In this Disability Sport Info episode, I'm joined by Professor Brett Smith to discuss physical activity and sport participation of disabled children and young people.
In our chat, we focus on the latest Chief Medical Officers’ (CMO) Physical Activity Guidelines for disabled children and young people. We consider what these findings mean for our understanding of disabled children and young people's participation in physical activity and sport.
This episode was recorded in February 2022.
Please click on the following link to access the CMO Guidelines and infographic: https://bit.ly/3OytbX6
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Speaker: CB: Dr Christopher Brown (Presenter – University of Hertfordshire, UK)
Speaker: BS: Professor Brett Smith (Participant – Durham University, UK)
Speaker: CB Time: 0:30
Hello Listener, welcome to the show. In this episode, we are joined by Professor Brett Smith of Durham University, who will discuss the physical activity and sport participation of disabled children and young people. In our chat, we focus on the latest Chief Medical Officers’ Physical Activity Guidelines for disabled children and young people. Brett was a leading researcher involved in creating the guidelines, providing an insider's perspective of the process and evidence that informed the making of the guidelines. I caught up with Brett to discuss this area in more depth.
So I think to kick off the discussion so our listeners can get a broad understanding, to what extent do disabled children and young people participate in sport and physical activity?
Speaker: BS Time: 1:07
I think that’s a really interesting question because it depends upon at least two factors. One is which data are we going to use to answer that question? The second one is let's look at the quality of that data to then be able to answer it with some tentative conclusions. If we start with the ‘which’ question in terms of the extent, when you look at the data, what's really interesting is you get some data from certain organisations and in different countries saying actually, to what extent, in terms of physical activity, and when we have a comparative approach between disabled children and non-disabled children, we see very similar patterns. Not huge levels of physical activity, of course, because we know there are issues there, but we see similar patterns. On the other hand, when you look at other data, you see the disparities there. You see, for example, impairment groups in particular, with much, much less types of physical activity engagement. So it really does depend upon which data you utilise to be able to answer that question. So if anybody poses the question, ‘are disabled children less active than non-disabled children?’ It's actually a very challenging question to be able to say yes or no on that front. And part of that revolves around the second issue in terms of the quality of data.
When we look at the quality of data, most of it is self-reported. Now, we know that's not as accurate as, for example, accelerometer data or Fitbit data on that front, and then of course, when we throw in other issues in relation to disability such as complex disabilities, intellectual and learning, then that throws up a whole set of conundrums about how well the self-reported data can be utilised, because, of course, we know we've got memory issues and, particularly with children, we've got assumptions about what counts as physical activity, and what doesn't count as physical activity if parents are filling them in, and so on. So when we look at the data, the surveillance data in particular, it's not great, is the long and short of it on that front.
All that said, if somebody put a gun to my head, and said, ‘are disabled children less active than non-disabled children?’ In my experiences, the answer would be yes. But do we have the evidence base to say that the answer’s equivocal, at best on that front? And it's certainly something that we really do need to progress upon quite considerably. So lots of different reasons, lots of different reasons. But when we look at COVID, and the health disparities that have arisen as a result of that, well enlarge, should we say, because they’ve always been there. That's what worries me. If we can capture that data that, for example, if children are less active than non-disabled children, then we can make that even more of a priority. But that data alone, and this is what frustrates me about researchers, when we just collect that data. That's not good enough. In many respects that should just be the starting point of an article. One line. And then we need to move on to the question, how can we make things better? How can we make things better? There's too much emphasis just simply, simply on that data collection, but we do need to improve it.
Speaker: CB Time: 4:21
Interesting. Yeah, that's a really good distinction that you made about the availability of data and then the quality of data. I just wondering if you know, because I’m not sure if the quality of data exists here, but what's the picture globally? I think, traditionally, a lot of research has probably been Western in focus. I think that's probably a fair comment to make. So how much knowledge do we have when we're looking at, globally, participation in sport and physical activity?
