Original quantitative research – Physical activity among children and youth in Canada living with disabilities

Abstract

Introduction: Limited evidence exists on physical activity (PA) participation among children and youth living with disabilities (CYLWD) in Canada. CYLWD may experience barriers and inequitable access to PA opportunities that differ by disability type. This study provides national-level estimates for PA participation among CYLWD.

Methods: Using data from the 2019 Canadian Health Survey on Children and Youth (CHSCY), we identified children and youth with various physical, cognitive, and behavioural disabilities using the Washington Group/UNICEF Child Functioning Module. We examined a comprehensive set of PA measures (average minutes of moderate-to-vigorous PA per day; meeting moderate-to-vigorous PA recommendations; organized sport; outdoor PA/play; indoor PA; walking to school) for children aged 5 to 11 years (N = 16 694) and youth aged 12 to 17 years (N = 11 077). We employed linear and logistic regression adjusted for age group and sex to assess disparities in PA between CYLWD and those without.

Results: CYLWD were 26% to 52% less likely to meet PA recommendations and 27% to 64% less likely to participate in organized sport than those without, with the greatest disparities among those with mobility limitations. Outdoor PA/play was less likely among those with physical disabilities and diagnosed with autism, while indoor non-organized PA was less likely among youth with cognitive, behavioural, or mobility-related disabilities, or a neurodevelopmental disorder.

Conclusion: While overall, CYLWD in Canada engage in less PA than those without disability, participation differs by disability type. Improved PA data that are specific to the realities of CYLWD is needed to strengthen the evidence base and inform policy and program development to promote PA.

Keywords: disabled persons, exercise, child, adolescent, Canada, mobility limitation

Introduction

Regular physical activity (PA) has crucial benefits for the growth and development of children and youth, as well as mental and psychosocial health.^{Footnote 1Footnote 2} Physical inactivity is a key modifiable risk factor for chronic disease,^{Footnote 3Footnote 4} and large-scale studies show that PA during childhood tracks into adulthood.^{Footnote 5Footnote 6} As such, the equitable promotion of PA among all children and youth is an important goal for population health.

The Canadian 24-Hour Movement Guidelines for Children and Youth (5 to 17 years) recommend at least 60 minutes of moderate-to-vigorous PA (MVPA) per day, with at least three days per week of vigorous PA and muscle and bone strengthening activities, and several hours of structured and unstructured light PA per day.^{Footnote 7} These recommendations are based on studies that excluded individuals with diagnosed medical conditions,^{Footnote 8} and preliminary research suggests the recommendations are not perceived to be inclusive or compatible with the experiences of this population.^{Footnote 9} Although the evidence on the health benefits of at least 60 minutes/day of MVPA for children and youth living with disabilities (CYLWD) is not conclusive;^{Footnote 10} some amount of MVPA is still beneficial,^{Footnote 11} and in the absence of disability-specific evidence, this benchmark is believed to be useful to identify disparities in PA.

CYLWD experience barriers and inequitable access to PA opportunities that limit their PA levels.^{Footnote 12Footnote 13Footnote 14Footnote 15} Organized PA and sport are not always adapted to those with disabilities. Large-scale surveys in Europe and the U.S. have suggested that CYLWD are less likely to meet PA recommendations and participate in sports compared to those without disabilities.^{Footnote 16Footnote 17Footnote 18Footnote 19} Surveys have also suggested that CYLWD have less access to physical education classes at school globally.^{Footnote 11} Few studies have examined population-level disparities in PA among children and youth in Canada, and none in recent years. The 2001–2002 Health Behaviour in School-Age Children study found that children and youth achieved at least 60 minutes of MVPA on a similar number of days per week regardless of disability status.^{Footnote 20} The 2006–2007 Canadian National Longitudinal Survey of Children and Youth found that children with selected neurodevelopmental disorders (i.e. epilepsy, cerebral palsy and intellectual and learning disabilities) were less likely to participate in organized sports, but as likely to engage in non-organized PA.^{Footnote 21}

CYLWD may have different experiences and barriers with PA depending on disability type. National-level evidence on PA for CYLWD is needed to develop targeted strategies to promote PA for these subpopulations. The objective of this study is to examine PA participation among CYLWD in Canada, and to assess disparities compared to those without disabilities. Based on previous studies,^{Footnote 16Footnote 17Footnote 18Footnote 19} we hypothesize that CYLWD report lower levels of PA than their counterparts.

Methods

Data source

We analyzed data from the 2019 Canadian Health Survey on Children and Youth (CHSCY), a national cross-sectional survey administered by Statistics Canada. The CHSCY collects health-related information among children and youth aged 1 to 17 years. Its sampling frame consists of beneficiaries of the Canada Child Benefit (CCB) and excludes those living on First Nation reserves and other Aboriginal settlements, or in foster homes and institutions. The CCB covers 98% of the Canadian population aged 1 to 17 in all provinces and 96% in all territories.

