Content uploaded by Danie G Van Zyl
Author content
All content in this area was uploaded by Danie G Van Zyl on Oct 19, 2016
Content may be subject to copyright.
106
Original Research: Factors influencing non-attendance of clinic appointments in diabetic patients
2009 Volume 14 No 2JEMDSA
Factors inuencing non-attendance of clinic appointments
in diabetic patients at a Gauteng hospital in 2007/2008
a Ngwenya BT, Post graduate student b van Zyl DG, MBChB, DipPec, FCP(SA), MMed(Int), MSc(ClinEpid) a Webb EM, BSc(Agric)(Genetics), MPH(Pret)
a School of Health Systems and Public Health, University of Pretoria, South Africa b Department of Internal Medicine, University of Pretoria, South Africa
Correspondence to: Dr D van Zyl, e-mail: dgvanzyl@kalafong.up.ac.za
Introduction
Diabetes is the fourth leading cause of non-violent death globally.
Without urgent action being taken, diabetes-related deaths are
set to increase by more than 50% over the next 10 years.1 Unless
preventative measures are taken, 380 million people worldwide will
have diabetes by 2025, with the largest increase occurring in the
developing countries, of which most are in Africa.2
Diabetes is responsible for multiple serious long-term health
complications. These include diabetic neuropathy; retinopathy,
nephropathy and macrovascular disease, which can lead, and
contribute, to significant morbidity related to foot ulcer amputations;
renal failure, coronary heart disease and stroke.
In Africa diabetes was virtually unknown decades ago but has now
become a disease of major public health concern. The exact extent
of the problem in Africa is not well understood, since the disease is
not a research priority.
In developing countries, diabetes is frequently diagnosed in people
aged between 35 and 64, implying that diabetes is impacting on
people during their most economically productive years.3
Currently, the health systems in Africa are already overwhelmed
with communicable diseases, such as TB, malaria, and HIV/AIDS.
The rise in diabetes prevalence has the potential of further straining
the capacity of many national health care systems and thereby
negatively affecting the quality of life of millions on the continent.
In sub-Saharan Africa, diabetes is already a major contributor to ill
health, with the overall burden currently being placed on the health
system.4
Diabetes is an incurable disease and hence the treatment offered
to diabetes patients aims to minimise complications and maximise
quality of life. Diabetes requires regular and structured follow-
up and surveillance by health professionals.5 Non-attendance of
appointments is one of the major contributors to poor control in
diabetic patients.6 Greater compliance may be associated with a
decreased probability of diabetes-related complications.7
Abstract
Objective: To determine the factors influencing non-attendance with clinic appointments in diabetic patients at a Gauteng Hospital in
2007/2008,
Setting: Two diabetes clinics situated at a secondary-level hospital, that offer more specialised outpatient care to adult patients with type
1 and 2 diabetes.
Design: Between 21 November 2007 and 12 March 2008, a convenience sample of consecutive non-attending diabetic patients (n = 76)
was prospectively recruited for the study. A survey of the non-attending patients was conducted, using two data collection methods, namely
face-to-face interviews and telephone interviews. Patient demographics, reasons for non-attendance, perceived severity of diabetes, and
perceived encouragement from others to attend were investigated. The characteristics of the non-attending patients and the reasons for
non-attendance were explored.
Results: Of the 520 patients who were booked during the study period, 35% were not compliant with their clinic visit. The mean age of the
patients was 51 years (range 18–85). All patients perceived diabetes to be a serious disease. Of the interviewed patients, 83% perceived their
health to be either good or excellent, and 95% claimed that a clinic visit assisted them in managing their diabetes. Only 20% of the patients
diarised their appointment dates, while the rest simply used the appointment card given by the clinic. Patients had various reasons for not
complying with their clinic appointments, with forgetting being the most frequently dominant response (22%).
Conclusion: Forgetfulness, which was found to be the major cause of non-attendance, can easily be addressed in ensuring the attendance
of scheduled clinic visits.
JEMDSA 2009;14(2):106-109
107
Original Research: Factors influencing non-attendance of clinic appointments in diabetic patients
2009 Volume 14 No 2JEMDSA
Numerous studies have been conducted to investigate the
characteristics of the non-attending patient, and the reasons for
patients’ non-attendance of health care appointments.7-10 Some of the
studies have revealed the effects of non-attendance on the patient,
as well as the effects on the quality of service provision at the health
care facility. Other studies have shown that non-attendance brings
about undesirable results for both patients and clinic personnel.
