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Review
Barriers to and facilitators of sports participation for people with
physical disabilities: A systematic review
E. A. Jaarsma1, P. U. Dijkstra1,2, J. H. B. Geertzen1, R. Dekker1,3
1Department of Rehabilitation Medicine, Center for Rehabilitation, University of Groningen, University Medical Center Groningen,
Groningen, The Netherlands, 2Department of Oral and Maxillofacial Surgery, University of Groningen, University Medical Center
Groningen, Groningen, The Netherlands, 3Center of Sports Medicine, University of Groningen, University Medical Center Groningen,
Groningen, The Netherlands
Corresponding author: Eva A. Jaarsma, MSc, Department of Rehabilitation Medicine, Center for Rehabilitation, University of
Groningen, University Medical Center Groningen, Hanzeplein 1, CB41, P.O. Box 30 001, 9700 RB, Groningen, The Netherlands. Tel:
+31 50361 4393, Fax: +31 50361 1708, E-mail: e.a.jaarsma@umcg.nl
Accepted for publication 19 February 2014
Most people with physical disabilities do not participate
in sports regularly, which could increase the chances of
developing secondary health conditions. Therefore,
knowledge about barriers to and facilitators of sports
participation is needed. Barriers and facilitators for
people with physical disabilities other than amputation or
spinal cord injuries (SCI) are unknown. The aim of this
study was to provide an overview of the literature focus-
ing on barriers to and facilitators of sports participation
for all people with various physical disabilities. Four
databases were searched using MeSH terms and free texts
up to April 2012. The inclusion criteria were articles
focusing on people with physical disabilities, sports and
barriers and/or facilitators. The exclusion criteria were
articles solely focusing on people with cognitive disabili-
ties, sensory impairments or disabilities related to a
recent organ transplant or similar condition. Fifty-two
articles were included in this review, with 27 focusing on
people with SCI. Personal barriers were disability and
health; environmental barriers were lack of facilities,
transport and difficulties with accessibility. Personal
facilitators were fun and health, and the environmental
facilitator was social contacts. Experiencing barriers to
and facilitators of sports participation depends on age
and type of disability and should be considered when
advising people about sports. The extent of sports partici-
pation for people with physical disabilities also increases
with the selection of the most appropriate sport.
People with physical disabilities do not participate in
sports as regularly as those without disabilities. For
example, in the United States, nearly two-thirds of
people with physical disabilities do not participate in
sports, whereas just over one-third of people without
disabilities do not participate in sports (US Department
of Health and Human Services, 2010). Sports can be
defined as “an activity involving physical exertion with
or without a game or competition elements, with a
minimal duration of 30 min for at least two times a week,
and where skills and physical endurance are either
required or to be improved” (Kemper et al., 2000).
During rehabilitation, sports are often made part of the
treatment to familiarize people with physical disabilities
with sports (Van der Ploeg et al., 2007). However, only
few people with disabilities decide to stay physically
active after they have completed their rehabilitation (Van
der Ploeg et al., 2007).
The physical benefits of sports have been frequently
documented. Several studies noted the potential for
sports to decrease the risk of secondary health condi-
tions, such as heart disease, diabetes type II, and obesity,
especially for individual program participants (Heath &
Fentem, 1997; US Department of Health and Human
Services, 2010). It is therefore important to understand
what prevents or stimulates people with physical dis-
abilities to participate in sports. Insight into the barriers
and facilitators in this respect can also help in providing
opportunities to increase sports participation among
people with physical disabilities.
Previous studies focusing on barriers to and facilita-
tors of sports participation for people with physical dis-
abilities have been very diverse in terms of study
outcomes, data reporting (only barriers, only facilitators
or both), and assessment methods (Kegel et al., 1980;
Wu & Williams, 2001; Rimmer et al., 2004; Shihui et al.,
2007; O’Donovan et al., 2009). Most studies have also
focused solely on people with amputation or spinal cord
injuries (SCI) (Wu & Williams, 2001; Kars et al., 2009;
Kehn & Kroll, 2009; Pepper & Willick, 2009) and do not
provide information about barriers to and facilitators of
sports participation for people with other disabilities. To
structure the results of such studies, barriers and facili-
tators could be divided into personal and environmental
Scand J Med Sci Sports 2014: ••: ••–••
doi: 10.1111/sms.12218
© 2014 John Wiley & Sons A/S.
