"Just as curry is needed to eat rice, antibiotics are needed to cure fever"-a qualitative study of individual, community and health system-level influences on community antibiotic practices in rural West Bengal, India.

OBJECTIVES: To understand community antibiotic practices and their drivers, comprehensively and in contextually sensitive ways, we explored the individual, community and health system-level factors influencing community antibiotic practices in rural West Bengal in India. DESIGN: Qualitative study using focus group discussions and in-depth interviews. SETTING: Two contrasting village clusters in South 24 Parganas district, West Bengal, India. Fieldwork was conducted between November 2019 and January 2020. PARTICIPANTS: 98 adult community members (42 men and 56 women) were selected purposively for 8 focus group discussions. In-depth interviews were conducted with 16 community key informants (7 teachers, 4 elected village representatives, 2 doctors and 3 social workers) and 14 community health workers. RESULTS: Significant themes at the individual level included sociodemographics (age, gender, education), cognitive factors (knowledge and perceptions of modern antibiotics within non-biomedical belief systems), affective influences (emotive interpretations of appropriate medicine consumption) and economic constraints (affordability of antibiotic courses and overall costs of care). Antibiotics were viewed as essential fever remedies, akin to antipyretics, with decisions to halt mid-course influenced by non-biomedical beliefs associating prolonged use with toxicity. Themes at the community and health system levels included the health stewardship roles of village leaders and knowledge brokering by informal providers, pharmacists and public sector accredited social health activists. However, these community resources lacked sufficient knowledge to address people's doubts and concerns. Qualified doctors were physically and socially inaccessible, creating a barrier to seeking their expertise. CONCLUSIONS: The interplay of sociodemographic, cognitive and affective factors, and economic constraints at the individual level, underscores the complexity of antibiotic usage. Additionally, community leaders and health workers emerge as crucial players, yet their knowledge gaps and lack of empowerment pose challenges in addressing public concerns. This comprehensive analysis highlights the need for targeted interventions that address both individual beliefs and community health dynamics to promote judicious antibiotic use.

Elevation and latitude interact to drive life-history variation in precocial birds: a comparative analysis using galliformes.

Elevational gradients provide a powerful laboratory for understanding the environmental and ecological drivers of geographic variation in avian life-history strategies. Environmental variation across elevational gradients is hypothesized to select for a trade-off of reduced fecundity (lower clutch size and/or fewer broods) for higher offspring quality (larger eggs and/or increased parental care) in higher elevation species and populations. In birds, a focus on altricial species from north temperate latitudes has prevented an evaluation of the generality of this trade-off, and how it is affected by latitude and intrinsic factors (development mode). We performed a comparative analysis controlling for body size and phylogenetic relationships on a global data set of 135 galliform species to test (i) whether higher elevation precocial species have lower fecundity (smaller clutch and/or fewer broods) and invest more in offspring quality (greater egg mass) and (ii) whether latitude influences the traits involved and/or the trade-off, and (iii) to identify ecological and environmental drivers of life-history variation along elevational gradients. Life-history traits showed significant interaction effects across elevation and latitude: temperate higher elevation species had smaller clutches and clutch mass, larger eggs and shorter incubation periods, whereas more tropical species had larger clutches, eggs and clutch mass, and longer incubation periods as elevation increased. Number of broods and body mass did not vary with elevation or latitude. Latitudinal gradient in clutch size was observed only for low-elevation species. Significantly, an overlooked latitude-by-elevation interaction confounds our traditional view of clutch size variation across a tropical-to-temperate gradient. Across all latitudes, higher elevation species invested in offspring quality via larger eggs but support for reduced fecundity resulting from smaller clutches was found only along temperate elevational gradients; contrary to expectations, tropical high-elevation species showed increased fecundity. Variation in nest predation risk could explain differences between temperate and tropical elevational gradients, but we lack a consistent mechanism to explain why predation risk should vary in this manner. Alternatively, a resource availability hypothesis based on physical attributes that globally differ between elevation and latitude (seasonality in day length and temperature) seems more plausible.

Assuring health coverage for all in India.

