Principles and strategies of inclusive physical activity: a European Delphi study

Abstract

Aim/Purpose

The article seeks to articulate a consensus of the opinions of a group of subject experts about the principles and strategies of inclusive physical activity.

Methods

A 3-stage Delphi study involving a group of 34 Europe-based subject specialists was used to articulate shared expert opinions on the main research question: What are the key principles (general theories, values, or framework) that should guide practice of inclusive approaches to physical activity? What are the key strategies (practical approaches that can promote inclusive physical activity) of inclusive approaches to physical activity?

Results

Four core principles and four core strategies (and six less-supported principles/strategies for each) were identified through this process. The core principles were: focus on participants’ needs; include disabled people in planning; focus on ability, not disability; and promote equal opportunities. The four core strategies were: adapt the rules and aims of the programme to the abilities of participants; apply adaptability of teaching/coaching methods; be accessible and available to participants; and establish models to make sure participants’ voices are heard.

Conclusions

The article concludes by offering ten concepts – drawn from the empirical findings – that might act as a starting-point for the development of the concept for an inclusive physical activity programme.

Introduction

Physical activity plays a vital role in improving and maintaining health and well-being (Franklin 2011), and growing epidemiological and physiological research has highlighted adverse health implications for prolonged sedentary time, regardless of age, personal characteristics, and activity status (Patterson et al. 2018). Physical activity is known to be lowest among sectors of the population at the lower end of the social gradient (Kay 2016), making marginalised and disadvantaged groups at greater vulnerability to a range of non-communicable diseases, including cardiovascular diseases, diabetes, cancers, chronic respiratory diseases and obesity (United Nations 2011). However, policy and research attention towards these groups have been inconsistent and often lacking (Kay 2016; Williams and Gibson 2018). Using an adaptation of the Delphi methodology, this article reports on a study aiming to identify a consensus regarding the most impactful principles and strategies for all members of communities regardless of their personal or social characteristics. Drawing on the perspectives of a group of European informants, this scoping study offers the first Delphi study of inclusive physical activity principles and strategies. This study is part of a wider project called ‘Health-Enhancing Physical Activity for All (HEPA4ALL), which aims to build national and local networks of inclusive physical activity provision and policies.

Background

Optimising population physical activity levels has become a priority for public health agencies worldwide (Fineberg 2012). Recent years have witnessed a steady growth in evidence regarding the profound and multifaceted physiological, psychological, and social health benefits resulting from sustained engagement with physical activity (Bailey et al. 2013; Eime et al. 2013). In many ways, the long-standing concern with the ‘why’ of physical activity has been overtaken by a focus on its ‘how’, especially among marginalised people (Baker et al. 2015).

In the light of low levels of health-enhancing physical activity across populations in general and within relatively consistent patterns in the disparity between specific groups, certain priorities are emerging. First, the sustainable and self-determined change of health-related practices needs to draw on behavioural change mechanisms (Pringle et al. 2021). Second, universal guidance, such as the World Health Organization’s most recent physical activity guidelines (WHO 2020), must be translated to acknowledge specific communities and interest groups (Bekemeier et al. 2018). Third, if physical activity is to become a core element of public health policy, there must be a proper acknowledgement that there are significant differences in terms of both opportunity and outcomes by gender (Matud 2017), dis/ability (Lobenius-Palmér et al. 2018), ethnicity (Armstrong et al. 2018) and other factors. Moreover, the confluence of the multiple socio-cultural factors impacting disadvantaged groups means that the groups that would most benefit from regular, varied, and safe physical activity are offered the least opportunities.

