Redefining Urban Boundaries for Health Planning Through an Equity Lens: A Socio-Demographic Spatial Analysis Model in the City of Rome

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

General Evaluation

The manuscript correctly acknowledges that OMI values may not fully capture socio-demographic realities due to price distribution asymmetries. However, to strengthen the methodological framework, it would be valuable to explicitly integrate additional socio-economic indicators—such as income levels, employment status, or deprivation indices—and to clarify the rationale behind subdivisions made along road axes, possibly via accessibility metrics or expert consultation methods.

Much of the discussion reiterates earlier claims rather than critically analyzing how the results confirm or challenge them. The authors should more clearly relate specific outcomes to the planning goals introduced in the introduction.

Moreover, the manuscript could benefit from acknowledging a broader urban geography literature that discusses persistent patterns of residential segregation in Southern European cities. As noted by Maloutas (2012) and Tulumello & Dagkouli-Kyriakoglou (2021), spatial inequalities in Mediterranean contexts are often historically embedded and linked to high rates of homeownership, rather than the effects of market volatility alone. Thus, while the OMI index may capture real estate values, it may not fully reflect entrenched socio-spatial divisions that are structured by long-term tenure patterns and path-dependent urban development.

Relevant references:

• Maloutas, T. (2012), "Introduction: Residential segregation in context", in T. Maloutas and K. Fujita, Residential Segregation in Comparative Perspective, Farnham: Ashgate, pp. 1–36.

• Tulumello, S., & Dagkouli-Kyriakoglou, M. (2021). Financialization of housing in Southern Europe: Policy analysis and recommendations. European Parliament.

• Logan, J.R. & Martinez, M.J. (2018). "The Spatial Scale and Spatial Configuration of Residential Settlement: Measuring Segregation in the Postbellum South", American Journal of Sociology, 123(4), 1161–1203.

The Discussion section acknowledges some key methodological limitations and makes a strong case for the practical relevance of mesoarea-based planning. However, it does not sufficiently interpret the study’s results in relation to the stated aims. Much of the discussion is descriptive rather than analytical and lacks engagement with alternative methods or critical reflection on feasibility and institutional uptake. Additionally, the authors do not assess whether the proposed model is generalizable beyond the specific case of Municipality III. A more robust discussion would include comparative insights, implementation challenges, and concrete pathways for integrating this tool into real planning frameworks.

Detailed Comments

Methodological Transparency and Replicability

The methodological process lacks formalization. While the paper references visual inspection and iterative reclassification, it does not present a clear and reproducible set of steps or criteria. There is no mention of algorithmic or statistical validation of the resulting mesoareas, nor an evaluation of their internal or external consistency. The authors claim that the proposed mesoareas are more internally homogeneous than Urban Zones, but do not provide any statistical indicators or tests to substantiate this. Metrics such as intra-unit variance, interquartile range (IQR), or entropy would strengthen the validity of this claim.

This limits the replicability of the study and reduces confidence in its general applicability.The justification for selecting variables and the decision thresholds for clustering or aggregating areas are not sufficiently described. For example, the logic behind aggregating or subdividing areas with small populations, or the choice to maintain pre-existing boundaries in some cases, is not made transparent.

Use of OMI and Socio-Economic Indicators

The manuscript correctly acknowledges that OMI values may not fully reflect socio-demographic realities due to price distribution asymmetries. However, it would benefit from the integration of more direct socio-economic indicators—such as household income, employment status, or deprivation indices—into the delineation process.

A relevant precedent is Barreca et al. (2018), who used OMI-derived property-value zones in Turin to explore housing vulnerability and social inequality. Their findings demonstrate spatial correlation between real estate values and social vulnerability indicators, which supports the potential utility of OMI in socio-spatial modeling.

Reference: Barreca, A., Curto, R., & Rolando, D. (2018). Housing vulnerability and property prices: Spatial analyses in the Turin real estate market. Sustainability, 10(9), 3068. https://doi.org/10.3390/su10093068

Including this kind of reference would strengthen the manuscript’s methodological foundation and help frame the choice of OMI within a validated Italian empirical context.

However, it would benefit from the integration of more direct socio-economic indicators—such as household income, employment status, or deprivation indices—into the delineation process.

Spatial Logic and Delineation Criteria

The rationale for delineating boundaries along major road axes remains insufficiently justified. These divisions appear arbitrary and lack supporting criteria. The authors should clarify whether these were based on transport accessibility, expert knowledge, or other spatial logic. Visual criteria alone are insufficient to support generalizable spatial zoning. Referencing accessibility analyses or expert consultation methods (e.g., Delphi) could enhance methodological transparency.

The final classification into five types of mesoareas lacks a corresponding table or statistical profile to justify the clustering. Readers would benefit from a summary of defining characteristics per group.

Mapping and Visual Communication

The maps and cartographic outputs are generally weak. In particular, Figure 3 uses a grey scale that makes it difficult to distinguish between classes. Labels or indicators on the maps could clarify which zones are being described in the text (e.g., in Figure 1 the referencing categories of urban fabric or population density). Maps should be fully legible and function as standalone communicative tools.

Policy Relevance and Institutional Uptake

While the paper claims alignment with the LHU Roma 1’s strategic planning and the Decree 77/2022, the direct link between the mesoarea delineation and health policy implementation remains vague. It is not made clear how these zones are expected to be adopted by LHU planners or how they integrate with service provision tools. Including a discussion of stakeholder feedback or pilot implementation would enhance the applied relevance.

The authors are optimistic about the planning applications of their method, yet they do not provide evidence of institutional uptake or practical feasibility. A more cautious tone would be appropriate, or at least a discussion of potential barriers to implementation.

F. Literature Integration and Conceptual Framing

The literature review overlooks major studies on residential segregation, urban inequality, and spatial governance in Southern European contexts. Incorporating urban geography insights—especially concerning homeownership patterns and long-term spatial path dependencies—would improve the theoretical framing. References such as Maloutas (2012), Tulumello & Dagkouli-Kyriakoglou (2021), and Logan & Martinez (2018) provide a valuable foundation for this discussion.

Adiotionaly the manuscript would benefit from references to international experiences with small-area geographies used for planning, which would highlight the novelty or potential adaptation of mesoareas [e.g. LSOAs (UK), IRIS (France), CBS buurt/wijken (Netherlands), Census tracts (USA/Canada).

G. Internal Consistency and Redundancy

• There is some internal redundancy between paragraphs, e.g., [428–432] and [433–437] appear to reiterate similar ideas. Streamlining these sections would help clarity and improve narrative efficiency.

Comments on the Quality of English Language

The manuscript is generally understandable and written in a formal academic tone. However, there are occasional minor grammatical errors, awkward phrasing, or overly complex sentence structures that may hinder clarity. A careful final proofreading or professional language editing would improve readability, fluency, and the overall professionalism of the text.