Data were collected by electronic questionnaire or telephone interview between February 2019 to August 2019. Questionnaires for children ages 1 to 11 were administered to the person-most-knowledgeable (PMK; most often a parent), whereas questionnaires for youth ages 12 to 17 were administered to the PMK or youth depending on the module. This study focusses on children aged 5 to 11 years and youth aged 12 to 17 years. The CHSCY is conducted under the authority of the Statistics Act, and the use of these data for research purposes does not require research ethics board review.

Response rates for the 2019 CHSCY were 57.8% among children and 41.3% among youth.^{Footnote 22} In total, the PMK of 16 694 children and 11 077 youth agreed to share their responses with the Public Health Agency of Canada (82.4% shared rate). These Share data files, which include survey weights adjusted specifically for the Share file, contain responses from all participants who consented to have their data shared with CHSCY’s designated partners. Data were accessed through the Public Health Agency of Canada secure network that ensures data are protected in accordance with data privacy and data security requirements.

We employed pairwise deletion, where respondents with missing data for a specific disability or PA measure were only excluded from analyses involving those specific measures. The number of respondents with missing data ranged from 6 to 416 for disability measures, and from 156 to 1953 for PA measures. Data on indoor PA (youth-only) had 23 missing responses.

Disability measures

Washington Group/UNICEF Child Functioning Module

The Washington Group/UNICEF Child Functioning Module (WG/UNICEF-CFM) is a validated, PMK-reported module that assesses difficulties in functional domains as measures of disability.^{Footnote 23Footnote 24Footnote 25} For ages 5 to 17 years, these domains include vision, hearing, walking, communication/comprehension, behaviour, learning, self-care, remembering, concentrating, and coping with change, relationships, and emotions.^{Footnote 23} Following a Likert response scale, the module allows for identification of those with mild, moderate, or severe levels of disability,^{Footnote 24Footnote 25} and those requiring assistive devices.^{Footnote 26}

PMKs reported whether their child had “no difficulty,” “some difficulty,” “a lot of difficulty,” or “cannot do at all” for tasks within each domain. To increase statistical power and the ability to detect PA disparities among CYLWD, domains were grouped as: (1) physical disabilities; (2) cognitive disabilities; or (3) behavioural disabilities.^{Footnote 25} Emotional functional difficulties (i.e. anxiety and depression) were outside the study scope. Some individuals reported difficulties across multiple domains and are represented across more than one functional limitation or disability group.

Physical disabilities

Walking, seeing, hearing, and self-care were considered physical domains. Those with “some difficulty,” “a lot of difficulty,” or “cannot do at all” were identified as having a functional difficulty, as any physical limitation may greatly impact PA. Given the differences in experiences across these domains, they were assessed separately and under an overall measure of “any physical disabilities.”

Cognitive or behavioural disabilities

The validity of the WG/UNICEF-CFM to capture cognitive and behavioural functional difficulties at the population level in Canada was recently assessed.^{Footnote 25} Communication/comprehension, learning, remembering, and concentrating were considered cognitive domains, while coping with change, controlling behaviour, and making friends were considered behavioural. Those with “a lot of difficulty” or “cannot do at all” were identified as having a functional difficulty within each domain. Those with “some difficulty” were not considered as having a functional difficulty given the large percentage of participants in this category (~50% of children). Given the overlap between the different cognitive and behavioural functional domains, these were assessed under two overall measures of “any cognitive disabilities” and “any behavioural disabilities.”

Use of assistive devices and assistance

PMKs reported whether their child used a walking aid or received assistance for walking. Although PMKs also reported on the use of glasses or contact lenses and hearing aids, these were outside the study scope.

Neurodevelopmental disorders

PMKs were asked whether their child had been diagnosed with a learning disability or disorder, attention-deficit/hyperactivity disorder (ADD/ADHD), autism (also known as autism spectrum disorder), and fetal alcohol spectrum disorder (FASD). These reported diagnoses were assessed separately and grouped together.

Physical activity measures

Moderate-to-vigorous physical activity (MVPA)

Average minutes of MVPA per day

Youth self-reported, and PMKs reported for their child, the total time they participated in any PA that made them sweat at least a little or breathe harder in each day over the past 7 days, excluding during school for children. Total minutes of MVPA were divided by 7 to obtain the average minutes of MVPA per day.

Meeting PA recommendations

Individuals were identified as “meeting PA recommendations” if they averaged at least 60 minutes of MVPA per day.

Organized sport participation

Youth self-reported and PMKs reported for their child, the time spent participating in sports or PA with a coach or instructor in the past 7 days, excluding during school for children. Individuals were identified as “participating in organized sports” if they spent any amount of time participating in organized sports or PA in the past 7 days.

Outdoor non-organized physical activity/play

PMKs reported the time their child spent playing outside in the past 7 days in their free time, while youth self-reported the time they spent participating in outdoor physical activities in their free time, excluding organized activities. Response options were “less than 1 hour,” “1 hour to less than 3 hours,” “3 hours to less than 7 hours,” “7 hours to less than 14 hours,” and “14 hours or more.” Individuals were identified as “participating in outdoor non-organized PA” if they spent at least 3 hours participating in outdoor play/PA in the past 7 days. This threshold is in line with published indicators of outdoor active play.^{Footnote 27Footnote 28}

Indoor non-organized physical activity

Youth self-reported the time they spent participating in indoor physical activities in their free time (e.g. playing at an indoor play centre, working out at home or in a gym) in the past 7 days. Data were not collected for children aged 5 to 11 years. Youth were identified as “participating in indoor non-organized PA” if they spent any amount of time in indoor PA in the past 7 days.

