Assistant Professor of Public Health
Mari Armstrong-Hough is Assistant Professor in the Department of Social & Behavioral Sciences and in the Department of Epidemiology. Armstrong-Hough’s research interests are at the social and epidemiologic interfaces among tuberculosis (TB), HIV, and non-communicable diseases. Combining training in epidemiology and sociology, her work informs and develops interventions to increase early case-finding, status awareness, and linkage to care in high-burden settings like Uganda and South Africa. She has published on predictors of evaluation for TB among high-risk groups, novel approaches to active case-finding for TB and HIV, the ways that providers and patients imagine and communicate risk for respiratory infection, and the availability of essential medicines in settings with double burdens of infectious and non-communicable disease. In addition, her first book, Biomedicalization and the Practice of Culture: Globalization and Type 2 Diabetes in the United States and Japan (University of North Carolina Press, 2018), examined how the practice and experience of global evidence-based medicine is shaped by local cultural repertoires.
Armstrong-Hough’s current work focuses on active case-finding for TB, HIV, and diabetes in sub-Saharan Africa. One line of this research aims to elucidate how group processes within households shape testing behavior in settings where living with HIV or exposure to TB is common, and to develop interventions to increase uptake of testing by altering the architecture of home test offers. Her recent work has appeared in the Journal of AIDS, International Journal of Tuberculosis and Lung Disease, Public Health Action, and the Journal of Medical Internet Research. She also co-directs the NIH-funded Mixed-Methods Fellowship of the Pulmonary Complications of AIDS Research Training Program at Makerere University in Kampala, Uganda. She is PI of a prospective cohort study of patients initiating treatment for pulmonary TB in Uganda and a co-investigator on NIH-funded studies of contact tracing for TB.
Before coming to NYU, Dr. Armstrong-Hough was an Associate Research Scientist in Epidemiology in the Department of Epidemiology of Microbial Diseases at Yale School of Public Health. She previously taught at Davidson College, Meiji University in Tokyo, and Duke University. She earned her B.A. with majors in Sociology, History, and Political Science from the University of Wisconsin–Madison, M.A. in East Asian studies from Duke University, Ph.D. in Sociology from Duke University, and postdoctoral M.P.H. in Applied Biostatistics and Epidemiology from Yale. She has conducted fieldwork in the United States, Japan, Uganda, Ethiopia, and Nepal and is a recipient of the Robert E. Leet and Clara Guthrie Patterson Trust Mentored Research Award in Clinical, Health Services and Policy Research.
Experiences and intentions of Ugandan household tuberculosis contacts receiving test results via text message: An exploratory studyGgita, J. M., Katahoire, A., Meyer, A. J., Nansubuga, E., Nalugwa, T., Turimumahoro, P., Ochom, E., Ayakaka, I., Haberer, J. E., Katamba, A., Armstrong-Hough, M., & Davis, J. L.
Journal titleBMC public health
Issue1Background: The World Health Organization (WHO) recommends household contact investigation for tuberculosis (TB) in high-burden countries. However, household contacts who complete evaluation for TB during contact investigation may have difficulty accessing their test results. Use of automated short-messaging services (SMS) to deliver test results could improve TB status awareness and linkage to care. We sought to explore how household contacts experience test results delivered via SMS, and how these experiences influence follow-up intentions. Methods: We conducted semi-structured interviews with household contacts who participated in a randomized controlled trial evaluating home sputum collection and delivery of TB results via SMS (Pan-African Clinical Trials Registry #201509000877140). We asked about feelings, beliefs, decisions, and behaviors in response to the SMS results. We analyzed the content and emerging themes in relation to the Theory of Planned Behavior. Results: We interviewed and achieved thematic saturation with ten household contacts. Nine received TB-negative results and one a TB-positive result. Household contacts reported relief upon receiving SMS confirming their TB status, but also said they lacked confidence in the results delivered by SMS. Some worried that negative results were incorrect until they spoke to a lay health worker (LHW). Household contacts said their long-term intentions to request help or seek care were influenced by perceived consequences of not observing the LHW's instructions related to the SMS and follow-up procedures; beliefs about the curability of TB; anticipated support from LHWs; and perceived barriers to responding to an SMS request for further evaluation. Conclusion: Household contacts experienced relief when they received results. However, they were less confident about results delivered via SMS than results delivered by LHWs. Delivery of results by SMS should complement continued interaction with LHWs, not replace them.
