Participation in physical activity by adolescents with physical disability: cross-sectional snapshot and future priorities (“Youth Experience Matters” protocol)

Young people with physical disability experience challenges to being physically active. To attain the health benefits of physical activity (PA) and sustain engagement, it is essential that participation is meaningful and enjoyable. This study aims to describe current participation in PA by adolescents with physical disability in Ireland, and to establish consensus on their priorities for enhancing physical activity participation. A parallel convergent mixed methods study will be undertaken, comprising a national cross-sectional quantitative assessment of PA participation (“Participation Snapshot”) and Delphi consensus study (“Delphi”). Adolescents (n=100) aged 13–17 years with a physical disability will be invited to take part. The Participation Snapshot primary outcome is the Children’s Assessment of Participation and Enjoyment (CAPE). Contextual factors including underlying medical diagnosis, demographics, mobility (Functional Mobility Scale), hand function (Manual Ability Classification System) and health related quality of life (Child Health Utility 9D) will also be collected. The Delphi will comprise two to four survey rounds, until consensus is reached. Round 1 consists of a bespoke survey, designed and piloted with a public and patient involvement (PPI) panel, with open-ended questions and Likert scales inviting contributions from adolescents on their prior experience and ideas to enhance participation. Responses will be analysed using inductive thematic analysis to construct items and themes, which will then be deductively mapped to the “F-words” and the family of Participation-Related Constructs frameworks. These items will be presented back to participants in subsequent rounds for selection and ranking, until consensus is achieved on the “top 10 priorities” for enhancing PA participation. The project team and PPI panel will then co-design dissemination material and identify targets for dissemination to relevant stakeholder or policy groups. The findings will provide a basis for developing interventions aiming to enhance future PA participation for adolescents with physical disability.


Introduction
The benefits of regular physical activity (PA) are undisputed.Regular PA can positively influence cardiorespiratory fitness, muscular fitness, cardiometabolic health, bone health and cognitive function for children and adolescents (World Health Organisation, 2020).Children and young people with disability stand to benefit significantly from sustained PA participation, as demonstrated by the following evidence.Engagement in PA, as measured by the self-reported Physical Activity Questionnaire for Adolescents (PAQ-A), was found to predict quality of life and happiness in adolescents with Cerebral Palsy (CP) (Maher et al., 2016).Evidence from high-quality randomised controlled trials (RCTs) has shown that young people with disability can gain cardiovascular fitness and strength from participation in PA (Taylor et al., 2013), particularly PA at a moderate-to-vigorous intensity (Verschuren et al., 2014).This demonstrates high potential to benefit from PA across multiple domains of health (Smith et al., 2022).
A recent proposed update to Ireland's National Physical Activity Guidelines recommend all children and young people with disability to engage in moderate to vigorous activity at least 60 minutes every day, and to include muscle strengthening, flexibility and bone-strengthening exercises three times a week (Murtagh et al., 2024), though it is noted that health benefits can still accrue with lower amounts.This is reflected in the UK Chief Medical Officer's guidelines, specific to children and young people with physical disability, which recommend 120 to 180 minutes of aerobic physical activity at a moderate-to-vigorous intensity each week, with strength and balance activities on at least three days per week (Smith et al., 2022).Despite the guidance and potential benefit, young people with physical disability do not achieve the recommended PA targets and are much less active than their non-disabled peers (Carlon et al., 2013;Ryan et al., 2015;Verschuren et al., 2016).A systematic review, comprising six studies with data from 343 young people with CP and 706 typically-developed peers, found that young people with CP participated in 13-53% less PA and were sedentary for twice the recommended amount (Carlon et al., 2013).It appears that the COVID-19 pandemic has also impacted PA participation for people with disability: an online public engagement, non-peer reviewed survey of 1,842 disabled people found that just 30% of respondents felt encouraged to return to PA after the pandemic (Activity Alliance, 2022).The effects of physical inactivity in this population are profound.A recent meta-analysis found higher incidence and prevalence of metabolic, cardiovascular diseases and non-communicable disease, for which physical inactivity is a risk factor, in people with CP (Ryan et al., 2023).There is an urgent need to address physical inactivity across all populations (Santos et al., 2023) but particularly in young people with physical disability, who already have lower baseline levels of cardiorespiratory endurance and muscle strength and may be at risk of declining mobility and musculoskeletal complications (O'Sullivan et al., 2020).
Physical activity can be achieved through incidental physical activity or through planned participation in organised, structured exercise often with other people.Participation, defined in the International Classification of Functioning, disability and health (ICF) (World Health Organisation, 2001) as "involvement in a life situation", is aptly construed as "both a means and an end" (Imms et al., 2017).The "F-words" conceptualisation of the ICF captures participation under the F-word "friends", to denote the social interactions from participating with others (Rosenbaum & Gorter, 2012).Participation could be crucial to sustaining PA.Adolescence is a significant time of change in participation, when adolescents with physical disability shift away from recreational and physical activities towards more social participation (Imms & Adair, 2017).In a recent systematic review, McKenzie et al. (2021) reported the social and physical environment as strong influences on PA participation in young people and adults with childhood-onset disabilities.They found that social connectedness, social support and the physical environment were fundamental to 'finding the right balance', which could tip the balance in favour of being physically active or not.This is an important consideration in informing research into interventions to improve physical activity, as many exercise programmes are not sustained in the medium-to long-term.Understanding how young people participate in PA is crucial to any intervention that aims to enhance and enable sustained PA participation.There is no one-size-fits-all approach to participation (Shields & Synnot, 2016).
To determine how a participation-based approach could improve physical activity, it is necessary to measure current participation and understand the perspectives of adolescents themselves on the factors that could enhance participation.

