In industrialized countries there is a precipitous decline in activity with age in part because of sedentary lifestyles (Pate, Pratt, & Blair, 1995). In the United States, more than 40% of individuals age 65 and older do not participate in any leisure time physical activity (United States Department of Health and Human Services, Public Health Service [USDHHS, PHS], 1991). Of those individuals who do exercise, less than one third participate in regular moderate physical activity such as walking and gardening, and less than 10% are involved in vigorous physical activity. Habitual exercise can improve strength and maximum aerobic capacity (Greene & Crouse, 1995; Jette et al., 1996; King, Haskell, Taylor, Kramer, & Debusk, 1991; Province et al., 1995), as well as prevent disease (Bravo et al., 1996; LaCroix, Leveille, Hecht, Grothaus, & Wagner, 1996), decrease the risk of falling (Province et al., 1995), reduce physical disability (King, Oman, Brassington, Bliwise, & Haskell, 1997), improve sleep (Sharpe et al., 1997), and enhance mood and general well-being (Büchner, 1997). Because of these obvious benefits, the goal of Healthy People 2000 (USDHHS, PHS, 1991) is to reduce the proportion of people age 65 and older who do not engage in leisuretime physical activity to no more than 22%.
It is difficult to initiate exercise behavior in older adults, and influencing them to adhere to an exercise program over time is even more challenging. Approximately 50% of sedentary adults who start exercise programs stop them within the first 6 months of involvement (Desharnais, Bouillon, & Godin, 1986; Dishman, 1994; Ettinger et al., 1997; Fitzgerald, Singleton, Neale, Prasad, &c Hess, 1994). The causes of inactivity in older adults are multifactorial and include:
* Lack of motivation (Dishman, 1994).
* Social issues and cultural expectations (Dishman, 1991).
* Environmental factors such as insufficient room to walk (Dishman, 1994).
* Coexisting disease states (Morey, Pieper, & Cornoni-Huntley, 1998).
* Fear of falling (Hill, Schwarz, Kalogeropoloulos, & Gibson, 1996).
* Impaired health (Blair et al., 1996).
* Unpleasant sensations associated with exercise (Resnick, 1998).
* Lack of knowledge about the benefits of exercise on the part of the older adult (Dishman, 1994; Mann, Pruitt, Meehan, & Kemper, 1997).
Efficacy expectations (Bandura, 1977, 1986, 1995, 1997), which often are equated with motivation, are described as essential to the adoption and maintenance of exercise behavior in older adults (Conn, 1998; Jette et al., 1996; McAuley, 1993; McAuley, Shaffer, & Rudolph, 1995; Sharpe & McConnell, 1992). Efficacy expectations include selfefficacy expectations (i.e., individuals' judgment of their capabilities to organize and execute courses of action) and outcome expectations (i.e., beliefs that if a certain behavior is performed there will be a specific outcome or benefit).
The purposes of this study were to:
* Compare differences in motivation, efficacy expectations (selfefficacy and outcome expectancy), eight dimensions of health status, function and performance behaviors, age, fear of falling, frequency of falls, and fall-related injuries between the individuals who adhered to a walking program and those who did not.
* Use a qualitative approach to explore the factors that influenced adherence to an exercise program in older adults. Adherence to the exercise program was defined as walking at least two to three times per week for 20 minutes during the first 6 months of the walking group.
A nonexperimental, combined qualitative and quantitative design was used to address the study questions. Data were collected on all participants approximately 6 months following the initiation of a walking program in a continuing care retirement community (CCRC). All measures were obtained in the same sequence and were completed by a research assistant during a face-toface interview. Questionnaires were completed prior to the performance measures. At a prearranged time, open-ended interviews were conducted by the principal investigator (B. R.) to consider the factors that influenced adherence to the walking program. The open-ended interviews, which lasted approximately 20 to 30 minutes, were audiotaped and transcribed verbatim. Questioning began by asking the participant to talk about what helped them to adhere to a regular walking program and what decreased their willingness to exercise or walk regularly. Participants were encouraged to talk about what they believed were the benefits of exercise and to discuss past exercise experiences.
