Mari Armstrong-Hough
Mari Armstrong-Hough
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Associate Professor of Social & Behavioral Sciences and Epidemiology
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Professional overview
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Dr. Mari Armstrong-Hough is Associate Professor in the Department of Social & Behavioral Sciences and in the Department of Epidemiology. She is a medical sociologist and epidemiologist of respiratory disease.
Dr. 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.
Dr. 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. Dr. 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.
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Education
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BA, Sociology, History, and Political Science, University of Wisconsin–MadisonMA, East Asian Studies, Duke UniversityPhD, Sociology, Duke UniversityPostdoctoral MPH, Applied Biostatistics and Epidemiology, Yale
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Publications
Publications
A Delphi Consensus on Recommendations for Improving Research Processes and Infrastructure to Address Health Disparities
AbstractArmstrong-Hough, M., Mohamed, A., Adegunsoye, A., Armstrong-Hough, M., Ferguson-Myrthil, N., Hassan, I., Mayr, F. B., Valley, T. S., Winkfield, D. R., Walsh, C. B., & Chen, J. T. (n.d.).Publication year
2025Journal title
CHEST Critical CareVolume
3Issue
3AbstractBackground: Racial and ethnic disparities in critical care medicine remain poorly understood, making them difficult to address. This initiative developed a thought leader consensus with recommendations for critical care research to document, assess, and understand potential disparities. Research Question: What key areas should future critical care research focus on to better identify and address disparities related to race, ethnicity, and language? Study Design and Methods: A modified Delphi-based method was used to form a consensus about addressing racial disparities through future critical care research. Nine thought leaders discussed aspects related to 4 topics: collection of race, ethnicity, and language variables; establishing recruitment plans for researchers from racial and ethnic minority groups; designating minority serving institutions; and health disparity education and community engagement. Consensus was reached when ≥ 80% of members agreed (answered with yes or with 4 to 5 points on a Likert scale). Results: Thought leaders arrived at a consensus agreement (100%) that improved data quality, achieved by more robust recruitment of research participants from racial and ethnic minority groups and standardization of race and ethnicity data, is crucial as the initial step of uncovering health disparities. They agreed that collection of language preferences should be part of all research studies to expose potential biases and disparities in non-English speakers (100% agreement). Engagement of racial and ethnic minority communities was agreed to be essential to obtain involvement of research participants from such minoritized groups (100%). Interpretation: This consensus revealed the notable data deficiency impacting health disparities within critical care research especially when compared with other settings, highlighting the crucial need for comprehensive focus on this domain. Standardization of race, ethnicity, and language data collection, with the goal of increasing the number of research participants from racial and ethnic minority groups, is vital for understanding health disparities in critical care research and its potential causes.Adaptation and validation of perceived HIV and TB stigma scales among persons with TB
AbstractArmstrong-Hough, M., Ponticiello, M. N., Nanziri, L. M., Hennein, R., Ochom, E., Gupta, A. J., Turimumahoro, P., White, M. A., Armstrong-Hough, M., Katamba, A., Davis, J. L., & Davis, J. L. (n.d.).Publication year
2025Journal title
International Journal of Tuberculosis and Lung DiseaseVolume
29Issue
3Page(s)
127-134AbstractB A C K G R O U N D: Stigma is a barrier to care for people affected by TB and HIV in Uganda, where these conditions remain endemic. While scales have been adapted and validated to measure stigma among TB-affected households in Uganda, there is a need for scales that measure the experiences of persons with TB (PWTB). M E T H O D S: We adapted the Van Rie 12-item individual perspectives TB scale and 10-item individual perspectives HIV scale for use in Uganda through cross-cultural discussions with a multidisciplinary research team and four cognitive interviews with community health workers and PWTB. We then conducted a cross-sectional study administering each scale to 125 PWTB. We performed exploratory factor analysis, evaluated internal validity, and assessed convergent validity with perceived social support. R E S U L T S: Exploratory factor analysis yielded a one-factor solution for both scales, with marginal model fit (standardised root mean square residual ¼ 0.09 for TB, ¼ 0.07 for HIV). There was evidence of convergent validity through a positive correlation of the TB (r ¼ 0.22, p ¼ 0.01) and HIV stigma (r ¼ 0.22, p ¼ 0.01) scales with perceived social support. Both scales had good internal validity (Cronbach’s a ¼ 0.86 for TB, ¼ 0.87 for HIV). C O N C L U S I O N: Adapted scales to measure perceived HIV and TB stigma among PWTB in Uganda demonstrated promising psychometric properties by removing one and two items, respectively.Communication attributes modify the anxiety risk associated with problematic social media use : Evidence from a prospective diary method study
