Processes Associated with Participation and Adherence to a 12-Month Exercise Programme for Adults Aged 70 and Older

Abstract

This study investigated the processes associated with the engagement of adults aged 70 years and older in a 12-month long research-based structured exercise programme. A sample of 21 participants (Mean age (SD) 75.8 (3.9); 14 females) and six exercise class leaders or researchers involved in the programme participated in individual semi-structured interviews. Transcripts were analysed with the principles of interpretive qualitative analysis. Our findings suggest that a programme that runs locally, provides individual attention/tailoring, delivers meaningful benefits, offers a staged approach to efficacy building, creates a sense of ownership, and provides intergenerational support and opportunities for social interaction, facilitates exercise engagement in later life.

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Journal of Health Psychology
http://hpq.sagepub.com/content/15/6/838
The online version of this article can be found at:
DOI: 10.1177/1359105309357090
2010 15: 838 originally published online 7 May 2010J Health PsycholA. Stathi, J. Mckenna and K.R. Fox
Programme for Adults Aged 70 and older
Processes Associated with Participation and Adherence to a 12-month Exercise
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838
Processes Associated
with Participation
and Adherence to a
12-month Exercise
Programme for
Adults Aged 70
and older
A. STATHI
University of Bath, UK
J. MCKENNA
Leeds Metropolitan University, UK
K. R. FOX
Bristol University, UK
Abstract
This study investigated the processes
associated with the engagement of
adults aged 70 years and older in a
12-month long research-based
structured exercise programme. A
sample of 21 participants (Mean age
(SD) 75.8 (3.9); 14 females) and six
exercise class leaders or researchers
involved in the programme
participated in individual semi-
structured interviews. Transcripts
were analysed with the principles of
interpretive qualitative analysis. Our
findings suggest that a programme
that runs locally, provides individual
attention/tailoring, delivers
meaningful benefits, offers a staged
approach to efficacy building, creates
a sense of ownership, and provides
intergenerational support and
opportunities for social interaction,
facilitates exercise engagement in
later life.
Journal of Health Psychology
Copyright © 2010 SAGE Publications
Los Angeles, London, New Delhi,
Singapore and Washington DC
www.sagepublications.com
Vol 15(6) 838–847
DOI: 10.1177/1359105309357090
ACKNOWLEDGEMENTS. The study was part of the Better Ageing Project
funded by the Framework V initiative of the European Commission. Thanks
also go to Marco Narici and Jeannette Thom, Manchester University, and
Mark Perry, King’s College, London for their help in organizing and
completing this qualitative study.
COMPETING INTERESTS: None declared.
ADDRESS. Correspondence should be directed to:
AFRODITI STATHI, School for Health, University of Bath, Bath,
BA2 7AY, UK. [Tel. +44(0)1225 383027; fax +44 (0)1225 383833;
email: A.Stathi@bath.ac.uk]
Keywords
■activity
■commitment
■empowerment
■environment
■maintenance
■qualitative
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Introduction
A WEALTH of evidence has established the multiple
physical and mental health benefits of physical activ-
ity (PA) for men and women over the age of 65. This
is the least physically active age group (Chodzko-
Zajko et al., 2009) and in the UK, 52 per cent of men
and 61 per cent of women in the 65–74 age group are
inactive. Among people aged 75 and above only 7
per cent of men and 4 per cent of women reach cur-
rent PA recommendations (Department of Health,
2004). Engaging older people in physical activity and
helping them to maintain an active lifestyle is there-
fore a significant public health issue.
A common form of physical activity provision for
older people is the community or leisure centre-
based group exercise programme. Adherence to
group-based programmes can be as high as 84 per
cent (van der Bij, Laurant, & Wensing, 2002).
However, there is little evidence to indicate that such
rates are achieved in long-term programmes (≥ 1
year) even though this is necessary for sustained
health benefit. Nigg, Borrelli, Maddock and
Dishman (2008) stressed that the factors predicting
physical activity adoption may be different to those
required for longer-term physical activity adherence.
