Gamification as a health education strategy of adolescents at school: Protocol for a systematic review and meta-analysis

Thais Teixeira dos Santos; Manuel Pardo Ríos; Gidyenne Christine Bandeira Silva de Medeiros; Ádala Nayana de Sousa Mata; Danyllo do Nascimento Silva Junior; Daniel Martínez Guillen; Grasiela Piuvezam

doi:10.1371/journal.pone.0294894

. 2023 Nov 30;18(11):e0294894. doi: 10.1371/journal.pone.0294894

Gamification as a health education strategy of adolescents at school: Protocol for a systematic review and meta-analysis

Thais Teixeira dos Santos ^1,^2,^#, Manuel Pardo Ríos ³, Gidyenne Christine Bandeira Silva de Medeiros ^1,^2,⁴, Ádala Nayana de Sousa Mata ^2,⁵, Danyllo do Nascimento Silva Junior ^1,², Daniel Martínez Guillen ³, Grasiela Piuvezam ^1,^2,^6,^*,^#

Editor: Delfina Fernandes Hlashwayo⁷

PMCID: PMC10688727 PMID: 38033047

Abstract

The objective of the study is to present a systematic review and meta-analysis protocol for evaluating the effects of health education gamification-based interventions, on health parameters (food consumption, sleep quality and physical activity) of adolescent students. This protocol was registered on the International Prospective Register of Systematic Reviews (PROSPERO) database (CRD42022373833). The search will be performed in the following databases: MEDLINE, Embase, Scopus, ERIC, ScienceDirect, Web of Science, Cochrane, LILACS, APA, and ADOLEC. Intervention studies (clinical trials ‐ randomized or non-randomized) and quasi-experimental studies will be included. The risk of bias will be assessed using the Risk of Bias in Non-randomized Studies of Interventions tool for randomized controlled trials, non- randomized controlled trials and quasi-experimental trials. Two independent researchers will conduct all assessments, and any disagreements will be consulted with a third reviewer. Data analysis and synthesis will be analyzed using RevMan 5.4.1 software. We will conduct the study in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) guideline. The review will summarize the current evidence on gamification health education changes in parameters related to the health of adolescents. Gamification has been used to verify the increase in adherence to healthy habits or the development of health-related skills, but there are still few results for the adolescent population. We expect that the systematic review could indicate strategies with gamification interventions and also determine how these strategies can improve health parameters of adolescent students, and they will be available as a reference for these interventions.

Introduction

Adolescence is defined by the World Health Organization [1] as the period between 10 and 19 years of age. This phase is characterized by the gradual transition from childhood to adulthood with the appearance of signs of puberty, which comprise important physiological, psychological, and social changes [2].

Due to all of these changes, there is an increasing interest for in-depth studies on of this phase, especially with regard to health aspects. Also, this population has increased in recent years, and it is already well known that the health-related habits during the period of adolescence will have a lasting impact on the adults they will become, and the children of the next generation [3].

Children and adolescents may have difficulties in adapting to new, healthier lifestyles, and therefore, efforts need to be made to apply new approaches aimed at the successful adherence to these new habits [4]. In this perspective, in many intervention strategies implemented in studies aimed at promoting health among adolescents, techniques have been adopted based on immersive technologies, such as gamification, by bringing this population closer to technology and electronic devices [5, 6].

According to Deterding et al. [7], ‘gamification’ or ‘game-based learning’ corresponds to the “use of game design elements to improve academic performance”, such as learning attitudes, behaviors and results. Furthermore, some authors [8–11] clearly define gamification as the use of game elements in non-gaming contexts. The evaluation of gamified resources is one of the great debates of today. It is not yet clear how to measure these interventions and whether there is also an improvement in learning outcomes, despite there being an increase in student motivation. Future research should clarify mechanisms underlying gamified educational interventions and explore theories that could explain the effects of these interventions on learning outcomes, using well-defined control groups, in a longitudinal manner [12].

The use of gamification in health education promotes dialogue between the trained team and intervention participants, with active engagement and the promotion of participant reflection in a relaxing learning environment [13]. Furthermore, the use of active games by children and adolescents can help to promote healthy habits [14], such as improving diet, eating habits and body composition [15], improving the sleep quality and symptoms of sleep interruption due to the COVID-19 pandemic [16], for example, and in the practice of physical activity [17].

It is important to highlight that positive results have been obtained with patients diagnosed with illnesses such as diabetes [13], when seeking to promote playful education [18], and general change of behavior for healthier life habits in children [6].

Thus, the objective of the study is to present a protocol that will assist in conducting a systematic review and meta-analysis to evaluate the effects of health education gamification-based interventions on health parameters (food consumption, sleep quality and physical activity) of adolescent students.

Methods and analysis

Study registration and reporting

This protocol was registered on the International Prospective Register of Systematic Reviews (PROSPERO) database on November 29^th, 2022 (CRD42022373833). The protocol is based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) guidelines [19] (S1 Checklist). The final report will be developed following PRISMA [20] and the Cochrane Handbook for Systematic Reviews of Interventions [21], and any changes to the protocol will be described in the Methods section. The planned start and end dates registered are January 10th, 2024, and September 10^th, 2024, respectively.

The review questions guiding this proposal are: what are the main intervention strategies with gamification techniques for the health education of adolescent students? What are the effects of using gamification/game-based interventions on sleep quality parameters of adolescent students? What are the effects of using gamification/game-based interventions on the food consumption parameters of adolescent students? What are the effects of using gamification/game-based interventions on the physical activity parameters of adolescent students?

Eligibility criteria

Types of study

Intervention studies (clinical trials ‐ randomized or non-randomized) and quasi-experimental studies that describe interventions using gamification as a health education strategy with adolescent students, will be included. The latter must necessarily have a control group.

Participants

Only studies whose population is adolescents will be included. For this investigation, the definition of “adolescents” by the World Health Organization [22] will be considered, which refers to a person aged between 10 and 19 years old.

Intervention

Studies in which interventions with gamification for health education were carried out will be included.

Compares

We will consider studies with a control group that compare the intervention with the no gamification intervention group.

Outcome measures

The main expected outcome is changes in parameters related to the health of adolescents, such as: food consumption parameters (eating frequency; eating habits; biological, psychological, and psychological and sociocultural factors related to food), sleep quality (sleep habits, sleep disorders), and physical activity (aerobic, anaerobic and sports modalities; health benefits) that support or explain the effect of interventions based on the use of gamification in the health education of adolescents. The studies to be included must present at least one of the expected outcomes.

