Gym staff perspectives on disability inclusion: a qualitative study

Abstract Purpose To explore gym staff perspectives on the inclusion of people with disability in the gym setting. Materials and methods Semi-structured interviews were conducted with 16 staff at four urban gym facilities, exploring perspectives on disability inclusion. An interpretive descriptive approach was adopted with reflexive thematic analysis of interview data and subsequent mapping of themes to the socioecological model. Results Consistent with the socioecological model, the themes identified were “people with disability benefit from participation in gym settings” (personal); “positive interactions with people with disability” (interpersonal); “managing expectations of other gym users” (interpersonal); “inclusion is supported by a positive ethos, staff training and accessible facilities” (organisational); “people with disability lack awareness of inclusive exercise opportunities” (community); “desire to increase collaboration with healthcare professionals” (community); “access to transport can facilitate gym attendance” (community) and “local gym policy” (policy). Conclusion Although an overall ethos of inclusion was apparent, areas identified for enhancement were: awareness of gym services in the community; inter-sectoral collaboration with healthcare and disability organisations; comprehensive disability inclusion training; transport systems and accessibility; engaging people with disability in gym service planning. Implications for rehabilitation Gym staff value collaboration with healthcare and rehab professionals to support inclusion of people with disability in exercise. Standardised disability inclusion training for gym staff is recommended. Individuals with disability should be empowered to contribute to the development of inclusive gym facilities and services. Rehab professionals have a role to play in raising awareness and advocating for inclusive exercise opportunities.


Introduction
The benefits of physical activity for individuals with disability include, but are not limited to, enhancing wellness, increasing physical fitness, promoting functional independence and reducing the risk of secondary co-morbidities [1,2]. In addition, participation in sports and recreational exercise programmes has been shown to promote autonomy, self-confidence and social interaction and is proposed as an effective vehicle for social inclusion for people with disability [3][4][5]. Despite these known benefits, literature shows people with disability are generally not meeting physical activity guidelines [6,7] and the quantity and quality of research on physical activity in people living with disability lags far behind physical activity research in the general population [7]. Nor do people with disability participate to the same extent in sport as their peers without disability [8][9][10][11]. Furthermore, it is known that children with disability engage in less physical activity compared to their typically developing peers [12][13][14] and adults with long-term neurological conditions report numerous barriers to exercise participation [11,15].
In exploring determinants of health behaviours such as exercise and physical activity, social ecological models are regularly used as they recognise individuals as embedded within larger social, physical and policy environments [16,17]. Having appropriate resources, equipment, supportive and social exercise environments are known determinants of physical activity participation for people with disability [18][19][20]. Gyms are one such physical and sociocultural environment, dedicated to facilitating physical training with specialised equipment and qualified instructors. As such, gyms should act as enabling exercise environments [19]. However, barriers persist, including poor gym access, financial issues such as the cost of gym membership, a lack of awareness of programmes and facilities, insufficient gym staff capacity and a lack of staff training [12,18,[20][21][22][23][24]. Low self-efficacy and a lack of belief in the benefits of being physically active are recognised barriers [9] to exercise participation and indicate a need for gym staff to adopt appropriate behavioural strategies.
Although, the pivotal role of sports and gym service providers in the experience and participation of individuals with disabilities in exercise is well recognised [10, 25,26], research focusing on their real world experience, relating to inclusion of people with disability in gym settings is limited. More recently, the quality of the gym participation experience has received more focus, with gym staff integral to that experience [9,26]. Exploring gym staff perspectives on challenges and facilitators to gym exercise engagement of people with disability may reveal important determinants of participation across socio ecological levels [16,17] and give new insights. This could, in turn, inform initiatives and policies which seek to enhance not only attendance but also the quality of the experience in the gym setting. This study therefore aims to explore gym staff perspectives on disability inclusion in a gym setting.

Ethical approval
This study was approved by the University College Dublin Human Research Ethics Committee-School of Public Health, Physiotherapy and Sports Science (UREC-SPHPSS). All participants provided written informed consent.

