Patient-reported outcomes (PROs) are an emerging paradigm in clinical research and healthcare, aiming to capture the patient's self-assessed health status in order to gauge efficacy of treatment from their perspective. As these patient-generated health data provide insights into the effects of healthcare processes in real-life settings beyond the clinical setting, they can also be viewed as a resolution beyond what can be gleaned directly by the clinician. To this end, patients are identified as a key stakeholder of the healthcare decision making process, instead of passively following their doctor's guidance. As this joint decision-making process requires constant and high-quality communication between the patient and his/her healthcare providers, novel methodologies and tools have been proposed to promote richer and preemptive communication to facilitate earlier recognition of potential complications. To this end, as PROs can be used to quantify the patient impact , they can play a prominent role in providing patient-centric care. In this paper, we introduce the MyPal platform that aims to support adults suffering from hematologic malignancies, focusing on the technical design and highlighting the respective challenges. MyPal is a Horizon 2020 European project aiming to support palliative care for cancer patients via the electronic PROs (ePROs) paradigm, building upon modern eHealth technologies. To this end, MyPal project evaluate the proposed eHealth intervention via clinical studies and assess its potential impact on the provided palliative care. More specifically, MyPal platform provides specialized applications supporting the regular answering of well-defined and standardized questionnaires, spontaneous symptoms reporting, educational material provision, notifications etc. The presented platform has been validated by end-users and is currently in the phase of pilot testing in a clinical study to evaluate its feasibility and its potential impact on the quality of life of palliative care patients with hematologic malignancies. AccordiTo this end, the aim of palliative care is to assess and aid the patient needs regardless of the place where they are cared for . Though frequently interpreted as end-of-life care, palliative care focuses on life and takes into consideration dying as a normal process, without any intention of hastening or postponing death. Its main goal is to preserve the best possible quality of life until death by supporting the patient not only through physical problems but other additional problems of a social, psychological, and spiritual nature. To this aim, palliative care is focusing not only on the patients themselves but also on their families. As the main purpose of palliative care is to improve quality of life, it can be offered to patients (and their families) who are receiving active treatment either in a curative fashion or aimed at disease control. In this modern view, the adoption of palliative care should not be restricted only to end-of-life or hospice care. It is an essential component of the trajectory of any serious chronic illness and a necessary component of care for patients with chronic diseases. Along this line, palliative care should begin at diagnosis and increases in “dosage” throughout the continuum of illness. Randomized controlled trials conducted in the US support the benefits of early integration of palliative care into clinical care. Though these results were not replicated in European studies, they deserve further investigation considering their potential relevance for the management of the patients with chronic conditions and in particular those diagnosed with solid tumors or hematological malignancies.As palliative care is a highly personalized treatment paradigm, the patient is (or at least should be) an active member of the decision-making team. Thus, the communication between the patient and the respective healthcare team, is identified as a top-class priority, and eHealth tools could provide the means to move toward better communication and cooperation in terms of treatment decision making process.Patient-reported outcomes (PROs) are an emerging paradigm of patient management and patient-doctor communication focusing on the patient reporting his/her health status instead of the doctor evaluating it. In the last 10 years, a number of digital interventions aiming to support palliative cancer care based on the electronic PRO (ePRO) systems have been evaluated. In , 24 releThis paper provides details for the design and development of the MyPal infrastructure, based on a user centered development process. More specifically, for the realization of MyPal, web and mobile applications have been developed including the MyPal mobile app, the healthcare professional tool and the administrator panel offering a unique user experience to patients, doctors/researchers and caregivers. The design and the implementation of the MyPal intervention is based on extending and adapting recent achievements from other projects, such as iManageCancer , 8, and The rest of the manuscript is structured as follows: Section Methods presents the methods used for the design, development and validation. In section Proposed digital intervention model we elaborate on the proposed digital intervention model and section Validation presents the results of the internal validation for the platform. In section Discussion we discuss the results, while section Conclusions concludes this paper and provides directions for future work.An agile user-centered or “participatory design” methodology has been adopted to identify end-user needs and to design the overall MyPal platform. More specifically, focus groups, i.e., focused discussions among groups of end-user representatives, were conducted to elaborate on the use cases and identify potential restrictions and end-user requirements. To facilitate the discussion, a number of vignettes were designed, i.e., scenarios that present at an abstract level the envisioned functionalities of the platform to be developed with the help of one or more imaginary users of the platform. A vignette has been designed following an imaginary middle-aged male diagnosed with chronic lymphocytic leukemia (CLL) or myelodysplastic syndrome (MDS) in his journey. The vignette has been translated to the following languages: English, Greek, Italian, and Czech as focus groups were conducted in Greece, Italy and Czech Republic. A discussion guide has also been designed, consisting of a general comment section (addressing the platform as a whole) and several feature/functionality specific sections. The audio material of the focus groups was analyzed, and the main findings of each focus group were expressed as three separate lists of themes, namely positive comments, negative comments, and recommendations. The identified themes were additionally tagged according to the functionality they refer to and they were taken into account to guide the design of the platform. Each use case was checked against the relevant focus group themes to ensure that the resulting use case was compatible with the opinion of the corresponding end-users; in case of discrepancies, the use case was revised accordingly.The patients engaged in this “participatory design process” were recruited via patient advocacy groups, approximately matching the targeted patients' profile. The enrolled patients' profile is outlined based on specific eligibility criteria defined by the respective clinical study protocol to be applied during the pilot phase of the project and can be summarized as follows: Adults (≥18 years); Diagnosed with CLL or small lymphocytic lymphoma (SLL), a condition equivalent to CLL, or MDS; Scheduled to receive any line of treatment for CLL/SLL or MDS or who have been previously exposed to any treatment for CLL/SLL or MDS; Able to understand and communicate in the respective language; Users of an Internet connected device (smartphone/tablet); life expectancy more than 3 months.The MyPal software architecture refers to the fundamental structures of the MyPal platform and the discipline of creating such structures and systems. The development phase followed a scrum methodology , which odata tier, which contains data extraction, transformation and serving functionalities, (ii) the tools tier, which contains the technology components, such as ePROs (via mobile/desktop apps and a game), self-management tools and psycho-emotional assessment, (iii) the interaction tier, which contains disruptive user interfaces for the end users, particularly adapted to their needs and preferences, and, finally, (iv) the privacy and security tier coping with user privacy and data security aspects.The conceptual framework of MyPal includes the integration of several building blocks supporting patients and their healthcare providers, having at its cornerstone advanced PRO systems, data reporting, storage and tools . The buiThe procedures of automatically generating, storing and exchanging personal data, in compliance with data security regulations, require a large number of functionalities offered by well-designed and interconnected building blocks. To this end, MyPal defines a modular architecture with interoperable functional blocks, combining, and going beyond the current state-of-the-art in ePROs with voice ePROs, interactive information access and intelligent recommendations of goals. All these technologies are combined in order to finally develop an innovative solution for an enhanced user interface, enabling patients, healthcare professionals (HCPs), and family caregivers to fully utilize their potential, knowledge, and valuable skill sets.MyPal combines all the technological blocks to provide a unique user experience supported by electronic questionnaires, conversational agents and gamification to overcome the limitations in acceptability of traditional human-computer interaction techniques for the MyPal users.A privacy and security layer wrap the whole architecture, data flow and interactions. The privacy-by-design approach , i.e., tThe validation of the platform before being deployed in real-world conditions was identified as an important part of the overall participatory design process. It involved end-users, namely both patients and healthcare professionals via virtual and physical focus groups. More specifically, scenario-based “think-aloud” sessions were conducted to collect user feedback and identify potential issues before testing the platform in real-world settings. The walk-through usage scenario was divided into episodes, each describing a specific functionality/task pertaining to the MyPal platform . A “think aloud” approach was adopted during these meetings, where the participants were encouraged to be as talkative as possible while performing the requested actions, expressing their initial reactions, thoughts, worries and other considerations and also discouraging the validators from intervening or providing guidance. At the end of each meeting, the participant was asked to complete an anonymous short questionnaire either online (for the HCPs) or in printed forms (for the patients). The questionnaire included some general demographics questions, the questions of the Post-Study System Usability Questionnaire (PSSUQ) and 3 