Physical activity and health researchers have
conceptualized the influences on PA participation as
intrapersonal, interpersonal and environmental
(King, 2001; Sallis & Owen, 1999). Intrapersonal
factors include self-efficacy, perceived competence,
enjoyment of physical activity and perceived con-
trol (Brawley, Rejeski, & King, 2003; McAuley et al.,
2007). Positive perceptions about exercise benefits
and positive feelings about exercise itself are also
important motivators for, and consistent predictors
of exercise adherence (Cohen-Mansfield, Marx, &
Guralnik, 2003; Resnick, Palmer, Jenkins,&
Spellbring, 2000).
Interpersonal factors refer to transactions and
engagement with other people. Different types of
social support may offer distinct effects at different
stages of PA involvement. Thus, informational and
instrumental support might be more important dur-
ing the adoption phase, but once adherence has been
achieved, emotional support may play a more sig-
nificant role (Booth, Owen, Bauman, Clavisi,&
Leslie, 2000; Culos-Reed, Rejeski, McAuley,
Ockene, & Roter, 2000). Social opportunities and
group dynamic factors associated with a supervised
group exercise programme such as attachment, social
integration and group fun have been associated with
exercise adherence (Cohen-Mansfield et al., 2003;
Estabrooks & Carron, 1999; McAuley et al., 2000;
McAuley, Jerome, Elavsky, Marquez, & Ramsey,
2003). The leadership style and quality of exercise
instructors might also influence sustained atten-
dance (Cohen-Mansfield, Marx, Biddison,&
Guralnik, 2004; Stathi, McKenna, & Fox, 2004).
Comparatively less attention has been paid to
environmental determinants of PA participation
(King, 2001). Physical activity takes place in many
different settings. For example, it can take the form
of direct provision such as in facility-based activity
or occur incidentally in the local neighbourhood
where it can be accumulated as part of daily living.
Targeting intrapersonal and interpersonal variables
only has not produced the effect needed to make
long-term lifestyle changes (Stathi, 2009). Recent
reviews (Li et al., 2005; Sugiyama & Thompson,
2007) show a synergistic effect of intrapersonal and
interpersonal factors with the physical and socio-
ecological environment such as the characteristics of
the residential neighbourhood (e.g. access to facili-
ties, level of walkability). They stress the need for
multi-level ecological approaches that will enable us
to understand the determinants and the constraints for
the adoption and maintenance of an active lifestyle.
This study investigated the processes associated
with the engagement of older adults aged 70 years
and older in a 12-month research-based structured
exercise programme and continued physical activity
following its termination. In addition to the
accounts of exercise participants, views about fac-
tors leading to programme adherence were sought
from the exercise class leaders and researchers
involved with the programme.
Methods
This interview study was conducted within the con-
text of Better Ageing, a three year European
Commission funded project, that is described in
more detail elsewhere (Davis & Fox, 2007; Fox,
Stathi, McKenna, & Davis, 2007). The Multi-centre
Research Ethics Committee and local ethics com-
mittees approved the study in the UK.
The exercise programme
Participants attended a 12-month exercise programme
developed and widely used as part of a falls preven-
tion project (Skelton & Dinan, 1999). This included:
(a) two instructor-led group exercise sessions/week
lasting 60–80 mins (15–20 mins warm up, 15–20
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JOURNAL OF HEALTH PSYCHOLOGY 15(6)
840
mins aerobic exercise, 20–25 mins strength exercise
with resistance therapy bands and weight training in
multigym, and 10–15 mins flexibility and balance
exercise in the form of adapted Tai-Chi); (b) one
home-based exercise session/week lasting 40–60
mins (exercise with resistance therapy bands and a
20–40-minute brisk walk); (c) diary monitoring of all
exercise; and (d) home-based exercise, which substi-
tuted for group sessions during holidays. The inter-
vention did not include a systematic health behaviour
change approach (e.g. Intervention Mapping
Approach; Bartholomew, Parcel, Kok, & Gottlieb,
2006). Behaviour change strategies were embedded
in the structure of the intervention and included sup-
port for both the centre-based and the home-based
programme and goal setting through incremental
increases in resistance exercise load.