Exclusion criteria

We will exclude studies in which interventions were exclusively applied to certain diseases/pathologies and when the population includes young people (from 10 to 24 years old) or children without an analysis of the subgroup of adolescents. Studies without a control group or intervention, or when the undergoing interventions do not use gamification will also be excluded. Studies that evaluate only nutrients and not the food will not be included. Adolescents will not be excluded due to the level of education (high school or college or technical school), as long as they meet the other eligibility criteria.

Search strategies

The reviews will be divided into three thematic areas: food consumption, sleep quality, and physical activity. For each thematic area, reviewers should follow the following steps: apply the inclusion and exclusion criteria when searching the databases by reading the titles and abstracts; apply the eligibility criteria after reading the articles selected in the initial stage in full; assess the methodological quality and the risk of bias of the articles included in the previous step and perform a quantitative synthesis of data from selected articles (meta-analysis).

Electronic search

The search will be performed in the following databases: MEDLINE/PubMed, Embase, Scopus, ERIC ‐ Education Resources Information Center, ScienceDirect, Web of Science, LILACS–Latin American and Caribbean Health Sciences Literature, American Psychological Association PsycINFO, and ADOLEC.

A free combination of Medical Subject Heading (MeSH) terms and Keywords will be performed. The search string will be defined considering the following items: participants (adolescents; students), intervention (gamification; school; health education), outcomes (diet, food and nutrition; dairy products; sleep quality; dyssomnias; sleep disorders, intrinsic; sleep hygiene; exercise; sedentary behavior), and study design (clinical trial, intervention, observational).

The search terms for composing the strings will be combined with specific filters in each database (S1 File). There will be no restrictions on publication date or language in the searches.

Additional search

To ensure the scope of this research, we will complement the searches with a manual search in the reference lists of the retrieved studies or relevant reviews that are related to the topic.

Screening procedure

Two systematic reviews will be conducted: one addressing the main gamification strategies used in health education interventions, and another addressing the main effects of these interventions on the dimensions of food consumption, sleep, and physical activity of adolescents.

For all identified studies, at least two authors will independently select and review titles and abstracts using the Rayyan® application for systematic reviews [23]. Articles that meet the inclusion criteria will be ordered for a full review. Any disagreement will be resolved by discussion with a third reviewer. A manual search will be performed if any relevant studies are found using the defined search strategies. All researchers will then review the full text of all eligible studies. The information on the phases of the selection process will be described through a Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols diagram (PRISMA Flow diagram) [20].

Data extraction

Two reviewers will extract the following information from the relevant studies selected: publication identity, participant characteristics, control group, intervention characteristics, outcome measures, and analysis methods. Some examples of data extraction are available in Table 1. Any disagreement will be resolved through a discussion and review of the article, and a third researcher will be consulted.

Table 1. Data extraction.

DATA TO BE EXTRACTED	ITEM
Publication ID	Title, first author, publication year, country, study name, population.
Study design	Randomized Controlled Trials. Non-Randomized Controlled Trials. Quasi-experimental studies.
Participants’ characteristics	Sex. Age. Sample size.
Control group	No intervention. Other NOT Game-based Intervention
Intervention characteristics	Duration of intervention. Follow-up period. Intervention description. Game-based learning approach. Social factors associated.
Outcomes measurements	Food consumption. Sleep quality. Physical activity.
Analysis methods	Statistical methods used. Quantitative synthesis.

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Data analysis

Risk of bias and quality assessment

Two independent researchers will carry out the evaluation, and in case of doubts or discrepancies, a third researcher will be consulted. The methodological quality of randomized clinical trials will be assessed using Version 2 of the Cochrane Risk of Bias (ROB 2) tool for randomized clinical trials [24].

For non-randomized, before-after controlled studies, the risk of bias will be assessed using the Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tool, which was developed to assess the risk of bias in the results of non-randomized studies and quasi-experimental studies with a control group that compare the effects of two or more interventions on the health of the study population, by classifying the risk of bias as low, high, or unclear [25].

The overall strength of evidence for each outcome will be analyzed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool [26]. To calculate the inter-rater reliability, we will use the kappa coefficient.

Statistical analysis

A narrative approach will be used to summarize the effectiveness of the interventions regarding food consumption, sleep quality, and physical activity. The use of gamification as a health education strategy in intervention studies will be analyzed separately. If the studies are methodologically homogeneous, a meta-analysis will be conducted.

Review Manager (RevMan V5.3.3) software will be used for the data analysis. Heterogeneity between assay results will be evaluated by performing a standard chi-square test with a significance level of 0.05. To assess heterogeneity, the I² statistic will be calculated, corresponding to a quantitative measure of inconsistency between studies. A value of 0% indicates that no heterogeneity was observed, while I² values of 50% indicate a moderate level, and 75% or higher indicate a substantial level of heterogeneity.

If possible, funnel plots will be used to assess the presence of potential reporting biases. A linear regression will be performed to evaluate the asymmetry of the funnel plot. If the studies are heterogeneous, a narrative summary will be carried out.

Missing data

In the case of interesting data missing or being unclear, the research team will try to contact the corresponding author by email, phone or correspondence. If this communication is unsuccessful, the data from the analysis will be excluded. This will be covered in the Discussion section, to describe the possible impact of missing data.

Subgroup analysis

If sufficient data are available, the following subgroup analyses will be performed: specific details of the interventions (e.g. methodological strategy, components, and duration), and research setting (family participation, socioeconomic conditions).

Patient and public involvement

Patients and/or the public were not involved in the design, performance, reporting, or dissemination plans of this research. Patient consent for publication is not applicable.

Ethics and dissemination

Ethical approval and human consent are not required because this is a protocol for a systematic review, and only secondary data will be used. Findings will be published in a peer-reviewed journal and presented at conferences. In case of any changes in this protocol, the protocol will be updated in the International Prospective Register of Systematic Reviews (PROSPERO) website, and the modifications will be explained in the final report of this review.

Discussion

The purpose of this investigation is to carry out systematic reviews and meta-analyses to evaluate the main effects of interventions with gamification in the dimensions of food consumption, sleep quality, and physical activity of adolescent students.

