Exploring the Psychosocial Impact on Families Caring for Children with Cerebral Palsy: A Qualitative Study in Saudi Arabia

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The authors performed a qualitative study to document the psychosocial impact of having a child with CP in families in Saudi Arabia. The methodology is apt for this kind of research and the results are well presented. My suggestions are below:

1) Is Intermedia school the same as scondary school? It is not very clear. 

2) I think the discussion should also have a paragraph about the differences and similarities of the subject with other nations, so that the reader would have a perspective about it. The authors just summarized their findings without giving much insight about the cultural differences of Saudi Arabia. 

3) The authors can also compare the similarity of quotes with other pathologies, since most of the expressions are general for parents of children with and disability such as autism spectrum disorder. 

4) According to .... [13,14] improved child outcomes are closely correlated with in- 255 creased parental efficacy and self-competence. In this sentence I think the authors should be names as According to so and so et al...

Author Response

Response to Reviewer #1 Comments

 

The authors performed a qualitative study to document the psychosocial impact of having a child with CP in families in Saudi Arabia. The methodology is apt for this kind of research and the results are well presented.

AUTHORS’ REPLY: Thank you very much for the valuable and helpful comments.

 

My suggestions are below:

 

Is Intermedia school the same as scondary school? It is not very clear. 

AUTHORS’ REPLY: We changed it to middle school. In the Saudi education system, general education is structured into three main levels: primary school (6 years), intermediate school (3 years), and secondary school (3 years). Intermediate school refers to the middle stage between primary and secondary education and is not the same as secondary school. Therefore, the term “intermediate school” in this study corresponds to middle school students. In addition, we changed ‘illiterate’ to ‘no formal education’, as suggested during language editing. Please refer to Table 1, in Lines 222-224.

 

I think the discussion should also have a paragraph about the differences and similarities of the subject with other nations, so that the reader would have a perspective about it. The authors just summarized their findings without giving much insight about the cultural differences of Saudi Arabia. 

AUTHORS’ REPLY: We have implemented this, as suggested, throughout the Discussion section. Please refer to Lines 332-399.

 

The authors can also compare the similarity of quotes with other pathologies, since most of the expressions are general for parents of children with and disability such as autism spectrum disorder. 

AUTHORS’ REPLY: We have also implemented this as suggested throughout the Discussion section. Please refer to Lines 332-399.

 

According to .... [13,14] improved child outcomes are closely correlated with in- 255 creased parental efficacy and self-competence. In this sentence I think the authors should be names as According to so and so et al...

AUTHORS’ REPLY: We have corrected this in the Discussion section, Yue et al. (2024) and Riquelme et al. (2021). Please refer to Lines 363-364.

Reviewer 2 Report

Comments and Suggestions for Authors

This manuscript explores the psychosocial impact on families caring for children with cerebral palsy through a qualitative study conducted with caregivers in Saudi Arabia. The topic is important and timely. Families caring for children with cerebral palsy often experience significant emotional, social, and financial pressures, yet these experiences remain underreported in many regional contexts. By focusing on caregiver perspectives, the authors contribute valuable insight into an area that is highly relevant for pediatric rehabilitation, nursing, and family-centered care.

The qualitative design using semi-structured interviews and thematic analysis is appropriate for exploring lived experiences and understanding the complexities of caregiving in this context. The inclusion of participant quotations adds depth to the findings and helps foreground caregiver voices.  However, several areas of the manuscript require strengthening before the paper is ready for publication. The most significant issues relate to methodological transparency, analytic depth, consistency between results and discussion, and clarity of language. These concerns are addressable through revision, and the study has the potential to make a meaningful contribution if these areas are improved.

Overall, I encourage the authors to revise and resubmit the manuscript, as the topic and dataset are valuable and worthy of publication once the reporting and interpretation are strengthened.

Major Comments

1. Clarify the qualitative methodology and research approach

The manuscript states that a “qualitative exploratory methodology” was used with semi-structured interviews and thematic analysis.  While this is appropriate, the description of the methodology is currently too brief for a qualitative study. Greater transparency will strengthen the credibility and reproducibility of the work.

