gender perspectives on views and preferences of older...

RESEARCH ARTICLE Open Access

Gender perspectives on views andpreferences of older people on exercise toprevent falls: a systematic mixed studiesreviewMarlene Sandlund1* , Dawn A. Skelton2, Petra Pohl3, Christina Ahlgren1, Anita Melander-Wikman4

and Lillemor Lundin-Olsson1

Abstract

Background: To offer fall prevention exercise programs that attract older people of both sexes there is a needto understand both women’s and men’s views and preferences regarding these programs. This paper aims tosystematically review the literature to explore any underlying gender perspectives or gender interpretations onolder people’s views or preferences regarding uptake and adherence to exercise to prevent falls.

Methods: A review of the literature was carried out using a convergent qualitative design based on systematicsearches of seven electronic databases (PubMed, CINAHL, Amed, PsycINFO, Scopus, PEDro, and OTseeker). Twoinvestigators identified eligible studies. Each included article was read by at least two authors independently toextract data into tables. Views and preferences reported were coded and summarized in themes of facilitatorsand barriers using a thematic analysis approach.

Results: Nine hundred and nine unique studies were identified. Twenty five studies met the criteria for inclusion. Onlyfive of these contained a gender analysis of men’s and women’s views on fall prevention exercises. The results suggeststhat both women and men see women as more receptive to and in more need of fall prevention messages. Thesynthesis from all 25 studies identified six themes illustrating facilitators and six themes describing barriers forolder people either starting or adhering to fall prevention exercise. The facilitators were: support from professionals orfamily; social interaction; perceived benefits; a supportive exercise context; feelings of commitment; and having fun.Barriers were: practical issues; concerns about exercise; unawareness; reduced health status; lack of support; and lack ofinterest. Considerably more women than men were included in the studies.

Conclusion: Although there is plenty of information on the facilitators and barriers to falls prevention exercise in olderpeople, there is a distinct lack of studies investigating differences or similarities in older women’s and men’sviews regarding fall prevention exercise. In order to ensure that fall prevention exercise is appealing to bothsexes and that the inclusion of both men and women are encouraged, more research is needed to find outwhether gender differences exists and whether practitioners need to offer a range of opportunities and support strategiesto attract both women and men to falls prevention exercise.

Keywords: Accidental falls, Adherence, Aged, Exercise, Gender identity

* Correspondence: [email protected] of Community Medicine and Rehabilitation, Physiotherapy,Umeå University, Umeå, SwedenFull list of author information is available at the end of the article

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Sandlund et al. BMC Geriatrics (2017) 17:58 DOI 10.1186/s12877-017-0451-2

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http://orcid.org/0000-0003-4781-862X

mailto:[email protected]

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BackgroundFalls present the most common cause of injury in oldage. At least one third of people aged 65-years and abovefall every year, half of them more than once [1], and theincidence increases with advancing age [2]. Women aremore prone to falling compared to men and sustainmore fall related injuries [3]. The annual rates of non-fatal injuries due to falls for women have been reportedto be 48.4% higher than the rates for men [4]. However,a recent study has shown that when the values for co-morbidities, lean and fat body mass, and balance weresimilar between men and women, men actually demon-strated a higher probability of falling [5]. Indeed, men inall age groups are more likely than women to suffer froma fatal fall injury [4]. It is, therefore, important to con-sider men in fall prevention research and interventions.According to recent systematic reviews and meta-

analyses on interventions to reduce falls, exercise pro-grams that focus on balance combined with musclestrength in the lower limbs are effective interventionsto address risk and rate of falling [6, 7]. Exercise programsdelivered at home with support from health professionalsare cost effective, at least in adults 80 years and older, andcost neutral in those younger [8]. However, both groupand home based fall prevention exercise programs areeffective as long as they are performed for an effectivelength of time, regularly enough, and include adequatestrength and balance progression [7, 9].Despite consistent evidence that strength and balance

training is effective in reducing falls and fall relatedinjuries across a range of ages and settings, participantuptake is often poor. In a recent systematic review ofolder people’s participation in and engagement with fallprevention interventions in community settings, only64.2% accepted the invitation to join the exercise inter-vention and 19.4% then dropped out of the interventionwhen they learned what the intervention entailed. How-ever, once they started the intervention there was a 90%retention to the end of the intervention [10]. Averageadherence to group based exercise programs have beenestimated to around 75% [11], and for home based longterm training, adherence rates lower than 50% havebeen reported [12]. Previous reviews investigating viewsand preferences of older people for general fall preventionprograms have found that ‘autonomy supportive’ pro-grams, perceived as relevant and life-enhancing, facili-tated participation. Such programs included education,involvement in decision-making, individually tailoredinterventions and social support [13, 14].Research has tended to focus on women in fall preven-

tion interventions. Between 70 and 77% of participants inreviews of intervention studies were women [6, 9]. Men areless likely than women to report falls, seek medical care,and/or discuss falls and fall prevention with a healthcare

provider [15]. In order to offer fall prevention exerciseprograms that attract older people of both sexes thereis a need to understand both women’s and men’s viewsand preferences regarding these programs. With theexception of walking, which is the most common typeof leisure time physical activity for both women andmen in most cultures, women tend to prefer differenttypes of physical activity than men [16]. Different exerciseprograms may have different ‘meanings’ to men and womenand the way in which we market these opportunities or howthey are run may have differing effects in terms ofuptake and adherence for them. Therefore, careful analysisof womens’ and mens’ views and preferences to the deliveryof falls prevention exercise is crucial.No previous reviews have explicitly considered similarities

or differences between men and women in their views orpreferences. Therefore, the aim of this study was toreview the literature and explore underlying gender per-spectives within older people’s views or preferences regard-ing uptake and adherence to exercise to prevent falls.

MethodAlthough this review was interested in gender perspectives,a pilot scoping review prior to this study suggested verylittle literature with gender views or preferences specifically.Therefore it was decided not to apply an inclusion criteriabased on gender, but instead review all current literature onthe topic and extract any gender information reportedwithin the wider literature for this review. The researchquestion was “What are the views and preferences of olderadults in exercise to prevent falls and are there any differ-ences between women and men?”

Criteria for considering studies for this reviewTypes of studiesBoth quantitative, qualitative and mixed methods articleswere included in this review to ensure this review was asinclusive as possible. The key feature of this review wasto get a wide scope of the literature with breadth anddepth. Previous reviews have often rated the quality ofstudies so the present review, which updates previousreviews but whose aim is to consider the gender perspec-tives, did not entail the appraisal and exclusion of articlesbased on the quality of research methodology [17].

