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

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