AbstractAllen Weng, C., Bulgin, J., Diaz, S., Zhang, J., Tan, R., Li, L., & Armstrong-Hough, M. (n.d.).Publication year
2025Journal title
Addictive BehaviorsVolume
166AbstractPurpose: Social media use in younger people has shown mixed associations with mental health. We hypothesized that communication types during social media use might alter the relationship between problematic social media use (PSMU) and anxiety over time. We aimed to identify how four dimensions of communication influence the link between PSMU and anxiety. Methods: We recruited a cohort of undergraduate students aged 18–26 to participate in daily surveys over two weeks using a diary method to assess daily social media use, PSMU, anxiety symptoms, and the four dimensions of communication: Consumption, Broadness, Online Exclusivity, and Parasociality. Lagged logistic regression models with generalized estimating equations evaluated the influence of daily PSMU and communication type on subsequent anxiety levels. Results: Out of 79 participants, 1009 daily records were analyzed. PSMU positively correlated with anxiety (Kendall rank correlation τ = 0.30). Interaction analysis indicated that levels of parasociality and consumption moderated the association between PSMU components and anxiety outcomes. In young adults with high levels of consumption or parasociality, a 1-standard-deviation rise in PSMU's social conflict component led to an 11 %-13 % increase in next-day anxiety scores. This association was absent for those with low to moderate levels of parasociality and consumption. Discussion: Elevated levels of passive consumption and one-sided interactions amplify the anxiety risk associated with PSMU. Further longitudinal evidence can elucidate the connections between communication types, social media exposure, and anxiety, guiding the development of a model for healthy social media use.Female sex worker preferences for HIV pre-exposure prophylaxis delivery in Uganda : A discrete choice experiment
AbstractMpirirwe, R., Makabayi-Mugabe, R., Muteebwa, L., Kamacooko, O., Wamono, F., Kajumba, M. M., Nangendo, J., Semitala, F. C., Kyambadde, P., Davis, K. J., Kalyango, J., Karamagi, C., Kiragga, A., Armstrong-Hough, M., Moor, S. E., Katahoire, A. R., Kamya, M. R., & Mujugira, A. (n.d.).Publication year
2025Journal title
PLOS Global Public HealthVolume
5Issue
6AbstractCisgender female sex workers (FSWs) in sub-Saharan Africa have a high risk of HIV acquisition, highlighting the need for innovative approaches to expand coverage of evidence-based HIV prevention methods, including oral pre-exposure prophylaxis (PrEP). Our study aimed to identify FSWs’ preferences for a PrEP delivery model with structured choices for delivery location, services offered, and adherence support. We conducted a discrete choice experiment (DCE) with female sex workers (FSWs) aged 18 and above at the Most At-Risk Population Initiative (MARPI) clinic in Kampala, Uganda, from October to November 2023. Participants were recruited consecutively. To identify the most preferred PrEP delivery model, we designed eight choice sets using a D-efficient design. Each set included three PrEP service options and an opt-out. Options varied by provider, delivery location, channel, and support services. Participants selected their preferred option in each set. Preferences and trade-offs were analyzed using a panel mixed model, and the highest median utility identified the top model. Overall, 203 participants completed the DCE. The median age was 24 years (interquartile range [IQR] 20–32). Most FSWs preferred receiving PrEP from a healthcare worker at the clinic with short message service (SMS) reminders for adherence support (median utility score 0.87; interquartile range [IQR] 0.82, 0.94). This preference remained consistent across all age groups, with a median utility score of 0.88 for ages 15–19, 0.87 for ages 20–24, and 0.85 for ages ≥25. FSWs preferred to receive PrEP care directly from providers at healthcare facilities and highlighted the need for additional support in the form of SMS reminders to improve adherence and prevent HIV acquisition. This preferred model, if implemented, could increase prevention coverage and inform future approaches to delivering PrEP through the Uganda National PrEP Program.Representation of Hispanic Patients in Clinical Trials for Respiratory Failure : A Systematic Review
AbstractHarlan, E. A., Malley, K., Quiroga, G., Mubarak, E., Lama, P., Schutz, A., Cuevas, A., Hough, C. L., Iwashyna, T. J., Armstrong-Hough, M., & Valley, T. S. (n.d.).Publication year
2025Journal title
Critical Care ExplorationsVolume
7Issue
1Page(s)
