Glaucoma is a chronic eye disease that is one of the leading causes of blindness in the United States, especially in African Americans and Hispanics.1–3 Eye drops are the usual treatment to prevent progression of glaucoma4 but are difficult to use properly.5 Although many educational videos are available on YouTube, none of these have been tested rigorously in controlled studies.6 We recently found that an online educational video intervention, the 4-minute Meducation eye drop technique video (Polyglot Systems, a division of First Databank, Morrisville, NC), improved eye drop technique significantly in a randomized controlled trial of 92 glaucoma patients.7
Other interventions that have shown success at improving eye drop technique in previous studies include printed eye drop instructions,8 educational videos,9,10 and mechanical devices.11 However, these studies collected little information on how the intervention should be improved or disseminated to other patients. Patients were asked only general questions about whether the intervention helped them, was useful, or made them feel more confident in instilling eye drops.8,9 Collecting detailed data on how an intervention should be delivered and disseminated is crucial because the real-world effectiveness of an intervention is often contingent on its ability to be adopted and implemented outside a controlled study environment. For example, an educational video that plays in a clinic's waiting room may have little effect if most patients are distracted and do not pay attention to the video. Similarly, a video that is posted online may be very convenient for some patients but completely inaccessible for patients with no Internet access or no understanding of how to find relevant material online.
The purpose of this study was to describe patient perspectives on how to improve the Meducation eye drop technique video and how to disseminate it to other glaucoma patients, and how these perspectives may differ across patient demographic characteristics. To inform improvements to the video and nationwide dissemination, we gathered data on patients' overall rating of the video, how it helped them, how it should be modified, and how it should be made available to other glaucoma patients.
This article reports the results related to patients' perspectives on how to improve the video and disseminate it to other glaucoma patients. Ninety-two patients with primary open-angle glaucoma (as verified by medical records) who self-administered their own eye drops participated in a randomized controlled trial of the Meducation eye drop technique video. Results for the primary eye drop technique outcome of the trial are reported elsewhere; the current article is focused on those patients who were randomized to the intervention group. The 4-minute video uses an animation to explain all the important steps in eye drop technique, including getting the drop accurately into the eye. The video is available in 21 languages and written at approximately a fifth-grade reading level to be useful to patients of all literacy levels. Institutional review board approval was obtained. All patients provided informed consent, and the study conformed to the tenets of the Declaration of Helsinki.
After initial assessment of their eye drop technique, patients completed an interview and then were randomized to watch the Meducation video in the intervention group or a nutrition video (attentional control) in the control group. Patients were given an access code and a link to watch the video as many times as they wanted, online or on their mobile device, over the course of the next month. At the end of the 1-month time frame, they were seen for a follow-up interview, and intervention patients were asked questions about how to improve the video and disseminate it to other glaucoma patients. Control group patients were given an access code and a link to the video at the follow-up visit but were not asked for feedback on the video.
Of 46 patients randomized to receive the intervention, 43 were included in the analysis of their feedback regarding the video; the other three patients were lost to follow-up. Based on the mean and standard deviation of eye drop technique steps performed correctly in our previous observational study of eye drop technique12 and the need to have at least 80% power to detect a difference of at least one-third of a step in mean eye drop technique score between the intervention and control groups, a power calculation showed that 46 patients per group were required.
Subjective evaluation of the video's usefulness was scored as 1 (not at all useful), 2 (a little useful), 3 (fairly useful), or 4 (very useful). With whom the video was watched had the following response choices: friend, family member, health care provider, other (specify), or no one. Whether patients would recommend the video to others was measured as a dichotomous variable (yes/no). How the video should be made available to other glaucoma patients had the following response choices: on a social media site such as YouTube, in the waiting room at the doctor's office, in the examination room at the doctor's office, on the doctor's office website, on a digital video disk or flash drive that you could take home, and other (specify). Health literacy was measured using the Rapid Estimate of Adult Literacy in Medicine.13
Other variables that were collected included sex (male/female), race (African American vs. other), age (in years), glaucoma severity (early vs. moderate to severe), length of time using glaucoma medications (in years), diagnosis of arthritis or other condition affecting manual dexterity, years of education, number of glaucoma medications the patient is taking, number of times per day the patient takes glaucoma medications, visual acuity in the better-seeing eye as a continuous decimal (e.g., 20/20 vision, 1.0), whether the patient's eyes were dilated during the visit (yes/no), whether the physician educated the patient about technique (yes/no), and patient Internet use. Questions about patient Internet use included how comfortable they were with using the Internet, how often they used the Internet, whether they owned a cell phone, whether they used their cell phone to go on the Internet, whether they had Internet access in their home, which Internet-capable devices they used, and whether they had ever used the Internet to learn more about glaucoma. The medical record was used to determine glaucoma severity, diagnosis of arthritis or other condition affecting manual dexterity, number of glaucoma medications the patient is taking, number of times per day the patient takes glaucoma medications, and visual acuity. An electronic tracking system was used to determine the total number of times each patient watched the video based on the personalized access code given to each patient.