The authors may consider expanding the methods section to clarify:

• the qualitative approach guiding the study (e.g., qualitative descriptive, phenomenology, or exploratory qualitative research)
• recruitment procedures through the Children with Disability Association
• inclusion and exclusion criteria
• who conducted the interviews and their professional background
• interview setting and duration
• whether interviews were recorded and transcribed
• the language used during interviews and whether translation occurred
• the relationship (if any) between researchers and participants
• reflexivity and researcher positioning

Example revision

The authors might expand the methods section as follows:

“A qualitative descriptive approach was used to explore caregivers’ experiences of raising children with cerebral palsy. Participants were recruited through the Children with Disability Association using purposive sampling. Inclusion criteria included parents or primary caregivers of a child diagnosed with cerebral palsy who were willing to participate in an in-depth interview. Interviews were conducted by the first author, a trained nurse researcher with experience in qualitative interviewing. Each interview lasted approximately 30–45 minutes and was audio recorded with participant consent. Interviews were conducted in Arabic and later transcribed and translated into English.”

Providing this level of detail will help readers better understand how the data were generated.

2. Provide greater transparency in the analytic process

The manuscript states that Braun and Clarke’s six-step thematic analysis approach was used. This is appropriate, but the analytic process could be described more clearly. Readers would benefit from understanding how codes were generated and how themes were developed.

For example, the authors might describe:

• how initial codes were developed from the transcripts
• whether coding was conducted manually or with software
• whether coding focused on semantic or latent meanings
• how themes were refined and agreed upon
• how external reviewers contributed to validating themes

Example revision

The authors could clarify the analytic process in language such as:

“Initial coding was conducted by the first author through repeated reading of transcripts to identify meaningful segments of text. Codes were grouped into preliminary categories and reviewed by two qualitative research experts to ensure analytic rigor. Through iterative discussions, categories were refined into broader themes that reflected shared caregiver experiences.”

Adding this explanation would improve the methodological rigor of the manuscript.

3. Clarify how data saturation was determined

The manuscript indicates that saturation was achieved after eleven interviews, with two additional interviews confirming saturation. This is reasonable, but the manuscript would benefit from briefly explaining how saturation was assessed.

For instance:

• Was saturation determined when no new codes emerged?
• Who assessed saturation?
• Did it refer to thematic saturation or code saturation?

Example revision

“Data collection continued until thematic saturation was reached, defined as the point at which no new codes or themes emerged during analysis. Saturation was initially observed after the eleventh interview and confirmed through two additional interviews.”

4. Ensure consistency between results and discussion

One issue that should be addressed is the reference to spiritual coping in the discussion.

This theme does not appear in the results section or in Table 2, which instead presents six subthemes related to diagnosis, accessibility, stigma, financial strain, and future concerns.  The authors may wish to either:

1. Include a theme or subtheme related to spiritual coping in the results section (with supporting quotes), or
2. Remove or revise this discussion point if it was not part of the analyzed data.

Ensuring alignment between the results and discussion will strengthen the coherence of the manuscript.

5. Deepen the interpretation of the findings

The results identify several important caregiver challenges, including delayed diagnosis, service barriers, financial strain, and stigma.  Currently, the discussion mainly reiterates these themes and compares them to existing literature. The manuscript could be strengthened by offering deeper interpretation.

For example, the authors might explore:

• how delayed diagnosis affects parental stress and decision-making
• how stigma influences social participation and family relationships
• how financial strain intersects with access to rehabilitation services
• how cultural expectations shape caregiving roles

Providing more interpretation would help the paper move beyond description and highlight the broader implications of the findings.

6. Expand the implications for practice and policy

The conclusion notes the need for emotional, financial, and social support for families.

The manuscript would benefit from more specific recommendations for healthcare professionals and policymakers.

For example, the authors might consider discussing:

• caregiver support programs
• parent education and training initiatives
• early diagnostic pathways
• integrated rehabilitation services
• psychosocial support within pediatric care systems

This would increase the practical relevance of the study.

Minor Comments

1. Language and grammar

The manuscript would benefit from professional English editing. Several sentences contain awkward phrasing or grammatical inconsistencies.

Examples include phrases such as:

• “families of rearing children with cerebral palsy”
• “cerebral motor disability children”

These could be revised for clarity.

Example revision

Instead of:

“families of rearing children with cerebral palsy”

Consider:

“families raising children with cerebral palsy.”