This study explicitly addresses these questions. Its primary objective is to identify the long-term measures required to encourage inclusive participation in adapted inclusive health-enhancing physical activities from all segments of society, including disabled and disadvantaged people, through the inclusive involvement of different disciplines in a system-wide, cross-sectoral approach. In itself, this is a somewhat unusual interpretation of ‘inclusion’, which is a phrase conventionally employed concerning specific groups. For example, the US Centers for Disease Control (2020) explicitly explains ‘inclusive physical education and physical activity’ in terms of the participation, support, and encouragement of disabled students. Others frame ‘inclusive physical activity’ within the context of immigrants (Pickett and Cunningham 2017), members of LGBTQ+ communities (Landi 2018), girls and women (Henderson and Bialeschki 1995), and overweight people (Lleixà and Nieva 2020). This narrative is not made distinctive by its focus on specific groups, per se, but by the absence of reference to other groups for whom the concept of inclusion could also apply. We might call the conventional approach ‘exclusive inclusion’ because it focuses on pre-determined groups, implicitly excluding everyone else. The approach taken here is different, framing inclusion as an interdisciplinary and multi-factorial framework that prioritises fair and equitable access and participation of all citizens irrespective of differences (Thomas 2013). This might be labelled an ‘inclusive inclusion’ stance, as nobody falls outside its conceptual boundary. Our decision to adopt this interpretation of inclusion is partly in acknowledgement of its increasing usage among theorists (Thomas 2013), and partly in response to arguments that there is value in and need for conceptions of inclusion that connect different historically marginalised groups (De Luca 2013). A potential criticism of this way of thinking is that it raises a risk that the specific needs of different groups could be overlooked. However, it should be stressed that conceptualising inclusion in a general and cross-cutting way does not preclude the implementation of focused interventions to meet identified needs. ‘Inclusive inclusion’ is not synonymous with mainstreaming or undifferentiated provision. Rather, it suggests that framing inclusion in terms of rights-based (not identity-based) principles offers a stronger foundation for supporting access to and engagement with health-related opportunities, including traditionally marginalised groups. According to Artiles (2011), this approach would both encourage research through a common conceptual framework and support developments in policy and practice.

To the best of our knowledge, this is the first study aiming to identify experts’ views of the core and foundational principles and strategies of inclusive physical activity promotion. It is also one of a few studies explicitly adopting a generic or inclusive frame for inclusion in this context (as opposed to being dis/ability-, gender-, ethnicity-, etc.-focused). Therefore, this study is best understood as a scoping study aiming not just to learn about the consensus of a group of experts but also as a context of learning from subsequent research on this topic.

Method

Objective

The objective of this study was to identify the long-term measures required to encourage inclusive participation in adapted inclusive health-enhancing physical activities among all segments of society, including disabled and disadvantaged people, through the inclusive involvement of different disciplines in a system-wide, cross-sectoral approach. The study sought to articulate a consensus of the opinions of a group of subject experts and then submit those opinions to structured rounds of analysis and reorganisation.

Expert group

Experts were identified by a 5-step procedure. First, organisations within the ‘HEPA4ALL’ (Health-Enhancing Physical Activity for All) Project (see Acknowledgements) suggested individuals with extensive experience of promoting inclusive physical activity. The criteria for selection were: current experience of working in either explicitly ‘inclusive’ settings in which physical activity was a significant element; at least 5 years of voluntary or employed engagement in physical activity promotion; based in Europe. In addition, the selection was purposively guided by an aspiration for gender balance, professional expertise, and geographical coverage. Second, discrepancies in gender, expertise, and geographical representation were addressed by approaching specific researchers and practitioners from across Europe who filled these gaps. Third, following email communication with the identified experts, the selection process was repeated to add new experts to the study. Finally, the research team divided the experts into two groups: Group A comprised ten people judged to have extensive experience in inclusive physical activity settings; Group B comprised the remaining 24 experts.

The combined group (Groups A and B) came from 18 European countries. It included respondents from a diverse range of roles and expertise. Following published guidance (Goodman 2017), recruitment aimed for a pool of between 15 and 35 experts, resulting in a non-probabilistic, purposive sample of 34 people (Table 1). Each final participant was sent information about the study via email, and a direct link to the online questionnaire, with the landing page reiterating project information and informing the experts of the anonymity and confidentiality of individual responses, as well as their right to be informed, and voluntary consent. Ethical approval was given by the Executive Board of Ikkaido Ltd (21/02/22-Bailey).

