Abstract
Importance
Pathways and Resources for Engagement and Participation (PREP) is an evidence-based, environmental intervention to improve an individual's participation in activities of choice. However, the specific intervention strategies employed have not been systematically examined.
Objective
To identify and describe PREP strategies used to promote the participation of youth and young adults with disabilities in community-based self-chosen occupations.
Design
A descriptive qualitative study was employed. Data were extracted from PREP Intervention Forms documenting step 3 of the interventions (“Make it Happen”) for 65 youth and young adults with physical disabilities. PREP Forms included 524 strategies to enhance participation in 127 goals set by the youth (e.g., taking cooking classes, playing badminton, playing a musical instrument, and volunteering in a radio station). Inductive content analysis was conducted.
Setting
Community.
Participants
Sixty-five youth and young adults with physical disabilities aged 12 to 25 (mean=18, SD = 3.67) who received the PREP intervention.
Results
Twenty-eight actions organized by four overarching strategy categories were identified: (1) reach out to community resources and partners, (2) set the stage for an accessible and adaptable context for participation, (3) engage partners in learning and education to foster their agency and enable feasible and supportive participation, and (4) monitor the process and consider new solutions.
Conclusions and Relevance
Findings provide new knowledge about the practical application of the PREP approach, highlighting strategies that can enhance the participation of youth and young adults with physical disabilities. Findings can also redirect occupational therapists’ attention toward engaging youth and community partners to build capacity for future participation.
Plain Language Summary
PREP (Pathways and Resources for Engagement and Participation) is an intervention approach used by occupational therapists to support individuals to pursue self-chosen activities (i.e., taking a cooking class and learning to play an instrument). This study described the specific strategies used to support 65 youth and young adults with physical disabilities (ages 12–25) to participate in a total of 127 activities of choice. Text from a total of 524 strategies documented on PREP intervention forms were analyzed. Four overarching categories were identified which included 28 actions. The four intervention strategy categories included: (1) reach out to community resources and partners, (2) set the stage for an accessible and adaptable context for participation, (3) engage partners in learning and education to foster their agency and enable feasible and supportive participation, and (4) monitor the process and consider new solutions.
Keywords
Introduction
Participation, defined as “involvement in a life situation” (WHO, 2001), is a fundamental component of health, development, and wellbeing for children, youth, and young adults with disabilities. It is widely recognized that participation in meaningful everyday occupations—such as those related to school, leisure, social life, and community engagement—is not only a key indicator of functioning, but also a central outcome in pediatric rehabilitation (Imms et al., 2017). Compared to their typically developing peers, youth and young adults with physical disabilities encounter barriers to participation across all life domains (Guyard et al., 2024). According to current evidence, participation-level outcomes are best achieved when therapy interventions address activities within the client's natural environments (Novak & Honan, 2019).
Recognizing the multifactorial nature of participation, occupational therapy interventions have increasingly shifted toward approaches that go beyond impairment-based therapy to target contextual facilitators and barriers. For example, there is growing evidence for environmental-based interventions that improve participation of children cerebral palsy (Darrah et al., 2011), youth with physical disabilities (Anaby et al., 2018, 2015), and youth with developmental disabilities (Kramer et al., 2018). Among these, the Pathways and Resources for Engagement and Participation (PREP) is recognized as a structured, evidence-informed intervention that focuses on modifying environmental factors and building on supports to enable participation in self-chosen occupations (Anaby et al., 2018, 2015). Grounded in ecological and client-centered principles, PREP involves collaborative goal-setting, environmental modifications, coaching, and resource mobilization to support individuals in achieving self-identified participation goals that occur in their natural environment.
