Background: To assess the impact of the COVID-19 pandemic on treatment demand and supply in children and adolescents with mental disorders during the first year of the pandemic from the perspective of child and adolescent psychiatrists and psychologists in Switzerland. Methods: The survey was conducted anonymously, in German or French and online in April/May 2021. Mental health professionals working in child and adolescent psychiatry, psychotherapy services or independent practices were contacted by email. Results: N = 454 professionals completed the survey (176 child and adolescent psychiatrists and 276 psychologists). After an initial period of decreased demand during the lockdown in spring 2020, requests for treatment increased, considerably exceeding the demand pre-pandemic and reaching a peak in January/February/March 2021. The vast majority of professionals (78.2%) estimated that there was currently too little supply during the pandemic, which differed from the evaluation of the pre-pandemic situation (37%). A total of 65% of participants indicated that waiting time until the initiation of treatment increased during the pandemic, 41% reported their current workload to be somewhat higher and 44.5% much higher. Conclusions: For the first pandemic year, youth mental health professionals reported a large increase in the treatment demand and waiting time and a worrisome overload of treatment services. The COVID-19 pandemic has had a tremendous impact on the everyday life and mental health of children and adolescents. The pandemic has caused stress, anxiety, depression, and increased risky or social behavioral problems , and theAs another effect of the pandemic, the implementation of telemental health increased, although a number of barriers were identified, such as unclear funding for services, limited internet access, family/client reluctance, or problems linked to online sessions with younger children . A CanadThe present study aims to assess the impact of the COVID-19 pandemic on children’s and adolescents’ mental health, on the treatment for children and adolescents with mental disorders, and on care service providers during the first year of pandemic from the perspective of youth mental health professionals. In the present analysis, we focus on treatment supply, treatment conditions, and the mental health professionals’ situation during COVID-19. More specifically, we hypothesize that the professionals would report an increased demand for treatment in the long term and extended waiting times until the initiation of treatment in children and adolescents. In addition, we seek to assess the burden and challenges experienced by mental health professionals working with children and adolescents in Switzerland during the pandemic. Since the pandemic made the delivery of in-person psychotherapy difficult or impossible, we expect a sizable number of mental health professionals to recur to telemental health, which, before the pandemic, was very rarely used in child and adolescent psychiatry and psychotherapy in Switzerland. The survey was developed as a follow-up and complement to surveys for patients and their parents on the impact of the pandemic on mental health and media use ,15. AfteThe participants responded by selecting one answer from several options. If none of the options seemed appropriate, they could skip the respective item or specify an answer as a free-text comment. These free-text comments were subsequently analyzed and classified according to the principles of content analysis. While many children and adolescents across the globe had to stay at home for several months, receiving online schooling or no schooling at all, restrictions in Switzerland were less severe. With exception of a lockdown period from mid-March to mid-May 2020, primary schools were allowed to offer on-site schooling if COVID-19 protection measures could be implemented. Many schools already resumed in May 2020 with reduced numbers of students and reduced hours of presence. Nevertheless, secondary schools generally continued to rely on digital classes and homeschooling, and most leisure or group activities were not permitted. There was no further complete lockdown in Switzerland after spring 2020, despite a serious second wave with high incidences of infections in autumn 2020.A total of 454 professionals completed the survey. This corresponds to a response rate of 24.3%. The majority were from the German-speaking part of Switzerland, 14.4% were from the French-speaking part, and 0.4% were from the Italian-speaking part . CompareWhen the different time periods of the pandemic were compared in terms of treatment demand, a relevant decrease (indicated by 45.6% of participants) was limited to the time of the lockdown, in spring 2020. All other time periods were marked by an increased demand for treatment. The winter/spring 2021 period clearly emerges as the time with the greatest increase, with 60.1% of participants indicating a much higher demand than before the pandemic .According to 33% of participants, the demand increased by up to 50% more than usual, and 24.9% of participants stated a 50 to 100% higher demand than usual . Moreove= 360). For responses given as a time range , which was the case in about 40%, the mean value of the range was used. This analysis resulted in a mean waiting time of 1.68 months (SD 1.49) before the pandemic and a mean waiting time of 3.57 months (SD 3.72) in March/April 2021. This difference was highly significant . However, it should be noted that the averages do not adequately reflect the wide range of responses. We additionally calculated the mean waiting time, including responses from participants who provided both pre-pandemic and March/April 2021 waiting times (N = 23), or that appointments were cancelled because of quarantine measures (N = 11)  believed the treatment supply to be insufficient c. ResponCompared to before the pandemic, 41% of participants reported their current workload to be somewhat higher and 44.5% much higher a. For moParticipants reported that particularly stressful aspects of their work were the difficulty of communicating with patients while wearing a mask or via telemental health (very or extremely burdensome for 27.3%), the worry of no longer being able to meet the needs of the patients (26.2%), and the accumulation of patients with acute crises (25.3%) . In the However, when asked whether there were also any positive aspects of the pandemic, 61% of the participants agreed. With regard to work, the most frequently mentioned positive aspects were the familiarization with digital techniques and methods of telemental health (N = 128). Telemental health and digital technology included the advantages of being able to conduct sessions with all family members more easily than would be the case in on-site meetings, being able to work from home (N = 35), and having the opportunity for continuous education online (N = 28) .Almost 70% of the participants N = 317) reported currently using telemental health for sessions with patients or their parents a.  and a peak in demand in the first quarter of 2021. This peak came with a considerably increased waiting time for the initiation of treatment and a general shortfall in treatment supply for children and adolescents with mental health problems. Notably, as the two professional groups, psychiatrists and psychologists, did not differ in their evaluation of insufficient treatment supply, these findings cannot be explained by specific professional policies. It is important to point out that the increased need for treatment peaked with a certain delay to the course of the pandemic. In Switzerland, the lockdown was confined to a relatively short period at the beginning of the pandemic and without a strict curfew, and its effects on the well-being of children and adolescents with mental health problems were comparatively mild . For manRegarding their own situation, most respondents indicated that their workload peaked in January/February/March 2021, which is not surprising as it parallels increased demands for treatment. The unusual accumulation of crisis/emergency interventions and the fear of being unable to retain the quality of treatment due to work overload were among the most stressful worries. It was also reported that the triage of whom to accept as an emergency and whom to put on a waiting list was extremely burdensome. In contrast, fear for one’s own health or the health of one’s family members was seldom indicated at this stage of the pandemic, although several respondents mentioned an increasing depletion of their own resources. An increased risk of burnout or psychological distress for mental health professionals under COVID-19 was described , but resThe percentage of almost 70% of respondents who administered online therapies at some time during the pandemic was remarkable, as the use of telemental health, with exception of phone consultations, seemed very uncommon in child and adolescent psychiatry and psychotherapy in Switzerland before COVID-19. This percentage of almost 70% equals that reported in other surveys with mental health professionals during the pandemic . The prTaken together, mental health professionals reported an alarming increase in treatment demand, a large increase in the waiting time before the initiation of treatments, and an increasing work overload, all peaking after one year of the pandemic, in January/February/March 2021. Despite the fact that Switzerland, in comparison to other European countries, only had a short phase of lockdown and school closures, children and adolescents had to face an increase in mental health problems. Health care professionals warned that the lack of school routine and other support provided in the school context might particularly affect children and adolescents with pre-existing mental illness or vulnerabilities , and it The results of the present study indicate that the shortage of mental health care and services of children and adolescents already existed before the pandemic. This gap has considerably widened since then, due to an alarming increase in the need for treatment during the pandemic. While it was imperative to take measures to protect vulnerable groups during the pandemic, too little attention was paid to other vulnerable groups, namely children and adolescents at risk of mental disorders or with pre-existing mental problems. To counteract this problematic situation and to prevent similar developments in the future, actions have to be taken on various levels.In the short and medium term, psychiatric and psychotherapeutic care in clinics and practices should be expanded even further to increase treatment capacity. Being forced to perform a triage of patients due to limited resources, as described by many professionals in this survey, is challenging and stressful. It is professionally and ethically difficult to decide which one of two patients may be more in need of treatment, especially as seemingly less acute cases can turn soon into emergencies if they are not treated in time. A more systematic networking of mental health professionals including those in independent practice and a system to report available outpatient and inpatient therapy places could be helpful in times of crises, but, of course only, if free capacities are still available. At the same time, services must be adapted more specifically to the needs of children and adolescents, for example, with the expansion of low threshold access for brief crisis interventions, to home treatment services with a focus on the support of families and on the environment of the child or