The umbilical cord acts as the critical lifeline of the developing fetus by providing nutrients and oxygen to it. Umbilical cord abnormalities are considered the leading cause of stillbirth in humans, but information on stillbirths associated with umbilical cord abnormalities is very scant in the clinical practice of animals. Here, we described a case of fetal demise in camels indicated to be caused by fetal death from strangulation by its umbilical cord, which is commonly known as the nuchal cord. A pregnant camel at its 36 weeks of gestation spontaneously aborted a single fetus. The camel was 5 years old and nullipara. A 6-day-old cloned embryo was transferred transcervically to the recipient. Pregnancy was confirmed 50 days after embryo transfer by ultrasonography, and the pregnant camel was maintained under a standard nutritional plan. The neck of the aborted fetus was strangulated tightly by a double loop of the umbilical cord. There was no congenital anomaly or other malformation in the fetus. We concluded that the nuchal cord was tightly coiled around the neck of the fetus and interfered with the blood flow in the fetus by collapsing the umbilical vein and subsequently causing fetal death and abortion. To the authors' knowledge, this is the first reported case of a nuchal cord in camels. Intrauterine life is maintained by the umbilical cord, which is the conduit between the developing fetus and the placenta. The fetus receives oxygenated and nutrient-rich blood from the placenta through umbilical veins, and umbilical arteries send back low oxygen and nutrient-depleted blood to the placenta. Any kind of lesions to the umbilical cord originating from structural, mechanical, hamartomatous, infectious, or other damage may lead to an indisputable cord failure which eventually prejudices the life or wellbeing of the fetus .A nuchal cord develops when the umbilical cord becomes wrapped around the fetal neck. The prevalence of nuchal cord is very common in humans, and at parturition, it ranges between 6 and 36% , 3. It cThe predisposing cause of the nuchal cord could be the uterine, fetal, and/or umbilical cord biometrics, such as length of the umbilical cord, volume of placental and amniotic fluid, and fetal movement in the uterus . Sherer in vivo matured oocytes. A photograph of the transferred embryo is presented in A 36-week pregnant camel  spontaneously aborted a single fetus in a large-scale cloning facility. The camel received a single 6 day old embryo produced by somatic cell nuclear transfer using Camelus dromedarius confirmed the reliability of cloned calves from donor cells (data may be provided upon request).A fetal sac was observed on the ground in the morning. The recipient had obvious signs of abortion. On autopsy, a full-grown fetus was found. The neck of the fetus was strangulated tightly by double loops of the umbilical cord . There wPregnancy loss is a common ailment that affects a large number of camel pregnancies. However, there is no complete study on the incidence and causes of abortion in Camelidae. Here, we describe the first reported case of pregnancy loss in a camel by fetal death from strangulation by its umbilical cord, which is commonly known as nuchal cord. Although this is the first reported case of fetal strangulation in camel, it is likely not unique. We assume that this may be a fairly common event, although there is little supportive evidence, and to our knowledge, no direct data are reported.The possible connotation between nuchal cord and stillbirth is unclear. Hammad et al.  reportedThe utilization of advanced reproductive biotechnologies in camels has increased substantially in recent years. Our group alone has produced hundreds of cloned pregnancies in the past 3 years –9, and tIn conclusion, although no nuchal strangulation reports are known in veterinary medicine, reports on human are prevalent. Ultrasonographic evaluation of pregnancy in camels at the later period of gestation is particularly difficult. No non-surgical methods exist at present to address the nuchal cord, and induction of parturition may be the only recourse. The umbilical cord may be affected by a number of abnormalities that may originate during pregnancy, labor, or delivery. It is important to investigate the underlying mechanisms of the development of cord morphology and possible pathologies associated with it, because this may provide important insights regarding fetal growth in the intrauterine environment and its impact on later life.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The animal study was reviewed and approved by Management of Scientific Centers and Presidential Camels (Accession No: PC4.1.5).Y-BS and MH designed the experiments and prepared the manuscript. XY, YJ, and PO collected the samples and reviewed the manuscript. WH supervised the project. All authors have read and approved the final version of the manuscript.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.


Studies have shown that aerobic exercise (AE) may improve symptoms related to non-specific neck pain (NNP); however, the variables of the exercise programs and the overall effectiveness of AE have not been evaluated in a systematic review. Therefore, this review aimed to describe and discuss the variables of the AE programs used in clinical trials for patients with NNP. Included studies were analyzed for the selected AE variables such as intensity, frequency, duration, delivery, supervision, and adherence. The PEDro scale was used to assess the methodological quality of the studies. From the literature search, six studies met the inclusion criteria and were evaluated. After reviewing all the included studies, it was found that a range of AE interventions were used such as cycling, brisk walking, aerobics, stationary bike, treadmill running, circuit training, and swimming. Further, the duration was between 30 and 45 min for each session, with or without progressive increases from week to week. The intervention periods ranged from 1 month to 6 months in duration. Most studies used AE three times per week. Furthermore, exercise intensity was measured with either subjective (BORG) or objective measures (heartrate reserve). Justification for the specified intensity and reporting of adverse events was reported only in two studies and differed between studies. Exercise interventions were poorly reported. This review showed that moderate-intensity AE undertaken three times per week, in patients with NNP, may be beneficial for pain and function; however, the development of reporting standards is essential for the successful replication of studies. Neck pain affects approximately 70% of the global population, with women being more at risk than men ,2. Of thStudies and one expert consensus suggest that exercise remains the mainstay treatment for the management of NNP ,8,9. A rIt is important to note that aerobic exercise has been shown to be an effective intervention for the management of many functional disorders such as low back pain , fibromyThus, this review aimed to assess the effectiveness of aerobic exercise in NNP and more specifically the exercise program parameters that were employed in the eligible studies. We anticipated that an updated systematic review would provide more definitive answers regarding the effectiveness of aerobic exercise in NNP in several outcomes regularly used in this clinical population.This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. This study was prospectively registered on PROSPERO (CRD42022373528).International electronic databases were used for the literature search, including PubMed, Scopus, and PEDro, from inception up to October 2022. We consulted with experts in the field, manually reviewed the reference lists of articles that fulfilled the eligibility criteria, and searched the grey literature for eligible articles. The keywords that were used for the search were neck pain, cervical spine, aerobic exercise, running, walking, cycling, dancing, and a similar combination of words. Combining keywords in relation to the populations  and the intervention  using Boolean operators allowed us to construct different research equations, introduced into the databases. We consulted the Cochrane Back and Neck Review Group for our search strategy. All studies were downloaded into Endnote X8 for screening.Randomized controlled trials (RCTs) published in English were screened for eligibility by title and abstract and then by full text. Two independent reviewers  performed the search, as well as the full inclusion process using the PICOS framework . The full texts of all potentially eligible studies were retrieved for the last process of the evaluation. The process of selecting the final eligible studies was performed by consensus. Disagreements were resolved by a third reviewer (GK) when required for the final judgment.Studies were considered if they included adult patients (≥18 years) of either sex. Only studies that recruited symptomatic participants with a chief complaint of musculoskeletal neck pain were included in this review. Studies were eligible if they recruited patients with a duration of symptoms of at least 4 weeks, as previously suggested . StudiesStudies that evaluated the effectiveness of aerobic exercise were eligible. We considered studies that delivered aerobic exercise programs with either light, moderate, or high-intensity aerobic exercise. Moreover, studies that evaluated the effectiveness of aerobic exercise with or without other interventions were eligible.Studies were considered eligible for inclusion if they compared groups of patients that received any other interventions or placebo or sham treatment.Studies were included in this review if they analyzed at least one of the following outcome measures at baseline and final follow-up assessment: pain that was measured with a subjective tool , disability and quality of life with a questionnaire , respectively). Further, studies were eligible if they reported their exercise program parameters such as intensity, frequency, duration, delivery, supervision, and adherence.Only RCTs were considered eligible for this review. Case studies and pilot studies were excluded. Articles in English and Greek were accepted for inclusion.The studies that were included in this review were classified for their methodological quality and risk of bias according to PEDro. This is a tool that consists of 11 items related to the validity of the articles assessed and is considered highly reliable . The PEDTwo of the authors of the review  assessed all studies, and the third author (GK) was available in case of disagreement if needed. Based on the results of PEDro, the methodological quality of each study can be considered high (≥7), moderate (5 or 6), or poor (≤4). For the methodological assessment, we measured the interrater