PREP was found effective in improving a range of outcomes through participation (Hsieh et al., 2024). Findings suggest that youth not only improve their participation in the targeted self-chosen activities but also make changes to their overall participation (frequency/involvement) in other settings (i.e., community, school, and home). Additionally, improvements across a range of motor, cognitive, and affective outcomes such as trunk control, attention, and/or reduced anxiety have been documented. Furthermore, PREP is positively perceived by youth (Anaby et al., 2025), parents (Anaby et al., 2017), and therapists (Anaby et al., 2018, 2015) and initial qualitative evidence suggests that PREP builds capacity of families and teams to develop solutions beyond the support of a therapist (Burrough et al., 2020). However, specific strategies to enhance participation have not been systematically examined. An initial description of PREP strategies used to support youth's participation in self-chosen activities during the COVID-19 pandemic is documented by Anaby et al. (2021). Further investigation about specific strategies used within the PREP intervention to support youths’ participation is warranted. This study, therefore, aimed to identify and describe the PREP intervention strategies used to promote participation of youth and young adults with physical disabilities in their self-chosen occupations. Such knowledge will provide a better understanding of how the PREP approach is applied in practice and describe the practical strategies used by therapists, youth, and family to achieve successful outcomes together through PREP.
Method
Study Design
A qualitative descriptive approach was used to identify and describe intervention strategies used within the PREP intervention. PREP consists of five steps: Make Goals, Map Out a Plan, Make It Happen, Measure Process and Outcomes, and Move Forward. The present study focused specifically on step 3 (Make It Happen), which involves the process of implementing the chosen activity by identifying barriers and applying solution-based strategies. Data were extracted from PREP Intervention Forms documenting this process completed by occupational therapists.
Data Source and Participants
The dataset involves aggregated data from a series of studies led by the senior author's research team, all focused on improving community-based participation through PREP. Most of these studies’ outcomes are summarized in a synthesis of PREP's effects (Hsieh et al., 2024), indicating, on average, a clinically significant change in participation goals (i.e., 2 or more points on the Canadian Occupational Performance Measure), with medium-to-large effect sizes.
PREP Intervention Forms documenting the intervention for 65 youth and young adults (35 females and 30 males), aged 12 to 25 years (mean=18, SD = 3.7) were included. Intervention forms addressed between one and three participation goals set by each youth (depending on the study protocol). Forms, completed by occupational therapists, included 524 strategies addressing a total of 127 unique participation goals. All youth who received the PREP intervention had a physical disability involving a mobility restriction (e.g., inability to navigate all surfaces and stairs independently and safely without the use of aids, physical assistance, or external support); of them, 26% also had developmental delay and/or communication difficulties. Most youth lived in a large Canadian province (n = 63) and the remaining in Israel (n = 2).
Intervention duration was either 8 or 12 weeks, depending on the study protocol. To ensure intervention fidelity, occupational therapists received standardized training in the PREP approach prior to delivering the intervention.
Each of the studies received ethical approval by McGill or CRIR IRB ethics boards. Written informed consent was obtained from all youth participants and/or their parents depending on their age.
Data Analysis
An inductive qualitative content analysis (Elo & Kyngäs, 2008) was conducted to identify and describe PREP strategies. This inductive approach was selected to answer the research objective since no prior analysis of PREP strategies exists.
Preparation Phase
Data from PREP Intervention Forms were extracted word-for-word into an Excel database, including goals, barriers, and strategies. The documented strategies were read repeatedly (along with the barrier/goals) to ensure familiarity with the content and to capture an overall understanding of their scope and meaning. Each documented strategy text was considered the primary unit of analysis.
Organizing Phase
The physiotherapist researcher (first author), who had no prior experience with the PREP framework conducted line-by-line open coding of all 524 strategies. Codes were generated inductively to reflect the function or intent of each strategy and were recorded in structured coding sheets. A subset of the data was independently reviewed by a second researcher (second author), an occupational therapist with expertise in the PREP approach. Coding decisions were compared, discrepancies were discussed, and revisions were made when necessary. When uncertainties remained, a third expert (senior author), co-developer of the PREP model, was consulted.
