Publications by authors named "Sara Van Belle"

52 Publications

Local Dynamics of Collaboration for Maternal, Newborn and Child Health: A Social Network Analysis of Healthcare Providers and Their Managers in Gert Sibande District, South Africa.

Int J Health Policy Manag 2021 Sep 8. Epub 2021 Sep 8.

School of Public Health, University of the Western Cape, Cape Town, South Africa.

Background: Accountability for maternal, newborn and child health (MNCH) is a collaborative endeavour and documenting collaboration dynamics may be key to understanding variations in the performance of MNCH services. This study explored the dynamics of collaboration among frontline health professionals participating in two MNCH coordination structures in a rural South African district. It examined the role and position of actors, the nature of their relationships, and the overall structure of the collaborative network in two sub-districts.

Methods: Cross-sectional survey using a social network analysis (SNA) methodology of 42 district and sub district actors involved in MNCH coordination structures. Different domains of collaboration (eg, communication, professional support, innovation) were surveyed at key interfaces (district-sub-district, across service delivery levels, and within teams).

Results: The overall network structure reflected a predominantly hierarchical mode of clustering of organisational relationships around hospitals and their referring primary healthcare (PHC) facilities. Clusters were linked through (and dependent on) a combination of district MNCH programme and line managers, identified as central connectors or boundary spanners. Overall network density remained low suggesting potential for strengthening collaborative relationships. Within cluster collaborative patterns (inter-professional and across levels) varied, highlighting the significance of small units in district functioning.

Conclusion: SNA provides a mechanism to uncover the nature of relationships and key actors in collaborative dynamics which could point to system strengths and weaknesses. It offers insights on the level of fragmentation within and across small units, and the need to strengthen cohesion and improve collaborative relationships, and ultimately, the delivery of health services.
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http://dx.doi.org/10.34172/ijhpm.2021.106DOI Listing
September 2021

Policy Processes in Multisectoral Tobacco Control in India: The Role of Institutional Architecture, Political Engagement and Legal Interventions.

Int J Health Policy Manag 2021 Jul 14. Epub 2021 Jul 14.

Department of Political Science, Faculty of Arts, McGill University, Montreal, QC, Canada.

Background: The development and implementation of health policy have become more overt in the era of Sustainable Development Goals, with expectations for greater inclusivity and comprehensiveness in addressing health holistically. Such challenges are more marked in low- and middle-income countries (LMICs), where policy contexts, actor interests and participation mechanisms are not always well-researched. In this analysis of a multisectoral policy, the Tobacco Control Program in India, our objective was to understand the processes involved in policy formulation and adoption, describing context, enablers, and key drivers, as well as highlight the challenges of policy.

Methods: We used a qualitative case study methodology, drawing on the health policy triangle, and a deliberative policy analysis approach. We conducted document review and in-depth interviews with diverse stakeholders (n = 17) and anlayzed the data thematically.

Results: The policy context was framed by national law in India, the signing of a global treaty, and the adoption of a dedicated national program. Key actors included the national Ministry of Health and Family Welfare (MoHFW), State Health Departments, technical support organizations, research organizations, non-governmental bodies, citizenry and media, engaged in collaborative and, at times, overlapping roles. Lobbying groups, in particular the tobacco industry, were strong opponents with negative implications for policy adoption. The state-level implementation relied on creating an enabling politico-administrative framework and providing institutional structure and resources to take concrete action.

Conclusion: Key drivers in this collaborative governance process were institutional mechanisms for collaboration, multi-level and effective cross-sectoral leadership, as well as political prioritization and social mobilization. A stronger legal framework, continued engagement, and action to address policy incoherence issues can lead to better uptake of multisectoral policies. As the impetus for multisectoral policy grows, research needs to map, understand stakeholders' incentives and interests to engage with policy, and inform systems design for joint action.
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http://dx.doi.org/10.34172/ijhpm.2021.66DOI Listing
July 2021

Intégration de la santé mentale dans les services de soins de santé primaires en République démocratique du Congo.

Sante Publique 2021 Jun;Vol. 33(1):77-87

Objective: The study aims to document the experience of integrating a mental health care package into the general health care system of Lubero district in the Democratic Republic of Congo (DRC) between 2011 and 2015, and more specifically, the effects of this integration on the access to and use of health services offering mental health care.

Method: This is a retrospective study using a case study design. Data collected from different project documents and an analytic review of the official reports of the Ministry of Public Health were used for an analysis of the results of the integration.

Results: The results indicate that 3,941 patients with mental health problems used the care offered at the health centers and the district hospital between 2012 and 2015. In 2015, the average utilization rate of curative care in health centers for mental health problems was 7 new cases/1,000 inhabitants/year. The majority of these patients were treated on an outpatient basis, at primary health care level.

Discussion: Our study shows that it is possible to integrate mental health into existing general health services in the DRC. Nevertheless, the major problems in terms of access and use of basic care in the Lubero district indicate that the success of such an integration depends on the quality of the health system in place and the involvement of a wide range of both health and non-health actors, including key people within communities.
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http://dx.doi.org/10.3917/spub.211.0077DOI Listing
June 2021

Piloting sexual assault care centres in Belgium: who do they reach and what care is offered?

Eur J Psychotraumatol 2021;12(1):1935592. Epub 2021 Jul 27.

Department of Public Health and Primary Care, International Centre for Reproductive Health, Ghent University, Ghent, Belgium.

Background: Sexual assault (SA) is highly prevalent in Belgium. In order to mitigate the negative consequences for victims of acute SA, Sexual Assault Care Centres (SACCs) were piloted from October 2017 to October 2018 in three Belgian hospitals. SACCs offer medical and psychological care, forensic examination and the possibility to report to the police at the SACC.

Objective: Aiming to improve SACC services, we quantitatively assessed the number and characteristics of victims attending the SACC, the SA they experienced, and the care they received over 12 months upon admission.

