Balance on the Brain: Facilitators and Barriers of Intervention Implementation

Abstract

Introduction

Balance on the Brain is a balance-focused multi-modal community-based exercise intervention aimed at reducing falls and improving health outcomes for people living with mild cognitive impairment (MCI). This study completed an important step when conducting randomised controlled trials (RCTs) by evaluating the barriers and facilitators of the program from the perspective of the intervention participants and the exercise providers delivering the intervention. This study also explored the perspective of the main informal support people (MISP) of intervention participants living with MCI.

Methods

This was a qualitative study using face-to-face semi-structured interviews. Interviews were audio-recorded to enable verbatim transcriptions. Braun and Clarke’s 6-step thematic analysis process was used to analyse the data.

Results

A total of 26 RCT intervention participants, 4 physiotherapists, and 14 MISPs were interviewed at the end of the 6-month intervention. There was moderate diversity in the overall experiences; for example, what may have been a barrier for some was a facilitator for others. Overall, lack of motivation and other health issues were the most identified barriers across the Balance on the Brain intervention. Key facilitators for the intervention participant were the guidance provided by the physiotherapists delivering the program and the ease of adding the intervention into their daily routine. The MISPs had varying levels of involvement and support throughout the intervention; some completed the intervention exercises with the intervention participant, others were supportive and encouraged participation, and some had no input into the intervention participant’s involvement in the Balance on the Brain intervention.

Conclusion

The Balance on the Brain RCT was largely accepted by intervention participants, physiotherapists delivering the intervention, and the MISPs. Exercise interventions that can be tailored to each participant’s needs are likely to be viewed more favourably. Future interventions for this population may be improved by adding opportunities for the MISPs to be more involved.

Introduction

The proportion of older adults within populations around the world is increasing. Within Australia, this is placing increased pressure on healthcare systems and residential aged-care providers [1]. With this increase in older adults, it is even more important to prioritise improving and maintaining their health and wellbeing. One of these strategies is known as ageing in place. Helping older people remain at home for as long as possible is a strategy known to help maintain independence and function for longer [2] and reduces pressure on residential aged-care facilities [2]. In 2018 in Australia, 95.3% of older adults (65 years and over) were community-dwelling [3]. Falls are a major health issue for older adults and can affect their ability to live independently. Falls accounted for 77% of injury-related hospitalisations, with one in two falls resulting in hospitalisation occurring at home, compared to one in five falls resulting in hospitalisation occurring in a residential aged-care facility [4].

As we age, the risk of developing cognitive impairment increases [5]. Mild cognitive impairment (MCI), while not a neurodegenerative disease, is a condition commonly known as the stage between normal ageing and dementia [6, 7]. It is characterised by an objective cognitive impairment (identified during neurocognitive testing), and one’s ability to complete instrumental activities of daily living is maintained (minimal changes may be noted) [8]. MCI can be transient, with some people having a higher risk of developing dementia, some having a stable MCI, and for others, their cognition may return to normal [9].

People with MCI are known to spend between 48 and 61% of their day engaged in sedentary activities, and have a higher chance of falling compared to their non-cognitively impaired counterparts (43% compared to approximately 30%, respectively) [10–13]. Increased risk of falling in people with MCI is typically accompanied by a slower gait speed, impaired postural control, and reduced ability to complete dual-task activities (such as walking and talking) [12].

Physical activity, strength, and balance training are known to reduce fall risk for older adults and for people living with dementia [14]. For people living with MCI, the literature is growing but the quality of evidence on the effects of aerobic, resistance, and multicomponent exercise on physical function remains low [15] and there is a dearth of interventions investigating fall prevention.

The Balance on the Brain intervention is aimed at improving physical health and reducing falls for people with MCI. Balance on the Brain is a single-blind randomised controlled trial (RCT) that compares a balance-focused multi-modal exercise intervention for people with MCI [16]. Participants who received the intervention received a health promotion leaflet and had a physiotherapist (PT) visit them six times in their homes within the first 6 months. During the sessions, the PT implemented three different programs, a stepping program (with cognitive aspects), a dynamic and static balance program, and a walking program [16]. They also received four motivational phone calls from the PT in between the six home visits and were encouraged to complete the exercises independently in between sessions [16]. The control group received a health promotion educational leaflet and continued with their usual care [16].

Both the stepping program (clock yourself) and the static and dynamic balance program (Balance Yourself) were pre-existing programs. These two interventions were developed by Australian PT Lowry [17]. Clock Yourself is an app-based brain game that combines physical and cognitive activities to challenge participants’ dual-tasking abilities while also working to build reaction time and stepping speed [17]. Balance Yourself is a home-based set of balance exercises strategically organised in a book so that people can progress their balance exercises in small achievable increments [17]. The walking intervention was tailored to each participant and implemented with guidance and support from the PT. The aim of the walking intervention was for participants (where suitable) to increase their walking over the 24-week intervention to 30 min per day, 5 days a week [16].

An important aspect of RCTs is to explore the experiences of participating in the intervention from the perspectives of the participants involved and from the people delivering the intervention. The experience of an individual participating in a physical activity intervention can greatly influence the perceived value of the activity being completed [18]. Using qualitative methods can assist in identifying changes in how interventions are being implemented, identify unanticipated causal pathways, and generate new theories [19]. Knowing the barriers and facilitators from the perspective of the participants and providers can assist with the successful translation of the intervention into practice.

In addition to capturing the experiences of the people participating in an intervention, previous evidence in dementia research suggests it is also important to investigate the role of the main informal support people (MISP) to determine whether support is required, and if so, to ensure appropriate supports are in place for both the person living with dementia and their MISP [20–22]. For MISPs of people living with MCI, much less is known about their experience and how community-based balance interventions for the person with MCI impact the life of the MISP. However, it is known that MISPs of people living with MCI have increased pressure to assist the person with MCI in higher executive tasks such as medication management, appointment planning, and financial tasks [23]. The Zarit Burden Interview scale was used in studies by Paradise et al. [24] and Munawar et al. [23], and they found 36% and 47% of MISPs reported clinically significant carer burden, respectively. To our knowledge, the role MISPs may or may not play in assisting people living with MCI to participate in a balance-focused multi-modal exercise intervention is unknown.

This present study explored the experiences and perspectives of three different groups: people living with MCI who participated in the Balance on the Brain intervention, the PTs who delivered the program, and the participants’ MISPs. This study aimed to answer three questions. What were the barriers and facilitators of participating in a balance and mobility intervention for people living with MCI? What were the barriers and facilitators to delivering the Balance on the Brain intervention from the PTs’ perspective? And what were the perspectives of the MISPs in supporting the person living with MCI to participate in Balance on the Brain?

Methods

In reporting the findings of this study, the 32-item checklist Consolidated Criteria for Reporting Qualitative Research (COREQ) was followed [25]; see online supplementary Table 1 for more details (for all online suppl. material, see https://doi.org/10.1159/000549641).

Study Design

This study included intervention participants from the Balance on the Brain RCT and other people who were closely linked to the RCT (PTs providing the intervention and MISPs). It was a qualitative study using semi-structured interviews that took a hermeneutic phenomenological approach [26]. The term MISP was selected by consumer representatives from the Balance on the Brain consumer advisory group, as they deemed it a more appropriate term than carer or caregiver.

