Article Text

Para athletes’ perceptions of abuse: a qualitative study across three lower resourced countries
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  1. Emily Anne Rutland1,
  2. Sakinah C Suttiratana2,
  3. Sheila da Silva Vieira3,
  4. Rekha Janarthanan3,
  5. Michael Amick4,
  6. Yetsa A Tuakli-Wosornu2,5
  1. 1 Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
  2. 2 Chronic Disease Epidemiology, Yale University School of Public Health, New Haven, Connecticut, USA
  3. 3 Katholieke Universiteit Leuven, Leuven, Flanders, Belgium
  4. 4 Yale School of Medicine, New Haven, Connecticut, USA
  5. 5 Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
  1. Correspondence to Dr Yetsa A Tuakli-Wosornu, Chronic Disease Epidemiology, Yale University School of Public Health, New Haven, Connecticut, USA; yetsa.tuakli-wosornu{at}yale.edu

Abstract

Objectives Interpersonal violence is an increasingly recognised risk of sport participation and causally linked to negative physical and mental health outcomes. Para athletes from low- and middle-income countries may be at highest risk of physical, psychological, sexual and neglect-related violence due to various factors; however, their perceptions of these abusive behaviours are unknown. This study examined the perceptions and experiences of abuse in para athletes from three lower resourced countries: Ghana, India and Brazil.

Methods Qualitative data from semistructured focus group interviews conducted with 26 individuals were collected to explore characteristics of abuse observed, navigated and experienced by para athletes. The framework method for multidisciplinary qualitative research guided data analysis.

Results Athletes identified a wide range of abusive behaviours they experienced within and outside of sport, including psychological, emotional, physical, sexual and neglect-related violence, which operated on both interpersonal and systemic levels. Most athletes described three less easily recognised forms of abuse in greater detail and more frequently than others: financial abuse, neglect and disability stigma.

Conclusion It is important to hear directly from athletes with diverse experiences and backgrounds and to integrate their insights and priorities into sport safeguarding policies, programmes and interventions. Understanding the requirements and challenges of para athletes and para sport is needed to achieve safe, equitable and inclusive sport. As new insights from diverse sport settings are added to the evidence base, globally balanced, athlete-generated and locally relevant preventative strategies can better protect all athletes.

  • sports
  • disability
  • paralympic
  • interpersonal violence
  • sexual abuse

Data availability statement

Data are available upon reasonable request. Data are available, stored as encrypted audio files with all authors.

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Introduction

Interpersonal violence (neglect and psychological, physical and sexual harassment and abuse) is an increasingly recognised risk of sport participation.1–5 In sport and other sociocultural settings, this type of exposure is causally linked to negative mental and physical health outcomes in the short and long term.6 7 Recent high-profile cases suggest athlete abuse is endemic and a significant threat to modern sport.4 8 9 An array of factors along societal, cultural and personal axes influence the likelihood of interpersonal violence in any setting.10 Furthermore, the risks of abuse are compounded when disparities associated with disability, ethnicity, socioeconomic status, gender and sexuality are considered.11–13 In sport, best-available data suggest that athletes with physical, developmental and/or intellectual impairment may be up to four times more likely to experience abuse compared with their non-disabled peers.4 Therefore, athletes with disabilities, especially from less-resourced countries, may be the archetypal athlete group of concern due to a higher need for protection against abuse in sport.

Data related to abuse in para sport are limited. Despite the fact that 80% of all people living with disabilities live in low-income or middle-income countries, safeguarding studies from para sport in these settings are even more rare.14–16 In fact, there are presently no safeguarding studies focused on the lived experiences of para athletes from less-resourced countries.17–19 As a result, these athletes’ voices and experiences may not be considered or integrated into global sport safeguarding policies, programmes and protocols. Understanding the experiences, perceptions and priorities of global para athletes will expand the safeguarding debate and help ensure that abuse prevention strategies in sport are more socioculturally relevant and globally representative. Advancing more inclusive safeguarding research also has relevance beyond study participants’ country context. In fact, insights from this work may apply to any athlete group that is either equally or less vulnerable to abuse as this athlete cohort.

The aim of this study is to examine the perceptions and experiences of abuse in para athletes from three settings on three continents: Ghana, India and Brazil. This study is the first to examine sport safeguarding from the perspective of para athletes from regions under-represented in current research.15

Table 1 provides our working definitions of key terms commonly used throughout this paper.