agreement with the intraclass correlation coefficient (ICC) using the SPSS software (IBM version 28).Two of the authors  independently extracted all data using a standardized form and collected information related to participant characteristics, study design, follow-up, interventions , comparison groups characteristics, outcomes, the intensity of the program, and availability of supervision.A narrative synthesis was used to synthesize the data of the included studies and comment on the results. The three phases of narrative synthesis included “developing a preliminary synthesis, exploring relationships within and between studies, and determining the robustness of the synthesis” . The datWe identified 608 trials after removal of duplicates that were potentially relevant and after reading the titles and abstracts, 9 articles were found as potentially eligible for review. Full texts of the nine articles were scrutinized for eligibility based on our inclusion and exclusion criteria, and three articles were excluded. The reasons for the removal of the studies can be found in The characteristics of the participants from the included studies are available in Characteristics of the interventions are listed in Pain was assessed in five studies ,20,25,26The final score of all studies ranged from 5 to 8, as shown in Exercise frequency and intensity were reported in all studies. Exercise intensity was specified in all studies; however, justification for the specified intensity was reported only in two studies ,20 and dThe purpose of this systematic review was to determine the effectiveness of aerobic exercise for patients with NNP and to identify the aerobic exercise variables that may have a positive effect on pain, function, and disability in this clinical population. Another aim of this review was to provide recommendations for future practice and research. It is important to note that to our knowledge, this is the first systematic review that examined the aforementioned intervention in this population and the first that examined the effectiveness of exercise variables related to intensity, frequency, duration, delivery, supervision, and adherence to the program. Overall, aerobic exercise was superior to other interventions or a control group; however, the program variables showed significant heterogeneity.Based on our literature search, we found six eligible studies ,20,25,26The intensity of the aerobic exercise was moderate to high in all studies. However, three studies ,18,25 usIn terms of intervention duration, this ranged from 6 to 12 weeks, except for one moderate quality study that carried out the intervention for 12 months . This isIt was not clear in the available studies whether group interventions of aerobic exercise were provided. Based on the information provided in the Methodology section of the included studies, it seemed that group interventions were not part of the interventions. Previous research in older adults has shown that both group interventions of aerobic exercise and individualized exercise can have significant health benefits; however, group exercise may be superior regardless of the total frequency of the exercise program . FurtherOther exercise variables such as supervision or adherence were not reported in the majority of the eligible studies. Supervision is essential in patients, especially when they are prescribed high-intensity aerobic exercise, for safety ,36. FurtOverall, based on the FITT principle, progressive or not progressive aerobic exercise in patients with NNP comprising either cycling, brisk walking, aerobics, stationary bike, treadmill running, circuit training, or swimming, with or without neck strengthening exercises and pain education or health promotion interventions (type), undertaken at moderate to high intensities (intensity), 2 to 3 times per week (frequency), with sessions lasting 30 to 45 min and with a minimum duration of 6 weeks (time), may be beneficial. The benefits of aerobic exercise were found in pain, function, and levels of disability.When comparing the aforementioned exercise variables that were found in this review with those found in patients with low back pain , it seemThe findings of this study showed that aerobic exercise is beneficial in NNP; however, this study did not include trials that recruited patients with whiplash-associated disorders or neuropathies caused by cervical spine pathologies. Thus, the generalizability of the findings in other clinical populations with neck pain is not feasible. Further, the effects of other types of aerobic exercise  or unstructured exercise  were not evaluated. It is also important to note that limiting the inclusion criteria solely to English-language publications may have affected the overall conclusions since we may have missed studies published In other languages. Lastly, since a variety of outcome measures was included in the study and a relatively small number of studies exist that evaluated the effectiveness of aerobic exercise in NNP, a meta-analysis was not possible, which limits the possibility for strong conclusions to be made at this point.Aerobic exercise may be an effective intervention for the management of NNP. The available evidence showed that aerobic exercise at a moderate or high intensity for 30–45 min for at least 6 weeks may result in beneficial outcomes. However, the available clinical trials are limited by poor reporting of their program variables and their justification for selection. Reporting standards should be implemented to allow for the replication of these studies in the future. More research is necessary in order to identify the minimum effective dose required for substantial health benefits in patients with NNP.


Current research has been aimed mainly at specific instances of collaborative immersive virtual environment (CIVE) applications for learning. The fields utilizing iVR for knowledge construction and skills training with the use of spatial visualizations show promising results. The objective of this study was to assess the effectiveness of collaborative and individual use of iVR for learning geography, specifically training in hypsography. Furthermore, the study’s goals were to determine whether collaborative learning would be more effective and to investigate the key elements in which collaborative and individual learning were expected to differ–motivation and use of cognitive resources. The CIVE application developed at Masaryk University was utilized to train 80 participants in inferring conclusions from cartographic visualizations. The collaborative and individual experimental group underwent a research procedure consisting of a pretest, training in iVR, posttest, and questionnaires. A statistical comparison between the geography pretest and posttest for the individual learning showed a significant increase in the score  and speed , while for the collaborative learning, there was a significant increase in the score  but not in speed . Thus, iVR as a medium proved to be an effective tool for learning geography. However, comparing the collaborative and individual learning showed no significant difference in the learning gain , speed gain , or performance motivation . Nevertheless, the collaborative learning group had significantly higher use of cognitive resources  than the individual learning group. The results were discussed in relation to the cognitive load theories, and future research directions for iVR learning were proposed.Many university-taught courses moved to online form since the outbreak of the global pandemic of coronavirus disease (COVID-19). Distance learning has become broadly used as a result of the widely applied lockdowns, however, many students lack personal contact in the learning process. A classical web-based distance learning does not provide means for natural interpersonal interaction. The technology of  It has been studied for its utilization in areas such as cognitive training [The increasing amount of training , 4, rehatraining , 6, paintraining , 8, labotraining , museum training , heritagtraining , journaltraining , multiditraining , data antraining , urban ptraining , and edutraining . Our preaffordance formulated by Gibson [Cognitive Affective Model of Immersive Learning (CAMIL), which identifies the psychological affordances of presence and agency, and describes how they influence cognition and motivation. In the research by Meyer et al. [In the educational context, iVR offers the capacity for overcoming the limitations of a specific time and space, in a sense that education is not bounded by a classroom lesson at a specific hour, thanks to the possibility of synchronous and asynchronous learning in a virtual environment. To describe what iVR has to offer in the learning context, the concept of y Gibson  appears y Gibson  studied y Gibson  proposedr et al. , learninr et al.  identifivirtual geographic environment (VGE) [geovisualization immersive virtual environment (GeoIVE), which is considered to be a 1:1 scaled 3D geovisualization. Several studies on the usability of iVR for geography education have been conducted. In the research by Shakirova et al. [Immersive virtual reality applications have been emerging extensively in the field of geography, with the term nt (VGE)  often bent (VGE) , focusina et al. , 60 studa et al.  study, wzone of proximal development (ZPD) [scaffolding. De Lisi [computer-supported collaborative learning (CSCL) [flow, which is connected with intrinsic motivation.Social factors in learning have been getting much attention from researchers in recent years, with Hanko  summariznt (ZPD) , describ De Lisi  describeg (CSCL)  emerged g (CSCL) , howeverg (CSCL) : educatig (CSCL)  utilizedg (CSCL)  showed tg (CSCL) , 39 consvirtual reality-based collaborative learning (VRCL). According to Burdea and Coiffet [non-immersive virtual reality (non-iVR) collaboration. As for the resource sharing affordance, thanks to the representations that iVR offers, collaborators have an opportunity to share information in a more embodied manner and can see what each of them is currently working on. Lastly, the knowledge construction affordance highlights the scaffolding for complex and meaningful problem solving and high-level cognitive activities.The development of CSCL and its fusion with iVR technology led to the emergence of an even more novel approach called  Coiffet , iVR is  Coiffet  identificollaborative immersive virtual environment (CIVE) for education in geography. The results showed that the participants felt the benefit of iVR for learning geography and considered the spatial representation of terrain as helpful. They also appreciated the help of a collaborator in iVR and were glad they had some kind of personal contact. However, they lacked the visibility of emotions on the avatar in iVR and struggled with the limitations