Digital monitoring technologies could enhance tuberculosis medication adherence in Uganda: Mixed methods studyMusiimenta, A., Tumuhimbise, W., Mugaba, A. T., Muzoora, C., Armstrong-Hough, M., Bangsberg, D., Davis, J. L., & Haberer, J. E.
Journal titleJournal of Clinical Tuberculosis and Other Mycobacterial Diseases
Volume17Background: Effective administration of tuberculosis therapy remains challenging. The recommended strategy of direct observed therapy is challenging and its implementation has been limited in many settings. Digital adherence technologies could be promising patient-centered strategies for monitoring adherence. However, few quality studies have assessed patients’ experiences with these technologies. Objective: To explore TB patients’ perceptions of a digital adherence intervention composed of a digital adherence monitor and SMS texts. Methods: We purposively sampled TB patients who owned phones, had been taking TB medication for at least a month, and were receiving their treatment from Mbarara Regional Referral Hospital. We interviewed 35 TB patients to elicit information on perceptions of the proposed intervention which electronically monitors how they take their medication, and sends SMS reminders to patients to help them take their medications, as well as send SMS notifications to patients’ social supporters to provide the patient with assistance if possible. We inductively analyzed data using content analysis to derive categories describing how participants perceived the intervention. Results: Participants anticipated that the intervention would enhance medication adherence by reminding them to take medication, and helping in the management of complicated regimen. Participants felt that monitoring adherence could enable them to demonstrate their commitment to adherence. Participants expressed concerns about not seeing the SMS on time and unintended TB status disclosure. Conclusion: Digital adherence technologies may provide acceptable alternative approaches to monitoring TB medication, especially in settings where DOT is difficult to implement.
"Give mesome time": Facilitators of and barriers to uptake of home-based HIV testing during household contact investigation for tuberculosis in Kampala, UgandaArmstrong-Hough, M., Ggita, J., Ayakaka, I., Dowdy, D., Cattamanchi, A., Haberer, J. E., Katamba, A., & Davis, J. L.
Journal titleJournal of Acquired Immune Deficiency Syndromes
Page(s)400-404Background: Integrating home-based HIV counseling and testing (HCT) with tuberculosis (TB) evaluation could improve the uptake of HIV testing among household contacts of patients with active TB. We sought to identify the facilitators of and barriers to HCT during household contact investigation for TB in Kampala, Uganda. Methods: We nested semi-structured interviews with 28 household contacts who were offered home-based HCT in a householdrandomized trial of home-based strategies for TB contact investigation. Respondents reflected on their experiences of the home visit, the social context of the household, and their decision to accept or decline HIV testing. We used content analysis to identify and evaluate facilitators of and barriers to testing, then categorized the emergent themes using the Capability, Opportunity, Motivation, and Behavior (COM-B) model. Results: Facilitators included a preexisting desire to confirm HIV status or to show support for the index TB patient; a perception that home-based services are convenient; and positive perceptions of lay health workers. Key barriers included fear of results and feeling psychologically unprepared to receive results. The social influence of other household members operated as both a facilitator and a barrier. Conclusions: Preexisting motivation, psychological readiness to test, and the social context of the household are major contributors to the decision to test for HIV at home. Uptake might be improved by providing normalizing information about HCT before the visit, by offering a second HCT opportunity, by offering self-tests with follow-up counseling, or by introducing HCT using "opt-out" language.
'Something so hard': A mixed-methods study of home sputum collection for tuberculosis contact investigation in UgandaArmstrong-Hough, M., Ggita, J., Turimumahoro, P., Meyer, A. J., Ochom, E., Dowdy, D., Cattamanchi, A., Katamba, A., & Davis, J. L.
Journal titleInternational Journal of Tuberculosis and Lung Disease
Page(s)1152-1159BACKGROUND: Home sputum collection could facilitate prompt evaluation and diagnosis of tuberculosis (TB) among contacts of patients with active TB. We analyzed barriers to home-based collection as part of an enhanced intervention for household TB contact investigation in Kampala, Uganda. DESIGN: We conducted a convergent mixed-methods study to describe the outcomes of home sputum collection in 91 contacts and examine their context through 19 nested contact interviews and two focus group discussions with lay health workers (LHWs). RESULTS: LHWs collected sputum from 35 (39%) contacts. Contacts reporting cough were more likely to provide sputum than those with other symptoms or risk factors (53% vs. 15%, RR 3.6, 95%CI 1.5-2.8, P, 0.001). Males were more likely than females to provide sputum (54% vs. 32%, RR 1.7, 95%CI 1.0-2.8, P ¼ 0.05). Contacts said support from the index patient and the convenience of the home visit facilitated collection. Missing containers and difficulty producing sputum spontaneously impeded collection. Women identified stigma as a barrier. LHWs emphasized difficulty in procuring sputum and discomfort pressing contacts to produce sputum. CONCLUSIONS: Home sputum collection by LHWs entails different challenges from sputum collection in clinical settings. More research is needed to develop interventions to mitigate stigma and increase success of home-based collection.
