Assistant Professor, GPH-Social & Behavioral Sciences; Epidemiology
Mari Armstrong-Hough is Assistant Professor in the Department of Social & Behavioral Sciences and in the Department of Epidemiology. She is a medical sociologist and epidemiologist of respiratory disease.
Armstrong-Hough’s global health research examines the epidemiologic interfaces among tuberculosis (TB), HIV, and non-communicable diseases. Combining training in epidemiology and sociology, her work develops and evaluates 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. 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. Her recent work has appeared in the Journal of AIDS, International Journal of Tuberculosis and Lung Disease, and the The Lancet Respiratory Medicine. 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.
Armstrong-Hough’s US-based research examines racial and ethnic disparities in survival of respiratory failure and seeks to develop interventions to ensure that all patients with respiratory failure receive evidence-based care. Approximately 750,000 Americans die each year from respiratory failure, and its 2.5 million survivors experience poor physical function and quality of life persisting five years after discharge. Minority patients are significantly less likely to survive respiratory failure, with up to twice the odds of death as non-Hispanic White patients. Armstrong-Hough co-PIs the Promoting Equity via Changes In Practice for Respiratory Failure (PRECIPICE) studies, which use large-scale, multicenter data from US ICUs to identify care processes associated with inequities in survival and long-term outcomes. Early work related to these studies has been accepted to Annals of the American Thoracic Society.
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 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.
BA, Sociology, History, and Political Science, University of Wisconsin–MadisonMA, East Asian Studies, Duke UniversityPhD, Sociology, Duke UniversityPostdoctoral MPH, Applied Biostatistics and Epidemiology, Yale
Assessing a norming intervention to promote acceptance of HIV testing and reduce stigma during household tuberculosis contact investigation: Protocol for a cluster-randomised trialArmstrong-Hough, M., Ggita, J., Gupta, A. J., Shelby, T., Nangendo, J., Ayen, D. O., Davis, J. L., & Katamba, A. (n.d.).
Journal titleBMJ open
Issue5AbstractIntroduction HIV status awareness is important for household contacts of patients with tuberculosis (TB). Home HIV testing during TB contact investigation increases HIV status awareness. Social interactions during home visits may influence perceived stigma and uptake of HIV testing. We designed an intervention to normalise and facilitate uptake of home HIV testing with five components: guided selection of first tester; prosocial invitation scripts; opt-out framing; optional sharing of decisions to test; and masking of decisions not to test. Methods and analysis We will evaluate the intervention effect in a household-randomised controlled trial. The primary aim is to assess whether contacts offered HIV testing using the norming strategy will accept HIV testing more often than those offered testing using standard strategies. Approximately 198 households will be enrolled through three public health facilities in Kampala, Uganda. Households will be randomised to receive the norming or standard strategy and visited by a community health worker (CHW) assigned to that strategy. Eligible contacts ≥15 years will be offered optional, free, home HIV testing. The primary outcome, proportion of contacts accepting HIV testing, will be assessed by CHWs and analysed using an intention-to-treat approach. Secondary outcomes will be changes in perceived HIV stigma, changes in perceived TB stigma, effects of perceived HIV stigma on HIV test uptake, effects of perceived TB stigma on HIV test uptake and proportions of first-invited contacts who accept HIV testing. Results will inform new, scalable strategies for delivering HIV testing. Ethics and dissemination This study was approved by the Yale Human Investigation Committee (2000024852), Makerere University School of Public Health Institutional Review Board (661) and Uganda National Council on Science and Technology (HS2567). All participants, including patients and their household contacts, will provide verbal informed consent. Results will be submitted to a peer-reviewed journal and disseminated to national stakeholders, including policy-makers and representatives of affected communities. Trial registration number ClinicalTrials.gov Identifier: NCT05124665.
