Pregnancy physical activity questionnaire (PPAQ): Translation and cross cultural adaption of an Arabic version.

INTRODUCTION: Physical activity level during pregnancy is unknown in Middle Eastern and North African countries, since no valid tools assessing it exist in Arabic. The aim of this study is to culturally adapt and translate to Arabic an internationally validated instrument, the Pregnancy Physical Activity Questionnaire (PPAQ), and to measure the physical activity of pregnant women using the adapted PPAQ, Arabic version. This tool is time-sparing, self-administered and is the only one taking into account childcare and household chores.
METHODS: After following the guidelines for translation and back-translation by certified translators, a committee composed of professionals in the field reviewed each item of the PPAQ, for its comprehensibility. This Arabic version of the PPAQ was tested on a sample of 179 pregnant Lebanese women, from different educational backgrounds, socioeconomic status and gestational ages.
RESULTS: Cross-cultural adaptations were applied on the newly translated PPAQ in Arabic version, thus questions referring to some types of outdoor activities were excluded from the final format. Our results reported that 51% and 1.7% of women engage respectively in light and high intensity physical activity, while 18% had a sedentary lifestyle. Occupational type of activities were significantly more performed by women having a higher education (p value 0.001), as opposed to those who attended only high school, who were physically more active in household activities (p value 0.038). Second trimester was a period where pregnant women were active for household, caregiving (p value 0.031), whereas women in their third trimester were physically more active in occupational activities (p value 0.001). Sport-oriented activities were performed by women reporting a good physical status (p value 0.03). Age and crowding index were significantly correlated with occupational, household and caregiving activities (p values 0.004, 0.008 respectively). No significant correlations were observed with pre-gestational body mass index and the physical activity levels.
CONCLUSION: A valid tool will help researchers in Arab countries identify physical activity levels of pregnant women and consequently emit specific guidelines relative to the importance and the benefits of a daily active lifestyle throughout gestation.

Introduction

Physical activity (PA) together with proper nutrition are key contributors of maternal and fetal well-being. Numerous studies highlight the positive impact of an active lifestyle on low incidence of maternal complications [1] such as preeclampsia, gestational diabetes [2], and excess maternal weight gain [3]. The American College of Obstetricians and Gynecologists (ACOG) recommends pregnant women to engage in 30 minutes of moderate intensity exercise on daily basis [4]. However, despite the recommendations of medical instances, in some cultures, pregnant women are advised to follow a sedentary lifestyle [5]. In addition, due to religious sensitivities, exercising in public areas or local gyms are forbidden for women in some Middle-Eastern countries [6].

Reports published worldwide focus on the knowledge and the practice of PA among pregnant women and explore maternal physical and psychological factors that enhance or hinder this behavior [7-11]. Hence, with the expansion of researches on the advantages of PA on health, various questionnaires have been developed such as the Godin Leisure-Time Exercise Questionnaire [12], the Simple Physical Activity Questionnaire [13], and the Global Physical Activity Questionnaire [14], but few were appropriate for pregnant women, mainly because they did not take into account daily routine activities frequently performed by them, such as childcare and household, were long and not validated during pregnancy [15]. Compared to the other tools, The Pregnancy Physical Activity Questionnaire (PPAQ) was the only self-administered tool, with sufficient reliability in assessing total PA and vigorous activities during the last three months of gestation, preceding the survey [16]. It has been translated into different languages and used in numerous clinical studies [17-20].

Hence, a valid PA tool in Arabic is necessary to help researchers assess, monitor and evaluate PA in North African and Middle-Eastern pregnant women. However, translation alone can’t guarantee the compatibility of the questionnaire, because it must undergo some cross-cultural adaptations, to ensure its validity with the local culture [21]. Hence, the aim of this research was primary to translate and cross-culturally adapt this tool into Arabic and secondly to evaluate the PA levels of healthy Middle Eastern pregnant women by applying this newly translated version of PPAQ. In addition, the associations between some maternal variables and PA levels were analyzed.

Methods

Besides being easy, cost-effective, time sparing and noninvasive, this specific tool takes into account the time spent in 33 different activities divided as follows: 16 activities dealing with household and caregiving, 3 concerning transportation and inactivity, 9 sports related activities, and 5 occupational activities. Each participant chooses the answer which represents the closest to the amount spent on daily or weekly basis, during the preceding three months. Six possible answers are available to respondents: never, less than half an hour per day, between half and 1 hour per day, 1 and 2 hours per day, 2 and 3 hours a day, and more than 3 hours a day. In addition, two open ended questions, concerning sport type activities, allow the responder to specify types not listed previously and practiced on weekly basis. This gives the questionnaire an added value, by individualizing the evaluation of each responder. The original English version of the PPAQ takes approximately 10 minutes to be filled up. After the obtention of the written approval of its creator, Lisa Chasan-Taber, by mail, for cross-culturally translating and using this tool in a sample of Lebanese pregnant women, the study was divided into two stages: preparing the Arabic version and evaluating the PA levels of our target population.

The research team followed the guidelines depicted by Guillemin et al., which were composed of 4 phases, designed to guarantee the reliability of the translated tool [17].

Phase 1: Translation

The translation of the original English questionnaire to Arabic was conducted by separate translators to produce several versions of the translated document. Initial translations to Arabic were performed by two nutrition bilingual graduates, who were unaware of the purpose of the study. A qualified translator whose native language was Arabic, and having a linguistic but not a scientific background, was engaged to submit a third translated version.

Phase 2: Back-translation

Experts recommend conducting independently the same number of back-translation from the final language (Arabic) to the original English version, as done in the first phase. This helps to highlight all the ambiguities present in the translated version, and hence confirm accuracy. Two senior university students, specializing in translation and a qualified translator (not related to the first translator) were given the task to undergo the back-translation. Once again, the intentions and the objectives related to the document were not revealed to the translators, to minimize biases and subjective inputs.

Phase 3: Committee review

A multidisciplinary team was created in our department composed of a gynecologist, a midwife, two nutritionists, two sports experts, and two graduate assistants. Their aim was to review each item in each translation separately, in order to come up with the final translated version during joint meetings. Both versions were compared for its semantic equivalence and to ensure the full comprehensibility of the questionnaire, and the instructions to fill it. A final consensus was made after discussions and synthesis.

Phase 4: Pre-testing

For pre-testing purposes, Beaton D. et al [22] recommend testing it on a sample of 10 to 40 persons. Hence, before administrating it on a larger scale, 45 pregnant women, mostly instructors, university and hospital employees, filled the newly translated Arabic version, as part of a pilot study, to test the proper comprehensibility of the items. The research team used the same format of the initial PPAQ concerning the font used and the sequences of questions. In addition, they were recording all aspects dealing with the questionnaire from lay-out, flow of question, time and ambiguities. A probing approach was chosen during this phase, to have a direct feedback on the clarity of the questions presented.

After completion of this pretesting, some revisions were needed. The first 3 questions (date of recruitment, last menstrual period, and predicted date of delivery) were unanimously judged unnecessary, since as mentioned before, the PPAQ was going to be used with a main questionnaire concerning the health and the nutritional status of pregnant women, and those questions were already addressed. Hence, the numbering of the questions was corrected and the final questionnaire started with 1 referring to the question 4 of the initial document. To avoid confusing the respondents, some changes were done concerning the lay-out of the questionnaire such as writing the questions with similar wording in bold characters.

After this initial phase of translation, some cultural adaptations had to be implemented too. Those concerned questions number 18 and 19 of the original version, which consisted of assessing the time spent on mowing the lawn and showering the snow off. Those activities can’t be realized in Middle Eastern and Arab countries, which have hot, humid and desert climate environment. With those omissions, the number of items of our PPAQ dropped to 31. Other changes included the conversion of English measurements (gallons and pounds) mentioned in the original questionnaire into metric equivalents (liters and kilograms). We preferred mentioning “the last three months of your pregnancy”, instead of last trimester, to avoid some misinterpretations (S1 File).

Our tool was ready to be administered on a larger scale, since our research team was studying the nutritional status of pregnant women and the impact of diet, exercise and other factors on maternal complications and neonatal outcomes in a cross-sectional study. The inclusion criteria were to include Lebanese women, with singleton pregnancy, Arabic literate, aged between 18 and 40 years old, healthy, not suffering from gestational diabetes, preeclampsia, or any other chronic disease affecting their health.

