Psychology of Sport and Exercise 22 (2016) 114e122 Contents lists available at ScienceDirect Psychology of Sport and Exercise journal homepage: www.elsevier.com/locate/psychsport Health behaviour change theory meets falls prevention: Feasibility of a habit-based balance and strength exercise intervention for older adults Lena Fleig a, b, c, *, Megan M McAllister a, b, Peggy Chen a, b, Julie Iverson d, Kate Milne e, Heather A McKay a, b, Lindy Clemson f, Maureen C Ashe a, b a Centre for Hip Health and Mobility, Vancouver, Canada Department of Family Practice, The University of British Columbia, Vancouver, Canada €t Berlin, Berlin, Germany Health Psychology, Freie Universita d Parks & Recreation Vancouver, Vancouver, Canada e Cardea Health Consulting, Vancouver, Canada f Faculty of Health Sciences, The University of Sydney, Sydney, Australia b c a r t i c l e i n f o a b s t r a c t Article history: Received 20 May 2015 Received in revised form 30 June 2015 Accepted July 2015 Available online 17 July 2015 Objectives: Habit formation is a proposed mechanism for behaviour maintenance Very few falls prevention studies have adopted this as an intervention 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 FrameworkMethod to post-intervention, semi-structured interviews to evaluate program content and delivery Results: In total, 10 of 13 women completed the program (Mage ¼ 66.23, SD ¼ 3.98) and showed changes in their level of action control [mean differenceT1ÀT2 ¼ 1.7, 95% CI (À2.2 to À0.8)], action planning [mean differenceT1ÀT2 ¼ 0.8, 95% CI (À1.1 to À0.2)], automaticity [mean differenceT1ÀT2 ¼ 2.5, 95% CI (À3.7 to À1.2)], and exercise identity [mean differenceT1ÀT2 ¼ 2.0, 95% CI (À3.2 to À0.8)] 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 Keywords: Habit formation Balance and strength exercises Older adults Falls prevention Mixed methods Feasibility 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 guidelines for regular physical activity across the lifespan that include a * 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) http://dx.doi.org/10.1016/j.psychsport.2015.07.002 1469-0292/© 2015 Elsevier Ltd All rights reserved number of recommended components; aerobic, musclestrengthening, 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, L Fleig et al / 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' engagement 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 behaviours 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 experiences 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 maintenance 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 performed efficiently, without awareness, control, and potentially without intention (Bargh, 1994) Similar to other motivationalvolitional theories of health behaviour change (e.g., integrated behaviour change model, Hagger & Chatzisarantis, 2014; health action 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 behaviour (e.g., one-leg stand) in an unvarying context over and over again (e.g., while brushing teeth) thereby strengthening a mental representation 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) Individuals are encouraged to 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 115 behaviour repetitions as individuals encounter them very frequently (i.e., every day) and in close proximity (i.e., in homebased environment or close neighbourhood) Most importantly, in comparison to time-based cues, such external cues 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 Functional 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 balance 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 permission 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 exercise 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 incentives for study participation Intervention The EASY-LiFE program duration was four months We followed the LiFE protocol established by Clemson et al (2012) Specifically, the intervention consisted of seven two-hour group sessions, and 116 L Fleig et al / Psychology of Sport and Exercise 22 (2016) 114e122 Scholz, et al (2005), namely ‘I am sure that I can engage in balance and strength exercises at least five times a week, even if I feel a strong temptation not to exercise,’ and ‘ … even if I don't see success immediately’ Action planning was measured with items and coping planning with items as per Sniehotta, Scholz, et al (2005) and Sniehotta, Schwarzer, et al (2005) General use of action planning 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 progress?” (Baldwin, Rothman, Hertel, Keenan, & Jeffrey, 2006; Fleig, Lippke, Pomp, & Schwarzer, 2011a) As part of the semistructured interviews (described below) we also asked participants 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 otherwise stated, response formats for psychosocial measures were 5point Likert scales, ranging from completely disagree (1) to totally agree (5) two 30 follow-up phone calls (up to contact sessions) During each of the group sessions a certified exercise physiologist, accompanied by a personal trainer, introduced and reviewed balance 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, participants completed the Life Assessment Tool (LAT) with an exercise professional (Clemson et al., 2012) We deviated in two ways from the original protocol by Clemson et al (2012) First, we asked participants 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 session 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 describes 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 (see Table 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) Qualitative measures We also requested that participants take part in a semistructured 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 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 least five times a week.” Self-efficacy was measured with two items adapted from Sniehotta, Table Content of intervention by session based on the CALO-RE taxonomy (Michie et al., 2011) Week Week Week Week Shaping knowledge (i.e., information on antecedents of habit formation) Shaping knowledge (i.e., instruction on how to perform the behaviour) Demonstration of behaviour Feedback on behaviour (i.e., form) Behavioural practice/rehearsal Graded tasks Goal setting (behaviour) Review of goals Focus on past success Action planning Prompt/Cues Self-monitoring of behaviour Social support (practical) Social support (emotional) Use of follow-up prompts Relapse prevention/Coping planning