Method: Data on victims presenting at the SACC were routinely collected in electronic patient files by the SACC personnel between 25 October 2017 and 31 October 2019. These data were analysed in IBM SPSS Statistics 25.

Results: Within the first year 931 victims attended the SACCs. Mean age was 24.5 years (SD = 12.8), and one-third were under 18. The majority were female (90.5%) and 63.1% presented for rape. About one-third of the victims were considered vulnerable due to previous SA (35.6%), prior psychiatric consultation (38.7%) or disability (8.5%). The assailant was known to the victim in 59.2% of the cases. Of all SACC presentations, 35.2% self-referred to the SACC while 40.9% were referred by the police. Two out of three victims attended the SACC within 72 h post-assault. Respectively 74.7% of victims received medical care, 60.6% a forensic examination, 50.2% psychological care, and 68.7% reported to the police.

Conclusion: Despite the absence of promotion campaigns, the SACCs received a high number of victims during the pilot year. Use of acute and follow-up services was high, although new approaches to offer more accessible psychological support should be explored. The big proportion of vulnerable victims warrants careful monitoring and adaptation of care pathways.
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http://dx.doi.org/10.1080/20008198.2021.1935592DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8317926PMC
July 2021

Integration or Fragmentation of Health Care? Examining Policies and Politics in a Belgian Case Study.

Int J Health Policy Manag 2021 Jul 6. Epub 2021 Jul 6.

Department of Family Medicine and Population Health (FAMPOP), Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.

Background: Globally, health systems have been struggling to cope with the increasing burden of chronic diseases and respond to associated patient needs. Integrated care (IC) for chronic diseases offers solutions, but implementing these new models requires multi-stakeholder action and integrated policies to address social, organisational, and financial barriers. Policy implementation for IC has been little studied, especially through a political lens. This paper examines how IC policies in Belgium were developed over the last decade and how stakeholders have played a role in these policies.

Methods: We used a case study design. After an exploratory document review, we selected three IC policies. We then interviewed 25 key stakeholders in the field of IC. The stakeholder analysis entailed a detailed mapping of the stakeholders' power, position, and interest related to the three selected policies. Interview participants included policy-makers, civil servants (from ministry of health and health insurance), representatives of health professionals' associations, academics, and patient organisations. Additionally, a processual analysis of IC policy processes (2007-2020) through literature review was used to frame the interviews by means of a chronic care policy timeline.

Results: In Belgium, a variety of policy initiatives have been developed in recent years both at central and decentralised levels. The power analysis and policy position maps exposed tensions between federal and federated governments in terms of overlapping competence, as well as the implications of the power shift from federal to federated levels as a consequence of the 2014 state reform.

Conclusion: The 2014 partial decentralisation of healthcare has created fragmentation of decisive power which undermines efforts towards IC. This political trend towards fragmentation is at odds with the need for IC. Further research is needed on how public health policy competences and reform durability of IC policies will evolve.
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http://dx.doi.org/10.34172/ijhpm.2021.58DOI Listing
July 2021

How medical dominance and interprofessional conflicts undermine patient-centred care in hospitals: historical analysis and multiple embedded case study in Morocco.

BMJ Glob Health 2021 07;6(7)

Unit of Equity and Health, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.

Background: In Morocco's health systems, reforms were accompanied by increased tensions among doctors, nurses and health managers, poor interprofessional collaboration and counterproductive power struggles. However, little attention has focused on the processes underlying these interprofessional conflicts and their nature. Here, we explored the perspective of health workers and managers in four Moroccan hospitals.

Methods: We adopted a multiple embedded case study design and conducted 68 interviews, 8 focus group discussions and 11 group discussions with doctors, nurses, administrators and health managers at different organisational levels. We analysed what health workers (doctors and nurses) and health managers said about their sources of power, perceived roles and relationships with other healthcare professions. For our iterative qualitative data analysis, we coded all data sources using NVivo V.11 software and carried out thematic analysis using the concepts of 'negotiated order' and the four worldviews. For context, we used historical analysis to trace the development of medical and nursing professions during the colonial and postcolonial eras in Morocco.

Results: Our findings highlight professional hierarchies that counterbalance the power of formal hierarchies. Interprofessional interactions in Moroccan hospitals are marked by conflicts, power struggles and daily negotiated orders that may not serve the best interests of patients. The results confirm the dominance of medical specialists occupying the top of the professional hierarchy pyramid, as perceived at all levels in the four hospitals. In addition, health managers, lacking institutional backing, resources and decision spaces, often must rely on soft power when dealing with health workers to ensure smooth collaboration in care.

Conclusion: The stratified order of care professions creates hierarchical professional boundaries in Moroccan hospitals, leading to partitioning of care and poor interprofessional collaboration. More attention should be placed on empowering health workers in delivering quality care by ensuring smooth interprofessional collaboration.
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http://dx.doi.org/10.1136/bmjgh-2021-006140DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8280911PMC
July 2021

Applying the Realist Evaluation Approach to the Complex Process of Policy Implementation-The Case of the User Fee Exemption Policy for Cesarean Section in Benin.

Front Public Health 2021 8;9:553980. Epub 2021 Jun 8.

Complexity and Health Unit, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.

Realist evaluation is making inroads in the field of health policy and systems research to a large extent because of its good fit with complex issues. Until now, most realist studies focused on evaluating interventions or projects related to health care delivery, organization of health services, education, management, and leadership of health workers in high income countries. With this paper, we apply the realist approach to the study of national health policy implementation in a low resource country. We use the case of the user fee exemption policy for cesarean section in Benin, which we followed up from 2009 to 2018. We report on how realist evaluation can be applied for policy implementation research. We illustrate how we developed the initial programme theory-the starting point of any realist evaluation -, how we designed the study and data collection tools, and how we analyzed the data. For each step, we present current good practices, how we adapted them when needed, the challenges and the lessons learned. We report also on how the dynamic interactions between the central level (the national implementing agency) and the peripheral level (an implementing hospital) shaped the policy implementation. We found that at central level, availability of resources for a given policy is constantly challenged in the competitive national resource allocation arena. Key factors include the political power and the legitimacy of the group supporting the policy. These are influenced by the policy implementation structure, how the actual outputs of the implementation align with promises of the group supporting the policy and consequently how these outputs, the policy and its promoters are perceived by the community. We found that the service providers are key to the implementation, and that they are constrained or influenced by the dependability of the funding, their autonomy, their personal background, and the accountability arrangements. This study can inform the design and implementation of national health policies that involve interactions between central and operational level in other low-income countries.
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http://dx.doi.org/10.3389/fpubh.2021.553980DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8219213PMC
July 2021

Multilevel governance framework on grievance redressal for patient rights violations in India.

