Evidence-informed health policy making contributes to improved health outcomes by strengthening health systems. In addition, health policy decisions should take into consideration the needs and priorities of users of healthcare services. However, little research has been done to find best ways to facilitate evidence-informed and participatory health policymaking, particularly in low- and middle-income countries. This thesis is written based on three studies done in Ethiopia to fill this knowledge gap. In the first study, we examined whether, how and under what conditions evidence was used and service-users participated during the agenda-setting and policy formulation phases of selected policies in the ‘prevention of mother-to-child transmission of HIV’ program in Ethiopia using a multiple-case study design. In the second study, we identified strategies to facilitate evidence-informed health policy making using an online survey. In the third study, we identified strategies to facilitate participatory health policy making using a combined paper-based and Internet-based Delphi approach. The thesis does not have direct theoretical contribution. However, it will draw on two theoretical frameworks, namely Kingdon’s framework and the 3I+E framework. and use them in a setting from where they were originally developed. This thesis has two substantive and three methodological contributions. Substantively, the first study provides empirical evidence about the current practice of evidence-informed and participatory health policy making in a low-income, ‘revolutionary’ democratic country (Ethiopia). In addition, the studies have identified strategies to concretize the constitutional and policy provisions for evidence-informed and participatory health policy making in Ethiopia. The thesis has the following three methodological contributions. First, the studies explored the use of Kingdon’s multiple-streams framework and the 3I+E framework in predicting factors influencing agenda-setting and policy formulation phases, respectively, and in explaining the use of research evidence in informing these two phases in a ‘revolutionary’ democratic country where they have not previously been used. Second, the thesis has shown that paper-based and Internet-based Delphi could be combined in contexts with limited resources. Third, the thesis has demonstrated the possibility of training service-users as ‘peer’ researchers to collect and analyze data to inform their participation and maximize their contribution in surveys, forming a pyramid of participation. / Thesis / Doctor of Philosophy (PhD) / Evidence-informed health policy making can contribute to improved health outcomes by strengthening health systems. In addition, health policy decisions ultimately affect users of healthcare services. Thus, such decisions should take into consideration their needs and priorities. However, little research has been done to find best ways to facilitate evidence-informed and participatory health policymaking, particularly in low- and middle-income countries. This thesis is written based on three studies done in Ethiopia. In the first study, we examined whether, how and under what conditions evidence was used and service-users participated in the ‘prevention of mother-to-child transmission of HIV’ program in Ethiopia. In the second and third studies, we identified strategies to facilitate evidence-informed and participatory health policy making. In addition, we explored the possibility of combining Internet- and paper-based methods for consensus-building among policymakers, program managers, researchers, healthcare providers and service-users in settings with limited resources.

The study aimed at assessing the factors influencing the low involvement of men in prevention of mother-to-child transmission (PMTCT) of HIV programmes in the Mambwe district, Zambia. The factors studied were grouped as knowledge and awareness, socio-cultural, programmatic and demographic characteristics. A quantitative, exploratory study was used and 127 men were interviewed. The major findings were: Knowledge of PMTCT was the strongest factor which was positively associated with the level of men's involvement in PMTCT. Socio-cultural and programmatic factors were found to negatively influence men's involvement (although weakly); and among the demographic characteristics, age and level of education were positively associated with an increase in the level of involvement, while the duration of the relationship with the female partner was negatively associated with the level of men involvement. / Health Studies / M.A. (Public Health)

This study sought to determine if ANC and PMTCT services are utilized within the first trimester of pregnancy by the women in East Ekurhuleni sub-district. Quantitative descriptive research was conducted on 390 eligible pregnant women and data collection was done using structured questionnaires. The results indicated that women start ANC late despite their knowledge of first trimester as the best time to start ANC. Actions that would motivate them to start ANC early were explored and barriers were identified. / Health Studies / MA (Public Health)

