Development and Peer Review of an Evidence-Based Decision-Support Tool for Non-Drug Prescribing for Healthy Ageing

Round 1

Reviewer 1 Report

Dear Authors

Congratulations on initiating focus in a much needed direction, we definitely need to have more robust means of supporting 'social prescribing' and non-pharmaceutical responses to underpin health and wellbeing.

My concerns with the paper are that it lacks a well described and constructed academic research framework. I think what you have done could be called a modified Delphi study  (https://www.frontiersin.org/articles/10.3389/fpubh.2020.00457/full) where your Methodology has been:

Step 1 Draft list of topics developed based on initial knowledge and research

Step 2 Narrative review to underpin topics with evidence

Step 3 Experts asked for their input re (this is unclear - we need to know what they were asked to do)

Step 4 Experts input was use to modify the draft you had developed.

Results then becomes the final document developed (including topics, evidence to support topics, expert additions).

Discussion = key points people identified as missing, how tool can now be used, comments re next stages etc

Conclusion - summing up

If you agree with the above (you may not!) then your title should be a little more specific ie "Development and peer review of an evidence based tool to support non-drug prescribing for healthy ageing"

Your tables at this point have no referencing included - so what is your basis for claiming "evidence based"? And if you are aiming for practitioners to be using the tables - how do you envisage this? What should they do with them? How should they use them eg when sitting with a client?

At this point the paper needs a great deal more work to become a robust academically sound AND practitioner useful tool that can help all to understand and recommend/prescribe non-drug approaches to health. It has the potential to move us ahead in a great direction, in a space that is crying out for tools, but needs further work to lift it to this position.

 

 

 

Author Response

Dear Reviewer.

Thank you for your constructive feedback on our paper. Our point-by-point responses are below and the paper has been resubmitted with track changes to demonstrate the updates.

Congratulations on initiating focus in a much needed direction, we definitely need to have more robust means of supporting 'social prescribing' and non-pharmaceutical responses to underpin health and wellbeing.

Author response: Thank you for your encouraging and constructive peer review comments.

My concerns with the paper are that it lacks a well described and constructed academic research framework. I think what you have done could be called a modified Delphi study  (https://www.frontiersin.org/articles/10.3389/fpubh.2020.00457/full) where your Methodology has been:

Step 1 Draft list of topics developed based on initial knowledge and research

Step 2 Narrative review to underpin topics with evidence

Step 3 Experts asked for their input re (this is unclear - we need to know what they were asked to do)

Step 4 Experts input was use to modify the draft you had developed.

Author response: Thank you for these comments with which we agree and have revised the methods section accordingly.

Results then becomes the final document developed (including topics, evidence to support topics, expert additions).

Author response: Thanks, we have moved all the relevant coverage on topics within the pathway, evidence and expert review amendments into the results section. We have restructured the section to focus on each of the domains of social wellbeing, physical fitness and function, emotional wellbeing, sleep, cognitive health and diet and nutrition covering the evidence, expert review and referenced table within each section to make for a more condensed read.

Discussion = key points people identified as missing, how tool can now be used, comments re next stages etc

Author response: We have added relevant discussions on missing elements identified by the experts as well as how the tool can be used and next-stage plans.

Conclusion - summing up

If you agree with the above (you may not!) then your title should be a little more specific ie "Development and peer review of an evidence based tool to support non-drug prescribing for healthy ageing"

Author response: We have revised the title as suggested. Thank you

Your tables at this point have no referencing included - so what is your basis for claiming "evidence based"?

Author response: Thank you for noting this. We had not included all the references in the tables due to formatting as well as the consequent extensive list of references and so had included discussion of the evidence for the interventions within the relevant paragraphs that preceded the table. However we have since added key references to the tables.

And if you are aiming for practitioners to be using the tables - how do you envisage this? What should they do with them? How should they use them eg when sitting with a client?

Author response: We have added clarity on this that the intention is for the tool to be integrated into a digital healthy ageing platform.

At this point the paper needs a great deal more work to become a robust academically sound AND practitioner useful tool that can help all to understand and recommend/prescribe non-drug approaches to health. It has the potential to move us ahead in a great direction, in a space that is crying out for tools, but needs further work to lift it to this position.

