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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. [ABSTRACT FROM AUTHOR]

The South African Middle Stone Age (MSA) has in recent years become increasingly important for our understanding of the emergence of ‘modern human behaviours’. Several key innovations appeared in this context for the first time, significantly pre-dating their re-invention in the European Upper Palaeolithic. One of these innovations was heat treatment of stone to improve its quality for the production of stone tools. Heat treatment may even be the oldest well-documented technique used to intentionally alter the properties of materials in general. It is commonly thought of as requiring the skilled use of fire, a high degree of planning depth and complex cognitive abilities. However, to work on these fundamental concepts we need to analyse the techniques and procedures used to heat-treat and we need to understand what they imply. In this paper, we present a direct and expedient comparison between the technical complexities of four alternative heat treatment procedures by coding the behaviours required for their set-up in so-called cognigrams, a relatively new method for understanding complexity based on the problem-solution distance. Our results show that although the techniques significantly differ in complexity, the techniques used in the MSA fall within the range of complexities known from other MSA techniques. Heat treatment in above-ground fires, as it was practised during this period in South Africa, was even one of the most complex techniques at the time of its invention. Early heat treatment can therefore be considered an important behavioural proxy that may shed light on the behaviour and socioeconomic structure of past groups. The implications of this are highlighted by the ongoing debate about ‘modernity’, ‘behavioural flexibility’ and ‘complex cognition’ of early anatomically modern humans in Africa. [ABSTRACT FROM AUTHOR]