Examples of problematic sentences include:

• [178-183] "As a first step, in order to associate each Census Section (CS) with its corresponding Municipality, the intersection function was used, with the point vector layer of the census geographic data as the input layer and the vector layer of the Municipalities of Rome as the output layer" → Consider rewriting for clarity: "First, to associate each Census Section (CS) with its Municipality, the intersection function was applied using the census geographic data as input and the Municipalities vector layer as output."
• [214-216] "Following the identification of UZs or mesoareas with persistently high population levels—despite their internal homogeneity in terms of real estate values—Monte Sacro Alto UZ was further subdivided, and Val Melaina UZ was divided into three mesoareas." → Consider rewriting for concise phrasing "After identifying densely populated but internally homogeneous UZs, Monte Sacro Alto was further subdivided, and Val Melaina was split into three mesoareas"
• [307–308] “This division resulted in 20 mesoareas, with an inhabitants range from 299 (Northern Tor S. Giovanni) to 36,060 (Val Melaina, residual area) (Table 2).” → Consider clarifying the phrasing: "...with a population range from 299..."
• [349] “Finally, 22 mesoareas of the III Municipality of Rome...” → Consider rewriting for clarity: "A total of 22 mesoareas were ultimately identified..."
• [368–369] “Nonetheless, the UZ classification remains the most used territorial framework in the Municipality of Rome for providing and describing population characteristics...” → Consider simplifying: "...remains the primary framework used..."
• [370 “..finer-grained ..” → Consider: "... more detailed ."
• [428–429] “Other subdivisions based on major road axes did not yield statistically significant differences. However, when deemed necessary, these subdivisions were retained to delimit already homogeneous territories into smaller units...” → Consider separating this into clearer, shorter sentences. "Other subdivisions based on major road axes did not yield statistically significant differences; however, these subdivisions were retained where necessary to divide homogeneous territories into smaller units."
• [433–437] Repetition of the same content from the previous paragraph [428–432]. → Consider removing or rephrasing to avoid redundancy.
• [455–465] “Identifying homogeneous areas is crucial for effective healthcare planning based on the actual needs of the population.” → Consider rephrasing for conciseness. "..healthcare planning tailored to actual population needs."

Most of these issues are minor and do not obstruct understanding, but their correction would enhance the paper’s clarity and flow.

Author Response

General Evaluation

We would like to thank Reviewer 1 for the thorough and constructive feedback, which allowed us to explore in greater depth several thematic and methodological aspects of the study. In response to the comments, we have undertaken additional analytical steps that have led to what we consider a substantial revision of the manuscript—effectively a version 2.0 of the article.

We believe that the revised manuscript now adequately addresses all the points raised. We also wish to apologize for the delay in submitting this revised version; as the reviewer will notice, the changes required significant reworking of both content and structure.

The manuscript correctly acknowledges that OMI values may not fully capture socio-demographic realities due to price distribution asymmetries. However, to strengthen the methodological framework, it would be valuable to explicitly integrate additional socio-economic indicators—such as income levels, employment status, or deprivation indices—and to clarify the rationale behind subdivisions made along road axes, possibly via accessibility metrics or expert consultation methods.

Much of the discussion reiterates earlier claims rather than critically analyzing how the results confirm or challenge them. The authors should more clearly relate specific outcomes to the planning goals introduced in the introduction.

We not only fully revised the Methods section—clarifying its objectives and improving transparency—but also restructured the Introduction, Discussion, and Conclusions to ensure stronger internal coherence across sections. In doing so, we incorporated the reviewer’s suggestion to consider additional health determinants, including the potential integration of validated tools developed for the Italian context (albeit currently calibrated on different datasets, as specified in the revised Discussion).

We also reformulated several passages and re-examined parts of the analysis in order to justify, through additional methodological tools, choices that may have previously appeared arbitrary. We sincerely thank the reviewer for this insightful comment, which was instrumental in guiding the improvement of the manuscript.

Moreover, the manuscript could benefit from acknowledging a broader urban geography literature that discusses persistent patterns of residential segregation in Southern European cities. As noted by Maloutas (2012) and Tulumello & Dagkouli-Kyriakoglou (2021), spatial inequalities in Mediterranean contexts are often historically embedded and linked to high rates of homeownership, rather than the effects of market volatility alone. Thus, while the OMI index may capture real estate values, it may not fully reflect entrenched socio-spatial divisions that are structured by long-term tenure patterns and path-dependent urban development.

Relevant references:

• Maloutas, T. (2012), "Introduction: Residential segregation in context", in T. Maloutas and K. Fujita, Residential Segregation in Comparative Perspective, Farnham: Ashgate, pp. 1–36.

• Tulumello, S., & Dagkouli-Kyriakoglou, M. (2021). Financialization of housing in Southern Europe: Policy analysis and recommendations. European Parliament.

• Logan, J.R. & Martinez, M.J. (2018). "The Spatial Scale and Spatial Configuration of Residential Settlement: Measuring Segregation in the Postbellum South", American Journal of Sociology, 123(4), 1161–1203.

We thank the reviewer for this valuable comment and the suggested references. We have chosen to cite several of these works—particularly in the revised Discussion section—as they provide useful insights into one of the core components of our analysis: the real estate market, which we have employed as a proxy for socioeconomic status.

As the cited authors rightly point out, the relationship between housing and social stratification is far more complex than what we briefly addressed in the original manuscript. In particular, the emphasis on high rates of homeownership in Southern European contexts adds an important layer of complexity to the interpretation of housing values.

Nevertheless, this very observation reinforces our argument: the market value of residential property can be understood as a form of crystallized—or potential—capital. In this sense, it remains closely correlated with the wealth available to individuals and households, and thus constitutes a meaningful, albeit indirect, indicator of socioeconomic position.

The Discussion section acknowledges some key methodological limitations and makes a strong case for the practical relevance of mesoarea-based planning. However, it does not sufficiently interpret the study’s results in relation to the stated aims. Much of the discussion is descriptive rather than analytical and lacks engagement with alternative methods or critical reflection on feasibility and institutional uptake. Additionally, the authors do not assess whether the proposed model is generalizable beyond the specific case of Municipality III. A more robust discussion would include comparative insights, implementation challenges, and concrete pathways for integrating this tool into real planning frameworks.

In this regard as well, we sought to clarify certain logical passages that may have previously appeared insufficiently connected, by integrating specific methodological considerations into the Introduction, Discussion, and Conclusions. This was aimed at strengthening the internal consistency of the manuscript and providing clearer guidance on the rationale underlying our approach.

Detailed Comments

Methodological Transparency and Replicability

The methodological process lacks formalization. While the paper references visual inspection and iterative reclassification, it does not present a clear and reproducible set of steps or criteria. There is no mention of algorithmic or statistical validation of the resulting mesoareas, nor an evaluation of their internal or external consistency. The authors claim that the proposed mesoareas are more internally homogeneous than Urban Zones, but do not provide any statistical indicators or tests to substantiate this. Metrics such as intra-unit variance, interquartile range (IQR), or entropy would strengthen the validity of this claim.

This limits the replicability of the study and reduces confidence in its general applicability.The justification for selecting variables and the decision thresholds for clustering or aggregating areas are not sufficiently described. For example, the logic behind aggregating or subdividing areas with small populations, or the choice to maintain pre-existing boundaries in some cases, is not made transparent.

