Barriers, facilitators and solutions for active inclusive play for children with a physical disability in the Netherlands: a qualitative study

Background Children with physical disabilities (PD) are less physically active than typically developing peers. The most important contributor to physical activity for primary school-aged children is outside play and therefore this should be part of every child’s life. However, children with PD experience multiple barriers to participation in playgrounds. Despite recent improvements in the accessibility of Dutch playgrounds, the participation of children with PD has not increased. This study aims to explore facilitators, barriers and solutions influencing the participation of children with PD in Dutch outdoor playgrounds, from parents’ and professionals’ perspectives. Methods Twelve semi-structured interviews with parents of children with PD aged 2–12 years and five focus group meetings with professionals working with these children were conducted. To ensure data saturation, we performed three member-check meetings. Two independent researchers analyzed the data using an inductive thematic approach. Results Similar barriers, facilitators and solutions were mentioned by parents and professionals. Three main themes were identified: the emotional barrier versus the physical barrier, play as a part of an inclusive society and the role of professionals in facilitating active inclusive play. The most important personal factors were physical and social problems experienced when children with PD wanted to join outdoor play. Interestingly, parents and professionals believed the social barrier was far more important than the physical one. The most important environmental factor was that the Dutch society is not sufficiently inclusive. Conclusions According to both parents and professionals, the most important barrier to active inclusive outdoor play was social, hindering the participation of children with PD in play with typically developing peers. To overcome such problems, professionals should take an active role in empowering children with PD and their parents. Furthermore, it is important to introduce outdoor active play early, so it becomes part of normal daily life. In addition, a change in the mindset of typically developing children and their parents seems essential to achieve true inclusive active play. Supplementary Information The online version contains supplementary material available at 10.1186/s12887-021-02827-5.


Background
Between 109,000 and 129,000 children in the Netherlands have a disability, roughly 3.5% of children aged 0-18 years [1]. In the last decade, the importance of play for children with physical disabilities (PD) has become more and more recognised. Play is so important it is included in the United Nations Convention on the Rights of the Child: "The Committee … emphasizes the obligations of States parties to ensure that children with disabilities have equal access with other children to participation in play … Pro-active measures are needed to remove barriers and promote accessibility to and availability of inclusive opportunities for children with disabilities to participate in all these activities" [2]. Although this quote implies that children with disabilities are entitled to opportunities to play, these opportunities are not always available.
When playing, children develop motor skills, learn to take risks, push their limits, interact with peers, and learn social norms and values [3,4]. Neighborhood and school playgrounds are important sites where children play and very suitable places to be physically active [5][6][7][8]. Play in the playground is the most important contributor to physical activity for primary school-aged children [9]. A physically active lifestyle is beneficial, especially for people with disabilities [10][11][12][13][14]. Being physically active, including physically active play, has positive effects on motor, social and cognitive development, and on overall health [15][16][17]. A physically active lifestyle leads to reduced risks of illness and mortality from various chronic illnesses [15][16][17]. In particular, physical activity has positive effects on the functional independence of children with disabilities, improving their integration into society and their quality of life [11]. Nowadays, typically developing children lack physical activity [18][19][20] and children with disabilities are even less physically active than their peers [19][20][21][22].
'The Playground Gang' (De Speeltuinbende), an initiative of the Dutch Foundation for the Handicapped Child (NSGK), strives to create accessible playgrounds for children with PD. Since the main focus in literature [23][24][25][26][27][28] is that children with PD do not participate in the playground because of physical inaccessibility, you expect increased participation of children with PD when accessibility is improved. However, even when 'The Playground Gang' improved the physical accessibility of playgrounds, the number of children with PD in playgrounds did not increase. Thus, other factors than physical inaccessibility may influence participation of children with PD in outdoor play negatively. Research by the LUDI network (international research consortium to increase participation in play for children with disabilities) found, even when play locations are physically accessible, they can still be socially exclusive due to social and attitudinal barriers [28]. In each country there are differences in cultural and societal structures, influencing social and attitudinal barriers. In the Netherlands for example, many children with PD attend special schools (mostly further away from home) instead of regular schools located in the neighborhood. To understand possible solutions and to create interventions to stimulate inclusive outdoor play in the Netherlands, research specific to the Dutch situation is needed.
The focus of this study will be on parents of children with PD and professionals. According to the Family-Centered Care approach, parents are the heart of the family and have by far the most important role in stimulating their child to play outside [29]. The perspective of professionals is also valuable since they work closely with children with PD and their parents. In addition, they have a role in facilitating inclusive play in the playground [30][31][32]. Insight into their perspectives is necessary to develop effective intervention strategies to improve participation in the playground.
The objective of this study is to analyze facilitators, barriers and solutions important for active and inclusive outdoor play for children with PD (aged 2-12 years), from both the parental and professional perspectives.

