Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

• Lack of Focused Problem Statement (Lines 21–43)
  The introduction section provides general information about early child marriage but lacks a clearly defined research problem. The background discussion is overly broad and repetitive, particularly in the description of adolescent age ranges and the prevalence of early marriage. There is no clear articulation of the study’s relevance in addressing an existing gap or unresolved issue in the literature, which weakens the foundation of the paper.

• Insufficient Methodological Detail (Lines 88–103)
  The study design is described in vague terms, with limited information on how participants were selected, the rationale for using a qualitative approach, or how ethical procedures were applied. While purposive sampling is mentioned, there is no description of the inclusion criteria or participant characteristics. This lack of transparency makes it difficult to assess the validity and reliability of the research process.

• Unclear Analytical Procedure (Lines 117–122)
  The description of the data analysis lacks clarity and specificity. The manuscript notes that a thematic approach was used but provides no further detail on how themes were identified, coded, or verified. There is no mention of tools, coding processes, or researcher reflexivity. This weak methodological reporting limits the credibility of the analysis and prevents meaningful evaluation of its rigor.

• Underdeveloped Findings Presentation (Lines 140–165)
  The findings are presented in a generalized narrative without a clear thematic structure or sufficient use of direct quotations. Themes such as economic factors or low education are mentioned briefly, but they are not supported by participant voices or deeper contextual explanation. This weakens the qualitative contribution of the study and makes the insights appear superficial.

• Weak Conclusion and Recommendations (Lines 213–229)
  The conclusion reiterates general concerns about early marriage but fails to synthesize the study’s specific findings or provide actionable recommendations. Statements about stakeholder collaboration and socialization efforts are too vague and not directly grounded in the study data. Furthermore, there is no acknowledgment of the study’s limitations or suggestion for future research, which are essential components of a well-rounded academic discussion.

Author Response

Response to Reviewer 1 Comments
We thank Reviewer 1 for their thoughtful comments and have carefully revised the manuscript accordingly. All substantially revised or newly added text is highlighted in yellow in the revised manuscript. Comment 1: Lack of Focused Problem Statement
Reviewer: The introduction provides general information but lacks a clearly defined research problem. Background is overly broad and repetitive. Response: Introduction revised (page 2, Lines 58–70). We emphasized the literature gap on adolescent and nurse engagement in hospital-based sustainability and climate resilience. The revised passage positions this scoping review as addressing the lack of empirical evidence and mapping existing strategies, situating our contribution within scholarly and policy debates.
Comment 2: Insufficient Methodological Detail
Reviewer: Study design is vague, with limited details on inclusion criteria, rationale, and ethics. Response: Methods revised (page 3, Lines 110–125). We now specify that the study employed a scoping review design (Arksey & O’Malley, 2005; Levac et al., 2010). Inclusion criteria: English-language, 1990–2023, focused on hospital-based carbon reduction and youth/nurse engagement. Exclusion criteria and rationale for country selection are clarified. Only published sources and secondary macro-level datasets were used; hence, no human participants were involved and ethical approval was not required.
Comment 3: Unclear Analytical Procedure
Reviewer: Data analysis lacks clarity on how themes were identified, coded, or verified. Response: Data Analysis revised (p.3-4, Lines 136–142). Stepwise detail added: • Organizing cases and policy documents into three thematic domains • Synthesizing evidence narratively, with comparative mapping • Using descriptive/correlation/regression analysis for macro-level datasets (Norway and Korea) • Clarifying that no qualitative coding software (e.g., NVivo) was applied, consistent with scoping review methodology All data sources are fully referenced to ensure reproducibility.
Comment 4: Underdeveloped Findings Presentation
Reviewer: Findings presented in a generalized narrative without thematic structure or exemplars. Response: Results revised (page 4, Lines 144-151; page 5, 202-216, 218-223). Organized into three thematic domains: 1. Governance approaches (top-down and bottom-up) 2. Roles and models of adolescent and nurse participation 3. Barriers and enablers We added case vignettes from published reports (e.g., adolescent advisory groups in Australia; nurse-led anesthetic substitution in Norway). Although primary participant quotations were unavailable, these documented cases provide concrete exemplars supporting thematic claims.
Comment 5: Weak Conclusion and Recommendations
Reviewer: Conclusion is vague and lacks actionable recommendations; no limitations or future research noted. Response: Conclusion revised (page 9-10, Lines 375-392). We now synthesize key findings on adolescents and nurses as partners in sustainability. Concrete recommendations added: (1) forming hospital green teams, (2) integrating adolescent climate literacy modules, and (3) promoting tripartite government–healthcare–education partnerships. A Limitations subsection is included, noting reliance on secondary data, limited geographic coverage, and lack of longitudinal evaluation. Future research directions emphasize intervention studies in LMICs and long-term outcomes of adolescent participation in carbon reduction

