Citation
Physical Activity and Quality of Life Experienced by Participants of a Wheelchair Basketball Tournament

Material Information

Title:
Physical Activity and Quality of Life Experienced by Participants of a Wheelchair Basketball Tournament
Creator:
Stancil, Michael Adam
Place of Publication:
[Gainesville, Fla.]
Publisher:
University of Florida
Publication Date:
Language:
english
Physical Description:
1 online resource (95 p.)

Thesis/Dissertation Information

Degree:
Master's ( M.S.)
Degree Grantor:
University of Florida
Degree Disciplines:
Applied Physiology and Kinesiology
Committee Chair:
Giacobbi, Peter B.
Committee Members:
Tillman, Mark D.
Levy, Charles M.
Stopka-Boyd, Christine E.
Graduation Date:
8/11/2007

Subjects

Subjects / Keywords:
Basketball ( jstor )
Disabilities ( jstor )
Disabled persons ( jstor )
Exercise ( jstor )
Physical disabilities ( jstor )
Quality of life ( jstor )
Social psychology ( jstor )
Trucks ( jstor )
Wellbeing ( jstor )
Wheelchairs ( jstor )
Applied Physiology and Kinesiology -- Dissertations, Academic -- UF
activity, disability, happiness, life, quality
Genre:
Electronic Thesis or Dissertation
born-digital ( sobekcm )
Applied Physiology and Kinesiology thesis, M.S.

Notes

Abstract:
Quality of life is a construct that has different meanings for researchers in various disciplines. Within the medical field, QOL is conceptualized as the presence or absence of symptoms while those in physical or occupational therapy might evaluate the ability to complete functional tasks of daily living. Within psychology researchers emphasize subjective assessments of well-being or happiness or how individuals interpret their own lives, goals, achievements, and subjective evaluations. My study used a subjectively oriented approach to examine physical activity and subjective assessments of life quality with 26 individuals with physical disabilities. The participants completed the Physical Activity Scale for Individuals with Physical Disabilities (PASIPD) and a semi-structured interview focused on the physical activity experiences and the role those experiences played in their subjective evaluations of the participants' lives. The physical activity for persons with disability model and Dijkers' conceptualization of subjective quality of life served as sensitizing concepts during the analysis phase. Grounded theory analyses revealed that participants of a wheelchair basketball tournament perceived a number of psychological, social, and health benefits associated with physical activity involvement. These experiences in turn allowed the participants to develop self-efficacy beliefs and expectations that facilitated future involvement in their chosen physical activities. By all accounts the participants in this sample were generally very active and appeared to experience subjective well-being. ( en )
General Note:
In the series University of Florida Digital Collections.
General Note:
Includes vita.
Bibliography:
Includes bibliographical references.
Source of Description:
Description based on online resource; title from PDF title page.
Source of Description:
This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Thesis:
Thesis (M.S.)--University of Florida, 2007.
Local:
Adviser: Giacobbi, Peter B.
Statement of Responsibility:
by Michael Adam Stancil.

Record Information

Source Institution:
University of Florida
Holding Location:
University of Florida
Rights Management:
Copyright Stancil, Michael Adam. Permission granted to the University of Florida to digitize, archive and distribute this item for non-profit research and educational purposes. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder.
Resource Identifier:
660373617 ( OCLC )
Classification:
LD1780 2007 ( lcc )

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Full Text





The quality of well-being scale (QWB; Kaplan & Anderson, 1988) places individuals into

categories based on their level of functioning and their symptoms. Functioning is measured on

scales of mobility, physical activity, and social activity. Interviewers ask patients questions

concerning their level of limitation for the previously mentioned scales in order to classify their

obj ective level of functioning. Then patients are given a list of symptoms they might experience.

The interviewer then asks the patient to choose the symptom they are experiencing that is most

undesirable to them (Kaplan, 1994). To generate a score for wellness the weighted score for

symptom is summed with the weighted scores for mobility, physical activity, and social activity

along with 1. Possible scores range from 0 to 1, with zero indicating worst possible well-being

(death) and a score of one meaning the individual is completely well. For example, a weight of 0

is given for no limitations across the three scales and for no symptoms. A person who has no

limitations and no symptoms would score a one. The well-being score is then multiplied by

a time component, usually years, to determine the duration of stay in various health states.

The weights assigned to states of functioning were obtained through cross-validation

studies that demonstrated a high degree of accuracy (R2 = 0.96). Studies have also shown that

these weights are stable over a one-year period and that they are consistent across an assorted

groups of users (Kaplan, Bush, and Berry, 1978). Additionally studies have shown that the

QWB scale is both valid and reliable in the general population (Kaplan, Bush, Berry, 1976). As

with the SF-36, the QWB scale is considered "problematic" for individuals with disabilities due

to its quantification of functioning (Hays et al., 2002, p. S7).

Health Risks for Individuals with Disabilities

In the following sections I will review literature that has shown that individuals with

disabilities are at a greater health risk than those without disabilities (Cooper, Quatrano, Axelson,









and researchers have struggled to extend conceptual and theoretical frameworks to individuals

with physical disabilities. In chapter one I will review important conceptual definitions in the

QOL literature. This review will be followed by a discussion of theoretical frameworks of

quality of life that are relevant to this thesis. This discussion will be followed by a review of

literature and the rationale and specific purposes of this thesis. To begin however it is important

to precisely characterize study population and offer specific definitions of what it means to be

physically disabled.

Study Population

There are an ever-increasing number of adults in the United States who have some form of

disability. According to the United States Bureau of the Census the number of people who report

disabling conditions is approximately 54 million while approximately 26 million report

conditions that significantly impact one or more activities of daily living (McNeil, 1997). In

addition, there are roughly 11,000 reported spinal cord related injuries each year (Spinal Cord

Injury Information Network, 2003). With such large numbers of individuals who report

disabling conditions it becomes important to precisely characterize what it means to be

physically disabled.

The term disability can have several meanings. According to Mosby's Medical, Nursing,

and Allied Health Dictionary (5th ed.), disability is the loss, absence, or impairment of physical

or mental fitness. Impairment is defined as any negative change in function or structure that

interfere with ordinary activities as a result of bodily or mental abnormalities. (Mosby's

Dictionary, 1998). It may also be defined as when the physical capacity to move, coordinate

movement, and perform physical activities is significantly impacted.

According to the World Health Organization, the terms impairment, disability, and

handicap are distinctly different (Block, Griebenauw, & Brodeur, 2004). Impairment refers to










LIST OF FIGURES


Figure page

1-1. The model of Functioning and Disability (ICF model) from the International
Classification of Functioning, Disability and Health. ......___ .... ... ._ ........._.......46

1-2. The attitude, social influence, and self-efficacy (ASE) model ................. ............ .........46

1-3. The Physical Activity for people with Disability Model .........._._ ....... .._ ..........._.....47

3-1. Triadic reciprocal causation adapted from Bandura (1997) representing the three maj or
determinants of behavior ................. ...............72........... ....

3-2. A grounded theory of the determinants of physical activity and the role it plays in
subj ective QOL ........._.._.. ...._... ...............73....




























Environmental
factor


Personal factors


Social Influenee Attitude Belf-eticlacyF



External variables


Health1 cOdi~tion
(disorder or disease)



Levels of functioning



and stuctures Acvtis riipln


Figure. 1-1. The model of Functioning and Disability (ICF model) from the International
Classification of Functioning, Disability and Health (Reproduced from the World
Health Organization).


Figure.1-2. The attitude, social influence, and self-efficacy (ASE) model. (Reproduced from
DeVries et al., 1988).









CHAPTER THREE
RESULTS

The purpose of this thesis was to explore the role that physical activity plays in the

quality of life for individuals with physical disabilities. A secondary purpose was to use the

constant comparative method commonly employed by grounded theorists (Charmaz, 2000) to

explore differences in motives and perceived benefits between individuals who were more active

versus those who were less active, males and females, and age groups. To achieve these

purposes, 26 individuals were administered the PASIPD and interviewed about their physical

activity experiences. What follows is a presentation of the results broken up into three sections.

The first section summarizes the descriptive quantitative findings from the PASIPD. The second

section describes the higher-order and first order themes derived from the interview text.

Finally, the third section presents a grounded theory that represents a theoretical integration of

the results observed here with previous models of physical activity and subj ective QOL.

Descriptive Statistics

The focus of this thesis included determining activity levels of the participants. The

PASIPD broke down activity level into several different categories. These categories were

physical activity, household activity, lawn and garden activity, caring for another person, and

work activity. Physical activity was broken down further into the subscales reported by

Washburn et al. (2002) that included a total score, home repair/gardening, housework, vigorous

sport, light/moderate sport, and occupational activities. This latter category includes general

wheeling not intended for exercise. The participants' total scores on this measure ranged from

6.20 and 71.22 for both males and females while the average for the entire sample was 36.34 (SD

= 15.28). The PAD model suggested previously that an individual's gender played a role in their

participation in physical activity. An independent samples t-test was then performed in order to









Still another participant received cognitive benefits from physical activity saying, "...I've

learned a lot of like really life lessons, you know from like winning and losing and...I've just

learned a lot about sports but also about how to communicate with others." For these three

participants, physical activity provided them a means to learn new skills and become mentally

strong.

Another psychological benefit was that some participants felt better emotionally (N = 15)

as a result of physical activity. In this analysis, statements by participants were coded as

"emotional benefit" if there was mention of increases in positive affect (i.e. happiness), decreases

in negative affect, or stress relief. A 35 year old female with a PASIPD score of 51.49 said,

"That [water skiing], I think is just relaxing, you know its more of a relaxing type sport, you go

out there and you just enj oy yourself and it really just a fun thing." Another participant who

benefited emotionally was a 51 year-old female who had the highest score on the PASIPD with a

71.22. She stated, "I played rugby, softball. It was a good way to deal with the rage and um, the

depression and all the stuff that came with it." A third participant, a 24 year-old female with a

35.6 on the PASIPD, added, "And the marathon now...it' s more of a release for me. I can go out

and push 20 miles a day and it' s such a stress reliever for me, I just feel good afterwards." From

the interview responses, it appeared that physical activity was a good way to reduce stress and

depressive symptoms, as well as a source of fun for over half of the participants.

A third psychological benefit, behavioral benefits, was identified when participant

mentioned a change in their day-to-day behavioral or health, routines. For instance, the 51 year-

old female who had the highest PASIPD score for this sample felt that through physical activity

she developed the will to not quit, which forced her to be more creative.

Just...I guess my desire not to give up. You know? There' s a lot of things I can't do and
that' s real aggravating. But um...I painted the bottom part of my house by adapting rollers










(De Vries et al., 1988). Self-efficacy towards a behavior refers to the confidence an individual

has in their own ability to perform that behavior. For instance, if an individual with a disability

was not confident they could push themselves a mile up steep terrain because he had never

accomplished this task this person would be said to have low self-efficacy for that task. Their

lack of self-efficacy would then lessen the intention to push themselves for a mile, and would

ultimately determine whether or not they would perform that behavior. Additionally, attitudes

towards behavior can affect intentions and engagement in a specific task and refer to what an

individual thinks about a certain behavior for them. Using the example from above, if an

individual with a disability thinks that pushing for a mile in their wheelchair is good for him

because it provides exercise then that would strengthen his intentions and increase the likelihood

of that behavior.

Finally, subj ective norms, or social influence, also have an impact on behavior intentions.

Subj ective norms are often socially influenced and may include what family, friends, or doctors

think about a certain behavior as well as how society regards that behavior. Physical activity for

individuals with disabilities, for instance, has become more popular recently as old stigmas about

disabled individuals have been shed. When an expectation exists for a specific behavior,

whether it' s smoking less or exercising more, then there is a better chance that an individual will

be persuaded to engage in that behavior.

In the ASE model, external variables can also influence activity behavior. These variables

are similar to personal factors in the ICF model, and can include age, gender, race and socio-

economic status. Their influence on behavior can only occur through one or more of the three

determinants of behavior listed above (van der Ploeg et al., 2004). The last part of the ASE

model takes into account the presence or absence of barriers and skills. As with the ICF model,










CHAPTER 2
METHOD S

Participants

The participants included 12 male and 14 female adults between the ages of 18 to 54 (M =

31.12, SD = 10.75) who all reported one or more conditions) that impacted their daily living

(e.g., spina bifida, cerebral palsy, T-11/12 paraplegia, bi-lateral amputee, etc.). The sample

consisted of 20 Caucasians, 1 Asian American, 4 African-Americans, and one individual

reported being mixed racial and ethnic background. The participants reported a variety of health

conditions including specified and unspecified paraplegia (N = 14), bi-lateral or single amputee

(N = 3), cerebral palsy (N = 2), quadriplegia (N = 1), spina bifida (N= 1), chronic pain (N= 1),

complete fusion of the spine (N = 1), and 3 individuals did not specify why they used a

wheelchair. Twenty-Hyve of the twenty-six participants were either active in wheelchair

basketball at the time of the interview or had been previously. Twenty-two individuals from the

sample gave a specific time period for their participation. The average time playing wheelchair

basketball by those who reported specific times was 9.03 years and ranged from 26 years to 3

months. Some participants reported participation in other activities such as swimming, road

racing, wheelchair tennis, darts, and pool. The median age of the sample was 29 and consisted

of 10 individuals between 18 and 24, 6 were 25 to 34, 6 aged 35 and 44, and 4 individuals who

were 45-54. The breakdown of the age variable was done according Center for Disease Control

guidelines (Center for Disease Control and Prevention, 2005).



Measures

The Physical Activity Scale for Individuals nI ithr Physical Disabilities (PASIPD). The

PASIPD is a 13-item scale developed and validated to measure physical activity, health, and










equals one year of life without any functional limitations related to health. When applied

correctly the QWB scale should quantify medical treatment or health activities in terms of how

many QALYs it generates or retains.

A third group of QOL researchers would define QOL based upon subj ective indicators.

For instance, mainstream psychologists have defined quality of life as "a conscious judgment of

satisfaction with one's life" (Rejeski & Mihalko, 2001, p. 23). From this perspective one's

judgment of their quality of life is based largely on one' s values and experiences and is entirely

subj ective. Many authors have used subj ective indices of quality of life interchangeably with

terms such as subjective well-being, affect, and happiness (Berger & Motl, 2001). For instance,

Duggan and Dijkers (2001) stated that an individual's obj ective characteristics do not always

correspond with their subj ective experience. They conceptualized subj ective QOL as how well a

person's expectations coincide with their achievements or one's level of satisfaction with these

expectancies. Therefore, if someone' s reality falls short of his or her dreams or goals, they will

have a negative emotional and cognitive reaction and therefore be less satisfied with their quality

of life. If there is congruence between one' s goals and achievements, they will react more

positively and experience increased life satisfaction. These authors make the assumption that, if

there is a gap between expectations and achievement, the individual will try to bring a balance

between the two by changing their obj ective circumstance, or adjusting their expectations

(Duggan & Dijkers, 2001). For example, a person with a physical disability may be unable to

perform certain tasks such as bed transfers. This may have a negative impact on their quality of

life. In order to increase subj ective QOL they can adjust their expectations and consider the

ability to perform a bed transfer less important than other tasks that they are able to complete.

An alternative would be to change their circumstance so that they can perform a bed transfer.










a. Never (Go to question #5)
b. Seldom (1-2 days)
c. Sometimes (3-4 days)
d. Often (5-7 days)
On average, how many hours per day did you spend in these moderate sport or
recreational activities?
a. Less than hour
b. 1 but less than 2 hours
c. 2-4 hours
d. More than 4 hours

5. During the past 7 days, how often did you engage strenuous sport or recreational activities
such as jogging, wheelchair racing (training), off-road pushing, swimming, aerobic dance, arm
cranking, cycling (hand or leg), singles tennis, rugby, basketball, walking with crutches and
braces, or other similar activities?
a. Never (Go to question #6)
b. Seldom (1-2 days)
c. Sometimes (3-4 days)
d. Often (5-7 days)
On average, how many hours per day did you spend in these strenuous sport or
recreational activities?
a. Less than hour
b. 1 but less than 2 hours
c. 2-4 hours
d. More than 4 hours

6. During the past 7 days, how often did you do any exercise specifically to increase muscle
strength and' endurance such as lifting weights, push-ups, pull-ups, dips, or wheelchair push-ups,
etc.?
a. Never (Go to question #7)
b. Seldom (1-2 days)
c. Sometimes (3-4 days)
d. Often (5-7 days)
On average, how many hours per day did you spend in these exercises to increase muscle
strength and' endurance?
a. Less than hour
b. 1 but less than 2 hours
c. 2-4 hours
d. More than 4 hours

Household Activity
7. During the past 7 days, how often have you done any light housework such as dusting,
sweeping floors, or washing dishes?
a. Never (Go to question #8)
b. Seldom (1-2 days)
c. Sometimes (3-4 days)









The study included 13 females and 35 males with physical disabilities. The research team

recruited potential participants at sporting and community events and gave instructions about the

surveys used. Participants filled out surveys assessing personality, daily life events, mood, and

activity for eight consecutive days. Then they were required to mail in their completed surveys

to the primary researcher (Giacobbi et al., 2006).

Statistical analyses revealed several important findings. First, positive affect was

associated with increased positive events and fewer negative events. Additionally, there was a

significant positive relationship between exercise and positive affect and a negative relationship

between exercise and negative affect. More importantly, the effects of exercise on positive mood

were seen despite the occurrence of positive or negative daily life events. Finally, personality

moderated the effects of physical activity on affect. Individuals that showed higher levels of

Neuroticism were more likely to have more positive affect and less negative affect on days that

they exercised more. However, this same moderating relationship was not seen in extroversion

nor for the length of time after injury (Giacobbi et al., 2006).

Giacobbi et al.'s (2006) study showed that exercise could have a positive impact on mood

regardless of daily life events for individuals with disabilities. This study provides more support

to the notion that exercise and physical activity should be encouraged among persons with

physical disabilities.

In the literature reviewed, it was shown that exercise increased strength and functioning in

children (Blundell et al. 2003) and adults (Jacobs et al., 2003; Hicks et al., 2003), as well

provided important psychological and social benefits (Blinde & McClung, 1997; Taub et al.,

1999; Giacobbi et al., 2006). In addition to improving muscular strength and functioning,

exercise can also increase cardiovascular fitness as well as decrease shoulder pain. Physical









Harlan, Stineman, Franklin et al., 1999; Rimmer & Wang, 2005). Additionally, I will review

empirical studies that demonstrate links between physical activity and QOL for this population.

This will be followed by a review and synthesis of the literature review and the scientific

rationale for the present study.

Since individuals with disabilities are more likely to have activity limitations than their

able-bodied peers, it is important to examine outcomes related to low physical activity levels.

According to Healthy People 2010 those individuals who had activity limitations also reported

more days of depression, anxiety, sleeplessness, and pain than persons who did not have any

activity limitations (U.S.D.H.H.S, 2001). Also, there is more risk for secondary health

conditions such as cardiovascular disease and diabetes. These trends demonstrate a need to

further study the determinants and consequences of physical activity for individuals with

disabilities since the negative consequence of an obese lifestyle have been widely documented.

For instance, exercise has been shown to increase function as well as increase muscular strength

and cardio-respiratory fitness in individuals with physical disabilities. (Blundell, Shepard, Dean,

& Adams, 2003; Jacobs, Nash, and Ruminowski, 2001; Hicks, Martin, Ditor, Latimer, Craven,

Bugaresti, & McCartney, 2003). Another physical outcome associated with exercise is a decrease

in pain (Hicks et al., 2003; Fullerton, Borckardt, & Alfano, 2003). In addition, there is evidence

that suggests that exercise is related to increased positive affect and decreased negative affect in

middle-aged women and high school seniors while physical activity has social benefits as well

(Brown, Ford, Burton, Marshall, Dobson, 2005; Block, Griebenauw, & Brodeur, 2004; Leonard,

1998).

Rimmer and Wang analyzed data from a clinical trial that examined the effects of a health

promotion program for people with physical and cognitive disabilities (2005). Before Rimmer










LIST OF TABLES


Table


page


3-1. Means and standard deviations for the PASIPD .............. ...............72....









barriers can consist of any obstruction in the environment or personal life, which limit the

performance of a behavior. Skills can be conceptualized as actual control over a behavior and is

different from perceived control, or self-efficacy (De Vries et al., 1988). For example, an

individual might have high self-efficacy that they can push a mile in their wheelchair, but they

may not have the physical strength or endurance required to do so.

In summary, the ASE model is a tool for determining behavior or behavior change. The

authors took the self-efficacy component, borrowed from Social Learning theory (Bandura,

1977) and combined it with attitudes and subj ective norms from Fishbein and Ajzen' s (1975)

theory of reasoned action (Fishbein and Ajzen, 1975; DeVries et al., 1988). This model has

recently been adapted by van der Ploeg et al. (2004) and included in their PAD model, which

will now be explained.

Van der Ploeg and colleagues first introduced the physical activity for people with a

disability (PAD) model in 2004. Their goal was to develop a model that described how physical

activity behavior, determinants of behavior, and functioning of persons with a disability were

related (See Figure 1-3). They used the ICF model as a means of describing functioning and

disability and combined it with elements of the ASE model that described factors that determined

physical activity (van der Ploeg et al., 2004).

As was mentioned in the previous section, the ICF model has three levels of functioning

consisting of body structures and function, activity and participation. The PAD model views

physical activity within each of these domains, while at the same time, showing the benefits of

physical activity at each level. Consider this example of an individual with paraplegia: having

use of their upper body falls under the body structures and functions domain. Physical activity

can result in improved muscle power in the upper body and increase cardiopulmonary function









purposes I will expand this latter category (biological events) to include overall functional

capabilities and health. It is this interaction between the person and the environment that dictates

behavior as part of a larger interdependent system of variables.

In the present study reciprocal causation was reflected in how the participants began

involvement in various physical activity behaviors, the enj oyment, personal satisfaction, or other

benefits they perceived from these behavioral choices, with future decision making processes. In

other words, the perceived benefits of physical activity influenced behavioral choices to sustain

these behaviors that then lead to other benefits and continued participation. Now that conceptual

clarity has been established about how the higher-order themes are related to one another and

with other important constructs, my grounded theory will be discussed along with extensive

participant quotations as support.

My observations and the participants quotations' about environmental and personal factors

largely confirmed predictions of the PAD model (van der Ploeg et al., 2004). However, the

grounded theory being proposed here extends the PAD model by incorporating the maj or

psychological, physical health, and social benefits discussed by the participants in this study.

The double arrows within Figure 3-2 represent the reciprocal nature between the physical health,

social, and psychological benefits of physical activity behavior with the initiation and

maintenance of these behaviors over time. What follows is an explanation for each of the

pathways and exemplar quotations that offer support for my synthesis of research.

As shown in Figure 3-2, boxes A and B represent the maj or elements within the PAD

model. Within the present study these determinants of physical activity behavior included

environmental and personal factors respectively. With regard to the role of environmental

factors in physical activity, the participants' quotations revealed that environmental factors











SN=2 2


Like being on a team
Soilcomponent very important
Metbest friends
Metwonderful people
Camaraderie of teammates
SoilAspect of team sport vs. individual
Forced to interact with teammates
Bigwith others with disabilities


Public more aware of abilities
Bridge to able-bodied world
Sekto children about accomplishments
Coaching kids to success


Metinspirational others
Othr podutive people in wheelchairs


Euain paid for
Able to see the world

Compete at Olympic level
Compete at an international level
moving to the United States
Introduced to other wheelchair sports
Epnshorizons


LemDiscipline
ore positive
Reflecting on life of achievement
Would prefer to be in wheelchair
QL is better now then before injury
Sprt has given a positive direction in life
Cagdself-perception
Gaeback self-esteem
Found new strength in self
More comfortable in other areas of life
Saisfied with accomplishments in sport


Meeting Friends
N =12


Spreading a message
N = 9




Influential Others
N= 5




Travel/Education/Compet.
N =10


Reappraisal of self
N= 6


Increased Overall QOL
N= 6


Social Opportunities
N= 23









BIOGRAPHICAL SKETCH

Michael Stancil was born in Gainesville, Florida on July 1, 1980. Throughout his

childhood he lived on the east and Gulf coasts of Florida. He received his Bachelor of Science

degree in psychology in August of 2002 from the University of Florida. Michael began graduate

school in the spring of 2004 where he met his wife Leah. They were married in Barbados in

August of 2006 and currently reside in Columbia, South Carolina.









important within physical activity. One man, aged 46 years and a PASIPD score of 29.94 said, "I

think having that type of personality, being a bit of a competitor and a battler made it more likely

that I was going to be aggressive in my rehabilitation," when asked if his personality helped him

after his injury. These results are consistent with the predictions within the PAD model. All of

the individuals from this sample reported a favorable attitude towards physical activity due to the

benefits they gained from it. These benefits have been reported earlier in this chapter.

Other personal factors discussed by participants included level of injury or condition, and

self-efficacy. In this investigation level of injury or condition, was assessed by asking

individuals why they used a wheelchair. Answers varied, but most of the participants with a

spinal cord injury indicated that their level of injury did not limit function in their hands or arms.

Others reported congenital conditions such as cerebral palsy, spina bifida, or did not specify their

injury. No one reported that his or her condition or injury limited hand or arm function, which

appears to be reflected in the higher than average levels of physical activity reported by the

participants in this sample.

There are a range of other participant quotations that support the linkages between the

constructs shown in Figure 3-1. For instance, this sample included several elite wheelchair

athletes whose goals included making future Paralympic basketball teams. For instance, one

man said, "My main goal now is to get a gold medal," as he discussed his chances of making the

next Paralympic team. In addition to such high-reaching goals, others mention exercise-related

goals, as well as future educational and occupational goals. In order to achieve these goals the

participants must have perceived and therefore experienced the social, physical, and

psychological benefits of physical activity. Additionally, the quotes discussed above also reflect

a sense of self-efficacy beliefs about the participants' ability to achieve these goals.










A B


Figure 3-2. A grounded theory of the determinants of physical activity and the role it plays in
subjective QOL.







































Figure 3-1. Triadic reciprocal causation adapted from Bandura (1997) representing the three
major determinants of behavior. B represents behavior; P the internal cognitive,
affective, and biological events; and E the external environment.


I P


I I


I I


Table 3-1. Means and standard deviations for the PASIPD


Sample Mean


Subcategory
Home Repair/Gardening
Housework
Vigorous Sport
Moderate Sport
Work not for Exercise
Total


SD
.55
2.68
13.68
5.53
7.92
15.28


.16
2.49
18.62
5.33
9.73
36.34









which the respondents discuss their overall happiness in more general terms over their lifetime.

These descriptions also tended to be longer and more vivid than other responses.

For instance, when asked if sports improved her quality of life this 31 year-old female with

a score of 36.87 on the PASIPD discussed how basketball and the school she attended impacted

her life.

When I got hurt I was in this horrible 16 inch chair with push handles and arm rests and
brakes and all sorts of horrible things because I didn't know any better, but then when I
went to Illinois an met all these other wheelchair athletes I discovered the whole
wonderful world of well moving, really nice, lightweight well-fitted wheelchairs and so,
if I hadn't had that I think life would be harder just because I' d be in a bigger chair with
more junk on it which means it would be harder to push around and so I think absolutely
in just learning and just seeing the impact of strength and how much of a difference that
makes, the stronger you are the easier everything is.

As can be seen from the quote, this person's life was greatly impacted by her participation

in sports. More specifically, the culture in place already at the school and the athletes there

introduced her to new equipment that made her life easier than it was before she arrived.

A 47 year-old basketball player who operates a not-for-profit program that teaches water

skiing to children with disabilities provided another powerful quote.

So I know it changes people's lives. That' s the great thing that sports does right there.
Not only does it make you healthier, mentally it can change your life...1ike I said, sports
is probably the single most important thing or has been the single most important thing
since I've been injured. If I could turn back the hands of time, I'd still be sitting here in
this chair. I wouldn't change a thing. Because I know it' s made my life so much better.

This quote exemplified just how powerful an impact physical activity, in this case sport,

can have on an individual's life. This particular individual was so profoundly affected by his

participation in sport that he began to view his paralysis as a positive life change. Another male

participant aged 46, and a former basketball player at the highest level of wheelchair basketball

shared a similar sentiment.









function for individuals with physical disabilities (Washburn, Zhu, McAuley, Frogley, & Figoni,

2002). This instrument consisted of five subscales: home repair/lawn and garden work,

housework, vigorous sport and recreation, moderate sport and recreation, and occupational

activities. The PASIPD requested respondents to indicate how often during the past seven days

they participated in various activities at home and outside the home as never, seldom (1-2

days/week), sometimes (3-4 days/week), or often (5-7 days/week) and on average how many

hours a day they participated hourou, 1 but <2 hours, 2-4 hours, >4 hours. With regard to the

occupational item 13, the response categories include <1 hour, 1 but < 4 hours, 5 but < 8 hours, >

8 hours. Scores for the PASIPD are computed by multiplying the average hours per day by an

estimated MET value based upon the intensity of the activity; this scoring procedure results in a

mathematically maximum score of 199.5 and estimated MET values for each of the five factors

and a total score. Washburn et al. (2002) demonstrated preliminary evidence of the construct

validity of the PASIPD and the five latent factors using factor analytic and correlational

analyses.

Their data also resulted in total PASIPD scores of 24.6 + 14.6 for individuals a ed 51 and

youn er and 16.5 + 13.4 for those older than 51. The mean total score for males on this measure

was 20.5 + 15.1 while the avera e for females was 19.9 + 13.5. Finally individuals who self-

reported no activity at all had a mean of 13.2 + 12.1, those who reported moderate activity had a

mean of 19.8 + 12.7, and individuals who self-r ported extreme activity had a mean score of 30.7

+ 14.0. These means will allow me to group participants for this thesis by their level of activity.

With regard to males and female participation in vigorous sport and physical activity the two

Brou s were virtually the same scoring an avera e MET hours/da of 2.9 + 6.6 and 2.7 + 6.7 for

males and females respectively.









included persons who introduced participants to adaptive sport or physical activity (i.e. social

influences), the social aspects of the sports participants chose to participate in, and the

availability of facilities and programs that facilitated or helped to sustain involvement. In the

PAD model, social influences are a separate construct from environmental facilitators. These are

referred to as facilitators because they increase the likelihood of participation in sports by

making sports more fun and by providing a place to participate. In contrast, perceived barriers

could include a lack of available facilities, lack of assistance from others, or physical activity that

does not lend itself to social opportunities.

As was reported in the previous section, many of the participants in this investigation

reported social influences and benefits as a result of their participation in physical activity and

sport. In the context of this investigation, social influences are considered an environmental

factor that facilitates physical activity for persons with disabilities as per the PAD model (van

der Ploeg et al., 2004). For instance, one woman, who scored a 51.49 on the PASIPD and was

3 5 at the time of the interview, spoke briefly about how she became involved in wheelchair

sports saying, "I lucked out, when I was doing my rehabilitation, there was a gentleman there

that competed internationally and he's actually our coach... and he introduced me to basketball."

Another female basketball player, who was 21 years old and scored a 40.87 on the PASIPD,

spoke about her family saying, "It was never, 'Oh, Emily can't play.' It was always, 'that' s my

sister and she's going to play with us.'" Finally, one last female basketball player, aged 21 years

with a PASIPD score of 52.69, mentioned her doctor saying, "I got exposed to wheelchair sports

because my doctor at Johns Hopkins." Eleven of the twenty-six participants mentioned the

person who influenced them to become physically active.










Abstract of Thesis Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Master of Science

PHYSICAL ACTIVITY AND QUALITY OF LIFE EXPERIENCED BY PARTICIPANTS OF
A WHEELCHAIR BASKETBALL TOURNAMENT

By

Michael A. Stancil

August 2007

Chair: Peter R. Giacobbi, Jr.
Major: Applied Physiology and Kinesiology

Quality of life is a construct that has different meanings for researchers in various

disciplines. Within the medical field, QOL is conceptualized as the presence or absence of

symptoms while those in physical or occupational therapy might evaluate the ability to complete

functional tasks of daily living. Within psychology researchers emphasize subj ective assessments

of well-being or happiness or how individuals interpret their own lives, goals, achievements, and

subj ective evaluations.

