Corrina Moucheraud
Corrina Moucheraud
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Associate Professor of Public Health Policy and Management
Co-Director of the Global Center for Implementation Science
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Professional overview
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Corrina Moucheraud, ScD, MPH is an Associate Professor in the Department of Public Health Policy & Management, and Co-Director of the Global Center for Implementation Science. As a global health researcher and implementation scientist, she seeks to improve outcomes by strengthening health systems and enabling the delivery of effective, equitable health services. Much of Dr. Moucheraud’s focus is on meeting the needs of women and young people, particularly in low- and middle-income countries. Dr. Moucheraud is currently leading efforts for cervical cancer prevention, including HPV vaccination, in Kenya and Malawi. She also researches HIV & non-communicable disease prevention and treatment internationally and in the U.S.
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Education
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MPH, Health Behavior, University of North Carolina Gillings School of Public Health, Chapel Hill, NCScD, Global Health & Population, Harvard T.H. Chan School of Public Health, Cambridge, MA
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Honors and awards
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Visiting Scholar, Clinical and Translational Science Awards Program (NCATS, NIH) (2021)Delta Omega Honorary Society (2020)Faculty Career Development Award (UCLA) (2017)Hellman Fellowship (UCLA) (2017)Maternal Health Task Force award (Harvard University) (2013)
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Publications
Publications
"a loving man has a very huge responsibility" : A mixed methods study of Malawian men's knowledge and beliefs about cervical cancer
AbstractLewis, S., Moucheraud, C., Schechinger, D., Mphande, M., Banda, B. A., Sigauke, H., Kawale, P., Dovel, K., & Hoffman, R. M. (n.d.).Publication year
2020Journal title
BMC public healthVolume
20Issue
1AbstractBackground: In Malawi, numerous barriers may prevent women from accessing cervical cancer screening services-including social factors such as male partner involvement. We conducted surveys that included open-and closed-ended questions with married Malawian men to evaluate their knowledge and beliefs about cervical cancer. Methods: HIV-positive adult (≥18 years) men (married or in a stable relationship) were recruited from an antiretroviral therapy clinic in Lilongwe, Malawi. Men were asked a series of survey questions to assess their knowledge about cervical cancer, experience with cervical cancer, their female partner's screening history, and their beliefs about gender norms and household decision-making. Following the survey, participants responded to a set of open-ended interview questions about cervical cancer screening, and men's role in prevention. Results: One hundred-twenty men were enrolled with average age 44 years and 55% having completed secondary school or higher education. Despite only moderate knowledge about cervical cancer and screening (average assessment score of 62% correct), all men expressed support of cervical cancer screening, and most (86%) believed they should be involved in their female partner's decision to be screened. Over half (61%) of men said their female partner had previously been screened for cervical cancer, and this was positively correlated with the male respondent having more progressive gender norms around sexual practices. Some men expressed concerns about the screening process, namely the propriety of vaginal exams when performed by male clinicians, and whether the procedure was painful. Conclusions: Male partners in Malawi want to be involved in decisions about cervical cancer screening, but have limited knowledge about screening, and hold rigid beliefs about gender norms that may affect their support for screening. Messaging campaigns addressing men's concerns may be instrumental in improving women's adoption of cervical cancer screening services in Malawi and similar settings.A multi-component intervention to reduce bias during family planning visits : qualitative insights on implementation from Burkina Faso, Pakistan and Tanzania
AbstractMoucheraud, C., Wollum, A., Awan, M. A., Dow, W. H., Friedman, W., Koulidiati, J. L., Sabasaba, A., Shah, M., & Wagner, Z. (n.d.).Publication year
2024Journal title
Contraception and Reproductive MedicineVolume
9Issue
1AbstractBeyond Bias was an intervention introduced in Burkina Faso, Pakistan and Tanzania, with the aim of reducing health worker bias toward young, unmarried and nulliparous women seeking family planning services. This study used qualitative methods – based on interviews with health workers who participated in the intervention, managers at health facilities that participated in the intervention, and policy and program stakeholders at the national level – to understand implementation experiences with the intervention. The results offer insights for organizations or countries seeking to implement Beyond Bias or similar programs, and point to some other key implementation challenges for multi-component interventions in lower-resource settings. The intervention, developed using a human-centered design approach, was seen as key for successful implementation but there were logistical challenges. The digital intervention was disruptive and distracting to many. In addition, the non-financial rewards intervention was perceived as complex, and some participants expressed feeling discouraged when they did not receive a reward. Beyond Bias did not sufficiently attend to the “outer setting,” and this was perceived as a major implementation barrier as it limited individuals’ capacity to fully achieve the desired behavior change; for example, space constraints meant that some health facilities could not ensure private services for all clients. There were scalability concerns related to cost, and there is uncertainty whether diversity of contexts (within and across countries) might constrain implementation of Beyond Bias at scale.A Multi-Dimensional Characterization of Aging and Wellbeing Among HIV-Positive Adults in Malawi
AbstractMoucheraud, C., Paul-Schultz, J., Mphande, M., Banda, B. A., Sigauke, H., Kumwenda, V., Dovel, K., & Hoffman, R. M. (n.d.).Publication year
2021Journal title
AIDS and BehaviorVolume
25Issue
2Page(s)
