Inadequate sanitation in healthcare facilities: A comprehensive evaluation of toilets in major hospitals in Dhaka, Bangladesh.

BACKGROUND: Lack of access to functional and hygienic toilets in healthcare facilities (HCFs) is a significant public health issue in low- and middle-income countries (LMICs), leading to the transmission of infectious diseases. Globally, there is a lack of studies characterising toilet conditions and estimating user-to-toilet ratios in large urban hospitals in LMICs. We conducted a cross-sectional study in 10-government and two-private hospitals to explore the availability, functionality, cleanliness, and user-to-toilet ratio in Dhaka, Bangladesh. METHODS: From Aug-Dec 2022, we undertook infrastructure assessments of toilets in selected hospitals. We observed all toilets and recorded attributes of intended users, including sex, disability status, patient status (in-patient/out-patient/caregiver) and/or staff (doctor/nurse/cleaner/mixed-gender/shared). Toilet functionality was defined according to criteria used by the WHO/UNICEF Joint-Monitoring Programme in HCFs. Toilet cleanliness was assessed, considering visible feces on any surface, strong fecal odor, presence of flies, sputum, insects, and rodents, and solid waste. RESULTS: Amongst 2875 toilets, 2459 (86%) were observed. Sixty-eight-percent of government hospital toilets and 92% of private hospital toilets were functional. Only 33% of toilets in government hospitals and 56% in private hospitals were clean. A high user-to-toilet ratio was observed in government hospitals' outpatients service (214:1) compared to inpatients service (17:1). User-to-toilet ratio was also high in private hospitals' outpatients service (94:1) compared to inpatients wards (19:1). Only 3% of toilets had bins for menstrual-pad disposal and <1% of toilets had facilities for disabled people. CONCLUSION: A high percentage of unclean toilets coupled with high user-to-toilet ratio hinders the achievement of SDG by 2030 and risks poor infection-control. Increasing the number of usable, clean toilets in proportion to users is crucial. The findings suggest an urgent call for attention to ensure basic sanitation facilities in Dhaka's HCFs. The policy makers should allocate resources for adequate toilets, maintenance staff, cleanliness, along with strong leadership of the hospital administrators.

Is it selfish to be filamentous in biofilms? Individual-based modeling links microbial growth strategies with morphology using the new and modular iDynoMiCS 2.0.

Microbial communities are found in all habitable environments and often occur in assemblages with self-organized spatial structures developing over time. This complexity can only be understood, predicted, and managed by combining experiments with mathematical modeling. Individual-based models are particularly suited if individual heterogeneity, local interactions, and adaptive behavior are of interest. Here we present the completely overhauled software platform, the individual-based Dynamics of Microbial Communities Simulator, iDynoMiCS 2.0, which enables researchers to specify a range of different models without having to program. Key new features and improvements are: (1) Substantially enhanced ease of use (graphical user interface, editor for model specification, unit conversions, data analysis and visualization and more). (2) Increased performance and scalability enabling simulations of up to 10 million agents in 3D biofilms. (3) Kinetics can be specified with any arithmetic function. (4) Agent properties can be assembled from orthogonal modules for pick and mix flexibility. (5) Force-based mechanical interaction framework enabling attractive forces and non-spherical agent morphologies as an alternative to the shoving algorithm. The new iDynoMiCS 2.0 has undergone intensive testing, from unit tests to a suite of increasingly complex numerical tests and the standard Benchmark 3 based on nitrifying biofilms. A second test case was based on the "biofilms promote altruism" study previously implemented in BacSim because competition outcomes are highly sensitive to the developing spatial structures due to positive feedback between cooperative individuals. We extended this case study by adding morphology to find that (i) filamentous bacteria outcompete spherical bacteria regardless of growth strategy and (ii) non-cooperating filaments outcompete cooperating filaments because filaments can escape the stronger competition between themselves. In conclusion, the new substantially improved iDynoMiCS 2.0 joins a growing number of platforms for individual-based modeling of microbial communities with specific advantages and disadvantages that we discuss, giving users a wider choice.

Hospital wastewater (HWW) treatment in low- and middle-income countries: A systematic review of microbial treatment efficacy.

