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   Table of Contents      
BRIEF COMMUNICATION
Year : 2009  |  Volume : 57  |  Issue : 1  |  Page : 63-68

Patient-reported barriers to glaucoma medication access, use, and adherence in southern India


1 University of North Carolina and Research Associate, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
2 Aravind Medical Research Foundation, Aravind Eye Care System, Madurai, India
3 New York University, Department of Ophthalmology, NYU Medical Center New York, New York, USA
4 Department of International Health, Bloomberg School of Public Health, USA
5 Department of Ophthalmology, School of Medicine; Johns Hopkins University and University of Maryland School of Medicine, Baltimore, Maryland; Alcon Research Ltd., Fort Worth, Texas, USA
6 Department of Mathematics/Statistics, Husson College, Bangor, Maine, USA

Date of Submission14-Jul-2007
Date of Acceptance07-Apr-2008
Date of Web Publication12-Dec-2008

Correspondence Address:
Betsy L Sleath
Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill; CB # 7360, Chapel Hill, NC 27599-7360
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0301-4738.44495

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  Abstract 

The objectives of the study were to (a) describe the different types of problems that patients in southern India reported having when taking their glaucoma medications and (b) examine the relationship between patient reported-problems in taking their glaucoma medications and the self-reported patient adherence. A survey was conducted by clinical staff on 243 glaucoma patients who were on at least one glaucoma medication in an eye clinic in southern India. We found that 42% of patients reported one or more problems in using their glaucoma medications. Approximately 6% of patients reported being less than 100% adherent in the past week. Unmarried patients and patients who reported difficulty squeezing the bottle and difficulty opening the bottle were significantly more likely to report nonadherence.

Keywords: Access, adherence, barriers, glaucoma, medication, problems, southern India


How to cite this article:
Sleath BL, Krishnadas R, Cho M, Robin AL, Mehta R, Covert D, Tudor G. Patient-reported barriers to glaucoma medication access, use, and adherence in southern India. Indian J Ophthalmol 2009;57:63-8

How to cite this URL:
Sleath BL, Krishnadas R, Cho M, Robin AL, Mehta R, Covert D, Tudor G. Patient-reported barriers to glaucoma medication access, use, and adherence in southern India. Indian J Ophthalmol [serial online] 2009 [cited 2019 Oct 16];57:63-8. Available from: http://www.ijo.in/text.asp?2009/57/1/63/44495

It is estimated that by 2010 approximately 8.2 million people in India will have open-angle glaucoma and 3.7 million will have angle closure glaucoma, which translates to approximately 18.4% and 23.7% of the world's open-angle glaucoma and angle closure glaucoma, respectively. [1] In a study conducted in rural and urban populations in southern India, glaucoma was found to be responsible for 10.2% of bilateral blindness. [2] The absence of symptoms in almost all glaucoma patients increases the risk of treatment nonadherence among these patients.

Prior work conducted in southern India examined why patients who felt the need for eye care did not utilize eye services. [3],[4] To our knowledge, no prior study in India has examined self-reported problems of patients and adherence to glaucoma medications. Prior work in India has examined barriers and facilitators that affect adherence to antiretroviral medications and the patterns of prescribing and dispensing of medications by pediatric resident physicians. [5],[6],[7]

Despite the availability of effective medications for glaucoma and greater awareness of the importance to follow these treatment regimens, patient nonadherence to prescribed therapy continues to be a significant problem. [8],[9]

The purpose of the current study was to (1) describe the different types of problems reported by the patients in India when taking their glaucoma medications and (2) examine the relationship between patient-reported problems in taking their glaucoma medications and patient adherence to treatment.


  Materials and Methods Top


A survey to assess patient-reported problems and adherence to glaucoma medications that had been used in a prior U.S. study [9] was translated into Tamil; it included questions about the access to medication that were relevant to glaucoma patients living in India. The questions used to assess medication adherence were originally taken from the Brief Medication Questionnaire (BMQ). [10] The BMQ is a validated self-report measure of adherence. [10] Appendix A contains the questionnaire.

The study was approved by the Aravind Institutional Review Board. Patients who received care at a large subspecialty glaucoma clinic in southern India participated in the survey. The survey questions were distributed by trained clinical staff to consecutive adult glaucoma patients taking glaucoma medications over a period of one month in 2006. The clinical staff assisted glaucoma patients who needed help. The survey was completed by 243 patients before they visited their ophthalmologists.

All analyses were performed using SPSS (version 14.0). Descriptive statistics were calculated. Next, we examined the bivariate relationships between the independent and dependent variables using Fisher's exact tests and t -tests.


  Results Top


[Table 1] presents the demographic characteristics. [Table 2] presents information about patient access to medications. Patients living in rural areas (28%) reported to take an hour or longer to get to their pharmacy than patients living in urban areas (11%; Fisher's exact test = 0.002).

Forty-two percent of patients reported one or more problems in using their glaucoma medications. [Table 3] presents the types of patient-reported problems experienced by them. Younger patients were significantly more likely to report having difficulty paying for their medications ( t -test = 2.00, P = 0.04) and getting their drops in their eyes ( t -test = 2.27, P = 0.02) than older patients.

