either embedding v-LiFE activities into daily routines or doing the activities in sets was reported. For most, embedding was the preferred method. This aligns with habit formation theory, whereby behaviours are repeated in response to contextual cues, until which point they become automatic. 20 However, some recipients preferred to modify the program so that activities were done together rather than throughout the day, often because of time constraints, or preference for a more traditional set-based exercise program.

Orientation and Mobility Specialist (Instructor) perspectives
Individualised adaptations.
Number of sessions. Views were divided among Instructors about whether they should modify program length for each participant or not. For those who didn't, it was usually because of concern about deviating from the research protocol. All Instructors reported that if the program was rolled out as part of usual service delivery in the future, they would vary session number based on recipients' circumstances.
Program materials. Typically, recipients' level of vision had the most impact on whether materials were used and/or modified. For those with functional vision, the activity planner and activity counter were used to record activity completion. For those with low vison, the planner and counter were modified with less text/increased font size. For those with low or no vision, tactile markers were used to aid or replace the activity planner or counter. Other technologies, such as voice recorders or electronic documents were used for some. For those who lived with others, a family member often assisted with completing the activity planner and counter.
Complimentary to scope of practice. All Instructors interviewed reported feeling comfortable and supportive delivering the v-LiFE program to older adults with vision impairment. The benefits experienced by recipients during the program were particularly motivating, and the clear structure of the program was appreciated by the Instructors.
Conversely, Instructors reported that other work priorities, such as travel and data collection for the RCT, were external barriers to delivering the program.
Challenges to delivery. Although reported challenges were scarce, Instructors noted two main challenges when delivering the v-LiFE program to older adults with vision impairment. The first related to the large number of activities recipients were required to embed into their daily routine, particularly those who were older or with cognitive issues.
The second related to recording activities; although there were many options to record activities, there were instances where Instructors had difficulty finding a method appropriate to the recipient's vision, memory or technological ability.

Discussion
This study revealed that Instructors made dynamic adaptations to the v-LiFE program, Specialists may be a viable mode of delivery for older adults with vision impairment.
Environmental restructuring and enablement were found to be particularly instrumental to the positive attitudes of recipients and Instructors in the delivery of the v-LiFE program.
Environmental restructuring and enablement facilitate behaviour change through changing the physical or social context, and increasing means and reducing barriers, respectively. 15 People are often reluctant to participate in falls prevention programs due to competing priorities, as well as travel concerns 16,21 , particularly those with vision impairment who may have additional mobility issues. 21 These barriers were alleviated through delivery of the v-LiFE program in the home, and tailoring the mode of activity completion (activities completed throughout the day or in a block). Also, the program was delivered by professionals with expertise delivering individualised programs to people with vision impairment, further improving recipients' physical opportunity (a source of behaviour) to participate in the program.
A motivational barrier to participation for some of the younger (≤65 years) or more active recipients was that they did not perceive a need to reduce their risk of falling. Elskamp et al 21 investigated reasons people refuse to participate in falls prevention trials, and similarly found that younger and more active participants considered themselves 'too healthy' to participate in a falls prevention program, despite having presented at an Emergency Department due to a fall. However, participants did recognise the benefits for other older adults. 21 These findings are consistent with other similar studies 16 , as well as those targeted at older adults with vision impairment 22 , which concluded that people do not want to consider themselves at risk of falls because of the negative connotations associated with this perception. A point of difference in this study is that our participants agreed to and participated in a fall prevention trial, and still considered the program not suitable for them. According to the COM-B model, reflective motivation can be improved through education, persuasion, incentivisation and coercion. 15 It is possible our participants did not realise or did not want to think they were at risk of falls; did not recognise the additional functional benefits related to improvements in strength and balance from participating in an exercise fall prevention program; or weren't overly challenged by program activities. Adaptations to this particular program are needed to make it more motivating to younger, more active people with vision impairment. In a small feasibility study, Schwenk et al 23 24 It is critical to document these adaptations in order to understand the impacts specific adaptations may have on the positive findings when these programs are evaluated for effectiveness. 25 The practical adaptations reported in this paper can inform future research and further integration of public health interventions for people with vision impairment.

Strengths and limitations
Strengths of this study are the in-depth investigation of the perspectives of both receivers and deliverers of a novel program, and a rigorous analysis process using an accepted theoretical framework. Further, Instructors were trained in and delivered a state-wide program across regional and metropolitan areas. However, a limitation is that the

Consent for publication: Not applicable
Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests:
The authors declare that they have no competing interests

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