Do African American patients with glaucoma ask their eye providers the questions they have?

PURPOSE: The objective of this study was to describe what questions patients checked on a glaucoma question prompt list and how often patients asked the same checked questions during medical visits. DESIGN: A randomized controlled trial was conducted to test the effectiveness of a pre-visit video/glaucoma question prompt list intervention to increase African American patient question-asking during medical visits. METHODS: Adult African American patients with glaucoma and a history of non-adherence to glaucoma medications were enrolled and randomized into intervention and usual care groups from three glaucoma practices. Visits were audio-recorded, transcribed, and coded for the questions patients asked during their visits. Researchers collected the pre-visit question prompt lists from the intervention group and compared their checked questions to the questions patients asked during their visit. RESULTS: Ninety-three subjects were randomized to the question prompt list intervention group. Subjects checked an average of 6.77 questions on the prompt list. Of the subjects who checked at least one question, 54.8% asked their provider at least one of the questions they checked. The most common questions asked about glaucoma medications that they had checked were "What time(s) of day should I take my drops?" (50.0%, 9 out of 18) and "How many times a day do I use my glaucoma medicines?" (50.0%, 3 out of 6). CONCLUSION: Although African American subjects with glaucoma have questions about glaucoma and their medications, few asked all their questions during visits. Future research should focus on how to improve question asking using a question prompt list.

Communication About Adolescent and Caregiver Smoking and Vaping During Pediatric Asthma Visits: Implications for Providers.

INTRODUCTION: Although rates of cigarette smoking among U.S. adolescents have declined, rates of vaping (i.e., using e-cigarettes) have increased. We conducted a secondary analysis of 359 transcripts of medical visits of adolescents with asthma to examine communication about caregiver and adolescent smoking and vaping. METHOD: Adolescents aged 11-17 years with persistent asthma and their parents were enrolled from four pediatric clinics in 2015-2017. Youth were randomized to the intervention or usual care groups. Intervention group adolescents watched a video and then completed an asthma question prompt list before their visits. RESULTS: Forty providers and 359 patients participated. Providers, adolescents, and caregivers discussed smoking during 38.2% of their visits. Vaping was never discussed. DISCUSSION: There is room to improve how often providers in a primary care setting discuss smoking and vaping. Further investigation might focus on how a smoking and vaping prompt list for adolescents could increase tobacco discussions during visits.

Provider-adolescent discussion and provider education about asthma triggers during pediatric visits: results of a randomized trial.

OBJECTIVE: We examined how an asthma question prompt list with video intervention influenced discussion of and provider education about asthma triggers. METHODS: English or Spanish-speaking adolescents ages 11-17 with persistent asthma and their caregivers were enrolled from four pediatric clinics. Adolescents were randomized to the intervention or usual care groups. Adolescents in the intervention group watched the video on an iPad and then completed a one-page asthma question prompt list before their visits. All visits were audio-recorded. Generalized Estimating Equations were used to predict the number of trigger areas discussed and the number of areas providers educated adolescents about during visits. RESULTS: Forty providers and 359 patients participated. Triggers were discussed during 89% of intervention group visits and 81% of usual care visits; providers educated adolescents about triggers during 59% of intervention group visits and 46% of usual care visits. More triggers were significantly more likely to be discussed and providers educated about more trigger areas during visits of adolescents in the intervention group and when adolescents asked one or more questions during visits. More trigger areas were significantly more likely to be discussed if the adolescent was White and male. Providers were significantly more likely to educate adolescents whose family spoke Spanish at home about more trigger areas than adolescents who spoke English at home. CONCLUSIONS: More trigger areas were significantly more likely to be discussed and providers educated about more trigger areas during visits of adolescents who received the intervention and when adolescents asked one or more questions.

Communication about Contraception with Adolescent Females with Asthma in Pediatric Visits.

