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CHAPTER ONE: BACKGROUND INFORMATION
Introduction
Zimbabwe is one of the countries with high HIV burden. According to the recently published ZIMPHIA report, Prevalence of HIV among adults aged 15 to 64 in Zimbabwe is 14.1%: 12.0% among males and 16.0% among females. This corresponds to approximately 1.2 million persons aged 15 to 64 living with HIV in Zimbabwe (ZIMPHIA, 2015-16). On another note, Zimbabwe has committed to having 90% of all persons diagnosed receiving ART, and 90% of all persons receiving ART virally suppressed by 2020. ZIMPHIA shows that among all HIV-positive persons aged 15 to 64 years, 72.9% knew they were HIV positive, which is still somewhat below 90% target for awareness of HIV status. Of those who knew their HIV status, 86.8% were on ART, and of those who reported being on ART, 86.5% were virally suppressed both very close to the 90% targets (ZIMPHIA, 2015-16).

HIV Care and Treatment service has been at the epicentre of fighting the pandemic ever since exponential increase of HIV related mortality. Skovdal et al, (2011). With the ever increasing number of people on treatment, approximately 1.2 million (ZIMPHIA, 2016), there is need for efficient and effective service delivery as far as art is concerned. ministry of health has adopted different strategies in its hope of curbing the pandemic. Zimbabwe like most countries globally has adopted a differentiated care model which entails decentralization of ART services. This model has its own strengths and weaknesses as highlighted by most scholars. This paper will mainly focus in examining the role of community ART service delivery in form of community ART refill groups in addressing a plethora of challenges faced by PLHIV and communities at large. In its quest to examine the role of the CARGs as a community ART initiative, this research will also explore strengths and weaknesses of other models of ART delivery currently being implemented.

Background of the study
At the end of 2013, 12.9 million people were receiving antiretroviral therapy (ART) globally; that same year, the percentage of people with HIV receiving ART rose to37% (up from 10% in 2006) (MSF2016). Whereas this marks a substantial improvement, it means that of the 35 million people living with HIV at the end of 2013, 22 million people-3 in 5 people living with HIV were not accessing ART (UNAIDS,2014). At the same period, about 700 00 -800 000 people in Zimbabwe were HIV Positive 55% of them were on ART and facilities providing ART being less than 440 (UNAIDS, 2014). By 2016, the total number of clients on ART was now 975 667 compromising 66 159 children and 908 508 adults (UNAID, 2017). However, there has been a significant increase in the number of sites providing ART from 530 in 2010 to 1566 in 2016. (MOHCC, 2016). This however translated in an increase in overall ART coverage which by December 2016 was now at 68.3% from 55%, with 83% ART coverage among children (0-14) while adult ART coverage was at 66%, based on the total number of people living with HIV in line with the ”Treat All” approach (UNAID, 2017).

Antiretroviral therapy (ART) provision to people living with HIV (PLHIV) remains a key priority for Zimbabwe’s Ministry of Health (MOHCC, 2013). According to the recent ZIMPHIA 2016 report, 74% of PLHIV (15 to-64 years) are aware of their HIV status and 87% of them on treatment and 86% virally suppressed. Although the country has achieved high treatment coverage, issues of quality and retention in care remain a challenge, according to the FHI360, 2015) Zimbabwe HIV Care and Treatment (ZHCT)program), of those testing HIV positive, 84.2% of PLHIV were enrolled in care and 70.4% were initiated on HIV treatment (97.2% and 78.0% in Manicaland; 74.2% and 64.5% in Midlands). These data show that there are still gaps in HIV care and treatment coverage in supported facilities, particularly in Midlands where the gaps is larger, indicating a need for enhanced strategies to improve service linkage across all supported sites in order to achieve UNAIDS’ second 90-90-90 target, 90% ART coverage among PLHIV. This however calls for integrated efforts in closing the gap.