We have completely revised the Methods section, organizing the analytical steps in a more structured manner and providing greater detail on each phase of the process. Several new elements have been introduced, including more specific tests designed to detect potential distortions, along with more refined analyses addressing key methodological aspects.

As a result, some findings have been revised. Thanks in part to the reviewer’s insightful suggestions, these results are now more consistent with the aims and objectives originally set out for this study. Minor residual issues remain; however, we have chosen not to intervene further in these cases, as doing so would have led to an excessive fragmentation of the territory. This, in turn, would have undermined the potential applicability of the results for practical health service planning.

Use of OMI and Socio-Economic Indicators

The manuscript correctly acknowledges that OMI values may not fully reflect socio-demographic realities due to price distribution asymmetries. However, it would benefit from the integration of more direct socio-economic indicators—such as household income, employment status, or deprivation indices—into the delineation process.

A relevant precedent is Barreca et al. (2018), who used OMI-derived property-value zones in Turin to explore housing vulnerability and social inequality. Their findings demonstrate spatial correlation between real estate values and social vulnerability indicators, which supports the potential utility of OMI in socio-spatial modeling.

Reference: Barreca, A., Curto, R., & Rolando, D. (2018). Housing vulnerability and property prices: Spatial analyses in the Turin real estate market. Sustainability, 10(9), 3068. https://doi.org/10.3390/su10093068

Including this kind of reference would strengthen the manuscript’s methodological foundation and help frame the choice of OMI within a validated Italian empirical context.

However, it would benefit from the integration of more direct socio-economic indicators—such as household income, employment status, or deprivation indices—into the delineation process.

We would once again like to thank Reviewer 1 for the thorough analysis and, above all, for the constructive tone of the comments, which enabled us—through the study and integration of the cited sources—to address certain gaps in our initial line of reasoning.

We have incorporated one of the suggested references into the revised Discussion section, as it allows for a broader reflection on the potential applicability of our analytical framework in other contexts.

Furthermore, in both the Discussion and Conclusions, we explicitly acknowledge that the overall methodological structure would benefit from the inclusion of a synthetic indicator of socioeconomic position—currently unavailable in the dataset we employed. Nonetheless, we believe that our work, though partial in this respect, has still offered valuable insights by testing the robustness of a single, well-established determinant: educational attainment, used here as a proxy for individual socioeconomic status.

Spatial Logic and Delineation Criteria

The rationale for delineating boundaries along major road axes remains insufficiently justified. These divisions appear arbitrary and lack supporting criteria. The authors should clarify whether these were based on transport accessibility, expert knowledge, or other spatial logic. Visual criteria alone are insufficient to support generalizable spatial zoning. Referencing accessibility analyses or expert consultation methods (e.g., Delphi) could enhance methodological transparency.

The final classification into five types of mesoareas lacks a corresponding table or statistical profile to justify the clustering. Readers would benefit from a summary of defining characteristics per group.

The classification used in paragraph 1.1, at the end of the Introduction, reflects a typology that is widely recognized within the field of historical-qualitative urban analysis, and was adopted to meet the specific need of contextualizing the case of Rome. This typology partially corresponds to the classification of urban fabrics defined in the Technical Regulations of the General Regulatory Plan (Piano Regolatore Generale).

In response to the reviewer’s suggestion, we have further refined the methodology by incorporating additional tools—such as administrative classifications of the road network and its functional role in delineating neighborhood boundaries. This allowed us to reduce the level of arbitrariness in certain methodological choices. We thank the reviewer for this helpful observation.

Mapping and Visual Communication

The maps and cartographic outputs are generally weak. In particular, Figure 3 uses a grey scale that makes it difficult to distinguish between classes. Labels or indicators on the maps could clarify which zones are being described in the text (e.g., in Figure 1 the referencing categories of urban fabric or population density). Maps should be fully legible and function as standalone communicative tools.

We have worked to improve the overall layout of the figures in order to enhance their readability. We thank the reviewer for this observation, which led to a substantial improvement in the visual clarity of the entire manuscript. Most of the figures have been revised to ensure better legibility, including the addition of legends in each image to facilitate interpretation.

Policy Relevance and Institutional Uptake

While the paper claims alignment with the LHU Roma 1’s strategic planning and the Decree 77/2022, the direct link between the mesoarea delineation and health policy implementation remains vague. It is not made clear how these zones are expected to be adopted by LHU planners or how they integrate with service provision tools. Including a discussion of stakeholder feedback or pilot implementation would enhance the applied relevance.

The authors are optimistic about the planning applications of their method, yet they do not provide evidence of institutional uptake or practical feasibility. A more cautious tone would be appropriate, or at least a discussion of potential barriers to implementation.

Thanks to the reviewer’s comments, we have formalized the development of the methodological framework, with the goal of making it as reproducible as possible—certainly within the context of Rome, but also more broadly across Italy. All the tools employed in our analysis (including the road network graph, OMI zones, and Census data) are available for all Italian urban areas, thereby ensuring methodological scalability.

As for potential barriers to implementation, these are primarily of a political or institutional nature, rather than technical. Both the methodological framework and the institutional mandate for its application are clearly defined. We have sought to clarify these aspects in the revised Conclusions, where we also expanded on specific choices made regarding the population thresholds adopted for the definition of the study areas.

F. Literature Integration and Conceptual Framing

The literature review overlooks major studies on residential segregation, urban inequality, and spatial governance in Southern European contexts. Incorporating urban geography insights—especially concerning homeownership patterns and long-term spatial path dependencies—would improve the theoretical framing. References such as Maloutas (2012), Tulumello & Dagkouli-Kyriakoglou (2021), and Logan & Martinez (2018) provide a valuable foundation for this discussion.

Adiotionaly the manuscript would benefit from references to international experiences with small-area geographies used for planning, which would highlight the novelty or potential adaptation of mesoareas [e.g. LSOAs (UK), IRIS (France), CBS buurt/wijken (Netherlands), Census tracts (USA/Canada).

We have enriched the Discussion section by incorporating bibliographic references related to the reviewer’s suggestions, which have allowed us to further explore the generalizability of our findings in light of both national and international experiences.

At the same time, we have clarified that our approach is not intended as a study methodology in the conventional analytical sense, but rather as a planning-oriented methodology—developed in response to recent regulatory reforms concerning the reorganization of territorial healthcare services.

G. Internal Consistency and Redundancy

• There is some internal redundancy between paragraphs, e.g., [428–432] and [433–437] appear to reiterate similar ideas. Streamlining these sections would help clarity and improve narrative efficiency.

We have revised the entire manuscript, aiming to eliminate all redundancies highlighted by the reviewer—as well as additional ones we identified during the revision process. We sincerely thank the reviewer for the time, patience, and thoughtful effort devoted to evaluating our work.

Reviewer 2 Report

Comments and Suggestions for Authors

The study as a whole is in line with local policy orientation, but the study discusses very little about this part of "health care planning", and the division indicators do not seem to consider urban medical and health indicators. The introduction seems to overemphasize policy, and the relevant research trends need to be supplemented, and the significance of this study needs to be further emphasized. In addition, the study did obtain a more refined regional division, but it is necessary to emphasize how local health planning can use these areas to formulate more targeted and fairer intervention measures. If only the area is used, then health planning is not enough, and medical points, road networks, etc. need to be considered, and the population size and the arrival time of these points need to be further analyzed, because even based on more refined administrative divisions, there may be low accessibility to medical points, which is still unfair.

