According to Foster (1983), ”well elderly” are people over the age of 65 who live in the community out of an institutional setting who continue their life-long patterns of coping with life and living.
2.2.0 Physical activity and Exercise
2.2.1 Definitions of Physical Activity and Exercise
Caspersen, Powell and Christenson (1985) defined physical activity as ‘any bodily movements produced by skeletal muscles that result in energy expenditure’ whereas exercise was defined as ‘ planned, structured, repetitive, and purposive bodily movement done to improve or maintain one or more components of physical fitness.’ In several studies these two terms are used interchangeably.
Melillo et al. (1996) stated that when compared to physical activity, exercise is only a component of the overall concept. According to O’ Brien Cousins (1998) when gerontologists need to measure amounts of physical movements that the elderly may be doing , they tend to use the term physical activity instead of exercise or sport as the latter two may sound like high-exertion and risky activity.
2.2.2 Perceptions of Physical Activity and Exercise
Hutton et al. (2009) studied the view of physical activity in older adults. Some consider the involvement in everyday activities such as household chores, leisure pursuits and gardening sufficient for them to meet their physical requirements. On the other hand, others believed that activity needs would be met if one participates in specific tasks other then daily activities.
Lavizzo-Mourey et al. (2001) studied the difference in perception of exercise between the less and the more physically capable group of old adults. The less physically capable group defined exercise as maintaining basic abilities and movement. The more physically capable think that exercise should push physical limits and eventually have a goal, although they did not oppose that ageing increases the challenge in activities of daily living. Wilcox, Oberrecht, Bopp, Kammermann and McElmurray (2005) came to similar conclusions after analysing elderly women’s attempt in describing the difference between the physical activity and exercise. Physical activity was viewed as broader than exercise.
Walcott- McQuigg and Prohaska (2001) distinguished exercise definition between older adults at different stages of readiness to change, used in the Transtheoretical Stages of Change model by Prochaska et al. (1997). Precontemplators viewed exercise as a form of physical exertion such as performing calisthenics and push ups. Participation in formal programs, walking and home exercises were contemplators’ perceptions of exercise. A broader definition was given by the action and maintenance group as exercise was defined as housework, dancing, general movement and attending social functions.
2.2.3 Recommendations of Exercise
The American College of Sports Medicine (ACSM) and the American Heart Association (AHA) released exercise guidelines in 2007 which are an update from the 1995 guidelines by ACSM and Centers for Disease Control and Prevention (CDC). The new recommendation of moderate-intensity aerobic exercise for adults over age 65 identified 30 minutes a day, five days per week as the recommended minimum as opposed to previous one that stated accumulation of 30 minutes or more on most, preferably all days of the week (Haskell et al., 2007). A subjective scale that ranges from 1 (resting) and 10 (an all out effort), is used since moderate intensity cannot be defined in absolute terms. Moderate intensity exercise means working hard at about level-six intensity and being able to carry on a conversation during exercise (ACSM & AHA, n.d.).
2.2.4 Perceptions of Exercise Recommendation
In 2004, Belza et al. found that older adults understood the ACSM and CDC recommendation. In a similar study done by Wilcox et al. (2005) amongst old women, the participants expressed the idea that moderate-intensity is subjective as it depends on the person. Housework and walking were the two most examples given to illustrate the meaning. Others defined moderate intensity by the level of exertion such as sweating, when the heart start pounding and going beyond comfort level. The word ‘accumulate’ in the recommendation resulted in uncertainty. When asked to give their general opinion on the recommendation, some said that it was good and realistic and others said it was not. In the same study it has been shown that older adults believe that tailoring recommendations to one’s age and physical health is more sensible than just using ‘one-size-fits-all’ recommendation.
