Indoor Thermal Comfort of Pregnant Women in Hospital: A Case Study Evidence
Round 1
Reviewer 1 Report
File attached.
Comments for author File: 
Comments.pdf
Author Response
Dear Reviewer, thanks for all your suggestions, we send in attachment our detailed response. The authors tried to improve the paper accordingly taking into account also the request of the other reviewers.
Thank you very much for the time you dedicated to this work.
Author Response File: 
Author Response.docx
Reviewer 2 Report
Dear Authors
I read with great interest this research paper focused on the evaluation of Indoor thermal Comfort of pregnant women in hospitals. The paper deals with a very interesting issue, in a specific context where is very difficult meet thermal comfort needs of three categories of persons as patients, staff and visitors.
I feel to stress that my observations have to be considered only as suggestions aimed at a high-quality paper.
Here below my major concerns (other minor issues in the pdf marked file)
Best regards
Introduction
The section is clear as far objectives is concerned, but it reveals some historical inaccuracies (e.g Fanger was not a physiologist) and a general lack in the knowledge of the scopes of International Standards in the field that reduces its impact (e.g. ISO 7730 and ASHRAE 55 are not aimed at the calculation of PMV). Besides, it is unclear the subjective survey has been carried out on pregnant/women in childbirth/new mothers.
Research aims
The originality of the research is very clear. Notwithstanding this, 70 lines of discussion about scattered topics (often out of the topic of the manuscript) appear excessive. You are invited to reduce it of 50% at least reporting only that information closely related to the survey discussed in the paper. In addition, they should specify that a hospital hosts 3 categories of people (patients, staff and visitors).
Materials and methods
It is unclear in what manner you have assessed the insulation of the bedding sheet (all investigated persons are covered by bedding sheets in the same way? All pregnant stay at bed?). In case of they stay at bed did you consider the high thermal insulation provided by the mattress? Please consider that thermal insulation of a chair is about 0.1-0.2 clo (0.35 in case of the seat of an aircraft). So I think that inconsistencies between TSV and PMV are mostly related to: 1) uncertainties in assessing Icl; 2) uncertainties in assessing the metabolic rate (maybe 1.2, 1.4 met is more realistic); 3) wrong placement of probes; 4) inability of PMV of considering this special kind of subjects (this applies also to adaptive models). Maybe you are not aware the high sensitivity of PMV with respect to the evaluation of subjective parameters as clothing insulation and metabolic rate, as investigated by several authors in the past (since 2011 due to the impact on the categorization of thermal comfort levels); The microclimatic monitoring has been carried out ignoring ISO 7726 that specifies the height of sensors. In addition, local thermal discomfort has not been investigated. According to the basic principles of thermal comfort and EN Standard 16798-1: "adaptive method only applies for occupants with sedentary activities without strict clothing policies where thermal conditions are regulated primarily by the occupants through opening and closing of elements in the building envelop (e.g. windows, ventilation flaps, roof lights, etc.). This method applies to office buildings and other buildings of similar type used mainly for human occupancy with mainly sedentary activities, where there is easy access to operable windows and occupants can freely adapt their clothing to the indoor and/or outdoor thermal conditions". Is this the case? Unfortunately no (see L 306): “the window was not opened for the entire duration of the test”. In addition, likewise PMV, also adaptive method is affected by the health conditions of people. Position of sensors has to be representative of the real position of occupants. I regret to observe that, according to figure 5 the bed is near a window whose effects on the mean radiant temperature depend upon solar radiation and outdoor temperature. In addition, the small dimensions of the globe and its placing on a table, results in the shielding of radiations coming from the ground. According to EN 16798-1, equations to be used are different from those reported in figure 9 where the independent variable is not the outdoor air temperature but the running mean outdoor temperature (exponentially averaged) Subjective survey does not contain the question on the evaluative scale (e.g. Do you find it ? from COMFORTABLE to very (or extremely), UNCOMFORTABLE) The week of pregnancy has e to be considered as key factor in discussion.
Discussion
Adjusting the metabolic rate value to obtain the agreement between subjective and objective investigation, sounds quite absurd is the final metabolic rate for a pregnant is more than twice of a standard person under sedentary activity conditions. This is especially because the oxygen demand during normal pregnancy varies from 220 (week 0) to 250 ml/min (week 38).
