Substance use disorders are a major contributor to the economic and healthcare burden in Australia. Therapeutic communities (TCs) are utilised treatment methods globally, though low program completion rates continue to represent a major obstacle in effective and sustainable drug and alcohol treatment. The aim of this study was to explore reasons for early withdrawal from TC programs and perceptions of successful recovery. This study also aimed to explore how employment and volunteering related to early exit and perceptions of successful recovery.Semi-structured qualitative interviews were conducted with 13 ex-residents from a long-term TC program at a community-based rehab organisation in regional Australia.Thematic analysis revealed a complex interplay of factors contributing to early TC withdrawal, and perceptions of successful recovery from a lived experience perspective and how this was shaped by employment and volunteering. Eleven themes were identified. Three relating to reasons for joining the program, which connected with ultimate withdrawal from the program: Pre-program existing relationships, pre-program employment situation and needing a ‘circuit breaker’ in their life. Three relating to reasons for early withdrawal: TC program characteristics, relationships during the program and planning future employment. Five relating to perceptions of successful recovery: Improved understanding of their addiction, reduced substance use, improved physical and psychological health, relationship success and employment success.Reasons for leaving treatment early are multi-faceted and revolve around relationships, planning future employment and program characteristics. The influence that each plays on their decision to leave early is varied and determined by the value they assign it. Perceived success extends far beyond achieving and maintaining abstinence to encompass improved relationships, psychological and physical wellbeing, understanding of addiction and employment, studying or volunteering. Self-worth and feeling able to contribute to society through employment, study and volunteering were perceived to be essential elements of successful recovery. Clinicians, policy makers and program developers should use the extended definition of successful recovery from the ex-clients perspective when determining the clinical and economic effectiveness of TC programs. Improvements in Drug and Alcohol (DA) treatment services help to address these issues, particularly by targeting demand reduction, peer-education networks, social competence training and increasing community engagement.Substance use disorders are a major contributor to the economic and healthcare burden in Australia; costing $55 billion annually through crime, road accidents, workplace productivity losses and healthcare costs . The NatTherapeutic communities (TCs) are drug-free residential rehabilitation programs where clients live together in a hierarchal-based supportive environment with increasing levels of social and personal responsibility . This trSuccess of these programs has been evaluated through a literature review of 16 controlled TC studies . TC resiLow program completion rates, ranging from 9 to 56%, continue to represent a major obstacle in effective and sustainable DA treatment , 6. LengThree quantitative studies investigated predictors of TC completion , 9. DisaA qualitative approach enables exploration of the complex relationships between client variables, treatment retention, and re-integration into society from the clients’ perspective. Despite the benefit, there is a deficit of qualitative research exploring reasons for early withdrawal from adult TCs. Two qualitative studies investigating adolescent TC populations identified negative relationships with staff as major contributors to early withdrawal , 11. LanChen et al.  used semMost TC research focuses on abstinence as a surrogate for program success, however little research has investigated what recovery success looks like for clients. Aslan  aimed toAslan  highlighThere is a considerable lack of qualitative research, and, to our knowledge, none in an Australian context, exploring both reasons for early exit and successful recovery from a lived-experience perspective. The current study aimed to gain a better understanding of the reasons for early withdrawal from TC programs and perceptions of successful recovery. A secondary aim was to explore how employment and volunteering related to early exit and perceptions of successful recovery.Participants comprised ex-residents from a long-term TC program at a community-based rehab organisation located in regional Australia. All participants left the TC program early, either voluntarily or involuntarily, and had given consent to be contacted for future research.Participants were informed about the project via email from the organisation, and given the opportunity to advise if they did not wish to be contacted by the researchers. Recruitment was targeted to ensure demographic diversity. In particular, a varied sample of age groups, gender and voluntary or involuntary withdrawal from the program was sought.Participants were contacted by author TP via telephone or email and provided an information sheet with the goals of the research. No prior relationship was established prior to study commencement between the participants and TP. Prior to the interview, participants were asked to sign a consent form or give verbal consent over the telephone. Participants were also provided with resources to contact should any distress arise from the interview.The semi-structured interview schedule was developed from the literature and in consultation with the staff. Questions were designed to explore factors related to reasons for early withdrawal, substance use and treatment history, employment, social supports and perceptions of recovery. The interview schedule was pre-tested for clarity and appropriate question ordering, and further refined where necessary.The interviews were conducted by TP via telephone from October 2017 to December 2017. TP has a bachelor degree in psychology and has received training in interviewing techniques as part of a psychology and medical degree. Author TR provided content expertise through explaining the context of the programs. Further guidance in qualitative data analyses was provided by author SWP. Telephone interviews were conducted as the majority of participants now lived inter-state, making face-to-face interviews unfeasible. Data saturation was achieved and no new themes emerged in the final two interviews.Reflective notes were kept during the interview process to guide analyses. Interviews were audio-recorded, transcribed verbatim and analysed thematically . MicrosoEthics approval for this project was granted by Western Sydney University Human Research Ethics Committee (HREC No: H11353) and the University of Wollongong Human Research Ethics Committee (Ethics Number 2017/404).n = 7), no reply to telephone or email contact (n = 13), not wishing to partake (n = 1) and unable to be contacted after initial positive contact (n = 1). Thirteen interviews were conducted . The age range was 31–61 years, mean age 44 years. The interviews varied in length, ranging from 15 to 39 min (average 27 min). Participant demographics are listed in Table Thirty-five residents who left the TC program early were contacted. Reasons for non-participation were: inability to contact due to a disconnected or incorrect telephone number or email address (tact n = 3, not wiThe main themes and their complex relationships are depicted in Fig. Both existing relationships, and pre-program employment situations were linked with the need for a circuit breaker in life and formed the basis for participants’ perceived need to enter the TC program.Support networks prior to the TC program were varied. Whilst some reported positive relationships with family and friends, they also felt that their supports did not understand their journey. Others described a strong sense of isolation in the later stages of their addiction and whilst some may have had support around them at this time, it was not recognised.‘…when I was in the end of my addiction I didn’t really speak to anyone…my family begrudgingly communicated with me. But I didn’t really have proper conversations with anyone.’For others, craving an emotional connection of any form resulted in maintaining destructive relationships, such as other substance users, which negatively influenced their addiction.‘……<family member> and I used a lot of ecstasy… smoked heroin once together. This is just completely what you don’t do with your <family member>, ever.’The influence of employment on substance abuse is complex. For most, periods of employment were interspersed with long periods of unemployment and lack of stability. For one participant, her work played such an integral part in her identity that its’ loss directly influenced her to relapse. Others reported poor decision-making and lacked the skills to maintain jobs.‘…I was really good at getting jobs and really shithouse at keeping them.’For twelve participants, employment allowed access and means to maintain their addiction, such as working in a drug and alcohol environment like clubs and pubs, or working in high paying jobs like law and finance. For others, working alone or in remote and rural locations with no oversight allowed for their addiction to continue unnoticed at work.‘I ran nightclubs for a long time … I was given a lot of free cocaine. Um and a lot of free everything…’Participants talked about several factors leading to them joining the program. The reasons for joining the program set the scene for being able to talk about their life in relation to the program itself, their reasons for leaving and their subsequent perceptions of successful recovery. Reasons for joining the program were mainly based on negative experiences such as early childhood trauma, being in trouble with the law, feeling that attending the program was their last chance in life and poor mental health. A positive factor was that some had heard positive feedback about the program. Eleven participants had a history of life-long challenges. Most participants described early life challenges such as childhood trauma and substance use, isolation and complex mental health issues. For most, their substance use began in middle childhood or early adolescence as a means of escaping reality.‘… anything you’d put in front of me that would change the way I felt and make me feel a bit better I’d take it.’Further challenges included drug-related offences and legal issues, with three participants having spent time in prison.‘I went to prison when I was 23 as a result of my drug using behaviours.’Twelve participants described a turning point that led to their decision to apply for the program. Some described feeling desperate and fearful of the consequences of continued addiction and feeling that their life was on the line. Others felt isolated and crippled by poor mental health.