2.3.0 Benefits of Exercise
2.3.1 Documented Benefits of Exercise
Juarbe, Turok and Perez-Stable (2002) declared that physical inactivity is one of the most important amendable risk factor for many diseases. WHO (2003) stated that physical activity is important in the prevention of non-communicable chronic diseases such as osteoporosis, type 2 diabetes mellitus and obesity. The risk of deaths from cardiovascular disease is reduced by moderate levels of physical activity (Bassett et al., 2002, as cited in Belza et al., 2004). Blumenthal et al. (1999) stated that routine physical exercise diminishes mental concerns such as depression and anxiety. Regular exercise is also related to a reduction in the risk of falling (Gregg, Pereira & Caspersen, 2000). Cress et al. (2005, as cited by Hardy & Grogan, 2009) stated that physical activity helps the elderly to keep up a better quality of life by enabling them to have the opportunity for a more active and independent life. O’Brien Cousins (2000, as cited in O’Brien Cousins, 2003) explains that elderly see physical activity as high risk behaviour, when in actual fact it is chronic lying in bed which decondition the body and increases the risk of health problems. In fact Booth, Bauman and Owen (2002) confirm that the risks associated with a sedentary lifestyle far exceed the risks associated with regular participation in regular physical activity.
2.3.2 Knowledge and Perceptions of the Benefits of Exercise
It was found that when elderly lack the confidence in physical activity engagement, that is exercise self efficacy, being knowledgeable about the benefits of exercise will not necessarily result in increased physical activity engagement (Phillips, Schneider & Mercer, 2004).
Crombie et al. (2004) in their study found out that elderly had high levels of knowledge about the specific health benefits from exercise participation. However, a small number of participants gave the wrong responses or were unsure of the effects. 15% thought that physical activity can lead to long-term hypertension and 13% thought that exercise can weaken bones. 10% did not believe that participation in regular physical activity would not help them to feel better and in remaining independent. Most elderly believed that exercise can help to improve physical fitness, maintain levels of energy, maintain or increase muscle strength and tone, prevent aches and pains, and give them the opportunity to socialise with other people.
Wilcox et al. (2005) examined perceptions of exercise benefits and came up with three types namely being weight and appearance, physical health and mental health benefits. Physical health benefits were the most regularly mentioned benefits of exercise in this study. Such examples include heart strengthening, improving arthritis, and decreasing joint stiffness. Some pointed out specific conditions that would benefit from exercise such as diabetes, high blood pressure and cholesterol. ‘Stress reduction’, ‘improved alertness’, ‘feeling better’, ‘feeling good’ and ‘improved sleep’ are examples of mental health benefits cited in the study.
When asked about the health benefits of exercise in the study of Lavizzo-Mourey et al. (2001), many seniors mentioned weight loss and improvements in the heart and breathing. However, it was found that it was easier for elderly to appreciate or detect increased leg strength than increased cardiac fitness, even though they were interested in increasing aerobic and cardiovascular capacity.
Walcott-McQuigg and Prohaska (2001) discovered the difference in discussion of benefits between elderly at different stages of exercise. Precontemplators and contemplators discussed benefits in terms of disease processes, such as ‘it keeps you from having the hardening of arteries’, ‘prevents weight gain’ and ‘helps the circulation’. While those who exercised used terms such as ‘keeping alert’, ‘energizing’, ‘relief of stress’, ‘keeps you in shape’ and ‘prevents you from getting stiff’. Leavy and Aberg (2010) found out that the inactive and moderately active elderly did not believe strongly that being active could add to life span or avoid disease, despite not denying potential health benefits of exercise.
2.4.0 Motivators to Exercise
Resnick (1996, as cited in Keiba, 2004) defined motivation as
“the inner urge that moves or prompts a person to action…motivation comes from within.”
18.104.22.168 Personal Motivators
22.214.171.124 Health and Fitness
Newson and Kemps (2007) in their study among 222 elderly participants examined the incidence of exercise motivation from fitness, challenge or health factors. Fitness factors such as wanting to stay in shape and physically fit were marked as very frequent motivating factors in 51.3% and 51.6% of participants respectively. 30% of elderly stated that weight loss has never been a motivating factor to exercise, while 24.5% always exercise to lose weight. Cholesterol reduction and weight loss promote healthy behaviours adoption such as healthy eating and exercise in elderly (Greaney, Lees, Greene & Clark, 2004). Improving fitness, keep healthy and joint mobility maintenance were the most reported motives to engage in exercise and sports in participants of the study of Kolt, Driver and Giles (2004).