Factors associated with willingness to use oral pre-exposure prophylaxis (PrEP) in a fisher-folk community in peri-urban Kampala, UgandaSsuna, B., Katahoire, A., Armstrong-Hough, M., Kalibbala, D., Kalyango, J. N., & Kiweewa, F. M. (n.d.).
Journal titleBMC public health
Issue1AbstractBackground: The World Health Organization (WHO) recommends the use of pre-exposure prophylaxis (PrEP) in key populations at elevated risk for exposure to HIV. If used effectively, PrEP can reduce annual HIV incidence to below 0.05%. However, PrEP is not acceptable among all communities that might benefit from it. There is, therefore, a need to understand perceptions of PrEP and factors associated with willingness to use PrEP among key populations at risk of HIV, such as members of communities with exceptionally high HIV prevalence. Objective: To examine the perceptions and factors associated with willingness to use oral PrEP among members of fishing communities in Uganda, a key population at risk of HIV. Methods: We conducted an explanatory sequential mixed-methods study at Ggaba fishing community from February to June 2019. Survey data were collected from a systematic random sample of 283 community members in which PrEP had not been rolled out yet by the time of we conducted the study. We carried out bivariate tests of association of willingness to use PrEP with demographic characteristics, HIV risk perception, HIV testing history. We estimated prevalence ratios for willingness to use PrEP. We used backward elimination to build a multivariable modified Poisson regression model to describe factors associated with willingness to use PrEP. We purposively selected 16 participants for focus group discussions to contextualize survey findings, analysing data inductively and identifying emergent themes related to perceptions of PrEP. Key results: We enrolled 283 participants with a mean age of 31 ± 8 years. Most (80.9%) were male. The majority of participants had tested for HIV in their lifetime, but 64% had not tested in the past 6 months. Self-reported HIV prevalence was 6.4%. Most (80.6, 95%CI 75.5–85.0) were willing in principle to use PrEP. Willingness to use PrEP was associated with perceiving oneself to be at high risk of HIV (aPR 1.99, 95%CI 1.31–3.02, P = 0.001), having tested for HIV in the past 6-months (aPR 1.13, 95%CI 1.03–1.24, P = 0.007), and completion of tertiary education (aPR 1.97, 95%CI 1.39–2.81, P < 0.001). In focus group discussions, participants described pill burden, side-effects and drug safety as potential barriers to PrEP use. Conclusions and recommendations: Oral PrEP was widely acceptable among members of fishing communities in peri-urban Kampala. Programs for scaling-up PrEP for fisherfolk should merge HIV testing services with sensitization about PrEP and also increase means of awareness of PrEP as an HIV preventive strategy.
Implementation, interrupted: Identifying and leveraging factors that sustain after a programme interruptionHennein, R., Ggita, J., Ssuna, B., Shelley, D., Akiteng, A. R., Davis, J. L., Katamba, A., & Armstrong-Hough, M. (n.d.).
Journal titleGlobal Public Health
Page(s)1868-1882AbstractMany implementation efforts experience interruptions, especially in settings with developing health systems. Approaches for evaluating interruptions are needed to inform re-implementation strategies. We sought to devise an approach for evaluating interruptions by exploring the sustainability of a programme that implemented diabetes mellitus (DM) screening within tuberculosis clinics in Uganda in 2017. In 2019, we conducted nine interviews with clinic staff and observed clinic visits to determine their views and practices on providing integrated care. We mapped themes to a social ecological model with three levels derived from the Consolidated Framework for Implementation Research (CFIR): outer setting (i.e. community), inner setting (i.e. clinic), and individuals (i.e. clinicians). Respondents explained that DM screening ceased due to disruptions in the national supply chain for glucose test strips, which had cascading effects on clinics and clinicians. Lack of screening supplies in clinics limited clinicians’ opportunities to perform DM screening, which contributed to diminished self-efficacy. However, culture, compatibility and clinicians’ beliefs about DM screening sustained throughout the interruption. We propose an approach for evaluating interruptions using the CFIR and social ecological model; other programmes can adapt this approach to identify cascading effects of interruptions and target them for re-implementation.
