Communication With Low-Income Women Using Today's Technology
This section will describe the study setting and sample, along with the procedures used to collect the data and the data analysis. It will also present findings, discuss the implications of these findings in light of both our clinic patients and mobile technology trends in healthcare, and consider the limitations of this study.
This study was conducted at an academic, Magnet®-designated hospital center OB-GYN clinic in the Midwestern US. A cross-sectional interview/survey design was used. The clinic served primarily low-income, inner city women, approximately 80% of which were African American, 10% Caucasian, and 10% of another ethnicity. Approximately 90% of the participants lived below the 2010 federal poverty guidelines. Medicaid insured 80% of the clinic patients; 5% were privately insured with high co-pay, low-coverage plans; and the remaining 15% were self-pay. In this clinic five advanced practice nurses and 27 residents in obstetrics and gynecology conducted 24,000 visits annually with visits scheduled throughout the week for prenatal care, gynecological care, and colposcopy examinations. The Institutional Review Board of the hospital and university medical school affiliate approved this study prior to data collection.
The 60 participants in this study included African Americans (80%), Caucasians (10%), and members of other ethnic groups (10%). Fifty two of the participants were younger than 36 years of age.
The convenience sample was recruited from daily clinic appointment records that listed missed appointments. A specific day each week was selected for data collection, starting with Monday and advancing by one day each week to ensure that all days of the week were included in this study. Our intention was to collect data each week. However, during some weeks trained clinic staff members were not available to make phone calls for data collection purposes. When this occurred, the data collection day was advanced in the following week when data collection resumed. Data collection continued until an endpoint where saturation of descriptive findings was evident and sample size (N=60) was sufficiently large to meet the aims of this study (Morse, 1995).
Participants were clinic patients, 18 years of age or older, who had both provided a contact telephone number and missed a scheduled appointment for prenatal care, gynecologic care, or colposcopy examination within the previous two weeks. At the time this study was conducted, patients were routinely asked to provide a landline or 'home' phone number, and this was the number used to call the patient. Both new and returning patients of nurse practitioners and OB-GYN residents were contacted and invited to participate in the study. This method of sampling was utilized to promote a representative sample of the overall clinic population. The data collection occurred among both gynecologic and obstetric patients and was equally distributed on all five days of the week.
Five clinic staff members were trained to conduct interviews by phone to the selected patients and, using an interview guide, to collect information about the circumstances contributing to a recent missed appointment. Interviewers invited and recorded qualitative comments, in addition to the survey responses, so as to provide more depth to our understanding of missed appointments. A maximum of three calls was made to each potential participant. Once the participants were reached by phone, they were provided with a description of the study and asked if they would participate in a five to seven minute telephone interview. If they consented, a code number was assigned to maintain confidentiality of responses.
Participants were asked several yes/no questions and one open-ended question about the circumstances of their missed appointment. The yes/no questions, listed in Table 1, were based on information gathered from the literature as well as from observations made by clinic staff. To minimize the possibility of influencing the participants' replies, interviewers were cautioned to ask questions in a straightforward manner and to follow the interview guide. As an additional safeguard, participants were informed that one of the aims of the research project was to determine what actions the clinic might take to help patients attend their scheduled appointments. This information was important because we did not want participants to feel embarrassed about missing a prior appointment; rather we wanted to create an environment where they would feel comfortable giving their honest responses and opinions. Participants were asked to give the main reason for their missed appointment.
Before concluding the interview, participants were asked whether they had tried to cancel their appointment and whether they had encountered any difficulties when they attempted to cancel. Participants were also asked whether they had rescheduled their missed appointment. If they had not yet rescheduled, the interviewer offered to assist them in rescheduling.
The responses to the interview questions were collected on an interview response form designed to collect both closed- and open-ended responses. The responses were then coded and included with the participant's age and information regarding visit type. Although the sample was too small and homogeneous for inferential statistical analysis, we did use STATA (StataCorp, College Station, TX) to analyze the data. We focused on descriptive analyses and an independent samples t-test to compare the mean age of those who were not aware that they had missed an appointment and those who were aware.
