SHAPING EVIDENCE-BASED SOCIAL POLICY FOR THE DISABLED: MAKING THE CASE FOR SPORT

TO IMPROVE HEALTH AND WELL-BEING

Liz Adams, MPH, VA Technology Assessment Program, BostonTed Fay, PhD, SUNY Cortland

Presented to:ISDPA Power of Sport Summit

June 10-12, 2010

Evaluation of sport from an individual & global public health perspective

Evidence-based social policy: myths &

realities

Evidence

Current policy trends

Recommendations for policy & research

Oh, the possibilities!!!

Objectives

“Public Health is defined as improvement of health through the organized efforts of society—social

interventions.” (Gray 1997)

Sport is an organized social intervention for health improvement

Physical activity through sport is an attainable & essential health behavior

A Public Health Perspective

Evidence

ValuesResources

Opinion-based Social Policy

Evidence

ValuesRESOURCES

Evidence-based Social Policy: What it is

Policy based on a systematic appraisal of the best available evidence in

the context of societal values & available

resources (Gray 1997)

Evidence = science & experiences

Policy makers must have the skills to find & assess the quality & applicability of available evidence

Policy shapers must be able to produce & present the evidence on which a decision change should be based

To Affect Evidence-based Social Policy

Impossible to practice

“Cookbook”

Restricted to RCTs & meta-analyses

Cost-cutting

Evidence-based Social Policy: What it isn’t

VALUE “Physical activity” for disabled = a major

public health priority

Sport orgs help promote social policies, healthy environments & behavior

Effective program development

Maximize community participation

Evidence-based Social Policy: Why we need it

Systematic/critical reviews published from 2000-present in English

Databases: Pubmed, EBSCO Rehabilitation and Sports Medicine Source, Cochrane Lib, Embase, Current Contents, Social Science/Science Citation Index, PsychInfo

Terms: “sport”, “exercise”, “physical activity”, “physical fitness”, “recreation” & “leisure”

All disabilities

All outcomes

What is the Evidence?

Psychological benefits of sport (non-sys review) Empowerment model:

◦ performance accomplishments & functional efficiency◦ perceived self-efficacy, self-concept & self-esteem◦ personality disorders, mood states & locus of control◦ activity level & social acceptance

Findings: “most psychological constructs expressed within the empowerment model are positively affected by physical activity in disabled people, when applied properly”◦ Multiple study design limitations

What is the Evidence? Hutzler 1993

Survey of sport disability, age & scientific discipline

Most frequent subjects = wheelchair users (58%), adults (90%), males (98%)

Most frequent outcomes= physiology (41%), psychology (29%)

Findings: Evidence base represented assessment of physiological responses to physical activity in adult males who used wheelchairs

What is the Evidence? Hutzler 1999

Physical activity & exercise, age ≥ 60 yrs

2 SR + 2 critical reviews: 11- 41 RCTs

Findings: Exercise enhances strength, aerobic capacity & function esp. walking, but unclear if exercise prevents or minimizes disability

◦ Multiple study design limitations

What is the Evidence? Keysor 2003

Physical activity in youth w/developmental disability, ages 0-20

3 SR, 1 RCT, 13 uncontrolled studies Findings:

◦ Strong evidence for group exercise, treadmill training, therapeutic riding/hippotherapy

◦ Lower evidence for adapted skiing, aquatic programs

◦ Positive outcomes: enjoyment, satisfaction or physical benefit

◦ Study limitations

What is the Evidence? Johnson 2009

Health promotion activities, age 18-65 80 studies: 32 RCTs, 16 NRCTs, 32 NR uncontrolled Disability groups w/ higher prevalence (20% stroke,

15% MS, 13% intellectual disability (Downs)) Interventions: 26% aerobic, 25% strength, 23%

combo Outcomes: 62.5% functional, 42% musculoskel.,

27% cardioresp., 26% mental Findings: Overall broad in scope, limited quality &

generalizability

What is the Evidence? Rimmer 2010

Sport & games in ↓ symptoms of PTSD (Lawrence 2010)

Policy interventions through sport orgs to promote healthy behavioral changes (Priest 2008)

Policy interventions through sport orgs for increasing participation in sport (Priest 2008)

Findings: 0 studies met inclusion criteria, largely anecdotal

What is the Evidence? Cochrane reviews

Evidence represents a narrow range of disabilities, interventions & relevant outcomes in studies of variable quality.

Benefits of regular physical activity confirmed in general pop but less clear in disabled pop

The effects of sport as a health intervention in the disabled have not been quantified in a meaningful way

Conclusions

Underpowered

Many disabilities under-represented

Randomization infrequent or impractical

Lack of valid disability outcome measurement tools

◦ impairment vs. disability

◦ relevance

Results not stratified by age, health status, functional level, cause of disability, setting & exposure

Poor reporting, no replication

Limitations

Lacks clear & consistent definition of sport

Lacks clear & consistent theoretical framework for eval disabled

◦ WHO International Classification of Impairments, Disabilities and Handicaps (ICIDH) 1980

◦ WHO International Classification of Functioning, Disability and Health (ICF) 2001

What and why?

Limitations

Public Health is paying attention to sport

Population is aging

Lifestyle and “Real world” outcomes are valued

Policy makers want actionable findings

◦ Consider consequences of doing something + not doing something

Personalized vs. one-size-fits-all◦ Shifting from reactive to proactive

Current Public Health Policy Trends

It’s difficult to prove cause and effect without good evidence

◦ Integrative methodologies

Centralized data coordination

Define sport as a health intervention

Identify & use common theoretical framework

Policy and Research Recommendations

Prioritize disability groups

Innovative recruitment strategies targeted toward non-volunteers

Factors affecting participation in sport

Effects of assistive technologies

Policy and Research Recommendations