Research design
This exploratory study was completed using interpretive description, a qualitative approach which centres on the way human beings make sense of their subjective reality and attach meanings to it [27]. As such, it lends itself to questions that seek an inductively derived description of a phenomenon with consideration of the context and an orientation toward the generation of practicerelevant findings [27,28]. It allows a question of relevance to a particular discipline to be answered, where understanding something of the nature of the focus of that discipline's action is considered important, in this case the action of gym staff. Semi structured interviews were chosen to explore the perspectives of staff working with individuals with disability in a gym context, allowing participants to expand on their experience while the interviewer followed a study-specific interview schedule.

Setting and participants
The setting for this study was three community gyms and one university gym, all with pool facilities, within the same urban location. A government local authority provides the funding to a private company to run the community gyms which were built in the 1970/80s (upgrades 2000-2009) and have a staff of 100. The public can access the facilities via a "pay as you go" or three to 12-month membership mechanisms with inclusion of the diverse local community a priority for the organisation.
The university gym, established in 1981 (major redevelopment, 2013), has a staff of approximately 60 and also operates as a private company but with shared university governance structures and its clients are a mix of university staff, students and members of the broader community. All staff across all gym facilities were invited to volunteer via staff e -mail in accordance with the approved ethics proposal with sixteen staff volunteering (Table 1).

Interviews and settings
An interview schedule was developed, with domains and questions informed by the disability inclusion in sports and exercise literature and the authors' (CC, NS) related research, coupled with their professional and advocacy roles (Supplementary Appendix 1). Interview domains related to level of experience working with people with disability, challenges, facilitators, staff preparedness and confidence, training and the organisation's overall performance relating to disability inclusion. Three pilot interviews were conducted with minor subsequent amendments to the schedule and the addition of question prompts to enhance clarity.
Interviews were conducted in quiet, private settings at the gym facilities by a physiotherapy researcher-educator [CC] who also has substantial clinical experience. For all interviews, contemporaneous notes were taken by another member of the research team. Each interview lasted approximately 45 min. resulting in sixteen interviews. Interview data were digitally recorded and stored in password protected files.

Data analysis
Interview data were transcribed verbatim, anonymised and entered onto NVivo 12 data management programme. These data were then analysed using reflexive thematic analysis [28] (Supplementary Appendix 2). Researchers immersed themselves in the data by reading and re-reading the interviews and developing initial themes. Consistent with a critical friends process [29] a collaborative, reflexive approach [30,31], with considerable researcher discussion, challenging of individual interpretations and revisiting of data, resulted in construction of the final themes presented.
These themes were subsequently mapped to the socioecological model to help synthesise findings and present them in a meaningful way that aligns with previous research regarding determinants of physical activity and exercise participation [32,33].
By recognising individual, interpersonal, organisational, community and public policy factors which may influence a person's ability to be physically active, the SEM is also useful in framing opportunities to facilitate participation in exercise [15,16].

Results
Eight themes were identified and subsequently mapped across the five levels of the socioecological model as appropriate (Figure 1). These were "people with disability benefit from participation in gym settings" (personal); "positive interactions with people with disability" (interpersonal); "managing expectations of other gym users" (interpersonal); "inclusion is supported by a positive ethos, staff training and accessible facilities" (organisational); "people with disability lack awareness of inclusive exercise opportunities" (community); "desire to increase collaboration with healthcare professionals" (community); "access to transport can facilitate gym attendance" (community) and "local gym policy" (policy).

People with disability benefit from participation in gym settings
People with disability were perceived to benefit from exercising in the gym setting. The benefits of social inclusion and of physical activity for people with disability were commonly mentioned, with one participant saying: You have your typical benefits … a healthier body and living longer lives, but you also have the massive thing, which is probably bigger than the actual sport itself, is the socialisation of it (#111) along with another mentioning: it's a mental release (#105) One participant perceived people with disability gained confidence from attending the gym and interacting with the staff members: … the fear of coming into the facility, and not knowing what to expect, and all of a sudden you are met by a group of, or a team, that are willing to provide the service and provide exercise for everybody (#108) The importance of the individual with disability being motivated, using their initiative and having clear goals to create physical activity opportunities for themselves, was apparent among participants. This was described as leading to positive gym experiences including the development of independence: what I find is they are coming to the gym for a specific reason. And a lot of the times it's because they are either looking for assistance or looking for an opportunity to develop independence (#102) Gym instructors recognised that devising individualised, meaningful goals in conjunction with the person with disability, led to better outcomes: … her first goal was that her best friend was getting married and she wanted to go there without the aid of using crutches, [ … ] And then her next goal was to go ice skating[ … ], and she did it [ … ] And her next goal she said she wanted to be able to swim, and she did that too (#108)