Beljic (2007) stated that competition can be an efficient motivational tool for elderly to exercise as it was common amongst elderly who constantly compared their blood glucose measurements whilst on a summer camp. Other people can be a source of external motivation through competition, cooperation and comparison (Fogg, 2003, as cited in Albaina, 2009). Factors such as competitivity and skills improvement were mostly marked as rare stimulating factors (Newson & Kemps, 2007).
Resnick et al. (2002) explained social cognitive theory of Bandura (1997). They stated that forethought regulates human motivation and action. Outcome expectations and self-efficacy expectations are the basis of the behaviour cognitive control. This means that the person has to believe that a personal action will be followed by a certain outcome, and has to believe in his or her capability to perform such course of action. Exercise engagement has been repeatedly found to be predicted by a strong self belief in accomplishing exercise (Phillips et al., 2004). Resnick (2002) identified factors that had been found to increase self efficacy in older adults. Such factors include role modelling, verbal persuasionf and encouragement, education about exercise and reduction in exercise associated unpleasant sensations.
Doing an activity the elderly really enjoy, was found to be a motivating factor to exercise (Melillo et al., 1996). Exercise adherence is influenced by physical activity enjoyment as discussed by Hardy and Grogan (2009).
126.96.36.199 Other motivators
Another exercise enabler, time availability, emerged from the various studies including that of Scanlon-Mogel and Roberto (2004). 60% of elderly in the study agreed that role changes in later life such as retirement permit more time available for elderly to participate in exercise. 9.1% of elderly in the study of Cohen-Mansfield, Marx and Guralnik (2003) mentioned increased time availability as a motivating factor.
Tolma, Lane, Cornman and Uddin, (2003) indicated that some elderly are motivated to exercise because of their perceived exercise benefits such being able to perform simple activities of daily living, keeping busy and prevent boredom.
2.4.2 Social Motivators
Keiba (2004) discussed that social support could encourage individuals to complete necessary unappealing activities because we as individuals are social in nature. This is particularly significant in the older adult who is more reluctant and cautious in attempting certain activities due to fear of decreased physical abilities and mental acuity. Berkman (1995, as cited in Resnick et al., 2002), described different types of social support related to exercise including instrumental, informational, emotional and appraisal types. Such examples of support include accompanying an old adult for a walk, sharing information about exercise, calling a friend to check if they have walked or giving verbal encouragement. According to Hardy and Grogan (2009), social support would increase elderly confidence and reassurance and thus enhance elderly self efficacy in exercise.
‘Family as encouragement’ was one of the most important themes that emerged from the study by Belza et al. (2004). Family assisted elderly participation in exercise in several ways, such as getting them exercise equipment, providing transport to exercise facilities and by encouraging their participation. Grossman and Stewart (2003, as cited in Bunn et al., 2008) agrees with the latter study as they both cited that decreasing the burden on their family by avoiding sickness was an incentive for some elderly to keep physically active. The motivation of some elderly to stay active and maintain a good quality of life arises from the death and weight problems of their loved ones (Hardy and Grogan, 2009).
Cohen-Mansfield et al. (2003) found that 14% of participants stated that having someone to exercise with, motivates them to be physically active. Wilcox et al. (2005) supported this finding as they found that elderly physical activity participation increases and becomes more enjoyable when having someone to exercise with. It was reported that elderly discussed the idea of organizing neighbourhood groups to enable increased communication, support, and planning of physical activities. Because of increased social contact and motivation, group exercise encourages some elderly to be physically active according to Lavizzo-Mourey et al. (2001). 31.3% of African American and 27% of European American in the study of Schuler et al. (2006) stated that they exercise as it is something they can do with their friends.
Swinburn, Walter, Arroll, Tilyard and Russell (1998) stated that patients consider a physician’s exercise prescription important. Pfeiffer, Clay and Conatser (2001) in the evaluation of the former statement, pointed out that the physician believe in the health benefits of exercise since he or she equates exercise with medication. 6.1% of elderly in Nowak study (2006) mentioned physician’s recommendation as a motive to exercise.
