Corrina Moucheraud
Corrina Moucheraud
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Associate Professor of Public Health Policy and Management
Co-Director of the Global Center for Implementation Science
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Professional overview
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Corrina Moucheraud, ScD, MPH is an Associate Professor in the Department of Public Health Policy & Management, and Co-Director of the Global Center for Implementation Science. As a global health researcher and implementation scientist, she seeks to improve outcomes by strengthening health systems and enabling the delivery of effective, equitable health services. Much of Dr. Moucheraud’s focus is on meeting the needs of women and young people, particularly in low- and middle-income countries. Dr. Moucheraud is currently leading efforts for cervical cancer prevention, including HPV vaccination, in Kenya and Malawi. She also researches HIV & non-communicable disease prevention and treatment internationally and in the U.S.
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Education
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MPH, Health Behavior, University of North Carolina Gillings School of Public Health, Chapel Hill, NCScD, Global Health & Population, Harvard T.H. Chan School of Public Health, Cambridge, MA
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Honors and awards
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Visiting Scholar, Clinical and Translational Science Awards Program (NCATS, NIH) (2021)Delta Omega Honorary Society (2020)Faculty Career Development Award (UCLA) (2017)Hellman Fellowship (UCLA) (2017)Maternal Health Task Force award (Harvard University) (2013)
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Publications
Publications
Characterizing provider bias in contraceptive care in Tanzania and Burkina Faso: A mixed-methods study
AbstractWollum, A., Moucheraud, C., Gipson, J. D., Friedman, W., Shah, M., & Wagner, Z. (n.d.).Publication year
2024Journal title
Social Science and MedicineVolume
348AbstractProvider bias based on age, marital status, and parity may be a barrier to quality contraceptive care. However, the extent to which bias leads to disparities in care quality is not well understood. In this mixed-methods study, we used four different data sources from the same facilities to assess the extent of bias and how much it affects contraceptive care. First, we surveyed providers in Tanzania and Burkina Faso (N = 295) to assess provider attitudes about young, unmarried, and nulliparous clients. Second, mystery clients anonymously visited providers for contraceptive care and we randomly assigned the reported age, marital status, and parity of each visit (N = 306). We used data from these visits to investigate contraceptive care disparities across 3 domains: information provision and counseling quality, contraceptive method provision, and perceived treatment. Third, we complemented mystery client data with client exit surveys (N = 31,023) and client in-depth interviews (N = 36). In surveys, providers reported biased attitudes against young, unmarried, and nulliparous clients seeking contraceptives. Similarly, we found disparities according to these characteristics in the reporting of contraceptive care quality; however, we found that each characteristic affected a different quality of care domain. Among mystery clients we found age-related disparities in the provision of methods; 16/17-year-old clients were 18 and 11 percentage points less likely to perceive they could take a contraceptive method relative to 24-year-old clients in Tanzania and Burkina Faso, respectively. Unmarried mystery clients perceived worse treatment from providers compared to married clients. Nulliparous mystery clients reported lower quality contraceptive counseling than their parous counterparts. These results suggest that clients of different characteristics likely experience bias across different elements of care. Improving care quality and reducing disparities will require attention to which elements of care are deficient for different types of clients.Cost-effectiveness of approaches to cervical cancer screening in Malawi: comparison of frequencies, lesion treatment techniques, and risk-stratified approaches
AbstractRasmussen, P. W., Hoffman, R. M., Phiri, S., Makwaya, A., Kominski, G. F., Bastani, R., Moses, A., & Moucheraud, C. (n.d.).Publication year
2024Journal title
BMC health services researchVolume
24Issue
