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THE PHY SICAL ACTIVITY PATTERNS OF
ADULTS WITH DEVELOPMENTAL DISABLITlES
by
Dana M. Paquette
A thesis submitted to the Department of Community Health and Epidemiology
in conformity with the requirements for the degree of Master of Science
Queen's University
Kingston, Ontario
September, 1997
copyright O Dana M. Paquette, 1997
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Abstract
The purpose of this study was to describe the physical activity patterns of adults with developmental disabilities and determine the factors associated with participation in physical activity. It was hypothesised that living arrangement would have a significant impact on physical activity, independent of other variables examined. A secondary objective of this study was to describe the barriers p n x e n ~ g this group from engaging in more phy sical ac tivi ty .
Information on 6 indicators of physical activity was gathered h m 301 clients residing in an institution, in a group home, or in a cornrnunity living setting.
The results of this survey indicate that many adults with developmental disabilities lead sedentary lives. Eighty-nine percent of the sample were considered inactive, and only 24% engaged in regular physical activity. The fiequency of physical activity is similar to that found in other studies of adults with developmental disabilities but considerably lower than in the gened population.
Variables which were signifcantly associated with increased levels of physical activïty were: king in a younger age group, living in a community or group home s e t ~ g , not talang antimanic agents, the absence of a sensory impairment, anhritis and diabetes. Further research is needed into the associations between medical disorders and physicd activity.
The b&s preventing clients fiom participating in more physical activity could be groupeci in two categones: client baniers and resource barriers. niese reported barriers should be interpreted with caution as they may not retlect reasons for inactivity, rather they may represent post-hoc explanations for inactivity by proxies.
1 would like to thank my thesis advisors, Ms. Helene Ouellette-Kuntz and Dr. Ron Lees for their guidance and support over the past year. As well, thanks to Dr. Kristen Aronson for her assistance with a l l things statistical and to Dr. Brenda Brouwer for her assistance with the literature review.
I would also like to express my deepest appreciation to Barbara Stanton who has k e n a great supervisor, advisor and fnend. Th& also to a i l my CO-workers at the Developmental Consulting Program (Allison Langille, Kristen Murphy and Philip Burge) for their support and encouragement 1 have learned so much in the past two years, thanks to the always f?iendly and supportive environment at DCP.
Thanks to the agencies who participated: Rideau Regional Centre, Ongwanada, Christian Horizons, Kingston & District Association for Community Living, ARC Industries of Lennox & Addington Association for Comrnunity Living, and the Ottawa Carleton Association for Persons with Developmental Disabilities for their support and their help with the organisation of this projecc and to a l l the clients and their caregivers who participated
A special thanks to my husband Victor for his love and understanding, and for always king able to make me laugh even at the most smssed of tirnes; to my fnend Monique for recognizhg the importance of such things as fudge; and to my parents, Sylvana and Robert for their limitless encouragement and their belief in my abilities.
Table of Contents
List of Tables
Literature Review Developmental Disability Physical Achvity, Exercise and Physical Fimess Benefits of Physical Activh Prevalence of Physical Ac tivity Factors Associated with Participation in P hysical Activity Measurement of Physical Activïty
S tudy Objectives
Me thod Study Design Sample Design Sample Size Subjects Questionnaire
Frequency of physical activity Participation in physical activity in past month Phy sical activity index
Data Collection Data Analysis
Response rate Client characteristics Information on pruxies Objective l Objective 2 Secondary objective
Results Response rate Client charac teristics Description of proxies Objective 1
Participation in phy sical activity Types of physical activity Correlation between outcomes
Objective 2 Collapsed variables Correlation between exposure variables
Bivariate analysis Daily routines or work activities Vigorous activity Frequency of physical actiMty D d y phy sicd activity Physical activity in past month Physical activity index
Multivariate andysis Daily routines or work activities Vigorous activity Frequency of physical activity Daily physical activity Physical activity in past month Physical activity index
Secondary Objective
Discussion Response rate Description of proxies Objective 1 Objective 2 Secondary objective Biases Confounding Limitations
Conclusion Future S tudies
References
Appendix A MET Values
Appendix B Questionnaire
Appendix C Information Sheet for Roxies
Vita
List of Tables
Table 1: Frequency of physical activity
Table 2: Physical Activity Index
Table 3: Variables of interest
Table 4: Age, gender and level of mental retardation by smtum
Table 5: Medical conditions and medications by stratum in %
Table 6: Description of proxies by stratum in %
Table 7: Participation in physical activity by stratum in % institutional setting.
Table 8: Ten most common types of physiczl zctivity in the p s t month by stratum in %
Table 9: S pearman Correlation Coeeficients Measuring Correlation B etween the Six Physical Activity Outcornes.
Table 10: Variables collapsed for bivariate and multivariate analysis by stratum in %
Table 11: Bivariate analysis with daily routines or work activities involving walkkg, lifting or heavy work as the outcome
Table 12: Bivariate analysis with vigorous activity in past two weeks as the outcome
Table 13: Bivariate analysis with higher frequency of physical activity as the outcome
Table 14: Bivariate analysis with daily physical activity as the outcome
Table 15: Bivariate analysis with participation in physical activity in past month as the outcome
Table 26: Bivariate analysis with physical activity index as the outcome
Table 17: Model containing living arrangement, age and gender with d d y activities / work habits as the outcome
Table 18: Model containing living arrangement, age and gender, with daily activ-ities / work habits as the outcome
Table 19: Model containing living arrangement, age and gender, with vigorous activîty as the outcome
Table 20: Model containing living arrangement, age and gender with frequency of physical activity as the outcome
Table 2 1: Model containing living arrangement, age and gender, with antirnanic agents, arthritis and diabetes added; with frequency of physical activity as the outcome.
Table 22: Model containing living arrangement, age and gender, with daily physical activi~y as the outcorne
Table 23: Model containhg living arrangement, age and gender, with diabetes added and daily physical activity as the outcome
Table 24: Model containing living arrangement, age and gender, with physical activity in the past month as the outcome
Table 25: Model containhg living arrangement, age and gender, with use of antimanic agents added and participation in physical activity in the past month as the outcome
Table 26: Model containing living arrangement, age and gender with the physical activity index as the outcume
Table 27: Ten most common baniers by stratum in %
vii
Li terature Review
This study airneci to describe the physical acuvity patterns of adults with
developmental disabilities and the factors associated with participation in physical activity.
The following section summarizes the literature as it relates to the research project
Definitions of developmental disability and physical activity are providd The benefits of
physical activity are discussed to illustrate the importance of this study. Following this, the
prevalence of physical activity and factors associated with physical activity as found in
previous snidies are discussed. The literature review concludes with a summary of
methods used to assess physical activity.
Developmental Disability
A developmental disability is defined by three essential criteria: 1) signifcantly
subaverage general inteliectual functioning, 2) Limitations in adaptive functioning in at least
two of the following areas: communication, sekare , home living, social/interpersonal
s u s , use of community resowes, self-direction, functional academic skills, work, leisure,
heaith and safety, 3) onset before the age of 18 (McCreary, 1997). While other ternis
exist, developmental disabiüty is the term used in Ontario (Mcbary, 1997), and that
which will be used thughout this study.
Persons with developmental disabilities are often categorized according to level of
mental retardauon or intellectual impairment. There are four categones of mental
retardanon based on IQ: mild, moderate, severe and profound (Grossman, 1983; as
referenced by Pitetti, Rimmer & Femhall, 1993). The degree of personal support required
by individuals with developmental disabilities differs according to the level of menrai
retardation. This issue will be discussed more fully, further in the literature review.
While the information available on the prevalence of developmental disabiliiy in
Canada is hgmenüuy, a survey of studies by the Ministry of Health and Weifare (1988)
suggests a prevalence of approximately 8 per thousand population for all levels of mental
retardation. Within that group of persons with developmental disability, approximately
85% have a mild level of mental retardation, 10% moderate, 34% a severe and 1-2%
profound level of mental retardation (Developmental Consulting Program, 1992).
Phvsical Activity. Exercise and Phvsicd Fitness
Physical activity, exercise and physical fitness are terms that describe dflerent
concepts, however they are often confused with one another. Caspersen, Powell, and
Christenson (1985) propose the foilowing dehitions. Physical activity is defined as "any
bodily rnovement produced by skeletal muscles that results in energy expenditure" (p.
126). While physical activity is a behavior, physical fitness is considered "a set of attributes
that people have or achieve that relates to the abüity to perform physical activity" (p. 128).
This suxvey assessed physical activity and not physical fimess.
Physical activity is often categonzed as either leisure-time physical activity or
physical activity that occurs while at work. Leisure-time physical activity c m be further
subdivided into categones such as sports, conditioning exercises, household tasks and
other activities (Caspersen, Powell & Christenson, 1985). Exercise is a subset of physical
activity that is "planneci, sîmctured, and repetitive and has as a fmal or an intermediate
objective the improvement or maintenance of physical fitness" (p. 128). Exercise, rhen, as
a subset of physical activity, may constitute ail or part of leisure-time or occupational
physical activity.
Benefits of Physical Activity
This section s u ~ z e s the potential benefits of physical activity for adulo with
developmental disabilities. This information is provided to relay the importance of
measuring physical activity patterns for this population.
Physical activity has become a major component of preventive medicine in our
society today. It is recognized that physical activity can decrease the nsk of developing
coronary hem disease (Rzppe, Ward, Porcan & Freedson, 1988; Siscovick, Laporte &
Newman, 1985; Fletcher et al, 1996). Berlin and Colditz (1990) conducted a meta-
analysis of dl available cohort smdies exarnining the relationship between physical activity
and coronary hem disease, and concluded that a sedentary Mestyle almost doubles the
risk for heart attack Furthemore, they found that the methodologically stronger studies
revealed in a Iarger benefit of physical activity than the weaker studies. Similady, the
Centers for Disease Conml and Prevention (1987), in reviewing 43 studies that provided
associations between p hy sical ac tivity and coronary hem disease, de termined that p hy sical
inactivity is, by itself, a significant nsk factor for the developrnent of coronary hem
disease. After adjustment for other nsk factors, the relative risk was 1.9 in sedentary
people as compared with active people (Centers for Disease Conuol, 1987).
If the association between physicd activity and coronary heart disease also holds
me for adults with developmentd disabilities, these snidies have important implications
for this population. Cardiovascular disorders have been found to be more comrnon in
populations with than without mental remdation (Fernhall, 1992), and are the most
prevalent form of disease among elderiy with mental retardation (Pitetti & Campbell,
199 1). In a study of the cardiovascular risk factors in a population of adults with mental
retardation, m e r , Braddock and Fujiura (1994) found that their sample had
cardiovascular nsk profües s i d a r to those without mental retardation in the Frarningham
Offspring Study. They concluded that "to the extent that cardiovascular health is a
concem to the geneml population, i t must also be a concem for individuals with mental
retardation" (p. 157).
Regular physical activiry may also lead to a reduced risk of developing
hypertension (Rippe et al, 1988; Siscovick et al, 1985; Levine & Balady, 1993). In a study
of Harvard alurnni, sedentary individuds were at 35% greater risk of developing
hypertension than those who were active (Paffenbarger, Wing, Hyde & Jung, 1983). There
is also evidence that regular exercise prevents the onset of non-insulin-dependent diabetes
rnellitus (Helmrich, Ragland, Leung, 1991), and of osteoporosis (Siscovick et al, 1985).