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you for submitting your scholarly work to Adolescents. The manuscript possesses certain merits including currency of topic, cross national comparison, well-structured and clearly written.  However, to increase its possibility to be published some revisions deemed to be necessary. I suggest the authors to consider the following points.

1. The study lacks a conceptual framework. The researchers can add a conceptual framework in the Introduction section mentioning underpinning theory or theories to provide theoretical basis to the study (for example Theory of Planned Behaviour, Health Belief Model).
2. In the Methodology section needs improvement. Clarify inclusion /exclusion criteria for literature review. Detail regression approach: number of observations, time-series vs. cross-sectional design. Explain why Norway and Korea analyzed quantitatively and why not others.
3. In the result section Australia and US sections are too descriptive. Suggest shortening and put more focus on adolescent engagement. Add a comparative table of Scope 1–3 strategies.
4. In the discussion section add critical analysis of barriers to adolescent participation. Consolidate repetitive points about nurses’ roles. Suggest how nurses and adolescents can practically collaborate (e.g., through school programs, policy advocacy, curriculum designs).
5. In the conclusion section avoid giving generic recommendations. Your recommendations should be consistent with the findings of the study.
6. Give a dedicated section on limitations of the study and discuss the various limitations thoroughly.
7. While the abstract and introduction emphasize adolescents, most results are hospital-centric. Place more emphasis on adolescent engagement in later parts of the manuscript and there should be a consistency throughout the manuscript.

Author Response

Response to Reviewer 2 Comments

We thank Reviewer 2 for their constructive feedback. All suggested revisions have been incorporated into the revised manuscript. Below, we provide a point-by-point response. All major changes are highlighted in green in the revised file, with line numbers indicated for clarity.

Comment 1:

Reviewer: The study lacks a conceptual framework. The researchers can add a conceptual framework in the Introduction section mentioning underpinning theory or theories to provide theoretical basis to the study (for example Theory of Planned Behaviour, Health Belief Model).

Response: Thank you for this valuable suggestion. In response, we have explicitly added a conceptual framework to the Introduction (see p.2, lines 85–89 in the revised manuscript). Specifically, the value-belief-norm (VBN) theory and the Theory of Planned Behaviour (TPB) are now referenced as theoretical foundations for understanding adolescent engagement in climate action and sustainability initiatives. We briefly describe how these widely recognized behavioral models underpin our analysis, guide interpretation of pro-environmental actions among adolescents, and provide the theoretical link between attitudinal, normative, and behavioral determinants cited in the study. 

Comment 2: Methods – Inclusion/Exclusion Criteria

Reviewer: The methodological description is insufficient. Please clarify inclusion/exclusion criteria and the rationale for country selection.
Response: Revised in Methods section (Lines 110–125, 130-135). We now state that only English-language peer-reviewed articles published between 1990–2023, focused on hospital-based sustainability and adolescent/nurse engagement, were included. Excluded were studies outside the healthcare sector or lacking direct relevance. Country selection rationale clarified: Norway and Korea were chosen due to availability of macro-level datasets and policy documents, while other countries were referenced narratively.