BACKGROUND: Proper treatment of hospital wastewater (HWW) is crucial to minimize the long-term effects on human health and aquatic ecosystems. However, the majority of HWW generated in low and middle-income countries (LMICs), is discharged without adequate treatment. This systematic review aims to fill the knowledge gap in LMICs by examining the efficacy of HWW treatment and the types of technologies used. METHODS: Studies included in the review offered valuable insights into the current state of HWW management in LMICs. Between 2000 and 2022, only 36 research studies focused on hospital-based wastewater treatment within LMICs. Data were extracted on wastewater treatment technologies in hospitals or healthcare settings in LMICs. Data on sampling techniques, effectiveness, microorganisms and risk of bias of included studies were recorded. RESULTS: A total of 36 articles met the eligibility criteria: mentioned about 1) hospitals 2) wastewater treatment 3) LMICs and 4) treatment efficacy. Twenty-two studies were conducted in Asia (22/36), 17 were conducted in countries with high Human Development Index. Constructed wetland, and activated sludge process were the most common technologies used in LMICs. A few studies utilized membrane bioreactors and ozone/UV treatment. Fourteen studies reported the concentration reduction to assess the microbial efficacy of the treatment process, 29/36 studies did not meet the national standards for effluent discharge. Reporting on sampling methods, wastewater treatment processes and efficacy of HWW treatment were at high risk of bias. Extreme heterogeneity in study methods and outcomes reporting precluded meta-analysis. CONCLUSIONS: The existing evidence indicates inadequate microbial treatment in low- and middle-income country hospitals, with this systematic review emphasizing the need for improvement in healthcare waste management. It underscores the importance of long-term studies using innovative treatment methods to better understand waste removal in LMIC hospitals and calls for further research to develop context-specific healthcare waste treatment approaches in these regions.

In vitro digestion of designed emulsions based on milk protein and guar gum systems.

There is a growing interest in designing novel food microstructures that can control nutrient digestion and provide satiety for tackling obesity. In this study, phase separated microstructures of skimmed milk powder (SMP) and guar gum (GG) were the main focus, and these can be considered as water-in-water (W/W) emulsions. Through the incorporation of oil into these systems, it was possible to form model systems of SMP-GG-OIL, showing the lipid phase within the protein phase within the polysaccharide phase. The in vitro digestibility of such phase separated model systems of SMP-GG-OIL with different microstructures was investigated using a pH stat method. Confocal laser scanning microscopy also revealed structural changes that occurred to the emulsified lipid droplets as they passed through a gastrointestinal (GI) model. The microstructures were created based on the tie-lines on a previously established phase diagram of SMP-GG, and shown to be able to control lipid digestion. For a selected tie-line, the lipolysis follows the order: protein continuous > bi-continuous > polysaccharide continuous system, at a certain level of oil addition. The mechanism involved in the lipolysis of the designed formulations/microstructures was dependent upon the protein, rather than GG, and was driven by the protein concentration. These findings provide insights for potential applications in functional food designing in the food industry.

Effects of different moisture contents on the structural and functional properties of cellulose with cell wall components in different citrus fibres.

This research used a multi-method approach to analyse the influence of different moisture levels (low, medium and high) on the structural and functional properties of cellulose with cell wall materials such as pectin, lignin, and hemicellulose present in citrus fibres. The influence of the drying and purification processes and the source of the citrus fibres on these interactions were also considered. A fluidized bed dryer results in a higher aggregation of cellulose fibres, which limits their interactions with water, pectin, lignin, and hemicellulose. Citrus fibre suspension produce by a alcohol washing in combination with a centrifugal drying process showed higher storage modulus (G'), loss modulus (G'') and water retention capacity. The compositions of the citrus fibres and the type of hydrogen bonding (analysed by FTIR) play a key role in generating stable rheological and thermal properties as well as controlling the moisture sorption behaviour of the citrus fibres.

A method for correcting underestimation of enteric pathogen genome quantities in environmental samples.

