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Bsc.gwu.edu

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 daily 910
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 levels 914
Staff use of percent exposure data with selected participant 915
Scheduled a meeting with behavior therapist on DPP staff 999 other (please specify):

Source: http://www.bsc.gwu.edu/dpp/f051.pdf

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