Once again, if these associations hold me for adults with developmental disabilities,
physical activity may have a significant impact on the prevention of these chronic
conditions.
In addition to the positive effects of physical activity on disorders such as coronary
hem disease, hypertension, diabetes and osteoporosis, physical activity has k e n shown to
be associateci with reduced symptorns of depression and anxiety, improved self-concept
and more effective coping with stress (Stephens, 1988; Barr Taylor, Sallis & Needle,
1985; Raglin, 1990). Stephens (1988) conducted a secondary andysis of four population
surveys and concluded that level of physical activity is positively associated with general
well-being, positive m d , and relatively infrequent symptoms of anxiety and depression.
This association has also k e n examined in populations with developmental disabilities.
Gabler-Halle, Halle and Chung (1993), in a review of the literature, stated that while there
is a need for more carefully designeci studies, available data suggests that exercise may
have a positive effect on the self-concept of individuals with mental retardation. These
hdings saengthen the importance of phyacal activity for adults with developmental
disabilities. It has been argued that people with mild and moderate levels of mental
retardation are at increased risk for depression due to stress not only h m the nomal
range of everyday problems but also fiom the stigma and additional consequences of their
inteliectual disability (Turner & Moss, 1996).
In addition to the health benefits above mention&, adults with developmental
disabilities are likely to gain social and functional benefits through participation in regular
physical activity (Compton, Eisenman & Henderson, 1989; S hephani, 199 1). The social
benefits of physical activity include countering stigmatization and the provision of new
opportunities. Social stigmatization can lead to isolation for pesons with disabilhies.
Achievements in cornpetitive sport may act to decrease the stigmatization by
demonsuating the potential of people with disabilities (Shephard, 1991). Spon and
physical activity may also lead to new opportunities for encouraging new friendships and
developing social support networks (S hephard, 199 1).
Participation in regular physical activity may lead to functional benefits by enabling
adults to work throughout a normal career span, enjoy their leisure time and to continue to
live independently (Shephard, 1991). In ternis of work productivity, physical activity has
led to improvements in both motor skills and the speed at which manual work is
perfomed (Fentem, 1992). Physical activity, through its social and funccional benefits rnay
enhance quality of life and mwimize potential for independence.
Prevalence of Physical Activity
Despite the many benefits of physical activity, iittie is known about the physical
activity habits of adults with developmentd disabilities. However, it is generally accepted
that adults with developmental disabilities lead sedentary lives (Rimmer, Braddock &
PiteM, 1996).
In a review of the literature on the physical fimess of adults with mental
rerardation, Pitetti, Rimmer and Fernhall(1993) state that the prevalence of obesity in
populations with mental retardation may be twice as high as their peers without mental
retardation, and is probably associatecl with sedentary lifestyles. In this same review, it is
found that with few exceptions, investigations have shown that individuals with mental
retardation have very low levels of cardiorespiratory fimess. Once again, sedentary
lifestyles are implicated as contributing gready to these low levels (Pitetti, Rimmer &
Femhall, 1993).
While studies of obesity and tests of cardiovascular fitness have led researchers to
speculate that persons with developmental disabilities lead sedentary lifestyles, few have
substantiated those speculations with acnial surveys. Furthemore, those studies which
have examined this question have gone into little depth, leaving many questions
unanswered.
One study by Steele (1986) compared the functional weilness skills of a group of
46 community-based adolescents with mild mental retardation to their able-bodied peers.
Steele (1986) found that the group with mental retardation exercised less, with only 24%
participating in regular exercise, defined as 3 times weekly. Sirnilarly, Rimmer, Braddock
and Marks (1995). in an examination of the hedth behaviors of adults with mentai
retardation, found that 24% of the participants exercised on a regular bais (3-4 days a
week). In this study, the most common exercise was walking.
Beange, McElduff and Baker (1995) compared the cardiovascular nsk factors of a
sample of adults with developmental disabilities to the general population. It was found
that adults with developmental disabilities exercise less. Only 26% of the sample of adults
with developmental disabilities had engaged in vigorous exercise in the previcus ?NO
weeks. Vigorous exercise was defined as exercise which makes you breathe harder or puff
and pant. in contrast, 51% of the sample of the general population had engaged in such
exercise in the same time M e .
Unfomuiately, information on pariicipation in physicd activity was colIected in a
cursory manner in the previous three stuaies meange et al. 1995; Rimmer et al, 1995;
Steele, 1986). For example, duration vent in exercise was not examined by these studies.
As weil, only Rimmer et al (1995) collected information on types of exercise engaged in,
and only the rnost common activity was reported in this study. In response to the paucity
of information available on physicd activity and persons with disabilities, Rimmer,
Braddock and Pitetti (1996) state that the study of the activity patterns of persons with
mental disabilities is an emerging research pnonty.
Factors associated with pamcipation in oh~sical activity
For adults with developmental disabilities, little information is available on the
factors associated with participation in physical activity. In the general population,
however, several studies have examinecl characteristics associated with ph ysicai activity
(Stephens, Jacobs & White, 1985; Bauman, Owen & Rushwortb, 1990; Dannenberg,
Keller, Wilson, & Castelli, 1989) Three variables have ernerged as king consistently
associated with a lack of leisure-time physical activity in various surveys of adults: old
age, fernale gender and low socioeconomic status (Weyerer & Kupfer, 1994; Stephens,
Jacobs & White, 1985; Bauman, Owen & Rushwonh, 1990; Dannenberg, Keller, Wilson,
& Castelli, 1989).
After reviewing eight national surveys, Stephens, Jacobs & White (1985)
concluded that the proportion of the population defineci as active declines with age. While
this relationship has not been exarnined in adults with developmental disabilities, a similar
trend has k e n observed in a survey of the physical activity levels of students, aged 4-21,
with developmental delays. The developmental delays consisted of mental rebrdation,
exnotional disturbances, vaiying degrees of autism anaor miid foms of neurological
impairments (Levinson & Reid, 1991). This survey found that 75% of parents of younger
students (4-10 years old) placed their child in the active category, compared to 56% for
older students (1 1-21 years).
Gender is also often found to be associated with levels of physical activity in the
general population, with a larger proportion of males classifiai as physically active
(Weyerer & Kupfer, 1994; Stephens, Jacobs & White, 1985; Bauman, Owen &
Rushworth, 1990). The relationship between gender and level of physical activity was
examined in two studies in the developmental disabled population (Beange et al, 1995;
Rimmer et al, 1995). No signifiant difference was found between males and femdes in
either study. However, due to the cmory manner in which physical activity was assessed,
this association should be further examineci in future studies.
The third characterisuc often associated with physical activity is that of
socioeconornic stams (Weyerer & Kupfer, 1994; S tephens, Jacobs & White, 1985;
Baurnan, Owen & Rushworth, 1990). The relevance of this variable to adults with
developmental disabilities is questionable as there is Little variation in socioeconomic status
among this group. In the sample of adults with developmental disabilities used by Beange
et al (1995), no subjects had cornpleted high school and 92% had an annual gross income
of less than $5252 US. With such homogeneity in education and income, it would be
diffcult to demonsirate a relationship between physical activity levels and socioeconomic
status.
A variable which might have more relevance in this group is that of living
arrangement. People with developmental disabilities live in a varies, of settings, including
institutions, and community-based settings. In Ontario, there are cunently about 2 100
individuals living in six Minisüy-operated institutions (Ministry of Cornrnunity and Social
Services, 1997). Institutional settings involve a large number of persons living in ward-like
settings and receiving 24 hour supervision. During the last 20 years, there has been a trend
towards relocating people from institutional settings to residences in the community.
In cornparison to institutional settings, community-based settings are much smaller
and more flexible (Ministry of Community and Social Services, 1997). Community-based
settings include adults living alone with minimal support, living in a home with 'foster
parents', living in the home with one or more family members, or Living in a group home.
Adults living in group homes share their residence with up to five other clients and are
supported by staff from 8 to 24 h o m a day. In Ontario , in 1974, about 4,600 people with
developmental disabilities were supponed in the community-based service system.
Currently in Ontario, it is estimated that this sarne senrice system supports more than
50,000 people with developmental disabilities (Mhistry of Community and Social
SeMces, 1997). As this shift in living arrangements continues, it is important to look at its
impact on the health status of persons with developmental disabilities.
A snidy which did examine this relationship is that of Rimmer, Braddock and
Marks (1995) who compared the health behaviors of adults with developmental
disabilities, accordkg to their living arrangements. It was found that subjects in the
institutional and nanual family setting had a higher participation rate in exercise than
subjects living in the group home settings. This finding is surprising, especially when
considering that studies involving what rnight be a simüar living arrangement to an
institutional setting, that of nursing homes for the elderly, indicate that neglect of physical
exercise is prevalent (Weyerer & Kupfer, 1994). A German survey by Petzold (1985; as
referenced by Weyerer & Kupfer, 1994) found that less than 1% of the residents of a
nursing home pursued any regular physical activity to which a training effect could be
attributed, although more than 80% would have been able to participate in a physical
exercise program.
Level of mental retardation is another variable which would be important to
examine in adults with developmental disabilities. As previously mentioned, level of mental
retardation is typically divided into four categories based on IQ: mild, moderate, severe
and profound. An individual with a mild level of mental retardation has an IQ ranging from
approximately 50 to 70 points. Persons with mild mental retardation are capable of living
independently, working and marrying. However, they are often socially isolated as a result
of their disability, and may need assistance and guidance when unda social or econornic
stress Pitetti et al, 1993; Developmental C o n s u l ~ g Group, 1992).
Lndividuals with a moderate level of mental retardation have an IQ in the 35 to 55
range and have signifiant deficits in adaptive behavior (Grossman, 1983; as referenced by
Pitetti et al, 1993). Adults with moderate mental retardation are often employai in
sheltered workshops, most do not get manid and many wiIl have problems with speech,
language, social interactions and gait (Pitetti et al, 1993).
For adults with severe mental retardation (IQ between approximately 25 and 40)
and profound mental retardation (IQ below 25), fuU-time care is often necessary, with the
vast majority having difficulty with activities of daily living (Pitetti et al, 1993;
Developmental Consulting Program, 1992).
The descriptions provided on ievel of mental retardation indicate an increasing
need for support as the level of mental retardation becomes more severe. Studies
describing fitness programs for aduIts with developmental disabilities have also shown that
motivational problems and task understanding are accentuateci with increased severity of
mental retardation (Pitetti & Campbell, 199 1; Pitetti et al, 1993). These findings indicate
that level of mental retardation may have an impact on the participation in physicd activity
by adults with developmental disabilities.
Other characteristics which might be important to examine in this group are
medication use and medical conditions. Beange et al (1995) found that in their sample of
adults with developmental disabilities, over half were taking daily presrribed dnigs and a
third were taking multiple medications. As weU, the sarnple had an average of five medical
disorders per person. Due to the large number of medical conditions and the use of
medications, it was suspected that these are two variables important to examine as
possible associations with levels of physical activity.
Measurement of Ph~sical Activity
One way physical activity can be assessed is by s w e y (Laporte, Montoye &
Caspersen, 1985). Sunrey procedures offer the best compromise as measures of physical
activity on large populations. In a critique of the various methods of assessing physical
activity, Lapone, Montoye & Caspersen (1985) state that survey procedures are
"relatively reliable," inexpensive to adrninister and uniikely to alter normal daily physical
activity as a motion sensor rnight. In this article (Lapone, Montoye & Caspersen, 1985)
and others (Washbm and Montoye, 1986; Lamb & Brodie, 1990), survey procedures are
said to be the most practical p hysical activity measure.
