The multidimensional nature of health problems, health service settings and their interactions with individual service users implies that the mechanisms supporting or undermining patient attendance at outpatient appointments following receipt of a reminder are likely to be varied, complex and context dependent. Therefore, we sought to develop a comprehensive conceptual framework that could guide our review of the available literature systematically in order to explore the wide range of contextual and mechanistic factors that may influence reminder effectiveness. To construct this framework, we initially conducted a rapid review of our available literature base to identify any prior conceptual models or frameworks that had been employed to explain why and how reminder systems do, or do not, work. It was established early in this process that the majority of the reminder-focused literature was theory light, with a noticeable lack of attention within the identified RCTs to process evaluation that could explain why, how and in what circumstances reminders are effective and there were few and limited theories being advanced by authors to explain reminder system functioning. Indeed, it was apparent that much of the literature was framed very narrowly around the notion that reminders simply remind forgetful patients, with little consideration of the broader range of factors that could be at play.
We identified only one conceptual model specifically about appointment reminder systems. This model, developed by Coomeset al.,22proposes that communication functionality of SMS reminders (e.g. single or multicomponent, interactivity, frequency of reminder, timing of reminder and tailoring of the message) and patient psychosocial factors (e.g. patient involvement, social support, medication adherence, risk behaviours, and health and well-being) could mediate the impact of SMS reminders on health-care quality and health outcomes for people living with a human immunodeficiency virus (HIV) infection.22For the purposes of the current project, this model was limited in two regards: first, it dealt only with SMS reminders rather than the spectrum of available reminders; and, second, it dealt with mechanisms leading to health-care outcomes rather than considering the mechanisms leading to appointment attendance. However, it did identify features of SMS functionality that were potentially useful to consider within our own framework, which aimed to be more comprehensive.
Given the limited theoretical understanding available from the prior literature on reminder systems, it was decided to conduct a focused review of the conceptually close topic area of medical compliance and adherence. It was known to the team that at least some of the research in this area had been theoretically driven and it was decided that this literature could therefore yield conceptual insight of relevance to the topic of the current review. From this literature, we identified a number of conceptual models specifying factors that can explain medical adherence (including appointment attendance behaviour). These were:
l theory of planned behaviour,23which had been adapted to explain attendance at screening appointments,24adherence with psychological therapies25and attendance at a cardiac rehabilitation programme26
l transtheoretical model (also known as‘stages of change’),27which had been adapted to explain adherence with psychological therapies25and attendance at dental check-ups28
l self-determination theory,29which had been used to explain adherence with psychological therapies25 and dental clinic attendance30
l health-care utilisation model,31which has been adapted for use to explain medication adherence.32 A further three models which appeared to have some relevance to our topic of enquiry were also identified during this stage of our work, although they had not been used to guide empirical work on adherence/ attendance specifically. These were:
l protection motivation theory,33which contends that how a person behaves will be broadly explained by a person appraisal of the threat and an appraisal of how to cope with that threat and can, therefore, potentially be related to health behaviours such as making and attending appointments
l rational choice theory, a development of William Glasser’s choice theory34that has been discussed in relation to the role of message framing to motivate healthy behaviours35
l complexity theory,36which provides a scientific framework for understanding complex phenomena in the natural, biological and human sciences.