The specific detailed suggestions are as follows:

1. The abstract should reflect relevant quantitative results, such as the number of different regions (mesoareas) after fine division, etc.

2. The description in the introduction is a bit too long. It is recommended to add some research status related to the article, such as the current research trends from the perspective of urban equity? The boundary division of current urban research planning, and the analysis model of related methods, etc. Rather than a simple policy analysis.In addition, the purpose and significance of the research need to be further emphasized.

3. Page 5, It is recommended to add relevant diagrams to the description of the research method, including the research framework diagram of this study.

4. It is recommended to clarify the data sources used in the form of a table. In addition, the conclusion part mostly describes the direct relationship between the region and the sales price. It is strongly recommended to visualize the original data (population or price) of the entire research area based on GIS software.

5. The boundary lines in the pictures related to 3. Results, such as fig8, do not correspond to the scene. It is recommended to review them carefully and mark the corresponding legends.

6. The purpose of this study is to explore more reasonable administrative boundaries based on population, housing price and other data, taking "III Municipality" as a research case. But what is strange is that this study uses a fairness perspective. What does the fairness perspective of this study refer to? What factors affect this perspective? In addition, the population data and housing price data are used to redefine "Health Planning through". Are the data mentioned in the article sufficient for redefining boundary divisions? Are there potential influencing factors?

7. Is it necessary to explain the connection between population, housing price and health? This is important for the perspective of the article "Redefining Urban Boundaries for Health Planning".

8. It is necessary to emphasize the advantages of the planned administrative boundaries redefined in this study compared with the previous administrative planning. In addition, does the redefinition of "Redefining Urban Boundaries for Health Planning" not require some medical facility data? From a planning perspective, the distribution of related infrastructure such as medical points and transportation networks will affect the fairness of administrative divisions.

Author Response

We would like to thank Reviewer 2 for the thorough review, which has, in our view, significantly contributed to improving the overall quality of the manuscript.

The study as a whole is in line with local policy orientation, but the study discusses very little about this part of "health care planning", and the division indicators do not seem to consider urban medical and health indicators.

We have sought to develop this point more thoroughly in the Introduction, and have subsequently referenced it in both the Methods and Discussion sections. We thank the reviewer for this insightful comment. In particular, we believe we have clarified the intended use of the tool we propose—namely, as a prospective planning instrument (ex ante) rather than a measure of service accessibility (ex post). We also clarified the institutional mandate set forth by Ministerial Decree 77/2022, which defines specific catchment areas for different types of territorial healthcare services, as well as the broader administrative framework within which our analysis was conducted.

The introduction seems to overemphasize policy, and the relevant research trends need to be supplemented, and the significance of this study needs to be further emphasized. In addition, the study did obtain a more refined regional division, but it is necessary to emphasize how local health planning can use these areas to formulate more targeted and fairer intervention measures. If only the area is used, then health planning is not enough, and medical points, road networks, etc. need to be considered, and the population size and the arrival time of these points need to be further analyzed, because even based on more refined administrative divisions, there may be low accessibility to medical points, which is still unfair.

We thank the reviewer for this helpful comment. We believe we have now more clearly articulated the purpose of the present study, which is not to evaluate the accessibility of existing services, but rather to support the planning of future service provision. As previously noted, our work is framed within the institutional mandate defined by Ministerial Decree 77/2022, and we have revised the manuscript to explicitly reflect its key provisions—thanks in part to this valuable comment.

The specific detailed suggestions are as follows:

1. The abstract should reflect relevant quantitative results, such as the number of different regions (mesoareas) after fine division, etc.

 

2. The description in the introduction is a bit too long. It is recommended to add some research status related to the article, such as the current research trends from the perspective of urban equity? The boundary division of current urban research planning, and the analysis model of related methods, etc. Rather than a simple policy analysis.In addition, the purpose and significance of the research need to be further emphasized.

We have incorporated the reviewer’s suggestion and expanded on the topic, particularly in the revised Discussion section. The Methods section has also been reformulated to clarify that certain choices—previously appearing arbitrary—were in fact based on specific criteria that we had not made sufficiently explicit in the original version.

3. Page 5, It is recommended to add relevant diagrams to the description of the research method, including the research framework diagram of this study.

We have added the requested content as suggested.

4. It is recommended to clarify the data sources used in the form of a table. In addition, the conclusion part mostly describes the direct relationship between the region and the sales price. It is strongly recommended to visualize the original data (population or price) of the entire research area based on GIS software.

5. The boundary lines in the pictures related to 3. Results, such as fig8, do not correspond to the scene. It is recommended to review them carefully and mark the corresponding legends.

The population density map had already been included in Appendix 1, and we have improved Figure 3—depicting the OMI zones (corresponding to Table A1, which presents the detailed extrapolated data)—to enhance its readability. As suggested, we have also added a table specifying the data sources used in the study. Finally, all figures have been reviewed to improve their clarity and overall readability.

6. The purpose of this study is to explore more reasonable administrative boundaries based on population, housing price and other data, taking "III Municipality" as a research case. But what is strange is that this study uses a fairness perspective. What does the fairness perspective of this study refer to? What factors affect this perspective? In addition, the population data and housing price data are used to redefine "Health Planning through". Are the data mentioned in the article sufficient for redefining boundary divisions? Are there potential influencing factors?

We thank the reviewer for this insightful comment, which allowed us to elaborate on certain lines of reasoning that were only implicit in the original version. We believe that this has helped to clarify the broader conceptual framework within which the study was conducted.

The equity perspective is closely tied to the intended use of this territorial subdivision: by disaggregating health data according to socioeconomically differentiated populations, it becomes possible to highlight specific health issues and thus support a public health planning approach that explicitly addresses equity—even in the organization of basic services.

In response to the reviewer’s suggestion, we expanded our analysis beyond educational attainment to include additional socioeconomic dimensions, such as employment status and the proportion of single-parent households—variables drawn from the deprivation index developed by Caranci et al, although this index has not yet been validated using data from the 2021 Census. We did not include housing density in the analysis, as this information has not yet been released by ISTAT for the 2021 Census. More broadly, we revised the Introduction, Discussion, and Conclusions, and completely redesigned the Methods section to reflect these improvements.

7. Is it necessary to explain the connection between population, housing price and health? This is important for the perspective of the article "Redefining Urban Boundaries for Health Planning".

The connection in question is discussed in both the Introduction and the Discussion, where we have incorporated additional sources that allowed us to better contextualize the issue and to strengthen the rationale for using property prices as a valid indicator.

8. It is necessary to emphasize the advantages of the planned administrative boundaries redefined in this study compared with the previous administrative planning. In addition, does the redefinition of "Redefining Urban Boundaries for Health Planning" not require some medical facility data? From a planning perspective, the distribution of related infrastructure such as medical points and transportation networks will affect the fairness of administrative divisions.

