Health Literacy and Adherence to Glaucoma Therapy

doi:10.1016/j.ajo.2006.03.018

American Journal of Ophthalmology

Volume 142, Issue 2, August 2006, Pages 223-226.e2

https://doi.org/10.1016/j.ajo.2006.03.018 Get rights and content

Purpose

To describe the health literacy of subjects with open angle glaucoma and to investigate the hypothesis that low health literacy is associated with poor glaucoma medication adherence.

Design

Cross-sectional patient survey and concomitant chart review.

Methods

One hundred and ninety-seven subjects with open angle glaucoma participated in a survey which included basic demographic information such as age, gender, ethnicity, and level of education completed, and a test of heath literacy, the Rapid Assessment of Adult Literacy in Medicine. Information was collected regarding visual field tests and prescribed medication. The subjects’ pharmacies were contacted to ascertain the number of refills requested over the previous six months.

Results

Although 146 subjects (74%) reported completing high school, only 94 subjects (48.0%) read at or above a ninth grade level; 23 (11.7%) read at a level of third grade or below. The mean number of refills requested by a subject in the preceding six months was not predicted by race (P = .27,) gender (P = .31), age (P = .92), mean deviation of the visual field (P = .36), or level of education (P = .58). There was a positive relationship between health literacy and the number of refills obtained (P = .003).

Conclusions

Many patients with open angle glaucoma may have poor health literacy. The subjects in our study with low literacy were less adherent with their glaucoma medications than those with a higher level of literacy. Interventions specifically targeting patients with low literacy may improve medication adherence.

Section snippets

Methods

The study, approved by the Duke University Institutional Review Board, was designed as a cross-sectional patient survey and concomitant chart review. Potential subjects were recruited from the Glaucoma Service of Duke University Eye Center. Inclusion criteria included a diagnosis of open-angle glaucoma and presence of visual field tests in the medical record. Subjects who refused to participate or scored less than 13 on the Mini Mental State Examination (MMSE), a measurement of cognitive status,

Results

Of the 208 patients approached, eight declined to participate in the survey, including six women and two men, six African-Americans and two Caucasians. Three subjects were excluded for not meeting the MMSE criteria with scores of three, five, and ten. These subjects were all men ranging in age from 77 to 90 years and included one Caucasian and one African-American and one subject of unknown ethnicity. Characteristics of the 197 subjects who completed the survey are presented in the Table.

Discussion

The National Adult Literacy Survey of 1992, the most comprehensive assessment of English-language literacy in the United States to date, revealed that nearly one fourth of the American adult population is functionally illiterate.²¹ Inadequate health literacy (the inability to comprehend written material in a health care context), may compromise health care. In one study involving 2659 patients in two urban hospitals, 41.6% of subjects were unable to understand written instructions for taking

Kelly W. Muir, MD, is a graduate of the University of North Carolina at Chapel Hill and Duke University Medical School. Dr Muir completed her ophthalmology residency at the Duke University Eye Center, where she is currently a glaucoma fellow. Dr Muir will serve as chief resident beginning in July, 2006.

References (29)

J. Cramer et al.
Medication compliance feedback and monitoring in a clinical trialpredictors and outcomes
Value Health
(2003)
M.J. Sewitch et al.
Patient non-adherence to medication in inflammatory bowel disease
Am J Gastroenterol
(2003)
M.A. Kass et al.
Compliance with topical pilocarpine treatment
Am J Ophthalmol
(1986)
O. Kosoko et al.
Risk factors for noncompliance with glaucoma follow-up visits in a residents’ eye clinic
Ophthalmology
(1998)
M.F. Folstein et al.
“Mini-mental state.” A practical method for grading the cognitive state of patients for the clinician
J Psychiatr Res
(1975)
J.F. Steiner et al.
The assessment of refill compliance using pharmacy recordsmethods, validity, and applications
J Clin Epidemiol
(1997)
A.L. Robin et al.
Does adjunctive glaucoma therapy affect adherence to the initial primary therapy?
Ophthalmology
(2005)
M.V. Williams et al.
Inadequate literacy is a barrier to asthma knowledge and self-care
Chest
(1998)
R.D. Powers
Emergency department patient literacy and the readability of patient-directed materials
Ann Emerg Med
(1988)
H. Ebrahimzadeh et al.
Literacy levels of ophthalmic patient education materials
Surv Ophthalmol
(1997)

C.A. Jackevicius et al.

