Sports-focused interventions are defined as any modality provided by health professionals that contributes to participation in leisure-time physical activity (i.e. attendance or involvement in sports and physical recreation).¹ Children with disabilities such as cerebral palsy (CP) frequently have restrictions that impact their engagement in leisure-time physical activity and require sports-focused interventions to support their participation in community sports.¹ While many sports-focused interventions usually target children's unique challenges using individual sessions,¹ modified sports interventions promote leisure-time physical activity participation by developing fundamental motor skills and other physical literacy components (i.e. social, cognitive, and psychological skills for lifelong participation in physical activity²) in real-world group contexts.^3-8 Sports Stars is a modified sports intervention that has recently been investigated for use in ambulant children and adolescents with CP and autism.^5-9

Sports Stars is a practitioner-led, peer group, modified sports intervention that aims to support the transition from usual physical therapy care to participation in leisure-time physical activity in the community.⁸ It includes sports-specific locomotor and object control skills training and the introduction of four culturally relevant sports. This intervention was originally designed for the Australian context and included some of Australia's most popular team sports, that is, soccer, netball, T-ball, and cricket.^{5, 7, 8} Sports Stars is effective in improving participation in leisure-time physical activity and sports-specific skills capacity in ambulant children with CP.⁸ In addition, Sports Stars Australia was a feasible and well-accepted intervention that parents and physiotherapists perceived as beneficial in improving children's skills in all physical literacy components.⁵

Interventions aiming at improving participation are scarce in low- and middle-income countries (LMICs) such as Brazil.^10-12 To promote leisure-time physical activity in Brazilian children with CP, the Australian Sports Stars intervention was culturally adapted for the Brazilian context.⁶ Sports Stars Brazil uses the same structure as the original Sports Stars programme, with the following adaptations: (1) culturally relevant Brazilian sports (soccer, handball, basketball, and athletics) were included to ensure that children would be exposed to the sports that they could have access to in their community; (2) a multidisciplinary team (i.e. physical therapists and physical education professionals) was included because of their specific role in providing modified sports interventions for individuals with disabilities in Brazil.^{6, 13}

An ongoing randomized controlled trial (RCT) is underway to evaluate the effectiveness of Sports Stars Brazil compared with waitlist and control groups in children and adolescents with CP.⁶ Children (6–12 years old) in the intervention group of this RCT have concluded the intervention and all follow-up assessments. The results of this trial might strengthen the evidence for modified sports interventions for individuals with CP. It is also important to investigate the experiences and perspectives of Brazilian parents of children who participated in this new intervention to explore the experiences of this intervention within an LMIC. Parents' perceptions of the acceptance and feasibility of Sports Stars were investigated in the Australian cohort survey.⁵ So far, other aspects regarding the experiences of parents and participants of Sports Stars have not been investigated.

When providing a new intervention such as Sports Stars, it is important to analyse how it impacts different aspects of functioning. The biopsychosocial model of the International Classification of Functioning, Disability and Health (ICF) is the guiding model most frequently used in rehabilitation practice.¹⁴ In the context of childhood disability, Rosenbaum and Gorter¹⁵ represented this model using the F-words: fitness, functioning, friends, fun, family, and future. F-words include all important aspects of development and involve all important participants in the child's life. The first F-word, ‘functioning’, refers to what children can do in their daily lives and represents the ICF's ‘activity’ domain. The second word, ‘family’, refers to the main environment in which the child lives and is related to the ICF's classification of environmental factors. The next word ‘fitness’ relates to the body structures and function domain of the ICF. The F-word ‘fun’ represents what is meaningful and pleasurable for the child and relates to the ICF's personal factors. The word ‘friends’ refers to social aspects that are essential for the child and relates to the ICF's ‘participation’ domain. Finally, the last F-word, ‘future’, encourages those involved with the disabled child to think about their development and long-term prospects.¹⁵

The F-word framework is powerful in promoting childhood development, especially in LMICs.¹² Thus, Brazilian stakeholders would benefit from understanding the F-words and how they relate to different interventions offered to children with CP. Recently, F-words have been used to evaluate the benefits of other physical activity programmes and to indicate the ingredients of interventions in children with CP.^16-18 Up to this point, to our knowledge, no other study has analysed the repercussions of a modified sports intervention, using F-words. The F-word framework could be used to elicit information as to how the Sports Stars intervention influenced different aspects of functioning. Taken together, the main purpose of this descriptive qualitative study is to explore the perceptions of parents of children who participated in Sports Stars Brazil, through the lens of the F-words of childhood disability.