1AbstractBackground: Recently-updated global guidelines for cervical cancer screening incorporated new technologies—most significantly, the inclusion of HPV DNA detection as a primary screening test—but leave many implementation decisions at countries’ discretion. We sought to develop recommendations for Malawi as a test case since it has the second-highest cervical cancer burden globally and high HIV prevalence. We incorporated updated epidemiologic data, the full range of ablation methods recommended, and a more nuanced representation of how HIV status intersects with cervical cancer risk and exposure to screening to model outcomes of different approaches to screening. Methods: Using a Markov model, we estimate the relative health outcomes and costs of different approaches to cervical cancer screening among Malawian women. The model was parameterized using published data, and focused on comparing “triage” approaches—i.e., lesion treatment (cryotherapy or thermocoagulation) at differing frequencies and varying by HIV status. Health outcomes were quality-adjusted life years (QALYs) and deaths averted. The model was built using TreeAge Pro software. Results: Thermocoagulation was more cost-effective than cryotherapy at all screening frequencies. Screening women once per decade would avert substantially more deaths than screening only once per lifetime, at relatively little additional cost. Moreover, at this frequency, it would be advisable to ensure that all women who screen positive receive treatment (rather than investing in further increases in screening frequency): for a similar gain in QALYs, it would cost more than four times as much to implement once-per-5 years screening with only 50% of women treated versus once-per-decade screening with 100% of women treated. Stratified screening schedules by HIV status was found to be an optimal approach. Conclusions: These results add new evidence about cost-effective approaches to cervical cancer screening in low-income countries. At relatively infrequent screening intervals, if resources are limited, it would be more cost-effective to invest in scaling up thermocoagulation for treatment before increasing the recommended screening frequency. In Malawi or countries in a similar stage of the HIV epidemic, a stratified approach that prioritizes more frequent screening for women living with HIV may be more cost-effective than population-wide recommendations that are HIV status neutral.Removal of long-acting reversible contraceptive methods and quality of care in Dar es Salaam, Tanzania: Client and provider perspectives from a secondary analysis of cross-sectional survey data from a randomized controlled trial
AbstractWollum, A., Moucheraud, C., Sabasaba, A., & Gipson, J. D. (n.d.).Publication year
2024Journal title
PLOS Global Public HealthVolume
4Issue
1AbstractAccess to removal of long-acting reversible contraception (LARCs) (e.g., implants and intrauterine devices (IUDs)) is an essential part of contraceptive care. We conducted a secondary analysis of cross-sectional survey data from a randomized controlled trial. We analyzed 5,930 client surveys and 259 provider surveys from 73 public sector facilities in Tanzania to examine the receipt of desired LARC removal services among clients and the association between receipt of desired LARC removal and person-centered care. We used provider survey data to contextualize these findings, describing provider attitudes and training related to LARC removals. All facilities took part in a larger randomized controlled trial to assess the Beyond Bias intervention, a provider-focused intervention to reduce provider bias on the basis of age, marital status, and parity. Thirteen percent of clients did not receive a desired LARC removal during their visit. Clients who were young, had lower perceived socioeconomic status, and visited facilities that did not take part in the Beyond Bias intervention were less likely to receive a desired removal. Clients who received a desired LARC removal reported higher levels of person-centered care (β = .07, CI: .02 - .11, p = < .01). Half of providers reported not being comfortable removing a LARC before its expiration (51%) or if they disagreed with the client’s decision (49%). Attention is needed to ensure clients can get their LARCs removed when they want to ensure patient-centered care and protect client autonomy and rights. Interventions like the Beyond Bias intervention, may work to address provider-imposed barriers to LARC removals.The impact of primary health care on AIDS incidence and mortality: A cohort study of 3.4 million Brazilians
AbstractPinto, P. F., Macinko, J., Silva, A. F., Lua, I., Jesus, G., Magno, L., Teles Santos, C. A., Ichihara, M. Y., Barreto, M. L., Moucheraud, C., Souza, L. E., Dourado, I., & Rasella, D. (n.d.).Publication year
2024Journal title
PLoS MedicineVolume
21Issue
7AbstractBackground AU Primary: Pleaseconfirmthatallheadinglevelsarerepresentedcorrectly Health Care (PHC) is essential for effective, efficient, : and more equitable health systems for all people, including those living with HIV/AIDS. This study evaluated the impact of the exposure to one of the largest community-based PHC programs in the world, the Brazilian Family Health Strategy (FHS), on AIDS incidence and mortality. Methods and findings A retrospective cohort study carried out in Brazil from January 1, 2007 to December 31, 2015. We conducted an impact evaluation using a cohort of 3,435,068 ≥13 years low-income individuals who were members of the 100 Million Brazilians Cohort, linked to AIDS diagnoses and deaths registries. We evaluated the impact of FHS on AIDS incidence and mortality and compared outcomes between residents of municipalities with low or no FHS coverage (unexposed) with those in municipalities with 100% FHS coverage (exposed). We used multivariable Poisson regressions adjusted for all relevant municipal and individual-level demographic, socioeconomic, and contextual variables, and weighted with inverse probability of treatment