Regarding areas for improvement, a single coder classified patient responses to open-ended questions into categories and identified the most commonly reported areas for improvement.
Descriptive statistics (means, frequencies, percentages) were computed for the variables of interest using SPSS version 24 (IBM SPSS, Armonk, NY). Tests of trend or Pearson χ2 were computed to assess differences in ratings of the video by demographic group.
The demographic characteristics of the 43 patients are shown in Table 1. The majority was white (62.8%) or African American (30.2%), and 60.5% were male. The average (SD) age was 69.0 (12.0) years, and patients had a high level of schooling, at roughly a bachelor's degree. The majority had moderate to severe glaucoma, and approximately half reported having previously been educated about eye drop technique. More than three-quarters scored at ninth grade or higher on the Rapid Estimate of Adult Literacy in Medicine.
Data on Internet usage and Internet-capable devices used are shown in Table 2. Most of the patients (62.8%) considered themselves very comfortable with using the Internet. Approximately two-thirds of the patients used the Internet daily. Eighty-six percent had a cell phone, and 70.2% of those (or 60.5% of all participants) used it to access the Internet. The most common Internet-capable devices other than cell phones were laptop computers, followed by desktop computers and iPads (Apple Inc., Cupertino, CA). Fifty-four percent had used the Internet to learn about glaucoma.
Of 43 patients analyzed, the tracking data for access codes revealed that a total of 5 participants (11.6%) watched the video at least once after their baseline visit. Including the baseline visit, two (4.7%) watched the video a total of two times each, and three (7.0%) watched it three times each.
In addition to the video instruction, two patients (4.7%) reported that someone had shown them how to use eye drops since the baseline visit. One said that he had been educated by the doctor, and one said that she had been educated by both the doctor and the ophthalmic technician.
Descriptive statistics for the evaluation questions are shown in Table 3. All 43 patients said that they would recommend that others watch the video. No patients reported that they watched the video with anyone else. On a 4-point scale ranging from 1 (“not at all useful”) to 4 (“very useful”), the mean (SD) rating of the video was 3.4 (0.8; range, 1 to 4). Sixty percent of patients (n = 26) rated the video as very useful. Patients who said that they thought the video was not at all useful or only a little useful tended to say that they knew most of the material in the video already, but the video might be more useful for people who were just starting to use eye drops.
African American patients rated the video's usefulness higher at a mean of 3.8 compared with 3.2 for non–African Americans (test of trend: χ2 = 5.25, df = 1, P = .02). Patients who had used eye drops for a longer time gave the video lower ratings (r = −0.34, P = .03). Other patient and clinical characteristics, including having been previously educated about eye drop technique, were not significantly associated with patient rating of usefulness of the video.
Participants' responses to the question “How did the video help you?” are summarized in Table 3. The greatest number of participants said that the video helped them by teaching them to block the tear duct with the finger (32.6%), put the cap on its side (27.9%), mix the medication correctly (25.6%), or keep the eye closed after instillation (25.6%).
Participants suggested improving the video by using a real person instead of an animation (32.6%), making it easier to view on their cell phone (16.3%), explaining the steps differently (4.7%), adding other topics (4.7%), or “other” (32.6%). Suggestions in the “other” category are detailed in Table 4.
When allowed to endorse multiple options for ways to disseminate the video, the most commonly endorsed options for video dissemination were the doctor's office website (79.1%), the waiting room at the doctor's office (76.7%), the examination room at the doctor's office (76.7%), and a social media site such as YouTube (74.4%). Fewer patients endorsed a digital video disk or flash drive that they could take home (53.5%) or “other” (23.3%). The “other” category included the hospital website (7.0%), through Google or search engines (4.7%), other glaucoma sites (4.7%), having the video on its own site (4.7%), and advertising it on TV (2.3%). Two patients (4.7%) also suggested providing the same information in print format.