Published by John Wiley & Sons Ltd
1
factors in accordance with the International Classifica-
tion of Function, Disability and Health (ICF) (World
Health Organization, 2001). Lack of motivation, lack of
energy, and sports history have been reported as personal
barriers to sports participation. Environmental barriers
that have been reported were transportation, accessibility
to sports facilities, and costs (Tasiemski et al., 2004;
Scelza et al., 2005; Van der Ploeg et al., 2008; Kars
et al., 2009). Fun and health have been considered to be
important personal facilitators (Kosel, 1993; Wu &
Williams, 2001; Tasiemski et al., 2004; Van der Ploeg
et al., 2008). Because these studies have primarily
focused on amputation or SCI, it is unknown whether
these barriers and facilitators are also experienced in
other disability groups.
To date, no overview of studies focusing on barriers to
and facilitators of sports participation for all people with
various physical disabilities has been provided (Rimmer
et al., 2004).
The aim of this systematic review was therefore to
provide an overview of such studies.
Methods
Search strategy
A search was performed in Medline, Embase, Cinahl, and
SPORTDiscus using a combination of MeSH terms and free text
words (see Appendix S1 for the complete database search strat-
egy). The main keywords for the search included “people with
disabilities,” “athletes,” “exercise,” “sports,” “physical activity,”
“motivation” and “attitude” in combination with “barrier,”
“obstacle,” “hurdle,” “constraint” and “facilitator,” “motivate,”
“encourage,” “benefit,” “advantage,” and “stimulate.” The search
was performed up to April 2012.
Procedure
The inclusion and exclusion criteria used to screen the articles
were similar for the titles, abstracts, and full texts. First inclusion
criterion was that the studies focused on people with physical
disabilities or a certain type of physical disability. Second criterion
was that studies focused on a sport(s), athlete(s), exercise, physical
activity, motor activity, sports participation, or other general or
specific sporting/exercising activities. Last criterion was that
studies contained words, such as stimulation, barriers, facilitators,
promotion, or synonyms of these words. Studies written in
English, Dutch, or German were included.
Exclusion criteria were studies focusing solely on people with
cognitive impairments without a concomitant physical disability,
on people with hearing or visual impairments or on people with
disabilities related to a recent organ transplant or similar condition,
as this systematic review only focused on diagnoses frequently
observed in rehabilitation medicine. Studies were also excluded if
they focused on the biomechanical (kinetics, kinematics, dynam-
ics, wheelchair propulsion) or physiological (energy expenditure,
muscle strength, metabolism) aspects of physical disability, on
surgical procedures, treatment modalities, orthopedic examina-
tion, diagnostic methods, or training programs. Reviews, com-
ments, interviews, letters, posters, book chapters, and books were
also excluded.
For the full text stage, qualitative studies were excluded, as the
focus of our systematic review was on studies with quantitative
results.
Two reviewers (EAJ, RD) independently assessed titles,
abstracts, and full texts, after which Cohen’s kappa and absolute
agreement for different stages were calculated. A pilot study was
performed before every stage to determine whether the inclusion
and exclusion criteria and instructions were clear for both review-
ers. After every stage, a consensus meeting was held to agree on
differences in assessment between the two reviewers. In cases in
which consensus was not met in any of the stages, a third reviewer
(PUD) made the final decision.
After the full text assessment, both reviewers used a checklist to
identify relevant information to our research question from the
included studies (see Appendix S2).
Data extraction
Data extracted from the included studies were number of partici-
pants, study design, assessment method, population characteris-
tics, response rate, clinometric characteristics, theoretical
framework and barriers, and facilitators. Barriers to and facilitators
of sports participation reported in the included studies were struc-
tured into personal and environmental factors according to the ICF
model (World Health Organization, 2001). Barriers and facilitators
were also divided into two age groups, namely children and ado-
lescents (mean age 0–20 years) and adults (mean age >20 years),
as children and adolescents may experience different barriers and
facilitators than adults.
The mean age of the research population within a study was
pooled if possible and necessary. The weighted mean age of all
included studies was calculated by first multiplying the mean age
by the number of participants for each study. Then, these values
were added and divided by the total number of participants of all
included studies.
Results
Study characteristics
Study selection
A total of 4979 articles were identified in the search, with
716 duplicates. After the evaluation of titles (kappa:
0.64; absolute agreement: 82%) and abstracts (kappa:
0.48; absolute agreement: 81%), 176 articles were
included in the full text phase. After excluding qualita-
tive studies, 82 quantitative studies were included for the
full text phase. Thirteen articles were excluded because
the full texts of the articles were unavailable, despite
attempts to retrieve the studies from other libraries or by
contacting the authors. An additional 23 articles were
excluded because they did not meet our definition of
sports (Kemper et al., 2000; Bragaru et al., 2011). After
assessing the full texts and checking the references of the
included articles (kappa: 0.78; absolute agreement:
89%), 52 articles published between 1988 and 2011 were
included in this study (Fig. 1).
