Testing cognitive function in patients after severe brain damage is a major clinical challenge. In the absence of both verbal and motor communication, tests commonly used to assess cognitive function are completely or partially undoable for disorders of consciousness patients. The study involved 12 patients with varying degrees of impaired consciousness due to brain damage, with no verbal and motor communication. Memory was assessed in study participants using oculography. Memory tasks were presented in four categories. The total percentage of correctly completed tasks obtained across the group was 39.58%. The most difficult tasks included category C.4 with tasks involving working memory. Regardless of the subjects' level of consciousness, there was no statistically significant difference in the percentage of correct responses obtained in subgroups distinguished by CRS-R score. Eye tracking technology can be successfully used in the assessment of cognitive function, particularly when eye movements are the only channel of communication in individuals after brain damage. We suggest that the cognitive functions of people after brain damage should be further analyzed using eye tracking. As one of the components of cognitive function, memory is a very diverse phenomenon that is responsible for encoding information coming from the environment, consolidating the memory trace, storing it and decoding, that is, recalling the information in question, Information is encoded in the form of memory traces, the essence of which are biochemical and morphological processes. Memory traces are encoded in various brain structures in the prefrontal area, lateral temporal lobes, and hippocampus, among others –4.The theoretical construct of memory has been developed and evolved over the years to the contemporary categorization of memory into long-term, short-term, and working memory. Short-term memory has been defined as temporarily available information that has limited storage time, while long-term memory has been defined as a reserve of knowledge about past events .The concept of working memory is of particular interest to researchers. Baddeley and Hitch proposed a multi-component model of working memory , which hOngoing research has brought light to the understanding of working memory. Daneman and Carpenter showed that working memory capacity (as reflected by the reading span task), correlated strongly with various comprehension tests. Similarly, in time-based resource-sharing model, working memory capacities were a product of attention that a person allocates to tasks at hand. The allocated attention and its duration accounted the likelihood of success in performing the tasks . Cowan aThus, contemporary understanding of memory emphasizes the role of executive processes involved in working memory . This isNevertheless, the process of remembering information does not always work properly. Memory impairment is characteristic in people after brain damage caused by injury or neurodegenerative diseases such as Alzheimer's disease , 15. OneNevertheless, before the patient begins neurorehabilitation, he or she undergoes diagnostics of the state of consciousness, which has a significant impact on the selection of appropriate therapeutic methods. One of the most popular scales used to assess consciousness in patients is the CRS-R . Patients can score a maximum of 23 on this scale. Some authors suggest, that individuals in an unresponsive wakefulness syndrome (UWS) score no more than 9 points, individuals in a minimally conscious state (MCS) score 18 points, and above that, patients qualify for eMCS  –30. HoweTesting patients after severe brain damage is challenging, because very often patients score inadequately on tests of cognitive function as a result of impaired interaction with their environment when performing known tests such as the Mini Mental Status Examination, the Clock Drawing Test and the Montreal Cognitive Assessment. In the absence of both verbal and motor communication, these tests are completely or partially unfeasible for patients. One solution to this problem became testing patients with a binary system (yes or no answers). An example of research in a binary system conducted in 2008 is the use of the Cognitive Test for Delirium, which was designed for use with seriously ill patients. The test allows the use of non-verbal responses in the form of pointing, nodding, or raising the hand . In otheUsing computers to create virtual environments tailored to the sensory and motor abilities of the brain-injured patient with impaired interaction constitutes a potential solution. By doing so, contact with the community can be made possible regardless of the degree of disability . One forAnother popular technology is eye tracking. Eye tracking technology can be used in specific stages of the brain neurorehabilitation process, specifically when eye movements are the only channel of communication in people after brain damage. It is therefore reasonable to use eye tracking for medical purposes, for example in supporting neurological assessment of patients with severe communication barriers . An examThe literature reports that the use of eye tracking facilitates the understanding of communication signals of patients with severe motor and communication impairments. Early practice of using eye trackers can improve the quality of communication and enable more reliable patient assessments .This raises the question of whether, and if so: to what extent, tasks involving different categories of memory are possible for brain-injured patients who do not communicate verbally. The answer to this question provides an opportunity to use oculography in the process of memory training in such patients. The purpose of this study was to compare the results of memory tests conducted with an eye tracker among patients with varying degrees of impaired consciousness.The study group consisted of individuals between the ages of 26 and 67 who did not communicate verbally. The average age of the participants was 45.67 years. The subjects' state of consciousness was determined by the physician based on the traditional (paper) version of CRS-R. The study group was divided into three subgroups  according to the Administration and Scoring Guidelines . Twelve The study protocol received a positive opinion from the Senate Committee on Research Ethics at the Wroclaw University of Health and Sport Sciences, Poland . All participants' guardians provided written informed consent for participation and publication of this report in accordance with the guidelines established by the Declaration of Helsinki.Data collection was made possible by using an eye-controlled, eye-tracking-based device that recorded data separately for each patient. Eye tracker uses invisible infrared radiation (IR) in its operation, without disturbing the patient. The device consisted of a monitor mounted on a rack with a metal boom, allowing it to be placed directly in front of the subject's face. For proper operation of the eye tracker, the first action after startup was to perform a calibration. Calibration was based on the patient's observation of a red, flickering dot with a white border, displayed in the center of the screen. After a few seconds, the started moving randomly across the screen. The system analyzed gaze fixation and dot tracking. The system reported the calibration success. If the patient was unable to fixate the eyes, the system reported that the calibration was not successful and therefore it was impossible for the patient to work with the device .Each patient had 12 tasks to complete. The tasks involved one of four categories: memory for visual material (C.1), semantic memory (C.2), orientation to time (C.3), and working memory (C.4).In the C.1 category tasks, three black and white pictographs were presented. Each patient had 15 s to memorize them. Time was measured by the device using a displayed stopwatch. After a time specified by the software, the pictograms flipped, changing their appearance to white squares with a question mark. The device automatically read aloud the command “find the displayed example”. At the very top of the screen, only one image was presented to be found under the corresponding question mark. Tasks in category C.2, involved choosing the appropriate pictogram from the three displayed. The example presented fit only one of them; the other two were not thematically related to the example. The tasks in this category were also shown as black outlines of objects on a white background. Category C.3; device displayed and read command: point to appropriate photo; day. Choosing from three photographs, the patient selected, for example, the time of day that was appropriate to the command heard. In category C.4, the patient was told to look closely for 5 s and to memorize three consecutively displayed images. In the last part of the task, the device displayed three sets of images, with only one set containing the correct order of the previously displayed items. Each patient worked for 1 h with the device. We observed situations when during the examination the patient would close his eyes for a moment or direct his gaze away from the monitor. The researcher tried to encourage further cooperation by calling the patient by name. If the subject continued to close their eyes, the researcher allowed the patient to rest.Images of the four task categories are shown below  while exWe performed basic statistical analyses. All analyses were performed for the entire group and for three subgroups listed by their scores on the CRS-R, providing information on their level of consciousness. We first analyzed the distributions of correct responses, then counted median values  and percentages of correct responses separately for subgroups and categories. In this paper, we chose to present analyses using percentages of correct responses. For this purpose, we used the Kruskal-Wallis rank-sum test to analyze the differences between the percentages of correct responses across subgroups and across the four task categories, namely for C.1, C.2, C.3, and C.4 . AdditioThe results of the subjects broken down into the three subgroups of UWS, MCS, and eMCS are included in C.2 involving semantic memory were the easiest. Additional information was contributed by analyses using the Kruskal-Wallis rank-sum test, which showed that there were no statistically significant differences between the percentage of correct responses obtained in both categories C.1, C.2, C.3, and C.4, as well as the global score obtained in subgroups distinguished by consciousness level. This means that regardless of the consciousness level of the respondents, the percentage of correct answers is similar.Analysis of individual patient outcomes also provides valuable information. Only four patients were able to complete at least half of the tasks . Of particular note are the highest scores obtained by P9 and P1, qualified for UWS and MCS, respectively, with CRS-R scores of 8 and 16, respectively. With significantly different scores on the CRS-R, they achieved similarly high completion rates of 75.00 and 66.67%, respectively (a 1 point difference in raw score). As can be seen, different states of consciousness do not determine a significant difference in eye tracker test results.Brain damage can lead to impaired consciousness , i.e., cIt is worth noting the relatively high scores obtained by MCS patients, who had a task completion rate of 50.00%; this is higher than that in eMCS patients (the percentage of correct answers was 39.58%). The observed discrepancies in outcomes between the MCS and eMCS groups may be related to the observed reduction in emotional state resulting either from longing for loved ones (in the eMCS group) or are due to other factors, the identification of which requires further detailed observation and analysis. This is particularly evident in P5 (25.00%) and P12 (33.33%). Similar conclusions are drawn from other studies conducted, which also indicate a significant role of emotional state for the effectiveness of cognitive-behavioral therapy for patients after acquired brain injury (ABI). Because patients not only have to come to terms with the traumatic event, but