Absent or not invited? A multilevel qualitative study of patients and healthcare professionals’ perspectives on barriers and enablers of outpatient attendance in Southern Denmark

BACKGROUND: Missed outpatient appointments are commonly framed as a problem of patient compliance and responsibility (non-attendance). This paper challenges that assumption by demonstrating how communication practices and organisational structures shape experiences of care and access in Southern Denmark. Drawing on participatory action research, the study explores barriers and enablers of attendance from the perspectives of patients and healthcare professionals and identifies potential measures to reduce missed appointments. METHOD: We adopt a multilevel participatory approach. As part of participatory action research, we conducted two workshops and two focus groups, working closely with Danish and immigrant patients, professional interpreters, health care administrative professionals, and technical specialists to explore barriers and enablers of outpatient attendance. Participants were purposively recruited through patient and professional networks and via digital platforms, including LinkedIn and FB. We complemented the study with ethnographic observations and semi-structured interviews with head nurses and medical secretaries in orthopaedic surgical departments at two regional hospitals. Seven patients were additionally interviewed. Field notes, workshop transcripts, and interview data were analysed using reflexive thematic analysis to identify patterns of meaning, and barriers and enablers of attendance, across participant groups and organisational contexts. RESULTS: The study identified a range of interrelated barriers to attendance grouped into eight overarching themes: (1) structural barriers related to digital and logistic inequalities, (2) systemic and organisational barriers, (3) communication barriers, (4) psychological or illness-related barriers, (5) cultural and language barriers, (6) emotional barriers; (7) relational barriers, and (8) barriers related to physical space and wayfinding. Continuity of care and clear and direct communication were identified as factors contributing to attendance. Suggestions for improving attendance included strengthening cross-departmental collaboration, adopting more person-centred communication, and implementing multilingual communication tools. CONCLUSIONS: Non-attendance may stem from communication failures, systemic limitations, and structural barriers within the healthcare system, rather than solely from poor patient compliance. Although most patients make considerable efforts to attend appointments, these efforts may be overlooked within the standardized healthcare system, which prioritizes digital solutions and consumer-oriented care logic. Improving attendance requires addressing organisational and systemic barriers affecting care delivery and access, including rigid scheduling systems, hospital-initiated cancellations and rescheduling, limited coordination across departments, and inadequate information provision. Efforts to reduce missed appointments must also address digital and language inequalities, illness-related limitations and needs, and ensure that patient communication is clear, respectful, and free from stigma or blame.