Table 1.

Participant information

Gender
Female	20
Male	14
Profession
Athlete	1
Consultant	3
Educationalist	4
Employee of regional/national disability organisation	4
International NGO employee	2
Politician	1
Regional/national sports organisation employee	1
Sports coach	1
University researcher/teacher	15
Youth worker	2
Country of work
Cyprus	2
Czech Republic	1
Denmark	2
France	2
Germany	3
Hungary	1
Ireland	4
Italy	2
Luxembourg	1
Poland	2
Portugal	1
Romania	1
Sweden	1
Turkey	4
Spain	1
UK	6

Procedure

The approach chosen for eliciting an expert group’s view was a 3-stage modified Delphi study, a widely used research method for eliciting and refining group judgement based on the rationale that a group of experts is better than one expert when exact knowledge is not available (Kaynak and Macauley 1984). The primary reason for employing this method in this study is that it provides experts with an opportunity to share their ideas, individually and as part of a group, in a manner that avoids potential confrontation of their views (Okoli and Pawlowski 2004). Anonymity throughout the process and multiple rounds of controlled feedback helped the research team limit the influence of comments from peers (Hsu and Sandford 2007). This method is a well-established way of improving group decision-making (Goodman 2016).

Opinions were submitted to repeated rounds of analysis and reorganisation, and the experts were invited to engage with increasingly aggregated iterations of the group’s shared decision-making. All rounds of data-gathering were administered electronically, using an online software program (www.surveymonkey.com). The utilisation of an online procedure allowed much greater flexibility in the exercise’s administration and provided time for reflection. Since the timing of this study coincided with the outbreak of COVID-19, this approach made the research tenable. Following discussions with the expert group, it was decided to continue with the study.

The research process took place between 1 January 2021 and 31 March 2021, with the data-gathering and analysis occurring between and 1 April 2021 and 31 May 2021. Two research questions were the foci of the study:

• What are the key principles of inclusive approaches to physical activity?

• What are the key strategies of inclusive approaches to physical activity?

The definitions given to respondents were: ‘principles: general theories, values, or framework that should guide practice’; ‘strategies: practical approaches that can promote inclusive physical activity’. For round 1, members of group A were asked to propose five responses each to the two questions. These lists were reviewed by three experienced, linguistically diverse researchers, who identified additional sources of information, modifications of terms, and other changes. After eliminating redundancies and trialling of terms among this community, 67 ‘principles’ statements and 65 ‘strategies’ statements were used to form round 2’s content. Groups A and B took part in rounds 2 and 3 (Fig. 1), in which they recorded their agreement with each statement on a 7-point Likert scale. Weighted means of the total scores for each statement were calculated (x₁w₁ + x₂w₂ + x₃w₃ ... x_nw_n / total; where w = weight of answer choice, and x = response count for answer choice); the statement with the highest mean ranking was judged the most supported choice overall. A ‘fuzzy’ divide was placed between the statements carried over to the final round (the top 10-to-15 responses for each question) and those rejected. This was to facilitate the completion of the ranking exercise in the third round (ranking is much more manageable, and presumably valid, with relatively small groups of statements rather than larger groups). Fourteen ‘principles’ and 13 ‘strategies’ statements were identified for progression to the final round. For this final round, experts were presented with the 14 and 13 statements representing ‘principles’ and ‘strategies’, respectively, and used a simple sliding interface to order the statements.

Fig. 1.

The Delphi technique process

The process used in this study is summarised in Fig. 1.

Response rates for the different stages of the study were:

• Round 1 – 34 responses

• Round 2 – 23 responses

• Round 3 – 23 responses

This represents a 68% completion rate over three rounds.

Findings

Tables 2 and 3 present the statements for the two lists - principles and strategies - proposed by group A.

Table 2.