Participants
Participants were volunteers from the UK research
sites delivering the Better Ageing exercise pro-
gramme (Manchester Metropolitan University
[MMU], and King’s College, London [KC].
Exercise classes at the MMU site were delivered
using campus facilities, whereas KC classes were
located in health and fitness clubs in London sub-
urbs.At each site, the exercise professionals provided
a list of participants who had completed the 12-
month intervention and had agreed to be approached
for an interview. The first author invited all partici-
pants on that list to contribute to the evaluation of the
exercise programme. Individual semi-structured
interviews with 21 participants (14 females; mean
age (SD) 75.8 (3.9) years) were undertaken either
immediately at the end of the intervention (MMU)
(n= 14) or at eight months after completing the inter-
vention (KC) (n= 7). Six individual semi-structured
interviews were also conducted with exercise class
leaders who were experienced with older adult
groups (n= 4) and researchers involved in the design
and delivery of the intervention (n= 2) from both
centres, giving a total of 27 interviews.
Data collection
Interviews were conducted at the exercise centre for
MMU participants and in KC participants’homes. A
semi-structured interview format was chosen to
explore how experiences during and at different
time-points following the 12-month intervention,
might have facilitated exercise adherence.
Participants were invited to talk about: (a) reasons
for involvement in the programme; (b) positive and
negative experiences of the programme; (c) the level
and types of support received; (d) reasons for com-
mitment to the programme; and (e) current and/or
future exercise plans. Facilitators of adherence were
explored with questions relating to intrapersonal,
interpersonal and environmental factors (Patton,
2002). The interviews lasted between 30–50 minutes
and were delivered flexibly with all topics covered
but the order varied. With permission, interviews
were audio taped, transcribed, anonymized, checked
for accuracy and imported into QSR NVivo qualita-
tive software (QSR International, 2002).
Data analysis
The principles of interpretive qualitative analysis
(Miles & Huberman, 1994) were adopted. First, the
authors read the transcripts several times. Second,
a free textual analysis was performed in which
comments and preliminary interpretations were
prepared. Third, the first author developed the-
matic coding frames (Patton, 2002) separately
for programme participants and for programme
researchers and class leaders. These were then con-
firmed by the second and third authors. Fourth,
they compared and contrasted the thematic coding
with: (a) the main influences on adherence (intrap-
ersonal, interpersonal and environmental); and (b)
the time-point at which interviews were conducted
(i.e. zero or eight months post-intervention).
Themes emerging from the first cases oriented
the subsequent analysis of further cases taking into
account data convergence and divergence. The list
of themes was checked for consistency and inter-
pretation. A range of further strategies were also
adopted to ensure the validity of the findings.
Member checking via programme participants’
feedback was used to determine the accuracy of the
interpretation. We also asked programme researchers
and class leaders to comment on the relevance of
the thematic coding frames. Three independent
researchers coded selected transcripts and verified
the appropriateness of our themes and classifications.
Data triangulation was achieved by comparing
the accounts provided by participants, programme
researchers and class leaders with the recorded
attendance to the facility-based sessions and the
self-reported compliance to home-based sessions.
Results
Quantitative findings from the Better Ageing study
(Fox et al., 2007) showed that participants’ attendance
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to the 12-month facility-based sessions was 93 per
cent, while their self-reported compliance to home-
based sessions was 85 per cent. The findings of the
qualitative study suggest that these impressive fig-
ures were the result of a wide range of facilitators
of programme adherence, which we present in
three categories relating to chronological stages of
involvement within the exercise intervention: start-
ing up;developing adherence;physical activity
maintenance after programme completion. Sub-
sections present the identified intrapersonal,
interpersonal and environmental elements within
each category. Participants at both sites reported
similar experiences; however any differences are
described and discussed where appropriate.
Pseudonyms are used to ensure participants’ con-
fidentiality.
