Understanding a constellation of eight COVID-19 disease prevention behaviours using the COM-B model and the theoretical domains framework: a qualitative study using the behaviour change wheel.

Background: The use of behavioural science and behaviour change within local authorities and public health has supported healthful change; as evidenced by its importance and contribution to reducing harm during the COVID-19 pandemic. It can provide valuable information to enable the creation of evidence-based intervention strategies, co-created with the people they are aimed at, in an effective and efficient manner. Aim: This study aimed to use the COM-B model to understand the Capability, Opportunity and Motivation of performing a constellation of eight COVID-19 disease prevention behaviours related to the slogans of 'Hands, Face, Space, Fresh Air'; 'Find, Isolate, Test, (FIT), and Vaccinate' in those employed in workplaces identified as high risk for transmission of the SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) to support intervention development. Methods: This qualitative study recruited twenty-three participants (16 female, 7 male), who were interviewed from three environments (schools, care homes, warehouses) across three local authorities. Semi-structured interviews were analysed using thematic analysis. Findings: Ten core themes were identified inductively; (1) knowledge and skills, (2) regulating the behaviour, (3) willingness to act, (4) necessity and concerns, (5) emotional impact, (6) conducive environment, (7) societal influence, (8) no longer united against COVID-19, (9) credible leadership, and (10) inconsistent adherence to COVID-19 prevention behaviours. Themes were then deductively mapped to the COM-B model of behaviour change and the theoretical domains framework and a logic model using the behaviour change wheel (BCW) was produced to inform intervention design. Conclusion: This study offers a novel approach to analysis that has included eight behaviours within a single thematic analysis and COM-B diagnosis. This will enable local authorities to direct limited resources to overarching priorities. Of key importance, was the need for supportive and credible leadership, alongside developing interventions collaboratively with the target audience. COVID-19 has had an emotional toll on those interviewed, however, promoting the value of disease prevention behaviours, over and above their costs, can facilitate behaviour. Developing knowledge and skills, through education, training, marketing and modelling can further facilitate behaviour. This supports guidance produced by the British Psychological Society COVID-19 behavioural science and disease prevention taskforce.

Developing habit-based health behaviour change interventions: twenty-one questions to guide future research.

OBJECTIVE: Habitual behaviours are triggered automatically, with little conscious forethought. Theory suggests that making healthy behaviours habitual, and breaking the habits that underpin many ingrained unhealthy behaviours, promotes long-term behaviour change. This has prompted interest in incorporating habit formation and disruption strategies into behaviour change interventions. Yet, notable research gaps limit understanding of how to harness habit to change real-world behaviours. METHODS: Discussions among health psychology researchers and practitioners, at the 2019 European Health Psychology Society 'Synergy Expert Meeting', generated pertinent questions to guide further research into habit and health behaviour. RESULTS: In line with the four topics discussed at the meeting, 21 questions were identified, concerning: how habit manifests in health behaviour (3 questions); how to form healthy habits (5 questions); how to break unhealthy habits (4 questions); and how to develop and evaluate habit-based behaviour change interventions (9 questions). CONCLUSIONS: While our questions transcend research contexts, accumulating knowledge across studies of specific health behaviours, settings, and populations will build a broader understanding of habit change principles and how they may be embedded into interventions. We encourage researchers and practitioners to prioritise these questions, to further theory and evidence around how to create long-lasting health behaviour change.

Modelling Successful Self-Management in Adults With Cystic Fibrosis: Vicarious Self-Efficacy From Videos of 'People Like Me'.

Background Self-efficacy is an important determinant of treatment adherence, and peer modelling of success can provide vicarious self-efficacy. A series of patient stories ('talking heads' videos) were developed with people with cystic fibrosis (CF) as part of the CFHealthHub multi-component adherence intervention, aiming to demonstrate success with daily therapy in 'people like me'. Methodology One-to-one semi-structured interviews exploring patients' experiences, barriers and facilitators of nebuliser adherence were audio and video-recorded between October 2015 and August 2016. Interview transcripts were reviewed to identify descriptions of problem-solving and sustained treatment success. Positive stories potentially providing vicarious descriptions of success were selected as video clips. Results In total, 14 adults with CF were recruited from five UK CF centres. Each participant contributed a median of five (interquartile range: 3-6) video clips, and a total of 57 unique clips were uploaded onto the CFHealthHub digital platform. Nine of those clips spanned two categories, hence, there were 66 clips across 16 categories. Conclusions The videos were well received though some adults were concerned that comparisons with peers might create anxiety by highlighting the possibility of future decline or current relative underperformance. It is important to sensitively support choice when providing resources aiming to increase vicarious self-efficacy. Our experience may guide the development of similar videos for people with other long-term conditions.