The qualitative component of the study used naturalistic or construe - tivist inquiry (Crabtree & Miller 1992; Haberman-Little, 1991), which is based on several underlying assumptions:
* Reality is dynamic and multiple.
* Phenomena must be studied within the context in which they occur.
* The researcher is an integral part of the research process.
The qualitative component of this study was added to gain a greater understanding of the phenomena of interest (i.e., exercise behavior), and it involves an ongoing process of discovery and interpretation.
Participants consisted of 23 of the original 24 members of a walking group established in December 1996. One member of the original group died prior to data collection. The walking group was a program initiated by the Activities, Health Care, and Rehabilitation departments within the CCRC. It included a voluntary group of older adults interested in increasing their exercise activity. These individuals were encouraged to walk for 20 minutes three times per week at preset times with other group members. Sessions included three morning and three afternoon options to allow for individual choices and schedules. The group met in the health care center offices and walked inside on a preset, measured route. When the weather allowed, some participants walked outside on the grounds around the facility. Participants were encouraged to walk at their own speed and to use assistive devices as appropriate. Attendance records were maintained by the health care center staff. Walking group members who walked at least one time were eligible to be included in the study and were contacted by telephone and invited to participate. The study was approved by the Institutional Review Board at the University of Maryland, and signed informed consent was obtained prior to data collection.
MEAN DIFFERENCES OF STUDY VARIABLES BY GROUP
Motivation. Intrinsic motivation, which is considered to be a single unitary trait reflecting a disposition to persevere, was measured using the 7item Apathy Evaluation Scale (AES) (Marin, 1990; Resnick, 1998). This scale measures apathy, which is defined clinically as the lack of motivation (Marin, Firinciogullari, & Biedrzychi, 1993). All items are coded so a higher score indicated a higher level of apathy, or lower motivation. This measure was used with a similar group with reported reliability (alpha = .89) and validity (Resnick, Zimmerman, Adelman, & Magaziner, 1998). Internal consistency of the AES in this study was slightly lower (alpha = .62) than previously reported, which may be due in part to sample size.
Self- Efficacy. The self-efficacy-barriers to exercise measure (McAuley, 1992) is a 13-item measure which focuses on self-efficacy beliefs related to the ability to continue to exercise in the face of barriers to exercising. Prior use of this measure with older adults provided evidence of reliability (alpha = .93) (McAuley, Lox, & Duncan, 1993) and validity (McAuley, 1992, 1993). Reliability in this study was sufficient (alpha = .84).
Outcome Expectancy. The Expected Outcomes for Habitual Exercise Scale (Stcinhardt & Dishman, 1989) is a 12-item measure developed based on descriptive epidemiological studies which asked individuals to identify expected positive outcomes of physical activity (Steinhardt & Dishman, 1989). There was reported evidence of reliability (alpha = .78, test-retest correlations of .89) and validity (Steinhardt & Dishman, 1989) of this measure. The current study provided further support for reliability (alpha = .91).
Falls, Fear of Falling, and Injuries Related to Falls. A fall was defined as an unintentional change in position resulting in coming to rest on the ground or other lower level (Purushottam et al., 1996). Injuries related to falls included skin tears, fractures, sprains, hematomas, and lacerations (Purushottam et al., 1996). Fear of falling was evaluated by asking the participant, "Would you say that you are not afraid, somewhat afraid, or very afraid of falling?". This single question was reported to be a valid measure of fear of falling in community-dwelling older adults (Chandler, Duncan, Sanders, & Studenski, 1996). Information regarding the occurrence of falls was based on reported falls from the initiation of the walking program until data collection - a 6month interval.
Health Status Questionnaire (HSQ). The Health Status Questionnaire measures eight dimensions of health status:
* Physical functioning (10 items).
* Role limitations due to physical problems (4 items).