Author response: Thank you for your feedback. We have revised the paper structure and strengthened the referencing as well as added details on the intended use of the tool. We value the feedback to date and would be happy to make any further revisions if needed.

Reviewer 2 Report

congratulations, very informative article indeed.

It is not quite clear if the "Wellness Intervention Pathway for Healthy Ageing" has been developed exclusively for this publication or are there any predecessors because the dicussion of appropriate wellness models lasts already some decades.

Author Response

Dear Reviewer

Thank you for your helpful comments on our paper. We have responded to your comments point-by-point below and made revisions to the paper as shown in track changes.

congratulations, very informative article indeed.

Author response: Thank you for your encouraging comment.

It is not quite clear if the "Wellness Intervention Pathway for Healthy Ageing" has been developed exclusively for this publication or are there any predecessors because the dicussion of appropriate wellness models lasts already some decades.

Author response: The Systematic Wellness Intervention Pathway for Healthy Ageing (or Pathway) has been developed as a reference tool to support providers and people in the selection of non-drug interventions to meet the needs and goals of those who want to engage in evidence-based activities to promote aspects of their physical, cognitive and emotional health and wellbeing. The Pathway is also intended to be integrated into a healthy ageing digital health and wellbeing platform that delivers online classes and programmes to support healthy ageing. We have added further clarity on the intended purpose in the introduction section.

Reviewer 3 Report

Thank you very much for giving me the possibility to review this highly interesting manuscript dealing with a very relevant topic! I have some specific comments and suggestions for further elaborating the manuscript:

1. Introduction:

You clearly point out the issue on how especially the COVID pandemic impacted and challenged older people in several ways. As you already describe the problems evoked by the pandemic, also the issue of loneliness needs to be addressed in this regard. Just think of the times during lockdowns and isolation legislations and how they may have adversely affected the daily life of people in general and older people especially (e.g. nursing homes, elderly living alone etc.). In general, not only COVID poses a challenge to healthy ageing.

Paragraph 78-81: You describe the domains applied for healthy ageing. Why did you choose these domains? This should be underpinned by further evidence, e.g. literature describing healthy ageing frameworks or models (see: https://doi.org/10.1007/s40520-021-02049-w and 10.1093/geront/gny029 for example), otherwise it seems a bit arbitrary.

2. Methodology

2.1. Scoping literature review

Paragraph 89-90: Please state why you included people from age 50 on. I see it critical that you included literature for the general adult population (if not stated otherwise) for development of a pathway for healthy ageing --> does this mean from the age of 18 on? Older people constitute a very diverse and heterogeneous population with complex needs as their age increases. Think alone of the domain physical activity, you most probably cannot recommend the same intervention for a 65-year old as for a 18-year old.  Therefore, I would suggest to clearly limit literature describing interventions for older people to a specific age.

Please also disclose the search strategy used with inclusion and exclusion criteria as there is no information how you conducted the scoping literature review.

2.2. Evidence mapping

Please also provide further details for this methodological research step. How many researchers have conducted the mapping process? How did you ensure independency and how did you manage any disagreements between researchers?

Table 1 and Table 2: It may be a bit less overwhelming for the reader if you could merge these two tables into one. I also suggest to include references in the tables stating which domains, categories and goals were extrapolated from which evidence-based literature.  

2.1. Peer review survey (I guess this should be numbered 2.3)

Please also provide further details for this methodological research step. How did you "recruit" the reviewers? How did you perform data analysis of the feedback? How did you further process the feedback, based on which criteria? Was there a threshold to reach for data (e.g. frequency) to be considered?

3. Results

Section 3.1: In general, the results section is very long and difficult to read. I suggest to streamline and break it down to the most relevant points or illustrate the results in a way that is easier to handle for readers (e.g. with the help of figures, graphs, further clustering).

Section 3.2: Paragraph 278-282: This describes a methodological step and fits better into the method section.

Otherwise the same suggestion as for paragraph 3.1: please streamline.

Paragraph 290-291 and 302-303: You state that you consider this specific feedback for future pathways. Please explain why.

4. Discussion:

You describe that this pathway should be provided to older people and providers, most probably in a digital way. I think it is important to discuss your further plans in reflection with the concepts of health literacy and digital literacy, especially in the context of older people.