Health Policy Plan 2021 Jun 16. Epub 2021 Jun 16.

Health Equity Cluster, Institute of Public Health, 3009, II A Main, 17th Cross, KR road, Sidanna Layout, Banashankari stage II, Banashankari, Bengaluru, Karnataka-560070, India.

The notion of patient rights encompasses the obligations of the state and healthcare providers to respect the dignity, autonomy and equality of care-seeking individuals in healthcare processes. Functional patient grievance redressal systems are key to ensuring that the rights of individuals seeking healthcare are protected. We critically examined the published literature from high-income and upper-middle-income countries to establish an analytical framework on grievance redressal for patient rights violations in health facilities. We then used lawsuits on patient rights violations from the Supreme Court of India to analyse the relevance of the developed framework to the Indian context. With market perspectives pervading the health sector, there is an increasing trend of adopting a consumerist approach to protecting patient rights. In this line, avenues for grievance redressal for patient rights violations are gaining traction. Some of the methods and instruments for patient rights implementation include charters, ombudsmen, tribunals, health professional councils, separating rules for redressal and professional liability in patient rights violations, blame-free reporting systems, direct community monitoring and the court system. The grievance redressal mechanisms for patient rights violations in health facilities showcase multilevel governance arrangements with overlapping decision-making units at the national and subnational levels. The privileged position of medical professionals in multilevel governance arrangements for grievance redressal puts care-seeking individuals at a disadvantaged position during dispute resolution processes. Inclusion of external structures in health services and the healthcare profession and laypersons in the grievance redressal processes is heavily contested. Normatively speaking, a patient grievance redressal system should be accessible, impartial and independent in its function, possess the required competence, have adequate authority, seek continuous quality improvement, offer feedback to the health system and be comprehensive and integrated within the larger healthcare regulatory architecture.
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http://dx.doi.org/10.1093/heapol/czab066DOI Listing
June 2021

Multisectoral action for health in low-income and middle-income settings: how can insights from social science theories inform intragovernmental coordination efforts?

BMJ Glob Health 2021 05;6(5)

School of Public Health, Department of Health Policy Planning and Management, Makerere University College of Health Sciences, Kampala, Uganda.

There is consensus in global health on the need for multisectoral action (MSA) to address many contemporary development challenges, but there is limited action. Examples of issues that require coordinated MSA include the determinants of health conditions such as nutrition (malnutrition and obesity) and chronic non-communicable diseases. Nutrition, tobacco control and such public health issues are regulated separately by health, trade and treasury ministries. Those issues need to be coordinated around the same ends to avoid conflicting policies. Despite the need for MSA, why do we see little progress? We investigate the obstacles to and opportunities for MSA by providing a government perspective. This paper draws on four theoretical perspectives, namely (1) the political economy perspective, (2) principal-agent theory, (3) resource dependence theory and (4) transaction cost economics theory. The theoretical framework provides complementary propositions to understand, anticipate and prepare for the emergence and structuring of coordination arrangements between government organisations at the same or different hierarchical levels. The research on MSA for health in low/middle-income countries needs to be interested in a multitheory approach that considers several theoretical perspectives and the contextual factors underlying coordination practices.
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http://dx.doi.org/10.1136/bmjgh-2020-004064DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8160194PMC
May 2021

Practice of death surveillance and response for maternal, newborn and child health: a framework and application to a South African health district.

BMJ Open 2021 05 6;11(5):e043783. Epub 2021 May 6.

School of Public Health, South African Medical Research Council (MRC)/Health Services and Systems Unit, Cape Town, South Africa.

Objective: To assess the functioning of maternal, perinatal, neonatal and child death surveillance and response (DSR) mechanisms at a health district level.

Design: A framework of elements covering analysis of causes of death, and processes of review and response was developed and applied to the smallest unit of coordination (subdistrict) to evaluate DSR functioning. The evaluation design was a descriptive qualitative case study, based on observations of DSR practices and interviews.

Setting: Rural South African health district (subdistricts and district office).

Participants: A purposive sample of 45 front-line health managers and providers involved with maternal, perinatal, neonatal and child DSR. The DSR mechanisms reviewed included a system of real-time death reporting (24 hours) and review (48 hours), a nationally mandated confidential enquiry into maternal death and regular facility and subdistrict mortality audit and response processes.

Primary Outcome Measures: Functioning of maternal, perinatal, neonatal and child DSR.

Results: While DSR mechanisms were integrated into the organisational routines of the district, their functioning varied across subdistricts and between forms of DSR. Some forms of DSR, notably those involving maternal deaths, with external reporting and accounting, were more likely to trigger reactive fault-finding and sanctioning than other forms, which were more proactive in supporting evidence-based actions to prevent future deaths. These actions occurred at provider and system level, and to a limited extent, in communities.

Conclusions: This study provides an empirical example of the everyday practice of DSR mechanisms at a district level. It assesses such practice based on a framework of elements and enabling organisational processes that may be of value in similar settings elsewhere.
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http://dx.doi.org/10.1136/bmjopen-2020-043783DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8103944PMC
May 2021

Learning from intersectoral action beyond health: a meta-narrative review.

