Encyclopedia of Gerontology and Population Aging

Living Edition
| Editors: Danan Gu, Matthew E. Dupre

Exercise Adherence

  • Helen L. GrahamEmail author
Living reference work entry
DOI: https://doi.org/10.1007/978-3-319-69892-2_807-1



Exercise is a structured and repetitive physical conditioning program and a subcategory of physical activity (PA) (Rivera-Torres et al. 2019). Major purposes of exercise are conditioning, maintaining, and improving individual health (Room et al. 2017). Adherence, once referred to as compliance (Rosner 2006), has not been consistently defined. The World Health Organization defines adherence by the degree of how well a person’s behavior corresponds to the instructions received from medical or other health-care providers (Sabate 2003). Adherence to exercise can be intentional or non-intentional (Horne et al. 2013). Exercise adherence is a modifiable health risk factor over which individuals have a degree of control. Older adults’ willingness and ability to commit to a routine exercise plan affect health outcomes.


Scientific evidence supports the benefits of physical activity and regular exercise for adults with and without chronic health conditions (Hoffmann et al. 2016; Eckel et al. 2014). The American Heart Association recommends physician referral to a cardiac rehabilitation exercise program for adults of all ages following a heart attack and for other cardiac conditions (Labarthe et al. 2016). For older adults, the World Health Organization (Sabate 2003) recommends 150 min of weekly aerobic exercise including 2–3 days of resistance training (Franco et al. 2015). A physician assessment ideally precedes the initiation of an exercise program, and recommendations should be made for the appropriate level of exercise intensity (low, moderate, or high) for older adults. Rarely however do older adults engage in moderate to vigorous levels of exercise (Sparling et al. 2015; Garber et al. 2011; Hill, et al. 2011). Health-care providers prescribe exercise regimes for patients with the expectation recommendations will be followed. According to Picorelli et al. (2014), variability in adherence measures makes comparisons between studies difficult. Although there is not an agreed-upon optimal exercise adherence measure, it has been measured as (1) average number of home, gym, or program exercise sessions attended per week, (2) number of weeks exercising, (3) portion of days undertaken, or (4) number of minutes exercising/weekly (Rivera-Torres et al. 2019).

Meeting physical activity recommendations is a challenge for adults, especially for older adults (Franco et al. 2015). Exercise adherence is multifactorial and affected largely by physical ability, personality, psychosocial characteristics, and demographic factors (Picorelli et al. 2014). For older adults, there is a fear of falling, of strains, or of getting hurt (Hill et al. 2011). According to Franco et al. (2015), social influence, physical limitations, competing priorities, access difficulties, personal benefits, motivation, and beliefs influence exercise adherence. Long-term adherence to health-promoting behaviors is more complex and difficult to sustain than short-term adherence (D’Angelo et al. 2014). Problems associated with poor exercise adherence are not solely influenced by individual factors but also by factors associated with provider and health-care systems (Hawley-Hague et al. 2014). Attitudes of the therapist as well as the patient regarding exercise should be considered when setting exercise goals (Franco et al. 2015).

Individual commitment and adherence to routine exercise are largely behavioral in nature. Behavioral theories are the basis for measuring exercise adherence and testing physical activity interventions. Frequently cited theories include Social Cognitive Theory (Bandura 1997) and the Theory of Planned Behavior (Madden et al. 1992). Both provide a comprehensive framework taking into account individual and social factors effecting adherence and nonadherence behaviors. Bandura’s Social Cognitive Theory, the most often cited health behavioral change model, stresses, regardless of an individual’s behavior, that adherence will be dependent on the individual’s outcome expectations and his or her belief in their ability to engage in a particular behavior (Bandura 1997; Brosse et al. 2002). Keller et al. (1999) found Social Cognitive Theory resourceful in predicting initiation and maintaining physical activity behaviors among adults. Attitudinal components affecting exercise adherence in older adult are cognitive, affective, and behavioral; each influences intention to exercise and to maintain exercise behaviors. Ajzen and Madden (1986) studied behavior, attitudes, and subjective norms when testing interventions designed to increase physical activity and found intention to act correlated more with behavior than with attitudes and subjective norms. Perceived behavioral control, a concept of the Theory of Reasoned Action, includes both personal and external factors of time, money, willpower, and opportunity (Shumaker et al. 1998) which influence health behavior decisions. Exercise programs based on health behavior theoretical constructs are effective in promoting and increasing physical activity (Garber et al. 2011).

