Review Reports - Integrating Well-Being in Living and Learning Through Occupational Therapy Fieldwork on a College Campus: The WILL Thrive Program

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The study has a very thorough theoretical background.

The presentation of the sample and methodology is also appropriate.

In terms of interpretation, it could draw more heavily on the thorough theoretical background, thereby emphasizing the innovation and the different results more strongly. The differences caused by the different diagnoses and the differences in their treatment should definitely be highlighted.

Congratulations on your work.

Author Response

Thank you for your time in reviewing this article. It is much appreciated.

Reviewer comment: In terms of interpretation, it could draw more heavily on the thorough theoretical background, thereby emphasizing the innovation and the different results more strongly. The differences caused by the different diagnoses and the differences in their treatment should definitely be highlighted.

Response: We appreciate this recommendation. We have revised the Discussion to more explicitly draw on the theoretical foundations presented in the introduction, including occupational therapy models and health promotion frameworks, to contextualize the findings. Additionally, we have incorporated discussion of observed variation in student needs and intervention approaches across diagnostic presentations (e.g., ADHD, ASD, anxiety). These distinctions are framed cautiously as emerging patterns within a small sample, intended to illustrate potential areas for further investigation rather than to establish diagnosis-specific conclusions.

Reviewer 2 Report

Comments and Suggestions for Authors

The manuscript addresses a relevant and timely topic by exploring the feasibility of integrating occupational therapy services within higher education settings through a Level II fieldwork placement. The focus on neurodivergent students and mental health challenges aligns with increasing concerns about student well-being on university campuses.

The manuscript demonstrates potential value in describing an innovative service model; however, several conceptual, methodological, and analytical limitations reduce its scientific robustness. The theoretical framing requires stronger integration with the empirical component, the methodological procedures lack sufficient transparency and rigor, and the analytical approach remains largely descriptive.

Several aspects of the manuscript would benefit from clarification and strengthening. The research design should be more clearly defined, particularly regarding the relationship between the program description and the feasibility study framework. Greater methodological transparency is needed concerning sampling procedures, data collection methods, and analytical strategies. Additionally, the small sample size and the absence of systematic outcome measures limit the strength of the conclusions and should be acknowledged more explicitly.

The discussion would also benefit from moderating some claims and positioning the findings as preliminary evidence within an exploratory context. With substantial revisions addressing these issues, the manuscript could make a meaningful contribution to the emerging literature on occupational therapy services in higher education settings.

A detailed line-by-line review highlighting specific areas for improvement is provided in the accompanying report.

Comments for author File: Comments.pdf

Comments on the Quality of English Language

The manuscript is generally understandable; however, the clarity and precision of the language could be improved in several sections. Minor grammatical revisions and stylistic adjustments are recommended to enhance readability and ensure greater consistency in terminology throughout the manuscript. Careful language editing would help improve the overall clarity and academic presentation of the text.

Author Response

Thank you for this thoughtful and comprehensive feedback. In response, we have undertaken substantial revisions to strengthen the manuscript’s conceptual clarity, methodological transparency, and analytical rigor. The study is now more clearly defined as a program description and implementation case study, with explicit alignment to Bowen et al.’s feasibility framework to clarify the relationship between program description and feasibility evaluation. We have expanded the Methods section to provide greater detail on sampling procedures, data collection, and analytic strategies, including how qualitative and descriptive data were synthesized. The Discussion has been revised to more fully integrate the theoretical framework with the empirical findings.

In addition, we have moderated claims throughout the manuscript to reflect the exploratory nature of the study, explicitly framing findings as preliminary indicators of feasibility rather than definitive evidence. Limitations related to small sample size, absence of formal outcome measures, and descriptive analytic approach are now more explicitly acknowledged. These revisions aim to improve the rigor, transparency, and interpretability of the manuscript while positioning it as a meaningful exploratory contribution to the emerging literature on occupational therapy in higher education.

Please see attached line by line response to your line suggestions.

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

thank you very much, it seems indeed interesting and useful manuscript

1-)be sure that abbreviations are consistent.

2-）be sure keywords are correct.

3-)its not recent year:

(Auerbach et al., 2016, Lipson et al., 2019)

4-)be sure that references are correct.

5-)be sure that references are updated and recently published to demonstrate novelty of your work.

6-)be sure that the font is consistent (line 609)

7-)please add suggestions for further studies.

8-)please give more information about the figure 1.