Health Policy Plan 2021 May;36(4):552-571

Department of Political Science, McGill University, 855 Sherbrooke Street West, Montreal, Quebec H3A 2T7, Canada.

Intersectoral action (ISA) is considered pivotal for achieving health and societal goals but remains difficult to achieve as it requires complex efforts, resources and coordinated responses from multiple sectors and organizations. While ISA in health is often desired, its potential can be better informed by the advanced theory-building and empirical application in real-world contexts from political science, public administration and environmental sciences. Considering the importance and the associated challenges in achieving ISA, we have conducted a meta-narrative review, in the research domains of political science, public administration, environmental and health. The review aims to identify theory, theoretical concepts and empirical applications of ISA in these identified research traditions and draw learning for health. Using the multidisciplinary database of SCOPUS from 1996 to 2017, 5535 records were identified, 155 full-text articles were reviewed and 57 papers met our final inclusion criteria. In our findings, we trace the theoretical roots of ISA across all research domains, describing the main focus and motivation to pursue collaborative work. The literature synthesis is organized around the following: implementation instruments, formal mechanisms and informal networks, enabling institutional environments involving the interplay of hardware (i.e. resources, management systems, structures) and software (more specifically the realms of ideas, values, power); and the important role of leaders who can work across boundaries in promoting ISA, political mobilization and the essential role of hybrid accountability mechanisms. Overall, our review reaffirms affirms that ISA has both technical and political dimensions. In addition to technical concerns for strengthening capacities and providing support instruments and mechanisms, future research must carefully consider power and inter-organizational dynamics in order to develop a more fulsome understanding and improve the implementation of intersectoral initiatives, as well as to ensure their sustainability. This also shows the need for continued attention to emergent knowledge bases across different research domains including health.
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http://dx.doi.org/10.1093/heapol/czaa163DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8128009PMC
May 2021

Multilevel modelling and multiple group analysis of disparities in continuity of care and viral suppression among adolescents and youths living with HIV in Nigeria.

BMJ Glob Health 2020 11;5(11)

Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium.

Introduction: Substantial disparities in care outcomes exist between different subgroups of adolescents and youths living with HIV (AYLHIV). Understanding variation in individual and health facility characteristics could be key to identifying targets for interventions to reduce these disparities. We modelled variation in AYLHIV retention in care and viral suppression, and quantified the extent to which individual and facility characteristics account for observed variations.

Methods: We included 1170 young adolescents (10-14 years), 3206 older adolescents (15-19 years) and 9151 young adults (20-24 years) who were initiated on antiretroviral therapy (ART) between January 2015 and December 2017 across 124 healthcare facilities in Nigeria. For each age group, we used multilevel modelling to partition observed variation of main outcomes (retention in care and viral suppression at 12 months after ART initiation) by individual (level one) and health facility (level two) characteristics. We used multiple group analysis to compare the effects of individual and facility characteristics across age groups.

Results: Facility characteristics explained most of the observed variance in retention in care in all the age groups, with smaller contributions from individual-level characteristics (14%-22.22% vs 0%-3.84%). For viral suppression, facility characteristics accounted for a higher proportion of variance in young adolescents (15.79%), but not in older adolescents (0%) and young adults (3.45%). Males were more likely to not be retained in care (adjusted OR (aOR)=1.28; p<0.001 young adults) and less likely to achieve viral suppression (aOR=0.69; p<0.05 older adolescent). Increasing facility-level viral load testing reduced the likelihood of non-retention in care, while baseline regimen TDF/3TC/EFV or NVP increased the likelihood of viral suppression.

Conclusions: Differences in characteristics of healthcare facilities accounted for observed disparities in retention in care and, to a lesser extent, disparities in viral suppression. An optimal combination of individual and health services approaches is, therefore, necessary to reduce disparities in the health and well-being of AYLHIV.
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http://dx.doi.org/10.1136/bmjgh-2020-003269DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7646327PMC
November 2020

Towards a multilevel governance framework on the implementation of patient rights in health facilities: a protocol for a systematic scoping review.

BMJ Open 2020 10 15;10(10):e038927. Epub 2020 Oct 15.

Health Equity Cluster, Institute of Public Health, Bengaluru, India.

Introduction: Patient rights are "those rights that are attributed to a person seeking healthcare". Patient rights have implications for quality of healthcare and acts as a key accountability tool. It can galvanise structural improvements in the health system and reinforces ethical healthcare. States are duty bound to respect, protect and promote patient rights. The rhetoric on patient rights is burgeoning across the globe. With changing modes of governance arrangements, a number of state and non-state actors and institutions at various levels play a role in the design and implementation of (patient rights) policies. However, there is limited understanding on the multilevel institutional mechanisms for patient rights implementation in health facilities. We attempt to fill this gap by analysing the available scholarship on patient rights through a critical interpretive synthesis approach in a systematic scoping review.

Methods: The review question is 'how do the multilevel actors, institutional structures, processes interact and influence the patient rights implementation in healthcare facilities? How do they work at what level and in which contexts?" Three databases PubMed, LexisNexis and Web of Science will be systematically searched until 30 April 2020, for empirical and non-empirical literature in English from both lower middle-income countries and high-income countries. Targeted search will be performed in grey literature and through citation and reference tracking of key records. Using the critical interpretive synthesis approach, a multilevel governance framework on the implementation of patient rights in health facilities which is grounded in the data will be developed.

Ethics And Dissemination: The review uses published literature hence ethics approval is not required. The findings of the review will be published in a peer-reviewed journal.

Registration Number: PROSPERO 2020 CRD42020176939.
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http://dx.doi.org/10.1136/bmjopen-2020-038927DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7566736PMC
October 2020

Confronting power in low places: historical analysis of medical dominance and role-boundary negotiation between health professions in Nigeria.

BMJ Glob Health 2020 09;5(9)

Department of Public Health, Institute of Tropical Medicine, Antwerp, Antwerpen, Belgium.

