Green Hospital Awareness: Evidence from Healthcare Technician Students

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Overview

This study addresses a relevant and timely topic: awareness of sustainability in hospital settings, focusing specifically on healthcare technician students – a professional group often overlooked in the green hospital literature. The research is well-founded, with a solid introduction that adequately contextualizes the problem, and the methodology is appropriate for the proposed objectives.

Strengths

1. Originality: The focus on health technicians fills an important gap in the literature.

2. Methodology: Use of a validated scale (HOQGD) with high reliability (α=0.949) and appropriate statistical analysis.

3. Data presentation: The tables are clear and informative, especially Table 6, which offers a detailed view of item-by-item responses.

4. Discussion: The authors appropriately compare their findings with existing literature and acknowledge the study's limitations.

Suggestions for Improvement

1. Gender imbalance in the sample: The sample consists of 87.2% female participants. Although this reflects the composition of the programs in Turkey, the gender comparisons (Table 5) should be interpreted with caution given the small number of male participants (n=40). It is suggested to mention this limitation more explicitly in the discussion.

2. Discrepancy between "unfamiliarity with the concept" and "high scores": 68.4% of students had never heard of the "green hospital" concept, but the mean scale score was high. This suggests that students may be practicing sustainable behaviors without associating them with the "green hospital" label. It would be interesting to explore this apparent contradiction in the discussion.

3. More concrete recommendations: The practical implications mentioned in the discussion are pertinent but could be more specific. For example, how exactly should curricula be modified? What types of workplace training would be most effective to address the identified gaps (especially in water efficiency)?

4. Editing error in Table 6: The explanatory paragraph "The table presents the distribution of responses..." appears duplicated (at the end of page 7 and again at the end of page 8). Please remove the repetition.

5. Future research: The suggestions for future research are good, but could include recommendations for qualitative studies (interviews, focus groups) to explore the reasons behind the observed patterns, especially the lower awareness in technical areas such as water efficiency.

Conclusion

The manuscript represents a valuable contribution to the literature on sustainability in healthcare. The above recommendations are suggestions to further enhance the clarity and impact of the work.

Comments on the Quality of English Language

The English could be improved to more clearly express the research and deepen the discussion of the findings.

Below are guidelines for the authors to revise the manuscript:

1. Deepen the analysis of the contradiction between lack of concept knowledge and high scores

The authors report that 68.4% of students had never heard of the "green hospital" concept, but the mean scale score was high. This contradiction deserves deeper analysis. Authors are requested to:

• Explore why students without formal knowledge of the concept still achieved high scores.

• Discuss whether the scale may be measuring behaviors that students perceive as routine professional conduct, rather than sustainability awareness.

• Consider whether implicit learning during hospital training may be occurring without explicit labeling as "green practices."

• Add reflection on the implications of this disconnect for sustainability education.

2. Expand the discussion on gender differences

It was identified that female students scored higher on the total scale and the materials and resources subdimension. Authors are requested to:

• Present additional hypotheses to explain this difference, beyond "environmental sensitivity."

• Discuss whether sociocultural or educational factors may contribute to this disparity.

• Consider whether the sample imbalance (87.2% female) may have influenced the results.

• Suggest directions for future research investigating the causes of these differences.

3. Better elaborate the explanation for low scores in water efficiency

Water efficiency was the area with the lowest awareness. Authors are requested to:

• Deepen the explanation of why students are less aware of this dimension.

• Relate this finding to the "invisibility" of water infrastructure in hospital settings.

• Discuss how to make these issues more visible in the training of health technicians.

• Compare this finding with other studies addressing water awareness in healthcare settings.

4. Make educational recommendations more specific

The current recommendations on integrating sustainability into curricula are generic. Authors are requested to:

• Offer concrete examples of how curricula can be modified.

• Specify which content should be included and in which disciplines.

• Suggest specific pedagogical methods (case studies, audits, simulations) to address the identified gaps.

• Indicate how to evaluate the effectiveness of these educational interventions.

