Journal of Physiotherapy 60 (2014) 151–156

Journal of
PHYSIOTHERAPY
journal homepage: www.elsevier.com/locate/jphys

Research

Adherence to exercise programs for older people is influenced by program

characteristics and personal factors: a systematic review
Alexandra Miranda Assumpção Picorelli a, Leani Souza Máximo Pereira a, Daniele Sirineu Pereira a,
Diogo Felı́cio a, Catherine Sherrington b
a
Physiotherapy Department, Federal University of Minas Gerais, Belo Horizonte, Brazil; b The George Institute for Global Health, The University of Sydney, Australia

K E Y W O R D S A B S T R A C T

Adherence Question: How has adherence been measured in recent prospective studies focusing on adherence to
Older people exercise programs among older people? What is the range of adherence rates? Which factors are
Physical activity associated with better adherence? Design: Systematic review of prospective studies that had a primary
Exercise
aim of assessing adherence to exercise programs. Participants: Older people undertaking exercise
Physiotherapy
programs. Intervention: Exercise programs. Outcome measures: Measures of adherence, adherence
rates and factors associated with adherence. Results: Nine eligible papers were identified. The most
common adherence measures were the proportion of participants completing exercise programs (ie, did
not cease participation, four studies, range 65 to 86%), proportion of available sessions attended (five
studies, range 58 to 77%) and average number of home exercise sessions completed per week (two
studies, range 1.5 to 3 times per week). Adherence rates were generally higher in supervised programs.
The person-level factors associated with better adherence included: demographic factors (higher
socioeconomic status, living alone); health status (fewer health conditions, better self-rated health,
taking fewer medications); physical factors (better physical abilities); and psychological factors (better
cognitive ability, fewer depressive symptoms). Conclusion: Older people’s adherence to exercise
programs is most commonly measured with dropout and attendance rates and is associated with a range
of program and personal factors. [Picorelli AMA, Pereira LSM, 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. Journal of Physiotherapy 60: 151–156]
ß 2014 Published by Elsevier B.V. on behalf of Australian Physiotherapy Association. This is an open
access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).

Introduction The aims of this study were to systematically review prospec-

tive studies of older people’s adherence to exercise programs, in
Physical activity has a range of physical and psychological order to answer the following research questions:
health benefits for people of all ages.1 Structured exercise
programs are a type of physical activity and have been found to 1. In prospective studies focusing on adherence to exercise
be beneficial in older people. Carefully designed, structured programs among older people, how was adherence measured?
exercise programs can prevent falls,2 increase muscle strength3 2. What adherence rates were found in these studies?
and enhance balance in older people.4 3. Which factors were associated with better adherence in these
The benefits of exercise depend on continued participation; studies?
however, a change in lifestyle to include regular exercise is difficult
for many people of all ages. Older adults have more co-morbidity,
less social support, and more disability and depression than the Method
general population; these factors have all been associated with
lower exercise adherence in people with particular health Identification and selection of studies
conditions.5,6 Studies of exercise interventions in older people
have demonstrated declining levels of adherence over time.7 An electronic search using the strategies outlined in Appendix 1
In order to develop effective strategies for increasing participa- (see eAddenda) was conducted for five databases: Medical
tion in structured exercise programs by older adults it is important Literature Analysis and Retrieval System Online (MEDLINE),
to understand the individual, social, community and demographic Excerpta Medica Database (EMBASE), Scientific Electronic Library
factors associated with adherence to this health-promoting (SciELO), Latin American Literature in Health Sciences (LILACS) and
behaviour.6,8 Studies have measured adherence to exercise pro- Physiotherapy Evidence Database (PEDro).
grams in a range of ways, which makes comparison between studies The inclusion criteria for studies are presented in Box 1. Eligible
difficult. Previous reviews have not systematically documented studies involved male and/or female participants with a mean age
measurement methods and factors associated with adherence. of over 65, were prospective in design and evaluated factors

http://dx.doi.org/10.1016/j.jphys.2014.06.012
1836-9553/ß 2014 Published by Elsevier B.V. on behalf of Australian Physiotherapy Association. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/3.0/).
152 [(Figure_1)TD$IG]
Picorelli et al: Exercise program adherence among older people

Titles and abstracts screened

Box 1. Inclusion criteria. (n = 1231)

