There are approximately 55,000 falls-related emergency hospital admissions in England among patients aged 65 years and older, and around a third of people aged 65 years and above fall each year [1], costing the National Health Service (NHS) £4.6 million (US $6.2 million) per day [1]. Strength and balance exercises have been proven to be effective in reducing the risk and rate of falls [2-4]. However, for these exercises to be effective, a minimum effective dose (3 times a week) must be reached and then maintained in the long term for sustained effects [3]. We know that the role of health care professionals is important in both motivating older adults and progressing their exercise to ensure that the exercises are challenging [5,6]. Currently, strength and balance programs delivered by NHS falls rehabilitation services are inadequate in dose [7], and most services see patients only once per week [7].

Teleconferencing could be an effective way of delivering evidence-based strength and balance exercises by providing increased contact with health care professionals. It has been demonstrated that introducing video consultations is complex and disrupts established processes and routines [8,9]. Concerns have been raised about technical and clinical quality, privacy, safety, and accountability [8,9]. The evidence base on remote consultations by video technology is increasing [10-12], and studies have reported positive benefits and similar satisfaction levels. However, studies that focus on the role of teleconferencing for fall prevention are sparse. Some studies have focused on the delivery of Tai Chi [13,14], and others have focused on other types of rehabilitation [15-17]. The systematic review by Kairy et al [15] examines the clinical outcomes, clinical process, health care utilization, and costs associated with telerehabilitation (therapy delivered through teleconferencing). Clinical outcomes of telerehabilitation programs were found to be as good if not better when compared with those of standard programs. In addition, adherence to telerehabilitation was found to be good. Other reviews have provided some potential but are still not conclusive [18]. Social networks and friendship have also been identified as important aspects of group telerehabilitation programs [19].

As health professionals do not need to travel (cost and time) to patients’ houses, teleconferencing could allow them to see patients more regularly than once a week, increasing exercise dose and motivation. We know that health professionals are an important source of motivation [5,6,20]. Strength and balance exercises could be delivered both one-to-one in patients’ homes or in groups. Some patients do not have the confidence or ability to attend face-to-face group exercise sessions [21]. It may be that being part of a small virtual group either increases confidence and ability to attend a face-to-face group session or enables adherence through long-term exercise and peer support available in the home [22].

The aim of our study is to examine whether smartphone-based teleconferencing (linked to a television [TV] or screen) is usable, acceptable, and feasible for health professionals and older adults as a means of delivering evidence-based fall prevention strength and balance home exercise programs. Acceptability is a multifaceted construct that considers the extent to which people that deliver or receive a health care intervention consider it to be appropriate [23]. When referring to feasibility, we particularly focus on practicality (to what extent teleconferencing could be conducted with the intended participants using existing means, resources, and circumstances) and implementation (to what extent teleconferencing could be used to successfully deliver rehabilitation to intended participants) [24]. Usability focuses on whether a person can use it for its intended purpose [25]. Models such as the technology acceptance model (TAM), which focuses on whether a technology is perceived as useful and whether it is easy to use [26], are important when developing technological interventions and are considered within our study. We took a two-step approach to explore acceptability, usability, and feasibility.

We held 2 patient and public involvement (PPI) workshops to gain initial feedback on teleconferencing:

The teleconferencing involved using Skype on the smartphones of health professionals and patients and connecting the phones to either a screen or TV. We know that older adults feel more comfortable using technology they are familiar with [27], and therefore, we thought this would be more acceptable than specific teleconferencing equipment.

The health professional workshop was run by a researcher who was also an occupational therapist (OT) in a different falls team. The older adult workshop was run by the OT and the lead researcher for the project. In the workshops, we discussed the initial concept of the technology with an explanation of why we thought it was important (perceived usefulness), what we were trying to achieve, and how teleconferencing could work for rehabilitation. We then connected the phone to a large screen (as would have been done for delivery) and demonstrated to the whole group what patients and health professionals would need to do and what they could see. We asked for feedback on the concept and whether participants (health professionals and older adults) thought health professionals and patients would be able to use it (perceived ease of use). Discussions on stands for smartphones and equipment used (whether to use Chromecast or a high-definition multimedia interface [HDMI] cable to connect the phone to a TV or screen) were included. Notes were taken on the feedback provided.