The gaming market is increasing around the world, with valuations of US$175.8 billion in the year 2021, and the expectation that it will exceed US$200 billion by 2023 [27]. Brazil is the largest market in Latin America [28] for many products, with videogames one of them. With the expansion of this industry, the applications of games will not only be for entertainment purposes, but also gamification of education.

Implications

Gamification can be applied in several areas of health and education dimensions. In the educational context, gamification is used to offer students the possibility of learning autonomously [29].

The use of gamification can also make long-term activities more pleasurable, with positive cognitive, social, and emotional results [30]. In the teaching-learning process, the use of gamification has increased as a strategy to encourage student motivation and involvement in this process, and to influence the social aspect [31]. However, it is important to highlight that to achieve the full potential of the application of gamification, it is important to deeply understand its mechanisms and the psychological effects of its use [32].

Still in this context, Lee and Hammer [33] describe the importance of the dimension of challenging oneself when using gamification techniques in learning, as this makes students develop new skills. In addition, gamification brings out emotions in the players, such as pride, joy, optimism, curiosity, and even frustration. Finally, the authors make it clear that there is also a stimulus towards the social component, as the student’s results and achievements are made known to other people, which could further encourage students to improve.

It is the application of different game mechanisms that guarantees the development of cognitive skills, such as achieving greater concentration, problem solving capacity, and a sense of orientation towards an end goal [34], producing brain responses to extrinsic stimuli received [35]. Thus, the use of game-based learning techniques can be an attractive alternative for promoting health education in adolescents.

During an initial analysis of the literature, a diversity was found in the application of gamification depending on the object of study. Therefore, it is possible to find research involving the application of gamification in health promotion and disease prevention [36, 37] in teaching health professionals [38, 39], in teaching during the COVID-19 pandemic [40], and in school learning [41].

Some reviews document the positive effect of interventions using gamification to increase the knowledge of children and adolescents regarding habits related to healthier eating and nutrition [14, 42, 43]. In addition to these, it is also possible to find systematic reviews that attest to the positive effects of gamification in encouraging greater adherence to physical activity in isolation [44], and even in association with healthy eating habits [45].

Another study that evaluated the use of gamification in applications related to health habits reported that 97% of the evaluated tools used such techniques, regarding the practice of physical activity and weight loss, down to 11% when the focus was on sleep [46]. Regarding this last variable, an alternative for promoting sleep hygiene is the use of serious game techniques [47], which seek effects on emotional, psychological and social well-being [16].

In addition, it can be stated that the proposal to use active games strategically follows the logic that it is about the union between fun and activities aimed at health, through prevention, promotion, and improvement of its parameters [48], with increased energy expenditure and reduced sedentary behavior [6].

Limitations

We may find some limitations with this review. These may be: the lack of systematic reviews that evaluate the dimensions of food consumption, sleep quality, and physical activity of the adolescent population, associating them with a gamification intervention; the difficulty in finding studies that evaluate food consumption and not the nutritional composition of the diet of adolescents; the studies on health education of adolescents may involve children [49] and/or young adults [50], moving away from our proposal to focus on adolescence; the variety of study types included can also generate heterogeneity between studies, which could compromise the quantitative summary of the results (meta-analysis).

Despite these limitations, the elucidation of the main gamification techniques used in the health education of adolescents, and the main findings related to the effects of these applications in the promotion of the health of this population, is expected from the development of the systemic review from this protocol article. As an example, the following can be cited: a greater adherence to healthy eating habits, and the practice of physical activity, improvement in sleep quality, and subsequent reduction in sleep disorders and sedentary behavior.

Supporting information

S1 Checklist. PRISMA-P (Preferred Reporting Items for Systematic review and Meta-Analysis Protocols) 2015 checklist: Recommended items to address in a systematic review protocol*.

(DOC)

Click here for additional data file.^{(91.5KB, doc)}

S1 File. Draft of search strategy.

(DOC)

Click here for additional data file.^{(57KB, doc)}

Data Availability

Deidentified research data will be made publicly available when the study is completed and published.

Funding Statement

This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior-Brasil (CAPES) (finance code: 001), and in part by the Ignacio H Larramendi Research Grant granted by the Mapfre Foundation in 2022 to UCAM-Catholic University of Murcia for the 'PECES' research project to MPR and his research team (finance code: N/A).

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PLoS One. doi: 10.1371/journal.pone.0294894.r001

Decision Letter 0

Delfina Fernandes Hlashwayo

2 May 2023

PONE-D-23-04396Gamification as school adolescents’ health education strategy: protocol for a systematic review and meta-analysisPLOS ONE

Dear Dr. Piuvezam,

The reviewers have provided feedback on the manuscript for further improvement. To enhance the quality of the manuscript, attention should be given to the following four key points in any subsequent revision:

1. Language and Abbreviations: The authors should improve the English writing and correct any errors that may be present. Additionally, abbreviations must be defined upon first appearance in the text. Non-standard abbreviations should be avoided unless they appear at least three times in the text, and their use should be kept to a minimum.

2. Introduction: The introduction should be improved by justifying how gamification can be associated with the parameters that will be measured.

3. Methodology: The methodology should be reviewed to ensure that the risk of bias in the studies included is measured appropriately. The exclusion criteria should be clarified, and the research questions proposed should be clearly stated. The information should also be presented in a logical sequence.

4. References: The references should be reviewed to ensure that they correspond to what is intended to be cited.

In addition, authors should adhere to the following formatting guidelines:

1. PLOS One guidelines for Study Protocols (https://journals.plos.org/plosone/s/submission-guidelines#loc-study-protocols), including the use of the PRISMA-P checklist for systematic review protocols (http://www.prisma-statement.org/Extensions/Protocols).

2. Although optional, authors are encouraged to register with OSF and provide the registration number in the Materials and Methods section.

3. The PLOS One Study Protocol Article Template and an OSF discipline or study-specific template should be used as a guide.

4. The discussion should include any issues involved in performing the study that are not covered in other sections, such as limitations of the study design, dissemination plans, and how amendments to the study will be dealt with.

Please submit your revised manuscript by Jun 09 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Delfina Fernandes Hlashwayo, M.Sc.

Academic Editor

PLOS ONE

Journal requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Please note that we require the PRISMA-P checklist as supplementary file to be provided with protocols for systematic reviews. Therefore, please remove the standard PRISMA checklist from your submission and provide a completed PRISMA-P checklist as supplementary file instead. For further information please refer to: https://www.prisma-statement.org/Extensions/Protocols. Thank you for your attention. We look forward to hearing from you.