Design Papers excluded after screening

 Randomised trials titles/abstracts and removal of
duplicates (n = 1209)
 Cohort studies
Participants
Papers retrieved for evaluation of full
 Adults text (n = 22)
 Average age > 65 yr
Intervention Papers excluded after evaluation of
 Exercise programs full text (n = 13)
Outcome measures • ineligible participants (n = 10)
 Participant adherence to the exercise program • not enough information (n = 1)
 Associations between program characteristics and • specific disease (n = 1)
adherence • cross-sectional design (n = 1)

Papers included in review (n = 9)

associated with adherence as a primary aim. Studies were

excluded in which all participants had specific diseases or the Figure 1. Flow of studies through the review.
sample did not consist only of older people. Studies published
more than 10 years ago were also excluded, because the context proportion of participants completing exercise programs (ie, did not
was judged to be outdated. cease participation, four studies, range 65 to 86%), proportion of
available sessions attended (five studies, range 58 to 77%) and
Assessment of study characteristics average number of home exercise sessions completed per week (two
studies, range 1.5 to 3 times per week). Other measures were: class
For each included study, descriptive data regarding partici- attendance expressed as a proportion of participants reaching
pants, interventions, measures of adherence, rate of adherence and certain cut offs (two studies); total number of classes attended (one
factors associated with adherence were extracted, along with study); number of weeks in which home exercise was undertaken
statistics indicating the strength of association. (one study); proportion of days on which home exercise was
undertaken (one study); number of minutes walked (one study);
Data analysis proportion of participants meeting physical activity guidelines (one
study); and proportion of participants exercising regularly (one
For each included study, two reviewers independently study). There was some inconsistency in the denominator used to
extracted the relevant data. If different data were extracted by calculate proportions, with some studies using the total participant
the two reviewers, data were rechecked by both reviewers. If number and some using the number of program completers, which
disagreement continued, a third author arbitrated. The character- gave a higher number. As adherence was measured in so many
istics of the studies were summarised with descriptive statistics. different ways, it was not possible to compare adherence rates
The range of approaches for measuring adherence was noted and across the studies included in this review.
the number of studies measuring adherence with each approach
was tallied. Comparable measures of adherence were summarised
as ranges. The factors associated with adherence in each study Factors associated with adherence
were tabulated, including the strength of the association.
The factors that were significantly associated with adherence in
Results each study and the strength of the associations are presented in
Table 1. Generally, adherence rates were higher in the supervised
phases of exercise programs but there were no clear patterns of
Flow of studies through the review
greater adherence for different types of group exercise.
The person-level factors associated with better adherence can
The MEDLINE and EMBASE database searches via Ovid
be classified as demographic, health-related, physical and psycho-
identified 838 articles, of which 17 papers were retrieved in full
logical. Better program retention was evident in people with higher
text. The SciELO search did not identify any studies. The LILACS
socioeconomic status and better education. Living alone was
search identified six studies, but none met the eligibility criteria.
associated with better program attendance. In general, program
The PEDro search identified 13 articles, of which five were eligible.
attendance was better in people with better health (measured by
Therefore, a total of nine publications met the inclusion criteria.
fewer health conditions, better self-rated health, taking fewer
Reasons for exclusion are presented in Figure 1.
medications) and lower body mass index. One study found better
adherence in people with a pacemaker, which may reflect a greater
Characteristics of studies
motivation to exercise after the diagnosis of a heart condition.9
Better physical function, as measured by gait speed or endurance
The information contained in the included studies was
(6-minute walk test), was associated with better adherence.
summarised independently by the authors of this review. The
Psychological factors were associated with poorer adherence in a
characteristics of the included studies are summarised in Table 1.
number of the included studies. These factors included depression,
Sample sizes ranged from 52 to 293. In all studies, the participants
loneliness, lower scores on the Mini-Mental Status Examination,
were judged to be representative of those undertaking exercise
psychoactive medication use and a higher perceived risk of falling.
programs and the assessment methods used were judged to be
valid and appropriate for the older population.
Discussion
Measurement of adherence
This systematic review found that recent studies focusing on
The method of measuring adherence in each of the nine exercise program adherence in older adults have used a variety of
included studies and the adherence rates reported in each study methods to measure adherence. There is no agreed method of
are presented in Table 1. Most studies used more than one method assessing adherence to exercise among older people, so various
for measuring adherence. The most common measures were the approaches are used, making the comparison of adherence rates
 Research 153

Table 1
Characteristics and findings of the studies included in the review (n = 9).

