Barriers and Facilitators to the Uptake and Maintenance of Healthy Behaviours by People at Mid-Life: A Rapid Systematic Review

Abstract

Background: With an ageing population, there is an increasing societal impact of ill health in later life. People who adopt healthy behaviours are more likely to age successfully. To engage people in health promotion initiatives in mid-life, a good understanding is needed of why people do not undertake healthy behaviours or engage in unhealthy ones.

Methods: Searches were conducted to identify systematic reviews and qualitative or longitudinal cohort studies that reported mid-life barriers and facilitators to health behaviour. Mid-life ranged from 40 to 64 years, but younger adults in disadvantaged or minority groups were also eligible to reflect potential earlier disease onset.

Two reviewers independently conducted reference screening and study inclusion. Included studies were assessed for quality. Barriers and facilitators were identified and synthesised into broader themes to allow comparisons across behavioural risks.

Findings: From 16,426 titles reviewed, 28 qualitative studies, 11 longitudinal cohort studies and 46 systematic reviews were included. Evidence was found relating to uptake and maintenance of physical activity, diet and eating behaviours, smoking, alcohol, eye care, and other health promoting behaviours and grouped into six themes: health and quality of life, sociocultural factors, the physical environment, access, psychological factors, evidence relating to health inequalities. Most of the available evidence was from developed countries.

Barriers that recur across different health behaviours include lack of time (due to family, household and occupational responsibilities), access issues (to transport, facilities and resources), financial costs, entrenched attitudes and behaviours, restrictions in the physical environment, low socioeconomic status, lack of knowledge. Facilitators include a focus on enjoyment, health benefits including healthy ageing, social support, clear messages, and integration of behaviours into lifestyle. Specific issues relating to population and culture were identified relating to health inequalities.

Conclusions: The barriers and facilitators identified can inform the design of tailored interventions for people in mid-life.

Full text

RESEARCH ARTICLE
Barriers and Facilitators to the Uptake and
Maintenance of Healthy Behaviours by
People at Mid-Life: A Rapid Systematic
Review
Sarah Kelly
1
*, Steven Martin
1
, Isla Kuhn
2
, Andy Cowan
1
, Carol Brayne
1
, Louise Lafortune
1
1Institute of Public Health, Forvie Site, University of Cambridge School of Clinical Medicine, Box 113
Cambridge Biomedical Campus, Cambridge CB2 0SR, United Kingdom, 2University of Cambridge Medical
Library, University of Cambridge School of Clinical Medicine, Box 111 Cambridge Biomedical Campus,
Cambridge CB2 0SP, United Kingdom
*sak65@medschl.cam.ac.uk
Abstract
Background
With an ageing population, there is an increasing societal impact of ill health in later life.
People who adopt healthy behaviours are more likely to age successfully. To engage peo-
ple in health promotion initiatives in mid-life, a good understanding is needed of why people
do not undertake healthy behaviours or engage in unhealthy ones.
Methods
Searches were conducted to identify systematic reviews and qualitative or longitudinal
cohort studies that reported mid-life barriers and facilitators to healthy behaviours. Mid-life
ranged from 40 to 64 years, but younger adults in disadvantaged or minority groups were
also eligible to reflect potential earlier disease onset. Two reviewers independently con-
ducted reference screening and study inclusion. Included studies were assessed for quality.
Barriers and facilitators were identified and synthesised into broader themes to allow com-
parisons across behavioural risks.
Findings
From 16,426 titles reviewed, 28 qualitative studies, 11 longitudinal cohort studies and 46
systematic reviews were included. Evidence was found relating to uptake and maintenance
of physical activity, diet and eating behaviours, smoking, alcohol, eye care, and other health
promoting behaviours and grouped into six themes: health and quality of life, sociocultural
factors, the physical environment, access, psychological factors, evidence relating to health
inequalities. Most of the available evidence was from developed countries. Barriers that
recur across different health behaviours include lack of time (due to family, household and
occupational responsibilities), access issues (to transport, facilities and resources), finan-
cial costs, entrenched attitudes and behaviours, restrictions in the physical environment,
PLOS ONE | DOI:10.1371/journal.pone.0145074 January 27, 2016 1/26
OPEN ACCESS
Citation: Kelly S, Martin S, Kuhn I, Cowan A, Brayne
C, Lafortune L (2016) Barriers and Facilitators to the
Uptake and Maintenance of Healthy Behavioursby
People at Mid-Life: A Rapid Systematic Review.
PLoS ONE 11(1): e0145074. doi:10.1371/journal.
pone.0145074
Editor: Yue Wang, National Institute for Viral Disease
Control and Prevention, CDC, China, CHINA
Received: August 11, 2015
Accepted: November 26, 2015
Published: January 27, 2016
Copyright: © 2016 Kelly et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any
medium, provided the original author and source are
credited.
Data Availability Statement: All relevant data are
within the paper and its Supporting Information files.
Funding: This work was funded by the National
Institute for Health and Care Excellence (NICE),
invitation to tender reference DDER 42013, and
supported by the National Institute for Health
Research School for Public Health Research. The
scope of the work was defined by NICE and the
protocol was agreed with NICE prior to the start of
work. The funders had no role in data analysis,
preparation of the manuscript or decision to publish.

low socioeconomic status, lack of knowledge. Facilitators include a focus on enjoyment,
health benefits including healthy ageing, social support, clear messages, and integration of
behaviours into lifestyle. Specific issues relating to population and culture were identified
relating to health inequalities.
Conclusions
The barriers and facilitators identified can inform the design of tailored interventions for peo-
ple in mid-life.
Introduction
With an ageing population, there is an increasing economic, societal and health and social care
impact of dementia, disability, frailty and non-communicable chronic diseases (NCDs) in later
life. Ill health in later life is heavily influenced by behaviours across the life course, which in
turn are influenced by a variety of wider contextual social, economic, and organisational factors
[1,2]. People who adopt healthy behaviours are more likely to age successfully and have
improved quality of life [3–5].
As they age, those people now in mid-life have a greater risk of development of disease and
frailty than younger people in the next decades [6–8]. There is also considerable potential for
inequalities in health promoting behaviours and health outcomes, arising from poverty, social
and environmental factors [9,10], so risk factors for ill health in later life may manifest at a
younger age in disadvantaged, minority or harder to reach groups. To minimise the risk of ill
health in later life in these populations, effective ways to change people’s behaviours are
needed. In order to engage people in health promotion initiatives in mid-life and inform the
design of effective interventions that consider their specific circumstances, a good understand-
ing is needed of why people do not undertake healthy behaviours or engage in unhealthy ones.
This systematic review was one of a series of reviews conducted to inform the development of
UK national public health guidance on mid-life approaches to prevent dementia, disability and
frailty (DDF) in later life (https://www.nice.org.uk/guidance/ng16). The aim of the review was 1)
to identify key issues (barriers and facilitators) for people in mid-life that prevent or limit or which
help or motivate them to take up and maintain healthy behaviours that may ultimately impact on
healthy ageing including prevention or delay of dementia, disability, frailty or NCDs, and 2) to
identify any specific issues that may influence health inequalities, for example by ethnicity, socio-
economicstatus,genderorinminorityorhardertoreachgroups.Clearly,thegoalwasnottosum-
marise the whole of the public health literature on barriers and facilitators to behaviour change.
Rather, we aimed to identify evidence targeted at or of particular relevance to people at mid-life.
People in this segment of the population are likely to share some of the same issues and challenges
when it comes to changing or maintaining behaviours. With a similar focus, the other two reviews
in the series looked at the association between mid-life risk factors and late life outcomes, and at
the effectiveness of mid-life interventions on behavioural risks and late life outcomes.
Methods
The review was conducted as a rapid systematic review to provide best available evidence
within limited timescales. The scope of the review was defined by the funders (National Insti-
tute for Health and Care Excellence—NICE), after open consultation with stakeholders and the
protocol (available on request) was agreed prior to the start of work. Established systematic
review methods of NICE [11] were broadly followed, except as described below.
Barriers and Facilitators to Midlife Healthy Behaviours
PLOS ONE | DOI:10.1371/journal.pone.0145074 January 27, 2016 2/26
Competing Interests: It is worth nothing that LL is a
topic expert on NICE’s Public Health Advisory
Committee in relation to the public health guidance
(NICE PHG 64) for which this evidence review was
commissioned. This does not alter the authors'
adherence to PLOS ONE policies on sharing data
and materials.