Comment 3: Results – US and Australia Cases

Reviewer: US and Australia sections are overly detailed; consider shortening.
Response: Revised Results section (Lines 144-156, 202-223). US and Australia are now presented in a single narrative paragraph focusing on key strategies and adolescent/family involvement, reducing duplication while retaining relevance.

Comment 4: Discussion – Nurse Role Redundancy

Reviewer: The role of nurses is repeated excessively.
Response: Revised Discussion section (Lines 313-323). Nurse contributions are now consolidated and reframed as facilitation roles that enable adolescent engagement. Overlapping sentences have been merged for conciseness.

Comment 5: Discussion – Barriers and Models

Reviewer: Please expand on barriers to adolescent participation and provide concrete collaboration models.
Response: Revised Discussion section (Lines 328-340). We now specify barriers such as limited decision-making power, lack of youth councils, and resource constraints. Collaboration models include school–hospital partnerships, youth advisory councils, and curriculum-linked programs.

Comment 6: Conclusion and Limitations

Reviewer: Conclusion should be more specific, with clear linkage to findings. Limitations should be a separate subsection.
Response: Revised Conclusion section (Lines 375-392). We now explicitly link recommendations to study findings and present Limitations as a dedicated subsection, noting reliance on secondary data, limited country scope, and lack of longitudinal assessment. Future research directions highlight LMIC interventions and long-term outcomes of youth–nurse partnerships.

Reviewer 3 Report

Comments and Suggestions for Authors

The manuscript presents an important and underexplored issue—engaging adolescents in hospital-based sustainability and carbon-reduction initiatives. While it addresses an urgent global health and climate intersection, the paper suffers from limited empirical grounding, vague theoretical support, insufficient methodological detail, and an overreliance on secondary data without critical evaluation. I offer the following comments as constructive criticism to improve the quality of the manuscript:

The abstract mixes literature review and case analysis without clearly stating what was measured, what data was used, and what kind of comparison was made.

The study identifies hospitals as emitters and adolescents as vulnerable, but never clearly defines the central research question or objective in precise terms.

The claim that adolescent engagement lays the groundwork for climate-resilient healthcare is not supported with empirical evidence or clear mechanisms.

The abstract does not disclose that the paper is based primarily on literature review and secondary sources, which affects the strength of the conclusions.

The manuscript does not draw from any theory (e.g., health behavior theory, youth empowerment frameworks, institutional change) to explain why adolescents should be involved or how they influence healthcare systems.

The authors need to discuss  literature review in seperate section. Thus, they must do so by drawing on recently (newly) published studies. In this case, these papers are directly relevant to your study, from which insights can be drawn and cited to support your analysis:
https://doi.org/10.1108/MEQ-09-2023-0304

The concept of “engagement” is used loosely, referring at times to education, participation, awareness, or behavior. This ambiguity weakens the argument.

There is almost no discussion of how decision-making works in hospitals or how adolescent participation fits within hospital governance or policy structures.

The paper uses “resilience,” “carbon neutrality,” and “sustainability” interchangeably, without clarifying the distinct roles of adaptation versus mitigation in climate-resilient healthcare.

Terms like “empowerment,” “collaborative practice,” and “institutional transformation” are used frequently without operational definitions or supporting models.

The paper claims to use a literature review and case study method, but does not explain how studies or cases were selected, what inclusion/exclusion criteria were used, or how evidence was coded and analyzed.

Statements such as nurse-led sustainability practices and youth education initiatives promote behavior change”are not substantiated with actual examples, programs, or outcome measures.

The study would benefit greatly from a comparative table summarizing the country cases (e.g., carbon monitoring, youth initiatives, hospital governance policies).

The central claim that adolescent engagement enhances climate resilience remains speculative—there’s no causal link, nor even correlational evidence, shown.

The conclusion lacks actionable steps for hospital administrators, educators, or policymakers on how to integrate youth into climate initiatives in healthcare.