Patient preferences for facility-based management of hypertension and diabetes in rural Uganda: A discrete choice experimentMoor, S. E., Tusubira, A. K., Wood, D., Akiteng, A. R., Galusha, D., Tessier-Sherman, B., Donroe, E. H., Ngaruiya, C., Rabin, T. L., Hawley, N. L., Armstrong-Hough, M., Nakirya, B. D., Nugent, R., Kalyesubula, R., Nalwadda, C., Ssinabulya, I., & Schwartz, J. I. (n.d.).
Journal titleBMJ open
Issue7AbstractObjective To explore how respondents with common chronic conditions - hypertension (HTN) and diabetes mellitus (DM) - make healthcare-seeking decisions. Setting Three health facilities in Nakaseke District, Uganda. Design Discrete choice experiment (DCE). Participants 496 adults with HTN and/or DM. Main outcome measures Willingness to pay for changes in DCE attributes: getting to the facility, interactions with healthcare providers, availability of medicines for condition, patient peer-support groups; and education at the facility. Results Respondents were willing to pay more to attend facilities that offer peer-support groups, friendly healthcare providers with low staff turnover and greater availabilities of medicines. Specifically, we found the average respondent was willing to pay an additional 77 121 Ugandan shillings (UGX) for facilities with peer-support groups over facilities with none; and 49 282 UGX for 1 month of medicine over none, all other things being equal. However, respondents would have to compensated to accept facilities that were further away or offered health education. Specifically, the average respondent would have to be paid 3929 UGX to be willing to accept each additional kilometre they would have to travel to the facilities, all other things being equal. Similarly, the average respondent would have to be paid 60 402 UGX to accept facilities with some health education, all other things being equal. Conclusions Our findings revealed significant preferences for health facilities based on the availability of medicines, costs of treatment and interactions with healthcare providers. Understanding patient preferences can inform intervention design to optimise healthcare service delivery for patients with HTN and DM in rural Uganda and other low-resource settings.
Perceptions, preferences, and experiences of tuberculosis education and counselling among patients and providers in Kampala, Uganda: A qualitative studyAyakaka, I., Armstrong-Hough, M., Hannaford, A., Ggita, J. M., Turimumahoro, P., Katamba, A., Katahoire, A., Cattamanchi, A., Shenoi, S. V., & Lucian Davis, J. (n.d.).
Journal titleGlobal Public HealthAbstractTuberculosis (TB) education seeks to increase patient knowledge about TB, while TB counselling seeks to offer tailored advice and support for medication adherence. While universally recommended, little is known about how to provide effective, efficient, patient-centred TB education and counselling (TEC) in low-income, high HIV-TB burden settings. We sought to characterise stakeholder perceptions of TEC in a public, primary care facility in Kampala, Uganda, by conducting focus group discussions with health workers and TB patients in the TB and HIV clinics. Participants valued TEC but reported that high-quality TEC is rarely provided, because of a lack of time, space, staff, planning, and prioritisation given to TEC. To improve TEC, they recommended adopting practices that have proven effective in the HIV clinic, including better specifying educational content, and employing peer educators focused on TEC. Patients and health workers suggested that TEC should not only improve TB patient knowledge and adherence, but should also empower and assist all those undergoing evaluation for TB, whether confirmed or not, to educate their households and communities about TB. Community-engaged research with patients and front-line providers identified opportunities to streamline and standardise the delivery of TEC using a patient-centred, peer-educator model.
Theory-Informed Design of a Tailored Strategy for Implementing Household TB Contact Investigation in UgandaDavis, J. L., Ayakaka, I., Ggita, J. M., Ochom, E., Babirye, D., Turimumahoro, P., Gupta, A. J., Mugabe, F. R., Armstrong-Hough, M., Cattamanchi, A., & Katamba, A. (n.d.).
