The Impact of a Gamified Mobile Mental Health App (eQuoo) on Resilience and Mental Health in a Student Population: Large-Scale Randomized Controlled Trial

Background With many digital mental health interventions failing to engage clients for enough time to demonstrate substantive changes to their well-being and with only 2% of all digital solutions on app stores having undergone randomized controlled trials, the rising demand for mental health prevention and early intervention care is not being met. Young adults in particular struggle to find digital well-being apps that suit their needs. Objective This study explored the effects of eQuoo, an evidence-based mental health game that teaches psychological skills through gamification, on resilience, depression, anxiety, and attrition in a student population. Methods In total, 1165 students from 180 universities in the United Kingdom participated in a 5-week, 3-armed randomized controlled trial. Participants were randomly allocated into 1 of 3 groups: eQuoo users, users of a treatment-as-usual evidence-based cognitive behavioral health app called Sanvello, and a no-intervention waitlist. The Rugged Resilience Scale, Generalized Anxiety Disorder–7, and Patient Health Questionnaire–8 were administered to all participants at baseline and every 7 days until completion. Results A repeated measures–ANOVA revealed statistically significant increases in resilience scores in the test group (P<.001) compared with both control groups (Sanvello: P=.10 and waitlist: P=.82) over 5 weeks. The app also significantly decreased anxiety and depression scores (both P<.001). With 64.5% (251/389) adherence, the eQuoo group retained 42% more participants than the control groups. Conclusions Digital health interventions such as eQuoo are effective, scalable, and low-cost solutions for supporting young adults and are available on all leading mobile platforms. Further investigation could clarify the extent to which specific elements of the eQuoo app (including gamification) led to better outcomes. Trial Registration German Clinical Trials Register (DRKS) DRKS00027638; https://drks.de/search/en/trial/DRKS00027638


1a-i) Identify the mode of delivery in the title
Identify the mode of delivery. Preferably use "web-based" and/or "mobile" and/or "electronic game" in the title. Avoid ambiguous terms like "online", "virtual", "interactive". Use "Internet-based" only if Intervention includes non-web-based Internet components (e.g. email), use "computer-based" or "electronic" only if o ine products are used. Use "virtual" only in the context of "virtual reality" (3-D worlds). Use "online" only in the context of "online support groups". Complement or substitute product names with broader terms for the class of products (such as "mobile" or "smart phone" instead of "iphone"), especially if the application runs on different platforms. Does your paper address subitem 1a-i? * Copy and paste relevant sections from manuscript title (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study The title introduces the mode of delivery clearly, as well as clarifying that it's a game. The Titel: "The Impact of a Gamified Mobile Mental Health App (eQuoo) on Resilience and Mental Health in a Student Population: A Large-Scale Randomised Controlled Trial"

