Multisectoral collaboration highlighted as key in delivering on the Sustainable Development Goals (SDGs), but still little is known on how to move from rhetoric to action. Cambodia has made remarkable progress on child health over the last decades with multisectoral collaborations being a key success factor. However, it is not known how country stakeholders perceive child health in the context of the SDGs or multisectoral collaborations for child health in Cambodia.Through purposive sampling, we conducted semistructured interviews with 29 key child health stakeholders from a range of government and non-governmental organisations in Cambodia. Guided by framework analysis, themes, subthemes and categories were derived.We found that the adoption of the SDGs led to increased possibility for action and higher ambitions for child health in Cambodia, while simultaneously establishing child health as a multisectoral issue among key child stakeholders. There seems to be a discrepancy between the desired step-by-step theory of conducting multisectoral collaboration and the real-world complexities including funding and power dynamics that heavily influence the process of collaboration. Identified success factors for multisectoral collaborations included having clear responsibilities, leadership from all and trust among stakeholders while the major obstacle found was lack of sustainable funding.The findings from this in-depth multistakeholder study can inform policy-makers and practitioners in other countries on the theoretical and practical process as well as influencing aspects that shape multisectoral collaborations in general and for child health specifically. This is vital if multisectoral collaborations are to be successfully leveraged to accelerate the work towards achieving better child health in the era of the SDGs. Using semistructured interviews, diverse themes around the complex phenomenon of multisectoral collaboration for child health could be explored to reach high information power.The study included a relatively large sample of child health stakeholders at a national level with unique insights into multisectoral collaboration and knowledge of the Cambodian context.The sample participants interviewed is unbalanced in terms of gender and expertise in different SDG areas.Halfway until the United Nations Sustainable Development Goals (SDGs) are to be achieved, practitioners, experts and policy-makers are trying to speed up the pace of progress on child health. This has become even more urgent with the setback of the COVID-19 pandemic which left 147 million children out of proper education, rising child labour and significantly higher rates of malnutrition and over 22 million children missing essential vaccinations.5 6Multisectoral collaborations have long been seen as critical for achieving gains in health and well-being when it comes to universal health coverage, non-communicable diseases and succeeding in governing multisectoral issues going back to the WHO Constitution and the Alma Ata Declaration.13During the Millennium Development Goal era, many countries made significant gains in child health, and approximately half of the reduction in child mortality between 1990 and 2010 have been attributed to investments in sectors outside of health.17–19Cambodia has managed to improve the health and well-being of children over a short period of time while using collaborations across sectors to do so among other changes. However, it is not known how child health stakeholders have been influenced by the SDGs or how they theorise multisectoral collaborations, here defined as ‘multiple sectors and stakeholder intentionally coming together and collaborating in a managed process to achieve shared outcomes and common goals’,Guided by the The COnsolidated criteria for REporting Qualitative (COREQ) recommendationsKey child health stakeholders with country-specific knowledge as well as non-health sector stakeholders on a national level in Cambodia were identified for participation by the research team. Participants were purposively selected based on predefined criteria of having expertise in child health or being from a non-health sector  but with implementation knowledge of how child health interacts with other sectors in Cambodia. Efforts were made to recruit participants from many different sectors, including having participants from inside and outside of government. Further, the recruitment of participants was aimed to be balanced in terms of sex and seniority. The outreach to participants was done by DH, SS and TC through email and phone. The expected total number of participants was 30, balancing the need for reaching satisfactory information poweret alA total of 29 participants were interviewed between April and June 2020. Information was given verbally to all participants on the purpose of the study, what their involvement in the study would be, the risks and benefits of taking part in the study, and that they had the right to decline participation or withdraw from the study at any time for any reason. Participants were asked to sign an informed consent form, written in Khmer before the interview started. The interviews were held in Khmer by authors SS and TC, audiorecorded and transcribed verbatim into English. The interviews took place in Phnom Penh city vicinity, at the participant’s place of employment or other convenient but private location for the participant. An interview guide was developed based on established multisectoral frameworks; the SDG synergies framework,10.1136/bmjopen-2023-073853.supp1Supplementary dataTranscripts were imported into NVivo software for analysis. The transcripts were first analysed by framework method analysis22No patients or public representatives were directly involved in the design, conduct or reporting of this study. The findings will be disseminated and discussed with involved stakeholders. A reflexivity statement can be found in 10.1136/bmjopen-2023-073853.supp2Supplementary dataA diverse set of perspectives were provided by the participants  play an important role in shaping the determinants of child health in Cambodia. They further urged a concrete focus on preventive measures, improving quality and reach of health services related to the child and the family to improve child health further. Lastly, interviewees made the case for a life course approach to child health and setting a higher ambition for children with a focus on child growth and stronger acknowledgement of the rights of the child.To understand about the needs of children, we need to understand the growth of them first. Children’s development consists of children before birth, children after birth to two years old, children in kindergarten and primary school, and children in high school. The development of children on physical health, education and morality are ongoing process.—Nr 5, governmental organisationWhen discussing multisectoral collaborations for child health, it became clear that there is a step-by-step linear process of thinking around the collaboration and its activities while aspects influencing the collaboration shape and direct the process in non-linear fashions. Participants also critically assess the collaborations, identifying success factors and obstacles for these types of collaborations in Cambodia.The beginning of a multisectoral collaboration typically began with the identification and framing of a problem. This could be from a top-down approach, whereby government ministries identified a gap or need, or through policy or development plans while funding opportunities and the own organisational strategy or values could be other ways of identifying a problem. On the other hand, interviewees also described a bottom-up approach of problems being identified through routine data or findings from the grassroot level, complemented by listening and learning from community or subnational stakeholders. The identified problem was often not primarily concerned with health but noted that child health might stand to benefit as an effect of a successful solution to the problem. The problem was typically framed in a detailed problem statement following involvement of many stakeholders in the collective process, often using research in some way to narrow the problem.So, the needs can be identified through annual reports and through our observation in different sectors. Sometimes, we also do things following the donors’ research and findings.—Nr 1, governmental organisation.They  collected all data from institutions under Ministry of Health. Then, they identified the challenge and priority action plans for next year. Besides, each unit need to monitor their annual results and to identify the priority action plans. That’s how the Ministry of Health and different units identify the needs on child health, status, results and ways forward to reach SDGs.—Nr 6, governmental organisation.The stakeholders involved in the discussed collaborations varied substantially, however, the government  was seen as a natural leader of collaborations while non-governmental organisations often organised in networks. Interviewees expressed territory feelings, with relatively strict boundaries between stakeholders and a critical view of government by the non-governmental organisations and vice versa.I am not blaming the government institutions, but there are some institutions which have too clear boundaries on their responsibilities and work. This leads to failure in our work.—Nr 29, international organisation.Planning of the collaboration was seen as a complex, detailed and resource demanding process. Often not formalised, a capacity assessment of the stakeholders in the collaboration, primarily focusing on implementation capacity and not on specific knowledge or expertise in a particular sector or area, was usually done at this stage, with the division of activities based on this assessment. If there was not enough implementation capacity to solve the problem identified, the collaboration could not begin. During the planning process interviewees noted that prioritisation of activities was done depending on the funding requirements and to secure buy-in from certain stakeholders  seen as necessary for the success of the collaboration.For example, they (government servants) may plan 20 activities, but receive inadequate budget. So, they prioritize the activities to be done. According to my observation, district level is the same. They engage politics into their work. They like infrastructure development more than social development because it is eye-catching and visible.