Participant criteriaTrials were included if they specified an inclusion criterionof 60 years of age or over. Trials that include youngerparticipants were included if the mean age minus onestandard deviation was more than 60 years. Participantscould be community dwelling or living in residentialsettings but not if they were currently in hospitalsettings.

Sandlund et al. BMC Geriatrics (2017) 17:58 of 14

Inclusion criteria

� majority of participants being aged ≥ 60 years(see above)

� living in the community or in care home settings,with any medical condition[s]

� presented the views and preferences on fall preventionexercise programs by the older people

Exclusion criteria

� studies not reporting views on exercise to prevent falls� studies not specific to fall prevention� studies which only reported adherence to a program or

program components, not reasons for non-adherence� studies limited to perspectives of significant others

or personnel� patients within a hospital ward setting� studies not presented in English

Literature searchThe electronic databases PubMed, CINAHL, Amed,PsycINFO, Scopus, PEDro, and OTseeker were searchedfor applicable studies, up to February 2016. A professionallibrarian was consulted to plan the search strategy. Thesearch terms were free-text and ‘medical subject heading’(MeSH) terms combined with appropriate Boolean opera-tors. An additional file explains the search strategy inmore detail (see Additional file 1). Limits were set to peerreviewed articles written in English, concerning humansubjects. In addition the reference lists of all includedpapers and identified reviews [13, 14, 18, 19] were screenedfor further articles.

Study selection process and data extractionSearch returned titles were reviewed for inclusion bytwo authors (MS/LLO). In all cases of uncertainty theabstract or the full text article was read. Discrepancieswere discussed and resolved between the two reviewers,where necessary, involving one of the other authors.Data extraction and analysis of the included articles wasperformed by two pairs of authors (all authors read aselection of articles) independently. Data was extractedinto tables summarizing: aim; methods; number andcharacteristics of participants; participant’s views andpreferences on fall prevention exercise programs. Noteswere made on any gender perspectives found or reported.Profession and gender of the authors was extracted by thefirst author. The final data extraction tables were checkedby all authors. Studies were not ranked on quality.

Data synthesisSince studies of all designs were included, the standardsystematic review steps for mixed studies reviews with a

convergent qualitative design was used to synthesize theresults [20]. The views and preferences reported in thearticles were coded and categorized by the first authorinto facilitators and barriers to falls prevention exercise.Within these two categories the codes were analyzedand summarized into themes using a thematic analysisapproach [21]. The first author made the first analysisinto themes and these were later presented and discussedwithin the author group until consensus was reached. Inaddition, all quotes related to gender differences in theparticipant’s views and preferences were identified.However, due to potential bias in the selection ofquotes made by the original studies authors, and a lim-ited number of quotes found, no formal analyses ofthese quotes was performed.

ResultsCharacteristics of the included studiesThe literature search and inclusion of articles are presented,as recommended, following the PRISMA guidelines [22]. Atotal of 1476 articles were identified in the search. Afterremoving duplicates, 909 abstracts were screened, 56met the inclusion criteria. After full text screening, 25of the retrieved papers were considered appropriate toinclude in this review based on the inclusion and exclu-sion criteria [23–47] (Fig. 1).The aim, study design, and number of participants of

the included studies are presented in Tables 1 (quantita-tive and mixed) and 2 (qualitative). Over half of the 25studies identified for inclusion were conducted withinthe last six years (2010 or later). Most of these studiesoriginated in Europe (n = 14), some in Australia or NewZealand (n = 7), and Asia (n = 3) and one in the USA.Most studies were set in the community, only one studyincluded nursing-home residents. Fifteen studies includedparticipants who had actually started some form of fall pre-vention exercises while nine studies did not encompass anactual intervention but investigated older adults’ intentionto undertake fall prevention interventions, includingexercise. One study included people with experiencesof participation and non-participation. The type ofexercises involved in the studies were group based (n = 6),home based (n = 4) and a mix of both home and groupexercises (n = 5). The exercise programs generally in-cluded both strength and balance components, includ-ing The Otago Exercise Programme [48] and FallsManagement Exercise - FaME [49], one study investi-gated Tai Chi [29] and one study aqua-aerobics [35].The most common data collection method used to

explore participant’s views and preferences of fall pre-vention exercises was one to one interviews (n = 13)followed by focus group discussions (n = 10) and sur-veys (n = 4). Several studies used a mix of qualitative


methods. Mixed methods with both qualitative andquantitative design was used in two studies.The number of participants in all included studies was

about 7000. About 90% of the participants were includedin studies involving postal surveys. All studies, excepttwo [32, 47], had a minimum age of 60 years for inclusionand, based on available information, the mean age of allparticipants was approximately 76 years. Three of thestudies did not report the gender distribution of thesample [24, 30, 39] but in the remaining studies themean proportion of included women was 76%.Not only were participants primarily female, but the

authors were as well. The first author was a female in88% of the studies and the mean proportion of maleauthors was 20%. This may be a reflection of the disci-plines of the authors. The first author was a physio-therapist in 40% and a nurse in 28% of the studieseach. The remaining studies were authored either bymedical doctors, health psychologists, occupationaltherapists or other experts in public health.

Gendered views of older adults to falls prevention exerciseOnly five of the 25 articles retrieved in this reviewincluded some sort of gender analysis, regarding simi-larities or differences in men’s and women’s percep-tions on fall prevention exercises [24, 30, 43, 46, 47].None of these studies included participants alreadytaking part in exercise to prevent falls. Two of thesegender analyses were based on surveys, two on focusgroup discussions and one on interviews. In the articleswithout an explicit gender analysis (n = 20) the sex of thequoted participants was reported in 56% of the qualitativepapers. Four studies included women only.Results from the limited gender analysis performed

indicate that men protectively identify women as high-

priority recipients of balance and fall prevention exer-cise and that women see themselves as more receptiveto fall prevention messages than men [24]. In additionthe results indicate that men rely on women for motiv-ation to enroll in health programs [24]. Even though manywomen seem to consider themselves as already activeenough in their everyday life [30, 43], significantly morewomen than men are likely to attend group sessions [47].However, the results seem inconclusive as to whetherwomen are more or less inclined than men to undertakestrength and balance training specifically [46, 47] (Table 1).No studies contained information on women and men’sspecific preferences for program characteristics (e.g.approach) in exercise to prevent falls. See summary inTables 1 and 2.