STUDY OBJECTIVE: The occurrence and characteristics of contraception discussions with adolescents are unexplored. Our study sought to address this gap using transcripts of audiotaped healthcare visits. DESIGN, SETTING, AND PARTICIPANTS: This study was a secondary analysis of 153 transcripts of medical visits with female adolescents with asthma. Medical visits took place among 4 outpatient clinics in North Carolina. MAIN OUTCOME MEASURES: Transcripts were reviewed for occurrence and characteristics of contraception discussions. Demographics were collected from adolescent interviews, caregiver questionnaires, and provider questionnaires. RESULTS: Contraception was mentioned in 3% (n = 5) of office visits. Conversations about contraception included the topics of contraception efficacy (20%), contraception side effects (60%), contraception adherence (20%), and adolescent sexual health (20%). No conversations included the topics of contraception indication or alternative methods. CONCLUSIONS: Conversations about contraception occurred infrequently in healthcare visits. When conversations did occur, the topics that they covered lacked alignment with guideline recommendations.

Questions and reported medication problems from pediatric patients and caregivers after intervention.

PURPOSE: The effectiveness of an asthma question prompt list with video intervention to increase question-asking during pediatric office visits among youth who reported medication problems was evaluated. METHODS: English- or Spanish-speaking youth age 11-17 years with persistent asthma and their caregivers were enrolled from 4 pediatric clinics in a randomized controlled trial. Youth were randomized to intervention or usual care groups. Youth in the intervention group watched an educational video with their caregivers on an iPad. The youth then received a 1-page asthma question prompt list to complete before their visits. The audio of all baseline medical visits was recorded. Youth were interviewed and caregivers completed questionnaires at baseline and 6 months later. RESULTS: A total of 40 providers and 359 of their patients participated. Youth who reported at least 1 medication problem who were in the intervention group were significantly more likely to ask 1 or more questions about medications during their visits than youth in the usual care group (odds ratio = 3.1, 95% confidence interval = 2.0, 4.1). Seventy-four percent of youth and 71% caregivers who reported the youth had problems using asthma medications at baseline still reported 1 or more problems 6 months later. CONCLUSION: Among youth who reported 1 or more problems with using their asthma medications, the intervention significantly increased youth question-asking. Many youth- and caregiver-reported problems with using asthma medications persisted over time.

Discussions About Antibiotics During Adolescent Asthma Visits: Implications for Providers.

Children with asthma are exposed to antibiotics more frequently than their peers. The quality of provider-patient discussion about antibiotics is unknown. In this secondary data analysis, we reviewed existing transcripts of audiotaped adolescent asthma visits using a standardized coding sheet to analyze the quality of communication about antibiotics. Of 539 transcripts, we identified 12 discussions about antibiotics. No patient or parent requested antibiotics. In most cases, discussion was limited to assessment of drug allergies and preferred formulation. In 5 cases (42%), the prescribed antibiotic was not named. We propose a set of communication elements that should be included whenever antibiotics are prescribed, classified into ( a) Essential, such as the drug name and dosing schedule; ( b) Encouraged, such as expected response to therapy; or ( c) Situational, such as discussion of alternatives to antibiotics. Future research should further explore the quality of antibiotic-related conversations among different groups of providers and patients.

Online Information-Seeking Behaviors of Parents of Children With ADHD.

This article describes ( a) parent questions about ADHD (attention deficit/hyperactivity disorder), ( b) parent Internet use to seek ADHD information, and ( c) associations between type of Internet access and ADHD information-seeking. Seventy parents of children (ages 7-17 years) with ADHD completed questionnaires after their child's visit with their pediatrician. Bivariate relationships were assessed using chi-square statistics, Pearson correlation coefficients, or t tests. Parents identified an average of 8.9 questions about ADHD for their child's provider. Common questions were related to medication and long-term implications of ADHD. A majority of parents searched the Internet for general ADHD information (87%) and ADHD medication information (81%). White parents accessed the Internet significantly more via home computer, mobile phone, and tablet, and significantly less via public library than non-White parents. Parents who accessed the Internet via home computers and tablets were more likely to search the Internet for ADHD medication information than parents who did not.

African American Patient Preferences for Glaucoma Education.

