Page 166 - SAHCS HIVMed Journal Vol 20 No 1 2019

Page 11 of 14 Original Research

BOX 2: A modified programme theory of the adherence club intervention. This could add value to understanding in what context or
Grouping clinically stable patients on antiretroviral therapy [Actors] with available circumstances the intervention works or not. This follows the
resources and buy-in from healthcare workers in a convenient space [Context] to
receive a quick and uninterrupted supply of medication, health talks, counselling, notion that programmes are open systems. By open system,
immediate access to a clinician when required while guided by rules and realists argue that programmes cannot be fully isolated or
regulations [Intervention], works because their self-efficacy improves and they
become motivated and nudged [Mechanisms] to remain in care and adhere to kept constant and that they are affected by various conditions
medication [Outcome].
such as physical and technological shifts, personnel
movements and learning, organisational imperative and so
works (Figure 4). This is backed up by the respondents in the on. Such externalities always impact the delivery of a
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realist interviews. Most suggested that a combination of both programme, and this entails that they are never quite
theories could explain how the club intervention works. They implemented in the same way. In some instances, these
used phrases like: ‘It is a combination of both your theories …’ externalities are introduced into the ‘system’ to engender a
[Nurse 1] or ‘I think both [theories]’ (Counsellor 2). positive impact and are usually changes made to address the
challenges that the intervention previously encountered.
In the next step, we formulate a modified programme theory
of the adherence club intervention based on the analysis of The failure of the intervention to kick off was attributed to a
the Facility Y data set (see Box 2). myriad of factors, including lack of proper understanding
of the adherence club programme, which led to poor buy-in
Discussion from the healthcare providers and lack of required
infrastructure. Buy-in, although considered an important
We aimed to confirm, refute or modify the initial programme
theory of the adherence club intervention, which we drafted mechanism at the level of implementing the intervention in
based on literature reviews and exploratory research. We the facility, nevertheless constitutes an important contextual
examined the implementation of the adherence club factor regarding the day-to-day running as it affects the way
intervention at Facility Y, chosen as a deviant case – poor the intervention is organised and delivered to the patients.
performing based on 2014 routine data. Our hypothesis Lack of buy-in was identified by the participants of the
suggested two possible explanations of how and why the study as part of the reasons why the intervention was
adherence club intervention improves retention in care and poorly implemented and executed at this facility. It was also
sustains adherence to medication: by motivating and mentioned that the operational staff failed to understand
empowering the patients towards adopting the desired how the adherence club was going to work in their
behaviours or by nudging them into doing so. favour, and thus did not welcome the intervention until
they were made to understand how it would decongest the
These study findings showed that the two initial alternative healthcare facility. Because of the instructions received from
theories complement each other to explain how and why sub-structure to roll out the adherence club programme in
the intervention works and in what context. Although Facility Y, the operational staff working on the ART
some patients would become motivated and empowered, programme felt compelled to do something, although they
through improved self-efficacy to remain in care and adhere did not share in the vision of the programme.
to their medication, others were made to remain in care by
strictly enforcing rules and regulations of the adherence Our study unveiled that apart from the lack of a conducive
club programme. It is worth mentioning that different space, impacting the buy-in of the healthcare providers, their
patients would respond better to different aspects of care understanding that the adherence club intervention would
embedded in the adherence club programme. Patients who increase their workload also contributed to the diminishing
already possess self-motivation would be empowered by buy-in. The notion of increased workload was compounded
the adherence club intervention as it enforces convenience by perceived staff shortage. The perceived staff shortage also
to the patients. Other patients who may not be adequately ties with the contextual factor of not having a programme
self-motivated could respond better to being ‘told what to champion to run the adherence club programme when it was
do’, which is the role that the rules and regulations of the first adopted by the facility in the first phased rollout.
adherence club programme plays, or fulfills. A combination
of these two explanations provides a comprehensive Another important context element that was identified as a
understanding of how and why the adherence club hindrance to the effective implementation and execution of
intervention works. In another case study testing the initial the adherence club intervention at Facility Y was the lack of
programme theory, it was also confirmed that the combined a conducive physical space where the meetings could be
programme theory explains how and why the adherence conducted. Our interviews revealed that when the
club enhances adherence to medication and promotes intervention was rolled out at the facility, there was no
retention in care among stable patients on ART. 43 physical space where the patients could meet to conduct the
meetings. It took an intervention from the management to
Although the retention in care and the adherence rates of the provide a makeshift building at the back of the facility for the
patients at the facility seemed to have improved from 2014, intervention to be officially implemented. While exploring
as reflected in our current programme theory, it is worth the context under which the adherence club is implemented
exploring why the intervention failed to take off as intended. in another facility, the authors found that lack of a conducive

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