3. We note that your article has been submitted as a "Registered Report Protocol" article type. Please note that your submission is not suitable for the article type "Registered Report Protocol". The "Registered Report Protocol" article type is only suitable for proposals of studies that have not yet started, and which will undergo editorial assessment per the Registered Reports framework. When resubmitting your manuscript, we ask that you update your article type to "Study Protocol" in the online submission form. Please note that some fields in the submission form, particularly in the "Additional Information" field, will have been reset with this change, so please go through your submission in full to ensure that all information is accurate and complete when resubmitting your manuscript.

4. Thank you for stating the following financial disclosure:

“This study was partially financed by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) - Finance Code 001”

Please state what role the funders took in the study. If the funders had no role, please state: "The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript."

If this statement is not correct you must amend it as needed.

5. We note that you have stated that you will provide repository information for your data at acceptance. Should your manuscript be accepted for publication, we will hold it until you provide the relevant accession numbers or DOIs necessary to access your data. If you wish to make changes to your Data Availability statement, please describe these changes in your cover letter and we will update your Data Availability statement to reflect the information you provide.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions?

The research question outlined is expected to address a valid academic problem or topic and contribute to the base of knowledge in the field.

Reviewer #1: No

Reviewer #2: Yes

**********

2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses?

The manuscript should describe the methods in sufficient detail to prevent undisclosed flexibility in the experimental procedure or analysis pipeline, including sufficient outcome-neutral conditions (e.g. necessary controls, absence of floor or ceiling effects) to test the proposed hypotheses and a statistical power analysis where applicable. As there may be aspects of the methodology and analysis which can only be refined once the work is undertaken, authors should outline potential assumptions and explicitly describe what aspects of the proposed analyses, if any, are exploratory.

Reviewer #1: Yes

Reviewer #2: Partly

**********

3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors described where all data underlying the findings will be made available when the study is complete?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception, at the time of publication. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: No

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above and, if applicable, provide comments about issues authors must address before this protocol can be accepted for publication. You may also include additional comments for the author, including concerns about research or publication ethics.

You may also provide optional suggestions and comments to authors that they might find helpful in planning their study.

(Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Dear Authors,

Thank you for writing this protocol.

Please find below my comments

1. Your title indicates that you want to do a quantitative systematic review but in your abstract, you have mentioned the inclusion of both quantitative and qualitative study. If all you are including in your study are quantitative studies, then your title is fine. But if you are including both quantitative and qualitative studies than your title needs to reflect that it is a mixed methods systematic review protocol.

2. What is RX, please say what that means in the abstract.

3. You have mentioned the use of Risk of Bias in Non-randomised studies for RCTs, please check that and correct.

Introduction

4. From your introduction, could you please provide more evidence/ examples on how gamification is associated with the three main health parameters you are considering. (Food consumption, sleep quality and physical activity).

5. Could you also state in your introduction, that this review hasn’t been done. This implies you checking different databases and ascertaining that the systematic review does not exist.

Methods 2.1

6. Rather than have a protocol that encompasses two systematic reviews, why don’t you do two separate systematic reviews. 1. A systematic review on the content of gamification and 2.) the systematic review, which you are currently proposing. Otherwise please adjust the topic of your systematic review to reflect what you want to achieve.

7. Please check the spelling of ‘quase’-experimental. What is RQ2, RQ3 and RQ4. They have not been stated anywhere else in the document, hence, it is better that you state them out clearly rather than use RQ1, RQ2 and RQ3.

Methods 2.2

8. Line 142 – You may consider using the PICO format (Participants, Intervention, Comparator and Outcome)

9. Please check and correct Subgroup ‘analyzes’

Methods 2.3

10. I am not sure why you have thematic areas here since you have already identified them as your outcomes previously.

Discussion

11. I would rather that some of the evidence that you have given in the discussion be presented more concisely in the introduction. As it is a protocol which is to describe what you want to do; it is not necessary to have a discussion part yet.

Reviewer #2: This paper provides a protocol for a systematic review and meta-analysis that intends to evaluate the effects of gamified interventions in health education on health risk factors (food consumption, sleep quality and physical activity) in adolescents.

The protocol is registered with PROSPERO and was developed according to the PRISMA statement guidelines. Four research questions are specified and these will be addressed by two systematic reviews and a meta-analysis. As part of the discussion and justification for conducting the study, some indication is provided of the scope of papers available to complete the review and meta-analysis, but not the results of such. The paper may be useful to researchers because it provides a detailed example of how to conduct a review and meta-analysis.

Recommended courses of action

The author appears to be writing in English as a second language as the choice of words and phrases in not as expected in common use. For example, use of the word ‘public’ as in Lines 92,101,142, is unusual and may be better understood if replaced by a word such as ‘demographic’ or ‘age-group’. Also, the word ‘parameters’ in Line 120, may be better replaced by ‘behaviours’. As a general comment the English grammar in parts of the paper would benefit from an editorial review. Eg Line 158, It will be excluded studies in which:

Reference is made in Lines 129-133 to the research questions RQ1 to RQ4 but these are not directly defined. The research questions are specified in Lines182-189 but without the shortened name, and it would improve clarity if the abbreviations were used in these lines along with the definition eg Line 183 ……..RQ1 What are the main intervention strategies with gamification…..?

Line 201: Why are dairy foods singled out for inclusion in the MeSH and Keywords when other food groups important for health are not included eg fruit and vegetables.

Lines 161- 163, “Young people (from 10 to 24 years old) will be excluded ………….no longer fit as adolescents (over 19 years old);” Would these studies be excluded if data available separately for the age groups of interest?

Is the reference provided in Lines 506-508, the correct one for citation 25 on Line 261?

Line 275 Please state what criteria would make it possible to use funnel plots to assess reporting bias?

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PLoS One. 2023 Nov 30;18(11):e0294894. doi: 10.1371/journal.pone.0294894.r002

Author response to Decision Letter 0

29 May 2023

To Editor and reviwers

Plos One

Subject: Submission of the revised Study Protocol article entitled “Gamification as a health education strategy of adolescents at school: protocol for a systematic review and meta-analysis”

I confirm that we have made the adjustments indicated by Plos One academic editor and reviewer(s) in the PLOS ONE Decision: Revision required [PONE-D-23-04396] - [EMID:9192f11600e35ee3] email. The following are responses to the review requests:

Dear Dr. Piuvezam,

• Language and Abbreviations: The authors should improve the English writing and correct any errors that may be present. Additionally, abbreviations must be defined upon first appearance in the text. Non-standard abbreviations should be avoided unless they appear at least three times in the text, and their use should be kept to a minimum.