* Role limitations due to emotional problems (3 items).
* Social activity limitations attributable to health (2 items).
* Current health perceptions (5 items).
* Pain (2 items).
* Psychological distress or wellbeing (5 items).
* Energy or fatigue (4 items).
These health dimensions have demonstrated evidence of reliability (alpha = .67 to .88) and validity (Stewart, Hays, & Ware, 1988), and are likely to be affected by exercise (Stewart, King, & Haskell, 1993). For all subscales, higher scores reflect more positive feelings of well-being and higher functioning.
Performance Measures. Chair-tostand time was the amount of time, determined using a handheld stopwatch, needed to stand up from a chair with a level seat .42 meters from the floor without using the upper extremities (Skelton, Greig, Davies, & Young, 1994). Gait velocity was the amount of time it took to walk 50 feet at a normal pace. There is prior evidence for test-retest reliability for both chair to stand time (r = .73) (Seeman et al., 1994) and gait velocity (r = .89) (Nevitt, Cummings, Kidd, & Black, 1989), as well as validity (Guralnik, Ferrucci, Simonsick, Salive, & Wallace, 1995).
Functional Inventory Measure (FIM). The FIM was used to assess self-care abilities including eating; grooming; bathing; dressing of the upper body; dressing of the lower body; toileting; bowel and bladder management; transfer ability to bed, chair, or wheelchair; locomotion including either walking or wheelchair propulsion; and stair climbing. The measure includes a seven-level response option anchored by extreme ratings of total assistance (1) to complete independence (7). Prior research provided evidence of reliability and validity (Heinemann, Linacre, Wright, Hamilton, & Granger, 1994). In the current study there was continued support for the internal consistency (alpha = .76) of the measure.
Descriptive statistics were used to characterize the sample. A twogroup analysis of variance was used to determine the differences between adherers and nonadherers, and p < .05 was used as the level of significance. The qualitative data analysis was performed using basic content analysis (Crabtree & Miller 1992; Miles & Huberman 1984) and was started with the first interview. A code list and definition of each code was made and continually revised as new codes were added. These codes then were grouped based on similarities and differences. For example, pain, fear of falling, being short of breath, or feeling dizzy initially were coded separately and then were categorized together as unpleasant sensations that impacted motivation to exercise. Likewise, "laziness" and "determination" were identified by informants as components of their personality that influenced motivation to perform exercise activities. These were categorized together under the theme of personality.
The average age of participants was 81 ± 7.2 years, and the majority were women (n = 21, 91%) and unmarried (n = 18, 88%). All of the participants were White and had completed at least high school. Of the 23 participants, 14 (60%) did not adhere to walking (i.e., walked less than two to three times per week during the 6- month period). Of these 14 individuals, seven walked only one time, five walked two to four times, and the remaining two individuals walked seven and nine times during the 6-month period. Nine participants (40%) adhered to the program and walked regularly at least two to three times per week during the 6month period.
Differences Between Groups
The Table provides the mean study variables by group (i.e., adherers versus nonadherers). There was a statistically significant difference between the two groups regarding the impact of health on physical function (F = 7.7, ? < .05), actual functional performance (measured by the FIM) (F = 4.0, ? < .05), selfefficacy expectations related to adherence to an exercise program (F = 4.3, p < .05), and number of falls in the past 6 months (F = 4.4, p < .05). Although not statistically significant, the adherers did have stronger motivation, higher outcome expectations, less fear of falling, fewer injuries related to falling, faster scores on the performance measures, less pain, better mental health, and fewer role limitations related to physical and emotional problems than the nonadherers. There was no statistically significant difference between the groups in vitality, social function, or age.
Analysis of the semistructured interviews revealed 30 codes which were categorized and reduced, as described above, to 6 major themes:
* General beliefs about exercise.
* Specific benefits of exercise.
* Past experiences with exercise.
* Unpleasant sensations associated with exercise.