This study investigated the factors influencing the utilisation of PMTCT of HIV services and proposed measures to promote service utilisation by HIV positive pregnant women in the FCT, Abuja, Nigeria. Effective interventions exist that can reduce the transmission of HIV infection to the baby. The study is a quantitative descriptive one, with 190 HIV positive pregnant women from 20 health Centres in three area councils in Abuja, who were interviewed using structured questionnaire to get their opinion. The findings revealed that the majority (90.4%) of the respondents were aware of PMTCT and how HIV can be transmitted from mother-to-child. The respondents (95.9%) were of the opinion that all pregnant women should be tested. Notably, PMTCT services will be hindered by the following: permission from spouse before being tested, couple counselling not done, group post test counselling, non-incorporation of family planning and low support group enrolment. Recommendations made include emphasis on couple counselling, confidentiality and friendly environment / Health Studies / M.A. (Public Health)

This study aimed at exploring the influence of the home environment of women that were on the prevention of mother-to-child transmission (PMTCT) programme for HIV/AIDS. A qualitative descriptive study was conducted to explore the home environment for the psycho-social support that was available for women on the PMTCT programme and the influence this had on compliance to the programme. Data collection was done using a semi-structured interview guide, with a sample size of 14 participants (n=14). The data was then coded and grouped into categories and major themes. The findings revealed that the common barriers that prevented full disclosure of an HIV positive status included stigma and discrimination, fear of social isolation and financial dependence. A major constraint that affected the women’s full utilisation of the PMTCT preventative strategies and their adherence to treatment was the poor acceptance of people living with HIV in the family and community / Health Studies / M.A. (Health Studies)

The study aimed at assessing the factors influencing the low involvement of men in prevention of mother-to-child transmission (PMTCT) of HIV programmes in the Mambwe district, Zambia. The factors studied were grouped as knowledge and awareness, socio-cultural, programmatic and demographic characteristics. A quantitative, exploratory study was used and 127 men were interviewed. The major findings were: Knowledge of PMTCT was the strongest factor which was positively associated with the level of men's involvement in PMTCT. Socio-cultural and programmatic factors were found to negatively influence men's involvement (although weakly); and among the demographic characteristics, age and level of education were positively associated with an increase in the level of involvement, while the duration of the relationship with the female partner was negatively associated with the level of men involvement. / Health Studies / M.A. (Public Health)

This study aimed at exploring the influence of the home environment of women that were on the prevention of mother-to-child transmission (PMTCT) programme for HIV/AIDS. A qualitative descriptive study was conducted to explore the home environment for the psycho-social support that was available for women on the PMTCT programme and the influence this had on compliance to the programme. Data collection was done using a semi-structured interview guide, with a sample size of 14 participants (n=14). The data was then coded and grouped into categories and major themes. The findings revealed that the common barriers that prevented full disclosure of an HIV positive status included stigma and discrimination, fear of social isolation and financial dependence. A major constraint that affected the women’s full utilisation of the PMTCT preventative strategies and their adherence to treatment was the poor acceptance of people living with HIV in the family and community / Health Studies / M.A. (Health Studies)

This study investigated the factors influencing the utilisation of PMTCT of HIV services and proposed measures to promote service utilisation by HIV positive pregnant women in the FCT, Abuja, Nigeria. Effective interventions exist that can reduce the transmission of HIV infection to the baby. The study is a quantitative descriptive one, with 190 HIV positive pregnant women from 20 health Centres in three area councils in Abuja, who were interviewed using structured questionnaire to get their opinion. The findings revealed that the majority (90.4%) of the respondents were aware of PMTCT and how HIV can be transmitted from mother-to-child. The respondents (95.9%) were of the opinion that all pregnant women should be tested. Notably, PMTCT services will be hindered by the following: permission from spouse before being tested, couple counselling not done, group post test counselling, non-incorporation of family planning and low support group enrolment. Recommendations made include emphasis on couple counselling, confidentiality and friendly environment / Health Studies / M.A. (Public Health)

