The theoretical model (Fig. 1) that emerged from the data depicts older adults’ experiences of maintaining an exercise routine to prevent falls as a process represented by the core category ‘Maintaining balance in life’. Maintaining balance reflected balance both in physical matters but also an overall balance in life between activities of everyday life as well as a representation of independence. Three categories were identified that represent three stages of establishing exercise habits: ‘Acting against threats to one´s own identity’, ‘Coordinating strategies to establish a routine’, and ‘Forming habits through cues and evaluation’. The stages were informed by intrinsic and extrinsic mediators. The intrinsic mediators were person-dependent and influenced both why and how the process of maintaining balance in life was initiated, but also how the process developed over time. The Safe Step program acted as an external mediator, which facilitated the process of establishing routines and forming habits.

Fig. 1

The theoretical model of older adults´ process of forming exercise habits supported by the Safe Step application. The process comprised three different stages reflecting the stages presented in the habit formation framework [15], of which all were permeated by the desire to maintain balance in life

Acting against threats to one´s own identity

The model’s first stage encompasses the impact on the older adults’ self-perception through gained insights into their risk of falling. Their identity as an independent and capable person was threatened by an affected confidence in performing activities independently and without getting hurt. The category also describes the choice of taking command over the threatening situation by looking for solutions and support to act against the threat of losing balance in life. The intrinsic mediators of health literacy as well as previous experiences and confidence in performing physical activity and managing technology influenced their choice to act, and their decision to enrol in the study.

Increasing awareness

The threat to one’s identity was revealed through increasing awareness. This insight could have been gained from either an unexpected turning point or by gradually gaining insight of decline or impairment. The turning point was often an event during which a feeling of vulnerability and shame arose, and which also resulted in a difficulty in trusting one's body in challenging situations. The event could be a fall that resulted in limiting and/or painful injury, or one related to a lingering feeling of concern over what might have happened. The event could also be a gradual decline in bodily function that caused a growing sense of imbalance. The increasing awareness caused growing unease or frustration in performing activities, such as not being able to rise from a chair. This activity in particular was symbolic of the threat against independence and self-perception and was expressed as a catalyst of action.

“If I can’t stand up, I can’t do anything. I can’t clean, I can’t wash, I can’t lift, I can’t bake. I can’t do anything at home. It’s horrific just to sit. You get depressed to the max. In addition, if I can’t get up, I can’t go anywhere… You get broken. And people will treat you differently, they’ll think your head is as stupid as your legs.” (Woman, Interview 18)

Seeking solutions

By seeking solutions, the older adults acted against the threat to their health and the threat to their views of themselves as independent persons. Their knowledge of the ageing process and potential consequences of an accidental fall mediated seeking both immediate and long-term measures, which was informed by previous experiences of physical activity and technology.

To reduce the perceived risk of falling, immediate measures were taken such as using poles when walking or altogether avoiding what were perceived as high-risk situations for falling. Although longer recovery time was expected after injuries due to older age, states of fear and bodily concern were not accepted as a new normal condition. Maintaining independence was seen as priority, and the sense of being vulnerable was reshaped to decisiveness in seeking solutions.

“I knew that I had to start training to be able to maintain my independence… I simply had to get started. Because they discussed putting me in a home. I would be in a residence. And I don’t want that. If I am placed there, I might as well die. *becomes emotional*” (Interview 17, Woman)

Looking for health advice was a common strategy that could have sprung from previous interest in and the habit of seeking information regarding physical activity, nutrition, and general healthy living. The generated health information, from the internet or counselling through health care, could serve as a mediator to reflect the need of fall prevention measures when gaining insight into deterioration, which was a predisposed factor when receiving information about the Safe Step study. Some older adults had developed a habit of taking up offers of trying different measures to counteract their balance impairments, such as signing up for the study, as they had refused to give up hope of finding a solution to their problems.

Coordinating strategies to establish a routine

In the model’s second stage, the intention to exercise with the Safe Step program was transformed into action through coordinating strategies by aligning intentions and plans to act. A routine that aimed to create a balance between the new exercise routine and other activities was established. This process was intrinsically mediated by motivation for and previous experiences of physical activity. The Safe Step application acted as an extrinsic mediator, facilitating the onset of the exercise and the making of an exercise plan.

Creating a mindset

Creating a mindset with a clear intention of exercise maintenance was important when establishing a routine. This could be done by generating a feeling of commitment to oneself or to the research project. When possessing stronger self-regulatory skills, making a commitment to oneself was enough to initiate the new exercise routine. This mindset was more easily created when it was mediated by a long experience of exercise performance that increased self-confidence in the ability to establish a sustainable routine.

“Well, I have promised myself that I will do it three times a week and imprinted it in my brain that it must be done. And if it wasn't done in the three days that I had planned from the beginning, it will be three other days.” (Interview 15, Woman)

Making a plan

Making a plan aimed to provide a structure and sustainability for the intended exercise. This plan could be to establish a concrete routine for performing the exercise, or to incorporate it as a part of already existing routines. Adopting a clear structure could be both a strategy based on previous positive experiences of having established routines for exercising, or as a concern of not performing it otherwise. Making a weekly exercise plan could therefore support setting a goal and a commitment to oneself.

“I think that it’s really important that you’ve decided upon a set time, i.e., after morning coffee. Otherwise it’s so easy that the day just goes on and you do it half-heartedly in the evening because you feel guilty.“ (Interview 10, Woman)

The clear structure of the Safe Step application further facilitated the making of an exercise plan and supported confidence in performing the exercises, especially for those with less experience in performing physical activity.