571-581AbstractThere is relatively little research on aging with HIV and wellbeing in sub-Saharan Africa. A cross-sectional survey was implemented in Malawi; eligible respondents were ≥ 30 years old and on ART for ≥ 2 years. Univariate and multiple regression analyses were stratified by age (younger adults: aged 30–49; older adults: aged ≥ 50) and gender. The median age was 51 years (total sample n = 134). Viral suppression was less common among older respondents (83.7% versus 93.0% among younger respondents) although not significant in adjusted models. Despite exhibiting worse physical and cognitive functioning (any physical functioning challenge: aOR 5.35, p = 0.02; cognitive functioning score difference: − 0.89 points, p = 0.04), older adults reported less interpersonal violence and fewer depressive symptoms (mild depression: aOR 0.23 p = 0.002; major depression: aOR 0.16, p = 0.004); in gender-stratified models, these relationships were significant only for females. More research is needed to disentangle the interplay between aging, gender and HIV in high-burden contexts and develop interventions to support comprehensive wellbeing in this population.A Qualitative Assessment of Provider and Client Experiences with 3- And 6-Month Dispensing Intervals of Antiretroviral Therapy in Malawi
AbstractHubbard, J., Phiri, K., Moucheraud, C., McBride, K., Bardon, A., Balakasi, K., Lungu, E., Dovel, K., Kakwesa, G., & Hoffman, R. M. (n.d.).Publication year
2020Journal title
Global health, science and practiceVolume
8Issue
1Page(s)
18-27AbstractIntroduction: Multimonth dispensing (MMD) of antiretroviral therapy (ART) is a differentiated model of care that can help overcome health system challenges and reduce the burden of HIV care on clients. Although 3-month dispensing has been the standard of care, interest has increased in extending refill intervals to 6 months. We explored client and provider experiences with MMD in Malawi as part of a cluster randomized trial evaluating 3- versus 6-month ART dispensing. Methods: Semi-structured in-depth interviews were conducted with 17 ART providers and 62 stable, adult clients with HIV on ART. Clients and providers were evenly divided by arm and were eligible for an interview if they had been participating in the study for 1 year (clients) or 6 months (providers). Questions focused on perceived challenges and benefits of the 3- or 6-month amount of ART dispensing. Interviews were transcribed, and data were coded and analyzed using constant comparison. Results: Both clients and providers reported that the larger medication supply had benefits. Clients reported decreased costs due to less frequent travel to the clinic and increased time for income-generating activities. Clients in the 6-month dispensing arm reported a greater sense of personal freedom and normalcy. Providers felt that the 6-month dispensing interval reduced their workload. They also expressed concerned about clients’ challenges with ART storage at home, but clients reported no storage problems. Although providers mentioned the potential risk of clients sharing the larger medication supply with family or friends, clients emphasized the value of ART and reported only rare, short-term sharing, mostly with their spouses. Providers mentioned clients’ lack of motivation to seek care for illnesses that might occur between refill appointments. Conclusions: The 6-month ART dispensing arm was particularly beneficial to clients for decreased costs, increased time for income generation, and a greater sense of normalcy. Providers’ concerns about storage, sharing, and return visits to the facility did not emerge in client interviews. Further data are needed on the feasibility of implementing a large-scale program with 6-month dispensing.Are Unequal Policies in Pre-Exposure Prophylaxis Uptake Needed to Improve Equality? An Examination among Men Who Have Sex with Men in Los Angeles County
AbstractNguyen, A., Drabo, E. F., Garland, W. H., Moucheraud, C., Holloway, I. W., Leibowitz, A., & Suen, S. C. (n.d.).Publication year
2022Journal title
AIDS patient care and STDsVolume
36Issue
8Page(s)
300-312AbstractRacial and ethnic minority men who have sex with men (MSM) are disproportionately affected by HIV/AIDS in Los Angeles County (LAC), an important epicenter in the battle to end HIV. We examine tradeoffs between effectiveness and equality of pre-exposure prophylaxis (PrEP) allocation strategies among different racial and ethnic groups of MSM in LAC and provide a framework for quantitatively evaluating disparities in HIV outcomes. To do this, we developed a microsimulation model of HIV among MSM in LAC using county epidemic surveillance and survey data to capture demographic trends and subgroup-specific partnership patterns, disease progression, patterns of PrEP use, and patterns for viral suppression. We limit analysis to MSM, who bear most of the burden of HIV/AIDS in LAC. We simulated interventions where 3000, 6000, or 9000 PrEP prescriptions are provided annually in addition to current levels, following different allocation scenarios to each racial/ethnic group (Black, Hispanic, or White). We estimated cumulative infections averted and measures of equality, after 15 years (2021-2035), relative to base case (no intervention). By comparing allocation strategies on the health equality impact plane, we find that, of the policies evaluated, targeting PrEP preferentially to Black individuals would result in the largest reductions in incidence and disparities across the equality measures we considered. This result was consistent over a range of PrEP coverage levels, demonstrating that there are "win-win"PrEP allocation strategies that do not require a tradeoff between equality and efficiency.ART Adherence Among Malawian Youth Enrolled in Teen Clubs : A Retrospective Chart Review
AbstractMcBride, K., Parent, J., Mmanga, K., Chivwala, M., Nyirenda, M. H., Schooley, A., Mwambene, J. B., Dovel, K., Lungu, E., Balakasi, K., Hoffman, R. M., & Moucheraud, C. (n.d.).Publication year
2019Journal title
AIDS and BehaviorVolume
23Issue
9Page(s)
2629-2633AbstractTo improve outcomes among HIV-positive adolescents, the Malawi Ministry of Health is supporting scale-up of “Teen Clubs,” a facility-based antiretroviral treatment (ART) delivery model. Teen Clubs are monthly ART clinics for adolescents (10–19 years old) that provide clinical services and peer psychosocial support. This paper assesses ART adherence among Teen Club attendees in Malawi. We performed a retrospective analysis of medical records and Teen Club attendance data on 589 HIV-positive adolescents at 16 Partners in Hope (PIH)—Extending Quality Improvement for HIV/AIDS in Malawi (EQUIP) supported facilities across Malawi, from January to June of 2017, who attended at least two Teen Club sessions. Multi-level logistic regression models were used to examine the role of gender and age on optimal ART adherence (≥ 95% based on pill count) among HIV-positive adolescents enrolled in Teen Clubs. The median age of adolescents in this sample was 14 years, and 47% were male. Older adolescent males (15–19 years) were 64% more likely to achieve ≥ 95% ART adherence (aOR 1.64, 95% CI 1.16–2.31, p ' 0.01) compared to younger (10–14 years) males. The effect of age on adherence was smaller and not significant among females (aOR 1.36, 95% CI 0.96–1.94, p = 0.08). In the full model including males and females, older adolescence was associated with higher odds of optimal adherence (aOR 1.48, 95% CI 1.16–1.90, p ' 0.01). These results reinforce the need for age-specialized programming for adolescents, and future research should evaluate this in achieving optimal ART adherence.Assessing sustainment of health worker outcomes beyond program end : Evaluation results from an infant and young child feeding intervention in Bangladesh