Walking to school

Youth self-reported and PMKs reported whether their child walked to get to school in the past 7 days. Children and youth who did any walking to school were identified as “walking to school.” Although the 2019 CHSCY collected information on the use of cycling and other active ways to get to school, they were not examined due to the low frequency among CYLWD.

Statistical analyses

We calculated descriptive statistics for disability and PA measures overall and stratified by age group (children 5–11 years/youth 12–17 years). We conducted logistic regressions with each binary PA measure as the outcome and each disability type as the exposure, adjusting for age group and sex, to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for the likelihood of meeting each PA measure, comparing those with and without each disability type. We similarly conducted linear regressions for the outcome of average minutes of MVPA per day to estimate adjusted mean differences, comparing those with and without each disability type. We identified significant differences where the 95% CI for an aOR or mean difference excluded the null values of 1.0 and 0 respectively. We conducted subgroup analyses by disability severity by estimating separate aORs for those with “some difficulty” and “a lot of difficulty or cannot do at all” with “no difficulty” as the reference group. All estimates were calculated using survey weights specific to the CHSCY 2019 Share files supplied by Statistics Canada to account for sampling and non-response and generate population-level estimates. Bootstrap weights supplied by Statistics Canada were applied to calculate 95% CIs accounting for the survey sampling method. Analyses were conducted in SAS Enterprise Guide version 7.1 (SAS Institute Inc., Cary, NC, US).

Results

Table 1 presents the prevalence of disabilities among children and youth in Canada. Physical disabilities were prevalent in 15.8% of children and youth. The most prevalent were difficulties seeing (6.5%) and walking (6.4%), followed by self-care (3.7%) and hearing (2.2%). Difficulties seeing were more prevalent among youth than children, while difficulties walking and with self-care were more prevalent among children. Cognitive disabilities were reported in 4.6% of children and youth, while behavioural disabilities were reported in 7.8% of this population. Cognitive and behavioural disabilities were more prevalent among children than youth. Overall, 14.3% of children and youth were diagnosed with a neurodevelopmental disorder, with a higher prevalence among males and youth. The most prevalent neurodevelopmental disorders were learning disabilities (8.5%) and ADD/ADHD (8.7%).

Descriptive statistics for each PA measure overall and by disability type are presented in Table 2. Descriptive statistics disaggregated by age and sex are available in Supplementary Tables S1 to S6. Within the total population, 31.6% met PA recommendations, averaging 46.8 minutes of MVPA per day. Around half of children and youth in Canada participated in organized sports and PA (54.5%) and achieved at least 3 hours of outdoor PA/play (50.2%) in the past week, while 28.6% used any walking to get to school. Among youth, 53.0% participated in any indoor non-organized PA.

Across all disability types (except hearing), prevalences for meeting PA recommendations were lower than the overall population, with the lowest prevalences among those who used a walking aid or assistance (17.6%) or had difficulty walking (19.4%). Average minutes of MVPA were lowest among those using a walking aid or assistance (28.7 minutes/day) or with difficulty walking (32.2 minutes/day), as well as those with autism (32.8 minutes/day). Sport participation prevalences were lower than the overall population for all disability types, and particularly low among those using a walking aid or assistance (31.2%), and for individuals diagnosed with FASD (30.1%) or autism (32.2%). Outdoor PA prevalences were lowest among individuals with difficulty seeing (37.5%). Indoor PA prevalences were lowest among youth diagnosed with autism (30.9%), who had difficulties with self-care (35.3%), and with cognitive disabilities (35.9%). Prevalences for walking to school were lowest among individuals who had difficulties with self-care (22.8%).

After adjustment for age and sex, the likelihood of meeting PA recommendations was lower among all disability types, except hearing, compared to those without disabilities (Figure 1). Individuals with mobility, seeing, self-care limitations or using walking aids or assistance were 26% to 57% less likely to meet PA recommendations, while individuals with cognitive disabilities, behavioural disabilities and any of the four neurodevelopmental disorders were 24% to 49% less likely to meet PA recommendations. Average minutes of MVPA per day were lower by 5 to 20 minutes/day among all disability types except hearing after adjustment for age and sex compared to those without disabilities (Figure 2). The largest differences were for those using a walking aid or assistance (19.5 fewer minutes/day), diagnosed with autism (17.6 fewer minutes/day), and experiencing difficulties walking (16.3 fewer minutes/day) or with self-care (13.5 fewer minutes/day).