of iVR controllers. The study uncovered the themes significant for collaborative learning of geography in iVR, but the qualitative nature of the research had its limitations. It was not possible to objectively determine if the participants benefited from the iVR collaborative learning. Therefore, a follow-up quantitative study was designed to examine iVR as a medium for learning and the benefit of collaborative use. The objective of the present follow-up study was to quantitatively assess the effectiveness of individual and collaborative learning of geography in CIVE, and to determine whether the collaborative use is more effective. Furthermore, this study aimed to provide new insights into the key elements in which the individual and collaborative learning in CIVE differ, by investigating the use of cognitive resources and the motivation of users.In our previous qualitative study , we utilscientific discovery learning (SDL) [learning through problem solving (LPS) [This quantitative study utilized the geography learning CIVE application, developed by our interdisciplinary team, which was described in detail in our previous qualitative study . The appng (SDL)  and facing (LPS) . One of To test the level of users’ hypsography skills before and after educational training in the CIVE application, a pretest and posttest were created on the platform called Hypothesis. It enables the construction of cartographic and psychodiagnostic test batteries, which are stored on the servers of Masaryk University and can be administered on any computer connected to the internet . Among tflow from the LMI inventory [To assess the use of cognitive resources and the motivation of the users, two questionnaires were utilized. Both of them inquired about the beginning, middle, and ending phase of the educational training in the CIVE application. They consisted of statements, which were to be rated on a Likert-type scale. Users indicated their level of agreement by choosing an integer between one and seven, where one corresponded with “The statement does not fit at all” and seven corresponded with “The statement fits completely”. The first questionnaire incorporated statements about cognitive resources, which Wiley and Bailey  describenventory  by SchulFor the purpose of adjusting the head-mounted display to the user and allowing them to get acquainted with the iVR controllers and movement in the virtual environment, a free-to-play application “The Lab”  was used® Core™ i7-5820K processor, Nvidia GeForce GTX 980 graphics card, 64 GB RAM) with an HTC Vive Pro full kit  connected to it in each room. The PCs were directly interconnected via a twisted-pair data cable running from one room to the other to minimize latency. The temperature and light in each room were adjusted to ideal conditions for iVR sensors’ operation and students’ performance. One participant and one research assistant were present in each room, with an additional supervising investigator for both rooms, to ensure the smooth flow of the procedure and to address potential unexpected technical issues.Our research was conducted at the Faculty of Arts of Masaryk University in Brno, Czech Republic, in two rooms simultaneously. The first room was the HUME Lab Experimental Humanities Laboratory, and the second room was a lecture room on the same floor. There was a personal computer (Intelcybersickness [n = 54) and 32.5% male (n = 26), and all reported daily use of PC. Participants were randomly divided into two experimental groups: individual learning in CIVE; and collaborative learning in CIVE.The participants of this research were recruited from a pool of volunteers consisting of students or absolvents of universities located in Brno. The inclusion criteria were age between 18 and 30, Czech or Slovak nationality, and regular use of PC. The exclusion criteria consisted of having a history of experiencing sickness  or attenThe study was approved by the Research Ethics Committee of Masaryk University in Brno. Each participant signed an informed consent form prior to inclusion in the study. The confidentiality of personal information was strictly maintained, and the participants had the right to withdraw from the study at any time during the procedure.Guides on how to collaborate in the instructional step. The flow of the research procedure for both experimental groups is shown in The procedure differed for experimental groups in the circumstances of the immersive virtual learning intervention–whether the participant underwent it solo or in a dyad with another participant. The collaborative learning in CIVE group, therefore, received additional Personal data inquiry and signing of the informed consent form. The information was collected in a verbal and written manner. That is, the participants filled out the form and were asked additional questions to clarify their written answers. They were inquired about their experience with iVR devices, non-iVR devices, and also about their education to ensure that they did not major in any geography-related field of study.The research procedure consisted of eight steps: 1. Personal data inquiry; 2. Contour line explanation; 3. Pretest; 4. Training with the iVR device; 5. Instruction; 6. Learning in CIVE; 7. Posttest; and 8. Questionnaires. The first step involved Contour line explanation. A definition of a contour line together with a basic explanatory picture thereof were given to the participants. This was done to ensure that all participants had knowledge about what a contour line looks like on a map, what it represents, and that the number subscribed to it refers to altitude. This was to ensure that the participants knew the meaning of the basic hypsographic element that was later used in the pretest, learning in CIVE, and posttest steps.As the second step, there was a Pretest consisting of four types of tasks, each with four test items. All tasks were related to the contour lines on a given map, however, required an ability to complexly analyze the map and infer a conclusion about the terrain it represents. Half of the participants in each experimental group received “geo α” as the pretest and “geo β” as the posttest, and half of the participants vice versa.The third step was the Training with the iVR device in the form of a simple virtual experience using the “Vesper Peak” environment of Valve’s application “The Lab”. This served as screening against cybersickness. Participants were observed for signs of nausea and asked if they feel any discomfort. The headset was adjusted according to the size of the participant’s head and their interpupillary distance. Participants also had the opportunity to get acquainted with the iVR controllers and how to use them for interaction with an immersive virtual environment. The additional objective of this step was to mitigate the novelty effect, posing as a potential threat to the external validity of the research due to the effects that new technology has on its users [As the fourth step, the participants received ts users .Instruction and consisted of an explanation of the assignment and user interfaces for the subsequent task in the CIVE application. The collaborative learning in CIVE group received also additional Guides on how to collaborate. It was explained to them that they would see an avatar of their collaborator in the CIVE application and that they are supposed to work together on the given task. Verbal and non-verbal ways of communication were presented–participants could talk to each other via headphones and make gestures utilizing their avatars’ movements and positioning. In addition, virtual models of their iVR controllers, shown in the CIVE application, enabled the use of laser pointers. The dyad of participants was prompted to talk to each other, verbalize what they are currently working on, and discuss the solution before submitting it for evaluation.The fifth step was Learning in CIVE either solo or in a dyad, according to the experimental group they were assigned to. The duration of the learning intervention in our CIVE application was designed to be 30±5 minutes. The seventh step was the Posttest consisting of the same four types of tasks as the Pretest, but with different test items. Finally, as the eighth step, the Questionnaires were administered, aimed at motivation, use of cognitive resources, and evaluation of the learning procedure. The whole research procedure with each participant lasted approximately 90 minutes.The final three steps started with the sixth step–the participants underwent Shapiro–Wilk test of normality  and the geo-speed . Individual learning in CIVE was effective in increasing the score in the geographical test and increasing the speed of solving. The distribution of the values is shown in The Friedman’s Two-way ANOVA was applied to the individual learning experimental group data from the geographical pretest and posttest. The results showed that there was a statistically significant difference in both the geo-score  but not in the geo-speed . Collaborative learning in CIVE was effective in increasing the score in the geographical test; however, the increase in the speed of solving was not significant. The distribution of the values is shown in Using the Friedman’s Two-way ANOVA on the collaborative learning experimental group data from the geographical pretest and posttest, we obtained the following results. There was a statistically significant difference in the geo-score , nor between the speed gains . We hypothesized that collaborative learning would be more effective; however, the data was inconclusive and did not confirm this. Even though significant evidence was not found, the results indicated the collaborative learning group to be more effective in achieving higher learning gain but lower speed gain in comparison to the individual learning group. The distribution of the values is shown in The Mann–Whitney U test was utilized to compare the learning gain and the speed gain between the experimental group of individual and collaborative learning in CIVE. The results showed that there was no statistically significant difference between the learning gains  but not in the performance motivation . The results showed that the collaborative learning group achieved significantly higher scores in the use of cognitive resources questionnaire; however, the increase in scores in the performance motivation questionnaire was not significant, in comparison to the individual learning group. The distribution of the values is shown in Using the Mann–Whitney U test on the scores for the use of cognitive resources and the performance motivation of the participants, we compared the experimental groups and obtained the following results. There was a statistically significant difference in the use of cognitive resources Click here for additional data file.