Characteristics of the study population
The weighted mean age of the studied population was
36.1, with ages ranging from 9 to 80 years. The
minimum and maximum sample sizes were 8 and 709
participants, respectively. The response rate was reported
in 30 studies (58%), with a minimum of 10% and a
Jaarsma et al.
2
maximum of 88%. Thirty-eight studies (73%) reported
the disability researched. Twenty-seven studies (52%)
included people with SCI in their study population, but
the majority of these studies included more than one
disability group. Twenty-two studies (42%) reported the
sport in which the research population participated. The
most frequently researched sports were wheelchair bas-
ketball and swimming (both n=7). Thirty-five studies
(67%) included either amateur-level or non-active par-
ticipants in their study population. Nine studies (17%)
reported age (SD), gender, types of disabilities, and
types of sports for their study population (Martin &
Adams-Mushett, 1995; Yarwasky & Furst, 1996;
Pensgaard et al., 1999; Santiago & Coyle, 2004; Martin,
2006, 2008; Beckerman et al., 2010; Shapiro & Martin,
2010; Saebu & Sorensen, 2011). All information about
the included articles can be found in Table 1.
Assessment method
Forty-six studies (88%) were cross-sectional: five
studies featured a control group of people without dis-
abilities, three (6%) were cohort studies (Kosma et al.,
2007; Knittle et al., 2011; Suh et al., 2011), two (4%)
were non-randomized control trials (Maher et al., 1999;
Van der Ploeg et al., 2008) and one (2%) was a random-
ized control trial (Rimmer et al., 2009). All studies used
either questionnaires or interviews (or both) to assess
barriers and/or facilitators. Two studies performed
Medline
1849
Cinahl
764
Embase
762
SPORTDiscus
1604
4979
Excluded duplicates
716
Excluded after title
stage
3115
Excluded after
abstract stage
953
Excluded because of
qualitative design
94
Unavailable
13
Excluded because of
physical activity
23
Excluded after full
text stage
16
Title screening
K: 0.64
AA: 82%
Abstract screening
K: 0.48
AA: 81%
Quantitative screening
K: 0.96
AA: 97%
Full text and reference
screening
K: 0.78
AA: 89%
Included after
reference check
3
4263
1148
195
101
88
65
49
52
Fig. 1. Flow chart of the systematic review, including Kappa value (K) and Absolute Agreement (AA) for screening stages.
Barriers to and facilitators of sports
3
Table 1. Study characteristics of the included studies
Author Gender (M/F) Age†Disability Sport Rel Val Level SM RR
(%)
Design AT Model Barriers Facilitators
Lathen et al. (1988) 123 (../..) [14–18] – Backpacking, (winter)
camping,
canoeing,
cycling,
rafting
Y Y A – 49 CS Q – – Past participation, family
participation, social
contacts
Fung (1992) 90 (45/45) 27.3 SCI Athletics Y N E C – CS Q – – Energy, fitness, fun, goals,
skills, social contacts
Furst et al. (1993) 22 (18/4) 36.5 [14–56] SCI Triathlon N N CT – 88 CS Q – – Competition, fun, health,
pre-injury sports
participation, social
contacts
Kosel (1993) 241 (../..) – AMP, SCI, Sensory – N N E – – CS I – – Competition, fun, health,
social contacts
Shifflett et al. (1994) 203 (77/126) 26.6 (10.5) Arthritis, Congenital
Anomalies, Neuro, SCI
– N N – CL 41 CSc Q – Accessibility, disability,
energy, health, pain, time
Health
Martin & Adams-Mushett
(1995)
57 (30/27) 16.2 (1.3) AMP, CP, Les Autres, SCI Swimming Y Y E – 70 CS Q – – Competition, self-identity,
social identity, win and goal
orientation
Hedrick & Broadbent
(1996)
229 (151/78) – – – N N A TP – CS Q – – Previous activity behavior
(college)
Potmesil & Snajdr (1996) 62 (43/19) 33.7 – – N N E TP – CS Q – – Competition, fun, social
contacts, travel
Yarwasky & Furst (1996) 8 (7/1) 35.1 CP, SCI Diving N N A – – CSc Q – – Fun, self-confidence
Lockwood (1997) 493 (276/217) – – – N N A TP – CS I, Q – Disability, possibilities,
support (staff), time,
transport
–
Wilhite et al. (1997) 704 (333/ 371) 14.2 [11–21] AMP, Brain, CP, MS, Musc,
Neuro, SCI, Sensory