The minimum sample size to be included in this study was calculated initially by following the formula of Tabachnick and Fidell [23] that takes into consideration the number of explanatory variables to be include in the model: N = 50 + 8m (m being the number of explanatory variables); Given that m equals to 8, a minimum of 114 women should participate in this study. They were recruited during prenatal visits, for routine gynecological check-ups, independently of their weeks of gestation. Face to face interviews permitted to collect sociodemographic data and details concerning dietary intakes. The indicators used in the first part of the questionnaire dealing with the socioeconomic status were the crowding index (deducted by the interviewer as the total number of co- residents per household, excluding the newborn infant, divided by the total number of rooms, excluding the kitchen and bathrooms), the educational level, and the work status. A crowding index higher than one suggests a household with restricted economic resources [24]. At the end of the first part of this questionnaire, the research team requested from the participants to subjectively assess their physical and nutritional wellbeing, by choosing from the list “very bad, bad, average, good and excellent”, the status that currently fits them best.

Anthropometric measurements (weight before pregnancy, actual body weight, height), age, and gestational age were copied directly from the medical file, the day of the recruitment, to avoid ending up with irrelevant information. Body mass index (BMI) was then calculated as the ratio of pre-gestational weight in kilograms to the square of height in meter. It was categorized according to the World Health Organization (WHO) cut-off points (underweight <18.5, normal 18.5 to 24.9, overweight 25 to 29.9 and obese >30) [25]. The last part of the questionnaire, concerned the newly translated PPAQ and was self-filled by the participants themselves, in the presence of the research assistants. Their role was to avoid having any missing data. A follow-up was maintained with participants thru telephone calls to compile information on delivery outcomes (weight at hospital admission, delivery complications …). Total GWG was then calculated by deducting weight at delivery from the initial and comparing it to the values defined by the Institute of Medicine (IOM) [26]. Field work was conducted between January and May 2018 by trained dietitians.

The study protocol was approved by the Institutional Review Board of Saint-Joseph University at Beirut, Lebanon, the Hotel-Dieu Hospital Ethics Committee (CE 624/ FPH 49) and the participating gynecologists. All subjects gave their written consent prior to participation.

Statistical analysis

Descriptive data was calculated as the mean +/- standard deviation. Data collected was analyzed using SPSS Data Analysis version 22.0 (SPSS Inc, Chicago, IL). The alpha error was set at 0.05. Kolmogorov-Smirnov tests were used to assess the normality of the distribution of continuous variables. Univariate followed by multivariate analyses were performed to assess the factors associated with PPAQ. Spearman Correlation coefficient and Pearson Correlation coefficient were used to assess the relationship between continuous variables. Kruskal-Wallis tests and Analysis of variance (ANOVA) were performed to compare continuous variables between three or more groups. Multiple regression analysis was used and explanatory variables with a p value less than 0.200 in univariates analyses were included in the model. Variables highly correlated together were not included in the same model.

We followed the calculation guidelines described by Chasan-Taber et al. [27] to deduct the daily energy expenditure and classify the participants into different metabolic equivalent (MET) categories: sedentary (<1.5 METs), light (1.5<3.0 METs), moderate (3.0–6.0 METs), or vigorous (>6.0 METs). Briefly, each self-reported answer of each category was multiplied by its MET value, specified by the original author, to reach the total of daily energy expenditure (METs x hours/day), knowing that 1 MET is the metabolic equivalent of the energy expended at rest and equals 3.5 ml O2/kg/min. The final values for each question were summed up to reach a total score that was divided by the total number of questions and then by 7 to reach the mean daily energy expenditure expressed in METs. Following those calculations, women were classified as having a sedentary, light, moderate or vigorous PA levels.

Results

Demographic characteristics

One hundred and seventy-nine women participated in this study, with a mean age of 29.94 ± 5.03 years old. Fifty nine percent of our sample had a university degree, with a mean crowding index of 0.73. The majority of the participants (68.2%) were in their third trimester, and the rest were equally distributed in their first and second trimester. The mean BMI calculated based on their pre-gestational weight was 22.94± 3.60 kg/m2, reflecting a sample within the normal BMI range before gestation.

Women were asked to self-report their nutritional status and physical well-being. The majority of the women reported an excellent and a good physical and nutritional status. Detailed results of all the descriptive variables are presented in Table 1.

Table 1

Descriptive variables of the sample population (N = 179).

	Mean ± SD
Age	29.94± 5.03
Crowding Index	0.72± 0.31
Pre-gestational BMI‡	22.94± 3.60
		N	%
Education
Elementary		3	1.70
Intermediate		12	6.70
Secondary		15	8.40
Technical		10	5.60
Undergraduate Studies		105	58.70
Graduate Studies		34	19.00
Total GWG*
Insufficient		42	23.50
Adequate		74	41.30
Excessive		63	35.20
Trimester
First		30	16.80
Second		27	15.10
Third		122	68.20
Nutritional Status
Very bad		4	2.20
Bad		9	5.00
Average		54	30.20
Good		94	52.50
Excellent		18	10.10
Physical well being
Very bad		8	4.50
Bad		20	11.20
Average		52	29.10
Good		81	45.30
Excellent		18	10.10

‡ BMI: Body Mass Index

*GWG: Gestational weight gain categorized according to Institute of Medicine (IOM) classification [26]

Levels of physical activity

Mean MET value of our sample was 2.52, suggesting that women participating in this study engaged in low levels of PA. Classifications according to the MET values revealed that only 1.7% of women participated in high intensity/vigorous exercise, 51.4% conducted light intensity of exercise, while 18% had a sedentary lifestyle.

Significant associations were observed between the type and intensity of PA and the educational level (No higher education/ higher education) of our participants. Hence, a p value less than 0.01 was seen in women who engaged in sedentary type of exercise and having a university or a higher degree, while a p value of 0.038 was found for those who attended only school and were more active for household chores. When all the types of activities were summed up, women who had achieved a university degree were physically more active, than non-educated ones (p value 0.037). Summary of those results are presented in Table 2.

Table 2

Type and intensity of PA, deducted from the PPAQ, in women categorized depending on their educational level (N = 179).

	No higher education (n = 40)	Higher education (n = 139)	p value*
Total score of PPAQ (MET.h/wk)**	181.21 ± 89.73	210.89 ± 85.30	0.037*
By intensity
Sedentary	62.70 ± 42.64	95.80 ± 43.78	<0.01*
Light	89.91 ± 45.72	82.48 ± 45.71	0.366
Moderate	28.40 ± 52.46	32.44 ± 45.69	0.635
Vigorous	0.21 ± 0.84	0.18 ± 0.81	0.583
By type
Household/Caregiving	93.29 ± 59.47	72.68 ± 53.54	0.038*
Occupational	29.58 ± 54.52	65.90 ± 58.93	0.001*
Sports/exercise	2.38 ± 5.71	4.58 ± 9.92	0.036*

* Statistical analysis by ANOVA / Kruskal-Wallis tests with a p value less than 0.05 considered as significant

**MET metabolic equivalent turnover

The next table (Table 3) indicates the correlations between the type and the intensity of physical activity depending on the gestational trimesters. Women in their last trimester of gestation had a more sedentary lifestyle (p value 0.001) and were oriented mostly towards occupational activities (p value 0.001), compared with those in their first or second trimester of pregnancy. In addition, household chores were significantly higher in women, in their second trimester (p value 0.031).

Table 3

Type and intensity of PA, deducted from the PPAQ, in women categorized depending on their gestational trimesters (N = 179).

	First trimester (n = 30)	Second trimester (n = 27)	Third trimester (n = 122)	p value*
Total score of PPAQ (MET.h/wk)**	190.65 ± 96.70	191.27 ± 76.10	210.48 ± 86.67	0.377
By intensity
Sedentary	75.33 ± 50.70	65.46 ± 36.35	96.70 ± 43.86	0.001*
Light	86.83 ± 36.02	96.24 ± 40.11	80.80 ± 48.66	0.267
Moderate	28.04 ± 39.67	29.39 ± 43.17	32.87 ± 50.07	0.855
Vigorous	0.45 ± 1.30	0.18 ± 0.94	0.12 ± 0.61	0.151
By type
Household/Caregiving	87.77 ± 56.35	97.99 ± 42.07	70.13 ± 56.59	0.031*
Occupational	37.78 ± 49.81	29.01 ± 51.87	69.07 ± 60.59	0.001*
Sports/exercise	3.45 ± 5.13	2.46 ± 2.98	4.60 ± 10.72	0.503

*Statistical analysis by ANOVA / Kruskal-Wallis tests with a p value less than 0.05 considered as significant

**MET metabolic equivalent turnover

The next two tables (Tables 4 and 5) show the correlations between the personal perception of nutritional status and physical well-being in relation to the type and the intensity of PA performed by participating candidates. As explained previously, women were asked to rate subjectively their nutritional and physical status; those who spent more energy for occupational purposes, had classified themselves as having a poor nutritional status (p value 0.021). Even though only 7% of participants felt having a bad nutritional status, but when correlated to the total PA levels, statistically significant associations were found (p value 0.019). Sports/ exercise activities were significantly performed by women that considered themselves as having a good and an excellent physical status (p value 0.03).

Table 4

Type and intensity of PA, deducted from the PPAQ, in women categorized depending on their subjective perception of nutritional status (N = 179).