also with the biological and psychological changes and numerous losses associated with ABI, they very often struggle with anxiety and depression which affects cognition, mood and motivation, making rehabilitation difficult , 52.Respondents found category C.4, which contains tasks involving working memory, to be the most difficult tasks. This is important information for continued recovery, because it tells us that in the long term, if functional recovery were to occur, such patients may have difficulty with current tasks in daily life, because of their limited ability to use working memory in completing tasks. This conclusion is also supported by the results of other studies suggesting that severe TBI is associated with a reduction in resources within the central executive of working memory. Working memory limitations are likely related to impaired activation of the brain's executive networks due to diffuse axonal damage. These deficits have consequences that impair activities of daily living . AnotherIt is also worth noting the global percentage of correct answers obtained by all patients when performing the tasks (39.58%). Such a value may be more a result of poor eye control through weakness of the muscles controlling them, and less to do with difficulty in understanding the task due to cognitive limitations. The weaker control of eye movements in brain-injured subjects was supported by a study by Cifu et al.  which foOne of the first clinical signs distinguishing MSC from UWS is eye movements occurring in direct response to moving stimuli . Eye movAlthough our study was based on a limited number of participants in a specific context, we have shown that patients have the most difficulty with tasks based on short-term memory. We suggest that the cognitive functions of people after brain damage should be further analyzed using eye tracking. Modern technology shows that solving various cognitive tasks leads to the emergence of brain activity states that can be precisely identified and even used to control devices external to the brain like BCIs . FurtherThere are some limitations to the study that need to be taken into account. One of them involved performing the CRS-R scale assessment once. Because behavioral fluctuations in patients may affect diagnostic accuracy, the number of assessments performed on the CRS-R may influence the clinical diagnosis of patients with chronic disorders of consciousness.We suggest that more than one test be performed in a short interval  in each patient with impaired consciousness to reduce misdiagnoses.It also seems that it would be valuable to repeat the memory study in quick succession. This would reduce the risk of error in the assessment of memory status by averaging it and would make this result more independent of the patient's emotional state.Testing memory in people with impaired consciousness provides a better understanding of the brain function in this group of patients. The study demonstrated that memory impairment in individuals in the UWS, MCS, and eMCS groups primarily involved working memory. Innovative approaches to patients after brain damage can significantly expand our current understanding of therapy and influence the variety of therapeutic interventions and, in particular, the appropriate adaptation to the functional abilities of the patient with communication and motor disorders. In conclusion, therapy for cognitive function including memory should be introduced in brain-injured patients regardless of the degree of impairment of consciousness using oculography.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the Senate Committee on Research Ethics at the Wroclaw University of Health and Sport Sciences (Consent No. 29/2017). All participants' supervisors, or the guardians of the patients/participants, provided written informed consent for participation and publication of this report in accordance with the guidelines established by the Declaration of Helsinki.Material preparation, data collection, and analysis were performed by KK, AŻ, AG, and GZ. The first draft of the manuscript was written by KK, AŻ, and GZ. AG, AŻ, and GZ contributed substantially to the interpretation of the results, provided critical feedback, and revised the manuscript. All authors contributed in review and editing of the manuscript, approved its final version, and contributed to the study conception and design.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Research assessing the validity and reliability of many forensic science disciplines has been published; however, the quality of this research varies depending on the methodologies employed. This was a major point of contention with the United States' President's Council of Advisors on Science and Technology, who recognized the existing literature but found the majority lacking because of methodological issues. Questionable scientific methodologies have undermined the forensic science community's ability to defend the scientific foundations and examination protocols used to examine evidence in criminal cases. Such scientific failures have significant legal implications. Registered reports, which strengthen the quality of scientific research and reliability of laboratory protocols, can provide transparency, validity and a stronger scientific foundation for forensic science. Interpretations and conclusions made by specialists following forensic examinations have life-changing consequences for individuals and society. Thus, it is imperative that interpretations and conclusions are based on sound scientific principles, methods and practices. Over the years, increasing concerns have been raised within the scientific community as it relates to the validity and reliability of scientific methodologies underpinning various forensic science disciplines ,2; for escience in any given forensic science discipline [Issues concerning the quality of existing research supporting forensic science became a key point of contention in 2009, when the National Research Council (NRC) raised the question of the extent to which there is scipline  applied scipline . Many wiscipline –6). Theyscipline . These cscipline –15. ThesIrrespective of whether one agrees with the PCAST and others within the scientific community that have been critical of the methodological design of forensic science research, the controversy has nevertheless cast a shadow over the credibility of many forensic science disciplines. This has caused some litigators and courts to question the reliability of many traditional forensic science practices and challenge the admissibility of forensic evidence. This is a problem that cannot be addressed through mere arguments and critiques in response. Instead, it will require a fundamental shift in how forensic science research is approached.. 2One of the most important aspects of admission and reliance on forensic evidence in criminal trials is the extent to which a forensic discipline is founded on a reliable scientific methodology . HoweverThe summary provided under this subparagraph must describe the witness's opinions, the bases and reasons for those opinions, and the witness's qualifications (emphasis added) [At the defendant's request, the government must provide a written summary of any testimony that the government intends to use under Rules 702, 703, or 705 of the Federal Rules of Evidence during its case-in-chief at trial. If the government requests discovery under subdivisions (b)(1)(C)(ii) and the defendant complies, the government must, at the defendant's request, give to the defendant a written summary of testimony that the government intends to use under Rules 702, 703, or 705 of the Federal Rules of Evidence as evidence at trial on the issue of the defendant's mental condition. s added) .For example, US Federal Rule of Criminal Procedure, 16 A(1)G states,(c) the testimony is the product of reliable principles and methods; and (d) the expert has reliably applied the principles and methods to the facts of the case (emphasis added) [A witness who is qualified as an expert by knowledge, skill, experience, training, or education may testify in the form of an opinion or otherwise if…s added) .Federal Rule of Evidence 702 states, in part,White Burgess Langille Inman v Abbott and Haliburton Co, 2015). Similarly, several Australian jurisdictions require expert witnesses to provide the court with the ‘necessary scientific criteria for testing the accuracy’ of their opinions as a requirement for admitting that evidence .The USA is not unique in these requirements. The Supreme Court of Canada has adopted Rule 702's reliability requirements in its expert evidence doctrine  prior to collecting data—or looking at the data if the data are pre-existing. Stage 1 manuscripts are peer-reviewed based on methodological quality and their ability to address research questions. If they pass this process, then the ‘Stage 2’ manuscript (the approved protocol plus results) will be published if the authors follow through with the accepted methodology.The registered report format is designed to reward best practices in the design of transparent, reproducible methods which lead to unambiguous reporting, regardless of the outcome. It eliminates a variety of questionable research practices by removing the incentive to selectively report results and increasing transparency such that selective reporting would be easy to detect. The format also allows reviewers to help improve the methods by suggesting more appropriate statistical models and encouraging higher powered designs, among other benefits.PLoS Biology observed an 88% acceptance rate for registered reports with substantial revisions for most submissions, compared to 50% acceptance in its regular track [Early research on registered reports suggests that these salutary aims have been achieved. Registered reports are associated with more realistic proportions of positive results  and a pear track . The 88%. 4While forensic practitioners focus on daily operational activities, many are motivated to involve themselves in scientific research and development as well as validation studies required for accreditation and admissibility. Depending on their organization and the scientific health and cultural changes within their organizations, practitioners may have limited access to qualified collaborators. At the same time, practitioners bring an important perspective with direct access to specialist tools, other qualified practitioners in allied disciplines and expertise. How these projects are designed, what is being performed, and the results, let alone their validity, remain largely unknown and less defensible than those with more transparent methodological designs.1; however, in terms of the quality, validity and reliability of the methods applied and the resulting published results, in-house studies still lack scientific accountability. Registered reports provide accountability and, more importantly, from the practitioner's perspective, they provide a set of clear instructions to ensure a robust and more defensible approach  .io/rr/) . Althoug. 5Forensic Science International: Synergy was the first journal in forensic science to adopt registered reports2. Part of the journal's mission is that because forensic services are sciences integral to a just society governed by the rule of law, they are unarguably a public good and should be accessible to anyone. Open, transparent science helps to promote justice, and we believe that registered reports support this mission.To this end, registered reports can provide more reliable results through the vetting of methods prior to data collection, decreasing the realistic proportion of positive results and addressing issues with method quality before conclusions are drawn. Moreover, the registered reports are in line with many laws that provide methodological transparency in the justice process. For example, the ability to fully examine evidence tendered against an accused is a component of the right to fair trial in many jurisdictions. For example, in the United States, the Sixth Amendment of the Constitution provides that a person accused of a crime has the right to confront a witness against them in a criminal action. This ensures that witnesses testify under oath and understand the serious nature of the trial process, allows the accused to cross-examine witnesses who testify against them, and, crucially for registered reports, allows jurors to assess the credibility of a witness. The witness's credibility, in large part, stems from the validity of their methods and the conclusions drawn from them. On the stand, the witness would be able to discuss the vetting of the method, its increased validity through the registered reports process, and thus be better seen as the neutral arbiter of science, rather than an advocate using untested methods only they can make work; see  for a paSeveral jurisdictions also exclude evidence when its probative value is exceeded by the danger of unfair prejudice . The pro. 63 to help bring registered reports to other forensic science journals. The profession and discipline of forensic science must demonstrate validity and transparency to its stakeholders and the public it serves.In summary, registered reports can provide a strong evidence base for forensic science. They align with principles of justice, such as the right to examine and confront evidence and the purposes that underlie the rules of evidence in many jurisdictions. Researchers, editors and other stakeholders can sign an open letter