• We improved the English writing and corrected any errors that were present. Abbreviations were kept to a minimum.

• Introduction: The introduction should be improved by justifying how gamification can be associated with the parameters that will be measured.

• The introduction was improved as requested.

• The methodology was reviewed to ensure that the risk of bias in the studies included is measured appropriately, as well we clarified the exclusion criteria and the research questions proposed.

4. References: The references should be reviewed to ensure that they correspond to what is intended to be cited.

• We also reviewed the references to ensure that they correspond to what is intended to be cited.

Journal requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

• Our manuscript meets PLOS ONE's style requirements, and the PLOS ONE style templates were used;

• We provided the PRISMA-P checklist as supplementary file.

• When resubmitting our manuscript, we updated our article type to "Study Protocol" in the online submission form.

4. Thank you for stating the following financial disclosure:

“This study was partially financed by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) - Finance Code 001”

If this statement is not correct you must amend it as needed.

• We updated our Funding statement to: This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) - Finance Code 001; and in part by the Ignacio H. Larramendi Research Grant granted by the Mapfre Foundation in 2022 to UCAM - Catholic University of Murcia for the "PECES" research project to Dr. Manuel Pardo Ríos and his research team. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript;

• We updated our Data Availability statement to: All relevant data are within the paper and its Supporting Information files. No datasets were generated or analyzed during the current study;

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions?

The research question outlined is expected to address a valid academic problem or topic and contribute to the base of knowledge in the field.

Reviewer #1: No

Reviewer #2: Yes

Kind regards,

Grasiela Piuvezam

Lab-SYS (Systematic Review and Meta-Analysis Laboratory-CNPq)

Department of Public Health

Department of Postgraduate in Public Health,

Federal University of Rio Grande do Norte (UFRN)

Campus Lagoa Nova, CEP 59078-970, PO Box 1524

Natal/RN, Brazil

Attachment

Submitted filename: Response to Reviewers.docx

Click here for additional data file.^{(127.5KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0294894.r003

Decision Letter 1

Delfina Fernandes Hlashwayo

22 Jun 2023

PONE-D-23-04396R1Gamification as a health education strategy of adolescents at school: protocol for a systematic review and meta-analysisPLOS ONE

Dear Dr. Piuvezam,

We would like to express our appreciation for your efforts in addressing the editor's questions and meeting the journal's requirements in the recent revision of your manuscript.

While reviewing the revised manuscript, we noticed that the "Response to Reviewers" section does not include the specific comments and concerns raised by the two reviewers, as well as how those comments were addressed. In order to provide a comprehensive evaluation and reach a final decision, it is crucial for us to have access to this information. Therefore, we kindly request that you revise the "Response to Reviewers" section to include the comments from both reviewers and clearly indicate how each comment was addressed in the manuscript.

Including the reviewers' comments and the corresponding responses will help us make an informed decision and provide valuable feedback to the reviewers. Additionally, it will facilitate a transparent and thorough evaluation of the manuscript.

Please submit your revised manuscript by Aug 06 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Delfina Fernandes Hlashwayo, M.Sc.

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

[Note: HTML markup is below. Please do not edit.]

PLoS One. 2023 Nov 30;18(11):e0294894. doi: 10.1371/journal.pone.0294894.r004

Author response to Decision Letter 1

3 Jul 2023

July 3rd, 2023

Rebuttal Letter for PLOS ONE

Dear Oriel Jerome Delas Alas Vida,

Thank you for considering our manuscript for publication at PLOS ONE. We are certain of the credibility and commitment that PLOS ONE has to quality in science, and we hope that the modifications made in our manuscript fully meet the publication criteria.

We have sure that the suggestions add quality and clarity to our paper. We list at the end of this letter the answers for each one of them.

Once again, thank you for considering our manuscript and we are at your disposal for any further information.

Sincerely,

The authors.

Authors’ responses to the Editor (Email June 30th, 2023)

1. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

We have reviewed the reference list and confirmed that we do not cite any retracted articles. The adjustments made to the reference list are highlighted and referred to the required formatting. All cited references refer to corresponding citations throughout the manuscript text and they are complete and correct.

Authors’ responses to the Editor (Email May 2nd, 2023)

2. Language and Abbreviations: The authors should improve the English writing and correct any errors that may be present. Additionally, abbreviations must be defined upon first appearance in the text. Non-standard abbreviations should be avoided unless they appear at least three times in the text, and their use should be kept to a minimum.

We improved the English writing and corrected any errors that were present. We add the certificate of professional translation during the submission of the revised article. Abbreviations were kept to a minimum.

3. Introduction: The introduction should be improved by justifying how gamification can be associated with the parameters that will be measured.

The introduction was improved as requested.

4. Methodology: The methodology should be reviewed to ensure that the risk of bias in the studies included is measured appropriately. The exclusion criteria should be clarified, and the research questions proposed should be clearly stated. The information should also be presented in a logical sequence.

The methodology was reviewed to ensure that the risk of bias in the studies included is measured appropriately, as well we clarified the exclusion criteria and the research questions proposed.

5. References: The references should be reviewed to ensure that they correspond to what is intended to be cited.

We also reviewed the references to ensure that they correspond to what is intended to be cited.

Authors’ responses to Journal requirements (Email May 2nd, 2023)

6. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

Our manuscript meets PLOS ONE's style requirements, and the PLOS ONE style templates were used.

7. Please note that we require the PRISMA-P checklist as supplementary file to be provided with protocols for systematic reviews. Therefore, please remove the standard PRISMA checklist from your submission and provide a completed PRISMA-P checklist as supplementary file instead. For further information please refer to: https://www.prisma-statement.org/Extensions/Protocols. Thank you for your attention. We look forward to hearing from you.

We provided the PRISMA-P checklist as supplementary file.

8. We note that your article has been submitted as a "Registered Report Protocol" article type. Please note that your submission is not suitable for the article type "Registered Report Protocol". The "Registered Report Protocol" article type is only suitable for proposals of studies that have not yet started, and which will undergo editorial assessment per the Registered Reports framework. When resubmitting your manuscript, we ask that you update your article type to "Study Protocol" in the online submission form. Please note that some fields in the submission form, particularly in the "Additional Information" field, will have been reset with this change, so please go through your submission in full to ensure that all information is accurate and complete when resubmitting your manuscript.

