Physical activity and quality of life in community dwelling older adults
© White et al; licensee BioMed Central Ltd. 2009
Received: 04 September 2008
Accepted: 06 February 2009
Published: 06 February 2009
Physical activity has been consistently associated with enhanced quality of life (QOL) in older adults. However, the nature of this relationship is not fully understood. In this study of community dwelling older adults, we examined the proposition that physical activity influences global QOL through self-efficacy and health-status.
Participants (N = 321, M age = 63.8) completed measures of physical activity, self-efficacy, global QOL, physical self worth, and disability limitations. Data were analyzed using covariance modeling to test the fit of the hypothesized model.
Analyses indicated direct effects of a latent physical activity variable on self-efficacy but not disability limitations or physical self-worth; direct effects of self-efficacy on disability limitations and physical self worth but not QOL; and direct effects of disability limitations and physical self-worth on QOL.
Our findings support the role of self-efficacy in the relationship between physical activity and QOL as well as an expanded QOL model including both health status indicators and global QOL. These findings further suggest future PA promotion programs should include strategies to enhance self-efficacy, a modifiable factor for improving QOL in this population.
The demographic landscape of the United States is changing rapidly, with older adults representing the fastest growing segment of the population . It has been well-established that the aging process can be associated with increased susceptibility to chronic conditions, disability, and comorbidity, which often results in reductions in quality of life (QOL). Physical activity has been consistently associated with enhanced QOL [2–4]; however, few efforts have been made to determine whether this relationship is direct or whether it potentially operates through other psychosocial factors.
The traditional approach in the physical activity literature has been to conceptualize QOL as representing physical, mental, and social indicators of health status, or health-related quality of life (HRQL; ). Stewart and King  adopted this approach to explain the relationship between physical activity and QOL in older adults by conceptualizing QOL as an overarching term with other factors, such as function and well-being, influencing the effect of physical activity on QOL. More recently, McAuley and colleagues  have tested several alternative models of the physical activity and QOL relationship in a sample of older women. In these models, they adopted Diener and colleagues'  position that QOL is a global construct reflecting a cognitive judgment of an individual's life. This contrasts with more traditional approaches to HRQL which view physical and mental health status as QOL outcomes. McAuley et al.  argued that HRQL represents a more proximal QOL indicator than global QOL. The model that best fit their data was based on social cognitive theory  and suggested that physical activity had a direct influence on self-efficacy  and, in turn, indirectly influenced QOL through indicators of physical and mental health status. Some support for such a model has also been reported in a study of individuals with multiple sclerosis .
In the context of older adults, a number of physical and psychosocial factors might represent mental and physical health status outcomes. For example, Elavsky and colleagues  have noted that self-esteem has consistently been shown to be influenced by physical activity, especially when measured from a multidimensional and hierarchical perspective [10–12]. Moreover, self-esteem has repeatedly been shown to be a strong predictor of QOL [13, 14]. Importantly, self-efficacy has also been suggested to mediate physical activity effects on self-esteem  and some evidence exists to support this proposition . Thus, self-esteem, and in particular physical self-esteem, would appear to be an important mental health status indicator in the context of the physical activity and QOL relationship. From a physical health status perspective, the likelihood of developing some type of disability increases exponentially as we age,  and there is evidence to suggest that disability is an important outcome of physical inactivity [17, 18]. Additionally, physical activity has been suggested to offer a protective effect against functional limitations , a precursor to disability. Whether factors such as physical self-esteem and disabilities are implicated in the physical activity and QOL relationship, however, has yet to be determined.
