Chapter 2
Literature Review on the Barriers to Physical Activity in Adults with Intellectual Disabilities
2.1 Health and Physical Activity
Physical activity for adults with intellectual disabilities is important to let them maintain a healthy lifestyle. This is because participation in regular physical activity may help reduce the rate of occurrence of heart disease and cancer (Stalker and Harris 1998). The same relationship also exists between disease and physical activity, such as exercise because with increased levels of physical activity, there is a decreased prevalence for an individual to develop certain diseases (Draheim et al 2002). Currently, there is strong evidence that physical activity has powerful effects on mortality, and with other fatal diseases, such as coronary heart disease or CAD, blood lipid profiles, and colon cancer.
Rimmer and Braddock (2002) stated that regular physical activity could help reduce high blood pressure, obesity, type 2 diabetes, stroke, and osteoporosis (Stear 2003). As such, it can be perceived that regular physical activity helps an individual to have a good health, having a sound body and sound mind. Given this, it can be emphasized that regular physical activity for individuals with intellectual disabilities can produce great effects. Adequate physical activity for adult with intellectual disabilities depends on having a well-rounded program that encompasses all aspects of improving health and preventing diseases. Such a well-rounded program must include cardiovascular fitness, and muscular strength and endurance, which may influence their quality of life in several ways. It can also be used to improve their self-image, self-esteem, physical wellness, flexibility, posture, and maintenance of body composition (Messent et al 1997; Hillsdon et al 2005). Thus, in this sense, not only an adequate physical activity program will produce physical and health improvements on the part of the individual, but can provide psychological and emotional benefits as well.
2.2 Relationship of Health and Physical Activity
In relation to this is the fact that physical activity is related to health. The emphasis of this relation is based on the changing lifestyles of individuals during the course of human development. It has been reported that the analysis of evolutionary history in relation to current lifestyles stresses the central issue, indicating that human beings nowadays are living their lives, at least in developed countries, in ways that are largely unhealthy and different from what human beings have done for most of the past. It was suggested that four evolutionary periods are essential in considering the relationship between physical activity and health. The first evolutionary period is the pre-agricultural period, which is up until about 10,000 years ago, and characterized by hunting and gathering activities. In this particular period, exercise levels were high and diet was low in fat. The second evolutionary period is the agricultural period, which happened 10,000 years ago until about the beginning of the 19th century, and was characterized by practically high physical activity levels and relatively low fat diets, similar to the pre-agricultural period. However, the fat content during this period probably increased. The third evolutionary period is the industrial period, which was from 1800 to 1945. This period gave way to the development of the ‘industrialized society’, along with social problems and issues, such as over-crowding, poor diet, poor public health measures, and inadequate medical facilities and care. In this particular period, infectious diseases were responsible for a high proportion of premature deaths, such as the bubonic plague. However, this trend was reversed in the fourth and last evolutionary period, the nuclear/technological period, which was identified as from 1945 until the present time. The major improvement in this evolutionary period is evident in its public health measures and medical advances, making infectious diseases less common in developed societies. However, the causes of health problems only shifted, making premature mortality being caused by changes in terms of lifestyle. Due to the change in lifestyle of many individuals around the globe, different health problems have emerged, including coronary heart disease, with risk factors, such as cigarette and tobacco smoking, fatty diet, and lack of physical activity and exercise (cited in Biddle and Mutrie 2003). In this sense, it can be analyzed that during the course of history, human beings have adopted different lifestyles, which may have contributed to the deterioration of health. This is supported by the fact that the average life expectancy of individuals decreased from 70 to 50 years old. Although physical and mental healths have shown improvements, such have only been observed in developed countries. Today, due to the change in lifestyle, changes in health and mental status have also been recognized, leading to identify different diseases and problems caused by the lack of physical activity, such as poor mental health, coronary heart disease or CHD, obesity, low back pain, osteoporosis, hypertension, diabetes, and cancers. In this regard, the relationship of health and physical activity can be recognized to be crucial in the growth and development of an individual, particularly of adults with intellectual capabilities.
