Corrina Moucheraud
Corrina Moucheraud
Scroll
Associate Professor of Public Health Policy and Management
Co-Director of the Global Center for Implementation Science
-
Professional overview
-
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.
-
Education
-
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
-
Honors and awards
-
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)
-
Publications
Publications
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
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.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.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.Effects of the COVID-19 pandemic on antenatal care utilisation in Kenya: A cross-sectional study
AbstractLandrian, A., Mboya, J., Golub, G., Moucheraud, C., Kepha, S., & Sudhinaraset, M. (n.d.).Publication year
2022Journal title
BMJ openVolume
12Issue
4AbstractObjective The aim of this study was to assess the effects of COVID-19 on antenatal care (ANC) utilisation in Kenya, including women's reports of COVID-related barriers to ANC and correlates at the individual and household levels. Design Cross-sectional study. Setting Six public and private health facilities and associated catchment areas in Nairobi and Kiambu Counties in Kenya. Participants Data were collected from 1729 women, including 1189 women who delivered in healthcare facilities before the COVID-19 pandemic (from September 2019-January 2020) and 540 women who delivered during the pandemic (from July through November 2020). Women who delivered during COVID-19 were sampled from the same catchment areas as the original sample of women who delivered before to compare ANC utilisation. Primary and secondary outcome measures Timing of ANC initiation, number of ANC visits and adequate ANC utilisation were primary outcome measures. Among only women who delivered during COVID-19 only, we explored women's reports of the pandemic having affected their ability to access or attend ANC as a secondary outcome of interest. Results Women who delivered during COVID-19 had significantly higher odds of delayed ANC initiation (ie, beginning ANC during the second vs first trimester) than women who delivered before (aOR 1.72, 95% CI 1.24 to 2.37), although no significant differences were detected in the odds of attending 4-7 or ≥8 ANC visits versus <4 ANC visits, respectively (aOR 1.12, 95% CI 0.86 to 1.44 and aOR 1.46, 95% CI 0.74 to 2.86). Nearly half (n=255/540; 47%) of women who delivered during COVID-19 reported that the pandemic affected their ability to access ANC. Conclusions Strategies are needed to mitigate disruptions to ANC among pregnant women during pandemics and other public health, environmental, or political emergencies.Gendered differences in perceptions and reports of wellbeing: A cross-sectional survey of adults on ART in Malawi
AbstractMoucheraud, C., Paul-Schultz, J., Mphande, M., Banda, B. A., Sigauke, H., Kumwenda, V., Dovel, K., Moses, A., Gupta, S., & Hoffman, R. M. (n.d.).Publication year
2022Journal title
AIDS Care - Psychological and Socio-Medical Aspects of AIDS/HIVVolume
34Issue
12Page(s)
1602-1609AbstractFew studies have examined gender differences in reported quality of life among persons living with HIV (PLWH) in low-income countries. We conducted a cross-sectional survey of adults on antiretroviral therapy in Malawi, including questions focused on wellbeing, and collected clinical data on these respondents. We compared men’s and women’s self-reported health and wellbeing using Poisson models that included socio-demographic covariates. Approximately 20% of respondents reported at least one physical functioning problem. In multiple variable models, men were significantly more likely to have a high viral load (≥200 copies/mL; aIRR 2.57), consume alcohol (aIRR 12.58), receive no help from family or friends (aIRR 2.18), and to feel worthless due to their HIV status (aIRR 2.40). Men were significantly less likely to be overweight or obese (aIRR 0.31), or report poor health (health today is not “very good;” aIRR 0.41). Taken together, despite higher prevalence of poor self-rated health, women were healthier across a range of objective dimensions, with better viral suppression, less alcohol use, and less social isolation (although they were more likely to have an unhealthy BMI). Research that includes multi-dimensional and gender-specific measurement of physical, mental and social health is important for improving our understanding of well-being of PLWH.Health behaviours and beliefs among Malawian adults taking antihypertensive medication and antiretroviral therapy: A qualitative study
AbstractMoucheraud, C., Phiri, K., & Hoffman, R. M. (n.d.).Publication year
2022Journal title
Global Public HealthVolume
17Issue
5Page(s)