Data collection was carried out over a five-month period of time. A total of 175 phone calls were made to 95 patients who had recently missed appointments. Of these, 63 patients were successfully contacted and all but 3 agreed to participate in a brief interview. Ages of the 60 participants ranged from 18 to 55 (M = 27.33, SD = 8.4). The participants were predominantly young women, with 86.7% (n = 52) younger than 36 years of age. This age distribution was representative of the population of our clinic. The ages of the 32 who were not successfully contacted ranged from 18 to 35 (M = 24.44, SD = 4.59).
The reasons reported for missed appointments at this clinic are provided in Table 2 which gives the main reason for each missed appointment. Nearly 27% of the participants (n=16) reported that they had forgotten that they had an appointment; 8.3% (n = 5) reported that they were confused about the date and/or time of the appointment. Furthermore, 5% (n = 3) of the sample said that they did not recall being informed about their upcoming appointments. An administrative error of this nature typically happens when a patient is transferred from an outside clinic or between services within the hospital ambulatory care system. Clinic secretaries make the requested appointment but may fail to contact the patient with the appointment information.
The mean age of those who were not aware of a missed appointment was 28 years (M=28.11, SD=9.44), compared to the mean age of those who were aware which was 26.5 years (M=26.55, SD=7.63); t(58)=0.67, p=0.5). Hence this difference was not statistically significant. Taken together, over 40% of the sample reported missing a recent appointment due to forgetfulness, appointment-time confusion, or administrative error.
Nearly 17% (n = 10) of the sample identified transportation problems as the main reason for the missed appointment, while 15% (n = 9) reported work or school conflicts. Other reasons, such as childcare issues, personal illness, family issues, no insurance, and oversleeping were cited by a smaller number of participants as shown in Table 2. No significant relationships were found between the type of visit (new vs. return visit) and the missed-appointment reason.
When asked whether they had received a phone call and postal mail reminder of their upcoming visit, only 30% (n = 18) of the participants remembered receiving even one of these reminders. These findings suggest that phone calls and mailed reminders were not very effective for this sample.
When asked if they had a cell phone for personal use, and if they would like a text-message reminder of an upcoming appointment, all but one participant replied that they had a cellular phone for personal use, and 95% (n = 57) stated that they would like to have a text-message reminder for their upcoming appointments. Some respondents were quite enthusiastic about this option. Of the three participants who did not want a text-message reminder, two stated that they did not know how to use text messaging while the third participant said that she did not currently have a cellular phone. The two participants who did not know how to use text messaging were over 40 years of age.
The majority of the sample indicated that although they would like a text-message reminder, they were in favor of phone and postal mail reminders as well. It was not possible to determine specific reminder preferences because most of the participants declined to specify; 11.7% (n = 7) indicated that they would also like to have a phone call reminder while 68.3% (n = 41) indicated that they would like all three reminders.
Of interest, a subgroup of 16.7% of the participants (n = 10), whose mean and median age was 27 years, stated that they did not want either a telephone or letter reminder, only a text message. Reasons given for a missed appointment in this subgroup included forgetfulness, transportation problems, and school or work conflicts. Anecdotally, a few of the participants in this subgroup mentioned that they were very busy with jobs and children and did not always check voice or postal mail. Hence they would likely miss a reminder left by either of these methods, while they would more easily receive a text message.
We also inquired about appointment cancellation. Of the 36 participants who missed appointments for reasons other than forgetfulness, confusion, or administrative error, 94.4% (n = 34) indicated that they had not tried to cancel in advance of the appointment time. Two participants reported that they had tried to cancel their appointments but were unsuccessful because the appointment desk was closed for lunch. They did not leave a message or call back after the lunch hour suggesting that the cancellation process needs to be convenient for patients in order to be effective.
Overall we found that 40% of low-income, inner city women who missed a recent appointment at an inner city OB-GYN clinic either forgot they had an appointment, were confused about the date and/or time of the appointment, or missed an appointment due to administrative error. Importantly, we found that 70% of the sample indicated that they did not recall receiving either a phone call or letter reminder of the upcoming appointment although reminder phone calls and postal letters were standard practice. More effective appointment reminders could potentially improve clinic attendance.