My study used a subj ectively oriented approach to examine physical activity and

subjective assessments of life quality with 26 individuals with physical disabilities. The

participants completed the Physical Activity Scale for Individuals with Physical Disabilities

(PASIPD) and a semi-structured interview focused on the physical activity experiences and the

role those experiences played in their subj ective evaluations of the participants' lives. The

physical activity for persons with disability model and Dijkers' conceptualization of subj ective

quality of life served as sensitizing concepts during the analysis phase. Grounded theory

analyses revealed that participants of a wheelchair basketball tournament perceived a number of

psychological, social, and health benefits associated with physical activity involvement. These









convergent and divergent validity between a number of personality scales and other subj ective

well-being scales (Diener et al., 1985). The SWLS is a uni-dimensional measure and has been

validated for a wide range of age groups (Pavot, Diener, Colvin, & Sandvik, 1991). Other QOL

measures contain sub domains that measure work, self, primary social contacts, acceptance by

others, recognition, and prestige (Landers & Arent, 2001). Pavot and Diener (1993) also

demonstrated that self-reports correlated highly with reports made by peer, family members, and

friends.

The SF-36 measures health related QOL by taking both mental and physical health and

breaking each down into four scales for a total of eight scales ranging from 2 items to 10 items

(Ware, Kosinski, & Dewey, 2000). The score for physical health is broken down into scales for

physical function, role-physical (e.g. work activity or activities of daily living), bodily pain, and

general health (Ware, Kosinski, and Keller, 1994). Likewise, mental health is measured on

scales of vitality, social functioning, role-emotional (e.g. how emotions affect work or ADL),

and mental health. These items are scored on a Likert scale, which range from 1-3, 1-5, or 1-6

depending on the specific item (Ware et al., 2000). The SF-36 has been shown to be valid and

reliable measurement of HRQOL for the general population as principal component analysis

confirmed the two-factor higher-order structure for this instrument across a range of samples

(Ware et al., 2000). Because the SF-36 was designed and validated with able-bodied individuals

it is generally not recommended for use with individuals with disabilities (Hayes, Hahn, &

Marshall, 2002). However, recent recommendations in the literature have demonstrated how

specific items on the SF-36 can be modified to be more pertinent for this group (Tate,

Kalpakjian, Forchheimer, 2002).









CHAPTER 4
DISCUSSION

Conclusion

In this chapter I will summarize the findings of this exploration of the role of physical

activity in subjective quality of life for individuals with physical disabilities. I will also discuss

how the findings from this study contribute to and extend the extant literature. Finally, I will

review study limitations and examine possible applications of the findings in real-world settings.

The purposes of the present study were to explore the role that physical activity plays in

the subj ective quality of life in individuals with physical disabilities. Also investigated were the

determinants of physical activity and factors perceived by the participants that may have helped

sustain their participation in physical activity. As shown in the previous chapter, the participants

discussed a range of emotional, cognitive, and behavioral benefits from physical activity such as

"feeling good," staying focused, and developing a work ethic. In addition to these psychological

benefits, the participants in this sample also reported social and physical health benefits. The

social benefits reported included meeting friends, being able to spread a message, and positively

influencing disabled peers, able-bodied peers, and children. The physical benefits included pain

management, staying in cardiovascular shape, and developing muscle. In some cases these

perceived benefits of physical activity also provided motivation for participants to continue their

participation.

The findings from the present study suggest conceptual support for predictions put forth by

Dijkers (2005). That is, the present study adds further specificity and clarity about the role that

participation in physical activity plays in maintaining subjective quality of life. In Dijkers'

conceptualization, subjective QOL included achievements, goals, and subjective evaluations.

Specifically, when individuals' achievements meet or exceed their previously held goals or









participation in physical activity behaviors. One problem however is the data make it difficult to

disentangle any differential impact the perceived social opportunities and benefits that resulted

from participation in physical activity with those derived from physical activity itself. From

either perspective, the participants in this sample, who were relatively active as indicated by the

data reported about activity from the PASIPD, appeared to be happy, well adjusted, and

experiencing positive subj ective quality of life.

With regard to factors predicting physical activity by individuals with disabilities, the

PAD model suggested that environmental factors and personal factors played a role in

participation (van der Ploeg et al., 2004). Environmental factors included social influences and

barriers and facilitators in the environment, while personal factors encompassed health condition,

attitude, and barriers and facilitators in one's personal life (van der Ploeg et al., 2004). The

Endings from this investigation lend support to this model and suggest that social/environmental

factors are implicated in decisions to initiate and sustain physical activity behaviors for

individuals with physical disabilities. For instance, eleven participants from the sample spoke

about the individuals who influenced them to become physically active such as doctors, coaches,

and family members. Twenty-three of the participants interviewed reported that they gained

tremendous satisfaction from the varied social aspects of their chosen sports. These social

benefits included meeting friends, spreading a message, being a role-model, opportunities to

travel, and receiving scholarships.

Another main construct in the PAD model that predicts activity behavior are personal

factors. As previously stated, personal factors include self-efficacy, health condition, attitude

toward the behavior, and personal facilitators and barriers such as available time, gender, age,

and motivation. Factors such as age and gender did not appear to influence participation in










dynamic interplay between psychological, emotional, and physical health domains reviewed in

previous sections. Other researchers, who see QOL as an umbrella term for multiple outcomes as

it relates to health, have echoed this sentiment. (Rejeski & Mihalko, 2001). According to Diener

subjective well being, a term closely related to quality of life (Rej eski & Mihalko, 2001) can be

broken down into the smaller components of life satisfaction, satisfaction with important

domains, positive affect, and low levels of negative affect (Diener, 2000). One common

underlying assumption within subj ective definitions of one's QOL is that individuals judge for

themselves whether they are satisfied with their current circumstances or not. It is this subj ective

dimension of QOL that will be embraced within the current investigation because as will be

discussed physical activity, recreation, and high levels of community integration are all

associated with positive affective experiences and quality of life.

Measuring Quality of Life

As discussed above quality of life researchers have produced many conceptual definitions

and measurement instruments to assess this construct: Berger and Motl (2001) estimated that

over 300 scales have been produced that measures quality of life. Because of the plethora of

quality of life scales and due to the fact that my thesis will adopt a subj ective approach to

assessing this construct I will only review the psychometric characteristics of two widely used

instruments: the SF-36 (Ware, Kosinski, & Dewey, 2000) and the Satisfaction with Life Scale

(Diener, Emmons, Larson, & Griffin, 1985).

The Satisfaction with Life Scale is a five-item survey that includes statements such as, "In

most ways my life is close to ideal," and "If I could live my life over, I would change almost

nothing," (Diener, Emmons, Larson, & Griffin, 1985). Respondents give answers based on a 7-

point Likert Scale, so scores can range from 5 to 35. The SWLS was shown to have adequate

internal consistency (a = .87) and a two-month test-retest reliability (a = .82), and it has









The reason that many wheelchair users experience pain in the shoulder is attributed to the new

role of the shoulder as a weight bearing j oint, something it was not designed to do (Taylor &

Williams, 1995; Bayley, Cochran, & Sledge, 1987). Another cause of shoulder pain is thought to

be muscle imbalance around the shoulder joint (Burnham, May, Nelson, Steadward, & Reid,

1993; Miyahara, Sleivert, & Gerrard, 1998). A question that arose was whether sports

contributed to earlier onset and increased occurrence of shoulder pain or whether the increased

strength and endurance of wheelchair athletes would help to prevent pain. The purpose of

Fullerton et al.'s study was to compare onset and prevalence of shoulder pain in athletic and non-

athletic wheelchair populations. The authors developed their own 20-item questionnaire to give

to participants. They mailed the questionnaire, along with an informed consent form to 500

random individuals using the Virginia Spinal Cord Injury Registry. To gain more responses

from athletes, they also published the questionnaire in a newsletter for a leading wheelchair

sports organization. To qualify as an athlete for this study the individual must have: 1) trained at

least 3 hours per week, 2) be involved in at least 3 competitions per year, and 3) had a

wheelchair which had been modified for sports. Basketball was the most represented sport with

51% of the respondents. Athletes made up two-thirds of the sample, while the remaining third

served as the comparison group.

Forty-eight percent of the subj ects (N = 257) reported shoulder pain at the time of

questionnaire completion. After dividing the group into athletes and non-athletes, the authors

found that 66% of non-athletes reported pain, while 39% of athletes reported pain. Additionally,

findings from this study contradicted earlier findings that quadriplegic had more shoulder pain

than paraplegics.










experiences in turn allowed the participants to develop self-efficacy beliefs and expectations that

facilitated future involvement in their chosen physical activities. By all accounts the participants

in this sample were generally very active and appeared to experience subj ective well-being.









this construct using the Rand-36, which combines scales of physical health, mental health, and

global health to measure quality of life (Hays, 1998). The participants were 22 men and 18

women, the maj ority of which had suffered either a traumatic brain injury (TBI) or a stroke.

Their ages ranged from 20 to 66 with close to half living at home and the rest living with family,

friends, or in community homes. Potential participants were excluded if they did not have the

capacity to self-report. The participants completed surveys concerning attitudes towards

disability, acceptance of disability, community integration and quality of life. Family members

or other caregivers filled out surveys measuring functional independence and assessing function.

They found that better quality of life was positively related to greater acceptance of

disability and a positive attitude towards disability. The authors also linked positive attitudes

about oneself to more self-confidence and seeking out others' company as well as more active

lifestyles (Snead & Davis, 2002). This is important because it suggests that encouraging

individuals with TBI to have more positive attitudes about their disability may lead them to

become more active.

Snead and Davis (2002) admitted they were limited in the fact that they could not

determine which variables acted as catalysts for improving attitudes, acceptance, and quality of

life. They suggested that qualitative research could improve understanding of how these

attitudes are developed and influenced.

Differences in quality of life between individuals are predicted by several different

factors (Berger & Motl, 2001). According to Diener, Oishi, and Lucas (2003) an individual's

personality is moderately to strongly correlated with subj ective well-being. They reached this

conclusion after years of research indicated that external factors had only a modest impact on

reported subjective well-being (Deiner, Suh, Lucas, & Smith, 1999). Additionally, research has






























To my wife, Leah.










Recommended Physical Activity by: Age. Retrieved February 22, 2007, from
http://apps. nced. cdc.gov/PASurveillance.

Charmaz, K. (2000). Grounded theory: Objectivist and constructivist methods. In K. Charmaz
(Ed.), H~andbook of qualitative methods (2nd edition ed., pp. 509-535). Thousand Oaks,
CA: Sage Publications Inc.

Craft, L.L., & Landers, D.M. (1998). The effect of exercise on clinical depression and
depression resulting from mental illness: A meta-analysis. Journal of Sport and Exercise
Psychology, 20, 339-357.

Cooper, R.A., Quatrano, L.A., Axelson, P.W., Harlan, W., Stineman, M., Franklin, B. (1999).
Research on physical activity and health among people with disabilities: A consensus
statement. Journal ofRehabilitation Research & Development, 36 (2), 142-154.

Curtis, K.A., Drysdale, G.A., Lanza, R.D., Kolber, M., Vitolo, R.S., & West, R. (1999).
Shoulder pain in wheelchair users with tetraplegia and paraplegia. Archives ofPhysical
and Medical Rehabilitation, 80, 453-457.

Dale, G.A. (1996). Existential phenomenology: Emphasizing the experience of the athlete in
sport psychology research. The Sport Psychologist, 14, 17-41.

Damiano, D.L., Kelly, L.E., Vaughan, C.L. (1995). Effects of quadriceps femoris muscle
strengthening on crouch gait in children with spastic diplegia. Physical Thelpay, 75, 658-
671.

Damiano, D.L., Vaughan, C.L., Abel, M.F. (1995). Muscle response to heavy resistance
exercise in children with spastic cerebral palsy. Developnzental medicine and Child
Neurology, 37, 731-739.

Darrah, J., Fan, J.S.W., Chen, L.C. (1997). Review of the effects of progressive resistance
muscle strengthening in children with cerebral palsy: A clinical consensus exercise.
Pediatric Physical Therapy, 9, 12-17.

Diener, E. (1994). Assessing subjective well-being: Progress and opportunities. Social
Indicators Research, 31, 103-157.

Diener, E., Emmons, R.A., Larson, R.J., & Griffin, S. (1985). The Satisfaction with Life Scale.
Journal ofPersonality Assessment, 49, 71-75.

Diener, E., Oishi, S., & Lucas, R.E. (2003). Personality, culture, and subjective well-being:
Emotional and cognitive evaluations oflife. AnnualReview ofPsychology, 54, 403-425.

Diener, E. Suh, E.M., Lucas, R.E., & Smith, H.E. (1999). Subjective well-being: Three decades
of progress. Psychological Bulletin, 125, 276-302.









and Wang's (2005) study, most obesity data came from self-report surveys. Research has shown

that estimates of obesity prevalence are much lower for self-report data than for those based on

measured data (Flegal, Carroll, Ogden, & Johnson, 2002). Nevertheless, the rate of obesity for

adults with disabilities was 66% higher than for able-bodied adults (Rimmer & Wang, 2005).

Rimmer and Wang used measurements of body mass index (BMI) to determine whether

individuals in their sample were overweight, obese, or extremely obese with a sample of 306.

The authors obtained height and weight measurements in order to calculate BMI. Then they

compared the prevalence of obesity from their sample to data collected previously for able-

bodied adults and published self-report data for individuals with disabilities (Rimmer & Wang,

2005).

Results showed that there were higher rates of overweight, obese, and extremely obese

individuals in the disability sample versus the able-bodied sample. The highest prevalence of

obesity and extreme obesity occurred amongst those with arthritis and diabetes. Examination of

race and gender revealed that females with disabilities are 4 times more likely than disabled

males to fall into the extreme obesity category, while African American women with disabilities

were at the greatest risk for obesity and extreme obesity (Rimmer & Wang, 2005).

Cooper et al. (1999) echoed the sentiment that persons with disabilities are at greater health

risks than the able-bodied population. Part of this is due to the fact that physical inactivity

occurs disproportionately among the disabled population. Aside from benefits in cardiovascular

health, physical activity can also be beneficial by increasing muscular strength and flexibility.

That will in turn improve the ability to perform activities of daily living (Cooper et al., 1999).

Physical activity was also recommended for children with disabilities. Cooper and colleagues









ACKNOWLEDGMENTS

I would like to first thank my wife who has stood beside me and encouraged me when

completing this thesis seemed impossible. I am also extremely appreciative to my advisor for all

of his efforts, patience, and time during this entire process. Also I want to thank all the

wheelchair athletes who took part in this study and agreed to share their experiences with a

complete stranger. Finally I would like to thank my parents, Mark and Patricia Stancil, for

always encouraging me in school and beyond.



































O 2007 Michael Adam Stancil









context of healthcare, Kaplan suggested that the goal of health professionals should not only be

to extend people's lives, but also to make their lives worth living by maintaining each

individual's ability to function. Kaplan gives the example of possible treatments for prostate

cancer. In the past doctors would have aggressively treated the tumor with radiation or surgery.

In many cases this could lead to impotency and incontinency, which may lead to decreased

ability to function normally (Kaplan, 1994.) If the doctors applied the Ziggy Theorem, they

would have taken the patient' s preference into consideration, which might mean avoiding

aggressive treatment.

In order to assess functioning and QOL, Kaplan and Anderson developed the quality of

well-being scale (QWB; Kaplan & Anderson, 1988.) The QWB scale assesses well-being at a

specific time point so the patient is giving their health status for one particular day. This

instrument classifies functioning on scales of mobility, physical activity, and social activity.

Additionally, the QWB scale contains a list of possible symptoms that a patient can choose from

as the most undesirable for them (Kaplan, 1994). Once a patient has been classified in an

observable health state the next step is to place them on a scale of wellness from 0-1.0 (with 0

indicating death and 1.0 indicating good health with no symptoms). In order to achieve this, the

health states are weighted according to ratings obtained from human value studies. These

weights provide quantifieation for the relevant importance of "doin' stuff' (Kaplan, 1994).

The Einal piece of the puzzle in the Ziggy Theorem is the duration in a particular state of

health. One year in a state of health that has been assigned a weight of 0.5 is equivalent to one

half of a quality adjusted life year (QALY). Basically the QWB scale takes a rating of well-

being from a specific point in time and applies it to a longer duration of time assuming that the

individual will remain in that health state for the longer duration. Conceptually, one QALY












TABLE OF CONTENTS


page

ACKNOWLEDGMENTS .............. ...............4.....


LIST OF TABLES ............ ..... .__ ...............7...


LIST OF FIGURES .............. ...............8.....


AB S TRAC T ......_ ................. ............_........9


CHAPTER


1 INTRODUCTION ................. ...............11.......... ......


Study Population................... .. .... ...............1
Conceptual Issues in the Study of Quality of Life.................... ..... ........ ...... ............ ...1
Theoretical Models of Quality of Life for Individuals with Physical Disabilities .................19
Empirical Studies on the QOL Construct ................. ...............27...............
Measuring Quality of Life ................. ...............3.. 1.............
Purpose .............. ...............45....

2 METHODS .............. ...............48....


Participants .............. ...............48....
M measures ................. ...............48.......... ......
Data Analy sis............... ...............50

3 RE SULT S .............. ...............54....


Descriptive Statistics ................ .... ...............54.
Interview Results: Higher Order Themes ................ ...............55........... ...
Proposed Grounded Theory ................. ...............64................

4 DI SCUS SSION ................. ...............74................


Conclusion ............... ............ ... .... ........ .............7
Practical Applications and Future Directions ................. ...............77........... ...
Study Limitations............... ...............7
Summary ................. ...............78.................

APPENDIX


A INTERVIEW GUIDE............... ...............80.


B THEMES FROM THE DATA ................ ...............82........... ...


C THE PHYSICAL ACTIVITY SCALE FOR PERSONS WITH DISABILITIES .................85










compare differences between males and females on the total PASIPD score. The results of this

test proved non-signifieant t(24) = .48, p = .64.. The sub scale scores representing vigorous sport

and light/moderate sport were well above the averages reported by Washburn et al. (2002) in

their validation study and ranged from 2 to 42.57 and 0 and 23.15, respectively. In contrast, the

participants in this sample reported less activity with regard to occupation as the means here

were ~ one standard deviation below those reported by Washburn et al. (2002). In short, the

participants in the current study were relatively active as they reported participation in moderate

and vigorous sport activities and had higher total scores than Washburn et al. (2002) as shown in

Table 3-1.

Interview Results: Higher Order Themes

Psychological Benefits. The results of the coding process described above are shown in

appendix B. As shown, 5 higher-order themes (psychological benefits, physical health, social

influences, social opportunities, and increased overall quality of life) were defined by 16 more

specific first-order themes. The psychological benefits higher-order theme was defined by the

first-order themes of cognitive benefits (N = 10), emotional benefits (N = 15), behavioral

benefits (N = 8), and self-perception (N = 15). Ten participants mentioned that they benefited

cognitively from participation in physical activity. One participant, a 21 year-old male who

scored a 47.97 on the PASIPD, said,

I've actually developed a pretty good mental strength through basketball. You really have
to stay focused and concentrate and like doing it back to back has not only helped me
physically but mentally to get through a whole 40 minutes of basketball.

In addition a 43 year old female who scored a 30.75 on the PASIPD stated, "I don't know I

guess more specific to basketball I guess than in general, but the ability to get better at something

and learn new skills. I thought, I wasn't sure that was possible, you know."









physical activity in this sample as no differences were observed in activity levels between gender

or between age groups within the interview data. The lack of differences discerned within the

interviews between these groups could be due to sampling issues (e.g., the highly active sample)

or for other methodological reasons described below.

Practical Applications and Future Directions

The results from this investigation offer practitioners several recommendations for

practice. The first application could be at the policy level. While physical activity has been

previously recommended for individuals with disabilities (Cooper et al., 1999), the reasons have

been almost exclusively physical. In the future health professionals should also emphasize the

social and psychological benefits of sport participation as suggested by the participants in this

study and previous research (Giacobbi et al., 2006). A second more community or family

oriented series of recommendations can be gleaned from the participants' reports about important

influences that opened opportunities for physical activity. As demonstrated from the participant

quotations, family members and caregivers of individuals with physical disabilities can play a

facilitative role by encouraging, modeling, or actively persuading persons to be active. In

contrast, it is highly possible that individuals could also encourage or model sedentary behaviors

that could then influence individuals with disabilities to be inactive. While the findings here

probably do not generalize to less active individuals, it would be interesting to examine how

community or family based interventions could facilitate involvement in physical activity

behaviors over time. Specifically, the participants initial involvement in physical activity

behaviors were either encouraged or modeled by influential others and these experiences

facilitated formation of initial self-efficacy beliefs regarding these activities which then perhaps

allowed the participants to sustain these behaviors over time. An interesting theoretical and










and brushes and things so that I didn't have to bend and...so I tend to be a bit more
creative with the things I'm doing. Innovative.

She also added, "Well I'm a smoker. So when I'm playing tennis or working out I'm not

smoking. So that' s a nice way to keep myself busy so I don't smoke."

Another participant, a 21 year-old female who played college basketball and scored a

52.69 on the PASIPD, said, "Um, I think my ability to adapt to pretty much any environment and

to pretty much anybody." A 24 year-old female basketball player (PASIPD = 16.59) added, "So

it' s helped me translate a lot more responsibilities into 'alright, that' s how hard I work at

basketball, I got to work that hard for school and other stuff. '"

Finally, a marathoner and former college basketball player (PASIPD = 35.6) reported that

athletics helped her become more outgoing. In fact, she revealed that she would have declined an

interview before she became active in sports.

I used to be a really, really shy person as a kid when I was a kid. And through athletics
I've been like...I can sit here and have this conversation with you, like a complete
stranger, I don't know you. When I was younger I would have been like, No, I'm not doing
an interview.

In all, eight participants reported changes in behavior as a result of their sport and physical

activity participation ranging from improved work ethic and adaptability to smoking less and

being more outgoing.

The fourth and final psychological benefit was labeled improved self-perception. This

label referred to interviewees who viewed themselves differently as a result of participating in

athletics or physical activity. Some participants discovered attributes about themselves that they

were previously unaware of prior to their activity experiences. One example is of a 22 year-old

female with a PASIPD score of 35.33. She had one leg amputated as a result of a tumor when

she was eleven years old and transferred to her current school for the sole reason to play

wheelchair basketball.









Interview Guide. An interview guide was developed for the purposes of this study (See

Appendix A). Although an interview guide was used during all interviews, a semi-structured

approach was used as the flow of conversation dictated the questions asked to the participants.

The interview questions focused on the following: (a) the nature and etiology of the participants'

disabilities, (b) occupational or school related questions, (c) perceived benefits of physical

activity, (d) motives that sustain involvement in physical activities. Probes were used throughout

the interviews to encourage the participants to expand upon specific ideas, experiences, and

incidents that highlighted their physical activity experiences. The author and another graduate

student conducted all interviews, which lasted between 30 to 90 minutes.

Procedure. A purposive sampling procedure was used in an effort to recruit physically

active individuals with physical disabilities. The participants were recruited with help from a

member of the research team who facilitated a wheelchair basketball tournament at the

Lakeshore foundation in Birmingham Alabama (Dr. Brent Hardin in the Department of

Kinesiology). During this tournament individuals familiar with this member of the research team

were approached and asked to participate in this study. I conducted 14 of the interviews while a

graduate student advisee of Dr. Hardin interviewed the remaining 12 participants. Institutional

approval was obtained from the University of Florida Institutional Review Board (IRB) prior to

data collection.

Data Analysis

Grounded theory procedures guided the present analysis (Charmaz, 2000). The author

used open- and focused-coding of interview text, the use of memos, constant comparisons,

sensitizing concepts, and the development of theory (Charmaz, 2000). The following data

analytic procedures were followed in this investigation:










(1999) felt that in addition to physical benefits, children would also benefit socially because

sports can help develop self-esteem, social integration, and learning social and team skills.

Jacobs et al. (2001) used a circuit-training program for 10 men with SCI between the T5

and L1 levels and between the ages of 28 and 44. Prior studies of physical activity in this

population used arm ergometry and wheelchair ergometry, which often caused injuries in the

upper extremities and as a result, hindered the participants' abilities to perform activities of daily

living. They also cited a lack of studies that reported both strength and endurance outcomes. As

a result, Jacobs et al. proposed a 12-week circuit-training program as a safe and effective

program for increasing cardio-respiratory endurance and muscular strength by targeting

important muscle groups such as the upper trunk, shoulders, and upper back. These muscle

groups were reported as especially weak for persons with paraplegia. In addition to

strengthening muscles, the program also sought to stretch certain muscles to increase range of

motion as well as stability and balance in the shoulders. The intensity of the workouts were

based on the percentage of peak muscular effort required to push a wheelchair, depress and

transfer body, and elevate and support the body during pressure relief. These activities were

singled out because they are tasks that require the most muscular effort and generate the most

pain and feelings of weakness among individuals with paraplegia (Jacobs et al., 2001). The

participants took part in a 12-week training program that required them to attend 3 sessions per

week. Each session lasted 40-45 minutes and combined weight training with arm cranking

activities. Each individual would perform one set of exercise at each station before moving on to

the next in this circuit program. All participants completed the 12-week program without any

medical complications.










any loss or abnormality of structure or function in the body. An individual with paralysis of the

lower extremities would be considered to have an impairment. If that same person is prevented

or restricted from executing a task or activity, or is otherwise functionally limited as a result of

their impairment, they would be said to have a disability. This person would be considered to be

handicapped if accommodations were not made in order to allow the person to live a normal life.

For example, this individual would be handicapped if steps were not taken at the work place such

as building ramps or making the restrooms wheelchair accessible.

Recently the term activity has replaced disability. Activity refers to the type and level of

functioning displayed at the individual level. For instance it could refer to a person's ability to

take care of him or herself, walking, or communicating (Hays et al., 2002). Also, the term

handicap has been replaced by participation. Participation describes the level and degree of a

person' s involvement in life situations. An individual's level of participation can be affected by

personal or environmental factors (Block, Griebenauw, & Brodeur, 2004).

Types of disabilities vary from physical to developmental, congenital to acquired, and mild

to severe. For example, an individual with multiple sclerosis is said to have a congenital

physical disability because they are born with their disability. A common acquired physical

disability is spinal cord injury, which may result, from among other things, a spinal tumor or a

car accident. The focus of this thesis will be on patterns of physical activity and subj ective QOL

for individuals with physical disabilities who have either acquired their disability or were born

with their condition.

Conceptual Issues in the Study of Quality of Life

The definition of quality of life has undergone tremendous debate in recent years (Fayers,

Hand, Bjordal, & Groenvold, 1997; Rejeski & Mihalko, 2001; Dijkers, 2005). At the broadest

level, QOL researchers and theorists can be characterized by their focus. One group of









My quality of life I think is better now than it was before I got hurt. I do a lot more, I see a
lot more, um, I couldn't say I would have done half of what I have done if I hadn't suffered
a spinal cord injury.

This college aged female basketball player evaluated her activity experience in a positive

way. She said, "I like the feeling you get from doing things ... I like feeling fit." A 29 year-old

man added, "I feel like it [b-ball] gave me back a lot of self esteem."

In this chapter I reported descriptive statistics on the sample in addition to presenting

higher and first-order themes that emerged from the interview data. I also provided quotations to

lend more support to the themes. In the latter section of the chapter I proposed a grounded

theory based in part on the PAD model (van der Ploeg et al., 2004), a subj ective definition of

QOL (Dij kers, 2003), and used Bandura' s (1997) notion of triadic reciprocal causation. The

grounded theory suggests that physical activity participation by individuals with disabilities is

influenced by personal and environmental factors. Physical activity participation then plays a

role in subj ective QOL by increasing the opportunity to set and meet goals in a sport or exercise

setting thus resulting in more favorable evaluations of those events. The results from this

investigation will be discussed in further detail in the last chapter.









CHAPTER 1
INTTRODUCTION

In recent years there has been increased focus on the importance of quality living (Hays,

Hahn, & Marshall, 2002; Ware, 2000). In fact, an informal search of Medline (Pubmed) data

base using the search terms "quality-of-life" (QOL) resulted in 65,522 hits involving all

publications focused on human beings while an identical search on the Psychinfo data base

resulted in 13,506 publications. This research attention is justified because quality-of-life is an

important predictor of diverse outcomes including physical and mental health, happiness at work

and satisfaction in interpersonal relationships (Deiner, 2000).

In able-bodied samples, subjective well-being, a psychological construct related to

subj ective QOL, has been shown to be correlated to various specific domains in a person' s life

(Rejeski & Mihalko, 2001). Variables such as age, education level, social class, income, marital

status, employment, religion, leisure, life events, social skills, and health all can affect happiness,

although most effects are small (Argyle, 1999). The strongest effects are seen from marriage,

occupational status, leisure, health, and social skills. Others have suggested that since humans

have an instinctual urge to belong, developing and maintaining close relationships with others

plays a role in happiness (Myers, 1999). Additionally, it has been posited that when people

report well-being, they will often compare themselves to others. The level of reported well-

being may depend on whether comparisons were made to others who are better or worse off than

the individual (Schwarz & Strack, 1999).

The focus of this thesis is on quality-of-life with individuals with physical disabilities. As

will be shown there is a plethora of published studies focused on QOL with able-bodied

individuals. However, only recently have researchers extended this line of inquiry to individuals

with physical disabilities. Additionally, there is no one accepted definition of the QOL construct










past experience (van der Ploeg et al., 2004). As has been mentioned before, there is a

relationship between disability and functioning and contextual factors such as the environment

and personal factors. Age is one personal factor that may have an impact on a person's

functioning, as is lifestyle. An active individual who acquires an injury may decide to pursue an

active lifestyle post-injury sooner than someone who was not active simply because they were

active before their injury (Wu & Williams, 2001).

The ICF model is a broad and multidimensional tool that is used to assess health status in

persons with and without disabilities. It has utility in rehabilitation settings as well as research.

Clinicians can use this tool to assess the impact of disability on an individual's ability to function

while researchers can use this model in order to provide results in a more uniform manner.

Another theoretical model is the physical activity for people with disability model (PAD;

van der Ploeg et al., 2004). The PAD model combines the ICF framework with elements of the

attitude, social influence and self efficacy model (ASE; De Vries, Dijkstra, & Kuhlman, 1988) to

create a new model that shows which variables determine physical activity behavior of

individuals with disabilities (van der Ploeg, 2004). In order to explain the PAD model, however,

it is important to first discuss the ASE model and its framework.

The attitude, social influence, and self-efficacy (ASE) model, developed by De Vries and

colleagues (1988), combines the self-efficacy element of social learning theory (Bandura, 1977)

with the attitude and subj ective norms constructs from the theory of reasoned action (Fishbein

and Ajzen, 1975). These three psychosocial determinants of behavior are considered to be the

most important (van der Ploeg et al., 2004). In the ASE model (See Figure 1-2), behavior results

from intention to engage in a particular behavior. The intention towards a certain behavior is

determined by a combination of self-efficacy, attitudes, and social influence towards a behavior










APPENDIX C
THE PHYSICAL ACTIVITY SCALE FOR PERSONS WITH DISABILITIES

Leisure Time Activity
1. During the past 7 days how often did you engage in stationary activities such as reading,
watching TV, computer games, or doing handcrafts?
a. Never (Go to question #2)
b. Seldom (1-2 days)
c. Sometimes (3-4 days)
d. Often (5-7 days)
On average, how many hours per day did you spend in these stationary activities?
a. Less than hour
b. 1 but less than 2 hours
c. 2-4 hours
d. More than 4 hours

2. During the past 7 days, how often did you walk, wheel, push outside your home other than
specifically for exercise. For example, getting to work or class, walking the dog, shopping, or
other errands?
a. Never (Go to question #3)
b. Seldom (1-2 days)
c. Sometimes (3-4 days)
d. Often (5-7 days)
On average, how many hours per day did you spend wheeling or pushing outside your
home?
a. Less than hour
b. 1 but less than 2 hours
c. 2-4 hours
d. More than 4 hours

3. During the past 7 days, how often did you engage in light sport or recreational activities such
as bowling, golf with a cart, hunting or fishing, darts, billiards or pool, therapeutic exercise
(physical or occupational therapy, stretching, use of a standing frame) or other similar activities?
a. Never (Go to question #4)
b. Seldom (1-2 days)
c. Sometimes (3-4 days)
d. Often (5-7 days)
On average, how many hours per day did you spend in these light sport or recreational
activities?
a. Less than hour
b. 1 but less than 2 hours
c. 2-4 hours
d. More than 4 hours

4. During the past 7 days, how often did you engage in moderate sport and recreational
activities such as doubles tennis, softball, golf without a cart, ballroom, dancing, wheeling or
pushing for pleasure or other similar activities?









