Older people are generally aware that physical activity produces health benefits, but like other age groups, express barriers to its adoption (Cohen-Mansfield, Marx et al. 2003). Two barriers found particularly amongst older people are concerns about the risks of physical activity for those with existing health problems and age itself: 20% of the older people in the above mentioned study thought that they were too old to exercise (Cohen-Mansfield, Marx et al. 2003). These barriers can be addressed by a healthcare provider / health educator: such counselling will be discussed further in section 5.2.
A person’s beliefs in their capability to be physically active (under a range of circumstances) will influence their actions. Similarly, the strength of their beliefs that certain consequences, for example improved health and wellbeing, will be achieved by undertaking physical activity clearly influences both adoption and maintenance of that behaviour. Several theories have been used to understand personal physical activity behaviour and to underpin interventions construction to optimise successful outcomes (Burbank and Riebe 2002; Browning, Menzies et al. 2004). These are principally social learning theories, such as:
- The Health Belief model,
- The Transtheoretical model,
- Relapse prevention,
- Social cognitive theory, and
- Self efficacy theory.
Behaviour change programs tailor programs according to a person’s readiness to change and their activity preferences. Health professionals have used motivational interviewing techniques to encourage people to take up physical activity (Adams and White 2003). They encouraged participants to integrate physical activity into daily living. Both planned and unplanned activity has been promoted using a range of social cognitive theory based models. Goals are set and strategies to maintain activity and avoid relapse, such as positive feedback, social support and problem solving are used (Cress, Buchner et al. 2005). The findings have been positive across a diverse range of populations and settings. In their review of physical activity interventions, Kahn et al. (2002) found individually-adapted behaviour change programs to be effective. Four studies in the review focused on people aged 50 years or above where the positive outcomes were time spent being physically active (McAuley, Courneya et al. 1994; Jarvis, Friedman et al. 1997), maximum oxygen consumption (King, Haskell et al. 1991), attendance at sessions or sessions completed (King, Haskell et al. 1991; McAuley, Courneya et al. 1994) and physical function, such bas strength and flexibility (Jette, Lachman et al. 1999). Although there is evidence that these interventions can produce short term impact, the findings about longer term maintenance to date are disappointing
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Figure 5.1 A heuristic multilevel model of influences on physical activity.
Source: Li et al, 2005
Adoption: mediators of physical activity uptakeFactors mediating an individual’s adoption of physical activity fall along a continuum, with immutable and modifiable as the end points. Chronological age falls into the first category, then health, socio-economic status and disability, with attitudes and behaviour being potentially more modifiable. Physical activity behaviour can be modified and there is a growing literature concerning the effectiveness of interventions that aim to change older people’s physical activity behaviour. Earlier interventions may have failed to achieve intended outcomes at least in part as they often failed to directly address the barriers to participation. Other potentially modifiable features are societal and structural factors, such as social and physical environment. These are discussed in Sections 5.2 and 5.3.
The impact of motivating factors has not been fully tested in older people, although interviews with older people indicated that self efficacy was the most important predictor of all domains of physical activity: intensity, frequency, session duration and months per year of physical activity engagement (Conn, Burks et al. 2003). A UK trial with adults attending a general practice used free vouchers to the leisure centre as an incentive, but these did not produce a significant impact on behaviour (Harland, White et al. 1999). There is encouraging level II evidence from the United States that a brief motivational strategy, namely the use of weekly phone and mail prompts, can help to sustain physical activity behaviour in older adults (Conn, Burks et al. 2003). The factorial experimental design showed that three brief motivational interviewing sessions based on social cognitive theory did not of themselves impact significantly on activity. The United States Community Health Advice by Telephone (CHAT) study is a randomised controlled trial comparing cognitive mediation (self efficacy, beliefs and outcome expectations) with social mediation via social support (King, Friedman et al. 2002). The findings of this trial have not been published as yet.
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The maintenance of physical activity behaviour: the challenge of adheranceMaintaining physical activity behaviour is critical. Whilst the underlying reasons may differ, older adults show similar rates of attrition in exercise programs to younger adults. Approximately 50% of people drop out of programs within 6 months of starting them (Dishman 1994). For example, Ettinger et al. (1997) reported 85% adherence in the first three months, 70% at nine months and 50% at 18 months for an aerobic exercise program designed to manage degenerative joint disease. The adherence to an aquatic exercise program for arthritis was only 28% amongst volunteer participants (Belza, Topolski et al. 2002). As Patrick et al. (2001) noted, the program’s reach and desired impact was limited and so its cost effectiveness must be questioned. Fortunately, some public health benefit can be obtained even where there is limited adherence, e.g. (Clark, Stump et al. 2003) but researchers and program planners should still strive to optimise adherence in their programs.
Williams and Lord (1995) considered psychological, physiological, and health and lifestyle factors that could explain adherence to a 12 month structured exercise program for older women. In their trial, 78% of participants continued to exercise beyond the trial for at least 6 months. Multiple regression analysis revealed that most of the variance in adherence was explained by reduced muscle strength, slow reaction time, and psychoactive drug use during the trial. Muscle strength, reasoning ability, depression, and self-reported improvement in strength best predicted continued participation.
Clark has noted the need to assess different strategies for optimising the reach of and adherence to exercise programs (Clark 2001). Depression is associated with poor participation in physical activity and health promotion programs (McAuley, Courneya et al. 1994), making it particularly critical to fully engage participants with depression in enjoyable activity to enable sustained benefits. Studies that have evaluated community-based interventions for frail older people have tended to report poor adherence rates (Morey, Cowper et al. 1989; McMurdo and Johnstone 1995) amongst those with poor mobility and multiple chronic conditions, highlighting the need for more tailored interventions to promote ongoing physical activity.
Several authors, including King et al. (1998) have recommended key features to enable program adherance by participants:
- Preceding and ongoing education,
- Motivational techniques,
- Activity choice,
- Flexibility in meeting goals and targets, and
- Individualised schedules.
Long term adherance can be improved when the person makes physical activity part of their lifestyle (King 1991). Whilst some older people may prefer to exercise at home or on their own, for others joining a group based program can assist adherance via social interaction and the mutual commitment amongst participants (King, Rijeski et al. 1998). Group based physical activity also allows instruction and review of technique by a qualified instructor, overcoming some of the safety concerns mentioned above that act as barriers to physical activity in older people (Cohen-Mansfield, Marx et al. 2003).
Lower intensity physical activity that is incorporated into daily activities is generally more acceptable to older people, and has greater potential for long-term compliance (DiPietro 2001). Once people have begun to experience the benefits of physical activity, then there will be opportunities to work with them to progress the intensity of the physical activity.
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