Older participants views and preferences on fallprevention exerciseFacilitators and barriers for taking part in fall preventionexercises, expressed by older women and men as a group,from the 25 included studies, are reported in Table 3. Thethree most commonly occurring themes emerging as facil-itators for commencement or adherence to an exerciseprogram were: support from professionals or family; socialinteraction; and perceived benefits. In addition to these fre-quently represented themes, three other themes emerged:a supportive exercise context; feelings of commitment; andhaving fun. Being recommended or invited to join fall pre-vention exercise by a professional or having a professionalinstructor giving individually tailored exercises were re-peatedly reported as important for improving uptakeand adherence, as was social support and approval fromfamily and friends. Social interaction was a recurrenttheme in the studies as an important factor of relevancefor adherence, it could sometimes even be a goal in

Fig. 1 Details on the process of including papers for this mixed studies review


Table

1Summaryof

aim,m

etho

ds,p

articipantsandrepo

rted

results

onge

nder

analysis,ifapplicable,for

theinclud

edqu

antitativestud

iesandstud

ieswith

amixed

design

Article

Aim

Metho

dsParticipants

Repo

rted

gend

eranalysis

Whitehead

etal.[43]

Investigatingthereason

forno

ttaking

upfallor

injury

preven

tionstrategy

amon

golde

rpe

oplewho

have

sustaine

dafall

andattend

edan

emerge

ncyde

partmen

t.

Structuralindividu

alinterviews

Results

presen

tedin

coun

tsandpe

rcen

tage

s

60(44wom

enand16

men

)commun

itydw

ellingparticipantswho

attend

edthe

emerge

ncyde

partmen

tof

apu

blicho

spital

with

afall.Meanage78

years.

Cou

ntry:A

ustralia

Con

side

rablymorewom

enthan

men

men

tione

dalreadybe

ingactiveen

ough

(wom

en27.3%,m

en18.8%);can’tdo

exercises(wom

en22.7%,m

en12.5%);

andcan’tleaveho

use/spou

se(wom

en13.3%,m

en0%

),as

reason

forreluctance

totake

partin

exercise

classes.

Yardleyet

al.[46]

Tode

term

inewhe

ther

threat

orcoping

appraisalare

mostcloselyrelatedto

olde

rpe

ople’sintentionto

unde

rtakestreng

thandbalancetraining

.

Postalsurvey

(n.451)a

ndstructuralinterviews(n.107)

Structuraleq

uatio

nmod

eling

558(397

wom

enand161men

)olde

rpe

ople.

Age

dbe

tween60

and95

years,meanage74.

Cou

ntry:U

K

Youn

gerrespon

dentsandwom

enwere

somew

hatmorepo

sitivein

theircoping

appraisalthanwereolde

rrespon

dents

andmen

.Fem

alege

nder

was

positively

relatedto

threat

appraisal(r=

.11,p=009)

andcoping

appraisal(r=

.18,p=.001).

Wom

enwereslightlyless

inclined

than

men

toun

dertakeSBT.

Yardleyet

al.[47]

Tode

term

inetheextent

towhich

olde

rpe

ople,indifferent

sectors,arewilling

toen

gage

indifferent

falls

preven

tion

activities.

Postalsurvey

Logisticregression

s5440

(2846wom

enand2482

men

)patients

from

10ge

neralp

ractices.A

ged>54

years.

Cou

ntry:U

K

Substantially

morewom

enthan

men

indicatedthat

they

werelikelyto

attend

grou

psessions

(p<0.001),and

carryou

tSBTat

home(p<0.001).

Linet

al.[32]

Toexploreattitud

esandbe

liefsof

Taiwaneseolde

rwom

enregardingSBT

prog

ramsandtheirintentions

toattend

such

prog

rams.

Survey

Multip

lelinearregression

sand

Pearson’scorrelations

221wom

enrecruitedfro

mcollege

forpe

ople

with

awishto

learnin

laterlife.Age

dbe

tween

55and94

years,meanage72.

Cou

ntry:Taiwan

Onlywom

eninclud

ed.

Snod

grassand

Rivett[39]

Toexploretheview

sandpe

rcep

tions

ofolde

rpe

opleabou

tfalls

andfalls

injury

preven

tionservices,toiden

tifyincentives

andbarriersto

attend

ingafalls

injury

preven

tionservice.

Survey

95%

confiden

ceinterval(CI)

75mem

bersof

commun

itygrou

ps.N

oexpe

rience

offallpreven

tionexercisesrequ

ired.

Age

dbe

tween

61and93

years,meanage74.Sex

notrepo

rted

.Cou

ntry:A

ustralia

Statisticsno

treportedaccordingto

gend

er.

Hed

leyet

al.[26]

Toexplorethereason

swhy

theparticipants

either

didor

didno

tadhe

reto

anRC

Tinterven

tionwith

both

grou

pandho

me

exercises.

Mixed

design

:Qualitative:Individu

alinterviews

andon

efocusgrou

pQuantitative:Atten

dancerates,

gaitandbalanceassessmen

tsThem

aticanalyses

andde

scrip

tive

statistics

5commun

itydw

ellingwom

en.Participantsin

the

StayingSteady

prog

ram

with

32weeks

ofgrou

pandho

mebasedexercises.Age

dbe

tween60

and88

years,meanage77.

Cou

ntry:U

K

Onlywom

eninclud

ed.

Robinson

etal.[36]

Toexploretheprocessof

behavior

change

inasm

allsam

pleof

olde

rpe

oplewith

the

fall-associated

chronicliver

diseaseprim

ary

biliary

cirrho

sis(PBC

)receivingeither

astandard

oran

enhanced

prog

ram

ofstreng

thandbalancetraining

.

Mixed

design

:Individu

alinterviewsandgraphical

represen

tatio

nsof

patient-rep

orted

outcom

esmeasures(PBC

-40;FES-I;

SEEScale)

Criticalrealistparadigm

ofen

quiry

9commun

itydw

ellingwom

enwith

PBCwho

participated

ina6-weekor

6-mon

thstreng

thand

balancetraining

prog

ram.A

gedbe

tween63

and

80year.m

eanage70

year.

Cou

ntry:U

K

Onlywom

eninclud

ed.