questions on general comments and recommendations for the MyPal platform.More specifically, the virtual validation workshops with HCPs were conducted as one-on-one teleconference meetings. Each meeting lasted for ~1 h and was recorded for later analysis of end user behavior, comments, and reactions. Every participant received in advance an email containing a presentation of the walkthrough scenario, a consent form for the recording and a PDF file of a CLL-related scientific article to serve as a sample document to upload for the MyPal search functionality.The validation focus groups with patients were organized by CERTH  engaging adult patients diagnosed with CLL, all living with the disease for an extended amount of time. This was deemed important for the validation purposes, since they had a good understanding of their disease and its management needs. It should be noted that these validation sessions focused on the MyPal mobile app as this was identified as the riskiest part of the specific intervention in terms of usability.In order to evaluate the potential impact on both emotional and physical symptoms of the proposed platform on adult patients with hematological malignancies, a specialized clinical study has been designed aiming to investigate if it can lead to improved quality of life via a two-arms randomized control trial (RCT). To this end, a number of widely accepted measurement scales and standardized questionnaires are included, i.e., the EORTC QLQ-C30 General Questionnaire , the EurThe study protocol was defined by MyPal-Adult Task Force which comprises of representatives of each involved clinical site as well as contributing members of the project's consortium. The participating clinical centers involved in the MyPal clinical trial are:Università Vita-Salute San Raffaele (USR)/IRCCS San Raffaele Hospital in ItalyUniversity General Hospital of Heraklion (PAGNI) in GreeceGeneral Hospital of Thessaloniki “George Papanikolaou” in GreeceUniversity Hospital Brno (FNBRNO) in Czech RepublicKarolinska Institutet (KI) in SwedenParticipating center selection was based on disease-related established expertise for MDS and CLL, relevant experience in clinical trial design and conduct and longstanding collaboration in previous research projects. The MyPal4Adults study  aims at improving the quality of life of patients with hematologic malignancies by implementing the use of palliative care at an early stage in the disease course. The study design is based on the comparison of a standard care arm with an experimental arm. Only patients randomized to the experimental arm will use the MyPal eHealth system and complete ePROs at pre-specified timepoints. Data collected will be analyzed to understand if MyPal intervention is leading to improved QoL and should be implemented as standard approach for patients with hematologic malignancies. The expected advantages will be analyzed in terms of both effectiveness and cost-effectiveness.Prior to the recruitment, a rehearsal testing was performed, to evaluate the platform and assess its usability in clinical practice. Major technical issues were eliminated and feedback from participants was taken into consideration. As part of the clinical study protocol, initially, patients are informed, sign consent, and complete baseline questionnaires. Then each patient in the experimental “intervention” arm actively participates in the study regularly providing ePRO information for 6 months (main usage phase). After the first 6 months, there is a further 6 month “follow up” phase where only monthly questionnaire input is collected. Patients recruitment is currently ongoing at all clinical sites .The architecture of the MyPal infrastructure, shown in The MyPal mobile application was developed as a part of the MyPal platform for adults to advance palliative care for people with cancer by leveraging PRO systems through their customization to the personal needs of the cancer patient and their caregiver. In doing so, important variations in the patient's condition and quality of life (QoL) need to be identified as soon as possible. The app allows adults suffering from hematologic malignancies to capture and provide reports on QoL, side effects of cancer therapy, and medication adherence to their treating oncologists. The application provides users with functionalities for reporting questionnaire data, symptoms, medications, searching validated medical content and viewing the data collected from a wearable. The patient will be able to capture and send the following reports to the MyPal server:Study Support survey – a six-item questionnaire representing factors related to patient engagement . Depending on the answers to the questions, the patient will receive periodic motivational messages that address the factors in their survey responses in priority order. The patient will complete the survey three times during the study: at the start of the study, by the end of the third month, and the sixth month after the subject patient is enrolled in the MyPal Adult clinical trial.Treatment Support survey – a six-item questionnaire representing risk factors for non-adherence. Patients who are on treatment for CLL or MDS will be prompted to complete this via the app. The answers to the questions will guide the treating physician to conduct a tailored patient interview during the next appointment, using the HCP Discussion Tool in the MyPal platform. The patient will complete the survey three times during the study: at baseline, by the end of the third month, and the sixth month after the subject patient is enrolled in the MyPal Adult clinical trial.Three questionnaires to capture symptoms, pain, and emotional state to be completed weekly. These questionnaires represent corresponding standardized questionnaires: the Edmonton Symptom Assessment System (ESAS), Brief Pain Inventory (BPI) severity and Emotion Thermometers (ET).QoL questionnaires on a monthly basis.The patient will be directed to the MyPal web application to complete four additional The patient is notified when to complete a questionnaire.symptoms on an ad hoc fashion (including pictures)The patient can record and communicate his/her view the data collected from a FitBit activity tracker in the application: the number of steps and the data about his/her sleep quality. This data is also sent to the MyPal server.The patient will be able to medications in the app to define reminder times for taking the medication in order to receive reminders in the defined times.The patient can enter his/her search engine to search for content related to her/his disease using advanced search techniques for medical terms . The MyPal Adult app is being implemented with FlutterThe MyPal web application for the healthcare professionals was developed as the central access tool of the MyPal platform for clinicians and nurses. A user centered design was adopted for the development and healthcare professionals were involved from the early stages of the design. The web application is responsive and accessible through smartphones, tables, and desktop computers and is available in five languages Greek, Italian, Swedish, Czech, and English (only for demonstration purposes). The web application provides to healthcare professionals interactive tools based on data and visual analytics, reinforcing their actions through the identification of important deviations in the patient's symptoms and quality of life. The goal of the web application for the HCP is to reinforce patient-clinician communication and improve symptom management. The potential improvement in symptom management and relief is based on meaningful interpretation of PROs which are fed directly and in real-time at the point of care. Furthermore, the exploitation of these heterogeneous data provides long-term and consistent health information along the disease timeline.The web application for the healthcare professionals consists of various components including notifications, aggregated dashboard, individual's dashboard, discussion tool, CRF cost form and upload medical documents. Notificationspage  of health-related quality of life as well as costs for the intervention vs. non-intervention cohorts. The CRF cost form is completed by the clinician for a specific patient during the regular visit of the patient to the clinic.The back-end infrastructure of MyPal consists mainly of a database to store MyPal data, an authentication server based on OAuth2.0 and software modules that are necessary to support the functionality of these tools. An audit/log mechanism is in place which records all the transactions of the users supporting the visibility and transparency, while the administrator has in his/her disposal a UI for the management of the users, overview of the audits and a testbed for all the available REST services.At each clinical site the MyPal administrator can use the platform to add new users. In In the section “Groups” the administrator can see a list of group categories. Usually there is no need to view/modify anything in this section; these have been configured for MyPal during the initial installation of the platform.In the section “Users” the administrator can view a list of the existing users (user accounts' pseudonym and only with the minimum data) or add/modify a user account.For security privacy and legal reasons, it was decided that each clinical site will have an independent deployment in their premises. With local deployments in each clinical site  a separate instance of the software platform is installed in order to collect and store the data of each clinical study to a dedicated database, located at the corresponding hospital where the patients are enrolled. Scripts, manuals and virtual machines were provided to the IT teams of each hospital from the MyPal developers for the local deployments. Local deployments provide separation of datasets per clinical site and isolation of any security issues, and no risks from data transfer. Nevertheless, local/independent installations have also drawbacks such as more effort for the multiple deployments and extra processing and anonymization of the datasets for the evaluation of the results.Regarding validation, seven virtual validation workshops with HCPs were conducted to validate the HCP web application; five of them were involved in the MyPal-Adult study and two in the MyPal-Child study. However, since HCP part of the MyPal web platform is almost identical for the two studies, the results of the validation workshops were consolidated. The vast majority of the HCPs involved, managed to complete the scenario-based actions mostly without assistance from the validation expert. The initial patient registration proved to be the most confusing, which later led to the creation of an “HCP Quick Reference Guide” to clarify the process. Moreover, the “think aloud” approach as the HCPs performed their tasks, offered several insights on the intuitiveness of the platform's design; the interactive features of the dynamic graphs presented in the aggregated and individual's dashboards were not always apparent although once familiar with them, the HCPs expressed very positive feedback for their usefulness. The need for a consistent user experience, intuitive design and adequate communication of information  