AbstractMoucheraud, C., Epstein, A., Sarma, H., Kim, S. S., Nguyen, P. H., Rahman, M., Tariquijaman, M., Glenn, J., Payán, D. D., Menon, P., & Bossert, T. J. (n.d.).Publication year
2022Journal title
Frontiers in Health ServicesVolume
2AbstractIntroduction: Alive and Thrive (A&T) implemented infant and young child feeding (IYCF) interventions in Bangladesh. We examine the sustained impacts on health workers' IYCF knowledge, service delivery, job satisfaction, and job readiness three years after the program's conclusion. Methods: We use data from a cluster-randomized controlled trial design, including repeated cross-sectional surveys with health workers in 2010 (baseline, n = 290), 2014 (endline, n = 511) and 2017 (post-endline, n = 600). Health workers in 10 sub-districts were trained and incentivized to deliver intensified IYCF counseling, and participated in social mobilization activities, while health workers in 10 comparison sub-districts delivered standard counseling activities. Accompanying mass media and policy change activities occurred at the national level. The primary outcome is quality of IYCF service delivery (number of IYCF messages reportedly communicated during counseling); intermediate outcomes are IYCF knowledge, job satisfaction, and job readiness. We also assess the role of hypothesized modifiers of program sustainment, i.e. activities of the program: comprehensiveness of refresher trainings and receipt of financial incentives. Multivariable difference-in-difference linear regression models, including worker characteristic covariates and adjusted for clustering at the survey sampling level, are used to compare differences between groups (intervention vs. comparison areas) and over time (baseline, endline, post-endline). Results: At endline, health workers in intervention areas discussed significantly more IYCF topics than those in comparison areas (4.9 vs. 4.0 topics, p < 0.001), but levels decreased and the post-endline gap was no longer significant (4.0 vs. 3.3 topics, p = 0.067). Comprehensive refresher trainings were protective against deterioration in service delivery. Between baseline and endline, the intervention increased health workers' knowledge (3.5-point increase in knowledge scores in intervention areas, vs. 1.5-point increase in comparison areas, p < 0.0001); and this improvement persisted to post-endline, suggesting a sustained program effect on knowledge. Job satisfaction and readiness both saw improvements among workers in intervention areas during the project period (baseline to endline) but regressed to a similar level as comparison areas by post-endline. Discussion: Our study showed sustained impact of IYCF interventions on health workers' knowledge, but not job satisfaction or job readiness—and, critically, no sustained program effect on service delivery. Programs of limited duration may seek to assess the status of and invest in protective factors identified in this study (e.g., refresher trainings) to encourage sustained impact of improved service delivery. Studies should also prioritize collecting post-endline data to empirically test and refine concepts of sustainment.Association of antiretroviral therapy with high-risk human papillomavirus, cervical intraepithelial neoplasia, and invasive cervical cancer in women living with HIV : a systematic review and meta-analysis
AbstractMoucheraud, C., ART and HPV Review Group, A., Kelly, H., Weiss, H. A., Benavente, Y., de Sanjose, S., Mayaud, P., Qiao, Y. l., Feng, R. M., DeVuyst, H., Tenet, V., Jaquet, A., Konopnicki, D., Omar, T., Menezes, L., Moucheraud, C., & Hoffman, R. (n.d.).Publication year
2018Journal title
The Lancet HIVVolume
5Issue
1Page(s)
e45-e58AbstractBackground The interactions between antiretroviral therapy (ART) and high-risk human papillomavirus (HPV) and cervical lesions in women living with HIV are poorly understood. We reviewed the association of ART with these outcomes. Methods We did a systematic review and meta-analysis by searching MEDLINE and Embase databases for cross-sectional or cohort studies published in English between Jan 1, 1996, and May 6, 2017, which reported the association of ART with prevalence of high-risk HPV or prevalence, incidence, progression, or regression of histological or cytological cervical abnormalities, or incidence of invasive cervcal cancer. Studies were eligible if they reported the association of combination ART or highly active ART use with the following outcomes: high-risk HPV prevalence; squamous intraepithelial lesion (SIL) or cervical intraepithelial neoplasia (CIN) prevalence, incidence, progression, or regression; and invasive cervical cancer incidence among women living with HIV. We did random-effects meta-analyses to estimate summary statistics. We examined heterogeneity with the I2 statistic. This review is registered on the PROSPERO database at the Centre of Reviews and Dissemination, University of York, York, UK (registration number CRD42016039546). Findings We identified 31 studies of the association of ART with prevalence of high-risk HPV (6537 women living with HIV) and high grade cervical lesions (HSIL-CIN2+; 9288 women living with HIV). Women living with HIV on ART had lower prevalence of high-risk HPV than did those not on ART (adjusted odds ratio [aOR] 0·83, 95% CI 0·70–0·99; I2=51%, adjusted for CD4 cell count and ART duration), and there was some evidence of association with HSIL-CIN2+ (0·65, 0·40–1·06; I2=30%). 17 studies reported the association of ART with longitudinal cervical lesion outcomes. ART was associated with a decreased risk of HSIL-CIN2+ incidence among 1830 women living with HIV (0·59, 0·40–0·87; I2=0%), SIL progression among 6212 women living with HIV (adjusted hazard ratio [aHR] 0·64, 95% CI 0·54–0·75; I2=18%), and increased likelihood of SIL or CIN regression among 5261 women living with HIV (1·54, 1·30–1·82; I2=0%). In three studies among 15 846 women living with HIV, ART was associated with a reduction in invasive cervical cancer incidence (crude HR 0·40, 95% CI 0·18–0·87, I2=33%). Interpretation Early ART initiation and sustained adherence is likely to reduce incidence and progression of SIL and CIN and ultimately incidence of invasive cervical cancer. Future cohort studies should aim to confirm this possible effect. Funding UK Medical Research Council.Association of Dual Eligibility for Medicare and Medicaid with Heart Failure Quality and Outcomes among Get with the Guidelines-Heart Failure Hospitals
AbstractBahiru, E., Ziaeian, B., Moucheraud, C., Agarwal, A., Xu, H., Matsouaka, R. A., Devore, A. D., Heidenreich, P. A., Allen, L. A., Yancy, C. W., & Fonarow, G. C. (n.d.).Publication year
2021Journal title
JAMA CardiologyVolume
6Issue
7Page(s)