The gap in terms of treatment coverage might be as a result of compounding factors such as attitude of health facility staff. Campell et al, 2011) alluded to the fact that patients not properly adhering to their medicines are labelled as good patients hence listened to when compared to defaulters. They again reinforced the point that this will rather keep defaulters outside of the facility rather than inviting them in. Campell et al 2011 also highlighted that facility based ART service provision exposed PLHIV to more stigma rather than reducing it. They in their conclusions highlighted that community ART groups will address this key challenge and as well serve as platform to discuss for PLHIV.

Since adoption of the primary health care policy in 1980, Zimbabwe ministry of health regardless of support from civil societies, faced a plethora of challenges in terms of quality service delivery. However, communities have raised issues of health workers shortages and attitudes, availability of medicines and equipment, patient transport, impatient facilities such as beds, food and ablution facilities, amongst other things as key challenges to the health facility level service service system. Zimbabwe MOHCC adopted a differentiated care model by turn of 2011 were ART services were to be offered at lower level facilities (MOHCC, 2014). This was a positive move in decongesting provincial and district hospitals but however since then human resources to support such move has been a major crisis. World Health organization densities per 1000 populations were 1.34 and 0.083 midwives/nurses and physicians. Hirschhorn et al 2006 asserts that for efficient delivery of ART services at each facility, there is need for 1-2 physicians and 2-7 nurses who will be doing all duties from outpatient’s services, anti-natal care to ART services. This has been one of the reason why there are high rates of defaulting. Nkatha et al (2016), states that one of the key strategies to deal with the human resource shortage is task shifting to communities.

The national goal for MOHCC is to achieve HIV epidemic control by decreasing HIV related illnesses and deaths, and decreasing new HIV infections. However, all this will only be achieved through consistent and constant supply of ART services coupled with adherence. Of late adherence and consistent supply of ART services has been ART services has been a challenge largely because of both individual and facility factors. Continued decentralization of the delivery of HIV care and treatment services has helped increase access to ART at decreases cost to the client. The MOHCC acknowledges the need to minimize the client related costs and opportunity costs incurred by ART clients because of frequent visits to facilities and extended waiting time within the facilities as ART client volumes increase.

Even if coverage is increased, the health of people living with HIV and AIDS can only be achieved when adherence to antiretroviral treatment is strictly maintained (Machitinger and Bangsberg, 2005). Adherence to antiretroviral treatment reduces mortality in HIV positive people through viral load suppression; conversely, no adherence is highly correlated with risk of progression to AIDS, demonstrating that adequate adherence is vital to promoting positive treatment outcomes (Bangsberg et al…2001; Gifford etal…200). Research has it that there is a likelihood of drop outs if drug refills are done at a distant facility (Gregson et al…). Research purports that those who are 80% adherent to antiretroviral treatment have nearly doubled doubled viral reduction compared to individuals with less than 80% adherence rates (Steele ; Grauer, 2003). Studies indicate that adherence to antiretroviral treatment averages 70%. Some antiretroviral medications, however, require;95% adherence to have their full intended and sustained effect (Machtinger ; Bangsberg, 2005). Men are generally less likely to join groups where HIV and AIDS are discussed.

Community level services relate to those services provided in the community and at sub district and even at village or household level as part of community participation in co- production of needed services closer to the families or households. Community ART groups are one great example of community level provision.

Community based ART groups are a community initiated strategy to reduce adherence barriers related to difficult access to care (fhi360 2014). CARGs have been commonly implemented with hard to reach groups and in rural settings. They rely on preexisting social networks such as support groups. In urban settings, it is recommended that CARGs be promoted for groups of family members and workmates. A CARG is a self-forming group and must have a minimum of two clients (referred to as ”treatment buddies”) and a maximum of six clients. The efficiency (time and monetary) of this model is through cost sharing achieved by rotation of clients (group representatives) in visiting the facility to collect ART treatment for group members.

To join group, patients have to be stable on ART (being at least six months on a first line regimen with CD4 above 200/mm# and, MOHCC 2015 and FHI360 2015). Each group elects a group leader among its members, who coordinates the group activities and functions as a spokesperson of the group. The group will coordinate periodically on who will go and collect medication for all the group members. The group will also serve as a platform and social discussions on issues affecting people living with HIV.

