13 research outputs found
Unearthing how, why, for whom and under what health system conditions the antiretroviral treatment adherence club intervention in South Africa works: A realist theory refining approach
BACKGROUND: Poor retention in care and suboptimal adherence to antiretroviral treatment (ART) undermine its
successful rollout in South Africa. The adherence club intervention was designed as an adherence-enhancing
intervention to enhance the retention in care of patients on ART and their adherence to medication. Although
empirical evidence suggests the effective superiority of the adherence club intervention to standard clinic ART care
schemes, it is poorly understood exactly how and why it works, and under what health system contexts. To this
end, we aimed to develop a refined programme theory explicating how, why, for whom and under what health
system contexts the adherence club intervention works (or not).
METHODS: We undertook a realist evaluation study to uncover the programme theory of the adherence club
intervention. We elicited an initial programme theory of the adherence club intervention and tested the initial
programme theory in three contrastive sites. Using a cross-case analysis approach, we delineated the conceptualisation
of the intervention, context, actor and mechanism components of the three contrastive cases to explain the outcomes
of the adherence club intervention, guided by retroductive inferencing.
RESULTS: We found that an intervention that groups clinically stable patients on ART in a convenient space to receive a
quick and uninterrupted supply of medication, health talks, counselling, and immediate access to a clinician when
required works because patientsâ self-efficacy improves and they become motivated and nudged to remain in care and
adhere to medication. The successful implementation and rollout of the adherence club intervention are contingent
on the separation of the adherence club programme from other patients who are HIV-negative. In addition, there
should be available convenient space for the adherence club meetings, continuous support of the adherence club
facilitators by clinicians and buy-in from the health workers at the health-care facility and the community.
CONCLUSION: Understanding what aspects of antiretroviral club intervention works, for what sections of the patient
population, and under which community and health systems contexts, could inform guidelines for effective
implementation in different contexts and scaling up of the intervention to improve population-level ART adherence
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 designersâ and managersâ 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 â 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 âreal intervention casesâ 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
Ambulanssjuksköterskors erfarenheter av att delta vid prehospitala förlossningar
Validerat; 20101217 (root
Exploring 'generative mechanisms' of the antiretroviral adherence club intervention using the realist approach: a scoping review of research-based antiretroviral treatment adherence theories
BACKGROUND: Poor retention in care and non-adherence to antiretroviral therapy (ART) continue to undermine the success of HIV treatment and care programmes across the world. There is a growing recognition that multifaceted interventions - application of two or more adherence-enhancing strategies - may be useful to improve ART adherence and retention in care among people living with HIV/AIDS. Empirical evidence shows that multifaceted interventions produce better results than interventions based on a singular perspective. Nevertheless, the bundle of mechanisms by which multifaceted interventions promote ART adherence are poorly understood. In this paper, we reviewed theories on ART adherence to identify candidate/potential mechanisms by which the adherence club intervention works. METHODS: We searched five electronic databases (PubMed, EBSCOhost, CINAHL, PsycARTICLES and Google Scholar) using Medical Subject Headings (MeSH) terms. A manual search of citations from the reference list of the studies identified from the electronic databases was also done. Twenty-six articles that adopted a theory-guided inquiry of antiretroviral adherence behaviour were included for the review. Eleven cognitive and behavioural theories underpinning these studies were explored. We examined each theory for possible 'generative causality' using the realist evaluation heuristic (Context-Mechanism-Outcome) configuration, then, we selected candidate mechanisms thematically. RESULTS: We identified three major sets of theories: Information-Motivation-Behaviour, Social Action Theory and Health Behaviour Model, which explain ART adherence. Although they show potential in explaining adherence bebahiours, they fall short in explaining exactly why and how the various elements they outline combine to explain positive or negative outcomes. Candidate mechanisms indentified were motivation, self-efficacy, perceived social support, empowerment, perceived threat, perceived benefits and perceived barriers. Although these candidate mechanisms have been distilled from theories employed to explore adherence to ART in various studies, the theories by themselves do not provide an explanatory model of adherence based on the realist logic. CONCLUSIONS: The identified theories and candidate mechanisms offer possible generative mechanisms to explain how and why patients adhere (or not) to antiretroviral therapy. The study provides crucial insights to understanding how and why multifaceted adherence-enhancing interventions work (or not). These findings have implications for eliciting programme theories of group-based adherence interventions such as the adherence club intervention.IS