Mari Armstrong-Hough

Mari Armstrong-Hough
Mari Armstrong-Hough

Assistant Professor, GPH-Social & Behavioral Sciences; Epidemiology

Professional overview

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.

Publications

Publications

An emerging syndemic of smoking and cardiopulmonary diseases in people living with HIV in Africa

Peprah, E., Armstrong-Hough, M., Cook, S. H., Mukasa, B., Taylor, J. Y., Xu, H., Chang, L., Gyamfi, J., Ryan, N., Ojo, T., Snyder, A., Iwelunmor, J., Ezechi, O., Iyegbe, C., O’reilly, P., & Kengne, A. P.

Publication year

2021

Journal title

International journal of environmental research and public health

Volume

18

Issue

6

Page(s)

1-12
Abstract
Abstract
Background: African countries have the highest number of people living with HIV (PWH). The continent is home to 12% of the global population, but accounts for 71% of PWH globally. Antiretroviral therapy has played an important role in the reduction of the morbidity and mortality rates for HIV, which necessitates increased surveillance of the threats from pernicious risks to which PWH who live longer remain exposed. This includes cardiopulmonary comorbidities, which pose significant public health and economic challenges. A significant contributor to the cardiopulmonary comorbidities is tobacco smoking. Indeed, globally, PWH have a 2–4-fold higher utilization of tobacco compared to the general population, leading to endothelial dysfunction and atherogenesis that result in cardiopulmonary diseases, such as chronic obstructive pulmonary disease and coronary artery disease. In the context of PWH, we discuss (1) the current trends in cigarette smoking and (2) the lack of geographically relevant data on the cardiopulmonary conditions associated with smoking; we then review (3) the current evidence on chronic inflammation induced by smoking and the potential pathways for cardiopulmonary disease and (4) the multifactorial nature of the syndemic of smoking, HIV, and cardiopulmonary diseases. This commentary calls for a major, multi-setting cohort study using a syndemics framework to assess cardiopulmonary disease outcomes among PWH who smoke. Conclusion: We call for a parallel program of implementation research to promote the adoption of evidence-based interventions, which could improve health outcomes for PWH with cardiopulmonary diseases and address the health inequities experienced by PWH in African countries.

Availability, functionality and access of blood pressure machines at the points of care in public primary care facilities in Tororo district, Uganda

Besigye, I. K., Okuuny, V., Armstrong-Hough, M., Katahoire, A. R., Sewankambo, N. K., Mash, R., & Katamba, A.

Publication year

2021

Journal title

South African Family Practice

Volume

63

Issue

1

Page(s)

1-6
Abstract
Abstract
Background: Early diagnosis of hypertension prevents a significant number of complications and premature deaths. In resource-variable settings, diagnosis may be limited by inadequate access to blood pressure (BP) machines. We sought to understand the availability, functionality and access of BP machines at the points of care within primary care facilities in Tororo district, Uganda. Methods: This was an explanatory sequential mixed-methods study combining a structured facility checklist and key informant interviews with primary care providers. The checklist was used to collect data on availability and functionality of BP machines within their organisational arrangements. Key informant interviews explored health providers’ access to BP machines. Results: The majority of health facilities reported at least one working BP machine. However, Health providers described limited access to machines because they are not located at each point of care. Health providers reported borrowing amongst themselves within their respective units or from other units within the facility. Some health providers purchase and bring their own BP machines to the health facilities or attempted to restore the functionality of broken ones. They are motivated to search the clinic for BP machines for some patients but not others based on their perception of the patient’s risk for hypertension. Conclusion: Access to BP machines at the point of care was limited. This makes hypertension screening selective based on health providers’ perception of the patients’ risk for hypertension. Training in proper BP machine use and regular maintenance will minimise frequent breakdowns.

Availability, functionality and access of blood pressure machines at the points of care in public primary care facilities in Tororo district, Uganda

Besigye, I. K., Okuuny, V., Armstrong-Hough, M., Katahoire, A. R., Sewankambo, N. K., Mash, B., & Katamba, A.

Publication year

2020

Journal title

South African Family Practice

Volume

62

Issue

1

Experiences and intentions of Ugandan household tuberculosis contacts receiving test results via text message: An exploratory study

Ggita, 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.

Publication year

2020

Journal title

BMC public health

Volume

20

Issue

1
Abstract
Abstract
Background: 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.

Implementing mhealth interventions in a resource-constrained setting: Case study from Uganda

Meyer, A. J., Armstrong-Hough, M., Babirye, D., Mark, D., Turimumahoro, P., Ayakaka, I., Haberer, J. E., Katamba, A., & Davis, J. L.