Design and data collection
This case study employed a qualitative descriptive design, with a thematic analysis [33] and has a basis in social constructivism [34,35]. In this approach, questions remain broad to encourage participants to construct their meaning, supported by the interaction with others (the social part of social constructivism) [34,35]. The Consolidated criteria for reporting qualitative studies (COREQ) was used to describe the method of this study (Additional file 1) [36]. The focus of this study is on parental and professional perspectives on participation in physically active play of children with PD aged 2-12 years with a physical disability comparable to a score of I-IV on the Gross Motor Function Classification System (GMFCS) for children with cerebral palsy [37]. How play and playgrounds were defined in this study was explained to the participants at the start of the interview (included in the topic lists, for more information see Additional file 2 and Additional file 3). The parents and professionals were interviewed separately with comparable topic lists, so any differences and similarities between these groups could become evident. However, during data collection, the topic lists were adjusted due to usability reasons, and gained knowledge related to the aim of this study. The topic lists were created by the research team, consisting of one experienced (> 15 years) MSc. pediatric physical therapist/pedagogue (MBO), two experienced (> 10 and 15 years respectively) Ph.D. pediatric physical therapists (EB, MB), and two junior researchers (< 5 years) with a MSc. pediatric physical therapy background (ME and LVE). The research team was trained to conduct qualitative research and had multiple years of experience with qualitative research.
We conducted semi-structured individual interviews to obtain data from parents of children with PD. Such interviews provide participants with an opportunity to introduce their own subjects and insights [35,38]. For parents, we chose individual interviews over focus group interviews because of practical reasons. The interviews were solely led by the moderator ME (MSc. PPT) who made field notes to make sure all topics were discussed and to register peculiarities and non-verbal reactions.
The professionals were interviewed during focus group meetings. These are semi-structured discussions to gain insight into the perceptions of participants. Focus groups were chosen since interactions in groups can help to reveal more in-depth information [35,38]. The ideal number of participants is reported to be six to ten [39]. Focus group meetings were led by one moderator LvE (MSc. PPT). There was one observer who made fieldnotes and supported the moderator in making sure all topics of the topic list were discussed.
In all interviews, the moderator posed open questions to which the participants responded. The participants were not directed towards any particular preconceived response. The interviews were filmed and audio-taped. Both the individual interviews and the focus group interviews were conducted at various locations such as a rehabilitation center, the HU University of Applied Sciences Utrecht, a pediatric physical therapy practice, and at the participant's home.
Data collection was continued until data saturation was achieved, meaning that no new information was collected during a subsequent interview or meeting. To assess the likelihood of saturation [39,40], three member checks with new participants were performed after the data collection was finished. One member check group consisted of parents, the other two of professionals. When no new information arose during the member check meetings, saturation was assumed.
The Institutional Medical Ethical Screening Committee (Department of Health, HU University of Applied Sciences Utrecht) approved all methods and concluded that the present study did not fall under the Medical Research Involving Human Subjects Act, since no intervention was conducted and the burden for participants was low. All protocols were carried out according to the Good Clinical Practice Statement. All participants were provided with a standardized information letter. Prior to the individual interviews, the focus group meetings, and the member check group meetings, every participant gave written informed consent.