Survey procedures acquire information from the participants about their physical
activity and Vary in the nature and the detail of the information collected. For example, the
information collected by studies previously referred to, Steele (1986), Beange et al (1995)
and Rimmer et al (1995), provide linle detail on physicd activity. Beange and her
colleagues (1995) were interested only in participation in vigorous activity in the past two
weeks, while Steele (1986) and Rimmer, Braddock and Marks (1995) reponed
information only on frequency of physical activity, while duration and intensity were
ig nored.
A more detailed survey procedure is a diary survey in which individuals complete
an ongoing diary, entering the specific tasks they performed throughout the day. From this
information, an overall estimate of total daily caloric expenditure is made. While this
technique provides highly accurate infoxmation on physical activity, it also suffers from
cos t and time constraints. In addition, persons may be unwilling to enter every ph ysical
activity they do throughout the day, or rnay record false levels of physical activity in order
to appear more physically active (Lapone, Montoye & Caspersen, 1985).
A compromise between the generai questions asked in the above mentioned
studies, and the use of the highly detailed diary survey is a quantitative history survey. In
this technique, participants recall over a specified amount of t h e the frequency and
duration spent in specific activities. With the information provided, a summary index is
O ften used to rank-order persons according to their Ievel of p hy sical activity (Laporte,
Montoye & Caspersen, 1985).
An example of such a survey is the Ontario Health Survey (Premier's Council on
Health, Well-Being and Social Justice, 1992). The questions on physical activity in this
survey asked people whether they had panicipated in any of 20 different types of physical
activity in the past month, and if so, the frequency and time spent in each activity. This
information ailowed the ministry to estimate Ontarians' monthly, weekly and daily rate of
physical activity as well as to categorize people on their daily energy expendinire
according to a physical activity index.
The physical acavity questions on the Ontario Health S m y (Premier's Council
on Hedth, Well-Being and Social Justice, 1992) focused almost exclusively on leisure-
tirne physical activity. Many current questionnaires assessing physical activity also focus
on leisure-urne physicai activity. This is in recognition that leisure-time physical activity
contributes almost wholly to the total physical activity of developed populations (Lamb &
Brodie, 1990)
Smdy Objectives
The primary objectives of the study are to:
1. describe the physical activity patterns of aduIts with deveIopmentaI disabilities, and
2. detemine the factors associated with participation in physical activity.
The secondary objective is to:
1. describe the barriers, as identified by caregivers, which might prevent adults with
developmental disabilities fiom engaging in physical activity.
Method
Study Design
A cross-sectional survey was used to address the objectives of this snidy.
Sam~le Design
Six agencies which serve individuals wiîh developmental disabilities in south
eastem Ontario participateci in the study, Rideau Regional Centre, Ongwanada, Kingston
& District Association for Community Living (KDACL), Christian Horizons, ARC
Industries of Lennox and Addington Association for Community Living (L&AAU') and
the Ottawa Carleton Association for Persons with Developmental Disabilities (OCAPDD).
Clients served by these agencies f d under the Developmental SeMces Act (1985), and
have "a condition of mental impairment present or occirrring during a person's formative
years, that is associated with limitations in adaptive behavior" (chap. 118).
Stratifieci sampling was used to ensure adequate representation fiom three different
Living arrangements: institution, group home and community living. For the purposes of
this study, the community living setthg included: adults living alone with minimal support,
living in a home with 'foster parents' or living in the home with one or more farnily
members. A sample of clients was drawn h m the institution stratum, and a i l eligible
clients were asked to participate from the group home and community living strata due to
the small nurnbers of clients in these settings.
The institutional stratum was comprised of a systernatic sample of 155 residents
from a List of 450 eligible residents of Rideau Regional Centre. The group home stratum
was made up of al1 eligible clients living in group homes served by: Ongwanada (n = 30),
Christian Horizons (n = 4), ARC Indusmes (n = 1 l), KDACL (n = 21) and OCAPDD (n =
53), for a total of 119 subjects in the group home saaturn The community Living swtum
was made up of all eligible clients served by community programs at Ongwanada (n =
1 15) and a l l community living clients served by ARC Industries (n = 29), for a total of 144
clients in the community living stratua
SampIe Size
The sample size was calculateci using POWER (Epicenter Software). This snidy
aimed to determine the physical activity patterns of adults with developmental disabilities.
It was hypothesised that a 15% difference would be detected between Living arrangements;
with an equal number of clients in the group home and cornmunity living strata
participa~g in physical activity and less clients in the institution stranirn participating in
physical activity. Using an overall proportion of 26% found in the study by Beange et al
(1995), it was estimated that 3 1% living in both group homes and in the community, and
16% in institutions would have engaged in exercise (the average of which is 26%). With
these parameters along with a power of 8095, and a significance of .05%, the required
sample size was 120 individuals in each saatum. Note that in the group home smnim, the
required sample size was not met (n=l19).
Subjects
To be eligible for the study, clients had to: be 18 years of age or older and able to
walk without assistance (except from a cane).
Questionnaire
A questionnaire, designed to be completed by a proxy, was developed for this study.
A question adapted from the Ontario Health Survey (Premier's Council on Health, Well-
Being and Social Justice, 1992) asked proxies whether the client had participated in any of
14 different types of physicd activity during the past month and if so, the £iequency and
time spent at each activîty. This information allowed the investigator to estimate the
clients': frequency of physical activity, participation in any physical acrivity in the past
month, daily physical activity, and physical activity index, consistent with the definitions
used in the Ontario Health Survey (Premier's Council on Health, Well-Being and Social
Justice, 1992). These measures of physical activity are further explaine. below .
of physical activity
This variable measures the nurnber of times clients took part in a physicd activity in
the past month which lasted more than 15 minutes (see Table 1). Clients who engaged in
12 or more physical activities in the past month were categorized as regular. Those who
engaged in physical activity 4 - 11 times per month were categorized as occasional.
Clients who engaged in physical activity fewer than 4 times per month were categorized as
m u e n t .
Table 1: Frequency of physical activity
Number of times respondent took part in a physical Descrip tor activity Iasting more than 15 min. 12 or more times per month 4 to 1 1 times per month O to 3 times Der month
Regular Occasional Infreauent
Participation in phvsical activitv in ~ a s t month
Clients were considered a participant in physical activity in the p s t month if they had
engaged in at least 1 physical activity in the past month, regardless of how much time was
spent in the activity.
Participation in dailv physical activity
Those who participateci in physical activity 30 or more times during the past month,
with each activity h s ~ g over 15 minutes were classifrai as participating in daily physical
activity.
Phvsical activitv index
In order to derive a physical activiiy index, the energy expenditure (EE) of
participants in their leisure activities was estimated. EE was calculated using the frequency
and time per session of the physical activity as weil as its MET value. The MET is a value
of metabolic energy cost expressed as a multiple of the resting metabolic rate. Energy
expenditure values were calculated as follows:
EE (kcd/kg/day) = SU of ((Ni * Di * METS) / 30)
Ni = the number of tirnes respondents engaged in an activity over the past month Di = the average duration in hour of the activity METS = the energy cost of the activity expressed as kilocalories expended per kilogram of bodyweight per hour of activity
MET values tend to be expressed in three intensity levels (Le. low, medium, high
intensity). Respondents were not asked to speciQ the intensity level of their activities,
rather the MET values adopted correspond to the Iow intensity value of each activity. This
approach was adopted fmm the Ontario Health Survey because individuais tend to
overestimate the intensity, frequency and duration of their activities. The MET values used
are in accordance with those used in the Ontario Health Survey (Premier's Council on
Health, Well-Being and Social Justice, 1992) and are specified in Appendix A.
Energy expenditure values were then used to categonze respondents. Clients with an
average energy expenditure of 3.0 or more were considered active. Clients who averaged
between 1.5 - 2.9 were categorized as moderate, and clients with an average energy
expenditure below 1.5 were caregorized as inactive (see Table 2).
Table 2: Physical Activity Index
Energy Expendinire Descrip tor 3.0+ kcal/kg/day Active 1.5 - 2.9 kcal/kg/day Moderate below 1.5 kcai/kg/day Inactive
Also adapted h m the Ontario Health Survey (Premier's Council on Health, Well-
Being and Social Justice, 1992) was a question on the usud activity level inherent in daily
routines or work habits. A question on participation in vigorous activity in the past two
weeks was adapted from Beange et al (1995). As weU, a question modified h m the
Health and Activity Limitation S urvey (S tatistics Canada, 1988) gathered information on
the barriers preventing the client fkom doing any or more physical acavity.
The questionnaire also included questions on medical conditions and medication use.
For clients living in group homes or in cornrnunity living settings, the questionnaire also
asked about living arrangement, age, gender and level of mental retardation. Questions on
the proxy's relationship to the client concluded the questionnaire.
A pre-test of the questionnaire was performed with the proxies of five clients from
each of the three living arrangements, for a total of 15 clients. For each of the 15 clients,
two proxies were asked to complete the questionnaire (their answers were exciuded from
the analyses). The pre-test was designed to provide a 'feel' for the suitability of the
questions as opposed to king a full-scale 'pilot study' airned at yielding definitive results.
Several of the respondents involved in the pre-test did not provide information on the
frequency of physical activity. It was believed that the non-response was due ro the small
type size on this question, and the type size was subsequently increased. The questionnaire
used is found in Appendix B.
Data Collection
Supervisors in each of the agencies were asked to provide a Est of eligible clients
within their respective programs along with a corresponding staff or caregiver who would
best know the physical activity patterns of the client. Whenever possible, the supervisor
was asked to identify a staff or caregiver who had known or worked with the client for
longer than six months, and had contact with the client for a minimum of once a week.
In cases where a staff person was identified as the proxy, the supe~sors were asked
to p a s on the questionnakes to the staff and retum them to the investigator once
completed. In cases where a family member was idenrifieci as the proxy, the questionnaire
was mailed along with a stamped, self-addresseci retum envelope. AU proxies were
provided with background information on the study. The information sheet to proxies is
found in Appendix C.
In the case of clients living in the institutional setting, the following information was
coiiected from client records: age, gender and level of mental retardation. For al1 other
clients, this information was collected as part of the questionnaire.
The data collection took approximately 5 months to complete (October 1996 to
Febru-iry 1997).
Data Analysis
Res~onse rate
Response rate was calculated as the number of questionnaires that were completed
and retumed divided by the total number of questionnaires that were sent out to eligible
clients (total number sent out less those retumed because client was not eligible or wrong
address). Response was calculated for the study group as a whole, and separately for each
stratum.
Client characteristics
The folIowing client information was collected: age, gender, living arrangement, level
of mental retardation, medical conditions and medication use (see Table 3). Univariate
staastics were calculated for these variables. Bivariate analyses using ANOVA, chi-
squares, and Fisher's exact test were used to compare these client characteristics across
living arrangements.
In formation on proxies
Information gathered on proxies included: the method by which the proxy was made
aware of the client's physical activity habits, the amount of contact the proxy had with the
client, the length of time the proxy had known the client, the nature of the proxy-client
relationship, and whether the proxy had received assistance by the client in completing the
questionnaire (see Table 3). Univariate statistics (frequency tables) were used to descnbe
the proxies. Bivariate statistics (chi-squares and Fisher's exact test when the expected
value of at least one cell was less than 5) were used to compare proxy characteristics by
living arrangement.