Searches: The following electronic sources were searched for peer-reviewed studies pub-
lished in the English language (to March 2014): MEDLINE; EMBASE; PsycINFO; CINAHL;
HMIC; Cochrane Central Register of Controlled Trials; Cochrane Database of Systematic
reviews; Database of Abstracts of Reviews of Effectiveness; HTA database; NHS EED database;
Web of Science, Applied Social Sciences Index and Abstracts and relevant websites (S1 Text).
Time constraints precluded hand searches or contact of authors for additional data.
Searching was conducted 1) for systematic reviews using a search filter (SIGN filter [12]) for
a broad range of health behaviours, 2) for primary studies for a broad range of health behav-
iours specifically at mid-life, and 3) specific targeted searches for studies where there were gaps
in the evidence, relating to vision, hearing and inequalities. Due to an initial large number of
search hits, searches were limited by the use of mid-life terms and indexing (S2 Text). Studies
from any country, published in English, from year 2000 onwards were eligible.
Inclusion and exclusion criteria
Populations: The populations covered by this review included 1) mid-life adults (aged 40–64
years), including those at increased risk of disability, dementia, frailty, or other NCDs or 2)
adults aged 39 and younger in populations at higher risk of health inequalities, which refer to
people from disadvantaged and minority groups. These groups include (but are not limited to)
people of low socioeconomic status, ethnic minority groups, lesbian, gay, bisexual and trans-
gender (LGBT) groups; travellers, and other groups with protected characteristics under the
equality and diversity legislation.
Outcomes: Barriers and facilitators which prevent or limit or which help and motivate peo-
ple to take up and maintain healthy behaviour, including (but not limited to): 1) physical activ-
ity or inactivity; diet and nutrition; weight loss (in overweight people) or control; smoking or
tobacco consumption; alcohol consumption; multiple behavioural risk factors; healthy behav-
iours in general, social activity or prevention of loneliness; prevention of sight or hearing loss
2) behaviour at individual, group, family, community level in any setting. Barriers and facilita-
tors relating to participation in or effectiveness of specific interventions are not included.
Study design: Systematic reviews, primary qualitative studies and primary longitudinal
cohort studies were considered for inclusion in this review. As few reviews focused on mid-life,
systematic reviews in adults in general were included.
Exclusions: Studies in populations with: existing dementia or cognitive impairment, disabil-
ity, frailty and NCDs, including obesity or their diagnosis, care and management. Barriers and
facilitators to: use of medications; recreational drugs; supplements; national policies, legislation
or implementation. Cross-sectional studies, systematic reviews that only included cross-sec-
tional studies, abstracts, letters, editorials and unpublished theses were excluded.
Identification of relevant studies: Titles and abstracts were screened, and then checked,
independently by two reviewers. Differences were resolved by discussion or with a third
reviewer. Fig 1 illustrates the flow chart for the study selection process. Studies excluded at the
full paper screening stage are reported in S1 Table along with reason for exclusion.
Assessment of methodological quality: Systematic reviews were assessed using AMSTAR
[13]. Primary studies were assessed using NICE checklists [14,15] and rated as ++, + or–based
on the checklist criteria (Table 1; detailed assessments are in S2 Table). A minimum of 10% of
the studies were assessed by two reviewers and discrepancies resolved by discussion. No studies
were excluded on the basis of methodological quality.
Data extraction and evidence synthesis: Study data was extracted on population, setting,
study design, outcomes, method of analysis, results and funding (S3 Table) by one reviewer
and checked for accuracy by another. Issues relevant to the uptake and maintenance of health
Barriers and Facilitators to Midlife Healthy Behaviours
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behaviours and their context were identified in the literature and analysed thematically to iden-
tify common themes, integrating qualitative and quantitative evidence [16].
Results
In total 81 studies (46 systematic reviews and 39 primary studies specifically in mid-life) are
included in the review. The studies’characteristics and overall quality ratings are shown in
Table 1 (Detailed quality assessments are in S2 Table).
Nineteen systematic reviews focused on physical activity, seven on diet, three on overweight,
four on smoking, three on alcohol consumption, four on cardiovascular health, and six on
Fig 1. Flow Chart of Searches for Systematic Reviews and Primary Studies.
doi:10.1371/journal.pone.0145074.g001
Barriers and Facilitators to Midlife Healthy Behaviours
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Table 1. Overview of Included Studies.
First Author,
Year
Location Aims Included population Quality
1
Physical Activity
Systematic Reviews
Amireault 2013 International Psychosocial and socio-demographic determinants of physical
activity maintenance
Mid-life (18–64 yrs) +
Babakus 2012 Can, UK, US,
Australia
Physical activity and sedentary time among South Asian
women
Adults (16–90+ yrs). Ethnic
group
++
Beenackers
2012
Europe Socioeconomic inequalities in occupational, leisure-time, and
transport related physical activity among European adults
Mid-life (18–65 yrs) -
Daniel 2011 International Correlates of physical activity among South Asian Indian
immigrants
Adults (17–91 yrs). Ethnic group -
Engberg 2012 Can, UK, US,
Australia
Life events and change in leisure time physical activity Adults (17–83 yrs) -
Fischbacher
2004
UK Levels of physical activity in South Asian population in the UK Adults. Children +
Eyler 2002 US Correlates of physical activity among women from diverse
racial/ethnic groups
Women (age not specified).
Ethnic group
-
Fransson 2012 Europe Job strain as a risk factor for leisure-time physical inactivity Adults (mean 43.5 yrs) -
Gidlow 2005 UK Attendance of exercise referral schemes in the UK Adults (>18 yrs) -
Gidlow 2006 International Relationship between socio-economic position and physical
activity
Adults (18–89 yrs).
Socioeconomic
+
Kirk 2011 International Occupation correlates of adults’participation in leisure-time
physical activity
Adults (18–64 yrs). Occupation +
Lewis 2002 Not reported Psychosocial mediators of physical activity behaviour among
adults (and children)
Adults (>18 yrs) -
Pavey 2012 UK, others not
reported
Levels and predictors of exercise referral scheme uptake and
adherence
Middle aged (mean 51–64 yrs) -
Rhodes 2013 International Moderators of the intention-behaviour relationship in the
physical activity domain
Adults (>18 yrs) +
Rhodes 2012 International Factors linked to adult sedentary behaviour Adults (18–91 yrs) +
Siddiqi 2011 USA Understanding impediments and enablers to physical activity
among African American adults
Adults (18–89 yrs). Ethnic group +
Trost 2002 Not reported Correlates of adults’participation in physical activity Adults (age not specified) -
Vrazel 2008 USA, Latin America Framework of social-environmental influences on the physical-
activity behaviour of women
Women (20–60 yrs) -
Wendell-Vos
2007
International Potential environmental determinants of physical activity in
adults
Adults (>18 yrs) -
Cohort Studies
Segar 2008 US To investigate the effects of physical activity goals on physical
activity participation
Mid-life. Women +
Sorensen 2005 Finland Correlates of physical activity among middle-aged Finnish
male police officers
Mid-life. Male police officers +
Wurm 2010 Germany Study the effect of a positive view on aging on physical
exercise among middle-aged and older adults
Mid-life. Old age +
Qualitative Studies
Berg 2002 US Physical activity perspectives of Mexican American and Anglo
American midlife women (focus groups)
Mid-life. Women. Ethnic group +
Caperchione
2012
Australia Understanding the challenges and motivations to physical
activity participation and healthy eating in middle-aged
Australian men (focus groups)
Mid-life. Men +
DH 2010 England Insight research conducted in middle-aged adults to inform the
Change4Life campaign (a national marketing programme
which aims to help people in England change their dietary and
physical behaviours) (focus groups)
Mid-life -
(Continued)
Barriers and Facilitators to Midlife Healthy Behaviours
PLOS ONE | DOI:10.1371/journal.pone.0145074 January 27, 2016 5/26

