Virtual Forest Bathing Programming as Experienced by Disabled Adults with Mobility Impairments and/or Low Energy: A Qualitative Study
Round 1
Reviewer 1 Report
Comments on the article Virtual Forest bathing compared with waitlist control improved symptom severity, rumination, and social connection in adults with mobility impairment and/or low energy-Virtual Forest bathing for adults with mobility impairment (Manuscript ID forests-2290915)
Introduction
please clearly state which is the research gap you identified and how you planned to fill it in.
exclude line 131, 1.1 Aims
Materials and Methods
2.1. Design
Line 148-149 too small number of respondents, only N=31. There should be a larger sample in the survey.
Result
there are 14 parts in Results. This is enormous. Please integrate and reduce to a maximum 8 of them.
Discussion
In the Discussion section, the authors should discuss and explain the findings and results of the paper more.
This would contribute to a high improvement of the paper. The authors should compare their project and results with the results of similar studies on this topic from other parts of the world.
Conclusion
Please move 4.1. Limitations and future directions (lines 681-689) to the final part of the manuscript.
References
Technical errors to be corrected:
The literature list needs to be improved according to the journal's guidelines.Author Response
Reviewer 1 comments
Thank you for your thoughtful comments which have helped us to much improve the paper.
Introduction
please clearly state which is the research gap you identified and how you planned to fill it in.
exclude line 131, 1.1 Aims
Author response
We have tried to clarify in the Introduction what we considered as research gaps and how we planned to fill these by adding the following new text (in red). Please note that following your comment about sample size for the survey respondents, we have removed all survey data and only report the qualitative data for this study.
‘Access to nature has benefits for physical and mental wellbeing [1, 2]. However, opportunities to access nature are not equal for all, and for those with mobility impairment, access to nature can be limited. In addition to poor physical access to nature, few nature-based programs make provision for people with mobility impairment and there are very few previous studies evaluating participants experiences of pro-grams adapted for people with mobility impairment. In addition, very few studies obtain qualitative feedback from participants with mobility impairment, concerning efforts to make nature experiences more accessible. This paper therefore addresses this research gap by providing a qualitative evaluation of a virtual (online) alternative to accessing and connecting with nature for those with mobility impairment.’
‘To date there have been few studies exploring the experience of people with mobility impairment and/or low energy when engaging in virtual nature-based programs. Therefore, this study aimed to address this research gap by offering a qualitative evaluation of participant experiences and sought to summarise this into a contextual framework to inform the delivery of future accessible alternatives allowing those with mobility impairment to engage with nature.’
We have excluded line 131 as requested.
Materials and Methods
2.1. Design
Line 148-149 too small number of respondents, only N=31. There should be a larger sample in the survey.
Author response
Due to the burden of chronic illness, it can be challenging to recruit and retain participants with mobility impairment and low energy. In addition to the participants living with low mobility and low energy, the forest bathing guides delivering the intervention mostly have low mobility and low energy. Hence a limited number of programs may be offered each year and are often subject to guides and participants being well enough to participate. Any participation in a study (or delivery of an intervention) can mean making a choice about where to put one’s energy that day and potentially require more carer input which incurs further costs to the participant. Having looked at previous literature focusing on interventions for those with spinal injury and mobility impairment we do acknowledge that these studies tend to typically recruit more participants (e.g. N=70). Given that the submission deadline for this special issue is the 25th April, we cannot collect more survey data in time. We propose that to resolve your comment we could only report the qualitative data in this paper and report the survey data in a future publication when more data is available. Therefore we have removed the survey data from the paper and only report the qualitative data obtained from 26 participants at post-intervention, and 24 participants at one month follow-up.
Related to this point, we want to change the order of the authorship among our team members for this new version of the paper given its focus on the qualitative data to: Kirsten McEwan, Kari Krogh, Mahnoor Khan, Kim Dunlop and Alyssa Krogh.
Result
there are 14 parts in Results. This is enormous. Please integrate and reduce to a maximum 8 of them.
Author response
We have carefully gone through the results and deleted all tables and sections deemed unnecessary. Ten themes were confirmed by participants at the theme checking stage, so in order to fully capture participants experience and value their collaborative input in the research-process, we present the ten themes they confirmed. In addition, removing the survey data from the results has also reduced the length of the results section.
