Review Reports

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review this manuscript. The paper describes an interesting approach to involving people with chronic breathlessness in the development of a walking football intervention. The taster sessions are a useful aspect of the work, as they allowed the intervention to be modified based on participants’ actual experience. I have a few comments for the authors.

It would be helpful to clarify the distinction between PPIE and research in this study. The manuscript includes feedback from the sessions, a debrief meeting, and quotations from PPIE members, while ethical approval and informed consent are stated as not applicable. A short explanation of how this distinction was made would make the methods clearer.

Some basic information about the PPIE group would be useful. For example, if available, the authors could provide the age range, underlying respiratory conditions, use of oxygen or walking aids, and previous pulmonary rehabilitation experience. This would help the reader understand who contributed to the development of the intervention.

I suggest reconsidering the wording around safety. Session 3 was stopped after a collision between two participants, and several additional precautions were introduced afterwards. This is actually a useful example of how the intervention evolved during the co-design process. The manuscript could focus more on this process rather than suggesting that the approach was simply shown to be safe.

A few statements in the Discussion go beyond what was assessed in this work. The study did not formally evaluate exercise capacity, quality of life, longer-term adherence, or other clinical outcomes. Claims regarding behaviour change or health benefits should therefore be toned down, with the conclusions kept closer to what was learned from the co-design process.

Author Response

Please see letter attached.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

This is a well-organized communication describing a novel active Patient and Public Involvement and Engagement (PPIE) process used to co-design a walking football intervention with people with chronic breathlessness. Transparency about the session-3 collision, the honest discussion of the tension between "working together" and researcher over-involvement, and the "areas for improvement" column in Table 3 are genuine strengths that many PPIE reports lack. I recommend making revisions to address the points below before publication.

1. Introduction and background: The background correctly establishes the PPIE and co-design concepts with appropriate citations, and the rationale linking pulmonary rehabilitation (PR) attrition to the need for a maintenance intervention is logical. It would benefit from a brief epidemiological framing of the chronic breathlessness/COPD burden before moving into PPIE theory and from engagement with existing literature on team sports or walking football interventions in other clinical or older adult populations, which would help justify why walking football specifically was selected as the maintenance activity. The claim that PR benefits "diminish within 6–12 months" rests on a single citation [6], now over two decades old; even if it remains the standard reference in this area, supplementing it with more recent evidence on PR maintenance/attrition would help demonstrate the rationale’s currency.

2. Inconsistency in the ethics statement. The Institutional Review Board and Informed Consent statements are both listed as "Not applicable," yet the manuscript explicitly describes obtaining "image consent forms," conducting pre-exercise health screening, collecting emergency contact details, and reporting a collision incident during a session. Please reconcile these: clarify explicitly why formal ethical approval and informed consent for participation were not required for this PPIE activity (citing the relevant guidance), while separately confirming what consent procedures were used and for what purpose (e.g., image use). As currently written, the statements risk being inconsistent with the body text.

3. Participant characterization and data capture: No demographic or clinical information is provided for the PPIE members (e.g., age range, gender balance, underlying diagnosis such as COPD versus other respiratory or cardiac conditions), which limits the readers' ability to judge the transferability of the findings. It is also not stated how qualitative feedback was captured and synthesized into Tables 1–3 (field notes, audio recording, thematic coding or informal recall). Including both would enhance the methodological transparency of the manuscript.

4. Placement of safety and ethical procedures. Several operationally important details — the risk assessment process, emergency first-aid course, and pre-football checklist — are introduced in the Discussion (Section 4.2) rather than in the Methods (Section 2.3), where the intervention procedure itself is described. Consider describing these procedures where the taster sessions are first introduced, using the Discussion section to interpret their impact.

5. Attendance and retention rates were also assessed. Only an aggregate attendance range is provided (approximately 10–12 members per taster session, following an initial n = 20 at the introductory meeting). It is unclear whether this reflects a stable core group returning across all four sessions or a rotating set of individuals, and no reason is discussed for the apparent drop-off between phase one and phase two. Reporting per-session attendance and basic retention data would add useful texture to the results.

6. Limitations. The manuscript does not include a dedicated limitations discussion. Given that the sample was a single, self-selected charity group in one UK region (likely biased toward individuals mobile enough to attend in-person community meetings), and that the conclusions call for wider adoption of active PPIE forms, an explicit paragraph acknowledging these generalizability constraints, along with the informal nature of the qualitative data capture, would better calibrate the strength of the claims made.

7. Minor points. The Abstract states that the debrief involved "n = 10-12" members, while Section 2.3 specifies 12 members — please reconcile. Consider clarifying author JE's role (charity coordinator/staff versus PPIE member with lived experience), consistent with the GRIPP2's emphasis on describing contributors' roles. The finding that PPIE members "sought further funding to continue walking football on their own accord" (Section 4.1) is a compelling indicator of impact but is reported without detail (outcome, funder, timeline); even a brief update would strengthen it as evidence.

8. Language. The manuscript is fluent and easy to follow. There is a minor inconsistency in terminology (alternating between "researchers," "the team," and "the research team" without clear distinction) and occasional informal phrasing (e.g., "as per Community Engagement guidelines"). These do not impede comprehension; a light copy edit is recommended rather than a substantive revision.

Author Response

please see attached letter.

Author Response File: Author Response.pdf