Older Adults’ Perceptions of Health, Quality of Life, and Access to Health Promotion Initiatives for Active Aging: A Qualitative Approach

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The introduction establishes the demographic context well (e.g., aging in Brazil, data from WHO and IBGE) and the importance of physical activity for active aging. However, it could be strengthened by including more recent references on inequalities in access to health promotion programs in Latin American contexts (e.g., studies on the impact of the COVID-19 pandemic on older adults in Brazil, as in Oliveira et al., 2022, cited in references). Additionally, the critical qualitative approach is briefly mentioned, but key citations on qualitative epistemologies in health are missing (e.g., works by Minayo on qualitative research in Brazil). This would enrich the theoretical framework and avoid a sense of generality.

The qualitative design with focus groups is ideal for capturing subjectivities and perceptions in a small group (n=14), aligned with the exploratory objective. The integration with a randomized clinical trial (NCT06380413) adds robustness to recruitment. I suggest adding an explicit justification for why two focus groups were chosen instead of more, and briefly discussing whether thematic saturation was achieved to reinforce validity.

The methods are well detailed: sampling, focus group guide, transcription, software (MAXQDA), and thematic analysis. However, depth is lacking in aspects such as the role of the moderator, the reflexivity of the researchers, and inclusion/exclusion criteria beyond age and participation in the program. Including a brief section on triangulation would improve reproducibility.

The results are logically organized into themes and subthemes (Table 3), with illustrative quotes and a balance between description and analysis. Table 2 provides useful sociodemographic context. To improve, I suggest adding more cross-quotes between genders or marital status to highlight variations (e.g., how widowed women perceive family barriers differently). This would enrich interpretive depth without altering clarity.

The conclusions align directly with the findings: positive perceptions of health despite comorbidities, socioeconomic barriers, and the need for integrated policies. I recommend linking more explicitly to practical implications (e.g., how to expand programs like Tai Chi), and exposing limitations such as selection bias.

 

The study adds value by exploring qualitative perceptions in an underrepresented Brazilian context, integrating physical activity with social equity. However, themes like socioeconomic barriers are common in the literature; to elevate novelty, it could be compared more with studies in other Low and Middle Income Countries.

The research has great relevance for active aging policies in Brazil and Latin America, aligned with SDGs 3 and 10. It highlights SUS inequalities and the role of university programs, offering actionable insights for health promotion.

The 45 references are pertinent. They cover global and local aspects, but I would suggest adding 2-3 more recent ones on post-pandemic issues to update (2023-2025).

Comments on the Quality of English Language

The English is functional and academic, but there are awkward or redundant phrases (e.g., "body practices" could be "physical practices" for greater precision; "re-presented" seems like a typo for "represented"; inconsistencies like "older adults" vs. "elderly" – I recommend standardizing to "older adults" per WHO). I suggest a professional review for fluency, especially in sections like the discussion, where long sentences could be divided to improve readability.

Author Response

Response to Reviewers - Manuscript [Older Adults’ Perceptions of Health, Quality of Life, and Access to Health Promotion Initiatives for Active Aging: A Qualitative Approach]

Dear Editor and Reviewers,

Thank you for your insightful comments and suggestions regarding our manuscript, "Older Adults’ Perceptions of Health, Quality of Life, and Access to Health Promotion Initiatives for Active Aging: A Qualitative Approach". We appreciate the time and effort you dedicated to reviewing our work.

We have carefully considered all the points raised and have revised the manuscript accordingly. Our point-by-point response to the reviewers’ comments is detailed below. The changes in the manuscript have been highlighted in yellow.

We believe that the manuscript is significantly improved based on your feedback.

Sincerely,

The Authors

 

Reviewer 1

• Comment 1: The introduction establishes the demographic context well (e.g., aging in Brazil, data from WHO and IBGE) and the importance of physical activity for active aging. However, it could be strengthened by including more recent references on inequalities in access to health promotion programs in Latin American contexts (e.g., studies on the impact of the COVID-19 pandemic on older adults in Brazil, as in Oliveira et al., 2022, cited in references). Additionally, the critical qualitative approach is briefly mentioned, but key citations on qualitative epistemologies in health are missing (e.g., works by Minayo on qualitative research in Brazil). This would enrich the theoretical framework and avoid a sense of generality.
• Response: We appreciate the reviewer’s valuable suggestion and have included additional information on inequalities in access to health promotion programs for older adults in Latin America, as well as key references on qualitative research approaches, in the Introduction section as requested.

 

• Comment 2: The qualitative design with focus groups is ideal for capturing subjectivities and perceptions in a small group (n=14), aligned with the exploratory objective. The integration with a randomized clinical trial (NCT06380413) adds robustness to recruitment. I suggest adding an explicit justification for why two focus groups were chosen instead of more, and briefly discussing whether thematic saturation was achieved to reinforce validity.
• Response: We appreciate the reviewer’s valuable suggestion and have made the corresponding revisions in the Methods section, as requested.

 

• Comment 3: The methods are well detailed: sampling, focus group guide, transcription, software (MAXQDA), and thematic analysis. However, depth is lacking in aspects such as the role of the moderator, the reflexivity of the researchers, and inclusion/exclusion criteria beyond age and participation in the program. Including a brief section on triangulation would improve reproducibility.
• Response: We appreciate the reviewer’s valuable suggestion and have included the additional aspects mentioned, as well as added a brief note on triangulation in the Methods section.

 

• Comment 4: The results are logically organized into themes and subthemes (Table 3), with illustrative quotes and a balance between description and analysis. Table 2 provides useful sociodemographic context. To improve, I suggest adding more cross-quotes between genders or marital status to highlight variations (e.g., how widowed women perceive family barriers differently). This would enrich interpretive depth without altering clarity.
• Response: We appreciate the reviewer’s thoughtful suggestion. We carefully considered the possibility of adding more cross-quotes between genders or marital status; however, we believe that the selected quotations already capture the key variations among participants and accurately represent their characteristics. Furthermore, the current analysis highlights the interplay between perceptions and social aspects without overextending the data beyond thematic saturation.

 

• Comment 5: The conclusions align directly with the findings: positive perceptions of health despite comorbidities, socioeconomic barriers, and the need for integrated policies. I recommend linking more explicitly to practical implications (e.g., how to expand programs like Tai Chi), and exposing limitations such as selection bias.
• Response: We appreciate the reviewer’s valuable suggestion and have revised the Final Considerations section to more explicitly discuss the practical implications of expanding health promotion programs, as well as to acknowledge the study’s limitations.

 

• Comment 6: The study adds value by exploring qualitative perceptions in an underrepresented Brazilian context, integrating physical activity with social equity. However, themes like socioeconomic barriers are common in the literature; to elevate novelty, it could be compared more with studies in other Low- and Middle-Income Countries.
• Response: We appreciate the reviewer’s valuable suggestion and have incorporated additional references to further enrich the Discussion section and highlight the novelty of our findings.

 

• Comment 7: The 45 references are pertinent. They cover global and local aspects, but I would suggest adding 2-3 more recent ones on post-pandemic issues to update (2023-2025).
• Response: We appreciate the reviewer’s suggestion and carefully considered the inclusion of additional references. After review, we believe that the studies regarding the effects of the COVID-19 pandemic, published in 2024 and 2025, are sufficiently recent to address post-pandemic issues in the context of our study.

 

• Comment 8: The English is functional and academic, but there are awkward or redundant phrases (e.g., "body practices" could be "physical practices" for greater precision; "re-presented" seems like a typo for "represented"; inconsistencies like "older adults" vs. "elderly" – I recommend standardizing to "older adults" per WHO). I suggest a professional review for fluency, especially in sections like the discussion, where long sentences could be divided to improve readability.
• Response: We appreciate the reviewer’s valuable suggestion and have conducted a thorough linguistic review to improve fluency, standardize terminology, and correct any awkward or redundant phrases.

 

Reviewer 2

• Comment 1: [Abstract] In the methods description, it is important to mention the research setting (was the offer of health promotion services and initiatives made through public or private primary health care services, or were the focus groups conducted at the university?). It should be stated that two focus groups were conducted. Insert the data collection period. Specify the method used for data analysis. The results are described in a very generic way, without indicating the three major themes identified in the analysis.
• Response: We appreciate the reviewer’s valuable suggestion and have revised the abstract to provide more detailed methodological information, including the research setting, number of focus groups, data collection period, and analytical method. We also specified the three major themes identified in the analysis and made the section more direct and concise.