Table

2Summaryof

aim,m

etho

ds,p

articipantsandrepo

rted

results

onge

nder


theinclud

edqu

alitativestud

ies

Article

Aim

Metho

dsParticipants

Repo

rted

gend

eranalysis

Clark

etal.[24]

Toexploreolde

r,commun

ity-dwelling

adults’attitu

desandvalues

abou

tprop

osed

church-delivered

balance

classesforfallpreven

tionto

inform

asocialmarketin

gcampaign.

Focusgrou

ps(n=6)

Indu

ctiveanalysis

60church

mem

bersandpo

tential

usersof

thefallpreven

tionexercise

classes.Age

d≥60

year.Sex

not

repo

rted

.Cou

ntry:U

SA

Wom

enrespon

dto

afall-preven

tionmessage

morethan

men

,and

men

relyon

wom

enfor

motivation.Wom

en’sge

ndered

iden

tities

positio

nedthem

tobe

theprim

arymotivators

who

couldsoften

their“stubb

orn”

men

toen

rollin

health

prog

rams.Men

’sge

ndered

iden

titiespo

sitio

nedthem

toprotectively

iden

tifywom

enas

high

-prio

rityrecipien

tsof

balanceandfall-preven

tionmessage

s.

Jagn

ooret

al.[30]

Toinvestigatefallpreven

tionas

ahe

alth

priorityam

ongolde

rpe

ople;

toun

derstand

peop

le’spe

rcep

tionof

riskandconcep

tsof

fallinjury

preven

tion;

andto

exploreacceptability

ofyoga

asan

interven

tionforfalls

preven

tion

inthecommun

ity.

Focusgrou

ps(n=6)

Them

aticanalysis

Gen

derdivide

dfocusgrou

psin

threesociod

emog

raph

icclusters.

12–18participantsin

each

constellatio

n.Age

d>60

year.

Sexno

trepo

rted

.Cou

ntry:Ind

ia

Theexpe

rience,know

ledg

e,pe

rcep

tions

and

health

prioritieswerediverseanddiffered

across

thethreesociod

emog

raph

icgrou

ps,

althou

ghtheseweresimilaram

ongmen

andwom

enwith

ineach

sociod

emog

raph

icgrou

p.Wom

enconsidered

them

selves

active

enou

ghwith

domestic

work.Noge

nder

discussion

.

BerlinHallru

pet

al.[23]

Toexplorethelived

expe

rienceof

fall

riskfro

malifeworld

perspe

ctive.

Individu

alinterviews

Phen

omen

olog

ical

reflectivelifew

orld

approach

13commun

itydw

ellingolde

rwom

enwith

previous

fragilityfractures.

Participantsin

ahipfracturepreven

tion

prog

ram

comprisingabo

nemineral

density

scanning

,and

writtenfall

preven

tiveadvice

includ

ingadvice

onexercises.Age

dbe

tween76

and

86years.

Cou

ntry:Swed

en

Onlywom

eninclud

ed.

Haw

ley[25]

Toexplorewhatmight

encourage

olde

rpe

opleto

exercise

atho

me

afterfalls

rehabilitation.

Individu

alinterviews

Groun

dedtheo

ryapproach

8commun

itydw

elling,

1nu

rsing

homereside

nt.A

llhadbe

enthroug

hfalls

rehabilitationandofferedho

me

exercise

prog

ramsAge

d≥60

year.

Sexno

trepo

rted

.Cou

ntry:U

K

Quo

tesfro

mbo

thmen

andwom

enbu

tno

comparison

.

Horne

etal.[27]

Toexplorethebe

liefsof

both

South

Asian

andWhite

British

commun

itydw

ellingolde

radultsin

their60sabou

tfalls

andexercise

forfallpreven

tion.

Focusgrou

ps(n=15)

andindividu

alinterviews

Fram

eworkanalysis

87+40

(81wom

enand46

men

)commun

itydw

ellingparticipants.

Age

dbe

tween60

and70

year,Focus

grou

pmeanage65.Ind

ividualinterview

smeanage64.

Participantswith

different

expe

riences

ofparticipationor

nonp

articipationin

exercise.

Cou

ntry:U

K

Quo

tesfro

mbo

thmen

andwom

enbu

tno

comparison

.

Horne

etal.[28]

Toiden

tifysalient

beliefsthat

influen

ceup

take

andadhe

renceto

exercise

for

fallpreven

tionam

ongcommun

ity-

dwellingCaucasian

andSouthAsian

inUK.

Ethn

ograph

icstud

yparticipantob

servations,

focusgrou

ps(n=15)

andindividu

alinterviews

Fram

eworkanalysis

87+40

(81wom

enand46

men

)commun

itydw

ellingparticipants.

Age

dbe

tween60

and70

year,Focus

grou

pmeanage65.Ind

ividual

interviewsmeanage64.

Quo

tesfro

mbo

thmen

andwom

enbu

tno

comparison

.


Table

2Summaryof

aim,m

etho

ds,p

articipantsandrepo

rted

results

onge

nder


theinclud

edqu

alitativestud

ies(Con

tinued)

Participantswith

different

expe

riences

ofparticipationor

nonp

articipationin

exercise.

Cou

ntry:U

K

Huttonet

al.[29]

Tode

velopan

unde

rstand

ingof

the

percep

tions

that

olde

radultsat

riskat

offalls,and

previouslyinvolved

inorganizedgrou

pexercise,haveof

physicalactivity.

Focusgrou

ps(n=5)

Them

aticanalysis

20commun

itydw

ellingpe

rson

s(90%

females)recruitedfro

maRC

Tinvestigatingtheeffectiven

essof

TaiC

hiin

redu

cing

falls.A

ged

betw

een68

and81

year,m

ean

age73.

Cou

ntry:N

ewZe

aland

Gen

derno

trepo

rted

inqu

otes.

Lam

etal.[31]

Toexam

ineolde

rpe

ople’spe

rcep

tions

andexpe

riences

offalls,p

hysiothe

rapy

andexercise.

Individu

alinterviews

Phen

omen

olog

icalapproach

19(10wom

enand9men

)commun

itydw

elling

Australian-bo

rnandItalian-bo

rnolde

rpe

rson

swho

hadmorethan

onefall

inthepast

12mon

thsandcompleted

acommun

ity-

basedph

ysiotherapyprog

ram.A

ged

betw

een65

and89

years.

Cou

ntry:A

ustralia

Quo

tesfro

mbo

thmen

andwom

enbu

tno

comparison

.