PURPOSE: The objectives of the study were to examine (a) the types of questions that African American patients have about glaucoma for their providers and (b) how patients' sociodemographic characteristics are associated with where and from whom they would like to learn about glaucoma and glaucoma medications. METHODS: Forty-nine adult African American patients with glaucoma were recruited at a private ophthalmology clinic where they completed a questionnaire for this cross-sectional study. RESULTS: African American patients had a mean of 3.9 questions for their ophthalmologists; the questions that patients checked as having most often were "What is my prognosis with glaucoma?" (49%) and "What is my intraocular pressure?" (45%). Seventy-six percent of patients preferred that an educational program about glaucoma be offered at the doctor's office and 39% preferred it be offered at a community or senior citizen center. Ninety percent said that the education program should be offered by doctors. Patients under the age of 70 were significantly more likely to want a program on the Internet than patients age 70 and over (Pearson χ = 4.7, P = .03). If an educational program was developed patients reported being most interested in the following topics, glaucoma medications (84%), what is glaucoma and what does it mean to have it? (83%). CONCLUSIONS: African American patients have many questions about glaucoma for their eye care providers. African American patients would prefer glaucoma educational programs be offered at their provider's office. Our findings could be used to develop educational programs for African American patients with glaucoma.

Youth Views on Communication About ADHD and Medication Adherence.

The purpose of this study was to examine youth perceptions of attention deficit hyperactivity disorder (ADHD) communication with their pediatric providers, their reported adherence to their ADHD medications, and their desired location for an ADHD educational program. Youth ages 7 through 17 with an ADHD diagnosis were recruited. A research associate interviewed the youth. Parents completed demographic questionnaires. Seventy families participated. One-third of the youth wanted more discussion about ADHD with their providers during visits. The average youth had over eight questions about ADHD and its treatment. Most youth wanted to learn about ADHD at their provider's office. Non-white and older youth were significantly more likely to be less adherent to their ADHD medications. Youth want their providers to engage them more during visits. Providers should take advantage of this interest to engage youth more in discussions regarding ADHD and its treatment during pediatric ADHD visits.

Development of the Weight-Related Sign and Symptom Measure.

BACKGROUND: Overweight and obesity have been associated with physical and emotional signs & symptoms. Research has shown that modest weight loss can mitigate some symptoms in individuals with overweight or obesity. This study's purpose was to conduct concept elicitation (CE) interviews to provide documented qualitative support for the development of the Weight-Related Sign and Symptom Measure (WRSSM) to assess weight-related signs/symptoms in U.S. adults with overweight or obesity, with or without type 2 diabetes (T2DM).Eight focus groups were conducted in the U.S. with adults with overweight or obesity to understand weight-related sign/symptom impact from the patient perspective. Individual interviews were conducted with clinical experts to understand the impact of overweight or obesity on patient signs and symptoms. Transcripts were analyzed to identify symptoms and observable signs. A clinical challenge was conducted with clinical experts to confirm the signs/symptoms were clinically relevant, important to patients, and would improve with modest weight loss. Cognitive debriefing (CD) was conducted with individuals with overweight or obesity to confirm readability and symptom relevance. RESULTS: CE interviews were conducted with four clinical experts, and 61 people, 32% of whom had T2DM, participated in the focus groups. Analyses identified two major areas of obesity impacts: weight-related physical signs/symptoms, and emotional impacts. The most frequently reported physical signs/symptoms were feeling tired (74%), shortness of breath (69%), and joint pain (64%). The most often reported emotional impacts included poor self-image (72%) and depression (51%). Twelve signs/symptoms were identified during item generation and included on the preliminary measure. Twelve adults with overweight/obesity, who were not part of the focus groups, participated in CD. After the CD, a validation-ready, 10-item WRSSM measure was generated. CONCLUSIONS: Findings provide evidence of content validity for the validation-ready WRSSM in U.S. adults with overweight or obesity, including people with and without T2DM.

Glaucoma patient-provider communication about vision quality-of-life.

OBJECTIVE: The purpose of this study was to: (a) describe the extent to which ophthalmologists and glaucoma patients discuss vision quality-of-life during office visits, and (b) examine the association between patient and ophthalmologist characteristics and provider-patient communication about vision quality-of-life. METHODS: Patients with glaucoma who were newly prescribed or on glaucoma medications were recruited at six ophthalmology clinics. Patients' visits were video-tape recorded and quality-of-life communication variables were coded. Generalized estimating equations were used to analyze the data. RESULTS: Two hundred and seventy-nine patients participated. Specific glaucoma quality-of-life domains were discussed during only 13% of visits. Older patients were significantly more likely to discuss one or more vision quality-of-life domains than younger patients. African American patients were significantly less likely to make statements about their vision quality-of-life and providers were less likely to ask them one or more vision quality-of-life questions than non-African American patients. CONCLUSION: Eye care providers and patients infrequently discussed the patient's vision quality-of-life during glaucoma visits. African American patients were less likely to communicate about vision quality-of-life than non-African American patients. PRACTICE IMPLICATIONS: Eye care providers should make sure to discuss vision quality-of-life with glaucoma patients.

