It is well documented that physical activity (PA) participation results in multiple health benefits, including overall improvements in physical health as well as reduction in risks to chronic diseases. In addition, participating in PA results in benefits, including improved mental health and increased positive mood, and can assist in weight management (1). These benefits to PA are consistent with everyone, including persons with disabilities (PWDs). However, despite known PA benefits, many PWDs do not meet recommended PA guidelines (2). PWDs are less likely to engage in PA than their peers without disabilities (2) and, as a result, have a greater risk of heart disease, diabetes, and obesity (3). Because of what have been deemed preventable gaps in these risks between PWDs and persons without disabilities, PWDs have been identified as a health disparities group (4). Health disparities are preventable and exist as a result of a lack of inclusive community PA opportunities. It is common for organizations, such as fitness facilities or programs, to have a disability policy statement, yet follow-through and outward action of policies is less common. Throughout the literature, many solutions and guidelines are provided to these organizations, but they are not always action oriented. Commit to Inclusion gives an excellent set of guidelines to start the process (5), but a guide with more tangible examples and solutions is needed so that organizations can successfully include PWDs and be fully compliant with the current U.S. Americans with Disabilities Act (ADA) law. This article outlines the necessary steps and provides examples for community organizations, such as fitness facilities and community fitness programs, to successfully implement inclusion for PWDs. To successfully implement inclusion, five proactive steps must occur, including 1) defining an inclusion policy, 2) increasing staff education, 3) removing barriers, 4) engaging the disability community, and 5) continuous evaluation to ensure that goals are being met. Not only is this needed to address health disparities, it is required by U.S. law.
STEPS FOR ENGAGING IN INCLUSION
Step 1: Define an Inclusion Policy Specific to Your Organization and Your Organizational Goals
When community organizations wish to begin their process of being inclusive of all individuals, the first step is to clearly define the inclusion definition and policy. It is important to start with defining what the end goal of inclusion will look like for that organization, as it sets the foundation for further actions in the process of becoming inclusive. For the purposes of this article, it is important that the authors recognize these strategies are specific to inclusion of PWDs as a typically underrepresented group when considering equity, diversity, and inclusion. Intersections including, but not limited to, race, ethnicity, socioeconomic status, LGBTQ+ identity, and citizenship must be considered when aspiring for true inclusion but discussed at length within is a disability-specific approach. However, the authors cannot underscore enough the importance of including the community within every step to inclusion, most specifically in this introductory step of defining what “inclusion” means for each organization and their community.
Literature indicates that inclusion is poorly defined and that there is a need for a more conceptual framework through which organizations can define their inclusive practices (6–8). The social ecological model is ideal when implementing inclusion as it highlights the various factors and the dynamic interrelations between them. For more details on what the social ecological model is, please see the article by King and Gonzalez (9) in the July/August issue of ACSM’s Health & Fitness Journal®. Generally, inclusion is defined as the opportunity to participate in every aspect of life to the fullest extent possible by transforming the system to make it better for everyone (5). However, organizations must understand how to apply this definition specifically to their organization and their goals. There are different needs in various disability populations, such as, but not limited to, those with physical disabilities, those with intellectual and/or developmental disabilities, and those in both populations who have challenging behaviors. Those writing inclusion definitions do not need nuanced knowledge of each specific disability but, instead, must operate with an understanding that all potential members have different needs and capabilities. For specific examples of what “inclusion” could mean, it is recommended for organizations to regularly take advantage of trainings and resources provided in our Resources section but, more importantly, consult their community members with disabilities. From there, the organization can begin to formulate a plan, possibly with a goal of rolling out a series of changes over several years, that is both feasible given their resources and catered toward their community. This step should not be taken lightly and should be given much time and consideration. Developing an inclusive practice definition is a process needing constant revision and attention.
After organizations have defined what inclusion may look like at their facility, this should be reflected in their mission and vision statements. These statements should include language that directly states that PWDs are included in the organization’s focus. These statements are a bigger way to ensure that all stakeholders at the organization are on the same page for future directions. An example of an inclusive mission statement is to “enhance the quality of life and citizenship for people of all ages and abilities by providing inclusive programs and services of the highest quality and value” (10). This reflects inclusion that is directed to individuals of all abilities, and this is mentioned directly in their statement.
Current practices for organizations include having some sort of inclusivity and/or diversity statement, but there is a gap in statement versus implementation. External pressures of inclusion often drive these statements without so much of an understanding as to what the organization can do and concrete steps of how they will get there. By understanding what inclusion will look like within the organization, teams can take a critical look at steps that are realistic in achieving those goals. It is highly recommended that inclusion and diversity statements not be used until a written or conceptual strategy of steps the organization will take to reach their goals is in place. This, again, is a process that will take considerable time, research, and community engagement and should be understood as subject to change as more knowledge is acquired.