was also regularly stressed during the workshops. The PSSUQ score  was calcNine patients in total participated in the validation focus groups, as mentioned in the Methods section. After being presented with the validation scenario (similar to the vignettes used during the participatory design phase) the patients were asked to perform a series of actions on the MyPal mobile app. All of the participants successfully completed the actions with the majority of them requiring no assistance in doing so. As with the HCP web platform's graphs, the dynamic, color coded controls for answering the ePROs were met with enthusiasm. However, for the older patients, the rather small font size of the application, as well as some interactions/gestures–like double-tapping and scrolling through various menus—seemed to cause frustration. The spontaneous symptom report confused a lot of the patients, since they were unfamiliar with the terms mentioned in the menu . Finally, the two quick reference guides for the MyPal mobile app exploited the feedback gathered during the validation sessions. The overall PSSUQ score was 2.8 with the subfactors being 2.7, 3.1, and 2.5 for the System Usefulness, Information Quality and Interface Quality, respectively, as shown in After a cancer diagnosis, patients and their families face a series of challenges such as coping with fear and anxiety associated with a life-threatening disease and having to make difficult decisions about treatments . CommuniOn the other hand, healthcare providers encounter a lot of challenges in the provision of care to patients with cancer, a chronic, complex, and life-limiting disease. Communication with patients can be demanding across the disease trajectory from the moment of disclosure of cancer diagnosis, to the administration of treatment, treatment failure or relapse as well as the provision of any act of supportive palliative care throughout .Considering the above, it is obvious that more sophisticated and thorough approaches are urgently needed for refined cancer management. A paradigm-shift is occurring in healthcare  whereby MyPal is one of the few research projects that proposes an eHealth intervention and evaluates it with international clinical trials across Europe. The volume and range of tasks related to the organizational and technical aspects of on-site preparations raised a number of challenges especially with the decision to support five independent deployments, one at each clinical site. Fortunately, the expertise and active involvement of all clinical and technical partners was essential to overcome these challenges.We must acknowledge that data collection and data handling, especially for information coming from patients, pose various challenges. For that reason, MyPal applied widely accepted risk management approaches  during the Data Protection Impact Assessment process.Another challenge is the Coronavirus COVID-19 pandemic that delayed the commencement of the clinical studies. Until now, all participating hospitals are using their resources to deal with the emergency at hand and patients with serious conditions are advised against visiting the hospital unless it is absolutely necessary. Since MyPal digital intervention supports remote reporting of health-related data from patients, the clinical trials started with a small delay taking into consideration all the protocols for COVID-19.The validation phase proved to be essential to the development cycle of the MyPal platform, continuing the participatory approach that has been adopted during the design phase. Both the HCP virtual workshops and the patient focus groups, using the MyPal solution well-before the clinical trials, offered valuable insights for the users' actual experiences. The HCP web application and the mobile app were both very favorably received by the participants and their perceived value regarding PROs was validated. Several usability issues regarding functionality and appearance aspects were revealed and elucidated into clear action points for each development team and thus resolved in a timely manner.Currently the MyPal clinical trials in all five hospitals are running and it seems that there may be some differences between individual clinical sites in terms of recruitment rate. In some hospitals, for example, out of all the patients that meet the study criteria, only a very few are willing to participate. Patients are not familiar with mobile devices, they are used to classic phones only, which makes them ineligible for the study. All the patients above 60 years are reluctant to use modern technologies and do not seem to trust them. Younger patients, who are more accepting and capable of using mobile device, are often a part of another clinical study, or are too busy or generally not interested in being observed at higher frequency by the HCP. A high proportion of patients with CLL are in watch and wait mode so not receiving any treatment, therefore qualifying as not eligible to the study protocol. Another drawback for the recruitment is that the patients are not willing to attend the clinic every month especially with the COVID-19 pandemic. In some cases, it seems difficult to persuade patients to take part in the study, since they do not feel any need to be more involved. This passivity in terms of patients' engagement might be specific to the central Europe environment.As a whole, we argue that the train of new clinical operational paradigms  based on emerging technical paradigms  is already moving. However, due to the huge volatility and speed of technical developments, their actual integration as part of every-day clinical routine is far from trivial, raising cross-cutting issues going beyond technical or operational sciences silos, including aspects of both . To this end, the evaluation of eHealth interventions via clinical studies is crucial, and as such we argue that MyPal could provide a useful example both in technical and methodological terms.The diversity of cancer patient needs for palliative care is enormous. A patient-centered approach for palliative care should take into account many aspects, such as the spectrum of symptoms and clinical manifestations of the particular disease, the patient's age and overall physical condition (including comorbidities), the treatment aim , the medication plan and its impact in QoL, life expectancy, lifestyle and exposures (including concomitant medication) as well as patient preferences, health literacy, etc. Some of the above aspects, such as the experience of adverse drug effects, are dynamic by nature, adding further difficulties in adequately addressing the individual patient needs for palliative care. MyPal aspires to provide such a patient-centered approach for palliative care of cancer patients in capturing more accurately their symptoms/conditions and communicating them in a seamless and effective way to their healthcare providers. While there are various PRO systems available, they typically lack the required flexibility to address the individual patient needs, hampering their potential due to their inherent “one-size-fits-all” approach.MyPal focused on the thorough understanding of the varying patient needs across disease trajectories and designed a comprehensive, adaptive intervention to accommodate these needs. MyPal successfully developed and deployed a digital intervention for palliative care cancer patients overcoming several technical challenges with the continues collaboration of the clinical and technical partners of the project. Apart from the technical challenges of such an effort, one must be prepared for unpredictable parameters, such as COVID-19, and provide flexible solutions.Through the validation activities, MyPal not only confirmed the perceived usefulness of the developed digital tools but also achieved higher levels of user acceptance by implementing modifications according to the end-user's feedback. It seems that clear communication with the end user through consistent menus, intuitive visual cues and notification messages is key to a positive user experience that ensures the engagement with the MyPal platform.Our validation results demonstrate that such a digital platform for palliative care can improve the QoL of the patient and improve the communication between patient and physicians, a finding that is in line with literature. MyPal will evaluate a digital intervention in adults suffering from haematologic malignancies through clinical trials that are conducted in diverse healthcare settings across Europe.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.LK: conceptualization, methodology, and writing—original draft. FS, MC, PA, and GZ: methodology and implementation. PB, JD, and EK: validation. MS: implementation. CKak: validation and writing. CKar: conceptualization, methodology, and validation. LS: conceptualization and validation. KM: supervision, conceptualization, and review. PN: supervision, review, and project administration. All authors contributed to the article and approved the submitted version.Research supported by the MyPal project which has received funding from the European Union's Horizon 2020 research and innovation program under the grant agreement No 825872.This article reflects only the author's view. The Commission is not responsible for any use that may be made of the information it contains.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Learning analytics aims to analyze data from students and learning environments to support learning at different levels. Although learning analytics is a recent field, it reached a high level of maturity, especially in its applications for higher education. However, little of the research in learning analytics targets other educational levels, such as high school. This paper reports the results of a systematic literature review (SLR) focused on the adoption of learning analytics in high schools. More specifically, the SLR followed four steps: the search, selection of relevant studies, critical assessment, and the extraction of the relevant field, which included the main goals, approaches, techniques, and challenges of adopting learning analytics in high school. The results show that, in this context, learning analytics applications are focused on small-scale initiatives rather than institutional adoption. Based on the findings of this study, in combination with the literature, this paper proposes future directions of research and development in order to scale up learning analytics applications in high schools. Over the last several years, technology has become an essential tool to support students and instructors in creating more effective educational experiences. In this context, the propagation of online learning environments  has increased significantly, expanding the data generated about the educational process . These dTo reach the potential of analysis of this data, learning analytics emerged as a field that focuses on collecting, analyzing, and reporting data about learners and contexts in which learning occurs . The useLearning analytics has been widely researched and used in higher education institutions, especially due to the maturity level of adopting data analysis tools in these institutions . HoweverThere are many educational challenges