After constructing the initial hierarchy, a second literature review was conducted to determine the dimensions that were most likely to have a specific, significant impact on individual participation in recreation and leisure. It is important to note that although the hierarchy is depicted level by level and bottom to top, it is a dynamic, fluid model. Several dimensions may just as easily assume a more inferior or superior position. For instance, one could argue that preemptory attitudes, values, and beliefs must be in place for adequate resources to be pursued rather than the reverse. The base level, body functions and structures, was purposely excluded because it was our assumption that all practicing PTs and OTs have basic knowledge in these areas as a result of their formal training and practical experience.
Once the hierarchy was developed, a set of dimensions was used to construct a battery of pilot survey questions. Dillman’s 37 methods were relied on for survey design. The dimensions included were judged by the researchers to be crucial to the promotion of community recreation and leisure as gathered from literature reviews. Three PTs, one OT, and one medical doctor reviewed the pilot survey. Their draft comments were reviewed, and the survey was revised. Data gathered from the therapists completing the pilot survey were not included in final survey results. Additional assistance with survey content and design was provided by statisticians. Final survey questions focused on the hierarchical dimensions depicted in Figure 2.
Names and addresses of pediatric PTs and OTs in five local counties were obtained through the American Physical Therapy Association (APTA) and the American Occupational Therapy Association (AOTA). The counties were chosen because of their adequate numbers of PTs and OTs meeting research criteria and for their contrasting rural and urban localities. Search criteria yielded names and mailing addresses for 50 PTs and 102 OTs. Two mailings, three weeks apart, resulted in a total of 82 returned surveys. The response rate for PTs was 60% and 51% for OTs. The average number of years of pediatric experience was 13.7 for PTs (range = 0–37.5 years) and 6.6 for OTs (range = 0–25 years). Other characteristics and demographics of respondents are listed in Table 1. Various local organizations contributed funds to a nonprofit therapeutic horseback riding facility based on the number of surveys returned, thus providing an incentive for survey completion.
Using information provided on returned surveys, data sets were created and analyzed with the Statistical Package for the Social Sciences (SPSS) version 6.0. The extent to which both therapist groups indicated that they were able to identify and assist in minimizing the impact of potential barriers to community participation was measured by analyzing the response frequencies presented in tabular form in this paper.
Survey items addressing physical barriers yielded information about facility accessibility, transportation, and adapted equipment. Questions pertaining to social barriers focused primarily on professional and community member attitudes surrounding disability and inclusive recreation. Awareness of community program costs and other issues related to funding were examined in survey items concerning resource barriers.
To quantify subjective data, two scales were developed (α level = 0.83) to determine at what level therapists were currently functioning in the hierarchy as a whole. These scales allowed us to apply numerical values to groups of subjective responses and associate a hierarchical level with each of them. For both scales, a value was assigned to each possible response to survey questions and an overall range of scores was obtained. Values ranged from 6 to 14 for one scale and from 0 to 8 for the other. The frequencies of scores falling into each of three hierarchical categories (intermediate level I, intermediate level II, and optimal) were tabulated for each scale (Table 2).
The first scale measured therapists’ perceptions of their alignment of client interest in community participation with their promotion of participation. The survey questions used to develop this scale were as follows: (1) Generally, how would you rate satisfaction with your facilitation of participation in community recreation or leisure activities by your clients with disabilities? (2) How would you rate your own satisfaction with your facilitation of participation in community recreation or leisure activities for your clients with disabilities? (3) Overall, how often do you feel you are able to link the skill requirements of community recreation/leisure activities with your clients’ abilities? (4) Overall, how often do you feel you are able to link the skill requirements of community recreation/leisure activities with your clients’ interests? For the first scale, the hierarchical level intermediate level I was set equal to the reported responses of “dissatisfied” or “rarely,” intermediate level II was set equal to “somewhat” or “sometimes,” and optimal level was set equal to “satisfied” or “often.”
For the second scale, an effort was made to gauge therapists’ interest in pursuing education related to promoting community activities among their pediatric clients. Frequency of item selection was used to create scale values in response to the question “Would you be interested in a continuing education series that provided information about any of the following in relation to community recreation and leisure participation for all children regardless of ability?” Options listed were funding, community training, accessing resources, modifying activities, using adaptive equipment, creating accessible facilities, self-assessment, and other (Appendix 2). Score ranges were based on the number of positive responses and were assigned to one of the three categories of intermediate level I, intermediate level II, and optimal level. Distributions of responses falling into discrete categories were analyzed to determine whether a particular group or pair of groups of the three types of potential barriers (physical, social, and resource) appeared to account for the greatest perceived limitation(s) to community recreation and leisure participation.