Starting up
Intrapersonal: previous experiences Some par-
ticipants had no intention of starting exercising until
finding out about the local availability of a suitable
programme. Others had realized that declining
physical capacity was beginning to impact nega-
tively on ordinary, every-day activities. Some par-
ticipants identified the need for more discipline and
structure in their day-to-day life and decided that
participation in the programme would help them to
resist the effects of their increasingly sedentary
lifestyle:
Well I think, as you get older it is very easy to
just sit back and do nothing and well it’s just the
right thing to do, isn’t it? (Mary, 71)
Because unless I do something disciplined like
that I shall be too lazy to do anything on my
own. (Jim, 73)
People with a history of exercise relapses referred
to their past unsuccessful attempts and they expressed
their intention to become regular exercisers again: ‘I
needed an incentive. I joined a gym at the leisure cen-
tre across the road but I kept making excuses not to
go. But with the programme here, you have to go. I
don’t want to slip back again’ (Helen, 73).
Some participants were motivated to try to
increase their physical activity after their success in
losing weight: ‘I started losing weight and I felt bet-
ter about myself. That’s why I decided to join this
exercise programme as well’ (Susan, 74).
Intrapersonal: outcome expectations Partici-
pants with previous exercise experiences anticipated
improvements in fitness, mobility and functional
ability, and delay of physical deterioration.
However, among people with no previous involve-
ment in organized exercise programmes, only a few
reported any expectation as this was a novel experi-
ence. For them, the major motivator was the curios-
ity about the new incentive in their local
community. Especially for the KC participants,
expectations were influenced by their beliefs about
the sporty image usually linked to fitness club
members:
I thought, I’ll take a step in advance and join the
programme before I begin to fall. (Karl, 87)
I do not think I expected anything, because I did
not believe that gym could be any good for any-
one—all these people jumping around and lift-
ing heavy weights. (Margaret, 70)
Interpersonal: staged approach to confidence
building The appropriately paced programme
was particularly important in the early stages when
exercise was accompanied with some discomfort
and delayed onset muscle soreness. By understand-
ing the programme approach and rationale, partici-
pants’ confidence increased even when they
experienced muscle soreness. This combination of
understanding and success ensured that discomfort—
a known barrier to continued physical activity—
was overcome:
They were very careful not to overstretch us,
certainly at the beginning. Everything was on
the basis of ‘don’t do more than you feel you can
do’. Then gradually, they increased the pressure
on us to do more and feel that we should go on
until we felt that’s enough. So gradually, we
were building up the strength to lift, to pull, and
to push more. (Karl, 87)
Interpersonal: individual tailoring Through
one-to-one support, exercise class leaders pro-
vided reassurance and helped participants to
build self-efficacy and physical competence to
cope with the exercise loading. They demon-
strated public and private vigilance and exercise
pragmatism:
I watch each individual as we are doing the
aerobics—see how they’re coping with it …
you see the exertion in the face … I’ll
announce to everybody, ‘If you are finding this
one hard, this is what you can do’. (A, exercise
class leader)
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Developing adherence
Int rapersonal: meeting outcome expecta-
tions Matching expectations with outcomes
facilitated programme adherence. A key motivator
was the inclusion of functional exercises.
Participants—even those who did not specifically
expect changes in their fitness levels and functional
ability—soon noticed fitness improvements that
were in some cases substantial in areas such as
strength, flexibility and general mobility: ‘I get out
of bed easier. Hoovering is so easy, you just walk up
and down much better. Because those were the
movements that came into the exercise, the walking
and the pushing’ (Helen, 73).
The notion of better body control was linked with
increased empowerment. As Susan suggests below,
the inevitable powerlessness associated with the
ageing process had been reversed for her, contribut-
ing to important changes in her life-world: ‘I just
feel I’m in charge of my body. Perhaps before, my
body was in charge of me’ (Susan, 74).
Strength training provided direct and speedy
feedback; a strong motive for participants who
could see improvement in a short time period.
Helen (73), when comparing multi-gym sessions
to exercise to music sessions, mentions: ‘But the
machines are better. Well, they seem to need
more effort and I think they increase your
strength.’ Staff also noticed how participants
‘really enjoy using the exercise machines’ and
how this ‘was quite new to them’ (O, male exercise
class leader).