Step 2: Build Knowledge and Understanding among the Facility Staff
A prevalent barrier for PWDs is the lack of knowledge among facility staff when it comes to fitness for PWDs (11). As stated earlier, PA guidelines are the same, regardless of ability, which should be understood by organization staff. As such, a disability-specific component must be present during staff training for employees at every level. Initial training can be broad, to include, for example, the utilization of person-first language and an awareness of identity-first language uses, as well as a commitment to minimizing clutter and any obvious physical barriers in all spaces. Other considerations may include more culturally significant examples such as sitting in a chair, instead of standing, while chatting with a member who is in a wheelchair, or using simple and concise language when talking to someone with a cognitive disability, while being mindful not to talk down to them. These trainings must be conducted by professionals in the field and experts on disability sensitivity training who can tailor trainings to the community identified during the organization’s inclusion policy development.
Additional training recommendations include prioritizing the hire or subsequent certification of staff who are trained to work with PWDs in a fitness setting. Several national certification organizations offer programs specific to disability, including Certified Inclusive Fitness Trainer (American College of Sports Medicine [ACSM]), Personal Trainer for Special Populations Certification (American Fitness Professionals and Associates), and Autism Specialist Exercise Certification (Exercise Connection and ACSM). Additional trainings could include providing staff with behavioral trainings, such as crisis prevention intervention, which can be an asset to aid in the successful inclusion of individuals with challenging behaviors. These trainings are imperitive to broaden the staff’s overall understanding of fitness for PWDs and the realization that every person, with and without disabilities, comes with their own unique needs and challenges. Staff certifications and trainings help enforce the knowledge that each person ought to be approached in the same way, regardless of their disability status or identity, and increase recognition that many physical or psychological barriers, such as underdeveloped motor skills, fear of injury, low perceived physical competence, or lower exercise self-efficacy, are present in people of all abilities. Having staff with these trainings and certifications can help with modifying exercises to the unique needs of each individual and bring this knowledge to the organization, which is an essential aspect to be incorporated into all staff trainings. Supporting disability and chronic condition-specific training, both financially and with protected time, is a way to ensure staff are up to date on this population and are constantly evaluating their environment to be welcoming to PWDs.
Step 3: Create a Concrete Action Plan to Remove All Barriers
To ensure accessibility, the organization must make sure that the physical, social, and monetary factors are inclusive (11). With that in mind, it is time to move past the conversation of building access and ADA compliance and start to focus on all barriers, including societal, that surround inclusion by creating a thoughtful and concrete plan.
For physical barriers beyond building access, there are many things to consider from the built environment to the exercise equipment (11). Considerations may include leaving enough room between machines so that a person in a wheelchair can successfully and independently travel around the facility and equipment. Additional considerations include having folding chairs in the gym and group exercise spaces to allow for resting places and having quieter gym spaces available to allow for sensory breaks. Further considerations could include providing simple and clear instructions on how to complete the exercise at all equipment stations and group exercise rooms, such as task cards (see Figure). For a list of commonly identified barriers and solutions, see the National Center on Health, Physical Activity and Disability’s (NCHPAD) interactive floor-mapping activity (12).
Societal barriers include the attitudes and perceptions of the professionals, employees, and members of the organization without a disability (11). These perceptions that create a barrier include seeing inclusion as unimportant, or believing the myth that PWDs do not want to engage in PA (11). To overcome these barriers, organizations must commit to creating a culture of acceptance and awareness throughout their facility that is modeled by their staff. Further, it should be expected that current members without disabilities adopt this sensitivity to the unique needs of the PWDs in their community. Emerging research is finding that, although an organization’s physical and staff barriers have been overcome, existing member perceptions toward new members with a disability have not changed and are unwelcoming. Therefore, it is up to each organization to address and educate their existing members on the same perception and attitudinal barriers as with their staff. This is something that may take time to achieve, but it is an essential culture to create for successful inclusion. PWDs are often accompanied by family, friends, or other supporters who can help with inclusive cultural shift. Person-first and identity-first language considerations, staff modeling behavior, and even buddy systems, discussed later, for these new members also can assist in changing the culture of an organization.
Further considerations, particularly financial, are important aspects that need to be discussed as part of the overall inclusion plan. Full inclusion does not have to “break the bank” but will incur an extra cost. Accessible equipment, changes to floor layouts, continued staff training, and hire of additional staff aides are a few areas needing budget consideration. In addition, barriers of cost are largely influential for most PWDs (11), which means having a plan for addressing this barrier is imperative. Some solutions include offering discounted rates for PWDs or allowing caregivers to attend for free with the PWDs. An emerging strategy also includes a “buddy system” or offering discounted rates of membership or participation for existing members who wish to attend gym sessions, or classes, alongside a PWD after having received training to do so. This can reduce cost for the organization by allowing them to use a volunteer system consisting of their own members, rather than outsourcing and managing volunteers or hired professionals. Further, this strategy also can contribute to the overall culture at the organization and perpetuate an expectation of inclusion by all.