Although none of the above models specifically dealt with our topic, they provided a useful starting point for mapping out the contextual factors, mechanisms and outcomes that were important to consider in any attempt to explain how reminder systems work, for whom and in which circumstances. In addition to these behavioural models, which were predominantly informed by psychological theory, we also engaged with relevant sociological literature. This approach was in keeping with our desire to develop a comprehensive conceptual framework that mapped the range of influences operating at different levels, thereby seeking to understand the functioning of reminder systems within a broad psychosocial-systems perspective, rather than locating the phenomenon entirely at the individual level. Although our review did not identify any sociologically driven research papers that dealt specifically with responses to appointment reminders, a number of contributions were felt to be useful in relation to expanding our conceptual framework to encompass a broader range of potentially important factors. First, we noted earlier work on the uptake of screening interventions that highlighted the way in which attendance can be understood as a response to normative expectations about what constitutes responsible and legitimate action–a form of moral obligation–rather than an individual choice or decision (e.g. Griffithset al.37on breast screening).38This strand of work can be seen to be influenced by Pierre Bourdieu’s concept of habitus:39the embodiment of social rules, values and dispositions. Individuals, he argues, acquire a‘sense of one’s place’within
hierarchically structured society and include/exclude themselves from goods, persons and places that are inside/outside their social group.39Understanding differential patterns of appointment behaviour between
‘groups’may be enhanced by considering the way in which such behaviours may be supported or
undermined by other taken-for-granted‘ways of being’or‘sticky habits’that exist within particular groups or communities.39Second, we identified work that seeks to highlight the roles of concrete, situated contingencies that shape and constrain behaviours, such as the practical demands of daily living, including health-related adherence/attendance. For instance, Rosenfield and Weinberg38alert us to the need to counter the tendency for adherence research to focus on thought processes, knowledge and beliefs, thereby
overlooking the importance of‘the contours and rhythms of situated domestic practices’.37Understanding more about the day-to-day lives of patients can potentially throw light on how people respond to
appointment reminders. Finally, we saw value in critical sociological contributions that take a more macro focus seeking to explore and expose the linkages between the health-care system and the broader political, economical and social systems of society in historical perspective. Critical theory has enriched various bodies of work exploring patient experiences of health care, revealing the ways in which medical ideology helps to maintain and reproduce class structure (as well as other social divisions, e.g. gender, race/ethnicity). These perspectives tend to challenge the way in which health-related behaviours and their promotion are frequently presented as unproblematic by health professionals and health researchers, while downplaying the complex costs and benefits that may be involved for the patient, particularly patients from more marginalised groups. These sociological contributions complemented the more individualistic focus of the psychological models and allowed us to usefully expand our conceptual framework.
At an operational level, team members drew on this wide-ranging theoretical literature together with evidence gathered during early data extraction and synthesis to develop a series of internal concept notes that were then discussed in team meetings. The multidisciplinary make-up of the project team meant that different members were well placed to engage with different literatures and to produce summaries for the rest of the team to consider. Deliberative discussions were combined with visual tools to iteratively consider alternative ways of representing reminder system functioning, considering:
l Process maps of attendance charting patient decisions, appointment attendance/cancellation/ rescheduling behaviour and consequent outcomes, looking at the day of initially receiving the appointment, the day of receiving a reminder closer to the appointment (if applicable) and, finally, the day of the appointment itself.
l Balance-sheets focusing on patient decision(s) to attend or not, in terms of a weighing-up of the advantages of attending compared with the advantages of not attending. It was felt that, overall, the balance would tend to be weighed heavily in favour of not attending (as this is the easier option for the patient in the short term), but that various factors, including reminder interventions, may help tip the balance the other way.
l A‘tumblers in a safe’model whereby various factors need to align if a patient is to attend the appointment. Such factors include individual patient characteristics, the wider social system (including norms, expectations and enablers such as transport) and the health service system (including flexibility of the appointment system and the effectiveness of the reminder system). Similarly, for an appointment reminder system to be effective, various elements must‘line up’, namely the reminder should be received in time and its content should be accurate, the patient should be receptive and genuinely not forget and the service should be sufficiently flexible to enable cancellation/rebooking.
This process enabled the development of our conceptual framework, which is depicted in its final iteration inFigure 2. In this framework, propositions A–F identify various important contextual elements that are hypothesised to contribute to attendance outcomes. The individual (proposition A) is placed at the centre to convey the centrality of the patient role in deciding whether or not he or she will attend (or at least
intends toattend). Each patient can be perceived as mentally constructing a balance sheet by which they weigh up perceived obstacles to attendance against enablers. The centrality of the patient interaction with the reminder system further indicates its central importance within this review. There are different factors that will influence the‘baseline’of where the patient is‘at’with respect to attendance obstacles or enablers when he or she receives an appointment notification. These include various social factors
(proposition D) and health-care setting factors (proposition C), with the appointment system located at the heart of the latter. The model shows some possible‘distal/proxy attributes’(proposition F)–attributes that could be used to characterise a patient (or patient group) that may tend to give that patient or group a certain‘baseline’or which may predict the effectiveness of different types of reminder system. The reminder system (proposition B), depending on its characteristics and depending on where the patient weights the balance of obstacles/enablers before receiving the reminder, may tip the balance in favour of enablers so that the patient intends to attend. Other factors outside the reminder system per se, but within the control of the health-care system, may be modifiable in order to tip the balance in favour of intention to attend. Finally, the model recognises that there may be individual- and system-level obstacles and enablers to cancellation and rebooking (proposition E) that warrant consideration. An accompanying articulation document expands/explains the elements of the conceptual framework and highlights possible causal pathways between them (seeAppendix 2). These propositions form the basis of our evidence statements and discussions inChapters 4and5.