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
A multi-component intervention to reduce bias during family planning visits: qualitative insights on implementation from Burkina Faso, Pakistan and Tanzania
AbstractMoucheraud, C., Wollum, A., Awan, M. A., Dow, W. H., Friedman, W., Koulidiati, J. L., Sabasaba, A., Shah, M., & Wagner, Z. (n.d.).Publication year
2024Journal title
Contraception and Reproductive MedicineVolume
9Issue
1AbstractBeyond Bias was an intervention introduced in Burkina Faso, Pakistan and Tanzania, with the aim of reducing health worker bias toward young, unmarried and nulliparous women seeking family planning services. This study used qualitative methods – based on interviews with health workers who participated in the intervention, managers at health facilities that participated in the intervention, and policy and program stakeholders at the national level – to understand implementation experiences with the intervention. The results offer insights for organizations or countries seeking to implement Beyond Bias or similar programs, and point to some other key implementation challenges for multi-component interventions in lower-resource settings. The intervention, developed using a human-centered design approach, was seen as key for successful implementation but there were logistical challenges. The digital intervention was disruptive and distracting to many. In addition, the non-financial rewards intervention was perceived as complex, and some participants expressed feeling discouraged when they did not receive a reward. Beyond Bias did not sufficiently attend to the “outer setting,” and this was perceived as a major implementation barrier as it limited individuals’ capacity to fully achieve the desired behavior change; for example, space constraints meant that some health facilities could not ensure private services for all clients. There were scalability concerns related to cost, and there is uncertainty whether diversity of contexts (within and across countries) might constrain implementation of Beyond Bias at scale.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.Contraceptive Care Visit Objectives and Outcomes: Evidence From Burkina Faso, Pakistan, and Tanzania
AbstractMoucheraud, C., Wollum, A., Brooks, M., Shah, M., Gipson, J., & Wagner, Z. (n.d.).Publication year
2024Journal title
Studies in family planningVolume
55Issue
4Page(s)
315-332AbstractGlobally, care experiences of the growing population of contraceptive users are not well-understood. We leverage a large client dataset (n = 71,602) from three countries (Burkina Faso, Pakistan, and Tanzania) to characterize contraceptive services sought (visit objective and method preference), assess whether these visit objectives were met and for whom, and explore if visit objective fulfillment was associated with care quality. Most people in all three countries said they were seeking to continue their current method or adopt a method for the first time. Clients seeking to change their method were least likely to have their objective met: 63.7 percent of clients in Burkina Faso, 73.3 percent in Pakistan, and 61.1 percent in Tanzania who wanted to switch actually achieved this during the visit. In Burkina Faso, people with lower socioeconomic standing, lower educational attainment, and lower parity less commonly had their switching objective, fulfilled. Method preference fulfillment was generally high, although approximately 15 percent of Tanzanian clients were given implants despite wanting another method. Among those seeking to adopt or restart a method in Pakistan and Tanzania, having this visit objective fulfilled, was correlated with better perceived treatment and higher person-centeredness of care.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.High rate of uncontrolled hypertension among adults receiving integrated HIV and hypertension care with aligned multi-month dispensing in Malawi: results from a cross-sectional survey and retrospective chart review
AbstractWhitehead, H. S., Phiri, K., Kalande, P., Van Oosterhout, J. J., Talama, G., Phiri, S., Moucheraud, C., Moses, A., & Hoffman, R. M. (n.d.).Publication year
2024Journal title
Journal of the International AIDS SocietyVolume
27Issue
9AbstractIntroduction: People living with HIV have high rates of hypertension. Integrated HIV and hypertension care with aligned multi-month dispensing of medications (MMD) could decrease the burden of care for individuals and health systems. We sought to describe hypertension control and evaluate its association with different durations of MMD among Malawian adults receiving integrated care with aligned dispensing of antiretroviral therapy (ART) and antihypertensive medication. Methods: We conducted a cross-sectional survey and retrospective chart review of adults (≥18 years) receiving integrated HIV and hypertension care on medications for both conditions for at least 1 year, with aligned MMD at seven clinics in Malawi. Data were collected from July 2021 to April 2022 and included socio-demographics, clinical characteristics, antihypertensive medications and up to the three most recent blood pressure measurements. Bivariate analyses were used to characterize associations with hypertension control. Uncontrolled hypertension was defined as ≥2 measurements ≥140 and/or ≥90 mmHg. Chart reviews were conducted for a random subset of participants with uncontrolled hypertension to describe antihypertensive medication adjustments in the prior year. Results: We surveyed 459 adults receiving integrated care with aligned dispensing (58% female; median age 54 years). Individuals most commonly received a 3-month aligned dispensing of ART and antihypertensive medications (63%), followed by every 6 months (16%) and every 4 months (15%). Hypertension control was assessed in 359 respondents, of whom only 23% had controlled hypertension; 90% of individuals in this group reported high adherence to blood pressure medications (0−1 missed days/week). Control was more common among those with longer aligned medication dispensing intervals (20% among those with 1- to 3-month dispensing vs. 28% with 4-month dispensing vs. 40% with 6-month dispensing, p = 0.011). Chart reviews were conducted for 147 individuals with uncontrolled hypertension. Most had high self-reported adherence to blood pressure medications (89% missing 0−1 days/week); however, only 10% had their antihypertensive medication regimen changed in the prior year. Conclusions: Uncontrolled hypertension was common among Malawian adults receiving integrated care with aligned MMD and was associated with shorter refill intervals and few antihypertensive medication escalations. Integrated care with aligned MMD is promising, but further work is needed to understand how to optimize hypertension outcomes.Intervention-amenable factors associated with lack of HPV vaccination in Kenya: Results from a large national phone survey
AbstractMoucheraud, C., Ochieng, E., Ogutu, V., Chang, L. C., Golub, G., Crespi, C. M., & Szilagyi, P. G. (n.d.).Publication year
2024Journal title
VaccineVolume
42Issue
26AbstractBackground: Coverage of human papillomavirus (HPV) vaccination remains suboptimal in many countries, but the determinants are not well-understood particularly in low- and middle-income countries. We undertook a random digit dialed phone survey across Kenya between July–October 2022, with parents/caregivers of preadolescent girls, to identify intervention-amenable factors associated with respondents' daughter's HPV vaccination status. Methods: Informed by the World Health Organization Behavioral and Social Drivers of Vaccination framework, we collected information about respondents' knowledge about and hesitancy toward HPV vaccine, perceived risk of cervical cancer, social norms around HPV vaccination, trust in institutions, and access to HPV vaccination services. Results: 1416 parents/caregivers completed the survey (97.4 % of those eligible), of whom 38.2 % said that age-eligible girl(s) in their household had received any doses of the HPV vaccine. Knowledge/perceptions: In multivariable models adjusted for sociodemographic characteristics, respondents with less HPV vaccine hesitancy and fewer concerns about safety were more likely to have vaccinated daughter(s), as were those with greater knowledge about HPV vaccine and knowing someone who had died from cervical cancer. Social norms: Having spoken with others about HPV vaccination, although reported by less than half of respondents, and believing that other parents have vaccinated their daughters were associated with having vaccinated daughter(s). Respondents with more trust in information about HPV vaccination from health systems, and with higher trust in institutions, had greater odds of having vaccinated daughter(s). Access: One-fifth of respondents had experienced, or anticipated experiencing, challenges accessing HPV vaccination services, and these respondents had approximately half the odds of having a vaccinated daughter compared to their counterparts. Conclusions: Promising areas for intervention include: targeted messaging about safety of the HPV vaccine, increasing parents'/caregivers' knowledge about the vaccine, and leveraging trusted messengers including health workers, faith leaders, and peer parents/caregivers.Preferences for Hypertension Care in Malawi: A Discrete Choice Experiment Among People Living with Hypertension, With and Without HIV
AbstractHoffman, R., Phiri, K., Kalande, P., Whitehead, H., Moses, A., Rockers, P. C., Tseng, C. H., Talama, G., Banda, J. C., Van Oosterhout, J. J., Phiri, S., & Moucheraud, C. (n.d.).Publication year
2024Journal title
AIDS and BehaviorAbstractHypertension is the most common non-communicable disease diagnosed among people in sub-Saharan Africa. However, little is known about client preferences for hypertension care. We performed a discrete choice experiment in Malawi among people with hypertension, with and without HIV. Participants were asked to select between two care scenarios, each with six attributes: distance, waiting time, provider friendliness, individual or group care, antihypertensive medication supply, and antihypertensive medication dispensing frequency (three versus one month). Eight choice sets (each with two scenarios) were presented to each individual. Mixed effects logit models quantified preferences for each attribute. Estimated model coefficients were used to predict uptake of hypothetical models of care. Between July 2021 and April 2022 we enrolled 1003 adults from 14 facilities in Malawi; half were living with HIV and on ART for a median of 11 years. Median age of respondents was 57 years (IQR 49–63), 58.2% were female, and median duration on antihypertensive medications was 4 years (IQR 2–7). Participants strongly preferred seeing a provider alone versus in a group (OR 11.3, 95% CI 10.4–12.3), with stronger preference for individual care among those with HIV (OR 15.4 versus 8.6, p < 0.001). Three-month versus monthly dispensing was also strongly preferred (OR 4.2; 95% CI 3.9–4.5). 72% of respondents would choose group care if all other facility attributes were favorable, although PLHIV were less likely to make this trade-off (66% versus 77%). These findings have implications for the scale-up of hypertension care in Malawi and similar settings.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.Telemedicine for HIV care: a cross-sectional survey of people living with HIV receiving care at two federally qualified health centers in Los Angeles during a mature phase of the COVID-19 pandemic