Ninety-five percent of the sample indicated that they would like a text message reminder of an upcoming appointment. Although 80% of the sample liked telephone and/or postal letter reminders as well as text-messages, it would not be cost-effective to provide text message, telephone, and postal letter reminders especially when traditional reminders were not found to be very helpful in this sample. Furthermore, if three different reminders were received for a single appointment, some patients may feel annoyed or overwhelmed. These findings suggest that new communication technologies may enhance, but should not completely replace traditional methods. A more reasoned approach would be to balance preferences and costs while tracking results and adopt the reminder options that are cost effective and most likely to result in patient's keeping their appointments. Nurses are cautioned that there is little information available on use of text messaging among patients over 50 years of age. Phone calls and postal letter reminders might be the preferred option for older patients and those with social and physical challenges.
Decisions such as how many messages should be sent, when the message(s) should be sent, and wording of messages are administrative decisions as they have cost and privacy implications. Interviewers were prepared, if queried, to explain that a text message reminder would simply provide the appointment date and time, the clinic phone number, and a brief request to call if the appointment needed to be changed. While the option to text back that one cannot keep an appointment might be convenient, it is also much more complicated and would require carefully trained staff to skillfully handle a variety of reply text responses.
Transportation problems were noted to be the second most common reason cited for a missed appointment. Transportation remains a salient barrier to clinic attendance, especially for low-income populations. Although public transportation is available in our urban location, adverse weather conditions, walking distance to the local bus stops, and challenges of travel with young children sometimes provide insurmountable obstacles to taking the bus. Transportation assistance through Medicaid was available, but only if scheduled several days in advance; this was not practical when transportation or childcare arrangements fell apart at the last minute. Additional community resources are needed to help meet transportation needs.
Most clinic patients in this study did not call to cancel and reschedule their appointments. As a result, their appointment times could not be offered to other patients. Appointment cancellation is important in busy clinics where a backlog of patients can be waiting for earlier appointment times. When all available appointments are booked, patients either have to wait to be seen or find an alternative source of healthcare, such as an urgent care center or emergency room. While we did not plan to collect descriptive data on barriers to appointment cancellation, during the interview some participants offered that they were not aware that they should cancel their appointments and some commented that the automated clinic telephone system was inconvenient. These findings are consistent with those reported by Lacy et al. (2004) indicating that patients who miss appointments without notifying staff often do not understand the scheduling system and may feel disrespected by a healthcare system that seems to ignore their time, opinions, and feelings. Nurses need to be aware of these findings and take time to explain attendance policies as well as suggest best methods for making contact if an appointment cannot be kept. More information is needed about this finding so that culturally sensitive solutions can be found.
Given widespread ownership and utilization of cell phones, voice or text messaging to assist in disease management and self-care is increasing, though still in early stages of development. Use of cell phones and text messaging to enhance standard care in disease management has been tested with notable positive results in diabetes, asthma, HIV/AIDS, schizophrenia, and hypertension (Car, Ng, Atun, & Card, 2008; Krishna et al., 2009). Text messaging has been studied and found to be effective in promoting healthy behaviors, such as smoking cessation, weight loss, medication adherence, increased physical activity, and vaccination compliance (Car et al., 2008; Gerber, Stolley, Thompson, Sharp, & Fitzgibbon, 2009; Karbanda et al., 2009; Krishna et al., 2009; Sahm, MacCurtain, Hayden, Roche, & Richards, 2009).
Text messaging is currently offered as an option for appointment reminders by many private medical and dental offices in the US and by major commercial drugstore chains to inform participants that their prescriptions are filled and ready for pick-up. With text messaging becoming increasingly widespread in the healthcare arena, more research is needed to determine (a) whether text-message appointment reminders will be accepted and effective in populations that are diverse in gender, age, and ethnicity, and (b) under what circumstances text messages can most appropriately be utilized.
The results of this study were limited by a small sample size, homogeneity of the sample, and non-randomized selection of subjects. Sample size and selection preclude generalizing these findings to other settings, age groups, diverse ethnicities, and genders. Although the interviewers were trained, bias cannot be excluded in the way survey questions were asked. Additionally, it would have been helpful to know whether participants owned a cell phone or shared one and how often they sent or received text messages. Knowing patients' insights as to why they did not receive the telephone or postal letter appointment reminders would also be helpful.
