Factors influencing repeated non-utilized healthcare appointments from patients’ and healthcare providers’ perspectives in a Saudi Arabian hospital Outpatient Department: A qualitative study

Abstract

Abstract In healthcare settings, multiple non-utilized appointments generate resource waste, longer wait times, and negative patient outcomes. Multiple non-utilized appointments are associated with poorer health, higher hospitalization rates, and premature mortality. Despite research in Western healthcare systems, there remains a significant knowledge gap regarding multiple non- utilized appointments in Gulf Cooperation Council (GCC) countries particularly in Saudi Arabia. Even though the issue is serious, we still do not know much about the reasons behind 10 multiple non-utilized appointments in Saudi Arabia’s healthcare system and effective strategies to address this problem. This thesis set out to address that gap, by examining multiple non-utilized appointments globally before narrowing its focus to the Saudi context. The aim was to identify the factors that contribute to multiple non utilized appointments from the perspectives of patients and healthcare providers and then examine what needs to be done to provide solutions. To achieve this, a two-phase qualitative research design was employed. The first study involved a systematic review of the global literature which included five qualitative studies from diverse healthcare systems. The second study was conducted in a Saudi Arabian hospital outpatient department. Twenty patients and twenty healthcare providers from different outpatient clinics were interviewed. Reflexive thematic analysis was conducted, with findings subsequently interpreted through Levesque’s healthcare access framework to understand the causes and potential interventions to the problem of multiple non-utilized appointments. The results were that multiple non-utilization is not a matter of patient irresponsibility. Instead, it reflects a complex interplay between systemic inefficiencies and patient circumstances. Barriers were identified by using Levesque’s conceptual framework across four access dimensions: approachability (fear and anxiety, language barriers, technological challenges with digital systems, communication inefficiencies, administrative problems), acceptability (cultural mismatches, lack of empathy, unauthorized walk-in accommodations undermining scheduled appointments, privacy concerns for mental health), availability and accommodation (long waiting times, inflexible scheduling, overbooked clinics, staff shortages, geographical barriers for rural patients, problematic health apps) and appropriateness (provider-patient relationship issues, inconsistent records, frequent provider changes, structural barriers in booking systems). While some transportation cost issues found, affordability was not a primary 11

barrier theme. These barriers corresponded with compromised patient abilities to perceive, seek, reach, and engage with healthcare services. Although some existing interventions showed promise many did not fully align with patient needs. The study recommends interventions targeting Levesque framework dimensions through enhanced healthcare delivery systems, improved patient access and engagement, and culturally sensitive service delivery. Interventions aimed only at reducing service-level inefficiencies must give opportunities for approaches that are more open to the needs, backgrounds, and lived experiences of different patient groups. This thesis contributes to the existing literature by clarifying the confusing terminology related to non-utilized appointments and demonstrating using Levesque’s framework that these non- utilized appointments are evidence of deeper issues. In addition, the results of this thesis found that the influence of male guardianship on women’s access to healthcare and the confusion caused by using both the Hijri and Gregorian calendars are two examples of the unique cultural factors that affect appointments utilization in Saudi Arabia. Moreover, the results revealed that although digital health tools intended to improve access can actually pose barriers particularly for older patients and patients with limited technological literacy underscoring the importance of designing culturally and contextually appropriate technologies. Lastly, the analysis revealed a gap between the demands of patients and the interventions that are now in place, providing important information for creating more efficient interventions to reduce non-utilized appointments.