Communication Predicts Medication Self-Efficacy in Glaucoma Patients.

PURPOSE: Medication self-efficacy, or patients' confidence that they can perform medication-related behaviors, is associated with better glaucoma medication adherence. Little is known about how to enhance glaucoma patients' medication self-efficacy. Our purpose is to examine whether patient-provider communication increases glaucoma patients' medication self-efficacy. METHODS: During an 8-month cohort study of 279 glaucoma patients and 15 providers, two office visits were videotape-recorded, transcribed, and coded for six patient-provider communication behaviors. A validated scale was used at baseline and 8-month follow-up to assess patients' confidence in overcoming adherence barriers (adherence barriers self-efficacy) and carrying out tasks to use eye drops correctly (eye drop task self-efficacy). We ran two generalized estimating equations to examine whether more frequent patient-provider communication during office visits predicted increased patient adherence barriers self-efficacy and eye drop task self-efficacy at 8-month follow-up. RESULTS: For each additional topic providers educated about, patients reported an average increase of 0.35 in self-efficacy in overcoming adherence barriers (p < 0.001). Patients also reported an average increase of 1.01 points in eye drop task self-efficacy when providers asked about patients' views of glaucoma and its treatment versus not (p < 0.001). Patients who asked more medication questions (p < 0.001) and African-American patients (p < 0.05) reported lower adherence barriers self-efficacy by 0.30 and 2.15 points, respectively. Women had a 0.63 lower eye drop task self-efficacy than men (p < 0.05). CONCLUSIONS: When providers educate glaucoma patients and assess patient views about glaucoma and its treatment, patients report higher medication self-efficacy. Providers should be aware that patients who ask more medication questions may have less confidence in their ability to overcome barriers to adherence.

The Effect of Eye Drop Technique Education in Patients With Glaucoma.

Education about how to administer eye drops may improve a patient's ability to instill his or her eye drops correctly. Our objectives were to (a) document the methods providers use to educate glaucoma patients about eye drop technique; (b) determine whether eye drop technique education varies by provider and patient characteristics; and (c) evaluate whether education predicts improved patient technique. We conducted an 8-month longitudinal study of 279 glaucoma patients and 15 providers in which we recorded on videotape the content of glaucoma office visits at two time points (baseline and 4- to 6-week follow-up) and videotaped patient eye drop technique at three time points (baseline, 4- to 6-week follow-up, and 8-month follow-up). Mann-Whitney rank sum tests were used to determine whether education was associated with improved patient eye drop technique over time. Ninety-four patients (34%) received technique education at either visit; 31% received verbal education and 10% received a technique demonstration. Only 24 patients (47%) who were new to eye drops received technique education at the baseline visit. Patients who were new to drops at baseline (p = .008) and patients who asked a question about drops (p < .001) were more likely to receive technique education. Education was not associated with improved technique. Eye drop technique education occurs infrequently during glaucoma office visits. Future studies should compare the effectiveness of different educational methods, such as patient demonstration versus provider verbal instruction, to determine which method is best at improving patient eye drop technique.

How glaucoma patient characteristics, self-efficacy and patient-provider communication are associated with eye drop technique.

OBJECTIVES: The objective of this study was to examine the extent to which patient characteristics, eye drop technique self-efficacy, and ophthalmologist-patient communication about eye drop administration are associated with glaucoma patients' ability to instil a single drop, have the drop land in the eye, and avoid touching the applicator tip of the medication bottle to the eye or face while self-administering eye drops. METHODS: Glaucoma patients (n = 279) were recruited from six ophthalmology clinics. Medical visits were videotape-recorded. Afterwards, patients were interviewed and demonstrated administering an eye drop on a videotaped-recording. Generalized estimating equations were used to analyse the data. KEY FINDINGS: Ophthalmologists provided eye drop administration instruction to 40 patients. Patients with more years of education were significantly more likely to both instil a single drop (P = 0.017) and have the drop land in their eye (P = 0.017). Women were significantly more likely to touch the applicator tip to their eyes or face (P = 0.014). Patients with severe glaucoma (P = 0.016), women (P = 0.026), and patients who asked at least one eye drop administration question (P = 0.001) were significantly less likely to instil a single drop. Patients with arthritis were significantly less likely to have the drop land in their eye (P = 0.008). African American patients were significantly less likely to touch the applicator tip to their eyes or face (P = 0.008). CONCLUSIONS: Some glaucoma patients have a difficult time self-administering eye drops. As so few patients received eye drop administration instruction from their providers, there is an opportunity for pharmacists to complement care.