	Very bad/bad nutritional status (n = 13)	Average nutritional status (n = 54)	Good/Excellent nutritional status (n = 112)	p value*
Total score of PPAQ (MET.h/wk)**	261.95 ± 116.51	187.94 ± 63.53	205.44 ± 90.59	0.021*
By intensity
Sedentary	110.53 ± 42.41	83.36 ± 45.31	88.27 ± 45.65	0.155
Light	103.56 ± 56.69	80.50 ± 36.10	83.64 ± 48.23	0.260
Moderate	47.48 ± 74.52	23.89 ± 38.74	33.37 ± 46.78	0.216
Vigorous	0.38 ± 1.35	0.18 ± 0.76	0.16 ± 0.77	0.681
By type
Household/Caregiving	88.35 ± 30.96	78.44 ± 47.02	75.45 ± 58.74	0.720
Occupational	97.99 ± 85.69	46.55 ± 50.98	58.53 ± 58.69	0.019*
Sports/exercise	4.52±5.86	2.78 ± 5.54	4.67 ± 10.75	0.459

* Statistical analysis by ANOVA / Kruskal-Wallis tests with a p value less than 0.05 considered as significant

**MET metabolic equivalent turnover

Table 5

Type and intensity of PA, deducted from the PPAQ, in women categorized depending on their subjective perception of physical well-being (N = 179).

	Very bad/bad physical state (n = 28)	Average physical state (n = 52)	Good/Excellent physical state (n = 99)	p value*
Total score of PPAQ (MET.h/wk)**	176.37 ± 67.44	202.37 ± 78.58	213.14 ± 94.65	0.140
By intensity
Sedentary	78.78 ± 35.00	89.26 ± 42.65	90.68 ± 49.53	0.471
Light	73.26 ± 40.92	87.13 ± 46.08	85.64 ± 46.73	0.386
Moderate	24.33 ± 29.54	25.79 ± 40.82	36.59 ± 53.61	0.279
Vigorous	0.00 ± 0.00	0.19 ± 0.77	0.23 ± 0.95	0.408
By type
Household/Caregiving	81.96 ± 54.07	70.23 ± 48.63	79.67 ± 59.20	0.544
Occupational	39.49 ± 45.86	64.83 ± 65.45	59.54 ± 59.55	0.155
Sports/exercise	1.48 ± 5.14	2.43 ± 3.50	5.69 ± 11.55	0.03*

*Statistical analysis by ANOVA / Kruskal-Wallis tests with a p value less than 0.05 considered as significant

**MET metabolic equivalent turnover

The next table (Table 6) exposes the correlations between age, crowding index, pregestational BMI and the type and intensity of PA. Significant correlations were observed regarding maternal age and occupational activities (p value 0.004) and crowding index and household chores (p value 0.008). However, no significant relationship was seen between the type and the intensity of exercise and pregestational BMI.

Table 6

Correlations between the type and the intensity of physical activity, deducted from the PPAQ, in women with maternal age, crowding index and pre-gestational BMI (N = 179).

	Maternal age		Crowding Index		Pre-gestational BMI
	R	p value*	r	p value*	r	p value*
Total score of PPAQ (MET.h/wk)**	0.113	0.132	0.093	0.217	-0.007	0.930
By intensity
Sedentary	-0.024	0.748	-0.073	0.330	-0.069	0.356
Light	0.085	0.256	0.133	0.076	0.050	0.505
Moderate	0.101	0.178	0.052	0.491	-0.031	0.678
Vigorous	-0.136	0.069	-0.059	0.436	0.067	0.375
By type
Household/Caregiving	0.035	0.643	0.197	0.008*	0.078	0.300
Occupational	0.214	0.004*	-0.027	0.725	-0.094	0.212
Sports/exercise	-0.139	0.063	-0.106	0.156	-0.128	0.087

*Statistical analysis by Spearman and Pearson correlation coefficient with a p value less than 0.05 considered as significant

**MET metabolic equivalent turnover

Following a multiple regression analysis, neither maternal age nor the educational level were associated with the total score of PPAQ among the participants. Self-assessed nutritional and physical status were declared significantly correlated with the PA levels (p values 0.007 and 0.022 significantly). All results are presented in Table 7.

Table 7

Multiple regression analysis of explanatory factors associated with the total score of PPAQ in women.

	Unstandardized Coefficients		Standardized Coefficients	t	Sig.	95.0% Confidence Interval for B
	B	Std. Error	Beta			Lower Bound	Upper Bound
(Constant)	176.566	71.302		2.476	0.014	35.831	317.300
Maternal age	1.654	1.281	.096	1.291	0.198	-.875	4.183
Education	20.560	15.499	.099	1.327	0.186	-10.031	51.150
Nutritional status [Ref: very bad/bad]	-70.038	25.462	-.202	-2.751	0.007*	-120.294	-19.782
Physical status [Ref: very bad / Bad]	41.538	17.988	.171	2.309	0.022*	6.034	77.043

*p value less than 0.05 considered as significant

Discussion

This study aimed in translating to Arabic, a tool, used in various researches across Europe, Asia and North American countries and to cross-culturally adapt it to women living in Northern Africa, the Gulf region and the Middle-East. Two certified translators were given the task to translate and back-translate the English version of PPAQ into Arabic. The advantages of this newly translated PPAQ are multiple; it’s a simple, rapid and self-administered tool that takes into account the contribution of different daily activities often neglected in other PA questionnaires [28]. Plus, the sum of its components determines MET values, easily representing “true” activity levels.

Following this part, the research team deducted from the final version, two questions not compatible with the societal and living lifestyle of people in this area of the world, such as mowing the lawn and showering the snow off. Other improvements concerning the lay-out of the tool were adopted too. After a pretest, the newly translated version was tested to evaluate the PA status of 179 pregnant women, recruited from different educational and socio-economic background.

Our sample size, age, gestational trimesters, and pre-gestational BMI were similar to the study of Xiang Mi et al., which used the Chinese version of PPAQ, among 182 pregnant women, having mostly an initial BMI in the normal category [29].

Patterns of PA evolve during pregnancy. A review published by Forczek et al. in 2017 observed a net decline in activities in the first trimester of pregnancy, followed by a rise, after the 14th week of gestation, with women mostly oriented towards occupational activities, housework/caregiving, active lifestyle combining essentially aerobic sports, such as walking and stationary cycling [30]. On the other hand, in a sample of Polish pregnant women, no differences were observed in terms of total PA, across the trimesters of pregnancy [7]. In our sample, the intensity and the type of PA increased in women of second and third trimester, compared to those in their first trimester. Our results join those published by Santos et al. [31], where women in their third trimester reported mostly a tendency towards sedentary lifestyle, dominated by occupational type of PA, whereas those in their second trimester had a light level of PA and were oriented more towards household activities. Indeed, the second trimester of pregnancy is considered to be the most comfortable period during gestation, where women often feel more energetic and eager to be physically active [7]. Although, PA may decline before delivery due to excess body weight, lower back pain and pressure caused by the expansion of the uterus [32], our study demonstrated an elevated intensity of PA during the last trimester among ladies for occupational oriented activities. This highlights that working moms stay active before gestation, outside and inside their homes, to accomplish all professional and family duties, before delivery. It should be noted that laws in the Middle East allow only a relatively short period of maternity leave, to be taken after birth. In this research, vigorous levels of PA, mostly conducted in sports or exercise context, were not observed across the trimesters of pregnancy. These results join those obtained in the Chinese study, where few pregnant women reported engaging in high intensity/vigorous activities [29]. Similar results were obtained by Yi-Li Ko et al. in a cohort of 150 pregnant women in Taiwan [33].

Another issue is the difficulty to assess low intensity PA, since people often neglect daily routine chores (such as tidying the house, light cleaning, taking care of a child or an animal), because such activities become habits over time and will no more be considered or felt by the respondent as a way of exercising [34]. Thus, the added value of the PPAQ is the inclusion of normal daily low intensity tasks (household and childcare), frequently assumed in Middle-Eastern countries by women, as part of their responsibilities toward their family. Light activities were prevalent among 51.4% of our participants’, as mentioned in a similar cross-cultural adaptation of PPAQ, among Brazilian women, with comparable results [35]. The reason may be that those women initially had a sedentary lifestyle or due to cultural pressure and believes were afraid to start a rigorous PA.