1a-ii) Non-web-based components or important co-interventions in title
Mention non-web-based components or important co-interventions in title, if any (e.g., "with telephone support").
C l e a r s e l e c t i o n Does your paper address subitem 1a-ii?
Copy and paste relevant sections from manuscript title (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study The intervention is completely mobile based. There are no non-web-based interventions.
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subitem not at all important Does your paper address subitem 1a-iii? * Copy and paste relevant sections from manuscript title (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study The title of the paper addresses the fact that the game is directed towards young adults, ea students: "The Impact of a Gamified Mobile Mental Health App (eQuoo) on Resilience and Mental Health in a Student Population: A Large-Scale Randomised Controlled Trial " Your response is too large. Try shortening some answers.
subitem not at all important Does your paper address subitem 1b-i? * Copy and paste relevant sections from the manuscript abstract (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study "The present study explored the effects of eQuoo-an evidence-based mental health game that teaches psychological skills through gamification-on resilience, depression, anxiety, and attrition in a student population." Your response is too large. Try shortening some answers.
subitem not at all important 1 2 3 4 5 essential 1b-ii) Level of human involvement in the METHODS section of the ABSTRACT Clarify the level of human involvement in the abstract, e.g., use phrases like "fully automated" vs. "therapist/nurse/care provider/physician-assisted" (mention number and expertise of providers involved, if any). (Note: Only report in the abstract what the main paper is reporting. If this information is missing from the main body of text, consider adding it) C l e a r s e l e c t i o n Does your paper address subitem 1b-ii?
Copy and paste relevant sections from the manuscript abstract (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study "In total, 1,166 student participants from 180 universities in the United Kingdom participated in a 5-week, three-armed randomised controlled trial. Participants were randomly allocated into one of three groups: eQuoo users, users of a treatment as usual evidence-based cognitive behavioural health app called Sanvello, and a no-intervention waitlist. The Rugged Resilience Scale, the GAD7, and the PHQ8 were administered to all participants at baseline and every 7 days until completion. " Your response is too large. Try shortening some answers.
subitem not at all important 1 2 3 4 5 essential 1b-iii) Open vs. closed, web-based (self-assessment) vs. face-to-face assessments in the METHODS section of the ABSTRACT Mention how participants were recruited (online vs. o ine), e.g., from an open access website or from a clinic or a closed online user group (closed usergroup trial), and clarify if this was a purely web-based trial, or there were face-to-face components (as part of the intervention or for assessment). Clearly say if outcomes were self-assessed through questionnaires (as common in web-based trials Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study METHODS 3a) Description of trial design (such as parallel, factorial) including allocation ratio 3b) Important changes to methods after trial commencement (such as eligibility criteria), with reasons Does your paper address CONSORT subitem 2b? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study "Primary Outcome Hypothesis -Resilience levels We hypothesised that resilience levels would increase significantly over the course of the intervention period in the gamified intervention group and that resilience would be significantly higher in the intervention group compared with the active control and waitlist control groups. Secondary Outcome Hypotheses -Depressive and Anxiety Symptoms, and Attrition Does your paper address CONSORT subitem 3a? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study "An a priori power analysis using G*Power 3.1.9.4 revealed that a sample size of n = 207 participants was required to detect a within-between interaction for the primary outcome (input parameters: repeated measures analysis of variance [ANOVA], ES F = 0.10, alpha = .05, power = .95, number of groups = 3, number of measurements = 6, repeated measures intercorrelation = .50, nonsphericity correction = 1). However, given the high attrition rates reported in previous research (e.g., 40-60% [27]), we aimed to enrol a minimum of n = 850 participants." Your response is too large. Try shortening some answers.
subitem not at all important 1 2 3 4 5 essential Does your paper address CONSORT subitem 3b? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study Not applicable at all at any time.

3b-i) Bug fixes, Downtimes, Content Changes
Bug xes, Downtimes, Content Changes: ehealth systems are often dynamic systems. A description of changes to methods therefore also includes important changes made on the intervention or comparator during the trial (e.g., major bug xes or changes in the functionality or content) (5-iii) and other "unexpected events" that may have in uenced study design such as staff changes, system failures/downtimes, etc. [2].

4a) Eligibility criteria for participants
Does your paper address subitem 3b-i?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study The authors chose to use a specific version of the game (V3) for testing purposes. This is despite understanding that updates and feedback from users could make it better. This is a limitation of digital products, as each piece of research only addresses a segment in time of that digital product. This is addressed by the authors in the discussion of the paper.
Does your paper address CONSORT subitem 4a? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study "Participants had to be aged 18 or above and enrolled as college or university students. They had to have access to a smartphone or tablet device and an app store (Apple/Google Play) to install the eQuoo app. There were no further exclusion criteria." Your response is too large. Try shortening some answers.
subitem not at all important Does your paper address subitem 4a-i?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study The Authors made the assumption that a young adult able to enroll and commence eductation at a university would be internet/mobile literate.
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subitem not at all important 1 2 3 4 5 essential 4a-ii) Open vs. closed, web-based vs. face-to-face assessments: Open vs. closed, web-based vs. face-to-face assessments: Mention how participants were recruited (online vs. o ine), e.g., from an open access website or from a clinic, and clarify if this was a purely web-based trial, or there were face-to-face components (as part of the intervention or for assessment), i.e., to what degree got the study team to know the participant. In online-only trials, clarify if participants were quasi-anonymous and whether having multiple identities was possible or whether technical or logistical measures (e.g., cookies, email con rmation, phone calls) were used to detect/prevent these.
C l e a r s e l e c t i o n Does your paper address subitem 4a-ii? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study It was purely web and mobile based: "Recruitment took place in two waves between March and April 2021 using the UNiDAYS subscriber database, a global student discount platform.
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subitem not at all important 1 2 3 4 5 essential 4b) Settings and locations where the data were collected 4a-iii) Information giving during recruitment Information given during recruitment. Specify how participants were briefed for recruitment and in the informed consent procedures (e.g., publish the informed consent documentation as appendix, see also item X26), as this information may have an effect on user self-selection, user expectation and may also bias results.
C l e a r s e l e c t i o n Does your paper address subitem 4a-iii?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study "On the landing page, the study goal was explained via a brief, the study protocol was shared, and a consent box needed to be clicked that read "I have understood the trial terms and I consent". This checkbox needed to be checked for participants to join the trial, without it, they could not gain access to the questionnaires and information on what to test." Your response is too large. Try shortening some answers.
subitem not at all important Does your paper address CONSORT subitem 4b? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study "Data were collected using LimeSurvey, a widely used secure open-source tool." 4b-i) Report if outcomes were (self-)assessed through online questionnaires Clearly report if outcomes were (self-)assessed through online questionnaires (as common in web-based trials) or otherwise.
C l e a r s e l e c t i o n Does your paper address subitem 4b-i? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study "Data were collected using LimeSurvey, a widely used secure open-source tool." Your response is too large. Try shortening some answers.
subitem not at all important Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study The institutional affiliation was explained on the study landing page: "On the landing page, the study goal was explained via a brief, the study protocol was shared, and a consent box needed to be clicked that read "I have understood the trial terms and I consent". This checkbox needed to be checked for participants to join the trial, without it, they could not gain access to the questionnaires and information on what to test, ensuring consent." Your response is too large. Try shortening some answers.
subitem not at all important 1 2 3 4 5 essential 5-i) Mention names, credential, affiliations of the developers, sponsors, and owners Mention names, credential, a liations of the developers, sponsors, and owners [6] (if authors/evaluators are owners or developer of the software, this needs to be declared in a "Con ict of interest" section or mentioned elsewhere in the manuscript).
C l e a r s e l e c t i o n

