An Innovative Approach to Health Promotion and Wellness for University Students with Intellectual and Physical Disabilities: A Case Series

Abstract

A university setting offers a unique opportunity to address physical activity for individuals with disabilities. The purpose of this case series was to highlight the development of a formal student-assisted exercise program and examine its impact on the perceived quality of life, exercise confidence, and functional mobility of college-aged individuals with intellectual and physical disabilities. Data from twelve participants was analyzed. Seven participants demonstrated an improvement in scores on the Self-Efficacy to Exercise scale and eight improved in functional measures associated with strength. Thus, a collaborative assisted exercise program in a university setting may positively impact health and physical activity, and exercise participation in young adults with physical and/or intellectual disabilities.

“The SAW program model would be feasible to facilitate at other universities in the hopes to increase self-efficacy and overall health and well-being in the young adult population with PD and/or ID.”

Introduction and Background

The numbers of individuals living with developmental disabilities have increased as demonstrated by a reported prevalence of 16.2% to 17.8%. ¹ Advances in healthcare are resulting in increasing life spans for individuals with developmental disabilities that are similar to their neurotypical peers. The aging population will include larger numbers of older adults living with developmental disabilites. ²

The Center for Disease Control reports less than half of individuals with disabilities consistently engage in physical activity. ³ Diminished participation may be in part due to the physical and emotional barriers to exercise, and especially aerobic physical activity adults with disabilities encounter. Adults with disabilities often lack of knowledge of exercise activities, access, and social support systems promoting exercise and wellness which negatively impacts their self-efficacy and engagement in physical activity. When examining existing social supports and programing for health promotion and physical activity adults with disabilities often are uncertain who is best suited to provide physical activity options that match their specific abilities. ³ These barriers to health promotion and wellness is concerning as it results in diminished participation in exercise and physical activity which has been shown to positively impact the health and well-being in those individuals who meet the exercise recommendations of the American College of Sports Medicine.

Individuals with developmental disabilities are at increased risk for additional comorbidities as they age making exercise even more important. Consistent exercise can aide in the prevention of diseases such as coronary artery disease, obesity, and type II diabetes. ⁴ Individuals with intellectual and physical disabilities are more likely to lead sedentary lifestyles when compared to aged-match neurotypical individuals. ⁴ Among those who have intellectual disabilities (IDs), most do not meet exercise requirements. ⁵ This lack of physical activity may contribute to the increased likelihood of obesity in individuals with intellectual disabilities. ⁶ Many individuals with intellectual disabilities experience barriers to exercise and physical activity experience barriers to physical activity as exercise as described above. ⁴ The result of these barriers include decreased social support, limited options for transportation, fewer opportunities, and financial burdens which may prevent individuals with intellectual disabilities from meeting the minimum daily recommendation of exercise and/or physical activity. ⁴

Insights from research reveal that similar trends of diminished participation in exercise and physical activity exist in individuals with physical disabilities (PDs). For example, individuals with cerebral palsy who use an assistive device, such as a wheelchair, perform less physical activity than their non-wheelchair user counterparts. ⁷ These decreased levels of physical activity remain despite evidence demonstrating that exercise participation in children with cerebral palsy who use wheelchairs is safe and leads to improvements in physical fitness. ⁷

Current literature suggests that individuals with ID and PD need programs that identify barriers and facilitators to promote exercise and physical activity. ⁸ Furthermore, health promotion and development of healthy behaviors is an adaptive process in which an individual with a disability needs an appropriate environment that decreases barriers and allows for successful exercise participation. ⁹

A university that possesses resources and personnel trained in exercise physiology principles and prescription with appropriate contextual understanding of intellectual and physical disabilities is uniquely positioned to make a positive impact on individuals with intellectual and physical disabilities. Therefore, the purpose of this case series is to describe a university-embedded exercise and wellness program and its impact on participants with intellectual and physical disabilities.