Table 1. (Continued)
First Author,
Year
Location Aims Included population Quality
1
Hooker 2011 US Factors related to physical activity and recommended
intervention strategies as told by midlife and older African
American men (interviews)
Mid-life. Old age. Men. Ethnic
group
+
Hooker 2012 US The potential influence of masculine identity on health-
improving behaviour in mid-life and older African American
men (interviews)
Mid-life. Old age. Men. Ethnic
group
+
Im 2013 US Exploring midlife women’s attitudes toward physical activity
(online forum)
Mid-life. Women +
Im 2012 US Asian American midlife women’s attitudes towards physical
activity (online forum)
Mid-life. Women. Ethnic group +
Rimmer 2004 US Physical activity participation among persons with disabilities
(focus groups)
Mid-life. Disabilities +
Segar 2006 US To investigate the relationship between midlife women’s
physical activity motives and their participation in physical
activity (surveys)
Mid-life. Women +
Vandelanotte
2013
Australia What kinds of website and mobile phone-delivered physical
activity and nutrition interventions do middle-aged men want?
(focus groups)
Mid-life. Men. Technology +
Vaughn, 2009 Latin America Factors that influence the participation of middle-aged and
older Latin-American women in physical activity (participant
observation and questionnaire)
Mid-life. Old age. Women.
Ethnic group
+
Withall 2010 UK Who attends physical activity programmes in deprived
neighbourhoods (questionnaire)
Adolescent. Adults (74%).
Deprived neighbourhoods
++
Yarwood 2005 US Factors influencing ability of midlife women to maintain
physical activity over time (interviews)
Mid-life. Women +
Diet
Systematic Reviews
Bisogni 2012 Not reported How people interpret healthy eating Adults (age not specified) -
De Irala-Estevez
2000
Europe Socio-economic differences in food habits in Europe:
consumption of fruit and vegetables
Adults (18–85 yrs).
Socioeconomic inequalities
-
Fleischhacker
2011
International Fast food access studies Children and adults (age not
specified)
-
Guillaumie 2010 USA, Netherlands,
Great-Britain
Psychosocial determinants of fruit and vegetable intake in
adult population
Adults (18–65 yrs) -
Kamphuis 2006 International Environmental determinants of fruit and vegetable
consumption among adults
Adults (18–60 yrs). Environment +
Lachat 2012 International Eating out of home and its association with dietary intake Adults and children (5–74 yrs) +
Power 2005 Canada Determinants of healthy eating among low-income Canadians Adults (age not specified).
Socioeconomic
-
Cohort Studies
Yates 2012 US To examine predictors of change over time in healthy eating
behaviours in mid-life and older women in response to a one
year health-promoting intervention
Mid-life. Old age. Women +
Mejean 2011 France To determine sociodemographic, lifestyle and health
characteristics associated with consumption of fatty-
sweetened and fatty-salted foods in middle-aged French
adults
Mid-life +
Teixera 2010 Portugal Weight loss readiness in middle-aged women: Psychosocial
predictors of success for behavioural weight reduction
Mid-life. Women +
Qualitative Studies
Brown 2012 US To determine the perception of women of the relationship
between recent life events, transitions and diet in midlife
(focus groups)
Mid-life. Women +
(Continued)
Barriers and Facilitators to Midlife Healthy Behaviours
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Table 1. (Continued)
First Author,
Year
Location Aims Included population Quality
1
Caperchione
2012
Australia Understanding the challenges and motivations to physical
activity participation and healthy eating in middle-aged
Australian men (focus groups)
Mid-life. Men +
DH 2010 England Insight research conducted in middle-aged adults to inform the
Change4Life campaign (a national marketing programme
which aims to help people in England change their dietary and
physical behaviours) (focus groups)
Mid-life -
Hammond 2010 US To determine the perception of women of the relationship
between recent life events, transitions and diet in midlife
(focus groups)
Mid-life. Women +
Jilcott 2009 US Perceptions of the community food environment and related
influences on food choice among midlife women residing in
rural and urban areas (interviews).
Mid-life. Women. Rural/urban
settings
++
Vandelanotte
2013
Australia What kinds of website and mobile phone-delivered physical
activity and nutrition interventions do middle-aged men want?
(focus groups)
Mid-life. Men. Technology +
Vue 2008 US Need states based on eating occasions experienced by
midlife women (focus groups)
Mid-life. Women +
Overweight
Systematic Reviews
Giskes 2011 International Environmental factors and obesogenic dietary intakes among
adults
Adults (>18yrs) -
Giskes 2010 Europe Socioeconomic inequalities in dietary intakes associated with
weight gain and overweight/obesity conducted among
European adults
Adults (>18 yrs) +
Lovasi 2009 US Built environments and obesity in disadvantaged populations Adults and children (age not
specified). Disadvantaged
communities
-
Smoking and Smokeless Tobacco
Systematic Reviews
Bader 2007 International &
Canada
Smoking cessation among employed and unemployed young
adults
Young adults (18–24 yrs).
Unemployed
-
Kakde 2012 India, Pakistan,
Nepal, Bangladesh,
UK
Social context of smokeless tobacco use in the South Asian
population
Adults and children (8–96 yrs).
Ethnic group
-
Niederdeppe
2008
Not specified Media campaigns to promote smoking cessation among
socioeconomically disadvantaged populations
Adults (>18yrs). Socioeconomic
status
-
Vangeli 2011 International Predictors of attempts to stop smoking and their success in
adult general population samples
Adults (>18yrs) -
Cohort Studies
Honjo 2010 Japan To determine predictive factors for smoking cessation among
middle-aged Japanese
Mid-life +
Alcohol
Systematic Reviews
Brienza 2002 International Alcohol use disorders in primary care: do gender-specific
differences exist?
Adults (age not specified).
Women
-
Bryden 2012 International Influence on alcohol use of community level availability and
marketing of alcohol
Adults and adolescents (age not
specified). Community factors
+
Bryden 2013 International Influence of community level social factors on alcohol use Adults and adolescents (15–59
yrs). Community factors
+
Cohort Studies
(Continued)
Barriers and Facilitators to Midlife Healthy Behaviours
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Table 1. (Continued)
First Author,
Year
Location Aims Included population Quality
1
Caldwell 2008 UK Lifecourse socioeconomic predictors of midlife drinking
patterns, problems and abstention
Mid-life ++
Qualitative studies
Pettinato 2008 US Life experience of the misuse of alcohol among midlife and
older lesbians (interviews)
Mid-life. Old age. Women.
Lesbian
+
Cardiovascular Health
Systematic Reviews
Bock 2012 UK, US, Can, NZ Practices and factors associated with behavioural counselling
for cardiovascular disease prevention in primary care settings
Adults (mean 41 yrs range 34–
45 yrs)
-
Hart 2005 US Women’s perceptions of coronary heart disease Adults (>40 yrs). Women -
Kurian 2006 US Racial and ethnic differences in cardiovascular disease risk
factors
Adults (>18 yrs). Ethnic groups -
Murray 2012 International Patient reported factors associated with uptake and
completion of cardiovascular lifestyle behaviour change
Adults. (>18 yrs) -
Qualitative Studies
Folta 2008 US Factors related to cardiovascular disease risk reduction in
midlife and older women (focus groups)
Mid-life. Old age. Women +
Health Promoting Behaviour
Systematic Reviews
Bécares 2012 International Ethnic density effects on physical morbidity, mortality, and
health behaviours
Adults (>18 yrs). Ethnicity -
Coles 2012 Developed
industrialized
countries
Community-based health and health promotion for homeless
people
Adults (16–89 yrs).
Homelessness
+
Dryden 2012 Western/developed
countries
Existing knowledge about who does and does not attend
general health checks
Adults (age not specified). Hard
to reach populations
-
Jansen 2012 Germany The influence of social determinants on the use of prevention
and health promotion services
Adults (age not specified).
Socioeconomic inequity
-
Ryan 2009 UK Factors associated with self-care activities among adults in the
United Kingdom
Adults (age not specified) +
Yarcheski 2004 US, England, Can Predictors of positive health practice Adults. Adolescents (age not
specified)
+
Cohort Studies
Benzies 2008 Sweden To measure factors that predict change in health-related
behaviours among midlife Swedish women
Mid-life. Women +
King 2007 US To determine factors related to adopting a healthy lifestyle in a
middle-aged cohort
Mid-life ++
Petersson 2008 Sweden To determine predictors of successful self-reported lifestyle
changes in a defined middle-aged population
Mid-life +
Shi 2004 Japan Health values and health information seeking in relation to
positive change of health practice among middle-aged urban
men
Mid-life. Men. Urban setting -
Qualitative Studies
Enjezab 2012 Iran Internal motivations and barriers effective on the healthy
lifestyle of middle-aged women: A qualitative approach
(interviews).
Mid-life. Women +
DH 2010 England Insight research conducted in middle-aged adults to inform the
Change4Life campaign (a national marketing programme
which aims to help people in England change their dietary and
physical behaviours) (focus groups)
Mid-life -
(Continued)
Barriers and Facilitators to Midlife Healthy Behaviours
PLOS ONE | DOI:10.1371/journal.pone.0145074 January 27, 2016 8/26

