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Patient Question-Asking About Glaucoma and GlaucomaMedications During Videotaped Medical VisitsBetsy Sleathab, Robyn Saynera, Susan J. Blalocka, Delesha M. Carpentera, Kelly W. Muirc, MaryE. Hartnettd, Gail Tudore, Scott Lawrencefg, Annette L. Giangiacomoh & Alan L. Robini

a Division of Pharmaceutical Outcomes and Policy, University of North Carolina EshelmanSchool of Pharmacyb Cecil G. Sheps Center for Health Services Research, University of North Carolina at ChapelHillc Department of Ophthalmology, School of Medicine, Duke University and Durham VA MedicalCenterd Department of Ophthalmology and Visual Sciences, University of Utahe Department of Science and Mathematics, Husson Universityf University of North Carolina Kittner Eye Centerg Department of Ophthalmology, University of North Carolina at Chapel Hillh Department of Ophthalmology, Emory University School of Medicinei Department of International Health, Bloomberg School of Public Health and Department ofOphthalmology, Johns Hopkins University School of MedicinePublished online: 25 Jul 2014.

To cite this article: Betsy Sleath, Robyn Sayner, Susan J. Blalock, Delesha M. Carpenter, Kelly W. Muir, Mary E. Hartnett,Gail Tudor, Scott Lawrence, Annette L. Giangiacomo & Alan L. Robin (2014): Patient Question-Asking About Glaucoma andGlaucoma Medications During Videotaped Medical Visits, Health Communication, DOI: 10.1080/10410236.2014.888387

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Health Communication, 00: 1–9, 2014Copyright © Taylor & Francis Group, LLCISSN: 1041-0236 print / 1532-7027 onlineDOI: 10.1080/10410236.2014.888387

Patient Question-Asking About Glaucoma and GlaucomaMedications During Videotaped Medical Visits

Betsy SleathDivision of Pharmaceutical Outcomes and Policy

University of North Carolina Eshelman School of Pharmacy andCecil G. Sheps Center for Health Services Research

University of North Carolina at Chapel Hill

Robyn Sayner, Susan J. Blalock, and Delesha M. CarpenterDivision of Pharmaceutical Outcomes and Policy

University of North Carolina Eshelman School of Pharmacy

Kelly W. MuirDepartment of Ophthalmology, School of Medicine

Duke University andDurham VA Medical Center

Mary E. HartnettDepartment of Ophthalmology and Visual Sciences

University of Utah

Gail TudorDepartment of Science and Mathematics

Husson University

Scott LawrenceUniversity of North Carolina Kittner Eye Center and

Department of OphthalmologyUniversity of North Carolina at Chapel Hill

Annette L. GiangiacomoDepartment of Ophthalmology

Emory University School of Medicine

Alan L. RobinDepartment of International Health

Bloomberg School of Public Health andDepartment of Ophthalmology

Johns Hopkins University School of Medicine

Correspondence should be addressed to Betsy Sleath, Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School ofPharmacy, 2212 Kerr Hall CB # 7573, Chapel Hill, NC 27599-7573. E-mail: betsy_sleath@unc.edu

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2 SLEATH ET AL.

We applied the ecologic model of communication in medical consultations to examine howpatient, physician, and situational/contextual factors are associated with whether patients askone or more questions about glaucoma and glaucoma medications during visits to ophthalmol-ogists. Patients with glaucoma who were newly prescribed or already on glaucoma medicationswere recruited at six ophthalmology clinics. Patients’ visits with their doctors were video-recorded and patients were interviewed after visits. Generalized estimating equations wereused to analyze the data. Two hundred and seventy-nine patients participated. Patients askedone or more questions about glaucoma during 59% of visits and about glaucoma medicationsduring 48% of visits. Patients who were newly prescribed glaucoma medications were signif-icantly more likely to ask one or more questions about glaucoma and glaucoma medications.Whether providers asked patients if they had questions was not significantly associated withpatient question-asking. Patients were significantly more likely to ask older providers ques-tions about glaucoma medications and female providers questions about glaucoma. Eye careproviders should encourage glaucoma patients to ask questions during their medical visits.