The importance of “social capital” in offender rehabilitation has been well established: Stable family and community relationships offer practical assistance in the resettlement process after being released from custody and can serve as motivation for building a new sense of self off the criminal past, thus reducing the risk of re-offending. This also applies to offenders with severe mental disorders. The aim of this study was to identify factors that promote or hinder the establishment or maintenance of social relationships upon release from a court-ordered inpatient treatment using a modern statistical method—machine learning (ML)—on a dataset of 369 offenders with schizophrenia spectrum disorder (SSD). With an AUC of 0.73, support vector machines (SVM) outperformed all the other ML algorithms. The following factors were identified as most important for the outcome in respect of a successful re-integration into society: Social integration and living situation prior to the hospitalization, a low risk of re-offending at time of discharge from the institution, insight in the wrongfulness of the offense as well as into the underlying psychiatric illness and need for treatment, addressing future perspectives in psychotherapy, the improvement of antisocial behavior during treatment as well as a detention period of less than 1 year emerged as the most predictive out of over 500 variables in distinguishing patients who had a social network after discharge from those who did not. Surprisingly, neither severity and type of offense nor severity of the psychiatric illness proved to affect whether the patient had social contacts upon discharge or not. The fact that the majority of determinants which promote the maintenance of social contacts can be influenced by therapeutic interventions emphasizes the importance of the rehabilitative approach in forensic-psychiatric therapy. Stable family relationships and community ties are known to have great potential in the prevention of re-offending among former inmates –3. In crThe present study aims to determine the most predictive factors of social capital upon discharge from court mandated inpatient treatment, based on a unique group of forensic offenders with schizophrenia spectrum disorder (SSD). To the authors’ knowledge, this is the first scientific evaluation of social capital in such a large homogenous population of offender patients with SSD.The files of 370 delinquent patients diagnosed with SSD according to ICD-9 (295.x)  and ICD-The comprehensive dataset included items from the following domains: social-demographic data, childhood/youth experiences, psychiatric history, past criminal history, social/sexual functioning, details on the offense leading to forensic hospitalization, prison data, and particularities of the current hospitalization and psycho-pathological symptoms. The latter was defined by an adapted positive and negative syndrome scale (PANSS), whereby symptoms were divided into the usual 30 sub-categories and then rated on a three-tier scale instead of a seven-tier one . Social capital was defined as having at least one of the following social contacts: family ties, spousal relationships, a circle of friends of more than one person, and membership in a club. The dataset has already been evaluated in other studies as part of a larger, ongoing project with the goal of gaining further knowledge about the complex field of offender patients with SSD , 26–35. Parts of the following section were published beforehand in a study by Kirchebner et al.  and, as n = 258), was used for variable reduction and model building/selection. To enable the flexible application of all ML algorithms, imputation of missing values was carried out and imputation weights saved for later were reused on the validation subset (see n = 111) was applied  was also identified as negative predictor of social ties upon discharge. This seems obvious: Establishing a social network is already difficult for patients with SSD due to their symptomatology, and is further exacerbated by institutionalization, which is usually accompanied, at least initially, by strict regulation of access to the outside world . It seems therefore understandable, that the formation of community ties is severely impaired due to their often year-long hospitalization. This is in line with findings regarding offenders without mental disorders who have been subjected to long imprisonment  (The  SAPROF) , 54. In  SAPROF) . Just asmain psychotherapeutic content was future perspectives. Yet, this item did not exclusively refer to the current or future social network, but could include ideas on housing, occupational and financial perspectives as well. This fits well with findings from non-offending patients with SSD highlighting the importance of an encouraging psychotherapy as part of the recovery process  or the severity of the offense previously committed. Insight into the illness and the consecutive need for treatment, reflected in treatment adherence, has also been associated with recovery in non-offender patients with SSD , 57. HowConsidering limitations of the present study, the retrospective approach is of course notable. Accordingly, the parameters studied were not collected continuously in a standardized manner comparable to a prospective study design. This is not so much a problem for clearly defined variables, such as the length of the prison sentence, but poses difficulty for variables with a certain degree of latitude in their definition , as they may be subjected to a higher interrater bias. Even though interrater reliability was sustainable, as described in the methodology section, one has to be careful as to draw conclusions from especially the dynamic predictors and their clinical implications. While for instance the focus on future perspectives in psychotherapy was found to be of influence regarding social contacts, it was not clearly defined as to how exactly future perspectives were targeted . The authors therefore recommend a replication of the current findings in a prospective setting to evaluate the robustness of causal inferences drawn from them. Furthermore, while populations in forensic psychiatric research are often relatively small compared to general psychiatry and other medical specialties, it has to be acknowledged that our sample of 369 patients, all collected from one single institution, can merely serve an exploratory purpose. Further application of the model to larger populations and other institutions is therefore recommended. As our population consisted only of offender patients with SSD, it has to be noted that the results presented may not be applied to other offender populations . Also, as it would be expected in an offender population, there were only few women in our sample. This may limit the generalizability to female offender populations. Another notable aspect is that the focus in this study is exclusively on the presence or absence of a social network after discharge. Of course, social contacts are merely one facet of the complex concept of personal recovery. While it is well established how social capital benefits reintegration in society of mentally ill offenders, it is not possible to infer the actual importance of the social network at discharge in the overall construct of personal recovery from the present results. Future research on that matter is therefore needed. Finally, the study design allowed only an explorative variable reduction—although it was possible to break down over 500 variables to the 8 most influential, the findings do not allow a prospective model building regarding social reintegration. Lastly, when critically evaluating the process of model building, it has to be noted that the uneven distribution of the outcome variable would have had negative impact on the model building process and had to be counteracted through up-sampling. This however was performed merely on the training set during the model building process with the goal of creating optimal “lab conditions.” As the validation set did not undergo up-sampling, this procedure does not interfere with the validity of the results. The lack of up-sampling and the resulting uneven distribution of the outcome variable in the validation set also explains why the SVM performed with better performance parameters in the training set under artificially created ideal conditions.In summation, the present findings contribute to a better understanding of social rehabilitation of offender patients with SSD after court mandated inpatient therapy. Through the use of ML as modern statistic instrument, we were able to identify the 8 factors most related with social capital upon discharge as well as their complex interplay out of a large dataset with over 500 different parameters. Clinical implications here are most likely to arise from the dynamic parameters that can be influenced by therapeutic interventions during hospitalization, whereas the static parameters that cannot be influenced by the course of treatment  might highlight special needs of affected patients. Of course, these findings do not allow other factors known to influence social reintegration to be dismissed as unimportant. As stated in the discussion of the limitations, social reintegration and recovery are complex processes which cannot be comprehensively evaluated with one single exploratory analysis. However, the findings highlight the value and importance of focusing on social resources and factors promoting them . Further research on the subject is needed, ideally in prospective trials considering various aspects of social re-integration and the maintenance of the social capital gained.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Ethics Committee of the Canton of Zurich. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.JK: conceptualization, methodology, software, and data curation. JK and LH: validation, formal analysis, and investigation. LH, JK, and SL: resources and writing—review and editing. LH: writing—original draft preparation and visualization. SL and JK: supervision. SL: project administration. All authors have read and agreed to the published version of the manuscript.