Participants and procedure
We included parents of children with PD comparable to a score of I-IV on the GMFCS and aged 2-12 years old and professionals who were experienced in working with children with PD in the field of physical activity [37]. Exclusion criteria was insufficiency in the Dutch language. We used purposive sampling to assure variation in GMFCS score, and age of the children, family background and family composition. For the professionals, we included participants with different levels of experience and different professions [40]. Maximum variation of demographic origin was aimed for. Participants were recruited by flyers through different routes, including our network, treatment practices found on the internet, and by networking at a wheelchair event. To reduce the burden of travel and time, the focus groups were formed by convenience, rather than variation by age, gender, profession, or level of experience. Prior to individual interviews and focus group meetings, every participant completed a standardized questionnaire with background information (Additional file 4 and Additional file 5). Parents provided information about their children and families and professionals about their working experience.

Data analysis
All individual interviews and focus group meetings were transcribed verbatim based on the audio-and videotapes. A thematic analysis was performed using an inductive strategy [33] with MAXQDA2018 (version 18.0.4). It was an iterative process in which fragments were coded, resulting in themes. The first step was familiarization with the data by reading the transcripts several times. The second step was identifying fragments and coding these fragments to distinguish between barriers, facilitators and solutions. Barriers and facilitators were defined as aspects already present and which have a negative or positive influence on physically active participation by children with PD in playgrounds. Solutions were defined as factors, not yet present but with a potentially positive influence on participation in playgrounds. During the third step, we searched for a broader level of themes within the codes. The fourth step specified the detailed reviewing of the themes in relation to the individual codes and to the entire data set to conclude if the themes display all the collected information. The fifth step was defining and naming the themes and distinguish themes from subthemes.
The analyses were conducted independently by two trained researchers (ME and LvE) and then compared. In the case of disagreement, a third researcher (MB) was consulted to achieve consensus. To prevent research bias, critical peer debriefing occurred after each step, and results were discussed thoroughly within the research team [39,40].

Results
From November 2017 to February 2018, 12 semistructured interviews with parents and five focus group meetings with professionals (n = 25) were conducted. The characteristics of the parents and professionals are displayed in Table 1 and Table 2. The average duration of the interviews with parents was 46 min and 90 min for the focus group meetings. After the eleventh interview and the fourth focus group meeting, no new information was revealed. In addition, no new information was discussed by the participants (parents n = 5; professionals n = 15) during the member checks. Therefore, the researchers concluded that saturation had been achieved. No additional information emerged from the non-verbal communication (video) and the field notes, so they have not been further analyzed.
The overall results are displayed in Tables 3, 4, and 5. The most important themes are discussed in the text and supported with relevant quotes. The main themes are presented as follows: 1. The emotional barrier versus the physical barrier. 2. Play as part of an inclusive society. 3. The role of the professional.