When resubmitting our manuscript, we updated our article type to "Study Protocol" in the online submission form.

9. Thank you for stating the following financial disclosure:

“This study was partially financed by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) - Finance Code 001”

If this statement is not correct you must amend it as needed.

We updated our Funding statement to: This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) - Finance Code 001; and in part by the Ignacio H. Larramendi Research Grant granted by the Mapfre Foundation in 2022 to UCAM - Catholic University of Murcia for the "PECES" research project to Dr. Manuel Pardo Ríos and his research team. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

10. We note that you have stated that you will provide repository information for your data at acceptance. Should your manuscript be accepted for publication, we will hold it until you provide the relevant accession numbers or DOIs necessary to access your data. If you wish to make changes to your Data Availability statement, please describe these changes in your cover letter and we will update your Data Availability statement to reflect the information you provide.

We updated our Data Availability statement to: All relevant data are within the paper and its Supporting Information files. No datasets were generated or analyzed during the current study.

Authors’ Responses to Reviewers' comments (Email May 2nd, 2023)

11. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions?

The research question outlined is expected to address a valid academic problem or topic and contribute to the base of knowledge in the field.

Reviewer #1: No

Reviewer #2: Yes

Considering the importance of making clear the justification for our study, as well as the research questions, we decided to add this information more clearly in the introduction of our manuscript. In addition, after the suggestions received, we made changes to highlight the innovative character of our study for an existing valid academic problem, as well as the contribution of the construction of this study to science. We hope we were able to clarify this information after reviewing the manuscript.

Attachment

Submitted filename: Response to Reviewers.docx

Click here for additional data file.^{(42.2KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0294894.r005

Decision Letter 2

Delfina Fernandes Hlashwayo

31 Jul 2023

PONE-D-23-04396R2Gamification as a health education strategy of adolescents at school: protocol for a systematic review and meta-analysisPLOS ONE

Dear Dr. Piuvezam,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Sep 14 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Delfina Fernandes Hlashwayo, M.Sc.

Academic Editor

PLOS ONE

Journal Requirements:

Additional Editor Comments:

The reviewers have provided feedback on the manuscript to enhance its quality. In addition to the reviewer’s comments, the authors are advised to consider the following four key points for any subsequent revisions:

To enhance the ease of reference, we kindly request that you present the PRISMA-P checklist using page numbers instead of line numbers.
While the strategy for Embase is present in the supplementary file, we recommend adding the search strategies for the following databases as well: MEDLINE, Scopus, ERIC, ScienceDirect, Web of Science, Cochrane, LILACS, APA, and ADOLEC.
The addition of a translation certificate as a supplementary file is not required. We kindly ask that you exclude it from the submission. Similarly, the funding disclosure should not be included as a supplementary file.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions?

The research question outlined is expected to address a valid academic problem or topic and contribute to the base of knowledge in the field.

Reviewer #3: Yes

Reviewer #4: Partly

**********

2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses?

Reviewer #3: Yes

Reviewer #4: Partly

**********

3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable?

Descriptions of methods and materials in the protocol should be reported in sufficient detail for another researcher to reproduce all experiments and analyses. The protocol should describe the appropriate controls, sample size calculations, and replication needed to ensure that the data are robust and reproducible.

Reviewer #3: Yes

Reviewer #4: No

**********

4. Have the authors described where all data underlying the findings will be made available when the study is complete?

Reviewer #3: Yes

Reviewer #4: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #3: Yes

Reviewer #4: No

**********

6. Review Comments to the Author

You may also provide optional suggestions and comments to authors that they might find helpful in planning their study.

(Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #3: The authors carefully responded to all requests from reviewers.

In general, the study's proposal is innovative and will bring contributions to teaching and learning, as well as future research and university extension actions for adolescents.

The introduction is well delimited and now well justified in relation to the purpose of the protocol. The authors propose a search in several databases, which may help to overcome a study limitation of finding research to compose the study, as long as the theme is relatively new and directed only to adolescents.

Some notes:

In eligibility criteria: It must be clear in the protocol whether students up to high school or college or technical students will be included (In some countries there are technical education courses). As a result of in the first semesters of college or technical courses most are composed by teenagers.

The suggestion is that the approach be taken regardless of the level of schooling in progress, as data to be extracted and analyzed.

Reviewer #4: It is interesting work but not entirely clear to the reader. The abstract was well written but I could not understand it fully despite reading the main manuscript 2-3 times.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #3: Yes: Flaviana Vely Mendonça Vieira

Reviewer #4: No

**********

PLoS One. 2023 Nov 30;18(11):e0294894. doi: 10.1371/journal.pone.0294894.r006

Author response to Decision Letter 2

13 Sep 2023

September 14th, 2023

Rebuttal Letter for PLOS ONE [PONE-D-23-04396R2] -[EMID:12c7612585d2c131]

Dear M.Sc. Delfina Fernandes Hlashwayo,

We have read the reviewers' and editor’s comments carefully, answering all questions in this letter and made the requested changes in the revised manuscript. We are sure that the suggestions add quality and clarity to our paper. We hope the revised manuscript is now suitable for publication at PLOS ONE.

Once again, thank you for considering our manuscript and we are at your disposal for any further information.

Best regards,

The authors.

Authors’ responses to the Editor

1. To enhance the ease of reference, we kindly request that you present the PRISMA-P checklist using page numbers instead of line numbers.

We appreciate your availability to revise our manuscript. We attended to your request and update PRISMA-P using page numbers.

2. While the strategy for Embase is present in the supplementary file, we recommend adding the search strategies for the following databases as well: MEDLINE, Scopus, ERIC, ScienceDirect, Web of Science, Cochrane, LILACS, APA, and ADOLEC.

We thank you for your considerations. PRISMA-P Statement recommends, we have to “specify all databases, registers, websites, organisations, reference lists, and other sources searched or consulted to identify studies. Specify the date when each source was last searched or consulted”.

We confirm that we will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) guidelines in developing our systematic review, but we have chosen to make it available in this protocol article, as a supplementary file, the precise and full search strategies for only one database (EMBASE) including any filters and limits used, as a way of guarding against a possible misuse of our search strategies while we are developing the systematic review.

