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.
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