"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.

Mapping chicken production and distribution networks in Vietnam: An analysis of socio-economic factors and their epidemiological significances.

The growing chicken industry in Viet Nam has an increasingly important contribution to the country's food security, but its development requires careful planning to prevent disease risks. This study characterizes the chicken production and distribution networks in Vietnam and identifies potential factors that could promote disease emergence and transmission. Qualitative data were collected from interviews with 29 key informants from five stakeholder groups representing the main nodes from chicken production and distribution networks (PDN). Three main networks were identified based on production type: a colored broiler and spent hen network, a white (or exotic) broiler network, and an egg network. Colored chickens and spent hens are the most preferred commodity by vietnamese consumers and their PDN is composed of production units differing in their scale and management and with long distribution chains involving numerous small-scale independent stakeholders. Live bird markets plays a central role in this network, which is driven by consumers' preference for live chickens. The white chicken network presents an important duality, as it is composed of both a large number of independent household farms and traders operating independently with little chain coordination, and of large farms contracted by vertically-integrated companies. The egg PDN was the most organized network, being mostly controlled by large vertically-integrated companies. High level specialization and diversification of stakeholders is found in all three networks. Stakeholders' perceptions of the main factors promoting disease risk along the PDN were the low biosecurity in household farms and live bird markets, mobile traders, the informal slaughter of birds and the management of sick birds. Findings from this study can be used to plan future studies to support food system planners in the development of safer poultry production and distribution in Vietnam.

Pharma-cartography: Navigating the complexities of antibiotic supply to rural livestock in West Bengal, India, through value chain and power dynamic analysis.

Antibiotic resistance threatens provision of healthcare and livestock production worldwide with predicted negative socioeconomic impact. Antibiotic stewardship can be considered of importance to people living in rural communities, many of which depend on agriculture as a source of food and income and rely on antibiotics to control infectious diseases in livestock. Consequently, there is a need for clarity of the structure of antibiotic value chains to understand the complexity of antibiotic production and distribution in community settings as this will facilitate the development of effective policies and interventions. We used a value chain approach to investigate how relationships, behaviours, and influences are established during antibiotic distribution. Interviews were conducted with key informants (n = 17), value chain stakeholders (n = 22), and livestock keeping households (n = 36) in Kolkata, and two rural sites in West Bengal, India. Value chain mapping and an assessment of power dynamics, using manifest content analysis, were conducted to investigate antibiotic distribution and identify entry points for antibiotic stewardship. The flow of antibiotics from manufacturer to stockists is described and mapped and two local level maps showing distribution to final consumers presented. The maps illustrate that antibiotic distribution occurred through numerous formal and informal routes, many of which circumvent antibiotic use legislation. This was partly due to limited institutional power of the public sector to govern value chain activities. A 'veterinary service lacuna' existed resulting in livestock keepers having higher reliance on private and informal providers, who often lacked legal mandates to prescribe and dispense antibiotics. The illegitimacy of many antibiotic prescribers blocked access to formal training who instead relied on mimicking the behaviour of more experienced prescribers-who also lacked access to stewardship guidelines. We argue that limited institutional power to enforce existing antibiotic legislation and guide antibiotic usage and major gaps in livestock healthcare services make attempts to curb informal prescribing unsustainable. Alternative options could include addressing public sector deficits, with respect to both healthcare services and antibiotic provision, and by providing resources such as locally relevant antibiotic guidelines to all antibiotic prescribers. In addition, legitimacy of informal prescribers could be revised, which may allow formation of associations or groups to incentivise good antibiotic practices.

Social embeddedness of pig value chains in Myanmar and its implications for food and nutrition security.

Agricultural intermediaries - traders and middlemen/women - play a critical role for food security in low- and middle-income countries (LMICs). Yet, their role in improving or undermining food safety, an indicator for food quality, is not well understood. As middle-class citizens increasingly demand high-quality perishable and nutritious produce, food safety has become an important issue in LMICs. The existing literature offers limited insights as to whether and, if so, how intermediaries manage information regarding food safety in LMICs. This article fills this gap based on an in-depth qualitative study on pig value chains in Myanmar. We document that intermediaries helped reduce transaction costs of trade by linking farmers to buyers based on an intricate socio-economic relationship. While we find no evidence of intermediaries actively concealing facts about invisible (i.e. microbiological or chemical) nature of pig products, they facilitated selling sick animals. On the other hand, intermediaries withheld information about potential buyers and sellers in order to maintain their role along the value chains. In order to improve food safety in LMICs, policies need to reduce transaction costs of trade as well as access to public health expertise.