Author Response

Thank you for your time in reviewing our article. In response, we have made substantial revisions to strengthen the manuscript’s methodological clarity and overall rigor. Specifically, we have clarified the study design as a program description and implementation case study, expanded the analytic procedures to improve transparency and reproducibility, and strengthened alignment with Bowen et al.’s feasibility framework. We have also moderated claims throughout to reflect the exploratory nature of the study and positioned findings as preliminary indicators rather than definitive evidence. These revisions aim to improve the clarity, interpretability, and contribution of the manuscript to the emerging literature on occupational therapy in higher education contexts. Thank you for your time in reviewing this article. It is much appreciated.

Specific responses to your comments are as follows:

Comments	Responses
1-)be sure that abbreviations are consistent.	Reviewed and corrected
2-）be sure keywords are correct.	Reviewed and corrected
3-)its not recent year: (Auerbach et al., 2016, Lipson et al., 2019)	Re-organized to re-focus intent and updated literature with more recent and systematic research: (Bannigan et al., 2025; Worsley et al., 2022) and updated other literature to strengthen flow and coherence in literature review( Worley, 2023; Hunt, 2021; Keptner & Rogers, 2019, Keptner et al. 2026 2016 and 2019 is within ten years of research
4-)be sure that references are correct.	Reviewed and corrected
5-)be sure that references are updated and recently published to demonstrate novelty of your work.	Reviewed and corrected
6-)be sure that the font is consistent (line 609)	Reviewed and corrected
7-)please add suggestions for further studies.	Line 649: "Further research across diverse institutional contexts is warranted to examine the generalizability and scalability of occupational therapy fieldwork programs in higher education settings.” Discussion & conclusions section redesigned to support these areas
8-)please give more information about the figure 1.	Moved into discussion section, added qualitative info

Reviewer 4 Report

Comments and Suggestions for Authors

Dear Authors,

This manuscript addresses an important and underexplored area: the possible role of occupational therapy within higher education support systems. The topic is timely, the practical orientation is valuable, and the manuscript has clear applied relevance. At the same time, the current version needs substantial strengthening before the claims are fully supported. The study is framed as a feasibility study, but several core elements of feasibility reporting remain underdeveloped, especially with respect to sampling transparency, analytic procedures, and the evidentiary basis for some of the broader conclusions.