Trial Participants Intervention Adherence Factors associated with adherence

Dorgo14 Community volunteers aged Exercise sessions targeted Group 1:  Retention rate was higher in the
>60 (yr) participating in one cardiovascular fitness, strength,  90% 14-wk retention rate peer mentor group
of two intervention groups in muscle mass, power, agility and  25 (SD 5) of 35 sessions  Participation rates were
a randomised trial flexibility. attended by completers (72%) significantly higher in the
n = 60 75-min group sessions, 3/wk x Group 2: student mentor group (p = 0.008)
14 wk  77% 14-wk retention rate
Group 1: peer mentors  29 (SD 4) of 35 sessions
Group 2: student mentors attended by completers (82%)

Findorff7 Sedentary women Home exercise program with At 12 wk (self-reported): Walking:

participating as the nurse home visits (6) and  Mean 95 min (SD 69) walked/  Clinical variables accounted for
intervention group in a telephone counselling (6) with a wk 17% and cognitive variables for
randomised trial goal of walking, 30 min x 5/wk  17% walked > 150 min 12% of the variance in walking
n = 137 and 12 reps of 11 balance  Mean 1.5 sessions (SD 1.6) of adherence (frequency)
exercises, 2/wk, for 12 wk. Then balance exercises/wk  A multivariate analysis explained
16 wk tapered computerised At 2 yr (self-reported among 19% of the variance in walking
telephone follow up. 127 completers): adherence, with significant
 66% walked 20 min x 3/wk or predictors: absence of probable
more depression (p = 0.05); fewer
 40% did balance exercises 2/wk chronic conditions (p = 0.019); use
or more of behavioural process of change
 29% did neither regularly (p = 0.027)
 71% did one or both regularly Balance:
 Health-related quality of life
variables accounted for 14% and
cognitive variables for 12% of the
variance in completing balance
exercises >1/wk
 A multivariate model explained
24% of the variance in adherence to
the balance program, with
significant predictors: MMSE < 27
(OR 0.08, 95% CI 0.01 to 0.73), self-
efficacy (OR 1.04, 95% CI 1.002 to
1.08), self-rated health (OR 0.03,
95% CI 0.002 to 0.50)

Flegal13 ‘Generally healthy’ seniors Group 1: yoga, 90-min class/wk Group 1:  The adherence differences
participating in one of two and home practice daily  86% completed study between the yoga and the exercise
intervention groups in a Group 2: outdoor aerobic Among Group 1 completers: group did not reach statistical
randomised trial walking class, 60 min/wk and at  77% classes attended significance (for percent
n = 91 home 5/wk  home exercise on 64% of days attendance (p = 0.056) and for
Group 2: percent days practiced out of all
 81% completed study days possible, t = –1.822, p = 0.073)
Among Group 2 completers:  Home practice sessions lasted an
 69% classes attended average of 38 min for the yoga
 home exercise on 64% of days group and 56 min for the exercise
(76% of the prescribed 5 d/wk) group (t = 3.8, p = 0.0003)
 Class attendance was significantly
(p < 0.05) correlated with baseline
measures of depression, fatigue
and physical components of
health-related quality of life

Jancey12 Insufficiently active adults Walking, strength and flexibility  65% completed the program  A multivariate model found that
aged 65 to 74 yr recruited from exercise sessions conducted in 30  77% of those who didn’t non-completion was significantly
the Australian federal local neighbourhoods using social- complete the program ceased associated with lower
electoral roll cognitive theory incorporating participation in the first 3 mth socioeconomic status (OR 0.4,
participating as the self-efficacy factors. 95% CI 0.19 to 0.83), overweight
intervention group in a 2 sessions/wk x 6 mth (OR 2.29, 95% CI 1.01 to 5.19),
randomised trial insufficient physical activity at
n = 248 baseline (OR 2.40, 95% CI 1.30 to
4.43), lower walking self-efficacy
scores (OR 0.77, 95% CI 0.66 to
0.89) and higher loneliness scores
(OR 1.03, 95% CI 1.01 to 1.07)