Positive interactions with people with disability
Participants described the positive interactions between gym staff, people with disability and other gym-users, that led to an atmosphere of social inclusion.
Social inclusion would be another big thing, so we wouldn't (just) have mainstream people in the gym, we'd have a combination (#105) The positive impact people with disability had on other gymusers' motivation was commonly reported as "very motivational" (#108). Similarly, there were positives noted in the behaviour of some gym users who would "help out" a person with disability "if they see them stuck" (#105). Many gym staff spoke positively of their experiences of working with people with disability reporting it to be "quite rewarding" (#106) compared to working with other gym users: I enjoy working with people with disabilities because they have a clear mind set of what their goals are; very attainable goals as well (#102)

Managing expectations of other gym users
Participants raised challenges and issues that arose in relation to people with disability using the gym facilities alongside other gym users, highlighting the need to manage all gym user expectations. Although, not recalling any official complaints, participants acknowledged there could be frustration at times: … sometimes in the swimming lesson, in the slower lane, you might have people with a disability, and it does frustrate....say a slower swimmer who wants to pass them out [ … ] I can just sense it, and you know we try an alternative, "look, try and move into the medium lane for today" you know, there's alternatives (#110) One staff member reported other gym users may be apprehensive about having people with disability in their exercise class saying that "some people would be very iffy in that kind of way … " (#105). Another concern was the use of dedicated disability parking spaces by other gym users, which caused inconvenience for people with disability. One member of staff mentioned "being aware of potential friction" (#102) when other gym users park in disability car spaces acknowledging "people will put convenience in front of any moral obligation" (#102).

Inclusion supported by a positive ethos, staff training and accessible facilities
Participants commonly reported their organisation had a positive and inclusive ethos and culture. Responses indicated a recognition of the diversity of people with disability: they're all different and they all have different ways of doing things and different ways of understanding things as well (#106) and a genuine concern and willingness to be respectful in communication and responsive to the individual needs of a person: staff worried about the language they might use, … and that they are afraid of insulting or offending someone with disability (#111) … we had to engage with Rowing Ireland in terms of adaptive rowing and specialist equipment and just a bit of education in terms of our coaches so they could modify how they were coaching individuals that had a physical disability. (#112) Staff training was considered an essential component of creating an inclusive environment, particularly for younger staff who may lack disability experience and could be "out of their comfort zone" (#105). Although tertiary training courses were acknowledged as preparing staff with skills to work with diverse groups, participants believed additional, dedicated and contemporary training was needed: … unless they've been educated and given any sort of initial training or formal training on how to deal with people with disabilities … it's difficult to just place them in front of any sort of group or individual with disability (#101) Some participants sought out additional training themselves through external providers such as Special Olympics, Sport Ireland, or Cara, a national disability in sport organisation [33], particularly when their employer did not provide training. However, other participants reported poor uptake of formal training offered: Participants described elements they believed should be included in staff training: communication, dealing with challenging situations and knowledge about types of disability. Informal learning and building confidence through working with people with disability was also considered a mechanism by which gym staff could acquire skills.
Opinions were mixed regarding the accessibility of physical resources in the gyms. One participant described: we have a lot of equipment that would be accessible. The equipment is fantastic. Between hoists and between ramps and between machines … . (#109) However, another participant highlighted issues around inaccessible changing rooms and a lack of adapted equipment reporting: none of the equipment, with the exception of one of the racks over in the gym is actually adaptive … (#112) In this case, the participant reported approaching management about this issue, but was told addressing accessibility was " … not viable as a business proposition, given the increased cost and the insufficient numbers that would be using such equipment" (#112). Administrators at one gym talked about being "embarrassed" because "our building wasn't accessible" and of having "to fight for four years to get that lift so people could actually access the gym" (#112). Typically, interviewees felt they were able to overcome most barriers and facilitate the gym users' needs: "whether it be moving classes downstairs due to a lack of lifts, making it fully accessible for them (people with disability)", or adapting exercises due to a lack of equipment, by being able to "think outside the box" (#108). An area highlighted for enhancement was greater staff consultation during gym facility construction as: … if we're not consulted in the build stage you can end up with a building that doesn't have what you're looking for (#101)

