Abstract
Regular exercise lowers the risk of disease progression for many chronic illnesses, but older adults experience relatively low rates of exercise. Although multiple intervention studies indicate that community-based programs can facilitate exercise participation, whether this research has resulted in widespread targeted exercise programs within communities is unknown. This study seeks to understand the ecological context of exercise for older adults through a cross-sectional survey of community exercise facilities within a mid-Atlantic city. The findings highlight the limited nature of the existing exercise infrastructure and reveal gaps in the community translation of research evidence regarding exercise adherence. An expansion in the availability of community exercise programs for older adults and more uniform policies to support older adult exercise are needed.
Although exercise reduces the risk of disease progression and the development of secondary conditions for many chronic illnesses, the majority of older adults do not meet recommended guidelines for regular exercise. Efforts to explain the low levels of exercise increasingly are incorporating a social ecological perspective, which suggests that exercise participation is the outcome of interacting community-, institutional-, and personal-level variables (Cress et al., 2005; King, Stokols, Talen, Brassington, & Killingsworth, 2002). However, while much research has identified successful interventions for modifying the personal-level variables, particularly self-efficacy beliefs and outcome expectations (Marks, Allegrante, & Lorig, 2005; Resnick, Luisi, & Vogel, 2008), fewer studies have examined community- and institutional-level variables, such that little is known about the availability of community-based exercise programs for older adults, particularly those with chronic health conditions. Further data are critically needed on facilities’ services, costs, screening practices and staff, all of which are associated with personal-level variables like self-efficacy and exercise participation. This study thus seeks to increase understanding of the community exercise contexts for older adults through a survey of the public, nonprofit, and commercial exercise facilities in a major mid-Atlantic metropolitan area. We begin this article by reviewing the current evidence regarding the role of exercise in reducing the chronic disease burden of older adults and the importance of an ecological perspective for understanding exercise participation. We then turn to the findings of our survey, which suggest community opportunities for older adults, particularly those with chronic illness, are highly constrained and primarily limited to spaces that are identified as belonging to older adults, that is, senior centers. At the same time, across each type of facility, institutional variables, including screening practices and the availability of staff, may not fully promote older adults’ self-efficacy beliefs and outcome expectations. Ultimately, this study reveals serious limitations in existing community facilities and the uneven translation of older adult exercise research.
Chronic Illness and Exercise Among Older Adults
Exercise refers to planned, repeated physical activity that is designed to enhance physical fitness (Chodzko-Zajko et al., 2009). Physical activity, especially exercise, plays a critical role in promoting perceived quality of life (Kelley, Kelley, Hootman, & Jones, 2009; Motl & McAuley, 2010) and in the management of chronic illnesses among older adults (Chodzko-Zajko et al., 2009). Physical activity, for example, influences glycemic control and cardiovascular health among persons with diabetes (McGavock et al., 2004; Shinji, Shigeru, Ryusei, Mitsuru, & Shigehiro, 2007; Sigal, Kenny, Wasserman, Castaneda-Sceppa, & White, 2006). For individuals with low bone mass, stretching, balance, and weight-bearing exercises improve functioning, falls risk, back pain, and quality of life (Chien, Yang, & Tsauo, 2005; Liu-Ambrose, Kahn, Eng, Gillies et al., 2005; Liu-Ambrose, Khan, Eng, Lord et al., 2005).
Increasing evidence also suggests that exercise can improve conditions previously considered intractable. For example, poststroke exercise improves mobility and metabolic fitness, even among persons whose stroke occurred many years prior to the commencement of exercise (Ivey, Ryan, Hafer-Macko, Goldberg, & Macko, 2007; Macko, Ivey, & Forrester, 2005; van de Port, Wood-Dauphinee, Lindeman, & Kwakkel, 2007). These exercises do not need to be costly or involve sophisticated rehabilitation equipment in order to be effective as both treadmill- and ground-based walking courses can enhance walking speed among persons with stroke (Moseley, Stark, Cameron, & Pollock, 2005). Indeed, the relative effectiveness of inexpensive, low technology exercise has led to a call for the development of more affordable, low-tech programs (Dickstein, 2008).