Table 1

Definition of terms

Methods

Qualitative methodologies help researchers explore questions about how phenomena are experienced and shaped by processes and contextual factors in which such phenomena are embedded. One aim of understanding phenomena from the perspective or lens of non-researchers is to better align research projects and outcomes with the needs of people influenced by a research discipline. Given the dearth of information about and limited inclusion of the study’s target population in research and policy discourse related to safeguarding, an exploratory qualitative research study was initiated. This research was interpretivist, meaning that the research questions did not seek one objective reality and assert that different positions and perspectives may result in different interpretations of reality.

Research team

The research team comprised six people based in three countries: the study principal investigator and board-certified physical medicine and rehabilitation physician (YAT-W) whose research interests include adaptive physical activity and sport, one PhD faculty (SCS) with significant qualitative health research and intervention experience, two graduate students (SdSV and RJ) participating in a European-based sport integrity course and two US-based medical students (EAR and MA). Team member familiarity with qualitative research ranged from novice to expert, but the team was united by their interest in learning about the experiences of para athletes from less resourced countries. Three team members conducted focus groups with para athletes from Brazil (SdSV), Ghana (YAT-W) and India (RJ). All focus group facilitators were either born in or had lived in the countries where they conducted focus groups enhancing their ability to both interpret colloquial expressions as well as to rapidly build rapport with participants. Only YAT-W encountered athletes with whom she had previous interactions at global sports events. Prior knowledge of participants potentially facilitated familiarity and ease during the focus group discussion in Ghana.

Research approach

The framework method was used to guide the multidisciplinary team through a systematic qualitative research process. Implementation of the framework method was informed by Gale et al’s synthesis of the methodology as well as the qualitative research experiences of team members.20 The framework method is a style of thematic analysis that facilitates qualitative data summation through the use of a matrix comprised of cases, codes and exemplar quotations and definitions arrived at through iterative team discussions. This approach is useful when summarising diverse or abundant qualitative data and when generating themes by comparing across and within cases. Further, it was selected as a knowledge-generating approach to manage varied experiences with qualitative research; interest in balancing deductive and inductive inquiry into a novel subject matter; a shared epistemology that values lived experiences; the perspectives of under-represented voices and the richness of multidisciplinary interpretation; geographic dispersion of team members and participants and an expectation that meta-lessons across geographic sites would emerge. Methodological meetings were held prior to data collection, transcription and data analysis to reinforce the structure, process and products to be developed using the framework method to examine study research questions. Clear and consistent team communication, iterative interpretation and decision-making and developing and documenting procedures for analytic refinement and disagreement resolution were leveraged. Additional online supplemental materials present methods that may provide readers with insight into the research team’s analyses.

Supplemental material

Sampling and recruitment

We accessed athletes by advertising through athletic clubs, non-governmental organisations and social media. The final convenience samples were based on those able to join for the scheduled focus groups. Potential participants for the electronic focus groups helped select the focus group time. For example, in Ghana, the President of the Ghana Wheelchair Basketball Federation (GWBF) initially posted information about the study on the GWBF Facebook page inviting participation. In Brazil and India, information about the study was initially distributed to athletes by administrators at each national Paralympic committee. Verbal consent was obtained and confirmed prior to the start of each focus group, which were scheduled at mutually convenient times for participants and facilitators. Participants were eligible for inclusion if they were adult (greater than or equal to 18 years of age), active in para sport and able to participate in a focus group discussion in English or Portuguese. Given the sensitive nature of the topics being discussed as well as the role of local sports organisations in facilitating access to participants, broad inclusion criteria were used to balance research inquiry with participant privacy. The focus group in Ghana occurred in person in January 2020. Electronic focus groups among para athletes from Brazil and India took place between October and December 2020. Study recruitment and data collection ended during the global COVID-19 pandemic which limited research-related travel and in-person data collection.

In order to preserve privacy in para sport networks that are relatively small and interconnected, a limited set of participant characteristics has been shared to avoid unintentionally disclosing the identity of research participants.

Participant involvement

Para athletes from Ghana contributed to the development of the research protocol and focus group discussion guides prior to implementation of the first focus group. Ghanaian focus group participants also provided feedback about the process and focus group discussion to YAT-W. Minor adjustments were made to wording. Research findings will be disseminated to all participants in the form of a plain language summary.

