“To Live or Not to Live”: The Silent Voices of Adolescents with Disabilities in Ghana

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The article addresses the important and timely issue of societal perceptions of disability in the context of the experiences of Ghanaian adolescents. The authors convincingly demonstrate that young people with disabilities are not only subjects of institutional and educational discrimination, but also victims of deeply entrenched cultural narratives rooted in religious and traditional beliefs about “guilt” and “repentance.”
The choice of topic is valid, and its exploration adds cognitive value to the literature on the subject - especially in terms of the perspective of youth from sub-Saharan African countries, which is rarely addressed in research. The article fills an important research gap by identifying specific manifestations and consequences of stigma, including suicidal thoughts - a topic usually overlooked in disability research.

The qualitative research method used was correctly selected for the research purpose. The sampling process (purposive sampling) and the method of data collection (semi-structured interviews and focus groups) are adequate. Particularly valuable is the consideration of the diversity of regions (north, centre and south of Ghana) and types of disability (motor, visual, hearing), which gives the work an intersectional dimension.

Data analysis was carried out using a recognised thematic procedure according to Braun and Clarke (2006). The authors took care to make the coding transparent and to ensure the reliability of the results by triangulating the researchers, controlling the participants and documenting the course of the analysis.
The article presents high cognitive value and originality. The identification of cultural determinants of stigma sheds light on the socially embedded mechanisms of exclusion. The authors reveal that children and adolescents are not only the recipients of stigma, but also its internal bearers, leading to self-deprecation and depression.

The findings of the article can serve as a basis for the development of tools to measure stigmatisation among young people with disabilities and as an impetus for social policy based on the reduction of exclusion and the promotion of inclusion.

In order to increase the value of the presented manuscript, I propose to take into account the following guidelines:
1. although the target group is 'adolescents', no specific age distribution, educational or family status of the participants is given. This makes it difficult to assess whether, for example, the experiences of people from urban and rural backgrounds or students from special and inclusive schools were comparable.

2. The analysis is based on a thematic model, which is a good choice, but the description of coding and categories is relatively vague.

3. there is a lack of examples of first-order codes and a description of how overarching themes emerged from them. More transparency would increase the credibility of the analytical process (audit trail).

4. the paper says that young people with motor, hearing and visual disabilities were surveyed, but does not explain whether those with intellectual disabilities were deliberately excluded or did not take part in the study for other reasons.

5. The article mentions the use of both methods, but lacks justification as to why mixed data collection techniques were chosen.

6. Although the article pays a lot of attention to the lack of education and emotional support for young people with disabilities, the conclusions do not develop this theme.

7. The results of the study indicate that religious and traditional narratives play a key role in perpetuating stigma, while at the same time can be a source of change. However, it is worth pointing out the importance of these aspects in the context of building recommendations for work with religious leaders and local communities,

8. The authors emphasise that they are giving voice to "young people with disabilities", but the group surveyed does not represent the whole of this population (some disabilities are omitted); therefore, it is worth including in the conclusions a reflection on the limitation of representativeness and a caution in generalising the results.

9 No in-depth analysis of gender as a variable influencing the experience of stigma. Although mentioned in the introduction, there is a lack of exploration of differences in the experiences of girls and boys.

10. Limited political and institutional commentary. The conclusions could have been expanded to include suggestions for reforms in the education system, social welfare or health policy in Ghana.

In conclusion, the article is of scientific, methodological and social value. It meets the standards of qualitative research, makes an original contribution to knowledge and can serve as a starting point for further research and social action. It requires only minor additions and deepening of selected themes.

 

Author Response

Reviewer 1 point by point responses

Comment 1: although the target group is 'adolescents', no specific age distribution, educational or family status of the participants is given. This makes it difficult to assess whether, for example, the experiences of people from urban and rural backgrounds or students from special and inclusive schools were comparable.

Response: We appreciate the reviewer’s comment. However, we captured the age group of the adolescents as between 10-19 years based on the World Health Organization operationalization. This could be seen on page 3 of the manuscript. Also, we indicated that all the participants were recruited from special schools and therefore share similar characteristics. All the special schools are in urban areas of Ghana and therefore we did not consider comparing the participants on their demographics. This can bee seen on page 3, paragraph 2, line 3.

 

Comment 2: The analysis is based on a thematic model, which is a good choice, but the description of coding and categories is relatively vague.