These are just some of the barriers that could be present at organizations that can affect the participation of PWDs. There are multiple other barriers that are commonly experienced by PWDs (see Table). It is important to engage with the local disability community to see what barriers they are experiencing and strategies they have to successfully participate in PA.
Step 4: Engage the Local Disability Community
Engaging the community includes prioritizing the availability and access of resources, bidirectional communication with community members with disabilities, and considering the structure of activities that are offered. While implementing inclusion, it is important to know the community and understand their unique needs. This should be done by including PWDs at every step (5). Including PWDs helps to ensure that services provided are truly accessible and wanted by the community. It is important that organizations not make assumptions about the needs and wants of PWDs, but, instead, trust the first-hand accounts of PWDs and thoughtfully consider the guidance they offer.
Involve community members with disabilities in the inception of the organization’s goals and communicate these goals with the disability population often. Continued communication in formats that are accessible to all individuals is key to the success of the initiative. Marketing materials should include photos of members with disabilities. There must be a clear objective of targeting PWDs as potential members by integrating them into sales and marketing literature. This literature also must be written at an appropriate reading level and with font size and format that is accessible to members with cognitive disabilities and visual impairments.
When reaching out to the community, inquire about the types of programming that they are looking for. For example, are PWDs looking for segregated or inclusive classes, as different individuals prefer different structures (6). Segregated classes can build a social community with others who experience disability and can improve personal and situational resilience. Fully integrated classes provide individuals with disabilities the greatest opportunity to promote positive awareness and receive full independence (6). It is important to engage with local PWDs to determine and offer the programming that is most desirable to the community.
Step 5: Evaluation of the Policy and Practice
Inclusion is a process that should be consistently evaluated, with the help of PWDs, to ensure that the organization’s plan of inclusion aligns with practice. Ensuring organizational maintanence of staff awareness and sustainability of practices by including PWDs at every step is paramount to inclusive practice success. Integration into current organization boards and/or creating an advisory board of invested stakeholders such as members with a disability, donors, physical therapists, and/or community experts in fitness inclusion can be helpful to creating the organization’s plan for inclusion and can assist in accountability and evaluation. This advisory board can play a key role in evaluating whether the success of the established plan and culture is being maintained. Is inclusion being embodied by all staff and members? If not, how can it be changed to establish a culture of healthy acceptance? Are there still barriers in the facility preventing complete participation of PWDs? How can these be removed? Questions such as these should be regularly evaluated with the help of PWDs and maintained throughout the initiation and maintenance of being an inclusive organization. As refered to earlier, having a clearly designed mission and vision statement can be helpful in creating an overall atmosphere and culture of health for everyone.
Along this journey to inclusion, many resources are available to assist in the process. The first is NCHPAD. This is a great resource that offers practical suggestions and exercises, community health inclusion sustainability planning guides, as well as resources for creating a coalition of stakeholders and evaluating progress. Their interactive floor-mapping activity can help staff and administrators evaluate the facility layout for accessibility. They also highlight many certifications and resources that can be helpful to fitness and medical practioners wishing to continue their education on inclusion and PA for PWDs.
To help increase understanding of the barriers that PWDs face, Rimmer and colleagues (11) wrote a seminal article that discusses multiple barriers as well as facilitators to help overcome these barriers. This can be a great resource to develop a better understanding of some of the barriers that may exist at your organization.
Another resource is committoinclusion.org. This web site is funded and provided by many national fitness, health, and disability organizations. This offers nine steps to inclusion in a brief document that quickly summarizes many of the aspects discussed throughout this article.
Many community inclusion resources exist once an organization has made the commitment to define what inclusion looks like at their organization. It is imperative that the organization finds what works best for them and their participants first, and then explores the resources that will be the most beneficial to them.
Many actionable steps exist for community PA organizations to engage in inclusive practices. Included within this article are only a fraction of the examples organizations can employ. It is recommended that organizations make the initial commitment to inclusion, define what that looks like throughout their organization, and then engage in strategies that will continue to build them toward creating a culture of health for every individual while including PWDs at every step. It should be understood that grasping the nuance of disability in PA requires constant and continual attention, which should be revisited and refined, often, in conjunction with the local community, to fully engage and serve the population.
BRIDGING THE GAP
To successfully implement inclusion practices, many steps must occur, including defining an inclusion policy, increasing staff education, removing barriers, engaging the disability community, and continuous evaluations to ensure that all goals are being met. This article illustrates the steps necessary for community organizations, such as fitness facilities and community fitness programs, to successfully implement inclusive practices. Not only is this needed to address known health disparities for PWDs, but it is required by U.S. law. Successful inclusion must occur, proactively, in conjunction with the local community and requires constant and continual attention to grasp the nuance of disability in PA.
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