health promoting practices more generally. Most reviews focused on the adult population in
general with six examining specifically mid-life populations. Of the 46 reviews, seven focused
on ethnic groups, nine related to disadvantaged groups, four focused specifically on women.
All 39 primary studies focused on specifically mid-life healthy behaviours. Of these, 28 were
qualitative studies and 11 were longitudinal cohort studies. In the qualitative studies, 15 were
in women only and five in men only, four studies were relevant to health inequalities focused
on ethnic groups or deprived, hard to reach or minority groups. Of the cohort studies, four
studies were exclusively in female cohorts and two in male cohorts.
The findings were organised in three levels (Table 2): 1) by health behaviour: evidence was
found for physical activity, diet, smoking, smokeless tobacco, alcohol, eye care, health behav-
iours in general including cardiovascular prevention 2) under broad themes identified: health
and quality of life, sociocultural factors, the physical environment, access to facilities and
resources, psychological factors, health inequalities 3) barriers and facilitators identified within
each broad theme. Some issues could be both barriers and facilitators depending on the
context.
Physical Activity (PA)
Health and wellbeing. Barrier: Existing physical ailments or chronic conditions were a
barrier to PA participation in four qualitative studies [17–20], one cohort [21], and three sys-
tematic reviews [22–24].
Facilitators: 1) Improved sense of wellbeing, energy, positive feelings or self-esteem. Evi-
dence from six qualitative studies [18–20,25–27] indicates that promotion of ‘feel good’bene-
fits like greater self-esteem and confidence can be a motivator for behaviour change. A cohort
study [28] found that females who focused on a sense of wellbeing and/or stress reduction
goals participated in significantly more PA than those who focused on weight loss and/or
health benefits.
2) Health benefits in general. Eight qualitative studies [17,18,20,25,27,29,30,31] and a cohort
study [28] reported improved health benefits as motivators for participation in PA. Another
cohort study [32] found that a high value placed on health was positively associated with
change in health practices in men. One systematic review [33] found associations between
expected health benefits and PA in repeated studies.
Table 1. (Continued)
First Author,
Year
Location Aims Included population Quality
1
Gower 2013 US Barriers to attending an eye examination after vision screening
referral within a vulnerable population (telephone based
questionnaires/interviews)
Mid-life (mean age 48).
Underserved
+
Meadows 2001 Canada Health promotion and preventive measures: Interpreting
messages at midlife (interviews)
Mid-life ++
Smith-Dijulio
2010
US The shaping of midlife women’s views of health and health
behaviours (interviews)
Mid-life. Women +
Guide
1
Description of overall methodological quality ratings
++ All or most of the checklist criteria have been fulfilled; where they have not been fulfilled the conclusions are very unlikely to alter
+ Some of the checklist criteria have been fulfilled; where they have not been fulfilled or adequately described the conclusions are very unlikely to alter
- Few or no checklist criteria have been fulfilled and the conclusions are very likely to alter
doi:10.1371/journal.pone.0145074.t001
Barriers and Facilitators to Midlife Healthy Behaviours
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3) Fear of illness or ageing and wanting to promote a healthy old age was reported in seven
qualitative studies [17,18,20,25,29,31,34] so that people were able to do the things they wanted,
for example, travel, hobbies and caring for families in later life.
4) Weight loss, body image, physical appearance was reported in six qualitative studies [17–
19,25,27,35]. However, in cohort studies [28,35], participants with weight loss goals partici-
pated in significantly less PA than those with sense of wellbeing or stress reduction goals or
body shape, toning or losing weight motives.
Table 2. Barriers and Facilitators to the Uptake and Maintenance of Healthy Behaviours by People in Mid-life.
Health
behaviour /
Theme
Health and quality of
life
Sociocultural
factors
Physical
environment
Access (to
facilities and
resources)
Psychological
factors
Health inequalities
Physical
Activity
Barriers Physical ailments or
chronic conditions
Lack of time. Lack of
knowledge. Self-
consciousness or
social concerns (in
women). Low
socioeconomic
status. More time at
home
Neighbourhood
safety. Driving
instead of
walking
.
Weather
Financial costs.
Transport. Lack of
availability or
access to
community physical
activity programmes
or facilities
.
Programmes
delivered by mobile
phones/social
networking
Lack of motivation.
Low self-efficacy.
Perception of lack
of capability (in
women).
Entrenched
attitudes and
behaviours in
midlife
Ethnic minority
groups Language
barriers. Cultural
barriers. Gender
Female gender and
gender roles. Hair
maintenance People
with disabilities
Barriers relating to the
built and natural
environment. Barriers
relating to cost.
Equipment related
barriers. Information-
related barriers.
Emotional and
psychological
barriers. Perceptions
and attitudes relating
to accessibility and
disability. Lack of
resources. Low SES
(as a barrier)
Facilitators Enjoyment. Sense of
wellbeing/Quality of
life. Prevention of
illness/Healthy
Ageing. Health
benefits in general.
Previous experience
of ill health. Focus on
short term benefits.
Weight loss/ body
image. Specific tools.
Integration of physical
activity into lifestyle
Support. Being a
good role model
(men)
None found Fast, easy websites None found Ethnic minority
groups Type of
activity. Having
exercise equipment at
home Gender
Physically active,
adult, female role
models People with
disabilities
Facilitators relating to
the built and natural
environment.
Facilitators relating to
cost. Equipment
related facilitators.
Information-related
facilitators. Emotional
and psychological
facilitators.
Perceptions and
attitudes relating to
accessibility and
disability. Resources
Diet
(Continued)
Barriers and Facilitators to Midlife Healthy Behaviours
PLOS ONE | DOI:10.1371/journal.pone.0145074 January 27, 2016 10 / 26

