In 2014, 15.6% (more than six million) of the Canadian population was aged 65 years or older [1]. By 2030, it is estimated that seniors will constitute 23% (more than 9.5 million) of Canadians [1]. Aging is related to decreased muscle mass and strength as well as declined cognitive speed and memory performance [2-7]. Balance control also decreases during aging, likely due to reduction in muscle strength and joint range of motion, increased reaction time, and changes in sensory systems [8]. Myers et al [9] and Carter et al [10] reported that a decrease in muscle strength, diminished cognitive function, and impaired balance in older adults increases the risk of falls. Approximately 30% of all community-dwelling seniors experience one or more falls every year [11-13]. Falls are estimated to cost the Canadian health care system Can$2 billion annually (in 2004 dollars) [14]. Almost half of all individuals who have had a fall experience a minor injury, and 5% to 25% experience a more serious injury like a fracture or sprain [15]. Most falls in community-dwelling older adults are due to slips and trips [16-18]. It is proposed that such falls occur due to a person’s inability to regain balance [16].

Physical activity and exercise promote healthy aging [8,19-28]. Resistance exercise has been shown to mitigate muscle fiber loss and improve balance and cognitive function [8,19-23,27-29]. Several studies have reported that resistance exercise combined with balance exercise could prevent falls in older adults [28,30-33]. It is thought that exercise accomplishes this by ameliorating specific age-associated physiological changes that act as risk factors for falls, including reduced muscle strength, impaired balance, and diminished cognitive function [9,10]. Promoting physical activity is specifically important among older adults living in rural communities because of the prevalence of physical inactivity and the greater likelihood of falls [34-37].

The Otago Exercise Program (OEP) was developed by Campbell and Robertson [28] in 1997 to prevent falls in older adults. This program consists of individually tailored exercises intended to improve strength and balance in seniors [28,30] (Figure 1). The exercises aim to strengthen lower limb muscles (eg, knee extensors and flexors, hip abductors, and ankle plantarflexors and dorsiflexors) and improve balance (eg, balance retraining exercises include knee bends, backwards walking, walking and turning around, sideways walking, tandem stance and walk, one leg stand, heel walking, toe walking, heel-toe walking backwards, and sit-to-stand activities). The OEP is designed to be performed at least three times a week for 30 minutes [28]. Participants are also encouraged to take short walks at least twice a week. The program is normally delivered by a physical therapist who makes four or five home visits with the individual over six months. During the initial visit, the physical therapist conducts a physical assessment on the individual and prescribes exercises from the instructional OEP booklet. Participants then receive a copy of the exercise booklet, ankle cuff weights, and a calendar to record exercise and fall frequency. The physical therapist makes progressive adjustments to the exercises in the follow-up visits.

Robertson et al [38] conducted a meta-analysis of the OEP using individual level data from the initial four OEP controlled trials [28,30-32,39] with a total of 1016 community-dwelling seniors. The results showed a 35% reduction in falls and fall-related injuries when comparing the exercise groups against the control groups (falls: incidence rate ratio [IRR] 0.65, 95% CI 0.57-0.75; fall-related injuries: IRR 0.65, 95% CI 0.53-0.81). The program was more effective in reducing injurious falls for individuals aged 80 years and older compared to younger individuals (IRR 0.54, 95% CI 0.34-0.87). The fall-reducing benefits were equal for older adults with and without previous falls and for women and men. Approximately 70% of participants in the OEP group were engaging in some exercise at the end of the studies. In a one-year randomized controlled trial, Liu-Ambrose et al [40] evaluated the effectiveness of the OEP in 74 community-dwelling seniors in British Columbia, Canada. After one year, the adjusted IRR of falls in the OEP group compared to the guideline care control group was 0.47 (95% CI 0.24-0.96). Gillespie et al [41] reported in a Cochrane systematic review that individual home exercise programs for community-dwelling older adults that incorporated two or more components of strength, balance, flexibility, or endurance exercises reduced the rate of falls (IRR 0.66, 95% CI 0.53-0.82) and the number of individuals falling (IRR 0.77, 95% CI 0.61-0.97). The review concluded that there was strong evidence supporting the use of the OEP for fall reduction among older adults. Suggested plausible mechanisms may include improvements in executive functioning, balance, and/or lower body strength.

Evidence supports the use of the OEP for reducing fall occurrences in older adults. It is not always feasible, however, to deliver the program in its current state in some rural communities because it requires multiple home visits by a physical therapist, and there is a shortage of health professionals, including physical therapists, in rural Canada [42]. Although 19% of the Canadian population lives in rural areas (Statistics Canada, 2011 Census of Population), only 8% of physical therapists work in rural or remote communities [43], so they usually have a heavy caseload. Due to these challenges, alternatives to the four to five physical therapist home visits are required in order to sustain the delivery of the OEP program in a rural setting. DVDs are a viable option for delivering health and lifestyle interventions. The sale of exercise DVDs experienced an annual growth of 11.2% from 2008 to 2012, with over 20% of them purchased by older adults [44]. Past studies suggest that adherence to video-based exercise programs can increase muscle strength [45,46], physical function [46,47], health-related quality of life [48], and psychological well-being in older adults [49]. Average adherence rates in these studies was 58% to 100% [45-49].