2.3 Definition of Physical Activity
Physical activity can be defined as any bodily movement produced by skeletal muscles that result in energy expenditure (Stanish et al 2006). It is a broad term that encompasses all forms of muscle movements and can range from sport to lifestyle activities (DOH 2004). In addition, physical activity is planned and structured for movement of the body, and designed to enhance physical fitness. Strong muscles are important for carrying out everyday tasks and through physical activities, it can help keep the body in proper alignment, prevent back and leg pain, and provide support for good posture (Welk 2002). Moreover, physical activity cannot only contribute to the improvement and development of one’s physique, but also can also contribute to the growth and development of an individual in terms of his or her emotional, mental, and psychological facets. Through physical activity, physical characteristics and aspects of an individual are certainly improved, leading one to feel good about him or herself, thus, improving one’s perception regarding his or her personality. Therefore, one’s attitude and behavior is improved and developed, making one more positive, sociable, and active. In this regard, it can be seen that a number of benefits can be achieved in engaging in physical activities. Thus, indicating the fact that total wellness can be achieved with regards to engaging in adequate physical activity.
Types of physical activity include structured activities such as sports, swimming, and exercise, as well as unstructured activities, such as walking, cooking, housework, gardening, DIY, dancing, shopping, jogging, cycling, running, and other manual activities (Gates 2007). In addition, physical activity can also be classified according by moderate activity, which includes large muscle group activities equivalent to brisk walking, dancing, and yard work; and by vigorous activity, which includes repetitive large muscle activity at an intensity equal to 70% of age-predicted maximum heart rate, such as jogging and lap swimming (Stanish et al 2006).
2.4 Definition of Disability
It has been reported that disability is a dynamic concept that has changed dramatically over the last half century and will likely continue to change. It has been defined in various ways, depending on conceptual view, research intent, or its purpose (Krahn et al 2006). It has been emphasized that in general, disability means, with respect to an individual, (a) a physical or mental impairment that substantially limits one or more of the major life activities of the individual; (b) a record of such an impairment; and (c) being regarded as having such an impairment. A number of causes have been identified, causing disability to many individuals. Such causes include musculoskeletal and connective tissue disorders, circulatory disorders, respiratory disorders, nervous and sensory disorders, endocrine, nutritional, metabolic and immunity disorders, mental disorders, and visual and hearing impairments (van der Ploeg et al 2004). From such range of disorders, it can be given emphasis that individuals suffering from disabilities, whether physical or mental can be viewed as individuals who less physically active, and may be more susceptible to problems with functioning, mobility, and other medical diseases that affect their lifestyles, such as coronary artery diseases (CAD), type 2 diabetes, osteoporosis, osteoarthritis, colon cancer, high blood pressure, decreased balance, decreased strength, decreased endurance, decreased fitness, decreased flexibility, spasticity, weight problems including obesity, depression, urinary infections, diminished self-concept, reduced ability for normal social interactions and greater dependence upon others (van der Ploeg et al 2004).
In addition, it has been reported that individuals with intellectual disability may be limited not only in their cognitive and adaptive behavior skills, but also by emotional and behavioral disorders that further limit their ability to learn new skills, adapt to changing environments, and develop appropriate social interaction skills. When such intellectual disorders are of a sufficient severity and intensity, they may constitute a diagnosable psychiatric disorder. In this sense, individuals with intellectual disabilities and mental illnesses present several challenges to both community and health services in terms of the difficult behaviors they present, the complexities of diagnoses and treatment, and the complex service needs they require. In addition, aside from such problems, individuals with intellectual disabilities may also be masked by poor language skills and life circumstances, where often reports of mental illness may be conveyed through a support worker rather than the individual him or herself (Hudson and Chan 2002).
Intellectual disability includes mental disorders such as mental retardation, learning disorders, and psychological disorders, such as schizophrenia, bipolar disorder, other psychotic disorders, gender and personality disorders, and anxiety and depressive disorders. With this, it can be perceived that an individual considered to suffer from intellectual disabilities refers to an individual that has an inability or has severe incapacity to deal with complex mental, emotional, and psychological matters at hand, in comparison to normal individuals.