Being more educated and having a university degree were among the maternal factors triggering women to adopt a healthier lifestyle and engage in sport activities. Hence, in our sample, educated women were often more sedentary during work time, but engaged more in sport activities during their free time, compared to less educated housewives (p value 0.036). In our research, the age of the participants was another factor influencing patterns of PA. As women get older, occupational activities tend to increase, most probably due to an increase in their professional responsibilities. Besides, household activities were mostly observed in women having larger families, with a higher crowding index. The reason behind is the numerous home duties of Middle-Eastern females and their responsibilities towards their larger family. However, following a multiple regression analysis, those two variables (educational level and age) were no more significantly correlated with the total PPAQ score, unlike the results of Nascimento et al. in Brazil, where educational level was among the maternal factors inducing an active lifestyle [32]. On the other hand, after controlling cofounding variables, self-rated physical and nutritional well-being remained significantly associated with PA. Future areas of research should focus on the evaluation of the quality of life and the nutritional status by administering validated questionnaires among pregnant women of Arabic descent.

Our findings showed a net decline in sports/exercise related activities irrespective of gestational age or BMI. Watching television was the sedentary behavior that the majority of women spent doing, similar to the study of Santos et al [31] and Chasan-Taber et al [16]. Chandonnet et al. applied the French version of PPAQ among pregnant obese women and showed that they were predominantly active in household and caregiving activities [36]. Although our sample was mostly composed of women with a normal BMI, housewives or those with no higher academic education were engaged mostly in household and caregiving activities.

In parallel, our translated tool (PPAQ-Arabic) was used among another sample of 141 Lebanese pregnant women in another research aiming to study the relationship between their quality of life, insomnia, depression and PA. Published results of that study showed positive correlations between maternal age and total PA (p value 0.034), with no associations seen between PPAQ scores, pregestational BMI, gestational age, worry and insomnia [37].

Our study has some limitations. First, there are possible sampling and recall bias, because the randomly selected participants filled the PPAQ at one single moment of their gestation and PA may change, evolve or decrease during the entire pregnancy. Secondly, MET values used in the calculations were not specific for pregnancy, since Compendium-based MET values were used to estimate the intensity of PPAQ activities. However, this limitation is to be neglected, since those conversion factors were recommended by the original creator of the PPAQ and all other authors who translated this instrument in their native language, applied it too. In addition, the PPAQ is a subjective technique of assessing the PA levels during pregnancy. Better results can be obtained if coupled with a pedometer or an accelerometer that offer a more objective assessment. The future aim of our team is to assess the validity of our tool against accelerometers in a sample of pregnant women. Our sampling approach was not representative of all Lebanese women since we followed a convenient sampling strategy, however it included participants coming from different Lebanese regions, irrespective of their educational, socioeconomic and religious backgrounds. The strengths of our study are the participants being distributed among various gestational weeks and having a normal BMI. In addition, the compliance of all the participants and the easiness to fill this newly adapted tool, with no missing data or dropouts were an added asset of this research. Moreover, seasonal variation did not influence results reflecting to sports / exercise questions, since Lebanon is known for its mild Mediterranean climate, proper to the practice of different type of sports, all year long.

Conclusion

The ACOG recommends pregnant women with low risk pregnancies to maintain a moderate-intensity level of exercise for the prevention of excessive gestational weight gain [38], optimal fetal outcomes, and maternal well-being [4]. Nevertheless, assessment of PA is hard to interpret and presents many limitations, since there is no gold standard for a specific and a validated tool to be administered exclusively during pregnancy [39]. Following this study, the translation to the Arabic language and the cultural adaptation of the original PPAQ will help researchers depict the PA levels of pregnant women in twenty two Arabic speaking countries, across Asia and Africa.

Because pregnancy is full of physiological and psychological changes, a decline in PA levels is not surprising. Earlier counseling during prenatal services on the advantages of PA is crucial, since this period represents a unique event in women’s life and an ideal moment to implement strategies and guidelines to promote and install new health focused behaviors, such as exercise.

Pregnancy Physical Activity Questionnaire (PPAQ)–Arabic version.

(DOCX)

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11 Nov 2019

PONE-D-19-25377

Pregnancy physical activity questionnaire (PPAQ): translation and cross cultural adaption of an Arabic version.

PLOS ONE

Dear Dr Papazian,

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

General comments

The manuscript is not presented in an intelligible fashion and typographical errors are commonly encountered.

The approach used for classifying some of your key variables (e.g. gestational weight gain, nutritional status and physical well being) has not been clearly described at all.

Please make sure that you have followed the PLOS one standards in writing the in-text citations and references.

Please revise the discussion section as per the recommendation provided by the two reviewers.

We would appreciate receiving your revised manuscript by Dec 26 2019 11:59PM. When you are ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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We look forward to receiving your revised manuscript.

Kind regards,

Samson Gebremedhin, PhD

Academic Editor

PLOS ONE

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2. Please include additional information regarding the sample size of your main study and how this number of participants was reached - e.g. referring to previous studies or a power calculation.

3. Thank you for stating the following in the Acknowledgments Section of your manuscript:

This research received no specific grant from any funding agency, commercial or not-for-profit sectors.

We note that you have provided funding information that is not currently declared in your Funding Statement. However, funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form.

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The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

4.  Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information.

5. Please amend the manuscript submission data (via Edit Submission) to include author Daisy Chammas.

6. We note you have included a table to which you do not refer in the text of your manuscript. Please ensure that you refer to Table 6 in your text; if accepted, production will need this reference to link the reader to the Table.

Additional Editor Comments (section-by-section comments):

Abstract

Please make sure that the abstract is prepared in line with the standards of the journal.

Can you please provide additional information on how the “translation, pre-testing, and cross-cultural adaptation” was made?

It would be good to change the header “discussion” to “conclusion”

Background

Line 44-47: the sentence “The Pregnancy Physical Activity Questionnaire (PPAQ) is a self-administered tool, created to evaluate the frequency, duration and intensity of different types of activities conducted by pregnant females during the last three months.” Is vague? When you say last 3 months, do you mean the last trimester or in the preceding 3 months of the survey?

Methods

Did you evaluate the adequacy of the sample size for measuring the level of physical activity in the study population? In the manuscript nothing has been said about it.

Line 121: the PPAQ items were dropped to 31. Do you think this had implication on the level of physical activity you estimated in your population? As you reduce the item have you proportionally reduced the cut-off for defining the level of physical activity?

Page 130-31: how did you assure that pregnant females from different educational backgrounds, socioeconomic status and gestational age were recruited? Did you apply kind of purposive sampling? And how did this affect the external validity of your study?

Line 132-33: did you observe considerable difference between the information collected by interviewer-administered and self-administered questionnaires? Nothing has been said about this in the results and discussion sections.

Results

Table 7: please report the means and the standard deviations with the same precision.

Table 7, do you really need 5 decimal place number for the crowding index.

In the methods section please describe how you computed the variable “crowding index”.

Table 7: seems few of the study subjects were illiterates. So how did they fill the self-administered version of the questionnaire? I think they should have been excluded from the study in the first place.

Table 7: How did you classify gestational weight gain as insufficient, adequate or excessive? Similarly, the approach used to classify the variables “nutritional status” and “physical wellbeing” is confusing because no operational definitions had been given.

Line 170: I think you need to have another sub-header here. Information about MET should not be under socio-demographic information

176-78: “Significant correlations were observed when we stratified the sample depending on …….” Correlation between what?

Line 178: “a p value of 0.00” >> “p value < 0.01”

Table 3: please clearly indicate with * all the significant p values.

Line 221: “The last table ” >> “Table 6”

Table 6: what was the basis for selecting the three variables (maternal age, crowding index and pregestational BMI) as key predictors of physical activity during pregnancy? Have you had a priority hypothesis or was that a post-hoc analysis?

Again, it is not clear how the pre-pregnancy BMI was determined. How did you manage to get information about their pre-pregnancy weight?

Discussion

Please see blow the comments forwarded by the reviewers

Conclusion

Line 301-5: I think this should rather be in the discussion, not conclusion, section

Reference and citation

Please note that PLOS uses “Vancouver” style, as outlined here https://www.nlm.nih.gov/bsd/uniform_requirements.html: please modify the intext citations and references accordingly.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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

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

Reviewer #1: No

Reviewer #2: Partly

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

Reviewer #1: Yes

Reviewer #2: No

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

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

Reviewer #1: No

Reviewer #2: Yes

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

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

Reviewer #1: No

Reviewer #2: No

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5. Review Comments to the Author

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

Reviewer #1: The authors present an article about an interesting topic: adaptation of The Pregnancy Physical Activity Questionnaire (PPAQ) to Arabian conditions. However, it is necessary to justify the choice of instrument. Maybe it would be more informative the use of a specific questionnaire for pregnant women than a general questionnaire, e.g. Pregnancy Sympton Inventory – PSI (Foxcroft KF, Callaway LK, Byrne NM, Webster J. Development and validation of a pregnancy symptoms inventory. BMC Pregnancy Childbirth. 2013;13:3. Published 2013 Jan 16. doi:10.1186/1471-2393-13-3). The PSI provides a comprehensive inventory of pregnancy related symptoms, with a mechanism for assessing their effect on function. It was robustly developed, with good test re-test reliability, face validity, comprehension and readability. This provides a validated tool for assessing the impact of interventions in pregnancy.