Exposure to enteric pathogens in the environment poses a serious risk for infection and disease. The accurate detection and quantification of enteric pathogens in environmental samples is critical for understanding pathogen transport and fate and developing risk assessment models. In this study, we successfully applied TaqMan real-time PCR assays to quantitatively detect five human-specific pathogens (Shigella/EIEC, Salmonella Typhi, Vibrio cholera, Norovirus, and Giardia) in samples from open drains, canals, floodwater, septic tanks, and anaerobic baffled reactors (ABR) collected in Mirpur, Dhaka, Bangladesh from April to October 2019. Overall, the grab and sediment samples showed low inhibition but the ultrafiltration samples collected from open drain had significantly higher (P = 0.0049) degree of PCR inhibition (median Ct = 31.06) compared to the extraction controls (Ct = 28.54). We developed a two-step method to adjust underestimation of pathogen quantities due to PCR inhibition and non-optimum PCR efficiency. Compared to other sample types, ultrafiltration samples demonstrated a wide range of concentration increase (1.0%-182.5%) by pathogens after adjusting for PCR inhibition and non-optimum efficiencies. These quantitative qPCR assays are successful in quantifying multiple enteric pathogens in environmental samples, and the adjustment method would be useful for correcting underestimates of pathogen quantities due to partial PCR inhibition and non-optimum efficiency.

Development of a separated-dough method and flour/starch replacement in gluten free crackers by cellulose and fibrillated cellulose.

Two strategies were combined and applied in this study to achieve a desired structure and texture of gluten free crackers and to reduce the calorie content. The first strategy is increasing structural heterogeneity of crackers and doughs and a separated-dough method was developed. A butter dough and a water dough were prepared separately and mixed together and the influence of mixing time was investigated. In the second strategy, which is the incorporation of a structuring material, powdered cellulose and fibrillated cellulose were incorporated in formulation to replace flour and pregelatinised starch with enhanced health benefits of low calorie and high fibre. Powdered cellulose played the role of the skeleton of the gluten free crackers. A laminar structure was observed in crackers when powdered cellulose was initially added to the butter dough. The crackers exhibit high thickness, hardness and fracturability and sharp sound emission which are typically observed in wheat crackers. Pregelatinised starch can be replaced by fibrillated cellulose at a lower addition level.

Effects of psyllium seed husk powder, methylcellulose, pregelatinised starch, and cold water swelling starch on the production of gluten free crackers.

The production of gluten free crackers is challenging because the formation of a gluten network is required. This study investigated the effects of psyllium seed husk powder (PSY), methylcellulose (MC), pregelatinised starch (PGS), and cold water swelling starch (CWSS) on gluten free crackers made of rice flour. The evaluations of pasting properties, dough rheological properties, textural properties, acoustic emissions, and structures were included in this study. Gluten free cracker doughs were more solid-like compared to wheat doughs based on their frequency dependence shown in the mechanical spectra. However, PGS significantly increased the fluid-like property and shapeability. The addition of MC at a high level significantly modified the pasting profile and a secondary swelling and breakdown might occur. As for the crackers, PSY and PGS crackers had comparable textural properties and sound release to wheat crackers, while CWSS crackers were slightly weaker. However, MC did not improve the textural properties compared to rice crackers because the interaction between the MC molecules was limited at the low water addition level, which limited its functionality in cracker making.

Faecal contamination of groundwater self-supply in low- and middle income countries: Systematic review and meta-analysis.

Self-supply is a ubiquitous response by households to the public water supply inadequacies found worldwide. Self-supply is invested in and managed by an individual household, accessible on-premises and unregulated. Vulnerability to faecal contamination is a concern due to reliance on low-cost technologies and shallow groundwater. This review aims to evaluate the evidence base on the safety of groundwater self-supply in low- and middle income countries in relation to faecal contamination. Differences in microbial water quality between source types, settings, countries and ownership were investigated. A search of peer-reviewed studies in low- and middle income countries was conducted in online databases, including PubMed, Web of Science, ProQuest and Environmental Complete. Studies were included if they had sufficient detail about the water samples to be related to groundwater self-supply, contained extractable data on faecal indicator bacteria (FIB) including thermotolerant coliform or Escherichia coli and were published in English between 1990 and April 2020. A total of 30 studies were included, resulting in 100 datasets and 26,981 water samples across the studies. FIB were present in 36% self-supply samples. The odds of FIB being detected was significantly higher for unimproved sources (OR=8.19, 95% CI [4.04-16.59], p<0.001) and for sources in low income countries (OR=3.85, 95% CI [1.85-7.69], p<0.001). Self-supply was significantly more likely to be contaminated than piped supply (OR=3.45, 95% CI [1.52-7.82], p=0.003). However, water quality was highly heterogeneous (I2=90.9%). Egger's test found no evidence of small study publication bias for self-supply compared to public supply. No evidence of bias due to lack of randomization or season was found, but study design and quality could potentially bias the results. To achieve Sustainable Development Goal 6.1 on safe drinking water for all, more attention is needed from governments to engage with self-supply and formulate balanced policy responses.