Sampling and Recruitment

Full details of the RCT, participant inclusion criteria, and intervention are presented in the published RCT protocol [16]. People who participated in the intervention arm of the RCT between January 2021 and February 2023 were invited to be in this study. All participants were contacted via phone; if they were interested in participating, a date was arranged for the interview to take place at the participant’s home, or when appropriate, their workplace depending on the participants’ preference. Intervention participants had agreed to participate in interviews when they consented to be involved at the commencement of the RCT. The MISPs and PTs were given information about the research and provided written consent before their interview commenced. All PTs delivering the intervention were interviewed. MISPs were identified by the intervention participants and included spouses, friends, and/or other family members. Not all intervention participants had a MISP. For the interviews, MISPs also needed to be able to understand and speak English.

Data Collection Methods

Demographic information about each intervention participant, MISP, and PT was collected before the interview. All intervention participants and MISPs were interviewed face-to-face in their own homes by the lead researcher (J.H.) at the 6-month time point, after PT input was ceased. All intervention participants continued with their Balance on the Brain intervention independently for a further 6-month maintenance period, which was not included in the interviews. When the intervention participant and MISPs were interviewed in the same location, the one not being interviewed left the room unless the person being interviewed asked for the other person to remain in the room. Three of the four PTs were interviewed face-to-face (two at their place of work and one at a café). The fourth PT was interviewed using Microsoft Teams due to them moving out of the metropolitan area before the interview was conducted. A professional relationship was already established with the intervention participants and most of the MISPs because J.H. was completing monthly phone calls with all the RCT participants to discuss monthly physical activity and if they had experienced any falls. J.H. was alerted to intervention status at the 6-month follow-up to conduct the interviews. All participants (intervention participants, PTs, and MISPs) knew that J.H. was a PhD candidate and occupational therapist completing the research. They were aware it was an area of clinical interest and was contributing towards the completion of her PhD studies. Interview questions were phrased using neutral tones to avoid leading questions that would introduce bias. This was the first qualitative study completed by J.H.; however, E.B. is an experienced qualitative researcher who supervised J.H. throughout the topic guide development, data collection, and analysis process. The topic areas were identified by reviewing the research questions and aspects of the Balance on the Brain intervention. All three topic guides were reviewed by another senior PT researcher with qualitative study experience (K.H.) and were considered appropriate. The three different topic guides were then piloted during the first interview for each specific group (RCT participant, PT, MISP) and deemed appropriate.

All interviews were audio-recorded; however, the lead researcher (J.H.) also made written field notes during the interviews. Everyday language was used to design the interview questions; if needed, they were rephrased to help with participant understanding. Interviews were completed with all four PTs and conducted until data saturation with the intervention participants and MISPs (i.e., until no new information was acquired). It was estimated that saturation would occur between 16 and 24 intervention participants. To minimise researcher bias, questions to each of the three groups were sequenced in the same way. Firstly, questions were asked about the Balance on the Brain interventions; then, more specific questions about other aspects of the program were asked. For the intervention participants, this included questions about how they found their interactions with the PT and how they found completing the falls and physical activity diaries. PTs were asked about each intervention (Clock Yourself, Balance Yourself, and walking) before being asked about participant engagement. MISPs were asked about the participant’s engagement with the intervention, and then their perspective on the program and their level of involvement (online suppl. Table 2). Participants (people with MCI, PTs, and MISPs) were not asked to review of transcripts, concept maps, or findings. There was a delay between interview completion and the availability of concept maps for review, which may have reduced the accuracy of participant feedback.

Data Analysis

Thematic analysis of interview data used Braun and Clarke’s 6-step process [27]. Interviews were transcribed “verbatim” by a professional transcriber and were then read and re-read, with notes being made throughout for data familiarisation. Two independent researchers (J.H. and E.B.) used an inductive approach to generate initial codes from the transcriptions [28]. Common components were identified, and information was then grouped into themes and, where possible, into sub-themes [27]. Microsoft Excel was used to manage all collected qualitative data. The two researchers’ findings were compared and collated before being sent to a third researcher for review (K.H.) [29].

Using the approach of Multiple Perspectives Interviews, triangulation of qualitative data from the participants, PTs’, and the MISP’s perspectives was used to identify similarities and differences between each viewpoint and to help better understand the data collected [30]. This approach has previously been used to investigate the experience of people with dementia, their caregivers, and healthcare professionals [31]. Concept maps were created to assist with identifying all facets of the developing analysis [27]. Descriptive statistics were used to analyse demographic data.

Results

Participant Demographics

Twenty-six intervention participants, four PTs, and 14 MISPs participated in semi-structured interviews. All participants approached agreed to participate in the research, and 12 (46%) of the intervention participants could not identify an MISP that could be interviewed for the study. Of the intervention participants, 69% (n = 18) were female. Median age was 75.5 years (interquartile range 72–82), and most (54%) had high school as their highest level of education. All PTs interviewed were female (n = 4), and their years of experience ranged from 14 to 32 years. The median age of the MISPs was 77.5 years (interquartile range 73–82), and 93% (n = 13) were the spouses of the intervention participant (the other MISP was the intervention participant’s daughter). Interview durations ranged from 16 to 42 min for intervention participants, 35 to 63 min for the PTs, and 6 to 19 min for the MISPs. Participant characteristics are presented in Table 1.

Table 1.

Intervention participant (people living with MCI) and main informal support person demographics

Intervention participant, n	26
Age, median (IQR), years	75.5 (72–82)
Gender, female, n (%)	18 (69)
Country born, n (%)
Australia	18 (69)
UK	4 (15)
New Zealand	1 (4)
India	1 (4)
Malaysia	1 (4)
Israel	1 (4)
Education, n (%)
High school	14 (54)
Trade/diploma	5 (19)
University	7 (27)
Employment status, n (%)
Retired	24 (92)
Employed (part-time)	2 (8)
Main informal support person, n	14
Age, median (IQR), years	77.5 (73–82)
Gender, female, n (%)	8 (57)
Relationship to study participant, n (%)
Daughter	1 (7)
Spouse	13 (93)
Country born, n (%)
Australia	10 (71)
UK	1 (7)
America	1 (7)
Germany	1 (7)
Singapore	1 (7)
Education, n (%)
Primary school	1 (7)
High school	5 (36)
Trade/diploma	1 (7)
University	7 (50)
Employment status, n (%)
Retired	13 (93)
Employed (part-time)	1 (7)

IQR, interquartile range.

The themes that arose for the intervention participants and the PTs could be grouped into enablers and barriers and further separated into enablers and barriers for each of the Balance on the Brain interventions (Clock Yourself, Balance Yourself, walking). Overarching themes and sub-themes can be seen in Figure 1. The themes that arose for the MISPs could not be triangulated with the data from the intervention participants and the PTs’ data and therefore are presented separately in Figure 2.

Fig. 1.

Intervention participant and PT concept map.

Fig. 2.

Main informal support person concept map.

Reasons for Signing Up to Balance on the Brain

Intervention participants gave insight into why they signed up to participate in the Balance on the Brain RCT. Many were independent in the process, either hearing advertisements for the RCT on their local radio, in the paper, on television or from Facebook. “I saw it on Facebook actually and as soon as I saw it, I sent an email to the program because as soon as I saw the ad, is just, I thought ‘Oh, that’s for me; I must do it’” (ID08) and “I’m pretty certain I saw it on Facebook first and then I saw it advertised on the telly …. I wasn’t quite sure what it was about, but I thought it was probably something that would help me” (ID71). Some participants had their spouses hear about the RCT and had their encouragement to start the signup process. “I think she found it online and she thought it might be good for me, which I tend to agree, she proved right in her usual manner [Laughter]” (ID42).