Participants' responses to the question “What do you think is the best way to make the video available to other glaucoma patients?” are shown in Table 5. The greatest number of participants (30.2%) favored disseminating the video by showing it in the examination room. Unlike when allowed for multiple options, when patients were asked for the best way to make the video available, the examination room was clearly preferred over the waiting room, which was selected by only 4.7%. A website (other than social media or the doctor's office website) was the most frequently mentioned option for watching the video outside the doctor's office. Some patients mentioned that having the video come up first when people typed relevant terms into a search engine would maximize dissemination. Several wanted to view it in the doctor's office and also have an online option. Some of these thought that an online option would be preferred by younger people, but they personally preferred to see the video in the doctor's office.
Glaucoma patients believed that the eye drop technique video intervention was useful. In prior studies of eye drop technique educational interventions, patients were asked only binary questions about whether they found the intervention useful and whether it made them more confident.8,9 In the study of a video intervention by Feng et al.,9 91% of patients thought that the video would help them in administering their drops, and 91% felt more confident administering their drops as prescribed. The ratings of a printed eye drop chart in the study by McVeigh and Vakros8 were lower; 64% said that the chart was useful, and 60% said that it helped them deliver their drops correctly.
Previous studies of educational interventions for eye drop technique and adherence did not report how ratings of the intervention varied by patient characteristics.8,9,14 The mean rating of the video's usefulness was significantly higher in African Americans and in patients who had been using eye drops for a shorter period. Our finding is consistent with prior studies that have found that African Americans were more interested in learning about glaucoma than patients of other races.15,16 In a study of African American glaucoma patients by Sleath et al.,16 76% of survey respondents wanted education on how to use eye drops, and 84% wanted education on glaucoma medications in general.
Patients most frequently reported being helped by the video in learning to perform punctal occlusion, lay the cap down on its side, mix the medication correctly, and close the eye after instillation. Each of these themes was mentioned by more than 25% of the intervention group participants. Less frequently, patients also mentioned topics related to the other technique steps, such as not touching the eye and getting the drop accurately into the eye. Among the five technique steps that we scored, topics related to instilling a single drop were least often mentioned. Prior glaucoma eye drop technique intervention studies did not specifically ask patients how the intervention had helped them,8,9 so our results add to the literature in this area.
Patients most commonly suggested improving the video by using a real person instead of an animation and a variety of other suggestions. Approximately one-third of the patients wanted a real person in the video, such as a doctor self-administering eye drops. However, an animation has the benefit that it avoids using a person of a specific race or sex in the video. The video may be improved in the future by making it easier to view on mobile devices, as well as changing some language that patients found difficult, such as by using inches instead of centimeters for a U.S. audience.
Most patients endorsed multiple means of disseminating the video, often including both online options, such as the doctor's office website or social media, as well as in-person options, such as the doctor's office waiting room or examination room. When allowed to choose as many options as they liked, equal numbers of patients chose the waiting room and the examination room, but when asked for their top choice, 30.2% chose the examination room, whereas only 4.7% chose the waiting room. Therefore, we conclude that the video needs to be disseminated in person when the drops are prescribed, most likely in the examination room, and also online in a place where patients can easily find it. There was not a great deal of consensus on where the best online location was, so it might be worthwhile to provide the video in multiple locations if possible. For example, it could be posted on YouTube but also have links to it from doctor's office websites, hospital websites, and general glaucoma informational websites.
Few patients watched the video more than once. This may be because they thought that they learned everything they needed on the first viewing or found it challenging to access the video online with an access code. It may be important for staff members to observe patients' eye drop technique after they watch the video to determine whether there is a need to watch it again. Otherwise, patients may assume that they learned the skill successfully even if they still do not have perfect technique.
In general, our results agree with a prior study by Rosdahl et al.15 that found that ophthalmology patients tend to prefer either one-on-one education from their doctor or materials recommended by their doctor. Patients seem to trust their doctors to recommend trustworthy materials, suggesting that some would not trust a video posted on social media if it was not endorsed by their doctor. When doctors do not have time to provide one-on-one education, they should make it clear what educational materials they endorse, so that patients may access the materials in a way that does not consume the physician's time.