Successive Governments of India have promised to transform India's unsatisfactory health-care system, culminating in the present government's promise to expand health assurance for all. Despite substantial improvements in some health indicators in the past decade, India contributes disproportionately to the global burden of disease, with health indicators that compare unfavourably with other middle-income countries and India's regional neighbours. Large health disparities between states, between rural and urban populations, and across social classes persist. A large proportion of the population is impoverished because of high out-of-pocket health-care expenditures and suffers the adverse consequences of poor quality of care. Here we make the case not only for more resources but for a radically new architecture for India's health-care system. India needs to adopt an integrated national health-care system built around a strong public primary care system with a clearly articulated supportive role for the private and indigenous sectors. This system must address acute as well as chronic health-care needs, offer choice of care that is rational, accessible, and of good quality, support cashless service at point of delivery, and ensure accountability through governance by a robust regulatory framework. In the process, several major challenges will need to be confronted, most notably the very low levels of public expenditure; the poor regulation, rapid commercialisation of and corruption in health care; and the fragmentation of governance of health care. Most importantly, assuring universal health coverage will require the explicit acknowledgment, by government and civil society, of health care as a public good on par with education. Only a radical restructuring of the health-care system that promotes health equity and eliminates impoverishment due to out-of-pocket expenditures will assure health for all Indians by 2022--a fitting way to mark the 75th year of India's independence.

Are residents of downtown Toronto influenced by their urban neighbourhoods? Using concept mapping to examine neighbourhood characteristics and their perceived impact on self-rated mental well-being.

BACKGROUND: There is ample evidence that residential neighbourhoods can influence mental well-being (MWB), with most studies relying on census or similar data to characterize communities. Few studies have actively investigated local residents' perceptions. METHODS: Concept mapping was conducted with residents from five Toronto neighbourhoods representing low income and non-low income socio-economic groups. These residents participated in small groups and attended two sessions per neighbourhood. The first session (brainstorming) generated neighbourhood characteristics that residents felt influenced their MWB. A few weeks later, participants returned to sort these neighbourhood characteristics and rate their relative importance in affecting residents' 'good' and 'poor' MWB. The data from the sorting and rating groups were analyzed to generate conceptual maps of neighbourhood characteristics that influence MWB. RESULTS: While agreement existed on factors influencing poor MWB (regardless of neighbourhood, income, gender and age), perceptions related to factors affecting good MWB were more varied. For example, women were more likely to rank physical beauty of their neighbourhood and range of services available as more important to good MWB, while men were more likely to cite free access to computers/internet and neighbourhood reputation as important. Low-income residents emphasized aesthetic attributes and public transportation as important to good MWB, while non-low-income residents rated crime, negative neighbourhood environment and social concerns as more important contributors to good MWB. CONCLUSION: These findings contribute to the emerging literature on neighbourhoods and MWB, and inform urban planning in a Canadian context.

Standardized observation of neighbourhood disorder: does it work in Canada?

BACKGROUND: There is a growing body of evidence that where you live is important to your health. Despite numerous previous studies investigating the relationship between neighbourhood deprivation (and structure) and residents' health, the precise nature of this relationship remains unclear. Relatively few investigations have relied on direct observation of neighbourhoods, while those that have were developed primarily in US settings. Evaluation of the transferability of such tools to other contexts is an important first step before applying such instruments to the investigation of health and well-being. This study evaluated the performance of a systematic social observational (SSO) tool (adapted from previous studies of American and British neighbourhoods) in a Canadian urban context. METHODS: This was a mixed-methods study. Quantitative SSO ratings and qualitative descriptions of 176 block faces were obtained in six Toronto neighbourhoods (4 low-income, and 2 middle/high-income) by trained raters. Exploratory factor analysis was conducted with the quantitative SSO ratings. Content analysis consisted of independent coding of qualitative data by three members of the research team to yield common themes and categories. RESULTS: Factor analysis identified three factors (physical decay/disorder, social accessibility, recreational opportunities), but only 'physical decay/disorder' reflected previous findings in the literature. Qualitative results (based on raters' fieldwork experiences) revealed the tool's shortcomings in capturing important features of the neighbourhoods under study, and informed interpretation of the quantitative findings. CONCLUSIONS: This study tested the performance of an SSO tool in a Canadian context, which is an important initial step before applying it to the study of health and disease. The tool demonstrated important shortcomings when applied to six diverse Toronto neighbourhoods. The study's analyses challenge previously held assumptions (e.g. social 'disorder') regarding neighbourhood social and built environments. For example, neighbourhood 'order' has traditionally been assumed to be synonymous with a certain degree of homogeneity, however the neighbourhoods under study were characterized by high degrees of heterogeneity and low levels of disorder. Heterogeneity was seen as an appealing feature of a block face. Employing qualitative techniques with SSO represents a unique contribution, enhancing both our understanding of the quantitative ratings obtained and of neighbourhood characteristics that are not currently captured by such instruments.