the following is a literature review that is part of a phd students first year of research and will go onto form methods, a refined proposal and the final dissertation thesis for the final phd qualification. your task is to perform the role of an expierienced academic advisor who is skilled in academic writing. You will review the following article and provide systematic feedback which addresses each line and each paragraph: 
Introduction
Artificial Intelligence (AI) has emerged as a transformative force in healthcare, offering unprecedented opportunities to enhance patient outcomes, streamline clinical workflows, and revolutionise medical research. In the context of neonatal care, AI holds particular promise due to the controlled environment of Neonatal Intensive Care Units (NICUs) and the availability of high-quality data (Rios et al., 2020; Schouten et al., 2024). Despite significant technological advancements, the adoption and integration of AI in healthcare settings lag behind their technical potential (Davenport & Kalakota, 2019; Topol, 2019). This discrepancy is especially pronounced in critical care environments like NICUs, where the stakes are high, and the margin for error is minimal.

The concept of Explainable AI (XAI) has gained traction as a means to bridge the gap between AI capabilities and clinical adoption by enhancing transparency and trust (Arrieta et al., 2020; Rudin, 2019). However, traditional XAI approaches often neglect the user-centric aspects essential for practical implementation in healthcare settings (Ehsan et al., 2021). This realization has led to the emergence of Human-Centered Explainable AI (HCXAI), which integrates principles of Human-Centered AI (HCAI) with explainability to create AI systems that are both interpretable and aligned with user needs (Abdul et al., 2018; Shneiderman, 2020).

This literature review explores the evolution from HCAI to HCXAI, focusing on neonatal care as a domain with high potential for AI integration. By synthesizing a wide array of scholarly sources, we critically analyze the challenges, opportunities, and multidisciplinary approaches to accelerating HCXAI adoption in healthcare. We aim to identify the barriers hindering AI implementation, evaluate existing frameworks for ethical compliance, and highlight the necessity of human-centric design in developing explainable AI systems. Ultimately, this review seeks to provide a roadmap for researchers, practitioners, and policymakers to facilitate the responsible and effective integration of HCXAI in neonatal care.

The Promise of AI in Healthcare
Potential Benefits of AI Integration
AI technologies have demonstrated significant potential in diverse healthcare domains, including diagnostic imaging, predictive analytics, personalized medicine, and drug discovery (Esteva et al., 2019; Rajkomar et al., 2018). Machine learning algorithms, particularly deep learning models, have achieved near-human or even superhuman performance in tasks such as image recognition, enabling improved detection of diseases like cancer and diabetic retinopathy (McKinney et al., 2020; Gulshan et al., 2016).

In critical care settings, AI can assist in early detection of patient deterioration, optimize resource allocation, and support clinical decision-making by analyzing complex physiological data (Komorowski et al., 2018; Shillan et al., 2019). For instance, AI models have been used to predict sepsis onset hours before clinical recognition, allowing for timely interventions that can save lives (Desautels et al., 2016).

Importance of High-Quality Data
The efficacy of AI systems in healthcare is heavily dependent on the quality and quantity of data available for training and validation (Obermeyer & Emanuel, 2016; Ghasemaghaei & Calic, 2019). High-quality data enhances predictive accuracy, reduces bias, and improves the diagnostic value of AI models. In medical imaging, access to comprehensive datasets has enabled AI algorithms to identify subtle patterns indicative of disease, improving diagnostic outcomes (Esteva et al., 2019).

In the context of NICUs, continuous monitoring systems generate vast amounts of real-time physiological data, providing an ideal substrate for AI applications (Stone et al., 2020). The high-fidelity data collected includes vital signs, laboratory results, and sensor data, which can be leveraged to develop predictive models for various neonatal conditions (Lee et al., 2020).

Big Data and ICU Settings
The term "Big Data" in healthcare refers to datasets characterized by high volume, velocity, and variety, which, when properly managed, can unlock significant insights and capabilities (Nilashi et al., 2023; Javaid et al., 2021). Intensive Care Units (ICUs), including NICUs, are prolific generators of Big Data due to the continuous monitoring of patients and the complexity of care provided (Shillan et al., 2019).

AI systems designed to process and analyze Big Data in ICUs can assist clinicians by identifying trends, predicting adverse events, and recommending interventions (Gutierrez, 2020). For example, predictive analytics models have been developed to forecast episodes of hypoxia or bradycardia in neonates, enabling preemptive clinical actions (Vistisen et al., 2019).