adolescent. It should be avoided that adolescents in acute crisis have to be triaged into adult psychiatry due to a shortage of inpatient treatment places in child and adolescent psychiatry.In the long term, the focus should be placed on primary and secondary prevention. All professionals working with children and adolescents can make an important contribution here, e.g., teachers, pediatricians and general practitioners or school social workers and counselors. Professional training for the strengthening of mental health and early recognition of mental disorders to prevent psychiatric disorders and chronicity is recommended. Programs to ensure psychological stability or promote resilience, such as sports or recreational programs, should be expanded and made accessible to all—in particular, to socially disadvantaged families.In the event of a recurrent coronavirus crisis, professionals should be better prepared to offer alternative treatment options to maintain therapeutic/psychiatric care. Access to telemedicine should be offered early and facilitated, both for the patients and for mental health professionals, without having to struggle with technical difficulties or barriers to financing. However, only ensuring funding for online therapies does not solve the problem with younger or suicidal patients not eligible for telemental health.Children’s and adolescents’ mental health—especially in times of crises—should be treated as a priority. Child and adolescent psychiatrists or psychologist, and not just adult psychiatrists, should be members of advisory bodies to the government. As far as we know, the situation in child and adolescent psychiatry and the impact of the pandemic on children’s and adolescents’ mental health differed considerably from those reported for adult psychiatry in Switzerland.Finally, better recognition of the work of mental health professionals and better protection in times of pandemic is urgently needed, especially in mental health care for children and adolescents. In normal times, this could mean a remuneration comparable to that of other medical disciplines, during pandemic, e.g., a prioritization of vaccination, just as for other health professions.Further research should analyze whether or to what extent countries with more liberal COVID-19 policies still have an advantage regarding the mental health outcomes of their youth, compared to countries with strict home confinement measures and prolonged school closures. Keeping the schools open during the pandemic was probably the best alternative for all concerned, but obviously not sufficient to guarantee good mental health for children and adolescents at risk.The study presents several limitations. All responses were explicitly based on subjective impressions of mental health care professionals, not on objective data, and may thus be biased. In addition, information on pre-COVID-19 conditions and the different periods of the pandemic were collected retrospectively and may be subject to cognitive bias. Information on the age and gender of participants, which might influence the responses, was not collected. Additionally, we did not assess the use of pre-pandemic telemental health. The response rate was relatively low, albeit satisfactory, considering the difficult context of an anonymous survey for a group of people with very little time and work overload. The proportion of professions and language regions of the participants seems to roughly be in agreement with the proportion of mental health care professionals in this domain, to the best of our knowledge, but the representativeness of the study remains questionable. Although the survey items were clearly aimed at the changes brought about by the pandemic, other causes for the reported changes cannot completely be ruled out. Finally, we focused here exclusively on the situation of mental health professionals and did not discuss the reasons or the nature of the increased demand for treatment.Taken together, after one year of the pandemic, mental health professionals indicated a large increase in the treatment demand for children and adolescents with mental health problems and a dramatic shortfall of treatment supply, which many already deemed to be insufficient before the pandemic. We also conclude that for the comparative analysis of the pandemic effects, it is crucial to consider the timing of the assessment and the timing of measures taken by the respective national/local governments to combat the pandemic. Research on mental health related to a first lockdown should not be confounded with the results on the long-term consequences of the pandemic. The fact that the negative effects of the pandemic on young people’s mental health seem to have accumulated over time should prompt vigilance regarding the possible future long-term effects.


Pasta is an increasingly popular food worldwide and different formulations have been developed to improve its nutritional profile. Semolina that is high both in protein and gluten content is recognized as the ideal raw material to produce conventional dry pasta. When alternative raw materials are used, an understanding of the relationship between processing variables and pasta quality is crucial in order to optimize the redesign of the production process. This review aims to: (1) investigate the main challenges of the pasta-making process, highlighting the processing variables that most affect pasta quality; and (2) indicate the unknown factors that influence the pasta-making process and which need to be studied. After overviewing the last twenty years of research in the pasta sector, the interplay/relationship between processing variables and pasta quality is examined, together with the main innovations proposed for each step of pasta processing. An analysis of all the variables involved in the process and their influence on each other will elucidate how to optimize certain parameters to ensure the production of pasta with the desired characteristics. Triticum durum Desf.)  . What these studies have in common is the awareness that pasta can be considered an important and interesting carrier for bioactive compounds, especially dietary fiber. For example, a portion of 80 g of whole wheat pasta provides up to 6 g of the recommended daily 25 g of dietary fiber for those with energy intakes of less than 2000 kcal/day . From thIn a recent study, Cecchini et al.  elaboratAs regards processing, pasta-making is a continuous process, consisting of three main steps: dosing and mixing, kneading and shaping (by extrusion or sheeting), and drying. Despite the vast amount of bibliographic information on pasta, the debate over the question “Does the raw material or the pasta-making process matter more?” is still ongoing, also considering that wholegrain pasta is becoming more and more popular. It is well known that durum wheat semolina characterized by high protein content and strong gluten—able to withstand the physical stress occurring during extrusion, drying, and cooking—is the ideal raw material for high-quality pasta . HoweverSo far, the effect of each step of the pasta-making process has been evaluated with respect to its impact on pasta structure and quality ,30,31,32In the first step of pasta-making, semolina and water are carefully dosed and blended together to form a hydrated mixture with a total moisture content of about 30–32%. The amount of water added to semolina (27–29 g/100 g) is far from the hydration level used in bread-making , which is essential for promoting the even water dispersion inside the solid mass. In other words, in the pasta-making process, hydration ensures the correct solvation of proteins while gluten is only partially developed at this stage. Only appropriate protein hydration will assure—in the following steps—the formation of a continuous gluten network capable of restricting and preventing excessive starch swelling during cooking. Besides the amount of water, other factors may affect semolina hydration and thus the physical properties of pasta and its quality. Among them, protein, ash, fiber, and damaged starch content, as well as particle size . SemolinParticle size also plays a key role in wholewheat semolina. A positive correlation between the geometric mean diameter of flour particles and the cooking behavior of wholemeal semolina pasta  was assessed. At the same time, broad particle distribution negatively impacts pasta cooking quality . As regaThe amount of water added to semolina and its uniform dispersion inside the mass are critical parameters because mistakes made in this first operation can hardly be corrected in the following steps of pasta-making. In the case of uneven hydration (often caused by limited amounts of water), the final product may form the characteristic white spots which indicate a potential weak structure and decrease the quality of the product in terms of both appearance and texture. On the contrary, excessive hydration results in a sticky product, with low mechanical resistance and poor cooking quality . De la Peña and Manthey  evaluateAs a result of the decrease in extrusion pressure and mechanical energy, the diameter and density of the spaghetti decreases as hydration increases. Since dough at 30% hydration shows high consistency and resistance to flow, it was hypothesized that these systems could bring high pressure to bear on the Teflon coatings of the die inserts, compressing them and thus resulting in an increase in the diameter of extruded spaghetti . On the The hydration operation is even more critical when grains other than durum wheat or ingredients are included in the formulation. Re-formulating pasta makes it essential to study and optimize the level of hydration as this affects not only the characteristics of the dough (in particular its processing during the extrusion phase) but also the quality of the final product. Fiber, due to its high hydrophilicity, competes with proteins for water absorption; it could, therefore, reduce the water available for their solvation, compromising the formation of a uniform network. Furthermore, the worsening of pasta quality in the presence of fiber is due to the dilution effect of gluten (as a result of the lower amount of semolina in the formulation), as well as a discontinuity in the protein network caused by the interference of the non-starch polysaccharides . Considering the effect on the formulation, wholemeal semolina doughs showed higher viscosity, even at high levels of hydration (34%), compared to the reference sample (refined semolina). The bran fractions in the wholemeal sample would require more water to show the same rheological behavior as the reference sample . SimilarA possible solution to limit the competition for water between fiber and proteins could be to hydrate the two ingredients separately  before extrusion, as proposed by La Gatta et al. . From a Since hydration is mostly influenced by the physicochemical characteristics of the raw material , to ensu® and Bakmix® mixing systems  were compared with a conventional system  [® would promote the rapid (1–2 s) and uniform hydration of the surface of each individual semolina particle, followed by a rest phase (10 min) before extrusion. In the Bakmix® system, hydration is divided into two phases: 2 s in the Premix® system and 18 s in an extruder operating at low pressure (about 106 Pa). All the mixing processes result in products (fresh pasta obtained by two shaping approaches: extrusion or lamination) of acceptable quality and characterized by good cooking behavior, with cooking loss values lower than 3 g/100 g pasta.Among the other solutions suggested to improve