Inclusion of persons with disability in sport: part 1 – rights and challenges in Qatar

‘a core reference point internationally for policy development about human rights and sustainable development in the context of disability’. This Declaration was the landmark outcome of the Doha International Conference on Disability and Development, held on 7–8 December 2019, under the guidance and patronage of Her Highness Sheikha Moza bint Nasser, Founder of Qatar Foundation for Social Work and its affiliated civil society centres. This Declaration, that sets forth 11 recommendations to make Qatar (and other countries who may come to commit to it) actively adjusting itself to the needs of PWDs, is an incentive to all those who are already on the ground working towards making Qatar a more welcoming and inclusive country.


Inclusion of persons with disability in sport: part 1 -rights and challenges in Qatar
Sanaa Taha Al-Harahsheh , 1 Kamilla Swart , 2 Josélia Neves, 3 Sabika Shaban 4 Sport is considered a powerful tool to foster social inclusion and improve the well-being of persons with disabilities (PWDs). While it can place people on equitable social footing, 1 PWDs remain under-represented in sport and physical activities compared with their peers without disabilities.
The participation of PWDs in sport is influenced by the type and severity of disability. Those with learning disabilities or with profound and multiple disabilities have the lowest participation levels. 1 Globally, disability rates are rising dramatically, presently estimated at over 1 billion people-including 190 million people (3.8%) who experience significant difficulties in functioning. 2 In Qatar, census data estimates 1.2% of the population have a disability, with 232 athletes registered at the Qatar Paralympic Committee (QPC). 3 However, it is important to note that defining and operationalising disability remains a challenge despite significant progress in measurement. Qatar has around 1.3 million employees, mostly young, healthy men, and uses a narrow definition of disability when estimating the number of PWDs. Therefore, the Washington Group Questions should be adopted in the future to measure PWDs more accurately. 4 Over the past few decades, the State of Qatar has achieved tangible progress in catering to the needs of PWDs. For example, various projects, initiative and programmes that accommodate to the needs of PWDs, while protecting their basic human rights were developed. Furthermore, the QPC is not only committed to enabling para-athletes to achieve sporting excellence but also to developing sport opportunities for all PWDs in Qatar (beginner to elite). 5 This editorial reflects on how sport and physical activities affect PWDs in Qatar and the obstacles to their participation.

DIsabIlIty rIghts: InclusIon anD sport
As a form of social engagement, sport participation is a fundamental human right supported by many international and national policies, including the Universal Declaration of Human Rights (1948) (See table 1). Qatar, like every state, has an obligation to take proactive and appropriate measures to ensure that PWDs participate in all aspects of society on an equitable basis. The rights of PWDs were also emphasised in the Qatar National Vision 2030, and in the first (2011-2016) and second (2018-2022) Qatar National Development Strategies. Although Qatar has taken important steps to promote and protect the rights of PWDs, challenges persist and PWDs remain under-represented in all forms of cultural life, including sport.

DIsabIlIty anD sport
In this editorial, the term disability sport is used to refer to all sport, physical activity, recreation and leisure for and involving PWDs, including adaptive sport or parasport. 6 Adapted physical activity is found in different application areas, including inclusive and specialised physical education, competitive sport and recreational physical activity; and can be placed on par with mainstream modalities.

aDapteD moDalItIes
The QPC is responsible for managing participation at the Paralympics and other international competitions as well as for providing opportunities for PWDs in Qatar to participate in sport at all levels. The Paralympics is an international sporting event in which para-athletes compete in six disability groups (amputee, cerebral palsy, visual impairment, spinal cord injuries, intellectual disability and 'les autres'-any disability that does not fall into any of the other categories). The Paralympic movement recognises 10 impairment types and para-athletes are divided further into classes depending on the type and extent of their disabilities. 7 The International Paralympic Committee serves as an umbrella organisation that represents all sports with disability. It supports 200-plus members, including 182 national Paralympic committees (of which QPC is 1), 4 Paralympic sport federations (boccia, sitting volleyball, wheelchair basketball and wheelchair rugby) and 4 international organisations of sport for disability that focus on grassroots sport development, viz CP-ISRA (cerebral palsy), IBSA (vision impairment), IWAS (wheelchair and amputee) and Virtus (intellectual impairment), among others (see online supplemental file).