Between 9 and 12% of all blindness in the United Statesis attributed to glaucoma (Glaucoma Research Foundation,2010). The absence of symptoms in glaucoma patientsincreases the risk of regimen nonadherence among thesepatients. Approximately 50% of individuals who start onglaucoma medications discontinue them within 6 months(Nordstrom, Friedman, Mozaffari, Quigley, & Walker, 2005;Schwartz, Platt, Reardon, & Mychaskiw, 2007). Also,research has shown that continued users of glaucoma medi-cations are nonadherent (Friedman et al., 2009; Muir et al.,2006; Sleath et al., 2006; Sleath, Blalock, Stone, et al., 2012).

Further, even when patients attempt to adhere to theireye drop medications, research has shown that patient per-formance during eye drop administration is poor (Sleath,Blalock, Stone, et al., 2012; Stone, Robin, Novack, Covert,& Cagle, 2009). In a recent study where 140 experiencedglaucoma patients were videotaped while instilling their eyedrops, 18% of patients missed their eye when administer-ing their drops, only 60% of patients correctly instilled thecorrect number of drops, and 65% of patients contaminatedthe bottle by touching it to the eye (Stone et al., 2008).Research has also shown that 60% or more of glaucomapatients express problems in using their glaucoma medica-tions as prescribed (Sleath et al., 2006; Sleath et al., 2009;Sleath, Blalock, Covert, et al., 2012), including, paying forthe medication, difficulty getting the drops in the eyes, read-ing the print on the bottle, and remembering to take themedication (Sleath et al., 2006; Sleath et al., 2009; Sleath,Blalock, Covert, et al., 2012).

This suggests that many patients might have reasons toask their ophthalmologists questions about their glaucomaand how to correctly use prescribed glaucoma medications,yet little is known about ophthalmologist–patient communi-cation during glaucoma visits. Two qualitative studies foundthat glaucoma patients reported poor communication withtheir providers as negatively impacting adherence (Tayloret al., 2002; Tsai et al., 2003). Unfortunately, these stud-ies did not investigate actual communication (Taylor et al.,2002; Tsai et al., 2003). Another prior study found thatpatients who reported being less likely to ask their eye doctor

questions during visits also reported being less adherent totheir glaucoma medications (Stryker et al., 2010). One priorstudy that did examine ophthalmologist and patient commu-nication during 51 videotaped glaucoma visits found thatpatients asked questions about the following topics mostoften during visits: intraocular pressure (20%), details aboutthe medication regimen (20%), and disease status (14%)(Friedman et al., 2009). However, the study did not describethe types of questions asked in any detail, nor did it tryto examine what factors predicted patient question-asking(Friedman et al., 2009).

Patient question-asking is important because it is a formof active patient participation during medical visits wherepatients can ask for more information (Cegala, Street, &Clinch, 2007; Street, Gordon, Ward, Krupat, & Kravitz,2005). Patient question-asking can potentially improvepatient self-efficacy in managing glaucoma, because ifpatients ask questions about how to correctly use eye dropsor resolve problems in using glaucoma medications, they canreceive information from the doctor and gain more confi-dence in managing their glaucoma (Sleath et al., 2010; Sleathet al., 2011; Sleath, Blalock, Covert, et al., 2012).

Patient activation has been found to increase patient satis-faction, perceived health, and adherence; decrease anxietylevels; and improve diabetes and hypertension manage-ment (Greenfield, Kaplan, Ware, Yano, & Frank, 1988;Harrington, Noble, & Newman, 2004; Katz, Jacobson,Veledar, & Kripalani 2007; Venetis, 2013).

The theoretical rationale for this study is the ecologicmodel of communication in medical consultations (Street,2003; Street et al., 2005). This model hypothesizes that theway patients communicate with physicians is influenced bypersonal, physician, and contextual factors (Street, 2003;Street et al., 2005). Personal factors could be the patient’sgender, race, age, health literacy (Street et al., 2005); physi-cian factors could be age, gender, race; and contextual orsituational factors could be if the physician asks the patientwhether they have questions during the visit or it could bewhether the visit is a follow-up or initial visit (Street, 2003;Street et al., 2005).