Mining communities have been identified as among the highest risk groups for HIV infection in countries with high overall rates of HIV and AIDS prevalence (MOHCC 2014). Vulnerability to HIV and AIDS stems from, the time panners spend away from home, their access to cash income, their demographic profile, the ready availability of commercial sex in gold panning fields and the sub cultures of risk taking and hyper masculinity in gold panners. It also can be noted that adherence for people in such communities is extremely poor as well since they spend most of the time away from their homes, no time to visit health facilities to have refills. However, Community ART refill Groups in such communities have been viewed as an immediate solution by retaining more clients in care.

It however is against this background that the author found it useful to conduct this research and unpack the GARG model, examine its role in addressing plethora of challenges faced by PLHIV in Kwekwe as well as providing evidence for policy formulation and decision making.

Research Problem
Since advent of antiretroviral therapy (ART), it has proved to be a key element in curbing the spread of HIV. When adequately adhered to, ART is known to halt the progression of the virus and allow the HIV infected person to live a longer, more productive life. However, retention to care for ART patients collecting medicines at facilities individually has been on the decline in the past five years and some of the reasons for the decline are attributed to the deteriorating patient client relationship (WHO 2014).

Looking at the continuum of care framework, quite a number of patients drops out at every stage of the HIV Care and treatment model (MOHCC 2014). Ministry of health with support from non-governmental organizations such as FHI360, MSF has resorted to adopting the differentiated care model with the aim of strengthening the community systems. This has been viewed as a solution to a myriad of problems being faced by health facility in line with providing ART services for people living with HIV. Implementation of various community initiatives including the CARGS have been going on for more than 3 years now and effectiveness of such initiatives has not been examined widely. Therefore, there is need for examining the impact of the community ART initiatives being implemented in Kwekwe district with the thrust of wanting to articulate on lessons learnt.

This research will however focus on examining the role of the CARGs in improving adherence and retention too care f of PLHIV. The research will start by understanding the role of CARGS WITH THE AIM of providing lessons learnt from areas already having these groups. Since Alternative care models implemented in resource limited settings have been taken to scale this research will also work in providing sufficient evidence for scale up.

Significant of the study
Public health authorities often seek evidence that new models of care have proved to be feasible, acceptable, cost efficient and effective outside of research settings, yet such ”real-life” evaluations of programmes that have achieved partial or full scale are rare (Nkatha et al 2016). The study will add value to the body of data that will inform public health policy and programming by providing promising practices as well as lessons learnt from community ART initiatives in Kwekwe district. The findings of the study will help in the health quality improvement especially within the concept of differentiated care model. The knowledge gained in this study will help in making recommendations regarding development of appropriate health strategies to empower clients, health personnel and policy makers about the importance of community ART initiatives such as the CARGs to improve retention into care and treatment. It will also help the health planners in reviewing the ART guideline to make the necessary changes regarding community antiretroviral therapy from the individual, community to national levels.

Objectives of the study
To describe the Community ART Refill Group and its goal
To examine the role of Community ART Refill Groups in addressing challenges faced by PLHIV in Kwekwe
To provide lessons learnt from implementation of Community ART Refill Model in Kwekwe
Delimitation of the Study
Kwekwe district is located in Midlands with a total estimated population of 289 687, 49% males, 51% females, 36.7% urban population and 41.1% aged between 0-14years (ZIMSTAT, 2012). Its home to the second largest urban community in the Midlands Province after Gweru. The district capital is located approximately 220 kilometres, by road, South West of Harare, the capital of Zimbabwe and he largest city in that country. Kwekwe lies on the main road, Highway A-5, between Harare and Bulawayo. Zimbabwe’s second largest city, located approximately 230 kilometres, further South West of Kwekwe.