The study ends with a call for empowering youth and supporting nurses, which while valuable, is not derived from data or tied to specific policy mechanisms.

The paper is more of a policy commentary than a rigorous academic contribution. Without clearer theory, methods, and analysis, its impact on the literature will be limited.

Author Response

Response to Reviewer 3 Comments

We thank Reviewer 3 for their detailed and constructive comments. All suggested revisions have been considered carefully. Because substantial restructuring had already occurred in response to Reviewers 1 and 2, we incorporated Reviewer 3’s suggestions primarily by clarifying definitions, strengthening linkages, and adding concise case-based evidence and recent references. Below, we provide a point-by-point response with line numbers indicated.

Comment 1: Abstract clarity

Reviewer: The abstract does not sufficiently describe the data, methods, and comparative scope.
Response: Revised Abstract to specify that the study used a scoping review design, relied on secondary datasets from Norway and Korea, and conducted comparative analysis. This clarifies the scope and methodology (page 1, Lines 4–21).

Comment 2: Research question and objectives

Reviewer: The research problem and objectives are vague.
Response: Revised Introduction (page 2, Lines 59–67) to explicitly state the research question: ‘How can adolescents and nurses be engaged as partners in hospital-based carbon reduction and sustainability, and what evidence exists across country cases?’

Comment 3: Linkage of adolescent participation to climate resilience

Reviewer: The manuscript does not sufficiently explain how adolescent engagement links to resilience.
Response: The Introduction (page 2, lines 85–89) was revised to explicitly incorporate behavioral science theories (Value-Belief-Norm theory and Theory of Planned Behaviour), clarifying the mechanisms by which adolescent engagement drives climate resilience outcomes. In addition, the Discussion was expanded (page 8, lines 317–340, 371-373) to emphasize behavioral factors—risk perception, efficacy, and social norms—as determinants of adolescent participation, strengthening the conceptual link between adolescent engagement and resilience.

With these combined revisions, the manuscript now provides a clear theoretical and empirical basis for how adolescent involvement enhances climate-resilient healthcare.

Comment 4: Literature review and updated sources

Reviewer: The literature review should be more clearly separated and include recent research.
Response: Methods revised (page 3, Lines 110–125) to clarify scoping review inclusion/exclusion criteria. While no additional references were added, we reviewed the literature up to 2021 and confirmed alignment with recent debates. The scope remains consistent with current scholarship.

Comment 5: Conceptual clarity of engagement

Reviewer: The concept of engagement is ambiguous.
Response: The Discussion was revised (page 8, Lines 313-316) to define engagement as comprising knowledge acquisition, participatory decision-making, and behavior adoption.

Comment 6: Link between hospital governance and adolescent participation

Reviewer: Stronger linkage between hospital governance/decision-making and adolescent participation is needed.
Response: Examples of school–hospital partnerships and youth advisory councils were added (page 8, lines 303-310, 317-323) to illustrate governance linkages.

 

Comment 7: Terminology consistency

Reviewer: Terms such as resilience, carbon neutrality, and sustainability are used inconsistently.
Response: We thank the reviewer for highlighting the need for clear and consistent terminology. Due to the insertion of new material and additional restructuring, line numbers may differ compared to the originally reviewed version. All citations in this response refer to the revised manuscript uploaded on September 12.

To address this, we revised both the Introduction (page 2, lines 59-67, 82-89) and Discussion (page 8, lines 317-323) to provide explicit definitions and distinctions:

Comment 8: Empowerment and collaboration concepts

Reviewer: Concepts like empowerment and collaborative practice lack clear definitions.
Response:  Thank you for indicating the need for clearer definitions. In the revised Discussion (Lines 313–323) and supported in the Introduction (Lines 82-89), we now define empowerment as granting adolescents meaningful authority and participation in institutional decision-making related to hospital sustainability and climate action—such as involvement in youth councils or hospital green teams with real advisory or voting roles. Collaborative practice is clarified as structured, ongoing cooperation between adolescents and nurses, where both groups jointly plan, implement, and evaluate sustainability activities (e.g., developing education campaigns, conducting resource audits). These definitions are grounded directly in the value-belief-norm (VBN) model and the theory of planned behaviour (TPB) cited in the Introduction and Discussion (References 21, 22), which highlight perceived efficacy, participatory norms, and behavior intention as key enablers for adolescent engagement in environmental action.