Finally, codes with similar meanings or purposes were grouped into subcategories, which were then clustered into broader categories. Labels were chosen to represent each category's core concept. This process resulted in a preliminary categorization which was reviewed iteratively by the full research team. Disagreements were discussed until consensus was reached, and, when needed, the original intervention forms were revisited. In some cases, categories were merged or organized under higher-order categories. Data extracts could be assigned multiple codes and could be included in more than one subcategory. Through this iterative process of review, discussion, and revision, the final categorization system was established.
To address credibility, multiple researchers with different educational backgrounds and levels of PREP knowledge contributed to the analysis and validation. Notably, the initial coding was conducted by a researcher (first author) who was not involved in generating the original study data, which helped to reduce potential bias. To further enhance credibility of the study, the first and second authors used an iterative process involving open dialogue and weekly discussion to organize the data. The senior author provided frequent input to verify and achieve agreement with the way data were labeled and sorted, through a total of eight team meetings (Graneheim & Lundman, 2004).
Results/Findings
Twenty-eight action subcategories were identified clustered under four categories of strategies (Table 1). These four overarching categories illustrate the practical application of PREP to support youth participation in real-world settings. Specific examples of data extracts from the PREP forms supporting each category are included below, paraphrased to clarify the context.
Overarching Categories and Subcategories/Actions of Intervention Strategies in the PREP Framework.
Note. OP = Occupational Therapists; PREP= Pathways and Resources for Engagement and Participation; PT = Physiotherapist .
Strategy Category 1: Reach Out to Community Resources and Partners
This process involved researching existing resources related to the youth's desired activity and exploring alternative activity options as needed. It included six actions. For example, for a youth who was in the process of deciding which activity to do, the occupational therapist shared their screen over Zoom with them to search and discuss potential available activities. For another youth who was interested in playing a noncompetitive local team sport with their peers, the occupational therapist brainstormed options with the family using YouTube videos of kids participating (i.e., bowling, boccia, and luge hockey). This process also included searching for organizations, classes, instructors, or volunteers to support the activity. In a few cases, for example, the occupational therapist and/or youth posted online through social media channels (i.e., Facebook) or relevant school program pages (i.e., Physical & Occupational Therapy departments, music departments) to search for an instructor, a volunteer, or peers who might be interested in the activity (i.e., swimming, saxophone, and power hockey). It also included communicating with these individuals or institutions to gather further information as needed (i.e., more specific details about scheduling, rates, and eligibility). Information was obtained through online searches, telephone calls, e-mails, and by drawing on existing networks (i.e., asking colleagues about potential volunteers or equipment, exploring community resources and asking for suggested contacts/programs, encouraging youth/family to ask their friends/family for volunteers and/or resources). In another example where a youth wanted to take swimming classes, the occupational therapist contacted the local swimming pool to ask about integrating the youth into their regular swimming classes and the family also suggested contacting a nonprofit organization regarding funding. Depending on the situation, this process may be led/initiated by the occupational therapist or collaboratively carried out with the youth and their family.
Strategy Category 2: Set the Stage for an Accessible and Adaptable Context for Participation
This strategy category included 10 actions aimed at overcoming barriers encountered in the process of initiating the desired activity and accessing or advocating for the necessary resources. Strategies involved collecting comprehensive information regarding the youth's abilities, needs, and preferences related to the activity through various approaches, including observing youth in their “real-life” contexts and interviews with the youth and/or their family. This information informed the planning of the session content, the structure of breaks throughout the sessions, and the most appropriate mode of delivery—whether through online platforms, in-home services, or individualized one-on-one sessions. In addition, this category addresses key aspects of the environment such as providing adaptive equipment, making necessary modifications, ensuring facility accessibility, organizing transportation, and securing financial support. In several cases, the occupational therapist negotiated with community organizations to advocate on behalf of the youth for price reductions or shorter lessons, or to make exceptions to eligibility requirements for the youth to participate. Another action used to set the stage was to visit the organization together and coordinate a trial of the activity when possible. These actions also involved coordinating a suitable location and schedule for both the instructor and the youth, assisting families with the registration process, offering reminder systems (i.e., calendar/alarm) to plan and organize the activity (i.e., book transportation and attend scheduled event/class), and planning for any additional support required to facilitate smooth participation (i.e., verbal cues and prompts). Particular consideration is given to ensuring that the activity environment is accessible, acceptable, and sustainable for the youth.