Prohaska et al.  have made the important observation that many theoretical approaches to understanding physical activity and its consequences in older adults rarely take into consideration the role played by the demographic characteristics of participants. This may be an important issue to consider given that the lowest levels of physical activity participation are reported by adults of poorer socioeconomic status (SES)  and that fewer exercise facilities are found in low SES neighborhoods . Furthermore, minorities typically report greater levels of sedentary behavior than their white counterparts . Moreover, age is inversely related to physical activity with only 26% of individuals aged 65–74 years, and only 10% percent of those aged 85 years and over, meeting public health recommendations . It is therefore important to determine whether the proposed relationships among physical activity, self-efficacy, and indicators of QOL hold when controlling for demographic influences.
We recruited community dwelling adults aged 50 and older via flyers and electronic newsletters advertising participation in a study of physical activity beliefs. A total of 349 individuals expressed initial interest and 343 individuals agreed to participate following telephone contact. We mailed a battery of questionnaires to the participants, of which 320 (93%) were returned. Incorrect or missing contact information was the primary reasons for non-participation following initial recruitment into the study.
A brief questionnaire was used to collect the demographic variables of sex, age, education, income, and race/ethnicity.
We used two self-report measures to assess physical activity participation. The first was the Godin Leisure Time Exercise Questionnaire (GLTEQ; ), a simple, self-report instrument assessing usual physical activity during the past seven days. This measure includes three open-ended items that measure the frequency of strenuous (e.g., jogging), moderate (e.g., fast walking), and mild (e.g., easy walking) exercises for periods of more than 15 minutes. We also measured physical activity with the Physical Activity Scale for the Elderly (PASE; ). The PASE is a 10-item instrument designed to assess physical activity in large samples of older persons over a one-week time period. The PASE assesses frequency and duration of participation in leisure activities (e.g., walking outside the home, light, moderate and strenuous sport and recreation) along with participation in housework, lawn work/yard care, home repair, outdoor gardening and caring for others. Scores from the PASE have been reported to be a valid measure of physical activity participation in the elderly [27, 28] and are expressed as activity counts. In subsequent analyses, we modeled these two measures as a latent physical activity variable.
We measured self-efficacy with a modification of the Exercise Self-Efficacy Scale  which assesses participants' beliefs in their ability to continue exercising five times per week, at moderate intensities, for 30 or more minutes per session, and at two-week increments over the next 12 weeks. This measure has been frequently used to assess self-efficacy for physical activity [30, 31] and is composed of six items scored on a 100-point percentage scale ranging from 0% (not at all confident) to 100% (highly confident). Item responses are summed and divided by six resulting in a possible range of 0–100. Internal consistency for the measure was excellent (α > .90).
Physical Health Status
We used the eight-item disability limitations subscale of the abbreviated Late Life Function and Disability Instrument (LL-FDI; ) to assess physical health status. The measure is scored on a 1 to 5 scale (1 = completely limited; 5 = not at all limited) with higher scores reflecting fewer limitations. This measure had good internal consistency (α = .83) and reflects physical health status in the context of carrying out household and social activities.
Mental Health Status
As previously noted, we characterized mental health status as self-esteem, specifically, physical self-worth, as it has been identified as a consistent psychological determinant of QOL. We used the 6-item physical self-worth scale of Fox and Corbin's Physical Self-Perception Profile . A sample item from this scale is "I am extremely proud of who I am and what I can do physically." Participants indicated on a 4-point scale the degree to which each item was characteristic or true of them. Responses range from 1 (not at all true) to 4 (completely true). Internal consistency of this scale was excellent (α = .90) in the present study.
Quality of Life
We measured global QOL with the Satisfaction with Life Scale (SWLS; ), a 5-item measure, with each item rated on a 7-point scale from strongly disagree (1) to strongly agree (7). Higher scores represent greater life satisfaction. In a review of SWLS research, Pavot and Diener  presented evidence for the ability of SWLS to successfully detect changes in life satisfaction over time and the course of clinical interventions. The SWLS has demonstrated acceptable internal reliability and validity in older populations [35, 36] and has been shown to be associated with physical activity levels [2, 9]. Internal consistency in the present study was excellent (α = .90).