—Nr 9, governmental organisation.Coordination was done in various ways depending on the collaboration; however, there were usually a common information sharing mechanisms, focal points at each stakeholder or joint committees with continuous coordination often built on somewhat already existing structures. There was also a clear division of responsibilities, although participation in joint coordination could be difficult to achieve and often those who coordinate do not have decision-making power. Clear leadership of the collaboration was seen as paramount, with coordination succeeding or faltering based on the competence and willingness of the leader. As such, coordination was both a formal and informal process. Indeed, power and hierarchies shaped the coordination efforts where power imbalances or competition for funds between stakeholders could threaten the whole collaboration.Those people also need to have the authorization in decision-making in the meeting. In the past, there were people who attended the meeting, but did not do what were discussed. It was useless when people came to listen, but didn’t share to their management and colleagues.—Nr 15, non-governmental organisation.Implementation of the collaboration tried to follow the planning and set coordination mechanisms. However, collaborations were able to change depending on a change in the context or influencing aspects such as the COVID-19 pandemic or funding changes. Interviewees emphasised the difference between the national and sub-national level in terms of the collaboration, with larger collaborations having an administrative or policy function at the national level while implementation occurred at the subnational level. This structure often led to increased complexities, with a different set of stakeholders needing to be involved at the different levels and the subnational system having its own set of priorities.National level only work on policy. So, implementation goes to community level. I think that we should focus on provincial and communal level first to let them implement the work. We should also try to integrate the coordination with national level too by using forum to meet and discuss on the challenge.—Nr 28, international organisation.Monitoring and evaluation were seen as integral to the collaboration, enabling learning and improvement of the collaboration itself and its activities and serving as the main accountability mechanism. The responsibility of conducting the monitoring and evaluation varied depending on the context and funding available, with external evaluation being seen as favourable if it could be funded. The national government and international organisations relied heavily on monitoring and evaluation for making decisions about the collaborations. However, it was seen as hard to move beyond pure outputs, with quantitative indicators believed to be most reliable, and to attribute successes or failures to different stakeholders in the collaboration.Dissemination of the collaboration and its activities were primarily thought of as information spreading, trying to raise awareness of the identified problem and engage the public and relevant stakeholders at national and international level in the efforts to solve it. It was also deemed important as a means of ensuring recognition from national level government ministries or the international community for the work done.We shared a lot, especially early childhood development program. We shared at provincial level and national committee on children education. We invited those committees to see our target location and our work. So, we disseminated a lot. Nr 22, non-governmental organisation.There were a range of aspects influencing the process, often challenging the idea of a step-by-step linear approach of the collaboration. The most prominent aspect throughout was the funding, interviewees described the budget as the greatest limitation to the collaboration and called for more governmental funding at the national and subnational level for multisectoral collaborations. Funding was seen as the most important source of power in the collaboration. Leadership roles, agenda setting and decision-making were mostly done by the organisation that controlled the funding.More importantly, we need the money to be available at sub-national level. The partners are all institutions. If the government can’t manage to work on everything, we can ask civil society to help working on that. Nowadays, we are sceptical with non-governemental organisations. But, we also have example of government providing budget for non-governemental organisations to work. Nr 4, governmental organisation.Relationships between the collaborators could facilitate or hamper the collaboration, with tensions between non-governmental organisations and the government existingand at the same time conflicts between government ministries or civil society networks that added complexity. For this reason, many collaborations tried to actively build relationships over time particularly between coordination focal points or joint committees, seeing mutual understanding leading to trust and confidence in the collaboration.The collaborative work also became better. During my time at education sectors, the relationship between partners was going very well, and we were happy to share any documents or data.—Nr 23, non-governmental organisation.There are many non-governemental organisations working to promote children. The government don’t even know who they are. Some non-governemental organisations don’t care about networking with the government too. This is the challenge according to my observation as a person in the middle of the two institutions. Both have their own weakness. Some non-governemental organisations do not know what the ministry have. For example, some non-governemental organisations do not know about existing guideline, plan or projects to work consistently. They only focus on their own work, and not pay attention to what others do to work collaboratively on the topic.—Nr 2, governmental organisation.Capacity building was deemed to be key for the sustainability of the collaboration and its activities, particularly at the subnational or implementation level, although demanding significant resources and the actual method varied depending on the type of collaborations and the stakeholders involved.Whenever there are requests from anyone or any organisations, we always respond and provide the training or sharing of experiences. We never hide our knowledge. We don’t even charge them. We do it from our heart and soul.—Nr 10, governmental organisation.An enabling environment, particularly concerning policy and national governmental direction within which the collaboration took place, was seen as being of crucial importance. The introduction and adoption of the 2030 Agenda and the Cambodia SDGs, subnational plans for development and national level plans promoted the idea of multisectoral collaboration. Government ministries that actively promoted or worked in multisectoral ways or through multisectoral committees, although not always successful, further promoted the advantages of tackling problems in a multisectoral fashion.The main thing is whether or not they have the commitment to work together. When commitment on that occur, the work can be done easily because visions created in country and global level has already been created.—Nr 17, non-governmental organisation.Interviewees reflected critically on their collaborations and had through experience identified some key success factors and often faced obstacles of multisectoral collaborations in Cambodia. Having clear responsibilities with agreement on division of activities, leadership from all and functioning monitoring and evaluation as well as a common vision and understanding based on continuous learning in an open environment where benefits and goals were explicit seem to be key success factors. Further, many emphasised the necessity of securing buy in, trust and commitment from all stakeholders in the collaboration from the beginning with the national government having a special role in all collaborations.Problems always occur. To work well with each other, we need to have collaborative plan with everyone’s ownership. Secondly, we need to build trust and not allow any mistrust to happen.—Nr 27, international organisation.We also work closely and indirectly with selected institutions which have the most power.—Nr 3, governmental organisation.Obstacles identified were lack of funding or long-term sustainability of the collaboration and its activities, with politics on subnational and national level could mean unfavourable conditions for a collaboration or simply competing priorities or work of the stakeholders in the collaboration. There could also be a sense of a lack of accountability towards each other or the thought beneficiaries, with sometime faltering commitment to work together, lack of transparency of funds or efforts and difficulty of attributing failures or successes.For instance if we are looking among 25 sub national civil society working group at the provincial/municipal level, there was only 50% who were active. Among these half, only 20 to 30 % who were very active in fulfilment of their collaborative work.—Nr 20, non-governmental organisation.et alIn this study, we found that the adoption of the SDGs led to an increased perceived possibility for action and higher ambitions for child health, perpetuating child health as a multisectoral issue. Further, there seems to be a gap between the desired step-by-step theory of conducting multisectoral collaboration and the real-world complexities of conducting such collaborations for child health in Cambodia. This is the first study to provide in-country insights that can be transferable on multisectoral collaborations for child health, overcoming some of the key methodological gaps noted by Glandon The expanded view of child health and higher ambition for children to thrive led to a more compelling case for multisectoral collaborations to have a collaborative advantage over single-sector or single-stakeholder efforts. The 2030 Agenda and the SDGs influence social norms at a global, country, organisational and individual level.35 36et al,44 45Multisectoral collaborations depicted by the participants in this study showcase that there is often no linear process but rather ongoing non-linear flow of activities that intentionally lead to a multisectoral collaboration (see Our limitations include that the purposive sampling led to selection bias in the recruitment of participants. As illustrated in We found that stakeholders in Cambodia perceived the SDGs to inspire an expanded view on child health that enabled change and promoted multisectoral collaboration. Interviewees experienced a gap between the desired theory of conducting multisectoral collaborations for child health and the real-world complexities of engaging in such an endeavour. The findings from this in-depth study can inform policy-makers and practitioners who wish to encourage and take advantage of multisectoral collaborations for accelerating the work towards achieving better health in general and child health specifically the era of the SDGs.