Initial list of principles of inclusive physical activity

Address special needs and limitations Apply the Universal transformational management framework Apply universal design principles Awareness of social justice Base inclusive practices on the principles of quality physical education Base programmes on self-determination theory Base programmes on the bio-psycho-social model Base the programme on evidence-based practice Build stakeholder partnerships Celebrate achievement Celebrating differences Challenge stigmatisation Connect with the local community Consider the lived experience of participants

Create a culture of diversity Develop a shared understanding of inclusion Develop cognitive abilities Develop policies for inclusion Develop an expectancy of involvement Education for primary carers Ensure adequate government funding Focus on the needs of specific groups Focus on the needs of the individual Follow legal requirements Foster a deep-felt wish to engage Foster a sense of belonging Have knowledge of the range of additional needs Include disabled people in planning Incorporate reflection into programme development and implementation

Maintain dialogues Maintain the integrity of the activity Make sure sessions provide a social experience Make sure those working with groups have relevant knowledge Participation-oriented rather than performance-oriented Provide activities at no or low cost Provide safe and activity-friendly areas for all members of the community Question norms and values Recognise intersectionality Target parents Target young people Work with appropriately trained coaches Work with other organisations concerned with inclusion

Table 3.

Initial list of inclusive physical activity strategies

Adapt the rules and aims of the programme to the abilities of participants Apply adaptability of teaching/coaching methods Be accessible and available to the participant Consult the participants in the planning and delivery of sessions Develop talent and competitive participation Diversify the range of movements taught Early interventions Easy language Employ specialist coaches who are trained in inclusive physical activity/sport Ensure there are opportunities to socialize Establish models to make sure participants’ voices are heard Establish peer support Explain the benefits of sport & physical activity Focus on the community aspect of the sessions Focus on the development of basic movement skills Identify Include activities that everyone can do together barriers Include activities to enhance cognitive abilities Include individual tutoring Include traditional games

Integrate physical activity in everyday settings (schools, work, transport) Maintain a supportive environment Make accessible spaces and equipment available to all Make sure groups are easy to reach Make sure participants know the responsible person Make sure participants understand the programme’s values Make sure there is a welcoming environment Make sure there is fun and enjoyment Non-competitive activities Offer a variety of activities Offer flexible timings of activity sessions Use outdoor and experiential activity Use peer coaching Offer non-traditional games and activities Provide awareness and empowerment training Provide choice Provide easy access to information about physical activity opportunities Provide group activities Provide individual tutoring Provide individualised programmes and support Set achievable goals

Make sure groups are easy to reach Make sure participants know the responsible person Share written programmes to all stakeholders Start or join inclusive sport competitions STEP Model Support participants’ courage to become and show who they are Support the emotional needs of participants Target specific audiences Use a collaborative approach Use athletes/coaches as role models Use clear communication Use group activities Use media/promotional images of inclusion Use personalised approaches Use sensory adaptations Use technology to support inclusion Use the inclusion spectrum Use virtual reality Use visual cues Using images of participants with different body types Work with advocacy groups Work with childcare service providers Work with governing bodies of sport Work with schools

As already stated, the long list of principles and strategies for inclusive physical activity was put to the test. The experts were initially asked to rate (score) the importance and relevance of the statements. These ratings were analysed statistically, and a shortlist emerged of the 14 most supported statements for each category. The statements were sent back to the experts, who ranked (placed in order) the resulting list in order of importance and relevance. This led to the final list of principles and statements. Analysis of the findings from round 3 produced 20 statements: ten related to the principles of inclusive physical activity; and ten referring to the strategies of inclusive physical activity.

An additional analysis was then carried out to differentiate between what we have called “core” principles and strategies, and “foundational” principles and strategies. This distinction was considered necessary, as the HEPA4ALL project aimed to develop materials and guidance for policymakers and practitioners, which necessarily involves prioritising some ideas over others. The “core” ideas receive the strongest support from the expert group, and therefore, could be considered essential or key principles and strategies.

The refinement of principles and strategies for inclusive physical activity from round 2 to round 3 is shown in Tables 4 and 5 below.

Table 4.