688-699AbstractIn order to understand HIV-positive Malawian adults’ experiences with hypertension management, we conducted qualitative interviews with 30 hypertensive adults who were also taking antiretroviral therapy. These interviews regarding hypertension management behaviours and beliefs were audio-recorded, transcribed, translated into English, and coded in Atlas.ti. Despite acknowledging the dangers of hypertension and the benefits of medication, many respondents missed their antihypertensive medication. Primary reasons included feeling healthy, health workers’ advice to stop taking medicine when blood pressure normalised, side effects, and using herbs or non-prescription medicines to manage hypertension. Women highlighted difficulties with dietary modifications, and changes in their social relationships. Both men and women spoke about hypertension-related challenges with employment and household economics. These results suggest numerous challenges among adults managing hypertension and HIV in Malawi, and frequent suboptimal adherence to medication. We identified new key themes–the quality of adherence counselling for antihypertensive medication, the effects of hypertension on financial stability, and the role of social relationships in self-care–and encourage further investigation into these topics in low-income, high-burden countries.High rate of left ventricular hypertrophy on screening echocardiography among adults living with HIV in Malawi
AbstractHoffman, R. M., Chibwana, F., Banda, B. A., Kahn, D., Gama, K., Boas, Z. P., Chimombo, M., Kussen, C., Currier, J. S., Namarika, D., Van Oosterhout, J., Phiri, S., Moses, A., Currier, J. W., Sigauke, H., Moucheraud, C., & Canan, T. (n.d.).Publication year
2022Journal title
Open HeartVolume
9Issue
1AbstractBackground There are limited data on structural heart disease among people living with HIV in southern Africa, where the success of antiretroviral therapy (ART) has drastically improved life expectancy and where risk factors for cardiovascular disease are prevalent. Methods We performed a cross-sectional study of screening echocardiography among adults (≥18 years) with HIV in Malawi presenting for routine ART care. We used univariable and multivariable logistic regression to evaluate correlates of abnormal echocardiogram. Results A total of 202 individuals were enrolled with a median age of 45 years (IQR 39-52); 52% were female, and 27.7% were on antihypertensive medication. The most common clinically significant abnormality was left ventricular hypertrophy (LVH) (12.9%, n=26), and other serious structural heart lesions were rare (<2% with ejection fraction less than 40%, moderate-severe valve lesions or moderate-severe pericardial effusion). Characteristics associated with abnormal echocardiogram included older age (OR 1.04, 95% CI 1.01 to 1.08), higher body mass index (OR 1.09, 95% CI 1.02 to 1.17), higher mean systolic blood pressure (OR 1.03, 95% CI 1.02 to 1.05) and higher mean diastolic blood pressure (OR 1.03, 95% CI 1.01 to 1.05). In a multivariable model including age, duration on ART, body mass index, and systolic and diastolic blood pressure, only mean body mass index (adjusted OR 1.10, 95% CI 1.02 to 1.19), systolic blood pressure (aOR 1.05, 95% CI 1.03 to 1.08) and diastolic blood pressure (aOR 0.96, 95% CI 0.92 to 1.00) remained associated with abnormal echocardiogram. Conclusions LVH was common in this population of adults on ART presenting for routine care and was associated with elevated blood pressure. Further research is needed to characterise the relationship between chronic hypertension, LVH and downstream consequences, such as diastolic dysfunction and heart failure in people living with HIV.Implementation of two policies to extend maternity leave and further restrict marketing of breast milk substitutes in Vietnam: a qualitative study
AbstractPayán, D. D., Zahid, N., Glenn, J., Tran, H. T., Huong, T. T. T., & Moucheraud, C. (n.d.).Publication year
2022Journal title
Health Policy and PlanningVolume
37Issue
4Page(s)
472-482AbstractPolicy research can reveal gaps and opportunities to enhance policy impact and implementation. In this study, we use a theoretically informed qualitative approach to investigate the implementation of two policies to promote breastfeeding in Vietnam. We conducted semi-structured interviews with national and local policy stakeholders (n = 26) in 2017. Interviews were audio-recorded, transcribed verbatim and then translated to English by certified translators. Transcript data were analysed using an integrated conceptual framework of policy implementation. Respondents identified several positive outcomes resulting from implementation of an extended maternity leave policy (Labour Code No. 10/2012/QH13) and further restrictions on marketing of breast milk substitutes (Decree No. 100/2014/ND-CP). Decree No. 100, in particular, was said to have reduced advertising of breast milk substitutes in mass media outlets and healthcare settings. Key implementation actors were national-level bureaucratic actors, local organizations and international partners. Findings reveal the importance of policy precedence and a broader set of policies to promote the rights of women and children to support implementation. Other facilitators were involvement from national-level implementing agencies and healthcare personnel and strength of government relationships and coordination with non-governmental and international organizations. Implementation challenges included insufficient funding, limited training to report violations, a cumbersome reporting process and pervasive