European Journal of Sport Science, vol.

3, issue 4
SF-36 Predicts Exercise Adherence / 1
2003 by Human Kinetics Publishers and the European College of Sport Science

Health Perceptions As Predictors

of Exercise Adherence in Older Women
Alison Kleppinger, Mark Litt, Martin Kulldorff,
Christine Unson, and James Oat Judge
Purpose: To determine if health perceptions, measured by SF-36 subscales,
could identify women more likely to adhere to exercise, particularly during
exercise adoption and maintenance phases. Design and Methods: Subjects
(Age = 67 5 yr, BMI = 24.4 3 kg/m2) were 189 estrogen-taking, postmenopausal women in a 2-year home-based resistance-training program. Results:
Vitality, role-emotional, bodily pain, social functioning, and mental health
subscales of the SF-36 were significantly (p < .05) predictive of exercise adoption. Vitality, role-emotional, general health, and bodily pain subscales were
significantly (p < .05) predictive of exercise maintenance. Implications: Women
who perceived themselves as having more energy, fewer emotional problems,
less pain, fewer social problems, less feelings of nervousness and depression
were more likely to start exercising. Women who perceived themselves as
having more energy, fewer emotional problems, excellent health, less pain
were more likely to continue exercising. Additionally, the present study indicated that different components of the SF-36 affected different behavior phases
of adherence during the exercise program.
Key Words: health perceptions, exercise, self-rated health, SF036
Key Points:
1. Women who perceived themselves as having more energy, fewer emotional problems, less pain, fewer social problems, less feelings of nervousness and depression
were more likely to start exercising.
2. Women who perceived themselves as having more energy, fewer emotional problems, excellent health, less pain were more likely to continue exercising.
3. Different components of the SF-36 affected different behavior phases of adherence
during the exercise program.

In an attempt to keep older adults active longer, health care providers encourage
healthy behaviors. Health behaviors can be defined as exercise, treatment therapies,

A. Kleppinger and C. Unson are with the Claude Pepper Older Americans Independence Center at the University of Connecticut Health Center, Farmington, CT 06030. M. Litt
is with the Department of Behavioral Sciences at the University of Connecticut Health
Center. M. Kulldorff is with the Division of Biostatistics in the Department of Community
Medicine and Health Care at the University of Connecticut School of Medicine. J.O. Judge
is with the Center on Aging at the University of Connecticut School of Medicine.
1

2 / Kleppinger et al.

medications, or several other actions that improve wellness and quality of life. An
abundance of research has supported exercise as a means of health maintenance.
Many aspects of exercise adherence have been monitored to determine how to keep
older adults active and maintain healthy activities or behaviors. However, attrition
rates as high as 50% in the first 6 months have been documented in some exercise
programs (4, 16). It has become important to determine what factors are most
predictive of adherence to exercise, particularly in the long-term, if exercise regimens are to have their optimal effects. Motivating or inspiring older adults to adhere
to exercise behaviors is thus an important goal.
According to Janis and Rodin (7), A persons health-seeking behavior is, to a
great extent, based on his or her perception of a bodily state, rather than on the bodys
true, physical condition (7: p. 488). Learning more about an individuals health
perceptions could improve strategies to maximize exercise adherence, particularly
at home.
Several studies have linked perceived health status or self-health perceptions with exercise behaviors (8, 10, 12, 13, 20). Marks and Lutgendorf (13)
confirmed the notion that older adults who perceived themselves as healthier engaged in more health behaviors, specifically exercise. Laforge et al. (10) found that
self-perceived health status improved as stages of exercise behaviors progressed
from adoption to maintenance.
There are, however, several dimensions to health perceptions, including perceptions of vitality, physical functioning, mental health, emotional health, and so
on. It is not clear what kinds of health perceptions are most predictive of exercise
behavior, particularly in the elderly. Those who perceive themselves as more ill or
more at risk for conditions, such as osteoporosis, could be more motivated to seek a
remedy. On the other hand, those who perceive themselves as too impaired may feel
fearful or hopeless about the prospects of exercise (15). Perceptions of good health
may predict high levels of exercise behavior, but may also predict low levels, in that
those who feel generally well may not perceive a need to exercise. Likewise, one
could perceive oneself as physically healthy but emotionally overburdened, and
thus not be prepared to embark on an extended exercise program. Knowing which
type of health perceptions predict exercise behavior may help researchers tailor
communications that could improve exercise adherence.
Finally, it is possible that the factors influencing exercise adoption may be
different from those that assist in maintaining exercise (2, 11, 17, 18). Investigating
behavior influenced by health perceptions during the adoption stage, as well as the
maintenance stage, may provide insight into boosting initiation of exercise as well
as optimizing long-term adherence to exercise programs.
The present paper is based on a study of 189 older women taking estrogen and
enrolled in a 2-year study of the effects of exercise on bone density. Various social,
psychological, and physical measures were obtained prior to the exercise trial. The
Medical Outcomes Study 36-item short form health survey, or SF-36, was one of the
measures attained from each volunteer at baseline. The SF-36 has been used to
assess the health status and quality of life in the general population, and is considered a valid and reliable measure (25). The specific scoring of eight different health
perceptions, including bodily pain, role-emotional, physical functioning, role-physical, vitality, general health, and mental health, allow a more detailed exploration of
perceptions of health. Although the SF-36 is usually viewed as an outcome measure
to rate health status, the current study treated the subscales, obtained prior to an