India has been struggling with infant malnutrition for decades. There is a need to identify suitable platforms for community engagement to promote locally feasible, resource efficient Infant and Young Child Feeding (IYCF) interventions. This study aims to explore if and how schools could represent a site for community engagement in rural India, acting as innovation hubs to foster positive change in partnership with the Angawadi centres.Five-phase formative study; A parallel mixed methods approach structured by a socioecological framework was used for data collection at individual, household and community levels. This paper focuses on the qualitative findings.This study was undertaken in nine villages within two blocks, ‘Ghatol’ and ‘Kushalgarh’, in the Banswara district of Rajasthan, India.17 schools were identified. Interviews were conducted with local opinion leaders and representatives in the education sector, including principals, schoolteachers, block and district education officers. Across the nine study villages, information was gathered from 67 mothers, 58 paternal grandmothers using Focus Discussion Groups (FDGs) and 49 key respondents in Key Informant Interviews.Schools were considered an important community resource. Challenges included limited parental participation and student absenteeism; however, several drivers and opportunities were identified, which may render schools a suitable intervention delivery site. Enrolment rates were high, with schools and associated staff encouraging parental involvement and student attendance. Existing initiatives, including the mid-day meal, play opportunities and education on health and hygiene, further highlight the potential reliability of schools as a platform for community mobilisation.Schools have been shown to be functional platforms frequently visited and trusted by community members. With teachers and children as change agents, schools could represent a suitable setting for community mobilisation in future wider scale intervention studies. Expanding the supportive environment around schools will be essential to reinforce healthy IYCF practices in the long term. The Participatory Approach for Nutrition in Children: Strengthening Health Education Engineering and Environment—HEEE Linkages project was an interdisciplinary study, designed to explore an array of important interconnected themes such as health, education, engineering and environment that influence Infant and Young Child Feeding (IYCF) practices and nutrition in India with the aim of developing a socio-culturally appropriate, tailored, innovative and integrated multisectoral HEEE Nutrition package to optimise IYCF practices for children aged 6–24 months.This study established the advantages of using schools to bring communities together and disseminate information regarding IYCF practices while exploring the potential of working with children as community change agents.Due to time and resource constraints, the study relied on the coverage and completeness of external data, for example, a list of the children under the age of 2 years resident in the study area , as a starting point for the data collection.The study covered only nine villages in total across two blocks in the state of Rajasthan. Despite the main formative study being led across 18 villages, the phase of study directly related to testing the feasibility and acceptability of selected pilot school-based interventions were only conduced in nine villages.The data collection phase of this study fell into the months of January to March, the peak of agricultural season in the Banswara district. This impacted our sample size due to absence of functionaries at schools for Key Informant Interviews and Focus Discussion Groups (FDGs) and/or participants in our household survey.Many low and middle-income countries (LMIC) have been grappling with the problem of malnutrition for decades. Given its persistent and chronic nature, malnutrition affects a large proportion of the population in these countries. The triple burden of malnutrition presents itself in the form of stunting, wasting and anaemia—all of which are especially common in women and children.It is well known that the period between 6 and 24 months of age represents a critical time for infant growth.In response to this, in 1975, India introduced an ‘Integrated Child Development Service’ (ICDS)—an intervention comprising supplementary nutrition, immunisation and preschool education to enhance health outcomes for pregnant women, breastfeeding mothers and children up to age 6.Schools appear to be one potential setting for community mobilisation and implementation of interventions, as they offer continuous, intensive contact with children. By contributing to students’ health literacy and behaviours, school-based health promotion can be particularly valuable in the context of developing countries, where low public health literacy and high burden of disease are faced.In an attempt to maximise the potential of schools and achieve greater convergence, and an improved continuum of care for early childhood, the Government of India (GoI) subsequently scaled up the so-called ‘Rajasthan model’—an initiative that leads to the establishment and colocation of 11 000 AWCs with schools by mid-2017 in rural India.This soon led to schools emerging as a logical platform for intervention delivery in the context of the Participatory Approach for Nutrition in Children: Strengthening Health Education Engineering and Environment Linkages (PANChSHEEEL) project. At the conceptualisation stage, schools, in conjunction with the government-funded, colocated AWCs, were, thus, considered as a potential platform and resource for community mobilisation to improve IYCF practices in rural India.In this paper, we present the qualitative findings from our formative study, exploring the acceptability and feasibility of schools as a platform for community mobilisation and health promotion activities related to IYCF practices and the role of children as community change agents.This present study forms part of a wider project: The PANChSHEEEL—initiative; a project involving a five-phase formative interdisciplinary study, designed to explore health, education and environmental (HEEE) factors that influence IYCF practices and nutrition in India. Informed by the socioecological model, the study aimed to develop a socioculturally appropriate, tailored, innovative and integrated cross-sector HEEE Nutrition package to support optimal IYCF practices for children in rural India aged 6–24 months.In this project, members from University College London, Institute of Child Health, Institute of Education and Faculty of Engineering Sciences and expertise from; Save the Children-India, Indian Institute of Technology, New Delhi and Jawaharlal Nehru University, New Delhi formed the core research team (CT). The participatory approach actively involved local community researchers (CR), community champions (CC) and CM selected from the nine villages within Ghatol and Kushalgarh Block of Banswara district of Rajasthan (India).The study was conducted in tribal areas including households from the lowest quintiles of the economic strata and women with poor schooling levels. At the outset of the study, understanding and reflecting on the village structure and positioning of schools in relation to other village resources were key for the field team. Village profiles were, therefore, created by the means of social mapping and community profiling. Social mapping was conducted using a participatory approach, with 10–15 participants per village being identified by key figures in the community . Field investigators acted as facilitators, explaining the purpose of drawing a village map and working with the participants to produce it. The first step in this process was drawing the concrete or pucca roads, followed by the foot-roads or kuccha roads. Important institutions , houses and water sources  were then marked on the map. Participants were required to discuss with one another before reaching a consensus on the final map. The participants’ map was then validated by the village representatives.Phase 1 of the study focused on identifying and documenting local practices with regards to IYCF practices, sanitation, education and access to local resources (such as energy and water). The existing GoI initiatives in the study sites were also mapped during phase 1. Phase 2 involved extensive fieldwork to identify local challenges, drivers, resources, opportunities and needs for children in the first 6–24 months of life at individual, household, community and environmental levels. Phases 3, 4 and 5 focused on the analysis and mapping of HEEE linkages, the cocreation and piloting of an IYCF intervention package (IP) using an iterative process as well as review and dissemination phases of this project.The formative research phase commenced after a systematic selection of nine study villages from the two blocks of Banswara, namely, Ghatol and Kushalgarh. Out of the 18 villages proposed initially by ‘Save the Children India’, 9 were selected purposively based on an interaction of the CT with (1) the local community, (2) the teachers at the local elementary schools and (3) the Anganwadi workers (AWW) and Accredited Social Health Activist (ASHA) in each village. Schools where the relationship with the local village and functionality of the school itself were poor, eg, low number of teachers and students, insufficient engagement with the study, were excluded. Second, villages where a lack of interaction between different social groups or lack of interest in the project was noted, were subject to exclusion. Finally, the linkage of the schools with the AWCs, for example, the government-funded centres that provide facilities such as food, vaccines, medical treatments to 2–5-year olds alongside assisting mothers in accessing other government schemes/services, was a key determining factor. Schools, where the AWC was not directly associated with the school or where the AWW displayed insufficient interaction, were excluded. A summary of the inclusion and exclusion criteria for the study villages and schools is outlined in Patient/participant and Public Involvement and Engagement representatives were identified, selected and engaged in every step of the study from protocol development over study design to the dissemination of the results.CM from the nine villages within Ghatol and Kushalgarh Blocks of the Banswara district of Rajasthan were actively supporting the CT in the context of PANChSHEEEL’s participatory approach. To help steer the project across its phases locally, CRs from the study blocks Ghatol and Kushalgarh were recruited. The inclusion criteria encompassed (1) being educated, (2) having previous field experience in Banswara district, for example, understanding the village context and social networks locally and (3) being conversant