Table 2. (Continued)
Health
behaviour /
Theme
Health and quality of
life
Sociocultural
factors
Physical
environment
Access (to
facilities and
resources)
Psychological
factors
Health inequalities
Barriers Misinterpretation of
health messages
Social environment
around food. Food
environment. Eating
out of home.
Competing priorities.
Lack of time. Low
socioeconomic
status. Unplanned
shopping routines.
Alcohol consumption.
Co-existence of other
unhealthy lifestyle
behaviours
None found Financial costs.
Food availability.
Programmes
delivered by mobile
phones/social
networking. Low
SES groups.
Access to
supermarkets
Lack of motivation.
Identity. Perception
of lack of capability.
Existing entrenched
behaviours around
eating
Low SES groups
Access to
supermarkets
Facilitators Clear food choices.
Health concerns
.
Previous experience
of ill health
.
Swapping
foods. Weight loss
.
Specific tools
Support. Social
environment around
food
None found Accessibility. Fast,
easy websites
Identity Disadvantaged
groups Access to
supermarkets
Smoking
Barriers None found Low SES. Higher
level of current
smoking. Younger
age of initiation of
smoking
None found None found Lack of motivation Unemployed young
adults Lack of
motivation. Low SES
(as a barrier)
Facilitators Development of
disease (including
initiation of prescribed
medicine).
Participation in other
health behaviours
(including PA)
For media
campaigns in low
SES populations.
High exposure.
Combination with
community
component.
Appropriate media
use, language
preferences, literacy
needs, cultural
values
None found Information None found Low SES
populations (as
listed for health and
quality of life and
sociocultural factors)
Smokeless
Tobacco
Barriers Misperception of
benefits (some
perceived health
benefits include relief
of abdominal
problems, enhanced
digestion, stress relief,
as an aid to oral
hygiene, relaxation
and concentration).
Limited knowledge of
harmful health effects
Cultural and social
acceptance
(associated with
socialising and family
tradition)
Easy availability Low cost. Lack of
information and
resources to aid
quitting
Lack of motivation Ethnic minority
groups All data
relating to smokeless
tobacco was from one
systematic review in
South Asian
populations in UK,
India, Pakistan,
Nepal.
(Continued)
Barriers and Facilitators to Midlife Healthy Behaviours
PLOS ONE | DOI:10.1371/journal.pone.0145074 January 27, 2016 11 / 26

5) Enjoyment of the activity. There is consistent evidence from three qualitative studies
[18,20,30], one systematic review [33] and one cohort study [33,36] in which ‘enjoyment’was a
powerful determinant of later PA.
6) Previous experience of ill health. Two qualitative studies [19,29] reported ill health (high
blood pressure, diabetes, obesity, stroke) as a motivator for PA and one reported a family
Table 2. (Continued)
Health
behaviour /
Theme
Health and quality of
life
Sociocultural
factors
Physical
environment
Access (to
facilities and
resources)
Psychological
factors
Health inequalities
Facilitators None found Social, physical and
emotional support to
quit. Advice from
doctors or dentists
(but devalued when
they were users
themselves)
None found None found None found As above
Alcohol
Barriers None found Socioeconomic
status.
Neighbourhood
disorder and crime
Advertising and
media.
Availability
None found None found Gender Female
LGBT groups
Disconnection from
identity (lesbian
women)
Facilitators None found None found None found None found None found None found
Eye Care
Barriers Other medical
problems prioritised
Lack of
understanding of
information (e.g.
need for follow up
examination)
Could not find
transportation
Could not afford
transportation.
Appointment
arrangements (e.g.
forgetting, attending
but not being seen
by the clinician, no
clinic contact details
or location). Long
waits
None found Low SES All data
reported for eye care
was from a population
with little or no health
insurance in the US.
Facilitators None found None found None found Appointment
arrangements (e.g.
appointment
reminders, same
day appointments,
decreased wait
times, better
information about
appointment
location and contact
details, flexible clinic
hours)
None found As above
General
Health
Promoting
Behaviours
Barriers None found Alcohol consumption.
Lack of time
Distance None found None found Gender Female
Ethnic minority
groups
Facilitators Health check-ups.
Knowledge. Physical
activity. Experience or
fear of ill health
Marital status.
Education. Having
a child at home
None found None found Self-efficacy None found
doi:10.1371/journal.pone.0145074.t002
Barriers and Facilitators to Midlife Healthy Behaviours
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history of disease was important when considering preventive health care [37]. However, evi-
dence was not always consistent. In cohort studies, elevated blood pressure, risk factors for car-
diovascular disease or myocardial infarction were associated with positive lifestyle changes in
men [38] but a history of hypertension or diabetes was not [21].
7) Integration of PA into lifestyle. In qualitative studies [27] key messages related to positive
swapping of behaviours; for example, walking as an easily integrated part of everyday activity
to replace sedentary travel [27] and strategies for incorporating PA into daily lifestyle [39]; a
systematic review in UK South Asian populations found a need for PA to be incorporated into
everyday activities [40].
8) Focus on short-term benefits. One qualitative study found the promotion of short-term
benefits that are quickly achievable, potentially leads to longer-term benefits such as prevention
of heart disease [27].
9) Supplying the tools to make and sustain behaviour changes. In one qualitative study most
people felt they lacked specific information and strategies to make changes in their daily lives [27].
Sociocultural factors. Barriers: 1) Lack of time. In seven qualitative primary studies, lack
of time was raised as a barrier to participation in mid-life activity [17–20,25,29,41] in particular
because of conflicting demands of work, childcare, family and household responsibilities in all
genders and ethnic groups represented. Additionally, six systematic reviews also raised relevant
barriers relating to lack of time [23,24,33,42]; high job strain [43] and having child care respon-
sibilities [22].
2) Self-consciousness or social concerns. Concerns about social discomfort or self-con-
sciousness about participation in PA programmes or in the gym were raised in three qualitative
studies [19,39,44], all in women.
3) Lack of knowledge. This was raised in one qualitative study [31] in middle-aged women
in Iran and one systematic review in adults in general [24].
Facilitators: 1) Support. Supportive partners, family or friends, having a companion to do
PA, or support from a physician were cited as facilitators of PA in three qualitative studies
[17,20,30] and three systematic reviews [22,33,42]. Conversely, lack of support was cited as a
barrier in four qualitative studies [17,20,29,41].
2) Being a good role model. Two qualitative studies in men [25,34] reported being a good
role model for children and others as being a motivator for PA.
Barrier/Facilitator: Life changes/more time at home. In one qualitative study, middle-aged
adults reported spending more time in front of the computer or TV once children had moved
out [27]. A review [45] found that changes at work were associated with increased PA in mid-
dle-aged women.
Physical environment. Barriers: 1) Neighbourhood safety. Two qualitative studies [19,29]
and three systematic reviews [22–24] reported concerns about unsafe neighbourhoods.
2) Weather. Two qualitative studies in women reported the weather as a barrier to PA par-
ticipation [19,39].
3) Driving instead of walking. One qualitative study reported tendency to drive instead of
walk, with cars seen as a symbol of status and security [27].
4) Lack of recreational space. One systematic review in mid-life populations reported lack of
parks or recreational space and traffic as a barrier [24].
Access (to facilities and resources). Barriers: 1) Financial costs. Three qualitative studies
[18,20,34] and one systematic review [24] reported that the costs of organised PA or fitness
club membership were a barrier to PA.
2) Transport issues. Inconvenience, for example, having to drive to participate in PA, was
cited as a barrier in one qualitative study in men [17]. Lack of transport was a barrier to PA in
one qualitative study in women [20] and in one systematic review in adults [22].
Barriers and Facilitators to Midlife Healthy Behaviours
PLOS ONE | DOI:10.1371/journal.pone.0145074 January 27, 2016 13 / 26