2.5 Determinants of Physical Activity
Based on the previous discussions, it has been emphasized that physical activity and health of individuals are related and interdependent with one another. This is because one’s engagement in physical activity, including the rate of engaging in physical activity determines one’s health. However, it has also been mentioned that one’s health is also affected by his or her lifestyle, particularly of his or her type of diet. Thus, it can be perceived that one’s health depends on a variety of factors, such as physical activity, heredity, environment, and diet. In addition, in the previous discussion, the different types of physical activities have been characterized and identified according to the muscle groups involved during activity. As such, it can be understood that anybody and everybody can engage in any physical activity, as it evidently involves any action that would require one to exert effort and energy.
The major determinants of physical activity of both normal individuals and individuals with disabilities include environmental, physical, personal/psychological/emotional, and social determinants. Environmental determinants refer to factors that can serve to limit the ability and opportunities of individuals to participate or engage in physical activities, such as the weather, location, and other environmental constraints. Such constraints may include the home, school, day care, and workplace settings of the individual. Physical determinants include the physical abilities or capacities of an individual, which may include mental abilities, height, weight, and physical characteristics. Because each individuals share different heredity and physical characteristics, the ability of an individual to engage in physical activities can be significantly affected as well. Some individuals may have physical attributes that are more useful in physical activities, while some do not. This also supports the fact that the choice of physical activity depends on one’s physical characteristics. Personal, emotional, and psychological determinants pertain to the psychological aspects of an individual and are significantly affected by different factors in one’s environment, thus, shape and influence one’s ability to perform and become motivated to engage in physical activities. It has been reported that physical activity was consistently associated with positive effect, mood and psychological well-being in both healthy and clinical populations (Hawkins and Look 2006). However, given the positive effects that physical activity poses on the psychological aspects of an individual, other determinants, such as the environment, physical factors, and social determinants may serve as hindrances or limitations. Lastly, social determinants also play an important role in giving opportunities for individuals to engage in physical activities, particularly to individuals having intellectual disabilities. Social determinants pertain to the individuals or groups of individuals a certain person, either normal or a person having intellectual disabilities relate to, including his or her peers, family, friends, teachers, neighbors, and other individuals that a person communicates with (Durvasula and Beange 2001). The social determinants of an individual play important roles in the lives of others, particularly with regards to involving and motivating one to participate in physical activities. In relation to this paper, most pieces of literature have reported that the extent, motivation, and willingness of individuals having intellectual disabilities to participate in physical activities depend on the people around them, most especially those individuals in charge of providing them care, protection, and attention. In this regard, it can be emphasized that the extent of the participation of individuals with intellectual disabilities depends upon the encouragement, motivation, support, communication, and care by the people around them (Durvasula and Beange 2001). As such, if in case, the people around the individuals having intellectual difficulties would not be as supportive, encouraging, and motivating, then such individuals would not be as encouraged and motivated to engage in physical activities as they should. In this sense, they would be more susceptible to acquiring diseases related to physical inactivity, such as coronary heart diseases, diabetes, obesity, and many others. With this, it can be perceived and understood that the many determinants of physical activity may either allow or restrict the ability and the opportunity of individuals with intellectual disabilities to engage in physical activities. In this regard, such factors or determinants must be able to be identified, examined, and given emphasis in order for one to be able to contribute to changes needed by individuals having intellectual disabilities.
2.6 Barriers to Physical Activities of Individuals with Intellectual Disabilities
Based on the first chapter, it can be seen from this paper has a number of themes, which would be tackled and addressed in this literature review and the rest of the paper. It has been listed that the unclear policy guidelines for residential services provision, financial support, social support, geographical location in relation to leisure center, and the physical active community leisure are considered to be the themes for this paper. In addition, these themes indicate the barriers to physical activities of individuals with intellectual disabilities.
The first barrier to physical activities of individuals with intellectual disabilities is the unclear policy guidelines for residential services provision. Based on the different pieces of literature and journals on this matter, it has been reported that both the parents/caregivers of individuals with intellectual disabilities and the health care staffs believe that their skills would not be enough without the support of policy makers (Temple and Walkley 2007).This is because policies can influence the deployment of resources that would enable individuals with intellectual disabilities participate with physical activities in the community or society. In addition, public policies must be able to value the voices of people with intellectual disabilities and their carers or advocates and actively support partnerships between government sector and community organizations if the needs of communities and families are to be met (Hand and Reid 1998). Thus, in this sense, it can be perceived that the need for policies and policy guidelines for residential services provision must be achieved.