in the high school context that involve all stakeholders in teaching and learning processes . LearninBased on this context and in the fact that several literature reviews present the potential in using learning analytics in different educational contexts, such as higher education, professional and workplace learning, vocational education, for massive open online courses, but not for the high school context, this paper presents a systematic literature review focusing on the applications of learning analytics 59 in high schools. The SLR enables the identification, evaluation, and interpretation of previous works that provide details about methods, tools and use of learning analytics in this context. More specifically, this review aims to provide a broad description of the main approaches, educational goals, techniques and challenges related to learning analytics and high schools.The following sections of the paper present: The most popular definition of learning analytics was presented by the Society for Learning Analytics Research (SoLAR) at the First Learning Analytics and Knowledge Conference in 2011—LAK′11 . LearninDespite the presumable advantages of using learning analytics, few publications explore the benefits of the learning analytics field in high schools . AlthougSeveral literature reviews about learning analytics have been published in the last 11 years since the first edition of the LAK conference. For instance, Besides these general reviews, the most common topics of the previous SLR are related to specific methods, especially related to the development of visualizations and dashboards . In shorPrevious studies also described how learning analytics developed in specific world regions. For instance, Finally, other reviews report on the use of learning analytics in higher education , professMoreover, it is important to remark that the high school context is significantly different from the educational settings of the previous reviews. For instance, the students in high school are usually under 18 years , which could raise different ethical concerns and needs for LA. Besides, in general, the high school teachers’ technology backgrounds are not the same as professors at the universities. Finally, the data collected from students in high schools do not involve many interactions with learning management systems or MOOC platforms, which are the primary data collected for LA application.The objective of this SLR was to identify primary studies that focus on the use of Learning Analytics techniques aiming at solving high school problems. Based on this context, this study addresses the following research questions:RESEARCH QUESTION 1 (RQ1):What are the educational goals of using learning analytics in high schools?The first research question focuses on the fact that the primary purpose of using Learning Analytics is educational rather than technological . TherefoRESEARCH QUESTION 2 (RQ2):What are the approaches for the use of learning analytics in high schools?Prediction: the use of regression and classification techniques to predict learning outcomes; 2) Clustering: application of different unsupervised methods to group similar instances of the data ; 3) Relationship mining: this category includes methods related to association rule mining, sequential pattern mining, process mining, and casual data mining; 4) Distillation of data for human judgment: methods in this category include visualizations  and statistical analysis to assist humans to make sense of the findings and support decision making; 5) Discovery with models: this category describes the application of models proposed in previous study, but analyzing new data to discover more patterns.To answer the second research question, we adopted the categories proposed by previous works : 1) PredAfter understanding the approach of using learning analytics, we intended to identify the leading machine learning algorithms that have been implemented in the development of learning analytics systems for high schools. This analysis is essential as machine learning approaches are largely used by the LA community . TherefoRESEARCH QUESTION 3 (RQ3):Which machine learning techniques have been used to support learning analytic systems in high schools?In order to evaluate the potential of using LA for high school, the fourth research question focuses on describing the evidence of learning analytics research in high schools. Previous literature performed a similar evaluation for higher education success . In thisRESEARCH QUESTION 4 (RQ4):What evidence, if any, shows that Learning Analytics improves the performance of students in high schools?Finally, we also looked into the main challenges in using learning analytics reported by the studies retrieved in this literature review. This research question aims to make research aware of potential issues with the adoption of LA to high schools and provide a direction on how to avoid them. As such, the last research question is:RESEARCH QUESTION 5 (RQ5):What are the challenges in using learning analytics in high schools?The SLR developed in this study followed the guidelines proposed by Kitchenham . The revThe first step in the systematic review was a keyword search. This study explored five academic databases to conduct the search: ACM Digital Library, IEEE Xplore, ScienceDirect, SpringerLink, and Scopus. The selection of these databases was based on the literature  and assu“learning analytics” AND “high school” was applied to each academic database cited above to conduct the search. To obtain a wider range of papers in this initial interaction, the keywords were applied for all fields of the article, not restricted to title and abstract. The query The second step of the review was carried out to exclude papers out of the scope. In this review, only primary studies published in journals, conferences, or workshops about applying learning analytics to improve teaching and learning in the context of high schools were included. Moreover, studies that were not published in the English language nor available online were excluded.Rayyan, a free web tool designed to help researchers work on systematic reviews and dramatically accelerate the process of screening and selecting studies , followed by Brazil and the Netherlands (n = 2).The search process retrieved 42 relevant studies. They were written by 111 authors based on institutions from 23 different countries, distributed in four continents. n = 0) and the years with most publications were 2020 (n = 10).Finally, the most common keywords used in the selected articles with their respective frequency were: students (16), Learning Analytics (12), data mining (12), teaching (6), high school 5) education (5), high school students (5), computer-aided instruction (5), E-learning (5), learning systems (4), learning (4), curricula (4), feedback (4), machine learning (4), and data visualization (4). The top five keywords–students, learning analytics, data mining, teaching and high school–reflect precisely the research theme of this SLR.The first research question raised in this SLR was related to the main educational goals of using learning analytics in the context of high school. The main goal of applying learning analytics in high school was to predict student droput or to predict and enhance students’ learning outcomes. There was an effort to predict students’ grades in order to provide support and personalization . For insIn addition to the prediction of final grades, learning analytics in high school was used to predict school dropout , discoveThe second most cited educational goal identified was to analyze students’ learning processes. Most works aligned to this goal investigated students’ participation in assessment and educational games using log data. For instance, multiple data sources, including self-report models and activity logs, were collected from 25 classes at a senior high school in northern Taiwan, aiming at the application of supervised and unsupervised lag sequential analysis (LSA) for examining students’ learning processes . Grover The support of teachers’ decision making and reflection was also found relevant in the papers retrieved. In this context, Another relevant topic found within the scope of this research question was the support of writing activities . The mosFinally, we also found papers related to real-time adjustable feedback , analyseIn learning analytics, visualization is one of the main topics of research and practice. In the categories that we used for evaluating the approaches used in high schools, visualizations are categorized as the distillation of data for human judgment. There were several examples of the application of visualizations to support different stakeholders in high schools. For instance, Visualizations were also employed to provide reflections for high school language teachers . In thisThere were two main lines of work in terms of prediction: predicting students at risk and student learning outcomes. This finding is closely related to the results of RQ1, but it includes a broader view of prediction in the context of high schools. For example, In terms of prediction learning outcomes, Relationship mining aims at analyzing association, sequential, and collaborative patterns in educational data. In this context, learning analytics was used to examine student practices in different learning scenarios. For instance, The papers related to discovery with model categories focused on the use of previous models in new contexts. For instance, Finally, the category with the fewest papers was clustering. In this case, data analysis techniques were applied to assess the student-student and student-teacher interaction to see how the information extracted from clustering analysis can affect teaching strategies, especially those related to strategic group formation and school management . LailiyaThe techniques listed in this section are highly related to the educational goals presented in The papers related to analyzing students’ learning processes predominantly applied decision tree algorithms and clustering techniques . It is iAs expected, natural language processing (NLP) techniques were found in papers that support writing activities. For instance, This section reports the results about the evidence found on the impact of learning analytics in the context of high school Unfortunately, the majority of the papers retrieved (25–59.52%) did not present any details that could ensure this kind of evidence. Moreover, none of them reported negative evidence. We divided the papers with positive evidence with and without empirical evaluation, which related to the papers that reported the adoption of learning analytics in practice and the papers reporting only experimentation, respectively.The papers that reported empirical evaluation presented the practical use of learning analytic tools by students or teachers. For instance, The majority of the papers retrieved in this SLR did not explicitly highlight any challenges of the application of learning analytics in high schools. However, the main issues raised were related to data quality, especially when considering different sources of data , and priOther technical issues related to possible data collections were also considered. For