Introduction: Interprofessional interaction is intrinsic to health service delivery and forms the basis of task-shifting and task-sharing policies to address human resources for health challenges. But while interprofessional interaction can be collaborative, professional hierarchies and discipline-specific patterns of socialisation can result in unhealthy rivalry and conflicts which disrupt health system functioning. A better understanding of interprofessional dynamics is necessary to avoid such negative consequences. We, therefore, conducted a historical analysis of interprofessional interactions and role-boundary negotiations between health professions in Nigeria.

Methods: We conducted a review of both published and grey literature to provide historical accounts and enable policy tracing of reforms related to interprofessional interactions. We used Nancarrow and Borthwick's typology for thematic analysis and used medical dominance and negotiated order theories to offer explanations of the conditions that facilitated or constrained interprofessional collaboration.

Results: Despite an overall context of medical dominance, we found evidence of professional power changes (dynamics) and role-boundary shifts between health professions. These shifts occurred in different directions, but shifts between professions that are at different power gradients were more likely to be non-negotiable or conflictual. Conditions that facilitated consensual role-boundary shifts included the feasibility of simultaneous upward expansion of roles for all professions and the extent to which the delegating profession was in charge of role delegation. While the introduction of new medical diagnostic technology opened up occupational vacancies which facilitated consensual role-boundary change in some cases, it constrained professional collaboration in others.

Conclusions: Health workforce governance can contribute to better functioning of health systems and voiding dysfunctional interprofessional relations if the human resource for health interventions are informed by contextual understanding (informed by comparative institutional and health systems research) of conditions that facilitate or constrain effective interprofessional collaboration.
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http://dx.doi.org/10.1136/bmjgh-2020-003349DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7526320PMC
September 2020

Health systems recovery from COVID-19: a window of opportunity for (in)fertility care.

Sex Reprod Health Matters 2020 12;28(1):1790090

Lecturer in Law, The Law School, Huddersfield Business School, Centre for Sustainability, Responsibility, Governance and Ethics, University of Huddersfield, Huddersfield, UK.

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http://dx.doi.org/10.1080/26410397.2020.1790090DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7888027PMC
December 2020

Perceptions and experiences of frontline health managers and providers on accountability in a South African health district.

Int J Equity Health 2020 07 1;19(1):110. Epub 2020 Jul 1.

School of Public Health, University of the Western Cape, Robert Sobukwe Road, Bellville, Private Bag X17, Cape Town, 7535, South Africa.

Objective: Public primary health care and district health systems play important roles in expanding healthcare access and promoting equity. This study explored and described accountability for this mandate as perceived and experienced by frontline health managers and providers involved in delivering maternal, newborn and child health (MNCH) services in a rural South African health district.

Methods: This was a qualitative study involving in-depth interviews with a purposive sample of 58 frontline public sector health managers and providers in the district office and two sub-districts, examining the meanings of accountability and related lived experiences. A thematic analysis approach grounded in descriptive phenomenology was used to identify the main themes and organise the findings.

Results: Accountability was described by respondents as both an organisational mechanism of answerability and responsibility and an intrinsic professional virtue. Accountability relationships were understood to be multidirectional - upwards and downwards in hierarchies, outwards to patients and communities, and inwards to the 'self'. The practice of accountability was seen as constrained by organisational environments where impunity and unfair punishment existed alongside each other, where political connections limited the ability to sanction and by climates of fear and blame. Accountability was seen as enabled by open management styles, teamwork, good relationships between primary health care, hospital services and communities, investment in knowledge and skills development and responsive support systems. The interplay of these constraints and enablers varied across the facilities and sub-districts studied.

Conclusions: Providers and managers have well-established ideas about, and a language of, accountability. The lived reality of accountability by frontline managers and providers varies and is shaped by micro-configurations of enablers and constraints in local accountability ecosystems. A 'just culture', teamwork and collaboration between primary health care and hospitals and community participation were seen as promoting accountability, enabling collective responsibility, a culture of learning rather than blame, and ultimately, access to and quality of care.
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http://dx.doi.org/10.1186/s12939-020-01229-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7328263PMC
July 2020

Accountability for SRHR in the context of the COVID-19 pandemic.

Sex Reprod Health Matters 2020 12;28(1):1779634

South African Research Chair in Health Systems, Complexity, and Social Change, School of Public Health, University of the Western Cape, Bellville, South Africa.

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http://dx.doi.org/10.1080/26410397.2020.1779634DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7888058PMC
December 2020

The crowded space of local accountability for maternal, newborn and child health: a case study of the South African health system.

Health Policy Plan 2020 Apr;35(3):279-290

School of Public Health, University of the Western Cape, Robert Sobukwe Road, Private Bag X17 Bellville, Cape Town 7535, South Africa.

Global and national accountability for maternal, newborn and child health (MNCH) is increasingly invoked as central to addressing preventable mortality and morbidity. Strategies of accountability for MNCH include policy and budget tracking, maternal and perinatal death surveillance, performance targets and various forms of social accountability. However, little is known about how the growing number of accountability strategies for MNCH is received by frontline actors, and how they are integrated into the overall functioning of local health systems. We conducted a case study of mechanisms of local accountability for MNCH in South Africa, involving a document review of national policies, programme reports, and other literature directly or indirectly related to MNCH, and in-depth research in one district. The latter included observations of accountability practices (e.g. through routine meetings) and in-depth interviews with 37 purposely selected health managers and frontline health workers involved in MNCH. Data collection and analysis were guided by a framework that defined accountability as answerability and action (both individual and collective), addressing performance, financial and public accountability, and involving both formal and informal processes. Nineteen individual accountability mechanisms were identified, 10 directly and 9 indirectly related to MNCH, most of which addressed performance accountability. Frontline managers and providers at local level are targeted by a web of multiple, formal accountability mechanisms, which are sometimes synergistic but often duplicative, together giving rise to local contexts of 'accountability overloads'. These result in a tendency towards bureaucratic compliance, demotivation, reduced efficiency and effectiveness, and limited space for innovation. The functioning of formal accountability mechanisms is shaped by local cultures and relationships, creating an accountability ecosystem involving multiple actors and roles. There is a need to streamline formal accountability mechanisms and consider the kinds of actions that build positive cultures of local accountability.
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http://dx.doi.org/10.1093/heapol/czz162DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7152728PMC
April 2020

Opening the 'implementation black-box' of the user fee exemption policy for caesarean section in Benin: a realist evaluation.