e1193AbstractOBJECTIVES: Hispanic individuals comprise one-fifth of the U.S. population and Hispanic patients with acute hypoxemic respiratory failure (AHRF) experience higher odds of death compared with non-Hispanic White patients. Representation of Hispanic patients in clinical trials for respiratory failure is critical to address this inequity. We conducted a systematic review to examine the inclusion of Hispanic patients in randomized controlled trials for AHRF and assessed language as a potential barrier to enrollment. DATA SOURCES: National Library of Medicine PubMed, Elsevier Embase, and Cochrane Central Register of Controlled Trials databases through January 2024. STUDY SELECTION: Randomized controlled trials assessing AHRF interventions enrolling U.S. patients receiving mechanical ventilation, noninvasive mechanical ventilation, or high-flow nasal cannula were included. The systematic review was registered prospectively through PROSPERO (CRD42023437828). DATA EXTRACTION: Two authors independently screened studies and extracted data for each included study. DATA SYNTHESIS: Ninety-four trials published from 1975 to 2023 were included; 33.0% (n = 31) of studies reported ethnicity, and 11.2% of participants in studies reporting race or ethnicity (1,320/11,780) were identified as Hispanic. The proportion of Hispanic-identified participants was significantly lower than the U.S. Hispanic population from 1996 to 2019 (p < 0.01). Starting in 2020, the proportion of Hispanic-identified participants was significantly higher than the U.S. population (27.8% vs. 19.1%; p < 0.01). Two studies (4.9%) reporting race or ethnicity excluded non-English speaking participants; the remainder did not specify language requirements for enrollment. CONCLUSIONS: Hispanic-identified individuals were underrepresented in trials for AHRF until 2020 when Hispanic patient representation increased during COVID-19. Exclusion of participants who do not speak English may represent a barrier to trial enrollment.Tobacco spending and the perceived cost of tobacco among smokers living with HIV and receiving treatment at outpatient clinics in Viet Nam : A mixed methods study
AbstractAlvarez, G. G., Hoang, T., Kapur, R., Nguyen, C., Armstrong-Hough, M., Nguyen, T., Nguyen, N., Van Minh, H., & Shelley, D. (n.d.).Publication year
2025Journal title
PloS oneVolume
20Issue
7 JulyAbstractBackground Tobacco use among people living with HIV (PWH) is 2–3 times higher than among HIV-negative individuals. In Viet Nam, over 50% of men living with HIV use tobacco. Reducing smoking is important to improving disparities among PWH who smoke including their higher exposure to chronic disease. However, data on tobacco spending as well as the potential impact of tobacco policies, such as taxation, is limited among PWH. Viet Nam has one of the lowest taxes on tobacco in the world, thus underutilizing this tool. Our study aims to understand tobacco spending among PWH who smoke as well as examine the financial burden of tobacco use, and their perceptions about the affordability of tobacco products. Methods We conducted qualitative interviews (n=24) that explored smoking behavior and perceptions about the cost of tobacco, alongside cross-sectional quantitative surveys (n=75) that assessed daily tobacco expenditures and the proportion of income spent on tobacco. We applied convergent parallel design to these two independent samples taken from the same study population of PWH enrolled in a tobacco use treatment study at HIV clinics in Ha Noi, Viet Nam. Results Participants spent 7.47% of their annual income on tobacco products. Tobacco dependence was positively associated with higher daily expenditure on tobacco. Qualitatively, participants did not describe tobacco-related spending as a financial burden and did not consider the price of cigarettes as a motivation to quit. However, participants acknowledged that smoking is still a costly expenditure and indicated that quitting would yield financial savings which could be redirected to other household needs. Conclusion Despite spending a considerable percentage of their income spent on tobacco, most participants perceived cigarettes as affordable. This may reflect our sample’s strong socioeconomic resources as well as the low price of cigarettes in Viet Nam, which may be too low to cause financial hardship and thus reduce motivation to quitting.An adapted scale to measure perceived TB and HIV stigma during household contact investigation
AbstractArmstrong-Hough, M., Armstrong-Hough, M., Shelby, T., Ggita, J., Nangendo, J., Gupta, A. J., Davis, J. L., & Katamba, A. (n.d.).Publication year
2024Journal title
International Journal of Tuberculosis and Lung DiseaseVolume
28Issue
9Page(s)
433-438AbstractBACKGROUND: Measuring stigma for TB and HIV in households undergoing contact investigation for TB is critical for understanding its impacts on health behaviours and identifying opportunities for intervention. However, standardised measurements for TB-HIV stigma in household contact investigations are limited. METHODS: We adapted and validated a household stigma scale in Uganda. This involved field testing measures from another setting with 163 household contacts of newly diagnosed TB patients, conducting cognitive interviews with seven household contacts, adapting scale items using cognitive interview data, and retesting the adapted scales in a random sample of 60 contacts. We assessed inter-item covariance and performed factor analysis to select the final scale items. RESULTS: In whole-scale factor analysis, no cross-loading of items with scores ≥0.32 was found after the elimination of items based on covariance and symmetry. All TB items were loaded onto a single factor with scores ≥0.5, and all but one HIV item was loaded onto a second factor with scores ≥0.5. The final subscale internal consistency (Cronbach’s alpha) was 0.92 for TB and 0.89 for HIV. CONCLUSIONS: The adapted TB-HIV stigma scale demonstrated acceptable psychometric properties and is substantially shorter and easier to administer than previous scales, making it suitable for programmatic research and evaluation.Depression and associated factors among HIV-positive smokers receiving care at HIV outpatient clinics in Vietnam : A cross-sectional analysis