instance, problems related to internet connectivity  and the This section presents the main insights of this systematic literature review, in the light of previous literature on learning analytics. Moreover, we highlight the main aspects that should be addressed by studies that adopt Learning Analytics in the high schools’ context.The first research question analyzed in this study focused on the main educational goals for using learning analytics in schools. We found that these goals are focused on predictions of learning outcomes rather than supporting instructors and students in the decision-making process, or understanding students’ behavior. This is a characteristic of the initial articles in the field of learning analytics . Recent Our review did not reveal papers suggesting the analysis of school context, which is considered a critical activity to ensure successful learning analytics adoption . In geneConcerning the second research question, about the main technical approaches used in learning analytics for high schools, it is possible to draw a direct comparison of learning analytics for high schools and higher education. Although the top-3 categories coincide between the findings of the current review and the In terms of machine learning algorithms used in the studies included in the current review (third research question), almost 50% benefited from white-box algorithms such as decision trees and logistic regression. The use of white-box algorithms is a trend, and even a recommendation, in educational applications of machine learning . PreviouThe fourth research question revealed the lack of evidence on the success of the application of learning analytics reported in the studies included in the current review, suggesting that learning analytics is in the early days of adoption in high schools. The majority of the papers did not indicate any evidence demonstrating that learning analytics could be efficient when applied to practice. On the other hand, in the context of higher education, learning analytic applications are starting to scale to an institutional level .Another reflection of limited maturity in adopting learning analytics in high schools is the reduced number of challenges reported in the studies included in the current SLR (fifth research question). The central claims in this direction were related to data quality, privacy, and technical issues . While in the case of higher education institutions, the literature reported more complex concerns, such as stakeholders’ involvement, understanding of institutional needs, and more general ethical, privacy protection, and data governance issues .Institutional diagnosis: A very important issue we have noticed in the papers included in the SLR is the absence of a methodological process to understand schools needs and context for learning analytics adoption. In this direction, several frameworks have been proposed for adoption of learning analytics in higher education. For instance, 1. Ethical concerns: In a similar direction, it is important to consider ethical issues (2. l issues . For insLearning analytic techniques: learning analytic applications, in general, focus on the learning process and not only on the learning outcome (3.  outcome . For ins outcome , it is n outcome , epistem outcome , and pro outcome  instead Explainable artificial intelligence: Although this literature review highlighted the importance of using white-box machine learning methods, recent literature proposes the combination of deep learning with explainable artificial intelligence techniques in the analysis of educational data (4. nal data . Specifinal data .Based on the results described in this paper, we highlight the following aspects to be considered by researchers working with learning analytics in high schools:The primary limitation of this study is related to the search process in which we only focused on papers that contain the specific keyword “high school”. This could potentially exclude papers that describe the adoption of learning analytics in secondary schools, the terminology used by other countries to refer to high school in their educational systems.Secondly, a few papers had limited information about the methods and techniques used, which led to several coding some studies with labels such as “no details” and “no evidence” in some of the categories that were analyzed in the current review. We decided to keep these papers nevertheless because they contained relevant information to at least one research question. However, it is important to highlight that we performed a critical assessment to assure the quality of the paper.Finally, this review did not focus on papers in the fields that are related to learning analytics such as educational data mining and artificial intelligence in education, which could broaden the reach of this SLR.


Although pharmacotherapy is considered the first-line treatment for bipolar disorders (BD), adjunctive psychoeducation has proven its effectiveness in improving self-management of the disease and reducing relapse rates. Few studies have evaluated the effect of brief group psychoeducation on pragmatic variables, such as the number of hospitalizations. The aim of the present study was to assess the mid-term effect of a four-session group psychoeducation on course-related variables in BD. Thirty-two individuals with BD were included in the study. Sixteen were exposed to psychoeducation and were matched to sixteen nonexposed individuals who received their usual treatment. Both groups were compared on insight, treatment adherence, change in the number of hospitalizations and visits to the emergency services, occurrence rate after intervention, and time to the first psychiatric hospitalization and the first urgent attendance. There was a significant reduction in the mean number of hospitalizations and urgent attendances in the exposed group in comparison to the nonexposed group. The first urgent attendance was significantly sooner in the nonexposed cohort. There were no differences between groups in any of the other variables. This intervention has shown benefits for pragmatic variables of the disease course and may be a feasible and cost-effective intervention to routinely implement in the management of BD. Bipolar disorder (BD) is a chronic and recurrent illness characterized by mood oscillation episodes associated with a reduced quality of life ,2 and a Most studies on group psychoeducation perform long therapies, usually up to 21 sessions, while shorter ones would be even more cost-effective. In this line, some authors have proposed brief psychoeducation interventions, ranging from four sessions ,17 to eiTo this purpose, the present study aimed at assessing the mid-term effect of a brief group psychoeducation program (with both information and coping skills components) on the objective measurement of course-related variables in a sample of bipolar patients. The implementation of feasible and cost-effective interventions is to be investigated so as to provide real-world data, which should guide public health decisions.This was a retrospective cohort study conducted in outpatient facilities of the Department of Psychiatry of the Hospital de la Santa Creu i Sant Pau . All participants were adults (age ≥ 18 years old) meeting criteria for bipolar I disorder according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). The total sample included 32 subjects, 16 of whom had received the exposition.In this study, exposition refers to having participated to brief psychoeducation groups consecutively held in the unit, from September 2015 to April 2017. Attendance to these groups is open to all outpatients. These structured groups consist of four weekly sessions of 90 min each, imparted by two clinical psychologists. We designed the intervention based on the Spanish version of the Psychoeducation Manual for Bipolar Disorders by Drs. Colom & Vieta , as it hThe nonexposed cohort was composed of 16 outpatients also affected by bipolar I disorder, whose psychiatrist did not refer them to psychoeducation intervention (specific reasons could not be gathered). To avoid differences between exposed and nonexposed individuals, both groups were matched by educational level, years until bipolar diagnosis, basal level of insight, and basal level of medication adherence. The educational level was considered because this factor may influence the results of psychosocial interventions. The reason for pairing by basal level of insight and treatment adherence was to prevent the outcomes from being biased by initial differences between cohorts. For each subject in the exposed group, his/her matched pair was randomly selected among those outpatients meeting the matching characteristics. These 16 nonexposed subjects had been receiving their usual pharmacological treatment and psychiatric controls while their exposed pairs attended the group psychoeducation. The study time points coincided in both groups.The following outcomes were compared between the exposed and the nonexposed cohorts:Insight improvement: a comparison of the insight level at baseline and a year after the intervention, to determine if there had been an improvement or not. The insight level at each point was classified as poor, partial, or good, according to the patients’ psychiatrists’ clinical impression. This information was obtained from the patients’ routine medical records; if it was missing, we directly asked the patients’ psychiatrists to classify their insight into poor, partial, or good. Improvement was defined as changing from poor at baseline to partial or good after a year, or from partial to good.Treatment adherence improvement: a comparison of the treatment adherence at baseline and a year after the intervention, to determine if there had been an improvement or not. The treatment adherence at each point was evaluated by checking the registers of the plasmatic levels of the drugs, and was classified into poor, partial, or good. Improvement was defined as changing from poor at baseline to partial or good after a year, or from partial to good.Change in the number of psychiatric hospitalizations: the number of hospitalizations during the year after the intervention was compared to the number of hospitalizations during the previous year.Change in the number of visits to the psychiatric emergency services: the number of emergency consultations for depressive or hypomanic/manic symptoms during the year after the intervention was compared to the number of consultations during the previous year.Occurrence rate of psychiatric hospitalizations and visits to the psychiatric emergency services after the end of the group psychoeducation.Time to the first psychiatric hospitalization and the first visit to the psychiatric emergency services after the end of the group psychoeducation.Our hospital belongs to the public national health system, which is free and universal. Patients can visit the psychiatric emergency service whenever they need to, and the decision to carry out a psychiatric hospitalization is made by the psychiatrist in the emergency room according to the severity of symptoms. It can also be taken by the patient’s regular psychiatrist.All the information was obtained from patients’ medical records and/or by asking