Does your paper address subitem 5-i?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study "The authors have the following competing interests: 1. Silja Litvin is a shareholder of the company PsycApps Limited, which developed the intervention tested in the present trial (eQuoo). 2. Stefan Luettke, along with a group of other scientists, has received public funding for a project on an app-based aftercare for adolescents and young adults suffering from depression. He has received consultancy fees from companies for offering advice on study design and interventions as well as payments for lectures from psychotherapy associations in the context of e-mental health matters. 3. The other authors declare no conflicts of interest." Your response is too large. Try shortening some answers.
subitem not at all important 1 2 3 4 5 essential 5-ii) Describe the history/development process Describe the history/development process of the application and previous formative evaluations (e.g., focus groups, usability testing), as these will have an impact on adoption/use rates and help with interpreting results.
C l e a r s e l e c t i o n

Does your paper address subitem 5-ii?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study "The original version of the emotional fitness app eQuoo was a five-week mental health game that presented psychoeducational material and psychological exercises based on the principles of CBT, systemic psychology, and positive psychology [49]. It combined a mix of endogenous and exogenous design features that were designed to maximise engagement. The game was mobile only and was available internationally on the Google Play store and the Apple App Store. It was designed to be a prevention and early intervention (pre-clinical threshold) tool. In a recent trial, the app was found to reduce anxiety significantly while improving resilience, perceived growth skills, and interpersonal relationships [50]. After examining feedback from thousands of users through clinical trials, focus groups, case studies, and players offering their opinions on the app stores and via email, the developers of eQuoo sought to revise the app to enhance enjoyment, immersion, and retention. This resulted in eQuoo, the Next Generation [49] (hereafter, eQuoo) and is the version of the app that was tested in the present study." Your response is too large. Try shortening some answers.
subitem not at all important

5-iii) Revisions and updating
Revisions and updating. Clearly mention the date and/or version number of the application/intervention (and comparator, if applicable) evaluated, or describe whether the intervention underwent major changes during the evaluation process, or whether the development and/or content was "frozen" during the trial. Describe dynamic components such as news feeds or changing content which may have an impact on the replicability of the intervention (for unexpected events see item 3b).
C l e a r s e l e c t i o n Does your paper address subitem 5-iii?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study "The original version of the emotional fitness app eQuoo was a five-week mental health game that presented psychoeducational material and psychological exercises based on the principles of CBT, systemic psychology, and positive psychology [49]. It combined a mix of endogenous and exogenous design features that were designed to maximise engagement. The game was mobile only and was available internationally on the Google Play store and the Apple App Store. It was designed to be a prevention and early intervention (pre-clinical threshold) tool. In a recent trial, the app was found to reduce anxiety significantly while improving resilience, perceived growth skills, and interpersonal relationships [50]. After examining feedback from thousands of users through clinical trials, focus groups, case studies, and players offering their opinions on the app stores and via email, the developers of eQuoo sought to revise the app to enhance enjoyment, immersion, and retention. This resulted in eQuoo, the Next Generation [49] (hereafter, eQuoo) and is the version of the app that was tested in the present study." Your response is too large. Try shortening some answers.
subitem not at all important 1 2 3 4 5 essential 5-iv) Quality assurance methods Provide information on quality assurance methods to ensure accuracy and quality of information provided [1], if applicable.
C l e a r s e l e c t i o n Does your paper address subitem 5-iv?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study I'm not 100% sure what is meant by this. I was assuming that the detailed description of the trial would indicate quality.
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subitem not at all important 1 2 3 4 5 essential 5-v) Ensure replicability by publishing the source code, and/or providing screenshots/screen-capture video, and/or providing flowcharts of the algorithms used Ensure replicability by publishing the source code, and/or providing screenshots/screencapture video, and/or providing owcharts of the algorithms used. Replicability (i.e., other researchers should in principle be able to replicate the study) is a hallmark of scienti c reporting.
C l e a r s e l e c t i o n Does your paper address subitem 5-v?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study No, we did not. The paper doesn't allow for screenshot.
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subitem not at all important