Flavour distribution and release from gelatine-starch matrices.

Microstructure design of protein-polysaccharide phase separated gels has been suggested as a strategy to nutritionally improve food products. Varying the phase volumes of a phase separated matrix may affect texture and overall flavour balance of the final product, which are both important for consumer acceptance. The aims of this study were to investigate how modifying the phase volumes of a gelatine-starch biphasic mixture affected aroma release, and how addition of sucrose affects phase separation, flavour distribution and aroma release. Biphasic gels of different microstructures with the same effective concentration of gelatine and starch in each phase were developed. Microstructure significantly affected aroma release in vitro but not in vivo when panellists (n = 5) chewed and swallowed the sample. Addition of sucrose (0-60%) to the biphasic mixture significantly reduced water activity, affected the microstructure and affected aroma distribution in each phase and subsequent release rates depending on the physicochemical properties of the aroma volatile. In general, affinity for the gelatine phase for the less hydrophobic, more volatile compounds was not significantly affected by sucrose concentration. Whereas an increased affinity for the starch phase for the more hydrophobic, less volatile compounds was observed with increased sucrose as the starch phase becomes more dispersed at sucrose concentrations between 40 and 60%. The results of this study may be of interest to researchers and industry to enable prediction of how reformulation, such as reduction of sucrose, to meet nutritional guidelines may affect the overall aroma balance of a phase separated food matrix.

Reducing sugar and aroma in a confectionery gel without compromising flavour through addition of air inclusions.

Sugar plays an important role in both the flavour and structure of confectionery. Targets have been set to reduce sugar; however, common strategies often result in changes in flavour and consumer rejection. In this study, an approach was developed to reduce sugar in confectionery gels by aeration, without significantly affecting perceived chewiness. Gelatine based gels with a 23% and 38% reduction in density were formulated using aeration. Mean bubble size was consistent across all gels (0.05-0.06 mm). Time-intensity sensory evaluation was carried out by a trained sensory panel (n = 10). With aeration, no significant difference in overall flavour perception was observed in the 23% and 38% reduced sugar and aroma gels. Air inclusions create a greater surface area, therefore accelerating mass transfer of volatiles and release of sucrose at the food-saliva interface. Consequently, we propose that less calorie dense products can be produced without compromising flavour by using gel aeration technologies.

Housing conditions and health in Indigenous Australian communities: current status and recent trends.

Ensuring sufficient and adequately maintained housing in Indigenous Australian communities remains an ongoing policy challenge for government, with major implications for the health of Indigenous Australians. This study sought to characterise the current status of housing conditions experienced by Indigenous Australians, with special reference to the Northern Territory. The assessment examined a range of indicators relating to crowding, dwelling condition, 'health hardware', and provision of maintenance and repairs. While acknowledging data deficiencies and inconsistencies, the analysis produced mixed results. There was evidence of a reduction in crowding but little observable improvement in the provision of maintenance and repairs. Some housing-related health outcomes have shown improvement, though these have tended to coincide with mass treatment campaigns. Achieving the goal of healthy homes - and ultimately closing the gap on Indigenous disadvantage - requires further investment in new houses that are appropriately designed and constructed, alongside an increased emphasis on cyclical maintenance.

Modelling faecal pathogen flows and health risks in urban Bangladesh: Implications for sanitation decision making.