Figure 1 - Text description

Odds ratios for the likelihood of meeting different physical activity measures comparing Canadian children and youth living with and without different types of disability

Disability	Physical activity measure	Odds ratio	Lower 95% CI	Upper 95% CI	Result	Significant
Any physical disability	Meeting PA recommendations	0.66	0.59	0.74	0.66 (0.59, 0.74)	Yes
Difficulty walking	Meeting PA recommendations	0.5	0.42	0.59	0.48 (0.41, 0.57)	Yes
Difficulty seeing	Meeting PA recommendations	0.76	0.64	0.9	0.74 (0.62, 0.88)	Yes
Difficulty hearing	Meeting PA recommendations	1	0.79	1.26	1.10 (0.83, 1.34)	No
Difficulty with self-care	Meeting PA recommendations	0.63	0.51	0.79	0.58 (0.47, 0.73)	Yes
Use of walking aid or assistance	Meeting PA recommendations	0.45	0.23	0.88	0.43 (0.22, 0.87)	Yes
Any cognitive disability	Meeting PA recommendations	0.8	0.66	0.96	0.73 (0.60, 0.89)	Yes
Any behavioural disability	Meeting PA recommendations	0.79	0.68	0.91	0.75 (0.64, 0.87)	Yes
Any of the four neurodevelopmental disorders	Meeting PA recommendations	0.76	0.67	0.86	0.72 (0.63, 0.81)	Yes
Learning disability	Meeting PA recommendations	0.77	0.66	0.89	0.71 (0.61, 0.83)	Yes
ADD/ADHD	Meeting PA recommendations	0.8	0.69	0.93	0.76 (0.65, 0.89)	Yes
Autism	Meeting PA recommendations	0.57	0.43	0.76	0.51 (0.38, 0.68)	Yes
Fetal alcohol spectrum disorder	Meeting PA recommendations	0.53	0.19	1.5	0.51 (0.17, 1.50)	No
Any physical disability	Sport participation	0.61	0.56	0.67	0.61 (0.56, 0.67)	Yes
Difficulty walking	Sport participation	0.54	0.47	0.62	0.54 (0.47, 0.62)	Yes
Difficulty seeing	Sport participation	0.73	0.64	0.84	0.73 (0.64, 0.84)	Yes
Difficulty hearing	Sport participation	0.71	0.57	0.87	0.71 (0.57, 0.87)	Yes
Difficulty with self-care	Sport participation	0.48	0.4	0.58	0.48 (0.40, 0.58)	Yes
Use of walking aid or assistance	Sport participation	0.36	0.2	0.63	0.36 (0.20, 0.63)	Yes
Any cognitive disability	Sport participation	0.45	0.38	0.53	0.45 (0.38, 0.53)	Yes
Any behavioural disability	Sport participation	0.5	0.44	0.57	0.50 (0.44, 0.57)	Yes
Any of the four neurodevelopmental disorders	Sport participation	0.57	0.51	0.63	0.57 (0.51, 0.63)	Yes
Learning disability	Sport participation	0.59	0.52	0.67	0.59 (0.52, 0.67)	Yes
ADD/ADHD	Sport participation	0.57	0.5	0.65	0.57 (0.50, 0.65)	Yes
Autism	Sport participation	0.36	0.29	0.46	0.36 (0.29, 0.46)	Yes
Fetal alcohol spectrum disorder	Sport participation	0.37	0.15	0.92	0.37 (0.15, 0.92)	Yes
Any physical disability	Outdoor PA	0.69	0.63	0.76	0.69 (0.63, 0.76)	Yes
Difficulty walking	Outdoor PA	0.54	0.47	0.63	0.54 (0.47, 0.63)	Yes
Difficulty seeing	Outdoor PA	0.72	0.62	0.84	0.72 (0.62, 0.84)	Yes
Difficulty hearing	Outdoor PA	1.02	0.82	1.27	1.02 (0.82, 1.27)	No
Difficulty with self-care	Outdoor PA	0.72	0.6	0.87	0.72 (0.60, 0.87)	Yes
Use of walking aid or assistance	Outdoor PA	0.84	0.47	1.51	0.84 (0.47, 1.51)	No
Any cognitive disability	Outdoor PA	1.09	0.92	1.29	1.09 (0.92, 1.29)	No
Any behavioural disability	Outdoor PA	0.91	0.8	1.04	0.91 (0.80, 1.04)	No
Any of the four neurodevelopmental disorders	Outdoor PA	1	0.9	1.11	1.00 (0.90, 1.11)	No
Learning disability	Outdoor PA	1.1	0.97	1.26	1.10 (0.97, 1.26)	No
ADD/ADHD	Outdoor PA	1.08	0.94	1.24	1.08 (0.94, 1.24)	No
Autism	Outdoor PA	0.61	0.49	0.77	0.61 (0.49, 0.77)	Yes
Fetal alcohol spectrum disorder	Outdoor PA	1.88	0.89	4.01	1.88 (0.89, 4.01)	No
Any physical disability	Indoor PA	0.8	0.69	0.92	0.80 (0.69, 0.92)	Yes
Difficulty walking	Indoor PA	0.66	0.52	0.83	0.66 (0.52, 0.83)	Yes
Difficulty seeing	Indoor PA	0.92	0.77	1.11	0.92 (0.77, 1.11)	No
Difficulty hearing	Indoor PA	0.92	0.69	1.24	0.92 (0.69, 1.24)	No
Difficulty with self-care	Indoor PA	0.46	0.31	0.69	0.46 (0.31, 0.69)	Yes
Use of walking aid or assistance	Indoor PA	0.82	0.36	1.87	0.82 (0.36, 1.87)	No
Any cognitive disability	Indoor PA	0.47	0.36	0.62	0.47 (0.36, 0.62)	Yes
Any behavioural disability	Indoor PA	0.63	0.51	0.78	0.63 (0.51, 0.78)	Yes
Any of the four neurodevelopmental disorders	Indoor PA	0.58	0.5	0.67	0.58 (0.50, 0.67)	Yes
Learning disability	Indoor PA	0.57	0.48	0.67	0.57 (0.48, 0.67)	Yes
ADD/ADHD	Indoor PA	0.61	0.51	0.73	0.61 (0.51, 0.73)	Yes
Autism	Indoor PA	0.36	0.25	0.53	0.36 (0.25, 0.53)	Yes
Fetal alcohol spectrum disorder	Indoor PA	0.43	0.14	1.27	0.43 (0.14, 1.27)	No
Any physical disability	Walking to school	0.98	0.88	1.09	0.98 (0.88, 1.09)	No
Difficulty walking	Walking to school	1.1	0.95	1.28	1.10 (0.95, 1.28)	No
Difficulty seeing	Walking to school	1.02	0.87	1.19	1.02 (0.87, 1.19)	No
Difficulty hearing	Walking to school	0.99	0.78	1.26	0.99 (0.78, 1.26)	No
Difficulty with self-care	Walking to school	0.71	0.57	0.88	0.71 (0.57, 0.88)	Yes
Use of walking aid or assistance	Walking to school	0.84	0.48	1.46	0.84 (0.48, 1.46)	No
Any cognitive disability	Walking to school	0.93	0.78	1.11	0.93 (0.78, 1.11)	No
Any behavioural disability	Walking to school	0.94	0.82	1.08	0.94 (0.82, 1.08)	No
Any of the four neurodevelopmental disorders	Walking to school	0.93	0.83	1.03	0.93 (0.83, 1.03)	No
Learning disability	Walking to school	0.87	0.76	1	0.87 (0.76, 1.00)	No
ADD/ADHD	Walking to school	0.97	0.84	1.12	0.97 (0.84, 1.12)	No
Autism	Walking to school	0.85	0.64	1.11	0.85 (0.64, 1.11)	No
Fetal alcohol spectrum disorder	Walking to school	2.01	0.87	4.62	2.01 (0.87, 4.62)	No

