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Behavior and abilities are arguably the most fundamental concepts in life. Hence, these concepts and their causes and consequences, are studied in many disciplines, such as economics, psychology, sociology, and health sciences. The research of behaviors and abilities is quickly changing: data sets are rapidly growing in size, both in terms of observations and variables. The increase in the sample size of studies, repeated measurements and complex multi-level designs necessitates the use of modern - often more complex and flexible - statistical methods. This thesis employs modern statistical models in the field of fundamental economic behavior and medical sciences with the aim to generate more reliable inferences and more accurate predictions than would have been the case with established methods. In the present thesis I will give two examples. In the first part of the thesis, I develop the Censored Mixture Model (CMM) to analyze risk behavior and show two applications. In the second part, I compare two machine learning approaches with various simpler commonly used baseline approaches in their performance to predict cognitive ability using brain morphology.

Many older patients take multiple medicines each day. The patients, and sometimes their informal caregiver, have responsibility to manage the medication therapy as well as to reach the desired health outcomes. Healthcare professionals, such as home care nurses, also play a role in the medication therapy. This dissertation provides insight into the contribution of home care nurses to the pharmaceutical care of the patients. In this dissertation it was examined how older patients self-manage the use of their medication and how they experience support from home care nurses. Besides, potential problems such as the lack of information about changes in medication for home care nurses and the consequences for patients if problems result in administration errors have been described. Furthermore, collaboration between the healthcare professionals regarding the home care nurses’ activities for the support of pharmacists’ and general practitioners’ work in a clinical medication review and home care nurses’ competences were explored. This dissertation shows that older patients have problems with organizing their medication intake, do not adequately discuss medication use and problems with their caregiver. It also shows that storage and disposal of medication is not always done correctly. Patients indicate that home care nurses’ support helps them with the medication self-management. This dissertation also shows that home care nurses can contribute to collaboration with healthcare professionals by observing potential medication-related problems, patient preferences and medication efficacy, and providing patient information and education. Finally, 60 nursing competences for pharmaceutical care has been described in detail. Home care nurses have an essential contribution to pharmaceutical care, for example in a clinical medication review, but there is room for improvement. Collaboration between healthcare professionals would benefit from regular medication consultation, the more frequent use of modern tools for efficient communication such as smartphone apps. Also more attention to medication in the education programs of nurses and in lifelong training, preferably together with other healthcare professionals, would benefit the home care nurses.

Nienke E Dijkstra,1,2 Marcia Vervloet,3 Carolien G M Sino,1 Eibert R Heerdink,2,4 Marjorie Nelissen-Vrancken,5 Nienke Bleijenberg,1,6 Marijn de Bruin,7 Lisette Schoonhoven6,8 1Research Group Care for the Chronically Ill, University of Applied Sciences Utrecht, Utrecht, the Netherlands; 2Research Group Innovation in Pharmaceutical Care, University of Applied Sciences Utrecht, Utrecht, the Netherlands; 3Nivel, Netherlands Institute for Health Services Research, Utrecht, the Netherlands; 4Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands; 5Dutch Institute for Rational Use of Medicine, Utrecht, the Netherlands; 6Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; 7IQ Healthcare, Radboud University Medical Centre, Nijmegen, the Netherlands; 8School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southhampton, UKCorrespondence: Nienke E DijkstraResearch Group Proactive Care for Elderly People Living at Home, University of Applied Sciences Utrecht, Heidelberglaan 7, Utrecht, 3584 CS, the NetherlandsTel +31 641620681Email nienke.dijkstra@hu.nlPurpose: To describe nurses’ support interventions for medication adherence, and patients’ experiences and desired improvements with this care.Patients and Methods: A two-phase study was performed, including an analysis of questionnaire data and conducted interviews with members of the care panel of the Netherlands Patients Federation. The questionnaire assessed 14 types of interventions, satisfaction (score 0– 10) with received interventions, needs, experiences, and desired improvements in nurses’ support. Interviews further explored experiences and improvements. Data were analyzed using descriptive statistics and a thematic analysis approach.Results: Fifty-nine participants completed the questionnaire, and 14 of the 59 participants were interviewed. The satisfaction score for interventions was 7.9 (IQR 7– 9). The most common interventions were: “noticing when I don’t take medication as prescribed” (n = 35), “helping me to find solutions to overcome problems with using medications” (n = 32), “helping me with taking medication” (n = 32), and “explaining the importance of taking medication at the right moment” (n = 32). Fifteen participants missed ≥ 1 of the 14 interventions. Most mentioned the following: “regularly asking about potential problems with medication use” (33%), “regularly discussing whether using medication is going well” (29%), and “explaining the importance of taking medication at the right moment” (27%). Twenty-two participants experienced the following as positive: improved self-management of adequate medication taking, a professional patient–nurse relationship to discuss adherence problems, and nurses’ proactive attitude to arrange practical support for medication use. Thirteen patients experienced the following as negative: insufficient timing of home visits, rushed appearance of nurses, and insufficient expertise about side effects and taking medication. Suggested improvements included performing home visits on time, more time for providing support in medication use, and more expertise about side effects and administering medication.Conclusion: Overall, participants were satisfied, and few participants wanted more interventions. Nurses’ support improved participants’ self-management of medication taking and enabled patients to discuss their adherence problems. Adequately timed home visits, more time for support, and accurate medication-related knowledge are desired.Keywords: medication adherence, patient preference, home care, home care nurses, patient satisfaction, patient adherence