their regular psychiatrists in order to avoid missing data. The study was approved by the Clinical Research Ethics Committee at the Hospital de la Santa Creu i Sant Pau, and it followed the principles outlined in the Helsinki Declaration of 1975.Data were analyzed using the StataIC 13.1 .t-test for independent samples . For categorical variables, chi-square tests were performed (or Fisher’s exact tests if the expected frequencies were <5).Descriptive statistics were performed to describe the sociodemographic and clinical profile of both cohorts (exposed and nonexposed) at baseline. Quantitative variables were compared using a Student’s t-test for independent samples was performed. The same method was conducted for the number of visits to the psychiatric emergency services, but, in this case, a two-sample Wilcoxon rank-sum test was performed, since this variable did not follow a normal distribution.Improvements in insight and treatment adherence were analyzed by comparing the proportions for matched data. Their 95% confidence intervals (95% CI) were also calculated. Changes in the number of hospitalizations were analyzed by comparing the differences of means  between both cohorts. Since this variable followed the assumptions of normality and homoscedasticity, a Student’s To determine if there were differences between both cohorts in the occurrence rate of hospitalizations, a Cox’s regression model for recurrent events (counting the process model of Andersen–Gill ) was useThere were no statistically significant differences between the groups, either in terms of insight improvement  or in terms of treatment adherence improvement .p = 0.018). There was also a decrease in the mean number of visits to psychiatric emergency services in the exposed group and an increase in the nonexposed one (see right side of p = 0.029).As shown in Most of the psychiatric hospitalizations and visits to psychiatric emergency services were due to manic episodes. Specifically, manic symptoms were the cause of 100% of the hospitalizations and 40% of the emergency attendances in the exposed cohort, and of 78.6% of the hospitalizations and 75% of the emergency attendances in the nonexposed cohort. When analyzing the raw data, there were no differences between the groups either in terms of the occurrence rate of hospitalizations  or in terms of the occurrence rate of urgent attendances . However, when controlling for the presence or absence of psychotic features, the rate of hospitalization was significantly lower for the exposed group . This means that the estimated risk of hospitalization for those subjects that were nonexposed to the brief psychoeducation intervention was 2.39 times higher than the risk for the exposed subjects (95% CI = 1.05–5.44). There were no differences between the groups in terms of urgent attendances . A summary of these results is exposed in H) and first psychiatric urgent attendance (HRU) were higher in the nonexposed cohort, these differences were not statistically significant .Even though the hazard ratios of the first psychiatric hospitalization (HRp = 0.046).As represented in Our results show that this brief group psychoeducation for subjects with bipolar I disorder may be effective in reducing the number of psychiatric hospitalizations and urgent attendances in the following months, as well as in increasing the time to the first urgent attendance. The design of the study does not allow one to draw robust conclusions, but these promising preliminary results encourage one to perform experimental studies to properly evaluate its efficacy.The effectiveness of adjunctive group psychoeducation in improving the course of bipolar disorder has been extensively proven , but theContrary to our expectation, this brief intervention was not able to improve either the insight or the pharmacological adherence of our patients. One reason may be that many subjects in both cohorts had good basal levels of insight and treatment adherence see , and theDespite its promising results, this is a pilot study with limitations, such as a small sample size and limited follow-up period. To validate these results, a randomized controlled trial should be conducted with a larger sample, a more accurate assessment of insight, and a longer follow-up period. This latter aspect would enable one to test whether treatment effects dissipate over time, and whether or not it may require additional prompting after the conclusion of the intervention. Given the observational nature of the present study, it was not possible to gather specific reasons for the nonreferral to the group intervention of the nonexposed cohort. This is a controversial issue for interpreting the results, but in any case special efforts in matching the two groups were made so as to have comparable individuals. Another limitation was that this intervention was administered in patients with bipolar I disorder, so these results cannot be generalized to patients with other types of the disorder. Besides these weaknesses, this study provided clinically relevant information since it was carried out in the context of the usual clinical practice, reflecting the conditions and resources available in the Spanish health system. The implementation of common strategies such as brief group psychoeducation, as well as monitoring and evaluating them, can be useful as the results allow one to guide evidence-based therapeutic decisions for BD patients.Studying the impact of these interventions, specifically on objective indicators, would motivate their inclusion in the routine treatment of people with BD beyond pharmacological intervention and symptom management.In conclusion, this brief four-session group psychoeducation may be a feasible and cost-effective intervention to routinely implement in the management of bipolar I disorder. The benefits of this program on pragmatic variables of the disease course provide useful information favoring public health stakeholders’ decisions regarding cost-effective interventions.


In order to develop a gripping system or control strategy that improves scientific sampling procedures, knowledge of the process and the consequent definition of requirements is fundamental. Nevertheless, factors influencing sampling procedures have not been extensively described, and selected strategies mostly depend on pilots’ and researchers’ experience. We interviewed 17 researchers and remotely operated vehicle (ROV) technical operators, through a formal questionnaire or in-person interviews, to collect evidence of sampling procedures based on their direct field experience. We methodologically analyzed sampling procedures to extract single basic actions . Available equipment, environment and species-specific features strongly influenced the manipulative choices. We identified a list of functional and technical requirements for the development of novel end-effectors for marine sampling. Our results indicate that the unstructured and highly variable deep-sea environment requires a versatile system, capable of robust interactions with hard surfaces such as pushing or scraping, precise tuning of gripping force for tasks such as pulling delicate organisms away from hard and soft substrates, and rigid holding, as well as a mechanism for rapidly switching among external tools. The versatility of the human hand in manipulation is still barely emulated by robotic grippers ,2. In thIf robotic manipulation is demanding on land, issues become even more evident in challenging environments such as space, oceanic depths, and hazardous or disaster sites. Bringing human manipulation capabilities to harsh environments is a challenge that must overcome traditional design and robotic concepts , and preWhen tackling the robotic design of manipulation tools that are strongly characterized by capability in versatile manipulation, a methodological approach consists of investigating how manipulative actions are performed in order to understand fundamental design features in terms of architecture choice or control modes. In particular, manipulative actions are often classified into a comprehensive and hierarchical structure, namely a taxonomy of manipulative actions, which might suggest insights for implementation. In the following, we mention some works that follow this approach.One of the basic manipulations is the grasping of an object. Cutkosky  developeA comprehensive taxonomy of manipulative actions for the human hand was also proposed by Bullock , which dContact discrimination was exploited recently in an automatic algorithm for semantic decomposition and recognition of manipulative actions, called semantic event chain (SEC) . This alThe reasons for choosing a specific manipulation procedure or tool for marine sampling with a remotely operated vehicle (ROV) has never been systematically described, and this knowledge is still limited to those who have personally taken part in ROV cruises. To the best of our knowledge, a book chapter by Clark et al.  on deep-For these reasons, we performed an investigation concerning biological sample collection procedures. Investigations can be performed with different methodologies. For example, in Mizera et al.  this anaCollection of reports of sampling procedures involved researchers that took part in sample collection campaigns; those descriptions were integrated with the analysis of video reports from . Once thOur aim was primarily to identify the specific needs of deep-sea scientific sampling that could lead to the development of efficient and versatile technologies. The added value of our approach does not reside in the claim of a new technology that could potentially solve manipulation related issues, but in a clear statement of the needs that a versatile solution should cover.The contribution of this paper resides in the identification of task-related requirements for the design of an innovative gripper and shared control algorithms for assisting the pilot during deep-sea sampling.This process required two steps, the results of which are reported in the present series of two papers. The first step consisted of a thorough analysis of the commercially available gripper technologies currently used for underwater collection of scientific samples, and a systematic review of the research status of underwater grippers, which we performed in . As a seConsequently, the paper is organized as follows. In In The survey had a two-step structure: Step 1 involved a brief questionnaire, Step 2 a more in-depth questionnaire or interview. The brief questionnaire was sent to marine researchers from the institutes and universities listed in Role assumed in ROV cruise operations;Detailed list of samples collected;His/her availability for a second, more in-depth questionnaire or interview.Step 1 consisted of a brief questionnaire, in which the researcher had to indicate:Description of the sample and its consistency and deformation properties;Surrounding environment;ROV sampling methods: detachment, collection and release type;Suggestions on the “ideal” tools, and the features of samples that should be preserved for analysis.Researchers that expressed availability for further collaboration were invited to contribute to Step 2 of the survey, either through a questionnaire supplied by email or via