We begin by discussing the studies that make up a generic public health review on physical activity and provide an assessment of the individual papers, in accordance with our decision aid (Table 12, based on studies in Dobbinset al.133).
The settings for these public health interventions were mostly high- to middle-income countries. Physical activity primarily focused on the prevention of obesity in children and young people. A total of 44 RCTs
TABLE 12 School-based physical activity reviews
Interventions
Ranking
Dignity Inclusion Intersectionality Accessibility Equity Total
Angelopouloset al.526 Amber Red Amber Red Amber 1.5
Araújo-Soareset al.527 Amber Red Amber Red Amber 1.5
Barbeauet al.528 Amber Red Amber Red Amber 1.5
Bayne-Smithet al.529 Amber Amber Amber Amber Amber 2.5
Burkeet al.530 Amber Red Amber Red Amber 1.5
Bushet al.531
Colin-Ramirezet al.532 Amber Red Amber Amber Amber 2
Dishmanet al.533 Amber Red Amber Red Amber 1.5
Donnellyet al.136 Amber Green Green Amber Amber 3.5
Dorgoet al.137 Amber Green Green Green Red 3.5
Ewartet al.534 Amber Amber Amber Amber Red 2
Gentileet al.535 Amber Red Amber Amber Amber 2
Haerenset al.536 Amber Amber Amber Amber Amber 2.5
Haerenset al.537 Amber Amber Amber Amber Amber 2.5
Joneset al.538 Amber Red Amber Red Amber 1.5
Kippinget al.539 Amber Amber Amber Amber Red 2
Kriemleret al.540 Amber Red Amber Red Amber 1.5
Liet al.541 Amber Amber Amber Amber Amber 2.5
Lubanset al.542 Amber Red Amber Amber Amber 2.5
Luepkeret al.543 Amber Green Amber Amber Green 3.5
Martinezet al.544 Amber Amber Amber Amber Amber 2.5
McManuset al.545 Amber Red Amber Red Amber 1.5
Neumark-Sztaineret al.546 Amber Red Amber Amber Amber 2
Peraltaet al.547 Amber Amber Amber Amber Amber 2.5
Petcherset al.548
Reedet al.135 Green Amber Amber Amber Amber 3
Robinson549 Amber Amber Amber Amber Amber 2.5
Salmonet al.550 Amber Amber Amber Amber Amber 2.5
Simonet al.551 Amber Amber Amber Amber Amber 2.5
Singhet al.552 Amber Amber Amber Amber Red 2
Singhalet al.553
Stephens and Wentz554 Amber Red Amber Red Red 1
Stoneet al.555 Amber Amber Amber Red Amber 2
Treviñoet al.138 Amber Green Green Green Green 4
Verstraeteet al.556 Amber Red Amber Red Red 1
Walteret al.557
Waltheret al.558
were included. A total of 24 of these were based in the USA and the rest were located in Australia (6), Belgium (3) and six other European countries (France, Greece, Portugal, Spain, Switzerland and the UK), all of which contributed one study, in addition to Canada, India, Mexico, China and Hong Kong, all of which also contributed one study each.133The studies dated back to the 1980s, and the early US studies had
particularly large samples. The 44 studies comprised 36,593 participants, including young people, families, teachers, schools and communities.133Most of the trials were longitudinal, usually>6 months in duration,
with many of the US studies lasting several years.
When assessing these public health studies we noted three inter-related thematic observations from which to explore the potential of an inclusive disability research agenda, namely, linking theory to empirical design; disability and mainstreaming; understanding intersectionality.
Linking theory to empirical design
Most of the studies could be said to be theoretically informed by public health paradigms, often with an implicit focus on combating inequalities, although some studies did not make this explicit and, more generally, there was little engagement with more theoretical explanations of inequalities or disadvantage. Poverty, for example, was rarely mentioned, despite its importance in exploring obesity and physical activity.565Many studies, however, reflected a sustained commitment to health promotion and (theoretical)
use of health belief models such as Bandura’s social cognitive theory, theory of planned behaviour or socioecological approaches. The use of behavioural change models were usually focused on the individual (micro) issues rather the broader social (structural) context, in which people made choices. No study engaged with an explicit model of disability.
It was rare for any theoretical connections to be made between inequalities, public health paradigms, diagnosis of conditions or impairments, the outcome measurements being used and how long-term impact was measured for sustainability. When contacted, authors could not provide convincing explanations for this and seemed uncertain what was meant by theory. This explains why many of the studies offered a descriptive rather than explanatory analysis, which made it difficult to assess why an intervention was successful. Most studies gave a narrow quantitative appraisal about what evidence existed to support the intervention and how bias was controlled.529For example, Burkeet al.530discussed a trial of health
promotion programmes for 11-year-olds that was geared towards high-risk children and illustrated the statistical robustness of methods as well as the characteristics of the higher risk children who left the intervention. An understanding of why those higher risk children left the study was not, however, part of the analysis.
TABLE 12 School-based physical activity reviews (continued)
Interventions
Ranking
Dignity Inclusion Intersectionality Accessibility Equity Total
Wanget al.559 Amber Amber Amber Amber Amber 2.5
Webberet al.560 Amber Red Amber Red Amber 1.5
Weekset al.561 Amber Red Amber Amber Amber 2
Williamsonet al.562 Amber Amber Amber Red Amber 2
Wilsonet al.563 Amber Amber Amber Amber Amber 2.5
Younget al.564 Amber Red Amber Red Amber 1.5
Amber, nominal inclusion; green, inclusion; red, no inclusion.