5-vi) Digital preservation
Digital preservation: Provide the URL of the application, but as the intervention is likely to change or disappear over the course of the years; also make sure the intervention is archived (Internet Archive, webcitation.org, and/or publishing the source code or screenshots/videos alongside the article). As pages behind login screens cannot be archived, consider creating demo pages which are accessible without login.
C l e a r s e l e c t i o n Does your paper address subitem 5-vi?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study This was not considered, but now, reading your question, might be worth doing.
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subitem not at all important

5-vii) Access
Access: Describe how participants accessed the application, in what setting/context, if they had to pay (or were paid) or not, whether they had to be a member of speci c group. If known, describe how participants obtained "access to the platform and Internet" [1]. To ensure access for editors/reviewers/readers, consider to provide a "backdoor" login account or demo mode for reviewers/readers to explore the application (also important for archiving purposes, see vi).
C l e a r s e l e c t i o n Does your paper address subitem 5-vii? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study In the study description, the participant was given a deeplink that unlocked all content via the app store: "They had to have access to a smartphone or tablet device and an app store (Apple/Google Play) to install the eQuoo app." Your response is too large. Try shortening some answers.
subitem not at all important  Does your paper address subitem 5-viii? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study Your response is too large. Try shortening some answers.
"The app begins by explaining the player's role as a Lodestar. Each page has a picture with characters in it and a speech bubble with a maximum of 160 characters per screen. The player moves to the next page by tapping on the screen. they can also click a back button to re-read the previous screen. The type of introduction used in eQuoo is commonly known as game lore, a game-specific mythology, or the so-called backstory of the general narrative within a game. Lore in video games has been proven to motivate players to read and learn more, making it more likely that they will engage, read, and therefore learn the skills presented The game consists of multiple books of different genres (fantasy, historical drama, teen drama, etc). Each book consists of 8 -10 chapters where the player can learn and repractice up to 4 skills. Before each new chapter of a book in the game they are led through a gamified skill tutorial by the game's guide, Joy, who is introduced to have been a player themselves and is now a Lodestar thanks to having completed the game. Once they have successfully learned the skills, they continue into the book where they -playing themselves via an avatar that they customised at the beginning of their journey -meet the characters of the game and are thrown into various situations where they need to correctly use the psychological skills that they learned in the tutorial. To facilitate between-session learning and incorporation of the necessary skills, users have to wait 7 days until the next chapter unlocks. This allows them to practice the skills in real-life settings, which has a positive impact on the therapeutic outcome [52]. The weekly lock is also to protect players from addictive patterns and not flood them with too much information that they have retained after only one session.
Out of the 18 gamification elements named by Cheng et al.
[53], 11 have been incorporated into eQuoo: Levels; Points -in the form of gem shards; Rewards -in the form of unlocking levels and completing gems; Narratives; Personalisation -in the form of the story choices; Customisation -in the form of the avatar; Mini-games; Quests and challenges -in the form of stories; Badges -in the form of personality types; Artificial assistance -in the form of the guide, Joy; Unlockable content -in the form of a free trial. The intervention group was instructed to download eQuoo via the Apple or Google Play Store and install it on their digital device. Participants were informed at the start of the study that they could stop using the app at any time. After starting the game, the player is introduced to the game's lore. Participants are asked to design an avatar that resembles themselves as a virtual person in the game The application's content is divided into multiple Your response is too large. Try shortening some answers.
subitem not at all important 1 2 3 4 5 essential themselves as a virtual person in the game. The application s content is divided into multiple multi-genre stories that consist of 8-10 chapters presented as levels. In the chapters, users are first presented with one to four lessons that teach them psychological concepts, such as emotional bids [54]; generalisation [55]; catastrophisation [56]; beliefs [57]; and 52 psychological skills commonly used in therapeutic sessions for anxiety and depression (as well as prevention programmes designed to increase resilience). After each lesson, the players can test their mastery of the skills with a simple multiple-choice scenario. They are then either debriefed on why their choice was not the most beneficial one (and are invited to choose another answer) or allowed to enter an interactive adventure story where they play themselves while practising the skills in a low-cost environment. A low-cost environment means that failure to succeed comes at a low cost like having to replay a level. All prompts during the psychoeducational part of the game to check if the player has understood the skill are divided into three responses: (a) beneficial -the skill has been implemented by the player in a way that is beneficial for the player's mental health; (b) neutral -the skill has been ignored and not used, and the counter indication was not chosen; and (c) unbeneficial -the player chose an answer that is considered unbeneficial for the player's mental health. The onboarding of the game consists of three levels of introduction to the lore, the building of the avatar, the first in-app baseline assessment of the RRM, GAD-7, and PHQ-8 in form of a pop-up chatbot where the player can chat with the game's guide, Joy and fill out the questionnaires. After acquiring their second skill, they play the first chapter of the first story and hit the level lock until the next week. This ensures that they play only one level a week for the 5 weeks of the clinical trial. Each survey includes a question that players can answer only if they have completed the level for the week."