791-800AbstractImportance: The Centers for Medicare & Medicaid Services uses a new peer group-based payment system to compare hospital performance as part of its Hospital Readmissions Reduction Program, which classifies hospitals into quintiles based on their share of dual-eligible beneficiaries for Medicare and Medicaid. However, little is known about the association of a hospital's share of dual-eligible beneficiaries with the quality of care and outcomes for patients with heart failure (HF). Objective: To evaluate the association between a hospital's proportion of patients with dual eligibility for Medicare and Medicaid and HF quality of care and outcomes. Design, Setting, and Participants: This retrospective cohort study evaluated 436196 patients hospitalized for HF using the Get With The Guidelines-Heart Failure registry from January 1, 2010, to December 31, 2017. The analysis included patients 65 years or older with available data on dual-eligibility status. Hospitals were divided into quintiles based on their share of dual-eligible patients. Quality and outcomes were analyzed using unadjusted and adjusted multivariable logistic regression models. Data analysis was performed from April 1, 2020, to January 1, 2021. Main Outcomes and Measures: The primary outcome was 30-day all-cause readmission. The secondary outcomes included in-hospital mortality, 30-day HF readmissions, 30-day all-cause mortality, and HF process of care measures. Results: A total of 436196 hospitalized HF patients 65 years or older from 535 hospital sites were identified, with 258995 hospitalized patients (median age, 81 years; interquartile range, 74-87 years) at 455 sites meeting the study criteria and included in the primary analysis. A total of 258995 HF hospitalizations from 455 sites were included in the primary analysis of the study. Hospitals in the highest dual-eligibility quintile (quintile 5) tended to care for patients who were younger, were more likely to be female, belonged to racial minority groups, or were located in rural areas compared with quintile 1 sites. After multivariable adjustment, hospitals with the highest quintile of dual eligibility were associated with lower rates of key process measures, including evidence-based β-blocker prescription, measure of left ventricular function, and anticoagulation for atrial fibrillation or atrial flutter. Differences in clinical outcomes were seen with higher 30-day all-cause (adjusted odds ratio, 1.24; 95% CI, 1.14-1.35) and HF (adjusted odds ratio, 1.14; 95% CI, 1.03-1.27) readmissions in higher dual-eligible quintile 5 sites compared with quintile 1 sites. Risk-adjusted in-hospital and 30-day mortality did not significantly differ in quintile 1 vs quintile 5 hospitals. Conclusions and Relevance: In this cohort study, hospitals with a higher share of dual-eligible patients provided care with lower rates of some of the key HF quality of care process measures and with higher 30-day all-cause or HF readmissions compared with lower dual-eligibility quintile hospitals..Association of HIV status and treatment characteristics with VIA screening outcomes in Malawi : A retrospective analysis
AbstractLewis, S., Mphande, M., Chibwana, F., Gumbo, T., Banda, B. A., Sigauke, H., Moses, A., Gupta, S., Hoffman, R. M., & Moucheraud, C. (n.d.).Publication year
2022Journal title
PloS oneVolume
17Issue
1 1AbstractBackground Although evidence from high-resource settings indicates that women with HIV are at higher risk of acquiring high-risk HPV and developing cervical cancer, data from cervical cancer “screen and treat” programs using visual inspection with acetic acid (VIA) in lower-income countries have found mixed evidence about the association between HIV status and screening outcomes. Moreover, there is limited evidence regarding the effect of HIV-related characteristics (e.g., viral suppression, treatment factors) on screening outcomes in these high HIV burden settings. Methods This study aimed to evaluate the relationship between HIV status, HIV treatment, and viral suppression with cervical cancer screening outcomes. Data from a “screen and treat” program based at a large, free antiretroviral therapy (ART) clinic in Lilongwe, Malawi was retrospectively analyzed to determine rates of abnormal VIA results and suspected cancer, and coverage of same-day treatment. Multivariate logistic regression assessed associations between screening outcomes and HIV status, and among women living with HIV, viremia, ART treatment duration and BMI. Results Of 1405 women receiving first-time VIA screening between 2017–2019, 13 (0.9%) had suspected cancer and 68 (4.8%) had pre-cancerous lesions, of whom 50 (73.5%) received same-day lesion treatment. There was no significant association found between HIV status and screening outcomes. Among HIV+ women, abnormal VIA was positively associated with viral load ≥ 1000 copies/mL (aOR 3.02, 95% CI: 1.22, 7.49) and negatively associated with ART treatment duration (aOR 0.88 per additional year, 95% CI: 0.80, 0.98). Conclusion In this population of women living with HIV with high rates of ART coverage and viral suppression, HIV status was not significantly associated with abnormal cervical cancer screening results. We hypothesize that ART treatment and viral suppression may mitigate the elevated risk of cervical cancer for women living with HIV, and we encourage further study on this relationship in high HIV burden settings.Barriers to HIV treatment adherence : A qualitative study of discrepancies between perceptions of patients and health providers in Tanzania and Uganda
AbstractMoucheraud, C., Stern, A. F., Ahearn, C., Ismail, A., Nsubuga-Nyombi, T., Ngonyani, M. M., Mvungi, J., & Ssensamba, J. (n.d.).Publication year
2019Journal title
AIDS patient care and STDsVolume
33Issue
9Page(s)
406-413AbstractPrevious qualitative studies about antiretroviral therapy (ART) adherence have largely focused on patient experiences. Less is known about the perspective of health care providers - particularly in low-income countries - who serve as gatekeepers and influencers of patients' HIV care experiences. This study explored patients' and providers' perceptions of important ART adherence determinants. Interviews were conducted at HIV treatment sites in Tanzania and Uganda, with adult patients on ART (n = 148), and with health care providers (n = 49). Patients were asked about their experiences with ART adherence, and providers were asked about their perceptions of what adherence challenges are faced by their patients. All interviews were conducted in local languages; transcripts were translated into English and analyzed using a codebook informed by the social ecological model. Themes were examined across and within countries. Adherence-related challenges were frequently reported, but patients and providers did not often agree about the reasons. Many patients cited challenges related to being away from home and therefore away from their pill supply; and, in Uganda, challenges picking up refills (access to care) and related to food sufficiency/diet. Providers also identified these access to care barriers, but otherwise focused on different key determinants (e.g., they rarely mentioned food/diet); instead, providers were more likely to mention alcohol/alcoholism, stigma, and lack of understanding about the importance of adhering. These findings suggest areas of opportunity for future research and for improving clinical care by aligning perceptions of adherence challenges, to deliver better-informed and useful ART counseling and support.Bedside availability of prepared oxytocin and rapid administration after delivery to prevent postpartum Hemorrhage : An observational study in Karnataka, India