– Y Y A P – CS Q – Disability, time Fun,
relaxation
Kinne et al. (1999) 113 (47/66) 47 (1.4) Brain, MS, Musc, Neuro,
SCI
– Y N A CM 83 CS Q TTM Accessibility, costs,
disability,
fatigue, information
Self-efficacy
Maher et al. (1999) 19 (8/11) 47.4 Brain, MS, Neuro, SCI – N N A – – nRCT I, Q – – –
Pensgaard et al. (1999) 30 (23/7) 30.4 (9.4) AMP, CP, SCI, Sensory All winter sports Y Y E TP 74 CS I, Q – Dependency of external
factors, management
disability sport
Competition, social
contacts
Rimmer et al. (2000) 50 (0/50) [18–64] – – Y N A C 45 CS I, Q – Costs, energy, possibilities,
transport
–
Szalda-Petree et al. (2000) 119 (63/53) 43 Arthritis, AMP, Brain, CP,
MS, Musc, Neuro, SCI
– Y Y A – 56 CS Q Influences on PA Secondary conditions –
Field & Oates (2001) 166 (../..) 10.0* CF, Neuro Aerobics,
archery,
athletics,
(10-pin) bowling,
cricket, cycling, fencing,
football,
karate,
netball, (disabled) skiing,
squash, swimming tennis,
wheelchair sports, weight
lifting
Y Y A – 57 CS Q – Possibilities, information,
unequal time distribution
between brothers/sisters
and disabled child
–
Wu & Williams (2001) 143 (132/11) 33.3 [18–55] SCI Athletics,
wheelchair basketball,
wheelchair rugby,
wheelchair tennis
Y N CT TP – CS Q – – Competition, fitness, fun,
health, pre-injury sports
participation, social
contacts
Jaarsma et al.
4
Kalyvas & Reid (2003) 15 (11/4) [9–12] – Volleyball Y N A IS – CSc I, PM, Q – – –
Kosma et al. (2004) 151 (34/117) 37.9 (8.8) CP, MS, SCI – Y N A – 50 CS Q TTM – Behavioral and cognitive
processes, self-efficacy
Latimer et al. (2004) 124 (86/38) 43.4 (16.2)* SCI – Y Y A C 22 CS Q TPB – Perceived behavioral
control (paraplegia)
Santiago & Coyle (2004) 170 (0/170) 46.8 (9.0) Arthritis, Brain, Neuro,
Ortho, Pain, SCI, Sensory
Cycling, dancing,
gymnastics, walking,
weight lifting
Y Y A R 30 CS Q – – –
Tasiemski et al. (2004) 678 (570/108) 44.5 (12.1) SCI – Y Y MX TP 56 CS Q – Accessibility, costs,
dependency of others,
dislike of “traditional”
disabled sports, health,
information, possibilities,
time, transport
Competition, fun, health,
self-confidence, social
contacts, strength, travel,
weight control
Tsai & Lau (2004) 18 (12/6) – AMP, Neuro, SCI, Wheelchair fencing N N E – – CS Q – Information, social
acceptance, support
(family)
Fitness, self-actualization,
support (family)
Bae et al. (2005) 112 (75/37) [10–80] – Baseball,
basketball,
football,
swimming,
table tennis, volleyball
N N A TP – CS Q – Accessibility, transport Accessibility
Scelza et al. (2005) 72 (50/22) 44.1 (13.0) SCI – Y Y A – 10 CS I, Q – Boredom, costs, disability,
do not know how to
exercise, energy, fractures,
health, injury, interest,
laziness, motivation, pain,
possibilities,
–
Martin (2006) 112 (63/49) 15.3 (1.6) AMP, CP, Neuro, SCI Athletics, swimming Y Y E C – CS Q SCT, sport
commitment
model
– Fun, physical ability, social
contacts, sport
commitment, support
Ellis et al. (2007) 223 (65/158) 45.4 (10.8) AMP, Brain, CP, Lung, MS,
Musc, Neuro, SCI,
Sensory
– Y Y A – – CS Q TPB Accessibility, costs,
energy, fatigue, injury,
pain, support, time,
transport, weather
Accessibility, costs,
emotional functioning,
energy, health, strength,
social contacts, support,
weight control
Kosma et al. (2007) 143 (42/101) 46.0 (10.8) AMP, Brain, CP, Lung, MS,
Musc, Neuro, SCI,
Sensory
– Y Y A – 71 CH Q TPB, TTM – Attitude, intention,
perceived behavioral
control
Perreault & Vallarand
(2007)
72 (41/31) 30.1 (5.6) – Wheelchair basketball Y N A – – CS Q SDT Motivation Intrinsic motivation
Shihui et al. (2007) 115 (64/51) 22.4 – – Y Y E – 82 CS Q – – Body function and ability,
fun, health, skills, social
contacts
Heo et al. (2008) 76 (47/29) 42 (14.1) Dev Dis, Ortho, SCI – Y N MX C 33 CS Q – Structural constraints Self-determination, skills
Martin (2008) 79 (66/13) 31.4 (11.5) AMP, CP, Les Autres,
Neuro, Ortho, SCI
Wheelchair basketball Y Y CT C – CS Q SCT Negative affect Positive affect, self-efficacy,
thought control
Van der Ploeg et al.
