Elderly care in Nepal: Are existing health and community support systems enough.

In Nepal, a few governmental and community-based programmes for elderly care are in place; however, information about successful implementation and overall effectiveness of these programmes is not well understood. In this article, we introduced these programmes and discussed existing programmes' gaps and implementation problems in light of existing grey and peer-reviewed evidence. A few notable governmental programmes, such as providing monthly allowances, pensions and free health care, have targeted specifically the elderly individuals. Yet, most health care institutions and providers are privately owned and profit-oriented, and there is a general lack of proper governmental health as well as social security systems for the elderly in the country. Generally, Nepalese communities consist of neighbourhood-based and religious-based groups that provide emotional and spiritual support to elderly individuals as well as provide support for health care access when needed. However, the influence that these groups can have on health and social well-being of elderly remains not well understood. Traditional family-based support systems may be feasible only for some families, while for others it could impose financial and psychological burdens. The role of the state is important in the effective implementation of existing programmes as well as in the development and implementation of additional programmes to ensure health and social well-being of elderly individuals. Furthermore, there is a need to establish partnerships with existing community structures and to mobilize them in the implementation of community-based programmes.

'Menstruation means impurity': multilevel interventions are needed to break the menstrual taboo in Nepal.

BACKGROUND: During their menstrual period, women are generally considered impure in Nepal; in the rural areas of the western part of the country, they are even banished to stay in sheds (called chhaupadi) during this time, which increases their vulnerability to a variety of health consequences. There is lack of clarity regarding the effectiveness of interventions that have been implemented to address menstrual taboo and improve menstrual hygiene and practices in Nepal (e.g., public awareness, community sensitization and legislation). In this paper, we discuss why menstruation management interventions, particularly those implemented to change the menstrual taboo might not work, and the opinions and experiences regarding the implementation of such interventions. MAIN TEXT: Anecdotal reports from the field and empirical studies suggest that interventions to address menstrual taboos have only been effective for short durations of time due to several reasons. First, local community stakeholders have been reluctant to take actions to abandon retrogressive menstrual practices in rural areas. Second, women who have stopped practising chhaupadi have faced stigma (e.g., fear of exclusion) and discrimination (e.g., blaming, physical and verbal abuse). Third, contextual factors, such as poverty and illiteracy, limit the effectiveness of such interventions. Fourth, community sensitization activities against chhaupadi have faced resistance from community leaders and traditional healers. Fifth, the law prohibiting chhaupadi has also faced implementation problems, including poor filing of complaints. CONCLUSION: Multilevel, multisectoral interventions could be more effective than single-component interventions in breaking the prevailing menstrual taboo and in improving menstrual health and hygiene practices among young girls and women in the rural areas of Nepal. Moreover, interventions that have an active community mobilization component could be effective within local contexts and cultural groups.

Sex trafficking, prostitution, and increased HIV risk among women during and after the 2015 Nepal earthquake.

Women might be at increased risk of HIV infection after a disaster situation due to several interlinked environmental and social factors, such as increased sex trafficking and prostitution, in resource-limited settings. However, this information has not been clearly understood. Based on the review of available gray and peer-reviewed evidence, the present debate paper summarizes potential factors for increasing women's HIV risk during/after two earthquakes that hit Nepal in 2015. Poverty and socio-economic crisis, displacement and reduced social capital, increased rate of sex trafficking and prostitution, and poor access to health care seem to be the factors to increase women's HIV risk in the earthquake-affected areas of Nepal. There is a lack of essential empirical evidence on environmental and social factors (e.g. increased sex trafficking and prostitution) that are linked with women's HIV risk in the post-disaster phase. Therefore, the factors and interactions discussed should be further studied potentially in disaster-affected areas so that locally and culturally salient and sustainable relief and reconstruction strategies, which include strategies for preventing HIV risk in post-disaster situations, can be developed.

Hormone replacement therapy and mammographic density: a systematic literature review.

