Evaluating a Behavioural Theory-Based Board Game (S-S-LIBOG) Against Traditional Health Talk (HT) in Prostate Cancer Education: Findings from a Quasi-Experimental Study, Plus Introducing 17 Other S-S-LIBOGs^†

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The manuscript addresses a relevant topic; however, several aspects require improvement before it can be considered for publication.

Abbreviations: The use of abbreviations throughout the manuscript is inconsistent. Authors are strongly encouraged to introduce each abbreviation in full at its first appearance, followed by the acronym in parentheses. Thereafter, only the acronym should be used. This applies particularly to terms that are repeated at least three times within the text.

Tables and Figures: The current presentation of tables is not self-explanatory. Each table should be accompanied by a descriptive title and a clear legend that enables the reader to understand the data without referring back to the main text. Similarly, figures are presented without defining the abbreviations used in their footnotes, which reduces clarity and interpretability. Authors should ensure that all abbreviations are explicitly defined in the figure legends.

Language: The quality of English requires substantial revision. It is recommended that the manuscript be edited by a native English speaker or a professional editing service to ensure clarity, precision, and consistency.

Limitations, Biases, and Applications: A dedicated section discussing the study's limitations, potential sources of bias, and the practical implications of the findings is missing. Including this section would strengthen the discussion, provide balance, and contextualise the results for both clinical and research applications.

Author Response

Reviewer 1

Comment 1: The use of abbreviations throughout the manuscript is inconsistent. Abbreviations should be introduced in full at first appearance and then used consistently thereafter.
Response: We carefully revised the entire manuscript to ensure consistent use of abbreviations. All terms (e.g., Prostate Cancer [PCa], socioecological model/social cognitive theory Literacy Board Game [S-S-LIBOG or LIBOG for shorter], Health Talk [HT], Social Cognitive Theory [SCT], Socioecological Model [SEM]) are now written in full at first mention, followed by their acronyms, and consistently abbreviated thereafter. These are used throughout the manuscript and can be seen in all parts of the body of the text, and in red font.

Comment 2: Tables and figures are not self-explanatory. Each table should have a descriptive title and a clear legend. Figures do not define abbreviations in footnotes.
Response: All tables have been revised with clear, descriptive titles and self-contained legends. Abbreviations have been defined at the bottom of each table. All figure legends have also been updated to define abbreviations (e.g., AOR, CI, LIBOG, HT). Please see pages 8-9(line 223-266), pages 8 to 9; (lines 233 to 236), 

Comment 3: The quality of English requires substantial revision.
Response: The manuscript has been thoroughly edited for clarity, conciseness, and readability. Redundant expressions were removed, grammar and syntax improved, and overall flow streamlined. English editing service from MDPI will also be purchased; we are working on funds for that.

Comment 4: A dedicated section on limitations, biases, and applications is missing.
Response: A new subsection titled “Limitations, Biases, and Applications” has been added to the Discussion. It highlights potential biases (selection, attrition, social desirability), methodological constraints (semi-urban sample, short follow-up), and the practical applications of LIBOG for community health education in Ghana. This can be located, highlighted in red font, on page 17, line 439 to 450

Reviewer 2 Report

Comments and Suggestions for Authors

Dear Editor of the Journal

Hello

This is a very interesting topic

The title is long and confusing. It should be written more clearly

The abstract is long. It is better to shorten it

The introduction of the article is not clear about the importance of the work and the reason for doing it.

What was the method of work? How were the samples collected?

Why were women used in the case of prostate cancer?

The graphs should be corrected

It is better to address the reasons in the discussion

References should be updated

Author Response

Comment 1: The title is long and confusing.
Response: The title has been shortened and clarified. Revised title:
“

Evaluating a Behavioural Theory – Based Board Game (S-S-LIBOG) Against Traditional Health Talk (HT) in Prostate Cancer Education: Findings from a Quasi-Experimental Study, Plus Introducing 17 Other S-S-LIBOGs

please see page 1, lines 2 to 5.

”

Comment 2: The abstract is too long.
Response: The abstract has been rewritten in a concise, structured format (Background, Aim, Methods, Results, Conclusion). It is now shorter and more focused. Please see pages 1 to 2; lines 40.

