Background
The public health burden of physical inactivity in the UK is substantial with an estimated cost to the National Health Service (NHS) of approximately £1.06 billion per year (National Institute for Health and Care Excellence) [
1]. As such, physical inactivity has been said to be “one of the most important public health problems of the 21
st century” [
2] (p 1).
The role of sustained participation in physical activity (PA) throughout the life-course provides some of the best prospects for ageing well [
3]. Regular PA has been shown to reduce the risk of chronic diseases such as ischaemic heart disease, hypertension, type 2 diabetes, osteoporosis, some cancers, and depression [
4]. Maintaining a PA lifestyle has also been shown to reduce the risk of all-cause mortality [
5,
6]. A growing body of evidence is developing regarding the cognitive benefits of sustained PA in older people as well as improved quality of sleep, health-related quality of life, and lower risk of falls [
2,
4].
The importance of being physically active through life and exercising with others is well acknowledged but approximately half of participants who commence an exercise programme will drop out within the first six months [
7,
8]. Reviews of community-based group exercise interventions for older people have shown more favourable adherence outcomes with adherence rates of between 69.1–75% [
9,
10].
Not only have community-based group exercise programmes (CBGEP) been shown to increase PA levels for older people, they have been found to provide functional improvements such as increased mobility, flexibility, and upper and lower limb function [
11‐
18]. CBGEP also have positive effects on participants’ subjective sense of wellbeing, balance and fear of falling, and health related quality of life [
18,
19].
One key facilitator for influencing older people’s adherence to CBGEP is the role of social support and its ensuing networks [
9,
20,
21]. This is important because the quality and quantity of a person’s social relationships are a key health determinant, not only in terms of mental health but also in relation to morbidity and mortality [
22]. Individuals with adequate social relationships have been found to have a 50% greater likelihood of survival when compared to those with limited social support [
23]. The extent of this effect was argued to be comparable with cessation of smoking [
23]. It has been suggested that there is a need to explore types of intervention that offer older people the opportunity to interact with others whilst increasing PA levels within real-life programmes within a community settings [
9,
24].
The current study offers a unique insight into real-life programmes (i.e. not under laboratory conditions or research trial conditions) which have been successful in helping participants maintain adherence for a year or more. Specifically, the aim of this study was to understand how and why older people (≥ 60 years) have sustained long-term adherence (≥ 69.1% for ≥ 1 year) to three CBGEP in the South West of England. Ethical approval for the study was obtained from Bournemouth University Research Ethics Committee (reference number 5103). All participants gave written informed consent.
Discussion
This multiple-case study was conducted to understand how and why older people (≥ 60 years) have sustained adherence (≥ 1 year) to real-life CBGEP. The analytical technique of explanation building was employed to seek to build an explanation of the role of six theoretical propositions as derived from the literature might influence participant adherence. Five of these propositions were found to be noteworthy in influencing ongoing adherence. The sixth proposition (related to the energising and empowering effects) was discounted due to a lack of cumulative evidence following the explanation building technique.
Firstly, the importance of
factors related to the individual was highlighted as being important for participant adherence to CBGEP. Aspects such as participant characteristics of commitment, perseverance, preference for a routine or structure in their week, a desire to stay active in order to maintain independence, and being physically active in the past have been similarly reported by Chiang et al. [
47] in their study of the experiences of ethnic older people (mean age 76 years, 85% female) in CBGEP. What this current study adds is the way that in some situations, participant circumstances appeared to play a role in their ongoing adherence. For example, for participants who lived alone, the opportunity to leave the house and be with others was important. For others, the personal circumstances of being a carer for their spouse meant that the CBGEP served as an opportunity to have time to themselves. In this way there was a sense that the CBGEP acted as a mental escape. The CBGEP afforded participants the opportunity to have time away when they were not required to function in another role, for example in their caring role. Participants commented that it was a time when they could forget their day-to-day worries and switch off, perhaps escaping mentally. This concept of escapism has similarly been reported in relation to regular, long-term exercise adherence [
48] and in relation to pleasure as a source of immersion through which the focus on the exercise facilitates an escape [
49]. However, this notion of escape has not been noted as a factor in relation to older peoples CBGEP adherence before.