Journal titleFrontiers in Public Health
Volume10AbstractSince 2012, the World Health Organization has recommended household contact investigation as an evidence-based intervention to find and treat individuals with active tuberculosis (TB), the most common infectious cause of death worldwide after COVID-19. Unfortunately, uptake of this recommendation has been suboptimal in low- and middle-income countries, where the majority of affected individuals reside, and little is known about how to effectively deliver this service. Therefore, we undertook a systematic process to design a novel, theory-informed implementation strategy to promote uptake of contact investigation in Uganda, using the COM-B (Capability-Opportunity-Motivation-Behavior) model and the Behavior Change Wheel (BCW) framework. We systematically engaged national, clinic-, and community-based stakeholders and collectively re-examined the results of our own formative, parallel mixed-methods studies. We identified three core behaviors within contact investigation that we wished to change, and multiple antecedents (i.e., barriers and facilitators) of those behaviors. The BCW framework helped identify multiple intervention functions targeted to these antecedents, as well as several policies that could potentially enhance the effectiveness of those interventions. Finally, we identified multiple behavior change techniques and policies that we incorporated into a multi-component implementation strategy, which we compared to usual care in a household cluster-randomized trial. We introduced some components in both arms, including those designed to facilitate initial uptake of contact investigation, with improvement relative to historical controls. Other components that we introduced to facilitate completion of TB evaluation—home-based TB-HIV evaluation and follow-up text messaging—returned negative results due to implementation failures. In summary, the Behavior Change Wheel framework provided a feasible and transparent approach to designing a theory-informed implementation strategy. Future studies should explore the use of experimental methods such as micro-randomized trials to identify the most active components of implementation strategies, as well as more creative and entrepreneurial methods such as human-centered design to better adapt the forms and fit of implementation strategies to end users.
An emerging syndemic of smoking and cardiopulmonary diseases in people living with HIV in AfricaPeprah, 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. (n.d.).
Journal titleInternational journal of environmental research and public health
Page(s)1-12AbstractBackground: 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, UgandaBesigye, I. K., Okuuny, V., Armstrong-Hough, M., Katahoire, A. R., Sewankambo, N. K., Mash, R., & Katamba, A. (n.d.).
Journal titleSouth African Family Practice
Page(s)1-6AbstractBackground: 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.
Gaps in TB preventive therapy for persons initiating antiretroviral therapy in Uganda: an explanatory sequential cascade analysisKalema, N., Semeere, A., Banturaki, G., Kyamugabwa, A., Ssozi, S., Ggita, J., Kabajaasi, O., Kambugu, A., Kigozi, J., Muganzi, A., Castelnuovo, B., Cattamanchi, A., & Armstrong-Hough, M. (n.d.).
Journal titleInternational Journal of Tuberculosis and Lung Disease
Page(s)388-394AbstractBACKGROUND: The WHO recommends TB symptom screening and TB preventive therapy (TPT) for latent TB infection (LTBI) in persons living with HIV (PLWH). However, TPT uptake remains limited. We aimed to characterize and contextualize gaps in the TPT care cascade among persons enrolling for antiretroviral therapy (ART).SETTING: Four PEPFAR-supported facilities in Uganda.METHODS: We studied a proportionate stratified random sample of persons registering for ART when TPT was available. Patient-level data on eligibility, initiation, and completion were obtained from registers to determine proportion of eligible patients completing each cascade step. We interviewed providers and administrators and used content analysis to identify barriers to guideline-concordant TPT practices.RESULTS: Of 399 study persons, 309 (77%) were women. Median age was 29 (IQR 25-34), CD4 count 405 cells/µL (IQR 222-573), and body mass 23 kg/m² (IQR 21-25). Of 390 (98%) screened, 372 (93%) were TPT-eligible. Only 62 (17%) eligible PLWH initiated and 36 (58%) of 62 completed TPT. Providers reported hesitating to prescribe TPT because they lacked confidence excluding TB by symptom screening alone and feared promoting drug resistance. Although isoniazid was available, past experience of irregular supply discouraged TPT initiation. Providers pointed to insufficient TB-dedicated staff, speculated that patients discounted TB risk, and worried TPT pill burden and side effects depressed ART adherence.CONCLUSIONS: While screening was nearly universal, most eligible PLWH did not initiate TPT. Only about half of those who initiated completed treatment. Providers feared promoting drug resistance, harbored uncertainty about continued availability, and worried TPT could antagonize ART adherence. Our findings suggest urgent need for stakeholder engagement in TPT provision.