PURPOSE: Hormone replacement therapy (HRT) is used to reduce climacteric symptoms of menopause and prevent osteoporosis; however, it increases risk of breast cancer. Mammographic density (MD) is also a strong risk factor for breast cancer. We conducted this review to investigate the association between HRT use and MD and to assess the effect of different HRT regimens on MD. METHODS: Two of authors examined articles published between 2002 and 2019 from PubMed, Embase, and OVID using Covidence systematic review platform. Any disagreements were discussed until consensus was reached. The protocol used in this review was created in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Quality of each eligible study was assessed using the Oxford Center for Evidence-Based Medicine (OCEBM) hierarchy. RESULTS: Twenty-two studies met the inclusion criteria. Six studies showed that using estrogen plus progestin (E + P) HRT was associated with higher MD than estrogen alone. Four studies reported that continuous estrogen plus progestin (CEP) users had higher MD than sequential estrogen plus progestin (SEP) and estrogen alone users. However, two studies showed that SEP users had slightly higher MD than CEP users and estrogen alone users. CONCLUSIONS: Epidemiological evidence is rather consistent suggesting that there is a positive association between HRT use and MD with the highest increase in MD among current users, and CEP users. Our results suggest that due to increase in MD and masking effect, current E + P users may require additional screening procedures, shorter screening intervals, or using advanced imaging techniques.

Implementation of interventions targeting the uptake of genetic testing services for breast cancer risk: protocol for a systematic review.

INTRODUCTION: The timely identification of breast cancer-related pathogenic variants can help to identify the risk of potential disease development and determine healthcare choices. However, the uptake rate of genetic testing services for breast cancer risk remains low in many countries. Interventions targeting the uptake of these services among individuals potentially at risk for inherited breast cancer are often complex and have multiple components, and are therefore difficult to implement, replicate and disseminate to new contexts. Our aim is to systematically review studies targeting the uptake of genetic testing services for breast cancer risk and critically assess the quality of implementation outcomes and the reporting of intervention descriptions. METHODS AND ANALYSIS: PubMed, CINAHL, PsycINFO, Embase, Cochrane Library and all Campbell Coordinating Group databases will be searched for intervention studies that target individuals' participation in breast cancer genetic testing programmes. Papers published in English within the time period from January 2005 until October 2019 will be considered for inclusion. Titles, abstracts and full papers will be screened for eligibility by two pairs of reviewers independently. For data analysis and synthesis, study-level and intervention-level characteristics will be abstracted. We will present all implementation outcomes that are mentioned in each of the studies and register the number of studies that do not at all look at or report implementation outcomes. The quality of implementation will be checked using a 5-point rubric item, and the quality and completeness of reporting of intervention description will be evaluated using the 12-item Template for Intervention Description and Replication (TIDieR). ETHICS AND DISSEMINATION: Ethical approval is not required to conduct this review. Review findings will be disseminated to academic and non-specialist audiences via peer-reviewed academic journals and presented at appropriate conferences, workshops and meetings to policymakers, practitioners and organisations that work with our population of interest. PROSPERO REGISTRATION NUMBER: CRD42018105732.

Correlates of mistimed and unwanted pregnancy among women in the Democratic Republic of Congo.

Unwanted and mistimed pregnancies impose threats on the health and well-being of the mother and child and limit the acquisition of optimal sexual and reproductive health services, especially in resource-constrained settings like the Democratic Republic of Congo (DRC). This study aimed to determine the prevalence and correlates of mistimed and unwanted pregnancies among women in the DRC. Data were drawn from the 2013-14 DRC Demographic Health Survey (EDS-RDC II). Bivariate and multivariate logistic regression analysis was performed to identify correlates of mistimed and unwanted pregnancies. Sequential logistic regression modelling including distal (place of residence), intermediate (socio-demographic and socioeconomic factors) and proximal (reproductive health and family planning) factors was performed using multivariate analysis. More than a quarter (28%) of pregnancies were reported as unintended (23% mistimed and 5% unwanted). Women who wanted no more children (aOR 1.21; CI: 1.01, 1.44) had less than 24 months of birth spacing (aOR 2.14; CI: 1.80, 2.54) and those who intended to use a family planning method (aOR 1.24; CI: 1.01, 1.52) reported more often that their last pregnancy was mistimed. Women with five or more children (aOR 2.13; CI: 1.30, 3.49), those wanting no more children (aOR 13.07; CI: 9.59, 17.81) and those with more than 48 months of birth spacing (aOR 2.31; CI: 1.26, 4.23) were more likely to report their last pregnancy as unwanted. The high rate of unintended pregnancies in the DRC shows the urgency to act on the fertility behaviour of women. The associated intermediate factors for mistimed and unwanted pregnancy indicate the need to accelerate family planning programmes, particularly for women of high parity and those who want no more children. Likewise, health promotion measures at the grassroots level to ensure women's empowerment and increase women's autonomy in health care are necessary to address the social factors associated with mistimed pregnancy.