AbstractMoucheraud, C., Gass, J., Lipsitz, S., Spector, J., Agrawal, P., Hirschhorn, L. R., Gawande, A., & Kodkany, B. (n.d.).Publication year
2015Journal title
Global health, science and practiceVolume
3Issue
2Page(s)
300-304AbstractPostpartum hemorrhage is a leading cause of maternal death worldwide. Rapid provision of uterotonics after childbirth is recommended to reduce the incidence and severity of postpartum hemorrhage. Data obtained through direct observation of childbirth practices, collected in a study of the World Health Organization's Safe Childbirth Checklist in Karnataka, India, were used to measure if oxytocin prepared for administration and available at the bedside before birth was associated with decreased time to administration after birth. This was an observational study of provider behavior: Data were obtained during a baseline assessment of health worker practices prior to introduction of the Safe Childbirth Checklist, representing behavior in the absence of any intervention. Analysis was based on 330 vaginal deliveries receiving oxytocin at any point postpartum. Oxytocin was prepared and available at bedside for approximately 39% of deliveries. We found that advance preparation and bedside availability of oxytocin was associated with increased likelihood of oxytocin administration within 1 minute after delivery (adjusted risk ratio = 4.89, 95% CI = 2.61, 9.16), as well as with decreased overall time to oxytocin administration after delivery (2.9 minutes sooner in adjusted models, 95% CI = -5.0, -0.9). Efforts to reduce postpartum hemorrhage should include recommendations and interventions to ensure advance preparation and bedside availability of oxytocin to facilitate prompt administration of the medicine after birth.Beyond availability and affordability : how access to medicines affects non-communicable disease outcomes
AbstractWirtz, V. J., & Moucheraud, C. (n.d.).Publication year
2017Journal title
The Lancet Public HealthVolume
2Issue
9Page(s)
e390-e391Abstract~'Blood pressure can kill you tomorrow, but HIV gives you time' : Illness perceptions and treatment experiences among Malawian individuals living with HIV and hypertension
AbstractHing, M., Hoffman, R. M., Seleman, J., Chibwana, F., Kahn, D., & Moucheraud, C. (n.d.).Publication year
2019Journal title
Health Policy and PlanningVolume
34Page(s)
II36-II44AbstractNon-communicable diseases like hypertension are increasingly common among individuals living with HIV in low-resource settings. The prevalence of hypertension among people with HIV in Malawi, e.g. has been estimated to be as high as 46%. However, few qualitative studies have explored the patient experience with comorbid chronic disease. Our study aimed to address this gap by using the health belief model (HBM) to examine how comparative perceptions of illness and treatment among participants with both HIV and hypertension may affect medication adherence behaviours. We conducted semi-structured interviews with 75 adults with HIV and hypertension at an urban clinic in Lilongwe, Malawi. Questions addressed participants' experiences with antiretroviral and antihypertensive medications, as well as their perspectives on HIV and hypertension as illnesses. Interviews were performed in Chichewa, transcribed, translated into English and analysed using ATLAS.ti. Deductive codes were drawn from the HBM and interview guide, with inductive codes added as they emerged from the data. Self-reported medication adherence was much poorer for hypertension than HIV, but participants saw hypertension as a disease at least as concerning as HIV - primarily due to the perceived severity of hypertension's consequences and participants' limited ability to anticipate them compared with HIV. Differences in medication adherence were attributed to the high costs of antihypertensive medications relative to the free availability of antiretroviral therapy, with other factors like lifestyle changes and self-efficacy also influencing adherence practices. These findings demonstrate how participants draw on past experiences with HIV to make sense of hypertension in the present, and suggest that although patients are motivated to control their hypertension, they face individual- and system-level obstacles in adhering to treatment. Thus, health policies and systems seeking to provide integrated care for HIV and hypertension should be attentive to the complex illness experiences of individuals living with these diseases.Bridging the Gap between Pilot and Scale-Up : A Model of Antenatal Testing for Curable Sexually Transmitted Infections from Botswana
AbstractWynn, A., Moucheraud, C., Martin, N. K., Morroni, C., Ramogola-Masire, D., Klausner, J. D., & Leibowitz, A. (n.d.).Publication year
2022Journal title
Sexually Transmitted DiseasesVolume
49Issue
1Page(s)
59-66AbstractBackground Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) are common sexually transmitted infections (STIs) associated with adverse outcomes, yet most countries do not test and conduct syndromic management, which lacks sensitivity and specificity. Innovations allow for expanded STI testing; however, cost is a barrier. Methods Using inputs from a pilot program in Botswana, we developed a model among a hypothetical population of 50,000 pregnant women to compare 1-year costs and outcomes associated with 3 antenatal STI testing strategies: (1) point-of-care, (2) centralized laboratory, and (3) a mixed approach (point of care at high-volume sites, and hubs elsewhere), and syndromic management. Results Syndromic management had the lowest delivery cost but was associated with the most infections at delivery, uninfected women treated, CT/NG-related low-birth-weight infants, disability-adjusted life years, and low birth weight hospitalization costs. Point-of-care CT/NG testing would treat and cure the most infections but had the highest delivery cost. Among the testing scenarios, the mixed scenario had the most favorable cost per woman treated and cured ($534/cure). Compared with syndromic management, the mixed approach resulted in a mean incremental cost-effectiveness ratio of $953 per disability-adjusted life years averted, which is cost-effective under World Health Organization's one-time per-capita gross domestic product willingness-to-pay threshold. Conclusions As countries consider new technologies to strengthen health services, there is an opportunity to determine how to best deploy resources. Compared with point-of-care, centralized laboratory, and syndromic management, the mixed approach offered the lowest cost per infection averted and is cost-effective if policy makers' willingness to pay is informed by the World Health Organization's gross domestic product/capita threshold.Burnout and depression : A cross sectional study among health care workers providing HIV care during the COVID-19 pandemic in Malawi
