Safe Steps: A Text Message Intervention to Increase Physical Activity After Emergency Department Discharge in Older Adults

Safe Steps: A Text Message Intervention to Increase Physical Activity After Emergency Department Discharge in Older Adults | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Short Report Safe Steps: A Text Message Intervention to Increase Physical Activity After Emergency Department Discharge in Older Adults Brian Suffoletto, Waverly Mayer, Caitlin Toth, Nick Ashenburg, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5883387/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 21 Apr, 2025 Read the published version in Aging Clinical and Experimental Research → Version 1 posted 13 You are reading this latest preprint version Abstract Background : Older adults face increased risk of functional impairments after Emergency Department (ED) discharge, yet no evidence-based physical activity interventions exist for this population. Objective : To evaluate the feasibility, safety, and effectiveness of Safe Steps, a text message intervention designed to increase daily step counts among older adults discharged from the ED. Methods : In this single-center pilot study, we recruited ED patients aged ≥60 years reporting low physical activity (<7,500 steps/day OR <75 minutes/day walking). Participants received a pedometer and daily text messages to report steps and set weekly goals over 4 weeks. Feasibility was assessed via step count reporting rates, safety through fall monitoring, and effectiveness by changes in step counts. Results : Forty-three participants enrolled; 40 completed the study. Step reporting rates were 87.2%. Three participants reported falls, none attributed to activity. Low-active participants (<5,000 steps) increased steps by 23.3%. Participants rated intervention motivation 7.4/10. Conclusion : Safe Steps appears feasible, safe, and effective for promoting activity post-ED discharge, warranting further study. Background Older adults account for over 20 million annual ED visits 1 , with nearly 25% experiencing functional decline within 30 days post-discharge 2 . Functional decline is often linked to physical inactivity, which modest increases in daily movement can mitigate 3 . Despite this, no evidence-based interventions address physical activity in this population during the critical post-ED recovery period. Digital health interventions, particularly text messaging 4 , offer an accessible and low-barrier solution to support physical activity. This study evaluates Safe Steps, a text-based intervention tailored to older adults discharged from the ED. Using behavior change techniques such as self-monitoring and goal setting, the intervention aims to increase daily step counts. The primary objectives were to assess the intervention’s feasibility and safety, with a secondary focus on preliminary effectiveness. Methods This single-center, single-arm pilot study was approved by the institutional review board. A sample size of 40 participants was chosen based on recommendations for pilot studies designed to estimate parameters for future larger trials when the standardized effect size is small (0.2) to medium (0.5) and to assess feasibility metrics 4 . Eligible participants were ED patients aged ≥ 60 years reporting low physical activity (< 7,500 steps/day or < 75 minutes/day walking) who could walk unaided and consent to participate. Exclusion criteria included living in a nursing home, limited English proficiency, or inability to provide informed consent. Safe Steps Intervention : Safe Steps uses behavior change strategies (i.e. self-monitoring and goal setting) previously shown to effectively enhance physical activity 5 , 6 and provides tailored suggestions to guide individuals toward increasing their daily steps while maintaining autonomy and choice 7 , 8 . Flow diagrams and sample messages are included in Supplemental materials . Daily end-of-day messages focused on raising awareness of step counts and encouraging daily physical activity. Daily feedback was tailored based on evidence-based step count thresholds for older adults 9 . Daily end-of-day text prompts at 8 PM asked participants to report pedometer-measured steps, followed by tailored feedback for three threshold levels (> 5,000; 2,000–5,000; <2,000 steps) based on evidence-based step count thresholds for older adults 9 . During weeks 1–3, participants who provided four or more days of step data received a weekly summary report and goal-setting prompt at 2 PM each Sunday, as prior research has established that a minimum of four days provides reliable estimates of weekly physical activity patterns in older adults 10 . After enrolling 20 participants, we modified the goal-setting protocol due to low adherence to the preset weekly targets (only 45% of participants setting goals aligned with recommendations). The original protocol suggested specific step count increases (e.g., "Consider setting a goal of X steps above your average"). The revised protocol emphasized participant choice (e.g., "Based on your average of X steps, what goal would you like to set for next week?"). This modification aligned with self-determination theory principles supporting autonomy in behavior change 8 . Study