Data collection

Seven semistructured focus groups (four in Brazil, one in Ghana and two in India) were conducted with 2–6 participants in each group for a total of 26 participants. Focus groups ranged from 53.2 to 134.1 min (mean: 76.3 min) and were audio recorded. Participant data were stored on a Yale University-encrypted server. The focus group in Ghana was conducted in person, while the focus groups in India and Brazil were conducted via Zoom. Focus groups were facilitated by YAT-W (Ghana), SdSV (Brazil) and RJ (India); SCS observed one focus group.

The focus group discussion guide followed a pragmatic approach starting with familiarisation questions designed to build rapport between facilitators and interviewees prior to addressing primary research questions. Next, participants were provided with an explanation of intentional violence and the purpose of the study and were asked a series of questions to elicit knowledge, attitudes and beliefs about abuse in sport, as well as suggestions about supporting sport ecosystems to help eliminate or reduce interpersonal violence. The semistructured focus group discussion guide explored questions such as: ‘Can you tell me about yourself and your club?’, ‘What comes to mind when you hear the words ‘abuse in sports’?’ and ‘If an instance of violence happens, what do you do?’. Focus group facilitators were also encouraged to probe emerging themes for thick description, nuance and clarity. Iterative and concurrent data collection and analysis meant that analysis from one site began while focus groups were still being scheduled for another site. As data were added, the team discussed important elements of site context, expansion or refinement of existing codes and the need for new codes to describe previously uncovered phenomena.

Data analysis

Audio recordings were transcribed verbatim in the language in which the focus groups occurred. Brazilian Portuguese language focus groups were then translated by a professional interpreter from Portuguese to English. Translated transcripts were reviewed by three people with fluency in Brazilian Portuguese (including SdSV and SCS) and some idiomatic expressions appear in transcripts in both Portuguese and English with explanatory annotation in order to preserve the essence of participants’ comments. Likewise, explanatory notes are included in transcripts from Ghana and India to describe idiomatic expressions or terms that are not commonly used or do not exist in colloquial UK English. Focus group facilitators reviewed transcripts for accuracy and completeness. Each transcript was assigned two coders as well as a site expert, the focus group facilitator, responsible for helping the research team keep the geographic, social and political context of the site in mind while discussing findings and interpretations. For analytical purposes, themes were categorised by country sites such that these data represent three cases (country sites). Analyses considered the occurrence and absence of themes across and within cases.

In fidelity with the framework method, the research team completed five essential elements of data analysis and synthesis to prepare this manuscript. First, prior to characterising and coding segments of the transcripts, team members familiarised themselves with the data by reading and discussing perspectives on the transcripts. The team reviewed and refined a priori thematic areas determined by the study research questions while also proposing emergent, primary codes for analysis. Next, the team agreed on a coding scheme. After applying primary codes on the first-available transcript, the team further refined the coding scheme and discussed potential relationships between codes. Coders analysed each transcript, the team discussed both the application of codes to transcripts as well as potentially missing concepts and after reviewing coding based on refined frameworks, researchers indexed their data by identifying examples of codes from each case (country site) or transcript. While indexing, the team noted similarities, differences and unevenness across cases for identified themes. Charting data in tables by case and codes helped enhance interpretative consensus and the development of themes based on relationships between codes. Charting also enabled researchers to describe dimensions of data across and within cases. Thematic saturation, defined as the point at which no new concepts were revealed in the dataset, was achieved for the main themes describing the nature and experiences with abuse. Online supplemental table 1 recreates portions of charts used by the team. Finally, voluminous team review and discussion about coding, interpretations and relationships between codes and contexts guided synthesis of findings.

To enhance the trustworthiness of interpretations, thematic findings were compared with emerging literature and anecdotal accounts of others familiar with global para sport.3 4 21–23 Several team members maintain active membership in global research and practice consortia considering equity in both sports and health, and the findings were discussed by the research team throughout the research process.24 Research team meeting and process notes provide an extensive audit trail.

Findings

Twenty-six para athletes from three countries (Ghana, India, Brazil) participated. Participant and site characteristics are summarised in table 2. Sports represented across all sites included para athletics, para tennis, para football and para swimming, among others. Most but not all athletes compete or had competed in International Paralympic Committee (IPC)-sanctioned events.

Table 2

Participant and site characteristics

Common themes identified through analysis of data from all three sites are presented here and supported by exemplary quotations. Online supplemental table 2 contains additional quotations from this cohort. Contextual and/or sociocultural factors relevant to para athletes’ experiences both within and outside of sport are also described; where important differences emerged, they are mentioned.