The judicialization of health care can be understood as a societal response to pressing healthcare needs, which probably are not being adequately addressed by the current healthcare system. This phenomenon increases the strain on service resources, both in the health sector and in the judiciary system as well, demanding an institutional reorganization to manage judicial actions. It is believed that each institution has developed strategies for coping with the problem in isolation and with little public disclosure. The purpose of this review will be to identify institutional strategies implemented and to investigate their effects in approaching the judicialization of health care.Electronic searches will be conducted up to December 2021 on 11 databases, supplemented with gray literature and references lists of secondary studies. The descriptor “judicialization of health” will be the basis for conducting the main research. Studies describing any strategy implemented by public institutions to approach the judicialization of health care will be included. Results related to the quality of services provided by the implemented strategy reported in the studies and those that report accessibility, usability, and potential adverse effects or harms caused by the implemented strategy will be investigated. In addition, it will be explored if there have been changes related to the value or characteristics of health litigation. Two reviewers will independently screen all citations, abstract data, and full-text papers. The risk of bias in each study will be appraised using a tool suggested by Cochrane Effective Practice and Care Organization Group (EPOC). Subsequently, the reviewers will also extract the data of interest and classify the findings of these studies according to their performance at the institutional level. The results obtained will be described as a narrative synthesis.This review may provide evidence on the effects of the strategies implemented to approach the judicialization of health care. It will potentially benefit health care and legal professionals, decision-makers, and researchers by identifying the types and characteristics of strategies that have the potential to improve service delivery in the future.PROSPERO CRD42020160608The online version contains supplementary material available at 10.1186/s13643-022-02043-x. Health is considered a human right , supportRestrictions upon universal access to healthcare technology, whether due to budgetary issues, lack of inventory forecasting, or limitations in coverage of insurance system, reflect a deficient healthcare system . In thesThe judicialization of health care, in part, reflects a social and participatory evolution of the citizen , but it The accelerated and cumulative growth of healthcare lawsuits has alarmed both healthcare managers and jurists, urging debates  concerniThe increased demand for services and financial resources in the healthcare area as well as in the judiciary system , 14–16 fPublic health and legal institutions have implemented a wide range of strategies to approach the judicialization of health care.This protocol adopted the term “strategy” to define any action or service, experience or practice, or support for decision-making, which has been used by public institutions to approach the judicialization of health care .The systematic review will investigate the institutional strategies that have been implemented to avoid or minimize the negative effects of judicialization on the public health system. These strategies were implemented to resolve disputes extrajudicially (before filing a lawsuit) or during a judicial process or to organize the institutional services  to prevent litigation . Table 1The strategies can be implemented at various stages of access to health care, from the search to the effective provision of services to citizens.Organization of services: strategies implemented in public institutions aiming to organize work processes following public policies and government programs. They may include the creation of support services.Nonjudicial or extrajudicial approach: strategies that favor dialogue between claimant and public institutions without filing a lawsuit.Judicial approach: strategies used at any point during the judicial process, including the enforcement of court decisions. They may provide expert health technical support to judges and courts or to defend the health authority .They can be divided according to their performance at the institutional level:Strategies focused on the organization of services and extrajudicial approaches aim to avoid lawsuits by facilitating the delivery of healthcare services. They may include the provision of technologies not covered by the healthcare system, conditioned to the availability of financial resources and the fulfillment of medical and legal requirements .Strategies implemented in judicial sector aim to support the judge’s decision-making through the analysis of judicial processes or the availability of technical reports based on scientific evidence in the health area. Such strategies are expected to reduce attempts of corruption and the impacts of the judicialization of health care on institutional resources  Fig. 1)1).Fig. 1It is believed that each institution has developed strategies for coping with the problem in isolation. Information about these experiences regarding the planning, implementation, or evaluation may occasionally be described in institutional administrative documents and, in some cases, local legislation , 13, 17.Previous publications on the subject revealed that many studies have only characterized the lawsuits  –21; howeGiven this scenario, the purpose of the review will be to scrutinize the literature to identify and investigate the effects of the implemented strategies used by the public sector to approach the judicialization of health care.This systematic review protocol is being reported in accordance with the reporting guidance provided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) criteria (Guidelines checklist) . The revNon-randomized trials, before-and-after controlled studies, interrupted time series, and repeated measures studies will be included. The documents will be included if they are in English, Spanish, and Portuguese, without restrictions of date or country. There will be no restriction on publication status.The ECLIPSE framework is a set of structured questions used as an alternative aid to help in the search for information on health and social care management .We look for strategies or good practices implemented in public institutions, both in the health and judicial sectors, aiming to approach the judicialization of health care.They are people who have not been able to access public health services and who are willing to file a lawsuit to claim their rights.It is across the entire public health and judicial sectors involving public healthcare issues.Reduction or avoidance of health litigation, improvement, or expansion in access to health services, promotion of rational use of health technologies and institutional resources, reduction of expenses with health litigation, and improvement in communication between professionals.These include health professionals, mainly physicians, pharmacists, nutritionists, and nurses; legal professionals, attorneys, defenders, public lawyers, judges; and managers of public institutions.They are public institutions that deal with the judicialization of health care. For example, in the healthcare sector, this includes the Ministry of Health, state, municipal, or regional health departments, hospital care, outpatient services, and pharmaceutical services. In the judicial sector, this includes the Court of Justice, Public Prosecution Service, Public Defender Service, State Attorney’s Office, and City Attorney’s Office.Rate of use of technical reports and notes prepared by the implemented strategy, by the legal department, or by court of lawAdherence rate of citizens, magistrates, defenders, or promoters to the implemented strategyAdherence rate of doctors, magistrates, lawyers, defenders, or attorneys to institutional guidelines and recommendationsAttendance rate of people served versus not attendedAny parameter reported in studies to measure the effectiveness of the implemented strategy is as follows:Waiting time rate for user service, for the acquisition of health technologies, or for the provision of health careResolution ratePatient satisfaction rate with the health care providedAny measure that assessed an improvement in the provision services is as follows:Acceptability rate or worker satisfaction with the implemented strategyAssessment of worker productivity after strategy implementationDifference between the costs of judicialization of health care before and after strategy implementationDifference between institutional costs before and after strategy implementationAny reports that addressed issues about inequalities caused in the populations served by the strategy implemented, according to the classification of the PROGRESS-Plus tool , 26, forChanges in the pattern or type of lawsuits and changes in the profile of claimantMean difference between requests granted and not grantedMean difference between lawsuits and administrative proceedingsReduction in the number of lawsuits filedProportion of successful lawsuits to rejected lawsuitsRate of extrajudicial resolutionsAny changes detected in the characteristics of the lawsuits after the strategy is implemented:Increased time spent by providers to perform administrative tasksFailures in verbal or nonverbal communicationPrivacy and information disclosure issuesFailure or delay in the delivery of health technologyLoss or misuse of health technologiesUnintended consequences caused by the implemented strategy that may result in adverse effects or harms are as follows:Studies that merely describe or characterize lawsuits in the healthcare area  will be excluded. In addition, studies reporting the motives of claimants or discussing, from a conceptual or theoretical point of view, possible and not implemented strategies to approach the judicialization of health care will not be included.Finally, strategies aimed at promoting the judicialization of health  will also be excluded.Electronic databases: Portal de Periódicos da Coordenação de Aperfeiçoamento de Pessoal de Nível Superior do Brasil (Periódicos CAPES) , Directory of Open Access Journals, Sociological Abstracts, MEDLINE/PubMed, Scientific Electronic Library Online (SciELO), SciELO Brazil, JSTOR Archival Journals, NDLTD Union Catalog, SAGE Journals and Publications, Science Direct Journals and Books, Elsevier, Oxford Journals, Materials Science & Engineering Database, Cambridge Journals, Dialnet, Embase), Cumulative Index to Nursing and Allied Health Literature, and Virtual Health Library Regional Portal-BVS (which included LILACS)Electronic database specialized in public health: the Cochrane Library, Health System Evidence, and EpistemonikosGray literature: websites of government agencies, health ministry or department, justice ministry or department, non-indexed journals, public institutions that were cited in the documents found, and other sources of gray literature that may be considered relevant for the systematic reviewElectronic searches will be tested and performed by two reviewers in the following electronic databases:A search with the keyword “judicialization of health” , according to the descriptors described by