Review Reports

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This single-center observational study evaluated an animal-assisted psychoeducational intervention for 60 pediatric patients. The intervention included observing an in-ward aquarium, virtual animal encounters, and a psychoeducational booklet featuring drawing, reflection, and role-playing activities to address emotions encountered during therapy.

In the background consider shortening "This study evaluates the feasibility and perceived benefits of an animal-assisted psychoeducational intervention to enhance emotional coping during hospitalisation."

Ensure consistent hyphenation for compound adjectives like "single-centre observational study" (e.g., "single-centre," "long-term") throughout the document (abstract, introduction, methods).

The introduction is well written and nicely discusses the rationale for the project.

The results section is weighted toward the quantitative data (Table 2, percentages), overshadowing some of the narrative qualitative findings (narratives, drawings) that address key areas like children's emotional needs and adaptive behaviors. To improve the rigor and clarity of the presented data consider reorganizing the section to include a separate subheading, "6.2. Qualitative and Thematic Findings," for a balanced presentation of the study's findings.

The methods used to identify and subsequently code themes in the qualitative feedback—specifically the recurring patterns found in children's narratives and drawings require a little  more description. Please elaborate on the procedures employed for this identification of these themes.

Further granular description in the methods section describing the "five-point Likert scale" would improve the data collection process.

I would focus the conclusion on feasibility and acceptability (high enjoyment, 100% perceived care) since there is a limited effect on personal self-reflection (60% uncertain about new insights into emotions). This better aligns with the findings from the analysis.

The "Most frequent emotion experienced" row (listing Anger, Sadness, Surprise, Joy) is inconsistent with other rows' percentage data. Add percentages if available.

For categorical responses, like "Perceived emotional state," the "Main responses (%)" column is too dense. Improve clarity by separating the breakdown into columns (e.g., "Very good/Very much," "Good/Yes," "Average/Not sure/No").

The selection of behaviours/characteristics that kids would like to adopt to better adapt to their environment are fascinating/revealing.

For Figures 1 (Adaptive Behaviors) and 2 (Physical and Behavioral Adaptations), please make sure there are clear labels, concise titles, and accurate, readable visual representation of the percentages listed. For figure 1, correct the spelling of "strength." "I live in a group, unity is strenght 45%".

Table 1 is really limited. Can further patient, disease, psychosocial characteristics not be defined?

Consider providing a link/QR code to the booklet used in the manuscript.

Author Response

This single-center observational study evaluated an animal-assisted psychoeducational intervention for 60 pediatric patients. The intervention included observing an in-ward aquarium, virtual animal encounters, and a psychoeducational booklet featuring drawing, reflection, and role-playing activities to address emotions encountered during therapy.

In the background consider shortening "This study evaluates the feasibility and perceived benefits of an animal-assisted psychoeducational intervention to enhance emotional coping during hospitalisation."

Many thanks, we have followed your instructions.

Ensure consistent hyphenation for compound adjectives like "single-centre observational study" (e.g., "single-centre," "long-term") throughout the document (abstract, introduction, methods).

Many thanks, we have followed your instructions.

The introduction is well written and nicely discusses the rationale for the project.

The results section is weighted toward the quantitative data (Table 2, percentages), overshadowing some of the narrative qualitative findings (narratives, drawings) that address key areas like children's emotional needs and adaptive behaviors. To improve the rigor and clarity of the presented data consider reorganizing the section to include a separate subheading, "6.2. Qualitative and Thematic Findings," for a balanced presentation of the study's findings.

We thank the reviewer for this insightful comment. In response, we have strengthened the presentation of the qualitative findings by integrating them more explicitly into the existing Results paragraph, ensuring that narratives and drawings are more clearly described and linked to key themes such as children’s emotional needs and adaptive behaviors. This integration was chosen to maintain coherence and avoid unnecessary fragmentation of the Results section, while providing a more balanced and rigorous representation of both quantitative and qualitative data.

The methods used to identify and subsequently code themes in the qualitative feedback—specifically the recurring patterns found in children's narratives and drawings require a little  more description. Please elaborate on the procedures employed for this identification of these themes.