Complete details of recruitment procedures and data collection procedures can be found elsewhere . Briefly, Institutional Review Board approved informed consent and all study materials were mailed to participants who then returned completed forms in a self-addressed stamped envelope whereupon participants were entered into a lottery to win one of twenty $50.00 cash prizes.
We analyzed the data using covariance modeling with the full-information maximum likelihood (FIML) estimator in Mplus 5.0 . In the present study, 0.9% of disability limitations data (n = 3), 0.3% of self-efficacy data (n = 1), 1.9% of GLTEQ physical activity data (n = 6), 1.9% of physical self-worth data (n = 6), 1.9% of satisfaction with life data (n = 6), and 6.2% of PASE physical activity data (n = 20) were missing.
The hypothesized model proposed: direct effects of the latent physical activity variable on self-efficacy but not disability limitations or physical self-worth; direct effects of self-efficacy on disability limitations and physical self-worth but not QOL; and direct effects of disability limitations and physical self-worth on QOL. Given that the proposed model adequately fit the data, we conducted a second analysis in which the effects of demographic factors on model fit and path coefficients, as well as the model components themselves, were tested.
We evaluated the fit of the proposed model for the data with the chi-square statistic, standardized root mean square residual (SRMR), and Comparative Fit Index (CFI). The chi-square statistic assesses perfect fit of the model to the data . The SRMR is the average of the standardized residuals between the specified and obtained variance-covariance matrices. The SRMR should be less than .08 to indicate good model fit . The CFI is an incremental fit index and tests the proportionate improvement in fit by comparing the target model to a baseline model with no correlations among observed variables. Values approximating 0.95 are indicative of good model-data fit . The model tested and standardized parameter estimates are shown in Figure 1.
Correlations among all model constructs
Physical Activity Scale for the Elderly
Godin Leisure Time Physical Activity
Satisfaction with Life
Physical Activity Scale for the Elderly
Godin Leisure Time Physical Activity
Satisfaction with Life
Structural Equation Modeling of Hypothesized Relationships
The path model tested and all standardized path coefficients are shown in Figure 1. The model represented a good fit to the data, χ2 = 15.59, p = .05; CFI = .97; SRMR = .04, meeting the accepted criteria suggested by Hu and Bentler  with the SRMR below .08 and CFI approximating .95. As can be seen, higher levels of the latent physical activity construct were significantly associated with greater self-efficacy (β = .60) which was, in turn, associated with fewer disability limitations (β = .28) and higher physical self-worth (β = .44). Finally, reporting fewer disability limitations (β = .20) and higher self-worth (β = .40) was associated with being more satisfied with one's life. Overall, the model accounted for 22.4% of the variance in satisfaction with life. Thus, these data would appear to support the social cognitive perspective argued by McAuley and colleagues  that self-efficacy and physical and mental health status variables play intermediary roles in the physical activity and QOL relationship. Additionally, the findings are supportive of the position that self-esteem, in the present context reflected by physical self-worth, is an important component of the physical activity and QOL relationship.
Physical Activity, Quality of Life, and Demographics
As noted earlier, relationships among physical activity and quality of life have been examined relatively independent of demographic characteristics. Thus, the next model that we tested controlled for the contribution of age, race, sex, education, and income to model constructs. This allowed us to determine: (a) whether demographic characteristics changed the nature of the model relationships and (b) how demographic factors were related to individual components of the model.
This model fit the data reasonably well, χ2 (13) = 38.16, p < .001; CFI = .93; SRMR = .04. The path coefficients of the hypothesized model were not dramatically changed, although the relationship between physical activity and self-efficacy increased from β = .60 to β = .73. All path coefficients for this model are shown in parentheses in Figure 1. In terms of the relationships among model constructs and the demographic factors, several interesting relationships emerged. Participant age was significantly (p <.05) associated with physical activity (β = -.34), self-efficacy (β = .30), physical self-worth (β = .22), and satisfaction with life (β = .12). There were less consistent patterns of significant associations among the other demographic factors and model constructs: females reported fewer disability limitations (β = -.12), white participants had a better sense of physical self-worth than other races (β = -.21), and those participants reporting higher levels of education also reported higher levels of satisfaction with life (β = .13). Finally, participants reporting higher income also reported fewer disability limitations (β = .20).