(2008)
731 (369/ 362) 46 (14) AMP, Arthritis, Brain,
Neuro, Ortho, Pain, SCI
– N N A – 61 nRCT PM, Q PAD model Costs, energy, health
possibilities, transport
Attitude, fitness, health,
self-confidence,
self-efficacy, social
influence
Rimmer et al. (2008) 83 (25/58) 54.2 (8.2) Brain – Y Y A C – CS Q – Costs, information,
transport
–
Spivock et al. (2008) 205 (94/111) 41 (11.4) Brain, Musc, Neuro, SCI,
Sensory
– N N A P 35 CS I, DB EM – Presence of active living
buoys
Swanson et al. (2008) 193 (133/60) 19.8 (4.9) – Wheelchair basketball Y Y CT C – CS Q – – Goals, self-confidence,
social contacts
Yoh et al. (2008) 122 (57/65) – CP, SCI – N N A C 61 CS Q – Accessibility, gender
(female)
–
Barriers to and facilitators of sports
5
Table 1. (continued)
Author Gender (M/F) Age†Disability Sport Rel Val Level SM RR
(%)
Design AT Model Barriers Facilitators
Kars et al. (2009) 105 (71/31) 58.7 (12.6)* AMP Cycling, fitness,
swimming, walking
N N A – 37 CS Q – Absence of needs,
age, assistive devices,
costs, disability, fear,
possibilities, secondary
conditions
Health, medical advice,
need to participate,
self-confidence, social
contacts
Pittet et al. (2009) 709 (354/ 355) 18.1* – – N N A RNS 90 CSc Q – Disability, injury, physically
demanding job, preferring
other activities, time
–
Rimmer et al. (2009) 92 (5/87) 58.8 – – Y Y A – – RCT PM, Q – – –
Stroud et al. (2009) 93 (18/75) 50 (10) MS – Y Y A – 22 CS Q – Energy, fatigue,
inconvenient training
schedules, places too far
away, possibilities,
Muscle tone, personal
accomplishment,
physical fitness, strength
Beckerman et al. (2010) 106 (40/66) 42.7 (9.6) MS Fitness, gymnastics,
swimming
Y Y A C 86 CS Q – Activity too intense,
energy, fatigue, health,
motivation, social
constraints
Fitness,
strength
Molik et al. (2010) 174 (./.) 26.1 (6.3)* – Boccia,
wheelchair basketball,
wheelchair rugby
Y N CT – – CS Q – – Fun, therapy
Shapiro & Martin (2010) 36 (27/9) 16 (2.8) Brain, CP, Heart Condition,
Hip Condition, Musc,
Neuro,
Football, wheelchair
basketball
Y Y CT TP – CS Q – – Endurance, sport
competence, strength
Brittain et al. (2011) 248 (0/248) 48.9 (12.9) Arthritis – N N A C – CS Q – Disability,
health
Dlugonski et al. (2011) 54 (9/45) 46.1 (9.9) MS – Y Y A C 60 CS Q SCT – Goal setting, health,
positive overall, social
expectation for exercise
Knittle et al. (2011) 271 (93/178) 60.5 (13.6) Arthritis – Y Y A – 16 CH Q – – Self-efficacy
Plow et al. (2011) 335 (88/267) 53.0 (10.2) MS – Y N A Min 34 CS Q TTM – Cognitive process of
change, decision balance,
self-efficacy, stage of
change placement
Protic & Valkova (2011) 88 (83/5) [15–60] – Sitting volleyball N N CT TP 60 CS Q – – Fitness, fun, health, social
contacts
Saebu & Sorensen (2011) 327 (149/178) 24.2 (3.9) CP, Musc, Neuro, SCI,
Sensory
Boccia, dancing,
equestrian, fitness,
gymnastics, swimming
Y Y A – 35 CS Q ICF, SDT – Exerciser schematic,
health, intrinsic motivation,
possibilities
Suh et al. (2011) 218 (21/197) 43.5 (10.0) MS – Y Y A C 71 CH Q SCT – Goals, self-efficacy
*Pooled means and standard deviations.
†Mean age or (SD) or [range].