 

• Comment 2: [Keywords] They are coherent with the title and objective, but adjustments are needed to ensure fidelity to the MeSH thesaurus. Replace the term “elderly” with “older adults.” Replace “Social determinations” with “Social Determinants of Health.”
• Response: We appreciate the reviewer’s valuable suggestion and have made the corresponding revisions to the keywords, as requested.

 

• Comment 3: [Introduction] Which references support the statement presented in lines 47–49? Which references support the statement presented in lines 51–53? Which references support the statement presented in lines 60–62?
• Response: We appreciate the reviewer’s comments and have added the appropriate references to support the statements mentioned in the Introduction section, as requested.

 

• Comment 4: [Introduction] Line 86: the word “considering” is used twice.
• Response: We appreciate the reviewer’s observation and have corrected the repetition of the word “considering” in the Introduction section.

 

• Comment 5: [Introduction] The text is too generic; it is necessary to clearly present what is known about this topic in Brazil and to address evidence on “physical activity programs.” The knowledge gap needs to be explicitly stated.
• Response: We appreciate the reviewer’s valuable comment and have strengthened the Introduction by adding references that contextualize physical activity programs in Brazil and contribute to clarifying the knowledge gap addressed in this study.

 

• Comment 6: [Introduction] A more direct dialogue with international public policies (SDGs and WHO’s Healthy Ageing framework) would improve the robustness of the study’s justification.
• Response: We appreciate the reviewer’s valuable suggestion and have revised the Introduction to better align the discussion with international public policies, particularly the SDG and the WHO’s Healthy Ageing framework.

 

• Comment 7: [Methods] It is important to mention the research setting (was the offer of health promotion services and initiatives made through public or private primary health care services, or were the focus groups conducted at the university?). The link with the randomized clinical trial (NCT06380413) is cited, but the qualitative design appears as a “component” without detailing how participants were selected. Was the sample composed only of participants from the experimental group? How were these participants recruited for the randomized clinical trial? Were all eligible individuals invited to participate in the study? What were the reasons for refusal?
• Response: We appreciate the reviewer’s detailed observations and have expanded the Materials and Methods section to clarify these aspects, including a reference to the randomized clinical trial protocol. The study setting is now explicitly described, along with a clearer explanation of the link between the qualitative component and the randomized clinical trial (NCT06380413). Furthermore, we have detailed the inclusion and exclusion criteria for participant recruitment in both the trial and the qualitative component.

 

• Comment 8: [Methods] Where were the focus groups held? Was the focus group guide pre-tested? Was there a moderator in the focus groups? Which author conducted them? What was the moderator’s role during the intervention program in the clinical trial? Please report if there was researcher reflexivity. How were the transcripts made? Who conducted the data analysis?
• Response: We appreciate the reviewer’s valuable suggestions and have updated the Methods section to address the questions regarding the conduct of the focus groups and data analysis, as requested.

 

• Comment 9: [Methods] Include excerpts from participants’ statements for each subcategory.
• Response: We appreciate the reviewer’s suggestion and have revised the Results section accordingly. Each subcategory now includes excerpts from participants’ statements to better illustrate and support the findings.

 

• Comment 10: [Discussion] The references used to discuss the findings need updating. Response: We appreciate the reviewer’s suggestion and have updated the references in the Discussion section to include more recent and relevant studies.

 

• Comment 11: [Discussion] The findings should be discussed in dialogue with international public policies (SDGs and WHO’s Healthy Ageing). The discussion does not sufficiently explore how the results advance beyond previous studies—there is more comparison than innovation.
• Response: We appreciate the reviewer’s valuable suggestion and have revised the Discussion section to better integrate the findings with international public policies (SDGs and WHO’s Healthy Ageing framework) and to emphasize the innovative contributions of our study.

 

• Comment 12: [Discussion] Line 462: insert the primary reference, i.e., the original WHO document. Reference 29: consider replacing it with another. Lines 498–500: the primary WHO reference must be cited.
• Response: We appreciate the reviewer’s suggestion and have updated the references in accordance with the comment, as requested.

 

• Comment 13: [Discussion] Lines 514–520: review the description. SUS has a healthcare network, including primary, secondary, and tertiary care services. Insert reference. Review throughout the text the use of the terms “secondary and tertiary care.”
• Response: We appreciate the reviewer’s suggestion and have added the requested reference and revised the description. The text now highlights that the SUS (Brazilian Unified Health System) is the country’s largest public health policy, operating across primary, secondary, and tertiary care levels. We also clarified that most participants use these services, reporting both positive and negative experiences, which directly influence their perceptions of health.

 

• Comment 14: [Discussion] Line 538: insert reference.
• Response: We appreciate the reviewer’s suggestion and have added a reference to support the statement in the text.

 

• Comment 15: [Conclusions] Insert the limitations of the study.
• Response: We appreciate the reviewer’s suggestion and have added a discussion of the study’s limitations, as requested.

 

• Comment 16: [References] Provide access links for documents 43 and 44. For references of articles originally published in Portuguese, check one by one if there is an English version available. If so, cite the English version.

• Response: We appreciate the reviewer’s suggestion and have added the corresponding access links for the references (currently numbered 49 and 50 after adjustments).

 

Reviewer 3:

• Comment 1: I think this is an interesting paper that warrants publication. My suggestions are minor.  I would suggest that you just say Tai Chi throughout the paper and not Tai Chi Chuan. There is no difference (at least in my understanding) and Tai Chi is much more commonly used.  I am 79 years old and actually do both Tai Chi and quite a bit of walking and like what you are doing and saying.  I would encourage you to also add a bit more discussion about the complementary nature of Tai Chi and walking as part of overall wellness.
• Response: We appreciate the reviewer’s valuable suggestion and have adjusted the terminology to use “Tai Chi” throughout the manuscript. We have also added a brief discussion in the Discussion section on the complementary benefits of Tai Chi and walking for health.

 

Reviewer 4:

• Comment 1: The sample is predominantly female (11 out of 14 participants), which may limit the generalizability of findings, particularly regarding gender-specific perspectives on aging and physical activity. The authors should acknowledge this limitation and discuss how the feminization of aging in Brazil may have influenced the results. Additionally, more detail on the recruitment process and any potential selection bias would be helpful.
• Response: We appreciate the reviewer’s valuable suggestion and have added a discussion of the study’s limitations, including the predominantly female sample and considerations regarding its potential impact on the findings.

 

• Comment 2: While the use of focus groups is appropriate, the manuscript would benefit from a more detailed description of the data analysis process. For example, how were themes finalized? Was any form of member checking or inter-coder reliability used to enhance credibility? A brief discussion of the rigor and trustworthiness of the qualitative analysis would strengthen the methods section.
• Response: We appreciate the reviewer’s valuable suggestion and have added additional information about the data analysis process to further clarify and strengthen the Methods section.

 

• Comment 3: Some themes (e.g., “health” and “quality of life”) are closely intertwined, which is acknowledged by the authors. However, a more nuanced discussion of how these concepts are distinct or overlapping in the participants’ narratives would add depth. Similarly, the theme “Perspectives on health promotion strategies” could be more clearly differentiated from “Engagement with physical activity.”
• Response: We appreciate the reviewer’s valuable suggestion and have added some additional discussion in the Discussion section to further clarify the distinctions and overlaps among the themes, as requested.

 

• Comment 4: The study would benefit from a stronger theoretical foundation, such as the use of the WHO Active Aging Framework or the Social Determinants of Health model, to contextualize the findings. This would help readers understand how the results align with or challenge existing conceptual models.
• Response: We appreciate the reviewer’s valuable suggestion and have made some adjustments in the Discussion section to better contextualize the findings within relevant theoretical frameworks, as requested.

 

• Comment 5: While the conclusion calls for integrated public policies, the recommendations are somewhat general. More specific, actionable suggestions—such as improving information dissemination, reducing bureaucratic barriers in the SUS, or expanding community-based programs—would enhance the practical impact of the study.
• Response: We appreciate the reviewer’s valuable suggestion and have added a paragraph in the Final considerations section to provide further remarks addressing this comment.

 

• Comment 6: The abstract could be more concise and highlight key findings more prominently.
• Response: We appreciate the reviewer’s valuable suggestion and have revised the abstract to make it more concise and to better highlight the key findings of the study.

 

• Comment 7: Table 2 is helpful, but it would be useful to include additional sociodemographic variables (e.g., education, income level) to better contextualize the participants’ backgrounds.
• Response: We appreciate the reviewer’s valuable suggestion. However, these sociodemographic variables were neither collected nor analyzed in the present study.