weighting (IPTW). We also estimated the FHS impact by sex and age and performed a wide range of sensitivity and triangulation analyses; 100% FHS coverage was associated with lower AIDS incidence (rate ratio [RR]: 0.76, 95% CI: 0.68 to 0.84) and mortality (RR: 0.68, 95%CI: 0.56 to 0.82). FHS impact was similar between men and women, but was larger in people aged ≥35 years old both for incidence (RR: 0.62, 95% CI: 0.53 to 0.72) and mortality (RR: 0.56, 95% CI: 0.43 to 0.72). The absence of important confounding variables (e.g., sexual behavior) is a key limitation of this study. Conclusions AIDS should be an avoidable outcome for most people living with HIV today and our study shows that FHS coverage could significantly reduce AIDS incidence and mortality among low-income populations in Brazil. Universal access to comprehensive healthcare through community-based PHC programs should be promoted to achieve the Sustainable Development Goals of ending AIDS by 2030.Trust in health workers and patient-centeredness of care were strongest factors associated with vaccination for Kenyan children born between 2017–2022
AbstractMoucheraud, C., Ochieng, E., Ogutu, V., Sudhinaraset, M., Szilagyi, P. G., Hoffman, R. M., Glenn, B., Golub, G., & Njomo, D. (n.d.).Publication year
2024Journal title
Vaccine: XVolume
19AbstractObjective: Although vaccination confidence is declining globally, there is little detailed information from low- and middle-income countries about factors influencing routine vaccination behavior in these contexts. Methods: In mid-2022, we surveyed people who gave birth in Kenya between 2017–2022, and asked them about their children's vaccination history and about hypothesized correlates of vaccination per the Behavioural and Social Drivers of Vaccination model. Results: Of 873 children in this sample, 117 (13%) were under-vaccinated (i.e., delayed or missing vaccine dose(s)) – and under-vaccination was more common among births during the COVID-19 pandemic (2020–2022) versus pre-pandemic (2017–2019). In multi-level multivariable models, children of respondents who expressed concerns about serious side effects from vaccines had significantly higher odds of missed vaccine dose(s) (aOR 2.06, 95 % CI 1.14–3.72), and there was a strong association between having more safety concerns now versus before the COVID-19 pandemic (aOR missed dose(s) 4.44, 95 % CI 1.71–11.51; aOR under-vaccination 3.03, 95 % CI 1.28–7.19). People with greater trust in health workers had lower odds of having a child with missed vaccine dose(s) (aOR 0.85, 95 % CI 0.75–0.97). People who reported higher patient-centered quality of vaccination care had much lower odds of having children with delayed or missed vaccine dose(s) (aOR missed dose(s) 0.14, 95 % CI 0.04–0.58; aOR under-vaccination 0.27, 95 % CI 0.10–0.79). Conclusions: These findings highlight potential strategies to improve vaccine coverage: greater focus on patient-centered quality of care, training healthcare workers on how to address safety concerns about vaccines, and building trust in the health care system and in health workers.Burnout and depression: A cross sectional study among health care workers providing HIV care during the COVID-19 pandemic in Malawi
AbstractPhiri, K., Songo, J., Whitehead, H., Chikuse, E., Moucheraud, C., Dovel, K., Phiri, S., Hoffman, R. M., & Van Oosterhout, J. J. (n.d.).Publication year
2023Journal title
PLOS Global Public HealthVolume
3Issue
9AbstractHealth care workers (HCWs) in eastern Africa experience high levels of burnout and depression, and this may be exacerbated during the COVID-19 pandemic due to anxiety and increased work pressure. We assessed the prevalence of burnout, depression and associated factors among Malawian HCWs who provided HIV care during the COVID-19 pandemic. From April-May 2021, between the second and third COVID-19 waves in Malawi, we randomly selected HCWs from 32 purposively selected PEPFAR/USAID-supported health facilities for a cross-sectional survey. We screened for depression using the World Health Organization Self Report Questionnaire (positive screen: score ≥8) and for burnout using the Maslach Burnout Inventory tool, (positive screen: moderate-high Emotional Exhaustion and/or moderate-high Depersonalization, and/or low-moderate Personal Accomplishment scores). Logistic regression models were used to evaluate factors associated with depression and burnout. We enrolled 435 HCWs, median age 32 years (IQR 28–38), 54% male, 34% were clinical cadres and 66% lay cadres. Of those surveyed, 28% screened positive for depression, 29% for burnout and 13% for both. In analyses that controlled for age, district, and residence (rural/urban), we found that screening positive for depression was associated with expecting to be infected with COVID-19 in the next 12 months (aOR 2.7, 95%CI 1.3–5.5), and previously having a COVID-19 infection (aOR 2.58, 95CI 1.4–5.0). Screening positive for burnout was associated with being in the clinical cadre (aOR 1.86; 95% CI: 1.2–3.0) and having a positive depression screen (aOR 3.2; 95% CI: 1.9–5.4). Reports of symptoms consistent with burnout and depression were common among Malawian HCWs providing HIV care but prevalence was not higher than in surveys before the COVID-19 pandemic. Regular screening for burnout and depression should be encouraged, given the potential for adverse HCW health outcomes and reduced work performance. Feasible interventions for burnout and depression among HCWs in our setting need to be introduced urgently.Changes in Use of Complementary and Integrative Health Therapies at the Veterans Affairs: Findings from a Whole Health System Pilot Program