Interventions to promote physical distancing behaviour during infectious disease pandemics or epidemics: A systematic review.

OBJECTIVES: Physical distancing, defined as keeping 1-2m apart when co-located, can prevent cases of droplet or aerosol transmitted infectious diseases such as SARS-CoV2. During the COVID-19 pandemic, distancing was a recommendation or a requirement in many countries. This systematic review aimed to determine which interventions and behavior change techniques (BCTs) are effective in promoting adherence to distancing and through which potential mechanisms of action (MOAs). METHODS: Six databases were searched. The review included studies that were (a) conducted on humans, (b) reported physical distancing interventions, (c) included any comparator (e.g., pre-intervention versus post-intervention; randomized controlled trial), and (d) reported actual distancing or predictors of distancing behavior. Risk of bias was assessed using the Mixed Methods Appraisal Tool. BCTs and potential MoAs were identified in each intervention. RESULTS: Six articles (with seven studies and 19 comparisons) indicated that distancing interventions could successfully change MoAs and behavior. Successful BCTs (MoAs) included feedback on behavior (e.g., motivation); information about health consequences, salience of health consequences (e.g., beliefs about consequences), demonstration (e.g., beliefs about capabilities), and restructuring the physical environment (e.g., environmental context and resources). The most promising interventions were proximity buzzers, directional systems, and posters with loss-framed messages that demonstrated the behaviors. CONCLUSIONS: The evidence indicates several BCTs and potential MoAs that should be targeted in interventions and highlights gaps that should be the focus of future research.

Adherence to behaviours associated with the test, trace, and isolate system: an analysis using the theoretical domains framework.

BACKGROUND: The UK's test, trace, and isolate system are key measures to reduce the impact and spread of COVID-19. However, engagement with and adherence to guidance on testing, self-isolation, and providing details of contacts can be low and interventions are needed. This qualitative study aimed to identify the key factors affecting adherence to test, trace, and isolate behaviours using the Theoretical Domains Framework (TDF). METHODS: We conducted six online focus groups between October 2020 and February 2021 with people living in Sheffield who came into close contact with others in work or social settings (N = 30). The focus groups explored capability, opportunity, and motivational barriers to adherence to test, trace, and isolate behaviours. Framework analysis was used to code the data into TDF domains. RESULTS: There is a complex relationship between the factors affecting COVID-19 symptom identification, testing, and self-isolation. People who perceived significant barriers to testing and self-isolation were less likely to interpret potential symptoms as COVID-19, and perceiving barriers to self-isolation reduced the likelihood of requesting a test. Concerns about the negative consequences of self-isolation for themselves and others were common and also influenced willingness to pass on details of contacts. There was a lack of trust in the Test and Trace system, with people wanting further evidence of being at risk of infection. CONCLUSIONS: Communications and interventions to increase adherence to test, trace, and isolate strategies need to consider the interplay of these behaviours and their influences and target them collectively. Efforts to promote testing should focus on the range of barriers to self-isolation, especially increasing financial and practical support, and include new messaging to promote symptom identification.

Implementing the use of objective medication adherence data in routine clinical practice via the digital CFHealthHub platform: situation analysis and strategy development using the theoretical domains framework.