The authors chose a qualitative approach because they felt it was the most appropriate tool

to explore perceptions and lived experiences of their participants. They analyzed the tape-

recorded interviews using techniques introduced by Bogdan and Biklen (1992). The researchers

developed agreed upon codes for organizing and interpreting the data. Physical competence and

bodily appearance emerged as two primary themes and sources of stigma management.

The authors reported two ways in which physical competency assisted in stigma

management. The first was through demonstration of physical skill. Participation in sport and

physical activity gave individuals the opportunity to counter perceived stereotypes that persons

with disabilities are incapable of playing sports. The second part of physical competency was

demonstration of a healthy body. Over half of the participants revealed that they felt they looked

healthier as a result of physical activity. This helped contradict the perception that disabled

persons were sick or weak. Nearly all of the participants felt that they were able to influence the

attitudes of others towards them through demonstration of physical competence.

Bodily appearance was the second means by which individuals with disabilities could

counter prevailing negative stereotypes through physical activity. One way this was

accomplished was through demonstration of a muscular body. Some respondents felt that

physical activity helped them develop muscular physiques, which compensated for negative

assumptions other held about the disabled body (Taub et al., 1999). In addition to demonstrating

a muscular body, respondents also reported that physical activity allowed them to demonstrate a

liberated body. Sports enabled them to show others that their wheelchair does not constrain

them. One person stated that he enjoyed swimming because he was free of his wheelchair when

he was in the water (Taub et al., 1999).









Two maj or Eindings came out of the statistical analysis. The first was that athletes were

less likely to have pain than non-athletes. This finding holds true across other variables such as

age, level of injury, and number of years spent in a wheelchair. The second Einding was athletes

also have more years without shoulder pain after SCI than non-athletes. On average athletes had

four more years without shoulder pain (Fullerton et al., 2003).

Before, it was thought that shoulder pain was due to overuse and it was predicted that the

demands of wheelchair athletics would exacerbate this process. The study's results appear to

contradict that prediction.

Taub et al. (1999) interviewed 24 male college students with physical disabilities about

their physical activity experiences. Previous research showed that individuals with disabilities

often have their physical competencies and skills questioned by others (Higgins, 1980). Others

have suggested that physically disabled individuals are stigmatized and devalued because their

bodies do not conform to normative standards (Hahn, 1988). In order to manage the effects of

stigma, individuals with disabilities can engage and become proficient in behaviors that they are

not expected to do well in (Taub et al., 1999). Taub and colleagues set out to investigate how

participation in sport and physical activity can help manage stigma in individuals with physical

disabilities (1999).

They interviewed 24 male students with a variety of physical disabilities ranging from

paralysis to cerebral palsy. The participation level of the sample also varied from occasionally

lifting weights to being a member of a wheelchair basketball team, but each participant averaged

two sessions of physical activity per week. Also, with the exception of the wheelchair basketball

players, most physical activity was done in integrated settings alongside able-bodied peers (Taub

et al., 1999).










Taub, D.E., Blinde, E.M., & Greer, K.R. (1999). Stigma management through participation in
sport and physical activity: Experiences of male college students with physical disabilities.
Human Relations, 52 (11), 1469-1484.

Tate, D.G., Kalpakjian, C.Z., Forchheimer, M.B. (2002). Quality of life issues in individuals
with spinal cord injury. Archives ofPhysical2\~edicine and Rehabilitation, 83, S18-S25.

Taylor, D., & Williams, T. (1995). Sport injuries in athletes with disabilities: wheelchair racing.
Paraplegia, 33, 296-299.

Ustun, T.B., Chatterji, S., Bickenbach, J., Kostanjsek, N., & Schneider, M. (2003). The
international classification of functioning, disability and health: a new tool for
understanding disability and health. Disability and Rehabilitation, 25(11-12), 565-571.

Van der Ploeg, H. P., Van der Beek, A.J., Van der Woude, L.H.V., Van Mechelen, W. V. (2004).
Physical activity for people with a disability: A conceptual model. Sports M~edicine,
34(10), 639-649.

Ware, J.E., Kosinski, M., & Keller, S.D. (1994). SF-36 Physical and Ment~al Hath Summary
Scales: A User 's Manual. Boston: The Health Institute, New England Medical Center.

Ware, J. E. (2000). SF-36 Health Survey: Manual and interpretation guide. Lincoln, Rhode
Island: Quality Metric.

Ware, J.E., & Sherbourne, C.D. (1992). RandRRRRR~~~~~~~RRRRRR 36-Item Health Survey, 1.0O, Santa Monica, CA:
Rand.

Washburn, R. A., Weimo, Z., McAuley, E., Frogley, M., & Figoni, S. F. (2002). The physical
activity scale for individuals with physical disabilities: Development and evaluation.
Archives ofPhysical M~edicine and Rehabilitation, 83, 193-200.

Wu, S.K., & Williams, T. (2001). Factors influencing sport participation among athletes with
spinal cord injury. Medicine and Science in Sports and Exercise, 33 (2), 177-182.

World Health Organization. International Classification ofFunctioning, Disability, and Health
(ICF). Geneva: World Health Organization, 2001.









recreational activities. These activities included swimming, horseback riding, weight lifting,

tennis, fishing, and walking. The authors assigned participants to able-bodied partners for the

duration of the program. Most of them remained in the program for 5 to 10 weeks. Graduate

students conducted interviews with the participants two weeks after they completed the

recreational program.

Results of the interviews showed improvements in physical self-perceptions similar to that

of Taub et al. (1999). These physical changes resulted in psychological gains as well.

Individuals in the sample were able to experience their body in new ways through swimming and

horseback riding. Respondents described the feeling as "less restrictive" and "barrier-free"

(Blinde & McClung, 1997, p. 333). Additionally some respondents felt increased sense of self as

a result of feeling stronger and fitter due to their recreational activity.

Another important outcome of this study was increased perceptions of the social self. This

was done by expanding social interactions and experiences and initiating social activities in

contexts outside of recreational activity. Respondents reported that the recreational activity

program gave them the opportunity to get out and meet new people. In addition to meeting other

people with disabilities, there was also the chance to interact positively with able-bodied

individuals. Also, participation resulted in increased confidence in social skills, which led to

greater motivation to go out and meet other people.

Other research studying the impact of physical activity and individuals with disabilities

examined the impact of exercise on positive and negative affect (Giacobbi, Hardin, Frye,

Hausenblas, Sears, & Stegelin, 2006). Giacobbi et al. (2006) also assessed personal variables

such as personality and time since injury in order to determine who would experience the

greatest emotional benefits on days of increased exercise.









The ICF model is used as a tool in rehabilitation medicine and research as well as for

health, educational, and social policy (Stucki, 2005). It was developed and endorsed by the 54th

World Health Assembly in May 2001 (Stucki, 2005). The original intent of the ICF model was

to provide a unified language for classifying health domains and organizing information on

health status, with the ultimate goal of providing a common framework to measure health

outcomes (Stucki, 2005; Perenboom & Chorus, 2003; van der Ploeg et al., 2004).

As shown in Figure 1-1, the ICF model views disability and functioning in the context of

personal and environmental factors (Ustun, Chatterji, Bickenbach, Kostanj sek, & Schneider,

2003; van der Ploeg et al., 2004; Stucki, 2005). Van der Ploeg et al. (2004) suggested that the

presence of the environmental and personal factors indicates that an individual's functioning is

dynamic in that it can change depending on the environmental factors. To understand this

changing relationship between functioning and environment, further explanation of the ICF

model is necessary.

Contextual factors, such as environmental and personal factors, along with functioning and

disability make up the two parts into which information is organized in the ICF model

(Perenboom & Chorus, 2003). To begin, contextual factors can include environmental barriers

such as a lack of ramps and personal factors such as education level. These factors play a role in

individual's ability to function and the types of activities they choose to participate in. For

instance, someone who has been educated on the health benefits of exercise and instructed how

to perform specific exercises may be more likely to start an exercise program than someone who

did not receive the same information. Additionally, if the place where the individual wants to

exercise has ramps and is accessible, then the likelihood of that person following through on a

program might be greater than if there were not an accessible facility.









This could be done by increasing muscular strength in their upper body, so that they can lift

themselves out of their chair with greater ease.

An individual who is assessing his or her own subj ective QOL may use an internal or

external benchmark for comparison. A person may have a well-developed notion of how they

feel their life should unfold and they might have established a timetable for certain maj or life

events to occur. This timeline may serve has an internal benchmark from which assessments

about subj ective QOL can be made. They may have decided they would be married by age 25

and start a family by age 30. If these events do not occur as expected as a result of their

disability, they will more than likely assess their subj ective QOL lower than if events occurred

the way they wanted them to. Persons with physical disabilities may use able-bodied

individuals, other individuals with the same disability, or others with a different disability as

their external benchmark (Duggan & Dijkers, 2001).

Overall, Duggan and Dijkers' (2001) concept of subj ective QOL can be divided into three

components. Those three components are achievements, expectations, and evaluations. The

achievement component has been the focus of obj ective QOL research, with attention paid to

marital status, number of days restricted from activity, income level, physical capabilities, etc.

Researchers employing the subj ective definition have previously only highlighted the subj ective

reactions, or evaluations. Evaluations can include satisfaction with marriage, happiness, self-

esteem, depression, etc (Duggan & Dijkers, 2001). These authors' concept of subjective QOL is

among the first to include expectations along with achievements and evaluations. Expectations

are defined as goals, values, desires, aspirations, or any other variable that may affect how

achievements are evaluated. For instance, an individual's evaluation of their income level will









The interview data also revealed that many of the participants found that they enjoyed the

social aspect of physical activity. For one male basketball player who competed at the highest

level of wheelchair basketball, the social aspect of the game is what drew him to the sport. He

said, "I love, I mean to me like athletics, as far as that I enj oy being around the team more than I

do the actual sport." Another male basketball player from a lower division team said, "I like that

aspect of doing that...being part of a team, cooperating, talking to each other." The availability

of a nearby facility encouraged this 51 year-old woman with a PASIPD score of 71.22 to become

more physically active, saying, "Fortunately I was in an area here in Birmingham that has

Lakeshore and I was encouraged early on to go into chair sports." In all, there were twenty-three

individuals from the sample who cited a social opportunity as a direct result of their sport

involvement. The social opportunities and benefits played an important role in decisions to

initiate and maintain physical activity participation.

Another construct discussed within their PAD model is personal factors. As shown in

Figure 3-2 (paths 1 and 2), personal factors within the current study interacted with

environmental factors as part of the physical activity experience for our participants. Personal

factors included an individual's health or level of injury, their attitude towards exercise, self-

efficacy expectations and other personality constructs, and personal facilitators and barriers such

as energy, time, money, motivation, age, and gender. Within the present investigation neither

age nor gender emerged as important within the analysis. Essentially these two variables were

not significant in this investigation nor were there any differences in participation or level of

activity between males and females or individuals within different age strata.

There was evidence, however, that the other personal factors may have played roles in the

activity levels of specific individuals. Some of our participants perceived personality factors as










LIST OF REFERENCES


Anderson, K.N., et al. (Eds.). (1998). M~osby 's medical, nursing, and allied health (5th ed.). St.
Louis: Mosby.

Andrews, F.M., & Whithey, S.B. (1976). Sociallndicators of well-being: Anzerica 's perspective
of hife quality. New York: Plenum Press.

Argyle, M. (1999). Causes and correlates of happiness. In D. Kahneman, E. Diener, & N.
Schwarz (Eds.), Well-Being: The Foundations ofHedonic Psychology. (pp. 353-373).
New York: The Russell Sage Foundation.

Bandura, A. (1997) Self-efficacy: The exercise of control. New York: W. H. Freeman & Co.

Bandura, A. (2001). Social cognitive theory: An agentic perspective. Annual Review of
Psychology, 52, 1-26.

Bandura, A. (2004). Health promotion by social cognitive means. Health Education and
Behavior, 31, 143-164.

Bayley, J.C., Cochran, T.P., & Sledge, C.B. (1987). The weight-bearing shoulder. Journal of
Bone and Joint Surgely, 69 (A), 676-678.

Berger, B.G., & Motl, R. (2001). Physical activity and quality of life. In R.N. Singer, H.A.
Hausenblas, & C.M. Janelle (Eds.), Handbook of Sport Psychology 2nd Ed. (pp. 636-671).
New York: John Wiley & Sons, Inc.

Blinde, E.M., & McClung, L.R. (1997). Enhancing the physical and social self through
recreational activity: Accounts of individuals with physical disabilities. Adapted Physical
Activity Quarterly, 14, 327-344.

Block, M.E., Griebenauw, L., & Brodeur, S. (2004). Psychosocial Factors and Disability:
Effects of Physical Activity and Sport. In M.R. Weiss (Ed.) Developmental Sport and
Exercise Psychology: A Lifespan Perspective 1st Ed. (pp. 425-452). Morgantown, WV:
Fitness Information Technology, Inc.

Burnham, R.S., May, S.L., Nelson, E., Steadward, R., Reid, D.C. (1993). Shoulder pain in
wheelchair athletes: the role of muscle imbalance. American Journal of Sports M~edicine,
21, 238-242.

Cantor, N., & Sanderson, C.A. (1999). Life task participation and well-being: The importance
of taking part in daily life. In D. Kahneman, E. Diener, & N. Schwarz (Eds.), Well-Being:
The Foundations ofHedonic Psychology. (pp. 230-243). New York: The Russell Sage
Foundation.

Centers for Disease Control and Prevention (CDC) (2005). National Average:










applied question might involve who would be an effective role model or supportive other to

encourage physical activity behaviors?

Another intriguing practical issue and potential set of research possibilities is offered

through an interpretation of the present findings through a social-cognitive and/or self-efficacy

explanation (Bandura, 1997). If Bandura' s (1997) predictions are correct then a variety of

possible social, family, and community interventions could effectively enhance self-efficacy

beliefs and nurture motivated behavior in the physical activity domain.

Study Limitations

There are several limitations from this study that should be acknowledged. First, the study

sample was gathered using convenience sampling and comprised relatively active individuals

recruited from a basketball tournament. Additionally, these individuals were pre-selected for

physical activity due to being recruited at a basketball tournament. This may have led to the

overwhelmingly positive evaluations of physical activity. Although results from the PASIPD

data demonstrated a high degree of variability between individuals, the planned comparisons

between active versus less active individuals could not be performed. Another design weakness

was the single shot interview procedure with each participant. While the data did provide a

unique perspective with which to examine the important influences for active participants, a

more rigorous approach might be conducted to examine how and why individuals sustain their

physical activity behaviors and health over time. For example, subsequent interviews could have

been conducted to explore the possible reciprocal relationship between participation, benefits,

and motives.

Summary

In summary, this mixed-method study explored the role of physical activity on the subj ective

quality of life in a sample of active wheelchair users. It provided rich qualitative descriptions of









tasks should have stark negative effect on how a person views their quality of life. For persons

with physical disabilities, improvements in their ability to function and perform basic living tasks

could have beneficial consequences for their quality of life.

Based upon this line of reasoning, adopting or integrating the subj ective well-being and

level of functioning conceptual approaches to quality of life may be appropriate to fully capture

the experience of individuals with disabilities. Lower levels of functioning may be associated

with lower levels of QOL, but only if the individual feels that performing daily living tasks is

important to their happiness. For these reasons, I will adopt a definition of QOL that includes

level of functioning as well as subj ective indicators for this thesis. Throughout this thesis I will

continue to use the terms and concepts adopted by particular researchers who study quality of

life from the various disciplines previously described. However, when referring to this concept

in reference to data from my participants I will refer to this construct as subj ective quality of life

(SQL) because this term reflects the conceptual and methodological approach adopted here.

Theoretical Models of Quality of Life for Individuals with Physical Disabilities

In the following section I will review theoretical frameworks that are relevant to this study.

These frameworks seek to integrate individual differences in disability with relevant

socio/environmental variables in an effort to explain choices in behaviors. The first framework

is the international classification of functioning, disability and health (ICF) model (World Health

Organization, 2001). The next model discussed will be the attitudes, social influences, and self-

efficacy model (ASE; De Vries, Dijkstra, & Kuhlman, 1988), which attempted to predict health

behaviors by determining the attitudes, social influence, and self-efficacy towards those

behaviors. Finally, I will explain the physical activity and disability model (PAD), which

combines the framework of the ICF model with themes from the ASE model (van der Ploeg, van

der Beek, van der Woude, & van Mechelen, 2004).










Dijkers, M.P.J.M. (2005). Quality of life of individuals with spinal cord injury: A review of
conceptualization, measurement, and research findings. Journal ofRehabilitation
Research and Development, 42 (3), 87-110.

Duggan, C.H. & Dijkers, M.P.J.M. (2001). Quality of life after spinal cord injury: A qualitative
study. Rehabilitation Psychology, 46 (1, 3-27.

Flegal, K.M., Carroll, M.D., Ogden, C.L., Johnson, C.L. (2002). Prevalence and trends in
obesity among US adults. Journal of the American M\~edical Association, 288, 1723-1727.

Fontana, A., & Frey, J.H. (2000). The interview: From structured questions to negotiated text. In
N. K. Denzin & Y. S. Lincoln (Eds.), Handbook of qualitative research (pp. 645-672).
Thousand Oaks, CA: Sage.

Fowler, E.G., Ho T.W., Nwigwe, A.I. et al. (2001). The effects of quadriceps femoris muscle
strengthening exercises on spasticity in children with cerebral palsy. Physical Therapy, 81,
1215-1223.

Fullerton, H.D., Borckardt, J.J., Alfano, A.P. (2003). Shoulder Pain: A comparison of
wheelchair athletes and non-athletic wheelchair users. Medicine and Science in Sports and
Exercise, 35(12), p. 1958-1961.

Giacobbi, P.R., Hardin, B., Frye, N., Hausenblas, H.A., Sears, S., & Stegelin, A. (2006). A
multi-level examination of personality, exercise, and daily life events for individuals with
physical disabilities. Adapted Physical Activity quarterly, 23, 129-147.

Hahn, H. (1988). The politics of physical differences: Disability and discrimination. Journal of
Social Issues, 44, 39-47.

Hales, R., & Travis, T.W. (1987). Exercise as a treatment option for anxiety and depressive
orders. M\~ilitazry M~edicine, 152, 299-302.

Hays, R.D., Hahn, H., & Marshall, G. (2002). Use of the SF-36 and other health related quality
of life measures to assess persons with physical disabilities. Archives ofPhysical2\~edicine
and Rehabilitation, 83, S4-S9.

Heady, B., & Wearing, A. (1992). Thiderstanding happiness: A theory of subjective well-being.
Melbourne, Australia: Longman Cheshire.

Hicks, A.L., Martin, K.A., Ditor, D.S., Latimer, A.E., Craven, C., Bugaresti, J. and McCartney,
N. (2003). Long term exercise training in persons with spinal cord injury: effects on
strength, arm ergometry performance and psychological well-being. Spinal Cord, 41, 34-


Higgins, P.C. (1980). Societal reaction and the physically disabled: Bringing the impairment
back in. Symbolic Interaction, 3, 139-156.









a. Could you describe the most important lessons you learned about yourself
after you experienced [your injury, illness, or disability]?
b. How have you grown as a person since you experienced this [disability,
ac cident] ?
i. If so, how?
c. Have you grown as a person since you became involved in wheelchair
athletics?
i. Tell me about your strengths you discovered or developed through
your sport/physical activity participation [dealing with your
disability]?
ii. Tell me about your strengths you discovered or developed through
sport or physical activity?

VI. Is there anything that you might not have thought about before that occurred to
you during this interview?











LIST OF REFERENCES ................. ...............89................

BIOGRAPHICAL SKETCH .............. ...............95....


































































6









contextualized descriptions of the participants' experiences are presented to allow readers to

judge for themselves the trustworthiness of the data (Sparkes, 1998).









I've had a, not that I want to die right now, but if I died right now, I could truly say that
I'm satisfied with you know, I've been able to compete on an international level, I've been
able to win national championships athletically, I have 2 incredible kids, great wife, good
job, I live in a place where I'm happy.

Proposed Grounded Theory

In the previous section, I discussed the higher-order themes that emerged from the data and

provided quotes from the interview text to provide context to my observations and conclusions.

In this section I will propose a grounded theory of the role physical activity plays in the quality

for life for individuals with physical disabilities and why the participants in this sample

maintained involvement in physical activity behaviors. This portion of the analysis represents a

second more deductive analysis typically conducted by grounded theorists and involves making

links between previous theory and research and the findings observed here (e.g., sensitizing

concepts). Another purpose of this section is to elaborate more specifically about how the major

higher-order themes are related to one another and other outcomes such as quality of life. In

other words, it is important here to explicate theoretically whether the higher-order themes are

related to one another and other variables in a causal, correlational, or bi-directional manner. For

the purposes of this discussion it appears warranted to introduce Bandura' s (1986, 1997) notion

of triadic reciprocal causation adapted graphically in Figure 3-1. This view uses the term

causation to refer to "functional dependence between events" (Bandura, 1997, p. 5) and

considers human agency and behavior to operate within an interdependent structure of causal

mechanisms. Indeed one can find clear examples oftriadic reciprocal or perhaps even quadratic

or polynomial causation in the previously described ICF and PAD models. Simply put,

individuals' choices to engage in physical activity behaviors are determined by environmental

contingencies (e.g., opportunities, resources, accessible facilities, supportive others), and

personal factors that Bandura describes as cognitive, affective, and biological events; for my









activity can also result in important social and psychological gains as well and have a positive

impact on the way individuals view their bodies and also provide a means to counter negative

stigma regarding their bodies and physical abilities (Taub, Blinde, & Greer, 1999; Blinde &

McClung, 1997). Exercise can also provide a means in which social skills are developed and

practiced (Blinde & McClung, 1997). Finally, physical activity can have an impact on mood

despite daily life events (Giacobbi, Hardin, Frye, Hausenblas, Sears, & Stegelin, 2006). As

discussed, all of these benefits of exercise and physical activity are associated with subj ective

well being and improved quality of life.

With all this evidence demonstrating the importance of exercise in the lives of individuals

with physical disabilities it is imperative that researchers continue examining the antecedents and

consequences of physical activity with this population. Due to an apparent lack of qualitative

research in the area, it is essential that we obtain a fuller understanding of concepts such as

quality of life and how they relate to physical activity and individuals with disabilities.

Individuals with disabilities stand to gain the most from regular physical activity and it is

important that the physical and mental benefits of physical activity be explored in an in-depth

manner.

Purpose

The purpose of this thesis will be to use a mixed method approach to explore the role

physical activity plays in quality of life for individuals with physical disabilities. Quantitative

methods will be used to categorize individuals as more versus less physically active, while

qualitative interview methods will be used in order to obtain a richer understanding of how

individuals with disabilities describe their quality of life and subj ective activity experiences. A

secondary purpose will be to compare individuals who are more active with those who are less

active in their descriptions of daily life events and physical activity involvement.









definitely keep lifting to make sure I'm not developing any kind of shoulder problems and for

basketball..." Finally, a 36 year-old youth director and former athlete said, "I mean I look at

myself now I train 4 or 5 days a week primarily doing it for health reasons, lower my cholesterol,

lose some weight."

As the selected quotes have shown, several of the participants value the physical health

aspect of their physical activity experience. They listed benefits such as staying in shape,

preventing shoulder injury, sleeping better, and preventing wear on the body.

SociallInfluences. The third higher order theme to emerge from the interview data was

social influences (N = 11). Eleven of the participants revealed important people in their lives

that either introduced them to sports or encouraged them to participate. These findings were

consistent with the previously described work by van der Ploeg et al. (2004) and their PAD

model. For instance, participants were influenced by family, friends, disabled peers, and health

professionals to initiate and adhere to physical activity behaviors. It should be noted that the

social influences theme includes only those persons who introduced the participants to physical

activity and sports. Individuals who continue to influence responders in the form of a role model

were coded under social opportunities. This was done to remain more consistent with the PAD

model .

For example, one 46 year-old male who scored a 29.94 on the PASIPD and currently

coached the same basketball team he used to play for said, "I had met a guy when I was in the

hospital... So he told me about it, so when I got out of the hospital I went out and visited a couple

of practices and try to play a little bit with the folks there." A 21 year-old female basketball

player with a PASIPD score of 40.86 spoke about the influence of her brothers saying, "It was

never, 'Oh, Emily can't play.' It was always, 'That's my sister and she's going to play with us.'"










the physical activity experiences and the perceived benefits of their participation as well as their

motives to sustain participation. The present study also explored the reciprocal relationship

between participation, perceived benefits, and motives to participate.










So, um, just...it' s [basketball] really changed my self concept, my uh, you know my,
what I think other people see of me and also what I see in myself. I think I am a lot more
disciplined and I...I look at myself more now...a lot of times before, it' s not that I ever
really didn't like myself. I didn't mind. But a lot of times I felt like other people just
were like, 'Oh there's that poor one-legged girl.' Or you know, something like that. And
so for me that' s really changed and in a lot of ways that helps your self-esteem too.

Another participant who became more extroverted after playing basketball was a 38 year-

old male with cerebral palsy (PASPID = 25.17). He stated, "It's changed me a lot. I was just

very introverted before going to college. And I saw all these different things. I saw people

going through the same experience I was and it just opened me up." A 36 year-old male

(PASIPD = 46.42) who, as a former athlete and current youth sport director, witnessed the

positive impact of sports. He stated "you know it' s a self confidence kind of thing and to me you

get a lot of that through athletics." This sentiment was echoed by another female college

basketball player and Paralympic swimmer (PASIPD = 47.05), aged 20, who said, "Athletics

provides a sense of confidence."

Sport and physical activity also allowed some responders to see themselves in a different

light. For example, one 47 year-old male who was a two-time world champion water skier and

current basketball player said, "I came from a pretty small town, so that' s when I really found

out that I was more of a natural athlete than I knew because I had never had those opportunities

when I was living in my small town." When asked about the impact of basketball on his life

another 54 year-old male with a PASIPD score of 21.57, stated, "Certainly, to a degree it was my

identity. It' s given me an outlet for physical activities, I've made a lot of wonderful friends over

the years and here now I am just down here enjoying the games" A total of 15 individuals cited

changes in self-perception as one of the benefits of an active lifestyle. These changes came in

the form of improved self-confidence, improved self-esteem, and identifying oneself as an

athlete.










































Peents smoking behavior
Godfor heart
Godfor pain management
Loer cholesterol
Loer risk of secondary health issues
Peents shoulder problems
Peent wear of body


Srtnin/dopamine/endorphins


Disabled peers at hospitals
Disabled peers at other sporting events
Disabled peers at college
Teammates

Dotor introduced them to sport
Youth director of rehab center


Prnsencouraged sports
Slings included them in games


Coach of team


Built character
l've found that I can be a leader

Changed self concept
Elelps self-esteem
Self-growth
Focus on ability
Feel more able-bodied
Sense of confidence
Sense of independence
Others look up to you
Looked up to


Improved self-perception
N= 13

















Physical Fitness
N =13


Sleep better
Maintain Fitness
Maintain Health

Keeps you Young
It develops muscle
Keeps you in shape


Preventing health risk
N = 7


Physical Health
N =18


Other Health Benefits
N= 2




Disabled Peers
N= 4



Health Professional
N = 3


Family
N= 3


SCoaches


Social Influences
N =12









APPENDIX A
INTTERVIEW GUIDE


I. Basic Demographic Questions
a. Age
b. Gender
c. Race/ethnicity

II. Intermediate questions this part of the interview will focus on your typical
day.
a. Could you describe a typical day for yourself!
b. Tell me about your job (if appropriate).
i. What do you do?
ii. How long have you been in that occupation?
c. Describe some of the activities (hobbies, recreation) you enj oy during a
typical day [besides work].
i. How long have you participated in that [those] activity[ies]?
ii. Why are those particular activities enjoyable to you?


III. Physical Activity
a. What physical activities do you engage in regularly?
i. Could you please describe these activities?
ii. How often do you engage in ?
iii. Do you compete? If so, how often?
iv. Could you tell me about your goals
term)?
b. Has participation in impacted your life
how?


(short or long


Sin any way? If so,


i. Potential probes include the following:
1. How so?
2. Could you tell me more about this?
3. What was that like?
4. Could you describe a specific time or incident where
occurred?
c. After having these experiences in sport and physical activity, what advice
would you give someone?

IV. Disability Specific Issues
a. Right now I'd like to learn more about your disability. Could you tell me
about your disability?
i. How did occur?
b. If this was an injury: What was your life like before
c. What helps you manage or cope with ?
d. Who is most helpful to you? How has he/she been helpful?


V. Quality of Life









likely be influenced by the value they place on wealth or possessions. If they place a high value

on wealth, then their lack of it may be evaluated negatively.

Diener' s (1984) theory of subj ective well-being is similar to the subj ective definition of

quality of life. In fact, using a benchmark for comparison, whether internal or external, would be

considered a cognitive judgment of one's life. This would constitute the life satisfaction

component of subjective well-being (Diener, 1984). Additionally, one trademark of subjective

well-being is that it revolves around an individual's own beliefs on what they feel is important to

their happiness, not what the researcher determines is important (Diener, Emmons, Larsen, &

Griffin, 1985).

The subj ective approach to quality of life allows the individual to appraise their quality of

life both emotionally and cognitively. That is to say, a person may feel happy and be able to tell

him or herself that the circumstances of their life are great, when someone else may view those

same circumstances as undesirable. Each individual takes into account their own experiences,

thoughts, and emotions when rating their quality of life. Specifically, for individuals with

disabilities, the subj ective definition allows them to place importance on achievable goals and

their own expectations of what the "good life" should be like while de-emphasizing goals that

are unattainable, other peoples' views, and societal expectations.

It is difficult to say which definition most adequately describes the QOL construct for

individuals with disabilities. Intuitively it seems obvious that level of functioning would play an

important role in quality of life for this population. It could be argued that the ability to provide

oneself with basic care, perform the tasks of everyday living, and be physically active figure

heavily into how a person rates their life quality. While the ability to perform those tasks would

not necessarily guarantee that someone views their life positively, the inability to perform those










1) All interviews were transcribed verbatim by multiple coders that included the author and

two researchers with training and experience using qualitative data analysis at the University of

Alabama Birmingham. During this stage of the coding process, participants' quotations were

coded as raw data themes and stored for future analysis and discussion between the authors.

Throughout the interview and open-coding process my advisor supervised and provided

guidance concerned with this proj ect.

2) The research team next engaged in focused coding procedures whereby the most

frequently mentioned raw data themes were sorted and grouped according to their common

properties (Charmaz, 2000). This involved making connections and distinctions between the

motives and perceived benefits reported by our participants and how these perceived benefits

impacted subj ective well-being. The process of focused coding also facilitated the comparison

process described below.

3) A constant comparative method was used that allowed the author to make comparisons

between the participants' experiences (a) reported by different participants, (b) within

participants about descriptions of the same and different experiences (c) with important

experiences reported by different participants. Additionally, consistent with the purposes of this

study, the constant comparative method allowed for direct comparisons between males and

females, individuals in different age groups, and between those who were more versus less

active .

4) Sensitizing concepts served as "points of departure" from which to organize, interpret,

and extend previous stress and coping research findings (Charmaz, 2000, p. 515). As noted by

Charmaz (2000) "Sensitizing concepts offer ways of seeing, organizing, and understanding









Their study found that the 12-week circuit-training program resulted in significant

increases in cardio-respiratory endurance and muscular strength in individuals with paraplegia.

Participants increased maximum oxygen uptake by an average of 30%, while the strength was

improved 12-30% (Jacobs et al., 2001; Hicks et al., 2003). Although this study did not purposely

test outcomes of function and well-being, informal exit interviews with participants revealed that

several individuals reported greater ease performing daily activities that required upper body

strength and endurance.