AbstractResnick, A., Zeliadt, S. B., Ganz, D. A., Moucheraud, C., Chuang, E., Yano, E. M., & Taylor, S. L. (n.d.).Publication year
2023Journal title
Journal of Integrative and Complementary MedicineVolume
29Issue
12Page(s)
805-812AbstractIntroduction: The Department of Veterans Affairs (VA) launched a Whole Health System pilot program in 18 VA ‘‘Flagship’’ medical centers in 2018 in part to expand the provision of complementary and integrative health (CIH) therapies. Materials and methods: A longitudinal quasi-experimental design was used to examine Veterans’ use of at least 1 of 12 CIH therapies 2 years after initiation of the Flagship pilot program compared with the year before the program started. The sample included Veterans with chronic musculoskeletal pain with at least one visit to a VA primary care, mental health care, or pain clinic in each of the 3 study years. A population-average logit model was used to measure changes in the percentage of Veterans using at least one the CIH therapies over time. Results: Among Veterans with chronic musculoskeletal pain receiving health care at Flagship sites, 9.7% used a CIH therapy before the Flagship program initiation, whereas 14.2% used a therapy in the second year of the program (46.0% increase). In comparison, CIH therapy use among Veterans at non-Flagship sites increased from 10.3% to 12.0% over the same period (16.5% increase). Results from the population-average logit model show that Veterans at Flagship sites were significantly more likely to be CIH therapy users in the first (p < 0.001) and second (p < 0.001) years of the implementation compared with non-Flagship sites. Discussion: The Flagship pilot program was successful in terms of increasing the use of CIH therapies among Veterans with chronic musculoskeletal pain compared with non-Flagship sites. Conclusions: The Whole Health System implementation that included financial incentives, education, and other support to 18 VA ‘‘Flagship’’ medical centers helped to increase the use of CIH therapies in the VA. Future research should examine which of these efforts were most effective in expanding CIH therapy provision.Correlates of uptake of COVID-19 vaccines and motivation to vaccinate among Malawian adults
AbstractWhitehead, H. S., Songo, J., Phiri, K., Kalande, P., Lungu, E., Phiri, S., Van Oosterhout, J. J., Hoffman, R. M., & Moucheraud, C. (n.d.).Publication year
2023Journal title
Human Vaccines and ImmunotherapeuticsVolume
19Issue
2AbstractCOVID-19 vaccine coverage in most countries in Africa remains low. Determinants of uptake need to be better understood to improve vaccination campaigns. Few studies from Africa have identified correlates of COVID-19 vaccination in the general population. We surveyed adults at 32 healthcare facilities across Malawi, purposively sampled to ensure balanced representation of adults with and without HIV. The survey, informed by the World Health Organization’s Behavioural and Social Drivers of Vaccination Framework, asked about people’s thoughts and feelings about the vaccine, social processes, motivation to vaccinate, and access issues. We classified respondents’ COVID-19 vaccination status and willingness to vaccinate, and used multivariable logistic regression to assess correlates of these. Among 837 surveyed individuals (median age was 39 years (IQR 30–49) and 56% were female), 33% were up-to-date on COVID-19 vaccination, 61% were unvaccinated, and 6% were overdue for a second dose. Those up-to-date were more likely to know someone who had died from COVID-19, feel the vaccine is important and safe, and perceive pro-vaccination social norms. Despite prevalent concerns about vaccine side effects, 54% of unvaccinated respondents were willing to vaccinate. Access issues were reported by 28% of unvaccinated but willing respondents. Up-to-date COVID-19 vaccination status was associated with positive attitudes about the vaccine and with perceiving pro-vaccination social norms. Over half of unvaccinated respondents were willing to get vaccinated. Disseminating vaccine safety messages from trusted sources and ensuring local vaccine availability may ultimately increase vaccine uptake.Experiences with telemedicine for HIV care in two federally qualified health centers in Los Angeles: a qualitative study
AbstractWalker, D., Moucheraud, C., Butler, D., De Vente, J., Tangonan, K., Shoptaw, S., Currier, J. S., Gladstein, J., & Hoffman, R. (n.d.).Publication year
2023Journal title
BMC health services researchVolume
23Issue
