Economic Evaluation of Nature-Based Therapy Interventions—A Scoping Review

Round 1

Reviewer 1 Report

The article is very methodically and technically organized. It raises the important topic of the economic benefits of NBT. The research is exploratory. A typical review article, but carefully prepared. They address the positive effects of Nature Based Therapy (NBT) and its positive effects on various health outcomes. NBT is becoming an increasingly common approach in various rehabilitation interventions with positive results
In the literature, the economic assessments of NBT have not yet been reviewed. The authors undertook interesting research aimed at discovering the existing types and characteristics of economic evaluation in the field of nature-based therapeutic interventions. A comprehensive search of selected databases was used, incl. MEDLINE; EMBASE; Scopus; PSYCinfo and others.
Works that met the inclusion criteria were analyzed, with differences in design, type and dose of nature-based therapeutic interventions, outcomes measures, and group goals. It was emphasized that in the studies of various authors there is a tendency towards a good treatment effect and a positive economic effect in favor of NBT. Evidence of economic benefits of NBT is still scarce in the literature. The economic evaluation of NBT is a new area that requires more research in this field, including high-quality research research where the economic evaluation model is incorporated / incorporated from the start of the research design. The results provide some insight into the scope to quantify the benefits of NBT based on clinical judgment or cost-effectiveness / cost-benefit point of view.

The only aspect that could be a bit more specific is the reference to studies on the effects, impact (s) of NBT, but I understand that these aspects could constitute a separate work. It is suggested that the results of Japanese scientists regarding the analysis of NBT costs (if it is possible to obtain them) should be considered / taken into account. Table 2 summarizes the key features of the intervention, and Table 3 summarizes the key features of economic evaluation in articles included. Perhaps a different presentation of the contents of the table should be considered.

The last aspect / suggestion that will enrich this research in the future is the possibility of striving to achieve the highest possible quality and standard of clinical trials.
A detailed discussion takes up the strengths and needs, and indicates the limitations of the research. The article also contains indications for the future, which is a very valuable remark for future researchers of this topic. The small number of published studies on this topic highlights the need for comprehensive research and a clear formulation of ingredients and understanding of the NBT intervention investigated.

Author Response

Respond to Reviewer 1:

Thank you Reviewer 1 for your review and feedback on this manuscript.

There is a lot of interesting Japanese research going on, especially within forest bathing. The focus here, however, is on NBT in a health professional context with economic evaluation of it, which according to our literature search no Japanese studies have.

Towards your wish for a more visual presentation of the results than table 2 and 3, I agree that visual graphs would present the results in a better look and would also make the results easier to interpret. But since there are no studies with overlap in either intervention, outcomes, results or economic evaluations and thereby no trends in the three different articles, tables and charts will unfortunately just bring more clutter in this article.

I agree that in future studies it is desirable and recommendable to striving to achieve the highest possible quality and standard of clinical trials which we also are stating at the end of the discussion section on page 16.

And thank you so much for your last comment on the need for a comprehensive research and a clear formulation of ingredients and understanding of the NBT intervention. We very much agree to that and wish to do so in a new research project.

Author Response File: Author Response.docx

Reviewer 2 Report

The example on page one intro, of nature-based recreation, is perhaps trivial. It might not be the best one to make when discussing the value of nature. Beyond recreation, nature has long been essential to life on the planet and is still at the heart of many jobs. 

I am surprised there isn't any literature or studies that could be used to compare wellness for rural people/communities, including Indigenous peoples, vs. urban/city dwellers. Those who live and work in nature vs in the city. Morbidity rates might be the same for both, there could be poverty issues underlaying any comparison, etc.

What is missing up front, struck my on page 2 is that there is an assumed liberal or western view on NBT. For me there must be at least some effort to understand Indigenous cultural practices, traditions, healing and otherwise. The authors should at least acknowledge Saami and other Indigenous peoples (RAIPON, etc.) whose healing practices included land based traditions that predate colonization in each respective "nation". Even despite genocide in each jurisdiction, these practices have more or less persisted the world over.

By page 9 I was noticing that nature and farm seem to be synonymous. They are not. It would be like saying park and nature are the same, again they are not. I was also thinking that there has to be literature on prison farms and rehabilitation of working in agricultural settings, but I do not know how useful this literature would be as many of the health outcomes for prisoners would be problematic.

 

Author Response

Respond to Reviewer 2:

Thank you so much for your comments and reflections on this manuscript

Nature-based therapy is not a new subject, but the focus on economic evaluations hereof is, and around this subject it is also more and more clear that we need to define what Nature-Based Therapy is, and which components it contains of.

By page 9, nature and farm seem to be synonymous.

The study by Elsey et al. uses care farms as their nature interventions. I strongly agree that care farms and nature is not completely the same, but care farming does take place in an natural envirinment for some of the components and the study has an economic evaluation which is in this case very important for inclusion in the review. Since this is a scoping review to elaborate on the topic of nature-based interventions and the economic evaluation hereof, the study was included even though care farming and nature-based therapy is not the same.

In the discussion, page 15 under the section: Nature-Based Therapy this sentence is now added (in red):

“In the absence of several studies that look at nature-based therapeutic interventions and economic evaluation thereof in combination, we have chosen to include the study by Elsey et al., studying care farming only with limited components of NBT, as current review understands and defines it.”

We find many, however, no clear, common and consensual use, understanding, and definition of NBT and its essential components/constituents.

Your other comments are a bit out of the topic for this review/manuscript and we therefore cannot implement the content of your reflections. But it is lovely to see how our manuscript invites further elaborations and reflections.

Author Response File: Author Response.docx

Reviewer 3 Report

Dear authors,

I would like to congratulate you on conducting this scoping review in which economy of nature-based therapies were evaluated. The manuscript is well-written and informative which can be of a great interest for readers.  I poised one question here which I would like the authors to respond.

Given the complex nature of this type therapy, which component would you think contribute the most in terms of economy? Has it been any more in-depth analysis exploring each and every component of the NBTs? 

Author Response

Respond to Reviewer 3:

 

Thank you so much for your acknowledging words towards our manuscript and work. We hope to be able to contribute to further elaboration of the field of Nature-Based Therapy both in terms of definition and in the economic evaluation of the intervention.

The NBT is a complex intervention and is given as a whole, therefore we find it currently impossible to pin out one or two elements both in the intervention and in the in the economic evaluations, and to know which is most important.

Author Response File: Author Response.docx