Construction and Preliminary Validation of a Multidimensional Physical Health Assessment System for Preschool Children in China

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

paper title - Construction and Preliminary Validation of a Comprehensive Physical Health Assessment System for Preschool Children in China

an interesting study, on intial reading was thinking that the paper seems short...

for the positive side, topic is timely and relevant, variable or indicator selections are grounded in both literature and empirical prevalence data from a large regional database with 5,846 participants

AHP application is also sound and clearly presented

adequate sample size for the current study, with CFA also seems robust (with most factor loading ok)

here are some of my concern

- BMI (body morphology) and overweight/obesity (clinical health) are derived from the same  data? elaboration or clarification might be needed

- treating one as continuous and the other as a categorical risk indicator does not fully resolve the problem of double-counting or reduced discriminant validity

- CFA results would be more convincing if the authors had examined modification indices, residual correlations, or alternative models that remove one of the overlapping indicators

also a concern of mine is that i noticed body morphology and physical fitness use norm-referenced standard scores, while clinical health uses a deduction system starting from 100 that is then mapped onto a 60–90 scale. while the authors noted that the dimension scores should not be compared directly, yet a weighted composite is still formed and classified into four levels. This hybrid approach risks information loss and arbitrary cut-offs.... should clarify on this part

Cronbach’s α is mentioned for “most dimensions,” but exact values are not provided - please check and verify

also the exact operational definitions and measurement protocols for each clinical indicator should be noted

 

 

 

Author Response

Please see the attachment.

