Research paper
Reasons for missed appointments with a hepatitis C outreach clinic: A qualitative study

https://doi.org/10.1016/j.drugpo.2015.12.027Get rights and content

Abstract

Background

Non-attendance in drug service hepatitis C outreach clinics means clients miss the opportunity of being given lifestyle advice and referral to hospital for assessment and treatment. A similar problem is experienced in other services throughout the UK. A qualitative study was undertaken to investigate the problem.

Methods

Clients with a history of not attending the outreach clinic were invited to participate during a routine drug clinic appointment. A contact details sheet with a preferred telephone number was completed by those agreeing to take part. Verbal consent was taken and a telephone interview took place. The participants were remunerated for taking part with a five pounds high street voucher. The ‘framework method’ was used to analyse the data with key themes identified.

Results

Twenty-eight telephone interviews were undertaken from April to June 2012. All the clients gave ‘prima-facie’ reasons for non-attendance including ‘not a priority’ and ‘forgot’. However, the study indicates these are insufficient to explain the various experiences and influences. Underlying reasons that impacted upon attendance were identified. These reasons relate to (i) client characteristics e.g. ‘priority’ to score drugs and the ‘cost of travel’ and (ii) clinic service e.g. ‘difficult journey’ to the clinic and timing of the ‘appointment’. The reasons operated within a complex context where other factors had an impact including addiction, welfare policy, stigma and the nature of hepatitis C itself.

Conclusion

The study revealed that beneath apparently simple explanations for non-attendance, such as clients’ chaotic lifestyle resulting in them forgetting or not being bothered to attend, there were far more complex and varied underlying reasons. This has important implications for drug policy including the need to better incorporate clients’ perspectives. Policy that is based only on the simple, surface reasons is unlikely to be effective.

Section snippets

Background

Hepatitis C is a blood-borne virus which primarily affects the liver. In the UK people who inject drugs (PWID) are at greatest risk of infection. Approximately half of all PWID have been infected with hepatitis C through the sharing of blood contaminated equipment (e.g. syringes, needles, spoons, filters and water) (Public Health England, 2014). Individuals are also at risk of infection if they have received medical or dental treatment abroad in countries where hepatitis C is common and

Methods

Ethics approval was granted by the South Yorkshire NHS Research Ethics Committee study number 12/YH/0078. The methods and techniques of the study including interview questions were developed with two ex-service users, known as Ambassadors, from the local Drug and Alcohol Action Team (DAAT). They were invited to comment on the study forms, including the participant information leaflet and interview guide, and the best way of getting participants to speak about non-attendance, including negative

Setting

The interview participants were recruited from two drug treatment clinics in a city in the North of England. ‘Service 1′ was a GP led treatment clinic for clients with non-complex opiate addiction and was located outside the city centre. ‘Service 2′ was run by consultant psychiatrists, treated clients with complex needs including underlying mental health problems and was situated closer to the city centre. Both were co-located with the drug service. These two treatment services were able to

Sample

Purposive sampling meant an adequate range of relevant characteristics was included. These were: age; length of drug use; hepatitis C diagnosis; home; and family and employment circumstance. Client exclusion criteria included:

  • ●

    Clients who had not missed at least one appointment with the hepatitis C outreach clinic before April 2011;

  • ●

    Clients who cancelled an appointment, re-booked and attended;

  • ●

    Clients who were not able to or did not want to give informed consent to participate; and

  • ●

    Clients unable

Identification and recruitment of participants

The interview participants were identified from electronic data kept by the drug service staff and previous outreach clinic lists. As part of the researcher's professional role he was able to view this data as a member of the clients’ care team (and he ran the outreach clinic).

At a routine appointment, at the end of their consultation, the staff of the drug treatment service offered clients with a history of not attending the outreach clinic an information leaflet. They invited the client to

Data collection

Twenty-eight telephone interviews were undertaken from April to June 2012. The interviews were undertaken by telephone rather than face-to-face (see rationale – Box 2). The telephone interviews were conducted by the researcher at a time convenient to the participant. The participants had received an information sheet before the telephone call; at the time of the call before the interview started this information was restated and verbal consent obtained and recorded. This process had been agreed

Data analysis

The interviews were transcribed verbatim by a medical secretary covered by a confidentiality agreement. The researcher subsequently read each transcript alongside the relevant tape for accuracy. The ‘framework method’ was used to analyse the client interviews (Ritchie, Spencer, & O’Connor, 2003). This is a well-established process of thematic review that involves coding, developing and applying an analytical framework, charting and sorting the material into key issues and themes. The background

Results

Demographic information is summarised in Table 1.

All the clients gave surface or ‘prima-facie’ reasons for non-attendance: ‘not a priority’; ‘forgot’; ‘not bothered’ and ‘others’ e.g. felt ill. However, the study revealed the reasons for forgetting or not being bothered which varied greatly between clients. These reasons themselves operated within a complex context of factors including welfare policy, addiction, stigma, and importantly idiosyncratic features of hepatitis C itself (see Fig. 1:

Reasons for non-attendance

The reasons for non-attendance are categorised under the themes: (i) ‘client characteristics’ and (ii) ‘clinic service’. For the full thematic schema and all the reasons for non-attendance, see Table 2.

Discussion

Despite a different health system and culture the findings from the research into non-attendance in hepatitis C in Canada (Butt et al., 2013) appear to largely concur with those in this study. However, there appear to be a small number of factors which were not identified in the latter. These factors were:

  • ●

    Within the ‘self-protection’ theme the requirement of frequent in-person visits to the clinic when ill due to treatment side-effects;

  • ●

    Under ‘knowledge gaps’ reported by patients, being able to

Conclusions

The apparently simple phenomenon of non-attendance at hepatitis C outreach clinics is often given simple catch-all explanations relating to the chaotic drug-using lifestyle of clients. And the clients themselves give simple prima-facie reasons that accord with these explanations. Such simplicity is deceptive and can be hazardous for policy-makers. Investment in a reminder system to tackle people forgetting to attend may be wasted where such ‘forgetting’ is a manifestation of many other factors,

Conflict of interest statement

The authors declare they have no conflict of interests.

References (33)

  • M. Denscombe

    The good research guide: For small-scale social research projects

    (2003)
  • Department of Health

    Hepatitis C strategy for England

    (2002)
  • N. Gale et al.

    Using the framework method for the analysis of qualitative data in multidisciplinary research

    BMC Medical Research Methodology

    (2013)
  • M. Harris et al.

    Hepatitis C treatment access and uptake for people who inject drugs: A review mapping the role of social factors

    Harm Reduction Journal

    (2013)
  • M. Hayter

    Reaching marginalized young people through sexual health nursing outreach clinics: Evaluating service use and the views of service users

    Public Health Nursing

    (2005)
  • Hepatitis C Trust

    The uncomfortable truth – Hepatitis C in England: The state of the nation

    (2013)

    • Cited by (0)

    1

    Present address: School of Nursing and Midwifery, University of Sheffield, Barber House Annexe, 3a Clarkehouse Road, Sheffield S10 2LA, England, United Kingdom.

    View full text
    Crown Copyright © 2016 Published by Elsevier B.V. All rights reserved.