Key Research Findings

Nonadherence to a healthy lifestyle including physical activity and exercise is a significant health concern nationally and globally (Franco et al. 2015). Despite strong evidence of physical and mental benefits from regular exercise (Chodzko-Zajko et al. 2009; Garber et al. 2011), fewer than 80% of individuals in the United States meet the PA recommended guidelines set forth by the US Department of Health and Human Services (2002). In fact, fewer than 50% of the population in developed countries adhere to long-term health therapies, and rates for adherence are even lower in developing countries (Sabate 2003). Researchers report that 50% of older adults have trouble staying with exercise (Rosner 2006). The barriers related to exercise adherence are known, but the motivations of individuals who maintain exercise adherence are not as easily understood.

Empirical research for predicting adherence guides interventional physical activity studies. Supervised exercise programs demonstrate better adherence outcomes than unsupervised programs. Effective communication and positive relationships between providers, therapists, and patients are other factors contributing to increased exercise program attendance (Picorelli et al. 2014). Additional adherence factors include individual health condition and psychological (Brosse et al. 2002) as well as physical status (Liu and Miyawaki 2019). A Cochrane study reviewed interventions designed to improve exercise adherence in adults 65 years and older and found that motivation classes, information messages, and other interventions were unsuccessful as compared to interventions offering participant monitoring, feedback, and booster sessions (Room et al. 2017). The perspectives of older people to physical activity are found in comments from systematic qualitative studies. Predominant themes include personal benefits of physical activity, physical limitations, social influences, and competing priorities (Franco et al. 2015).

Health-care providers and policy makers recognize the need to increase exercise adherence among adults, especially older adults. Randomized control trials (RCT), the gold standard of studies, overwhelmingly demonstrate an association between supervised exercise participation and increased longevity, including reduced hospitalizations in older adults with cardiac conditions (Heran et al. 2011). In a review of 16 meta-analyses, investigators observed exercise, compared to certain medications, decreased mortality. This finding however was limited to specific disease conditions (Naci and Ioannidis 2013).

Social support and encouragement to exercise coming from external sources have been shown to be exceptionally beneficial. Family members, neighbors, community members, social network, and media all influence individual exercise behavior (Rivera-Torres et al. 2019). Social support is a benefit of attending community center-based adult exercise programs (Picorelli et al. 2014), a benefit not acquired from home-based programs. In one community center, physical strength and conditioning program researchers found long-term training promising in individuals 75 years and older (Aartolahti et al. 2015). Overall, studies find group-based exercise programs appear to have better adherence rates compared with home-based programs (Kohn et al. 2016).

Future Directions for Research

The complexity of issues surrounding exercise adherence, especially for older adults, is significant. Researching interventions, which optimally support older adults exercising, should continue in developed and developing countries. Interventional research will be instrumental in developing methods to increase exercise adherence and for tackling nonadherence issues. Identifying what exercise is enjoyable and meets individuals’ values and needs could lessen nonadherence. An interdisciplinary systematic theory-based approach to studying individual and population-based exercise adherence is strongly encouraged. Up to now, studies have focused on exercise adherence associated with specific disease conditions. There is also a need for more general older adult non-disease-specific studies (Room et al. 2017) and ones that address gender, ethnic, and disability issues. The World Health Organization (Sabate 2003) recommends a patient-tailored prescribed exercise plan recognizing that the “one-size-fits-all” approach to exercise adherence has the potential to overlook significant individual distinctions and result in negative outcomes. Exploring self-determined motivation through more qualitative studies may provide needed insight into what exercise programs are valuable and appeal to older adults. Additionally, increased use of Internet-based technologies to include activity monitoring, telecommunication, and systems providing prompt individual feedback is another option for improving exercise adherence outcomes (Room et al. 2017). More RCT trials are also needed comparing medication treatment with exercise prescriptions for specific diseases.