3) Lack of availability or access to community programmes and facilities. Two qualitative pri-
mary studies [17,19] and two systematic reviews highlighted lack of availability or limited places
on PA programmes or access to places to do PA including recreational space, gyms [22,24].
4) Programmes delivered by mobile phones/social networking. One qualitative study [46]
found interventions delivered via mobile phone was not of interest to most participants; though
if they had a smartphone they were more open to the idea. Social media networking was not a
high priority in the mid-life population studied due to lack of time.
Facilitator: Fast, easy to use websites. Middle-aged men preferred websites that were fast,
easy to use, clutter-free, and concise with reliable information and interactive features that
could give feedback, such as podcasts, step-by-step videos and pictures [46].
Psychological factors. Barriers: 1) Lack of motivation. This was reported in three qualita-
tive studies [19,25,34] and one systematic review [24].
2) Low self-efficacy. Three systematic reviews in adults found a relationship between self-
efficacy (belief in one’s own ability to complete tasks and reach goals) and PA participation
[33,47,48]. Two qualitative studies [20,41] in women found perception of lack of capability
often prevented PA participation.
3) Entrenched attitudes and behaviours in mid-life. For example when structured PA was
not a part of self-identity or had become associated with a fear of being judged for decreasing
abilities [27].
Facilitator: Positive view of ageing. One cohort study [49] found that a positive view of age-
ing was associated with increased sporting activity in those who were healthy enough to take
part.
Health inequalities. Barriers or facilitators cited previously were also applicable in broader
population groups. Only those more specific to disadvantaged and minority groups are dis-
cussed here:
Socioeconomic status. Barriers: Six systematic reviews [22,33,50,51–53] in adults in gen-
eral linked higher SES, education or income with higher levels of PA. Lower occupation status
was associated with higher total PA in one review [50] and two reviews [52,53] reported a
higher level of occupational PA in lower socioeconomic groups; those with higher socioeco-
nomic position were more active during leisure time.
Ethnic minority groups. Barriers: 1) Language barriers. Language was highlighted as a
barrier to PA participation in two qualitative studies in US women [19,41], one in an Asian
population and one in a Latin-American population.
2) Cultural barriers. Cultural beliefs and traditional roles for women that focus on family
and domestic duties were cited in US qualitative studies, in Asian [29,41] and Latin American
populations [19]. An emphasis of intellectual activity over physical activity in Asian culture
was also a barrier [41]. From systematic reviews [23,40], culturally inappropriate facilities
included mixed sex swimming pools and male instructors (for women).
Facilitators: 1) Type of activity. Walking was most commonly recommended PA followed
by sports-related activities in one qualitative primary study in mid-life African American men
[23,34].
2) Having exercise equipment at home. South Asian populations reported this as a facilita-
tor [23].
Gender and gender roles. Barriers: 1) Female gender and gender roles. This was highlighted
in four qualitative studies [19,29,30,41] and three systematic reviews [23,40,54], including two
specifically in South Asian women. One systematic review [54] reported that women were more
likely to begin exercise referral schemes but less likely to maintain participation.
2) Hair maintenance. One systematic review found that hair maintenance was perceived as
a barrier to PA in African American women [24].
Barriers and Facilitators to Midlife Healthy Behaviours
PLOS ONE | DOI:10.1371/journal.pone.0145074 January 27, 2016 14 / 26

Facilitator: Physically active female role models. One systematic review in adult women in
general found [42] that they would feel more confident about adding PA to their lifestyles if
they had female role models.
People with disabilities. One qualitative study [55] reported detailed barriers and facilita-
tors to PA participation among people with disabilities. Due to space issues only the main
themes are reported in Table 2.
Diet
Health and quality of life. Barrier: Misinterpretation of health messages. In a UK qualita-
tive study [27], misinterpretation of food messages like eating ‘five a day’could mean fruit and
vegetables were being added to existing daily food intake.
Facilitators: 1) Clear and simple food advice. One qualitative study about bone health [56]
found that women preferred to have clear and simple food choices for overall health.
2) Health concerns. In one qualitative study in US women [56] food choices were affected
by personal health concerns.
3) Previous experience of ill health. In one qualitative study [57], a motivating factor for
changes in diet relating to bone health was diagnosis of osteoporosis in a family member.
4) Focus on swapping foods. A UK qualitative study [27] reported that strategies for replac-
ing unhealthy snacks with healthy ones, replacing high calorie meal components with lower
calorie ones providing new and interesting ways to add fibre to the diet were behaviour change
messages that engaged mid-life adults. Reducing alcohol consumption was less motivating due
to the pleasure associated with drinking.
5) Weight loss/short term benefits. Promotion of weight loss was a facilitator for dietary
change when it was supported by information on other short-term benefits [27].
6) Supplying the tools to make and sustain behaviour changes. Most people felt they were
aware of the changes they needed to make but lacked the specific information and strategies to
make the changes in their daily lives [27].
Sociocultural factors. Barriers: 1) Eating out of home. In one systematic review [58], eating
out of home was associated with higher energy and fat intake and lower micronutrient intake.
2) Competing priorities. One systematic review [59] identified competing food choice prior-
ities as a barrier. These included enjoyment, cost, managing relationships and convenience and
may be influenced by personal, social and food context.
3) Lack of time. Insufficient time for healthy eating was highlighted in one systematic review
[59] often related to family schedules and work demands.
4) Unplanned shopping routines. In a qualitative study [27] it was found that unplanned
shopping trips encouraged impulsive and indulgent purchases.
5) Co-existence of other unhealthy lifestyle behaviours. In a qualitative study, [27], alcohol
consumption increased the energy of the overall diet and encouraged unhealthy food choices.
In one cohort study, drinkers or smokers were more likely to consume higher amounts of fatty,
sweetened or salted foods [60].
Facilitator: Support. Family support was a determinant of the uptake and maintenance of
healthy eating behaviour in one cohort study [61] and identified as a factor influencing eating
behaviour in one systematic review [59].
Barrier/facilitator: Social environment around food. In one qualitative study conducted in
women [56] food choices were influenced by family members and co-workers. In one systematic
review [59], social relationships and context influenced how people interpret healthy eating.
Physical environment. Barrier/facilitator: Food environment. In one qualitative study
conducted in US women [56], food chosen at home and at work was influenced by the
Barriers and Facilitators to Midlife Healthy Behaviours
PLOS ONE | DOI:10.1371/journal.pone.0145074 January 27, 2016 15 / 26

surrounding food environment including the type of food available and convenience of access.
In two systematic reviews [62,63], greater access to supermarkets or less access to takeaway
outlets was associated with lower prevalence of overweight and obesity but mixed associations
were found with dietary behaviours [63].
Access (to facilities and resources). Barriers: 1) Financial costs. One systematic review
[59] found that people reported that healthy foods were too expensive.
2) Interventions delivered by mobile phones/social networking were considered in one pri-
mary qualitative study, as above [46].
Barrier/Facilitator: Food accessibility or availability. Widespread availability of unhealthy
food such as junk food and lower availability of healthy food was reported in a systematic
review [59]. Another review [64] found some limited evidence that fruit and vegetable con-
sumption was higher when more easily available and having your own vegetable garden or a
supermarket in the local area.
Facilitator: Fast, easy to use websites. One primary qualitative study [46], as above.
Psychological factors. Barriers: 1) Perception of lack of capability/knowledge/motivation.
In one systematic review beliefs about capabilities and knowledge and motivation were consis-
tently associated with fruit and vegetable intake [65].
2) Existing entrenched behaviours around eating. In one qualitative study [27] unhealthy
behaviours around eating were deeply embedded, such as snacking, bingeing, junk food, skip-
ping meals, oversized portions, or fussy eating habits retained from childhood.
Barrier/facilitator: Identity. One systematic review [59] reported the influence of a person’s
self-concept on how they eat, as some people desire to be healthy eaters whereas others viewed
it as weird or picky.
Health inequalities. Barriers: 1) Socioeconomic status. Lower household income or SES
was associated with lower fruit, vegetable or fibre consumption and higher total fat intake from
three systematic reviews [62,64,66]. A further review found that fast food restaurants were
more prevalent in low-income areas [67].
2) Food environment. In two systematic reviews [63,68] there was some limited data that
the food environment (greater access to supermarket or less access to takeaway outlets) was
associated with lower prevalence of overweight and obesity in socioeconomically deprived
areas and in US black or Hispanic populations.
Smoking
Health and quality of life. Facilitators: 1) Participation in other healthy behaviours. One
systematic review [65] and one cohort study [69] found that those who participated in other
healthy behaviours were more likely to quit.
2) Initiation of prescribed drug use or development of disease were identified as facilitators
in one cohort study [69].
Sociocultural factors. Barriers: 1) Higher level of current smoking. In one cohort study
[69] quit attempts were less successful in heavier smokers. In one systematic review, higher
number of cigarettes smoked was associated with failed quit attempts [70].
2) Younger age of initiation of smoking. One cohort study found that those who started
smoking at a younger age were less likely to stop smoking [69].
Psychological factors. Facilitator: Motivational factors. In one systematic review [70],
motivation to quit and intention to quit were positively associated with making a quit attempt
but not with quit attempt success.
Barriers and Facilitators to Midlife Healthy Behaviours
PLOS ONE | DOI:10.1371/journal.pone.0145074 January 27, 2016 16 / 26