Comment 3: The introduction is unclear about the importance of the work.
Response: The Introduction has been reorganized in a logical sequence (global → Africa → Ghana), emphasizing the significance of prostate cancer in Ghana and the rationale for using a board game intervention. Please see pages 2 to 3; lines 51 to 119.

Comment 4: Clarify the method of work and sample collection.
Response: The Methods section has been rewritten to clearly describe participant recruitment, sample size determination, allocation, and data collection procedures. Please see pages 2 to 7; lines 120 to 209.

Comment 5: Why were women included in a prostate cancer study?
Response: We clarified in the Methods that women were included intentionally because they play an important role in family health decision-making and care giving in Ghana. Also based on the socio-ecological model [28] the family circles of an individual do affect their healthful and health seeking choices, so prostate cancer is a whole family concern; and women are integral in family settings. Their awareness and perceptions significantly influence men’s screening behaviours. Please see page 4, line 136.

Comment 6: Graphs should be corrected.
Response: All figures have been revised. A new forest plot and CONSORT-style flow diagram were created. Legends now include all abbreviations. pages 5 (lines 151 to 161), 6(lines 174 to 181), 11 (line 261 to 268), 13 (line 306 to 312), 15 (line 344 to 350). 

Comment 7: Address the reasons in the Discussion.
Response: The Discussion now includes a focused section comparing our findings with existing literature and explaining why LIBOG is appropriate for Ghana’s health literacy landscape. (Please see pages 16 to 17, lines 351 to 439).

Comment 8: References should be updated.
Response: References have been updated to include more recent studies (2022–2024) on prostate cancer awareness, gamified interventions, and health education in Africa.  pages 20 to 22 (lines 529 to 601).

Reviewer 3 Report

Comments and Suggestions for Authors

This is both an interesting and important research article reporting on the effectiveness of a health education intervention in cancer patients. However, the manuscript is poorly written and requires a substantial rewrite to improve the clarity of data presentation and make it more straightforward.

1. The Introduction section is unnecessarily lengthy and includes information that could be omitted. For example, the entire paragraph in Lines 112–127 does not belong here. Other parts of the Introduction could also be reduced. It is also unclear why some references are underlined while others are not.

2. The conceptual framework (Lines 180–226) is better presented as supplementary material. Similarly, the subsection on study design and participants would benefit from being split into two parts:

   • The description of the game design should be moved to the supplementary materials along with links to the Google folders.

   • The description of participant recruitment, sample size determination, and sampling frame should remain in the main text.

    

3. The formula reported for sample size determination is typically used in cross-sectional studies. Given that this was an experimental study, the formula should include the expected frequency of the intervention outcome and the distribution of participants between the two arms. Also, unlike in cross-sectional studies, formulas for intervention studies do not usually require specifying the total target population size.
4. A standardized questionnaire developed for the study (Line 328) is best presented as supplementary material rather than in an appendix. The same applies to the PowerPoint slides (Line 336) and the description of the board game. At present, the manuscript is overloaded with information and should be more concise.
5. Results (Lines 375–417) should be condensed. There is no need to describe Table 1 in detail; only the most important characteristics should be highlighted. Merge cells in the first column of Table 1 to avoid repetition of variable names.
6. Lines 422–525: Condense the description of Figure 4 to no more than two paragraphs. The multivariable analysis should be described in the Statistical Analysis subsection, and in Table 2 the cells should be merged to avoid repeating model characteristics.
7. Lines 568–596 and Table 3 could also be summarized more effectively in the Statistical Analysis subsection. If detailed presentation is still required, it should be moved to the supplementary materials.
8. Large sections of text (Lines 597–660, 628–699, 678–755, 758–840, 855–888) should be condensed. Figure 5 is more appropriate for the supplementary materials, and the authors must confirm whether all individuals appearing in the photo provided informed consent for publication.
9. Tables 4 and 5 should be restructured to avoid unnecessary length, with merged cells where applicable. The legends of Figures 6, 8, and 10 are overly detailed; figure legends should not include full descriptions of findings. Tables 6–12 are redundant and do not add new information; they should be removed along with the corresponding text.
10. The Discussion section is unnecessarily long and should be presented in a more concise form.
11. Overall, the manuscript gives the impression of being a direct submission of a thesis rather than a focused journal article. Although the topic is relevant and the study is important, the manuscript in its current form cannot be published. Major revision is required, including substantial rewriting and restructuring. If the authors are unwilling to make such efforts, the manuscript should be rejected.