Finally, patient education cannot be overlooked. Compared with younger adults, older adults have more difficulty understanding recommendations (Dimatteo et al. 1992). Exercise recommendations from providers and trainers include type, duration, and intensity, and for some older adults, these details can be overwhelming. Developing simple measures to assess individual knowledge and capacity for learning and maintaining an exercise plan prior to developing a plan would be a significant step forward. Disseminating research findings to practitioners and trainers related to assessing exercise adherence and program development should be a constant goal. Exercise adherence research in years to come will require ingenuity, innovative strategies, and substantial financial funding.



  1. Aartolahti E, Tolppanen AM, Lonnroos E, Hartikainen S, Hakkinen A (2015) Health condition and physical function as predictors of adherence in long-term strength and balance training among community-dwelling older adults. Arch Gerontol Geriatr 61:452–457.  https://doi.org/10.1016/j.archger2015.06.016CrossRefGoogle Scholar
  2. Ajzen I, Madden TJ (1986) Prediction of older adults directed behavior, attitudes, intentions, and perceived behavioural control. J Exp Soc Psychol 22:453–474CrossRefGoogle Scholar
  3. Bandura A (1997) Self-efficacy: the exercise of control. Freeman, New YorkGoogle Scholar
  4. Brosse AL, Sheets ES, Lett HS, Blumenthal JA (2002) Exercise and the treatment of clinical depression in adults recent findings and future directions. Sports Med 32(12):741–760CrossRefGoogle Scholar
  5. Chodzko-Zajko W, Proctor DN, Singh MA, Minson CT, Nigg CR, Salem GJ, Skinne JS (2009) Exercise and physical activity for older adults. Med Sci Sports Exerc:1510–1530.  https://doi.org/10.1249/MSS.0b013e33181a0c95c
  6. D’Angelo ME, Pelletier LG, Reid RD, Huta V (2014) The roles of self-efficacy and motivation in the prediction of short-and long-term adherence to exercise among patients with coronary heart disease. Health Pyschol 33(11):1344–1353CrossRefGoogle Scholar
  7. Dimatteo MR, Hays RD, Sherbourne CD (1992) Adherence to cancer regimens: implications for treating the older patient. Oncology 6(2 Supplement):50–57Google Scholar
  8. Eckel RH, Jakicic JM, Ard JD, DeJesus JM, Miller NH, Hubbard VS et al (2014) AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association task force on practice guidelines. Circulation 129(suppl 2):S76–S99CrossRefGoogle Scholar
  9. Franco MR, Tong A, Howard K, Sherrington C, Ferreira PH, Pinto RZ, Ferreira ML (2015) Older people’s perspectives on participation in physical activity: a systematic review and thematic synthesis of qualitative literature. Br J Sports Med 49:1268–1276.  https://doi.org/10.1136/bjsports-2014-094015CrossRefGoogle Scholar
  10. Garber CE, Blissmer B, Deschenes MR, Franklin B, Lamonte MJ, Lee IM, Nieman DC, Swain DP (2011) Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc 43:1334–1359CrossRefGoogle Scholar
  11. Hawley-Hague H, Horne M, Campbell M, Demack S, Skelton D, Todd C (2014) Multiple levels of influence on older adults’ attendance and adherence to community exercise classes. The Gerontologist 54(4):599–610.  https://doi.org/10.1093/geront/gnt075CrossRefGoogle Scholar
  12. Heran BS, Chen JM, Ebrahim S, Moxham T, Oldridge N, Rees K, Thompson DR, Taylor RS (2011) Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev Cochrane Collab 7:10–11Google Scholar
  13. Hill AM, Hoffmann T, McPhail S, Beer C, Hill KD, Brauer GG, Hainers TP (2011) Factors associated with older patients’ engagement in exercise after hospital discharge. Arch Phys Med Rehabil 92:1395–1405.  https://doi.org/10.1016/j.apmr.2011.04.009CrossRefGoogle Scholar