Author Response File: Author Response.docx

Reviewer 2 Report

Comments and Suggestions for Authors

Section	Line / Topic	Comment / Critical Point	Suggestion / Recommendation
Title	Construction and Preliminary Validation of a Comprehensive Physical Health Assessment System for Preschool Children in China	The title is appropriate, but “comprehensive” may be somewhat overstated given that the proposed system includes only three broad dimensions and selected indicators, with validation based on a single regional sample.	Consider “Development and Preliminary Validation of a Multidimensional Physical Health Assessment System for Preschool Children in China”. This would better reflect the preliminary and regional nature of the study.
Abstract	Lines 12–24	The abstract presents the assessment system as “comprehensive,” although the system is based on a relatively limited set of indicators and relies partly on expert-derived weights.	Clarify that this is a preliminary multidimensional assessment framework, rather than a comprehensive clinical assessment of preschool health.
Abstract	Lines 21–24	The “84.5% pass rate” may be misleading because the overall score combines indicators measured and weighted using substantially different procedures.	Briefly clarify how the overall pass rate was derived and emphasize that it reflects the proposed scoring system, not a validated clinical diagnosis of physical health.
Introduction	Lines 32–36	The manuscript links obesity and physical fitness with executive and academic outcomes.	Consider incorporating recent preschool evidence showing associations between BMI, movement behaviours, motor skills, inhibition, and visuospatial working memory, such as Ltifi et al. (2026), Children, 13, 306, doi:10.3390/children13020306. This would strengthen the developmental rationale while acknowledging that the cited study is observational.
Introduction	Lines 34–36	The relationship between physical fitness and executive functions is mentioned, but the literature could better address physical activity and executive functioning in preschoolers.	Consider citing Ltifi et al. (2025), Children, 12, 1405, doi:10.3390/children12101405, which examined mini-trampoline training, executive functions, and motor skills in preschoolers. Clearly distinguish intervention evidence from the present assessment-system study.
Introduction	Lines 39–44	The authors discuss insufficient physical activity and motor development but do not sufficiently integrate the 24-h movement behaviour framework.	Ltifi et al. (2024), Pediatric Exercise Science, 37(2):94–101, doi:10.1123/pes.2023-0152, could be cited to provide evidence on 24-h movement behaviours in preschool children and to contextualize physical health beyond isolated fitness measures.
Introduction	Lines 49–73	The manuscript treats body morphology and physical fitness as established components, then adds clinical health indicators. However, the conceptual rationale for combining these dimensions into a single composite score remains insufficiently developed.	Provide a conceptual framework or model explaining why body morphology, physical fitness, and clinical health should constitute one physical-health construct rather than three correlated but distinct domains.
Introduction	Lines 75–92	The Chinese context is well described, but the rationale for the specific five clinical indicators needs stronger justification.	Explain why dental caries, overweight/obesity, vision, malnutrition, and hemoglobin were selected while other clinically relevant indicators were excluded.
Introduction	Lines 90–92	The objective states that the system will provide evidence for “structural validity,” but the study also claims to assess the current health status of children.	Clearly distinguish between the two objectives: (1) development/weighting of the assessment system and (2) preliminary validation/descriptive application of the system.
Methods – Indicator Selection	Lines 96–106	The five clinical indicators were selected partly according to abnormality rates in a regional database. This may introduce a prevalence-driven selection bias.	Provide a more explicit theoretical and clinical rationale for indicator selection in addition to prevalence.
Methods – Indicator Selection	Lines 101–105	The use of abnormality rates from N=5,846 children in Shandong is useful, but the source population and sampling methodology are not adequately described.	Describe the database, sampling frame, age distribution, recruitment method, and whether the monitoring population was representative of preschool children in Shandong.
Methods – AHP	Lines 113–119	Averaging the pairwise comparison scores across experts requires methodological justification.	Explain why arithmetic averaging was selected and whether the geometric mean, which is commonly used for aggregating AHP judgments, was considered.
Methods – Weighting	Lines 146–156	The secondary indicators within body morphology and physical fitness are assigned weights based on the 2023 Chinese standards, whereas clinical indicators use a deduction system. These weighting procedures are conceptually heterogeneous.	Discuss the implications of combining normative weighting and expert-derived AHP weighting with deduction-based clinical scoring.
Methods – Clinical scoring	Lines 150–158	Clinical health indicators are not assigned proportional weights; instead, points are deducted from a baseline of 100. This makes the clinical dimension fundamentally different from the other dimensions.	Provide a mathematical justification for the deduction values (e.g., −2 for dental caries, −10/−15 for overweight/obesity, etc.) and conduct a sensitivity analysis to determine how these arbitrary thresholds affect the final classification.
Methods – Participants	Lines 161–167	The manuscript states that 1,462 children aged 3–7 years were recruited, but the reported age groups are 3–4, 4–5, and 5–6 years. Children aged 6–7 are not clearly represented.	Correct the age description and explain whether the sample actually includes children aged 6–7 years. This is an important internal consistency issue.
Methods – Procedure	Lines 169–176	The assessment was performed by trained medical personnel and teachers, but inter-rater reliability is not reported.	Report the training protocol and, if available, inter-rater reliability for anthropometric, fitness, visual, and other clinical assessments.
Statistical Analysis	Lines 178–190	The manuscript standardizes body morphology and fitness variables using sample-based means and SDs. This may make classifications dependent on the study population rather than external normative standards.	Clarify whether the standardization is based on external Chinese reference standards or the present sample's mean and SD. If based on the sample, discuss the implications for generalizability and reproducibility.
Results – Table 7	Lines 223–225	Table 7 formatting is difficult to interpret, and some values appear potentially inconsistent with the reported distributions.	Carefully verify all table values, labels, degrees of freedom, p-values, and superscripts.
Discussion	Lines 227–239	The authors state that the three dimensions are “mutually influencing,” but the present study does not demonstrate causal or directional relationships between them.	Replace causal wording with “interrelated” or “potentially associated” unless longitudinal or mechanistic evidence is provided.
Discussion	Lines 230–239	The discussion focuses strongly on obesity and motor performance.	Consider integrating evidence on BMI, motor skills, inhibition, working memory, and movement behaviours from Ltifi et al. (2026), Children, 13, 306, to provide a broader developmental perspective.
Discussion	Lines 240–246	The clinical relevance of integrating vision and dental health is plausible, but the proposed system is not itself a clinical diagnostic tool.	Clearly distinguish screening/risk identification from clinical diagnosis. The system should not be described as replacing specialized medical screening.
Discussion	Lines 264–270	The interpretation of age-related changes is speculative. The observed decline from 4–5 to 5–6 years may reflect sampling, scoring, or cohort effects rather than developmental decline.	Avoid attributing the pattern to reduced physical activity or school transition without longitudinal evidence.
Discussion	Lines 264–270	The manuscript refers to the transition to primary school, but the oldest participants appear to be 5–6 years old according to the reported groups.	Clarify the age range and whether participants were actually approaching or undergoing school transition.
Limitations	Lines 273–287	The authors appropriately acknowledge BMI/overweight overlap, the deduction scoring system, and regional convenience sampling.	Add further limitations concerning expert-derived weighting, lack of external validation, possible circularity between indicators, and lack of test–retest reliability.
Limitations	Lines 274–279	BMI and overweight/obesity overlap is recognized, but this is more than a minor limitation because it may artificially increase the contribution of adiposity to the overall health score.	Consider a sensitivity analysis removing one of the overlapping measures and comparing the resulting classifications.
Limitations	Lines 280–284	The authors acknowledge scale inconsistency but do not quantify its impact.	Conduct sensitivity analyses comparing the current deduction-based model with alternative standardization or weighting approaches.
Limitations	Lines 285–287	Single-region convenience sampling limits generalizability.	Strongly emphasize that the system requires external validation in independent samples from different provinces and socioeconomic settings.
Validation	Overall	The study does not demonstrate whether the proposed score predicts clinically relevant outcomes.	Future research should examine criterion-related and predictive validity, including longitudinal health and developmental outcomes.
Conclusion	Lines 289–294	The conclusion appropriately states that further validation is needed, but “developed and preliminarily validated” should be interpreted cautiously.	Emphasize that the study provides initial evidence of structural validity, not definitive validation of a comprehensive preschool physical-health assessment system.
References	Overall	The reference base is broad, but the manuscript would benefit from recent evidence linking movement behaviours, motor skills, body composition and executive functions in preschool children.	Consider strategically adding Ltifi et al. (2024; 2025; 2026) and Meksi et al. (2026) where they directly support the relevant conceptual arguments.