 

• Comment 8: Some participant quotes are lengthy; consider shortening or focusing on the most impactful excerpts.
• Response: We appreciate the suggestion. While we recognize that some excerpts are relatively lengthy, we have chosen to retain them because they provide essential contextual depth and preserve the participants’ voices, which are central to the qualitative approach. Nonetheless, we have reviewed the quotes to ensure their relevance and readability.

 

• Comment 9: The discussion section effectively links findings to prior research, but could be more critical in addressing contradictions or gaps in the literature.
• Response: We appreciate the reviewer’s valuable suggestion and have added some additional references and reflections in the Discussion section to further address this comment.

Author Response File: Author Response.docx

Reviewer 2 Report

Comments and Suggestions for Authors

The article addresses a highly relevant topic, with strong social impact (the findings have the potential to support health and active aging policies) and scientific contribution. The text is well structured, but it requires adjustments to reach good scientific quality.

Abstract

• In the methods description, it is important to mention the research setting (was the offer of health promotion services and initiatives made through public or private primary health care services, or were the focus groups conducted at the university?).

• It should be stated that two focus groups were conducted.

• Insert the data collection period.

• Specify the method used for data analysis.

• The results are described in a very generic way, without indicating the three major themes identified in the analysis.

Keywords

• They are coherent with the title and objective, but adjustments are needed to ensure fidelity to the MeSH thesaurus.

• Replace the term “elderly” with “older adults.”

• Replace “Social determinations” with “Social Determinants of Health.”

Introduction

• Which references support the statement presented in lines 47–49?

• Which references support the statement presented in lines 51–53?

• Which references support the statement presented in lines 60–62?

• Line 86: the word “considering” is used twice.

• The text is too generic; it is necessary to clearly present what is known about this topic in Brazil and to address evidence on “physical activity programs.”

• The knowledge gap needs to be explicitly stated.

• A more direct dialogue with international public policies (SDGs and WHO’s Healthy Ageing framework) would improve the robustness of the study’s justification.

Methods

• It is important to mention the research setting (was the offer of health promotion services and initiatives made through public or private primary health care services, or were the focus groups conducted at the university?).

• The link with the randomized clinical trial (NCT06380413) is cited, but the qualitative design appears as a “component” without detailing how participants were selected.

• Was the sample composed only of participants from the experimental group? How were these participants recruited for the randomized clinical trial?

• Were all eligible individuals invited to participate in the study? What were the reasons for refusal?

• Where were the focus groups held?

• Was the focus group guide pre-tested?

• Was there a moderator in the focus groups? Which author conducted them? What was the moderator’s role during the intervention program in the clinical trial? Please report if there was researcher reflexivity.

• How were the transcripts made? Who conducted the data analysis?

Results

• Include excerpts from participants’ statements for each subcategory.

Discussion

• The references used to discuss the findings need updating.

• The findings should be discussed in dialogue with international public policies (SDGs and WHO’s Healthy Ageing).

• The discussion does not sufficiently explore how the results advance beyond previous studies—there is more comparison than innovation.

• Line 462: insert the primary reference, i.e., the original WHO document.

• Reference 29: consider replacing it with another.

• Lines 498–500: the primary WHO reference must be cited.

• Lines 514–520: review the description. SUS has a healthcare network, including primary, secondary, and tertiary care services. Insert reference.

• Review throughout the text the use of the terms “secondary and tertiary care.”

• Line 538: insert reference.

• Insert the limitations of the study.

References

• Provide access links for documents 43 and 44.

• For references of articles originally published in Portuguese, check one by one if there is an English version available. If so, cite the English version.

Author Response

Response to Reviewers - Manuscript [Older Adults’ Perceptions of Health, Quality of Life, and Access to Health Promotion Initiatives for Active Aging: A Qualitative Approach]

Dear Editor and Reviewers,

Thank you for your insightful comments and suggestions regarding our manuscript, "Older Adults’ Perceptions of Health, Quality of Life, and Access to Health Promotion Initiatives for Active Aging: A Qualitative Approach". We appreciate the time and effort you dedicated to reviewing our work.

We have carefully considered all the points raised and have revised the manuscript accordingly. Our point-by-point response to the reviewers’ comments is detailed below. The changes in the manuscript have been highlighted in yellow.

We believe that the manuscript is significantly improved based on your feedback.

Sincerely,

The Authors

 

Reviewer 1

• Comment 1: The introduction establishes the demographic context well (e.g., aging in Brazil, data from WHO and IBGE) and the importance of physical activity for active aging. However, it could be strengthened by including more recent references on inequalities in access to health promotion programs in Latin American contexts (e.g., studies on the impact of the COVID-19 pandemic on older adults in Brazil, as in Oliveira et al., 2022, cited in references). Additionally, the critical qualitative approach is briefly mentioned, but key citations on qualitative epistemologies in health are missing (e.g., works by Minayo on qualitative research in Brazil). This would enrich the theoretical framework and avoid a sense of generality.
• Response: We appreciate the reviewer’s valuable suggestion and have included additional information on inequalities in access to health promotion programs for older adults in Latin America, as well as key references on qualitative research approaches, in the Introduction section as requested.

 

• Comment 2: The qualitative design with focus groups is ideal for capturing subjectivities and perceptions in a small group (n=14), aligned with the exploratory objective. The integration with a randomized clinical trial (NCT06380413) adds robustness to recruitment. I suggest adding an explicit justification for why two focus groups were chosen instead of more, and briefly discussing whether thematic saturation was achieved to reinforce validity.
• Response: We appreciate the reviewer’s valuable suggestion and have made the corresponding revisions in the Methods section, as requested.

 

• Comment 3: The methods are well detailed: sampling, focus group guide, transcription, software (MAXQDA), and thematic analysis. However, depth is lacking in aspects such as the role of the moderator, the reflexivity of the researchers, and inclusion/exclusion criteria beyond age and participation in the program. Including a brief section on triangulation would improve reproducibility.
• Response: We appreciate the reviewer’s valuable suggestion and have included the additional aspects mentioned, as well as added a brief note on triangulation in the Methods section.

 

• Comment 4: The results are logically organized into themes and subthemes (Table 3), with illustrative quotes and a balance between description and analysis. Table 2 provides useful sociodemographic context. To improve, I suggest adding more cross-quotes between genders or marital status to highlight variations (e.g., how widowed women perceive family barriers differently). This would enrich interpretive depth without altering clarity.
• Response: We appreciate the reviewer’s thoughtful suggestion. We carefully considered the possibility of adding more cross-quotes between genders or marital status; however, we believe that the selected quotations already capture the key variations among participants and accurately represent their characteristics. Furthermore, the current analysis highlights the interplay between perceptions and social aspects without overextending the data beyond thematic saturation.

 

• Comment 5: The conclusions align directly with the findings: positive perceptions of health despite comorbidities, socioeconomic barriers, and the need for integrated policies. I recommend linking more explicitly to practical implications (e.g., how to expand programs like Tai Chi), and exposing limitations such as selection bias.
• Response: We appreciate the reviewer’s valuable suggestion and have revised the Final Considerations section to more explicitly discuss the practical implications of expanding health promotion programs, as well as to acknowledge the study’s limitations.

 

• Comment 6: The study adds value by exploring qualitative perceptions in an underrepresented Brazilian context, integrating physical activity with social equity. However, themes like socioeconomic barriers are common in the literature; to elevate novelty, it could be compared more with studies in other Low- and Middle-Income Countries.
• Response: We appreciate the reviewer’s valuable suggestion and have incorporated additional references to further enrich the Discussion section and highlight the novelty of our findings.

 

• Comment 7: The 45 references are pertinent. They cover global and local aspects, but I would suggest adding 2-3 more recent ones on post-pandemic issues to update (2023-2025).
• Response: We appreciate the reviewer’s suggestion and carefully considered the inclusion of additional references. After review, we believe that the studies regarding the effects of the COVID-19 pandemic, published in 2024 and 2025, are sufficiently recent to address post-pandemic issues in the context of our study.

 

• Comment 8: The English is functional and academic, but there are awkward or redundant phrases (e.g., "body practices" could be "physical practices" for greater precision; "re-presented" seems like a typo for "represented"; inconsistencies like "older adults" vs. "elderly" – I recommend standardizing to "older adults" per WHO). I suggest a professional review for fluency, especially in sections like the discussion, where long sentences could be divided to improve readability.
• Response: We appreciate the reviewer’s valuable suggestion and have conducted a thorough linguistic review to improve fluency, standardize terminology, and correct any awkward or redundant phrases.