Focus on Neonatal Care
Justification for AI in Neonatal Intensive Care Units (NICUs)
Neonatal care presents a promising area for AI implementation due to several unique factors:

Lower Diversity of Illnesses: Neonates typically present with a narrower range of conditions compared to adult populations, simplifying the complexity of AI models required for diagnosis and treatment (Rios et al., 2020). Common conditions include respiratory distress syndrome, sepsis, and prematurity-related complications.
Lack of Non-Compliance Issues: Unlike older pediatric patients or adults, neonates do not exhibit behavioral non-compliance, reducing variability in treatment outcomes and enhancing data consistency (Blake et al., 2018). This consistency facilitates the development of more accurate predictive models.
Controlled Environmental Conditions: NICUs offer highly controlled settings with standardized protocols and continuous monitoring, minimizing external variables and enhancing the reliability of collected data (Fairchild et al., 2017).
High-Quality Data Availability: The abundance of real-time, high-resolution physiological data enables the training of robust AI models capable of detecting subtle patterns that may precede clinical deterioration (Stone et al., 2020).
Contrast with Pediatric Intensive Care Units (PICUs)
While Pediatric Intensive Care Units (PICUs) also generate significant data, they handle a broader and more heterogeneous patient population in terms of age, size, developmental stage, and disease spectrum (Herzenberg et al., 2021). This diversity introduces additional complexity in developing AI models that generalize well across different patient subgroups (Keane et al., 2018). Behavioral variability and differences in treatment adherence among older children further complicate data consistency.

As a result, most AI research and system development have been concentrated in NICU settings, where the environmental control and patient homogeneity offer a more conducive environment for AI integration (Schouten et al., 2024).

Advancements in Neonatal and Pediatric Intensive Care
Recent studies have demonstrated promising applications of AI in NICUs and PICUs. Adegboro et al. (2021) identified 31 academic sources showcasing AI's potential to improve health outcomes in neonatal and pediatric intensive care settings. These studies highlight AI's ability to enhance diagnostic accuracy, predict adverse events, and optimize treatment strategies.

However, many of these technologies remain in the prototype testing phase, emphasizing operational constraints, regulatory standards, and ethical dilemmas as critical considerations for safe implementation. Schouten et al. (2024) further examined the readiness and risk of bias in AI applications within NICUs and PICUs, concluding that while some technologies are closer to clinical implementation than previously thought, significant barriers remain. These include the added complexity and time required to integrate transparency and explainability into AI systems, as well as the need for continual model evaluation and the associated financial costs.

Predictive Analytics and Early Intervention
Advancements in machine learning and AI have facilitated the shift from reactive to proactive care in NICUs. Predictive analytics models can analyze historical and real-time data to forecast clinical deterioration, such as sepsis onset or respiratory failure (Komorowski et al., 2018; Morales-Nebreda, 2020). Early warning systems that replicate clinician assessments enable timely interventions, potentially reducing morbidity and mortality (Lal et al., 2020).

For example, Desautels et al. (2016) developed a machine learning model capable of predicting sepsis onset in neonates up to 12 hours before clinical recognition, providing a crucial window for intervention. Similarly, AI models have been used to predict the risk of necrotizing enterocolitis (NEC) in preterm infants, facilitating early diagnostic measures (Sanchez-Pinto et al., 2018).

Automation and Control Systems
AI-driven automation has also been explored in managing environmental controls within NICUs. Gutierrez (2020) examined the automation of oxygen delivery systems for preterm infants, highlighting the limitations of rule-based systems and the potential benefits of intelligent AI systems capable of adapting to sensor insensitivity and environmental changes.

Zhang et al. (2023) demonstrated the effectiveness of a physics-informed AI model in monitoring and controlling incubator air temperature, resulting in greater accuracy and consistency compared to traditional methods. This approach leverages AI's ability to process large datasets and model complex physical interactions, enhancing the stability of the neonatal environment.

Clinical Decision Support Systems
AI-powered Clinical Decision Support Systems (CDSS) have shown potential in augmenting clinician decision-making by providing evidence-based recommendations derived from vast datasets (Choi et al., 2020). In neonatal care, CDSS can assist in dosage calculations, ventilation settings, and management of complex conditions like sepsis and hypoxic-ischemic encephalopathy.

Plaza (2024) proposed a CDSS model utilizing Health Level Seven Fast Healthcare Interoperability Resources (HL7-FHIR) standards to integrate AI-driven insights into clinical workflows seamlessly. Such systems can reduce cognitive load on clinicians, improve adherence to best practices, and enhance patient outcomes.


