Occupational Performance Coaching with Parents to Promote Community Participation and Quality of Life of Young Children with Developmental Disabilities: A Feasibility Evaluation in Hong Kong
Round 1
Reviewer 1 Report
The aim of this case study is to examine the influence of a specific coaching intervention strategy in Hong Kong parents on quality of life, esp. the participation in communities, in children with disabilities. The study was a case study using a pre-post design applying several standardized questionnaires and a semi-structured interview.
The manuscript is well-written, logical, and easy to comprehend. The underlying relevance of the topic was embedded in a theoretical background and current lacks of evidence-based knowledge were shown. The greatest strength of the study is that instruments used were well selected for this research question. However, the study does have one big limitation; the sample size was too small. Therefore, it was, unfortunately, not possible to compare the collected data quantitatively, to valid interpret potential changes pre and post the intervention, and it limits the conclusion that were drawn. The descriptive data were well presented, but the results must be interpreted carefully (due to the sample size) and are only to be understood as a trend. For example, in lines 440 / 453-454 / 460-461, it seems for me that your results are very clearly interpreted as representative statements of the study (“children had higher physical wellbeing […] after OPC” / “parents in this study showed improvements” / “a small reduction of their stress […] at post-intervention”). You did not a valid quantitative statistics for those pre-post comparison. I would recommend, working out this even clearer for the reader (before the last section of limitations); that the results are only to be interpretable as a trend.
I fully understand why the goals (Table 2) for the COPM scores are presented individually. If there is planned to expand the study, it would be valuable to think about creating upper categories to facilitate comparison between families. For example: concentration during homework or better communication skills with peers. That would be also more comprehensible for the naive reader to understand and read these goals.
As usual in qualitative research, the sub-categories are very reading consuming. As reader, I would prefer a short summary (maybe as figure and/or with a just key points of the examples. The description and examples of the sub-categories may put in the supplementary material for those who want to know more details.
Author Response
Responses to Reviewer 1’s comments
Comment 1: The manuscript is well-written, logical, and easy to comprehend. The underlying relevance of the topic was embedded in a theoretical background and current lacks of evidence-based knowledge were shown. The greatest strength of the study is that instruments used were well selected for this research question. However, the study does have one big limitation; the sample size was too small. Therefore, it was, unfortunately, not possible to compare the collected data quantitatively, to valid interpret potential changes pre and post the intervention, and it limits the conclusion that were drawn. The descriptive data were well presented, but the results must be interpreted carefully (due to the sample size) and are only to be understood as a trend. For example, in lines 440 / 453-454 / 460-461, it seems for me that your results are very clearly interpreted as representative statements of the study (“children had higher physical wellbeing […] after OPC” / “parents in this study showed improvements” / “a small reduction of their stress […] at post-intervention”). You did not a valid quantitative statistics for those pre-post comparison. I would recommend, working out this even clearer for the reader (before the last section of limitations); that the results are only to be interpretable as a trend.
Response: We appreciate the Reviewer 1’s insightful comments. To avoid making the overestimating statements of the study findings from descriptive statistics, we have followed your suggestions to interpret all the changes in the pre-post comparison as a trend only. For example, in the Abstract (Lines 25-26), the terms “trend” or “tendency” has been added in the sentence as follows” “Results showed a trend of improvement in goal performance …”. In the Discussion section (Lines 453-466), the statements have also been revised as follows: “… the parents in this study tended to show improvements … some parents in this study tended to report a small reduction of … This suggests that the tendency for their improved emotional wellbeing … ”. Such the interpretation has been applied throughout the revised manuscript (e.g., the Results section [Lines 302-338], the Discussion section [Lines 399-402; Line 424; Lines 439-447; Lines 453-462], and the Conclusion section [Lines 504-505]).
Comment 2: I fully understand why the goals (Table 2) for the COPM scores are presented individually. If there is planned to expand the study, it would be valuable to think about creating upper categories to facilitate comparison between families. For example: concentration during homework or better communication skills with peers. That would be also more comprehensible for the naive reader to understand and read these goals.