Glucose monitoring is key to the management of diabetes mellitus to maintain optimal glucose control whilst avoiding hypoglycemia. Non-invasive continuous glucose monitoring techniques have evolved considerably to replace finger prick testing, but still require sensor insertion. Physiological variables, such as heart rate and pulse pressure, change with blood glucose, especially during hypoglycemia, and could be used to predict hypoglycemia. To validate this approach, clinical studies that contemporaneously acquire physiological and continuous glucose variables are required. In this work, we provide insights from a clinical study undertaken to study the relationship between physiological variables obtained from a number of wearables and glucose levels. The clinical study included three screening tests to assess neuropathy and acquired data using wearable devices from 60 participants for four days. We highlight the challenges and provide recommendations to mitigate issues that may impact the validity of data capture to enable a valid interpretation of the outcomes. Monitoring of one’s health has never been easier and more convenient thanks to the technological progress made in wearables. These lightweight devices can be interfaced with computers and smartphones to measure and collect different physiological variables such as activity level, heart rate, temperature, and respiration rate through watches, wrist bands, bracelets, lenses, earphones, socks, and glasses . The popIn 2021, the International Diabetes Federation estimated that there were 537 million people with diabetes and predicted that this number will reach 700 million by 2045. Patients with diabetes need to maintain optimal blood glucose levels and avoid hypoglycemia by monitoring their blood sugar, regulating their calorie intake, and adhering to treatment strategies ,13,14,15A change in glucose levels, especially hypoglycemia, mediates autonomic activation and a change in the heart rate, sweating, and even consciousness level, which can be detected using wearables technologies ,25,26. AWe describe the key considerations whilst undertaking clinical studies using wearable devices to enable the acquisition of robust data to allow the development of glucose and hypoglycemia prediction models in patients with diabetes.Provide key considerations to enable a successful outcome for a clinical study using wearables.Highlight the major challenges faced when undertaking a longitudinal study using wearables.Recommend solutions to mitigate issues in the execution of a study using wearables.The contributions of this study are as follows:There are general and ethical considerations that the research team must consider prior to conducting any clinical research activities involving participants.Recruiting an adequate number of participants is key to establishing statistical power by satisfying the sample size representing the target population . RecruitIn this study, subjects with T1DM (n = 20) and T2DM (n = 20) were screened by their physician and referred to the research team for eligibility and consent. Healthy participants (n = 20) were enrolled through referrals and advertising at the approved sites. The participants had an average age of 36 years with 18 females and 42 males. Inclusion criteria were patients with type 1 or type 2 diabetes over the age of 18, treated with insulin. Exclusion criteria were: cardiac, liver, or renal dysfunction, vitamin B12 or folic acid deficiency, cancer, pregnancy or breastfeeding, and those who had undergone ocular surgery or trauma within the last 6 months, or had corneal pathology, or an allergy to eye drops.Eligibility criteria are set of specifications written in human-readable form highlighting the clinical characteristics of patients governing their entry into a medical trial ,36. TheyThe Institutional Review Board (IRB) is comprised of individuals that oversee research protocols and ensure the adherence of investigators to regulations that protect human subjects participating in research . ObtainiIn the current study, the research was jointly reviewed and approved by three collaborating institutions. The approved documents included the main protocol containing the details of the objectives, background, inclusion and exclusion criteria, recruitment methods, procedures involved, statistical analysis, data management, withdrawal of participants, and risks to participants. Other approved documents included a diary log, an invitation email and flyer, an eligibility screening form, a consent form, a questionnaire, and a data collection sheet. The approved documents were in English and Arabic to meet the requirements of the local community.Clinical studies and trials are conducted to collect data from eligible participants to answer specific research questions pertaining to the efficacy of a new treatment, educational approaches, screening methods, procedures, or a medical device . WearablThis section highlights the steps towards a successful outcome to ensure that adequate data are captured from the wearable devices.Continuous glucose levels are needed to establish their relationship with variable data acquired from wearable devices. Standard self-administered glucose measuring systems rely on a disposable test strip that reads the blood glucose from a drop of blood acquired through finger pricking. This method may cause discomfort and pain and provides only a limited number of data points. The CGM device measures the interstitial glucose continuously using a thin enzyme-coated subcutaneous sensor, which is comfortable and cost-effective compared to using blood test strips ,23. AlthCurrently, there are a number of CGM devices that are user-friendly, require no calibration, and conveniently acquire data. Two CGM devices were considered for the present study, namely the Dexcom G6 and FreeStyle Libre.Empatica E4: A wristband that acquires electrodermal activity, acceleration, interbeat interval, temperature, heart rate, and blood volume pulse.Bittium Faros: A chest wearable device that acquires a continuous electrocardiogram (ECG).Polar Verity sense: An armband that uses photoplethysmography (PPG) sensors to detect the heart rate.When considering different wearables, one must take into account the modality, location, convenience, data storage, and battery. Three wearable devices were selected  to enablThese three devices vary in terms of their battery life and storage. The Bittium Faros can store data for up to 12 days without recharging. Empatica E4 can store data for approximately 67 h in offline mode and requires charging after 35 h. The Polar has limited built-in storage; hence, a phone App was developed to store the acquired data on dedicated study phones a. The reA typical study using several wearables with many participants requires a common logging sheet shared among the team members to keep track of all the devices and the timings when they were given to the participants. A logging sheet is key to avoiding the misplacement of devices and mistakenly mixing the data of the participants. The logging sheet considered in the study contained an identifier for the participants along with details about the CGM, wearables, study phone, and time of visit .Write down the time when the wearables were given to the participant and when returned.Write down the phone number .Write down the device number at the back of the watch under “E4”  to identify which device was given to the participant.Create a main unique folder name for each participant.Clear instructions were given to the medical team to log all the required details:All assigned tasks should be clear and appropriate with respect to the team members’ expertise. In this study, the principle investigators monitored and oversaw the study, medical investigators screened and recruited the participants, and the technical team helped with the deployment of the wearable devices and the acquisition of the data .Activity recognition using self-annotated data or sensory readings  from wearables is useful in healthcare applications ,42,43. BUsing multiple devices  and their Apps can lead to issues in data collection that require troubleshooting to resume the normal intended mode of operation. It is important to compile a list of all possible malfunctioning scenarios that the participant may face with the wearables along with steps to troubleshoot them to ensure robust data collection. Instructions on the proper usage of wearables were also included in the developed App c.A successful study should include a detailed and clear protocol highlighting the procedures of the study. Prior to recruiting participants, it is essential to test the protocol and devices to evaluate their feasibility, accuracy, and efficiency . Pilot ew/v). A drop of hypotears gel (Carbomer 0.2% eye gel) was placed on the tip of the objective lens, and a sterile disposable TomoCap was placed over the lens, allowing optical coupling of the objective lens to the cornea. Six images were selected from the sub-basal nerve plexus in the central cornea (2), corneal nerve branch density (branches/mm2), corneal nerve fiber length (mm/mm2), corneal nerve fiber tortuosity, and inferior whorl length using CCMetrics. The investigator was blind to the study group when performing CCM and analyzing CCM images.Corneal confocal microscopy (CCM) is a rapid, non-invasive, and well-tolerated technique to detect and quantify neurodegeneration in adults and children with diabetes ,48. CCM l cornea c and thel cornea d to manuSudoscan  is a noninvasive sudomotor test that allows the measurement of sweat gland function and, hence, peripheral sympathetic integrity a. The SuCardiac autonomic profiling was performed using ANX-3.0 . Subjects were instructed to refrain from smoking and coffee consumption before the test. The test was performed while the subject was seated; a blood pressure cuff was placed on the left arm, and three ECG leads were placed below the clavicle, each approximately 1.5–2 inches from the sternum and the third at the base of the rib cage .The test is based on six different breathing patterns  and blood pressure measurements while sitting and standing. The ANX test assesses sympathetic and parasympathetic activity, as well as sympathovagal balance to provide a measure of cardiac autonomic neuropathy.The wearable devices acquire data of different modalities and at different rates and are susceptible to noise and motion artifacts. Preprocessing of the data is required for the machine learning application.A clear set of instructions was required to retrieve the data from the different wearable devices. After collecting a participant’s data, it was imperative to create multiple secure backups in different storage devices and on the cloud to avoid data loss.Preprocessing of the data from the wearables was needed to accommodate different sampling rates, noise, and missing values. In this study, three wearables to collect data of different modalities sampled at various frequencies were used. For example, the ECG signal was acquired at 250 Hz, while acceleration on the Empatica was at 34 Hz. Hence, resampling was required to ensure that all the data matched. Upsampling using linear interpolation and downsampling were performed on the wearables and CGM data to unify the sampling frequency at 125 Hz.Readings acquired from sensors and wearable devices are susceptible to motion artifact, temperature change, and baseline drifting, for which filtering techniques are needed to counter or mitigate their effects. For the ECG signal, the filtering technique proposed by Gamboa and implemented by the NeuroKit2 python library was used ,51. For When dealing with data containing large amounts of noise, it is useful to establish a quality index to identify the usable and noise-free data. For example, when dealing with the ECG signal, the team considered the MIT-BIH noise stress dataset and tested five different ECG quality index methods . These mMissing data from wearables and CGM occurred due to many factors such as running out of battery charge, accidentally turning off the device, random malfunction, and forgetting to scan regularly. When using more than one device to collect data from the