5-ix) Describe use parameters
Describe use parameters (e.g., intended "doses" and optimal timing for use). Clarify what instructions or recommendations were given to the user, e.g., regarding timing, frequency, heaviness of use, if any, or was the intervention used ad libitum.

5-x) Clarify the level of human involvement
Clarify the level of human involvement (care providers or health professionals, also technical assistance) in the e-intervention or as co-intervention (detail number and expertise of professionals involved, if any, as well as "type of assistance offered, the timing and frequency of the support, how it is initiated, and the medium by which the assistance is delivered". It may be necessary to distinguish between the level of human involvement required for the trial, and the level of human involvement required for a routine application outside of a RCT setting (discuss under item 21 -generalizability).
C l e a r s e l e c t i o n Does your paper address subitem 5-x?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study The paper makes it quite clear that the intervention is mobile only.
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subitem not at all important 1 2 3 4 5 essential 5-xi) Report any prompts/reminders used Report any prompts/reminders used: Clarify if there were prompts (letters, emails, phone calls, SMS) to use the application, what triggered them, frequency etc. It may be necessary to distinguish between the level of prompts/reminders required for the trial, and the level of prompts/reminders for a routine application outside of a RCT setting (discuss under item 21 -generalizability).
C l e a r s e l e c t i o n Does your paper address subitem 5-xi? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study "Bi-weekly in-app nudges and weekly emails pull the participants back into the game." Your response is too large. Try shortening some answers.
subitem not at all important 1 2 3 4 5 essential 6a) Completely defined pre-specified primary and secondary outcome measures, including how and when they were assessed 5-xii) Describe any co-interventions (incl. training/support) Describe any co-interventions (incl. training/support): Clearly state any interventions that are provided in addition to the targeted eHealth intervention, as ehealth intervention may not be designed as stand-alone intervention. This includes training sessions and support [1]. It may be necessary to distinguish between the level of training required for the trial, and the level of training for a routine application outside of a RCT setting (discuss under item 21 -generalizability. C l e a r s e l e c t i o n Does your paper address subitem 5-xii? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study There are no co-interventions as the study is mobile-only.
Your response is too large. Try shortening some answers.
Does your paper address CONSORT subitem 6a? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study "Primary Outcome: Resilience As eQuoo exists primarily in the digital space of prevention and early intervention, resilience was considered the primary outcome. To assess resilience, we used the Rugged Resilience Measure (RRM). The RRM is a 10-item self-report questionnaire designed to measure key psychologically protective factors that foster resilience [43]. Participants respond to the items on a 5-point Likert-type scale (1 = not at all, 2 = a little, 3 = somewhat, 4 = quite a bit, 5 = a lot). The questionnaire was initially validated with a sample of young adults (16-30 years old), which matched the population of the study. Since an understanding of resilience has shifted from a fixed trait to a process encompassing the development and application of skills and resources that support positive outcomes despite the experience of distress [44,45], the RRM taps the key internal resources necessary to initiate said development. In the present study, the internal consistency of the RRM was .87 (Cronbach's alpha; α).