Finally, exercise carries critical mental health benefits, with exercise interventions resulting in reduced depression and social isolation among persons with stroke and older adults in general (Blake, Mo, Malik, & Thomas, 2009; Duncan et al., 2003). Exercise further contributes to an “experience of well-being” among persons with chronic illness (Penedo & Dahn, 2005).
Despite the importance of exercise, older adults experience among the lowest levels of physical activity of all age groups (Centers for Disease Control and Prevention, 2003). While 31% of older adults aged 65 to 74 engage in moderate physical activity for ≥20 min for 3 or more days per week, only 16% of older adults engage in physical activity for ≥30 min for 5 or more days. Over 28% of older adults (age 65+) have no leisure-time physical activity, with higher levels of inactivity occurring with age (Agency for Healthcare Research and Quality and the Centers for Disease Control and Prevention, 2002). Thus, most older adults do not meet the American College of Sports Medicine/American Heart Association’s recommendation for older adults of 150 min per week of moderate-intensity exercise (Chodzko-Zajko et al., 2009).
Social Ecological Context of Exercise
Social ecological theory suggests that individuals are embedded in multiple, interlocking settings, but individual responses to a setting depend on characteristics of the individual and the environmental setting (Bronfenbrenner, 1979). An individual’s expectations, self-perceived congruity with an environment, and the nature of the interaction between an individual and the social, physical, and symbolic elements of a setting over time, that is, the “proximal processes,” among other factors, can shape the individual’s “development” or success within that environment (Bronfenbrenner, 1999; Stokols, 1996). Social ecological theory thus recognizes that personal beliefs and behaviors combine with the broader social and built environmental context to influence outcomes.
Social ecological theory’s incorporation of multiple theoretical perspectives is particularly helpful for understanding older adult exercise. Distinct streams of research point to the role of both personal and environmental variables in determining health behaviors like physical activity and exercise (King et al., 2002; Stokols, 1996). For example, personal-level research based on social cognitive theory indicates that an individual’s self-efficacy beliefs and outcome expectations strongly correlate with exercise participation (Bandura, 2005; McAuley et al., 2009; McAuley, Lox, Rudolph, & Travis, 1994; McAuley et al., 2007). Briefly, self-efficacy refers to a “belief in one’s ability to perform a specific behavior in order to attain a desired result,” while an outcome expectation is “the belief that a particular behavior will bring about a certain result” (Casado et al., 2009, p. 50). Change in exercise self-efficacy beliefs, which may reflect feelings of mastery and outcome achievement, also is associated with exercise (Brassington, Atienza, Perczek, DiLorenzo, & King, 2002). Social cognitive theory and intervention research further suggest that older adults’ self-efficacy beliefs are modifiable and can be influenced by preexercise safety screening, exercise monitoring and feedback from experts, and assistance in developing achievable outcome goals (Bandura, 2005; Resnick, 2001a, 2001b, 2002; Seefeldt, Malina, & Clark, 2002).
At the same time, examinations of the community influences on exercise indicate that a strong correlation exists between the physical activity opportunities within a community and levels of physical activity (Task Force on Community Preventive Service, 2002). Based on their systematic review of interventions to increase physical activity, the Task Force on Community Preventive Services argues that promoting community exercise opportunities is critical for enhancing physical activity levels. Particularly key are community resources that are perceived as both safe and accessible (Brownson, Baker, Housemann, Brennan, & Bacak, 2001; Cress et al., 2005; Kahn et al., 2002).
Community intervention studies also indicate that community-based exercise programs can effectively address specific health issues, for example, arthritis (Boutaugh, 2003), falls risk among people with stroke (Au-Yeung, Hui-Chan, & Tang, 2009) or osteoporosis (Li et al., 2008), and increase overall health and well-being (Belza, Shumway-Cook, Phelan, Williams, & Snyder, 2006; Chiang, Seman, Belza, & Tsai, 2008; Frye, Scheinthal, Kemarskaya, & Pruchno, 2007; Hughes, Seymour, Campbell, Whitelaw, & Bazzarre, 2009; Yan, Wilber, Aguirre, & Trejo, 2009). Indeed, a Cochrane review suggests community programs have a higher training effect than home programs, especially for peripheral vascular disease (Ashworth, Chad, Harrison, Reeder, & Marshall, 2005). Studies of Medicare data further indicate that regularly attending a community fitness facility can reduce health care costs over time (Nguyen, Ackermann et al., 2008; Nguyen, Maciejewski et al., 2008). From the participants’ perspective, community programs also have an added social value (Chiang et al., 2008), and best-practice research has found a strong demand for community-based multidimensional exercise programs among older adults (Hughes et al., 2009). Together, these studies, among others, provide models of community exercise programs that safely and effectively increase exercise participation and that help to address many of the health problems of older adults.