Physical Activity, Mental Health, and Wellbeing among Older Adults in South and Southeast Asia: A Scoping Review.

BACKGROUND: Physical activity is believed to enhance body functions and sense of wellbeing in general population. OBJECTIVES: This study aimed to explore physical activity measures; and the association between those measures, and mental wellbeing among older adults in South and Southeast Asia. METHODS: A systematic search was made in CINHAL, EMBASE, PubMed, and PsycINFO. Articles published between 2008 and 2018 were selected with participants aged 60 years and above, living at home, community, supported housing, or residential care homes, with no diagnosed/limiting illness. RESULTS: Five observational and four interventional studies on physical activity were analysed. Depression and sleep quality were the commonest outcome variables. Exercise frequency, regularity, and duration were found to positively impact mental wellbeing. CONCLUSION: Physical activity was generally found protecting against depression and improved sleep quality of older adults from South and Southeast Asia. Future studies should focus on more objective measures of physical activity.

Organisational factors that facilitate research use in public health policy-making: a scoping review.

BACKGROUND: Although important syntheses and theoretical works exist in relation to understanding the organisational factors that facilitate research use, these contributions differ in their scope and object of study as well as their theoretical underpinnings. Therefore, from an exploratory angle, it may be useful to map out the current literature on organisational factors of research use in public health policy-making when revisiting existing theories and frameworks to gain further theoretical insights. METHODS: Herein, a scoping review technique and thematic content analysis were used to bring together findings from both synthesised and empirical studies of different types to map out the organisational factors that facilitate research use in public health policy-making. RESULTS: A total of 14 reviews and 40 empirical studies were included in the analysis. These were thematically coded and the intra-organisational factors reported as enabling research use were examined. Five main categories of organisational factors that advance research use in policy organisations - (1) individual factors, (2) the management of research integration, (3) organisational systems and infrastructures of research use, (4) institutional structures and rules for policy-making, and (5) organisational characteristics - were derived as well as 18 subcategories and a total of 64 specific factors, where 27 factors were well supported by research. CONCLUSIONS: Using a scoping review methodology, the intra-organisational factors influencing research use in policy-making (including individual factors) were systematically mapped and the theories applied in this area of research were assessed. The review findings confirm the importance of an intra-organisational perspective when exploring research use, showing that many organisational factors are critical facilitators of research use but also that many factors and mechanisms are understudied. The synthesis shows a lack of studies on politicians and the need for more theoretically founded research. Despite increased efforts to update the existing evidential and theoretical basis of research use, we still need frameworks that combine different approaches and theories to help us grasp the complex organisational mechanisms that facilitate research use in policy settings.

Health Promotion and Obesity in the Arab Gulf States: Challenges and Good Practices.

This debate paper focuses on available strategies, policies, and challenges of health promotion for combating obesity in the Arab Gulf states (Saudi Arabia, Bahrain, Kuwait, Oman, and Qatar). The paper focuses on the abovementioned countries due to their similarity on many aspects and because of their alarming obesity rates that are on the rise and keep increasing. The paper argues that there are significant efforts to be made in sectors such as policies, intersectoral work, primary healthcare, health promotion strategies development, and qualified personnel for health promotion and health education. Among the six states, Qatar, United Arab Emirates, and to a degree Oman have shown some development with regard to the implementation and evaluation of obesity-related health promotion policies, and thus other Arab Gulf countries could be inspired by existing good practices and move from good intentions to using their available wealth to invest in the implementation and evaluation of published policies and strategies. All Arab Gulf countries are in need of more qualified personnel and the development of infrastructure that can help tackle the growing obesity challenge that such countries are experiencing.