the Health Sciences Descriptors (DeCS) of Brazil , will beOther related descriptors, and their synonyms, will also be tested. The final version of the search strategy will be adapted to be used in other information sources in accordance with the specificities of each selected database.In the databases The Cochrane Library, Health System Evidence, and Epistemonikos, we will conduct the searches using the term judicialization of health and generic terms such as legal, judicial, and litigation. This adaptation is justified by the fact that judicialization of health care is not a widely used descriptor, being only recently incorporated into the DeCS   containing all the exported searches without duplicates.Reviewers will work in pairs and independently to select titles and abstracts using the eligibility criteria. When there are disagreements between the pairs of reviewers, a third reviewer will be consulted.A new calibration exercise will be conducted before the full-text study distribution. The full texts of eligible studies will be grouped and distributed among reviewers. The same pair of reviewers will evaluate these documents and identify studies for inclusion. Also, they will record the reasons for the exclusion of the ineligible studies.Two independent reviewers will scrutinize the reference list of secondary studies to identify potentially eligible articles. They will also perform a hand search for eligible articles in unindexed journals that publish on the subject. In the case of disagreements between the reviewers, a third reviewer will be consulted.The systematic review will begin after the publication of this protocol and is expected to be completed in December 2022.Two reviewers will independently extract the data from the full texts according to a pre-piloted and standardized data-extraction template with fill-in instructions, using the Excel 2016 software.Specific details about the characteristics of the study Specific details about the strategy implemented Population and setting characteristicsStudy durationOutcomes measuredFunding sources and competing interestsThe extracted data will include the following information:If an implemented strategy is reported in several publications, only data from the study considered to be the most complete will be extracted.In cases when a study has an outcome reported in different measurement units, or if the results have many variables or items, the variable that was considered the most important by its authors will be selected. In the absence of this criterion, the reviewers of the systematic review will choose, by consensus, the most appropriate data to be collected for this study.If there are disagreements between two reviewers about any information to be extracted from the studies collected, a third reviewer will be consulted. If needed, reviewers will contact the lead author of the study to clarify any doubts.A criteria-based tool to analyze the risk of bias for systematic reviews suggested by the Cochrane Effective Practice and Organization of Care Group (EPOC) will be applied for studies conducted with a separated control group, such as non-randomized trials, before-and-after controlled studies, interrupted time-series, and repeated measures studies .The findings will be grouped by similar practices (characteristics and objectives) and analyzed together. Subsequently, the reviewers will assess whether the biases found are sufficiently relevant to interfere with the interpretation of the results.The systematic review will be reported according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA 2020) statement  and syntThe strategies implemented to approach the judicialization of health care identified in this study will be grouped, analyzed, and discussed according to their similarities, and the respective clusters will be coded according to Table Considering the diversity of strategies and outcomes measured, we anticipate that the available data will not be sufficient to group the estimate and perform a meta-analysis. Therefore, the findings will be reported as a narrative synthesis .How the strategy worked and how it affected the judicialization of health careWhat are the effects of the strategy implemented on issues involving health inequities. We will use the PROGRESS-Plus framework  , 26 to iWhat are the barriers and facilitators interfering with the implementation of the selected strategies. We will use the SUPPORT tools  to guide analyses of the barriers and facilitators that affect the implementation of a strategy and its implications for health, the health system, users, policymakers, and professionals involved .The narrative synthesis will be elaborated considering three aspects:A comprehensive search strategy associated with an extensive list of electronic databases and gray literature sources will be employed to obtain a greater number of publications to be scrutinized. If sufficient data is found, funnel plots and Egger’s test  will be The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) tool  will be Two reviewers independently will assess the certainty of the evidence and resolve discrepancies through a third reviewer.The implementation of an institutional strategy to approach judicialization should be carefully monitored using a robust methodology capable of informing the decision-maker about the real benefits of the intervention.The evaluation and monitoring of any strategy are needed since it can point out barriers and facilitators for its implementation, indicating areas for improvement according to the local context. Consequently, the results will be improved, and the application of resources can be optimized, with potential positive impacts on the quality and access of services by citizens.It is expected that the systematic review will provide crucial information on the effectiveness of strategies implemented in public institutions to approach the judicialization of health care and insights regarding how these strategies can be replicated or adapted to similar contexts.Policymakers and stakeholders will be able to use the systematic review to support the planning and implementation of more efficient and comprehensive healthcare policies, such as cost-effective programs and services that can potentially reduce inequities in access to healthcare technologies.In addition, this study is expected to identify and report gaps in scientific knowledge about the judicialization of health in public health systems, including the management, financing, and delivery arrangements, providing data that can be useful to guide further research.Any changes made to this protocol when conducting the study will be described in PROSPERO and the final manuscript.Studies that investigate the strategies implemented in the public sector to approach the judicialization of health care are scarce and difficult to access. Therefore, it is useful to provide an overview of these strategies so that they can be disseminated to a wider audience.The main challenge of the systematic review will be able to adequately group and interpret the results of different types of studies and implemented strategies.The elaboration of a narrative synthesis and an evidence gap map will better describe how public services have organized to approach the judicialization of health care.Additional file 1. Examples of search strategy. Guidelines checklist. PRISMA-P  2015 checklist: recommended items to address in a systematic review protocol.


The importance of strategies and services by caregivers and family members substantially impact the psychological and emotional wellbeing of autistic children. The rapid research developments in clinical and non-clinical methods benefit the features of autistic children. Among various internal and external factors, the influence of the built environment also impacts the characteristics of autistic children. This study investigates primarily the psychological effect of light and colors on the mood and behavior of autistic children to identify the most favorable and preferred indoor lights and color shades.A questionnaire survey was conducted at an autism center among autistic children and their parents. This study included autistic children aged between 6 and 16 . Eighty-seven participants were involved in the survey to determine the sensory perceptions, intolerance, preferences, and sensitivities of children with an autism spectrum disorder toward colors and lighting. The margin of error at the statistical analysis’s 95% confidence level is ± 0.481.As per this case report, the children have various color preferences and respond differently to different shades. Different hues have varying effects on autistic children, with many neutral tones and mellow shades proven to be autistic-friendly with their calming and soothing effect, while bright, bold, and intense colors are refreshing and stimulating. The stimulus of bright-lighting causes behavioral changes in autistic children prone to light sensitivity.The insights gained from this interaction with parents and caretakers of autistic children could be helpful for designers to incorporate specific autistic-friendly design elements that make productive interior spaces. A complete understanding of the effect of factors like color and lighting on the learning ability and engagement of autistic children in an indoor environment is essential for designers and clinicians. The main findings of this study could be helpful for a designer and clinicians to address designing an autism-friendly built environment with a color palette and lighting scheme conducive to their wellbeing and to maximize their cognitive functioning. A significant instance of pervasive development being witnessed throughout the globe is the complex neurodevelopment condition called autism spectrum disorder (ASD) which impacts behavior, communication, and social interaction –4. The sAutistic children tend to perceive and experience their environment differently from others , 21. By Any autism-friendly design depends first and foremost on the end-user’s unique needs, preferences, and comfort. The design considerations for sensory-friendly spaces must be based on the core aspects of functionality, connectivity and responsiveness following a careful study of the inherent features of the built environment and after gaining a good understanding of the unique perspectives of autistic individuals . Design Information comes through all the senses, which are processed and organized by the brain. Processing sensory information is extremely difficult for autistic children, affecting their sensory responsiveness and reactions. Human senses are interconnected and cannot be separated, but multisensory integration is challenging for autistic children. The eight sensory systems are visual, auditory, olfactory, gustatory, tactile, proprioceptive, vestibular, and interoception. These are highly central to understanding sensory processing in autism and a sensory integration approach would make them very relevant to investigating visual processing –29. SensAccording to the literature, sensory difficulties and processing disorders appear to be more prevalent in autistic children and ASD is perceived to be the root cause of their sensory system . People Since ASD impairments can fluctuate between moderate and severe with few or mild characteristics and with co-occurring conditions, the abilities, needs and services demand to vary wildly across individuals. However, almost all require therapeutic