Text in English / This qualitative descriptive phenomenological study explored the experiences of HIV positive women utilising PMTCT services at a central hospital in Zimbabwe. Data was collected using in-depth interviews of fifteen participants. The interviews were audio recorded and transcribed verbatim. Using the Interpretive Phenomenological Analysis framework for data analysis, two super-ordinate themes emerged, namely resources for provision of PMTCT services and approaches and nature of PMTCT care. The study revealed challenges experienced by HIV positive women emanating from material, financial and human resource related constraints in the PMTCT setting. The resource challenges negatively affected access and utilisation of PMTCT services. A practice model, whose purpose is to enhance the quality and utilisation of PMTCT services, was developed and described. The model was evaluated using Chin and Krammer (2011) criteria plus a modified form of the Delphi technique. These findings have implications for effective PMTCT service provision. The key lessons learnt for programmatic improvement were that in order to provide quality and accessible PMTCT services the health care system will need to be well resourced. There is need to strengthen the health care system in line with HIV related programmatic changes. / Health Studies / D. L.itt. et Phil. (Health Studies)

L'intégration du traitement et de la prévention des maladies chroniques non transmissibles (MNT) au sein des soins de santé primaires représente le principal défi à venir pour la santé publique et les systèmes de santé dans les pays à faible et moyen revenu comme l’Afrique du Sud. Il constitue le principal objectif de cette thèse. L’expérience de l'intégration de la prévention de la transmission du VIH de la mère à l'enfant (PTME) dans les soins de santé primaires (SSP) peut apporter des leçons importantes pour l'intégration de la prévention du diabète chez les femmes souffrant de diabète gestationnel récent (DSG) dans les SSP. Il a été estimé que le DSG touche plus de 9,1 % des grossesses en 2018 en Afrique du Sud. Le DSG augmente le risque de développer ultérieurement du diabète de type 2 (DT2). Le DSG multiplie par plus de 7 le risque de développer un DT2 ainsi que les risques de troubles métaboliques pour les bébés des femmes qui en sont atteintes. Cette thèse explore comment appliquer les leçons tirées de l’intégration de la PTME pour intégrer le dépistage du DSG et les initiatives de prévention du DT2 dans les soins de santé primaires de routine en Afrique du Sud. Le cadre conceptuel adapté pour cette thèse permet ainsi de comprendre les aspects de l’intégration au niveau du patient et du système de santé, englobant les contextes, les mécanismes et la mise en œuvre de l’intégration d’interventions préventives dans les services existants. L'étude s'inscrit dans le cadre du projet IINDIAGO, « Intervention intégrée du système de santé visant à réduire les risques de diabète de type 2 chez les femmes défavorisées après un diabète gestationnel en Afrique du Sud ». La thèse présente d’abord une revue narrative de l’impact de la PTME sur les services et les systèmes de soins de santé en Afrique subsaharienne (Article 1). Les résultats de cette revue montrent que la PTME a eu l’impact positif et négatif sur d’autres services de soins de santé et que son intégration dans les systèmes de santé est de plus en plus privilégiée. L’article 2 est une étude qualitative analysant l’histoire et l’expérience locales de l’intégration de la PTME dans les SSP de routine en Afrique du Sud de différents points de vue. Bien qu’elle ait constaté un fort soutien en faveur de l’intégration parmi tous les répondants, cette étude a fait état de multiples obstacles à la pleine intégration de la PTME dans les SSP, le post-partum en particulier. Les articles 3 et 4 ont utilisé les méthodes mixtes et révélé que l’intégration des services dans les SSP de routine, à base communautaire, pour dépister universellement le DSG et pour prévenir ou retarder le DT2 après le DSG, était perçue comme faisable, acceptable et nécessaire de toute urgence en Afrique du Sud. L’article 6 (dont le protocole est l’article 5) présentait une revue systématique et une méta-analyse sur la prise en charge intégrée du DSG et du DT2 dans le contexte de la multimorbidité en Afrique. Les 13 études incluses dans cette étude ont montré que la gestion intégrée du DSG et du DT2 dans le cadre de la