Non-adherence to diabetes treatment strategies prevents patients
from receiving optimal care.8 Jacobsen et al9 found that 34% of
patients with type 1 diabetes who defaulted from care had poor
glycaemic control, compared to those who kept their appointments.
Patients who miss appointments also miss opportunities for
detecting complications and treatment adjustments and, as a result,
may experience poorer patient outcomes.
Non-attendance of appointments also disrupts the management
of patients, in that the hospital clerks have to waste time locating
records and preparing for patients who fail to arrive. Patients who
need immediate care may also be required to wait longer to be seen
because of a high (unanticipated) turnout of unscheduled patients.
The efficiency of the health system is thus hindered.8
A study evaluating the financial significance of failed appointments
revealed that non-attendance results in allocated resources not being
utilised.10 For example, staff get paid, even when patients do not
attend. Cost increases of this nature are unwelcome in developing
countries, where resources are already very limited.
Various reasons for missing appointments have been reported
in different studies and these include forgetfulness, financial or
transportation issues, feeling that the appointment was unimportant,
an inability to get time off from work, feeling too ill, administrative
errors, and long waiting times.7-11
A Medline search revealed that only a few studies on compliance
with appointments have been done in Africa. Among these, none has
been done specifically for diabetic patients.
This study seeks to identify the characteristics of non-attending
patients and to determine the reasons for the non-attendance of
clinic appointments in diabetes patients being treated at Kalafong
Hospital in Pretoria, South Africa. It is hoped that the outcome of this
study will aid in the formulation of strategies aimed at reducing the
incidence of non-attendance.
Kalafong Hospital is a secondary-level hospital, with two diabetes
clinics that offer specialised outpatient care to adult patients with
type 1 and 2 diabetes. The clinics are attended by patients with
a type of diabetes and/or hypertension that is difficult to control,
diabetes-related complications or a need for treatment that is not
available at primary health care level.
The two clinics operate from 08:00–13:00 on Wednesdays and
Fridays. An appointment system is used by both clinics in order to
manage the number of patients attending the clinic each day. Each
consultation is managed according to a structured consultation
schedule, which includes an eye examination, a foot examination
and a kidney function test. Appointments are arranged to ensure that
each patient visits the clinic four times a year (i.e. once a quarter).
Both clinics keep records of the patients booked for a certain clinic
date, as well as of their actual attendance.
A problem with non-attendance of such clinic appointments was
noted by the clinic staff. Some patients fail to turn up for their
appointments, whereas some turn up on a date later than that
scheduled. Though a maximum of 40 patients were booked for
each clinic per day, an average of seven patients per day attended
without an appointment, with an average of eight patients per day
missing their appointment. The low rate of compliance with clinic
appointments was of concern for the physicians at both the diabetes
clinics. Prior to the current study, the reasons for non-attendance
had not been examined.
Materials and methods
A sample of consecutively non-attending diabetic patients who were
willing to participate in the study were prospectively recruited for the
study. All patients included in the study were older than 18 years,
and able to speak and understand English or Northern Sotho. The
patients had to be receiving outpatient diabetic treatment from one
of the two diabetes clinics at Kalafong Hospital during the study
period (i.e. November 2007 to March 2008).
Non-attending patients were defined as patients who missed at least
one appointment with the diabetes clinics. Patients who attended
the clinics without a prior appointment, and having missed their
previous appointment, were also classified as non-attending, and,
as a result, were considered for the study. All non-attending patients
must have had, and attended, a previous clinic appointment, in
order to be included in the study. Clinic appointment records and
attendance registers were used to identify those patients who had
missed appointments at the clinic.
Two data collection methods were used in this study. Non-attending
patients who visited the clinic after the appointment date were asked
to consent to a face-to-face interview. Those for whom contact details
were available, who failed to turn up for an appointment, were phoned
within seven days of the previous appointment date, and were also
asked to consent to participate in the study telephonically.
A semi-structured questionnaire (available online as Appendix 1)
was used to collect the data, with each interview taking an average
of seven minutes. The questionnaire investigated, among other
issues, the perceived severity of the patient’s diabetes, the amount
of perceived encouragement from others to attend, the perceived
obligation to attend the visit, and the perceived difficulty with
attending the clinic.