In order to say that policies and policy guidelines support the engagement of people with intellectual disabilities, and that the lack of such policies and policy guidelines serve as one of the barriers to their physical activity, the many advantages or benefits of providing policies for residential services provision can be given emphasis. It has been stated that a greater resident involvement in policy-making within the residence was significantly related to greater levels of community integration at follow-up, and beyond size and facility, opportunities for choice and involvement in policy making, were related to outcomes of adaptive behavior and community integration (Bray and Gates 2003). Moreover, people living in either “village communities” or community-based residences had larger social networks than did people living in residential state campuses; people living in community-based residences had more people with an intellectual disability in their social networks than did people living in residential state campuses; people living in community-based residences had more people without disabilities, who were not family members, and who were not staff in their social networks than did people in either village communities or state campuses; people living in smaller community-based services had larger social networks and more non-disabled, non-staff, and non-family members in their social networks than did people living in larger residences; and people with an intellectual disability expressed greater satisfaction with their friendships and relationships if they had a greater number and proportion of people with an intellectual disability in their social networks (Bray and Gates 2003). From such advantages or benefits, it can be seen that through residential services provision, people with intellectual disabilities greater opportunities for physical activities can be provided for them. They are able to expand their social networks, be able to achieve greater satisfaction in terms of how they relate with other people, and be able to have more fun and enjoyment in life.
However, Hand and Reid (1998) reports that the failure of policy as created by the governmental sector to support family caregivers and to take into account changes in the household/family sector reflects unexamined assumptions about the community and family. One of the reasons why policy has not effectively or efficiently achieved community integration for people with lifelong intellectual disability is that this real meaning of community has not been acknowledged. Costs to family and agency caregivers have been underestimated and unacknowledged. The assumption that resources of the community are available for care is doubtful, or at least not strategically established. The effects of social and demographic trends, as well as a decade of governmental restructuring and policy change on community organisations, are difficult to estimate. The issue is that unremitting demands and lack of support result in progressively negative effects and inability to sustain caring roles (Hand and Reid 1998). In addition, the National Survey of 1989 – 1991 identified a number of service needs that are not being met by individuals with intellectual disabilities from residential institutions, namely, membership in clubs, day programmes, recreational and retirement services, support and respite for families, review of medication, and regular health checks and treatment, vision and hearing services, education and learning of self care and social skills, transport (to increase independent mobility, to enable participation), and more choice in place of residence (Hand and Reid 1998). With such unmet needs, it can be recognized that if policies and policy guidelines would not be provided as soon as possible, death rates among individuals with intellectual disabilities will continue to increase. Currently, death rates in sedentary individuals are approximately twice as high as for active persons (Messent et al 1999 & 2000). In addition, it has also been stated that the life expectancy of persons with mental retardation is increasing, and accordingly, more attention has been given to preventing secondary disabling conditions, such as obesity, diabetes, and hypertension in efforts to improve the overall health and quality of life of such individuals (Temple et al 2006). Nonetheless, residential institutions and family members would not be able to manage without the policies to guide them.
In this case, it is important that health care providers and policy makers acknowledge that many people with intellectual disabilities have special needs that may require modification of standard health care practices and service models. In addition, administrators and policy makers need to understand that, in some cases, clinically indicated and relatively expensive techniques and expertise may prove cost-effective in the long term. Thus, in this sense, health care providers and policy makers need to eliminate attitudinal, architectural and health care reimbursement barriers that interfere with the provision of high quality health services for people with intellectual disabilities (Evenhuis et al 2000).