The major mistypes have been detected:

1. The structure of the Abstract does not comply with PLoS One guidelines. The aim is not clearly defined. In addition to adapting PPAQ to Arabic conditions, the purpose of the work is - as I understand it - to study the relationship of physical activity (PA) of pregnant women with their age, crowding index and pregestational body mass index. Abbreviations should not be used in the Abstract. The authors write that they analyze the socioeconomic status - which is not consistent with the paper. By the way, this is a big limitation of this study. Physical activity in pregnancy may depend on the socio-economic status and support of a partner, friends or family.

2. The Introduction does not present the background of the paper. There is no information on the state of knowledge regarding PA in pregnant women. There are many publications on this subject, e.g .:

- Krzepota J., Sadowska D., Biernat E. Relationship between physical activity and quality of life in pregnant woman in the second and third trimester. International Journal of Environmental Research and Public Health 2018: 15: 2745.

- Gjestland, K., Bø, K., Owe, K. M., & Eberhard-Gran, M. (2012). Do pregnant women follow exercise guidelines? Prevalence data among 3482 women, and prediction of low-back pain, pelvic girdle pain and depression. Br J Sports Med, bjsports-2012.

- Fell, D. B., Joseph, K. S., Armson, B. A., & Dodds, L. (2009). The impact of pregnancy on physical activity level. Maternal and Child Health Journal, 13(5), 597–603.

- Evenson, K. R., Savitz, A., & Huston, S. L. (2004). Leisure‐time physical activity among pregnant women in the US. Paediatric and Perinatal Epidemiology, 18(6), 400–407.

Line 48-60 - this fragment should be moved to the Method chapter

3. Statistical Analysis

Line 153 – it is necessary to make the following sentence more specific: 1 MET is the metabolic equivalent of the energy expended at rest and equals 3.5 ml O2/kg/min.

4. Results

Line 184 - missing ”p”, as in line 222

Line 190 –it is necessary to mark significant differences* in tab. 3

Line 199 - full stop is not placed at the end of legend

In Tab. 2-6 it is necessary to standardize the p value record in the legend. In tab. 2 and 3 there is: p value less than 0.05 considered as significant. In tab. 4, 5, 6 - * P < 0.05

Line 205 – standardize the lower case p (e.g. line 182), the capital P (e.g. line 205)

Line 224-226 – this fragment should be moved to Discussion

5. Apart from the Introduction, the Discussion is the weakest part of the paper. The Authors refer to data from 35 years ago (line 236).

Line 237-240 – The sentence Although the ACOG recommends pregnant females to maintain a moderately steady intensity level of exercise, yet a low percentage of pregnant women exercise at recommended levels, which is significantly lower when compared to the general population (“ACOG Committee Opinion No. 650,” 2015) is not clear. Which women? Lebanese?

Line 249 – where does this conclusion come from? As expected, PA increased during the second trimester in our sample. The results indicate that it only refers to household/caregiving and light intensity PA.

Line 258-260 – instead of 52% it should be 51,4%

Line 266 - Watching television was the sedentary behavior that the majority of women spent, similar in the study of Santos PC et al (Santos et al., 2016) and Chasan-Taber et al (Chasan-Taber et al., 2004a). How do we know it? How does it relate to the phrase in line 174? -

18% had a sedentary lifestyle

Line 267 i 268 - the first letter of the name is not necessary

Line 268 – The following sentence raises controversy: Chandonnet N. et al. applied the French version of PPAQ among pregnant obese women who were predominantly active in household and caregiving activities, as in our sample specially among housewives, or those with no higher academic education (Chandonnet et al., 2012). The quoted study can only be compared to obese participants. Have the authors examined the professional status? Where does this conclusion come from? Besides, the quote (Chandonnet et al., 2012) should appear after Chandonnet N. et al. – and not at the end of the sentence, because this part of the sentence regards the study of the Authors.

Line 273-276 –In the sentence Results derived from this study showed positive correlations regarding maternal age and total PA ( P= 0.034), however no associations were seen between PPAQ scores and pregestational BMI, gestational age, worry or insomnia (Mourady et al., 2017) it is not clear which results refer to the study by Mourady et al., 2017, and which refer to the Authors’ study. Moreover, worry and insomnia were not tested.

Reviewer #2: The authors present a work of interest and the translation of a widely used tool during pregnancy, that is useful to use in other countries and languages. Also, it gives a general insight of the PA levels of Lebanese pregnant women for the first time, being a topic of interest. However, the presentation of the results and discussion needs review, as well as some part of the statistical analysis. The full text need a deep revision of the English writing, as well as the construction of several sentences.

Abstract

Line 5. Please change PA level for “levels” throughout the text, as it refers to different intensities.

Line 7-9. Please rephrase the sentence or watch the punctuation, as it is difficult to follow.

Line 13. Please change females for women throughout the text.

Line 19-20. Compare to what? To first trimester? Or to other types of activities? Please specify in abstract. Also, the second trimester does not have the highest results for occupational activities, if you see the respective table.

Introducition

Page 9 line 41. Change benefice for benefits.

Line 41-44. Could you cite any of those questionnaires that are too long or subjective?. How is PPAQ not subjective, as it is a self-administred questionnaire. Please rewrite if necessary.

Line 51. Add to the sentence that is the amount of time spent in the specific activity.

Line 51. Start the sentence with Six instead of 6.

Methods

Line 100. Don’t know if I understand well. The 45 pregnant females were all part of the university staff? If not, please, rephrase.

Line 109. Mentioned where? In the introduction you say PA is important together with nutrition, but no mentioning of using another questionnaire. Furthermore, even if this particular study does not need that specific information as you used another complimentary questionnaire to assess that, maybe another study will use the full information, and therefore, the final Arabic version should take into account all the questions.

Line 118. There are no other activities more usual in the Middle East that could be changed for those activities with a similar MET expenditure? This way the totals could be comparable with studies from other countries using the PPAQ.

Line 120. Please change “our” environment for “Middle Eastern” or “Arabic” countries.

Line 127. Please cite the sutyd of there is a clinical trial or pprevious work published.

Line 129. Singleton baby or singleton pregnancy?

Line 134. Please refer to self-administer the newly translated PPAQ

Line 154. Please specify that the final number was 2 less in your study and you took that into account in the corresponding kind of activity/intensity totals.

Statistical Analyses. Please indicate the corresponding table of results to each of the statistical analyses described.

The authors don’t specify any confounders for the ANOVA analyses comparing the PPAQ results by groups. However, when comparing, for example the PA levels by high education of low education (table 2) they don’t take into account how many women there are of each trimester of gestation, in each group. Even more, given the information that the PA levels differ significantly during the different trimesters, they may consider it as confounder. The same would apply for other tables and confounders.

Results

162 add “of pregnancy” at the end of the sentence.

Line 204-205. Please keep the hypothesis and subjective approach for the discussion section with the proper citation.

Tables. In all titles of the tables, please add “sedentary time” to the “Type and intensity of PA”. Also, please add units of measurement.

Line 222. Add “respectively” after the P values.

Lines 224-228. Please put this information into the discussion section.

Discussion.

Line 251. The authors state “PA increased during the second trimester in our sample. Indeed, this period is considered to be the most comfortable period during gestation, where women often feel themselves more energetic and eager to be physically active”, while in the table, the total score for PPAQ is higher in the third trimester than the second, as well as in some particular intensities and activities. Also, please use references when explaining your results.

Line 253-256. Please rephrase into shorter sentences (there is twice the word “since”)

277. Highlights.

286-287. Final part of the sentence is not clear.

294. How is the sample homogenous if there are women of all gestational ages and from different studies and economic backgrounds?

Conclusions.

Line 303. Please rephrase the last sentence.

Line 310. Women

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Reviewer #1: No

Reviewer #2: No

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25 Dec 2019

PONE-D-19-25377

Pregnancy physical activity questionnaire (PPAQ): translation and cross cultural adaption of an Arabic version.

PLOS ONE

Dear Dr Papazian,

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

General comments

• The manuscript is not presented in an intelligible fashion and typographical errors are commonly encountered.

The article has been reviewed by a colleague who is fluent in English to correct all grammatical and typing mistakes.

• The approach used for classifying some of your key variables (e.g. gestational weight gain, nutritional status and physical well being) has not been clearly described at all.

We added the classifications and details of those key variables in the main manuscript. Thank you.

• Please make sure that you have followed the PLOS one standards in writing the in-text citations and references.

All corrections were done.

• Please revise the discussion section as per the recommendation provided by the two reviewers.

Done. New references were added as recommended by the reviewers.

We would appreciate receiving your revised manuscript by Dec 26 2019 11:59PM. When you are ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter.

To enhance the reproducibility of your results, we recommend that if applicable you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). This letter should be uploaded as separate file and labeled 'Response to Reviewers'.

