Highlights
- The Support, Educate, Empower (SEE) program achieved a 19.7% absolute improvement in medication adherence compared to standard written education (P < .001).
- Over half (54.9%) of participants in the intervention group achieved the clinical target of ≥80% adherence, more than doubling the rate seen in the control group.
- The intervention utilized a non-physician counselor model, demonstrating the efficacy of task-shifting in busy ophthalmic practices.
- The program significantly reduced glaucoma-related distress, addressing the psychological burden of chronic vision-threatening disease.
Background
Glaucoma remains the leading cause of irreversible blindness globally, with its management heavily dependent on the consistent application of ocular hypotensive therapies. Despite the availability of effective pharmacologic agents, medication nonadherence is a pervasive challenge in clinical ophthalmology. Estimates suggest that nearly half of patients with glaucoma fail to follow their prescribed regimens, leading to accelerated visual field loss, diminished quality of life, and increased healthcare costs.
Traditional approaches to improving adherence have often relied on didactic education or simple reminders, which frequently fail to address the complex behavioral and psychological barriers patients face. These barriers include forgetfulness, difficulty with drop administration, side effects, and the ‘silent’ nature of the disease, which can lead to a lack of perceived urgency. The Support, Educate, Empower (SEE) program was developed to address these multifactorial barriers through a personalized, behavioral-science-based coaching model.
The SEE Program Intervention Model
Behavioral Framework and Motivational Interviewing
The cornerstone of the SEE intervention is Motivational Interviewing (MI), a goal-oriented, client-centered counseling style for eliciting behavior change by helping patients explore and resolve ambivalence. Unlike standard medical advice, which is often prescriptive, MI empowers the patient to identify their own motivators for adherence. The SEE program was administered by trained non-physician counselors, facilitating a more accessible and potentially scalable model for health systems.
Program Components
The 6-month intervention included a structured progression of support:
- In-Person Sessions: Three comprehensive sessions focused on goal setting, barrier identification, and technique training.
- Telehealth Support: Four between-visit phone calls to reinforce goals and troubleshoot adherence challenges in the patient’s home environment.
- Multimedia Education: Personalized materials that tailored information to the patient’s specific disease stage and health literacy level.
- Technological Integration: Automated medication reminders and electronic monitoring via the AdhereTech system, providing real-time data to both the coach and the patient.
Study Design and Methodology
The SEE trial (NCT04735653) was a parallel, 1:1 randomized clinical trial conducted across two major health systems: the University of Michigan and Henry Ford Health System. Between 2021 and 2023, 235 adults were randomized. Eligibility required a self-reported adherence rate of 85% or lower, ensuring the study targeted those most in need of intervention.
Crucially, the primary outcome was measured using objective electronic monitoring rather than self-report, which is known to be subject to social desirability bias. Adherence was calculated as the percentage of doses taken within the prescribed time windows over the 6-month period. This rigorous methodology allowed for a precise quantification of the intervention’s effect size.
Clinical Outcomes and Statistical Significance
Primary Outcome: Medication Adherence
The results revealed a profound disparity between the intervention and control groups. The mean medication adherence in the SEE group was 77.6% (SD 19.7%), whereas the control group (standard care plus mailings) averaged only 58.0% (SD 25.2%). The mean difference of 19.7% (95% CI, 13.7 to 25.6; P < .001) underscores a high degree of clinical and statistical significance.
Furthermore, when examining the proportion of 'adherent' patients (defined as ≥80% of doses taken), 54.9% of the SEE group met this threshold, compared to only 23.7% of the control group. This shift is particularly relevant because adherence levels above 80% are frequently cited in literature as the minimum required to maintain intraocular pressure stability and prevent visual field progression.
Secondary Outcome: Glaucoma-Related Distress
Chronic disease management often imposes a significant psychological toll. The SEE trial investigated changes in glaucoma-related distress as a secondary measure. After adjusting for baseline levels, the intervention group showed a significant reduction in distress (difference -0.3; 95% CI, -0.5 to -0.1). This suggests that personalized coaching not only changes behavior but also improves the patient’s emotional relationship with their condition, potentially fostering long-term resilience.
Expert Commentary
Translational Implications
The success of the SEE program highlights the limitations of ‘usual care,’ which often consists of brief physician instructions and printed pamphlets. The substantial 19.7% adherence gap demonstrates that behavioral interventions can produce effects comparable to adding a new medication class, but without the physiological side effects.
Non-Physician Deployment
A critical insight for health policy experts is the effectiveness of the non-physician counselor. As ophthalmologists face increasing patient volumes, delegating behavioral coaching to trained staff (such as technicians or health coaches) provides a viable path for integrating these services into busy clinical workflows. This ‘task-shifting’ is consistent with broader trends in chronic disease management for diabetes and hypertension.
Limitations and Research Gaps
While the 6-month results are compelling, the long-term durability of the SEE program’s effects remains to be established. Chronic diseases require lifelong adherence, and future research must determine whether ‘booster’ sessions are necessary to maintain these gains. Additionally, while electronic monitoring is the gold standard for research, its cost and logistics may still pose barriers for universal implementation in community practice.
Conclusion
The SEE Randomized Clinical Trial provide high-level evidence that a personalized, motivational interviewing-based coaching program can drastically improve glaucoma medication adherence and reduce patient distress. By moving beyond simple education to address the behavioral drivers of nonadherence, the SEE program offers a scalable framework to preserve vision and improve outcomes for the millions of patients living with glaucoma. Future integration of these behavioral protocols into standard ophthalmic practice could represent a major step forward in preventing avoidable blindness.
References
- Newman-Casey PA, Niziol LM, Lu MC, Darnley-Fisch D, Imami N, Mitchell J, MacKenzie C, Heisler M. Effect of the Support, Educate, Empower Personalized Glaucoma Coaching Program on Medication Adherence: The SEE Program Randomized Clinical Trial. JAMA Ophthalmol. 2026 Feb 26. doi: 10.1001/jamaophthalmol.2026.0001. PMID: 41746659.
- Boland MV, Chang DS, Frazier T, Plyler R, Jefferys JL, Quigley HA. Automated telecommunication to improve adherence with once-daily glaucoma medications. Ophthalmology. 2014;121(4):938-945.
- Newman-Casey PA, et al. The development of a personalized glaucoma coaching program. J Glaucoma. 2015;24(5):e106-112.