Liu-Ambrose et al recently developed and tested a new method of delivering the OEP to older adults in rural communities [50]. This pre-post study evaluated a new method that involved one in-person visit with a physical therapist, who performed an assessment and prescribed specific exercises from a new OEP DVD. The OEP DVD consisted of narrated video footage of a model performing the various exercises. The footage aimed to instruct, inform, and motivate the user. Prior to demonstrating each exercise, introductory narrated footage described the muscle(s) the exercise targets and its potential affects on physical function. This was followed by detailed instructions on how to perform the exercise. The physical therapist followed up with individuals monthly by telephone for six months to adjust their exercise program. Individuals also received an exercise manual, ankle cuff weights, and a program calendar.

We embedded a qualitative enquiry within the evaluation of this new method of delivering the OEP. The purpose was to understand older adults’ experiences in using the DVD-delivered OEP and to explore the barriers and facilitators to implementing this new method of OEP delivery.

This qualitative study is informed by the principles of grounded theory as outlined by Glaser and Strauss [51]. Grounded theory is a methodology that “uses iterative data collection (such as interviews, observations) and analysis to build theories about social phenomena” [52]. While generating a theory was not the goal of this study, an understanding of participants’ experiences was the intended outcome. The knowledge generated using this approach is developed inductively from the empirical data obtained in naturalistic settings.

A total of 32 people living in Sechelt and Gibsons, two rural communities in British Columbia, volunteered to participate in the six-month OEP evaluation (the main study). Individuals were eligible if they (1) were 75 years or older, (2) were community-dwelling (ie, not residing in a nursing home, extended care unit, or assisted care facility), (3) scored 24 or higher in the Mini-Mental State Examination (MMSE), (4) were capable of walking 100 meters independently (with or without assistive tools), (5) owned a working DVD player and television, and (6) were able to provide informed consent. The study excluded people who had (1) a previous diagnosis of a neurodegenerative disease, (2) a previous diagnosis of dementia, (3) a clinical stroke, or (4) a history indicating carotid sinus sensitivity (ie, syncopal falls). All participants from the main study were invited to partake in the qualitative study.

This qualitative study was composed of initial group interviews followed by in-depth individual interviews. The purpose of the groups was to explore the breadth of topics brought forth by participants and identify topics for further in-depth exploration by individual interviews. For the individual interviews, participants had the option of face-to-face or telephone interviews. During data collection, we recorded field notes and reflections. This study received ethics approval from the University of British Columbia (H11-01604) and the Vancouver Coastal Health Authority.

Following each interview, audio recordings were transcribed verbatim and verified. NVivo 10 software (QSR International) was used for data organization and analysis. An inductive constant comparison analysis was performed [53]. Each transcript was read and codes were assigned to sentences, paragraphs, and sections [53]. Codes were generated from the data and were not pre-determined. After initial coding, the data were constantly revisited until saturation was achieved [53]. Similarly coded sections were compared against each other to ensure consistency in the definition of the codes [54]. Codes with similar elements were combined to form categories [54]. These categories were then clustered around the research questions they contributed to answering, and broad themes and patterns were identified [53]. This analytical process was recorded and an audit trail was maintained. The first author (AA) led all analyses, and team members queried main categories and justifications. One investigator (LL) and one volunteer team member (MK, see Acknowledgements) reviewed four individual interview transcripts to enhance credibility by detecting issues in the analysis such as overemphasized or underemphasized points, vague descriptions, and assumptions made by the researchers.

Between April 2013 and January 2014, 21 OEP main study participants took part in the qualitative study (five participants in group interviews and 16 participants in individual interviews). The majority were female. Participants varied in age from 74 to 97 years, and half had some post-secondary education. Table 1 presents demographic characteristics of participants who completed group and individual interviews.

Eleven OEP main study participants did not participate in the interviews; of those, six were men. The age of the 11 individuals varied from 78 to 89 years, and six had a high school certificate or diploma as their highest level of education.

The majority of participants found the OEP to be useful and reported that the program positively impacted their physical and mental health. Participants felt that the OEP improved their balance and lower body strength, which some believed alleviated their fear of falling. Living with chronic health conditions acted as a significant barrier to engaging in certain activities, including domestic chores and exercise. Participants spoke about living very busy lives and managing their limited time to fulfill all their commitments. Nevertheless, most participants planned to continue performing the OEP in some capacity to further reap the benefits of the program.

The purpose of this study was to understand older adults’ experiences using the DVD-delivered OEP and explore the barriers and facilitators to implementing this new method of OEP delivery. Three themes emerged from the analysis of the interviews. The first theme represents how the OEP DVD provided participants with important guidance at program onset but was too slow, long, and low-energy for continued use. The second theme outlines participants’ appreciation of the flexibility of the program, but their own health, their loved ones’ health, and other activities in their lives sometimes make it challenging to exercise. The third theme describes participants’ beliefs about the benefits of social interaction in exercise programs like the OEP to maintain motivation and long term adoption of exercise habits.