At this stage in the development of the methodological framework for implementing Ministerial Decree 77/2022, the focus is primarily on the definition of catchment areas. As explained in the manuscript, this territorial delineation is intended to support future healthcare planning—specifically the prospective localization of socio-health infrastructure financed through the Next Generation EU program. The issue of accessibility falls outside the scope of the present article and will be addressed in a dedicated analysis, as this topic is currently under active discussion within the coordination structures of LHU Roma 1.

Nevertheless, thanks to Reviewer 2’s comment, we have been able to clarify these aspects more explicitly in the revised manuscript. We also note that a follow-up article is in preparation, based on the work we are currently carrying out.

Reviewer 3 Report

Comments and Suggestions for Authors

This is a very valuable and extremely practical study. The work aims to redistribute the existing Urban Zones (UZs) of a Roman administrative district according to sociodemographic indicators in order to create more homogeneous 'mesoareas' and thus support more equitable and accurate health planning. The research idea is clear, the approach is new, and the methodology is innovative. However, the methodological rigor of the study, the interpretation of some conclusions and the argumentation can be further revised and improved to increase the quality of the work.

(1) Problem with the rules for delineating OMI. Lines 190-195, 209-213, 313-318: The core of the paper lies in the allocation of existing UZs. The split based on OMI and main roads is not justified and not derived rigorously enough.

(2) Lines 206-208, 216-218: When OMI boundaries did not match census section (CS) boundaries, the authors stated that "efforts were made to delineate mesoareas that approximated the OMI boundaries as closely as possible." If the population was too large, the authors "divided arbitrarily following the main road arteries." These descriptions lack a clear, reproducible rule.

(3) Lines 340-346: In cases like Fidene and Serpentara, there was no statistically significant difference in education attainment between the newly divided areas. Yet, the authors decided to "retain" these new divisions. This is a crucial logical contradiction. If your validation metric does not support your split, the rationale for retaining the split needs to be very well justified.

(4) Discussion section. In lines 378-396 and 397-408, the authors attempt an explanation (e.g., asymmetric OMI price ranges, imprecise CS boundaries) that goes in the right direction but needs to be stated more clearly. Or recognize this as a limitation and suggest that future research needs more multidimensional SES indicators for validation.

(5) Lines 498-506. The limitations of a single proxy indicator should be discussed in more detail. Using only the "proportion of tertiary degrees" as a proxy indicator for SES may be an oversimplification.
The limitations of the OMI data itself should also be discussed. The authors mention that there is no median, which is an important point. Housing prices may be influenced by non-local SES factors such as speculation and school districts, which weakens their effectiveness as an SES proxy indicator.
Rationale for the population threshold. Why was a population of 1,500 to 20,000 chosen as the standard for a meso-area? This is mentioned in the methods section (lines 154-155), but there is no justification. Is it based on practical standards for health administration in Italy or Rome, or is it supported by the literature? Justification needs to be added.

(6) Other errors. Line 299: There is a clear citation error in "Figure 7Figure 8". Lines 433-437: There are two completely identical paragraphs; one needs to be deleted. Line 391: The text mentions "(see IMAGE)".

Author Response

This is a very valuable and extremely practical study. The work aims to redistribute the existing Urban Zones (UZs) of a Roman administrative district according to sociodemographic indicators in order to create more homogeneous 'mesoareas' and thus support more equitable and accurate health planning. The research idea is clear, the approach is new, and the methodology is innovative. However, the methodological rigor of the study, the interpretation of some conclusions and the argumentation can be further revised and improved to increase the quality of the work.

We sincerely thank the reviewer for the overall evaluation of the article and for the thoughtful and constructive feedback provided. The reviewer’s suggestions have been incorporated into the revised manuscript, and we believe the resulting version is significantly improved thanks to these valuable comments. We apologize for the delay in submitting our response, which was due to the substantial revisions undertaken to address the points raised.

(1) Problem with the rules for delineating OMI. Lines 190-195, 209-213, 313-318: The core of the paper lies in the allocation of existing UZs. The split based on OMI and main roads is not justified and not derived rigorously enough.

We have worked to more clearly redefine the boundaries of both the original areas (OMI zones and Urban Zones) and the newly developed mesoareas. In the Methods section, we have integrated the road network graph into the analysis, both as a GIS input and by reconstructing road-based subdivisions using the administrative and functional classification of the street system.

The revised Methods section also includes a table summarizing all GIS operations performed to overlay the various spatial layers. Additionally, we have included in the Appendix a comparative table providing a synoptic overview of OMI zones and Urban Zones, also in relation to Census data.

(2) Lines 206-208, 216-218: When OMI boundaries did not match census section (CS) boundaries, the authors stated that "efforts were made to delineate mesoareas that approximated the OMI boundaries as closely as possible." If the population was too large, the authors "divided arbitrarily following the main road arteries." These descriptions lack a clear, reproducible rule.

Thank you for this comment. The issue was also raised by other reviewers, and we have addressed it accordingly. We introduced several theoretical improvements to justify certain subdivisions that may have previously appeared arbitrary—particularly by linking them to the population thresholds of primary care catchment areas as defined by recent Italian healthcare legislation, which forms the institutional foundation of our analysis.

As mentioned earlier, we also refined the use of additional urban planning instruments, especially administrative classifications, to reduce the arbitrariness of territorial delineations.

Moreover, we worked to formalize and make more reproducible the methodological steps involved in the creation of the mesoareas, which are now explicitly described in both the Methods section and the Appendix.

(3) Lines 340-346: In cases like Fidene and Serpentara, there was no statistically significant difference in education attainment between the newly divided areas. Yet, the authors decided to "retain" these new divisions. This is a crucial logical contradiction. If your validation metric does not support your split, the rationale for retaining the split needs to be very well justified.

We have revised the methodology in order to ensure greater rigor in the identification of mesoareas. In particular, the mesoareas within the Serpentara zone have been re-evaluated in light of this comment, which prompted us to reassess the overall classification scheme—resulting, in our view, in significant improvements.

All subdivisions were also tested to identify potential sources of distortion, and the entire process was systematically revalidated. We thank the reviewer once again for this valuable contribution.

(4) Discussion section. In lines 378-396 and 397-408, the authors attempt an explanation (e.g., asymmetric OMI price ranges, imprecise CS boundaries) that goes in the right direction but needs to be stated more clearly. Or recognize this as a limitation and suggest that future research needs more multidimensional SES indicators for validation.

We have thoroughly revised the structure of the manuscript in order to clarify several aspects, including those rightly identified by the reviewer as limitations. We thank the reviewer for this constructive comment.

We have also expanded the section on study limitations, acknowledging that we relied on a single indicator—educational attainment—as a proxy for socioeconomic position. In the revised version, we have made this choice more explicit and provided a stronger justification for it, drawing on prior national experiences and supported by a rigorous evaluation framework that also included two additional health determinants, which were considered and tested in the analysis.

(5) Lines 498-506. The limitations of a single proxy indicator should be discussed in more detail. Using only the "proportion of tertiary degrees" as a proxy indicator for SES may be an oversimplification.

We have enriched the analytical methodology based on the reviewer’s comments. In particular, in addition to educational attainment, we have included two further variables: employment status and the proportion of single-parent households.