Using the definitions and concepts suggested by the WHO, a literature review, experts in the pediatric field, and our hierarchical framework, content validity was established for the measurements used to test each research goal.
Response frequencies to survey questions representing the degree to which therapists were aware of and identified the influence of potential physical, social, and resource barriers to their clients’ community participation are listed in Tables 3, 4, and 5. Questions relating to therapists’ perceptions of the influence of physical barriers were designed to sample the primary hierarchical dimensions of access/environmental factors, transportation, and community (Appendix 2, questions 23, and 25). Therapists most often answered “never” or “no” (52.1%–87.9%) when asked if they were aware of or identified facility accessibility, activity modification, adaptive equipment provisions, or facility location as criteria for assessing community programs (Appendix 2, question 23). Similarly, therapists most frequently indicated that these potential barriers were not considerations when either suggesting or not suggesting community activities to their clients with disabilities (Appendix 2, question 25). The majority (90.1%) of all therapists responding to questions pertaining to transportation indicated that they identified transportation used by their clients for less than 25% of their clients (Table 3).
Questions relating to therapists’ perceptions of the influence of potential social barriers to their clients’ recreation and leisure participation were based on the hierarchical dimensions of independence, motivation, and choice and attitudes, values, and beliefs. The most frequent responses were “sometimes” (34.8%–43.5%) and “never” (17.4%–24.6%) when therapists were asked whether social information was requested during evaluations. However, “supportive” was checked most often as being descriptive of attitudes surrounding disability held by healthcare professionals and the therapists themselves (68.1% and 94.6%, respectively) compared with “tolerant” regarding community member attitudes (38%). Survey questions (Appendix 2, questions 16, 16a, 16b, 17) and corresponding responses are listed in Table 4.
Questions pertaining to therapists’ perception of potential resource barriers prohibiting their clients’ participation in community recreation and leisure focused on the hierarchical dimensions of funding and resource channels. Of therapists who completed these questions, approximately half (45.5%) cited cost as a reason for either suggesting or not suggesting particular community activities. In addition, therapists indicated that they asked colleagues or looked up information pertaining to community recreation and leisure programs rather than maintaining a personal list. Response results related to resource barriers (Appendix 2, questions 23, 25) are listed in Table 5.
The preponderance of therapist responses distributed in the middle (eg, 50% or “sometimes”) to low-end (eg, 0–25% or “never”) ranges were consistent with respect to each potential barrier group (physical, social, and resource). These results indicated that no single group or pair of groups was outstanding as a perceived primary impediment to community participation by therapists surveyed.
Differences Between Therapist Groups
A t test revealed that PTs were more likely than occupational therapists to consider cost as a potential barrier to client participation in recreation and leisure pursuits by individuals with disabilities (Table 6). For all other survey questions, no significant difference existed between the two therapist groups.
Responses related to the two hierarchical dimensions of promotion of disability awareness and continued education are illustrated by the frequency data for the two scales created in Table 2. On one scale, therapists identified themselves as practicing in the intermediate level I in terms of their overall abilities and satisfaction in promoting community participation on behalf of their clients with disabilities. On the scale that gauged therapists’ interest in pursuing continuing education programs related to community recreation and leisure participation, responses clustered in the intermediate level II category. However, fully 54.3% of respondents had not attended any relevant seminars within the past three years (Table 1).
The process of creating and promoting inclusive community environments in which all individuals have access to recreation and leisure programs regardless of ability is ongoing and complex. To realize the vision of equal opportunity for all individuals regardless of ability in the arena of community recreation and leisure participation, it is crucial to identify the potential barriers to participation and apply strategies to minimize their impact. Both subjective and objective results from this limited survey indicate that pediatric PTs and OTs may not be practicing at an optimal level in relation to their degree of awareness and consideration of the potential physical, social, and resource barriers that can hinder their pediatric clients’ participation in community recreation and leisure pursuits. Consequently, application of therapists’ knowledge and their promotion of community involvement are seemingly deficient. A greater sampling of pediatric therapists is needed to determine whether they are, as a population, actively promoting community participation. In addition, a refined survey should provide client data related to therapists’ knowledge and chosen interventions as well as information about their specific health conditions and socioeconomic status.
