Aging in rural communities: Engagement in indoor leisure activities and older adult health

PLOS ONE

Dear Dr. Chiang,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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Could you please revise the manuscript to carefully address the concerns raised?

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We look forward to receiving your revised manuscript.

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Helen Howard

Staff Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

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2. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #1: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #1: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #1: Yes

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Reviewer #1: Dear Autors,

I would like to express my gratitude for the opportunity to review the manuscript titled "Aging in rural communities: Engagement in indoor leisure activities and older adult health." In my view, this type of research, which examines the effectiveness of various physical activities in older adults, is highly relevant. From both a scientific and methodological perspective, I find the manuscript to be rigorous in its justification, design, analysis, and interpretation.

However, there are some areas that require clarification and improvement, which, if addressed, would enhance the overall quality of the manuscript:

• There is a lack of clarity regarding the selection and assignment of participants to each group. A more detailed explanation is needed regarding the criteria and process for categorizing participants into the respective groups (page 12, line 211);

• Additional clarification is required concerning the effects of physical activities on the ability to perform activities of daily living (page 24, lines 439-451)

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what does this mean? ). If published, this will include your full peer review and any attached files.

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Reviewer #1: No

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Dear Dr. Chiang,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

• I think the control group proposed by Reviewer 4 is worth discussing. Please provide a reasonable explanation or supplement relevant research by the author.

Please submit your revised manuscript by Aug 29 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Bifeng Zhu

Academic Editor

PLOS ONE

Journal Requirements:

If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise. 

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

Reviewer #4: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions??>

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: No

**********

3. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: No

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4. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: No

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5. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: (No Response)

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Reviewer #2: The revised manuscript is well-written, methodologically sound, and addresses a timely and socially relevant topic—the impact of indoor leisure activities on older adults' physical and mental health during the COVID-19 pandemic in rural Taiwan. The authors present a thoughtful design, appropriate measures, and a clear analysis using repeated-measures ANOVA.

The paper contributes to the literature on aging, leisure therapy, and rural health promotion. However, I recommend minor revisions before acceptance:

1. Clarify Group Assignment Strategy:While the authors explain that group assignment was based on location (to reduce participant burden), this introduces a risk of community-level confounding. Although randomization is not claimed, I suggest adding a brief statement in the Limitations section to acknowledge this limitation and its potential influence on between-group comparability.

2.Proofreading for Minor Language Corrections: A few grammatical or typographical edits are needed. For example:

Line 27: “complete self-reported their activities” → should be revised for clarity.

Line 449: “participants were women who were as familiar with baking as with meal preparation” → consider rephrasing for smoother readability.

Reviewer #3: The study has significant merit and high relevance for aging in rural communities. so it may be publishable. Paper has insights and it will help policy making in different stakeholder.

Reviewer #4: This manuscript addresses an important and increasingly relevant topic by exploring the impact of indoor leisure activities on successful aging in rural older adults. The authors present an intervention study comparing horticultural, handicraft, and baking activities and report positive effects on depression, physical, mental, and social health outcomes. The study’s focus on an aging rural population and its practical aim of promoting well-being in resource-limited settings are commendable.

I noted one major weakness in the study, which I believe makes the results unpublishable in their current form. The study uses a pre- and post-intervention design in the same participants, without any control group. This approach is highly vulnerable to confounding factors such as seasonal changes in mood or health. In the absence of control groups (e.g. no-intervention or delayed-intervention groups), the observed effects cannot confidently be attributed to the interventions.

There are also some minor weaknesses in the study, most notably the use of a paired t-test to compare IADL data. A Wilcoxon signed-rank test would be better, since the data would not be expected to be continuous, normally distributed, have equal variances between groups, and are also bounded at 0 and 8.

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what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

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Reviewer #2: No

Reviewer #3: No

Reviewer #4: No

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While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step.

Dear Dr. Chiang,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

• The concerns of the reviewer do not necessarily indicate that the results of the paper are incorrect, but rather that the methodology is flawed. And as mentioned by the reviewer and authors, the flaw is caused by specific events during the pandemic. We cannot avoid (ignore the flaw) or overcome it (supplement the complete control experiment). It is just like the complexity of sociological issues, which is often determined by multiple factors. The continuous contemplation and collision of ideas between the author and the reviewer in pursuit of truth in this paper have high academic contribution and reflect the diversity of sociological issues.
• Therefore, I suggest the author to: a) reflect the concerns of the reviewers in the discussion section. b) increase the credibility of the results as much as possible by supplementing necessary tests. c) improve the transparency of data. d) complete legends and labeling.

Please submit your revised manuscript by Sep 19 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Bifeng Zhu

Academic Editor

PLOS ONE

Journal Requirements:

1. If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise. 

2. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #2: All comments have been addressed

Reviewer #4: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions??>

Reviewer #2: Yes

Reviewer #4: No

**********

3. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #2: Yes

Reviewer #4: No

**********

4. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #2: Yes

Reviewer #4: No

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #2: Yes

Reviewer #4: Yes

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Reviewer #2: Thank you for the attentive and comprehensive revision. The manuscript is now methodologically sound, clearly written, and ready for publication.

Reviewer #4: I would like to thank the authors for revising the manuscript and for adding a detailed rationale for the design, an expanded Limitations section, and relevant citations. I also appreciate the transparent discussion of the ethical and logistical challenges faced during the pandemic. While these additions are helpful, they do not fully address the previously mentioned concerns with the experimental design.

Referring to Paulus et al, one of the additional sources cited in the revised manuscript, a few of the conditions that must be met for a before–after study to yield valid inferences include the following:

Each participant’s baseline must accurately predict what would have happened without treatment

Changes in the environment must be addressed

The condition studied should be relatively stable (i.e. not subject to natural recovery or intermittent fluctuations).

While the authors might see some way forward to address these threats to validity, I do not. As these data were collected during the COVID-19 pandemic, a unique and sometimes rapidly changing environment, the unique context likely precludes attempts to address these issues using historical or external data. Indeed, it was implied that some outcome measures (e.g. depression scores) were likely strongly influenced by the environment.

Additionally, the highly confounded study design should effectively preclude the between-group comparative analyses reported here, rather than enabling them as the manuscript states. Prioritizing participant well-being is commendable, but it is my belief that equipoise was neglected in this study design.

I would also like to call attention to several other issues:

Lack of correction for multiple comparisons. The study conducts within-group and between-group tests across multiple metrics and timepoints without any adjustment for Type I error.

Insufficient data transparency. While the authors report summary statistics, reliance on summary statistics alone prevents readers and reviewers from evaluating the validity of the non-parametric analyses. Please provide the underlying individual-level data.

Incomplete legends and labeling. Several tables and figures lack sufficiently detailed legends or labels, making it difficult to interpret the results independently. Reported summary statistics are not clearly labeled, etc. Please ensure that all such materials are fully self-explanatory.

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what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy

Reviewer #2: No

Reviewer #4: No

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[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org

Aging in rural communities: Engagement in indoor leisure activities and older adult health

PONE-D-24-46685R3

Dear Dr. Chiang,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Bifeng Zhu

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: