A Preliminary Evaluation of a Social-Cognitive Theory-Based Structured Physical Activity Program for Improving Fitness in Populations with an Intellectual Disability

written by Krishna Dipnarine (Graduate Student), Anthony Delisle (Doctoral Student), & Christine Stopka (Professor), Department of Health Education & Behavior, University of Florida, Gainesville, Florida

ABSTRACT

Background: Populations with an intellectual disability (PID) consistently have significantly higher rates of obesity and lower rates of physical activity, cardiorespiratory fitness (CRF), and muscular endurance than populations without an intellectual disability.

Purpose: To evaluate the efficacy and effectiveness of a Social Cognitive Theory-based (SCT) structured physical activity intervention for PID to increase time spent on health enhancing physical activities, increase CRF, increase muscular endurance and decrease percentage of total body fat.

Methods: Thirteen young adults with an intellectual disability (ages 17-22, 38.5% female) participated in a 1-hour structured physical fitness intervention, held twice a week, for 8 weeks. Physical fitness assessments were conducted pre and post intervention.

Results: On average, heart rate decreased 24.2% 1-minute post YMCA step test, bench press reps increased 41.7%, upright seated-row reps increased 81.3%, seconds maintaining static plank form increased 58.4%, wall pushups reps increased 61.7%, and muscle mass increased from 34.83% to 35.41%.

Conclusion: Results of this study show that PID who received this SCT-based intervention significantly increased time spent on health enhancing physical activity, increased CRF and muscular endurance, and decreased percentage of total body fat. This substantiates the need for exercise programs for this population.

INTRODUCTION AND LITERATURE REVIEW

Intellectual Disabilities (ID) account for 25% of all disabilities in the population of those diagnosed with any form of a disability according to the United States 2000 Census (Stern, 2003). An ID is "a disability, originating before age 18, which is characterized by significant limitations both in intellectual functioning and in adaptive behavior as expressed in conceptual, social, and practical adaptive skills" (Temple, Frey, & Stanish, 2006, p. 2; American Association on Mental Retardation, 2002, p. 8). An individual is considered to have an ID if he or she has an Intellectual Quotient (IQ) less than 70 (Hatton, 2002).

Obesity-related diseases, such as cardiovascular disease (CVD), cancer, and stroke are the leading causes of morbidity and mortality in the United States (American Heart Association, 2008; McGinnis & Foege, 1993). Obesity is increasing at epidemic rates in the general population with more than 72 million adults classified as obese (Bean, Olbrisch, & Stewart, 2008). Alarmingly, obesity rates are even greater in populations with an intellectual disability (PID). More than two thirds (66%) of young adults with ID are reported to be either obese or overweight (Yamaki, 2005). Subsequently, PID are at an even greater risk of developing and dying from CVD, cancer, and stroke when compared to populations without an ID (Hill, Gridley, & Cnattingius, 2003; Day, Straus, & Shavelle, 2005; Draheim, 2006).

Large prospective cohort studies consistently show that physical inactivity and low cardiorespiratory fitness (CRF) are strong and independent predictors of obesity, fatal and nonfatal CVD, cancer, and stroke rates in men and women (Warburton, Nicol, & Bredin, 2006; Peterson, Magid, & Ross, 2008). Adequate levels of physical activity are needed to increase CRF, decrease obesity, and to protect against the development of CVD, cancer, and stroke (Pate, Pratt, & Blair, 1995; Kesaniemi et al., 2001).

In 2002, the U.S. Department of Health and Human Services (DHHS) released physical activity guidelines calling for an hour of moderate to vigorous physical activity on five or more days a week for young adults (U.S. DHHS, 2002). National surveillance data and recent research estimates that less than 15% of PID meet these guidelines, compared to 33% of people without ID (Eaton et al., 2008, Pate, Long, & Heath, 1994; Pate, Freedson, & Sallis, 2002; Faison-Hodge & Porretta, 2004).

The effectiveness of improving CRF through physical activity in PID is poorly understood. Unfortunately, few prospective studies have examined the relationship between physical activity, CRF, obesity, and health outcomes in young adults with ID. However, researchers hypothesize PID will increase CRF in the same manner as the general population with adequate levels of health enhancing physical activity.

THEORY OF SOCIAL-COGNITIVE FUNCTIONING

Bandura's Social-Cognitive Theory (SCT) posits that behavior changes may occur from setting personal goals based on the outcomes of these goals, and the tasks and self-efficacy expectations needed to achieve these goals (Heller, Hsieh, & Rimmer, 2004; Bandura, 1977 & 1986). In accordance with this theory, individuals are more inclined to change their habits if they believe that

1. they are appropriately reinforced to perform a behavior,
2. they observe the desired behavior and desired consequences that accompany the behavior,
3. they possess the behavioral capability to perform the desired behavior,
4. and they possess the confidence to successfully perform the desired behaviors (self-efficacy expectations) (Heller et al., 2004).

Social-Cognitive Theory (SCT) is demonstrating the most promise for effectively intervening on the social, environmental, and institutional policy levels (Booth, Owen, Bauman, Clavisi, & Leslie, 2000). SCT rationalizes that social factors, such as peer influences, role modeling of behaviors, and vicarious learning are significant mechanisms involved in physical activity behaviors (Booth et al., 2000).

INCREASING PHYSICAL ACTIVY IN PID THROUGH ADAPTED PHYSICAL EDUCATION

Physical education (PE) classes in the school based setting have been the focus of efforts to increase physical activity levels in youths and adolescents. Over 82% of school districts require schools to mainstream students with disabilities into regular PE classes (Burgeson, Wechsler, Brener, Young, Spain, 2001). However, students with ID often do not participate in health enhancing physical activity behaviors during PE classes due to a number of barriers. These barriers include the students' disability, lack of qualified adapted physical educators, high student-to-teacher ratios which often preclude effective adapted PE efforts, and the lack of resources necessary to engage students with ID in health enhancing physical activity behaviors in the traditional PE setting (Ayvazoglu, Ratliffe, & Kozub, 2004).

This exemplifies the need of adapted PE for PID. Adapted PE is "a diversified, direct instructional program of developmental activities, games, sports, and rhythmical movements suited to the interests, capabilities, and limitations of students with disabilities" (Sherrill, 2004; Silliman-French, Candler, French, & Hamilton, 2007).

The barriers mentioned above undermine the ability of PID to meet the recommended levels of physical activity set by DHHS, as well as the ability to meet national PE standards for all children set by the National Association for Sport and Physical Education (Ayvazoglu et al., 2004). School health officials are calling for urgent action to address the issue of physical inactivity and obesity in PID. For PID, the SCT approach to intervention may result in the reduction of the internal and external barriers to physical activity mentioned earlier. Research is needed to inform the feasibility of developing and implementing innovative interventions to promote health enhancing physical activity, increase CRF, decrease obesity, and to prevent the development of chronic disease in PID.

RESEARCH QUESTION/HYPOTHESIS

It is hypothesized that young adults with an ID who receive an 8-week peer-guided, SCT-based structured physical fitness intervention will significantly increase time spent on health enhancing physical activities, increase cardiorespiratory fitness, increase muscular endurance, and decrease percentage of total body fat when compared to pre-intervention measures. This research aims to gain an understanding of SCT-based physical activity interventions as they pertain to PID to develop and implement effective and efficient programs.

METHODS

Participants. The participants in this study included 13 young adults with either mild or moderate ID (ages 17-22, 38.5% female) from a PE class within the Sidney Lanier Center (SLC) in Florida, which is a self-contained school exclusively for students with mild to profound ID. Participation in the study was based on teacher recommendation, physician approval, parent/guardian consent and the students' own desire to participate. Each student, with his or her parent/guardian, completed a medical release form as well as an informed-consent form/assent script approved by the University of Florida (UF) Institutional Review Board. SLC instructors, UF staff, and UF student volunteers supervise participation in the program.