Author Response

Comment 1: The Introduction is unnecessarily lengthy and includes irrelevant information. Some references are underlined.
Response: The Introduction has been shortened, redundant text removed, and underlined references corrected. The flow now moves from global burden → African context → Ghana → rationale → objective. Please see pages 2 to 3; lines 51 to 119.

Comment 2: The conceptual framework is too detailed; should go to supplementary material.
Response: We summarized the conceptual framework (SEM and SCT) briefly in the main text and moved the detailed diagrams and notes to the Supplementary Material. Please see page 3 ( lines 121 to 128).

Comment 3: Game design description should be in supplementary, while recruitment/sample size should remain in main text.
Response: This has been done. Detailed game design and question bank are now in Supplementary, while recruitment, sample size, and data collection remain in the main Methods. Please see pages 4  to 7, (lines 135 to 197).

Comment 4: Sample size formula used is for cross-sectional studies, not intervention studies.
Response: We corrected this by using an intervention-appropriate formula based on expected effect size, power (80%), and significance level (5%). This is clarified in the Methods. Please see pages 4(lines 147 to 155).

Comment 5: Standardized questionnaire, PowerPoint slides, and board game description should be supplementary.
Response: These have been moved to Supplementary Material for conciseness. (Kindly see the supplementary material document)

Comment 6: Results are too detailed; Table 1 description too long; merge cells where possible.
Response: Results have been condensed, highlighting only major findings. Table 1 and others have been reformatted with merged cells where appropriate. Pages 7 to 16 (lines 210 to 350).

Comment 7: Condense Figure 4 description, restructure Table 2, move redundant tables (6–12).
Response: Figure 4 (forest plot) description was shortened to two paragraphs. Table 2 was restructured. Tables 6–12 were removed from the main text and placed in Supplementary.  Pages 5 (lines 151 to 161), 6(lines 174 to 181), 11 (line 261 to 268), 13 (line 306 to 312), 15 (line 344 to 350). 

Comment 8: Confirm informed consent for Figure 5 (photos).
Response: All individuals in photos provided informed consent. They consented for the study and Photos

Comment 9: Tables 4 and 5 too long; legends of Figures 6, 8, and 10 overly detailed.
Response: Tables 4 and 5 were streamlined. Figure legends were reconsidered and standardized, with abbreviations defined but without repeating results. Considering the fact that reviewer one also requested for detailed legends for tables and figures, we balanced your two expectations. Most of these figures were moved to the supplementary material document as well). Pages 5 (lines 151 to 161), 6(lines 174 to 181), 11 (line 261 to 268), 13 (line 306 to 312), 15 (line 344 to 350). 

Comment 10: Discussion is unnecessarily long.
Response: The Discussion was condensed by removing repeated introduction material, while retaining focused comparisons, implications, and the new limitations/applications subsection. (Please see pages 16 to 17, lines 351 to 439).

Reviewer 4 Report

Comments and Suggestions for Authors

Introduction: The section is excessively lengthy and replete with literature references, which leads to redundancy and a diversion from the primary issue in Ghana. The information should be organised in a logical sequence, with a shortened version as follows: global data → Africa → Ghana.

Methods and Materials: Duplication of inclusion/exclusion criteria necessitates consolidation. The conceptual frameworks (SEM and SCT) are described in an excessively exhaustive manner and should be restricted to the elements that are directly applicable to the intervention. The inclusion of technical notes and external links ("javascript:void(0)", Google Drive, ResearchGate) creates the impression of an incomplete draft and should be eliminated. Subsections necessitate more rigorous organisation.

Results: The text is explicitly presented with detailed statistical values and an abundance of data in this section. Tables and figures should contain the complete statistical results, while the text should emphasise only the most significant discoveries. The tables are bloated with information and frequently repeat the text; some could be condensed or relegated to an appendix. Figures (e.g., forest plot, SEM, and SCT diagrams) are beneficial; however, their descriptions in the text are excessively detailed and should be restricted to the legends of the figures. Technical notes and links must be eliminated, and authorship or copyright issues must be clarified. However, pictures (photos of the game and educational sessions) are pertinent.

Discussion: It is necessary to conduct a more focused comparison with the existing literature in order to prevent the introduction from being repeated. Practical implications should be prioritised, including the reasons why LIBOG is appropriate for Ghana, the ways in which it can be implemented in real-world settings, and the ways in which it differs from conventional health lectures.