Comments on the Quality of English Language

The English could be improved to more clearly express the research.

Author Response

Please see the attachment.

Author Response File: Author Response.docx

Reviewer 3 Report

Comments and Suggestions for Authors

Reviewer Comments

The manuscript addresses a relevant and potentially important topic by attempting to develop a multidimensional physical health assessment system for preschool children that integrates body morphology, physical fitness, and clinical health. The relatively large validation sample is a strength, and the effort to move beyond a narrowly fitness-oriented assessment toward a broader conception of preschool physical health is potentially valuable. However, the manuscript currently presents several substantial conceptual, methodological, and interpretative issues that should be addressed before the proposed assessment system can be considered sufficiently validated.

1. Alignment between the study aims, analytical strategy, and reported results

The introduction states that the study aims to develop an assessment system integrating body morphology, physical fitness, and clinical health, and to provide preliminary evidence for its structural validity. However, the results subsequently include an extensive description of the current physical health status of the sample, overall ‘pass rates’, and comparisons by age and sex, although these objectives are not clearly anticipated in the study aims or formulated as research questions or hypotheses. This creates a disconnect between the stated purpose of the study and the analyses eventually reported.

The authors are therefore encouraged to revise the study aims and explicitly align the Introduction, research questions or hypotheses, statistical analyses, and reported results.

2. Theoretical justification of the proposed three-dimensional construct

The manuscript assumes that body morphology, physical fitness, and clinical health together constitute a coherent multidimensional construct of preschool physical health. However, the theoretical basis for this structure is not sufficiently developed. In particular, the clinical health dimension includes heterogeneous indicators such as dental caries, overweight/obesity, visual impairment, malnutrition, and anemia. Although these indicators are clearly relevant to child health, it is not sufficiently explained why they should be considered manifestations of a common latent “clinical health” dimension rather than a set of distinct health risks.

