Exploring ‘generative mechanisms’ of the antiretroviral adherence club intervention using the realist approach: a scoping review of research-based antiretroviral treatment adherence theories

Abstract

BackgroundPoor retention in care and non-adherence to antiretroviral therapy (ART) continue to undermine the success of HIV treatment and care programmes across the world. There is a growing recognition that multifaceted interventions – application of two or more adherence-enhancing strategies – may be useful to improve ART adherence and retention in care among people living with HIV/AIDS. Empirical evidence shows that multifaceted interventions produce better results than interventions based on a singular perspective. Nevertheless, the bundle of mechanisms by which multifaceted interventions promote ART adherence are poorly understood. In this paper, we reviewed theories on ART adherence to identify candidate/potential mechanisms by which the adherence club intervention works.MethodsWe searched five electronic databases (PubMed, EBSCOhost, CINAHL, PsycARTICLES and Google Scholar) using Medical Subject Headings (MeSH) terms. A manual search of citations from the reference list of the studies identified from the electronic databases was also done. Twenty-six articles that adopted a theory-guided inquiry of antiretroviral adherence behaviour were included for the review. Eleven cognitive and behavioural theories underpinning these studies were explored. We examined each theory for possible ‘generative causality’ using the realist evaluation heuristic (Context-Mechanism-Outcome) configuration, then, we selected candidate mechanisms thematically.ResultsWe identified three major sets of theories: Information-Motivation-Behaviour, Social Action Theory and Health Behaviour Model, which explain ART adherence. Although they show potential in explaining adherence bebahiours, they fall short in explaining exactly why and how the various elements they outline combine to explain positive or negative outcomes. Candidate mechanisms indentified were motivation, self-efficacy, perceived social support, empowerment, perceived threat, perceived benefits and perceived barriers. Although these candidate mechanisms have been distilled from theories employed to explore adherence to ART in various studies, the theories by themselves do not provide an explanatory model of adherence based on the realist logic.ConclusionsThe identified theories and candidate mechanisms offer possible generative mechanisms to explain how and why patients adhere (or not) to antiretroviral therapy. The study provides crucial insights to understanding how and why multifaceted adherence-enhancing interventions work (or not). These findings have implications for eliciting programme theories of group-based adherence interventions such as the adherence club intervention.Electronic supplementary materialThe online version of this article (doi:10.1186/s12889-017-4322-8) contains supplementary material, which is available to authorized users.

Developing an Initial Program Theory to Explain How Patient-Reported Outcomes Are Used in Health Care Settings: Methodological Process and Lessons Learned

“…Despite this guidance, there is variation in the literature on how people develop an IPT for realist inquiry. For example, some researchers develop IPTs through realist synthesis (Groot et al, 2017), qualitative research (Mukumbang et al, 2017), other forms of knowledge synthesis (Lhussier et al, 2016), or by using/further developing an explicit program theory that already existed (MacDonald et al, 2016). Shearn et al (2017) provide four potential approaches for developing IPTs: (1) using concepts from abstract theories which are used to inform current or comparable interventions, (2) using concepts from abstract theory which are selected purposively for the research synthesis or evaluation by the research team but which have not been referenced in the program literature, (3) extracting tacit theories about what is working and why from interventions on similar topics, reported in the literature, and (4) extracting tacit theories (about what is working and why) directly from stakeholders via one-to-one interviews, brainstorming, documentation of the current intervention, and/or developed by the research team who may use their own experiential or professional knowledge.…”

Role of Temporal Discounting in a Conditional Cash Transfer (CCT) Intervention to Improve Engagement in the Prevention of Mother-to-Child Transmission (PMTCT) Cascade

“…As we did not measure discounting levels before and after shifts in economic circumstances, we do not know whether our measures of discounting re ect intrinsic preferences or situational constraints. Nonetheless, our study is among the rst to explore any potential mechanisms by which CCT are hypothesized to improve HIV treatment and prevention [52] and high monetary discounting, regardless of cause or permanence, could arguably have similar effects on behavior in the immediate future when monetary rewards are offered, as is the case in our study.…”

ART adherence clubs in the Western Cape of South Africa: what does the sustainability framework tell us? A scoping literature review

“…Thirdly, the lack of qualitative studies investigating the experience of club members, non‐members, staff and other stakeholders limited the evaluation of their perception on clubs and their daily operation. The absence of qualitatively based approaches was also confirmed in a recent review focusing on effectiveness of group‐based care models in sub‐Saharan Africa . A final limitation is associated with the generalization of results since the concept of ACs is context‐related and thus cannot be transferred easily from one setting to another without any adjustment.…”

“…ACs present a promising intervention, addressing poor long‐term RIC and suboptimal adherence, using a multipronged adherence‐enhancing approach such as patient education and peer support, also recommended by the WHO . According to the analysis of MacGregor et al .…”