Adherence with statin therapy in elderly patients with and without acute coronary syndromes

JAMA

(2002)

L. Osterberg et al.

Adherence to medication

N Engl J Med

(2005)

J.H. Gurwitz et al.

Treatment for glaucomaadherence by the elderly

Am J Public Health

(1993)

S.E. Norell et al.

Self-medication with pilocarpine among outpatients in a glaucoma clinic

Br J Ophthalmol

(1980)

Cited by (122)

Health literacy and ophthalmology: A scoping review
2023, Survey of Ophthalmology
Citation Excerpt :
Four papers with 4 total findings examined the association between a measure of HL with treatment adherence.16,24,38 With glaucoma patients, REALM score was found to be positively associated with the number of refills obtained.38 Also with glaucoma patients, those with poor HL measured with TOFHLA had a significantly higher frequency of eye drops the patient forgot to instill as compared to those with adequate HL.24
As of 2020, it is estimated that 43.3 million people are blind, and an additional 553 million have mild to severe vision impairment.⁵⁰ At least 1 billion worldwide have a vision impairment that could have been prevented or has yet to be addressed.⁵⁴ Poor health literacy may be a significant contributor to the prevalence of eye disease. With implications on disease burden, progression, and health outcomes, a greater understanding of the role health literacy plays in ophthalmology is needed. This is the first scoping review to assess the impact of health literacy on eye health outcomes and blindness, including ocular screening rates and/or follow-up rates, treatment adherence, and self-care practices. PubMed, Embase, and CINAHL databases were searched systematically through November 12, 2021, and we evaluated the association between health literacy and ophthalmic outcomes in 4 domains: clinical outcomes, treatment adherence rates, screening and/or follow-up rates, and self-care practices. There is evidence to suggest that health literacy is associated with ophthalmic outcomes in all these domains. To better understand how health literacy impacts eye health, further longitudinal studies examining the effect of health literacy (using standardized health literacy measures) on ophthalmic outcomes are needed. We believe a specific ophthalmic health literacy survey could help achieve this goal and help target interventions to ultimately improve outcomes among ophthalmology patients.
The Importance of Health Literacy in Addressing Eye Health and Eye Care Disparities
2022, Ophthalmology
Disparities in eye health and eye care frequently result from a lack of understanding of ocular diseases and limited use of ophthalmic health services by various populations. The purpose of this article is to describe the principle of health literacy and its central role in enhancing health, and how its absence can result in poorer health outcomes. The article evaluates the current status of health literacy in visual health and disparities that exist among populations. It also explores ways to improve health literacy as a means of reducing disparities in visual health and eye care. Advancing dissemination of health information and enhancing health literacy may help not only to reduce healthcare barriers in the underserved populations but also to lessen visual health disparities.
Readability and Suitability of Online Patient Education Materials for Glaucoma
2022, Ophthalmology Glaucoma
To assess the quality, content, readability, and accountability of information about glaucoma found online.
Cross-sectional study.
Thirteen websites containing patient education materials for glaucoma were analyzed in this study.
An online Google search was conducted using the keyword “glaucoma.” Thirteen medical website results were selected for analysis. Each website was assessed by 3 independent reviewers for suitability, readability, and accountability. The standardized Suitability Assessment of Materials (SAM) tool was used to evaluate the quality and content of information on each website. The Flesch Reading Ease (FRE) score, Flesch-Kincaid Grade Level (FKGL), Coleman-Liau Index (CLI), Simple Measure of Gobbledygook (SMOG) index, Automated Readability Index (ARI), and Linsear Write Formula (LWF) score were used to assess the readability of the websites. The Journal of the American Medical Association (JAMA) accountability benchmarks were used to evaluate each website’s accountability.
These included SAM, FRE, FKGL, CLI, SMOG index, ARI, and LWF scores as well as JAMA accountability benchmarks.
The average SAM score for all the websites included in this study was 18 points out of a possible 34 points. Eyewiki.org was the lowest-scoring website (11.7 ± 0.6 points), whereas aao.org and nei.nih.gov were the highest-scoring websites (26.0 ± 1.0 points and 26.0 ± 2.6 points, respectively). Three content graders in this study were in moderate agreement (kappa statistic = 0.50). The average FRE score among all the websites was 47.0 (95% confidence interval [CI], 39.3–54.7). The average reading grade score among all the websites was 11.2 (95% CI, 10.0–12.4). Two of the 13 websites (15.4%) satisfied all 4 JAMA accountability criteria.
There is significant variation in the content and quality of freely available, online glaucoma education material. The material is generally either not suitable or only adequate for use. Most websites reviewed are written at a reading grade level higher than that recommended for patient education materials.
Health Literacy and Success with Glaucoma Drop Administration
2022, Ophthalmology Glaucoma
To assess the relationship between health literacy and successful glaucoma drop administration.
Substudy of a single-site interventional randomized controlled trial.
Veterans receiving care at the Durham Veterans Affairs Eye Clinic who had a diagnosis of open-angle glaucoma were recruited if they endorsed poor drop adherence.
Participants underwent a health literacy evaluation using the Rapid Estimate of Adult Literacy in Medicine (REALM) as well as a qualitative assessment of eye drop administration technique using 3 different criteria: (1) the drop was instilled in the eye, (2) only 1 drop was dispensed, and (3) the bottle was not potentially contaminated. A multivariate logistic regression model was used to assess the association of REALM score and successful drop administration, adjusting for age, disease severity, and Veterans Administration Care Assessment Needs (CAN) score.
Successful drop administration.
Of the 179 participants with REALM scores and observed drop administration, 78% read at a high school level (HSL) or more and 22% read at less than HSL. Of the 179 participants, 87% (n = 156) successfully instilled the drop into the eye (criterion 1). A greater proportion of participants who read at HSL or more successfully instilled the drop in the eye compared with those reading at less than HSL (90.6% vs. 75.0%; P = 0.02). Rates of success with criterion 1 were similar across different levels of visual field severity. Care Assessment Needs scores were not statistically significant between those who did and those did not have successful overall drop technique.
Poor health literacy may be associated with decreased successful drop instillation in the eye in patients with glaucoma. Screening for and considering health literacy in developing interventions to improve glaucoma self-management may improve treatment adherence in a vulnerable population.
Insights Into Eye Care Accessibility: Geospatial Distribution of Eye Care Providers and Socioeconomic Factors by ZIP Code
2024, Translational Vision Science and Technology
Social determinants of health and health disparities in glaucoma: A review
2024, Clinical and Experimental Ophthalmology