Hicks et al. (2003) examined the effects of an exercise-training program in individuals with

SCI, looked at QOL outcomes in addition to gains in strength and function. They argued that

because life expectancy for individuals with SCI is on the rise, rehabilitation goals should be

shifted from prolonging life to enhancing quality of life and independence. Due to the fact that

coronary heart disease is a leading cause of death among the SCI population, amendable risk

factors such as inactivity have received more attention from researchers and health care

professionals. Many previous studies, including Jacobs et al. (2001) have studied the effects of

exercise on muscular strength and/or cardio-respiratory function, but none had looked at QOL

outcomes. Hicks et al. (2003) predicted that their 9-month, twice a week training program for

individuals with SCI would lead to increased muscular strength, enhanced exercise capacity, and

improved quality of life.

Their study sample consisted of 34 men and women between the ages of 19 and 65. All

participants had acquired an SCI at least one year before they enrolled in the study. The

researchers randomly selected individuals to be placed in either the exercise group or a waiting-

list control group and used several different instruments to measure the outcome variables. Heart

rate and power output were measured using an arm ergometer while muscular strength was









Another important factor that impacts quality of life is recreation (Slater & Meade, 2004).

Studies in the general population have shown that recreation is more important than job status,

health, and finances in determining life satisfaction. This suggests that promoting a lifestyle that

places an emphasis on recreational activity could influence an individual's quality of life.

Many researchers examining quality of life or one of its related concepts such as life

satisfaction or subj ective well-being note the relative stability of this construct over time (Lucas,

Clark, Georgellis, & Diener, 2004). Subjective well-being is affected for less than 3 months by

most major life events (Suh, Diener, & Fujita, 1996). Heady and Wearing (1992) posited that

individuals have set points for SWB. According to their theory, when a person encounters an

event they will have an initial reaction, but will soon return to a baseline level of happiness while

an individual's baseline is determined by their personality (Heady & Wearing, 1992). This

precept has guided much of the research done on SWB (Diener, Suh, Lucas, & Smith, 1999).

For instance, Lucas et al. (2004) found evidence that suggested that the set point could be

altered. If set point theory were correct participants would have an initial reaction to

unemployment but would return to their baseline levels within 2 years. The data, which was

obtained from a longitudinal study in Germany, indicated that unemployment created a new

baseline level of life satisfaction (Lucas et al., 2004). The decline in life satisfaction for these

participants remained stable at the lower level even after employment was regained. The authors

suggested that their findings were not totally inconsistent with set point theory, but considered

the possibility that there are only a few life events powerful enough to alter the set point for life

sati sfacti on.

Berger and Motl (2001) suggested that quality of life is a global assessment of life as

whole rather than a focus on specific life domains. Thus, subjective QOL can be viewed as a










d. Often (5-7 days)
On average, how many hours per day did you spend doing light housework?
a. Less than hour
b. 1 but less than 2 hours
c. 2-4 hours
d. More than 4 hours

8. During the past 7 days, how often have you done any heavy housework or chores such as
vacuuming, scrubbing floors, washing windows, or walls, etc.?
a. Never (Go to question #9)
b. Seldom (1-2 days)
c. Sometimes (3-4 days)
d. Often (5-7 days)
On average, how many hours per day did you spend doing heavy housework or chores?
a. Less than hour
b. 1 but less than 2 hours
c. 2-4 hours
d. More than 4 hours

9. During the past 7 days, how often have you done home repairs like carpentry, painting,
furniture refinishing, electrical work, etc.?
a. Never (Go to question #10)
b. Seldom (1-2 days)
c. Sometimes (3-4 days)
d. Often (5-7 days)

On average, how many hours per day did you spend doing home repairs?
a. Less than hour
b. 1 but less than 2 hours
c. 2-4 hours
d. More than 4 hours

10. During the past 7 days, how often have you done knen work or yard care including mowing,
leaf or snow removal, tree or bush trimming, or wood chopping, etc.?
a. Never (Go to question #11)
b. Seldom (1-2 days)
c. Sometimes (3-4 days)
d. Often (5-7 days)
On average, how many hours per day did you spend doing knen work?
a. Less than hour
b. 1 but less than 2 hours
c. 2-4 hours
d. More than 4 hours

11. During the past 7 days, how often have you done outdoor gardening?
a. Never (Go to question #12)









Another important factor in subj ective QOL is achievements. According to Dijkers (2005)

achievements can include performances, relationships, status, health, and accomplishments.

Some individuals in this sample reported achieving many athletic accomplishments and building

lasting relationships through sports and activity. This 46 year-old basketball coach and former

player said it, perhaps most eloquently.

I've had a, not that I want to die right now, but if I died right now, I could truly say that
I'm satisfied with you know, I've been able to compete on an international level, I've been
able to win national championships athletically, I have 2 incredible kids, great wife, good
job, I live in a place where I'm happy.

Another middle-aged basketball player said, "And I've done, I've been on some U.S.

teams and I've accomplished far more than I ever thought I could." This same man also forged

lifelong friendships through basketball. He said, "Well I mean my best friend [has] been on the

team as long as I can remember. I consider him my brother because of just all the years we've

been together." Still another man spoke about the inspirational people he met saying, "Then

when I started playing sports I met a lot of people that were doing incredible things...they had

families...I thought I wasn't going to have all that."

Another form of achievement is developing or maintaining relationships. As I reported

earlier in this chapter, twenty-three individuals from this sample cited social opportunities as a

reason to participate in sports and exercise. These opportunities allowed them to form

relationships such as meeting friends, influencing others, and being influenced by others. For

instance a 38 year-old male with a PASIPD score of 25.17 said, "It's the 10 or 12 guys. Before

basketball we're trading j okes with each other, or we're going out to dinner, or just talking at

work." An example of influencing others was given by 21 year-old female who scored a 40.68

on the PASIPD. She said, "I think it was really cool for me to speak to them and kind of show

them that people with disabilities can still be active...are still normal people you know."










Kaplan, R.M. (1994). The Ziggy Theorem: Toward an outcomes-focused health psychology.
Health Psychology, 13, 451-460.

Kaplan, R.M., Bush, J.W., & Berry, C.C. (1976). Health status: Types of validity and the index
of well-being. Health Services Research, 11, 478-507.

Kaplan, R.M., Bush, J.W., & Berry, C.C. (1978). The reliability, stability, and generalizability
of a health status index. In Proceedings of the Social Status Section (pp. 704-705).
Alexandria, VA: American Statistical Association.

Kessler, R.C., McGonagle, K.A., Zhao, S., Nelson, C.B., Hughes, M., Eshelman, S., Wittchen,
H.U., & Kendler, K.S. (1994). Lifetime and 12-month prevalence ofDSM\~-III-R
psychiatric disorders in the United States: Results from the National Co-Morbidity Survey.
Archives of General Psychiatry, 51, 8-19.

Kette, G. (1991). Haft: Eine Socialpsychologische Analyse (Prison: A social psychological
analysis). Gottingen, Ger.: Hogrefe.

Lucas, R.E., Clark, A.E., Georgellis, Y., & Diener, E. (2004). Unemployment alters the set point
for life satisfaction. Psychological Science, 15 (1, 8-13.

MacPhail, H.E., & Kramer, J.F. (1995). Effect of isokinetic strength training on functional
ability and walking efficiency in adolescents with cerebral palsy. Developmental~edicine
and Child Neurology, 37, 763-775.

Martinsen, E.W. (1987). The role of aerobic exercise in the treatment of depression. Stress
Medicine, 3, 93-100.

Martinsen, E.W. (1990). Benefits of exercise for the treatment of depression. Stress Medicine,
9, 380-389.

McKevitt, C., Redfern, J., La Placa, V., & Wolfe, C.D.A. (2003). Defining and using quality of
life: A survey of health care professionals. ClinicalRehabilitation, 17, 865-870.

Miyahara, M., Sleivert, G.G., & Gerrard D.F. (1998). The relationship of strength and muscle
balance to shoulder pain and impingement syndrome in elite quadriplegic wheelchair
rugby players. International Journal of Sports Medicine, 19, 210-214.

Myers, D.G. (1999). Close relationships and quality of life. In D. Kahneman, E. Diener, & N.
Schwarz (Eds.), Well-Being: The Foundations ofHedonic Psychology. (pp. 374-391).
New York: The Russell Sage Foundation.

North, T.C., McCullagh, P., & Tran, Z.V. (1990). Effect of exercise on depression. Exercise
and Sport Science Reviews, 18, 379-415.

Patrick, D., Danis, M., Southerland, L.I., Hong, G. (1988). Quality of life following intensive
care. Journal of Gerontology andlnternal M~edicine, 3, 218-223.









Ultimately sports and other physical activities allowed this sample of college men with

physical disabilities the opportunity to shed common perceptions about the abilities of

wheelchair users and others with physical disabilities. For most of the respondents, involvement

in sport alone was more important than type and intensity level of activity. They believed that

their involvement in sport could alter negative stereotypes other had about persons with

disabilities. Taub et al. (1999) recommended that future research should examine the physical

activity experiences of females as well as people in other age groups with disabilities.

Other researchers have suggested that sport and recreational activity represented a way in

which individuals with disabilities could improve physical and social self-perceptions (Blinde &

McClung, 1997). Improvements in physical self-perception may be achieved through physical

activity because individuals can perform tasks and activities that they or others may have

considered impossible for them. In addition, sport and recreational activity occur within a social

context, thus enabling active individuals to boost their social self-perceptions. One study

examined the impact of sport and recreational activity physical and social self-perceptions of

individuals with disabilities (Blinde & McClung, 1997). They used qualitative methods in order

to allow the participants the chance to talk about what they felt was the most important aspects of

their activity experiences.

The sample included 11 women with a mean age of 31.5 years and 12 men with a mean

age of 26.2 years. Fifteen members of the sample were college students and the rest were

recruited from the local community. The study consisted of individuals with a wide variety of

physical disabilities ranging from cerebral palsy and paralysis to muscular dystrophy. A

maj ority indicated that they had limited participation in recreational activities prior to the study.

After consenting to be a part of the study, participants could choose from a number of offered









As shown in the figure above, the functioning and disability element is broken down into

three sections labeled body, activity, and participation. The body component concerns itself with

body functions and structures. Impairment refers to a loss or deviation from normal body

functions and structures (van der Ploeg et al., 2004). For example, a person would be considered

to have impairment if they either lost a leg to amputation, or lost use of their leg due to paralysis.

The activity component refers to the ability to perform a task one is functionally capable of doing

and is distinct from the participation component, which refers to whether or not one chooses to

play such activities. The participation portion of the ICF model refers to taking part in activities

and may also include social behaviors. Likewise, the individual may be capable of executing a

task, but their ability to perform that task in a social setting, such as wheelchair basketball, may

be inhibited by environmental factors such as transportation to and from practice, cost of chair

built for basketball, or simply the absence of a wheelchair basketball team in the community.

Environmental factors include social and physical settings as well as the attitudes of other

people (van der Ploeg et al., 2004). The social environment can impact a person's functioning

through infrastructure, which could include accessible sidewalks and buildings, laws and

regulations that provide and maintain an accessible physical environment, and attitudes towards

disability that can influence the kind of behavior is expected from an individual. An individual

with a disability may exhibit higher functioning and participation if they live in an environment

that is physically accessible and one in which they are encouraged to be active. On the other

hand, if that individual lives in a place where they encounter physical barriers or are not expected

to be active due to their disability, they will be at risk for lower functioning and participation.

The final dimension of the ICF model is personal factors. Personal factors can include

demographic variables such as gender, race, age, and education as well as their coping style and









In all, 26 out of 26 participants reported some sort of psychological benefit from

participating in sports and other physical activity. Some responders reported that they felt better

emotionally because they were able to relieve stress, release aggression, increase their level of

endorphins, or participate in an activity they viewed as enjoyable. Others reported they received

cognitive benefits and were able to learn to concentrate and stay focused, stay positive, and learn

about new sports. As reported, many of the participants found that physical activity impacted

their thoughts, feelings, and behaviors which included improved work ethic, the ability to adapt

to people and places, decreased smoking behavior, and more outgoing towards strangers.

Finally, over half (N = 15) of the participants reported that their self perceptions were changed

due to sports and physical activity.

Physical Health. The second higher-order theme derived from the interview data was

physical health. Physical health was coded as any statement that referred to the health benefits

of physical activity. This theme was further broken down into physical Sitness and preventing

health risks. The interviews revealed that half of the participants (N = 13) cited physical health

as a benefit of physical activity.

A 47 year-old male basketball player and former champion water skier (PASIPD = 36.16)

said, "Um, again the physical part of it has kept me, I know, in a lot better shape than I would

have been had I not done those sports." A 39 year-old female who scored a 30.81 on the

PASIPD added, "Yeah, it helps keep you young, it helps keep you healthy and at this point in my

life it' s not something that I am willing to give up yet." In addition, a 22 year-old female

basketball player stated, "Since I've started playing basketball I've gotten in so much better

shape." A 31 year-old female who scored only a 6.2 on the PASIPD also received health

benefits from exercise saying, "... Since I was lifting all of the time it really helped, so I'll









PHYSICAL ACTIVITY AND QUALITY OF LIFE EXPERIENCED BY PARTICIPANTS OF
A WHEELCHAIR BASKETBALL TOURNAMENT



















By

MICHAEL A. STANCIL


A THESIS PROPOSAL PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF SCIENCE

UNIVERSITY OF FLORIDA

2007









as well (van der Ploeg et al., 2004). That in turn will make activities such as pushing a

wheelchair easier. The participation domain is impacted by physical activity through

improvements in functioning. According to the authors of the PAD model, improved

functioning will result in better performance in real-life situations and in social situations (van

der Ploeg et al., 2004).

Another similarity between the ICF and PAD models is the domain of environmental

factors. The PAD model uses this domain differently from the ICF model in that the PAD model

seeks to explain what environmental factors determine physical activity behavior. Social

influence and environmental barriers and facilitators are the primary determinants of physical

activity behavior within this domain (van der Ploeg et al., 2004).

There are some differences between how social influence works between able-bodied

people and persons with disabilities. Family and friends are the primary source of social

influence on physical activity for able-bodied individuals. Individuals with disabilities, however,

are more likely to be influenced by health professionals (van der Ploeg et al., 2004). This

difference is important because if a link between physical activity and quality of life is

established and published in the future, such information will become available to health

professionals who can then recommend exercise or other forms of physical activity to individuals

with disabilities as a way to improve to their quality of life.

Barriers or facilitators in the environment can also impact physical activity behavior for

individuals with disabilities. Barriers are those things in the environment that reduce the amount

of physical activity behavior. They can range from poor transportation and a lack of accessible

equipment to a lack of assistance, distress with physical activity with non-disabled individuals

present, and season. Facilitators are often viewed as opposite to barriers and they typically









and external validity of the PAD model. Another important area of interest is determining the

most important personal and environmental barriers and facilitators to physical activity.

The three models discussed thus far all play a role in the exploration of physical activity

behaviors and functioning among persons with disabilities. The ICF model is a broad and

multidimensional tool that is used to assess health status in persons with and without disabilities.

Clinicians can use this tool to assess the impact of disability on an individual's ability to

function. The ASE model provides a foundation for examining the determinants of physical

activity behavior. The PAD model incorporates both of these models in order to look at the

relationships that may exist between functioning, determinants of activity, and physical activity

behavior (van der Ploeg et al., 2004).

In this thesis I will use the PAD model in order to explore physical activity behavior

among individuals with disabilities. This model provides a framework that enables the researcher

to examine the roles of body structure and function, along with environmental and personal

factors to ascertain levels of activity and participation. To my knowledge, it is also the only

theoretical model that attempts to explain exercise behavior specifically within the disabled

population.

Empirical Studies on the QOL Construct

In the following sections I will review empirical studies focused on quality of life for

individuals with various populations. These studies are organized generally around

contextual/environmental, personality, and cultural factors that impact the quality of life

construct. Following this part of the review will be studies that focus more specifically on

physical activity and quality of life.

In their study on individuals with traumatic brain injury and attitudes towards disability

Snead and Davis (2002) defined quality of life as physical and mental health and operationalized










b. Seldom (1-2 days)
c. Sometimes (3-4 days)
d. Often (5-7 days)
On average, how many hours per day did you spend doing lawn work?
a. Less than hour
b. 1 but less than 2 hours
c. 2-4 hours
d. More than 4 hours

12. During the past 7 days, how often did you care for another person such as children, a
dependent spouse, or another adult?
a. Never (Go to question #13)
b. Seldom (1-2 days)
c. Sometimes (3-4 days)
d. Often (5-7 days)
On average, how many hours per day did you spend caring for another person?
a. Less than hour
b. 1 but less than 2 hours
c. 2-4 hours
d. More than 4 hours

Work Related Activity
13. During the past 7 days, how often did you work for pay or as a volunteer? (Exclude work
that mainly involved sitting with slight arm movement such as light office work, computer work,
light assembly line work, driving bus or van, etc.)
a. Never (Go to END)
b. Seldom (1-2 days)
c. Sometimes (3-4 days)
d. Often (5-7 days)
On average, how many hours per day did you spend working for pay or as a volunteer?
a. Less than 1 hour
b. 1 but less than 4 hours
c. 5 but less than 8 hours
d. More than 8 hours

























Faclli~taors~erriers
e.g. transpo rtation, avai labi lity and access bil ity -
of bu ilt and natu al facilities, assistanon from
others, equipment,.social aspect






L -

SociLal influence
eQg farni ly, friends, colleagues, health
professionals, genera opinion

En~viironmental factors


Facli~taors~aeirrir
-- -- l .g. energy, time,
mo~neY, motivtion,
Skills, ago, sex
Health crondilian
a.g. disease,
disorder, injury,


traum MM- ac



Attiturde

Personal fators


Level of iph~sical activity f-unctionimg


Figure. 1-3. The Physical Activity for people with Disability Model (van der Ploeg et al., 2004).









A 38 year-old male with cerebral palsy and a PASIPD score of 25.17 spoke about why he

enjoyed team sports as opposed to individual sports.

Um, I think because, for me, it' s a team sport. You have to...the people on the court have
to get along together. At least there has to be some form of cooperation. I like that aspect
of doing that. Being part of a team, cooperating, talking to each other.

Another participant mentioned that she made friends through basketball. This 21 year-old

female with a PASIPD score of 52.69 said, "I mean I have like a lot of connections and friends

you know through being exposed to wheelchair sports."

In some cases, participants have found other disabled peers to be role models. A 29 year-

old male who scored a 59.47 on the PASIPD said, "After I met guys and they were doing

stuff...j obs that I didn't think that disabled people would." Later in the interview he stated,

"Then when I started playing sports I met a lot of people that were doing incredible things...they

had families...I thought I wasn't going to have all that." In other cases, the participants had the

chance to be a role model to children with disabilities. The director of the youth center quoted

earlier said, "it's about creating people and really in helping raise people's expectations about

what they can do and that' s one of the neat things through sport I think."

In this section I have presented interview quotes to lend support to the posited higher-

order theme of social opportunities. The social opportunities higher-order theme was defined

social interaction, opportunities for education and travel, and either being a role model or being

exposed to a role model. Twenty-three of the twenty-six individuals in this sample reported a

social opportunity benefit.

Increased Overall subjective QOL. The Einal higher-order theme that emerged was

increased overall subj ective QOL. While most of the previously discussed themes have focused

on specific factors or components of the subj ective QOL construct, this theme included quotes in









experience; they are embedded in our disciplinary emphases and perspectival proclivities" (p.

5 1)

5). Sensitizing concepts also offer researchers a way to make sense of qualitative data in a

manner consistent with the extant literature. In the present study the PAD model by van der

Ploeg, van der Beek, van der Woude, and van Mechelen (2004) as well as Dijkers'

conceptualization of subj ective QOL served as sensitizing concepts. In this way I interpreted my

combined quantitative and qualitative data by using important constructs in the PAD model (e.g.,

facilitators/barriers, social influences, health conditions, self-efficacy, intention, and attitudes) as

well as components of subj ective QOL (e.g. values, achievements, and evaluations) during my

analysis.

Issues of Ti 11\ns 1,i thines' \ Several sources of trustworthiness were developed in this study.

First, multiple coders examined the raw data independently and discussed similarities and

differences in the coding of the participants' experiences. Second, the author, a fellow graduate

student, and the author's thesis advisor explored multiple interpretations and discrepant findings

during structured research discussions (Sparkes, 1998). The use of a research group has also been

described as a way to establish credibility and dependability of qualitative data (Dale, 1996).

Third, an individual trained in qualitative research methods performed an independent audit on a

select group of coded quotations. This individual independently coded the determinants and

benefits of physical activity and found agreement with 61% of the codes completed by the

author. The independent coding comprised identifying blocks of quotes by labeling it with one

of the higher order themes. Once this was completed, the author then compared the results to his

own system of coding. Finally, the participants' direct quotations are presented along side









values, they may evaluate those achievements in a positive manner. Conversely, if their

achievements fall short of their set goals or values their evaluations may be considered negative.

Thus in the present study a number of the participants reported positive evaluations, or

psychological benefits, such as improved self-esteem, changes in self-concept, and the desire to

share their achievements with other individuals with physical disabilities. Additionally

participants described social and physical health benefits, or achievements, in the form of

relationships, health, performances, and status again consistent with Dijkers' definition.

Consequently, since the present sample reported greater frequency and intensity of leisure time

physical activity than normative data reported by Washburn et al. (2002), it is likely the benefits

derived from physical activity would be multi-dimensional and associated with a range of health,

behavioral, or other lifestyle factors. Thus, when interpreting the findings from this study one

needs to recognize the higher than average levels of physical activity participation reported by

this sample.

A range of previously reviewed literature showed that subj ective indicators of life quality

such as positive and negative affect, life satisfaction, or other interpretations of one' s life are

often used to study people' s lives. Further the approach adopted here was to focus on subj ective

quality of life from the perspectives of my participants. From Dijkers perspective subj ective

evaluations are considered reactions to achievements and can be either positive or negative, or

emotional or cognitive depending on person, the situation, or the context. Thirteen participants

interviewed for this study reported that their self-esteem was improved by their participation in

wheelchair basketball while nearly the entire sample experienced psychological benefits

associated with physical activity behaviors. The extensive and richly detailed quotations

provided by the participants clearly suggest enhanced subj ective quality of life associated with









shown that SWB does not change over time, it returns to stable levels after major life events, and

a strong relationship exists with stable personality traits (Diener et al., 2003). More specifically,

extraversion and neuroticism are the two personality traits that exhibit the strongest relationship

with subjective QOL. Generally speaking, extraverts are outgoing, sociable, comfortable in

social situations and generally happier than introverts. In contrast, neurotics are anxious,

depressed, they often feel self-conscious, and are typically unhappier. Since extraversion and

neuroticism provided the strongest correlations to affect, the authors suggested that these two

traits could provide the link between personality and subj ective well-being (Diener, Oishi, &

Lucas, 2003).

Others have noted that personality might also interact with the environment and impact

self-reported SWB. Kette (1991) found that extroverted prisoners report lower levels of

happiness than introverted prisoners. This finding was counter to previous research that stated

that extroverts are generally happier than introverts (Diener et al., 2003). Since then researchers

have suggested that higher levels of positive affect are correlated with trait-congruent behaviors

and trait-incongruent behaviors are correlated with higher levels of negative affect (Diener et al.,

2003). Essentially people are happier when they engage in activities that better suit their

personality traits.

Other factors influencing differences in quality of life are socio-demographic

characteristics and contextual and situational factors (Berger & Motl, 2001). Socio-demographic

characteristics can include age, education, marital status, gender, income, social class and social

relationships (Berger & Motl, 2001). Emotion, stress, and physical health are the contextual or

more situation based factors that are associated with quality of life.









For a third participant, it was her future coach who introduced her to wheelchair basketball. This

35 year-old female who scored a 51.49 on the PASIPD discussed her introduction to the sport.

I lucked out, when I was doing my rehabilitation, there was a gentleman there that
competed internationally and he's actually our coach now for the women's team, and he
introduced me to basketball and then to a school that had a program, and you know it all
works out.

Social Opportunities. In addition to social influences, social opportunities, which

comprised the fourth higher order theme, were made available for our participants within

physical activity contexts. In fact, 23 participants in this sample mentioned social opportunities.

as being a benefit of physical activity. These social opportunities included valued interactions

with others, being able to connect and form relationships with others including able-bodied

persons, having the opportunity to go to college, and travel opportunities.

The 46 year-old male coach quoted above said, "It's a very nature bridge to the able-

bodied world. People are comfortable to say, 'tell me about your basketball.'" Another example

of sport playing a role in the interaction between participants and able-bodied peers comes from

a 21 year-old female basketball player (PASIPD = 40.86) who had the chance to speak to a

classroom of children. She said, "I think it was really cool for me to speak to them and kind of

show them that people with disabilities can still be active." A 20 year-old male basketball player

added, "And so from the social aspect it' s like the campus looks at us not as a group of guys in

wheelchairs who are just in wheelchairs. They look at us as a basketball team."

That same individual made several comments about the social aspect of wheelchair

basketball, including the opportunities for education and travel.

But basketball and athletics has given me a chance to, you know, have a lot of my
education paid for. It's taken me all over the world...And that' s really something that the
maj ority of, you know my friends in high school, they're in school doing whatever they do,
and they may be working, but they're not college athletes. And that' s...basketball as been
the savior of my life. It' s been the single most important thing.










Another example of a social relationship reported by the sample was meeting other individuals

who were influential. A male aged 29 years with a PASIPD score of 59.47 said, "After I met

guys and they were doing stuff...j obs that I didn't think that disabled people would."

Health was also important to many individuals in this sample as 13 out of 26 talked about

physical fitness and health risk prevention. A female, aged 51 years with a PASPID score of

71.22 said, "It' s a good way to help with pain management, it helps strengthen my back and the

muscles so that I am still able to walk." A 36 year-old male who scored a 46.42 on the PASIPD

added, "I mean I look at myself now I train 4 or 5 days a week primarily doing it for health

reasons, lower my cholesterol, lose some weight."

The final component of subj ective QOL is subj ective evaluations. Within the PAD model,

subjective evaluations are the responses a person has to their achievements based on their

expectations. If an individual achieved something they valued as important, then their evaluation

would likely be positive. If they were unable to achieve something they perceived to be

important, then they would evaluate the situation negatively. These evaluations can also be

called life satisfaction, self-esteem, subjective well-being, and positive or negative affect.

Many of the more global evaluations came from older adults looking back on their lives,

although younger participants did report positive affect and improved self-esteem. The 47 year-

old man who is a basketball player as well as two-time champion water skier was one such

person.

Like I said, sports is probably the single most important thing or has been the single most
important thing since I've been injured. If I could turn back the hands of time, I'd still be
sitting here in this chair. I wouldn't change a thing. Because I know it' s made my life so
much better.

A 35 year-old female made a similar statement. This woman, with a PASIPD score of

51.49 revealed the following view.










Parker, D.F., Carriere, L., Hebestreit, H. et al. (1993). Muscle performance and gross motor
function of children with spastic cerebral palsy. Developmental M~edicine and Child
Neurology, 35, 17-23.

Pavot, W., & Diener, E.F. (1993). Review of the Satisfaction with Life Scale. Psychological
Assessment, 5, 164-172.

Pavot, W., Diener, E.F., Colvin, C.R., & Sandvik, E. (1991). Further validation of the
Satisfaction with Life Scale: Evidence for the cross-method ,convergence of well-being
measures. Journal ofPersonality Assessments, 57, 149-161.

Petruzzello, S.J., & Landers, D.M. (1994). State anxiety reduction and exercise: Does
hemispheric activation reflect such changes? Medicine and Science in Sport and Exercise,
26 (8), 1028-1035.

Rejeski, W.J., & Mihalko, S.L. (2001). Physical activity and quality of life in older adults.
Journals ofGerontology, 56(A), 23-35.

Rimmer, J.H., & Wang, E. (2005). Obesity prevalence among a group of Chicago residents
with disabilities. Archives ofPhysical M~edicine and Rehabilitation, 86, 1461-1464.

Schwarz, N., & Strack, F. (1999). Reports of subjective well-being: Judgmental processes and
their methodological implications. In D. Kahneman, E. Diener, & N. Schwarz (Eds.),
Well-Being: The Foundations ofHedonic Psychology. (pp. 61-84). New York: The
Russell Sage Foundation.

Sharp, S.A., & Brouwer B.J. (1997). Isokinetic strength training of the hemiparetic knee:
Effects on function and spasticity. Archives of Physical M~edicine and Rehabilitation, 78,
1231-1236.

Sie, I.H., Waters, R.L., Adkins, R.H., & Gellman, H. (1992). Upper extremity pain in the post
rehabilitation spinal cord injured patient. Archives of Physical and Medical Rehabilitation,
73, 44-48.

Simon, G.E., VonKorff, M., & Barlow, W. (1995). Health care costs of primary care patients
with recognized depression. Archives of General Psychiatry, 52, 850-856.

Slater, D., & Meade, M.A. (2004). Participation in recreation and sports for persons with spinal
cord injury: Review and recommendations. NeuroRehabilita~tion, 19, 121-129.

Snead, S.L., & Davis, J.R. (2002). Attitudes of individuals with acquired brain injury towards
disability. Brain Injury, 16 (11, 947-953.

Sparkes, A.C. (1998). Validity in qualitative and the problem of criteria: Implications for sport
psychology. The Sport Psychologist, 12, 363-386.

Suh, E., Diener, E., & Fujita, F., (1996). Events and subjective well-being: Only recent events
matter. Journal ofPersonality and SocialPsychology, 70, 1091-1102.









trained and tested using a multi-station wheelchair accessible weight training system. The

researchers employed a circuit-training program with the participants completing two sets of

each exercise at the outset and increasing to three sets after four weeks. To assess QOL the

authors employed the 11-item perceived quality of life scale that required some modifications in

order to ensure item-content relevance (PQOL; Patrick, Danis, Southerland, & Hong, 1988) and

surveys measuring stress, depression, physical self-concept, pain, and perceived health.

The results showed that a twice a week training program over the course of nine months

lead to increases in muscular strength, arm ergometry performance, and several PQOL outcomes.

Individuals in the exercise group reported less pain, less stress, greater satisfaction with physical

functioning, lower levels of depression, and better quality of life than individuals in the control

group. The authors speculated that improved exercise capacity and muscular strength over the

nine month period could imply better functioning and greater ease of completing tasks of daily

living than was possible at baseline. In addition to physical improvements, Hicks et al. also

suggested that exercise should be used as a means to enhance psychological well-being in

persons with SCI. They suggested that exercise affects PQOL by reducing pain, improving sense

of control with regards to functioning, and social interactions (Hicks et al., 2003; Martin Ginis et

al. 2003).

Fullerton et al. (2003) also studied role of pain in wheelchair users. They compared the

onset and prevalence of shoulder pain in wheelchair users who were athletes to those who were

not athletes. Extant literature has shown that shoulder pain is a prevalent problem in wheelchair

users, with up to 78% of individuals with SCI reporting shoulder pain. Other researchers place

that number closer to one third of paraplegics and a slightly higher number of quadriplegic

(Curtis, Drysdale, Lanza, Kolber, Vitolo, & West, 1999; Sie, Waters, Adkins, & Gellman, 1992).














First Order Themes I


Higher Order Th~emes


Emotional
N =12

















Cognitive
N =10


Raw Data Themes

Relieves aggression
Good for disposition
Fights depression
Deal with rage
Relaxing
Relieves stress
It's therapeutic
Feel Good
Keeps you positive and grounded
More independence = more happiness


Competition is good
Athletics teaches leadership
Good mental strength
Stay focused and concentrate
Change life mentally
It's Fun
Gives you patience
Develop trust
Desire to not give up
Feeling of accomplishment


Work with others
Depend on others
Become more assertive
More outgoing
1 can do anything anyone else can
Ability to adapt
Developed work ethic
Showing that it can be done
Perseverance
Become less introverted
Able to achieve goals
increased control over life
Increased ability to do things


SBehavioral I
SN =8 I


SPsychological Benefits
SN = 25


APPENDIX B
THEMES FROM THE DATA


More outgoing









researchers would classify QOL as being the presence versus the absence of various disease

states or symptoms (Fayers et al., 1997). For instance, an individual with terminal cancer and the

inability to carry on tasks of daily living would be considered to have low QOL. Conversely

someone who is relatively healthier would be classified as high QOL. This objective

classification of QOL is called health-related QOL or "health status" and individuals in the

medical community generally use these terms interchangeably and focus on the effects that

illness or disability has on an individual's ability to function independently (Rej eski & Mihalko,

2001).

