This form must be completed when medication adherence is assessed on the Standard (form F01) orMajor (form F02) Follow-up Visit Inventory. This form is also completed at the Month 1 Titration Visit with theInterim (form F03) Follow-up Visit Inventory. Complete this form only if the participant has taken any codedmetformin since the last visit. The Medication Adherence Interview is for all DPP participants taking codedmetformin, regardless of level of adherence. Complete the interview and F05 form, and then transferappropriate data to Section H (Coded Medication) of the corresponding Follow-up Visit Inventory.
Complete Part II of this form during the interview, keeping as close to the wording of the interview questions aspossible and as appropriate for the DPP participant. For items which require the Code Sheet, choose the codewhich you think best describes the response most important to the participant and list on line a. If the participantoffers additional responses, list as b and c. If code 99 is used, please specify response on the line under the item.
Initials of person reviewing completed form
PROMPT: For the most recent typical week, what is your estimate of the number of days when you took your metformin pills as prescribed?
Record results on the corresponding Follow-up Visit Inventory, section H.
1. How did you remember to take your DPP pills as prescribed since the
last visit? (see Code Sheet, 700 series) _______________________________________
2. How helpful was the plan we decided on at the last visit to help you take your DPP medications as prescribed?
Did not try that plan (i.e., not implemented)
3. Taking pills every day is hard for some people. What is your main
problem, if any, in trying to take your DPP pills as prescribed? (see Code Sheet, 800 series)
4. What plan or strategy do you think could be helpful to deal with this problem?
(see Code Sheet, 900 series) ________________________________________
5. Do you intend to follow this plan (from question # 4) until the next visit?
For DPP Staff Use Only 6. Do you consider the participant's estimation of medication adherence "for the most recent week" to be reliable?
Code Sheet for the Medication Adherence Interview (F05.1) Record the code most important to the participant (their primary response) on the “a”line. If participant offers additional response(s), record on lines “b” and “c.”1. How did you remember to take your DPP pills as described since the last visit? (700 series) (Do not read options) 700 701 keeping to a time “routine” (e.g., time of day; meal-time activity)702 keeping to a “strategy/routine” (e.g., medication in a convenient place, withinsight, or marking dates on blister packs)703 used calendar or log book to document pills taken 704 used pill-taking reminder devices (e.g., pillbox) 705 family/friends reminded me 706 DPP staff phone contact 707 stopped taking study medication since last visit 799 other (please specify): 3. What is your main problem, if any, in trying to take your DPP pills as prescribed? (800 series) (Do not read options) 800 no barriers reported 801 forgets to take DPP pills 802 reports doesn’t like to take pills 803 fear of taking DPP pills 804 adverse reaction to DPP pills (please specify) 805 inconvenient to take pills as prescribed (e.g., with meals) 806 difficult to swallow DPP pills 807 forgets to take evening (second dose) of metformin 808 specifically a GI reaction to DPP pills 809 sometimes takes too many DPP pills 810 outside influence to stop taking medication (e.g., MD, family, friends, media) 811 disruption of regular routine (e.g., vacation, significant life events) 812 hospitalization/new illness/medical reasons 813 study fatigue/lack of motivation 814 lost/misplaced pills 815 excessive alcohol usage 816 unwilling to take DPP pills as prescribed 899 other (please specify): 4. What plan or strategy do you think could be helpful to deal with this problem? (900 series) (May suggest options, as needed) 900 no barriers reported, not applicable 901 will continue current plan 902 new device (e.g., pill box) 903 new routine/strategy (e.g., take with other pills, mark dates on blisterpacks)904 remedy for adverse reactions to pills 905 change type and/or frequency of DPP staff communication (e.g., phonecalls, letters, e-mail)906 interim visits for adherence counseling 907 given tip sheet to address specific barriers 908 remedy for difficulty swallowing pills (please specify) 909 staff-prescribed deviation of taking a half tablet of metformin daily910 DPP staff- prescribed deviation from medication protocol during this quarter, other than a half tablet of metformin daily (please specify) 911 accept participant’s proposed level of adherence to DPP pills to promote retention 912 use new tool/strategy to assess barriers (i.e., record when and how oftenadverse events occur, monitor eating patterns)913 Reduce alcohol intake to acceptable levels914 Staff use of percent exposure data with selected participant915 Scheduled a meeting with behavior therapist on DPP staff999 other (please specify):
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