We appreciate the reviewers’ suggestion. In the present study, qualitative feedback from children’s narratives and drawings was examined in an exploratory manner to complement the quantitative findings, without applying a formal coding scheme. We acknowledge that a more detailed thematic coding approach would strengthen future research and will be considered in subsequent studies.

Further granular description in the methods section describing the "five-point Likert scale" would improve the data collection process.

We have now clarified the anchoring of the Likert scale in the Methods section, specifying that the questionnaire responses ranged from 0 (“not at all”) to 5 (“extremely”).

I would focus the conclusion on feasibility and acceptability (high enjoyment, 100% perceived care) since there is a limited effect on personal self-reflection (60% uncertain about new insights into emotions). This better aligns with the findings from the analysis.

We revised the Discussion and Conclusions to prioritise feasibility and acceptability outcomes, emphasising high enjoyment and the universal perception of being cared for, while adopting a more cautious interpretation of the limited effects on personal self-reflection. The language was refined to clearly distinguish acceptability-related findings from psychological or emotional outcomes, explicitly framing the intervention as a low-threshold, complementary support rather than a psychological treatment. This revision ensures closer alignment between the conclusions and the study’s findings, consistent with the exploratory and observational nature of the study.

The "Most frequent emotion experienced" row (listing Anger, Sadness, Surprise, Joy) is inconsistent with other rows' percentage data. Add percentages if available.

Percentages referring to the most frequently experienced emotions have now been explicitly reported and clearly presented in the Results section, both in tabular form and in the accompanying text.

 

For categorical responses, like "Perceived emotional state," the "Main responses (%)" column is too dense. Improve clarity by separating the breakdown into columns (e.g., "Very good/Very much," "Good/Yes," "Average/Not sure/No").
We considered restructuring the table as suggested; however, after careful evaluation, we concluded that the existing format offers a clearer and more compact representation of the main categorical responses, particularly given the exploratory nature of the study. For this reason, the table layout was retained.

The selection of behaviours/characteristics that kids would like to adopt to better adapt to their environment are fascinating/revealing.

For Figures 1 (Adaptive Behaviors) and 2 (Physical and Behavioral Adaptations), please make sure there are clear labels, concise titles, and accurate, readable visual representation of the percentages listed. For figure 1, correct the spelling of "strength." "I live in a group, unity is strenght 45%".

We have revised the Figures as recommended.

Table 1 is really limited. Can further patient, disease, psychosocial characteristics not be defined?

We have expanded Table 1 by including additional clinical information related to patients’ diagnoses.

 

Consider providing a link/QR code to the booklet used in the manuscript.

We appreciate the suggestion to provide access to the psychoeducational booklet. The material was developed as an internally produced, context-specific tool designed for use within the clinical setting and is therefore not intended for external dissemination. However, the intervention procedures and core components are described in sufficient detail in the manuscript to ensure transparency and coherence between the reported data and the implemented activities.

 

This manuscript addresses an important and underexplored aspect of pediatric oncohaematology care: the feasibility and acceptability of an animal-assisted psychoeducational intervention aimed at supporting children’s emotional well-being during hospitalization. The topic is timely, relevant, and well aligned with growing interest in integrative and nature-based interventions in healthcare settings. The intervention is thoughtfully designed, developmentally sensitive, and ethically sound, and the manuscript is generally well written, coherent, and clearly structured. The authors provided a rich contextual background and a detailed description of the intervention, which enhances reproducibility and practical relevance. The inclusion of both in-person and virtual components is a notable strength, particularly for immunocompromised pediatric populations. The discussion appropriately acknowledges the exploratory nature of the findings and the limitations inherent to the observational design. However, several areas would benefit from clarification and strengthening, particularly regarding methodological rigor, outcome assessment, and interpretation of findings. Greater precision in defining study aims, analytic approaches, and the conceptual distinction between feasibility, acceptability, and psychological impact would improve the scientific robustness of the manuscript. Minor editorial refinements and clearer alignment between objectives, results, and conclusions are also recommended. Overall, the manuscript makes a valuable preliminary contribution to the field and, with minor to moderate revisions, would be suitable for publication.

Comments:

 

 

General Review Comments (6)

1. Clarify Study Objectives and Outcomes: The aims of the study should be stated more explicitly, particularly distinguishing between feasibility, acceptability, educational outcomes, and emotional or psychological impact. Clear alignment between objectives, measures, and conclusions would strengthen internal coherence.
   