According to Duggan and Dijkers (2001), the domains within health related QOL

(HRQOL) encompass variables such as disease symptoms, treatment side effects, cognitive

functioning, handicap, and impairments among others. In other words an individual who

exhibits disease symptoms, or has a handicap would be thought to have low HRQOL. On the

other hand, one would assume that someone with no observable symptoms, exhibiting no

treatment side effects, and possessing no impairments, disabilities, or handicaps has a high

HRQOL. From this perspective, most of the research conducted on HRQOL employs

quantitative measures and one of the most utilized measures of health status is the Medical

Outcomes Study 36-Item Short-Form Health Survey (SF-36; Ware, Kosinski, & Keller, 1994).

As will be shown this perspective downplays an individuals' subj ective appraisal of their life

situation and is therefore distinct from the way psychologists view this construct.

Another way quality of life is defined is through assessing an individual's level of

functioning. According to Kaplan (1994), quality of life can be objectively defined in terms of

behavioral functioning. He called this idea the Ziggy Theorem, based on a cartoon that

suggested that the meaning of life was "doin' stuff' (Kaplan, 1994, p. 451). Placed in the









increase the amount of physical activity. Examples of environmental facilitators are an

accessible park or gym nearby, access to the proper equipment, or knowing other physically

active individuals (van der Ploeg et al., 2004).

Another determinant of physical activity behavior are personal factors. Personal factors

encompass demographic, biological, cognitive, and behavioral variables. The PAD model shows

those personal factors that are most important for persons with disabilities. For example, a

person's health condition, or ability to function, is an important personal factor that affects

physical activity. Other personal factors are intention to be active, self-efficacy, attitude, and

barriers and facilitators (van der Ploeg et al., 2004).

As with the environment, there are personal barriers and facilitators to physical activity

behavior as well. Personal barriers include a lack of time, money and energy as well as low

motivation and a lack of skills. Facilitators would be having sufficient time, money, and energy

to participate in physical activity.

According to the authors of the PAD model, intention is the most important determinant of

physical activity (van der Ploeg et al., 2004). Activity will not occur if there is no intention to

pursue it, however the intention to become physically active alone does not predict activity

behavior. The factors listed above, such as self-efficacy, barriers and facilitators help determine

whether intention leads to action. The PAD model's specific intention was to show the different

variables that play a role in physical activity behavior for persons with disabilities (van der Ploeg

et al., 2004). In addition, it attempted to describe how physical activity behavior, its

determinants, and functioning in persons with disabilities may be potentially related. The

authors of the model suggested that future research should aim to demonstrate the practicality




Full Text

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1 PHYSICAL ACTIVITY AND QUALITY OF LI FE EXPERIENCED BY PARTICIPANTS OF A WHEELCHAIR BASKETBALL TOURNAMENT By MICHAEL A. STANCIL A THESIS PROPOSAL PRESENTE D TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE UNIVERSITY OF FLORIDA 2007

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2 2007 Michael Adam Stancil

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3 To my wife, Leah.

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4 ACKNOWLEDGMENTS I would like to first thank m y wife who has stood beside me and encouraged me when completing this thesis seemed impossible. I am al so extremely appreciative to my advisor for all of his efforts, patience, and time during this en tire process. Also I want to thank all the wheelchair athletes who took part in this study and agreed to share th eir experiences with a complete stranger. Finally I would like to tha nk my parents, Mark and Patricia Stancil, for always encouraging me in school and beyond.

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5 TABLE OF CONTENTS page ACKNOWLEDGMENTS...............................................................................................................4 LIST OF TABLES................................................................................................................. ..........7 LIST OF FIGURES.........................................................................................................................8 ABSTRACT.....................................................................................................................................9 CHAP TER 1 INTRODUCTION..................................................................................................................11 Study Population............................................................................................................... ......12 Conceptual Issues in the Study of Quality of Life ..................................................................13 Theoretical Models of Qualit y of Life for Individuals w ith Physical Disabilities .................19 Empirical Studies on the QOL Construct........................................................................ 27 Measuring Quality of Life............................................................................................... 31 Purpose...................................................................................................................................45 2 METHODS.............................................................................................................................48 Participants.............................................................................................................................48 Measures.................................................................................................................................48 Data Analysis..........................................................................................................................50 3 RESULTS...............................................................................................................................54 Descriptive Statistics......................................................................................................... .....54 Interview Results: Higher Order Themes............................................................................... 55 Proposed Grounded Theory....................................................................................................64 4 DISCUSSION.........................................................................................................................74 Conclusion..............................................................................................................................74 Practical Applications and Future Directions ......................................................................... 77 Study Limitations.............................................................................................................. ......78 Summary.................................................................................................................................78 APPENDIX A INTERVIEW GUIDE.............................................................................................................80 B THEMES FROM THE DATA............................................................................................... 82 C THE PHYSICAL ACTIVITY SCALE FO R PERSONS W ITH DISABILITIES.................85

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6 LIST OF REFERENCES...............................................................................................................89 BIOGRAPHICAL SKETCH.........................................................................................................95

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7 LIST OF TABLES Table page 3-1. Means and standard deviations for the PASIPD ....................................................................72

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8 LIST OF FIGURES Figure page 1-1. The model of Functioning and Disabili ty (IC F model) from the International Classification of Functioni ng, Disability and Health......................................................... 46 1-2. The attitude, social influence, and self-efficacy (ASE) model. ..............................................46 1-3. The Physical Activity for people with Disability Model........................................................47 3-1. Triadic reciprocal causat ion adapted from Bandura (1997) representing th e three major determinants of behavior.................................................................................................... 72 3-2. A grounded theory of the determinants of physical activity and the role it plays in subjective Q OL................................................................................................................. .73

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9 Abstract of Thesis Presen ted to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Science PHYSICAL ACTIVITY AND QUALITY OF LI FE EXPERIENCED BY PARTICIPANTS OF A WHEELCHAIR BASKETBALL TOURNAMENT By Michael A. Stancil August 2007 Chair: Peter R. Giacobbi, Jr. Major: Applied Physiology and Kinesiology Quality of life is a construct that has di fferent meanings for researchers in various disciplines. Within the medical field, QOL is conceptualized as the presence or absence of symptoms while those in physical or occupational therapy might eval uate the ability to complete functional tasks of daily living. Within psychol ogy researchers emphasize subjective assessments of well-being or happiness or how individuals interpret their own lives, goals, achievements, and subjective evaluations. My study used a subjectively oriented a pproach to examine physical activity and subjective assessments of life quality with 26 individuals with physical disabilities. The participants completed the Physical Activity Sc ale for Individuals with Physical Disabilities (PASIPD) and a semi-structured interview focused on the physical activity experiences and the role those experiences played in their subjectiv e evaluations of the participants lives. The physical activity for persons with disability mode l and Dijkers conceptua lization of subjective quality of life served as sens itizing concepts dur ing the analysis phase. Grounded theory analyses revealed that participants of a wheelch air basketball tournament perceived a number of psychological, social, and health benefits associated with physical activity involvement. These

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10 experiences in turn allowed the participants to de velop self-efficacy beliefs and expectations that facilitated future involvement in their chosen phy sical activities. By all accounts the participants in this sample were generally very active a nd appeared to experien ce subjective well-being.

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11 CHAPTER 1 INTRODUCTION In recent years there has been increased fo cus on the im portance of quality living (Hays, Hahn, & Marshall, 2002; Ware, 2000). In fact, an informal search of Medline (Pubmed) data base using the search terms quality-of-life (QOL) resulted in 65,522 hits involving all publications focused on human beings while an identical search on the Psychinfo data base resulted in 13,506 publications. This research atte ntion is justified because quality-of-life is an important predictor of diverse outcomes including physical and ment al health, happiness at work and satisfaction in interpersonal relationships (Deiner, 2000). In able-bodied samples, subjective well -being, a psychological c onstruct related to subjective QOL, has been shown to be correlated to various specific domains in a persons life (Rejeski & Mihalko, 2001). Variable s such as age, education level, social class, income, marital status, employment, religion, leisure, life events, social skills, and health all can affect happiness, although most effects are small (Argyle, 1999). Th e strongest effects are seen from marriage, occupational status, leisure, health, and social skills. Others ha ve suggested that since humans have an instinctual urge to belong, developing an d maintaining close rela tionships with others plays a role in happiness (Mye rs, 1999). Additionally, it has been posited that when people report well-being, they will often compare themselves to others The level of reported wellbeing may depend on whether comparisons were made to others who are better or worse off than the individual (Schwarz & Strack, 1999). The focus of this thesis is on quality-of-life w ith individuals with physi cal disabilities. As will be shown there is a plethora of publis hed studies focused on QOL with able-bodied individuals. However, only recently have researchers extended this line of inquiry to individuals with physical disabilities. Add itionally, there is no one accepted de finition of the QOL construct

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12 and researchers have struggled to extend conceptual and theoretical frameworks to individuals with physical disabilities. In ch apter one I will review important conceptual definitions in the QOL literature. This review will be followed by a discussion of theoretical frameworks of quality of life that are relevant to this thesis This discussion will be followed by a review of literature and the rationale and spec ific purposes of this thesis. To begin however it is important to precisely characterize study popul ation and offer specific definitions of what it means to be physically disabled. Study Population There are an ever-increasing num ber of adults in the United States who have some form of disability. According to the Unite d States Bureau of the Census the number of people who report disabling conditions is approximately 54 m illion while approximately 26 million report conditions that significantly impact one or more activities of daily liv ing (McNeil, 1997). In addition, there are roughly 11,000 reported spinal cord related injuries each year (Spinal Cord Injury Information Network, 2003). With such large numbers of individuals who report disabling conditions it becomes important to precisely characterize what it means to be physically disabled. The term disability can have several meani ngs. According to Mosbys Medical, Nursing, and Allied Health Dictionary (5th ed.), disability is the loss, ab sence, or impairment of physical or mental fitness. Impairment is defined as any negative change in f unction or structure that interfere with ordinary activities as a result of bodily or mental abnormalities. (Mosbys Dictionary, 1998). It may also be defined as when the physical capacity to move, coordinate movement, and perform physical activit ies is significantly impacted. According to the World Health Organization, the terms impairment, disability, and handicap are distinctly different (Block, Griebenauw, & Brodeur, 2004). Impairment refers to

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13 any loss or abnormality of structur e or function in the body. An indi vidual with paralysis of the lower extremities would be considered to have an impairment. If that same person is prevented or restricted from executing a task or activity, or is otherwise functionally limited as a result of their impairment, they would be said to have a di sability. This person would be considered to be handicapped if accommodations were not made in order to allow the person to live a normal life. For example, this individual would be handicapped if steps were not taken at the work place such as building ramps or making the rest rooms wheelchair accessible. Recently the term activity has replaced disability Activity refers to the type and level of functioning displayed at the individu al level. For instance it coul d refer to a persons ability to take care of him or herself, walking, or co mmunicating (Hays et al., 2002). Also, the term handicap has been replaced by participation. Pa rticipation describes th e level and degree of a persons involvement in life situations. An individuals level of participat ion can be affected by personal or environmental factors (Block, Griebenauw, & Brodeur, 2004). Types of disabilities vary from physical to developmental, congenita l to acquired, and mild to severe. For example, an individual with mu ltiple sclerosis is said to have a congenital physical disability because they are born with their disability. A co mmon acquired physical disability is spinal cord injury, which may result, from among other thi ngs, a spinal tumor or a car accident. The focus of this thesis will be on patterns of physical activity and subjective QOL for individuals with physical disa bilities who have either acquired their disability or were born with their condition. Conceptual Issues in the Study of Quality of Life The definition of quality of life has undergone tremendous debate in recent years (Fayers, Hand, Bjordal, & Groenvold, 1997; Rejeski & Mihalko, 2001; Dijk ers, 2005). At the broadest level, QOL researchers and theorists can be characterized by their focus. One group of

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14 researchers would classify QOL as being the presence versus th e absence of various disease states or symptoms (Fayers et al ., 1997). For instance, an individua l with terminal cancer and the inability to carry on tasks of daily living would be considered to have low QOL. Conversely someone who is relatively healthier would be classified as high QOL. This objective classification of QOL is called health-related QO L or health status and individuals in the medical community generally use these terms in terchangeably and focus on the effects that illness or disability has on an individuals abil ity to function independently (Rejeski & Mihalko, 2001). According to Duggan and Dijkers (2001), th e domains within health related QOL (HRQOL) encompass variables such as disease symptoms, treatment side effects, cognitive functioning, handicap, and impairments among othe rs. In other words an individual who exhibits disease symptoms, or has a handicap would be thought to have low HRQOL. On the other hand, one would assume that someone with no observable symptoms, exhibiting no treatment side effects, and possessing no impa irments, disabilities, or handicaps has a high HRQOL. From this perspective, most of the research conducted on HRQOL employs quantitative measures and one of the most utiliz ed measures of health status is the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36; Ware, Kosinski, & Keller, 1994). As will be shown this perspective downplays an individuals subjective appraisal of their life situation and is therefore distinct from the wa y psychologists view this construct. Another way quality of life is defined is through assessing an i ndividuals level of functioning. According to Kaplan (1994), quality of life can be objectively defined in terms of behavioral functioning. He called this idea the Ziggy Theorem, ba sed on a cartoon that suggested that the meaning of life was doi n stuff (Kaplan, 1994, p. 451). Placed in the

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15 context of healthcare, Kaplan s uggested that the goal of health professionals should not only be to extend peoples lives, but also to make their lives worth living by maintaining each individuals ability to function. Kaplan gives the example of po ssible treatments for prostate cancer. In the past doctors would have aggressive ly treated the tumor with radiation or surgery. In many cases this could lead to impotency a nd incontinency, which may lead to decreased ability to function norm ally (Kaplan, 1994.) If the doctors applied the Ziggy Theorem, they would have taken the patients preference into consideration, which might mean avoiding aggressive treatment. In order to assess functioning and QOL, Kaplan and Anderson developed the quality of well-being scale (QWB; Kaplan & Anderson, 1988.) The QWB s cale assesses well-being at a specific time point so the patient is giving their health status for one particular day. This instrument classifies functioning on scales of mobility, physical activit y, and social activity. Additionally, the QWB scale contains a list of po ssible symptoms that a patient can choose from as the most undesirable for them (Kaplan, 1994). Once a patient has been classified in an observable health state the next step is to place them on a scale of we llness from 0-1.0 (with 0 indicating death and 1.0 indicating good health with no symptoms). In order to achieve this, the health states are weighted according to ratings obtained from human value studies. These weights provide quantification for the relevant importance of doin stuff (Kaplan, 1994). The final piece of the puzzle in the Ziggy Theorem is the durati on in a particular state of health. One year in a state of health that has been assigned a weight of 0.5 is equivalent to one half of a quality adjusted life year (QALY). Basically the QWB scale takes a rating of wellbeing from a specific point in time and applies it to a longer duration of time assuming that the individual will remain in that health state for the longer duration. Conceptually, one QALY

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16 equals one year of life without any functional limitations related to health. When applied correctly the QWB scale should qua ntify medical treatment or hea lth activities in terms of how many QALYs it generates or retains. A third group of QOL researchers would defi ne QOL based upon subjec tive indicators. For instance, mainstream psychologi sts have defined quality of lif e as a conscious judgment of satisfaction with ones life (Rejeski & Mihalko, 2001, p. 23). From this perspective ones judgment of their quality of life is based largely on ones valu es and experiences and is entirely subjective. Many authors have us ed subjective indices of quality of life interchangeably with terms such as subjective well-be ing, affect, and happiness (Berger & Motl, 2001). For instance, Duggan and Dijkers (2001) stated that an individuals objectiv e characteristics do not always correspond with their subjective ex perience. They conceptualized subjective QOL as how well a persons expectations coincide w ith their achievements or ones level of satisfaction with these expectancies. Therefore, if someones reality falls short of his or her dreams or goals, they will have a negative emotional and c ognitive reaction and ther efore be less satisfied with their quality of life. If there is congrue nce between ones goals and achie vements, they will react more positively and experience increased life satisfaction. These authors make the assumption that, if there is a gap between e xpectations and achievement, the indi vidual will try to bring a balance between the two by changing thei r objective circumstance, or adjusting their expectations (Duggan & Dijkers, 2001). For example, a person with a physical disability may be unable to perform certain tasks such as bed transfers. Th is may have a negative im pact on their quality of life. In order to increase subjective QOL they can adjust their expectations and consider the ability to perform a bed transfer less important than other tasks that they are able to complete. An alternative would be to change their circumst ance so that they can pe rform a bed transfer.

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17 This could be done by increasing muscular strength in their u pper body, so that they can lift themselves out of their ch air with greater ease. An individual who is assessing his or he r own subjective QOL may use an internal or external benchmark for comparison. A person may have a well-developed notion of how they feel their life should unfold and they might have established a timetable for certain major life events to occur. This timeline may serve has an internal benchmark from which assessments about subjective QOL can be made. They may have decided they would be married by age 25 and start a family by age 30. If these events do not occur as expected as a result of their disability, they will more than likely assess their subjective QOL lower than if events occurred the way they wanted them to. Persons with physical disabilities may use able-bodied individuals, other individuals with the same disability, or others with a different disability as their external benchmark (Duggan & Dijkers, 2001). Overall, Duggan and Dijkers (2001) concept of subjective QOL can be divided into three components. Those three components are achieve ments, expectations, and evaluations. The achievement component has been the focus of obj ective QOL research, with attention paid to marital status, number of days restricted from activity, income level, physical capabilities, etc. Researchers employing the subjectiv e definition have previously only highlighted the subjective reactions, or evaluations. Evaluations can incl ude satisfaction with ma rriage, happiness, selfesteem, depression, etc (Duggan & Dijkers, 2001). These authors concept of subjective QOL is among the first to include expectations along with achievements and evaluations. Expectations are defined as goals, values, desi res, aspirations, or any other variable that may affect how achievements are evaluated. For instance, an indi viduals evaluation of their income level will

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18 likely be influenced by the value they place on we alth or possessions. If they place a high value on wealth, then their lack of it may be evaluated negatively. Dieners (1984) theory of s ubjective well-being is similar to the subjective definition of quality of life. In fact, using a benchmark for comparison, whether internal or external, would be considered a cognitive judgment of ones life This would constitute the life satisfaction component of subjective well-being (Diener, 19 84). Additionally, one trademark of subjective well-being is that it revolves ar ound an individuals own beliefs on wh at they feel is important to their happiness, not what the researcher determ ines is important (Diener, Emmons, Larsen, & Griffin, 1985). The subjective approach to qual ity of life allows the individual to appraise their quality of life both emotionally and cognitively. That is to say, a person may feel happy and be able to tell him or herself that the circumstances of their life are great, when someone else may view those same circumstances as undesirabl e. Each individual takes in to account their own experiences, thoughts, and emotions when rating their quality of life. Specifically, for individuals with disabilities, the subjective defini tion allows them to place impo rtance on achievable goals and their own expectations of what the good life should be like while de-e mphasizing goals that are unattainable, other peoples views, and societal expectations. It is difficult to say which definition most adequately describes the QOL construct for individuals with disabilities. Intuitively it seem s obvious that level of functioning would play an important role in quality of life for this population. It could be argued that the ability to provide oneself with basic care, perform the tasks of everyday living, and be physically active figure heavily into how a person rates their life quality. While the abili ty to perform those tasks would not necessarily guarantee that someone views thei r life positively, the inability to perform those

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19 tasks should have stark negative effect on how a person views their quality of life. For persons with physical disabilities, improvements in their ability to function and perform basic living tasks could have beneficial consequences for their quality of life. Based upon this line of reasoning, adopting or integrating the subj ective well-being and level of functioning conceptual approaches to qua lity of life may be appropriate to fully capture the experience of individuals with disabilities. Lower levels of functioning may be associated with lower levels of QOL, but only if the indivi dual feels that performing daily living tasks is important to their happiness. For these reasons, I will adopt a definition of QOL that includes level of functioning as well as subj ective indicators for th is thesis. Throughout this thesis I will continue to use the terms and concepts adopted by particular research ers who study quality of life from the various disciplines previously described. However, when referring to this concept in reference to data from my participants I will re fer to this construct as subjective quality of life (SQL) because this term reflect s the conceptual and methodological approach adopted here. Theoretical Models of Quality of Life fo r Ind ividuals with Physical Disabilities In the following section I will revi ew theoretical frameworks that are relevant to this study. These frameworks seek to integrate individua l differences in disability with relevant socio/environmental variables in an effort to explain choices in behaviors. The first framework is the international classification of functioning, disability and health (ICF) model (World Health Organization, 2001). The next model discussed will be the attitudes, social influences, and selfefficacy model (ASE; De Vries, Dijkstra, & Kuhl man, 1988), which attempted to predict health behaviors by determining the attitudes, soci al influence, and self-efficacy towards those behaviors. Finally, I will ex plain the physical activity and disability model (PAD), which combines the framework of the ICF model with themes from the ASE model (van der Ploeg, van der Beek, van der Woude, & van Mechelen, 2004).

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20 The ICF model is used as a tool in rehabilitation medicine and research as well as for health, educational, and social policy (Stucki, 2005). It wa s developed and endorsed by the 54th World Health Assembly in May 2001 (Stucki, 2005). The original intent of the ICF model was to provide a unified language for classifying health domains and organizing information on health status, with the ultimate goal of pr oviding a common framework to measure health outcomes (Stucki, 2005; Perenboom & Chorus, 2003; van der Ploeg et al., 2004). As shown in Figure 1-1, the ICF model views di sability and functioning in the context of personal and environmental factors (Ustun, Chat terji, Bickenbach, Kostanjsek, & Schneider, 2003; van der Ploeg et al., 2004; St ucki, 2005). Van der Ploeg et al (2004) suggested that the presence of the environmental and personal factor s indicates that an in dividuals functioning is dynamic in that it can change depending on th e environmental factors. To understand this changing relationship between functioning and e nvironment, further explanation of the ICF model is necessary. Contextual factors, such as environmental a nd personal factors, along with functioning and disability make up the two parts into which information is organized in the ICF model (Perenboom & Chorus, 2003). To begin, contextual factors can include environmental barriers such as a lack of ramps and personal factors such as education level. These factors play a role in individuals ability to function and the types of activities they choose to participate in. For instance, someone who has been educated on the h ealth benefits of exerci se and instructed how to perform specific exercises may be more likely to start an exercise program than someone who did not receive the same information. Additionall y, if the place where the individual wants to exercise has ramps and is accessible, then th e likelihood of that person following through on a program might be greater than if there were not an accessible facility.

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21 As shown in the figure above, the functioning and disability element is broken down into three sections labeled body, activ ity, and participation. The body component concerns itself with body functions and structures. Impairment refers to a loss or deviation from normal body functions and structures (van de r Ploeg et al., 2004). For example, a person would be considered to have impairment if they either lost a leg to amputation, or lost us e of their leg due to paralysis. The activity component refers to the ability to perform a task one is functionally capable of doing and is distinct from the participation component, which refers to whether or not one chooses to play such activities. The participation portion of the ICF model refers to taking part in activities and may also include social beha viors. Likewise, the individua l may be capable of executing a task, but their ability to perform that task in a social setting, su ch as wheelchair basketball, may be inhibited by environmental fact ors such as transportation to a nd from practice, cost of chair built for basketball, or simply the absence of a wheelchair basketball team in the community. Environmental factors include so cial and physical settings as well as the attitudes of other people (van der Ploeg et al., 2004) The social environment can impact a persons functioning through infrastructure, which c ould include accessible sidewa lks and buildings, laws and regulations that provide and maintain an accessi ble physical environment, and attitudes towards disability that can influence the kind of behavior is expected from an individual. An individual with a disability may exhibit higher functioning and participation if they live in an environment that is physically accessible and one in which they are encouraged to be active. On the other hand, if that individual lives in a place where they encounter physical barrie rs or are not expected to be active due to their disabili ty, they will be at risk for lowe r functioning and participation. The final dimension of the ICF model is personal factors. Personal factors can include demographic variables such as ge nder, race, age, and education as well as their coping style and

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22 past experience (van der Ploeg et al., 2004). As has been mentioned before, there is a relationship between disability and functioning a nd contextual factors such as the environment and personal factors. Age is one personal f actor that may have an impact on a persons functioning, as is lifestyle. An active individual who acquires an injury may decide to pursue an active lifestyle post-injury sooner than someone who was not active simply because they were active before their injury (Wu & Williams, 2001). The ICF model is a broad and multidimensional tool that is used to assess health status in persons with and without disabilities. It has utility in rehabilitati on settings as well as research. Clinicians can use this tool to assess the impact of disability on an indivi duals ability to function while researchers can use this model in order to provide results in a more uniform manner. Another theoretical model is the physical act ivity for people with disability model (PAD; van der Ploeg et al., 2004). The PAD model comb ines the ICF framework with elements of the attitude, social influence and self efficacy mode l (ASE; De Vries, Dijkstra, & Kuhlman, 1988) to create a new model that shows which variab les determine physical activity behavior of individuals with disabilities (van der Ploeg, 2004). In order to explain the PAD model, however, it is important to first discuss the ASE model and its framework. The attitude, social influence, and self-effi cacy (ASE) model, developed by De Vries and colleagues (1988), combines the self-efficacy elem ent of social learning theory (Bandura, 1977) with the attitude and subjective norms constructs from the theory of reasoned action (Fishbein and Ajzen, 1975). These three psychosocial determ inants of behavior are considered to be the most important (van der Ploeg et al., 2004). In the ASE model (See Figure 1-2), behavior results from intention to engage in a particular behavior. The intention toward s a certain behavior is determined by a combination of self-efficacy, attitudes, and social influence towards a behavior

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23 (De Vries et al., 1988). Self-efficacy towards a beha vior refers to the confidence an individual has in their own ability to perfor m that behavior. For instance, if an individual with a disability was not confident they could push themselves a mile up steep terrain because he had never accomplished this task this person would be said to have low self-efficacy for that task. Their lack of self-efficacy would then lessen the inte ntion to push themselves for a mile, and would ultimately determine whether or not they would perform that behavior. Additionally, attitudes towards behavior can affect intentions and engagement in a specific task and refer to what an individual thinks about a certain behavior for them. Us ing the example from above, if an individual with a disability thinks that pushi ng for a mile in their wheelchair is good for him because it provides exercise then that would stre ngthen his intentions and increase the likelihood of that behavior. Finally, subjective norms, or soci al influence, also have an impact on behavior intentions. Subjective norms are often socially influenced a nd may include what family, friends, or doctors think about a certain behavior as well as how society regards that behavior. Physical activity for individuals with disabilities, fo r instance, has become more popular recently as old stigmas about disabled individuals have been shed. When an expectation exists for a specific behavior, whether its smoking less or exercising more, then there is a better chance that an individual will be persuaded to engage in that behavior. In the ASE model, external variables can also influence activity beha vior. These variables are similar to personal factors in the ICF mode l, and can include age, gender, race and socioeconomic status. Their influen ce on behavior can only occur thr ough one or more of the three determinants of behavior listed above (van der Ploeg et al., 2004). The last part of the ASE model takes into account the presence or absence of barriers and skills. As with the ICF model,

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24 barriers can consist of any obs truction in the environment or personal life, which limit the performance of a behavior. Skills can be conceptu alized as actual contro l over a behavior and is different from perceived contro l, or self-efficacy (De Vries et al., 1988). For example, an individual might have high self-efficacy that they can push a mile in their wheelchair, but they may not have the physical strength or endurance required to do so. In summary, the ASE model is a tool for dete rmining behavior or behavior change. The authors took the self-efficacy component, borro wed from Social Learning theory (Bandura, 1977) and combined it with attitudes and subjec tive norms from Fishbein and Ajzens (1975) theory of reasoned action (Fishbein and Ajzen, 1975; DeVries et al., 1988). This model has recently been adapted by van der Ploeg et al. (2004) and included in their PAD model, which will now be explained. Van der Ploeg and colleagues first introduced the physical activity for people with a disability (PAD) model in 2004. Their goal was to develop a model that described how physical activity behavior, determinants of behavior, and functioning of persons with a disability were related (See Figure 1-3). They used the ICF model as a means of describing functioning and disability and combined it with el ements of the ASE model that de scribed factors that determined physical activity (van der Ploeg et al., 2004). As was mentioned in the previous section, the ICF model ha s three levels of functioning consisting of body structures and function, activ ity and participation. The PAD model views physical activity within each of these domains, while at the same time, showing the benefits of physical activity at each level. Consider this example of an individual with paraplegia: having use of their upper body falls under the body structur es and functions domain. Physical activity can result in improved muscle power in the upper body and in crease cardiopulmonary function

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25 as well (van der Ploeg et al., 2004). That in turn will make activities such as pushing a wheelchair easier. The part icipation domain is impacted by physical activity through improvements in functioning. According to the authors of the PAD model, improved functioning will result in better performance in real -life situations and in social situations (van der Ploeg et al., 2004). Another similarity between the ICF and PAD models is the domain of environmental factors. The PAD model uses this domain differ ently from the ICF model in that the PAD model seeks to explain what environmental factors determine physical activity behavior. Social influence and environmental barrie rs and facilitators are the primary determinants of physical activity behavior within this dom ain (van der Ploeg et al., 2004). There are some differences between how so cial influence works between able-bodied people and persons with disabilities. Family and friends are the primary source of social influence on physical activity for able-bodied indi viduals. Individuals with disabilities, however, are more likely to be influenced by health pr ofessionals (van der Pl oeg et al., 2004). This difference is important because if a link betw een physical activity and quality of life is established and published in the future, such information will become available to health professionals who can then recommend exercise or other forms of physical activity to individuals with disabilities as a way to improve to their quality of life. Barriers or facilitators in th e environment can also impact physical activity behavior for individuals with disabilities. Barriers are those things in the environment that reduce the amount of physical activity behavior. They can range fr om poor transportation and a lack of accessible equipment to a lack of assistance, distress with physical activity with non-disabled individuals present, and season. Facilitato rs are often viewed as opposite to barriers and they typically

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26 increase the amount of physical activity. Examples of envi ronmental facilit ators are an accessible park or gym nearby, access to the pr oper equipment, or knowing other physically active individuals (van der Ploeg et al., 2004). Another determinant of physical activity behavi or are personal factors. Personal factors encompass demographic, biologi cal, cognitive, and behavioral va riables. The PAD model shows those personal factors that are most important for persons with disabilities. For example, a persons health condition, or ability to function, is an important persona l factor that affects physical activity. Other personal fa ctors are intention to be activ e, self-efficacy, attitude, and barriers and facilitators (van der Ploeg et al., 2004). As with the environment, there are personal ba rriers and facilitators to physical activity behavior as well. Personal ba rriers include a lack of time, money and energy as well as low motivation and a lack of skills. Facilitators would be having sufficien t time, money, and energy to participate in physical activity. According to the authors of the PAD model, in tention is the most important determinant of physical activity (van der Ploeg et al., 2004). Acti vity will not occur if there is no intention to pursue it, however the intention to become physically active alone does not predict activity behavior. The factors listed above, such as sel f-efficacy, barriers and faci litators help determine whether intention leads to action. The PAD models specific intention was to show the different variables that play a role in phys ical activity behavior for persons with disabilities (van der Ploeg et al., 2004). In addition, it attempted to describe how physical activity behavior, its determinants, and functioning in persons with disabilities may be potentially related. The authors of the model suggested that future rese arch should aim to demo nstrate the practicality

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27 and external validity of the PAD model. Another important area of interest is determining the most important personal and environmental barrier s and facilitators to physical activity. The three models discussed thus far all play a role in the explorat ion of physical activity behaviors and functioning among persons with di sabilities. The ICF model is a broad and multidimensional tool that is used to assess health status in persons with a nd without disabilities. Clinicians can use this tool to assess the imp act of disability on an individuals ability to function. The ASE model provides a foundation fo r examining the determinants of physical activity behavior. The PAD model incorporates both of these mode ls in order to look at the relationships that may exist between functioning, determinants of activity, and physical activity behavior (van der Pl oeg et al., 2004). In this thesis I will use the PAD model in order to explore physical activity behavior among individuals with disabilities. This model pr ovides a framework that enables the researcher to examine the roles of body structure and function, along with envi ronmental and personal factors to ascertain levels of activity and participation. To my knowledge, it is also the only theoretical model that attempts to explain exer cise behavior specifically within the disabled population. Empirical Studies on the QOL Construct In the following sections I will review empirical studies focused on quality of life for individuals with various populations. These studies are organized generally around contextual/environmental, persona lity, and cultural factors that impact the quality of life construct. Following this part of the review will be studies that focus more specifically on physical activity and quality of life. In their study on individuals w ith traumatic brain injury and attitudes towards disability Snead and Davis (2002) defined qua lity of life as physical and me ntal health and operationalized

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28 this construct using the Rand-36, which combines scales of physical heal th, mental health, and global health to measure quality of life (H ays, 1998). The participants were 22 men and 18 women, the majority of which had suffered either a traumatic brain injury (TBI) or a stroke. Their ages ranged from 20 to 66 with close to half living at home and the rest living with family, friends, or in community homes. Potential partic ipants were excluded if they did not have the capacity to self-report. The participants completed surveys concerning attitudes towards disability, acceptance of disability, community integration and quality of life. Family members or other caregivers filled out surveys measuring functional independence a nd assessing function. They found that better quality of life was positively related to greater acceptance of disability and a positive attitude towards disability. The au thors also linked positive attitudes about oneself to more self-conf idence and seeking out others company as well as more active lifestyles (Snead & Davis, 2002). This is important because it suggests that encouraging individuals with TBI to have mo re positive attitudes about their disability may lead them to become more active. Snead and Davis (2002) admitted they were limited in the fact that they could not determine which variables acted as catalysts fo r improving attitudes, acceptance, and quality of life. They suggested that qualitative research could impr ove understanding of how these attitudes are developed and influenced. Differences in quality of life between i ndividuals are predicted by several different factors (Berger & Motl, 2001). A ccording to Diener, Oishi, and Lucas (2003) an individuals personality is moderately to st rongly correlated with subjective well-being. They reached this conclusion after years of research indicated that external factors had only a modest impact on reported subjective well-being (Deiner, Suh, Lu cas, & Smith, 1999). Additionally, research has

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29 shown that SWB does not change over time, it return s to stable levels after major life events, and a strong relationship exists with st able personality traits (Diener et al., 2003). More specifically, extraversion and neuroticism are the two personality traits that exhibit the strongest relationship with subjective QOL. Generally speaking, extr averts are outgoing, sociable, comfortable in social situations and generally happier than in troverts. In contrast neurotics are anxious, depressed, they often feel self-conscious, and ar e typically unhappier. Since extraversion and neuroticism provided the strongest correlations to affect, the au thors suggested that these two traits could provide the link be tween personality and subjective well-being (Diener, Oishi, & Lucas, 2003). Others have noted that persona lity might also interact with the environment and impact self-reported SWB. Kette (1991) found that extroverted prison ers report lower levels of happiness than introverted prisoners This finding was counter to previous research that stated that extroverts are generally happ ier than introverts (Diener et al ., 2003). Since then researchers have suggested that higher levels of positive aff ect are correlated with trait-congruent behaviors and trait-incongruent behaviors ar e correlated with higher levels of negative affect (Diener et al., 2003). Essentially people are ha ppier when they engage in ac tivities that be tter suit their personality traits. Other factors influencing differences in quality of life are socio-demographic characteristics and contextual a nd situational factors (Berger & Motl, 2001). Socio-demographic characteristics can include age, education, marital status, gender, income, so cial class and social relationships (Berger & Motl, 2001). Emotion, stress, and physical health are the contextual or more situation based factors that are associated with quality of life.