Reasons for signing up included their awareness of their cognitive decline and desire to help prevent the progression of their cognitive impairment. “Because I was getting quite forgetful and I was getting worried about my memory” (ID32) and “Um, physio. I really wanted physio – someone that could tell me how to walk properly and, you know, that sort of thing …. I think I’ve got a lot of cognitive impairment but no one else believes me” (ID75).

Others felt that their physical fitness was reducing, and they wanted to improve it while they could. “Let me think… I thought it was a good idea. I could see the sense in it or the logic, and I also thought it might be a discipline for me to do more exercise” (ID27) and “Because I was having falls; because I like challenge; I like new things and it seemed like a worthwhile thing anyway” (ID65).

Concept Maps

Themes and sub-themes were developed from each group interviewed. A concept map was developed for the Balance on the Brain intervention and each program delivered within it (Clock Yourself, Balance Yourself, and walking) that included the perspectives of the intervention participants and the PTs (Fig. 1). One additional concept map has been developed to highlight the MISP’s perspective of Balance on the Brain (Fig. 2).

Overall Perspectives of the Balance on the Brain Intervention

Barriers to Participating in Balance on the Brain

Barriers identified by intervention participants included not seeing value or change from their participation in Balance on the Brain, “Yep, yep. No major brain improvement” (ID29) and “When I’m doing the exercises sometimes, I can go through and do them perfectly and other times it’s a write-off …. and that would frustrate me which automatically I’d think, oh, what am I doing this for?” (ID16).

Eight intervention participants reported that other health issues prevented them from maintaining consistent engagement, “I’ve got to have two more eye operations which will mean nothing strenuous for a while” (ID19) and “One, two, three, four laparoscopies, and then they found I have got a leak from my pancreas …. So that knocked me back four days in hospital instead of an overnight stay” (ID26). Others highlighted that their lack of motivation was a contributing factor, “Yes, I know, but these are different, I’ve never been into structured exercises” (ID06) and “Lack of discipline on my part. Not doing things I should do. …. It’s just it wasn’t that important” (ID27). Additional commitments were noted as a barrier with one intervention participant reporting she had her grandson come to live with her during the program, “He’s not used to living here, he’s used to having every third weekend here. So, I just didn’t have any head space” (ID55). Other intervention participants prioritised house chores over completing the program, “If I didn’t have all that heavy gardening I would have been walking, simple as that” (ID15).

Overall, the PTs reported that it was difficult to deliver all three aspects of Balance on the Brain together, “I think generally, a lot of people had problems to do it regularly all of them, the walking, the app, the book, like as a routine as a daily thing” (PT1) and “I think doing three. Doing all three components was always too hard” (PT3). This coincided with there being a lot to cover in sessions, “I spent nearly an hour there …. I felt that that was necessary – like it could have been quicker but because you are having three components, it’s quite a lot for people who have memory issues to take in” (PT4). Finally, two of the PTs felt that the cognitive load of Balance on the Brain was too high for some participants, and PT1 reported “I had a few clients where I felt that I don’t think they were suitable for the program, just cognitively how difficult it was for them.”

Facilitators for Participating in Balance on the Brain

Motivation was noted by 17 of the intervention participants as a key facilitator to engaging in Balance on the Brain, “The programme itself is brilliant, but it’s the participants who need to be really motivated” (ID06), “I was just determined that I was going to do it” (ID45), and “It’s made me a bit more wanting to exercise. It makes me a bit more motivated. And yeah, I think the last couple of days have been a bit of a challenge, so it’s been good” (ID62).

More than 50% of the intervention participants reported the guidance from the PT supported their engagement, “It’s nice to have contact with people who respect you even though you are an older person and yes, you are treated like a human being and not something that is… sometimes people can treat you incorrectly” (ID01) and “Having contact with somebody sensible and it was gratifying to see the care and attention that the health organisation is” (ID27). Enjoyment completing the program was another commonly identified facilitator, “I can’t say enough – it’s been amazing; it’s helped me tremendously, it really has” (ID01), “Oh, well it’s an achievement and with my nature; give me a challenge and I’m into it” (ID15), and “I’m so grateful that it came into my life when I absolutely needed it. It’s been a game changer for me” (ID55).

Thirteen intervention participants reported that they felt improvement from completing the exercises, “I found it quite inspiring and I’ve sort of tried to do everything that I was presented with and I think it’s definitely improved things for me” (ID42) and “When I woke up this morning my legs were aching and I thought oh, I’ll do the Clock thing and then do the exercises so that I loosen up and of course, that happened” (ID71). For many, the entire program became an easy routine, ID84 stated, “I do it every day, even though when I work, I still walk up and down the line or go for a walk around the block, you know, anything that’s to do with exercise,” and ID60 reported, “I found it very pleasant, quite easy to do, not intrusive and didn’t interfere with my daily activities or anything.”

Individual intervention participant awareness of their cognitive limitations was also noted as an enabling factor as described by ID26, “I mean my day-to-day life is basically unchanged; I don’t think I’m getting worse. Do I have a problem? Yes, I do have a mild problem and I’m conscious of that.” For their overall summary of Balance on the Brain, the PTs did not identify any facilitators that would enable greater success across the entire intervention.

Suggestions for Improvement to the Overall Intervention and Other Themes

Two sub-themes were developed from intervention participants discussing the overall facilitators of Balance on the Brain. Some intervention participants suggested that more face-to-face interactions with the PT would have been helpful; some considered that the intervention should be offered to more people in the community. However, many reported no changes were required and others stated that Balance on the Brain was good as it was.

PTs reported that the motivational phone calls were more successful when they approached it in a casual manner. PT4 stated, “They didn’t like the formal questions, so I had to be asking them the questions but not so formally to try and gauge what they were doing. It was sort of difficult to draw that information out of them with the set of questions that were on the paper.” Two of the PTs also reported that some of the intervention participants had trouble recalling activities over the last 7 days which was a factor in how well the conversation went and how much they could use motivational interviewing to assist and encourage the participants. PT2 described the following: “The level of detail that they give you on the phone calls really comes down to how well they remember what they have actually done in the last seven days. And how detailed are they with their recall, their ability to recall all that information from seven days ago just depends on the information that I get out of them.” The intervention participants described the motivational interviewing as “the phone calls with the physiotherapists,” and eight intervention participants felt that the phone calls were supportive and gave an opportunity for reinforcement. This was evidenced by ID71 stating “All her phone calls have been really great because it just keeps me on track with what I’m doing.” One other intervention participant reported that they did not remember any of the phone calls.

Clock Yourself

Barriers to Participating in Clock Yourself

Barriers identified by intervention participants included their lack of motivation, the presence of other health issues, not enjoying the exercises, and not seeing improvements. The high cognitive load and other commitments in their life also reduced their engagement in the Clock Yourself intervention. PTs reported that intervention participants had difficulty progressing further than the initial Clock Yourself levels and that some of the intervention participants were limited by their motivation and cognitive abilities. Both intervention participants and PTs noted that technology was a barrier. Interestingly, it was also noted as a facilitator by both intervention participants and PTs. PTs noted that technology while suitable and enabling for some intervention participants was not effective for others who were not regularly using technology (i.e., smartphones) in their daily lives and found it difficult to navigate the phone and app (Table 2).

Table 2.