Exploring the influence of patient-provider communication on intraocular pressure in glaucoma patients.

OBJECTIVE: We examined whether six patient-provider communication behaviors directly affected the intraocular pressure (IOP) of glaucoma patients or whether patient medication adherence and eye drop technique mediated the relationship between self-efficacy, communication, and IOP. METHODS: During an 8-month, longitudinal study of 279 glaucoma patients and 15 providers, two office visits were videotape-recorded, transcribed, and coded for six patient-provider communication behaviors. Medication adherence was measured electronically and IOP was extracted from medical records. We ran generalized estimating equations to examine the direct effects of communication on IOP and used bootstrapping to test whether medication adherence and eye drop technique mediated the effect of communication on IOP. RESULTS: Provider education about medication adherence (B=-0.50, p<0.05) and inclusion of patient input into the treatment plan (B=-0.35, p<0.05) predicted improved IOP. There was no evidence of significant mediation. CONCLUSION: The positive effects of provider education and provider inclusion of patient input in the treatment plan were not mediated by adherence and eye drop technique. PRACTICE IMPLICATIONS: Providers should educate glaucoma patients about the importance of medication adherence and include patient input into their treatment plan.

Accuracy of Patient-reported Adherence to Glaucoma Medications on a Visual Analog Scale Compared With Electronic Monitors.

PURPOSE: Glaucoma medications can improve clinical outcomes when patients adhere to their medication regimen. Providers often ask patients with glaucoma to self-report their adherence, but the accuracy of self-reporting has received little scientific attention. The purpose of this article was to compare a self-reported medication adherence measure with adherence data collected from Medication Event Monitoring Systems (MEMS) electronic monitors. An additional goal was to identify which patient characteristics were associated with overreporting adherence on the self-reported measure. METHODS: English-speaking adult patients with glaucoma were recruited from 6 ophthalmology practices for this observational cohort study. Patients were interviewed after their initial visit and were given MEMS contains, which recorded adherence over a 60-day period. MEMS percent adherence measured the percentage of the prescribed number of doses taken. MEMS-measured timing adherence assessed the percent doses taken on time. Patients self-reported adherence to their glaucoma medications on a visual analog scale (VAS) ~60 days after the baseline visit. Bivariate analyses and logistic regressions were used to analyze the data. Self-reported medication adherence on the VAS was plotted against MEMS adherence to illustrate the discrepancy between self-reported and electronically monitored adherence. FINDINGS: The analyses included 240 patients who returned their MEMS containers and self-reported medication adherence at the 60-day follow-up visit. Compared with MEMS-measured percent adherence, 31% of patients (n = 75) overestimated their adherence on the VAS. Compared with MEMS-measured timing adherence, 74% (n = 177) of patients overestimated their adherence. For the MEMS-measured percent adherence, logistic regression revealed that patients who were newly prescribed glaucoma medications were significantly more likely to overreport adherence on the VAS (odds ratio, 3.07 [95% CI, 1.22-7.75]). For the MEMS-measured timing adherence, being male (χ(2) test, 6.78; P = 0.009) and being prescribed glaucoma medications dosed multiple times daily (χ(2) test, 4.02; P = 0.045) were significantly associated with patients overreporting adherence. However, only male sex remained a significant predictor of overreporting adherence in the logistic regression (odds ratio, 4.05 [95% CI, 1.73-9.47]). IMPLICATIONS: Many patients with glaucoma, especially those newly diagnosed, overestimated their medication adherence. Because patients were likely to overreport the percent doses taken and timing adherence, providers may want to ask patients additional questions about when they take their glaucoma medications to potentially detect issues with taking these medications on time.

Glaucoma patient expression of medication problems and nonadherence.