Contact with older adults and health professionals was classed as PPI rather than formal research. Therefore, we only collected aggregate details on gender, ethnicity, and previous experience of technology for participants and gender and clinical background for health care professionals.

The research proposed in this stage was predominantly qualitative. This enables us to establish whether the technology is acceptable to patients and health professionals (qualitative methods) and assess its usability and feasibility in practice (technology testing) and to make improvements if required. The study was granted ethical approval by the North West Greater Manchester Central NHS Ethics Committee (integrated research application system: 205980, June 2016).

Initial informal consultation with 3 services indicated that teleconferencing could aid delivery of rehabilitation, reduce the commute time of health care professionals and their chance of being caught up in traffic, and provide extra support to patients. Health professionals suggested that any intervention had to be carefully planned due to safety issues.

Demographics of the older adults and health professionals in the workshops are reported in more depth in a previous study [33]. We recruited 5 health professionals, including 2 physiotherapists, 1 OT, 1 rehabilitation assistant, and 1 assistant practitioner. A total of 8 older adults were recruited, 6 of whom were female and all were White British. Two of the older adults participating in the workshop had previously used technology such as smartphones, tablets, or computers.

A total of 7 patients (4 men) with a mean age of 77 years (range: 64-92) participated, and of these patients, 6 agreed to be interviewed; for one interview, the participant’s son was also present. Only 2 of the participants who took part already owned a smartphone. Only 2 of the patients already had Wi-Fi, and 1 agreed to let us install Wi-Fi to enable them to use teleconferencing. A total of 11 health professionals took part in the focus groups; 8 were women, 9 were physiotherapists, 1 was a nurse, and 1 was an OT (see the study by Hawley-Hague et al [33] for further demographics).

Data were summarized under barriers and facilitators, with 7 further subthemes. We have also linked themes to the theoretical framework (Table 2). Two overarching themes related to smartphone were established and are discussed in a separate paper where patients used a smartphone app (see the study by Hawley-Hague et al [33]). Some themes only occur for either patients or health professionals.

Using teleconferencing for the delivery of rehabilitation exercises for falls prevention seemed to offer more barriers than facilitators. However, the barriers are not insurmountable if we have better connectivity and equipment. The original aim was to make teleconferencing accessible and easy to use by using existing equipment (eg, smartphones’ cameras). Although the current technology system is acceptable (perceived usefulness) to health professionals and patients and adequate for follow-up support calls, it is not adequate for the delivery of exercises (not easy to use, feasible, or reliable) [26]. Phones overheated, there was poor connectivity where there was no Wi-Fi, and the view was not adequate for the delivery of new exercises. Issues highlighted around ease of use were predominantly related to the smartphone camera and positioning. The only issue raised with the software (Skype) was the view and sound during group teleconferencing, and the reliability of the teleconferencing was affected by connectivity regardless of the platform. Further equipment is required to enable the safe delivery of exercises to patients.

Overall, participants and health professionals in the workshops and usability testing could see some benefits of teleconferencing in terms of additional support that could be provided and better utility of resources, for example, travel time (perceived usefulness and acceptability). Increased contact and support was identified as the main facilitator for teleconferencing in both the workshops and usability testing and has been identified as important in previous studies [19], and it has also previously been found to lead to higher levels of adherence [15]. We know from other exercise studies and behavioral theory, such as the Theory of Planned Behavior, that social support or social norms (perception that the health professional thinks it is a good thing to do) from health professionals is important to exercise behavior [5,34].

Some of the older adults in the workshop and patients in the usability testing did have some concerns about bringing the technology in to their homes and the technology being intrusive (feasibility), which is something often found in the literature [27]. This was one of the reasons that we tried to focus on technology that patients would already have, for example, connecting phones to existing TVs. However, the location of the TV was not always the best place for the patient to exercise; therefore, separate screens were provided.