‘If I hadn’t had gone through the <rehab organisation> I’d probably be dead to be honest.’For others, decisions to attend the rehab organisation were influenced by hearing positive things about the programs from previous residents, or being referred by other treatment facilities because of their long addiction history.Reasons for withdrawal revealed three major themes: the TC program characteristics, relationships and planning for future employment. Firstly, TC characteristics that led to participants leaving early varied, including a misunderstanding of the program and different expectations of the program when they joined. Some had time during the program to reflect on their life and substance use and mentioned they were able to come to the conclusion that the program was not for them or they felt they had learnt enough during the program and were ready to leave early. Some participants did not cope with the intensity of the program and relationships with others within the program such as being with others 24/7. On the contrary, other participants reported feeling very isolated from the outside world such as friends and family and therefore left the program early. The intensity of the program and the rule of no contact with the outside world during the program has a clear link with participants’ relationships with others and their reasons for leaving early.Four participants reported an initial misunderstanding about the TC program rules or duration. This misunderstanding had positive consequences for some whom otherwise may not have attended the program had they fully comprehended the rules.‘I was very naïve um about what I was getting myself in for, but that was good in a way.’For others, a better understanding of the program duration may have allowed arrangements to be made to stay longer.Some participants found the intensity of the TC program to be very challenging and confronting. Some described the therapy as “tiring and relentless”, and found it difficult to be open about their feelings and deal with past traumas.‘… the program’s very tiring… necessary but it’s work… it’s therapy all day, all night it’s relentless.… it’s 24/7.’Others felt uncomfortable openly confronting other residents about disagreements. One participant described a ‘shame and blame’ environment. Another attributed their decision to leave the program early to the ‘informant culture’. Some disagreed with the program rules, and one participant described the program as ‘cultish’. However, on reflection of their experiences, most developed an appreciation for the rules and the commitment of those who stayed.‘There were rules that I found really odd. Um but now I understand how the program works.’For others, the decision to leave early was self-guided. Some felt they were adequately equipped and were ready to leave. Others had just had enough and expressed feelings of guilt for leaving the program early.All participants discussed feeling isolated from the outside world. Whilst this isolation was challenging, it was also recognised as necessary. For some, isolation provided a safe environment away from violent relationships and temptations.‘ … I needed to be taken totally out of my environment … out of the people, places and things that I was associated with, and dropped into a therapeutic community where I could recover…’For others, isolation from their support network outside of the TC program constituted a major reason for leaving early.For some, missing family and friends influenced their decision to leave early. Relationships formed with staff and residents within the program were challenging. In particular, some reported difficulties living and communicating with other people. Two participants developed feelings for others that were not reciprocated and one participant was asked to leave after breaching a program rule; starting a relationship with another resident. Some felt that the counsellors could have been more understanding and others felt like the counsellors weren’t supportive. However, despite these difficulties, on reflection most participants recognised the necessity of the isolation and relationships within the program.‘…everyone’s their brother’s keeper and everyone’s brother’s policeman.’Conversely, for others the support of family and friends served as a motivating factor to stay in the program, as did the support of program staff and residents. Several reported the therapeutic value of staff also being recovering addicts and seeing them as a positive role model. Living and interacting with people who had faced similar challenges to them helped to foster a sense of belonging within the community, and some reported feeling accountable to the therapeutic community.‘… I just felt for the first time that I had love around … and I had a massive amount of support.’Work commitments outside the program also influenced the decision to leave the program early. For some this was having a job to go back to and for others this was feeling ready to find a job and start working.‘…my employer in <city> had given me time off.’Participants discussed their life after leaving the TC program and several themes emerged that demonstrated a variety of important elements of successful recovery which will be discussed below.Ten participants reported gaining a better understanding of their addiction triggers and barriers to ongoing recovery.‘… I didn’t really want to give up that <living-place> but I understand that it was part of my recovery you know because it was a trigger with everyone using in that house …’Six participants learnt that ‘recovery is a journey’. For some this involved sharing their own and other people’s stories, whereas others felt isolated in their journey.As part of ‘recovery as a journey’, most participants recognised the importance of ongoing treatment. All participants had engaged in further drug and alcohol treatments since leaving the program. The treatment varied from NA and AA support groups, counselling and doctors, medications and alternative therapies such as yoga and meditation. Most participants had engaged in a multi-faceted treatment approach.‘I’ve done a little bit of work with a psychologist. I’ve worked the steps. I’ve done you know I’ve explored meditation, acupuncture, I do Bikram Yoga.’For some, ongoing recovery involved incorporating the TC program’s morning routine into their lives. One participant attributed the core of their addiction problems to this lack of stability and routine.‘I would just get up and do my morning program which was brisk walk, some exercise, come home and eat, basically. Which would set me up you know um for the day…’Ten participants were abstinent at the time of the interview. Five had remained abstinent since leaving the program, ranging from one to four years. For many, the achievement they are most proud of was the accomplishment and maintenance of abstinence. Most attributed their abstinence in some way to the program, in addition to external sources such as social supports, ongoing DA treatments and employment.‘… I haven’t touched a drink or drugs since leaving the <rehab organisation>.’For some, abstinence was interrupted by lapses or relapse but overall these were much shorter than previous relapses. These shorter periods were seen as success because participants reported using skills learnt at the program to better recognise the early signs and halt the progression of the lapse before losing control.‘I often use the knowledge that I gained while I was in the <rehab organisation>, like daily…’Ten participants reported an improvement in physical health, rating it as good or excellent. Two participants rated their physical health as fair or poor because of the desire to lose weight or increase fitness. Many reported improvements in psychological health and outlook on life. Some felt they had gained the ability to listen and be honest with themselves and others.‘… I was just happy that my life looked like it was going to start going in a different direction.’Most participants reported the positive influence of relationships after leaving the program. They began to form close relationships with new people and rebuild existing relationships. Some participants became a source of support for others.‘…the ability to be able to listen and be honest with myself … and be able to share other people’s stories and listen to them to be a support.'However, initial re-integration into the family model was quite challenging for one participant.‘…you know just because I’m clean, not everyone’s jumping for joy and patting me on the back about that. There’s a lot of damage that’s done in active addiction. So dealing with some of the family members um distain, for lack of better words, of my behaviour while I was using that’s been hard.’One participant turned to helping others as a way of ignoring their own trauma.‘I tried to make my situation that I was helping other people so that I didn’t have to look at my own stuff.’Participants recognised the positive role that the program had played in developing the skills necessary to obtain and maintain employment or study after leaving the program.‘…I wouldn’t have been able to get this job without having gone through the <TC program>.’‘They may have lost me for 6 months but they’ve actually got a better employee.’Eight participants reported volunteering after leaving the program, particularly in drug rehabilitation. Participants found helping and supporting others rewarding. Of the remaining five who were not volunteering, one was exploring options, two were gainfully employed and one was medically retired. For five participants, working in a volunteer position subsequently allowed them to attain paid employment.‘…from volunteer work I ended up getting a job in drug and alcohol rehab, working with women and children in a residential environment.’For some, employment has also helped to maintain abstinence.‘… If I’m busy and being productive I’m not likely to smoke pot…’The current study revealed a complex interplay of factors contributing to early TC withdrawal, and the perceptions of successful recovery from a lived experience perspective and how this was shaped by employment and volunteering. Eleven main themes were identified. Three relating to reasons for joining the program, which connected with ultimate withdrawal from the program: Pre-program existing relationships, pre-program employment situation and needing a ‘circuit breaker’ in their life. Three relating to reasons for early withdrawal: TC program characteristics, relationships during the program and planning future employment. Five relating to perceptions of successful recovery: Improved understanding of their addiction, reduced substance use, improved physical and psychological health, relationship success and employment success.Backgrounds of childhood trauma, abuse, isolation and an early age of first substance use were common amongst participants. Years of addiction culminated in the recognition of the need for an ‘extreme’ measure such as a long-term TC program, which was also influenced by pre-existing relationships and employment situation. The suffering associated with hitting rock bottom is a strong motivator for addiction recovery as individuals are forced to reassess their life and seek help . The decThe reasons for early withdrawal were varied. Many participants described aspects of the TC program as challenging, such as feeling confronted by the intensity of the program, disagreement with the program rules or struggling with the isolation. Others described a misunderstanding of the program or feeling ready to leave. Relationships and work commitments were also contributory factors. These findings are consistent with Chen et al.’s  who foun“unsuccessful” can be successful, the current study results show that individuals who leave the TC program early can still experience recovery success, regardless of whether they left voluntarily or were asked to leave involuntarily. Participants in the current study reported improvements in relationships, psychological and physical health, stability, employment and