SF-36 Predicts Exercise Adherence / 3

exercise study, as different perceptions of health that might later influence behavior,
such as exercise adherence.
The primary purpose of this study was to determine if health perceptions,
measured by the SF-36 subscales, could identify women more likely to adhere to
healthy behaviors such as at-home exercise. The secondary purpose was to investigate the influence health perceptions might have on exercise adherence over the
adoption and maintenance stages of exercise behavior. If health perceptions can
help determine exercise adherence, then new strategies to improve adherence rates
might be developed. We expected that women with positive perceptions of their
health to have higher adherence than those women with negative perceptions of
their health.

Method
Participants
Participants were 189 women taking estrogen replacement therapy recruited for an
intervention study measuring the effect of exercise on osteoporosis (low bone mineral density). Women were included in the study if they had been receiving hormone
replacement for at least 2 years. Exclusion criteria were developed to exclude any
variables that may effect bone mineral density: current smoker, use of medications
known to affect bone mineral density (calcitonin, bisphosphonates, prednisone \gte\
5 mg/day, testosterone, phenytoin), prior hip fracture, body mass index > 30 kg/m2
(based on self-report of height and weight), history of cancer in the last 5 years
(excluding skin cancer), regular heavy resistance exercises, or physically active
more than 210 min per week.
Measures and Instruments
SF-36. Research staff administered the SF-36 at baseline, prior to randomization
and exercise. The SF-36 was developed to attain a quantitative measure of health
perceptions. It is a paper and pencil survey with 36 items and eight different subscales.
Most items on the survey questioned the subjects views about his or her health,
assessing the persons estimate of his or her health in a variety of domains. Items
were scored using several different Likert scales to rank responses appropriately.
Each subscale was transformed to a scale ranging from 0100. Eight subscales can
be obtained from the SF-36 including role-emotional, role-physical, vitality, physical function, social function, general health, mental health, and bodily pain. Refer to
Table 1 for a list of the SF-36 subscales and the meaning of their scores. Scoring was
obtained using the program supplied by Medical Outcomes Trust Manual, the score
developer (26). Despite the conceptual uniqueness of each of the subscales, subscale
scores were highly intercorrelated in this sample (minimum r = .40, p < .001).
Adherence Measurements. Adherence to exercise was measured using exercise
logs. Self-report logs of behavior have been generally reliable and valid (1). Subjects were instructed to record at the end of each day whether they had exercised the
prescribed 3045 min (one exercise session). Logs were kept for the duration of the
study.
Adherence was calculated by the total number of at-home exercise sessions
reported on the exercise logs divided by the expected sum of sessions as determined

4 / Kleppinger et al.

Table 1

SF-36 Health Status Scales

Concepts/
subscales

Items
(no.)