Objective 1
Describe the p hysical activiry patterns of aduIts with datelopmental disabilities.
Physical activity was examined by loolcing at the following outcomes: daily routines
or work activities, panicipation in vigorous activity in the past 2 weeks, frequency of
p hysical acrivity , participation in daily ph y sical activity , participation in ph y sical activity in
the past month, a physical activity index, and types of physical activity engaged in (see
Table 3). Univariate statistics (frequency tables) were used to calculate the clients'
participation in physical activity according to the above outcomes.
Participaaon was calculated for the snidy group as a whole, and for each of the living
arrangements. Chi-squares, and Fisher's exact tests where appropnate, were calculated to
compare participation in physical activity across living arrangements. Spearrnan
correlation coefficients were used to rneasure the correlation between the physical activity
outcornes, with the exception of types of physical activity engaged in.
Obiective 2
Determine the factors msociated with participation in physical activity .
The degree of bivariate correlation between the client characteristics was assessed
with the calculation of Speamian correlation coefficients. In instances where there was a
high degree of correlation (-60 or greater) between variables, only one of the strongly
comeiated variables was used to examine the associations between exposure and outcome
variables.
Bivariate analyses were perfomed between the client characteristics and the physical
activity outcornes, with the exception of types of physical activity engaged in. Chi
squares, Fisher's Exact Test (where appropriate), and odds ratios with corresponding 9 5 %
confidence intervals were used for the bivariate comparisons. For each of the six outcorne
variables, a logistic regression model which included age, gender and living arrangement
was created. This mode1 aliowed the investigator to determine the effect of living
arrangement on physical activity, whlle adjusting for age and gender, two variables which
have k e n shown to be associated with physical activity in previous smdies. Variables
from the bivariate analyses that showed an association at a p-value of 0.10 or less were
then added to the model. Age, gender and living arrangement were kept in the model, and
fonvard stepwise model selection was performed on a i l other independent variables that
were added to the model. Any remaining independent variables that were rernoved in the
model selection were added individually to the mode1 to examine their role as potential
confounders. Variables e f f e c ~ g a change in the parameter of a mode1 variable of 10 % or
greater were added to the model.
Table 3: Variables of interest
Information on Proxies Method by which the proxy was made aware of client's physical activity Amount of contact with client Length of tirne proxy had known client Nature of proxy-client reiationship Assisted by client in completing questionnaire
Independent Variables Living arrangement Level of mental retardation Age Gender Psyc hiatric disorder Epilepsy Arthntis Diabetes Asthrna Cerebral Palsy Congeni ta1 Heart Disorder Allergies Sensory Impairment (s) Number of medical conditions Antidepressants Anticonvuisants An tipsychotics Antimanic agents Anxioly tics Number of medications
Outcome Variables Daiiy routines or work activities Participation in vigomus activity in the past 2 weeks Frequency of physical activity Participation in daily physical activity Participation in physical activity in the past month Physicalactivity index Types of physical activity
Secondarv Obiective
Describe the bamers, as identified by caregivers which might prevent
developmentally dikabled adults from engaging in physical ocrivity.
Univariate statistics (frequency tables ) were caiculated to describe the barriers as
identified by caregivers. Bivariate statistics (chi-squares and Fisher's exact test) were used
to compare barriers across living arrangements.
Results
Reswnse Rate
Of the 418 questionnaires sent, 301 completed questionnaires were retumed. The
response rate was 72%. The rate differed by stratum, with 83% obtained for persons in the
institutional semng, 80% for those in group homes, and only 54% for those living in the
community.
Client Characteristics
Table 4 shows the age, gender and level of mental retardation of the clients. The
mean age was 42 and the range was 18 to 80 years. Sixty percent of the sample were male
and 40% were female. There was no significant difference in age or in gender between the
strata. Clients were roughl y evenl y dismbuted across levels of men ta1 retardation, with
25% having a level of mental retardation in the mild range, 28% in the moderate range,
19% in the severe range and 28% in the profound range. A significant difference across
Living arrangements was found in level of mental retardation. Clients in the cornmunity
were primarily mildly to moderately affected (96%), while almost half of clients in group
homes were moderately affected (44%), and most in institutions were severely to
profoundl y affected (83%). The difference was significant at pcO.00 1.
Table 4: Age, gender and level of mental retardation by saaturn
Characteristic Community Group Home Institution Study Sarnple n=78 n=95 n=128 N=30 1
Age (years; mean + SD) 41 + 14.72 41 f 11.13 44 + 1 1-25 42 + 12.28
Gender Male
Level of mental retardation *
Mild 53% 29% 7% 25% Modem te 43% 44% 10% 28% S evere 4% 24% 24% 19% Pro fo und O 3% 59% 28%
*Significant at pcO.00 1
The medical conditions and medications of the clients are presented in Table 5. A
third of the clients had a psychiaaic disorder (33%), and almost a third had epilepsy
(31%). More clients in the institutional setting had epilepsy than clients in the community
living or in the group home settings (pc0.001).
The category 'other medical conditions' includes one or more of the following:
allergies, asthma, diabetes, or arthntis. More clients in the comrnunity living and group
home settings had one or more of these medical conditions dian clients in the institutional
setting (pc0.05). Three percent of clients had a sensory impairment, which included either
The number of medical conditions is specified in Table 5. Almost a third (29%) of
clients had one medical condition, and a quarter (25%) were identified as having two
medical conditions. There was no significant difference in the number of medical
conditions across strata. Almost a third of the clients (32%) were taking anticonvulsants.
Other medications being taken included: antipsychotics (21 %), anridepressants ( 1 1 %),
anxiolytics (6%) and antimanic agents (5%). More clients in the institutional setting were
taking anticonvulsant medications (pc0.01) and antimanic agents (pcO.05) than in the
community living or in the group home semngs, and more clients in the institutional and the
group home settings were taking antips ychotic mulications than in community living settings
(p<0.00 1). Almost a quarter of the clients (2495) were taking four or more medications.
Clients in the institutional and group home settings were taking more medications than were
clients in the community living setting @<0.001).
Table 5: Medical conditions and medications by stratum in %
Community Group Home Institution Study Sample n=78 n=95 n=128 N=301
Medical conditions f Psychiairic disorder 23 39 35 3 3 Epilepsy*** 23 23 41 31 Cerebral Pals y 8 11 3 7 Other medical conditions* 41 42 27 35
Sensory impairments 3 4 3 3
Number of medical conditions
O 1 2 3 4+
Medication f Anticonvulsant** 24 Antipsychotic*** 5 Antidepressan t 5 Anxiolytic 1 Antimanic agent* 1
Number of medications*** O 3 6 22 5 18 1 30 17 15 19 2 20 t l 2 1 18 3 7 22 28 21 4+ 7 28 31 24
* Signifiant at ~~0.05 ** Significant at pe0.01 *** Significant at pcO.001 (1 Not rnutuaIly exclusive
Description of Proxies
In addition to answering questions about client characteristics, proxies were also
asked whether clients had assisted them in completing the questionnaire, about their
relationship with the client, the length of time they had known the client, the amount of
contact they had with the client, and finally, how they knew of the clients' physical acnvity
habits. The foLlowing section summarizes this information.
In the questionnaire Xormation sheet, proxies were instructed that, when possible,
the client could be consulted in completing the questionnaire. Almost a quarter of the
clients (24%) assisted in cornplethg the questionnaire. This varied significantl y b y living
arrangement, with almost two thirds (63%) of clients assisMg with the questionnaire in
the community setting, approximately a quarter (27%) of clients assisting in the group
home setting and no clients assisting in the institutional setting (see Table 6).
Only 2% of proxies were family members of the client, the remaining 98% were
staff. Roxies' relationship with the client varied significantly by living arrangement No
family members of clients in institutions or group homes completed the questionnaire,
while 8% of proxies in the community setthg were family members (see Table 6).
Sixty-eight percent of proxies had known or worked with the client for 2 years or
longer. Only 9% had known the clients for less than 6 months (see Table 6). This also
differed significantly by living arrangement, with more proxies in the institutional setting
having known the client for one year or longer.
Three quarters (75%) of proxies were in contact with the client for more than 3
days per week. The amount of contact varied significantly by living arrangement, with
proxies in the institutional setting having more contact with clients than in the other two
settings (see Table 6).
Sixy-nine percent of proxies were aware of the clients' exercise habits because
they had designed the exercise programs, because they observed the clients' exercising, or
because they had assisted the client with phy sicai activity. The remaining 3 1 % of proxies
were made aware of the clients' exercise habits by receiving reports from others. The
manner in which proxies were made aware of the clients' exercise habits differed
significantly by living arrangement. While rnost proxies in the institution and group home
settings (8 1% and 75% respectively) were aware of the clients' exercise habits through
observation, assisting the client or by designing the program, only 38% of proxies in the
community setting were aware of clients' exercise habits through these same methods (see
Table 6).
Table 6: Description of proxies by stratum in %
Community Group Home Ins tiûition Study Sample n=78 n=95 n=128 N=30 1
Client assisteci** Yes No
Proxy's relationship with client**
Family Staff
Length of tirne proxy knew client*
less than 6 months 6 months to less than 1 Y=- L year to Iess chan 2 years 2 years or Ionger
Proxy's contact with client** More than 3 days/week 1 to 3 days a week less than one day per month
Manner in which proxy's were aware of client's physical activity**
Design programs, observe ancilor assist Receive reports frorn otfiers
* Significant at pcO.01 ** Significant at p4.001
Objective 1
Describe the physical activiry panerns of adults with developmental disabilities.
Descriptive data on the six outcornes (usual activity level inherent in daily routines
or work habits, participation in vigorous activity in the past two weeks, frequency of
physical activity, daily physical activity, participation in any physical activity in the past
month and physical activity index) are presented in Table 7. As there was rnissing data for
some of the physical activity outcornes, the number of observations is specified in the
table.
Overall, participation in physical activity was low. Only 16% of the study group
participated in vigorous activity in the past two weeks, 24% participated in regular
physical activity, 10% participated in daily physical activity, and only 4 5 were classified as
active according the physical acàvity index. Further, just over a quarter of the snidy group
(28%) had daily routines that usually involved sitting, and sirnilarly, approximately a
quarter (26%) of the sample had participated in no physical activity in the past month.
Participation was approximately equal for all living arrangements except for in two
of the measures: fiequency of physical activity and participation in any physical activity in
the past month. For these two measures, clients in the institutional setting participated in
significantly less physical activity than clients in the group home or in the community lwing
settings,
Tabie 7: Participation in physicai activity by stratum in 9%
Ph ysical Activity Outcome Community Group Home institution Study Sample n=78 n=95 n=128 N=301
Daily routines or work n=78 n=95 n=128 N=301 activities
Heavy Work 4 2 1 2 Li ft/Carry 24 13 11 15 S tand/WaIk 50 55 58 55 Sit 22 30 30 28
Vigorous activity in past 2 n=7 1 n=90 n= 124 n=285 weeks
Yes 34 16 12 16 No 76 84 88 84
Frequency of physical n=49 n=64 n=88 n=20 1 ac tivity*
Regular 26 27 21 24 Occasional 35 23 15 23 Infrequen t 39 50 64 53
Participation in dail y physicai activity
Yes No
Participation in physicaf n=77 n=93 n=128 n=298 activity in past month**
Yes 83 84 67 74 No 17 16 3 3 26
Physical activity index n=49 n=64 n=88 n=201
Active 4 5 3 4 Modera te 14 5 5 7 Inactive 82 90 92 89
*Significant at p<0.05 **Significant at p4.0 1
Table 8 lists the ten most comrnon types of physical activity. Walking was the most
cornmon type of physical activity, 60% of clients walked for exercise in the past month.