The second barrier to the physical activity of individuals with intellectual disabilities is financial support, which includes resourcing and transport. In this regard, both personal and governmental financial constraints can be considered a barrier. It has been reported that both environmental and personal factors serve as barriers to physical activity. Some environmental barriers for individuals with disabilities include poor transportation, poor availability and accessibility of equipment and built and natural facilities to become more physically active. On the other hand, personal factors include the lack of money (Ohtani 2002). This is because access barriers play an important role in determining participation in physical activity, such as limited income and the cost of participation were major barriers to physical activity (Cleaver 2007). In this sense, money or finances serve as limiting factors for the families of individuals with intellectual disabilities. It has been stressed that enough money can make individuals do some interesting things, like trips or having some choice of places they like to go to or things they like to do (Mactavish et al 2007). However, without adequate resources and money, this would be impossible.
As a matter of fact, it has been emphasized that financial constraints were identified as a major barrier for the obese population, as funds are needed in order to encourage them to engage in physical activities, such as through equipments or going to different residential institutions (Cascella 2005). This is because practical things can pose problems too, such as not having enough money, not being able to use a telephone, and no transport. With limited budget or money, not only are the persons with intellectual disability affected, but also their caregivers who support and take care of them. Resourcing constraints mean that individual and group leisure facilities and preferences widely available to the general population at weekends and during week day evenings can rarely be offered to adults with intellectual disabilities (Godbey et al 2007). Another example is indicated in one study wherein it has been emphasized that similar to the general population, personal finance can also restrict or limit the degree of choice available to an individual with a learning disability (Cothran and Kulinna 2005). Similar with many others who experience poor health outcomes, people with intellectual disability tend to be socio-economically disadvantaged, and majority of them depend either partly or wholly on government income support (Knowles et al 1998). Those who are employed tend to work in low paid jobs which are often part-time or casual in nature. People with intellectual disabilities and low income levels have limited access to some types of preventive health care (Knowles et al 1998). For example, preventive dental services are more difficult to obtain due to the high cost of private dental care and the limited availability of publicly funded services. Additionally, for those who live in rural or outer metropolitan areas, inadequate transport facilities hinder access to health care services in regional or city centers (Bowling and Windsor 2001). In addition, thus socioeconomic disadvantage, as in other marginalized groups, can be a major barrier to primary and preventive health care access in people with intellectual disability. There are, however, other barriers which are specific to this population (Heller et al 2002).
In addition, aside from personal financial problems, government problems in relation to financial allocation can also serve as a barrier. It has been mentioned that official government policy now supports the principle that people should be helped full and independent lives and that services for people with learning disabilities should be provided with proper participation of the individuals concerned (Prasher and Janicki 2002). In order to do so, professionals from health, education, and social services are now expected to facilitate this. However, currently daily activity and job choices are extremely limited to few alternatives to the adult training center or social education center for adults with learning disabilities due to scarce funds by the government. As such, like most legislation concerning the disabled, it requires local authorities to only provide within the resources available, thus, making the quality and consistency between and within authorities varied (Rimmer and Braddock 2002). In this sense, individuals with intellectual disabilities and their advocates or caregivers are not allowed to demand a particular type or quality of service (Sutherland et al 2002). They are only allowed to accept what is provided by such centers. Thus, in this sense, due to limited governmental financial support, adequate services cannot be provided to individuals with intellectual disabilities.
Aside from financial problems, transport problems can also be identified as affecting the extent of how persons with intellectual disabilities can have access to physical activities. It has been mentioned that transport and the location of day service provision centers in relation to open space and community facilities, may hinder participation in physical activity (Mactavish et al 2000). Limited transport options may lead to difficulties in accessing health services and/or implementing management recommendations (Lunsky and Benson 1999). It can be suggested that as an answer to the problems with transportation, other cheaper forms of physical activities, such as brisk walking, climbing the stairs, washing windows or the car, or fast social dancing can be deemed as useful and equally relevant. In addition, in relation to transport, the major sources of physical activity for adults with mental retardation or intellectual disability were walking and cycling, chores and work, dancing, and Special Olympics (Frey et al 2005). However, it has been emphasized that the intensity of walking alone may not be sufficient to meet the minimum recommendations to achieve health benefits desired. It has been stated that persons with severe or profound mental retardation or intellectual disability frequently experience co-occurring conditions, such as medical complications, diseases, and particularly mobility limitations that make physical activity more difficult (Emerson 2005). In this regard, it can be perceived that even the simplest means of physical activity available to individuals with intellectual disability may present hazardous consequences or threats to their health, based on their biological, personal, and social limitations.
