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Perceived barriers and facilitators to physical activity for children with disability: a systematic review
  1. Nora Shields,
  2. Anneliese Jane Synnot,
  3. Megan Barr
  1. School of Physiotherapy, La Trobe University, Melbourne, Victoria, Australia
  1. Correspondence to Dr Nora Shields, School of Physiotherapy, La Trobe University, Melbourne, VIC 3086, Australia; n.shields{at}latrobe.edu.au

Abstract

Aim The aim of this systematic review was to investigate the perceived barriers and facilitators to physical activity among children with disability.

Methods 10 electronic databases were searched from the earliest time available to September 2010 to identify relevant articles. Articles were included if they examined the barriers or facilitators to physical activity for children with disability and were written in English. Articles were excluded if they included children with an acute, transient or chronic medical condition, examined sedentary leisure activities, or societal participation in general. Two reviewers independently assessed the search yields, extracted the data and assessed trial quality. Data were analysed descriptively.

Results 14 articles met the inclusion criteria. Barriers included lack of knowledge and skills, the child's preferences, fear, parental behaviour, negative attitudes to disability, inadequate facilities, lack of transport, programmes and staff capacity, and cost. Facilitators included the child's desire to be active, practising skills, involvement of peers, family support, accessible facilities, proximity of location, better opportunities, skilled staff and information.

Conclusion Personal, social, environmental, and policy and programme-related barriers and facilitators influence the amount of activity children with disability undertake. The barriers to physical activity have been studied more comprehensively than the facilitators.

https://doi.org/10.1136/bjsports-2011-090236

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    Introduction

    Physical activity is integral to a child's health, fitness and well-being.1 Regular participation in physical activity enhances body composition,2 skeletal health,3 ,4 and contributes to the prevention or delay of chronic disease.5 It also improves several aspects of psychological health including self-esteem6 ,7 and promotes social contacts and friendships.8 Participation in physical activity is particularly important for children with disability as it can have a positive impact on their development, quality of life and future health and life outcomes.1 ,9

    Children with disability often undertake low levels of physical activity.10 A systematic review suggested children with intellectual disability were less active then their typically developing peers11 and similar findings have also been reported for children with physical disability.12 ,13 Youth with physical disability are also reported to have less variety in their recreation and leisure participation, spending more time in sedentary recreational activities than their typically developing peers14 and in slower tempo skills-based activities and sports.12

    The reasons for the low levels of participation in physical activity among children with disabilities are complex. They are thought to include social, cultural and environmental factors that can act as barriers to a child's participation.15 A full understanding of potential factors that hinder and assist participation is essential for parents, teachers, health professionals and those working in the health, recreation and leisure industries who are involved in the design, organisation and delivery of effective exercise opportunities. This information is also important for clinical intervention programmes that promote physical activity, active recreation, active leisure and exercise for children with disability.5 ,16

    In order to increase participation in activity, we must understand the reasons why children with disability do not participate and identify what factors might enable or prevent their participation. Therefore, we undertook a systematic review as the available literature has not been previously collated. The aim of this review was to identify perceived barriers and facilitators to physical activity for children with disability.

    Method

    Search strategy

    A search of the following 10 electronic databases was undertaken to identify relevant studies: Embase (1988 to September 2010), Medline (1950 to April 2010), AMED (1985 to September 2010), PsychINFO (1967 to September 2010), CINAHL (1982 to September 2010), SPORTDiscus (1830 to September 2010), ERIC (1966 to September 2010), PubMed (1950 to September 2010), Australian Education Index (1978 to September 2010) and Proquest Central (1923 to September 2010). A comprehensive search strategy for each database was developed around four main concepts and their synonyms: barriers and facilitators, physical activity, children and disability. Additional relevant studies were identified by manually searching the reference lists of included studies and by citation tracking using the Web of Science, Google Scholar and Scopus.

    Inclusion and exclusion criteria

    Original research studies and systematic reviews were included if they were written in English and examined either the perceived barriers or facilitators to exercise, physical activity or physically active recreation pursuits in children with disability. Physically active recreation included active play. Where a study examined different types of recreation pursuits (active and sedentary), at least 75% of the specified activities had to have been active pursuits in order for the study to be included. The study participants had to include either children (a group mean age <18 years) with disability (physical, intellectual or sensory impairment including vision and hearing impairment), parents of children with disability under 18 years or support people of children with disability (coaches, policy makers). Systematic reviews needed to have provided a transparent and reproducible protocol, that is, at least reported on databases searched, search dates and inclusion criteria.17 Studies that examined the experiences of physical activity among children with disability and their parents or support people were included only if they explored the perceived barriers to or facilitators of physical activity as a major theme of the study.