 

Reviewer 2

• Comment 1: [Abstract] In the methods description, it is important to mention the research setting (was the offer of health promotion services and initiatives made through public or private primary health care services, or were the focus groups conducted at the university?). It should be stated that two focus groups were conducted. Insert the data collection period. Specify the method used for data analysis. The results are described in a very generic way, without indicating the three major themes identified in the analysis.
• Response: We appreciate the reviewer’s valuable suggestion and have revised the abstract to provide more detailed methodological information, including the research setting, number of focus groups, data collection period, and analytical method. We also specified the three major themes identified in the analysis and made the section more direct and concise.

 

• Comment 2: [Keywords] They are coherent with the title and objective, but adjustments are needed to ensure fidelity to the MeSH thesaurus. Replace the term “elderly” with “older adults.” Replace “Social determinations” with “Social Determinants of Health.”
• Response: We appreciate the reviewer’s valuable suggestion and have made the corresponding revisions to the keywords, as requested.

 

• Comment 3: [Introduction] Which references support the statement presented in lines 47–49? Which references support the statement presented in lines 51–53? Which references support the statement presented in lines 60–62?
• Response: We appreciate the reviewer’s comments and have added the appropriate references to support the statements mentioned in the Introduction section, as requested.

 

• Comment 4: [Introduction] Line 86: the word “considering” is used twice.
• Response: We appreciate the reviewer’s observation and have corrected the repetition of the word “considering” in the Introduction section.

 

• Comment 5: [Introduction] The text is too generic; it is necessary to clearly present what is known about this topic in Brazil and to address evidence on “physical activity programs.” The knowledge gap needs to be explicitly stated.
• Response: We appreciate the reviewer’s valuable comment and have strengthened the Introduction by adding references that contextualize physical activity programs in Brazil and contribute to clarifying the knowledge gap addressed in this study.

 

• Comment 6: [Introduction] A more direct dialogue with international public policies (SDGs and WHO’s Healthy Ageing framework) would improve the robustness of the study’s justification.
• Response: We appreciate the reviewer’s valuable suggestion and have revised the Introduction to better align the discussion with international public policies, particularly the SDG and the WHO’s Healthy Ageing framework.

 

• Comment 7: [Methods] It is important to mention the research setting (was the offer of health promotion services and initiatives made through public or private primary health care services, or were the focus groups conducted at the university?). The link with the randomized clinical trial (NCT06380413) is cited, but the qualitative design appears as a “component” without detailing how participants were selected. Was the sample composed only of participants from the experimental group? How were these participants recruited for the randomized clinical trial? Were all eligible individuals invited to participate in the study? What were the reasons for refusal?
• Response: We appreciate the reviewer’s detailed observations and have expanded the Materials and Methods section to clarify these aspects, including a reference to the randomized clinical trial protocol. The study setting is now explicitly described, along with a clearer explanation of the link between the qualitative component and the randomized clinical trial (NCT06380413). Furthermore, we have detailed the inclusion and exclusion criteria for participant recruitment in both the trial and the qualitative component.

 

• Comment 8: [Methods] Where were the focus groups held? Was the focus group guide pre-tested? Was there a moderator in the focus groups? Which author conducted them? What was the moderator’s role during the intervention program in the clinical trial? Please report if there was researcher reflexivity. How were the transcripts made? Who conducted the data analysis?
• Response: We appreciate the reviewer’s valuable suggestions and have updated the Methods section to address the questions regarding the conduct of the focus groups and data analysis, as requested.

 

• Comment 9: [Methods] Include excerpts from participants’ statements for each subcategory.
• Response: We appreciate the reviewer’s suggestion and have revised the Results section accordingly. Each subcategory now includes excerpts from participants’ statements to better illustrate and support the findings.

 

• Comment 10: [Discussion] The references used to discuss the findings need updating. Response: We appreciate the reviewer’s suggestion and have updated the references in the Discussion section to include more recent and relevant studies.

 

• Comment 11: [Discussion] The findings should be discussed in dialogue with international public policies (SDGs and WHO’s Healthy Ageing). The discussion does not sufficiently explore how the results advance beyond previous studies—there is more comparison than innovation.
• Response: We appreciate the reviewer’s valuable suggestion and have revised the Discussion section to better integrate the findings with international public policies (SDGs and WHO’s Healthy Ageing framework) and to emphasize the innovative contributions of our study.

 

• Comment 12: [Discussion] Line 462: insert the primary reference, i.e., the original WHO document. Reference 29: consider replacing it with another. Lines 498–500: the primary WHO reference must be cited.
• Response: We appreciate the reviewer’s suggestion and have updated the references in accordance with the comment, as requested.

 

• Comment 13: [Discussion] Lines 514–520: review the description. SUS has a healthcare network, including primary, secondary, and tertiary care services. Insert reference. Review throughout the text the use of the terms “secondary and tertiary care.”
• Response: We appreciate the reviewer’s suggestion and have added the requested reference and revised the description. The text now highlights that the SUS (Brazilian Unified Health System) is the country’s largest public health policy, operating across primary, secondary, and tertiary care levels. We also clarified that most participants use these services, reporting both positive and negative experiences, which directly influence their perceptions of health.

 

• Comment 14: [Discussion] Line 538: insert reference.
• Response: We appreciate the reviewer’s suggestion and have added a reference to support the statement in the text.

 

• Comment 15: [Conclusions] Insert the limitations of the study.
• Response: We appreciate the reviewer’s suggestion and have added a discussion of the study’s limitations, as requested.

 

• Comment 16: [References] Provide access links for documents 43 and 44. For references of articles originally published in Portuguese, check one by one if there is an English version available. If so, cite the English version.

• Response: We appreciate the reviewer’s suggestion and have added the corresponding access links for the references (currently numbered 49 and 50 after adjustments).

 

Reviewer 3:

• Comment 1: I think this is an interesting paper that warrants publication. My suggestions are minor.  I would suggest that you just say Tai Chi throughout the paper and not Tai Chi Chuan. There is no difference (at least in my understanding) and Tai Chi is much more commonly used.  I am 79 years old and actually do both Tai Chi and quite a bit of walking and like what you are doing and saying.  I would encourage you to also add a bit more discussion about the complementary nature of Tai Chi and walking as part of overall wellness.
• Response: We appreciate the reviewer’s valuable suggestion and have adjusted the terminology to use “Tai Chi” throughout the manuscript. We have also added a brief discussion in the Discussion section on the complementary benefits of Tai Chi and walking for health.

 

Reviewer 4:

• Comment 1: The sample is predominantly female (11 out of 14 participants), which may limit the generalizability of findings, particularly regarding gender-specific perspectives on aging and physical activity. The authors should acknowledge this limitation and discuss how the feminization of aging in Brazil may have influenced the results. Additionally, more detail on the recruitment process and any potential selection bias would be helpful.
• Response: We appreciate the reviewer’s valuable suggestion and have added a discussion of the study’s limitations, including the predominantly female sample and considerations regarding its potential impact on the findings.

 

• Comment 2: While the use of focus groups is appropriate, the manuscript would benefit from a more detailed description of the data analysis process. For example, how were themes finalized? Was any form of member checking or inter-coder reliability used to enhance credibility? A brief discussion of the rigor and trustworthiness of the qualitative analysis would strengthen the methods section.
• Response: We appreciate the reviewer’s valuable suggestion and have added additional information about the data analysis process to further clarify and strengthen the Methods section.

 

• Comment 3: Some themes (e.g., “health” and “quality of life”) are closely intertwined, which is acknowledged by the authors. However, a more nuanced discussion of how these concepts are distinct or overlapping in the participants’ narratives would add depth. Similarly, the theme “Perspectives on health promotion strategies” could be more clearly differentiated from “Engagement with physical activity.”
• Response: We appreciate the reviewer’s valuable suggestion and have added some additional discussion in the Discussion section to further clarify the distinctions and overlaps among the themes, as requested.

 

• Comment 4: The study would benefit from a stronger theoretical foundation, such as the use of the WHO Active Aging Framework or the Social Determinants of Health model, to contextualize the findings. This would help readers understand how the results align with or challenge existing conceptual models.
• Response: We appreciate the reviewer’s valuable suggestion and have made some adjustments in the Discussion section to better contextualize the findings within relevant theoretical frameworks, as requested.