2.4.3 Environmental Motivators
Exercise facility proximity to the elderly’s house promotes exercise engagement in 10% of the participants in the study of Chen, Snyder and Krichbaum (2001). Huston, Evenson, Bors and Gizlice, (2003) studied further this enabler among elderly in America and found that performance in some type of leisure-time physical activity is increased by having access to parks, clubs and fitness centres, in the vicinity of their homes or workplace.
Bunn, Dickinson, Barnett-Page, Mcinnes and Horton (2008) identified accessible and appealing information about physical and psychological benefits of exercise as facilitators to exercise. Convenient scheduling of exercise programmes which are tailored to needs or lifestyles enable exercise participation.
2.5.0 Barriers of exercise
The Oxford Study Dictionary (1994, pg.50) defined Barrier as “something that prevents or controls advance, access, or progress”. Hardy and Grogan (2009) stated that real or perceived barriers can significantly obstruct exercise participation.
188.8.131.52 Personal Barriers
In the study of Juarbe et al. (2002), 28.6% of elderly claimed that the maintenance of a regular physical activity program was impeded by their personal health condition. Cohen-Mansfield et al. (2003) reported that the ability to stay physically active can be influenced by a variety of chronic disabling illnesses and a general lack of understanding of the role of physical activity. 53% reported pain or health problems as a limitation to exercise. The elderly had the belief that due to their medical diagnosis they should not and were not allowed to participate in physical activity. 12% were restricted by shortness of breath while 27% were impeded by painful joints (Crombie et al., 2004). The perception of making their pain worse and feeling of tiredness and dizziness restricted physical activity (Belza et al., 2004).
Petersen (2006) argued that for many older people, fear of injury is an impediment to exercise. Elderly may have multiple pathologies and they might be afraid of exacerbating their symptoms such as pain, inducing injury such as a fracture and triggering hypoglycaemia for instance. Overexertion concerns were brought up in the study of Lavizzo-Mourey et al. (2001) such as worrying of death when the heart starts beating too fast. Fear of exercise-associated falls were cited as obstacles to exercise ( Lavizzo-Mourey et al., 2001) as they lead to a decline in confidence, which in turn discourage exercise participation (Bruce, Devine & Prince, 2002, as cited in Bunn et al., 2008). Unwillingness to go out at night due to fear of being out alone hinders exercise participation (Crombie et al., 2004; Hardy and Grogan, 2009).
Wilcox et al. (2005) discussed elderly perception of being too old to exercise and their concern of doing more harm than good. 34.9% of elderly participants in the study of Nowak (2006) and 14.3% in the study of Chen et al. (2001) voiced their idea that their inappropriate age is occluding them from exercising. Zunft et al. (1999, as cited in Leavy & Aberg, 2010) in their examination of perceived barriers of the older European adults, found that being too old or ‘not being the sporty type’ were major barriers in physical activity participation. Relating physical activity to sport and the unawareness of the moderate-intensity activity importance on healthy aging, could rationalize these perceptions, argues Leavy and Aberg (2010). Crombie et al. (2004) pointed out the contribution of lack of positive beliefs of physical activity to sedentary behaviour. Some elderly women voiced their ideas that housework serves as a sufficient exercise and eliminate outside exercise activities requirement (Walcott-McQuigg & Prohaska, 2001).
Nowak (2006) reported that 7.8% of elderly women cited self-consciousness as their reason for physical passivity. Lavizzo-Mourey et al. (2001) in their study assumed that participation in group exercise might be influenced by embarrassment. As reported in the study, an elderly person was concerned that when bending over, the person behind would see the whole rear exposed. Hutton et al. (2009) in their findings of exercise barriers reported feeling of self-consciousness when exercising in the presence of younger people with gym equipment.
Dissatisfaction of the body appearance and body mass index, would affect the old adults’ body esteem and this would influence the level of physical activity (McLaren, Hardy & Kuh, 2003, as cited in Hardy & Grogan, 2009). McLaren et al. (2003) attributed this negative influence to the effect of body dissatisfaction on the person’s sense of well-being and quality of life.