    Studies were excluded if they examined the perceived barriers and facilitators to physical activity or exercise in children with typical development or in children with an acute, transient or chronic medical condition or disease such as obesity, juvenile chronic arthritis, heart failure, asthma or cancer. Studies were also excluded if they if they examined sedentary leisure activities (eg, watching TV or art), functional competency, societal participation in general (eg, access to public transport), participation in school-based physical education classes or if it was unclear what type of leisure or recreational activity (active or sedentary) was being investigated. Studies were also excluded if they were narrative literature reviews. Where the results of a study were duplicated, the most comprehensive publication was included in the review.

    Two reviewers (NS, AJS) independently applied these criteria to the titles and abstracts of the studies identified. When a decision regarding the relevance of the study could not be made based on the title and abstract alone, the full text of the article was obtained. Discrepancies in the decisions made were discussed until a consensus was reached.

    Quality assessment

    The quality of the included articles was assessed using the McMaster Critical Review Forms for qualitative and quantitative research.18 ,19 These forms were chosen because they are accompanied by guidelines on how the items should be interpreted,20 ,21 have demonstrated inter-rater agreement of 75–86%22 and have been previously used to assess the quality of studies undertaken using qualitative and non-experimental quantitative methods.23

    As the McMaster Forms provide a narrative assessment only, the scoring criteria developed by Imms23 for these guidelines was used. Qualitative studies were scored on a checklist of four criteria: credibility, transferability, dependability and confirmability (table 1). Quantitative studies were scored on three criteria: sample, measure and analysis (table 1). Each criterion was scored as one star (no evidence of study meeting criterion), two stars (some evidence or unclear reporting) or three stars (evidence of study meeting criterion).

    View this table:
    Table 1

    Quality assessment process adapted from Imms23 and Letts21

    All included articles were assessed independently by two assessors (AJS, MB). Any disagreements were resolved by discussion until a consensus was reached. If agreement could not be reached, the results were discussed with a third assessor (NS), who made the final decision.

    Data extraction and analysis

    A standardised form was developed to extract the relevant data about the following: study design, participant details (including the number of participants and their sex, age and type of disability or relationship to the child with disability), method of data collection and the identified barriers and facilitators to exercise and physical activity. Data extraction was conducted by two reviewers independently (NS, AJS). Any disagreements were resolved by discussion until a consensus was reached. The authors of included articles were contacted for additional data where this would inform the results of the review. A content analysis of the extracted data was conducted, whereby the reviewers agreed on a structure to help categorise the results. This consisted of four themes: personal (relating to personal, physical or psychological factors of children), social (relating to people the child would come in contact with), environmental (structural elements such as facilities and transport) and policy and programme (relating to programmes, organisations and staff). This structure was based on the physical activity for people with disability model proposed by van der Ploeg et al.24 An inductive approach was used to further categorise these data into subthemes within each main theme. Meta analysis of studies using quantitative designs was not performed because of the heterogeneity of the included studies.

    Results

    The search strategy for the electronic databases yielded 2363 articles, of which 2270 were excluded based on their title or abstract. Full text copies of 93 articles were obtained and a further 79 articles were excluded. The references for excluded articles and the associated reasons for exclusion are provided in figure 1 and table 2. Reference checking and citation tracking of the included articles and contact with authors of included articles identified 57 additional items that were potentially relevant. However, none of these items met the inclusion criteria.

    Figure 1
    Figure 1

    Study selection process.

    View this table:
    Table 2

    Excluded articles and reasons for exclusion

    Fourteen studies investigating barriers and facilitators to physical activity for children with disability were included in the review (table 3). Four studies focused on children with physical disability,1 ,16 ,25 ,26one study on children with intellectual disability,27 one study on children with vision impairment,28 seven studies on children with mixed disabilities10 ,28,–,34 and one study did not specify the type of disability.6 The authors of seven of the papers were contacted to clarify participant demographic information (n=3), provide further information about the results (n=2) or both (n=2). Six of the seven authors provided a response.