 

• Comment 5: While the conclusion calls for integrated public policies, the recommendations are somewhat general. More specific, actionable suggestions—such as improving information dissemination, reducing bureaucratic barriers in the SUS, or expanding community-based programs—would enhance the practical impact of the study.
• Response: We appreciate the reviewer’s valuable suggestion and have added a paragraph in the Final considerations section to provide further remarks addressing this comment.

 

• Comment 6: The abstract could be more concise and highlight key findings more prominently.
• Response: We appreciate the reviewer’s valuable suggestion and have revised the abstract to make it more concise and to better highlight the key findings of the study.

 

• Comment 7: Table 2 is helpful, but it would be useful to include additional sociodemographic variables (e.g., education, income level) to better contextualize the participants’ backgrounds.
• Response: We appreciate the reviewer’s valuable suggestion. However, these sociodemographic variables were neither collected nor analyzed in the present study.

 

• Comment 8: Some participant quotes are lengthy; consider shortening or focusing on the most impactful excerpts.
• Response: We appreciate the suggestion. While we recognize that some excerpts are relatively lengthy, we have chosen to retain them because they provide essential contextual depth and preserve the participants’ voices, which are central to the qualitative approach. Nonetheless, we have reviewed the quotes to ensure their relevance and readability.

 

• Comment 9: The discussion section effectively links findings to prior research, but could be more critical in addressing contradictions or gaps in the literature.
• Response: We appreciate the reviewer’s valuable suggestion and have added some additional references and reflections in the Discussion section to further address this comment.

Reviewer 3 Report

Comments and Suggestions for Authors

I think this is an interesting paper that warrants publication.  My suggestions are minor.  I would suggest that you just say Tai Chi throughout the paper and not Tai Chi Chuan.  There is no difference (at least in my understanding) and Tai Chi is much more commonly used.  I am 79 years old and actually do both Tai Chi and quite a bit of walking and like what you are doing and saying.  I would encourage you to also add a bit more discussion about the complementary nature of Tai Chi and walking as part of overall wellness.

Author Response

Response to Reviewers - Manuscript [Older Adults’ Perceptions of Health, Quality of Life, and Access to Health Promotion Initiatives for Active Aging: A Qualitative Approach]

Dear Editor and Reviewers,

Thank you for your insightful comments and suggestions regarding our manuscript, "Older Adults’ Perceptions of Health, Quality of Life, and Access to Health Promotion Initiatives for Active Aging: A Qualitative Approach". We appreciate the time and effort you dedicated to reviewing our work.

We have carefully considered all the points raised and have revised the manuscript accordingly. Our point-by-point response to the reviewers’ comments is detailed below. The changes in the manuscript have been highlighted in yellow.

We believe that the manuscript is significantly improved based on your feedback.

Sincerely,

The Authors

 

Reviewer 1

• Comment 1: The introduction establishes the demographic context well (e.g., aging in Brazil, data from WHO and IBGE) and the importance of physical activity for active aging. However, it could be strengthened by including more recent references on inequalities in access to health promotion programs in Latin American contexts (e.g., studies on the impact of the COVID-19 pandemic on older adults in Brazil, as in Oliveira et al., 2022, cited in references). Additionally, the critical qualitative approach is briefly mentioned, but key citations on qualitative epistemologies in health are missing (e.g., works by Minayo on qualitative research in Brazil). This would enrich the theoretical framework and avoid a sense of generality.
• Response: We appreciate the reviewer’s valuable suggestion and have included additional information on inequalities in access to health promotion programs for older adults in Latin America, as well as key references on qualitative research approaches, in the Introduction section as requested.

 

• Comment 2: The qualitative design with focus groups is ideal for capturing subjectivities and perceptions in a small group (n=14), aligned with the exploratory objective. The integration with a randomized clinical trial (NCT06380413) adds robustness to recruitment. I suggest adding an explicit justification for why two focus groups were chosen instead of more, and briefly discussing whether thematic saturation was achieved to reinforce validity.
• Response: We appreciate the reviewer’s valuable suggestion and have made the corresponding revisions in the Methods section, as requested.

 

• Comment 3: The methods are well detailed: sampling, focus group guide, transcription, software (MAXQDA), and thematic analysis. However, depth is lacking in aspects such as the role of the moderator, the reflexivity of the researchers, and inclusion/exclusion criteria beyond age and participation in the program. Including a brief section on triangulation would improve reproducibility.
• Response: We appreciate the reviewer’s valuable suggestion and have included the additional aspects mentioned, as well as added a brief note on triangulation in the Methods section.

 

• Comment 4: The results are logically organized into themes and subthemes (Table 3), with illustrative quotes and a balance between description and analysis. Table 2 provides useful sociodemographic context. To improve, I suggest adding more cross-quotes between genders or marital status to highlight variations (e.g., how widowed women perceive family barriers differently). This would enrich interpretive depth without altering clarity.
• Response: We appreciate the reviewer’s thoughtful suggestion. We carefully considered the possibility of adding more cross-quotes between genders or marital status; however, we believe that the selected quotations already capture the key variations among participants and accurately represent their characteristics. Furthermore, the current analysis highlights the interplay between perceptions and social aspects without overextending the data beyond thematic saturation.

 

• Comment 5: The conclusions align directly with the findings: positive perceptions of health despite comorbidities, socioeconomic barriers, and the need for integrated policies. I recommend linking more explicitly to practical implications (e.g., how to expand programs like Tai Chi), and exposing limitations such as selection bias.
• Response: We appreciate the reviewer’s valuable suggestion and have revised the Final Considerations section to more explicitly discuss the practical implications of expanding health promotion programs, as well as to acknowledge the study’s limitations.

 

• Comment 6: The study adds value by exploring qualitative perceptions in an underrepresented Brazilian context, integrating physical activity with social equity. However, themes like socioeconomic barriers are common in the literature; to elevate novelty, it could be compared more with studies in other Low- and Middle-Income Countries.
• Response: We appreciate the reviewer’s valuable suggestion and have incorporated additional references to further enrich the Discussion section and highlight the novelty of our findings.

 

• Comment 7: The 45 references are pertinent. They cover global and local aspects, but I would suggest adding 2-3 more recent ones on post-pandemic issues to update (2023-2025).
• Response: We appreciate the reviewer’s suggestion and carefully considered the inclusion of additional references. After review, we believe that the studies regarding the effects of the COVID-19 pandemic, published in 2024 and 2025, are sufficiently recent to address post-pandemic issues in the context of our study.

 

• Comment 8: The English is functional and academic, but there are awkward or redundant phrases (e.g., "body practices" could be "physical practices" for greater precision; "re-presented" seems like a typo for "represented"; inconsistencies like "older adults" vs. "elderly" – I recommend standardizing to "older adults" per WHO). I suggest a professional review for fluency, especially in sections like the discussion, where long sentences could be divided to improve readability.
• Response: We appreciate the reviewer’s valuable suggestion and have conducted a thorough linguistic review to improve fluency, standardize terminology, and correct any awkward or redundant phrases.

 

Reviewer 2

• Comment 1: [Abstract] In the methods description, it is important to mention the research setting (was the offer of health promotion services and initiatives made through public or private primary health care services, or were the focus groups conducted at the university?). It should be stated that two focus groups were conducted. Insert the data collection period. Specify the method used for data analysis. The results are described in a very generic way, without indicating the three major themes identified in the analysis.
• Response: We appreciate the reviewer’s valuable suggestion and have revised the abstract to provide more detailed methodological information, including the research setting, number of focus groups, data collection period, and analytical method. We also specified the three major themes identified in the analysis and made the section more direct and concise.

 

• Comment 2: [Keywords] They are coherent with the title and objective, but adjustments are needed to ensure fidelity to the MeSH thesaurus. Replace the term “elderly” with “older adults.” Replace “Social determinations” with “Social Determinants of Health.”
• Response: We appreciate the reviewer’s valuable suggestion and have made the corresponding revisions to the keywords, as requested.

 

• Comment 3: [Introduction] Which references support the statement presented in lines 47–49? Which references support the statement presented in lines 51–53? Which references support the statement presented in lines 60–62?
• Response: We appreciate the reviewer’s comments and have added the appropriate references to support the statements mentioned in the Introduction section, as requested.

 

• Comment 4: [Introduction] Line 86: the word “considering” is used twice.
• Response: We appreciate the reviewer’s observation and have corrected the repetition of the word “considering” in the Introduction section.

 

• Comment 5: [Introduction] The text is too generic; it is necessary to clearly present what is known about this topic in Brazil and to address evidence on “physical activity programs.” The knowledge gap needs to be explicitly stated.
• Response: We appreciate the reviewer’s valuable comment and have strengthened the Introduction by adding references that contextualize physical activity programs in Brazil and contribute to clarifying the knowledge gap addressed in this study.

