Page 163 - SAHCS HIVMed Journal Vol 20 No 1 2019

Page 8 of 14 Original Research

Initial programme theory 2 the interview process that are challenging or complex to
measure (these are not part of the primary outcomes of
Perceived coercion
retention in care and adherence to medication). These
Perceived coercion is the awareness of being compelled or outcomes include decongesting the healthcare facility and
pressured to do something. Although the club intervention is reducing the workload of the healthcare workers.
beneficial to the patients, there are also some managerial
benefits, such as decongesting the facility. Thus, the club Decongestion of the facility
rules are there to ensure the smooth functioning of the
intervention as well as to promote the success of the One of the emerging outcomes of the adherence club
programme. Nevertheless, some patients might interpret intervention is that it contributes to decongesting the
some of the club rules as being coercive: healthcare facility. One of the participants explained how
this is being achieved:
‘I know the club [has] got rules and like the one rule. It [club rules]
helps a lot because then you must take your medication. It is ‘It [the club] is decongesting because remember, there are
necessary that you take it [medication]; otherwise, you will go 35 patients per club. There are some days that we have two clubs.
back to where you came [regular ART clinic].’ (Patient 4, male) So, remember, if it is one day, every day 35 patients from the
normal waiting area are being removed. So, they receive
their medication and their treatment thus decongesting the
Our observation revealed that the patients were being
reminded of the club rules at every club visit. They are waiting area … On days that there are two clubs per day, that is
70 patients out of your waiting area.’ (Nurse 1, female)
particularly reminded of the circumstances that could lead to
being sent back to the main clinic care.
Quantitative findings
Fear The role of quantitative (extensive) methods in realist
Fear relates to the awareness of the dangers of being returned research is considered to be predominantly descriptive. To
to the mainstream care and experiencing the barriers that the this end, our quantitative findings are mostly descriptive.
adherence club intervention addressed. One of the patients Table 3 illustrates the characteristics of the participants of
explained how the fear of being sent back to the main ART the two selected adherence clubs.
scheme, characterised by long waiting times and frequent
travels to the clinic, causes them to not afford to miss a club Retention in care
session: The combined retention in care within a 24-month period is
‘So, you do not want to be sent back, because you know you will 77.8%, with ‘club A’ registering a much lower retention in
return to waiting for two hours for tablets. You have to wait there care rate (71.4%) compared to ‘club B’ (83.8%) (Table 4).
and you go to the Pharmacy, there will be a queue. You know
that if I miss the appointment with the club, then they might The survival distributions of the patients receiving care in the
send me back.’ (Patient 3, female) two adherence clubs are shown in Figure 2. At 6 months, the
retention in care rate of club A was 91.4% (95% CI, 75.8–97.8).
Nudging At 12 months, the retention in care rate dropped to 77.1%
Nudging is the notion of being guided towards making (95% CI, 59.4–89). At 24 months, the rate decreased further to
decisions that are considered beneficial (to the patient), 65.7% (95% CI, 47.7–80.3). Club B registered better retention
usually by the healthcare providers by presenting options in
a specific way. By providing restricted options to the patients TABLE 3: Characteristics of patients in clubs A and B.
receiving care in the adherence club programme, they are Total number Club A Club B
nudged to acting in a particular way as guided by the 35 37
resources and principles that are on offer at the adherence Gender 9 12
Males
club. A patient suggested they are being made to attend their Females 26 25
adherence club sessions and to take their medication through Mean age 32 (interquartile range 20–57) 30 (interquartile range 22–60)
the rules of the club, because if the rules are not abided to, Marital status
then they are sent back to the main clinic care: Single 12 16
‘They make you come to the clinic, and they make you take your Married 13 10
medication, because if you are going back to the main clinic, my Divorced 10 11
dear, you will stay there for the whole day in the main clinic. You Employment status
come at half past six, you stand in a queue there at the reception, Unemployed 13 17
then at eight o’clock, they start giving your folders and then from Employed 22 20
there you go to the scale.’ (Patient 1, male)
TABLE 4: Retention in care distributions in two adherence clubs at Facility Y.
Total
Outcome Adherence number Number of patients Patients retained
not retained in care
club
Number %
The outcomes that are identified here are based on the Club A 35 10 25 71.4
findings of quantitative analysis (retrospective cohort Club B 37 6 31 83.8
analysis – primary outcomes) and emergent outcomes from Overall 72 16 56 77.8
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