Preventive Medicine 39 (2004) 1056 – 1061

www.elsevier.com/locate/ypmed

Review
Barriers and motivations to exercise in older adults
Karen A. Schutzer, R.N., M.S. a,* and B. Sue Graves, Ed. D. b,1
a
Florida Atlantic University, Davie, FL 33314, USA
b
Department of Exercise Science and Health Promotion, Florida Atlantic University, Davie, FL 33314, USA

Available online 11 June 2004

Abstract

Although exercise is an established component in the management of many chronic diseases associated with aging, activity levels tend to
progressively decline with increasing age. Given the growing proportion of older adults, these suboptimal levels of physical activity represent
an increasing public health problem. The predicators of adherence elucidated in younger adults are unreliable in elderly populations. Age-
specific barriers and motivators unique to this cohort are relevant and must be acknowledged. The identification of reliable predictors of
exercise adherence will allow healthcare providers to effectively intervene and change patterns of physical activity in sedentary elderly. In
particular, because older patients respect their physician’s advice and have regular contact with their family doctor, physicians can play a key
and pivotal role in the initiation and maintenance of exercise behavior among the older population.
D 2004 The Institute For Cancer Prevention and Elsevier Inc. All rights reserved.

Keywords: Elderly; Aging; Exercise adherence; Physical activity

Introduction Trends in physical activity consistently show that activity

In 1996, the Surgeon General’s Report on Physical
Activity and Health established the importance of a phys-
ically active lifestyle in the prevention of chronic disease
and the promotion of health and well being [1]. The report
linked sedentary behavior to osteoporosis, obesity, depres-
sion, and to the staggering death rates from coronary heart
disease, type 2 diabetes, and colon cancer. Participation
and maintenance of regular physical activity was recog-
nized as one of the most important health behaviors in
preventing the onset or reducing the severity of many
chronic diseases.
Yet, despite documentation of the physical and psycho-
logical benefits derived from regular activity, surveys con-
clude more than 60% of the adult population is not engaged
in physical activity on a regular basis and 31% of adults are
not exercising at all [1]. In the United States, the annual
number of deaths related to physical inactivity is estimated
at more than 250,000 [2].
* Corresponding author. Florida Atlantic University, 2912 College
Ave., Davie, FL 33314. Fax: +1-267-989-4938.
E-mail addresses: karenschutzer@hotmail.com (K.A. Schutzer),
sgraves@fau.edu (B.S. Graves).
1
Fax: +1-954-236-1259.
levels progressively decrease with age. The prevalence of
inactivity is highest among adults aged 65 or greater [1],
which due to aging baby boomers will shortly become the
fastest growing segment of the American population. Cur-
rent estimates indicate that 66% of adults over 75 do not
engage in any regular physical activity [3]. Moreover,
evidence suggests that 50% of sedentary adults have no
plan of starting an exercise program [4]. Among those
engaged in physical activity, adherence rates reveal only
30% of older men and 15% of older women actually
participate in regular sustained activity [1].
Given the growing proportion of older adults, the sub-
optimal levels of physical activity in the United States
represent an increasing public-health problem. This predic-
ament will continue to increase as the growth of the over 65
age group is expected to increase by 29.7– 36.4% between
the years 2010 and 2020 when the large cohort of baby
boomers reach retirement age [5]. Although an increased
vulnerability to chronic disease and disability is inherent in
the aging process, evidence suggests being physically active
may alter the course of many frequently occurring diseases
among the elderly. Not only has regular exercise been
specifically reported to reduce the risk factors associated
with heart disease and stroke, exercise is also an important
factor in reducing overall morbidity and mortality [6]. In