Patient experiences of switching from Efavirenz- to Dolutegravir-based antiretroviral therapy: a qualitative study in UgandaTwimukye, A., Laker, M., Odongpiny, E. A. L., Ajok, F., Onen, H., Kalule, I., Kajubi, P., Seden, K., Owarwo, N., Kiragga, A., Armstrong-Hough, M., Katahoire, A., Mujugira, A., Lamorde, M., & Castelnuovo, B. (n.d.).
Journal titleBMC Infectious Diseases
Issue1AbstractBackground: In 2019, the World Health Organisation (WHO) recommended Dolutegravir (DTG) as the preferred first-line antiretroviral treatment (ART) for all persons with HIV. ART regimen switches may affect HIV treatment adherence. We sought to describe patient experiences switching from EFV to DTG-based ART in Kampala, Uganda. Methods: Between July and September 2019, we purposively sampled adults living with HIV who had switched to DTG at the Infectious Diseases Institute HIV clinic. We conducted in-depth interviews with adults who switched to DTG, to explore their preparation to switch and experiences on DTG. Interviews were audio-recorded, transcribed and analysed thematically using Atlas ti version 8 software. Results: We interviewed 25 adults: 18 (72%) were women, and the median age was 35 years (interquartile range [IQR] 30–40). Median length on ART before switching to DTG was 67 months (IQR 51–125). Duration on DTG after switching was 16 months (IQR 10–18). Participants reported accepting provider recommendations to switch to DTG mainly because they anticipated that swallowing a smaller pill once a day would be more convenient. While most participants initially felt uncertain about drug switching, their providers offer of frequent appointments and a toll-free number to call in the event of side effects allayed their anxiety. At the same time, participants said they felt rushed to switch to the new ART regimen considering that they had been on their previous regimen(s) for several years and the switch to DTG happened during a routine visit when they had expected their regular prescription. Some participants felt unprepared for new adverse events associated with DTG and for the abrupt change in treatment schedule. Most participants said they needed additional support from their health providers before and after switching to DTG. Conclusion and recommendations: Adults living with HIV stable on an EFV-based regimen but were switched to DTG in a program-wide policy change found the duration between counselling and drug switching inadequate. DTG was nonetheless largely preferred because of the small pill size, once daily dosing, and absence of EFV-like side effects. Community-engaged research is needed to devise acceptable ways to prepare participants for switching ART at scale.
Risk, race, and structural racismValley, T. S., Armstrong-Hough, M., & Adegunsoye, A. (n.d.).
Journal titleAnnals of the American Thoracic Society
Social support for self-care: Patient strategies for managing diabetes and hypertension in rural ugandaTusubira, A. K., Nalwadda, C. K., Akiteng, A. R., Hsieh, E., Ngaruiya, C., Rabin, T. L., Katahoire, A., Hawley, N. L., Kalyesubula, R., Ssinabulya, I., Schwartz, J. I., & Armstrong-Hough, M. (n.d.).