“I thought the description you got in the app were excellent. Because I have a certain tendency to misunderstand things [training instructions]. I thought those were the best explanations I’d seen.” (Interview 8, Man)

Forming habits through cues and evaluation

In the third stage of the model, habits were developed by continuously performing the exercise program supported by cues to action, evaluating the exercise routine against one’s expectations, and making the exercise conform to everyday life. Forming habits was a stage of striking and maintaining a balance between exercise and everyday activities. This process was mediated by the older adults’ own self-regulatory capabilities, motivation, and prior experiences, as well as their confidence in performing physical activity and managing digital technology.

Developing routines

When initiating the training, a period of establishing preferences in how to manage the program and the exercises followed. The goal was to create seamlessness with other everyday activities in order to produce a long-term commitment.

One way to develop routines was to strictly adhere to the previous established plan, where days and times acted as cues to initiate the exercise. For those with well-established habits for exercising, the new elements from the Safe Step program could be introduced into existing routines, e.g., dog walking or rehabilitation exercises. Push notices from the Safe Step program also mediated training by helping participants remember to exercise on set days and times. The push notices could become imperative for continuing to maintain the exercise, for some, throughout the entire intervention period, especially those with experience exercising and those who found exercise boring.

“Some say that there’s a natural need to continue to exercise. I don’t have that need! I’m lazybones. I come up with excuses to avoid exercise! I really needed the reminder and the push from the application. “ (Interview 1, woman)

Participation in the research project could also give rise to a sense of duty. The cue from the application could therefore be perceived as a nudge to act on the commitment. The commitment towards the research project could also be appreciated as it was perceived as easier to maintain the exercise routine with the feeling of contributing to research or of belonging to a social context. This was often because the participant either did not appreciate physical activity in general or wanted motivational support.

In practice, the application could be used in every exercise session, by watching the exercises and performing them simultaneously. This was usually a strategy used at the beginning of the intervention, before learning the exercises. However, over time, this process of starting the application and clicking on each exercise became part of the exercise routine because it required less deliberate thought to just follow instructions, and the company of the older adults on the videos was appreciated.

“You get some kind of personal relationship [with the older adult performing the exercises], even though I can’t give something back. But, it feels like a nice person exercising with me.” (Interview I5, Woman)

The exercise routines could change from the entire program being performed in one session to being incorporated into everyday life. Therefore, the support of the application could become less imperative as the exercises were learned by heart. Through repetition, the information regarding the body’s reaction when performing the exercises transformed into bodily knowledge. Bodily sensations, as, for example, stiffness after sitting too long, could therefore signal a need for doing a few repetitions of sit-to-stand. The exercises themselves or the place the exercises were usually performed could act as contextual cues. For example, one could stop to do a few toe lifts while climbing the stairs. Over time, other contextual cues could form, such as continuously doing mobility exercises for the feet while watching TV, or even seeing the phone or the application.

“I think that it’s good that when you have a lot on your mind and you open the phone, then the app is there and beams. ‘Oh right, I should do my exercises’. Because it's not like I've done it at the same time every day!” (Interview 16, Woman)

Validating the routine

Validating the routine was a parallel process to forming exercise routines and reducing friction that supported developing habits. The perception of the Safe Step application as supportive to the exercise routines was validated by the support it provided for creating the exercise program and its ease of management. However, effects were central to evaluating whether it provided added value in and to life.

The exercise program in itself required continuous validation to attain appropriate strenuousness. This continuous management was mediated by the Safe Step program as the information on how the exercises should feel when performed and when they should become more challenging was perceived as clearly stated, which supported a feeling of competency.

“It was a bit like, I have never been involved in sports or exercise in my entire life, can I really handle this? And then I discover that it's going really well.” (Interview 9, Woman)

At the beginning of the intervention, the exercise was driven by the hope of improvements and the purpose of preserving health. After a while, there was an observed improvement in physical function and less fear of falling which validated the exercise program and the routines. Improvement increased confidence in the capability to self-manage the exercise and gave a sense of meaning to the repeated performance. Therefore, the exercise became more joyous to perform and easier to instigate.

“When I was out with some friends in the woods to pick mushrooms or something, I was not able to join the best parts. The others could walk on a cliff or rock and even descend from them. Earlier I took a step back, but now I dare to join in more often… For me, that’s quality of life.” (Interview 14, Man)

When experiencing the physical status as unchanged, motivation could also be found in the lack of further bodily deterioration. Counteracting deterioration could feel meaningful due to awareness of or information from health care of the importance of physical activity for healthy ageing, which became even more meaningful due to limitations of other physical activities during the Covid-19 pandemic.

Reducing friction

For the exercise routine to be developed into a habit in tune with other parts of life, friction continuously needed to be reduced. This was done by adapting how the exercise program was performed, or by adjusting expectations according to motivation and bodily function. The home-based exercise was in itself a mean to reduce friction because of a preference for exercising alone, or not wanting to or being able to travel to activities. Low exercise thresholds were considered key to maintaining the exercise routine.

“The technology is available all the time. The development has come to the point where I can decide when I want to do things. Paper training programs are in the past, digital is much better.” (Interview 3, Woman)

When the exercises were learned, progression could come to a halt as low exercise thresholds were prioritized and comfort was found in knowing the exercises. Therefore, maintaining the life balance and doing some of the exercises was prioritized over following the recommended exercise dose. This could also be the case when the desired improvements were attained and the goal shifted to maintaining advancements. Therefore, the exercises that had helped them to attain the improvements were kept.

“Yes, I changed some exercises. Probably three times or something like that. I had some exercises I thought worked well with my life, and I stuck to those. “ (Interview 13, Woman)

Due to suspended activities because of the Covid-19 pandemic, home-based exercises were also explored out of necessity, as participants confined themselves to their own homes. Consequently, some perceived it as easier to continue to exercise with the help of the Safe Step application.