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This descriptive research used the Health Belief Model (HBM) to assess HIV/AIDS knowledge, perceived severity, perceived susceptibility, and behavioral practices within the population throughout the State of Sonsonate, El Salvador. Geographic Information Systems (GIS) was also utilized to display the results of this population study. The study population was composed of 15-39 year olds consisting of a total sample size of 1,500 (250 participants from each of the six cities). The basis of this study was to evaluate where this population fit within the Health Belief Model (HBM) and also to practically represent the results pictorially. Also, this information was collected so that the government of El Salvador could see and understand where their educational deficits existed so that future programs could be established to alleviate these discrepancies. An instrument consisting of 65 items including demographics, knowledge, perceived severity, perceived susceptibility, and behavioral practices was used for the general population. The analysis of the data was two-fold using Geographic Information Systems (GIS) mapping and statistical analysis. GIS mapping was used to graphically pinpoint areas of knowledge deficit and misinformation about HIV/AIDS. Results were based on a general population of 1,454. Various indices were created to show the level of knowledge or frequency of safe behavioral practices. The Perceived Severity and Perceived Susceptibility sections were not aggregated into an index but rather treated as individual variables. An item analysis of the questionnaire found that on average the general population responded correctly to 78% of the knowledge questions. However, a total of 11 questions in the knowledge section had less 75% (n=385) of the general population answering correctly. Another 3 questions in the behavior section were also found to have less than 75% (n=385) indicating safe behavioral practices. Linear regression analyses were performed to explore correlations between the areas of demographics, knowledge level, perceived severity, and perceived susceptibility to safe behavior. GIS maps were created to pictorially show where this population's deficiencies were in regard to the HBM. This research helped to pinpoint where this population fits within the construct of the Health Belief Model so that future educational efforts can be targeted in geographic areas with the greatest need. This will help to move this sample toward behavioral change. / Ph. D.

Infectious diseases attract a lot of mediatic, cultural and political attention. But are those diseases like Ebola, or ‘disease x’ actually what kills us? Since 1946, the WHO is the most authoritative figure in the fights against infectious disease outbreaks. So how does the WHO maintain this power and authority after tremendous budget cuts, competition for authority, and a shift to non-communicable disease epidemiology? This thesis uses a mixed-methods approach of quantitative analysis of ‘Disease Outbreak News’ reports, and qualitative analysis of key WHO literature, to develop the alternative narrative answering those questions. This thesis found that the WHO activities surrounding the collection and distribution of data create a political and institutional environment in which the WHO seems to be the only logical solution to prevent them. Additionally, the narrative put forth by the WHO prioritizes the ‘alert and response’ and operational capabilities of the organization to further expand authority in outbreak response. This study concludes that the WHO, through the collection and distribution of knowledge, and efforts to increase operational capability as seen through the Global Outbreak Alert and Response Network (GOARN), seeks to maintain normative authority and power as an international organization. / M.A. / Globalization of trade and travel has only increased the fear of infectious disease transmission. There is a great demand for a global health security system that is alert and capable. Based on this ‘threat’ the WHO justifies their role as global health leader. The Global Outbreak Alert and Response Network (GOARN) is the system that currently acts as the operational arm of the WHO, monitoring and coordinating response to infectious disease outbreaks globally. Despite the critical role of GOARN, its day-to-day endeavors remain unexplored by the public health field. This thesis analyzes how the WHO uses GOARN and its surveillance capabilities to collect and transform data as a method to maintain normative authority, and projects a powerful narrative as the leader of ‘alert and response’. In a competitive environment with limited financial resources, the WHO has adapted in terms of surveillance and operational capability to maintain its leadership and authority in the global public health field.