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30 Another important factor that impacts quality of life is recreation (Slater & Meade, 2004). Studies in the general po pulation have shown that recreation is more important than job status, health, and finances in determini ng life satisfaction. This suggests that promoting a lifestyle that places an emphasis on recreational activity could influence an indi viduals quality of life. Many researchers examining qual ity of life or one of its rela ted concepts such as life satisfaction or subjective well-being note the relativ e stability of this construct over time (Lucas, Clark, Georgellis, & Diener, 2004). Subjective well-being is affect ed for less than 3 months by most major life events (Suh, Diener, & Fujita 1996). Heady and Wearing (1992) posited that individuals have set points for SWB. According to their theory, when a person encounters an event they will have an initial r eaction, but will soon return to a ba seline level of happiness while an individuals baseline is determined by th eir personality (Heady & Wearing, 1992). This precept has guided much of the research done on SWB (Diener, Suh, Lucas, & Smith, 1999). For instance, Lucas et al. (2004) found evidence that suggested that th e set point could be altered. If set point theory were correct pa rticipants would have an initial reaction to unemployment but would return to their baseline levels within 2 years. The data, which was obtained from a longitudinal study in Germany, indicated that unemployment created a new baseline level of life satisfaction (Lucas et al., 2004). The decline in life satisfaction for these participants remained stable at the lower level even after employment was regained. The authors suggested that their findings were not totally inconsistent with set point theory, but considered the possibility that there are onl y a few life events powerful enough to alter the set point for life satisfaction. Berger and Motl (2001) suggested that quality of life is a global assessment of life as whole rather than a focus on specific life domains Thus, subjective QOL can be viewed as a

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31 dynamic interplay between psychological, emotional, and physical health domains reviewed in previous sections. Other researchers, who see QOL as an umbrella term for multiple outcomes as it relates to health, have echoed this sentiment. (Rejeski & Mihalko, 2001) According to Diener subjective well being, a term closely related to qu ality of life (Rejeski & Mihalko, 2001) can be broken down into the smaller components of lif e satisfaction, satisfaction with important domains, positive affect, and low levels of negative affect (Diener, 2000). One common underlying assumption within subjective definitions of ones QOL is that individuals judge for themselves whether they are satisfied with their cu rrent circumstances or not. It is this subjective dimension of QOL that will be embraced within the current investigation because as will be discussed physical activity, recreation, and hi gh levels of community integration are all associated with positive affective experiences and qua lity of life. Measuring Quality of Life As discussed above quality of life research ers have produced many conceptual definitions and measurement instruments to assess this c onstruct: Berger and Motl (2001) estimated that over 300 scales have been produced that measures quality of life. Because of the plethora of quality of life scales and due to the fact that my thesis will adopt a subjective approach to assessing this construct I will only review the ps ychometric characteristics of two widely used instruments: the SF-36 (Ware, Kosinski, & Dewe y, 2000) and the Satisfaction with Life Scale (Diener, Emmons, Larson, & Griffin, 1985). The Satisfaction with Life Scale is a five-item survey that includes statements such as, In most ways my life is close to ideal, and If I could live my life over, I would change almost nothing, (Diener, Emmons, Lars on, & Griffin, 1985). Respondents give answers based on a 7point Likert Scale, so scores can range from 5 to 35. The SWLS was shown to have adequate internal consistency ( = .87) and a two-month te st-retest reliability ( = .82), and it has

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32 convergent and divergent validity between a number of personality scales and other subjective well-being scales (Diener et al ., 1985). The SWLS is a uni-dimensional measure and has been validated for a wide range of age groups (Pa vot, Diener, Colvin, & Sa ndvik, 1991). Other QOL measures contain sub domains that measure wor k, self, primary social contacts, acceptance by others, recognition, and prestige (Landers & Arent, 2001). Pavot and Diener (1993) also demonstrated that self-reports co rrelated highly with reports made by peer, family members, and friends. The SF-36 measures health related QOL by taking both mental and physical health and breaking each down into four scales for a total of eight scales ranging from 2 items to 10 items (Ware, Kosinski, & Dewey, 2000). The score for phys ical health is broken down into scales for physical function, role-physical (e .g. work activity or act ivities of daily living), bodily pain, and general health (Ware, Kosinski, and Keller, 1994 ). Likewise, mental health is measured on scales of vitality, social f unctioning, role-emotional (e.g. how em otions affect work or ADL), and mental health. These items are scored on a Likert scale, which range from 1-3, 1-5, or 1-6 depending on the specific item (Ware et al., 2000) The SF-36 has been shown to be valid and reliable measurement of HRQO L for the general population as principal component analysis confirmed the two-factor higher-order structure for this instrument across a range of samples (Ware et al., 2000). Because the SF-36 was designe d and validated with able-bodied individuals it is generally not recommended for use with individuals with disabilities (Hayes, Hahn, & Marshall, 2002). However, recen t recommendations in the litera ture have demonstrated how specific items on the SF-36 can be modified to be more pertinent for this group (Tate, Kalpakjian, Forchheimer, 2002).

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33 The quality of well-being scal e (QWB; Kaplan & Anderson, 1988) places individuals into categories based on their level of functioning an d their symptoms. Functioning is measured on scales of mobility, physical ac tivity, and social activ ity. Interviewers ask patients questions concerning their level of limitation for the previously mentioned scales in order to classify their objective level of functioning. Then patients are given a list of sy mptoms they might experience. The interviewer then asks the patient to choose the symptom they are experiencing that is most undesirable to them (Kaplan, 1994). To generate a score for wellness the weighted score for symptom is summed with the weighted scores for mobility, physical activity, and social activity along with 1. Possible scores range from 0 to 1, with zero indicating worst possible well-being (death) and a score of one meaning the individual is completely well. For example, a weight of 0 is given for no limitations across the three scal es and for no symptoms. A person who has no limitations and no symptoms would score a one. The well-being score is then multiplied by a time component, usually years, to determine the duration of stay in various health states. The weights assigned to states of functio ning were obtained th rough cross-validation studies that demonstrated a high degree of accuracy (R2 = 0.96). Studies have also shown that these weights are stable over a one-year period and that they are consistent across an assorted groups of users (Kaplan, Bush, and Berry, 1978). Additionally studies have shown that the QWB scale is both valid and reli able in the general population (Kaplan, Bush, Berry, 1976). As with the SF-36, the QWB scale is considered pr oblematic for individuals with disabilities due to its quantification of functioning (Hays et al., 2002, p. S7). Health Risks for Individuals with Disabilities In the following sections I will review literatu re that has shown that individuals with disabilities are at a grea ter health risk than those without di sabilities (Cooper, Quatrano, Axelson,

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34 Harlan, Stineman, Franklin et al., 1999; Ri mmer & Wang, 2005). Additionally, I will review empirical studies that demonstr ate links between physical activity and QOL for this population. This will be followed by a review and synthesis of the literature review and the scientific rationale for the present study. Since individuals with disabilities are more lik ely to have activity limitations than their able-bodied peers, it is important to examine outcomes related to low physical activity levels. According to Healthy People 2010 those individual s who had activity limitations also reported more days of depression, anxiety, sleeplessness, and pain than persons who did not have any activity limitations (U.S .D.H.H.S, 2001). Also, there is more risk for secondary health conditions such as cardiovascular disease and diabetes. These trends demonstrate a need to further study the determinants and consequen ces of physical activity for individuals with disabilities since the negative c onsequence of an obese lifestyl e have been widely documented. For instance, exercise has been shown to increas e function as well as increase muscular strength and cardio-respiratory fitness in individuals with physical disabilities. (Blundell, Shepard, Dean, & Adams, 2003; Jacobs, Nash, and Ruminowski, 2001; Hicks, Martin, Ditor, Latimer, Craven, Bugaresti, & McCartney, 2003). Anot her physical outcome associated with exercise is a decrease in pain (Hicks et al., 2003; Fullerton, Borckard t, & Alfano, 2003). In addition, there is evidence that suggests that exercise is related to increased positive affect and decreased negative affect in middle-aged women and high school seniors while physical activity has social benefits as well (Brown, Ford, Burton, Marshall, Dobson, 2005; Bl ock, Griebenauw, & Br odeur, 2004; Leonard, 1998). Rimmer and Wang analyzed data from a clinical trial that examined the effects of a health promotion program for people with physical and cognitive disabilities (2005). Before Rimmer

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35 and Wangs (2005) study, most obesi ty data came from self-report su rveys. Research has shown that estimates of obesity prevalence are much lo wer for self-report data than for those based on measured data (Flegal, Carroll, Ogden, & Johnso n, 2002). Nevertheless, the rate of obesity for adults with disabilities was 66% higher than for able-bodied adults (Rimmer & Wang, 2005). Rimmer and Wang used measurements of body mass index (BMI) to determine whether individuals in their sample were overweight, obese, or extremely obese with a sample of 306. The authors obtained height and weight measuremen ts in order to calculate BMI. Then they compared the prevalence of obesity from their sample to data collected previously for ablebodied adults and published self-report data fo r individuals with disabilities (Rimmer & Wang, 2005). Results showed that there were higher rates of overweight, obese, and extremely obese individuals in the disability sample versus th e able-bodied sample. The highest prevalence of obesity and extreme obesity occurred amongst those with arthritis and diabetes. Examination of race and gender revealed that females with disabi lities are 4 times more likely than disabled males to fall into the extreme obesity category, while African American women with disabilities were at the greatest risk for obesity and extreme obesity (Rimmer & Wang, 2005). Cooper et al. (1999) echoed the sentiment that pe rsons with disabilities are at greater health risks than the able-bodied population. Part of this is due to the fact that physical inactivity occurs disproportionately among the disabled populat ion. Aside from benefits in cardiovascular health, physical activity can also be beneficial by increasing muscular st rength and flexibility. That will in turn improve the ab ility to perform activities of daily living (Cooper et al., 1999). Physical activity was also recommended for child ren with disabilities. Cooper and colleagues

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36 (1999) felt that in addition to physical benefits, children would also benefit socially because sports can help develop self-esteem, social inte gration, and learning social and team skills. Jacobs et al. (2001) used a circuit-training program for 10 men with SCI between the T5 and L1 levels and between the ages of 28 and 44. Prior studies of phys ical activity in this population used arm ergometry and wheelchair ergometry, which of ten caused injuries in the upper extremities and as a result, hindered the partic ipants abilities to perf orm activities of daily living. They also cited a lack of studies that reported both strength a nd endurance outcomes. As a result, Jacobs et al. proposed a 12-week circuit-training program as a safe and effective program for increasing cardio-respiratory e ndurance and muscular st rength by targeting important muscle groups such as the upper trunk, shoulders, and upper back. These muscle groups were reported as especially weak for persons with paraplegia. In addition to strengthening muscles, the program also sought to stretch certain muscles to increase range of motion as well as stability and ba lance in the shoulders. The intensity of the workouts were based on the percentage of peak muscular effort required to push a wheelchair, depress and transfer body, and elevate and support the body duri ng pressure relief. These activities were singled out because they are tasks that require th e most muscular effort and generate the most pain and feelings of weakness among individual s with paraplegia (Jacobs et al., 2001). The participants took part in a 12-w eek training program that required them to attend 3 sessions per week. Each session lasted 40-45 minutes and combined weight training with arm cranking activities. Each individual would perform one se t of exercise at each station before moving on to the next in this circuit program All participants completed the 12-week program without any medical complications.

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37 Their study found that the 12week circuit-training program resulted in significant increases in cardio-respiratory e ndurance and muscular strength in individuals with paraplegia. Participants increased maximum oxygen uptake by an average of 30%, while the strength was improved 12-30% (Jacobs et al., 2001; Hicks et al., 2003). Although this study did not purposely test outcomes of function and well-being, informal ex it interviews with par ticipants revealed that several individuals reported greater ease performing daily ac tivities that required upper body strength and endurance. Hicks et al. (2003) examined the effects of an exercise-training program in individuals with SCI, looked at QOL outcomes in addition to gains in strength and function. They argued that because life expectancy for indivi duals with SCI is on the rise, rehabilitation goals should be shifted from prolonging life to enha ncing quality of life and independe nce. Due to the fact that coronary heart disease is a leading cause of death among th e SCI population, amendable risk factors such as inactivity have received more attention from resear chers and health care professionals. Many previous stud ies, including Jacobs et al. ( 2001) have studied the effects of exercise on muscular strength and/or cardio-respiratory func tion, but none had looked at QOL outcomes. Hicks et al. (2003) predicted that their 9-month, twice a week training program for individuals with SCI would lead to increased muscular strength, enhanced exercise capacity, and improved quality of life. Their study sample consisted of 34 men and women between the ages of 19 and 65. All participants had acquired an SC I at least one year before they enrolled in the study. The researchers randomly selected individuals to be placed in either the ex ercise group or a waitinglist control group and used several different instru ments to measure the outco me variables. Heart rate and power output were meas ured using an arm ergometer while muscular strength was

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38 trained and tested using a multi-station wheelch air accessible weight training system. The researchers employed a circuit-tr aining program with the particip ants completing two sets of each exercise at the outset and increasing to thre e sets after four weeks. To assess QOL the authors employed the 11-item perceived quality of life scale that required some modifications in order to ensure item-content relevance (PQOL ; Patrick, Danis, Southerland, & Hong, 1988) and surveys measuring stress, depression, physical se lf-concept, pain, and perceived health. The results showed that a twice a week trai ning program over the course of nine months lead to increases in muscular strength, arm ergo metry performance, and several PQOL outcomes. Individuals in the exercise group reported less pain, less stress, gr eater satisfaction with physical functioning, lower levels of depressi on, and better quality of life than individuals in the control group. The authors speculated th at improved exercise capacity a nd muscular strength over the nine month period could imply better functioning and greater ease of completing tasks of daily living than was possible at baseline. In additi on to physical improvements, Hicks et al. also suggested that exercise should be used as a means to enhance psychological well-being in persons with SCI. They suggested that exerci se affects PQOL by reducing pain, improving sense of control with regards to functi oning, and social inter actions (Hicks et al., 2003; Martin Ginis et al. 2003). Fullerton et al. (2003) also studi ed role of pain in wheelchai r users. They compared the onset and prevalence of shoulder pain in wheelch air users who were athlet es to those who were not athletes. Extant literature has shown that shoulder pain is a prevalent problem in wheelchair users, with up to 78% of indivi duals with SCI reporting shoulder pain. Other researchers place that number closer to one third of paraplegic s and a slightly higher number of quadriplegics (Curtis, Drysdale, Lanza, Kolber, Vitolo, & We st, 1999; Sie, Waters, A dkins, & Gellman, 1992).

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39 The reason that many wheelchair us ers experience pain in the shoulder is attributed to the new role of the shoulder as a weight bearing joint, something it was not designed to do (Taylor & Williams, 1995; Bayley, Cochran, & Sledge, 1987). Another cause of shoulder pain is thought to be muscle imbalance around the shoulder jo int (Burnham, May, Nelson, Steadward, & Reid, 1993; Miyahara, Sleivert, & Gerrard, 1998). A question that arose was whether sports contributed to earlier onset and increased occurrence of shoulder pain or whether the increased strength and endurance of wheelchair athletes would help to prevent pain. The purpose of Fullerton et al.s study was to compare onset and prevalence of shoulder pain in athletic and nonathletic wheelchair populations. The authors de veloped their own 20-item questionnaire to give to participants. They mailed the questionnaire, along with an informed consent form to 500 random individuals using the Virginia Spinal Cord Injury Registry. To gain more responses from athletes, they also published the questionna ire in a newsletter fo r a leading wheelchair sports organization. To qualify as an athlete for this study the individual must have: 1) trained at least 3 hours per week, 2) be involved in at least 3 competitions per year, and 3) had a wheelchair which had been modified for sports. Basketball was the most represented sport with 51% of the respondents. Athletes made up two-th irds of the sample, while the remaining third served as the comparison group. Forty-eight percent of the subjects (N = 257) reported shoulder pain at the time of questionnaire completion. After dividing the group into athletes and nonathletes, the authors found that 66% of non-athletes reported pain, while 39% of athletes reported pain. Additionally, findings from this study contradicted earlier findings that quadriplegics had more shoulder pain than paraplegics.

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40 Two major findings came out of the statistical analysis. The first was that athletes were less likely to have pain than non-athletes. This finding holds true across other variables such as age, level of injury, and number of years spent in a wheelchair. The second finding was athletes also have more years without shou lder pain after SCI than non-athl etes. On average athletes had four more years without shoulder pa in (Fullerton et al., 2003). Before, it was thought that shoulder pain was du e to overuse and it was predicted that the demands of wheelchair athletics wo uld exacerbate this process. The studys results appear to contradict that prediction. Taub et al. (1999) interviewed 24 male colleg e students with physical disabilities about their physical activity expe riences. Previous research showed that individuals with disabilities often have their physical competencies and skills questioned by others (H iggins, 1980). Others have suggested that physically disabled individua ls are stigmatized and devalued because their bodies do not conform to normative standards (Ha hn, 1988). In order to ma nage the effects of stigma, individuals with disabilitie s can engage and become proficie nt in behaviors that they are not expected to do well in (Taub et al., 1999). Taub and colleagues set out to investigate how participation in sport and physical activity can he lp manage stigma in i ndividuals with physical disabilities (1999). They interviewed 24 male students with a variety of physical di sabilities ranging from paralysis to cerebral palsy. The participation leve l of the sample also varied from occasionally lifting weights to being a member of a wheelchair basketball team, but each participant averaged two sessions of physical activity per week. Also, with the excep tion of the wheelchair basketball players, most physical activity was done in inte grated settings alongside able-bodied peers (Taub et al., 1999).

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41 The authors chose a qualitative approach because they felt it was the most appropriate tool to explore perceptions and lived experiences of their participants. They analyzed the taperecorded interviews using tec hniques introduced by Bogdan and Bi klen (1992). The researchers developed agreed upon codes for organizing and in terpreting the data. P hysical competence and bodily appearance emerged as two primary them es and sources of stigma management. The authors reported two ways in which phys ical competency assisted in stigma management. The first was through demonstration of physical skill. Part icipation in sport and physical activity gave individuals the opportunity to counter perceived stereotypes that persons with disabilities are incapable of playing sports. The second part of physical competency was demonstration of a healthy body. Over half of the pa rticipants revealed that they felt they looked healthier as a result of physical activity. This helped contradi ct the perception that disabled persons were sick or weak. Nearly all of the part icipants felt that they were able to influence the attitudes of others towards them thr ough demonstration of physical competence. Bodily appearance was the second means by wh ich individuals with disabilities could counter prevailing negative stereotypes thr ough physical activity. One way this was accomplished was through demonstration of a muscular body. Some respondents felt that physical activity helped them develop muscul ar physiques, which compensated for negative assumptions other held about the disabled body (Taub et al., 1999). In addition to demonstrating a muscular body, respondents also reported that p hysical activity allowed them to demonstrate a liberated body. Sports enabled them to show others that their wheel chair does not constrain them. One person stated that he enjoyed swimming because he was free of his wheelchair when he was in the water (T aub et al., 1999).

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42 Ultimately sports and other physical activities allowed this sample of college men with physical disabilities the opportunity to shed common perceptions about the abilities of wheelchair users and others with physical disabilities. For most of the respondents, involvement in sport alone was more important than type and intensity level of activity. They believed that their involvement in sport c ould alter negative st ereotypes other had about persons with disabilities. Taub et al. (1999) recommended that future research should examine the physical activity experiences of females as well as peopl e in other age groups with disabilities. Other researchers have suggested that sport and recreational activity represented a way in which individuals with disabili ties could improve physical and so cial self-perceptions (Blinde & McClung, 1997). Improvements in physical self-p erception may be achieved through physical activity because individuals can perform tasks and activities that they or others may have considered impossible for them. In addition, spor t and recreational activity occur within a social context, thus enabling active individuals to boost their social self-perceptions. One study examined the impact of sport and recreational activit y physical and social self-perceptions of individuals with disabilities (B linde & McClung, 1997). They used qualitative methods in order to allow the participants the chance to talk abou t what they felt was the most important aspects of their activity experiences. The sample included 11 women with a mean age of 31.5 years and 12 men with a mean age of 26.2 years. Fifteen members of the samp le were college student s and the rest were recruited from the local community. The study consisted of individuals w ith a wide variety of physical disabilities ranging from cerebral palsy and paralysis to muscular dystrophy. A majority indicated that they had limited participa tion in recreational activiti es prior to the study. After consenting to be a part of the study, par ticipants could choose from a number of offered

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43 recreational activities. Thes e activities included swimming, hor seback riding, weight lifting, tennis, fishing, and walking. The authors assigned participants to ablebodied partners for the duration of the program. Most of them remained in the program for 5 to 10 weeks. Graduate students conducted interviews with the participants two weeks after they completed the recreational program. Results of the interviews showed improvements in physical self-perceptions similar to that of Taub et al. (1999). These physical change s resulted in psychological gains as well. Individuals in the sample were able to expe rience their body in new ways through swimming and horseback riding. Respondents described the feel ing as less restrictiv e and barrier-free (Blinde & McClung, 1997, p. 333). Add itionally some respondents felt in creased sense of self as a result of feeling stronger and fitter due to their recr eational activity. Another important outcome of this study was incr eased perceptions of the social self. This was done by expanding social intera ctions and experiences and initiating social activities in contexts outside of recreational activity. Res pondents reported that the recreational activity program gave them the opportunity to get out and meet new people. In addition to meeting other people with disabilities, there was also the ch ance to interact positively with able-bodied individuals. Also, participation resulted in increased confidence in social skills, which led to greater motivation to go out and meet other people. Other research studying the impact of physical activity and individuals with disabilities examined the impact of exercise on positive a nd negative affect (Giacobbi, Hardin, Frye, Hausenblas, Sears, & Stegelin, 2006). Giacobbi et al. (2006) also asse ssed personal variables such as personality and time since injury in order to determine w ho would experience the greatest emotional benefits on days of increased exercise.

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44 The study included 13 females and 35 males with physical disabil ities. The research team recruited potential participants at sporting and co mmunity events and gave instructions about the surveys used. Participants filled out survey s assessing personality, da ily life events, mood, and activity for eight consecutive days. Then they were required to mail in their completed surveys to the primary researcher (Giacobbi et al., 2006). Statistical analyses revealed several impor tant findings. First, positive affect was associated with increased positive events and fewer negative events. Additionally, there was a significant positive relationship between exercise and positive affect and a negative relationship between exercise and negative affect. More impor tantly, the effects of exercise on positive mood were seen despite the occurrence of positive or negative daily life events. Finally, personality moderated the effects of physical activity on affect. Individuals that showed higher levels of Neuroticism were more likely to have more positive affect and less negative affect on days that they exercised more. However, this same mode rating relationship was no t seen in extroversion nor for the length of time after in jury (Giacobbi et al., 2006). Giacobbi et al.s ( 2006) study showed that exercise c ould have a positive impact on mood regardless of daily life events for individuals with disabilities. This study provides more support to the notion that exercise and physical activ ity should be encouraged among persons with physical disabilities. In the literature reviewed, it was shown that ex ercise increased streng th and functioning in children (Blundell et al. 2003) and adults (Jaco bs et al., 2003; Hicks et al., 2003), as well provided important psychological and social benefits (Blinde & McClung, 1997; Taub et al., 1999; Giacobbi et al., 2006). In addition to improving muscular strength and functioning, exercise can also increase cardiovascular fitne ss as well as decrease shoulder pain. Physical

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45 activity can also result in important social a nd psychological gains as well and have a positive impact on the way individuals view their bodies and also provide a means to counter negative stigma regarding their bodies and physical ab ilities (Taub, Blinde, & Greer, 1999; Blinde & McClung, 1997). Exercise can also provide a means in which social skills are developed and practiced (Blinde & McClung, 1997). Finally, physical activity can have an impact on mood despite daily life events (Giacobbi, Hardin, Fr ye, Hausenblas, Sears, & Stegelin, 2006). As discussed, all of these benefits of exercise and physical activity are associated with subjective well being and improved quality of life. With all this evidence demonstrating the importa nce of exercise in th e lives of individuals with physical disabilities it is im perative that researchers conti nue examining the antecedents and consequences of physical activity with this population. Due to an apparent lack of qualitative research in the area, it is esse ntial that we obtain a fuller unders tanding of concepts such as quality of life and how they re late to physical activity and in dividuals with disabilities. Individuals with disabilities sta nd to gain the most from regul ar physical activity and it is important that the physical and mental benefits of physical activity be explored in an in-depth manner. Purpose The purpose of this thes is will be to use a mixed method approach to explore the role physical activity plays in quality of life for indivi duals with physical disa bilities. Quantitative methods will be used to categorize individuals as more versus less physically active, while qualitative interview methods will be used in order to obtain a rich er understanding of how individuals with disabilities desc ribe their quality of life and subjective activity experiences. A secondary purpose will be to compare individua ls who are more active with those who are less active in their descri ptions of daily life events an d physical activity involvement.

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46 Figure. 1-1. The model of Functioning and Di sability (ICF model) from the International Classification of Functioning, Disability a nd Health (Reproduced from the World Health Organization). Figure.1-2. The attitude, social influence, and self-efficacy (ASE) model. (Reproduced from DeVries et al., 1988).

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47 Figure. 1-3. The Physical Activity for people with Disability Model (van der Ploeg et al., 2004).

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48 CHAPTER 2 METHODS Participants The particip ants include d 12 male and 14 female adults between the ages of 18 to 54 (M = 31.12, SD = 10.75) who all reported one or more c ondition(s) that impact ed their daily living (e.g., spina bifida, cerebral palsy, T-11/12 paraplegia, bi-lateral amputee, etc.). The sample consisted of 20 Caucasians, 1 Asian Ameri can, 4 African-Americans, and one individual reported being mixed racial and ethnic background. The participants reported a variety of health conditions including specified and unspecified parapl egia (N = 14), bi-later al or single amputee (N = 3), cerebral palsy (N = 2), quadriplegia (N = 1), spina bifida (N= 1), chronic pain (N= 1), complete fusion of the spine (N = 1), and 3 individuals did not specify why they used a wheelchair. Twenty-five of th e twenty-six participants were either active in wheelchair basketball at the time of the interview or had b een previously. Twenty-t wo individuals from the sample gave a specific time period for their part icipation. The average time playing wheelchair basketball by those who reported specific time s was 9.03 years and ranged from 26 years to 3 months. Some participants reported participa tion in other activities such as swimming, road racing, wheelchair tennis, darts, and pool. The median age of the sample was 29 and consisted of 10 individuals between 18 and 24, 6 were 25 to 34, 6 aged 35 and 44, and 4 individuals who were 45-54. The breakdown of the age variable was done according Center for Disease Control guidelines (Center for Disease Control and Prevention, 2005). Measures The Physical Activity Scale for Individual s with Physical Di sabilities (PASIPD) The PASIPD is a 13-item scale developed and valid ated to measure physical activity, health, and

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49 function for individuals with physical disabilities (Washburn, Zhu, McAuley, Frogley, & Figoni, 2002). This instrument consisted of five s ubscales: home repair/l awn and garden work, housework, vigorous sport and recreation, modera te sport and recreation, and occupational activities. The PASIPD requested respondents to indicate ho w often during the past seven days they participated in various activities at home and outside the home as never, seldom (1-2 days/week), sometimes (3-4 days/week), or often (5-7 days/week) and on average how many hours a day they participated (<1hou r, 1 but <2 hours, 2-4 hours, >4 hours. With regard to the occupational item 13, the response categories include <1 hour, 1 but < 4 hours, 5 but < 8 hours, > 8 hours. Scores for the PASIPD are computed by multiplying the average hours per day by an estimated MET value based upon the in tensity of the activity; this scoring procedure results in a mathematically maximum score of 199.5 and estimated MET values for each of the five factors and a total score. Washburn et al. (2002) demonstrated preliminary evidence of the construct validity of the PASIPD and the five latent f actors using factor analytic and correlational analyses. Their data also resulted in total PASIPD scores of 24.6 + 14.6 for individuals aged 51 and younger and 16.5 + 13.4 for those older than 51. The mean total score for males on this measure was 20.5 + 15.1 while the average for females was 19.9 + 13.5. Finally, individuals who selfreported no activity at all had a mean of 13.2 + 12.1, those who reported moderate activity had a mean of 19.8 + 12.7, and individuals who self -reported extreme activity had a mean score of 30.7 + 14.0. These means will allow me to group participan ts for this thesis by their level of activity. With regard to males and female participati on in vigorous sport and physical activity the two groups were virtually the same scor ing an average MET hours/day of 2.9 + 6.6 and 2.7 + 6.7 for males and females respectively.