   1. We have revised the manuscript to clarify the study objectives and outcomes. The aims are now more explicitly defined, distinguishing between the evaluation of feasibility and acceptability of the intervention and the exploratory assessment of children’s educational engagement and symbolic coping processes. Emotional and psychological aspects are clearly framed as descriptive and experiential observations, rather than formal clinical outcomes.
   
   
2. Strengthen Methodological Transparency: While the intervention is well described, the manuscript would benefit from clearer reporting of data analysis procedures, including how qualitative feedback was analyzed and whether any steps were taken to enhance reliability or reduce subjectivity.
   
   2.  We have clarified the qualitative data analysis procedures in the Methods section, specifying the thematic approach adopted and the steps taken to enhance reliability and reduce subjectivity, including independent review and consensus discussion among psychologists.

 

1. Interpret Emotional Outcomes More Cautiously: The finding that only a minority of children reported increased emotional insight warrants a more critical discussion. The authors should further clarify how this result aligns with the intervention’s theoretical framework and avoid overstating emotional regulation outcomes.
   
   3. We addressed Comments 3 and 5 jointly, as both concern the interpretation and positioning of the intervention’s impact.
   We revised the Discussion and Conclusions to more clearly distinguish feasibility and acceptability outcomes from psychological or emotional effects, adopting more cautious language and explicitly framing the intervention as a low-threshold, complementary support rather than a psychological treatment. This integrated revision ensures conceptual coherence between outcome interpretation and proposed clinical integration, fully aligned with the exploratory and observational nature of the study.

 

1. Improve Presentation of Results: Tables and figures would benefit from clearer captions and, where possible, more explicit links to the research questions. Percentages should consistently be accompanied by raw numbers to enhance interpretability.
   
   4. We have revised the presentation of the Results section to improve clarity and interpretability. Specifically, all tables and figures now include clearer and more informative captions, explicitly describing the content of the data and, where relevant, linking the findings to the study aim of exploring children’s perceived coping strategies and symbolic resources during hospitalisation.
   
   Percentages are now consistently accompanied by raw numbers (n/N) throughout the Results section, including within table entries, figure captions, and the accompanying narrative text.
   
   We have expanded Table 1 by including additional clinical information related to patients’ diagnoses.
   
   Percentages referring to the most frequently experienced emotions have now been explicitly reported and clearly presented in the Results section, both in tabular form and in the accompanying text.
   
   Additionally, brief introductory and linking sentences have been added to guide the reader in understanding how the reported results address the research questions. These revisions enhance transparency and facilitate a clearer interpretation of both quantitative and qualitative findings.
   
   
2. Expand Discussion of Clinical and Practical Implications: The discussion could be strengthened by more clearly articulating how this intervention could be integrated into routine pediatric oncology care and how it complements existing psychological services.
   
   5. We addressed Comments 3 and 5 jointly, as both concern the interpretation and positioning of the intervention’s impact.
   We revised the Discussion and Conclusions to more clearly distinguish feasibility and acceptability outcomes from psychological or emotional effects, adopting more cautious language and explicitly framing the intervention as a low-threshold, complementary support rather than a psychological treatment. This integrated revision ensures conceptual coherence between outcome interpretation and proposed clinical integration, fully aligned with the exploratory and observational nature of the study.

 

1. Minor Editorial and Language Revisions: The manuscript would benefit from careful proofreading to address minor grammatical inconsistencies, repetition, and formatting issues (e.g., spacing, figure references, and citation formatting).
   
   6. The manuscript was carefully proofread and revised to address minor editorial and language issues. Specifically, we ensured consistency in spelling and terminology (e.g., British English usage), corrected grammatical and spacing inconsistencies, reduced repetition, and improved the clarity and formatting of tables and figures. Citations, references, and figure captions were also standardised in accordance with the journal’s style guidelines. Should you require it, we can provide a certificate confirming the English language revision.
   