Lack of enjoyment is another known barrier to exercise (Wilcox et al., 2005), in fact it impedes 8.3% of elderly participants in the study of Cohen-Mansfield et al. (2003). Laziness, lack of motivation and willpower were identified as barriers to exercise (Walcott-McQuigg & Prohaska, 2001; Wilcox et al., 2005). Dergance et al. (2003) in their study about the difference of barriers to leisure time physical activity across cultures found that 19% of Mexican Americans elderly and 45.9% of European Americans elderly stated lack of interest as a barrier. 11.4 % of elderly in the study of Chen et al. (2001) have never considered practicing T’ai Chi as they were not interested.
184.108.40.206 Other barriers
O’ Brein Cousins (2003) argues that since older people pack their schedules with voluntary work, care giving roles and probably bingo and other passive games, they genuinely feel they have no spare time left to engage in physical activity. Similarly Schuler al. (2006) reported that among their study population, 12.2% of African American and 10.1% of European American cited lack of time as an exercise barrier.
Twenty nine percent of participants in Cheng et al. study in 2007 referred to their difficulty in memorising exercise styles as a barrier to exercise. 22.9% of elderly do not consider practicing T’ai Chi as they think they will forget its complicated movements (Chen et al., 2001). The necessity of a walking aid is an impediment to exercise in the elderly (Lavizzo-Mourey et al., 2001).
2.5.2 Social Barriers
Petersen (2006), mentioned that physicians occasionally hinder lifestyle changes unintentionally. Patients are given the impression that exercise is not important as physicians do not inquire much about exercise. Rogers et al., (2006) reported low levels of physician counselling on physical activity. Only 34% of a survey participants cited being advised on exercise at their last doctor visit (Wee, McCarthy, Davis & Phillips, 1999, as cited in Resnick et al., 2002). O’Neil and Reid (1991, as cited in Melillo et al., 1996) found that 16% of elderly did not exercise as their doctor advised them to be careful and not to over-exert themselves.
Belza et al., (2004) reported that elderly mentioned family and work obligations which interfere with physical activity routine maintenance. Walcott-McQuigg and Prohaska (2001) indicated that family responsibilities such as caring for grandchildren and older or ailing relatives are restricting the time available for elderly to be physically active. It was also stated that repeated family advice and encouragement can become irritating to the elderly person. Lack of social support from spouse, family and lack of company obstruct exercise participation (Lees, Clark, Nigg & Newman, 2005; Wilcox et al., 2005). Ball, Bauman, Leslie and Owen (2001, as cited in Salvador, Florindo, Reis & Costa, 2009) stated that walking during leisure time is 31% less likely in individuals who do not have anyone to exercise with. Antikainen et al., (2010) pointed out the elderly family members’ concern of overexertion and thus resulting in little encouragement to exercise.
Negative comments directed to elderly who attempted to exercise discourage physical activity participation (Jancey, Clarke, Howat, Maycock, & Lee, 2009). Lavizzo-Mourey et al. (2001) emphasize this barrier as a group of children was a source of intimidation and hazard for certain elderly whilst doing exercise.
2.5.3 Cultural Barriers
A barrier that emerged in the study of Wilcox et al. (2005) was that in the past, exercise was not something discussed and stressed on, and they did not have exercise role models. In fact one elderly woman cited that she cannot visualize her mother doing exercise or even speaking about it. Similarly in the study of Nowak (2006) it was found that the most barriers associated with physical inactivity were cultural, originating from the lack of cultivated customs of a physically active lifestyle in the society. Physical labour of past African American’ jobs led to their perception that additional exercise was not necessary (Walcott-McQuigg & Prohaska, 2001).
2.5.4 Environmental Barriers
Difficulty, element of competition and lack of attraction of exercise classes were some of the elderly views that hindered their participation in a class, according to Hutton et al. (2009). Uneasiness was a mentioned concern in a group exercise environment and this pressure is owed to the inability of keeping pace with the class. Wilcox et al. (2005) supported this report by his findings in which elderly discussed the lack of age-appropriate classes and expenses.
