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 at GPH, and Co-Director of its Global Center for Implementation Science. A global health researcher and implementation scientist, her work 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 conducts research on HIV prevention and treatment, internationally and in the U.S. Prior to joining GPH, Dr. Moucheraud was an Associate Professor at the University of California Fielding School of Public Health, and Associate Director at the Center for Health Policy Research at UCLA. She obtained her ScD degree from the Harvard T.H. Chan School of Public Health (Global Health & Population), and her MPH from the University of North Carolina Gillings School of Public Health (Health Behavior).
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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
Using Microsimulation Modeling to Inform EHE Implementation Strategies in Los Angeles County
AbstractDrabo, E. F., Moucheraud, C., Nguyen, A., Garland, W. H., Holloway, I. W., Leibowitz, A., & Suen, S. C. (n.d.).Publication year
2022Journal title
Journal of Acquired Immune Deficiency SyndromesVolume
90Page(s)
S167-S176AbstractBackground:Pre-exposure prophylaxis (PrEP) is essential to ending HIV. Yet, uptake remains uneven across racial and ethnic groups. We aimed to estimate the impacts of alternative PrEP implementation strategies in Los Angeles County.Setting:Men who have sex with men, residing in Los Angeles County.Methods:We developed a microsimulation model of HIV transmission, with inputs from key local stakeholders. With this model, we estimated the 15-year (2021-2035) health and racial and ethnic equity impacts of 3 PrEP implementation strategies involving coverage with 9000 additional PrEP units annually, above the Status-quo coverage level. Strategies included PrEP allocation equally (strategy 1), proportionally to HIV prevalence (strategy 2), and proportionally to HIV diagnosis rates (strategy 3), across racial and ethnic groups. We measured the degree of relative equalities in the distribution of the health impacts using the Gini index (G) which ranges from 0 (perfect equality, with all individuals across all groups receiving equal health benefits) to 1 (total inequality).Results:HIV prevalence was 21.3% in 2021 [Black (BMSM), 31.1%; Latino (LMSM), 18.3%, and White (WMSM), 20.7%] with relatively equal to reasonable distribution across groups (G, 0.28; 95% confidence interval [CI], 0.26 to 0.34). During 2021-2035, cumulative incident infections were highest under Status-quo (n = 24,584) and lowest under strategy 3 (n = 22,080). Status-quo infection risk declined over time among all groups but remained higher in 2035 for BMSM (incidence rate ratio, 4.76; 95% CI: 4.58 to 4.95), and LMSM (incidence rate ratio, 1.74; 95% CI: 1.69 to 1.80), with the health benefits equally to reasonably distributed across groups (G, 0.32; 95% CI: 0.28 to 0.35). Relative to Status-quo, all other strategies reduced BMSM-WMSM and BMSM-LMSM disparities, but none reduced LMSM-WMSM disparities by 2035. Compared to Status-quo, strategy 3 reduced the most both incident infections (% infections averted: overall, 10.2%; BMSM, 32.4%; LMSM, 3.8%; WMSM, 3.5%) and HIV racial inequalities (G reduction, 0.08; 95% CI: 0.02 to 0.14).Conclusions:Microsimulation models developed with early, continuous stakeholder engagement and inputs yield powerful tools to guide policy implementation.“When You Have Gotten Help, That Means You Were Strong”: A Qualitative Study of Experiences in a “Screen and Treat” Program for Cervical Cancer Prevention in Malawi
AbstractMoucheraud, C., Kawale, P., Kafwafwa, S., Bastani, R., & Hoffman, R. M. (n.d.).Publication year
2022Journal title
Journal of Cancer EducationVolume
37Issue
2Page(s)
405-413AbstractDisproportionate cervical cancer burden falls on women in low-income countries, and there are new efforts to scale up prevention worldwide, including via “screen and treat” for detection and removal of abnormal cervical lesions. This study examines Malawian women’s experiences with “screen and treat”; this is an under-explored topic in the literature, which has focused largely on knowledge about and attitudes toward screening, but not on experiences with screening. We interviewed 47 women who have been screened at least once for cervical cancer. The interview guide and analysis approach were informed by the Multi-Level Health Outcomes Framework. Women were recruited at facilities that offer “screen and treat” and asked about their experiences with screening. The average age of respondents was 40 years, and approximately half were HIV-negative. Although women were knowledgeable about the benefits of screening, they articulated many barriers including being turned away because of stock-outs of equipment, far distances to services, discomfort with male providers, and poor communication with providers. Alongside the many health education campaigns to increase awareness and demand for “screen and treat” services, the global public health community must also address implementation barriers in the resource-constrained health systems where burden is greatest. Particular attention should be paid to quality and person-centeredness of “screen and treat” services to optimize uptake and engagement in care.