Barriers to AI Adoption in Healthcare
Despite the demonstrated potential of AI in healthcare, several barriers hinder its widespread adoption, particularly in critical care environments like NICUs.

Ethical Considerations and Trust
Implementing AI systems in healthcare raises significant ethical concerns related to patient autonomy, data privacy, informed consent, and potential biases in AI algorithms (Morley et al., 2020). The "black-box" nature of many AI models, particularly deep learning networks, exacerbates these concerns by obscuring the decision-making process (Rudin, 2019).

Trust is a crucial factor influencing clinician acceptance of AI systems. Studies have shown that clinicians are reluctant to rely on AI recommendations without understanding the underlying reasoning, especially when patient safety is at stake (Shortliffe & Sepúlveda, 2018). Castelo et al. (2019) found that task-dependent algorithm aversion can diminish trust in AI, emphasizing the need for transparency and explainability.

Regulatory Compliance and Legal Challenges
Regulatory compliance is a significant hurdle for AI adoption in healthcare. Compliance with data protection regulations such as the General Data Protection Regulation (GDPR) in the European Union and the Health Insurance Portability and Accountability Act (HIPAA) in the United States is essential to safeguard patient data (Voigt & Bussche, 2017).

The EU AI Act further emphasizes the need for transparency, robustness, and accountability in AI applications, especially those considered high-risk, such as healthcare AI systems (Act, 2021). Legal accountability for AI decisions remains an unresolved issue, complicating the deployment of AI systems in clinical settings (Yu et al., 2018).

Technical and Operational Constraints
Technical challenges include the integration of AI systems into existing healthcare infrastructures, requiring interoperability with various electronic health record (EHR) systems and compliance with health data standards (Kumar et al., 2021). Operational constraints involve the financial costs associated with deploying and maintaining AI technologies, the need for continual model evaluation, and the scarcity of AI expertise among healthcare professionals (He et al., 2019).

The complexity and time required to integrate transparency and explainability into AI systems add additional layers of challenge (Arrieta et al., 2020). Moreover, the need for real-time data processing and high computational resources can pose logistical challenges in resource-constrained settings.



From Ethical AI to Human-Centred AI (HCAI)
Limitations of Current Ethical Approaches
While ethical AI is widely recognized as a priority, many current approaches lack actionable strategies and fail to address practical implementation challenges (Article 19, 2019). The proliferation of ethical guidelines and frameworks has not necessarily translated into ethical AI practices, leading to criticisms of "ethics washing," where organizations superficially engage with ethical discussions without substantive action (Jobin et al., 2019; Ochigame, 2019).

Critics argue that normative ethical approaches serve as a "softer version of the law," allowing organizations to avoid legally enforceable restrictions while appearing socially responsible (Rességuier & Rodrigues, 2020). This gap highlights the need for concrete, actionable frameworks that can guide the development and deployment of ethical AI systems.

Frameworks for Ethical Compliance
Treacy (2023) proposes a comprehensive framework for ethically compliant AI programs, identifying six key areas:

Transparency: Ensuring that AI systems are understandable to users and stakeholders.
Accountability: Establishing clear lines of responsibility for AI decisions.
Diversity: Promoting inclusivity and preventing bias in AI systems.
Data Governance: Implementing robust data management practices to protect privacy.
Safety: Ensuring that AI systems do not pose undue risks to users.
Organizational Culture: Fostering an ethical culture that supports responsible AI practices.
This framework provides organizations with a structured approach to ethical management as AI becomes more prevalent. By operationalizing ethical principles, organizations can move beyond rhetoric to tangible actions that promote trust and compliance.

Treacy (2022) further contributes to data compliance strategy development by applying a knowledge-based dynamic capabilities framework. This approach outlines mechanisms required at each stage of strategy formulation and implementation, enabling organizations to adapt to evolving regulatory landscapes and technological advancements.

Principles of Human-Centered AI
Human-Centered AI (HCAI) emphasizes the design and development of AI systems that augment human capabilities, align with human values, and prioritize user needs (Shneiderman, 2020). HCAI principles include:

User Empowerment: Designing AI systems that enhance human decision-making rather than replace it.
Transparency: Making AI processes understandable to users.
Inclusivity: Addressing diverse user needs and preventing biases.
Collaboration: Facilitating effective human-AI interaction.
In healthcare, HCAI can improve clinician engagement with AI systems by making them more transparent, interpretable, and aligned with clinical workflows (Abdul et al., 2018). By focusing on the human element, HCAI aims to promote trust, acceptance, and ethical AI adoption.