3. The addition of a translation certificate as a supplementary file is not required. We kindly ask that you exclude it from the submission. Similarly, the funding disclosure should not be included as a supplementary file.

We thank you for this recommendation. We will exclude both translation certificate and funding disclosure from the submission.

Authors’ Responses to Reviewers' comments:

1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions?

The research question outlined is expected to address a valid academic problem or topic and contribute to the base of knowledge in the field.

Reviewer #3: Yes

Reviewer #4: Partly

We appreciate your availability to revise our manuscript and all your comments. Considering the innovative nature of using gamification as a health education strategy for schoolchildren, we guided our research questions according to the dimensions to be explored in the construction of the review: food consumption, sleep and physical activity. The research questions, in addition to being in the registered PRISMA-P protocol, are fully described in the manuscript methodology, more specifically on page 5, lines 94-11, and they have been constructed in accordance with the justification presented in the Introduction section.

2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses?

Reviewer #3: Yes

Reviewer #4: Partly

We thank you for your revision. As described in the manuscript, the protocol is based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) guidelines, which can be found as supplementary material S1. We will follow all the necessary steps to develop the systematic review according to the described protocol, which was methodologically developed to allow us to test the hypotheses and answer the questions proposed in our study.

We hope that the results presented in the systematic review that will be developed based on this protocol can guide the creation of new health education tools for school adolescents using immersive technologies.

3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable?

Reviewer #3: Yes

Reviewer #4: No

We appreciate your revision. We confirm that the protocol is based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) guidelines and the final report will be developed following PRISMA and the Cochrane Handbook for Systematic Reviews of Interventions.

Therefore, we confirm that this protocol has enough details for another researcher to reproduce the review and analyses. Furthermore, the protocol contains a description of all eligibility criteria, the selection steps that will be followed, the data that will be extracted and the possible analyzes to be carried out. Therefore, it is a protocol that can be reproduced.

4. Have the authors described where all data underlying the findings will be made available when the study is complete?

Reviewer #3: Yes

Reviewer #4: Yes

We thank you for your revision. All information related to the construction of the article to be published was made available in the files added in the submission.

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #3: Yes

Reviewer #4: No

Thank you for your comments. We reviewed the translation of our article with a professional translator.

6. Review Comments to the Author

You may also provide optional suggestions and comments to authors that they might find helpful in planning their study.

(Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #3: The authors carefully responded to all requests from reviewers.

In general, the study's proposal is innovative and will bring contributions to teaching and learning, as well as future research and university extension actions for adolescents.

Some notes:

The suggestion is that the approach be taken regardless of the level of schooling in progress, as data to be extracted and analyzed.

Reviewer #4: It is interesting work but not entirely clear to the reader. The abstract was well written but I could not understand it fully despite reading the main manuscript 2-3 times.

We thank you for all the comments and evaluations presented. We always do our best to respond to suggestions and increase the quality of our work.

The amount of database is extensive so that our search is more comprehensive, and we have a better chance of finding articles that can answer our research questions.

We thank you for the suggestion regarding the study locations of the adolescents included in the studies and made an adjustment to the eligibility criteria (highlighted on page 6 of the manuscript)

To make our introduction more understandable, we made some adjustments.

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #3: Yes: Flaviana Vely Mendonça Vieira

Reviewer #4: No

We are grateful for all the contributions presented by both reviewers to improve the construction of our article.

Attachment

Submitted filename: Response to Reviewers_R2.docx

Click here for additional data file.^{(47.4KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0294894.r007

Decision Letter 3

Delfina Fernandes Hlashwayo

31 Oct 2023

PONE-D-23-04396R3Gamification as a health education strategy of adolescents at school: protocol for a systematic review and meta-analysis

PLOS ONE

Dear Dr. Piuvezam,

To enhance the overall quality and accuracy of your manuscript, please take into consideration the following key points:

Ensure to check for any spelling, grammar, or phrasing errors.
When referring to the level of education (high school, college, or technical school), please avoid using the term "place of study."
Review the planned start and end dates, as the protocol has not yet been published. The registered start and end dates are January 10th, 2023, and September 8th, 2023, which have passed.
Kindly revise the text in the methodology section where it is written in the past tense (line 129).
Please ensure the correct naming of Supplementary Files.
In line 201, please provide the complete name of the program. Additionally, in line 202, consider using the correct symbol for the chi-square test or write it out in full.
Please avoid defining the included population as "population used" (line 287).

Please submit your revised manuscript by Dec 15 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Delfina Fernandes Hlashwayo, Ph.D.

Academic Editor

PLOS ONE

Journal Requirements:

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions?

The research question outlined is expected to address a valid academic problem or topic and contribute to the base of knowledge in the field.

Reviewer #3: Yes

**********

2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses?

Reviewer #3: Yes

**********

3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable?

Reviewer #3: Yes

**********

4. Have the authors described where all data underlying the findings will be made available when the study is complete?

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #3: Yes

**********

6. Review Comments to the Author

You may also provide optional suggestions and comments to authors that they might find helpful in planning their study.

(Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #3: I appreciate the opportunity to evaluate this study, which makes an important contribution to the area.

The authors made the indicated adjustments.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #3: No

**********

PLoS One. 2023 Nov 30;18(11):e0294894. doi: 10.1371/journal.pone.0294894.r008

Author response to Decision Letter 3

6 Nov 2023

November 7th, 2023

Rebuttal Letter for PLOS ONE [PONE-D-23-04396R3]

Dear M.Sc. Delfina Fernandes Hlashwayo,

We have read the reviewer's and editor’s comments carefully, answering all questions in this letter and made the requested changes in the revised manuscript. We are sure that the suggestions add quality and clarity to our paper. We hope the revised manuscript is now suitable for publication at PLOS ONE.

Once again, thank you for considering our manuscript and we are at your disposal for any further information.

Best regards,

The authors.

Authors’ responses to the Editor

1. Ensure to check for any spelling, grammar, or phrasing errors.

We appreciate your availability to revise our manuscript. We attended to your request, and we revised all the text.

2. When referring to the level of education (high school, college, or technical school), please avoid using the term "place of study."

We thank you for your considerations and we have made the changes.

3. Review the planned start and end dates, as the protocol has not yet been published. The registered start and end dates are January 10th, 2023, and September 8th, 2023, which have passed.

We thank you for this recommendation. We reviewed the planned start and end dates in the protocol.