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.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..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; p<0.05) was associated with ART initiation. Two health system factors were associated with ART initiation among men and one for women: trust that accessing ART services would not lead to unwanted disclosure (women: AOR=4.51, p<0.01; men: AOR=1.71, p<0.01) and trust that clients were not turned away from ART services (men: 12.36, p=0.001). Conclusions: Qualitative data indicate that men were concerned about unwanted disclosure due to engaging in ART services and long waiting times for services. Interventions to remove health system barriers to ART services should be explored to promote social support among men.Effects of spousal migration on access to healthcare for women left behind: A cross-sectional follow-up study
AbstractWest, H. S., Robbins, M. E., Moucheraud, C., Razzaque, A., & Kuhn, R. (n.d.).Publication year
2021Journal title
PloS oneVolume
16Issue
12AbstractBackground Women left behind by migration represent a unique and growing population yet remain understudied as key players in the context of migration and development. Using a unique longitudinal survey of life in Bangladesh, the Matlab Health and Socioeconomic Surveys, we examined the role of spousal migration in healthcare utilization for women. The objective of this study was to assess realized access to care (do women actually get healthcare when it is needed) and consider specific macrostructural, predisposing, and resource barriers to care that are related to migration. Methods and findings In a sample of 3,187 currently married women, we estimated multivariate logistic and multinomial regression models controlling for a wide range of baseline sociodemographic factors measured as far back as 1982. Our analyses also controlled for selection effects and explored two mechanisms through which spousal migration can affect healthcare utilization for women, remittances and frequent contact with spouses. We found that women with migrant spouses were approximately half as likely to lack needed healthcare compared to women whose spouses remained in Bangladesh (predicted probability of not getting needed healthcare 11.7% vs. 21.8%, p<0.001). The improvements in access (logistic regression coefficient for lacking care for left-behind women -0.761 p<0.01) primarily occurred through a reduction in financial barriers to care for women whose spouses were abroad. Conclusions Wives of international migrants showed significantly better access to healthcare even when accounting for selection into a migrant family. While the overall story is one of positive migration effects on healthcare access due to reductions in financial barriers to care, results also showed an increase in family-related barriers such as not being permitted to get care by a family member or travel alone to a facility, indicating that some of the benefits of migration for women left behind may be diluted by gendered family structures.High Rates of Uncontrolled Blood Pressure in Malawian Adults Living with HIV and Hypertension
AbstractHoffman, R. M., Chibwana, F., Kahn, D., Banda, B. A., Phiri, L., Chimombo, M., Kussen, C., Sigauke, H., Moses, A., Van Oosterhout, J. J., Phiri, S., Currier, J. W., Currier, J. S., & Moucheraud, C. (n.d.).Publication year
2021Journal title
Global HeartVolume
16Issue
1AbstractBackground: Hypertension is among the most commonly diagnosed non-communicable diseases in Africa, and studies have demonstrated a high prevalence of hypertension among individuals with HIV. Despite high prevalence, there has been limited attention on the clinical outcomes of hypertension treatment in this population. Objective: We sought to characterize rates of and factors associated with blood pressure control over one year among individuals on antiretroviral therapy (ART) and antihypertensive medications. Methods: We performed a prospective observational cohort study at an HIV clinic in Malawi. We defined uncontrolled hypertension as a systolic blood pressure ≥140 mm Hg and/or diastolic blood pressure ≥90 mm Hg at two or more follow-up visits during the year, while controlled hypertension was defined as <140 mm Hg systolic and <90 mm Hg diastolic at all visits, or at all but one visit. We calculated an antihypertensive non-adherence score based on self-report of missed doses at each visit (higher score = worse adherence) and used rank sum and chi-square tests to compare sociodemographic and clinical factors (including adherence) associated with blood