compliance lecture

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Exercise Motivation and Adherence Predictors of
Exercise Compliance Strategies to
Improve Adherence to Exercise Programs
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or else!!!
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approximately 40 to 50 of referred patients
drop out of supervised cardiac rehabilitation
programs within 6 to 12 months for various
reasons
Oldridge, N.B. (1988). Cardiac rehabilitation
programmes compliance and compliance enhancing
strategies. Sports Medicine , 642-55.
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A summary of predictive approaches using entry
level profiles suggests that select groups of
patients, in certain types of programs, who are
prone to adhere or to drop out can be identified
with fairly high accuracy.
Dishman, R.K. (1992). Exercise adherence its
impact on public health, Champaign, IL Human
Kinetics Publishers (at page 419)
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• General factor
• Dropouts are more likely to be...
• younger than older
• single than married

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Socioeconomic Good credit ratings, which are
usually associated with high socioeconomic
status, are linked quite consistently with better
adherence
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Physical/Biological characteristics Overweight
individuals are often dropout candidates.
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Health factors Non-smokers report more physical
activity and are more likely to stay with
exercise programs than are smokers.
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Psychological factors Those who are physically
active report that they have received support and
encouragement from their family (spouse) and
friends. Dropouts report having received less
social support
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Personality characteristics Individuals who are
depressed or hostile are likely dropout
candidates.
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Characteristics of the exercise program The
convenience of the facility location and the
class scheduling are important factors when
encouraging people to stay with their exercise
programs.
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Characteristics of the exercise program Regular
attendees who have completed a physical activity
program are less likely to say they initially
joined the program for fun. Dropouts are more
likely to list fun as a reason for joining.
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Characteristics of the exercise
program Participants are more likely to stay
with an exercise program if they believe that
they have input into the choice of their
activities.
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Characteristics of the exercise program One of
the best predictors of dropping out of an
exercise program is the occurrence of injuries.
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Characteristics of the exercise program Dropout
rates are higher for jogging and calisthenics
than for other types of exercise.
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Characteristics of the exercise program High
intensity exercise is another good predictor
that people will drop out.
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Characteristics of the exercise
program Satisfaction with the leader of the
program is an important issue for participants.
In general, participants prefer supportive and
attentive leaders.
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Unexpected events Unexpected disruptive life
events such as moving, divorce, or a change in
job may precipitate dropping out.
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Perceived improvement Participants in exercise
programs who do not achieve their own goals drop
out approximately twice as early as those who do
attain their goals.
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The Stages of Change Model

• Precontemplation
• Contemplation
• Preparation
• Action
• Maintenance

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Precontemplation

• There is no physical activity or exercise
  occurring and there is no intention to start
  within the next 6 months
• Discuss benefits, what can be learned from
  previous attempts and the change process (many
  people decide to become a regular exerciser and
  then have difficulty maintaining a regular
  program)

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Precontemplation(continued)

• Clients may not be aware of the risks associated
  with being sedentary, or may have been
  discouraged by previous attempts
• Do not assume the client is READY to begin an
  exercise program
• Counseling should center on achievable goals

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Contemplation

• There is no physical activity or exercise, but
  there is intention to start within the next six
  months
• Discuss the benefits of exercise and help the
  client problem-solve to eliminate barriers
• Encourage setting specific short-term goals

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Preparation

• There is participation in some physical activity
  or exercise, but not at recommended levels
• Discuss further reductions of barriers and
  continued building of self-efficacy
• Monitor gains and reward achievement of goals
• Reinforce small steps toward action (gradually
  increase time, intensity, and adherence)

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Action

• The person is engaged in physical activity that
  meets recommended guidelines but has not
  maintained this program for six months
• People in the action stage are at the greatest
  risk of relapse
• Instruction on avoiding injury, exercise boredom,
  and burnout

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Action(continued)

• Provide social support and praise
• Plan for high-risk relapse situations such as
  holidays, sickness, bad weather, and increased
  demands on time.
• A short lapse in activity can be a learning
  opportunity

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Maintenance

• Exercise or activity has been occurring for six
  months or longer
• Risk for dropping out remains present
• Scheduling check-in appointments can help the
  maintainer stay motivated
• Continued feedback is important (if a maintainer
  is absent for several sessions, a prompt such as
  a telephone call can help)

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Strategies to Improve Adherence
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Coordination of the time of day the exercise
program is offered with the patients daily
schedule
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Reinforcement during or shortly after the
behavior (exercise) by the specialist
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Stimulus control whereby patients are encouraged
to make use of cues and prompts that stimulate a
desired behavior
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Cognitive strategies (drawing attention to what
patients think about before, during and after
exercise)
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Behavioral contracting between patient and
therapist
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• Adjunct programs that focus on patient concerns
  (includes spouse and family) and creation of
  long-range exercise,
• diet, or spouse clubs
• Coronary Care Club
• Mended Hearts
• Pulmonary Pals
• Better Breathers

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Increased physician presence and interaction with
patients
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Increased feedback on progress
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Increased Exercise Tolerance Achieve
d Not Achieved Inadequate High
Optimal exercise prescription Ov
eradequate Compliance Low exercise
enhancing prescription strategy
needed
C o m p l I a n c e
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Factors Affecting Adherence to a Physical
Conditioning Program
Negative Factors Positive Factors
Inadequate Leadership Instruction
Encouragement Time Inconvenience Regular
Routine Orthopedic Problems Freedom from
Injury Exercise Boredom Enjoyment
Variety Individual Commitment Group
Camaraderie Lack of Progress Awareness Progress
Testing Recording Spouse Peer
Disapproval Spouse Peer Approval
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