Lack of awareness of inclusive exercise opportunities in the community
Many participants reported a lack of awareness and a lack of confidence among people with disability about available sports and exercise opportunities: I think the biggest barrier is knowing for the person with the disability [ … ] knowing that there are facilities over here, that kind of can fulfil their needs (#108) A lot of the time people would say "oh I have this", or "I wasn't able to" … and they're generally quite surprised when we, when we try to reassure them that it's not going to be an issue and they can come along and take part. (#113) An ongoing challenge for staff was difficulty connecting with individuals to provide targeted support when an individual did not disclose their disability or ask for specific supports.
Students don't have to disclose a disability to the university at all. So sometimes we would have students with disabilities involved with our clubs and I might not necessarily know about it (#112) Participants recognised gyms have a responsibility to improve awareness of services among people with disability. Examples of how participants had attempted to address this included gym open days, referral pathways or presentations at university student orientation sessions as part of the Disability Access Route to Education (DARE) programme. Participants also identified that disability (e.g., Paralympics and Special Olympics) and government sport organisations had a role in raising awareness of inclusive sports and exercise initiatives, including through national and international events. Participants perceived these organisations to have responsibility for providing funding and resources for disability inclusion in sport and exercise and for providing education opportunities and learning resources for staff working with people with disability.

Gym staff desire increased collaboration with healthcare professionals
Gym staff expressed a desire for more contact with healthcare professionals to facilitate the participation of people with disability. The extent of the interaction participants reported with health referrers such as GPs, cardiac rehabilitation providers and physiotherapists was mixed. One participant said they recently "developed a pathway with [ … ] a physio. And the programmes we've done [ … ] have been hugely successful" (#102), while another reported intermittent contact and a third participant reported "a breakdown" (#102) in communication with health professionals. A major reason for wanting more contact with healthcare professionals was for advice when an individual with disability presented with a health issue gym staff were concerned about. This was similar for gym clients without disability: However, staff believed that overall people with disability were no more likely to encounter safety issues compared to those without disability: … the truth over the last ten years or so is that if you look at any of the incidents that have occurred in any of our centres there's been more with the "Joe Public" (#101)

Access to transport can facilitate gym attendance
Transport was proposed as an issue by some participants. Depending on gym location, public transport availability varied. There were also challenges due to the lack of availability of wheelchair accessible taxis with one participant referring to a client: … he'd be [ … ] waiting for a good hour for the taxi to arrive to take him back home [ … ] because they never had one that was wheelchair accessible … . that made him stop coming after a while because he was left waiting too long for a taxi to bring him back (#106) One participant proposed a "bus service that can pick people up from their houses" (#104) as a transport solution. Typically, participants recognised that having access to a private car, adapted as required, positively influenced gym access.

Local gym policy
Participants were aware of policies put in place to encourage disability inclusion in their gyms such as the special needs provision statement, the dual use procurement policy for developing the facility and purchasing equipment and the organisation's "disability mission statement" all of which were regarded as promoting positive attitudes towards people with disability. A policy to have all staff trained in facilitating disability inclusion existed at the public gym facilities, with this regarded as important to protect the staff themselves: … if we can get the staff to buy into it [ … ] the sort of underlying ethos behind this is that nobody that works for me would do something that they're not qualified to do [ … ] that's kinda the unwritten rule we've kinda said to them. It's really a level of protection for themselves more than anything else [ … ] So that's nearly more like a policy … (#101)