The purpose of this study was to determine whether the relationship between physical activity and QOL operates through self-efficacy and physical and mental health status pathways, as proposed by McAuley and colleagues , in a sample of community dwelling older men and women. The hypothesized associations were all significant, supporting the position that the relationship between physical activity and QOL can be understood as incorporating more proximal, modifiable, and temporally sensitive factors (e.g. self-efficacy), as well as more stable and global constructs (e.g. satisfaction with life). When we controlled for demographic variables the nature of these relationships did not change. The strengths of this study include the adoption of a well-established theoretical framework to understand the physical activity and QOL relationship, use of a relatively large community dwelling sample, and the application of contemporary statistical methods to examine the hypothesized associations.
In testing this model, we have restricted our assessments of mental and physical health status to physical self-esteem and disability frequency, respectively. In the case of esteem, we have done so because self-esteem has been frequently identified as a determinant of QOL. However, it has been demonstrated that the effects of physical activity interventions on global self-esteem have tended to be rather small . This contrasts with physical activity effects on domain levels of self-esteem, i.e., the physical level . Given that we have previously proposed a model of physical activity and QOL as one which capitalizes on factors which are modifiable and thereby likely to be influenced by physical activity interventions, the inclusion of physical self-esteem in concert with other indicators of mental health status may be warranted.
Similarly, there is an increasing literature which suggests that physical activity has a protective effect on functional limitations as we age [19, 42]. Within the disability model framework , functional limitations precede disability. However, little is known about physical activity effects on disability in older adults, in large part because few physical activity studies have measured disability . Even in the present sample, which was relatively disability-free, disability limitations were significantly associated with QOL and self-efficacy. Importantly, self-efficacy has previously been reported to be predictive of self-reported disability over a 30-month period in a large sample of older adults with osteoarthritis of the knee . Further identification of other factors that might map onto physical and health status outcomes is called for in order to further understand the complex relationship between physical activity and QOL in older adults.
Self-efficacy, however, does appear to play an important role as both an outcome of physical activity and an antecedent of more distal QOL indicators. Perceptions of capabilities are modifiable by virtue of providing the appropriate sources of efficacy information from physical activity participation and interventions. This would suggest that such interventions can be effectively structured to maximize physical activity effects on those factors which may influence more global QOL. For example, it has been demonstrated in both cross-sectional and longitudinal designs [15, 46] that self-efficacy is associated with elements of physical self-esteem reflecting physical conditioning, strength, and attractive body. Designing programs that provide information about improvements in those aspects of physical activity associated with these elements of esteem (i.e., enhancing self-efficacy) are likely to further improve physical self-worth and, in turn, QOL. In a similar vein, provision of these types of efficacy enhancing experiences can lead older adults to change their views on what might be disabling conditions or perceived frequency of disability limitations . Indeed, Katula, Rejeski, and Marsh  have recently reported that a relatively short (12-week) intervention of high velocity power training resulted in impressive gains in self-efficacy and QOL outcomes in a sample of older adults.
Although our findings offer support for a social cognitive model of physical activity and QOL, it is not without its limitations. First, we acknowledge the cross-sectional nature of the data and therefore relationships must be interpreted cautiously. Prospective studies and randomized controlled exercise trials will be needed to determine how the proposed relationships among changes in model constructs hold up across time. Additionally, our analyses, with the exception of physical activity, were all conducted using manifest or measured constructs rather than latent variables. We believe that this is a necessity in the early stages of developing complex models of these relationships. Effectively determining which factors may or may not play an important role in representing the latent elements of physical and mental health status is necessary for further understanding their roles in this relationship. McAuley et al.  tested their model on a sample of older women, and although we include both males and females in our sample, the numbers of males included was substantially less than females. In this regard, our sample could be considered relatively homogenous and testing the model on more diverse samples is recommended.