BACKGROUND: Preventative inhaled treatments preserve lung function and reduce exacerbations in cystic fibrosis (CF). Self-reported adherence to these treatments is over-estimated. An online platform (CFHealthHub) has been developed with patients and clinicians to display real-time objective adherence data from dose-counting nebulisers, so that clinical teams can offer informed treatment support. METHODS: In this paper, we identify pre-implementation barriers to healthcare practitioners performing two key behaviours: accessing objective adherence data through the website CFHealthHub and discussing medication adherence with patients. We aimed to understand barriers during the pre-implementation phase, so that appropriate strategy could be developed for the scale up of implementing objective adherence data in 19 CF centres. Thirteen semi-structured interviews were conducted with healthcare practitioners working in three UK CF centres. Qualitative data were coded using the theoretical domains framework (TDF), which describes 14 validated domains to implementation behaviour change. RESULTS: Analysis indicated that an implementation strategy should address all 14 domains of the TDF to successfully support implementation. Participants did not report routines or habits for using objective adherence data in clinical care. Examples of salient barriers included skills, beliefs in consequences, and social influence and professional roles. The results also affirmed a requirement to address organisational barriers. Relevant behaviour change techniques were selected to develop implementation strategy modules using the behaviour change wheel approach to intervention development. CONCLUSIONS: This paper demonstrates the value of applying the TDF at pre-implementation, to understand context and to support the development of a situationally relevant implementation strategy.

Self-management intervention to reduce pulmonary exacerbations by supporting treatment adherence in adults with cystic fibrosis: a randomised controlled trial.

INTRODUCTION: Recurrent pulmonary exacerbations lead to progressive lung damage in cystic fibrosis (CF). Inhaled medications (mucoactive agents and antibiotics) help prevent exacerbations, but objectively measured adherence is low. We investigated whether a multi-component (complex) self-management intervention to support adherence would reduce exacerbation rates over 12 months. METHODS: Between October 2017 and May 2018, adults with CF (aged ≥16 years; 19 UK centres) were randomised to the intervention (data-logging nebulisers, a digital platform and behavioural change sessions with trained clinical interventionists) or usual care (data-logging nebulisers). Outcomes included pulmonary exacerbations (primary outcome), objectively measured adherence, body mass index (BMI), lung function (FEV1) and Cystic Fibrosis Questionnaire-Revised (CFQ-R). Analyses were by intent to treat over 12 months. RESULTS: Among intervention (n=304) and usual care (n=303) participants (51% female, median age 31 years), 88% completed 12-month follow-up. Mean exacerbation rate was 1.63/year with intervention and 1.77/year with usual care (adjusted ratio 0.96; 95% CI 0.83 to 1.12; p=0.64). Adjusted mean differences (95% CI) were in favour of the intervention versus usual care for objectively measured adherence (9.5% (8.6% to 10.4%)) and BMI (0.3 (0.1 to 0.6) kg/m2), with no difference for %FEV1 (1.4 (-0.2 to 3.0)). Seven CFQ-R subscales showed no between-group difference, but treatment burden reduced for the intervention (3.9 (1.2 to 6.7) points). No intervention-related serious adverse events occurred. CONCLUSIONS: While pulmonary exacerbations and FEV1 did not show statistically significant differences, the intervention achieved higher objectively measured adherence versus usual care. The adherence difference might be inadequate to influence exacerbations, though higher BMI and lower perceived CF treatment burden were observed.

What influences people's responses to public health messages for managing risks and preventing infectious diseases? A rapid systematic review of the evidence and recommendations.

BACKGROUND: Individual behaviour changes, such as hand hygiene and physical distancing, are required on a population scale to reduce transmission of infectious diseases such as COVID-19. However, little is known about effective methods of communicating risk reducing information, and how populations might respond. OBJECTIVE: To synthesise evidence relating to what (1) characterises effective public health messages for managing risk and preventing infectious disease and (2) influences people's responses to messages. DESIGN: A rapid systematic review was conducted. Protocol is published on Prospero CRD42020188704. DATA SOURCES: Electronic databases were searched: Ovid Medline, Ovid PsycINFO and Healthevidence.org, and grey literature (PsyarXiv, OSF Preprints) up to May 2020. STUDY SELECTION: All study designs that (1) evaluated public health messaging interventions targeted at adults and (2) concerned a communicable disease spread via primary route of transmission of respiratory and/or touch were included. Outcomes included preventative behaviours, perceptions/awareness and intentions. Non-English language papers were excluded. SYNTHESIS: Due to high heterogeneity studies were synthesised narratively focusing on determinants of intentions in the absence of measured adherence/preventative behaviours. Themes were developed independently by two researchers and discussed within team to reach consensus. Recommendations were translated from narrative synthesis to provide evidence-based methods in providing effective messaging. RESULTS: Sixty-eight eligible papers were identified. Characteristics of effective messaging include delivery by credible sources, community engagement, increasing awareness/knowledge, mapping to stage of epidemic/pandemic. To influence intent effectively, public health messages need to be acceptable, increase understanding/perceptions of health threat and perceived susceptibility. DISCUSSION: There are four key recommendations: (1) engage communities in development of messaging, (2) address uncertainty immediately and with transparency, (3) focus on unifying messages from sources and (4) frame messages aimed at increasing understanding, social responsibility and personal control. Embedding principles of behavioural science into public health messaging is an important step towards more effective health-risk communication during epidemics/pandemics.