Faecal-oral infections are a major component of the disease burden in low-income contexts, with inadequate sanitation seen as a contributing factor. However, demonstrating health effects of sanitation interventions - particularly in urban areas - has proved challenging and there is limited empirical evidence to support sanitation decisions that maximise health gains. This study aimed to develop, apply and validate a systems modelling approach to inform sanitation infrastructure and service decision-making in urban environments by examining enteric pathogen inputs, transport and reduction by various sanitation systems, and estimating corresponding exposure and public health impacts. The health effects of eight sanitation options were assessed in a low-income area in Dhaka, Bangladesh, with a focus on five target pathogens (Shigella, Vibrio cholerae, Salmonella Typhi, norovirus GII and Giardia). Relative to the sanitation base case in the study site (24% septic tanks, 5% holding tanks and 71% toilets discharging directly to open drains), comprehensive coverage of septic tanks was estimated to reduce the disease burden in disability-adjusted life years (DALYs) by 48-72%, while complete coverage of communal scale anaerobic baffled reactors was estimated to reduce DALYs by 67-81%. Despite these improvements, a concerning health risk persists with these systems as a result of effluent discharge to open drains, particularly when the systems are poorly managed. Other sanitation options, including use of constructed wetlands and small bore sewerage, demonstrated further reductions in local health risk, though several still exported pathogens into neighbouring areas, simply transferring risk to downstream communities. The study revealed sensitivity to and a requirement for further evidence on log reduction values for different sanitation systems under varying performance conditions, pathogen flows under flooding conditions as well as pathogen shedding and human exposure in typical low-income urban settings. Notwithstanding variability and uncertainties in input parameters, systems modelling can be a feasible and customisable approach to consider the relative health impact of different sanitation options across various contexts, and stands as a valuable tool to guide urban sanitation decision-making.

Compositional, thermal and water sorption properties of wheat flour: comparing wild-relatives v/s elite wheat varieties used in current plant breeding.

Plant breeders are focused on creating new varieties of wheat with enhanced yield potential without affecting the quality of wheat for food. In this study, four cultivated varieties of wheat, Triticium asetivum and two wild relatives of wheat; Triticum timopheevii and Triticum urartu were studied. The impact of starch and protein content on structural, thermal and water sorption properties of four main wheat cultivars in comparison to the wild relatives has been studied. Wild relatives of wheat required higher temperatures to initiate starch gelatinisation and amylose/lipid complex formation as compared to the four main wheat cultivars. The carbohydrate region in FTIR indicates structural differences (ordered and unordered starch) in the different varieties of wheat flour. The differentiation between wild relatives and main varieties is at the species level. Both wild relatives showed a noticeable difference in moisture sorption behaviour as compared with the 4 main cultivars, especially in terms of monolayer (M0) and the strength of water binding to the primary sites (C) values.

Perspectives from CO+RE: How COVID-19 changed our food systems and food security paradigms.

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Pathogen flows from on-site sanitation systems in low-income urban neighborhoods, Dhaka: A quantitative environmental assessment.

BACKGROUND: Despite wide usage of on-site sanitation, there is limited field-based evidence on the removal or release of pathogens from septic tanks and other primary treatment systems, such as anaerobic baffled reactors (ABR). In two low-income areas in Dhaka, we conducted a cross-sectional study to explore pathogen loads discharged from commonly used on-site sanitation-systems and their transport in nearby drains and waterways. METHODS: We collected samples of drain water, drain sediment, canal water, and floodwater from April-October 2019. Sludge, supernatant, and effluent samples were also collected from septic tanks and ABRs. We investigated the presence and concentration of selected enteric pathogens (Shigella, Vibrio cholerae (V. cholerae), Salmonella Typhi (S. Typhi), Norovirus Genogroup-II (NoV-GII), and Giardia) and presence of Cryptosporidium in these samples using quantitative polymerase chain reaction (qPCR).The equivalent genome copies (EGC) of individual pathogens were estimated in each sample by interpolation of the mean Ct value to the corresponding standard curve and the dilution factor for each sample type. Absolute quantification was expressed as log10 EGC per 100 mL for the water samples and log10 EGC per gram for the sediment samples. RESULTS: Among all samples tested (N = 151), 89% were contaminated with Shigella, 68% with V. cholerae and NoV-GII, 32% with Giardia, 17% with S. Typhi and 6% with Cryptosporidium. A wide range of concentration of pathogens [range: mean log10 concentration of Giardia = 0.74 EGC/100 mL in drain ultrafiltration samples to mean log10 concentration of NoV-GII and Giardia = 7.11 EGC/100 mL in ABR sludge] was found in all environmental samples. The highest pathogen concentrations were detected in open drains [range: mean log10 concentration = 2.50-4.94 EGC/100 mL], septic tank effluent [range: mean log10 concentration = 3.32-4.65 EGC/100 mL], and ABR effluent [range: mean log10 concentration = 2.72-5.13 EGC/100 mL]. CONCLUSIONS: High concentrations of pathogens (particularly NoV-GII, V.cholerae and Shigella) were frequently detected in environmental samples from two low-income urban neighbourhoods of Dhaka city. The numerous environmental exposure pathways for children and adults make these findings of public health concern. These results should prompt rethinking of how to achieve safe sanitation solutions that protect public health in dense low-income areas. In particular, improved management and maintenance regimes, further treatment of liquid effluent from primary treatment processes, and appropriate application of onsite, decentralised and offsite sanitation systems given the local context.