1AbstractBackground: The SARS-CoV-2 pandemic has resulted in an increase in telemedicine utilization for routine HIV care. However, there is limited information on perceptions of and experiences with telemedicine from United States (U.S.) federally qualified health centers (FQHCs) offering HIV care. We sought to understand telemedicine experiences of stakeholders with various roles: people living with HIV (PLHIV), clinical (clinicians and case managers), programmatic (clinic administrators), and policy (policymakers). Methods: Qualitative interviews about benefits and challenges of telemedicine (telephone and video) for HIV care were conducted with 31 PLHIV and 23 other stakeholders (clinicians, case managers, clinic administrators, and policymakers). Interviews were transcribed, translated to English if conducted in Spanish, coded, and analyzed for major themes. Results: Almost all PLHIV felt capable of engaging in telephone visits, with some expressing interest in learning how to use video visits as well. Nearly all PLHIV wanted to continue telemedicine as part of their routine HIV care, and this was also endorsed by clinical, programmatic and policy stakeholders. Interviewees agreed that telemedicine for HIV care has benefits for PLHIV, especially savings of time and transportation costs, which also reduced stress. Clinical, programmatic, and policy stakeholders expressed concerns around patients’ technological literacy and resources, as well as their access to privacy, and some felt that PLHIV strongly preferred in-person visits. These stakeholders also commonly reported clinic-level implementation challenges, including integrating telephone and video telemedicine into workflows and difficulty with video visit platforms. Conclusions: Telemedicine for HIV care, largely delivered via telephone (audio-only), was highly acceptable and feasible for both PLHIV, clinicians, and other stakeholders. Addressing barriers for stakeholders in incorporating video visits will be important for the successful implementation of telemedicine with video as part of routine HIV care at FQHCs.Four very basic ways to think about policy in implementation science
AbstractPurtle, J., Moucheraud, C., Yang, L. H., & Shelley, D. (n.d.).Publication year
2023Journal title
Implementation Science CommunicationsVolume
4Issue
1AbstractBackground: Policy is receiving increasing attention in the field of implementation science. However, there remains a lack of clear, concise guidance about how policy can be conceptualized in implementation science research. Building on Curran’s article “Implementation science made too simple”—which defines “the thing” as the intervention, practice, or innovation in need of implementation support—we offer a typology of four very basic ways to conceptualize policy in implementation science research. We provide examples of studies that have conceptualized policy in these different ways and connect aspects of the typology to established frameworks in the field. The typology simplifies and refines related typologies in the field. Four very basic ways to think about policy in implementation science research. 1) Policy as something to adopt: an evidence-supported policy proposal is conceptualized as “the thing” and the goal of research is to understand how policymaking processes can be modified to increase adoption, and thus reach, of the evidence-supported policy. Policy-focused dissemination research is well-suited to achieve this goal. 2) Policy as something to implement: a policy, evidence-supported or not, is conceptualized as “the thing” and the goal of research is to generate knowledge about how policy rollout (or policy de-implementation) can be optimized to maximize benefits for population health and health equity. Policy-focused implementation research is well-suited to achieve this goal. 3) Policy as context to understand: an evidence-supported intervention is “the thing” and policies are conceptualized as a fixed determinant of implementation outcomes. The goal of research is to understand the mechanisms through which policies affect implementation of the evidence-supported intervention. 4) Policy as strategy to use: an evidence-supported intervention is “the thing” and policy is conceptualized as a strategy to affect implementation outcomes. The goal of research is to understand, and ideally test, how policy strategies affect implementation outcomes related to the evidence-supported intervention. Conclusion: Policy can be conceptualized in multiple, non-mutually exclusive ways in implementation science. Clear conceptualizations of these distinctions are important to advancing the field of policy-focused implementation science and promoting the integration of policy into the field more broadly.Impact of COVID-19 Response on the HIV Epidemic in Men Who Have Sex With Men in San Francisco County: The Importance of Rapid Return to Normalcy
AbstractLiang, C., Suen, S. C., Nguyen, A., Moucheraud, C., Hsu, L., Holloway, I. W., Charlebois, E. D., & Steward, W. T. (n.d.).Publication year
2023Journal title
Journal of Acquired Immune Deficiency SyndromesVolume
92Issue
5Page(s)
