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Contents
Abstract
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1. Factors Influencing Exercise Adherence Among Older Adults . . . . .
2. Demographics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.1 Age and Gender . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.2 Education and Income . . . . . . . . . . . . . . . . . . . . . . . .
3. Exercise Experiences . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.1 Exercise History . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4. Physical Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.1 Physical Condition . . . . . . . . . . . . . . . . . . . . . . . . . . .
5. Knowledge About Exercise . . . . . . . . . . . . . . . . . . . . . . . . .
6. Psychological Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6.1 Exercise and The Theory of Reasoned Action/Planned Behaviour
6.2 The Stages of Change . . . . . . . . . . . . . . . . . . . . . . . . .
6.3 Self-Efficacy and Social Cognitive Theory . . . . . . . . . . . . . .
6.4 Locus of Control . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6.5 The Perception of Benefits and Barriers to Exercise Adherence .
7. Perceived Social Influence Factors . . . . . . . . . . . . . . . . . . . .
7.1 Perceived Peer and Family Social Support . . . . . . . . . . . . .
7.2 Perceived Physician Support . . . . . . . . . . . . . . . . . . . . .
8. Activity Preference and Enjoyment of the Programme . . . . . . . . .
9. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Abstract
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This paper reviews the literature concerning factors at the individual level
associated with regular exercise among older adults. Twenty-seven cross-sectional
and 14 prospective/longitudinal studies met the inclusion criteria of a mean participant age of 65 years or older. The findings are summarised by demographics,
exercise experience, exercise knowledge, physiological factors, psychological
factors, activity preferences and perceived social influences. In general, education
and exercise history correlate positively with regular exercise, while perceived
physical frailty and poor health may provide the greatest barrier to exercise adoption and adherence in the elderly. Social-cognitive theories identify several constructs that correlate with the regular exercise behaviour of older adults, such as
398
Rhodes et al.
Although the benefits of regular physical activity have been well documented,[1] the majority of
adults in developed countries do not exercise. Sample surveys conducted in Canada and the US have
indicated that 40% of the adult population are sedentary and another 40% exercise with a frequency
and intensity too low to derive any substantial health
benefits.[2] Further, most exercise programmes typically suffer high attrition in their early stages. It is
estimated that over 50% of people will drop out of
their attempted exercise routine within 6 to 12
months of initiation.[3] Unfortunately, those who
could stand to gain the greatest health benefits from
an exercise programme tend to be the individuals
who fail to realise their exercise intentions.[3]
In addition, epidemiological research indicates
that physical activity decreases with age.[4] This
problem is even greater for females, as older women
report the least amount of regular physical activity
of all demographic age groups.[5-8] This lack of
physical activity among the elderly is of even
greater concern when considering the changing demographics. Data from the US National Center for
Health Statistics indicate that the most rapidly
growing segment of the population is that of individuals aged 85 and older, with a women to men
ratio of 2.36 : 1 by the year 2000.[9] Moderate regular exercise has been shown to improve the physical health[10-12] and mental wellbeing[13-16] of elderly individuals. Furthermore, no age limits to these
positive health benefits have been observed.[17]
Therefore, successful aging, characterised by minimal functional decline, is an achievable goal for
Adis International Limited. All rights reserved.
many adults.[18,19] Considering the benefits of regular exercise and the current trend in demographics,
it is important to understand what factors influence
physical activity among the older population in order to implement effective intervention strategies.[20]
1. Factors Influencing Exercise
Adherence Among Older Adults
Relatively few studies on exercise adherence have
been published about individuals over the age of
65 years in comparison to middle-aged and younger adults.[9,21] Further, factors associated with adherence are both complex and diverse. Potential
determinants encompass psychological, physiological and social-environmental characteristics from a
range of disciplines, and elements associated with
regular adherence to an exercise programme can be
influenced by both individual and environmental
components. Factors at the individual level comprise demographics, personality, skills, history, social
cognitive variables and perceived barriers and influences, while environmental factors reflect socialenvironmental situations that exert influence external to the individual.[22,23] However, interactions
between individual and environmental factors are
likely to be reciprocal.[24] Further, when examining
what variables are important in the determination
of the exercise adoption and maintenance process,
it is equally important to discover which variables
contribute to non-adherence and the intention not
to exercise in order to clarify directional relationships
among variables.[3,25] Since exercise determinant
research has traditionally relied on cross-sectional
Sports Med 1999 Dec; 28 (6)
399
physiological factors, psychological factors, perceived social influences and activity preferences.