4. Kindly revise the text in the methodology section where it is written in the past tense (line 129).

We appreciate your considerations and we have reviewed the text.

5. Please ensure the correct naming of Supplementary Files.

We thank you for this recommendation. We reviewed the names of Supplementary Files.

6. In line 201, please provide the complete name of the program. Additionally, in line 202, consider using the correct symbol for the chi-square test or write it out in full.

We appreciate your considerations. We provided the information required.

7. Please avoid defining the included population as "population used" (line 287).

We are grateful for your recommendations. All suggestions were very important to improve the quality of our study.

Authors’ Responses to Reviewers' comments:

1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions? The research question outlined is expected to address a valid academic problem or topic and contribute to the base of knowledge in the field.

Reviewer #3: Yes

We thank you for all the comments and evaluations presented. We always do our best to respond to suggestions and increase the quality of our work.

2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses? The manuscript should describe the methods in sufficient detail to prevent undisclosed flexibility in the experimental procedure or analysis pipeline, including sufficient outcome-neutral conditions (e.g. necessary controls, absence of floor or ceiling effects) to test the proposed hypotheses and a statistical power analysis where applicable. As there may be aspects of the methodology and analysis which can only be refined once the work is undertaken, authors should outline potential assumptions and explicitly describe what aspects of the proposed analyses, if any, are exploratory.

Reviewer #3: Yes

We appreciate your revision.

3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable? Descriptions of methods and materials in the protocol should be reported in sufficient detail for another researcher to reproduce all experiments and analyses. The protocol should describe the appropriate controls, sample size calculations, and replication needed to ensure that the data are robust and reproducible.

Reviewer #3: Yes

We appreciate your revision, and we confirm that this protocol can be reproduced.

4. Have the authors described where all data underlying the findings will be made available when the study is complete? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception, at the time of publication. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #3: Yes

We are grateful for your revision. All information related to the construction of the article to be published was made available in the files added in the submission.

5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #3: Yes

Thank you for your comments. We reviewed the translation of our article with a professional translator.

6. Review Comments to the Author. Please use the space provided to explain your answers to the questions above and, if applicable, provide comments about issues authors must address before this protocol can be accepted for publication. You may also include additional comments for the author, including concerns about research or publication ethics.

You may also provide optional suggestions and comments to authors that they might find helpful in planning their study. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #3: I appreciate the opportunity to evaluate this study, which makes an important contribution to the area.

The authors made the indicated adjustments.

We appreciate your availability to revise our manuscript and all your comments. We hope that the results presented in the systematic review that will be developed based on this protocol can be an instrument on health education for school adolescents.

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #3: No

We are grateful for all your contributions presented to improve the construction of our article.

Attachment

Submitted filename: Response to Reviewers PONE-D-23-04396R3.docx

Click here for additional data file.^{(45.4KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0294894.r009

Decision Letter 4

Delfina Fernandes Hlashwayo

13 Nov 2023

Gamification as a health education strategy of adolescents at school: protocol for a systematic review and meta-analysis

PONE-D-23-04396R4

Dear Dr. Piuvezam,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Delfina Fernandes Hlashwayo, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Please ensure the thorough elimination of any grammatical errors throughout the manuscript

Line 63: Instead of "the authors" I suggest using "some authors" or another appropriate expression.

There is a repetition of the phrase "systematic review" in lines 81-82. Please adjusting to avoid redundancy.

Line 116: I suggest using "compares" in the plural for greater accuracy.

Line 130: Please review the wording in this line for clarity and precision.

The sentence in the first paragraph of the limitations section is excessively long. Please revise and split it for improved flow.

Reviewers' comments:

PLoS One. doi: 10.1371/journal.pone.0294894.r010

Acceptance letter

Delfina Fernandes Hlashwayo

22 Nov 2023

PONE-D-23-04396R4

Gamification as a health education strategy of adolescents at school: protocol for a systematic review and meta-analysis

Dear Dr. Piuvezam:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at customercare@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Ms. Delfina Fernandes Hlashwayo

Academic Editor

PLOS ONE

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 Checklist. PRISMA-P (Preferred Reporting Items for Systematic review and Meta-Analysis Protocols) 2015 checklist: Recommended items to address in a systematic review protocol*.

(DOC)

Click here for additional data file.^{(91.5KB, doc)}

S1 File. Draft of search strategy.

(DOC)

Click here for additional data file.^{(57KB, doc)}

Attachment

Submitted filename: Response to Reviewers.docx

Click here for additional data file.^{(127.5KB, docx)}

Attachment

Submitted filename: Response to Reviewers.docx

Click here for additional data file.^{(42.2KB, docx)}

Attachment

Submitted filename: Response to Reviewers_R2.docx

Click here for additional data file.^{(47.4KB, docx)}

Attachment

Submitted filename: Response to Reviewers PONE-D-23-04396R3.docx

Click here for additional data file.^{(45.4KB, docx)}

Data Availability Statement

Deidentified research data will be made publicly available when the study is completed and published.

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PERMALINK

Gamification as a health education strategy of adolescents at school: Protocol for a systematic review and meta-analysis

Thais Teixeira dos Santos

Manuel Pardo Ríos

Gidyenne Christine Bandeira Silva de Medeiros

Ádala Nayana de Sousa Mata

Danyllo do Nascimento Silva Junior

Daniel Martínez Guillen

Grasiela Piuvezam

Roles

Abstract

Introduction

Methods and analysis

Study registration and reporting

Eligibility criteria

Types of study

Participants

Intervention

Compares

Outcome measures

Exclusion criteria

Search strategies

Electronic search

Additional search

Screening procedure

Data extraction

Table 1. Data extraction.

Data analysis

Risk of bias and quality assessment

Statistical analysis

Missing data

Subgroup analysis

Patient and public involvement

Ethics and dissemination

Discussion

Implications

Limitations

Supporting information

Data Availability

Funding Statement

References

Decision Letter 0

Delfina Fernandes Hlashwayo

Roles

Author response to Decision Letter 0

Decision Letter 1

Delfina Fernandes Hlashwayo

Roles

Author response to Decision Letter 1

Decision Letter 2

Delfina Fernandes Hlashwayo

Roles

Author response to Decision Letter 2

Decision Letter 3

Delfina Fernandes Hlashwayo

Roles

Author response to Decision Letter 3

Decision Letter 4

Delfina Fernandes Hlashwayo

Roles

Acceptance letter

Delfina Fernandes Hlashwayo

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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