Meaning of
low scores

Meaning of
high scores

Physical
functioning

10

Limited a lot of performing

all physical activities including
bathing or dressing due to health

Performs all types of physical

activities including the most
vigorous without limitations
due to health

Rolephysical

Problems with work or other

daily activities as a result of
physical health

No problems with work or

other daily activities as a
result of physical health

Bodily
pain

Very severe and extremely

limiting pain

No pain or limitations due to

pain

General
health

Evaluates personal health as

poor and believes it is likely
to get worse

Evaluates personal health as

excellent

Vitality

Feels tired and worn out all

of the time

Feels full of pep and energy

all of the time

Social
functioning

Extreme and frequent interference with normal social

activities due to physical or
emotional problems

Performs normal social

activities without interference
due to physical or emotional
problems

Roleemotional

Problems with work or other

daily activities as a result of
emotional problems

No problems with work or

other daily activities as a
result of emotional problems

Mental
health

Feelings of nervousness and

depression all of the time

Feels peaceful, happy, and

calm all of the time

by the assigned protocol (3 times each week). To investigate the adoption and
maintenance stages of behavior over time, adherence was calculated into 6-month
time intervals of weekly compliance. Exercise adherence in the adoption phase was
the average weekly number of home exercise sessions reported in the exercise logs
calculated from months 7 through 12. The maximum number of sessions prescribed
for these women was 3 sessions per week. Adherence in months 0 through 6 was not
considered valid for judging adoption because most sessions during these months of
the study were performed in hospital-based classes, not at home. Thus, months 712
represent a period during which participants either did or did not independently
adopt the at-home exercise program. Exercise adherence in the maintenance phase
was calculated as the average number of weekly sessions reported in months 19
through 24.

SF-36 Predicts Exercise Adherence / 5

Each month, subjects were asked to return their completed exercise logs.
Exercise logs that were never returned to instructors were considered missing data.
If a participant failed to turn in a set of logs, the volunteer filled in those daily data at
the next follow-up visit. If the missing data were never recalled by the volunteer,
then it was resolved by imputing predicted values based on a linear trend model
using SPSS software (23). Missing values were replaced with the mean of the values
of the points on the preceding and succeeding days. Data points were imputed only
for those values missing, not for the values following exercise drop out. Participants
were considered exercise dropouts when they explicitly informed the research staff
that they no longer had any intention to continue prescribed exercise. For participants who did drop out, zeroes were recorded for all log data after the drop date.
Drop dates were defined as the date on which the participant submitted her last
exercise log.
Procedures
Recruitment. Recruitment targeted a diverse group of older women from central
Connecticut. Participants were recruited via targeted direct mailing, print, and broadcast media, and through a community outreach program. Letters of invitation were
sent to patients of a large obstetric and gynecological group practice (6,350), patients of the University of Connecticut Health System internal medicine practices
(1,914), Department of Motor Vehicle licensees (approx. 5,800), university alumni
(1,366), and community organizations (170). Flyers were also inserted in newsletters of retiree associations (approx. 4,800). Four advertisements in the food section
of a metropolitan newspaper were run. Multiple feature articles in area newspapers,
television news, and radio programs with a predominantly older audience were also
used. Several community talks were also given at senior centers, retirement communities and retiree associations. A total of one hundred and eighty-nine women were
randomized to an exercise intervention group; either the upper body or the lower
body. The current study was a sub-study of the exercise intervention study.
Exercise Interventions. Both exercise groups were required to attend two classes
each week for the first 2 months. In the next 2 months participants attended one class
each week. In months 5 and 6, participants were attending class every other week.
Following the 6-month point, participants were told to attend either one or two
classes each month. Participants were expected to perform the prescribed exercises
three times each week, including both their at-home exercise and monthly class
sessions. Exercise sessions lasted 1 hour in class; however, most at-home sessions
were reported as lasting only 3045 min. Variation in the order of exercises performed was encouraged. A videotape and paper handouts of the exercises were
distributed to ensure good form and technique. In addition to upper- or lower-body
exercises, participants of both groups were encouraged to walk at least 45 min each
week (15 min, three times per week).
Lower-Body Intervention. Each class began with a 5-min warmup, weight-resistance exercises, 15-min abdomen and lower-back exercises, and a 5-min cooldown. The weight-resistance exercises consisted of 4 different loaded exercises;
chair-rise, stair climb, calf raises, and hip flexion. Each exercise consisted of 34
sets of 10 repetitions. Participants were loaded with weighted belts around the waist.

6 / Kleppinger et al.