'Menstrual blood is bad and should be cleaned': A qualitative case study on traditional menstrual practices and contextual factors in the rural communities of far-western Nepal.

OBJECTIVE: Unhealthy menstrual practices and the contexts surrounding them should be explored and clearly understood; this information could be useful while developing and implementing interventions to increase hygienic practices during menstruation and consequently increase health and well-being of women. Therefore, this study was conducted to explore traditional menstrual practices and the contextual factors surrounding the practices in the rural communities of far-western Nepal. METHODS: This was a qualitative case study conducted in the Achham district of Nepal. Semi-structured interviews were conducted among four women, three men and two female community health volunteers to collect data and thematic analysis was performed to analyze the data. RESULTS: We found two commonly reported menstrual practices: seclusion practice (Chhaupadi) and separation practice. In the Chhaupadi practice, women are secluded to stay in a small shed away from the house and restricted to wash or take a bath in public water sources for 5-7 days of the periods, whereas in the separation practice, women can stay in the house, but they still have several restrictions. The contextual factors that were reported to influence the cultural practices are as follows: cultural beliefs that symbolize menstruation as impure, menstrual stigma, poverty, illiteracy, the influence of traditional healers and family members, and limited effect of Chhaupadi elimination interventions. We also found that some development in the reduction of cultural myths and practices is happening, but the rate of change is rather slow. CONCLUSION: Most of the Nepalese women, especially in the rural areas of far-western Nepal, are forced to follow the harmful menstrual practices because of the socio-cultural context surrounding their lives. We believe the findings of this study would be relevant in terms of developing and implementing further menstrual health-related, community-based interventions that will be responsive to the local cultural context, beliefs, and practices.

Regular physical activity and mammographic density: a cohort study.

PURPOSE: Physical activity is a modifiable lifestyle risk factor in prevention of breast cancer. Mammographic density (MD) is a strong risk factor for breast cancer. We investigate the association of regular physical activity with MD. METHODS: For 5,703 women who participated in the Danish Diet, Cancer and Health cohort (1993-1997) and attended mammographic screening in Copenhagen (1993-2001), MD was assessed at the first screening after cohort entry. MD was defined as a binary measure equivalent to Breast Imaging Report and Data System (BI-RADS) to either mixed/dense or fatty. Participation and duration in physical activities (hours/week) and confounders were assessed by questionnaire at cohort baseline. Logistic regression was used to estimate associations [odds ratios (OR), 95% confidence intervals (CI)] between physical activities and MD. RESULTS: 56.3% of women had mixed/dense MD and 47.6% participated in sports. We found a significant positive association between participation in sports (OR 1.15; 95% CI 1.03-1.28) and do-it-yourself work (1.17; 1.05-1.31) and odds of having mixed/dense MD, which attenuated (1.08; 0.96-1.22 and 1.11; 0.98-1.25, respectively) in a fully adjusted model. No associations were found for time spent on physical activities or total metabolic equivalent of task scores with MD, in fully adjusted models. There was no effect modification of association between any physical activities and MD by obesity (BMI ≥ 30 kg/m2) and menopause status. CONCLUSIONS: Physical activity is not a determinant of MD.

Strategies to integrate community-based traditional and complementary healthcare systems into mainstream HIV prevention programs in resource-limited settings.

BACKGROUND: Global spending for HIV prevention has been decreasing over the years. As a result, several low-income countries, including Nepal, are increasingly facing the challenge to minimize the funding gap to continue providing HIV prevention services to the people. In this paper, we have attempted to clarify why it is important to integrate community-based traditional and complementary healthcare systems and mobilize them into the mainstream HIV programs to ensure access to HIV prevention messages, HIV testing, and treatment in resource-limited settings. MAIN BODY: First, we argue that the traditional and complementary healthcare practitioners can be mobilized to routinely provide HIV prevention messages to their clients, and, next, some of them can be trained to build their capacity to work as counselors or educators for HIV prevention in the community. CONCLUSION: These approaches, if implemented, can help continue HIV prevention initiatives and contain the HIV epidemic at the local level in the rural communities with limited cost and resources.