volunteering, mirroring findings that recovery success extends beyond abstinence [Consistent with Aslan’s  conclusistinence , 12, 13.In line with previous research , 13, absParticipants reported improved trigger recognition and understanding of recovery as a journey, as described by Best  “recoverAll participants had engaged in further treatment, compared to Aslan’s  85%. ThePositive relationships defined perceptions of successful recovery after leaving the program. Skills learnt from the program helped to rebuild emotional connections, which continue to positively influence their recovery. Results of the current study parallel what is shown through TC study outcomes reviews , 5. HoweThe secondary aim was to explore how employment and volunteering related to early exit and perceptions of successful recovery. Employment, like relationships, showed varying influence across different time-points. Prior to the TC program, many reported difficulty attaining and maintaining jobs due to substance use. On the contrary, for some work was an enabler for substance use due to working in remote areas leading to social isolation, working in pubs and clubs or having the finances to afford buying substances. Commitments and motivation to find work because they felt ready to work again were reasons for leaving the program early. After leaving the program, participants reported improved self-worth and feeling able to contribute to society through study, volunteer work and paid employment, which was heavily represented in perceptions of successful recovery. These results are consistent with Vanderplasschen et al.’s  review oA qualitative approach allowed for richer data on individual reasons and challenges. Telephone interviews were used for feasibility. Given the sensitive nature of the topic this approach may have afforded more honest data. One participant discussed feeling more comfortable speaking honestly when not face-to-face, which may reflect the view of many because of associated stigma. No studies have previously looked at the extended definition of what success looks like from ex-clients point of view in an Australian context.Recollection bias and accurate recall may have been difficult for individuals who left the program four years ago compared to one year ago, however similar themes emerged regardless of time since leaving. Similarly, selection bias was an initial concern of the researchers, that only individuals who were abstinent and doing well would be willing to take part, however this was not the case. There was a reasonable spread of participants that dropped out of the program early and those that stayed. About 50% of participants stayed less than eight weeks. We had one participant that stayed less than two weeks, two that stayed between two and four weeks and four that stayed between five and eight weeks. Seven men and six women participated in the study. This was similar to the male-female ratio of those that have taken part in the residential programs at the residential rehabilitation service provider from which our participants were sampled. This may be different compared to other organisations and readers should take this into account when interpreting the results in the light of their own organisations client base. The validity of self-report data may be threatened by social desirability bias, though telephone interviews potentially countered this. Self-report among substance users has been investigated previously and found to have acceptable levels of validity and reliability –21. AddiThe current research illustrates the beneficial impact of the interpersonal skills training implemented in TC programs. It supports the program’s role in addressing recommendations of the National Drug Strategy , improveMany participants in the current study reported their substance use began at a young age. Future policy may look to target education around addiction at children. This education may draw parallels from other chronic conditions with a relapsing course or the anti-smoking campaigns; ‘never give up giving up’ .In conclusion, reasons for leaving treatment early are multi-faceted and revolve around positive and negative relationships, planning future employment, and program characteristics. The influence that each plays on their decision to leave early is varied and determined by the value they assign it. Perceived success extends far beyond achieving and maintaining abstinence to encompass improved relationships, psychological and physical wellbeing, understanding of addiction and employment, studying and volunteering. Self-worth and feeling able to contribute to society through employment, studying and volunteering were perceived to be essential elements of successful recovery. For many, it was only after leaving the TC program that they began to understand and appreciate the skills they had learnt and recognised the importance of ongoing DA treatment. Clinicians, policy makers and program developers should use the extended definition of successful recovery from the ex-clients perspective when determining the clinical and economic effectiveness of TC programs.


While our report demonstrated that the diagnostic sensitivities and specificities of the two methods were in almost perfect agreement, it was observed that EP-QuIC reactions elicited higher RFU values at the 90-h reaction time and that the thresholds determined for the two versions of the test were distinctly different  , which i2–1–−2 dilution of product as seed (PAS), made from the positive QuIC reaction products from an autopsy-confirmed sCJD patient  for EP-QuIC, instead of the value of 4 required for a 90-h reaction time  samples were tested. The negative control was artificial CSF (Harvard Apparatus), and the positive control was a 10 patient . Tests pMany factors affect QuIC reactions , and the


The “ED Stories” project is a novel method for promoting individual wellness and interpersonal relationships on a virtual platform in an emergency medicine residency program. We engaged multiple individuals across all levels of medical training on a virtual platform to facilitate discussion regarding difficult situations, patient interactions, and tips on how to succeed in challenge circumstances in the future. The platform was outlined as a “safe space,” free of judgment and criticism. We engaged 54 participants with a culmination of 131 interactions; there were 14 original posts with a total of 22 comments. We believe that this virtual platform allowed for safe discussion of difficult concepts related to our jobs and served as an outlet to promote physician wellness and reduce burnout in the future. Physician wellness is a complex issue that has recently become a focus in the medical education community. Many studies have indicated an alarming rate of burnout and high levels of stress in residents and medical students, with higher rates in emergency medicine when compared with other specialties -5. BurnoVarious methods have been designed and implemented to measure the characteristics and symptoms of burnout and well-being in subjects within different levels of medical training -7. StratThe sharing of meaningful experiences and stories with peers may improve interpersonal relationships and help strengthen the residency community. In addition, “unloading” some of the more difficult cases may help prevent internalization and demoralization. Previous efforts with similar goals have focused on live communication events -19. HoweThis initiative was developed to meet the following objectives: assess if an opportunity for discussion on a virtual platform would be utilized by invited participants; serve as an outlet for “difficult to discuss” cases to help an individual process and share experiences; provide a virtual safe space and guidance for the EM residency members to share stories and experiences; and promote bonding between residents and attending physicians with the goal of strengthening the educational community.The project began with a brief lecture and introduction to the “ED Stories” project, as well as an explanation of program goals and objectives. A unique page was preemptively created and hosted on the Slack digital-messaging platform (Slack Technologies) used by the residency, a community-based four-year program with eight residents per year, for general program communication. One senior resident and one core faculty member were selected to act as moderators. All emergency medicine residents and faculty were encouraged to voluntarily join the specific conversation site. Participation was not required. They were invited to use this space to write about their thoughts and challenges, as well as professional and personal stresses. Other participants then had the opportunity to read the post and directly comment, or select other “reactions,” small ideograms linked to the post. Participation was voluntary and included writing posts as well interacting with previous messages. The “ED Stories” page listed specific goals of the project and initial examples of posts. The program was initiated in November 2018. Fifty-four people were invited to participate. In the first month of the implementation of the “ED Stories” project, 81 interactions were recorded on the page. There were 10 unique written posts, 17 comments, and 54 other reactions. Seventeen people  posted unique messages  support to facilitate discussion and add additional perspectives.As this is a brief observed pilot evaluation to review utilization, participants were not surveyed on the personal benefit of the program. This is a significant limitation in evaluating to see if specific wellness objectives are met and addressed. However, future initiatives can focus on directly surveying the participants to obtain feedback regarding the program, and if they feel that they are benefiting from the discussions. This would allow for additional changes to the program to maximize participant benefit. Another limitation of the program is the self-selection of participants. As there are varying levels of comfort with sharing in a public forum, residents may feel reluctant to share vulnerable thoughts and feelings. Unfortunately, anonymous posting is not supported by the Slack channel. However, the moderators could make themselves available to post for an individual not comfortable with publicly sharing their experience. Resident support groups and debriefing sessions have been used as a resource for sharing professional struggles and clinical experiences, eliciting support, establishing relationships, and providing a forum for discussion -18. One The impact of social networks to influence both positive and negative emotions and behaviors demonstrated by an individual has been previously reported . ElevateHowever, barriers to use of these types of community-building sessions, both real and perceived, including confidentiality, accessibility, and time commitment may inhibit participation ,22. The The use of this virtual space appears to provide a useful area for members of the emergency medicine residency to post and react to difficult and sometimes highly emotional situations at their convenience. There are future plans to assess the effectiveness of this initiative and encourage additional use of the space. Other programs could easily implement a similar system using their specific platform for communication. We hope to inspire other residency programs to create similar projects that foster an environment of shared experiences and emotions that can empower an individual and strengthen the community.