   
   
   

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Author Response File: Author Response.docx

Reviewer 2 Report

Comments and Suggestions for Authors

This manuscript addresses an important and underexplored aspect of pediatric oncohaematology care: the feasibility and acceptability of an animal-assisted psychoeducational intervention aimed at supporting children’s emotional well-being during hospitalization. The topic is timely, relevant, and well aligned with growing interest in integrative and nature-based interventions in healthcare settings. The intervention is thoughtfully designed, developmentally sensitive, and ethically sound, and the manuscript is generally well written, coherent, and clearly structured. The authors provideed a rich contextual background and a detailed description of the intervention, which enhances reproducibility and practical relevance. The inclusion of both in-person and virtual components is a notable strength, particularly for immunocompromised pediatric populations. The discussion appropriately acknowledges the exploratory nature of the findings and the limitations inherent to the observational design. However, several areas would benefit from clarification and strengthening, particularly regarding methodological rigor, outcome assessment, and interpretation of findings. Greater precision in defining study aims, analytic approaches, and the conceptual distinction between feasibility, acceptability, and psychological impact would improve the scientific robustness of the manuscript. Minor editorial refinements and clearer alignment between objectives, results, and conclusions are also recommended. Overall, the manuscript makes a valuable preliminary contribution to the field and, with minor to moderate revisions, would be suitable for publication.

Comments:

General Review Comments (6)

1. Clarify Study Objectives and Outcomes: The aims of the study should be stated more explicitly, particularly distinguishing between feasibility, acceptability, educational outcomes, and emotional or psychological impact. Clear alignment between objectives, measures, and conclusions would strengthen internal coherence.

2. Strengthen Methodological Transparency: While the intervention is well described, the manuscript would benefit from clearer reporting of data analysis procedures, including how qualitative feedback was analyzed and whether any steps were taken to enhance reliability or reduce subjectivity.

3. Interpret Emotional Outcomes More Cautiously: The finding that only a minority of children reported increased emotional insight warrants a more critical discussion. The authors should further clarify how this result aligns with the intervention’s theoretical framework and avoid overstating emotional regulation outcomes.

4. Improve Presentation of Results: Tables and figures would benefit from clearer captions and, where possible, more explicit links to the research questions. Percentages should consistently be accompanied by raw numbers to enhance interpretability.

5. Expand Discussion of Clinical and Practical Implications: The discussion could be strengthened by more clearly articulating how this intervention could be integrated into routine pediatric oncology care and how it complements existing psychological services.

6. Minor Editorial and Language Revisions: The manuscript would benefit from careful proofreading to address minor grammatical inconsistencies, repetition, and formatting issues (e.g., spacing, figure references, and citation formatting).

 

Comments on the Quality of English Language

can be improved

Author Response

This single-center observational study evaluated an animal-assisted psychoeducational intervention for 60 pediatric patients. The intervention included observing an in-ward aquarium, virtual animal encounters, and a psychoeducational booklet featuring drawing, reflection, and role-playing activities to address emotions encountered during therapy.

In the background consider shortening "This study evaluates the feasibility and perceived benefits of an animal-assisted psychoeducational intervention to enhance emotional coping during hospitalisation."

Many thanks, we have followed your instructions.

Ensure consistent hyphenation for compound adjectives like "single-centre observational study" (e.g., "single-centre," "long-term") throughout the document (abstract, introduction, methods).

Many thanks, we have followed your instructions.

The introduction is well written and nicely discusses the rationale for the project.

The results section is weighted toward the quantitative data (Table 2, percentages), overshadowing some of the narrative qualitative findings (narratives, drawings) that address key areas like children's emotional needs and adaptive behaviors. To improve the rigor and clarity of the presented data consider reorganizing the section to include a separate subheading, "6.2. Qualitative and Thematic Findings," for a balanced presentation of the study's findings.

We thank the reviewer for this insightful comment. In response, we have strengthened the presentation of the qualitative findings by integrating them more explicitly into the existing Results paragraph, ensuring that narratives and drawings are more clearly described and linked to key themes such as children’s emotional needs and adaptive behaviors. This integration was chosen to maintain coherence and avoid unnecessary fragmentation of the Results section, while providing a more balanced and rigorous representation of both quantitative and qualitative data.

The methods used to identify and subsequently code themes in the qualitative feedback—specifically the recurring patterns found in children's narratives and drawings require a little  more description. Please elaborate on the procedures employed for this identification of these themes.