Disparities in availability of essential medicines to treat non-communicable diseases in Uganda: A poisson analysis using the service availability and readiness assessmentArmstrong-Hough, M., Kishore, S. P., Byakika, S., Mutungi, G., Nunez-Smith, M., & Schwartz, J. I.
Journal titlePloS one
Issue2Objective Although the WHO-developed Service Availability and Readiness Assessment (SARA) tool is a comprehensive and widely applied survey of health facility preparedness, SARA data have not previously been used to model predictors of readiness. We sought to demonstrate that SARA data can be used to model availability of essential medicines for treating noncommunicable diseases (EM-NCD). Methods We fit a Poisson regression model using 2013 SARA data from 196 Ugandan health facilities. The outcome was total number of different EM-NCD available. Basic amenities, equipment, region, health facility type, managing authority, NCD diagnostic capacity, and range of HIV services were tested as predictor variables. Findings In multivariate models, we found significant associations between EM-NCD availability and region, managing authority, facility type, and range of HIV services. For-profit facilities’ EM-NCD counts were 98% higher than public facilities (p < .001). General hospitals and referral health centers had 98% (p = .004) and 105% (p = .002) higher counts compared to primary health centers. Facilities in the North and East had significantly lower counts than those in the capital region (p = 0.015; p = 0.003). Offering HIV care was associated with 35% lower EM-NCD counts (p = 0.006). Offering HIV counseling and testing was associated with 57% higher counts (p = 0.048). Conclusion We identified multiple within-country disparities in availability of EM-NCD in Uganda. Our findings can be used to identify gaps and guide distribution of limited resources. While the primary purpose of SARA is to assess and monitor health services readiness, we show that it can also be an important resource for answering complex research and policy questions requiring multivariate analysis.
Feasibility, acceptability, and adoption of digital fingerprinting during contact investigation for tuberculosis in Kampala, Uganda: A parallel-convergent mixed-methods analysisWhite, E. B., Meyer, A. J., Ggita, J. M., Babirye, D., Mark, D., Ayakaka, I., Haberer, J. E., Katamba, A., Armstrong-Hough, M., & Davis, J. L.
Journal titleJournal of medical Internet research
Issue1Background: In resource-constrained settings, challenges with unique patient identification may limit continuity of care, monitoring and evaluation, and data integrity. Biometrics offers an appealing but understudied potential solution. Objective: The objective of this mixed-methods study was to understand the feasibility, acceptability, and adoption of digital fingerprinting for patient identification in a study of household tuberculosis contact investigation in Kampala, Uganda. Methods: Digital fingerprinting was performed using multispectral fingerprint scanners. We tested associations between demographic, clinical, and temporal characteristics and failure to capture a digital fingerprint. We used generalized estimating equations and a robust covariance estimator to account for clustering. In addition, we evaluated the clustering of outcomes by household and community health workers (CHWs) by calculating intraclass correlation coefficients (ICCs). To understand the determinants of intended and actual use of fingerprinting technology, we conducted 15 in-depth interviews with CHWs and applied a widely used conceptual framework, the Technology Acceptance Model 2 (TAM2). Results: Digital fingerprints were captured for 75.5% (694/919) of participants, with extensive clustering by household (ICC=.99) arising from software (108/179, 60.3%) and hardware (65/179, 36.3%) failures. Clinical and demographic characteristics were not markedly associated with fingerprint capture. CHWs successfully fingerprinted all contacts in 70.1% (213/304) of households, with modest clustering of outcomes by CHWs (ICC=.18). The proportion of households in which all members were successfully fingerprinted declined over time (?=.30, P<.001). In interviews, CHWs reported that fingerprinting failures lowered their perceptions of the quality of the technology, threatened their social image as competent health workers, and made the technology more difficult to use. Conclusions: We found that digital fingerprinting was feasible and acceptable for individual identification, but problems implementing the hardware and software lead to a high failure rate. Although CHWs found fingerprinting to be acceptable in principle, their intention to use the technology was tempered by perceptions that it was inconsistent and of questionable value. TAM2 provided a valuable framework for understanding the motivations behind CHWs' intentions to use the technology. Weemphasize the need for routine process evaluation of biometrics and other digital technologies in resource-constrained settings to assess implementation effectiveness and guide improvement of delivery.
