A realist approach to eliciting the initial programme theory of the antiretroviral treatment adherence club intervention in the Western Cape Province, South Africa

BACKGROUND: The successful initiation of people living with HIV/AIDS on antiretroviral therapy (ART) in South Africa has engendered challenges of poor retention in care and suboptimal adherence to medication. The adherence club intervention was implemented in the Metropolitan area of the Western Cape Province to address these challenges. The adherence club programme has shown potential to relieve clinic congestion, improve retention in care and enhance treatment adherence in the context of rapidly growing HIV patient populations being initiated on ART. Nevertheless, how and why the adherence club intervention works is not clearly understood. We aimed to elicit an initial programme theory as the first phase of the realist evaluation of the adherence club intervention in the Western Cape Province. METHODS: The realist evaluation approach guided the elicitation study. First, information was obtained from an exploratory qualitative study of programme designers’ and managers’ assumptions of the intervention. Second, a document review of the design, rollout, implementation and outcome of the adherence clubs followed. Third, a systematic review of available studies on group-based ART adherence support models in Sub-Saharan Africa was done, and finally, a scoping review of social, cognitive and behavioural theories that have been applied to explain adherence to ART. We used the realist evaluation heuristic tool (Intervention-context-actors-mechanism-outcome) to synthesise information from the sources into a configurational map. The configurational mapping, alignment of a specific combination of attributes, was based on the generative causality logic – retroduction. RESULTS: We identified two alternative theories: The first theory supposes that patients become encouraged, empowered and motivated, through the adherence club intervention to remain in care and adhere to the treatment. The second theory suggests that stable patients on ART are being nudged through club rules and regulations to remain in care and adhere to the treatment with the goal to decongest the primary health care facilities. CONCLUSION: The initial programme theory describes how (dynamics) and why (theories) the adherence club intervention is expected to work. By testing theories in “real intervention cases” using the realist evaluation approach, the theories can be modified, refuted and/or reconstructed to elicit a refined theory of how and why the adherence club intervention works

The experience of violence against children in domestic servitude in Haiti: Results from the Violence Against Children Survey, Haiti 2012

There have been estimates that over 150,000 Haitian children are living in servitude. Child domestic servants who perform unpaid labor are referred to as “restavèks.” Restavèks are often stigmatized, prohibited from attending school, and isolated from family placing them at higher risk for experiencing violence. In the absence of national data on the experiences of restavèks in Haiti, the study objective was to describe the sociodemographic characteristics of restavèks in Haiti and to assess their experiences of violence in childhood. The Violence Against Children Survey was a nationally representative, cross-sectional household survey of 13–24year olds (n=2916) conducted May–June 2012 in Haiti. A stratified three-stage cluster design was used to sample households and camps containing persons displaced by the 2010 earthquake. Respondents were interviewed to assess lifetime prevalence of physical, emotional, and sexual violence occurring before age 18. Chi-squared tests were used to assess the association between having been a restavèk and experiencing violence in childhood. In this study 17.4% of females and 12.2% of males reported having been restavèks before age 18. Restavèks were more likely to have worked in childhood, have never attended school, and to have come from a household that did not have enough money for food in childhood. Females who had been restavèks in childhood had higher odds of reporting childhood physical (OR 2.04 [1.40–2.97]); emotional (OR 2.41 [1.80–3.23]); and sexual violence (OR 1.86 [95% CI 1.34–2.58]) compared to females who had never been restavèks. Similarly, males who had ever been restavèks in childhood had significantly increased odds of emotional violence (OR 3.06 [1.99–4.70]) and sexual violence (OR 1.85 [1.12–3.07]) compared to males who had never been restavèks, but there was no difference in childhood physical violence. This study demonstrates that child domestic servants in Haiti experience higher rates of childhood violence and have less access to education and financial resources than other Haitian children. These findings highlight the importance of addressing both the lack of human rights law enforcement and the poor economic circumstances that allow the practice of restavèk to continue in Haiti