5. Strengthen analytical language in the discussion

The current discussion lists findings sequentially but lacks language that establishes relationships between ideas. Authors are requested to:

• Use connectives such as "however," "furthermore," "conversely," "notably," "this suggests that" to create a more cohesive narrative.

• Explicitly link findings to practical and theoretical implications.

• Avoid repeating results; instead, focus on interpreting and contextualizing them.

6. Standardize terminology

The term "healthcare technician students" is used in the title, but "health technician students" appears in the text. Authors are requested to standardize to a single form throughout the manuscript.

7. Correct editing error in Table 6

The explanatory paragraph "The table presents the distribution of responses..." appears duplicated. Authors are requested to remove the repetition.

These revisions will deepen the discussion and elevate the overall quality of the manuscript.

Author Response

Dear reviewer, The responses are presented in the Word document.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Comments and suggestions for authors
This study makes a valuable and timely contribution to the literature by exploring green hospital awareness among healthcare technician students, who are a crucial yet often overlooked group. The manuscript is well structured and logically presented. To further strengthen the paper, I recommend the following revisions:
Methodology section:
Please provide more specific details about the data collection protocol. For example, when and where were the questionnaires distributed to the students?
To enhance methodological transparency, please consider including the formula used for the sample size calculation, or citing the reference from which it was derived.
Please state the inclusion and exclusion criteria for participants explicitly.
Discussion Section:
You astutely note that student awareness was lowest for infrastructure-dependent practices (e.g. rainwater harvesting). It would be interesting to discuss whether this gap in awareness might be due to a lack of coverage in the academic curriculum or a lack of exposure to such practices in clinical training environments.
The finding that female students demonstrated significantly higher awareness is intriguing. Could you elaborate on this, perhaps by connecting it to other studies that have examined gender differences in pro-environmental attitudes or behaviours, particularly within the healthcare context?
Conclusion Section:
You correctly identify the single-institution setting as a limitation. When recommending future research, it would be beneficial to explicitly suggest comparative studies across different universities and geographical regions in Turkey to assess the generalisability of your findings.
Overall, this is a strong piece of research, and I commend the authors for their work. Addressing these minor points will undoubtedly enhance the paper's impact and quality.

Author Response

Dear reviewer, The responses are presented in the Word document.

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

Reviewer Report

General Comments

This manuscript explores an important and timely issue: awareness of green hospitals among healthcare technician students, a professional group that is operationally vital yet underrepresented in sustainability research. The study is pertinent from a public health and health systems sustainability standpoint and provides valuable empirical data from Türkiye.

Overall, the manuscript is well structured, methodologically sound, and clearly written. The Introduction follows a logical funnel approach, the Results are systematically presented, and the Conclusions are aligned with the findings.

However, several sections need clarification and improvement, especially the Methodological description, Results presentation, the analytical depth of the Discussion, and the development of the study limitations.

I recommend a major revision, with good potential for acceptance after revision.

Introduction

Introduction is very well structured and logically organised, following a clear funnel approach: from the global challenge of climate change and the environmental impact of the healthcare sector to the specific role of healthcare technicians as an underrecognized yet critical workforce. The text is relevant from a public health perspective, and the operational role of technicians in everyday practices that directly affect sustainability is well emphasised.

I have a minor note about the sentence in line 84, where there is a punctuation error "[16]. which needs to be corrected (e.g., "[16], together with ..." or separated into two sentences).

Material and methods

The methodological section is generally well organised, and the main statistical procedures are appropriate. However, several elements require clarification:

• Data collection procedure: The manuscript does not adequately specify how the data were gathered (paper-based or online questionnaire, location of data collection, duration, timing in relation to clinical practice). This should be described more clearly.
• Inclusion and exclusion criteria: These are not clearly defined. The manuscript should specify the eligibility criteria (e.g., year of study, clinical training status, voluntary participation, and exclusion criteria).
• Description of HOQGD subdimensions: Although five subdimensions are mentioned, they are not clearly and systematically listed in the “Data Collection Tools” section. These should be explicitly named.
• Consistency in decimal reporting: Different formats are used for Cronbach’s alpha (e.g., 0.94 vs. 0.949). The number of decimal places should be standardised throughout the manuscript.
• Structure of instruments: It is unclear whether only the HOQGD scale was used or if an additional general questionnaire was also administered. If both a personal information form and HOQGD were used, this should be explicitly stated.