Obesity is a top public health priority in the United States. This article reports on the Fit For Life (FFL) health education program designed to address the determinants of obesity in rural settings and help participants lose weight.We evaluated the implementation of the original FFL program, a replication program, and a diabetes-focused program.The original FFL program (2006 to 2012) was a 12-week session of classes meeting once weekly. Lecture topics included stress management, nutrition, healthy eating, reading food labels, fitness, disease prevention, and healthy aging. The replication program, conducted in 4 locations from 2012 to 2015, helped determine if the FFL program could be implemented on a larger scale, with outcomes similar to the original program. The longer, more-intensive FFL diabetes prevention program, conducted in 2016 and 2017, sought to reduce the number of rural adults at risk for diabetes.We evaluated FFL participation and outcome data from 2009 through first quarter 2017. We calculated rates of course participation and completion and measured changes in several health indicators. We constructed a linear regression model to examine the impact of health behaviors on weight loss and calculated program cost-effectiveness.From 2009 to 2017, FFL was delivered to over 1,200 people; 82% of participants completed the program. Completing participants lost an average of 2.7 kg or 3% of their total weight. Overall, 68% of participants said they exercised more per week at the end of the program than at the beginning. Estimated cost per kilogram lost for replication sites was between $73 and $101 for original FFL, in line with other programs. The more resource-intensive diabetes prevention program cost per kilogram lost was $151 to $171.Weight loss and lifestyle management are major ways to counteract obesity. Improving program options, especially in rural locales, should be a key policy priority. These programs should be considered for population-based expansion, perhaps by health departments or public–private health care consortiums. Obesity and other lifestyle-related chronic diseases are a top US health policy priority –3. ObesiThe policy priority for reducing obesity and improving heart health has driven the creation of initiatives, both large and small –12. FromThis article aims to contribute to the gap in the literature on the adoption of rural weight loss programs and lifestyle interventions. It relays the experience of a lifestyle intervention delivered in person, specifically focused on assessing the effectiveness, replicability, and cost-effectiveness of lifestyle changes for weight loss, as implemented in a rural Appalachian county.Tuscarawas County is an Appalachian county located in east central Ohio. The county is home to about 92,000 people, of whom 97% are non-Hispanic white. About 86% of the population have graduated from high school, and 14% have a bachelor's degree or higher (compared with 26% in Ohio and 30% nationwide). About 9% of Tuscarawas County residents do not have health insurance. The median household income in the county is just over $45,000 . Thirteen percent of the population lives in poverty . TuscaraIn 2006, Trinity Hospital Twin City received funding from the US Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA), Office of Rural Health Policy (ORHP) Rural Health Outreach Grant Program to offer the Fit For Life (FFL) program in Tuscarawas County, Ohio. IRB approval was not sought because analyses were performed on de-identified secondary data.1c was added as a pre/post measurement and a repeat measurement was added 3 months after conclusion of the 12-week program.After the pilot program (2006–2009), HRSA supported growth of the FFL program and systematic data collection on health outcomes associated with the program. Health outcomes were pre and post measures of weight, total cholesterol, high-density lipoprotein (HDL), low-density lipoprotein (LDL), triglycerides, and blood pressure (systolic/diastolic). In 2012, for the replication study, pre- and post-program surveys were administered to participants, focusing largely on individual health behaviors. In 2015, with the diabetes prevention (DP) program, HbATrinity Hospital Twin City’s original FFL Program (from 2006 to 2012) provided health education and promotion through FFL curricula on wellness and disease prevention in classes designed specifically for adult men and women. In a 12-week session of classes that met once weekly for 90 minutes, students heard lectures on stress management, nutrition, healthy eating, reading food labels, fitness, disease prevention, healthy aging, and more . In the The primary aim of the Fit For Life Replication Project was to assess whether the original program could be implemented on a larger scale with similar clinical outcomes. The replication project sought to provide a multi-agency approach to reduce the number of adults with overweight or obesity in rural Tuscarawas County, Ohio and replication sites in the bordering Appalachian counties of Carroll, Harrison, Holmes, and Jefferson. Effectiveness and sustainability were primary outcomes of interest, leading to an increased number of sites and, ultimately, individuals served by FFL. The curriculum taught at the replication sites was the same as taught in the original FFL project, though different trainers were used. The replication project used a train-the-trainer approach, with 4 replication sites offering services in their respective counties after being trained by staff from the original site. In the first year, 2 half-day trainings were held, and for the last 2 years, 1 half-day training was held each year. A standardized trainer’s manual with a step-by-step guide about how to set up an FFL program was developed. Evaluators participated in the replication site courses to ensure fidelity to the curriculum. Two replication sites left after year 1 of the 3-year project and were replaced in year 2 by other partners. The sites that ceased operation of FFL did so because of staffing constraints and resourcing issues. Of the 4 replication sites, 2 were physician-led, 1 was led by a master’s level health educator, and 1 was co-led by a chiropractor and a master’s level health educator. All other aspects of the program remained the same.1c (HbA1c) ≥5.7% or a BMI ≥25). The aim of the DP program was to reduce the number of adults at risk for diabetes – measured through weight loss or BMI change and changes to HbA1c. Like the original FFL program, this curriculum also involved the foundational 12-week session that met once a week for about 90 minutes, and it added 3 classes that met once a month. FFL DP students also had access to 3 individual counseling sessions and 3 personal training sessions at no additional cost. This program was conducted at the original FFL site in Tuscarawas County, beginning in late 2015.The most recent evolution of FFL is in prediabetes management. Interventions for prediabetes are critical, but consistent evidence is lacking about the effectiveness of such programs ,20. The General health outcomes data were aggregated, by year, for FFL participants. The health outcomes data set and the health behavior survey data set were linked through a participant ID number. No names or contact information were included in analytic data sets. Outcomes were organized by FFL project type: original FFL (classes ending in 2010–2012), FFL replication (2013–2015), and FFL DP (2016 and 2017).2), cholesterol, triglycerides, blood pressure, and, for the DP program, HbA1c. Individual health behaviors were assessed, including intake of sugar-sweetened beverages, use of Nutrition Facts labels, and exercise (days per week), all of primary interest in this analysis. Additional variables examined were daily servings of fruit and vegetables, daily servings of whole grains, avoidance of trans fats, and how often the individual ate outside the home. Age and gender were also accounted for. Anyone who signed up for the program became a participant; no exclusion criteria were used. Completion of the program was defined as a participant attending 7 or more classes (minimum dosing requirement) and not missing more than 3 classes in a row . Completions were only counted once per person for the years analyzed.The primary outcome of interest was change in weight. Other outcomes were changes in BMI  are presented as summary measures only, because the program was still in development and only historical summary measures existed . For 2013–2017, individual-level pre/post records are available. We describe changes to health outcomes, focusing especially on weight loss and, for the DP program, changes to HbAtrans fats, and how often the individual ate outside the home. These variables were excluded from the final model because of high correlation with other covariates . In addition to descriptive analyses, we constructed a linear regression model by using robust variance estimators. Weight change in kilograms was the primary dependent variable. Independent variables included baseline information: weight, age, gender, days of exercise per week, consumption of any sugar-sweetened beverages in a week (yes/no), and whether the individual used Nutrition Facts labels “most of the time” or “always.” The model also controlled for program iteration and FFL site. Other variables were examined for inclusion, including baseline daily servings of fruit and vegetables, daily servings of whole grains, avoidance of The analytic data set used in the regression consisted of pre/post measurements from participants who completed FFL, the replication project, or the DP project. Respondents were excluded from overall analyses if they did not complete the program. We also conducted a cost-effectiveness analysis in an effort to quantify potential utility of FFL if replicated more broadly. HRSA and Trinity Hospital Twin City have made substantial investments in the program’s creation since 2006. However, replication program costs  are relatively modest. We conducted cost-effectiveness analyses for potential replication sites for both original FFL and FFL DP, using cost per kilogram (kg) lost as the primary outcome of interest. This is in line with previous examinations of the cost-effectiveness of weight management interventions . We esti1C value was 5.7. The 25th and 75th percentiles were 5.4 and 6.0, respectively. The mean and median BMI were 36 and 34, respectively.Between 2009 and 2017, FFL was delivered to over 1,200 people in 3 distinct iterations. First, between 2009 and 2012, FFL was delivered at its primary site. Second, between 2012 and 2015, FFL was delivered at 4 replication sites. Third, in 2016 and 2017, FFL was delivered at its primary site in an expanded format to individuals at risk for diabetes (the DP program). Overall, more women than men participated – 74% versus 26% . Most paSince 2009, FFL completion rates have been tracked by session and delivery site. During 2013–2015, participants’ weight changed:20% lost more than 5 kg29% lost between 2.5 and 5 kg34% lost between 0 kg and 2.5 kg15% gained between 0 and 2.5 kg, and 2% gained more than 2.5 kg. Overall, 52% of individuals in 2013–2015 lost 3% or more of their bodyweight, and 27% lost 5% or more. Comparatively, for the 2016 and 2017 FFL DP, 74% of individuals lost 3% or more of their total weight, and 48% lost 5% or more. In FFL DP during 2016 and 2017, participants’ weight changed:41% lost more than 5.0 kg28% lost between 