Other popular types of physicai activity included: dancing (23%), swirnming (17%),
bowling (14%) and exercises at home (14%).
More clients in the community living and group home settings participated in
dancing (p4.001). bowling (p<0.001), floor hockey (p<0.05), exercises at home
(p<0.01), gardening or yard work (p4.001) than clients in the institutional setting. More
clients in the group home s e t ~ g s participated in swimming (pc-01) than clients in the
institutional setting.
Table 8: Ten most common types of physicai activity in the past month by stratum in %
Types of Physicd Activity Community Group Home Institution S tudy SampIe n=78 n=95 n=128 N=30 1
Walking 69 59 56 60 Dancing*** 39 26 1 1 23 Swimming** 19 25 9 17 Bowling*** 25 22 2 14 Exercises at Home*** 29 19 2 14 Bicycling 9 11 4 7 Gardeningf'ard work* ** 13 7 O 6 Fioor hockey* 6 6 O 4 Running 4 2 5 4 Class exercises O 4 3 3 *Significant at pq0.05 **Significan t at pc0.01 ***Significan t at p<0.00 1
Correlation between outcornes
The degree of bivariate correlation between outcome variables was assessed.
Strong correlations (greater than ?=0.60) were found between frequency of physical
activity and any physical activity in the past month (?=0.68), and between the physical
activit y index and daily ph y sicd activity (?=0.76).
Table 9: Speman Correiation Coefficients Between the Six Physical Activity Outcornes.
Spearman Correlation Coefficient @) b l p l
Dai1 y Ph ysicai Frequency of Vigorous Any activity Dai1 y routines or Activity phy sical activity in in p s t activity work habits Index activiîy past 2 weeks month
Daily routines or work habits - O. 18 0.28 0.11 0.25 O. 13
Ph ysical Activity Index O. 19
Frequency of physical activity 0.28 0.38
Vigorous activity in past 2 weeks O. L 1 0.11 0.34 - 0.22 0.04
Any activity in past mon th 0.25 0.26 0.68 0.22 0.24
Daily activity 0.13 0.76 0.35 0.04 0.24
Objective 2:
Determine the factors associated with participation in physical activiiy.
Collapsed variables
For the purposes of the bivariate analyses exarnining associations between client
c harac teristics and p hysical activity and for the mul tivariate analyses, age was collapsed
into four categones and the following variables: level of mental retardation, number of
medical conditions, number of medications, usual activity level inherent in daily routines or
work habits, hquency of physical activity, and physical activity index were collapsed into
nvo categories. These collapsed variables are displayed in Table 10.
Table 10: Variables coliapsed for bivariate and rnultivariate andysis by straturn in %
ColIapsed variables Community Group Home Institution S tudy Sample n=78 n=95 n=128 N=301
Age (years) 18-30 34 17 7 17 31-40 17 3 3 37 3 1 4 1-50 24 29 3 3 29 51+ 25 2 1 23 23
Level of mental retardation m ild/moderate 96 73 sevedprofound 4 27
Number of medicai conditions
O- 1 2c
Number of medications 0-2 86 50 3+ 14 50
Daily routines/work habits Stand/Walk, LifUCarry or Heavy Work 79 70 70 Usually sitting 22 30 30
Frequency of physical activity
Occasional or 61 50 Regular Infrequent 39 50
Physicai activity index Active or moderate 18 1 O 8 11 Inactive 82 90 9 2 89
Correlation between exDosure variabIes
The degree of bivariate correlation between exposure variables was assessed
through the calculation of Spearman correlation coefficients. In instances in which
variables were strongly correlated (?=CL60 or greater), only one of the highly correlated
variables was used in further analysis. This o c m e d between two sets of variables: living
arrangement and level of mental retardation (4a.68, p=O.ûûûl), and epilepsy and use of
anticonvulsant medications (?=0.66, p=0.0001). Due to the strong co~~elations between
these variables, level of mental retardation and anticonvulsant medications were not used
in further analysis.
Bivariate AnaIysis
Odds ratios and comsponding 95% confidence intervals were calculated to
detemine what client characteristics were associated with the 6 physical activity
outcomes. Note that the odds ratios cannot be interpreted as estimates of relative risk due
to the outcomes not king rare (less t h a . 0.05 in ai l study groups).
Dailv routines or work activities
Not having a sensory impainnent was found to be significantly associated with
daily r o u ~ e s or work activities involving waLking, lifting or heavy work (OR=6.66; CI
1.98 - 22.38). No other client characteristic was significantly associateci with this physical
activity outcome.
Table 11: Bivariate analysis with daily routines or work activities involving walking, lifting or heavy work as the outcorne
C h a m teristic Yes No P-Value OR (95% CI)
Living arrangement comrnunity living group home institution
Gender male fernale
Psychiauic disorder no yes
Sensory impairrnents no yes
Cerebral Palsy no Y=
Congeni ta1 heart disease no 0.59 (O. 17 - 2.10)
Table 1 1 (cont,): Bivariaie analysis with daily routines or work activities involving walking, lifting or heavy work as the outcome
Characteristic Yes No P-Value OR (95% CI)
Allergies no yes
Number of medicai conditions
0 - 1 2+
An tipsycho tics no yes
An timan ic agents no Y=
Num ber of medications 0- 1
0.98 (0.56 - 1.64)
0.46 (0.17 - 121)
1-15 (0.63 - 2.12)
0.7 1 (O. 19 - 2.6 1)
1.24 (0.46 - 3.38)
1 .O3 (0.6 1 - 1.72)
Viorous activitv
Characteristics associated with participation in vigorous activity in the past two
weeks at a p-value of 0.10 or less include: living in the comrnunity (0R=2.33; CI 1 .O9 -
4.97), being between 18 and 30 years old (OR=2.38; CI 0.9 1-6-17), not having a
psychiatrie disorder (OR=1.96; CI 0.93-4.13) and having arthntis (OR=0.40; CI 0.14-
1-18).
Table 12: Bivariate d y s i s with vigorous activity in past two weeks as the outcome
Characteristic Yes No P-Value 95% Confidence Interval
Living arrangement community 17 53 0.03 2.33 (1.09 - 4.97) group home 14 76 0.47 1.34 (0.6 1 - 2.94) institution 15 109
Gender maIe fernale
Psychiatrie disorder no 35 148 0.08 1.96 (0.93 - 4.13) YeS 10 83
Epileps y no Y S
Number of conditions 0 - 1 22 102 2+ 25 132
Sensory impairment no yes
Dia be tes no yes
Cerebrai Pals y no
0.80 1 .O9 (0.58 - 2.05)
0.23 0.43 (O. 1 1 - 1.69)
O. IO 0.40 (O. 14 - 1.18)
0.64 0.67 (0.14 - 3.32)
1 .O0 1.49 (0.33 - 6.7 1)
Table 12 (cont): Bivariate analysis with vigorous activity in pst two weeks as the outcome
Characteristic Yes No P-Value 95% Confidence
Congenital h a r t disorder no 44 223 1 .O0 1.28 (0.28 - 5.88) F 2 13
Allergies no yes
Antipsychoucs no Y S
Antimanic agents no 45 226 0.70 2.39 (0.32 - 17.78) Y= 1 12
Anxioly tics no Y a
Number of medications O- 1 22 126 0.75 0.90 (0.47 - 1.74) 2+ 20 103
Freauencv of ohvsical activity
Characteristics associateci with a higher frequency of physical activity at a p-value
of 0.10 or less include: living in the community (OR=2.82; CI 1.37-5.8 l), k i n g between
18 to 30 years old (0R=2.33; CI 0.89-6.02) having arthritis (ORd.27; CI 0.09-0.81) and
diabetes (OR=O. 14; CI 0.02-0.88).
Table 13: Bivariate analysis with higher frequency of physical activity as the outcome C haracteristic Occasional or Infrequent P-Vaiue 95% Confidence
Regular Intemal Living arrangement
comrnunity Living 29 18 0.0 1 2.82 (1 -37 - 5.8 1) group home 32 32 0.09 1.75 (0.9 1 - 3.37) institution 32 56
Age 18-30 18 11 0.08 2.33 (0.89 - 6.02) 3 1-40 33 34 0.4 1 1.38 (0.65 - 2.95) 41-50 22 30 0.92 1.04 (0.46 - 2.34) 5 1+ 19 27
Gender male fernale
Psyc hiamc disorder no yes
Epilepsy no Y S
Number of medical conditions
O- 1 34 50 2+ 57 55
Sensory impairment no yes
Cerebral Palsy no Y=
102 0.3 1 0.42 (O. 1 1 - 1.68)
Table 13 (cont): Bivariate analysis with higher frequency of physical activity as the outcorne
Characteristic Occasional or Infiequent P-value 95% Confidence Regular Interval
An hpsychoacs no Y S
Antimanic agents no yes
Number of medications O- 1 49
da il^ phvsical activity
Living in the community (OR=2.80; CI 0.94-8.38) and having diabetes (OR*. 12;
CI 0.03-0.48) were the only characteristics associated with participation in daily physical
activity at a p-value of 0.10 or less (Table 14).
Table 14: Bivariate anaiysis with daily physical acûvity as the outcorne
Yes No P-Value 95% Confidence In tervd
Living arrangement community group home institution
Gender male female
Epilepsy no Y=
Number of medical conditions
no Y=
Sensory impairment no Y=
Arthri tis no F
Table 14 (cont): Bivariate anaiysis with daily physical activicy as the outcorne
C haracteristic Yes NO P-due 95% Confidence
Congeni ta1 hem disease no 19 169 0.32 2.19 (0.12 - 39.02) yes O 9
An tidepressan ts no Y=
An tipsycho tics no Y S
An timanic agents no Y S
12 137 O. 17 0.50 (O. 19 - 1.34) 7 40
0.64 1.44 (0.3 1 - 6.56)
1-00 1.04 (0.33 - 3.13)
0.60 2.40 (O. 14 - 42.59)
Num ber of medicarions O- 1 1 O 89 0.94 1.04 (0.40 - 2.68) 2+ 9 83
Physical activitv in past month
Clients who were 18 to 30 years old (0R=3.67; CI 1.40-9.62), 41 to 50 years
(OR=2.65; CI 0.98-4.27), who lived in the cornmnnity (0R=2.57; CI 1.27-5.20) or in
group homes (OR=2.54; CI 1.32-4.89) were significantly more LikeIy to have participated
in physical activiry in the past month at a p-value of 0.10 or less (Table 15).