A, amateur; AMP, amputation; AT, assessment tool; Brain, CVA, traumatic brain injuries, cerebral injuries; C, convenient sample; CF, cystic fibrosis; CH, cohort study; CL, clustered sample; CM, community sample; CP, cerebral palsy; CS, cross-sectional design without
control group; CSc, cross-sectional design with control group; CT, competitive; DB, retrieving data from existing database; Dev Dis, developmental disabilities; E, elite; EM, ecological model; F, female; I, interview; IS, intact sample; M, male; Min, minimum sample
for data analysis; MS, multiple sclerosis; Musc, muscular disabilities such as muscular dystrophy, musculoskeletal disabilities; MX, mixed level (elite and amateur); N, no; Neuro, other neurological disabilities such as polio, spina bifida and neuromuscular conditions;
nRCT, non-randomized controlled trial; Ortho, orthopedic injuries; P, purposeful; PA, physical activity; PM, physical measurements; Q, questionnaire; R, random; RCT, randomized controlled trial; Rel, reliability; RNS, representative national sample; RR, response rate;
SCI, spinal cord injuries; SCT, social cognitive theory; SDT, self-determination theor y; Sensory, visual or hearing impairment; SM, sampling method; TP, total population; TPB, theory of planned behavior; TTM, transtheoretical model (including stages of change); Val,
validity; Y, yes.
Jaarsma et al.
6
physical measurements (Van der Ploeg et al., 2008;
Rimmer et al., 2009), and one study also included data
extracted from a large database (Spivock et al., 2008).
Thirty-five studies (67%) used either a reliable or valid
instrument, with 25 studies (48%) using an instrument
that was both reliable and valid.
Theory
Fifteen studies (29%) used a theory or framework in their
study. Social cognitive theory (SCT) (Martin, 2006, 2008;
Dlugonski et al., 2011; Suh et al., 2011) and the
transtheoretical model (TTM) (Kinne et al., 1999; Kosma
et al., 2004, 2007; Plow et al., 2011) were used
in four studies (8%), and the theory of planned behavior
(Latimer et al., 2004; Ellis et al., 2007; Kosma et al.,
2007) was used in three studies (6%). Other theories and
frameworks that were used only once or twice included
self-determination theory (Perreault & Vallarand, 2007;
Saebu & Sorensen, 2011), the ecological model (Spivock
et al., 2008), and the ICF (Saebu & Sorensen, 2011).
Barriers and facilitators
Barriers
Personal factors.
Children and adolescents. Children and adolescents
with different types of disabilities mentioned each
disability itself as a personal barrier (Wilhite et al., 1997;
Pittet et al., 2009). Other personal barriers were lack of
time (Wilhite et al., 1997; Pittet et al., 2009) and unequal
time distribution of the parents between the disabled
child and their siblings (Field & Oates, 2001).
Adults. The disability itself was reported in several
studies including adults with different types of disabili-
ties (Shifflett et al., 1994; Kinne et al., 1999; Scelza
et al., 2005; Kars et al., 2009; Brittain et al., 2011).
Health was a personal barrier for adults with physical
disabilities (Shifflett et al., 1994; Tasiemski et al., 2004;
Scelza et al., 2005; Beckerman et al., 2010; Brittain
et al., 2011). Lack of energy and fatigue were also
reported as a personal barrier in studies including adults
with different types of disabilities (Shifflett et al., 1994;
Kinne et al., 1999; Scelza et al., 2005; Stroud et al.,
2009; Beckerman et al., 2010).
Environmental factors.
Children and adolescents. No studies reported envi-
ronmental barriers to sports.
Adults. A lack of sports possibilities (Tasiemski
et al., 2004; Kars et al., 2009; Stroud et al., 2009) and
difficulties with accessibility (Shifflett et al., 1994;
Kinne et al., 1999; Tasiemski et al., 2004) and transport
(Tasiemski et al., 2004; Rimmer et al., 2008) were
reported as barriers by adults with physical disabilities.
A lack of information about sports was also experienced
as a barrier by adults with physical disabilities (Kinne
et al., 1999; Tasiemski et al., 2004; Rimmer et al., 2008).
Costs were reported by adults with amputation, stroke,
or SCI (Tasiemski et al., 2004; Scelza et al., 2005;
Rimmer et al., 2008; Kars et al., 2009).
Facilitators
Personal factors.
Children and adolescents. Fun was a frequently
reported facilitator for children and adolescents (Martin
& Adams-Mushett, 1995; Wilhite et al., 1997). Children
and adolescents with different types of physical disabili-
ties also experienced relaxation as a personal facilitator
(Wilhite et al., 1997).