Intervention. The participants with ID were engaged in a peer-guided 1-hour structured program which included aerobic-based group games and sports activities, muscular endurance exercises, and functional training twice a week for 8 weeks. All physical activities were modified to adapt to the unique capabilities of all participants in order to achieve maximal participation. Each participant had between one to five trainers and volunteers to work with during each session. The trainers served to develop satisfying routines, model the appropriate form and range of motion for each workout, and motivate the participant to achieve better results each time, since motivation and understanding the movement is a major barrier to proper performance.

Data analysis. Pre and post testing on a variety of physical fitness measures were taken immediately prior to and following implementation of the fitness intervention. These included a YMCA cardiorespiratory fitness test, six muscular endurance assessments (using the same weights pre and post), and four body composition measures as well as demographic information. All testing was administered by trained research assistants. Intra-rater reliability testing was conducted to assess the accuracy and consistency of measures taken from each research assistant performing the physical fitness testing. The data was analyzed using a dependent paired samples t-test to determine any differences between pre and post-intervention measures. The traditional level of significance (alpha = 0.05) was used to detect statistical significance.

RESULTS

A paired samples t-test revealed that there were statistically significant differences between pre and post measures in the following results.

• The average heart rate 1-minute after the YMCA 3-minute step test was 24.2% lower after the 8-week training program (M = 113.77 ± 7.87 bpm) compared to before the program (M = 150.15 ± 22.76 bpm), t(12)= 7.300, p <0 .001 with a relatively large effect size (r = 0.90).
• The average leg extension repetitions doubled from M = 11.69 ± 4.17 to M = 22.38 ± 11.39, t(12)= -3.265, p= 0.007.
• Average bench press repetitions significantly increased by 41.7%, from M = 10.69 ± 2.93 to M = 15.15 ± 5.58, with t(12) = -2.761, p = 0.017.
• Average upright seated-row repetitions significantly increased by 81.3% from M = 14.85 ± 4.16 to M = 26.92 ± 14.07, with t(12)= -3.168, p = 0.008.
• The average time that each participant maintained proper form in a static plank significantly increased by 58.4% from M = 43.23 ± 29.29 seconds to M =68.49 ± 45.72 seconds, with t(12)= -2.246, p = 0.044.
• The average number of wall-pushups significantly increased by 61.7% from M = 12.78 ± 2.82 to M = 20.67 ± 9.04, with t(8)= -2.399, p = 0.043.

The remaining results are not statistically significant but they show a change on average between pre and post-intervention measures.

• Average percent body fat decreased from M = 26.67% to M = 26.55%.
• Average muscle mass percent increased from 34.83% to 35.41%.
• The average leg curl repetitions increased from M =14.92 to M =18.46.
• Average weight increased from M = 155.94 lbs to M = 156.55 lbs.
• Average body mass index remained similar between baseline and post measures (from pre M = 26.52 kg/m² to post M = 26.81 kg/m²).
• Waist circumference differed slightly from pre M = 33.19 inches to post M = 34.85 inches.
• After accounting for an outlier, the average maximum time for wall sits increased from M = 39.92 seconds to M = 47.75 seconds.
• The average number of shooting stars (in which the participant squatted and jumped to reach a height as many times as possible in 30 seconds) remained very similar, with pre M = 11.50 and post M = 11.75.
• The average number of mountain climbers (in which participants were in an extended push-up position and alternated flexing their legs to their mid-section and extending back to original position to simulate climbing and working the leg muscles) increased from M = 18.36 to M = 22.36.

DISCUSSION

The results of this study supported the hypothesis that young adults with an ID, who received an 8-week structured physical fitness intervention, would significantly increase time spent on health enhancing physical activities, increase CRF, and increase muscular endurance when compared to pre-intervention measures.