Procedures : Research associates provided participants with a 3DFitBud pedometer (3DActive.com) in the ED. This device was selected for its documented accuracy 11 , intuitive interface, and large digital display suitable for older adults with visual impairments. At baseline, we collected information on demographics (age, sex, race, ethnicity, marital status, living situation), ED chief complaint, prior falls, mobility, activity history, and barriers to routine physical activity to assess as potential covariates in engagement and intervention response. Fall history questions were taken from the CDC STEADI tool 12 . Mobility was assessed using an EQ-5D 13 item, where participants rated difficulty with walking on a 4-point scale. Activity history measured typical walking time per day and other strenuous activity using items from the CHAMPS Physical Activity Questionnaire for Older Adults 14 . Barriers to routine physical activity were measured using a validated instrument measuring agreement with seven potential reasons not to exercise 15 with responses on a 5-point scale collapsed into a dichotomous variable of agreement if participant agreed somewhat or agreed completely with a statement. At 30 days post-enrollment, we assessed falls during the study period—focusing on whether participants perceived the fall was related to the Safe Steps intervention. Participants rated the intervention's motivational impact on a scale from 0 (completely unmotivating) to 10 (highly motivating). Safety was assessed by asking if participants ever felt unsafe increasing their step count (with response options of yes or no), with a prompt for description if they answered yes. Data Analyses : Feasibility was evaluated by calculating the proportion of days participants provided step counts and the percentage achieving the minimum four readings per week needed for weekly summaries. We distinguished between missing data due to unworn pedometers versus unreported readings. Univariate linear regression examined associations between baseline characteristics and missing step count data. Weekly goal-setting feasibility was assessed through goal submission rates and comparison of goals to previous week's performance. Safety outcomes included fall incidence, attribution of falls to increased activity, and self-reported safety concerns. Effectiveness measures incorporated changes in step counts throughout the intervention period and participants' perceived effectiveness ratings. Analyses were performed using Stata 14.0 (Stata Inc). Results Study enrollment and retention : Between January and May 2024, we screened 170 participants from an ongoing fall study. Of these, 61 (35.9%) met our low physical activity criteria, and 43 (71.6%) enrolled in Safe Steps. Three participants (7.0%) withdrew due to pedometer loss (n = 2) or other reasons (n = 1). Among the 40 retained participants, we achieved high completion rates for follow-up assessments: 95.0% (n = 38) for fall assessment and 92.5% (n = 37) for effectiveness and safety measures. Participant characteristics : The study cohort (mean age 70 years) was predominantly White (77%) with balanced gender distribution (49% female). ED presenting complaints varied widely, with dizziness/weakness (19%), chest pain (16%), and other conditions (26%) being most common. While only 14% reported falls in the previous three months, nearly half reported near-falls, unsteady gait, or positional dizziness. Most participants (76%) reported walking less than one hour daily. Few participants cited barriers to physical activity, with health concerns (16%) and injury fears (9%) being most frequent. See Table 1 for participant characteristics. Table 1 Baseline Characteristics Variable Enrolled (N = 43) SD/% Demographics Age 70 6 Sex Female 21 49% Male 22 51% Race Caucasian/white 33 77% Black 4 9% Hawaiian/Pacific Islander 2 5% Asian 2 5% Multiracial 2 5% Ethnicity Hispanic/Latino 1 2% Marital status Single 7 16% Married 26 61% Separated/ Divorced 4 9% Widowed 6 14% Living situation Self 8 19% Others 35 81% Chief complaint category Abdominal/Digestive 5 11.6 Chest pain 7 16.3 Shortness of breath 4 9.3 Pain 4 9.3 Dizziness/Weakness 8 18.6 Vision issue 1 2.3 Leg swelling 2 4.7 Fever 1 2.3 Other 11 25.6 Fall History Any fall in the past 3 months 6 14% Any near-fall past 3 months 20 46% Feels unsteady when walking 19 44% Feels dizzy when standing (at least sometimes) 21 49% Typical walking per day 2 hours 3 7% Typical time with other strenuous PA None 14 33% 2 hours 3 7% Barriers to routine physical activity No time 3 7% Afraid I will get hurt 4 9% No activity partner 3 7% Health reasons 7 16% No appropriate exercise programs 2 5% Lacks transportation 0 0% Not interested 2 5% Intervention Adherence : Overall, 63% (100/160) of daily text message queries were completed, with 90% (36/40 participants) achieving the minimum four daily reports per week for four weeks. Missing data stemmed from unworn pedometers (57.5%) or unreported evening steps (42.5%). Weekly goal-setting completion improved from 37.5% in week one to 52.5% in week three, with 37.5% of participants completing at least two weekly goals. Daily step count reporting adherence is shown in Supplemental Fig. 1 . Safety Outcomes : Three participants (7.5%) reported falls during follow-up, with two sustaining minor injuries. No falls were attributed to increased walking activity, and fall risk showed no association with step counts or activity progression. Two participants reported safety concerns: one due to calf strain and another from balance issues. Effectiveness Measures : Among participants providing sufficient data (n = 36), 77.8% increased their median daily steps from week one to four, averaging 329 additional steps/day (SD 765). Initial activity level influenced improvement: participants starting above 5,000 steps/day (n = 13) were less likely to increase steps over time compared to participants starting below 5,000 steps/day (n = 23), with odds ratio = 0.11 (95% CI 0.02 to 0.51). The subset of participants with < 5000 steps in week one were found to have a mean increase of 564 steps/day over time, translating into a 23.3% increase. Participants rated the intervention's motivational impact favorably (mean 7.4/10), with a trend toward higher ratings among those who increased their activity (7.7 vs 6.6, p = 0.28). Discussion Safe Steps demonstrates that a simple, text-based intervention is feasible, safe, and effective for increasing physical activity among older adults after ED discharge. High adherence rates and favorable safety outcomes suggest the intervention’s suitability for this population. Importantly, participants with lower baseline activity levels showed the greatest improvements, highlighting the intervention’s potential to address functional decline in high-risk individuals. Several lessons emerged from this pilot study. First, adherence to step reporting suggests that the intervention’s design is well-suited to older adults’ capabilities. Second, the revised goal-setting approach, emphasizing participant autonomy, aligns with behavior change theories and supports sustainable engagement. Future studies should explore the relative contributions of self-monitoring and goal-setting components and evaluate long-term outcomes such as functional status and healthcare utilization. The evolving design of Safe Steps raises important questions about optimal behavior change strategies. While we incorporated established techniques like self-monitoring and goal-setting, the relative contribution of each component remains unclear. Our mid-study shift from prescribed to autonomous goal-setting did not significantly impact engagement, suggesting other factors may influence goal-setting behavior during post-ED recovery. The study’s limitations include its single-center design and convenience sampling, which may limit generalizability. Reliance on self-reported data introduces potential bias, and the short follow-up period precludes assessment of long-term effects. Future research should address these limitations by incorporating automated data collection and multi-center designs. Conclusion Safe Steps shows promise as a scalable, digital intervention to promote physical activity during a critical transition period for older adults. The positive findings warrant larger studies to confirm effectiveness and explore broader implementation in diverse populations. Declarations Funding: Department of Emergency Medicine, Stanford University Author Contribution B.S. conceived the intervention and planned the experiment. C.T. and W.M. screened, recruited and followed up with participants. All authors contributed to the interpretation of the results. B.S. took the lead in writing the manuscript. All authorsprovided critical feedback and helped shape the research, analysis and manuscript. Data Availability De-identified participant data that underlie the results reported in this article will be made available to researchers who provide a methodologically sound proposal. Data will be available beginning 3 months and ending 36 months following article publication. Proposals should be directed to [email protected] ; to gain access, data requestors will need to sign a data access agreement. References Ashman JJ, Schappert SM, Santo L (2020) Emergency Department Visits Among Adults Aged 60 and Over: United States, 2014–2017. NCHS Data Brief. ;(367):1–8 Nagurney JM, Fleischman W, Han L, Leo-Summers L, Allore HG, Gill TM (2017) Emergency Department Visits Without Hospitalization Are Associated With Functional Decline in Older Persons. Ann Emerg Med 69(4):426–433. 10.1016/j.annemergmed.2016.09.018 Lee IM, Shiroma EJ, Kamada M, Bassett DR, Matthews CE, Buring JE (2019) Association of Step Volume and Intensity With All-Cause Mortality in Older Women. JAMA Intern Med 179(8):1105–1112. 10.1001/jamainternmed.2019.0899 Whitehead AL, Julious SA, Cooper CL, Campbell MJ (2016) Estimating the sample size for a pilot randomised trial to minimise the overall trial sample size for the external pilot and main trial for a continuous outcome variable. Stat Methods Med Res 25(3):1057–1073. 10.1177/0962280215588241 Senkowski V, Gannon C, Branscum P (2019) Behavior Change Techniques Used in Theory of Planned Behavior Physical Activity Interventions Among Older Adults: A Systematic Review. J Aging Phys Act 27(5):746–754. 10.1123/japa.2018-0103 Knittle K, Nurmi J, Crutzen R, Hankonen N, Beattie M, Dombrowski SU (2018) How can interventions increase motivation for physical activity? A systematic review and meta-analysis. Health Psychol Rev 12(3):211–230. 