This study aimed to explore the attendance rate and factors influencing attendance and non-attendance at an adult audiology diagnostic clinic at a tertiary hospital in Gauteng, South Africa.

The specific objectives of this study were:

A mixed-methods research design that used qualitative and quantitative methods, utilising structured questionnaires as an interview-based data collection method and a retrospective record review, was adopted for this study. This approach was adopted as it allowed for the gathering of specific and standardised information from participants in a consistent and efficient manner while considering patients’ reading and writing abilities. The structured questionnaire allowed for the systematic collection of data, enhancing the reliability and validity of the research findings. The interview allowed for the exploration of the reasons for attendance and non-attendance at the clinic. Furthermore, a retrospective record review of the audiology departmental appointment schedules, patient records and statistics was conducted to determine the attendance rate at the adult audiology diagnostic clinic.

The study was conducted at a tertiary hospital in Gauteng, South Africa, whose Audiology and Speech Therapy department provides in- and outpatient services across the lifespan. This hospital is a public healthcare facility servicing individuals who cannot afford private healthcare and falls under the healthcare sector that provides access to healthcare to over 80% of the South African population. Evidence suggests that only 16% of South Africans belong to medical aid schemes, allowing them access to the private healthcare sector for their healthcare needs (Naidoo 2012).

Simple random sampling was utilised for adult patients attending their initial appointments, and purposive sampling was used for the patients who did not attend follow-up appointments. A convenience sampling method was utilised for the retrospective record review (appointment schedules, patient records and statistics) to establish the diagnostic clinic’s attendance and return rate from May 2019 to March 2020 (Etikan et al., 2016). A total of 31 adult patients were recruited ensuring representation of the diverse sociodemographic population seen at the clinic. This sample size was determined by data saturation, where participant recruitment was stopped the minute data saturation was confirmed for a category, and this was guided by the responses to the open-ended questions as well as questions where the interviewer had the flexibility to ask additional probing questions or seek clarification on certain responses to gain a deeper understanding of participants’ perspectives. This was defined as when no new data were obtained from participants in response to any question under the various categories (Boddy, 2016; Guest et al., 2006; Morse, 2000).

A structured questionnaire that was used as an interview-based data collection tool and a retrospective record review form was used. The structured questionnaire was carefully developed to ensure that it effectively captured the research objectives and addressed the research questions. The questionnaire included a set of predetermined questions and response options. The questionnaire contained mainly closed-ended questions, with a few open-ended questions focusing on the suggestions that participants might have that would help improve their attendance and/or reduce their non-attendance. The questionnaire consisted of five sections: (1) personal details, (2) length of time since onset of symptoms, (3) knowledge about audiology, (4) severity of symptoms and (5) reasons for non-attendance/attendance. With regard to exploring reasons for attendance and non-attendance within the questionnaire, patients were allowed to provide more than one reason from the list of reasons provided. The response options were derived from a thorough review of the existing literature, expert opinions and research objectives, and the five sections were designed to cover the key variables, concepts or themes related to the research topic. The questionnaire was translated into isiZulu as well as it is the most commonly spoken language in the area where the research site is located. IsiZulu is the home language to more than 24% of South Africa’s population and more than 50% of the population understand it (Ethnologue, 2022). The questionnaire was adapted from Asvat (2011) who used the tool in the study conducted at a physiotherapy department in a tertiary hospital in South Africa where adherence to attending appointments in an outpatient section was investigated.

Prior to the main data collection phase, a pilot study was conducted to assess the clarity, comprehensibility and relevance of the questionnaire. The pilot testing involved a small group of individuals who were similar to the target participants. Feedback from the pilot study was used to refine and improve the questionnaire to enhance validity and reliability, with each interview session following a standardised structure to ensure consistency across participants. The interview process commenced with an introduction, followed by an explanation of the purpose of the study and the confidentiality of participants’ responses. The structured questionnaire was then administered systematically, with the interviewer asking questions and recording participants’ responses. While using a structured questionnaire, the interviewer had the flexibility to ask additional probing questions or seek clarification on certain responses to gain a deeper understanding of participants’ perspectives. However, care was taken to maintain consistency across interviews and avoid excessive deviations from the structured questionnaire. To further enhance validity, member checking and peer debriefing were conducted.

During data preparation, the data collected through the structured questionnaire were transcribed, coded and anonymised to ensure confidentiality and anonymity. The quantitative data collected through structured questionnaires were analysed using statistical software (e.g., Excel). Descriptive statistics, such as frequencies and percentages, were used to summarise the responses, with these presented in graphic and tabular forms (Cooksey, 2020; Kaur et al., 2018). Open-ended questions, and questions where the interviewer had the flexibility to ask additional probing questions or seek clarification on certain responses to gain a deeper understanding of participants’ perspectives, were analysed qualitatively via thematic analysis through a deductive approach where patterns, themes or emerging concepts were identified (Braun & Clarke, 2006).