Athletes’ perceptions of abuse

This cohort identified a wide range of abuse with varying severity and impact, including psychological, emotional, physical, sexual and neglect-related abuse. The majority described personal experience with psychological/emotional abuse. One athlete explained that, while coaches and teammates can offer support, they ‘can also kill you in so many words’. Psychological abuse was also described as undue pressure from coaches and bullying from teammates:

I think it is an abuse if you come to an athlete and talk like this ‘you have to do this; you will do this mark [(ie, performance)]’. And so on. Kind of putting pressure…How does the athlete’s psychological state gets at this time? (Brazilian athlete)

…when I came into [wheelchair basketball], I was the youngest…so everybody was using me, everybody was saying…go do this, do this, do this, do this (Ghanaian athlete)

Sexual abuse was described least frequently and was mentioned in the context of other forms of abuse. Said one athlete:

…when you say abuse, most of us think we are talking about…something like sexual harassment and so on. But when it comes to abusing, it happens at different angles…between players and their coach and at the same time, players among ourselves. (Ghanaian athlete)

Most athletes described three forms of abuse in greater detail and more frequently than others: financial abuse, neglect and disability stigma. Exemplar quotes illustrate how these themes emerged as operating on two different levels: interpersonal, such as in relationships between athlete and coach or athlete and athlete, and systemic, including victimisation by institutions and broader society.

Financial abuse

Financial exploitation was cited as a tool to reinforce power differentials by controlling and/or restricting sport-related earnings. This mode of abuse was particularly harmful for those who were independent, full-time professional athletes earning a living through sport in order to sustain themselves and their families.

Interpersonal

Earnings were unfairly withheld, misappropriated or reluctantly released by sport officials:

So even though the [competition] started well, at the end, about the transportation [reimbursement] that they were supposed to give…they denied us. (Ghanaian athlete)

Athletes prepare themselves to go for competition, but an administrative officer…and his own friends or colleagues take the money… At the end of the day, they'll say the government have no money [to bring athletes to the competition]. (Ghanaian athlete)

Some athletes were mocked and treated as if they had less need for salary earnings than non-disabled athletes:

The time I won the silver [medal], we went for our per diem [allowance]. Do you know one thing one of the leaders said? ‘What are you going to use this money for?’ …he didn't think that I valued this money compared to the chair I'm using… Do you see how abusing that is to you as an athlete? If you don’t take care, you can kill somebody about that…’ (In the local colloquial context, the phrase ‘kill somebody’ means and was taken to mean by the people in the conversation, severely discourage, frustrate, or dishearten.) (Ghanaian athlete)

Systemic

Unequal compensation between Para and non-disabled athletes resulted in undue financial stress among para athletes and their families. One para athlete noted that, unlike able-bodied elite volleyball, where one has a full-time contract, para volleyball players must find supplemental ways of supporting themselves financially.

…conventional volleyball, you train every day, all day, you have a contract, you have a job, it’s your job. We from sitting volleyball, we have to sell books, there are frontmen, there are people who sell real estate, there are people who don’t work… (Brazilian athlete)

Additionally, gender-based pay inequities both resulted from and reinforced societal norms and expectations, highlighting the intersectional nature of athletes’ identities while illustrating the possibility for abuses to compound:

So because of [the expectation women should give birth], they ask for the female team to keep on reducing [pay], and the majority of us to keep on complaining about financial problem. (Ghanaian athlete)

Neglect

A Ghanaian athlete described ‘…sometimes denying [athletes] something that’s entitled to [them]’. This sentiment was articulated by many athletes. Others described being denied appropriate equipment, nourishment and being subjected to unfair or arbitrary policies.

Interpersonal

Athletes recounted being denied adequate equipment, nutritional support as well as training and competition considerations tantamount to physical and psychological abuse:

…sometimes equipment that you use that fits you better to perform…a coach can force another [teammate] to use that chair, even though it might not be in a good sitting position for him. (Ghanaian athlete)

Some athletes were denied appropriate help or support following poor athletic performance. One Indian athlete described that, after performing well, ‘escorts come quickly to hold your wheelchair and to give you whatever…you need. But if you are not performing that much they don’t come’.

Athletes had to go out of their way to find out about available competitive opportunities. A Brazilian athlete described himself as a ‘victim of a competition’ because he was not informed of an opportunity.