Round 2 to round 3 list of principles

Connect with the local community (5.96)		Core principles 1. Focus on participants’ needs 2. Include disabled people in planning 3. Focus on ability, not disability 4. Promote equal opportunities
Create a culture of diversity (5.74)
Develop a shared understanding of inclusion (7.7)
Develop and implement an Inclusion Awareness strategy (7.91)
Ensure inclusive leadership (7.91)
Focus on ability, not disability (8.78)		Foundational principles 5. Ensure inclusive leadership 6. Develop and implement an Inclusion Awareness strategy 7. Develop a shared understanding of inclusion 8. Provide safe and activity-friendly areas for all members of the community 9. Focus on the needs of the individual 10. Foster a sense of belonging
Focus on participants’ needs (9.65)
Focus on the needs of the individual
Foster a sense of belonging
Include disabled people in planning (9.22)
Promote equal opportunities (8.35)
Promote play (5.3)
Promote values that support physical activity (6.39)
Provide safe and activity-friendly areas for all members of the community (7.57)

Table 5.

Round 2 to round 3 list of strategies

Adapt the rules and aims of the programme to the abilities of participants (7.26)	Core strategies 1. Adapt the rules and aims of the programme to the abilities of participants 2. Apply adaptability of teaching/coaching methods 3. Be accessible and available to participants 4. Establish models to make sure participants’ voices are heard
Apply adaptability of teaching/coaching methods (7.48)
Be accessible and available to participants (7.48)
Establish models to make sure participants’ voices are heard
Integrate physical activity in everyday settings (7.57)
Maintain a supportive environment (7.83)	Foundational strategies 5. Integrate physical activity in everyday settings 6. Maintain a supportive environment 7. Make accessible spaces/equipment available to all 8. Make sure there is a welcoming environment 9. Make sure there is fun and enjoyment 10. Offer a variety of activities
Make accessible spaces/equipment available to all (8.43)
Make sure there is a welcoming environment (7.48)
Make sure there is fun and enjoyment (6.52)
Offer a variety of activities 6.96)
Provide easy access to information about physical activity opportunities (6.35)
Set achievable goals (6.7)
Use clear communication (4.96)
Adapt the rules and aims of the programme to the abilities of participants (7.26)

The relative lack of variation among the final scores of the most popular and the least popular principles and strategies is unsurprising as the expert group had already selected these lists of principles and strategies as having the most importance and relevance for inclusive physical activity. However, the fact that all statements in both lists received some degree of support suggests that those statements that were removed from the list for the final round of the consensus-building exercise could have been retained and used in some way in the host project. Consequently, findings from both round two and round three were communicated to the project partners. Nevertheless, the Delphi methodology demands that a line is drawn somewhere in the dataset to distinguish between the most- and least-supported statements. This line is always somewhat arbitrary. In this case, items that received a weighted average of 7.0 or higher were carried over to the third round. Items that came below that threshold were dropped from this analysis.

Discussion

The aim of this study was to identify experts’ views of the measures required to encourage participation in inclusive health-enhancing physical activities among all segments of society. This is fundamentally different from approaches that have previously dominated research in their field, which have tended to focus on organisational and administrative variables. One systematic review categorised interventions into four types (Cavill and Foster 2004), and this typology still seems broadly relevant (Baker et al. 2015):

1. comprehensive integrated community approaches, where physical activity is part of an overall risk factor reduction programme;

2. community-wide ‘campaigns’ using mass media;

3. community-based approaches using person-focused techniques; and

4. community approaches to environmental change.

There are, of course, points of overlap between these approaches and those reported in the present studies. For example, the third category of the review includes programmes that use methods and strategies, and the fourth category includes programmes that use some form of community action. These interventions are often delivered to communities in combinations. Nevertheless, this study’s focus on principles and strategies is complementary rather than repetitive of earlier studies.