10.1080/17437199.2018.1435299 Deci EL, Ryan RM (2012) Self-determination theory. Handbook of Theories of Social Psychology, Vol. 1. Sage Publications Ltd, pp 416–436. doi: 10.4135/9781446249215.n21 Teixeira PJ, Carraça EV, Markland D, Silva MN, Ryan RM (2012) Exercise, physical activity, and self-determination theory: a systematic review. Int J Behav Nutr Phys Act 9:78. 10.1186/1479-5868-9-78 Tudor-Locke C, Craig CL, Aoyagi Y et al (2011) How many steps/day are enough? For older adults and special populations. Int J Behav Nutr Phys Act 8:80. 10.1186/1479-5868-8-80 Hart TL, Swartz AM, Cashin SE, Strath SJ (2011) How many days of monitoring predict physical activity and sedentary behaviour in older adults? Int J Behav Nutr Phys Act 8:62. 10.1186/1479-5868-8-62 Le Masurier GC, Tudor-Locke C (2003) Comparison of pedometer and accelerometer accuracy under controlled conditions. Med Sci Sports Exerc 35(5):867–871. 10.1249/01.MSS.0000064996.63632.10 Stevens JA, Phelan EA (2013) Development of STEADI: a fall prevention resource for health care providers. Health Promot Pract 14(5):706–714. 10.1177/1524839912463576 EuroQol Group (1990) EuroQol–a new facility for the measurement of health-related quality of life. Health Policy 16(3):199–208. 10.1016/0168-8510(90)90421-9 Stewart AL, Mills KM, King AC, Haskell WL, Gillis D, Ritter PL (2001) CHAMPS physical activity questionnaire for older adults: outcomes for interventions. Med Sci Sports Exerc 33(7):1126–1141. 10.1097/00005768-200107000-00010 Moschny A, Platen P, Klaassen-Mielke R, Trampisch U, Hinrichs T (2011) Barriers to physical activity in older adults in Germany: a cross-sectional study. Int J Behav Nutr Phys Act 8:121. 10.1186/1479-5868-8-121 Additional Declarations No competing interests reported. Supplementary Files AgingCERSSsupplement.docx Cite Share Download PDF Status: Published Journal Publication published 21 Apr, 2025 Read the published version in Aging Clinical and Experimental Research → Version 1 posted Editorial decision: Revision requested 24 Feb, 2025 Reviews received at journal 20 Feb, 2025 Reviews received at journal 13 Feb, 2025 Reviewers agreed at journal 13 Feb, 2025 Reviews received at journal 13 Feb, 2025 Reviewers agreed at journal 13 Feb, 2025 Reviewers agreed at journal 13 Feb, 2025 Reviewers agreed at journal 12 Feb, 2025 Reviewers agreed at journal 10 Feb, 2025 Reviewers invited by journal 05 Feb, 2025 Editor assigned by journal 01 Feb, 2025 Submission checks completed at journal 30 Jan, 2025 First submitted to journal 22 Jan, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Functional decline is often linked to physical inactivity, which modest increases in daily movement can mitigate\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. Despite this, no evidence-based interventions address physical activity in this population during the critical post-ED recovery period. Digital health interventions, particularly text messaging\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e, offer an accessible and low-barrier solution to support physical activity. This study evaluates Safe Steps, a text-based intervention tailored to older adults discharged from the ED. Using behavior change techniques such as self-monitoring and goal setting, the intervention aims to increase daily step counts. The primary objectives were to assess the intervention\u0026rsquo;s feasibility and safety, with a secondary focus on preliminary effectiveness.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e This single-center, single-arm pilot study was approved by the institutional review board. A sample size of 40 participants was chosen based on recommendations for pilot studies designed to estimate parameters for future larger trials when the standardized effect size is small (0.2) to medium (0.5) and to assess feasibility metrics\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. Eligible participants were ED patients aged\u0026thinsp;\u0026ge;\u0026thinsp;60 years reporting low physical activity (\u0026lt;\u0026thinsp;7,500 steps/day or \u0026lt;\u0026thinsp;75 minutes/day walking) who could walk unaided and consent to participate. Exclusion criteria included living in a nursing home, limited English proficiency, or inability to provide informed consent.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eSafe Steps Intervention\u003c/span\u003e: Safe Steps uses behavior change strategies (i.e. self-monitoring and goal setting) previously shown to effectively enhance physical activity\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e and provides tailored suggestions to guide individuals toward increasing their daily steps while maintaining autonomy and choice\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. Flow diagrams and sample messages are included in \u003cb\u003eSupplemental materials\u003c/b\u003e.