Interpersonal: trusting relationship with
exercise professionals The measured
progress experienced during the first weeks of
the programme and the individual tailoring
built a trusting relationship between partici-
pants and exercise class leaders who soon
relaxed from their controlling and prescriptive
style to a more informal attitude and eased their
vigilance. This emerged through better under-
standing of participants’ needs, meeting their
expectations during the classes and by con-
tributing to the participants’ impressive physi-
cal and social potential:
You are quite careful to be polite around them,
do things properly, very strict in the way you
do things; you make sure you deliver every-
thing very correctly and then you just get
more relaxed around them. (O, male exercise
class leader)
At first we had a few sort of frail women who I
think they felt that they would not be able to get
on the machines and then, after a while, they
were just talking as though that was normal.
(J, female exercise researcher)
Participants valued the knowledge, patience,
enthusiasm and team work of the exercise class
leaders: ‘We have had good people teaching. They
had a super team, there is not one of them who have
not been nice to us and they are great’ (Mary, 71).
With a sensitive and measured approach, partici-
pants learned through seeing and then doing, grow-
ing into increased exercise knowledge, competence
and self-efficacy:
I am really quite amazed at what I have learnt,
and how good it has been for me. At my age, I
have never been to the gym in my life. I
expected that after the first session I would be
knackered. But the way the trainer slowly
worked you in—he used to show you how to do
things, so you were watching him for a while.
Towards the end, of course, we all knew it all
well, and we would do our thing. (Karl, 87)
Interpersonal: intergenerational rapport
Although the leaders were young, participants said
that they never felt inferior and highlighted the
expression of inter-generational respect. This was
also confirmed by the researchers:
One person said to me the other day that he used
to think that young people sort of looked down
on them. But after working with our group, he
had more faith in the younger generation. We
have actually come across to them as being a
good experience, so probably that is the most
rewarding thing. (J, female exercise researcher)
Interpersonal: social support and
connectedness With only one exception—‘My
wife says I have gone mad, she says “you should
not be doing this at your age”’ (Colin, 73)—all par-
ticipants stressed that their families and significant
others were very supportive: ‘My two sons were
amazed that their retired father still had the energy
to have a go at something and my wife was
delighted as she felt that I was not getting enough
exercise anyway’ (Martin, 75).
Group-based exercise and social network build-
ing were important elements of enjoyment and rea-
sons to adhere to the programme. Comparing the
two components of the exercise programme, the
group exercise and the individual home-based
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exercise, participants reported a clear preference for
the group option: ‘The group exercise programme
helps because suffering the whole thing together
builds a relationship’ (Martin, 75).
Participants who performed the home-based
exercise programme with a partner reported better
rates of adherence. However, many participants
described the home-based programme as boring and
they reported lack of interest and self-discipline to
adhere to it. The structured format, the friendly
environment and the opportunities for socialization
made the group programme the preferred option:
Definitely the class, although we have been
lucky that we could do the home exercises
together. I think that if you were on your own it
would be very easy to say ‘oh I have not really
got time to do that’or ‘I have got to go and do the
shopping’. With being two of us, we have been
able to encourage each other, so it was not so
bad. Definitely the class one was better because
of the other people there as well. (Mary, 71)
Staff increasingly appreciated the importance of
the social experience during the exercise classes
and promoted the development of intragroup rela-
tionships: ‘A major benefit is the social side which
is what really keeps them going. Possibly they were
not expecting the social benefits, they have orga-
nized events outside the programme, get-togethers
between them’ (O, exercise class leader).
Interpersonal: ‘pay back’ motivation The
opportunity to repay a societal debt was one of the
strongest reasons for adherence. Participants saw
their engagement in this research project as a means
of contributing to the community. By helping sci-
ence they believe they contribute to a better life for
future generations. The considerable investment of
time and effort required by the programme were
seen as a form of compensation for all the medical
attention and resources that had been dedicated to
them across their lives: ‘What we decided was that
this was obviously putting something back into
medical science. And we have had quite a bit out of
it over our years so it was a means of putting some-
thing back in’ (Jack, 73).