Emotional barrier vs. physical barrier
In order to facilitate active and inclusive outdoor play for children with PD, the environment needs to be physically accessible: "… naturally, when you have a playground, you strive to have accessibility …, so a child  with a disability feels that he is being thought of. That is already a first thing …" [professional 1]. However, all parents and professionals say improving physical accessibility alone will not lead to increased participation, since emotional barriers also prevent children from participating in playgrounds.
Most parents state they were not able to even think of play as an option in the first years of their child's life since they were still preoccupied with mourning, processing, and everyday struggles. Professionals share the same experiences: "I think at first, when they are so young, they want their child to sit and walk. There are so many basic questions, that they only start thinking about play later on" [professional 10]. Children and parents need to realize that the child can enjoy him-or herself in the playground. However, parents also need to realize they cannot always prevent the child from having a negative experience. All professionals state that parents find it difficult to let go of their child and worry about her or his safety when the child is able to or is allowed to play with other children. "You often see that the child is able to do it physically, but that it is just really the connection between the child and parents and being afraid that it is socially incapable, rather than physically incapable, of getting there. …cannot keep up with the other children … also cannot handle conflicts. I think that is what parents encounter" [professional 13]. Most parents and professionals believe overprotection has a negative effect on the self-esteem, autonomy, and the self-solving ability of the child: "… the key is actually, that they do everything for the child, so the child doesn't develop self-esteem, that he/she is able to do something …" [professional 1]. The lack of self-esteem, autonomy and self-solving abilities are the building blocks of the emotional barrier.
Many professionals observe the presence of friends as an important factor: "… I think they really don't care … if there is either a swing, a seesaw, or a jungle gym. It is more important they are with children from the neighborhood …" [professional 3]. A majority of parents describe difficulties their child has connecting with typically developing children. A parent describes the example of her 10-year-old daughter: "… that she now tries to connect with the four-year-olds, but she will not ask: can I play along? She just waits … until she gets an offer, or that she can secretly take a scoop (of sand) and that the [other] child actually finds it okay" [parent 4]. On top of that, a child often grows into deficit, meaning the difficulties experienced with, for example, low cognition increases with the years, when compared to typically developing peers. Growing into deficit is an important negative factor in making friends. According to several parents, a possible way to decrease the social barrier might be for the child to go to the playground with a peer without a disability. "It makes it easier for other children to make contact when the child with a disability is accompanied by a child they already know and it is easier for the child with a disability to feel equal" [parent 6]. However, some children with PD need physical help and it is unclear whether another child could provide enough assistance. Moreover, physical problems also play a role in engaging with peers. Usually, typically developing children are faster, stronger, and more skilled. A parent reflects on this problem: "She wants to play together, but the pace of other children is much higher … That's why she sometimes doesn't mind to just play alone in the garden … other children go outside and she goes her own way" [parent 10].
On top of these barriers, some parents state they are sometimes tired of stimulating their child in play and  they feel everything turns into a therapy session. Taking care of children with PD is emotionally demanding for parents, which leaves little or no emotional reserves for recreative trips to the playground. In order to decrease these barriers, an initiative has been suggested where families would be paired when going to the playground.

Play as part of an inclusive society
All parents and professionals believe behavioral change is needed in the whole society towards the inclusion of children with PD. "I do not think it is possible to say that by tomorrow we make the playground this way, we take into account these conditions, we support the parents and 1.5 years later or 2 years later all children with disabilities play in a playground…I believe it takes at least 10 years for this to become normal. This is behavioral change in my opinion, within families of children with disabilities…but also within society to make everything accessible" [professional 1]. Behavioral change starts with raising awareness about play and inclusion within society, for example by running large-scale campaigns focusing on the current way society sees children with PD. Several parents say that typically developing children perceive children with PD as unusual and children with PD were sometimes bullied because of this. As a result, children with PD encounter difficulties in connecting with peers. One parent reported an example where their child was not allowed to play with typically developing children because parents of these children sometimes felt the responsibility of taking care of children with a disability was too great. Many parents and professionals say that children with PD are stigmatized. They hope, by Child knows its own capabilities. (pro) Fun play equipment: nest or wheelchair swing or carousel; small field with goals, hills, tunnels, and bridges; interactive elements with sand and water; a fort, ship, or house to play in or under; room for fantasy game; trail for wheelchairs but also bicycles; and steps, etc. changing the stigma, society will be able to truly include children with PD in everyday life in the neighborhood. All participating parents and professionals found it important to familiarize typically developing children and their parents with children with PD by meeting each other: "… but he has little connection with the kids from nearby. Most children only see the wheelchair and then they ask me, what does he have? Is something wrong with his legs? Then I think, you can also ask him. Yes, I find that very difficult" [parent 7]. Encouraging young children with PD to play in playgrounds is not only important for the child with a disability but also for children without PD and adults. Most parents and professionals feel that, when children without PD grow up with a child with a disability, they do not see the disability but instead they see the child. "There is a huge gap in society, which can be very annoying at an older age … That's just how society works. And then the government pays lip service to a society where participation plays a central role. But if you don't grow up together, you don't know each other" [parent 7]. One example parents and professionals mention that preserves this gap in society and holds children with PD back from making friends in the neighborhood is special (i.e. regional not local) education. Both parents and professionals say that inclusive education and inclusive daycare could improve the integration All playgrounds need to be adapted for physical accessibility. The network around the parents and child needs to be involved and needs to know how to play with and support the child during outside play. of children with PD in society: "Special education is, what I just said, a regional school, so friends are in school and do not live around the corner…I now have a number of children who changed from special education to regular local education once a week…and those parents all indicated that there is more participation in play in the neighborhood" [professional 3].

