How Healthcare Can Teach Us About Exercise Adherence

Zachary Walston
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Perhaps laziness is the reason people don’t exercise in some cases, but that should not be the overarching assumption. Ironically, chalking the answer up to laziness and calling it a day is, well, lazy. It remains a tempting line of reasoning, however, as you will be hard-pressed to find many people who don't have some level of understanding that exercise is good for you.

There are plenty of examples that the knowledge of health benefits is not enough to sway behavior — smoking, healthy eating, and sleep hygiene are a few prime examples.

What seems like a simple cost-benefit analysis rarely is.

Healthy eating may be at odds with one’s socioeconomic status, location (food desert), age (parents decide food options), culture, family recipes and traditions, and misinformation (from the internet and healthcare providers). Even smoking has draws — especially once addiction takes hold — such as supporting socialization (smoke break with friends at work) and stress relief (a global pandemic doesn’t help).

So, what about physical activity? Chances are many barriers have already popped into your head. And this brings us back to the first question and answer. Are people simply lazy for failing to overcome those barriers?

In many cases, the answer is a firm no.

Drawing on adherence to healthcare as an example

As a physical therapist, I have to address patient inactivity on a regular basis. I live in a world where only 10–30% of adults report meeting physical activity guidelines. That number falls below 10% for adults over the age of 50.

Again, knowledge of benefit, or ability to reduce risk of harm, is not enough. My patients know exercise is good for them but that doesn’t mean I can simply hand them a sheet of paper outlining a home exercise program and it would be adhered to.

That lack of adherence is not laziness on the side of the patient, it is laziness on the side of the physical therapist.

Before I dive a little deeper into strategies to increase exercise motivation and adherence, let’s look at some of the reasons why people choose not to exercise.

This study was an umbrella review — it reviewed published reviews — assessing the adherence to physical exercise in chronic patients and older adults. It identified fourteen adherence-related key factors more frequently suggested in studies to increase adherence to physical exercise:

  • Characteristics of the exercise program
  • Involvement of professionals from different disciplines
  • Supervision
  • Technology
  • Initial exploration of participant’s characteristics, barriers, and facilitators
  • Participants education, adequate expectations and knowledge about risks and benefits
  • Enjoyment and absence of unpleasant experiences
  • Integration in daily living
  • Social support and relatedness
  • Communication and feedback
  • Available progress information and monitoring
  • Self-efficacy and competence
  • Participant’s active role
  • Goal setting

The most common factors were performing a pre-participation evaluation of the patient’s previous lifestyle habits as well as their physical and mental health status, assessing possible barriers and facilitators to exercise, and developing an individualized exercise intervention.

These studies are specific to the physical rehabilitation setting but they translate well to the general population. These barriers are not solved by explaining why exercise is good for you.

One proposed strategy to address the problem is to instill exercise habits in children — although removing P.E. and recess from school isn’t helping. Here’s the kicker: children have just as many barriers and many are similar to the adult barriers.

This study is focused on youths with musculoskeletal conditions. The goals are the same though. What are the barriers, facilitators, and strategies to boost exercise therapy adherence?

The most common barriers were time, physical environment, personal expersonal experience, lack of confidence, forgetfulness, fatigue, and not understanding the purpose of the exercise. The common facilitators included opportunities to adhere, social environment, group exercise programs, family involvement, peer support (in person or online), a strong therapeutic alliance, relieving pain and/or other symptoms, were fun, and were modified to include other enjoyable activities. Lastly, some effective adherence-boosting strategies were check-in in, exercise diaries monitored or reviewed by the parents or clinicians, rewards, regular exercise progressions or variations, teaching exercise techniques, and written or video instructions for reference at home.

These two studies provide us a plethora of reasons why people don’t exercise and they miss one other big reason that I see regularly in the clinic and on social media: misinformation.

Social media influencers and medical professions regularly spew nonsense such as squatting and running are bad for your knees, lifting with a rounded back is dangerous, maintain alignment or you will become injured, and don’t fall out of perfect posture.

It’s all nonsense.

Instead of focusing on what we “can’t do,” we should be encouraging more movement. Our bodies are resilient and robust, not fragile.

But education is not enough. So, how do we address the barriers we face?

Breaking down barriers to exercise

The first thing we need to do is acknowledge everyone’s personal situation. If you are reading this and believe willpower is enough, consider the differences between the following patients from the paper Privileging the Privileged:

A high-earning professional living in a leafy suburb with a stay-at-home partner and safe access to a well- equipped gym, who easily finds opportunities to exercise after work and enjoys being active after sitting at work for much of the day.
A single parent looking after two young children and working three low-wage jobs, who is living in a small studio in an apartment block where it is unsafe to go outside after dark, and who has limited opportunities to exercise (and after paid work, looking after the house and caring for the children, is fatigued and just wants to rest).

How would you design an exercise routine for the second individual? What about lifestyle habits to support regular physical activity such as sleep and nutrition?

Discipline is not the only requirement for exercise.

Resources matter.

It is easy to take for granted what many assume to be basic resources, like a safe sidewalk to walk or run on. It was not until I developed strong relationships with my patients and learned about their circumstances that I understood safe neighborhoods are not a given.

Time is a finite resource that is more strained for some people than others. I didn’t realize how much time I wasted until I had a full-time job and two kids. Even so, I am fortunate to have stability through a salaried job. I do not need to work 60+ hours a week away from my family or commute two hours a day.