The manuscript would benefit from a much clearer methodological identity. Right now, it is described as a “program description and feasibility study,” but the design appears to combine needs assessment, service development, process evaluation, descriptive service data, and qualitative stakeholder input. These components are all legitimate, but they need to be distinguished more explicitly. The paper should state more directly whether this is primarily a qualitative feasibility study, a mixed-methods feasibility study, or a descriptive implementation case study. Without that clarification, it is difficult to judge the rigor of the design and the adequacy of the evidence relative to the stated research questions.
The sampling and recruitment section is still too vague for readers to evaluate who actually contributed data to which part of the study. The manuscript notes that 188 first-year students were introduced to the program, that 390 registered accessibility-services students received weekly emails, and that eight staff members were interviewed, but it does not clearly report the response rates for the OHETI, the Google Form survey, or any other student needs-assessment components. It is therefore difficult to understand the empirical basis for later intervention decisions. A flow-style accounting of participants and data sources would greatly improve transparency
The manuscript needs a more explicit analytic section. Data collection is described, but data analysis is not sufficiently specified. For example, how were stakeholder interviews analyzed? Were field notes coded? If so, by whom and using what procedure? How were observational data synthesized into the feasibility domains? How were survey and OHETI findings reviewed and translated into intervention choices? At present, the paper describes data sources but not a reproducible method for transforming those sources into findings.
The claims regarding “acceptability” and “demand” should be made more cautiously and operationalized more clearly. The evidence presented for acceptability is largely based on utilization and referral behavior, while the evidence for demand relies on very small numbers of participants: five students attending an initial individual OT session and four students participating in WAMs. These are promising indicators, but they are preliminary and should not be overstated. The manuscript would be stronger if it explicitly framed these as early signals of feasibility rather than robust evidence of established demand.
The results section would benefit from a sharper distinction between descriptive service activity and actual participant outcomes. At present, the manuscript shows that services were implemented and attended by some students, but it does not yet demonstrate whether students improved in occupational performance, well-being, academic participation, or related outcomes. This limitation is acknowledged later, but the discussion and conclusion sometimes move too quickly from feasibility to implied effectiveness. The wording throughout should be revised to avoid suggesting impact where no outcome data have been presented.
The theoretical framing is relevant, but the connection between the framework and the analysis needs to be tightened. The PEOP Model and the Okanagan Charter are introduced convincingly, yet the manuscript does not consistently show how these frameworks guided specific analytic categories, intervention design decisions, or interpretation of findings. At present, the frameworks function more as background justification than as analytical scaffolds. A more explicit table or subsection mapping framework, constructs to program components, and findings would strengthen coherence.
The role of the OT FWII student, supervisors, and institutional stakeholders should be clarified in relation to the researcher's positionality and potential bias. The program appears to have been developed, implemented, monitored, and interpreted by closely involved actors, including the OT FWII student, faculty advisor, and supervisors. That embeddedness is understandable in an implementation-oriented study, but it increases the importance of reflexivity. The manuscript should explicitly discuss how insider roles may have influenced data collection, interpretation, and reporting, and what steps were taken to reduce confirmation bias.
The ethical procedures need clearer explanation, especially regarding the incentives and overlapping research activities around the OHETI. The manuscript states that students received a $10 Amazon gift card for completing the OHETI and could also opt into a separate OHETI research study with a chance to win $100. Because this manuscript relies partly on those data for program development, the relationship between service development, institutional needs assessment, and research participation should be clarified carefully. Readers need a more precise explanation of what data were used in this study, what belonged to the separate validation study, and how consent procedures distinguished the two.
The intervention package is interesting but currently feels somewhat diffuse. The manuscript includes individual OT sessions, WAMs, targeted emails, yoga sessions, and a resource list. Because these are quite different forms of support, the paper should do more to justify why they all belong within a single feasibility model and how each maps onto the study aims. Otherwise, the intervention begins to look more like a broad campus wellness initiative than a clearly bounded OT feasibility program. Readers would benefit from clearer criteria for what counted as an OT-informed intervention and why.
The manuscript would benefit from a stronger and more critical limitations section. While the authors acknowledge the small sample and single-site context, there are additional limitations that should be discussed directly: the absence of formal outcome measures, possible self-selection bias, the heavy reliance on referral pathways already aligned with the program, limited analytic detail, and the challenge of separating the feasibility of OT-on-campus from the feasibility of this very specific supervision model. Expanding the limitations section would make the manuscript more credible and balanced.
The discussion sometimes treats students with ADHD, ASD, and anxiety as the main or natural target population for campus OT, but the actual sample is extremely small and heterogeneous. I would encourage the authors to avoid broader population-level statements that are not well supported by the data. The paper can still suggest that these groups may be promising targets for future work, but the present study is not yet sufficient to define the likely service-user profile with confidence.
Ending the manuscript with a figure is not especially effective in its current form. Rather than strengthening the conclusion, it interrupts the rhetorical closure of the paper and leaves the manuscript ending on a descriptive visual rather than on a clear scholarly takeaway. The conclusion would be stronger if it ended with a concise integrative paragraph, while the figure could be repositioned earlier or more explicitly discussed as part of the argument.
The manuscript needs careful language editing before publication. There are many issues with phrasing, grammar, punctuation, capitalization, and consistency throughout the text. Examples include inconsistent tier terminology, awkward sentence construction, repeated wording, and several typographical errors. These issues do not invalidate the study, but they currently reduce clarity and give the manuscript a less polished appearance than the topic deserves. This is especially important because the study’s contribution depends heavily on conceptual and methodological precision. For example, “determine the feasibility to sustain” should read “determine the feasibility of sustaining”; one research question is written as a question but ends with a period; terms such as “Tier,” “Tiered,” and population-level labels are not used consistently; and there are clear proofreading errors such as “campus Champlain” and “occupational therapies capacity.” These issues do not by themselves undermine the study, but they reduce clarity and professionalism and should be corrected throughout.

Author Response

Thank you for this thoughtful summary in review of our article. In response, we have made substantial revisions to strengthen the manuscript’s methodological clarity and overall rigor. Specifically, we have clarified the study design as a program description and implementation case study, expanded the analytic procedures to improve transparency and reproducibility, and strengthened alignment with Bowen et al.’s feasibility framework. We have also moderated claims throughout to reflect the exploratory nature of the study and positioned findings as preliminary indicators rather than definitive evidence. These revisions aim to improve the clarity, interpretability, and contribution of the manuscript to the emerging literature on occupational therapy in higher education contexts. Thank you for your time in reviewing this article. It is much appreciated.

As follows are line by line responses to your comments which can also be viewed for easier readability in attached PDF:

The manuscript would benefit from a much clearer methodological identity. Right now, it is described as a “program description and feasibility study,” but the design appears to combine needs assessment, service development, process evaluation, descriptive service data, and qualitative stakeholder input. These components are all legitimate, but they need to be distinguished more explicitly. The paper should state more directly whether this is primarily a qualitative feasibility study, a mixed-methods feasibility study, or a descriptive implementation case study. Without that clarification, it is difficult to judge the rigor of the design and the adequacy of the evidence relative to the stated research questions

Response 1: Thank you for this important feedback. To strengthen methodological identity the study has been defined as a “program description and implementation case study” to describe the WILL Thrive program and evaluation of feasibility providing occupational therapy services on a college campus through a Level II fieldwork placement.