pressure control over the year. Results: At study entry, 158 participants (23.5%) were on antihypertensive medication; participants had a median age of 51.0 years, were 66.5% female, and had a median of 6.9 years on ART. 19.0% (n = 30) achieved blood pressure control over the year of follow-up. Self-reported non-adherence to hypertension medications was the only factor significantly associated with uncontrolled blood pressure. The average non-adherence score for those with controlled blood pressure was 0.22, and for those with uncontrolled blood pressure was 0.61 (p = 0.009). Conclusions: Adults living with HIV and hypertension in our cohort had low rates of blood pressure control over one year associated with self-reported non-adherence to antihypertensive medications. Given the high prevalence and incidence of hypertension, interventions to improve blood pressure control are needed to prevent associated long-term cardio- and cerebrovascular morbidity and mortality.Nomadic Tibetan women’s reproductive health: findings from cross-sectional surveys with a hard-to-reach population
AbstractGipson, J. D., Moucheraud, C., Gyaltsen, K., Tsering, L., Nobari, T. Z., & Gyal, L. (n.d.).Publication year
2021Journal title
Reproductive HealthVolume
18Issue
1AbstractBackground: Western China has undergone substantial sociodemographic change, yet little is known about the health status of ethnic minority populations living in these areas. Methods: We report findings from two cross-sectional surveys conducted with female Tibetan nomads living in rural areas of Western China/Eastern Tibet. We present results of descriptive analyses of data collected from reproductive-aged females who attended community health fairs in 2014 (n = 193) and 2016 (n = 298). Results: On average, sexual debut preceded marriage among study participants, with fertility near replacement levels (2.7 and 2.1 in 2014 and 2016, respectively). Contraceptive use was common, and dominated by use of IUDs and female sterilization. Although over three-quarters (76%) of 2016 survey participants reported ever having at least one sexually transmitted infection (STI) symptom, there was low awareness of STIs (59%) and action to prevent STIs (21%). Younger women (< 40) were more likely to report having had had an STI symptom, as compared to older women (84% versus 71%; p < 0.05). Conclusions: We demonstrate feasibility of collecting data with this hard-to-reach population. Reporting of STI symptoms warrants further investigation to identify and address health conditions in this population of Tibetan nomadic women, especially amidst broader social and contextual changes that may affect the Tibetan population. Plain English Summary: Western China has undergone substantial sociodemographic change, yet little is known about the health status of ethnic minority populations living in these areas. We report findings from two cross-sectional surveys conducted with female Tibetan nomads living in rural areas of Western China/Eastern Tibet. We present results of descriptive analyses of data collected from reproductive-aged females who attended community health fairs in 2014 (n = 193) and 2016 (n = 298). On average, sexual debut preceded marriage among study participants, with fertility near replacement levels (2.7 and 2.1 in 2014 and 2016, respectively). Contraceptive use was common, and dominated by use of IUDs and female sterilization. Although over three-quarters (76%) of 2016 survey participants reported ever having at least one sexually transmitted infection (STI) symptom, there was low awareness of STIs (59%) and action to prevent STIs (21%). Younger women (less than 40 years old) were more likely to report having had had an STI symptom, as compared to women over 40 years old (84% versus 71%; p < 0.05). We demonstrate feasibility of collecting data with this hard-to-reach population. Reporting of STI symptoms warrants further investigation to identify and address health conditions in this population of Tibetan nomadic women, especially amidst broader social and contextual changes that may affect the Tibetan population.Provider experiences with three- and six-month antiretroviral therapy dispensing for stable clients in Zambia
AbstractPhiri, K., McBride, K., Siwale, Z., Hubbard, J., Bardon, A., Moucheraud, C., Haambokoma, M., Pisa, P. T., Moyo, C., & Hoffman, R. M. (n.d.).Publication year
2021Journal title
AIDS Care - Psychological and Socio-Medical Aspects of AIDS/HIVVolume
33Issue
4Page(s)