Intervention participant (people living with MCI) and PT identified barriers to the clock yourself intervention

Sub-themes	Intervention participant (people living with MCI) quotes
Lack of motivation	I’m not very motivated I suppose (ID30)
	I suppose I’m lazy (laughter) that’s about all. But I don’t dislike them; I disliked them initially but I don’t dislike them now (ID75)
Other health issues	Yes, during those ones and with the iPad, with the whole bit. The longer I went on, the harder it was on my lower back (ID16)
	I had no trouble physically doing it until I stuffed the Achilles and then everything was… well, painful just to stand on it (ID32)
Did not enjoy	I suppose it’s like a lot of things – there are some things that you enjoy 100 per cent and some 50 per cent and some only a small amount (ID22)
	No, there was no joy out of them (ID29)
	I think maybe I need something, like something new every week or something like that because maybe I was just getting a bit bored with them (ID62)
Not seeing improvement	Oh, well, if exercise is going to stimulate your brain then I’ve been pushing the exercise with the long term… it’s a bit disappointing that there wasn’t any improvement, but at least it didn’t get too much worse (ID15)
	I’ve never progressed past the Clock (ID63)
Cognitive load	I realise that it’s made me realise that I don’t think in English as such. I translate quickly so I guess I forget on the way what I’m doing (ID08)
	Focus. Part of it is I’m pretty physically capable, so physically it is not a problem, but to understand quick enough what you are asking me to do, that’s the problem (ID26)
	I think when I was doing them, I was getting a bit confused with a couple of things, but they were simple and that annoys me. And it was always at the beginning of whatever I was doing, like when you changed feet I got confused and I tried to get my hands… instead of them going like that [demonstrating] they were going out there, and I couldn’t remember how to get them back in again, and it just annoyed me, so I stopped doing it (ID62)
Other commitments	Grandkids, appointments. Yeah, I was taking people for appointments quite a lot all last year. And then in my down time, I didn’t really feel like doing it (ID30)
	Oh, it would have only been I was too busy and of course with losing mum and that took care of 2 months (ID45)

Sub-themes	PT quotes
Progressing past initial levels	They got very comfortable with it and so it took a lot of explaining as to why they needed to move on and not be comfortable with it anymore. Instead trying to make them challenge themselves a little bit (PT3)
Lack of motivation and cognition	I think cognition and motivation were my two biggest factors (PT4)
	I never had the chance to do different languages or star signs. A lot of people were just not interested in it. It was more like we have to actually sit down and learn first …. then start using it. And I found a lot of people were like “Oh, I don’t want to learn that and then do the exercises” (PT1)

Sub-themes	Intervention participant (person living with MCI) and PT quotes
Technology	I have a participant who we wanted to give a CD player to, but she had very, very moderate, I would say, issues with her memory and probably cognitive decline and was actually aware of it, and was absolutely overwhelmed with the functions of a CD player and that involved me having to label the buttons on the CD player, and then she still didn’t know how to work it, so we actually ended up giving up (PT2)
	The other ones that weren’t really tech savvy, they did find it a little bit difficult for them to navigate it sometimes; it was hard for them to remember just to pick up a phone or an iPad to use. Yeah, so it was a bit of a mix (PT3)

Facilitators for Participating in Clock Yourself

Ease of adding into their daily routine was the most reported facilitator of the Clock Yourself intervention. Other facilitators reported by intervention participants were that they enjoyed it, felt improvements, and could progress through the different stages and that it was easy to complete (Table 3). PTs reported that the easy-to-follow instructions, their enjoyment while delivering the intervention, and their ability to monitor the intervention participant’s engagement through the app were all facilitators for Clock Yourself. Both intervention participants and PTs reported that motivation, knowledge of technology, and guidance from the PT also facilitated better outcomes for the Clock Yourself intervention. Intervention participants who identified technology as an enabler reported they were already using technology (such as being active on social media) and using their phones on a regular basis. PTs reported technology was an enabler for many intervention participants because instructions were easy to follow and exercises were supported by the visual and audio prompts.

Table 3.

Intervention participant (person living with MCI) and PT identified facilitators to the clock yourself intervention

Sub-themes	Intervention participant (person living with MCI) quotes
Became routine easily	Yes, and because it was important to do the speed, yeah, but I was very happy that it was 5 min only (ID8)
	Yeah, and I had a routine. I had made that fit into my routine. I made sure I did it kind of between tea and sitting down to News or something like that (ID55)
Enjoyed it	I just like the variation of, you know, plain face to, you know, months Virgo signs – just the variation of it I enjoyed and then being able to then do the exercises in the brain coordination one, yeah (ID45)
	I initially felt very nervous about it and then I got to do it and I loved it and I just went on and on and on and I am quite addicted to it (ID65)
	I didn’t to start with, but I love it now. I even know all the animals off by heart (ID75)
Felt improvement	It was very good; it gave me a lot of confidence. I really liked it because I was getting better (ID08)
	Well, after a while it got repetitive and I could actually remember some of the numbers and steps, but I found that my balance must have improved quite a bit because altering around and going from left to right backwards and forwards (ID32)
	When I saw a bit of benefit and then I put more effort into it (ID57)
Able to progress	Well, I think that was sort of demonstrated when the person said to me well, shall we say that you’ll do the first and second exercises or the first three exercises – I can’t remember, it was either two or three. And I said no, no, I’ll have enough just to do the one, that’s how unsure about the whole thing I was. And when she came back I had done one, two, three and probably four (ID65)
	Yeah, I started off with just the Clock and then I went to the months, and then onto animals and then I was doing number double ups. And, at the moment, I have just started that one (indicating to one of the higher-level Clock Yourself exercises). I’ve only done that twice but this morning I thought oh, yeah, I’ll give it a go and I’ll just persevere with that one because the others are getting a bit easy (ID71)
Easy to complete	That was good, pretty easy. I’d tried all of the different things with it, but I did find sometimes I put my feet in the wrong place and all that sort of stuff, but instead of stopping I would just forward it and just keep moving, so I found it quite good (ID16)
	Oh yes, that was good; there was nothing adverse about it; it was easy enough to do (ID34)
	They were not that difficult and it was easy to follow (ID60)

Sub-themes	PT quotes
Relatable activities and easy-to-follow instructions	It is easy to relate to the instructions and I guess they don’t really get time to contemplate or think, it’s just a prompt and then they do it (PT2)
	The simple Clock and simple colours they found easy. They also tended to always go towards the calendar if they wanted to change the clock face. They seemed to understand the calendar face and animals was also a good one (PT3)
PT enjoyed delivering	I actually quite like the Clock Yourself app and I actually use it outside of the research study as well which has enabled me to get a good feel for the extra requirements to perform the tasks that are asked of the app and to get a feel for myself for what’s physically required and what I need to be paying attention to (PT2)
	I enjoyed giving that probably the most out of the descriptions and exercises because it was something that was visual; there was verbal, so it appealed to many different learning styles, which is why I liked delivering it, if that makes sense (PT4)
Ability to monitor engagement	With the app you have the activity log and I love that and it’s actually a really great way of showing them look how much stepping exercise you have done today, because we all know we should be doing about 10,000 steps or so and you know by the time you do that a few times, you actually crank up a whole lot of steps, so it’s very satisfying for the participants. And it’s good for me to see how they have done their homework. I cannot do that with the Balance book because they could tell me anything (PT2)

Sub-themes	Intervention participant (person living with MCI) and PT quotes
Motivation	Because I committed to it and I intend to see it through (ID16)
	Because I’m doing something for myself (ID45)
	Whereas other people who volunteered themselves because they can see the benefit for themselves. Probably progressed a lot more quickly (PT3)
Technology	Yes, that was fine, and fortunately I was presented with a machine [CD player] to be able to use it and that was very helpful (ID01)
	Well, it was handy because I usually do it over there by the sideboard and put the tablet on the top and set it all up and get my stance right and push the start button and go for it (ID42)
	The app, it was easy to switch on when it was on the phone; it was easy to follow instructions; it was easy to sort of play around with it a little bit and see what else is there; changing it from the clock to the months and increasing time and increasing speed. So I think it was the interest of having something on the phone and while you were on the phone just opening it and have a look at it (PT1)
	It was like there was a visual and an audio vs. just you are walking by yourself or you are looking at it by yourself (PT4)
Guidance from PT	Yeah, I most probably went back to them when I knew that they were coming out to see me (ID06)
	Repetitive use. My mentor had me decreasing the amount of time through each phase and she checked that when she paid a visit here. And yes, I was following it down in time that is of course. So that’s how it ran here (ID18)
	I had a lady who went quite fast and she said “Oh, I’m up to 80” and I said “Wow, I can’t do that.” So, let’s have a look then I saw that she totally missed the weight shift, she just was tapping. So, I said ok, now we have to take the speed quite a little bit back and concentrate on proper weight shifting because weight shift is what we need to do (PT1)

PT, physiotherapist.