McAuley18 Sedentary adults aged 60 to Group 1: Walking group 88% completed the programs  Attendance rates did not differ
75 yr participating in one of Group 2: Stretching and toning Group 1: significantly between treatment
two intervention groups in a program  56 d (SD 15) average groups (p = 0.30)
randomised trial 3 sessions/wk x 6 mth attendance  18 mth follow up physical
n = 174 Group 2: activity score did not differ
 58 d (SD 13) average significantly between groups
attendance  Structural equation modelling
indicated significant paths from
social support, affect and exercise
frequency to efficacy at 6 mth.
Efficacy, in turn, was related to
physical activity at 6-mth and 18-
mth follow-up. The model
accounted for 40% of the variance
in 18-mth activity levels
154 Picorelli et al: Exercise program adherence among older people

Table 1 (Continued )

Trial Participants Intervention Adherence Factors associated with adherence

Rejeski9 People aged 70–89 yr who Walking aiming for 150 min/wk,  71% of sessions attended in mth  Month 1 to 2: a multivariate
were at elevated risk of and ‘limited’ training for balance 1 to 2 model explained 10% of
disability participating as the and strength.  61% of sessions attended in mth variability in adherence with
intervention group in a Mth 1 to 2: group exercise, 40- 3 to 6 significant predictors: lung
randomised trial 60 min sessions, 3/wk, plus  Average of 3.7 sessions/wk in disease (est –10.9, SE 4.5,
n = 213 weekly group behaviour mth 7 to 12 p = 0.017) and low barriers to
counselling sessions, monthly efficacy score (est 2.1, SE 0.8,
telephone contact and home p = 0.010)
exercise sessions.  Month 3 to 6: a multivariate
Mth 3 to 6: group exercise, 2/wk, model explained 10% of
behaviour counselling sessions, variability in adherence, with
monthly phone call. significant predictors:
Mth 7 to 12: optional centre- pacemaker (est 23.75, SE 11.91,
based sessions, 1/wk, monthly p = 0.047), slower 400 m walk
phone contact. times (est –2.30, SE 1.00,
p = 0.020), less than high school
education (est –9.4, SE 4.2,
p = 0.027). 21% of variability
explained when prior
attendance added
 Month 7 to 12: a multivariate
model explained 13% of
variability in adherence, with
significant predictors:
pacemaker (est 1.8, SE 0.8,
p = 0.029) and tiredness (est 0.3,
SE 0.1, p = 0.014), 48% of
variability was explained when
prior attendance added

Sjosten15 Community-dwelling people Group and home exercise,  Average of 58% (SD 30) of group  Univariate analyses: lower age,
aged >65 yr who had fallen in psychosocial group activities and exercise sessions attended low self-perceived risk of falling
the past yr participating as lectures.  47% of participants were highly at home and better functional
the intervention group in a Exercise targeted balance, adherent (> 66% adherence ability were strongest predictors
randomised trial strength and respiratory rates) with group sessions of exercise group adherence.
n = 293 function.  Mean 3 (SD 2.1) home exercise Using less than four prescription
45-min sessions, 2/mth, plus sessions completed/wk medicines was significantly
home exercise, 3/wk. associated with home-exercise
adherence
 Multivariate analysis: Low self-
perceived probability of falling at
home (OR 1.6, 95% CI 1.0 to 2.6)
and good physical functional
abilities (OR 2.7, 95% CI 1.5 to
4.8) were significant predictors
of exercise group adherence

Stineman10 Older people who had fallen Exercise targeted fitness,  87% attended 4+ of 7 classes  On-site exercise adherence was
and visited an emergency balance, strength and flexibility.  73% attended all 7 classes better than home
department participating as Mth 1: on-site group classes,  78% exercised at home for 7 of  Univariate predictors of full
the intervention group in a 1/wk. the 12 wk (via diary) adherence to on-site exercise:
randomised trial Mth 2–4: exercises at home,  1% exercised 3 times/wk at advanced age, non-African
n = 102 3 session/wk, plus 1 on-site home for all twelve weeks (via Americans, males, high school or
class/mth, plus 1 home visit from diary) higher education, living alone,
a trained community worker/ SF-36 score, lower BMI, fewer
mth. comorbidities, fewer
medications, physical function,
physical role function, perceived
general health, 6 MWD, less
depression, fewer psychometric
medications and MMSE scores
 Multivariate analysis: Living
alone associated with full
adherence to on-site exercise
(adjusted OR = 3.0, 95% CI 1.1 to
8.1). Depressed mood was
associated with decreased
adherence to on-site exercise
(adjusted OR = 0.85, 95% CI 0.72
to 1.0)
 Analysis of factors associated
with adherence to home
program not undertaken due to
low adherence rates

Sullivan-Marx17 African American women Warm-up, walking intervals,  71% completed program  Completers had lower scores on
needing assistance in ADL lower extremity exercises, cool Among completers: the depression scale than non-
participating in an down and deep breathing.  48% attended 3+ x/week completers (p = 0.004)
observational study 30 to 50-min group sessions,  71% attended 2+ x/week
n = 52 3/wk x 16 wk.