Adults. Adults with physical disabilities experienced
fun as a personal facilitator (Fung, 1992; Furst et al.,
1993; Potmesil & Snajdr, 1996; Yarwasky & Furst,
1996; Wu & Williams, 2001; Tasiemski et al., 2004;
Shihui et al., 2007; Saebu & Sorensen, 2011). Health
(Furst et al., 1993; Shifflett et al., 1994; Wu & Williams,
2001; Tasiemski et al., 2004; Kars et al., 2009;
Dlugonski et al., 2011; Saebu & Sorensen, 2011) and
fitness (Fung, 1992; Wu & Williams, 2001; Stroud et al.,
2009; Beckerman et al., 2010) were reported by adults
with physical disabilities. Intrinsic motivation (Perreault
& Vallarand, 2007; Saebu & Sorensen, 2011) and self-
efficacy (Kinne et al., 1999; Martin, 2008; Knittle et al.,
2011; Plow et al., 2011; Suh et al., 2011) were experi-
enced as personal facilitators by adults with different
types of physical disabilities. Goals or goal setting were
reported by adults with multiple sclerosis or SCI
(Dlugonski et al., 2011; Suh et al., 2011). Pre-injury par-
ticipation was reported by adults with an amputation or
SCI (Furst et al., 1993; Wu & Williams, 2001; Kars
et al., 2009).
Environmental factors.
Children and adolescents. The main environmental
facilitator of sports among children with physical dis-
abilities was social contacts (Martin, 2006; Swanson
et al., 2008).
Adults. Social contacts was also the main environ-
mental facilitator for adults with different types of dis-
abilities (Fung, 1992; Furst et al., 1993; Potmesil &
Snajdr, 1996; Pensgaard et al., 1999; Wu & Williams,
2001; Tasiemski et al., 2004; Shihui et al., 2007; Kars
et al., 2009).
Discussion
The aim of this systematic review was to provide an
overview of studies focusing on the barriers to and
facilitators of sports participation for people with
Barriers to and facilitators of sports
7
physical disabilities. Personal barriers included the dis-
ability itself and health, whereas lack of possibilities,
difficulties with accessibility, and transport were among
the environmental barriers that were reported. Personal
facilitators were factors such as fun, health and fitness,
and the environmental facilitator was social contacts.
Barriers
Personal barriers, such as the disability, health and lack
of energy are directly related to a person’s physical
disability. Health was experienced both as a barrier
when it restricted people from participation in sports,
as well as a facilitator in terms of improving health
through sports. Barriers to sports participation for
people without physical disabilities differ from those
for people with physical disabilities, as people without
disabilities usually mention lack of time and motivation
as the main barriers to sports participation (Tenenbaum
& Eklund, 2007). This study demonstrated environ-
mental barriers, such as lack of possibilities, lack of
accessibility, and transport, are additional barriers spe-
cifically experienced by people with physical disabili-
ties. Both personal and environmental barriers are
therefore very important to keep in mind when advising
people with physical disabilities about participation in
sports. Providing information about possible barriers
prior to participation in sports makes a person more
prepared for these barriers that need to be overcome
and possibly also makes it easier to actually encounter
and overcome these barriers.
The abovementioned barriers are also generally expe-
rienced by people with different types of disabilities.
However, as only few studies provide barriers of a single
disability, differences in barriers per disability group
cannot be distinguished. Experienced barriers also
appear to vary with age. Therefore, advice on sports
participation should be tailor-made, and disability and
age should also be considered in addition to other barri-
ers and facilitators. By including all of these factors in
the choice of sport, the chances of finding the most
appropriate sport will increase, which could also
increase a person’s chances of not only becoming but
also staying active in sports.
Facilitators
Facilitators should of course also be considered when
advising people with physical disabilities about partici-
pation in sports. Facilitators, such as fun, fitness, and
motivation are very much applicable to people with all
types of disabilities. For people who have acquired a
disability, pre-injury participation in sports has a large
influence on post-injury participation, and the emphasis
of the stimulation (whether advice or a program) should
be on the positive experiences gained through pre-injury
participation.
Social contacts were reported by people with all
types of disabilities and of different ages. Interaction
with other athletes should therefore be introduced as
soon as possible. Introducing people with physical dis-
abilities to different team sports could therefore be of
value, perhaps more so than introducing people with
physical disabilities to individual sports. However, for
people to also stay active, it is important that they are
provided with sufficient information about the possi-
bilities of participating in both team and individual
sports. If team sports are not available in their commu-
nities, being able to participate independently in sports
is also important. These results show that people with
disabilities also consider the psychosocial factors of
sports to be very important in addition to the health
benefits thereof.
Methodological issues
A large majority of studies chose a cross-sectional
design in determining barriers to and facilitators of
sports participation. A cross-sectional design allows for
the provision of information about barriers to and facili-
tators of sports participation at a given time. This infor-
mation about barriers and facilitators should then be
used to develop sport stimulation programs and deter-
mine the effectiveness of these programs. Because only a
few included articles used a longitudinal design for their
research, little information can be provided about the
effectiveness of programs in stimulating sports partici-
pation and reducing barriers. Part of the successful bid
for the 2012 Olympic and Paralympic Games in London
was the legacy of the Olympic and Paralympic Games.