in both ‘Hindi’ and ‘Wagdi’ languages . With the help from the ‘Save the Children’ Team from the Rajasthan State Office, two suitable individuals were identified. The CRs were initially male adult members of the study population who understood the local village and social context, providing special insight about their communities and environment to the study. Both had shown satisfactory engagement in a previous project by ‘Save the Children’, were local to the study blocks of Ghatol and Kushalgarh and, hence, recruited on contractual basis during phase 1 of the study to support community engagement and data collection. Their main role was to identify potential candidates who could engage actively in project activities as well as engaging with the CCs, who in turn helped establish linkages with the CMs and improve networks between schools, frontline workers (FLWs) and villages.Aligning with the principle of reflexivity in research, that is, the continuous process of examining relationships, the dynamics of that relationship and its impact,CCs were associated voluntarily in the research. They played no direct part in data collection but did have an important role in being advocates for the study and facilitating access to the community themselves.For the whole PANChSHEEEL study, a mixed-methods approach structured by a socioecological framework was employed for data collection. Primary data were collected at an individual, household and community level by the CT and CR together. Qualitative data were obtained using two methods: (1) Key Informant Interviews (KII) with AWWs, ASHAs, Auxiliary nurse Midwifes (ANMs), Elected Panchayat Representatives (PRI members), school teachers and principals, relevant block and district officers and (2) Focus Group Discussions (FGD) with mothers and grandmothers of children 0–2 years of age. While not directly involved in the data analysis, findings were presented to CRs at each stage for verification and interpretation purposes.Participants were asked for consent in the context of both the qualitative and quantitative data collection. Written consent was obtained from participants of the KIIs. Verbal consent was obtained from all participants of FGDs and recorded by the means of an audio device. All interviews were documented with a voice recorder for subsequent analysis. Field notes were taken during the interviews with stakeholders. The coding was carried out by the field team and was done first in Hindi and, subsequently, in English.The members of the research team conducting the qualitative data collection received a 2-day training by an experienced coinvestigator in the Banswara district in December 2017. This training was followed by a 2-day field practice. Data were collected by the CRs with assistance from CCs for scheduling meetings with stakeholders. The CR were supported by the CT and received thorough training on techniques and tools to FGDs, KII and broad narrative group discussions. PowerPoint presentations and handouts were used for training and reflective sessions were organised with the CT.During the formative phase and stakeholder mapping workshop, relevant stakeholders were identified and recruited. Considering the possibility of snowballing, a sampling method where existing participants inform the recruitment of future participants from among their acquaintances and relevant to the study, the research team was open to any new stakeholder(s) identified during the data collection.The CMs were interviewed in FGDs, whereas key informants (KII) were interviewed individually. A focus was placed on interviewing paternal grandmothers, primarily due to their significant influence on mothers: after the delivery, it is common for mother and infant to spend the initial postpartum and puerperal period in her husband’s living environment. This makes paternal grandmothers key in guiding the mother after the delivery on breastfeeding and complementary feeding practices. All participants in the mothers’ group had children below the age of 2 years; most of them also had an older school-going child. Similarly, all grandmothers who had a grandchild under 2 years of age were included. Interviews were also held with other key informants from the village namely elected representatives, ANM, AWW and ASHA, and the village school teachers and principals. Block and district level officers from the Health, Education and ICDS departments were also interviewed. The recruitment of participants was conducted based on availability and willingness to participate.The CT and CR designed thematic guides designed through literature review, expert and stakeholder consultation and evolved through pilot testing with different population subsets.Qualitative data were collected in Hindi or Wagdi and transcribed and translated by local translators who were proficient in Wagdi and Hindi. Research team members who were proficient in Hindi and English translated the Hindi texts to English. At each stage, quality assurance measures were adopted by checking for reverse translation. Coding was done by two junior researchers who had considerable experience of the study sites and contexts. Final consensus was arrived at collectively by the senior researchers of the team. Data were collected from schools in all the nine study villages.The qualitative data collected were transferred from the recording device to the encrypted laptop of the Save the Children India (SCI) Nodal Person. The research team also met at the end of each day to share the key observations and reflections about the data based on the notes taken during the KII and FGD.Audio-recorded data were translated and transcribed alongside detailed summary of field notes prepared. Data from open-ended questionnaire questions were evaluated, discussed and summarised across the various IYCF themes for each intervention point. The coding was conducted by the field team and was done first in Hindi, and subsequently, in English.The initial data collected by CR further underwent respondent validation. Respondent validation was conducted in a workshop involving CCs facilitated by CR under the guidance of SCI staff. The steps of a thematic analysis were employed; this means identifying, analysing and interpreting patterns of meaning (a.k.a. themes) within the qualitative data sets.For the purpose of this paper, we have narrowed down our findings to those relevant to schools within the two blocks.Across the nine study villages, information was gathered from 67 mothers, 58 paternal grandmothers using FDGs and 49 key respondents in the KIIs. Findings from both KIIs and FGDs revealed several activities and facilities provided by schools that may render them a suitable site for community mobilisation. The challenges, drivers and opportunities of schools as change agents across the nine examined study villages are summarised in Across a majority of schools studied, parent–teacher interaction was reported to be positive, but not optimal. Parents generally reported attending two kinds of school events: (1) national day celebrations in school  or (2) if a parent was summoned to discuss their child’s progress. School management committee meetings were also held in the school once per month. Both teachers and mothers, from the study village, were of the opinion that parents usually visited formal school meetings and some teachers reported organising meetings at the community level. While not offered at all schools, the teachers conducting such community meetings felt that they were able to effectively engage with the community. However, it was difficult to maintain the regularity of such events due to teacher shortages.We go inside the village to interact with the parents. The School Management Committee helps to fix a date, time and place for these meetings. These meetings are useful. […] It is easy for them to attend those meetings, but we cannot do it frequently .Teachers and mothers reported school attendance to be high throughout the year. Absenteeism was identified as a problem mainly during harvesting season by teachers in both blocks, specifically in Ghatol where school-aged girls were kept at home to take care of younger siblings while boys assisted the family in the agricultural work.Children mostly miss school when there is harvesting season. Sometimes the entire family gets busy so there is no one to send the child to school. The girls also miss school when they have to take care of their little siblings, but rarely .In cases where students were absent for long stretches of time, it was found that teachers conducted home visits to explore the reason for the non-attendance, hence playing an important role as change agents.Evidence from the interviews showed that school enrolment was conducted by the means of door-to-door identification by the primary school teachers. All children above 5 years of age were identified and validated with birth listing done by Frontline Health Workers like AWW and ASHAs. The teachers across the nine villages reported this method to be successful, allowing a recruitment rate of 100%, with no children under 5 years not attending school.There are no children who are not in school. All children above 5 years come to school .In Ghatol, it was reported that some children did not attend governmental school given the existence of a private school in the vicinity of three out of five study villages. This was, however, not the case for Kushalgarh where none of the study villages had access to private schools and all enrolled students attended government schools.School enrolment is not a problem in this village. Once a year we do a door to door survey to identify school going children. Some families who can afford to send their children to the private do so, rest send them to the government school .High school enrolment levels across the nine villages studied indicate the potential reliability of schools as an intervention delivery platform. Furthermore, the regularity with which children were found to attend school and the degree of parental participation in school activities are important considerations.According to the teachers from both blocks, homework was given regularly to reinforce the lessons taught. The response to and success in completing the tasks correctly, however, varied across children in the two study blocks and can broadly be divided into three categories: (1) children who failed to complete the tasks entirely, (2) children who completed the tasks, but with some errors and (3) children who completed the tasks with no errors. The teachers mentioned in the interviews that they believe this difference in performance to be at least partially attributable to the level of engagement of the children’s family members.Only educated mothers can help. We just tell the child to study .The first category of students was mostly those who stayed with their grandparents or the parents who were illiterate and, therefore, had little to no support for in their education.Most children stay with the grandparents. They do not have any environment for studying at home. Homework is done at schools. .The second category of students were those where the child’s mother was educated till fifth standard or had a school going elder sibling who assisted him/her. Occasionally, the parents of children in the third category were engaged in teaching the child, hence leading to better performance in homework tasks. According to teachers in Kushalgarh, the majority of students belonged to the first category and the remaining few were in the second category. In case of Ghatol, the first category of students was relatively smaller. In general, these results suggest that teachers are an important reference point for students and play an essential role in supporting students, especially where limited support is available at home.The school adopted different approaches to improve student health and hygiene practices. For health, an annual check-up was conducted each year by ANMs. The teachers explained that ANMs came with adequate medicine for camps, and mostly provided first aid treatment. They also identified children who needed special medical attention. Health services were also available from their local AWC. The