Meta-analysis of Facilitators and Barriers to Participation of Adults with Physical-Motor Disabilities in Sports and Physical Activity

Introduction
Physical activity and sport are integral components of a healthy lifestyle, playing a vital role in promoting overall health and well-being across the lifespan (Khan & Sobhan, 2023). Beyond preventing and managing a wide range of non-communicable diseases, such as cardiovascular diseases, type 2 diabetes, certain cancers, and musculoskeletal disorders (12), regular participation in physical activity exerts profound psychological benefits (23). These include reductions in stress, anxiety, and depression, improvements in cognitive function, and enhancement of sleep quality (23, 24). Furthermore, sport and physical activity serve as important platforms for social interaction, fostering a sense of belonging and the development of individual and group skills (29, 30). International organizations such as the World Health Organization (WHO) have developed clear guidelines on physical activity levels for different age groups and emphasize equitable access for all individuals regardless of ability to achieve these benefits (10).

For people with physical-motor disabilities—who may face unique health challenges—participation in sport and physical activity holds particular significance (28). Globally, approximately 650 million people live with disabilities, yet only 29% meet the WHO’s recommended minimum of 60 minutes of daily physical activity, and between 16% to 62% participate below recommended levels (10). Disability is defined as the impairments, activity limitations, and participation restrictions experienced by an individual due to various physical, social, cultural, or environmental barriers (18). Based on classification standards in various countries, people with physical disabilities represent the largest and most heterogeneous subgroup within the disabled population (14).

This highlights the urgent need for targeted interventions for individuals with physical-motor disabilities (22). However, understanding the complex determinants influencing their decision and ability to participate in sport requires an in-depth examination of multiple interacting factors (9). In scientific literature, these factors are broadly categorized into facilitators and barriers. Facilitators are elements that increase or ease participation likelihood, such as personal motivation, positive attitudes, family and friend support, qualified coaches, appropriate adapted equipment, inclusive programs and clubs, accessible transportation, and supportive policies (15, 25). Barriers refer to challenges or obstacles limiting participation, including pain, fatigue, fear of injury, low self-confidence, financial costs (equipment, membership, transportation), negative or patronizing societal attitudes, lack of awareness about available opportunities, and critical physical or environmental impediments such as inadequate sporting venues and difficult access routes (25). These determinants operate across ecological levels—including individual, interpersonal, organizational, social, and policy dimensions—and often interact dynamically to shape participation experiences. Hence, a comprehensive understanding and dynamic assessment of these factors is essential for removing barriers and enhancing facilitators (26).

Although numerous studies worldwide have explored factors related to sport participation among people with physical disabilities, the overall picture remains fragmented. Prior investigations have been conducted in diverse cultural, social, and economic settings, utilized various methodologies (e.g., survey, qualitative, correlational, scoping reviews), applied differing definitions of physical activity or participation, and focused on heterogeneous subgroups with diverse disability types and severities (e.g., visually impaired, physically disabled, veterans). This heterogeneity has led to inconsistent or condition-dependent findings regarding the relative prominence and importance of different factors. For instance, Akbari Kandelji et al. (1403) found economic problems to be the main barrier among blind and low-vision athletes, while Chen et al. (2024) reported socioeconomic and environmental factors exerting a stronger impact than psychological individual factors (13). Some psychological factors showed no significant association in their study, contrasting with findings by Samadi et al. (1402) and Ayyildiz et al. (2024) pointing to positive associations between physical activity and factors like self-regulation or motivation (3, 11).
To address the critical need for evidence synthesis, meta-analysis presents a superior alternative to traditional qualitative narrative reviews. Rather than simply describing study findings, meta-analysis employs advanced statistical techniques to combine and quantitatively synthesize results from independent studies. This approach increases the effective sample size, enhancing statistical power to detect even small effects, and provides more precise and robust summary estimates of overall effect sizes for each facilitator or barrier. Thus, the primary objective of the present study is to execute a comprehensive systematic review and meta-analysis of all available quantitative evidence to identify the most robust and influential facilitators and barriers impacting the participation of adults with physical-motor disabilities in physical activity and sport. This research aims to provide weighted effect size estimates for each factor, generating a clear, prioritized profile of determinants guiding policy and practice. The value of this study lies in supplying summarized, evidence-based knowledge critical for key stakeholders—policy makers can use results to enact supportive legislation and allocate resources, rehabilitation specialists and sport coaches can tailor interventions more effectively, and researchers can identify remaining knowledge gaps to steer future investigations. Ultimately, this study aspires to advance evidence-informed strategies to enhance sporting participation, thereby improving health, quality of life, and health equity for people with physical disabilities.
Methodology

This research employed a systematic review and meta-analysis design focused on identifying and quantitatively integrating determinants—both facilitators and barriers—of sport and physical activity participation among adults with physical-motor disabilities. The study adhered to PRISMA guidelines for systematic reviews and meta-analyses. Eligibility criteria were framed according to the PICOS model:

Population (P): Studies sampling adults (≥18 years) with physical-motor disabilities in Iran. Studies mixing disability types without providing subgroup-specific data were excluded.
Intervention or determinant (I): Studies quantitatively investigating at least one determinant (individual, psychological, social, interpersonal, organizational, cultural, economic, barriers or facilitators) in relation to participation.
Comparator (C): Typically comparisons among levels of determinants or across determinant types; no specific control group required.