2. Demographics
2.1 Age and Gender
Recent estimates from large scale surveys indicate that differences in age and gender correlate
with various regular exercise rates in senior citizens. Discrepancies in the operational definition of
adherence used, the type of exercise and the country of origin for the sample population also make
the relationship of age and gender with physical
activity less clear.[7] For example, although people
over 65 years have generally improved their rate of
activity in the past 15 years (for example Canada:
36 to 53%;[4] gender disparities with males being
more active than females still continue,[8,47-50] even
though the differences are not significant in all research.[51,52] These disparities also tend to differ by
country, as Canada (36% men and 49% women)
has a far greater reported gap between the genders
than the US (28.6% men and 32.3% women) among
the sedentary population.[7] The age of senior citizens is also an important factor to consider for activity prevalence. Physical activity tends to increase
slightly at retirement (age 60 to 65 years) but begins a downward slope a few years after, reaching
the lowest activity rates of the population.[4,7,53,54]
2.2 Education and Income
Education and income have been positively correlated with regular exercise among middle-aged
adults.[55,56] Higher rates of exercise behaviour have
been correlated with increased socioeconomic
standing,[57] and frequency of exercise participation has also been related to years of education.[6,8,58]
Among adults over 65 years of age, education has
not been found to be a significant predictor of adherence in prospective exercise trials,[52-54] yet
larger longitudinal survey samples have indicated
significant associations.[49,50] Further, the association of income with physical activity was found to
be spurious when education was entered into the
regression equation.[49] The discrepancy of findings
Sports Med 1999 Dec; 28 (6)
400
Rhodes et al.
401
402
Rhodes et al.
403
404
Rhodes et al.
may need to be considered in intervention. Exercise self-efficacy among older women has also been
associated with social support,[87] perceived health
and childhood movement confidence.[88] As well,
the stages of behaviour change paradigm identified
self-efficacy as the most important factor to discriminate a sample of 347 older adults between
stages.[63]
Another study has examined the relationship of
self-efficacy and social support appreciation of an
exercise programme among middle-aged adults.[89]
Bandura[76] hypothesised that self-efficacy plays a
mediating role for social support in health behaviours. This was in agreement with the findings of
Duncan and McAuleys[89] study of the social support and self-efficacy relationship among 85 men
and women aged 45 to 64 years. Self-efficacy was
found to mediate the relationship between attendance
and social support in these previously sedentary
volunteers after 10 weeks of aerobic exercise using
growth curve analysis. However, the relationship
between self-efficacy and exercise social support
has not been measured among adults aged 65 years
and older at present.
SCT provides 4 priority sources for the attainment of self-efficacy, in order of importance: personal experience, vicarious experience, social and
verbal persuasion, and emotional and physiological
states.[76] Obviously, these sources encompass a wide
range of factors that may influence behaviour, indicating the pervasive depth of individual cognition
and the environment that self-efficacy represents.
These sources of efficacy also provide for specific
intervention goals that can be tested against both
self-efficacy improvement and behaviour change.
Unfortunately, neither a specified self-efficacy intervention programme nor adequate exploratory
research among the sources of self efficacy and
actual efficacy and behaviour change have been
conducted with the elderly at this time. However,
the only randomised trial attempting to influence
exercise adherence utilising an efficacy enhancing
treatment produced a 12% improvement among
middle-aged adults.[90]
Adis International Limited. All rights reserved.