All data were entered using EpiData-Entry 3.1. STATA 10 was used
to analyse the data. Other statistical packages, such as EpiData-
Analysis, were also used, where appropriate.
The study protocol was submitted and approved by the Ethics
Committee of the Faculty of Health Sciences of the University of
Pretoria. Informed consent was obtained from all the participants
in the study.
Results
During the study period, 520 patients were booked to attend the
diabetes clinic and 182 patients missed an appointment. Seventy-
four patients could not be contacted to participate in the study. The
reasons for not being able to contact patients were: incorrect contact
details recorded in the hospital files; patients’ telephone number
108
Original Research: Factors influencing non-attendance of clinic appointments in diabetic patients
2009 Volume 14 No 2JEMDSA
having changed; patients giving phone numbers of relatives living
apart from them; and patients not answering when phoned (after
more than three attempts to phone them at different times). As a
result, only 76 participated in the study (see Figure 1).
The mean age of the patients was 51.30 years (SD 14.01). Of the
non-attending patients, 59% were married. The unemployment rate
was high (43%), with 55% of the patients having only a primary
education, or less (see Table I).
In response to being asked why it is important to control hypertension
and diabetes, most (49%) patients stated that they perceived death
to be a major risk, followed by stroke (22%), while 19% mentioned
fainting, dizziness and weakness as the possible result of uncontrolled
hypertension and diabetes. Blindness (9%) and kidney failure (1%)
were perceived as unimportant risks in relation to uncontrolled
hypertension and diabetes.
Of the interviewed patients, 83% perceived their health to be either
good or excellent. The patients were asked how likely they thought
they were to develop serious complications due to diabetes. Despite
patients being very optimistic about their current health status, 74%
expressed a belief that they are very likely to develop diabetes-
related complications.
Of the participants, 95% claimed that a visit to the clinic assisted
them with managing their diabetes. Only 20% of the patients diarised
the appointment dates, while the rest simply used the appointment
card given by the clinic.
Only 46 (60%) of the patients interviewed had someone who
assisted them to keep to an appointment. Difficulty with keeping a
clinic appointment was expressed by 3 of the 76 patients. Two of the
three patients stated that they live far from the clinic and suggested
that they would prefer to be transferred to a clinic nearer to where
they stay. The third patient claimed that it was difficult to keep an
appointment due to financial constraints. The patient did not know
that it was government policy to be treated even if you cannot pay
for such treatment.
When asked where they had to wait the longest when coming to
hospital to attend the clinics, 64 patients (85%) indicated that they
wait the longest at the hospital pharmacy, while 6 (8%) indicated that
they had to wait the longest for the administrative clerks, and 5 (7%)
for the doctors and sisters, at the clinics.
Fifty-three patients (70%) reported using minibus taxis, 11 (14%)
private vehicles, 7 (9%) buses, and 5 (7%) trains to get to the
hospital. Patients took an average 48.86 min (SD 41.34) to travel
to the clinics.
Most of the patients (69 = 91%) reported having to rely exclusively on
the Kalafong diabetes clinics for the management of their diabetes.
Of the 7 (9%) who sought alternative care, 3 consulted a private
doctor.
All the patients stated that keeping a clinic appointment was
important to them. The reasons for missing clinic appointments
are illustrated in Table II. Patients had various reasons for missing
clinic appointments, with 22% of the responses being forgetfulness.
No patient mentioned that the clinic appointment system was an
obstacle to their compliance with clinic appointments. Instead, only
individual patient factors were given as reasons for missing an
appointment.
When asked whether receiving a reminder of an appointment
would help to boost attendance, 68 of the patients affirmed that
such a reminder would help. Of the 68, 69.7% preferred receiving
a telephone call, 28.8% preferred receiving an SMS, and 1.5%
preferred another method of communication (e.g. the mail service).
Discussion
This study sought to identify factors influencing the non-attendance
of clinic appointments by diabetic patients. The major reason given
for not complying with an appointment was forgetting, followed by
being out of town on the day of appointment, financial problems,
and work/school commitments. The findings are consistent with
other studies, which also mention forgetting as the major reason
for missing clinic appointments.7,9,11 Some of the reasons given for
not attending clinic appointments are impossible for the clinic to
address, such as bad weather, funerals and travel out of town. In
such cases, it is recommended that the patients be encouraged to
reschedule their clinic appointment before the set date.