Balance Yourself

Barriers to Participating in Balance Yourself

The most identified barrier by intervention participants was that they preferred to do other things rather than completing the Balance Yourself exercises (n = 7) and that some felt unsafe while completing the Balance Yourself exercises (n = 5). No falls occurred while intervention participants were completing the Balance Yourself exercises. Similar to the use of technology for the Clock Yourself intervention, PTs identified the physical book as both a barrier and a facilitator and this depended on the individual intervention participant. PTs reported that the book helped guide some intervention participants, whereas others misplaced the book and forgot to document their progress within it. Intervention participants and PTs identified two common sub-themes with both groups reporting that some of the more challenging exercises within the Balance Yourself intervention were too difficult to progress past and that some intervention participants appeared to be limited by a lack of motivation/laziness (Table 4).

Table 4.

Intervention participant (person living with MCI) and PT identified barriers to the balance yourself intervention

Sub-themes	Intervention participant (person living with MCI) quotes
Other commitments	My daughter-in-law and two children arrived from Africa to stay here and it’s been pretty flat out with them (ID27)
	Umm… probably busy in other areas you know – out in the garden or something and you don’t always feel like doing it when you come back in (ID42)
Felt unsafe	The ones which I had to close my eyes I didn’t like doing on my own. When I had somebody here I was happy to do it, but when you are on your own and you’ve got to… if you were to fall and you’ve got your eyes closed and you’re sort of like trying to pull yourself to save yourself from falling or something (ID01)
	It frightened me a little bit, yeah (ID56)
Did not see value/change	When I do that, I don’t seem to find any advantage to it (ID22)
	The end result wasn’t really, sorry, the end of the course wasn’t really productive in terms of improving (ID29)
Preferred other physical activity	Probably because I just do a lot of things outside; I do a lot of walking; I do things in the pool; I do a lot of things; I’m probably not really an indoor person (ID30)
Other health issues	I was just so tired all the time (ID56)
	I’m trying not to let it limit me. If it gets too painful then I will have some tablets, some drugs, but it’s not going to stop me from doing the things I want to do (ID56)

Sub-themes	PT quotes
The physical book	Yeah, it got lost and was under a pile of other papers or in a cupboard somewhere even though I told them leave it out; leave it on your table because when it’s on your table it reminds you of doing your exercises. If you put it in the cupboard you forget about it. And I tried to give all these instructions or ideas, but it just got lost (PT1)
	Yeah, and often they don’t remember. The biggest challenge is that they do not document on the book; they get either confused with the boxes and they think it’s how many times they have to do it. And if they don’t understand it’s the seconds, then they don’t actually cross it off. So when I go back and see them for a home visit, I couldn’t really adequately tell if they have actually done those exercises or not (PT3)
	I felt that they thought it was harder than the app in that the app could go everywhere with them. And I know some clients put their book in the drawer or they put the book on a table and then something would get put on top of it, so they were forgetting to use that more than they were the app (PT4)
Not the right challenge	The difficulty where most of my clients were struggling was tandem – one foot in front of the other and then turning head up/down or left and right and eyes closed. That’s where most of the time I started with the exercises because that was challenging. And the one that was in the book before was too easy, so most of the time I started with that one tandem eyes open and then tandem left and right, tandem up and down, and then eyes closed. So I stuck around that exercise quite a bit and I had a few that were able to do single leg but I wasn’t surprised that they were able to do it because they were generally quite fit and active (PT1)
	I’d always say to them this will take you about six to eight weeks to get right, but it was still frustrating for them (PT3)
Hard to gauge improvements	Yeah, I got stuck with the book exercises quite a bit. The first few times I came and assessed - Ok, let’s start with either one and see how you go and it was too easy. Let’s go to the next one – oh, that’s too easy; Let’s go to the next one, so I found an exercise that’s challenging but not dangerous, so we got to that point and a lot of the times they were stuck around that exercise and when I came back they hadn’t progressed a lot (PT1)
	All I can do is make them do the exercises and see how they are performing and, based on that, maybe go like ok they might have practised, but often they do not use the book how they should be using it as in ticking off the boxes, putting the date on completed and moving to the second page. Often it’s unwritten, undocumented (PT2)
More advanced cognitive impairment	But the main fact is actually that it’s not suitable for people that have cognitive issues (PT2)
	So one of my ladies, you know how you’d have to do something for 30 seconds and put a date, she’d do one exercise, count to 30 and then tick if off and then she wouldn’t return back to that exercise at all. So she’d go through as far as she could and then she got stuck on one exercise. Then when she got stuck she got very upset because she couldn’t get to the 30 in that one go and didn’t understand the concept of just practice and you can practice five or six different exercises and you know, if you got to 20 that’s ok, but when you get to 30 you need to write the date down (PT4)

Sub-themes	Intervention participant (person living with MCI) and PT quotes
Too difficult	Yeah. When it comes to things like that that I know are difficult, I avoid that (ID22)
	These ones I had a lot of difficulty with, so they didn’t result in me getting better, they just got to a plateau …. I lost interest because I was unsuccessful doing it (ID29)
	I think a lot of the clients found some of it difficult to understand (PT4)
	People said it wasn’t as “user friendly” (PT4)
Lack of motivation/laziness	For a while and then I got a bit bored with it (ID10)
	Well, I think I already said I wasn’t very motivated and I found them quite boring (ID30)
	You have to be driven enough to want to get to the 30 seconds, you have to concentrate, you have to really understand how your body has to work to position yourself and support yourself in that position (PT2)

Facilitators for Participating in Balance Yourself

Intervention participants identified fewer facilitators for Balance Yourself compared to the Clock Yourself intervention. These included their motivation to complete the Balance Yourself exercises and to track their balance, that they felt improvements when completing the exercises, and that many of the early exercises were easy to complete. While enjoying the exercises was identified as a facilitator, only six intervention participants mentioned this for the Balance Yourself intervention compared to 14 who reported enjoying the Clock Yourself intervention. Two PTs noted that the initial exercises were easy to achieve and that helped with the initial implementation of the intervention. Their other identified facilitators were also noted as facilitators by the participants. This included the guidance provided by the PT and the physical Balance Yourself book (Table 5).

Table 5.