Role of professional
A few parents are critical of the professionals involved in their child's development, especially when these professionals do not consider play to be important. Parents say, for example, some doctors focus solely on medical issues and often do not consider the broader perspective. Many therapists use play as a method of achieving therapy goals but rarely set therapy goals focused on play: "Yes, I apply it in my therapy, when children have to learn something, then I use play as a method, which I do playfully. But how many times was I really focused on whether a child could play? Well, then that is pretty limited" [professional 18]. Some professionals state that the reason they are not focused on play and inclusion of children with PD is a lack of awareness about their role and the importance of play, and the fact they lack skills. However, therapists find it very important to provide parents and children with enough tools to ensure play is part of the child's everyday life. Parents and professionals state that providing therapy on the level of participation in real-world situations is crucial but is not at present embedded in regular therapy: "Yes … we were always here in the practice [setting] … But I'd rather that the therapist tells me there (in the playground) … what I can do with my daughter, or that what I do is good" [parent 5]. Some professionals feel fostering play as part of the everyday life of children with PD should be the aim of long-term therapy. However, therapists also experience a financial barrier when treating children with PD in the home environment for a longer period of time. This financial barrier is caused by the reluctance of physicians in prescribing home-treatment referrals and the amount of time and, therefore money, these home treatments require.
In order to make parents aware of the importance of play, professionals should stimulate, coach, and empower parents: "… create awareness with parents. I think that this process should start at a very early age "[professional 18]. Some parents are not always aware that play is important for the development of their child. Children need to be encouraged to play in playgrounds at a young age, to let play become a normal part of their lives: "Children will enjoy it more, I think, when you start at an early age, it becomes natural. I think the longer you wait before you go, the less they [children with PD] are going to enjoy it for themselves" [professional 19]. Moreover, when a child is young, it is normal to provide assistance and parents can adapt to gradually let go of their child. Many professionals stated a solution might be to support parents by integrating play into regular interventions, including groups, and organize play weekends or play workshops.

Discussion
The purpose of this study was to describe parents' and professionals' perspectives on barriers, facilitators and solutions influencing participation of children with PD in physically active play in playgrounds in the Netherlands. The results indicate that participation in playgrounds for children with PD is complex and influenced by multiple personal and environmental factors. Besides physical barriers, the emotional barriers seem to be the most important factors holding children with PD and their parents back from active participation in the playground. There were no fundamental differences observed in the perspectives of parents and professionals.

Emotional barrier vs. physical barrier
Results of our present study correspond with previous research describing children with disabilities facing exclusion in a playground, because of physical inaccessibility [23][24][25][26][27][28]. However, since the emotional barrier seems crucial, it is interesting to notice literature about children with PD playing outside is mainly focused on physical aspects [23][24][25][26][27][28]. A study that did focus on both the physical and the emotional barriers in relation to play for children with disabilities found key themes similar to the findings of our present study, such as social exclusion by peers, lack of friends, not being able to adjust the type of outdoor play, the need for an adult to facilitate play, and the attitude of professionals to, and parents' worries about the risks of outdoor play [28]. They also underline the necessity to focus on both the physical and the emotional barriers to increase participation of children with PD [28]. So besides improving accessibility of playgrounds, developing additional interventions focusing on experienced emotional barriers seem essential. Two studies on participation and happiness of parents and children with disabilities state that in order to increase participation of children with disabilities policy's and interventions need to address factors (e.g. reducing stress associated with caring for a child with a disabilities, improving social skills of the child) on a system-wide level such as community-level support groups, stress relief strategies and exercise [41,42].

