Towards Key Principles for the Design and Implementation of Nature Prescription Programs
Round 1
Reviewer 1 Report
Manuscript: sustainability-2257535
Comments to the Authors
We thank the authors for their work on this manuscript, which is well-written and provides timely information regarding the role that nature prescriptions can have within the health care setting.
Title
The title is appropriate and reflects what the study is about.
Abstract
The abstract reflects what the paper is about and summarises the main findings.
Introduction
Relevant background information and a rationale for the study are provided and study aims are clearly outlined.
Methods
Detailed information is provided regarding participant recruitment, data collection and data analysis. The gender of the participants could have been provided in a brief summary within section 2.2 (Participants and recruitment).
Results
The results are presented in logical sequence and detailed discussion is provided regarding each theme, however, the formatting of the Results (e.g., the domain headings and theme headings) need to be reformatted for easier readability.
Edits:
- Please clearly label in bold text each domain heading and each theme heading in their respective places within the Results section. For example:
Domain 1 Community: consultation and customisation
Theme: Tailoring to the specific and unmet needs of the population
Theme: Adapting for accessibility in nature prescription activities
Theme: Engagement and trust-building with community
Discussion
The main findings of the study are discussed in relation to the overall aims, and links are made to previous research in this area (or similar research in this area). Study limitations are stated and elaborated on. A sound conclusion is provided.
Author Response
Reviewer 1 Comments to Authors
Methods: Detailed information is provided regarding participant recruitment, data collection and data analysis. The gender of the participants could have been provided in a brief summary within section 2.2 (Participants and recruitment).
Author Response: We thank the Reviewer for these considered comments. In order to maintain the anonymity of participants, no demographic data were collected. Subsequently, it was not possible to report on the gender of participants.
Results: The results are presented in logical sequence and detailed discussion is provided regarding each theme, however, the formatting of the Results (e.g., the domain headings and theme headings) need to be reformatted for easier readability. Edits: Please clearly label in bold text each domain heading and each theme heading in their respective places within the Results section. For example: Domain 1 Community: consultation and customisation; Theme: Tailoring to the specific and unmet needs of the population; Theme: Adapting for accessibility in nature prescription activities; Theme: Engagement and trust-building with community
Author Response: The manuscript that was provided to Reviewers appears to have been re-formatted by the journal publisher during the submission process. Accordingly, it appears that a number of formatting errors had occurred, including the deletion and mis-numbering of some sub-headings. The Findings section has been reviewed for such errors and amended accordingly.
Discussion: The main findings of the study are discussed in relation to the overall aims, and links are made to previous research in this area (or similar research in this area). Study limitations are stated and elaborated on. A sound conclusion is provided.
Author Response: Thank you to the Reviewer for their time and careful consideration of our manuscript. The feedback provided is appreciated.
Reviewer 2 Report
In this paper the authors present findings from a study on enablers and barriers to nature prescriptions in Australia. The rationale for the research is that while the health benefits of nature are well recognised, nature prescriptions are not routine in many health systems, and so there is a need to understand the process and implementation of green prescribing. Data were collected by semi-structured interviews from a range of providers and prescribers (n =13) and analysed by inductive thematic analysis (Braun & Clarke, 2006). Thirteen themes were clustered into five domains: community – consultation and customisation; systems – building partnerships and networks; prescribers – cultivating awareness and capacity to implement; prescriptions – recognising the foundations; and external settings – interfacing social and natural environments. Key findings included the importance of community support and collaboration, the importance of tailoring nature prescriptions to the specific needs of communities and well-designed systems, all of which are important for effective implementation of nature prescriptions.
Understanding the issues of implementation of nature prescriptions from the from the perspectives of providers and prescribers is an important step forward in contributing to the evidence base and informing future intervention development. The limited robust evidence on nature prescriptions, means that this study is both timely and relevant. The manuscript is well-written and logically structured. The data collection and data analysis are clearly reported and the five themes are explained and illustrated with quotations from the research participants. The discussion draws out the key findings of community support and collaboration, matching nature prescriptions to community needs and well-designed systems and partnerships between prescribers and providers. The challenge of aligning the health care systems with the complexity of nature prescriptions is also highlighted. The importance of tailoring nature prescriptions to individuals was highlighted in the findings and I think this is fundamental and could have been considered in the discussion. The possibility of a nature prescription not being person-centred and not fitting with an individual’s needs, raises the risk that the prescription could be detrimental to health and wellbeing.
Overall, this is a well-reported study; the authors have been clear about the research process and the research findings have potential to make a significant practical contribution to our knowledge on the design and implementation of nature prescribing.
Author Response
Reviewer 2 Comments to Authors
The importance of tailoring nature prescriptions to individuals was highlighted in the findings and I think this is fundamental and could have been considered in the discussion.