The sampling and recruitment section is still too vague for readers to evaluate who actually contributed data to which part of the study. The manuscript notes that 188 first-year students were introduced to the program, that 390 registered accessibility-services students received weekly emails, and that eight staff members were interviewed, but it does not clearly report the response rates for the OHETI, the Google Form survey, or any other student needs-assessment components. It is therefore difficult to understand the empirical basis for later intervention decisions. A flow-style accounting of participants and data sources would greatly improve transparency

OHETI: Of 47 students who took part in the OHETI assessment, 39 of them agreed that their data can be shared with the college for reporting purpose (ln 438)

Google Form Survey- removed : Upon further review- this survey was removed from this study- the survey was developed by college student success team during the time of the program development- while results were shared with the OT student and supervisor, they were not a formal consideration in guiding OT intervention services which this program description & implementation study is describing.

Observation of 11 Accessibility Services interactive meetings

Ln 302 “ This engagement of the campus voice was created through staff, faculty and administrator stakeholder semi-structured interviews (8 total), targeted student participatory approaches of 188 first year students across nine sessions of a 101 core curriculum course and review of 39 responses to an occupational therapy assessment (OHETI). Additionally, the OT FWII student observed 11 interactive meetings between students and accessibility services staff.”

The manuscript needs a more explicit analytic section. Data collection is described, but data analysis is not sufficiently specified. For example, how were stakeholder interviews analyzed? Were field notes coded? If so, by whom and using what procedure? How were observational data synthesized into the feasibility domains? How were survey and OHETI findings reviewed and translated into intervention choices? At present, the paper describes data sources but not a reproducible method for transforming those sources into findings.

Thank you for this important feedback. We agree that the analytic procedures required further clarification. We have added a “ Data Analysis” to section 2.5 to describe how qualitative and quantitative data sources were reviewed, coded, and synthesized. Specifically, we now clarify the procedures used to analyze stakeholder interviews and observational data, the role of the research team in analysis, and how findings were mapped onto feasibility domains and used to inform intervention development

Ln 499:

“Data analysis followed an interactive, descriptive approach consistent with feasibility and program evaluation research. Multiple data sources were analyzed and integrated to identify service gaps, inform intervention development, and assess feasibility within the campus context.

Daily service logs were analyzed during process evaluation to ensure objectives were met and in alignment to Bowen’s feasibility measures. Qualitative data from stakeholder interviews and observational field notes were reviewed by researchers and coded to identify recurring themes related to service gaps and opportunities for OT intervention. Observational and environmental scan data were synthesized descriptively to identify patterns in environmental support and barriers and then mapped into feasibility domains. Quantitative aggregate data from the OHETI were analyzed descriptively to identify common areas of challenge in student occupational performance. These findings were used to prioritize intervention targets. Data were integrated across sources through triangulation and ongoing collaboration among the OT FWII student, OT faculty advisor, OT Fieldwork Educator and OT site supervisor documented and analyzed within a 27 page Needs Assessment Report.

Researchers of this study received Institutional Review Board approval prior to secondary analysis of data collected from human participants. All participation was voluntary with confidentiality maintained throughout the study. ”

The claims regarding “acceptability” and “demand” should be made more cautiously and operationalized more clearly. The evidence presented for acceptability is largely based on utilization and referral behavior, while the evidence for demand relies on very small numbers of participants: five students attending an initial individual OT session and four students participating in WAMs. These are promising indicators, but they are preliminary and should not be overstated. The manuscript would be stronger if it explicitly framed these as early signals of feasibility rather than robust evidence of established demand.

Discussion revised to integrate this feedback :” Findings provide preliminary support for feasibility of campus based OT services within this context. Early indicators of acceptability of services were observed through stakeholder engagement and referral behaviors, while signals of demand were reflected in student utilization of services, although participation numbers were small. Services were most frequently utilized by students experiencing functional challenges related to academic participation, including students with identified neurodivergent profiles (ADHD, ASD) and mental health concerns such as anxiety. These findings should be interpreted cautiously as early indicators of feasibility with recommendations for future research to establish robust evidence of established demand. Program evaluation further suggests that an occupational therapy fieldwork student can contribute meaningful services that address gaps in behavioral and academic support on campus, however supervision demands emerged as a key implementation barrier impacting sustainability”

The results section would benefit from a sharper distinction between descriptive service activity and actual participant outcomes. At present, the manuscript shows that services were implemented and attended by some students, but it does not yet demonstrate whether students improved in occupational performance, well-being, academic participation, or related outcomes. This limitation is acknowledged later, but the discussion and conclusion sometimes move too quickly from feasibility to implied effectiveness. The wording throughout should be revised to avoid suggesting impact where no outcome data have been presented.