541-547AbstractMulti-month dispensing of antiretroviral therapy (ART) has been taken to scale in many settings in sub-Saharan Africa with the benefits of improved client satisfaction and decreased client costs. Six-month ART dispensing may further increase these benefits; however, data are lacking. Within a cluster-randomized trial of three- versus six-month dispensing in Malawi and Zambia, we performed a sub-study to explore Zambian provider experiences with multi-month dispensing. We conducted 18 in-depth interviews with clinical officers and nurses dispensing ART as part of INTERVAL in Zambia. Interview questions focused on provider perceptions of client acceptability, views on client sharing and selling of ART, and perceptions on provider workload and clinic efficiency, with a focus on differences between three- and six-month dispensing. Interviews were analyzed using inductive thematic analysis to identify key themes and patterns within the data. Providers perceived significant benefits of multi-month dispensing, with advantages of six-month over three-month dispensing related to a reduced burden on clients, and for reductions in their own workload and clinic congestion. Among nearly all providers, the six-month dispensing strategy was perceived as ideal. Further research is needed to quantify clinical outcomes of six-month dispensing and feasibility of scaling-up this intervention in resource-limited settings. Clinical Trial Number: NCT03101592.Trust In Governments And Health Workers Low Globally, Influencing Attitudes Toward Health Information, Vaccines
AbstractMoucheraud, C., Guo, H., & Macinko, J. (n.d.).Publication year
2021Journal title
Health AffairsVolume
40Issue
8Page(s)
1215-1224AbstractTrust, particularly during emergencies, is essential for effective health care delivery and health policy implementation. We used data from the 2018 Wellcome Global Monitor survey (comprising nationally representative samples from 144 countries) to examine levels and correlates of trust in governments and health workers and attitudes toward vaccines. Only one-quarter of respondents globally expressed a lot of trust in their government (trust was more common among people with less schooling, those living in rural areas, those who were financially comfortable, and those who were older), and fewer than half of respondents globally said that they trust doctors and nurses a lot. People’s trust in these institutions was correlated with trust in health or medical advice from them, and with more positive attitudes toward vaccines. Vaccine enthusiasm varied substantially across regions, with safety being the most common concern. Policy makers should understand that the public may have varying levels of trust in different institutions and actors. Although much attention is paid to crafting public health messages, it may be equally important, especially during a pandemic, to identify appropriate, trusted messengers to deliver those messages more effectively to different target populations.What is the impact of removing performance-based financial incentives on community health worker motivation? A qualitative study from an infant and young child feeding program in Bangladesh
AbstractGlenn, J., Moucheraud, C., Payán, D. D., Crook, A., Stagg, J., Sarma, H., Ahmed, T., Epstein, A., Luies, S. K., Rahman, M., Kruk, M. E., & Bossert, T. J. (n.d.).Publication year
2021Journal title
BMC health services researchVolume
21Issue
1AbstractBackground: Community health worker (CHW) motivation is an important factor related to health service quality and CHW program sustainability in low- and middle-income countries. Financial and non-financial motivators may influence CHW behavior through two dimensions of motivation: desire to perform and effort expended. The aim of this study was to explore how the removal of performance-based financial incentives impacted CHW motivation after formal funding ceased for Alive and Thrive (A&T), an infant and young child feeding (IYCF) program in Bangladesh. Methods: This qualitative study included seven focus groups (n = 43 respondents) with paid supervisors of volunteer CHWs tasked with delivering interpersonal IYCF counseling services. Data were transcribed, translated into English, and then analyzed using both a priori themes and a grounded theory approach. Results: Results suggest the removal of financial incentives was perceived to have negatively impacted CHWs’ desire to perform in three primary ways: 1) a decreased desire to work without financial compensation, 2) changes in pre- and post-intervention motivation, and 3) household income challenges due to dependence on incentives. Removal of financial incentives was perceived to have negatively impacted CHWs’ level of effort expended in four primary ways: 1) a reduction in CHW visits, 2) a reduction in quality of care, 3) CHW attrition, and 4) substitution of other income-generating activities. Conclusions: This study provides new evidence regarding how removing performance-based financial incentives from a CHW program can negatively impact CHW motivation. The findings suggest that program decision makers should consider how to construct community health work programs such that CHWs may continue to receive performance-based compensation after the original funding ceases."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 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.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. T., Ahmed, T., Epstein, A., Glenn, J., Hanh, H. H., Huong, T. 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.Health care workers’ experiences with implementation of “screen and treat” for cervical cancer prevention in Malawi: A qualitative study