teachers felt this was a successful and necessary initiative, given the generally limited knowledge about health and hygiene in the local community.Hand pumps available in the premises of most schools were used as a drinking water source though the water quality was not tested regularly. In a majority of schools, the same hand pumps were also used for handwashing. In a few schools, special filtering plants were present. Toilets were available for children, in schools; while only few had separate facilities for boys and girls. Overall, the toilets in most schools were in an unsatisfactory condition, with a large proportion of toilets dysfunctional.Several teachers reported the provision of special programmes related to diarrhoea prevention and hygiene promotion in schools. In these programmes, awareness was generated about health and hygiene practices. The teachers felt that children proved to be an effective channel to pass on this information at home, hence fostering better understanding about nutrition, health and hygiene practices, also across generations.We tell the students about good hygiene practices like handwashing, taking a bath every day, cutting nails. They then go and tell their family. Spreading messages through children are very effective .The presence of playgrounds or outdoor activity areas was noted among all except two schools visited. Additionally, physical education teachers and sporting facilities were available in a few schools. It was reported that facilities were mostly only operational during summer rather than rain season. In the KIIs, several teachers noted that they incorporate play activities in the last period of every school day, since no such opportunities were available at the children’s homes. The teachers believe this to be essential for the development of the children, promoting both their physical and mental well-being.Playing is very necessary for the holistic development of children. We devote the last period each day for that .FGDs showed that not all parents were convinced of the usefulness of play activities for their children.Parents sometime question us why we play games, school is for studying not playing .This highlights another potential area where teachers could use their positive standing in the local community to influence and change current practices.All teachers, PRI members and mothers responded that the mid-day meal was prepared in the school and served regularly to students. The menu for each day was fixed by the education department, with diet plans including cereals such as wheat and rice, pulses, vegetables. Fruit was also served once a week. The food was prepared by a cook and an assistant under the supervision of the principal or other teachers.I have seen food being served in schools regularly. Sometimes I go to check the quality also .No concerns regarding school meal quality were raised in the FGDs with mothers, nor in the interviews with PRIs. The teachers, especially from schools in Kushalgarh, were of the opinion that nutrition diversity offered in mid-day meals was superior to foods served to children at their homes.Yes, we provide food to children regularly. […] The food that they get in schools is better than what they get in home. Dal is not cooked in the homes every day. Fruit is also an attraction among kids .Furthermore, it was reported that the general standards of cleanliness and hygiene, for example, when storing, preparing and serving food, were higher at the schools than those encountered at home: at schools, clean water was always used to prepare and cook meals and hygiene practices were implanted for hands, cooking equipment and cutlery.Appropriate supplementary IYCFs are inherently linked with growth and development, especially in children younger than 24 months. Based on the evidence globally, universal coverage of optimal breastfeeding could prevent 13% of global deaths occurring in children less than 5 years of age, while appropriate IYCF practices could result in an additional 6% reduction in under-5 mortality.Efforts to improve IYCF hence remain a potent intervention target. Awareness generation among mothers and families with young children is crucial for successful intervention implementation. Identifying occasions and settings where CMs gather at regular intervals, hence is a crucial step to increase reach of possible health interventions, especially in rural states.Since 1986, the WHO has placed particular emphasis on the potential of health promotion strategiesIn our study, schools have been shown to be an important and viable setting for community mobilisation in the context of nutrition, health and hygiene practices. The qualitative evidence from the FDGs and KIIs, as well as intervention development and the piloting of the fore-mentioned interventions, indicates that schools may indeed represent a feasible potential platform for community engagement and mobilisation. Many existing, local government bodies within the village, for example, AWCs, Health Sub Centre, Panchayat, Public distribution system, are closely associated with the schools, again rendering them a potentially suitable site for intervention delivery to collaboratively improve IYCF practices.Enrolment rates were high across the nine villages investigated in this study. Schools and associated staff were dedicated to encouraging parent involvement in the school and discouraging student absenteeism. Initiatives, such as the mid-day meal, play opportunities and education on health and hygiene , all highlight the schools’ potential for community engagement and reliability as an intervention delivery platform. Festivals and local celebrations such as Janmashtami, Independence Day, Republic Day, Annual Day Celebration take place on the school campuses. Furthermore, schools can act as research sites, playing a crucial role in capturing the diversity and dynamics that exist in particular communities. As one of the only functional places in the rural communities, they represent the ‘beating heart’ of villages, where CMs of all generations gather at frequent intervals.In this context, teachers were found to be a crucial stakeholder in bringing about positive change in local communities, acting as a reliable and sophisticated source of information regarding the communities they serve alongside being potential change agents for children, their parents and the wider community via; (a) their connections and respect from their local communities and (b) their interest in codesigning interventions with us. Thus, engaging with the schoolteachers in further analysis of the problem and codesigning any future interventions holds merit. This has been recognised locally and was translated into initiatives of the District Collector of Bansawar, including the Swachhta Pakhwada and Alakh programmes where school staff, parents and PRI members gather at regular intervals to discuss challenges and improvement opportunities for the village.Furthermore, many school-based interventions have the advantage of being a cost-effective method to deliver interventions with a broad reach, enrolling participants from different socioeconomic backgrounds, ages and at-risk groups.Finally, while the findings from our study strongly suggest that schools represent a suitable site for community mobilisation and health promotion in rural India, the possible limitations of our primary data collection need to be considered. One significant challenge was that of time—for efficiency purposes, data collection was restricted to 2 hours per village; hence, possibly limiting the information gathered from the study participants in the FDGs and KIIs. Second, conducted between January and March 2018, the timing of our primary data collection exercises overlapped with the peak of agricultural season in the Banswara district. This may have impacted our sample size, due to absence of functionaries at schools and/or preoccupation of participants of our household survey with agricultural activities.In the future, efforts, thus, need to be focused into gathering data from a larger sample size and area, to capture the complexity of actual practices and, hence, gain a more holistic overview of current challenges and opportunities. Our qualitative findings will then be able to translated into practice, namely, by developing culturally sensitive, locally effective, school-based interventions to positively influence in IYCF in rural India. Future studies using the PANChSHEEEL model (IYCF IP combined with multilevel engagement with schools and AWC at the centre) will investigate this further and explore how the colocation with the Angawandi centres may be best leveraged in subsequent intervention development and implementation.Schools are likely to act as a central theme in deployment for behaviour change interventions, owing to the fact that they form a central part of the child’s daily routine in addition to schools being a centre of community activities. These activities could be incorporated into the ongoing programmes, through either leveraging of the mid-day meal programme or other such child development schemes that will provide opportunities to use these interactions to improve the wider determinants of healthy living in children as well as their families.Developing a supportive environment around schools, geared towards reinforcing messaging on healthy practices and using children as change agents to bring about community change, therefore, requires further investigation.


People experiencing homelessness (PEH) are disproportionally affected by the COVID-19 pandemic. The realities of their daily lives have been given little consideration in the pandemic response. They are not represented in existing health information campaigns, and many are structurally excluded from digital information. The project aimed to develop inclusive COVID-19-information material to strengthen infection prevention and control of PEH.In a participatory process, PEH were involved in the planning, production, and evaluation of poster and video information material on COVID-19. Various stakeholders were consulted for external supervision. Service providers all over Germany were informed about the material that could be ordered free of charge. For the evaluation, semi-structured interviews with homeless service providers and PEH were conducted, and the online views of the videos were measured.Sixteen PEH participated actively in the project. Two COVID-19-information videos were launched in 5 languages in February 2021. Posters promoting vaccination against COVID-19 were produced in 9 languages. As of May 2022, the videos have been viewed more than 2,000 times. A total of 163 service providers for PEH and public institutions received the posters, thereof 72 upon request. Twelve service providers and 8 PEH participated in the evaluation. They pointed out the lack of targeted information material for PEH. The consideration of the concerns and the diverse representation of PEH was perceived as particularly important. Most of the service providers were unable to show the videos due to technical and spatial limitations. Digital challenges for PEH, like the lack of and maintenance of a smart phone, became apparent.The cooperation of research, practice and the community were key factors for the realization of this project. Strong links to the community and the involvement of relevant stakeholders are indispensable when working with PEH. Exclusion from digital information is an increasingly important component of the structural marginalization of PEH. Digital inclusion for PEH and service providers can help to counteract social and health inequalities. The lessons learned through this project can contribute to strengthen participation of PEH and to consider their perspectives in future health communication strategies. People experiencing homelessness (PEH) are disproportionally affected by the COVID-19 pandemic. Precarious living conditions on the street, in encampments and cramped shelters, limited access to hygienic supplies and prevention measures, stigmatization, marginalization from social, political and economic resources as well as exclusion from health services result in high rates of underlying health