The Emergence of Explainable AI (XAI)
The Importance of Explainability
Explainable AI (XAI) has emerged as a critical area of research in response to the opacity of complex AI models, particularly deep learning networks (Rudin, 2019). XAI aims to make AI decisions transparent and understandable to humans, enhancing trust and facilitating adoption in high-stakes domains like healthcare and finance (Arrieta et al., 2020).

Explainability is crucial for several reasons:

Trust and Acceptance: Users are more likely to trust and accept AI systems whose decisions they can understand (Doshi-Velez & Kim, 2017).
Regulatory Compliance: Regulations like the GDPR and the EU AI Act require transparency in automated decision-making processes (Voigt & Bussche, 2017; European Commission, 2021).
Error Analysis: Explainability enables users to identify and correct errors or biases in AI models (Tonekaboni et al., 2019).
Applications in Finance
The finance industry, while receptive to AI innovations for tasks such as fraud detection, credit scoring, and algorithmic trading, faces adoption hurdles due to the opacity of AI decision-making (Weber et al., 2024). XAI can help overcome these barriers by providing insights into AI models, supporting practitioners in implementing AI in financial practices responsibly (Venkataramanan et al., 2024).

For instance, regulatory requirements such as the Fair Credit Reporting Act and the Equal Credit Opportunity Act in the United States necessitate explanations for credit decisions, prompting financial institutions to adopt XAI approaches (Venkataramanan et al., 2024).

Applications in Healthcare
In healthcare, integrating explainability into AI systems is essential for clinician trust and patient safety (Tonekaboni et al., 2019). Hu et al. (2024) developed an explainable AI model for mortality risk prediction in ICUs, demonstrating that explainability enhances clinicians' trust and facilitates AI adoption. By providing feature importance scores and visualizations, clinicians could understand the factors influencing predictions, enabling more informed decision-making.

Moreover, explainability can aid in regulatory compliance and ethical considerations by providing transparency into AI decision processes, addressing concerns about biases and errors (Arrieta et al., 2020).

Challenges and Limitations
Despite the benefits, XAI faces challenges:

Technical Complexity: Methods for explainability can be complex and may not fully capture the intricacies of AI models, leading to oversimplification (Rudin, 2019).
Usability: Explanations generated by XAI methods may not be readily interpretable by end-users, particularly those without technical expertise (Nguyen et al., 2024).
Trade-offs with Performance: Simplifying models to enhance explainability may compromise predictive accuracy, which is especially critical in healthcare applications (Sadeghi et al., 2024).
Human-Centered Explainable AI (HCXAI)
Definition and Principles
Human-Centered Explainable AI (HCXAI) integrates the principles of HCAI with XAI to develop AI systems that are not only explainable but also centered around user needs and contexts (Ehsan et al., 2021). HCXAI emphasizes:

User-Centric Design: Tailoring explanations to the user's expertise, preferences, and tasks.
Interactivity: Allowing users to interact with AI systems to explore explanations and underlying data.
Contextualization: Providing explanations within the context of the user's workflow and decision-making processes.
By combining explainability with human-centered design, HCXAI seeks to enhance usability, trust, and effective human-AI collaboration.

Integrating HCAI and XAI
Integrating HCAI and XAI involves addressing both technical and human factors:

Technical Factors: Developing AI models that are inherently interpretable or employing post-hoc explainability methods that generate meaningful explanations (Arrieta et al., 2020).
Human Factors: Understanding user needs, cognitive processes, and decision-making contexts to design explanations that are relevant and useful (Abdul et al., 2018).
Ehsan et al. (2021) propose a framework that considers the socio-technical context, user characteristics, and explanation goals to guide the design of HCXAI systems.

Benefits of HCXAI in Healthcare
In healthcare, HCXAI can:

Enhance Trust: By providing understandable and relevant explanations, clinicians are more likely to trust AI recommendations (Tonekaboni et al., 2019).
Improve Decision-Making: Contextualized explanations can enhance clinicians' ability to interpret AI outputs and integrate them into clinical reasoning (Ehsan et al., 2021).
Facilitate Adoption: User-centered designs that align with clinical workflows reduce barriers to adoption (Usmani et al., 2023).
Examples and Case Studies
Developing HCXAI Interfaces
Thieme et al. (2024) highlight the importance of designing AI interfaces that communicate transparency about outputs and processes. Interactive visualizations, customizable displays, and plain-language explanations are tools that enhance the usability of AI systems.