AbstractMoucheraud, C., Kawale, P., Kafwafwa, S., Bastani, R., & Hoffman, R. M. (n.d.).Publication year
2020Journal title
Implementation Science CommunicationsVolume
1Issue
1AbstractBackground: Cervical cancer remains a major cause of mortality and morbidity in low- and middle-income countries, despite the availability of effective prevention approaches. “Screen and treat” (a single-visit strategy to identify and remove abnormal cervical cells) is the recommended secondary prevention approach in low-resource settings, but there has been relatively scarce robust implementation science evidence on barriers and facilitators to providing “screen and treat” from the provider perspective, or about thermocoagulation as a lesion removal technique. Methods: Informed by the Consolidated Framework for Implementation Research (CFIR), we conducted interviews with ten experienced “screen and treat” providers in Malawi. We asked questions based on the CFIR Guide, used the CFIR Guide codebook for a descriptive analysis in NVivo, and added recommended modifications for studies in low-income settings. Results: Seven CFIR constructs were identified as positively influencing implementation, and six as negatively influencing implementation. The two strong positive influences were the relative advantage of thermocoagulation versus cryotherapy (Innovation Characteristics) and respondents’ knowledge and beliefs about providing “screen and treat” (Individual Characteristics). The two strong negative influences were the availability of ongoing refresher trainings to stay up-to-date on skills (Inner Setting, Implementation Climate) and insufficient resources (staffing, infrastructure, supplies) to provide “screen and treat” to all women who need it (Inner Setting, Readiness for Implementation). Weak positive factors included perceived scalability and access to knowledge/information, as well as compatibility, leadership engagement, and team characteristics, but these latter three were mixed in valence. Weak negative influences were structural characteristics and donor priorities; and mixed but weakly negative influences were relative priority and engaging clients. Cross-cutting themes included the importance of broad buy-in (including different cadres of health workers and leadership at the facility and in the government) and the opportunities and challenges of offering integrated care (screening plus other services). Conclusions: Although “screen and treat” is viewed as effective and important, many implementation barriers remain. Our findings suggest that implementation strategies will need to be multi-level, include a diverse set of stakeholders, and explicitly address both screening and treatment.Integrated care experiences and out-of-pocket expenditures: A cross-sectional survey of adults receiving treatment for HIV and hypertension in Malawi
AbstractMoucheraud, C., Hing, M., Seleman, J., Phiri, K., Chibwana, F., Kahn, D., Schooley, A., Moses, A., & Hoffman, R. (n.d.).Publication year
2020Journal title
BMJ openVolume
10Issue
2AbstractObjectives As HIV-positive individuals' life expectancy extends, there is an urgent need to manage other chronic conditions during HIV care. We assessed the care-seeking experiences and costs of adults receiving treatment for both HIV and hypertension in Malawi. Design, setting and participants A cross-sectional survey was conducted with HIV-positive adults with hypertension at a health facility in Lilongwe that offers free HIV care and free hypertension screening, with antihypertensives available for purchase (n=199). Questions included locations and costs of all medication refills and preferences for these refill locations. Respondents were classified as using a € integrated care' if they refilled HIV and antihypertensive medications simultaneously. Data were collected between June and December 2017. Results Only half of respondents reported using the integrated care offered at the study site. Among individuals using different locations for antihypertensive medication refills, the most frequent locations were drug stores and public sector health facilities which were commonly selected due to greater convenience and lower medication costs. Although the number of antihypertensive medications was equivalent between the integrated and non-integrated care groups, the annual total cost of care differed substantially (approximately US21 in integrated care vs US90 for non-integrated care) - mainly attributable to differences in other visit costs for non-integrated care (transportation, lost wages, childcare). One-third of those in the non-integrated care group reported no expenditure for antihypertensive medication, and six people in each group reported no annual hypertension care-seeking costs at all. Conclusions Individuals using integrated care saw efficiencies because, although they were more likely to pay for antihypertensive medications, they did not incur additional costs. These results suggest that preferences and experiences must be better understood to design effective policies and programmes for integrated care among adults on antiretroviral therapy.Variability in health care quality measurement among studies using service provision assessment data from low- And middle-income countries: A systematic review