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PATIENT QUESTION-ASKING ABOUT GLAUCOMA 3

Empirical research has provided support for Street’smodel by documenting that personal, physician, and con-textual factors all affect patient–provider communication.Regarding personal characteristics, non-White, working-class, less educated, and low-literacy patients are all lesslikely to participate in the medical visit (Brody, 1989;Davis et al., 1993; Eggly et al., 2011; Street, Voigt, Geyer,Manning, & Swanson, 1995; Street et al., 2005; Waitzkin,1985).

Studies have found contradictory results in terms ofhow patient age impacts question-asking (Kidd, Marteau,Robinson, Ukoumunne, & Tydeman, 2004; Maly, Umezawa,Leake, & Silliman, 2004; Sleath, Roter, Chewning, &Svarstad, 1999; Sleath, Rubin, & Huston, 2003; Street et al.,1995).

Regarding physician factors, patients seeing olderphysicians are significantly more likely to ask a questionduring medical visits (Aboumatar, Carson, Beach, Roter, &Cooper, 2013; Sleath et al., 1999; Sleath, Rubin, Campbell,Gwyther, & Clark, 2001; Sleath et al., 2003). In terms of situ-ational factors, patients started on new medications are morelikely to ask questions during medical visits (Sleath et al.,1999; Sleath et al., 2003).

Therefore, the purpose of this study was to apply theecologic model of communication in medical consultations(Street, 2003; Street et al., 2005) to examine how patient(age, gender, race, literacy, years of education), physician(age, gender, race), and situational (whether the physicianasks the patient if they have questions during the visit,whether glaucoma medications are prescribed for the firsttime) factors are associated with whether patients ask one ormore questions about glaucoma and one or more questionsabout glaucoma medications.

METHODS

Procedure

English-speaking adult glaucoma patients were enrolledbetween 2009 and 2012 at six geographically distinctophthalmology clinics located in four states. Two siteswere private offices and four were affiliated with aca-demic ophthalmology departments. At each site, clinic staffreferred eligible patients to research assistants who werebased at the clinics. Written patient and provider consent wasobtained. Providers completed a short demographic ques-tionnaire after providing consent. The patient’s medical visitwas video-taped. Videotapes were kept if they fit into one oftwo criteria: (a) the patient was diagnosed with glaucoma andglaucoma medications were prescribed for the first time or(b) patients were already on glaucoma medications. Patientswere interviewed after their medical visits. The study wasapproved by the University of North Carolina InstitutionalReview Board and was Health Insurance Portability andAccountability Act (HIPAA) compliant.

Measurement

Sociodemographic characteristics. Patient age, race,gender, years of education, and whether the patient wasprescribed a glaucoma medication for the first time wereassessed. Additionally, each subject completed the RapidEstimate of Adult Literacy in Medicine (REALM). This isa validated, rapid screening instrument designed to identifypatients who have difficulty reading common medical andlay terms that are routinely used in patient education mate-rials (Davis et al., 1993). We choose the REALM because ithas high face validity and high criterion validity, it has beenwell received by patients, and it only takes 2 to 3 minutes toadminister and score (Davis et al., 1993). Patient scores onthe REALM correspond to reading levels (score of 0–60 =eighth grade and below, 61–66 = ninth grade and above).Physician age, gender, and race were measured.

Communication measures. All of the medical visitvideotapes were transcribed verbatim. A detailed transcriptcoding tool was developed over a 1-year period for thestudy using input from the communication experts andophthalmologists on the study team. Using a detailed cod-ing tool and coding rules for the transcribed medicalvisits, three research assistants (who were not the sameresearch assistants who recruited the patients at the clinics)recorded whether patients asked one or more questions aboutglaucoma medications and whether they asked one or morequestions about glaucoma. The coders also wrote down allof the actual questions that patients asked. The coders alsonoted whether the doctor asked whether the patient had anyquestions.

The glaucoma and glaucoma medication question-askingcoding categories were developed using the patient question-asking literature (Kidd et al., 2004; Maly et al., 2004; Sleathet al., 1999; Sleath et al., 2003; Street et al., 1995) andinput received from the ophthlamologists on the study team.After the original categories were developed and defined, thepatient questions were reviewed and the categories were fur-ther refined with input from the principal investigator andthe research team. The questions were then classified intothe categories described in Table 1.