The city of Kwekwe is sustained by both formal and informal mining activities. As industry collapsed owing to a decade long political crisis, thousands of workers formerly employed by disintegrating mining companies and downstream industries turned to artisanal gold panning for survival (Ejatlas 2017). Economically, like most of the districts in the Midlands, Kwekwe is a mining town with a lot of illegal gold panning activity, iron mining and smelting industries. It consists of both Shona and Ndebele speaking groups both in urban and rural. This district was selected for its uniqueness in terms of socio economic factors, being driven by gold panning activities. Evidence has shown that gold panning (24% which is higher than urban 22% and rural 21%) background has a large impact in terms of fuelling the spread of HIV, largely because of their risky sexual behaviours (MOHCC 2015).

Limitations of the Research
The findings will be limited to the selected health facilities and their catchment areas in one programmatic district and cannot be generalized to other districts in Zimbabwe.

Ethical considerations
The study will be done in line with the minimum required standards as guided by Medical Research Council as well as the Great Zimbabwe University ethical review board.

Informed consent is a mechanism for ensuring that people apprehend what it means to partake in a particular research study so they can choose in a mindful, thoughtful way whether they want to participate. Informed consent is one of the most vital tools for ensuring respect for persons during research (fhi360 2001). Those not agreeing will not be coerced or have their relationship with any institution or person affected. Participants will be required to sign a consent form before participating and be ensured that there is no harm in participating in the research.

Confidentiality: Data collection will be kept in confidence and decoded to minimize chances of identifying the source at analysing level.

Opt in Opt out- participants will not be coerced to continue with the study even if the few like discontinuing. The research study will adopt an opt in opt out.

Definition of Key Terms
Adherence-It is an extent to which clients behaviour coincides with the prescribed health care regimen as agreed upon through a shared decision making process between the client and a health care provider
Retention into care- defined as the proportion of participants remaining in care 12 months after enrolment by intention to treat
CARGS- These are self-formed groups of stable patients on ART from a community in the same geographic location.

CHAPTER TWO: LITERATURE REVIEW
Introduction
Weaknesses of Health facility centred ART provision
Traditional models (facility centred) has led to overcrowding and long waiting times at clinics, with many people waiting solely to pick up drug refills. This high workload tend to overtax health workers and, due to weak structure, they also face challenges to follow-up according to the guidelines in which they have been trained Apollo et al 2017. These challenges have led to a varied picture of effectiveness among HIV care and treatment systems. However, on the other hand, individuals who have been linked to care and treatment and retained on ART achieve high rates of viral suppression (Apollo et al 2017). However, studies report substantial loss to follow up across all steps of the care cascade.

Most pregnant women in Zimbabwe and most other Sub Saharan countries are expected to get an HIV test during anti natal visit. With the advent of the ”treat all” approach globally, there are a number of key lessons to be learned from the prevention of mother to child (PMTCT) OPTION b+ FOR PREGNANT WOMAN. Myer et al 2017 suggest that there are poor rates of retention among women initiated on ART during pregnancy. Myer et al 2017, also postulates that the six month post-partum outcomes of women who are initiated during pregnancy are reported after their self-selection into a healthcare worker managed group (community adherence clubs) or referral to their local primary care clinic. While their study provided vital evidence of poor retention, the study could not assess if women referred to but not retained in adherence clubs where retained on the other ART services, it however provided evidence that PLHIV may benefit from different service delivery models throughout their life time.

In Malawi, the PMTCT Uptake and Retention (PURE) study showed that mothers living with HIV who received expert peer support were significantly more likely to be retained in care at 24 months post initiation of ART. This was true regardless if the support was provided at facilities or in the community (approximately 80%, 83% vs. 66%). The positive effect of peer support was primarily seen in the period between 12 and 24 months after ART initiation (McGuire etal, 2010). Rates of attrition were between 30% and 40% less among women receiving expert peer support. The number of women coming back into care after a period of defaulting was also higher in settings s throughout their life time.

