How to investigate levels of Adherence to antiretroviral ... - INRUD

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4 CHAPTER 4 --- Survey design Sampling facilities Carrying out a survey of these indicators could be done in a single facility or in a sample of facilities. A survey to examine adherence in a large programme or system of care, such as the National AIDS Programme, should include a minimum of 20 health facilities. If a system of care includes fewer facilities, then all of them should be included in a survey to measure system performance. A survey in a single facility only reflects the performance in that facility so it cannot be used to represent the performance in the country (unless it is the only facility providing treatment). Facilities are best selected randomly within specific strata defined by key characteristics such as geographic location, facility type and facility management. The sample of facilities should be as randomly chosen as is feasible, taking into account the logistics of travel and the days the clinics are open. The retrospective sample of patients is 100, so that it is preferable to only choose facilities that had at least 100 patients on ARVs six months ago. However, if one wants to look at smaller facilities, this can be done but instead of sampling, all patients’ records should be looked at. The data to calculate each indicator should be collected at each facility. The sample sizes suggested are sufficient for a moderately reliable set of adherence measures at each facility (such as when monitoring performance over time) and a very reliable cross-sectional or longitudinal estimates of these measures in the system as a whole. Sampling retrospective patient records The purpose of this exercise is to give us all the adherence indicators except the self report of the exit interview. As such it is the single most important exercise of the survey. Retrospective data from attendance records and pharmacy records are useful because they allow computation of indicators related to success of short-term and long-term adherence, defaulting, and clinical outcomes. It is necessary to take a sample of 100 patients who attended the clinic during the month seven months before. To end up with information on 100 patients, it is advisable to sample 120 patients from the list of those who attended during that month as some records may be unavailable. 25
How to Investigate Adherence to Antiretroviral Treatment: An Indicator-Based Approach This means that if the data collection is taking place in June, you need the patients who attended in November the year before. This is because you need to follow the patient for six whole months and if the patient attended on the last day of November, then six months from then would be the last day of May. Depending on the month of data collection, the months to sample patient attendance from is documented in Table 6. Table 6. Attendance months to retrospectively sample and the month to look at for judging the attendance of the next appointment Survey data collection month Retrospective sample for those patients attending 7 months before, during the previous month of: For looking at attending next appointment start with visit 4 months before in the previous month of: January 2008 June 2007 September 2007 February 2008 July 2007 October 2007 March 2008 August 2007 November 2007 April 2008 September 2007 December 2007 May 2008 October 2007 January 2008 June 2008 November 2007 February 2008 July 2008 December 2007 March 2008 August 2008 January 2008 April 2008 September 2008 February 2008 May 2008 October 2008 March 2008 June 2008 November 2008 April 2008 July 2008 December 2008 May 2008 August 2008 Retrospective sampling methods If present, the pharmacy or clinic attendance register is the primary source of data for identifying patients in treatment who attended in the required month. Situation 1. Functioning attendance register and patient identification numbers If there is an attendance register that distinguishes between those on ART and those not on ART, and if a patient identification number is recorded there that can be used to find the relevant clinical and pharmacy records, the following method can be adopted. If there is a register in the pharmacy, then this is preferable as it will be the pharmacy records that are being examined. The sample of visits should be spread evenly across the month. Simple or systematic random sampling is acceptable. For example, if there were 300 patient attendances of patients on ART during that month and you want to choose 120, then to find the sampling interval you can divide 300 by 120 to get 2.5. Then randomly take the first or second patient on the list and alternately take every second and third patient. Take the Patient Selection 26
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