The third barrier to allowing individuals with intellectual disability to participate in physical activity is social support that includes staffing ratios (Graham and Reid 2000). In order to discuss and emphasize why staffing ratios and social support serve as barriers to allowing people with intellectual disabilities to participate in physical activities, a number of factors that shape the provision of care to individuals with such situations. The first factor is the trend toward person-directed or person-centered care, wherein the needs and preferences of individuals with such conditions are beginning to form the basis of care plans. The second factor is the increasing longevity of individuals with developmental disabilities. It has been mentioned that individuals with intellectual disabilities are now living beyond their years and are continuously encountering medical illnesses often associated with aging. The third factor is the pervasive trend toward consumer choice, which affects how the lifestyle choices of individuals influence their lives and their health as well (Rubin et al 1998). Such factors were included because they influence the secondary barriers that help increase the risk of danger of individuals with intellectual disabilities. In this regard, the combination of both the primary and the secondary barriers to physical activities of such individuals contribute to detrimental consequences. In addition, the three factors that shape the provision of care to individuals and the secondary barriers to physical activities such as obesity or overweight status, risks of developing medical diseases, poor self-image, and difficulty with job placement and retention, influence how staffing ratios are in the residential institutions and vice versa.
It has been mentioned that the health benefits of being physically active include prevention of disease to the blood vessels and heart, prevention of colon cancer, the control and prevention of Type 2 diabetes, and improved bone and mental health (Prior 1999). Given such benefit, it must be understood that many individuals, particularly health professionals and the caregivers of individuals with intellectual disabilities must support and come up with strategies that would help such individuals to achieve good health and dispositions in life. In this regard, the ordinary living principle has been developed to help guide day and residential staff with the decision-making process and redress a situation in which historically service providers have been accused of exerting too much control over the lives of adults with learning disabilities (Emerson 2005). However, despite this, support services and staffing ratios still serve to limit or restrict the access of individuals with intellectual disabilities to services that they deserve.
It has been reported that the focus of public debate on disability issues has increasingly moved away from medical definitions of “disability” to social models of understanding systemic barriers that prevent the full and active participation of persons with a disability in society. This, in turn, has resulted in greater public awareness of disability issues and the need for policy intervention (Chong 2006). There is therefore abundant evidence to show that people with intellectual disability are disadvantaged in terms access to primary and preventive health care. Many barriers to access have been identified in the literature, including socioeconomic disadvantage; inadequate knowledge and awareness of health issues; negative, discriminatory or nihilistic attitudes to people with disabilities; communication issues and poor inter-sectoral collaboration, and many health care providers, caregivers and people with intellectual disability have insufficient knowledge of the relevant health issues in this population (Kraus et al 1998). It has been emphasized that whether adults with learning disabilities want to go for a walk, visit the shops, the cinema, or the local swimming pool, real empowerment through self advocacy requires adequate staff support (Heath and Fentem 1997). In this sense, staffing ratios exert a powerful and direct influence on the range and quality of physically active leisure choices available for individuals with intellectual difficulties (Kmietowicz 2003). This is because individuals with intellectual difficulties cannot make sound decisions and actions on their own, they rely heavily on companions, thus, making them dependent upon their care, attention, and support. Without the support, care, and attention of their caregivers, individuals with intellectual disabilities would never be able to fed, cared for, and talked to effectively, thus, leading to either their death or severe mental, emotional, psychological, and physical damage. In this sense, the heavy dependency of individuals with intellectual disorders or disabilities upon their caregivers may either allow, encourage, or motivate them to participate in physical activities or discourage them to do so.