English wording
I am not a native speaker, but it seemed to me that the manuscript contains several spelling errors.
References
The authors are invited to verify the date of release of International Standards and consider only necessary references. Please consider these paper to sthrenghten your discussion and your methods section.
d'Ambrosio Alfano F.R., Olesen B.W., Palella B.I. (2017). Povl Ole Fanger’s Impact Ten Years Later. Energy and Buildings vol. 152, pp. 243-249. ISSN: 0378-7788, doi: 10.1016/j.enbuild.2017.07.052. d'Ambrosio Alfano F.R., Palella B.I., Riccio G., Malchaire J., (2016). On the Effect of Thermophysical Properties of Clothing on the Heat Strain Predicted by PHS Model. Annals of Occupational Hygiene, vol. 60(2), pp. 231-251. ISSN:0003-4878, doi: 10.1093/annhyg/mev070. Metabolic requirements for oxygen during the course of normal pregnancy in 11 normal pregnant women. (Based on data of Emerson K, Saxena GN, Poindexter EL, et al: Caloric cost of normal pregnancy. Obstet Gynecol 40(6):786, 197). Nancy F Butte, William W Wong, Margarita S Treuth, Kenneth J Ellis, E O'Brian Smith. Energy requirements during pregnancy based on total energy expenditure and energy deposition. The American Journal of Clinical Nutrition, Volume 79, Issue 6, June 2004, Pages 1078–1087, https://doi.org/10.1093/ajcn/79.6.1078 Ricciu R, Galatioto A, Desogus G, Besalduch LA. Uncertainty in the evaluation of the Predicted Mean Vote index using Monte Carlo analysis. J Environ Manage.2018 Oct 1;223:16-22. doi: 10.1016/j.jenvman.2018.06.005
Comments for author File: Comments.pdf
Author Response
Dear Reviewer, thanks for all your suggestions, we send in attachment our detailed response. The authors tried to improve the paper accordingly taking into account also the request of the other reviewers. Thank you very much for the time you dedicated to this work.Author Response File: Author Response.docx
Reviewer 3 Report
The authors have done an excellent job for this manuscript. The research is rigorous, and the authors have a stunning amount of rich data they have meticulously sorted and analysed in various ways, and then they have organised and presented the information in a clear and logical way that furthers their argument and addresses their research question(s). The paper organisation is quite good, where each section ends with reinforcing the importance of the study and relating information in the section to other data. Although, therefore, I would expect to see more data analysis in regard to use statistical analyses in section 5 (Results). I recommend to the others to generate more solid statistical graphs generated by the software program used for this study.
In overall, this research paper is well-written and presented in regard to demonstrate novel methodological approach for assessing pregnant women’s thermal comfort concurrently with in-situ measurements at one point in a time. The study sits on the research design of an
exploratory case study in order to provide subsequent information for retrofit interventions could be implemented for this particular case study building. This is the reason is that as a reviewer, I found that this study is novel, and methodology could be an exemplar model for the future studies in this field. Although, therefore, this paper could require major amendments to be published in Sustainability journal. I highlighted all my comments in order to improve the credibility of your research work as follows:
Both the title of the paper and abstract should be revised. The reason is that the abstract is lacking clarity of explaining research aim and methodological approach chosen for this study. In this view, the title should be a reflection of the abstract. Anecdotally, in the abstract, the contribution of knowledge should be highlighted as well and what are the main philosophical and theoretical underpinnings of examine before and after retrofitting of building envelopes must be highlighted. As, I understood, these are main methodological approaches on undertaking this project and should be clarified form the beginning of paper.
2.On page 7 - the Figure 2 is not clear at all. It requires more additional work to be readable. The location of weather station should be indicated and labelled accordingly. The scale of map must be highlighted as well.
In section 4.1 the authors mentioned on case study location of Bologna. The authors should be embedded a map of case study location and highlighted its distances from the weather station where the data was generated for assessing outdoor environmental conditions. Alternatively, I highly recommend to the authors to design a graphical abstract in order to demonstrate the map of pilot case study location. In this section, the authors should be mapped and interrogated the location of weather station.