In Malawi, the PMTCT Uptake and Retention (PURE) study showed that mothers living with HIV who received expert peer support were significantly more likely to be retained in care at 24 months post initiation of ART. This was true regardless if the support was provided at facilities or in the community (approximately 80%, 83% vs. 66%). The positive effect of peer support was primarily seen in the period between 12 and 24 months after ART initiation (McGuire etal, 2010). Rates of attrition were between 30% and 40% less among women receiving expert peer support. The number of women coming back into care after a period of defaulting was also higher in settings where there was community based expert peer support compared with either standard of care or facility based expert peer support (McGuire et al 2010). This study however supported the positive effect of peer support in retaining in care and uptake of health services by mothers living positively.

Staff Attitude
In one study conducted in the United States to determine if there was a correlation between adult HIV positive patients, satisfaction with their physicians, and ART adherence. Results showed a seeming association between the perceived relationship and levels of adherence- good patient provider relationships strengthened adherence and poor relationships hurt adherence (Robert W et al 2013)). In a study in Nigeria found that a significant number of health professionals showed discriminatory attitudes and engaged in unethical behaviour towards patients with HIV and AIDS, such attitudes serve as a barrier for delivery of health services to HIV positive (Reis et al, 2005).

Campell et al (2011) alluded to the act that patients not properly adhering to their medicines are labelled as good patients hence listened to when compared to defaulters. They again reinforced the point that this will rather keep defaulters outside of the facility rather than inviting them in. Campell et al 20111 also highlighted that the facility based ART SERVICE PROVISION exposed PLHIV to more stigma rather than reducing it.

Decentralized Community ART Centred Initiatives
For purposes of this research, ART decentralized is defined as provision of care and treatment not only at a primarily care facility but also at community level either through village health workers or other cadres. Despite the introduction of ART and its rapid scale up in each country, staffing levels were not increased to cater for these new and specialised services. Nkatha et al, 2016 a 2010 study of 17 countries showed that a third of patients on ARVs dropped out of treatment within two to three years. Patients accessing care through community models, however have better treatment adherence than those who choose to stay in conventional care. In Khayelista, South Africa, for example, 97% of patients in adherence clubs remained in treatment after 40 months, compared to 85% of their peers. Among stable patients on ARVs, over 90% of patients in the Tete Province of Mozambique were still taking their medication after four years in CAGs. In the DRC, after two years, 91% of PODI members were still undergoing treatment.

A number of different approaches have decentralised care to the community or to the home. These models minimise the number of required clinic visits by utilising community health workers or peers to deliver care or treatment either at home or at community meeting point. The spacing of appointments as well as the use of lay workers to dispense drugs means that already overworked nurses can dedicate their time to other things. With the CAGs there is a 59% reduction in ARV refill visits and a 43% reduction in overall clinic visits (data from 2013). This equates to a large reduction in health staff workload (MSF 2017). The community health workers ranged in education and training, and the qualifications and pay for community health care workers varied throughout the models. Overburdened health systems, lack of patient focused services, resource limitations and mixed quality of care have led to efforts to modify the delivery of HIV care in a framework that addresses the causes of poor retention. Task shifting is one of most common approaches.

A number of studies evaluated the impact of a decentralised, facility based model in which stable individuals were down referred from HIV clinic (where care was generally provided by a doctor or clinical officer) to a primary care health centre (where the care was generally provided by a nurse). Among the 39 000 individuals included in a meta-analysis of this approach, loss to follow up per 100 patient years 7.4 (95% CI 6.0-9.3) in the primary care centre group compared to 13.4 in the HIV clinic group and mortality per 100 patient years was 2.8 (95% CI 1.1-7.3) in the primary care centre group compared to 8.4 in the HIV clinic group.

In the Western Cape of South Africa, MSF, driven by the need to provide better patient centred care and to decongest over crowded HIV clinics, developed a model in which care, including ART drugs refills, is provided either at the clinic or in community venues in a group setting. These groups, referred to as ART adherence clubs, are facilitated by a community healthcare worker. Forty month retention in the clubs in Khayelista is 97% (club) vs 83% (clinic) with a 67% reduction in virological rebound among those in clubs compared to clinics. This model has been adopted by Metro District Health Services from initial MSF project in Khayelista to include 27 800 people (1/4 of total individuals in care by end of June 2014) in the Cape Town Metropolitan region. A model that is effective in urban South Africa, where resources and infrastructure are generally better, may not be reproducible with similar results in more resource limited Tsondai et al 2017. Assessed outcomes of clients in healthcare worker managed adherence clubs in the Western Cape of South Africa, with a random sample of 10% of clients from non-research supported sites with high rates of retention and viral suppression, this evidence confirms that good outcomes among patients differentiated into a healthcare worker managed groups are not limited to pilot projects.