Aim
The aims of this study are: 1. To describe current participation in physical activity by adolescents with physical disability in Ireland;

Amendments from Version 2
Summary of changes to this revised version: 1. We shortened the title further for clarity and ease of reading.
2. Adolescents with physical disability are a diverse population.We added additional detail to Methods | Recruitment, describing measures to account for this diversity and ensure representativeness.
3. The primary outcome measure, the Children's Assessment of Participation and Enjoyment (CAPE), is not validated specifically for the Irish population, although it has been used in several other countries.We added a statement to this effect to Methods | Outcome measures | Participation snapshot.We also detailed how we would use the free-text comments to help contextualise the CAPE findings within the Irish context, cognisant of cultural differences in physical activity participation.
Any further responses from the reviewers can be found at the end of the article 2. To establish consensus among adolescents with physical disability regarding their priorities for enhancing their physical activity participation.

Specific objectives are:
1. To report participation in physical activity over the previous four months by adolescents with physical disability 2. To compare participation between categories of gender, mobility, geography and diagnosis; 3. To classify factors that enable or constrain participation in physical activity from free text responses, using the family of participation-related constructs (fPRC) framework 4. To describe adolescents' perceived importance of each factor using data from Likert scales 5. To achieve consensus on top 10 priorities for enhancing physical activity participation.

Methods and analyses
A cross-sectional convergent mixed methods study will be conducted.Figure 1 outlines the phases.

Participation Snapshot Study
The Participation Snapshot is a cross-sectional study, comprising an online, paper and/or interview led survey, aiming to describe and quantify current participation in PA by adolescents with physical disability in the Republic of Ireland.This will be achieved through quantitative data from standardised scales and Likert scales, supplemented by open-ended questions exploring current participation.The Children's Assessment of Participation and Enjoyment (CAPE) is the primary outcome measure (King et al., 2007).

Delphi Study
The Delphi study is a mixed methods study aiming to determine the Top 10 Priorities from the perspectives of adolescents themselves on the factors that could enhance their participation in PA.The Delphi technique is a well-established approach to achieving consensus between experts in a field, through an iterative process using questionnaires (Barrett & Heale, 2020;Stennett et al., 2018).In the Delphi, young people with physical disability will be considered the experts in their lived experience.A minimum of two rounds and maximum of four rounds will be undertaken, until a clear consensus is achieved.

Public and Patient Involvement (PPI)
A PPI panel, comprising three young people who have a physical disability and three parents/guardians of young people who have a physical disability, works alongside the project team at all stages from inception to dissemination.They helped identify the research question, inputted in the development of the proposal and the methodological approach.They helped develop Round 1 surveys, particularly with regard to language, order and visual appearance, and piloted initial drafts of the online and paper versions.They guided the project team on recruitment strategies and contributed video and photo footage to the promotional material on the project website.
The PPI panel will similarly input into the design of subsequent Delphi rounds.When consensus is reached on the "Top 10 Priorities", a focus group will be convened, at which the project team and PPI panel will co-design dissemination materials (including infographics, videos and other media) and identify target audiences with whom to share these outputs.