Thank you for this important feedback. We agree that the original wording did not sufficiently distinguish between descriptive service activity and participant outcomes. As this study was designed as a program description and feasibility evaluation, outcome measurement was not a primary aim. We have revised the Results section to more clearly present findings as descriptive indicators of service utilization, integration, and feasibility. Additionally, we have refined the Discussion and Conclusion sections to avoid implying effectiveness and instead frame findings as preliminary indicators of feasibility, with recommendations for future research to examine participant outcomes.

Is this statement required for clarity within the results section? “As this study focused on feasibility and program implementation, participant-level outcomes were not formally measured.”

Revising wording suggesting outcome impact such as “demonstrated acceptability” to “showed preliminary indicators of acceptability through utilization of OT services”

The theoretical framing is relevant, but the connection between the framework and the analysis needs to be tightened. The PEOP Model and the Okanagan Charter are introduced convincingly, yet the manuscript does not consistently show how these frameworks guided specific analytic categories, intervention design decisions, or interpretation of findings. At present, the frameworks function more as background justification than as analytical scaffolds. A more explicit table or subsection mapping framework, constructs to program components, and findings would strengthen coherence.

Okanagan charter framework Calls to Action highlighted and connected in section 2.3 Implementation of Will Thrive Program. Calls to action further highlighted to rationale for tiered system of OT interventions in Results section 3.2 Implementation and Service Delivery and included in table 5 to assist with more specific mapping of framework.

The role of the OT FWII student, supervisors, and institutional stakeholders should be clarified in relation to the researcher's positionality and potential bias. The program appears to have been developed, implemented, monitored, and interpreted by closely involved actors, including the OT FWII student, faculty advisor, and supervisors. That embeddedness is understandable in an implementation-oriented study, but it increases the importance of reflexivity. The manuscript should explicitly discuss how insider roles may have influenced data collection, interpretation, and reporting, and what steps were taken to reduce confirmation bias.

Added ln section 2.3. Implementation of the WILL Thrive program, ln 381: “2.3. Implementation of the WILL Thrive program, “The OT FWII student, faculty advisor, and site supervisors were actively involved in the development, implementation, and monitoring of the WILL Thrive program, which introduces potential for confirmation bias and influences on data collection and interpretation. To mitigate this, triangulation across multiple perspectives was employed, including input from staff, faculty, and administrators not directly involved in the program, structured field notes, and regular reflective discussions among the OT FWII student, fieldwork supervisor, and faculty advisor. These steps were taken to ensure that interpretations of data were informed by multiple viewpoints and to reduce the influence of insider bias on feasibility evaluation.”

The ethical procedures need clearer explanation, especially regarding the incentives and overlapping research activities around the OHETI. The manuscript states that students received a $10 Amazon gift card for completing the OHETI and could also opt into a separate OHETI research study with a chance to win $100. Because this manuscript relies partly on those data for program development, the relationship between service development, institutional needs assessment, and research participation should be clarified carefully. Readers need a more precise explanation of what data were used in this study, what belonged to the separate validation study, and how consent procedures distinguished the two.

Clarification added in ln 2.4.1. Student Recruitment, ln 445 “To mitigate potential response bias through the use of financial incentives, incentives for this study were modest, not contingent on responses, and participation was voluntary. Students could also choose to complete the assessment while not releasing data. Of 47 students who took part in the OHETI assessment, 39 of them agreed that their data can be shared with the college for reporting purposes. These factors intended to mitigate the risk of undue influence on participant responses.

“

The intervention package is interesting but currently feels somewhat diffuse. The manuscript includes individual OT sessions, WAMs, targeted emails, yoga sessions, and a resource list. Because these are quite different forms of support, the paper should do more to justify why they all belong within a single feasibility model and how each maps onto the study aims. Otherwise, the intervention begins to look more like a broad campus wellness initiative than a clearly bounded OT feasibility program. Readers would benefit from clearer criteria for what counted as an OT-informed intervention and why.

