When Betsy Sleath needs an example of the importance of effective communication between a physician and a patient, she only has to point to the time she had an allergic reaction that caused her to keep breaking badly out in hives.

“I was afraid I was going to go into anaphylaxis; I kept swelling up,” she says. “First I went to a primary care doctor who wasn’t my usual primary care doctor, and that wasn’t very helpful. Then I went to an allergist who did exactly what he should’ve done. He explained everything. Then he gave me a written information sheet that further explained it. Then he had me demonstrate how I would use an EpiPen if I was going into anaphylaxis. He truly made sure that patients understood. Just imagine if you were going into anaphylaxis and you are trying to use your EpiPen and you used it wrong.”

Sleath, a professor in the UNC Eshelman School of Pharmacy, is doing research that could help spawn more effective communication between patients and their heath-care providers. Her work examines the impact that doctor-patient communication has on adherence to medication, mental health, and quality of life. Her current research focuses on four groups: children with asthma, rheumatoid arthritis patients, Latino patients, and glaucoma patients.

“In all my research, my main goal is hoping that the study will help patients somehow, to help them be able to better communicate with their providers or have the providers better communicate with them, to help show that maybe we aren’t educating patients to the best that we can, and that we need to think about how to develop education in the most effective way,” says Sleath, who joined the School’s Division of Pharmaceutical Outcomes and Policy in 1995.

Children with Asthma

Sleath is the principal investigator on a $1.6 million grant from the National Heart Lung and Blood Institute for a project examining how communication between pediatricians and children with asthma and their caregivers is related to asthma control and children outcomes, such as how well the children’s lungs are functioning and whether the children are adherent to the medication.

Also involved in the project are Stephanie Davis, an associate professor in the Department of Pediatrics; Dennis Williams, PharmD, an associate professor at the School; Karin Yeatts, a research assistant professor in the Department of Epidemiology; and Guadalupe Ayala, an assistant professor at San Diego State University who used to be at the UNC School of Public Health.

The study is being conducted in five pediatric practices in North Carolina, mostly in rural areas. Researchers make audio recordings of office visits for children enrolled in the study to examine the interaction with pediatricians.

Sleath says the tapes are currently being transcribed. Researchers will then develop a method for coding the transcripts to assess the communication between pediatricians and patients.

Rheumatoid Arthritis Patients

Sleath is also coprincipal investigator and site principal investigator on a $2 million grant from the National Institute of Aging. The project reunites Sleath with a familiar face from the University of Wisconsin-Madison, where Sleath earned her doctorate. Betty Chewning, a UW School of Pharmacy professor who was on Sleath’s dissertation committee, approached Sleath about designing a study on how communication between rheumatologists and rheumatoid arthritis patients impact medication use.

“That was a great example of team work because that was a $2 million grant,” says Sleath, who also collaborated with Chewning on a paper while completing her doctorate. “It’s hard doing research in two states, but it worked well because we knew each other well.”

The study investigates whether it would help communication to have patients answer questions about their medication and quality of life before they see a physician. While waiting to see their rheumatologists, rheumatoid arthritis patients are given handheld computers with questions. The control group answered questions about exercise and diet, while the experimental group answered questions about medication and quality of life. Both the doctor and the patient receive a printout of the answers before they see each other. Researchers then code audio recordings of the visits to gauge the effectiveness of the communication.

“It’s thought that by asking the patients, getting them to think about it, and giving them a printout of their answers and giving the doctor a printout of the answers, that might lead to better communication and the patients will do better,” Sleath says.

Sleath is currently collecting and analyzing data at the study’s four-year mark. The investigation has already yielded one paper that is under review, which looks at communication about depression in rheumatoid arthritis patients.

“We screened people to see if they have symptoms of depression, and of those people that screened as having moderate to severe symptoms of depression, did they talk about it with their providers,” says Sleath, who has a strong interest in mental health and works with the mental health and aging research groups at the Cecil G. Sheps Center for Health Services Research.