I miss a critical reflection against literature and discussion of challenges and issues in this section. Also, there already is a plethora of healthy ageing recommendations and interventions available (e.g. leaflets, homepages etc.), how to deal with that? Which added value does the pathway provide? 

 

Author Response

Dear Reviewer

Thank you for your most helpful and constructive comments on our paper. We have responded point-by-point in blue text below and made revisions to the paper indicated by track changes.

Thank you very much for giving me the possibility to review this highly interesting manuscript dealing with a very relevant topic! I have some specific comments and suggestions for further elaborating the manuscript:

Author response: Thank you for the most encouraging and helpful comments. We have addressed each one below.

1. Introduction:

You clearly point out the issue on how especially the COVID pandemic impacted and challenged older people in several ways. As you already describe the problems evoked by the pandemic, also the issue of loneliness needs to be addressed in this regard. Just think of the times during lockdowns and isolation legislations and how they may have adversely affected the daily life of people in general and older people especially (e.g. nursing homes, elderly living alone etc.). In general, not only COVID poses a challenge to healthy ageing.

Author response: We agree loneliness is a very important topic which we do mention in the introduction and cover in the updated section on social well-being.

Paragraph 78-81: You describe the domains applied for healthy ageing. Why did you choose these domains? This should be underpinned by further evidence, e.g. literature describing healthy ageing frameworks or models (see: https://doi.org/10.1007/s40520-021-02049-w and 10.1093/geront/gny029 for example), otherwise it seems a bit arbitrary.

Author response: This is a helpful observation. We have added further clarity regarding the domains of healthy ageing and our selection of the domains within our pathway as well as relevant references which we had also previously read and thank you for reminding us of them.

2. Methodology

2.1. Scoping literature review

Paragraph 89-90: Please state why you included people from age 50 on. I see it critical that you included literature for the general adult population (if not stated otherwise) for development of a pathway for healthy ageing --> does this mean from the age of 18 on? Older people constitute a very diverse and heterogeneous population with complex needs as their age increases. Think alone of the domain physical activity, you most probably cannot recommend the same intervention for a 65-year old as for a 18-year old.  Therefore, I would suggest to clearly limit literature describing interventions for older people to a specific age.

Author response: Thank you for this important observation. We do agree that healthy ageing should start from youth. However, we aimed to focus on interventions for people over the age of 50 as this is the population of focus for our healthy ageing platform and programmes. We have added further clarification on the population ages covered in the evidence search as well as brief discussion on the challenge around different definitions of older age and where there was lack of available evidence for the age groups over 50, evidence for the 18+ age ground was considered.

Please also disclose the search strategy used with inclusion and exclusion criteria as there is no information how you conducted the scoping literature review.

Author response: Thank you, we have added further details on the search strategy in the methods section which has been further revised based on comments from another reviewer as well.

2.2. Evidence mapping

Please also provide further details for this methodological research step. How many researchers have conducted the mapping process? How did you ensure independency and how did you manage any disagreements between researchers?

Author response: Thank you, we have added further details on the mapping process.

Table 1 and Table 2: It may be a bit less overwhelming for the reader if you could merge these two tables into one. I also suggest to include references in the tables stating which domains, categories and goals were extrapolated from which evidence-based literature.

Author response: This is a good suggestion and we have combined tables 1 and 2 and have now added references within all the tables.

2.1. Peer review survey (I guess this should be numbered 2.3)

Please also provide further details for this methodological research step. How did you "recruit" the reviewers? How did you perform data analysis of the feedback? How did you further process the feedback, based on which criteria? Was there a threshold to reach for data (e.g. frequency) to be considered?

Author response: We have added further clarification on reviewer recruitment and processing of the feedback.

3. Results

Section 3.1: In general, the results section is very long and difficult to read. I suggest to streamline and break it down to the most relevant points or illustrate the results in a way that is easier to handle for readers (e.g. with the help of figures, graphs, further clustering).

Author response: Thanks, yes we agree it is very long. We have restructured the results section in response to both these and another peer reviewer’s comments. We have focused on each domain of healthy ageing within the pathway covering the interventions and peer review feedback within each section in the hope that this will be more engaging for the reader.