Patient questions about glaucoma medications were clas-sified into five main areas: (a) information about glaucomamedications, including the name, strength, and side effectsof the medication; (b) information about the medicationregimen, such as dose, which eye(s) to instill the medica-tion in, and frequency of use; (c) how to administer themedication, which includes questions about how to instilleye drops and about how long to wait between instillingtwo different eye drops; (d) cost or supply of the medica-tion; and (e) information about the purpose or importanceof using glaucoma medications and adherence strategies.If a question was asked that did not fit into these five cate-gories, it was classified as an “other question about glaucomamedications.”

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TABLE 1Description of the Types of Patient Questions About Glaucoma Medications and Glaucoma

Glaucoma Medication Question Category Description

How to administer the glaucoma medication Includes questions about the amount of time to wait between administeringtwo eye medications and about the nasolacrimal occlusion

Medication regimen Includes questions about the dose, frequency, which eye in which to instill theeye drop, whether to continue the current medication regimen, and thepossibility of long-term use of glaucoma medications

Cost or supply Includes various topics such as the cost of the medication, genericformulations, the need for refills, and how long a bottle of medicationshould last before needing a refill

More detailed information about glaucoma medications Includes questions such as the about the possible side effects of themedication and about the name of the medication

Adherence strategies, purpose of using, and the importance of usingglaucoma medications

Includes topics such as why glaucoma medications were prescribed and howto remember to take the medications consistently

Other Includes various unusual topics such as patient concerns or barriers with usingglaucoma medication, how well the glaucoma medication was working,and the use of nonglaucoma medications

Glaucoma Question Category Description

More detailed information about glaucoma Includes questions about the diagnosis or prognosis of the patient’s glaucoma,and whether other health conditions, such as high blood pressure ordiabetes, interfere with glaucoma

Treatment of glaucoma, excluding questions about medications Includes questions about the goals of treatment, the likelihood of long-termtherapy, ways to manage glaucoma with surgery, and ways to manageglaucoma with lifestyle changes

Intraocular pressure (IOP) Includes questions about the current IOP measurement and how IOP relates toglaucoma

Other Includes various unusual questions about the physical or emotional changesthat occur with glaucoma

Similarly, questions asked by patients about glaucomawere classified into three main areas: (a) information aboutthe disease, including diagnosis and prognosis; (b) treatmentoptions for glaucoma, such as whether to treat or to watchand wait, information about surgery versus medications, andthe duration of glaucoma treatment; and (c) informationabout intraocular pressure (IOP), including the definition ofit as well as what was the current IOP reading. If a patientquestion did not fit into the three main categories, it wascategorized as an “other question about glaucoma.”

The three research assistants coded 25 of the same tran-scripts throughout the study period. After the coders weretrained using the coding rules and sheets, they met monthlyto discuss discrepancies in coding to prevent coder decay.Intercoder reliability was calculated using Cohen’s kappa.Cohen’s kappa was 0.78 for whether the patient asked aquestion about glaucoma medications, 0.84 for whetherthe patient asked one or more questions about glaucoma,and 1.0 for whether the doctor asked if the patient had anyquestions.

Analysis

We set the a priori level of statistical significance to p <

.05. First, we presented descriptive statistics. Second, weexamined the bivariate relationships among the independent

variables and between the independent and dependent vari-ables using Pearson correlation coefficients, chi-squaredstatistics, and t-tests.

We ran generalized estimating equations (GEE) to exam-ine how patient age, patient gender, patient race, patientyears of education, patient health literacy, whether thepatient was newly prescribed glaucoma medication on theday of the medical visit, and physician age and genderwere associated with (a) whether the patient asked one ormore questions about glaucoma medications and (b) whetherthe patient asked one or more questions about glaucoma.Physician race could not be included in the multivariableanalysis because there was only one non-White physician.

RESULTS

Fifteen physicians who cared for glaucoma patients agreedto participate in the study; one physician refused to partic-ipate for a participation rate of 94%. Fourteen physicianswere White and one was African American. Ten physicianswere male (66.7%). The age of the physicians ranged from26 to 66 years (M = 40.8 years, SD = 11.7 years).