\u003c/p\u003e \u003cp\u003eDaily end-of-day messages focused on raising awareness of step counts and encouraging daily physical activity. Daily feedback was tailored based on evidence-based step count thresholds for older adults\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. Daily end-of-day text prompts at 8 PM asked participants to report pedometer-measured steps, followed by tailored feedback for three threshold levels (\u0026gt;\u0026thinsp;5,000; 2,000\u0026ndash;5,000; \u0026lt;2,000 steps) based on evidence-based step count thresholds for older adults\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eDuring weeks 1\u0026ndash;3, participants who provided four or more days of step data received a weekly summary report and goal-setting prompt at 2 PM each Sunday, as prior research has established that a minimum of four days provides reliable estimates of weekly physical activity patterns in older adults\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. After enrolling 20 participants, we modified the goal-setting protocol due to low adherence to the preset weekly targets (only 45% of participants setting goals aligned with recommendations). The original protocol suggested specific step count increases (e.g., \"Consider setting a goal of X steps above your average\"). The revised protocol emphasized participant choice (e.g., \"Based on your average of X steps, what goal would you like to set for next week?\"). This modification aligned with self-determination theory principles supporting autonomy in behavior change\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eStudy Procedures\u003c/span\u003e: Research associates provided participants with a 3DFitBud pedometer (3DActive.com) in the ED. This device was selected for its documented accuracy\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e, intuitive interface, and large digital display suitable for older adults with visual impairments. At baseline,\u003c/p\u003e \u003cp\u003ewe collected information on demographics (age, sex, race, ethnicity, marital status, living situation), ED chief complaint, prior falls, mobility, activity history, and barriers to routine physical activity to assess as potential covariates in engagement and intervention response. Fall history questions were taken from the CDC STEADI tool\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. Mobility was assessed using an EQ-5D\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e item, where participants rated difficulty with walking on a 4-point scale. Activity history measured typical walking time per day and other strenuous activity using items from the CHAMPS Physical Activity Questionnaire for Older Adults\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. Barriers to routine physical activity were measured using a validated instrument measuring agreement with seven potential reasons not to exercise\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e with responses on a 5-point scale collapsed into a dichotomous variable of agreement if participant agreed somewhat or agreed completely with a statement. At 30 days post-enrollment, we assessed falls during the study period\u0026mdash;focusing on whether participants perceived the fall was related to the Safe Steps intervention. Participants rated the intervention's motivational impact on a scale from 0 (completely unmotivating) to 10 (highly motivating). Safety was assessed by asking if participants ever felt unsafe increasing their step count (with response options of yes or no), with a prompt for description if they answered yes.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eData Analyses\u003c/span\u003e: Feasibility was evaluated by calculating the proportion of days participants provided step counts and the percentage achieving the minimum four readings per week needed for weekly summaries. We distinguished between missing data due to unworn pedometers versus unreported readings. Univariate linear regression examined associations between baseline characteristics and missing step count data. Weekly goal-setting feasibility was assessed through goal submission rates and comparison of goals to previous week's performance. Safety outcomes included fall incidence, attribution of falls to increased activity, and self-reported safety concerns. Effectiveness measures incorporated changes in step counts throughout the intervention period and participants' perceived effectiveness ratings. Analyses were performed using Stata 14.0 (Stata Inc).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eStudy enrollment and retention\u003c/span\u003e: Between January and May 2024, we screened 170 participants from an ongoing fall study. Of these, 61 (35.9%) met our low physical activity criteria, and 43 (71.6%) enrolled in Safe Steps. Three participants (7.0%) withdrew due to pedometer loss (n\u0026thinsp;=\u0026thinsp;2) or other reasons (n\u0026thinsp;=\u0026thinsp;1). Among the 40 retained participants, we achieved high completion rates for follow-up assessments: 95.0% (n\u0026thinsp;=\u0026thinsp;38) for fall assessment and 92.5% (n\u0026thinsp;=\u0026thinsp;37) for effectiveness and safety measures.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eParticipant characteristics\u003c/span\u003e: The study cohort (mean age 70 years) was predominantly White (77%) with balanced gender distribution (49% female). ED presenting complaints varied widely, with dizziness/weakness (19%), chest pain (16%), and other conditions (26%) being most common. While only 14% reported falls in the previous three months, nearly half reported near-falls, unsteady gait, or positional dizziness. Most participants (76%) reported walking less than one hour daily. Few participants cited barriers to physical activity, with health concerns (16%) and injury fears (9%) being most frequent. See Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e for participant characteristics.