Table 2.
Representative patient and provider quotes for CCMDD themes related to overall CCMDD acceptability, intervention (CCMDD)-specific barriers to implementation, and external environmental factors
| Patient perspective | Provider/administrator perspective |
|---|---|
| Overall patient and provider enthusiasm for CCMDD | |
| “[NAME] stores close after six. So, it is easy to collect your treatment and continue with your work routine." (Patient, Clinic) | “…number one, it’s a dream of every [patient], especially the ones who are working that when they get to the clinic, they just take and go…Number two, it really decreases the workload from the facilities. As much as there are some challenges but we really do appreciate CCMDD because they just come and take. Number three…Most people default because they don’t want long queues. And then when you go to that person, the person would tell you in front of your face that they didn’t come because they don’t want those long queues, they are busy. …so I think it is sustainable.” (CCMDD Eligibility Screener, Clinic Pick-up Point) |
| Communication issues and errors | |
| Communication with the CCMDD program | |
| “… we are treated well at the pickup points but the problem is that I only received a [text] message once… I once raised it and they said it’s not a problem, even if I haven’t received it I must come and collect my pills. In fact the messages no longer come.” (Patient, Clinic Pick-up point) | “You get the patients who are like, ‘I've never got the [text] and then you get patients that say, ‘sometimes I receive [it], sometimes I don't… but I always tell them, whether you get a [text] or don't and you know it’s your date, come and check for your parcel… we only keep the parcel for 7 days, and after 7 days it goes back and you have to go back to your clinic.” (Pharmacy Assistant, External Pick-up Point) |
| “My problem is, I usually do not get all my pills. I find my box opened and with a sticker written 'incomplete parcel'. When I ask why it is opened this month, I do not get a straight answer because I do not see the same nurse all the time. When there are missing pills inside, they say I should not be taking those pills all the time. Then I get confused because the doctor from [clinic] said I should take these pills.” (Patient, Clinic Pick-up Point) | “Sometimes a person takes two different pills…I don't know what happens, you find that they get the fixed dose combination. So, they come back saying, ‘I got the single pill’. So, people know, they are educated about their pills. They come back to the clinic and say, ‘this is not mine.’” (Nurse, Clinic Pick-up Point) |
| N/A (no parallel patient quote about CCMDD distributor communication issues) | “We have a problem of not having a direct person that we contact if we have a problem with them. We only communicate with the consultants from the call centre, and there’s never a follow-up on the problem that you inquired about.” (Nurse, Clinic Pick-up Point) |
| Poor communication among providers | |
| N/A (no parallel patient quote about communication between clinic and pick-up point) | “We don't communicate with [the pick-up point] at all. If we have to relay a message, it's relayed through the patient. And if something [goes] wrong, it's with [the distributor]…It’s not one specific clinic where…you can communicate with them. There's like, I'd say, five, six clinics that we're dealing with or hospitals, now…If there was one, then yeah, maybe we'll phone and be like, 'Okay, this is the story.' So they know there's a relationship…but six different hospitals and clinics is like, that's chaos.” (Pharmacy Assistant, External Pick-up Point) |
| “What is worrying me about the CCMDD is that you sometimes get there and they say your parcel did not arrive. Now you must start again and go to the clinic while the work that I do, I only get off when it’s weekends only. I cannot go to the clinic in the middle of the week because I work in someone’s house, so they don’t allow me to go during the week because I take care of children.” (Patient, Clinic Pick-up Point) | “[The NGO tracking patients] will give you dates for when you should collect the treatment and write them down on the client’s card and when they reach the pick-up points, they are told that the dates are wrong. And you end up not knowing what is happening because they do turn patients away.” (Nurse, Clinic Pick-up Point) |
| Lack of patient education about CCMDD | |
| “…a lot of people are initiated on treatment without being educated about it… without any knowledge as to why they are being initiated.” (Patient, Clinic) | “The manager recently asked me to deliver educational talks about CCMDD every morning because we are seeing a rise in the number of people being deregistered on CCMMD because they did not understand CCMDD even from the beginning…” (Provider, Clinic Pick-up Point) |