Athletes also experienced the careless assignment of training routines not tailored to athletes’ impairments and absent impairment-related safety considerations. One Brazilian athlete perceived that some coaches and trainers outside of the national training centre ‘don’t know the physical [limitations]’ of athletes and ‘end up exaggerating’ training, meaning that trainers demand a level of training suitable for those with mild impairment but risky and/or harmful for para athletes with higher support needs. Some trainers demonstrate negligence when it comes to understanding the specific needs of para athletes, which may lead to physical harm. The withholding of physical and/or impairment-related support left athletes feeling vulnerable despite great passion for and commitment to their sport.

Systemic

Athletes offered examples of negligence and negligent oversight by sporting institutions that did not bother to gain knowledge about para athletes or their varying levels of impairment. This type of neglect manifested as national and/or international policies that endangered athletes and denied them the ability to participate safely. For example, one athlete described an international policy, recently introduced, that limits the number of people who can assist during an athlete’s transfer from wheelchair to throwing frame:

[Only] one escort will do the shifting and no other assistance will be provided. And that is very difficult… this is not very practical for a severely disabled person to be shifted by a single person. (Indian athlete)

Athletes were denied access to training facilities and opportunities due to overall under-resourcing in para sport. Inaccessible spaces, equipment and/or transportation were discussed frequently as both physically and psychologically harmful to athletes. One Brazilian athlete described that, outside of a training centre for people with disabilities in Sao Paulo, ‘we don’t have training instruments 100% adapted for people’.

The scarcity of accessible training facilities coupled with inaccessible infrastructure forced athletes to make time-consuming, expensive, physically taxing, and dangerous journeys—the costs of which sometimes outweighed the benefits:

…the issue of accessibility and even for locomotion to reach the training places…makes psychologically many athletes, good athletes, even abandon the training, abandon the career because of the difficulty of locomotion. (Brazilian athlete)

The relatively limited number of competitive opportunities and accessible facilities for para athletes as compared with able-bodied athletes made competing at the highest levels of para sport particularly burdensome. Federations’ policies were frequently difficult and impractical for para athletes to implement, especially for athletes in remote areas. One Brazilian athlete reported being told that in order ‘to be selected [for the National team]…You have to live where I tell you to’. However, the lack of accessible transportation and infrastructure made this particularly difficult for para athletes and left them vulnerable to pressure and coercion from sporting federations in order to have successful careers.

Disability stigma

Athletes’ narratives of neglect, financial abuse and other forms of abuse were very often shaped by their status as persons with disabilities. Athletes identified disability stigma—negative attitudes and social prejudice towards people with disabilities—as both an underlying cause of abuse in sport and as a form of abuse itself. Disability stigma fostered harmful power dynamics that athletes described as pervasive and affecting their lives both within and outside of sport. A majority of athletes delineated both interpersonal and systemic manifestations of disability stigma, including belittling from able-bodied peers, ability-related power imbalances with peers and teammates, negative public attitudes towards para athletes and ableist societal attitudes that resulted in inaccessible environments and general invisibility—even in the sport context.

Interpersonal

In households and families, disability stigma was rooted in local cultural norms:

In the family, if you are disabled, if you open your mouth to talk, they will shut you down. You don't matter. The able-bodies need to talk. You need to be the last person who needs…hearing. (Ghanaian athlete)

Athletes consistently described the tension between their personal self-efficacy and identification with elite athleticism and others’ assumptions of their general incapacity, incompetence and sport-related inferiority—including from able-bodied peer athletes:

Now when you play with a person who walks and knows how to play, it’s visible… the guys decrease the intensity of playing with us…so, I think this too, whether you like it or not, is an abuse of us…the only thing is that we have a deficiency that they don't have. Period. (Brazilian athlete)

You only see my disability…but I can feel my ability. I know my ability… (Indian athlete)

Systemic

Para athletes were often generally viewed as less deserving of the same resources and attention as able-bodied peers. Several athletes discussed feeling hurt that awareness, resources and competitive opportunities were significantly more limited for para sport when compared with able-bodied sport:

Many times, we feel able body competitions are more recognised in comparison to Para sports. (Indian athlete)

A majority of athletes described numerous examples of ableism—the sometimes unintentional belief that non-disabled individuals are ‘normal’ and should be taken as the reference point—that underpinned disability stigma. Athletes described living in societies built for able-bodied individuals in terms of limitations in the built environment, including inaccessible spaces, buildings, roads, public transportation vehicles, training facilities and even athletic equipment. This systemic form of abuse was interpreted as a form of personal discrimination that negatively affected athletes’ daily lives as high-performance athletes and at times even resulted in sport drop-out.