Eighty-six percent of eligible patients participated in thestudy. Table 2 presents the patient demographics. Patientsasked one or more questions about glaucoma medications

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PATIENT QUESTION-ASKING ABOUT GLAUCOMA 5

TABLE 2Subject Characteristics (N = 279)

Percent (n)

GenderMale 40.9 (114)Female 59.1 (165)

RaceAfrican American 35.5 (99)Non-African American 64.2 (179)

Newly prescribed glaucoma medications at visitor was on glaucoma medications before visitNewly prescribed at visit 18.3 (51)Was on glaucoma medications before visit 81.7 (228)

Rapid Estimate of Adult Literacy in Medicine(REALM)Eighth grade or lower 14.0 (39)Ninth grade or higher 84.2 (235)

Range; M (SD)Age 21 to 93; 65.8 (12.8)Years of education 5 to 26; 15.1 (3.5)

during 59% of the visits. Eighty percent of patients whowere newly started on a glaucoma medication asked oneor more questions, compared to 55% of those who werealready on glaucoma medications. The number of questionsabout glaucoma medications that patients asked during theirmedical visit ranged from 0 to 16 (M = 1.7, SD = 2.4).

Table 3 presents the types of glaucoma medicationquestions asked by patients who were newly prescribedglaucoma medications at the medical visit compared to thosealready taking a glaucoma medication. Twenty-three percentof new users compared to 8% of continued users asked oneor more questions about how to administer their glaucomamedications (Pearson χ2 = 9.7, p = .002). Thirty-seven

percent of new users compared to 14% of continued usersasked for more information on the glaucoma medicationssuch as the name of the medication or what the side effectsare (Pearson χ2 = 15.9, p = .000). Fifty-five percent ofnew users compared to 29% of continued users asked oneor more questions about the glaucoma medication regimen,such as which eye to use the medication in or how manydrops to use each time (Pearson χ2 = 12.6, p = .000).Seventeen percent of new users asked about adherence,the purpose of the medication, or the importance of usingglaucoma medications compared to 6% of continued users(Pearson χ2 = 8.2, p = .0004).

Patients asked one or more questions about glaucoma in48% of visits. Sixty-nine percent of patients who were newlyprescribed glaucoma medications asked a question aboutglaucoma compared to 45% who were on continued medi-cations. The number of questions about glaucoma asked bythe patients during their medical visit ranged from 0 to 17(M = 1.3, SD = 2.0).

Table 3 presents the types of glaucoma questions asked bypatients who were newly prescribed glaucoma medicationsversus those already taking a glaucoma medication. Thirty-seven percent of new users compared to 8% of continuedusers asked one or more questions requesting more detailedinformation on glaucoma (Pearson χ2 = 32.9, p = .000).

Providers asked if the patients had questions during 51%of the videotaped medical visits. This was not associatedwith patients asking at least one question about glaucomamedications (Pearson χ2 = 2.114; p = .146), or with patientsasking at least one question about glaucoma (Pearson χ2 =2.679; p = .102).

Table 4 presents the GEE results predicting whetherpatients asked one or more questions about glaucoma

TABLE 3Categorization of Patient Questions That Were Asked About Glaucoma Medications and Glaucoma During the Medical Office Visit (N = 279)

Patients Prescribed Glaucoma Medicationsfor First Time During the Medical Visit

(n = 51)Patients on Glaucoma Medications Before the

Medical Visit (n = 228)

Percent (n) of PatientsWho Asked a Question

Number ofQuestions Asked

Percent (n) of PatientsWho Asked a Question

Number ofQuestions Asked

Glaucoma medication question categoryHow to administer glaucoma medications 23.5 (12) 16 8.3 (19)∗∗ 27Glaucoma medication regimen 54.9 (28) 49 28.9 (66)∗∗∗ 104Cost or supply of glaucoma medications 21.6 (11) 20 12.3 (28) 45More detailed information about glaucoma medications 37.3 (19) 31 13.6 (31)∗∗∗ 32Adherence, purpose, or the importance of using

glaucoma medications17.6 (9) 16 5.7 (13)∗∗∗ 16

Glaucoma question categoryTreatment of glaucoma excluding glaucoma

medications15.7 (8) 15 13.2 (30) 40

More detailed information about glaucoma 37.3 (19) 68 7.5 (17)∗∗∗ 84Intraocular pressure 23.5 (12) 18 25.9 (59) 87

∗∗Significant at p < .01, Pearson χ2.∗∗∗Significant at p < .001, Pearson χ2.

