-->PONE-D-25-63871-->-->Exploring the perceived impact of physical activity on physical and mental health among individuals with long COVID: A qualitative interview inquiry-->-->PLOS One

Dear Dr. Sirotiak,

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-->Comments to the Author

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

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. -->

Reviewer #1: Yes

Reviewer #2: Yes

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

Reviewer #1: N/A

Reviewer #2: Yes

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

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.-->

Reviewer #1: No

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: No

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-->5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)-->

Reviewer #1: Clinically relevant qualitative interview inquiry exploring the perceived impact of physical activity on physical and mental health among individuals with long COVID. Clinically relevant qualitative interview inquiry exploring the perceived impact of physical activity on physical and mental health among individuals with long COVID.

Reviewer #2: Dear Editor and authors,

Thank you very much for granting me the opportunity to review this manuscript entitled “Exploring the perceived impact of physical activity on physical and mental health among individuals with long COVID: A qualitative interview inquiry”. The study uses a qualitative interview approach to explore the perceived effects of physical activity on the physical and mental health of people with long COVID, and the topic has important practical significance. However, the manuscript still has some shortcomings. Below I will list the issues point by point and provide specific suggestions for revision based on the content of the paper.

1.Lack of objectivity in physical activity measurement

Basis: In the Methods section (lines 136–137), a single question was used for participants to self‑report “the number of minutes per week they typically engage in moderate or vigorous aerobic physical activity”, with rather coarse categories (0 minutes, 1–<150 minutes, 150–<300 minutes, ≥300 minutes). Is there any reference to support this classification? Compared with recognised physical activity assessment tools (e.g., the International Physical Activity Questionnaire, IPAQ), this approach lacks detail and validation.

Suggestion: Clearly state in the limitations section that this study did not use objective measurement devices (e.g., accelerometers) or a standardised questionnaire to assess physical activity, and that self‑report may be subject to recall bias and social desirability bias.

2.Incomplete description of ethics review details

Basis: In the Methods section (lines 104–106), it is stated that “the Iowa State University IRB deemed this project exempt and did not require formal written or verbal informed consent”, yet participants still read an information sheet and indicated consent by clicking “forward” on the screen. Whether such “click‑to‑consent” is ethically appropriate for a qualitative interview study is open to question.

Suggestion: Add to the ethics statement an explanation of why the IRB considered the project exempt (e.g., minimal risk, anonymised data handling). Also clearly state that, although formal written consent was not required by the IRB, the research team still provided participants with complete study information and obtained their clear informed consent.

3.Insufficient description of the interview guide development process

Basis: The Methods section (lines 127–129) mentions that the interview guide was developed by a physical therapist (ZS) with input from a qualitative methods expert (AO), a physical activity and health expert (AB), and a clinical psychologist (ET). However, it does not indicate whether the guide was pilot‑tested or whether revisions were made based on pilot results.

Suggestion: Add details about the development of the interview guide: Was a pilot interview conducted? If yes, what was the sample size of the pilot? What modifications were made to the guide after the pilot?

4.Inconsistency between the abstract and the main text

Basis: The abstract (lines 52–53) reports that “most participants (64.7%) reported worsening of long COVID symptoms with PA, while 14.7% reported improvement”. Table 2 shows 22 participants (64.7%) reporting worsening and 5 (14.7%) reporting improvement, so these numbers are consistent. The Discussion (line 199) also mentions “64.7% reported worsened health, 14.7% reported improvement”, and line 207‑208 mentions “20.6% reported no effect”. The sum of these percentages is 100%, which is consistent. However, when citing Wright et al. (2022) on lines 207‑208, the statement “28.7% reported no effect” is given without a direct comparison.

Suggestion: Add a direct comparison in the Discussion: the “no effect” proportion in this study was 20.6%, which is lower than the 28.7% reported by Wright et al. Possible reasons (e.g., sample differences, measurement differences) should be discussed.

5.Please use the terms “worsened / improved / no effect” consistently throughout the manuscript, avoiding different expressions for the same meaning.

6.The language of the manuscript needs further checking in places, such as tense and repeated or redundant expressions.

7.In “post‑acute sequalae of COVID‑19”, the word “sequalae” should be “sequelae”. Is this a spelling error? Please check the whole manuscript.

8.Lines 66–68: “Long COVID … affects up to 20% of those affected by COVID‑19 and over 65 million worldwide [1,2]”. Reference [1] was published in 2023, but the cited data may have been updated (e.g., more recent estimates from WHO or other sources). Please consider citing the most up‑to‑date data and literature.

9.The discussion of the “external control of PA” theme (lines 277–298) lacks theoretical support.

Issue: This theme relates to a perceived external control over physical activity, but no relevant psychological theories (e.g., Self‑Determination Theory, perceived control theory) are cited to explain this phenomenon.

Suggestion: Introduce the concept of “autonomy” from Self‑Determination Theory to explain why a sense of external control can be detrimental to the mental health of individuals with long COVID.

Thank you again for the opportunity to review this manuscript. I hope these comments are helpful for improving the paper.

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Reviewer #1: No

Reviewer #2: Yes: Moran Lyu

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Exploring the perceived impact of physical activity on physical and mental health among individuals with long COVID: A qualitative interview inquiry

PONE-D-25-63871R1

Dear Dr. Sirotiak,

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.

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Kind regards,

Wanli Zang, Ph.D.

Guest Editor

PLOS One

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

-->Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.-->

Reviewer #2: All comments have been addressed

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

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. -->

Reviewer #2: Yes

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

Reviewer #2: Yes

**********

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

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.-->

Reviewer #2: Yes

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

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.-->

Reviewer #2: Yes

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-->6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)-->

Reviewer #2: This revision has significantly improved the quality of the manuscript, and all the previously raised issues have been well addressed. I have no further suggestions for revision, as the manuscript in its current form is of high quality.

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-->7. PLOS authors have the option to publish the peer review history of their article (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: Yes: Moran Lyu

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