Exploring the hurdles that remain for control of African swine fever in smallholder farming settings.

To honour the 100 years anniversary of the first publication about African swine fever (ASF) a webinar with a particular focus on disease control in the smallholder sector was organized. This article is based on the webinar, summarizing the early history of ASF research, reflecting on the current global disease situation and bringing forward some suggestions that could contribute towards achieving control of ASF. The first description of ASF by R. Eustace Montgomery in 1921 laid the foundations for what we know about the disease today. Subsequent research confirmed its association with warthogs and soft ticks of the Ornithodoros moubata complex. During the latter half of the 21st century, exponential growth of pig production in Africa has led to a change in the ASF-epidemiology pattern. It is now dominated by a cycle involving domestic pigs and pork with virus spread driven by people. In 2007, a global ASF epidemic started, reaching large parts of Europe, Asia and the Americas. In Europe, this epidemic has primarily affected wild boar. In Asia, wild boar, smallholders and industrialized pig farms have been affected with impact on local, national and international pig value chains. Globally and historically, domestic pigs in smallholder settings are most frequently affected and the main driver of ASF virus transmission. Awaiting a safe and efficacious vaccine, we need to continue focus on other measures, such as biosecurity, for controlling the disease. However, smallholders face specific challenges linked to poverty and other structural factors in implementing biosecurity measures that can prevent spread. Improving biosecurity in the smallholder sector thus remains an important tool for preventing and controlling ASF. In this regard, interdisciplinary research can help to find new ways to promote safe practices, facilitate understanding and embrace smallholders' perspectives, engage stakeholders and adjust prevention and control policies to improve implementation.

Understanding drivers of private-sector compliance to large-scale food fortification: A case study on edible oil value chains in Bangladesh.

Micronutrient deficiency is a pertinent global challenge that affects billions of people and has deleterious health effects. Large-scale food fortification (LSFF) is a cost- effective way to tackle micronutrient deficiency and improve health outcomes, particularly in low- and middle-income countries (LMICs). However, the success of LSFF in LMICs is often hampered by limited compliance with fortification mandates by the private sector, who supply fortified foods. In this paper, we use a case study of the edible oil produced in Bangladesh to analyze the factors facilitating and impeding this compliance by for-profit actors. We identified four bottlenecks that disincentivize private sector actors' decision to comply. First, fortified and non-fortified products co-exist in the market, disincentivizing producers to invest in fortification. Second, the lack of traceability reduces the risk for large-scale producers' non-compliance with the regulation. Third, small-scale producers face economic pressures that prevent them from adequately fortifying oil products. Lastly, law enforcement is currently inconsistent, allowing the supply of under-fortified oil in the market. Given the evidence, we recommend to strengthen the control of bulk item fortification through more frequent and rigorous surveillance at the production level. This will ensure that resource constrained consumers who also have the greatest potential to benefit from added nutrients, remain able to access affordable and nutrient-enriched food.

Firm's compliance behaviour towards food fortification regulations: Evidence from oil and salt producers in Bangladesh.

Impact of national food fortification programs is contingent on the extent to which there is compliance with national standards. However, this compliance is often sub-optimal and is not consistently measured. One of the challenges to more regular measurement is an over-reliance on quantitative assessments of micronutrient levels for compliance, which are costly. In resource constrained environments, this contributes to weaknesses in regulatory monitoring. We offer an alternative, systems-based approach to determine compliance, presenting a unique score that can capture firms' compliance behaviour, based on whether and how firms actually carry out stages of the fortification process. The key utility of such a measure being its use to monitor fortification propensity and assess changes in response to interventions. Further, we present an empirical application of this measure, providing novel evidence on firms' compliance towards food fortification regulations in Bangladesh, investigating the institutional and firm-level factors that correlate with compliance behaviour towards food fortification regulations among edible oil and salt producers.

Intensification of fragility: Poultry production and distribution in Bangladesh and its implications for disease risk.