*redefined study aims at start of results sections with alignment and connection to Okanagan charter framework for rationale of integrating within the Health Promoting Campus settings-based model of already established services

The manuscript would benefit from a stronger and more critical limitations section. While the authors acknowledge the small sample and single-site context, there are additional limitations that should be discussed directly: the absence of formal outcome measures, possible self-selection bias, the heavy reliance on referral pathways already aligned with the program, limited analytic detail, and the challenge of separating the feasibility of OT-on-campus from the feasibility of this very specific supervision model. Expanding the limitations section would make the manuscript more credible and balanced.

*added & reorganized Discussion section: “ ln 764: As a single-site, exploratory case study with a 12-week implementation timeline, findings are intended to document process, program development and preliminary feasibility rather than to establish generalizable outcomes. Findings should be considered as process documentation and lessons learned to inform future program development efforts in similar contexts.

Additional limitations include the absence of formal outcome measures, which precludes conclusions regarding student-level changes in occupational performance, participation, or well-being. Recruitment relied heavily on self-selection and referral pathways aligned with existing services, which may introduce some selection bias and limit the representativeness of the participants. Analytic procedures, while systematic and triangulated, were descriptive and qualitative and do not allow for strong causal inferences. The close involvement of the OT FWII student, faculty advisor and supervisors may have introduced confirmation bias, despite efforts to mitigate this through triangulation and reflective discussions. Furthermore, it is difficult to separate the feasibility of providing occupational therapy on a college campus in general from the feasibility of this specific supervision and fieldwork delivery model. As such, findings should be interpreted as early signals of feasibility rather than robust evidence of effectiveness or generalizability.

The discussion sometimes treats students with ADHD, ASD, and anxiety as the main or natural target population for campus OT, but the actual sample is extremely small and heterogeneous. I would encourage the authors to avoid broader population-level statements that are not well supported by the data. The paper can still suggest that these groups may be promising targets for future work, but the present study is not yet sufficient to define the likely service-user profile with confidence.

Discussion reframed to not overstate population based conclusions

Ending the manuscript with a figure is not especially effective in its current form. Rather than strengthening the conclusion, it interrupts the rhetorical closure of the paper and leaves the manuscript ending on a descriptive visual rather than on a clear scholarly takeaway. The conclusion would be stronger if it ended with a concise integrative paragraph, while the figure could be repositioned earlier or more explicitly discussed as part of the argument.

Figure moved into discussion section

The manuscript needs careful language editing before publication. There are many issues with phrasing, grammar, punctuation, capitalization, and consistency throughout the text. Examples include inconsistent tier terminology, awkward sentence construction, repeated wording, and several typographical errors. These issues do not invalidate the study, but they currently reduce clarity and give the manuscript a less polished appearance than the topic deserves. This is especially important because the study’s contribution depends heavily on conceptual and methodological precision. For example, “determine the feasibility to sustain” should read “determine the feasibility of sustaining”; one research question is written as a question but ends with a period; terms such as “Tier,” “Tiered,” and population-level labels are not used consistently; and there are clear proofreading errors such as “campus Champlain” and “occupational therapies capacity.” These issues do not by themselves undermine the study, but they reduce clarity and professionalism and should be corrected throughout.

Proof read and integrated this information including revised study questions to study aims

Author Response File: Author Response.pdf

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

The revised manuscript presents a clear and relevant contribution to an emerging area of practice, namely the integration of occupational therapy services within higher education settings. The authors have made substantial improvements in response to the previous round of review, particularly in clarifying the study design, strengthening methodological transparency, and appropriately positioning the work as an exploratory feasibility case study. The manuscript is now more coherent, and the conclusions are suitably aligned with the scope and limitations of the data.

Notwithstanding these improvements, a few minor points should be addressed to further enhance the clarity and scientific robustness of the manuscript:

Consistency of study positioning

Ensure full consistency throughout the manuscript (especially in the abstract and conclusion) regarding the nature of the study as an exploratory feasibility case study. In some sections, the distinction between program description and feasibility evaluation could still be slightly refined.

Clarification of methodological details

Although methodological transparency has improved, it would be beneficial to:

clearly summarise the final sample sizes across all data sources in a single table or paragraph;
briefly reinforce how qualitative data were analysed (e.g., coding procedures, thematic organisation), even if descriptively.

Theoretical integration

The integration of the PEOP model and the Okanagan Charter is now clearer; however, a more explicit articulation of how these frameworks informed both data interpretation and intervention design would strengthen the conceptual coherence of the manuscript.

Results presentation

Consider enhancing clarity in the presentation of results by:

including percentages alongside absolute frequencies where appropriate;
ensuring that all tables are clearly introduced and interpreted in the text.