General inclusion
One specific example of a system wide change is inclusive education and daycare. Separate, and thereby exclusive, education in the Netherlands (special versus regular) seems to increase problems with general inclusion. Evidence shows that 85% of children with disabilities attending special education in the Netherlands have few or no friends in their neighborhood [43]. Properly organized inclusive education and daycare decreases social emotional barriers and stimulates integration in the community [44][45][46].

Role of professional
Both parents and professionals in this study expressed that professionals could help to overcome multiple barriers, especially emotional ones. Solutions mentioned were: home-based therapy in the playground, coaching and empowering parents to overcome social/emotional barriers, early-age intervention focusing on outside play starting around the age of 2 years, teaching children their own capabilities and boundaries and increasing selfesteem. These elements coincide with implications Palisano et al. (2012) drew in their study regarding participation-based therapy for children with PD [47]. Furthermore, coaching and cooperating with parents are important elements of Family-Centered Care, and are known to support children and parents applying learned skills in natural environments [48]. Moreover, coaching is considered to increase knowledge, self-solving abilities, and selfadvocacy skills of both children and parents and can help them develop strategies to overcome barriers leading to increased participation in the playground [48][49][50].
The use of behavioral change interventions in pediatric rehabilitation aimed at the interaction of children with disabilities and their parents and the physical and social context seems promising [51][52][53][54]. However, nowadays, professionals such as pediatric physiotherapist and occupational therapist still seem too much focused on function and activity, f.e. motor skills such as learning to walk or cycle, rather than on changing or involving the environment and thus participation. Professionals still seem to be insufficiently aware of existing social barriers, while the social aspect is essential in inclusive outdoor play [51,[55][56][57][58].
Professionals in this study reported barriers in the organization of care for children with PD in the Netherlands. One example is the difficulty of providing home-based therapy in the natural environment, as children with PD in the Netherlands typically receive their therapy at their regional special education school or within private practices. Since these schools are not located in the neighborhood of children with disabilities, it is very time-and cost consuming for the therapist to provide therapy in children's living situations.

Strengths and limitations
Several strengths and limitations were present in our study. The method of this study was described using the Consolidated criteria for reporting qualitative studies (COREQ) [36]. We conducted the analysis with two independent researchers, included critical peer review and member checking which enhanced the credibility, conformability, and reliability of this qualitative study [35,37]. Professionals with a diverse range of experiences participated in our study, leading to a broad overview of perspectives about play in the playground for children with disabilities. The selection of participating professionals positively affected the heterogeneity of the research group. In terms of medical diagnosis, gender, age, and mobility of the child, heterogeneity of parents and professionals was particularly high. To our knowledge, the present study is the first in the Netherlands to analyze participation in physically active play in the playground for children with PD.
A limitation of our study was that parents were recruited at events for children with PD and approached through 'The Playground Gang' (De Speeltuinbende). There is a chance parents who agreed to participate in our study were those who already found play important for their child. Confirmation bias may have been present since the interviews were conducted by only one interviewer. We tried to prevent bias by using an interview guide. In addition, only two of the five focus group meetings consisted of six to ten participants, the ideal range [35], which could have influenced the results: however, interactions in focus group meetings seemed adequate.

Implications for the future
As children are the main stakeholders in this project, future research to find additional facilitators, barriers and solutions should include their perspectives. Furthermore, a system wide intervention could be developed based on the outcomes of this study. This intervention should focus on and be created in co-creation with health care professionals, policy-makers, the government, and other stakeholders. These solutions should in turn be evaluated with children (with and without PD), parents, and professionals, investigating the feasibility of these interventions to increase play in playgrounds for children with PD in the long term.

Conclusion
According to parents and professionals, the main reason for children with PD not participating in play in the playground is the emotional barrier that both parents and their children experience. Professionals and parents see many routes for improvement, mainly with regard to the organization of services for children with PD. Suggested solutions all focus on empowering and coaching both children and parents. To enable