    View this table:
    Table 3

    Summary of included studies

    Five studies included only children with disability as participants,1 ,16 ,32,–,34 seven studies included only parents (usually mothers) of children with disability,10 ,25,–,27 ,29,–,31 one study included both parents and children28 and one study included staff from organisations that work in disability or manage play environments.6 Data were collected in the included studies using interviews,1 ,6 ,26 ,30,–,32 postal questionnaires,10 ,25 ,29 interviewer-assisted questionnaires16 ,28 ,33 ,34 and focus groups.27

    Quality assessment

    Qualitative studies

    Seven studies used a qualitative research design.1 ,6 ,26 ,27 ,30,–,32 Two studies26 ,30 scored the maximum ranking in all four components of quality assessment. These studies triangulated their data from multiple sources, using multiple researchers and multiple methods. They also provided in-depth descriptions of participants, methods and data analysis and both used member checking to verify their findings. With the exception of one study,6 all studies demonstrated evidence of trustworthiness. Four studies1 ,27 ,31 ,32 met at least one of the components of quality assessment and provided some evidence of meeting at least one other component. In general, these studies did not report either member checking, triangulation of sources or lacked an adequate description of the sample and setting. One study6 provided no evidence of meeting any of the quality-assessment criteria.

    Quantitative studies

    Seven studies used a quantitative research design.10 ,16 ,25 ,28 ,29 ,33 ,34 Overall, the quality of the quantitative studies was not as high as the qualitative studies. Two studies33 ,34 scored the maximum ranking in two of the three components of quality assessment. Six studies10 ,16 ,25 ,28 ,29 ,34 provided either no evidence or unclear evidence of the representativeness of their participants; participants in all six studies were recruited through convenience sampling. Four studies either reported the reliability or validity of some but not all their outcome measures,25 or established face and content validity only29 or reliability only.10 ,16

    Barriers and facilitators to physical activity

    All of the included studies identified barriers to physical activity for children with disability, while only six studies identified facilitators (tables 4 and 5).

    View this table:
    Table 4

    Barriers to physical activity

    View this table:
    Table 5

    Facilitators to physical activity

    Barriers to physical activity

    Personal barriers

    Twelve studies identified personal barriers to participation for children with disability.1 ,6 ,10 ,16 ,27,–,34 Four subthemes emerged: lack of skills (physical and social), preference for activities other than physical activities, fear and a lack of knowledge about exercise (table 4). Children with disability also disliked having to deal with negative perceptions of disability (referred to as the ‘stigma of disability’) or of attracting unwanted attention.1 ,35

    Social barriers

    Thirteen studies identified social barriers to participation for children with disability.1 ,6 ,10 ,16 ,25,–,32 ,34 Three subthemes emerged: parental actions, behaviour or concerns, a lack of friends to participate with or unsupportive peers and negative societal attitudes to disability (table 4).

    A number of notable findings relating to social barriers to activity participation were reported. Twenty-one per cent of parents of children with spina bifida reported that they believed recreation was more important for children without disability.25 Mothers of school-aged children with Down syndrome reported their child's interest in physical activity waned as the gap between their motor skills and the motor skills of their peers with typical development widened.27 Some children with disability chose not to participate in activity because they believed their peers viewed them as helpless1 or the parents of their peers without disability were unfriendly and had misconceptions about their ability.6 ,16 ,31

    Environmental barriers

    Eleven studies identified environmental barriers to participation.1 ,6 ,10 ,16 ,25,–,34 Two subthemes emerged: inadequate, inaccessible or inconvenient facilities and a lack of transport (table 4). Almost 80% of parents of children with disability (mean age 7 years) reported that a lack of facilities was a major barrier.10

    Policy or programme barriers

    Thirteen studies identified policy or programme barriers to participation.1 ,6 ,10 ,16 ,25,–,31 ,33 ,34 Four subthemes emerged: lack of appropriate physical activity programmes, lack of staff capacity, negative staff attitudes towards working with children with disability and cost (table 4).