Program Design and Development

To facilitate the health and well-being of the student population with disabilities, a large public university in the southeastern United States developed an inclusive fitness program. This program entitled “Student Assisted Workout” program (SAW) is offered through the university Recreation and Wellness Center and affords exercise instruction and planning to individuals with ID and PD. The program was originally founded in 2008 for students with physical disabilities. In 2015, the university established Inclusive Education Services (IES) to offer an inclusive college experience for individuals who have intellectual disabilities. IES students live on campus in a dorm and receive SAW services at no cost as part of this a comprehensive program. In response to the development of the IES program, Recreation and Wellness expanded SAW services to include students with ID or PD. Individuals with intellectual disabilities who participated in the study will be referred to “IES-students” from this point forward to designate their involvement with the IES program.

The SAW program assists participants in the development and participation in an active exercise program. Participant self-efficacy is promoted through the teaching of proper exercise techniques and strategies for accessing this environment. Participants are taught health promotion strategies and are encouraged to exercise independently after graduation from the IES program.

SAW trainers are students in a Doctor of Physical Therapy Program (DPT), who work in consultation with two DPT faculty members. One possesses neurologic and exceptional education expertise, while the other possesses orthopedic and exercise science expertise. The faculty and students collaborate with the university’s Recreation and Wellness Center personnel within their adaptive sports and recreation division to meet the individual needs of students with disabilities. This division is equipped with adaptive exercise equipment that is accessible to students with physical limitations, such as wheelchairs or other ambulatory devices. Thus, both the facility and the personnel are well-equipped to manage the inherent conditions of the participants who possess physical and/or intellectual disabilities to develop the most effective and individualized strategies to enhance participation and independence in exercise and health lifestyles.

In consultation with the faculty, trainers create and carry out an exercise program to meet their client’s individual goals. This may include adapting exercises to allow for successful client participation. Furthermore, these individuals participate in exercise within the recreation and wellness center among peers who do not have intellectual or physical disabilities.

Case Series Description and Methods

Data was collected from the university Recreation and Wellness Center utilizing the SAW program assessments and outcome measures. This study was approved by the University of Central Florida Institutional Review Board prior to the retrospective analysis.

Prior to the beginning of each semester, SAW trainers received training on assessments, outcome measures, and protocols for safe exercise prescription and supervision prior to the start of each semester. When completing self-report outcome measures, participants with disabilities had access to a SAW trainer to assist with understanding and completing the measures to ensure validity of data. Data was extracted from each participant’s intake forms, session logs, and outcome measure forms. Data analysis was completed for all descriptive statistics. Outcome Measures:

Self-Efficacy to Exercise (SEE): The Self-Efficacy for Exercise (SEE) scale is a revision of McAuley’s 1990 self-efficacy barriers to exercise measure, a 13-item instrument that focuses on self-efficacy expectations related to the ability to continue exercising in the face of barriers to exercise. ¹⁰ This measure was developed initially for sedentary adults in the community who participated in an outpatient exercise program including biking, rowing, and walking. Prior research demonstrated sufficient evidence for internal reliability α= .93) and validity, with efficacy expectations significantly associated with actual participation in an exercise program. ¹¹

Center for Epidemiologic Studies Depression Scale (CES-D): The CES-D index is a highly reliable and widely used scale. ¹² The scale is comprised of 20 items with the higher scores indicating higher levels of depressive symptoms and was summed for analysis. ¹³ Among current research regarding this scale, the standard cut-off score suggesting depression >16 points (sensitivity = .95; specificity = .29). ¹² The cut-off suggested for CES-D used in the workplace for the general population was >19 points (sensitivity = 92.7%; specificity = 91.8%). ¹⁴

Short Form 12 Health Survey (SF-12 v1): The Short Form-12 survey (SF-12), a shortened version of the SF-36 survey, is one of the most widely used instruments for the purpose of measuring health-related quality of life.^15,16 SF-12 contains 12 questions that can be answered in less than 2 minutes. It reflects the general health status and leads to 2 separate scores; a ‘‘physical component summary’’ and a ‘‘mental component summary.’’ ¹⁷

Other fitness outcome measures included: vitals [heart rate (HR) and blood pressure (BP)], 6 Minute Walk Test (6MWT), 3-RM chest press, 3-RM leg press, Modified Functional Reach Test/Functional Reach Test, and body weight in pounds.