Template for Rapid Iterative Consensus of Experts (TRICE).

BACKGROUND: Public health emergencies require rapid responses from experts. Differing viewpoints are common in science, however, "mixed messaging" of varied perspectives can undermine credibility of experts; reduce trust in guidance; and act as a barrier to changing public health behaviours. Collation of a unified voice for effective knowledge creation and translation can be challenging. This work aimed to create a method for rapid psychologically-informed expert guidance during the COVID-19 response. METHOD: TRICE (Template for Rapid Iterative Consensus of Experts) brings structure, peer-review and consensus to the rapid generation of expert advice. It was developed and trialled with 15 core members of the British Psychological Society COVID-19 Behavioural Science and Disease Prevention Taskforce. RESULTS: Using TRICE; we have produced 18 peer-reviewed COVID-19 guidance documents; based on rapid systematic reviews; co-created by experts in behavioural science and public health; taking 4-156 days to produce; with approximately 18 experts and a median of 7 drafts per output. We provide worked-examples and key considerations; including a shared ethos and theoretical/methodological framework; in this case; the Behaviour Change Wheel and COM-B. CONCLUSION: TRICE extends existing consensus methodologies and has supported public health collaboration; co-creation of guidance and translation of behavioural science to practice through explicit processes in generating expert advice for public health emergencies.

Learning from previous lockdown measures and minimising harmful biopsychosocial consequences as they end: A systematic review.

BACKGROUND: Infectious outbreaks, most recently coronavirus disease 2019 (COVID-19), have required pervasive public health strategies, termed lockdown measures, including quarantine, social distancing, and closure of workplaces and educational establishments. Although evidence analysing immediate effects is expanding, repercussions following lockdown measures remain poorly understood. This systematic review aims to analyse biopsychosocial consequences after lockdown measures end according to short, medium, and long-term impacts. METHODS: PubMed, Ovid MEDLINE, Embase, PsycInfo, Web of Science, and Scopus databases were searched from inception to January 12, 2021. Reference lists were manually reviewed. Eligible studies analysed biopsychosocial functioning after lockdown measures secondary to recent infectious outbreaks ended. Lockdown measures were defined as quarantine, isolation, workplace or educational closures, social or physical distancing, and national or local closure of public institutions deemed non-essential. Studies exclusively researching outcomes during lockdown measures, examined infectious participants, or analysed lockdown measures not pertaining to an infectious outbreak were excluded. Two independent reviewers extracted data and assessed bias with a third resolving discrepancies. Data was extracted from published reports with further information requested from authors where necessary. The mixed methods appraisal tool assessed study quality, languages were restricted to English, German, Italian, and French and narrative synthesis was applied. RESULTS: Of 5149 identified studies, 40 were eligible for inclusion. Psychological distress, economic repercussions, social, biological, and behavioural ramifications were observed. Short to medium-term effects comprised reactions relating to early trauma processing whereas medium to long-term repercussions manifested in maladaptive behaviours and mental health deterioration. Increased alcohol intake, stigmatisation, and economic effects were also identified consequences. High-risk groups included health care workers, children, elderly, inpatients, those with pre-existing psychiatric diagnoses, and socially isolated individuals. CONCLUSIONS: Supporting vulnerable groups and offering education, workplace modifications, financial, and social assistance may mitigate negative repercussions. Establishing a rapid and comprehensive evidence base appraising the efficacy of such interventions and identifying areas for development is essential. This review was limited by study heterogeneity and lack of randomisation in available literature. Given the unprecedented nature and progression of COVID-19, the relevance of previous outcomes remains uncertain. PROTOCOL REGISTRATION: PROSPERO registration CRD42020181134.

The development of a theory and evidence-based intervention to aid implementation of exercise into the prostate cancer care pathway with a focus on healthcare professional behaviour, the STAMINA trial.