Lind

gren

DeGroot

and

Fage

rström

[33]

Tode

scrib

emotivatingfactorsand

barriersforolde

radultsto

adhe

reto

grou

pexercise

inthelocalcom

mun

ity.

Individu

alinterviews

Descriptiveconten

tanalysis

10(5

wom

enand5men

)commun

itydw

ellingpe

rson

sandform

erparticipants

inafallpreven

tiveexercise

prog

ram.

Age

dbe

tween71

and91

year,m

ean

age83.

Cou

ntry:N

orway

Gen

derno

trepo

rted

inqu

otes.

Meyer

etal.[34]

Toun

derstand

thepe

rspe

ctives

ofolde

rpe

oplein

adop

tingaho

me-based

balanceexercise

prog

ram

toaddress

mild

balancedysfun

ction,andto

iden

tify

barriersandop

portun

ities

facing

commun

ityhe

alth

PTsin

deliveringthisprog

ram.

Focusgrou

ps(n=2)

with

olde

rparticipants,(focus

grou

ps,w

rittensurveys,

anddata

recordingsheets

forPTs).

Phen

omen

olog

icalapproach.

Them

aticconten

tanalysis

9(6

wom

enand3men

)commun

itydw


hadcompleted

asix-mon

thprog

ram.A

gedbe

tween

67and86

years.

10PTs

Cou

ntry:A

ustralia

Gen

derno

trepo

rted

inqu

otes

Moo

dyet

al.[35]

Toinvestigateparticipants’p

erceptions

ofatw

elve

weekaqua-aerob

icsprog

ram

onfalls

riskandph

ysicalfunctio

nin

olde

radultswith

lower

extrem

ityosteoarthritis.

Focusgrou

ps(n=4),

oneindividu

alinterview

Gen

eralindu

ctiveapproach

17(13wom

enand4men

)commun

itydw

ellingparticipantswith

lower

extrem

ityosteoarthritiswho

hadcompleted

a12

weekwater-based

exercise

prog

ram.

Age

dbe

tween68

and89

years,mean

age78.

Cou

ntry;N

ewZe

aland

Gen

derno

trepo

rted

inqu

otes.

Robinson

etal.[37]

Toinvolveolde

rpe

opleandPTsin

the

developm

entof

acceptablestrategies

toprom

oteup

take

andadhe

rence

with

anexercise-based

fallpreven

tion

prog

ram

Focusgrou

ps(n=3)

with

olde

rpe

opleandwith

localP

Ts(n=4)

Fram

eworkanalysis

12(8

wom

enand4men

)olde

rpe

ople

attend

ingaregion

alfalls

andsyncop

eserviceinclud

ingexercises.Age

dbe

tween

72and88

years,meanage79.

18(14wom

enand4men

)PTsin

the

region

.Cou

ntry:U

K

Quo

tesfro

mbo

thmen

andwom

enbu

tno

comparison

.


Table

2Summaryof

aim,m

etho

ds,p

articipantsandrepo

rted

results

onge

nder


theinclud

edqu

alitativestud

ies(Con

tinued)

Simpson

etal.[38]

Toexam

inetheextent

towhich

olde

rpe

oplearewillingto

adop

tanyof

the

followingstrategies

inorde

rto

avoid

falling

:balance

andlower

limb

streng

then

ingexercises.ho

mesafety

advice,and

‘taking

care’.

Individu

alinterviews

Metho

dof

analysisno

trepo

rted

32(26wom

enand6men

)pe

rson

sdischarged

from

acuteelde

rlycare

med

icalwards.N

oexpe

rienceof

fall

preven

tionexercisesrequ

ired.

Age

d>65

years,meanage83.

Cou

ntry:U

K

Quo

tesfro

mbo

thmen

andwom

enbu

tno

comparison

.

Stathi

andSimey

[40]

Toexploretheexercise

expe

riences

ofnu

rsingho

mereside

ntswho

participated

ina6-mon

thfalls

preven

tionexercise

interven

tion.

Individu

alinterviews,

14at

baselineand7at

follow-up

Interpretiveph

enom

enolog

ical

analysis

14(12wom

enand2men

)nu

rsing

homereside

ntswho

participated

ina

6-mon

thchair-basedexercise

prog

ram.

Age

dbe

tween86

and99

years.

Cou

ntry:U

K

Quo

tesfro

mbo

thmen

andwom

enbu

tno

comparison

.

Suttanon

etal.[41]

Iden

tifyfactorsthat

influen

cecommen

cemen

tandadhe

renceto

aho

me-basedbalanceexercise

prog

ram

forolde

rpe

oplewith

mild

tomod

erate

Alzhe

imer’sdisease(AD).

Individu

alinterviews

Phen

omen

olog

icaltheo

retical

framew

ork

10(7

wom

enand3men

)participants

with

ADand9(6

wom

enand3men

)of

theircaregivers,w

hohadcompleted

asix-mon

thho

me-basedbalanceexercise

prog

ram.

Participantswith

ADaged

betw

een

75and89

years,meanage81.

Careg

iversaged

betw

een58

and85

years,meanage71.

Cou

ntry:A

ustralia

Mostly

quotes

from

wom

en,nocomparison

.

Vernon

andRo

ss[42]

Toexplorethereason

solde

rpe

ople

hadforattend

inglocalp

ostural

stability

exercise

classes.

Individu

alinterviews,22

atbaselineand17

atfollow

upThem

aticanalysis

22(20wom

enand2men

)commun

itydw


hadfallen

andattend

edbalanceexercise

classes.

Age

dbe

tween65

and94

years.

Cou

ntry:U

K

Gen

derno

trepo

rted

inqu

otes.

Won

get

al.[44]

Toestim

atetheup

take

rate

ofafall

preven

tionprog

ram

Toexploretheattitud

estowards

acceptance

oftheexercise

class

includ

edin

afallpreven

tionprog

ram.

amon

golde

rfallersandexplore

relatedfactors

Focusgrou

ps(n=3)

Con

tent

analysis

(Baselineteleph

oneinterviews

(n.1194)

anda1-year

follow-up

teleph

onesurvey

(n.969)w

itholde

rpe

opleor

theircarers)

FocusGroup

s:(9

wom

enand4men

)previous

fallersam

ongwho

attend

edexercise

classesbasedon

theFaME

protocol.A

gedbe

tween65

and

91year,m

eanage76.

Cou

ntry:H

ongKo

ng

Gen

derno

trepo

rted

inqu

otes.