multimorbidité était mise en œuvre avec succès, mais qu’elle nécessitait une formation et une supervision adéquates des infirmières, et la fourniture d’équipements et de médicaments additionnels au sein des systèmes de santé nationaux en Afrique. Les conclusions de cette thèse suggèrent que, bien qu’elle n’ait pas toujours été retenue, en raison de défis structurels et opérationnels, l’intégration complète plutôt que partielle des services de santé est considérée comme souhaitable et réalisable par les femmes, les travailleurs de la santé, les gestionnaires et les experts. L’intégration complète pourrait être idéale pour dépister, diagnostiquer et soigner les maladies chroniques, y compris le DSG et le DT2, au sein des SSP de routine et selon l’approche de la PTME dont les leçons d’intégration n’ont pas été adaptées à ce prochain défi de santé publique. / Integrating chronic, non-communicable diseases (NCDs) and their prevention into primary health care is the next major challenge for public health and health systems in low and middle-income countries like South Africa and is the primary focus of this thesis. The experience of integration of Prevention of Mother-to-Child Transmission (PMTCT) of HIV into primary health care (PHC) may have important lessons for integrating prevention of diabetes among women with recent gestational diabetes (GDM) into PHC. GDM was estimated to affect more than 9.1% of pregnancies in 2018 in South Africa. GDM increases the risk of developing subsequent type 2 diabetes (T2DM) more than 7-fold as well as increasing the risks of metabolic disorders for the babies of women who had GDM. This thesis conducted a systematised narrative synthesis, a systematic review and a convergent mixed methods study using primarily qualitative methods in South Africa (focus on Cape Town, Western Cape) to explore how to apply lessons from PMTCT integration in order to integrate GDM screening and T2DM prevention initiatives into routine PHC in South Africa. The adapted conceptual framework for this thesis enables to understand both patient-level and health system-level aspects of integration and encompassing the contexts, mechanisms and implementation for integrating preventive interventions in the existing services. The study was nested in the IINDIAGO project, “Integrated health system intervention aimed at reducing type 2 diabetes risks in disadvantaged women after gestational diabetes in South Africa”. The thesis first presents a narrative review of the impact of PMTCT on health care services and systems in sub-Saharan Africa (Paper 1). This review findings show that PMTCT has had positive and negative impacts on other health care services and that its integration into health systems is increasingly favored. Paper 2 qualitatively documented the local history and experience of PMTCT integration into routine PHC in South Africa from different perspectives. Though it found strong support for integration among all respondents (N=20), this study reported multiple barriers for the full integration of PMTCT into PHC, especially in postpartum. Papers 3 and 4 used mixed methods and highlighted that integrating services within routine, community-based PHC to universally screen GDM and to prevent or delay of T2DM after GDM, was perceived as feasible, acceptable and urgently needed in South Africa – but that it is not currently occurring at a satisfactory level, despite international and national guidelines. The fifth article is a published protocol for Paper 6, a systematic review and meta-analysis on the integrated management of GDM and T2DM in the context of multimorbidity in Africa. This was a study in which all 13 included studies showed that integrated management of GDM and T2DM within multimorbidity was successfully implemented but it required adequate training and supervision of nurses, provision of additional equipment and drugs to the existing resources within national health systems in Africa. This thesis concludes that although not always opted for, due to structural and operational challenges, the full instead of partial integration of health services to screen, diagnose and care for chronic diseases including GDM and T2DM into routine PHC, following the PMTCT approach, was seen as both desirable and feasible by women, health workers, managers, and experts. However, the lessons learned through the history of PMTCT and its integration have not been adapted to this next public health challenge.