conditions and a high risk of SARS-CoV-2-infection . The preSince the beginning of the COVID-19 pandemic, the need to consider the living conditions of PEH when implementing measures of infection control and prevention (IPC) has been addressed by the German national working group on homelessness services  . In JulyWith the onset of the pandemic, digitalization was discussed more publicly than before as it affected everyone to a substantial extent. Being digitalized took on a new relevance, as it was, for example, a prerequisite for the digital EU certificate, which allowed unrestricted access to public buildings, use of transport and freedom to travel between international borders . MultiplIn a previous COVID-19 project among PEH, we identified the necessity to address language barriers, to include digital information formats, and to use participatory approaches considering homeless people's needs and life situation , a self-organization (Selbstvertretung wohnungsloser Menschen e. V.), the coordination group for homeless shelters in Berlin (Koordinierungsstelle Berliner Kältehilfe), the Robert Koch Institute as well as staff of the Berliner Stadtmission .Scripts in German language were created for two videos with general information about COVID-19 and SARS-CoV-2 testing. Expertise of the medical specialists and social workers and the experience of the community partners were combined to gain a better understanding of the health, personal needs and coping strategies of PEH during the pandemic. The scripts were edited in a multi-step revision process. After they were shared with and adapted by all stakeholders, the main protagonist translated them to a simple and clear language. Native speakers translated the scripts into four other languages that were identified in the previous project we performed . All PEH who contributed to the implementation of the project were paid for their work. The study was explained to PEH in the preferred language, and written informed consent was provided for participation. The scope and time frame of the project were transparently communicated, as well as the possibility to withdraw participation at any point of the project without repercussions. As PEH are a particularly vulnerable group, privacy, data security and a familiar atmosphere (to avoid any discomfort) were taken into careful consideration during the interviews.Sixteen PEH participated actively in the production of the information material. All participants were experiencing homelessness at the time of the study. Ten protagonists were recruited in the 24/7 shelter, 3 in the clothing store and 3 were recruited in the streets during the shooting days. Four of the participants were women and 12 were men, aged between 25 and 75 years from 6 countries speaking 8 different languages, two of them were in a wheelchair.substitution is provided” was replaced by “you can stay there, also if you consume”. The 5-day shooting of the videos took place at 15 locations.We produced two multilingual COVID-19 information videos under the slogan “We keep Corona off the streets”. The protagonist changed some parts of the script for a better understanding. For example, regarding information about the opioid substitution programme in the quarantine facility, “The videos were produced with 13 protagonists. Six protagonists chose spots on the grounds of the Berliner Stadtmission or in the near vicinity as shooting locations, while 7 chose spots around the main railway station, a nearby park and public places.The first video clip (duration 3 min 13 s) contained general information about COVID-19 . It explIn the second step, we designed multilingual posters with seven different motifs , 3 19)..19). Wit- 1st language version: German, Polish, English, Farsi, Russian- 2nd language version: German, Romanian, Bulgarian, Arabic, FrenchYou can get vaccinated. Even with no fixed address, no health insurance, no documents. Get informed in the social or health care services you know”. In another poster version we included the sentence “Even if you use drugs”. The posters that address drug use do not contain portraits of PEH to avoid stigmatization  event. It was screened in the homeless shelter of Berliner Stadtmission under COVID-19 hygiene measures to allow community partners without internet access or mobile devices to participate. Over 100 participants joined online from various fields such as homeless services, politics, research and community.via the social media channel of the Charité – Universitätsmedizin Berlin took place in February 2021. Between February 8, 2021 and May 31, 2022, the videos have been viewed 2,064 times via the project website. We registered peaks in the numbers of requests of the posters at the beginning of the vaccination campaigns in spring 2021 and then again in winter 2021. At that time, the booster vaccinations started, the night shelters opened for winter season, and the institutions were informed about the material by email.By May 2022, a total of 1,754 posters were sent to 163 institutions and facilities in 53 cities within Germany . WhereasOut of 20 homeless service providers that were invited to the evaluation, 12 agreed to participate in a telephone interview which were conducted by two of our study team members in August 2021. At the same time, another team member interviewed 8 PEH on 2 days in front of a shelter and in a day center. All were experiencing homelessness at the time of the study. Out of the notes that were taken during the interviews, thirteen categories of different topics were identified , 2. Not All service providers approved that the posters were widely used for the vaccination campaigns. All 3 respondents who knew the videos considered them helpful for providing targeted information and allowing PEH to feel addressed directly. However, the streaming of the videos in the services was reported to be difficult due to lack of digital devices. Only 1 institution reported to have used the videos within the counseling context. Eight out of 12 service providers pointed out the digital challenges for PEH, e.g., owning and maintaining a mobile or smart phone, and the lacking digital infrastructure in services for PEH. It was acknowledged that digital tools and offers can be a chance to provide better health and social care for PEH, also those living in hidden homelessness. All respondents spoke about the lack of targeted information material for PEH in general. It was suggested to address a wide range of further topics with targeted digital information material.via videos. One person addressed the digital gap, saying that it was only useful if you had the convenience of owning a digital device.Out of 8 PEH, 3 had seen the posters in relevant facilities of homelessness services in Berlin. None had seen the videos before. Participants appreciated that PEH were protagonists of the videos and posters, but even more diversity would have been appreciated. They could identify with the material and pointed out that mentioning consuming drugs and alcohol was crucial. It was reported that the posters encouraged PEH to think about a vaccination. Precise information on vaccination offers in the respective locations would have been helpful. Both, dissemination of information through posters and videos was appreciated. It was pointed out, that visually and auditorily appealing videos could be suitable especially for illiterate people. Respondents appreciated the idea of disseminating information A key factor for the realization of the videos and posters was the set-up of an interdisciplinary team together with community partners and thus bridging the gap between research, practice and community. Of particular significance were good contacts of the study team with homeless service providers and PEH. Furthermore, it was crucial to involve various local and national stakeholders right from the beginning of the project for advice, support and distribution of the materials. The participatory approach enables active generation of knowledge together with practice and communities . AccordiI think I'm someone people accept”. In front of the camera, most PEH placed emphasis on a proud attitude showing an active and upright posture.A challenge was to deal with poverty and precarious living conditions in a sensitive way. Poverty was neither to be tabooed nor trivialized. The goal was to show a realistic picture of the social system and living environment of PEH without reproducing stereotypes or exposing people. The image and portrayal of homelessness in times of the pandemic was therefore to be determined primarily by the community partners themselves. The main protagonist decided to participate by stating “For the evaluation, 8 PEH and 12 service providers were interviewed. They acknowledged the sensitive implementation of the project. The consideration of the concerns and the diverse presentation of PEH was perceived as particularly important.In this manuscript we have chosen the term “people experiencing homelessness” because it presents homelessness as one aspect among others and is less generalizing than the term “homeless people”.To enable participation according to the needs of the community partners, work conditions were defined and arranged together. For example, the main protagonist's condition for participation was the assurance of permanent access to barrier-free sanitary facilities. He knew from personal experience that this would be a main challenge, especially during the pandemic when sanitary facilities were even less available for PEH. This highlights one of the fundamental problems that people living in the streets face on a daily basis.For some people there were barriers that made participation difficult or impossible such as hidden homelessness, illegalization, and precarious employment. We have tried to enable safe participation for them as well. For some, a solution was to participate by dubbing the videos, translating the scripts or by attending the feedback sessions. Others chose to not participate altogether. Our impression was that it has been easier for people to participate if there was pre-existing contact with project staff or other PEH who had already taken part. In regard to the evaluation, we found it easier to find interview partners in the day center which provided a safe setting for the interview compared to the recruitment in front of the shelter where the interviews were performed outdoors. It is crucial to be aware of and respect the right to non-participation.We did not collect socio demographic data from the PEH who participated in the production and evaluation of the materials. All were experiencing homelessness at the time of the study. Some had shelter available. Similar to varying infection risks, differences in the participation and responses between sheltered and unsheltered individuals are possible, but this could be not further analyzed in this study .via social media and email lists. It remains unclear to what extent they reached the actual target group. However, considering the important role that social media has in shaping people's state of information and attitudes toward public health interventions such as vaccination campaigns, efforts should be increased to utilize these means of communication  online counseling should also be considered.Valuable lessons were learned through the project, that can help to strengthen participation of PEH and to consider their perspectives in health communication strategies .Engaging marginalized populations as community experts and partners in the planning, implementation and evaluation of projects is crucial to adequately grasp their situation and needs. Strong links to the community, trust and the involvement of relevant stakeholders are indispensable when working with PEH.Progressive health communication in terms of hybrid information material  considers the heterogeneity of the target group, identifies the specific needs and addresses them concretely but sensitively, without stereotypes. The material should be readily accessible, multi-lingual with a simple and clear message, addressing taboo topics while being designed in a discrimination-sensitive way. In this project people were addressed in their various spoken languages, including minority languages and a clear and simple language for functional illiterates. The experiences and feedback of peers and communities must be included in the development of information material.Access to mobile and digital devices positively impacts the daily lives and health of PEH. Sustained use of the devices requires access to electricity and Wi-Fi as well as safe storage facilities. Social institutions should receive financial and professional support to develop a digital infrastructure and have it available for its users. Exclusion from  information, on the other hand, is a major factor in the structural marginalization of PEH. Closing the digital gap can be a contribution to counteracting social and health inequalities.