Language and style

The overall quality of English has improved; however, a final careful revision is recommended to ensure precision and conciseness, avoiding occasional repetition and improving readability in some longer sentences.

Implications for practice and research

The discussion appropriately acknowledges the exploratory nature of the findings. A slightly more explicit distinction between practical implications and directions for future research would further strengthen the contribution of the paper.

In summary, the manuscript is now well positioned for publication and offers useful preliminary insights into the feasibility of occupational therapy services in higher education contexts. The suggested revisions are minor and intended to further refine clarity and coherence.

Comments on the Quality of English Language

Author Response

Thank you for your thoughtful feedback. We have addressed all remaining reviewer comments to improve clarity, transparency, and coherence. Sample sizes across all data sources are now clearly summarized, and qualitative data analysis is described, including coding and thematic organization. Theoretical integration has been strengthened by explicitly linking the PEOP model and Okanagan Charter to both data interpretation and intervention design. Tables are now fully introduced and interpreted in the text, with percentages added alongside absolute counts to clarify small-sample trends. Comparisons between interventions have been softened to remain descriptive. Practical implications and directions for future research are clearly separated under distinct subheadings, and minor language and style issues—including subject–verb agreement and word choice—have been corrected. Major revisions/ additions have been highlighted in yellow in the paper.

A point-by-point response follows to each comment:

Consistency of study positioning

Response: *we believe this has been addressed- although we have defined the study as a “program description and implementation case study”, Does this comment intend that we change the description to a “exploratory feasibility case study”? Please provide specific areas where refinement may still be needed.

Clarification of methodological details

Although methodological transparency has improved, it would be beneficial to:

-clearly summarise the final sample sizes across all data sources in a single table or paragraph;
Response: Ln 348 “Table one displays participant data sources used including 39 OHETI assessments, 8 staff interviews, five students attending at least one individual OT session, and four WAM participant students.” ..added to table 1
-briefly reinforce how qualitative data were analysed (e.g., coding procedures, thematic organisation), even if descriptively. Response: Line 178 “Materials and Methods” intro paragraph added “Qualitative data were descriptively coded and analyzed to support the structured integration of stakeholder perspectives within the feasibility domains of acceptability, demand, implementation, and practicality.”

Theoretical integration

Response: Line 425 added context to data analysis section, “Observational data were used to identify environmental facilitators and barriers to student participation and were interpreted using the PEOP model to examine interactions among person factors, environmental contexts and occupational performance demands. Findings were subsequently mapped onto the Okanagan Charter to contextualize results within a health-promoting campus framework and inform intervention development.”

Results presentation

Consider enhancing clarity in the presentation of results by:

including percentages alongside absolute frequencies where appropriate; ensuring that all tables are clearly introduced and interpreted in the text.
Response: *Added percentages alongside all absolute counts where feasible (students, visits, diagnoses) in Results section including in Table 2
Small sample sizes are now clearly expressed as percentages, helping readers interpret relative trends.
The text now introduces tables with context, aligning with prior reviewer feedback to clearly introduce and interpret tables.

- ensuring that all tables are clearly introduced and interpreted in the text.

Response: Updated table introductions & interpretations including more explicit interpretation sentences:

Ln 318 “Table 1 provides an overview of how research methods were structured across program phases in alignment with Bowen et al.’s (2009) feasibility aspects of acceptability, demand, implementation and practicality, including corresponding data sources, methods, and outputs used to inform the different phases (needs assessment, intervention development, and process evaluation). This phased approach illustrates how multiple data sources were integrated to address the study’s research questions related to acceptability, demand, and implementation feasibility.”

Ln 571, added increased interpretation, “This table demonstrates how a multi-tiered approach allowed the OT FWII student to deliver individualized, targeted, and population-level interventions, supporting both feasibility of service delivery and alignment with the health promoting campus Okanagan Charter framework.”

Language and style

Response: careful revision completed, deleted repeated words and edited run on sentences

Implications for practice and research

Response: Clarified using distinct sub-headings “ 4.5.1. Practical Implications for Campus OT Programs, 4.5.2. Directions for Future Research, and 4.5.3. Study Limitations”

Line 745 paragraph on “Future research should include”.. Was moved back into discussion section (was moved into conclusion in version 2) and placed under new sub heading; “4.5.2. Directions for Future Research” …. “Future research should examine “Does it work” as outlined by Bowen et al.'s (2009) framework through pre-post outcome measures assessing occupational performance, participation, well-being and academic engagement, as well as “Will it work” across diverse campus contexts. While limited by small sample size and contextual specificity; these findings remain informative as early indicators for feasibility for institutions exploring occupational therapy integration within higher education. Further research across diverse institutional contexts is warranted to examine the generalizability and scalability of occupational therapy fieldwork programs within higher education. “

Thank you for your time and thoughtful review of our manuscript.

