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Confidence and positive attitude help older adults stick with exercise

This is an excerpt from Developing Effective Physical Activity Programs by Lynda Ransdell,Mary Dinger,Jennifer Huberty & Kim Miller.

Because the majority of older adults clearly can engage in physical activity safely, a growing body of research has been conducted to identify effective programs for increasing physical activity in this population (Brawley, Rejeski, & King, 2003; Taylor et al., 2004; U.S. Department of Health and Human Services, 1996). However, increasing older adult physical activity participation presents unique challenges. Although some programs have been effective in the short term, the effectiveness of long-term physical activity programs has been limited (Brawley, Rejeski, & King, 2003; Taylor et al., 2004).

Factors Related to Successful Physical Activity Interventions

To develop effective older adult physical activity interventions, it is important to understand factors that predict participation and adherence. Numerous research studies have investigated correlates of older adult physical activity participation (Benjamin, Edwards, & Baharti, 2005; Brassington, Atienza, Perczek, DiLorenzo, & King 2002; Hays & Clark, 1999; Lee & Lafferty, 2006; Stuart, Marret, Kelly, & Nelson, 2002). Although many factors influence the participation rates of older adults, we will examine the following, which demonstrate the greatest potential for increasing physical activity:

• Psychological factors of self-efficacy, self-regulation, positive attitudes toward physical activity, and social support
• Health care provider referral
• Physical activity intensity
• Group- and home-based interventions
• Disease management

Psychological Factors

As with other populations, self-efficacy, or the confidence a person has to perform an activity, is one of the strongest determinants of physical activity for older adults (Brassington et al., 2002; Resnick, Orwig, Magaziner, & Wynne, 2002; Schutzer & Graves, 2004). Interventions should help older adults build their confidence through mastery of the physical activity. This can be achieved by beginning the intervention at a low intensity and gradually increasing the intensity over time. This gradual increase is especially important for frail older adults. Improvements in fitness and or health that result from physical activity will also enhance self-efficacy.

To promote long-term adherence to physical activity, interventions need to be designed so older adults move from a supervised, or center-based, setting to the home, where they can use self-regulation skills to make physical activity part of their lifestyle (Rejeski & Brawley, 2006). Behavioral counseling is one method that can be used to help older adults transition from center-based to home-based activity. Through counseling, older adults can develop a plan of action for making physical activity a part of their daily routine.

Having a positive attitude toward physical activity is another factor influencing older adult participation (Stuart et al., 2002). If the activity is positive and enjoyable, older adults will be more likely to continue to exercise. Past participation is also a predictor of future participation (Benjamin et al., 2005). For those who have had a negative attitude toward physical activity, strategies such as providing positive images depicting the activity with role models who may have similar limitations can be used to entice older adults to participate.

Receiving positive reinforcement or social support from friends and family is also one of the predictors of physical activity involvement in the older adult population (Booth, Owen, Bauman, Clavisi, & Leslie 2002; McAuley, Jerome, Elavvsky, Marquez, & Ramsey, 2003; Resnick et al., 2002). Litt, Kepplinger, and Judge (2002) found that social support is a strong determinant of physical activity particularly for older women. In addition, positive comments help strengthen people's self-efficacy and can enhance exercise adherence. Programs need to be carefully designed to create a positive environment. In residential care facilities, older adults may have limited contact with family members; thus, support from friends may be more important.

Health Care Provider Referrals

Receiving a recommendation from a physician to exercise is another important positive predictor of physical activity in the older adult population (Benjamin et al., 2005; Navarro, Sanz, del Castillo, Izquierdo, & Rodriguez, 2007; Stuart et al., 2002). Having a health care provider "prescribe" exercise helps older adults overcome their fear of being injured during the physical activity. This type of prescription may be especially important for physically frail older adults (Benjamin et al., 2005). More research needs to be conducted in this area to determine the most effective type of physician advice and the amount of contact needed with the older adult to improve physical activity levels.