Table 15: Bivariate anaiysis with participation in physical activity in past month as the outcome
Characteristic Yes No P-Value 95% Confidence In terval
Living arrangement community group home institution
Gender male fernale
Epiieps y no Y=
Nurnber of medicai conditions
no 99 30 Y= 125 3 8
Sensory impairment no 220 66 yes 7 3
Arth ritis no Y S
Diabe tes no Y S
Cerebral Palsy no 212 63 0.73 1.20 (0.42 - 3.47)
14 5
Table 15 (cont): Bivariate analysis with participation in physicai activity in past month as the outcome
Characteris tic Occasional or Infrequen t P-value 95% Confidence Reguiar Interval
Congenital hem disease no 213 Yes 13
An timanic agents no yes
Number of medications no 122 32 0.24 1.39 (0.80 - 2.42) yes 93 34
Phpicai Ac tivity Index
Only living in the community (0R=2.74; CI 0.97-7.71) was signifcantly associateci
with the physical activity index at a p-value of 0.10 or Iess cable 16).
Table 16: Bivariate anaiysis with physical activity index as the outcome
Characteristic Yes No P-Vahe 95% Confidence Interval
Living anangement community group home institution
Gender male female
Psychiatrie disorder no yes
Epilepsy no Y=
Number of medical conditions
no yes
Sensory impairment no yes
Dia be tes no Y=
Cerebral Pals y no
0.48 (O. 10 - 2.35)
Table 16 (conf.): Bivariate analysis with physical activity index as the outcome
Characteris tic Yes No P-Value 95% Confidence Interval
Congenitai heart disease no Y=
0.1 1 0.47 (O. 18 - 1.19)
An tipsycho tics no yes
Antimanic agents no yes
0.6 1 2.82 (O. 16 - 49.80)
Anxiol y tics no Y=
Number of medications no
The six physical activity outcornes were fkther examined using multivariate
analyses. The results of the rnultivariate analyses are presented in Tables 17-26. For each
outcome, age, gender and living arrangement were kept in the model to examine their
impact on the physical activity outcome while a d j u s ~ g for each other. Any other
exposure variables that were associated with the outcome at a p-value of 0.10 or less in
the bivariate analysis were added to the model.
Daily routines or work activities
Using a rnodel containing age, gender and iiving arrangement, no variable was found
to be significantly associated with daily activities involving standing, lifting or heavy work
Table 17: Mode1 containing living arrangement, age and gender with daily routines / work activities as the outcome Variable Parameter Standard Error P-Value OR (95% Cr)
Estimate
Living arrangement Community Group home
Gender Femaie
* Regression was done on the totai sample of 301 clients.
Sensory impairment was added to the model, and the absence of a sensory
impairment was found to be significantly associated with daily activities or work habits
involving standing, waiking, üfting or heavy work, after adjusting for age, gender and
living arrangement.
Table 18: Mode1 containing living arrangemenr, age and gender, with daily routines / work activiües as the outcome Variable Parameter Standard Error P-Value OR (95% CI)
Living arrangement Community 0.607 0.370 0.101 1.83 (0.89 - 3.78) Group home 0.015 0.305 0.960 1.02 (0.56 - 1.84)
Gender FemaIe -0.254 0.272 0.350 0.76 (0.05 - 2.59)
Absence of a sensory 1.965 0.7 18 0.006 7.14 (1.75 - 29.08) impairment
* Regression was done on the total sample of 301 clients.
Vigorous activity
Neither age, gender or Living anangement were found to be significantly associated
with vigorous activity in the past 2 weeks.
Table 19: Mode1 containing living arrangement, age and gender, with vigorous activity as the outcome
Variable Parame ter S tandard Erro r P- Value OR (95% CI)
Living arrangement Community 0.736 0.4 19 Group home 0.229 0.406
Gender FemaIe O. 251 0.334
* Regression was done on 284 cIients, 17 less than the total sarnple due to missing observations.
The variables arthritis and psychiamc disorder were added to the model as they were
found to be signifcantly associateci with vigorous activity in the past 2 weeks at a p-value
of less than 0.10 in the bivariate analysis. After adjus~g for age, gender and living
arrangement, arthn tis and psychiatrie disorder were not found to be significantl y
associated with vigorous activity in the past 2 weeks.
Freauencv of Phvsical Activitv
After adjusting for age and gender, living in the community was significandy
associated with a higher frequency of physical activity.
Table 20: Mode1 containing living arrangement, age and gender with Erequency of physical activity as the outcorne Variable Parame ter Standard E m r P-VaIue OR (95% CI)
Living arrangement Community 1 .O62 0.399 0.008 2.89 (1.32 - 5.64) Group home 0.620 0.345 0.072 1.86 (0.95 - 3.63)
Gender Femaie -0.464 0.3 12 0.137 0.63 (0.34 - 1.16)
* Regression was done on 199 clients, 102 Iess than the total sample due to missing observations.
The use of antirnanic medications, arthritis and diabetes were added to the previous
model as they were found to be associated with frequency of physical activity at a p-value
of 0.10 or less in the bivariate analysis. Forward stepwise model selection was performed
on these three exposure variables, using significance levels of 0.15 and 0.05 for entry into
die model and for remaining in the model. After a d j u s ~ g for age, gender and living
anangement, having anhntis was found to be significantly associated with a higher
kquency of p hysicai activity.
In order to determine whether other variables have a confounding effect on the
variable of arthritis, the remaining exposure variables (diabetes and antimanic agents) were
added sepaiately to the model. A variable was considered to be a potential confounder if
its addition to the rnodel resultcd in a change in the parameter estimate of 10% or greater.
Neither diabetes or antimanic agents resulted in a change in the parameter estimate of
greater than 10% and so were not included in the model as confounders.
TabIe 21: Mode1 containing living arrangement, age and gender, and arthritis; with frequency of physical activity as the outcome. Variable Parameter StandardEnor P-Value OR (95% CI)
Estimate
Living arrangement Community Group home
Gender Female
Arthri tis
* Regression was done on 196 cIients, 105 l e s than the total sampIe due ro missing observations.
Dailv p h~sical activitv
In the model containing living arrangement, age and gender, no exposure variable was
found to be significantly related to participation in daily physical activity.
Table 22: Modet containing living arrangement, age and gender, with daily physicd activïty as the outmrne Variable Parameter Standard Error P-Value OR (95% CI)
Estimate
Living mangement Community 1 .O60 0.613 0.084 2.89 (0.87 - 958) Group home 0283 0.639 0.658 1-33 (0.38 - 4.62)
Gender Fernale -0.872 0.598 O. 145 0.42 (0.13 - 1.35)
* Regression was done on 199 clients, 102 less than the total sample due to missing observations.
The variable diabetes was added to the mode1 as it was found to be significantly
associated with participation in daily activity in the bivariate analysis. Diabetes was found
to be significantly associated widi daily physical activity after adjusting for age, gender and
living arrangement.
Table 23: Model containing living arrangement, age and gender, with diabetes added and daily physical activity as the outcome Variable Parame ter S tandard Error P-Vdue OR (95% CI)
Estimate
Living arrangement Community 0.705 0.655 0.28 1 2.02 (0.56 - 7.24) Group home 0.159 0.650 0.806 1-17 (0.33 - 4.18)
Age 18-30 -0.660 0.873 0.450 0.52 (0.09 - 2.86) 3 1-40 -0.300 0.67 1 0.654 0.74 (0.18 - 2.75) 4 1-50 -0.426 0.696 0.540 0.65 (O. 17 - 2.56)
Gender Female -0.865 0.605 O. 153 0.42 (0.23 - 1.38)
Dia betes - 1.797 0.90 1 0.046 O. f 7 (0.03 - 0.97) * Regression was done on 197 clients, 104 l e s than the total simple due to missing observations.
After a d j u s ~ g for age and gender, living in the community and living in a group
home were found to be significantly associated with participation in physical activity in the
past month. Being between 18 and 30 years of age was aiso found to be significantly
associated with participation in physical activity in the past month, after adjusting for
living arrangement and gender.
Table 24: Model containing living arrangement, age and gender, with physical activity in the past month as the outcome Variable Pararne ter Standard Error P-Value OR (95% CI)
Living arrangement Comm unity 0.88 1 0.386 0.022 2.41 (1- 13 - 5-16) Group home 0.928 0.345 0.007 2.53 (1 -29 - 5.00)
' Age 18-30 1.102 0.5 16 0.033 3.01 (1.10 - 8.25) 31-40 0.620 0.367 0.09 i 1.86 (0.91 - 3.82) 41-50 0.738 0.375 0.050 2.09 (1.00 - 4.55)
Gender Female -0.060 0.292
* Regression was done on 296 clients, 5 les than the total sample due to missing observations.
The use of ancimanic agents was added to the model as it was found to be associated
with participation in physical activity in the past month in the bivariate analysis. Forward
stepwise model selection was perfomied, using significance levels of 0.15 and 0.05 for
entry into the mode1 and for remaining in the mode1 on antimanic agents, while age,
gender and üuing arrangement were kept in the model. After adjusting for age, gender and
living arrangement, not using antimanic medications was found to be significantly
associated with participation in physical activity in the past month.
Table 25: Mode1 containing living arrangement, age and gender, with use of antimanic agents added and participation in physical activity in the past month as the outcome Variable Parame ter Standard Emr P-Value OR (95% CI)
Living arrangement Community Group home
Gender Fernale
Not taking antirnanic
* Regression was done on 296 clients, 5 less than the total sample due to missing observations.
Physical Activity Index
None of the variables examined (age, gender and living arrangement) were found to
be significantly associated with the physical acàvity index. No other variables were added
to the model, as no other exposure variables were found to be sipificantly associated witb
the physical activity index in the bivariate analysis.
Table 26: Mode1 containhg living arrangement, age and gender with the physical activity index as the outcorne Vanable Parame ter Standard Error P-Value OR (95% Cr)
Living arrangement Community 1 .O79 0.575 0.060 2.94 (0.95 - 9.39) Group home 0.231 0588 0.694 1.26 (0.39 - 3.97)
Gender Fernale -0.222 0.498
* Regression was done on 196 clients, 105 les than the total sample due to missing observations.
Secondary Objective:
Describe the barriers, as identified by caregivers which might prevent adults with
developrnenral disabilities from engaging in physical activity .
The ten most common barrien, as reported by proxies, are presented in Table 27.
For more than two thirds of the clients (69%), proxies indicated that "the client was nor
inrerested in doing more." This was the most common bmier cited. The second most
common barrier cited by proxies was that the client is physically not able to do more
(39%). Thirdy, for approximately one fifth of clients, Iack of nearby facilities or p r o g r a .
was cited as a barrier.
More clients in the group home settings were prevented by high costs than clients
in ins titutional or community living s e t ~ g s (pe.00 1). More clients in the group home
settings and in the institutional setting were prevented by a lack of staffing (pc.01). More
clients in the institutional setting were prevented by disruptive behavior than clients in the
group home or community living settings (p<.OZ).
TabIe 27: Ten most common barriers by stratum in %
Baniers Comrnunity Group Home Institution Study Sample n=78 n=95 n=128 N=30 1
Client not interested in 66 63 76 69 doing more Client is physically unable 42 37 to do more Lack of nearby facilities or 21 23 programs Programs not adapted to the 13 24 client's needs Cost too high** 18 36
Lack of Staff* O 14 15 1 1
Client feels self-conscious, 11 il1 at ease The client's behavior is too O dk~ptive* The client is too old 1
Proxies were also asked to rank the barriers in order of importance. The banier
ranked most important in preventing clients from participa~g in physical activity was that
the client was not interested in doing more, with 39% of proxies ranking this barrier as
number one. Twenty-two percent ranked "client is physically unable to do more" and 6%
ranked "lack of staff' as the most important barriers.
