Determinants of physical activity and lifestyle of Czech 11 – 15 years old students with visual impairments

This pilot study of lifestyle of 11–15 years old students with visual impairment is the spin-off project from longitudinal HBSC study (The Health Behavior in School Aged Children) entitled disHBSC. The aim of the study was to analyze the determinants of physical activity and lifestyle of 11to 15-year-old students with visual impairment, who are actively engaged in sports. The pilot study is based on original HBSC survey, which was adapted to meet specific needs of children with visual impairments. DisHBSC survey contained 48 questions divided to the following areas: demographical information, nutritional habits, physical activity and leisure, health, abuse of drugs, self-esteem, violence, school, family and peers. We have found surprising results regarding the amount of weekly physical activity, where only 9% of students met WHO minimal suggestions for physical activity. More than 50% of students identified school-based physical education as the main area of physical activities. We found alarming examples in school-based bullying. 11.7% of boys and 21% of girls experienced bullying 2–3 times in the past months. The main motive for engagement in a physical activity was to improve health. The most preferred activity is swimming, adapted aquatics and ball games. Our respondents spend significant time in sedentary activities and screen time, less in from of TV but more with PC, tablets or smartphones.


Introduction
HBSC (The Health Behavior in School-aged Children) is a cross-national study focused on young people's well-being, health behaviors and their social context.This research is conducted every four years in 45 countries and regions.HBSC is done in collaboration with the World Health Organization (WHO) Regional Office for Europe.The assumption of this study is that the lifestyle of adults is significantly influenced by behavior in childhood and adolescence (Kalman et al., 2011).The Czech Republic is part of international HBSC study since 1994 with regular data collection in four-year cycles.Until recently, the data collection did not include specific needs of children with disabilities and impairments (Brindová, Kmeť, & Ješina, 2013).In HBSC network, there have been tendencies to focus on specific needs of children with long-term illnesses (Rintala et al., 2011).The only published results of HBSC study are with longitudinal data from Finland, where they included optional questions allowing them to identify children with long-term illnesses (Ng et al., 2016a;Ng et al., 2016b).However only children with mild impairments were able to respond to the mainstream national HBSC study and therefore the need to further investigate lifestyle of children with moderate and severe impairments (e.g.blindness or deafness) was identified with HBSC network.
Inclusion of persons with visual impairments in leisure time physical activities can be a very effective tool to prevent social exclusion (Janečka & Bláha, 2013).Riley, Rimmer, Wang and Schiller (2008) argue that participation in physical activities is an essential part of lifestyle of persons with disabilities, which can also increase the quality of life and social participation (Kudláček, 2008).Psychosocial aspect of physical activities is especially important in the sensitive time of child's development, which includes entry to elementary education and prepubescence (Janečka & Bláha, 2013).In working with children with visual impairments, we find significant impact of environmental and personal contextual factors (Bláha, 2011;Haegele, Zhu, Lee, & Lieberman, 2016;WHO, 2001).Janečka and Bláha (2013) highlight the following specific needs of children with VI: a) actual limits of visual loss; b) lack of experience with movement in strange environment; and c) learned movement stereotypes, which can hinder participation in a changing environment.EUJAPA, vol.9, no.2, 2016 In Czech education, we can find significant differences between children with VI educated in special school and children included in mainstream schools.While students attending special schools often take part in organized physical activity in school PE and school-based sport clubs, students attending general schools are frequently excluded from physical education and all sport-related extracurricular activities (Kudláček, 2008).Students with visual impairment can be very active, being good at sports as well as at school and we can find also successful examples of them doing sport studies at university level and serving as good examples to peers with and without disabilities (Reina & Alvaro-Ruiz, 2016).
Unfortunately, these important determinants of quality of life are not well documented in the literature.On the other hand, there is a possibility to influence the quality of life of persons with impairments by facilitating their involvement in physical activities, improvement of their physical literacy and health education (Ng et al., 2016a).International recommendation for physical activity of children and youth suggests 60 minutes of physical activity daily (Kalman, 2012).Unfortunately, these recommendations and most international renowned studies do not reflect specific needs of persons with visual impairments (Kalman, Hamřík, & Ješina, 2011).Therefore we need to pay extra attention to facilitate participation of persons with impairments in physical activity in general (Ng et al., 2016b), the improvement of quality of physical education (Block, 2007) as well as leisure time physical activities (Hutzler & Sherrill, 1999;Sherrill, 2004).
Understanding the real problems in lifestyle of children with VI can help us to make recommendations for strategic policies and transformation of educational, medical and social support systems.For this, we need valid and reliable evidence, which can help us to compare this population with non-disabled children.The purpose of this study was to analyze the determinants of physical activity and lifestyle of 11-to 15-year-old children with visual impairment.

Sample
The survey was conducted in the years 2013-2015, with 53 participants, 34 boys (average age 13.4 yrs.) and 19 girls (average age 12.8 yrs.).Students were attending both special schools for students with visual impairments as well as general school setting from Olomouc, Brno, Opava, Liberec, Praha and Plzeň.Students filled in the survey during their leisure time in special schools, at sport camps and during goalball competition, which took place in Olomouc in 2015.This purposive sampling implies potentially higher level of physical literacy and engagement in physical activity.Students filled in the survey in a paper format individually with the help of a trained independent assistant.Blind students used blind friendly version of the survey.