General Beliefs About Exercise
The older adults in this study held many different beliefs about exercise, and these beliefs influenced their exercise behavior. If the beliefs about exercise were positive they were more likely to exercise regularly. Comments included:
*I think the exercise is good for me. It is important for me at my age. I think everyone should take a certain amount of exercise.
* I think walking is a good thing. I don't think I need push-ups or anything, but I do think I need to stay limber and keep walking.
Other older adults held negative beliefs about exercise or just did not consider it to be a worthwhile activity at their age. Participants stated:
* At my age I guess I don't think exercise is worthwhile. I am pretty old and I don't think too much about it at my age.
*Maybe exercise will help, but I really don't know. Look at some of the athletes...they die suddenly from exercising.
* For me I feel good and I don't think I need to exercise.
* What is the use of exercising. I sure don't want to live to be 1 00!
There were several older adults who believed they did enough exercise in daily activity and, therefore, they did not feel additional regular exercise was necessary. These older adults remarked:
* Having to get the mail, see if there is any chicken salad sandwiches in the deli, or visiting a friend in the Health Care Center keeps me pretty active.
* I did it for a while coming down here [to walk with the walking group] and walking but I was going other places [museums and other day trips] too so I figured that was enough.
Specific Benefits of Exercise
One of the most common reasons for older adults in this study to adhere to the walking program was the benefits they associated with walking. These benefits most often were related to physical health, but psychological well-being also was described.
Health Benefits. Participants' comments included:
* I believe my health is better overall from walking. My blood pressure is down and is consistendy lower than it was when I first started.
* Walking helps keep me moving. My motivation is to keep my body moving so I can do what I need to do and stay in good physical shape.
* I feel I can breathe better and I don't get as short of breath as I used to.
Psychological Benefits. Some of the older adults were not convinced there was a true change in their physical status from walking. However, psychologically they described a sense of well-being from walking:
* I generally feel good all day after I have walked. I feel having just walked for 20 minutes or 30 minutes that I have a done a good thing, and I just feel better in my mind. I don't know if it really changes anything.
* I don't know if I have a sense of euphoria but I do feel better. It is satisfactory. I think it is valuable.
* I feel like I have accomplished something and I feel good inside.
The participants in this study identified two different components of personality that influenced their exercise activity: laziness and determination. Determination was described as an inner drive to continue to walk regularly. Participants stated:
* I don't walk because I am just plain lazy. I think I am lazy. Whenever I look at the clock it is way beyond the time we should have started. I am always doing something, and I can't show a thing for it! I just love to lie down.
* I don't really mind exercise but I am lazy and if I can get out of it I will!
* I have a built-in desire to exercise. I have that inside me and so I go do it.
* I have something inside me, willpower, that I can walk and I just do it. I start making long strides and I think I do not have far to go now. I look at that place and I keep on going, even if I am tired. I just stop and rest and then I get on up.
Past Exercise Experiences
Past experiences with exercise seemed to impact the older adults' current exercise behavior. Many of the older adults who adhered to a regular exercise program exercised regularly when they were younger. They commented:
*When I was younger I did about 45 minutes of sitting up exercises. I did that to keep limber not to build muscles. After my eye operations I never went back to it. All these years I just kept walking.
* I have always been a walker. As a kid I would go out and walk, even by myself. The other activity that I like is swimming. When I was growing up this was part of what I enjoyed and I kept it up. If there is the opportunity or the place then I do it.
The older adults who had never exercised were less likely to exercise. Participants reported:
* I never did do a lot of exercise.
* Well, to get me to exercise you would have to give me a few years.
Although I never remember doing much exercise even when I was younger!
There were some older adults who reported exercising in the past. However, as older adults they did not see the benefit of a regular exercise program. Their comments included:
* I used to do a lot of walking. I would walk around this building three times which was a mile. I used to walk to keep my figure, but now I decided what the heck. I can't do anything about that now. I put on some weight and it is all in my stomach.