The Study
This section will describe the study setting and sample, along with the procedures used to collect the data and the data analysis. It will also present findings, discuss the implications of these findings in light of both our clinic patients and mobile technology trends in healthcare, and consider the limitations of this study.
Setting and Sample
This study was conducted at an academic, Magnet®-designated hospital center OB-GYN clinic in the Midwestern US. A cross-sectional interview/survey design was used. The clinic served primarily low-income, inner city women, approximately 80% of which were African American, 10% Caucasian, and 10% of another ethnicity. Approximately 90% of the participants lived below the 2010 federal poverty guidelines. Medicaid insured 80% of the clinic patients; 5% were privately insured with high co-pay, low-coverage plans; and the remaining 15% were self-pay. In this clinic five advanced practice nurses and 27 residents in obstetrics and gynecology conducted 24,000 visits annually with visits scheduled throughout the week for prenatal care, gynecological care, and colposcopy examinations. The Institutional Review Board of the hospital and university medical school affiliate approved this study prior to data collection.
The 60 participants in this study included African Americans (80%), Caucasians (10%), and members of other ethnic groups (10%). Fifty two of the participants were younger than 36 years of age.
Data Collection Procedures
The convenience sample was recruited from daily clinic appointment records that listed missed appointments. A specific day each week was selected for data collection, starting with Monday and advancing by one day each week to ensure that all days of the week were included in this study. Our intention was to collect data each week. However, during some weeks trained clinic staff members were not available to make phone calls for data collection purposes. When this occurred, the data collection day was advanced in the following week when data collection resumed. Data collection continued until an endpoint where saturation of descriptive findings was evident and sample size (N=60) was sufficiently large to meet the aims of this study (Morse, 1995).
Participants were clinic patients, 18 years of age or older, who had both provided a contact telephone number and missed a scheduled appointment for prenatal care, gynecologic care, or colposcopy examination within the previous two weeks. At the time this study was conducted, patients were routinely asked to provide a landline or 'home' phone number, and this was the number used to call the patient. Both new and returning patients of nurse practitioners and OB-GYN residents were contacted and invited to participate in the study. This method of sampling was utilized to promote a representative sample of the overall clinic population. The data collection occurred among both gynecologic and obstetric patients and was equally distributed on all five days of the week.
Five clinic staff members were trained to conduct interviews by phone to the selected patients and, using an interview guide, to collect information about the circumstances contributing to a recent missed appointment. Interviewers invited and recorded qualitative comments, in addition to the survey responses, so as to provide more depth to our understanding of missed appointments. A maximum of three calls was made to each potential participant. Once the participants were reached by phone, they were provided with a description of the study and asked if they would participate in a five to seven minute telephone interview. If they consented, a code number was assigned to maintain confidentiality of responses.
Participants were asked several yes/no questions and one open-ended question about the circumstances of their missed appointment. The yes/no questions, listed in Table 1, were based on information gathered from the literature as well as from observations made by clinic staff. To minimize the possibility of influencing the participants' replies, interviewers were cautioned to ask questions in a straightforward manner and to follow the interview guide. As an additional safeguard, participants were informed that one of the aims of the research project was to determine what actions the clinic might take to help patients attend their scheduled appointments. This information was important because we did not want participants to feel embarrassed about missing a prior appointment; rather we wanted to create an environment where they would feel comfortable giving their honest responses and opinions. Participants were asked to give the main reason for their missed appointment.
Before concluding the interview, participants were asked whether they had tried to cancel their appointment and whether they had encountered any difficulties when they attempted to cancel. Participants were also asked whether they had rescheduled their missed appointment. If they had not yet rescheduled, the interviewer offered to assist them in rescheduling.
Data Analysis
The responses to the interview questions were collected on an interview response form designed to collect both closed- and open-ended responses. The responses were then coded and included with the participant's age and information regarding visit type. Although the sample was too small and homogeneous for inferential statistical analysis, we did use STATA (StataCorp, College Station, TX) to analyze the data. We focused on descriptive analyses and an independent samples t-test to compare the mean age of those who were not aware that they had missed an appointment and those who were aware.