However, we believe that these indicators would ideally require a composite index, rather than being used cumulatively. For this reason, we have clarified in the revised manuscript that our analysis shows a strong correlation between educational level and the other two variables available from the 2021 Census. Therefore, as discussed, we consider that in the context under study—and in light of the existing literature on socioeconomic inequalities in health in Rome—educational attainment alone provides a reasonably accurate reflection of the underlying dynamics. All these aspects have been expanded upon in the Methods, Discussion, and Conclusions sections.

The limitations of the OMI data itself should also be discussed. The authors mention that there is no median, which is an important point. Housing prices may be influenced by non-local SES factors such as speculation and school districts, which weakens their effectiveness as an SES proxy indicator.

We have further developed this point in light of a broader analysis of real estate dynamics in Southern European cities. Given the absence of major exogenous factors impacting the study area—such as large university institutions—we believe that the economic patterns reflected by the OMI zones can reasonably be considered relatively homogeneous.

This comment allowed us to make this point more explicit in the Discussion section, which we believe now contributes to a more coherent and robust overall structure of the manuscript. We thank the reviewer once again for this valuable observation.

Rationale for the population threshold. Why was a population of 1,500 to 20,000 chosen as the standard for a meso-area? This is mentioned in the methods section (lines 154-155), but there is no justification. Is it based on practical standards for health administration in Italy or Rome, or is it supported by the literature? Justification needs to be added.

Thank you for this comment. We take this opportunity to expand upon a point already addressed more generally in previous responses. Ministerial Decree 77/2022—which introduces a substantial reorganization of primary territorial care in Italy—explicitly establishes, for the first time in a regulatory text, fixed catchment areas based on the type of service to be provided by Local Health Units (LHUs). In this framework, the sizing of the study areas was developed starting from the smallest catchment area defined by the decree—namely, that of family counseling services—while allowing for a limited degree of variation to avoid excessive fragmentation of census tracts. These aspects have now been explicitly stated in the manuscript, both in the Introduction and in the Discussion, thereby reinforcing the overall coherence and methodological soundness of the study.

(6) Other errors. Line 299: There is a clear citation error in "Figure 7Figure 8". Lines 433-437: There are two completely identical paragraphs; one needs to be deleted. Line 391: The text mentions "(see IMAGE)".

These and other typographical errors identified in the manuscript have been corrected. Thank you.

We would like to sincerely thank Reviewer 3, whose detailed analysis of the manuscript allowed us to further develop several sections that were indeed incomplete in relation to the complexity of the reasoning that underpinned this work.

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

I appreciate the substantial effort made by the authors in revising the manuscript. Many of the initial concerns were addressed with diligence and clarity. The revised version shows improved methodological transparency, clearer cartographic outputs, and a stronger alignment between objectives and analytical procedures. However, some of the claims made in the response letter are only partially substantiated in the actual text. Below is a detailed evaluation of the authors’ response by thematic area.

Socio-Economic Indicators and Use of OMI-> Partially addressed

The authors acknowledge the limitations of using OMI values alone and refer to the utility of integrating additional socio-economic indicators (e.g., income, employment, deprivation). They also cite relevant literature (e.g., Barreca et al., 2018). However, despite this acknowledgment, no alternative indicators or proxy variables are incorporated into the delineation process. A sensitivity analysis, even exploratory, using available data (e.g., education, unemployment) would strengthen methodological robustness. The reliance on educational attainment as the sole proxy remains a limitation.

Internal Homogeneity and Statistical Testing-> Addressed

The revised Methods section includes significant enhancements, notably using intra-unit statistical indicators (e.g., Kruskal–Wallis, Bonferroni, IQR, variance). The comparison between Mesoareas and Urban Zones is now statistically grounded and clearly articulated. This marks a substantial improvement and strengthens the empirical validity of the classification.

Delineation Criteria – Road Axes and Spatial Logic->Addressed

The authors justify the use of road axes through reference to official administrative classifications (PGTU) and functional roles in urban structure. Their integration of spatial datasets and refinement of boundary-setting logic addresses the initial concern about arbitrariness in spatial subdivision.

Cartographic Quality and Visual Clarity-> Addressed

Significant effort has been made to improve the readability and interpretability of the maps. Figures now include clearer legends, classification categories, and improved design. This notably enhances the manuscript’s communicative value.

Connection Between Results and Stated Planning Objectives-> Partially addressed

While the manuscript has improved in structural coherence across sections, the results section remains somewhat descriptive. The connection between empirical findings and the planning objectives introduced in the introduction still lacks analytical depth. Further reflection on how specific findings align (or not) with territorial health planning priorities would be beneficial.

Theoretical Framing and Urban Segregation Literature-> Partially addressed

Although the authors claimed to have cited several relevant works—including Maloutas (2012), Tulumello & Dagkouli-Kyriakoglou (2021), and Logan & Martinez (2018)—only the second appears in the bibliography, and referenced in the main body of the manuscript. This represents a missed opportunity to strengthen the conceptual grounding regarding residential segregation, tenure regimes, and the Southern European housing context. Integration of these references would enrich the discussion of the spatial embeddedness of inequality.

Scalability and Generalizability Beyond Rome’s Municipality III->Partially addressed

The manuscript explains that all necessary data and tools are available across Italian urban areas, supporting potential scalability. However, there is no discussion of a pilot application elsewhere or a hypothetical comparative scenario. The claim of generalizability thus remains theoretical.

Policy Integration and Alignment with Health Policy Objectives ->Partially addressed

While the manuscript references national regulatory frameworks—particularly the DM 77/2022 decree—and acknowledges the institutional prerogatives of the LHU Roma 1, the actual connection between the mesoarea delineation and concrete health policy mechanisms remains vague. The text does not provide sufficient clarity on how the proposed zoning would be integrated into existing service planning tools, nor does it outline any structured dialogue with institutional actors (e.g., planners, health authorities). Additionally, the lack of documented feedback or piloting within the LHU weakens the argument for immediate policy relevance. A more explicit discussion of operational pathways, potential institutional barriers, and the integration of the method into actual territorial healthcare planning processes would substantially strengthen the paper’s applied impact.

Internal Consistency and Redundancy->Addressed

The revised version is noticeably more concise and coherent. Repetitive elements have been removed or streamlined, and section transitions are more fluid.

Comparative Reference to International Small-Area Geographies->Addressed

The inclusion of international references (LSOAs, IRIS, CBS buurt/wijken, Census tracts) helps contextualize the originality of the mesoarea concept. This is a welcome addition and supports the manuscript’s relevance for broader planning audiences.

Overall Recommendation

The manuscript has evolved substantially since its initial version and demonstrates methodological and presentational improvements. However, a few critical gaps remain—particularly in the integration of urban segregation theory and the practical application of socio-economic indicators. I would recommend:

Minor Revisions, focusing on:

1. Fulfilling the claimed inclusion of references (Maloutas, Logan, etc.) in both bibliography and Discussion.
2. Exploring the use or at least testing of a composite socio-economic indicator (or making the limitations more explicit).
3. Clarifying how findings support specific planning outcomes introduced in the Introduction.