2. Use consistent person-centered terminology

The manuscript uses multiple terms to describe the population, including “children with cerebral palsy,” “cerebral motor disability children,” and “child with disability.”

healthcare-4199394-peer-review-…

For clarity and person-centered language, the authors may wish to consistently use:

“children with cerebral palsy.”

3. Improve Table 2 formatting

Table 2 contains minor formatting issues such as “Sub-them,” which should be corrected to “Sub-theme.”

Additionally, the wording of some subthemes could be streamlined.

For example:

Instead of:

“Accessibility obstacles in caring for cerebral palsy child”

Consider:

“Barriers to accessing care and support services.”

4. Clarify the funding statement

The manuscript indicates that no external funding was received, but the acknowledgments thank the Deanship of Scientific Research at King Saud University for funding.  The authors may wish to clarify whether this represents internal institutional support.

5. Review ethics and consent wording

The informed consent section mentions completing a “questionnaire,” although the study used interviews.

This manuscript addresses an important topic and presents valuable qualitative insights into the experiences of families caring for children with cerebral palsy. With clearer methodological reporting, improved analytic explanation, strengthened discussion, and careful language revision, the paper has strong potential to contribute meaningfully to the literature.

I encourage the authors to revise the manuscript accordingly and resubmit it for further consideration.

Author Response

Response to Reviewer #2 Comments

 

This manuscript explores the psychosocial impact on families caring for children with cerebral palsy through a qualitative study conducted with caregivers in Saudi Arabia. The topic is important and timely. Families caring for children with cerebral palsy often experience significant emotional, social, and financial pressures, yet these experiences remain underreported in many regional contexts. By focusing on caregiver perspectives, the authors contribute valuable insight into an area that is highly relevant for pediatric rehabilitation, nursing, and family-centered care.

The qualitative design using semi-structured interviews and thematic analysis is appropriate for exploring lived experiences and understanding the complexities of caregiving in this context. The inclusion of participant quotations adds depth to the findings and helps foreground caregiver voices.  However, several areas of the manuscript require strengthening before the paper is ready for publication. The most significant issues relate to methodological transparency, analytic depth, consistency between results and discussion, and clarity of language. These concerns are addressable through revision, and the study has the potential to make a meaningful contribution if these areas are improved.

Overall, I encourage the authors to revise and resubmit the manuscript, as the topic and dataset are valuable and worthy of publication once the reporting and interpretation are strengthened.

AUTHORS’ REPLY: We express our sincere appreciation for your specific, thoughtful and generous recommendations; thank you immensely.

 

Major Comments

Clarify the qualitative methodology and research approach

The manuscript states that a “qualitative exploratory methodology” was used with semi-structured interviews and thematic analysis.  While this is appropriate, the description of the methodology is currently too brief for a qualitative study. Greater transparency will strengthen the credibility and reproducibility of the work.

 

The authors may consider expanding the methods section to clarify:

the qualitative approach guiding the study (e.g., qualitative descriptive, phenomenology, or exploratory qualitative research)

recruitment procedures through the Children with Disability Association

• inclusion and exclusion criteria
• who conducted the interviews and their professional background
• interview setting and duration
• whether interviews were recorded and transcribed
• the language used during interviews and whether translation occurred
• the relationship (if any) between researchers and participants
• reflexivity and researcher positioning

AUTHORS’ REPLY: All of these have been implemented throughout the Materials and Methods section, in Lines 62-192. Importantly, we are not associated with the chosen Children's Disabled Association. Throughout the study, the authors consistently analyzed and discussed perspectives and opinions, acknowledging that thinking might be influenced by preconceptions, prejudices, and beliefs. The authors' keen awareness of the research roles informed their actions and choices. The researchers minimized bias in the research conclusions by doing intersubjective checks, using a reflexive strategy, and staying grounded in the facts to maintain rigor.

 

Example revision

The authors might expand the methods section as follows:

“A qualitative descriptive approach was used to explore caregivers’ experiences of raising children with cerebral palsy. Participants were recruited through the Children with Disability Association using purposive sampling. Inclusion criteria included parents or primary caregivers of a child diagnosed with cerebral palsy who were willing to participate in an in-depth interview. Interviews were conducted by the first author, a trained nurse researcher with experience in qualitative interviewing. Each interview lasted approximately 30–45 minutes and was audio recorded with participant consent. Interviews were conducted in Arabic and later transcribed and translated into English.”