METHOD

This qualitative descriptive^{19, 20} study aimed to explore parents' experiences after participating in Sports Stars Brazil. It was approved by the ethics review board of Universidade Federal de Minas Gerais, Brazil (CAEE 33238520.5.0000.5149). This study followed the recommendations of the Consolidated Criteria for Reporting Qualitative Research.²¹ In addition, the method and results were reported according to the recommendations outlined by Jack and Phoenix¹⁹ for qualitative research in developmental medicine and child neurology. This study presents additional data from an ongoing RCT⁶ registered in the Brazilian Clinical Trials Registry (RBR-3RWTYW, World Health Organization Universal Trial Number U1111-1256-4998).

RESULTS

Of the 19 parents of children from the Sports Stars Brazil intervention group, four did not attend the focus group days because of health issues. Thus, 15 parents participated and were grouped into four focus groups of four to six parents. Children's characteristics are described in Table 2. Children's mean adherence to Sports Stars Brazil was 7 of the 8 days (87.5%). The results were grouped into three categories: (1) general perceptions of the Sports Stars Brazil intervention; (2) Sports Stars Brazil and the F-words; and (3) the integration of all F-words and Sports Stars Brazil, and their respective subcategories. The number of parents who provided perceptions in each subcategory is presented in Table 3. Examples of quotes in the following sections were translated into English.

F-word integration in the Sports Stars Brazil intervention

After discussing the influence of the Sports Stars Brazil intervention on individual F-words and watching the F-word instructional video, parents were invited to reflect more on this topic. At this time, parents expressed how Sports Stars Brazil integrated all F-words into the intervention, as shown in the following quotes:

… everything is involved, when I started with the project, I was looking for a movement for her. A physical activity, it was a physical activity, I thought of the ‘F' of family, suddenly at that moment it wasn't the ‘f' of family, it was the ‘f' of function, it was the question of activity, health, at first, but whether or not one thing leads to another … everything comes in the package, a whole package!

Parent no. 9, mother of a 9-year-old child with unilateral CP in GMFCS level I

… Family: you are closer to them, you have to come, to follow them. Fitness: it's good for health and development … functioning too … They all assemble in the project, they have everything to do with it …

Parent no. 15, father of an 8-years-old child with unilateral CP in GMFCS level I

After the group discussion and after watching the F-word instructional video, one mother reflected more on her vision of the future before and after Sports Stars Brazil, as the following excerpt shows:

… we are already keeping an eye on which group he will fit into from now on because, I am still in the process of elaboration. As she said [pointed to another mother], I haven't thought about it yet. What I can tell you right away is that I had already noticed a change in me in the sense that, as parents of children with disabilities… we are going through changes… I initially thought for many years that it was a crime to level him with other children below his abilities or at his level because I thought I would lose the opportunity to make him develop, you know? … I used to say the quote—Don't accept me as I am—but it's not in the sense of not accepting me, it's not letting me stay there, simply… accommodating, you know? Somehow, I have caused him some damage over the years, which I am still reformulating in my head, putting him with different people, with greater capabilities than his, afraid of him always being left behind, in the sense that I wanted him to have a reference, you know? And then I never looked for groups that he participated in, children who were more or less like him, even because I didn't know it, I knew a child or another who had CP and who walked, and I knew a child or another who had CP and an active life as he has… I always thought that the issue of inclusion is an equal opportunity but that he had to develop within the environment he is in already, which I thought was great for him, but I also believe that he had losses. So, my future today, the only thing I can see here within the project is him participating in a group to see that he will find his place, he has to find his place, that's it… my vision of the future is for him to find himself…

Parent no. 5, mother of an 11-year-old child with bilateral CP in GMFCS level I

Briefly, parents recognized that Sports Stars Brazil influenced and integrated all F-words into a single intervention. Figure 1 represents the categories and sample quotations.