participants, there is a high potential for missing data in one of the devices, and the regions of missing data collected by a wearable device are unusable. Hence, to achieve consistency, these regions should be discarded from all the other devices being used in parallel when the contemporaneous data of all are needed in an application. However, when the missing data from a wearable device are many (>60% of a session), then that specific sensor reading should be dropped. When the reference device  values are largely missing, then that participant’s data are unusable. The research team members handling the data analysis should decide what to keep or discard depending on the amount of missing data and their objectives.This section highlights the many challenges faced during this study involving the collection of multiple datasets from participants using wearables. Some challenges can be avoided, whilst others can only be mitigated.Approvals from the institutional review board are essential in any clinical research involving human subjects to ensure the protection of the rights and welfare of human research subjects involved in the study. However, approval can take time, thus delaying the start of a study, or may require a pause mid-study if an issue is identified that may potentially cause harm to the participants, or there is a delay in the submission of the continuation report. This study was a collaboration between Hamad Medical Cooperation, Qatar University, and Weill Cornell Medicine Qatar; therefore, approvals to start the study and to make amendments were a challenge.No direct or obvious benefits to the subjects.Length of the visit. The first research visit included: consenting, the CCM test, Sudoscan, the ANSAR test, providing wearables, and explaining how to use each device (1 to 2 h for each subject).The number of wearable devices discouraged participants, especially females.The need to log activities for four days.The study was conducted during the COVID-19 pandemic, making subjects more hesitant to come to the hospital.There are many issues and challenges associated with the recruitment and participation of subjects in a clinical study ,33,55. EA study logistics issue that was hindering recruitment was the number of wearable device sets available to the research team , which limited recruitment to no more than five subjects per week. Additionally, due to technical issues, the number of sets available was at times reduced to three sets, further reducing recruitment to three subjects per week.Access to clinical data on electronic medical record systems (Cerner).Inclusion and exclusion criteria.Difficulties in screening depend on the following:In this study, screening was performed by the physician principle investigator and there was no difficulty in accessing the database. Some of the inclusion and exclusion criteria made it more difficult to find eligible subjects.Difficulty for the participants to sit still for the duration of the tests and to follow instructions properly.Eye movement during the CCM test. It was hard for the participants to avoid moving their eyes and blinking during the test, increasing the time needed for the examination.Length of the test. For example, on average, CCM took 10–15 min for each participant.Valsalva maneuver in the ANSAR test: it was somewhat difficult for some of the participants to hold their breath for 15 s.There were challenges related to the use of three tests used to define neuropathy :Even after referral and confirmation, several participants did not attend the hospital to participate. Furthermore, 6/60 participants did not complete the 4-day trial and returned the wearables early, creating considerable discrepancy in the amount of data collected between participants .The commitment of the participants to continuously collect data and log their activity was challenging . In studThe research team faced significant challenges with the configuration and interaction with the data collection with the Dexcom CGM device, which required a change to the Freestyle Libra and, hence, a delay in starting the study due to a change in the protocol and IRB approval.The selection of wearable devices for longitudinal studies can be challenging. The design and structure of a wearable device need to be both robust to withstand normal daily living conditions and comfortable for the user to be worn over extended periods of time. Patch-based wearables, such as the ECG, require direct skin contact and access to sanitizing and shaving kits before application. In this study, a few participants faced issues with the patch of the CGM and ECG, as they came off accidentally during sports or sleeping. There may also be issues associated with wearing devices for 4 days, which may cause discomfort or irritation of the skin. The participants were instructed to either re-adjust the tightness of the straps, change the location of the wearable device, or take a short break from wearing it.The battery life of wearable devices is critical in longitudinal studies collecting continuous data. The wearable device should require no to minimum troubleshooting and infrequent charging. Wearable devices that need to be charged often will create more missing data. Of the wearables deployed, the ECG device lasted the longest for up to 12 days without the need for charging, and indeed, the data availability of the ECG was the highest of all the wearables . The armThe outcome of a clinical study using wearables can be challenging due to multiple factors. This article was limited to highlighting the challenges and to providing recommendations to address issues affecting the validity of collecting data from wearables. We identified the usual issues pertaining to delays in IRB approval and screening and identifying eligible participants. However, in addition, issues around continuous data collection from wearables require extra considerations and specific solutions.After finalizing the set of wearables to be used, the research team should produce manuals with clear instructions on how to use the wearable devices and how to retrieve the data. Long-term use of wearables may cause discomfort and irritation to the skin. The limit of the number of wearables requires effective cleaning and maintenance with the anticipation of malfunctioning and missing units.Prior to starting the clinical study, the research team should test all the devices to identify issues in the hardware or bugs in the software. The research team should also have strategies to reduce the burden on the participants, e.g., provide training upon using the wearables with continuous help and support during the period of data acquisition. The research team may consider developing their own App to provide a basic troubleshooting guide, assist in storing wearable sensor data, remind the participants to upload data in order to reduce missing data, and annotate data in relation to the activity.The research team may also need to explore various filtering and data-processing techniques to optimize data collection. Apart from successful data collection, future research utilizing wearables to enable glucose monitoring should focus on improving the accuracy, reliability, and convenience, as well as deploying AI and other emerging technologies to provide personalized and effective diabetes management strategies.


Indirect inguinal hernia in sheep can reduce the fertility and affected animals may present serious problems that can be life-threatening. The aim of this work is to describe a laparoscopically assisted technique to suture the internal inguinal ring in rams, preserving testicles. In six ram cadavers, both vaginal rings were partially closed. Two methods were tested on each side. The number of sutures required to achieve a satisfactory closure was recorded. After the cadaveric study, the procedure was performed on three rams with inguinal hernia and the occurrence of re-herniation was followed up. In cadavers, the technique could be easily and satisfactorily performed with either of the two systems. In two clinical cases, the procedure was successfully performed without hernia recurrence or alterations in reproductive behavior in the following months. In the third case, problems during laparoscopy prevented hernioplasty and the animal herniated again. This technique can be used as a simple and feasible surgical treatment for rams with inguinal hernias when preservation of the testicles is preferred. Although a larger number of cases are needed to evaluate long-term safety and effectiveness, this technique should be considered as an alternative to castration in rams with inguinal hernia.The aim of this study is to evaluate a laparoscopically assisted percutaneous suture (LAPS) procedure to treat inguinal hernia (IH) while preserving testicles in rams. An ex vivo experiment with six ram cadavers and a report of three clinical cases are discussed. In cadavers, both internal inguinal rings (IIR) were partially closed by LAPS. Two LAPS methods were tested: (1) using a laparoscopic portal closure device and (2) using a suture loop inserted through needles in each IIR. After each procedure, the closure was laparoscopically evaluated and the number of U- sutures was recorded. The procedure was also performed on three client-owned rams with unilateral non-strangulated IH and the occurrence of re-herniation was followed up. In cadavers, LAPS of the IIRs could be easily and satisfactorily performed with either of the two systems, requiring one to three U-sutures per IIR. No differences were observed between the two surgical procedures. In two clinical cases, the procedure was successfully performed without reoccurrence of herniation or alterations in reproductive behavior in the following 3 and 6 months. In the third case, the hernia was reduced but a retroperitoneal emphysema during laparoscopy prevented hernioplasty and the animal herniated again. In conclusion, LAPS of IIR can be used as a simple and feasible treatment to preserve testicles in rams with IH. Unlike direct inguinal hernia, in which the bowel penetrates directly into the abdominal wall, indirect inguinal hernia (IIH) is characterized by the intestinal bundle protruding through the inguinal canal. This type of hernia accounts for up to 7% of congenital disorders  and up tSurgical treatment is required when inguinal hernias occur. In humans  and horsIn children, partial closure of the IIR has been described using laparoscopically assisted percutaneous suture (LAPS) techniques. This procedure allows the resolution of the hernia defect in a quick, simple manner and with low recurrence rates, avoiding the use of specific high-cost consumable materials, and, fundamentally, it can be performed without the use of complex laparoscopic techniques ,6,7. RecSheep could also benefit from hernioplasty techniques. Although laparoscopy is not so extended in ovine species as in other species, mainly because of the high costs associated, its availability is spreading and is used for some artificial insemination techniques  and intrThe aim of this study was to evaluate the feasibility and efficacy of using a LAPS procedure to treat inguinal/scrotal hernias while preserving testicles in rams. We hypothesized that a modified procedure based on the LAPS technique used in children could be used to achieve partial closure of the vaginal ring in rams with IH. We first conducted a cadaveric study to assess the new technique and to overcome the initial learning curve, and subsequently evaluated the clinical performance of the procedure in three client-owed rams with naturally occurring unilateral non-strangulated IH.Six cadavers of adult rams of Rasa Aragonesa breed without signs or history of IH or testicular abnormalities were used, making a total of n = 12 IIRs to test the LAPS technique. The number of animals was based on previous studies describing the development of laparoscopic techniques ,14.The rams were euthanized for reasons unrelated to this study. All procedures were carried out under Project Licence PI63/22 approved by the Ethic Committee for Animal Experiments from the University of Zaragoza. The care and use of animals were performed accordingly with the Spanish