Inclusion/Exclusion Criteria

Inclusion criteria for this study required that all participants were university students enrolled in the SAW program. All students served by the SAW program have either a physical or intellectual disability. In addition, a minimum of 2 sets of outcome measures, 6–8 weeks apart, must have been collected from the participant to be included in this retrospective analysis. Participants must have consistently attended SAW workouts; however, due to the nature of personal and educational obligations in the college-aged individual, it is possible some students missed workouts with their trainers throughout the semester. Data was collected at the start and end of the 12-week summer semester. During the 16-week fall semester, data was collected at the beginning, mid-semester, and end of term.

Results

Subjects

A total of 15 students participated in the SAW program over the course of the analysis. Three participants were excluded due to insufficient data points. Data was analyzed for the remaining 12 participants who met inclusion criteria. Six of the participants were IES students with an ID, while six were SAW participants with a PD. Six participants identified as male with six identified as female.

Self-Report Outcome Measures

Seven out of twelve participants (58.3%) improved on the SEE, two participants demonstrated no change, and three participant’s scores decreased (Figure 1). Of the seven who improved: three improved 1–10 points, two improved 11–20 points, one improved 21–30 points, and one improved greater than 30 points (Figure 2). Of the IES participants, five out of six improved on the SEE, one decreased. Out of the non-IES participants, two improved, two stayed the same, and two decreased.

Figure 1.

Change in Self-Efficacy for Exercise scale for IES and IES students.

Figure 2.

Distribution of improvement on Self-Efficacy for Exercise scale (SEE) for all participants.

The CES-D scale demonstrated no trend in the amount of exercise participation with the SAW program on depression. Of the SF-12 v1 scores, four participants (33%) reported improvements in their self-perceived general overall health, five reported no change in their health status, and three reported decreases. Of the five who reported no change, two subjects reported their health was excellent at every point of the data collection which demonstrates a possible ceiling effect to this outcome measure with this population.

Strength Outcome Measures

Seven out of twelve participants experienced an increase in their 3-RM chest press scores, four non-IES and three IES participants, three decreased including one non-IES and two IES participants, and one IES and one non-IES student did not change (Table 1; Figure 3). Five IES participants and three non-IES participants improved on the 3-RM leg press, two non-IES participants experienced a decrease in scores, and one IES student experienced no change (Figure 4). One participant in the 3-RM leg press was excluded due to his status as wheelchair bound and was unable to perform a lower extremity functional strength assessment (Table 2).

Table 1.

Change in 3 Repetition Max Chest Press.

CP Weight Increase	# Of Participants
1-10 lbs	2
11-20 lbs	4
>20 lbs	1

Figure 3.

Change in 3 repetition max (RM) chest press for IES and IES students.

Figure 4.

Change in 3 repetition max (RM) leg press for IES and IES students.

Table 2.

Change in 3 Repetition Max Leg Press.

LP Weight Increase	# Of Participants
1–20 lbs	4
21–40 lbs	2
>40 lbs	2

Aerobic Capacity and Functional Reach Outcome Measures

Four IES participants (33%) and three non-IES participants (25%) experienced increases in their 6MWT scores, three non-IES participants experienced decreases, and one IES student experienced no change. Five IES and two non-IES participants experienced increases in their functional reach scores. Two non-IES participants experienced decreases in their functional reach scores and one IES and one non-IES student experienced no change in their scores.

Anthropometric Measures

Body mass index remained stable throughout the course of the analysis (Table 3; Figure 5). Blood pressure/heart rate showed variation throughout the initial and final periods among all the participants (Table 4). The non-ambulatory participant’s BMI was not calculated due to limitations in obtaining a wheelchair-accessible scale.

Table 3.

Body Mass Index (BMI) of Participants.

BMI Range	Label	# Of Students
Below 18.5	Underweight	0
18.5–24.9	Normal	3
25–29.9	Overweight	6
30 and above	Obese	2

Figure 5.

Body mass index of participants.

Table 4.

Resting Heart Rate and Blood Pressure Demographics of Participants.