Providing this level of detail will help readers better understand how the data were generated.

AUTHORS’ REPLY: We have implemented your suggested revisions throughout the Materials and Methods section, specifically in Lines 64-72, 83-92, and 102-141.

 

Provide greater transparency in the analytic process

The manuscript states that Braun and Clarke’s six-step thematic analysis approach was used. This is appropriate, but the analytic process could be described more clearly. Readers would benefit from understanding how codes were generated and how themes were developed.

For example, the authors might describe:

how initial codes were developed from the transcripts

whether coding was conducted manually or with software

whether coding focused on semantic or latent meanings

how themes were refined and agreed upon

how external reviewers contributed to validating themes

Example revision

The authors could clarify the analytic process in language such as:

“Initial coding was conducted by the first author through repeated reading of transcripts to identify meaningful segments of text. Codes were grouped into preliminary categories and reviewed by two qualitative research experts to ensure analytic rigor. Through iterative discussions, categories were refined into broader themes that reflected shared caregiver experiences.”

Adding this explanation would improve the methodological rigor of the manuscript.

AUTHORS’ REPLY: We have implemented this suggestion in Data Analysis sub-section (see Lines 164-173).

 

Clarify how data saturation was determined

The manuscript indicates that saturation was achieved after eleven interviews, with two additional interviews confirming saturation. This is reasonable, but the manuscript would benefit from briefly explaining how saturation was assessed.

For instance:

Was saturation determined when no new codes emerged?

Who assessed saturation?

Did it refer to thematic saturation or code saturation?

Example revision

“Data collection continued until thematic saturation was reached, defined as the point at which no new codes or themes emerged during analysis. Saturation was initially observed after the eleventh interview and confirmed through two additional interviews.”

AUTHORS’ REPLY: We have implemented this suggestion in Data Collection Process sub-section (see Lines 102-141).

 

Ensure consistency between results and discussion

One issue that should be addressed is the reference to spiritual coping in the discussion.

This theme does not appear in the results section or in Table 2, which instead presents six subthemes related to diagnosis, accessibility, stigma, financial strain, and future concerns.  The authors may wish to either:

Include a theme or subtheme related to spiritual coping in the results section (with supporting quotes), or

Remove or revise this discussion point if it was not part of the analyzed data.

Ensuring alignment between the results and discussion will strengthen the coherence of the manuscript. 

AUTHORS’ REPLY: We have removed ‘spiritual coping’ and ensured alignment between the Results and Discussion sections.

 

Deepen the interpretation of the findings

The results identify several important caregiver challenges, including delayed diagnosis, service barriers, financial strain, and stigma.  Currently, the discussion mainly reiterates these themes and compares them to existing literature. The manuscript could be strengthened by offering deeper interpretation.

For example, the authors might explore:

how delayed diagnosis affects parental stress and decision-making

how stigma influences social participation and family relationships

how financial strain intersects with access to rehabilitation services

how cultural expectations shape caregiving roles

Providing more interpretation would help the paper move beyond description and highlight the broader implications of the findings.

AUTHORS’ REPLY: We have provided and included more interpretation throughout the Discussion section in Lines 331-398.

 

Expand the implications for practice and policy

The conclusion notes the need for emotional, financial, and social support for families.

The manuscript would benefit from more specific recommendations for healthcare professionals and policymakers.

For example, the authors might consider discussing:

caregiver support programs

parent education and training initiatives

early diagnostic pathways

integrated rehabilitation services

psychosocial support within pediatric care systems

This would increase the practical relevance of the study.

AUTHORS’ REPLY: We have implemented your suggestion in Implications for Clinical Practice section, specifically in Lines 418-422.

 

Minor Comments

Language and grammar

The manuscript would benefit from professional English editing. Several sentences contain awkward phrasing or grammatical inconsistencies.

AUTHORS’ REPLY: After revising our manuscript, we submitted the revised version to professional English language editing, shown in the author information of the document as ‘Ed1 185’.

 

Examples include phrases such as:

“families of rearing children with cerebral palsy”

“cerebral motor disability children”

These could be revised for clarity.

Example revision

Instead of:

“families of rearing children with cerebral palsy”

Consider:

“families raising children with cerebral palsy.”