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline Characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEnrolled (N\u0026thinsp;=\u0026thinsp;43)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eSD/%\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eDemographics\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e6\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e49%\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e51%\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRace\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCaucasian/white\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e77%\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlack\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e9%\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHawaiian/Pacific Islander\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e5%\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e5%\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMultiracial\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e5%\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEthnicity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHispanic/Latino\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e2%\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarital status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e16%\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e61%\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeparated/ Divorced\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e9%\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWidowed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e14%\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLiving situation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e19%\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e81%\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChief complaint category\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbdominal/Digestive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChest pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShortness of breath\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDizziness/Weakness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVision issue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeg swelling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFall History\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny fall in the past 3 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e14%\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny near-fall past 3 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e46%\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFeels unsteady when walking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e44%\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFeels dizzy when standing (at least sometimes)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e49%\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTypical walking per day\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;30 minutes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e36%\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30 min to 1 hour\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e38%\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 to 2 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e19%\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;2 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e7%\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTypical time with other strenuous PA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e33%\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;30 minutes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e29%\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30 min to 1 hour\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e19%\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 to 2 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e12%\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;2 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e7%\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBarriers to routine physical activity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e7%\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAfraid I will get hurt\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e9%\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo activity partner\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e7%\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth reasons\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e16%\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo appropriate exercise programs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e5%\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLacks transportation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e0%\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot interested\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e5%\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eIntervention Adherence\u003c/span\u003e: Overall, 63% (100/160) of daily text message queries were completed, with 90% (36/40 participants) achieving the minimum four daily reports per week for four weeks. Missing data stemmed from unworn pedometers (57.5%) or unreported evening steps (42.5%). Weekly goal-setting completion improved from 37.5% in week one to 52.5% in week three, with 37.5% of participants completing at least two weekly goals. Daily step count reporting adherence is shown in \u003cb\u003eSupplemental Fig.