405
The second important variable in SCT is outcome expectation, defined as the expected outcome any given behaviour will provide.[76] This
construct is conceptually similar to the Theory of
Reasoned Actions[74] definition of an attitude, but
excludes the value of the expectation provided in
the TRA. At this time, very little research has been
conducted with outcome expectations and exercise
adherence, but so far, outcome expectations have
not provided for any explained variance over selfefficacy in research among older adults.[42,43]
6.4 Locus of Control
406
Rhodes et al.
cant antecedent for physical activity for 6780 respondents aged 70 years or greater in a longitudinal
study of aging.[50] Further, this factor has been indicated a predictor of prospective research as well.[53]
A large scale Canadian survey suggests that women
tend to report more barriers than men, many of
which could be perceived rather than actual,[8] perhaps a factor that could explain gender differences
in adherence. However, some differences among
women, young and old, have been found that may
have implications for differing intervention strategies. For example, Gill and Overdorf[100] examined
272 regularly exercising (3 times a week) women
aged 18 to 60 years, through cross-sectional selfreport, to compare their values towards exercise
ranked in order of importance. Although health and
physical activity were a priority for all ages, older
women placed greater importance on the social aspects of exercise, while young females found exercise as a means of weight control more important.
The social aspects of exercise have been found to
be of greater importance to older women in comparison with younger women and men, and to older
men in other studies.[99,101] Further, significant reported barriers among older African American
women include availability of exercise equipment,
exertion, embarrassment and safety.[101] Elderly
people also report less perception that exercise feels
good than younger individuals,[59] and report an
interest in less competitive, challenging and vertigoseeking exercise with a preference to less challenging activities.[8,29] Understanding the most frequently
reported barriers and benefits to regular exercise
among the elderly is an important consideration for
successful intervention. With greater emphasis
placed upon exercise benefits and attempts to reduce the perception of barriers, older adults will be
more likely to either adopt or continue a regular
exercise regime.
7. Perceived Social Influence Factors
Seven studies and 5 separate participant samples have attempted to measure the relationship between social influences and regular exercise among
adults over 65 years of age.[27,50,53,63,65,85,87] Except
Sports Med 1999 Dec; 28 (6)
407
As the aging process continues, individuals increase the frequency with which they interact with
the healthcare system, and especially with their
general practitioners. Therefore, physicians are in
an excellent position to encourage active behaviour.[103] More so, survey research indicates that the
opinions of physicians tend to have significant influence over the elderly,[93] especially in comparison to younger individuals.[58] Unfortunately, many
doctors do not seem to be informed about the benefits of geriatric exercise.[104] It seems that most
physicians do not view the importance of exercise
as critical to discuss with their patients, as it is not
perceived as a treatment to patients immediate illness.[105,106] Even among physicians who do prescribe exercise, few spend more than 3 to 5 minutes
to counsel.[107] This is certainly not enough time
Sports Med 1999 Dec; 28 (6)
408
Rhodes et al.
and long term adherence among younger and middle-aged adults.[112,113] Therefore, although more
research is required, a great diversity of activities
based on relatively moderate to low exertion and
maximum enjoyment should be provided to increase
adherence for elderly adults.
9. Conclusion
In summary, limited research exists to adequately
explain factors that influence exercise adherence
among the elderly at the individual level. Therefore, at present, research findings from younger and
middle-aged populations often have to be generalised to the senior citizen community. Further, the
quality of the data obtained in researching exercise
adherence among older adults may also be a problem. The majority of research consists of correlational, retrospective, self-report surveys among the
general population or motivated volunteers in a clinical setting and may lack external validity.[114,115]
The motivation of volunteers used in adherence
predictor research in prospective studies may especially be problematic when attempting to identify
significant psychological factors in regression
analysis because of restriction of range in measures. Similarly, elderly individuals in these studies
show perseverance and adherence rates often higher
than the 50% attrition rate speculated for the population.[3] Unfortunately, the lack of variability in
motivation among the participants may be providing for poor statistical discrimination between
those who adhere to exercise and those who do not.
Therefore, even when sampled from the community, prospective studies may lack the variability to
appropriately differentiate the determinants responsible for those who adhere to exercise and those
who do not, as only those who intend to exercise
are included in the study.
However, several variables have been consistently cited and associated with continued physical
activity among the elderly, even though more future research is required. For example, attitude, perceived behavioural control/self-efficacy, perceived
social support and perceived benefits of and barriers to continued activity may provide considerSports Med 1999 Dec; 28 (6)
409
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