Journal titleAnnals of Global Health
Page(s)1-13AbstractBackground: Low-income countries suffer a growing burden of non-communicable diseases (NCDs). Self-care practices are crucial for successfully managing NCDs to prevent complications. However, little is known about how patients practice self-care in resource-limited settings. Objective: We sought to understand self-care efforts and their facilitators among patients with diabetes and hypertension in rural Uganda. Methods: Between April and June 2019, we conducted a cross-sectional qualitative study among adult patients from outpatient NCD clinics at three health facilities in Uganda. We conducted in-depth interviews exploring self-care practices for hypertension and/or diabetes and used content analysis to identify emergent themes. Results: Nineteen patients participated. Patients said they preferred conventional medicines as their first resort, but often used traditional medicines to mitigate the impact of inconsistent access to prescribed medicines or as a supplement to those medicines. Patients adopted a wide range of vernacular practices to supplement treatment or replace unavailable diagnostic tests, such as tasting urine to gauge blood-sugar level. Finally, patients sought and received both instrumental and emotional support for self-care activities from networks of family and peers. Patients saw their children as their most reliable source of support facilitating self-care, especially as a source of money for medicines, transport and home necessities. Conclusion: Patients valued conventional medicines but engaged in varied self-care practices. They depended upon networks of social support from family and peers to facilitate self-care. Interventions to improve self-care may be more effective if they improve access to prescribed medicines and engage or enhance patients’ social support networks.
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. (n.d.).
Journal titleBMC public health
Issue1AbstractBackground: 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 UgandaMeyer, A. J., Armstrong-Hough, M., Babirye, D., Mark, D., Turimumahoro, P., Ayakaka, I., Haberer, J. E., Katamba, A., & Davis, J. L. (n.d.).
Journal titleJMIR mHealth and uHealth
Issue7AbstractBackground: 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 StudyMusiimenta, A., Tumuhimbise, W., Atukunda, E. C., Mugaba, A. T., Muzoora, C., Armstrong-Hough, M., Bangsberg, D., Davis, J. L., & Haberer, J. E. (n.d.).
Journal titleTuberculosis research and treatment
Page(s)7401045AbstractBackground: 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 patientsLee, G., Meyer, A. J., Kizito, S., Katamba, A., Davis, J. L., & Armstrong-Hough, M. (n.d.).
Journal titleInternational Journal of Tuberculosis and Lung Disease
Prevalence, associated factors and perspectives of HIV testing among men in UgandaNangendo, 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. (n.d.).
Journal titlePloS one
Issue8AbstractBackground: 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 studyKaturamu, R., Kamya, M. R., Sanyu, N., Armstrong-Hough, M., & Semitala, F. C. (n.d.).
Journal titleImplementation science communications
Page(s)37AbstractBackground: 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 analysisArmstrong-Hough, M., Sharma, S., Kishore, S. P., Akiteng, A. R., & Schwartz, J. I. (n.d.).
Journal titlePloS one
Issue12AbstractBackground: 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 studyMusiimenta, A., Tumuhimbise, W., Mugaba, A. T., Muzoora, C., Armstrong-Hough, M., Bangsberg, D., Davis, J. L., & Haberer, J. E. (n.d.).
Journal titleJournal of Clinical Tuberculosis and Other Mycobacterial Diseases
Volume17AbstractBackground: 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 trialDavis, 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. (n.d.).
Journal titleERJ Open Research
Issue3AbstractIntroduction: 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.
'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. (n.d.).
Journal titleInternational Journal of Tuberculosis and Lung Disease
Page(s)1152-1159AbstractBACKGROUND: 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 = 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 perspectiveArmstrong-Hough, M. J. (n.d.). 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.
Page(s)261-269AbstractJapanese 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 JapanArmstrong-Hough, M. (n.d.).
Brief Report: "Give Me Some Time": Facilitators of and Barriers to Uptake of Home-Based HIV Testing During Household Contact Investigation for Tuberculosis in Kampala, Uganda: 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. (n.d.).
Journal titleJournal of Acquired Immune Deficiency Syndromes
Page(s)400-404AbstractBackground: 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.