Response: This comment made by the Reviewer 1 is great. As we have not yet obtained enough data for secondary analysis of these goal statements, we would like to keep them as original and thorough as possible in the Table 2. We also have the concerns that, if upper categories are created for these goals, their original meaning may be distorted or be interpreted by us differently. Thus, we decided not to create the upper categories of these goals for now.
Comment 3: As usual in qualitative research, the sub-categories are very reading consuming. As reader, I would prefer a short summary (maybe as figure and/or with a just key points of the examples. The description and examples of the sub-categories may put in the supplementary material for those who want to know more details.
Response: We agree with the Reviewer 1’s viewpoint that the sub-categories are very reading consuming in the original Table 5. Thus, we have followed your suggestion to provide the key points of the examples for each sub-category in the revised table (see page 13). For the original table, we have included it as Appendix C (pages 24-26) if the readers would like to inspect those illustrative quotations of the sub-categories.
Reviewer 2 Report
Review of ijerph-953647
Hello Authors,
Occupational Performance Coaching with Parents to Promote Community Participation and Quality of Life of Young Children with Developmental Disabilities: A Feasibility Evaluation in Hong Kong
This is a wonderful paper, insightful and important but
- Some grammatical errors need to be addressed
- Stating whether or not there was iRB approval is important
- No statistical analysis of the quantitative data was done. Inferences cannot be made without inferential statistics
See Concerns Below.
Abstract:
Line 25 “Results indicate improvement…” Suggest adding the p value to the abstract.
Page 2:
Line 42: Good justification for the research
Line 58, Nice operational definition of OPC
Line 79 to 80, “…there seems 79 a lot of stigma and…” Wording is in question. What do your references actually say? If there is sigma, just state that this is so. If it is a bit vague, then suggest rewording by adding the words “to be” like this, “…there seems to be a lot of…”
Page 3:
Line 97, Was this study passes by an IRB board prior to beginning. This might be good to add here.
Lines 111-113, “… the child had been diagnosed with developmental delay, autism spectrum disorder, intellectual disability, attention deficit/hyperactivity disorder, dyslexia, or developmental coordination disorder (add a comma between these two words),by local multidisciplinary Child Assessment Centers” This is a long list. Not every child with one or these syndromes would be considered to be DD (an example would be dyslexia).
Page 4:
Line 123, “The Canadian Occupational Performance Measure (COPM)” Was this test in Chinese or English? If it is in English then one of your criteria for inclusion should be that the parents can understand written English as well as Chinese.
Page 5:
Line 171. “Self-reported Emotional” Suggest capitalizing the R…” Self-Reported”
See: https://apastyle.apa.org/style-grammar-guidelines/capitalization/title-case
Line 188: “We designed a…” Suggest avoiding first-person language. Instead write, “A parent-reported questionnaire was designed to…”Also, for Demographics, were numbers used to replace names to allow for confidentiality of participants?
Page 6:
Line 203, “…and were screened for eligibility through telephone. Following…” The grammar is a bit confusing. Did you mean to say, “… were screened for eligibility during a telephone conversation.”
Line 206 and 207, “…by the first author (CWC) at a location of parents’ choice.” The grammar is a bit confusing. This might be better, “…by the first author (CWC), at a location of the parent’s choice.”
There are many grammatical concerns here:
Lines 208-213
Subsequently, parents attended a maximum of eight weekly sessions of OPC (each for one hour at most). OPC sessions were delivered through several modes, including face-to-face at a location of the parent’s choice parents’ choice, or through Zoom video communications (Zoom, San Jose, CA). Consistent with OPC guidance [25], children’s attendance at the coaching sessions was at the parents’ discretion. During the study period, parents and/or their child continued pre-existing service engagement.