• A marked-up copy of your manuscript that highlights changes made to the original version. This file should be uploaded as separate file and labeled 'Revised Manuscript with Track Changes'.

• An unmarked version of your revised paper without tracked changes. This file should be uploaded as separate file and labeled 'Manuscript'.

Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out.

We look forward to receiving your revised manuscript.

Kind regards,

Samson Gebremedhin, PhD

Academic Editor

PLOS ONE

Journal Eequirements:

1. When submitting your revision, we need you to address these additional requirements. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at http://www.journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and http://www.journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

Done.

2. Please include additional information regarding the sample size of your main study and how this number of participants was reached - e.g. referring to previous studies or a power calculation.

We included in the final analyses, the data of all participants who were recruited (N=179), even though, initially we aimed to include 150 subjects. This value was arbitrarily set, taking into account the sample sizes used in previous similar studies. The main developer of this tool, Lisa Chasan-Taber administered the newly created tool in a sample of 235 women 1, while Santos et al in 118 Portuguese females, in 2016. Çirak Y. et al translated and evaluated the physical activity level of 205 Turkish women, while in a country as overpopulated as China, this tool was translated and tested among 182 pregnant women Mi Xiang. Chandonnet et al. translated and applied this instrument among 56 French women (Plos one).

3. Thank you for stating the following in the Acknowledgments Section of your manuscript:

This research received no specific grant from any funding agency, commercial or not-for-profit sectors.

Done.

We note that you have provided funding information that is not currently declared in your Funding Statement. However, funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form.

Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows:

The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Corrections were done. This study received no funding.

4. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information.

Done. Corrections were done according to the instructions provided.

5. Please amend the manuscript submission data (via Edit Submission) to include author Daisy Chammas.

Done. Thank you.

6. We note you have included a table to which you do not refer in the text of your manuscript. Please ensure that you refer to Table 6 in your text; if accepted, production will need this reference to link the reader to the Table.

Done. Thank you.

Additional Editor Comments (section-by-section comments):

Abstract

• Please make sure that the abstract is prepared in line with the standards of the journal.

Done.

• Can you please provide additional information on how the “translation, pre-testing, and cross-cultural adaptation” was made?

A brief explanation was added in the abstract.

• It would be good to change the header “discussion” to “conclusion”

Done.

Background

• Line 44-47: the sentence “The Pregnancy Physical Activity Questionnaire (PPAQ) is a self-administered tool, created to evaluate the frequency, duration and intensity of different types of activities conducted by pregnant females during the last three months.” Is vague? When you say last 3 months, do you mean the last trimester or in the preceding 3 months of the survey?

The PPAQ measures physical activity level during the preceding 3 months of the survey. This was corrected in the manuscript. Thank you for your comment.

Methods

• Did you evaluate the adequacy of the sample size for measuring the level of physical activity in the study population? In the manuscript nothing has been said about it.

The primary aim of the study was to translate and culturally adapt an internationally validated tool (PPAQ) into Arabic and the secondary aim was to test it on a sample of pregnant women in a descriptive cross-cultural study. We aimed to include 150 subjects. This value was arbitrarily set, taking into account the sample sizes used in previous similar studies.(METTRE REF)

Our research team aims to validate our tool (PPAQ-arabic) against accelerometers in an upcoming study among a sample size with a more statistical power.

• Line 121: the PPAQ items were dropped to 31. Do you think this had implication on the level of physical activity you estimated in your population? As you reduce the item have you proportionally reduced the cut-off for defining the level of physical activity?

The removal of those two questions will not affect the total calculations/ cut-off determination, since those items were referring to mowing the lawn and showering the snow off. Those activities are not possible to be realized in the hot, humid, sandy and desert climate of the Middle-East. In addition, since the region is overpopulated, the housing system is mostly in buildings and not private houses, with no gardening facilities. Hence, our research committee presumed that the response “Never” of our participants to those 2 items, will not affect the outcome of our data analyses.

• Page 130-31: how did you assure that pregnant females from different educational backgrounds, socioeconomic status and gestational age were recruited? Did you apply kind of purposive sampling? And how did this affect the external validity of your study?

We did not apply a kind of purposive sampling. Women were recruited during their prenatal visits, in different clinics during their regular checkups to their gynecologist. After insuring that the patient fulfills the selection criterias, the research team explained to each participant the aim of this research, irrespective of her educational, socioeconomical or gestational age. We aimed to recruit pregnant women at different trimesters, in order to study the evolution of physical activity during gestation.

• Line 132-33: did you observe considerable difference between the information collected by interviewer-administered and self-administered questionnaires? Nothing has been said about this in the results and discussion sections.

The creation of the Arabic version of PPAQ to evaluate the physical activity level among our participants was part of our global questionnaire, which focused more on Mediterranean diet adherence and nutritional status of pregnant females. The section reserved to PPAQ was self-administered and not filled during the face to face interview. Research assistants were present in the medical cabinet, but their role was to interfere only if a woman was unable to understand an item present in the questionnaire.

Results

• Table 7: please report the means and the standard deviations with the same precision.

Done.

• Table 7, do you really need 5 decimal place number for the crowding index.

Two decimals were kept after the decimal point. Thank you for your comment.

• In the methods section please describe how you computed the variable “crowding index”.

Done. An explanation was provided.

• Table 7: seems few of the study subjects were illiterates. So how did they fill the self-administered version of the questionnaire? I think they should have been excluded from the study in the first place.

Those subjects were not illiterates, however they had a primary level of education. Hence, we omitted the word “illiterate” and replace it with “primary”. The rate of illiteracy is very low in our country and the Lebanese societal and cultural habits are quite different from the Arabic neighboring nations, since Lebanese women are more socially empowered, which helps them play an important role in our modern society.

In addition, according to the latest national statistics in our country (in 2007) concerning current educational level according to age, data show that more than 80% of the Lebanese population aged above 19 years has a university degree, even in low income regions. These percentages reach respectively 90 and 92.6% in Lebanese aged between 25-29 and 35-39 (with no significant differences between males and females). Hence, we can say that women in our sample were not illiterate. It was a vocabulary mistake. Thank you for your remark.

(Ref: http://www.cas.gov.lb/images/PDFs/Educational%20status-2007-ar.pdf, page 214)

• Table 7: How did you classify gestational weight gain as insufficient, adequate or excessive? Similarly, the approach used to classify the variables “nutritional status” and “physical wellbeing” is confusing because no operational definitions had been given.

Gestational weight gain was classified according to the values defined by the Institute of Medicine1. This was added in the manuscript with the corresponding reference.

1 Institute of Medicine (US) and National Research Council (US) Committee to Reexamine IOM Pregnancy Weight Guidelines. Weight Gain During Pregnancy: Reexamining the Guidelines [Internet]. Rasmussen KM, Yaktine AL, editors. Washington (DC): National Academies Press (US); 2009 [cited 2019 Mar 13]. (The National Academies Collection: Reports funded by National Institutes of Health). Available from: http://www.ncbi.nlm.nih.gov/books/NBK32813/

Women rated their “Nutritional status” and “Physical wellbeing” subjectively, by providing answers in a Likert scale; very bad, bad, average, good and excellent.

• Line 170: I think you need to have another sub-header here. Information about MET should not be under socio-demographic information

Done. We added a sub-header as requested. Thank you.

• 176-78: “Significant correlations were observed when we stratified the sample depending on …….” Correlation between what?

Done. The correction was done according to the remark. Thank you.

• Line 178: “a p value of 0.00” >> “p value < 0.01”

Done.

• Table 3: please clearly indicate with * all the significant p values.

Done.

• Line 221: “The last table ” >> “Table 6”

Done.

• Table 6: what was the basis for selecting the three variables (maternal age, crowding index and pregestational BMI) as key predictors of physical activity during pregnancy? Have you had a priority hypothesis or was that a post-hoc analysis?

The selection of those variables were highlighted and emphasized after finding significant associations with physical activity. We did not have a priority hypothesis, prior to that outcomes.

• Again, it is not clear how the pre-pregnancy BMI was determined. How did you manage to get information about their pre-pregnancy weight?

BMI was determined as the ratio of pregestational weight in kgs to the square of height in meter. It was then categorized according to the WHO cut-off points1. All anthropometric measurements were copied directly from the medical file, the day of the recruitment. Details and references concerning this issue were added in the manuscript. Thank you.

1Physical status: the use and interpretation of anthropometry. Report of a WHO Expert Committee. World Health Organ Tech Rep Ser. 1995;854:1–452.

Discussion

• Please see blow the comments forwarded by the reviewers

Done.

Conclusion

• Line 301-5: I think this should rather be in the discussion, not conclusion, section

Done. Thank you.