Findings
Data collection was carried out over a five-month period of time. A total of 175 phone calls were made to 95 patients who had recently missed appointments. Of these, 63 patients were successfully contacted and all but 3 agreed to participate in a brief interview. Ages of the 60 participants ranged from 18 to 55 (M = 27.33, SD = 8.4). The participants were predominantly young women, with 86.7% (n = 52) younger than 36 years of age. This age distribution was representative of the population of our clinic. The ages of the 32 who were not successfully contacted ranged from 18 to 35 (M = 24.44, SD = 4.59).
The reasons reported for missed appointments at this clinic are provided in Table 2 which gives the main reason for each missed appointment. Nearly 27% of the participants (n=16) reported that they had forgotten that they had an appointment; 8.3% (n = 5) reported that they were confused about the date and/or time of the appointment. Furthermore, 5% (n = 3) of the sample said that they did not recall being informed about their upcoming appointments. An administrative error of this nature typically happens when a patient is transferred from an outside clinic or between services within the hospital ambulatory care system. Clinic secretaries make the requested appointment but may fail to contact the patient with the appointment information.
The mean age of those who were not aware of a missed appointment was 28 years (M=28.11, SD=9.44), compared to the mean age of those who were aware which was 26.5 years (M=26.55, SD=7.63); t(58)=0.67, p=0.5). Hence this difference was not statistically significant. Taken together, over 40% of the sample reported missing a recent appointment due to forgetfulness, appointment-time confusion, or administrative error.
Nearly 17% (n = 10) of the sample identified transportation problems as the main reason for the missed appointment, while 15% (n = 9) reported work or school conflicts. Other reasons, such as childcare issues, personal illness, family issues, no insurance, and oversleeping were cited by a smaller number of participants as shown in Table 2. No significant relationships were found between the type of visit (new vs. return visit) and the missed-appointment reason.
When asked whether they had received a phone call and postal mail reminder of their upcoming visit, only 30% (n = 18) of the participants remembered receiving even one of these reminders. These findings suggest that phone calls and mailed reminders were not very effective for this sample.
When asked if they had a cell phone for personal use, and if they would like a text-message reminder of an upcoming appointment, all but one participant replied that they had a cellular phone for personal use, and 95% (n = 57) stated that they would like to have a text-message reminder for their upcoming appointments. Some respondents were quite enthusiastic about this option. Of the three participants who did not want a text-message reminder, two stated that they did not know how to use text messaging while the third participant said that she did not currently have a cellular phone. The two participants who did not know how to use text messaging were over 40 years of age.
The majority of the sample indicated that although they would like a text-message reminder, they were in favor of phone and postal mail reminders as well. It was not possible to determine specific reminder preferences because most of the participants declined to specify; 11.7% (n = 7) indicated that they would also like to have a phone call reminder while 68.3% (n = 41) indicated that they would like all three reminders.
Of interest, a subgroup of 16.7% of the participants (n = 10), whose mean and median age was 27 years, stated that they did not want either a telephone or letter reminder, only a text message. Reasons given for a missed appointment in this subgroup included forgetfulness, transportation problems, and school or work conflicts. Anecdotally, a few of the participants in this subgroup mentioned that they were very busy with jobs and children and did not always check voice or postal mail. Hence they would likely miss a reminder left by either of these methods, while they would more easily receive a text message.
We also inquired about appointment cancellation. Of the 36 participants who missed appointments for reasons other than forgetfulness, confusion, or administrative error, 94.4% (n = 34) indicated that they had not tried to cancel in advance of the appointment time. Two participants reported that they had tried to cancel their appointments but were unsuccessful because the appointment desk was closed for lunch. They did not leave a message or call back after the lunch hour suggesting that the cancellation process needs to be convenient for patients in order to be effective.
Discussion and Implications
Overall we found that 40% of low-income, inner city women who missed a recent appointment at an inner city OB-GYN clinic either forgot they had an appointment, were confused about the date and/or time of the appointment, or missed an appointment due to administrative error. Importantly, we found that 70% of the sample indicated that they did not recall receiving either a phone call or letter reminder of the upcoming appointment although reminder phone calls and postal letters were standard practice. More effective appointment reminders could potentially improve clinic attendance.
