[A] The reminder–patient interaction
A reminder increases intention to attend (and, therefore, likelihood of attendance) when it (1) reduces patient-specific obstacles to attendance and/or (2) increases patient-specific enablers to attend. The patient will intend to attend when the enablers outweigh the obstacles.
We hypothesised that a reminder will tend to increase intention to attend (and, therefore, likelihood of attendance) when it:
[A.1] Reminds a ‘forgetful’ patient of the timing and location of the appointment.
[A.2] Provides information that increases the patient’s perception that attendance at the appointment will positively contributes to his/her well-being (i.e. importance).
[A.3] Provides information that increases the patient’s perception that non-attendance at the appointment will negatively impact on his/her well-being (e.g. for screening appointments, if the patient is asymptomatic).
[A.4] Provides information that reduces the patient’s perceptions that attendance at the appointment will be difficult (e.g. transport issues, navigation of the hospital).
[A.5] Provides information that increases the patient’s perception that his/her experience of the appointment and associated procedures will be positive (e.g. fear, pain, communication difficulties, approachability of clinic/professional).
[A.6] Provides information that increases the patient’s perception of the compatibility between attending the appointment and his/her other commitments (e.g. OK to bring children).
[A.7] Provides information that increases the patient’s perception that attendance at the given appointment is the morally right thing to do.
[B] Reminder accessibility
The impact of a reminder varies between service settings because of variations in the patient population profile and the accessibility of the reminder to patients in different patient subgroups.
We hypothesised that characteristics of the reminder system can influence the accessibility of the reminder for particular patients because:
[B.1] The reminder may or may not be received by the patient.
[B.2] The reminder may or may not be understood by the patient.
[B.3] The content of the reminder may or may not effectively address the obstacles/enablers experienced by the patient in question.
[B.4] The format of the reminder may or may not compromise the delivery of the content to the patient (‘acceptability’, ‘receptivity’, e.g. personalised message from GP may be more effective at allaying fears than a standardised message for some groups).
[B.5] The timing of the reminder may or may not give patient time to address obstacles to attendance.
We identified the following modifiable factors within the reminder system:
timing of reminder
medium of reminder
reminder interactivity
content of reminder (message, language, framing, tone, etc.)
source/bearer of reminder
reminder intensity (frequency, content, ‘reminder plus’/patient navigation).
[C] Health-care setting
The impact of reminder systems on intention to attend (and, therefore, likelihood of attendance) varies between service settings (and patient subgroups) because health-care system factors and patient/procedure-specific factors can influence patient-level obstacles/enablers (i.e. the ‘baseline’ of obstacles/enablers that are potentially modifiable by the reminder).
We hypothesised that:
[C.1] The source of original appointment can influence the patient’s perception that attendance at the appointment will positively contribute to his/her well-being.
[C.2] The timing of the original appointment can influence the patient’s perception of (in)compatibility with other commitments.
[C.3] Service location can influence the patient’s perception that attendance at the appointment will be difficult (e.g. transport issues).
[C.4] Features of the service that impact on patient experience (procedure itself, wait times, provider–patient communication, provider attitudes, etc.) can influence the patient’s perception that his/her experience of the appointment and associated procedures will be positive [and (in)compatibility with other commitments].
[C.5] Whether the appointment is a first appointment or a follow-up appointment can influence the patient’s perception that attendance at the appointment will positively contribute to his/her well-being.
[C.6] A patient’s previous appointment attendance behaviour may predict future attendance at similar appointments.
We identified the following modifiable factors:
Within the reminder system
content reinforcing the benefits of attending the appointment for first or follow-up appointments as applicable
content reinforcing the benefits of attending the appointment for patients with a poor attendance history.
Without the reminder system
identity of sender of original appointment invitations
procedure for setting timing of original appointment, e.g. patient involvement, consideration of patient characteristics including past attendance patterns – mobile clinics, outreach services, drop-ins
staff training reduces wait times; ways in which procedures delivered (discomfort, etc.).
[D] Wider social systems
The a impact of reminder systems on intention to attend (and, therefore, likelihood of attendance) varies between service settings (and patient subgroups) because the wider social systems within which patient subgroups are situated vary and elements of these can influence reminder accessibility and patient-level obstacles/enablers (i.e. the ‘baseline’ of obstacles/enablers that are potentially modifiable by the reminder).