Comment 9: Lack of concrete case evidence

Reviewer: The study lacks concrete evidence or case illustrations.
Response: Thank you for this suggestion. We have added specific case vignettes in the Results to strengthen contextual illustration. For example, nurse-led QI teams in Norway spearheaded the substitution of low-carbon anesthetic gases, and an Australian hospital youth advisory group co-designed poster campaigns on sustainable behaviors leading to measurable waste reduction (page 4, Lines 144-151, 198-212, 202-216). These documented cases provide concrete exemplars to support our thematic findings.

Comment 10: Comparative table

Reviewer: Include a comparative table summarizing country cases.
Response: A comparative table was added (Table 1) presenting Scope 1–3 strategies across Norway, Korea, and other examples.

Comment 11: Practical recommendations in conclusion

Reviewer: The conclusion should offer more actionable recommendations.
Response: Conclusion revised (page 9, Lines 375-389) to provide concrete recommendations: (1) forming hospital green teams, (2) integrating adolescent climate literacy modules, and (3) promoting government–healthcare–education partnerships. Limitations and future research directions also added (page 10, Lines 387-394).

Reviewer 4 Report

Comments and Suggestions for Authors

This study presents an interesting review of practices that help reduce GHG emissions in the healthcare sector. While the review does provide some useful strategies to consider for the healthcare sector to reduce carbon emissions, I believe there are some significant issues with the scope of this manuscript that must be improved prior to publication.

Most importantly, this paper needs further scoping to ensure there is a very clear connection between the strategies discussed, the actors who will implement them, and the connection to adolescents. While the authors begin the manuscript discussing the importance of involving adolescents in sustainability practices, the connection between the identified practices and adolescents specifically is not always made clear. It strikes me that adolescents would have very little agency in deciding whether to enact many of the interventions discussed, particularly in terms of hospital administration, but even in the assumed pathway of translating to families or caregivers. Several of the strategies are also enacted at the level of national governments or international treaties, which are often far removed from adolescent sustainability education initiatives. Similarly, while the per capita CO2 emissions do capture trends, it is not clear how attributable this is to changes in the healthcare sector, let alone from adolescent-based interventions. Around line 259, the authors present the number of hospital beds as a way to connect some of these ideas, but is this not simply indicative of increases in the population? Line 284 similarly attempts to connect these ideas from a bottom-up perspective, but it is not explained why specifically it is this bottom-up approach that is needed. I am left unconvinced that this responsibility falls to the nurses and not governments, regulatory bodies, or healthcare administration. The discussion and conclusion help to support the recommendations made by the authors, but without strong evidence that the healthcare workers and adolescents play a significant active role in these decisions, it cannot be said that they “must” be included to achieve emissions reduction goals or sustainability goals. I agree that it would be very helpful, but as written, this connection is not supported strongly in this manuscript.

Potentially in support of the revised scoping, it would be helpful to see more information about how these case studies were selected and how articles were further filtered to identify only the most relevant studies. I would imagine these search terms would result in many studies, so what was your process to identify only those relevant to this analysis? Was there a specific reason you selected these particular countries for your comparison?

Given these concerns, I recommend major revision prior to publication. The study will not necessarily have to be re-conducted, but it must be clearly presented and explained. Please see the line-specific comment below for additional notes.

L152-156 – is this strategy linked with a particular case study or is this a potentially beneficial practice in general?

Author Response

Response to Reviewer 4 Comments

We thank Reviewer 4 for the constructive comments. All suggestions were carefully considered, and the manuscript has been revised to address the issues raised. Below, we provide point-by-point responses with line numbers corresponding to the revised manuscript.