* I did a lot of exercise in years gone by. I played golf and tennis. But in recent years no. At my age I guess I don't believe it makes a difference. I am pretty old and I don't think too much about it at my age.
Some of the participants had specific goals they articulated related to exercise. These goals gave them something to work toward and helped motivate them to adhere to an exercise program. Goals included being able to ambulate without an assistive device or being able to walk a certain distance to get to a desired location. Participants stated:
* That really is my goal to be able to walk to the pharmacy. If I get rid of my car that is one place I could go to without getting on a bus.
* I wanted to be able to get out of my wheelchair and walk. I want to walk to make myself better and exercise my legs.
Unpleasant Sensations Associated With Exercise
Participants described a number of unpleasant sensations associated with exercise that decreased their willingness to exercise. Unpleasant sensations included pain, shortness of breath, discomfort, fear of falling, and feelings of boredom. Comments reflecting these sensations included:
* If it was more fun I would keep coming. If it was a tour or something.
*The couple of times I walked I found I was short of breath and I had to sit down. So that took away my interest. The pain was in my chest as well, the two are pretty well connected.
* I just don't feel secure when I walk. When I am walking, even in my own apartment, I have to catch myself and that is very uncomfortable. I worry about falling. Lord knows I don't want to fall and break a hip.
The exercise behavior of the older adults in this study was consistent with prior research which showed 50% of older adults drop out of exercise programs within the first 6 months (Dishman, 1994; Emery & Blumenthal, 1990; Ettinger et al., 1997). Of the 23 participants who voluntarily started the walking program, only 40% adhered to walking regularly (i.e., at least two to three times per week for 6 months). Of the remaining 60%, seven (50%) dropped out after one walk, another five (36%) dropped out after walking only two to four times, and the remaining two individuals (14%) walked just slightly more than once per week. Moreover, the study findings supported the multidimensional quality of adherence to regular exercise in older adults (Blair et al., 1996; Dishman, 1994; Mann et al., 1997). The older adults who adhered to the walking program described an inner motivation to exercise, believed they were capable of safely exercising, recognized the benefits of exercising, set appropriate activity goals, and enjoyed the walking activity. The older adults who adhered to the walking program during a 6-month period had higher self-efficacy expectations related to exercising, fewer limitations in functional activities attributable to health, better functional performance, and fewer falls than those individuals who did not adhere to the walking program.
Based on the design of this study, it is impossible to determine if there were differences in the two groups related to self-efficacy beliefs, functional performance, number of falls, and limitations in physical function attributable to health because of walking regularly, or if those with better functional performance and stronger efficacy beliefs were more likely to walk and less likely to fall. However, it has been demonstrated (Bravo et al., 1996; LaCroix et al., 1993; Pate et al., 1995) that regular exercise improved physical health and function (Chandler et al., 1996; Guccione et al., 1994), strengthened efficacy beliefs (Fitzgerald et al., 1994; Kaplan, Atkins, & Reinsch, 1984; McAuley, 1992, 1993; Sallis, Hovell, & Hofstetter, 1992), and enhanced mood and general well-being of older adults (Chaouloft, 1997; Sharpe et al, 1997; Wolter & Studenski, 1996).
Although not statistically significant, the adherers had stronger motivation (based on the AES) than the nonadherers. Moreover, in the unstructured interviews the participants categorized themselves as being either lazy or the type of individual who was determined to keep moving and to exercise. Their underlying personality (i.e., being determined or lazy) was described as very influential in relation to their exercise behavior. Similarly, in studies of older adults in a rehabilitation program (Resnick, 1998) and in a long-term care setting (Resnick, in press), determination was identified as an essential component of motivation to participate in rehabilitation and perform functional activities. Self-motivation, which is defined as a single unitary trait reflecting a general disposition to persevere, consistendy correlates with physical activity and probably is indicative of the types of individuals who are prone to be active or inactive (Dishman, 1991).