One week after the completion of the OPC sessions, the parents repeated all outcome measures. The COPM was completed with the research assistant, who was blind to the treatment content. The research assistant also conducted the post-intervention interview of the parents’ experience of OPC. All interviews lasted 20–40 minutes, and were conducted via Zoom and audio-recorded. At the two month follow-up, all 217 measures except for the HCCQ were repeated a third time.
Page 7
Lines 246-249, “Quantitative data were next analyzed using descriptive statistics such as mean, standard deviation and proportion, and were reported in table format. No inference statistical analysis was performed because of the nature of descriptive case study design with small sample size.” If inferential statistics were not run than inferences cannot be made. Inferences were made in the abstract, line 25, “Results indicate improvement…” This is a very small sample size of 4 parents, but that does not mean that nonparametric statistics cannot be calculated. Suggest this be done. There is a lot of data, and a good pre-post-test using Wilcoxon Signed-Ranks Testing, along with a calculated effect size since you have such a small sample, would definitely lend power to this study.
Page 9
Nice demographic table and interesting pre-post mean table. Again making pre-post inferences without inferential statistics is not the best idea, but this is not a difficult fix. Have someone run the stats for you.
Page 10
Lines 320 to 324, mean changes are reported, but not level of significance. Have someone run the stats for you.
Page 12, Line 348 and 371, “…coach-coachee relationship” I wouldn’t use the word “coachee” unless it had been used previously in the paper. Prefer, “coach-parent relationship”
Page 12, Lines 366-368, “The parents attributed this lack of change to the fact that they had not gone out often for community activities in the past few months, particularly between June and December, 2019, when the social unrest was persistent [51].” This might be a limitation in the study. Suggest adding this to the limitation section prior to the Conclusions on page 19
Pages 13-18. Nice tables. More use of the quantitative data is highly suggested.
Author Response
Responses to Reviewer 2’s comments
Overall Comment: This is a wonderful paper, insightful and important but
- 1. Some grammatical errors need to be addressed
- 2. Stating whether or not there was iRB approval is important
- 3. No statistical analysis of the quantitative data was done. Inferences cannot be made without inferential statistics
Response: Thanks for the Reviewer 2’s compliment and comments for further improvement of this manuscript. We have addressed all of your comments as below.
Comment 1: (Abstract) Line 25 “Results indicate improvement…” Suggest adding the p value to the abstract.
Response: We decided not to perform inference statistical analysis in this case study (see our justifications in the response to 11th comment). Thus, no p-value was added in the Abstract. Instead, to avoid the overestimating statements from our descriptive analyses, we have revised this statement as follows: “Results showed a trend of improvement in goal performance, child involvement in community activities, and specific aspects of HRQOL among most participants.” (Lines 25-26). This revision is followed by the first reviewer’s suggestion for using the term “trend” to describe our quantitative findings.
Comment 2: (Page 2) Line 79 to 80, “…there seems a lot of stigma and…” Wording is in question. What do your references actually say? If there is sigma, just state that this is so. If it is a bit vague, then suggest rewording by adding the words “to be” like this, “…there seems to be a lot of…”
Response: The references we cited indicate a possibility of stigma toward children with disabilities and their families in the Chinese society. We have followed the Reviewer’s suggestion to revise this sentence, as follows: “… there seems to be a lot of stigma and shame surrounding children with disabilities and their families …” (Lines 79-80).
Comment 3: (Page 3) Line 97, Was this study passes by an IRB board prior to beginning. This might be good to add here.
Response: We have added the ethical approval statement, as follows: “Ethical approval for the study was granted by the Human Subjects Ethics Sub-committee at The Hong Kong Polytechnic University (number: HSEARS20190114005).” (Lines 104-106).
Comment 4: (Page 3) Lines 111-113, “… the child had been diagnosed with developmental delay, autism spectrum disorder, intellectual disability, attention deficit/hyperactivity disorder, dyslexia, or developmental coordination disorder (add a comma between these two words),by local multidisciplinary Child Assessment Centers” This is a long list. Not every child with one or these syndromes would be considered to be DD (an example would be dyslexia).