Abbreviations: ADD/ADHD, attention-deficit/hyperactivity disorder; CI, confidence interval; PA, physical activity.
Notes: For each analysis, participants without the disability type of interest were used as the reference group. Odds ratios are adjusted for age group (children/youth) and sex. Indoor PA analyses are limited to youth due to data availability for children.

Figure 2 - Text description

Mean differences in minutes of moderate-to-vigorous physical activity per day comparing Canadian children and youth living with and without different types of disability

Disability	Mean difference	Lower 95% CI	Upper 95% CI	Result
Any physical disability	-9	-11.3	-6.8	−9.0 (−11.3, −6.8)
Difficulty walking	-16.3	-19.1	-13.4	−16.3 (−19.1, −13.4)
Difficulty seeing	-5	-8.4	-1.6	−5.0 (−8.4, −1.6)
Difficulty hearing	0.8	-4.7	6.2	0.8 (−4.7, 6.2)
Difficulty with self-care	-13.5	-18.3	-8.7	−13.5 (−18.3, −8.7)
Use of walking aid or assistance	-19.5	-27.6	-11.3	−19.5 (−27.6, −11.3)
Any cognitive disability	-8.9	-13	-4.8	−8.9 (−13.0, −4.8)
Any behavioural disability	-8.4	-11.3	-5.5	−8.4 (−11.3, −5.5)
Any of the four neurodevelopmental disorders	-7.7	-10.2	-5.1	−7.7 (−10.2, −5.1)
Learning disability	-6.9	-10.2	-3.7	−6.9 (−10.2, −3.7)
ADD/ADHD	-5.8	-9.2	-2.3	−5.8 (−9.2, −2.3)
Autism	-17.6	-23.1	-12.2	−17.6 (−23.1, −12.2)
Fetal alcohol spectrum disorder	-4.6	-18.8	9.6	−4.6 (−18.8, 9.6)

Abbreviations: ADD/ADHD, attention-deficit/hyperactivity disorder; MVPA, moderate-to-vigorous physical activity.
Notes: For each analysis, participants without the disability type of interest were used as the reference group. Mean differences are adjusted for age group (children/youth) and sex.

Children and youth with physical disabilities or using walking aids or assistance were 27% to 64% less likely to participate in organized sports, while those with cognitive or behavioural disabilities and any of the four neurodevelopmental disorders were 41% to 63% less likely to participate in organized sports compared to those without these disabilities (Figure 1). Whereas individuals with physical disabilities or using walking aids or assistance, except for hearing, were 16% to 46% less likely to participate in outdoor PA. Individuals with cognitive as well as behavioural disabilities were as likely to participate in outdoor PA as those without, except for children and youth with autism (39% less likely). Indoor PA was only assessed for youth. Youth with difficulties walking or with self-care were 34% to 54% less likely to participate in indoor PA, while youth with other physical disabilities were as likely to participate in indoor PA as those without. Youth with cognitive or behavioural disabilities, as well as any of the four neurodevelopmental disorders were 37% to 64% less likely to participate in indoor PA. Individuals with self-care difficulties were 29% less likely to use walking to get to school, with no significant disparities for other disability types.