Reviewer 4 Report

Comments and Suggestions for Authors

Thank you for the careful and substantial revision. The manuscript is much improved in methodological clarity, tone, and alignment between the paper and the response letter. I believe the remaining issues are minor and can likely be addressed with a final round of revision.

A final language edit is still needed. Although the manuscript has been proofread, a number of small usage and copyediting issues remain in the revised version. For example, “2019).Regardless” needs spacing, “complimentary approach” should likely read “complementary approach,” and there are still places where subject–verb agreement with data (which is plural) should be corrected (e.g., “Data was collected …”; “This data informed …”). Because the paper depends heavily on conceptual and methodological precision, I would strongly recommend one last careful language pass.
One sentence in the WAM section still seems slightly over-interpreted relative to the evidence. The statement that tier 2 interventions were “more in demand” than individual OT sessions goes a bit beyond what can be concluded from four WAM participants and five individual-service users, even though the authors appropriately add caution immediately afterward. I suggest softening this sentence further and keeping the comparison purely descriptive.
The OHETI clarification has improved, but one final sentence would help more clearly distinguish between the data used in this manuscript and the separate OHETI validation study. The revision now explains consent procedures and the optional larger study, which is helpful, but the manuscript still shifts among “aggregate data,” “their data,” and program-development use in ways that could be made more precise. A brief clarifying sentence specifying exactly what OHETI outputs were used here would strengthen transparency.

Author Response

Thank you for your thoughtful review of our manuscript. We have addressed all remaining reviewer comments to improve clarity, transparency, and coherence. Sample sizes across all data sources are now clearly summarized, and qualitative data analysis is described, including coding and thematic organization. Theoretical integration has been strengthened by explicitly linking the PEOP model and Okanagan Charter to both data interpretation and intervention design. Tables are now fully introduced and interpreted in the text, with percentages added alongside absolute counts to clarify small-sample trends. Comparisons between interventions have been softened to remain descriptive. Practical implications and directions for future research are clearly separated under distinct subheadings, and minor language and style issues—including subject–verb agreement and word choice—have been corrected. Major revisions and additions are highlighted in yellow in the text.

A point-by-point response to reviewer's comments are as follows:

A final language edit is still needed. Although the manuscript has been proofread, a number of small usage and copyediting issues remain in the revised version. For example, “2019).Regardless” needs spacing, “complimentary approach” should likely read “complementary approach,” and there are still places where subject–verb agreement with data (which is plural) should be corrected (e.g., “Data was collected …”; “This data informed …”). Because the paper depends heavily on conceptual and methodological precision, I would strongly recommend one last careful language pass.

1.Response: Corrected and highlighted grammatical errors including, “2019).Regardless” needs spacing, “complimentary approach” should likely read “complementary approach,” and places where subject–verb agreement with data (plural). Thank you for highlighting these errors.

2. One sentence in the WAM section still seems slightly over-interpreted relative to the evidence. The statement that tier 2 interventions were “more in demand” than individual OT sessions goes a bit beyond what can be concluded from four WAM participants and five individual-service users, even though the authors appropriately add caution immediately afterward. I suggest softening this sentence further and keeping the comparison purely descriptive.

Response: Thank you, we see this over-interpretation and have edited line 523 to soften claim, keeping comparison descriptive “Compared with the five students who received individual OT sessions, WAM participants attended more frequently and consistently. These patterns describe attendance trends within this small sample size, suggesting that structured, less intensive tier 2 interventions embedded within the existing campus support system may support repeated engagement”

3. The OHETI clarification has improved, but one final sentence would help more clearly distinguish between the data used in this manuscript and the separate OHETI validation study. The revision now explains consent procedures and the optional larger study, which is helpful, but the manuscript still shifts among “aggregate data,” “their data,” and program-development use in ways that could be made more precise. A brief clarifying sentence specifying exactly what OHETI outputs were used here would strengthen transparency.

Response: Great idea, we revised Section 2.4.1. Student Recruitment (line 342) to clearly distinguish OHETI data including consistent terminology: “de-identified, aggregate OHETI responses” instead of “this data” or “their data.”

Included addition of a clarifying sentence “For the purposes of this manuscript, only de-identified, aggregate OHETI responses from these 39 students were used to inform program development; no individual-level or validation study data were analyzed here.”

Thank you for your time and thoughtful feedback on our manuscript submission. It is much appreciated.