Patterns of usage and preferences of users for tuberculosis-related text messages and voice calls in UgandaGgita, J. M., Ojok, C., Meyer, A. J., Farr, K., Shete, P. B., Ochom, E., Turimumahoro, P., Babirye, D., Mark, D., Dowdy, D., Ackerman, S., Armstrong-Hough, M., Nalugwa, T., Ayakaka, I., Moore, D., Haberer, J. E., Cattamanchi, A., Katamba, A., & Davis, J. L.
Journal titleInternational Journal of Tuberculosis and Lung Disease
Page(s)530-536B A C K G R O U N D: Little information exists about mobile phone usage or preferences for tuberculosis (TB) related health communications in Uganda. M E T H O D S: We surveyed household contacts of TB patients in urban Kampala, Uganda, and clinic patients in rural central Uganda. Questions addressed mobile phone access, usage, and preferences for TB-related communications. We collected qualitative data about messaging preferences. R E S U L T S: We enrolled 145 contacts and 203 clinic attendees. Most contacts (58%) and clinic attendees (75%) owned a mobile phone, while 42% of contacts and 10% of clinic attendees shared one; 94% of contacts and clinic attendees knew how to receive a short messaging service (SMS) message, but only 59% of contacts aged 745 years (vs. 96% of contacts aged,45 years, P ¼ 0.0001) did so. All contacts and 99% of clinic attendees were willing and capable of receiving personal-health communications by SMS. Among contacts, 55% preferred detailed messages disclosing test results, while 45% preferred simple messages requesting a clinic visit to disclose results. C O N C L U S I O N S: Most urban household TB contacts and rural clinic attendees reported having access to a mobile phone and willingness to receive TB-related personal-health communications by voice call or SMS. However, frequent phone sharing and variable messaging abilities and preferences suggest a need to tailor the design and monitoring of mHealth interventions to target recipients.
Text messages sent to household tuberculosis contacts in Kampala, Uganda: Process evaluationMeyer, A. J., Babirye, D., Armstrong-Hough, M., Mark, D., Ayakaka, I., Katamba, A., Haberer, J. E., & Lucian Davis, J.
Journal titleJMIR mHealth and uHealth
Issue11Background: Previous studies have reported the inconsistent effectiveness of text messaging (short message service, SMS) for improving health outcomes, but few have examined to what degree the quality, or “fidelity,” of implementation may explain study results. Objective: The aim of this study was to determine the fidelity of a one-time text messaging (SMS) intervention to promote the uptake of tuberculosis evaluation services among household contacts of index patients with tuberculosis. Methods: From February to June 2017, we nested a process evaluation of text message (SMS) delivery within the intervention arm of a randomized controlled trial of tuberculosis contact investigation in Kampala, Uganda. Because mobile service providers in Uganda do not provide delivery confirmations, we asked household tuberculosis contacts to confirm the receipt of a one-time tuberculosis-related text message (SMS) by sending a text message (SMS) reply through a toll-free “short code.” Two weeks later, a research officer followed up by telephone to confirm the receipt of the one-time text message (SMS) and administer a survey. We considered participants lost to follow-up after 3 unsuccessful call attempts on 3 separate days over a 1-week period. Results: Of 206 consecutive household contacts, 119 had a text message (SMS) initiated from the server. While 33% (39/119) were children aged 5-14 years, including 20% (24/119) girls and 13% (15/119) boys, 18 % (21/119) were adolescents or young adults, including 12% (14/119) young women and 6% (7/119) young men. 50% (59/119) were adults, including 26% (31/119) women and 24% (28/119) men. Of 107 (90%) participants for whom we could ascertain text message (SMS) receipt status, 67% (72/107) confirmed text message (SMS) receipt, including 22% (24/107) by reply text message (SMS) and 45% (48/107) during the follow-up telephone survey. No significant clinical or demographic differences were observed between those who did and did not report receiving the text message (SMS). Furthermore, 52% (56/107) reported ever reading the SMS. The cumulative likelihood of a text message (SMS) reaching its target and being read and retained by a participant was 19%. Conclusions: The fidelity of a one-time text message (SMS) intervention to increase the uptake of household tuberculosis contact investigation and linkage to care was extremely low, a fact only discoverable through detailed process evaluation. This study suggests the need for systematic process monitoring and reporting of implementation fidelity in both research studies and programmatic interventions using mobile communications to improve health.