There was a decrease in percentage of total body fat, although it was not statistically significant. The decrease in heart rate 1-minute post-YMCA step test indicates that the participant’s heart is able to recover from the stress (exercise) better compared to pre-intervention measures. This is an indicator of improved cardiorespiratory fitness. The participants of this study were engaged in endurance training through weight machines and functional training exercises, as well as recreational sports which involved continuous participation in activities that increased cardiovascular workout.

The trainers also led the participants through various personalized exercises and activities between pre and post testing according to the participants' preferences. The participants were also markedly more energetic, developed close social relations with their trainers, and interacted with each other better compared to pre-intervention observations. This social interaction seems to have motivated the participants to engage in physical activity, as the participants seemed to be more open to instruction and participation.

All of this together may account for the results obtained. Limitations of this study include the small sample size (N = 13) and there was not a control group, though there was a comparison group of the UF student volunteers, which is analyzed in a separate study.

CONCLUSIONS

The results of this study show strong support for the physical benefits of a health enhancing, peer-guided, SCT-based health intervention program as seen in the significant improvement in fitness measures. This peer-guided approach reduces the barrier of high student-to-teacher ratios, which often preclude effective adapted physical education efforts, as well as the lack of resources necessary to engage students with ID in health enhancing physical activity in a traditional PE setting.

Further research is needed to investigate the psychosocial benefits of this type of program, the benefits of using personalized training programs between pre and post measures, and the efficacy and efficiency of implementing this program structure in diverse institutions and fitness centers as a precursor to future programs of this type to benefit persons with intellectual disabilities on a global scale.

REFERENCES

BIOGRAPHIES

	Krishna Dipnarine is a graduate student at the University of Florida in the Department of Health Education & Behavior, College of Health & Human Performance. He recently completed the Health Science honors program at UF, with a minor in Rehabilitative Services. He has spent the last three years working with students with intellectual disabilities to improve fitness and quality of life. Through the University of Florida's I-cubed Program, he has also worked on investigating methods to improve the participation, support, and integration of students with disabilities in Science, Technology, Engineering and Mathematics (STEM) sciences in postsecondary institutions.
	Tony Delisle, MS (ABD) is a doctoral candidate in Health Education and Behavior, and has over 15 years of professional experience working with children, youth, and young adults with disabilities. His professional experience includes 12 years of special education instruction, over 4 years of counseling wayward youth and adolescents with disability, and 5 years experience as a program manager for an innovative nonprofit agency serving adolescents and young adults with disability. As a doctoral student, Mr. Delisle is the research director for a community academic partnership examining the health effects of outreach programs on young adults with an intellectual disability. Mr. Delisle is an active member of a graduate student advisory council for UF's I-Cubed Program, and provides perspectives from students with a disability in shaping the institutional integration of practices, programs, and policies that promote broadening participation of students in the Science, Technology, Engineering, & Mathematics (STEM) sciences.
	Dr. Christine Stopka is a full professor at the University of Florida where she has been teaching since 1982. There, she established the athletic training undergraduate and graduate specializations, the Student Injury Care Center, and the athletic training community out-reach program serving the north central Florida area high schools. In addition, she established the special physical education & exercise therapy specializations, the Special PE & Exercise Therapy Lab, the UF Adapted Aquatics program serving students with disabilities from Pre-K through adolescents, and the adapted physical activity community out-reach program serving over 50 schools, centers, sites. Interests include inclusive teaching methods for people of all ages with disabilities. She has published over 300 books, articles, abstracts, software and videos, made over 300 presentations, and has received over 80 university, state, national, and international honors for her work in teaching, research, service, leadership, and humanitarianism in the field. She is a certified adapted physical educator (CAPE), a master teacher of adapted aquatics (MTAA), a certified strength and conditioning specialist (CSCS), and a certified and licensed athletic trainer (ATC/LAT).

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