Speaker: BS Time: 4:44
Well, that's again, a challenging question. It's challenging because when we look at, for example, what's revolving around the anti-colonialism of science. Now, I can't read, for example, different languages, say, different forms of South African languages. When we look at, even Western countries like Spain, I can't read the data that's been published in their languages. So when, as a researcher, when we make these broad claims about global work, we're often just relying upon English language, only. And of course, we can no longer do that. We must do better to be able to make these claims. We must work better. We must engage better with other languages so that we can answer these types of questions. But, when we do look at the English speaking language, we find, again, similar patterns. Actually, very little data going on in these types of countries, and what we do find in that data in and of itself, of course, we end up with some similar evidence to, for example, the UK. We find some evidence that it's similar patterns to non-disabled children. And, equally, we find evidence saying that non-disabled children have lower levels of physical activity than disabled children, of course.
Of course, but when we move into those different countries, that's when the health disparities start amplifying even greater, even greater. So when I'm working, for example, with my South African colleagues, when you go out into the communities there, the visibility of the health disparities are shocking, absolutely shocking there.
So, we really, we really do need to work much better on the ground, in terms of these communities and enabling all sides to do much better, particularly in terms of the anti-colonialism as well, that's a necessity. And of course, don't forget, Listeners, there’s a difference between anti-colonialism and decolonisation, which too many universities talk about decolonisation, but that's just about land. Hence, why many universities do get it wrong.
Speaker: CB Time: 6:47
Again, thank you for that distinction. And I think that's kind of really highlighting that need to have that collaboration, and that kind of common idea of what is quality data and how best to collect the data as well.
So, if we could just move to more of a UK focus for the time being, I know you've been involved in the Chief Medical Officers’ guidelines for physical activity for disabled children and young people, so would you be able let our listeners know what the current guidelines are, and how they were developed and informed? What evidence was used?
Speaker: BS Time: 7:14
Yeah. I think the evidence is an important question which I'll come back to. But I think, firstly, it's important to note that these are the first UK Chief Medical Officers’ guidelines for disabled children and disabled young people. There's been a gap in that evidence base up until this month [February], in fact, where they’ve just been launched on the 16th of February. Alongside those guidelines, we have an infographic to communicate them, that was co-produced, and an animation as well, that was co-produced. I think it's also important to stress that these are public health guidelines, people often criticise public health guidelines based upon clinical ideas, when, of course, the two are very different and they conflate the two. So it first needs to be stressed that these are public health guidelines, not clinical guidelines, on that front, and the same with the adult guidelines as well.
Well, last year, the Chief Medical Officers tasked myself and the team at Durham University, and I want to highlight the role of Ben Rigby here who was a fundamental part of this team, who led the review of evidence, and also my colleague from Bristol, Professor Charlie Foster, on that front. We were tasked with answering three questions as part of the review:
1. Is physical activity safe?
2. What are the health benefits? And
3. When we look at the FITT principles as well, for example, you know, the intensity and the time, how much physical activity is needed for good health.
We were tasked with those three questions. We did a review of the evidence and we found, I think, 476 studies that were included at the end, having gone through the review synthesis process. So we reviewed this evidence and what did we really find from this? Well, firstly, there was a reasonably large quantity of good quality evidence, when of course we think quality evidence means a randomised control trial on that front and, of course, we can debate whether that is high quality evidence for disability and when we look at other parts of how we want to do research, but nonetheless, that was the high quality evidence that we found. Well, what did this tell us in terms of those three questions? One, we found no evidence that physical activity is unsafe or harmful when done appropriately, of course, when done appropriately on that front. Secondly, we found some health benefits which I could come back to if that's of interest. But I think what we found fascinating was the results of the looking at the FITT, in terms of the frequency and the intensity and the time and the types of physical activity. When we, of course, reviewed the evidence, we'd had the World Health Organisation guidelines for disabled children and disabled young people in front of me, we dissected those. Those guidelines recommended 60 minutes of physical activity per day for good health. When we looked at the evidence, we found no evidence for 60 minutes whatsoever. Now what we found was it was 20 minutes of physical activity, approximately, per day. Or we also found evidence for 120 minutes to 180 minutes per week. So we found this dual evidence there, which I can come back to as well in terms of what the children preferred in terms of communication.
