Page 158 - SAHCS HIVMed Journal Vol 20 No 1 2019

Page 3 of 14 Original Research

BOX 1: Initial programme theory of the adherence club intervention represented providing treatment and care services to PLHIV and those
by two tentative theories (hypotheses).
infected with tuberculosis (TB). Patients who are co-infected
Initial Programme Theory 1 with HIV and TB can easily access both services, as those
If adult (18+ years), clinically ‘stable’ patients with evidence of good clinic with HIV and TB share the same waiting area and are seen by
attendance are group-managed, receive quick symptom checks, quick access to
medication, consistent counselling and social support from the peer counsellor, the same counsellors.
Then they are likely to adhere to medication and remain in care,
Because they develop a group identity, which improves their perceived social Because of a lack of proper structures such as physical
support and increases satisfaction and trust, and acquire knowledge, which helps
them to understand their perceived threat and perceived benefits and improves meeting space, the programme could not be implemented at
their self-efficacy. As a result, they become encouraged, empowered and
motivated, thus more likely to remain in care and adhere to the treatment. the scheduled time. Following the construction of a makeshift
building for club activities, the intervention was initiated
Initial Programme Theory 2
at the facility. While conducting a preliminary qualitative
If operational staff receive goals and targets set to continuously enrol patients in
the adherence club and monitor their participation through strict standard exploration for the suitability of Facility Y for our study,
operating practices (the promise of exclusion in the event of missed appointment we uncovered that the adherence club programme was
and active patient tracing),
Then patients are likely to adhere to medication and remain in care, poorly implemented because of poor buy-in from the staff
Because they fear losing the benefits (easy access to medication, peer support, members, who failed to identify how the intervention would
reduced waiting times, and 2-month ART collection) of the club system and are
coerced through adhesive club rules. As a result, they are nudged to remain in care benefit them and/or improve the overall delivery of ART
and adhere to the treatment, which might decongest the health facility. services to the patients. They perceived the adherence club
intervention as extra work in their already busy schedule.
programme theory of the adherence club intervention. Consequently, even when a makeshift building was
In conducting and reporting the findings of the study, we constructed for the adherence club activities, the programme
followed the RAMESES II reporting standards for realist struggled to function properly.
evaluation developed by Wong et al. 26
When the sub-district managers identified the problem
Research design through routine monitoring and reporting, a nurse was
identified and trained in the implementation and execution of
This study is framed within the realist evaluation approach. the adherence club programme to champion the intervention
We sought to test the initial programme theory of the at Facility Y. This nurse subsequently ran workshops and
adherence club intervention in a real-life implementation meetings with the other ART care providers at the facility
situation to verify, refute and/or modify the initial programme expounding on the advantages of the intervention to the
theory of the adherence club intervention. To this end, we patients, the healthcare workers themselves and the clinic.
adopted an explanatory theory-building case approach and This strategy led to an overall improvement of the level of
the multiple embedded case study design. Facility Y was buy-in, uptake and implementation of the adherence club
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considered the case and the unit of analysis, with each of its intervention. To date, an estimated 50 clubs with 25–35 patients
ART clubs being sub-units embedded in the case. each have been established at the facility.

According to Creswell and Plano Clark, cases selected for Research methods
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case study research could be identified as typical, deviant or
crucial. Facility Y was selected as a deviant case, a most likely We combined a retrospective cohort analysis and an
case shown to be negative with regard to the phenomenon explanatory qualitative approach to data collection. Using a
under consideration. To this end, we considered Facility sequential explanatory approach, we first collected the
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Y for testing the initial programme theory of the adherence quantitative data, which informed the retention in care and
club intervention. This facility has retention in care rates of suppressive adherence to medication outcomes at the facility.
only 63.0% based on the routine monitoring and evaluation The quantitative data collection was followed by qualitative
data on the adherence club intervention of 2015. Although methods (non-participant observation, in-depth interviews
Facility Y was selected for the first phase rollout of the and focus group discussions) aimed at informing the nature
adherence club intervention in 2012 along with other clinics of the outcomes obtained. The combination of qualitative and
in the health sub-districts, the intervention only rolled out in quantitative methods allowed us to explore the important
September 2014. Reasons were challenges related to lack of contextual elements that influence the implementation of
physical space and poor buy-in from the facility healthcare that adherence club intervention, the mechanisms that the
providers. intervention introduces and the emergent outcome patterns.
The multi-method approach also allowed for triangulation.
Study setting

Facility Y is a provincial primary healthcare facility providing Selection of respondents
primary healthcare to the surrounding communities. Staff Regarding the retrospective cohort arm of the study, our
provide first-level and some second-level care, including a goal was to identify a typical ‘mature’ adherence club, that is,
24-h emergency service. Housed in a separate building from a club that reached its maximum capacity of 30–35 patients.
the main clinic, is an accredited ART initiation and on-going Firstly, we selected all the clubs that had opened in 2014, and
management site, which operates Mondays to Fridays then identified the clubs that had reached their maximum

http://www.sajhivmed.org.za 151 Open Access