Despite all of the known health benefits of exercise, inactivity increases with ageing and only 30% of those aged 65+ report any regular exercise (Skelton et al, 1999; Heath et al, 2002; Department of Health, 2010; Department of Health, 2011). Even when older adults initiate exercise they will often discontinue their involvement within the first 6 months (Robison & Rogers, 1994; Jancey et al 2007). Encouraging older adults who have experienced a major health issue (Stroke, Coronary Heart Disease, and a fall) to maintain exercise after rehabilitation is equally as difficult. It is not only national research that shows maintenance of exercise to be difficult but also compliance to exercise on a local service level. Community based falls rehabilitation projects in Rotherham (North of England) have shown that patients followed up in the community six months after falls rehabilitation, deteriorate almost back to their pre-rehabilitation state (Hawley, 2009). Therefore what does the evidence tell us are the key factors relating to older adults uptake and adherence to exercise classes and what can we do about it in practice? Recent work carried out as part of a PhD study working with both exercise instructors, their classes and participants and a Systematic Review of the literature suggests the following factors as important:
Internal factors which relate to older adults preferences, outcomes and attitudes have been found to be the most import factors relating to older adults uptake (Hawley et al, 2012).
Older adults are more likely to take-up classes if they prefer classes over home based exercise. Although in one study (Mills et al, 1997) participants who originally preferred to exercise at home were recruited into class based exercise and did adhere! It has been found to be important that participants feel the class meets their needs.
Outcomes and Attitudes
If participants feel they would be competent at the activity and that they would be able to master the task they are more likely to take it up. Participants with positive expectations about the class, who wanted to attend for enjoyment and because they felt it would maintain or improve their health, were also more likely to take them up. Those who had previously participated in exercise already had an understanding of the benefits and are more likely to take up opportunities.
Internal factors around experienced benefits and positive attitudes are important to adherence, but so are external factors such as group support and the instructor.
Experience of beneficial outcomes
Health improvement and improvements in function are found to relate to adherence. These outcomes can be both physical and mental, including increased optimism and improved self-efficacy (belief they can carry out the task).
Social support has a key role to play in continuing to attend the class. This support can be from family, friends, the group or the instructor. In qualitative interviews instructors discussed the importance of creating something ‘bigger’ than just the class, and that participants also appreciated other events and social gatherings which occurred as a result of the exercise class. Instructors experience and personality (Conscientiousness) were also found to relate to attendance and adherence to the class when we followed classes for 6 months, this could relate to the atmosphere that instructors were able to create.
THE FIRST SIX MONTHS
Long-term adherence is often considered to be over 6 months, as this is the commonly used period required to ensure behaviour is adopted (Prochaska & DiClementi, 1983; Stiggelbout et al, 2006). In our recent research where we followed up participants for 6 months we found that whether the participants who had attended for less than 6 months when we started the study were more likely to drop out. This was also supported by the results of qualitative interviews with instructors where they said that if participants were going to drop out it was in the initial stages of their attendance, those who stayed tended to adhere for the long term. The individual participant’s perception of their social interaction with the group increased over the first three months and was associated with both increased attendance and adherence to the class. This suggests group cohesion is particularly important when encouraging long term attendance (Hawley et al, 2011, PhD Thesis).
Therefore, the reasons why older adults first participate in exercise classes are often for reasons related to their positive attitudes about what they can achieve and the experiences they expect. They will continue to attend if their expectations are fulfilled and also they feel that there is an important social element to the class. Interestingly, when discussing this issue with instructors it was felt that in fact the importance of the social element did not differ whether the class was a falls rehabilitation class, an Otago or Postural stability class (evidence based strength and balance) or a more general community exercise class! Regardless of the reason for the class, it is evident that the initial promotion of the outcomes that can be gained from the class and then the social environment that is created are important.