0091-7435/$ - see front matter D 2004 The Institute For Cancer Prevention and Elsevier Inc. All rights reserved.
doi:10.1016/j.ypmed.2004.04.003
 K.A. Schutzer, B.S. Graves / Preventive Medicine 39 (2004) 1056–1061
addition, an active lifestyle helps to increase the quality of
life of older adults by preserving functional ability and
independence across the life span.
Physical activity has been defined as any bodily move-
ment produced by skeletal muscles which results in energy
expenditure [7]. Moderate physical activity performed at 3
to 6 METS (equivalent to brisk walking at 3 to 4 miles per
hour) is recommended for good health and optimal physical
function in the elderly [6]. In contrast, the term exercise
indicates a regularly structured program of physical activity
seeking optimal levels of fitness [7].
However, persuading the elderly to become physically
active is a difficult task. While the importance of an active
lifestyle is well known, the elderly often believe themselves
to be too old or frail for physical activity. Exercise is rarely
viewed as a necessary prescription medicine. In addition,
older adults, due to a preponderance of health problems,
encounter more barriers to physical activity and exercise
participation. Varied interventions studied to enhance exer-
cise participation have consistently revealed limited evidence
for long-term effectiveness in this age group. The largest
attrition occurs within 6 months of exercise initiation, with
approximately 50% of participants dropping out before
realizing any health benefits [8]. Unfortunately, those with
the most to gain from exercise activity are least likely to
participate.
Because physical activity is a complex and dynamic
process involving an intricate series of behaviors, identifi-
cation of the variables affecting exercise adherence is often
difficult. However, awareness of the individual factors
affecting exercise behavior in this cohort is essential to
determine the interventions associated with the greatest
participation and maintenance of exercise behaviors. Iden-
tification of reliable predictors among older adults will
allow healthcare providers, situated in a unique position to
influence health habits of their patients, to effectively
structure interventions to promote change in patterns of
physical activity in sedentary individuals. By improving
health status, physical activity participation will ultimately
reduce the need for healthcare services among the elderly
and ease the economic burden sedentariness places on
today’s healthcare system.
Elderly pose unique challenge
Although the benefits of regular physical activity have
been studied extensively, researchers have only recently
examined the determinants of physical activity in special
populations such as the elderly. The focus of earlier exercise
research was centered on healthy young and middle-aged
white men [9]. As research into the older population has
progressed, it is apparent that physical activity behavior in
older adults is associated with diverse factors from multiple
domains. Not surprisingly, the predictors of exercise adher-
ence elucidated in younger adults are unreliable in elderly
1057
populations. There does not appear to be a one-size-fits-all
approach to physical activity [10]. Unique challenges are
associated with initiating and maintaining physical activity
in the elderly.
First, as Chao et al. [10] point out, many elderly deem the
adoption of moderate physical activity as time consuming.
Time commitments include the time needed to perform
activity and the time required for travel to an exercise
facility. This time commitment increases substantially for
those who rely on public transportation.
Furthermore, these investigators maintained older adults
tended to view exercise as a recreational pursuit instead of
necessary medical therapy. This viewpoint is perpetuated
because health practitioners frequently give unclear direc-
tions when recommending exercise. Healthcare providers
were likely to instruct elderly patients to ‘‘be more physically
active’’ without offering specific guidelines. The ability of
providers to recommend appropriate exercise guidelines
is also compounded by the fact many elderly suffer from
poor concentration, memory deficits, and dementia.
Additionally, the authors contended that the elderly often
perceived the symptoms associated with exercise as nega-
tive. Sweating, labored breathing, and muscle soreness
typical during exercise is believed by some to do more
harm than good. Older women, in particular, were often
raised to believe exercise is not ‘‘ladylike.’’
Barriers to exercise
Thus, acknowledging the unique challenges and clarifying
the relevant issues is an essential step in developing a strategy
to facilitate exercise in the elderly population. Yet, regardless
of an individual’s beliefs in the benefits of regular exercise,
many barriers, real or perceived, exist which represent
obstacles to the adoption and maintenance of exercise be-
havior. O’Neill and Reid [11] found that 87% of the elderly
have at least one barrier to prohibit exercise participation.
An overview of the exercise science literature indicates
certain domains as strong influences for sustaining regular
exercise programming, although uncertainty still exists as to
what variables or strategies are most effective in influencing
long-term adherence. These domains can be classified as
either motivators or barriers to exercise. The following is a
discussion of the perceived barriers or constraints to exer-
cise that have gained empirical support.
Health
Unlike younger adults who typically cite lack of time as
the main constraint to exercise [4,12], the elderly most
frequently cite poor health as the leading barrier to both