Section 3.2: Paragraph 278-282: This describes a methodological step and fits better into the method section.

Author response: We have moved these sentences describing the peer review to the methods section.

Otherwise the same suggestion as for paragraph 3.1: please streamline.

Author response: We have revised the results section as noted above.

Paragraph 290-291 and 302-303: You state that you consider this specific feedback for future pathways. Please explain why.

Author response: In this first pathway, we have focused on prevention and health maintenance activities for healthy ageing. In the future we plan to develop more specific condition-focused pathways that will cover musculoskeletal and mental health conditions. We have clarified this in the text.

4. Discussion:

You describe that this pathway should be provided to older people and providers, most probably in a digital way. I think it is important to discuss your further plans in reflection with the concepts of health literacy and digital literacy, especially in the context of older people.

Author response :We have added explanation of how the Pathway is intended to be implemented within a healthy ageing online platform and have added comments around health literacy.

I miss a critical reflection against literature and discussion of challenges and issues in this section. Also, there already is a plethora of healthy ageing recommendations and interventions available (e.g. leaflets, homepages etc.), how to deal with that? Which added value does the pathway provide? 

Author response: We have added further description in the discussion on the utility of the pathway to help support older people meet their health goals and be given accessible ways in which to do so with the help of connected online classes.

Round 2

Reviewer 1 Report

Dear authors

Well done on improving your paper majorly.

Some minor tidying ups needed:

line 173 - typo re "Pathway"

line 177-78 - "Disease and chronic conditions..." phrase seems a bit random

line 187 - table  - should the right column be more accurately titled "Targeted outcomes"?

line 189 - no need to have a "however" as you have no comparator in the text

As a writing note - I think you need to have an introductory sentence before 3.1 to explain to your reader what you are covering in this section.

line 271 - need to clarify a little what is meant by "inclusion of fraility" - that it needs assessment? noting? other?

Overall please tidy up the tables ie remove additional rows where they occur, make sure borders are where they need to be etc.

Good work and an interesting addition to the field

Janette

Author Response

Dear Reviewer

Thank you very much for your feedback on our manuscript. Please see responses in blue text below.

Dear authors

Well done on improving your paper majorly.

Author response: Thank you very much for your previous most helpful comments which prompted the improvements to the manuscript.

Some minor tidying ups needed:

line 173 - typo re "Pathway"

Author response: Thanks, corrected.

line 177-78 - "Disease and chronic conditions..." phrase seems a bit random

Author response: Thank, we have expanded to clarify as follows: “Disease and chronic conditions decision-support pathways for non-drug interventions are planned for future work as adjunctive support to medical and surgical interventions.”

line 187 - table  - should the right column be more accurately titled "Targeted outcomes"?

Author response: We agree and have added Targeted to the column titles.

line 189 - no need to have a "however" as you have no comparator in the text

Author response: “However” deleted.

As a writing note - I think you need to have an introductory sentence before 3.1 to explain to your reader what you are covering in this section.

Author response: Thanks, we have added “While it is beyond the scope of this paper to discuss every intervention listed within the Pathway, the key intervention categories and examples of interventions are discussed below.”

line 271 - need to clarify a little what is meant by "inclusion of fraility" - that it needs assessment? noting? other?

Author response: Thanks, we realised through this that the statement was a repetition on line 267 to 269 and so have deleted that sentence and added clarification earlier in the paragraph.

Overall please tidy up the tables ie remove additional rows where they occur, make sure borders are where they need to be etc.

Author response: Thank you. We have tidied the tables and are seeking advice from the editorial team as to the required borders without to much wrapping of the text.

Good work and an interesting addition to the field

Author response: Thank you very much again. We have so appreciated your input and feedback.

Reviewer 3 Report

Thank you for clarification and response to my comments, the manuscript has improved substantially! From my point of view the manuscript can be published in its current form.

Author Response

Dear Reviewer

Thank you your very helpful feedback. Our further responses in blue text below.

Thank you for clarification and response to my comments, the manuscript has improved substantially! From my point of view the manuscript can be published in its current form.

Author response: Thank you very much for your previous most helpful comments which prompted the improvements to the manuscript. We very much appreciate your time and feedback.