Ethics
The study has been approved by the host institution RCSI University of Medicine and Health Sciences Research Ethics Committee (REC202207012) and two lead national disability agencies, the Central Remedial Clinic (REC12118) and Enable Ireland (RA88).As all participants will be under the age of 18 at study commencement, parent/guardian consent will be required, in addition to young person assent.The participant/parent dyad will receive a Parent Information Leaflet, Young Person's Information Leaflet, and consent form.Study information and materials will also be available on the study website.Participants who turn 18 during the timeframe of the Delphi study will be re-consented using a Participant Consent Form seeking informed consent, to be completed digitally (for online participants) or written on paper (for paperbased completion).

Participants and eligibility
Participants will be young people aged 13-17 years at study commencement with a primary diagnosis of physical disability.The definition, from a diagnostic perspective, of primary diagnosis of physical disability has been thoroughly considered in preparing this protocol.The following inclusion criteria will be applied in line with similar diagnostic categories reported by Anaby et al. (2020) For feasibility reasons, the following exclusion criteria will apply: 1. Intellectual disability of such severity that, even with supports, the parent judges that the adolescent is unable to understand or contribute meaningfully to the questionnaire.
2. Inability to read or write in English, even with support.

Sample size
The target sample size is 100 participants.et al., 2018).Therefore, we aim to recruit 100 participants to the Participation Snapshot and Delphi Studies, estimated to be 5% of the target population.

Recruitment
Participants will be recruited in two ways: firstly, through clinical services, and secondly through the wider community and public.Recruitment through clinical services will be led by 15-20 physiotherapists and occupational therapists who work within Children's Disability Network Teams (CDNTs) and national specialist services in Ireland and have been identified as "gatekeepers" for their teams.We considered the geographical distribution in identifying the study gatekeepers.
The lead clinical site, based in Dublin, serves young people from all over Ireland in its specialist services, and additionally has smaller clinics in the south east and west of Ireland.The other clinical partner provides children's services in 11 of 26 counties, and in all four provinces.Gatekeepers will share information about the study with potentially eligible parent/young person dyads through the course of their usual care or therapy interactions.Additionally, the database at the lead clinical site, the Central Remedial Clinic, will be screened to identify eligible service users who attended in the 18 months prior to data collection.The nominated parents/guardians of these eligible service users will receive an invitation to participate by post.Reminders will be sent three-six weeks from initial contact.
Local initiatives have been undertaken at the lead clinical site to promote the study.These include a screen to play the promotional video, placing pull-up banners at the clinic's reception and waiting areas, and the "interactive wall" (Figure 2) inviting contributions from young people on topics relevant to their participation in PA.Photos from the "interactive wall" will be shared on social media periodically to sustain interest.All promotional materials will be updated to denote the launch of the second and subsequent rounds.
Recruitment through the public and wider community will be undertaken by engaging with sporting organisations, disability charities and support groups, and the media.A promotional video and poster will be prepared for sharing via social media, with links to the study webpage and recruitment materials.Paper copies will be provided to supporting community organisations, charities and support groups, for onward sharing.
Adolescents with physical disability are a diverse population.
To ensure a representative sample, we will tailor our recruitment to consider diverse groups.From the perspective of clinical and support services, we will share information about the study through community organisations and charities for a range of conditions, such as neuromuscular, CP, spina bifida, and acquired brain injury.At clinical sites, we will make information available across a range of clinics for different groups.To mitigate the possibility of selection bias towards adolescents who are physically active, we will tailor our recruitment materials to state that we seek all perspectives, including people who do not enjoy physical activity or are not very active.To avoid geographical bias, we will liaise closely with our regional gatekeepers.We will travel to events organised by charities and community partners, where adolescents will be in attendance, to share recruitment materials.Cognisant of barriers to participation with respect to communication impairment or cognition, we will offer options for data collection.

Data collection
Data will be collected either online via the study website, via paper copies at participating clinical sites and community organisations, or via interview (in person or video / telephone call).The online survey will be hosted on the Research Electronic Data Capture Data Management platform (RED-Cap) platform, distributed via the project's website.Paperbased surveys will be distributed at participating clinical sites and community organisations.Participants can complete these independently or with support from a parent, guardian or other nominated person, with the stipulation that the responses reflect the young person's views and not those of the supporting person.Participants can request completion via interview, in person or phone, by contacting the project team at an email address provided in the Participant and Young Person Information Leaflets (see Extended data)

Outcome measures
In this convergent mixed methods design, quantitative and qualitative data will be captured simultaneously.

Participant characteristics
The following participant demographics will be collected for contextual purposes: age, gender (self-reported), diagnosis, residential area (county), any assistive equipment used to participate in daily activities.Participants will also be asked about any other additional needs that may impact their participation including medical conditions, learning difficulties, neurodiversity, communication difficulties, and recent medical or surgical intervention.The Functional Mobility Scale (FMS) (Graham et al., 2004) and Manual Ability Classification System (MACS) (Eliasson et al., 2006) will be captured to describe mobility and hand function, respectively.

