Breaking Down Stigma Against Disability: Genesis, Objectives, Implementation and Evaluation of the ABall4All Project

1. Introduction

Throughout human history, stigma has persistently affected individuals with conditions such as epilepsy [1,2], mental disorders [3,4], and physical or cognitive disabilities [5]. Additionally, self-stigma, driven by societal pressure, exacerbates the issue [6]. However, targeted interventions can significantly reduce stigma. For example, in the case of epilepsy, stigma has largely disappeared within half a century due to focused efforts [7]. From a psychosocial perspective, transforming attitudes and prejudices surrounding stigma is critical, as it impacts not only affected individuals but their broader social environment [8].

The transtheoretical model, TTM [9], based in Bandura’s self-efficacy theory [10], emphasizes how cognitive and emotional beliefs influence behavioral change. The TTM identifies six stages of change: pre-contemplation, contemplation, preparation, action, maintenance, and internalization [11]. It distinguishes between cognitive changes, which alter knowledge structures, and metacognitive changes, which enhance awareness and promote behavioral adaptation. The model has been empirically validated [12] and applied in various psychosocial interventions, such as the Erasmus+ Psytool project [13], which supported at-risk adolescents through youth football programs. Prochaska identified the careful selection of participants as a key factor for success, a principle applied in ABall4All.

Visual impairments restrict environmental perception and psychomotor skills, often leading to sedentary behavior and comorbidities such as obesity, which adversely affect physical and mental health. Given that 70% of the brain’s processed information is derived from vision, its absence significantly impacts physical and social development from early childhood. Despite barriers such as limited access to facilities, institutional support, and trained educators, it is essential to involve visually impaired individuals in exercise programs that promote autonomy, inclusion, and well-being.

Regarding this last issue, it may be interesting to know that while the participants in this project (and their families) must cope with the difficulties of their disability and the tasks to be performed, they can manage to maintain an adequate and stable psychological state. Ryan and Deci [14] have long since divided the idea of well-being into two major dimensions: hedonic, associated with “feeling good” or happiness, and eudaimonic, based on the overall development of human potential and its meaning for the person. This concept had been adapted to various situations, mainly by Carol Ryff [15,16] (in her latest formulation), in her model of Psychological Well-being composed of various factors: self-acceptance, positive relationships with other people, autonomy, mastery of the environment, purpose in life, and personal growth. As can be seen, and deduced from the meaning of its components, this broader and more humanistic concept fits perfectly into the practice of sports by people with and without disabilities [17,18,19] and, similarly, can be extended to the caregivers of these people who practice them and who have personal challenges that go beyond the simple concept of hedonism and immediate happiness.

ABall4All is an innovative program aimed at addressing visual impairment as a model for reducing stigma and promoting inclusion. Its cornerstone is the development of the world’s first mini football specifically designed for blind children. This patented lightweight ball incorporates internal bells for auditory tracking and is exclusively distributed to visually impaired children and their schools. Over seven years, the program has donated more than 215,000 mini blind footballs across 215 countries and territories, empowering blind children through sport and education, with support from the European Commission Erasmus+ Sport. The ABall4All project utilized mask-based simulations to raise awareness about visual impairments. Although such simulations can provoke confusion and vulnerability [20], their reversibility and non-discriminatory intent minimize negative effects [21]. This approach fosters empathy and promotes the inclusion of visually impaired individuals in sports and social activities, ultimately enhancing their quality of life.

The main objective of the ABall4All project was to assess the change in attitudes towards children with visual impairment following joint sport activities. Specific objectives included: 1) training of volunteers to support inclusion; 2) assessment of readiness to change; and 3) analyse the perceived burden on the families of children with visual impairment.

2. Materials and Methods

2.1. Participants

Of the 170 participants studied at the events, 32 were mentors (18.8%) and 138 were volunteers (81.2%). Regarding gender distribution, most of the participants were women (61% volunteers and 74% mentors).

Regarding the caregivers, just 15 responded fully and with reliability to the questionnaire, eight from Spain (53.3%) and seven from Greece (46.7%), of whom 7 were men (46.7%) and 8 were women (53.3%), with ages ranging from 36 to 61 years (M = 45.33, SD = 7.622).

2.2. Procedure

Recruitment and training of volunteers and mentors. Volunteers and mentors were recruited in Greece, Turkey and Spain between the ages of 18 and 25. Volunteers received online and face-to-face course training (through seven educational modules) in September and 2 days before participating in the events, while the mentors were offered face-to-face meetings and the online course with personal tutoring. The questionnaire was administrated after the events and/or the educational and sport activities via Google Form.

The caregivers were contacted personally by the different teams and received the questionnaires via Google Form.