Social ecology scholars seek to integrate these independent lines of self-efficacy and ecological research, arguing that personal beliefs, including self-efficacy beliefs and outcome expectations, and decisions regarding exercise are embedded in a broader built community that can contain further supports for these beliefs or other barriers to exercise (Brownson et al., 2001; King et al., 2002; Stokols, 1996). However, with respect to older adult exercise, while many studies have sought to refine understanding of the operation of self-efficacy and outcome expectations among older adults (McAuley et al., 2009; Morris, McAuley, & Motl, 2008; Resnick et al., 2008), far less research has explored the community exercise contexts for older adults. Despite calls for recognition of the interaction between personal-level and community variables (King et al., 2002), few studies have examined community facility practices, including exercise screening and staff availability, which can support the development of self-efficacy beliefs, or user fees that serve as a barrier to participation (Rimmer, Wang, & Smith, 2008; Traywick & Schoenberg, 2008). Furthermore, while recent recommendations argue that older adults should develop exercise plans and goals with their physician or an exercise expert (Cress et al., 2005; Nelson et al., 2007), little is known about the community availability of exercise trainers or experts to create these plans. This cross-sectional study thus seeks to help address these gaps in understanding of community exercise contexts. It seeks to provide further insight into the community availability and delivery of programs for older adults and the variation in facilities’ screening, staffing, and user fee practices.
Method
Project staff identified the community exercise facilities in a major mid-Atlantic metropolitan area using the telephone book, Internet, print advertisements, and referrals. An exercise facility was defined as a private, nonprofit, or government-funded facility that offers onsite exercise equipment or regular group classes for purposes of physical exercise. The inclusion criteria were that facilities were either open to the public or provided membership opportunities to the general public and that regularly offered exercise equipment and/or group exercise classes. Private workplace facilities that were available only to employees were excluded. Organizations that solely provided clinical rehabilitation, or physical or occupational therapy, also were excluded as these services often require a physician referral or insurance approval and are not a readily available exercise option for the public.
Interviewers telephoned the exercise facilities in 2005 and attempted to contact each facility a minimum of 3 times. The interviewer explained the purpose of the interview and asked to speak to an office manager who could answer the questions. Prior to beginning the interview with the facility representative, the interviewer engaged the representative in a discussion on the purpose of the project, read the oral consent form, and obtained the representative’s consent for the project, per the IRB-approved consent protocol.
The telephone interview used semistructured and close-ended questions to examine five facility dimensions: (1) policies regarding membership; (2) screening practices; (3) facility equipment, for example, treadmills and nautilus for independent exercise, and group classes, including classes for the general population and classes for specific health conditions, such as arthritis, coordination, hypertension, or obesity; (4) the training and availability of staff; and 5) the costs associated with membership and other service fees. The interview focused on these facility dimensions because existing literature, particularly intervention research, suggests they play an important role in exercise participation and adherence. Other studies have explored trends with respect to facilities’ physical plants (Cardinal & Spaziani, 2003; Rimmer, Riley, Wang, & Rauworth, 2005), but little is known about the nature of programs, user fees, and staff accessibility across facilities.
The PIs reviewed the responses to the semistructured questions in order to identify the themes that emerged from the interview, which were then organized into categories or codes, a standard practice with semistructured data (Bernard, 2005). These thematic codes were combined with the close-ended response options to form a codebook, which the PI and a research assistant then used to code the data. The second PI resolved discrepancies between the two coders. Data were analyzed using SPSS.
Results
Sample
Sixty-three exercise facilities were identified, of which 39 (62%) completed the telephone survey (Table 1). Commercial facilities represent the most common type of community exercise facility in the metropolitan area, followed by senior centers, YMCAs, and hospital-based facilities. Five facilities refused to participate; that is, four commercial fitness facilities refused on the grounds that they provide no specific services for persons with chronic health conditions, while one senior center refused because the manager believed participating in our survey might conflict with their affiliation with another local university. The primary nonresponders were commercial fitness facilities that either did not return telephone messages or consistently referred the interviewer to staff members who were absent.