Each exerciser was assigned to lift 6% of their body weight at the start. Based on
their form, participants progressed in 2-lb. increments. Muscle groups emphasized
were quadriceps, calves, gluteus maximus, hip flexors, hamstrings, lower back, and
abdomen.
Upper-Body Intervention. Each class began with a 5-min warmup, weight-resistance exercises, 15-min abdomen and lower-back exercises, and a 5-min cooldown. The weight-resistance exercises consisted of 4 Theraband stretches and 67
dumbbell exercises. Each exercise consisted of 2 sets of 10 repetitions. Muscle
groups emphasized were upper back, chest, shoulders, triceps, biceps, forearms,
lower back, and abdomen.
Statistical Analysis
The present trial is a substudy of an exercise intervention; therefore, it was possible
that the different types of exercises being performed may have affected adherence
rates. In order to rule out exercise type as affecting adherence rates, repeated measures analyses of covariance on the two sets of dependent variables (adoption phase
adherence scores and maintenance phase adherence scores) were conducted. Exercise condition was used as the independent variable and baseline SF-36 scores as the
covariates.
Logistic regression analysis was used to identify whether women who dropped
out of at-home exercise had different health perceptions than those women still
exercising after 24 months. Dropout at any point was the binary dependent variable,
and SF-36 subscale scores served as predictors. Each SF-36 subscale score was
analyzed independently in a logistic regression model adjusted for age, body mass
index, and exercise intervention. Odds ratios were presented, along with 95% confidence intervals and a p value for a test of no effect.
Linear regression analyses were performed using the intention-to-treat sample
of 189 subjects. Although considered conservative, this type of analysis produces
more accurate estimates of effects (5). Each SF-36 subscale score was analyzed
independently in a regression model adjusted for age, body mass index, and exercise
intervention. These independent analyses were conducted because SF-36 subscales
are highly correlated, making it difficult to analyze the effect each has on adherence
when they are combined in a single model. Eight multiple linear regressions, with
each SF-36 subscale as an independent variable, were therefore used to predict
adoption of at-home exercise (months 712). An additional eight multiple linear
regressions, with each SF-36 subscale as an independent variable, were used to
predict maintenance of at-home exercise (months 1924). The effect sizes were
calculated together with 95% confidence intervals and a p value for a test of no
effect. Tests of normality were conducted on the regression residuals and found to
be approximately normal.

Results
The age of the resulting sample ranged from 59 to 78 years, with the average age
being 67.4 years (SD = 4.8). Almost all the participants (99%) were white. The mean
body mass index (BMI) was 24.4 3 kg/m2.

SF-36 Predicts Exercise Adherence / 7

Health Perception Variables

Table 2 presents summary statistics of the SF-36 subscales in this sample. Inspection of the table suggests that this sample of older women viewed all aspects of their
health perceptions more positively than the norms (26).
Overall adherence at 24 months of exercising was good: 137 subjects (72.5%)
continued exercising. At month 12, 16% of the women had discontinued exercise.
By month 18, 23% of the participants had stopped exercising. Only 52 women
(27.5%) had discontinued exercise by 24 months.
Women were exercising an average of 1.4 times each week at month 24,
regardless of the exercise group to which they had been assigned. Figure 1 presents
the trend of adherence in the sample. Inspection of the graph suggests that overall
adherence decreased over time.
Influence of Exercise Intervention on Adherence
In analyses of covariance with exercise behavior at adoption (months 712) and at
maintenance (months 1924) as the dependent variables, no main effect was seen
for exercise condition, no time effect emerged, and there was no interaction of
exercise intervention and time. Additionally, both upper body and lower body
exercise groups had a similar number of dropouts.

Table 2

Characteristics of Respondents

Variables
Age
Body Mass Index
(kg/cm2)
Weight (kg)
Height (cm)
Vitality
Physical function
Role emotional
Role physical
General health
Bodily pain
Social functioning
Mental health

Norms for
SF-36*

Mean

189

65+

67

189
189
189
173
177
175
174
172
175
176
175

N/A
N/A
N/A
55.5
61.9
73.4
56.1
61.6
63.4
77.0
74.7

24.4
63
160.8
70.2
87.1
88.5
86.3
83.6
79.6
94.3
81.9

Minimum Maximum

SD

60

78

4.7

18
45
144
20
40
0
0
42
22
12.5
40

34
88
177
100
100
100
100
100
100
100
100

3.0
8.2
6.3
15.6
13.2
26.8
25.9
12.6
19.3
14.4
12.3

Note. SD = standard deviation. *SF-36 Manual of norms based on healthy women, ages 60
70.