 

• Comment 6: [Introduction] A more direct dialogue with international public policies (SDGs and WHO’s Healthy Ageing framework) would improve the robustness of the study’s justification.
• Response: We appreciate the reviewer’s valuable suggestion and have revised the Introduction to better align the discussion with international public policies, particularly the SDG and the WHO’s Healthy Ageing framework.

 

• Comment 7: [Methods] It is important to mention the research setting (was the offer of health promotion services and initiatives made through public or private primary health care services, or were the focus groups conducted at the university?). The link with the randomized clinical trial (NCT06380413) is cited, but the qualitative design appears as a “component” without detailing how participants were selected. Was the sample composed only of participants from the experimental group? How were these participants recruited for the randomized clinical trial? Were all eligible individuals invited to participate in the study? What were the reasons for refusal?
• Response: We appreciate the reviewer’s detailed observations and have expanded the Materials and Methods section to clarify these aspects, including a reference to the randomized clinical trial protocol. The study setting is now explicitly described, along with a clearer explanation of the link between the qualitative component and the randomized clinical trial (NCT06380413). Furthermore, we have detailed the inclusion and exclusion criteria for participant recruitment in both the trial and the qualitative component.

 

• Comment 8: [Methods] Where were the focus groups held? Was the focus group guide pre-tested? Was there a moderator in the focus groups? Which author conducted them? What was the moderator’s role during the intervention program in the clinical trial? Please report if there was researcher reflexivity. How were the transcripts made? Who conducted the data analysis?
• Response: We appreciate the reviewer’s valuable suggestions and have updated the Methods section to address the questions regarding the conduct of the focus groups and data analysis, as requested.

 

• Comment 9: [Methods] Include excerpts from participants’ statements for each subcategory.
• Response: We appreciate the reviewer’s suggestion and have revised the Results section accordingly. Each subcategory now includes excerpts from participants’ statements to better illustrate and support the findings.

 

• Comment 10: [Discussion] The references used to discuss the findings need updating. Response: We appreciate the reviewer’s suggestion and have updated the references in the Discussion section to include more recent and relevant studies.

 

• Comment 11: [Discussion] The findings should be discussed in dialogue with international public policies (SDGs and WHO’s Healthy Ageing). The discussion does not sufficiently explore how the results advance beyond previous studies—there is more comparison than innovation.
• Response: We appreciate the reviewer’s valuable suggestion and have revised the Discussion section to better integrate the findings with international public policies (SDGs and WHO’s Healthy Ageing framework) and to emphasize the innovative contributions of our study.

 

• Comment 12: [Discussion] Line 462: insert the primary reference, i.e., the original WHO document. Reference 29: consider replacing it with another. Lines 498–500: the primary WHO reference must be cited.
• Response: We appreciate the reviewer’s suggestion and have updated the references in accordance with the comment, as requested.

 

• Comment 13: [Discussion] Lines 514–520: review the description. SUS has a healthcare network, including primary, secondary, and tertiary care services. Insert reference. Review throughout the text the use of the terms “secondary and tertiary care.”
• Response: We appreciate the reviewer’s suggestion and have added the requested reference and revised the description. The text now highlights that the SUS (Brazilian Unified Health System) is the country’s largest public health policy, operating across primary, secondary, and tertiary care levels. We also clarified that most participants use these services, reporting both positive and negative experiences, which directly influence their perceptions of health.

 

• Comment 14: [Discussion] Line 538: insert reference.
• Response: We appreciate the reviewer’s suggestion and have added a reference to support the statement in the text.

 

• Comment 15: [Conclusions] Insert the limitations of the study.
• Response: We appreciate the reviewer’s suggestion and have added a discussion of the study’s limitations, as requested.

 

• Comment 16: [References] Provide access links for documents 43 and 44. For references of articles originally published in Portuguese, check one by one if there is an English version available. If so, cite the English version.

• Response: We appreciate the reviewer’s suggestion and have added the corresponding access links for the references (currently numbered 49 and 50 after adjustments).

 

Reviewer 3:

• Comment 1: I think this is an interesting paper that warrants publication. My suggestions are minor.  I would suggest that you just say Tai Chi throughout the paper and not Tai Chi Chuan. There is no difference (at least in my understanding) and Tai Chi is much more commonly used.  I am 79 years old and actually do both Tai Chi and quite a bit of walking and like what you are doing and saying.  I would encourage you to also add a bit more discussion about the complementary nature of Tai Chi and walking as part of overall wellness.
• Response: We appreciate the reviewer’s valuable suggestion and have adjusted the terminology to use “Tai Chi” throughout the manuscript. We have also added a brief discussion in the Discussion section on the complementary benefits of Tai Chi and walking for health.

 

Reviewer 4:

• Comment 1: The sample is predominantly female (11 out of 14 participants), which may limit the generalizability of findings, particularly regarding gender-specific perspectives on aging and physical activity. The authors should acknowledge this limitation and discuss how the feminization of aging in Brazil may have influenced the results. Additionally, more detail on the recruitment process and any potential selection bias would be helpful.
• Response: We appreciate the reviewer’s valuable suggestion and have added a discussion of the study’s limitations, including the predominantly female sample and considerations regarding its potential impact on the findings.

 

• Comment 2: While the use of focus groups is appropriate, the manuscript would benefit from a more detailed description of the data analysis process. For example, how were themes finalized? Was any form of member checking or inter-coder reliability used to enhance credibility? A brief discussion of the rigor and trustworthiness of the qualitative analysis would strengthen the methods section.
• Response: We appreciate the reviewer’s valuable suggestion and have added additional information about the data analysis process to further clarify and strengthen the Methods section.

 

• Comment 3: Some themes (e.g., “health” and “quality of life”) are closely intertwined, which is acknowledged by the authors. However, a more nuanced discussion of how these concepts are distinct or overlapping in the participants’ narratives would add depth. Similarly, the theme “Perspectives on health promotion strategies” could be more clearly differentiated from “Engagement with physical activity.”
• Response: We appreciate the reviewer’s valuable suggestion and have added some additional discussion in the Discussion section to further clarify the distinctions and overlaps among the themes, as requested.

 

• Comment 4: The study would benefit from a stronger theoretical foundation, such as the use of the WHO Active Aging Framework or the Social Determinants of Health model, to contextualize the findings. This would help readers understand how the results align with or challenge existing conceptual models.
• Response: We appreciate the reviewer’s valuable suggestion and have made some adjustments in the Discussion section to better contextualize the findings within relevant theoretical frameworks, as requested.

 

• Comment 5: While the conclusion calls for integrated public policies, the recommendations are somewhat general. More specific, actionable suggestions—such as improving information dissemination, reducing bureaucratic barriers in the SUS, or expanding community-based programs—would enhance the practical impact of the study.
• Response: We appreciate the reviewer’s valuable suggestion and have added a paragraph in the Final considerations section to provide further remarks addressing this comment.

 

• Comment 6: The abstract could be more concise and highlight key findings more prominently.
• Response: We appreciate the reviewer’s valuable suggestion and have revised the abstract to make it more concise and to better highlight the key findings of the study.

 

• Comment 7: Table 2 is helpful, but it would be useful to include additional sociodemographic variables (e.g., education, income level) to better contextualize the participants’ backgrounds.
• Response: We appreciate the reviewer’s valuable suggestion. However, these sociodemographic variables were neither collected nor analyzed in the present study.

 

• Comment 8: Some participant quotes are lengthy; consider shortening or focusing on the most impactful excerpts.
• Response: We appreciate the suggestion. While we recognize that some excerpts are relatively lengthy, we have chosen to retain them because they provide essential contextual depth and preserve the participants’ voices, which are central to the qualitative approach. Nonetheless, we have reviewed the quotes to ensure their relevance and readability.

 

• Comment 9: The discussion section effectively links findings to prior research, but could be more critical in addressing contradictions or gaps in the literature.
• Response: We appreciate the reviewer’s valuable suggestion and have added some additional references and reflections in the Discussion section to further address this comment.

Reviewer 4 Report

Comments and Suggestions for Authors

General Comments

This qualitative study explores older adults’ perceptions of health, quality of life, and access to health promotion initiatives, with a focus on participation in a structured physical activity program. The topic is highly relevant, particularly in the context of global population aging and health inequities. The manuscript is well-structured, methodologically sound, and clearly written. The use of thematic analysis is appropriate, and the findings are supported by rich qualitative data. However, there are several areas where the manuscript could be strengthened to enhance its contribution to the literature.