Facilities Regularly Offering Exercise Equipment or Group Classes
Membership Criteria
All facilities indicated that membership is open to individuals regardless of health status and that no health exclusions exist. Senior centers, however, also have minimum age requirements, and two senior centers specified that users must be “independent,” able to “move on their own,” or bring a caretaker to assist.
Preexercise Screening
Although the majority of facilities reported preexercise screening procedures (Table 2), the content of these procedures varies widely. For example, the senior centers and hospitals require participants to obtain a signature from their medical provider prior to beginning an exercise program. In contrast, the most frequent form of screening at the commercial facilities and YMCAs involved self-reported information, but only 38% of commercial facilities and 25% of the YMCAs reported that this information is collected when an individual joins the facility. These facilities either have a physical trainer complete a health profile datasheet with the new member or have the member take the physical activity readiness questionnaire (PAR-Q). The PAR-Q is a series of seven questions regarding a user’s general history of heart disease, chest pain, dizziness, joint pain, and use of blood pressure medication. The other commercial facilities’ and YMCAs’ screening procedures involve requesting a provider waiver for select classes, for example, high-intensity aerobics, or if the participant has a preexisting condition. The facility that reported they would request a provider waiver in cases of preexisting conditions does not report standing procedures for determining the presence of such a condition.
Facility Characteristics
missing = 1.
Facility Accessibility, Individual-Use Equipment, and Group Classes
The majority of facilities (95%) stated that their entrances were wheelchair-accessible, with the two exceptions being one commercial facility and one YMCA. Respondents also indicated that the exercise equipment was wheelchair-accessible with a YMCA further noting having a swimming-pool lift for persons needing assistance with entering or exiting the pool.
The commercial fitness facilities and YMCAs are the primary sources of fitness equipment for individual use in this region (Table 2). Their equipment resources similarly included treadmills, stationary bicycles, elliptical trainers and step machines, nautilus/cybex machines, and free weights. By comparison, only 21% of the senior centers at the time of this study had fitness equipment available for individual use. Likewise, just one of the hospital facilities provided this resource.
The majority of facilities have group exercise classes, however, striking differences exist in the types of facilities that provide specialized group classes targeting specific health conditions or symptoms (Table 2). Specifically, while the majority of senior centers, YMCAs, and hospitals have targeted classes, less than one third of commercial facilities offer classes that are geared toward back pain, arthritis, coordination, overweight, or for older adults in general. When asked about the availability of classes for specific conditions, the other commercial facilities suggested that persons with back pain or stroke, for example, could make arrangements to work with an individual trainer.
The senior centers offered the widest variety of exercise classes, including low-intensity aerobics, yoga, coordination, and chair-based exercises designed to increase flexibility and strength, with People With Arthritis Can Exercise (PACE), walking programs, and dance courses (e.g., line dancing) also offered periodically. At several senior centers, however, classes are led by videotape or DVD rather than an in-person instructor. The hospitals have taken yet another approach with their classes by offering both exercise classes for generalized preexisting conditions and wellness classes that combine education and exercise specifically for arthritis, obesity, hypertension, or diabetes.
Staff Characteristics and Assistance
The contrasts between commercial and public or nonprofit exercise facilities continue with their staff characteristics (Table 2). At large commercial facilities, 5 to 12 trainers are scheduled per shift, with high-use time periods having higher numbers of staff. Smaller commercial facilities, the YMCAs, the four senior centers with exercise facilities, and the hospital facilities report 1 to 3 staff members, depending on the shift. The 15 senior centers that offer fitness classes, but have no standing exercise equipment, do not have certified trainers on staff.
Very few facilities (25%) overall have specialized staff, that is, a physical therapist or exercise physiologist. While one senior center hires a physical therapist to teach a balance class, one-on-one appointments with specialized staff members are only available at select commercial facilities or YMCAs. Along with needing to be made in advance, these appointments require an additional fee.