8 / Kleppinger et al.

Figure 1 Line graph of exercise adherence over 24 months.

Predictors of Exercisers Versus Drop-Outs

After 24 months, dropouts totaled 52, leaving 137 women still exercising. Roleemotional and social function subscales were significant predictors of dropout (p <
.05). Lower scores on any of the above subscales indicated a greater likelihood of
dropping out; therefore, women who said they had no problems with work or daily
activities as a result of emotional problems and women who said they perform
normal social activities without interference due to physical or emotional problems
were more likely to keep exercising. These data are not shown in a table due to the
underwhelming results of the odds ratios (role-emotional = .99; social function =
.98).
Predictors of Exercise Adherence: Adoption Stage
Vitality, role-emotional, bodily pain, social functioning, and mental health were
significant predictors of adherence in the adoption stage (months 712) of exercise.
Women who said they feel full of pep and energy all of the time; have no problems
with work or other daily activities as a result of emotional problems; have no pain or
limitations due to pain; perform normal social activities without interference due to
physical or emotional problems; and feel peaceful, happy, and calm all the time were
more likely to adopt an at-home exercise program. Refer to Table 3 for the effect size
of the other SF-36 variables. Figures 2 through 4 presents some of the subscales of
the SF-36 that significantly predicted high and low adherers at the adoption stage.

SF-36 Predicts Exercise Adherence / 9

Figure 2 Box plots of vitality scores across 2 levels of exercise adherence (month 7
12).

Table 3

Predictors of Exercise Adherence at 712 Months (N = 189)

Predictors
Vitality
Physical function
Role emotional
Role physical
General health
Bodily pain
Social functioning
Mental health

Effect on
adherence
(session/wk)

95% C.I.

R2

.015
.007
.012
.004
.011
.010
.010
.016

.005 to .026
.005 to .020
.007 to .018
.002 to .006
.002 to .025
.002 to .019
.003 to .024
.003 to .030

.23
.09
.31
.09
.13
.19
.18
.19

.06
.02
.11
.02
.03
.05
.05
.05

.00
.22
.00
.25
.09
.01
.02
.01

Note. All analyses were adjusted for age, body mass index, and exercise intervention. SF-36
subscales are measured in units from 0100. C.I. = confidence interval.

10 / Kleppinger et al.

Figure 3 Box plots of role-emotional scores across 2 levels of exercise adherence

(month 712).

Figure 4 Box plots of bodily pain scores across 2 levels of exercise adherence (month
712).

SF-36 Predicts Exercise Adherence / 11

Table 4

Predictors of Exercise Adherence at 1924 Months (N = 189)

Predictors
Vitality
Vitality
Physical function
Role emotional
Role physical
General health
Bodily pain
Social functioning
Mental health

Effect on
adherence
(session/wk)

95% C.I.

R2

.015
.018
.012
.009
.004
.017
.012
.009
.012

.005 to .026
.007 to .028
.001 to .024
.004 to .016
.002 to .010
.003 to .030
.003 to .020
.002 to .021
.001 to .026

.23
.25
.14
.23
.09
.19
.20
.12
.14

.06
.10
.06
.09
.05
.07
.08
.06
.06

.00
.00
.07
.00
.21
.01
.01
.10
.07

Note. All analyses were adjusted for age, body mass index, and exercise intervention. SF-36
subscales are measured in units from 0100. C.I. = confidence intervals.

Predictors of Exercise Adherence:

Maintenance Stage
Predictors of exercise maintenance were vitality, role-emotional, general health,
and bodily pain. Women who said they feel full of pep and energy all of the time have
no problems with work or other daily activities due to emotional problems, evaluate
their personal health as excellent, and have no pain or limitations due to painwere
more likely to maintain an at-home exercise program. Refer to Table 4.