Response: Thank you. We have expanded the description of the coding process to include the various rounds of coding conducted before collating them into potential themes. The revised expansion has included as part of coding, we labelled similar concepts identified and conducted various rounds of coding before collating the codes into potential themes. This revision can be seen on page 4, paragraph 1, line 3.

Comment 3: there is a lack of examples of first-order codes and a description of how overarching themes emerged from them. More transparency would increase the credibility of the analytical process (audit trail).

Response: We appreciate the reviewer’s comment. We have revised the manuscript to elaborate the analysis process, including coding on page 4, paragraph 1, line 3.

Comment 4: The paper says that young people with motor, hearing and visual disabilities were surveyed, but does not explain whether those with intellectual disabilities were deliberately excluded or did not take part in the study for other reasons.

Response: We appreciate the reviewer’s comment. We have revised the manuscript to reflect the suggestion by the reviewer and it now reads “those who had intellectual disabilities were excluded, given their inability to grasp understanding of the phenomenon of interest and to articulate their views. Further, they lacked the capacity to give informed consent.” This revision can be on page 3, paragraph 2, line 5.

Comment 5: The article mentions the use of both methods but lacks justification as to why mixed data collection techniques were chosen.

Response: Thank you. We have revised to include a justification for the use of both focus group discussion and interviews. It now reads “The complementarity strength of using both FGDs and interviews was realized in this study given that we obtained a broader description and explanation of the phenomenon. This adjustment can be seen on page 3, paragraph 5, line 7.

 

Comment 6: Although the article pays a lot of attention to the lack of education and emotional support for young people with disabilities, the conclusions do not develop this theme.

Response: We appreciate the reviewer’s comment. We have revised to include a statement that suggests the need for a psychological/emotional support system for the affected population. This adjustment can be seen as part of the conclusion statement on page 10, paragraph 3, line 5.

Comment 7: The results of the study indicate that religious and traditional narratives play a key role in perpetuating stigma, while at the same time can be a source of change. However, it is worth pointing out the importance of these aspects in the context of building recommendations for work with religious leaders and local communities,

Response:  We appreciate the reviewer’s comment. We have revised and included the possible roles that the traditional/ religious leaders could play in correcting the erroneous belief about the causation of disability in Ghana. This can be seen on page 9, paragraph 2, line 10.

Comment 8: The authors emphasise that they are giving voice to "young people with disabilities", but the group surveyed does not represent the whole of this population (some disabilities are omitted); therefore, it is worth including in the conclusions a reflection on the limitation of representativeness and a caution in generalising the results.

Response: Thank you. We have revised and included the limitation as suggested, it now reads  “Whiles the study provides insightful information for policy and programme design, one has to be cautious in generalising the findings to the entire adolescents with disabilities in Ghana. In addition, the small simple size limits the generalizability of the study findings. The views expressed by the participants in this study who were in school might not be the same as those out of school.” This can be seen on page 10 paragraph 2, line 1.

 

Comment 9: No in-depth analysis of gender as a variable influencing the experience of stigma. Although mentioned in the introduction, there is a lack of exploration of differences in the experiences of girls and boys.

Response:  Many thanks for the suggestion. Unfortunately, we did not include that as part of our research question and may consider that in our future studies

Comment 10: Limited political and institutional commentary. The conclusions could have been expanded to include suggestions for reforms in the education system, social welfare or health policy in Ghana.

Response: We appreciate the reviewer’s comment. We have revised to include the need for psychological/emotional support for adolescents with disabilities based on the findings of the study. This can be seen on page 10, paragraph 3, line 5. The suggestion on educational reform and social welfare is captured in other aspects of the study which is under consideration for publication in a different journal.

 

 

Reviewer 2 Report

Comments and Suggestions for Authors

Dear authors,

Thank you for allowing me to read your manuscript “To live or not to live”: The silent voices of adolescents with disabilities in Ghana”. This study could be relevant, and I have the following recommendations.

Abstract. The abstract presents a good overview of the paper, Move the research objective closer to the beginning. Avoid overly detailed methodological steps in the abstract.

Introduction.

Be consistent with font-ing – fist sentence of the introduction and check the whole manuscript.

The introduction is generally informative and sets a clear foundation for the study, but the first half of the introduction is very broad and only late in the paragraph does the focus shift to Ghanaian adolescents. Introduce adolescents with disabilities in Ghana earlier as the focal group. Consider including - Why this age group is important (developmental vulnerability, identity formation).