Author response: Thank you to the Reviewer for taking the time to engage with our work and provide this reflective feedback. We agree that the importance of tailoring prescriptions to individuals as well as communities should be highlighted, and regret that it is difficult to comprehensively explore every important finding without over-burdening the reader with a lengthy Discussion. In order to better highlight this point, we have edited the paragraph in the Discussion that refers to the importance of tailored approaches, as below (Changes underlined. See page 11 of manuscript):
A key finding from this research is that implementation of nature prescriptions re-quires community support and collaboration. Participants in this study indicated that a one-size-fits-all approach to the provision of green spaces and associated activities is un-likely to be as effective as engaging the community and individual patients, and adapting opportunities to ensure relevant community needs are met. This emphasis on tailoring nature prescriptions to the specific needs of communities and individuals through collaboration and person-centred care is consistent with a recent nature prescribing trial in Australia, which recommends future endeavours co-design programs with intended users in order to optimise outcomes (Green Adelaide, 2022). Previous research on physical exercise interventions also recommends tailored approaches to addressing barriers arising in groups with different needs, such as elderly patients (Patel et al., 2012), children, and culturally diverse populations (Anderson et al., 2015; Tava’e and Nosa, 2012).
Reviewer 3 Report
Thank you for the opportunity to review the manuscript (sustainability-2257535). The authors submitted a paper with results of interviewed health stakeholders (n=13) who prescribe and provide nature prescriptions, to identify enablers and barriers surrounding nature prescriptions in Australia.
The topic is interesting; however the paper must be carefully revised.
Research questions and hypotheses are missing. Therefore, the paper has no scientific character.
Findings section: The paper is difficult to read. Authors use cursive writing inconsistently (e.g. page 5). Paragraphs and formal structures are missing.
The problems that are taken up here in this paper are much too general. It would be better to highlight a core area and work through it in detail, e.g. nature and medical care/hospital.
The statements and recommendations for action are also weak. Authors should also summarize concrete barriers and give solutions (please make a table in findings/conclusions).
Also it is important to give implications for further research. What are the concrete recommendations for action? Have the research questions been answered?
Limitation: a small number of interviewed persons.
Author Response
Reviewer 3 Comments to Authors
The topic is interesting; however the paper must be carefully revised. Research questions and hypotheses are missing. Therefore, the paper has no scientific character.
Author response: Thank you to the Reviewer for your time and for providing considered, detailed feedback on our manuscript. In keeping with standard reporting guidelines for qualitative research (CORE-Q, SRQR), the research aim is stated in our Methods section. In order to strengthen the scientific character of the paper, we have added the over-arching research question to the final paragraph of the Introduction (outlined below, changes underlined, see page 2 of revised manuscript for further detail).
This paper addresses the knowledge gaps surrounding nature prescription implementation by asking the research question “What factors are affecting the implementation of nature prescribing in Australia from the perspectives of prescribers and providers?”
The application of hypotheses to a qualitative descriptive research design is inappropriate, and as such, no hypotheses were generated for this research.
Findings section: The paper is difficult to read. Authors use cursive writing inconsistently (e.g. page 5). Paragraphs and formal structures are missing.
Author response: As the formatting was applied by the publisher during manuscript submission, it appears some of the original formatting was lost. The Findings section has been reviewed to ensure italics have been consistently applied to: 1) headings and 2) participant quotations, as appropriate. In addition, some sub-headings were entirely lost during submission and have now been re-inserted, along with the re-numbering of headings. Paragraph structures also have been reviewed throughout the Findings. See pages 2-11 of the revised manuscript for further detail.
The problems that are taken up here in this paper are much too general. It would be better to highlight a core area and work through it in detail, e.g. nature and medical care/hospital.
Author response: We appreciate the Reviewer’s perspective and agree that it is important for future research to examine specific areas in greater detail. However, our study was conducted in response to a particular knowledge gap, which was the need for a broad, foundational understanding of the various factors at play in the Australian context of nature prescribing implementation. In accordance, we have kept the reported findings and discussion of this paper within the scope of that broad knowledge gap. The Reviewer’s perspective about the value of exploring core areas in detail has been considered in response to the Reviewer’s comment below, regarding implications for future research.
The statements and recommendations for action are also weak. Authors should also summarize concrete barriers and give solutions (please make a table in findings/conclusions). Also it is important to give implications for further research. What are the concrete recommendations for action? Have the research questions been answered?
Author response: Thank you to the Reviewer for these suggestions to strengthen the manuscript. Upon review of the research aim and design, and consideration of the preliminary nature of the findings, we do not feel it is within the scope of this paper to define concrete barriers and solutions. We do, however, agree with the Reviewer about the importance of this process and have since conducted further research to refine the findings of this paper through a Delphi study (currently under peer-review) and develop more concrete guidelines for nature prescribing implementation. In response to the Reviewer’s suggestions, we have elaborated upon recommendations for future research/action in the Discussion section as follows: (changes underlined, see page 12 of revised manuscript):
The findings presented in this paper provide an impetus for such change, by revealing a set of foundational criteria to guide the development of such tools through further research, which is currently underway. Future research could build upon this work by exploring how these foundational criteria apply in specific and specialised settings, developing deeper, more concrete guidance for a range of stakeholders involved in nature prescription implementation.
Limitation: a small number of interviewed persons.
Author response: While the sample is a standard size for qualitative descriptive studies, we recognise that such research designs have inherent limitations associated with sample size. The following sentence has been added to the limitations paragraph of the Discussion section to acknowledge this (see page 12 of revised manuscript):
Finally, although the small sample size was considered suitable for the research aim and design, qualitative findings from small samples need to be interpreted with consideration of contextual factors.
Round 2
Reviewer 3 Report
The authors improved the paper according to the reviewers suggestions.