Publication year

2020

Journal title

JMIR mHealth and uHealth

Volume

8

Issue

7
Abstract
Abstract
Background: Mobile health (mHealth) interventions are becoming more common in low-income countries. Existing research often overlooks implementation challenges associated with the design and technology requirements of mHealth interventions. Objective: We aimed to characterize the challenges that we encountered in the implementation of a complex mHealth intervention in Uganda. Methods: We customized a commercial mobile survey app to facilitate a two-arm household-randomized, controlled trial of home-based tuberculosis (TB) contact investigation. We incorporated digital fingerprinting for patient identification in both study arms and automated SMS messages in the intervention arm only. A local research team systematically documented challenges to implementation in biweekly site visit reports, project management reports, and minutes from biweekly conference calls. We then classified these challenges using the Consolidated Framework for Implementation Research (CFIR). Results: We identified challenges in three principal CFIR domains: (1) intervention characteristics, (2) inner setting, and (3) characteristics of implementers. The adaptability of the app to the local setting was limited by software and hardware requirements. The complexity and logistics of implementing the intervention further hindered its adaptability. Study staff reported that community health workers (CHWs) were enthusiastic regarding the use of technology to enhance TB contact investigation during training and the initial phase of implementation. After experiencing technological failures, their trust in the technology declined along with their use of it. Finally, complex data structures impeded the development and execution of a data management plan that would allow for articulation of goals and provide timely feedback to study staff, CHWs, and participants. Conclusions: mHealth technologies have the potential to make delivery of public health interventions more direct and efficient, but we found that a lack of adaptability, excessive complexity, loss of trust among end users, and a lack of effective feedback systems can undermine implementation, especially in low-resource settings where digital services have not yet proliferated. Implementers should anticipate and strive to avoid these barriers by investing in and adapting to local human and material resources, prioritizing feedback from end users, and optimizing data management and quality assurance procedures.

Mobile Health Technologies May Be Acceptable Tools for Providing Social Support to Tuberculosis Patients in Rural Uganda: A Parallel Mixed-Method Study

Musiimenta, A., Tumuhimbise, W., Atukunda, E. C., Mugaba, A. T., Muzoora, C., Armstrong-Hough, M., Bangsberg, D., Davis, J. L., & Haberer, J. E.

Publication year

2020

Journal title

Tuberculosis research and treatment

Volume

2020

Page(s)

7401045
Abstract
Abstract
Background: Social support has been shown to mitigate social barriers to medication adherence and improve tuberculosis (TB) treatment success rates. The use of mobile technology to activate social support systems among TB patients, however, has not been well explored. Moreover, studies that tie supportive SMS (Short Message Service) texts to electronic monitoring of TB medication adherence are lacking.Objective: To explore TB patients' current access to social support and perceptions of utilizing real-time adherence monitoring interventions to support medication adherence.Methods: We purposively selected TB patients who owned phones, had been taking TB medications for ≥1 month, were receiving their treatment from Mbarara Regional Referral Hospital, and reported having ≥1 social supporter. We interviewed these patients and their social supporters about their access to and perceptions of social support. We used STATA 13 to describe participants' sociodemographic and social support characteristics. Qualitative data were analyzed using content analysis to derive categories describing accessibility and perceptions.Results: TB patients report requesting and receiving a variety of different forms of social support, including instrumental (e.g., money for transport and other needs and medication reminders), emotional (e.g., adherence counselling), and informational (e.g., medication side effects) support through mobile phones. Participants felt that SMS notifications may motivate medication adherence by creating a personal sense of obligation to take medications regularly. Participants anticipated that limited financial resources and relationship dynamics could constrain the provision of social support especially when patients and social supporters are not oriented about their expectations.Conclusion: Mobile telephones could provide alternative approaches to providing social support for TB medication adherence especially where patients do not stay close to their social supporters. Further efforts should focus on optimized designs of mobile phone-based applications for providing social support to TB patients and training of TB patients and social supporters to match their expectations.

Predictors of evaluation in child contacts of TB patients

Lee, G., Meyer, A. J., Kizito, S., Katamba, A., Davis, J. L., & Armstrong-Hough, M. In International Journal of Tuberculosis and Lung Disease.