AbstractMoucheraud, C., & McBride, K. (n.d.).Publication year
2020Journal title
American Journal of Tropical Medicine and HygieneVolume
103Issue
3Page(s)
986-992AbstractQuality of care is essential for improving health outcomes, but heterogeneity in theoretical frameworks and metrics can limit studies’ generalizability and comparability. This research aimed to compare definitions of care quality across research articles that incorporate data from Service Provision Assessment (SPA) surveys. Following Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines, we used a keyword search in PubMed. Each author reviewed abstracts, then full texts, for inclusion criteria, and peer-reviewed publications of empirical analysis using SPA data. The search yielded 3,250 unique abstracts, and 34 publications were included in the final analysis. We extracted details on the SPA dataset(s) used, theoretical framework applied, and how care quality was operationalized. The 34 included articles used SPA data from 14 surveys in nine countries (all in sub-Saharan Africa plus Haiti). One-third of these articles (n = 13) included no theoretical or conceptual framework for care quality. Among those articles referencing a framework, the most common was the Donabedian model (n = 7). Studies operationalized quality constructs in extremely different ways. Few articles included outcomes as a quality construct, and the operationalization of structure varied widely. A key asset of SPA surveys, owing to the standardized structure and use of harmonized data collection instruments, is the potential for cross-survey comparisons. However, this is limited by the lack of a common framework for measuring and reporting quality in the existing literature using SPA data. Service Provision Assessment surveys offer unique and valuable insights, and a common framework and approach would substantially strengthen the body of knowledge on quality of care in low-resource settings.“It is big because it's ruining the lives of many people in Malawi”: Women's attitudes and beliefs about cervical cancer
AbstractMoucheraud, C., Kawale, P., Kafwafwa, S., Bastani, R., & Hoffman, R. M. (n.d.).Publication year
2020Journal title
Preventive Medicine ReportsVolume
18AbstractAdoption of routine cervical cancer screening in Malawi is very low, even though it has the highest cervical cancer burden in the world. We performed a multi-level assessment of Malawian women's knowledge and perceptions of cervical cancer risk and screening. Using the Multi-Level Health Outcomes Framework, we conducted interviews with 60 adult Malawian women aged 18–62 at facilities with cervical cancer screening. Eligible participants were recruited regardless of HIV status or history of screening, and asked about their experiences with cervical cancer disease and screening. Interviews were audio recorded and a theory-informed codebook was developed. Analysis focused on thematic differences across groups by age, HIV status, and screening history. Half of the sample (n = 30) had either never been screened for cervical cancer or were at the facility for their first-ever screen. Most women said that cervical cancer is dangerous, and many knew someone affected. Many women spoke about the importance of screening for prevention of cancer. Risk factors were generally well-understood, including increased risk with HIV, although this was misunderstood by some HIV-negative women to mean they were not at risk. Social networks were identified as a key determinant of screening, and gender issues were likewise highly salient. Despite high knowledge levels about cervical cancer, there remain significant challenges to improving screening, including interpersonal and system-level barriers. Future work should strengthen service delivery, target social networks and intimate partners, and develop targeted communication strategies for HIV-positive and -negative groups, especially in high-burden settings.'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.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.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.Does health worker performance affect clients' health behaviors? A multilevel analysis from Bangladesh
AbstractEpstein, A., Moucheraud, C., Sarma, H., Rahman, M., Tariqujjaman, M., Ahmed, T., Glenn, J., Bossert, T., & Kruk, M. E. (n.d.).Publication year
