Barriers and Facilitators to Initial and Ongoing Implementation of Community-Based Exercise Programs for Persons with Physical Disabilities: Qualitative Perspectives of Program Providers

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Attached is the report

Comments for author File: Comments.pdf

Author Response

INTRODUCTION

Comment 1: Include references with respect to community-based exercise programs (CBEPs).

Response 1: Between lines 35-49, we have included 8 references that speak to CBEPs, including the recent burgeoning of programs (refs 2, 4, 8), how they are operationalized/ defined (ref 7), how they can act as a bridge between rehabilitation and the community for persons with disabilities (ref 8), how they can promote quantity and quality of physical activity participation for persons with physical disabilities (refs 4, 9, 10), and the fact that relatively few programs exist (ref 12). We have also added an additional reference that speaks to the limited literature about implementation of CBEPs (ref 13). We feel we have adequately supported our introduction of CBEPs; however, if the reviewer could kindly indicate what aspect of the content about CBEPs is currently lacking a reference, we would be happy to include an additional citation.

Comment 2: Refer to the International Classification of Functioning, Disability and Health (ICF).

Response 2: The ICF is typically used in reference to an operationalization of disability. We have reviewed the introduction as written and cannot find a reasonable place to introduce the ICF model without altering the flow of ideas. If the reviewer could kindly indicate where they would like to see the inclusion of the ICF, we can certainly consider this feedback a second time.

 

MATERIALS AND METHODS

Comment 3: In a qualitative study, it is understandable that there are subjective components that influence the interpretation of processes. I find it very useful that you have emphasized and shared this aspect.

Response 3:  Thank you very much for your positive feedback.

Comment 4: The two subsections 2.2.1 Identifying CBEPs and 2.2.2 Participants are very clear in their explanation of recruitment. The tables included also appear to be very detailed.

Response 4:  Thank you very much for your positive feedback about our description of recruitment and the level of detail included in the tables.

Comment 5: It might also be interesting to add the age range that the different programmes take into account, by adding this information in the program details section (Table 2).

Response 5: Thank you for the suggestion.  As indicated in Table 1, one of the inclusion criteria for CBEPs in our study was that the programs were appropriate for adults aged 18 years or older.  Unfortunately, we did not ask program providers to give us an age range or average age of their participants during the interviews, which means we do not have more specific details about participant age to add to Table 2.

 

RESULTS & DISCUSSION

Comment 6: In the results section, the tables present a clear and concise description of what the study has analysed, while the argumentation allows you to go into more detail on what the tables show.

Response 6: Thank you for the positive feedback about our results section. We struggled with the amount of detail to present in tables relative to the text.  Your comment reassured us that we struck the right balance for readers, thanks you!

Comment 7: Further references should be included in the discussion in order to reinforce what has been interpreted.

Response 7: Thank you for the suggestion.  We have since added five references to the discussion (refs 26, 27, 29, 31, and 36) that were not initially included in the reference list.  In addition, we have incorporated citations previously included in our introduction which were relevant to the arguments in the discussion.

 

CONCLUSIONS

Comment 8: The conclusions effectively summarize the main findings: a stronger concluding sentence could be inserted, perhaps referring to the importance of CBEPs for people with physical disabilities.

Response 8:  Thank you for the suggestion.  We have removed the second half of the last sentence (which previously gave a summary of how the barriers and facilitators can be used) and instead highlighted that focusing on implementation of CBEPs will ultimately enhance program success and thus PA participation among persons with physical disabilities (see lines 783-784).

Reviewer 2 Report

Comments and Suggestions for Authors

- The discussion of prior research on the application of CFIR 2.0 in the introduction is limited. Please expand the content based on previous studies.

 

- The research results appear excessively lengthy. Consider summarizing the content in the main text and providing the full quotes in the appendix.

 

- The tables in the results section are useful but somewhat complex. Consider simplifying them or dividing them into smaller components to improve readability.

 

- In the discussion, it is necessary to explicitly add concrete and actionable recommendations applicable to program providers (e.g., clinical implications or strengths).

 

- The references need to be formatted according to the journal's guidelines.

Author Response

Comment 1: The discussion of prior research on the application of CFIR 2.0 in the introduction is limited. Please expand the content based on previous studies.

Response 1: Thank you for pointing out this omission. Given it’s relative novelty, the CFIR 2.0 has yet to be used extensively to explore the implementation of CBEPs.  The original conceptualization of the CFIR (2009) has been used to synthesize the barriers and facilitators of community PA interventions; however, studies that included PWPD were excluded from the review given the unique considerations for delivering community PA interventions for this population.  We have now pointed to this review (Cooper et al., 2021), which was previously noted in the discussion, in the introduction (lines 61-63).

Comment 2: The research results appear excessively lengthy. Consider summarizing the content in the main text and providing the full quotes in the appendix.

Response 2: Thank you for the suggestion. Prior to submitting the manuscript to the journal, we debated the suggestion that you offered and opted to leave the quotes within the text. Given the qualitative nature of the study, we thought it was important to feature quotes within the text. Indeed, Reviewer 1 noted in comment 6 how “the tables present a clear and concise description of what the study has analyzed, while the argumentation allows you to go into more detail on what the tables show”.  If we remove the quotes from the text and place them into an appendix, the detail and argumentation will be lost. As such, we have opted to keep the format of the results text as is.