One of the areas of priority was sports participation
(London Organising Committee of the Olympic and
Paralympic Games, 2012). Even though many initia-
tives, such as National School Sports Week and Interna-
tional Paralympic Day, have been in place since the bid
was accepted in 2003 (London Organising Committee of
the Olympic and Paralympic Games, 2012), a longitudi-
nal study could provide insight into the successfulness
and effectiveness of these initiatives and, with that, the
legacy of the Olympic and Paralympic Games.
Few studies included in this review used a theory or
framework to structure their results. Studies that did use
theories chose different theories, namely SCT (Martin,
2006, 2008; Dlugonski et al., 2011; Suh et al., 2011) and
the TTM (Kinne et al., 1999; Kosma et al., 2004, 2007;
Plow et al., 2011). However, in these studies, the TTM
was generally used to determine the activity level of the
participants according to the stages of change and not
necessarily to structure results. The use of theories in
these studies is therefore mostly irrelevant as the theories
were not used to determine barriers to and facilitators of
sports participation.
Barriers to and facilitators of sports participation
could often not be distinguished for each disability
Jaarsma et al.
8
when studies included several types of disabilities, pre-
venting a comparison with studies focusing on a single
disability. For example, the study by Ellis et al. (2007)
included adults with SCI, cerebral palsy, multiple scle-
rosis, muscle or joint disabilities, brain-related injuries,
post-polio, amputation, spina bifida and sensory or lung
disabilities. In the results, the authors provide many
barriers to and facilitators of sports participation, but
do not distinguish between disabilities. It can therefore
not be concluded which barriers and facilitators are
specifically experienced by which disability group.
Future research should therefore consider reporting
barriers and facilitators for groups of disabilities or for
ambulant and non-ambulant persons. This division will
make it easier to compare results with those of other
(previous) studies.
There were also several studies that only reported
that their research focused on disability and sports, but
did not specify the investigated disability and/or the
sport. In the study by Pittet et al. (2009), for instance,
the only information provided was that they included
adolescents with a chronic health condition and/or a
physical disability, which were not specified into dif-
ferent types of diagnosis. These authors also mentioned
the extent of sports activity exhibited by these adoles-
cents but did not mention the sports in which the ado-
lescents participate. Again, by not including these
characteristics of the research population, comparison
with previous studies is very difficult.
Limitation of the current study
Cohen’s kappa was relatively low for the title and
abstract stage, namely 0.64 and 0.48, respectively. An
explanation for these results could be that bias occurred
between the two reviewers at these stages. This bias may
have occurred if the reviewers differed in their assess-
ment of the two stages, which would have led to differ-
ences in marginal distributions (Sim & Wright, 2005). A
bias index (BI) can be calculated to determine whether
the marginal distributions are equal (i.e. BI =0) (Sim &
Wright, 2005). An increase in BI will reduce the change
agreement, which will ultimately lead to a higher kappa
(Sim & Wright, 2005). The BIs for the title and abstract
stages in this study were 0.06 and 0.08, respectively.
These small BIs will result in large change agreements
and might be the cause for the relatively low kappa.
However, the percentage absolute agreement between
the two observers was also included and showed rela-
tively large agreement.
In this study, we chose to focus on barriers to and
facilitators of sports participation (Kemper et al., 2000)
and excluded articles that focused more on physical
activity. Physical activity can be defined in many
ways, from household chores to moderate intensive
exercise (Warms et al., 2007). However, because sports
are only a part of the broader definition of physical
activity (Caspersen et al., 1985), it could be interesting
to also systematically review studies that focused on
barriers to and facilitators of all types of physical
activity.
This systematic review included barriers to and facili-
tators of sports participation in different countries and
continents. Previous research hints that there might be
cultural differences for barriers to and facilitators of
sports participation among disabled athletes (Fung,
1992; Dijkers et al., 2002). Therefore, certain barriers or
facilitators mentioned in the included studies might not
be relevant for all countries or continents.
Perspective
Even though barriers were predominantly environmen-
tal and facilitators were personal, the experienced
barriers and facilitators depended on age and type of
disability. When advising people about sports partici-
pation, not just the age and disability type should
be considered, but also environmental and societal
barriers. Finding the most appropriate sport could
also increase the chances of people with physical dis-
abilities to not only become active but also staying
active.
Key words: Sports, people with physical disabilities, bar-
riers, facilitators, systematic review.
Supporting information
Additional Supporting Information may be found in the
online version of this article at the publisher’s web-site:
Appendix S1. Search strategy of the systematic review
Appendix S2. Assessment of full text articles included
in the systematic review
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