American medical culture is “clocktime” driven, and while time is money for nearly every business in our society, a medical practice lives by its schedule of appointments more than most. While socio-economic challenges clearly contribute to no-show rates for people from all cultures, specific cultural beliefs do further increase the number of appointment no-shows. The steep learning curve of navigating the U.S. health care system contributes significantly to this problem as well, but a patient’s failure to understand western medicine’s concepts of preventive care and self-care are major contributing factors. Failure to reschedule missed appointments or set follow-up appointments can be directly related to these factors
Contributing Factor 1:
Preventive Medicine is an Unfamiliar Concept.
In many societies around the world, there are immediate treatments for acute illness and injury, but little concept of preventive medicine in the way the American medical establishment conceives of it. In many cultures, if you are sick you go to the doctor, but if you aren’t sick there is no reason to go. Why would you seek out a doctor or traditional healer just to be sure you aren’t sick? For example, imagine a mother originally from Mexico who is recently immigrated to the U.S. She keeps missing her well-child check-ups even though she goes through the process of scheduling each follow-up appointment before leaving the doctor’s office. She might never call to say she won’t be there at the appointed time. Why? Well, perhaps this woman does not see any reason for going to the doctor because the doctor has already told her that her son is “well”. Why make all the arrangements and pay a co-pay? If her child screamed and cried after getting shots at the doctor’s office during the previous visit, she may not want to put him through more of the same if he isn’t even sick. This mother demonstrates a common cross-cultural communication challenge; she does not understand the concept of preventive medicine, well-child checks, or the importance of keeping her appointments.
There’s a much better chance the mother will show up for her appointments if this misunderstanding is cleared up. When people know the reason for something, and if it makes sense to them, they are more likely to comply.
Contributing Factor 2:
Who Controls Our Well-Being?
It is also important to remember the dimension of culture “control over destiny.” For people who have a strong belief in fate and karma, what happens to them in life—good or bad luck, health or illness—is in the hands of their higher power. Therefore, self-management of one’s health for a better future outcome won’t drive behavior in significant ways. (Notice that even U.S. Americans who, by comparison, may believe that control over destiny is in their own hands, are slow to make appointments for routine physical exams. And how many keep putting off that visit to the dentist for teeth cleaning?) Some appointments seem obviously more important than others. Routine appointments may not make a lot of sense to people who believe what happens to them is fate. It is useful to keep in mind that culture and religion are two sides of the same coin; many beliefs associated with fate and karma are based on guiding religious principles and, for that reason especially, can not be negated or dismissed by outsiders. It is important to show respect for people’s beliefs, but also to explain that their “higher power” has made western medicine available to them. In western medicine the focus on prevention of illness is very important.
Contributing Factor 3:
Status of Health Care Professionals
Consider another cultural component in the case of the mother who kept missing her well-child checks. Imagine that this mom nodded in agreement when her doctor told her to schedule the next check-up. She did not ask the doctor why she should bring her healthy child back to see him in two months time unless he was sick. She didn’t want to waste any more of his time. She followed his instructions and made the next appointment at the front desk. She did not write down the appointment. When the receptionist handed her a card with the appointment time written on it, she tucked it in her pocket. She was nodding and smiling pleasantly but not really looking forward to the next visit in a committed way. She was going through the motions to please the practice; she felt she needed to do this in order to be able to remain a patient of the doctor she liked.
Fast forward: She had forgotten about the appointment until a reminder call came from the doctor’s office. On the day of the appointment her child was healthy and happy. She thought it would be a waste of the doctor’s time to take the boy in. She also thought that if she didn’t show up, it just made the line of patients waiting for the doctor shorter. Where she came from, it was always first-come, first-served at clinics.
Contributing Factor 4:
Time Control/Management
As stated at the very beginning of this chapter, U.S. Americans have a very specific attitude about time. We manage time down to the minute. Our health care appointments are based on absolute time, whereas in many societies health care is much more informal. Appointments work like general admission. People who are more relaxed about managing time often do not keep calendars—on paper or electronic devices. They certainly don’t track their personal/family time. Again, using the same parent in the previous examples, she may not be prepared to write down the next appointment in a calendar when she is standing in the doctor’s office. When the practice calls the day before her appointment as a reminder, she may have forgotten all about it and simply can’t arrange transportation with only a day’s notice.
Why wouldn’t a person in this situation explain the problem and ask to reschedule? A parent’s explanation might sound something like this: “Well I hoped somehow I would find someone to take me. I was still trying to get my cousin to help me even when I was already late to the appointment. But when I knew I couldn’t go, I was afraid to call the doctor. They would be angry with me.”
An added note: We all know people who just don’t check their messages frequently, don’t return calls, don’t read their email and respond. Individuals vary greatly with respect to these behaviors—no matter what culture they come from. There may be important messages from a doctor’s office lost in a long backlog of voice-mail messages on someone’s phone. Their phone service may even be cut off. When patients/families have low English proficiency, low literacy, and low health literacy, relying on voice mail messages can be very problematic.
Contributing Factor 5:
Money Problems
Imagine another scenario. A father shows up with his son for an appointment only to discover there is an outstanding balance of $800 that needs to be paid before the doctor will see his child. What if the dad is out of work? How humiliating it will be in this situation if he can’t pay. Yes this is the way our system works in the U.S. In many other places in the world, “condition” determines care, not money or proof of insurance. In some cultures, the doctor has established personal rapport with patients/families over time and everything is much more informal. A physician or community healer may allow patients to pay in increments and will still continue care. In our own society, it is common for people to rely on credit cards so they can pay incrementally over very long periods of time. However, those who struggle to establish credit and those who have exceeded their credit limits do not have this option.
IMPORTANT NOTE: Even with Medicaid, families may have outstanding balances that will prevent them from showing up for an appointment.
Contributing Factor 6:
Transportation Problems
Finally, transportation challenges contribute significantly to no-show rates. Imagine not owning a car or sharing a car among numerous family members. Imagine, if you are a woman and your culture dictates that women can’t drive; you have to arrange a ride with a male family member. Perhaps you can’t get a male family member to agree. What if you can’t afford gas? If you have no choice but public transportation, it probably won’t be as convenient as a taxi. Imagine walking to a bus stop pushing a stroller in summer heat or winter snow. Imagine waiting for a bus that is late or never comes. Imagine having to navigate the bus with one child in a stroller and one or more toddlers in tow? It isn’t likely patients will call the doctor’s office to explain their problems. They may want to avoid a conversation with a busy front office receptionist. Perhaps their situation produces shameful feelings in them. Too often, people will avoid a situation entirely by not calling, not showing up, not rescheduling.
Summary
Cultural differences often contribute to the problem of missed medical appointments, and socio-economic realities for families are a crucial co-factor. The way practices and clinics communicate with their patients may not eliminate no-shows, but can make a difference in reducing the rate of missed appointments. Being able to anticipate the challenges people face and their degree of understanding about the U.S. health care system is very important. Also, understanding culturally based beliefs and behaviors about a person’s control over their own destiny, the status of doctors versus patients, and individual time control is very important in being culturally responsive. Helping families understand the concept of “preventive care” is enormously important in helping raise health literacy. Educating families about preventive care is a crucial factor in reducing health disparities among certain populations.