Policy for Animal Protection RD53/2013, which meets the European Union Directive 2010/63 on the protection of animals used for experimental and other scientific purposes.A wide caudal abdominal area and scrotum were clipped and washed. Cadavers were positioned in dorsal decubitus on a hydraulic surgical table that allowed for Trendelenburg positioning and were positioned as previously described . To creaIn all cases, the intervention started on the right side. Two different suture methods were used to perform LAPS on each IIR of each cadaver. The method used on each side was randomly assigned (coin-flipping method performed by the first author). With both methods, sutures should be placed partially closing the flap of the IIR against the abdominal wall, close enough to the cord to prevent the possibility of herniation but not too close as to compress the vas deferens and testicular vessels. Laparoscopic forceps were used to push caudally the testicular cord.In the needle suture loop technique (NSLT) method, a 12 G 80 mm needle was used to pass a suture loop and a suture end to perform a U-suture. First, a suture thread (polyamide 0 USP) was passed through the needle and bent back to create the loop. Then, the needle with the suture loop was inserted through the skin incision and introduced in the abdominal cavity under laparoscopic control. Once the needle with the loop was properly placed, the loop was pushed further into the abdominal cavity , top andIn the second method, the EndoClose Trocar Site Closure Device  was used. This device is designed for the closure of laparoscopic portals in human surgery. It is similar to a Veress needle. The main difference is that the retractable stylet has a notched tip which is used to capture and hold sutures. Similar to the first method, the device with the suture loop was punctured through the skin incision under laparoscopic guidance and laparoscopic forceps were used to retain the suture loop inside the abdomen while the device was withdrawn. With a second puncture of the EndoClose, the initial loop was grasped and externalized to create a U-suture in the IIR.Proper partial closure of the IIR was confirmed by inserting a blunt laparoscopic trocar through an incision in the scrotum and tunica vaginalis. Prior to tightening the suture, the trocar should easily enter the abdomen (pre-closure control). After knotting the suture on the outside, it was checked whether it was possible to insert the trocar and the outcome was recorded . If neceThis part of the study was also approved by the Ethic Committee for Animal Experiments from the University of Zaragoza (Project Licence PI66/22) and informed owner (or an authorized agent for the owner) consent was obtained before enrolling any ram.Three cases of herniated rams referred to our surgical service and subjected to IIR hernioplasty using the LAPS approach were reported. Since owners preferred to preserve the affected testicle, this surgical option was offered. Informed owner consent was obtained after specifically communicating that this disorder could have a hereditary component in case the animals had an intended reproductive use. Follow-up was performed with owners or referrals via telephone calls between 3 to 6 months after surgeries.All six carcasses used were of the Rasa Aragonesa breed. The approximate age and weight of cadavers are shown in the The surgical position allowed good visualization of the surgical area, although, in some cases, the cadaver slightly tilted with wedge-folded towels to work on each side. In the initial laparoscopic examination, no hernia or alterations in the IIR were detected in any of the cadavers.All the procedures were completed successfully. The mean number of U-sutures per IIR was 1.4 . The mean was similar for both methods: 1.5 when using EndoClose  and 1.3 when using NSLT . It should be noted that for the first cadaver, a total of five sutures were necessary, three with EndoClose and two with NSLT. The characteristics of the cadavers and the findings during the procedures are summarized in the Regarding potential adverse events of the surgical technique, complications related to the laparoscopic access, but not to the suture technique itself, were recorded in two cadavers. In one cadaver, the trocar reached the omental bursa during the placement of one of the additional portals. In another cadaver, the rumen was perforated when the first cannula was inserted. To prevent this complication, in two cadavers, part of the gas in the rumen was evacuated before the procedure using a 11 mm, 20 cm locking trocar percutaneously inserted into the rumen.A 6/7-year-old (87.5 Kg) Rasa Aragonesa ram was referred with a unilateral left IH. The hernia had appeared some weeks earlier. The ram was intended for breeding. Despite moderate posthitis, the ram had been otherwise healthy and had no history of trauma. General clinical examination and basic parameters were within normal limits. There was visible asymmetry to the scrotum, with left-sided large soft swelling in the scrotum , which cPrior to surgery, food was withheld for 24 h and water was withheld for 12 h. A jugular venous catheter was placed and was used to administer flunixin meglumine  and procaine penicillin G . After the induction of general anesthesia, the ram was intubated and connected to an anesthetic machine with a system of positive pressure ventilation and oxygen supply. The ram was placed in dorsal decubitus and secured to the surgical table in the Trendelenburg position. A wide caudal abdominal area and scrotum were clipped and surgically prepared. The testicles were also surgically prepared but kept outside of the surgically draped field, placing the drapes to allow a gloved assistant to manipulate the testicles outside of the sterile area during the surgery, in case external maneuvers were necessary to reduce the hernia.Access to the abdominal cavity and placement of the laparoscopic portals were performed as described above for the cadaveric study. Laparoscopic examination confirmed the presence of an indirect IH in the left inguinal canal, with a very enlarged IIR. The hernia could be reduced with the combination of external manipulation, laparoscopic atraumatic grasping traction , Trendelenburg position and capnoperitoneum . The LAPIn the first few days after surgery, there was a marked enlargement of the scrotal sac on the left side, which progressively disappeared in the following weeks. Ultrasonography revealed a moderate amount of hypoechoic fluid but without evidence of a herniated bowel. The incisions healed properly and there was no recurrence of the scrotal hernia. After a 6 months follow-up, there was no recurrence of the hernia and the animal maintained normal sexual behavior.An 11-month-old (70 Kg) Dorper ram intended for show and breeding was referred with unilateral right IH occurring several weeks earlier, with no relevant changes after initial veterinary assessment. General clinical examination and vital parameters were within normal limits except for an asymmetry with right-sided large soft swelling in the scrotum. The hernia could be reduced externally. Conventional and color Doppler ultrasonography confirmed the presence of an IH, with intestinal segments and omentum in the scrotal sac, hydrocele and with adequate testicular perfusion .The animal underwent surgery under similar operative and perioperative conditions to Case 1. To reduce the hernia, it was necessary to perform a vigorous external scrotal massage . The vagA 2/3-year-old (75 Kg) Rasa Aragonesa ram intended for breeding was referred for surgical treatment of a mild intermittent unilateral externally reducible left IH that appeared two weeks earlier. The ram was otherwise healthy and had no history of trauma.The animal was intervened under similar surgical and perioperative conditions to previous cases. The hernia was easily reduced by traction of the intestine from inside the abdomen using laparoscopic forceps. The amount of herniated bowel was more limited than in the two previous cases . On thisThree months after hospital discharge, no re-herniation had occurred and the animal maintained normal sexual behavior.This article describes, for the first time, the LAPS technique of the IIR for repair of inguinal/scrotal hernias in rams. Traditionally, surgical treatment of IH in small ruminants has been performed by complete herniorrhaphy of the external inguinal ring, after castration. If the testicle must be spared, the surgical technique of choice is to partially close the IIR, which requires the use of laparoscopic surgery. The veterinary species in which the largest number of laparoscopic techniques have been described for this purpose is the horse, for which we can find several different approaches ,16,17.The cost of laparoscopic procedures is often prohibitive for ruminant livestock. Despite this fact, different laparoscopic techniques have been reported in these animals ,20,21,22In the present study, we used a technique based on a laparoscopic methodology developed in human pediatrics ,6 and whDespite all the important advantages that laparoscopy can bring to small ruminant surgery, laparoscopic procedures in sheep present some adjunctive complications related to the placement of the first trocar, due to the possibility of accidentally puncturing the rumen or entering the omental bursa . To reduIn the development of a novel surgical technique, it is necessary to carry out pilot trials in order to be able to apply such technique in clinical cases, which is why many authors include in their work preliminary studies in which only experimental animals or cadavers are used ,27. In oAs a result of the trial in cadavers, although three laparoscopic portals were placed in all of them, we believe that the procedure could be performed using only one portal for the optics, or with only one extra portal for instruments. In our hands, this was facilitated when using the EndoClose device. In the three clinical cases, however, having two work portals facilitated the hernia’s reduction and LAPS maneuvers in both inguinal rings. In our opinion, the advantage of operating with only an optical portal is the main justification for using the commercial EndoClose device instead of the NSLT. However, as shown in dogs  and pigsAccording to our experience, the use of EndoClose does not bring any other additional benefit and increases the cost of the technique. In addition to being a more economic option, an additional advantage of NSLT over EndoClose is that it could facilitate making several entries with the needle around the margins of the ring to pass the suture several times through the same loop, thus creating a purse-string suture as described in children . This coAnother relevant point is the non-absorbable nature of the material used for suturing in this study. Several studies on laparoscopic hernioplasty in humans , dogs 88 and horAnother limitation to this study was that a control group was not included to compare the outcome of the new technique. However, it should be noticed that there are currently no standardized or preferred techniques for partial closure of IIRs in rams, with only two single-animal reports so far. Therefore, this study is presented as a first step to describe the technique with the aims of developing it further and comparing it with other methodologies according to the advancement of the field.In addition to the value of the LAPS methodology for small ruminant surgery, our results open up the possibility to use this technique in foals with congenital IH. It should be considered that some of the techniques and devices developed for adult horses have not yet been tested in foals or have only been described for standing surgery , which iLaparoscopically assisted percutaneous IIR suturing is a simple and feasible surgical procedure for rams with inguinal hernias when preservation of testicles is preferred. This laparoscopic hernioplasty technique can be considered as an alternative to herniorrhaphy with orchiectomy in rams. However, larger numbers of cases, as well as prospective, longer and more comprehensive follow-up would be required to evaluate long-term safety and effectiveness.