DISCUSSION

Interventions targeting participation in children and adolescents with CP are scarce in LMICs such as Brazil.¹⁰ Therefore, the implementation of culturally relevant, sports-focused interventions for Brazilian children with CP is crucial. This article reports the first results of an investigation into Sports Stars for ambulant children with CP in Brazil, specifically the perceptions of parents through the lens of the F-words in childhood disability. According to parents, Sports Stars Brazil was a beneficial intervention that brought benefits in all the F-word categories. The opportunity for the integration and coexistence of these children in a real-world environment, the low cost, and the dosage of the Sports Stars intervention are strengths that can facilitate future implementation of this modified sports intervention on a large scale.

The F-word framework is strongly recommended to support stakeholders in understanding the interventions offered to children with disabilities.¹⁶ Recently, Dan³⁰ suggested a seventh F-word, ‘freedom’, an F-word that professionals need to achieve when providing interventions for children with disabilities. ‘Freedom’ represents different essential concepts to integrate the biopsychosocial model domains and the other F-words (e.g. capability to use movement-related body functions, degrees of freedom, diversity and range of activities, possibility of choice, and autonomy).³⁰ All of these concepts were represented in the parents' perceptions of Sports Stars Brazil (Figure 1). This new F-word stresses the dynamic non-linear integration stated by the biopsychosocial model, that is, the interconnection of body structures and functions, activity, participation, and contextual factors.^{14, 30} Participants of Sports Stars Brazil perceived this integration and interrelation between F-words. They reported that all the F-words were ‘connected’ in Sports Stars Brazil, reinforcing its non-linearity. As stated by some of the parents, they first started the intervention looking for the ‘F' from ‘fitness’ and ‘functioning’; they then started to see how Sports Stars brought up ‘family’, ‘friends’, ‘fun’, and ‘future’, and integrated these F-words as one unifying concept. This is consistent with previous work by Soper et al.¹⁶ who highlighted that interventions targeting participation in leisure-time physical activity tend to fulfil all the F-words.¹⁶ Bearing in mind that Sports Stars Brazil is in line with the biopsychosocial model, it achieved all F-words, including ‘freedom’, by promoting different aspects of functioning in ambulant children with CP.

Interventions targeting leisure-time physical activity are often engaging for children as they highlight the ‘F' from ‘fun’ and ‘friends’.¹⁶ In our study, parents perceived that Sports Stars Brazil incorporated these elements (e.g. group activities, confidence building, and introduction to sports), thus differing from commonly provided physical therapy interventions offered to ambulant children with CP. These characteristics were also identified as motivators for the child's engagement in the rehabilitation process and their willingness to attend the intervention. Parents perceived that Sports Stars Brazil benefited different aspects of their children's functioning, including improved physical competence (e.g. fundamental motor skills), and social, cognitive, and psychological competence (e.g. engagement, confidence, and motivation). These results are in line with the experiences of Australian parents, whose children participated in Sports Stars,⁵ and objective improvements in fundamental motor skills compared to controls in an RCT.⁸ The active ingredients of Sports Stars are supported by best practice recommendations for children with CP and include the following: setting and working on client-chosen goals; providing enjoyable and motivating interventions; practising in real-life environments; and working as a team (therapists, child, and family) to achieve rehabilitation goals.^{4, 31} These ingredients validate the perceived improvement in physical literacy components after Sports Stars Brazil.

Parents perceived that Sports Stars Brazil positively impacted participation outside the target domain of leisure-time physical activity. These results may indicate the potential for an intervention focused on sports activities to broaden the involvement of children with disabilities in other areas of participation. Parents reported improvements in ‘functioning’ aspects such as autonomy, which improved participation at home, at school, and in the community. These perceived gains might be due to positive effects on children's cognitive, psychological, and social skills (e.g. rules, knowledge content, and collaboration), which are transferable to other life situations. Future results of our RCT will help to better understand these findings as participation aspects are evaluated objectively.⁶

One negative aspect reported by parents was the difficulty attending the intervention with their children. Sports Stars Brazil was offered in an out-of-the-way region at our research centre within a university. This was a challenge for some of the parents. Transport might be difficult when offering interventions to children with disabilities in Brazil¹⁰ because most of the population relies on public transport, which is precarious in many Brazilian cities. It reinforces the importance to provide, in the future, this modified sports intervention in more accessible regions with different transport options for parents and children.

FUNDING INFORMATION

No other specific funding was directed to this study.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interests.