Strategy Category 3: Engage Partners (Youth, Family, Peers/Volunteers, and Community Service Providers) in Learning and Education to Foster Their Agency and Enable Feasible and Supportive Participation
This strategy category included eight actions. Through engaged discussion and exchange of knowledge between all partners, new possibilities and resources for successful participation were proposed. A range of partners were involved including family members, peers, friends, instructors, and volunteers and other staff/personnel who bring knowledge and support surrounding the activity. This involved sharing information about different ways to participate or how to grade the demands of the activity or to co-create or plan an activity. To illustrate, the occupational therapist collaborated with a piano teacher about how to translate piano notes to be played using only one hand and together they brainstormed new ways to ensure a “just right” challenge for the youth. Other examples involved working with a volunteer to get familiar with selected board games beforehand and helping youth prepare for the social activity by working together to identify potential conversation topics. Partners were also engaged in discussions to find solutions. For example, for a youth who was involved with a local football team, the occupational therapist, the football coach, the youth and the youth's brother discussed adding a strap to the wheelchair footrests to enable him to participate more fully in learning football skills. Other ways that the occupational therapist engaged partners included building on family's ideas about ways to sustain motivation of the youth, educating others about needs, strengths, and preferences of the youth, and sharing resources such as support groups for parents. For example, for a youth who wanted to enjoy music in a social setting, the family and youth, with the support of the occupational therapist, led a presentation about the youth's needs, strengths, likes, and dislikes in music to the high schools students who were involved in the music club that the youth was joining. In another activity, the occupational therapist engaged students in brainstorming ideas for sensory art and craft projects that could be done with the youth.
Strategy Category 4: Monitor the Process, and Consider New Solutions
This strategy category describes four actions related to monitoring and follow up. Regular check-ins with youth, experts, and team members helped ensure flexibility and necessary adjustments while maintaining alignment with the youth's evolving needs. For instance, to support a youth in achieving the goal of walking dogs, the first solution to address pain in their wrist involved changing the leash to the other hand and later modifying the activity by attaching the leash to the youth's hips instead of their wrists. In another case, due to the seasonal nature of the activity, the frequency of sessions was increased to twice per week to ensure timely completion. The process also involved gathering feedback from youth and updating or modifying the schedule, goals, and activities based on barriers or feedback related to the youth, occupational therapist, family, instructor, or available resources. For one youth, the goal of playing the violin was prioritized over soccer due to the physical demands of the latter. In a few cases, the activity was revised based on availability of programs (i.e., seasonal activity and COVID-19 pandemic closures). Additionally, planning ahead with families and stakeholders included exploring upcoming programs scheduled for the following year and discussing practical aspects such as transportation and accessibility of locations to ensure sustainable and feasible participation. The aim of these actions is to foster effective support by ensuring continuous adjustments that enable youth to achieve their goals and make steady progress.
Discussion
This study categorized 524 intervention strategies employed within the PREP practice model to enhance participation among youth and young adults with physical disabilities. The resulting four strategy categories containing a total of 28 actions provide a comprehensive and nuanced understanding of how participation is enabled in real-world settings. These findings illustrate a unique practice model and shed light on what practice can be. Findings reflect a multilayered and dynamic approach that involves collaboration with youth, families, and community partners to address participation outcomes through focusing on the environment. Actions provide concrete examples of intervention processes that go beyond standard skill training or impairment-based approaches and highlight the valuable roles and contributions of the youth, family, and other partners in achieving real-world participation outcomes.