Comment 1: Limited linkage of adolescents to strategies

Reviewer: The manuscript does not sufficiently explain how adolescent participation is connected to strategies, and it seems distant from hospital administration and government policy.
Response: We expanded the Discussion to clarify the mechanisms of adolescent engagement, including school–hospital partnerships, youth advisory councils, and climate literacy modules (page 8, Lines 313-323, 328-340, 371-373). We also acknowledged barriers such as limited agency, absence of councils, and resource constraints. These revisions strengthen the connection between adolescent roles and institutional/governmental strategies.

Comment 2: Unclear role of nurses vs. government

Reviewer: The manuscript blurs whether responsibility lies with nurses or with government/regulatory agencies.
Response: The revised Discussion clarifies that nurses function primarily as facilitators and implementers at the clinical and hospital level, while governments and regulatory agencies provide top-down frameworks and incentives. This complementary relationship is described in Discussion (page 8, Lines 313-323, 328-332).

Comment 3: Transparency of methods

Reviewer: The selection of cases and the inclusion/exclusion process are not described clearly.
Response: Methods were revised to specify inclusion and exclusion criteria (English-language, 1990–2023, hospital-based sustainability, adolescent/nurse engagement) and to explain country selection rationale. Norway and Korea were chosen for data availability, while the US and Australia were included narratively for policy examples (page 3, Methods, Lines 110-125).

Comment 4: Lack of case attribution

Reviewer: In lines 152–156, it was unclear whether strategies were derived from real cases or general recommendations.
Response: Results were revised to attribute strategies directly to documented cases. For example, the US section discusses clinical waste reduction and anesthesia substitution; Norway describes nurse-led substitution of low-carbon anesthetics; and Korea highlights hospital waste segregation and renewable energy adoption (page 4, Lines 144-151, 202-223, 294-297). This ensures clarity that recommendations are evidence-based rather than general suggestions.

Reviewer 5 Report

Comments and Suggestions for Authors

see attached

Comments for author File: Comments.pdf

Author Response

Response to Reviewer 5 Comments

We thank Reviewer 5 for the thoughtful feedback. All points were carefully addressed in the revised manuscript, as detailed below.

Comment 1: Abstract clarity

Reviewer: The abstract lacks clarity regarding methodology and scope.
Response: The abstract was revised to explicitly specify the scoping review design, the inclusion of comparative analysis between Norway and Korea, and the narrative synthesis of US and Australia cases (page 1, Lines 4–21). Language about the importance of climate change was softened per feedback, now stating: "Climate change is an important challenge with potentially serious ramifications for environment and health," instead of "the most pressing global challenge.

Comment 2: Research objectives

Reviewer: The objectives are vague.
Response: The Introduction (page 2, Lines 59–67) was rewritten to state the research question directly (“How can adolescents and nurses be engaged as partners in hospital-based carbon reduction and sustainability, and what evidence exists across country cases?”). Also, the country selection rationale for Norway and Korea is clarified in Methods (page 3, Lines 110–125).

Comment 3: Concept of engagement

Reviewer: Engagement is not clearly defined.
Response: The Discussion now defines 'engagement' as involving knowledge acquisition, participatory decision-making, and behavior adoption (page 8, Lines 313–315). This is reinforced by citing relevant behavioral science theoretical frameworks.

Comment 4: Repetition in Discussion

Reviewer: The role of nurses is repeated, and adolescent connection is weak.
Response: The "upper-middle-income" and similar qualifiers were removed; countries are now listed simply by name (page 2, Lines 51-54). The term "adolescents" is defined as individuals aged 10–19, aligned with WHO conventions (page 3, Lines 110–113). Wording such as "adolescents are increasingly recognized" now reads "adolescents can play an important role..." and supporting literature is cited. The introduction now states, "Adolescents can participate meaningfully in climate adaptation..." and cites supporting research (page 2, Lines 68-71, 80-89).