Discussion
In the Discussion section, the authors should discuss and explain the findings and results of the paper more.
This would contribute to a high improvement of the paper. The authors should compare their project and results with the results of similar studies on this topic from other parts of the world.
Author response
We have completely re-written the Discussion to discuss the findings in more detail and relate these to previous literature.
The paragraph in the Introduction about Canada was meant to set out brief information about accessibility policies in the country where the research took place. We recognise that for some readers this might be confusing and make it seem like the whole write-up is Canada focused. We have therefore removed this paragraph. The results were already compared to all the available literature we could find relating to nature-based interventions in mobility impaired populations (of which there is very little) and qualitative findings (of which there are few as most previous studies use quantitative methods) from previous nature-based intervention studies from all over the world.
Conclusion
Please move 4.1. Limitations and future directions (lines 681-689) to the final part of the manuscript.
Author response
We have removed this text to the final part of the manuscript as advised.
References
Technical errors to be corrected: The literature list needs to be improved according to the journal's guidelines.
Author response
We have formatted the reference list according to the journal guidelines.
Reviewer 2 Report
This paper investigates the effectiveness of virtual Forest bathing for adults with mobility impairment. The authors involved 31 people with motor disabilities in a waitlist/repeated measures study design, that was carried out one week before, 24hr before and 24hr after virtual Forest bathing, also collecting qualitative feedback. The main outcomes show that virtual Forest could improve health and wellbeing, reducing difficulties with memory/concentration, depression/anxiety and rumination.
Although interesting and well presented, the paper presents some flows that should be addressed to improve the scientific outcomes:
1. In order to improve the readability of the paper context, as well as the motivations behind the proposed research, I recommend the authors divide the “Introduction” Section into “Introduction” and “State-of-the-art” Sections.
2. Strictly related to the previous comment, the authors should clearly highlight how their research differs/improves the current state of the art (Section 1.1 seems too vague and there are no references)
3. Please, clarify at the beginning of the paper what the authors mean by “virtual Forest bathing”. As I started reading the paper, I thought it was related to virtual reality interfaces (3D immersive VR), and only after a few pages, I realized the authors employed 2D videos and images.
4. Please, add images of the virtual Forest bathing to the paper. It would improve the readability (similar to reference [49]).
5. Line 165: why does the number of participants differ (N=26, N=24)?
6. Section 3: the authors employed a paired-sample t-test without testing the data distribution. Paired-sample t-test should be used only with normal data distributions. Wilcoxon Signed Rank Test should instead be used in case of data not normally distributed. Data distribution can be tested with the Shapiro-Wilk test.
Comments for author File: 
Comments.pdf
Author Response
Reviewer 2
Thank you for your thoughtful comments which have helped us to much improve the paper.
This paper investigates the effectiveness of virtual Forest bathing for adults with mobility impairment. The authors involved 31 people with motor disabilities in a waitlist/repeated measures study design, that was carried out one week before, 24hr before and 24hr after virtual Forest bathing, also collecting qualitative feedback. The main outcomes show that virtual Forest could improve health and wellbeing, reducing difficulties with memory/concentration, depression/anxiety and rumination.
Although interesting and well presented, the paper presents some flows that should be addressed to improve the scientific outcomes:
In order to improve the readability of the paper context, as well as the motivations behind the proposed research, I recommend the authors divide the “Introduction” Section into “Introduction” and “State-of-the-art” Sections.
Author response
We have re-organised the Introduction so that state of the art text comes first and the final paragraph provides information on the current study and how this addresses gaps in the literature.
Strictly related to the previous comment, the authors should clearly highlight how their research differs/improves the current state of the art (Section 1.1 seems too vague and there are no references)
Author response
Section 1.1 has been removed
Please, clarify at the beginning of the paper what the authors mean by “virtual Forest bathing”. As I started reading the paper, I thought it was related to virtual reality interfaces (3D immersive VR), and only after a few pages, I realized the authors employed 2D videos and images.
Author response
We have added the following text to the Abstract and Methods sections:
Virtual programs were presented online to a group and involved 2D videos and images of nature accompanied by guidance from a certified forest bathing guide.
- Please, add images of the virtual Forest bathing to the paper. It would improve the readability (similar to reference [49]).
Author response
We have now added two 2D photographs used in the online intervention as examples.