Reference and citation

• Please note that PLOS uses “Vancouver” style, as outlined here https://www.nlm.nih.gov/bsd/uniform_requirements.html: please modify the intext citations and references accordingly.

Done. All references were written in Vancouver style.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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

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

Reviewer #1: No

Reviewer #2: Partly

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

Reviewer #1: Yes

Reviewer #2: No

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

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

Reviewer #1: No

Reviewer #2: Yes

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

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

Reviewer #1: No

Reviewer #2: No

Submitted filename: Rebutal letter PPAQ.docx

Click here for additional data file.

14 Jan 2020

PONE-D-19-25377R1

Pregnancy physical activity questionnaire (PPAQ): translation and cross cultural adaption of an Arabic version.

PLOS ONE

Dear Dr Papazian,

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

Abstract

Line 7-9: Please also indicate one of the objectives of the study was to measure the physical activity of pregnant women using the adapted PPAQ.

The methods sub-section is very superficial and does not clearly describe the four steps followed in the adaptation process.

The results sub-section looks deficient because it does not report on the cross-cultural adaptations made to the PPAQ tool, which is one of the objectives of the study.  Please revise accordingly.

“with a significant p-value of 0.031 and 0.001 respectively” which specific groups are these p-values referring to? Household? Caregiving? occupational activities?

“Our results reported that 51% of women engage in light intensity physical activity. Please also report % who had high intensity exercise and sedentary life style.

Background

Line 38-9: Can you put a citation for the claim “In addition, due to religious sensitivities, exercising in public areas or local gyms are forbidden for women in some Middle-Eastern countries”.

Methods

Line 76-76: please provide citation for the sentence “Our research team followed the guidelines depicted by Guillemin et al., which were composed of 4 phases, to guarantee the reliability of the translated tool”.

In the methods section please clearly describe how the 179 student participants were selected for the study and how this sample size was reached at.

Results

Line 177-8: “The mean BMI calculated based on their pregestational weight was 22.94± 3.60 kg/m” how did you manage to determine the pre-pregnancy weight? Please describe in the methods section.

Line 180-182 and table-1: it is not clear what you mean by “self-reported nutritional status” and “self-reported physical well-being”. Please also clearly describe in the methods section how these variables were measured.

Line 192: “Significant correlations……” please change to “significant association”.

Discussion

Line 250-1: “This ensured the homogeneity of our sample.”??? Not clear please rephrase it again?

Line 315 “The strength of our study is the homogeneity of the sample”. Homogeneity on the basis of what?

We would appreciate receiving your revised manuscript by Feb 28 2020 11:59PM. When you are ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter.

To enhance the reproducibility of your results, we recommend that if applicable you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). This letter should be uploaded as separate file and labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. This file should be uploaded as separate file and labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. This file should be uploaded as separate file and labeled 'Manuscript'.

Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out.

We look forward to receiving your revised manuscript.

Kind regards,

Samson Gebremedhin, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (if provided):

Please also make sure that the following comments, which had been forward by one of the reviewers during the first-round review, had been accommodated.

The authors present a work of interest and the translation of a widely used tool during pregnancy, that is useful to use in other countries and languages. Also, it gives a general insight of the PA levels of Lebanese pregnant women for the first time, being a topic of interest. However, the presentation of the results and discussion needs review, as well as some part of the statistical analysis. The full text need a deep revision of the English writing, as well as the construction of several sentences.

Abstract

Line 5. Please change PA level for “levels” throughout the text, as it refers to different intensities.

Line 7-9. Please rephrase the sentence or watch the punctuation, as it is difficult to follow.

Line 13. Please change females for women throughout the text.

Line 19-20. Compare to what? To first trimester? Or to other types of activities? Please specify in abstract. Also, the second trimester does not have the highest results for occupational activities, if you see the respective table.

Introducition

Page 9 line 41. Change benefice for benefits.

Line 41-44. Could you cite any of those questionnaires that are too long or subjective?. How is PPAQ not subjective, as it is a self-administred questionnaire. Please rewrite if necessary.

Line 51. Add to the sentence that is the amount of time spent in the specific activity.

Line 51. Start the sentence with Six instead of 6.

Methods

Line 100. Don’t know if I understand well. The 45 pregnant females were all part of the university staff? If not, please, rephrase.

Line 109. Mentioned where? In the introduction you say PA is important together with nutrition, but no mentioning of using another questionnaire. Furthermore, even if this particular study does not need that specific information as you used another complimentary questionnaire to assess that, maybe another study will use the full information, and therefore, the final Arabic version should take into account all the questions.

Line 118. There are no other activities more usual in the Middle East that could be changed for those activities with a similar MET expenditure? This way the totals could be comparable with studies from other countries using the PPAQ.

Line 120. Please change “our” environment for “Middle Eastern” or “Arabic” countries.

Line 127. Please cite the sutyd of there is a clinical trial or pprevious work published.

Line 129. Singleton baby or singleton pregnancy?

Line 134. Please refer to self-administer the newly translated PPAQ

Line 154. Please specify that the final number was 2 less in your study and you took that into account in the corresponding kind of activity/intensity totals.

Statistical Analyses. Please indicate the corresponding table of results to each of the statistical analyses described.

The authors don’t specify any confounders for the ANOVA analyses comparing the PPAQ results by groups. However, when comparing, for example the PA levels by high education of low education (table 2) they don’t take into account how many women there are of each trimester of gestation, in each group. Even more, given the information that the PA levels differ significantly during the different trimesters, they may consider it as confounder. The same would apply for other tables and confounders.

Results

162 add “of pregnancy” at the end of the sentence.

Line 204-205. Please keep the hypothesis and subjective approach for the discussion section with the proper citation.

Tables. In all titles of the tables, please add “sedentary time” to the “Type and intensity of PA”. Also, please add units of measurement.

Line 222. Add “respectively” after the P values.

Lines 224-228. Please put this information into the discussion section.

Discussion.

Line 251. The authors state “PA increased during the second trimester in our sample. Indeed, this period is considered to be the most comfortable period during gestation, where women often feel themselves more energetic and eager to be physically active”, while in the table, the total score for PPAQ is higher in the third trimester than the second, as well as in some particular intensities and activities. Also, please use references when explaining your results.

Line 253-256. Please rephrase into shorter sentences (there is twice the word “since”)

277. Highlights.

286-287. Final part of the sentence is not clear.

294. How is the sample homogenous if there are women of all gestational ages and from different studies and economic backgrounds?

Conclusions.

Line 303. Please rephrase the last sentence.

Line 310. Women

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

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

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

19 Feb 2020

Rebuttal Letter

Dear editor and reviewers,

On behalf of all the authors, we highly appreciate your valuable comments and recommendations, that were fully taken into consideration in the final revised submitted manuscript. Hope it will meet your requirements.

PONE-D-19-25377R1

Pregnancy physical activity questionnaire (PPAQ): translation and cross cultural adaption of an Arabic version.

PLOS ONE

Dear Dr Papazian,

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

Abstract

• Line 7-9: Please also indicate one of the objectives of the study was to measure the physical activity of pregnant women using the adapted PPAQ. Done.

• The methods sub-section is very superficial and does not clearly describe the four steps followed in the adaptation process. An explanation was added.

• The results sub-section looks deficient because it does not report on the cross-cultural adaptations made to the PPAQ tool, which is one of the objectives of the study. Please revise accordingly. Done.

• “with a significant p-value of 0.031 and 0.001 respectively” which specific groups are these p-values referring to? Household? Caregiving? occupational activities? An explanation was added.

• “Our results reported that 51% of women engage in light intensity physical activity. Please also report % who had high intensity exercise and sedentary life style. Done.

Background

• Line 38-9: Can you put a citation for the claim “In addition, due to religious sensitivities, exercising in public areas or local gyms are forbidden for women in some Middle-Eastern countries”. A citation was added.

Methods

• Line 76-76: please provide citation for the sentence “Our research team followed the guidelines depicted by Guillemin et al., which were composed of 4 phases, to guarantee the reliability of the translated tool”. Done.

• In the methods section please clearly describe how the 179 student participants were selected for the study and how this sample size was reached at. An explanation was provided.

Results

• Line 177-8: “The mean BMI calculated based on their pregestational weight was 22.94± 3.60 kg/m” how did you manage to determine the pre-pregnancy weight? Please describe in the methods section. An explanation was provided.

• Line 180-182 and table-1: it is not clear what you mean by “self-reported nutritional status” and “self-reported physical well-being”. Please also clearly describe in the methods section how these variables were measured. An explanation was provided.

• Line 192: “Significant correlations……” please change to “significant association”. Done

Discussion

• Line 250-1: “This ensured the homogeneity of our sample.”??? Not clear please rephrase it again?

• Line 315 “The strength of our study is the homogeneity of the sample”. Homogeneity on the basis of what?

Corrections were done and the term “homogeneity” was removed from the manuscript. Thank you.