Open Science enhances information sharing and makes scientific results of transport research more transparent and accessible at all levels and to everyone allowing integrity and reproducibility. However, what future impacts will Open Science have on the societal, environmental and economic development within the transport sector? Using the Future Wheel methodology, we conducted a workshop with transport experts from both industry and academia to answer this question. The main findings of this study point in the direction of previous studies in other fields, in terms of increased innovation, increased efficiency, economic savings, more equality, and increased participation of citizens. In addition, we found several potential transport specific impacts: lower emission, faster travel times, improved traffic safety, increased awareness for transport policies, artificial intelligence improving mobility services. Several potential negative outcomes of Open Science were also identified by the expert group: job loss, new types of risks, increased cost, increased conflicts, time delays, increased inequality and increased energy consumption. If we know the negative outcomes it is much easier to put in place strategies that are sustainable for a broader stakeholder group, which also increase the probability of taking advantage of all the positive impacts of Open Science. The purpose of this paper is twofold: First to examine how Open Science will impact the future on a social, environmental and economic level in the transport sector and second, to explore how the Futures Wheel methodology can be used as a methodological framework in order to predict future scenarios. The paper is first and foremost a methodological and empirical in nature. This is the first study on Open Science in the transport sector, and hence we try to establish knowledge about both the positive and negative implications of this phenomenon.1. The increasing diffusion of Open Science practices around the globe fostered by political decisions, such as the rollout of the Open Science Policy of the European Union, e.g. across Horizon Europe, the 9th research and innovation framework programme (2021–2027)1, could cause a multitude of impacts on research organisation, markets, technologies, society and environment. Open Science can enhance information sharing and makes scientific results of transport research more transparent and accessible at all levels and to everyone allowing integrity and reproducibility leading to more efficiency in research2. However, there is limited evidence on how Open Science will impact the future in the transport sector. While the demand for sustainable, seamless, secure and safe transport is growing, new technologies are cost-intensive and their acceptance and transferability to other regions or use cases depends on many factors3. Learned from many positive and negative lessons, social, organisational and technical innovations should be assessed in advance and during their diffusion in order to minimize threats caused by unknown side effects. One of the most impressive lessons learned has been the leakage of CFC gases from refrigerators causing tremendous effects, such as shrinking the ozone layer. These, and other lessons lead to the evolvement of qualitative and quantitative impact assessment4. In order to create a sustainable environment for Open Science within the transport sector we need to know both potential positive and negative effects, and effects that are specific to transport in regard to potential economic, social and environmental changes. Open Science consists of several different concepts (eg.7), and for this study Open Data (OD), Open Source Software (OSS), Open Access (OA) and Citizen Science (CS) will be in focus.Open Science is “a system change allowing for better science through open and collaborative ways of producing and sharing knowledge and data, as early as possible in the research process, and for communicating and sharing results”9. It is too expensive for any individual or organization to subscribe to all journals10, making a lot of the knowledge produced unavailable to both the general public, but also to other researchers. Opening up the access to research, it gives on one hand a broad citation advantage for researchers who publish openly12. Furthermore, it has economic impacts on innovation enterprises and a range of governmental and non-governmental services, potentially saving a lot of resources9. On a societal level it can also improve citizen science initiatives and levelling the playing field for researchers in developing countries8 However, it could also have negative impacts if high-cost options are allowed in an unregulated marked (ibid.). The business model of OA journals, where the authors pay, also invites predatory journals to enter the market11, corrupting the publishing system and promoting unethical behaviour among researchers in need for publications13. There has been an increase in the share of open access articles in the transport research community the last decade14 and open access publishing has been highly prioritized politically in several countries. However, in the transport research community, the few open access journals have a lot of issues related to quality15, making it less attractive for researchers to publish. Also, the models for open access publishing created by coalition S, may have implications for the development of Open Access in general—causing non-equal opportunities on a national level, where some countries can pay for publishing openly in high quality journals, while others cannot afford to pay for these journals15.Open access has been one of the focus areas of Open Science for a long time. This is also one of the areas within OS where there is quite a lot of disagreement on the advantages16. How and what values will be created in the future is impossible to predict, however, there are some value creation that is already possible to point to18: transparency, democratic control, participation, self-empowerment, improved or new private products and services, innovation, efficiency and effectiveness of services and new knowledge through combining data sources in large volumes. Some innovation examples increasing social value through participation and self-empowerment are17:Open data can possibly add a lot of value to the society. One of the main motivations for opening up publicly funded data is to increase return of investment, generate wealth and manage to solve more complex problemsDenmark: Findtoilet.dk, a woman created an app that shows people where all the public toilets are, so that people with bladder issues can move more freely.The Netherlands: Vervuilingsalarm.nl, an app that shows the air-quality in your vicinity.New York: finding where to walk your dog and people who use the same park.19.Other social benefits than empowerment of citizens is increased societal participation, collaboration, and inclusion of marginalized groups19. Open data is also seen as a driver for economic growth, contributing to innovation and creation of new business models. Businesses re-use data to gather meaningful insights and develop and improve products and services20. Despite all the positive possibilities of opening up data, there are also barriers related to open data, and negative aspects needs to be addressed more attention21. There is a large potential for open data within the transport sector and the importance is increasing. However, open data is possibly more problematic for the transport research sector than other fields due to large data generation outside the traditional research community22, making it more difficult to access the data.Several studies have estimated the economic value of open data at several tens of billions of Euros annually in the EU alone. In the Netherlands, the Ministry of Education publishes education-related data for reuse, which has in turn reduced the number of questions they receive, reducing workload and costs23. Specifically, Linux and Apache were successful case studies that revealed the potential of OSS24. Many companies adopted OSS due to its adjustability in order to develop customized applications53. More recently, OSS has been adopted in several sciences such as engineering25, architecture26, physics27, biology28, etc. In this context, latest EC’s strategies focus on the increase of digital transformation schemes in various sectors to achieve a research-friendly environment through the usage of ICT services and existing open-source data infrastructures.Since early 2000, OSS has been identified as a promising strategy to support the efficiency and quality of software developments29, OSS is a powerful tool also offering valuable societal and economic benefits to support innovation. OSS can benefit all users with control options, training opportunities, system’s security and stability. On the other hand, OSS initiatives produce problems related to software patents and their regulatory framework. Free Software Foundation Europe30 highlights the problematic relationship between OSS tools and current legal framework. Existing regulations at national and international level leave significant blind spots for the exploitation of data production and outputs. More specifically, various legal risks and problems with OSS products patenting and commercialization bring other direct and indirect societal and economic effects on the scientific research communities and general public subsequently.In general, according to the Open Forum Europe organization31 have studied the barriers and adapters that influence the adoption of OSS by SMEs in South Africa. In general, developing countries primarily focus on cost-efficient alternatives to become competitive against the developed markets . These researchers highlighted several significant impacts of the usage of OSS tools replacing commercial software solutions for text editing (MS Office), geographical and meteorological representation  and other similar software categories. Similar findings were highlighted in research from India32. Economic impacts are savings from hardware & software cost, cost of ownership (including training schemes and indirect costs for operation and maintenance of software products), social impacts involve complexity on administration and OSS establishment and change management adaptation of employees within an organization. According to Xing32 the presence of commercial open source software can lead to the decrease of the software price and profit for proprietary software producer, while the consumer surplus and social welfare will be increased. Interestingly it does not necessarily cause a decline in the market share for proprietary software producer. Environmentally this could have effects on energy savings from the re-use of older computer units (with Linux OS) and other free-open access OSS tools31. OSS is still not used a lot in transport research, but there is a large potential: A survey sent out to all transport research institutions in Europe shows increasingly positive attitudes towards OSS, especially for the last 1–2 years22.Ellis & Van Belle34. Citizen science is important to increase democracy in science and promoting universal and equitable access to data and information35. Economically, Citizen Science can contribute to the design of new solutions through emerging technologies and making transport more efficient36. Citizen Science can also utilize creativity of citizens to react to challenges and in monitoring and designing cities. For example, citizen Science can deliver data to decision-making in policy37, to