Participation Snapshot
The Participation Snapshot will capture current participation in PA, using a quantitative standardised outcome measures (the sliding or Likert scales.Round 2 will be analysed using descriptive statistics, specifically, frequency with which an item was positively rated on the sliding or Likert scale, and mean Likert score.We set the threshold for consensus at 70% agreement, meaning that at least 70% of participants must give an item a positive score for it to be considered a priority.Depending on the number of items exceeding this threshold, and the aggregate Likert scores for these items, it may be feasible to rank selected items in Round 2, thereby combining Rounds 2 and 3 into a single Round 2. This decision will be taken by the PPI panel and Project Management Team.A final round will present the top 10 priorities for agreement.Consensus will be defined as at least 75% agreement with the top 10 priorities in the final round.
The phases and timeline of the project are outlined in Figure 3.
A detailed version of each of the proposed Delphi rounds is outlined in Figure 1.The study will take place between March 2023 and March 2024.Recruitment is ongoing since March 2023.

Participant retention
The following strategies will be administered to help promote completion of the Participation Snapshot and Delphi Study, participant retention in the Delphi Study, and reduce missing data and attrition rates.Online questionnaires will utilise REDCap survey platform's inbuilt functionality to require completion of questions and a progress bar with positive feedback encouraging completion, for example, "You are over half way there!Just two questions to go".For retention to the second and subsequent survey rounds, participants will be contacted via email/post with reminders to complete the next round of the questionnaire.Awareness-raising initiatives on social media and at clinical sites (described in 'Recruitment' section) aim to promote sustained interest.

Participant withdrawal
Participants may withdraw from the study at any time without consequences.Participants and parents will be informed of their right to withdraw at any time in the study information leaflets.Any de-identified data collected up to the time of withdrawal will be retained and included in analysis.The reason for withdrawal from the study will be documented, if known.

Statistical analysis
The Participation Snapshot will be analysed by descriptive statistics and graphical analysis, in accordance with the objective to describe current participation in PA by young people aged 13-17 across Ireland.Data will be presented disaggregated by gender.As a secondary analysis, we will describe the dependent variables CAPE (primary) and CHU-9D (secondary) by relevant categories of participant characteristics (age, gender, condition, geographical location, mobility via FMS, hand function via MACS).
Delphi Round 1 will be analysed using reflexive thematic analysis, an interpretative approach that facilitates the identification and analysis of patterns or themes in a given data set Health related quality of life HRQoL as a secondary outcome will be measured using the Child Health Utility 9D CHU-9D (Ryan et al., 2020;Stevens, 2009).

Delphi study
The Delphi study will follow a similar format to that described by Stennett et al. (2018), with up to four Rounds to achieve consensus on young people's priorities for enhancing their participation in PA.The surveys in each round will be designed with the PPI panel and piloted by three to five young people age 13-17 before data collection commences.).The epistemological consideration will be constructionist.As such, the team will consider not just the recurrence, but also the meaning and meaningfulness of the issues arising within the dataset, in determining the themes.An experiential orientation to data interpretation will be adopted to prioritise the respondents' own accounts of their experience, rather than imposing any expected findings (Braun & Clarke, 2021a).Analysis will be predominantly inductive, with open coding to represent the meaning as communicated by respondents.Reflexivity notes will be kept at each stage.The software NVivo 12 (QSR International, Melbourne, Australia) will be used to organise the text in the data set.
A collaborative approach to analysis will be undertaken, with two members of the research team undertaking step 1 (familiarisation) and step 2 (coding) independently.They will then meet to generate initial themes (step 3) through a process of peer debriefing, leading to the creation of a thematic map of themes and subthemes.The "F-words" conceptualisation of the ICF (Rosenbaum & Gorter, 2012) and the fPRC (Adair et al., 2018;Imms et al., 2017).will be used as frameworks for the thematic map.At step 4, themes and the thematic map will be reviewed by the project management team, followed by the creation of a final map and Round 2 of the Delphi survey, which will be piloted by the PPI panellists.
As outlined under subheading "Delphi study", Round 2, and subsequent rounds, will be analysed using descriptive statistics, specifically, frequency with which an item was positively rated on the sliding or Likert scale, and mean Likert score.
Demographic and contextual data will be described for respondents of each survey round.To ensure findings can be interpreted in context, participant characteristics (e.g., age, gender, diagnosis, FMS and MACS levels) will be compared descriptively between rounds to explore for differences in the profile of respondents across the Delphi rounds.