Slightly more facilities (33%), again mainly commercial facilities and the YMCAs, indicated that a physical trainer could assist a member either with exercises recommended by a physician or with a transfer from a wheelchair to exercise equipment (Table 2). As with appointments with specialized staff, such help would have to be scheduled in advance and would require an additional fee. Fees ranged from US$25 per hour at the hospital to US$75 per hour at a commercial facility. In not offering these services, several senior centers noted that members must be self-sufficient or bring their own assistance in order to participate in programs.
Membership and Monthly Fees
The survey revealed many differences in the fee structures across facilities (Table 2). The majority of the commercial facilities and YMCAs charge an initial application fee and monthly dues. These application fees range from less than US$30 for one YMCA to more than US$150 at two commercial facilities. The monthly dues depend on the membership level within the facilities, but range from US$25 to US$99. The senior centers and hospitals do not charge an initial application fee but rather may charge an annual fee that ranges from US$10 to US$25 or have a per-activity fee, with rates varying by activity. One senior center, for example, charges per class, with fees running US$15 to 20 for a 6- or 8-week session. Similarly, one hospital facility charges US$25 per 8-week session, while the other requires US$35 per month.
Commercial facilities do not offer individual discounts based on demographic status, for example, age or income, with the exception of one facility that offers discounts to U.S. Veterans. Five of these facilities, however, do negotiate discounts for organizations, for example, group business memberships. In contrast, the YMCAs have comprehensive discount programs for low-income individuals, older adults, and students, while one hospital provides discounts for low-income older adults.
Discussion
Exercise researchers are continuing to accumulate evidence on the benefits of exercise for older adults in general and to address chronic health conditions (Ivey, Macko, Ryan, & Hafer-Macko, 2005; Motl & McAuley, 2010). Community exercise opportunities encourage exercise (Task Force on Community Preventive Service, 2002) and have demonstrated effectiveness in reducing the effects of chronic illness (Hughes et al., 2009; Nguyen, Maciejewski et al., 2008). Little published data exist, however, on the nature of the community exercise programs that are available for older adults outside of intervention settings. In seeking to address this gap, this study has found that the services and practices of senior centers and hospitals contrast greatly with those of commercial facilities and, to a lesser extent, YMCAs. Exercise equipment for independent work-outs and tailored group exercise classes are not uniformly found across these facilities. In addition, while intervention studies have established that program characteristics, like screenings and trainer feedback, can increase motivation and adherence among older adult exercisers, such support also is not consistently available within and across facilities.
Membership and Screening Practices: Contrasting Approaches
First, with respect to membership, no facilities reported explicit membership exclusion criteria. Membership is open to all regardless of health condition. At the same time that facilities have open-membership policies, their preexercise screening procedures are highly heterogeneous, with few commercial facilities or YMCAs having active, systematic screening processes for all users, despite the American College of Sport Medicine/American Heart Association recommendations at the time of the survey (Balady et al., 1998). This finding is consistent with earlier research (McInnis, Hayakawa, & Balady, 1997). While our study did not verify survey responses with corporate main offices, the data likely reflect the daily, operational practices of the facilities that older adults would encounter when contacting the main desk of a facility. The finding that some sites only flag users who self-reveal, show signs of a condition, or enroll in high-intensity classes is particularly troubling. Independent treadmill, stationary bicycle, and nautilus machine users may receive little preexercise screening or information.
The senior centers and hospitals take a contrasting approach to screening. Rather than relying on self-report data, these facilities require that all members obtain a physician waiver before starting exercise programs.
The merits of universal preexercise screening and physicals are debated (Cress et al., 2005; Haskell et al., 2007), and our intent is not to advocate for universal referral or screening requirements. Rather, we suggest the increasing call for promoting community exercise among older adults with heart disease (Klieman et al. 2007) and the mainstreaming of postrehabilitation exercise for other chronic conditions requires renewed discussion on the role and consistency of screening in exercise facilities, regardless of the services used or visibility of conditions (Balady et al., 1998). Such discussions should acknowledge that preexercise screenings represent an opportunity to address the exercise concerns of older adults and “passing” a screening can reinforce an individual’s beliefs in the safety and efficacy of exercise, which correlates with exercise participation (Resnick, 2001a). Noting the problems associated with each of the screening methods found in the above facilities, that is, relying on the PAR-Q, physician waiver requirements, and other preexercise screenings for cardiovascular disease, Chodzko-Zajko, Ory, and Resnick (2004) further propose that screening sessions should be used not to detect illness, but rather, should aim to prevent injury by guiding older adults on the development of exercise plans that will safely address their goals.