e.g. making cities safer38. And lastly, on an environmental level Citizen Science can support research on environmental developments or impacts of certain ecologic factors, such as monitoring the ecologic conditions of areas.40. Citizen science is especially relevant in transport research as interactive maps of mobility are getting more common (Open Maps), together with apps for tracking (bikes etc.). Also, citizen science is very relevant in order to improve transport accessibility41.Citizen science deals with public participation in scientific research, it often results in advancements in scientific research by improving the scientific community’s capacity, as well as increasing the public's understanding of science to some extend42, and is used for identifying and packaging primary, secondary, and tertiary consequences of trends , together with apps for tracking (bikes etc.).Researchers from universities or transport research institutesTransport research associationsPublic transport authoritiesLibrariansSoftware engineersA total of 19 European experts were in the workshop representing the following:The workshop was recorded in order to analyse the discussion at a later stage.48. The futures wheel has been proven to derive potential ecologic and socio-economic impacts49. In the workshop the methodology based on Glenn42 described hereafter has been used. An example for Open Science in transport was provided to make it easier to understand In the middle of the wheel Fig.  is the t2)In the next round it has been looked away from the original trend, and the primary impact When the secondary impacts are established: Smarter solutions for better analysing, harmful effects for individuals if GDPR data is hacked, malicious users creating bugs i.e. to infect hardware. etc., a last step using the secondary impacts Based on the analysis of secondary impacts a third and final circle of tertiary impacts , which have then been analysed in relation to society, economy and environment. For presentation reasons and increased readability, we have presented the wheels in excel formats.The Futures Wheel is mainly concerned with the consequences of a given trend. Hereby not considering that the trend might turn due to potentially negative consequences. Also, it does not consider potential problems in the start-up phase of the new trend. This will further be debated in the discussion section.The point of departure for the discussion is that all areas of open science are increasing (in terms of use and sharing), and how a future increase in these areas will impact society, economy and environment in a positive or negative way. The workshop included transport experts within both Open Data, Open Source Software, Open Access and Citizen science.The experts were both representing research organisations, industry , and transport research umbrella organisations among others. Below are the results from the workshop, covering all four categories.50. Availability and access, reuse and redistribution of data, and universal participation are the key factors of Open data and content51. Below are the main findings  is a software with a source code that anyone can inspect, modify, and enhance. OSS applications have been increasing over the last decades and expanding in new key areas, such as transportation, tourism, health, etc.ngs Fig.  of how iInvestment costs can be divided in two main categories, i.e., the hardware-related expenses  and the software-related expenses . Utilization of OSS applications could significantly reduce investment costs as well as costs for operational, maintenance and upgrading purposes by mainly eliminating the cost of licensing of software products. As such, both scientific research communities and private transport industry stakeholders could benefit, and economic growth opportunities could be increased by using OSS. In more detail, OSS products and applications could be patented, reducing the existing barriers in public tendering. In addition, OSS products could provide a higher number of educational opportunities for students/researchers enabling them to capitalize new skills and knowledge.In this context, an increase in usage of OSS products could provide higher availability of software solutions for the research communities and could also increase the reproducibility of transport research outcomes. Thus, published results could be evaluated to reflect true findings or false positives. This also supports transparency and allows reviewers or other researchers to validate the published results. Additionally, new collaborative schemes between companies and research organizations could be promoted and the awareness and knowledge of OSS benefits towards the public (citizens & end-users) could be increased. New collaborative schemes and public engagement could further support OSS to provide more efficient services, innovative products and tools that could actively engage the general public in decision-making processes for transport research planning or related activities.Analysing the current tools  for urban transport planning, it is observed that OSS applications and products could promote Citizen Science by achieving a higher involvement of general public and engaging them into the scientific research world. They could offer valuable information and real-time data about the urban transportation network which could result in a competitive and innovative research environment. The engagement of certain communities or citizens could also generate alternative transportation solutions or new transport planning initiatives based on their personal experiences by utilizing and exploiting OSS. Hence, improved quality of OSS products could be also achieved through peer-review processes by testing OSS products for defects. Finally, it is worth mentioning that collaboration among the transport research community and general public could set the basis for creating proper documentation of existing OSS tools.Since OSS tools can be used by everyone, the steps followed for gaining the final results are freely available offering a more transparent framework that allows a more trustworthy provision and handling process of data to end-users. On the other hand, these lower security standards fail to follow GDPR and avoid cyberattacks and hacking. Mitigation actions are necessary to enhance general public participation in OSS products in an attempt to ensure qualitative data and their participation at a long-term horizon so as to achieve increased patents and profits. Towards an increased use of OSS, private software providers will be forced to properly adapt their business models in order to enhance the competitiveness between the research community and industry. As such, more advanced tools and solutions could be developed offering more effective and efficient tools, applications and solution approaches.However, no one organisation owns OSS and there is no one to provide sufficient marketing. It is mainly promoted via a “word of mouth” approach that could be insufficient on some occasions. Many OSS initiatives created from public research organizations have failed or delayed reaching the market due to the slow growth of their product or lack of end-users engagement to test their services, even though they are strongly supported by research communities .Open Access (OA) is in general known as the process of removing barriers such as price  and permission (e.g. copyright and licensing restrictions), in order to enable free, online access to full-text information. Below are the main findings Fig.  of how iIncreased usage of Open Access (OA) creates several opportunities as well as exposes the weaknesses which are important to address in order to move towards Open Science Fig. .Usage of Open Access enables equal access to publications as everybody, independent from the social status, monetary possibilities, country—developed or developing have a possibility to access the research results. This leads to better and broader publishing and using research results concluding higher quality of the research. It could create better awareness in the society by pinpointing strategically important areas where actions need to be taken to reduce economic differences.Broader use of Open Access in the transport sector can enable stakeholders access to publication in miscellaneous areas and reduce duplications in the database as more information is available and there is no need to “reinvent the wheel”. Having accessible information from other sectors for fast analyses could also potentially increase innovation. The probability that the research data is up-to-date is also higher as it is more used from various stakeholders. Consequently, solutions for complex problems could be found faster and by re-using research data, cost can be saved.Open Access is a challenge in the transport sector whereas the amount and complexity of data needs to be accommodated. In order to enable Open Access in the sector and to broaden the use, introduction of standardization and methods are important factors. Therefore, guidelines and recommendations at the European level need to be developed for Open Access in the transport sector and supportive infrastructure need to put in place. This would possibly increase the quality of research and leads to better presentation of the results, paving the way for an analysis of issues or challenges on a global level as the state of the art.A well-known factor is that Open Access is increasing the visibility of the publication as the publications are freely available to a broader audience, which also gives higher visibility for the author. This could be measured, using the growth of citations, making the author more popular and famous—and therefore supporting the researcher's scientific career. This again could trigger better job opportunities resulting in more funding. On the other hand, the creation of the new international communities could lead to more projects, enhancing cooperation in Horizon Europe for example and therefore enable international funding.The increasing request for free-of-charge access to full-text information affects the pricing formula for journal publications. Raising Article Publishing Charges (APC) leads to higher cost for OA publications on the author side. Due to limited budgets for publishing the overall publishing activities with OA could decrease, which could lead to a gap between OA results and the actual knowledge available in the research domain. This trend could be intensified by the fact that small authoring entities might not be in the position to pay higher APCs so that OA publication would represent less diversification of the research topics in transport. For example, institutes from third world countries with lower research budgets can only publish their results at high cost and thus lose opportunities for perception. In the most extreme case, this can lead to an even stronger unbalance in the visibility of institutions and countries.In the context of publishing results in general, there are several legal barriers when working with industry partners, which gets even more critical if OA is involved. There is the risk of infringement due to copyrights and IPRs leading to a focus on data protection, in case of doubt, and preventing a cultural change. Furthermore, even if publication is an option, «closed access» could be preferred to minimize a possible economic risk in the highly competitive transport area.To pre-empt those consequences by legal barriers, clear guidelines and regulations for OA in transport are needed. It would introduce a framework which allows to develop