The evaluation of technology-delivered fall prevention programmes for community-dwelling older people

Background: Falls and fall-related injury among older people are a major public health burden. Exercise-based fall prevention programmes are effective in reducing falls in older community-dwelling people. However, this effectiveness is hampered by low participation and adherence. Digital technologies are a novel and potentially effective method for delivering tailored fall prevention exercise programmes to older people. Aims and objectives: This thesis aims to evaluate the effectiveness, acceptability and cost-effectiveness of technology-driven fall prevention programmes in older community-dwelling people. The following research questions were examined: Are eHealth-delivered exercise programmes effective at improving balance in people aged 65 years and older living in the community compared to a control? Is a home-based balance exercise programme delivered through a tablet-based technology acceptable to older people living in the community? Is an e-Health balance exercise programme a cost-effective way to reduce falls and injurious falls in community-living older people compared to usual care? Methods: A series of related studies were conducted to answer these questions, including: a systematic review with meta-analysis, a qualitative study, and a health economic evaluation. The systematic review and meta-analysis evaluated randomised controlled trials of eHealth-delivered exercise programmes for community-dwelling people aged 65 years and over, published in English. The primary outcomes were static and dynamic balance. Secondary outcomes included fall risk and fear of falling. The standardised mean differences (SMDs, Hedges’s g) were calculated with 95% confidence intervals from random effects meta-analyses. The qualitative study recruited 50 participants from StandingTall, a large randomised controlled trial which delivered a home-based fall prevention programme via a tablet-computer. Participants were selected using purposive sampling and to ensure maximum variability. Data was collected via one-on-one interviews by qualified research staff at one of three different time points (1 month, 6 months and 12 months) over 12 months. Interviews were transcribed verbatim, verified for accuracy and then analysed thematically. The economic evaluation was a within-trial evaluation of StandingTall. Five hundred and three people aged 70 years or over participated. Cost-effectiveness was measured as the incremental cost per fall, and per injurious fall, prevented. General linear models were used with a gamma distribution for costs and a Poisson regression for rates of falls and injurious falls. Incremental Cost-Effectiveness Ratios (ICERs) were calculated to assess the additional expenditure required to generate an additional unit of benefit. One-way sensitivity analysis and sub-group analyses were performed. Results: The systematic review and meta-analysis identified nine trials of 498 participants. Eight trials measured static balance, with the pooled effect indicating that eHealth-delivered exercise programmes have a significant effect on static balance (eight trials; SMD = 0.40; 95% CI 0.14 to 0.67). All nine trials measured dynamic balance to find there was no effect on dynamic balance (nine trials; SMD=0.22; 95% CI -0.09 to 0.54). Three trials measured fall risk to find there was no evidence of an effect of eHealth-delivered exercise programmes on fall risk compared to control (SMD=0.28, 95% CI -0.06 to 0.63; I2 = 42.9%, p = 0.173). Three trials measured fear of falling to find there was no evidence of an effect of eHealth-delivered exercise programmes on fear of falling compared to control (SMD = -0.07, 95 % CI -0.34 to 0.20; I2 = 0.0%, p = 0.950). The qualitative study identified eight themes, which fall into two categories: experiences of using StandingTall and the design of StandingTall. Overall, participants appreciated the flexibility of StandingTall’s tablet-based online delivery, and described an improvement in physical awareness and confidence with everyday activities. Participants also reported various challenges with the technology, and determined that computer literacy is essential for successful engagement. Despite this participants found the overall design of StandingTall as user-friendly, clear, and easy-to-understand. The economic evaluation found the total programme delivery and care resource cost was $8,321 (standard deviation, SD 18,958) to intervention participants and $6,829 (SD 15,019) to control participants. The incremental cost per fall prevented was $4,785 and per injurious fall prevented was $6,585. Discussion and conclusion: Falls present a major age-related health challenge for society, and one which is likely to grow in significance as life expectancy increases. This body of research has provided preliminary evidence to demonstrate that balance exercise programmes delivered using technology are an effective, cost-effective and acceptable way of improving balance in older people. This, in combination with the ubiquitous availability of technology, could allow rapid scale-up and implementation of eHealth fall prevention programmes to large populations.