Secondary Outcomes: Anxiety, Depression, and Attrition
The secondary outcomes in this study concerned mental health (the level of anxiety and depression symptoms in particular) and attrition. To assess the former, we used the Generalised Anxiety Disorder Scale (GAD-7). This is a widely applied seven-item measure of generalised anxiety symptoms [46]. Each item is scored from 0 to 3 (0 = not at all, 1 = several days, 2 = more than half the days, and 3 = nearly every day). The internal consistency of the GAD-7 was high (α =.83). We also used the Patient Health Questionnaire-8 (PHQ-8).
The PHQ-8 is a well-established screening measure for depressive symptoms in large clinical studies [47] and encompasses the American Psychological Association's Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) criteria for a depressive episode (with the exception of the item regarding self-harm). It was preferred to the more widely known PHQ-9 [16] since the study design did not allow us to intervene in the event of selfinjurious behaviour. In the PHQ-8, participants are asked to rate how far they have been bothered by each symptom over the previous 2 weeks on a 4-point Likert-type scale (0 = not at all, 1 = several days, 2 = more than half the days, and 3 = nearly every day). The internal consistency of the PHQ-8 in the present study was high (α = .88). Finally, it was hypothesised that attrition would be significantly lower for the gamified group intervention at the last assessment (t5) than the other groups. In addition to measures of resilience, anxiety, and depression, participants also provided demographic information regarding their age, gender, living situation, and level of study." Your response is too large. Try shortening some answers.
subitem not at all important  Does your paper address CONSORT subitem 6b? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study There were no changes to the trial outcomes after the trial commenced.
Your response is too large. Try shortening some answers. Copy and paste relevant sections from manuscript title (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study "An a priori power analysis using G*Power 3.1.9.4 revealed that a sample size of n = 207 participants was required to detect a within-between interaction for the primary outcome (input parameters: repeated measures analysis of variance [ANOVA], ES F = 0.10, alpha = .05, power = .95, number of groups = 3, number of measurements = 6, repeated measures intercorrelation = .50, nonsphericity correction = 1). However, given the high attrition rates reported in previous research (e.g., 40-60% [27]), we aimed to enrol a minimum of n = 850 participants. " Your response is too large. Try shortening some answers.

8a) Method used to generate the random allocation sequence
NPT: When applicable, how care providers were allocated to each trial group 8b) Type of randomisation; details of any restriction (such as blocking and block size) Does your paper address CONSORT subitem 7b? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study There were no interim analyses and stopping guidelines.
Does your paper address CONSORT subitem 8a? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study "Participants were randomly assigned to a condition (eQuoo vs. active control vs. waitlist group), the details of which are described below) using a randomisation generator provided by random.org, which randomises based on atmospheric noise [48]." Does your paper address CONSORT subitem 8b? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study "Participants were randomly assigned to a condition (eQuoo vs. active control vs. waitlist group), the details of which are described below) using a randomisation generator provided by random.org, which randomises based on atmospheric noise [48]." 9) Mechanism used to implement the random allocation sequence (such as sequentially numbered containers), describing any steps taken to conceal the sequence until interventions were assigned 10) Who generated the random allocation sequence, who enrolled participants, and who assigned participants to interventions 11a) If done, who was blinded after assignment to interventions (for example, participants, care providers, those assessing outcomes) and how NPT: Whether or not administering co-interventions were blinded to group assignment Does your paper address CONSORT subitem 9? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study "Participants were randomly assigned to a condition (eQuoo vs. active control vs. waitlist group), the details of which are described below) using a randomisation generator provided by random.org, which randomises based on atmospheric noise [48]." Does your paper address CONSORT subitem 10? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study The paper does not describe who did what as an author, but the enrollment was done by myself, and the randomiser was developed by my ex-cofounder not mentioned in paper.
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subitem not at all important 1 2 3 4 5 essential 11a-i) Specify who was blinded, and who wasn't Specify who was blinded, and who wasn't. Usually, in web-based trials it is not possible to blind the participants [1,3] (this should be clearly acknowledged), but it may be possible to blind outcome assessors, those doing data analysis or those administering cointerventions (if any).
C l e a r s e l e c t i o n Does your paper address subitem 11a-i? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study No one was blinded in the paper.
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subitem not at all important 11a-ii) Discuss e.g., whether participants knew which intervention was the "intervention of interest" and which one was the "comparator" Informed consent procedures (4a-ii) can create biases and certain expectations -discuss e.g., whether participants knew which intervention was the "intervention of interest" and which one was the "comparator".
C l e a r s e l e c t i o n Does your paper address subitem 11a-ii?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study In the onboarding landing page, the process was described to the participants, as it was in the debrief.
12a) Statistical methods used to compare groups for primary and secondary outcomes NPT: When applicable, details of whether and how the clustering by care providers or centers was addressed Does your paper address CONSORT subitem 11b? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study There was no simularity per se, just "treatment as usual" in the active control group.
Does your paper address CONSORT subitem 12a? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study "To assess differences between interventions over timepoints, initial analyses used repeated-measures (RM-) ANOVAs with time (six levels) entered alongside the intervention group (three levels). To assess the impact of listwise deletion on these models, further analysis was conducted using mixed-effect models exploring change in the primary and secondary outcomes over time, entering the intervention arm as an independent variable and age, gender, and living situation as covariates. These mixed-effect models, using restricted maximum likelihood estimation, used all available data at each timepoint." Your response is too large. Try shortening some answers.
subitem not at all important 1 2 3 4 5 essential 12b) Methods for additional analyses, such as subgroup analyses and adjusted analyses 12a-i) Imputation techniques to deal with attrition / missing values Imputation techniques to deal with attrition / missing values: Not all participants will use the intervention/comparator as intended and attrition is typically high in ehealth trials. Specify how participants who did not use the application or dropped out from the trial were treated in the statistical analysis (a complete case analysis is strongly discouraged, and simple imputation techniques such as LOCF may also be problematic [4]).
C l e a r s e l e c t i o n Does your paper address subitem 12a-i? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study "Attrition rates and the number of participants who completed the levels at all timepoints were then compared across groups. Attrition was defined as not completing the assessments past t0. This is consistent with previous studies that defined attrition as the failure to complete the study protocol associated with the intervention [21]. ]." Your response is too large. Try shortening some answers. Does your paper address CONSORT subitem 12b? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study "Differences in participant characteristics between each intervention arm were first compared using chi-squared tests of independence (for categorical variables) and one-way ANOVAs (for continuous variables)."

