-->PONE-D-24-19286-->-->Children’s Right to Play in Chilean Hospitals. A Forgotten Right? – A Qualitative Study Protocol-->-->PLOS ONE

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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: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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-->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: Yes

Reviewer #3: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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-->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.

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Reviewer #1: Children’s right to play in Chilean Hospitals. A Forgotten Right? A Qualitative Study Protocol: Reviewers Comments

The rationale of the Study

The proposed study on children’s right to play is relevant within the context of Chilean public hospitals. The inquiry focuses on the institutional arrangements and opportunities for play available to children and adolescents who are hospitalised in public hospitals, an area that has received limited research attention, thus addressing an important gap in research.

This research will contribute to understanding the significance of mapping and enhancing play facilities in pediatric wards and advocating for children's right to play. The findings will benefit various disciplines beyond medicine, such as occupational therapy, social work, psychology, and physiotherapy. It is intended that the findings of the proposed study be used to enhance the play opportunities for children and adolescents in Chilean public hospitals. This proposed study has the potential to be replicated in hospitals globally, including private hospitals.

The rationale of the study is clear and valid. The aim and the objectives are feasible.

Theoretical Framework

The Play theoretical framework is suitable for the study. However, it is not explicitly stated which play theory is being used. It would therefore be beneficial for the authors specify and clearly articulate the theory they are employing, such as Huizinga's Cultural Play Theory, Stuart Brown's Theory, or others. Additionally, considering the integration of Locke's theory of human rights with the play theory could further enhance the theoretical framework as it relates to the rationale of the proposed study.

Methodology

Taking a qualitative approach using the constructive paradigm is well justified. Using a design that is exploratory design is appropriate. The location of the study is also suitable and well-justified.

To enhance the study, it is recommended that the authors consider using a mixed-method approach to incorporate and account for the rapid assessment checklist they plan to use, which is quantitative. This will provide a more comprehensive and balanced analysis of the data.

Sampling

The convenience and purposive sampling techniques are adequately described and justified. The selection process and criteria for the participants and hospitals are clear.

Issues to be addressed by authors are:

• To state the exclusion criteria for both participants and hospitals.

• Clarify which region will have two cases and the justification for that decision.

• The authors should include a section on how they will gain access to hospitals and how the ethical approval processes are carried out in Chilean public hospitals. Discuss the approval process in depth, including whether the Ministry of Health or hospitals themselves approve research.

Data Collection and tools

Semi-structured interviews, a non-participant observation guide, and a rapid assessment checklist are appropriate tools for collecting data in this study. The data collection process is described in detail.

Issues to be addressed by authors are:

• Will the semi-structured interview schedule and the NPO guide be piloted? If not, provide a justification.

• The authors should explain why they have chosen online data collection over face-to-face interviews.

• The use of Ethnographic methodology is mentioned, but clarity and justification are needed regarding the duration of observations. The NPO tool can be used as a stand-alone tool.

• Will the interviews be conducted in English or Spanish?

• Rapid Assessment Checklist:

� It is unclear who in the pediatric ward or hospital will be recruited to administer the assessment. Please clarify.

� The “WHO” assessment checklist covers seven standards for assessment. The translated checklist covers Standard No.1 from numbers 1 to 21. Is this intentional? If so, please justify.

Data Analysis

The data analysis processes are clearly outlined. If the mixed method approach recommendation is adopted, the analysis will have to be adjusted accordingly.

Trustworthiness and Rigour

The authors have explained how they will use triangulation to ensure the trustworthiness and rigor of the data.

• It is important to include all aspects of trustworthiness, such as credibility, transferability, dependability, and confirmability.

• Consider the validity and reliability of the Rapid assessment.

Ethical Considerations

The ethical considerations are well-described, but a discussion on beneficence is necessary.

Timeline of the study

The timeline needs to be revised for accuracy.

Dissemination of results

The authors have outlined a comprehensive plan for disseminating the study results, which includes:

• Publishing in peer-reviewed scientific journals

• Presenting at conferences

• Conducting a seminar for study participants

• Organizing a public conference by the research team

Reviewer #2: The proposed study is very good and the study design is apprpriate and well described. I wish the investigators all the very best for this study.

Reviewer #3: Dear authors, I appreciate the opportunity to review your proposal.

I would like to highlight that the proposal has significant potential to contribute to the advancement of knowledge and its implementation in developing countries such as Chile. The proposal is well-structured, clear, and addresses a relevant topic with a robust scientific approach. Additionally, it objectively presents the theoretical context of the research, emphasizing the importance of the right to play for hospitalized children and justifying the relevance of the study in the Chilean context. However, a few aspects could be improved or clarified to further strengthen the quality of the proposed research.

1. In the introduction, it is pertinent to highlight the reality of developed countries, such as the United States and Canada, which differ significantly from South American countries due to the presence of professionals known as Child Life Specialists. These professionals focus on using play to promote the well-being of hospitalized children. Comparing these distinct realities could further emphasize the relevance of the proposed study, demonstrating that, regardless of the existence of a professional dedicated to this role, play should be recognized and promoted as a fundamental right of every child.