If these points are addressed, I believe the manuscript will offer a well-grounded and methodologically sound contribution to spatial health planning literature.

Author Response

I appreciate the substantial effort made by the authors in revising the manuscript. Many of the initial concerns were addressed with diligence and clarity. The revised version shows improved methodological transparency, clearer cartographic outputs, and a stronger alignment between objectives and analytical procedures. However, some of the claims made in the response letter are only partially substantiated in the actual text. Below is a detailed evaluation of the authors’ response by thematic area.

Thank you once again for your thorough work, which gave us the opportunity to significantly improve our manuscript by refining both the methodology and several specific aspects that indeed required further adjustment.

Socio-Economic Indicators and Use of OMI-> Partially addressed

The authors acknowledge the limitations of using OMI values alone and refer to the utility of integrating additional socio-economic indicators (e.g., income, employment, deprivation). They also cite relevant literature (e.g., Barreca et al., 2018). However, despite this acknowledgment, no alternative indicators or proxy variables are incorporated into the delineation process. A sensitivity analysis, even exploratory, using available data (e.g., education, unemployment) would strengthen methodological robustness. The reliance on educational attainment as the sole proxy remains a limitation.

We thank the reviewer for this insightful comment. In line with the suggestion, we have further emphasized the limitation of relying solely on educational attainment (EL) as a proxy for socio-economic status (SES) in the delineation process. While education is a widely used indicator and was the only SES-related variable available with adequate spatial resolution at the time of analysis, we acknowledge that the absence of additional indicators—such as income, employment, or deprivation indices—represents a limitation. This point has now been more clearly stated in the revised manuscript, in the Limitations and Conclusions section.

Internal Homogeneity and Statistical Testing-> Addressed

The revised Methods section includes significant enhancements, notably using intra-unit statistical indicators (e.g., Kruskal–Wallis, Bonferroni, IQR, variance). The comparison between Mesoareas and Urban Zones is now statistically grounded and clearly articulated. This marks a substantial improvement and strengthens the empirical validity of the classification.

Delineation Criteria – Road Axes and Spatial Logic->Addressed

The authors justify the use of road axes through reference to official administrative classifications (PGTU) and functional roles in urban structure. Their integration of spatial datasets and refinement of boundary-setting logic addresses the initial concern about arbitrariness in spatial subdivision.

Cartographic Quality and Visual Clarity-> Addressed

Significant effort has been made to improve the readability and interpretability of the maps. Figures now include clearer legends, classification categories, and improved design. This notably enhances the manuscript’s communicative value.

Thank you for your comments. The suggestions provided during Round 1 have allowed us to significantly improve these aspects of the manuscript.

Connection Between Results and Stated Planning Objectives-> Partially addressed

While the manuscript has improved in structural coherence across sections, the results section remains somewhat descriptive. The connection between empirical findings and the planning objectives introduced in the introduction still lacks analytical depth. Further reflection on how specific findings align (or not) with territorial health planning priorities would be beneficial.

We appreciate the reviewer’s comments regarding the Results section and the need for a stronger analytical connection with the planning objectives introduced earlier in the manuscript. As noted, we intentionally adopted a descriptive approach in the Results section to ensure clarity in the presentation of the empirical outputs. Analytical interpretation and contextualization of findings—particularly in relation to the existing literature and planning frameworks—were deliberately reserved for the Discussion section.

If the reviewer’s comment was intended to refer to the Discussion rather than the Results section, we would like to highlight that the Discussion was substantially expanded following the first round of revisions, specifically in response to a request to provide a more thorough interpretation of the findings.

We appreciate the reviewer’s suggestion to better connect the empirical findings with the planning objectives introduced in the manuscript. As recommended, we have updated the Discussion section to elaborate on the potential applications of the mesoarea delineation in the context of local health planning, particularly in light of the ongoing reorganization of territorial healthcare services as outlined in DM 77/2022. We acknowledge that a full integration of this methodological framework into the reconstruction of the territorial healthcare service offering is a complex and ambitious task. For this reason, we consider it more appropriate to address such developments in a dedicated future study, which could build on the current methodological foundation. This work should be seen as a first step, aimed at proposing a replicable and data-informed approach to territorial segmentation, with potential relevance for planning but not yet implemented operationally.

Theoretical Framing and Urban Segregation Literature-> Partially addressed

Although the authors claimed to have cited several relevant works—including Maloutas (2012), Tulumello & Dagkouli-Kyriakoglou (2021), and Logan & Martinez (2018)—only the second appears in the bibliography, and referenced in the main body of the manuscript. This represents a missed opportunity to strengthen the conceptual grounding regarding residential segregation, tenure regimes, and the Southern European housing context. Integration of these references would enrich the discussion of the spatial embeddedness of inequality.

Thank you for the valuable bibliographic suggestions. We have taken them into careful consideration and used them to enrich the Discussion section, where we further elaborate on relevant themes inspired by the recommended literature. Additionally, the references have been incorporated into the updated bibliography.

Scalability and Generalizability Beyond Rome’s Municipality III->Partially addressed

The manuscript explains that all necessary data and tools are available across Italian urban areas, supporting potential scalability. However, there is no discussion of a pilot application elsewhere or a hypothetical comparative scenario. The claim of generalizability thus remains theoretical.

We thank the reviewer for raising this important point regarding the generalizability of our methodological approach. While we argue that the proposed method is theoretically generalizable—given the availability of the same core data sources (e.g., census microdata, OMI zones, urban road classifications) across Italian urban contexts—we acknowledge that this claim remains hypothetical in the absence of a pilot application in other regions or municipalities.

Although the authors are professionally involved in the local territorial health reorganization process, this study was not conducted under a formal institutional mandate, nor did it directly involve other institutional actors responsible for decision-making or implementation. Therefore, its current application remains exploratory and context-specific.

As suggested, we have made this limitation more explicit in the revised manuscript. Nevertheless, we believe that the standardized availability of the required datasets supports the scalability of the method to other Italian urban areas, pending future validation efforts in collaboration with relevant stakeholders.

Policy Integration and Alignment with Health Policy Objectives ->Partially addressed

While the manuscript references national regulatory frameworks—particularly the DM 77/2022 decree—and acknowledges the institutional prerogatives of the LHU Roma 1, the actual connection between the mesoarea delineation and concrete health policy mechanisms remains vague. The text does not provide sufficient clarity on how the proposed zoning would be integrated into existing service planning tools, nor does it outline any structured dialogue with institutional actors (e.g., planners, health authorities). Additionally, the lack of documented feedback or piloting within the LHU weakens the argument for immediate policy relevance. A more explicit discussion of operational pathways, potential institutional barriers, and the integration of the method into actual territorial healthcare planning processes would substantially strengthen the paper’s applied impact.

We thank the reviewer for the insightful comment regarding the institutional integration of the proposed method. As noted, this work represents a methodological proposal rather than a formally commissioned project. The authors are involved in the territorial health planning context; however, this specific study was not developed under an institutional mandate, nor does it reflect a piloted intervention at this stage.

