How does playing adapted sports affect quality of life of people with mobility limitations? Results from a mixed-method sequential explanatory study

The Ferrans and Powers Quality of Life Index (QLI) [28, 29] was used to measure quality of life. The QLI is a well-known and widely-used generic satisfaction with life tool (translated into 9 languages and used in clinical and research settings in 18 countries). It takes the individual’s reactions into account [30], includes norms [29] and has been used with individuals with varying disability levels [31]. The tool consists of two parts, each of which includes 32 items related to four life domains: 1) health and functioning, 2) socioeconomic, 3) psychological/spiritual, and 4) family. The first part of the questionnaire concerns the person’s satisfaction with items in each of the domains (6-point Likert scale ranging from ‘very dissatisfied’ to ‘very satisfied’), while the second part estimates the importance to the respondent of each item (from ‘very unimportant’ to ‘very important’). The total score and score for each of the four domains ranges from 0 to 30. To obtain these scores, 3.5 units are subtracted from each satisfaction item, and the result is multiplied by the level of importance associated with that item, providing a weighted score for each item. The mean scores for the weighted items are then calculated, and 15 is added to eliminate any negative scores [28, 29].

The QLI presents good concurrent validity with satisfaction with life in general (r = 0.65 to 0.75), good test-retest reliability (r = 0.81 in a group of students and 0.87 in a group of dialysis patients) and high internal consistency (Cronbach’s alphas of 0.90 and 0.93, respectively, in the aforementioned groups) [28, 29]. According to the study by Ferrans and Powers [28], the total mean score for the general population (mean age 48.4 +/− 16.8 years) is 23 (S.D. = 4.0); a score of 19 or less suggests poor quality of life and a difference of 2 or 3 points is clinically significant.

A self-administered questionnaire covering sociodemographic and clinical characteristics was used to collect data on the participants (see Table 1).

Prior to data collection, a semi-structured interview guide was developed for quality of life and associated dimensions identified in the literature and related to the quality of life theoretical model [4], namely self-esteem, self-efficacy and sense of belonging to a group. Examples of questions included: “How does playing your adapted sport affect your quality of life?” or “Tell me about your social life related to playing your sport”. This guide was verified during the first interview and modified and expanded based on the participants’ answers. Each student-researcher was trained by an experienced qualitative researcher to conduct the interviews and practised with a participant from the quantitative part of the study who was not selected for the qualitative interview. These practices were recorded, commented on by experienced qualitative researchers and shared with the other interviewers as a training method to ensure uniformity in the process and greater efficacy of the interviews.

The participants’ characteristics were first described by mean and standard deviation for continuous variables, and frequency and percentage for categorical variables. Using a t-test for independent groups, performed with SPSS, results on the QLI obtained by participants with mobility limitations were compared with the QLI scores of 34 people of comparable age, drawn from Lacroix et al. [27] and obtained from the general population, i.e., people between 18 and 64 years of age without any mobility problems (comparison group). With a standard deviation of 5 [standardized mean difference (effect size) of 3/5 = 0.60], alpha error of 5% and power of 80%, a sample size of 34 participants is sufficient to detect a minimum difference of 3 points on the QLI between these two types of participants [32].

A thematic content analysis was carried out simultaneously with data collection, using a lexical guide, summary sheets and a mixed coding grid [33] to systematically identify [34] and add categories as the analysis proceeded. The themes underlying the 3 general categories in the interview guide (self-esteem, self-efficacy and sense of belonging) emerged from this content analysis. Memos containing thoughts, questions, syntheses and discussions by the research team were also used [33]. After each interview was analyzed by at least two authors to enhance the credibility and confirmability via triangulation, the research team met to discuss the coding and modify the interview guides to allow exploration of emerging themes. The thematic content analysis was conducted using the Human Development Model - Disability Creation Process (HDM-DCP) [35] to identify and synthesize existing themes in a systematic process [34], and the emergence of additional categories based on new items identified during the analysis [36]. The HDM-DCP is an ecosystemic conceptual model illustrating the interaction of personal and environmental factors that result in social participation, i.e. all valued daily activities and social roles [35]. Personal factors include identity characteristics (e.g. age, sex, sociocultural identity, resilience and spirituality), organic systems (e.g. nervous and skeletal systems) and capabilities (e.g. intellectual, behavioral, motor). Environmental factors include social and physical facilitators and obstacles to social participation [35]. The analysis was carried out in Word and achieved theoretical data saturation.