Although subgroup analyses were not sufficiently powered to detect differences by functional difficulty severity, there appeared to be gradient effects where children and youth with severe difficulties (“a lot of difficulty or cannot do at all”) were less likely to engage in PA across all measures than those with “some difficulty” (Figure 3). This was most evident for sport participation, where the likelihood of participating in organized sports was significantly lower among individuals with severe walking, self-care, cognitive, and behavioural functional difficulties. The likelihood of indoor PA participation among youth with severe cognitive functional difficulties was also significantly lower than youth with less severe cognitive functional difficulties.

Figure 3 - Text description

Odds ratios for the likelihood of meeting physical activity measures comparing children and youth in Canada with versus without different types of functional difficulty by severity

Severity	Disability	Physical activity measure	Odds ratio	Lower 95% CI	Upper 95% CI	Result
Some difficulty	Walking	Meeting PA recommendations	0.51	0.42	0.61	0.51 (0.42, 0.61)
A lot of difficulty/cannot do at all	Walking	Meeting PA recommendations	0.33	0.21	0.53	0.33 (0.21, 0.53)
Some difficulty	Seeing	Meeting PA recommendations	0.75	0.63	0.9	0.75 (0.63, 0.90)
A lot of difficulty/cannot do at all	Seeing	Meeting PA recommendations	0.64	0.34	1.2	0.64 (0.34, 1.20)
Some difficulty	Hearing	Meeting PA recommendations	0.98	0.76	1.27	0.98 (0.76, 1.27)
A lot of difficulty/cannot do at all	Hearing	Meeting PA recommendations	2.27	0.97	5.32	2.27 (0.97, 5.32)Footnote a
Some difficulty	Self-care	Meeting PA recommendations	0.61	0.47	0.78	0.61 (0.47, 0.78)
A lot of difficulty/cannot do at all	Self-care	Meeting PA recommendations	0.47	0.27	0.84	0.47 (0.27, 0.84)
Some difficulty	Cognitive	Meeting PA recommendations	0.72	0.66	0.8	0.72 (0.66, 0.80)
A lot of difficulty/cannot do at all	Cognitive	Meeting PA recommendations	0.61	0.49	0.77	0.61 (0.49, 0.77)
Some difficulty	Behavioural	Meeting PA recommendations	0.84	0.77	0.92	0.84 (0.77, 0.92)
A lot of difficulty/cannot do at all	Behavioural	Meeting PA recommendations	0.7	0.6	0.81	0.70 (0.60, 0.81)
Some difficulty	Walking	Sport participation	0.6	0.52	0.71	0.60 (0.52, 0.71)
A lot of difficulty/cannot do at all	Walking	Sport participation	0.26	0.18	0.39	0.26 (0.18, 0.39)
Some difficulty	Seeing	Sport participation	0.76	0.66	0.88	0.76 (0.66, 0.88)
A lot of difficulty/cannot do at all	Seeing	Sport participation	0.5	0.31	0.8	0.50 (0.31, 0.80)
Some difficulty	Hearing	Sport participation	0.73	0.59	0.91	0.73 (0.59, 0.91)
A lot of difficulty/cannot do at all	Hearing	Sport participation	0.43	0.2	0.93	0.43 (0.20, 0.93)
Some difficulty	Self-care	Sport participation	0.55	0.45	0.67	0.55 (0.45, 0.67)
A lot of difficulty/cannot do at all	Self-care	Sport participation	0.24	0.15	0.37	0.24 (0.15, 0.37)
Some difficulty	Cognitive	Sport participation	0.69	0.63	0.75	0.69 (0.63, 0.75)
A lot of difficulty/cannot do at all	Cognitive	Sport participation	0.39	0.32	0.48	0.39 (0.32, 0.48)