Personality may be central to the individuals' motivation to perform, although goals, beliefs, and perceived benefits of exercise also influenced motivation and behavior. It is likely this personality attribute interacts with prior exercise experience and the individuals' beliefs about exercise and expected benefits (King et al, 1992; Resnick, 1998), and directs the individuals' ability to identify and work toward goals (Dishman, 1991).
Outcome expectations related to exercise were higher in the adherers compared to the nonadherers, although these differences were not statistically significant. The qualitative findings suggested the older adults' beliefs about exercise and the benefits of exercise had a major impact on their willingness to exercise regularly. If the expected outcome or benefit of exercise was not a desired outcome for the older adult, they were less willing to exercise regularly. For example, if the individual believed exercise prolonged fife but had no desire to "live to be 100," there was no motivation to exercise regularly.
Past experience with exercise influenced self-efficacy and outcome expectations related to exercising, outcome expectations, and perceived benefits of exercise (King et al., 1992). There were some participants who had exercised in the past but stopped exercising because the outcomes (i.e., benefits) were no longer important to them or the sensations associated with exercising had changed. Therefore, past experience indirectly may impact exercise adherence through efficacy expectations.
A major factor identified by the participants as decreasing their willingness to exercise was the unpleasant sensations associated with exercise (e.g., pain, feeling bored, fear of falling, shortness of breath). The cost or discomfort associated with an activity influenced motivation to participate in an exercise program (Kemp, 1988; Resnick, 1991, 1994, 1998) and accounted for a small (5%) but unique amount of the variance in exercise behavior in older women (Schneider, 1997). Based on the theory of self-efficacy (Bandura, 1997), unpleasant sensations associated with an activity impact self-efficacy expectations and thereby decrease motivation. However, continued research is needed to test the direct and indirect (via efficacy expectations) effects of physical sensations on motivation to exercise and exercise behavior. In a study (Resnick, 1998) of older adults in a rehabilitation program unpleasant sensations (e.g., pain) influenced behavior directly, rather than being mediated through self-efficacy beliefs.
This study was limited by the small sample and sample selectivity which included White, well educated older adults living in a CCRC and, therefore, cannot be generalized to all older adults. The older adults who exercised regularly had higher selfefficacy expectations related to exercise, better functional performance, and fewer functional limitations attributable to health. Beliefs about exercise and the perceived benefits of exercise activity, personality, past experiences with exercise, goal identification, and unpleasant sensations associated with the exercise activity were described as factors that influenced participants' motivation to exercise and adherence to a regular exercise program.
Although underlying personality and past experiences with exercise were reported to influence the older adults' motivation to exercise, it should not be assumed that because an individual is "lazy" when it comes to exercise or never has exercised in the past that they will be unable to change their exercise behavior. Aggressive attempts should be made to educate older adults about the many benefits of exercise, which may be quite different than what they perceived the benefits of exercise to be in their younger years. After teaching about the benefits of exercise, older adults should be helped to set specific, realistic goals and to recognize and celebrate the benefits of exercise as they are achieved (e.g., improved blood pressure, feelings of accomplishment).
Of equal if not greater importance, nurses should help older adults to decrease or eliminate the unpleasant sensations associated with exercising. Interventions to decrease pain such as giving medication prior to exercising, applying ice to a joint, or recommending better footwear can be implemented. Fear of falling or getting hurt during exercise also should be explored. The exercise program then should be individualized so it is free of the risks associated with falls (e.g., uneven surfaces, cluttered areas, poor lighting). For example, some older adults feel secure walking on a treadmill because they can hold on to the front frame. Helping these individuals understand that exercise itself may decrease pain in joints, shortness of breath due to deconditioning, and fatigue is essential.
Because older adults are a heterogeneous group of individuals, the factors that motivate them to exercise will vary. Not everyone wants to live to be 100 years old, but there are other goals to help older adults strive for, additional benefits from regular exercise to achieve, and many ways to help motivate these individuals to improve their exercise behavior.
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MEAN DIFFERENCES OF STUDY VARIABLES BY GROUP