misinformation about breast milk and breast milk substitutes. Limited reach for women employed in the informal labour sector and in rural communities was said to be a compatibility issue for the extended maternity leave policy in addition to the lack of impact on non-parental guardians and caretakers. Recommendations to improve policy implementation include designating a role for international organizations in supporting implementation, expanding maternity protections for all working women, building local-level policy knowledge to support enforcement, simplifying Decree No. 100 violation reporting processes and continuing to invest in interventions to facilitate a supportive policy environment in Vietnam.Preventing, but Not Caring for, Adolescent Pregnancies? Disparities in the Quality of Reproductive Health Care in Sub-Saharan Africa
AbstractMoucheraud, C., McBride, K., Heuveline, P., & Shah, M. (n.d.).Publication year
2022Journal title
Journal of Adolescent HealthVolume
71Issue
2Page(s)
210-216AbstractPurpose: There is concern that adolescents experience worse quality of health care than older women. We compare quality of reproductive health services (family planning and antenatal care) for adolescents (<20 years) versus adult women (≥25 years), in four sub-Saharan African countries. Methods: In total, 2,342 family planning visits and 8,600 antenatal care visits were analyzed from Democratic Republic of the Congo, Malawi, Senegal, and Tanzania. Service Provision Assessment surveys include observation of care and client exit interviews. We compare visit content and care satisfaction for adolescents versus adult women aged ≥25. All models are multilevel, weighted to reflect survey design, and include client, provider, and facility covariates (pooled models also include survey fixed effects). Results: Adolescents receive more overall family planning care activities compared to adult women (2.31 activities in adjusted generalized linear models, standard error [SE] 1.29, p <.1), and 3.76 more discussion activities (e.g., counseling) on average (SE 1.94, p <.1), but significantly fewer discussion activities during antenatal care (−3.10 activities, SE.97, p <.01). However, adolescents’ satisfaction with both care types was not significantly different than adult women. These relationships largely persist in country-stratified models, using different model specifications, and when comparing adolescents to women aged ≥20. Conclusions: Adolescents’ family planning visits are similar to, or even slightly more comprehensive than, adult women—but their antenatal visits include fewer recommended care components, with particular gaps for activities requiring provider-client dialog. This suggests opportunities for strengthening communication between providers and young women, and improving care across the reproductive health continuum.Rethinking integrated service delivery for malaria
AbstractAnsah, E. K., Moucheraud, C., Arogundade, L., & Rangel, G. W. (n.d.).Publication year
2022Journal title
PLOS Global Public HealthVolume
2Issue
6AbstractDespite worldwide efforts and much progress toward malaria control, declines in malaria morbidity and mortality have hit a plateau. While many nations achieved significant malaria suppression or even elimination, success has been uneven, and other nations have made little headway—or even lost ground in this battle. These alarming trends threaten to derail the attainment of global targets for malaria control. Among the challenges impeding success in malaria reduction, many strategies center malaria as a set of technical problems in commodity development and delivery. Yet, this narrow perspective overlooks the importance of strong health systems and robust healthcare delivery. This paper argues that strategies that move the needle on health services and behaviors offer a significant opportunity to achieve malaria control through a comprehensive approach that integrates malaria with broader health services efforts. Indeed, malaria may serve as the thread that weaves integrated service delivery into a path forward for universal health coverage. Using key themes identified by the "Rethinking Malaria in the Context of COVID-19" effort through engagement with key stakeholders, we provide recommendations for pursuing integrated service delivery that can advance malaria control via strengthening health systems, increasing visibility and use of high-quality data at all levels, centering issues of equity, promoting research and innovation for new tools, expanding knowledge on effective implementation strategies for interventions, making the case for investing in malaria among stakeholders, and engaging impacted communities and nations.Rural–Urban Differences: Using Finer Geographic Classifications to Reevaluate Distance and Choice of Health Services in Malawi
AbstractMcBride, K., & Moucheraud, C. (n.d.).Publication year
2022Journal title
Health Systems and ReformVolume
8Issue