AbstractNguyen, N. T., Nguyen, T., Vu, G. V., Truong, N., Pham, Y., Guevara Alvarez, G., Armstrong-Hough, M., & Shelley, D. (n.d.).Publication year
2024Journal title
BMJ openVolume
14Issue
2AbstractObjectives To assess the prevalence of depressive symptoms and associated factors among people living with HIV (PLWH) who were current cigarette smokers and receiving treatment at HIV outpatient clinics (OPCs) in Vietnam. Design A cross-sectional survey of smokers living with HIV. Setting The study was carried out in 13 HIV OPCs located in Ha Noi, Vietnam. Participants The study included 527 PLWH aged 18 and above who were smokers and were receiving treatment at HIV OPCs. Outcome measures The study used the Centre for Epidemiology Scale for Depression to assess depressive symptoms. The associations between depressive symptoms, tobacco dependence and other characteristics were explored using bivariate and Poisson regression analyses. Results The prevalence of depressive symptoms among smokers living with HIV was 38.3%. HIV-positive smokers who were female (prevalence ratio, PR 1.51, 95% CI 1.02 to 2.22), unmarried (PR 2.06, 95% CI 1.54 to 2.76), had a higher level of tobacco dependence (PR 1.06, 95% CI 1.01 to 1.11) and reported their health as fair or poor (PR 1.66, 95% CI 1.22 to 2.26) were more likely to have depression symptoms compared with HIV-positive smokers who were male, married, had a lower level of tobacco dependence and self-reported their health as good, very good or excellent. Conclusion The prevalence of depressive symptoms among smokers receiving HIV care at HIV OPCs was high. Both depression and tobacco use screening and treatment should be included as part of ongoing care treatment plans at HIV OPCs.Efficacy and Impact of Peer-Led Education for Persons with Tuberculosis in Kampala, Uganda: A Pre-Post Implementation Study
AbstractArmstrong-Hough, M., Baker, A., Gupta, A. J., Nanziri, L., Ggita, J. M., Hernandez-Ramirez, R. U., Shenoi, S. V., Ayakaka, I., Armstrong-Hough, M., Katamba, A., & Davis, J. L. (n.d.).Publication year
2024Journal title
Research squareAbstractUniversal TB education and counseling (TEC) is routinely recommended for promoting knowledge and medication adherence, but the quality of delivery often varies because of inadequate clinic space, time, and health worker training. Peer-led counseling is a promising but understudied solution to these challenges. We sought to evaluate the efficacy of a peer-led TEC strategy among newly diagnosed adults initiating TB treatment in Kampala, Uganda.Ethnic Disparities in Deep Sedation of Patients with Acute Respiratory Distress Syndrome in the United States : Secondary Analysis of a Multicenter Randomized Trial
AbstractArmstrong-Hough, M., Lin, P., Venkatesh, S., Ghous, M., Hough, C. L., Cook, S. H., Iwashyna, T. J., & Valley, T. S. (n.d.).Publication year
2024Journal title
Annals of the American Thoracic SocietyVolume
21Issue
4Page(s)
620-626AbstractRationale: Patients identified as Hispanic, the largest minority group in the United States, are more likely to die from acute respiratory distress syndrome (ARDS) than non-Hispanic patients. Mechanisms to explain this disparity remain unidentified. However, Hispanic patients may be at risk of overexposure to deep sedation because of language differences between patients and clinicians, and deep sedation is associated with higher ARDS mortality.Objective: We examined associations between Hispanic ethnicity and exposure to deep sedation among patients with ARDS.Methods: A secondary analysis was conducted of patients enrolled in the control arm of a randomized trial of neuromuscular blockade for ARDS across 48 U.S. hospitals. Exposure to deep sedation was measured over the first 5 days that a patient was alive and received mechanical ventilation. Multilevel mixed-effects models were used to evaluate associations between Hispanic ethnicity and exposure to deep sedation, controlling for patient characteristics.Results: Patients identified as Hispanic had approximately five times the odds of deep sedation (odds ratio, 4.98; 95% confidence interval, 2.02-12.28; P < 0.0001) on a given day, compared with non-Hispanic White patients. Hospitals with at least one enrolled Hispanic patient kept all enrolled patients deeply sedated longer than hospitals without any enrolled Hispanic patients (85.8% of ventilator-days vs. 65.5%; P < 0.001).Conclusions: Hispanic patients are at higher risk of exposure to deep sedation than non-Hispanic White patients. There is an urgent need to understand and address disparities in sedation delivery.Ethnic Disparities in Deep Sedation of Patients with Acute Respiratory Distress Syndrome in the United States: Secondary Analysis of a Multicenter Randomized Trial
AbstractArmstrong-Hough, M., Armstrong-Hough, M., Lin, P., Venkatesh, S., Ghous, M., Hough, C. L., Cook, S. H., Iwashyna, T. J., & Valley, T. S. (n.d.).Publication year
2024Journal title
Annals of the American Thoracic SocietyAbstractPatients identified as Hispanic, the largest minority group in the United States (U.S.), are more likely to die from acute respiratory distress syndrome (ARDS) than non-Hispanic patients. Mechanisms to explain this disparity remain unidentified. However, Hispanic patients may be at risk of overexposure to deep sedation due to language differences between patients and clinicians, and deep sedation is associated with higher ARDS mortality.Factors associated with retention in Quitline counseling for smoking cessation among HIV-positive smokers receiving care at HIV outpatient clinics in Vietnam