the initial steps of the pasta-making process, the effects of the innovative Premixrci Spa) . The cenIn general, the new systems facilitate a more uniform distribution of water throughout the flour compared to traditional mixing but in a significantly shorter time; therefore, a well-developed protein matrix may not be formed . This re®; Storci S.p.a., Collecchio, Italy), in place of the traditional shaft and blade mixing tank. The belt mixer consists of a slow-moving conveyor belt. Since the dough is not subjected to any kind of mechanical action, the system drastically reduces the oxidation of the raw materials, which maintains the bright yellow color of semolina. In addition, compared to the traditional mixer, the belt mixer is easier and faster to clean, as stated by the device manufacturer. In the new pasta-making plans, the pre-mixer system is connected to a stabilization belt mixer  and SME are useful for evaluating the overall process. They are correlated with and influenced by the same variables, including the level of hydration, the speed of the screw and the extrusion temperature. Since, as is known, the pressure varies during the advancement of the dough along the screw , studies usually consider the SME parameter. Specifically, the focus is on the relationship between hydration level and SME. An overly hydrated dough, being less compact, would require a lower SME and would not pose sufficient resistance, inside the extrusion cylinder, to promote protein aggregation and therefore a satisfying formation of gluten . On a maThe variables of the extrusion process  appear to be unrelated  or weaklThe extrusion temperature also influences the quality of pasta in terms of cooking losses. Indeed, the increase in temperature in the extrusion cylinder from 35 °C to 70 °C leads to an increase in cooking losses up of to 250% . If semoOptimal extrusion conditions vary according to the formulation and how the design of the experimental approach optimizes the process. This holds true for various formulations. For example, for the production of wheat spaghetti enriched with soy flour, the best product (in terms of color and cooking behavior) is obtained when about 57 g of flour, 12 g of soy and 31 g of water are extruded at 35 °C and 40 rpm . In the Sitophilus oryzae (L.) (Coleoptera Dryophthoridae) and therefore is a more likely place for insects to incubate compared to Teflon-extruded pasta [As regards die extrusion, it is known how the coating material of the die inserts affects the appearance of the pasta: Teflon gives the product a smooth and bright yellow appearance, while bronze inserts produce a rough surface . Furthered pasta .Some research compared the effect of the type of shaping on the structure and quality of the dough. Among these, the study by Zardetto and Dalla Rosa  involvedLastly, the study by Carini et al.  comparedThe different effect of the shaping processes on the quality of pasta is even more evident when using common wheat, as it is less able to stand the physical stresses occurring inside the press. The greater compactness of the structure obtained by extrusion corresponds to longer cooking times and slower water absorption, which, however, does not translate into better cooking behavior for dry pasta. This feature is clearly linked to the different organization of proteins. The gluten network, in fact, appears more continuous in the case of laminated pasta, probably thanks to the lower stress and the action of the rollers that more effectively align the protein fibrils. The result is a firm pasta without stickiness. Finally, in the case of a semolina-based formulation enriched with buckwheat (25%), the preferred technology involves the extrusion of a sheet whose thickness is gradually reduced by rolling . This prParticular attention is paid to the final step of the pasta-making process: the drying step. As is well-known, the drying process gives dry pasta its final characteristics of physical and chemical stability and allows its shelf life to be extended. The overall cooking quality of the final product  is the result of several simultaneous phenomena within pasta, whose extent depends on both raw material characteristics and the temperature–moisture conditions applied during drying. The variables that regulate this phase , in fact, can be modified by proposing various combinations (and as many drying cycles) in order to promote the coagulation of proteins and improve the cooking behavior of pasta . In partOver the years, the scientific community’s interest has changed as summarized in The focus of studies shifted from the effects of high- and low-temperature drying cycles on the denaturation of proteins and pasta quality ,59,60, aAs regards the effect of drying temperature on pasta quality, high temperature drying cycles (>65 °C) are effective in improving the sensory characteristics of pasta , especiaCountless studies have addressed the issue of starch digestion in pasta, in view of its relevance to controlling glycemia, but only a few studies have addressed the issue of protein digestion in pasta. Some of these reports have addressed protein-digestibility issues related either to the use of different wheat varieties or to the impact of processing on it ,64,65,66Findings on the relation between the products of the Maillard reaction  and protein digestibility ,69 as weUsing wholegrain semolina instead of refined semolina led to increased furosine content, affecting sensory traits. Indeed, pasta with high furosine content  is perceived to be more bitter than pasta with low furosine content  . On the Most innovations related to the drying stage have aimed at reducing drying times, without affecting pasta quality. In this context, recent work has been carried out on the use of microwaves . The process of drying pasta by microwaves has proven to be very efficient, not only as regards shortening the drying time but also because it is possible to have a final product without fissures, with higher firmness and a lower degree of gelatinization than pasta dried by hot air ,73,74. IMore recently, the effect of vacuum drying  on pasta quality has been assessed in semolina pasta at lab scale ,76. CompAt the industrial level, new drying lines capable of reducing the drying time to about 3 h for long pasta and less than 2 h for short pasta are available, with a significant reduction in the size of the plant. Although the superiority in quality of the product obtained from these systems is claimed by the company that manufactures the drying equipment, no data has been shared with the scientific community. Indeed, most of the studies on processing are mainly conducted by the manufacturers of pasta and/or pasta plants, and thus are subjected to company regulations related to privacy.In this section, the main knowledge gaps related to pasta-making process are summarized.Since each step in the pasta-making process impacts on the quality of the final product, it is extremely important to know how process variables and pasta properties relate in order to better predict and control product quality. The first steps of the pasta-making process—hydration of semolina and shaping of the dough by extrusion under pressure or roll-sheeting—have so far received less attention than the drying phase. The greater interest in the latter is justified by the modifications (which are well known and quantified) induced by temperatures above 60 °C on both proteins and starch properties and their great impact on pasta quality at both sensory  and nutritional  levels. A second reason for the apparent minor interest in the hydration and shaping phases is linked to the difficulties that their monitoring entails. In fact, the low humidity (between 30 and 32%) of the mixing system and, consequently, its low degree of smoothness inside the press, makes it difficult to study dough behavior during extrusion. Moreover, the mixture is uneven in temperature and viscosity ; these dFinally, to further complicate observations, process variables  are affected by dough properties  and any change in one of the processing variables influences all the others in an interdependent way. In other words, when a parameter changes, the system responds in a very complex way. A further aspect regards the high degree of heterogeneity of extrusion systems due to their different specifications  that could have different repercussions on the workability of the mixture and on the characteristics of the finished product. Some studies applied prediction models of dough behavior by modifying extrusion variables . HoweverMoreover, among the studies focusing on the extrusion step, none associates process conditions with the nutritional quality of the finished product, in terms of digestibility and/or the formation of resistant starch. This aspect is left to the reformulation of the product using modified starches or raw materials rich in amylose. In this context, Camelo-Méndez et al.  summarizFurther gaps come from the pasta quality evaluation side. Most of the studies aimed at understanding the relationship between processing conditions and pasta quality assessed the quality of the final products by evaluating changes in color, cooking loss and texture evaluated by instrumental analysis rather than sensory analysis. Besides requiring less time for the analysis, other factors account for the preference of instrumental tests: (1) a sensory evaluation testing facility should be set up to minimize the interactions occurring between participants; (2) consumer-based sensory evaluation measures liking of foods and requires large numbers of individuals; and (3) descriptive analysis requires trained tasters to evaluate the intensities of attributes found in foods .Finally, most of the studies devoted to understanding the relationships between process conditions and pasta quality considered only semolina as the raw material to be used. Although it is easy to understand the reasons for this choice, worldwide  hard wheat flour is the main raw material used for dry pasta. Indeed, it is widely available and less expensive than durum wheat. However, despite the great interest in describing the bread-making performance of common wheat, it is still unknown what features common wheat should have and what processing parameters should be adopted to obtain dried pasta of desirable quality.Dry pasta can be considered an iconic Italian food and is nowadays appreciated around the world for its nutritional and sensory features, as well as for its versatility. Although an established technology, the pasta-making process needs to be optimized, taking into consideration changes in lifestyle and consumer awareness. A healthy diet, resilience and sustainability are the keywords of the era we are living in. Thus, recent interest in fiber-enriched formulations, as well as in underexploited grains necessitates the re-examination, re-thinking and re-adjustment of the conditions currently used for preparing pasta. Attention should be paid to extrusion to ensure the formation of a protein structure that can withstand cooking.In this context, because the extrusion process is of great interest from an industrial point of view due to its high productivity and versatility, more resources must be allocated to the study and optimization of this phase of the process. More than this would be an opportunity to further the growing interest in alternative raw materials to satisfy increasing nutritional demands and foster environmental, social and economic sustainability, especially in light of future climatic changes that may limit wheat availability and/or deteriorate its quality.