Veel thuiswonende ouderen hebben problemen met het gebruik, bewaren en afvoeren van hun medicatie. Ook praten ze hierover niet altijd met zorgverleners. Dit leidt tot onveilige situaties en het uitblijven van behandeleffecten, stelt onderzoeker Nienke Dijkstra. Zij pleit voor betere ondersteuning en samenwerking tussen zorgverleners, patiënt en mantelzorger.

Background: Home care patients often use many medications and are prone to drug-related problems (DRPs). For the management of problems related to drug use, home care could add to the multidisciplinary expertise of general practitioners (GPs) and pharmacists. The home care observation of medication-related problems by home care employees (HOME)-instrument is paper-based and assists home care workers in reporting potential DRPs. To facilitate the multiprofessional consultation, a digital report of DRPs from the HOME-instrument and digital monitoring and consulting of DRPs between home care and general practices and pharmacies is desired. Objective: The objective of this study was to develop an electronic HOME system (eHOME), a mobile version of the HOME-instrument that includes a monitoring and a consulting system for primary care. Methods: The development phase of the Medical Research Council (MRC) framework was followed in which an iterative human-centered design (HCD) approach was applied. The approach involved a Delphi round for the context of use and user requirements analysis of the digital HOME-instrument and the monitoring and consulting system followed by 2 series of pilots for testing the usability and redesign. Results: By using an iterative design approach and by involving home care workers, GPs, and pharmacists throughout the process as informants, design partners, and testers, important aspects that were crucial for system realization and user acceptance were revealed. Through the report webpage interface, which includes the adjusted content of the HOME-instrument and added home care practice–based problems, home care workers can digitally report observed DRPs. Furthermore, it was found that the monitoring and consulting webpage interfaces enable digital consultation between home care and general practices and pharmacies. The webpages were considered convenient, clear, easy, and usable. Conclusions: By employing an HCD approach, the eHOME-instrument was found to be an easy-to-use system. The systematic approach promises a valuable contribution for the future development of digital mobile systems of paper-based tools.

Home care patients often use many medications and are prone to drug-related problems (DRPs). For the management of problems related to drug use, home care could add to the multidisciplinary expertise of general practitioners (GPs) and pharmacists. The home care observation of medication-related problems by home care employees (HOME)-instrument is paper-based and assists home care workers in reporting potential DRPs. To facilitate the multiprofessional consultation, a digital report of DRPs from the HOME-instrument and digital monitoring and consulting of DRPs between home care and general practices and pharmacies is desired. The objective of this study was to develop an electronic HOME system (eHOME), a mobile version of the HOME-instrument that includes a monitoring and a consulting system for primary care.