AbstractNguyen, N. T., Nguyen, T., Van Vu, G., Cleland, C. M., Pham, Y., Truong, N., Kapur, R., Alvarez, G. G., Phan, P. T., Armstrong-Hough, M., & Shelley, D. (n.d.).Publication year
2024Journal title
PloS oneVolume
19Issue
12AbstractBackground Quitline counseling is an effective method for supporting smoking cessation, offering personalized and accessible assistance. Tobacco use is a significant public health issue among people living with HIV. In Vietnam, over 50% of men living with HIV use tobacco. However, there is limited research on Quitline use and retention rates in this population and a lack of research on factors associated with retention in Quitline counseling. The study aims to evaluate the factors associated with retention in Quitline counseling for smoking cessation among HIV-positive smokers receiving care at HIV outpatient clinics in Vietnam. Method The study analyzed data from a randomized controlled trial (RCT) that compared the effectiveness of three smoking cessation interventions for smokers living with HIV at 13 Outpatient Clinics in Ha Noi. A total of 221 smokers aged 18 and above living with HIV participated in Arm 1 of the RCT, which included screening for tobacco use (Ask), health worker-delivered brief counseling (Assist), and proactive referral to Vietnam’s national Quitline (AAR), in which the Quitline reached out to the patient to engage them in up to 10 sessions of smoking cessation counseling. Retention in Quitline counseling was defined as participating in more than five counseling calls. The study used bivariate and logistic regression analyses to explore the associations between retention and other factors. Results Fifty-one percent of HIV-positive smokers completed more than five counseling sessions. Smokers living with HIV aged 35 or older (OR = 5.53, 95% CI 1.42–21.52), who had a very low/low tobacco dependence level (OR = 2.26, 95% CI 1.14–4.51), had a lower score of perceived importance of quitting cigarettes (OR = 0.87, 95% CI 0.76–0.99), had a household ban or partial ban on cigarettes smoking (OR = 2.58, 95% CI 1.39–4.80), and had chosen a quit date during the Quitline counseling (OR = 3.0, 95% CI 1.63–5.53) were more likely to retain in the Quitline counseling than those smokers living with HIV whose ages were less than 35, who had a high/very high tobacco dependence level, had a higher score of perception of the importance of quitting cigarettes, did not have a household ban on cigarettes smoking, and did not choose a quit date during counseling. Conclusion There is a high retention rate in Quitline counseling services among PLWHs receiving care at HIV outpatient clinics. Tailoring interventions to the associated factors such as age, tobacco dependence, perceived importance of quitting, household smoking bans, and setting a quit date during counseling may improve engagement and outcomes, aiding in the reduction of smoking prevalence among HIV-positive individuals.(Re)designing interventions: Research with a commitment to equity
AbstractArmstrong-Hough, M. (n.d.).Publication year
2023AbstractSymposium talkA user-centred implementation strategy for tuberculosis contact investigation in Uganda : protocol for a stepped-wedge, cluster-randomised trial
AbstractKatamba, A., Gupta, A. J., Turimumahoro, P., Ochom, E., Ggita, J. M., Nakasendwa, S., Nanziri, L., Musinguzi, J., Hennein, R., Sekadde, M., Hanrahan, C., Byaruhanga, R., Yoeli, E., Turyahabwe, S., Cattamanchi, A., Dowdy, D. W., Haberer, J. E., Armstrong-Hough, M., Kiwanuka, N., & Davis, J. L. (n.d.).Publication year
2023Journal title
BMC public healthVolume
23Issue
1AbstractBackground: Tuberculosis(TB) is among the leading causes of infectious death worldwide. Contact investigation is an evidence-based, World Health Organisation-endorsed intervention for timely TB diagnosis, treatment, and prevention but has not been widely and effectively implemented. Methods: We are conducting a stepped-wedge, cluster-randomised, hybrid Type III implementation-effectiveness trial comparing a user-centred to a standard strategy for implementing TB contact investigation in 12 healthcare facilities in Uganda. The user-centred strategy consists of several client-focused components including (1) a TB-education booklet, (2) a contact-identification algorithm, (3) an instructional sputum-collection video, and (4) a community-health-rider service to transport clients, CHWs, and sputum samples, along with several healthcare-worker-focused components, including (1) collaborative improvement meetings, (2) regular audit-and-feedback reports, and (3) a digital group-chat application designed to develop a community of practice. Sites will cross-over from the standard to the user-centred strategy in six, eight-week transition steps following a randomly determined site-pairing scheme and timeline. The primary implementation outcome is the proportion of symptomatic close contacts completing TB evaluation within 60 days of TB treatment initiation by the index person with TB. The primary clinical effectiveness outcomes are the proportion of contacts diagnosed with and initiating active TB disease treatment and the proportion initiating TB preventative therapy within 60 days. We will assess outcomes from routine source documents using intention-to-treat analyses. We will also conduct nested mixed-methods studies of implementation fidelity and context and perform cost-effectiveness and impact modelling. The Makerere School of Public Health IRB(#554), the Uganda National Council for Science and