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6 SLEATH ET AL.

TABLE 4Generalized Estimating Equation Results Predicting Whether Patient Asked One or More Questions

About Glaucoma or Glaucoma Medications (N = 279)

Independent Variable Glaucoma Medications, OR (95% CI) Glaucoma, OR (95% CI)

Patient age 1.01 (0.99 − 1.04) 1.00 (0.99 − 1.02)Patient gender, female 1.29 (0.71 − 2.33) 1.51 (0.84 − 2.71)Patient race, African American 0.76 (0.44 − 1.32) 0.69 (0.45 − 1.07)Patient, years of education 1.04 (0.96 − 1.14) 1.06 (0.97 − 1.17)REALM, reads at eighth grade level or less 0.85 (0.46 − 1.57) 1.44 (0.75 − 2.76)Newly prescribed glaucoma medications versus already on glaucoma medications 3.21 (1.68 − 6.12)∗∗ 2.46 (1.58 − 3.82)∗∗Physician age 1.03 (1.01 − 1.06)∗ 1.02 (0.99 − 1.04)Physician gender, female 1.99 (0.83 − 4.79) 2.85 (1.75 − 4.65)∗∗Physician asking whether patient had any questions during medical visit 1.01 (0.65 − 1.57) 0.98 (0.64 − 1.48)

∗Significant at p < .05.∗∗Significant at p < .01.

medications and one or more questions about glaucoma.None of the patient personal factors were associated withpatient question-asking about glaucoma medications orglaucoma. In terms of provider factors, patients were sig-nificantly more likely to ask questions about glaucoma med-ications to older physicians (OR: 1.03, 95% CI: 1.01–1.06),and they were significantly more likely to ask questionsabout glaucoma to female physicians (OR: 2.85, 95% CI:1.75–4.65). In terms of contextual factors, those who werenewly prescribed glaucoma medications were significantlymore likely to ask questions about glaucoma medications(OR: 3.21, 95% CI: 1.68–6.12) and glaucoma (OR: 2.46,95% CI 1.58–3.82). However, the other contextual factor weexamined, whether the physician asked the patients whetherthey had any questions, was not significantly associated withpatient question-asking.

DISCUSSION

As predicted by the ecological model of communication(Street et al., 2003; Street et al., 2005), we found that a con-textual factor (a patient being prescribed a glaucoma medi-cation for the first time versus being a continued user) wassignificantly associated with patient question-asking aboutglaucoma and glaucoma medications. Specifically, patientswho were newly prescribed glaucoma medications duringthe visit were more than twice as likely to ask questionsabout glaucoma than patients on continued medications.This is in contrast to Cegala (2011), who found that patientstatus (new vs. returning patient) was not significantly asso-ciated with patient participation during visits. Cegala (2011)posits that they did not have enough new patients in theirsample to see a difference by patient status. We did haveenough patients new to glaucoma medications to see a sig-nificant effect. Surprisingly, the contextual factor of whetherproviders asked patients whether they had questions was notsignificantly associated with patient question-asking.

It makes sense that patients prescribed a new glaucomamedication would be more likely to ask one or more

questions about glaucoma because they want to learn moreabout the disease. However, it is also important to encour-age all patients to ask questions during glaucoma visits sothat they can better understand their disease and increasetheir confidence or self-efficacy in managing their glaucoma(Sleath et al., 1999; Sleath et al., 2006; Sleath et al., 2009;Sleath, Blalock, Stone, et al., 2012). In addition, a previ-ous study found that patients who reported being more likelyto ask questions during glaucoma visits also reported beingmore adherent to their glaucoma medications (Stryker et al.,2010), further supporting the importance of encouragingpatients to ask questions.