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the Ethics Committee of the Charité – Universitätsmedizin Berlin (No.: EA2/168/21). The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.AS: conceptualization, methodology, investigation, and writing original draft. NS: conceptualization, methodology, and scientific advice. TL, TH, MH, and MW: methodology, investigation, and formal analysis. GE and JS: scientific advice and supervision. AL: project administration, conceptualization, and supervision. All authors: writing—review and editing. All authors contributed to the article and approved the submitted version.This study was funded by Bundesministerium für Bildung und Forschung/Federal Ministry of Education and Research: NaFoUniMedCovid19 (FKZ: 01KX2021) B-FAST. The funder had no role in the design and conduct of the study, analysis, interpretation of data, or in writing of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The objective of this study is to identify and analyze the scientific literature with a bibliometric analysis to find the main topics, authors, sources, most cited articles, and countries in the literature on virtual reality in education. Another aim is to understand the conceptual, intellectual, and social structure of the literature on the subject and identify the knowledge base of the use of VR in education and whether it is commonly used and integrated into teaching–learning processes. To do this, articles indexed in the Main Collections of the Web of Science, Scopus and Lens were analyzed for the period 2010 to 2021. The research results are presented in two parts: the first is a quantitative analysis that provides an overview of virtual reality (VR) technology used in the educational field, with tables, graphs, and maps, highlighting the main performance indicators for the production of articles and their citation. The results obtained found a total of 718 articles of which the following were analyzed 273 published articles. The second stage consisted of an inductive type of analysis that found six major groups in the cited articles, which are instruction and learning using VR, VR learning environments, use of VR in different fields of knowledge, learning processes using VR applications or games, learning processes employing simulation, and topics published during the Covid-19 pandemic. Another important aspect to mention is that VR is used in many different areas of education, but until the beginning of the pandemic the use of this so-called “disruptive process” came mainly from students, Institutions were reluctant and slow to accept and include VR in the teaching–learning processes. The knowledge society recognizes that Education Institutions are a fundamental part of the globalization process, where the use of information and communication technologies (ICT) improve students' attitudes towards learning  Table :Table 1RThis article is organized as follows: the first part introduces the study, including the objectives and the research questions. A second section presents a review of the literature on bibliometric analysis. The methodology used is defined in the third section, indicating the search procedures used to identify the literature on VR in education. The fourth section presents the results, and these are discussed in the fifth section. Finally, in the sixth section, the conclusions are drawn, and future lines of research are suggested.This study uses a bibliometric analysis, which is a term that was coined by Pritchard  who statBibliometric analysis is an approach that uses a set of quantitative methods to measure, track, and analyze scholarly literature  classified into an organized hierarchy of fields and subfields . The terms learn*, teach* class* and student* were also used to obtain articles with titles containing words related to learning, teaching, class or classroom, students. innovat* and Covid* were also included to obtain articles about innovation and the teaching process during the Covid pandemic.The search was performed in English to obtain the largest number of documents in the dataset on VR in education. Table The documents included in this analysis contain bibliographic information obtained after a manual review of the 436 relevant documents found in WoS, 584 found in Scopus and the 251 in Lens. 553 duplicate documents were eliminated, and the names of the authors and journals were normalized, which resulted in 718 documents unified in an.xlsx file. This whole process is summarised in the three stages of search strategies shown in Fig. Biblioshiny software was used for the analysis of the data. It is a tool which analyzes all the data identified in the body of literature and identifies the main themes Huber, . The appTables The use of ICTs in education is commonplace, with VR no exception and often included in the teaching–learning processes. The evolution in the productivity of articles over the period analyzed clearly shows a rapid growth from 2015 to 2021, as shown in Fig. This growth is due to the development of specific content in VR, with more and more sectors involved such as: real estate, locomotion, security, and even education itself with the new e-Learning systems.According to Heradio et al.  the mainThe information from the analyzed data is summarized in descriptive statistics presented in Table The average number of annual citations are presented in Fig. Figure Figure The journal with the most impact in this study is Computers & Education with an h-index of 16. This means that a number, h, of publications of the journal have been cited h times. An h-index of 16 implies that this number of publications have been cited at least 16 times. Table The authors with the highest productivity are shown in Fig. The most active authors in the last four years have been Chen W., Lee J., Kim, J., Ly Y. and Makransky G., as shown in Fig. Chen W. primarily studies problem solving in the classroom using VR technology, to assist in cognitive processing and knowledge transfer to the students. On the other hand, Lee J., studies the adaptation of the three-dimensional visualization made possible by immersive virtual reality.Other authors, such as Kim J., jointly approach the analysis of VR and augmented reality (AR) whith the current skin electronics are summarized as one of the most promising device solutions for future VR/AR devices.Ly Yan approaches the study of VR based simulation in hospital settings, that facilitates the acquisition of skills without compromising patient safety. Finally, Makransky's research deals with various aspects of RV in education, such as an important role in education by increasing student engagement and motivation.The main affiliations of institutions can be seen in Fig. Table The words which occur with the highest frequency in the dataset can be seen in Fig. A similarity measure known as the strength of association was used to construct the bibliometric maps  and desktop computer (DT) which may affect spatial learning (Srivastava et al., A person can interact in an environment created with VR in a seemingly real or physical way by using special electronic equipment, such as a helmet with a screen inside it or gloves equipped with sensors (Katsioloudis et al., The second group covers VR applied to education, which includes topics such as technologies that allow the visualization of situations, which receive more attention from students and motivate them. Examples of this type of technology are virtual communities, educational games, interactive learning environments, educational technologies that improve the teaching process, online learning, user experience, immersive learning, immersive virtual reality and deep learning. There is a wide variety of possibilities, most of which are immersive, using helmets, games or applications that provide an interactive learning experience for students.Learning environments using animation and multimedia highlight a change in VR learning which is more immersive, simulating the real world with 3D models that provide an interactive environment and reinforce the feeling of immersion. Using this technology, educators combine theory and instruction methods that allow intelligent use of these environments (Huang et al., VR applications enable potential learning. Authors such as Johnson-Glenberg,  explore Games are useful in educational technology with many examples available. Some of these are used to train students in safety through role-playing and social interaction (Palos-Sanchez et al., Articles were found concerning online learning which shares digital content and technological tools for e-learning and virtual reality learning. One of these articles compares techniques such as email, attachments, shared use of Web interfaces and a VR engine which provides a virtual interface. The results indicate that users completed their workflow 50% faster with the VR option (Lampert et al., Bibliometric mapping of the keywords used by the author was done to gain a thorough understanding of the conceptual structure. Apart from the Keyword Virtual Reality itself, it highlights those related to education, e-Learning and Students. The co-occurrence analysis is shown in Fig. Keyword co-occurrence analysis is an effective tool for understanding knowledge structures and research trends. This makes it easier to understand primary and secondary publications (Altınay Ozdemir & Goktas, In this bibliometric analysis we mainly distinguish the following keywords: 'virtual reality', 'e-learning' and 'students' in a first cluster. Each cluster represents a keyword and shows the most linked and repeated keywords in the publications. All clusters have a different colour. In Fig. The countries or regions with the highest document productivity in this study are the Republic of China with 273, United States of America with 242 documents, followed by South Korea with 57 and Spain with 50, as shown in Fig. In Fig. VR technology in the educational field is opening up space through e-learning, game-based learning to mobile learning, going from simulation, machine learning to Deep Learning, where immersive virtual reality is part of the topics present as shown in Fig. In Fig. This map gives an improved understanding of the social structure, not only of authors, but also of the countries to which they belong. Figure This section briefly summarizes the most cited articles, and they are classified into categories, in the literature few authors provide us with a panoramic view of virtual reality technology applied to the educational field. In contrast to other authors (Zappatore et al.  who perfAmong the most outstanding papers are the following: Merchant et al. , Lee et The most cited paper is Merchant et al. . This woThe study by Lee et al.  examinedMany authors investigate VR as a tool in learning processes. An example is Huang and Liaw,  who explAllcoat and von Mühlenen  assignedHewawalpita et al.  exploredWang,  proposedIn view of the works analyzed in the context of VR-based Instruction and Learning, we can say that the VR-based learning process is a useful tool for the educator, as it can replicate or complement traditional teaching methods. It is a fully effective concept even using basic forms, such as VR glasses or smartphones. This method is suitable for classroom teaching, distance learning, self-learning and other educational environments, and allows the simulation of scenarios that enrich teaching, even those dangerous experiments