Towards Developing an Initial Programme Theory: Programme Designers and Managers Assumptions on the Antiretroviral Treatment Adherence Club Programme in Primary Health Care Facilities in the Metropolitan Area of Western Cape Province, South Africa

Background
The antiretroviral adherence club intervention was rolled out in primary health care facilities in the Western Cape province of South Africa to relieve clinic congestion, and improve retention in care, and treatment adherence in the face of growing patient loads. We adopted the realist evaluation approach to evaluate what aspects of antiretroviral club intervention works, for what sections of the patient population, and under which community and health systems contexts, to inform guidelines for scaling up of the intervention. In this article, we report on a step towards the development of a programme theory—the assumptions of programme designers and health service managers with regard to how and why the adherence club intervention is expected to achieve its goals and perceptions on how it has done so (or not).
Methods
We adopted an exploratory qualitative research design. We conducted a document review of 12 documents on the design and implementation of the adherence club intervention, and key informant interviews with 12 purposively selected programme designers and managers. Thematic content analysis was used to identify themes attributed to the programme actors, context, mechanisms, and outcomes. Using the context-mechanism-outcome configurational tool, we provided an explanatory focus of how the adherence club intervention is roll-out and works guided by the realist perspective.
Results
We classified the assumptions of the adherence club designers and managers into the rollout, implementation, and utilisation of the adherence club programme, constructed around the providers, management/operational staff, and patients, respectively. Two rival theories were identified at the patient-perspective level. We used these perspectives to develop an initial programme theory of the adherence club intervention, which will be tested in a later phase.
Conclusion
The perspectives of the programme designers and managers provided an important step towards developing an initial programme theory, which will guide our realist evaluation of the adherence club programme in South Africa.

研究背景
为缓解南非西开普省基层医疗卫生机构的门诊拥堵状况，同时在患者就诊量持续增长的背景下提升患者的诊疗留存率与治疗依从性，当地推行了抗逆转录病毒治疗依从性互助小组（antiretroviral adherence club）干预方案。本研究采用现实主义评价法（realist evaluation approach），旨在明确该依从性互助小组干预方案在不同患者群体、社区与卫生系统情境下的有效实施维度，为该方案的规模化推广提供指南支撑。本文聚焦项目理论构建的前期探索环节：梳理项目设计者与卫生服务管理者关于该依从性互助干预方案实现目标的路径与原理的预设假设，以及其对方案实际执行效果（达成或未达成目标）的认知。

研究方法
本研究采用探索性质性研究设计。我们对12份有关该依从性互助干预方案的设计与实施文件开展文献审查（document review），并对12名经目的抽样选取的项目设计者与管理者开展关键知情人访谈（key informant interviews）。采用主题内容分析法（thematic content analysis）识别与项目参与方、实施情境、作用机制及干预结局相关的主题。依托现实主义评价视角，运用情境-机制-结果构型工具（context-mechanism-outcome configurational tool），阐明该依从性互助干预方案的落地路径与运行逻辑。

研究结果
我们将依从性互助方案设计者与管理者的预设假设分为三类，分别围绕项目推广、方案实施与患者使用三个维度，对应覆盖服务提供者、管理/运营人员与患者群体。在患者视角层面，本研究识别出两种对立的理论观点。基于上述视角，我们构建了该依从性互助干预方案的初始项目理论，该理论将在后续研究阶段中得到验证。

研究结论
项目设计者与管理者的认知视角为初始项目理论的构建提供了关键基础，该理论将用于指导后续针对南非该依从性互助项目的现实主义评价工作。