Research Impact


Helping keep patients on track with their medication

UCL’s Professor Robert Horne has helped tackle the common issue of patients not taking treatments as prescribed – informing both clinical guidelines and the design of new medical products.

The senior man asks the visiting homehealth nurse about the side effects of his perscription.

12 April 2022

Many health conditions require long-term treatment and management with medicines, but sticking to these regimes can be challenging for many patients. Not taking medicines as prescribed can have serious consequences for individuals (e.g. poorly managed chronic conditions such as diabetes or asthma, relapses and recurrences of disease) and for society (e.g. growing drug resistance, poor infection control, high cost to health systems).  

There are many reasons for this, but they can be grouped under two categories ‘can’t’ or ‘don’t want to’. Sometimes people want to follow the advice but can’t. They may have difficulties with the practicalities of following treatment advice; they may not understand what is required, they have difficulty sticking to a routine or struggle with other aspects such as cost. But, often, people decide to depart from the advice or stop following it. To understand this ‘don’t want to’ aspect of adherence, it is necessary to understand how the patient perceives the illness and treatment.  

World leaders in behavioural medicine  

Professor Horne’s research has focussed on understanding patients’ perspectives of illness and treatment and how adherence decisions are made. It shows that completing or adhering to a treatment plan often asks patients to balance their desire to improve their outcomes with the negative consequences of doing so, including social stigma, lifestyle restrictions and real or perceived harmful side effects.  

Professor Horne’s group at UCL is a world leader in behavioural medicine, particularly in creating reliable ways of capturing patients’ beliefs about medicines and illness and using these insights to design better treatment approaches. He has led the development of the Necessity Concerns Framework (NCF), a framework that can be used to create treatment interventions for any disease which take account of patient beliefs and behaviours to support informed treatment choices and help patients get the best from essential medicines. 

Informing clinical guidelines  

Professor Horne’s research and the NCF have informed his co-authorship of the National Institute for Clinical Excellence guidelines for the NHS on treatment adherence (most recently renewed in 2019) and of the 2015 British HIV Association Treatment Guidelines. Professor Horne was the first to map patients’ beliefs influencing starting and continuing with Anti-Retroviral Therapy for the treatment of HIV. This work led to a successful application to NIHR in 2011 to fund the development of an intervention to improve antiretroviral therapy (ART) adherence and the associated 6-year programme of research. More recently, his research has looked at the influence of digital technologies on treatment adherence and the implications for designing more effective adherence strategies, for example in treating TB and cancer. 

Advising the pharma industry 

The NCF has also provided a framework for Professor Horne’s advice to the pharmaceutical industry and the NHS when designing adherence-optimising products and services. For example, following his research on asthma medication adherence, the Global Initiative for Asthma (GINA) no longer recommends treatment of asthma with short-acting beta2 agonist (SABA) canisters alone for safety reasons, due to high use of such canisters being associated with severe reactions and death. Professor Horne also advised AstraZeneca on the design of their digital medication platform. In an industry where fewer than 1% of adherence interventions are successful, over 80% of AstraZeneca’s initiatives have seen double-digit increases in adherence to medication and self-management after implementing Professor Horne’s behavioural science research.  

Clinical and commercial success  

A successful consultancy spin-out company, Spoonful of Sugar, has translated Professor Horne’s research into several medical products and tools. Professor Horne’s work on asthma medication led to the co-development of an AstraZeneca app and ‘smart’ inhaler, Turbu+, which tracks medication use and provides automated adherence support to patients, and to the development of a simple self-administered test to identify over-reliance on SABA products which is featured on the AstraZeneca website. Spoonful of Sugar now employs the equivalent of ten full time staff and has an annual turnover of over £1 million. 

Research synopsis

New medical products and guidelines improve patient treatment adherence 

Professor Robert Horne has led the development of the Necessity Concerns Framework, used to support patient engagement with essential medicines. Horne’s work informed the National Institute for Clinical Excellence guidelines on involving patients in decisions about prescribed medicines and supporting adhernece and the co-authorship of the 2015 British HIV Association Treatment Guidelines. Based on the framework, Horne has advised the pharmaceutical industry on the development of adherence-enhancing products such as the Astra Zeneca Turbu+TM smart asthma inhaler, as well as developing tools to improve patient care