Physical Activity Intensity

Older adults are more likely to participate in low- to moderate-intensity physical activity (Brawley et al., 2003; Taylor et al., 2004) such as light housework, chair exercises, and walking. Lower-intensity activity is less likely to cause injuries and is often perceived as less threatening, especially to older adults who have functional disabilities or limitations. Although interventions should to be tailored to the ability level of the participant, planners must also recognize that low-intensity exercises conducted in a chair may have few functional benefits for the older adult. Specificity of the exercise is the issue. If the goal is to improve mobility and balance, exercises should be conducted while participants are standing and walking. Physical activity interventions that begin at lower intensities should progress over time to moderate intensities.

Group- and Home-Based Interventions

Physical activity interventions can be designed to be group based, home based, or a combination of both. Group-based interventions require participants to go to a facility or center where the activity program is usually supervised. For typical home-based interventions, the physical activity occurs at the older adult's home, and contact with the practitioner is minimal. Combination designs usually begin with a few weeks of group-based instruction followed by a period of home-based activity. Table 6.1 lists some of the positive and negative aspects of group- and home-based interventions.

Research has demonstrated that both home-based and group-based physical activity interventions can be successful with the older adult population (Campbell, Robertson, Gardner, Norton, & Buchner, 1999; King, Haskell, Taylor, Kraemer, & Debusk, 1991; King, Haskell, Young, Oka, & Stefanic, 1995; McMurdo & Rennie, 1993; van der Bij, Laurant, & Wensing, 2002). One study found similar participation rates in both home- and group-based environments for short-term programs; however, adherence rates tended to decrease as the length of the study increased (King et al., 1995; van der Bij et al., 2002). The use of behavioral strategies including phone calls and various incentives may help improve long-term participation rates. More research should be conducted using a combination of group- and home-based environments to determine which programs work best for which population.

Disease Management

Disease management, in the context of this chapter, is using physical activity as a strategy to prevent disease and maintain favorable health status. Studies have found that mobile older adults who have few or no limitations view physical activity as a way to maintain their health (Cohen-Mansfield, Marx, & Guralnick, 2003; Rasinaho, Herninalo, Leinonen, Linutenen, & Rantinen, 2006). Older adults with higher self-efficacy and a motivation to improve their health are more likely to be physically active than those with lower self-efficacy and little motivation to improve their health (Lee & Lafferty, 2006). Increased self-efficacy may help older adults overcome barriers that prevent them from engaging in physical activity. Physical activity can help all adults, both the young and the old, avoid chronic diseases.

When planning physical activity interventions for older adults, planners should consider factors that will improve participation and adherence. This section highlighted just a few of the factors that typically result in success. Intervention specialists are encouraged to use these strategies to overcome barriers to physical activity in older adults.

Sample Successful Interventions

Home-Based Progressive Strength Training

Osteoarthritis is a common ailment that causes pain, reduces functional abilities, and limits physical activity for many older adults. Baker and colleagues (2001) investigated the effectiveness of home-based strength training for improving symptoms of knee osteoarthritis in a group of 46 adults over the age of 55. Participants were randomized into a nutritional education control group or home-based strength training group. The home-based strength group trained for 4 months. Intervention participants received in-home visits twice a week for 3 weeks, one in the 4th week and every other week thereafter. Compared to the control group, the home-based training group significantly improved in strength, pain reduction, physical function, and quality of life. These important gains highlight the need for home-based programs designed to reduce pain and other osteoarthritis symptoms and improve older adult physical function.

Walk; Address Pain, Fear, Fatigue During Exercise; Learn About Exercise; Cue by Self-Modeling (WALC)

WALC was designed to address some of the common barriers older adults have relative to physical activity (Resnick, 2002). Twenty sedentary participants were divided into treatment or control groups. The treatment group followed the four phases of the WALC program. They were asked to walk in groups or individually for 20 minutes three times per week for 6 months. The intervention group received regular visits from a practitioner who addressed unpleasant reactions associated with exercise (i.e., addressed pain, fear, fatigue during exercise). This part of the intervention included pain management techniques, relaxation methods, and scheduling of rest and exercise. Those in the treatment groups were given a book about exercise benefits and barriers and received assistance developing short- and long-term goals, planning exercise sessions, and logging their results (i.e., learned about exercise).

When compared to the controls, the treatment group demonstrated significant improvement in exercise behavior, physical activity levels, and self-efficacy expectations. Although the number of participants used in this study was small, the results indicate that physical activity levels can be increased with the sedentary older adult population by using techniques to improve self-efficacy, which can mediate common exercise barriers.

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