Personal motivations to continue adhering stemmed from participants desires to maintain health and independence. For some this was so they could remain strong and healthy enough to continue to provide practical support in their role of caring for their spouses or family. For others, the motivation was based on remaining well enough to continue to live independently in their own home. This motivation to remain independent has similarly been reported by Hartley and Yeowell [
50] in their study of what would potentially influence older people’s adherence to CBGEP. This desire to keep healthy and maintain independence implied a view about caring for the future. This is a flourishing view of participants’ long-term health and wellbeing which could be inferred as a eudaimonic understanding of wellbeing [
51]. There was also a sense that PA was something that their body needed and attending the programme was enjoyable and thus a pleasure. Therefore conceptually this could be suggested as a hedonic experience [
51,
52]. The concepts of eudaimonia and hedonia are important because they are central to the study of wellbeing [
52].
There was evidence from this study regarding the role of the
instructor as an important construct for older people’s adherence to CBGEP. This is supported by the existing exercise literature around older people’s engagement in CBGEP where the instructor has been noted to play an important, but not isolated role [
53].
Based on the findings of this current study it is suggested that instructors need to be knowledgeable and competent yet approachable and human. It is this notion of the way participants were treated in a humanised manner which is unique knowledge generated from this current study. Instructors aided participants in maintaining agency by equipping them with information so they could self-select their exercise intensity depending upon their ability. This supported an environment whereby participants could exercise without criticism or judgement. Instructors were sensitive to the insider experiences and challenges faced by participants; they were not treated like an object. The instructors cared for and supported their participants. The fact that participants were treated in a humanised way suggests that this is a factor in the success of good programme adherence rates in these three cases.
This study highlighted the importance of considering several practical and structured features with regards
programme design to support ongoing participant adherence to CBGEP. Aspects of programme design such as of location, affordability, adaptability of the exercises, safety, music, and opportunities to socialise have previously been noted in the literature around older people’s exercise adherence [
47,
54‐
57]. This current study adds the suggestion that these features of programme design align with Herzberg’s dual factor theory [
58]. This theory has become acknowledged as one of the most widely used theories in understanding motivation and satisfaction [
59].
Herzberg argued that employees’ needs could be categorised as either relating to satisfaction (motivators), or to dissatisfaction (hygiene factors). This is relevant because when satisfiers and hygiene factors are present work outcomes are improved with a reduced rate of absenteeism [
58,
60]. Thus, there may be parallels to be found in hygiene factors and satisfiers relating to CBGEP adherence.
In the context of CBGEP, it is suggested that several extrinsic factors such as location, affordability, or having an individual and adaptable content may function as hygiene factors. This would mean that the extrinsic factors do not necessarily contribute to participant satisfaction, but if those extrinsic factors were not present, they may lead to participant dissatisfaction with the programme, and potentially non-adherence. Conversely, it is proposed that satisfiers or motivators such as social factors or humanising elements contribute little to participant dissatisfaction but much to satisfaction and thus ongoing adherence. What this would mean in practice is that whilst factors such as location, affordability, music, and an adaptable content need to be present, these factors are not necessarily key in promoting participant satisfaction. However, they need to be present to prevent participant dissatisfaction. Thus, for this reason these programme design features do have a role to play in supporting ongoing participant adherence. Other elements reported in this study may serve to work more explicitly as motivators for example the social factors.
The roles of social interactions in CBGEP have been noted to add to participants’ networks and serve as a source of support, enjoyment and belonging [
9,
50,
53]. This study corroborated these findings indicating that there was strong support for the social features of CBGEP in aiding participant adherence. The social, group dynamic of the programmes added to participants’ wellbeing by providing social, supportive environments which offered a means for older people to maintain social connectivity over the latter part of their lives. Maintaining these connections is important because there are increased health risks related to social isolation [
23].