370-377AbstractBackground: In response to the COVID-19 pandemic, San Francisco County (SFC) had to shift many nonemergency health care resources to COVID-19, reducing HIV control resources. We sought to quantify COVID-19 effects on HIV burden among men who have sex with men (MSM) as SFC returns to pre-COVID service levels and progresses toward the Ending the HIV Epidemic (EHE) goals. Setting: Microsimulation model of MSM in SFC tracking HIV progression and treatment. Methods: Scenario analysis where services affected by COVID-19 [testing, care engagement, pre-exposure prophylaxis (PrEP) uptake, and retention] return to pre-COVID levels by the end of 2022 or 2025, compared against a counterfactual where COVID-19 changes never occurred. We also examined scenarios where resources are prioritized to reach new patients or retain of existing patients from 2023 to 2025 before all services return to pre-COVID levels. Results: The annual number of MSM prescribed PrEP, newly acquired HIV, newly diagnosed, and achieving viral load suppression (VLS) rebound quickly after HIV care returns to pre-COVID levels. However, COVID-19 service disruptions result in measurable reductions in cumulative PrEP use, VLS person-years, incidence, and an increase in deaths over the 2020-2035 period. The burden is statistically significantly larger if these effects end in 2025 instead of 2022. Prioritizing HIV care/prevention initiation over retention results in more person-years of PrEP but less VLS person-years and more deaths, influencing EHE PrEP outcomes. Conclusions: Earlier HIV care return to pre-COVID levels results in lower cumulative HIV burdens. Resource prioritization decisions may differentially affect different EHE goals.Malawian caregivers’ experiences with HPV vaccination for preadolescent girls: A qualitative study
AbstractMoucheraud, C., Whitehead, H. S., Songo, J., Szilagyi, P. G., Hoffman, R. M., & Kaunda-Khangamwa, B. N. (n.d.).Publication year
2023Journal title
Vaccine: XVolume
14AbstractIntroduction: Many low- and middle-income countries have introduced the human papillomavirus (HPV) vaccine, but uptake remains extremely low. Malawi has the second-highest incidence of cervical cancer globally, and launched a national HPV vaccination program in 2019. We sought to understand attitudes about, and experiences with, the HPV vaccine among caregivers of eligible girls in Malawi. Methods: We conducted qualitative interviews with 40 caregivers (parents or guardians) of preadolescent girls in Malawi to understand their experiences with HPV vaccination. We coded the data informed by the Behavioural and Social Drivers of vaccine uptake model and recommendations from WHO's Strategic Advisory Group of Experts Working Group on Vaccine Hesitancy. Results: In this sample, 37% of age-eligible daughters had not received any HPV vaccine doses, 35% had received 1 dose, 19% had received 2 doses, and 10% had an unknown vaccination status. Caregivers were aware of the dangers of cervical cancer, and understood that HPV vaccine is an effective prevention tool. However, many caregivers had heard rumors about the vaccine, particularly its alleged harmful effect on girls’ future fertility. Many caregivers, especially mothers, felt that school-based vaccination was efficient; but some caregivers expressed disappointment that they had not been more engaged in the school-based delivery of HPV vaccine. Caregivers also reported that the COVID-19 pandemic has been disruptive to vaccination. Conclusions: There are complex and intersecting factors that affect caregivers’ motivation to vaccinate their daughters against HPV, and the practical challenges that caregivers may encounter. We identify areas for future research and intervention that could contribute to cervical cancer elimination: better communicating about vaccine safety (particularly to address concerns about loss of fertility), leveraging the unique advantages of school-based vaccination while ensuring parental engagement, and understanding the complex effects of the COVID-19 pandemic (and vaccination program).Preferences and acceptability for long-acting PrEP agents among pregnant and postpartum women with experience using daily oral PrEP in South Africa and Kenya
AbstractWara, N. J., Mvududu, R., Marwa, M. M., Gómez, L., Mashele, N., Orrell, C., Moucheraud, C., Kinuthia, J., John-Stewart, G., Myer, L., Hoffman, R., Pintye, J., & Davey, D. L. (n.d.).Publication year
2023Journal title
Journal of the International AIDS SocietyVolume
26Issue
5AbstractIntroduction: Long-acting pre-exposure prophylaxis (PrEP) options could overcome barriers to oral PrEP persistence during pregnancy and postpartum. We evaluated long-acting PrEP preferences among oral PrEP-experienced pregnant and postpartum women in South Africa and Kenya, countries with high PrEP coverage with pending regulatory approvals for long-acting injectable cabotegravir and the dapivirine vaginal ring (approved in South Africa, under review in Kenya). Methods: From September 2021 to February 2022, we surveyed pregnant and postpartum women enrolled in oral PrEP studies in South Africa and Kenya. We evaluated oral PrEP attitudes and preferences for long-acting PrEP methods in multivariable logistic regression models adjusting for maternal age and country. Results: We surveyed 190 women in South Africa (67% postpartum; median age 27 years [IQR = 22–32]) and 204 women in Kenya (79% postpartum; median age 29 years [IQR = 25–33]). Seventy-five percent of participants reported oral PrEP use within the last 30 days. Overall, forty-nine percent of participants reported negative oral PrEP attributes, including side effects (21% South Africa, 30% Kenya) and pill burden (20% South Africa, 25% Kenya). Preferred PrEP attributes included long-acting method, effectiveness, safety while