In conclusion, our findings support the role of self-efficacy in the relationship between physical activity and QOL, as well as an expanded QOL model including both health status indicators and global QOL. Given that the life expectancy of many countries continues to increase, a more comprehensive understanding of how we can enhance quality, as well as quantity of life would appear important. Physical activity has been consistently linked to disease risk reduction [28, 48] but the manner in which it influences quality of life is not as well-understood.
Our findings have a number of implications for future research and practice. From an application perspective, self-efficacy appears to play an important role in the relationship between physical activity and quality of life. As a modifiable construct, physical activity programs that target sources of efficacy information (e.g., provision of successful experience, supportive feedback, and credible role models) are thereby likely to have a greater effect on efficacy and, in turn, enhance QOL. Such positive experiences may have implications for adherence to community exercise programs. We note that we have sampled only a few of the possible variables that act as mediators between physical activity and QOL. McAuley et al.  has suggested that more complex models continue to be tested. In addition, it will be important in future studies to determine whether different types of physical activity interventions differentially affect model relationships.
Edward McAuley is supported, in part, by a Shahid and Ann Carlson Khan Professorship in Applied Health Sciences and by a grant (#AG025667) from the National Institute on Aging.
- Centers for Disease Control and Prevention and The Merck Company Foundation: The State of Aging and Health in America 2007. Whitehouse Station: The Merck Company Foundation; 2007.
- McAuley E, Konopack JF, Morris KS, Motl RW, Hu L, Doerksen SE, Rosengren K: Physical activity and functional limitations in older women: influence of self-efficacy. J Gerontol B Psychol Sci Soc Sci 2006,61(5):P270-P277.View ArticlePubMed
- Netz Y, Wu M, Becker BJ, Tenenbaum G: Physical activity and psychological well-being in advanced age: a meta-analysis of intervention studies. Psychol Aging 2005,20(2):272–284. 10.1037/0882-79184.108.40.2062View ArticlePubMed
- Rejeski WJ, Mihalko SL: Physical activity and quality of life in older adults. J Gerontol A Biol Sci Med Sci 2001,56A(Special Issue II):23–35.View Article
- Stewart A, King A: Evaluating the efficacy of physical activity for influencing quality of life outcomes in older adults. Ann Behav Med 1991,13(3):108–116.
- Diener E: Subjective well-being. Psychol Bull 1984, 95: 542–575. 10.1037/0033-2909.95.3.542View ArticlePubMed
- Bandura A: Editorial: The anatomy of stages of change. Am J Health Promot 1997,12(1):8–10.View ArticlePubMed
- Motl RW, McAuley E, Snook EM, Gliottoni R: Physical activity and quality of life in multiple sclerosis: intermediary roles of disability, fatigue, mood, pain, self-efficacy, and social support. Psychol Health Med 2009,14(1):111–24. 10.1080/13548500802241902View ArticlePubMed
- Elavsky S, McAuley E, Motl R, Konopack JF, Marquez DX, Hu L, Jerome GJ, Diener E: Physical activity enhances long-term quality of life in older adults: efficacy, esteem and affective influences. Ann Behav Med 2005,30(2):138–145. 10.1207/s15324796abm3002_6View ArticlePubMed
- Marsh H, Shavelson R: Self-concept: its multifaceted hierarchical structure. Educational Psychologist 1985, 20: 107–123. 10.1207/s15326985ep2003_1View Article
- Sonstroem R, Harlow L, Josephs L: Exercise and self-esteem: validity of model expansion and exercise associations. J Sport Exerc Psychol 1994, 16: 29–42.