Major Comments

1. Sample Representation and Diversity:

   The sample is predominantly female (11 out of 14 participants), which may limit the generalizability of findings, particularly regarding gender-specific perspectives on aging and physical activity. The authors should acknowledge this limitation and discuss how the feminization of aging in Brazil may have influenced the results. Additionally, more detail on the recruitment process and any potential selection bias would be helpful.

 

2. Methodological Transparency

   While the use of focus groups is appropriate, the manuscript would benefit from a more detailed description of the data analysis process. For example, how were themes finalized? Was any form of member checking or inter-coder reliability used to enhance credibility? A brief discussion of the rigor and trustworthiness of the qualitative analysis would strengthen the methods section.

3. Thematic Overlap and Depth

   Some themes (e.g., “health” and “quality of life”) are closely intertwined, which is acknowledged by the authors. However, a more nuanced discussion of how these concepts are distinct or overlapping in the participants’ narratives would add depth. Similarly, the theme “Perspectives on health promotion strategies” could be more clearly differentiated from “Engagement with physical activity.”

4. Theoretical Framing

   The study would benefit from a stronger theoretical foundation, such as the use of the WHO Active Aging Framework or the Social Determinants of Health model, to contextualize the findings. This would help readers understand how the results align with or challenge existing conceptual models.

5. Policy Implications

   While the conclusion calls for integrated public policies, the recommendations are somewhat general. More specific, actionable suggestions—such as improving information dissemination, reducing bureaucratic barriers in the SUS, or expanding community-based programs—would enhance the practical impact of the study.

Minor Comments

- The abstract could be more concise and highlight key findings more prominently.

- Table 2 is helpful, but it would be useful to include additional sociodemographic variables (e.g., education, income level) to better contextualize the participants’ backgrounds.

- Some participant quotes are lengthy; consider shortening or focusing on the most impactful excerpts.

- The discussion section effectively links findings to prior research, but could be more critical in addressing contradictions or gaps in the literature.

Author Response

Response to Reviewers - Manuscript [Older Adults’ Perceptions of Health, Quality of Life, and Access to Health Promotion Initiatives for Active Aging: A Qualitative Approach]

Dear Editor and Reviewers,

Thank you for your insightful comments and suggestions regarding our manuscript, "Older Adults’ Perceptions of Health, Quality of Life, and Access to Health Promotion Initiatives for Active Aging: A Qualitative Approach". We appreciate the time and effort you dedicated to reviewing our work.

We have carefully considered all the points raised and have revised the manuscript accordingly. Our point-by-point response to the reviewers’ comments is detailed below. The changes in the manuscript have been highlighted in yellow.

We believe that the manuscript is significantly improved based on your feedback.

Sincerely,

The Authors

 

Reviewer 1

• Comment 1: The introduction establishes the demographic context well (e.g., aging in Brazil, data from WHO and IBGE) and the importance of physical activity for active aging. However, it could be strengthened by including more recent references on inequalities in access to health promotion programs in Latin American contexts (e.g., studies on the impact of the COVID-19 pandemic on older adults in Brazil, as in Oliveira et al., 2022, cited in references). Additionally, the critical qualitative approach is briefly mentioned, but key citations on qualitative epistemologies in health are missing (e.g., works by Minayo on qualitative research in Brazil). This would enrich the theoretical framework and avoid a sense of generality.
• Response: We appreciate the reviewer’s valuable suggestion and have included additional information on inequalities in access to health promotion programs for older adults in Latin America, as well as key references on qualitative research approaches, in the Introduction section as requested.

 

• Comment 2: The qualitative design with focus groups is ideal for capturing subjectivities and perceptions in a small group (n=14), aligned with the exploratory objective. The integration with a randomized clinical trial (NCT06380413) adds robustness to recruitment. I suggest adding an explicit justification for why two focus groups were chosen instead of more, and briefly discussing whether thematic saturation was achieved to reinforce validity.
• Response: We appreciate the reviewer’s valuable suggestion and have made the corresponding revisions in the Methods section, as requested.

 

• Comment 3: The methods are well detailed: sampling, focus group guide, transcription, software (MAXQDA), and thematic analysis. However, depth is lacking in aspects such as the role of the moderator, the reflexivity of the researchers, and inclusion/exclusion criteria beyond age and participation in the program. Including a brief section on triangulation would improve reproducibility.
• Response: We appreciate the reviewer’s valuable suggestion and have included the additional aspects mentioned, as well as added a brief note on triangulation in the Methods section.

 

• Comment 4: The results are logically organized into themes and subthemes (Table 3), with illustrative quotes and a balance between description and analysis. Table 2 provides useful sociodemographic context. To improve, I suggest adding more cross-quotes between genders or marital status to highlight variations (e.g., how widowed women perceive family barriers differently). This would enrich interpretive depth without altering clarity.
• Response: We appreciate the reviewer’s thoughtful suggestion. We carefully considered the possibility of adding more cross-quotes between genders or marital status; however, we believe that the selected quotations already capture the key variations among participants and accurately represent their characteristics. Furthermore, the current analysis highlights the interplay between perceptions and social aspects without overextending the data beyond thematic saturation.

 

• Comment 5: The conclusions align directly with the findings: positive perceptions of health despite comorbidities, socioeconomic barriers, and the need for integrated policies. I recommend linking more explicitly to practical implications (e.g., how to expand programs like Tai Chi), and exposing limitations such as selection bias.
• Response: We appreciate the reviewer’s valuable suggestion and have revised the Final Considerations section to more explicitly discuss the practical implications of expanding health promotion programs, as well as to acknowledge the study’s limitations.

 

• Comment 6: The study adds value by exploring qualitative perceptions in an underrepresented Brazilian context, integrating physical activity with social equity. However, themes like socioeconomic barriers are common in the literature; to elevate novelty, it could be compared more with studies in other Low- and Middle-Income Countries.
• Response: We appreciate the reviewer’s valuable suggestion and have incorporated additional references to further enrich the Discussion section and highlight the novelty of our findings.

 

• Comment 7: The 45 references are pertinent. They cover global and local aspects, but I would suggest adding 2-3 more recent ones on post-pandemic issues to update (2023-2025).
• Response: We appreciate the reviewer’s suggestion and carefully considered the inclusion of additional references. After review, we believe that the studies regarding the effects of the COVID-19 pandemic, published in 2024 and 2025, are sufficiently recent to address post-pandemic issues in the context of our study.

 

• Comment 8: The English is functional and academic, but there are awkward or redundant phrases (e.g., "body practices" could be "physical practices" for greater precision; "re-presented" seems like a typo for "represented"; inconsistencies like "older adults" vs. "elderly" – I recommend standardizing to "older adults" per WHO). I suggest a professional review for fluency, especially in sections like the discussion, where long sentences could be divided to improve readability.
• Response: We appreciate the reviewer’s valuable suggestion and have conducted a thorough linguistic review to improve fluency, standardize terminology, and correct any awkward or redundant phrases.

 

Reviewer 2

• Comment 1: [Abstract] In the methods description, it is important to mention the research setting (was the offer of health promotion services and initiatives made through public or private primary health care services, or were the focus groups conducted at the university?). It should be stated that two focus groups were conducted. Insert the data collection period. Specify the method used for data analysis. The results are described in a very generic way, without indicating the three major themes identified in the analysis.
• Response: We appreciate the reviewer’s valuable suggestion and have revised the abstract to provide more detailed methodological information, including the research setting, number of focus groups, data collection period, and analytical method. We also specified the three major themes identified in the analysis and made the section more direct and concise.

 

• Comment 2: [Keywords] They are coherent with the title and objective, but adjustments are needed to ensure fidelity to the MeSH thesaurus. Replace the term “elderly” with “older adults.” Replace “Social determinations” with “Social Determinants of Health.”
• Response: We appreciate the reviewer’s valuable suggestion and have made the corresponding revisions to the keywords, as requested.

 

• Comment 3: [Introduction] Which references support the statement presented in lines 47–49? Which references support the statement presented in lines 51–53? Which references support the statement presented in lines 60–62?
• Response: We appreciate the reviewer’s comments and have added the appropriate references to support the statements mentioned in the Introduction section, as requested.

 

• Comment 4: [Introduction] Line 86: the word “considering” is used twice.
• Response: We appreciate the reviewer’s observation and have corrected the repetition of the word “considering” in the Introduction section.