Health Policy Plan 2020 Mar;35(2):153-166

School of Public Health, University of the Western Cape, Robert Sobukwe Road, Bellville 7535, Republic of South Africa.

To improve access to maternal health services, Benin introduced in 2009 a user fee exemption policy for caesarean sections. Similar to other low- and middle-income countries, its implementation showed mixed results. Our study aimed at understanding why and in which circumstances the implementation of this policy in hospitals succeeded or failed. We adopted the realist evaluation approach and tested the initial programme theory through a multiple embedded case study design. We selected two hospitals with contrastive outcomes. We used data from 52 semi-structured interviews, a patient exit survey, a costing study of caesarean section and an analysis of financial flows. In the analysis, we used the intervention-context-actor-mechanism-outcome configuration heuristic. We identified two main causal pathways. First, in the state-owned hospital, which has a public-oriented but administrative management system, and where citizens demand accountability through various channels, the implementation process was effective. In the non-state-owned hospital, managers were guided by organizational financial interests more than by the inherent social value of the policy, there was a perceived lack of enforcement and the implementation was poor. We found that trust, perceived coercion, adherence to policy goals, perceived financial incentives and fairness in their allocation drive compliance, persuasion, positive responses to incentives and self-efficacy at the operational level to generate the policy implementation outcomes. Compliance with the policy depended on enforcement by hierarchical authority and bottom-up pressure. Persuasion depended on the alignment of the policy with personal and organizational values. Incentives may determine the adoption if they influence the local stakeholder's revenue are trustworthy and perceived as fairly allocated. Failure to anticipate the differential responses of implementers will prevent the proper implementation of user fee exemption policies and similar universal health coverage reforms.
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http://dx.doi.org/10.1093/heapol/czz146DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7050689PMC
March 2020

Building a transformative agenda for accountability in SRHR: lessons learned from SRHR and accountability literatures.

Sex Reprod Health Matters 2019 May;27(2):1622357

Human Rights Advisor , World Health Organization , Geneva , Switzerland.

Global strategies and commitments for sexual and reproductive health and rights (SRHR) underscore the need to strengthen rights-based accountability processes. Yet there are gaps between these ambitious SRHR rights frameworks and the constrained socio-political lived realities within which these frameworks are implemented. This paper addresses these gaps by reviewing the evidence on the dynamics and concerns related to operationalising accountability in the context of SRHR. It is based on a secondary analysis of a systematic review that examined the published evidence on SRHR and accountability and also draws on the broader literature on accountability for health. Key themes include the political and ideological context, enhancing community voice and health system responsiveness, and recognising the complexity of health systems. While there is a range of accountability relationships that can be leveraged in the health system, the characteristics specific to SRHR need to be considered as they colour the capabilities and conditions in which accountability efforts occur.
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http://dx.doi.org/10.1080/26410397.2019.1622357DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7942763PMC
May 2019

The Need for a Dynamic Approach to Health System-Centered Innovations Comment on "What Health System Challenges Should Responsible Innovation in Health Address? Insights From an International Scoping Review".

Int J Health Policy Manag 2019 07 1;8(7):444-446. Epub 2019 Jul 1.

Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.

Lehoux and colleagues plea for a health systems perspective to evaluate innovations. Since many innovations and their scale-up strategies emerge from processes that are not (centrally) steered, we plea for any assessment with a dynamic, instead of a sequential, approach. We provide further guidance on how to adopt such dynamic approach, in order to better un-derstand and steer innovations for better health systems. A systems-level challenge is constituted by interactions and feedback loops between different actors and components of the health system. It is therefore essential to explore both the entry-point of innovation and the interactions with other components. If innovation is regarded as an injection of resources and opportunities into a health system, this system needs to have the capacity to transform these into desired outputs, the 'absorption capacity.' The highly organic diffusion of innovation in complex adapative systems cannot be easily controlled, but the system behaviours can be analysed, with occurance of phenomena such as path dependence, feedback loops, scale-free networks, emergent behaviour and phase transitions. This helps to anticipate unintended consequences, and to engage key actors in ongoing problem-solving and adaptation. By adopting a prospective approach, responsible innovation could set in motion prospective policy evaluations, which on the basis of iterative learning would allow decisionmakers to continuously adapt their policies and programmes. Priority-setting for innovation is an essentially political process that is geared towards consensus-building and grounded in values.
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http://dx.doi.org/10.15171/ijhpm.2019.25DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6706970PMC
July 2019

'At this [] club, we are a family now': A realist theory-testing case study of the antiretroviral treatment adherence club, South Africa.

South Afr J HIV Med 2019 26;20(1):922. Epub 2019 Jun 26.

School of Public Health, University of the Western Cape, Cape Town, South Africa.

Background: An estimated 7.9 million people were living with HIV in South Africa in 2017, with 63.3% of them remaining in antiretroviral therapy (ART) care and 62.9% accessing ART. Poor retention in care and suboptimal adherence to ART undermine the successful efforts of initiating people living with HIV on ART. To address these challenges, the antiretroviral adherence club intervention was designed to streamline ART services to 'stable' patients. Nevertheless, it is poorly understood exactly how and why and under what health system conditions the adherence club intervention works.

Objectives: The aim of this study was to test a theory on how and why the adherence club intervention works and in what health system context(s) in a primary healthcare facility in the Western Cape Province.