an online interview depending on their preference. The series of questions was identical in both the Step 2 interview and the questionnaire, and had the following structure , hence allowing their grouping. Once this framework is built, it can be exploited to create technologies that better suit the application, and planning and control frameworks that automate the series of actions can be developed.To classify actions, a series of definitions concerning the level of complexity of the action, the type of action according to its purpose, and the role of the agents involved in the manipulation were stated.Activity or Manipulation sequence is intended as an articulated sequence of manipulations involving multiple objects for a specific task ;Atomic manipulation or atomic action, intended as the specific interaction of the manipulator with an object ;Key-event is an event delimited by two specific time points, which are defined by the instant in which any pair of agents  involved in the activity makes contact, or releases the contact ;Manipulation primitive is the basic component of a manipulation, and consists of a semantic expression that is the nearest to the robot command language .Coherently with Aksoy et al. , we adopHand-only actions, where only the hand (or a grasped tool) acts on an object;Separation actions, where the hand manipulates an object to remove, detach or separate it from another object;Release determined actions, where the hand combines an object with a second target object.The concept of a key-event introduces a temporal segmentation to the activity, which depends on the spatial relationship between the objects observed in terms of contact. When observing contacts among all involved objects, the ongoing atomic action can be recognized by referring to a vocabulary of atomic actions proposed by Wörgötter et al. . WörgöttOur analysis of underwater manipulations differs from that in Wörgötter et al.  because Actions can be represented by means of SEC matrices ,24. The Answers to the questionnaires and interviews were initially reorganized by grouping the targeted organisms by phylum, and then describing all the possible manipulation sequences that were used for a particular phylum, also reporting the eventual tools employed. Features related to the organism, environment, available equipment or intended post-collection analysis guided the choice of a particular procedure, and hence they were also reported.As described in Each manipulation sequence reported by the researchers was manually segmented using the algorithm explained in Aksoy et al. . Brieflythe detachment of the organism from the substrate or the detachment of a fragment from the whole organism;the collection of the sample;the placement into the storage system.The manipulation sequence we targeted to build our taxonomy of manipulative actions was the activity of “sampling a marine organism or one of its parts with a robotic manipulator (SMO)”. SMO considered:the operations performed by the manipulator pilot to prepare, readjust, or open the selected storage system; generally, these actions are performed just before the sampling;the operation of fitting the sample to the storage system, which is often needed where the dimensions of the container are not suitable for the sample;measures to counteract eventual buoyancy or floating out of the sample after insertion in the storage system, or the closing mechanism of the container.This analysis of manipulation sequences tackles the placement, but it does not deal with preparation or opening of the container, nor corrective actions in case placing is not straightforward. More specifically, our analysis of SMO does not include:Nine had never directly participated in a campaign in which samples were collected with a ROV;Eight declared they were not available for further collaboration;Seven were sent the Step 2 questionnaire;Twenty were contacted to schedule the Step 2 interview.A total of 44 researchers responded to the Step 1 questionnaire:A total of 17 researchers responded to one or the other of the forms of Step 2. Hence, at the end of the data collection, we had two complete answers to the Step 2 questionnaire and 15 complete answers to the Step 2 interview.The roles of the researchers participating in Step 2 were biologists, zoologists, geologists, ROV pilots and developers a. The ge5. Grip, 5.1 Grip and twist);a number in case of a modified version of the basic action ;“A” if the action is performed using a tool; in this case, a third digit would distinguish among different tools : these atomic manipulations are just slightly modified versions of Suction on and off with suction sampler (atomic manipulations 7.A.1 and 9.A.1). Performing Suction on and off without an additional tool such as a suction sampler is possible if the gripper has a suction channel directly embedded into it.Scissor cut, Lever and Pull (Hook) : these manipulative actions extend the taxonomy we identified from the analysis of researcher reports. In researcher comments , for example for the pouring action or for twisting to detach organisms or fragments.The remaining outputs of the questionnaire are reported in The actions identified are easily framed within the ontology of atomic manipulations described by Wörgötter et al.  see Sec.Before presenting how we linked our taxonomy to the ontology identified for the human hand, a disambiguation is needed concerning the way we classified the pick-and-place action, which slightly differs from . WörgöttWithin our taxonomy of manipulative actions, it might happen that the gripper contacts the object when detaching it, and the hand might not be free again until the storage phase is complete. Regardless, in the case of marine sampling, it seems too simplistic to consider this sequence a single release-determined atomic action as in Wörgötter et al. , for at The framing of the actions of the underwater manipulation taxonomy into the ontology of actions identified for the human hand  was fairWe also carried out, based on Wörgötter et al. , analysiIn this section, we analyze the manipulation strategy trends for each major phylum targeted, discussing the reports by researchers : we try Cnidarians  include Leiopathes sp., and some alcyonaceans), the applied force might fail to sever the skeleton, or might break the skeleton but not separate the tissues, and the overall gripping action might result in a squashed sample: therefore, researchers suggested implementing a cutting tool on the gripper, which could be activated to cut a branch or a fragment once the sample has been gripped.When the desired sample is a fragment of an organism with a brittle deformation characteristic , the choices are picking and breaking , or scraping the branch tips with a tool that might eventually collect detached pieces before they fall; pushing branches to break them in order to collect fragments later is also a solution. For fragments of cnidarians that have a wiry skeleton and/or strong coenenchyme . Where brittle organisms  or wiry elastic alcyonaceans are on friable substrate , pushing and breaking the substrate and then grasping the lowest visible part of the skeleton of the focal species is an effective strategy. For antipatharians that generally grow on harder substrates, which are difficult to break, grasping the lowest visible part of the skeleton and pulling might be the only choice to try to collect the whole organism, but strong pulling force is required.When the whole colony (whole branching structure) is needed, the choice depends on a compromise between organism consistency and the consistency of the substrate. If the substrate is soft or loose, grasping the lowest visible part of the skeleton and pulling might work, since this will likely retrieve the whole organism, including the buried part. For brittle organisms, grasping the lowest visible part of the skeleton before pulling is important to avoid crumbling of the sample  might be scraped from their substrate, or a piece of the host structure could be collected if possible.Some cnidarian taxa, such as sea anemones, sea pens, and tube-dwelling anemones (ceriantharians), might retreat into their tube or substrate, so they need to be approached with caution. In particular, the gripper should be fast-closing to allow the organism to be gripped before it retracts. Sea pens may have spines: in this case, the use of a suction sampler should be avoided, as it could lead to self-piercing and spoil the sample.In our survey, jellyfish sampling was not addressed by the researchers. Deep-sea sampling of jellyfishes using ROV suction tools has been reported in the literature, mainly using suction samplers with gentle suction flow ,28.Dendronephthya and scleractinians were collected with the bellow-type actuator, and an alcyonacean whip coral with the boa-type [Stellamedusa collection directly from the water column was performed with RAD [As pointed out in , researcboa-type ,30; bothboa-type , and a Swith RAD .The dimensions of marine arthropod  taxa sucMacrocheira). Preferences among collection procedures depend mostly on size and lifestyle: pycnogonids of a few centimeters in size on soft substrates are well collected with sediment coring. Encrusting barnacles instead need to be detached from the substrate. Larger swimmers or crawlers such as crabs or shrimps are collected with traps, because the manipulator–gripper system is too slow to catch them in the water column . The suction sampler might be used for organisms of sizes compatible with the sampler nozzle; for larger sizes, their rigid carapace could block the tube, making the sampler device unusable for the rest of the dive. Additionally, it was reported that when storage jars have a metallic filter at the end, the turning flux in the jars during suction could scratch the exoskeletons of arthropods.Other taxa of this phylum are instead much larger  are picked or scooped as well, but due to their use of arm autotomy as a defense mechanism, the choice of grip location is fundamental. Sea stars were successfully collected with the Wyss 3DP gripper [Different collection strategies were reported for the echinoderms  accordin gripper . Sea cuc gripper , Tshingu gripper , Wyss 3D gripper  and five gripper . Finally gripper .Collection procedures for sponges  depend oThiolava veneris, that forms filamentous mats) was sampled by collecting the volcanic rocks on which this grew. Although not deep-sea, researchers also reported that algae [Polychaetae worms  can be cat algae  could beIn this section, we present a summary and discuss the issues raised and the perspectives offered in the free-text comments of researchers concerning grippers and tools they used during sampling procedures.Most of the comments on the grippers concerned the grasping force: not all devices provide force feedback to the pilot, and regulating the grasping force ends up being a difficult operation, highly reliant on the pilot’s experience. The issue of preventing unwanted release of the sample due to currents or during drag was often mentioned as well. Dimensions and closure range were two other important features: most of the animals, except for large benthic animals or rocks, would require a smaller gripper, or the possibility of having the full range