In the study of Cohen-Mansfield et al. (2003), 10.9% of participants reported bad weather as an obstacle to exercise. Several issues related to rurality such as transport unavailability, lack of pavements, lack of safety and facilities were considered as barriers in Wilcox et al. study in 2005. Pfeiffer et al. (2001) supported these findings by their study and attributed the unavailability of sidewalks with the fear of falling and hence makes walking an unappealing exercise. In the study of Lavizzo-Mourey et al. (2001), unevenness of steps and pavements was cited as another barrier. 16 % of elderly in Cheng et al. study (2007) cited limited public space available to do exercise. Limitation and inappropriateness of space to exercise in the house was found to be a barrier in the study done by Juarbe et al. (2002), usually due to the fact that they live in a confined space with their relatives, shared residential homes or in an apartment. Hardy and Grogan (2009) in their investigation of the factors influencing engagement in physical activity concluded that the lack of information about exercise and the elderly is limiting their participation.
2.6.0 Variables affecting Impeding and Motivating Factors
O’Brien Cousins (1995, as cited in O’Brien Cousins, 2003) has shown that the elderly involvement in exercise could be significantly affected by the individuals’ life circumstances such as the age, gender, education and health.
Bylina et al. (2006) cited National Center for Chronic Disease Prevention and Health Promotion when stating that 28-34% of adults between 65-74 years old and 35-44% of adults aged 75 or older are inactive, not exercising, and engaging in no leisure-time physical activities.
Newson and Kemps (2007) compared those older than 75 years to their younger counterparts. They were more likely to exercise to maintain an active lifestyle and medical problems were more likely to prevent them from engaging in exercise. Kolt et al. (2004) found that involvement factors such as getting out of the house and having something to do, and medical motivators were rated more highly by those 75 + than the ‘middle old’. The middle-age group reported fitness reasons to be more important than the old-age group. The high ratings of involvement factors may be explained by McMurdo (2000) when stating that loneliness and isolation faced by older adults may be countered by the experience provided by physical activity and exercise.
2.6.2 Level of Education
Walsh, Rogot, Pressman, Cauley and Browner (2001) found out that medium or high intensity activities were activities that elderly women with greater than a high school education, were more likely to engage in. Similarly Cheng et al. (2007) reported that exercise participation was lower in less educated people .
Highly educated elderly were found to be highly motivated to exercise by social and fitness motivators (Kolt et al, 2004) and an organized exercise program (Cohen-Mansfield, 2003). Involvement reasons were highly rated by those who did not complete high level education (Kolt et al, 2004).
2.6.3 Level of Exercise
Time constraints and physical weakness were identified as barriers by the exercisers, while fear of falling and the negative consequences were mentioned by the non-exercisers. Lack of social support is a significant barrier for both. Having a buddy-system in a group exercise would encourage non exercisers to exercise (Lees et al., 2005). Fitness and Challenge factors were reported as frequent motivators by the high-level exercisers when compared to low-level exercisers. Concern, medical factors and lack of facilities and knowledge were rated as frequent barriers to low-level exercisers (Newson & Kemps, 2007). Health problems were more likely to be identified as barriers by the precontemplators, although it was a common report among the other groups. Lack of motivation and laziness were identified as barriers by the elderly at every stage of readiness to change (Walcott-McQuigg & Prohaska, 2001). Social interaction was an opportunity which motivated the less active participants in particular, to take part in exercise (Leavy and Aberg, 2010).
2.6.4 Marital and Habitual Status
Cohen-Mansfield et al. (2003) found that having more time available would motivate a lot of married elderly to exercise more frequently. Additionally, it was discussed that since the unmarried would probably be more in need of social interactions, they showed more of an interest in finding someone to accompany them in exercise. It was further discussed that the more socially isolated persons may benefit from social forms of exercise as group exercise would motivate them to exercise.
Elderly persons have different perception of exercise definition, recommendation and benefits. A vast range of motivators and barriers were found to encourage or impede elderly participation in exercise. The perceptions, barriers and motivators were also found to differ with different elderly’ background characteristics and level of exercise.