If future focused studies substantiate deficits in therapy practice as they relate to community recreation and leisure, then close attention should be paid to the reasons behind them. Perhaps entry-level academic curricula lack sufficient content in the focus areas of disability prevention and health promotion through community partnerships, client involvement in community recreation and leisure, and applications of local and national legislation. Perhaps employers and third-party payers are reluctant to reimburse the efforts of therapists who wish to avail themselves of current information and strategies regarding community participation promotion. Perhaps therapists view themselves as too busy to obtain information related specifically to community recreation and leisure. These possibilities, among others, should be considered and explored in depth to gain insight into therapists’ performance with respect to promoting community recreation and leisure for their clients with disabilities.
To ensure promotion of lifelong community activities, the development of model continuing education training programs for pediatric PTs and OTs, as well as efforts to enhance current preservice educational programs, is indicated. Training programs can assist therapists to optimally evaluate their clients with disabilities with respect to recreation and leisure habits and use intervention techniques to promote community participation. Ultimately, training can lead to longer, healthier, more productive and satisfying lives for their clients with disabilities. These outcomes are not only desirable but are consistent with national legislation and state health objectives.
In terms of program design, a historical background regarding the gradual recognition of the importance of recreation and leisure in prolonging healthy lifestyles provides a starting point. Specifically identification of (1) potential barriers to participation, (2) the impact of barriers on the type and level of participation an individual experiences, and (3) successful techniques for promoting community participation might be incorporated into a series of targeted training segments. The model of functioning and disability provided by the WHO in the most current ICIDH-2 provides an excellent foundation upon which to construct program content.
Given that the majority of therapists surveyed did not indicate a specific interest in any of the proposed options for continuing education topics, a focused follow-up survey would be useful in determining whether this is due to a lack of interest or alternative reasons beyond the scope of this study. Results illustrated a conflict between interest in and pursuit of continuing education. Although therapists categorized themselves in intermediate level II with respect to interest in continuing education, more than half had not attended any related courses or seminars in the past three years. Whether this was due to reasons suggested earlier (eg, gap in academic training, lack of organizational support and sponsorship, lack of time) was unclear. However, the topic of “resources” was the most frequently selected continuing education topic, despite the fact that it did not emerge as a primary barrier to participation in this study.
Because frequently cited barriers to community participation in the literature include knowledge of resources and transportation, future studies should explore the relationship of these barriers to specific activity selection and whether therapists’ and/or clients’ assumptions about barriers or significant, “real” barriers are most influencing participation choices.
It is notable that we found no significant differences between therapist groups with respect to the promotion of community participation for their pediatric clients in the area of recreation and leisure. Although, overall, professional goals and academic programs continue to be distinct for PTs and OTs, there may be more apparent overlap in actual practice. Recreation and leisure promotion may serve as a useful venue to remind PTs and OTs of their roles as health professionals, working toward a common goal of facilitating practical, holistic services and opportunities for their clients with disabilities and their families. To promote community awareness and participation, we must first be a community unto ourselves.
Heightened efforts to encourage participation in and promotion of recreation and leisure pursuits are important to begin to address the chronic health issues that continue to confront many young Americans. Community-based pediatric PTs and OTs, in particular, are in an ideal position to promote healthy community attitudes and behaviors regarding inclusive recreation and leisure. Healthy People 2010 suggests many ways in which health professionals might play a role in improving the nation’s health including establishing community partnerships, sponsoring health fairs, and assessing school health education curricula. There are many additional ways in which therapists can expand on traditional training within a medical model and move toward a health-promoting, disability-preventing model. All therapists must recognize the influences that extrinsic factors, such as physical and social environments, can have on an individual’s physical and mental health status. In relation to this, PTs and OTs must consider the potential physical, social, and resource barriers and facilitators that ultimately determine their clients’ participation in recreation and leisure pursuits. Practitioners must recognize that physical impairment is just one of the myriad of factors that influence the development of healthcare goals. Finally, therapists must be aware of the evolving nature of disability and correspondingly alter their goals and interventions as their clients age.
We thank the Clinical Center for the Study of Development and Learning in Chapel Hill, NC, for its support of this body of work and sponsorship in its initial phase. We also thank Kathleen Hunter for her assistance in procuring community support in the form of incentives for survey completion. We are very grateful for the financial support from numerous local organizations that not only provided the incentive for therapists to return surveys but also allowed for the provision of hippotherapy services to families in need of financial assistance. We also extend our thanks to Darlene Sekerak from the Division of Physical Therapy at the University of North Carolina at Chapel Hill who recognized the importance of this work and provided additional financial resources for statistical support. Finally, we thank the PTs and OTs who found the time to respond to our survey.
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Keywords:© 2003 Lippincott Williams & Wilkins, Inc.
leisure activities; recreation; physical therapy; occupational therapy; primary prevention