Barrier identification/problem-solving Habit formation x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x a x x x x Week 11 and 15 were individual follow-up phone calls x x x x x Week Week Week 11a Behaviour change technique Week 13 Week 15a x x x x x x x x x x x x x x x x x x x x x x x x x x x x x 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 participants attended exercise intervention sessions Two additional interviews were conducted via telephone All interviews 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 percentiles if data were skewed Given the small sample size and the feasibility character of the study we refrained from using significance testing (Arain, Campbell, Cooper, & Lancaster, 2010) All analyses 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 authors (LF, PC) individually familiarized with the interviews, together developed an early conceptual model with “barrier” and “strengths” codes for two broad categories Category referred to how participants perceived the program content; category referred to participants' perceptions of program delivery After coding the first 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 generating a matrix in an excel spreadsheet The authors discussed the spreadsheets, compared and agreed upon coding allocations 117 highly educated (85% with at least post-secondary education, n ¼ 11) with a mean age of 66 years (SD ¼ 4.0, 59e71) More than half of all participants (70%, n ¼ 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, Q90 ¼ 10) and their overall experience with the program (Mdn ¼ 4.8, Q10 ¼ 3.5, Q90 ¼ 5) Participants who dropped out reported lower quality of life at baseline (Mdn ¼ 0.64) compared with those who completed the program (Mdn ¼ 0.84) Attendance for the group sessions ranged from n ¼ (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 (Mdn ¼ 6) Ten participants (77%) took part in the first follow-up phone call, (31%) participants chose to take part in the second follow-up phone call Quantitative analysis Table provides 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 between 18 and 35 (M ¼ 23.0, SD ¼ 0.1) minutes Results There were 13 participants who initially consented to take part in the study Retention rate at the final assessment was 77% (10/13) The reasons for withdrawal were flair up of a previous health problem (n ¼ 2) and a family emergency (n ¼ 1) Participants were Participants' perceptions about program content: what motivates individuals and which strategies 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 Characteristics of study participants across the two time points of the study.a Characteristics Psychological variables Mean (SD, range) Intention Self-efficacy Mean (SD, range) Action planning When Where How How often With whom Mean (SD, range) General use of action planning Mean (SD, range) Coping planning Mean (SD, range) Action control Mean (SD, range) Habit strength Automaticity Self-identity Short physical performance battery Balance score Gait score Sit to stand score Total score Mean (SD, range) Gait speed, (distance/s) Subjective health Mean (SD, range) EQ5D-5L VAS score Mean (SD, range) EQ5D-5L a Baseline (N ¼ 13) Final-6 months (n ¼ 10) 4.2 4.0 3.3 3.4 3.3 3.1 3.4 3.2 2.9 3.4 2.3 2.4 2.8 2.7 (0.6, 3.0e5.0) (1.0) (1.0, 2.0e5.0) (0.9, 2.0e5.0) (1.0, 2.0e5.0) (1.1, 2.0e5.0) (1.2, 2.0e5.0) (1.1, 2.0e5.0) (1.8, 1.0e5.0) (1.0, 1.5e5.0) (1.1, 1.0e4.0) (1.9, 1.0e6.3) (2.1, 1.0e6.4) (2.3, 1.0e7.0) 4.3 5.0 4.1 3.8 4.0 4.6 4.0 4.0 3.7 3.7 4.0 5.2 5.3 4.7 (0.6, 3.0e5.0) (0.4) (0.9, 1.8e5.0) (1.1, 1.0e5.0) (1.2, 1.0e5.0) (0.5, 4.0e5.0) (1.3, 1.0e5.0) (1.3, 1.0e5.0) (1.6, 1.0e5.0) (1.0, 1.0e4.3) (0.9, 2.0e5.0) (1.3, 3.6e7.0) (1.2, 3.6e7.0) (1.8, 2.0e7.0) 4.0 4.0 3.0 11.0 1.1 (0.0) (0.0) (1.0) (1.0) (0.2, 0.8e1.3) 4.0 4.0 3.5 11.0 1.1 (0.0) (0.0) (1.8) (1.8) (0.2, 0.8e1.3) 86.1 (11.1, 65e98) 0.8 (0.2, 0.4e1.0) 89.1 (7.0, 75e95) 0.9 (0.2, 0.8e1.0) Results are median (IQR) unless stated; EQ5D-5L ¼ EuroQol quality of life questionnaire Dimensions; VAS ¼ Visual Analogous Scale 118 L Fleig et al / Psychology of Sport and Exercise 22 (2016) 114e122 intentions, memory and attention, behavioural regulation, reinforcement (including direct experience), social influences, and social role We added a further theme of “barriers” to capture challenges that participants anticipated would impede their exercise goal pursuit beyond the program We expand on these themes below Table provides 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 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 the exercises (Maria, age 64) Whereas the exercise professionals focussed on providing procedural knowledge during group sessions, the health psychologist presented information on the psychological mechanisms of habit formation Participants appreciated the interdisciplinary character of the sessions (see Table 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 emphasized that they enjoyed learning about the scientific evidence on Table Participants' perceptions about program content: Motivation and strategies to change behaviour Facilitators Challenges 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) 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 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 it without thinking (Ruth, age 70) Problem solving Talk over what I was having difficulties with and what to (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 (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) Theoretical domain of behaviour change With some [exercises] I'm not sure I'll be able to turn them into a habit (Jane, age 66) L Fleig et al / Psychology of Sport and Exercise 22 (2016) 114e122 habit formation, hearing about research, the studies that you presented (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 (see Table 3) Skills During every group session (guided by exercise professionals), 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 appreciated that they were given exercise options tailored to their physical capabilities One participant mentioned that the heterogeneous group slowed down her individual progress (see Table 3) Beliefs about consequences Participants frequently referred to health-related reasons for joining the program Whereas some participants described positively framed expectations such as preserving 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 (see Table 3) In particular, 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 (see