benefIts of sport
The benefits of sport are universal for all including those with disabilities. Through sport, PWDs can advance social inclusion, health and life skills. 8 It fosters social and psychological well-being by providing opportunities for friendship, a sense of self and meaning and purpose in life. It positively affects the way PWDs perceive their bodies, leading to better mood states, less stress and increased self-esteem. 9 It develops social belonging, improved communication and better coping with the stigma associated with disability. 10 Despite these universal benefits, PWDs still face various barriers to participating in sport and other physical activities.

challenges anD constraInts
Factors that hinder sport participation by PWDs are summarised here into three categories. 9 Intrapersonal constraints involve psychological conditions that are internal to the individual (eg, personality, attitudes, mood, stress and perceived self-skill). Interpersonal constraints arise from interactions with other members of society. Structural constraints include factors such as the lack of opportunities and accessibility or the cost of activities that result from external conditions in the environment. Additionally, the global COVID-19 pandemic has had a significant influence editorial on sport and physical activity, leading to the closure of sport and physiotherapy facilities and spaces. It also resulted in the unprecedented delay of the Olympic and Paralympic Games, and the cancellation of athletic activities at every level, directly limiting the social opportunities and advantages of global, regional and local sporting events for PWDs. 11 In Qatar, it is difficult to produce evidence-based policies due to the lack of adequate data on disabilities. Pockets of data gathered by scattered entities, combined with dated or scant figures from previous censuses, have led to the disability community failing to receive due support, whether at the local or global scale. 12 Recognising these barriers and challenges creates an undeniable opportunity to effect change. Qatar has progressed through several formative stages and is currently ripe with prospects for advancing to an inclusive nation. Moving forward, evidence should be generated to better describe the current state of disability and inclusion in sport within Qatar. National and international organisations must also work together to increase the opportunities and access of PWDs to sporting activities. Governments have an important role to play in supporting such initiatives, increasing funding and promoting awareness for the importance of sport participation by PWDs. 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.   As stipulated in Article 30 of the UN's (2006) CRPWDs, signatories '…recognize the right of persons with disabilities to participate on an equal basis with others in cultural life' (defined as recreation, leisure, the arts, sport and tourism). The article highlights the importance of treating PWDs equally, and states should improve access to and support the inclusion of PWDs in recreational, leisure and sporting activities (article 4).

UNESCO's KAZAN Action Plan
The Action Plan states that to reduce inequalities at the national and international levels, inclusive sport policies are necessary. Therefore, physical education, physical activity and sport should be at the core of all national and international sport policies. The upcoming FIFA World Cup 2022 has been announced as the most accessible for persons with disabilities (PWDs) in the history of international FIFA tournaments, 1 a fact that will have a positive impact on the built environment and the lives of local communities. Such a major sporting event may galvanise the population to undertake greater physical activity, a contribution against obesity and sedentarism in the country. The commitment to a healthier population led to the establishment of National Sports Day, the only public holiday beyond Qatar National Day.
It is now acknowledged that all persons have the need and the right to engage in sport, and that PWDs are entitled to adaptations to access sport on equitable terms. Regrettably, there is no centralised data on the participation of PWDs in sport at the national level. The data gathered by different organisations makes comparisons and generalisations impossible. The purpose of this editorial is to offer a brief overview of PWDs' engagement with sports in Qatar, including CWD, participation in elite parasport, and policy and infrastructure engagement.

physIcal therapy anD eDucatIon In Qatar
In the case of CWDs, early intervention will be the gateway to physical activity, and physical therapy should be individualised to develop the child at multiple levels. For instance, psychomotor therapy should combine emotional, physical and cognitive development; and play therapy may meet sensory, physical or behavioural challenges. The services listed in the Qatar Educational Directory 2 show how physical therapies are integral to special education offered at high-quality state and independent schools, among which are the Al-Shafallah Center, Renad Academy and Al Noor Institute. CWDs attending inclusive (mainstream) education are offered adapted physical education.
Despite efforts to provide physical education to CWDs, there are few options for recreational activity. PWDs are less likely to travel, play non-competitive games, or simply share outdoor spaces, 3 which afford physical activity that would enhance physical, emotional and social well-being. 4

