A positive association between baseline physical activity level and adherence to exercise programs has been found [16, 34, 42, 43, 44]. Participation in sports activities at baseline surfaced as a major predictor of long-term exercise adherence [43]. A lower drop-out rate was also found in participants who participated in home-based activities [44] and with higher baseline physical activity levels [34]. Participation in exercise programs increased physical activity level after program cessation [42]. Roessler and Ibsen 2009 [42] found that, at baseline, only about 25% of the patients in their study complied with the daily moderate physical activity recommendations. However, after the intervention, participants were, in general, more physically active. Furthermore, exercise training in later life was more frequent in individuals who exercised during youth and middle age [45].

Self-reported health issues seem to interfere with hypertensive patient’s participation in exercise programs [38, 42, 43]. The major predictors of long-term exercise adherence were high health-related quality of life and high self-rated health [43]. Interestingly, Roessler and Ibsen 2009 [42] reported that, at baseline, only a third of the participants rated their health status as good or very good. However, after the 1-year intervention period, more than 50% declared an improvement in “self-reported health status”. One often reported aspect of being physically active was having more energy and self-control (e.g., “It is good to use my muscles and get my heart rate up”; “I feel better in controlling my daily life”). Awareness of being healthy after exercise training programs seems to be a predictor of future health status [42]. In the MOBILE study [38] patients with lower self-reported health reported more barriers to exercise and less motivation. Patients reported difficulty in escaping the vicious cycle of feeling too tired, unfit, or too fat to start exercising. Also, the coexistence of other chronic musculoskeletal problems and asthma were limiting factors for achieving the recommended dose of exercise [38]. Tailoring exercise programs to individual characteristics may help overcome these barriers.

Some reports defend that health beliefs can have both a negative [34, 46] or positive [42] effect in hypertensive patients. Hypertension causes no physical symptoms and patients, generally, do not feel limited in their daily life activities [14]. Therefore, usually these patients do not acknowledge the need to be physically active. Besides, some believe that exercise may be deleterious for hypertension and that exercising is hard work [46].

On the other hand, when patients have a positive attitude toward exercise (“exercise is beneficial”), the effects on adherence are also positive [34]. In addition, at exercise program completion, most patients reported a better attitude towards physical activity, enjoying it more than before the program [42].

Groups with higher motivation levels seem to have a greater probability of maintaining healthy behavior, namely exercise training [47]. Training under supervision or in a structured environment and feeling engaged in a group were also related to higher motivation levels [42]. The main reported motives to complete an exercise program were better health status and weight loss. Contrarily, weight gain was related to higher program dropout [42]. Lack of energy (e.g., “I haven’t got energy” and “I’m too tired after my job”) and an interest in other physical activities also had a negative effect on motivation to exercise [42, 48].

Patients’ experiences and emotions towards exercise were found to influence their adherence to exercise programs and maintenance after program cessation [34, 42, 48]. Saida et al. 2017 [34], noticed that participants with a positive attitude (“exercise is fun”) presented a higher adherence (80%) than participants with a negative emotion (“exercise is boring”) towards exercise (24%). Roessler and Ibsen 2009 [42] also stated that negative emotions (e.g., “I’m too lazy”) were related with less adherence. Contrarily, Hu et al. [49] in 2015 found no association between depression and anxiety and exercise adherence. Physical issues, like injuries, physical disabilities and movement limitations were found to act as barriers for participation in exercise training programs and were related to low physical activity levels [42, 43, 50].

Interestingly, Leijon et al. 2011 [16] reported that higher age at baseline was related to increased 12-month exercise adherence. However, older participants reported that environmental factors (e.g., seasonal issues) were a determinant for non-adherence and/or maintenance in exercise training programs [43, 48]. Perceived lack of time is a major determinant for non-adherence to exercise training programs [42, 43, 46, 48, 50]. This determinant was more frequently reported by participants with lower age than higher-aged participants [16].