1AbstractThere is no universal understanding of what defines urban or rural areas nor criteria for differentiating within these. When assessing access to health services, traditional urban–rural dichotomies may mask substantial variation. We use geospatial methods to link household data from the 2015–2016 Malawi Demographic Health Survey to health facility data from the Malawi Service Provision Assessment and apply a new proposed four-category classification of geographic area (urban major metropolitan area, urban township, rural, and remote) to evaluate households’ distance to, and choice of, primary, secondary, and tertiary health care in Malawi. Applying this new four-category definition, approximately 3.8 million rural- and urban-defined individuals would be reclassified into new groups, nearly a quarter of Malawi’s 2015 population. There were substantial differences in distance to the nearest facility using this new categorization: remote households are (on average) an additional 5 km away from secondary and tertiary care services versus rural households. Health service choice differs also, particularly in urban areas, a distinction that is lost when using a simple binary classification: those living in major metropolitan households have a choice of five facilities offering comprehensive primary care services within a 10-km zone, whereas urban township households have no choice, with only one such facility within 10 km. Future research should explore how such expanded classifications can be standardized and used to strengthen public health and demographic research.Screening Adults for HIV Testing in the Outpatient Department: An Assessment of Tool Performance in Malawi
AbstractMoucheraud, C., Hoffman, R. M., Balakasi, K., Wong, V., Sanena, M., Gupta, S., & Dovel, K. (n.d.).Publication year
2022Journal title
AIDS and BehaviorVolume
26Issue
2Page(s)
478-486AbstractLittle is known about screening tools for adults in high HIV burden contexts. We use exit survey data collected at outpatient departments in Malawi (n = 1038) to estimate the sensitivity, specificity, negative and positive predictive values of screening tools that include questions about sexual behavior and use of health services. We compare a full tool (seven relevant questions) to a reduced tool (five questions, excluding sexual behavior measures) and to standard of care (two questions, never tested for HIV or tested > 12 months ago, or seeking care for suspected STI). Suspect STI and ≥ 3 sexual partners were associated with HIV positivity, but had weak sensitivity and specificity. The full tool (using the optimal cutoff score of ≥ 3) would achieve 55.6% sensitivity and 84.9% specificity for HIV positivity; the reduced tool (optimal cutoff score ≥ 2) would achieve 59.3% sensitivity and 68.5% specificity; and standard of care 77.8% sensitivity and 47.8% specificity. Screening tools for HIV testing in outpatient departments do not offer clear advantages over standard of care.The 10th Annual Symposium on Global Cancer Research: New Models for Global Cancer Research, Training, and Control
Jallow, F., Bourlon, M. T., Cira, M. K., Duncan, K., Eldridge, L., Elibe, E., Estes, T., Frank, A., Gravitt, P., Llera, A. S., Moucheraud, C., Mulherkar, R., Musonda, W., Ogembo, J. G., Pearlman, P., Phiri, S., Sivaram, S., Stern, M., & Gopal, S. (n.d.).Publication year
2022Journal title
JCO Global OncologyVolume
8Page(s)
1-3Trust, Care Avoidance, and Care Experiences among Kenyan Women Who Delivered during the COVID-19 Pandemic
AbstractMoucheraud, C., Mboya, J., Njomo, D., Golub, G., Gant, M., & Sudhinaraset, M. (n.d.).Publication year
2022Journal title
Health Systems and ReformVolume
8Issue
1AbstractWe explore how the COVID-19 pandemic was associated with avoidance of, and challenges with, antenatal, childbirth and postpartum care among women in Kiambu and Nairobi counties, Kenya; and whether this was associated with a report of declined trust in the health system due to the pandemic. Women who delivered between March and November 2020 were invited to participate in a phone survey about their care experiences (n = 1122 respondents). We explored associations between reduced trust and care avoidance, delays and challenges with healthcare seeking, using logistic regression models adjusted for women’s characteristics. Approximately half of respondents said their trust in the health care system had declined due to COVID-19 (52.7%, n = 591). Declined trust was associated with higher likelihood of reporting barriers accessing antenatal care (aOR 1.59 [95% CI 1.24, 2.05]), avoiding care for oneself (aOR 2.26 [95% CI 1.59, 3.22]) and for one’s infant (aOR 1.77 [95% CI 1.11, 2.83]), and of feeling unsafe accessing care (aOR 1.52 [95% CI 1.19, 1.93]). Since March 2020, emergency services, routine care and immunizations were avoided most often. Primary reported reasons for avoiding care and challenges accessing care were financial barriers and problems accessing the facility. Declined trust in the health care system due to COVID-19 may have affected health care-seeking for women and their children in Kenya, which could have important implications for their health and well-being. Programs and policies should consider targeted special “catch-up” strategies that include trust-building messages and actions for women who deliver during emergencies like the COVID-19 pandemic.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.