Discussion
This exploration of gym staff perspectives found that overall staff were informed and had a positive attitude towards disability inclusion at gym facilities. Themes identified showed an awareness of enablers and challenges to participation across the socio ecological model levels. Identified facilitators of disability inclusion in gyms related to personal motivation, interpersonal interactions, creating awareness of gym services in the community, promoting inter-sectoral collaboration with healthcare and disability organisations, disability inclusion training and addressing transport and accessibility issues.
Gym staff perceptions were consistent with previous research findings, which show that similar to the general population, individual level factors (intrinsic motivation, identity as an active person, enjoyment, development of social contacts and improvement of health and fitness) influence physical activity behaviour in people with disability [7, 19,34,35]. Behavioural approaches, which recognise the social environment as an important predictor of a person's self-determined motivation [26,36], are therefore required to address the myriad of barriers to physical activity faced by people with disability [10], and education about such approaches was to be integrated into disability inclusion training programmes. Behavioural approaches highlight the importance of social factors [36] and require gym staff to be aware that low self-efficacy and a lack of belief in the benefits of being physically active act as barriers [8] to exercise participation and caution is required to ensure that low expectations are not conveyed to people with disability, who already face unique challenges in attempting to incorporate physical activity into their lives [5].
Recognised organisational level facilitators reflected socialrelational aspects of disability [5]. Trained staff, who utilise empowering communication are key to an "inclusion culture", alongside provision of appropriate material resources and accessible facilities, as highlighted by participants. Additionally, concerns expressed by some participants about other gym users' attitudes, point to ableism, a known regulator in sport and exercise settings [37,38]. The importance of acceptance from society, without experiencing discrimination and prejudice and the ability to participate in society are known to affect the quality of life of people with disability, consistent with the social -relational model of disability [39]. Findings from our study indicate the need for future research to explore how best to foster an inclusion culture among all gym users and gym service providers and framing this research within the social -relational model of disability is recommended [5,39].
The need to improve awareness of gym services within the community would likely require the adoption of social model approaches [37] to specifically target the population with disability, incorporating disability inclusion messaging into marketing materials and leveraging relationships with external organisations such as community and disability organisations, schools and the health sector. Indeed, data indicated a lack of consistent communication between the gym and health sectors, although ideally gym staff and fitness professionals should be part of the rehabilitation continuum [40][41][42]. Equally, rehabilitation professionals should advocate for inclusion and accommodation of individuals with disability at community gym facilities [1,43] and contribute to improving accessibility for individuals with more severe disability [20,40,44]. Indeed, all health professionals should emphasise the benefits of being active, connect patients with suitable physical activity opportunities [5,45] and offer guidance on physical activity adaptation and overcoming environmental barriers. To support health and exercise professionals in these roles, implementation of disability-specific physical activity guidelines, which have been informed by research which included people with disability [7], coupled with the use of appropriate messaging to promote exercise and physical activity are recommended [46].
Ensuring gym staff are competent in facilitating the participation of people with disability is known to encourage greater numbers of people with disability to exercise and was recognised by the study participants [9,40]. Staff valued disability inclusion training they had received, were interested in further training and recognised the need for training updates for those working in the health, recreation and leisure industries, incorporating content on potential factors that assist and hinder participation [7,12,47,48].
Given the variety of training programme content reported by staff, the inconsistent levels of training received and the non-mandatory nature of many training programmes, having standardised competencies and disability inclusion training for gym staff is recommended. To this end, Cara [49] and Swim Ireland (National Governing Body for Swimming) [50] were the named providers of such training for the community gym staff.
Consistent with the literature [12,18,20,21], staff identified how the physical environment influenced the inclusion of people with disability in gym settings. Physical infrastructure was regarded as key in the delivery of services with some buildings not being fully fit for purpose, precluding access and exercise participation and with the risk of psycho-emotional disablism, resulting from the signal this sent to people with disability [21,51]. As recommended, efforts should be directed at establishing and meeting universal accessibility guidelines for physical activity facilities [10, 47,48]. Our study participants noted the need to involve staff in the design process, but even more important is consultation with people with a range of disabilities to consider their needs, values and preferences [10, 52,53], aligning with empowering, user centred and inclusive design principles [54]. Such a co-development process has been well described [55] in relation to development of a physical activity intervention for people with spinal cord injury. Adopting the principles of universal design and accessibility [44] would support the achievement of equitable access for all, thereby allowing people with disability to participate actively in their community with dignity and autonomy [56] and also being of benefit to the general gym going population.