2. Although the project defines free play, chosen and directed by children, as a guiding principle of the process, it is important to emphasize that playful interactions between children and healthcare professionals are also valuable sources of data. These interactions can either promote or restrict play, depending on the actions of the professionals. Including an analysis in the interviews regarding how professionals approach play and their attitudes toward playful activities is insightful, but it could be further enriched if this analysis is also incorporated into the observation phase. For example, observing situations where professionals encourage or inhibit play (due to lack of time, perceptions of the value of play, or institutional factors) could reveal important dynamics. It is suggested to integrate these interactions into the observation process, considering the comparison between the narratives in the interviews and the actions observed in the environment, which are not always aligned.

3. The study's hypothesis is solid and addresses a real and potentially significant issue. Its approach offers the potential to reveal valuable insights into the disparities in upholding the right to play for hospitalized children in Chile.

4. The research setting is well-represented, and the selection of the four regions is appropriate to capture the geographical, socioeconomic, and cultural diversity of Chile, which may impact the guarantee of hospitalized children’s right to play.

5. The choice of a qualitative approach is appropriate as it allows for a deeper understanding of the factors influencing children’s opportunities to play in hospitals. This approach enables the exploration not only of the material and structural resources of healthcare institutions but also of the perceptions and decisions of healthcare professionals regarding play, which is essential for understanding practical barriers and opportunities. The focus on the different perspectives of healthcare professionals, including both medical and non-medical staff, is a relevant approach, as play can be influenced by various factors within the hospital. The comparison between interview narratives and observational d

6. Regarding the materials and methods, further clarification is needed on how the interviews will be conducted and the composition, roles, and qualifications of the research team. Will the research team be present in the various regions selected in the country? Are they residents of these regions? Will there be financial resources allocated for the team's travel? Who will conduct the interviews? Does the interviewer have expertise in qualitative interviews? Will there be training provided? Do they have any prior connection to the research setting? Additionally, it remains unclear whether the interviews will be conducted in person or remotely.ata will provide a robust foundation for understanding the phenomenon under study.

7. The systematic approach to observation needs to be better described. Who will be the observer? Do they have experience with this method of data collection? Will training be provided on how to document the findings from the observations and ensure consistency among observers? How much time, in hours or days, is planned for the observations? Will they occur during different shifts? Will the individuals working in the observed settings be informed about this proposal? If behaviors are being observed, I recommend consulting the Ethics Committee regarding the need to obtain informed consent (IC), even if prior approval has been granted. When observing behaviors, particularly in a context involving interactions with children, it is essential to ensure that informed consent is obtained. While the proposed non-participant observation might involve minimal or no interaction with individuals, it still requires informed consent, especially given the vulnerability of the child population.

8. I understand that the lack of information regarding how the research team will be composed, trained, and how the logistics for conducting observations in different hospitals will be handled is a significant gap in the proposal. In terms of resources, it would be crucial for the project to detail in the methodology whether there will be adequate financial support or logistical backing to ensure that the team has the necessary resources to travel, conduct observations, and collect data systematically. This would ensure the feasibility of the research and its potential for replication.

9. The proposal for analyzing the interviews and observation data is well-structured and follows a solid qualitative analysis approach. The use of a combination of deductive and inductive analysis is relevant, especially since the study is based on an in-depth and contextualized understanding of the phenomena, rather than seeking generalizations. Furthermore, the use of Atlas Ti software as a tool to facilitate the organization and coding of interviews is an effective choice. However, it would be interesting to provide more detail on how the integration between manual analysis and the software will be carried out. The idea of an interdisciplinary analysis also seems important, but could be more specified in terms of how different areas of expertise within the team will contribute to the analysis. Nevertheless, the proposal for triangulation is well-applied, relevant, and, in this context, provides clarity and depth to the research findings.

10. In summary, the study is promising and addresses a highly relevant topic with the potential to positively impact hospital practices related to the right to play. The suggestions presented aim to further strengthen the proposal, ensuring greater clarity and feasibility for its implementation.

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Reviewer #1: Yes:  Babalwa Dano

Reviewer #2: Yes:  Manoj Shankarrao Patil

Reviewer #3: No

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Children’s Right to Play in Chilean Hospitals. A Forgotten Right? – A Qualitative Study Protocol

PONE-D-24-19286R1

Dear Dr. Glos,

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.

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Academic Editor

PLOS ONE

Additional Editor Comments (optional):

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 #2: Yes

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?

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 #2: Yes

Reviewer #3: Yes

**********

-->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 #2: Yes

Reviewer #3: 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 #2: Yes

Reviewer #3: 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 #2: Yes

Reviewer #3: Yes

**********

-->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 #2: The proposed study is very good and the study design is apprpriate and well described. I will be happy to see the final results. I wish the investigators all the very best for this study.

Reviewer #3: Dear Authors,

I would like to congratulate you on the careful revisions made to the manuscript, which have greatly strengthened the work. The changes implemented, particularly those related to the interview guide with the additions about free play and medical play, are extremely valuable. These inclusions have deeply enriched the data collection, providing a more comprehensive understanding of the phenomenon being studied. It is with great pleasure that I contribute to the reading of this project, which will undoubtedly have a significant impact on understanding the dynamics of play in hospital settings and how it affects the well-being of Chilean children. The way you addressed the suggestions received, clearly explaining the decisions not to incorporate some of them, was also exemplary.

Sincerely,

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-->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 #2: Yes:  Dr. Manoj S. Patil

Reviewer #3: Yes:  Edmara Bazoni Soares Maia

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