 

• Comment 5: [Introduction] The text is too generic; it is necessary to clearly present what is known about this topic in Brazil and to address evidence on “physical activity programs.” The knowledge gap needs to be explicitly stated.
• Response: We appreciate the reviewer’s valuable comment and have strengthened the Introduction by adding references that contextualize physical activity programs in Brazil and contribute to clarifying the knowledge gap addressed in this study.

 

• Comment 6: [Introduction] A more direct dialogue with international public policies (SDGs and WHO’s Healthy Ageing framework) would improve the robustness of the study’s justification.
• Response: We appreciate the reviewer’s valuable suggestion and have revised the Introduction to better align the discussion with international public policies, particularly the SDG and the WHO’s Healthy Ageing framework.

 

• Comment 7: [Methods] It is important to mention the research setting (was the offer of health promotion services and initiatives made through public or private primary health care services, or were the focus groups conducted at the university?). The link with the randomized clinical trial (NCT06380413) is cited, but the qualitative design appears as a “component” without detailing how participants were selected. Was the sample composed only of participants from the experimental group? How were these participants recruited for the randomized clinical trial? Were all eligible individuals invited to participate in the study? What were the reasons for refusal?
• Response: We appreciate the reviewer’s detailed observations and have expanded the Materials and Methods section to clarify these aspects, including a reference to the randomized clinical trial protocol. The study setting is now explicitly described, along with a clearer explanation of the link between the qualitative component and the randomized clinical trial (NCT06380413). Furthermore, we have detailed the inclusion and exclusion criteria for participant recruitment in both the trial and the qualitative component.

 

• Comment 8: [Methods] Where were the focus groups held? Was the focus group guide pre-tested? Was there a moderator in the focus groups? Which author conducted them? What was the moderator’s role during the intervention program in the clinical trial? Please report if there was researcher reflexivity. How were the transcripts made? Who conducted the data analysis?
• Response: We appreciate the reviewer’s valuable suggestions and have updated the Methods section to address the questions regarding the conduct of the focus groups and data analysis, as requested.

 

• Comment 9: [Methods] Include excerpts from participants’ statements for each subcategory.
• Response: We appreciate the reviewer’s suggestion and have revised the Results section accordingly. Each subcategory now includes excerpts from participants’ statements to better illustrate and support the findings.

 

• Comment 10: [Discussion] The references used to discuss the findings need updating. Response: We appreciate the reviewer’s suggestion and have updated the references in the Discussion section to include more recent and relevant studies.

 

• Comment 11: [Discussion] The findings should be discussed in dialogue with international public policies (SDGs and WHO’s Healthy Ageing). The discussion does not sufficiently explore how the results advance beyond previous studies—there is more comparison than innovation.
• Response: We appreciate the reviewer’s valuable suggestion and have revised the Discussion section to better integrate the findings with international public policies (SDGs and WHO’s Healthy Ageing framework) and to emphasize the innovative contributions of our study.

 

• Comment 12: [Discussion] Line 462: insert the primary reference, i.e., the original WHO document. Reference 29: consider replacing it with another. Lines 498–500: the primary WHO reference must be cited.
• Response: We appreciate the reviewer’s suggestion and have updated the references in accordance with the comment, as requested.

 

• Comment 13: [Discussion] Lines 514–520: review the description. SUS has a healthcare network, including primary, secondary, and tertiary care services. Insert reference. Review throughout the text the use of the terms “secondary and tertiary care.”
• Response: We appreciate the reviewer’s suggestion and have added the requested reference and revised the description. The text now highlights that the SUS (Brazilian Unified Health System) is the country’s largest public health policy, operating across primary, secondary, and tertiary care levels. We also clarified that most participants use these services, reporting both positive and negative experiences, which directly influence their perceptions of health.

 

• Comment 14: [Discussion] Line 538: insert reference.
• Response: We appreciate the reviewer’s suggestion and have added a reference to support the statement in the text.

 

• Comment 15: [Conclusions] Insert the limitations of the study.
• Response: We appreciate the reviewer’s suggestion and have added a discussion of the study’s limitations, as requested.

 

• Comment 16: [References] Provide access links for documents 43 and 44. For references of articles originally published in Portuguese, check one by one if there is an English version available. If so, cite the English version.

• Response: We appreciate the reviewer’s suggestion and have added the corresponding access links for the references (currently numbered 49 and 50 after adjustments).

 

Reviewer 3:

• Comment 1: I think this is an interesting paper that warrants publication. My suggestions are minor.  I would suggest that you just say Tai Chi throughout the paper and not Tai Chi Chuan. There is no difference (at least in my understanding) and Tai Chi is much more commonly used.  I am 79 years old and actually do both Tai Chi and quite a bit of walking and like what you are doing and saying.  I would encourage you to also add a bit more discussion about the complementary nature of Tai Chi and walking as part of overall wellness.
• Response: We appreciate the reviewer’s valuable suggestion and have adjusted the terminology to use “Tai Chi” throughout the manuscript. We have also added a brief discussion in the Discussion section on the complementary benefits of Tai Chi and walking for health.

 

Reviewer 4:

• Comment 1: The sample is predominantly female (11 out of 14 participants), which may limit the generalizability of findings, particularly regarding gender-specific perspectives on aging and physical activity. The authors should acknowledge this limitation and discuss how the feminization of aging in Brazil may have influenced the results. Additionally, more detail on the recruitment process and any potential selection bias would be helpful.
• Response: We appreciate the reviewer’s valuable suggestion and have added a discussion of the study’s limitations, including the predominantly female sample and considerations regarding its potential impact on the findings.

 

• Comment 2: While the use of focus groups is appropriate, the manuscript would benefit from a more detailed description of the data analysis process. For example, how were themes finalized? Was any form of member checking or inter-coder reliability used to enhance credibility? A brief discussion of the rigor and trustworthiness of the qualitative analysis would strengthen the methods section.
• Response: We appreciate the reviewer’s valuable suggestion and have added additional information about the data analysis process to further clarify and strengthen the Methods section.

 

• Comment 3: Some themes (e.g., “health” and “quality of life”) are closely intertwined, which is acknowledged by the authors. However, a more nuanced discussion of how these concepts are distinct or overlapping in the participants’ narratives would add depth. Similarly, the theme “Perspectives on health promotion strategies” could be more clearly differentiated from “Engagement with physical activity.”
• Response: We appreciate the reviewer’s valuable suggestion and have added some additional discussion in the Discussion section to further clarify the distinctions and overlaps among the themes, as requested.

 

• Comment 4: The study would benefit from a stronger theoretical foundation, such as the use of the WHO Active Aging Framework or the Social Determinants of Health model, to contextualize the findings. This would help readers understand how the results align with or challenge existing conceptual models.
• Response: We appreciate the reviewer’s valuable suggestion and have made some adjustments in the Discussion section to better contextualize the findings within relevant theoretical frameworks, as requested.

 

• Comment 5: While the conclusion calls for integrated public policies, the recommendations are somewhat general. More specific, actionable suggestions—such as improving information dissemination, reducing bureaucratic barriers in the SUS, or expanding community-based programs—would enhance the practical impact of the study.
• Response: We appreciate the reviewer’s valuable suggestion and have added a paragraph in the Final considerations section to provide further remarks addressing this comment.

 

• Comment 6: The abstract could be more concise and highlight key findings more prominently.
• Response: We appreciate the reviewer’s valuable suggestion and have revised the abstract to make it more concise and to better highlight the key findings of the study.

 

• Comment 7: Table 2 is helpful, but it would be useful to include additional sociodemographic variables (e.g., education, income level) to better contextualize the participants’ backgrounds.
• Response: We appreciate the reviewer’s valuable suggestion. However, these sociodemographic variables were neither collected nor analyzed in the present study.

 

• Comment 8: Some participant quotes are lengthy; consider shortening or focusing on the most impactful excerpts.
• Response: We appreciate the suggestion. While we recognize that some excerpts are relatively lengthy, we have chosen to retain them because they provide essential contextual depth and preserve the participants’ voices, which are central to the qualitative approach. Nonetheless, we have reviewed the quotes to ensure their relevance and readability.

 

• Comment 9: The discussion section effectively links findings to prior research, but could be more critical in addressing contradictions or gaps in the literature.
• Response: We appreciate the reviewer’s valuable suggestion and have added some additional references and reflections in the Discussion section to further address this comment.

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

Dear authors, the modifications made were appropriate to the suggestions indicated in my first review. Congratulations on the research!