In relation to transport, participants tended to focus more on clients with disability who were successfully getting to the gym rather than considering how transport might be a barrier for others. Labbe [4] highlights the need to implement specific policies to support integrated community programmes with accessible public transport to allow full participation of people with disability, thereby increasing their social inclusion.
This study has given insight into gym staff perspectives of disability inclusion albeit among a small number of staff who were potentially more committed to disability inclusion, given they volunteered for the study. Overall, there was a sense of some participants appearing to want to avoid reporting any negative experiences or difficulties in relation to disability inclusion, lest they appear discriminatory, which may have precluded exploration of barriers and necessary solutions. In addition, participants tended to focus on people with disability who were successfully participating in the gym setting, who are less likely to represent people with more severe disability, for whom barriers to exercise may be greatest. Further research focusing on the exercise service needs of people with disability who are not meeting physical activity guidelines and overall consideration of the heterogeneity and diversity that exists among people with disability by policy makers and gym managers is required, as highlighted in a recent report [52].
The use of the socioecological framework in our study proved valuable in synthesising and presenting the findings in the context of existing literature regarding determinants of physical activity and exercise participation. This should help to make sense of findings by identifying the levels at which gym staff identified disability inclusion related issues and to perhaps frame the development of SEM level -specific strategies to enhance participation of people with disability in the gym setting.
Unsurprisingly there was less reference to determinants at policy level beyond local gym policy among the staff, most of whom were working on the ground at the public interface. Ensuring gym policy aligns with broader policy and legislation, including the National Disability Act (2005) [54] and the UN Convention on the rights of persons with disabilities [57] is clearly an important consideration for gym management and should be standard in disability inclusion training for both gym sector management and staff.
Having identified barriers and facilitators, a recent scoping review paper recommended agents of change [58]. As expected, change needs to occur at multiple levels, going beyond personal motivation, to community, healthcare and fitness industry workers, to local authorities, city planners, employers and environmental designers and to disability organisations and policy makers. While the approaches are diverse in different countries, all involve stronger leadership cultivating the culture and required conditions that support equality of opportunity in the field of physical activity, active leisure and sport. Improved coordination at a national level with examples such as Australia's National Sports Body having a Disability Sports Unit (DSU) is advocated and the need for intersectoral cooperation between all involved in the development and delivery of sport and physical exercise opportunities is critical [54].
In relation to a quality experience at sport and health centres, both the internal perspective which focuses on standards of service and the external perspective which relates to satisfying the expectations of users [59] require consideration. From the empirical research, strong leadership; improved and inclusive facilities, participating with peers, adequate and accessible information services and comprehensive education, training and coaching programmes that lead to knowledgeable staff, who foster mastery and autonomy and facilitate an inclusive sport and physical activity culture are important [54,[60][61][62][63]. The European Quality in Social Services (EQUASS) certification system of compliance of social services with European quality principles and criteria may prove useful in informing continuous quality improvement initiatives in the gym sector [64].
In conclusion, staff were positive regarding disability inclusion, demonstrated understanding of many facilitators and challenges with an overall organisational ethos of inclusion apparent across gyms. Areas identified for enhancement were the need to create greater awareness of gym services among members of the community with disability, promoting collaboration with healthcare and disability organisations, providing comprehensive disability inclusion training, having people with disability and gym staff more involved in gym service planning and improving transport systems and accessibility.
Dublin and University College Dublin (UCD); the following BSc Physiotherapy students at UCD for their research assistance; Aisling Clancy, Paddy Doherty, Niamh Hebblethwaite, Emma Rumley.

Disclosure statement
No potential conflict of interest was reported by the author(s).

Funding
The author(s) reported there is no funding associated with the work featured in this article.