\u0026nbsp;1\u003c/b\u003e.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eSafety Outcomes\u003c/span\u003e: Three participants (7.5%) reported falls during follow-up, with two sustaining minor injuries. No falls were attributed to increased walking activity, and fall risk showed no association with step counts or activity progression. Two participants reported safety concerns: one due to calf strain and another from balance issues.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eEffectiveness Measures\u003c/span\u003e: Among participants providing sufficient data (n\u0026thinsp;=\u0026thinsp;36), 77.8% increased their median daily steps from week one to four, averaging 329 additional steps/day (SD 765). Initial activity level influenced improvement: participants starting above 5,000 steps/day (n\u0026thinsp;=\u0026thinsp;13)\u003c/p\u003e \u003cp\u003ewere less likely to increase steps over time compared to participants starting below 5,000 steps/day (n\u0026thinsp;=\u0026thinsp;23), with odds ratio\u0026thinsp;=\u0026thinsp;0.11 (95% CI 0.02 to 0.51). The subset of participants with \u0026lt;\u0026thinsp;5000 steps in week one were found to have a mean increase of 564 steps/day over time, translating into a 23.3% increase. Participants rated the intervention's motivational impact favorably (mean 7.4/10), with a trend toward higher ratings among those who increased their activity (7.7 vs 6.6, p\u0026thinsp;=\u0026thinsp;0.28).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eSafe Steps demonstrates that a simple, text-based intervention is feasible, safe, and effective for increasing physical activity among older adults after ED discharge. High adherence rates and favorable safety outcomes suggest the intervention\u0026rsquo;s suitability for this population. Importantly, participants with lower baseline activity levels showed the greatest improvements, highlighting the intervention\u0026rsquo;s potential to address functional decline in high-risk individuals.\u003c/p\u003e \u003cp\u003eSeveral lessons emerged from this pilot study. First, adherence to step reporting suggests that the intervention\u0026rsquo;s design is well-suited to older adults\u0026rsquo; capabilities. Second, the revised goal-setting approach, emphasizing participant autonomy, aligns with behavior change theories and supports sustainable engagement. Future studies should explore the relative contributions of self-monitoring and goal-setting components and evaluate long-term outcomes such as functional status and healthcare utilization.\u003c/p\u003e \u003cp\u003eThe evolving design of Safe Steps raises important questions about optimal behavior change strategies. While we incorporated established techniques like self-monitoring and goal-setting, the relative contribution of each component remains unclear. Our mid-study shift from prescribed to autonomous goal-setting did not significantly impact engagement, suggesting other factors may influence goal-setting behavior during post-ED recovery.\u003c/p\u003e \u003cp\u003eThe study\u0026rsquo;s limitations include its single-center design and convenience sampling, which may limit generalizability. Reliance on self-reported data introduces potential bias, and the short follow-up period precludes assessment of long-term effects. Future research should address these limitations by incorporating automated data collection and multi-center designs.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eSafe Steps shows promise as a scalable, digital intervention to promote physical activity during a critical transition period for older adults. The positive findings warrant larger studies to confirm effectiveness and explore broader implementation in diverse populations.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eDepartment of Emergency Medicine, Stanford University\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eB.S. conceived the intervention and planned the experiment. C.T. and W.M. screened, recruited and followed up with participants. All authors contributed to the interpretation of the results. B.S. took the lead in writing the manuscript. All authorsprovided critical feedback and helped shape the research, analysis and manuscript.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eDe-identified participant data that underlie the results reported in this article will be made available to researchers who provide a methodologically sound proposal. Data will be available beginning 3 months and ending 36 months following article publication. Proposals should be directed to [email protected]; to gain access, data requestors will need to sign a data access agreement.