X26-i) Comment on ethics committee approval
Does your paper address subitem X26-i?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study Your answer Your response is too large. Try shortening some answers.
subitem not at all important

Does your paper address subitem X26-ii?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study Your answer Your response is too large. Try shortening some answers.
subitem not at all important

X26-iii) Safety and security procedures
Safety and security procedures, incl. privacy considerations, and any steps taken to reduce the likelihood or detection of harm (e.g., education and training, availability of a hotline)

Does your paper address subitem X26-iii?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study Your answer Your response is too large. Try shortening some answers.

13b) For each group, losses and exclusions after randomisation, together with reasons
Does your paper address CONSORT subitem 13a? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study "Of the 1,167 individuals who were recruited for the study, two individuals reported being less than 18 years old and were excluded, so the final sample comprised 1,165 participants. These individuals were then randomly allocated to the study groups: 389 (33.4%) were placed into the eQuoo group; 384 (33.0%) into the Savello group; and 392 (33.6%) on the waitlist group. " Does your paper address CONSORT subitem 13b? (NOTE: Preferably, this is shown in a CONSORT flow diagram) * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study "Whilst only 10% of the eQuoo group met the criteria for attrition, rates were 68% and 46% for the Savello and waitlist groups, respectively. The odds of attrition were significantly higher in the Savello group compared with that of the eQuoo group (OR = 18.51, 95% CI Does your paper address subitem 13b-i? Copy and paste relevant sections from the manuscript or cite the gure number if applicable (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study Yes, we have an attrition diagram, as it is also one of our secondary outcomes.
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subitem not at all important 1 2 3 4 5 essential Does your paper address CONSORT subitem 14a? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study "Recruitment took place in two waves between March and April 2021 using the UNiDAYS subscriber database, a global student discount platform. The trial was completed, closed, and all participants were debriefed June 2021." 14a-i) Indicate if critical "secular events" fell into the study period Does your paper address CONSORT subitem 14b? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study This is non-applicable because we did not stop the trial early.
Does your paper address CONSORT subitem 15? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study We show a table with demographis, but not clinically as this is a study about the general population.
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subitem not at all important  Does your paper address subitem 15-i? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study Our population was rather homogenic as it compromised of UK based students.
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subitem not at all important 1 2 3 4 5 essential 16-i) Report multiple "denominators" and provide definitions Report multiple "denominators" and provide de nitions: Report N's (and effect sizes) "across a range of study participation [and use] thresholds" [1], e.g., N exposed, N consented, N used more than x times, N used more than y weeks, N participants "used" the intervention/comparator at speci c pre-de ned time points of interest (in absolute and relative numbers per group). Always clearly de ne "use" of the intervention.
C l e a r s e l e c t i o n Does your paper address subitem 16-i? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study "Of the 1,167 individuals who were recruited for the study, two individuals reported being less than 18 years old and were excluded, so the final sample comprised 1,165 participants. These individuals were then randomly allocated to the study groups: 389 (33.4%) were placed into the eQuoo group; 384 (33.0%) into the Savello group; and 392 (33.6%) on the waitlist group. Figure 1 shows the participant flow diagram and the proportion of participants providing data at each timepoint. All participants completed baseline (T0) measures, and Endpoint (T5) measures were available for 251 participants in the eQuoo group, 77 in the Savello group and 101 in the waitlist group. Of eQuoo participants, 349 completed at least one measure after baseline (but potentially not T5), 123 of the Savello participants completed at least one non-baseline measure, as did 211 of the waitlist group." Your response is too large. Try shortening some answers.
subitem not at all important 1 2 3 4 5 essential 17a) For each primary and secondary outcome, results for each group, and the estimated effect size and its precision (such as 95% confidence interval)