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50 Interview Guide. An interview guide was developed for the purposes of this study (See Appendix A). Although an interview guide was us ed during all intervie ws, a semi-structured approach was used as the flow of conversation di ctated the questions aske d to the participants. The interview questions focused on the following: (a) the nature and etiology of the participants disabilities, (b) occupational or school related questions, (c) perceived benefits of physical activity, (d) motives that sustai n involvement in physical activiti es. Probes were used throughout the interviews to encourage th e participants to expand upon sp ecific ideas, experiences, and incidents that highlighted their physical activity expe riences. The author and another graduate student conducted all interviews, which lasted between 30 to 90 minutes. Procedure. A purposive sampling procedure was used in an effort to recruit physically active individuals with physical disabilities. The participants were recruited with help from a member of the research team who facilitated a wheelchair ba sketball tournament at the Lakeshore foundation in Birmingham Alabama (D r. Brent Hardin in the Department of Kinesiology). During this tournament individuals fa miliar with this member of the research team were approached and asked to participate in this st udy. I conducted 14 of th e interviews while a graduate student advisee of Dr. Hardin intervie wed the remaining 12 participants. Institutional approval was obtained from the University of Florida Institutional Review Board (IRB) prior to data collection. Data Analysis Grounded theory procedures guided the present analysis (Charm az, 2000). The author used openand focused-coding of interview te xt, the use of memos, constant comparisons, sensitizing concepts, and the development of theory (Charmaz, 2000). The following data analytic procedures were followed in this investigation:

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51 1) All interviews were transcribed verbatim by multiple coders that included the author and two researchers with training and experience using qualitative data analysis at the University of Alabama Birmingham. During this stage of the coding process, particip ants quotations were coded as raw data themes and stored for future analysis and discussion between the authors. Throughout the interview and open-coding process my advisor supervised and provided guidance concerned with this project. 2) The research team next engaged in fo cused coding procedures whereby the most frequently mentioned raw data themes were sorted and grouped according to their common properties (Charmaz, 2000). This involved maki ng connections and distinctions between the motives and perceived benefits reported by our participants an d how these perceived benefits impacted subjective well-being. The process of focused coding also fac ilitated the comparison process described below. 3) A constant comparative method was used th at allowed the author to make comparisons between the participants experiences (a) reported by different part icipants, (b) within participants about descriptions of the same and different experiences (c) with important experiences reported by different participants. Additionally, consistent with the purposes of this study, the constant comparative method allowed for direct comparisons between males and females, individuals in different age groups, and between those who were more versus less active. 4) Sensitizing concepts served as points of departure from which to organize, interpret, and extend previous stress and coping resear ch findings (Charmaz, 2000, p. 515). As noted by Charmaz (2000) Sensitizing concepts offer ways of seeing, orga nizing, and understanding

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52 experience; they are embedded in our disciplina ry emphases and perspectival proclivities (p. 51) 5). Sensitizing concepts also o ffer researchers a way to make se nse of qualitative data in a manner consistent with the extant literature In the present study the PAD model by van der Ploeg, van der Beek, van der Woude, and van Mechelen (2004) as well as Dijkers conceptualization of subjective QOL served as sensitizing concepts. In this way I interpreted my combined quantitative and qualitative data by us ing important constructs in the PAD model (e.g., facilitators/barriers, social influences, health conditions, self-efficacy, intention, and attitudes) as well as components of subjective QOL (e.g. valu es, achievements, and evaluations) during my analysis. Issues of Trustworthiness. Several sources of tr ustworthiness were de veloped in this study. First, multiple coders examined the raw data independently and discussed similarities and differences in the coding of th e participants experiences. Sec ond, the author, a fellow graduate student, and the authors thesis advisor explored multiple interpretations and discrepant findings during structured research discussions (Sparkes, 1998). The use of a research group has also been described as a way to establish credibility and dependability of qualita tive data (Dale, 1996). Third, an individual trained in qualitative research methods perf ormed an independent audit on a select group of coded quotations. This individual independently coded the determinants and benefits of physical activity a nd found agreement with 61% of the codes completed by the author. The independent coding comprised identifying blocks of quotes by labeling it with one of the higher order themes. Once this was complete d, the author then compared the results to his own system of coding. Finally, the participan ts direct quotations ar e presented along side

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53 contextualized descriptions of the participants experiences are presented to allow readers to judge for themselves the trustworth iness of the data (Sparkes, 1998).

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54 CHAPTER THREE RESULTS The purpose of this thesis was to explore the role that physical activity plays in the quality of life for individuals with physical di sabilities. A secondary purpose was to use the constant comparative method commonly employe d by grounded theorists (Charmaz, 2000) to explore differences in motives a nd perceived benefits between i ndividuals who were more active versus those who were less active, males and females, and age groups. To achieve these purposes, 26 individuals were administered the PASIPD and inte rviewed about their physical activity experiences. What follows is a presentati on of the results broken up into three sections. The first section summarizes the descriptive quantitative findings from the PASIPD. The second section describes the higher-ord er and first order themes deri ved from the interview text. Finally, the third section presents a grounded theory that represents a theoretical integration of the results observed here with previous models of physical activity and subjective QOL. Descriptive Statistics The focus of this thesis included determ ini ng activity levels of the participants. The PASIPD broke down activity level into several different categories. These categories were physical activity, household activity, lawn and gard en activity, caring for another person, and work activity. Physical activ ity was broken down further into the subscales reported by Washburn et al. (2002) that included a total sc ore, home repair/gar dening, housework, vigorous sport, light/moderate sport, and occupational activities. This latter category includes general wheeling not intended for exercise. The particip ants total scores on th is measure ranged from 6.20 and 71.22 for both males and females while the average for the entire sample was 36.34 (SD = 15.28). The PAD model suggested previously that an individuals gender played a role in their participation in physical activity. An independent samples t-test was then performed in order to

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55 compare differences between males and females on the total PASIPD score. The results of this test proved non-significant t(24) = .48, p = .64.. The subscale sc ores representing vigorous sport and light/moderate sport were we ll above the averages reported by Washburn et al. (2002) in their validation study and ranged from 2 to 42.57 a nd 0 and 23.15, respectively. In contrast, the participants in this sample reported less activit y with regard to occupation as the means here were ~ one standard deviation below those repo rted by Washburn et al. (2002). In short, the participants in the current study were relatively active as they re ported participation in moderate and vigorous sport activities and ha d higher total scores than Was hburn et al. (2002) as shown in Table 3-1. Interview Results: Higher Order Themes Psychological Benefits The results of the coding pro cess described above are shown in appendix B. As shown, 5 higher-order themes (p sychological benefits, ph ysical health, social influences, social opportunities, and increased ov erall quality of life) were defined by 16 more specific first-order themes. The psychological be nefits higher-order theme was defined by the first-order themes of cognitive benefits (N = 10), emotional benefits (N = 15), behavioral benefits (N = 8), and self-percep tion (N = 15). Ten participants mentioned that they benefited cognitively from participation in physical activity. One partic ipant, a 21 year-old male who scored a 47.97 on the PASIPD, said, Ive actually developed a pretty good mental st rength through basketball. You really have to stay focused and concentrate and like doi ng it back to back has not only helped me physically but mentally to get throug h a whole 40 minutes of basketball. In addition a 43 year old female who scored a 30.75 on the PASIPD st ated, I dont know I guess more specific to basketball I gu ess than in general, but the abil ity to get better at something and learn new skills. I thought, I wasnt sure that was possible, you know.

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56 Still another participant recei ved cognitive benefits from phys ical activity saying, Ive learned a lot of like really life lessons, you know from like winning and losing andIve just learned a lot about sports but also about how to communicate with othe rs. For these three participants, physical activity provided them a m eans to learn new skills and become mentally strong. Another psychological benefit was that some participants felt better emotionally (N = 15) as a result of physical activity. In this analysis, statements by participants were coded as emotional benefit if there was mention of increases in positive affect (i.e. happiness), decreases in negative affect, or stress relief. A 35 year old female with a PASIPD score of 51.49 said, That [water skiing], I think is just relaxing, you know its more of a relaxing type sport, you go out there and you just enjoy yourself and it really just a fun thing. Another participant who benefited emotionally was a 51 year-old female who had the highest score on the PASIPD with a 71.22. She stated, I played rugby, softball. It wa s a good way to deal with the rage and um, the depression and all the stuff that came with it. A third participant, a 24 year-old female with a 35.6 on the PASIPD, added, And the marathon nowit s more of a release for me. I can go out and push 20 miles a day and its such a stress reliever for me, I just feel good afterwards. From the interview responses, it appe ared that physical activity wa s a good way to reduce stress and depressive symptoms, as well as a source of fun for over half of the participants. A third psychological benefit, behavioral benefits, was identified when participant mentioned a change in their day-to -day behavioral or health, routin es. For instance, the 51 yearold female who had the highest PASIPD score fo r this sample felt that through physical activity she developed the will to not quit, which forced her to be more creative. JustI guess my desire not to give up. You know? Theres a lot of things I cant do and thats real aggravating. But umI painted the bottom part of my house by adapting rollers

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57 and brushes and things so that I didnt ha ve to bend andso I tend to be a bit more creative with the things Im doing. Innovative. She also added, Well Im a smoker. So when Im playing tennis or working out Im not smoking. So thats a nice way to keep myself busy so I dont smoke. Another participant, a 21 y ear-old female who played college basketball and scored a 52.69 on the PASIPD, said, Um, I think my ability to adapt to pretty much any environment and to pretty much anybody. A 24 year-old female basketball player (PASIPD = 16.59) added, So its helped me translate a lot more responsibili ties into alright, thats how hard I work at basketball, I got to work that hard for school and other stuff. Finally, a marathoner and former college bask etball player (PASIPD = 35.6) reported that athletics helped her become more outgoing. In fact, she revealed that she w ould have declined an interview before she became active in sports. I used to be a really, really shy person as a kid when I was a kid. And through athletics Ive been likeI can s it here and have this convers ation with you, like a complete stranger, I dont know you. When I was younger I would have been like, No, Im not doing an interview. In all, eight participants reported changes in behavior as a re sult of their s port and physical activity participation ranging from improved wo rk ethic and adaptability to smoking less and being more outgoing. The fourth and final psychological benefit was labeled improved self-perception. This label referred to interviewees who viewed themse lves differently as a result of participating in athletics or physical activity. Some participants discovered attribut es about themselves that they were previously unaware of prior to their activity experiences. On e example is of a 22 year-old female with a PASIPD score of 35.33. She had one leg amputated as a result of a tumor when she was eleven years old and transferred to he r current school for the sole reason to play wheelchair basketball.

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58 So, um, justits [basketball] really cha nged my self concept, my uh, you know my, what I think other people see of me and also what I see in myself. I think I am a lot more disciplined and II look at my self more nowa lot of times before, its not that I ever really didnt like myself. I didnt mind. Bu t a lot of times I felt like other people just were like, Oh theres that poor one-legged gi rl. Or you know, some thing like that. And so for me thats really changed and in a lot of ways that helps your self-esteem too. Another participant who became more extrover ted after playing basketball was a 38 yearold male with cerebral palsy (PASPID = 25.17). He stated, Its changed me a lot. I was just very introverted before going to college. And I saw all these different things. I saw people going through the same experience I was and it just opened me up. A 36 year-old male (PASIPD = 46.42) who, as a former athlete and current youth sport di rector, witnessed the positive impact of sports. He stated you know it s a self confidence kind of thing and to me you get a lot of that through athle tics. This sentiment was ech oed by another female college basketball player and Paralympic swimmer (P ASIPD = 47.05), aged 20, who said, Athletics provides a sense of confidence. Sport and physical activity also allowed some responders to see themselves in a different light. For example, one 47 year-old male who was a two-time world champion water skier and current basketball player said, I came from a pretty small tow n, so thats when I really found out that I was more of a natural athlete than I knew because I had ne ver had those opportunities when I was living in my small town. When asked about the impact of basketball on his life another 54 year-old male with a PASIPD score of 21.57, stated, Certainly, to a degree it was my identity. Its given me an outlet for physical activities, Ive made a lot of wonderful friends over the years and here now I am just down here enjoying the games A total of 15 individuals cited changes in self-perception as one of the benefits of an active lifestyle. These changes came in the form of improved self-confidence, improved self-esteem, and identifying oneself as an athlete.

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59 In all, 26 out of 26 participants reported some sort of psychological benefit from participating in sports and other physical activity. Some responders reported that they felt better emotionally because they were able to relieve stress, release aggression, increase their level of endorphins, or participate in an ac tivity they viewed as enjoyable. Others reported they received cognitive benefits and were able to learn to concentrate and stay focused, stay positive, and learn about new sports. As reported, many of the participants found that physical activity impacted their thoughts, feelings, and behaviors which included improved work ethic, the ability to adapt to people and places, decreased smoking behavi or, and more outgoing towards strangers. Finally, over half (N = 15) of th e participants reported that their self perceptions were changed due to sports and physical activity. Physical Health. The second higher-order theme deri ved from the interview data was physical health. Physical health was coded as any statement that referred to the health benefits of physical activity. This theme was further broken down into physical fitness and preventing health risks. The interviews rev ealed that half of the participan ts (N = 13) cited physical health as a benefit of physical activity. A 47 year-old male basketball player and former champion water skier (PASIPD = 36.16) said, Um, again the physical part of it has kept me, I know, in a lot bett er shape than I would have been had I not done those sports. A 39 year-old female who scored a 30.81 on the PASIPD added, Yeah, it helps k eep you young, it helps keep you healthy and at this point in my life its not something that I am willing to give up yet. In addition, a 22 year-old female basketball player stated, Since Ive star ted playing basketba ll Ive gotten in so much better shape. A 31 year-old female who scored onl y a 6.2 on the PASIPD also received health benefits from exercise saying, Since I was li fting all of the time it really helped, so Ill

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60 definitely keep lifting to make sure Im not developing any kind of shoulder problems and for basketball Finally, a 36 year-old youth director and former athl ete said, I mean I look at myself now I train 4 or 5 days a week primarily doing it for health reasons, lower my cholesterol, lose some weight. As the selected quotes have shown, several of the participants value the physical health aspect of their physical activity experience. They listed benefits such as staying in shape, preventing shoulder injury, sleeping better, and preven ting wear on the body. Social Influences. The third higher order theme to emerge from the interview data was social influences (N = 11). Eleven of the part icipants revealed important people in their lives that either introduced them to sports or encour aged them to participate. These findings were consistent with the previously described work by van der Ploe g et al. (2004) and their PAD model. For instance, participants were influen ced by family, friends, disabled peers, and health professionals to initiate and adhe re to physical activity behaviors. It should be noted that the social influences theme includes only those persons who introduced the pa rticipants to physical activity and sports. Individuals w ho continue to influence responders in the form of a role model were coded under social opportunities. This was done to remain more consistent with the PAD model. For example, one 46 year-old male who scored a 29.94 on the PASIPD and currently coached the same basketball team he used to pl ay for said, I had met a guy when I was in the hospitalSo he told me about it, so when I got out of the hospital I went out and visited a couple of practices and try to play a li ttle bit with the folks there. A 21 year-old female basketball player with a PASIPD score of 40.86 spoke about the influence of her br others saying, It was never, Oh, Emily cant play. It was always, Tha ts my sister and shes going to play with us.

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61 For a third participant, it was her future coach wh o introduced her to wheelchair basketball. This 35 year-old female who scored a 51.49 on the PA SIPD discussed her introduction to the sport. I lucked out, when I was doing my rehabi litation, there was a ge ntleman there that competed internationally and hes actually our coach now for the womens team, and he introduced me to basketball and then to a school that had a program, and you know it all works out. Social Opportunities. In addition to social influen ces, social opportunities, which comprised the fourth higher order theme, were made available for our participants within physical activity contexts. In fact, 23 participan ts in this sample mentioned social opportunities as being a benefit of physical activity. These social opportunities included valued interactions with others, being able to connect and form re lationships with others including able-bodied persons, having the opportunity to go to college, and travel opportunities. The 46 year-old male coach quoted above said, Its a very nature bridge to the ablebodied world. People are comfortable to say, tel l me about your basketball. Another example of sport playing a role in the interaction between participants and able-bodied peers comes from a 21 year-old female basketball player (PASIPD = 40.86) who had the chance to speak to a classroom of children. She said, I think it was really cool for me to speak to them and kind of show them that people with disabilities can still be active. A 20 year-old male basketball player added, And so from the social aspect its like th e campus looks at us not as a group of guys in wheelchairs who are just in wheelchairs. They look at us as a basketball team. That same individual made several comment s about the social aspect of wheelchair basketball, including the opportunities for education and travel. But basketball and athletics has given me a chance to, you know, have a lot of my education paid for. Its taken me all over th e worldAnd thats really something that the majority of, you know my friends in high school theyre in school doing whatever they do, and they may be working, but theyre not colleg e athletes. And thatsbasketball as been the savior of my life. Its b een the single most important thing.

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62 A 38 year-old male with cereb ral palsy and a PASIPD score of 25.17 spoke about why he enjoyed team sports as opposed to individual sports. Um, I think because, for me, its a team sport. You have tothe people on the court have to get along together. At least there has to be some form of cooperati on. I like that aspect of doing that. Being part of a team cooperating, talking to each other. Another participant mentioned that she made friends through basketball. This 21 year-old female with a PASIPD score of 52.69 said, I mean I have like a lot of connections and friends you know through being exposed to wheelchair sports. In some cases, participants have found other disabled peers to be role models. A 29 yearold male who scored a 59.47 on the PASIPD sa id, After I met guys and they were doing stuffjobs that I didnt think th at disabled people would. Later in the interview he stated, Then when I started playing sports I met a lot of people that were doing incredible thingsthey had familiesI thought I wasnt going to have all th at. In other cases, the participants had the chance to be a role model to children with disa bilities. The director of the youth center quoted earlier said, its about creating people and really in helping raise peoples expectations about what they can do and thats one of th e neat things through sport I think. In this section I have pres ented interview quotes to lend support to the posited higherorder theme of social opportuni ties. The social opportunities higher-order theme was defined social interaction, opportunities fo r education and travel, and either being a role model or being exposed to a role model. Twenty-three of the tw enty-six individuals in this sample reported a social opportunity benefit. Increased Overall subjective QOL. The final higher-order theme that emerged was increased overall subjective QOL. While most of the previously discussed themes have focused on specific factors or components of the subjectiv e QOL construct, this theme included quotes in

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63 which the respondents discuss their overall happine ss in more general terms over their lifetime. These descriptions also tended to be l onger and more vivid than other responses. For instance, when asked if sports improved her quality of life this 31 year-old female with a score of 36.87 on the PASIPD discussed how ba sketball and the school she attended impacted her life. When I got hurt I was in this horrible 16 inch chair with push handles and arm rests and brakes and all sorts of horrible things becau se I didnt know any bette r, but then when I went to Illinois an met all these other wheelchair athletes I discovered the whole wonderful world of well moving, really nice, lightweight we ll-fitted wheelchairs and so, if I hadnt had that I think life would be harder just because Id be in a bigger chair with more junk on it which means it would be harder to push around and so I think absolutely in just learning and just seei ng the impact of strength and how much of a difference that makes, the stronger you are the easier everything is. As can be seen from the quote, this person s life was greatly impacted by her participation in sports. More specifically, the culture in place already at the school and the athletes there introduced her to new equipment that made he r life easier than it was before she arrived. A 47 year-old basketball player who operates a not-for-profit program that teaches water skiing to children with disabiliti es provided another powerful quote. So I know it changes peoples liv es. Thats the great thing that sports does right there. Not only does it make you healthier, mentally it can change your lifelike I said, sports is probably the single most important thing or has been the single most important thing since Ive been injured. If I could turn back th e hands of time, Id stil l be sitting here in this chair. I wouldnt change a thing. Becau se I know its made my life so much better. This quote exemplified just how powerful an im pact physical activity, in this case sport, can have on an individuals life. This particul ar individual was so profoundly affected by his participation in sport that he began to view his paralysis as a positive life change. Another male participant aged 46, and a former basketball play er at the highest level of wheelchair basketball shared a similar sentiment.

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64 Ive had a, not that I want to die right now, but if I died right now, I could truly say that Im satisfied with you know, Ive been able to co mpete on an internationa l level, Ive been able to win national championshi ps athletically, I ha ve 2 incredible kids, great wife, good job, I live in a place where Im happy. Proposed Grounded Theory In the previous section, I disc ussed the higher-order them es that emerged from the data and provided quotes from the interview text to provi de context to my observations and conclusions. In this section I will propose a grounded theory of the role physical activity plays in the quality for life for individuals with physical disabiliti es and why the particip ants in this sample maintained involvement in physical activity behavior s. This portion of the analysis represents a second more deductive analysis typically condu cted by grounded theorists and involves making links between previous theory and research and the findings observed here (e.g., sensitizing concepts). Another purpose of this section is to elaborate more specifically about how the major higher-order themes are related to one another and other outcomes such as quality of life. In other words, it is important here to explicate th eoretically whether the higher-order themes are related to one another and other va riables in a causal, correlational, or bi-directional manner. For the purposes of this discussion it appears wa rranted to introduce Banduras (1986, 1997) notion of triadic reciprocal causation adapted graphica lly in Figure 3-1. This view uses the term causation to refer to func tional dependence between even ts (Bandura, 1997, p. 5) and considers human agency and behavior to operate within an interdependent structure of causal mechanisms. Indeed one can find clear examples of triadic reciprocal or perhaps even quadratic or polynomial causation in the previously desc ribed ICF and PAD models. Simply put, individuals choices to engage in physical activity behavi ors are determined by environmental contingencies (e.g., opportunities, resources, accessible faciliti es, supportive others), and personal factors that Bandura describes as cognitive, affective, and biological events; for my

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65 purposes I will expand this latter category (biological events) to include overall functional capabilities and health. It is this interaction between the person a nd the environment that dictates behavior as part of a larger inte rdependent system of variables. In the present study reciprocal causation was reflected in how the participants began involvement in various physical activity behaviors, the enjoyment, personal satisfaction, or other benefits they perceived from these behavioral ch oices, with future decision making processes. In other words, the perceived benef its of physical activity influenced behavioral choices to sustain these behaviors that then lead to other benefits and continued participation. Now that conceptual clarity has been established about how the higher-order themes are related to one another and with other important constructs, my grounded th eory will be discussed along with extensive participant quotati ons as support. My observations and the partic ipants quotations about enviro nmental and personal factors largely confirmed predictions of the PAD model (van der Ploeg et al., 2004). However, the grounded theory being proposed here extends the PAD model by inco rporating the major psychological, physical health, and social benefits discussed by th e participants in this study. The double arrows within Figure 32 represent the reciprocal natu re between the physical health, social, and psychological benefits of physical activity behavior with the initiation and maintenance of these behaviors over time. What follows is an explanation for each of the pathways and exemplar quotations that offer support for my synthesis of research. As shown in Figure 3-2, boxes A and B repres ent the major elemen ts within the PAD model. Within the present study these determinants of physical activity behavior included environmental and personal factors respectively. With regard to the role of environmental factors in physical activity, th e participants quotations revealed that environmental factors

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66 included persons who introduced participants to adaptive sport or physical activity (i.e. social influences), the social aspects of the sports participants chose to participate in, and the availability of facilities and programs that facilitated or helped to sustain involvement. In the PAD model, social influences are a separate construct from envir onmental facilitators. These are referred to as facilitators because they increase the likelihood of par ticipation in sports by making sports more fun and by providing a place to participate. In cont rast, perceived barriers could include a lack of available f acilities, lack of assistance from others, or physical activity that does not lend itself to social opportunities. As was reported in the previous section, many of the participants in this investigation reported social influences and bene fits as a result of their partic ipation in physical activity and sport. In the context of this investigation, social influences are considered an environmental factor that facilitates physical activity for persons with disabili ties as per the PAD model (van der Ploeg et al., 2004). For instance, one wo man, who scored a 51.49 on the PASIPD and was 35 at the time of the interview, spoke briefly about how she became involved in wheelchair sports saying, I lucked out, when I was doing my rehabilitati on, there was a gentleman there that competed internationally and hes actually ou r coach and he introduced me to basketball. Another female basketball player, who was 21 years old and scored a 40.87 on the PASIPD, spoke about her family saying, It was never, Oh, Emily cant play. It was always, thats my sister and shes going to play with us. Finally, one last female basketball player, aged 21 years with a PASIPD score of 52.69, ment ioned her doctor saying, I got exposed to wheelchair sports because my doctor at Johns Hopkins. Eleven of the twenty-six participants mentioned the person who influenced them to become physically active.

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67 The interview data also revealed that many of the participants found that they enjoyed the social aspect of physical activit y. For one male basketball player who competed at the highest level of wheelchair basketball, the social aspect of the game is what drew him to the sport. He said, I love, I mean to me like athletics, as far as that I enjoy being aroun d the team more than I do the actual sport. Another male basketball player from a lower division team said, I like that aspect of doing thatbeing part of a team, coopera ting, talking to each other. The availability of a nearby facility encouraged this 51 year-old woman with a PASIPD score of 71.22 to become more physically active, saying, F ortunately I was in an area here in Birmingham that has Lakeshore and I was encouraged earl y on to go into chair sports. In all, there were twenty-three individuals from the sample who cited a social opportunity as a direct result of their sport involvement. The social opportunities and benefits played an important role in decisions to initiate and maintain physical activity participation. Another construct discussed within their PAD model is personal factors. As shown in Figure 3-2 (paths 1 and 2), pe rsonal factors within the current study interacted with environmental factors as part of the physical activity experien ce for our participants. Personal factors included an individuals he alth or level of injury, their attitude towards exercise, selfefficacy expectations and other personality constr ucts, and personal facilitators and barriers such as energy, time, money, motivation, age, and gender Within the present investigation neither age nor gender emerged as important within the analysis. Essentially these two variables were not significant in this investigation nor were th ere any differences in pa rticipation or level of activity between males and females or indi viduals within different age strata. There was evidence, however, that the other pe rsonal factors may have played roles in the activity levels of specific individu als. Some of our participants perceived personality factors as

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68 important within physical activit y. One man, aged 46 years and a PASIPD score of 29.94 said, I think having that type of persona lity, being a bit of a competitor and a battler made it more likely that I was going to be aggressive in my rehabilitation, when aske d if his personality helped him after his injury. These results are consistent with the predictions within the PAD model. All of the individuals from this sample reported a favorab le attitude towards physic al activity due to the benefits they gained from it. These benefits ha ve been reported earlier in this chapter. Other personal factors discussed by participants included level of inju ry or condition, and self-efficacy. In this investig ation level of injury or condi tion, was assessed by asking individuals why they used a wheelchair. Answer s varied, but most of th e participants with a spinal cord injury indicated that their level of injury did not limit function in their hands or arms. Others reported congenital conditions such as cere bral palsy, spina bifida, or did not specify their injury. No one reported that his or her conditi on or injury limited hand or arm function, which appears to be reflected in the higher than average levels of physical activity reported by the participants in this sample. There are a range of other pa rticipant quotations that s upport the linkages between the constructs shown in Figure 3-1. For instance, this sample included several elite wheelchair athletes whose goals included making future Para lympic basketball teams. For instance, one man said, My main goal now is to get a gold me dal, as he discussed his chances of making the next Paralympic team. In addition to such hi gh-reaching goals, others mention exercise-related goals, as well as future educational and occupati onal goals. In order to achieve these goals the participants must have perceived and ther efore experienced the social, physical, and psychological benefits of physical activity. Addi tionally, the quotes discu ssed above also reflect a sense of self-efficacy beliefs about the par ticipants ability to achieve these goals.

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69 Another important factor in subjective QOL is achievements. According to Dijkers (2005) achievements can include performances, relation ships, status, health, and accomplishments. Some individuals in this sample reported achi eving many athletic accomplishments and building lasting relationships through spor ts and activity. This 46 year-o ld basketball coach and former player said it, perhaps most eloquently. Ive had a, not that I want to die right now, but if I died right now, I could truly say that Im satisfied with you know, Ive been able to co mpete on an internationa l level, Ive been able to win national championshi ps athletically, I ha ve 2 incredible kids, great wife, good job, I live in a place where Im happy. Another middle-aged basketball player sa id, And Ive done, Ive be en on some U.S. teams and Ive accomplished far more than I ever thought I could. This same man also forged lifelong friendships through basketba ll. He said, Well I mean my best friend [has] been on the team as long as I can remember. I consider him my brother because of just all the years weve been together. Still another man spoke about the inspirational people he met saying, Then when I started playing sports I met a lot of pe ople that were doing incr edible thingsthey had familiesI thought I wasnt going to have all that. Another form of achievement is developing or maintaining relations hips. As I reported earlier in this chapter, twenty-three individuals from this samp le cited social opportunities as a reason to participate in sports and exercise. These opportunities allowed them to form relationships such as meeting fr iends, influencing others, and be ing influenced by others. For instance a 38 year-old male w ith a PASIPD score of 25.17 said, Its the 10 or 12 guys. Before basketball were trading jokes with each other, or were going out to dinner, or just talking at work. An example of influencing others was given by 21 year-old female who scored a 40.68 on the PASIPD. She said, I think it was really c ool for me to speak to them and kind of show them that people with disabilities can stil l be activeare still normal people you know.

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70 Another example of a social rela tionship reported by the sample was meeting other individuals who were influential. A male aged 29 years with a PASIPD score of 59.47 said, After I met guys and they were doing stuffjobs that I di dnt think that disabl ed people would. Health was also important to many individuals in this sample as 13 out of 26 talked about physical fitness and health risk prevention. A female, aged 51 years with a PASPID score of 71.22 said, Its a good way to help with pain mana gement, it helps strengthen my back and the muscles so that I am still able to walk. A 36 year-old male who scored a 46.42 on the PASIPD added, I mean I look at myself now I train 4 or 5 days a week primarily doing it for health reasons, lower my cholestero l, lose some weight. The final component of subjective QOL is subj ective evaluations. W ithin the PAD model, subjective evaluations are the responses a pers on has to their achievements based on their expectations. If an individual achieved somethi ng they valued as important, then their evaluation would likely be positive. If they were unabl e to achieve something they perceived to be important, then they would evaluate the situat ion negatively. These evaluations can also be called life satisfaction, se lf-esteem, subjective well-being, a nd positive or negative affect. Many of the more global evaluations came from older adults looking back on their lives, although younger participants did report positive affect and impr oved self-esteem. The 47 yearold man who is a basketball player as well as two-time champion water skier was one such person. Like I said, sports is probably the single most important thin g or has been the single most important thing since Ive been in jured. If I could turn back the hands of time, Id still be sitting here in this chair. I wouldnt change a thing. Becau se I know its made my life so much better. A 35 year-old female made a similar statemen t. This woman, with a PASIPD score of 51.49 revealed the following view.

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71 My quality of life I think is better now than it was before I got hurt. I do a lot more, I see a lot more, um, I couldnt say I would have done ha lf of what I have done if I hadnt suffered a spinal cord injury. This college aged female basketball player evaluated her activity e xperience in a positive way. She said, I like the feeling you get from doing things I lik e feeling fit. A 29 year-old man added, I feel like it [b-ball] ga ve me back a lot of self esteem. In this chapter I reported descriptive statis tics on the sample in addition to presenting higher and first-order themes that emerged from th e interview data. I also provided quotations to lend more support to the themes. In the latter section of the chapter I proposed a grounded theory based in part on the PAD model (van de r Ploeg et al., 2004), a subjective definition of QOL (Dijkers, 2003), and used Banduras (1997) no tion of triadic reciprocal causation. The grounded theory suggests that physic al activity participation by indi viduals with di sabilities is influenced by personal and environmental factors. Physical activ ity participation then plays a role in subjective QOL by increasing the opportunity to set and meet goals in a sport or exercise setting thus resulting in more favorable evaluations of those events. The results from this investigation will be discussed in further detail in the last chapter.