Toward Engineering Biosystems With Emergent Collective Functions.

Many complex behaviors in biological systems emerge from large populations of interacting molecules or cells, generating functions that go beyond the capabilities of the individual parts. Such collective phenomena are of great interest to bioengineers due to their robustness and scalability. However, engineering emergent collective functions is difficult because they arise as a consequence of complex multi-level feedback, which often spans many length-scales. Here, we present a perspective on how some of these challenges could be overcome by using multi-agent modeling as a design framework within synthetic biology. Using case studies covering the construction of synthetic ecologies to biological computation and synthetic cellularity, we show how multi-agent modeling can capture the core features of complex multi-scale systems and provide novel insights into the underlying mechanisms which guide emergent functionalities across scales. The ability to unravel design rules underpinning these behaviors offers a means to take synthetic biology beyond single molecules or cells and toward the creation of systems with functions that can only emerge from collectives at multiple scales.

A comprehensive investigation of gluten free bread dough rheology, proving and baking performance and bread qualities by response surface design and principal component analysis.

Contribution of methylcellulose (MC), psyllium seed husk powder (PSY), and water addition level to gluten free bread quality and correlations between dough rheological properties and bread qualities were investigated by response surface design and principal component analysis. The generalised Maxwell model was applied to estimate the relaxation frequency of gluten free doughs. The addition of PSY has a complex influence on pasting viscosity at high temperature and an additional peak was observed. MC significantly influenced dough extensibility and work of adhesion, which are good predictors of bread volume and textural properties. Other rheological responses are less significantly correlated to specific volume, but they are sensitive to formulation variations, reflect dough structures and stability, related to proving behaviours, and correlated to loaf concavity. An inappropriate combination of water and hydrocolloids might lead to problems such as low stability of doughs, overexpansion, and weak crumb structure at high water addition levels, or, in contrast, high rigidity of dough, a trap of excessive air during mixing, and restrained gas cell expansion with high hydrocolloid addition and low water addition.

Measuring consumer emotional response and acceptance to sustainable food products.

With current global challenges such as population growth, climate change and water scarcity, it is critical to develop sustainable strategies to achieve food security. One way to tackle this is by developing new products that use alternative and more sustainable ingredients. Bambara groundnut is a low-impact African legume as it can be grown on marginal soils and is resistant to high temperatures. The aim of this study was to investigate UK consumer acceptability and emotional response to snack products containing Bambara groundnut flour as an alternative sustainable ingredient. A key objective was to understand the contribution that measuring emotional response would reveal. Additionally the impact of extrinsic information on consumer acceptability and emotional response to snack products was investigated by sharing information concerning Bambara groundnut's sustainability and nutritional credentials. 100 UK participants were recruited to evaluate two biscotti and two cracker products. For each category a standard product made from standard ingredients sourced commercially, and one made replacing some of standard flour with Bambara flour were obtained. For each sample, participants were asked to rate their overall liking and emotional response based on sensory properties of the product (the blind condition). Participants were invited back for a second session, where they were informed about global resource challenges, and the sustainable features and nutritional value of Bambara, and which products contained this as an ingredient (informed condition). Under the blind condition, no significant differences in overall liking were observed between standard and Bambara products, indicating UK consumers accept the sensory properties of products that contain Bambara flour. Interestingly, the extrinsic information shifted consumer emotional response towards more positive emotions and less negative emotions when consuming products containing Bambara flour. It also made them felt less guilty when consuming the Bambara products, suggesting consumers engage with the idea of sustainable ingredients, and that this sustainable ingredient has potential for future new product development. It also highlighted the value of measuring emotional response for novel products to understand what may drive purchase behaviour when products are matched for liking. Food neophobia status did not impact product acceptability and emotional response between Bambara and standard products, however overall a lower emotional response was found for medium neophobic consumers in general who are more likely to evade novel products.