Comment 5: Claims about adolescent impact

Reviewer: Overstated claims about adolescent impact; "essential" is too strong; be more realistic.
Response: The language regarding adolescent roles was softened throughout. Phrases such as "essential for achieving long-term decarbonization goals" have been changed to "can support long-term decarbonization efforts" (page 3, Line 106-107). Statements about adolescent agency were re-written to focus on participation within concrete, evidence-based interventions—e.g., school–hospital partnerships and youth advisory councils (page 8, Lines 313–323, 328–332).

 

Comment 5: Policy recommendations and limitations

Reviewer: The conclusion needs actionable recommendations and acknowledgment of study limitations.
Response: The Conclusion was revised to include three actionable recommendations (green teams, adolescent literacy modules, tripartite partnerships) and to explicitly present Limitations (page 9-10, Lines 375-386).

 

Comment 6: Justification for country/case selection and methods transparency

Reviewer: Why focus on Korea? Why exclude other regions? How many articles were found/excluded? Why 1990 as the start?
Response:

• Country/case selection rationale is now provided in Methods (page 3, Lines 110–125), explaining data availability and relevance.
• The Methods detail the search terms, databases, inclusion/exclusion criteria, and the reason for the 1990–2023 time frame (to align with early major IPCC/UNFCCC developments and comparable data availability).
• The PRISMA flow (if included or available) and numbers of articles screened/included/excluded are summarized in the Methods section.

Comment 7: Textual focus and narrative coherence (Nurses vs. Adolescents)

Reviewer: The article jumps back and forth; argument weak for adolescent influence; nurses' role seems more significant.
Response:

• The Discussion was restructured (page 8, Lines 313–340) to clearly delineate the roles: nurses are clinical facilitators and implementers; adolescents are partners in participatory and educational strategies but are not presented as primary policy drivers.
• Overlapping and repetitive text about nurses was condensed; adolescent content is kept within the scope of participatory engagement, not institutional policy leadership.
• Additional references and case vignettes now illustrate realistic adolescent contributions (page 4-5, Lines 149–151, 202–211, 213–214).

Comment 8: Evidence for claims and deletion of weak examples

Reviewer: "Passive recipients"—claims not backed by studies; US parent survey unclear in meaning.
Response: We appreciate this important point. In response:

The phrase “passive recipients” (previously in Introduction, page 2, Lines 74–75) is now either removed or immediately supported by concrete evidence and references.
Specifically, the section now states:
"Recent studies emphasize that adolescents are not merely passive recipients of healthcare but active stakeholders in climate resilience."
This is immediately followed by empirical studies from China and Ethiopia (, )—showing that adolescent knowledge and health literacy are linked to climate action and peer influence (page 2, Lines 75–81). We also substantiate all claims about adolescent behavioral determinants with up-to-date references [16–19].

The previous example regarding the “US parent survey” (formerly in Results, page 4, Lines 175–177) was deleted as suggested, in order to avoid confusion and strengthen the evidence base.
Instead, youth engagement sections now rely on peer-reviewed international studies and real-world cases from China, Ethiopia, and Australia (see page 2, Lines 77–81; page 5, Lines 212–216).

Comment 9: Discussion of allied health providers

Reviewer: Why not other health professionals? Why only nurses as role models?
Response:

• The Discussion justifies the focus on nurses as the largest clinical workforce, most directly involved in hospital operations and quality improvement. This is now stated clearly (page 8, Lines 317-323), and as a note in the limitations section [page 10, Lines 387–389]).
• The limitations also acknowledge the need for future research to examine the roles of allied health professionals.

Comment 10: Policy recommendations and limitations

Reviewer: Conclusion needs actionable points and explicit limitations.
Response:

• The Conclusion now includes three actionable recommendations: (1) establish green teams in hospitals, (2) integrate adolescent climate/youth engagement into health curricula, and (3) foster tripartite government–healthcare–education partnerships (page 9–10, Lines 382–386).
• Limitations and areas for future research (interventional and longitudinal studies) are presented (page 10, Lines 387-394).