Some difficulty	Behavioural	Sport participation	0.81	0.75	0.87	0.81 (0.75, 0.87)
A lot of difficulty/cannot do at all	Behavioural	Sport participation	0.46	0.4	0.53	0.46 (0.40, 0.53)
Some difficulty	Walking	Outdoor PA	0.54	0.47	0.63	0.54 (0.47, 0.63)
A lot of difficulty/cannot do at all	Walking	Outdoor PA	0.54	0.38	0.77	0.54 (0.38, 0.77)
Some difficulty	Seeing	Outdoor PA	0.75	0.64	0.89	0.75 (0.64, 0.89)
A lot of difficulty/cannot do at all	Seeing	Outdoor PA	0.46	0.27	0.78	0.46 (0.27, 0.78)
Some difficulty	Hearing	Outdoor PA	0.98	0.78	1.24	0.98 (0.78, 1.24)
A lot of difficulty/cannot do at all	Hearing	Outdoor PA	1.71	0.8	3.64	1.71 (0.80, 3.64)a
Some difficulty	Self-care	Outdoor PA	0.78	0.64	0.96	0.78 (0.64, 0.96)
A lot of difficulty/cannot do at all	Self-care	Outdoor PA	0.49	0.32	0.76	0.49 (0.32, 0.76)
Some difficulty	Cognitive	Outdoor PA	0.9	0.82	0.98	0.90 (0.82, 0.98)
A lot of difficulty/cannot do at all	Cognitive	Outdoor PA	1.01	0.83	1.23	1.01 (0.83, 1.23)
Some difficulty	Behavioural	Outdoor PA	0.93	0.86	0.99	0.93 (0.86, 0.99)
A lot of difficulty/cannot do at all	Behavioural	Outdoor PA	0.89	0.78	1.01	0.89 (0.78, 1.01)
Some difficulty	Walking	Indoor PA	0.63	0.5	0.79	0.63 (0.50, 0.79)
A lot of difficulty/cannot do at all	Walking	Indoor PA	0.91	0.47	1.78	0.91 (0.47, 1.78)
Some difficulty	Seeing	Indoor PA	0.98	0.8	1.19	0.98 (0.81, 1.19)
A lot of difficulty/cannot do at all	Seeing	Indoor PA	0.49	0.24	0.95	0.49 (0.24, 0.95)
Some difficulty	Hearing	Indoor PA	0.94	0.69	1.28	0.94 (0.69, 1.28)
A lot of difficulty/cannot do at all	Hearing	Indoor PA	0.68	0.12	3.93	0.68 (0.12, 3.93)
Some difficulty	Self-care	Indoor PA	0.44	0.29	0.67	0.44 (0.29, 0.67)
A lot of difficulty/cannot do at all	Self-care	Indoor PA	0.72	0.24	2.15	0.72 (0.24, 2.15)
Some difficulty	Cognitive	Indoor PA	0.74	0.65	0.84	0.74 (0.65, 0.84)
A lot of difficulty/cannot do at all	Cognitive	Indoor PA	0.44	0.32	0.6	0.44 (0.32, 0.60)
Some difficulty	Behavioural	Indoor PA	0.75	0.67	0.84	0.75 (0.67, 0.84)
A lot of difficulty/cannot do at all	Behavioural	Indoor PA	0.57	0.46	0.71	0.57 (0.46, 0.71)
Some difficulty	Walking	Walking to school	1.18	1.01	1.39	1.18 (1.01, 1.39)
A lot of difficulty/cannot do at all	Walking	Walking to school	0.67	0.42	1.05	0.67 (0.42, 1.05)
Some difficulty	Seeing	Walking to school	1.05	0.9	1.24	1.05 (0.90, 1.24)
A lot of difficulty/cannot do at all	Seeing	Walking to school	0.7	0.4	1.25	0.70 (0.40, 1.25)
Some difficulty	Hearing	Walking to school	0.93	0.72	1.2	0.93 (0.72, 1.20)
A lot of difficulty/cannot do at all	Hearing	Walking to school	1.91	0.86	4.22	1.91 (0.86, 4.22)a
Some difficulty	Self-care	Walking to school	0.76	0.6	0.97	0.76 (0.60, 0.97)
A lot of difficulty/cannot do at all	Self-care	Walking to school	0.46	0.25	0.86	0.46 (0.25, 0.86)
Some difficulty	Cognitive	Walking to school	1.08	0.98	1.19	1.08 (0.98, 1.19)
A lot of difficulty/cannot do at all	Cognitive	Walking to school	0.88	0.72	1.09	0.88 (0.72, 1.09)
Some difficulty	Behavioural	Walking to school	1.07	0.99	1.16	1.07 (0.99, 1.16)
A lot of difficulty/cannot do at all	Behavioural	Walking to school	0.96	0.83	1.11	0.96 (0.83, 1.11)