pregnant and breastfeeding, and free medication. Most participants (75%, South Africa and Kenya) preferred a potential long-acting injectable over oral PrEP, most frequently for a longer duration of effectiveness in South Africa (87% South Africa, 42% Kenya) versus discretion in Kenya (5% South Africa, 49% Kenya). Eighty-seven percent of participants preferred oral PrEP over a potential long-acting vaginal ring, mostly due to concern about possible discomfort with vaginal insertion (82% South Africa, 48% Kenya). Significant predictors of long-acting PrEP preference included past use of injectable contraceptive (aOR = 2.48, 95% CI: 1.34, 4.57), disliking at least one oral PrEP attribute (aOR = 1.72, 95% CI: 1.05, 2.80) and preferring infrequent PrEP use (aOR = 1.58, 95% CI: 0.94, 2.65). Conclusions: Oral PrEP-experienced pregnant and postpartum women expressed a theoretical preference for long-acting injectable PrEP over other modalities, demonstrating potential acceptability among a key population who must be at the forefront of injectable PrEP rollout. Reasons for PrEP preferences differed by country, emphasizing the importance of increasing context-specific options and choice of PrEP modalities for pregnant and postpartum women.Recent Alcohol Use Is Associated with Increased Pre-exposure Prophylaxis (PrEP) Continuation and Adherence among Pregnant and Postpartum Women in South Africa
AbstractMiller, A. P., Shoptaw, S., Moucheraud, C., Mvududu, R., Essack, Z., Gorbach, P. M., Myer, L., & Davey, D. L. (n.d.).Publication year
2023Journal title
Journal of Acquired Immune Deficiency SyndromesVolume
92Issue
3Page(s)
204-211AbstractBackground:South African women experience high levels of alcohol use and HIV infection during the perinatal period. Oral pre-exposure prophylaxis (PrEP) is highly effective at reducing HIV risk. We examined associations between alcohol use and PrEP use during pregnancy and postpartum.Methods:The PrEP in Pregnant and Postpartum women study is a prospective observational cohort of 1200 HIV-negative pregnant women enrolled at first antenatal care visit and followed through 12 months' postpartum in Cape Town, South Africa. The analytic sample comprised pregnant women who initiated PrEP at baseline and were not censored from study follow-up before 3-month follow-up. We examined associations between any or hazardous alcohol use (Alcohol Use Disorders Identification Test - Consumption score ≥3) in the year before pregnancy and PrEP continuation and adherence during pregnancy (self-report of missing <2 doses in past 7 days and biomarker-confirmed with tenofovir diphosphate in dried blood spots).Results:Of 943 women on PrEP (median age of 26 years), 50% reported alcohol use before pregnancy, and 33% reported hazardous use. At 3-month follow-up, 58% of women were still using PrEP; 41% reported recent adherence, and 23% were biomarker-confirmed adherent. In multivariable models, hazardous alcohol use was associated with increased odds of continuing PrEP [adjusted odds ratio (aOR) = 1.54, 95% confidence interval (CI): 1.16-2.06], self-reported PrEP adherence (aOR = 1.41, 95% CI: 1.07-1.87), and biomarker-confirmed PrEP adherence (aOR = 1.35 95% CI: 0.98, 1.87). Associations were similar in models of any alcohol use and PrEP continuation/adherence.Conclusions:Pregnant and postpartum women who reported recent alcohol use had increased odds of continuing to take PrEP, indicating that higher risk women may continue on oral PrEP.Uptake of the COVID-19 vaccine among healthcare workers in Malawi
AbstractMoucheraud, C., Phiri, K., Whitehead, H. S., Songo, J., Lungu, E., Chikuse, E., Phiri, S., Van Oosterhout, J. J., & Hoffman, R. M. (n.d.).Publication year
2023Journal title
International HealthVolume
15Issue
1Page(s)
77-84AbstractBackground: Little is known about coronavirus disease 2019 (COVID-19) vaccination in Africa. We sought to understand Malawian healthcare workers’ (HCWs’) COVID-19 vaccination and its hypothesized determinants. Methods: In March 2021, as the COVID-19 vaccine roll-out commenced in Malawi, we surveyed clinical and lay cadre HCWs (n=400) about their uptake of the vaccine and potential correlates (informed by the WHO Behavioral and Social Drivers of COVID-19 Vaccination framework). We analyzed uptake and used adjusted multivariable logistic regression models to explore how ‘what people think and feel’ constructs were associated with HCWs’ motivation to be vaccinated. Results: Of the surveyed HCWs, 82.5% had received the first COVID-19 vaccine dose. Motivation (eagerness to be vaccinated) was strongly associated with confidence in vaccine benefits (adjusted OR [aOR] 9.85, 95% CI 5.50 to 17.61) and with vaccine safety (aOR 4.60, 95% CI 2.92 to 7.23), but not with perceived COVID-19 infection risk (aOR 1.38, 95% CI 0.88 to 2.16). Of all the information sources about COVID-19 vaccination, 37.5% were reportedly negative in tone. Conclusions: HCWs in Malawi have a high motivation to be vaccinated and a high COVID-19 vaccine uptake. Disseminating vaccine benefits and safety messages via social media and social networks may be persuasive for individuals who are unmotivated to be vaccinated and less likely to accept the COVID-19 vaccine.Are Unequal Policies in Pre-Exposure Prophylaxis Uptake Needed to Improve Equality? An Examination among Men Who Have Sex with Men in Los Angeles County