Discussion
Reswnse Rate
The response rate was considerably lower in the communiry living setting than in
the group home and institutional settings (54% vs. 80% and 83% respectively). This may
be due to the difference in proxies betwccn living arrangements. Among the proxies who
responded to the survey, a significandy mater number in the community Living setting
were aware of the client's exercise habits through reports received by others rather than by
directly observing the clients exercising. If this is also m e of proxies who did not respond
to the survey, this may have led to the proxies not king comfortable with completing the
questionnaire, leading to a lower response rate in the community setting.
This difference ùi response rate can affect the results in two ways: limiting the
generalizability of the results andor biasing the associations found. The generalizability of
the physical activity levels found for adults with developmental disabilities is compromised
by the Low response rate in the cornmunity living settings.
A more serious effect of the low response rate is the potencial bias to the
associations found. If non-respondents differed from respondenrs in the associations found
between client characteristics and physicai activity, this would resuit in biased estimates of
association. Unfortunately, it is not known what impact the low response rate had on the
results since no information is available with which to the clients of non-respondents to the
clients of respondents.
Description of Proxies
Proxies in the three living arrangements were significantly different on all
measures. In the community setting, proxies were more likely to have received assistance
from the clients in completing the questionnaire, and were more likely to bc farnily
members rather than staff. However, they were less likely to have directly observed the
client exercising, and they had signifcantly less contact with the client than proxies in the
other two settings. In terms of the length of time they had known the client (if they were
staff), most proxies in the three settings had known the client for at least one year (76% in
the community living setting, 76% in the group home and 84% in the institutional setting
had known the client for at l e s t one year).
The differences in proxies may have Ied to differences in the amount of
misclassification b y Living arrangement. If the rnisclassification differed by living
arrangement, the odds ratios eshated may be biased away or towards the null.
Obiective I
Describe the physical acrivity patterns of aduhs with developmental disabilities
This survey provides important infoxmation on the physical activity patterns of
adults with developmental disabilities. The results indicate that many of the clients lead
sedentary lives. Twenty-eight percent of clients reported sitting during much of the day.
Ninety percent did not participate in daily physical activiv and 24% had not engaged in
any physical activity in the past month.
The frwluency of physical activity in this sample is similar to that found in other
studies of persons with developmental disabilities. In this snidy, 24% of clients
participateci in regular physical activity, defined as more than 12 times per month.
Similady, Steele (1986) found that in a group of adolescents with rnild mental retardation,
24% participateci in regular exercise, defined as 3 times weekly. In addition, Rirnrner,
Braddock and Marks (1995), in an examination of the health behaviors of adults with
mental retardation, found that 24% of the participants exercised on a regular basis (3-4
days a week).
Fewer clients in this smdy participateci in vigorous exercise in the past two weeks
in cornparison to adults with developmental disabilities surveyed in a previous snidy by
Beange and her colleagues (1995). Sixteen percent of clients engaged in vigorous activity
as compared to 26% in the Australian survey of adults with developmental disabilities
(Beange et al, 1995). It is possible that this difference may in part be explained by the
samples used in the two studies. The study group used by Beange and her colleagues
(1995) had a larger proportion of adults with mild mental retardation (34% vs. 25% in this
study) and living in the community (40% compared to 26% in the present snidy). These
differences in the two samples may have resulted in the d i f rent proportions found
engaging in vigorous activity. In the present study, 24% in the community living sethng
and 24% of adults with mild mental retardation engaged in vigorous exercise in the past
two weeks, which approaches what was found in the survey by Beange et a1 (1995).
While the clients in this sample exercised with a frequency sirnilar to that found in
other studies of persons with developmental disabilities, it was considerably lower than
that found in the general population. As previously mentioned, approximately a quater of
clients (24%) engaged in regular physical activity, defined as physical activity that lasted
over 15 minutes and that was peIfomed more than 12 times per month. This compares to
45% who engaged in regular physical activity found in the Ontario Health Sunrey
(Ministry of Health, 1992). Also, using the physical activity index, 11 % of the present
sample were considered moderately active or active, as compared with 28% in the Ontario
Health Survey (Ministry of Health, 1992). The Ontario Health Survey consisted of a
population-based survey of ai l Ontarians who were residents of private dwellings aged 12
years or older.
The clients sampled did not fare well in cornparison to recommended levels of
physical activity either. Traditiondy, organisations such as the Amencan Heart
Association and the Amencan College of Sports Medicine recommend that an individual
should engage in continuous activity at least three cimes per week with a minimum
duration of 20 minutes (Pate, 1995; Phillips, Pmia & King, 1996). Approximately three
quarters of this sample did not meet this cnteria for physical activity.
Physical activity reduces the risk of several chronic conditions in populations
without mental retardation (Rippe et al, 1988; Siscovick et al, 1985; Fletcher et al, 1996;
Helmrich et al, 1991). These relationships have not been investigated in populations with
developrnenral disabilities but if the same associations hold, the adults in this sample may
be at increased nsk for coronary heart disease, hypertension, non-insulin dependant
diabetes and osteoporosis.
These low levels of physical activity also have implications for
deinstitutionalization. As more individuals with developmenml disabilities are placeci in the
community, the need is inmduced to provide programs on active Living to prepare
individuals for community and independent Me. Participation in physical activity cm:
improve the selfconcept of adults with mentai retardaiion (Gabler-Halle et al, 1993),
provide opponunities to develop fnendships and social networks (S hephard, 199 1) and
lead to improvements in work productivity (Fentem, 1992).
Of those who did participate in physical activity, waIking was the most common
rype of physical activity, wirh 60% having walked for exercise in the past month. Walking
was also the most popular form of exercise reported by adults with developmental
disabilities in Rirnmer, Braddock and Marks (1995) and in the Ontario Hedth Survey
(Ministry of Health, 1992). There were differences found in rhe types of physical activity
across strata. More clients in the cornrnunity living and group home settings participateci in
dancing, swimming, bowling, exercises at home, gardening or yard work and flmr hockey
than did clients in the institutional setting. For some of these activities, including dancing,
swimming, bowling and floor hockey, this is probably reflective of specialised prograrns
made available to clients in group homes and in community living settings by the agency or
by organisations like Specid Olympics, which provide sports training and cornpetition for
people with developmental disabilities.
.Objective 2
Derermine the factors associated with partic@ation in physical activity.
In the general population, three variables are consisrently associated with
participation in ph y sicd ac rivity . These variables are age, gender and socioeconomic status
(Weyerer & Kupfer, 1994; Stephens, Jacobs & White, 1985; B a u m , Owen &
Rushworth, 1990; Dannenberg, Keller, Wilson & Castelli, 1989). Socioeconomic status
(SES) was not believed to be relevant due to the lack of variability in education, income or
occupation among this group. As previously mentioned, a survey of adults with
developmental disabilities found that no subjects had completed high school and 92% had
an annual gross income of less than $5252 US (Beange et al, 1995). This homogeneity
would make it difficult to demonsmte a relationship between socioeconomic status and
physical activity.
Perhaps for this sarne reason, no other snidy has examined the association between
SES and physical activity in this population, therefore it is unknown what impact SES
might have. It is suspected, however, that the relationship between socioeconomic status
and physical activity might not be as simple a relationship as it is in the general population.
The impact of SES would likely depend on such charactenstics as the individual's Living
arrangement and level of mental retardation. For example, a person with a mild level of
mental retardation who is living in the community with minimal support might benefit from
an increased income by using some of that income to pay for transportation or to joui a
sports club. However, this would likely not be the case of an individual with a profound
level of mental retardation who is living in an institutional setting. Further smdy is needed
into how socioeconomic status impacts on physical activity levels in this p u p , and what
effect raising SES would have.
The effects of gender and age on physical activity were examined in this sample.
Gender was found to have no significant impact on participation in physical activity in the
bivariate or in the multivariate analysis. This result agrees with the studies of both Beange
et al (1995) and R i m e r et al (1995) who also found no signifïcant ciifference in the level
of physical activity engaged in by male or fernale participants.
The age of the clients had ui impact on two physical activity outcornes. In the
bivariate analysis, clients in the youngesr age group (18 to 30 years) were significantly
more Iikel y to have engaged in p hysical ac tivity in the past than were clients in the oldest
age group (51 years and older). This association remained after adjusting for living
arrangement and gender in the multivariate analysis. In addition, clients in the youngest
age gmup were significantly more Uely to have participated in a higher frequency of
physical activiry after adjusting for living arrangement, gender and ardiritis in the
multivariate analysis.
In addition to age and gender, information on living arrangement, level of mental
retardation, medical conditions and medication use was collected in order to detennine the
impact of these variables on physical activity. Living arrangement and level of mental
retardation were found to be highly correlated and so ody living arrangement was
exarnined for its impact on physical activity, and level of mental retardation was removed
from further analyses.
Living arrangement was found to be associated with fhquency of physical activity
and physical activity in the past month after a d j u s ~ g for age and gender. Clients living in
community settings participated in a significantly higher frequency of physical activity than
clients Iiving in the institutional setting. Furthemore, clients in both community settings
and group homes were significantly more likely to have pamcipated in any physical
activity in the past moiith than clients living in the institutional setting.
These hdings are different nom the results obtained in the study by Rimmer,
Braddock and Marks (1995). By using fiequency of physical activity as the outcome,
Rimmer and his colleagues found that the highest activity levels were found among clients
in the institutionai and the natural family semngs, and the lowest activity levels were found
among those living in group homes.
The discrepancy in levels of physical activity for clients in institutions between the
two studies may refiect differences in the institutions in three possible areas: in the clients,
in staffing or in physical activity programs offered by the institutions. For example, in
Rimmer's institutional settings, there rnay be less clients with severe and profound levels
of mental retardation, or more staff to support physical activities for the clients, or
possibly more of an emphasis placed on physical activity with more specialised programs.
Also important to note is that the institutional group in the present study is made up of
clients fiom only one institution. The institution used may be atypical in the physical
activity levels of clients. A future study examining how and why living arrangements differ
from each other in t e m of the clients' participation in physical activity would be useful.
Funher study is also needed into the impact of mental retardation on physical
activity. Had mental retardation b e n lefi in the analyses, and living arrangement excluded,
it is iikely that a significant association between mental retardation and physical activity
would have k e n found This speculation is based on the high correlation between living
arrangement and Ievel of mental retardation, and the significant associations between
living arrangement and physical activity outcornes. The association between mental
retardation and physical activity should be examined in more depth in order to better
undentand the variables associated with physical activity in this group as well as to
provide caregivers and the agencies who support pesons with developmental disabilities
with the information necessary to plan effective health promotion strategies.
In terms of medical conditions or associated disabilities, three variables were found
to be associated with higher levels of physical activity: the absence of a sensory
impairment, arthritis and diabetes. Clients without a sensory impairment were significantly
more likely to have daily routines or work habits that involved standing, walking, climbing
stain or heavy work as opposed to s i t ~ g for most of the day. Clients with arthritis were
signifcantly more Likely to participate in a higher frequency of physical activity after
adjusting for age, gender and living anangemenr In addition, clients with diabetes were
more likely to participate in daily physical activity after adjusting for age, gender and living
arrangement,
The two associations between higher levels of physical activity and arthntis and
diabetes were unexpected. It is possible that clients with arthritis participate in more
physical activity to alleviate painful symptoms and clients with diabetes may participate in
more physical activity to control the diabetes. Another possible explmation is that the
associations are chance findings. Due to the s m d nurnber of adults with arthritis (n=17)
and diabetes (n=10) in the sample, the likelihood that the findings reflect the m e
expenence of all adults with developmental disabilities is decreasd The wide confidence
intervals of the odds raaos in question reflect the variability and the imprecision of the
estimates.