Discussion
The primary purpose of this study was to investigate the influence that health perceptions had on exercise adherence during the adoption and maintenance stages of
at-home exercise. More specifically, the eight SF-36 subscales were deemed health
perceptions and then used to predict exercise adherence.
The results of this investigation provided preliminary evidence that health
perceptions influenced exercise adherence in a group of older women. Women who
perceived themselves as having more energy, fewer emotional problems, less pain,
fewer social problems, less feelings of nervousness and depression were more likely
to start exercising. Women who perceived themselves as having more energy,
fewer emotional problems, excellent health, and less pain were more likely to continue exercising. Additionally, the present study discovered that different components of the SF-36 affected different behavior phases of adherence during the exercise program.
The reputation and use of the SF-36 is outstanding in the healthcare domain.
Having SF-36 results information could teach us to tone and build the areas of our

12 / Kleppinger et al.

psyche that need the most improvement for better adherence to healthy behaviors.
Similar to personal trainers committed to strengthen muscles, researchers could
learn to locate the weaknesses in the health perceptions of our patients and volunteers. Strengthening their mental and emotional muscles may be the key to strengthening our bodies and improving our health. We already know the physiological
advantages of beginning and maintaining exercise; now we need to focus on why
successful, healthy people keep exercising.
Interestingly, physical function and role-physical were not significant in the
current study, yet mental health, vitality, social function, and role-emotional were
important. In this study, mentally and emotionally healthy women were more likely
to keep exercising, or adhering to a healthy behavior. In fact, all the women who
adhered highly to the program reported no problems with work or daily activities
due to emotional problems. It appears that it is not how we perceive our physical
health as much as how we perceive our emotional and social health. Perceiving
ourselves as emotionally and socially unlimited could be paramount in adhering to
healthy behaviors.
It is possible that perceptions of health status as measured by the SF-36 reflect
another cognitive construct, like self-efficacy. Self-efficacy is the conviction that
one can successfully execute the behavior required to produce a certain outcome
(17). We have discovered similarities among the constructs of health perceptions
and self-efficacy, in that those with more favorable health perceptions also tend to
have higher self-efficacy for exercise. However, health perceptions focus more
specifically on health and health behavior, and represent perceived current states of
being, whereas self-efficacy is an expectancy of future performance. Additionally,
self-efficacy refers to confidence in the ability to perform specific behaviors (see
work by McAuley, 14), health perceptions, in this case, were more reflective of
emotional and social health. It would appear, then, that health perceptions and selfefficacy expectancies are separate, and possibly complementary, constructs as they
apply to exercise behavior.
Interestingly, Jette and his colleagues (8) reported, Subjects who saw exercise as more desirable and beneficial for their health and felt they had a greater
control over their exercise behavior were more likely to meet their exercise goals
(p. 418). Individuals who perceive they have less control over their health may be
less likely to exercise. This may reflect the common finding that perceived locus of
control has been associated with health and behavior (6, 24). Chen et al. (2), for
example, found that high internal locus of control was associated with greater
adherence to exercise in a sample similar to that studied here. It seems likely that
those with better perceptions of their own emotional and social health would have
higher internal locus of control, but this has yet to be studied.
Scores on the role-emotional and social function subscales were predictive of
dropouts. Women who felt they had emotional problems or who viewed themselves
more socially limited were more likely to drop out of the present study. Schmidt and
her colleagues deviated from our findings, as depression and self-rated health were
not predictive of dropouts in their study (21). However, Schmidt and her colleagues
(21) did report that dropouts had worse self-perceived physical health. In any case, it
seems likely that perceptions of both physical and emotional well-being will be
associated with dropping out of an exercise program. More knowledge of why older
adults stop exercising is critical in exploring exercise adherence. We focused on
why older adults start and continue exercising.