Prior to the study being conducted, ethical clearance was obtained from the University of the Witwatersrand’s Human Research Ethics Committee (Medical) (No. M1810644), and all relevant permissions were secured from the Head of the Department of Speech Therapy and Audiology and from the hospital’s research committee. The researchers adhered to all ethical considerations from the Declaration of Helsinki (1975 and revised in 2008).

Adult diagnostic assessments at this institution run daily with an average of 12 patients being scheduled per day. An analysis of patient attendances from May 2019 to March 2020 revealed an attendance rate of 84% for first-time initial consultations.

This high attendance rate for initial appointments as opposed to decrease follow-up attendance rate is not surprising. Initial appointments have been reported to have higher attendance rates when compared to follow-up appointments. As noted by McLean et al. (2014) and Wolff et al. (2019), numerous reasons have been proffered for this evidence, including factors such as: (1) urgency and symptom severity, where it is reported that patients will prioritise seeking healthcare when experiencing acute or severe symptoms, thus the urgency of the situation motivating them to attend the initial appointment to address their immediate health concerns; (2) diagnostic investigation, where initial appointments are often for diagnostic investigations or assessments to determine the cause of the symptoms or to establish a baseline for ongoing care, as it is often the case with ENT referred patients, thus patients may feel more compelled to attend these appointments to understand their condition better and receive a proper diagnosis; (3) concerns and uncertainty, where at the beginning of their healthcare journey, patients may have more questions and concerns about their health, thus may feel a greater need for reassurance, information and guidance, which can drive them to attend the initial appointment; (4) referral or recommendation, where if a healthcare professional or another trusted referral source recommends a specific clinic or specialist, patients may have a higher level of trust and confidence in attending the initial appointment; (5) curiosity and anticipation, where for some individuals, attending their first appointment represents a new experience, and therefore they may be curious about the healthcare process, eager to meet the healthcare provider and hopeful for improvement in their health condition and (6) lastly, access and convenience, where if the initial appointment is scheduled promptly, is conveniently located and accommodates the patient’s availability, they are more likely to attend.

Findings for the diagnostic clinic’s follow-up appointments where patients are seen after the initial appointment for further assessment and management showed that only 47.62% of patients attended their follow-up appointments.

As far as the reasons for attendance were concerned, Figure 1 displays three key reasons that emerged from the data: understanding reasons for appointment, staff attitudes and appointment reminders.

The first and second most prominent factors noted to contribute to attendance were personal factors such as understanding appointments (57%) and staff attitudes (42%). McLean et al. (2014) conceptualised a framework hypothesising that norms, attitudes and understanding relating to particular conditions or symptoms might shape attendance behaviours, which supports the current findings. The site’s audiology department’s protocol states that patients must be provided with the reason for and the importance of appointments. Understanding the reason for an appointment is dependent on clear informational counselling during audiology consultations (Meibos, 2018).

Staff adherence to the principles of Batho Pele was highlighted by patients who reported that a positive attitude of the attending audiologist was a key reason for their attendance. Research has found that establishing rapport with patients is one of the key reasons that patients attend their appointments (Ayat & Ahmed, 2016; Brewster et al., 2020).

Other reasons facilitating return for follow-up appointments in this study included being reminded about the appointment (17%), having access to transport (3%) and living close by to the healthcare facility (3%). A few systematic reviews conducted on the effects of patient reminders found that electronic or telephonic reminders significantly reduced missed appointment rates and improved attendance rates (Henderson, 2008; Opon et al., 2020). Evidence also indicates that reduced barriers to access, such as shorter wait times or flexible appointment scheduling options, can positively impact attendance rates although these were not found to be important factors in the current study.

As far as non-attendance was concerned, 52.38% of patients did not attend their follow-up appointments. As stated earlier, poor return rate as opposed to initial appointment rate is a well-documented phenomenon. Six reasons for non-attendance were prominent in the current study: (1) having multiple appointments, (2) work commitments, (3) forgetting the appointment, (4) transport difficulties, (5) attitudes and/or perceptions of the healthcare system and (6) sequelae of hearing impairment as depicted in Figure 2.

The fact that 9 out of 11 patients in this group had chronic medical diagnosis could explain having multiple appointments on the same day as a reason for missing appointments, as reported by 33% of the sample. Evidence suggests that individuals with complex medical conditions that require multiple appointments with different healthcare providers or specialists may struggle to balance numerous appointments, with this becoming overwhelming and leading to missed or rescheduled visits (Wolff et al., 2019). The logistical challenge of coordinating multiple schedules and managing conflicting appointment times can contribute to non-attendance (Marbouh, 2020).