| “The nurses… are harsh, they don’t have respect. Imagine a nurse that is the same age as your child speaking to you… you are wondering what you have done for them to speak to you that way. And then you end up making more mistakes because you are now confused what the problem is but instead of explaining to you, they shout at you. I’m not saying it’s all of them, but most of them.” (Patient, External Pick-up Point) | “There are those that are beyond control, you see that of patients who do not come on time… some of them I punish them on purpose, I say, ‘I am no longer taking you back even the next month because you did not honor your date…I told you that you must honor your date’…So there are ways you try to trick them as well using your own discretion.” (Nurse, Clinic Pick-up Point) |
| Rigid CCMDD policies | |
| “Collecting from here is okay because it is close by but if it happens that you forget to come and collect, you will find that [the medications] have been returned at the back. When you get to the back, even if you can come to the clinic in the morning, they put you aside and say, ‘oh, it’s this one who has defaulted, he/she will be served last’. So you will sit there until sunset while you see other people being served in front of you. It doesn’t matter how early you get there. It once happened to me. They said I had defaulted, even though I had just forgotten.” (Patient, External Pick-up Point) | “Some patients are not really loyal to the dates, they will come like a week or two after and they will tell you that ‘I was away.’ But then you have to take into consideration that the person has a life, they work … it's not easy for them to come on that particular date.” (Shop Assistant, External Pick-up Point) |
| “I am a person who works in a job that requires me to travel to far places on and off, you see. Maybe sometimes I will go and work in [another location], and I will be away for 6 months.” (Patient, Both External and Clinic Pick-up Points) | “Another challenge may sometimes be the people who are in the trucking business…you find that they would go for 3 months to other countries. So, it comes to a point where they should stop for a short while from CCMDD, because CCMDD does not cater for 3 months.” (Nurse, Clinic Pick-up Point) |
| N/A (no parallel patient quote about rejected prescriptions) | “Sometimes they don’t even tell you why [the prescription] is rejected…you have to find out yourself what did I do wrong and go through those scripts again.” (Nurse, Clinic Pick-up Point) |
| External environment | |
| HIV stigma | |
| “Nobody knows what pills you have come to collect. It’s just a parcel. It could be for blood pressure or anything. It’s only you who knows what you are collecting.” (Patient, Clinic Pick-up Point) | “I think there was a message that was circulated to make patients understand that it’s not just ARVs…It’s chronic medicine… so the stigma is no longer there” (Pharmacy Manager, External Pick-up Point) |
| “…if it’s a young person and [staff] are carrying such a big [clinic chart cover for patients in CCMDD], a person can see what this one has come to do…We don’t have blood pressure that we can be carrying such a big [clinic chart cover]…for some it’s obvious [that a young patient with chronic conditions is HIV-positive, rather than has another chronic condition like hypertension]. Once you say you are going to collect pills, they already know.” (Patient, Both External and Clinic Pick-up Points) | “Some of them don’t want us to give them this box. They are like, 'I’ll even buy a plastic if I have to.' I think there’s still a stigma. I think in terms of people still don’t understand that there is still so many chronic diseases and it’s just not confined to one thing.” (Pharmacy Manager, External Pick-up Point) |
| COVID-19 | |
| Even during the lockdown, they called me here at the clinic because we have to come collect the dates here, they called me and said they have revised my dates, I should continue collect up from [the external pick-up point]. I saw that way as easy. (Patient, Clinic) | We had an issue with the extended scripts… we got so excited and extended… It’s part of the contributing factor in defaulters because we will say they defaulted, yet they have received a communication at home that their scripts have been extended. So those we managed to get their files, we call them and tell them to just ignore the message and come to the facility. (CCMDD Administrator) |
| Ever since the lockdown started, I do not get the (text reminder) message. (Patient, Clinic) | “It is their date to come inside and you find that they do not come and then they get here late. When you ask why, they say they were waiting to receive a message with a password because normally during the dates in between, people get messages. Then even if it’s the date for them to come to the clinic, they do not come because they say they are waiting for an SMS.” (Nurse/CCMDD Eligibility Screener/Champion, Clinic Pick-up point) |
| N/A (no parallel patient quote for provider absence) | Covid started then we had an issue with the external pickup point…People were not available. I was one of them too, I was sick, I was in quarantine… That was our main challenge. (CCMDD Administrator) |
N/A indicates that no relevant patient excerpts were coded that parallel the provider quote in the same row, most likely because patients were not aware of all of the organizational barriers faced by providers