Technology(#HS1720ES), and the Yale Institutional Review Board(#2000023199) approved the study and waived informed consent for the main trial implementation-effectiveness outcomes. We will submit results for publication in peer-reviewed journals and disseminate findings to local policymakers and representatives of affected communities. Discussion: This pragmatic, quasi-experimental implementation trial will inform efforts to find and prevent undiagnosed persons with TB in high-burden settings using contact investigation. It will also help assess the suitability of human-centred design and communities of practice for tailoring implementation strategies and sustaining evidence-based interventions in low-and-middle-income countries. Trial registration: The trial was registered(ClinicalTrials.gov Identifier NCT05640648) on 16 November 2022, after the trial launch on 7 March 2022.A user-centred implementation strategy for tuberculosis contact investigation in Uganda: Protocol for a stepped-wedge, cluster-randomised trial
AbstractArmstrong-Hough, M., Katamba, A., Gupta, A. J., Turimumahoro, P., Ochom, E., Ggita, J. M., Nakasendwa, S., Nanziri, L., Musinguzi, J., Hennein, R., Sekadde, M., Hanrahan, C., Byaruhanga, R., Yoeli, E., Turyahabwe, S., Cattamanchi, A., Dowdy, D. W., Haberer, J. E., Armstrong-Hough, M., … Davis, J. L. (n.d.).Publication year
2023Journal title
Research squareAbstractTuberculosis (TB) is among the leading causes of infectious death worldwide. Contact investigation is an evidence-based, World Health Organisation-endorsed intervention for timely TB diagnosis, treatment, and prevention but has not been widely and effectively implemented. We are conducting a stepped-wedge, cluster-randomised, hybrid Type III implementation-effectiveness trial comparing a user-centred to a standard strategy for implementing TB contact investigation in 12 healthcare facilities in Uganda. The user-centred strategy consists of several client-focused components including 1) a TB-education booklet, 2) a contact-identification algorithm, 3) an instructional sputum-collection video, and 4) a community-health-rider service to transport clients, CHWs, and sputum samples, along with several healthcare-worker-focused components, including 1) collaborative improvement meetings, 2) regular audit-and-feedback reports, and 3) a digital group-chat application designed to develop a community of practice. Sites will cross from the standard to the user-centred strategy in six, eight-week transition steps following a randomly determined site-pairing scheme and timeline. The primary implementation outcome is the proportion of symptomatic close contacts completing TB evaluation within 60 days of TB treatment initiation by the index person with TB. The primary clinical effectiveness outcomes are the proportion of contacts diagnosed with and initiating active TB disease treatment and the proportion initiating TB preventative therapy within 60 days. We will assess outcomes from routine source documents using intention-to-treat analyses. We will also conduct nested mixed-methods studies of implementation fidelity and context and perform cost-effectiveness and impact modelling. The Makerere School of Public Health IRB (#554), the Uganda National Council for Science and Technology (#HS1720ES), and the Yale Institutional Review Board (#2000023199) approved the study with a waiver of informed consent for the main trial implementation-effectiveness outcomes. We will submit trial results for publication in a peer-reviewed journal and disseminate findings to local shareholders, including policymakers and representatives of affected communities. This pragmatic, quasi-experimental implementation trial will inform efforts to find and prevent undiagnosed persons with TB in high-burden setting using contact investigation. It will help assess the suitability of human-centred design and communities of practice for tailoring implementation strategies and sustain evidence-based interventions in low-and-middle-income countries. ClinicalTrials.gov Identifier: NCT05640648.Associations among past trauma, post-displacement stressors, and mental health outcomes in Rohingya refugees in Bangladesh : A secondary cross-sectional analysis
AbstractRitsema, H., & Armstrong-Hough, M. (n.d.).Publication year
2023Journal title
Frontiers in Public HealthVolume
10AbstractObjective: The Rohingya endured intense trauma in Myanmar and continue to experience trauma related to displacement in Bangladesh. We aimed to evaluate the association of post-displacement stressors with mental health outcomes, adjusting for previously experienced trauma, in the Rohingya refugee population in Cox's Bazar, Bangladesh. Methods: We analyzed data from the Cox's Bazar Panel Survey, a cross sectional survey consisting of 5,020 household interviews and 9,386 individual interviews completed in 2019. Using logistic regression, we tested the association between post-displacement stressors such as current exposure to crime and conflict and two mental health outcomes: depression and post-traumatic stress disorder (PTSD). In adjusted analyses, we controlled for past trauma, employment status, receiving an income, food security, and access to healthcare and stratified by gender. Results: The prevalence of depressive symptoms was 30.0% (n = 1,357) and PTSD 4.9% (n = 218). Most (87.1%, n = 3,938) reported experiencing at least one traumatic event. Multiple post-displacement stressors, such as current exposure to crime and conflict (for men: OR = 2.23, 95% CI = 1.52–3.28, p < 0.001; for women: OR = 1.92, 95% CI = 1.44–2.56, p < 0.001), were associated with higher odds of depressive symptoms in multivariable models. Trauma (OR = 4.98, 95% CI = 2.20–11.31, p < 0.001) was associated with increased odds of PTSD. Living in a household that received income was associated with decreased odds of PTSD (OR = 0.74, 95% CI = 0.55–1.00, p = 0.05). Conclusion: Prevalence of depressive symptoms was high among Rohingya refugees living in Cox's Bazar. Adjusting for past trauma and other risk factors, exposure to post-displacement stressors was associated with increased odds of depressive symptoms. There is a need to address social determinants of health that continue to shape mental health post-displacement and increase mental healthcare access for displaced Rohingya.Clinical Practices Following Train-The-Trainer Trauma Course Completion in Uganda : A Parallel-Convergent Mixed-Methods Study
AbstractTang, Z., Kayondo, D., Ullrich, S. J., Namugga, M., Muwanguzi, P., Klazura, G., Ozgediz, D., & Armstrong-Hough, M. (n.d.).Publication year
2023Journal title
World Journal of SurgeryAbstractBACKGROUND: Despite the growth of trauma training courses worldwide, evidence for their impact on clinical practice in low- and middle-income countries (LMICs) is sparse. We investigated trauma practices by trained providers in Uganda using clinical observation, surveys, and interviews.METHODS: Ugandan providers participated in the Kampala Advanced Trauma Course (KATC) from 2018 to 2019. Between July and September of 2019, we directly evaluated guideline-concordant behaviors in KATC-exposed facilities using a structured real-time observation tool. We conducted 27 semi-structured interviews with course-trained providers to elucidate experiences of trauma care and factors that impact adoption of guideline-concordant behaviors. We assessed perceptions of trauma resource availability through a validated survey.RESULTS: Of 23 resuscitations, 83% were managed without course-trained providers. Frontline providers inconsistently performed universally applicable assessments: pulse checks (61%), pulse oximetry (39%), lung auscultation (52%), blood pressure (65%), pupil examination (52%). We did not observe skill transference between trained and untrained providers. In interviews, respondents found KATC personally transformative but not sufficient for facility-wide improvement due to issues with retention, lack of trained peers, and resource shortages. Resource perception surveys similarly demonstrated profound resource shortages and variation across facilities.CONCLUSIONS: Trained providers view short-term trauma training interventions positively, but these courses may lack long-term impact due to barriers to adopting best practices. Trauma courses should include more frontline providers, target skill transference and retention, and increase the proportion of trained providers at each facility to promote communities of practice. Essential supplies and infrastructure in facilities must be consistent for providers to practice what they have learned.Clinical Practices Following Train-The-Trainer Trauma Course Completion in Uganda: A Parallel-Convergent Mixed-Methods Study
AbstractArmstrong-Hough, M., Tang, Z., Kayondo, D., Ullrich, S. J., Namugga, M., Muwanguzi, P., Klazura, G., Ozgediz, D., & Armstrong-Hough, M. (n.d.).Publication year
2023Journal title
World journal of surgeryVolume
47Issue
6Page(s)
1399-1408AbstractDespite the growth of trauma training courses worldwide, evidence for their impact on clinical practice in low- and middle-income countries (LMICs) is sparse. We investigated trauma practices by trained providers in Uganda using clinical observation, surveys, and interviews.Disparities among patients with respiratory failure
AbstractArmstrong-Hough, M., Blank, J. A., Armstrong-Hough, M., & Valley, T. S. (n.d.).Publication year
2023Volume
29Page(s)
493-504AbstractDisparities are common within healthcare, and critical illness is no exception. This review summarizes recent literature on health disparities within respiratory failure, focusing on race, ethnicity, socioeconomic status, and sex.Disparities among patients with respiratory failure
AbstractBlank, J. A., Armstrong-Hough, M., & Valley, T. S. (n.d.).Publication year
2023Journal title
Current Opinion in Critical CareVolume
29Issue
5Page(s)
493-504AbstractPURPOSE OF REVIEW: Disparities are common within healthcare, and critical illness is no exception. This review summarizes recent literature on health disparities within respiratory failure, focusing on race, ethnicity, socioeconomic status, and sex. RECENT FINDINGS: Current evidence indicates that Black patients have higher incidence of respiratory failure, while the relationships among race, ethnicity, and mortality remains unclear. There has been renewed interest in medical device bias, specifically pulse oximetry, for which data demonstrate patients with darker skin tones may be at risk for undetected hypoxemia and worse outcomes. Lower socioeconomic status is associated with higher mortality, and respiratory failure can potentiate socioeconomic inequities via illness-related financial toxicity. Literature on sex-based disparities is limited; however, evidence suggests males receive more invasive care, including mechanical ventilation. SUMMARY: Most studies focused on disparities in incidence and mortality associated with respiratory failure, but few relied on granular clinical data of patients from diverse backgrounds. Future studies should evaluate processes of care for respiratory failure that may mechanistically contribute to disparities in order to develop interventions that improve outcomes.Experiences of household food insecurity among individuals with tuberculosis in Kampala, Uganda