ADL = activities of daily living, est = estimate, MMSE = Mini Mental Status Exam, SF-36 = short form 36, 6 MWD = six-minute walk distance.
 Research 155

between studies difficult. This hampers progress toward under- contexts, to raise commitment to exercise among the largely
standing exercise adherence in older people, as well as how to sedentary population of older people with their multiple illnesses
enhance it. Adherence to centre-based exercise programs is and functional deficits.10,17
relatively easy to document but adherence to home-based exercise A limitation of this review is that the results of the individual
currently relies on self-report, which may overestimate or observational studies may have been confounded by the presence
underestimate actual exercise frequency and duration. In the of other variables that were associated with both participant
future, technology may enable more accurate measurement of characteristics and exercise adherence rates. Social and psycho-
adherence in home-based physical activity studies. logical variables, such as motivation and social support, were not
Given the variability in measurement of adherence it was not measured in all studies and may explain larger amounts of
possible to meaningfully compare adherence rates across studies. variance in exercise adherence than the measured variables.
However, it was noted that retention and adherence rates in most Furthermore, the pragmatic decision to limit this review to the last
of the included studies were suboptimal. ten years of research may have impacted on the results.
The apparently higher rate of adherence to centre-based Understanding the variables that influence adherence to
programs provides challenges for the widespread implementation exercise among older people is very important for clinical
of exercise programs. Some programs combine group and home- physiotherapists because low rates of adherence are likely to
based aspects. This may be a feasible and cost-effective solution. limit the benefits obtained from exercise. Exercise adherence in
Given the limitations of this review, this issue requires further older people is multifactorial, involving demographic, health-
investigation. related, physical and psychological factors. The range of predictors
A number of person-level factors were found to be associated of exercise adherence underscores the need for health profes-
with greater adherence rates. Interestingly, reduced mental sionals to consider these findings in designing strategies to
wellbeing appeared to present a greater barrier to exercise enhance exercise adherence in this vulnerable population.
adherence than reduced physical wellbeing.10 People at risk of
depression were less likely to adhere to prescribed programs.
What is already known on this topic: Physical activity has a
Physical activity is potentially beneficial for fatigue and depres-
range of benefits for older people. In particular, structured
sion, so future intervention could specifically target adherence in exercise programs can prevent falls and increase strength.
this group of people. The concept of loneliness also requires more However, older people’s adherence to exercise interventions
investigation. This group of people might require more encour- declines over time.
agement, affirmation and feedback.11,12 What this study adds: In studies of exercise interventions for
Adherence is promoted by the belief that an intervention will be older people, few studies measure adherence the same way.
effective (the outcome expectancy), as well as the belief that the Few studies report very high adherence, but adherence is
individual is capable of following the requirements of the generally higher in supervised programs. Factors associated
intervention (the efficacy expectancy).13 It has been postulated with greater adherence include: higher socioeconomic status,
living alone, better health status, better physical ability, better
that people with greater adherence may engage in other health-
cognitive ability and fewer depressive symptoms.
promoting behaviours. Thus, adherence may be a marker for a
personality type, or related to motivation or goal-directed
behaviours. Self-efficacy, which may relate to motivation, is the
eAddenda: Appendix 1 can be found online at doi:10.1016/
perceived confidence in one’s ability to accomplish a specific
j.jphys.2014.06.012
task.13 Self-efficacy has been shown to affect exercise adoption and
Ethics approval: Not applicable.
maintenance.11 Therefore, intervention programs should develop
Competing interests: Nil.
and nurture this characteristic to enable individuals to continue
Source(s) of support: Nil.
with the program.
Acknowledgements: Nil.
Several of the studies included in this review used a range of
Correspondence: Catherine Sherrington, The George Institute
strategies in an effort to enhance adherence. Strategies to promote
for Global Health, The University of Sydney, Australia. Email:
adherence included: making instructions to subjects simpler and
csherrington@georgeinstitute.org.au
less demanding; addressing cognitive-motivational factors such as
self-efficacy and health beliefs; offering social support and
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