Health behaviour change theory meets falls prevention- Feasibility of a habit-based balance and strength exercise intervention for older adults

Psychology of Sport and Exercise 22 (2016) 114e122

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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 1 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.fl (L. Fleig).
/>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 do 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 do 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


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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 5 items and
coping planning with 4 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 min follow-up phone calls (up to 9 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 1 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 1
Content of intervention by session based on the CALO-RE taxonomy (Michie et al., 2011).
Week 1

Week 2

Week 3

Week 4

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 6

Week 9

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 1 referred to how participants perceived the program content; category 2 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 7 group
sessions ranged from n ¼ 8 (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, 4 (31%) participants chose
to take part in the second follow-up phone call.
Quantitative analysis
Table 2 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 do 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 2
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 5 Dimensions; VAS ¼ Visual Analogous Scale.


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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 3 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 do 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 do 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 3
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 do 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 do it without thinking (Ruth, age 70)
Problem solving
Talk over what I was having difficulties with and what to do (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 do (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 do 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 do 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 do 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 do 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


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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 do 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 do 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 do 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 8 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 do 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; Ziegelmann & Knoll, 2015). In later life, promoting
physical activity through lifestyle-integrated activities rather than
through formal exercise sessions may be more encouraging and
effective to sustain activity. This may be especially true for those
with mobility impairments.
Acknowledgements
We gratefully acknowledge the generosity of our study participants and the support of the Centre for Hip Health and Mobility
staff. We also acknowledge Canadian Institutes of Health Research
(CIHR) for operation funds for this project. Dr. Ashe is supported by
career awards from the CIHR and the Michael Smith Foundation for
Health Research (MSFHR). The sponsor had no role in the study
design; collection, analysis, and interpretation of data; writing the
report; and the decision to submit the report for publication.
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