Page 157 - SAHCS HIVMed Journal Vol 20 No 1 2019

Page 2 of 14 Original Research

The adherence club intervention is an example of a (or not) rests on the ability of the evaluator to explain the
differentiated care model designed to streamline ART care decision-making process of the relevant actors regarding the
for adults (18+ years), treatment-experienced patients on resources, opportunities and constraints that the programme
first-line treatment with a good clinic attendance record and provides to the relevant actors.
6,7
evidence of medication adherence. Through quick group
consultations, convenient medication pickup processes Identifying the important generative mechanisms (social and
and direct access to a clinician when needed, the adherence psychological drivers) of a programme is not enough to
club drastically reduces the waiting times of the patients. The explain how and why a programme works (or not). For an
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adherence club intervention also provides a conducive social intervention to work, it must influence the reasoning
environment to encourage patient interactions with peers. (mechanism) of the targeted actors to cause them to adopt an
The adherence club intervention has been described in intended behaviour that, in a specific context, will lead to a
greater detail elsewhere. 8 specific outcome. Therefore, realists assume that an outcome
(O) is generated by a mechanism (M) being triggered in
The evidence supporting the effectiveness of the adherence context (C) through an actor (A) when an intervention (I) is
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club intervention 9,10,11,12 and its cost-effectiveness has implemented. This captures how, why, for whom and in
prompted plans to roll out the intervention nationwide. what circumstances programmes work. Formulating realist
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Nevertheless, there is a limited theory-based understanding theories is, therefore, achieved through the formation of
of how and why the adherence club intervention works and intervention–context–actor–mechanism–outcome (ICAMO)
in what health system context(s). To this end, a realist configurations. 20,21 The ICAMO configuration is a modification
evaluation of the adherence club intervention was of context–mechanism–outcome (CMO), originally proposed
commissioned. In this article, we report on the process of by Pawson and Tilley as the heuristic tool for the
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testing the hypothesis (initial programme theory) of how and development of realist theories. In the first phase of this
why the adherence club intervention is expected to work project, we elicited an initial programme theory of the
under real-life implementation conditions. adherence club intervention with information obtained from
Methodological approach four sources 23,24,25 (see Figure 1).

The realist evaluation, a theory-driven approach, guided We applied the ICAMO heuristic tool to configure the
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the inquiry. The goal of realist evaluation is about learning programme theory by applying the logic of retroduction –
‘for whom, in what circumstances, and in what respects mechanism-centred analysis and conceptualisation – to make
a programme works’, 15,16 through identifying, testing and inferences. Testable hypotheses were distilled from the
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refining programme theories. Therefore, realist evaluation configurational map, an approach to causality whereby
starts with an initial programme theory and the goal is to outcomes are considered to follow from the alignment of a
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obtain a more refined programme theory. specific combination of attributes, using the ‘if … then …
because’ phrase (Box 1).
Programmes work with the acquiescence of participants
(actors), and provide resources, opportunities or constraints The aim of this study was to test these initial programme
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of some kind that influence the target person’s decision- theories in a primary healthcare facility running the adherence
making. Therefore, understanding why a programme works club programme, with the goal of obtaining a more refined
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Step 1: Explanatory qualita ve study Step 2: Systema c review Step 3: Scoping review

Document review In-depth interviews Systema c review Scoping review
of the implementa on reports, with adherence club of studies repor ng on of cogni ve, affec ve and
data files, guildelines, toolkit, interven on designers and group-based adherence behavioural theories used in
blogs, newspaper clippings managers involved in interven ons implemented various peer-reviewed ar cles
and other artefacts on the coordina ng and monitoring in sub-Saharan Africa to explain adherence to
adherence club interven on the adherence club an retroviral medica on
interven on

Step 4: Formula ng the ini al
programme theory or theories

Ini al programme theory

FIGURE 1: Sources of information towards formulating the initial programme theory.

http://www.sajhivmed.org.za 150 Open Access