Data management
A Data Management Plan has been developed.All data will be stored securely on a shared drive with restricted access, with multifactor authentication in place for additional protection.Data entered electronically via the REDCap platform will be downloaded to a secure study database.Paper surveys will be manually entered in the study database and hard copies will be stored in a secure filing cabinet.Data entry and validation will be a continuous process.Any identifying information (namely parental or participant email) will be stored separately from the point of user input (REDCap) or receipt of survey and consent (paper versions) to preserve participant anonymity.Newly generated study data will be irrevocably anonymised from the time of entry, as no "key" will be generated.

Dissemination and knowledge translation
The results of this study will be shared within the scientific community through peer reviewed publications and national and international conferences.The project team and PPI panel will co-design dissemination materials (including infographics, videos and other media) and identify meaningful ways of sharing the results of this study, exploring possibilities such as a video voiced by young people with disability, infographics targeting the relevant stakeholders, PhotoVoice (Wang & Burris, 1997), social media and opportunities to influence policy and practice.We anticipate that adolescents' priorities for enhancing physical activity participation could have implications for intervention development, research, policy, education, and clinical practice.

Reporting guidelines
The Participation Snapshot will be reported in accordance with the STROBE guidelines (von Elm et al., 2007).The Delphi survey will be conducted and reported in accordance with Guidance on Conducting and REporting Delphi Studies (CREDES) (Jünger et al., 2017).
I find the paper interesting and in my opinion the topic is relevant and is suitable for indexing in HRB Open Research.Moreover, I appreciate the significant effort that you have invested in improving the overall quality of the manuscript and addressing the reviewers' questions and concerns.Unfortunately, I still have major concerns with the manuscript in its current form.Overall, it is my belief that significant restructuring still is necessary for the paper to meet the standards required for indexing in HRB Open Research.
Main Points for Revision/Clarification: Although the author had already reduced the title, the title should be reformulated.1.
The purpose is very noble but also probably too ambitious in my perspective, since "there is much going on" on this protocol, with such a diverse population.I'm afraid that the results and their implications will be very limited.

2.
Can this research address all the specific objectives within this study protocol?3.
Physical disability involves a wide range of functional profiles: mild to severe, degenerative and non-degenerative disorders, possible cognitive deficit, among several others conditions… did you take this diversity into account for the delphi study?And how many adolescents will participate?Authors finish the paper anticipating "that adolescents' priorities for enhancing physical activity participation could have implications for intervention development, research, policy, education, and clinical practice."Given the diversity of the sample I'm not sure that those guidelines are valid for ALL the adolescents with physical disability.

6.
Therefore, I strongly recommend that the article should be edited carefully before resubmission.

Are the datasets clearly presented in a useable and accessible format? Not applicable
Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Disability, Inclusion
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. 1.

1.
The purpose is very noble but also probably too ambitious in my perspective, since "there is much going on" on this protocol, with such a diverse population.I'm afraid that the results and their implications will be very limited.
Response: We agree this was an ambitious protocol and to achieve it, we put in place an experienced team from two universities (RCSI and QUB), a specialist clinical site (the Central Remedial Clinic), and a dedicated and engaged public and patient involvement panel of three young people with disability and their parents.The project had a dedicated resource of a clinical scientist working full-time for 16 months. 1.
Regarding the results and implications of the project, it may be useful to note that the project has concluded.(This protocol paper was submitted to HRB Open Research in May 2023 and the peer review process has taken time.)The Delphi study, covering aim 2 and objectives 3-5, has been published in Developmental Medicine and Child Neurology (Brady et al., 2024).The participation snapshot, covering aim 1 and objectives 1-2, is being prepared for publication.We delivered oral presentations on the findings of both the Delphi and participation snapshot at the European Academy of Childhood Disability annual conference in Bruges, Belgium, in May 2024.

2.
The point on the diverse population recurs in point 4 and we have addressed it there.

3.
Regarding the results and implications being limited, we address this by emphasising the health and social benefits of participation in physical activity, and its importance to stakeholders, particularly young people and families as conveyed by our PPI panel.To illustrate the importance, in March 2024 we held a World Café event to share the study's findings and had attendance from 40 stakeholders, including young people with disability and their families, healthcare professionals, community volunteers, national governing bodies for sport, teachers, and researchers.The purpose of the World Café was to identify "next steps" following the top 10 priorities.So far, this has led to two funding applications and a further PhD.