Participant	Resting HR (Initial)	Resting HR (Final)	Resting BP (Initial)	Resting BP (Final)
1	73	92	122/81	136/76
2	92	74	101/76	136/64
3	73	69	124/78	112/75
4	66	78	100/69	95/63
5	81	93	90/63	129/93
6	87	96	110/82	115/83
8	83	78	119/79	107/63
9	79	68	127/92	135/92
10	73	90	117/69	117/70
11	70	67	108/72	96/69
12	70	70	119/66	132/67

Discussion

Individuals with intellectual disabilities experience health disparities when compared to their peers.^18,19 Previous research demonstrates children with intellectual disabilities, ages 5–18 are less physically active when compared to other children without intellectual disabilities. ²⁰ Furthermore, sport and exercise participation are significantly lower in adolescents who have mild to moderate intellectual disability. ²¹ These individuals will eventually become adults and may continue to live sedentary lifestyles. It is well known increasing muscle mass early in life and promoting physical activity may lead to greater independence later in life for every person who participates by creating a greater reserve.

Fundamental components of health promotion and wellness such as limited access to care, decreased healthcare literacy, and lack of supportive networks present significant challenges to the health and well-being of adults with intellectual disabilities. ¹⁹ Barriers exist beyond access to the overall healthcare environment with challenges such as financial burdens, physical environments that are not conducive for all individuals, and perhaps one of the most challenging is the healthcare transition that occurs between pediatric services to adult care health services. ¹⁹

Universities with professional health profession programs are in a unique position to fill this gap for individuals with disabilities while also educating future healthcare providers on the care of individuals with disabilities. Doherty et al. (2020) conducted an integrative review of the literature and identified 6 common themes among barriers to healthcare experienced by individuals with intellectual disabilities including: 1) training of healthcare providers in the unique needs of this population, 2) knowledge to make reasonable adjustments as needed to support individuals with intellectual disabilities, 3) communication between the individual and healthcare providers, 4) fear and embarrassment present a barrier as these emotions may result in an individual being less likely to seek care, 5) lack of involvement in healthcare decision making, and 6) time constraints. ¹⁸ The documented barriers to healthcare for individuals with intellectual disabilities result in health disparities and ultimately an increased prevalence in long-term morbidities and a reduced life span.^18,19 As the numbers of individuals with developmental disabilities increased, it is critical to have healthcare work force equipped to meet their unique needs. Therefore, it is critical to examine health promotion and wellness initiatives, such as the one described within this case series that reduces the barriers for individuals with intellectual disabilities.

The results of this study suggest significant health benefits for individuals with disabilities who participated in the SAW program. This would suggest this program addresses many of the barrier’s experiences by individuals with intellectual disabilities. Several environmental barriers are addressed by the SAW program. First, a workforce of DPT faculty and students who are knowledgeable about the unique needs of this population is critical to its success. Second, the Recreation and Wellness Center has invested in adaptive fitness equipment improving access for individuals of all abilities. Third, ongoing reassessment and communication is built in between all stakeholders to ensure needs are being met. In addition, individual or personal barriers are addressed by the program as participants are challenged to establish their own fitness goals and education on strategies to achieve them which improves their overall health literacy. Students are provided access to the SAW program as a part of their student feed which results in reducing any financial burden associated with an external gym membership or personal trainer. Currently, there are 245 physical therapy programs in the United States (CAPTE). This program may offer a model for promoting health and well-being in young adults with disabilities that could be replicated at universities.

Limitations: This study includes a small sample size at a single university, in one geographical location. There was no way for researchers to standardize exercises and/or exercise programs due to the variations in baseline functional and intellectual status of the participants, and inability to control for extraneous lifestyle factors, as well as academic-related stressors. These factors also influenced participant attendance during the academic semesters, which also likely contribute to some of the variability in study results.

Conclusion

The participants in the SAWP demonstrated gains in strength, aerobic endurance, and exercise self-efficacy. Exercise benefits have been shown in both IES and non-IES participants. This study demonstrates the positive effects of designing a wellness program such as the SAW program, especially given the accessibility of equipment and expertise that a university may provide. The SAW program model would be feasible to facilitate at other universities in the hopes to increase self-efficacy and overall health and well-being in the young adult population with PD and/or ID.

ORCID iD

Patrick Pabian https://orcid.org/0000-0001-7653-5544