<p>The aims of this thesis were to expand the knowledge about sexual and reproductive health among urban Ugandan youths, living in a slum, and to evaluate the national flow-chart for management of the abnormal vaginal discharge (AVD) syndrome in adolescent girls. Data collection included individual interviews, focus-group discussions and clinical investigations with tests for chlamydia trachomatis (CT), neisseria gonorrhoea (NG), trichomonas vaginalis (TV), syphilis, and HIV infection. Poverty, peer pressure and gender power imbalance were obstacles to safe sexual practices: to abstain from sex, be faithful or to use condoms. Prevalence among the 199 female and 107 male adolescents for CT, NG, TV, syphilis and HIV was 4.5%, 9.0%, 8.0%, 4.0% and 15.2% for females and 4.7%, 5.7%, 0%, 2.8% and 5.8% for males. The national AVD flow-chart had a sensitivity of 61%, a specificity of 38.5% and a positive predictive value (PPV) of 11.6%. A flow-chart using risk factors, rather than symptoms, implicated a sensitivity/specificity and PPV of 82.6%/47% and 17.3% respectively. Socially disadvantaged females had a high risk to be HIV infected and HIV infection was associated to other STIs. Females were more likely than males to have any of the infections studied. Voluntary counselling and testing (VCT) for HIV was considered as helpful in preventing the spread of HIV. Obstacles for testing were: lack of time and money, fear of stigmatisation and fear that the knowledge of HIV positive status could shorten someone's life. An alternative flow-chart for management of AVD among adolescent girls should be evaluated. Girl's opportunities for education and income generating work should be a priority. VCT services for young people should be made accessible in terms of cost, time and quality of counselling.</p>

The aims of this thesis were to expand the knowledge about sexual and reproductive health among urban Ugandan youths, living in a slum, and to evaluate the national flow-chart for management of the abnormal vaginal discharge (AVD) syndrome in adolescent girls. Data collection included individual interviews, focus-group discussions and clinical investigations with tests for chlamydia trachomatis (CT), neisseria gonorrhoea (NG), trichomonas vaginalis (TV), syphilis, and HIV infection. Poverty, peer pressure and gender power imbalance were obstacles to safe sexual practices: to abstain from sex, be faithful or to use condoms. Prevalence among the 199 female and 107 male adolescents for CT, NG, TV, syphilis and HIV was 4.5%, 9.0%, 8.0%, 4.0% and 15.2% for females and 4.7%, 5.7%, 0%, 2.8% and 5.8% for males. The national AVD flow-chart had a sensitivity of 61%, a specificity of 38.5% and a positive predictive value (PPV) of 11.6%. A flow-chart using risk factors, rather than symptoms, implicated a sensitivity/specificity and PPV of 82.6%/47% and 17.3% respectively. Socially disadvantaged females had a high risk to be HIV infected and HIV infection was associated to other STIs. Females were more likely than males to have any of the infections studied. Voluntary counselling and testing (VCT) for HIV was considered as helpful in preventing the spread of HIV. Obstacles for testing were: lack of time and money, fear of stigmatisation and fear that the knowledge of HIV positive status could shorten someone's life. An alternative flow-chart for management of AVD among adolescent girls should be evaluated. Girl's opportunities for education and income generating work should be a priority. VCT services for young people should be made accessible in terms of cost, time and quality of counselling.