Environmental: transport and time/cost issues
All of the MMU and some of the KC participants
used their own cars to get to the exercise classes.
For some participants, the exercise classes were in
walking distance of their homes and only a few
people reported transport difficulties. However,
researchers from KC stressed that many participants
had not fully appreciated the time demands of the
programme and some had experienced difficulties
getting to exercise classes, with journeys of ‘up to
an hour and a half, several different buses and
trains’ (E, male exercise researcher).
Exercise class leaders initially did not consider
that time could be an issue for the participants but
quickly realized that many of the participants
needed support. Routines were merged with flexible
attendance arrangements to accommodate holidays,
days out, visits from friends or relatives and various
appointments.
The significant investment of resources (free
classes, treatments, equipment, tests, professional
tuition) provided a strong instrumental support for
programme adherence: ‘I had an idea that there
would be some gym work involved which can be
very expensive if you go to a gym to use equipment
like that. So, I thought it is worth looking into this
programme’ (Nick, 77).
Physical activity maintenance after
programme completion
The findings from the two UK sites present some dif-
ferences in the plans of participants to maintain a
physically active lifestyle following completion of
the 12-month programme. It is important to note here
that the MMU interviews were conducted immedi-
ately after the completion of the Better Ageing pro-
gramme whereas the KC interviews took place eight
months after the programme completion.
Most of the MMU site participants stressed their
intention to maintain the health benefits however
they did not report specific strategies or plans. They
said that it would be easier for them to continue the
exercise classes if the same or a new programme
was delivered in the same setting:
I think I am conscious that I have got to keep fit
and if this exercise was repeated for another year I
would be more than willing to take part. (Sue, 81)
If they were prepared to keep the classes on
here, we would come indefinitely. We shall cer-
tainly volunteer if they need anything for the
future. (Jack, 73)
The KC interviewees reported enrolment to new
exercise programmes and changes in their every-
day schedule to accommodate the new and more
active lifestyle. The provision of informational sup-
port in the form of ‘exit routes’ to other exercise
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opportunities facilitated them to continue exercise.
They praised the exercise class leaders’ support
during the transitional phase, and the available
information about exercise choices in their local
community:
At the end, we were given a list of other places
to go to. I often thought, ‘sounds interesting, I
think I’ll try it’, but it was so much easier to go
to the same place where we had been doing our
exercises, I knew it, I could park—it was easy
for me, so I didn’t bother with any of the others.
(Margaret, 70)
Environmental and interpersonal:
empowering environment The improved lev-
els of confidence and competence empowered some
participants to meet the challenge of moving from a
highly supervised environment to a more standard
exercise environment. The participants confirmed that
the 12-month experience in the Better Ageing pro-
gramme removed many personal barriers and helped
them to change their attitudes towards exercise:
I was very impressed really. It was lovely to
meet up with everyone twice a week. It broke
down the barrier eventually of being nervous of
going to the gym, because one has this idea of
everyone being in their slinky leotards, fantastic
gear and everything. (Margaret, 70)
Participants stressed the importance of emo-
tional, informational and instrumental support in
(from exercise class leaders and other exercisers)
and outside organized exercise programmes (family
and friends). They stressed that instrumental sup-
port in the form of low cost, free trial sessions and
free transportation to facilities could be useful
strategies to motivate people to continue exercise in
community-based programmes:
I have joined the gym in my own right. It is a
bit lonely, last week I was on my own but it is
good because it continues this terrific strength-
ening of my legs that came from the pro-
gramme. I do not enjoy it, and I do not feel
good after it for some reason or other, always
have that feeling low. Do not know why, does
not exhilarate me, maybe because when the
instructor was there, I had someone to motivate
me and other people around. When you go to
big place all by yourself, it is a bit miserable.
Still persevere because it is good and keeps the
old legs mobile. (Susan, 74)
There are many people like Susan who after partic-
ipating in an exercise programme feel empowered
and express their willingness for further action.