The medical autopsy  is a highly specialised medical procedure, which requires professional expertise and suitably equipped facilities. To ensure high standards of performance, the Working Group of Autopsy Pathology of the European Society of Pathology (ESP) suggests a code of practice as a minimum standard for centres performing medical autopsies. The proposed standards exclusively address autopsies in adults, and not forensic autopsies, perinatal/or paediatric examinations. Minimum standards for organisation, standard of premises, and staffing conditions, as well as minimum requirements for level of expertise of the postmortem performing specialists, documentation, and turnaround times of the medical procedure, are presented. Medical autopsies should be performed by specialists in pathology, or by trainees under the supervision of such specialists. To maintain the required level of expertise, autopsies should be performed regularly and in a number that ensures the maintenance of good practice of all participating physicians. A minimum number of autopsies per dedicated pathologist in a centre should be at least 50, or as an average, at least one autopsy per working week. Forensic autopsies, but not paediatric/perinatal autopsies may be included in this number. Turnaround time for final reports should not exceed 3 weeks (14 working days) for autopsies without fixation of brain/spinal cord or other time-consuming additional examinations, and 6 weeks (30 working days) for those with fixation of brain/spinal cord or additional examinations. The medical autopsy is a postmortem external and internal examination of the human body, performed with the intention of identifying or confirming cause of death and underlying diseases. In addition, the medical autopsy is of major importance for bereavement follow-up, quality assurance of clinico-medical practice, monitoring of diseases and treatments, cause of death statistics and public health monitoring, rehearsal of medical procedures, education of medical students and other types of health personnel, and for research purposes. The recent pandemic has confirmed the important role of autopsies in the understanding of diseases Table .Table 1TThe medical autopsy is a highly specialised medical procedure which requires professional expertise and suitably equipped facilities. From a historical view, autopsies have formed the basis of evidence-based medicine , 2. HoweA revival of the medical autopsy will require adjustments to and efforts on all the abovementioned factors, but will also have to focus on high standards of performance and quality of the procedure itself. Thus, as a first step in the revival process, common guidelines with the aim of standardizing the procedure are essential.With the exception of more or less updated guidelines in textbooks on autopsy pathology, published minimum standards for the medical autopsy procedure are few and mostly presented as detailed instructions on how to write the reports, or as scenario-based and forensically related guidelines , 11. ExiThe widely varying practice of autopsy performance in Europe raised concerns in the working group Autopsy pathology (WGA) of The European Society of Pathology (ESP). A survey among the ESP members showed general shortcomings in the knowledge on local or national autopsy rates, a fact proven by serious shortcomings in European statistics, which fail to depict autopsy activity in major European member States , 19. TheWith the purpose of presenting a set of minimum standards and recommendations for the performance of medical autopsies within Europe, WGA appointed in 2019 an ad hoc working group with expert members from ten European countries, working in academic and non-academic institutions. The adopted standards of the WGA are outlined below, after having been subject to discussion at the 32nd Congress of the ESP and XXXIII International Congress of the IAP .It is important to point out that these guidelines reflect current best practice and are subject to constant evaluation. Due to limited published research on the importance of quality of medical autopsies in recent years, it is not possible to grade any of the recommendations. Therefore, they are based on the professional experiences of the members of WGA.It is emphasized that the proposed standards for adult autopsy service intend to support pathologists in the quest for more resources for this important part of medical quality assurance and shall not be understood as restrictions to perform autopsies if proposed minimum standards are not met by smaller departments.The suggested minimum standards are primarily developed for autopsies in adults, and not for forensic autopsies or perinatal/paediatric examinations, although similarities are obvious.A first step in the revival process is to raise awareness for medical autopsies to colleagues within the own institution, and address the public. Hospital administrators recognizing the potential of autopsies in the hospital profiling on medical quality are as essential as dedicated pathologists, maintaining close collaboration with the clinicians and promoting knowledge in the wider public. The abovementioned approach has proven effective. A Swiss study has shown that raising awareness for the benefits of postmortem examination in the clinical departments by involving their management, combined with a systematic teaching of interns and residents about the importance of autopsy, resulted in doubling of autopsy rates within 6 months . BuildinHistorically, the medical autopsy procedure has been performed or supervised by any specialist in pathology, to whom competence has been assigned automatically after performance of a defined minimum number of autopsies during their pathology training. In consequence of the rapid decline in autopsy rates, the curriculum of core competency training requirements in pathology has been adjusted to a lower number of postmortem examinations. Contrary to the recommendation for basic competence in autopsy practices outlined by the European Union of Medical Specialists (UEMS), several European countries have removed the minimum requirements for autopsy training in its entirety , 23. ThuCentres performing medical autopsies should be part of a medical institution and have a dedicated staff, administration, and facilities.The autopsy practice should be identifiable in the organizational chart of the institution, and the institutional role of the autopsy procedure stated in policy documents.Yearly reports of the autopsy activity should be published on the institutional website and should include a number of autopsies , autopsy rates, and turnaround times and should include any research activities.Information material suitable for the public should be easily available on the institutional website.The autopsy practice should be under the leadership of a specialist in pathology with sufficient experience in autopsy practice.The medical autopsy should be integral part of clinico-pathologic conferences.Medical autopsies should only be performed by a specialist in pathology, or by a trainee supervised by a specialist in pathology.To maintain expertise, autopsies should be performed regularly and in a number that ensures the maintenance of good practice of all participating physicians. A minimum number of autopsies per pathologist in the autopsy-performing group in a centre should be at least 50, or as an average, at least one autopsy per working week. Forensic autopsies, but not perinatal autopsies may be included in this number.Quality is a product of high throughput training, and quantity is a result of organization and visibility. The classical medical autopsy is performed in hospitals all over Europe, and with great variation in frequency. UEMS recommends an autopsy frequency as low as 5–10% of hospital deaths, an estimate based on the continuously declining numbers . There aThe ongoing SARS-CoV-2 pandemic has demonstrated the importance of sufficient, competent, and dedicated staffing, at all times and levels . AutopsyNot only autopsy staff members, but also other visitors as clinicians and medical students, are exposed to potential infections in the autopsy room. To minimize the risk of inflicted disease, recommended basic vaccination programs should be followed by all autopsy-attending individuals. Staff members with chronically reduced immune systems should not attend regular work in the autopsy room, unless medically approved.Centres performing medical autopsies should have designated permanent staff, of a size ensuring the level of activity.Job descriptions should be available for all personnel groups and should include required education, norms for ethical standards, rules for conflict of interests, and confidentiality.All personnel in contact with the deceased or with access to autopsy facilities must follow recommended occupational health surveillance programs .Procedures in the event of accidental contamination should be outlined and easily available.Vaccination recommendations for medical professionals are constantly subject to reevaluation. The recommended vaccinations in public health programs also vary between the different European regions . HoweverCentres performing medical autopsies should have premises dedicated to and suitable for autopsy procedures at a minimum of biosafety level 2, with controlled access to the autopsy rooms. The centres should have the possibility to reject autopsies, for instance, when biological risk is found too high for protection of their personnel or equipment of facilities. In case of rejection of a request for autopsy, the centre should provide alternative approaches  or refer the autopsy request to another centre with sufficient biosafety level.The transportation of bodies from and to the morgue should be performed in areas not accessible to the public.Wardrobes with shower facilities must be available.Eyewash and other necessary first aid equipment must be present in the autopsy room.Security rules and procedures in case of accidents must be easily accessible.Protective clothing , clear visor, gloves (disposable with long sleeves and protective), boots, and FFP3 masks should be used at all times.Tools and equipment should be easy to clean and provided with mechanical protection and suction devices, to avoid unnecessary exposition to aerosols, dust, and injuries. Disposable equipment should be available.The facilities should have systems for storage of fixed and frozen biomaterials, and easy access to freezers (− 20 °C and − 80 °C).Fixation fluids  and fixated materials should be handled in ventilated areas.Cameras and safe IT storage facilities for photographic documentation should be provided.Autopsy facilities geographically separate from the procedure-requesting clinicians should be adequately equipped for a live video demonstration of gross findings and postmortem meetings.The autopsy procedure should be recognized as a form of medical examination, which, although not performed during the patient’s lifetime, requires basic health facility precautions. A revival of the autopsy thus should be reflected in a modernization of facilities, especially in regard to hygiene and safety, storage possibilities, and the implementation of adequate IT tools. The SARS-CoV-2 pandemic has highlighted the need for an update on personal protection and hygiene measures in the autopsy room , 31, 32.Centres performing medical autopsies should have access to necessary additional analytic methods and/or expertise from other specialties, especially within microbiology, toxicology, clinical chemistry, and radiology.Access to expertise from specialised areas within pathology, in particular within neuropathology, cardiovascular pathology, and forensic pathology, should be ensured.Guidance in the use of ancillary testing or involvement of additional expertise should be incorporated in guidelines.Ancillary testing may be crucial in achieving a correct postmortem diagnosis. A Norwegian study on the quality of medical autopsies in 2014 found that ancillary testing for viral infections was rare . One expWritten autopsy guidelines should be an integral part of department guidelines. Up-to-date guidelines are important at a number of levels and help prevent errors and waste of resources.hygiene and biosafety