Response: We appreciate the Reviewer’s insightful comment, and also agree that some of the diagnoses (e.g., dyslexia and DCD) were not actually considered nor included in the umbrella term of developmental disability, according to the Centers for Disease Control and Prevention, United States. We have removed these two terms from the original statements (see Lines 111-113). The removal of the two terms did not affect the findings of this study, as participating children had the diagnosis of developmental delay and/or autism.
Comment 5: (Page 4) Line 123, “The Canadian Occupational Performance Measure (COPM)” Was this test in Chinese or English? If it is in English then one of your criteria for inclusion should be that the parents can understand written English as well as Chinese.
Response: In this study, we used the Chinese version of the COPM that can be purchased from the website (http://www.thecopm.ca/buy/translations/). We have added this information in the relevant statement (Line 123).
Comment 6: (Page 5) Line 171. “Self-reported Emotional” Suggest capitalizing the R…” Self-Reported” See: https://apastyle.apa.org/style-grammar-guidelines/capitalization/title-case
Response: We have revised the style of all the titles by following the APA styles provided by the Reviewer throughout the revised manuscript.
Comment 7: (Page 5) Line 188: “We designed a…” Suggest avoiding first-person language. Instead write, “A parent-reported questionnaire was designed to…”Also, for Demographics, were numbers used to replace names to allow for confidentiality of participants?
Response: We have followed the Reviewer’s suggestion to revise this sentence (Line 188). We did collect participants’ names, and numbers were used to replace the names to allow for confidentiality in the study. Relevant statements have been added, as follows: “In addition, participants’ names were collected but replaced by the numbers in this study, allowing for confidentiality when reported.” (Lines 193-194).
Comment 8: (Page 6) Line 203, “…and were screened for eligibility through telephone. Following…” The grammar is a bit confusing. Did you mean to say, “… were screened for eligibility during a telephone conversation.”
Response: We have fixed the grammar, as follows: “… during a telephone conversation.” (Line 205).
Comment 9: (Page 6) Line 206 and 207, “…by the first author (CWC) at a location of parents’ choice.” The grammar is a bit confusing. This might be better, “…by the first author (CWC), at a location of the parent’s choice.”
Response: We have fixed the grammar, as follows: “… by the first author (CWC), at a location of the parents’ choice.” (Lines 208-209).
Comment 10: (Page 7) There are many grammatical concerns here: Lines 208-213, Subsequently, parents attended a maximum of eight weekly sessions of OPC (each for one hour at most). OPC sessions were delivered through several modes, including face-to-face at a location of the parent’s choice parents’ choice, or through Zoom video communications (Zoom, San Jose, CA). Consistent with OPC guidance [25], children’s attendance at the coaching sessions was at the parents’ discretion. During the study period, parents and/or their child continued pre-existing service engagement.
One week after the completion of the OPC sessions, the parents repeated all outcome measures. The COPM was completed with the research assistant, who was blind to the treatment content. The research assistant also conducted the post-intervention interview of the parents’ experience of OPC. All interviews lasted 20–40 minutes, and were conducted via Zoom and audio-recorded. At the two month follow-up, all 217 measures except for the HCCQ were repeated a third time.
Response: We appreciate the Reviewer’s grammatical suggestions. The grammar of relevant statements has been fixed accordingly (Lines 210-220).
Comment 11: (Page 7) Lines 246-249, “Quantitative data were next analyzed using descriptive statistics such as mean, standard deviation and proportion, and were reported in table format. No inference statistical analysis was performed because of the nature of descriptive case study design with small sample size.” If inferential statistics were not run than inferences cannot be made. Inferences were made in the abstract, line 25, “Results indicate improvement…” This is a very small sample size of 4 parents, but that does not mean that nonparametric statistics cannot be calculated. Suggest this be done. There is a lot of data, and a good pre-post-test using Wilcoxon Signed-Ranks Testing, along with a calculated effect size since you have such a small sample, would definitely lend power to this study.
