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An evaluation of patient engagement with diabetes out-patient services in an ethically diverse urban area in the UK

Campbell, D. (2018). An evaluation of patient engagement with diabetes out-patient services in an ethically diverse urban area in the UK. (Unpublished Doctoral thesis, City, University of London)


Diabetes has been described as an epidemic with a significant global burden of illness. This burden is associated with poorer engagement with services and the cost of managing avoidable complications. One outcome measure of engagement in the national health service (NHS) in the United Kingdom (UK) is attendance at appointments. The cost implications (direct and indirect) of non-attendance are significant, with empirical evidence consistently demonstrating higher than average non-attendance rates for out-patient appointments and education sessions by minority ethnic and socio-economically deprived individuals.

A gap was identified whereby a comprehensive understanding of non-attendance which moves beyond clinical and technical aspects such as capacity and demand is still required. This thesis provides a fresh approach and granular understanding of patient engagement which can influence clinical care, service delivery and policy.

The main research questions in this thesis were:
1. What are the predictors of out-patient attendance?
2. What are the barriers and enablers to attendance?

To answer these questions, a retrospective geo-demographic trend analysis, critical narrative literature review of Community Health Worker (CHW) and peer support interventions and a research study were conducted.

The case study is based on a dataset which comprised of 35,597 appointments. Its findings highlighted that factors such as age, gender, ethnicity, local geography and deprivation were significant predictors of out-patient attendance.

A critical review of CHW and peer support interventions demonstrated that despite the heterogeneity of programme designs, duration of interventions, follow up and healthcare systems in which they were used, they were assessed to be both clinically and cost effective. There was limited evidence on the sustainability of these interventions due to a lack of longitudinal studies.

The research element was conducted in two stages and utilised multi methods (focus groups, semi-structured interviews and questionnaires) to evaluate the barriers and facilitators to attendance. Key findings included the need for effective and on-going education, better alignment of health and social care due to the impact of the wider determinants of health but more interestingly, the influence of family on the concept of ownership for one’s health by some individuals whose self-determination is limited by language and health literacy. The relationship between patient activation (knowledge, skills and confidence) and attendance was also evaluated. This evaluation demonstrated that the more activated individuals are, they are significantly more likely to attend appointments. However, to maximise care planning and operational effectiveness, activation should not be assessed in isolation.

The findings of this thesis highlighted the influence of individual, organisational and structural factors on patients’ engagement with out-patient services and the need for a synergistic approach involving service users, clinicians, organisations and policy makers to minimise patient dis-engagement with healthcare services.

Publication Type: Thesis (Doctoral)
Subjects: R Medicine > RA Public aspects of medicine > RA0421 Public health. Hygiene. Preventive Medicine
Departments: Doctoral Theses
School of Health & Psychological Sciences > School of Health & Psychological Sciences Doctoral Theses
School of Health & Psychological Sciences
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