Conclusion: The conclusion should be more assertive and specific. In its present state, it implies that health discussions possess an advantage, whereas LIBOG merely "possesses potential." Explicit recommendations should be emphasised in order to clarify this message.

Author Response

Comment 1: Introduction too long and repetitive; should be organized global → Africa → Ghana.
Response: Introduction was rewritten following this sequence, with redundant citations removed. Please see pages 2 to 3; lines 51 to 119.

Comment 2: Methods: duplication of inclusion/exclusion; conceptual frameworks too exhaustive; external links inappropriate.
Response: Inclusion/exclusion criteria were consolidated. Framework details were summarized in main text, with diagrams moved to Supplementary. All technical links (Google Drive, ResearchGate) were removed. Please see pages 2 to 7; lines 120 to 209.

Comment 3: Results: overly detailed; tables bloated; figures should carry detail while text highlights key findings.
Response: Results were rewritten to emphasize only key findings in text. Redundant tables were moved to Supplementary. Figures (forest plot, bar charts) now carry the main detail, with concise explanatory text. Pages 7 to 16 (lines 210 to 350).

Comment 4: Discussion: needs focused comparison, practical implications, why LIBOG is appropriate, and how it differs from health talks.
Response: The Discussion was restructured to emphasize comparisons with existing literature, highlight practical applications of LIBOG in Ghana, and explain its added value over conventional health talks. (Please see pages 16 to 17, lines 351 to 439).

Comment 5: Conclusion: too weak; should be more assertive.
Response: The Conclusion was rewritten to state that LIBOG is not inferior to health talks and should be integrated into community health education. Explicit recommendations for practice and research are now included. Page 18, (lines 460 to 474).

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

The article may be accepted once the text revision with MDPI has been completed, as indicated by the authors.

Author Response

Comment: The article may be accepted once the text revision with MDPI has been completed, as indicated by the authors.

Response: We thank the reviewer for their positive recommendation. We would do as you say.

Reviewer 2 Report

Comments and Suggestions for Authors

Edited and its can be publish 

Author Response

Comment: Edited and it can be published.

Response: We sincerely thank the reviewer for their encouraging assessment. We would do as you say.

Reviewer 3 Report

Comments and Suggestions for Authors

The authors made substantial effort to improve the quality of their manuscript. I have only minor comment: Please present Figure 1 (Study Flow-Chart) as a supplementary material.

Author Response

Comment: Please present Figure 1 (Study Flow-Chart) as a supplementary material.

Response: We deeply appreciate the reviewer’s observation. However, we respectfully request to retain Figure 1 within the main manuscript. The figure visually conveys the structure of participant screening, enrolment, allocation, and follow-up, which is fundamental to understanding the quasi-experimental design and ensuring methodological transparency. Relocating it to supplementary material would diminish immediate clarity for readers.

Reviewer 4 Report

Comments and Suggestions for Authors

The study registration is retrospective (October 10, 2025), meaning that it was completed after the field period (June–November 2024).  This must be expressly described as a limitation, with a clear explanation of the reason for its occurrence and the steps taken to mitigate systematic bias (e.g., a pre-specified protocol/analysis plan, untouched primary endpoints, a time-stamped archive of materials...).  The original timeline, any deviations from the plan, and their impact (or absence thereof) on the interpretation of the results should be described in a separate paragraph titled "Trial registration and deviations".  In addition, provide a detailed definition of "other genders" (6.1%), including the method by which the variable was collected (self-identification/options), the method by which it was coded for analysis (separate category or collapsed due to small cell size), and the manner in which comparisons are reported. If collapsing was implemented, justify it and provide a sensitivity analysis.  The current description of "systematic random sampling + dice toss" resembles on-site quasi-randomization. Please provide a detailed explanation of the procedure, including the sampling frame, interval/starting point for systematic selection, the individual(s) who threw the die, the location and time of the throw, and the methods used to ensure independence and non-predictability. Additionally, please provide the measures for allocation concealment (e.g., sealed opaque envelopes, centralised call/app) and the prevention of contamination between groups (e.g., separate sessions in time and place, participant instructions, controls on material sharing).  The comparison's validity is still at risk in the absence of these clarifications.