Staff Support: Infrastructure Weaknesses Across Facilities
Our survey further indicates that the number of public, nonprofit, and commercial facilities with staff who are available without cost for individualized attention during exercise may be extremely limited. Trainers are not commonly accessible at the many senior centers providing classes via video and other electronic media. Commercial facility and YMCA staff fluctuate across peak and nonpeak hours, and many of these facilities charge additional fees for appointments, thereby reducing accessibility. These staffing policies may inhibit the establishment of self-efficacy, long-term exercise adherence, and the effectiveness of programs. A growing body of research suggests that professional staff represent “authorities” who can influence self-efficacy, self-regulation, and outcome expectations by recognizing goals, providing verbal feedback, and emphasizing the benefits of exercise (Bandura, 2005; Rosenberg & Resnick, 2003; Schlicht, Godin, & Camaione, 1999; Seefeldt et al., 2002). Exercise monitoring likewise influences adherence (Shepich, Slowiak, & Keniston, 2007) and can facilitate exercise progression, which is critical for obtaining a training effect and improving cardiovascular fitness (Mead et al., 2007; Michael & Macko, 2007; Salbach et al., 2004).
Furthermore, irregularities in exercise facility staff resources raises questions regarding recent guidelines suggesting that older adults and those with a chronic condition should develop a tailored exercise plan with a health care provider or exercise specialist (Cress et al., 2005; Nelson et al., 2007). Our study suggests such specialists are not readily available within the community. Older adults who initially develop exercise plans with their health care provider need to be aware that community assistance for the execution and progression of the exercise regimen may be lacking.
Exercise Equipment and Specialized Group Classes: Choices of One or the Other
Older adults can safely participate in and benefit from both independent exercise, like lifting weights or walking overland or on a treadmill, and group-based exercise like low-impact aerobics, yoga, or tai-chi (Agency for Healthcare Research and Quality and the Centers for Disease Control and Prevention, 2002; Chodzko-Zajko et al., 2009; Moseley et al., 2005). As with the general population, older adults’ exercise preferences are highly variable, with some preferring to exercise alone, while others favor group programs that allow for social interaction along with exercise (King, 2001). King’s systematic review notes, however, a general pattern that older adults desire exercise opportunities that are of moderate intensity, convenient, simple, and noncompetitive. The varied preferences of older adults suggest that access to different types of facilities that provide a range of options could help facilitate exercise in this population.
Our survey results indicate, however, that few fitness facilities offer both individual equipment and targeted exercise classes. Senior centers are the primary providers of targeted exercise classes for older adults in this region, but only a limited number of the senior centers have independent exercise equipment, like treadmills or nautilus. In addition, budget constraints at some senior centers require the use of alternate instruction (e.g., video recordings) for exercise classes. The lack of independent exercise equipment and the inconsistent availability of class instructors represent major weaknesses in the senior center programs. Instructors play a key role in encouraging class participants (Chiang et al., 2008). The aging services network is in the process of increasing senior center equipment and staff resources. This work is critically expanding the number of multidimensional exercise resources for older adults. Although the YMCAs and one hospital do have both targeted exercise classes and individual exercise equipment, relatively few YMCAs and hospital-based community exercise facilities are located in this metropolitan area.
In contrast to the senior centers, commercial facilities consistently provide exercise equipment for independent exercise and general group exercise classes, but they offer the fewest programs specifically for older adults or to address common health conditions. It is possible that commercial facility programs reflect the demographic structure of their members and their surrounding community, but further study is needed to determine the factors influencing commercial facilities’ program decisions.
Facility Fee Structures—an Additional Barrier
At the same time that commercial facilities are more likely to provide exercise equipment for independent exercise and general group classes, they also have higher upfront costs, with most requiring an initial membership fee plus monthly fees. Furthermore, only one commercial facility reported a standing discount, which is reserved for Veterans. These fees contrast with the per-class fees of the senior centers and hospitals, and the YMCA policies with respect to low-income older adults. The influence of commercial fees on accessibility, especially for individuals on a fixed income, should not be underestimated. Cost was the most frequent barrier to exercise listed by adults with arthritis (Shih, Hootman, Kruger, & Helmick, 2006) and stroke (Rimmer et al., 2008). Similarly, Traywick and Schoenberg (2008) found that the perception of commercial facility costs and membership criteria prevented female heart-attack survivors from joining a commercial fitness facility.