physical activity and exercise. In a relatively recent inves-
tigation of community-dwelling elderly, health problems
and pain emerged as the most common barrier to exercise
[13]. These findings were also consistent with survey data
1058 K.A. Schutzer, B.S. Graves / Preventive Medicine 39 (2004) 1056–1061
obtained from Booth et al. [14] in their investigation of
inactive elderly Australians. In this particular study, the data
obtained rated both ill health and injury as the major barrier
to exercise participation in respondents aged 60 to 78 years.
In a 10-year follow-up study of home-based walking in
postmenopausual women, illness was again found to best
predict long-term exercise behavior [15].
Environment
The physical environment can also present as a potential
barrier to exercise adherence. Environments with available
and convenient resources used both for exercise and phys-
ical activity performance, such as sidewalks, parks, recrea-
tion centers, and fitness facilities, make it easier for people
to be exercise. Conversely, environments with high crime
decrease the likelihood of people becoming more active.
The CDC was first to document a relationship between the
prevalence of physical activity and neighborhood safety
[16]. In 1996, data from the Behavioral Risk Factor Sur-
veillance System (BRFSS) were analyzed in selected states.
The results indicated older adults, especially for whom
walking was the preferred exercise modality, performed
greater levels of physical activity when they perceived
higher levels of safety in their neighborhoods.
In contrast, a similar study in Australia looking at perceived
environmental influences associated with physical activity,
found no significant difference between neighborhood safety
and levels of sustained walking [12]. Geography and crime
pattern differences between the two countries may offer a
possible explanation for the inconsistency in the findings.
Inevitably, these data suggest to promote exercise behavior
among older adults, some level of public health action and
community support is needed to provide alternatives or
ensure safe physical environments within communities.
Booth et al. did, however, confirm structural constraints
in the environment as barriers to exercise. Elderly individ-
uals not living in close geographic proximity to a recrea-
tion facility, park, golf course, swimming pool, or foot
path were found to be significantly more inactive. The
association between levels of exercise participation and
access or convenience to exercise facilities was demon-
strated as well in studies of exercise determinants among
younger populations [17].
Physician advice
Physicians play a key and pivotal role in promoting
exercise behavior among the elderly. In general, Americans
average 3.1 office visits per year to their doctor [18]. For the
older population, beleaguered by chronic health conditions,
this statistic is even higher. In a 2003 survey of 146 elderly
living in public housing, 94% of the respondents reported
visiting their physicians at least once in the past year [19].
Clearly, this establishes the family physician as the most
effective person for giving advice about exercise [20].
Despite optimum exposure to the general public, re-
search findings have indicated physicians are not regularly
counseling their patients about exercise [19 –21]. Balde et
al. [19] found only 62% of the respondents in their survey
received advice about exercise from physicians. However,
with advancing years, the inactive elderly generally pre-
ferred to receive exercise advice or support from their own
physician or healthcare professional [12]. In a selected
sample of 301 Medicare beneficiaries living in the metro-
politan Baltimore area, 40% of the patients who initiated
an exercise program did so because of their physician’s
influence [22].
Common barriers cited for lack of physician intervention
include: lack of time during the office visit, limited reim-
bursement for preventive counseling, and the lack of train-
ing and perceived effectiveness as a behavioral counselor
[21]. However, because patients respect their physician’s
advice, the elderly are more likely to change their levels of
activity as a result of conversations with their physicians.
Elderly adults who receive exercise advice from their
physician perform more moderate to heavy levels of exer-
cise per week than those who did not receive advice [19].
Knowledge
In the elderly population, the lack of knowledge and
understanding of the relationship between moderate exercise
activity and health is an especially relevant barrier, as many
lived through a time period when exercise was not valued or
deemed necessary. Many elderly feel they already receive
enough exercise in their activities of daily living [11]. Poor
awareness of the role of exercise in disease prevention is
seen not only among the elderly in the United States, but
also in other countries. For example, in Hong Kong, 812
Chinese adults were surveyed. The results revealed levels of
exercise and activity decreased with age. When asked to rate
various behaviors as factors contributing to their health,
older Chinese adults perceived any form of physical activity
as the least important influence to good health [23]. This
data confirm that sedentary behavior can be related to
limited educational opportunities. Interestingly, the authors
also reported a greater proportion of Chinese adults than
American adults were completely sedentary.
Knowledge of and belief in the health benefits derived
from exercise actually seem to be more helpful in motivat-
ing initial involvement in an exercise program. Yet as
Dishman [4] points out, the level of one’s knowledge does
not necessarily translate into long-term exercise adherence.
Over time, perceived feelings of enjoyment and satisfaction