It has been emphasized that lack of staff motivation to promote physical activity, a lack of physical activity counseling, and high client-to-staff ratios have all been reported to constraints to participation (Beange et al 1999). This is because people with intellectual disabilities are often living in environments where healthy choices, by them or their caregivers are difficult (Caine and Hatton 1998). Oftentimes, staff numbers and/or resources are inadequate to allow regular physical activities (Temple et al 2000). Care providers, managers, and supervisors report that inadequate physical activity policies and guidelines for residential and day service providers contribute to such difficulties (Messent et al 1998). This is because the perceptions of the caregivers regarding the benefits of exercise and other physical activities are being emphasized and not the perceptions of the adults with intellectual disabilities were involved in higher levels of participation (Jebb 1998). Such individuals would not be able to participate in different activities without the assistance of other people. It has been emphasized that even if they are aware of the relationship between physical activity and health, most of these individuals are unlikely to have either the capacity or the resources to alter their lifestyle without the assistance of others (Marshall et al 2003). In this sense, it can be perceived that in this situation, the caregivers or the carers are the ones lacking the understanding of the benefits of physical activity.
In relation to the perceptions and lack of initiative and interest of caregivers or carers, it has been emphasized that staffs that provide services to such individuals lacked interest in promoting physical activity and lacked the knowledge, skill, and confidence related to physical activity itself, while staff that are focused on the physical activity field lacked understanding and skills in working with adults with intellectual difficulties (Scully et al 1998). In this regard, if the parents and staff lacked the confidence and skills in promoting physical activity for the elderly, physically disabled, or frail, then it would be impossible and difficult for such individuals to be motivated and engaged in any physical activity. In addition to this, negative, discriminatory or nihilistic attitudes pose formidable barriers to equitable health care access in this population (Hand and Reid 1998). Negative attitudes also exist in some caregivers who feel that paying special attention to health problems and preventive health in this population ‘medicalises’ disability. A high proportion of people with intellectual disability have limited communication abilities, making it difficult for them to describe symptoms (Cummins 2005). For health care providers, there are complexities in obtaining an accurate history (which therefore often has to be obtained from carers) and explaining procedures and management plans. This compromises the quality of health care that is provided. For those involved in health promotion activities, successful communication of health messages using standard methods becomes difficult (Cummins 1997). Partly as a result of the communication barrier, people with intellectual disability are one of the very few groups in society that are reliant on others to facilitate their access to health care. However, as seen previously, family members and carers may find it difficult to recognise health problems in the individual for whom they provide care. In addition, for many there is a multiplicity of carers—family members, paid carers in the group home and support personnel at work and in social settings (Turner 1997). Staff in group homes work in shifts and there tends to be a high turnover of employees and a reliance on casual staff. In these circumstances, effective and consistent communication with carers can be difficult, and the successful implementation of health promotion programs a challenge. The problem can often be compounded by poor record keeping by accommodation and other support services (Eyman et al 1987).
The fourth barrier is geographical location in relation to leisure center. It has been emphasized that local leisure centers, although perceived to have improved in recent years through the work of disability sports development officers, were still not able to offer many appropriate opportunities for the learning disability population (Hatton and Emerson 1995). In this sense, it can be seen that the geographical location or venue of residential institutions and day care services serve as barrier to allow such individuals to engage in physical activity. This is because, as mentioned earlier, the issue of transportation, finances, and support of the family members and staff members are relevant and significant for such individuals to travel to the different day care services to engage in physical activities designed for them. It has been emphasized that some of these individuals are not able to access out-of-hours activities, not having support personnel at venues, and being rotated out of physical activity opportunities to give others the same opportunities. In addition, only limited spaces are available, and therefore, when selecting activities for a new term, they were obliged to choose something else. Moreover, although an accompanying family member or support worker are there to provide assistance to a person with intellectual difficulty, the institution must also have a central place within the consultation can be held. In this sense, it can be perceived that the location of the day care services must also be strategic in order to effectively provide services to many individuals with intellectual difficulties.