Patients who took part in the usability and feasibility testing at no point suggested that they would prefer face-to-face delivery or showed fear that technology would replace human interaction (acceptability and perceived usefulness), which is something often cited in the literature [27,35] and raised by older adults in the PPI workshop. Battery life was one of the other issues raised in the usability testing, and this was especially an issue when the phone was under high use (reliability). Battery life is a recurring issue in usability studies using smartphones [36,37]. The phones used have been upgraded for subsequent studies using smartphones.

In the usability and feasibility study, the main issue within the UK context was the lack of good 4G connectivity. This was particularly an issue in some of the more deprived areas of Manchester, where the connectivity was very poor (reliability and feasibility). It seems that due to socioeconomic reasons, patients had decided to have landlines removed and only used mobile phones (often not smartphones). This raises issues related to digital exclusion, an issue already associated with older adults and those who are on lower incomes [38]. In the current climate where rehabilitation is being delivered remotely because of the COVID 19 pandemic, there are concerns that patients will be excluded because they cannot afford Wi-Fi or a suitable device. They may be excluded because they do not have the skills to use the device even if they are provided with one (digital literacy), as our patients were provided with a large amount of support from the research team. They may have physical, cognitive, and sensory impairments or language barriers that make using technology challenging, particularly if they live alone [39].

Recruitment of health professionals covered 3 different teams in the workshops and usability and feasibility testing, but only 1 team used the technology in practice. We found that the teams that only had the technology demonstrated to them (service 2 and 3) but did not actually use it in practice were more positive about its use (perceived usefulness and acceptability) and generated further ideas around other functionality. In contrast, those who had used the technology (service one) identified more barriers, particularly because the technology was not reliable, but rather than being negative or resistive to technology, they also proposed potential solutions and implementation suggestions (adding another rotating camera).

There were limitations to the study during both the workshops and usability and feasibility study. During the workshop, we only illustrated how teleconferencing and the equipment would work, showing the patients and health professionals and older adults what would be seen. However, we did not demonstrate a full session. We did not ask health professionals to deliver an exercise session or ask the older adults to take part in one. This led to some issues not being identified until the usability testing that could have been preempted, such as the challenges related to the view from the phone camera.

At this point, the workshop was conducted with community-dwelling older adults and not patients; therefore, the participants were less frail and complex. It could be argued that they were two different populations, which may have influenced the feedback given. However, we would argue that it was a strength to represent a wide variety of older adults’ views. In both the workshops and the usability study, we had a good representation of gender across the older adults, patients, and health professionals.

For the usability and feasibility study, recruitment took longer than anticipated; therefore, a much smaller number of patients were recruited than initially planned. We were also unable to test group teleconferencing effectively, as only one set of patients had Wi-Fi at the same time. However, recruited participants represented a good mix of patients in terms of comorbidities, age, gender, and previous technology experience (some with experience of smartphones and some with no experience). None of the participants had previously used Skype or teleconferencing before the study.

The time period for testing the technology was short and may not have identified all the usability issues. If we had established a longer testing period, then we may have asked the patients to exercise alone using the technology without the presence of someone from the research team. However, during the testing period, we established that with the current technological setup, using the equipment alone would not have been safe.

Overall, we established that teleconferencing as a way of delivering falls rehabilitation can be acceptable to this group of patients and health professionals if it works effectively. There is a lack of research on smartphone-based teleconferencing interventions for the delivery of falls prevention exercise programs.

A larger usability and feasibility testing study is required to establish whether better equipment for delivery improves usability and makes delivery more feasible. The intervention can only be effectively delivered in patients’ homes where there is Wi-Fi. The options for delivery still need further investigation, as it is clear from testing that in normal circumstances, teleconferencing cannot be used as a full alternative to face-to-face delivery and can only be used to reduce face-to-face visits and to enhance current care. This study provides important information to health professionals now having to deliver care remotely because of the COVID-19 pandemic. In its current form, although it could possibly be a suitable delivery method for some older adults (those who are able to conduct their exercises without the requirement of physical correction by the health professional) because of connectivity issues, it can only be a suitable option for some patients, not all. The intervention may work more effectively in other countries, such as in the Nordic countries where Wi-Fi is more widely available.