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Author had answer all of my questions 

Author Response

We appreciate your feedback and are glad that our revisions satisfactorily addressed your previous questions. Thank you for your supportive comments.

Reviewer 2 Report

Comments and Suggestions for Authors

My comments have been incorporated satisfactorily

Author Response

Thank you for acknowledging the incorporation of your comments. We are pleased that the revisions meet your expectations and appreciate your constructive review.

Reviewer 4 Report

Comments and Suggestions for Authors

Thank you for the thorough revision, I believe the manuscript has been much improved from the first version. In particular, the additional language connecting the role of adolescents and nurses to sustainability initiatives is important to include and improves the clarity of the narrative. The explicit call for additional and more in-depth research on this topic is also good to see in a scoping review. The conclusions are mostly appropriate given that this paper is specifically framed as a scoping review and may help inform future research. I do still have some concerns with the quantitative analysis regarding attribution. For example, hospital beds are described as having a significant positive effect on CO2 emissions, which could be misleading due to the language. As written, this could be interpreted as the number of hospital beds causing increased emissions, when I believe it is more likely that countries with more hospital beds are larger and more developed, leading to more emissions. Please ensure this kind of language is clear, such as by describing it as "more hospital beds are associated with more emissions" or similar. Otherwise, I think this version is ready for publication.

Author Response

Comment:  Thank you for the thorough revision, I believe the manuscript has been much improved from the first version. In particular, the additional language connecting the role of adolescents and nurses to sustainability initiatives is important to include and improves the clarity of the narrative. The explicit call for additional and more in-depth research on this topic is also good to see in a scoping review. The conclusions are mostly appropriate given that this paper is specifically framed as a scoping review and may help inform future research. I do still have some concerns with the quantitative analysis regarding attribution. For example, hospital beds are described as having a significant positive effect on CO₂ emissions, which could be misleading due to the language. As written, this could be interpreted as the number of hospital beds causing increased emissions, when I believe it is more likely that countries with more hospital beds are larger and more developed, leading to more emissions. Please ensure this kind of language is clear, such as by describing it as ‘more hospital beds are associated with more emissions’ or similar. Otherwise, I think this version is ready for publication.    

Response:  We sincerely thank the reviewer for this valuable comment. We carefully revised the Results and Discussion sections to clarify the relationship as an association rather than a causal effect. Specifically, we replaced the wording ‘significant positive effect’ with ‘significantly associated with’ and added a clarifying statement that hospital beds should not be interpreted as directly causing higher emissions, but rather that countries with more hospital beds tend to be larger and more developed, and therefore are associated with higher emissions.

1. Page 7, lines 273–276 (Figure 2 explanation):
   ‘…a strong correlation between the number of hospital beds and CO₂ emissions, suggesting that more hospital beds are associated with higher energy consumption and emissions, particularly in larger and more developed healthcare systems.’
2. Page 8, lines 295–296 (Regression analysis results):
   ‘These results indicated that the number of hospital beds was significantly associated with higher CO₂ emissions in South Korea. By contrast, in Norway, both the number of hospital beds and the proportion of renewable energy consumption were identified as key factors.’

Reviewer 5 Report

Comments and Suggestions for Authors

You did a tremendous amount of rewriting but I really think you should not combine nurses with adolescents. Why not do two separate papers?

Author Response

Comment: You did a tremendous amount of rewriting but I really think you should not combine nurses with adolescents. Why not do two separate papers?

Response: We sincerely appreciate your thoughtful suggestion. We understand your concern regarding combining nurses and adolescents in the same paper. However, our intention in this scoping review was to highlight the complementary roles of both groups in promoting climate-resilient healthcare systems. Adolescents represent future leadership in sustainability efforts, while nurses play a frontline role in healthcare delivery. We believe presenting them together offers a more integrated perspective. Nevertheless, we have clarified this rationale more explicitly in the Introduction and Discussion sections to avoid potential confusion.