Note
Blank cells indicate that no response was received from study authors.
Disability and mainstreaming
In discussing mainstreaming with authors, we became aware that many studies did not use consistent definitions of disability, with few referencing international conventions or medical definitions. Authors who e-mailed us acknowledged that they were unclear about the definition of‘disability’that they should use, or who and what was included in the term‘disability’. There was confusion over whether or not‘disability’ was inclusive of illness, learning difficulties (e.g. ADHD), neurodiversity (e.g. Asperger syndrome) or mental health issues. Some authors stated that they had not asked about such issues and felt that they belonged to a private (personal) not public (political or social) realm. In a few cases, authors asked for clarification from the research team, asking what we understood disability to be. Authors also struggled to define what inclusive practices meant. Verstraeteet al.556had bought a range of robust equipment for their physical
activity intervention but admitted that they had not thought about accessibility or accommodation. One author, however, did send us material illustrating how the trial had thought about mainstreaming in physical activity interventions.135
Some authors thought that disability was‘probably’included or‘could’have been included or that
disabled children had participated, but they could not give specific details. One author stated confidentially via e-mail that they had tried to include disabled children by administering the questionnaire face-to-face. Other authors mentioned how disability became a part of exclusion criteria, such as in the case of walking or running interventions,540and stated that no disabled children had been included. Some authors
qualified this by saying that‘severe disabilities’were not included and added that those decisions belonged to the schools.563Despite the lack of inclusion, some of the interventions could have been adapted to be
accessible to disabled children.542The inclusion of families or carers was largely justified on the grounds of
ethics rather than analytical or explanatory significance. None of the authors mentioned universal design or what the notion of‘mainstreaming’included.
Although cultural sensitivity had been considered in several studies,135,138,528,555and a link made to
‘well-being’, the majority of studies were not particularly disability sensitive or inclusive of disability culture. Most studies had not adequately defined cultural sensitivity other than in terms of exclusion criteria. Several authors passed the onus of responsibility on to the institution from which the sample was taken, stating that they depended on the institutions to ensure accessibility or to define mainstreaming. One author noted that American schools are required by law to ensure disability mainstreaming but qualified this by stating that this is only if they are‘able’. These links to legislation are revealing. Although‘disability’ may have been implicitly included in trials, none of the studies’analyses discussed disability.
Disability and intersectionality
Some studies successfully related intersectionality to debates about inequalities. These included studies on improving health for girls, which connected ethnicity and lower socioeconomic status to hypertension, obesity and cardiovascular disease. Some studies focused on African American51and Mexican American
children.138,531Three studies focused explicitly on African American girls,528,534,564and others focused on the
mixed ethnic and socioeconomic backgrounds of children in inner cities, areas with deprivation or
urban–rural divides.533,538,557,563Generally, US studies tended to be better at engaging with intersectionality
associated with age, gender, ethnic origin and social economic status than some European studies.535–537,540
However, intersectionality remained poorly conceptualised theoretically. Eight of the US studies that explicitly focused on gender (girls) and health issues linked to obesity528,529,533,534,538,546,560,564struggled to explain their
findings in terms of ethnicity or socioeconomic disadvantage (or disability). Webberet al.560focused on
ensuring that participating girls came from a range of backgrounds and ethnicities, and they used a combination of qualitative and quantitative techniques linking health promotion in schools and within communities. However, their process evaluation considered gender and‘race’as statistical values as part of a broader strategy to understand fidelity.564Some smaller studies, however, were more successful, such as the
Australian study focusing explicitly on boys, which noted that a‘one size fits all’approach might not work and that a more targeted approach might be necessary.547However, within the Australian context,
Many of the authors said that they had collected data on comorbidities and chronic conditions, usually in a questionnaire. Few of the studies, however, explicitly examined comorbidities or chronic conditions unless they felt obliged to explain them as criteria for exclusion. McManuset al.545note that none of the
children included had any‘present illnesses or chronic conditions’and Treviñoet al.138excluded children
with‘type 1 and 2 diabetes’. Weekset al.561note that subjects were included if they were in
‘sound general health’and could participate in a jumping intervention. Wilsonet al.563noted that:
Adolescents were excluded if they had a medical condition that interfered with PA, (2) were developmentally delayed such that the intervention materials were not cognitively appropriate or, (3) were currently in treatment for a psychiatric disorder.
The inclusion of disability was usually seen to overcomplicate study design and/or be incompatible with outcome measures. Many authors also struggled to reflect on the extent to which the interventions that they were evaluating could function to exclude people with disabilities. Wanget al.559positively noted the
importance of the cultural sensitivity of their research (as it included a high percentage of African American participants) but did not include disability sensitivity.
Equally, concepts of inclusion, accessibility and theoretical and methodological connections to equity were poorly debated by many of the studies. This is why many studies found it difficult to accommodate the diverse experiences of disability and, more specifically, to offer explanations about the extent to which study findings had any relevance for a broad range of disabled groups.