Although several intrapersonal factors empowered
participants to enrol in community programmes, the
long-term commitment seem to be determined
by interpersonal and environmental facilitators linked
with the provision of these programmes. Translating
willingness into sustained action requires an empow-
ering environment, support from the local community
together with personal persistence and effort.
Discussion
The high adherence rates to group-based pro-
grammes for older adults (van der Bij et al., 2002)
were confirmed in this study as participants
reported a 93 per cent attendance to the facility-
based group sessions (Fox et al., 2007). High com-
pliance (85%) to home-based sessions was also
reported. This study adds to the limited evidence
available on factors leading to adoption of physical
activity opportunities and adherence to long-term
programmes (≥ 1 year).
Past behaviour, an important determinant for
physical activity participation (McAuley et al., 2003,
2007), did not seem to influence the joining deci-
sions of the participants in this study. Instead, the
opportunity to join a new, locally based initiative
designed for older people, the need for day-to-day
structure and discipline, avoiding relapse together
with success in other health behaviours provided a
range of interconnected motives.
The provision of intensive individual tuition
(within the group setting) during the early stages of
the programme supported participants in their pro-
gression. The participants reported improvements
in their sense of mastery, self-efficacy and physical
competence. For many participants, this pro-
gramme provided a genuine but unanticipated expe-
rience of personal development.
The improvements in performance of everyday
activities underline the value of engagement in
strength, flexibility and balance training in the form
of functional exercises (King et al., 2000). The reg-
ular feedback provided participants with informa-
tion not only about the recovery of lost capacity but
also about the discovery of new potential. The pro-
gramme helped many participants to widen their
sense of what is possible not only physically, but
also mentally and socially.
Even though social support is considered as one of
the most significant determinants of physical activity
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STATHI ET AL.: PROCESSES ASSOCIATED WITH PARTICIPATION AND ADHERENCE
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participation (Booth et al., 2000; Wendel-Vos,
Droomers, Kremers, Brug, & van Lenthe, 2007),
there is a need to examine carefully which sources of
support most impact physical activity behaviour.
Consistent with Culos-Reed et al. (2000), informa-
tional (e.g. how to use the equipment) and instru-
mental support were especially important in the
initial stages of the programme. As individuals pro-
gressed and improved their confidence, emotional
support (from family members) became more impor-
tant in determining adherence. Notwithstanding this,
informational and instrumental support (e.g. appro-
priate classes and venues) re-emerged as important
issues when individuals completed the programme
and were attempting to move back to community-
based facilities and programmes.
Similar to van der Bij et al. (2002), adherence in
the group exercise was higher than that in the home-
based programme. The opportunity to join a social
group was appreciated by participants, while
remaining in the programme for 12 months was
facilitated by the growing reserve of support from
group members and their increased sense of inter-
personal trust. As a result, social connectedness
improved along with a strong sense of authentic
programme ownership, which was a theme reported
both by participants and staff. The lower adherence
in the home-based programme was possibly due to
insufficient social commitment or lack of exercise
variety. From the outset, many participants were
already independent with adequate functional abil-
ity to perform their everyday tasks. Home-based
exercise was a less empowering experience for
these participants, even though other studies sug-
gest that home-based physical activity fosters
adherence (Atienza, 2001). Sampling issues may
reconcile these apparently conflicting findings;
home-based exercise may be most suited to people
who are less mobile and spend more time at home
than our participants.
Commitment to ‘science’and sensing an obligation
to society to repay for benefits already experienced—
especially through the National Health Service—
contributed to strong motives for full involvement in
the 12-month programme. Although this would
clearly not generalize to delivery of programmes in
non-research settings, developing a sense that regular
attendance is a duty (perhaps by emphasizing that cre-
ating a group is part of optimizing enjoyment and pro-
gression for oneself and for others) may also be
important in facilitating sustained attendance.
Similarly, sensing genuine programme ownership,
developed by regular discussions about design and
delivery, might help promote prolonged physical
activity engagement where the programme is not part
of a research project.