As one Ghanaian athlete explained, the national Paralympic office itself, located on the second floor of a story building, is inaccessible to seated persons who are unable to easily ascend stairs:

… the National Paralympic offices should be on the ground floor so any disabled person can access it independently. But the fact that our offices are upstairs… I think this is an abuse on a disabled person who is into Para sport. (Ghanaian athlete)

The majority of athletes commented on the personal pain and performance-related consequences of living in societies that consistently disregard their needs and fail to provide appropriate accommodation for one’s physical impairment both within and outside of sport. This systemic form of abuse threatened athletes’ emotional and psychological well-being, athletic advancement and career, physical health and safety.

Figure 1 graphically synthesises study findings.

Figure 1

Athletes’ perceptions of different forms of abuse on interpersonal and systemic levels.

Differences across sites

Ghanaian and Brazilian athletes more readily identified various forms of abuse, from physical abuse to neglect, and tended to see emotional harm as the ultimate consequence. In contrast, Indian athletes were less likely to define unpleasant behaviours as formal ‘abuse’, especially from coaches and authority figures. For example, Indian athletes believed ‘harsh’ words from coaches were a necessary component of sport:

Yes he may [be] harsh but we as an athlete we know why he is saying because for our improvement he wants us to improve. (Indian athlete)

Athletes’ discussions may have also reflected differences in the maturity of national para sport movements across sites—Brazil has hosted a Paralympic Games, whereas Ghana and India have not, for example. Ghanaian and Indian athletes expressed a desire to be acknowledged as athletes, the need for increased national para sport awareness and concern about basic injustices such as lack of sport-related infrastructure and inaccessible buildings. In contrast, Brazilian athletes focused on wanting increased media visibility and fair financial remuneration. One Brazilian athlete praised the strong investment Brazil has made in Paralympic sport:

[Brazil] really invests in Paralympic athletes. So much competition, everything. The Olympic, I don't know what they do with the money…They don't give hotels, they don't feed the athletes, and the Paralympic really invests in that. (Brazilian athlete)

While athletes in all three sites expressed the desire to be recognised as successful, elite athletes, Brazilian athletes expressed an interest in serving as national and international competitive ambassadors of sport.

Discussion

The aim of the study was to explore athletes’ perceptions of abuse in para sport in three Global South settings. Instead of assuming that athletes understand and experience abuse in the same way across intersections of identity, our study wanted to obtain first-person reports from a group that is often excluded from such discussions. Athletes from Brazil, Ghana and India expressed layered understandings of and experiences with abuse both in sport and in the broader societies in which sport occurs. Consistent with athletes in higher-resourced and non-disabled settings, this cohort identified psychological/emotional, physical, sexual and neglect-related abuse as imminent threats to their well-being,3 4 but uniquely, they emphasised financial exploitation, neglect and disability stigma as particularly harmful. Disability stigma seemed to underpin most athletes’ experiences with abuse and reflects broader systems of oppression that cause emotional and psychological harm to athletes who have disabilities.

This study expands on current research by exposing previously underanalysed forms of abuse that significantly impact athletes with disabilities. Athletes’ experiences represented here highlight the multilayered contextual environments where abuse manifests as products of interpersonal and/or systemic factors. Our analyses suggest that one’s feelings and/or physical bodies may be hurt by interpersonal violence, whereas systemic abuse was described as chronic pain and injustices experienced by people who live in and navigate through systems designed for able-bodied people.

The forms of abuse noted in athletes’ stories were qualitatively different than those noted in most sport safeguarding literature to date and emphasised neglect, financial exploitation and disability stigma.23 However, the most recent studies have also identified neglect and financial exploitation.21 22 This qualitative approach reveals emerging domains and concepts worthy of inclusion in future quantitative surveys related to safeguarding. Being denied opportunities, equipment and accommodating policies resulted in psychological and emotional harm, physical danger and even sport drop-out for some athletes. Athletes described slights and feelings of discouragement as ‘killing the spirit’ and also described abuse as ‘bring[ing] the sports we are doing down’. Being paid unfairly or reluctantly, despite their status as elite athletes, was interpreted as a personal slight. Overtly negative attitudes towards people with disabilities and unintentional disregard for the needs of people with disabilities in built environments and social conventions resulted in and reinforced para athletes’ stigmatisation and alienation in both sport and society. Although the experiences of abuse described in this study may only partially overlap with prior studies on the topic, these three themes (neglect, financial abuse and disability stigma) have been recently recognised as harmful to athletes and to people with disabilities in work done by Kerr et al,22 Rhind et al 21 and Patricios and Webborn.23