AbstractWalker, D., Moucheraud, C., Butler, D., Takayama, C., Shoptaw, S., Currier, J. S., Gladstein, J., & Hoffman, R. (n.d.).Publication year
2024Journal title
BMC Infectious DiseasesVolume
24Issue
1AbstractBackground: The COVID-19 pandemic resulted in the rapid implementation of telemedicine for HIV care at federally qualified health centers (FQHCs) in the United States. We sought to understand use of telemedicine (telephone and video) at two FQHCs in Los Angeles, and the client attitudes towards and experiences with telemedicine as part of future HIV care. Methods: We conducted surveys with 271 people living with HIV (PLHIV), with questions covering sociodemographic factors, telemedicine attitudes and experiences, technological literacy, and access to technological resources and privacy. Survey data were analyzed utilizing summary statistics, chi-square analyses, and Fisher’s exact test to understand associations between sociodemographic factors and telemedicine attitudes and experiences. Results: Sixty percent of the sample had used any telemedicine and, of these, 93% utilized only telephone visits. Almost all respondents (95%, n = 257) had access to a functioning smartphone and self-rated their technological literacy as high. Most had consistent access to privacy (88%, n = 239), and those without privacy noted this as a barrier to the use of telemedicine. The main benefits of telemedicine (compared to in person) were savings of time and money, convenience, and ability to complete appointments as scheduled. Just over half of PLHIV said they would feel more comfortable discussing sensitive topics (e.g., substance use, relationship issues) in person than over telephone (60%, n = 164) or video (55%, n = 151). Despite limited experience with video telemedicine, half of all participants desired a mix of telephone and video visits as part of their future HIV care. Conclusions: During a mature phase of the COVID-19 pandemic, PLHIV in our study showed high satisfaction with telemedicine, largely conducted as telephone visits, and high interest in telemedicine visits as a component of their future HIV care. Future studies should explore barriers to implementing video telemedicine in FQHCs and determine telemedicine’s impact on clinical outcomes, including engagement and viral suppression.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.Time series analysis of comprehensive maternal deaths in Brazil during the COVID-19 pandemic
AbstractCambou, M. C., David, H., Moucheraud, C., Nielsen-Saines, K., Comulada, W. S., & Macinko, J. (n.d.).Publication year
2024Journal title
Scientific reportsVolume
14Issue
1AbstractThe effects of the COVID-19 pandemic on comprehensive maternal deaths in Brazil have not been fully explored. Using publicly available data from the Brazilian Mortality Information (SIM) and Information System on Live Births (SINASC) databases, we used two complementary forecasting models to predict estimates of maternal mortality ratios using maternal deaths (MMR) and comprehensive maternal deaths (MMRc) in the years 2020 and 2021 based on data from 2008 to 2019. We calculated national and regional standardized mortality ratio estimates for maternal deaths (SMR) and comprehensive maternal deaths (SMRc) for 2020 and 2021. The observed MMRc in 2021 was more than double the predicted MMRc based on the Holt-Winters and autoregressive integrated moving average models (127.12 versus 60.89 and 59.12 per 100,000 live births, respectively). We found persisting sub-national variation in comprehensive maternal mortality: SMRc ranged from 1.74 (95% confidence interval [CI] 1.64, 1.86) in the Northeast to 2.70 (95% CI 2.45, 2.96) in the South in 2021. The observed national estimates for comprehensive maternal deaths in 2021 were the highest in Brazil in the past three decades. Increased resources for prenatal care, maternal health, and postpartum care may be needed to reverse the national trend in comprehensive maternal deaths.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.“I am forced to just give it to her because she is the one who wants it”: A qualitative study of providers’ perspectives on contraceptive counseling in Tanzania
AbstractWollum, A., Gipson, J. D., Sabasaba, A., Brooks, M. I., & Moucheraud, C. (n.d.).Publication year
2024Journal title
SSM - Qualitative Research in HealthVolume
6AbstractDrawing on 29 in-depth interviews with health care providers in Dar es Salaam, Tanzania, this paper describes providers’ attitudes and beliefs about contraceptive methods and the extent to which providers consider client choice and autonomy when providing contraceptive care. Interviews were analyzed thematically using the constant comparative approach. Providers described a preference for long-acting reversible methods (i.e., implants and IUDs) primarily due to concerns regarding injectables’ slow return to fertility, exposure to hormones, and concerns about client adherence to pills or injectables. Providers understood the importance of centering a client's preference to use a specific method and to have a method removed when the client desired. However, providers also described counseling clients toward their own preferences, highlighting a tension between what providers wanted for their clients and client preferences. While most providers described prioritizing client choice even when it contradicted their recommendation, some providers insisted on a certain outcome (e.g., a client taking up an implant), contradicting tenets of informed, full, and autonomous choice. Attention is needed to ensure providers center client autonomy and preferences and guarantee freedom from coercion in contraceptive care.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.