Findings from interviews at both sites suggest a
common pattern of intrapersonal and interpersonal
influences throughout the 12-month programme.
However, a different picture was drawn from par-
ticipants at the two sites regarding the importance
of environmental influences at the maintenance
stage after the programme completion. MMU par-
ticipants emphasized how joining a health club
would be completely different from exercising in
the highly protective environment of the university
centre. These participants were confident and will-
ing to continue in that environment but transferring
to community-based exercise facilities challenged
their confidence and efficacy beliefs. The partici-
pants at the MMU trial were more likely to live in
rural areas. Therefore, their community provision is
likely to be less convenient than that available to
those living in urban areas, as was the case with the
KC participants.
The transition for the KC participants was not so
challenging; these individuals were already using
community fitness centres within the intervention
and they were familiar with, and confident about,
continuing in similar environments. Providing
information about exercise opportunities in the
local community and the identification of the spe-
cific needs and preferences of the individual helped
the KC participants to make a smooth transition to
community-based programmes. Transition arrange-
ments seem to be a key issue for maintenance.
Attention needs to be paid to making the transition
into lifestyle-based activity or into providing ongoing
opportunities for organized exercise programmes at
the end of intervention studies.
The Better Ageing programme offered partici-
pants the opportunity to join a new social group.
This is particularly pertinent for older groups, since,
as individuals age the number of social groups
available to join decreases. Not having maintenance
strategies for this group seems to be a lost opportu-
nity given 12 months of intensive resourcing for the
programme.
This study investigated the processes associated
with the engagement of older adults aged 70 years
and older in a 12-month exercise programme.
Participants in this study were 21 independent,
mobile, community-living older adults. Although
the interventions sites were quite diverse in terms of
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JOURNAL OF HEALTH PSYCHOLOGY 15(6)
846
their urban/suburban environment, transferability of
the findings must be treated with caution in less
able, dependent or rural living older adults.
Interviews were conducted at different time
points for the two intervention sites—this limits the
ability to contrast the impact of environmental con-
text on maintenance. Follow-up of all participants’
activity behaviour post-intervention could have pro-
vided important information for processes of long-
term maintenance. However, this was not possible
for all participants in this study. Future studies could
interview at both time points for all participants to
provide a more robust longitudinal narrative on post-
intervention transition and maintenance. It should be
noted that the six interviews conducted with
researchers and exercise class leaders provide a form
of triangulation and confirmation of the insight pro-
vided by the participants.
Conclusion
Current policies typically emphasize the provision
of more exercise opportunities for older people
supported by a strong focus on more personal con-
trol and informed decision making regarding
lifestyle (Department of Health, 2004). To achieve
this, individuals need to feel confident to make
these lifestyle change decisions. However, many
older people have limited personal and interper-
sonal resources and that creates many constraints
in their attempts to change their activity behav-
iours. Even the increases in sense of control, self-
efficacy and empowerment reported across the
12-month programme were not sufficient to galva-
nize sustained physical activity involvement out-
side the intervention environment. Our findings
suggest that a programme that runs locally, pro-
vides individual attention/tailoring and a sense of
ownership, delivers meaningful benefits, offers a
staged approach to efficacy building and provides
intergenerational support and opportunities for for-
mation of new social groups facilitates exercise
engagement in later life.
Note
Guidelines for exercise programming for people
aged 70 years and over. The results of the European
Commission framework V Better Ageing Project
which featured aspects of this research are available
from Professor Fox (k.r.fox@ bristol .ac.uk).
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AFRODITI STATHI is Lecturer in Exercise
Psychology at the School for Health at the
University of Bath.
JAMES MCKENNA is Professor in Physical Activity
and Health and Head of Research Centre for
Active Lifestyles at the Carnegie Faculty of
Sport and Education at Leeds Metropolitan
University.
KENNETH R. FOX is Professor of Exercise and
Health Science and Director of Research at the
Department of Exercise, Nutrition, and Health
Sciences at Bristol University.
Author biographies
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