AbstractPhiri, K., Songo, J., Whitehead, H., Chikuse, E., Moucheraud, C., Dovel, K., Phiri, S., Hoffman, R. M., & van Oosterhout, J. J. (n.d.).Publication year
2023Journal title
PLOS global public healthVolume
3Issue
9AbstractHealth care workers (HCWs) in eastern Africa experience high levels of burnout and depression, and this may be exacerbated during the COVID-19 pandemic due to anxiety and increased work pressure. We assessed the prevalence of burnout, depression and associated factors among Malawian HCWs who provided HIV care during the COVID-19 pandemic. From April-May 2021, between the second and third COVID-19 waves in Malawi, we randomly selected HCWs from 32 purposively selected PEPFAR/USAID-supported health facilities for a cross-sectional survey. We screened for depression using the World Health Organization Self Report Questionnaire (positive screen: score ≥8) and for burnout using the Maslach Burnout Inventory tool, (positive screen: moderate-high Emotional Exhaustion and/or moderate-high Depersonalization, and/or low-moderate Personal Accomplishment scores). Logistic regression models were used to evaluate factors associated with depression and burnout. We enrolled 435 HCWs, median age 32 years (IQR 28–38), 54% male, 34% were clinical cadres and 66% lay cadres. Of those surveyed, 28% screened positive for depression, 29% for burnout and 13% for both. In analyses that controlled for age, district, and residence (rural/urban), we found that screening positive for depression was associated with expecting to be infected with COVID-19 in the next 12 months (aOR 2.7, 95%CI 1.3–5.5), and previously having a COVID-19 infection (aOR 2.58, 95CI 1.4–5.0). Screening positive for burnout was associated with being in the clinical cadre (aOR 1.86; 95% CI: 1.2–3.0) and having a positive depression screen (aOR 3.2; 95% CI: 1.9–5.4). Reports of symptoms consistent with burnout and depression were common among Malawian HCWs providing HIV care but prevalence was not higher than in surveys before the COVID-19 pandemic. Regular screening for burnout and depression should be encouraged, given the potential for adverse HCW health outcomes and reduced work performance. Feasible interventions for burnout and depression among HCWs in our setting need to be introduced urgently.Can complex programs be sustained? A mixed methods sustainability evaluation of a national infant and young child feeding program in Bangladesh and Vietnam
AbstractMoucheraud, C., Sarma, H., Ha, T. T., Ahmed, T., Epstein, A., Glenn, J., Hanh, H. H., Huong, T. T., Luies, S. K., Moitry, A. N., Nhung, D. P., Payán, D. D., Rahman, M., Tariqujjaman, M., Thuy, T. T., Tuan, T., Bossert, T. J., & Kruk, M. E. (n.d.).Publication year
2020Journal title
BMC public healthVolume
20Issue
1AbstractBackground: Poor early-life nutrition is a major barrier to good health and cognitive development, and is a global health priority. Alive & Thrive (A&T) was a multi-pronged initiative to improve infant and young child feeding behaviors. It aimed to achieve at-scale child health and nutrition improvements via a comprehensive approach that included nutrition counseling by health workers, policy change, social mobilization and mass media activities. This study evaluated the sustainability of activities introduced during A&T implementation (2009-2014) in Bangladesh and Vietnam. Methods: This was a mixed methods study that used a quasi-experimental design. Quantitative data (surveys with 668 health workers, and 269 service observations) were collected in 2017; and analysis compared outcomes (primarily dose and fidelity of activities, and capacity) in former A&T intervention areas versus areas that did not receive the full A&T intervention. Additionally, we conducted interviews and focus groups with 218 stakeholders to explore their impressions about the determinants of sustainability, based on a multi-level conceptual framework. Results: After program conclusion, stakeholders perceive declines in mass media campaigns, policy and advocacy activities, and social mobilization activities - but counseling activities were institutionalized and continued in both countries. Quantitative data show a persisting modest intervention effect: health workers in intervention areas had significantly higher child feeding knowledge, and in Bangladesh greater self-efficacy and job satisfaction, compared to their counterparts who did not receive the full package of A&T activities. While elements of the program were integrated into routine services, stakeholders noted dilution of the program focus due to competing priorities. Qualitative data suggest that some elements, such as training, monitoring, and evaluation, which were seen as essential to A&T's success, have declined in frequency, quality, coverage, or were eliminated altogether. Conclusions: The inclusion of multiple activities in A&T and efforts to integrate the program into existing institutions were seen as crucial to its success but also made it difficult to sustain, particularly given unstable financial support and human resource constraints. Future complex programs should carefully plan for institutionalization in advance of the program by cultivating champions across the health system, and designing unique and complementary roles for all stakeholders including donors.Can Self-Management Improve HIV Treatment Engagement, Adherence, and Retention? A Mixed Methods Evaluation in Tanzania and Uganda
AbstractMoucheraud, C., Stern, A. F., Ismail, A., Nsubuga-Nyombi, T., Ngonyani, M. M., Mvungi, J., & Ssensamba, J. (n.d.).Publication year
2020Journal title
AIDS and BehaviorVolume
24Issue
5Page(s)
1486-1494AbstractThis paper presents the evaluation results of a self-management support (SMS) initiative in Tanzania and Uganda, which used quality improvement to provide self-management counseling, nutritional support, and strengthened linkages to community-based services for highest-risk patients (those with malnutrition, missed appointments, poor adherence, high viral load, or low CD4 count). The evaluation assessed improvements in patient engagement, ART adherence, and retention. Difference-in-difference models used clinical data (n = 541 in Tanzania, 571 in Uganda) to compare SMS enrollees to people who would have met SMS eligibility criteria had they been at intervention sites. Interviews with health care providers explored experiences with the SMS program and were analyzed using codes derived deductively from the data. By end-line, SMS participants in Tanzania had significantly improved visit attendance (odds ratio 3.53, 95% confidence interval 2.15, 5.77); a non- significant improvement was seen in Uganda (odds ratio 1.62, 95% confidence interval 0.37, 7.02), which may reflect a dose–response relationship due to shorter program exposure there. Self-management can improve vulnerable patients’ outcomes—but maximum gains may require long implementation periods and accompanying system-level interventions. SMS interventions require long-term investment and should be contextualized in the systems and environments in which they operate.Cervical cancer prevention in Africa : A policy analysis