Now, what we're not saying is that the World Health Organisation's guidance is invalid. What we are stressing is several things. Number one, ours is evidence based. The World Health Organisation made their recommendations based upon very limited evidence, if evidence at all. And they also adopted a very different methodology than what we did on that front. Nonetheless, the Chief Medical Officers have accepted the recommendations, they’ve accepted the evidence. So what it is, is 20 minutes physical activity a day is good for your health. At the same time, of course, and I say 20 minutes because when we need to co-production afterwards, in relation to how we want to communicate these messages, we asked the questions, ‘does 20 minutes work for you?’ ‘Is 120 minutes, is 180 minutes a week message work for you?’ All the children, we worked with 233 disabled children and young people, and parents, carers, and some health and social care professionals, all of them, by and large, preferred the 20 minute message. It was more motivating, more easily achievable, and more memorable for those individuals.
But it's also important to stress two things. We also identified that it's important to do challenging but manageable strength and balance activities three times a week. That's really important, of course, for children with cerebral palsy as just one example. We also found evidence for that small amounts of physical activity are good for health. And that's a really important message I think as well. But what was really smart with the children in the co-production group, they're incredibly smart and nuanced in their finessing of the messages. And, if I can give you just one example of this. We're also in the evidence base looking at sedentary behaviour: ‘what's the impact of sedentary behaviour on children’, and also about the evidence of small amounts of physical activity as well. So there's this dual component to it. How to break up sedentary behaviour in small but frequent amounts of physical activity. And when we were discussing this with the children, we were throwing words out from the academic literature. There's a big emphasis now on snacking, for example. Every child, every young person, and every family member hated words associated with snacking. What they preferred was this ‘do bite sized chunks of physical activity throughout the day’ to communicate that message. That for me highlighted the significance of co-production. In other words, rather than a researcher waltzing in there producing messages that they believe are appropriate, usable, meaningful for a population, it’s actually, we’ve got to work with this population so that they themselves create messages that are appropriate and meaningful and usable and useful for them. And they created that message. And when I asked the question, ‘bite sized chunks?’ I just couldn’t get my head around it! Despite having an eight year old son! And they kept going back to the obvious points. Brett, this is how BBC works, you know, social media, the TV. This is how we're taught at school; bite size. So it was culturally meaningful and relevant for them, at least within the UK context, but these are UK guidelines, of course.
And I think what was also important in terms of the story that the told about this, they highlighted the significance, of course, of fun and exploring what makes you feel good. Those two, as well as inclusivity and equality, were really important for them to stress when we were producing the Chief Medical Officers’ guidelines, because of course, too much public health focuses upon the health benefits and how much physical activity. Now we're not cognitive drones: we don't just absorb this information and do it! If something isn't fun, if something isn't pleasurable, and if something isn't inclusive, we're not going to get those benefits. We're not going to do those 20 minutes or small amounts of physical activity. So they kept stressing to us, ‘we need finding what's fun. We need exploring what makes you feel good at the heart of all Chief Medical Officers’ guidelines and the communication of them for disabled children and disabled young people.
Speaker: CB Time: 14:38
Well, very interesting discussions, lots and lots of things I'd like to talk about. We are limited by time, so I can't talk about everything, but I think the point you made about co-design is fundamental and essential. And that’s shining through in lots of discussions I'm having about the importance of co-design, rather than imposing beliefs upon a particular population group. Really interesting anecdote about the bite size chunks. That was really interesting to learn.
I just want to go back to when you were talking about how when you were answering some of those questions that you were tasked with, one of them was about is physical activity safe. And you said, ‘yep. The evidence is very clear: it’s safe’. When you were looking at the evidence, was that evidence informed with a wide variety of impairment categories and types? Obviously, disability is a very complex, diverse group. It's a catch-all term which belies the individuality of the lived experience, etc. So what was your experience when you were looking at the evidence? What kind of data was collected on impairment types and categories?
Speaker: BS Time: 15:38
Yeah, we have to be careful of how we communicate this. And in the report, itself, we were very, very careful to highlight that we didn't find evidence to say that physical activity is not safe, is harmful. That was the first point. Now, of course, we had a preponderance of evidence around certain impairment groups and a lack of evidence around other impairment groups. So in the report itself, we're very cautious about certain groups and particularly, we still got issues to do with COVID and how that will impact upon people. So we did say, for example, certain impairment groups, we should then still, for example, engage with health professionals if they think it's going to be unsafe on that front.