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAshman JJ, Schappert SM, Santo L (2020) Emergency Department Visits Among Adults Aged 60 and Over: United States, 2014\u0026ndash;2017. 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Int J Behav Nutr Phys Act 8:121. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/1479-5868-8-121\u003c/span\u003e\u003cspan address=\"10.1186/1479-5868-8-121\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"aging-clinical-and-experimental-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"acer","sideBox":"Learn more about [Aging Clinical and Experimental Research](http://link.springer.com/journal/40520)","snPcode":"40520","submissionUrl":"https://submission.nature.com/new-submission/40520/3","title":"Aging Clinical and Experimental Research","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-5883387/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5883387/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Older adults face increased risk of functional impairments after Emergency Department (ED) discharge, yet no evidence-based physical activity interventions exist for this population.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e: To evaluate the feasibility, safety, and effectiveness of Safe Steps, a text message intervention designed to increase daily step counts among older adults discharged from the ED.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: In this single-center pilot study, we recruited ED patients aged ≥60 years reporting low physical activity (\u0026lt;7,500 steps/day OR \u0026lt;75 minutes/day walking). Participants received a pedometer and daily text messages to report steps and set weekly goals over 4 weeks. Feasibility was assessed via step count reporting rates, safety through fall monitoring, and effectiveness by changes in step counts.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Forty-three participants enrolled; 40 completed the study. Step reporting rates were 87.2%. Three participants reported falls, none attributed to activity. Low-active participants (\u0026lt;5,000 steps) increased steps by 23.3%. Participants rated intervention motivation 7.4/10.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: Safe Steps appears feasible, safe, and effective for promoting activity post-ED discharge, warranting further study.\u003c/p\u003e","manuscriptTitle":"Safe Steps: A Text Message Intervention to Increase Physical Activity After Emergency Department Discharge in Older Adults","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-02-03 18:25:30","doi":"10.21203/rs.3.rs-5883387/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-02-24T08:32:55+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-02-20T16:51:30+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-02-13T16:56:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"38825706666637600982156869652546724418","date":"2025-02-13T16:27:33+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-02-13T15:13:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"137139525272527095720405126313479573951","date":"2025-02-13T14:43:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"1916189408016563253816547617759132702","date":"2025-02-13T07:58:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"14109655718702452931272372257582913340","date":"2025-02-12T12:35:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"21510431408161414282045912135075193664","date":"2025-02-10T10:35:26+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-02-05T10:22:10+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-02-01T13:21:23+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-01-30T08:12:55+00:00","index":"","fulltext":""},{"type":"submitted","content":"Aging Clinical and Experimental Research","date":"2025-01-22T19:41:33+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"aging-clinical-and-experimental-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"acer","sideBox":"Learn more about [Aging Clinical and Experimental Research](http://link.springer.com/journal/40520)","snPcode":"40520","submissionUrl":"https://submission.nature.com/new-submission/40520/3","title":"Aging Clinical and Experimental Research","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"f661c20a-e516-4411-82a5-49c1ad7856c2","owner":[],"postedDate":"February 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-04-28T16:02:59+00:00","versionOfRecord":{"articleIdentity":"rs-5883387","link":"https://doi.org/10.1007/s40520-025-03030-7","journal":{"identity":"aging-clinical-and-experimental-research","isVorOnly":false,"title":"Aging Clinical and Experimental Research"},"publishedOn":"2025-04-21 15:58:00","publishedOnDateReadable":"April 21st, 2025"},"versionCreatedAt":"2025-02-03 18:25:30","video":"","vorDoi":"10.1007/s40520-025-03030-7","vorDoiUrl":"https://doi.org/10.1007/s40520-025-03030-7","workflowStages":[]},"version":"v1","identity":"rs-5883387","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5883387","identity":"rs-5883387","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}