In Mozambique, MSF has collaborated with the Health Ministry to implement and scale Community ART Groups (CAGs) throughout the country CAGs are group of six individuals from which one rotating person in the group acts as the monthly ART collector for all members. Thus, each CAG member visits the clinic every 6 months. Eligible people must be stable on ART for >6 moths and a CD4 count >200. Retention at 12, 24, 36 and 48 months, respectively has been 97.7%, 96%, 93.3% and 91.8%, and a mortality has been 2.1 per 100 people’s years.

Typically, majority of studies reported viral load suppression of people in adherence clubs and programs (programmes (Sarna et al…2008; Taiwo et al…2010, Van loggerenberg et al.. 2014), retention to care (Visnergarwala et al..,2006), high adherence levels (Williams et al..,2006, Pearson et al.., 2007, Sarna etal.., 2008) and increased CD4 counts (Coetzee et al..,2004; Kabore et al.., 2010). These studies demonstrate that behavioural and cognitive learning processes are vital in achieving the desired AT health outcomes. Chenneling specific interventions has proved vital in maintaining optimal levels of adherence (Tuldra et al., 2000; Amico et al., 2005)
This home based HIV care strategy is as effective as is a clinic based strategy, and therefore could enable improved and equitable access to HIV treatment, especially in areas with poor infrastructure and access to clinic care (Jaffar et al).

Sometimes accessing ART might be affected by long existing patriachical systems. Hegemonic notions of masculinity can interfere with women’s adherence to ART. It is important that those concerned with promoting effective treatment services recognise the gender and household dynamics that may prevent some women from successfully adhering to ART, and explore ways to work with both women and men to identify couple based strategies to increase adherence to ART (Skovdal et al) men are generally less likely to join groups where AIDS is discussed.

Community delivered ART requires simple and robust data collection. Unique identifiers, referral tools and data management systems are needed. However, an extensive literature review has demonstrated that to date little systematic scientific research has been performed on the contributory contributory role of these community support and expert patient structures in HIV and AIDS treatment programmes and the health systems at large in resource limited countries (Wouters et al 2009).

Comparable to other country findings, high rates of lost to follow up (LTFU) occur among pre-ART clients in Uganda (Muhamadi et al, 2010, Lubega et al, 2010, Scheibe et al, 2012). Lack of incentives for PLHIV and health care workers, long waiting times at health clinics, and inadequate counselling were associated with late ART initiation (Muhamadi et al 2010) and a high dropout rate of pre ART CARE (Lubega et al 2010). Additionally, high attrition rates in pre ART care in Eastern Uganda were also related to competition with traditional healers, transport costs and gender inequality, however quality counselling was motivation to return to care (Lubega et al 2010, Muhamadi et al., 2011). This study also shows equivalent challenges faced by most people living with HIV in Zimbabwe.

Observational research in Zambia has shown that 2 and 3 monthly visit intervals were associated with decreased loss to follow up (LTFU) and decreased visit lateness compared to patients who attended monthly (Lubega et al.,2010). A recent systematic review found that reduced frequency of clinic visits and medication pick up for ART patients might lead to improvements in program retention and patient outcomes (Tsondai et al., 2017).

Theoretical Framework
The successes of ART adherence programmes can also be explained by theories of human behaviours. Bandura (1991) noted that a theory of human behaviour explains how human and cognitive behaviour is acquired along with how individuals motivate and regulate their behaviour in everyday everyday life. Social modelling has the power to change human behaviour as it exhibit strong motivational effects (Bandura, 1991). The author suggests that good behaviour acts as social prompts that initiate, directs and aids modelled behaviour. In essence, the achievement of personal and programmatic goals I facilitated by interdependence efforts in which knowledge, skills and resources poling act in concert to shape personal wellbeing (Bandura, 1991).