- McAuley E, Blissmer B, Katula J, Duncan SC, Mihalko SL: Physical activity, self-esteem, and self efficacy relationships in older adults: a randomized controlled trial. Ann Behav Med 2000,22(2):131–139. 10.1007/BF02895777View ArticlePubMed
- Diener E, Diener M: Cross-cultural correlates of life satisfaction and self-esteem. J Pers Soc Psychol 1995,68(4):653–663. 10.1037/0022-35220.127.116.113View ArticlePubMed
- Lachman M, Weaver S, Bandura M, Elliott E, Lewkowicz C: Improving memory and control beliefs through cognitive restructuring and self-generated strategies. J Gerontol 1992, 47: 293–299.View Article
- McAuley E, Blissmer B: Self-efficacy determinants and consequences of physical activity. Exerc Sport Sci Rev 2000,28(2):85–88.PubMed
- U.S. Census Bureau: 2000 Census of Population and Housing, Demographic Profile. Atlanta: U.S. Census Bureau; 2000.
- Vita AJ, Terry RB, Hubert HB, Fries JF: Aging, health risks, and cumulative disability. N Engl J Med 1998, 338: 1035–1041. 10.1056/NEJM199804093381506View ArticlePubMed
- Leveille SG, Guralnik JM, Ferrucci L, Langlois JA: Aging successfully until death in old age: opportunities for increasing active life expectancy. Am J Epidemiol 1999,149(7):654–664.View ArticlePubMed
- Keysor JJ: Does late-life physical activity or exercise prevent or minimize disablement? A critical review of scientific evidence. Prev Med 2003,25(3):129–136. 10.1016/S0749-3797(03)00176-4View Article
- Prohaska T, Belansky E, Belza B, Buchner D, Marshall V, McTigue K, Satariano W, Wilcox S: Physical activity, public health, and aging: critical issues and research priorities. J Gerontol B Psychol Sci Soc Sci 2006,61(5):S267–273.View ArticlePubMed
- Sproston K, Primatesta P, Eds: Health Survey for England 2003. London: The Stationery Office; 2004.
- Estabrooks PA, Lee RE, Gyurcsik NC: Resources for physical activity participation: does availability and accessibility differ by neighborhood socioeconomic status? Ann Behav Med 2003,25(2):100–104. 10.1207/S15324796ABM2502_05View ArticlePubMed
- Centers for Disease Control and Prevention (CDC): Behavioral Risk Factor Surveillance System Survey Data. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2007.
- Federal Interagency Forum on Aging-Related Statistics: Older Americans 2008: Key Indicators of Well-Being. Washington, DC: U.S. Government Printing Office; 2008.
- Godin GS, RJ : A simple method to assess exercise behavior in the community. Can J Appl Sport Sci 1985, 10: 141–146.PubMed
- Washburn RA, Smith KW, Jette AM, Janney CA: The Physical Activity Scale for the Elderly (PASE): development and evaluation. J Clin Epidemiol 1993,46(2):153–162. 10.1016/0895-4356(93)90053-4View ArticlePubMed
- Martin KA, Rejeski WJ, Miller ME, James MK, Ettinger WH, Messier SP: Validation of the PASE in older adults with knee pain and physical disability. Med Sci Sports Exerc 1999,31(5):627–633. 10.1097/00005768-199905000-00001View ArticlePubMed
- Washburn RA, McAuley E, Katula J, Mihalko SL, Boileau RA: The Physical Activity Scale for the Elderly (PASE): evidence for validity. J Clin Epidemiol 1999,52(7):643–651. 10.1016/S0895-4356(99)00049-9View ArticlePubMed
- McAuley E: Self-efficacy and the maintenance of exercise participation in older adults. J Behav Med 1993, 16: 103–113. 10.1007/BF00844757View ArticlePubMed
- Duncan TE, McAuley E: Social support and efficacy cognitions in exercise adherence: a latent growth curve analysis. J Behav Med 1993,16(2):199–218. 10.1007/BF00844893View ArticlePubMed
- McAuley E, Jerome GJ, Marquez DX, Elavsky S, Blissmer B: Exercise self-efficacy in older adults: social, affective, and behavioral influences. Ann Behav Med 2003,25(1):1–7. 10.1207/S15324796ABM2501_01View ArticlePubMed
- McAuley E, Konopack JF, Motl RW, Rosengren K, Morris KS: Measuring disability and function in older women: psychometric properties of the Late-Life Function and Disability Instrument. J Gerontol A Biol Sci Med Sci 2005,60(7):901–909.View ArticlePubMed
- F Fox KR, Corbin CB: The Physical Self-Perception Profile: development and preliminary validation. J Sport Exerc Psychol 1989, 11: 408–430.