interventions and support for their lifespan . Apart fMany researchers have investigated the relationship between the five senses and their impact on the surrounding environment with multiple parameters. Investigating the quality and dynamics of early encounters is a difficult task. It usually necessitates observing and integrating multimodal social signals and comprehending how two interactions synchronize for understanding the autistic child’s behavior , 37. SucThe spatial element is a crucial factor that designers and architects must be aware of when building for people with ASD. This is attributed to the importance of routine, order, regularity, and predictability. Well-defined areas should be placed in a logical sequence based on the regular schedule followed in specific settings regarding spatial sequencing to make it easier for autistic children to navigate these spaces without assistance. A research study was conducted to recommend the setting up of an organized space focusing on accessibility to and inclusivity of autistic children by creating surroundings that were clearly defined, orderly, simple, safe, satisfying, predictable, welcoming, and stable –40. SpatThis technique develops a simple and easy navigational approach by incorporating assistive visual aids such as landmarks, decoration, and color-coding . EnvironThe importance of good lighting, both natural and artificial, is evident in the way it can transform any space. Lighting has a significant impact on the sensory system of autistic children. Evidence-based research was conducted on an active group of autistic users to determine their responses to lighting, their light sensitivity and possible light modifications that could be implemented for people with sensory challenges , 45. TheBased on the environmental conditions, the responses gathered included the children’s reactions to light (amount of illumination) and sound (number of decibels), which were studied to devise ways to help autistic children struggling with sound and light sensitivity. Ideally, the environmental circumstances should be constant for all participants, especially since bright lights and loud sounds can be bothersome sensory overloads to autistic children affecting their functioning and behavior. The restriction of visual stimulation was enforced through dimmer switches provided for all lighting installations to reduce light levels based on the need . StudentSound quality is perhaps the most critical component in managing and maintaining autism spectrum conduct on an even keel among all the visual inputs involved in building design . TherefoBy identifying and eliminating interfering sensory information under the user’s needs and creating a quiet and comfortable environment conducive to productivity, people with autism can enhance their attention, reduce stress, and prevent inappropriate behavior. The authors advised the integration of pink cacophony for privacy and a salutogenic sound design approach in a space with many activities. A lower sound intensity of less than 50 dB is preferable for autistic children and beyond 60 dB makes it inappropriate. It was also recommended that a suitable acoustic environment within an enclosed space by reducing the frequency of the room’s resonance for acoustic comfort and soundproofing a room by ensuring good sound absorption.Autistic children are sensitive to colors depending on how they perceive them. Most see them with greater intensity than they are. Colors in interior spaces affect their mood, learning, and behavior and must be chosen judiciously , 43. ColInvestigations are necessary to examine the impact of color indices on learning specific complex tasks. Thus, the variable effect of indices on generalization and persistence is mainly in the case of color formation. Investigations are necessary to examine the psychological impact and effects of color on learning specific complex tasks and cognitive task performance by autistic children. Evidently, with the understanding of the existing scenario and the available data, it seems worth examining the application of color techniques for autistic individuals . Using oPeople pick colors linked to things they like and do not prefer the colors they dislike . AutistiProtecting autistic children from harm by providing a safe and secure environment is vital as their sensory processing ability is not developed enough to recognize challenges and handle crises . As chilIn most research studies, the preferences and opinions of autistic people are kept for analysis at a later stage. Several studies have highlighted the importance of clear rules, consistent routines, and calm orderliness for the adaptive functioning of individuals with ASD. Such studies are to help them cope with a predictable environment, situation, or setting without unexpected changes and help them to be engaged without being overwhelmed by anxiety , 62. As Many behavioral changes are attributed to different colors, and many research studies have attempted to decode the physiological effects of colors observed in autistic people. A study found that the strategic use of color could foster learning and suggested that the materials for learning activities could be chosen based on favorable color perceptions . The fixMany diverse research studies conducted by various scholars have extensively investigated the fundamental aspects relevant to enabling an autism-friendly environment . HoweverAlthough several diseases fall under the gambit of ASD, this study focuses on autistic children’s visual sensitivity. The understanding of the sensory perceptions of ordinary people is evident. Understanding the sensory perceptions of ASD people are challenging to determine their human psychology toward colors and lights. The novelty of the present study is a non-clinical approach to identifying the favorable visual environment for ASD children using interaction with the parents and caretakers of children with ASD. The indoor domestic environment has been critically investigated to determine if it is conducive to the unique needs and requirements of the children. Many environmental circumstances can affect the behavior, learning, performance, functioning, and wellbeing of autistic children, such as sound, smell, temperature, sense perceptions, communication, and social interactions. This investigative study is limited to the influence and impact of the two crucial sensory factors of light and color on autistic children in addition to space, wayfinding, and acoustics. This case study is primarily aimed at improving the quality of life of children with ASD through architectural aspects of the indoor built environment.The present study examines the sensory impact of light and color in an indoor environment on autistic children whose senses are generally more heightened than usual. The insights on sensory triggers gained from this study can guide designers and clinicians while designing living spaces and taking steps to reduce stimuli that may lead to behavioral features. Understanding ASD is difficult due to neurological abnormality and a complex behaviorally defined development disorder with multiple contributing factors. With the increasing prevalence of autism worldwide, the need for progressive architectural design standards, guidelines and best practices to improve the built environment, explicitly incorporating sensory sensitivity strategies in interior spaces that cater to autistic requirements, is being keenly felt. There is greater recognition for design’s impact in providing a soothing yet engaging environment for children with special needs. The primary objective is to share the fundamental factors to be considered in an indoor space and the tools and techniques that can be deployed to transform it into a calm, supportive, and autism-friendly zone, thereby resolving several adaptive issues for autistic children.The primary objectives of the present study are as follows:•Identify the central impairments of sensory intolerance in autism and understand the functional impact of light and color on autistic children.•To provide a pleasant sensory experience of light and color to make them feel safe and secure within the built environment.•Investigate the perception of light and color by autistic children and their influence through a comprehensive survey with various parameters.•Section 1 provides the background and needs of the present study. Section 2 elaborates on the methods adopted in this case study. Section 3 discusses the results of the case study. Section 4 describes the discussion of the results. Section 5 summarizes the significant conclusions and further scope of the research.The current work is summarized in the following sections. The research commenced with an in-depth literature review carried out in an organized manner to identify the current knowledge and understanding of ASD before framing the questionnaire contents –66. The The questionnaire survey was conducted with the parents of autistic children in-person mode. Informed consent was obtained from the participants before the interaction. The data was collected manually from Autism Schools in Northern India. Responses were collected from parents and caretakers of autistic children by conducting a structured interview per the prepared questionnaire. The data collected was then statistically analyzed and interpreted the results. The survey was first conducted with eighty-seven participants, all parents, and caretakers of children with autism.Prior to commencing the interview, parents were briefed about the purpose of the research study, its envisaged contribution and its importance. The parents and caretakers were notified about the survey’s objectives and informed of the importance of the questionnaire survey. The main intention of the questionnaire was to understand the sensory preferences of autistic children in an indoor environment regarding light and color factors.The questionnaire was divided into three sections, details of which are as follows.•Section A comprises the names of the parents or the therapist/psychologist, the child’s age, gender and city of residence.•Section B includes open-ended questions about artificial and daylight conditions, window position, lighting position, the color of lights, degree of brightness, light color temperature, and favorable behavioral changes that can be brought about by altering lighting conditions.