Self-efficacy seems to positively influence and predict many health behaviors. Patients with more family support frequently present more self-care behaviors such as exercise adherence [49, 51, 52]. Self-efficacy seems to be a prerequisite of effective self-care for chronic disease [46, 52, 53]. In face of existing barriers, participants with higher self-efficacy are more likely to start or maintain a specific task [52]. Among patients with hypertension, some studies have demonstrated a positive association between self-efficacy and exercise adherence, however, these patients seem to have a tendency for low self-efficacy [46, 49, 52, 54]. Hu et al. 2015 [49], found that a 10-unit increase in self-efficacy increased the adjusted odds ratio for adhering to exercise to 1.25 (95% Confidence interval (CI) 1.04–1.49). The authors related these results to the possibility of self-efficacy being behavior specific. They suggested that patients might have felt more self-efficacy about exercising. Mansyur et al. 2013 [40], reported that higher self-efficacy seemed to be partially helpful for increasing physical activity in participants with hypertension. Furthermore, the authors reported that different barriers were more associated with behaviour change than were associated with self-efficacy, for example, being “too busy” directly interfered with physical activity.

Self-care management may be a struggle for many patients, needing the support of family, friends, and professional organizations to successfully manage their disease. Social support has been shown to positively influence independent exercise maintenance in the community [42, 49, 55]. Professional and friend support within the patient community offers positive experiences and social interaction. These have been shown to be important in behavioral change by adding to a non-intimidating atmosphere and encouraging patients to exercise [42, 43, 46]. Participants report that exercising among people with similar health problems is important for positive exercise and help overcome barriers [38, 42, 43]. Interestingly, patients also considered how their activity level influenced their social environment and family (e.g., “I feel I would be a better role model for others if I exercised regularly”, “I realize that I might be able to influence others to be healthier if I would exercise more” and “Some of my close friends might exercise more if I would”) [46].

In older patients with hypertension, received counseling on healthy lifestyle behaviors by physicians seems to predict higher adherence to these healthy lifestyle behaviors [19, 37]. Good communication and relationship between patient and physician are paramount for good adherence. Letting the patient talk without interruptions, using a language the patient understands and paying attention to the patient seem to be the most important aspects for patients [56]. Alefan et al. 2019 [19], reported that lifestyle and self-management counselling was found to be an independent predictor of patients’ compliance with lifestyle recommendations such as physical activity. The MOBILE study [38], reported that controlled blood pressure rates were four times higher in patients with an active physician compared to patients with an inactive physician. The reason for this could be related to fewer perceived exercise barriers for active physicians, positively influencing their patients to exercise. For active participants, the physician also motivated them to exercise by showing interest and monitoring the patient’s exercise training program, along with providing reassurance on potential health issues [38].

Literature regarding educational background is not consensual, with some studies reporting a positive correlation between educational status and adherence to exercise programs [34, 42, 43, 45] and others reporting no correlation [42]. However, in a study by Lee et al. 2006 [45], income level was the strongest predictor of exercise and physical activity suggesting its importance in reduced perceived barriers to exercise, perceived health status and blood pressure control.

Logistical determinants pointed for exercise adherence and exercise maintaining were difficulties in access, mainly inconvenience and scheduling around other important activities. Distance and existing transports were also reported as important determinants both for adhering to exercise programs and their maintenance. Patients reported that living in a walkable neighborhood and proximity to exercise facilities were common facilitators [57]. Communities with wider and better opportunities (such as community resources and availability of personal and exercise programs) are more likely to have better ranks of adherence to exercise [31, 35, 36, 41].

Regarding exercise training programs, higher adherence and maintenance rates were related to supervised training programs, a structured environment with fixed training timetables and feeling part of a group [35]. Exercise type/mode was another determinant, with walking, cycling, and gardening the most frequently reported activities [33, 42]. Goal setting and monitoring were consistently identified as the most useful intervention features, and activity planning support tools were also noted as helpful and important [57].

The most common health care system determinants identified by patients were cost [33, 46, 57], language barriers, negative experiences towards health care system, including excessive medical appointments, and lack of physician’s referral for exercise programs [32, 57]. Lack of time during medical appointments, reference services not being available and non-coverage from insurances were reported by physicians as determinants for lack of referral to exercise programs [58]. Reddeman et al. 2019 [57], reported that general advice to simply exercise more often or more vigorously was unhelpful for patients. Similarly, most participants were unaware of existing guidelines for exercise training or reluctant to them, perceiving them to be overly standardized. Even though patients seemed to be willing to receive exercise recommendations from various members of the health care team (e.g., physiotherapists, medical trainees, occupational therapists), many preferred to receive this information specifically from the family physician for a variety of reasons (e.g., knowledge of patient’s health context, relationship or rapport).