We would appreciate receiving your revised manuscript by Feb 28 2020 11:59PM. When you are ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter.

To enhance the reproducibility of your results, we recommend that if applicable you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). This letter should be uploaded as separate file and labeled 'Response to Reviewers'.

• A marked-up copy of your manuscript that highlights changes made to the original version. This file should be uploaded as separate file and labeled 'Revised Manuscript with Track Changes'.

• An unmarked version of your revised paper without tracked changes. This file should be uploaded as separate file and labeled 'Manuscript'.

Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out.

We look forward to receiving your revised manuscript.

Kind regards,

Samson Gebremedhin, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (if provided):

Please also make sure that the following comments, which had been forward by one of the reviewers during the first-round review, had been accommodated.

The authors present a work of interest and the translation of a widely used tool during pregnancy, that is useful to use in other countries and languages. Also, it gives a general insight of the PA levels of Lebanese pregnant women for the first time, being a topic of interest. However, the presentation of the results and discussion needs review, as well as some part of the statistical analysis. The full text need a deep revision of the English writing, as well as the construction of several sentences.

The manuscript was corrected by a colleague, whose native language was English. A regression analysis was done to improve the statistical outcomes and the results. The discussion section was reviewed as well.

Abstract

Line 5. Please change PA level for “levels” throughout the text, as it refers to different intensities.

Done.

Line 7-9. Please rephrase the sentence or watch the punctuation, as it is difficult to follow.

Done.

Line 13. Please change females for women throughout the text.

Done.

Line 19-20. Compare to what? To first trimester? Or to other types of activities? Please specify in abstract. Also, the second trimester does not have the highest results for occupational activities, if you see the respective table.

Corrections were done. Thank you.

Introducition

Page 9 line 41. Change benefice for benefits.

Done.

Line 41-44. Could you cite any of those questionnaires that are too long or subjective?

Done.

How is PPAQ not subjective, as it is a self-administred questionnaire. Please rewrite if necessary.

Corrections were done. This was added in the limitation section too.

Line 51. Add to the sentence that is the amount of time spent in the specific activity.

This is the sentence in line 51: “A valid PA tool in Arabic is necessary to help researchers assess, monitor and evaluate PA in North African and Middle Eastern pregnant females”.

We added as suggested: A valid PA tool in Arabic is necessary to help researchers assess, monitor and evaluate PA as well as the amount of time spent in each specific activity, in North African and Middle Eastern pregnant females.

Is this what you proposed?

Line 51. Start the sentence with Six instead of 6.

There is no 6 in the line 51.

Methods

Line 100. Don’t know if I understand well. The 45 pregnant females were all part of the university staff? If not, please, rephrase.

The participants of the pilot phase of the study were from our university community (lecturers, employees, students) and the affiliated hospital staff (nurses, employees, dietitians, doctors…).

Line 109. Mentioned where? In the introduction you say PA is important together with nutrition, but no mentioning of using another questionnaire.

Data in relation with the nutritional status and physical activity will be presented in another article.

Furthermore, even if this particular study does not need that specific information as you used another complimentary questionnaire to assess that, maybe another study will use the full information, and therefore, the final Arabic version should take into account all the questions.

Done. We can add to the translated PPAQ to be shared in the future with other researchers those questions related to the date of recruitment, last menstrual period, and the predicted date of delivery.

Line 118. There are no other activities more usual in the Middle East that could be changed for those activities with a similar MET expenditure? This way the totals could be comparable with studies from other countries using the PPAQ.

In Middle Eastern and Arabic countries, religious constraints, lack of green spaces, and societal traditions don’t offer new choices or behaviors of physical activity.

Line 120. Please change “our” environment for “Middle Eastern” or “Arabic” countries.

Done

Line 127. Please cite the sutyd of there is a clinical trial or pprevious work published.

After reviewing publications on Pubmed and to our knowledge, our study is the first to evaluate physical activity level among women in Arab countries and the Middle-East. Our research team conducted in parallel, another study, with different objectives, among a different sample of women, and used our translated version of the PPAQ. We provided in our manuscript, some details related to this study and cited the proper reference.

Line 129. Singleton baby or singleton pregnancy?

Singleton pregnancy. It was corrected in the text. Thank you.

Line 134. Please refer to self-administer the newly translated PPAQ

It was mentioned in line 144 as follow:

“The last part of the questionnaire, concerned the newly translated PPAQ and was self-filled by the participants themselves”

Line 154. Please specify that the final number was 2 less in your study and you took that into account in the corresponding kind of activity/intensity totals.

We did not understand the comment. Line 154 is a subtitle. What do you suggest? If you can explain further please.

Statistical Analyses. Please indicate the corresponding table of results to each of the statistical analyses described.

The authors don’t specify any confounders for the ANOVA analyses comparing the PPAQ results by groups. However, when comparing, for example the PA levels by high education of low education (table 2) they don’t take into account how many women there are of each trimester of gestation, in each group. Even more, given the information that the PA levels differ significantly during the different trimesters, they may consider it as confounder. The same would apply for other tables and confounders.

In order to control confounding factors, univariates analyses followed by multivariate analyses were performed to assess the association between each explanatory variable and the PPAQ. A new table was added at the end of the result section, as follows.

Table 7. Multiple regression analysis of explanatory factors associated with PPAC in women

Unstandardized Coefficients Standardized Coefficients t Sig. 95.0% Confidence Interval for B

B Std. Error Beta Lower Bound Upper Bound

(Constant) 176.566 71.302 2.476 .014 35.831 317.300

Maternal age 1.654 1.281 .096 1.291 .198 -.875 4.183

Education 20.560 15.499 .099 1.327 .186 -10.031 51.150

Nutritional status [Ref: very bad/bad] -70.038 25.462 -.202 -2.751 .007 -120.294 -19.782

Physical status [Ref: very bad / Bad] 41.538 17.988 .171 2.309 .022 6.034 77.043

Results

162 add “of pregnancy” at the end of the sentence.

Done.

Line 204-205. Please keep the hypothesis and subjective approach for the discussion section with the proper citation.

These are lines 204-205:

“… sedentary lifestyle with a significant p value of 0.001 compared with females in their first or second trimester. In addition, household chores were significantly higher in women, in their second..”

in these lines, there is no hypothesis or subjective approach, they are results of the study that we present.

Tables. In all titles of the tables, please add “sedentary time” to the “Type and intensity of PA”. Also, please add units of measurement.

Done. Thank you.

Line 222. Add “respectively” after the P values.

Done.

Lines 224-228. Please put this information into the discussion section.

Line 224-228 are in fact the table 4 and not a text. So we did not understand the comment.

Discussion.

Line 251. The authors state “PA increased during the second trimester in our sample. Indeed, this period is considered to be the most comfortable period during gestation, where women often feel themselves more energetic and eager to be physically active”, while in the table, the total score for PPAQ is higher in the third trimester than the second, as well as in some particular intensities and activities. Also, please use references when explaining your results.

All this section was reviewed and corrected. New references were added.

Line 253-256. Please rephrase into shorter sentences (there is twice the word “since”)

The sentence was reformulated and corrected accordingly. Thank you.

277. Highlights.

Done

286-287. Final part of the sentence is not clear.

Corrections were done. Thank you.

294. How is the sample homogenous if there are women of all gestational ages and from different studies and economic backgrounds?

The sentence was reformulated and the word “homogenous” was deleted. Thank you.

Conclusions.

Line 303. Please rephrase the last sentence.

Done.

Line 310. Women

Done.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

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

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

Submitted filename: Response to reviewers.docx

Click here for additional data file.

2 Mar 2020

Pregnancy physical activity questionnaire (PPAQ): translation and cross cultural adaption of an Arabic version.

PONE-D-19-25377R2

Dear Dr. Papazian,

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

Within one week, you will receive an e-mail containing information on the amendments required prior to publication. When all required modifications have been addressed, you will receive a formal acceptance letter and your manuscript will proceed to our production department and be scheduled for publication.

Shortly after the formal acceptance letter is sent, an invoice for payment will follow. To ensure an efficient production and billing process, please log into Editorial Manager at https://www.editorialmanager.com/pone/, click the "Update My Information" link at the top of the page, and update your user information. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to enable them to help maximize its impact. If they will be preparing press materials for this manuscript, you must inform our press team as soon as possible and no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

With kind regards,

Samson Gebremedhin, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

12 Mar 2020

PONE-D-19-25377R2

Pregnancy physical activity questionnaire (PPAQ): translation and cross cultural adaption of an Arabic version.

Dear Dr. Papazian:

I am pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please notify them about your upcoming paper at this point, to enable them to help maximize its impact. If they will be preparing press materials for this manuscript, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

For any other questions or concerns, please email plosone@plos.org.

Thank you for submitting your work to PLOS ONE.

With kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Samson Gebremedhin

Academic Editor

PLOS ONE