Poultry production is a valuable source of nutritious food and income and is considered a crucial part of global development. This is especially important for countries such as Bangladesh where levels of hunger and childhood stunting remain high. However, in many low- and middle-income countries poultry production remains dominated by small to medium scale enterprises operating with poor farm biosecurity associated with poultry and zoonotic disease risks. We aimed to characterize the structure of poultry production in Bangladesh in order to identify the underlying structural factors and resulting practices which create risk environments for emergence, persistence and transmission of infectious diseases. Using the concept of a production and distribution network (PDN), we conducted a review of the literature, 27 in-depth interviews with key-informants and stakeholders, and 20 structured interviews with poultry distributors to map the ways which poultry are raised, distributed and marketed in Bangladesh. Findings indicate that the PDN can be considered in the context of four major sub-networks, based on the types of chickens; broadly indigenous, cross-bred, exotic broiler, and layer chickens. These sub-networks do not exist in isolation; their transactional nodes - actors and sites - are dynamic and numerous interactions occur within and between the PDN. Our findings suggest that the growth in small and medium scale poultry enterprises is conducted within 'fragile' enterprises by inexperienced and poorly supported producers, many of whom lack capacity for the level of system upgrading needed to mitigate disease risk. Efforts could be taken to address the structural underlying factors identified, such as the poor bargaining power of producers and lack of access to independent credit and indemnity schemes, as a way to reduce the fragility of the PDN and increase its resilience to disease threats. This knowledge on the PDN structure and function provide the essential basis to better study the generation, mitigation and consequences of disease risks associated to livestock, including the analysis of potential hotspots for disease emergence and transmission.

Why behaviours do not change: structural constraints that influence household decisions to control pig diseases in Myanmar.

This article problematises the ways in which behavioural change by poor individuals dominates the global discussions on means to tackle issues caused by systemic problems. We do so by focusing on the case of animal diseases, a symptom of many systematic failures. While livestock farming has long been praised as a mitigating factor against poverty, livestock diseases threaten the lives and livelihoods of poor and marginalised people who depend on animals. Aiming at controlling animal diseases, policy makers tend to focus on behavioural change by individual farmers by enhancing their knowledge. We conducted an in-depth qualitative research among pig farmers in Myanmar, a country that is rapidly increasing livestock production, to document contextual and systematic constraints that influence farmers' understandings and perceptions of disease-related risks and household-level decisions to invest in animal disease control. We conducted in-depth interviews, focus group discussions and participant observation in three townships in the Yangon region. Structural constraints such as weak veterinary health system and limited access to low-interest credit prevent farmers from gaining necessary knowledge about disease prevention and make them economically vulnerable. These systematic constraints drive behaviours considered 'risky' for disease emergence and spread. As a result, many small- and medium-scale farmers in low- and middle-income countries remain trapped in a vicious cycle of poverty and ill health for both animals and humans. We conclude that, instead of focusing on individual behavioural change, interventions need to combine enhancing knowledge by individual farmers and tackling economic and structural constraints that limit their agency and ability to address practices that are considered risky.

Power, participation and their problems: A consideration of power dynamics in the use of participatory epidemiology for one health and zoonoses research.

The use of Participatory Epidemiology in veterinary research intends to include livestock keepers and other local stakeholders in research processes and the development of solutions to animal health problems, including potentially zoonotic diseases. It can also be an attempt to bring some of the methods and insights of social science into a discipline largely shaped by natural science methods and ways of seeing the world. The introduction of participatory methodologies to veterinary epidemiology and disease surveillance follows a wider movement in development thinking, questioning the top-down nature of much post-second world war development efforts directed from the Global North towards the Global South. In the best cases, participatory methods can help to empower the poor and marginalised to participate in and have some control over research and interventions which affect them. Compiled from experience in multi-disciplinary One Health projects, this paper briefly traces the rise of participatory epidemiology before examining some of the limitations observed in its implementation and steps that might be taken to alleviate the problems observed. The three areas in which the operationalisation of Participatory Epidemiology in veterinary and One Health research could be improved are identified as: broadening the focus of engagement with communities beyond quantitative data extraction; taking note of the wider power structures in which research takes place, and questioning who speaks for a community when participatory methods are used. In particular, the focus falls on how researchers from different disciplines, including veterinary medicine and the social sciences, can work together to ensure that participatory epidemiology is employed in such a way that it improves the quality of life of both people and animals around the world.