Yardleyet

al.[45]

Toiden

tifyfactorscommon

toa

variety

ofpo

pulatio

nsandsettings

that

may

prom

oteor

inhibitup

take

andadhe

renceto

falls

related

interven

tions

Individu

alinterviews

Fram

eworkanalysis

69(50wom

enand19

men

)olde

rpe

ople,

twothird

s(46)

hadbe

enofferedan

interven

tion,andhalf(32)

hadtakenpart

inan

interven

tion.Age

dbe

tween68

and

97years,meanage79.

Cou

ntries:Den

mark,Germany,Greece,

Switzerland

,The

Nethe

rland

s,andUK

Quo

tesfro

mbo

thmen

andwom

enbu

tno

comparison

.


Table

3Summaryof

thethem

aticanalysisof

facilitatorsandbarriersrepo

rted

inallstudies.Viewsandpreferen

cesrepo

rted

werecode

dandsimilarcode

sgrou

pedinto

them

es

Exam

ples

ofcode

sThem

esRepo

rted

inqu

antitativeor

mixed

stud

ies(see

Table1)

Repo

rted

inqu

alitativestud

ies(see

Table2)

Facilitators

“Recom

men

datio

nsfro

mhe

alth

profession

als”

“Sup

portfro

mprofession

al”

“Professionalexerciseinstructor”

“Fam

ilysupp

ort”

“Socialapp

roval“

“Positive

socialiden

tity”

“Being

accompanied

byafrien

d”

Supp

ortfro

mprofession

alsor

family

Quantitative:Yardleyet

al.[46],Snod

grass

andRivett[39],Lin

etal.[32]

Mixed

:Hed

leyet

al.[26],Ro

binson

etal.[36]

Haw

ley[25],H

uttonet

al.[29],

Moo

dyet

al.[35],Stathi

and

Simey

[40],Suttano

net

al.[41],

Won

get

al.[44],Yardleyet

al.[45],

Meyer

etal.[34]

“Socialization”

“Relationships”

“Valuedcompanion

ship”

“Enjoyableandsociableatmosph

ere”

“Havingacoffee/teaas

partof

activity”

“prefergrou

pexercises”

Socialinteraction

Quantitative:Snod

grassandRivett[39]

Mixed

:Hed

leyet

al.[26]

Clark

etal.[24],Haw

ley[25],

Huttonet

al.[29],Jagn

ooret

al.[30],

Lind

gren

DeGroot

andFage

rström

[33],

Moo

dyet

al.[35],Stathi

andSimey

[40],

Vernon

andRo

ss[42]

“Staying

inde

pend

ent”

“Increase

inde

pend

ence”

“Fun

ctionalimprovem

ents”

“Maintaining

health”

“Believe

that

exercise

hasbe

nefits”

“Feelingim

provem

ents”

“Improved

men

talh

ealth

”“Red

uctio

nof

fallrisk”

“Recen

tfalls”

“improved

self-efficacy”

Perceivedbe

nefits

Quantitative:Yardleyet

al.[46,47],Lin

etal.[32]

Mixed

:Hed

leyet

al.[26],Ro

binson

etal.[36]

Clark

etal.[24],Haw

ley[25],Jagno

oret

al.

[30],Lam

etal.[31],Lind

gren

DeGroot

andFage

rström

[33],M

eyer

etal.[34],

Moo

dyet

al.[35],Simpson

etal.[38],

Stathi

andSimey

[40],Suttano

net

al.[41],

Vernon

andRo

ss[42],Yardley

etal.[45]

“Trust-based

atmosph

ere”

“Smallsizeclasses”

“Suitableandne

arby

facility”

“Atho

meor

grou

p”“Participantsof

similarage”

“Program

characteristics”

“Individu

allyadapted”

“Feelingow

nershipof

theprog

ram”

“Highself-efficacy”

Asupp

ortiveexercise

context

Quantitative:Linet

al.[32],Yardleyet

al.[47]

Mixed

:Rob

insonet

al.[36]

BerlinHallru

pet

al.[23],Horne

etal.[27],

Huttonet

al.[29],Lam

etal.[31],

Meyer

etal.[34],Ro

binson

etal.[37]

Suttanon

etal.[41],Vernon

andRo

ss[42],

Won

get

al.[44]

“Com

mitm

entto

astructured

prog

ram”

“Exerciserecordingsheet”

“Measurablego

als”

“Minim

izingcaregiversbu

rden

”“Con

tributeto

research”

Feelings

ofcommitm

ent

Meyer

etal.[34],Moo

dyet

al.[35],

Stathi

andSimey

[40]

Suttanon

etal.[41]

“Interestanden

joym

ent”

“Enjoyableandjoyful”

“Activity

soun

dslikefun”

Havingfun

Quantitative:Snod

grassandRivett[39]

BerlinHallru

pet

al.[23],Suttano

net

al.[41],

Yardleyet

al.[45]

Barriers

”Transpo

rtationto

exercise

venu

e”“Enviro

nmen

talfactors”

“Lackof

suitableplaceat

home”

“Lackof

time”

Practicalissues

Quantitative:Snod

grassandRivett[39],

Whitehe

adet

al.[43]

Mixed

:Hed

leyet

al.[26]

Horne

etal.[27,28],H

uttonet

al.[29],

Lind

gren

DeGroot

andFage

rström

[33],

Moo

dyet

al.[35],Suttanon

etal.[41],


Table

3Summaryof

thethem

aticanalysisof

facilitatorsandbarriersrepo

rted

inallstudies.Viewsandpreferen

cesrepo

rted

werecode

dandsimilarcode

sgrou

pedinto

them

es(Con

tinued)

“Bad

weather”

Vernon

andRo

ss[42],W

onget

al.[44],

Yardleyet

al.[45]

“Fearof

adverseeffects”

“fear

offalling

again”

“Anxiety

atstart”

“Unableto

keep

upwith

othe

rsin

class”

“Acompe

titiveatmosph

ere”

“Too

difficultexercises”

“Differen

tfunctio

nallevelsam

ongparticipants”

“Previou

sun

pleasant

expe

riences”

“Dislikegrou

pactivities”

“Program

nottailored”

Con

cernsabou

texercise

Quantitative:Snod

grassandRivett[39]

Yardleyet

al.[46]

Mixed

:Rob

insonet

al.[36]

Horne

etal.[27,28],H

uttonet

al.[29],

Lam

[31],Lindg

renDeGroot

and

Fage

rström

[33],M

oody

etal.[35],

Simpson

etal.[38],Stathi

andSimey

[40],

Suttanon

etal.[41],Vernon

andRo

ss[42]