Line 165: why does the number of participants differ (N=26, N=24)?
Author response
The survey data has now been removed in line with two of the reviewers comments that 31 survey participants is too few to be generalizable. We now only report the qualitative data obtained from 26 participants at post-intervention, and from 23 participants at one month follow-up.
Section 3: the authors employed a paired-sample t-test without testing the data distribution. Paired-sample t-test should be used only with normal data distributions. Wilcoxon Signed Rank Test should instead be used in case of data not normally distributed. Data distribution can be tested with the Shapiro-Wilk test.
Author response
The survey data has now been removed in line with two of the reviewers comments that 31 survey participants is too few to be generalisable.
Reviewer 3 Report
It is a very interesting paper concerning quite important problem: the meaning of virtual forest bathing (visual and sound impact) as a way to improve health and mental wellbeing of adults with mobility impairment (people who have difficulties / barriers to contact directly with true nature). Of course, such support by virtual forest bathing should not replace a real contact with true nature, but it may be be a significant addition / supplement (the Authors have emphasized this aspect in discussion and not only there).
Presented mixed-methods approach and plan of research are well constructed. But this research venture has one important disadvantage: too small number of respondents in realised online survey: N=31.
There should be a larger sample in the survey. Such small sample makes the interesting results of the survey not very credible. The Authors should extend the research by larger sample of respondents - it is my main recommendation fot Authors.
Other notices:
The topic of the Paper is difficult in perception for readers. Please, think it over again, because now the topic is hard in meaning; formulate it better.
Line 19 - replace letter "F" into "f" (forests).
In general: It is a very interesting article considering importat issues, with well-planed methodical approach, but the research was made on too few sample of respondents; this affects rather low reliability of results. So, the paper is worth publishing after major revisions.
Author Response
Reviewer 3
Thank you for your thoughtful comments which have helped us to much improve the paper.
It is a very interesting paper concerning quite important problem: the meaning of virtual forest bathing (visual and sound impact) as a way to improve health and mental wellbeing of adults with mobility impairment (people who have difficulties / barriers to contact directly with true nature). Of course, such support by virtual forest bathing should not replace a real contact with true nature, but it may be be a significant addition / supplement (the Authors have emphasized this aspect in discussion and not only there).
Presented mixed-methods approach and plan of research are well constructed. But this research venture has one important disadvantage: too small number of respondents in realised online survey: N=31. There should be a larger sample in the survey. Such small sample makes the interesting results of the survey not very credible. The Authors should extend the research by larger sample of respondents - it is my main recommendation for Authors.
Author response
Due to the burden of chronic illness, it can be challenging to recruit and retain participants with mobility impairment and low energy. In addition to the participants living with low mobility and low energy, the forest bathing guides delivering the intervention mostly have low mobility and low energy. Hence a limited number of programs may be offered each year and are often subject to guides and participants being well enough to participate. Any participation in a study (or delivery of an intervention) can mean making a choice about where to put one’s energy that day and potentially require more carer input which incurs further costs to the participant. Having looked at previous literature focusing on interventions for those with spinal injury and mobility impairment we do acknowledge that these studies tend to typically recruit more participants (e.g. N=70). Given that the submission deadline for this special issue is the 25th April, we cannot collect more survey data in time. We propose that to resolve your comment we could only report the qualitative data in this paper and report the survey data in a future publication when more data is available. Therefore we have removed the survey data from the paper and only report the qualitative data obtained from 26 participants at post-intervention, and 24 participants at one month follow-up.
Related to this point, we want to change the order of the authorship among our team members for this new version of the paper given its focus on the qualitative data to: Kirsten McEwan, Kari Krogh, Mahnoor Khan, Kim Dunlop and Alyssa Krogh.
Other notices:
The topic of the Paper is difficult in perception for readers. Please, think it over again, because now the topic is hard in meaning; formulate it better.
Author response
We have carefully been through the paper and removed and reorganised some of the text to help with formulation. The paper has undergone a substantial re-write and the removal of survey data has also simplified the paper.
Line 19 - replace letter "F" into "f" (forests).
Author response
We have replaced ‘Forest bathing’ with ‘forest bathing’ throughout.
Round 2
Reviewer 3 Report
The article has been changed in comparison with previous version.
Some important aspects have been more emphasized and highlighted.
Now the paper is OK. - worth publishing