One of the prominent critics of programme theory, Donaldson (2007) suggests that many health behaviour programmes are informed by a variety of multiple component interventions. These programmes are hypothesised to have multiple mediator and moderator variables. The recent model by Fisher et al…(2006) , the information motivation behavioural skills Model (IMB Model) in cooperated constructs from earlier models or theories such as the health belief model, theory of reasoned action and theory of planned behaviour to explain ART adherence. Fisher et al (2006) argues that optimal ART adherence is linked to (1) the extent to which an individual retains information, (2) the individual’s motivation to act on the information, and (30 the individual’s ability to adopt positive behavioural skills.

Firstly ART adherence related information comprises giving out the exact information on specific schedules, ART dosing and optimal adherence, and side effects associated with the regimen (Fisher et al., 2006). Secondly, an individual’s motivation to adhere to treatment may be influenced by attitudes towards adherence, beliefs about health outcomes and evaluations of these outcomes (Amico e tal., 2005). In essence, a highly motivated individual may be inclined to adhere to ART treatment and vice versa. Moreover, social motivation to adhere depends on one’s perceptions regarding ART adherence and social support are associated worth greater ART adherence. Lastly, behavioural skills are thought to be critical in ensuring ART adherence include observing and strictly following prescribed regimens ability to minimize and cope with adverse effects, integration of ART into social structures and maintaining optimal adherence.

However, Fisher et al (2006) acknowledge that information and motivation may have direct effects on adherence behaviour in situations where complicated or new behavioural skills do not affect adherence. Nevertheless, in complex and challenging ART schedules, the effect of information and motivation on adherence behaviour is mediated by adherence related behavioural skills (Fisher et al., 2006). Moreover, an individual’s characteristics and social context may moderate the cause effect relationship. The model also stresses that ART adherence is directly connected with health outcomes which are believed to influence one’s future ART adherence through a feedback loop (Fisher et al., 2006). Through the IBM model, Fisher et al (2006) demonstrated that health behaviour programmes targeted programmes targeted at promoting ART adherence are not modelled by a simple causal link. In addition, literature on factors affecting the implementation of ART programmes revealed that the implementation of ART programmes is moderated by a number of factors discussed earlier. Therefore, although it is logical that the CARG programme leads to improved ART health outcomes, to accept that the programmes is informed by a simple causal link might be contentious.

CHAPTER THREE: RESEARCH METHODOLODY
This section looks at the methods used for data collection, analysis and presentation. The study is explorative in nature. Research methodology is a way to systematically solve the research problem. It may be understood as a science of studying how research is done scientifically (Kohlari C.R 2004).

Quantitative Methods
Burns and Grove (200:19) describe a qualitative approach as ” a systematic subjective approach used to describe life experiences and situations to give them meaning”. Parahoo (1997:59) states that qualitative research focuses on the experiences of people as well as stressing uniqueness of the individual. Holloway and Wheeler (2002:30) refer to qualitative research as ”a form of social enquiry that focuses on the way people interpret and make sense of their experience and the world in which they live”. Researchers use the qualitative approach to explore the behaviour, perspectives, experiences and feelings of people and emphasize the understanding of these elements.

Advantage of qualitative methods in exploratory research is the use of open ended questions and probing gives participants the opportunity to respond in their own words, rather than forcing them to choose from fixed responses, as quantitative methods do (fhi360, 2002). Opened ended questions have the ability to evoke responses that are meaningful and culturally salient to the participant, unanticipated by the researcher, rich and explanatory in nature (FHI360, 2002).

Research Design
Burns and Grove (2003:195) define a research design as ”a blue print for conducting a study with maximum control over factors that may interfere with the validity of the findings”. Parahoo (1997:142) describes a research design as ” a plan that describes how, when and where data are to be collected and analysed”. Polit et al (2001:167) define a research design as ” the researcher’s overall for answering the research question or testing the research hypothesis”. The study uses both descriptive approach.