Outcome (O): Quantitative measurement of sport or physical activity participation (duration, frequency, intensity, adherence, participation indices). Studies measuring only quality of life, motivation, or intention without actual participation metrics were excluded.

Study design (S): Quantitative observational designs (cross-sectional, correlational, survey) reporting effect sizes (e.g., correlation r, standardized path coeff.) or data enabling effect size calculation (t-values, p-values, sample sizes, standard errors). Qualitative, interventional-only, case studies, and reviews were excluded.

Timeframe and language: Studies published in Persian or English between March 2020 and March 2025 (1399–1403 Iranian calendar) were considered.

A systematic search was performed across six national and international databases: PubMed, Scopus, Web of Science, SID, Magiran, and Irandoc. Keywords included combinations of terms related to population (“physical disability”, “motor impairment”, “mobility impairment”), outcomes (“sport participation”, “physical activity”), and determinants (“facilitator”, “barrier”, “determinant”, “correlate”) linked by Boolean operators (AND, OR). Reference lists of selected articles were hand-checked to identify additional relevant studies. The search spanned from March 2020 to March 2025.
Study selection involved removal of duplicates, followed by title and abstract screening by two independent reviewers according to inclusion criteria. Disagreements were resolved via discussion or adjudication by a third reviewer. Full texts of eligible studies were assessed in detail. Data extraction utilized a pre-designed standardized form capturing bibliographic details, study characteristics (design, sample, measures, validity), and statistical data for effect size calculation. Quality appraisal was conducted via AXIS tool for cross-sectional studies and JBI checklist for correlational studies, assessing methodology, sampling, measurement, analysis, and bias risks.
Meta-analyses were performed using Comprehensive Meta-Analysis software (CMA v2) under a random-effects model to accommodate expected heterogeneity. Effect sizes were converted to a common metric (correlation coefficient r) and pooled with 95% confidence intervals. Statistical heterogeneity was assessed using Cochran’s Q test and I² statistic, with thresholds of 25%, 50%, and 75% representing low, moderate, and high heterogeneity respectively. Subgroup analyses explored differences between facilitators vs. barriers and across determinant categories (individual, social, environmental, organizational). Publication bias was evaluated visually via funnel plots and statistically via Egger’s regression test and Duval and Tweedie's trim-and-fill method. Significance was set at p < 0.05 for all tests.
Results
The meta-analysis incorporated 11 studies comprising 60 reported effect sizes on various determinants. Table 1 presents a summary of extracted effect sizes by study and determinant (e.g., individual traits, motivation, social support, environmental factors). A wide range of effects and significances was observed, highlighting the necessity for integrative quantitative synthesis.
Overall, facilitators showed a significant moderate positive pooled effect on participation (r = 0.38, 95% CI: 0.28 to 0.48, Z = 7.54, p < 0.001), while barriers exhibited a significant small negative pooled effect (r = –0.16, 95% CI: –0.21 to –0.12, Z = –6.98, p < 0.001). High heterogeneity was present in both groups (I² > 90%), justifying subgroup examinations.

Subgroup analysis revealed significant positive effects for individual-level facilitators (motivation, self-efficacy, psychological skills) (r = 0.22, p < 0.01) and social facilitators (family and peer support, positive societal attitudes) (r = 0.19, p < 0.01).

Discussion
This systematic meta-analysis confirms that sport participation among adults with physical disabilities in Iran is influenced by a complex interplay of facilitators and barriers spanning multiple ecological levels. Positive psychological factors such as intrinsic motivation and self-efficacy emerged as strong enablers, underscoring the centrality of individual agency in initiating and maintaining physical activity behaviors. Social facilitation via family and peer support further affirms the necessity of a supportive social environment.

Conversely, barriers primarily related to health limitations, negative socio-cultural attitudes, environmental inaccessibility, and deficient policy support critically impede engagement. The prominence of physical and psychological health barriers highlights the need for adapted programming and healthcare integration in sport promotion. Persistent stigma and structural inequities necessitate culturally sensitive community education and systemic reforms.

Compared with Western settings, Iranian studies point to more pronounced infrastructural deficiencies and socio-cultural barriers, highlighting the imperative for tailored, context-aware interventions. Policymakers and practitioners should prioritize integrated strategies that empower individuals psychologically, foster social inclusion, improve facility accessibility, and drive legislative and financial support for disability sport.

The study’s high inter-study heterogeneity suggests variability linked to sample characteristics, disability types, and study designs, advocating for future longitudinal and interventional research employing mixed methods to unravel causal pathways and lived experiences. Exploring technological innovations such as AI and assistive devices offers promising potential to mitigate barriers.
This meta-analytic review provides a comprehensive evidence synthesis of facilitators and barriers affecting sport participation among adults with physical disabilities in Iran. It validates the critical roles of motivation, social support, and accessible environments while elucidating persistent challenges including health constraints, societal stigma, and systemic gaps. Promoting equitable and sustainable sport engagement requires multi-level, multisectoral approaches engaging individuals, communities, policymakers, and service providers.