procedures, including disposal of material, bodily fluids, and tissuessafe storage of requisitions, reports, results, biomaterialsmorgue procedurescommunication with next of kin, clinicians, and non-medical personnel procedures in questions of hereditary diseases and genetic examinationsdifferent types of autopsy scenarios, including possible forensic scenarios Centres performing medical autopsies should have written guidelines on:The involvement of clinicians in the immediate aftermath of the procedure is important for the discussion of findings and ensures that one can still return to the body, should new information evolve. The clinico-pathological correlation and open discussion of discrepancies therein represent a valuable tool for improving communication with the clinicians, in addition to the educational aspect , 37, 38.A standardization of the reporting ensures provision of all important elements and eases the reading and comparison of clinico-pathological findings, also in regard to future research , 40, 41.Not all elements of the final report are required to be forwarded to the clinicians. One may consider which parts of the report are necessary to substantiate the conclusion. One example is photographic documentation, in case the autopsy report is being made available to the next of kin of the deceased. However, to allow the clinicians to validate the autopsy procedure and the diagnoses given, the report should as a minimum contain information about all types of sampling, tests, and documentations.Gross findings should be demonstrated to clinicians immediately after each autopsy procedure, if necessary by means of photographic or multimedia documentation. A preliminary written report should be given within two working days after the autopsy.The preliminary report should list all findings in an orderly manner and should address each clinical question. The preliminary report should include an estimate of the expected turnaround time of the final report.The final report should be in the form of a standardized autopsy protocol, ensuring a standardized setup of gross organ descriptions and areas and microscopic descriptions of studied organs and tissues.Cause of death, including chain of events from underlying disease to immediate cause of death or condition, and other major diagnoses and findings should be reported according to the WHO guidelines/International Statistical Classification of Diseases and related health problems (ICD).If necessary, additional comments should be given to explain the chain of events leading to the death of the patient, to answer any questions of the clinician, and/or to comment on major differences between the clinically estimated cause of death and patho-anatomical findings.There are examples of national jurisdictional provisions on the consent that may cause problems in obtaining samples for microscopy routinely . JurisdiID of body, date of birth, date of death, consignor (name and address), date and time of autopsy, ID nr of autopsy, name of pathologist, and autopsy technician.Legal requirements .Purpose of autopsy/clinical question.Clinical history.Type of autopsy .External examination.Internal examination, including gross description.List of sampled organs and/or lesions.Location of tissue samples taken for microscopy and their identification (block ID).Microscopic descriptions.Ancillary studies  and their results .Any photographic documentation.Any retained organs, with an explanatory note about the reasons for retainment.Other types of storage .An addendum should contain a reference to the relevant legislation and give a general description on the storage length and timeline of destruction of biological material and remnants from the autopsy.In recent years, turnaround times of autopsy reporting are generally too long, although being essential for clinicians and the bereaved, and representing important indicators of quality , 46, 47.Guidelines on turnaround times vary. CAPs guidelines recommend issuing of the final report within 30 working days for routine cases and 90 days for complex cases, although the latter is not defined . The sugMedical autopsies without fixation of the brain/spinal cord or additional examinations should be reported within a maximum of 3 weeks (14 working days).Medical autopsies with fixation of brain/spinal cord and/or additional examinations should be reported within a maximum of 6 weeks (30 working days).If a revival of the medical autopsy is to succeed, the procedure must be considered equal to a medical examination. The processing of autopsy material does not differ from tissues from the living but is often not considered a priority. The WGA is the opinion that turnaround times for medical autopsies should be defined according to what is technically possible to achieve, not according to what is practised today. The recommended turnaround times do not include the day of autopsy performance.


Safe and accessible water services for hand hygiene are critical to human health and well-being. However, access to handwashing facilities is limited in cities in the Global South, where rapid urbanisation, service backlogs, lack of infrastructure and capacity, and water scarcity impact on the ability of local governments to provide them. Community participation and the co-production of knowledge in the development of innovative technologies, which are aligned with Water, Sanitation and Hygiene (WASH) principles, can lead to more sustainable and socially-acceptable hand hygiene systems. This paper presents the outcomes of the testing of the Autarky handwashing station, a technology that provides onsite treatment and recycling of handwashing water, in an informal settlement in Durban, South Africa. The transdisciplinary research approach adopted enabled the participation of multiple stakeholders with different knowledge systems in the framing, testing and evaluation of the system. The process of co-producing knowledge, as well as the outcomes of the testing, namely high levels of functionality and social acceptability of the technology, supported the WASH principles. The evaluation revealed that the Autarky handwashing station is a niche intervention that improved access to safe and appealing handwashing facilities in an informal settlement. Its novel design, socially desirable features, reliability and ability to save water increased its acceptance in the community. The testing of the system in a real-world context revealed the value of including communities in knowledge production processes for technology innovation. Further work is required to ensure that real-time monitoring of system function is feasible before such systems can be implemented at larger scale.  •Access to handwashing facilities is limited in cities in the Global South.•The field-tested handwashing station addresses both social and environmental goals.•The system is a niche intervention that supplements state-provided water services.•Knowledge co-production achieves greater acceptability of innovative systems.•Participation in service delivery improves state-citizen relations and builds capacity. Addressing WASH challenges aligns with the Sustainable Development Goals (SDGs), particularly SDG 3 , SDG 6 , and SDG 11 (sustainable cities and communities). Handwashing with soap and water is widely recognised as being essential in reducing disease transmission. However, in 2018, only 28% of people in the least developed countries had access to handwashing facilities with water and soap . Safe anwww.autarky.ch).The responsibility for providing water for hand hygiene varies across the world. In cities in the Global South, local governments face numerous challenges in providing access to safe and accessible water for the urban poor. These include increasing service backlogs due to rapid urbanisation and natural population increase; growing informality in cities; water scarcity, exacerbated by climate change; lack of human and financial resources to deliver services; and failures in service provision due to a lack of community engagement in their development . As a reThis paper presents the results of the field-testing of the AHWS for six months in Quarry Road West informal settlement in Durban, South Africa, using a transdisciplinary (Td) research approach. The field-testing comprised both the technical testing of the AHWS, and a community-centred social assessment, with all stakeholders framing the problems to be addressed . This ap22.1A range of technologies have been developed that enable handwashing in places that lack access to a piped water supply. Tippy taps are simple, economical handwashing stations, made with commonly available materials. They work by using the foot to press a lever, which tips water out from a raised container . Non-govwww.autarky.ch). The system can thus provide safe water in places that do not have sufficient water resources, or that lack infrastructure to distribute clean water and collect the wastewater. The AHWS is also relevant in contexts where green technologies are being supported, and where existing service provision needs to be supplemented.The AHWS, developed by the water research institute Eawag, in collaboration with the design office EOOS, is a promising technology, as it provides onsite recycling of handwashing water without the need for external water input Fig. 1). The participation of residents of Quarry Road West informal settlement in the Palmiet Catchment Rehabilitation Project (PCRP), as well as ongoing research conducted in the settlement through a partnership between researchers from the School of Built Environment and Development Studies (UKZN), the municipality and the community, has built a platform of social learning and knowledge co-production . This pl3In February 2019, the technology was introduced to the community and an engagement and pre-evaluation process was initiated. This phase ran until April 2019, when the AHWS was installed in the community and opened for use (17 April 2020). The AHWS was tested for three months and a post evaluation survey was conducted at the end of July 2019.3.1The methodologies used for this study were approved by the Research Ethics Committee at UKZN .3.2The prototype used in this testing consisted of the frontend user interface and the backend water recycling technology . More deThe frontend was designed by the Austrian design office EOOS. It consisted of an aluminum casing covered by a large mirror at eye level. Users could wash their hands at three water valves . Two foaming soap dispenser  provided biodegradable soap. The used water was collected in a custom-made steel handwash basin, from where it entered the water treatment system.For use in a public setting, signage and constructive means were used to manage residents' use of the system and to prevent them from drinking the water. The constructive means comprised (i) a solid casing impeding access to critical parts, (ii) the use of self-closing water valves to avoid dripping taps, and (iii) the implementation of a flat-bed hand wash basin minimizing the distance between the basin and the taps to avoid users drinking from the taps or bottling water. Signage on how to use the system was attached to the mirror. Additionally, each tap was labelled with “do not drink the water” stickers. Community members were also informed by the Community Liaison Officer (CLO), field engineer and community leaders that they should not drink the water. The tap design, the signage and information that passed through community networks, ensured that no one drank the water. Two posters located next to the AHWS provided information on the technical functioning of the system and on the motivation for testing it in a field trial (including details of a contact person). All information was provided in English and isiZulu.3.3E. coli concentrations, turbidity and total suspended solids (TSS) defined by EWS , pH, residual chlorine,  EWS see  in order3.43.4.1The Quarry Road West informal settlement was selected for (i) being representative of informal settlements in South Africa, and for having (ii) well-established research relationships with the university and eThekwini Municipality, as well as (iii) internal participatory governance structures, which support decision making in the community. Because of the Td approach adopted, the