Limitations

Limitations arose from logistical constraints and the fact that one’s experience of sport is embedded within cultural and geopolitical contexts. First, differences in how focus groups were conducted (ie, the focus group in Ghana was conducted in person, while those in India and Brazil were conducted virtually using video conferencing and recording) and varied experience of the focus group facilitators may have led to systematic differences in the reporting of experiences by participants. Training, a focus group discussion guide, as well as shared stories about the facilitation process attempted to address any such differences in focus group administration. The participants for each site reflect a variety of sports, competition levels, experiences with abuse and social categories. While this analysis focused on shared themes rather than distinctions, the researchers realise that some experiences and perspectives remain unknown. It is of note that across focus groups instances of the most extreme forms of abuse were witnessed rather than direct, personal accounts. We also recognise that more vulnerable groups of para athletes including some participants may experience influence and pressure from sport governing bodies, institutions and leaders that facilitate their sports participation. Throughout the research and writing process, the team referred to the Standards for Reporting Qualitative Research25 in order to minimise biases and optimise study reporting. Finally, we would have liked to verify our interpretations with study participants but were not able to do so in part due to logistics, locations and scheduling limitations of study team and participants. Further, these focus groups were intended to help generate quantitative survey items that might be answered by larger numbers of people.

Conclusion

It is important to hear directly from diverse groups of athletes—especially from under resourced settings such as Sub-Saharan Africa26—and to integrate their voices into sport safeguarding policies, programmes and interventions. Based on this study, the scope of abuse may need to be expanded to better address financial exploitation, disability stigma and neglect—which may be priorities for some athletes who have disabilities. Understanding the requirements and challenges of para athletes and para sport is needed to achieve safe, equitable and inclusive sport.23 Ableist notions, including language and messaging, should be challenged and redesigned with input from those with disabilities.27 Additionally, cultural context must be considered when local sport safeguarding strategies are developed.

This study demonstrates the need for participation from athletes of various experiences and nationalities to address safeguarding challenges for all athletes. Having faced and navigated multiple levels of marginalisation within and outside of sport, para athletes from the Global South are arguably among the most qualified to meaningfully contribute to these conversations and improve inclusive protections for all athletes.

What are the new findings?

  • Para athletes experience abuse both within and outside of sport.

  • Para athletes experience unique forms of abuse, such as disability stigma, neglect and financial exploitation, that are qualitatively different than those noted in most sport safeguarding literature to date.

  • Disability stigma underpins para athletes’ experiences with abuse and reflects broader systems of oppression that cause emotional and psychological harm to para athletes.

  • Para athletes’ experience of abuse is multilayered and contextual, operating on interpersonal and systemic levels.

How might it impact on clinical practice in the future?

  • The importance of participation from athletes with diverse experiences and backgrounds in the development of sport safeguarding policies, programmes and interventions.

  • The importance of expanding the scope of safeguarding to better address disability stigma, neglect and financial exploitation, which may be priorities for some athletes who have disabilities.

  • The importance of understanding the insights, requirements, and challenges of para athletes and para sport to achieve safe, equitable and inclusive sport broadly.

Data availability statement

Data are available upon reasonable request. Data are available, stored as encrypted audio files with all authors.

Ethics statements

Patient consent for publication

Ethics approval

This study was approved by the Yale School of Public Health Institutional Review Board and Ghana Health Service Ethics Review Committee and it was endorsed by International Paralympic Committee representatives in Brazil and India.

Acknowledgments

The authors would like to thank the athletes who gave their time to this study and shared their experiences and stories and to the agencies who supported with recruitment and helped to make this research possible. Special additional thanks to Dr Sheree Bekker, Blake Caldwell and others who supported and consulted throughout this study.

References

Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

Footnotes

  • Twitter @YetsaTuakli

  • Contributors Study concept, design and management: YAT-W, SS, BC and SB. Data Collection: YAT-W, SdSV and RJ. Data analysis, data review and interpretation and manuscript writing: all authors. Author acting as guarantor: YAT-W.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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