Ninety-five percent of the sample indicated that they would like a text message reminder of an upcoming appointment. Although 80% of the sample liked telephone and/or postal letter reminders as well as text-messages, it would not be cost-effective to provide text message, telephone, and postal letter reminders especially when traditional reminders were not found to be very helpful in this sample. Furthermore, if three different reminders were received for a single appointment, some patients may feel annoyed or overwhelmed. These findings suggest that new communication technologies may enhance, but should not completely replace traditional methods. A more reasoned approach would be to balance preferences and costs while tracking results and adopt the reminder options that are cost effective and most likely to result in patient's keeping their appointments. Nurses are cautioned that there is little information available on use of text messaging among patients over 50 years of age. Phone calls and postal letter reminders might be the preferred option for older patients and those with social and physical challenges.
Decisions such as how many messages should be sent, when the message(s) should be sent, and wording of messages are administrative decisions as they have cost and privacy implications. Interviewers were prepared, if queried, to explain that a text message reminder would simply provide the appointment date and time, the clinic phone number, and a brief request to call if the appointment needed to be changed. While the option to text back that one cannot keep an appointment might be convenient, it is also much more complicated and would require carefully trained staff to skillfully handle a variety of reply text responses.
Transportation problems were noted to be the second most common reason cited for a missed appointment. Transportation remains a salient barrier to clinic attendance, especially for low-income populations. Although public transportation is available in our urban location, adverse weather conditions, walking distance to the local bus stops, and challenges of travel with young children sometimes provide insurmountable obstacles to taking the bus. Transportation assistance through Medicaid was available, but only if scheduled several days in advance; this was not practical when transportation or childcare arrangements fell apart at the last minute. Additional community resources are needed to help meet transportation needs.
Most clinic patients in this study did not call to cancel and reschedule their appointments. As a result, their appointment times could not be offered to other patients. Appointment cancellation is important in busy clinics where a backlog of patients can be waiting for earlier appointment times. When all available appointments are booked, patients either have to wait to be seen or find an alternative source of healthcare, such as an urgent care center or emergency room. While we did not plan to collect descriptive data on barriers to appointment cancellation, during the interview some participants offered that they were not aware that they should cancel their appointments and some commented that the automated clinic telephone system was inconvenient. These findings are consistent with those reported by Lacy et al. (2004) indicating that patients who miss appointments without notifying staff often do not understand the scheduling system and may feel disrespected by a healthcare system that seems to ignore their time, opinions, and feelings. Nurses need to be aware of these findings and take time to explain attendance policies as well as suggest best methods for making contact if an appointment cannot be kept. More information is needed about this finding so that culturally sensitive solutions can be found.
Given widespread ownership and utilization of cell phones, voice or text messaging to assist in disease management and self-care is increasing, though still in early stages of development. Use of cell phones and text messaging to enhance standard care in disease management has been tested with notable positive results in diabetes, asthma, HIV/AIDS, schizophrenia, and hypertension (Car, Ng, Atun, & Card, 2008; Krishna et al., 2009). Text messaging has been studied and found to be effective in promoting healthy behaviors, such as smoking cessation, weight loss, medication adherence, increased physical activity, and vaccination compliance (Car et al., 2008; Gerber, Stolley, Thompson, Sharp, & Fitzgibbon, 2009; Karbanda et al., 2009; Krishna et al., 2009; Sahm, MacCurtain, Hayden, Roche, & Richards, 2009).
Text messaging is currently offered as an option for appointment reminders by many private medical and dental offices in the US and by major commercial drugstore chains to inform participants that their prescriptions are filled and ready for pick-up. With text messaging becoming increasingly widespread in the healthcare arena, more research is needed to determine (a) whether text-message appointment reminders will be accepted and effective in populations that are diverse in gender, age, and ethnicity, and (b) under what circumstances text messages can most appropriately be utilized.
Study Limitations
The results of this study were limited by a small sample size, homogeneity of the sample, and non-randomized selection of subjects. Sample size and selection preclude generalizing these findings to other settings, age groups, diverse ethnicities, and genders. Although the interviewers were trained, bias cannot be excluded in the way survey questions were asked. Additionally, it would have been helpful to know whether participants owned a cell phone or shared one and how often they sent or received text messages. Knowing patients' insights as to why they did not receive the telephone or postal letter appointment reminders would also be helpful.
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