Notably, the strategy categories identified in this study underscore that therapists do not merely recommend participation—they actively co-construct the conditions under which participation becomes possible and sustainable. For example, the second category containing the largest number of actions, “set the stage for an accessible and adaptable context,” adds to existing knowledge about the role of environmental facilitators (Law et al., 2006; Imms et al., 2017), through expanding the notion of environment to address various facets. Findings offer rich details on how occupational therapists proactively coordinate with community organizations (2b, 2c), adapt schedules (2f), advocate for resources (2c, 2g), and support families through each logistical step (2e). Similar observations were made by the parents (of youth with physical disabilities) in a qualitative study following the PREP intervention. Parents recognized the unique role that occupational therapists have as key navigators who coordinate logistics, negotiate with community organizations, and systematically reduce environmental barriers to enable participation (Anaby et al., 2017). Likewise, studies of PREP implementation with children with acquired brain injury demonstrate how therapists operationalize environmental adaptations, resource navigation, and partnership-building as central mechanisms for enabling participation in everyday life (Burrough et al., 2020). Taken together, these studies converge with the present analysis to illustrate the unique role of occupational therapists in PREP as a guiding figure, building links, and networks.
These strategy categories also reflect a shift from therapist-as-expert to therapist-as-collaborator, emphasizing shared responsibility and mutual learning. As demonstrated through eight detailed actions in the third category, occupational therapists engaged a wide range of partners—including families (3c), peers (3e), instructors (3b), and professionals (3d)—to co-create solutions and build capacity. These strategies reflect therapists’ roles as facilitators of shared understanding and co-creators of solutions and align with principles and key ingredients of capacity building identified for youth with disabilities in a recent scoping review (Ryan et al., 2025). These include shared planning and decision making, building on strengths, and exchanging accessible, timely, and meaningful information and resources. The value of engaging youth in the process through flexible planning, contextual problem-solving, and collaborative decision making has been previously documented in qualitative findings from youth and therapists’ perspectives following PREP (Anaby et al., 2025). Findings revealed that PREP fostered youth agency and improved youth's self-confidence. Our current findings emphasize communication, mutual problem-solving, and adjusting the level of challenge which illustrates a participatory learning process that promotes both engagement and capacity building. This process is ongoing, as shown by the fourth category, “monitor the process and considering new solutions.” Therapists continuously adjust, revise, and individualize the intervention together with the youth and the team based on youth feedback, evolving needs, contextual constraints and changes in motivation or availability.
Limitations and Future Directions
There are several limitations to consider related to the scope of the data and context. The current study analyzed the strategies documented from existing PREP intervention studies. Data was primarily collected within Quebec, Canada, for youth with physical disabilities (ages 12–25). Therefore, findings may not reflect other contexts or populations. The text from the PREP intervention forms were often short notes without much detail. Certain details may have been missed or simplified. To mitigate this risk, strategies were read along with the documented goals and barriers and a PREP expert who was involved with data collection was also consulted to better understand contextual factors. Additionally, since forms are documented by the occupational therapist, the analyzed text may not reflect the perspectives of youth, parents, or other partners. Future research could examine PREP intervention strategies for younger ages and for youth with different types of disabilities across other geographical contexts. Furthermore, asking youth/family to document strategies in future studies may capture strategies and solutions that are led by youth and family. Incorporating therapist interviews into the analysis of intervention forms is warranted to better understand the rationale of selected strategies.
Implications for Occupational Therapy Practice
These findings further support the importance of focusing on the broader environment surrounding the youth when facilitating participation. The strategy categories and actions are not meant to be used as a procedural checklist, but rather as a guide for occupational therapists who seek to promote youth participation in community activities. Key implications for practice include:
Occupational therapists, youth, family, and community partners can consider the four overarching strategy categories when co-devising a plan to pursue participation goals. Based on the youth and family's context, a combination of the 28 actions identified in this study can be selected to achieve real-world participation outcomes.
Conclusion
This study identified and described PREP intervention strategies used to promote participation of youth with physical disabilities in self-chosen occupations. Findings provide valuable insights into the practical application of the PREP approach, highlighting strategies that can enhance the participation of youth with physical disabilities in real-world settings.
Footnotes
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Esra Keskin (corresponding author) was supported by the TÜBİTAK 2219 International Postdoctoral Research Fellowship Program (grant number 1059B192302268).
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