Drop-out from the tuberculosis contact investigation cascade in a routine public health setting in urban Uganda: A prospective, multi-center studyArmstrong-Hough, M., Turimumahoro, P., Meyer, A. J., Ochom, E., Babirye, D., Ayakaka, I., Mark, D., Ggita, J., Cattamanchi, A., Dowdy, D., Mugabe, F., Fair, E., Haberer, J. E., Katamba, A., & Davis, J. L.
Journal titlePloS one
Issue11Setting: Seven public tuberculosis (TB) units in Kampala, Uganda, where Uganda’s national TB program recently introduced household contact investigation, as recommended by 2012 guidelines from WHO. Objective: To apply a cascade analysis to implementation of household contact investigation in a programmatic setting. Design: Prospective, multi-center observational study. Methods: We constructed a cascade for household contact investigation to describe the proportions of: 1) index patient households recruited; 2) index patient households visited; 3) contacts screened for TB; and 4) contacts completing evaluation for, and diagnosed with, active TB. Results: 338 (33%) of 1022 consecutive index TB patients were eligible for contact investigation. Lay health workers scheduled home visits for 207 (61%) index patients and completed 104 (50%). Among 287 eligible contacts, they screened 256 (89%) for symptoms or risk factors for TB. 131 (51%) had an indication for further TB evaluation. These included 59 (45%) with symptoms alone, 58 (44%) children <5, and 14 (11%) with HIV. Among 131 contacts found to be symptomatic or at risk, 26 (20%) contacts completed evaluation, including five (19%) diagnosed with and treated for active TB, for an overall yield of 1.7%. The cumulative conditional probability of completing the entire cascade was 5%. Conclusion: Major opportunities exist for improving the effectiveness and yield of TB contact investigation by increasing the proportion of index households completing screening visits by lay health workers and the proportion of at-risk contacts completing TB evaluation.
Origins of Difference: Professionalization, Power, and Mental Hygiene in Canada and the United StatesArmstrong-Hough, M.
Journal titleAmerican Review of Canadian Studies
Page(s)208-225This study examines the emergence and development of mental hygiene professional organizations in Canada and the US by analyzing discursive differences in the publications of two sister committees: the National Committee for Mental Hygiene and the Canadian National Committee for Mental Hygiene. The analysis finds that while mental hygiene in North America initially emerged as a single, shared continental professional discourse, the two movements diverged in critical ways for reasons directly related to their institutional contexts and donor bases. Even as US popular and political discourse veered towards eugenic policies, the US mental hygiene discourse shifted sharply away from eugenics. In contrast, in Canada, mental hygiene publications focused increasingly on the moral dangers of Canadas immigrant population and played a role in producing scientific legitimacy for eugenic policies. This analysis suggests that the different trajectories of the two professional communities have their origins in organizations membership and donor bases, not broader differences in national character.
Performing prevention: risk, responsibility, and reorganising the future in Japan during the H1N1 pandemicArmstrong-Hough, M. J.
Journal titleHealth, Risk and Society
Page(s)285-301One distinguishing feature of modernity is a shift from fate to risk as a central explanatory principle for uncertainty and danger. Framing the future in terms of risk creates the possibility – and, increasingly, responsibility – for prevention. This study analyses qualitative data from semi-structured interviews with 20 physicians and 43 members of the general public in Japan during the H1N1 influenza pandemic of 2009 to examine how risk and responsibility were imagined, managed, and reorganised through preventative behaviours. I examined respondents’ discussions of a specific preventative recommendation issued in Japan during the 2009 pandemic: prophylactic gargling. I found that Japanese doctors had mixed, often conflicting, opinions about the efficacy of gargling to prevent infection; most felt its usefulness as a recommendation lay in its capacity to give patients the belief that they could mitigate the risk of infection. Doctors who were openly dubious about the effectiveness of gargling in reducing risk of infection continued to recommend it because they felt that gargling provided patients with peace of mind, reducing their sense of ontological insecurity. In contrast, lay respondents saw gargling as a practical, common-sense measure they could take to mitigate risk, but also citing responsibility to others as motivation for performing preventative practices that they would otherwise eschew.