AUTHORS’ REPLY: We have implemented this suggestion in Lines 332-333.

 

Use consistent person-centered terminology

The manuscript uses multiple terms to describe the population, including “children with cerebral palsy,” “cerebral motor disability children,” and “child with disability.”

For clarity and person-centered language, the authors may wish to consistently use:

“children with cerebral palsy.”

AUTHORS’ REPLY: We have consistently used the phrase “children with cerebral palsy” throughout the revised version of the manuscript.

 

Improve Table 2 formatting

Table 2 contains minor formatting issues such as “Sub-them,” which should be corrected to “Sub-theme.”

AUTHORS’ REPLY: This has been corrected in Table 2.

 

Additionally, the wording of some subthemes could be streamlined.

For example:

Instead of:

“Accessibility obstacles in caring for cerebral palsy child”

Consider:

“Barriers to accessing care and support services.”

AUTHORS’ REPLY: We have implemented this suggestion within Table 2, and in the Results section (see Line 255).

 

Clarify the funding statement

The manuscript indicates that no external funding was received, but the acknowledgments thank the Deanship of Scientific Research at King Saud University for funding.  The authors may wish to clarify whether this represents internal institutional support.

AUTHORS’ REPLY: We have corrected this during resubmission and confirmed that the Deanship of Scientific Research at King Saud University funded this research through the Ongoing Research Funding (ORF) Program.

 

Review ethics and consent wording

The informed consent section mentions completing a “questionnaire,” although the study used interviews.

AUTHORS’ REPLY: We have deleted this information (see Lines 459-460).

 

This manuscript addresses an important topic and presents valuable qualitative insights into the experiences of families caring for children with cerebral palsy. With clearer methodological reporting, improved analytic explanation, strengthened discussion, and careful language revision, the paper has strong potential to contribute meaningfully to the literature.

I encourage the authors to revise the manuscript accordingly and resubmit it for further consideration.

AUTHORS’ REPLY: Once again, thank you very much and Godspeed!

Reviewer 3 Report

Comments and Suggestions for Authors

The overall organization and presentation are aligned with the journal guidelines. The Title of the article should specify the demographic and cultural context of the study. In the Introduction, authors may find it useful to review that suggested additional papers as listed at the end of this review summary. Authors should identify current gaps in the literature and explicitly state how this study would contribute toward addressing the gaps in knowledge; this is especially relevant as data are spars in the specific demographic and cultural context of this study. 

The Aim of the study should also include reference to the demographics of the study. 

Material and Methods: The study more appropriately reflects the precepts of Thematic Analysis rather than pure qualitative study. Authors' use of iterative process in modifying questions and emerging themes is excellent.

In the Data Analysis section, second para, line 103-104, it would be useful to specify the expertise of the professional mentioned.

Results reporting follow COREQ guidelines - excellent. Results description is very well done. Authors may want to consider situating the themes within the greater context of literature base (see additional suggested refs below).

In the Discussion section, consider highlighting impact of culturally tailored interventions.

Limitations - well addressed. Consider mentioning attempts taken to minimize potential bias.

 

Comments for author File: Comments.pdf

Author Response

Response to Reviewer #3 Comments

 

The overall organization and presentation are aligned with the journal guidelines.

AUTHORS’ REPLY: Thank you so much for your valuable comments.

 

The Title of the article should specify the demographic and cultural context of the study.

AUTHORS’ REPLY: We added the phrase ‘in Saudi Arabia’ to the title and we are open for any specific suggestions from the honorable Reviewer #3.

 

In the Introduction, authors may find it useful to review that suggested additional papers as listed at the end of this review summary.

AUTHORS’ REPLY: We have considered other studies and added them to the Introduction section. Meanwhile, the ones you suggested, including: Alaee et al. (2015), Barreto et al. (2020), Liu et al. (2023), Elangkovan & Shorey (2020), and Irwin et al. (2019) have been added to the Discussion section. Please refer to Lines 386-401.

 

Authors should identify current gaps in the literature and explicitly state how this study would contribute toward addressing the gaps in knowledge; this is especially relevant as data are spars in the specific demographic and cultural context of this study. 

AUTHORS’ REPLY: We have addressed this, as suggested, in the Introduction section. Please refer to Lines 27-61.

 

The Aim of the study should also include reference to the demographics of the study. 