The authors are therefore encouraged to strengthen the theoretical justification for the proposed three-dimensional structure and to explain more clearly why the selected clinical indicators are expected to form a coherent common dimension.

3. Abrupt introduction and limited justification of the Analytic Hierarchy Process (AHP)

The Analytic Hierarchy Process (AHP) is introduced for the first time in the methods section, although expert-derived weighting constitutes a central component of the proposed assessment system. The rationale for using weighted dimensions, the decision to select AHP, and the advantages of this approach over alternative empirical or statistical weighting procedures are not sufficiently developed. In addition, the weighting process is based on eight experts, while limited information is provided regarding their selection criteria, expertise, and level of agreement before their judgments were averaged.

The authors are therefore encouraged to introduce and justify the use of AHP earlier in the manuscript, explain why this weighting approach was selected, and provide more detailed information about expert selection, expertise, and agreement.

4. Major concern regarding the measurement logic of the composite assessment system

A major methodological concern relates to the way different types of measurements are progressively transformed and combined. The study integrates continuous anthropometric and physical fitness measures, categorical clinical conditions, and deduction based clinical scores. These are then subjected to several successive procedures, including standardization, categorization, score deduction, numerical recoding, weighting, and aggregation. Although these steps allow the construction of a single numerical index, the manuscript does not sufficiently demonstrate that the resulting composite score preserves the original information and measurement meaning of the individual variables, nor that the different scoring procedures are metrically commensurable.

The authors are therefore encouraged to provide a substantially stronger methodological justification for the successive transformations and aggregation procedures and to demonstrate that the final composite score retains a meaningful and interpretable measurement structure.

5. Potential scale inconsistency and information loss

This issue is particularly important because the manuscript itself acknowledges that combining deduction-based clinical scores with standardized scores from the other dimensions may introduce scale inconsistency and information loss. This concern directly affects the validity of the proposed assessment system and should not be treated solely as a limitation for future research.

The authors are therefore encouraged to examine this issue within the present study, ideally through sensitivity analyses using alternative scoring or weighting approaches, rather than referring to it only as a limitation for future research.

6. Definition and justification of the term ‘comprehensive’.

The term ‘comprehensive’ is central to the title and conceptual positioning of the manuscript, yet it is not clearly defined. The proposed system operationalizes comprehensive physical health through three domains: body morphology, physical fitness, and clinical health, but the manuscript does not sufficiently explain why these three domains and their selected indicators together represent a comprehensive assessment of preschool children’s physical health.

The authors are therefore encouraged to provide an explicit conceptual definition of ‘comprehensive physical health’ clearly defines the boundaries of the construct, and justify why the selected dimensions are sufficient to support the use of the term ‘comprehensive’.

7. Unclear practical purpose and intended use of the final composite score

The practical function of the proposed assessment system remains insufficiently specified. It is unclear whether the system is intended for population surveillance, individual screening, clinical assessment, longitudinal monitoring, intervention evaluation, or another purpose. This distinction is important because different intended uses require different forms of validation evidence.

The authors are therefore encouraged to define clearly the intended practical use of the assessment system and to ensure that the validation strategy is appropriate for that intended use.

8. Interpretation of the ‘pass rate’ and health classifications

The manuscript classifies body morphology and physical fitness partly using sample-based thresholds derived from the mean and standard deviation. However, the results and discussion subsequently interpret these categories as if they represented external or clinically meaningful health standards, referring to an 84.5%  ‘pass rate’ and suggesting that most children met baseline health standards. Such interpretation appears stronger than the scoring procedure itself supports.

The authors are therefore encouraged to reconsider the terminology of ‘pass rate’ and ‘health standards unless these classifications are validated against independent external or clinical criteria, and to adopt more cautious language where appropriate.