That said, I think two points are really worth stressing. One was that when we spoke with the children and the parents, they were very, very keen for us not to communicate messages that utilise the words ‘health and safety’ in there. They didn't want to be deemed another example of a health and safety risk. They were very smart, very creative in how they termed this message. And what they did, was created the traditional message, which was when starting build up slowly, which of course, for certain impairment groups is really important, particularly if you're not that active from the very beginning. But what they also posed was this question, and that's in the infographic and on the animation, and it was asked, ‘can you do this today?’ And that was a really smart form of messaging for two reasons and different children got it either both of the reasons or at least one of the reasons. One was, well, ask, ‘can you do this today?’ ‘I'm an expert of my own body, Brett. I know whether I can be physically active today or whether it's a really bad day for me, and therefore I'm not going to be that physically active. So I can ask myself that question. Daily’. Secondly, also don't assume as a professional, that you know what's best for me. So you ask me what's best today, whether that’s a PE teacher, for example, a coach or whatsoever. And, for them, that was a really important way of messaging in managing the issues to do with risk, health, and safety on that.
Speaker: CB Time: 17:59
Really interesting. Yeah. And again, really important. Actually speak to the participant, the participant is the expert on themselves, like you said. Obviously provide the guidelines and frameworks but, ultimately, it's the individual who needs to be empowered to kind of take that message on.
You touched upon some of the health benefits and, obviously, you wouldn’t be promoting purely from the health angle, of course, but what are the kind of the benefits of participating in sport and being physically active?
Speaker: BS Time: 18:23
I think we could throw numerous benefits out there that we think would be in the evidence base, such as, for example, mental health benefits and meeting new friends. Well, when we look at the quantitative evidence base, we've seen rarely any strong evidence of that, sadly. However, when we look at the qualitative evidence base, and when we spoke with the children themselves during the co-production process, they highlighted the absolute importance, number one, making new friends and meeting new people. That to them was the most significant thing. Many of the children talked about the benefits of mental health. Many of them talked about it keeps me calmer, helps me feel less stressed. And also, they talked about a sense of achievement. And many of the parents backed that up when children had come from a sports or physical activity events, but the evidence itself, what we found was that it improves confidence, concentration, it also improves balance and coordination, and also muscles and motor skills. That was what the evidence was telling us. But, of course, in the infographics and communicating it in the animation, as well, we highlighted all of those. And I think what was really interesting from how the children talked about it, and some of the parents, was that the benefits can’t be looked at in terms of a one-shot approach. And what they meant by that was just because you do physical activity on X day, you're going to get these benefits. They talked about in terms of a lifelong approach. A life course approach in many ways, in terms of for example, yeah, ‘today, what's more important for me is meeting new people. But in a year's time when I’m entering those exams, feeling calmer and less stressed is going to be really important. And of course, as I grow up, balance, coordination and muscles are going to be absolutely crucial for me’.
So they looked at it in a really smart and clever way as well. I think we've got to focus much upon a life course approach, which we talk about, but I don't think we do as well as we could do.
Speaker: CB Time: 20:25
I’m just conscious that when we're talking about disabled children and young people. Were kind of, again, just kind of lumping them in one group, but were there any differences in terms of the evidence base, and also the recommendations, for those who have acquired an impairment versus those who have got a congenital impairment?
Speaker: BS Time: 20:41
Yeah, that's a good question. We do highlight the limited evidence with certain impairment groups in the report itself. And I think again, this is the type of common question we get when people have much more clinically orientated question in their head, and that's why I stress in the very beginning, this is a public health population-based report and population-based forms of communication. When we move into the clinical orientated, those the types of questions that we're more interested in and again, in the report we do touch upon that, and there is some stronger evidence for certain impairment groups than other impairment groups. So for example, there was a lot of evidence in relation to cerebral palsy, intellectual and learning, but very little evidence, for example, in terms of visually impaired in terms of the quantitative evidence, for example, on that front.