closed (sometimes the samples slide through the fixture for the T-bar handle); on the other hand, full closure of the gripper could squash the sample. The closure speed of the gripper is equally important for samples that could escape or retract.Comments on the suction sampler mentioned the issue of clogging: the choice of suction sampler for a sample is made looking at the compromise between suitable sample dimensions and consistency. In fact, big samples or very rigid ones are likely to block the tube. Once the sampler is clogged, it cannot be used for the remaining duration of the dive. Suction flow needs to be adjustable, because higher intensity is needed to detach the sample, but lower intensity flows prevent the loss of sample integrity for very fragile samples. Samplers need a good positioning system as well: positioning the tip close to the sample is crucial to obtain enough force for detachment, and a manipulator with good workspace and manipulability is important to use the sampler to approach organisms in the water column.Problems related to storage systems can depend on the choices made during pre-dive. It is not easy to foresee the right container dimension or box partitioning, as this requires guessing which samples are likely to be found during the next dive. Moreover, the ROV might lack a built-in storage rack: in this case, the positioning of the basket container needs to be carefully chosen with respect to the manipulator’s position. In any case, accessibility of the container should always be checked in pre-dive. The insertion of the samples into a container is not an easy procedure either, but it is structured enough to be the best suited for automation, especially for complex actions such as pouring into a container. A frequent problem concerns the use of multiple partitions within the same box, because when the cover of a box is opened a second time for the insertion of a new sample, the previously inserted samples might float out because of buoyancy, ROV stabilization movements, or currents.The answers to the questions regarding desired features for an ideal gripping tool highlighted additional fundamental and optional features. First of all, a general-purpose tool was preferred to task-specific tools, because changing tools resting in the ROV rack generally takes time and tools can become tangled. While an envelope grasp was suggested for delicate animals , the need for a prehensile gripper remains for detachment purposes. Tweezer-like extensions to the fingers of common grippers were suggested for dealing with smaller samples. Similarly, the need for rigid parts for scraping, and concave parts for scooping, was underlined. Suction sampler functionality could be enhanced with the possibility of tuning suction flow, and a pruner-like cutting tool would be ideal for the highly frequent sampling of corals. For corers, a means of automation of the insertion or retrieval procedure that preserves substrate stratification is desirable, especially for geological analysis.In this section, we list the requirements for a gripper for biological marine sampling: we distinguish among environmental requirements, operational requirements and task-related requirements. Environmental requirements  enable tAlong with the study of the literature on underwater grippers performed in  and fromGuaranteeing water resistance is normally tackled by exposing all mechanical components whose functioning is not hampered by the water, and enclosing only the water-sensitive ones (often motors and electronics) in water-resistant containers. Proper sealing techniques are available for different working depths and pressure. Water resistance is one of the main reasons why, in most of the designs, transmissions are employed to delocalize the actuators and control electronics from the distal part of the gripper. Issues in fabricating water-resistant electronic components affect the realization of functional tactile sensing for the marine environment .proper design and dimensioning of the component, including minimization of uncompensated volumes ;pressurization of the components .Tactile sensing functioning depends on pressure resistance: sensors should ideally work under a wide range of pressures while providing measurements that are independent from external pressure. In general, pressure-related issues are twofold: pressure adds design constraints to avoid the failure of the component, and it can affect water resistance by promoting water intrusion. Again, countermeasures are taken only for components sensitive to compression. Consistent with the expected working depth, countermeasures mainly involve:Ideally, the specific gravity of the gripper should be near to that of water, so that its weight is mostly supported by upthrust . Moreover, internal volume variation among different configurations of the gripper should be avoided in cases of pressurized components (unless “adaptive” pressurization systems are available). Internal volume variation changes the upthrust effect, after which variation avoidance is needed to achieve accurate modeling and control against gripper buoyancy effects.Recently implemented safety measures against mechanical overload or impacts consist of employing compliance, both intrinsic (as for soft technologies) and mechanical (as for backdrivable transmissions or decoupling actuation systems), and compliance in control systems, where the possibility of sensing is available.Along with the study of the literature we performed in  and fromConsidering that part of the weight of the gripper is also supported by upthrust, constraints on gripper mass related to arm payload requirements in general are not particularly stringent for hydraulically actuated manipulators, while they start becoming relevant for lightweight electronic manipulators. To reduce arm inertia, it is better to keep the mass as low as possible. This is one of the main reasons why under-actuation is selected for grippers: indeed, motors generally have a consistent weight.Efficiency of energy use is important, especially where use on untethered systems is foreseen. To ensure low impact on the energy consumption of the supporting system , ideallBased on analysis of the task (SMO) from researcher reports on sampling procedures that were analyzed in this paper, we extracted task-related fundamental and optional requirements .A first discussion point arises on the most suitable technology: a rigid gripper is a solution that generally satisfies RE.F T5. On the other hand, if the system is soft, it offers the possibility to absorb accidental impacts with the environment and to adapt its grasp to the organisms .A prehensile grasp emerged as an important feature for detachment. Whenever collection of the sediment is not possible, and cutting part of the organism would prevent the intended analysis, the strategy is to try to pull the sample out from the sediment. In this case, the request for proper tuning of the grasping force for soft organisms or samples is dependent not only on the consistency of the organism but also on the amount of pulling force required to pull out the organism without squashing it. Force feedback is provided by few technologies, and currently most of the ability to control force depends on the pilot’s experience. Advances in sensor technology  that achCombining multiple tools into a single instrument is advantageous from the perspective of saving time spent changing instruments, but might eventually require additional actuators to switch between the different configurations. A compromise between this integration and the number of controllable actuators should be envisioned, as well as a stable way to quickly and rigidly connect and disconnect tools that are not integrated into the gripper. The Victor 6000 claw , with itIssues envisioned in the automation of the storage procedure concern both the gripper and manipulator systems. In teleoperation, imprecise absolute positioning of the manipulator might not be that relevant because the teleoperator might compensate for it, but it becomes significant when automated actions are implemented ; hence, Finally, the payload requirements of the gripping system are mainly driven by the amount of force needed for performing the actions that are propaedeutic for sampling procedures. Typical payloads of commercial manipulator–gripper systems range from 10 kg to 40 kg for electrically actuated ones, and 10 kg to 500 kg for hydraulically actuated ones [Manipulator–gripper systems for underwater operations were mainly conceived for the heavy duties of industrial and commercial applications, such as pipe inspection, cable management or sunken object recovery. While adaptation of the vision and sensing systems of industrial ROVs to scientific aims is more straightforward, the feasibility of tasks such as sample collection is limited, and requires non-standard equipment to be added. Moreover, equipment has to meet rigorous safety standards. Consequently, the longer-term perspective on augmentation of industrial ROVs with functional equipment for scientific purposes is dependent on a comprehensive presentation of the requirements in advance of the actual possibility of final deployment .With this paper, we aimed to define the requirements for underwater biological sample collection in at least two respects. Firstly, a methodological analysis of the procedures for collection as explained by researchers in the field was performed to abstract the basic actions needed, regardless of the particular tool employed. A second approach considered further needs raised by the researchers, in order to improve the collection procedure, enable additional possibilities for sample analysis, or meet species needs.The challenges in building a system that meets the requirements listed is related not only to the obstacles imposed by immersion in deep water, such as waterproofing or pressurization, but also to the fact the ideal device seems to be an integrated multi-purpose tool that is able to handle multiple situations that might be encountered in unpredictable and unstructured environments, demonstrating robustness and reliability. Complementary to improvements to tools for gripping and storage systems, the automation of structured but demanding tasks is relevant.In our investigation, we had few reports on sampling procedures within the water column: this might have caused us to neglect specific actions for sampling in the water column in our taxonomy of manipulative actions. Further data collection in this area might extend this taxonomy.The ultimate benefits of a system that enhances possibilities for scientific marine research are the reduction of the duration of diving campaigns, the reduction of pilot efforts and, not least, successful sampling. This drives toward a smarter employment of the resources available for exploration and direct analysis of the biodiversity of the deep ocean, which is still widely unexplored. Finally, enhancing manipulator dexterity and capabilities results in a greater chance of preserving an environment to which humans had limited access until a few decades ago. Moreover, those advances pave the way towards performing in situ analyses, or tests that would be influenced by bringing the sample to the surface.