“Misun

derstand

ings

ofbe

nefits”

“Den

ialo

friskof

falling

”“Perceiveon

eselfas

tooyoun

gandfit”

“Being

activeen

ough

”

Unawaren

ess

Quantitative:Snod

grassandRivett[39],

Whitehe

adet

al.[43]

Horne

etal.[27,28],Jagno

oret

al.[30],

Simpson

etal.[38]

Yardleyet

al.[45]

“Deterioratio

nin

health”

“Painandpatholog

y”“Feelingun

well”

“Fatigue”

“Feelingtooold”

Redu

cedhe

alth

status

Quantitative:Whitehe

adet

al.[43]

Huttonet

al.[29],Lind

gren

DeGroot

andFage

rström

[33],M

oody

etal.[35],

Simpson

etal.[38],Suttanon

etal.[41],

Vernon

andRo

ss[42]

“Unp

rofessionalinstructor”

“With

draw

alof

profession

alsupp

ort”

“Lackof

supp

ortfro

mho

me”

“Careg

ivershe

alth”

Lack

ofsupp

ort

Quantitative:Whitehe

adet

al.[43]

Mixed

:Hed

leyet

al.[26]

Huttonet

al.[29],Stathi

andSimey

[40],

Suttanon

etal.[41],Won

get

al.[44]

“Lackof

motivation”

“Not

interested

”Lack

ofinterest

Quantitative:Snod

grassandRivett[39],

:Whitehe

adet

al.[43]

Huttonet

al.[29],Lind

gren

DeGroot

andFage

rström

[33]


itself and thereby important for uptake as well. Anothertheme frequently occurring in the studies was the import-ance of perceived benefits, meaning that the exercises wererecognized as beneficial for improving or maintaining per-sonal health and in particular for staying independent. Theimportance of a supportive exercise context was found inseveral studies, and included aspects such as an atmosphereof trust, small classes and easy access to exercise venues.Feelings of commitment was another recurrent themereflecting the participants’ willingness to pursue a program(adherence) and to do it well, but also to contribute, forexample by reducing a caregivers burden or contributeto research. The last theme, having fun, emphasizes theimportance of enjoyment and playfulness as incentivesfor both uptake and adherence.The barriers for taking part in fall prevention exercise

were expressed in six themes: practical issues; concernsabout exercise; unawareness; reduced health status; lackof support; and lack of interest. Practical issues werementioned in the majority of the studies as the reasonfor not taking part in exercises. Such barriers were oftenrelated to transportation to exercise venues, but couldalso be lack of time, bad weather, or lack of a suitableplace to exercise at home. Another barrier that washighlighted in many studies was the concerns olderpeople had about the exercise. Many older people voiced alack of confidence to do exercises and fear of adverseeffects or a new fall. Concerns about not being able to‘keep up’ with demanding exercises, or what other partici-pants could manage, were also expressed. At the sametime, for those who were functionally able, groups com-posed of participants at lower functional levels could alsobe frustrating. Unpleasant experiences from previousexercise or dislike of group exercises with a competitiveatmosphere could also pose a barrier for taking part.Unawareness was another barrier and included lack ofknowledge about specific benefits of exercise for fallprevention, older people perceiving they were alreadyactive enough, and denial of fall risk. Reduced health,such as pain, fatigue or other illness, as well as lack ofsupport in their situation was another barrier. Someolder people simply expressed that they were not inter-ested in fall prevention exercises.It was not possible to determine whether older adults

preferred group or home based exercises as studiesrarely offer both approaches. It seemed that the type ofintervention included in the particular studies affectedthe participants’ preferences, so that they preferredwhat they had been offered. The results of the fewstudies offering both alternatives suggest that homeexercises are more difficult to adhere to than the groupsessions [26] and that older people rely on their ownjudgment when deciding on whether to take part ingroup or individual exercise, based on their exercise

abilities, transportation issues, and willingness to ex-pose their disabilities to others [23].

DiscussionThe main aim of this review was to explore any genderdifferences in views about or preferences for falls pre-vention exercise within the current literature. Unfortu-nately, only five of the articles in this review included agender analysis of similarities or differences in men’sand women’s perceptions on fall prevention exercises,and none of these investigated if specific approachesattracted women or men differently. Despite the difficultiesin making conclusions due to the differing designs andsmall number of studies, in terms of ‘views’, the resultssuggest that women are seen as high-priority recipientsof balance and fall prevention messages by both womenand men. Though incidentally, perhaps researchers alsoview women as high-priority participants as the meanproportion of included women in the studies was 76%.Women seem more receptive to fall prevention messagescompared to men and are more likely to attend groupsessions. No studies considered preferences of men andwomen and whether these differed or would affect up-take or adherence.If services want to attract both older women and men to

fall prevention exercise they need to consider how theseprograms are marketed and designed, taking into accountthe preferences of older men and women. A large con-sumer market research study based on numerous focusgroup discussions, individual interviews and surveys con-cluded that messages must move beyond transmission ofbasic health information and focus on encouragement andinspiration, while being careful not to alienate [50]. Mes-sages will have more meaning if they are informed byknowledge on potential gender specific preferences.With respect to the gender, according to this review it

seems as if men are often not considered as being inneed of fall prevention, both by themselves and societyin general. These results conform to recent researchshowing that men to a lesser degree report and discussfalls and fall prevention with a healthcare provider [15].One large survey to gain insight into the barriers torecruiting and engaging older men in evidence-basedhealth promotion programs found that 78% of the re-spondents agreed that the perception of exercise pro-grams as feminine was a barrier and over 90% of thesurvey respondents believed program advertisementsfeaturing men would increase their participation [51].The reason for this pattern can be discussed in relation

to constructions of masculinity and gendered identities.From this perspective, gender does not reside in theperson but is viewed as a dynamic, social structure inwhich men and women conforms to stereotypic beliefsand behaviors based on dominant norms of femininity


