Exploring 'generative mechanisms' of the antiretroviral adherence club intervention using the realist approach: a scoping review of research-based antiretroviral treatment adherence theories
Date
2017Author
Mukumbang, Ferdinand C.
Van Belle, Sara
Marchal, Bruno
van Wyk, Brian Eduard
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BACKGROUND: Poor 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.
METHODS: We 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.
RESULTS: We 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.
CONCLUSIONS: The 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.
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