•Section C presents a color matrix. The child or the parent picks up the color of their choice based on parameters for gauging the children’s mood, whether they feel comfortable, uncomfortable, calm, and patient, or disturbed. Colors are chosen for different rooms and preferences are noted to determine autism-friendly colors. Section C also comprises generic questions regarding preferences for sensory dimensions of space and the importance of visual stimuli in providing favorable sensory experiences.To gain an understanding of the behavior of autistic children, the survey was conducted based on Section A, comprising of age, gender, and city of residence of the study participants. For this survey, eighty-seven participants were considered, amongst which 45 were male and 42 were female. Section B comprises a comprehensive questionnaire to determine the impact of light on autistic children. The analysis and the questionnaire survey findings are presented in this section with sub-sections for light and color, respectively. The standard deviation of the survey method is 2.3. The margin of error and coefficient of variation at a 95% confidence level is ± 0.85 and 0.27, respectively. This confirms that the results are within the permissible values.Sunscreen can be provided as it can be a convenient option for autistic children who want to block out direct light diffusion. The communication and behavior of the children were observed when they were studying under low light conditions to determine if they were calm and focused or agitated and irritable to identify an autism-friendly lighting arrangement. In most of the cases, it was observed from the survey that the children had difficulty with language activities that involved reading. They struggled with words and quickly got flustered. Autistic children have characteristics with the visual perception of the environment, tend to lose concentration, and have learning difficulties. A combination of factors considered in the study may be needed to better understand their behavior within an enclosed space. This is because autism is a complex spectrum disorder with a broad range of conditions and features that differ vastly from person to person.When conducting the survey, it was observed that most parents wanted a designated sensory space to provide an immersive sensory experience for their children. A sensory space is a specially designed and personalized therapeutic area with many sensory-friendly objects that autistic children are familiar with, which can be explored with the senses and are in different color palettes and textures. This space is designed to provide a calm and relaxing area for autistic children with sensory processing challenges to slowly habituate themselves to the visual and tactile environment. The survey reveals that it is critical to consider visual aspects at the preliminary design stage to ensure a good balance of visual elements and features in the built environment to make it a safe, secure, accessible, appealing, and comfortable for autistic children. A color-related questionnaire is handed out to the participants to determine color preferences; it is found that the most suitable colors are pastel, dull, neutral, and muted shades that are not distracting but have a tranquil effect. The chosen color scheme must accommodate visual sensitivity is of prime consideration for autistic children with sensory processing disorder as it can affect their mood, learning ability, and function. The darker shades are deemed to be unsuitable. The least preferred colors cause extreme behavioral changes like agitation, irritability, confusion, distress, anger, and aggressiveness.The interaction of light and color is observed in this survey as their physiological effects can positively impact an autistic child. The variables defined in the table for studying the impact of light create an understanding of whether artificial lights, LED, dimmable, and incandescent bulbs are preferable depending on their effect on the sensitive eyes of autistic children –80. The On examination of the various lighting conditions, a dark room, darker lights, and more brightness are not preferred. Natural daylight is perceived to be the best lighting for indoor spaces. Fluorescent lamps are suitable if they have the option for the brightness levels to be controlled. Neutral-colored lights are the preferred option. Most participants prefer LED lights over fluorescent lights as the harsh light from the latter tends to cause agitated behavior and extreme distress in autistic children with light sensitivity.Another component of lighting conditions within enclosed spaces must be considered the light’s and window’s positions. Autistic children can be oversensitive or under-sensitive to bright lights, which can debilitate their functioning; strategic light and window placements can help minimize the light intensity and provide a calm and relaxed work or play environment. The overhead lights option is preferable to avoid direct light visibility, and desk lights are another option. It is observed that in most cases, the window is situated at or directly above eye level. Windows at higher levels are not preferred. The study also included the color and temperature of lighting applications while determining the light efficacy factor as they tend to psychologically impact all humans, particularly autistic children with heightened sensory sensitivity. This becomes important as there is a definite connection between lighting and behavior, as evident from behavioral changes noticed in autistic children who become aggressive and flustered if they are not comfortable with the illumination provided by the lighting arrangements. Subtle manipulation of lighting can alter the mood, behavior, and perception of autistic children. Light color, source, quality, direction, and intensity are aspects to be considered in providing an optimally lighted environment that considers the light sensitivity of its inhabitants.A questionnaire survey method investigates the visual aspects that significantly influence a space. According to the study, it is noted that children have a broad range of color preferences and respond distinctively and differently to various shades showing the importance of using an ASD-friendly color palette. Light, color, and space are essential components of any indoor environment that must be considered when designing for children on the autism spectrum. Architecture, as a profession, uses best design practices to devise customized environments which are engaging spaces that fulfill the specific needs of individuals, help them cope with their surroundings, encourage their independence, and positively impact their performance and behavior. In this regard, with greater recognition of effective space design’s impact on individuals with autism, designers and clinicians can consider indoor environmental aspects at the primary level and research the same issue with other interlinked factors. This study is one kind to facilitate a macroenvironment that can promote clinical services for autistic children. These results help determine the external factors that could enhance the abilities and functioning of autistic children in the built environment.According to the survey results, light and color are significant variables within a built environment that greatly influence autistic children as they have a sensory processing disorder. Among the selected variables, light and color strongly correlate with the behavior of ASD children when compared to space and wayfinding. The results of the present study are on par with the literature –93. EverThe number of participants involved in the present study produces substantial input to the architects and clinicians. However, further studies with all stakeholders with more populations and their interactions are necessitated to improve the built environment designs more refined for autistic children. This study is mainly focusing on the non-clinical survey approach. However, the clinical and non-clinical approaches, like measuring heart rate, speech, language skills, emotions, social interactions, other motor, and non-motor skills could produce more appropriate solutions. Further clinical studies are required to expand the demography to improve autistic-friendly built environments and designs to assist the efficiency of the support and services to autistic children. The present study’s results are mainly pertinent to design an autistic-friendly built environment on a non-clinical approach using a questionnaire survey. Thus, further non-clinical and clinical studies on several micro factors are required to expand this survey to autistic adults.The effects of light and color on the behavior of autistic children were investigated using a questionnaire survey. The full involvement of all the users was critical from the commencement to the completion of the survey. The study shows that dialogues were substantially reshaped during the color matrix questionnaire. The findings were obtained through cost-effective non-clinical methods. This was crucial from the start, as most research studies on ASD offer unclear and hypothetical results. Therapists, parents, and children actively participated in the survey sessions and offered valuable insights to designers and clinicians. The therapists and parents are vital users closely involved in meeting the needs and demands of the children under their care. Their experiences with the children offer essential data that helps understand the likes and dislikes of autistic children in the built environment regarding the lights and colors. The major conclusions of the present study are as follows.•The standard deviation of the survey method is 2.3. The margin of error and coefficient of variation at a 95% confidence level is ± 0.85 and 0.27, respectively. This confirms that the results are reasonably within acceptable limits.•The literary assessment and survey were utilized to comprehend the effect of colors and light in any indoor environment for children with autism.•The lights and colors of indoor environments are the most influencing factors in promoting the harmony of autistic children compared to space and wayfinding.•Direct lighting and natural daylighting are preferable to intense light or glare in as many places as possible.•The spaces designed for people with ASD must address how these people perceive the environment and react to space features.•The study proves that dull and pastel colors and muted lights are more suitable for visually sensitive autistic children.•Lower sound levels of below 50 dB are autistic-friendly, and beyond 60 dB develops inappropriate behaviors.Light, color, and space are preliminary considerations of any inhabited environment. There is an increased need to ensure the suitability of light and color provisions in all interior spaces intended for autistic children to make them sensory-friendly. These findings emphasize the need to understand the different parameters associated with autistic users and the benefits of designing an autistic-friendly environment.Designers should look upon these three variables effectively for comprehensive design and further studies. By recognizing the influence of the sensory environment on autistic behavior, designers should consider these critical variables and adopt a sensory-sensitive approach to design inclusive spaces with optimum comfort. The current findings emphasize the need to understand the different sensory issues and parameters associated with autistic users and the importance of design considerations required for setting up an accommodative, supportive, neurodiverse, and autistic-friendly environment tailored to their need for positive sensory experiences. Thus, the present analysis and the scope for further research studies could benefit autistic individuals by appropriately analyzing the selective blended clinical and non-clinical techniques.The original contributions presented in this study are included in the article/supplementary material, further inquiries can be directed to the corresponding authors.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. The patients/participants provided their written informed consent to participate in this study.AN, RP, and PR contributed to the study’s conceptualization, design, and investigation. CP, RS, and SD critically verified the data and analyzed. KL, XW, and XZ contributed to the data analysis and revision of subsequent versions. All authors contributed to the article and approved the submitted version.