2.5 kg and 5.0 kg20% lost between 0 kg and 2.5 kg9% gained between 0 and 2.5 kg, and 2% gained more than 2.5 kg. At the 3-month post-intervention follow-up, FFL DP participants (n = 62) had lost 6.1 kg on average, representing further weight loss after the conclusion of the 12-week program (median = 5.5 kg). The median weight regain from the end of the 12-month program to 3-month follow-up was 0 kg. Among those further losing weight (n = 31), the average was an additional 3.3 kg. Among those regaining weight (n = 31), the gain was 2.0 kg, representing a net decrease of 1.3 kg from the beginning of the program for these participants.P = .6), although diastolic was . Cholesterol  and triglycerides were not statistically different between the 2 programs.On average, not only weight, but also blood pressure, total cholesterol, and triglycerides were reduced. Between original FFL and FFL DP, the change in systolic blood pressure was not substantial or statistically different . All sites had participants whose weight change was negative. The null hypothesis was that the program would have no effect on weight change. Weight change was comparable across sites . AlthougP < .001).Participants at the primary site lost 3 kg on average At Site 1, participants lost 1.9 kg on average At Site 2, participants lost 2.7 kg on average At Site 3, participants lost 2.1 kg on average .At Site 4, participants lost 2.7 kg on average , avoiding high fructose corn syrup (59%), and using Nutrition Facts labels  said they exercised 0 times per week, 37% said 1–3 times, and 17% said 4–7 times. At the end of the program, 11% said they exercised 0 times per week, 49% said they exercised 1–3 times, and 39% said they exercised more than 4 times. Overall, 68% of participants said they exercised more per week at the end of the program than at the beginning. Among these individuals, average increase in weekly exercise was 2.6 times per week . Similar positive changes in health behaviors were observed with eating fruit and vegetables (67% improved habit), eating whole grains (54%), avoiding els 56%, . Among DP = .001). Being in the FFL DP program was associated with greater weight loss compared with the original FFL program .We conducted a linear regression, modeling weight loss in kgs for participants in the replication study and the DP group . After cWe estimate program costs at $5,750 for original FFL and $7,188 for the longer FFL DP . This isThe FFL programs showed consistent, statistically, and clinically significant weight loss results between 2009 and 2017. Participants in the original FFL program lost 2.7 kg and 3.2% of their BMI on average, and participants in the FFL DP program lost 4.8 kg and 4.8% of BMI. Cholesterol improved  by 3.6%, blood pressure by 2.3% (systolic) and 1.4% (diastolic), and triglycerides by 4.8% on average. Moreover, participants, on average, said they exercised more, ate more fruits and vegetables, and employed more healthy behaviors after completion of FFL compared with before initiating the program.Estimates for cost-effectiveness for original FFL ranged between $73 and $101 per kg lost among completing students, contingent on class size. This is in line with findings from a recent meta-analysis on the cost and effectiveness of similar lifestyle interventions ,15,21–26In the higher-risk and higher-cost population — those in the DP program — estimates of cost effectiveness ranged from $150 to $170 per kg lost, based on class size. As the United States spends $237 billion a year in direct medical care for diabetes (28), FFL DP may be a cost-effective alternative. We posit this may be especially true in rural areas . Beyond In our view, cost-benefit and cost-utility analyses of lifestyle interventions and other weight-loss interventions must be expanded to include the broader set of benefits that participants realize ,30. AlthThe replication of FFL into other jurisdictions was successful; results were relatively consistent across sites, and all experienced reasonable participation rates. However, 2 sites did discontinue participation early on in the process. Circumstances at the sites themselves caused these changes, not the FFL program. In the withdrawal letter from 1 organization, a newly appointed leader cited the need to discontinue participation because of the organization’s small staff and the need to shift priorities to other projects within their jurisdiction; the project was something he “inherited” with the retirement of the prior leader, with whom Trinity Hospital Twin City had an excellent working relationship. The second site that discontinued participation was a critical access hospital. In their withdrawal letter, the CEO indicated a lack of staffing and resources for the program because the doctor who had been trained by Trinity Hospital Twin City was about to take maternity leave. About a year after the critical access hospital discontinued participation in FFL, the hospital experienced significant financial trouble which led to its sale. It is our belief that the hospital’s broader staff shortage and financial situation also played a role in the decision to discontinue. Successful partnerships in the replication phase required good institutional support from partners and ongoing technical assistance and collaboration from the primary site.1c levels were accepted into the DP program, as opposed to original FFL, which was open to anyone in the community). HRSA’s funding created the opportunity for the hospital to make the DP program affordable; however, for cost-effectiveness reasons, the program will be sustained beyond grant funding by returning to an adapted original FFL curriculum. The following adaptations will be made to the original FFL as a result of the success of the DP program: there will be continued involvement of the counseling and fitness professionals on a smaller scale by providing some services in-kind during class time and the 3 monthly classes will likely continue after the initial 12-week course is completed. We believe this maximizes sustainability while still using successful components of the DP program.We view the FFL DP program as a modest success. Because of the high number of Tuscarawas County adults at risk for diabetes, Trinity Hospital Twin City created FFL DP to target more specifically those at highest risk for diabetes .Trinity Hospital Twin City FFL is one among numerous lifestyle intervention and weight loss programs available in the United States . It seekRegardless of location or particular curriculum, lifestyle intervention programs and other behavioral interventions must come to form a foundation of universal access to health education and nutrition assistance. The programs are relatively inexpensive and relatively effective . Individ


Falls are a major contributor to the burden of disease in older adults. Home-based exercise programs are effective in reducing the rate and risk of falls in older adults. However, adherence to home-based exercise programs is low, limiting the efficacy of interventions. The implementation of technology-based exercise programs for older adults to use at home may increase exercise adherence and, thus, the effectiveness of fall prevention interventions. More information about older adults’ experiences when using technologies at home is needed to enable the design of programs that are tailored to older adults’ needs.SureStep, an interactive cognitive-motor step training program to reduce fall risk unsupervised at home; (2) explore program features that older adults found encouraged program uptake and adherence; (3) identify usability issues encountered by older adults when using the program; and (4) provide guidance for the design of a future technology-based exercise program tailored to older adults to use at home as a fall prevention strategy.This study aimed to (1) explore older adults’ experiences using SureStep at home for 4 months. All interviews were audiotaped and ranged from 45 to 60 min. Thematic analysis was used to analyze collected data. This study was guided by Pender’s Health Promotion Model.This study was part of a larger randomized controlled trial. The qualitative portion of the study and the focus of this paper used a qualitative descriptive design. Data collectors conducted structured, open-ended in-person interviews with study participants who were randomly allocated to use Overall, 24 older adults aged 70 to 97 years were interviewed. Findings suggest older adults are open to use technology-based exercise programs at home, and in the context of optimizing adherence to home-based exercise programs for the prevention of falls, findings suggest that program developers should develop exercise programs in ways that provide older adults with a fun and enjoyable experience (thus increasing intrinsic motivation to exercise), focus on improving outcomes that are significant to older adults (thus increasing self-determined extrinsic motivation), offer challenging yet attainable exercises (thus increasing perceived self-competence), provide positive feedback on performance (thus increasing self-efficacy), and are easy to use (thus reducing perceived barriers to technology use).This study provides important considerations when designing technology-based programs so they are tailored to the needs of older adults, increasing both usability and acceptability of programs and potentially enhancing exercise participation and long-term adherence to fall prevention interventions. Program uptake and adherence seem to be influenced by (1) older adults’ perceived benefits of undertaking the program, (2) whether the program is stimulating, and (3) the perceived barriers to exercise and technology use. Older adults shared important recommendations for future development of technologies for older adults to use at home. Accidental falls are a major contributor to the burden of disease in older adults and a major public health problem. One-third of people aged 65 years and above fall every year . Falls aDespite the robust evidence to support exercise as an effective fall prevention strategy among community-dwelling older adults -9, adherA review of older adults’ perspectives of fall prevention exercise programs found that social interaction was frequently suggested as a motivator to participate in group-based programs . QualitaTechnology-based exercise programs  offer several advantages over traditional exercise programs in that they can contribute to a more enjoyable and stimulating exercise experience. Some advantages include the opportunity to tailor the exercise modalities according to the abilities of each individual , provide individualized progression of exercises by unlocking levels of difficulty according to each individual’s performance, offer a wide variety of exercises to maintain engagement, provide users with reinforcement and real-time feedback while exercising, and monitor performance over time -27. ExerSeveral systematic reviews have shown that it is safe and feasible for community-dwelling older adults to engage in exergames -37. FurtThese results suggest that technology-based exercise programs may be an effective alternative or complement to conventional exercise programs. The possibility of using these programs in older adults’ homes may further increase exercise participation in the proportion of the community that is either unable or unwilling to take part in other exercise programs. However, it is important to consider that most randomized