Author Response

Comment 1: The study registration is retrospective (October 10, 2025)... describe as limitation and provide paragraph titled 'Trial registration and deviations'.

Response: We agree with this valuable observation. The retrospective registration occurred after the completion of data collection due to administrative delays during registry approval. The study, however, adhered strictly to a pre-specified protocol and analysis plan developed prior to fieldwork. No post-hoc outcome switching occurred.

Revised Text (inserted under a new subsection after ‘Ethical Considerations’, titled ‘Trial Registration and Deviations’):

“Trial Registration and Deviations: The study was retrospectively registered in the Pan African Clinical Trials Registry (PACTR202510512711680) on 10 October 2025. The delay was due to administrative timing between ethical clearance and registry acceptance. Nevertheless, all core procedures followed a time-stamped protocol archived with the principal investigator and ethics committee. The primary endpoints (knowledge, attitudes, and perceptions) remained unaltered. No deviation affected data collection or interpretation.”

Lines 224 to 229.

 

ADDITIONAL PARAGRAPH ADDED TO THE LIMITATION SUBSECTION:

An additional limitation of this study is that the trial registration was performed retrospectively (PACTR202510512711680). The delay arose from administrative processes between ethics approval and formal registry acceptance. Nonetheless, the study adhered strictly to a pre-specified protocol and analysis plan developed prior to data collection, and no outcome measures or endpoints were modified thereafter. Consequently, the retrospective nature of the registration is not expected to have introduced systematic bias or affected the integrity of the findings.

Lines 483 to 489

 

Comment 2: Provide definition of ‘other genders’, how collected, coded, and analyzed.

Response: Thank you for this suggestion. The questionnaire included three self-identified gender options — Male, Female, and Others. ‘Others’ referred to respondents who did not identify strictly within the binary categories. This was a self-selected option and was analyzed as a separate category. However, due to the small sample size (6.1%), this category was excluded from inferential statistics but retained descriptively for inclusiveness.

Revised Text (inserted in Section 3.1 – Sociodemographic Characteristics):
“Gender was self-reported with three options: Male, Female, and Others. The ‘Others’ category (6.1%) represented participants who did not identify within the binary gender categories. Due to its small cell size, it was retained descriptively but excluded from inferential analyses.”

Lines 223 to 237

Comment 3: Clarify the sampling and dice toss randomization procedure.

Response: We appreciate the request for methodological detail. The process combined systematic random sampling and quasi-random allocation via dice toss. A sampling frame of 197 eligible participants was established, with every second individual (k = 2) selected the starting point ‘n’ was also determined by the toss of a dice. Participants were divided into two groups (Group 1 and Group 2). Allocation was determined by repeated dice tosses by a neutral, non-participant arbiter. The group whose number appeared first most frequently received the intervention (LIBOG), and the other received the Health Talk (HT). This ensured transparency and reduced selection bias.

Revised Text (inserted under ‘Participants and Recruitment’):
“Sampling and Allocation: From a frame of 197 participants, systematic random sampling with k = 2 was employed (the starting point ‘n’ was also determined by the toss of a dice). Participants were divided into two groups (1 and 2). Group assignment was decided through repeated dice tosses conducted by a neutral arbiter. The group whose number appeared more frequently first was allocated to the LIBOG arm, and the other to the Health Talk arm.”

Lines 161 to 165.

Comment 4: Provide allocation concealment and contamination prevention measures.

Response: We appreciate this important methodological point. Allocation concealment was achieved through sealed opaque envelopes prepared before participant contact, opened only after group determination. To prevent contamination, both interventions were conducted in separate venues and on different days. Participants were instructed not to share materials or discuss intervention content across groups.

Revised Text (to insert after sampling paragraph in ‘Participants and Recruitment’):
“Allocation Concealment and Contamination Prevention: Group assignment was concealed using sealed opaque envelopes. Each intervention was held at different venues. Participants were briefed not to exchange materials or discuss intervention content, minimizing cross-group contamination.”

Lines 196 to 198

 

Summary Statement

We have implemented all requested additions, clarified methodological details, and created a dedicated ‘Trial Registration and Deviations’ subsection. We respectfully maintain Figure 1 within the main manuscript for clarity and transparency. We thank the editors and reviewers for their constructive feedback and are confident that the revised manuscript now meets the journal’s standards.