We hypothesised that:
[D.1] Prevailing norms of behaviour and attitudes can influence patient perceptions that attendance at the appointment will positively contribute to his/her well-being (e.g. understandings of the condition and potential for intervention by mainstream health care).
[D.2] Prevailing norms of behaviour and attitudes can influence the patient’s perception that non-attendance at the appointment will negatively impact on his/her well-being (e.g. understanding of the condition and its severity, general trust in medical intervention vs. other ways of managing the condition).
[D.3] Prevailing norms of behaviour and attitudes can influence the patient’s perception that attendance at the appointment will be difficult (e.g. general attitudes to moving outside own locality, wider experiences of discrimination in society, etc.)
[D.4] Prevailing norms of behaviour and attitudes can influence the patient’s perceptions that experience of the appointment and associated procedures will be positive/negative (e.g. stories circulating of other people’s bad experiences).
[D.5] Prevailing norms of behaviour and attitudes can influence the patient perceptions that attending the appointment is compatible with other commitments [e.g. (il)legitimacy of a wife attending an appointment if she is caring for a sick husband].
[D.6] Prevailing norms of behaviour and attitudes can influence patient perceptions that attending the appointment is the morally right thing to do (e.g. local understandings of entitlements, responsible behaviour, state funding, etc.)
[D.7] Structural factors (e.g. transport links, availability of child care, availability of someone to go with patient) can influence the patient’s perception that attendance at appointment will be difficult and/or incompatible with other commitments.
In recognising that the wider social system can influence the accessibility of the reminder to some patients, we hypothesised that:
[D.8] Prevailing norms of behaviour and attitudes can influence the accessibility of the reminder to the patient (e.g. high levels of mistrust of government may mean that patients are not receptive to a reminder delivered by the health-care system – perhaps thrown away, fear of technology).
[D.9] Structural factors can influence the accessibility of the reminder to the patient (e.g. lack of landline phones, mobile populations).
We identified the following modifiable factors:
Within the reminder system:
careful framing of content of reminder to address specific attitudes/understandings known to be prevalent within particular communities/patient groups
interactivity of reminders that allow patients to seek answers/information that address their own concerns/obstacles
careful choice of medium of reminder so that it reaches the intended recipient
careful choice of source/bearer of reminder to ensure receptivity
careful presentation of content so that it is comprehensible to the intended recipient.
Without the reminder system:
wider communications campaigns
interventions within health-care system to address issues of quality of care, cultural competence, etc.
[E] Cancellation and rebooking
Intention to attend may not result in attendance because additional obstacles can arise for patients who would otherwise intend to attend. This will include patients whose intention to attend has been influenced by the reminder (i.e. whose obstacles–enablers balance has been shifted by the reminder) and those who already intended to intend but for whom the timing/location was not convenient.
We hypothesised that, in the case of patients who intend to take up the offer of an appointment, whether or not they cancel and rebook will be influenced by:
[E.1] The patient’s perception of how easy it is to rebook.
[E.2] System factors that facilitate/hamper the patient’s intention to rebook (e.g. nobody answers the phone).
[E.3] Structural factors that facilitate/hamper the patient’s intention to rebook (e.g. has to be done online and no internet access).
We hypothesised that, in the case of patients who have no intention of taking up the offer of an appointment, whether or not they cancel the appointment will be influenced by:
[E.4] The patient’s perception of how easy it is to cancel.
[E.5] System factors that facilitate/hamper the patient’s intention to cancel (e.g. nobody answers the phone).
[E.6] Structural factors that facilitate/hamper the patient’s intention to cancel (e.g. has to be done online and no internet access).
[E.7] The patient’s perception that cancelling the appointment is the morally right thing to do.
We also recognised that elements of the health-care system, wider social system and reminder system will influence the likelihood that a patient will cancel or rebook.
[F] Distal/proxy attributes
A range of factors can act as markers/proxies for proximate individual factors that are enablers or obstacles to attendance.
We hypothesised that, at a service setting level, this information could be used to judge the likely effectiveness of a particular reminder approach given the patient population profile, or to explain why the impact of a reminder system differs from that observed in other settings.