In terms of the medications used by clients, only the use of antimanic agents was
found to be related to physical activity. After a d j u s ~ g for living arrangement, age and
gender, clients not raking antimanic agents were significantly more likely to have
pmicipated in physical activity in the past month.
The confidence intervals for the associations between medical conditions,
medications and physical activity are wide. This indicates a large amount of varïability and
imprecision in the estimates. These are important variables to examine. In a study of the
medical disorders of a sample of adults with developmental disabilities, Beange et al
(1995) found that over half of the sample had daily prescribed medications and a third
were taking multiple medications. As well, the sarnple had on average five medical
disorders per person. Further study is needed to determine the me impact of these
variables on physical activity in this population.
Secondary Objective
Describe the bamers, as identiflied by caregivers which might pratent adufts wirh
developmental disabilities from engaging in physical ac t i v i~ .
Adults with developmental disabilities face rnany obstacles in becorning physicalIy
active. The barrier most cited by proxies was that the client is not interested in doing
more, with 60% of proxies citing this as a barrier. This was also the number one ranked
bamier by proxies. This result is similar to that found by O'Neill and Reid (1991). In a
survey of the perceived barriers of older adults, O'Neill and Reid (1991) found that the
number one perceived barrier to physical activity was "1 get enough physical activity in rny
daily routine." This apparent lack of interest in physical activity is also consistent with
perceived barriers cited by the general population (Sallis et al, 1989; Dishman, Sallis and
Orenstein, 1985).
The second most comrnon bmier cited in the present study was that the client is
physically unable. This result was again similar to the second and third ranked baniers ''1
get tired easily" and "My state of health" found in a sample of older adults by Reid and
O'Neill (1991). Other client barriers include: the client is too old, or the client's behavior
is too disruptive. Disruptive behavior was especially a problem for clients living in the
institutional semng, and not a problem for clients in the community living setting.
Proxies cited several additional bamers which involved a lack of resources and
supports to facilitate active lifestyles. These barriers include: lack of nearby facilities or
programs, prograrns not adapted to the clients' needs, the cost was tw high, inadequate
msportation and a lack of staff. Cost was more of a problem for clients in the group
home setting, and lack of staff was more of a problem for clients in the institutional
setting.
These reponed barriers should be interpreted with caution as they may not reflect
reasons for inac tivity , rather they may represent post- hoc explmations for inactivity b y
proies. In a review of the determinam of physical activiq and exercise, Dishman, Sallis
and ûrenstein (1985) report that no data support the notion that removing stated baniers
leads to increased activity. Funher study is needed to determine nue barriers preventing
adults with developmental disabilities from pariicipating in physical activity.
Biases
Two types of bias that may have affected the results of this study are: selection
bias and information bias. A source of selection bias can be denved h m nonresponse
among shidy groups. In this study, different rates of response occurred by living
arrangement There was a considerably lower rate of response among proxies from the
community living settings than h m group homes or the institutional setting (54% vs.
80% and 83% respectively). Differential rates among study groups do not always indicate
the presence of bias, however if the rates of response are also related to the physical
activity outcomes, then bias may be an alternative explanahon for any observeci
association benveen exposure and outcome status. Unfomuiately, no infornation on the
outcomes is available on non-respondents, rnaking it difficult to determine whether
seIection bias exists in this study.
A type of information bias is misclassification which occurs whenever participants
are erroneously caregorized with respect to either exposure or outcome status. This study
relied on proxy-provided information, which increases the likelihood that misclassification
occurred. If the degree of misclassification was random or nondifferential (does not differ
by study group), the magnitude of the m e association between living arrangement and
physical activity will appear weakened. If, however, the misclassification differed by living
arrangement, the odds ratios estimated between living arrangement and the physical
activity outcomes may be biased away or towards the null. Considering the differences
that exists between the proxies of the different living arrangements, it is possible that
misclassification did diîfer by living arrangement. However, the impact of proxy
misclassification is not known in this study.
Confoundin g
The potentiai confounding effects of variables found to be associated with physical
activity in previous studies, age, gender and living arrangement, were conuolled for with
the use of multivariate modelling.
Limitations
Besides the presence of possible selection and information biases aforernentioned,
several other limitations exist. The data collection took place through most of the winter
months, from October to February. This probably led to an underestimate in the physical
activity of adults with developmental disabilities, since people tend to decrease their
p hy sical activity during winter (Laporte, Montoye & Caspersen, 1985).
Another limitation is the generalizability to the population of adults with
developmentd disabilities. Due to the low response rate in the community setting, and the
use of only one institution to represent the institutional setting, the generalizability of the
results to al1 adults with developrnental disabüities is questionable. The generalizability of
the associations are funher put in doubt by the discrepancy between the results found in
this study and those by Rimmer et al (1995). Lastly, the use of a cross-sectional survey to
investigate the variables associated with physical activity rnakes it difficult to establish a
temporal relationship between the exposure variables and the outcome.
Conclusion
Despite the Limitations, this study offers advantages over previous studies. Detailed
information on physical activity patterns is provided. As well, the impact on physical
activïty outcornes of client characteristics such as living arrangement is examineci. The
overall response rate (72%) is good and several agencies in the south-eastern Ontario
region agreed to participate in the study.
Results indicate that many of the clients lead sedentary lives. The fiequency of physical
activity is the same as that found in other studies of adults with developmental
disabilities (Rimmer et al, 1995; Steele, 1986), but considerably lower than in the
general population (Ministry of Health, 1992).
Variables which were significantiy associated with increased levels of physical activity
were: k ing in a younger age group, living in a community or group home setting, the
absence of a sensory impairment, having arthritis, king diabetes and not talàng
antimanic agents. Due to the small numbers, more research is needed to examine the
relationship between medical conditions and medications and physical activity
n ie barrier cited as most important was that the client is not interested in doing more
Other barriers cited could be groupeci into nvo categories: client bariers and resource
barriers.
Future studies
This s m y provides preliminary results on the physical activity patterns of adults with
developmental disabilities. A further study is needed which collects physical activity
data throughout the year to obtain an annual average. As well, in order to derive an
estimate generalizable to al l adults with developmental disabilities, the study should use
stratifieci sampling proportionate to size, in which a number of agencies participate
within each smtum. It would also be useful to incorporate a reliability study nested
within the larger study to assess the Likely impact of proxy-related misclassification on
the study results.
In light of the discrepancy found in institutional setting results between the present
study and that by Rimmer, Braddock and Marks (1995), it is important that future
study samples include a number of different agencies and living arrangements to
examine how and why living arrangements differ from each other. Important variables
to examine might include: the agency's support of physical acavity, in terrns of staffkg
levels. programs available and emphasis placed on physical activity.
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Appendix A MET Values Used to Calculate Energy Expendinire*
ACrrVITY Waking for Exercise Bicycling Running or jogging Exercises at home Exercise class, aerobics
[ Other (average of above) 4.2
. MET Value
3 4 9.5 3 4
- -
Swimming Softball, basebali Bowling Weigh t training Basketball or soccer Dancing, popular, bailet Gardening, yard work Fishing
* As found in the: Premier's Council on Health, Well-Being and Social Justice. (1992). The Ontario Health Surve~ 1 990: User's Guide. Toronto, Ontario.
- - -
3 3 2 3 3 3 3 3
Appendix B - Questionnaire
Queen's University Department Of Community Health And Epidemiology
Questionnaire On Exercise And Persons With Developmental Disabilities
1. Can the client wak... O without help (except ftom a cane), 0 with some help kom a person or with the use of a walker, or cmtches, etc ..., O or is the client completely unable to walk?
2. Which of the foliowing sentences best describes the client's usual daily activities or work habits? O The client is usually sitting during the day and does not wak about very much. O The client stands or walks about quite a lot during the day but does not have to
carry or lift things very ofien. O The client usually lifts or carries light loads, or has to climb stairs or hills often. O The client does heavy work or carries heavy loads.
3. Vigorous exercise is exercise which makes you breathe harder or puff and pant. Has the client engaged in vigorous exercise in the Fast 2 weeks? O Yes O No O Don't know
4. If yes, describe the activity:
5. In no, has the client been hospitalized or seriously sick in the past two weeks? O Yes CI No
6. Has the client participateci in the following physical activities duhg the iast month?
Waikir~g for wrercise
Bicychg
Rurining or jogging
Exercises at home
Exercise dass, aerobics
Swimrning
Softbaii, basebail
Bowling
Weight training
Basketbali or soccer
Dancing, popdar, bailet
Gardening, yard work
Fis hin g
Yoga or tai-chi
OtIier
Other
# of cimes in last month
About how much tirne does h&he spcnd an cach occasion?
1-15
minutes u
O
O
O
O
O
D
O
O
a
O
O
a
II
3140
minutes 0:
O
o
O
O
O
O
O
O
O
O
O
a
13
more
I hour O
u
cl
O
o
u
o
u
O
O
O
O
O
O
7. What stops the client from doing any or more physical activity? (check al1 that ~ P P ~ Y ) O a) Feel self-conscious, iIl at ease Ci b) Lack of nearby facilities or programs 0 c) Facilities, equipment or programs not adapted to rhe client's needs i3 d) Inadequate transportation Cl e) Physically unable to do more O f) Cost too high O g) Not interested in doing more
h) Other (please speciQ)
8. Please indicate the three most important things that stop the client from doing any or more physical activity fiom the list provided above. Most important: 2nd most important: 3rd most important
9. The previous 8 questions were concemed with the exercise habits of the client. Did the client assist you in a n s w e ~ g these questions? Ci Yes O No
10. Please indicate whether the client has any of these long-term conditions or health problem.
Condition No Allergies of any kir~d
Dia be tes
Epilepsy
I
Arthritis/Rheumatisrn of a serious nature
Psychiatric disorder
Congenital heart disease
Vision impairment
Other (please speci fy)
Other (please specify) - - - pp-
Other (please speci fy)
1 1. Plwe indicate aii medications the client is currently taking. Provide the name, dosage and indicate the frequency with which it is given.
Medication name and dosage 1 Frequency (ex.: once a day. twice a day, pm)
12. What is your relationship with the client: O a family member (please specSy) 0 staff (specify title) O home share provider O other (please spec3y)
If you are staff or a home share provider, please answer the foliowing 3 questions:
13. How long have you known (worked with) the client? O less than 6 months 0 6 months to less than 1 year O 1 year to less than 2 years O 2 years or longer
14. How often do you have contact with the client? O more than 3 days a week O 1 to 3 days a week O less than one day per month (please specify)
15. How are you aware of the client's exercise habits (check ail that apply) Cl you design exercise prograrns O you observe the client exercising O you assist the client when he/she exercises O you receive reports from the client or others about the client's exercise habits O other (please specify)
Where does the client live? O with a parent or guardian 13 in a group home O independently
in a residential institution O other (please specify)
Has the client lived in this location for longer than one year?
Please indicate whether the client is Cl male or O female
How old is the client?
What is the client's level of functioning? O mild O moderate O severe O profound O unspecifed
Comments: