Page 167 - SAHCS HIVMed Journal Vol 20 No 1 2019

Page 12 of 14 Original Research

space for conducting club activities strongly influences the Regarding the retention in care and adherence behaviours of
outcome of the intervention. This highlights the important patients in the adherence club, it would have been ideal to
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role that context plays in activating the mechanisms that are obtain the overall rates of the facility. This posed a challenge
provided by an intervention. In the absence of a conducive because the facility actively creates new clubs monthly.
space, the buy-in of the healthcare providers became reduced, This would potentially affect the overall retention in care
and they were not motivated to execute the intervention. and adherence rates of patients in the adherence club
This, in turn, affected the way the intervention was executed programme. To this end, we decided to sample two
and the way it was received by the patients, thus impacting adherence clubs that had reached their maximum capacity
the retention in care and adherence outcomes. Dudhia and and to study the rate at which patients drop out of the club
Kagee also uncovered that lack of resources for operating for various reasons – default, transferred out of the clinic,
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the club (delivery of care and support for club team) could lost to follow-up or died.
demotivate the healthcare providers, thus impacting the
quality of care delivered to patients. To improve the rigour of the study, we adopted the mixed-
method approach. The use of a multi-method approach to
The four important context conditions, lack of buy-in, lack data collection was informed by its ability not only to
of staff, the absence of a programme champion and lack improve the retroductive inferencing, but also to confirm
of physical space for the club meetings, caused the and complement the information required to test the
mechanisms that are provided by the adherence club initial programme theory. In addition, we used a variety of
intervention and naturally occurring in the environment participants to promote the triangulation of the information
not to be triggered. Consequently, this led to sustained obtained from the participants as it makes it easy for the
poor retention in care and suboptimal adherence to researchers to verify facts.
medication. While testing the initial programme theory in
another context, we found that ‘integrating’ the adherence Frequent debriefing sessions were held among the authors.
club programme with the management of patients with These sessions took place in all the phases of this study,
other non-communicable diseases (the presence of non- including the data collection, analysis and synthesis phases.
HIV-positive patients) presents a different prevailing
context within which the adherence club intervention did Conclusion
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not work. The context of integrated care was characterised
by a lack of resources (adherence club meeting room), We conducted a theory-testing case study within the realist
different execution models and poor adherence club approach. We uncovered that patients on ART in adherence
programme coordination. 44 clubs will continue to adhere to their medication and
remain in care because their self-efficacy is improved and
When a nurse was identified and trained to champion they are motivated through the programme modalities and/
the intervention, she exposed the other healthcare providers or because they are being nudged through the club rules and
to the benefits of the intervention and headed the regulations. Through the application of the realist evaluation
implementation. This engendered buy-in from the care approach, we modified the initial programme theory,
workers. Following the buy-in, the pharmacists also which combines alternative theories to formulate a
reorganised their schedules to prepare medication packages complementary theory. This is a step towards obtaining a
for the club members. Once these elements were put in refined programme theory of the adherence club intervention.
place, the context conditions of the adherence club changed, With the adherence clubs currently being rolled out
and the present conditions were favourable to incite the nationwide, understanding how, why, for whom and under
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mechanisms provided by the adherence club intervention to what health systems context the adherence club programme
cause the expected outcomes. These improved conditions works could inform its successful implementation to other
and performance of the adherence club intervention are contexts where it is required.
reflected in the high retention in care and adherence to
medication rates, as demonstrated in the retrospective cohort Acknowledgements
analyses.
The authors acknowledge the contributions of Dr Ebrahim
Limitations, rigour and Kriel through his expert knowledge.
trustworthiness This work was supported by the South African Medical

Although viral load is commonly used as a proxy for ART Research Council (National Health Scholars Programme). This
adherence, it is not considered a perfect benchmark for research was also funded by an African Doctoral Dissertation
evaluating how accurately an individual adheres to ART. Research Fellowship (ADDRF) award offered by the African
This is especially true because for patients in the adherence Population and Health Research Center (APHRC) in
club, their viral loads are only measured once a year. Thus, partnership with the International Development Research
the viral load does not offer a real-time measure of adherence, Centre (IDRC). The work was also partly funded by the
which could be considered a limitation of the study. Framework 4 Agreement between the Belgian Directorate

http://www.sajhivmed.org.za 160 Open Access