box 1 Qatar foundation ability friendly sports program (afp)
The Qatar Foundation AFP is an initiative that was launched officially by Qatar Foundation in 2019 to support people with autism, learning disabilities, hearing disabilities, visual impairments and physical disabilities to take part in sports and developmental activities. The programme offers football and swimming classes, as well as seasonal camps that are tailored to each participant's needs.
The programme is open to participants aged three and older. The idea for the programme initially inspired by the World Innovation Summit for Health 2016 report 'Autism: A Global Framework for Action'. This report contributed to Qatar Foundation's own policies surrounding inclusion and ability friendly programmes, which ultimately led to the implementation of such programmes across Qatar.
Since delivering its first class in 2018, the programme has played an undeniable role in improving the quality of life for children on the autism spectrum by filling in a critical need for sports-based programmes. Aside from capturing the attention of families with children with autism, the sports programme also attracted strong interest from families with children of other abilities. The present-day AFP incorporates swimming and football lessons that are adapted to children of all abilities and ages. 1175 PWDs have participated in AFP sport activities between 2019 and 2022 (731 in swimming and 444 in football). About 75% of the participants are male (880), with ages ranging from 3 to 36. The majority of participants have autism (863). Additionally, there are 140 students with learning disabilities, 120 with physical disabilities, 49 with Down syndrome, 14 with hearing impairments, and 8 with vision impairments. Since its inception, the AF has delivered 16 550 sessions. 8 1

Supplementary File
Further information on the International Paralympic Committee (IPC) and an overview of all other international organizations providing sport for persons with disabilities (PWDs)

Organization
Overview IPC • Paralympic Games was initially known as the Stoke Mandeville Games • It was organized in 1948 by a neurosurgeon, Sir Ludwig Guttmann, who had established the Stoke Mandeville Spinal Injuries Unit for rehabilitation purposes and became known as the father of the Paralympic movement. 1 • It was only in 1989 that the IPC was founded as a collective voice for advocacy for the Paralympic movement based on previous cooperation of several international organizations intent on stabilizing and extending elite sport to PWD . 1 • Based on a recent governance review of the IPC, it was agreed at that there would be a managed exit process of 10 IPC sports (alpine skiing, athletics, biathlon, cross country skiing, dance sport, ice hockey, power lifting, shooting, snowboarding and swimming) whereby the IPC would stop acting as the international federation for these sports by the end of 2026. 4 They will be governed by their respective international sport federations who have underscored that para-sport integration into their respective organizations demonstrates commitment to inclusivity and to the development of their sports. 4 International Committee of Sports for the Deaf (ICSD)   • Based on a recent governance review of the IPC, it was agreed at that there would be a managed exit process of 10 IPC sports (alpine skiing, athletics, biathlon, cross country skiing, dance sport, ice hockey, power lifting, shooting, snowboarding and swimming) whereby the IPC would stop acting as the international federation for these sports by the end of 2026. 4 They will be governed by their respective international sport federations who have underscored that para-sport integration into their respective organizations demonstrates commitment to inclusivity and to the development of their sports. 4  • Initially called the International Stoke Mandeville Games Federation (ISMGF) • Formed as a result of the annual festivals of sport taking place which became the inception of the Paralympic Games phenomenon we know today 1 • Participation was restricted to people with spinal cord lesions in its earlier years • In 1990 ISMGF's name changed to ISMWSF International Sports Organization for the Disabled (ISOD) • Established in 1964 to serve amputees and 'les Autres' 1 • Set out to provide for those PWD that were not represented in the other sport federations • With more disability-specific sport organizations emerging in the 1970s such as the International Blind Sport Association (IBSA) and the Cerebral Palsy -International Sports and Recreation Association (CP-ISRA), ISOD started to lose its importance as a coordinating body for athletes outside the ISMGF framework • In 2004 IMSWSF and ISOD merged to form the International Wheelchair and Amputee Sports Federation (IWAS). 1

CP-ISRA
• Formed in 1978 to promote sport and recreational activities for people with cerebral palsy and related conditions such as those affected by strokes and traumatic brain injury 1 • Takes responsibility for all athletes with cerebral palsy participating in the Paralympic Games • Active in ascertaining the most appropriate elite sport opportunities for people with severe disabilities together with the IPC.