Publication year

2020

Volume

24

Issue

8

Page(s)

847-849

Prevalence, associated factors and perspectives of HIV testing among men in Uganda

Nangendo, J., Katahoire, A. R., Armstrong-Hough, M., Kabami, J., Obeng-Amoako, G. O., Muwema, M., Semitala, F. C., Karamagi, C. A., Wanyenze, R. K., Kamya, M. R., & Kalyango, J. N.

Publication year

2020

Journal title

PloS one

Volume

15

Issue

8
Abstract
Abstract
Background: Despite overall increase in HIV testing, more men than women remain untested. In 2018, 92% of Ugandan women but only 67% of men had tested for HIV. Understanding men's needs and concerns for testing could guide delivery of HIV testing services (HTS) to them. We assessed the prevalence of testing, associated factors and men's perspectives on HIV testing in urban and peri-urban communities in Central Uganda. Methods and findings: We conducted a parallel-convergent mixed-methods study among men in Kampala and Mpigi districts from August to September 2018. Using two-stage sampling, we selected 1340 men from Mpigi. We administered a structured questionnaire to collect data on HIV testing history, socio-demographics, self-reported HIV risk-related behaviors, barriers and facilitators to HIV testing. We also conducted 10 focus-groups with men from both districts to learn their perspectives on HIV testing. We used modified Poisson regression to assess factors associated with HIV testing and inductive thematic analysis to identify barriers and facilitators. Though 84.0% of men reported having tested for HIV, only 65.7% had tested in the past 12-months despite nearly all (96.7%) engaging in at least one HIV risk-related behavior. Men were more likely to have tested if aged 25-49 years, Catholic, with secondary or higher education and circumcised. Being married was associated with ever-testing while being widowed or divorced was associated with testing in past 12-months. Men who engaged in HIV risk-related behavior were less likely to have tested in the past 12-months. Qualitative findings showed that men varied in their perspectives about the need for testing, access to HTS and were uncertain of HIV testing and its outcomes. Conclusions: Recent HIV testing among men remains low. Modifying testing strategies to attract men in all age groups could improve testing uptake, reduce gender disparity and initiate risk reduction interventions.

Sustainability of the streamlined ART (START-ART) implementation intervention strategy among ART-eligible adult patients in HIV clinics in public health centers in Uganda: a mixed methods study

Katuramu, R., Kamya, M. R., Sanyu, N., Armstrong-Hough, M., & Semitala, F. C.

Publication year

2020

Journal title

Implementation science communications

Volume

1

Page(s)

37
Abstract
Abstract
Background: Despite increasing access to antiretroviral therapy (ART), the proportion of eligible patients initiated on treatment remains suboptimal. Only 64.6% of the people living with HIV (PLHIV) globally were initiated on ART by June 2019. The streamlined ART (START-ART) implementation study was based on the PRECEDE model, which suggests that "predisposing, enabling, and reinforcing" factors are needed to create behavior change. START-ART increased ART initiation within 2 weeks of eligibility by 42%. However, the gains from some implementation interventions erode over time. We evaluated facilitators and barriers to sustainability of this streamlined ART initiation in the year following the implementation period.Methods: We designed a mixed-methods explanatory sequential study to examine the sustainability of START-ART implementation. Quantitative component consisted of cross-sectional patient chart reviews of routinely collected data; qualitative component consisted of key informant interviews of health workers in START-ART facilities 2 years after conclusion of the implementation period. We analyzed data from 15 public health centers of Mbarara district, where the START-ART implementation was carried out. We included PLHIV aged > 18 years who initiated ART from June 2013 to July 2016. The START-ART implementation took place from June 2013 to June 2015 while the sustainability period was from August 2015 to July 2016.Results: A total of 863 ART-eligible patients were sampled. The median CD4 count was 348 cells/ml (IQR 215-450). During the intervention, 338 (77.4%) eligible patients initiated on ART within 2 weeks compared with 375 (88.2%) during the sustainability period (risk difference 10.8%; 95% CI 5.9-15.8%). In 14 of the 15 health centers, the intervention was sustained. During key informant interviews, rapid ART initiation sustainability was attributed to counseling skills that were obtained during intervention and availability of point-of-care (POC) CD4 PIMA machine. Failure to sustain the intervention was attributed to three specific barriers: lack of training after the intervention, transfer of trained staff to other health facilities, and shortage of supplies like cartridges for POC CD4 PIMA machine.Conclusion: Rapid ART initiation was sustained in most health centers. Skills acquired during the intervention and functional POC CD4 machine facilitated while staff transfers and irregular laboratory supplies were barriers to sustainability of rapid ART initiation.