2.3. Instruments

To assess the perceived burden of caregivers of people with visual impairment, a reduced 12-item version was used of the Zarit Burden Inventory [22]. The questionnaire presents a Likert-type response format with 5 options: 1 (Not at all), 2 (A little), 3 (Somewhat), 4 (Very much) and 5 (Very much). It showed excellent internal reliability (Cronbach's alpha = .95). An example of the items is: “Do you feel that (care recipient) currently affects your relationships with other family members or friends in a negative way?”

To evaluate the level of well-being of family members of people with visual impairment, part of the Spanish version of Salavera and Usán [23] was used, which is based on the Questionnaire of Eudaimonic Well-being (QEWB) [24]. It is an instrument with a Likert-type format with 6 response options: 1 (Strongly disagree), 2 (Disagree), 3 (Somewhat disagree), 4 (Somewhat agree), 5 (Agree) and 6 (Strongly agree). In the research sample, Cronbach’s Alpha value was high (.82). Specifically, and in accordance with the objectives of the present study, ten items were chosen from three dimensions: Personal development and self-acceptance (4 items); Autonomy (4 items); and Personal expressiveness (2 items). An example of the items is: “I think I've discovered who I really am“.

Regarding the evaluation of volunteers and mentors’ satisfaction with the realization of the events, we used a questionnaire created ad hoc, with a Likert-type response scale with 4 options: 1 (poor), 2 (normal), 3 (good), 4 (excellent) and in some cases 5 (N/A). The questionnaire is composed of 10 items, and examples of the items are: “What is the the involvement of all participants in building the inclusive context”, and “What is the accessibility and suitability of the facilities, spaces, resources, signage, means of transport or accommodation, dynamics, and procedures used during the course of the activity”.

2.4. Design and Data Analysis

An ex post facto retrospective single-group design was carried out [25] in which the perceived burden and well-being of relatives of children with visual impairment were analyzed according to sex, age and country.

Firstly, basic descriptive statistics (mean and standard deviation) were calculated to provide an initial description of the variables under study. After checking the normality of the data and homogeneity of variances, Student’s T-test and Pearson's correlation coefficient were calculated to analyze the relationships between variables to test hypotheses about the difference in means between two groups. If the differences were statistically significant (p < .05), Cohen's d effect size was calculated to establish the magnitude of such differences (high effect magnitude from .8; moderate effect magnitude between .50 and .80; small effect between .20 and .49) [26]. For the analysis of the explanatory model, the simple linear regression model was used, taking perceived burden by caregivers and family members of people with visual disabilities as the dependent variable, and age as the independent variable.

All statistical analyses were carried out with IBM SPSS Statistics (version 27) for the Windows operating system [27].

3. Results

3.1. Satisfaction and Evaluation of the Final Events

The overall satisfaction and evaluation of the participants was 4.03 points (SD = .330) out of a maximum of 4.2 points, which was at a high level.

A trend was observed in terms of satisfaction with the event and the sex of the participants, since men reported feeling more satisfied (M = 4.14, SD = .150) than women (M = 3.95, SD = .388). Statistically significant differences were detected in the measurements carried out (t₁₆₈ = 3.739, p < .001) and a low effect size (d = .318). Furthermore, volunteers were more satisfied than mentors (volunteers: M = 4.07, SD = .255; mentors: M = 3.85, SD = .517), with a statistically significant difference (t₁₆₈ = 3.401, p < .001) and a low effect size (d = .320).

Finally, the age of the participants influenced the level of satisfaction with the event (r_xy = -.169, p < .05), although the relationship was weak and negative (the older the participant, the less satisfied they were with the event). The topics evaluated more positively were the fulfillment of the aspirations and motivations of VI participants regarding physical exercise and their progress in this regard (M = 3.86, SD = .406, and M = 3.82, M = 466) as well as the availability, variety and flexibility of technical aids for orientation, communication and mobility (M = 3.82, SD = .431). The worse evaluation was related to the level of alliances with organizations around inclusion (M = 3.75, SD = .520).

3.2. Perceived Burden and Well-Being of Family Members

Regarding the perceived burden and well-being of family members of visually impaired people, in the first place, we have found out that the family members and caregivers of visually impaired people reported not feeling overburdened, reporting mean values of 21.47 (SD = 7.472) out of a maximum of 60 points.

Men reported feeling more burdened (M = 23.14, SD = 8.840) than women (M = 20.00, SD = 6.280). Differentiating by country, caregivers in Greece showed more burden (M = 24.57, SD = 2.936) than those in Spain (M = 18.75, SD = 9.285). However, these results should be taken with caution, as no statistically significant difference was detected in the measurements carried out.

Furthermore, it was observed that the older the caregiver, the greater the perceived burden, since the age of the caregivers was positively related, statistically significantly and with moderate-high magnitude with the perceived burden (r_xy = .634, p < .05).

When analyzing the eudaimonic psychological well-being, caregivers reported perceiving a high level of well-being (M = 40.07, SD = 5.849), with the personal development and acceptance dimension being the highest rated (M = 20.00, SD = 3.606).