No studies identified barriers or facilitators related to the physical environment or access.
Health inequalities. Barriers: 1) Low SES. One systematic review found that media cam-
paigns to promote smoking cessation are often less effective in low SES groups [71]. In another
review [70], higher social grade was predictive of quit attempt success in two studies. One Japa-
nese cohort study [69] found that white-collar workers were more likely to quit than blue-collar
workers.
2) Unemployed young adults. One review reported a lack of literature relating to smoking
cessation among unemployed young adults [72].
Smokeless Tobacco
All data for smokeless tobacco is from one systematic review that examined the cultural and
social acceptance of use in South Asian communities including in the UK, India, Pakistan and
Nepal [73] and is summarised in Table 1.
Alcohol
Sociocultural factors. Barrier: Neighbourhood disorder and crime. One systematic review
[74] found evidence that alcohol use may be higher in communities with greater social
disorders.
Physical Environment. Barriers: 1) Availability. One systematic review [75] assessed the
relationship between alcohol use and availability from commercial sources at the community
level. Results were not significant in the included studies in adults overall but higher outlet den-
sity, defined as shops, bars and restaurants in a community, may be associated with an increase
in alcohol use.
2) Advertising and media. One systematic review [75] assessed the relationship between
alcohol use and advertising at the community level. Only one of the included studies for this
exposure was conducted in adults (in women) but that study reported a significant relationship
between advertising and alcohol use.
No studies were identified which assessed health and quality of life, access (to facilities and
resources), or psychological barriers and facilitators.
Health inequalities. Barriers: 1) Socioeconomic status. One UK cohort study [76] found
that socioeconomic disadvantage was linked to mid-life moderate-binge, non-/occasional and
problem drinking but not low-problem heavy drinking. One systematic review [74] found the
association between community-level socio-economic factors (deprivation, income, employ-
ment) and alcohol use was inconclusive with some indication that alcohol use may be greater
in high-income communities but also in communities with higher unemployment levels.
2) Gender. One review [77] concluded that while women with alcohol use disorders are
more likely to seek help, they are less likely to be identified by their physicians. Barriers to seek-
ing help include: fear of abandonment by partner, fear of loss of children and financial
dependency.
3) Identity. One qualitative study [78] with lesbian women found that the use of alcohol can
be associated with a disconnection from an individual’s identity; in particular with their lesbian
identity but also from other roles such as student, partner, employee and parent or from child-
hood issues.
Eye Care Behaviours
Only one qualitative primary study was found for eye care in mid-life men and women in the
US with little or no health insurance and is summarised in Table 2 [79].
Barriers and Facilitators to Midlife Healthy Behaviours
PLOS ONE | DOI:10.1371/journal.pone.0145074 January 27, 2016 17 / 26

Health Behaviours in General
Health and quality of life. Facilitators: 1) Health check-ups. One cohort study [80]
reported that those attending health check-ups were more likely to be engaged with healthy
behaviours. In a qualitative study [37] most participants reported going for regular, quick
annual check-ups; however women often reported that dismissive statements from healthcare
professionals sometimes stopped them seeking preventive check-ups.
2) Knowledge of healthy behaviour. One qualitative study [31] found that health related
knowledge, was positively related to health-promoting behaviours.
3) Participation in other healthy behaviours. One cohort study [80] found that participating
in physical activity had a positive effect on mental health (which is positively associated with
health-related behaviours) and in another cohort study [38] activity was a factor for success in
lifestyle change. In a systematic review [81] lack of exercise experience was a barrier to adopt-
ing health-promoting behaviours. In one cohort study [38] lower alcohol intake was associated
with positive lifestyle changes.
4) Experience or fear of ill health. One qualitative study conducted with women in Iran [31]
found that development of, or fear of chronic disease, or disease in relatives, prompted more
health-promoting behaviours.
Sociocultural factors. Barrier: Lack of time. In a review [81] lack of time was reported to
be a barrier to health-promoting behaviours. In one qualitative study [37] lack of time was
reported to be a barrier to accessing the healthcare system for rural women.
Facilitators: 1) Being married or cohabiting. Non-attenders for health checks were more
likely to be single in one systematic review [82]. Another review [83] found that not being mar-
ried, not living with a partner or being single could be a barrier to lifestyle change in (in six
included studies while eight studies found no association). In one cohort study [80] being mar-
ried or cohabiting at mid-life was a predictor of a positive change in health behaviour. How-
ever, in another cohort study [38] marital status was not significantly associated with
successful lifestyle change.
2) Education. In one review [82], those not engaging with preventative health practices were
less well educated. In two other reviews, people with higher levels of education tended to be
more physically active [84] and engaged in self-care activities [85]. In cohort studies, two
cohort studies reported that education was one of the strongest predictors of a positive change
in health behaviours [80][21]. However, education was not associated with positive lifestyle
change in another cohort study [38].
3) Support. In one qualitative study [30] women found it difficult to sustain healthy prac-
tices if they had no one supportive of their efforts. One systematic review [86] found that physi-
cians felt that their capability in helping patients change their lifestyle was generally low in the
areas of smoking, nutrition, exercise, and alcohol consumption.
4) Benefits of health behaviour including the opportunity for socialisation and improved
self-esteem was reported as a facilitator for women in one systematic review [81].
Barrier/facilitator: Family responsibilities. One cohort study [80] reported that having a
child at home was one of the strongest predictors of a beneficial change in health behaviours.
In a review [81] caretaking responsibilities and family obligations were found to be barriers to
health-promoting behaviour.
Physical Environment. Barrier: Distance. One review [83] found that longer travel time
and greater distances from healthcare facilities, or problems with transport, were consistently
associated with poorer uptake of lifestyle programmes. In rural mid-life women geographical
barriers to accessing healthcare systems were reported [37].
Barriers and Facilitators to Midlife Healthy Behaviours
PLOS ONE | DOI:10.1371/journal.pone.0145074 January 27, 2016 18 / 26