Replace informal or vague language (e.g., "What appears to be missing…") with precise academic language (e.g., “To date, no studies have explored…”)

Methods

Add more context on why special schools were chosen (e.g., access to diverse disability types).

 

Briefly describe the characteristics of each school (e.g., size, student population) to situate the reader.

Justify exclusion of intellectually disabled adolescents more sensitively (e.g., capacity for informed participation).

Consider rephrasing “lack of understanding” more respectfully.

Explain how saturation was operationalized (e.g., no new themes emerging).

Add the rationale for the mix of FGDs and interviews—why both were used.

Results

The label of Table 1 currently has formatting issues (e.g., “Manifestations of disabil-ity-related stigma”). Ensure hyphenation is corrected.

Include frequencies or number of studies/participants in the table (e.g., how many mentioned each sub-theme), if possible, for descriptive depth.

Some sections are heavily quote-based. Consider balancing quotes with interpretive synthesis. For example, after 2–3 quotes, add 1–2 sentences synthesizing what the quotes reveal collectively.

Unconcealable condition – rephrase as “visible disabilities”, which is more standard in disability literature.

When using participant quotes, consider this format to help readers better visualize the diversity:

Discussion

Should be the strongest part of your manuscript, however it lacks a transparency to your research aim, this section would benefit from explicit restatement of your research aim/questions and clearer mapping of how each theme answers them.

Consider referencing similar stigma research in low- and middle-income countries for broader relevance. Folostina, R., Dumitru, C., Iacob, C. I., & Syriopoulou-Delli, C. K. (2022). Mapping Knowledge and Training Needs in Teachers Working with Students with Autism Spectrum Disorder: A Comparative Cross-Sectional Investigation. Sustainability, 14(5), 2986. https://doi.org/10.3390/su14052986

Conclusion section - "perceived public stigma toward the participants with its consequences" is vague and grammatically awkward.

Acknowledge methodological limitations, such as sample size, context (special schools), and qualitative scope.

References

Well-referenced.

Author Response

Reviewer 2 point by point responses

Comment 1: Abstract. The abstract presents a good overview of the paper, Move the research objective closer to the beginning. Avoid overly detailed methodological steps in the abstract.

Response: We appreciate the reviewer’s comment. We have tried to limit the content of the abstract to only relevant information about the research process. This can be seen on page 1.

Comment 2: Introduction. Be consistent with fonting – first sentence of the introduction and check the whole manuscript.

Response:  We appreciate the reviewer’s comment. The font size has been checked and those wrongly formatted have been corrected throughout the entire document. This can be seen throughouthe entire document.

Comment 3: The introduction is generally informative and sets a clear foundation for the study, but the first half of the introduction is very broad and only late in the paragraph does the focus shift to Ghanaian adolescents. Introduce adolescents with disabilities in Ghana earlier as the focal group. Consider including - Why this age group is important (developmental vulnerability, identity formation).

Response: We appreciate the reviewer’s comment. However, we feel that the organization of the introduction is coherent and captures the relevant information to set the stage for this study. This can be seen in page 2.

Comment 4: Replace informal or vague language (e.g., "What appears to be missing…") with precise academic language (e.g., “To date, no studies have explored…”)

Response: We appreciate the reviewer’s comment. We have revised and replaced the statement what appears missing with “To date, no study has explored”.. as suggested. This can been in page 2, paragraph 5, line 4.

Comment 5: Methods. Add more context on why special schools were chosen (e.g., access to diverse disability types).

Response: We appreciate the reviewer’s comment. We have revised and included a statement that highlights the fact that the special schools have adolescents with varied types of disabilities and participants were readily accessible to the researchers. This can be seen on page 3, paragraph 1, line 4.

Comment 6: Briefly describe the characteristics of each school (e.g., size, student population) to situate the reader.

Response: Thank you. We made an attempt to describe the characteristic of the school by stating that they are in the three regions of Ghana and are funded by the government of Ghana. Also, we were specific on the different types of disabilities in the schools where we collected the data from. This can be seen on page 3, paragraph 1, line 5. What we do not have is the population of students in each of the schools.

Comment 7: Justify exclusion of intellectually disabled adolescents more sensitively (e.g., capacity for informed participation).