Variation in the availability and cost of essential medicines for non-communicable diseases in Uganda: A descriptive time series analysis

Armstrong-Hough, M., Sharma, S., Kishore, S. P., Akiteng, A. R., & Schwartz, J. I.

Publication year

2020

Journal title

PloS one

Volume

15

Issue

12
Abstract
Abstract
Background: Availability of essential medicines for non-communicable diseases (NCDs) is poor in lowand middle-income countries. Availability and cost are conventionally assessed using cross-sectional data. However, these characteristics may vary over time. Methods: We carried out a prospective, descriptive analysis of the availability and cost of essential medicines in 23 Ugandan health facilities over a five-week period. We surveyed facility pharmacies in-person up to five times, recording availability and cost of 19 essential medicines for NCDs and four essential medicines for communicable diseases. Results: Availability of medicines varied substantially over time, especially among public facilities. Among private-for-profit facilities, the cost of the same medicine varied from week to week. Private-not-for-profit facilities experienced less dramatic fluctuations in price. Conclusions: We conclude that there is a need for standardized, continuous monitoring to better characterize the availability and cost of essential medicines, understand demand for these medicines, and reduce uncertainty for patients.

Digital monitoring technologies could enhance tuberculosis medication adherence in Uganda: Mixed methods study

Musiimenta, A., Tumuhimbise, W., Mugaba, A. T., Muzoora, C., Armstrong-Hough, M., Bangsberg, D., Davis, J. L., & Haberer, J. E.

Publication year

2019

Journal title

Journal of Clinical Tuberculosis and Other Mycobacterial Diseases

Volume

17
Abstract
Abstract
Background: 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.

Home-based tuberculosis contact investigation in Uganda: a household randomised trial

Davis, J. L., Turimumahoro, P., Meyer, A. J., Ayakaka, I., Ochom, E., Ggita, J., Mark, D., Babirye, D., Okello, D. A., Mugabe, F., Fair, E., Vittinghoff, E., Armstrong-Hough, M., Dowdy, D., Cattamanchi, A., Haberer, J. E., & Katamba, A.

Publication year

2019

Journal title

ERJ Open Research

Volume

5

Issue

3
Abstract
Abstract
Introduction: The World Health Organization (WHO) recommends household tuberculosis (TB) contact investigation in low-income countries, but most contacts do not complete a full clinical and laboratory evaluation.Methods: We performed a randomised trial of home-based, SMS-facilitated, household TB contact investigation in Kampala, Uganda. Community health workers (CHWs) visited homes of index patients with pulmonary TB to screen household contacts for TB. Entire households were randomly allocated to clinic (standard-of-care) or home (intervention) evaluation. In the intervention arm, CHWs offered HIV testing to adults; collected sputum from symptomatic contacts and persons living with HIV (PLWHs) if ≥5 years; and transported sputum for microbiologic testing. CHWs referred PLWHs, children <5 years, and anyone unable to complete sputum testing to clinic. Sputum testing results and/or follow-up instructions were returned by automated SMS texts. The primary outcome was completion of a full TB evaluation within 14 days; secondary outcomes were TB and HIV diagnoses and treatments among screened contacts.Results: There were 471 contacts of 190 index patients allocated to the intervention and 448 contacts of 182 index patients allocated to the standard-of-care. CHWs identified 190/471 (40%) intervention and 213/448 (48%) standard-of-care contacts requiring TB evaluation. In the intervention arm, CHWs obtained sputum from 35/91 (39%) of sputum-eligible contacts and SMSs were sent to 95/190 (50%). Completion of TB evaluation in the intervention and standard-of-care arms at 14 days (14% versus 15%; difference -1%, 95% CI -9% to 7%, p=0.81) and yields of confirmed TB (1.5% versus 1.1%, p=0.62) and new HIV (2.0% versus 1.8%, p=0.90) diagnoses were similar.Conclusions: Home-based, SMS-facilitated evaluation did not improve completion or yield of household TB contact investigation, likely due to challenges delivering the intervention components.

"Give me some time": Facilitators of and barriers to uptake of home-based HIV testing during household contact investigation for tuberculosis in Kampala, Uganda

Armstrong-Hough, M., Ggita, J., Ayakaka, I., Dowdy, D., Cattamanchi, A., Haberer, J. E., Katamba, A., & Davis, J. L.

Publication year

2018

Journal title

Journal of Acquired Immune Deficiency Syndromes

Volume

77

Issue

4

Page(s)

400-404
Abstract
Abstract
Background: 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 Uganda

Armstrong-Hough, M., Ggita, J., Turimumahoro, P., Meyer, A. J., Ochom, E., Dowdy, D., Cattamanchi, A., Katamba, A., & Davis, J. L.