In response to the reviewer’s suggestion, we have expanded the "Limitations" section highlighting that this paper aims to present a new methodology that has never been applied before, and how this methodology could find a concrete application in light of the reorganization of the Italian healthcare system, but it was not developed under an institutional mandate. A draft version of this methodology has been included in the new Corporate Organizational Act of ASL Roma 1, but as of now, we have not yet begun to propose this methodology for concrete projects. Its full integration into policy mechanisms would require further validation, including institutional engagement, iterative feedback, and pilot testing within the LHU or other settings.

In the discussion section we further explore how the delineation of mesoareas could be operationalized within existing healthcare planning tools—such as catchment area design, needs assessment, or service accessibility models. We also acknowledge the absence of structured dialogue with institutional stakeholders during the development phase as a limitation.

Internal Consistency and Redundancy->Addressed

The revised version is noticeably more concise and coherent. Repetitive elements have been removed or streamlined, and section transitions are more fluid.

Comparative Reference to International Small-Area Geographies->Addressed

The inclusion of international references (LSOAs, IRIS, CBS buurt/wijken, Census tracts) helps contextualize the originality of the mesoarea concept. This is a welcome addition and supports the manuscript’s relevance for broader planning audiences.

Overall Recommendation

The manuscript has evolved substantially since its initial version and demonstrates methodological and presentational improvements. However, a few critical gaps remain—particularly in the integration of urban segregation theory and the practical application of socio-economic indicators. I would recommend:

Minor Revisions, focusing on:

1. Fulfilling the claimed inclusion of references (Maloutas, Logan, etc.) in both bibliography and Discussion.
2. Exploring the use or at least testing of a composite socio-economic indicator (or making the limitations more explicit).
3. Clarifying how findings support specific planning outcomes introduced in the Introduction.

If these points are addressed, I believe the manuscript will offer a well-grounded and methodologically sound contribution to spatial health planning literature.

We believe that we have addressed the reviewer’s comments through the additional revisions incorporated into this new version of the manuscript. We would like to thank the reviewer, as their careful and insightful perspective has enabled us to make the structure of the paper more coherent and well-organized, while also giving us the opportunity to explore in greater depth several aspects that had previously been addressed in a more general way.

We have therefore addressed the three points raised, as described, in the relevant sections of the manuscript, adding new short paragraphs particularly in the Discussion and Conclusions.

Reviewer 2 Report

Comments and Suggestions for Authors

After careful evaluation of the revised manuscript, we confirm that every point has been resolved. The paper now meets the journal's publication standards, and I recommend acceptance in its current form.

Author Response

After careful evaluation of the revised manuscript, we confirm that every point has been resolved. The paper now meets the journal's publication standards, and I recommend acceptance in its current form.

We would like to thank the reviewer for their support and careful analysis of the manuscript, which allowed us to refine our approach and achieve what we believe is an optimal result.

Reviewer 3 Report

Comments and Suggestions for Authors

It is commendable that the authors' response is thorough and of high quality. Not only have they corrected the problems, but also, inspired by the reviewers' comments, they have improved the rigor of their research. Although manuscript v2 shows significant improvements, a careful reading still reveals some details that could be further improved, including a critical conceptual confusion.
(1) The confusion between 'single-parent households' and “single-person families/households'. The former tend to be strongly correlated with potential economic vulnerability, while the latter have a complex composition (e.g. young people living alone on high incomes or older people living alone). This terminological inconsistency and contradiction can seriously mislead readers and undermine the rigor of the study.
(2) The current Methods and Results sections are presented in a diary-like, repetitive and iterative step-by-step format (Step 1, Step 2, ..., Step 6, Step 4b, Step 5b, Step 6b, ...), which makes it extremely difficult for readers to follow the authors' reasoning. This writing style is more like a lab notebook than a formal academic paper. It is recommended that the authors thoroughly reorganize these two sections.
(3) Proofread the entire manuscript to correct grammatical errors and awkward expressions and to increase the professionalism of the paper.

Comments on the Quality of English Language

Proofread the entire manuscript to correct grammatical errors and awkward expressions and to increase the professionalism of the paper.

Author Response

It is commendable that the authors' response is thorough and of high quality. Not only have they corrected the problems, but also, inspired by the reviewers' comments, they have improved the rigor of their research. Although manuscript v2 shows significant improvements, a careful reading still reveals some details that could be further improved, including a critical conceptual confusion.

(1) The confusion between 'single-parent households' and “single-person families/households'. The former tend to be strongly correlated with potential economic vulnerability, while the latter have a complex composition (e.g. young people living alone on high incomes or older people living alone). This terminological inconsistency and contradiction can seriously mislead readers and undermine the rigor of the study. 

We thank the reviewer for this important clarification regarding terminology. We acknowledge the confusion caused by the inconsistent use of "single-parent households" and "single-person households." We have corrected the terminology throughout the manuscript, adopting the term “single-person households”, as this is the variable available in the 2021 Italian Census.

We did not include single-parent households in the analysis, as this specific data point is not currently available at the disaggregated geographic level we worked with, and this limitation is stated in the Discussion section (“4.3. Educational, Occupational, and Household Structure Differences Across Mesoareas”).

While we recognize that single-person households are not as directly indicative of socio-economic vulnerability as single-parent households, they still represent a relevant dimension for exploring the demographic and social structure of mesoareas—especially in conjunction with other indicators such as education and employment status.

(2) The current Methods and Results sections are presented in a diary-like, repetitive and iterative step-by-step format (Step 1, Step 2, ..., Step 6, Step 4b, Step 5b, Step 6b, ...), which makes it extremely difficult for readers to follow the authors' reasoning. This writing style is more like a lab notebook than a formal academic paper. It is recommended that the authors thoroughly reorganize these two sections.

We appreciate the reviewer’s feedback regarding the structure of the Methods and Results sections. The current step-by-step organization (Steps 1–6, including sub-steps) was introduced in response to a previous reviewer’s request for greater clarity and transparency in the delineation process of mesoareas from urban zones—particularly given the iterative nature of this procedure. That reviewer also specifically suggested the inclusion of a flow chart, which we provided, to visually guide the reader through the methodological logic.

While we acknowledge that this structure may come across as repetitive and potentially less elegant, we believe it serves a valuable function: it enables a more direct connection between each methodological step and its corresponding empirical outcome, and supports the reader in navigating complex procedures—especially when referring to accompanying figures.

We also find that this format appropriately highlights the iterative nature of the approach, particularly in relation to repeated statistical testing and adjustments based on interzonal road structures. For these reasons, we would prefer to retain the current format, as we believe it improves the overall comprehensibility and traceability of the analysis.

(3) Proofread the entire manuscript to correct grammatical errors and awkward expressions and to increase the professionalism of the paper.

Comments on the Quality of English Language

Proofread the entire manuscript to correct grammatical errors and awkward expressions and to increase the professionalism of the paper.

We have carefully reviewed the entire manuscript to carry out a comprehensive revision of typographical errors, while also rephrasing overly long or convoluted expressions in order to improve the overall readability of the article.

We sincerely thank the reviewer for this valuable contribution, which has undoubtedly helped make our work more thorough, methodologically sound, and accessible to readers.