AUTHORS’ REPLY: We have added and implemented this in the Abstract section (see Line/s 13) and in the Materials and Methods section (see Line/s 71).

 

Material and Methods: The study more appropriately reflects the precepts of Thematic Analysis rather than pure qualitative study. Authors' use of iterative process in modifying questions and emerging themes is excellent.

AUTHORS’ REPLY: Thank you very much and this section has been generally improved in alignment with the other esteemed reviewers’ comments. Please refer to Lines 62-194.

 

In the Data Analysis section, second para, line 103-104, it would be useful to specify the expertise of the professional mentioned.

AUTHORS’ REPLY: This has been addressed in Lines 129-130.

 

Results reporting follow COREQ guidelines - excellent. Results description is very well done. Authors may want to consider situating the themes within the greater context of literature base (see additional suggested refs below).

AUTHORS’ REPLY: This has been implemented, as suggested, including: Alaee et al. (2015), Barreto et al. (2020), Liu et al. (2023), Elangkovan & Shorey (2020), and Irwin et al. (2019) in the Discussion section. Please refer to Lines 386-401.

 

In the Discussion section, consider highlighting impact of culturally tailored interventions.

AUTHORS’ REPLY: This has been addressed specifically in the Implications for Clinical Practice sub-section of the Discussion section in Lines 413-428.

 

Limitations - well addressed. Consider mentioning attempts taken to minimize potential bias.

AUTHORS’ REPLY: This has been addressed in Lines 405-412.

Reviewer 4 Report

Comments and Suggestions for Authors

Dear authors

 

Thank you for the valuable paper. Kindly check the attached comments and affect them to better your study

 

Kind regards

 

Kind regards

Comments for author File: Comments.pdf

Author Response

Response to Reviewer #4 Comments

 

The study is more valuable and important. However, it does not give a clear picture of the problem. Kindly check the comments below.

AUTHORS’ REPLY: Thank you very much for your constructive and helpful comments.

 

INTRODUCTION

-Kindly add more information on the introduction with more studies showing the seriousness of the problem globally, Sub-Saharan Africa, Nationally, and locally

AUTHORS’ REPLY: This has been addressed in Lines 27-37, as also indicated below, with updated references in the revised manuscript.

Cerebral palsy (CP) is the most common cause of childhood physical disability. Globally, the estimated prevalence of CP is more than 17 million people, with a rate of approximately 1.5–4 per 1,000 live births [1]. The incidence rate of CP varies between 2 and 3 per 1,000 live births in the USA, Europe, and Australia [2] and can reach 10 per 1,000 live births in Sub-Saharan Africa [3].

In Saudi Arabia, CP prevalence is estimated at approximately 2.34 per 1,000 children, with growing recognition of its impact on family well-being [4]. A higher prevalence of CP-related risk factors, such as prenatal and postnatal infections and nutritional deficits, are frequently blamed for this increased incidence [5].

 

 MATERIALS AND METHODS

-The sub-topic of 2.2. It should be the sampling process that includes the sampling method, sample size, and population. Kindly also specify the sampling criteria rather than just referring to purposive sampling.

AUTHORS’ REPLY: This has been addressed in Lines 82-92, as also indicated below, with updated references in the revised manuscript.

2.2. Sampling process

The study population consisted of primary caregivers of children diagnosed with CP. A purposive sampling strategy was used to recruit participants who could provide rich, firsthand accounts of the caregiving experience. The study’s inclusion criteria were as follows: adult caregivers (aged 18 years or older), primary responsibility for the daily care of a child with CP, and a minimum caregiving duration of one year to ensure depth of experience. The exclusion criterion is that the caregivers should not have any chronic physical or mental illnesses. Sampling continued until thematic saturation was reached, defined as the point at which no new codes or themes emerged during analysis. Saturation was initially observed after the 11th interview and confirmed through two additional interviews.

 

-Kindly include the research setting where the data were collected.

AUTHORS’ REPLY: This has been added, as suggested, in Lines 94-100. Please see below, with updated references in the revised manuscript.

2.3 Setting

Data were collected from the Children with Disability Association (CDA) in Riyadh, Saudi Arabia. The CDA provides specialized services for children with disabilities, and offers integrated medical, educational, and rehabilitation services to promote learning, functional development, and general health. In line with the study’s objectives, this environment provided suitable access to caregivers who had personal experience of providing care for children with CP.