    Between 25% and 60% of parents in four studies10 ,25 ,28 ,29 identified a lack of appropriate programmes or a deficiency in available programmes as a barrier. Forty per cent of children with disability also felt they had a lack of opportunities to be physically active28 and 35% believed there was a lack of transition programmes from the rehabilitation setting to a community setting16 or that there was a lack of ‘learn to exercise’ programmes.16 Some children were excluded from formal programmes because of specified rules and regulations, for example, motorised wheelchairs were not allowed in a wheelchair basketball competition.1

    Facilitators

    Personal facilitators

    Four studies identified personal facilitators to participation for children with disability.6 ,27 ,28 ,33 Two subthemes emerged: the child's desire to be fit and active and practice to gain skills and competence (table 5). Having fun and being fit were the main reasons given by children to be engaged in physical activity in one study.33

    Social facilitators

    Six studies identified social facilitators to participation.6 ,10 ,27 ,28 ,31 ,33 Two subthemes emerged: the involvement of peers and family support (table 5). Four studies indicated children with disability were more likely to participate if the activity included interaction, encouragement and assistance with their peers, friends or siblings.10 ,27 ,28 ,33 Having a social element to the activity was a particular motivator among children with Down syndrome.27 Children who had common interests with friends or family were also more likely to take part in physical activity.10 ,27 Parents reported supporting their children to engage in activity by creating opportunities for them to be active27 ,31 and through positive encouragement.27 ,28 Parents and siblings also facilitated involvement in physical activity by modelling and getting involved themselves.27 ,28

    Environmental facilitators

    Four studies identified environmental facilitators to participation.6 ,10 ,28 ,31 Two studies6 ,10 identified accessible facilities (including playgrounds) and two studies reported that the proximity of facilities were important factors in engaging children with disability in physical activity10 ,31 (table 5).

    Policy or programme facilitators

    Five studies identified policy or programme facilitators to participation.6 ,10 ,27 ,28 ,31 Three subthemes emerged: a greater number of and better quality community-based opportunities sensitive to the needs to children with disability, skilled staff and information dissemination (table 5). Structured programmes with a variety of activities,27 non-competitive, small group or individual programmes27 ,31 and age-appropriate programmes6 ,31 were seen as facilitators. Staff working in such programmes who were more disability-aware6 and more knowledgeable about how to modify activities so that children with disability could be included27 ,28 ,31 also facilitated engagement in activity. The provision of information about programmes to parents by schools,27 by other parents31 and by physical activity providers6 were regarded as important facilitators.

    Discussion

    Many of the perceived barriers and facilitators identified were based on similar constructs and were dependent on whether that factor was present or absent. For example, unsupportive peers acted as a barrier to activity, whereas supportive peers were perceived as facilitators to activity. Overall, the identified barriers and facilitators were consistent between the included studies. There were some inconsistencies related to the availability and appropriateness of programmes. For example, two studies28 ,33 reported a lack of competitive sport opportunities or leagues as barriers to participation, while two studies6 ,31 identified competitive team sports as a barrier to participation. It is important to remember that the data reflect what is happening on average and that for any one individual child with disability, an individualised assessment is required to cater for his or her personal needs.9 ,27

    Overall, the perceived barriers and facilitators identified by the different groups of participants (children, parents and organisation staff) were similar, but the emphasis placed on different themes varied between groups. Children most commonly identified personal, peer-related and environmental barriers to participation such as preferences for other activities, negative behaviour of peers and a lack of adaptive equipment.1 ,16 ,28 ,33 ,34 Parents focused on social, policy and programme barriers or on their own involvement in their child's activity. They more frequently identified barriers and facilitators relating to the quality and availability of programmes and staffing. Support people also identified more policy and programme barriers and facilitators. The different perspectives presented by these groups are not unexpected; parents are likely to negotiate programme policies when trying to engage their child in an activity, while their child has to physically access a venue. Parents also identified more facilitators than children, but this is likely a reflection of study methods where children with disability were often not asked about facilitators of physical activity.

    Many of the barriers and facilitators identified are similar to those reported for children with typical development. A review of 108 studies36 found participation in physical activity by younger children with typical development was associated with a child's preference for physical activities, motivation and previous participation in physical activity. In adolescents with typical development, parental support, family involvement, opportunities to exercise, new social networks and access to programmes and facilities were strongly associated with physical activity participation.36 ,37 Other barriers to activity for children and adolescents with typical development include age, a lack of time, a lack of interest and competitive sport.36,–,38 Each of these constructs, whether barriers or facilitators, were also suggested as factors among children with disability in our review. This suggests that much of the published literature on barriers and facilitators to activity for children with typical development is also relevant for children with disability.