4.On page 7, in Figure 3 — I assume that this is an analytical energy model of case study building for base case scenario development. I highly recommend to the authors to demonstrate all other surrounding buildings into building energy model in order to demonstrate accuracy of thermal sensation votes. From my perspective, the sole distribution of case study building does not provide accurate information to the readers, particularly considering the significance of occupants’ thermal comfort.
5.In section 4.4, Figure 9, the graphical representation is too weak, and the additional work is required on rasterizing the quality of data. The both indoor air temperature and outdoor air temperature fluctuations seem to be like that they are not clear.
6.I highly recommend to the authors to embedding particular representative floor plans of case study building and tabulate all different activities and demonstrate them on a legend map. It gives us an overall idea about geometry and different functions into the building. The location of research instruments (measurement devices) could be mapped onto floor plans.
7.In section 6 (Discussion), this section is too short. This section should be entitled as ‘Interpretations and Discussions’ section and further data interpretation is required.
In Conclusion section, the short descriptive summary of research should be mentioned, and this should be followed by polishing main findings and future recommendations in scope of Sustainability journal.
9.As an outcome of publishing in Sustainability journal, the author[s] should be stated clearly what type of policy implications should be implemented inter-related to their research project. This statement and any future guidance in policy making decisions to improve energy efficiency of existing educational buildings must be stated explicitly.
10.I also found many typesetting errors throughout the manuscript as follow.
In line 91, It should be written as Humphreys [49] In line 155, it should be written as ‘thermal a lighting control’. In line 169, please be careful about the word choice, I assume that ‘the closet week’ the authors indicated that the most similar approach In line 217, 4-5 years range In line 228, the Annex should be indicated as Appendix A (Survey on Indoor Comfort Conditions in the Hospital Bedrooms). In line 239, the word choice of ‘Annex’ should be indicated as ‘Appendix’ In line 434, it should be written as ‘patients would rather’ In line 440, it should be written as ‘wet bulb temperature’ In line 461, it should be written as ‘trial number zero corresponds’ In line 462, the authors indicated as ‘it has been..’. ‘i’ must be capitalised In line 495, the authors indicated as ‘it was focused’ ‘i’ must be capitalised. In line 504, it should be written as ‘has an indoor’ In line 513, it should be written as ‘reported in section 5.2’.
11.I also realised that the Appendix B has never mentioned in the text. I had a look through all data findings in Tables 1-4. I found that these data findings are highly valuable to increase the credibility of this manuscript. I recommend to the authors to opening up a new sub-section as section 5.3 and explicitly discussing these findings in conjunction with previously mentioned data in the text.
Comments for author File: Comments.pdf
Author Response
Dear Reviewer, thanks for all your suggestions, we send in attachment our detailed response. The authors tried to improve the paper accordingly taking into account also the request of the other reviewers. Thank you very much for the time you dedicated to this work.Author Response File: Author Response.docx
Reviewer 4 Report
It is a very interesting topic, deserving of dedicated investigation. It would have been interesting if authors could have presented in context with other works related to hospital occupants. However, that is not the biggest issue. I might have missed this but please provide reference to the ethics approval for this work since it involved pregnant women. Please have a look at the English (grammar, word usage). At present, it is problematic enough to create issues of comprehension for non-native speakers. The introduction is very disorganized. It can be useful to focus on literature related to hospitals/caregiving facilities. Right now, there does not seem to be an order now and you are referencing at random thermal comfort models, individual differences, hospital thermal comfort etc. It is wrong to state that there is no literature on metabolic activity of pregnant women. I have minimal knowledge on this field but I can point out at least these two works: Piers, Leonard S., et al. "Changes in energy expenditure, anthropometry, and energy intake during the course of pregnancy and lactation in well-nourished Indian women." The American journal of clinical nutrition 61.3 (1995): 501-513. Lawrence, M., et al. "The energy cost of common daily activities in African women: increased expenditure in pregnancy?." The American journal of clinical nutrition 42.5 (1985): 753-763. The background provided regarding adaptive thermal comfort can be shortened with reference being made to some germane works in the area (2/3) I would suggest drastically shortening section 2 (couple of paragraphs) and putting it in as a part of Introduction section Could you eliminate one of Figure 4 and Table 2? Table 5 – There is no justification to try to bridge the whole gap between PMV and TSV by changing met rate. The difference between PMV and TSV could be due to multiple differences (local thermal conditions, clothing, individual preferences). Difference between these two parameters is found in multiple studies. You cannot try to justify the whole difference in terms of met.Author Response
Dear Reviewer, thanks for all your suggestions, we send in attachment our detailed response. The authors tried to improve the paper accordingly taking into account also the request of the other reviewers. Thank you very much for the time you dedicated to this work.Author Response File: Author Response.docx
Round 2
Reviewer 1 Report
File attached
Comments for author File: Comments.pdf
Author Response
Dear Reviewer,
in attachment our notes
Regards
Author Response File: Author Response.docx
Reviewer 2 Report
Dear Authors, thank you for your replies and the time spent on this revision of your manuscript.