In addition, in relation to the discussion of the geographical location of day care services is the exposure of such individuals to the type of day care services. A study done by Walker (1999) found that adults with an intellectual disability spend their time in places that are typically designated for people with disabilities. Such places included separate locations and separate spaces within larger settings that included other people. Such places spanned most dimensions of daily life, such as educational, residential, work/day, and leisure time. In this sense, it can be seen that such individuals who spend most of their time in separate locations and separate spaces have limited social networks. Thus, the author concluded that their lack of access to private social worlds is related to their very limited social networks outside of family or group homes and the lack of transportation (cited in Bray and Gates 2003). As such, it can be understood that the location of day care services play an important role in the lives and physical activities of such individuals. In support of this, the study done by Robertson et al (2000) states that the more able people living in less restrictive settings are more likely to be physically inactive, while less able residents, being at less risk of obesity and smoking are at more risk of physical inactivity. In essence, the health behavior of people with intellectual disabilities, in the absence of the restrictions placed by institutional living, may be becoming more like that of the general population (Robertson et al 2000). As such, the geographical location of day care services and residences of many individuals with intellectual difficulties play an important role, with regards to barriers to physical inactivity.
The last barrier to physical activity of individuals with intellectual disability is physical active community leisure, which involves limited options and choices for such individuals. It has been reported from a recent study funded by the Robert Wood Johnson Foundation suggested that leisure-time physical activity contributed more to the health of adults than household or occupational work (Chow 2006). Such activities were said to improve many aspects of physical well-being, including health perception, physical functioning, mental health, vitality, pain, social functioning, and obesity. Therefore, leisure activities, especially those that are intrinsically motivated and satisfying appear to be the most promising arena for promoting physical activity among older adults, and there are several promising interdisciplinary programs, environments, and products that can promote active living among the population. In addition, leisure activities, such as vacations are often identified as positive contributors to life quality. As such, it can be perceived that such activities, along with physical activities may contribute to the health and life of an individual with intellectual disability.
It has been mentioned in the previous discussions that although local leisure centers have already improved in terms of its facilities, the staffs and resources that go with it were still unimproved. In this regard, due to the lack of appropriate resources and staffs for such venues, the provision of leisure activities to such individuals may serve as barriers. For example, it has been stated that in a local area, a variety of opportunities have been developed, such as trampolining, rebound, football, indoor bowls, cricket, sailing and trail orienteering. However, despite the enthusiasm of the individuals with intellectual disability, long term sustainability was a constant problem because of the necessity for adequate staff support to access such opportunities (Messent et al 2003). An example of this is sport training. It has been reported that sport training for persons with disability is often more expensive than it is for their able-bodied counterparts due to special transportation needs, specialized equipment, and requirements for personal care support, and other personnel specific to sport for persons with a disability (Temple and Walkley 2003). In addition, some environmental conditions are more conducive than others to the participation of persons with a disability in sport. Difficult or harsh climatic factors may represent even larger obstacles to sport participation for persons with a disability than for able-bodied participants (Chong 2006).
In addition, it has also been given emphasis that generally, clear administration regarding the value of and promotion of physical activity in community residential units and day training facilities are needed. Some of the individuals with disabilities believe that majority of the staff do not see promotion of physical activity as their responsibility, and until policy direction was provided, physical activity would continue to be inadequately promoted for adults with such conditions. Moreover, the lack of transportation and money for equipment and access were considered constraints by parents, direct care workers, and group home supervisors. Thus, it is hardly surprising that the leisure needs of those with mild and moderate learning disabilities receive only minimal attention. Limited attention means that staffing arrangements were determined by old patterns of organizational and care practices that paid inadequate attention to individual care planning and the promotion of maximum independence (Iacono et al 2006). Activities included almost always focus only on the services that the centers themselves could provide, without featuring or involving other educational, health, and voluntary agencies. Moreover, the absence of suitably trained staffs put the use of certain activities in jeopardy. Such activities may include activities in terms of locomotion or social development, for example, swimming (Gallagher 2002).
In this sense, it can be perceived that the limitations or restrictions of individuals with intellectual difficulties in terms of leisure activities rely on the other barriers identified. This is because the causes of limiting such activities are due to the lack of resources, staffs, policies, and venues appropriate for the activities of such individuals. In the end, the recognition of such barriers would enable one to come up with strategies or ways in providing solutions to the problems of the individuals concerned, provide new policies that would tackle the concerns of individuals suffering from intellectual difficulties, sustain and maintain the rights and safety of such individuals, and further improve and develop the facilities of day care and rehabilitation centers that provide services to such individuals.
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