    Specific barriers to physical activity were identified for children with disability that related to their impairment. These were negative societal and staff attitudes to disability, inadequate or inaccessible facilities, a lack of appropriate physical activity programmes and the lack of skilled staff who can appropriately engage them in activity. It was not possible to determine if these specific barriers to physical activity were different for children with different types of disability as most of the articles included children with a range of impairments. Negative societal attitudes,39,–,41 poorly trained or inexperienced staff40 ,41 and a lack of appropriate opportunities5 ,39 ,40 have also been reported as barrier to physical activity by adults with disability. Adults with disability, however, have tended to cite more personal factors influencing their participation than children with disability16 including motivational factors, such as the opportunity for improvement or to test oneself, a sense of fulfilment and the benefits to physical appearance.42 ,43

    Having a social component as part of a physical activity was a strong theme that emerged both as a facilitator and a barrier when it was deficient. In general, children with disability enjoyed participating in activity with their peers or siblings.10 ,28 This is potentially related to the social isolation that many children with disability feel.44 For some children with disability (eg, children with Down syndrome), social interaction was their primary reason for participation.27 Recreational staff, teachers, parents and programme planners should aim to promote and encourage a social element as a reason to engage in activities.10 Formal programmes have been recommended because of the structured opportunity they offer for socialisation, which can facilitate a sense of belonging.1 This was exemplified by the participants in the Anderson et al 1 study, who participated in formal programmes and experienced benefits from engagement above and beyond the benefits of exercise.

    The themes and subthemes identified in this review are consistent with established theories on health behaviour change including the Theory of Planned Behaviour and Social Cognitive Theory. The Theory of Planned Behaviour suggests that people are more likely to engage in physical activity if they have a positive attitude, they perceive social support to participate, and they believe they will be successful and are motivated to engage in activity.45 The subthemes identified in this review found that physical activity was facilitated in children with disability who wanted to be active, had parental and peer support, were competent in their motor skills and had a desire to be fit. The review findings are also consistent with Social Cognitive Theory, which suggests that behaviour change is influenced through observation of behaviours.46 Parents who were informed of the benefits of physical activity, who were physically active themselves (modelled behaviour), who initiated and encouraged their children to be active had children with disability who were more engaged in activity.

    Understanding the barriers and facilitators of physical activity for children with disability is essential for designing effective interventions to promote participation in this group.16 We currently know more about barriers to physical activity than we know about the facilitators. Knowing what hinders participation provides the opportunity to modify and improve available activity programmes.16 However, it is potentially more important to understand the facilitators of physical activity as these are successful, positive strategies that improve participation and are often easier to understand.16 It is also important to remember that some barriers are fixed and impossible to change, for example, an adolescent's running ability. In this case, the focus should be on external methods to maximise participation, for example, increasing physical accessibility, decreasing negative stereotypes and training staff members adequately. Future research should concentrate on identifying facilitators of physical activity and incorporating these strategies into activity programmes.

    The strengths of this review are that it used an extensive search strategy to locate 14 articles that met the predefined eligibility criteria. In most studies, the findings were consistent, although the emphasis differed based on the participants included. The limitations of the review are that it excluded articles not written in English, therefore some relevant literature may have been omitted. Also, publication bias cannot be ruled out as although two theses were included, no systematic attempts were made to locate unpublished material due to the difficulty in identifying and locating it.

    Conclusion

    The reasons for non-participation in physical activity by children with disability are complex and multifactorial. A range of personal, social, environmental, and policy and programme-related barriers and facilitators have been identified which influence the amount of physical activity that children with disability undertake. The barriers to physical activity have been studied more comprehensively than the facilitators. It is important that future research examines the facilitators to physical activity in more detail, given the benefits of physical activity for children with disability in terms of good health and social well-being. This information will assist parents, health professionals, teachers, carers, recreational staff and policy makers in developing successful exercise programmes and clinical interventions to encourage and increase participation levels of children with disability in physical activity.

    Acknowledgments

    The authors would like to acknowledge Professor Nicholas Taylor for his comments on the draft manuscript.

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    View Abstract

    Footnotes

    • Funding The study was funded by Victorian Health Promotion Foundation (VicHealth).

    • Competing interests None.

    • Provenance and peer review Not commissioned; externally peer reviewed.