Similar to previous studies (Sleath et al., 1999; Sleathet al., 2003), patients who were newly prescribed glaucomamedications were three times more likely to ask one ormore questions about glaucoma medications. It is importantfor providers to encourage patients on continued medica-tions to ask questions because they may have experiencedside effects or difficulties adhering to the medication. If so,the provider can then help the patient address these issuesby giving advice or recommendations. Provider advice onside effects may be particularly salient for patients, sinceprior research has shown that patients realize when they areexperiencing adverse events associated with glaucoma medi-cations, such as sedation, asthma, elevation of plasma levels,or systemic hypotension (Derick et al., 1997; Freedmanet al., 1993; Lee, Wang, Kifley, & Mitchell, 2006). Provideradvice on adherence may also be useful to patients sinceprior research has documented that patients on continuedmedications have adherence problems and they report dif-ficulties in using their medications (Muir et al., 2006; Sleathet al., 2006; Sleath et al., 2009). Providers could ask patientquestions like “What problems are you having in using yourmedications?” or “How are you doing with using your eyedrops?” to encourage patients to ask questions. Providerscould also ask patients to demonstrate how they use their eyedrops and correct and educate the patients on how to improveany mistakes the patients make. Prior work has found thatpatient administration of eye drops is poor (Robin et al.,2007; Sleath, Blalock, Stone, et al., 2012).

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PATIENT QUESTION-ASKING ABOUT GLAUCOMA 7

We found that another contextual factor, providers askingpatients “if they had any questions,” was not significantlyassociated with patients asking questions. Providers ask-ing patients whether they have questions could be con-sidered a proxy measure of whether the provider waspatient-centered. Thus, our finding that eliciting patientquestions (i.e., provider patient-centeredness) was unrelatedto patient participation (i.e., patient question-asking) runscounter to Street’s model, including previous studies thathave linked provider patient-centeredness to patient partic-ipation (Cegala, 2011). We argue that simply asking patientsif they have questions is not patient-centered enough, whichmay be why this provider behavior was not associated withgreater patient question-asking. Patients may have difficultythinking of questions they want to ask during the medicalencounter, so additional prompting by the provider couldhelp patients think of the questions they want to ask. Forexample, providers could instead say something like “Manypeople with glaucoma tell me they have trouble using theireye drops. Do you have any questions about using your eyedrops?” or “People with glaucoma often have trouble under-standing what intraocular pressure is. Do you have any ques-tions about glaucoma or intraocular pressure?” Abraham,Naik, and Street (2012) suggest that one partnership-buildingway to request patient questions is to say “Tell me moreabout that.” Providers could ask patients to tell them moreabout specific topics, such as administering and adhering toeye drops, to provide additional patient-centered probes andencourage patient participation.

In further support of the ecological model of health com-munication, we did find that provider factors significantlyinfluenced patient question-asking (Street et al., 2005).Glaucoma patients were significantly more likely to askolder providers about glaucoma medications than youngerproviders. This finding is similar to the findings of otherresearchers (Aboumatar et al., 2013; Sleath et al., 1999;Sleath et al., 2001; Sleath et al., 2003). More work is neededto better understand why patients are more likely to askolder providers questions. Is it because older physicians aredoing something different during the visits (either verballyor nonverbally) that causes patients to feel more comfort-able asking questions? Or is it because patients perceiveolder physicians differently than younger physicians and thismakes patients feel more comfortable asking older physi-cians questions? Future work applying the ecological modelof communication should also assess how patient percep-tions of physicians influence whether patients ask questionsduring medical visits.

Patients were also significantly more likely to ask femaleproviders about glaucoma than male providers. This is con-trary to prior work that found that patients were significantlymore likely to ask male physicians questions about over-the-counter medications (Sleath et al., 2001). Studies conductedby Cegala (2011) and Street (2005) did not find that providergender was significantly associated with patient participation

during visits, and Cegala (2011) attributes this to the factthat both studies included patient centeredness as a predictorvariable. It could be that in our study female providers hada more patient-centered communication style with patientsor they were perceived as less threatening by patients whowanted to ask questions. Future research should examinewhether female and male physicians differ in other aspects ofpatient-centered communication, because we only assessedwhether providers asked patients if they had any questions.In addition, future research should also examine whetherpatient perceptions of female versus male providers aredifferent and whether this influences patient question-asking.