appears to better predict higher levels of adherence [24].
Childhood exercise
In conjunction with the publication of the Surgeon
General’s Report on Physical Activity and Health, research-
ers are working to understanding the potential carryover
 K.A. Schutzer, B.S. Graves / Preventive Medicine 39 (2004) 1056–1061
effect of exercise benefits achieved during youth. Although
limited studies have been performed thus far, some evi-
dence exists that exercise patterns in childhood can ad-
versely affect levels of exercise in adulthood. In their
investigation, Taylor et al. [25] used a sample of 105
middle-aged males ranging in age from 32 to 60 years, to
administer a questionnaire on physical activity patterns and
psychosocial factors related to exercise during childhood.
The researchers found a weak negative relationship be-
tween the experiences and factors from childhood and
adolescence and current activity levels. Although participa-
tion in team sport was positively associated with greater
adult exercise behavior, being forced by parents to exercise
in the preteen years seemed to negatively affect exercise
participation in adulthood.
Motivators for exercise
Because of the complex interaction between the large
number of potential variables associated with behavioral
change, many of the barriers to exercise for the older adult
can actually serve as motivators to exercise activity. In their
research, Cohen-Mansfield et al. [13] noted barriers to
exercise to be highly related to motivators. For example,
deteriorating health, which can reduce an older adult’s
ability to exercise, was also frequently cited as a motivator
for increasing physical activity. Other motivators reported
by Cohen-Mansfield et al. include having more time,
receiving more information on exercise benefits or physi-
cian recommendation, and living closer to an exercise
facility.
Consequently, if more elderly are to profit from the
benefits of exercise, the salient issue for health and exercise
professionals is ensuring that the behavior becomes habit-
ual. Therefore, awareness of the cognitive processes specific
to motivation and behavioral change is fundamental to
understanding exercise adherence. Self-efficacy is the es-
sence of this process.
Self-efficacy
The concept of self-efficacy is consistently identified as
an important determinant of exercise behavior in various
populations and in many types of behavioral learning
throughout the scientific literature. Defined as an individ-
ual’s belief in their ability to successfully perform a specific
behavior, self-efficacy plays a central role in Bandura’s
social cognitive theory [26]. According to the theory of
social cognition, self-efficacy is a product of both expect-
ations (perceived ability to achieve a certain behavior) and
outcomes (expected success the behavior will provide).
Personal efficacy is based on four major sources of infor-
mation: performance experience or mastery, vicarious or
observational experiences of others, verbal persuasion, and
emotional and physiological states. Self-efficacy expect-
1059
ations mediate all behavioral change and determine whether
an individual attempts a given task, the degree of persis-
tence when difficulty is encountered, and ultimate success
or failure of the behavior [26]. The stronger one’s self-
efficacy expectations and outcomes, the more likely the
individual will initiate and persist with a specific behavior.
Barring health factors, self-efficacy exerts a consistently
powerful influence on the exercise behavior of older adults
[27 –29].
In one of few studies designed to systematically examine
long-term predicators of self-efficacy in the elderly, McAu-
ley et al. [30] independently assessed several of the social
cognitive constructs theorized to be important in the forma-
tion of self-efficacy beliefs. McAuley et al. studied the
extent to which the effects of perceived social support, the
value of physical health, affective responses to exercise
(pleasure or displeasure associated with an exercise session),
and exercise frequency were related to exercise adherence.
The data obtained in an 18-month follow-up after 6 months
of exercise training reaffirmed the role of self-efficacy in
long-term exercise participation.
As the investigators hypothesized, the frequency of
exercise influenced the degree of social support from the
group and the exercise-related affect. These two factors
acted together as sources of self-efficacy, ultimately deter-
mining levels of activity at the end of the trial and at follow-
up. Although the findings suggest a significant relationship
between social support and exercise adherence, this influ-
ence does appear to be indirect. Furthermore, enhancing
social support appears to be gender-specific. A higher level
of exercise efficacy associated with social support is usually
noted among older women [31].
Another variable in self-efficacy, group cohesiveness,
also appears to be related to levels of exercise adherence
in older adults. In an investigation involving two separate
studies focused on group cohesion, perceptions of similarity
and closeness within the group predicted both short and
long-term adherence [32]. In the first study, exercise partic-
ipation (attendance) was examined and in the second study,
the effects of team building strategies or group goal setting
to enhance cohesion were explored. Adherence data were
measured at months 1, 6, and 12 of a 12-month program in
study one and after a 10-week hiatus of a 6-week program in
study 2. Data collected on the participants in the team-
building condition indicated significantly higher rates of
adherence than in the other study condition.
The self-efficacy data cited in the above studies among