Access (to facilities and resources). Barrier: Lack of time (doctors). One review [86]found
that some clinicians lacked time to spend on preventive medicine. In one US qualitative study
[37] women reported that their physicians were very busy which prevented access to healthcare.
Psychological factors. Facilitators: 1) Self-efficacy. Two reviews found that uptake of life-
style programmes or lack of engagement with preventive health practices was related to self-
efficacy [82,83].
2) Value placed on health. One cohort study [32] found that a high value placed on health
was independently associated with positive change of general health practice. In one review
[82] those not engaging with preventive health practices were shown to value health less
strongly. In one qualitative study [31] women who valued their health were more likely to
undertake health-promoting behaviours.
Barriers: 1) Lack of time. Two reviews [81,82] found that lack of time was a barrier to
health-promoting behaviour. It was also raised as an issue in two qualitative studies in mid-life
women who found family obligations and caretaking responsibilities limited time for healthy
behaviours [31,37].
2) Entrenched attitudes and behaviours in mid-life. One qualitative study [27] reported
resistance to the idea of change in mid-life, including reluctance to be told what to do and a
belief that benefits of behaviour change needed to be experienced before adoption of the
changes long-term.
Health inequalities. Barrier: 1) Low SES. One review found that men on low incomes, low
SES, and unemployed or less well educated were less likely than others to attend health check-
ups [82]. Lack of money was reported in one systematic review [81].
2) Gender. One review [82] and one cohort study [21] found that men were less likely to
attend health checks or adopt a healthy lifestyle. In one qualitative study [37] in US women,
various roles (caring for homes, jobs, children, grandchildren, and parents) women fulfilled
limited time and access to the healthcare system. One qualitative study [31] found that social
responsibilities inside and outside home interfered with participation in health behaviours.
One systematic review [81] found that caretaking responsibilities and family obligations for
women were a barrier to health behaviours relating to CHD.
3) Ethnicity. In a cohort study [21] conducted in the US, those from African American, or
BME communities were less likely to adopt a healthy lifestyle.
Discussion
This review found a broad range of barriers and facilitators that either prevent or limit, or
which help or motivate individuals to take up and maintain healthy behaviours in mid-life. Evi-
dence was found relating to barriers and facilitators to physical activity, diet and eating, smok-
ing, smokeless tobacco, alcohol, eye care and health behaviours in general, in particular in
relation to prevention of cardiovascular disease. Evidence was sought, but not found, for barri-
ers and facilitators to other health behaviours, including mid-life social activity and prevention
of hearing loss.
Most of the available evidence is from developed countries (European nations, USA, Can-
ada, Australia and New Zealand). In relation to health inequalities, substantial evidence was
found that low SES is a barrier to healthy behaviour. Evidence for both men and women at
mid-life was found and the perspectives of a range of ethnic minority groups across different
health behaviours were represented. There is a comprehensive study of barriers and facilitators
to PA for disabled people in the US [55], and a qualitative study relating to alcohol use in les-
bian women. However, there is little evidence relevant to other minority or disadvantaged
groups or for different health behaviours.
Barriers and Facilitators to Midlife Healthy Behaviours
PLOS ONE | DOI:10.1371/journal.pone.0145074 January 27, 2016 19 / 26

The review had a wide scope as it sought information relating to a wide range of health
behaviours in mid-life. In order to provide timely evidence and obtain a manageable number
of search hits, the searches were limited to studies that included terms related to mid-life in the
title, abstract or indexing terms. There may be other studies that include a predominantly mid-
life population that have not been indexed in this way. While this was a rapid review, estab-
lished, rigorous systematic review methods have been used and reported in the methods, inclu-
sions, quality assessment and synthesis of studies [87,88].
Remarkably, we found no overlap between studies in systematic reviews and primary studies
identified perhaps reflecting differing inclusion criteria and dates for systematic reviews and
the challenges of searching the large volume of work that has been published in this area. This
review has only included studies published from 2000 onwards so it may be that some of the
available data was published before then.
Some systematic and narrative reviews included in this review contained both qualitative
and quantitative studies, including cross-sectional studies. To compensate for this we extracted
and focused on longitudinal data as much as possible, without going back to individual primary
studies. Most of the data in included quantitative studies was self-reported (S3 Table), and few
studies used objective measures.
Many of the barriers and facilitators identified were found in a number of different studies,
across different study designs, ethnic groups, in men and women. Some of the same issues were
also identified in disadvantaged and minority groups. Therefore there is a fairly high degree of
confidence in the crosscutting barriers and facilitators identified. Additionally, some of the
same barriers and facilitators were found across studies that examined different health
behaviours.
Key barriers that recur across different health behaviours include lack of time (in particular
in relation to family, childcare, household and occupational responsibilities), access issues
(transport, facilities and resources), financial costs, personal attitudes and behaviours (includ-
ing lack of motivation), personal identity, restrictions in the physical environment, low socio-
economic status and lack of knowledge. Key facilitators include a focus on enjoyment of the
healthy behaviour, doing other healthy behaviours, health benefits, prevention of illness, the
potential benefits for healthy ageing and wellbeing as motivation; social support and encour-
agement; clear, accurate health messages, and integration of behaviours into lifestyle and rou-
tine. Specific issues relating to population and culture were identified for disadvantaged and
minority groups.
While a number of studies have shown that mid-life interventions can be effective in chang-
ing health behaviours for those that participate [89], few existing mid-life interventions have
addressed issues that may affect uptake and participation in programmes or individual partici-
pation in the first place. There is scope to design tailored interventions at both population and
individual levels that address the mid-life barriers and facilitators identified in terms of inter-
vention design to address capability, opportunity and motivation [90], including ease of access
to and take up of programmes.
Conclusion and Recommendations
The barriers and facilitators to mid-life health behaviours identified in this review are impor-
tant considerations that can inform the design of mid-life interventions. While change in
health behaviour can occur in mid-life, health behaviours may be more entrenched. Yet, there
are opportunities to change behaviour as people start to think more about the need to maintain
health in later life in order to make the most of retirement, family and grandchildren for
example.
Barriers and Facilitators to Midlife Healthy Behaviours
PLOS ONE | DOI:10.1371/journal.pone.0145074 January 27, 2016 20 / 26

While interventions to change health-related behaviour in mid-life can be effective for peo-
ple that participate in them, issues around access, including availability and affordability also
need to be considered as part of the design of health promoting strategies to address time con-
straints and competing priorities, ease of access and financial issues for people in mid-life.
Strategies to promote mid-life healthy behaviours that could be considered include: The
provision of locally available, affordable programmes that allow quick and easy access such as
shorter, bite-sized interventions; strategies to enable people to integrate healthy behaviours
into their daily lives, such as promotion of home-based interventions, for example quick home
preparation of healthy food, home physical activity programmes or improving the local envi-
ronment to encourage walking, cycling, active transport or healthier food outlets; promote pro-
grammes as an opportunity for socialisation, support and enjoyment; highlight the short-term
and long-term benefits of healthy behaviour such as promotion of wellbeing and healthy age-
ing; ensure websites with information or programmes are fast and easy to use; develop inter-
ventions and strategies around children and family, using local community resources,
including those that their children also use, such as schools and recreational facilities; provide
interventions at convenient times and in easily accessible places, for example outside office
hours, in workplaces or local community settings; provide programmes and information in a
range of appropriate languages and culturally acceptable styles and facilities; target health pro-
motion at times in people’s lives when substantial change occurs such as retirement or when
children leave home; target lower socioeconomic status groups and consideration of specific
strategies to encourage women to take up activity programmes.
Addressing barriers and facilitators of behaviour change in the design and implementation
of public health interventions in mid-life, can inform the delivery of tailored, evidence-based
strategies towards maintaining health in later life.
Supporting Information
S1 PRISMA Checklist. PRISMA Checklist.
(DOC)
S1 Table. Excluded Studies.
(DOCX)
S2 Table. QA Tables.
(DOCX)
S3 Table. Evidence Tables.
(DOCX)
S1 Text. Search Strategies.
(DOCX)
S2 Text. Websites Searched.
(DOCX)
S3 Text. Review Protocol.
(DOCX)
Acknowledgments
Frances Cater for administrative support. Nadja Smailagic and Stefanie Buckner for assistance
with data extraction.
Barriers and Facilitators to Midlife Healthy Behaviours
PLOS ONE | DOI:10.1371/journal.pone.0145074 January 27, 2016 21 / 26

Author Contributions
Conceived and designed the experiments: SK LL SM. Performed the experiments: SK LL SM
IK. Analyzed the data: SK LL SM. Contributed reagents/materials/analysis tools: AC. Wrote
the paper: SK LL. Proofed the manuscript: AC. Reviewed the manuscript: CB.
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PLOS ONE | DOI:10.1371/journal.pone.0145074 January 27, 2016 26 / 26