We appreciate the reviewers’ suggestion. In the present study, qualitative feedback from children’s narratives and drawings was examined in an exploratory manner to complement the quantitative findings, without applying a formal coding scheme. We acknowledge that a more detailed thematic coding approach would strengthen future research and will be considered in subsequent studies.

Further granular description in the methods section describing the "five-point Likert scale" would improve the data collection process.

We have now clarified the anchoring of the Likert scale in the Methods section, specifying that the questionnaire responses ranged from 0 (“not at all”) to 5 (“extremely”).

I would focus the conclusion on feasibility and acceptability (high enjoyment, 100% perceived care) since there is a limited effect on personal self-reflection (60% uncertain about new insights into emotions). This better aligns with the findings from the analysis.

We revised the Discussion and Conclusions to prioritise feasibility and acceptability outcomes, emphasising high enjoyment and the universal perception of being cared for, while adopting a more cautious interpretation of the limited effects on personal self-reflection. The language was refined to clearly distinguish acceptability-related findings from psychological or emotional outcomes, explicitly framing the intervention as a low-threshold, complementary support rather than a psychological treatment. This revision ensures closer alignment between the conclusions and the study’s findings, consistent with the exploratory and observational nature of the study.

The "Most frequent emotion experienced" row (listing Anger, Sadness, Surprise, Joy) is inconsistent with other rows' percentage data. Add percentages if available.

Percentages referring to the most frequently experienced emotions have now been explicitly reported and clearly presented in the Results section, both in tabular form and in the accompanying text.

 

For categorical responses, like "Perceived emotional state," the "Main responses (%)" column is too dense. Improve clarity by separating the breakdown into columns (e.g., "Very good/Very much," "Good/Yes," "Average/Not sure/No").
We considered restructuring the table as suggested; however, after careful evaluation, we concluded that the existing format offers a clearer and more compact representation of the main categorical responses, particularly given the exploratory nature of the study. For this reason, the table layout was retained.

The selection of behaviours/characteristics that kids would like to adopt to better adapt to their environment are fascinating/revealing.

For Figures 1 (Adaptive Behaviors) and 2 (Physical and Behavioral Adaptations), please make sure there are clear labels, concise titles, and accurate, readable visual representation of the percentages listed. For figure 1, correct the spelling of "strength." "I live in a group, unity is strenght 45%".

We have revised the Figures as recommended.

Table 1 is really limited. Can further patient, disease, psychosocial characteristics not be defined?

We have expanded Table 1 by including additional clinical information related to patients’ diagnoses.

 

Consider providing a link/QR code to the booklet used in the manuscript.

We appreciate the suggestion to provide access to the psychoeducational booklet. The material was developed as an internally produced, context-specific tool designed for use within the clinical setting and is therefore not intended for external dissemination. However, the intervention procedures and core components are described in sufficient detail in the manuscript to ensure transparency and coherence between the reported data and the implemented activities.

 

This manuscript addresses an important and underexplored aspect of pediatric oncohaematology care: the feasibility and acceptability of an animal-assisted psychoeducational intervention aimed at supporting children’s emotional well-being during hospitalization. The topic is timely, relevant, and well aligned with growing interest in integrative and nature-based interventions in healthcare settings. The intervention is thoughtfully designed, developmentally sensitive, and ethically sound, and the manuscript is generally well written, coherent, and clearly structured. The authors provided a rich contextual background and a detailed description of the intervention, which enhances reproducibility and practical relevance. The inclusion of both in-person and virtual components is a notable strength, particularly for immunocompromised pediatric populations. The discussion appropriately acknowledges the exploratory nature of the findings and the limitations inherent to the observational design. However, several areas would benefit from clarification and strengthening, particularly regarding methodological rigor, outcome assessment, and interpretation of findings. Greater precision in defining study aims, analytic approaches, and the conceptual distinction between feasibility, acceptability, and psychological impact would improve the scientific robustness of the manuscript. Minor editorial refinements and clearer alignment between objectives, results, and conclusions are also recommended. Overall, the manuscript makes a valuable preliminary contribution to the field and, with minor to moderate revisions, would be suitable for publication.