View all citing articles on Scopus

Paul P. Lee, MD, JD, is the James Pitzer Gills III and Joy Gills Professor of Ophthalmology at Duke Medical Center, Senior Fellow in the Duke Center on Aging and Human Development, and part of the Health Services Program at RAND, Santa Monica, California. National service activities include the Board of Trustees of the American Academy of Ophthalmology and the Socioeconomics and Health Services Section Editor for the Archives of Ophthalmology.

: Supported by an unrestricted grant from Pfizer, Inc, Durham, North Carolina. Dr Lee is a consultant for Pfizer, Allergan, Merck, and Alcon, and has received research support from Pfizer, Allergan, and Merck. Research to Prevent Blindness, New York, New York.

View full text

Original articleHealth Literacy and Adherence to Glaucoma Therapy

Purpose

Design

Methods

Results

Conclusions

Section snippets

Methods

Results

Discussion

Value Health

Am J Gastroenterol

Am J Ophthalmol

Ophthalmology

J Psychiatr Res

J Clin Epidemiol

Ophthalmology

Chest

Ann Emerg Med

Surv Ophthalmol

Adherence with statin therapy in elderly patients with and without acute coronary syndromes

JAMA

Adherence to medication

N Engl J Med

Treatment for glaucomaadherence by the elderly

Am J Public Health

Self-medication with pilocarpine among outpatients in a glaucoma clinic

Br J Ophthalmol

Original article
Health Literacy and Adherence to Glaucoma Therapy