Intervention participant (person living with MCI) and PT identified facilitators to the balance yourself intervention

Sub-themes	Intervention participant (person living with MCI) quotes
Motivation	Yes, well, the motivation was to see that I’m on track with my balance (ID34)
	Oh, I know the results. I’m motivated to do them. I’m making myself be less frustrated with myself because the worst thing for poor balance for me is that, I don’t know, maybe I’m competitive (ID65)
Felt improvement	Because I felt good. I felt good and I thought oh, I can do another one of those so yeah (ID63)
	Um, there’s a sense of achievement and you can see benefits and that keeps you going (ID75)
Easy to complete	It was fine, yeah, yeah, you could follow it through, yes, yes, and some of them I could do quite well and moved on (ID10)
	They’re not stressful; they are quite pleasant and easy to do, yeah (ID60)
Became routine easily	Yes, just get out of bed and do it first thing in the morning, or if I left it to further on through the day, the mind would click in and say you’ve got exercises to do, and it would go through my brain until I did it (ID16)
	Again, it was part of me trying to develop new routines in my life and make something work (ID55)
Enjoyed it	I really was challenged, and I enjoyed them (ID08)
	Yes, yes, because it is easy, I’ve liked it all. I do things that pop up in my head and I’ll do that straight away because I remember (ID84)

Sub-themes	PT quotes
Initial exercises easy to achieve	Yeah, I think this one was similar across the whole board. I thought that everyone found up to number 14 easy. So we could always fly through those first 14 and then at the heel-toe one, number 15 (PT3)

Sub-themes	Intervention participant (person living with MCI) and PT quotes
Guidance from PT	If you live on your own it’s more difficult, you know, you’ve got to work harder on yourself and to have a voice or a person call it gives you motivation (ID01)
	Oh yes, and with the physios coming to your house and going through it with you, you know, that is a really big part of it because if you hadn’t done your exercises one day you’d think oh, no! (ID15)
	It was great in that you had all that time to really practice all of them and really get how that concept worked and then they get a picture and show the head position (PT3)
	I found engaging them if they were enjoying outdoor walking, then I just used some of those more dynamic balance tasks and added them to their walking program (PT2)
The physical book	It talks about where to place your feet and how to do exercises against the sink or whatever, which is quite useful, and I have a tendency to do that (ID01)
	Very handy. It was good to have something to be able to refer to if your memory is not as good as it used to be so it’s very handy (ID60)
	I have one lady at the moment who is very, very engaged and loves the Balance Book exercises, so every now and then you get one. So that’s nice (PT2)
	Yeah, some loved having a hard copy. Something they can flick through, some really liked that (PT3)
	I think it was relatively easy to deliver the exercises in the book for me as a person (PT4)

As mentioned previously, the physical book was also noted as a facilitator. Nine intervention participants identified the physical book as a facilitator as it helped them know how to complete the exercises, especially if they were having trouble remembering. When the physical book was identified as a facilitator from the PT’s perspective, this was related to intervention participants liking the book, and that it was easy to deliver.

Suggestions for the Balance Yourself Intervention

The PTs expressed two sub-themes as suggestions for improvement to the Balance Yourself intervention. The first was that they needed the ability to tailor the intervention to each intervention participant, “I don’t know. I mean, what I just said about the way they were presented, you could have done it maybe so they didn’t have the entire book in one go” (PT4) and “Target the exercises specifically to their level of balance or even with a challenge focus in it” (PT2). Finally, they also suggested a reduction in the number of options in the book, “I think there are too many options in the book” (PT2) and “Like a ring folder or something that you could add to just to eliminate some confusion” (PT4).

Walking

Barriers to Participating in Walking

Overall, intervention participants identified fewer barriers to walking than the other two interventions within the Balance on the Brain intervention. Table 6 provides a summary of intervention participant and PT quotes for each of the sub-themes identified. PTs reported that isolation for some of the participants was a limiting factor to them going for a walk in their local community.

Table 6.

Intervention participant (person living with MCI) and PT identified barriers to the walking intervention

Sub-themes	Intervention participant (person living with MCI) quotes
Other commitments	I was trying to do it three days a week, but I haven’t done that recently because spring has sprung and the garden called, so yeah (ID15)
	It was a bit hard to start with but I’ve persevered and like I was out this morning at half past six. I try and do it most mornings and there are sometimes like tomorrow we’ve got an early appointment so I won’t be able to do it because we will be sort of on the rush (ID42)
Other health issues	I find that after the surgery and sitting at home for such a length of time and being isolated from people and friends, I just didn’t want to walk on my own anymore (ID08)
	I try and do it every day, but what I’ve found lately since I’ve had this chest problem is that if I go out in the wind, I end up coming home and I’m coughing and I’ve got phlegm and I’m back to being sick again, so I’ve tried not to go out the last two days (ID71)

Sub-themes	PT quotes
Not knowing how far people are walking	Oh yeah, I would have liked sometimes to have had the time to actually go with them for a walk and see where they are going, and how long is the distance. Is it 10 minutes? Oh, you must be really, really slow to do it in 10 minutes, or are they walking really fast to do it in 10 minutes? So I would have liked to have the time to actually work out a walking, or a park where we can actually go ok, you walk for the next two weeks (PT1)
	That’s easy enough to do, but the majority of the time it is very difficult to come up with a relatable distance that they should be walking because nobody walks a tape measure and most of these clients do not have a Fit app or a Fitbit or a step counter, so yeah, I struggle with that (PT2)
Pre-existing activity/inactivity	The last client I have at the moment he’s quite… he always talks about his hydro sessions that he’s doing three days a week, 45 minutes, and I say how are you doing here with your exercises, you can see it’s like I’m enjoying it, but the hydro he goes straight away back to his hydro and that is such a big social thing, catching up with his people, doing hydro sessions, have a coffee, have a chat (PT1)
	And then you have the population who live very sedentary lifestyles and it’s very, very difficult to get them engaged in walking, and even if you try and do it (PT2)
Isolating	And I had a few ladies who were just living on their own and not comfortable leaving the ground. I had one lady I could convince her to walk up and down her driveway, but not ideal either just doing the short distance constantly. Yeah, the ones that were alone were the most tricky bit to get them to go for walks if they don’t have a dog (PT1)
	Like they were fearful of getting out on the streets, out and about or they had no where like their backyards was complete garden, and really uneven ground, and their front driveway, and lead on to a very busy road. And the house didn't really have one long corridor, it just had lots of little rooms (PT3)

Sub-themes	Intervention participant (person living with MCI) and PT quotes
Weather	A lot of it was because it was wet, so I just didn’t. I don’t like getting waterlogged (ID16)
	Well, I didn’t do a lot of that because of the heat, but I do intend to pursue that once it’s cooler, and it’s getting cooler now (ID34)
	A lot of people were sort of… the weather was a big impact like it’s too hot or it’s raining; it’s too cold (PT1)
	And then the weather or she was unwell or there were lots of reasons why they can’t or couldn’t. I think that was probably the biggest part (PT4)
Lack of motivation	No, well, I don’t know that it’s not that I didn’t enjoy them, I just think it was laziness (ID06)
	Umm… well, like I say, I think the walking is boring more or less (ID22)
	It is a bit tricky with clients that are older and alone. I think just the motivation to get out to do things. I had one gentleman in a retirement village and it was so hard to motivate him to actually get out of his house (PT1)
	It was very difficult to keep people motivated. I don’t know if any other clinicians have found that but I really struggled to get the walking component with those that weren’t already doing it (PT4)

Weather was also recognised by both intervention participants and PTs, either with the weather being too wet or too hot. Given the geographical location of the study population, this is unsurprising because during summer months, temperatures can rise above 40^oC. Although the weather was most often noted as a barrier, there was one participant who did not let it stop them from being able to go for a walk when they wanted to go, “I do, I do, because it was wet and miserable I told myself I really want to go for a walk, but I’m not going out in that. I drove over to Carousel and just walked around the shops” (ID62).

