EMMA: Empowerment Motivation and Medial Adherence

​Testing a new concept to motivate and empower patients to take control of their medication.

Gaining glycaemic control

Several patients with type 2 diabetes (T2D) experience poor glycaemic control with HbA1c higher than 8%. Studies have shown that low medical adherence contributes to suboptimal glycaemic control and poor clinical outcomes, and that improvement in glycaemic control can be achieved by improving adherence to medication.1,2,3

The Steno Diabetes Center (SDC) initiated the Empowerment, Motivation and Medical Adherence – or EMMA – pilot study in 2011 in order to investigate the feasibility of applying health education principles and methods in clinical consultations. The project targeted patients with T2D who demonstrate poor glycaemic control as well as poor medical adherence.

So far, the study has developed and pilot-tested a consultation intervention for such patients, with individualised, goal-oriented support based on methods of health education and empowerment.

Overall, EMMA aimed to investigate new ways of providing support to patients with T2D in poor glycaemic control, to improve medical self-management capabilities and to strengthen implementation of medical regimens.

The EMMA Concept

The concept consists of visual and tangible tools such as pictures, peer quotes, questions, illustrations and worksheets. The tools form basis for different exercises designed to explore challenges of the individual patients with regard to T2D and their medication regimen, perform medical review and facilitate interactive learning-, goal-setting- and action planning processes. The tools and exercises are hypothesised to enhance reflection, dialogue and participation and to promote informed patient decisions on handling their illness.

A cross-theoretical approach underlies the EMMA concept in which different theories, models and health education principles are incorporated and supplement each other. The overall flow of the consultation builds upon a ‘five-step empowerment model of goal-setting’4. The idea of using tools during consultations was inspired by health education principles5,6 and cultural probes methodology7.

The design of the individual tools and exercises applies elements from different models and theories such as the Health Belief Model8, WHO’s Five Dimensions of Adherence9, Trans Theoretical Model of Change10, Motivational Interviewing11 and Self-efficacy theory12.

The exact exercises and dialogue tools, their developmental background and the implementation process has been described previously.13

Measuring satisfaction and clinical end-points

The pilot study was a quasi-randomized, prospective open study design. Twenty-two patients with poor glycaemic control and medical adherence below 80%were enrolled in the project and each patient had three, individual consultations and a telephone consultation conducted by a medical doctor or a diabetes nurse.

All consultations were observed and audio recorded. Time records of physician/nurse talk and patient talk (measured every 10 seconds) were done to measure patient participation.
Two months after the last consultation, the patients were interviewed. Satisfaction with the consultations was assessed by parameters such as whether patients felt understood, did they feel a trusting relationship, did they find the focus of the consultations important, and did they participate actively in making decisions and setting goals?

The clinical end-points of the study were changes in HbA1c immediately following the intervention (baseline) and then six months later, and also changes medical possession rate (bought medicine / prescribed medicine).

Target group
The study targeted consultations with patients with type 2-diabetes, poor glycaemic control (higher than 8%) and medical adherence below 80% for at least one prescription drug.

Positive outcome

Nineteen patients finished the program. Most of them assessed the consultations very positively. During the consultations to a large or very large extent they felt understood and listened to, felt a trusting relationship to the physician/nurse and experienced relevant focus and active participation.

Also, most of the patients to a large or very large extent learned something new and valuable that they could use in their everyday life and felt better equipped to handle diabetes in the future. More than half of the patients said that they followed the plan and the goals that were agreed upon during the sessions.

Health care providers reported that the tools helped them to structure the consultations, to reflect on their practice, to identify patients’ problems and to facilitate difficult conversations.

The pilot-study showed beneficial effects on HbA1c (link til EASD Abstract)

We plan to further test the EMMA concept in larger scale studies in autumn and winter 2013.

Funding and collaborators

The study was a collaboration between Complications Research and Patient Education Research at Steno Diabetes Center. Furthermore, EMMA was:

  • part of a PhD study (Gudbjørg Andresdottir): The study of the clinical effects of the EMMA-program.
  • part of a Master of Drug Management thesis (Annemarie Varming) - the development and pilot testing of the intervention.
  • a study from Patient Education Research (Annemarie Varming, Gitte Engelund) – the development, prototyping and production of the health education tools, including guiding material.


1. Aikens JE, Piette JD. Longitudinal association between medication adherence and glycaemic control in Type 2 diabetes. Diabet Med. 2013; 30(3):338-44.

2. Rhee MK, Slocum W, Ziemer DC, et al. Patient adherence improves glycemic control. Diabetes Educ. 2005; 31(2):240-250.

3. Jensen, ML, Carstensen, B, Nielsen, A, et al. Assessment of medication adherence among patients with type 2 diabetes. Diabetologia 2010; 53 (Suppl. 1):1067

4. Anderson, RM, Funnell, MM, Aikens, JE, Krein, SL, Fitzgerald, JT, Nwankwo, R et al. Evaluating the efficacy of an Empowerment-based self-management consultant intervention: Results of a two-year randomised controlled trial. The Patient Educ. 2009; 1(1): 3-11.

5. Grabowski, D, Jensen, BB, Willaing, I, Zoffmann, V, Schiøtz, M. Sundhedspædagogik in patientuddannelse. A literature-based review of selected health education principles used in patient education . 2010;  Steno Diabetes Center.

6.  Engelund, G and Hansen, UM.  Det balancerende menneske. Sundhedspædagogisk model for patientuddannelse på tværs of diagnoser. 2011; Steno Health Promotion Center.

7. Gaver, B, Dunne, T, Pacenti, E. Design Cultural Probes. Interactions. 1999; 6(1):21-29.

8. Martin, LR, Haskard-Zolnierek, KB & DiMatteo, MR.  Health Behavior Change and Treatment Adherence. Evidence-Based Guidelines for Improving Healthcare. 2010; New York: Oxford.

9. WHO. Adherence to long-term therapies – evidence for action. 2003; Geneva. World Health Organisation.

10. Prochaska, JO & DiClimente, CC. Transtheoretical therapy: Toward a more integrative model of change. Psychotherapy: Theory, research and practice. 1982; 19(3): 276-88.

11.Rollnick, S, Mason, P, Butler, C. Health Behavior Change. A guide for practitioners. 1999; Churchill Livingstone.

12. Bandura, A. Self-efficacy Mechanism in Human Agency. Am Psycol. 1982; 37(2):122-147.

13.Varming A.  Development and usability of a participatory adherence programme aimed at patients with type 2 diabetes in poor glycemic control.  29-2-2012. 1-7-2013.    

Inspirational articles

’From compliance to concordance’: Cushing, A & Metcalfe, R. Optimising medicines management: From compliance to concordance. Therapeutics and Clinical Risk Management. 2007; 3(6): 1047-58

Measurement of participation
Skinner TC, Carey ME, Cradock S, et al. ‘Educator talk’ and patient change: some insights from the DESMOND (Diabetes Education and Self Management for Ongoing and Newly Diagnosed) randomized controlled trial. Diabetic Medicine. 2008; 25:1117-1120