Glaucoma Studies

Sleath has recently begun to work with partners in India and Greece on research about glaucoma patients. In the collaboration in India, she is working with the Aravind Eye Hospitals on a study that examines patients’ adherence to medication.

The study is surveying two hundred and fifty glaucoma patients at an Aravind clinic to examine how adherence and quality of life are impacted by various factors, such as depression, social support, whether the physicians involve the patients when deciding their treatment, what patients expect from eye care, and whether the patients are applying eye drops correctly.

“I was in a part of India where there was not a lot of English spoken except at the hospital,” Sleath says. “The language was called Tamil, which I didn’t know a word of, and a lot of the patients didn’t know English. I had a lot of fun. I was in the waiting area of the glaucoma clinic and working with the study coordinator. The patients were wonderful. I learned how important nonverbal communication is. It really felt like true cross-cultural research.”

Sleath is also helping investigators in Greece with a randomized control trial involving new glaucoma patients and patients whose condition has not improved from treatment. The study educates the patients about their glaucoma medications and examines whether that will lead to better outcomes. One group is receiving education intervention about glaucoma and compliance, while the control group is receiving an intervention about cataracts and macular degeneration. Sleath’s role is to help develop the survey instruments and help decide what should be in the educational intervention. She also helped develop easy-to-understand reminder leaflets for patients.

In addition to the international collaborations, Sleath also has done two studies with Alan Robin, an ophthalmologist at Johns Hopkins University, and David Covert, a scientist at Alcon Research Ltd., on glaucoma compliance in the United States. She is currently trying to get federal funding for another study.

“I’m linking my two worlds,” she says. “I’m now trying to get funding to look at ophthalmologist-patient communication about glaucoma and eye-drop use and how that impacts people’s interocular pressure and how that influences adherence.”

Health-Care Use by Latinos

Sleath has always had a passion for Latino culture. She got a heavy dose of it when she spent two years as a professor at the University of New Mexico before coming to UNC-Chapel Hill, and she still takes a trip to New Mexico every year.

That interest is reflected in her work as well. One of Sleath’s research interests is racial and ethnic disparities in health-care use, and she is finishing up a study that looks at ways to improve pharmacy services for Latinos in North Carolina.

“Latino health care is an important issue that I think we need to study more, especially in our state, where the Latino population has grown a lot,” she says.

“Our whole idea with that study is how we can improve pharmacy services for Latinos, especially those that may not be fluent in English.”

Sleath says patient illiteracy is a problem she has encountered in the U.S. and abroad, and she says it is an issue people aren’t always aware of.

“I use this example with my students: When I was in a Subway trying to get a sandwich, this woman asked the Subway workers what was on a certain kind of sandwich, and they said to her very rudely, ‘It’s up there on the sign,’ ” Sleath says.

“After she left, I said to them, ‘What if she couldn’t read the sign?’ I don’t think we think about that. And my collaborators in Greece and India said the same thing, that illiteracy is a huge problem.”

According to the National Institute for Literacy, more than twenty percent of adults in the U.S. read at or below a fifth grade level.

“That’s a high number,” Sleath says. “One out of five individuals might have difficulty reading a prescription bottle or those leaflets with the tiny print that they sometimes give you. We need to do something.”

Researchers in the project, which received a pilot grant from the UNC Program on Ethnicity, Culture, and Health Outcomes, interviewed 93 Latinos from Orange, Alamance, and Chatham Counties about their use of pharmacies.

“We interviewed Latino individuals from all over,” Sleath says. “We recruited them at pharmacies. We recruited them through the Orange County Healthy Start. We even got a table at a flea market in Mebane, where a lot of Latinos go. We really were trying to get Latinos that were and were not using pharmacies.

“We also asked Latino patients if they bought medicine in their home countries and if they buy them at the tiendas or the Mexican grocery stores. The North Carolina Department of Agriculture is concerned that some of these grocery stores are selling medication from other countries because there’s a danger in that.”