older adults were consistent with the observations of many
previously published research reviews on exercise adher-
ence also reporting perceptions of efficacy as important
predictors in the acquisition and maintenance of new be-
havior [9,33 – 39]. In general, the majority of research
affirms self-efficacy beliefs as critical in the initial adoption
of an exercise routine. Feelings of pleasure and satisfaction,
along with self-regulatory skills, are more important in
sustaining exercise behavior. Self-regulatory skills include
1060 K.A. Schutzer, B.S. Graves / Preventive Medicine 39 (2004) 1056–1061
goal setting, monitoring of progress, and self-reinforcement
or motivation.
Prompts
Various behavioral strategies have been analyzed to
enhance self-regulatory skills and facilitate exercise com-
pliance in aging adults. However, many of the tested
interventions have typically involved intense education with
lengthy contact between study participants and researchers.
In an attempt to identify more efficient and less costly
methods to motivate and promote exercise behavior, the
use of prompts, such as informational mailings and tele-
phone contact, have been investigated.
Telephone supervision is a common feature in home-
based exercise training programs. In a study comparing
home-based exercise to organized group exercise, the inves-
tigators discovered the telephone-supervised (home-based)
program was as effective as the face-to-face interventions of
the group program in increasing health benefits and exercise
participation [40]. This research suggested telephone
counseling serves as a source of social influence and
support, which can enhance participant motivation and
ultimately improve compliance.
In an effort to evaluate the effectiveness of telephone vs.
mail-mediated interventions on exercise in older adults,
Castro et al. [41] discovered although both interventions
were effective, once participants successfully adopted a
more active lifestyle, additional telephone contact did not
provide added benefit. This implies that the less intensive
intervention, mailed information, could be used to maintain
exercise. The mail-mediated intervention presents a viable
advantage because it is less expensive, can reach more
people, and offers an effective alternative for older adults
who prefer not to attend exercise classes. Moreover, in a
comparison between the use of prompts and the use of
motivational or educational interventions, simple prompting
was found significantly more effective than lengthy educa-
tional sessions in encouraging exercise adherence [42].
Music
Incorporating appropriate music into exercise programs
can add interest and may serve to facilitate exercise partic-
ipation and adherence in the older adult. Music is reported
to enhance the exercise experience by lessening the percep-
tions of difficulty, monotony, and discomforts associated
with exercise. When exercise sessions are presented without
music, with vocal music, or with instrumental music, older
adults demonstrated greater adherence in the instrumental
music condition [43].
Demographics
In general, the overall analysis of the exercise literature
reveals the best adherers to regular exercise are individuals,
who lead an active lifestyle, were more fit at baseline, have
lower body mass, have fewer chronic diseases and pain,
were nonsmokers, and have higher levels of self-efficacy
[19,44,45]. Exercise participation is greater among men than
women [14,19] and black women seem to be less active than
white women [46].
Discussion
Given the large cohort of aging Americans, the number
of older adults experiencing chronic disease and disability
will continue to increase substantially over the next few
decades. Consequently, maintaining health and postponing
the onset of debilitating disease for as long as possible is
necessary to avoid morbidity later in life. Compressing
morbidity can be accomplished through exercise and regu-
lar physical activity. Although the Surgeon General’s mes-
sage was disseminated in 1996, adherence to regular
physical activity remains problematic among the older
population.
Efforts to optimize health through physical fitness in the
elderly have incited researchers to investigate both barriers
and motivators of exercise. Since a one-size-fits-all strategy
does not address the specific needs of a given population,
identification of reliable exercise predictors is essential to
adherence research. However, in the older population, bar-
riers and motivators often intertwine, making it difficult to
isolate factors specific to this cohort. Additionally, much of
the data gathered on the elderly uses healthier adult partic-
ipants and the majority of research studies are based on
correlational, retrospective, and self-reported surveys [38].
Because lifestyle habits and perceived barriers to exercise
are often so ingrained in the older population, long-term
maintenance of any newly acquired behavior, including
exercise, is a challenge [34]. However, as the aging process
continues, the frequency of contact between the elderly and
their physicians increases substantially. The elderly, in
general, also demonstrate great respect for their physicians.
In particular, they hold their doctor’s directives as orders ‘‘of
higher authority’’ and subsequently are greatly influenced
by their advice. Even though barriers to exercise may be
present, the older adult may be more likely to overcome
these at the urging of their physician. Therefore, the physi-
cian and other healthcare providers can be the catalyst in the
behavioral change process for the elderly. Without their
help, sedentariness will impact public health. The effects
will have widespread implications for a healthcare system
already in crisis.
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