AbstractHalder, A., & Armstrong-Hough, M. (n.d.).Publication year
2023Abstract~Integrating diabetes mellitus care into Tuberculosis (TB) treatment in Uganda: A Parallel Convergent mixed-methods study
AbstractSsuna, B., & Armstrong-Hough, M. (n.d.).Publication year
2023Abstract~mHealth to improve implementation of TB contact investigation : a case study from Uganda
AbstractGupta, A. J., Turimumahoro, P., Ochom, E., Ggita, J. M., Babirye, D., Ayakaka, I., Mark, D., Okello, D. A., Cattamanchi, A., Dowdy, D. W., Haberer, J. E., Armstrong-Hough, M., Katamba, A., & Davis, J. L. (n.d.).Publication year
2023Journal title
Implementation science communicationsVolume
4Issue
1AbstractBackground: Implementation science offers a systematic approach to adapting innovations and delivery strategies to new contexts but has yet to be widely applied in low- and middle-income countries. The Fogarty Center for Global Health Studies is sponsoring a special series, “Global Implementation Science Case Studies,” to address this gap. Methods: We developed a case study for this series describing our approach and lessons learned while conducting a prospective, multi-modal study to design, implement, and evaluate an implementation strategy for TB contact investigation in Kampala, Uganda. The study included formative, evaluative, and summative phases that allowed us to develop and test an adapted contact investigation intervention involving home-based sample collection for TB and HIV testing. We concurrently developed a multi-component mHealth implementation strategy involving fingerprint scanning, electronic decision support, and automated reporting of test results via text message. We then conducted a household-randomized, hybrid implementation-effectiveness trial comparing the adapted intervention and implementation strategy to usual care. Our assessment included nested quantitative and qualitative studies to understand the strategy’s acceptability, appropriateness, feasibility, fidelity, and costs. Reflecting on this process with a multi-disciplinary team of implementing researchers and local public health partners, we provide commentary on the previously published studies and how the results influenced the adaptation of international TB contact investigation guidelines to fit the local context. Results: While the trial did not show improvements in contact investigation delivery or public health outcomes, our multi-modal evaluation strategy helped us identify which elements of home-based, mHealth-facilitated contact investigation were feasible, acceptable, and appropriate and which elements reduced its fidelity and sustainability, including high costs. We identified a need for better tools for measuring implementation that are simple, quantitative, and repeatable and for greater attention to ethical issues in implementation science. Conclusions: Overall, a theory-informed, community-engaged approach to implementation offered many learnings and actionable insights for delivering TB contact investigation and using implementation science in low-income countries. Future implementation trials, especially those incorporating mHealth strategies, should apply the learnings from this case study to enhance the rigor, equity, and impact of implementation research in global health settings.Perceived stigma related to TB preventive therapy
AbstractArmstrong-Hough, M., Palacios, C. F., Hough, M. A., Shrestha, R., Moll, A. P., Kompala, T., Andrews, L., & Shenoi, S. V. (n.d.).Publication year
2023Journal title
The international journal of tuberculosis and lung disease : the official journal of the International Union against Tuberculosis and Lung DiseaseVolume
27Issue
3Page(s)
209-214AbstractTB preventative therapy (TPT) is crucial for reducing the burden of TB in endemic settings. We assessed stigma associated with TPT and the social groups from whom stigma was anticipated. We conducted an anonymous cross-sectional survey of community-dwelling adults in rural South Africa. Descriptive statistics, exploratory factor analysis, χ² tests, Kruskal-Wallis tests, and Poisson regression were used to identify factors associated with TPT stigma. The mean age of the 104 participants was 35 years, 65% were female, and 26% had completed secondary school. The vast majority perceived stigma associated with TPT (71%; mean score 1.7, SD ± 1.4). Factor analysis identified a two-factor solution that explained 61.9% of the variance. Being single ( < 0.001), previously screened for TB ( = 0.04), worried about being infected by TB ( = 0.006), and interested in taking TPT ( = 0.01) were associated with higher perceived stigma scores. TPT stigma was perceived among 8%, 16%, and 66% of their family, friends, and other community members, respectively. The prevalence of TPT-related stigma in a rural South African community was high. Community members anticipated less stigma from family members compared to other social groups. Global expansion and implementation of TPT will require novel interventions, such as engaging patients´ families to support uptake and promote adherence.Racial and ethnic disparities in recovery of everyday activities among survivors of respiratory failure
AbstractParrotte, K., Mercado, L., Chen, Y., Liang, N., Wu, S., & Armstrong-Hough, M. (n.d.).Publication year
2023Abstract~