Purpose: The thesis determined how policy implementation and change management can be improved in Nigeria, with the health insurance scheme as the basis for narrative exploration. It sets out the similarities and differences in assumptions between supra-national organisations such as the World Bank and World Health Organisation on policy implementation and change management and those contained in the Nigerian national health policy; and those of people responsible for implementation in Nigerian organisations at a) the federal or national level and b) at sub-federal service delivery levels of the health insurance scheme. The study provides a framework of the dimensions that should be considered in policy implementation and change management in Nigeria, the nature of structural and infrastructural problems and wider societal context, and the ways in which conceptions of organisations and the variables that impact on organisations' capability to engage in policy implementation and change management differ from those in the West. Design/methodology/approach - A qualitative approach in the form of a case study was used to track the transformation of a policy into practice through examining the assumptions and expectations about policy implementation of the organisations financing the policy's implementation through an examination of relevant documents concerning policy, strategy and guidelines on change management and policy implementation from these global organisations, and the Nigerian national health policy document. The next stages of field visits explored the assumptions, expectations and experiences of a) policy makers, government officials, senior managers and civil servants responsible for implementing policy in federal-level agencies through an interview programme and observations; and b) those of sub-federal or local-level managers responsible for service-level policy implementation of the health insurance scheme through an interview programme. Findings - There are conflicts between the rational linear approaches to change management and policy implementation advocated by supra-nationals, which argue that these processes can be controlled and managed by the rational autonomous individual, and the narratives of those who have personal experience of the quest for 'health for all'. The national health policy document mirrors the ideology of the global organisations that emphasise reform, efficiencies and private enterprise. However, the assumptions of these global organisations have little relevance to a Nigerian societal and organisational context, as experienced by the senior officials and managers interviewed. The very nature of organisations is called into question in a Nigerian context, and the problems of structure and infrastructure and ethnic and religious divisions in society seep into organisations, influencing how organisation is enacted. Understandings of the purpose and function of leadership and the workforce are also brought into question. Additionally, there are religion-based barriers to policy implementation, change management and organisational life which are rarely experienced in the West. Furthermore, in the absence of future re-orientation, the concept of strategy and vision seems redundant, as is the rationale for a health insurance scheme for the majority of the population. The absence of vision and credible information further hinder attempts to make decisions or to define the basis for determining results. Practical implications: The study calls for a revised approach to engaging with Nigerian organisations and an understanding of what specific terms mean in that context. For instance, the definitions and understanding of organisations and capacity are different from those used in the West and, as such, bring into question the relevance and applicability of Western-derived models or approaches to policy implementation and change management. A framework with four dimensions - societal context, external influences, seven organisational variables and infrastructural/structural problems - was devised to capture the particular ambiguities and complexities of Nigerian organisations involved in policy implementation and change management. Originality/value: This study combines concepts in management studies with those in policy studies, with the use of narrative approaches to the understanding of policy implementation and change management in a Nigerian setting. Elements of culture, religion and ethical values are introduced to further the understanding of policy making and implementation in non-Western contexts.

L’internationalisation de l’action publique sanitaire est aujourd’hui incontestable, et cette thèse représente une contribution intellectuelle à l’analyse de ce phénomène reconnu mais encore à explorer dans les détails. Partant d’un point très précis voire étroit, la substitution progressive dans le vocabulaire et les pratiques de l’Organisation mondiale de la Santé (OMS) de l’éducation sanitaire par la promotion de la santé, on retrace un parcours autrement considérable qui n’engage rien moins que les représentations historiques et politiques qui ont conduit à la mise en place de politiques publiques dans le domaine sanitaire, et ce à l’international. A la croisée de l’histoire des idées et de l’analyse des politiques publiques internationales, c’est une méthodologie innovante – articulant démarche intellectuelle et recherche empirique, notamment par l’observation participante et la conduite d’entretiens – que nous mobilisons pour retracer l’histoire et le fonctionnement réel de l’OMS.Notre travail se présente comme une histoire d’enchevêtrements de savoir(s), de jeux de pouvoir et de processus d’institutionnalisation dans des contextes changeants. Partant de l’émergence, dès le XVIIIe siècle, de l’éducation sanitaire comme stratégie visant la modification des comportements individuels puis de son inscription au sein de l’OMS, on en arrive à la question du changement de l’action publique (internationale). L’affirmation progressive de la promotion de la santé à partir des années 1980 traduit le travail de sens opéré par des acteurs (de l’OMS) qui, confrontés à des tensions liées à des modifications dans les équilibres jusqu’alors établis, modifient leurs discours et leurs pratiques afin de conserver, ou d’acquérir, une capacité à orienter l’action publique. Surtout, notre recherche montre que l’action publique sanitaire (internationale) se caractérise aujourd’hui par l’effort pour concilier – dans un contexte de complexification des enjeux, d’hétérogénéité croissante des savoirs et de multiplication des acteurs susceptibles d’intervenir au nom de la santé publique – des registres de légitimation (la défense de la liberté individuelle et la nécessité d’une action collective au nom de ce « bien commun » qu’est la santé) et des stratégies d’action (individuelles et collectives) non seulement différentes mais qui souvent même s’opposent. / This doctoral thesis is an intellectual contribution to the analysis of the unquestionable, process of internationalization of public health policies. Starting from a precise and even narrow point—the transition from “health education” to “health promotion” in the discourses and practices put forward by the World Health Organization (WHO)—we retrace the historical and political representations that shape public health-related policies at the international level. This interdisciplinary work, at the crossroad of the history of ideas and the international public policies analysis, is based on an innovating methodology which articulates an intellectual and empirical research to the analysis of the history and the functions of the WHO.This history is one of knowledge intertwining with games of power and institutional processes in shifting contexts. Starting with the emergence as early as the XVIIIth century of health education as a strategy for changing personal behaviors and its inclusion far later in the WHO structure, we move to the question of (international) public (health) policies transformations. The progressive affirmation of health promotion in the 1980’s reflects how WHO instances reframed the meaning of their work, when confronted to the tensions provoked by the shifting balance of well-established conceptions, and how they modified their discourse and their practice in order to keep or acquire a capacity to influence public action.. Above all, our research shows that (international) public health policies are today characterized by a attempt to combine—in a context of complexified issues and increased heterogeneity in knowledge as well as of a greater number of stakeholders in public health (action)—an array of legitimizing discourses ranging from the defense of individual freedom and the need for collective action on behalf of health as a “common good” to (individual and collective) strategies of action that are not only different but often conflicting.

Introduction : Peu d’études internationales ont examiné les différences entre les hommes et les femmes dans la prévalence du syndrome métabolique (SM). Objectifs : Comparer les prévalences du syndrome métabolique chez les femmes et les hommes et évaluer le rôle du genre dans les associations entre le SM et les troubles de mobilité (TM). Méthodes : Nous avons utilisé les données repères de l’étude internationale sur la mobilité des personnes âgées de 65-74 ans (n=1995), des villes de Kingston (Ontario), Saint-Hyacinthe (Québec), Tirana (Albanie), Manizales (Colombie), et Natal (Brésil). Parmi les participants, 1728 ont donné un échantillon de sang pour des analyses. Les ratios de prévalence (RP) du SM et des TM ont été dérivés par la régression de Poisson. Résultats : Les prévalences du SM étaient significativement plus élevées chez les femmes dans les villes non canadiennes, cette différence entre sexes n’était pas significative dans les villes canadiennes. Relativement aux femmes de Kingston, les prévalences du SM étaient plus élevées chez les femmes de Tirana (RP= 2,66; 95 % IC = 1,98-3,58) et de Natal (RP= 2,21; 95 % IC = 1,52-3,22) et non significatives chez celles de Manizales et de Saint-Hyacinthe. Chez les hommes, peu de différences significatives étaient observées. Le SM n’était pas associé à la mobilité dans les villes non canadiennes. Conclusion : Nos résultats suggèrent que le genre est un facteur de risque pour le SM. Des recherches sur les relations entre le SM, la mobilité et le genre devraient être entreprises. Mots-clés : Syndrome métabolique, troubles de la mobilité, genre, santé internationale / Background: Few international studies have examined differences in metabolic syndrome (MetS) between men and women. Objectives: To compare the prevalence of MetS in women and men and to assess the role of gender in the association between MetS and mobility disability. Methods: We used baseline data from the International Mobility in Aging Study of community samples aged 65-74 years (n = 1995) of the cities of Kingston (Ontario), Saint- Hyacinthe (Quebec), Tirana (Albania), Manizales (Colombia), Natal (Brazil). Of these, 1,728 people donated a blood sample. Prevalence ratios of MetS and mobility disability were estimated by Poisson regression. Results: In non-Canadian cities the prevalence of MetS was significantly higher in women while in Canadian cities there was no significant sex difference. Among women, comparing with Kingston, MetS prevalence was significantly higher for women in Tirana (PR= 2.66; 95%CI = 1.98 to 3.58) and Natal (PR=2.21; 95%CI =1.52 - 3.22), but no significant differences were observed for women in Manizales and Saint-Hyacinthe. Among men, few significant differences were observed across cities. In non-Canadian sites, MetS was not associated with mobility disability. Conclusion Our results suggest that gender is a risk factor for MetS. Research on the relationship of MetS, mobility and gender need to be initiated. Keywords: Metabolic syndrome, mobility disability, gender, international health.