SF-36 Predicts Exercise Adherence / 13

Of the SF-36 subscales, the best predictor of exercise behavior was vitality,
which was significant in the adoption stage and in the maintenance stage. Vitality
represents one aspect of the mental summary score of the SF-36 that assesses a
persons degree of energy or pep. Vitality was added to the SF-36 to better
capture differences in subjective well-being (26). Rejeski and colleagues (19) have
also discovered that feelings of vitality affect exercise adherence. LaForge et al. (10)
revealed vitality to be moderately related to exercise behavior, because vitality
increased with each stage of exercise. Vitality was most related to exercise maintenance (10). Feeling energetic and lively may provide physical and psychological
benefits to both initiate and continue an exercise regimen. This finding could be
extremely helpful in identifying possible low exercise adherers early. Prior to beginning exercise programs, researchers and instructors could assess participants with
the SF-36. After learning that an individual scores low on vitality, for example, they
could focus on imagery, self-talk, verbal encouragement, or dietary adjustments to
increase their feelings of energy and pep. These actions may help improve their
perceptions of vitality and improve adherence.
Participants who reported no emotional problems at work or at daily activities
were more likely to adopt as well as maintain exercise. If participants perceive
themselves to be stressed or emotionally limited, it appears that adherence to healthy
behavior is difficult to initiate. We also found women who perceived themselves to
feel more nervous and depressed were less likely to begin exercising. Our finding is
related to those of King and her colleagues (9), who reported that a high stress level
was predictive of poor initial adherence. Contrary to our study, Jette and his colleagues (8) reported that people with higher degrees of depressed mood had higher
adherence. The relationship between depression and stress in older groups requires
further investigation.
Not surprisingly, bodily pain influenced adherence in both phases of exercise
behavior. Many women reported having pain or limitations due to pain. It is difficult
to measure perceptions of pain. It is clear from our findings that exercise behavior is
affected by pain. The SF-36 is an acceptable tool in measuring perceived pain and
should be used in future studies to quantify pain that may inhibit exercise behavior.
At the start of the study, participants who had reported their personal health as
good or excellent continued exercising later into the program than those who evaluated their health as fair or poor. The SF-36 could aid in identifying those participants
who require more support early in a program to remain active and healthy longer.
Limitations
The present sample was a fairly healthy group of women, scoring considerably
higher on the SF-36 compared to normative data of similar age women. Criteria for
the present study was limited to non-smokers, women on estrogen therapy for 2
years or more, age range of 60 to 78, women with low bone density, and willing to
exercise in a long-term study. Only women were assessed, mens self-perceptions
of health may be considerably different. In addition, most of the volunteers were
Caucasian. A more diverse sample could allow findings to be more generalized.
In regards to different adherence at the adoption and maintenance stages,
women may have adhered to exercise for reasons other than health perceptions, such
as medical advice, alternative health treatments, or weight gain. Volunteers may
have adopted this exercise program to build bone mass, since this was advertised in

14 / Kleppinger et al.

the recruitment for our bone study. Many women may have adhered more or less at
different times because of physiological changes, such as improved strength or
blood pressure. These factors were not revealed to the subjects by staff, yet they may
have felt and seen changes in themselves during daily activities.
Past physical activity behavior was not collected in detail. Past behavior has
been a significant predictor of future exercise behavior (6). The women joining this
study may have had more experiences with exercise than most women of this age,
making them more likely to join or rejoin a program like ours. Diverse experiences
in the past influence our present health perceptions. Our study is limited in that we
measured health perceptions at only one point in time. Administering the SF-36 at
the adoption and maintenance stage could add to our understanding of the effects of
exercise on health perceptions.
Using additional measures for health-related quality of life could strengthen
the study. The Perceived Health Competence Scale (22), Health Perception Scale,
or the Health Locus of Control Scale may be used at some point to reexamine the
present findings.

Conclusions
How individuals perceive their own health does affect their adherence to physical
activity, and perhaps other health-related behaviors. In this study, SF-36 subscales
were used to show an association between health perceptions and exercise adherence. A significant advantage of this study was its 2-year follow-up, which allowed
the investigation of the maintenance phase of exercise adherence. Different types of
communications aimed at people with different perceptions of their own health,
may be able to maximize adoption and maintenance of exercise in older women. We
suggest using the SF-36 as a tool to assess the health perceptions that affect adherence behaviors. Future studies should focus on improving specific health perceptions (low scores on specific SF-36 subscales) using new approaches and then
reassessing those perceptions with the SF-36 to determine which new approaches, if
any, can alter health perceptions. These approaches need to be better defined and
applied to more behaviors than exercise alone.