520 booked patients
91 attempted interviews
76 were interviewed
14 had no phones
74 could not be reached
3 had died
15 refused to
participate in the study
182 non-attendants 338 attendants
Figure 1: Flow chart of patients selected.
Table I: Characteristics of patients who participated in the study
Variable N (76) (%)
Female 40 (52.6)
Marital status
Never married 19 (25.0)
Married 45 (59.2)
Separated/Divorced 3 (3.9)
Widowed 9 (11.8)
Education
Primary school or less 42 (55.3)
High school 24 (31.6)
Trade/Diploma 7 (9.2)
Degree 3 (3.9)
Employment
Full-time 15 (19.7)
Part-time 15 (19.7)
Home duties/Unemployed 33 (43.4)
Student 1 (1.3)
Retired 11 (14.5)
109
Original Research: Factors influencing non-attendance of clinic appointments in diabetic patients
2009 Volume 14 No 2JEMDSA
One way of improving compliance to clinic visits would be improved
the diabetes care at the local primary health care clinics, so that the
patients can receive care closer to their homes.
Studies have shown that landline telephone or cellular phone
reminders may reduce non-attendance.11 However, a more
comprehensive intervention is required in the Kalafong situation,
where some patients have access to cellular phones, some have
landline telephone access, and others do not have ready access to
telephonic contact. Some of the latter, on registration, had given the
cellular phone numbers of their next of kin or the landline telephone
numbers of their neighbours. In many instances, the patients either
did not reside with the next of kin whose numbers were given, or
had no access to the phone for most of the day. A high turnover in
cell phone numbers contributed to the large number of unreachable
patients. It was therefore found necessary to confirm the correct
phone numbers on each visit of the patient to the clinic. The patients
should be informed of why it is important to provide reliable contact
information to the medical authorities.
The clinic may also provide counselling and education to all non-
attendant patients. The clinic should consider using positive
reinforcement, and giving incentives to every attending patient.
Care providers need to be aware of both their positive and
negative communication skills, which may also impact on clinic
attendance.11
The recruitment process for the present study focused on those
patients who came to the clinics without an appointment, having
missed a prior appointment, as well as those with cellular phones or
landline telephones. This might be a limitation on the study, as non-
attendant patients who did not attend one of the clinics throughout
the study period, and who had no cellular phone or landline
telephone were excluded from the study. This could introduce bias
into the study, especially if the excluded group differs distinctly from
the study group i.e. the excluded group being poorer and hence not
able to afford phones.
The non-attendance of clinic appointments impacts negatively on
patient care, since patients may miss out on the opportunity to
receive treatment or screening for the complications of diabetes.
Furthermore, the non-attendance of prescheduled appointments
adds to the frustrations of health care providers who already have
difficulty in planning the patient load at the clinics. More studies
need to be done in possible interventions to reduce non-compliance,
especially for diabetic patients in Africa.
References
1. World Health Organisation. Diabetes. Available from http://www.who.int/mediacentre/factsheets/
fs312/en/index.html. (Accessed 08/08/2007)
2. World Diabetes Foundation. Diabetes and non-communicable diseases – now considered as big a
threat to Africa as HIV/AIDS. Available from www.worlddiabetesfoundation.org/media(3781,1033)/
WDFpressreleaseEN.pdf.pdf. (Accessed 08/08/2007)
3. International Insulin Foundation. Diabetes in sub Saharan Africa. Available from www.access2insulin.
org/Factsheet.PDF. (Accessed 08/08/2007)
4. Mbanya JC, Kengne AP, Assah F. Diabetes care in Africa. Lancet. 2006;11:1628–9.
5. Williams R. Diabetes mellitus. In: Stevens A, Raftery J, eds. Health care needs assessment reviews.
Oxford: Radcliffe Medical Press; 1994.
6. Mollentze W F, Koning J M M. Where have all the diabetics gone? S Afr Med J. 2007;97:6.
7. Griffin SJ. Lost to follow-up: the problem of defaulters from diabetes clinics. Diabet Med, 1998;15
(Suppl 3):S14–S24.