Results

Results are clearly presented and statistically coherent. The choice of statistical tests is appropriate. However, I recommend:

• Reporting effect size measures (e.g., Cohen’s d, eta squared) in addition to p-values, to assess the practical significance of the findings.
• Reorganising the presentation of results so that the item-level descriptive analysis (Table 6) appears before inferential analyses (gender, age, department). Ž

This would provide important contextual grounding and improve interpretative coherence.

Discussion

The Discussion appropriately compares the findings with the national and international literature and correctly highlights lower awareness in the water efficiency subdimension.

However, the section is at times overly descriptive and reiterates results rather than engaging in deeper analytical interpretation. Therefore, I recommend:

• Expanding the explanation for why water efficiency scored lowest (e.g., infrastructural invisibility, limited curricular emphasis, technical aspects less observable in daily practice).
• Providing a more critical interpretation of gender differences, including reflection on their practical significance.
• More clearly articulating the specific contribution of this study relative to previous research focused on nurses or hospital managers.
• Briefly addressing the very high reliability coefficient (Cronbach’s α = 0.949), as such a value may indicate potential item redundancy.

Limitations

The authors acknowledge two relevant limitations: single-institution design and self-reported data.  However, this section should be expanded to include:

• The possibility of socially desirable responses (environmental desirability bias).
• The distinction between awareness and actual behaviour or competence in practice.

Conclusion

The Conclusion is consistent with the results and appropriately balanced. It clearly states that students demonstrate moderate to high awareness, with weaker performance in infrastructure-related sustainability domains.

Reference

The references are thematically appropriate and relatively up to date. Several sources from 2024–2025 are included, along with both international and Turkish literature and systematic reviews.

Author Response

Dear reviewer,

The responses are presented in the document.

Author Response File: Author Response.pdf

Reviewer 4 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review this interesting paper regarding green hospital awareness. I am familiar with the topic and many of the references. Expanding knowledge assessment to technical students is an important early step in improving daily work practices. The study is a well-designed cross-sectional study, using a validated scale, and appropriate statistical analyses. As stated, the results flow from the data, and the recommendations for water use awareness, needed education, and further research are related to the results, discussion, and conclusion. The limitations are correct. It would be interesting to follow these students into practice, perhaps identifying action-oriented outcomes. Of course, expanding the study to additional students, classes, and institutions would increase its significance and interest.

The analyses and writing are quite clear. I have no major suggestions. 

Minor corrections & suggestions:

These are primarily due to the difference in decimal place format between the text in U.S English and the tables (. vs ,) in their original language format. Specifically: Table 1, Table 3, Table 5, Table 6.

A few other odd deletions in the text: line 84, line 314. 

 

Author Response

Dear reviewer,

The responses are presented in the document.

Author Response File: Author Response.pdf

Round 2

Reviewer 3 Report

Comments and Suggestions for Authors

Dear Authors,

Thank you for submitting the revised version of your manuscript entitled “Green Hospital Awareness: Evidence from Healthcare Technician Students.” I appreciate the effort you have invested in revising the manuscript and in providing detailed responses to my comments.

After examining the revised version, I am satisfied that the main concerns raised in the previous review have been adequately addressed. The description of the study instruments, data collection procedures, and participant eligibility criteria has been clarified, and the statistical analysis has been strengthened by including effect sizes. In addition, the discussion and limitations sections have been further improved.

Overall, the manuscript has been substantially improved, and I consider it suitable for publication.

Kind regards,

Reviewer

Comments for author File: Comments.pdf

Author Response

Dear Reviewer,

Thank you very much for your valuable contributions.