The second most prevalent reason for non-attendance was related to patient employment and caring commitments. Twenty-eight percent of patients reported that commitments such as other appointments, family and work-related matters hindered them from attending their appointments. This has previously been reported by McLean et al. (2014) who described a higher non-attendance at particular times or on particular days that is centred around the incompatibility of the appointment with work and family-related commitments. Work-related responsibilities and commitments can create conflicts with scheduled medical appointments (Mache et al., 2015). Individuals may find it difficult to take time off from work or may fear potential negative consequences, such as salary deductions or job insecurity, which are particularly important factors to consider within the South African context where economic inequalities and unemployment rates are so high (Mache et al., 2015). Balancing work obligations and healthcare needs can be challenging, resulting in missed appointments (Marbouh, 2020).

Forgetting the appointment (8%) and transport difficulties (8%) were the next most prevalent reasons for non-attendance in the current study. Evidence suggests that forgetfulness is a common reason for non-attendance. People lead busy lives with numerous responsibilities, and therefore, it is easy to forget about a scheduled medical appointment, particularly if the appointment is scheduled far in advance or if individuals do not receive reminders or notifications (McLean et al., 2014).

Similarly, limited access to reliable transportation or difficulties in arranging or paying for transportation can be significant barriers to attending medical appointments. Lack of personal transportation, reliance on public transportation with inconvenient schedules or long travel distances or difficulties in finding someone to accompany and assist with transportation can prevent individuals from attending appointments. According to Butler et al. (2001), non-attendance could be because of transport, distance from the hospital and financial factors. Current findings align with this previous evidence as transport and costs pertaining to it were found to be the third highest contributor to non-attendance.

The National Department of Health has proposed a 5 km cluster ruling, which stipulates regulations around where patients can attend public healthcare facilities based on their living proximity to it (Mokgalaka, 2014). Thus, only patients living within the allowed proximity of the research site were participants in this study. While the aim of this regulation was to improve access, there are still associated costs for patients related to public transport. Mokgalaka (2014) found that individuals would rather use public transport, as a 5 km travel distance standard equates to a normal walking time of a maximum of 1 h (Mokgalaka, 2014). This travel time is especially challenging for vulnerable populations who are unable to access the facility on foot, that is, the elderly, the wheelchair-bound and the visually impaired (Green et al., 2015; Mokgalaka, 2014).

Furthermore, 4% of patients presented with findings that highlighted that their attitudes and/or perceptions of the healthcare system in general may have prevented them from attending their audiology appointments. This included factors such as being dissatisfied with the long registration queues, having faced clerical issues such as incorrect bookings and identifying themselves as not requiring audiology services anymore because of a noted improvement in their ear-related diagnoses. In a country such as South Africa, where a vast majority of the population are from the lower socioeconomic stratum, additional factors may influence access and attendance to audiology services. These factors include a lack of coordinated patient care, lack of centralised bookings, excessive waiting times within clinics and poor education for ease of understanding (Khoza-Shangase, 2021).

Generally, literature indicates that attitudes and perceptions of the healthcare system can significantly impact non-attendance at medical appointments in various ways, including: (1) trust and satisfaction – if individuals have negative experiences or perceive a lack of trustworthiness in the healthcare system or specific healthcare providers, they may be less inclined to attend appointments; evidence from studies by Davey et al. (2013), Graham et al. (2015) and Oguro et al. (2021) also suggests that past negative encounters, such as feeling dismissed, rushed or not being heard, can lead to a loss of confidence in the healthcare system and result in non-attendance; (2) communication and information gaps, where effective communication between healthcare providers and patients is not regarded as crucial, thus impacting engagement and attendance; (3) perceived quality of care – if individuals have doubts about the quality or effectiveness of the care they will receive, they may be less motivated to attend appointments; negative perceptions about the healthcare system, such as long waiting times, a perceived lack of expertise or resources or concerns about medical errors, can contribute to non-attendance; (4) cultural and language barriers, where cultural beliefs, language barriers and a lack of cultural sensitivity in healthcare settings influence perceptions of the healthcare system, especially in instances where health-seeking behaviour may be influenced by these cultural beliefs; if individuals feel that their cultural or linguistic needs are not adequately addressed or respected, they may be less likely to attend appointments and (5) accessibility and convenience, where perceptions of the healthcare system’s accessibility and convenience can impact attendance. If individuals perceive the system as difficult to navigate, with long waiting times, limited appointment availability or inconvenient clinic locations, they may be more prone to non-attendance.

According to the WHO (2015), hearing loss causes adults to be excluded from communication causing feelings of loneliness, isolation and frustration. Lin et al. (2013) found that cognitive decline in older adults is associated with hearing loss, which may affect cognitive abilities such as processing speed, working memory and executive functioning, all of which are essential for auditory communication. This sequela of hearing impairment was reported to be the reason for non-attendance for 8% of patients in the current study. These patients specifically scaled it as having a moderate-to-severe impact on their activities of daily living. Cognitive decline can impact healthcare attendance because forgetfulness associated with conditions such as dementia, impaired organisational skills, communication and comprehension challenges, lack of insight into the hearing condition, as well as caregiver burden and coordination, all play a significant role in the elderly patient’s ability to keep their appointment (Powell et al., 2022).