new/changed business models in the transport area, based on sharing information via OA publications.A free-of-charge, online access to full-text information provides new opportunities to link global transport experts. It allows a cross-sectoral information exchange due to removed pay-walls and easier accessibility. An example could be that scientists from the field of aeronautics can benefit from similar problems on fluid dynamics in the field of shipping. Barriers between the transport modes can be lowered or even fully removed. It could lead to a transferability of solutions beyond transport modes, so that beside the increasing information exchange existing economic resources can be used better/more effectively. Profiting from the linking of global transport export, there is a higher chance to solve transport issues in a common approach to improve cities, e.g. challenges in interaction of different transport modes in urban transport scenarios, and consequently life aspects.There is the fear that an increased use of OA would lead to a reduced quality of the publications. If confirmed, the risk increases that the transport community will lose the trust in Open Science in general and the number of OS activities could decrease. That leads to limited OS promotion in general, ending in reduced funding for transport research as more funding agencies indicate OA as a funding condition. To prevent a quality reduction of publications, the DOAJ Seal was established which is awarded to journals that demonstrate best practice in open access publishing and simplifies to recognize peer-reviewed OA journals.52. Below are the main findings  research activities in Europe, so citizens can benefit from a greater transparency, e.g. they can gain a better understanding on research results or the budget flows for research and innovation in transport. This could possibly impact their acceptance as well as their perception of new transport solutions and even their mobility behaviour itself. Secondly, attending citizen science projects can help to raise the awareness of citizens for specific transport issues, such as safety, energy consumption, design of new mobility solutions, etc. This allows citizens to contribute to policy making. At last, the increased awareness for research in Europe can help citizens to understand and thereby accept new policies in transport, even if this means uncomfortable regulations for them that should tackle ecologic challenges for instance.Citizen science in practice increases the outreach of funded projects in transport research. The understanding of money flows and budgets and outcomes of funding in transport research can thereby be raised. This could lead to the demand of citizens for more public research in how transport is funded. Citizen science can even be used as a means of dissemination leading to higher acceptance of transport research results and their application in transport.Even though the groups have been divided into four different themes in the workshop, most of the outputs are true for all areas of OS even though the focus was slightly different in the different working groups.The results from the workshop gave more insight to social and economic impacts, as compared with environmental concerns as we can see on Figs. 39 we found a lot of similar general implications of OS in the future:Supporting and confirming former sourcesOpen Science may have the possibility to create more equality due to better access of research for more people/countries/institutions through open access publishing, creating equal competition through new policies for data management and creating equal opportunities through free use of OSS. We also found that open Science might increase efficiency, through less time spent on data collection/duplicating work, better efficiency for end-users due to reduction in operational cost and solving complex problems faster due to access to more data.Economically there might be benefits through more efficient budgeting because of transparency, less time spent on duplication of work and collecting data, improved knowledge exchange and increased funding due to better marketing of research. Additionally, Open Science may lead to innovation and new technology. First of all, economic savings could potentially free a lot of resources that can be relocated to innovation activities. Secondly, the increased availability of data could lead to potentially faster innovation and arising use of AI technology to handle the amounts of data. In terms of citizens participation, it will bring citizens closer to policy making processes and hence potentially raise the awareness in the general public, simplifying the process of implementing new policies.In addition to reproduce some of the same conclusions as former studies the Futures Wheel workshop identified some transport specific implications of open science:Lower emission improving Quality of Life and air quality due to better planning of transport systems are one of the positive environmental impacts specific to the transport sector. This may also be improved through an increased awareness causing an increased acceptance of transport solutions/politics and faster changes in perceptions and behaviour i.e. important to change travel behaviour to reduce emission.Faster travel time increasing quality of life, saving costs and improving cities competitive advantage is another possible transport specific output of Open Science. The possibility to improve AI systems would potentially increase traffic safety, improve mobility services and improve commuting. However, AI systems also have some unknown risks.The competitive advantage of participating in Open Science can be seen both through better marketing of research, being able to relocate resources to other tasks and finding new white spots. It was mentioned that OS has the potential to attract more money into transport research, generate new projects and attract talented people to transport research.Most former studies and the general attitudes towards Open Science are positive, and in this study, we also found more positive than negative impacts. However, we did establish some negative impacts that is important to have in mind for OS to become as sustainable as possible.First, job loss due to loss of competitive advantage and increased use of artificial intelligence is one potential problem. Open Science will also create new type of risks—hacking & malicious users creating software bugs and potential system failures with larger unknown consequences are just two examples. This bring us over to the next negative—where Open Science in the short term might increase cost due to extra infrastructure needs and repair costs for malicious users creating software bugs. New infrastructure might also generate cost in terms of energy consumption. Another possible negative effect is that Open Science might increase decision making based on ‘wrong data’ due to low quality data, data bias or lack of knowledge of how to use the data (as data might be used by other people not trained in using the available data). Open Science might also increase conflicts due to more participants involved in research. This again might cause time delays. There is also the problematic aspect of increasing the equality gap due to decision making on biased data—hence where one is excluding already vulnerable groups from citizen science.To address the negative impacts of Open Science also have great practical implications on how to carry on the development of Open Science in transport further. Identifying possible negative outcomes is the first step in a risk analysis—making it possible to prevent these outcomes from happening. The paper demonstrates the importance of including negative impacts of this phenomenon, as most former literature and attitudes in the transport sector has a generally been positive. Next steps would be to do a risk assessment of each individual implications mentioned—and to analysis the probability of each consequence and hence create a plan of mitigating actions in or der to avoid the negative consequences.Using the Futures Wheel as a methodological tool to answer what consequences Open Science will potentially have on the society revealed potential weaknesses of the model. Firstly, applying the model on this particular research question, the output fails to take into consideration that the negative consequences might stop the trend of “increased use”. The negative effects of losing competitive advantage, costs of infrastructure and increased conflicts might reduce the potential of Open Science continuing to increase. Secondly, a more general problem with the model is the fact that the findings will very much depend upon what kind of experts are included in the workshops. This problem is however possible to reduce when putting together the workshop—making sure you have experts from different fields of expertise. As we have looked upon Open Science from four different angles, we have further reduced this problem. However, we still seem to have gathered more input on social and economic impacts, which may be a reflection of the field of expertise of the experts. On the positive note, as this study confirms former findings on open science in general, the methodology seems to be an efficient alternative to the more time-consuming Delfi-methodology.Even though there might be problematic aspects linked to Open Science, shedding light on these aspects will also help us implement it in a more sustainable way. To deal with this new emerging way of sharing data and research, as mentioned, proper risk management systems are important to establish to avoid any negative impacts. A lot of the negative impacts are possible to avoid if planned for. In terms of job loss due to AIs—this might free recourses for other jobs. I.e. improve the amount of time personnel has to offer service to customers. This way it is possible to turn around the potential negative effects to positive ones. As this study has identified the most important problematic areas of implementing Open Science in the transport sector, the results may be used by several different actors in the transport sector.Open Science may generate a lot of positive impacts on both the economic, social and environmental arena. For the transport sector especially better journey planning, improvements in AI systems and easier acceptance of political decisions through citizen science are important. To avoid the negative effects on loss of competitive disadvantage, some of the experts also focused on the advantage of finding white spots and better use of resource.As we have seen there are potential negative outcomes in the same areas as there are positive. Increased OS can both cause economic losses or economic gains, both lower emission and increase energy consumption, both improve equality and create more exclusion of vulnerable groups and both increase efficiency and reduce it. Loss of competitive advantage for some groups is important to consider in order to prevent potential losses, but also to understand why some nations, industries and individuals are not in favor of sharing. If we know the negative outcomes it is much easier to put in place strategies that are sustainable for a broader stakeholder group, which also increase the probability of taking advantage of all the positive impacts of Open Science. More research is needed on the individual impacts in order to create specific strategies for sustainably implement OS. Also, quantitative analysis like cost-benefits analysis, are needed to establish the actual numbers for each impact.