As I remarked in the first round of revision, the topic is worthy to be investigated, but, mainly due to some criticalities in carrying out the monitoring campaign, your answers still remain not effective. This is because:
Pregnant women at the 38th week of pregnancy cannot be considered “healthy subjects” as claimed by ISO 7730 and ASHRAE 55 standards (the application of the adaptive model is affected by health conditions too). The calculation of clothing insulation values, especially for women at the bed, still remains unrealistic. It is almost trivial that in winter conditions a standard value of 0.6 clo (this is typical for summer) is a very low value; The microclimatic campaign has been carried out in a position which is not representative of the real occupancy of the subject (it is near the door, very far from the bed which is near a large window). In addition, it is affected by the microclimate of the corridor. Finally, what sounds strange for me is the fact that you monitored the environment (room 15) for 2 hours in one day (November 21 from 10.00 to 12.00 am). How it is possible that in only 2 hours you administrated 55 questionnaires? Do you know the effects of the time of adaptation to the local microclimatic conditions? Finally, the idea of adjusting metabolic rate value from 1.0 to 2.17 met aiming at the agreement between objective and subjective investigation is quite absurd. I provided you for metabolic rate values for 38th- week pregnant (+20% of O2 consumption with respect to a non-pregnant women) but you seem to ignore that this results only in a slightly correction of the values suggested by the standard. As I told you there are several manuscripts stressing the effects of subjective parameters on the calculation of PMV: I suggest you to give a look to The Role of Measurement Accuracy on the Thermal Environment Assessment by means of PMV Index. Building and Environment 46(7), pp. 1361-1369. ISSN: 0360-1323, doi: 10.1016/j.buildenv.2011.01.001.
What I am asking you in the new version of the manuscript (besides the minor observations in the pdf marked file) is a better manner of highlighting of the limitations of your study especially concerning: a) clothing insulation; b) the application of international standards on “healthy people”; c) the need to place sensors close to people. In a few: an inaccurate monitoring campaign is not the proof of a lack in international standards and related reference models (e.g. PMV or adaptation).
I need to stress that my observations have to be considered only as suggestions aimed at a high-quality paper for a high ranking journal as Sustainability.
Thank you for your patience and comprehension.
Best regards
Comments for author File: Comments.pdf
Author Response
Dear Reviewer,
in attachment our notes
Regards
Author Response File: Author Response.docx
Reviewer 3 Report
The revision well incorporates reviewer comments while addressing the pregnant women's thermal comfort properly without distorting the study's original scope and findings.
Author Response
Thank you for investing so many time in the review process and in contributing to improve the quality. Very much appreciated.
Round 3
Reviewer 2 Report
Dear Authors,
thank you for your answers and for the time spent. Although I recognize your efforts, I am not completely sure about their effectiveness. The microclimatic survey (and generally the objective investigation of thermal comfort conditions) has been carried out in a not suitable manner (I understand the limitations due to the presence of the medical staff, but it is preferable not publishing and not reasoning about wrong measurements). This is also for subjective investigations: according to the best literature, before a subjective analysis, it is important that people have experience of their thermal environment for 20/30 min at least.
I am confident that in the future your investigations will be carried out with more care and in compliance with international standards and protocols.
Finally, I ask you to correct
L37: ASHARE into ASHRAE (this is the second time I remind you); L49: Parson into Parsons (this is the second time I remind you); ISO 10551: 1995 and UNI EN ISO 10551 have been withdrawn. New ISO 10551 has been released in 2019.
Best regards
Author Response
Dear Reviewer,
thank you for investing so many time in the review process and in contributing to improve the quality, we amended your remarks.
Best regards