 

-2.3. Data collection. Under that topic, it should be a data collection instrument and a data collection process.

AUTHORS’ REPLY: We respectfully request the honorable Reviewer #4 to name this sub-section as it is, ‘Data Collection Process’ in Lines 102-141, because the use of ‘data collection instrument’ may denote a survey study. But we totally respect further recommendations from the honorable Reviewer #4 regarding this matter. The updated version of this sub-section is indicated below, with updated references in the revised manuscript.

2.4 Data Collection Process

The interviews took place between November and December 2025. Participants were informed of the purposes and procedures of the study. They gave written informed consent, were made aware of their right to remain anonymous, and were free to withdraw from the study at any time.

In-depth semi-structured data collection was performed in Arabic and later transcribed and translated into English. Accordingly, interviews were based on a predetermined set of questions that were repeatedly changed to incorporate other topics as contributions permit. These questions include “Can you describe your experiences of raising a child with cerebral palsy?” “What difficulties have you faced in this situation?” “How do these challenges affect you and your family?” “What types of assistance do parents need when caring for a child with cerebral palsy?”

In this way, emergent themes were incorporated into the interview procedure during data collection to ensure that the study was adequately representative of nuanced and dynamic dimensions of participants’ experiences [11].

Before starting the interview, the first author discussed the objectives and questions of the interview with the recruited participants (2 participants) to ensure that the questions are clear, unbiased, and capable of eliciting rich, meaningful data. Furthermore, the findings of the pre-testing were not included in the main study to identify any practical or logistical challenges in data collection (e.g., timing, recording, participant engagement).

Participation in this study was completely voluntary. Each participant completed a separate interview to protect the confidentiality and privacy of the information they submitted. Adherence to ethical research standards was crucial throughout the investigation. The Declaration of Helsinki [12] was followed in addressing all ethical issues. Interviews were conducted by the first author, a trained nurse researcher with experience in qualitative interviewing, and 30–35 minutes were allotted for the interviews. The responses of the participants were recorded using audio device. Probing questions based on the participants’ opinions were used throughout the interview to extract crucial information, such as “Why?” “How?” and “What do you mean by this?”

For the sake of reflexivity, the authors are not associated with the CDA. Throughout the study, the authors consistently analyzed and discussed perspectives and opinions, acknowledging that thinking might be influenced by preconceptions, prejudices, and beliefs. The authors’ keen awareness of the research roles informed their actions and choices. They minimized bias in the conclusions by performing intersubjective checks, using a reflexive strategy, and staying grounded in the facts to maintain rigor.

 

-Indicate the pre-testing process that was done, how many participants were included in the pre-testing of the instrument, and whether the findings of the pre-testing were included in the main study or not.

AUTHORS’ REPLY: This has been addressed and mentioned above as response to your previous comment. Please refer to Lines 118-124 of the revised manuscript.

 

-Kindly indicate the recruitment process that was followed

AUTHORS’ REPLY: This has been addressed and mentioned above as response to your previous comment. Please refer to Lines 102-141 of the revised manuscript.

 

-Line 66 is talking about the data collected from children instead of family members caring for them. Kindly revise the statement.

AUTHORS’ REPLY: This has been clarified as ‘setting’ of the study and revised as, ‘Data were collected within the Children with Disability Association (CDA) facility in Riyadh, Saudi Arabia,’ in Lines 95-96.

 

-Ethical considerations of the institutions granted permission are not indicated, as it is very important to know whether ethical clearance was given or not, and the clearance number to be indicated.

AUTHORS’ REPLY: This has been added and mentioned during first submission in Institutional Review Board Statement section, Lines 461-463.

 

RESULTS

-Write a paragraph talking about the table of the characteristics of participants immediately after Table 1 to interpret the meaning of what is in the table.

AUTHORS’ REPLY: This has been added, as suggested. Please refer to Lines 209-217.

 

DISCUSSIONS

-Add more information regarding the emerged themes and subthemes supporting them with more literature and correlating them with what is in the introduction. The discussion is too scanty. Kindly beef it up with more literature and authors’ voices.

AUTHORS’ REPLY: This has been addressed completely and updated throughout the Discussion section in Lines 333-405.