Investigating the mechanisms behind behavioural strategies to improve medicines adherence

药物不遵守是影响近50%慢性病患者的重大卫生政策挑战，导致大量浪费和不理想的患者结果(世卫组织，2003年)。因此，对支持和促进遵从者行为的倡议和工具的需求很大，特别是对依赖定期长期用药制度维持或改善健康的个人而言。甚至有人提出，改进新的和当前的依从性干预措施的有效性的潜在影响可能比医疗方面的任何具体改进更大(Haynes等人，2002年)。增加严格按照处方坚持和正确地自我给药的人数需要长期、广泛的行为改变和习惯养成。因此，行为科学在为支持患者按处方服药而设计的现有和新的干预措施提供信息方面有很大的空间。人们广泛调查了低成本行为干预措施的有效性，以增加健康、预防和保护性的健康行为，并取得了不同程度的成功。如果一种干预能够有效地利用经济学和心理学对人类选择、决策和行为的研究、理论和见解，就可以被认为是“行为干预”。最近的证据表明，当新药首次发放时，签署服用新药承诺书的患者更有可能坚持自己的药物。然而，这一结果是以信息为条件的，强调了坚持的重要性，并伴随着承诺(Jachimowicz等人，2019年)。这些结果表明，从药学实践的角度来看，行为干预(或行为“推动”)可能是促进公共卫生倡议、加强药学实践和以最小成本或努力改善患者结果的有用的新工具。然而，更广泛和有效地使用这种方法的前景目前受到以下方面的限制：为什么一些轻推有效，另一些不起作用；为什么一个轻推在某些情况下可能有效而不在另一些情况下有效；或者轻推可能如何影响不同的患者群体。因此，为了利用基于轻推的工具的潜在力量来加强药学实践，需要进一步的工作来了解成功的轻推背后的工作机制。我的博士研究调查了成功的轻推背后的机制，以改善药物依从性。我们在60家Boots社区药店内进行了一项随机对照试验，以测试四种不同的行为推动策略，并与“一切照常”的控制组进行对比。我们的策略允许我们调查是否有可能复制和改进Jachimowicz等人(S，2019年)的结果，并取消潜在的机制，驱动患者行为的变化，以回应轻推。除了这个项目，我们还进行了一系列在线实验，以评估标准化的自我报告依从性问卷(由Thompson等人(2000年)开发的5项药物依从性评定量表)的可靠性，以准确评估行为干预对自我报告依从性的影响。在线实验允许我们检测某些行为策略是否促使受试者过度报告他们的依从性，并估计任何额外报告偏差的大小。

Medicines non-adherence is a major health policy challenge affecting almost 50% of patients with chronic disease, leading to massive wastage and sub-optimal patient outcomes (WHO, 2003). As such, there is significant demand for initiatives and tools to support and foster adherent behaviours, particularly for individuals dependent on regular long-term medication regimes to maintain or improve their health. It has even been suggested that the potential impact of improving the effectiveness of new and current adherence interventions, may be greater than any specific improvement in medical treatment (Haynes et al., 2002).Increasing the number of individuals who consistently and correctly self-administer medicines, exactly as prescribed, requires long-term, widespread behaviour change and habit formation. As a result, there is significant scope for the application of behavioural science to inform current and new interventions designed to support patients to take their medication as prescribed.The effectiveness of low-cost behavioural interventions to increase healthy preventative and protective health behaviours has been widely investigated to varying degrees of success. An intervention can be considered "behavioural" if it instrumentally utilises research, theory, and insights from economics and psychology on human choice, decision-making and behaviour. Recent evidence suggests that patients who sign a commitment to take a new medication, when the new medicine is first dispensed, are significantly more likely to be adherent to their medicines. However, this result was conditional on the message, highlighting the importance of adherence, that was paired with the commitment (Jachimowicz et al., 2019).These results suggest that behavioural interventions (or behavioural "nudges") may be a useful new tool for promoting public health initiatives, to enhance pharmacy practice and improve patient outcomes at minimal cost or effort from the perspective of pharmacy practice. However, the prospects for using such approaches more widely and effectively is currently limited by poor understanding of why some nudges work and others don't; why one nudge might work in some contexts and not others; or how nudges might impact different patient groups. Hence, in order to exploit the potential power of nudge-based tools to enhance pharmacy practice, further work is required to understand the mechanisms at work behind successful nudges. My PhD research investigates the mechanisms behind successful nudges to improve medicines adherence. We employ a randomised controlled trial within 60 Boots community pharmacies to test four different behavioural nudge strategies against a "business as usual" control group. Our strategy allows us to investigate whether it is possible to replicate and improve upon Jachimowicz et al.'s (2019) results, and unpick potential mechanisms driving changes in patient behaviour in response to the nudges. Alongside this project we have conducted a series of online experiments to evaluate the reliability of a standardised self-reported adherence questionnaire (the 5-item Medicines Adherence Rating Scale developed by Thompson et al. (2000)) to accurately evaluate the effect of a behavioural intervention on self-reported adherence. The online experiments allow us to detect whether certain behavioural strategies prompt subjects to over-report their adherence and estimate the size of any additional reporting bias.