control studies in this area have been conducted under close supervision in laboratory or clinical settings, using mostly commercial game consoles such as Nintendo Wii console, Xbox, and PlayStation  that areOnly few randomized controlled trials (RCTs) have tried to overcome these usability problems and improve exercise adherence to home-based interventions by using technology-based exercise programs that have been custom-developed for older adults ,41-43. RSureStep —an interactive step training system designed for older adults to use unsupervised in the home setting—and determine the effectiveness of this intervention on stepping performance and associated fall risk in older adults compared with a nonexercise control group. The study showed that 16 weeks of unsupervised interactive cognitive-motor training using the SureStep system led to improvements in specific cognitive functions associated with falls in older people ” as they thought that exercising would be “beneficial for them.” They seemed to be more conscious about the detrimental effect that inactivity can have on older adults. For example, they spoke of being aware of the “debilitating effects of lack of mobility,” which some described as “getting slow at doing things,” “losing [their] balance,” and “falling.” For Robert (aged 81 years), typical of the majority of study participants, having a fall represented a threat to his independence; thus, “preventing falls” and “remaining independent” were 2 of the most important motivators to take up and adhere to SureStep.A feature that distinguishes SureStep were the belief that using the program would help to keep [them] healthy and improve [their] abilities, including their balance, reaction time, ability to walk further, and stay fit. The perceived value of using SureStep seemed to rely on the belief that improving, or at least maintaining, their physical abilities would allow them to continue living independently for longer as portrayed in Thelma’s words. Thelma’s words also clearly indicate how important living independently is for these participants:Perceived benefits attributed to using [...] if you can save yourself from falling or tripping, you can still have your own shower; you can still get your own meals; you can still take yourself out and about. It’s worth everything to the individual to be able to do that. It doesn’t matter how old you are, being able to do that is just marvellous.Thelma, 87-year-old femaleSureStep training program was helping prevent cognitive decline and to keep their mind and body active:For this group of participants, adhering to the Well, I knew it would help me think faster and move faster. You don’t want to lose your faculties, you want to be able to remember people’s names, you want to be able to remember where you’re going and what you’re doing and remember things that happen.Agnes, 85-year-old femaledelay the effects of aging came through in Bernice’s words:Some older adults seemed to feel an aversion to aging, as they feared they would lose their physical and cognitive capacities. The desire to I thought it will keep me younger if I keep using my mind and my legs and arms [by doing SureStep training program].Bernice, 89-year-old femaleneeded to perform the exercises. The notion that people adhere to actions from which they derive personally valued outcomes, such as health benefits, comes through in Donald’s words:Higher adherence rates were attained by participants with lower self-perceived health status, poor balance ability, and fear of falling and by participants who were hoping to obtain health-related benefits. The improved physical and cognitive functioning participants spoke of reflects the notion of perceived benefits, which, according to HPM , helps p Yeah. Yes. The only thing I can think of is if—I was finding I was losing my physical fitness—that would motivate me because I’m going from here to the gym a few days still...I think that—yes, once people see they’re getting something out of it, yes, then you would take it on board. Yep. And that’s one of my problems, I can stand on one leg.Donald, 78-year-old maleSureStep, their main motivation to engage in SureStep was not for health-related motives, but rather for the value they put on helping other people by contributing to research. Participants felt that by becoming research participants, they were helping researchers get the numbers they needed and thereby, in future, helping others:In addition, 3 participants, all of whom rated their health and balance ability as good or very good, reported that even though they hoped to improve their physical and cognitive abilities using It was possibly helping somebody else that might be in an area where they are going to have problems with mobility. I think that was—that would be the number one driver as to why I did it; that it might benefit somebody that has had falls or suffered from some problem.Ron, 81-year-old maleRon who during the interview indicated he did not see himself as someone who was yet at risk of falling, was adhering to the program to help others as clearly reflected in his words. Similar to Ron, 78-year-old Donald who had described himself as being quite healthy and active was “committed to the program [SureStep]” to help with the research, “mainly because you need the numbers and you’re not getting them.”SureStep were to improve their physical and cognitive function  when compared with those whose main reason was to help others by contributing to research .It appears, overall adherence rates during the 16-week intervention period were higher in the group of participants whose main reasons to use SureStep that increased older adults’ intrinsic motivation to engage in the training program. The interviews revealed that participants found the exercise experience enjoyable and stimulating when they felt physically and mentally challenged, when there was variety in both exercises and difficulty levels, and when they could see that they were making progress.This theme relates to various features of SureStep as being fun and challenging. Ada’s words below suggest that what distinguished SureStep from other forms of exercise was the design of the program, which challenged both cognitive and motor tasks simultaneously preventing users from getting bored:Participants described Well going to the gym bores me to tears, walking bores me to tears, that [SureStep program] keeps me active, my mind as well as my body and that is the main thing I enjoy.Ada, 76-year-old femaleSureStep was appealing as it presented a challenge to their otherwise routine life:For participants of this study, such as Doris (93 years), there were not many things that would present a challenge to them in their current daily activities. Engaging in Well, I think it’s a challenge mentally for you to do it because as you get older there’s not that many challenges that make you think—that makes you think quicker...Yep. Because it’s very easy to let things slide, you know. You don’t challenge yourself very much, particularly when you’re living by yourself. If you have another person living with you they’re challenging you but if you’re living by yourself there’s no challenge. So that was a bit of a challenge [referring to the exercise program].Doris, 93-year-old femalevariety of exercises and different difficulty levels was a good way to keep them engaged with the program as it made the experience more interesting and also made them want to keep going from easy to more difficult and more difficult. Furthermore, the ability to progress through different levels of difficulty made them feel proud and good about themselves and at the same time provided a fun way to exercise. These findings also suggest that older adults’ self-efficacy and perceived competence to exercise with SureStep increased as they progressed from easier levels of gameplay to harder levels as depicted in Anna’s words:Participants expressed that having a Well, because if you are good at one level, then you can go up to the next. And then you feel, oh look you’ve done so well. Then you go up to the next one. And then you feel good. And you walk around saying, I did this and I did that.Anna, 72-year-old femaleThe importance of varying difficulty levels was expressed by participants of different ages, perceived health status, and balance ability.novelty wore off and they started to get bored with the exercises, which reduced their motivation to use the program. All 3 participants rated their balance to be “good” or “very good,” had low concern about falling, were engaged in other activities , and took part in other forms of exercise, for example, walking, going to exercise classes, and attending the gym. Two examples are the experiences of Ron and Donald:However, despite most participants finding the program fun and challenging, 3 participants found that as the weeks passed, the After you have done it for a couple of months, you sort of think, well, I have done that one, I have done another one [referring to the games]—and I can go up to level hard and that is about as far as I can go.Ron, 71-year-old maleLike Ron, as time passed, 78-year-old Donald found he was “running out of challenge” and he “wasn’t going to progress any further, [he] had reached the top,” making Donald lose interest in the program.had to do it because they had committed to participating in the research.For participants like Ron and Donald, their intrinsic motivation to use the program  decreased as time passed, and instead, their motivation became driven by nonself-determined sources of motivation: they felt they SureStep because of their commitment to the research study. Thus, under other circumstances, a lack of novelty could lead to reduced adherence rates and program discontinuation.The loss of interest in the program due to lack of novelty did not prevent these participants from reaching the recommended exercise dose. However, it is important to consider that they all reported continuing to use novelty. The need to have a larger variety of games to maintain the challenging nature of the exercises and with that the feeling of enjoyment in the activities reflect the “activity related affect” construct of HPM. That is, older adults are more likely to engage and continue a behavior, such as exercise participation, if they associate the behavior (performing exercise) with positive feelings and emotions. However, when participants got used to the exercises, the novelty and challenge wore off and with that enjoyment.Participants suggested that to prevent people from getting bored with the exercises and motivate them to continue, new games could progressively be introduced to the program to maintain they are improving, they have made progress was seen by all participants as an essential feature of the SureStep program. Before starting the program, some participants, particularly those with low self-reported health status and balance ability and moderate to high levels of fear of falling, questioned whether there was any point in starting an exercise program. They said “what’s the good of me doing it [referring to exercise in general],” as they thought they were already too old, too slow, and not [sufficiently] well to exercise. However, after having exercised with SureStep and having seen that they could progress to harder levels, they felt good and proud about themselves , improving their self-esteem.Designing exercise programs in a way that older adults can see that a great way of