References
1. Babor TF, Stephens RS, Marlatt GA. 1987. Verbal report methods in clinical research on
alcoholism: response bias and its minimization. J Stud Alcohol 48:410-24.
2. Chen CY, Neufeld PS, Feely CA, Skinner CS. 1999. Factors influencing compliance
with home exercise programs among patients with upper-extremity impairment. Am J
Occ Therapy 53:171-80.
3. DiClemente CC, Prochaska JO, Fairhurst SK, Velicer WF, Velasquez MM, Rossi JS.
1991. The process of smoking cessation: an analysis of precontemplation, contemplation, and preparation stages of change. J Consult Clin Psychol 59:295-304.
4. Dishman R. 1982. Health psychology and exercise adherence. Quest 33:116-80.
5. Hollis S, Campbell F. 1999. What is meant by intention-to-treat analysis? Survey of
published randomized controlled trials. Br Med J 319:670-74.
6. Jackson C, Smith RA, Conner M. 2003. Applying an extended version of the theory of
planned behaviour to physical activity. J Sports Sci 21:119-33.

SF-36 Predicts Exercise Adherence / 15

7. Janis, IL, Rodin J. 1979. Attribution, control and decision making. In: Stone GC, Cohen
F, Adler NE, editors. Social psychology and health care. San Francisco: Jossey-Bass. p.
487-521.
8. Jette AM, Rooks D, Lachman M, Lin TH, Levenson C, Heislein D, Giorgetti MM, Harris
BA. 1998. Home-based resistance training: predictors of participation and adherence.
Gerontologist 38:412-21.
9. King AC, Kiernan M, Oman RF, Kraemer HC, Hull M, Ahn D. 1997. Can we identify
who will adhere to long-term physical activity? signal detection methodology as a potential aid to clinical decision making. Health Psychol 16:380-89.
10. Laforge RG, Rossi JS, Prochaska JO, Velicer WF, Levesque DA, McHorney CA. 1999.
Stage of regular exercise and health-related quality of life. Prev Med 28:349-60.
11. Litt MD, Kleppinger A, Judge JO. 2002. Initiation and maintenance of exercise behavior
in older women: predictors from the social learning model. J Behav Med 25:83-97.
12. Manderbacka K, Lundberg O, Martikainen P. 1999. Do risk factors and health behaviours
contribute to self-ratings of health? Soc Sci Med 48:1713-20.
13. Marks GR, Lutgendorf SK. 1999. Perceived health competence and personality factors
differentially predict health behaviors in older adults. J Aging Health 11:221-39.
14. McAuley E, Jerome GJ, Marquez DX, Elavsky S, Blissmer B. 2003. Exercise selfefficacy in older adults: social, affective, and behavioral influences. Ann Behav Med
25:1-7.
15. OBrien CS. 2000. My heart couldnt take it: older womens beliefs about exercise
benefits and risks. J Gerontol 55:283-94.
16. Oldridge NB. 1982. Compliance and exercise in primary and secondary prevention of
coronary heart disease: a review. Prev Med 11:56-70.
17. Oman RF, King AC. 1998. Predicting the adoption and maintenance of exercise participation using self-efficacy and previous exercise participation rates. Am J Health Promot
12:154-61.
18. Prochaska JO, DiClemente CC. 1983. Stages and processes of self-change of smoking:
toward an integrative model of change. J Consult Clin Psychol 51:390-95.
19. Rejeski WJ, Ettinger WH Jr, Schumaker S, James P, Burns R, Elam JT. 1995. Assessing
performance-related disability in patients with knee osteoarthritis. Osteoarthritis Cartilage 3:157-67.
20. Rowland L, Dickinson EJ, Newman P, Ford D, Ebrahim S. 1994. Look after your heart
programme: impact on health status, exercise knowledge, attitudes, and behaviour of
retired women in England. J Epidemiol Community Health 48:123-28.
21. Schmidt JA, Gruman C, King MB, Wolfson LI. 2000. Attrition in an exercise intervention: a comparison of early and later dropouts. J Am Geriatr Soc 48:952-60.
22. Smith MS, Wallston KA, Smith CA. 1995. The development and validation of the
Perceived Health Competence Scale. Health Educ Res 10:51-64.
23. SPSS Windows release 11.0. 2001. Chicago, IL.
24. Steptoe A, Wardle J. 2001. Locus of control and health behaviour revisited: a multivariate analysis of young adults from 18 countries. Br J Psych 92:659-72.
25. Ware JE Jr, Sherbourne CD. 1992. The MOS 36-item short-form health survey (SF-36).
I. Conceptual framework and item selection. Med Care 30:473-83.
26. Ware JE Jr, Snow KS, Kosinski M et al. 1993. The SF-36 health survey manual and
interpretation guide. Boston: The Health Institute, New England Medical Center.