Barriers and facilitators to physical activity among urban residents with diabetes in Nepal.

INTRODUCTION: Physical activity is an important component of type 2 diabetes management. Physical activity level among general population in Nepal is reported to vary considerably. However, knowledge on physical activity in Nepali diabetics is very limited. Engagement in physical activity could be influenced by perception of barriers against adopting the behavior and benefits of adopting it. This study explores the prevalence of physical activity and factors that promote and hinder the behavior among urban residing diabetic patients from Nepal. METHODS: A descriptive cross-sectional design was adopted using a simple random sampling of type 2 diabetic patients from two diabetes clinics at Lalitpur and Kaski districts of Nepal. Two hundred and seventy participants were surveyed to obtain information on physical activity using Global Physical Activity Questionnaire. Metabolic equivalent values were calculated and categorized into high, moderate and low levels of physical activity. The information on perceived facilitators and barriers was collected by Exercise Barriers and Benefits Survey scale. Odds ratios and 95% confidence intervals of the measures were estimated using multinomial logistic regression. RESULTS: The study showed relatively high prevalence of physical activity among the urban Nepali diabetic patients; 52% were moderately active and 28% highly active. Travel and work-related activities were the major contributors. Male participants, educated and those living in extended families were more motivated for physical activity than their counterparts. Physical fitness, strength and flexibility, better sleep at night, social interaction and longevity, were identified as the major facilitators. Family responsibilities, busy schedule and family discouragement were identified as barriers against being physically active. CONCLUSION: The diabetic patients were mostly moderately physically active. Future research could explore different context-specific ways of remaining physically active, apart from walking and doing household chores. More focus should also be placed on leisure time physical activity as it was found to be low. Interventions could be designed by promoting the facilitators and addressing the barriers of physical activity, which is likely to reduce the healthcare costs of management of diabetic complications.

Development of measurable indicators to enhance public health evidence-informed policy-making.

BACKGROUND: Ensuring health policies are informed by evidence still remains a challenge despite efforts devoted to this aim. Several tools and approaches aimed at fostering evidence-informed policy-making (EIPM) have been developed, yet there is a lack of availability of indicators specifically devoted to assess and support EIPM. The present study aims to overcome this by building a set of measurable indicators for EIPM intended to infer if and to what extent health-related policies are, or are expected to be, evidence-informed for the purposes of policy planning as well as formative and summative evaluations. METHODS: The indicators for EIPM were developed and validated at international level by means of a two-round internet-based Delphi study conducted within the European project 'REsearch into POlicy to enhance Physical Activity' (REPOPA). A total of 82 researchers and policy-makers from the six European countries (Denmark, Finland, Italy, the Netherlands, Romania, the United Kingdom) involved in the project and international organisations were asked to evaluate the relevance and feasibility of an initial set of 23 indicators developed by REPOPA researchers on the basis of literature and knowledge gathered from the previous phases of the project, and to propose new indicators. RESULTS: The first Delphi round led to the validation of 14 initial indicators and to the development of 8 additional indicators based on panellists' suggestions; the second round led to the validation of a further 11 indicators, including 6 proposed by panellists, and to the rejection of 6 indicators. A total of 25 indicators were validated, covering EIPM issues related to human resources, documentation, participation and monitoring, and stressing different levels of knowledge exchange and involvement of researchers and other stakeholders in policy development and evaluation. CONCLUSION: The study overcame the lack of availability of indicators to assess if and to what extent policies are realised in an evidence-informed manner thanks to the active contribution of researchers and policy-makers. These indicators are intended to become a shared resource usable by policy-makers, researchers and other stakeholders, with a crucial impact on fostering the development of policies informed by evidence.

Obesity Prevention: A Systematic Review of Setting-Based Interventions from Nordic Countries and the Netherlands.