Depending on the gender of the caregiver, men reported feeling better than women in all measurements carried out, except in the expressiveness dimension (Table 1). No statistically significant differentiation was observed. Furthermore, the well-being perceived by Spanish caregivers was slightly higher than that perceived by Greeks in several cases: in general well-being (M = 42.13, SD = 7.473; M = 37.71, SD = 1.604), in the autonomy dimension (M = 18.75, SD = 4.921; M = 13.86, SD = 1. 069), in this case showing statistically significant differentiation and a low effect size (t13 = 2.567, p < .05; d = .36), and in the expressiveness dimension (M = 4.13, SD = 2.780; M = 3.00, SD = 2.236).

The age of the caregivers was positively related and with moderate magnitude to perceived well-being (r_xy = .402, p > .05), with the autonomy dimension (r_xy = .408, p > .05) and with the expressiveness dimension (r_xy = .437, p > .05), and negatively related and with a weak magnitude to the personal development and acceptance dimension (r_xy = -.148, p > .05). In this regard, age was a significant predictor variable in the perceived burden by caregivers and family members of people with visual disabilities (corrected R₂ = .36, p <.001) With an explanatory capacity of 36% of the variance (corrected R₂ = .356; F(1,13) = 8.745, p <.01), for each point that age increased, the perceived burden increased by .63 (Table 2).

4. Discussion

This project has been quantitatively assessed in three different ways: the evaluation by mentors and volunteers of the event; the willingness and disposition to change in people without disabilities who have participated in the activities and events, and the perceived burden related to the perceived level of psychological well-being of caregivers of children with visual impairments.

As regards the novel evaluation by volunteers (and their mentors) of the quality of the project events, the results indicate that they gave a very high rating. In this sense, women, mentors and older people gave the lowest rating to the quality of the events, with significant differences. The factor that received the highest rating was that the events fulfilled their function of meeting the expectations of the children with VI, both in their sporting practice and in the progress made by them. This aspect of “event evaluation”, which is not normally assigned to volunteers, has proven to be very effective and worthy of being included as standard in the event impact assessment, as it directly affects volunteers’ adherence to participating in more events of this nature.

Caregivers, primarily families of children with disabilities, have been extensively studied [28,29]. This study found that the perceived burden among these caregivers was relatively low, although it varied based on demographic factors. Notably, male caregivers reported greater burden than females, contrasting with previous research linking higher burden to women due to associated stressors [30]. As families grew older, and consequently children as well, the burden was perceived to be greater, instead of being reduced due to the learning and adjustments of this process. However, this result, which seems to be the most common [31], must be considered in relation to the last topic studied: perceived psychological well-being.

Interestingly, despite the challenges associated with caregiving, participants reported maintaining stable psychological well-being (PWB). Ryan and Deci [14] conceptualized well-being into two dimensions: hedonic (happiness and “feeling good”) and eudaimonic (personal growth and purpose). Ryff's model [15,16] expands on eudaimonic well-being through six factors: self-acceptance, positive relationships, autonomy, environmental mastery, purpose in life, and personal growth. This model aligns closely with the benefits of sports participation for individuals with and without disabilities [17,18,19] and can also extend to their caregivers.

Caregivers of children with visual impairments (VI) reported high levels of PWB, particularly in self-acceptance and personal development, which are core components of eudaimonic well-being. Similar patterns are observed in high-stress contexts, such as elite sports [32], where stress and pressure coexist with stable psychological well-being. Gender differences in PWB were minimal, though male caregivers scored slightly higher. Age, however, played a significant role: older caregivers reported higher overall PWB but lower scores in personal development and acceptance, reflecting a notable age-related decline in these dimensions.

These findings have implications for interventions aimed at reducing caregiver burden. Future research will assess whether participation in sports activities and engagement with other families of children with VI reduces perceived burden over time. This longitudinal analysis will help evaluate the long-term impact of these activities on the same population, providing further insights into the relationship between caregiving, burden, and psychological well-being.

4.1. Limitations and Future Developments

The primary limitation of this study lies in its inability to systematically assess factors influencing changes in attitudes toward sports participation among individuals with visual impairments (VI) and broader perceptions of disability. This limitation is primarily due to the cross-sectional nature of data collection, as a longitudinal approach was not feasible.

One key project objective—evaluating the disposition to change—did not achieve sufficient psychometric reliability and validity to be included as a result. This aspect will be addressed in the continuation of the ABallForAll SCP project with a more rigorous approach, involving a larger population engaged in educational and sports activities.

In the upcoming ABall4All SCP project (2025–2027), the evaluation will include a larger sample of mentors and participants, addressing this limitation by employing robust questionnaires on Disposition to Change, aligned with Prochaska's transtheoretical model [13].

Finally, the study's implementation across three culturally distinct countries limits the comparability of results. Future iterations of the project will seek to mitigate these cultural discrepancies to enhance the quality and reliability of cross-country comparisons.