Can this research address all the specific objectives within this study protocol?
We were confident with our team and collaborations that these could be achieved and as noted in point 2, the project has concluded with aims and objectives achieved.One paper has been published and a further is underway. 1.

3.
Physical disability involves a wide range of functional profiles: mild to severe, degenerative and non-degenerative disorders, possible cognitive deficit, among several others conditions… did you take this diversity into account for the delphi study?And how many adolescents will participate?

4.
We recognise diversity within physical disability and the challenges in representativeness of a study sample.We put in place the following measures.First, we worked closely with our clinical sites.The research scientist, who was responsible for data collection, attended several clinics to support recruitment at our partner clinical sites, including clinics for spina bifida, neuromuscular conditions, and CP.Second, to mitigate selection bias, we tailored our recruitment materials to specifically state that we sought all perspectives, including people who do not enjoy physical activity or are not very active.Third, we worked with the wider community through support groups, charities, and national governing bodies.We invited them to share recruitment materials through their websites, social media, and newsletters.We did an interview on a local radio show and podcast to reach young people who were not attending services.Fourth, to avoid geographic bias, the clinical scientist physically travelled to events around Ireland where young people with disability were in attendance.This was made possible through our collaborations with charities and community organisations.We enlisted clinical colleagues from all four provinces and major cities as gatekeepers.Fifth, cognisant of barriers to participation with respect to communication impairment or cognition, we offered a one-to-one interview in place of the written or online survey and the clinical scientist maintained a visible presence at clinics and events to support this.We added a condensed account of these points under Methods | Recruitment. 1.
To account for the diversity of the cohort, we recorded detailed demographic and contextual data using validated outcome measures including the Functional Mobility Scale for mobility, the Manual Ability Classification Scale for hand function, and recorded diagnosis and support needs .We compared findings from both work packages across categories of gender, ambulation status, diagnosis, and geography.This is described under statistical analysis 2.
The target sample size was 100 adolescents.The published paper on the Delphi study describes the characteristics of the 116 adolescents who took part.We achieved a representative sample in terms of diagnosis (half had CP, the other half, a variety of diagnoses including neuromuscular, spina bifida, acquired brain injury, skeletal conditions, spinal cord injury), ambulation (just over onethird were wheelchair users), and geographical distribution (just over one-third were based in Dublin).

Did the Children's Assessment of Participation and Enjoyment (CAPE) survey have been validated for the Irish population?
No, the CAPE has not been validated specifically for the Irish population.It was developed in Canada and has been reported in comparable populations in Australia.There is no validated outcome measure of participation that has been validated specifically for the Irish population.We recognised that there may be contextual and cultural differences impacting the findings of the CAPE.
To investigate this, we included some open-ended questions to gather context.
The CAPE asks about 16 categories of physical activity, including team sports, individual activities.We asked participants to specify the activity or code they took part in, so for example, under team sports, they could state whether this was football / soccer, rugby, or Gaelic games.This point has been added under 1.

5.
Methods | Outcome measures | Participation snapshot.Authors finish the paper anticipating "that adolescents' priorities for enhancing physical activity participation could have implications for intervention development, research, policy, education, and clinical practice."Given the diversity of the sample I'm not sure that those guidelines are valid for ALL the adolescents with physical disability.
We are not directly developing guidelines based on the findings.We suggest that the findings could be useful, potentially at multiple levels from individual to research and policy.We agree this is a diverse cohort and in previous points described how we aimed to account for this diversity.A limitation of Delphi method is that a threshold for consensus (typically 75%) needs to be set and within a consensus, there will be a diversity of perspectives.Now that our study has been published, we can report that we achieved consensus on the top 10 priorities of over 82-93%.Even with a strong consensus, we acknowledge that 7-18% of adolescents have a different perspective.We advise that individual variation must still be considered and that a different method (in-depth qualitative interviews) would be needed to explore the reasons behind the findings.However, we also argue that priorities of the majority can be impactful.We deemed adolescents to be the experts in their own lived experience in determining their own priorities, and the priorities are created entirely by them (iterated from their free text responses in round 1).We argue that these are important findings and have implications for future practice, research and policy, to which the perspectives of adolescents with lived experience should be central. 1.

6.
Is the rationale for, and objectives of, the study clearly described?

General comments
This is an interesting study and highlight ways to encourage people with disabilities to be the voices in research.It is a much needed area in research and can provide useful insights to help provide tailored programs for people with disabilities.The methods seem suitable for the study, although it could be written more clearly.I wonder what is the purpose of getting such a large panel, as getting consensus might not need so many people involved.The authors should consider data saturation, and the effort needed to recruit so many ○ people.
Lacking line numbers or page numbers to give specific comments.