In particular, what this current study adds to the literature around the social aspects of CBGEP is further support for the importance of the sense of togetherness and belonging experienced by participants. This appeared to affect the way the participants felt about the group. It reveals the importance of the lifeworld as a viewpoint in understanding “an experienced world of meaning” [
61] (p 55) with regards to CBGEP adherence. The notion of the lifeworld has been used as a philosophical foundation underpinning our perspectives for humanising healthcare [
61]. These current authors would suggest that the lifeworld as an experienced world of meaning can also support perspectives for humanising older people’s adherence to CBGEP.
The physical health benefits of sustained exercise are well documented [
62].
Perceived physical gains such as weight loss, cardiovascular fitness, and improved muscle strength were recognised by participants in this current study as an important outcome. However, the
perceived psycho-social gains such as fun, enjoyment, and the notion of togetherness were also essential. Understanding these broader gains is important because emphasising the breadth of positive improvements associated with PA engagement is key in optimising uptake [
63]. If CBGEP are to be promoted the psycho-social gains as well as the physical need to be affirmed. Participants seemed unlikely to adhere to a programme long-term that did not meet these psycho-social needs.
The CBGEP were noted to empower participants to self-manage painful long-term health conditions, such as back or neck pain. This is important not only in enabling individuals to maintain independence, but also in the context of financial challenges on the health service where self-management of long-term conditions may reduce health care costs [
64]. Thus, CBGEP are of interest to those who commission services as an effective opportunity for supporting and empowering older people to manage their long-term health conditions.
The above findings are important because they add to the literature around understanding older people’s adherence to CBGEP. This is of relevance to practitioners and policy makers alike since CBGEP appear to be a possible means of encouraging sustained PA and social connectivity.
Strengths and limitations of the study
Strengths
A strength of this study was the fact that the authors intentionally chose to study successful programmes (defined as adherence rates of ≥ 69.1% for ≥ 1 year), in a real-life context. To date, the authors are aware of only one study (from Canada) that chose participants in a real–life context who had displayed long-term adherence for the explicit purpose of studying ‘success’ [
55]. Thus this current study is unique, being the first of its kind to study older people’s adherence to CBGEP in a real-life, UK context, from a long-term (≥ 1 year) perspective. The real-life context of the study is an important asset since participants recruited for an interventional randomised controlled trial are recruited differently to community exercisers, thus generalisability is limited between populations [
65]. Findings from this current study are thus highly relevant in terms of real-life CBGEP. In addition, the cases included in this current study have all demonstrated ongoing sustainability to their programmes. The financial sustainability is particularly important in this present economic climate where programmes which have demonstrated sustainability are highly valued.
Limitations
This current study was subject to several limitations. This study only considered individuals who had been attending the CBGEP. There are many people who do not have this opportunity and the issue of how we engage with others who would benefit from this type of group was not addressed. Participants were self-selecting and thus might represent a highly motivated group of older people introducing potential bias. This means there is limited application to older people who drop out of CBGEP or to those who may be less social but still choose to exercise. Another limitation was the lack of data collected on ethnicity due to an omission by the researchers. Additionally, this study was limited to older people from one county in the South-West of England. Further cases should be selected from other counties using a similar study design to increase the applicability of the findings.
Conclusion
The aim of this study was to understand how and why older people (≥ 60 years) have sustained long-term adherence The current study offers five unique insights into real-life programmes which have been successful in helping older people maintain adherence for a year or longer.
Firstly, there were factors related to the individual such as their desire to maintain their health and independence. Secondly, the instructor supported adherence through their personality, professionalism, and humanised approach. This helped participants feel cared for and established their sense of belonging to the group. Thirdly, several aspects of programme design such as location, affordability, the use of music, and adaptable exercise content promoted adherence. Fourthly, the social, group dynamic of the programme led to participants expressing a sense of togetherness and belonging which served as a conduit to adherence. Finally, participants perceived physical and psycho-social benefits such as weight loss, cardiovascular fitness, sense of fun, and enjoyment as contributing to their ongoing adherence.
An area for further research has been highlighted from this study based on the concept of escapism in supporting adherence to CBGEP for those who act as a main carer. This will add further understanding about how carers can be supported to continue in their vital roles whilst maintaining their own physical and mental well-being.
Acknowledgements
The authors are grateful to the study participants from the community-based group exercise programmes and instructors who so generously gave their time.