AbstractAkanda, R., Kawale, P., & Moucheraud, C. (n.d.).Publication year
2022Journal title
Journal of Cancer PolicyVolume
32AbstractBackground: Cervical cancer is a major public health challenge in Africa. We analyzed the presence and content of policies for the primary, secondary and tertiary prevention of cervical cancer in Africa, to identify areas of opportunity for policy strengthening in the region most affected by cervical cancer globally. Methods: We searched for publicly-available policy documents among countries in Africa. Using a data extraction form, we gathered data from these policies about key elements of primary, secondary and tertiary prevention approaches and activities based on World Health Organization (WHO) guidelines. We also contacted key stakeholders in each country to confirm these details. We summarized each country's policy details (summed score for each prevention stage and overall), and compared these scores across individual countries and groups of countries based on economic, policy and public health characteristics. Results: Most countries had at least one policy addressing some aspect of cervical cancer prevention. Primary and secondary prevention were more commonly addressed, and certain details like age of vaccination, screening age/interval and method, were frequently mentioned in these policies. Conclusion: Countries with high HIV burden and relatively more donor financing for health had more comprehensive cervical cancer policies; there was no apparent association with cervical cancer mortality, female representation in government, or economic indicators (poverty prevalence or income inequality). Policy summary: There is room to improve cervical cancer policy comprehensiveness in Africa, and to bring these policies in line with evidence and expert recommendations. This analysis is timely given upcoming monitoring of the WHO Global Strategy to Accelerate the Elimination of Cervical Cancer as a Public Health Problem. These findings suggest some improvements in African cervical cancer policy, including increased inclusion of vaccination, but many topics remain under-specified. The influence of internal and external factors on policymaking should also be considered.Changes in Use of Complementary and Integrative Health Therapies at the Veterans Affairs : Findings from a Whole Health System Pilot Program
AbstractResnick, A., Zeliadt, S. B., Ganz, D. A., Moucheraud, C., Chuang, E., Yano, E. M., & Taylor, S. L. (n.d.).Publication year
2023Journal title
Journal of Integrative and Complementary MedicineVolume
29Issue
12Page(s)
805-812AbstractIntroduction: The Department of Veterans Affairs (VA) launched a Whole Health System pilot program in 18 VA ‘‘Flagship’’ medical centers in 2018 in part to expand the provision of complementary and integrative health (CIH) therapies. Materials and methods: A longitudinal quasi-experimental design was used to examine Veterans’ use of at least 1 of 12 CIH therapies 2 years after initiation of the Flagship pilot program compared with the year before the program started. The sample included Veterans with chronic musculoskeletal pain with at least one visit to a VA primary care, mental health care, or pain clinic in each of the 3 study years. A population-average logit model was used to measure changes in the percentage of Veterans using at least one the CIH therapies over time. Results: Among Veterans with chronic musculoskeletal pain receiving health care at Flagship sites, 9.7% used a CIH therapy before the Flagship program initiation, whereas 14.2% used a therapy in the second year of the program (46.0% increase). In comparison, CIH therapy use among Veterans at non-Flagship sites increased from 10.3% to 12.0% over the same period (16.5% increase). Results from the population-average logit model show that Veterans at Flagship sites were significantly more likely to be CIH therapy users in the first (p < 0.001) and second (p < 0.001) years of the implementation compared with non-Flagship sites. Discussion: The Flagship pilot program was successful in terms of increasing the use of CIH therapies among Veterans with chronic musculoskeletal pain compared with non-Flagship sites. Conclusions: The Whole Health System implementation that included financial incentives, education, and other support to 18 VA ‘‘Flagship’’ medical centers helped to increase the use of CIH therapies in the VA. Future research should examine which of these efforts were most effective in expanding CIH therapy provision.Characterizing provider bias in contraceptive care in Tanzania and Burkina Faso : A mixed-methods study
AbstractWollum, A., Moucheraud, C., Gipson, J. D., Friedman, W., Shah, M., & Wagner, Z. (n.d.).Publication year
2024Journal title
Social Science and MedicineVolume
348AbstractProvider bias based on age, marital status, and parity may be a barrier to quality contraceptive care. However, the extent to which bias leads to disparities in care quality is not well understood. In this mixed-methods study, we used four different data sources from the same facilities to assess the extent of bias and how much it affects contraceptive care. First, we surveyed providers in Tanzania and Burkina Faso (N = 295) to assess provider attitudes about young, unmarried, and nulliparous clients. Second, mystery clients anonymously visited providers for contraceptive care and we randomly assigned the reported age, marital status, and parity of each visit (N = 306). We used data from these visits to investigate contraceptive care disparities across 3 domains: information provision and counseling quality, contraceptive method provision, and perceived treatment. Third, we complemented mystery client data with client exit surveys (N = 31,023) and client in-depth interviews (N = 36). In surveys, providers reported biased attitudes against young, unmarried, and nulliparous clients seeking contraceptives. Similarly, we found disparities according to these characteristics in the reporting of contraceptive care quality; however, we found that each characteristic affected a different quality of care domain. Among mystery clients we found age-related disparities in the provision of methods; 16/17-year-old clients were 18 and 11 percentage points less likely to perceive they could take a contraceptive method relative to 24-year-old clients in Tanzania and Burkina Faso, respectively. Unmarried mystery clients perceived worse treatment from providers compared to married clients. Nulliparous mystery clients reported lower quality contraceptive counseling than their parous counterparts. These results suggest that clients of different characteristics likely experience bias across different elements of care. Improving care quality and reducing disparities will require attention to which elements of care are deficient for different types of clients.Community and health system factors associated with antiretroviral therapy initiation among men and women in Malawi : A mixed methods study exploring gender-specific barriers to care
