Service Design Strategies to Enhance Exercise Adherence in Extended Reality Interventions for Older Adults: Systematic Review
Background: Exercise has a positive impact on the health of older adults. However, due to physical conditions, psychological factors, and external environment constraints, older adults still face significant challenges in maintaining exercise. Exercise adherence is relatively low. Extended reality (XR) technology offers new ways for older adults to exercise and improve their adherence. Existing research mainly focuses on short-term effects, paying insufficient attention to maintaining long-term engagement and establishing effective incentive mechanisms. By introducing service design methods, user experience, stakeholder collaboration, and adherence support can be better integrated at different stages of exercise intervention, thereby enhancing the willingness and enthusiasm of older adults to continue to participate in exercise. Objective: This review aims to evaluate how XR‑based exercise interventions targeting populations with a mean age of older than 50 years integrate service design strategies to enhance exercise adherence and to identify critical gaps in their long‑term application. Methods: A systematic review was conducted across PubMed, Scopus, Web of Science, CINAHL, PsycINFO, and ACM Digital Library (January 2020-July 2025). Eligible studies (1) used XR to support exercise or rehabilitation, (2) included participants with a mean age of older than 50 years, (3) reported at least one service design activity, and (4) provided adherence‑related outcomes. Dual independent screening and structured data extraction were performed. Results: A total of 9 studies (242 participants) met the inclusion criteria. Most applied participatory, co‑design, or user-centered design with iterative prototyping, but few advanced to full implementation or applied a complete service design cycle. The user experience was generally positive, but evaluations were primarily based on self-reports with limited objective tracking. Although exercise adherence was generally high in most studies (80%-100%), this assessment was primarily based on attendance-related indicators. There was a lack of consistency in how adherence was defined across studies, and no unified measure of exercise adherence was established. Exercise frequency, duration, and attendance were commonly reported, whereas exercise intensity and accuracy were often overlooked. Existing evaluations also lacked long-term tracking of exercise adherence. Regarding intervention delivery settings, most studies were conducted in laboratories, hospitals, and care facilities. Few studies investigated implementation in community settings, which made XR interventions difficult to adapt to the real-world conditions faced by older adults in their daily lives and hindered their promotion and application to a broader community population. Conclusions: Current XR exercise interventions for older adults show promising short‑term adherence but rarely embed service design continuity or comprehensive adherence monitoring. The combination of structured service design processes with standardized and multidimensional adherence indicators can provide strong support for participants to continue engaging in XR exercise projects. When implemented in community settings, these interventions can enhance scalability and better support an age-friendly XR exercise system. Trial Registration: OSF Registries osf.io/c7t85; https://osf.io/c7t85/overview