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72 Table 3-1. Means and standard deviations for the PASIPD Subcategory Sample Mean SD Home Repair/Gardening .16 .55 Housework 2.49 2.68 Vigorous Sport 18.62 13.68 Moderate Sport 5.33 5.53 Work not for Exercise 9.73 7.92 Total 36.34 15.28 Figure 3-1. Triadic reciprocal causation adapted from Bandura (1997) representing the three major determinants of behavior. B represents behavior; P the internal cognitive, affective, and biological events; and E the external environment. P B E

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73 Figure 3-2. A grounded theory of the determinants of physical activity and the role it plays in subjective QOL. Environmental Factors Personal Factors Initiation and Maintenance of Physical Activity Behaviors Psychological Benefits Physical Benefits Social Benefits Subjective QOL C D E F G A B

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74 CHAPTER 4 DISCUSSION Conclusion In this chapter I will sum marize the findings of this exploration of the role of physical activity in subjective qualit y of life for individuals with physical disabilities. I will also discuss how the findings from this study contribute to an d extend the extant liter ature. Finally, I will review study limitations and examin e possible applications of the fi ndings in real-world settings. The purposes of the present study were to explor e the role that physical activity plays in the subjective quality of life in i ndividuals with physical disabilitie s. Also investigated were the determinants of physical activity and factors perceived by the participants that may have helped sustain their participation in physic al activity. As shown in the prev ious chapter, the participants discussed a range of emotional, cognitive, and beha vioral benefits from p hysical activity such as feeling good, staying focused, a nd developing a work ethic. In addition to these psychological benefits, the participants in this sample also reported social and physical health benefits. The social benefits reported included meeting friend s, being able to spread a message, and positively influencing disabled peers, able-bodied peers, and children. The physical benefits included pain management, staying in cardiovascular shape, and developing muscle. In some cases these perceived benefits of physical activity also provid ed motivation for participants to continue their participation. The findings from the present study suggest conc eptual support for predictions put forth by Dijkers (2005). That is, the pres ent study adds further specificity and clarity about the role that participation in physical activity plays in maintaining subjective quality of life. In Dijkers conceptualization, subjective QOL included achievements, goals, and subjective evaluations. Specifically, when individuals achievements meet or exceed their previously held goals or

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75 values, they may evaluate those achievements in a positive manner. Conversely, if their achievements fall short of their se t goals or values their evaluati ons may be considered negative. Thus in the present study a num ber of the participants repo rted positive evaluations, or psychological benefits, such as improved self-esteem changes in self-concept, and the desire to share their achievements with other individua ls with physical disabilities. Additionally participants described social a nd physical health benefits, or achievements, in the form of relationships, health, performances, and status again consistent with Dijkers definition. Consequently, since the present sample reported greater frequency and intensity of leisure time physical activity than normative data reported by Was hburn et al. (2002), it is likely the benefits derived from physical activity would be multi-dimensional and associated with a range of health, behavioral, or other lifestyle f actors. Thus, when interpreting th e findings from this study one needs to recognize the higher than average levels of physical activity pa rticipation reported by this sample. A range of previously reviewed literature s howed that subjective indicators of life quality such as positive and negative affect, life satisfact ion, or other interpretations of ones life are often used to study peoples lives. Further the ap proach adopted here was to focus on subjective quality of life from the perspec tives of my participants. From Dijkers perspective subjective evaluations are considered reactions to achievements and can be either positive or negative, or emotional or cognitive depending on person, the situ ation, or the context. Thirteen participants interviewed for this study reported that their self-esteem was improved by their participation in wheelchair basketball while near ly the entire sample experi enced psychological benefits associated with physical activity behaviors. The extensive and rich ly detailed quotations provided by the participants clearly suggest enhanced subjective quality of life associated with

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76 participation in physical activity behaviors. One problem however is the data make it difficult to disentangle any differential impact the perceive d social opportunities and benefits that resulted from participation in physical activity with t hose derived from physical activity itself. From either perspective, the participants in this sample, who were relatively active as indicated by the data reported about activity from the PASIPD appeared to be happy, well adjusted, and experiencing positive subjective quality of life. With regard to factors predicting physical activity by individuals with disabilities, the PAD model suggested that environmental fact ors and personal factors played a role in participation (van der Ploeg et al., 2004). Enviro nmental factors included social influences and barriers and facilitators in the environment, while personal factors encompassed health condition, attitude, and barriers and facilita tors in ones personal life (van der Ploeg et al., 2004). The findings from this investigation lend support to this model and sugge st that socia l/environmental factors are implicated in decisions to initia te and sustain physical activity behaviors for individuals with physical disabilities. For instance, eleven participants from the sample spoke about the individuals who influenced them to b ecome physically active such as doctors, coaches, and family members. Twenty-three of the partic ipants interviewed reported that they gained tremendous satisfaction from the varied social as pects of their chosen sports. These social benefits included meeting friends, spreading a message, being a role -model, opportunities to travel, and receiving scholarships. Another main construct in the PAD model th at predicts activity behavior are personal factors. As previously state d, personal factors in clude self-efficacy, hea lth condition, attitude toward the behavior, and personal facilitators and barriers such as availa ble time, gender, age, and motivation. Factors such as age and gender did not appear to influence participation in

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77 physical activity in this sample as no differences were observed in activity levels between gender or between age groups within the interview data. The lack of differences discerned within the interviews between these groups could be due to sampling issues (e.g., the highly active sample) or for other methodological reasons described below. Practical Applications and Future Directions The results from this investigation offer practitioners several recommendations for practice. The first application co uld be at the policy level. While physical activity has been previously recommended for individuals with disa bilities (Cooper et al., 1999), the reasons have been almost exclusively physical. In the future health professionals should also emphasize the social and psychological benefits of sport particip ation as suggested by the participants in this study and previous research (Giacobbi et al., 2006). A second more community or family oriented series of recommendations can be gleane d from the participants reports about important influences that opened opportunities for physical activity. As dem onstrated from the participant quotations, family members and caregivers of indi viduals with physical disabilities can play a facilitative role by encouraging, modeling, or actively persuading persons to be active. In contrast, it is highly possible th at individuals could also encourage or mode l sedentary behaviors that could then influence indivi duals with disabilities to be in active. While the findings here probably do not generalize to less active individuals, it would be interesting to examine how community or family based interventions coul d facilitate involvement in physical activity behaviors over time. Specificall y, the participants initial involvement in physical activity behaviors were either encouraged or modeled by influential others and these experiences facilitated formation of initial self-efficacy beliefs regarding these activities which then perhaps allowed the participants to sustain these beha viors over time. An interesting theoretical and

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78 applied question might involve who would be an effective role model or supportive other to encourage physical activity behaviors? Another intriguing practical issue and potential set of research possibilities is offered through an interpretation of the present findings through a social-cognitive and/or self-efficacy explanation (Bandura, 1997). If Banduras (1997) predictions ar e correct then a variety of possible social, family, and community interven tions could effectivel y enhance self-efficacy beliefs and nurture motivated behavior in the physical act ivity domain. Study Limitations There are several lim itations from this study that should be acknowledged. First, the study sample was gathered using convenience sampli ng and comprised relatively active individuals recruited from a basketball tournament. Additio nally, these individuals were pre-selected for physical activity due to being recruited at a bask etball tournament. This may have led to the overwhelmingly positive evaluations of physical activity. Although results from the PASIPD data demonstrated a high degree of variability between individuals, the planned comparisons between active versus less active individuals could not be performed. Another design weakness was the single shot interview procedure with each participant. While the data did provide a unique perspective with which to examine the important influences for active participants, a more rigorous approach might be conducted to examine how and why individuals sustain their physical activity behaviors and health over time. For example, subsequent interviews could have been conducted to explore the possible reciprocal relationship between pa rticipation, benefits, and motives. Summary In summ ary, this mixed-method study explored the role of physical activity on the subjective quality of life in a sample of activ e wheelchair users. It provided rich qualitative descriptions of

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79 the physical activity experiences an d the perceived benefits of thei r participation as well as their motives to sustain participation. The present st udy also explored the reciprocal relationship between participation, perceived bene fits, and motives to participate.

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80 APPENDIX A INTERVIEW GUIDE I. Basic Dem ographic Questions a. Age b. Gender c. Race/ethnicity II. Intermediate questions this part of the interview will focus on your typical day. a. Could you describe a typical day for yourself? b. Tell me about your job (if appropriate). i. What do you do? ii. How long have you been in that occupation? c. Describe some of the activities ( hobbies, recreation) you enjoy during a typical day [besides work]. i. How long have you participated in that [those] activity[ies]? ii. Why are those particular ac tivities enjoyable to you? III. Physical Activity a. What physical activities do you engage in regularly? i. Could you please describe these activities? ii. How often do you engage in ___________? iii. Do you compete? If so, how often? iv. Could you tell me about your goals ______________ (short or long term)? b. Has participation in ___________ impacted your life in any way? If so, how? i. Potential probes include the following: 1. How so? 2. Could you tell me more about this? 3. What was that like? 4. Could you describe a specific time or incident where _________________ occurred? c. After having these experiences in sp ort and physical activ ity, what advice would you give someone? IV. Disability Specific Issues a. Right now Id like to learn more about your disability. Could you tell me about your disability? i. How did ______________ occur? b. If this was an injury: What was your life like before__________________? c. What helps you manage or cope with_________________? d. Who is most helpful to you? How has he/she been helpful? V. Quality of Life

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81 a. Could you describe the most important lessons you learned about yourself after you experienced [your injury, illness, or disability]? b. How have you grown as a person sin ce you experienced this [disability, accident]? i. If so, how? c. Have you grown as a person since you became involved in wheelchair athletics? i. Tell me about your strengths you discovered or developed through your sport/physical activity pa rticipation [dealing with your disability]? ii. Tell me about your strengths you discovered or developed through sport or physical activity? VI. Is there anything that you might not have thought about before that occurred to you during this interview?

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82 APPENDIX B THEMES FROM THE DATA Raw Data Themes First Order Themes Higher Order Themes Relieves aggression Good for disposition Fights depression Deal with rage Emotional Relaxing N = 12 Relieves stress It's therapeutic Feel Good Keeps you positive and grounded More independence = more happiness Competition is good Athletics teaches leadership Good mental strength Stay focused and concentrate Change life mentally It's Fun Cognitive Gives you patience N = 10 Develop trust Desire to not give up Feeling of accomplishment Work with others Depend on others Become more assertive More outgoing I can do anything anyone else can Behavioral Psychological Benefits Ability to adapt N = 8 N = 25 Developed work ethic Showing that it can be done Perseverance Become less introverted Able to achieve goals increased control over life Increased ability to do things More outgoing

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83 Built character I've found that I can be a leader Changed self concept Helps self-esteem Improved self-perception Self-growth N = 13 Focus on ability Feel more able-bodied Sense of confidence Sense of independence Others look up to you Looked up to Sleep better Maintain Fitness Maintain Health Keeps you Young Physical Fitness It develops muscle N = 13 Keeps you in shape Prevents smoking behavior Good for heart Good for pain management Preventing health risk Lower cholesterol N = 7 Physical Health Lower risk of secondary health issues N = 18 Prevents shoulder problems Prevent wear of body Other Health Benefits Seratonin/dopamine/endorphins N = 2 Disabled peers at hospitals Disabled peers at other sporting events Disabled Peers Disabled peers at college N = 4 Teammates Doctor introduced them to sport Health Professional Social Influences Youth director of rehab center N = 3 N = 12 Parents encouraged sports Family Siblings included them in games N= 3 Coach of team Coaches

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84 N = 2 Like being on a team Social component very important Meet best friends Meet wonderful people Meeting Friends Camaraderie of teammates N = 12 Social Aspect of team sport vs. individual Forced to interact with teammates Being with others with disabilities Public more aware of abilities Bridge to able-bodied world Spreading a message Social Opportunities Speak to children about accomplishments N = 9 N= 23 Coaching kids to success Meet inspirational others Influential Others Other productive people in wheelchairs N = 5 Education paid for Able to see the world Travel/Education/Compet. Compete at Olympic level N = 10 Compete at an international level Moving to the United States Introduced to other wheelchair sports Expands horizons Learn Discipline More positive Reflecting on life of achievement Would prefer to be in wheelchair QOL is better now then before injury Sport has given a positive direction in life Reappraisal of self Changed self-perception N = 6 Gave back self-esteem Increased Overall QOL Found new strength in self N = 6 More comfortable in other areas of life Satisfied with accomplis hments in sport

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85 APPENDIX C THE PHYSICAL ACTIVITY SCALE FO R PE RSONS WITH DISABILITIES Leisure Time Activity 1. During the past 7 days how often did you engage in stationary activities such as reading, watching TV, computer games, or doing handcrafts? a. Never (Go to question #2) b. Seldom (1-2 days) c. Sometimes (3-4 days) d. Often (5-7 days) On average, how many hours per day did you spend in these stationary activities? a. Less than 1hour b. 1 but less than 2 hours c. 2-4 hours d. More than 4 hours 2. During the past 7 days, how often did you walk, wheel, push outside your home other than specifically for exercise For example, getting to work or class, walking the dog, shopping, or other errands? a. Never (Go to question #3) b. Seldom (1-2 days) c. Sometimes (3-4 days) d. Often (5-7 days) On average, how many hours per day did you spend wheeling or pushing outside your home? a. Less than 1hour b. 1 but less than 2 hours c. 2-4 hours d. More than 4 hours 3. During the past 7 days, how often did you engage in light sport or recreational activities such as bowling, golf with a cart, hunting or fishing, darts, billiards or pool, therapeutic exercise (physical or occupational therapy, stretching, use of a standing fram e) or other similar activities? a. Never (Go to question #4) b. Seldom (1-2 days) c. Sometimes (3-4 days) d. Often (5-7 days) On average, how many hours per day did you spend in these light sport or recreational activities? a. Less than 1hour b. 1 but less than 2 hours c. 2-4 hours d. More than 4 hours 4. During the past 7 days, how often did you engage in moderate sport and recreational activities such as doubles tennis, softball, golf without a cart ballroom, dancing, wheeling or pushing for pleasure or ot her similar activities?

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86 a. Never (Go to question #5) b. Seldom (1-2 days) c. Sometimes (3-4 days) d. Often (5-7 days) On average, how many hours per day did you spend in these moderate sport or recreational activities? a. Less than 1hour b. 1 but less than 2 hours c. 2-4 hours d. More than 4 hours 5. During the past 7 days, how often did you engage strenuous sport or recreational activities such as jogging, wheelchair raci ng (training), off-road pushin g, swimming, aerobic dance, arm cranking, cycling (hand or leg), singles tennis, rugby, basketball, walking with crutches and braces, or other similar activities? a. Never (Go to question #6) b. Seldom (1-2 days) c. Sometimes (3-4 days) d. Often (5-7 days) On average, how many hours per day did you spend in these strenuous sport or recreational activities? a. Less than 1hour b. 1 but less than 2 hours c. 2-4 hours d. More than 4 hours 6. During the past 7 days, how often did you do any exercise specifically to increase muscle strength and endurance such as lifting weights, push-ups, pull-ups, dips, or wheelchair push-ups, etc.? a. Never (Go to question #7) b. Seldom (1-2 days) c. Sometimes (3-4 days) d. Often (5-7 days) On average, how many hours per day did you spend in these exercises to increase muscle strength and endurance ? a. Less than 1hour b. 1 but less than 2 hours c. 2-4 hours d. More than 4 hours Household Activity 7. During the past 7 days, how often have you done any light housework such as dusting, sweeping floors, or washing dishes? a. Never (Go to question #8) b. Seldom (1-2 days) c. Sometimes (3-4 days)

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87 d. Often (5-7 days) On average, how many hours per day did you spend doing light housework ? a. Less than 1hour b. 1 but less than 2 hours c. 2-4 hours d. More than 4 hours 8. During the past 7 days, how often have you done any heavy housework or chores such as vacuuming, scrubbing floors, wash ing windows, or walls, etc.? a. Never (Go to question #9) b. Seldom (1-2 days) c. Sometimes (3-4 days) d. Often (5-7 days) On average, how many hours per day did you spend doing heavy housework or chores ? a. Less than 1hour b. 1 but less than 2 hours c. 2-4 hours d. More than 4 hours 9. During the past 7 days, how often have you done home repairs like carpentry, painting, furniture refinishing, el ectrical work, etc.? a. Never (Go to question #10) b. Seldom (1-2 days) c. Sometimes (3-4 days) d. Often (5-7 days) On average, how many hours per day did you spend doing home repairs ? a. Less than 1hour b. 1 but less than 2 hours c. 2-4 hours d. More than 4 hours 10. During the past 7 days, how often have you done lawn work or yard care including mowing, leaf or snow removal, tree or bush trimming, or wood chopping, etc.? a. Never (Go to question #11) b. Seldom (1-2 days) c. Sometimes (3-4 days) d. Often (5-7 days) On average, how many hours per day did you spend doing lawn work? a. Less than 1hour b. 1 but less than 2 hours c. 2-4 hours d. More than 4 hours 11. During the past 7 days, how often have you done outdoor gardening ? a. Never (Go to question #12)

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88 b. Seldom (1-2 days) c. Sometimes (3-4 days) d. Often (5-7 days) On average, how many hours per day did you spend doing lawn work? a. Less than 1hour b. 1 but less than 2 hours c. 2-4 hours d. More than 4 hours 12. During the past 7 days, how often did you care for another person such as children, a dependent spouse, or another adult? a. Never (Go to question #13) b. Seldom (1-2 days) c. Sometimes (3-4 days) d. Often (5-7 days) On average, how many hours per day did you spend caring for another person ? a. Less than 1hour b. 1 but less than 2 hours c. 2-4 hours d. More than 4 hours Work Related Activity 13. During the past 7 days, how often did you work for pay or as a volunteer ? (Exclude work that mainly involved sitting with slight arm movement such as li ght office work, computer work, light assembly line work, driving bus or van, etc.) a. Never (Go to END) b. Seldom (1-2 days) c. Sometimes (3-4 days) d. Often (5-7 days) On average, how many hours per day did you spend working for pay or as a volunteer ? a. Less than 1 hour b. 1 but less than 4 hours c. 5 but less than 8 hours d. More than 8 hours

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89 LIST OF REFERENCES Anderson, K.N., et al. (E ds.). (1998). Mosbys medical, nursing, and allied health (5th ed.). St. Louis: Mosby. Andrews, F.M., & Whithey, S.B. (1976). Social Indicators of well-bei ng: Americas perspective of life quality. New York: Plenum Press. Argyle, M. (1999). Causes and correlates of happiness. In D. Kahneman, E. Diener, & N. Schwarz (Eds.), Well-Being: The Foundations of Hedonic Psychology. (pp. 353-373). New York: The Russell Sage Foundation. Bandura, A. (1997) Self-efficacy: The exercise of control. New York: W. H. Freeman & Co. Bandura, A. (2001). Social cognitive theory: An agenti c perspective. Annual Review of Psychology, 52, 1-26. Bandura, A. (2004). Health promotion by social cognitive means. Health Education and Behavior, 31 143-164. Bayley, J.C., Cochran, T.P., & Sledge, C.B. (1987). The weight-bearing shoulder. Journal of Bone and Joint Surgery, 69 (A) 676-678. Berger, B.G., & Motl, R. (2001). Physical activity and quality of life. In R.N. Singer, H.A. Hausenblas, & C.M. Janelle (Eds.), Handbook of Sport Psychology 2nd Ed. (pp. 636-671). New York: John Wiley & Sons, Inc. Blinde, E.M., & McClung, L.R. (1997). Enha ncing the physical and social self through recreational activity: Accounts of individuals with physical disabilities. Adapted Physical Activity Quarterly, 14 327-344. Block, M.E., Griebenauw, L., & Brodeur, S. (2 004). Psychosocial Factors and Disability: Effects of Physical Activity a nd Sport. In M.R. Weiss (Ed.) Developmental Sport and Exercise Psychology: A Lifespan Perspective 1st Ed. (pp. 425-452). Morgantown, WV: Fitness Information Technology, Inc. Burnham, R.S., May, S.L., Nelson, E., Steadward, R., Reid, D.C. (1993). Shoulder pain in wheelchair athletes: the role of muscle imbalance. American Journal of Sports Medicine, 21, 238-242. Cantor, N., & Sanderson, C.A. (1999). Life ta sk participation and well-being: The importance of taking part in daily life. In D. Kahneman, E. Diener, & N. Schwarz (Eds.), Well-Being: The Foundations of Hedonic Psychology. (pp. 230-243). New York: The Russell Sage Foundation. Centers for Disease Control and Prev ention (CDC) (2005). National Average:

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90 Recommended Physical Ac tivity by: Age. Retrieve d February 22, 2007, from http://apps.nccd.cdc.gov/PASurveillance. Charmaz, K. (2000). Grounded theory: Objectivist and constructivist methods. In K. Charmaz (Ed.), Handbook of qualitative methods (2nd edition ed., pp. 509-535). Thousand Oaks, CA: Sage Publications Inc. Craft, L.L., & Landers, D.M. (1998). The e ffect of exercise on c linical depression and depression resulting from mental illness: A meta-analysis. Journal of Sport and Exercise Psychology, 20, 339-357. Cooper, R.A., Quatrano, L.A., Axelson, P.W., Harlan, W., Stineman, M., Franklin, B. (1999). Research on physical activity and health among people with disabilities: A consensus statement. Journal of Rehabilitation Rese arch & Development, 36 (2) 142-154. Curtis, K.A., Drysdale, G.A., Lanza, R.D., Ko lber, M., Vitolo, R.S., & West, R. (1999). Shoulder pain in wheelchair users wi th tetraplegia and paraplegia. Archives of Physical and Medical Rehabilitation, 80, 453-457. Dale, G.A. (1996). Existential phenomenology: Em phasizing the experience of the athlete in sport psychology research. The Sport Psychologist, 14 17-41. Damiano, D.L., Kelly, L.E., Vaughan, C.L. (1995) Effects of quadriceps femoris muscle strengthening on crouch gait in chil dren with spastic diplegia. Physical Therpay, 75, 658671. Damiano, D.L., Vaughan, C.L., Abel, M.F. (1995). Muscle response to heavy resistance exercise in children with spastic cerebral palsy. Developmental Medicine and Child Neurology, 37 731-739. Darrah, J., Fan, J.S.W., Chen, L.C. (1997). Review of the effe cts of progressive resistance muscle strengthening in children with cerebra l palsy: A clinical consensus exercise. Pediatric Physical Therapy, 9 12-17. Diener, E. (1994). Assessing subjective well-being: Progress and opportunities. Social Indicators Research, 31, 103-157. Diener, E., Emmons, R.A., Larson, R.J., & Griffin, S. (1985). The Satisfaction with Life Scale. Journal of Personality Assessment, 49, 71-75. Diener, E., Oishi, S., & Lucas, R.E. (2003). Personality, culture, and subjective well-being: Emotional and cognitive evaluations of life. Annual Review of Psychology, 54, 403-425. Diener, E. Suh, E.M., Lucas, R.E., & Smith, H.E. (1999). Subjective well-being: Three decades of progress. Psychological Bulletin, 125, 276-302.

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91 Dijkers, M.P.J.M. (2005). Quality of life of individuals with sp inal cord injury: A review of conceptualization, measurement, and research findings. Journal of Rehabilitation Research and Development, 42 (3), 87-110. Duggan, C.H. & Dijkers, M.P.J.M. (2001). Quality of life after spinal cord injury: A qualitative study. Rehabilitation Psychology, 46 (1), 3-27. Flegal, K.M., Carroll, M.D., Ogden, C.L., Johnson, C.L. (2002). Prevalence and trends in obesity among US adults. Journal of the American Medical Association, 288 1723-1727. Fontana, A., & Frey, J.H. (2000). The interview: From structured questions to negotiated text. In N. K. Denzin & Y. S. Lincoln (Eds.), Handbook of qualitative research (pp. 645-672). Thousand Oaks, CA: Sage. Fowler, E.G., Ho T.W., Nwigwe, A. I. et al. (2001). The effect s of quadriceps femoris muscle strengthening exercises on spasticity in children with cerebral palsy. Physical Therapy, 81, 1215-1223. Fullerton, H.D., Borckardt, J.J., Alfano, A.P. (2003). Shoulder Pain: A comparison of wheelchair athletes and non-at hletic wheelchair users. Medicine and Science in Sports and Exercise, 35(12) p. 1958-1961. Giacobbi, P.R., Hardin, B., Frye, N., Hausenblas, H.A., Sears, S., & Stegelin, A. (2006). A multi-level examination of personality, exercise and daily life events for individuals with physical disabilities. Adapted Physical Acti vity Quarterly, 23 129-147. Hahn, H. (1988). The politics of physical di fferences: Disability and discrimination. Journal of Social Issues, 44 39-47. Hales, R., & Travis, T.W. (1987). Exercise as a treatment option for anxiety and depressive orders. Military Medicine, 152, 299-302. Hays, R.D., Hahn, H., & Marshall, G. (2002). Us e of the SF-36 and other health related quality of life measures to assess pers ons with physical disabilities. Archives of Physical Medicine and Rehabilitation, 83 S4-S9. Heady, B., & Wearing, A. (1992). Understanding happiness: A theory of subjective well-being. Melbourne, Australia: Longman Cheshire. Hicks, A.L., Martin, K.A., Ditor, D.S., Latimer, A.E., Craven, C., Bugaresti, J. and McCartney, N. (2003). Long term exercise training in persons with spinal cord injury: effects on strength, arm ergometry performa nce and psychological well-being. Spinal Cord, 41 3443 Higgins, P.C. (1980). Societal reaction and the physically disabled: Bringing the impairment back in. Symbolic Interaction, 3 139-156.

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92 Kaplan, R.M. (1994). The Ziggy Theorem: Towa rd an outcomes-focused health psychology. Health Psychology, 13, 451-460. Kaplan, R.M., Bush, J.W., & Berry, C.C. (1976). Health status: Types of validity and the index of well-being. Health Services Research, 11 478-507. Kaplan, R.M., Bush, J.W., & Berry, C.C. (1978). The reliability, stabi lity, and generalizability of a health status index. In Proceedings of the Social Status Section (pp. 704-705). Alexandria, VA: American Statistical Association. Kessler, R.C., McGonagle, K.A., Zhao, S., Nelson, C.B., Hughes, M., Eshelman, S., Wittchen, H.U., & Kendler, K.S. (1994). Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: Results from the National Co-Morbidity Survey. Archives of General Psychiatry, 51, 8-19. Kette, G. (1991). Haft: Eine Socialpsychologische Anal yse (Prison: A social psychological analysis). Gottingen, Ger.: Hogrefe. Lucas, R.E., Clark, A.E., Georgellis, Y., & Diener E. (2004). Unemployment alters the set point for life satisfaction. Psychological Science, 15 (1), 8-13. MacPhail, H.E., & Kramer, J.F. (1995). Eff ect of isokinetic strengt h training on functional ability and walking efficiency in adolescents with cerebral palsy. Developmental Medicine and Child Neurology, 37 763-775. Martinsen, E.W. (1987). The role of aerobic exercise in the trea tment of depression. Stress Medicine, 3, 93-100. Martinsen, E.W. (1990). Benefits of exercise for the treatment of depression. Stress Medicine, 9, 380-389. McKevitt, C., Redfern, J., La Placa, V., & Wolfe, C.D.A. (2003). Defining and using quality of life: A survey of health care professionals. Clinical Rehabilitation, 17, 865-870. Miyahara, M., Sleivert, G.G., & Gerrard D.F. (1998). The relationship of strength and muscle balance to shoulder pain and impingement syndrome in elite quadriplegic wheelchair rugby players. International Journal of Sports Medicine, 19 210-214. Myers, D.G. (1999). Close relationships and qua lity of life. In D. Kahneman, E. Diener, & N. Schwarz (Eds.), Well-Being: The Foundations of Hedonic Psychology. (pp. 374-391). New York: The Russell Sage Foundation. North, T.C., McCullagh, P., & Tran, Z.V. ( 1990). Effect of exercise on depression. Exercise and Sport Science Reviews, 18, 379-415. Patrick, D., Danis, M., Southerl and, L.I., Hong, G. (1988). Quality of life following intensive care. Journal of Gerontology and Internal Medicine, 3 218-223.

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93 Parker, D.F., Carriere, L., Hebestreit, H. et al (1993). Muscle performance and gross motor function of children with spastic cerebral palsy. Developmental Medicine and Child Neurology, 35 17-23. Pavot, W., & Diener, E.F. (1993). Review of the Satisfaction with Life Scale. Psychological Assessment, 5, 164-172. Pavot, W., Diener, E.F., Colvin, C.R., & Sandvik, E. (1991). Further validation of the Satisfaction with Life Scale: Evidence fo r the cross-method ,convergence of well-being measures. Journal of Personality Assessments, 57, 149-161. Petruzzello, S.J., & Landers, D.M. (1994). State anxiety reducti on and exercise: Does hemispheric activation re flect such changes? Medicine and Science in Sport and Exercise, 26 (8), 1028-1035. Rejeski, W.J., & Mihalko, S.L. (2001). Physical activity and quality of life in older adults. Journals of Gerontology, 56(A), 23-35. Rimmer, J.H., & Wang, E. (2005). Obesity prevalence among a group of Chicago residents with disabilities. Archives of Physical Me dicine and Rehabilitation, 86 1461-1464. Schwarz, N., & Strack, F. (1999) Reports of subjective well-be ing: Judgmental processes and their methodological implicati ons. In D. Kahneman, E. Diener, & N. Schwarz (Eds.), Well-Being: The Foundations of Hedonic Psychology. (pp. 61-84). New York: The Russell Sage Foundation. Sharp, S.A., & Brouwer B.J. (1997). Isokinetic strength training of the hemiparetic knee: Effects on function and spasticity. Archives of Physical Me dicine and Rehabilitation, 78 1231-1236. Sie, I.H., Waters, R.L., Adkins, R.H., & Gellman, H. (1992). Upper extremity pain in the post rehabilitation spinal cord injured patient. Archives of Physical and Medical Rehabilitation, 73, 44-48. Simon, G.E., VonKorff, M., & Barl ow, W. (1995). Health care costs of primary care patients with recognized depression. Archives of General Psychiatry, 52, 850-856. Slater, D., & Meade, M.A. (2004). Participation in recreation and sports for persons with spinal cord injury: Review and recommendations. NeuroRehabilitation, 19, 121-129. Snead, S.L., & Davis, J.R. (2002). Attitudes of individuals with acquired brain injury towards disability. Brain Injury, 16 (11), 947-953. Sparkes, A.C. (1998). Validity in qualitative an d the problem of criteria: Implications for sport psychology. The Sport Psychologist, 12 363-386. Suh, E., Diener, E., & Fujita, F., (1996). Events and subjective well-being: Only recent events matter. Journal of Personality and Social Psychology, 70, 1091-1102.

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94 Taub, D.E., Blinde, E.M., & Greer, K.R. (1999). Stigma management through participation in sport and physical activity: Experiences of male college student s with physical disabilities. Human Relations, 52 (11), 1469-1484. Tate, D.G., Kalpakjian, C.Z., Forchheimer, M.B. (2002). Quality of life issues in individuals with spinal cord injury. Archives of Physical Medicine and Rehabilitation, 83, S18-S25. Taylor, D., & Williams, T. (1995). Sport injuries in athletes with disabilities: wheelchair racing. Paraplegia, 33, 296-299. Ustun, T.B., Chatterji, S., Bickenbach, J., Ko stanjsek, N., & Schneider, M. (2003). The international classification of functioning, disability and health: a new tool for understanding disabili ty and health. Disability and Rehabilitation, 25(11-12), 565-571. Van der Ploeg, H. P., Van der Beek, A.J., Van de r Woude, L.H.V., Van Mechelen, W. V. (2004). Physical activity for people with a disability: A conceptual model. Sports Medicine, 34(10), 639-649. Ware, J.E., Kosinski, M., & Keller, S.D. (1994). SF-36 Physical and Mental Health Summary Scales: A Users Manual. Boston: The Health Institute, New England Medical Center. Ware, J. E. (2000). SF-36 Health Survey: Manual and interpretation guide Lincoln, Rhode Island: Quality Metric. Ware, J.E., & Sherbourne, C.D. (1992). Rand 36-Item Health Survey, 1.0 Santa Monica, CA: Rand. Washburn, R. A., Weimo, Z., McAuley, E., Frogle y, M., & Figoni, S. F. (2002). The physical activity scale for individuals with physical disabilities: Development and evaluation. Archives of Physical Me dicine and Rehabilitation, 83 193-200. Wu, S.K., & Williams, T. (2001). Factors influe ncing sport participation among athletes with spinal cord injury. Medicine and Science in Sports and Exercise, 33 (2), 177-182. World Health Organization. International Classification of F unctioning, Disability, and Health (ICF). Geneva: World Hea lth Organization, 2001.

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95 BIOGRAPHICAL SKETCH Michael Stancil was born in Gainesville, Florida on July 1, 1980. Throughout his childhood he lived on the east and Gulf coasts of Florida. He received his Bachelor of Science degree in psychology in August of 2002 from the Univ ersity of Florida. Michael began graduate school in the spring of 2004 where he met his wife Leah. They were married in Barbados in August of 2006 and currently reside in Columbia, South Carolina.