Survey and data analysis
The whole study is realized within HBSC international study framework.Modifications to HBSC survey were done in coordination with colleagues from the Faculty of Medicine Pavol Jozef Šafárik University in Košice and colleagues within international disHBSC subgroup (Slovakia, Czech, Finland, France and Spain).Survey entitled disHBSC is a modified version of international HBSC survey, which is suitable for adolescents with impairment.The present study uses compulsory as well as optional items from the HBSC package.Original HBSC study The international network is organized around an interlinked series of focus and topic groups related to the following areas: Presented disHBSC survey consists of 48 items and is thus considerably shorter from the original HBSC study.The primary need for modification was the reduction of time needed for survey completion due to limited attention span of children with certain impairment, simplification due to limited cognition and communication skills and adding some impairment specific items.

Results
The presented results focus on the topic of physical activity, screen time, eating habits, family, bullying and self-evaluation.Girls in our sample are more active than boys.Seven out of 19 girls are physically active for 60 minutes seven days per week (Table 1).
The most frequent amount of physical activity among boys is five days per week.
The most common place to do physical activities is school-based physical education (54.7%).The second most common place to engage in a physical activity is being active with friends outside of school (52.8%).Only five children (9.4%) did not attend physical education lessons due to medical reasons (Table 2).
The most common reason for doing physical activity was to improve health (66%).The second most important reason (64.2%) was meeting with friends.On the other hand, 57% of respondents mark the reason to win as not important.Sixty percent of respondents mark the meeting new friends as an important reason to do physical activity.High cumulative scores of positive evaluation (important plus very important) are following: a) To prove I can do it and b) Maintain the weight.The highest cumulative score is in the item to Get in shape.
In the preference of physical activity (Table 4), ball games is the most common response -12 respondents participate in them at least twice per week.15 respondents did swimming and adapted activities at least once per week.Relatively high scores for nonparticipation are in the following: gymnastics, aerobics, Zumba, (24 respondents), martial arts and self-defense (31 respondents), baseball, softball and cricket (28 respondents), dance (22 respondents) and climbing (25 respondents).
Screen time (  Eating breakfast is not a natural part of lifestyle in all children with visual impairments (Table 6).The situation is better at the weekend when 76.5% of boys and 78.9% of girls eat on both Saturday and Sunday.The situation is approximately 10% worse during the five working days.Four boys and 4 girls do not eat breakfast as all.
Approximately 68% of boys and girls did not experience bullying in the past few months.In the frequency of 1-2x, we find bullying among 14.7% of boys and 10.5% of girls.However, approximately 18% of boys an 20% of girls experienced some bullying and about 9% of boys and 10% of girls experience regular bullying.

Discussion
Although our sample represents relatively active adolescents with visual impairments, it provides an interesting view of different determinants of their lifestyle.In comparison with hypokinetic lifestyle of adolescents without disabilities, where screen time  & Liao (2016).
The most preferred physical activity is tourism, swimming with adapted activities and ball games which is similar to the findings of Czech high school students of Kudláček and Frömel (2012).

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Based on our findings, the most alarming seems to be the experience with bullying where most students with VI had some experience with bullying and about 9% of boys and 10% of girls experience regular bullying (at least once per week).We did not find any such alarming finding in any European HBSC studies and common experience with bullying in Czech studies is approximately 6% with the highest rates of bullying in Ukraine and Poland, with 17-18% of 11-year-old students (Madarasová, Dankulincová, Sigmundová, & Kalman, 2016).

Conclusions
The main purpose of the study was to explore selected determinants influencing participation in physical activity and healthy lifestyle of active students with visual impairments.As our sample represents sport active population, it is difficult to generalize these findings to the whole population of students with VI.Furthermore we can expect that lifestyle of non-active students would be even worse.Especially among boys in our sample, only 8.8% meet WHO recommendation of daily amount of physical activity.More than fifty percent of our respondents do activity only in an organized school setting (physical education and sports).This therefore implies that when students are included in general schools, but not included in general physical education, the amount of physical activity would be much lower.It is important to realize specific aspects of screen time in population with visual impairments, where computers, tablets or smartphones can serve as facilitators of social interaction.Eating habits of students with VI are comparable to their non-disabled peers, but there seems to be higher prevalence of bullying, especially among girls with VI.For further studies, we would recommend to find a more representative sample and have a substantial number of students from special schools and general schools so their results can be compared.
a) Body image, b) Bullying and fighting, c) Eating behaviors, d) Health complaints, e) Injuries, f) Life satisfaction, g) Obesity, h) Oral health, i) Physical activity and sedentary behavior, j) Relationships: Family and Peers, k) School environment, l) Self-rated health, m) Sexual behavior, n) Socioeconomic environment, o) Substance use: Alcohol, Tobacco and Cannabis, and p) Weight reduction behavior.

Table 5 )
belongs to the most common negative aspects of lifestyle in children and adolescents.Screen time of children with visual impairments is not necessarily only negative as they use PC and smartphones for communication.The largest group of boys (23.5%) watch television one hour per day.

Table 3
Reasons for participation in physical activitiesspend considerable time watching television or being in front of PC.

Table 4
Organized leisure time physical activities

Table 6
Eating habits

Table 7
The experience of bullying from others during the past few months