Empowerment, motivation, and medical adherence (EMMA): the feasibility of a program for patient-centered consultations to support medication adherence and blood glucose control in adults with type 2 diabetes

Figures & data

Figure 1 “The why”, “the what”, and “the how” of the EMMA program. The overall theoretical framework describes why the EMMA program is important, the five-step empowerment model describes what steps the EMMA program consists of, and the selected techniques, models, and theories describe how the EMMA approach is operationalized into specific dialogue tools.

Abbreviation: EMMA, empowerment, motivation, and medical adherence.

Table 1 Flow of program content and tools across sessions

Name and theme	Purpose and description
Consultation 1
“My Day” Patient story about everyday life with diabetes	Purpose: To provide HCP with relevant and important information with regard to the everyday life of patients Tool: A sheet with a rough timeline of 24 hours framing “the patient” in the center with space for notes
“My Medication” Medication review	Purpose: • To identify and correct discrepancies between medication taken by patients and what is stated on their medication lists • To identify and rectify misunderstandings and errors with respect to taking medication • To assess whether the medication regimen could be optimized with regard to efficacy, adverse reactions, and convenience for individual patients • To clarify what patients know about their medication (eg, indications, mechanism, administration, and adverse reactions) Tool: A sheet with a rough timeline of 24 hours framing “the patient” in the center with space for notes
“My Use of Medication” How patients view medication adherence	Purpose: • To obtain patient-assessed levels of adherence and its importance • To talk about perspectives and attitudes on medication use Tool: A scale to mark level of medication use and the importance of taking medication
“My Challenges” Challenges patients’ experience	Purpose: To explore individual challenges and barriers in relation to living with T2DM and the treatment regimen Tool: 36 cards with pictures and quotations illustrating or expressing different challenges. A compiled list with all cards to mark patient’s selection
First consultation ends with summary and invitation to fill out the “postcard” tool as homework
Between 1 and 2
“Postcard” Challenges patients’ experience	Purpose: To encourage patients to reflect daily on their lives and the challenges of living with diabetes Tool: “Postcard” to write down reflections and experiences of living with diabetes
Consultation 2
“Follow-up” Summarize challenges and identify focus for further work	Purpose: • To follow-up on the first consultation, the “Postcard” tool, and resulting reflections • To summarize patient challenges and concerns • To identify focus for further work during consultations Tool: A sheet to summarize concerns and challenges and identify a selected challenge for further work
“Scrapbook” Worksheets to support knowledge exchange	Purpose: To promote relevant knowledge exchange in relation to T2DM through interactive learning exercises Tool: Fifteen worksheets with illustrations, questions, and scales addressing different themes: blood sugar control, symptoms of high and low blood sugar, treating type 2 diabetes, medication overview, insulin treatment, long-term complications of diabetes, and support from network. They support patients in understanding their disease, treatment, and situation and enable HCPs to tailor communication to individual patients’ needs
“Goal and Plan” Goal setting and action planning	Purpose: • To identify an attractive and realistic goal and plan action steps to reach it • To explore barriers, facilitators, and support in relation to achieving the goal Tool: Sheet to write down goal and action plan
“Importance and Confidence” Explore readiness in relation to goal setting and action planning	Purpose: To promote patient reflection on the importance of achieving the goal and their confidence in being able to do so. If patient considers the goal unimportant or unrealistic, then it is adjusted or changed. Tool: 0–10 scales indicating importance of reaching goal and confidence in ability to do so
Second consultation ends with summary and invitation to do homework of explaining to a relative what the patient has learned
Between 2 and 3
Phone call Follow-up	Purpose: To follow-up on progress toward goals and provide support and motivation and adjust goals as needed
Consultation 3
“Advantages and Disadvantages” Explore ambivalence and adjust goal and plan	Purpose: To explore goal-related ambivalence to provide support and enhance motivation by emphasizing advantages and/or identify need for adjustment Tool: Sheet to record advantages and disadvantages of present situation and advantages and disadvantages of reaching goal
Third consultation ends with adjustment of goal and plan, as needed, and summary

Abbreviations: HCP, health care professional; T2DM, type 2 diabetes mellitus.

Table 2 Key areas of focus for the feasibility study of the EMMA program related to acceptability, practicality, and implementation

Tools/exercises	Consultation process	Patient-centered outcomes
Active use of dialogue tools and exercises throughout consultations • Exercises performed as scheduled • Relevant worksheets completed	Patient-reported outcomes	Patient-reported
	• Patients feel understood • Patients feel listened to • Patients feel trusting relationship with the HCP • Patients feel that focus was on important issue(s) Patients experience that difficult issues were articulated • Patients feel encouraged to reflect more on having diabetes • Patients feel active and contributing during the sessions • Patients feel active in decision-making • Patients feel active in goal-setting process regarding the treatment	• Patients obtain clarity on situation and possibilities • Patients obtain valuable learning they can use in practice • Patients get relevant support in relation to living with diabetes • Patients get concrete ideas and suggestions • Patients obtain improved diabetes self-management capabilities • Patients follow the goal and plan
	HCP reported outcomes
	• HCPs feel at ease using the tools and exercises in conducting the consultations • HCPs feel supported in exploring challenges of the patients • HCPs feel supported in working with learning process of the patients • HCPs feel supported in goal-setting process with the patients
	10-second event coding
	• Patients talk as much as HCPs during the consultations

Abbreviations: EMMA, empowerment, motivation, and medical adherence; HCP, health care professional.

Table 3 Overview of dialogue tool use

Tool	% of patients with whom HCPs used tool	Outcomes
“My Day”	100%	–
“My Medication”	100%	45%, discrepancies between medications taken and prescribed 36%, dosage mistiming either unintended or due to outdated prescription
“My Use of Medication”	100%	50%, persistent non-adherence to a single medication or unintentional omission of dosages of different drugs
“My challenges”	100%	Average number of cards selected: 6 (range: 0–10) Most frequently selected challenges: 63%, not feeling ill 47%, anxiety about hypoglycemia 37%, concern about medication side effects 37%, concern about too many medications at once 37%, forgetfulness
“Postcard”/summarize challenges	100%, tool and follow-up challenges addressed 42%, completed postcards	Overall themes: Concerns about medication and disease management; concerns about long-term complications; emotional burden
Educational exercise(s)/“Scrapbook”	47%, one exercise 32%, ≥ two exercises 21%, zero exercises	–
“Goal and Plan”	100%	Primary goal: 68%, glycemic control 21%, weight loss
“Importance and Confidence”	74%	–
“Advantages and Disadvantages”	26%	–

Note: – Not possible to summarize outcomes.

Abbreviation: HCP, health care professional.

Figure 2 Patient ratings of experiences and importance of consultation parameters (N=17).

Figure 3 Patient assessment of EMMA intended outcomes (N=19).

Note: *N=17.
Abbreviation: EMMA, empowerment, motivation, and medical adherence.

Table 4 Average talk ratios

	Average HCP talk ratio, % (range) of total talk time	EMMA consultation compared with control, P-value
EMMA
Consultation 1	42 (14–60)	0.002
Consultation 2	53 (40–75)	0.722
Consultation 3	50 (28–76)	0.242
Total	48 (14–76)	0.059
Control consultations
Total	54 (29–72)

Note: Silent time is excluded.

Abbreviations: EMMA, empowerment, motivation, and medical adherence; HCP, health care professional.