BACKGROUND: Twice-weekly supervised aerobic and resistance exercise for 12 weeks reduces fatigue and improves quality of life in men on Androgen Deprivation Therapy for prostate cancer. Despite the National Institute for Health and Care Excellence (NICE) proposing this as standard of care, it does not routinely take place in practice. Healthcare professionals are in a prime position to deliver and integrate these recommendations. A change in the behaviour of clinical teams is therefore required. In this paper, we describe the development of a training package for healthcare professionals using theory and evidence to promote delivery of such recommendations as standard care. METHODS: The intervention development process was guided by the Medical Research Council guidance for complex interventions and the Behaviour Change Wheel. Target behaviours were identified from the literature and thirty-five prostate cancer care healthcare professionals (including oncologists, consultant urologists, clinical nurse specialists, physiotherapists, general practitioners and commissioners) were interviewed to understand influences on these behaviours. The Theoretical Domains Framework was used to identify theoretical constructs for change. Behaviour change techniques were selected based on theory and evidence and were translated into intervention content. The intervention was refined with the input of stakeholders including healthcare professionals, patients, and exercise professionals in the form of rehearsal deliveries, focus groups and a workshop. RESULTS: Seven modifiable healthcare professional target behaviours were identified to support the delivery of the NICE recommendations including identifying eligible patients suitable for exercise, recommending exercise, providing information, exercise referral, providing support and interpret and feedback on progress. Ten domains from the Theoretical Domain's Framework were identified as necessary for change, including improving knowledge and skills, addressing beliefs about consequences, and targeting social influences. These were targeted through twenty-two behaviour change techniques delivered in a half-day, interactive training package. Based on initial feedback from stakeholders, the intervention was refined in preparation for evaluation. CONCLUSIONS: We designed an intervention based on theory, evidence, and stakeholder feedback to promote and support the delivery of NICE recommendations. Future work will aim to test this training package in a multi-centre randomised trial. If proven effective, the development and training package will provide a template for replication in other clinical populations, where exercise has proven efficacy but is insufficiently implemented.

Feasibility study for supporting medication adherence for adults with cystic fibrosis: mixed-methods process evaluation.

OBJECTIVES: To undertake a process evaluation of an adherence support intervention for people with cystic fibrosis (PWCF), to assess its feasibility and acceptability. SETTING: Two UK cystic fibrosis (CF) units. PARTICIPANTS: Fourteen adult PWCF; three professionals delivering adherence support ('interventionists'); five multi-disciplinary CF team members. INTERVENTIONS: Nebuliser with data recording and transfer capability, linked to a software platform, and strategies to support adherence to nebulised treatments facilitated by interventionists over 5 months (± 1 month). PRIMARY AND SECONDARY MEASURES: Feasibility and acceptability of the intervention, assessed through semistructured interviews, questionnaires, fidelity assessments and click analytics. RESULTS: Interventionists were complimentary about the intervention and training. Key barriers to intervention feasibility and acceptability were identified. Interventionists had difficulty finding clinic space and time in normal working hours to conduct review visits. As a result, fewer than expected intervention visits were conducted and interviews indicated this may explain low adherence in some intervention arm participants. Adherence levels appeared to be >100% for some patients, due to inaccurate prescription data, particularly in patients with complex treatment regimens. Flatlines in adherence data at the start of the study were linked to device connectivity problems. Content and delivery quality fidelity were 100% and 60%-92%, respectively, indicating that interventionists needed to focus more on intervention 'active ingredients' during sessions. CONCLUSIONS: The process evaluation led to 14 key changes to intervention procedures to overcome barriers to intervention success. With the identified changes, it is feasible and acceptable to support medication adherence with this intervention. TRIAL REGISTRATION NUMBER: ISRCTN13076797; Results.

Mechanisms of Action of a Web-Based Intervention With Health Professional Support to Increase Adherence to Nebulizer Treatments in Adults With Cystic Fibrosis: Qualitative Interview Study.