○
Not sure why the authors change between the terms youth and young people.The target audience is 13-17 year old's these are considered as adolescents (Ref 1).Change all terminology to reflect that to reduce the words and being consistency in the writing.

Specific comments
First reference does not require 3 references.Choose one.

○
2nd sentence requires a reference to understand where the authors perspective come from.The f words should be written out on full.It is not clear how they would be used.It should be introduced in the introduction.
Response: We added an explanation of the F-words conceptualisation of the ICF to paragraph 3 of the introduction.Consistent with the aim of our study, we focused on the F-word "friends" as the conceptualisation of participation.Later, in Methods / Statistical Analysis, we explain that the F-words conceptualisation will be used as a framework for analysis of the free text responses to openended questions in the Delphi study.

Caitriona Cunningham
School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland Thank you for the invitation to review this protocol paper.An important study has been proposed and overall a comprehensive and detailed protocol is presented with well thought out methods described.The authors are to be commended for embarking on this major study.
The paper opens with an overview of evidence regarding the need for children and adolescents, with physical disability, to be physically active and makes the case for conducting the proposed study.Ethics approval has been obtained.Overall, the methods are clearly described with a snapshot survey of adolescents and a subsequent Delphi study proposed.PPI is described.Sample size is justified.Outcome measures are specified.Recruitment mechanisms are described with retention and participant withdrawal issues also considered.Data analysis and management mechanisms are also described.Extrapolating from Census 2016, 411,519 people living in Ireland will be age 13-17 in 202213-17 in (CSO, 2016 ) )... maybe reword so better integrated into paper as we're now in 2024-change tense -that x would be aged between 13 and 17… Dates November 2022 and March 2024.Does start date need revisiting ?Protocol paper ideally should be written/published prior to commencement of data collection.

Analysis of Delphi Study Data
Good description of thematic analysis of written data What about describing analysis of likert scale data ?(ie.quantitative data) Would query use of 'regression analysis' to explore for differences in profile of participants at different rounds.Recommend that proposed analysis is revised here.Reviewer Expertise: musculoskeletal health, promotion of physical activity and exercise for prevention and management of disease, disability inclusion I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

Figure 1 .
Figure 1.Participation Snapshot and Delphi Study: Data collection, analysis and integration.

Figure 2 .
Figure 2. "Interactive wall" to raise awareness and promote Youth Experience Matters.
Children's Assessment of Participation and Enjoyment (CAPE) survey have been validated for the Irish population? 5.

Figure 3 -
Figure 3 -Don't believe this is a necessary graphic but authors can decide.
(Adair et al., 2018;t of Participation and Enjoyment (CAPE)(King et al., 2007)and self-reported categorical frequency of PA participation) and supported by open-ended questions inviting free text qualitative responses.For feasibility, the Participation Snapshot will be distributed with Round 1 of the Delphi study, presented with subheadings to distinguish the sections.The measures used to quantify PA participation have been selected to align with the attendance, involvement, preferences, context and environment constructs of the family of participation-related constructs (fPRC)(Adair et al., 2018; Imms  et al., 2017).The primary outcome measure is the CAPE(King  et al., 2007), a 55-item questionnaire designed to examine how children participate in a range of everyday activities outside of school.As this study focuses on physical activity participation only, we used a 16-item subsection of the CAPE with the following items pertaining to physical activity: items 16-21 from the section Organised Sports, items 31-41 excluding items 38 (gardening) and 39 (fishing) from the section Active Physical Recreation, and item 24 (learning to dance) from the section Other Skill-Based Activities.This was based on the methods ofWoodmansee et al. (2016), who measured participation in physical activity in 163 children (6-17 years) with physical, intellectual, or sensory disability, using the same 16 CAPE items.The CAPE has not been validated in Ireland and there may be cultural or contextual differences to physical activity participation across different jurisdictions.We will include free-text questions on the specific activities within each CAPE item (e.g., within team sports, to specify which code or game is played, such as Gaelic games, football, rugby).