Aim: Effective evidence-based interventions have an important role in obesity prevention. Our aim was to present a qualitative synthesis of setting-based health promotion interventions on obesity, from Nordic countries and the Netherlands. Methods: A systematic review of the literature was completed for studies in the community, schools, and worksite, with BMI as an outcome. A descriptive analysis was completed for all full-text articles meeting the inclusion criteria. Results: Thirty-three articles were identified: 7 whole of community, 3 worksite, and 23 school-based interventions. The studies were largely quasiexperimental in design (21/33), with follow-up from 4 months to 8 years. The explicit use of theory was not featured in many of the studies (20/33). No consistent direction for BMI change could be identified in the whole of community interventions (2/7 positive, 2/7 negative, and 3/7 no effect) and no effect for worksite (3/3 no effect) or many of the school-based interventions (1/23 negative, 4/23 positive, 15/23 no effect, 1/23 BMI significant increase only for control group and 3/23 no data available). Conclusions: There is a need to prioritise interventions with study designs of high quality, theory, and a participatory approach, for optimal implementation and evaluation of obesity prevention interventions.

Hormone replacement therapy, mammographic density, and breast cancer risk: a cohort study.

PURPOSE: Hormone replacement therapy (HRT) use increases breast cancer risk and mammographic density (MD). We examine whether MD mediates or modifies the association of HRT with the breast cancer. METHODS: For the 4,501 participants in the Danish diet, cancer and health cohort (1993-1997) who attended mammographic screening in Copenhagen (1993-2001), MD (mixed/dense or fatty) was assessed at the first screening after cohort entry. HRT use was assessed by questionnaire and breast cancer diagnoses until 2012 obtained from the Danish cancer registry. The associations of HRT with MD and with breast cancer were analyzed separately using Cox's regression. Mediation analyses were used to estimate proportion [with 95% confidence intervals (CI)] of an association between HRT and breast cancer mediated by MD. RESULTS: 2,444 (54.3%) women had mixed/dense breasts, 229 (5.4%) developed breast cancer, and 35.9% were current HRT users at enrollment. Compared to never users, current HRT use was statistically significantly associated with having mixed/dense breasts (relative risk and 95% CI 1.24; 1.14-1.35), and higher risk of breast cancer (hazard ratio 1.87; 1.40-2.48). Association between current HRT use and breast cancer risk was partially mediated by MD (percent mediated = 10%; 95% CI 4-22%). The current HRT use-related breast cancer risk was higher in women with mixed/dense (1.94; 1.37-3.87) than fatty (1.37; 0.80-2.35) breasts (p value for interaction = 0.15). CONCLUSIONS: MD partially mediates some of the association between HRT and breast cancer risk. The association between HRT and breast cancer seems to be stronger in women with dense breasts.

Contextually tailored interventions can increase evidence-informed policy-making on health-enhancing physical activity: the experiences of two Danish municipalities.

BACKGROUND: The present study aims to test out contextually tailored interventions to increase evidence-informed health-enhancing physical activity policy-making in two Danish municipalities. METHODS: The study was performed as experiments in natural settings. Based on results from a pre-intervention study defining the needs and contexts of the two settings, the interventions were developed based on logical models. The interventions aimed at increasing the use of knowledge in policy-making, primarily via strengthening intersectoral collaboration. The interventions were evaluated via pre-, post- and 12-month follow-up questionnaires and qualitative interviews were carried out prior to the intervention start. RESULTS: The use of knowledge changed in several ways. In one municipality, the use of stakeholder and target group knowledge increased whereas, in the other municipality, the use of research knowledge increased. In both municipalities, the ability to translate knowledge to local context, the political request and the organisational procedures for use of knowledge increased during the interventions. There was some variation between the two settings, which shows the importance of tailoring to context. Most of the changes were diminished at the 12-month follow-up. CONCLUSION: Contextually tailored interventions have the potential to increase evidence-informed policy-making on health-enhancing physical activity. However, this finding needs to be tested in larger samples and its sustainability must be strengthened.

Building a Conceptual Framework to Study the Effect of HIV Stigma-Reduction Intervention Strategies on HIV Test Uptake: A Scoping Review.