Descriptive Research Design
The descriptive design is suitable for bringing out the characteristics and functions of the CARGs. Descriptive studies do not make an attempt to analyse the links between exposure and effect, they are limited to the description of an occurrence under investigation (Beaglehole, Bonita ; Kjellestrom, 2006). This design describes the phenomenon under study based on available data or data collected from research participants.

Descriptive research may be a pre cursor to future research because it can be helpful in identifying variable that can be tested. A researcher will be looking at the health outcomes for the community members in Kwekwe district. The findings will point the researcher to specific variables that may be impacting health that warrant further study.

The data collection allows for gathering in-depth information that maybe qualitative (observations or case studies) in nature. This allows for a multifaceted approach to data collection and analysis.

Population and Sample
Sample Size
This refers to the number of items to be selected from the universe to constitute a sample. The size of sample should be neither excessively large, nor too small. It should be optimum. An optimum sample is one, which fulfils the requirements of efficiency, representativeness, reliability and flexibility (Holloway and Wheeler (2002:118). A sample of 50 respondents will be used for the purpose of this research. The respondents will be classified into two categories for purposes of this research, primary and secondary respondents. Primary respondents are those directly involved in the day to day activities of the CARGS and secondary respondents are those who have an oversight role and some are just ordinary members of the community not in CARGs.

Target Population
Total of 30 Primary respondents will be interviewed, these include active CARG members and they will be purposively selected from existing CARGs in the selected communities served by the three health facilities. These respondents will be able to provide insights on the role of CARGs, effect and areas of improvement. From the 30, twenty (20) respondents will be selected from three health facilities namely Sherwood clinic, Torwood clinic and Zhombe district hospital. Three (3) in depth interviews with health personnel (preferably sister in charge for the selected facilities will also be interviewed. Village Health Workers (5) will also be interviewed and 2 community leaders. All these beneficiaries will be responding to the needs of all the objectives of the study.

A total of 15 Secondary respondents will be interviewed: these are selected to tell the other side of the story by narrating how they view the CARG model. These secondary beneficiaries will be selected from the same areas where the CARGs has been functioning. Interviewing secondary beneficiaries will provide answers to the objective seeking understanding of the role of CARGs.

Three (3) key informant interviews will be interviewed from the following sectors one from FHI360, an NGO facilitating the formation of CARGs in Kwekwe, Ministry of Health official (district community nurse/sister) and District aids coordinator from National AIDS Council.

Sampling
The study will adopt probabilistic methods of sampling. Respondents will be purposively selected from selected CARG groups since it is a defined subset with same characteristics.

Non-Probability Sampling
Non probability sampling is that sampling procedure which does not afford any basis for estimating the probability that each item in the population has of being included in the sample (Kothari 2004). It involves the selection of elements based on assumptions regarding the population of interest, which forms the criteria for selection. Hence, because the selection of elements is non-random, non-probability sampling not allows the estimation of sampling errors…Battaglia, M.P (2008). This methods was selected because of its cost effectiveness and time effectiveness compared to probability sampling.

Purposive Sampling
This entails non probabilistic sample based on characteristics of a population. It uses a concept of Maximum Variation Sampling- is to look at a subject from all available angles, thereby achieving a greater understanding. Also known as ”Heterogeneous Sampling”, it involves selecting candidates across a broad spectrum relating to the topic of study. Battaglia, M.P (2008). Key informant respondents selection is guided by type and amount of information they have. One major advantage of this type of sampling is that it is easier to generalize about your sample compare to say, a random sample where not all participants have the characteristic you are studying
Data Collection Methods
Key informant- Interview- are ideal for collecting data on individuals’ personal histories, perspectives and experiences, particularly when sensitive topics are being explored (FHI360, 2002). Health professionals and non-governmental organisations staff will be targeted as key informants largely because of their comparative advantage in working with CARGs
In Depth Interviews
Data Presentation and Analysis
Qualitative data will be managed in the NVIVO 10 software. Thematic analysis will be done responding to the themes guided by the research objectives.

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