social assessment team ensured that the leadership of the community, and through their structures, community members, were consulted to determine if they were willing to test the AHWS in their community.A focus group was held in the settlement on 4 February 2019 to present the idea of testing the AHWS in the settlement to the community. At this meeting, attended by team members from UKZN, Khanyisa Projects and the technology developers, community members asked questions about the technology and how it functioned, which proved useful to the project team. Community members were concerned about the safety of the water and wanted to understand details of how the system worked. They wanted to know how it inactivated pathogens and what safety mechanisms had been included in the system to ensure it would shut down should there be a malfunction. These safety mechanisms are now being developed and tested further in the laboratories at Eawag, partly as a result of the input received from the Quarry Road West informal community.The social assessment team proposed that community members should experience using the AHWS before making the decision about testing it in their community. The community leadership from Quarry Road West informal settlement were invited to visit UKZN, where the AHWS was being tested in the university community. A workshop was held on campus which included an explanation of the functioning of the system by a field engineer, and the use of the AHWS.Based on the focus group and the visit to UKZN, the community leadership, in consultation with the community, agreed to test the AHWS in Quarry Road West informal settlement. The location for the AHWS was selected by the community, considering the site requirements of the project team. The site needed to have (i) a footprint on flat ground, (ii) high foot traffic, (iii) access to an electrical connection, (iv) be easy to access for maintenance, and (v) be relatively secure. The AHWS was located along a main road in a place where the movement of people converges because of access to transport (taxi and bus stops) and spaza shops.3.4.2a) was conducted by UKZN social scientists and twelve trained community-based researchers (7 to 12 April 2019). The sample size was 10% of the settlement population. The survey comprised of both open- and closed-ended questions. Households were sampled using clustered systematic random sampling, with 27 households selected from each of the four sections. The survey determined residents' access to water and sanitation services and their perceptions and attitudes towards them. The researchers wore Autarky-branded T-shirts to promote the AHWS, to legitimize and acknowledge their position as they conducted the research, and to encourage residents to use the system  that had used the AHWS were surveyed. A further 20 households who had not used the AHWS were surveyed, which meant the total sample for the post-evaluation survey was 91 households, as saturation had been reached. Households were selected using clustered systematic random sampling, with 23 households selected from each section. The survey assessed residents' experiences of using the system and their acceptance of it. Respondents could provide more than one answer to many of the questions, and so provided a wide diversity of responses. The subscript refers to each sample (na: pre-test or nb: post-test). In cases where only a sub-set of respondents answered the questions, the percentage of the number that responded was calculated out of the sub-set of the sample . The questionnaire data was coded and analysed using descriptive statistics in SPSS.The post-test survey, which included both open- and closed-ended questions, was undertaken in July 2019, where 71 households  for chlorine production, the AHWS functioned without the need for regular maintenance. However, the electrolysis recirculation pump broke down on two occasions (days 19 and 63 of the field test) and required replacement. The AHWS was closed to the public from day 63 to 65, until the damaged pump was replaced. Apart from this closedown, water was available throughout the testing.Nearly all users (97%) indicated that the water in the AHWS was clear. The clarity of the water was explained in more detail by 13% of respondents, who said that it looked like natural or normal water, and that it was clean. Almost all the users stated that the water did not smell (97%). Most users (82%) were happy and willing to use recycled water, with 8% unwilling to use it, 5% uncertain, and 5% did not respond. Most respondents (87%) stated they did not have any concerns about the safety of using recycled water in the AHWS, as they were satisfied with evidence of its safety (33%), the system had a filter (22%), it saved water (22%), it was clean (5%), and was only used for handwashing (5%). The main concern of the sub-group who felt the water was not safe (12% of users) was related to the potential of pathogens (“germs”) being present in the water (21% of the sub-group). Others (13% of the sub-group) stated that it was acceptable, as it was only used for hand washing, and 4% stated that once they got used to using it, they were less concerned about safety issues.Almost all the residents that participated in the survey (97%) indicated that saving water by using treated recycled water for handwashing is an important need in Quarry Road West informal settlement. There was a high response (82%) by those who participated in the study as to why they thought this was important . Overall4.2In analysing how well the AHWS aligned with the community context and needs, it was important to understand hygiene practices in Quarry Road West informal settlement prior to the installation of the AHWS. Residents of Quarry Road West informal settlement have access to water through communal taps, CABs and a few self-installed, illegal household taps a. The waMany respondents stated that soap is important in handwashing to prevent the spread of disease and for good health, with 86% indicating that they used soap when they washed their hands, and 9% stating that they did not use soap. A majority of respondents (84%) said that they always have soap available to wash their hands. However, residents also stated that they do not regularly use soap to wash their hands in the CABs (69%), as soap is not available there. Only 25% of residents stated that they washed their hands with soap in the CABs. When they did wash their hands with soap, they reported that they had brought the soap to the CAB themselves (69%), with only 10% indicating that the municipality had provided it.The AHWS was used regularly by residents, with 96% reporting having used it at least once while it was installed, and 45% of residents making use of it every single day (regularity of use). Most residents (59%) reported on days that they used the AHWS, they used it multiple times (frequency of use).The AHWS represented a new form of technology. The attractiveness, innovation and novelty factor were the most significant reasons why residents used the AHWS, followed by hygiene-related reasons see . The locOther reasons listed by residents were that it was easy to use after going to the toilet (12%), and because the AHWS was clean and the water was clean (9%).Residents predominantly used the AHWS after using the toilet (90%), before eating food (20%), after handling waste (12%) and when they returned home from being outside (11%) see c. A rang4.3Research on the social acceptability of the system revealed that both design and functionality shaped resident's response to the system . CommuniResidents who used the system, were asked to comment on the particular elements of the system, including their design and how well they worked. This included the soap, soap dispenser, taps and sink. The respondents stated that the tap, sink and soap worked well and were easy to use for adults, but that the height of these three elements were challenging for children. A child-sized handwashing station could be developed in the future, particularly if the system is to be used in primary schools or step-up blocks could be attached to the base of the unit, in line with one of the taps for children. The details of these results are presented in the Supplementary information section (SI C).4.4The Td research approach ensured that community members in Quarry Road West informal settlement formed a central part of the research process. Community members were included in a focus group to describe and discuss concerns about the testing of the AHWS before it was installed in their community. Approval to test the system was obtained from the community leadership in consultation with all residents of the settlement. Community members were included in all research processes and worked with UKZN researchers in collecting data on water and sanitation practices pre and post the installation of the system. The CLO, who was selected by the community, was appointed through Khanyisa Projects to monitor the system from a socio-technical perspective in the community and alert the engineers when issues arose. The CLO provided information to community members on how the system worked and on how to use the taps. The different stakeholders who were included in the co-production of knowledge and their level of contribution are shown in The benefits of including community members in the testing process from the outset and their investment in the system was evident in at least two important ways during the testing process. Firstly, discussions were held between the engineers and social scientists prior to the installation of the system as to whether the AHWS should be secured using a security gate at night to stop people stealing or vandalizing the steel sink, the mirror and the soap dispenser, as these security risks are experienced in CABs. The social scientists argued that if the community were included in the process of establishing the AHWS in Quarry Road West informal settlement and in determining its location, this would not be necessary, as the community would feel a sense of ownership of the system. A decision was made in consultation with the community leadership that no security measures would be used to secure the system. Over the three months that the AHWS was present in the community, no elements of the system were stolen or damaged. Secondly, five days after opening the AHWS for use (22 April 2019), a major flood devastated Quarry Road West informal settlement. Protests were held a week later to pressurize the municipality to respond to the poor living conditions, lack of adequate services and the flood disaster in the settlement. Municipal services were vandalized during the protests. However, no damage was done to the AHWS. This was highly symbolic as it revealed the commitment of the community to the testing of this system. They felt included in the establishment and testing of the system, wanted to be part of leaving a legacy in improving WASH technologies, and hence they did not target the AHWS in the protests.Trust is critical in ensuring the social acceptability of new technologies and part of building trust is good communication and transparency about how systems work. The residents of Quarry Road West informal settlement trusted information on the AHWS from the field engineers (27%), the UKZN researchers (27%) and those who had used recycling systems before (16%). They had limited trust in knowledge transferred to them from the municipality, which reflects the politics of and tensions between the state and citizens in service provision in the city. Media and learning about recycling at school played a role (8%), but was not dominant. This data reveals the importance of trusted knowledge brokers, such as universities, in scaling up innovative water and sanitation solutions.Residents were asked how they felt about being test site for the AHWS. They were very happy to test the technology in their settlement see . RespondThe majority of respondents (56%) stated that they were given enough information on how the water treatment process worked, while 39% said they were not given enough information and 6% reported they did not know. The majority of the respondents (59%) wanted to have more scientific knowledge on the system .Table 6WResidents are interested in the