Interventions to Reduce Antibiotic Prescribing in LMICs: A Scoping Review of Evidence from Human and Animal Health Systems.

This review identifies evidence on supply-side interventions to change the practices of antibiotic prescribers and gatekeepers in low- and middle-income countries (LMICs). A total of 102 studies met the inclusion criteria, of which 70 studies evaluated interventions and 32 provided insight into prescribing contexts. All intervention studies were from human healthcare settings, none were from animal health. Only one context study examined antibiotic use in animal health. The evidence base is uneven, with the strongest evidence on knowledge and stewardship interventions. The review found that multiplex interventions that combine different strategies to influence behaviour tend to have a higher success rate than interventions based on single strategies. Evidence on prescribing contexts highlights interacting influences including health system quality, education, perceptions of patient demand, bureaucratic processes, profit, competition, and cultures of care. Most interventions took place within one health setting. Very few studies targeted interventions across different kinds of providers and settings. Interventions in hospitals were the most commonly evaluated. There is much less evidence on private and informal private providers who play a major role in drug distribution in LMICs. There were no interventions involving drug detailers or the pharmaceutical companies despite their prominent role in the contextual studies.

Physician-received scatter radiation with angiography systems used for interventional radiology: comparison among many X-ray systems.

Radiation protection for interventional radiology (IR) physicians is very important. Current IR X-ray systems tend to use flat-panel detectors (FPDs) rather than image intensifiers (IIs). The purpose of this study is to test the hypothesis that there is no difference in physician-received scatter radiation (PRSR) between FPD systems and II systems. This study examined 20 X-ray systems in 15 cardiac catheterisation laboratories (11 used a FPD and 9 used an II). The PRSR with digital cineangiography and fluoroscopy were compared among the 20 X-ray systems using a phantom and a solid-state-detector electronic pocket dosemeter. The maximum PRSR exceeded the minimum PRSR by ~12-fold for cineangiography and ~9-fold for fluoroscopy. For both fluoroscopy and digital cineangiography, the PRSR had a statistically significant positive correlation with the entrance surface dose (fluoroscopy, r = 0.87; cineangiography, r = 0.86). There was no statistically significant difference between the average PRSR of FPDs and IIs during either digital cineangiography or fluoroscopy. There is a wide range of PRSR among the radiography systems evaluated. The PRSR correlated well with the entrance surface dose of the phantom in 20 X-ray units used for IR. Hence, decreasing the dose to the patient will also decrease the dose to staff.

Comparison of dose at an interventional reference point between the displayed estimated value and measured value.

Today, interventional radiology (IR) X-ray units are required for display of doses at an interventional reference point (IRP) for the operator (IR physician). The dose displayed at the IRP (the reference dose) of an X-ray unit has been reported to be helpful for characterizing patient exposure in real time. However, no detailed report has evaluated the accuracy of the reference doses displayed on X-ray equipment. Thus, in this study, we compared the displayed reference dose to the actual measured value in many IR X-ray systems. Although the displayed reference doses of many IR X-ray systems agreed with the measured actual values within approximately 15%, the doses of a few IR units were not close. Furthermore, some X-ray units made in Japan displayed reference doses quite different from the actual measured value, probably because the reference point of these units differs from the International Electrotechnical Commission standard. Thus, IR physicians should pay attention to the location of the IRP of the displayed reference dose in Japan. Furthermore, physicians should be aware of the accuracy of the displayed reference dose of the X-ray system that they use for IR. Thus, regular checks of the displayed reference dose of the X-ray system are important.

Usefulness of non-lead aprons in radiation protection for physicians performing interventional procedures.

At present, interventional radiology (IVR) tends to involve long procedures (long radiation duration), and physicians are near to the source of scattered radiation. Hence, shielding is critical in protecting physicians from radiation. Protective aprons and additional lead-shielding devices, such as tableside lead drapes, are important means of protecting the physician from scattered radiation. The purpose of this study was to evaluate whether non-lead aprons are effective in protecting physicians from radiation during IVR procedures. In this study, the radiation protection effects of commercially available protective lead and non-lead aprons, when exposed to diagnostic X rays, are compared. The performance of these non-lead and lead aprons was similar for scattered X rays at tube voltages of 60-120 kV. Properly designed non-lead aprons are thus more suitable for physicians because they weigh approximately 20% less than the lead aprons, and are non-toxic.