Facilitators for Participating in Walking

The walking intervention brought out four new facilitator sub-themes as intervention participants noted that they enjoyed getting outside, nature, and observing new things while walking. They also found that when they were already interested in walking, they were more likely to continue doing it. Others reported that key facilitators were the social side of the activity, and for those intervention participants who had dogs, that the dog was one of the main reasons they would go out for a walk.

PTs identified that their support to increase walking for intervention participants was by follow-up phone calls to help with engagement in walking and giving them personalised goals to work on. They also noted that they had some positive outcomes when delivering the walking intervention when intervention participants were able to increase their walking over the 24-week period. Motivation was the only facilitator noted by both intervention participants and PTs for the walking intervention. The PTs reported most motivation was with people who were already doing some level of walking before starting the Balance on the Brain intervention (Table 7).

Table 7.

Intervention participant (person living with MCI) and PT identified facilitators to the walking intervention

Sub-themes	Intervention participant (person living with MCI) quotes
Became routine easily	I always really tried to do three. And then incidental walking, you know, you walk down to the coffee shop, walk out to [the] Marina. I never sort of counted that in my walk, it was just incidental stuff (ID45)
	I was, yes, walking mainly once a day unless I was working or anything (ID84)
Nature	The birds are around. I don’t know your birds over here too well, but my girlfriend and I managed to find a birdwatching thing so we are sort of bird-watching as well (ID01)
	Because I’m a stickybeak. I walk down to the river and walk along and see the big boats (ID29)
Already walking regularly	Walking has never been a problem to me. I could walk long distances (ID32)
	We’ve always walked and always enjoyed walking. You know, when we’ve gone on holiday we’ve had walking holidays and thoroughly enjoyed them (ID42)
Enjoyed it	I do, yes. It’s not a burden to go for a walk. I do enjoy, you know, doing things like that (ID06)
	That it does me good, that’s right, yes, and I also enjoy walking anyway (ID34)
Easy	Because it was a case of just walking, that’s all I really had to do and at a brisk rate (ID18)
	It was something that was quite easy that side of things (ID32)
Social aspect	I was looking for a park where there were lots of people, so you even look at people or just say hi or something (ID08)
	Oh, I was quite happy to walk up and down and around the park with someone, that was all (ID19)
Dogs to walk	Probably because I’ve always had dogs. I’m quite passionate that they should be exercised for motivation, stimulation, yeah (ID30)
	The dogs. I’ve got a lazy dog – he sleeps all day; he borders on his weight and he needs the exercise. That’s what gets me out the door and once I’m out the door I enjoy the walking; I enjoy the park; I enjoy the people I talk to; I enjoy the dog’s interaction with people and other dogs and I enjoy watching nature – the birds and the sky (ID65)

Sub-themes	PT quotes
Guidance from PT	Generally, when I asked them at the phone call, I think the one thing that I always get is that they feel encouraged by the phone calls and the home visits and I feel like they just do a little bit more. And I think that’s just our nature – when we know we will be followed up, we actually try and do well because we don’t want to look too bad (PT2)
	I would always say to them just start with 10 minutes, for the people who weren’t already doing it. Start with five or 10 minutes, do that over three to five sessions, if there’s no issues and you are doing okay you are doing well, with no extra pain then increase it by five minutes, and just keep doing that pattern, you know to continue to do the same thing for three to five sessions and then increase it by a small amount. And that did help people work out how to do it and go ahead (PT3)
Positive experience with people who increased their walking	I had one lady who had really poor health when she started but she was the one I got to the coordination. She was really motivated because she saw she was getting better and she increased her walking (PT1)
	I’ve certainly had my highlights with the walking in the core of people who were already walking, but then just engaged in further walking and they really noticed the benefits (PT2)

Sub-themes	Intervention participant (person living with MCI) and PT quotes
Motivation	Because it’s for my benefit, keeping the joints active, moving (ID06)
	Motivation, determination, wellbeing, health, just had to get back on my feet, yeah (ID45)
	A lot of them were already walking or they say I go walking. Most of them did walks in the morning with family, with neighbours, with friends (PT1)
	So yeah, people that were already walking, that was easy to motivate them to do a little bit more (PT3)

Main Informal Support Person Perspective

Overall, all MISPs interviewed were supportive of the program. They had varying levels of involvement during the Balance on the Brain intervention. Some actively tried to not be involved to allow the intervention participant to have autonomy with the activity, others assisted with reminders, and some also completed the exercises with the intervention participant. The MISPs who assisted with reminders generally also helped with managing appointments and supported the intervention participant through the signup to the program. Online supplementary Table 3 provides a summary of MISP statements for each of the sub-themes identified in Figure 2.

Changes noticed by the MISPs in the intervention participants during the program included improved confidence and short-term memory (such as being able to remember where the car was parked). Other changes were related to physical health with improvement differing for each intervention participant. For one, it was fewer falls, another it was better balance, and another two reported improved strength. Five of the MISPs reported that they did not notice any physical or cognitive changes, but they thought the engagement in the exercises and having something to do was still beneficial.

All feedback from the MISPs regarding the program was positive. Ten MISPs reported that they were supportive of the program, and three reported that they had recommended the program to their friends. One MISP helped their friends download the Clock Yourself app onto their phones. Other supportive comments were about the staff they met throughout the program and that they felt that there was a benefit for the intervention participant to engage in physical activity and cognitive tasks.

Final Perspectives of the Program

Some intervention participants, one MISP, and one of the PTs reported that they thought the program would have more cognitive training included (Table 8). As previously mentioned, several sub-themes were identified as both barriers and facilitators to engagement. Two of the PTs summarised this well when they reported “And the favourite was dependent on the client; it wasn’t the same for all” (PT4) and “I think with all the interventions you realise that there’s a broad spectrum in the level of participation and there’s no one intervention that works best and there’s no one intervention that is better than any other” (PT2). PT2 also further described the need to tailor interventions to individual intervention participants.

Table 8.

Expectations of the Balance on the Brain

Sub-themes	Intervention participant (person living with MCI), MISP, and PT quotes
Unexpected program content	In a way. It’s certainly a lot more active than I thought it would be, but I had no idea what it was going to be (ID63)
	I find it hard to say because I didn’t know what I was getting into in the beginning when I first started off. But I suppose, well, it’s been an advantage, put it that way. There hasn’t been a negative in it (ID22)
	I think that it wasn’t quite what I was expecting. I first got into it because of my memory and I thought that it would be something more based on memory things rather than exercise. But, I suppose, you’ve got to be using your brain to exercise (ID32)
	Well, obviously, I’m not involved in that area. So I don’t know how it all works with brain cognition and all the rest of it. But I wasn’t expecting exercise and I don’t think Mom was when she went into it either. So it was just a bit. Okay. Right, because I still don’t understand how that (ID16MISP)
	I think a lot of them didn’t realise that exercises on a regular basis were involved in the programme. So you would come and say I’m your physio; we’d go through some exercises; I want you to do them on a regular basis if possible and the ones that are important. I think over time they realised that actually they have to do something; they have to continue with something; they have to stick to something. And I think a lot of people didn’t realise what was involved in it (PT1)

I think you just have to tailor it to the patient or to the participant based on their fitness and activity level, their interest, their level of motivation, their level of understanding. There are so many external factors to be considered to get someone to be interested in performing a certain exercise task (PT2).