  14. Hoffmann TC, Maher CG, Riffa T et al (2016) Prescribing exercise interventions for patients with chronic conditions. CMAJ 188(7):510–518CrossRefGoogle Scholar
  15. Horne R, Chapman SC, Parham R, Freemantle N, Forbes A, Cooper V (2013) Understanding patients’ adherence-related beliefs about medicines prescribed for long-term conditions: a metanalytic review of the necessity-concerns framework. PLoS One 8(12).  https://doi.org/10.1371/journal.pone.0080633CrossRefGoogle Scholar
  16. Keller C, Fleury J, Gregor-Holt N, Thompson T (1999) Predictive ability of social cognitive theory in exercise research: an integrated literature review. Worldviews on Evidence-based Nursing presents the archives of Online Journal of Knowledge Synthesis for Nursing, 6(1):19–31.CrossRefGoogle Scholar
  17. Kohn M, Belza B, Petrescu-Prahova M, Miyawaki CE (2016) Beyond strength: participants perceptions on the benefits of an older adult exercise program. Health Educ Behav 43(3):305–312CrossRefGoogle Scholar
  18. Labarthe DR, Goldstein LB, Antman EM, Arnett D, Fonarow G, Albets MJ, Whitsel L et al (2016) Evidence-based policy making: assessment of the American Heart Association ‘s strategic policy portfolio: a policy statement from the American Heart Association. Circulation 133(18):e615–e653CrossRefGoogle Scholar
  19. Liu M, Miyawaki CE (2019) What types of physical function predict program adherence in older adults? Rehabil Nurs J Off J Assoc Nurs:1–8.  https://doi.org/10.1097/rnj.0000000000000209
  20. Madden TJ, Ellen PS, Ajzen I (1992) A comparison of the theory of planned behavior and the theory of reasoned action. Pers Soc Psychol Bull 18(1):3–9CrossRefGoogle Scholar
  21. Naci H, Ioannidis JP (2013) Comparative effectiveness of exercise and drug interventions on mortality outcomes: metaepidemilogical study. BMJ 347:5577.  https://doi.org/10.1136/bmj.f5577CrossRefGoogle Scholar
  22. Picorelli AM, Pereira LS, Pereira DS, Felicio D, Sherrington C (2014) Adherence to exercise programs for older people is influenced by program characteristics and personal factors: a systematic review. J Physiother 60:151–156CrossRefGoogle Scholar
  23. Rivera-Torres S, Fahey DT, Rivera MA (2019) Adherence to exercise programs in older adults: informative report. Gerontol Geriatr Med 5:I–10Google Scholar
  24. Room J, Hannink E, Dawes H, Barker K (2017) What interventions are used to improve exercise adherence in older people and what behavioral techniques are they based on? A systematic review. BMJ Open 7:e019221.  https://doi.org/10.1136/bmjopen-2017-019221CrossRefGoogle Scholar
  25. Rosner F (2006) Patient noncompliance: causes and solutions. Mt Sinai J Med 73(2):553–559Google Scholar
  26. Sabate E (2003) Adherence to long-term therapies: evidence for action. World Health Organization, GenevaGoogle Scholar
  27. Shumaker SA, Achron EB, Ockene JK, McBee WL (1998) The handbook of health behavior change, 2nd edn. Springer Publishing Company, New YorkGoogle Scholar
  28. Sparling PB, Howard BJ, Dunstan DW, Owen N (2015) Recommendations for physical activity in older adults. BMJ (6):350.  https://doi.org/10.1136/bmj.h100CrossRefGoogle Scholar
  29. U.S. Department of Health and Human Services (2002) Physical activity fundamental to preventing disease. Washington, DC. Retrieved from https://aspe.hhs.gov/basic-report/physical-activity-fundamental-preventing-disease
  30. U.S. Department of Health and Human Services (2008) Physical activity guidelines for Americans. Washington, DC. Retrieved from https://health.gov/paguidelines/pdf/paguide.pdf

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Helen and Arthur E. Johnson College of Nursing and Health SciencesUniversity of Colorado Colorado SpringsColorado SpringsUSA

Section editors and affiliations

  • Wei Zhang
    • 1
  1. 1.Department of SociologyUniversity of Hawaii at ManoaHonoluluUSA