encouraging people to continue to exercise. For 78-year-old Eva, getting a score motivated her to compete against herself to get a bigger score and this made exercising fun.Participants indicated that feedback on their performance such as getting a score for their performance was Stepper was the least preferred game. Participants attributed this to the lack of feedback from Stepper game:When comparing playtime between the 4 available games, it was apparent that […] it doesn’t tell you anything, you don’t know if you are doing better or not. The others give you a score or tell you how long you are takin to solve it you know? There is no challenge in this one.Ada, 76-year-old femalehelp themselves. This is reflective of the construct of self-efficacy in HPM. According to this theory, the higher older adults perceived competence or self-efficacy to perform the SureStep exercises, the higher is the likelihood that they would commit to participating. Self-efficacy, in turn, was increased when participants saw they could successfully perform the exercises and improve their scores. According to HPM, greater self-efficacy results in fewer perceived barriers to exercises. Thus, the less likely it will be that feelings of being too old, too slow, and not well will interfere with their commitment to engage in exercise.Feedback is, therefore, an important component of technology-based exercise programs, as it makes older adults feel they can still achieve their goals and SureStep led to 2 participants stopping the use of the program and other feeling frustrated with the system. This suggests that further development is needed to make the program more user-friendly for older adults to use unsupervised.This theme relates to the preference of participants to have a home-based exercise program and the importance of designing technology-based exercise programs that older adults can easily use independently in their homes. The interview responses revealed that participants liked having a home-based exercise program as it reduced common barriers to exercise. However, difficulties using SureStep as a home-based program, most participants conveyed that being able to exercise in their homes was very “convenient,” as it allowed them to exercise “when they liked and for as long as they liked” without having to be constrained to a schedule. Such convenience was important as many of these participants had a variety of caring, volunteering, social, and medical routines that impacted their availability to attend center-based exercise programs. For Gertrude (aged 97 years), a home-based program gave her flexibility as she poignantly expressed:When participants were asked about their perception of having This had all the elements that suited me. Because it was in my own home, because I didn’t have to answer at half past six in the morning, because I could see and adjust myself to what was presented on the TV screen [referring to exercises], all that was going my way. I had often looked at—because there’s four or five courses going all the time in this place, I’d often looked at them and thought no, I cannot make this body get up and be sure I’ll be there half past eight every morning, which is what some of them require. So you see if it rains I can't go anywhere, because I can't take the scooter out in the rain and I can’t walk. And buses only come at certain times, not when it suits you. So that I - this was absolutely handmade for me.Gertrude, 97-year-old femaleSureStep program as an “all-weather capability of moving your body around” comes through clearly in Gertrude’s words.The importance of having the privacy of their home was especially important to those who felt self-conscious about their bodies and their reduced abilities, as participants considered exercising in their home to be more personal.Being able to exercise in the Although most participants preferred to exercise in their home, for 3 participants, this was seen as a barrier to exercise participation, as they preferred other modes of exercise. For George (aged 87 years), who enjoyed being outdoors, using the program in his home was not appealing:Well, standing in front of the television and going backwards and forward, I get bored. Because before that and now, I generally go [out] every day, I go for a walk, I go through the bush. So I’d prefer going out. Because I like to get outside, so I’d rather go outside and do things outside and walk around.George, 87-year-old maleMarion , on the other hand, thought that joining an exercise class within the village would help her adhere to the program, as committing to a class would mean she had to attend, whereas at home she could “cheat and gradually stop exercising.”a social thing and thought it would be a good idea to set up the stepping mat exercise program in the retirement village, so people could go and exercise together.For 84-year-old Evelyn, the social aspect of exercising seemed to be very important. She preferred to make exercise In the context of exercise adherence, the higher the number of perceived barriers to exercise, the lower the likelihood is that individuals will adhere to an exercise program. This is in accordance with the perceived barriers to action construct of HPM.When designing technology-based exercise programs for older adults, it is important to take into account specific usability aspects of program design, as these can become a barrier to participation, especially for those without previous experience using technology. This subtheme is divided into participants’ experiences navigating through the program and the technical difficulties experienced.SureStep program were varied, with some older adults finding it easy to use and others very difficult. When contrasting participants’ experiences, it became apparent that those who described the program as being quite easy to use and self-explanatory were all accustomed to using other technologies , and they themselves talked about how their previous experience with technology may have facilitated the use of SureStep:Participant accounts of their experiences when interacting with the It was only a few days [before I became familiar with the program]—see, I’d worked on computerised stuff for 20 odd years on different programs, different workings, different—seen how programs worked and that [SureStep] was probably much easier for me than [for] some other people.Rubi, 78-year-old femaleAlthough participants like Rubi found navigating through the program very easy, others experienced difficulties when trying to select a game, change from one game to another, and move between difficulty levels, which led to feelings of frustration. This is portrayed by Betty (aged 80 years), who described herself as “not being computer savvy,” but rather a “luddite” when it comes to using technology:Well I know it drove me mad because, I obviously, I grew to understand it [referring to how to navigate through the program]. But at the beginning when I didn't know that if I did that, that would fix that, so I had a lot of frustration at the beginning. Well I think it was mostly my fault, the problem was that I wasn’t understanding computers. It might have taken me the first month [to learn how to navigate through the programs] because I know I fought with it for a long time.Betty, 80-year-old femaleSureStep as they would often forget how to use the program. Participants were given a booklet with detailed instructions on how to operate the program; however, some did not use it because they “had forgotten [they] had it” or thought it was a “nuisance” having to stop and get the book because that “used up the time [they] had to exercise.” The frustration participants felt when forgetting how to operate the program is portrayed in Gertrude’s words:Some participants, particularly those aged 80 years and over and those with low technology familiarity, spoke of having trouble using It irritated me that I, 'cause I get irritated with myself, that I couldn’t go straight into and do it, because I think my short term memory is a little bit weak and therefore, I was forgetting what you told me, by the time I tried to put it into practice. But that will happen to anybody of my age.Gertrude, 97-year-old femaleGertrude’s experience was quite typical of the difficulties that the study participants experienced when navigating through the program to select an exercise game, change from one game to another, and move between difficulty levels. These were all common sources of frustration for some participants and can act as perceived barriers to action.Participants encountered similar problems when navigating through the program interface. Again, this was more prevalent among participants aged 80 years and over and those who had limited experience using technologies. Some participants felt frustrated when unable to find a particular game they wished to play on the home screen. From observations made during home visits, it became evident that some participants were unable to remember that there were other game options in addition to what was presented on the screen and that by stepping right or left on the step mat they could access them. Future designs should ensure that all games are displayed on the home screen.Similarly, participants reported often forgetting how to select a game from the home screen, how to return to the screen to change the level of difficulty of the game, and how to exit the game to play another game. The instructions were not consistent between games and participants said they would like to have all 4 games “work the same way” and have “explicit step by step instructions” on the screen to guide users in the operating of the program. This comes clearly in Eva’s words:I think perhaps the instructions could have been a bit more explicit, yes...I think it could have been a bit more, a bit more basic, not presuming that everybody could use computers...For non-computer literate people- and you’re going to get a lot of them in this age group. A step-by-step [instruction] could have been better.Eva, 78-year-old femaleFinally, some participants also experienced technical problems such as the program temporarily not responding to the step mat or the program not starting correctly when turning it on. This impacted participants’ willingness to use the program as portrayed by Thelma:I think that sort of put you off a bit [the program not functioning properly] and I thought oh well I won’t do it now, it won't work. I haven’t got time now to fiddle with it [...] you almost lost interest in it [the program] because it didn’t operate immediately. It didn’t matter what you did. And you thought, oh I haven’t got time now and that’s what you do.Thelma, 87-year-old femaleDifficulties were also encountered when moving from one game to another or changing difficulty levels, as the program would sometime flick through the different options too quickly. This was only experienced by a couple of participants due to faulty equipment and resolved after replacing the mat. However, this shows that it is of crucial importance to optimize the design and development before providing it to older adults, especially to those with limited prior experiences with technology.A conceptual map of the 3 main themes that were generated from the analysis of participants’ interviews is summarized in This study explored older adults’ perceptions of using a technology-based exercise program unsupervised in the home setting. Findings from this study