<p>This thesis presents perspectives and experiences of different stakeholders and their ways of reasoning around pregnancy and pregnancy care. Data were generated from individual interviews with 25 health care providers, 18 women and 6 traditional birth attendants (TBAs) as well as 11 focus groups discussions with women, men and TBAs. </p><p>The challenges experienced by health care providers in their provision of antenatal care, while attempting to change antenatal care through routines proven to have medical value, are highlighted. Changing some long established routines, such as weighing and timing of visits, proved difficult mostly because of resistance from the users of care, whose reasoning and rationale for using care did not correspond with the professional perspectives of care. </p><p>Women also combined biomedical and traditional care. The women used the clinic to receive professional care and assurance that the pregnancy was progressing well and used TBAs, who are believed to have supernatural powers, for cultural forms of assurance and protection. The health care staff did not appreciate these aspects and discouraged women using TBAs. Midwives had problems to change routines of care because of their stressful working situations and the expectations of the women.</p><p>In addition, they described the paradoxes in providing antenatal care in the context of HIV and AIDS. The caregivers were aware of the magnitude of HIV and AIDS and yet did not have any information on the HIV status of the women they cared for. This also caused fear for occupational transmission. HIV/AIDS is highly stigmatised in this area and women used various strategies to avoid testing.</p><p>The study emphasised the need to broaden the conceptualisation and practice of evidence-based care to incorporate different types of evidence and include realities, knowledge and perspectives of not only the beneficiaries but also those implementing change as well as local knowledge. The necessity of reorganising the health care systems to accommodate the new challenges of the HIV/AIDS epidemic is also emphasised.</p>

<p>This thesis assesses the uptake of the national Prevention of Mother to Child Transmission of HIV (PMTCT) programme in South Africa, and the challenges of achieving safe infant feeding practices in the context of HIV. The research studies contained in this thesis utilised a variety of quantitative and qualitative research methods in order to provide a full understanding of the challenges of moving from efficacy to effectiveness in PMTCT programmes. The first paper utilised a cross-sectional approach to a programme evaluation, papers two and three utilised qualitative methodologies, and paper four was based on a longitudinal cohort study design. The findings highlight the low uptake of PMTCT interventions and inappropriate infant feeding choices. The experiences of women with HIV provide an important insight into the difficulties of operationalising the WHO/UNICEF HIV and infant feeding recommendations in real life settings, where rates of HIV disclosure are low and mixed feeding is the norm. Several personal and environmental characteristics were identified that contributed to success in maintaining exclusive infant feeding practices. The research provides some guidance on the definition of appropriateness in infant feeding choices, and highlights the poor outcomes associated with formula feeding under unsafe conditions. Modifying infant feeding practices is essential in order to reduce postnatal HIV transmission and improve child survival. Interventions to improve infant feeding need to include improving the quality of counselling and support provided by health workers, with more structured assessments used to guide infant feeding choices. Efforts are also needed at the community level to increase rates of disclosure and to promote exclusive infant feeding as a norm.</p>