Physical Plant Accessibility
One striking similarity across facilities is that the majority reported being accessible to persons in a wheelchair. This finding must be interpreted with caution. Studies of facility physical plants elsewhere suggest that even when doorways meet ADA guidelines, curbs and other front-access routes often are not wheelchair-accessible. Locker rooms, showers, exercise equipment, and elevators likewise can be inaccessible for a person with a wheelchair or assistive walking device (Rimmer, 2005). Thus, while it is encouraging that facilities verbalize being accessible, actual accessibility may be far different and present a further barrier to older-adult facility use.
Expanding Opportunities for Community Exercise: Addressing Gaps With Model Programs
As noted earlier, the literature on personal exercise motivations indicates that individual exercise preferences are highly variable (King, 2001). Predilections regarding exercise locations also vary. Some older adults are intimidated by the image of commercial facilities (Traywick & Schoenberg, 2008), but other older adults perceive senior centers as spaces for the “old,” as opposed to themselves, which limits their use of senior center resources (Fitzpatrick & McCabe, 2008; Lund & Engelsrud, 2008). The diversity of identities and exercise preferences among older adults suggests a need for independent exercise equipment and targeted group exercise classes across a range of facility types.
The expansion of senior center services in this region promises to add variability to the exercise opportunities for those older adults who prefer senior center settings. This expansion, however, is occurring with the assistance of a private foundation. Researchers elsewhere note that public funding for the expansion of facilities is limited and call for developing the role of commercial facilities, which often have resources, such as sophisticated marketing tools, which are less common in the public arena (Dunn & Blair, 2002). Cost barriers notwithstanding, our study suggests commercial facilities are an important source of independent exercise equipment and tend to have higher numbers of physical trainers or kinesiologists on staff. These facilities, however, currently tend to lack targeted group classes and would require users to pay for additional assistance.
National and international models for the inclusion of older adult or chronic illness group exercise classes within commercial fitness facilities do exist. For example, Healthways’ “SilverSneakers” program, a health insurance benefit that is offered through some Medicare Advantage programs and retiree group policies, provides beneficiaries with a membership in participating fitness centers (Healthways, 2010). These fitness centers, which include commercial fitness centers and YMCAs, have designated “senior advisors” to develop exercise plans and goals with new enrollees. Additional exercise advice and goal-tracking software is available through the SilverSneakers website. SilverSneakers also has developed strength training, aerobic, yoga, and aquatics classes specifically for older adults. This nationwide program thus reflects many of the principles espoused by social ecological theorists; that is, it is widely available at low cost to older adults, members have access to a range of exercise options within a single facility, and ongoing exercise support is offered. Initial studies indicate that the SilverSneakers program can reduce health care costs over time (Nguyen, Ackermann et al., 2008; Nguyen, Maciejewski et al., 2008). In addition to SilverSneakers, researchers also are evaluating the claims of Curves, a popular commercial fitness program (Kerksick et al., 2009), and whether it can inform program development elsewhere.
Other resources for community exercise facilities can be found through the National Blueprint Project, funded by the Robert Wood Johnson Foundation. The National Blueprint Project has developed a policy plan, compiled information resources for physicians and individuals, and created a small grants programs for local organizations, in an effort to increase physical activity levels among older adults (National Blueprint Project, n.d., a-b). International models for commercial fitness programs for older adults also exist. The Empoli Adaptive Physical Activity program in Tuscany, Italy, for example, provides multilevel exercise classes for persons with a range of conditions, including stroke, Parkinson’s Disease, and back pain through a collaboration between the local health authority and commercial fitness centers (Macko et al., 2008; Stuart, Chard, Benvenuti, & Steinwachs, 2009). Thus, models programs and information are available for commercial fitness facilities. Broader implementation of these programs is needed to expand the commercial-based exercise opportunities for older adults.