Response: We appreciate the reviewer’s comment. We have revised the manuscript to reflect the suggestion by the reviewer and it now reads “those who had intellectual disabilities were excluded, given their inability to grasp understanding of the phenomenon of interest and to articulate their views. Further, they lacked the capacity to give informed consent.” This can be seen in page 3, paragraph 4, line 6.

Comment 8: Consider rephrasing “lack of understanding” more respectfully.

Response: We appreciate the reviewer’s comment. Lack of understanding has been rephrased respectfully as “given their inability to grasp understanding of the phenomenon of interest and to articulate their views”. This can be see on page 3, paragraph 2, line 5.

 

Comment 9:  Explain how saturation was operationalized (e.g., no new themes emerging).

Response:   We appreciate the reviewer’s comment. Data saturation has been well explained as when ‘no new information emerged in the course of the interview. This can be seen on page 3, paragragh 4, line 6.

Comment 10: Add the rationale for the mix of FGDs and interviews—why both were used.

Response: Thank you. We have revised and included a justification for the use of both focus group discussion and interviews. It now reads “The complementarity strength of using both FGDs and interviews was realized in this study given that we obtained a broader description and explanation of the phenomenon”. This adjustment can be seen on page 3, paragraph 5, line 7.

 

Comment 11: Results. The label of Table 1 currently has formatting issues (e.g., “Manifestations of disabil-ity-related stigma”). Ensure hyphenation is corrected.

Response: Thank you. We have correted the hyphenation and  formatted the entire Table. Please refer to Table 1 on page 4.

Comment 12: Include frequencies or number of studies/participants in the table (e.g., how many mentioned each sub-theme), if possible, for descriptive depth.

Response: We appreciate the reviewer’s comment but contend that we followed the reporting based on the journal requirement.

Comment 13: Some sections are heavily quote-based. Consider balancing quotes with interpretive synthesis. For example, after 2–3 quotes, add 1–2 sentences synthesizing what the quotes reveal collectively.

Response: We appreciate the reviewer’s comment. We intentionally presented the findings in its current state to avoid repetition of information which becomes too boring for the reader. This can be seen in the results presentation section, from page 4 to 8.

Comment 14: Unconcealable condition – rephrase as “visible disabilities”, which is more standard in disability literature.

Response: We appreciated the reviewer’s comment. We have changed unconcealable conditions to disability as a visible condition throughout the manuscript.

Comment 15: Discussion. Should be the strongest part of your manuscript, however it lacks a transparency to your research aim, this section would benefit from explicit restatement of your research aim/questions and clearer mapping of how each theme answers them.

Response: We appreciate the reviewer’s comment. The first paragraph provides a summary of what the researchers sought to investigate and the findings. This, we believe gives the reader an idea of what the entire study is all about.

Comment 16: Consider referencing similar stigma research in low- and middle-income countries for broader relevance. Folostina, R., Dumitru, C., Iacob, C. I., & Syriopoulou-Delli, C. K. (2022). Mapping Knowledge and Training Needs in Teachers Working with Students with Autism Spectrum Disorder: A Comparative Cross-Sectional Investigation. Sustainability, 14(5), 2986. https://doi.org/10.3390/su14052986

Response: We appreciate the reviewer’s comment. The article suggested do not relate specifically to the phenomenon captured in this manuscript. We however, see it as relevant for one of our manuscript that relates to unmet supportive care needs of teachers in special schools in Ghana.

Comment 17: Conclusion section - "perceived public stigma toward the participants with its consequences" is vague and grammatically awkward.

Response: We appreciate the reviewer’s comment. We have revised the statement and it reads “we found that adolescents with disabilities experience stigma which affect them negatively. There is an urgent need for stigma reduction interventions for adolescents with disabilities in Ghana as part of an effort to improve their wellbeing”. This can be seen in be seen on page 10, paragraph 3, line 2.

Comment 18: Acknowledge methodological limitations, such as sample size, context (special schools), and qualitative scope.

Response: Thank you. We have revised and included some limitations to the study and its read “Whiles the study provides insightful information for policy and programme design, one has to be cautious in generalising the findings to the entire adolescents with disabilities in Ghana. In addition, the small sample size limits the generalizability of the study findings. The views expressed by the participants in this study who were in school might not be the same as those out of school. This can be seen in page 10, paragrapgh 2, line 1.

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

Dear authors, 

Thank you for addressing all the comments. 

Please check once again the manuscript and proofread it. 

All the best