Towards a mobile exercise application to prevent falls: A participatory design process

IntroductionFalls represent the most common cause of injury in old age. At least one third of community-dwelling people aged 65+ fall each year, half of them more than once (1), and the incidence increases with advancing age (2). Falls are declared to induce the most costly injuries among older people, and these costs are expected to increase rapidly if the development continues (3). It is not only the fallrelated physical injuries that have devastating consequences for older people, but fear of falling and decreased balance confidence have major implications for quality of life and health, including loss of functional independence and participation in society. Fear of falling is particularly common among older women (4). Falls are often a result of the existence of multiple risk factors, such as impaired balance, gait, vision, and drug side effects. Therefore, it has been assumed that interventions that address several of these risk factors, i.e., multifactorial falls prevention, will be most effective. However, according to recent systematic reviews, exercise programmes that focus on balance combined with muscle strength in the lower limbs are as effective in reducing both the number of falls and fallers among communitydwelling older people (5,6).The positive effects of exercise in old age to prevent falls are generally not known by older people (7). There is a lack of guidance on how they can counteract or decrease their fall risk by regaining or maintaining balance capacity and physical strength. Furthermore, for those who are offered fall preventive exercises, low adherence has been reported as a major concern (8). Even though evidence consistently suggests that balance and strength exercises are effective in reducing falls and fall related injuries, these kinds of interventions are still only effective if the older people at risk actually adhere to the training and continue to exercise. Average adherence rates to group based exercise programmes as low as 50% to 75% are not uncommon (9, 10).Through innovative technology, preventive interventions like balance and strength exercises for the avoidance of falls can be made available to large populations in both rural and urban areas. A number of reasons for introducing these kinds of welfare technology have been mentioned, but the two most important are: 1) to help in the implementation and adaptation of preventive actions to reduce the effects of chronic diseases and age-related complaints (11), and 2) to empower people and enable them to manage their own health and disease, i.e., self-management (12). In addition, interactive welfare technology does also have the potential to provide meaningful and motivating exercises, if strategically applied.Building on existing evidence-based knowledge within the field of falls prevention the aim of the project presented in this paper is to develop, evaluate and implement a best practice fall preventive programme in the shape of an application (App) for smartphones and tablets to be used in people's own homes and surroundings. The goal is to implement the programme on a broad base, equally accessible in urban and rural areas, with the long term ambition to provide effective and empowering prevention methods for healthy ageing and the maintenance of body functions, activity and participation throughout the life span. This project consists of two phases: 1) the design phase (design and develop the mobile App for falls prevention together with older women and men); and 2) an evaluation of an implementation and effects phase (pilot study, implementation study, randomized controlled trial).The aim of the present article is to present the methodology used and resulting experiences from the design phase. The next section describes the setup and theoretical background, and the following section describes how the theoretical and methodological underpinning was applied in the development process.MethodsA cross-disciplinary research group consisting of researchers in physiotherapy, informatics and knowledge engineering, including experts in falls prevention, e-health, and gender research, planned and carried out a series of workshops for communitydwelling older people. …