BACKGROUND: Adherence to nebulizer treatments in adults with cystic fibrosis (CF) is often low. A new complex intervention to help adults with CF increase their adherence to nebulizer treatments was tested in a pilot randomized controlled trial (RCT) in 2 UK CF centers. Patients used a nebulizer with electronic monitoring capabilities that transferred data automatically to a digital platform (CFHealthHub) to monitor adherence over time and to a tailored website to display graphs of adherence data and educational and problem-solving information about adherence. A trained interventionist helped patients identify ways to increase their adherence. OBJECTIVE: This study aims to explore the mechanisms of action underpinning the intervention. METHODS: A qualitative interview study was conducted concurrently with a pilot RCT. In total, 25 semistructured interviews were conducted with 3 interventionists at 2 time points, 14 patients in the intervention arm of the trial, and 5 members of the multidisciplinary teams offering wider care to patients. A framework approach was used for the analysis. RESULTS: The intervention was informed by a theoretical framework of behavior change. There was evidence of the expected behavior change mechanisms of action. There was also evidence of additional mechanisms of action associated with effective telehealth interventions for self-management support: relationships, visibility, and fit. Patients described how building a relationship with the interventionist through face-to-face visits with someone who cared about them and their progress helped them to consider ways of increasing adherence to medication. Rather than seeing the visibility of adherence data to clinicians as problematic, patients found this motivating, particularly if they received praise about progress made. The intervention was tailored to individuals, but there were challenges in how the intervention fitted into some patients' busy lives when delivered through a desktop computer. CONCLUSIONS: The mechanisms of action associated with effective telehealth interventions for self-management operated within this new intervention. The intervention was modified to strengthen mechanisms of action based on these findings, for example, delivery through an app accessed via mobile phones and then tested in an RCT in 19 UK CF centers. TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number 13076797; http://www.isrctn.com/ISRCTN13076797.

Healthy weight services in England before, during and after pregnancy: a mixed methods approach.

BACKGROUND: Maternal overweight and obesity are associated with numerous adverse outcomes including higher rates of maternal and infant mortality and morbidity. Overweight and obesity before, during and after pregnancy are therefore a significant public health priority in England. This project explored and mapped healthy weight service availability at different stages of the childbearing cycle. METHODS: A mixed methods approach included a questionnaire-based survey disseminated through Local Maternity Systems and semi-structured interviews or focus groups with providers and commissioners. Current maternal weight service provision was explored along with some of the barriers and facilitators for providing, delivering and accessing healthy weight services. Descriptive statistics were reported for quantitative data and content analysis was used for thematic reporting of qualitative data. RESULTS: A total of 88 participants responded to the survey. All services were offered most frequently during pregnancy; with healthy eating and/or weight management services offered more often than physical activity services. Few services were targeted specifically at women with a raised body mass index. There was a high degree of inconsistency of service provision in different geographical areas. Several themes were identified from qualitative data including "equity and variation in service provision", "need for rigorous evaluation", "facilitators" to encourage better access or more effective service provision, including prioritisation, a change in focus and co-design of services, "barriers" encountered including financial and time obstacles, poor communication and insufficiently clear strategic national guidance and "the need for additional support". CONCLUSIONS: There is a need to reduce geographical variation in services and the potential health inequalities that this may cause. Improving services for women with a raised body mass index as well as services which encourage physical activity require additional emphasis. There is a need for more robust evaluation of services to ensure they are fit for purpose. An urgent need for clear national guidance so that healthcare providers can more effectively assist mothers achieve a healthy weight gain was identified. Commissioners should consider implementing strategies to reduce the barriers of access identified such as childcare, transport, location and making services free at the point of use.

Investigating the Temporal Relationships between Symptoms and Nebuliser Adherence in People with Cystic Fibrosis: A Series of N-of-1 Observations.

Treatment adherence in adults with cystic fibrosis (CF) is poor. One of the reasons identified for lack of adherence to nebulised treatments is that patients may not experience any immediate relief in their symptoms or notice changes as a result of taking their treatment, thus many report that they do not perceive there to be consequences of non adherence. The aim of the study was to investigate the temporal relationships between symptoms and adherence to nebulised treatments in adults with CF using an N-of-1 observational design. Six participants were recruited for a six-week period during which time they completed a daily online respiratory symptom questionnaire. Adherence to treatment was measured throughout the duration of the study using an eTrack® nebuliser that logged date and time of treatments taken. Data generated from each participant was analysed separately. There were significant relationships between pain and adherence for three participants, tiredness and adherence for one participant and cough and adherence for one participant. For all of these findings, the symptom and adherence were experienced on the same day. Extending the monitoring period beyond six weeks may provide increased insight into the complex relationship between symptoms and adherence in CF.