Abbreviations: CI, confidence interval; PA, physical activity.
Notes: For each analysis, participants without the disability type of interest were used as the reference group. Odds ratios are adjusted for age group (children/youth) and sex. Indoor PA analyses are limited to youth due to data availability for children.
^a Data point out of range.

Discussion

CYLWD in Canada achieved less MVPA and were less likely to meet PA recommendations than those without. CYLWD were also markedly less likely to participate in organized sports. Children and youth with physical disabilities were less likely to participate in outdoor non-organized PA, while youth with cognitive or behavioural disabilities as well as any of the four neurodevelopmental disorders were less likely to participate in indoor non-organized PA. Prevalences of walking to school were similar regardless of disability, with the exception of individuals with self-care difficulties. These findings underscore the importance for greater attention and support to increase PA participation among CYLWD living in Canada.

We found that CYLWD in Canada, with the exception of hearing difficulties, were 24% to 57% less likely to meet PA recommendations than those without disabilities. While particularly large disparities exist for those with mobility limitations as well as those diagnosed with autism, others such as those with ADD/ADHD and learning disabilities were less likely to meet PA recommendations. Our findings are in line with literature from other countries indicating lower levels of MVPA among CYLWD,^{Footnote 11Footnote 29Footnote 30Footnote 31} but contrast from previous Canadian studies conducted over a decade ago that found similar levels of MVPA for CYLWD.^{Footnote 20Footnote 21}

Similar to the U.S.,^{Footnote 17} there were clear disparities in organized sport participation for all disability types. Considerable research has been conducted regarding barriers and facilitators to sport participation and other modes of PA for CYLWD,^{Footnote 14Footnote 32Footnote 33Footnote 34} and federal and provincial policies exist to promote organized sports in these populations.^{Footnote 35} Despite these efforts, more work needs to be done to implement policies and programs to address these disparities within Canada, including ensuring that CYLWD are afforded with quality participation experiences in sport and non-organized PA.^{Footnote 36}

Children and youth with difficulties walking, seeing, and self-care were less likely to engage in outdoor non-organized PA/play, as well as those diagnosed with autism. Outdoor facilities such as playgrounds and parks have been recognized as having social and physical barriers that may limit opportunities for outdoor play or PA for CYLWD.^{Footnote 37Footnote 38Footnote 39Footnote 40} Youth participation in indoor non-organized PA was less likely across all cognitive and behavioural disabilities and any of the four neurodevelopmental disorders, as well as youth with difficulties walking and with self-care, and particularly for those with severe functional difficulties. Accessibility issues and social factors such as stigma and lack of peer support have been noted as barriers to gyms and fitness centres among adults with physical disabilities,^{Footnote 41Footnote 42} and similar barriers likely exist for youth. Similarly, feelings of shame regarding physical capabilities have been reported as barriers for going to the gym for youth with intellectual disabilities.^{Footnote 43} Altogether, these findings suggest that individuals with different disabilities experience different barriers and preferences regarding non-organized PA in outdoor versus indoor settings.

Walking to school was less likely among children and youth with self-care difficulties, and among those with severe difficulties walking and seeing (with uncertainty). Our data source did not include information on wheelchair use as a mode of active transportation. Nonetheless, walking and wheeling in a wheelchair has been described in the literature as an approach to increase PA among people living with disabilities.^{Footnote 44} There is limited evidence on the use of active transportation to school and its barriers and facilitators among CYLWD, and a systematic review pointed to diverse experiences of children living with different disabilities.^{Footnote 45} While walking to school may be a practical way through which CYLWD can obtain PA, there may be barriers to non-active modes of transportation to school (e.g. public transit) that result in increased active transportation.^{Footnote 46}

Strengths and limitations

This study is the first to our knowledge to examine PA levels among CYLWD in Canada and to identify disparities compared to those without disabilities using national-level data. We examined a comprehensive set of PA measures across an array of disability measures, encompassing physical, cognitive, behavioural disabilities and selected neurodevelopmental disorders. Our findings fill a gap in reporting on PA among CYLWD in Canada.

Nevertheless, this study has several limitations. PA measures were self-reported for youth and PMK-reported for children, which may be subject to recall bias and may not correlate well with objective measures.^{Footnote 47} The use of PMK-reported PA for children may have also resulted in an inaccurate representation of children’s PA levels, and our measures excluded PA during school time. The survey response rates were low, further affected by the share rates. While the survey sampling weights provided by Statistics Canada were used in our analyses to account for sampling as well as non-response and share rates, sample and non-response bias could still have affected the representativeness of the results.

Our sample size was insufficient to examine how PA participation varied by age, sex, or other sociodemographic characteristics. Similarly, we could not draw definitive conclusions about differences in PA by severity levels due to insufficient statistical power. We pooled the study sample for regression analyses rather than stratifying by age group to increase power. Children and youth may experience differences in PA patterns, social support, and PA opportunities and barriers across these groups, and the use of a pooled analysis limits our ability to assess differences between age groups.

We used dichotomized measures to assess sport participation, outdoor and indoor non-organized PA, and walking to school. There are no established thresholds for these measures, and examining them as continuous (i.e. amount of time spent in each type of PA) could provide further insight into PA disparities between CYLWD and without. Additionally, the data used in this study were collected prior to the COVID-19 pandemic. Given the potential impact of the pandemic on PA participation,^{Footnote 48} future research using newly available data is important to investigate whether disparities in PA have shifted.

In general, greater efforts to collect data on PA specific to CYLWD are needed to strengthen the evidence base and inform policy development.^{Footnote 11} Given the heterogeneity of the disabilities examined, further research is warranted to investigate in more depth the potential barriers to PA associated with each disability type.

Conclusion

CYLWD in Canada achieved less MVPA and were less likely to meet PA recommendations and participate in organized sports than those without disability. Participation in outdoor and indoor non-organized PA was also less likely for certain disability types. Efforts to improve and expand population-level data collected on PA among CYLWD would better inform the development of targeted policies and programs to promote PA within these subpopulations.

Conflicts of interest

The authors declare no conflicts of interest.

Authors’ contributions and statement

KCR, MTB and CW conceptualized the study. CW and MTB designed the study and analytical approach and conducted the statistical analyses. CW, MTB and KCR interpreted the results. CW and MTB drafted the initial manuscript. All authors (CW, MTB, KCR, KMG, KAN) contributed to reviewing and editing the manuscript.

The content and views expressed in the article are those of the authors and do not necessarily reflect those of the Government of Canada.

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