9. Incomplete reporting of the confirmatory factor analysis

Because structural validation is presented as one of the central objectives of the study, the reporting of the CFA should be more complete. The manuscript reports overall fit indices and states that all factor loadings were statistically significant, yet only selected loadings are discussed. Important information such as the complete standardized factor loadings, factor correlations, standard errors or confidence intervals, and the precise specification of the tested measurement model is not clearly presented. Reliability coefficients are also described in general terms rather than fully reported.

The authors are therefore encouraged to provide a complete presentation of the CFA results, including all standardized factor loadings, factor correlations, uncertainty estimates, model specification details, and the actual reliability coefficients for each dimension.

10. Conceptual overlap between BMI and overweight/obesity

BMI is included within the body morphology dimension, whereas overweight/obesity is included within the clinical health dimension. Because these indicators are based on closely related body size information, their inclusion in separate dimensions may create redundancy or double representation of the same underlying information within the composite score. The authors acknowledge this issue as a limitation, but its impact may extend directly to the discriminant validity and weighting of the present model.

The authors are therefore encouraged to examine the potential redundancy between BMI and overweight/obesity more directly and to assess its possible impact on discriminant validity and on the construction of the overall score.

11. Inconsistencies in age reporting and Table 7

Several reporting inconsistencies require clarification. Participants are described as being aged 3-7 years, yet the reported age groups and corresponding mean ages do not appear fully consistent with the stated ranges. In addition, the Clinical Health means in Table 7 appear to use markedly different numerical scales for age-group comparisons and sex-group comparisons, suggesting a possible reporting or typographical error.

The authors are therefore encouraged to carefully verify and correct the age ranges, descriptive statistics, and the values reported in Table 7, ensuring that all group comparisons are presented on consistent and clearly defined scales.

12. Additional reporting of age and sex comparisons

The age and sex comparisons are presented primarily through significance testing. However, effect sizes, confidence intervals, and post-hoc comparisons for significant age effects are not adequately reported. Without these statistics, the practical importance of the observed group differences remains unclear.

The authors are therefore encouraged to report appropriate effect sizes, confidence intervals, and post-hoc comparisons where relevant, and to distinguish statistical significance from practical or clinical significance.

13. Overstatement and imprecision in the statement regarding ‘emerging evidence’

The statement that ‘emerging evidence supports evaluating body morphology, physical fitness, and clinical health within an integrated assessment system’ appears broader than what is clearly demonstrated by the cited references. The wording risks imply that the integrated three-domain construct has already been empirically established in preschool children. In addition, the citation is currently separated from the sentence by an unnecessary full stop.

The authors are therefore encouraged to reformulate this statement more cautiously and precisely, specify which relationships are supported by the cited evidence, and correct the citation placement and sentence structure.

14. Overall interpretation of the proposed system

Overall, the manuscript moves rapidly from heterogeneous primary measurements to a single weighted numerical system and then to claims of structural validity and meaningful health classification. The central issue is not simply whether the CFA shows acceptable model fit, but what the final composite score actually represents, how much of the original measurement information it preserves, and for what specific practical purpose it can be validly interpreted.

The authors are therefore encouraged to reconsider the overall conceptual and measurement logic of the proposed system and to clarify the meaning, validity, and intended interpretation of the final composite score before presenting it as a comprehensive physical health assessment system.

Recommendation

Major Revision

The study has potential and is based on a substantial dataset, but the issues identified above concern the conceptual and measurement foundation of the proposed system rather than only presentation or wording. A substantial revision is therefore required before the validity and practical interpretability of the assessment system can be adequately judged.

………………………………………

Author Response

Please see the attachment.

Author Response File: Author Response.docx

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

paper title - Construction and Preliminary Validation of a Comprehensive Physical Health Assessment System for Preschool Children in China

authors have done their effort in revising the paper - the current version is now better and ready for acceptance

Reviewer 2 Report

Comments and Suggestions for Authors

Dear Authors,

I have no further comments regarding the manuscript at this stage

Comments on the Quality of English Language

The English could be improved to more clearly express the research.