The themes underlying the identified principles and strategies implicitly reflect on-going discussions about the nature and scope of inclusion. There is widescale agreement among commentators that inclusion is not only about physical placement, as early presentations suggested (Göransson and Nilholm 2014). However, the very idea of inclusion continues to be conceptually contested and prone to numerous different interpretations (Thomas 2013). The themes emerging from the present study can be interpreted in terms of precisely these tensions. Perhaps most notably, is the distinction between what we have called ‘inclusive’ and ‘exclusive’ conceptions of inclusion earlier in this article. The tendency to frame discussions of inclusion within relatively strict disciplinary or contextual silos (aka ‘exclusive inclusion’) has been noted by several writers (DeLuca 2013; Penney et al. 2018). In communicating with experts, we asked that they adhered to the project’s conceptualisation of inclusion as an interdisciplinary and multi-factorial framework that prioritises fair and equitable access and participation of all citizens irrespective of differences, as discussed above (aka ‘inclusive inclusion’). In other words, we sought to avoid focusing on specific groups and implicitly excluded those who fell outside its self-defined boundary. It seems clear we were not successful in this. For example, the first two principles identified by the expert group were ‘Include disabled people in planning’ and ‘Focus on ability, not disability’, and core strategies included ‘Adapt the rules and aims of the programme to the abilities of participants’ and ‘Apply adaptability of teaching/coaching methods’ (‘adapted physical activity’ is often synonymous with physical activity for persons with a disability; Hutzler and Sherrill 2007).

This interpretation of inclusion is not without precedent (Thomas 2013; DeLuca 2013), although the distinction presented in this article is new. These earlier perspectives and this account share an assertion that inclusive practice, to be worthy of that name, ought to express a progressive broadening of scope away from narrowly defined concerns. This suggests principles and strategies that are either generic or focused on the removal of barriers at a community or societal level. Most of the principles and strategies emerging from the Delphi process are, in fact, consistent with these ideas. For example, half of the identified ‘core’ principles (focus on participants’ needs; promote equal opportunities) and strategies (be accessible and available to participants; establish models to make sure participants’ voices are heard) seem to fit well with our ambition. Likewise, most of the other principles and strategies reflected the inclusive idea of inclusion.

Conclusion

This study has been explicitly exploratory and scoping as it sought to understand the shared perspectives of an expert group, but also the methodological challenges of an under-researched and conceptually contested topic. There was a practical goal, too, namely the articulation of content for an informed curriculum for inclusive physical education promotion in Europe (see Acknowledgements). With this final ambition in mind, a list of themes was drafted based on the compiled principles and strategies from rounds 2 and 3 of the Delphi exercises which have been offered to the HEPA4ALL project partners as a possible starting point for curriculum development. An iterative, loop-like process of multiple rounds of feedback, redrafting, meaning-making, and progressive focusing consistent with qualitative content analysis (Srivastava and Hopwood 2009) was employed. The aim was to move towards a parsimonious set of tenets that could serve as a starting point for conversations about the translation of the findings of the study into practical programmes within the HEPA4ALL project. This process resulted in the following conjectural list of concepts:

• Inclusive values - positively promoting the value and benefits of inclusion

• Inclusive awareness - being aware of and promoting different needs and interests

• Inclusive communities – bringing people together in inclusive, activity-friendly environments

• Inclusive provision - adapting sessions to maximise participation and increase capacity

• Inclusive environments - ensuring physical activity settings are welcoming and suitable for all

• Inclusive spaces and resources - providing equal and fair access for all

• Inclusive planning and participation - involve the broadest possible range of stakeholders to improve and increase capacity

• Inclusive communication - maximum exposure through inclusive, promotion, distribution channels, content and messages

• Inclusive coach education – related to tools and knowledge to be used by deliverers of physical activity opportunities

• Inclusive coach development – related to accessible education for persons who are disadvantaged or with a disability

Funding

This study was part of the ‘HEPA4ALL’ (Health-Enhancing Physical Activity for All) Project, funded by the European Union’s Erasmus+ scheme Project Number 622480-EPP-1-2020-1-UK-SPO-SCP.

Declarations

Ethics approval

Ethical approval was provided by a special committee of the Board of Directors of Ikkaido Ltd (21/02/22-Bailey). The authors were not involved in this process.

Conflict of interest

Both authors declare that they have no conflicts of interest.