Response: We agree with the Reviewer’s viewpoint that the inferences cannot be made if inferential statistics are not provided. The relatively small sample size of this study may be still insufficient to support the use of the nonparametric statistics (i.e., the Wilcoxon Signed-Ranks Test). As four participants were included, there are only four rank-ordered data points in the Wilcoxon Signed-Ranks Test. When we attempted to analyze the pre-post data of the PEM-CY involvement scales, the resultant p-value was 0.068, which is the lowest value we could obtain from the four different, positive ranks in the Wilcoxon Signed-Ranks Test. Thus, we thought that reporting the p-value based on four cases could be misleading, which was underestimated by the insufficient power owing to the limited sample size.
Hence, we have followed the Reviewer 1’s suggestions by using the terms “trend” or “tendency” to describe our quantitative results. The revision has been made throughout the revised manuscript (e.g., the Abstract [Lines 25-26], the Results section [Lines 302-338], the Discussion section [Lines 399-403; Line 424; Lines 439-447; Lines 453-462], and the Conclusion section [Lines 504-505]), in order to avoid making inappropriate statements from the use of descriptive statistics in this case study.
Comment 12: (Page 9) Nice demographic table and interesting pre-post mean table. Again making pre-post inferences without inferential statistics is not the best idea, but this is not a difficult fix. Have someone run the stats for you.
Response: Thanks for the Reviewer’s comment. We did not perform inferential analysis in this case study due to the small sample size (see our justification in the response to 11th comment).
Comment 13: (Page 10) Lines 320 to 324, mean changes are reported, but not level of significance. Have someone run the stats for you.
Response: Thanks for the Reviewer’s comment. We did not perform inferential analysis in this case study due to the small sample size (see our justification in the response to 11th comment). We have revised this statement to avoid the misunderstanding, as follows: “… two to four children were reported by their parents as having a tendency to experience a positive increase …” (Lines 322-324).
Comment 14: (Page 12) Line 348 and 371, “…coach-coachee relationship” I wouldn’t use the word “coachee” unless it had been used previously in the paper. Prefer, “coach-parent relationship”
Response: We have made the revision by replacing “coach-coachee relationship” to “coach-parent relationship” in the revised text and Table 5.
Comment 15: (Page 12) Lines 366-368, “The parents attributed this lack of change to the fact that they had not gone out often for community activities in the past few months, particularly between June and December, 2019, when the social unrest was persistent [51].” This might be a limitation in the study. Suggest adding this to the limitation section prior to the Conclusions on page 19
Response: We have moved this statement in the Study Limitation section, as follows: “… and, especially, the influence of the social unrest and COVID-19 on study progress and outcome. For example, the parents attributed the lack of change in their child’s community participation to the fact that they had not gone out often between June and December, 2019, when the social unrest was persistent.” (Lines 492-495).
Comment 16: (Pages 13-18) Nice tables. More use of the quantitative data is highly suggested.
Response: Thanks for the Reviewer’s compliment on the Table 5. This table has been trimmed for easy understanding based on the first reviewer’s suggestion. The original table is now included as the Appendix C (pages 24-26). Regarding the use of quantitative data, we decided not to perform inferential analysis in this case study due to the small sample size (see our justification in the response to 11th comment). Thus, no more statements were added in our interpretation to avoid the overestimation of the findings of the quantitative results.
Reviewer 3 Report
This work is relevant and timely. The quality of the presentation and the assessment measures selected as well as the data analysis were exceptional. Minor grammatical errors were identified. Overall excellent work.
Author Response
Responses to Reviewer 3’s comments
Comment 1: This work is relevant and timely. The quality of the presentation and the assessment measures selected as well as the data analysis were exceptional. Minor grammatical errors were identified. Overall excellent work.
Response: We appreciate the Reviewer 3’s compliment on our work. The grammatical errors have been fixed by following the other reviewers’ suggestions as well as by our secondary proof reading.