suggest that older adults are open to using technology-based exercise programs in their home. Furthermore, program uptake and adherence seem to be enhanced by (1) older adults’ perceived benefits of undertaking the program; (2) whether the program was stimulating; and (3) the perceived barriers to exercise and technology use.Perceived benefits to health  were the most common reason for older adults to commence and continue their participation in the exercise program. Participants wanted to avoid having to rely on others and be able to care for themselves and felt that exercising would help maintain their independence and preserve their sense of self-value. This is consistent with previous literature on exercise adherence, which suggests that maintaining good health and independence and reducing health risk factors are among the most common self-determined extrinsic motivators for exercise participation in older adults -60. A sySureStep increased participants’ self-efficacy by providing a strong sense of achievement through successful completion of the exergames and progression to higher difficulty levels. Further findings from this study suggest that presenting older adults with positive feedback in the form of praise and scores further influenced their self-efficacy to exercise and increased their motivation to try and improve their scores. These findings emphasize the importance of an immediate positive experience when performing exercise. Tailoring the exercises to the individual’s physical capacities and providing variety of exercises, opportunities for success, and positive feedback on performance are key considerations to increase program adherence.The importance of developing exercise programs that are stimulating to enhance exercise participation and adherence was clearly evident in this study with participants. Participants suggested a wide variety of exercises, with progressive difficulty levels, combining physical and cognitive tasks were key factors to make exercising fun, challenging, and enjoyable. Consistent with these findings, other studies have also found the enjoyment derived from exercising and the experience of personal satisfaction after exercising to be linked to older adults’ motivation to continue exercise participation ,62,66. OSureStep was designed for older adults to use independently at home. The program was designed to deliver the training stimulus using a step pad connected to a computer unit and a television set. The step pad was designed to clearly indicate where the user should stand during game play, and large colored arrows were used to illustrate the different step directions the user could adopt. Two panels labeled “A” and “B” were used to access the home screen and select games and difficulty level, respectively. The program consisted of 4 games , which are modified versions of popular video games or converted neuropsychological tests. Parameters of game play including speed, color, object size, and drift rate of game elements were informed by an iterative process of design and testing involving collaboration between research staff, technologists, and older adults themselves such that the final exercise games delivered were appropriate for the physical, sensory, and cognitive abilities of an older population. As such, participants in this study did not report experiencing difficulties with factors such as the pace of gameplay or amount of graphical information displayed. However, results from our study revealed that participants with limited experience using technology experienced difficulties interacting with the program, including inability to access all available games, modify difficulty levels, and change from game to game. Older adults’ inability to use technology conveyed feelings of frustration and apathy toward the program, thus affecting exercise adherence. To facilitate a more user-friendly interface, participants suggested the use of on-screen step-by-step instructions.Finally, our findings emphasize the importance of providing programs that are accessible to older adults. Participants liked the convenience of performing exercise at home, and the ability to select the amount of time spent exercising and when to exercise emerged as desirable aspects of the program. Home-based programs can reduce common barriers to exercise participation in this population, including lack of time, inability to travel, and dislike for group-based programs. By reducing perceived barriers to exercise, such programs may increase exercise participation and adherence in older adults. These findings are consistent with HPM, which postulates that perceived barriers can affect adults’ commitment to action. However, it is important to consider that not all older adults prefer to exercise at home. For some participants, the self-reliance necessary to adhere to a home-exercise program and the lack of social opportunities were a concern. A study looking at the motivational determinants of exergame participation for older adults in assisted living facilities found that social interaction encouraged older adults to use the exergame as it created competition that resulted in motivation to improve their score . A previSureStep is the need for a greater variety of games and greater range of difficulty levels to cater for older people of varied levels of physical and cognitive function and maintain older people’s interest in the program. Results from our study showed that participants with better functional and cognitive abilities were able to successfully complete all 4 games at the highest difficulty level within the intervention period. Thus, if the aim of technologies such as SureStep is to provide older people with exercise programs they can successfully use at home over prolonged periods, the provision of a wider range of games with extensive difficulty levels is warranted.Furthermore, another element that requires attention to improve future implementation of Findings from this study provide important considerations when designing technology-based programs, which are tailored to the needs of older adults and aimed at increasing both usability and acceptability of programs, which can ultimately enhance exercise participation and long-term adherence to fall prevention interventions. Findings from our study highlight the need for designers of technologies to work closely with older adults throughout the design and development process to learn how their preferences, attitudes, and capabilities relate to technology adoption and how products and services can be designed to promote their widespread and long-term use.On the basis of this study’s findings, future technology-based exercise programs should consider the following recommendations. First, hardware and software should be extensively tested before deployment into people’s homes to avoid system malfunction leading to feelings of frustration and apathy toward the program, which can ultimately affect program adherence. Second, user testing to evaluate the ease of use of the program interface should be carried out during the development phase of the program, and explicit step-by-step instructions should be displayed on the screen to facilitate program use, especially among those with memory problems or cognitive impairment. Third, programs should incorporate a tailored exercise progression algorithm based on the user’s performance, with increasing difficulty levels and unlocking of new games to ensure that the program remains challenging and enjoyable over time. Fourth, programs should provide a sufficient variety of games or exercises with a wide variety of difficulty levels, ideally training both cognitive and motor capacities, to maximize the perceived benefits of the program and maintain engagement. Fifth, programs that use equipment should ensure the equipment does not pose a tripping hazard, causing an increased risk of falling while stepping on or off the equipment.Some limitations identified in this study need to be considered when interpreting the results. First, during the participant recruitment process, people were informed about the benefits of step training interventions in reducing fall risk factors; therefore, participants may have expected receiving health benefits from the program. Second, all participants volunteered to take part in the study knowing that if randomized to the intervention group, they would be required to use a technology-based exercise program; thus, all participants who volunteered were open to try new technologies and may have more positive attitudes toward the intervention. Third, participants were selected from the sample of older adults that returned for reassessment after a 4-month intervention period. Therefore, the interviewed participants did not include older adults who withdrew or dropped out of the study. Interviewing some of these participants may have provided further information on the perceived barriers to using a technology-based exercise program unsupervised at home. However, efforts were made to interview individuals who had stopped using the program but did not withdraw entirely from the RCT. Fourth, the structured nature of the interview questions may have prevented obtaining more in-depth information on participants’ experiences from the study. Finally, interviews were performed by the same person who provided assistance to participants during the RCT. Although this allowed for consistency and rapport building, it might have also allowed for demand characteristics, such as participants trying to provide more positive responses to the interviewer. However, data triangulation was performed using the logs from participants’ visits, telephone calls, and support required to validate the participants’ responses.Findings from this study suggest that it is feasible to use technology to deliver a home-based fall prevention intervention to community-dwelling older adults. However, to encourage uptake and long-term adherence, programs need to remain stimulating over time. Our results indicate that providing 4 different games with varying levels of difficulty did not offer sufficient variety, as over time, participants reported losing interest in the program as the novelty wore off. To maintain participants’ engagement over prolonged periods, we therefore recommend providing a greater variety of games with increasing levels of difficulty to ensure exercises remain challenging. Technologies must also be designed in ways that are accessible to older adults regardless of their previous technology exposure. This study indicates that program usability could be improved by providing on-screen step-by-step instructions as older adults with low technology familiarity as well as those with memory problems or cognitive impairment had difficulty remembering how to use the program.In light of this evidence and in the context of optimizing adherence to technology-based exercise programs for older adults to use at home, program developers should develop exercise programs in ways that provide older adults with a fun and enjoyable experience (thus increasing intrinsic motivation to exercise), focus on improving outcomes that are significant to older adults (thus increasing self-determined extrinsic motivation), offer challenging yet attainable exercises (thus increasing perceived self-competence), provide positive feedback on performance (thus increasing self-efficacy), and are easy to use (thus reducing perceived barriers to technology use).