Method: Within the realist evaluation framework, we applied a confirmatory theory-testing case study approach. Kaplan-Meier descriptions were used to estimate the rates of dropout from the adherence club intervention and virological failure as the principal outcomes of the adherence club intervention. Qualitative interviews and non-participant observations were used to explore the context and identify the mechanisms that perpetuate the observed outcomes or behaviours of the actors. Following the retroduction logic of making inferences, we configured information obtained from quantitative and qualitative approaches using the intervention-context-actor-mechanism-outcome heuristic tool to formulate generative theories.

Results: We confirmed that patients on ART in adherence clubs will continue to adhere to their medication and remain in care because their self-efficacy is improved; they are motivated or are being nudged.

Conclusion: A theory-based understanding provides valuable lessons towards the adaptive implementation of the adherence club intervention.
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http://dx.doi.org/10.4102/sajhivmed.v20i1.922DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6620516PMC
June 2019

Unravelling how and why the Antiretroviral Adherence Club Intervention works (or not) in a public health facility: A realist explanatory theory-building case study.

PLoS One 2019 16;14(1):e0210565. Epub 2019 Jan 16.

School of Public Health, University of the Western Cape, Cape Town, South Africa.

Background: Although empirical evidence suggests that the adherence club model is more effective in retaining people living with HIV in antiretroviral treatment care and sustaining medication adherence compared to standard clinic care, it is poorly understood exactly how and why this works. In this paper, we examined and made explicit how, why and for whom the adherence club model works at a public health facility in South Africa.

Methods: We applied an explanatory theory-building case study approach to examine the validity of an initial programme theory developed a priori. We collected data using a retrospective cohort quantitative design to describe the suppressive adherence and retention in care behaviours of patients on ART using Kaplan-Meier methods. In conjunction, we employed an explanatory qualitative study design using non-participant observations and realist interviews to gain insights into the important mechanisms activated by the adherence club intervention and the relevant contextual conditions that trigger the different mechanisms to cause the observed behaviours. We applied the retroduction logic to configure the intervention-context-actor-mechanism-outcome map to formulate generative theories.

Results: A modified programme theory involving targeted care for clinically stable adult patients (18 years+) receiving antiretroviral therapy was obtained. Targeted care involved receiving quick, uninterrupted supply of antiretroviral medication (with reduced clinic visit frequencies), health talks and counselling, immediate access to a clinician when required and guided by club rules and regulations within the context of adequate resources, and convenient (size and position) space and proper preparation by the club team. When grouped for targeted care, patients feel nudged, their self-efficacy is improved and they become motivated to adhere to their medication and remain in continuous care.

Conclusion: This finding has implications for understanding how, why and under what health system conditions the adherence club intervention works to improve its rollout in other contexts.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0210565PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6334969PMC
October 2019

Beyond the template: the needs of tribal women and their experiences with maternity services in Odisha, India.

Int J Equity Health 2018 09 24;17(1):134. Epub 2018 Sep 24.

Department of Public Health, Institute of Tropical Medicine, Nationalestraat 155, 2000, Antwerp, Belgium.

Background: Over the past 15 years, several efforts have been made by the Government of India to improve maternal health, primarily through providing cash incentives to increase institutional child birth and strengthen services in the public health system. The result has been a definite but unequal increase in the proportion of institutional deliveries, across geographical areas and social groups. Tribal (indigenous) communities are one such group in which the proportion of institutional deliveries is low. The persistence of these inequities indicates that a different approach is required to address the maternal health challenges in these communities.

Methods: This paper describes an exploratory study in Rayagada District of Odisha which aimed to understand tribal women's experiences with pregnancy and childbirth and their interactions with the formal health system. Methods included in-depth interviews with women, traditional healers and formal health care providers and outreach workers, observations in the community and health facilities.

Results: The exploration of traditional practices shows that in this community, pregnancy and childbirth is treated as part of a natural process, not requiring external intervention. There is a well-established practice of birthing in the community which also recognizes the need for health system interventions in case of high-risk births or complications. However, there has been no effort by the health system to build on this traditional understanding of safety of woman and child. Instead, the system continues to rely on incentives and disincentives to motivate women. Traditional health providers who are important stakeholders have not been integrated into the health system. Despite the immense difficulties that women face, however, they do access health facilities, but barriers of distance, language, cultural inappropriateness of services, and experiences of gross violations have further compounded their distrust.

Conclusions: The results of the study suggest a re-examining of the very approach to addressing maternal health in this community. The study calls for reorienting maternal health services, to be responsive to the requirements of tribal women, cater to their cultural needs, provide support to domiciliary deliveries, invest in building trust with the community, and preserve beneficial traditional practices.
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http://dx.doi.org/10.1186/s12939-018-0850-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6151937PMC
September 2018

"Patients Are Not Following the [Adherence] Club Rules Anymore": A Realist Case Study of the Antiretroviral Treatment Adherence Club, South Africa.

Qual Health Res 2018 10 21;28(12):1839-1857. Epub 2018 Jul 21.

1 University of the Western Cape, Bellville, South Africa.

There is growing evidence that differentiated care models employed to manage treatment-experienced patients on antiretroviral therapy could improve adherence to medication and retention in care. We conducted a realist evaluation to determine how, why, for whom, and under what health system context the adherence club intervention works (or not) in real-life implementation. In the first phase, we developed an initial program theory of the adherence club intervention. In this study, we report on an explanatory theory-testing case study to test the initial theory. We conducted a retrospective cohort analysis and an explanatory qualitative study to gain insights into the important mechanisms activated by the adherence club intervention and the relevant context conditions that trigger the different mechanisms to achieve the observed outcomes. This study identified potential mitigating circumstances under which the adherence club program could be implemented, which could inform the rollout and implementation of the adherence club intervention.
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http://dx.doi.org/10.1177/1049732318784883DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6154254PMC
October 2018

The Effect of a Community Health Worker Utilized Mobile Health Application on Maternal Health Knowledge and Behavior: A Quasi-Experimental Study.