have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Version 1
https://doi.org/10.21956/hrbopenres.15031.r37696

the study design appropriate for the research question? Partly Are sufficient details of the methods provided to allow replication by others? Partly Are the datasets clearly presented in a useable and accessible format?
Last sentence of the first paragraph, is unsubstantiated by the previous references.It is more about how to improve on qol and strength.But nothing about other areas of health, i.e. social or mental., is the study being carried out in the UK?Why not refer to the Irish PA guidelines?Most of Smith et Al study, includes children with CP, so although it makes sense in one way to use Smith, it is not completely relevant for the context where the WHO guidelines have been adopted.Reference from activity allowance needs more context and quality of evidence.Previous studies used quality essays to measure CP and PA and outcomes, activity allowance is less rigorous.Try to revise the elements of the ICF.See recent review on the ICF CY .thebackground, it is not evident that the are barriers.If this is the focus, authors need to write more about barriers.Many literature reviews have been missing.It is not clear about the participation snapshot.Is it the cape that is being used?If so, explain for the survey is converted into an instrument for the Dephi study.Even after reading the Dephi study section, it is still not clear how cape is used.The f words should be written out on full.It is not clear how they would be used.It should be introduced in the introduction.
○ ○ 2nd paragraph○ ○ 3rd paragraph seems disjointed.○ 4th, by ○ Sample size: Reference is needed for the way if calculating participation snapshot.○ Write ms in full the first time ○ Recruitment and data connection sections are well written.○ How does your ethics consider the use of country data?○ ○ ○ ○ Partly Is

have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. decision
on a sample size calculation informed by data from multiple data sources (Census, National Physical and Sensory Disability Database) and considered it appropriate due to the anticipated heterogeneity in perspectives from adolescents with disability, who are a diverse group.The target sample size equates to approximately 5% of the total population of 13-17 year olds (estimated to be 2,000 adolescents) with physical disability in Ireland and is comparable with other Delphi studies cited in this section.We anticipate attrition between Delphi rounds, so the final consensus may not involve all 100 participants (though they will all get the opportunity to contribute).Lacking line numbers or page numbers to give specific comments.Response:We added line numbers to the Word version (unsure if these will track across to online version).Not sure why the authors change between the terms youth and young people.The target audience is 13-17 year old's these are considered as adolescents (Ref1).Change all terminology to reflect that to reduce the words and being consistency in the writing.We cite the work of Maher et al(2016)showing higher levels of happiness in adolescents with CP who were physically active.We acknowledge that mental health is a complex construct but nonetheless argue that higher levels of happiness supports the point of benefit across multiple domains of health.2ndparagraph, is the study being carried out in the UK?Why not refer to the Irish PA guidelines?Most of Smith et Al study, includes children with CP, so although it makes sense in one way to use Smith, it is not completely relevant for the context where the WHO guidelines have been adopted.Response:This study is being undertaken in the Republic of Ireland.We added the Irish PA guidelines to the beginning of this paragraph, noting a recent proposed update.As our study focuses on adolescents with physical disability, we include the Smith guidelines as they are specific to this population.choosenot to complete subsequent rounds.For the purposes of data minimisation, we do not have tracking in place to know which email invitations progress to completed surveys.Statistical models seem rather ambitious with 100 participants and six variablesResponse: We have amended our statistical plan.Rather than exploring for evidence of interaction between predictor and dependent variables, we will now describe the findings of CAPE grouped by relevant participant characteristics (gender, underlying medical diagnosis, mobility, hand function, geography of place of residence).
Response:We changed all instances of "youth", "young people" and other variations to "adolescents" for consistency.○○SpecificcommentsFirstreferencedoesnot require 3 references.Choose one.Response:We selected the WHO reference to support this first statement.○ ○ 2nd sentence requires a reference to understand where the authors perspective come from.Response: This sentence intends to lead to the next points, which synthesise benefits of engagement in PA from a selection of indicative studies.For clarity, we have added "as demonstrated by the following evidence."○ ○ Last sentence of the first paragraph, is unsubstantiated by the previous references.It is more about how to improve on qol and strength.But nothing about other areas of health, i.e. social or mental.Response: ○ ○ ○ ○ Reference from activity allowance needs more context and quality of evidence.Previous studies used quality essays to measure CP and PA and outcomes, activity allowance is less rigorous.○ can simply ○ ○ Participation, defined in the ICF ......is crucial to sustaining meaningful engagement in PA. -Recommend rewording as participation more or less = 'engagement', so sentence doesn't fully make sense 'Adolescence is a significant time of change in participation' Be explicit that Imms' paper/s refers specifically to children with disability.Participation is not only a desirable goal from the perspective of self-efficacy but also that enabling participation in PA, self-determined by individual choice, is a potentially impactful public health CAPE Worth describing if it has a specific 'Physical activity domain' ….. any reference to support its use in capturing youth PA levels ?A reference is provided regarding it being used previously but clarify its use specifically for capturing childhood PA.
Some clarifications are required as outlined below, most importantly clarification in relation to what priorities are being established and with documentation of more specific study objectives Introduction