Publication year

2018

Journal title

International Journal of Tuberculosis and Lung Disease

Volume

22

Issue

10

Page(s)

1152-1159
Abstract
Abstract
BACKGROUND: 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.

ADHD in Japan: A sociological perspective

Armstrong-Hough, M. J. In M. R. Bergey, A. M. Filipe, P. Conrad, & I. Singh (Eds.), Global perspectives on ADHD: Social dimensions of diagnosis and treatment in sixteen countries.

Publication year

2018

Page(s)

261-269
Abstract
Abstract
Japanese research on ADHD is prolific, and clinical management of this condition in Japan takes place in one of the most accessible and efficient health care delivery systems in the world. It is therefore particularly instructive to examine differences in the identification, management, and social context of ADHD in Japan; these differences can tell us much about the role of 'local' cultural, political, and institutional forces in professional and popular perceptions of a global illness. As this subchapter shows, differences in the sociocultural and institutional context of ADHD in Japan lead not only to different experiences of illness among individuals, but also to different choices about its management and treatment for parents and clinicians. Although rates of medication usage for ADHD are on the rise in Japan, they remain low by international standards. The classic formulation of Ritalin, emblematic of the rise of ADHD in the United States, is eschewed completely, and there is evidence that clinicians and regulators alike have a preference for nonstimulant drug therapy. Medicalized understandings of the origins of ADHD symptoms do not seem to have removed the stigma associated with the diagnosis. These differences in the medicalization of ADHD in Japan are particularly notable in the context of the country’s notoriously competitive, exam-based educational system and high levels of anxiety surrounding child and adolescent behavioral issues. This short subchapter responds to three related sociological questions about the rise of ADHD in Japan. First, and most broadly, how has the medicalization of ADHD progressed in Japan? Second, what is the nature of the stigma associated with ADHD in Japan, what are its origins, and how is it changing? And finally, how has the course of its medicalization and its changing association with deviance influenced the identification and treatment of ADHD in Japan? (PsycINFO Database Record (c) 2018 APA, all rights reserved)

Biomedicalization and the Practice of Culture: Globalization and Type 2 Diabetes in the United States and Japan

Armstrong-Hough, M.

Publication year

2018

Conformity and communal decision-making: First-tester effects on acceptance of home-based HIV counseling and testing in Uganda

Armstrong-Hough, M., Meyer, A., Katamba, A., & Davis, J. L.

Publication year

2018

Journal title

PeerJ PrePrints
Abstract
Abstract
Background Individuals' observation of how group members ahead of them behave can

Disparities in availability of essential medicines to treat non-communicable diseases in Uganda: A poisson analysis using the service availability and readiness assessment

Armstrong-Hough, M., Kishore, S. P., Byakika, S., Mutungi, G., Nunez-Smith, M., & Schwartz, J. I.

Publication year

2018

Journal title

PloS one

Volume

13

Issue

2
Abstract
Abstract
Objective 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 analysis

White, 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.

Publication year

2018

Journal title

Journal of medical Internet research

Volume

20

Issue

1
Abstract
Abstract
Background: 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.

Integrating home HIV counselling and testing into household TB contact investigation: a mixed-methods study

Ochom, E., Meyer, A. J., Armstrong-Hough, M., Kizito, S., Ayakaka, I., Turimumahoro, P., Ggita, J. M., Katamba, A., & Davis, J. L.

Publication year

2018

Journal title

Public Health Action

Volume

8

Issue

2

Page(s)

72-78
Abstract
Abstract
Setting: Community health workers (CHWs) increasingly deliver community-based human immunodeficiency virus (HIV) counselling and testing (HCT) services. Less is known about how this strategy performs when integrated with household tuberculosis (TB) contact investigations. Objective: We conducted a prospective mixed-methods study to evaluate the feasibility and quality of CHW-facilitated, home-based HCT among household TB contacts. Design: CHWs visited households of consenting TB patients to screen household contacts for TB and HIV. They performed HIV testing using a serial enzyme-linked immunosorbent assay rapid-antibody testing algorithm. Laboratory technicians at health facilities re-tested the samples and coordinated quarterly HIV panel testing for CHWs. We conducted focus group discussions (FGDs) with CHWs on their experiences in carrying out home-based HCT. Results: Of 114 household contacts who consented to and underwent HIV testing by CHWs, 5 (4%) tested positive, 108 (95%) tested negative, and 1 (1%) had indeterminate results; 110 (96%) samples had adequate volume for re-testing. Overall agreement between CHWs and laboratory technicians was 99.1% (κ = 0.90, 95%CI 0.71-1.00, P < 0.0001). In FGDs, CHWs described context-specific social challenges to performing HCT in a household setting, but said that their confidence grew with experience. Conclusion: Home-based HCT by CHWs was feasible among household TB contacts and produced high-quality results. Strategies to address social challenges are required to optimize yield.