We did not find that any patient factors significantlyinfluenced patient question-asking. Unlike prior research(Aboumatar et al., 2013; Eggly et al., 2011; Sleath et al.,2001; Street et al., 1995; Street et al., 2005; Waitzkin, 1985),we did not find that health literacy, race, or years of edu-cation were significantly associated with patients asking oneor more questions about glaucoma or glaucoma medications.Therefore, our study did not find support for the part of theecological model of communication that posits that patientfactors such as race and literacy can influence patient partic-ipation during visits (Street et al., 2003; Street et al., 2005).Our finding that patient race was not associated with patientquestion-asking is similar to what other researchers havefound when applying the ecological model (Cegala, 2011;Street et al., 2005). We may not have found an associationbetween literacy and patient question-asking because only14% of our sample read at the eighth-grade level or belowaccording to the REALM. Future work should include morepatients with limited health literacy in their samples.

Our research provides support for the relevance of apply-ing the ecologic model of communication in specialty set-tings like ophthalmology clinics. Our finding that beingnewly prescribed a glaucoma medication influenced patientquestion-asking about both glaucoma and glaucoma medi-cations is important because it illustrates patient willingnessto ask questions when starting a new treatment. However, itis important to make sure that patients ask questions theymight have at any point when using medications becauseresearch has found that approximately 50% of individu-als who start on glaucoma medications discontinue themwithin 6 months (Nordstrom, Friedman, Mozaffari, Quigley,& Walker, 2005; Schwartz, Platt, Reardon, & Mychaskiw,2007) and that patient performance when administering eyedrops is poor (Stone, Robin, Novack, Covert, & Cagle, 2009;Sleath, Blalock, Stone, et al., 2012). Future research shouldexamine what questions patients might have about their dis-ease and its treatment and compare it to the actual questionsthat patients ask their providers.

In addition, we found that physician age and gender influ-enced patient question-asking during glaucoma visits. Thisindicates that more work is needed to better understandhow physician characteristics influence patient question-asking during medical visits. Do physician characteristics

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8 SLEATH ET AL.

influence patient perceptions of their physicians and there-fore their question-asking behavior or do certain physicianverbal or nonverbal behaviors facilitate or inhibit patientquestion-asking? More research is needed.

A systematic review of trials to improve provider–patient communication during medical visits found thatsimple approaches to increasing patient participation duringvisits, such as providing doctors a note from patients abouttheir concerns before visits, showed promise at increasingpatient involvement (Griffin et al., 2004). There have beentwo prior intervention studies conducted in ophthalmologythat successfully improved the communication skills ofophthalmologists to be more patient-centered (Hahn et al.,2010; Vegni, 2004). Future research in the glaucoma areashould design interventions focused on the patient thatencourage patients to ask questions and be more activelyinvolved during the visits.

This study has several limitations. Providers and patientsboth knew the visit was being recorded but they did not knowthe study hypotheses. Selection bias could be another limita-tion, since the ancillary staff did not track the characteristicsof the few patients who declined to speak with the researchassistant to learn more about the study. Despite these limita-tions, the study presents important new information on whatpatient, physician, and contextual factors were associatedwith patient question-asking about glaucoma and glaucomamedications.

When applying the ecologic model of communication,we found that patients were significantly more likely toask questions about glaucoma and glaucoma medicationswhen newly prescribed glaucoma medications. Eye careproviders should encourage glaucoma patients to ask ques-tions during all types of visits because patients on continuedmedications might have questions about barriers to using eyedrops. Additionally, we found that patients were significantlymore likely to ask older providers about glaucoma medica-tions and female providers about glaucoma. Future researchshould explore in more detail how provider characteristicsinfluence patient question-asking.

FUNDING

This work was supported by grant EY018400 from theNational Eye Institute and by grant UL 1RR02574 7 from theNational Center of Research Resources, National Institutesof Health (NIH). NIH had no role in the design or conduct ofthis research.

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