16-ii) Primary analysis should be intent-to-treat
Primary analysis should be intent-to-treat, secondary analyses could include comparing only "users", with the appropriate caveats that this is no longer a randomized sample (see 18-i).
C l e a r s e l e c t i o n Does your paper address subitem 16-ii?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study " Does your paper address CONSORT subitem 17a? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study Yes, Your response is too large. Try shortening some answers.
subitem not at all important 1 2 3 4 5 essential 17b) For binary outcomes, presentation of both absolute and relative effect sizes is recommended 17a-i) Presentation of process outcomes such as metrics of use and intensity of use In addition to primary/secondary (clinical) outcomes, the presentation of process outcomes such as metrics of use and intensity of use (dose, exposure) and their operational de nitions is critical. This does not only refer to metrics of attrition (13-b) (often a binary variable), but also to more continuous exposure metrics such as "average session length". These must be accompanied by a technical description how a metric like a "session" is de ned (e.g., timeout after idle time) [

18-i) Subgroup analysis of comparing only users
A subgroup analysis of comparing only users is not uncommon in ehealth trials, but if done, it must be stressed that this is a self-selected sample and no longer an unbiased sample from a randomized trial (see 16-iii).

19-i) Include privacy breaches, technical problems
Include privacy breaches, technical problems. This does not only include physical "harm" to participants, but also incidents such as perceived or real privacy breaches [1], technical problems, and other unexpected/unintended incidents. "Unintended effects" also includes unintended positive effects [2]. Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study Yes, we were transparent in discussing limitations and future research directions.
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subitem not at all important

20-i) Typical limitations in ehealth trials
Typical limitations in ehealth trials: Participants in ehealth trials are rarely blinded. Ehealth trials often look at a multiplicity of outcomes, increasing risk for a Type I error. Discuss biases due to non-use of the intervention/usability issues, biases through informed consent procedures, unexpected events.
C l e a r s e l e c t i o n Does your paper address subitem 20-i? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study Yes, any trial limitations were addressed as well as sources of potential bias and conflict of interest.
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subitem not at all important

21-i) Generalizability to other populations
Generalizability to other populations: In particular, discuss generalizability to a general Internet population, outside of a RCT setting, and general patient population, including applicability of the study results for other organizations Does your paper address subitem 21-i?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study Your answer Your response is too large. Try shortening some answers.
subitem not at all important Discuss if there were elements in the RCT that would be different in a routine application setting (e.g., prompts/reminders, more human involvement, training sessions or other cointerventions) and what impact the omission of these elements could have on use, adoption, or outcomes if the intervention is applied outside of a RCT setting.

Does your paper address subitem 21-ii?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study Your answer Your response is too large. Try shortening some answers. Does your paper address CONSORT subitem 23? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study Trial Registration Number: DRKS00027638 (German Trial Registry) Does your paper address CONSORT subitem 24? * Cite a Multimedia Appendix, other reference, or copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study The full trial protocol will be published along side the paper.
Does your paper address CONSORT subitem 25? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study "Funding: The study received no financial funding or sources of financial support externally or internally that might have influenced its outcome." Your response is too large. Try shortening some answers.
subitem not at all important About the CONSORT EHEALTH checklist X27-i) State the relation of the study team towards the system being evaluated In addition to the usual declaration of interests ( nancial or otherwise), also state the relation of the study team towards the system being evaluated, i.e., state if the authors/evaluators are distinct from or identical with the developers/sponsors of the intervention.
C l e a r s e l e c t i o n Does your paper address subitem X27-i?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study yes, major changes yes, minor changes no yes no Other: As a result of using this checklist, did you make changes in your manuscript? * What were the most important changes you made as a result of using this checklist?

Your answer
How much time did you spend on going through the checklist INCLUDING making changes in your manuscript * 3 hours in total over a 5 day period.
As a result of using this checklist, do you think your manuscript has improved? * Your response is too large. Try shortening some answers. yes no Other: STOP -Save this form as PDF before you click submit To generate a record that you lled in this form, we recommend to generate a PDF of this page (on a Mac, simply select "print" and then select "print as PDF") before you submit it.
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