science and technology of water and sanitation services. They would like to know how they work (from beginning to end), why they are being tested in the municipality and how they should use them. This reveals that they are not passive recipients of sanitation services, but rather engaged citizens who would like to be included in the knowledge processes of water and sanitation services and that they take responsibility for their own safety, health and well-being.4.5The outcomes of the testing process revealed that the AHWS addressed several elements of equality in service provision. The technology has been tested and used in both a public setting in Zurich, Switzerland, and in an informal settlement in Durban, South Africa, which reveals its appropriateness across a range of socio-economic and development contexts. The quality of the system and its high level of innovation and design were appreciated by the informal settlement residents see , Table 55The broader dimensions of sustainability are used to assess the value of the AHWS field test in a context of transforming and scaling up access to WASH services that are socially acceptable, environmentally sustainable and financially viable, and which are based on good governance.5.1xa kunjeThe AHWS had a high level of social acceptance in Quarry Road West informal settlement, with residents stating that they wished it could become a permanent feature. A community member made a plea for its return, during the first hard lockdown of the COVID-19 pandemic, stating that “I miss the Eawag machine in Quarry Road, Understanding the “cultural and historical context, needs, perception and preferences of households”  was impoThe urban poor often perceive the implementation of innovative technology in low-cost housing projects, townships and informal settlements in South Africa as being a cost saving strategy of providing inferior technology to the poor, that middle- and upper-income groups would not accept. This results in resistance to solar water geysers, urine-diversion dehydration toilets and non-sewered sanitation systems . What waThe residents' positive response are due to the high quality of materials used, the design features, the explanation and hence understanding of how the technology worked, the testing process, which ensured that community members could engage with and give their response to the system, and the collaboration of multiple stakeholders in an open and transparent process to assess its acceptability.5.2The AHWS not only considered principles of social sustainability and governance, but also addressed elements of environmental sustainability. Community members are very aware of water scarcity in Durban. As the AHWS saves water and provides handwashing water when the municipal system fails, it was rated as a valuable technology for informal settlements. At the same time, they raised concerns about the safety of the water in terms of pathogens and viruses, wanting to know how they could be sure that pathogens are inactivated. This supported a co-engagement process in the testing of the AHWS, as residents wanted to engage in the science of the technology to make sure they understood how the system worked, which is important in the future scaling up of water and sanitation technologies.Contrary to the common assumption that the urban poor are less concerned about the environment, environmental benefits were raised by residents of Quarry Road West. The main reason why residents thought water recycling is important was water scarcity, with almost all respondents indicating that saving water by using treated recycled water for handwashing water is an important need in the settlement.Interestingly, none of the respondents mentioned the second major environmental advantage of the handwashing station: the onsite treatment of wastewater. Research on the relationship between the community and the Palmiet River has been conducted through the PCRP and residents are aware of the impact of poor services in the settlement on the river. Through the CABs, Quarry Road West informal settlement is connected to bulk infrastructure, but the removal of wastewater in the settlement is a major problem, as there are no formal drainage systems, other than those that service the CABs and communal taps, and these regularly overflow in to the settlement. Unmanaged wastewater in the settlement pollutes the environment and impacts on people's health and mobility.5.3The field test of the AHWS showed that this technology could provide safe and appealing recycled water in a real-life implementation. In the context of Quarry Road West informal settlement, there is the mandate of eThekwini Municipality to provide informal settlements with water services on the one hand and the willingness of the residents to use novel water recycling technologies on the other. While it may not be realistic to implement high-technology systems in private applications , such WASH services could be made available in public locations such as schools, clinics or informal settlements, or all other contexts in which operation and maintenance can be ensured.The flexibility of the system, namely easily installed, mobile, independent from large infrastructure networks and serving a number of people at the same time, makes it highly appropriate for informal settlement contexts. A local service provider can install this system quickly . The system can be implemented where residents need a handwashing station i.e., also inside a settlement, and not only at its edges where the main infrastructure is.The AHWS tested in Quarry Road West informal settlement is a prototype, and is currently not fit for large-scale implementation due to high construction costs and need for optimization of system components for long-term use. Key factors will be to increase the system robustness and decrease the power requirements. Before larger-scale implementation, the technology will thus need to undergo an engineering redesign to allow for mass production using modern industrial methods. When mass-produced, the cost for manufacturing such small-scale water reuse technologies can presumably be kept at a relatively low level, especially if compared to capital-intensive centralized treatment approaches .Implementing water reuse technologies alone will not ensure long-term access to safe water. Operation and Maintenance (O&M), and the governance of O&M, are crucial elements of sustainability. The absence thereof is a frequent cause of failure of WASH service facilities , and theHowever, the testing of the AHWS also showed that technology can and does sometimes fail. During the field tests, these failures were noticed quickly, as a field engineer was on site to take water samples and to do regular system checks. Designing technologies for low maintenance is important but is not sufficient for systems where users could potentially get sick from using insufficiently treated water. If such decentralized water recycling technologies are to be implemented at a larger scale, it will be necessary to implement monitoring systems that provide real-time information on the system functioning and allow for direct intervention in case of treatment failures . The neeThe field test in Quarry Road West informal settlement revealed that the residents wanted to know how the technology works and were aware of potential risks linked to the use of recycled water. This interest could be used to improve operation and build user's trust in novel technologies. In addition to an automated monitoring system, which measures parameters that may be difficult for non-scientists to interpret, there could be benefits in providing local residents (“citizen scientists”) with simple means to check the water quality. In the case of the AHWS, this could for instance be colorimetric tests for measuring the free chlorine concentration that could provide direct and easily interpretable information on the hygienic water quality. While citizen science is increasingly used in water quality monitoring, for instance to estimate the quality of freshwaters , we woulIn the testing of the AHWS, the combination of a local and trusted CLO on site and a technician passing by twice per week proved successful, as problems were reported quickly and the trained technician had sufficient knowledge on how these could be solved. However, this reflects exceptionalism, as maintenance of water and sanitation services becomes challenging in cities that are rapidly urbanising. EWS uses community-based caretakers to maintain the CABs and so this approach is already established in the city. However, the quick turn-around time for maintenance may become a challenge.6The testing of the AHWS integrated technology with real-world contexts and challenges. The Td approach adopted enabled the participation of multiple stakeholders with different knowledge systems in the testing and evaluation of the system. The research revealed that the AHWS was a niche intervention, as it met a range of community needs, including hand hygiene and personal grooming, in an equitable way, filling a gap in water and sanitation provision. The system was well-located and easy to use, convenient, and supported people's desire to practice good hand hygiene. The AHWS met higher-level social needs of equality and belonging, as residents appreciated having a robust, innovative and attractive system in their neighbourhood. Community members benefited from the co-engaged social learning process, as they were included as researchers in the assessment of water and sanitation practices in the settlement and the assessment of the system, which in turn led to greater community investment in the sustainability of the system and improved knowledge of water and sanitation challenges in their settlement. The AHWS is a valuable niche intervention for informal settlements, and would be appropriate in rural areas and schools in the Global South. The next challenge is to scale up industrial production of this technology and make it commercially viable for implementation both in the Global South and North.Catherine Sutherland: Conceptualization, Methodology, Investigation, Formal analysis, Writing – original draft, Writing – review & editing, Visualization, Supervision. Eva Reynaert: Conceptualization, Methodology, Investigation, Formal analysis, Writing – original draft, Writing – review & editing, Visualization. Rebecca C. Sindall: Conceptualization, Methodology, Writing – review & editing, Supervision, Project administration. Michel E. Riechmann: Investigation, Writing – review & editing, Visualization. Fanelesibonge Magwaza: Investigation, Writing – review & editing. Juri Lienert: Investigation, Writing – review & editing. Sibongile Buthelezi: Investigation. Duduzile Khumalo: Investigation. Sifiso Dhlamini: Writing – review & editing. Eberhard Morgenroth: Writing – review & editing, Supervision. Kai M. Udert: Writing – review & editing, Supervision, Project administration, Funding acquisition.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


