Absent or not invited? A qualitative study of barriers and enablers of attendance at outpatient appointments in the Region of Southern Denmark

Background: An increased focus has been directed towards the qualitative research aspect of non-attendance at Danish hospitals. This article reports findings from on participatory evaluations of missed outpatient appointments in the Region of Southern Denmark and demonstrates how participatory action research (PAR) can be used to examine barriers to, and enablers of, attendance at outpatient appointments from the user perspective, to inform practical interventions. Method: As part of a participatory framework, we conducted a series of workshops and focus group interviews working closely with patients, stakeholders, professional interpreters, managerial staff, and medical secretaries to identify meaningful patterns and barriers within the practice context. We combined this approach with ethnographic observations and on-site, semi-structured interviews with head nurses and medical secretaries at orthopaedic surgical departments in two different regional hospitals. Field notes, workshop transcripts, and interview data were categorized by relevant themes and analysed using a thematic framework. Results: The PAR process revealed that non-attendance goes beyond poor patient compliance. It may stem from communication inadequacies, systemic limitations, and structural shortcomings within the healthcare system. Key barriers included digital and logistic inequalities, repeated diagnostic procedures, and hospital-initiated cancellations, appointment errors, unclear or dismissive communication, and lack of language assistance. These factors compromise both attendance and quality of care. While most patients make active efforts to attend their appointments, these efforts often remain overlooked and unacknowledged within the standardized healthcare system. Digital solutions may further exclude vulnerable groups, particularly those lacking necessary resources or digital identification to access the care system. Suggestions to potential solutions included optimizing cross-department collaboration, adopting more person-centred communication, and implementing multilingual communication tools. Conclusions: To improve appointment attendance, healthcare systems must address hospital-initiated cancellations, communication inadequacies in care delivery, and systemic barriers to ensure the system functions effectively. Reducing failed appointments also requires addressing digital and language inequalities and ensuring that patient communication is clear, respectful, and free from stigma or blame.