and masculinity. According to the norms, men shouldbe independent, self-reliant, strong, tough and willingto take risks [52]. In addition, this view of masculinityincludes denial of weakness or vulnerability and rejectionof feminine ideals, which include positive health beliefs orbehaviors. These gendered identities are believed to fosterboth unhealthy behavior among men and underminemen’s attempts to adopt healthier habits [53]. It is import-ant to know if men are less likely to take up falls preven-tion exercise as this could be considered as them beingfrail and needing help to maintain independence. Forexample, one study gave a quote from a Greek man“You should be very careful about the way you wouldapproach old men and tell them that they might needto participate in this…. Not everybody accepts his ageand his state” [45]. Would joining a group program ofexercise with women be a threat to their identity?These are questions we cannot answer with the currentliterature. Of course, it is also possible that exercisepreferences for older men and women with a history offalls may not differ, as is the case with men and womenwith multiple sclerosis [54]. However, with the muchsmaller number of men included in studies on exerciseto prevent falls we cannot be sure that part of the reasonis the lack of identification with such programs by men.A clear trend when investigating participant’s preferences

for fall prevention exercise, was that women do research onand for women. If researchers or clinicians tend to favorthe inclusion of women in prevention programs, genderbias (conscious or unconscious) may arise and stereotypegendered views and identities may be confirmed [55].Researchers and clinicians need to be aware of theirown gendered identities and how they are influenced bygender relations [56] in order not to strengthen orreinforce stereotypical gender views.This review has, from 25 included studies, identified

six themes as facilitators and six themes as barriers forolder people either starting or adhering to fall preventionexercise, irrespective of gender (Table 3). The identifiedfacilitators and barriers concur well with the results ofprevious (non-gender specific) reviews, which includedperceptions of fall prevention interventions includingexercise [13, 14]. Recurrent themes were the need forsocial and professional support and that exercise is per-ceived as beneficial and important for maintainingindependence. Barriers related to practical issues, likeaccess to programs and lack of support, were consistent[14] as were perceived poor health, poor self-efficacy,fear of falling, underestimation of fall risk and concernsabout exercise [13].The psychosocial factors expressed by the older partic-

ipants as important for engagement in fall preventionexercises conforms well with many health psychologytheories commonly used to predict health behaviors, in

particular the theory of planned behavior (TPB) [57].This theory has previously been applied in fall preven-tion research [58] and was also used in four of the in-cluded studies [27, 32, 45, 46]. From the 25 studies inthis review it is apparent that older people’s attitudes tothe effects of exercises are mainly positive. Older peopleare often aware of the beneficial effects of physical exer-cise to improve their general health, and this knowledgemotivates them to be active. However, exercise per-formed merely with the goal to prevent future falls, doesnot seem enough to attract this population. This attitudehas previously been explained by two coupled factors:(a) a belief that falls cannot be prevented, but are causedby external circumstances and bad luck, and (b) anunderestimation of the personal perceived fall risk [58].The influence of a subjective norm was confirmed asessential for many older people’s commencement oradherence to an exercise program. Both professional andsocial support as well as social interaction during fallprevention exercise was commonly reported as import-ant factors in the studies reviewed. Many of the barriersreported related to a perceived lack of control over theexercise situation, such as practical issues and variousconcerns about the exercises including lack of confi-dence, worries about not being able to keep up withothers, and fear of adverse effects.A number of methodological features could influence the

result of this review. A strength is the broad literature searchin a number of electronic databases, done systematicallywith the consultation of a librarian. However, despite theefforts to identify all eligible publications, we cannot excludethe possibility that some were missed. The lack of generallyused keywords for participant’s views and preferences andthe diverse research methodologies used in the studies aim-ing for made it difficult to develop a comprehensive searchstrategy. In order to compensate for this difficulty, the refer-ence lists of all included articles and previous resemblingreviews were searched for additional publications, whichresulted in a few more studies to include. No ranking ofquality of the included studies was performed.

ConclusionIn conclusion, although there is plenty of information onthe facilitators and barriers to falls prevention exercisein older people, there is a distinct lack of studies investigat-ing differences or similarities in older womens’ and mens’views regarding fall prevention exercise. In order to ensurethat fall prevention exercise is appealing to both sexes andthat the inclusion of both men and women are encouraged,more research is needed on preferences to find out whetherany gender differences exists and whether and how practi-tioners need to offer a range of opportunities and supportstrategies to attract both women and men to falls preven-tion exercise.


Additional file

Additional file 1: Literature search. (PDF 152 kb)

AcknowledgementsOur thanks to Umeå University library for valuable advice when planning theliterature search.

FundingThis work has been funded by: The Swedish Research Council, Dnr 2015–03481;The Strategic Research Programme in Care Sciences, Umeå University and TheKarolinska Institute, Sweden, and a grant provided by Umeå University for DS asa visiting Professor.

Availability of data and materialsThe data supporting the conclusions of this article are included within the articleand its additional file. Detailed information on the database search is provided inthe Additional file 1. Figure 1 shows a flowchart of the literature search, exclusionand inclusion of articles, further information on the excluded studies will beprovided by the authors on request. Tables 1 and 2 summarize the aim, methods,participants and gender analysis, if applicable, of the included studies. Table 3summarize the thematic analysis of facilitators and barriers reported in all studies.

Authors’ contributionsMS carried out the systematic search with help of the consulted librarian,selected the studies for inclusion, extracted data and summarized includedstudies, performed the qualitative coding and synthesized codes intothemes, revised the themes following discussions and negotiations withall co-authors, and wrote the manuscript. DAS contributed to extractdata and summarize the included studies, discussed and negotiated thethemes, revised the tables, and revised and commented on the manuscript. PPcontributed to extract data and summarize the included studies, discussed andnegotiated the themes, and revised and commented on the manuscript.CA contributed to extract data and summarize the included studies, discussedand negotiated the themes, wrote paragraphs in the discussion, and revisedand commented on the manuscript. AMW contributed to extract data andsummarize the included studies, discussed and negotiated the themes,and revised and commented on the manuscript. LLO selected the studiesfor inclusion, contributed to extract data and summarize the included studies,discussed and negotiated the themes, and revised and commented onthe manuscript. MS is the guarantor. All authors read and approved thefinal manuscript.

Competing interestsThe authors declare that they have no competing interests.

Consent for publicationNot applicable.

Ethics approval and consent to participateNot applicable.

Author details1Department of Community Medicine and Rehabilitation, Physiotherapy,Umeå University, Umeå, Sweden. 2School of Health and Life Sciences,Glasgow Caledonian University, Glasgow, UK. 3Department of Rehabilitationand Department of Medical and Health Sciences, Linköping University,Linköping, Sweden. 4Department of Health Sciences, Division of Health andRehabilitation, Luleå University of Technology, Luleå, Sweden.

Received: 22 June 2016 Accepted: 14 February 2017

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