Facility-Level Intervention to Improve Attendance and Adherence among Patients on Anti-retroviral Treatment in Kenya: A Quasi-experimental Study Using Time Series Analysis

Journal Article
  • Patrick Boruett
  • Dorine Kagai
  • Susan Njogo
  • Peter Nguhiu
  • Christine Awuor
  • Lillian Gitau
  • John Chalker
  • Dennis Ross-Degnan
  • Rolf Wahlström
  • Göran Tomson
  • on behalf of INRUD–IAA
BMC Health Services Research
1 July 2013; 13:242. doi: 10.1186/1472-6963-13-242


Achieving high rates of adherence to antiretroviral therapy (ART) in resource-poor settings comprises serious, but different, challenges in both the first months of treatment and during the life-long maintenance phase. We measured the impact of a health system-oriented, facility-based intervention to improve clinic attendance and patient adherence.


This was a quasi-experimental, longitudinal, controlled intervention study using interrupted time series analysis. The intervention consisted of (1) using a clinic appointment diary to track patient attendance and monitor monthly performance; (2) changing the mode of asking for self-reported adherence; (3) training staff on adherence concepts, intervention methods, and use of monitoring data; (4) conducting visits to support facility teams with the implementation.

We conducted the study in 12 rural district hospitals (6 intervention, 6 control) in Kenya and randomly selected 1894 adult patients over 18 years of age in two cohorts: experienced patients on treatment for at least one year, and newly treated patients initiating ART during the study. Outcome measures were: attending the clinic on or before the date of a scheduled appointment, attending within 3 days of a scheduled appointment, reporting perfect adherence, and experiencing a gap in medication supply of more than 14 days.


Among experienced patients, the percentage attending the clinic on or before a scheduled appointment increased in both level and trend (increase per month) following the intervention, as did the level and trend of those keeping appointments within three days. The relative difference between the intervention and control groups based on the monthly difference in visit rates increased significantly in both level and trend following the intervention for experienced patients attending the clinic within three days of their scheduled appointments.

The decrease in the percentage of experienced patients with a medication gap greater than 14 days approached statistical significance (-11.3%; 95% CI = -22.7, 0.1), and the change seemed to persist over 11 months after the intervention. All facility staff used appointment-keeping data to calculate adherence and discussed outcomes regularly.


The appointment-tracking system and monthly performance monitoring was strengthened, and patient attendance was improved. Scale-up to national level may be considered.