This study enriches the literature on entrepreneurial decisions by investigating the antecedents of the synergetic use of causal and effectual logic. Based on entrepreneurial metacognition and emotional complexity theories, we argued that the emotional complexity of an entrepreneur, referred to as the granular experience of, or variety in, experienced emotions during the entrepreneurial task, would contribute to the synergetic use of decision logic. With survey data gathered from 218 Chinese entrepreneurs, we found that entrepreneurs with higher emotional complexity are more likely to adopt two types of entrepreneurial logic in tandem, and cognitive flexibility mediates this positive relationship. Thereby, this study helps to unravel some of the complexities behind the choice of decision logic of entrepreneurs. We found that entrepreneurial emotional complexity is positively related to causal and effectual logic synergy, and cognitive flexibility mediates this relationship.We aspired to make three contributions through this study. First, the core contribution is introducing emotional complexity as a critical antecedent to the synergetic use of causation and effectuation, which addresses the shift in research focus from simple emotion to mixed/complex emotions . MoreoveEntrepreneurs can opt for different cognitive strategies  to cope Causation “takes a particular effect as given and focus on selecting between means to attain this effect” , p. 245,Even though effectual logic describes a decision process distinct from causal logic, these disparate cognitive strategies are not mutually exclusive within an individual. Based on the conception of causation and effectuation suggested by As “the condition of uncertainty is often not stable over time” , p. 789,Recently, empirical studies have confirmed that causation and effectuation could be adopted simultaneously or alternately under some conditions, and such synergy would be beneficial . SpecifiWhile combining causal logic and effectual logic is helpful for the success of a start-up, the road to their synergy is still vague. There are a few exceptions such as An entrepreneur is a “motivated tactician” , p. 13 wEven though causation and effectuation follow essentially different principles and assume fundamentally different behaviors, both effectual and causal decision logics are cognitive strategies focused on the “means” of entrepreneurial tasks . Here, cAccording to the study by The idea of metacognition is helpful in our investigation because the metacognition process describes the learning process of an entrepreneur, which can contribute to the cognitive flexibility of an individual. In this research, we followed the conceptualization of Through the active reflections of the awareness of an individual and control over the cognitive strategies employed to make assessments, judgments, or decisions, an entrepreneur can learn and incorporate new information into their consciousness and make better judgments in their selection of cognitive strategy  . In brieHypothesis 1: Cognitive flexibility of entrepreneurs positively relates to their synergetic use of causal and effectual logic.Since the entrepreneurial context is extreme (in terms of time pressure and uncertainty) and an entrepreneur often highly identifies with the venture , the entAccording to “affect as information theory,” emotion is often associated with confidence or doubt about cognitively accessible information, leading to greater or lesser reliance on their current beliefs, expectations, and inclinations of individuals . For exaHowever, emotional experience is rarely pure and simple but often mixed and complex . People Individuals differ in their emotional complexity . Some maIn contrast, entrepreneurs with emotional complexity would have mixed emotional experiences. They may first interpret the challenge as a signal of their incompetence and feel a litter sorrow. Then, they reconsider the situation and their previous related emotional knowledge; they categorize the challenge as a test of their pressure-bearing capacity and guess that the funder might be interested in their project. Finally, they felt energized or even pleased to meet the challenge.Furthermore, according to the entrepreneurial metacognitive theory, emotional experience is an essential type of metacognitive experience . It servIn summary, as “the selection of causal versus effectual reasoning may depend, in part, on the extent to which an entrepreneur employs metacognitive processes” , p. 225,Hypothesis 2: Emotional complexity of entrepreneurs positively relates to their synergetic use of causal and effectual logic.The human brain works as an active “Bayesian filter” to optimize energy efficiency by anticipating the needs of the body in a situation and preparing emotions and actions to meet those needs in advance . An indiMoreover, an emotional-complex entrepreneur is more likely to have extra regulatory resources for the metacognition process. Emotions are related to the most appropriate categories for the sensory experience aroused by external or internal events, which would prepare an existing policy for an individual to take action . While eTo summarize, an entrepreneur with emotional complexity would have more accurate and prudent predictions for his sensory experience and more regulatory resources for his metacognitive process. He would view his cognitive strategies from multiple directions and know more about the pros and cons of each decision logic. He would be more agile to switch his cognitive strategy to fit the dynamic changes in the environment. Thus, we formally stated as follows:Hypothesis 3: Emotional complexity of entrepreneurs positively relates to their cognitive flexibility.Therefore, we proposed a theoretical model in which cognitive flexibility, as a mediator, connects the emotional complexity of entrepreneurs to their collaborative use of the two decision logics see also .Hypothesis 4: Cognitive flexibility mediates the positive relationship between emotional complexity and the synergetic use of effectual and causal logic.We tested our theoretical model using the data collected from entrepreneurs in Sichuan, a southwestern province of the People’s Republic of China (PRC). We recruited entrepreneurs who attended the small business owner training program from a local university and invited them to complete the questionnaire. To ensure the quality of the survey, we told the participants that the purpose of this research was academic and promised that the company and personal information would not be released to third parties for commercial use. Furthermore, we asked the participants to leave their contact information and assured them that we would share the research findings with them in the future if they completed the questionnaire. During one lecture of the training program, 265 entrepreneurs attended, and 236 completed our questionnaires (response rate of 89.05%). After eliminating invalid samples, we retained 218 questionnaires . The average age of participants is 27.84 years (SD = 7.53), and 57.1% of them are female. The majority of our participants are highly educated, 32% with a college diploma and 53.9% with a bachelor’s degree; the average firm age is 2.47 years (SD = 3.35), and the average number of employees is 15.85 (SD = 15.85); the companies primarily engage in culture and art (16%), information technology (12.3%), and wholesale and retailing (12.3%). The demographic features of our participants were similar to those of relevant studies from China .The questionnaire used in this research is based on the related theoretical and empirical literature. The questionnaire was administered in Chinese but originally developed in English. We translated the questionnaire from English to Chinese by the translation-back procedure of We measured causation using a scale adapted from We measured effectuation using a scale adapted from Following the practice of Emotional complexity is conceptualized as the ability of an individual to have a granular experience of, or variety in, experienced emotions during the emotional episode. Accordingly, we adapted the Range and Differentiation of Emotional Experience Scale (RDEES) developed and validated by Cognitive flexibility is defined as the ability of individuals to broaden the scope of their attentional span to attend to divergent perspectives and engage in a balanced consideration of those different perspectives . CognitiWe controlled for several background characteristics of the entrepreneur that would influence the choice of decision logic. At the individual level, we controlled for the gender of an entrepreneur , age (in years), and education . We also controlled for the prior work experience of an entrepreneur (0 = new to the industry and 1 = have worked in the industry).Firm age (in years), size (number of full-time employees), industry sector, and subjective performance are control variables at the firm level. Prior research has found that the industry sector  and ventFollowing the suggestion by The established instruments were used to measure our constructs at the design stage, and the scales were arranged in counterbalanced question order. At the data analysis stage, Harman’s one-factor and latent-factor tests were used to evaluate the effect of common method variance.2(303) = 538.721; CFI = 0.922; RMSEA = 0.060], and the CFA result for one factor on which all items loaded showed a significantly worse fit .Harman’s one-factor test showed that the first factor explained 38.68% of the variance. A confirmatory factor analysis (CFA) with the independent, dependent, and mediating variables revealed a good fit [χThese results show that the common method bias may not be a serious problem in this research.Moreover, the results also show that the age of the founder is positively associated with the affordable loss subdimension of effectuation and negatively associated with experimentation. The education of the founder is positively associated with cognitive flexibility and negatively associated with the experimentation subdimension of effectuation.Hierarchical linear regression analysis was used to test our hypotheses, and the bootstrap method was used to test the mediating effect of the theoretical model. The results of the regression and mediation analyses are presented in We followed the procedures developed by b = 0.465, p < 0.000); thus, Hypothesis 3 is supported. In addition, after controlling the influence of cognitive flexibility of entrepreneurs , there is still a positive association between emotional complexity and the synergy of causation and effectuation ; thus, Hypotheses 1 and 2 are supported.b = 2.7343, SE = 0.449, and CI = 1.9123, 3.6809), which means that the mediating effect of cognitive flexibility can be assumed. Thus, Hypothesis 4 was supported.In Recently, several empirical studies have shown the synergetic effect of causal and effectual logic on venture performance . HoweverOur research makes several theoretical contributions to the literature.First, our core contribution is the introduction of emotional complexity as a critical antecedent to the synergetic use of causation and effectuation. Responding to the call from Second, by introducing emotional complexity theory, we addressed the call to shift from single emotion to complex emotions  and exteFinally, we advanced the entrepreneurial metacognitive theory by developing a novel theoretical link between emotional complexity, cognitive flexibility, and decision logic. Previous studies view the synergy of casual and effectual as an outcome of metacognitive functioning and propose that metacognitive experiences are especially likely to occur during intense emotional experiences , 2012. TThe results of this study should also raise entrepreneurs and educators’ awareness of the benefits of granular emotional experiences . We hopeThere are some limitations to this study that might open future research avenues.First, since the research design of this study is based on a cross-sectional survey, we can only confirm the correlation but not causality. Studies using longitudinal or experimental designs are needed to replicate our findings. Specifically, researchers could use the mediating experimental design  to test Second, we measured emotional complexity by asking entrepreneurs to characterize their emotional experiences in global and retrospective terms. There are several measurements for assessing the ability of an individual to identify or recognize affective feelings as differentiated emotional experiences . We recoThird, we conceptualized synergy as the conscious and proactive choice of decision logic of an entrepreneur. However, synergy might occur passively. For example, an entrepreneur may have to adopt casual and effectual logic in tandem to meet venture capital or incubator requirements . FurtherFourth, this research provides the emotional complexity of an entrepreneur to explain the emergence of synergy in the mind of an individual. However, synergy may arise from integrating team members with differentiated decision logic . TherefoThe 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 Southwestern University of Finance and Economics Ethics Committee. The participants provided their written informed consent to participate in this study.HC: literature review, methodology, and revision. QX: conceptualization, data collection, manuscript writing, and project administration. Both authors contributed to this study and approved the submitted version.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.