JMIR Publications

ABSTRACT

Background:

A sedentary lifestyle is a global health crisis that contributes to chronic disease and premature mortality. Adolescents with mild intellectual disability (ID) attending Dutch practical education (PrO) schools face elevated health risks due to low levels of physical activity (PA) and limited conceptual, social, and practical skills. Digital health interventions offer scalable solutions but require contextual adaptation informed by formative research, addressing gaps in theoretical rigor, inclusive participatory approaches, and multi-stakeholder triangulation.

Objective:

To identify PA determinants among adolescents with mild ID in Dutch PrO schools, using a theory-driven, participatory, and multi-stakeholder approach to inform the contextual adaptation of digital health interventions.

Methods:

We conducted a sequential exploratory mixed-methods study using three frameworks: the Theoretical Domains Framework (TDF) with COM-B for theoretical grounding, Context Mapping for inclusive creative exploration, and Concept Mapping for quantitative structuring and validation. Five adapted stages mapped the preconceptions of PA determinants in adolescents with mild ID from literature, experts (n=13), and teachers (n=8), and then adolescents’ own perceptions (n=83-90) through: sensitizing (daily reflection postcards), generation (collage-based timelines), structuring (visual rating cards on a 7-point scale), and validation (a gamified quiz). Inclusive participatory methods were co-designed with schools for adolescents. Qualitative data from all sources were thematically analyzed to identify PA determinants, which were mapped to TDF domains and COM-B components; quantitative data from adolescents’ ratings of these determinants and responses to the validation quiz were analyzed using descriptive statistics, Mann-Whitney U tests, and hierarchical clustering to reveal agreement and individual variation.

Results:

Twenty-nine PA determinants were identified and mapped to COM-B components: Opportunity (n=15), Motivation (n=8), and Capability (n=7). Adolescents emphasized emotional and social facilitators (e.g., fun activities, enjoyment, and peer or family support), while experts and teachers focused on capability barriers (e.g., impaired skills, cognitive fatigue). Quantitative ratings showed a positive bias towards facilitators (mean=5.09/7), with significant gender differences (P=.003), no age effect, and weak within-group agreement (rwg<0.7), indicating variation in individual perceptions. Determinants perceived as facilitators by adolescents showed greater consensus than barriers (ρ=0.74). Validation confirmed these patterns and highlighted the differences between adolescents’ perceptions and preconceptions from literature, experts, and teachers, particularly adolescents’ positive ratings of determinants that are preconceived as barriers by stakeholders.

Conclusions:

This study provides a theoretically grounded foundation for tailoring evidence-based digital interventions to adolescents with mild ID in PrO schools. Findings support a dual intervention strategy: group-level approaches for universal facilitators (higher agreement) and personalized strategies for individualized barriers (lower agreement). Digital health interventions are ideally positioned to deliver scalable facilitators along with personalized algorithms to reduce barriers.