Comments:

 

 

General Review Comments (6)

1. Clarify Study Objectives and Outcomes: The aims of the study should be stated more explicitly, particularly distinguishing between feasibility, acceptability, educational outcomes, and emotional or psychological impact. Clear alignment between objectives, measures, and conclusions would strengthen internal coherence.
   
   1. We have revised the manuscript to clarify the study objectives and outcomes. The aims are now more explicitly defined, distinguishing between the evaluation of feasibility and acceptability of the intervention and the exploratory assessment of children’s educational engagement and symbolic coping processes. Emotional and psychological aspects are clearly framed as descriptive and experiential observations, rather than formal clinical outcomes.
   
   
2. Strengthen Methodological Transparency: While the intervention is well described, the manuscript would benefit from clearer reporting of data analysis procedures, including how qualitative feedback was analyzed and whether any steps were taken to enhance reliability or reduce subjectivity.
   
   2.  We have clarified the qualitative data analysis procedures in the Methods section, specifying the thematic approach adopted and the steps taken to enhance reliability and reduce subjectivity, including independent review and consensus discussion among psychologists.

 

1. Interpret Emotional Outcomes More Cautiously: The finding that only a minority of children reported increased emotional insight warrants a more critical discussion. The authors should further clarify how this result aligns with the intervention’s theoretical framework and avoid overstating emotional regulation outcomes.
   
   3. We addressed Comments 3 and 5 jointly, as both concern the interpretation and positioning of the intervention’s impact.
   We revised the Discussion and Conclusions to more clearly distinguish feasibility and acceptability outcomes from psychological or emotional effects, adopting more cautious language and explicitly framing the intervention as a low-threshold, complementary support rather than a psychological treatment. This integrated revision ensures conceptual coherence between outcome interpretation and proposed clinical integration, fully aligned with the exploratory and observational nature of the study.

 

1. Improve Presentation of Results: Tables and figures would benefit from clearer captions and, where possible, more explicit links to the research questions. Percentages should consistently be accompanied by raw numbers to enhance interpretability.
   
   4. We have revised the presentation of the Results section to improve clarity and interpretability. Specifically, all tables and figures now include clearer and more informative captions, explicitly describing the content of the data and, where relevant, linking the findings to the study aim of exploring children’s perceived coping strategies and symbolic resources during hospitalisation.
   
   Percentages are now consistently accompanied by raw numbers (n/N) throughout the Results section, including within table entries, figure captions, and the accompanying narrative text.
   
   We have expanded Table 1 by including additional clinical information related to patients’ diagnoses.
   
   Percentages referring to the most frequently experienced emotions have now been explicitly reported and clearly presented in the Results section, both in tabular form and in the accompanying text.
   
   Additionally, brief introductory and linking sentences have been added to guide the reader in understanding how the reported results address the research questions. These revisions enhance transparency and facilitate a clearer interpretation of both quantitative and qualitative findings.
   
   
2. Expand Discussion of Clinical and Practical Implications: The discussion could be strengthened by more clearly articulating how this intervention could be integrated into routine pediatric oncology care and how it complements existing psychological services.
   
   5. We addressed Comments 3 and 5 jointly, as both concern the interpretation and positioning of the intervention’s impact.
   We revised the Discussion and Conclusions to more clearly distinguish feasibility and acceptability outcomes from psychological or emotional effects, adopting more cautious language and explicitly framing the intervention as a low-threshold, complementary support rather than a psychological treatment. This integrated revision ensures conceptual coherence between outcome interpretation and proposed clinical integration, fully aligned with the exploratory and observational nature of the study.

 

1. Minor Editorial and Language Revisions: The manuscript would benefit from careful proofreading to address minor grammatical inconsistencies, repetition, and formatting issues (e.g., spacing, figure references, and citation formatting).
   
   6. The manuscript was carefully proofread and revised to address minor editorial and language issues. Specifically, we ensured consistency in spelling and terminology (e.g., British English usage), corrected grammatical and spacing inconsistencies, reduced repetition, and improved the clarity and formatting of tables and figures. Citations, references, and figure captions were also standardised in accordance with the journal’s style guidelines. Should you require it, we can provide a certificate confirming the English language revision.
   
   
   
   

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Author Response File: Author Response.docx