Playing an adapted sport has a positive impact on physical and psychological factors, especially behavior-related abilities, including self-esteem, self-efficacy and sense of belonging (Fig. 1): “By getting involved in sport, […] I discovered I had many strengths, lots of things other people don’t have.” (P2). In addition, the participants said they transferred what they learned, as shown in the following extract concerning an increase in self-efficacy: “Through sport, I learned I could achieve my objectives, so I apply this in my everyday life.” (P9). Success in sports also helps them develop a sense of accomplishment, as shown by the following experience in international sports: “It’s an accomplishment [that] spreads through everyone around you, through your whole life.” (P5).

In addition, identification with teammates and a sense of fairness foster their feeling of belonging, as indicated by two participants: “We’re all at the same height [in a wheelchair], we’re all equal.” (P4) and “We understand each other, I think that’s an aspect you don’t get [in other social groups].” (P2). For one of the female participants, the magnitude of this sense of belonging was considerable: “[My team] is like my family.” (P9). Playing an adapted sport also influences quality of life by helping to develop the ability to manage emotions: “After sports, we try to gain some perspective, find some meaning.” (P2). Finally, by developing their physical capacities, adapted sports makes their day-to-day activities easier: “We are stronger physically, transfers are easier.” (P5). However, playing sports intensively can cause injuries and reduce quality of life: “You can wear out faster the muscles that need to be functional to help you in your everyday life.” (P4). Some participants said they experienced stress related to the pressure to perform in competitive sports.

The influence of playing adapted sports on the participants’ quality of life was also created through social participation, in general and through interpersonal relationships (Fig. 1). Adapted sports provide a variety of enjoyable experiences like travel: “It [adapted sport] gave me a real social life […] I developed a big social network with friends around the world.” (P9). Playing an adapted sport also influences quality of life by increasing participation in meaningful activities: “Since I wasn’t doing any sport, I felt a bit lost because I was no longer doing what I loved.” (P1). Some competition level participants, however, reported that playing adapted sports involved sacrifices: “You have to give up certain privileges […] you have to go to bed early instead of going to a party.” (P2). Finally, playing an adapted sport has a positive impact on quality of life by increasing the number of meaningful relationships with teammates and fostering mutual assistance: “It’s my group of wheelchair ‘friends’ […] we can help each other.” (P3).

Playing an adapted sport also influences the participants’ quality of life and self-esteem by changing society’s attitude to people with mobility limitations: “You have two profiles: you have people in wheelchairs and you have athletes in wheelchairs. As soon as you get active in a sport, people look at you differently” (P3). Playing adapted sports increases people’s involvement in their community and fosters the opportunity to build a reliable social environment: “Yes, we talk about sports but he is really a friend. We talk about anything, we see each other, hang around together and it really brings something different” (P3). Participation in higher levels of competition, however, tends to involve sacrifices in the social environment, particularly for families, which has a negative impact on athletes’ quality of life: “If you have a family and you’re gone for two months, it’s harder to manage” (P1). Participation in adapted sports also helps people develop the physical strength to overcome environmental barriers, such as moving in snow: “You think it’s difficult to roll your chair, then you realize it’s easier than you think” (P5). Participants also linked playing adapted sports to better physical well-being: “It gives me a sense of physical wellness and the pleasure of participating in a sport that makes me feel good in my body.” (P9) When financial, human and physical resources (equipment costs and transportation, coaches, funding for teams) are limited, participation is restricted, which creates dissatfaction with playing sports. Some participants also reported having problems with organizational accessibility (limited number of teams, schedule) and training facilities, which might contribute to reduced quality of life.