For example, Lauritsen et al. (2020) developed an HCXAI model for predicting acute critical illness from electronic health records. The system provided clinicians with visualizations of risk trajectories and feature contributions, facilitating understanding and acceptance.

Applications in Neonatal Care
In neonatal care, HCXAI can address the specific needs of clinicians by providing explanations tailored to the neonatal context. For instance, AI models predicting the risk of sepsis in neonates can provide explanations highlighting the most significant clinical features contributing to the prediction, such as changes in vital signs or laboratory values (Sullivan et al., 2024).

HCXAI in Neonatal Care
Current State and Research Gap
Despite the potential benefits, HCXAI in neonatal care is underexplored. Most AI models developed for NICUs focus on predictive accuracy without sufficient attention to explainability and user-centric design (Schouten et al., 2024; Rallis et al., 2024).

The scarcity of frameworks that incorporate AI effectively with human-centered design principles in neonatology represents a significant research gap. While other industries, such as finance and automotive sectors, have successfully implemented XAI systems, healthcare has been slower to transfer these advancements effectively (Goldfarb & Teodoridis, 2022; Benamira, 2024).

Potential Applications and Benefits
Implementing HCXAI in neonatal care can:

Enhance Clinical Decision-Making: Providing clear explanations can assist clinicians in interpreting AI recommendations, leading to better-informed decisions.
Improve Patient Outcomes: Early and accurate identification of risks with understandable insights can enable timely interventions.
Facilitate Training and Education: HCXAI systems can serve as educational tools, helping trainees understand complex clinical patterns.
Challenges and Considerations
Key challenges in implementing HCXAI in neonatal care include:

Technical Complexity: Developing models that are both accurate and explainable requires balancing performance and interpretability.
User Engagement: Clinicians must be involved in the design process to ensure that explanations meet their needs and fit within clinical workflows.
Ethical and Regulatory Compliance: Systems must adhere to data protection regulations and ethical guidelines, necessitating robust governance frameworks.
Recommendations and Future Directions
To accelerate the adoption of HCXAI in neonatal care, the following strategies are recommended:

Enhancing Human-AI Interaction
Multidisciplinary Collaboration: Engage clinicians, AI experts, ethicists, and human-computer interaction specialists in the design process (Udegbe et al., 2024).
User-Centered Design: Conduct user studies, focus groups, and iterative prototyping to align AI systems with clinician needs (Ehsan et al., 2021).
Addressing Ethical and Legal Concerns
Regulatory Compliance: Ensure adherence to data protection regulations (e.g., GDPR, HIPAA) and the EU AI Act requirements for transparency and accountability (European Commission, 2021).
Ethical Governance: Implement frameworks that operationalize ethical principles, such as Treacy's (2023) framework for ethically compliant AI programs.
Focusing on Continuous Evaluation and Scalability
Model Evaluation: Establish protocols for ongoing validation and monitoring of AI models to maintain performance and mitigate biases (He et al., 2019).
Scalability and Integration: Design systems that are interoperable with existing healthcare infrastructure and scalable across different clinical settings (Kumar et al., 2021).
Incorporating Explainability
Tailored Explanations: Develop explanation methods that are context-specific and align with clinician expertise (Nguyen et al., 2024).
Interactive Interfaces: Implement user interfaces that allow clinicians to explore AI recommendations and underlying data interactively (Thieme et al., 2024).
Developing Actionable Ethical Frameworks
Operationalizing Ethics: Move beyond abstract ethical discussions by adopting concrete frameworks that guide practical implementation (Treacy, 2023).
Transparency and Accountability: Establish clear lines of responsibility for AI decisions and provide transparency into AI processes (Morley et al., 2020).
Conclusion
AI has the potential to significantly improve patient outcomes in neonatal care by enhancing diagnostic accuracy, enabling early interventions, and supporting clinical decision-making. However, barriers related to ethical considerations, trust, regulatory compliance, and technical constraints hinder its widespread adoption.

Human-Centered Explainable AI (HCXAI) offers a promising approach to address these challenges by integrating explainability with user-centric design. By focusing on the needs of clinicians and providing transparent, understandable AI systems, HCXAI can enhance trust, facilitate adoption, and ultimately improve patient care.

Future efforts should concentrate on developing robust HCXAI frameworks tailored to neonatal care, engaging multidisciplinary teams in the design process, and implementing ethical and regulatory best practices. By doing so, we can bridge the gap between AI capabilities and clinical adoption, unlocking the full potential of AI to transform neonatal care.