2019Journal title
BMC health services researchVolume
19Issue
1AbstractBackground: Suboptimal healthcare quality may be a barrier to achieving child health improvements, yet little is known about the relationship between provider compliance with evidence-based practices and client behavior change. We assess provider compliance in the context of infant and young child feeding (IYCF) counseling, its relationship with client IYCF behaviors in Bangladesh, and explore its potential determinants. Methods: We use data from a 2017 evaluation of an IYCF program that includes a health worker survey (n = 74), caregiver survey (n = 232), and direct service observation checklists of counseling sessions (n = 232 observations of 74 health workers). We assess the relationship between provider compliance with recommended IYCF counseling topics and behaviors (standardized to a 100-point scale) and three reported IYCF behaviors among clients using multi-level models with random effects at the health worker and sub-district (sampling) levels. We also evaluate whether health worker self-efficacy, satisfaction, and technical knowledge are associated with provider compliance. Results: Health worker compliance was significantly associated with reported exclusive breastfeeding for children under 6 months of age (adjusted odds ratio per 1 percentage point increase in counseling compliance score = 1.06, 95% CI 1.01, 1.12) and marginally associated with minimum dietary diversity (adjusted odds ratio per 1 percentage point increase in counseling compliance score = 1.05, 95% CI 1.00, 1.11). Counseling compliance was significantly and positively associated with both health worker self-efficacy and technical knowledge. Conclusions: We find evidence for an association between health worker compliance and client health behaviors; however, small effect sizes suggest that behavior change is multifactorial and affected by factors beyond care quality. Improvements to technical quality of care may contribute to desired health outcomes; but policies and programs seeking to change health behaviors through counseling may also wish to target upstream factors such as self-efficacy, alongside technical skill-building and knowledge, for maximum impact.Engagement in Agriculture Protects Against Food Insecurity and Malnutrition in Peri-Urban Nepal
AbstractMoucheraud, C., Chandyo, R. K., Henjum, S., Strand, T. A., Ulak, M., Fawzi, W. W., Locks, L. M., Webb, P., & Thorne-Lyman, A. L. (n.d.).Publication year
2019Journal title
Current Developments in NutritionVolume
3Issue
1AbstractBackground: Urbanization is occurring rapidly in many low- and middle-income countries, which may affect households' livelihoods, diet, and food security and nutritional outcomes. Objective: The main objective of our study was to explore whether agricultural activity among a peri-urban population in Nepal was associated with better or worse food household security, household and maternal dietary diversity, and nutritional outcomes for children and women. Methods: A cross-sectional survey was administered to 344 mother-child pairs in Bhaktapur district, Nepal, including data on household agricultural practices, livestock ownership, food security, dietary diversity and expenditures, anthropometric measurements of children (aged 5-6 y), maternal body mass index (BMI), and maternal anemia. Multivariable adjusted odds ratios (AORs) and unadjusted odds ratios were calculated using logistic regression. Results: Our findings suggest that in this sample, cultivation of land was associated with lower odds of child stunting (AOR: 0.55; 95% CI: 0.33, 0.93) and household food insecurity (AOR: 0.33; 95% CI: 0.18, 0.63), but not low (or high) maternal BMI or anemia. Livestock ownership (mostly chickens) was associated with lower food insecurity (AOR: 0.34; 95% CI: 0.16, 0.73) but not with nutrition outcomes. Women in farming households were significantly more likely to eat green leafy vegetables than were women in nonfarming households, and children living in households that grew vegetables had a lower odds of stunting than children in households that cultivated land but did not grow vegetables (AOR: 0.49; 95% CI: 0.25, 0.98). Conclusions: Our study suggests that households involved in cultivation of land in peri-urban Bhaktapur had lower odds of children's stunting and of food insecurity than noncultivating households, and that vegetable consumption is higher among those households. Given Nepal's rapid urbanization rate, more attention is needed on the potential role of peri-urban agriculture in shaping diets and nutrition.Scaling up diagnostic-driven management of sexually transmitted infections in pregnancy
Wynn, A., Moucheraud, C., Morroni, C., Ramogola-Masire, D., Klausner, J. D., & Leibowitz, A. (n.d.). In The Lancet Infectious Diseases (1–).Publication year
2019Volume
19Issue
8Page(s)
809-810