AbstractNguyen, A., Drabo, E. F., Garland, W. H., Moucheraud, C., Holloway, I. W., Leibowitz, A., & Suen, S. C. (n.d.).Publication year
2022Journal title
AIDS patient care and STDsVolume
36Issue
8Page(s)
300-312AbstractRacial and ethnic minority men who have sex with men (MSM) are disproportionately affected by HIV/AIDS in Los Angeles County (LAC), an important epicenter in the battle to end HIV. We examine tradeoffs between effectiveness and equality of pre-exposure prophylaxis (PrEP) allocation strategies among different racial and ethnic groups of MSM in LAC and provide a framework for quantitatively evaluating disparities in HIV outcomes. To do this, we developed a microsimulation model of HIV among MSM in LAC using county epidemic surveillance and survey data to capture demographic trends and subgroup-specific partnership patterns, disease progression, patterns of PrEP use, and patterns for viral suppression. We limit analysis to MSM, who bear most of the burden of HIV/AIDS in LAC. We simulated interventions where 3000, 6000, or 9000 PrEP prescriptions are provided annually in addition to current levels, following different allocation scenarios to each racial/ethnic group (Black, Hispanic, or White). We estimated cumulative infections averted and measures of equality, after 15 years (2021-2035), relative to base case (no intervention). By comparing allocation strategies on the health equality impact plane, we find that, of the policies evaluated, targeting PrEP preferentially to Black individuals would result in the largest reductions in incidence and disparities across the equality measures we considered. This result was consistent over a range of PrEP coverage levels, demonstrating that there are "win-win"PrEP allocation strategies that do not require a tradeoff between equality and efficiency.Assessing sustainment of health worker outcomes beyond program end: Evaluation results from an infant and young child feeding intervention in Bangladesh
AbstractMoucheraud, C., Epstein, A., Sarma, H., Kim, S. S., Nguyen, P. H., Rahman, M., Tariquijaman, M., Glenn, J., Payán, D. D., Menon, P., & Bossert, T. J. (n.d.).Publication year
2022Journal title
Frontiers in Health ServicesVolume
2AbstractIntroduction: Alive and Thrive (A&T) implemented infant and young child feeding (IYCF) interventions in Bangladesh. We examine the sustained impacts on health workers' IYCF knowledge, service delivery, job satisfaction, and job readiness three years after the program's conclusion. Methods: We use data from a cluster-randomized controlled trial design, including repeated cross-sectional surveys with health workers in 2010 (baseline, n = 290), 2014 (endline, n = 511) and 2017 (post-endline, n = 600). Health workers in 10 sub-districts were trained and incentivized to deliver intensified IYCF counseling, and participated in social mobilization activities, while health workers in 10 comparison sub-districts delivered standard counseling activities. Accompanying mass media and policy change activities occurred at the national level. The primary outcome is quality of IYCF service delivery (number of IYCF messages reportedly communicated during counseling); intermediate outcomes are IYCF knowledge, job satisfaction, and job readiness. We also assess the role of hypothesized modifiers of program sustainment, i.e. activities of the program: comprehensiveness of refresher trainings and receipt of financial incentives. Multivariable difference-in-difference linear regression models, including worker characteristic covariates and adjusted for clustering at the survey sampling level, are used to compare differences between groups (intervention vs. comparison areas) and over time (baseline, endline, post-endline). Results: At endline, health workers in intervention areas discussed significantly more IYCF topics than those in comparison areas (4.9 vs. 4.0 topics, p < 0.001), but levels decreased and the post-endline gap was no longer significant (4.0 vs. 3.3 topics, p = 0.067). Comprehensive refresher trainings were protective against deterioration in service delivery. Between baseline and endline, the intervention increased health workers' knowledge (3.5-point increase in knowledge scores in intervention areas, vs. 1.5-point increase in comparison areas, p < 0.0001); and this improvement persisted to post-endline, suggesting a sustained program effect on knowledge. Job satisfaction and readiness both saw improvements among workers in intervention areas during the project period (baseline to endline) but regressed to a similar level as comparison areas by post-endline. Discussion: Our study showed sustained impact of IYCF interventions on health workers' knowledge, but not job satisfaction or job readiness—and, critically, no sustained program effect on service delivery. Programs of limited duration may seek to assess the status of and invest in protective factors identified in this study (e.g., refresher trainings) to encourage sustained impact of improved service delivery. Studies should also prioritize collecting post-endline data to empirically test and refine concepts of sustainment.Association of 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.