A scoping review of grey and peer-reviewed literature was conducted to develop a conceptual framework to illustrate mechanisms involved in reducing HIV stigma and increasing HIV test uptake. We followed a three-step approach to exploring the literature: developing concepts, organizing and categorizing concepts, and synthesizing concepts into a framework. The framework contains four types of intervention strategies: awareness creation, influencing normative behavior, providing support, and developing regulatory laws. The awareness creation strategy generally improves knowledge and the influencing normative behavior strategy changes stigmatizing attitudes and behaviors, and subsequently, increases HIV test uptake. Providing support and development of regulatory law strategies changes actual stigmatizing behaviors of the people, and subsequently, increases HIV test uptake. The framework further outlines that the mechanisms described are influenced by the interaction of various social-contextual and individual factors. The framework sheds new light on the effects of HIV stigma-reduction intervention strategies and HIV test uptake.

Determinants of evidence use in public health policy making: Results from a study across six EU countries.

The knowledge-practice gap in public health is widely known. The importance of using different types of evidence for the development of effective health promotion has also been emphasized. Nevertheless, in practice, intervention decisions are often based on perceived short-term opportunities, lacking the most effective approaches, thus limiting the impact of health promotion strategies. This article focuses on facilitators and barriers in the use of evidence in developing health enhancing physical activity policies. Data was collected in 2012 by interviewing 86 key stakeholders from six EU countries (FI, DK, UK, NL, IT, RO) using a common topic guide. Content analysis and concept mapping was used to construct a map of facilitators and barriers. Barriers and facilitators experienced by most stakeholders and policy context in each country are analysed. A lack of locally useful and concrete evidence, evidence on costs, and a lack of joint understanding were specific hindrances. Also users' characteristics and the role media play were identified as factors of influence. Attention for individual and social factors within the policy context might provide the key to enhance more sustainable evidence use. Developing and evaluating tailored approaches impacting on networking, personal relationships, collaboration and evidence coproduction is recommended.

Knowledge, attitude and practice of healthcare ethics among resident doctors and ward nurses from a resource poor setting, Nepal.

BACKGROUND: Healthcare ethics is neglected in clinical practice in LMICs (Low and Middle Income Countries) such as Nepal. The main objective of this study was to assess the current status of knowledge, attitude and practice of healthcare ethics among resident doctors and ward nurses in a tertiary teaching hospital in Nepal. METHODS: This was a cross sectional study conducted among resident doctors (n = 118) and ward nurses (n = 86) in the largest tertiary care teaching hospital of Nepal during January- February 2016 with a self-administered questionnaire. A Cramer's V value was assessed to ascertain the strength of the differences in the variables between doctors and nurses. Association of variables were determined by Chi square and statistical significance was considered if p value was less than 0.05. RESULTS: Our study demonstrated that a significant proportion of the doctors and nurses were unaware of major documents of healthcare ethics: Hippocratic Oath (33 % of doctors and 51 % of nurses were unaware), Nuremberg code (90 % of both groups were unaware) and Helsinki Declaration (85 % of doctors and 88 % of nurses were unaware). A high percentage of respondents said that their major source of information on healthcare ethics were lectures (67.5 % doctors versus 56.6 % nurses), books (62.4 % doctors versus 89.2 % nurses), and journals (59 % doctors versus 89.2 % nurses). Attitude of doctors and nurses were significantly different (p < 0.05) in 9 out of 22 questions pertaining to different aspects of healthcare ethics. More nurses had agreement than doctors on the tested statements pertaining to different aspects of healthcare ethics except for need of integration of medical ethics in ungraduate curricula (97.4 % doctors versus 81.3 % nurses),paternalistic attitude of doctor was disagreed more by doctors (20.3 % doctors versus 9.3 % nurses). Notably, only few (9.3 % doctors versus 14.0 % nurses) doctors stood in support of physician-assisted dying. CONCLUSIONS: Significant proportion of doctors and nurses were unaware of three major documents on healthcare ethics which are the core principles in clinical practice. Provided that a high percentage of respondents had motivation for learning medical ethics and asked for inclusion of medical ethics in the curriculum, it is imperative to avail information on medical ethics through subscription of journals and books on ethics in medical libraries in addition to lectures and training at workplace on medical ethics which can significantly improve the current paucity of knowledge on medical ethics.