Table 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 the exercises (see Table 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 recommended exercises, participants reported gaining mastery, but also mentioned that at the end of the program, they still faced some challenges (see Table 3) Memory and attention Remembering to 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 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 the activities, getting it on your iPhone, really helped to remember triggers (Pat, age 62) Another participant described how her Fitbit [wearable, electronic 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 119 their posture and paid more attention to executing the exercises (see Table 3) Behavioural regulation To promote habit formation of the balance and strength exercises, participants were encouraged to use paperbased 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 [selfmonitoring 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 (see Table 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 immediate and ‘outsourced’ self-monitoring and feedback options (see Table 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 (see Table 3) Although the usefulness of prompts to action was generally valued, completing the weekly planning sheets was frequently cited as repetitious, irritating, and annoying to fill in all the time (Jane, age 66) Participants described their experience with filling 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 the fit between the planningsheet strategy and her needs (see Table 3) Participants very frequently referred to their established balance and strength exercise 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 selfcare 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 continuous 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 problemsolving strategies as helpful (see Table 3) Reinforcement Participants described different experiences with practicing balance and strength exercises Whereas some interviewees emphasized the enjoyment they felt by doing the selfdirected 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 120 L Fleig et al / Psychology of Sport and Exercise 22 (2016) 114e122 mentioned that finding out how other group members managed to embed the exercises into their daily routines was very motivating (see Table 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 (see Table 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 (see Table 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 it, I could see it really helped her’, Pat, age 62) Participants also planned to facilitate their own program (see Table 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 professional, 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, interviewees 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, participants 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 afterwards’, 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-tomyself’-feature of the program In particular, interviewees highlighted 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 information and exchange, as well as exercise demonstrations were much emphasized themes As described by one participant, being shown how to 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 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 a fitness club (Linda, age 70) Discussion In this mixed-methods study, we aimed to evaluate the feasibility of an interdisciplinary, theory-based behaviour change program designed to encourage women at retirement age to embed balance and strength exercises into their daily routines In particular, we explored acceptability of intervention characteristics (e.g., delivery mode), as well as acceptance and utilization of the intervention 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 These findings underscore the program's potential to be tested in larger trials While gains in these psychosocial variables were pronounced, intervention recipients seemed to maintain baseline level of intention, selfefficacy and physical performance (i.e., SPPB), possibly due to a ceiling effect (e.g., high scores at baseline assessment) Our findings 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 processes of behaviour maintenance In particular, our quantitative results suggest that behaviour change strategies such as selfmonitoring, 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 automatic 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 triggers (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 challenges with how we implemented the behaviour change techniques action planning and self-monitoring Participants critiqued the frequency (i.e., weekly), duration (i.e., over 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 selfscreener (e.g., stage algorithm, Lippke, Ziegelmann, Schwarzer, & Velicer, 2009) may be applied to evaluate how far participants have progressed toward forming a habit Instead of filling in new sheets every week, it may be more feasible to suggest that participants 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 exercises 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 them correctly (i.e., based on provided procedural knowledge) Being mindful may also help participants derive enjoyment from the ‘doing’ 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 Qualitative findings 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 consequences 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 telephonebased 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 suggest 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 successful implementation can be replicated across different age and 121 sex groups Qualitative data were collected by the same person who facilitated the intervention and analysed the data Given that participants 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 performance 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 balance 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 increases 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 program 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 automaticity and self-identity among older women Theory-based principles of habit formation provide an acceptable and promising 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 principles of lifespan psychology (Gellert, Ziegelmann, Krupka, Knoll, & Schwarzer, 2014; 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