I can fit workouts into my schedule easily. My decision is between exercise and reading a book. For others, it may be between exercise and seeing their kids or taking on another work shift to pay the rent. Not exercising regularly isn’t a simple matter of discipline.

For those reading those who struggle with exercising regularly, which of the aforementioned barriers apply to you? Let’s review them and identify specific strategies that may be able to address (at least partially) each one:

  • Characteristics of the exercise program — Individualize the program based on your likes. Walking is a great form of exercise, for example. Don’t do something that brings no joy or fulfillment.
  • Involvement of professionals from different disciplines — seek multiple sources of information not a single magic bullet program or the advice of a single healthcare provider.
  • Supervision — If you are uncomfortable with exercise, fear injury, or don’t know how to start, seek out a friend or family member with some experience to exercise with. If you have the financial resources, hire a trainer, even if for a short period to become comfortable.
  • Technology — There are many programs available online that provide guidance. You can do group fitness classes at home too. There is no “best” program. You can get in shape and improve your health with nearly anything on the market.
  • Initial exploration of participant’s characteristics, barriers, and facilitators — always create a personalized approach and be honest about your barriers. Ignore the one-size-fits-all approaches. You also need less time than you think to see benefits from exercise. The exercise snack approach (one set of bodyweight exercise every hour throughout the day) is great for strength.
  • Participants' education, adequate expectations and knowledge about risks and benefits — There are many free resources available to learn more about exercise, just make sure it is a credible source.
  • Enjoyment and absence of unpleasant experiences — Experience will be one of the best teachers as you learn how much and what types of exercise fit your life and are meaningful to you. For me, that has shifted to calisthenics and strongman lifts.
  • Integration in daily living — Fit your exercise habits to your schedule. Ignore the people who say you have to exercise at a specific time or place. Perhaps you use exercise snacks or only perform long routines on the weekend, opting to focus on being more active during the week (e.g., taking the stairs and walking more).
  • Social support and relatedness — Find people to exercise with or at least share your exercise goals and experiences. Support can occur outside of the exercise routines. Accountability partners are strong motivators for behavior change.
  • Communication and feedback — Don’t only share your successes and struggles with exercise, listen to the stories of others and provide your perspective. Teaching others is one of the best methods for personal learning.
  • Available progress information and monitoring — Track your exercise. Write down how many reps you did, the total time of exercise, the number of exercise snacks, or the personal record weight you lifted. You will be amazed at the progress when you look back after a few weeks or months.
  • Self-efficacy and competence — Along with writing down numbers, track the type of exercise you do. If you have a camera, record your exercises so you can see how your movement quality and effort change. See the variety of exercises you can do that you couldn’t do previously (e.g., types of pushups)
  • Participant’s active role — If you hire a trainer or work with a healthcare provider to develop an exercise plan, don’t be a passive participant. Share your goals, barriers, and facilitators. Give your thoughts on all the details of the routine to personalize it. No one knows you better than you.
  • Goal setting — Set a variety of goals. Set goals that are easy to achieve and stretch goals. Set short-term and long-term goals. Share your goals with an accountability partner.

Maintaining an exercise routine is hard work. Every season of life brings a new set of barriers to contend with. I have only provided one perspective. Seek out the opinion of others for addressing the barriers you may be facing.

Sometimes, you starting small and focusing on physical activity rather than formal exercise may be the best approach for you. Just keep in mind that labor-intensive jobs may not be the solution.

Labor vs. exercise story

While research supports leisure-time physical activity, the evidence is mixed on whether occupational physical activity is beneficial for your health. A recent study published in the European Heart Journal sought to provide clarity.

The research paper defines leisure time and occupational physical activity as follows:

“Leisure-time physical activity often includes dynamic movements at conditioning intensity levels sufficient to improve cardiorespiratory fitness over short time periods with enough recovery time. In contrast, work often requires static loading, monotonous and awkward working postures, and other non-conditioning activities over several hours per day without sufficient recovery time.”

Higher leisure-time physical activity is associated with reduced major adverse cardiac events (e.g. a stroke or heart attack) and all-cause mortality risk, while higher occupational physical activity is associated with increased risks, independent of each other.

Physical activity does not have to be formal exercise in the gym, but it should be something you enjoy, such as going on a walk or gardening. For some people, a labor-intensive job may be enjoyable — great! For others, the aforementioned barriers may need to be addressed to successfully integrate leisure-time physical activity.

Find solutions instead of creating problems

I once completed a leadership seminar in which the speaker proposed substituting the phrase “I don’t have time” with “I don’t prioritize.” It was constructed as a shaming exercise to force people to stop making excuses. I used to embrace this philosophy. Now I cringe when I hear this substitution.

Many times something isn’t prioritized and it shouldn’t be. The problem is the shame-inducing message the substation often conveys. It is similar to the attitude I used to have towards my patients who were not adherent to a home exercise program.

I will grant you sometimes laziness is the culprit. That should not be the assumption, however.

We need to work together to find solutions to barriers to exercise.

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I am a physical therapist, researcher, and educator whose mission is to challenge health misinformation. You will find articles about health, fitness, medical care, psychology, and professional development on my site. As the husband of a real estate agent, you will also find real estate and housing tips.

Atlanta, GA

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