Although the generalizability of our survey beyond the mid-Atlantic metropolitan region is not known, the gaps in community exercise programs identified here likely apply to other urban areas. For example, the findings regarding the limited services for older adults in many commercial facilities echo the concerns raised by older adults elsewhere regarding the acceptability of these spaces for exercise (Traywick & Schoenberg, 2008). The broader context or “exosystem” (Bronfenbrenner, 1979) of facilities in this region also is similar to areas elsewhere. The outmigration of upper- and middle-class residents from the city and inner-ring suburbs that characterizes this region, for instance, is common in many U.S. cities. These population movements have reduced both the tax base available to support public older adult exercise programs and shifted the geographical focus of private facilities to the suburbs or specific urban settings, that is, business districts and gentrified neighborhoods. These business-oriented exercise facilities tend to have the higher membership costs. In addition, ongoing economic crises across many states and cities, including this area, are leading to dramatic reductions in the budgets of public programs, thus further limiting the availability of public exercise resources (e.g., Sweeney, 2010).
One limitation of this study is the refusal rate among commercial sites compared to other facilities. The refusal rate incorporates facilities that directly refused and those that repeatedly referred the interviewer to absent staff members. The primary reason for directly refusing was that the facility offered no services for individuals with a chronic health condition. The indirect refusals similarly may reflect that the facilities did not provide services specifically for older adults. If this is the case, it would further support our argument that only a limited number of commercial facilities actively are offering classes or services specifically for older adults.
Finally, the intent of our study is to examine facility-level practices and programs that previous research suggests facilitate the development of self-efficacy beliefs and exercise participation, that is, preexercise screening and regular monitoring and feedback from “experts.” Our study highlights gaps in these practices across community facilities, including an absence of such staff and the presence of supplemental fees that may serve as a barrier to access. Further studies now are needed at the individual level to determine whether the variation in the programming and availability of supports across community facilities does indeed affect older adults’ self-efficacy and explain exercise participation. We hope that these findings also promote discussion between providers and their patients regarding the range of regional exercise opportunities and mechanisms for overcoming weaknesses within local community options.
Conclusion
A robust public health infrastructure is needed to enhance physical activity levels (Yancey et al., 2007), but this study suggests that community exercise opportunities for older adults, particularly those with chronic health conditions, remain underdeveloped. Public and nonprofit facilities, particularly senior centers, are attempting to provide affordable, targeted exercise programs, but staff and equipment resources are not evenly distributed across senior centers. Public facilities’ low staff levels may undermine the potential effectiveness of these efforts, as exercise support plays a critical role in promoting adherence. Financial support to address exercise staff and equipment disparities is needed.
These findings also indicate that many commercial facilities have not fully developed exercise resources for older adults. Baby boomers who are reticent about attending senior centers, however, may find targeted programs in commercial fitness centers appealing. Research suggests that public-private partnerships on the local or national level have the potential to dramatically increase the availability of supervised, tailored programs (Stuart et al., 2009) and to reduce the health care costs of users (Nguyen, Ackermann et al., 2008). Resources for individual facilities seeking to expand their offerings for older adults are available (National Blueprint Project, n.d.-b). Further research is critically needed to determine the factors influencing commercial facilities’ programming decisions and to identify specific mechanisms for increasing commercial fitness facilities’ older adult programming.
Our study further suggests that health care providers and older adults need to assess the strengths and weaknesses of individual community exercise programs. While older adults are encouraged to develop their own exercise plans and risk management strategies prior to beginning exercise (Cress et al., 2005), support for implementing and progressing exercise plans can be costly and incomplete in many communities.
Thus, although a growing body of literature indicates that regular exercise can reduce the effects chronic disease among older adults, this examination of the community context of exercise reveals that exercise opportunities that specifically address chronic illnesses are limited. Public facility funding levels and the focus of many commercial facilities on specific geographic and demographic populations undermines the number of supportive exercise opportunities available for older adults. Expanded funding of public programs and increased research with the commercial fitness industry is needed in order to strengthen the availability of supportive, evidence-based community exercise opportunities for older adults.
Footnotes
Acknowledgements
The authors wish to thank Michele Pharr for her work as a research assistant on this project.
The author(s) declared no potential conflicts of interests with respect to the authorship and/or publication of this article.
This research was supported in part by the Department of Veterans Affairs Rehabilitation Research and Development Program and the Baltimore Veterans Affairs Medical Center Research and Education Foundation.