Comment 3: The tables in the results section are useful but somewhat complex. Consider simplifying them or dividing them into smaller components to improve readability.

Response 3: The versions of the tables that are included in the paper are simplified versions of the tables. Part of the complexity is their length (i.e., they span several journal pages). The only way to simplify or further divide the tables is to separate the tables by theme, which will result in Table 3 being divided into five tables and Table 4 being divided into four tables, adding an additional seven tables to the paper. The paper will then have 12 separate tables.  We are willing to make this change in a subsequent revision if the editor feels it is warranted.

Comment 4: In the discussion, it is necessary to explicitly add concrete and actionable recommendations applicable to program providers (e.g., clinical implications or strengths).

Response 4: Thank you for the suggestion. As currently written, each paragraph of the discussion includes a concrete and actionable recommendation according to each theme, which include:

1. Identifying and leveraging a program champion to support a CBEPs’ initial implementation sets a strong foundation for successful implementation (lines 660-662)
2. Connecting with well-established CBEPs, such as through a community of practice may be an effective strategy to combat the lack of knowledge and experience that new program providers may face when implementing a new CBEP (lines 674-677)
3. Program providers should work to develop connections with diverse groups within the community as the support of partnerships can be vital to the success of a CBEP (lines 692-693)
4. Having individualized program policies, appropriate scheduling, organized finances, strong quality improvement initiatives, effective management of staff and volunteers, and initiatives to optimize member inflow and outflow all should be thoughtfully mapped onto the context of the CBEP (lines 717-721)
5. Organizing social activities to help members form a sense of community (lines 736-737)
6. Hiring long-term staff who can form relationships with participants (lines 744-745)

The first paragraph of the discussion introduces the notion that the implications of the findings will be discussed in turn, where we say “By focusing on the connection of our themes to program implementation, our intent is to offer guidance for how our findings may apply within and beyond CBEP programs to the implementation of other community (e.g., employment training) or rehabilitation programs (e.g., stroke rehabilitation) for persons experiencing disability.” (lines 642-646).

However, we are happy to repeat the strategies in a separate paragraph close to the end of the discussion (before the limitations section) if the editor is keen to the idea.

Comment 5: The references need to be formatted according to the journal's guidelines.

Response 5: We have gone through the paper and reference list with a fine-tooth comb and made required revisions to ensure that the references (both in text and in the reference list) are formatted according to the journal’s guidelines.

Reviewer 3 Report

Comments and Suggestions for Authors

The study aims to determine the providers' perceptions of community-based exercise programs designed for persons with physical disabilities. It is reasonable and acceptable, however, taking into account that persons with disabilities are a historically disadvantaged social group, that they face power imbalances especially when it comes to services etc, and that the analysis of the providers' perceptions solely, without taking into account the perspective of service receivers persons with disabilities, can be interpreted as reiterating dominant and subjugating discourse on persons with disabilities by leaving them voiceless and agentless. I strongly suggest to make a separate chapter on the limitations of the study to recognize the limitations of the study due to the lack of perception of service receivers persons with disabilities who are the first concerned party and stakeholder in connection to the service provided. Such a critical perspective should be elaborated instead of the discussion part, which recapitulates the data but lacks of discoursive and critical outlook.

Author Response

Comment 1: The study aims to determine the providers' perceptions of community-based exercise programs designed for persons with physical disabilities. It is reasonable and acceptable, however, taking into account that persons with disabilities are a historically disadvantaged social group, that they face power imbalances especially when it comes to services etc, and that the analysis of the providers' perceptions solely, without taking into account the perspective of service receivers persons with disabilities, can be interpreted as reiterating dominant and subjugating discourse on persons with disabilities by leaving them voiceless and agentless. I strongly suggest to make a separate chapter on the limitations of the study to recognize the limitations of the study due to the lack of perception of service receivers persons with disabilities who are the first concerned party and stakeholder in connection to the service provided. Such a critical perspective should be elaborated instead of the discussion part, which recapitulates the data but lacks of discoursive and critical outlook.

Response 1: We wholeheartedly agree with you. This study did not ask persons with physical disabilities for their perceptions of the community-based exercise programs, and as such, it solely provides the perspectives of providers. Our intent was not to leave the participants of the programs (i.e., persons with physical disabilities) as agentless and voiceless. The reality is that for the majority of CBEPs established to date, persons with physical disabilities were not engaged in the initial or ongoing implementation from an administrative standpoint. Ideally, persons with physical disabilities need to be engaged as a partner during all stages of implementation in such programs. Thank you for calling this point out; we recognize that our original submission did not make this point explicit.  We have added a limitation in the discussion section (See lines 750-760) that speaks to the need to give weight to the experiences of persons with physical disabilities throughout the initial and ongoing implementation of such a program, given they are the ultimate recipients of the service. We have also offered a set of principles (i.e., IKT Guiding Principles; Gainforth et al., 2021) for optimizing the engagement persons with physical disability in a partnered process. In this section, we have used strong language (e.g., “Future research must...”) in our call to include persons with disabilities in research and knowledge mobilization efforts. We have also strategically placed this limitation as first to recognize its importance on the interpretation of findings. Thank you for again for your important comment.

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

The author has appropriately addressed the reviewer's comments through appropriate revisions and responses. Other responses are logical and respectful of the author's viewpoint. Therefore, it is recommended that the manuscript be accepted in its current form.