that cannot be reproduced in reality.These papers conclude that it is essential to design useful and learner-friendly VR learning tasks and activities in order to improve learning outcomes. These activities should be adapted to learners with different learning styles and special abilities. Although this is a novel experience, the gap in these research models lies in the need for new longitudinal studies to verify whether improvements in teaching processes are maintained over time. It is necessary to identify differences in teaching processes, such as context, sample, duration, cultural background or learning programs with different content.There is a need to deepen and explore the influence of virtual reality on the relationship between motivation and learning performance. That is, it is desirable to know whether students' disappointment can have a negative influence on their learning, using qualitative and quantitative methods in the study of prolonged periods.Geng et al.  explore VR learning environments are explained by Huang et al.  who indiFowler, Yang et al.  investigThe works analyzed emphasize that previous experiences with virtual reality in education have improved significantly. Although in the beginning they only used a mouse and keyboard as input devices, the benefits and educational effectiveness of 3D virtual learning and new virtual tools such as the PILE system, which allows students to interact with objects on the screen through physical movements, are gradually emerging.Although technology has accompanied the teaching process exponentially in recent years, replacing traditional whiteboards with smart boards and VR elements, the gap in these research models lies in the need for new research is needed to explore the variables that may affect learning outcomes when using VR simulations. The described works suggest that it would be convenient to explore aspects such as duration, users' prior knowledge or dual cognitive/affective component.The study of individual student differences, the long-term implications for knowledge acquisition, the frequent use of technology outside of teaching, the ease of use of different VR tools and the willingness of teachers to implement new VR-based utilities are also considered. This analysis evidences the importance of VR-based simulation processes, especially in areas of knowledge development that teachers deem necessary, allowing a balance between the cost and benefit of the experiences obtained.Osti et al.  They seeSchmidt and Glaser  investigVélaz et al.  studied A study by Eaves et al.  determinChen and Hsu  used a VAuthors M. Zhang et al.  studied Sood and Singh  considerMakransky et al.  investigHsu et al.  considerWu et al.  They usePaszkiewicz et al.  presenteYerden & Akkuş,  examinedTaçgın,  investigThe results showed that the production of documents on VR in education has increased since 2015, possibly due to the increase in interest in virtual reality technology. There were important changes in the field in 2014 with the introduction of the Oculus Rift Frame. The interest in VR is reflected in the number of publications in 2018 and has been increasing with the changes in education systems due to the Covid-19 pandemic. The productivity in the last two years has been much higher than before.The growth is then constant from 2015 onwards, increasing 10 times by 2020. There was a high number of publications in 2019 and a much higher number in 2020, possibly due to the new interest in VR and the impact of the Covid-19 pandemic. Higher production is expected for VR in Education in 2021. The recent growth is consistent with the results of the study on VR and motivation in the educational field (Soto et al., Figure Figure Co-occurrence was used to identify the conceptual structure by analyzing the words in the Keywords Plus of cited articles. The words that appear most often were found to be virtual reality with 107 occurrences, students with 70, education with 66, learning with 58 occurrences, and environments with 44. All these words are closely related to the search topics although technology, performance, simulation, design and learning systems were also found. This information is shown in Fig. The words covering the topics in the Keywords Plus of the documents were analyzed by means of a factorial map and a cluster analysis, as shown in Fig. Co-citation was used to analyze the intellectual structure. The authors of the documents were analyzed, and Lee was found to have a co-citation relationship Merchant, Dalgarno, Smith, Mikropoulos, Davis and Bouman, while a second group of co-citation authors was formed by Chen, Wang, Huang, Zhang, Chang, Yang and Lin. This information is shown in Fig. An inductive analysis found that the most cited papers were into the major categories of virtual reality-based instruction and learning, learning environments using VR, VR for teaching learning processes, instructional design and VR as a tool that enhances learning processes.VR learning environments contain different systems where VR is applied in education, ranging from conventional multimedia to a physically interactive learning environment.Research was found that investigated the use of VR in different fields of knowledge and various areas of education such as civil engineering, production lines and rehabilitation.Learning processes incorporating the use of VR applications, devices or games are considered disruptive technologies that alter the usual teaching, cognitive and learning practices of students. However, the combination of VR with computing was seen to provide effective e-learning.Articles were also found in the dataset about research using simulation models, for example driving vehicles, assembly lines, operations in the medical field. These simulation models used three-dimensional technology for the teaching process.The research topics published during the Covid-19 pandemic examined the new trend in the field of education caused by the abrupt change from face-to-face teaching to virtual, online teaching. Research topics included deep learning and machine learning using artificial intelligence as alternatives to everyday teaching technologies and platforms. These included robot teleoperation, remote access laboratories, Virtual Reality-Based Cognitive Telerehabilitation Systems, Machine Learning Predictions, Immersive Virtual Reality learning environments, intelligent virtual reality technology, distance learning classrooms using machine learning and virtual reality, Virtual Reality-Interactive Classroom, Student Orientation in Distance Education Programs, Virtual Reality and BIM Methodology for Teaching–Learning Improvement, virtual reality-based gaming instruction and virtual reality for students' adaptive learning among others.The six categories of the second analysis showed that improvements in VR learning processes have occurred in recent years and important advances have been made in the application and use of this technology. However, even though the engagement and motivation of students can be improved by using this technology, there still remains a lot to be discovered about the use of e-learning tools. VR learning environments have advanced significantly from multimedia to interactive environments with desktop and immersive VR processes, 360-degree tours and various applications and games. Education has generally adopted these changes slowly with most attention coming from the new generations of students. VR technology has existed for many years but has not been adopted as quickly as would be expected by educational centers, where it is seen as a disruptive process and is more commonly used by students for recreational purposes. The results of this study show that despite the multiple applications of VR in different fields of education, there is little evidence of incorporating them in teaching–learning processes. Educators have, however, quickly resorted to the use of technology platforms to teach because of the sudden change from face-to-face to virtual, online classes due to the Covid-19 pandemic. With the many available applications of VR in education and given that students have accepted the use of VR for recreational purposes, it can be incorporated as part of educational and training courses and demonstrations, as well as being useful for evaluating students.Finally, the quality assessment of this research work was evaluated applying contrasted methods, following recommendations proposed by Ramey and Rao  and Rao Bibliometric analysis is a valuable tool that can be used to reveal the evolution of the articles contained in the dataset and answer research questions.The conceptual structure shows that the most-used words are related to the search terms, although some words were found to be used with higher frequency. These were virtual reality, students, education, e learning, teaching, while the main topics investigated range from basic ones such as virtual reality and education to technology, teaching, visualization, student motivation and attention, e-learning, learning system, deep learning, and immersive virtual reality.Recent publications show an increasing interest in VR, but rather than delving deeper into this technology other technological options are being explored with combinations of VR and other technology and systems. The pandemic improved our abilities to adapt and innovate with virtuality, along with teleworking and virtual teams (Garro-Abarca et al., One of the contributions of this study has been to confirm the progress of VR technology. In the future, educational centers will be able to solve many challenges, such as learning by experiencing and interacting with an environment, instead of passively receiving the information to be assimilated. VR favors the motivation and involvement of students and educational staff in general, in addition to increasing the speed of learning. b. The frontier and future of VR learning environments. On the other hand, the frontier and future of VR learning environments, the article predicts that the increasing diffusion of virtual reality learning environments forces to create limits. One of the limits is based on the capacity of these didactic tools to improve their effectiveness at a training level compared to other more traditional methods. In addition, other aspects such as user privacy and equal opportunities for all students must be taken into consideration.Thus, the trends of type and use of VR in different fields of knowledge will be directed towards the inclusion of experiential VR models, adapted to each field of knowledge. The aim is to create learning vehicles that enhance the acquisition of knowledge by students in specific fields of knowledge. In this context, the training of teachers in the use of these technologies within a clear educational framework that is adaptable to the different academic disciplines will be increasingly important. In this sense, the future of VR in education will depend to a large extent on the motivation generated in students, and on being able to identify the necessary characteristics to achieve an adequate level of learning through VR. The push for VR-based education, brought about by the Covid-19 pandemic, is expected to make this style of learning one of the educational preferences in the future, especially for self-learning and teaching in certain areas where VR technology is more developed.This study was limited to investigating the use of virtual reality technology in education. Articles dealing with the medical field were not selected as primary data sources because the focus of research was on the application of VR in teaching and learning processes in secondary and university education, as well as other applications in conferences or training processes. However, articles were included from multidisciplinary areas that include research in the medical field to broaden the spectrum of practical applications of this technology.Suggestions for future bibliometric analyses include the evolution of other subject areas, using new search terms that allow other articles related to the field of education to be included for a broader analysis of the metadata and investigating other present and future lines of research.