The study had several limitations. In-person interviews may have resulted in social desirability bias, which may have led patients to provide inflated ratings of the video's usefulness. We enrolled only English-speaking patients because we did not have the staff needed to administer the interview in languages other than English. Future studies should test the Meducation video in multiple languages to see if video preferences differ by language. Using a single coder precluded calculating intercoder reliability. Also, the randomization did not balance the covariates exactly between groups. As a result, the intervention group was 60% male and had better baseline self-efficacy than did the control group, so the results may not be as representative of the opinions of women or patients with lower self-efficacy. The study also enrolled only patients who had been prescribed eye drops before enrollment in the study. Future studies should also examine patients who have never used eye drops before.
This study confirmed that patients are interested in seeing an eye drop technique video disseminated in medical offices nationwide, as well as online through multiple types of websites. By integrating the video into health systems' online electronic health records, it may be possible to save providers a great deal of time and effort while achieving better results from widely used eye drop medications. However, it is also essential to show the video during the visit, especially for patients with limited Internet access or technological literacy. In general, patients agreed that showing the video in the examination room rather than the waiting room would best ensure that people paid maximum attention to the video.
1. Friedman DS, Wolfs RC, O'Colmain BJ, et al. Prevalence of Open-angle Glaucoma among Adults in the United States. Arch Ophthalmol 2004;122:532–8.
2. Peters D, Bengtsson B, Heijl A. Lifetime Risk of Blindness in Open-angle Glaucoma. Am J Ophthalmol 2013;156:724–30.
3. Javitt JC, McBean AM, Nicholson GA, et al. Undertreatment of Glaucoma among Black Americans. N Engl J Med 1991;325:1418–22.
4. American Academy of Ophthalmology. Preferred Practice Pattern Guidelines: Primary Open-angle Glaucoma. 2010. Available at: www.aao.org/ppp
. Accessed August 7, 2018.
5. Lacey J, Cate H, Broadway DC. Barriers to Adherence with Glaucoma Medications: A Qualitative Research Study. Eye (Lond) 2009;23:924–32.
6. Davis SA, Sleath B, Carpenter DM, et al. Drop Instillation and Glaucoma. Curr Opin Ophthalmol 2018;29:171–7.
7. Davis SA, Carpenter DM, Blalock SJ, et al. A Randomized Controlled Trial of an Online Educational Video Intervention to Improve Glaucoma Eye Drop Technique. Patient Educ Couns 2018;Dec 18:epub ahead of print: doi 10.1016/j.pec.2018.12.019.
8. McVeigh KA, Vakros G. The Eye Drop Chart: A Pilot Study for Improving Administration of and Compliance with Topical Treatments in Glaucoma Patients. Clin Ophthalmol 2015;9:813–9.
9. Feng A, O'Neill J, Holt M, et al. Success of Patient Training in Improving Proficiency of Eyedrop Administration among Various Ophthalmic Patient Populations. Clin Ophthalmol 2016;10:1505–11.
10. Lazcano-Gomez G, Castillejos A, Kahook M, et al. Videographic Assessment of Glaucoma Drop Instillation. J Curr Glaucoma Pract 2015;9:47–50.
11. Nordmann JP, Baudouin C, Bron A, et al. Xal-Ease: Impact of an Ocular Hypotensive Delivery Device on Ease of Eyedrop Administration, Patient Compliance, and Satisfaction. Eur J Ophthalmol 2009;19:949–56.
12. Sayner R, Carpenter DM, Robin AL, et al. How Glaucoma Patient Characteristics, Self-efficacy and Patient-provider Communication Are Associated with Eye Drop Technique. Int J Pharm Pract 2016;24:78–85.
13. Davis TC, Long SW, Jackson RH, et al. Rapid Estimate of Adult Literacy in Medicine: A Shortened Screening Instrument. Fam Med 1993;25:391–5.
14. Friedman DS, Okeke CO, Jampel HD, et al. Risk Factors for Poor Adherence to Eyedrops in Electronically Monitored Patients with Glaucoma. Ophthalmology 2009;116:1097–105.
15. Rosdahl JA, Swamy L, Stinnett S, et al. Patient Education Preferences in Ophthalmic Care. Patient Prefer Adherence 2014;8:565–74.
16. Sleath B, Davis S, Sayner R, et al. African American Patient Preferences for Glaucoma Education. Optom Vis Sci 2017;94:482–6.