Discussion

This qualitative study aimed to explore the facilitators and barriers to people living with MCI participating in a balance and mobility intervention from the perspective of the person living with MCI (intervention participant), the PTs delivering the intervention, and the MISPs. Results indicate that people living with MCI taking up a novel, multidimensional physical activity intervention found it easier to complete when they enjoyed the physical activity they were prescribed and valued the intermittent support of the PT visiting them at home. However, different aspects of Balance on the Brain resonated with different intervention participants; for example, some preferred walking over the other two interventions, whereas others reported the Clock Yourself app being their most preferred activity. The main barriers to engaging in physical activity included motivation and other health issues, which were similar to another study investigating barriers and facilitators to engaging in physical activity for people with MCI and early dementia [32].

All interviewees were positive about the program and the need for people living with MCI to increase engagement in cognitive, physical, and balance activities to maintain their health outcomes. In delivering home-based programs, the PTs reported greater satisfaction when they could tailor changes to the intervention to meet the needs of each participant. For physical activity interventions to be successful in this population, there needs to be the opportunity for choice and for the interventions to be tailored to individuals. Previous studies involving older adults without cognitive impairment and those with dementia have discovered similar positive results when able to tailor the intervention [18, 33, 34]. Care also needs to be taken with the intervention design to not overcomplicate it. Providing the right challenge with support to progress has been found to alleviate anxiety and was identified as a facilitator by older adults participating in a perturbation-based balance training intervention [33]. For people with early dementia, a recent tailored multifactorial intervention that focused on strength, balance, and physical activity that tapered professional support towards the end of the intervention did not find any significant differences in outcomes between the intervention and control groups [35, 36]. Difficulties were noted in the areas of maintaining engagement while professional support was reduced, often due to the participant’s memory impairment [35]. Furthermore, they noted the importance of support from MISPs [35], unlike our study where support from the MISPs was mixed and dependent on the person living with MCI.

In relation to motivational interviewing via phone calls, the PTs found a casual approach more effective in engaging with the participants with MCI, and only eight of the people living with MCI reported finding the phone calls useful. Other ways to support people during physical activity interventions include promoting and providing education on the potential health benefits and using various forms of social encouragement, such as peer role models in the media and social supports, such as family and friends [37]. For the Balance on the Brain intervention, some people living with MCI found assistance and support from their MISP enabled them to engage with the intervention. This is similar to findings from a scoping review by Sultana et al. [38], who found that involvement from MISPs enhanced engagement in fall prevention interventions for participants with cognitive impairment.

From the perspective of the MISPs, the findings have provided insight into the different roles that the MISPs of a person with MCI have, compared to the MISP of people with higher physical or cognitive support needs. For the majority of MISPs, Balance on the Brain had minimal impact on them and their ability to continue with their usual activities, while the person living with MCI completed the balance and aerobic physical activity intervention. In some instances, the MISPs would also complete the exercises, and others would help ensure the person living with MCI was present for appointments. This indicates that activities like a more formal carer role are present for some MISPs, but not for all. While this finding may suggest that the MISP support is not essential for people living with MCI to successfully engage in a balance and mobility intervention, a study by Connors et al. [39] found that up to 29.5% of caregivers of people living with MCI reported a significant level of burden over 3 years. While the level of burden was not measured in this study, the different levels of participation that the MISPs required in supporting the person living with MCI throughout the Balance on the Brain intervention indicate that there is a potential for risk of carer burden for some MISPs when implementing interventions for people with MCI. In designing future intervention studies, the balance between MISP level of engagement and potential for increased stress or burden for the MISPs warrants consideration. This recommendation aligns with other recent studies that advocate for the need to provide more support to MISPs of a person with MCI [40, 41], and that interventions for people with MCI also need to factor in aspects that MISPs can be involved in [42].

Strengths and Limitations

A strength of this study was incorporating three key perspectives through the interviews (people living with MCI, their MISP, and PTs delivering the exercise intervention), and where possible, triangulating findings to identify commonalities and differences. The inclusion of MISP perspectives was valuable and has not commonly been reported in similar research previously. However, the richness of data collected from the MISP interviews was less than anticipated. This compromised the robustness of data triangulation across the three groups as planned. Question nine of the MISPs interview was designed to gain insight into the impact of the intervention on the MISP. However, because most other questions focused on the impact of the interventions on the participant with MCI, the MISPs may have been influenced in their responses and did not provide in-depth information about their own experiences or the extent to which they felt burdened. Future research should ask more specific questions about the MISP experience.

Data saturation was met for this qualitative study. However, the experiences of people with MCI concerning physical activity in general may have been biased by asking them about their experiences of being involved in the Balance on the Brain RCT during the same interview. The phrasing of the questions on how they found participating in each aspect of the Balance in the Brain may have influenced how they answered the questions. Notably, while COVID-19 movement restrictions were present during aspects of the Balance on the Brain intervention period, none of the groups interviewed identified the pandemic as a barrier. An additional limitation of the sample of people living with MCI was that they were predominantly from an Anglo-European background (84%).

Future Research

Evaluation of the efficacy and economic impact of the Balance on the Brain RCT is in progress and yet to be published. The perspective of the MISP and how some also engaged in the intervention program opens future opportunities for research studies to investigate interventions targeted to support people with MCI and their MISPs. Future studies should have a greater focus on the MISPs and their experience as the MISP before and after the intervention.

Future research with people living with MCI should also include the perspectives from the participants in the control group to investigate the impact of being involved in an RCT while not being part of the intervention. This is because they may have differing perspectives on engagement in physical activity and identify different strategies to maintain or improve their engagement in physical activity throughout data collection.

Conclusion

Overall, the Balance on the Brain RCT was viewed positively and accepted by all three groups interviewed. In delivering community-based programs, exercise interventions must be able to be tailored to participant’s needs and interests. This enables choice and ownership of the exercises selected and may enhance internal motivation for participants to maintain engagement in the interventions. Flexibility within the interventions and being able to offer personalised training can ensure that the participant has the right challenge to maintain engagement and work to enhance skills rather than stop because the exercises are too easy or too difficult.

Depending on the person with MCI and their MISP dyad, it may be beneficial for healthcare services and community providers to also provide an opportunity for the MISP of a person with MCI to engage in interventions. This may assist in addressing carer-related stressors in some MISPs.

Acknowledgments

The research team sincerely thank all participants involved in this research.

Statement of Ethics

The South Metropolitan Health Service (RGS3930), the Western Australian Department of Health (RGS3930), and the Curtin University Human Research Ethics Committees (HRE2020-0378) approved the research. All participants provided written informed consent before being interviewed or participating in the research (i.e., RCT participants at the commencement of the study, MISP, and physiotherapists before the interview).

Conflict of Interest Statement

No conflicts of interest have been declared.

Funding Sources

J.H. was supported by the Australian Postgraduate Award and Curtin University. E.B. was supported by a National Health and Medical Research Council Investigator Grant (GNT1174739).

Author Contributions

Conceptualisation: J.H., E.B., and K.H. Methodology and formal analysis: J.H. and E.B. Investigation and writing – original draft: J.H. Supervision: E.B. and K.H. Writing – reviewing and editing: E.B., K.H., and K.E. All authors provided final approval for submission after reviewing the final manuscript.

Funding Statement

J.H. was supported by the Australian Postgraduate Award and Curtin University. E.B. was supported by a National Health and Medical Research Council Investigator Grant (GNT1174739).

Data Availability Statement

The data that support the findings of this study are not publicly available due to privacy reasons but are available from the corresponding author upon request.