Front Public Health 2018 7;6:133. Epub 2018 May 7.

Faculty of Sciences, VU University Amsterdam, Amsterdam, Netherlands.

Background: Mobile technology (mHealth) is increasingly being used to achieve improved access and quality of maternal care, particularly in rural areas of low- and middle-income countries. In 2011, a mobile application-Mobile for Mothers (MfM)-was implemented in Jharkhand, India to support home visits by community health workers. The objective of this study is to assess the impact of the mHealth intervention on maternal health.

Methods: Households from three subdistricts in the Deoghar district of Jharkhand were selected using a multistage cluster sampling approach. Households from the Sarwan subdistrict received the MfM intervention, those from Devipur subdistrict received other interventions asides MfM from the implementing non-governmental organization (NGO), while households from Mohanpur subdistrict received the current standard of care. Women ( = 2,200) between the ages of 18 and 45 who had delivered a baby in the past 1 year were enrolled into the study. The primary outcomes of interest were maternal health knowledge, antenatal care (ANC) attendance, and delivery in a health facility.

Results: Post-intervention, women in the MfM group had higher maternal health knowledge, were more likely to attend four or more ANC visits, and deliver at the health facility when compared with the NGO and standard care group. After controlling for predictors, women in the intervention group significantly performed better than both the NGO and standard care groups on all three-outcome variables (all  > 0.05).

Conclusion: The results indicate that although the MfM mHealth intervention could influence adherence and practice of recommended maternal health behaviors, it could not overcome key sociocultural determinants of maternal health such as caste and educational status, which are specific to the Indian context. mHealth holds continued promise for maternal health but implementers and policy makers must additionally address health system and sociocultural factors that play a significant role in the uptake of recommended maternal health practices.
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http://dx.doi.org/10.3389/fpubh.2018.00133DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5949315PMC
May 2018

Broadening understanding of accountability ecosystems in sexual and reproductive health and rights: A systematic review.

PLoS One 2018 31;13(5):e0196788. Epub 2018 May 31.

World Health Organization, Geneva, Switzerland.

Background: Accountability for ensuring sexual and reproductive health and rights is increasingly receiving global attention. Less attention has been paid to accountability mechanisms for sexual and reproductive health and rights at national and sub-national level, the focus of this systematic review.

Methods: We searched for peer-reviewed literature using accountability, sexual and reproductive health, human rights and accountability instrument search terms across three electronic databases, covering public health, social sciences and legal studies. The search yielded 1906 articles, 40 of which met the inclusion and exclusion criteria (articles on low and middle-income countries in English, Spanish, French and Portuguese published from 1994 and October 2016) defined by a peer reviewed protocol.

Results: Studies were analyzed thematically and through frequencies where appropriate. They were drawn from 41 low- and middle-income countries, with just over half of the publications from the public health literature, 13 from legal studies and the remaining six from social science literature. Accountability was discussed in five health areas: maternal, neonatal and child health services, HIV services, gender-based violence, lesbian/gay/bisexual/transgender access and access to reproductive health care in general. We identified three main groupings of accountability strategies: performance, social and legal accountability.

Conclusion: The review identified an increasing trend in the publication of accountability initiatives in Sexual and Reproductive Health and Rights (SRHR). The review points towards a complex 'accountability ecosystem' with multiple actors with a range of roles, responsibilities and interactions across levels from the transnational to the local. These accountability strategies are not mutually exclusive, but they do change the terms of engagement between the actors involved. The publications provide little insight on the connections between these accountability strategies and on the contextual conditions for the successful implementation of the accountability interventions. Obtaining a more nuanced understanding of various underpinnings of a successful approach to accountability at national and sub national levels is essential.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0196788PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5978882PMC
July 2018

A realist approach to eliciting the initial programme theory of the antiretroviral treatment adherence club intervention in the Western Cape Province, South Africa.

BMC Med Res Methodol 2018 05 25;18(1):47. Epub 2018 May 25.

School of Public Health, University of the Western Cape, Cape town, South Africa.

Background: The successful initiation of people living with HIV/AIDS on antiretroviral therapy (ART) in South Africa has engendered challenges of poor retention in care and suboptimal adherence to medication. The adherence club intervention was implemented in the Metropolitan area of the Western Cape Province to address these challenges. The adherence club programme has shown potential to relieve clinic congestion, improve retention in care and enhance treatment adherence in the context of rapidly growing HIV patient populations being initiated on ART. Nevertheless, how and why the adherence club intervention works is not clearly understood. We aimed to elicit an initial programme theory as the first phase of the realist evaluation of the adherence club intervention in the Western Cape Province.

Methods: The realist evaluation approach guided the elicitation study. First, information was obtained from an exploratory qualitative study of programme designers' and managers' assumptions of the intervention. Second, a document review of the design, rollout, implementation and outcome of the adherence clubs followed. Third, a systematic review of available studies on group-based ART adherence support models in Sub-Saharan Africa was done, and finally, a scoping review of social, cognitive and behavioural theories that have been applied to explain adherence to ART. We used the realist evaluation heuristic tool (Intervention-context-actors-mechanism-outcome) to synthesise information from the sources into a configurational map. The configurational mapping, alignment of a specific combination of attributes, was based on the generative causality logic - retroduction.

Results: We identified two alternative theories: The first theory supposes that patients become encouraged, empowered and motivated, through the adherence club intervention to remain in care and adhere to the treatment. The second theory suggests that stable patients on ART are being nudged through club rules and regulations to remain in care and adhere to the treatment with the goal to decongest the primary health care facilities.

Conclusion: The initial programme theory describes how (dynamics) and why (theories) the adherence club intervention is expected to work. By testing theories in "real intervention cases" using the realist evaluation approach, the theories can be modified, refuted and/or reconstructed to elicit a refined theory of how and why the adherence club intervention works.
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http://dx.doi.org/10.1186/s12874-018-0503-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5970495PMC
May 2018
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