So in the report itself, we do stress, this limited evidence, and we do talk about we must be more cautious, particularly when we're at the individual level and particularly when we're moving into a more of a clinical health professional space that these differences and nuances do need to be focused upon. But hence why I come back to my other point, which the children said is ask, ‘can you do this today?’
Speaker: CB Time: 22:00
Okay. Again, a really important point worth emphasising there, looking at a kind of population wide.
What challenges exist in providing sport participation and physical activity for disabled children and young people in your opinion?
Speaker: BS Time: 22:14
We could be here for hours. So I'll just focus briefly on three. Cost. One. Inclusive environments; these are still lacking despite the rhetoric. And those, of course, aren’t just about the physicality i.e. ramps and accessible buildings. This is also about psycho-emotional disablism, for example, and ableism. So, ableism, like messages, ‘sit less, stand more. Get Britain standing’. Those ableist messages and psycho-emotional disablism for example, in terms of Carol Thomas's work, are just one example in terms of children being stared at, in environments that they're made to feel awkward and less of value. So I think those two, certainly cost and inclusive environments.
I think also it's a lack of high quality physical activity and sports. By high quality we can talk in many different ways, but there's some interesting research that I've talked about it in terms of having high quality environments in terms of providing choice. How many disabled children get a choice in comparison to non-disabled? Probably much less choice. A sense of belonging in terms of being respected and accepted in groups. Challenge. How often do we find sporting and physical activity environments that are appropriately challenging people? And competence, a sense of meaning, as well.
So those are some of the really big challenges for us to developing, cost effective, inclusive, high quality environments: we need to do much better.
Speaker: CB Time: 23:46
I think, finally, I'm interested in knowing about promotion of these opportunities because often, from my readings and maybe some of the Listeners’ readings, some of the barriers could actually be awareness of opportunities, and just lack of knowledge and accessible information. So I'm wondering if you could answer this in two stages, if I could be so bold. What would be your kind of best practice recommendations for promotion of activities? But then also what happens in practice currently, and is there a difference or we kind of aligning to both of those approaches? So what strategies are used to promote physical activity and sport participation?
Speaker: BS Time: 24:21
Challenging question! I think the Chief Medical Officers’ guidelines is a first and small metaphorical step. Of course, Chief Medical Officers’ guidelines won't change behaviour in and off themselves. And the infographics and animation in and off themselves won’t. However, we do believe, and we are already seeing having worked with numerous schools, it is starting to raise awareness. It is starting to put it on the agenda on that front. And I think there's other ways in terms of best practice, you know, seeing some sports organisations, in terms of developing coaching, much better coaching systems for disabled children or disabled young people. We're seeing small pockets and I stress, small pockets, of opportunities in summer schools as well for disabled children and disabled young people in terms of that.
I think the visibility of disability is slightly increasing at certain moments in time notably around, of course, the Paralympics where we have a mad rush of visibility. But of course when we look at it in practice, all this diminishes considerably when we get to the community-based grassroots physical activity and sports on that front. You know, ‘what is the visibility of disabled children, disabled young people in in the different settings?’ Very low, very limited. ‘Is the high quality coaching there? Is the high quality coaching done by disabled people themselves?’ Rarely, no. So, I think on the one hand, we're making inroads and strong inroads in relation to policy and practice at the academic and policy level. But filtering that to the ground level is still a challenge. We've got a long, long way to go. I would say that we've started the academic and policy challenge over the last few years. But in terms of getting it on the ground, we've still got a long, long way to go on that front.
Speaker: CB Time: 26:23
Okay, well, thank you, Brett. Some fascinating insights and fascinating discussions. I, again, really appreciate you taking the time to have a chat and to share your expertise on this area. It’s been really interesting to learn more about disabled children and young people. Hopefully, you, Listener, have also enjoyed that and also learned some new information and new knowledge.
So, thank you, Brett. It’ll be great to catch up soon. And thank you for being on the show.
Speaker: BS Time: 26:46
Thank you very much. Take care everybody. Bye bye.
*** Discussion ends ***
Speaker: CB Time: 26:49
That's it. That's the end of the show. Thank you for listening. Stay tuned for another episode of the Disability Sport Info Show. Until then, goodbye.
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