Patterns of usage and preferences of users for tuberculosis-related text messages and voice calls in Uganda

Ggita, 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.

Publication year

2018

Journal title

International Journal of Tuberculosis and Lung Disease

Volume

22

Issue

5

Page(s)

530-536
Abstract
Abstract
B 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.

Social determinants of tuberculosis evaluation among household contacts: a secondary analysis

Shelby, T., Meyer, A. J., Ochom, E., Turimumahoro, P., Babirye, D., Katamba, A., Davis, J. L., & Armstrong-Hough, M.

Publication year

2018

Journal title

Public Health Action

Volume

8

Issue

3

Page(s)

118-123
Abstract
Abstract
Setting: Seven public sector tuberculosis (TB) units and surrounding communities in Kampala, Uganda. Objective: To evaluate the influence of household-level socio-economic characteristics on completion of TB evaluation during household contact investigation. Design: A cross-sectional study nested within the control arm of a randomized, controlled trial evaluating home-based sputum collection and short messaging service communications. We used generalized estimating equations to estimate the association between completion of TB evaluation and socio-economic determinants. Results: Of 116 household contacts referred to clinics for TB evaluation, 32 (28%) completed evaluation. Completing evaluation was strongly clustered by household. Controlling for individual symptoms, contacts from households earning below-median income (adjusted risk ratio [aRR] 0.28, 95%CI 0.09-0.88, P = 0.029) and contacts from households in which the head of household had no more than primary-level education (aRR 0.40, 95%CI 0.18-0.89, P = 0.025) were significantly less likely to complete evaluation for TB. Conclusion: Socio-economic factors such as low income and education increase the risk that household contacts of TB patients will experience barriers to completing TB evaluation themselves. Further research is needed to identify specific mechanisms by which these underlying social determinants modify the capability and motivation of contacts to complete contact investigation.

Text messages sent to household tuberculosis contacts in Kampala, Uganda: Process evaluation

Meyer, A. J., Babirye, D., Armstrong-Hough, M., Mark, D., Ayakaka, I., Katamba, A., Haberer, J. E., & Lucian Davis, J.

Publication year

2018

Journal title

JMIR mHealth and uHealth

Volume

6

Issue

11
Abstract
Abstract
Background: 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.

Disparities in Availability of Essential Medicines to Treat Non-communicable Diseases in Uganda: A Cross-sectional Poisson Analysis Using the 2013 Service Availability and Readiness Assessment

Armstrong-Hough, M., Kishore, S., & Schwartz, J.

Publication year

2017

Journal title

Annals of Global Health

Volume

83

Issue

1

Page(s)

138
Abstract
Abstract
Background: The most widely endorsed methodology used to collect data on health system readiness is the Service Availability and Readiness Assessment (SARA), a comprehensive survey of health facility preparedness, developed by the World Health Organization. SARA data have not previously been used to model and analyze the predictors of readiness indicators measured in the survey. We sought to demonstrate that SARA data can be used in this way by modeling the availability of essential medicines for treating non-communicable diseases (EM-NCD). Methods: We built a Poisson regression model using data collected at 196 Ugandan health facilities in the 2013 SARA survey. Our outcome of interest was the number of different EM-NCD available in each facility. Basic amenities, basic equipment, region, health facility type, managing authority, capacity for diagnosing NCDs, and range of HIV services were used as predictor variables. Findings: Adjusting for basic amenities, basic equipment, and capacity for diagnosing NCDs, our final model indicates significant associations between EM-NCD availability and geographic region, health facility type, managing authority, and range of HIV services. Adjusting for other variables such as facility type and amenities, private for-profit facilities' number of EM-NCD is 124% higher on average than public facilities (p

Drop-out from the tuberculosis contact investigation cascade in a routine public health setting in urban Uganda: A prospective, multi-center study

Armstrong-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.

Publication year

2017

Journal title

PloS one

Volume

12

Issue

11
Abstract
Abstract
Setting: 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.

Contact

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