8. Benoit SR, Ji M, Fleming R, Philis-Tsimikas A. Predictors of dropouts from a San Diego diabetes
program: a case control study. Prev Chronic Dis 2004;1:1–8.
9. Jacobson AM, Adler AG, Derby L, Anderson BJ, Wolfsdorf JI. Clinic attendance and glycemic control.
Diabetes Care 1991;14:599–601.
10. Moore CG, Wilson-Witherspoon P, Probst JC. Time and money: effects of no-shows at a family
practice residency clinic. Fam Med 2001;33:522–7.
11. Pieper B, DiNardo E. Pearls for practice: reasons for missing appointments in an outpatient clinic for
indigent adults. JAANP 1998;10:359–364.
Table II: Reasons given for missing an appointment
Reason No of responses
received %
Forgot the appointment date 17 22
Was out of town at the time 12 15
Could not afford to attend the clinic 10 13
At work/school and could not take leave to attend clinic 8 10
Had to attend a funeral on the appointment date 7 8.9
Got dates mixed up 4 5.1
Lost clinic appointment card giving the appointment date 3 3.8
Had no transport to the clinic 3 3.8
Had to baby-sit/did not have a baby-sitter 2 2.5
Could not walk, due to illness 2 2.5
Had some other personal appointment 2 2.5
Could not read my appointment card, due to bad
eyesight 2 2.5
Misunderstood appointment requirements 2 2.5
Claims did attend 2 2.5
Arrived late at the clinic and found it closed 1 1.3
Weather was bad (i.e. raining) 1 1.3
Was an in-patient at the hospital on clinic day 1 1.3
TOTAL 79 100
Note: Due to the question allowing for multiple responses, the total number of responses is more than 76
(i.e. the number of respondents).
Original Research: Factors influencing non-attendance of clinic appointments in diabetic patients
2009 Volume 14 No 2JEMDSA
Appendix 1: Questionnaire
Q1. How old are you? _______________________________
Q2. What is your date of birth? _________________________
Q3. What is your gender? _____________________________
Q4. What is your marital status? ________________________
Q5. What is your race? ______________________________
Q6. How much schooling have you had? __________________
_____________________________________________
Q7. What is your current employment status?
_____________________________________________
Q8. Do you think diabetes is a serious disease?
_____________________________________________
Q9. Why is it necessary to control diabetes and high blood
pressure? _____________________________________
_____________________________________________
Q10. How do you rate your health? ______________________
_____________________________________________
Q11. How likely is it that you will have serious complications
because of your diabetes?
_____________________________________________
Q12. How useful do you consider a visit to the diabetes clinic?
_____________________________________________
Q13. Has a clinic visit assisted you in your diabetes management?
_____________________________________________
Q14. Do you write (on calendar or diary) the day of your next
diabetes clinic appointment?
_____________________________________________
Q15. Who assists you in keeping to an appointment?
_____________________________________________
Q16. How effective do you think is a diabetes clinic visit in helping
you to manage diabetes?
_____________________________________________
Q17. How important do you think is it to keep a diabetes clinic
appointment?
Q18. How easy is it for you to keep a clinic appointment?
_____________________________________________
Q19. If your response to Q18, is difficult or very difficult, please give
reasons why ___________________________________
_____________________________________________
_____________________________________________
Q20. If you attend the diabetes clinic where do you wait the
longest? (Choose one only) ________________________
_____________________________________________
Q21. How often does seeing the doctor fulfill your expectations?
_____________________________________________
Q22. In general, how satisfied are you with the service at the clinic?
_____________________________________________
Q23. What mode of transport do you use when coming for an
appointment? ___________________________________
_____________________________________________
Q24. How long does it usually take you to travel to hospital?
……hours ……min
Q25. Have you sought an alternative care facility for your diabetes
other than Kalafong diabetes clinic? __________________
Q26. If yes which one? _______________________________
Q27. Are you aware that you missed a clinic appointment at the
diabetes clinic on? ___________________________ (date)
Q28. Why did you miss the appointment? __________________
_____________________________________________
_____________________________________________
Q29. In relation to your response to Q28, what will help you not to
miss future appointments? ________________________
_____________________________________________
_____________________________________________
_____________________________________________
Q30. Would a reminder before the appointment day assist you?
_____________________________________________
Q31. If yes, in what format will you prefer the reminder?
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