Approximately 6% of patients reported being less than 100% adherent to their glaucoma medications in the past week. Difficulty squeezing the bottle (Fisher's exact test, P = 0.04), difficulty opening the bottle (Fisher's exact test, P = 0.02), and not being married (Fisher's exact test, P = 0.016) were significantly related to whether the patient reported being less than 100% adherent to glaucoma treatment.


  Discussion Top


Forty-two percent of patients reported one or more problems in using their glaucoma medications. Younger patients were significantly more likely to report difficulty paying for their medications and getting their drops in their eyes. This is an important finding and suggests that ophthalmologists and their clinical colleagues need to assess and make sure that patients, and especially the younger ones, know how to put their eye drops in. Also, providers need to assess whether patients, and especially those who are younger, can afford their medications, and if not, possibly prescribe something less expensive or help them receive their medications for free.

Patients who reported difficulty opening their glaucoma eye drop bottle and squeezing the bottle were significantly more likely to report being less than 100% adherent. Providers should make sure to assess whether patients have difficulty opening their eye drop bottles and squeezing them. If the patients are having difficulty in these two areas, then providers could suggest that a family member or a friend help patients administer the eye drops.

It is also interesting that unmarried patients were significantly more likely to report being less than 100% adherent. Providers should make sure to ask unmarried patients about what types of social support they have and whether they need assistance in managing their glaucoma. The providers could then help the patient find resources in their community to assist them in managing their glaucoma if this is needed.

The study has several limitations. The clinical staff did not track those patients who refused to complete the survey. Second, the study enrolled only patients who were at the clinic for a glaucoma visit. Future research should examine the barriers to medication use among those in the community with glaucoma who have not returned for follow-up examinations.

The generalizability of the study is limited because all patients were recruited at a single glaucoma clinic in southern India. Approximately 60% of the clinical patients stated that they lived in an urban area, which reflects the characteristics of individuals that receive care at this hospital. However, in other clinics in southern India, more patients might be from rural areas. The educational level reported by the patients reflects the educational level of patients living in this area of India. Despite the limitations, the study provides new information about the extent to which patients in India have problems getting and taking glaucoma medications and factors that contribute to patient adherence.


  Conclusions Top


Forty-two percent of patients reported one or more problems in using their glaucoma medications. Approximately 6% of patients reported being less than 100% adherent to their glaucoma medications in the past week. Difficulty squeezing the bottle, difficulty opening the bottle, and not being married were significantly related to whether patients reported being less than 100 percent adherent.


  Acknowledgment Top


We thank Rajendran Mahalakshimi and Uma Maheswari at the Aravind Eye Care System, Madurai, India, for their contributions to this study.

 
  References Top

1.
Quigley A, Broman AT. The number of people with glaucoma worldwide in 2010 and 2020. Br J Ophthalmol 2006;90:262-7.  Back to cited text no. 1
    
2.
Thulasiraj RD, Nirmalan PK, Ramakrishnan R, Krishnadas R, Manimekalai TK, Baburajan NP, et al . Blindness and vision impairment in a rural south Indian population: The Aravind Comphrensive Eye Survey. Ophthalmology 2003;110:1491-8.  Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.
Nirmalan PK, Katz J, Robin AL, Krishnadas R, Ramakrishnan R, Thulasiraj RD, et al . Utilisation of eye care services in rural south India the Aravind Comprehensive Eye Survey. Br J Ophthalmol 2004;88:1237-41.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.
Robin AL, Nirmalan PK, Krishnadas R, Ramakrishnan R, Katz J, Tielsch J, et al . The utilization of eye care services by persons with glaucoma in rural south India. Trans Am Ophthalmol Soc 2004;102:47-55.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.
Kumarasamy N, Safren SA, Raminani SR, Pickard R, James R, Krishnan AK, et al . Barriers and facilitators to antiretroviral medication adherence among patients with HIV in Chennai, India: a qualitative study. AIDS Patient Care STDS 2005;19:526-37.  Back to cited text no. 5
[PUBMED]  [FULLTEXT]  
6.
Wanchu A, Kaur R, Bambery P, Singh S. Adherence to generic reverse transcriptase inhibitor-based antiretroviral medication at a tertiary center in North India. AIDS Behav 2007;11:99-102.  Back to cited text no. 6
[PUBMED]  [FULLTEXT]  
7.
Karande S, Sankhe P, Kulkarni M. Patterns of prescription and drug dispensing. Indian J Pediatr 2005;72:117-21.  Back to cited text no. 7
[PUBMED]    
8.
Taylor SA, Galbraith SM, Mills RP. Causes of non-compliance with drug regimens in glaucoma patients: A Qualitative Study. J Ocular Pharm Ther 2002;18:401-9.  Back to cited text no. 8
    
9.
Sleath B, Robin AL, Covert D, Byrd JE, Tudor G, Svarstad B. Patient-reported behavior and problems in using glaucoma medications. Ophthalmology 2006;113:431-6.  Back to cited text no. 9
[PUBMED]  [FULLTEXT]  
10.
Svarstad B, Chewning BA, Sleath BL, Claesson C. The Brief Medication Questionnaire: A Tool for Screening Patient Adherence and Barriers to Adherence. Patient Educ Couns 1999;37:113-24.  Back to cited text no. 10
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]


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