Our findings suggest that existing health conditions associated with pain and fatigue may be a barrier for older adults to engage in an exercise program. This is in line with the literature [55-60]. In the Belza et al [55] qualitative study of 71 underserved, ethnically diverse older adults, barriers to physical activity included physical conditions, such as hearing or visual impairments and feeling tired or dizzy, and psychological conditions. Cohen-Mansfield et al [56] surveyed 324 community-dwelling older adults and found that the most common self-reported barriers to exercise were health problems such as depression and pain. Those authors suggested the need to address pain and depression and stress the importance of exercise even when living with health problems to increase older adults’ exercise participation. Programs like the OEP may be enhanced by integrating recommendations for accommodating adverse symptoms into the exercise instructions.

Participants largely felt that an OEP group, if they had the chance to access one, might have offered additional motivation to exercise. This supports other studies suggesting that social interactions and support are important facilitators of exercise in older adults [56,60-62]. In a qualitative study involving older adults, Stathi et al [62] identified social interaction as a reason for people attending group exercise sessions because they enjoyed connecting with others and expanding their social network. Fox et al [61] also demonstrated that older adults’ relationships with exercise instructors and peers facilitated their participation in an exercise program. Specifically, older adults felt that the group setting provided a friendly and supportive environment that offered socializing opportunities.

Social isolation is a major concern for older adults in rural communities. In a study by Paluck et al [63], older women living in a rural community spoke about the adverse impact that social isolation and loneliness had on their efforts to remain healthy, including engaging in exercise. Mutual support of peers in group settings could be a means to maintaining a physically active lifestyle in a rural community [63]. The themes generated in the current study are in line with a recent thematic synthesis of 132 qualitative studies involving 5987 participants on older adults’ perspective on participation in physical activity [64]. Particularly, social influences (eg, valuing interaction with peers, encouragement from others, dependence on professional instruction); physical limitations (eg, pain or discomfort, comorbidities); competing priorities (eg, work and family responsibilities); access difficulties (eg, environmental barriers including weather and transportation); personal benefits of physical activity (eg, strength, balance and flexibility, self-confidence, independence, improved health and mental well-being); and motivation and beliefs (eg, apathy, irrelevance and inefficacy, maintaining habits) were themes identified that resonated with our findings. It appears that an exercise program with DVD demonstration and a clear manual in combination with one or two physical therapist visits and some optional community support may be an option to be explored in any community, rural or urban, in order to deliver proven fall-prevention exercise interventions.

This study has several limitations. All participants were individuals who completed the six-month OEP evaluation study. Individuals who did not meet a certain level of cognitive functioning (ie, score 24 or higher in the MMSE) or who had a clinical stroke or diagnosis of a neurodegenerative disease were excluded from the main study. This limits the transferability of the findings to older adults with characteristics similar to those in this qualitative inquiry [65]. Because most of the individual interviews took place over the telephone, the depth of the observational data collected was limited. For example, we could not observe nonverbal communications or body language. Moreover, data collection occurred throughout a 10-month period (April 2013 to January 2014). As such, several factors, including seasonal changes and holidays, might have influenced participants’ experiences with the exercise program. For example, the cold and rainy winter in British Columbia might affect people’s participation in outdoor activities such as walking. Such aspects might not have been fully explored during the interviews. Despite the limitations, the inductive nature of this study facilitated the emergence of findings that were grounded in the lived experience of participants in rural communities. Moreover, we included strategies such as peer review, field notes, journaling, and an audit trail, which have been shown to improve rigor and trustworthiness.

This study’s results construct an understanding of the experiences of older adults living in a rural community in using the new DVD-delivered OEP. Insight was gained on the facilitators and barriers to partaking in this program from the participants’ perspectives. First, the versatility and convenience of the written manual might make it easier for participants to complete the OEP. Next, the home-based design of the OEP provided the flexibility and sense of control over when and where to exercise, allowing participants to better integrate exercise into daily routines. In addition, social support from family and friends was identified by participants to facilitate adherence to the OEP. In terms of barriers, personal health concerns were a key hurdle to performing exercise. This finding supports the importance of highlighting the benefits of resistance exercise and physical activity for people with a variety of health conditions as a way to encourage older people to adopt and maintain an active lifestyle. Moreover, individuals might prioritize certain other obligations and activities over exercise; thus, in addition to personal health concerns, everyday responsibilities or activities should be discussed prior to the start of the program and methods of integrating the program with these activities should be promoted (eg, promoting the versatility of the written manual). Finally, the boredom participants experienced in the OEP once they were familiar with the routine could be ameliorated by including a greater level of social interaction during exercise. It may be useful to recommend to participants to perform parts of the OEP with family members or peers. By identifying the facilitators and barriers, this study provides the necessary background for the implementation of the DVD-delivered OEP in other rural communities.