AbstractPhiri, K., McBride, K., Moucheraud, C., Mphande, M., Balakasi, K., Lungu, E., Kalande, P., Hoffman, R. M., & Dovel, K. (n.d.).Publication year
2021Journal title
International HealthVolume
13Issue
3Page(s)
253-261AbstractBackground: Although community and health system factors are known to be critical to timely antiretroviral therapy (ART) initiation, little is known about how they affect men and women. Methods: We examined community- and health system-level factors associated with ART initiation in Malawi and whether associations differ by gender; 312 ART initiates and 108 non-initiates completed a survey; a subset of 30 individuals completed an indepth interview. Quantitative data were analyzed using univariate and multivariate logistic regressions, with separate models by gender. Qualitative data were analyzed through constant comparison methods. Results: Among women, no community-level characteristics were associated with ART initiation in multivariable models; among men, receiving social support for HIV services (adjusted OR [AOR]=4.61; pConsequences of maternal mortality on infant and child survival : A 25-year longitudinal analysis in Butajira Ethiopia (1987-2011)
AbstractMoucheraud, C., Worku, A., Molla, M., Finlay, J. E., Leaning, J., & Yamin, A. E. (n.d.).Publication year
2015Journal title
Reproductive HealthVolume
12Issue
1AbstractBackground: Maternal mortality remains the leading cause of death and disability for reproductive-age women in resource-poor countries. The impact of a mother's death on child outcomes is likely severe but has not been well quantified. This analysis examines survival outcomes for children whose mothers die during or shortly after childbirth in Butajira, Ethiopia. Methods: This study uses data from the Butajira Health and Demographic Surveillance System (HDSS) site. Child outcomes were assessed using statistical tests to compare survival trajectories and age-specific mortality rates for children who did and did not experience a maternal death. The analyses leveraged the advantages of a large, long-term longitudinal dataset with a high frequency of data collection; but used a strict date-based method to code maternal deaths (as occurring within 42 or 365 days of childbirth), which may be subject to misclassification or recall bias. Results: Between 1987 and 2011, there were 18189 live births to 5119 mothers; and 73 mothers of 78 children died within the first year of their child's life, with 45% of these (n=30) classified as maternal deaths due to women dying within 42 days of childbirth. Among the maternal deaths, 81% of these infants also died. Children who experienced a maternal death within 42 days of their birth faced 46 times greater risk of dying within one month when compared to babies whose mothers survived (95% confidence interval 25.84-81.92; or adjusted ratio, 57.24 with confidence interval 25.31-129.49). Conclusions: When a woman in this study population experienced a maternal death, her infant was much more likely to die than to survive - and the survival trajectory of these children is far worse than those of mothers who do not die postpartum. This highlights the importance of investigating how clinical care and socio-economic support programs can better address the needs of orphans, both throughout the intra- and post-partum periods as well as over the life course.Contraceptive Care Visit Objectives and Outcomes : Evidence From Burkina Faso, Pakistan, and Tanzania
AbstractMoucheraud, C., Wollum, A., Brooks, M. A., Shah, M., Gipson, J., & Wagner, Z. (n.d.).Publication year
2024Journal title
Studies in family planningVolume
55Issue
4Page(s)
315-332AbstractGlobally, care experiences of the growing population of contraceptive users are not well-understood. We leverage a large client dataset (n = 71,602) from three countries (Burkina Faso, Pakistan, and Tanzania) to characterize contraceptive services sought (visit objective and method preference), assess whether these visit objectives were met and for whom, and explore if visit objective fulfillment was associated with care quality. Most people in all three countries said they were seeking to continue their current method or adopt a method for the first time. Clients seeking to change their method were least likely to have their objective met: 63.7 percent of clients in Burkina Faso, 73.3 percent in Pakistan, and 61.1 percent in Tanzania who wanted to switch actually achieved this during the visit. In Burkina Faso, people with lower socioeconomic standing, lower educational attainment, and lower parity less commonly had their switching objective, fulfilled. Method preference fulfillment was generally high, although approximately 15 percent of Tanzanian clients were given implants despite wanting another method. Among those seeking to adopt or restart a method in Pakistan and Tanzania, having this visit objective fulfilled, was correlated with better perceived treatment and higher person-centeredness of care.Correlates of uptake of COVID-19 vaccines and motivation to vaccinate among Malawian adults
AbstractWhitehead, H. S., Songo, J., Phiri, K., Kalande, P., Lungu, E., Phiri, S., van Oosterhout, J. J., Hoffman, R. M., & Moucheraud, C. (n.d.).Publication year
2023Journal title
Human Vaccines and ImmunotherapeuticsVolume
19Issue
2AbstractCOVID-19 vaccine coverage in most countries in Africa remains low. Determinants of uptake need to be better understood to improve vaccination campaigns. Few studies from Africa have identified correlates of COVID-19 vaccination in the general population. We surveyed adults at 32 healthcare facilities across Malawi, purposively sampled to ensure balanced representation of adults with and without HIV. The survey, informed by the World Health Organization’s Behavioural and Social Drivers of Vaccination Framework, asked about people’s thoughts and feelings about the vaccine, social processes, motivation to vaccinate, and access issues. We classified respondents’ COVID-19 vaccination status and willingness to vaccinate, and used multivariable logistic regression to assess correlates of these. Among 837 surveyed individuals (median age was 39 years (IQR 30–49) and 56% were female), 33% were up-to-date on COVID-19 vaccination, 61% were unvaccinated, and 6% were overdue for a second dose. Those up-to-date were more likely to know someone who had died from COVID-19, feel the vaccine is important and safe, and perceive pro-vaccination social norms. Despite prevalent concerns about vaccine side effects, 54% of unvaccinated respondents were willing to vaccinate. Access issues were reported by 28% of unvaccinated but willing respondents. Up-to-date COVID-19 vaccination status was associated with positive attitudes about the vaccine and with perceiving pro-vaccination social norms. Over half of unvaccinated respondents were willing to get vaccinated. Disseminating vaccine safety messages from trusted sources and ensuring local vaccine availability may ultimately increase vaccine uptake.