- Diener E, Emmons R, Larsen R, Griffin S: The Satisfaction with Life Scale. J Pers Assess 1985, 49: 71–75. 10.1207/s15327752jpa4901_13View ArticlePubMed
- Pavot W, Diener E: Review of the Satisfaction with Life Scale. Psychol Assess 1993,5(2):164–172. 10.1037/1040-3518.104.22.168View Article
- Pavot W, Diener E, Colvin CR, Sandvik E: Further validation of the Satisfaction With Life Scale: evidence for the cross-method convergence of well-being measures. J Pers Assess 1991,57(1):149–161. 10.1207/s15327752jpa5701_17View ArticlePubMed
- Wójcicki TR, White SM, McAuley E: Assessing outcome expectations in older adults: the Multidimensional Outcome Expectations for Exercise Scale (MOEES). J Gerontol B Psychol Sci Soc Sci, in press.
- Muthen L, Muthen B: Mplus user's guide. Los Angeles, CA; 1998.
- Bollen KA: A new incremental fit index for general structural equation models. Sociol Methods Res 1989, 17: 303–316. 10.1177/0049124189017003004View Article
- Hu L, Bentler PM: Cutoff criteria for fit indexes in covariance structure analysis: conventional criteria versus new alternatives. Structural Equation Modeling 1999,6(1):1–55.View Article
- Spence JC, McGannon KR, Poon P: The effect of exercise on global self-esteem: a quantitative review. J Sport Exerc Psychol 2005,27(3):311–334.
- McAuley E, Morris KS, Doerksen SE, Motl RW, Liang H, White SM, Wojcicki TR, Rosengren K: Effects of change in physical activity on physical function limitations in older women: mediating roles of physical function performance and self-efficacy. J Am Geriatr Soc 2007,55(12):1967–1973.View ArticlePubMed
- Verbrugge LM, Jette AM: The disablement process. Soc Sci Med 1994, 38: 1–14. 10.1016/0277-9536(94)90294-1View ArticlePubMed
- Keysor JJ, Jette AM: Have we oversold the benefit of late-life exercise? J Gerontol A Biol Sci Med Sci 2001,56A(7):M412-M4232.View Article
- Rejeski WJ, Miller ME, Foy C, Messier S, Rapp S: Self-efficacy and the progression of functional limitations and self-reported disability in older adults with knee pain. J Gerontol A Biol Sci Med Sci 2001,56B(5):S216-S265.
- Baldwin MK, Courneya KS: Exercise and self-esteem in breast cancer survivors: an application of the exercise and self-esteem model. J Sport Exerc Psychol 1997, 19: 347–358.
- Katula JA, Rejeski WJ, Marsh AP: Enhancing quality of life in older adults: a comparison of muscular strength and power training. Health Qual Life Outcomes 2008, 6: 45. 10.1186/1477-7525-6-45View ArticlePubMed
- Macera CA, Hootman JM, Sniezek JE: Major public health benefits of physical activity. Arthritis Rheum 2003,40(1):122–128. 10.1002/art.10907View Article
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.