PURPOSE: The purpose of this study was to examine if patient demographic factors influenced self-reporting of medication side effects, difficulty with drop instillation, and nonadherence to glaucoma therapy. METHODS: English-speaking adult glaucoma patients (n = 279) from six ophthalmology clinics were enrolled. Patients' medical visits were videotaped and patients were interviewed immediately afterward by research assistants. The videotapes were transcribed verbatim and coded to identify patients who expressed problems with medication side effects, eye drop administration, and nonadherence during the glaucoma office visits. Generalized estimating equations were performed to identify whether patient characteristics were associated with expression of problems with glaucoma medication and medication nonadherence during the office visit. RESULTS: Patients with lower health literacy were significantly less likely to express problems with side effects (odds ratio [OR], 0.47; 95% confidence interval [CI], 0.25 to 0.88) and eye drop administration (OR, 0.26; 95% CI, 0.11 to 0.63) during the visit. Patients who reported eye drop administration and side effect problems during the interview were significantly more likely to express these problems to their ophthalmologist (OR, 3.13; 95% CI, 1.82 to 5.37 and OR, 1.86; 95% CI, 1.12 to 3.08, respectively). Patients who expressed a problem with eye drop administration and with side effects were significantly more likely to express medication nonadherence to their ophthalmologist (OR, 2.89; 95% CI, 1.44 to 5.80 and OR, 2.03; 95% CI, 1.16 to 3.54, respectively). Patients who reported greater than 80% medication adherence during the interview were significantly less likely to express nonadherence to their ophthalmologist (OR, 0.22; 95% CI, 0.12 to 0.40). CONCLUSIONS: Eye care providers should be aware that glaucoma patients with lower health literacy are less likely to express problems with side effects and eye drop administration. Providers should work with patients to assess medication-related problems to mitigate potential barriers to medication adherence because patients who expressed medication problems were also more likely to express nonadherence.

Patient question-asking about glaucoma and glaucoma medications during videotaped medical visits.

We applied the ecologic model of communication in medical consultations to examine how patient, physician, and situational/contextual factors are associated with whether patients ask one or more questions about glaucoma and glaucoma medications during visits to ophthalmologists. Patients with glaucoma who were newly prescribed or already on glaucoma medications were recruited at six ophthalmology clinics. Patients' visits with their doctors were video-recorded and patients were interviewed after visits. Generalized estimating equations were used to analyze the data. Two hundred and seventy-nine patients participated. Patients asked one or more questions about glaucoma during 59% of visits and about glaucoma medications during 48% of visits. Patients who were newly prescribed glaucoma medications were significantly 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 with patient question-asking. Patients were significantly more likely to ask older providers questions about glaucoma medications and female providers questions about glaucoma. Eye care providers should encourage glaucoma patients to ask questions during their medical visits.

Ophthalmologist-patient communication, self-efficacy, and glaucoma medication adherence.

OBJECTIVE: To examine the associations of provider-patient communication, glaucoma medication adherence self-efficacy, and outcome expectations with glaucoma medication adherence. DESIGN: Prospective, observational cohort study. PARTICIPANTS: Two hundred seventy-nine patients with glaucoma who were newly prescribed or taking glaucoma medications were recruited at 6 ophthalmology clinics. METHODS: Patients' visits were video recorded and communication variables were coded using a detailed coding tool developed by the authors. Adherence was measured using Medication Event Monitoring Systems for 60 days after their visits. MAIN OUTCOME MEASURES: The following adherence variables were measured for the 60-day period after their visits: whether the patient took 80% or more of the prescribed doses, percentage of the correct number of prescribed doses taken each day, and percentage of the prescribed doses taken on time. RESULTS: Higher glaucoma medication adherence self-efficacy was associated positively with better adherence with all 3 measures. Black race was associated negatively with percentage of the correct number of doses taken each day (ß = -0.16; P < 0.05) and whether the patient took 80% or more of the prescribed doses (odds ratio, 0.37; 95% confidence interval, 0.16-0.86). Physician education about how to administer drops was associated positively with percentage of the correct number of doses taken each day (ß = 0.18; P < 0.01) and percentage of the prescribed doses taken on time (ß = 0.15; P < 0.05). CONCLUSIONS: These findings indicate that provider education about how to administer glaucoma drops and patient glaucoma medication adherence self-efficacy are associated positively with adherence.