{'fraction_non_alphanumeric': 0.03128550867358534, 'fraction_numerical': 0.012499053102037725, 'mean_word_length': 5.151910531220876, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Factors affecting non‐adherence to medical appointments among patients with hypertension at public health facilities in Punjab, India

Abstract Daily adherence to antihypertensive medications is necessary to control hypertension. Under the State hypertension control program, hypertensive patients are enrolled in public health settings, provided with 30‐day medication prescriptions, and advised to return to the health facility monthly. However, at least 50‐60% of patients do not visit the health facility for their scheduled follow‐up appointments. The authors aimed to document the major reasons for missed appointments and to characterize patient and health system barriers. By telephone, the authors interviewed 300 randomly selected patients who missed appointments for more than three consecutive months. Out of the 300, 206 were interviewed using a pre‐structured questionnaire to explore patients’ experiences along with medical record reviews from the patient database. Not feeling sick or not experiencing any symptoms (24.8%) was the major reason why patients did not return to the clinic, followed by far distance from the facility (22.3%). Among other reasons for missing follow‐up appointments, lack of instructions/guidance from the facility (15.3%), acute illness among patients (8.3%), and long waiting time at the facilities (7%) were also documented. Most of these patients (55.4%) continued treatment from other sources, and a majority (54%) preferred private clinics. These results suggest the need for a more patient‐centered care model, including education about hypertension as an asymptomatic but life‐threatening condition and addressing the barrier of travel distance between a patient's home and the health facility. Further, introducing a reminder system using telephone calls, text messages, or home visits by health workers may increase the follow‐up rate among patients.

potassium intake, reducing weight, and increasing physical activity, while simultaneously taking antihypertensive medications regularly help to reduce the occurrence of stroke, heart failure, and heart attack. 3 In India, it is estimated that the overall prevalence of hypertension is approximately 25.3% and the proportion of patients with controlled hypertension is very low (below 10%). 4 Following registration, the patient is provided with a blood pressure passport which mentions details of the visit and the date of the next visit, along with patient details that are entered into the digital recording system on mobile telephones used by the facility staff. Patients who miss medical appointments appear consecutively in the overdue list shown on the screen of the application and are eligible for calling through a secure or normal line by the staff.
Over time, the program has shown that a large proportion (approximately 50%) of registered patients fail to maintain regular appointments at public health facilities, thus leading to a significant decrease in the proportion of patients with controlled hypertension. As the continuity of appropriate treatment is a major factor for achieving adequate blood pressure control, the proportion of patients with missed visits significantly challenges the program in achieving its objectives. The present study explored the various reasons behind missed appointments using a combination of available information, perspectives, and experiences of hypertensive patients who missed their scheduled visits at public health facilities for more than three consecutive months. Specifically, we aimed to establish whether missed appointments are indicative of loss to follow-up and to characterize the patient and health system factors linked to missed appointments.

| Study design
We applied the telephonic interview method to determine patients' experiences, perceptions, and feelings. We also reviewed the medical records of the patients. The data were collected during 2019-2020 after obtaining ethical clearance and permission to research the relevant structures within the District Health Society of the Government of Punjab.

| Characteristics of the patient population
The present study was conducted in the Bathinda district of Punjab province, India. Although the utilization rate of public health facilities in the state is about 18%, there is no available evidence of the utilization of such facilities by patients with chronic diseases. 8

| Selection of patients
In 2019, the program enrolled approximately 14 000 hypertensive patients through the State Government's existing health care systems (ie, primary health centers, public Dispensaries, community health centers, sub-divisional hospitals, and divisional/district hospitals) in both urban and rural areas. Hypertensive patients were diagnosed and registered by qualified health workers and treatment was initiated by a medical professional, along with recording patients' details and clinical parameters in the digital record system and providing blood pressure passports containing details of the visit (blood pressure control status, medications prescribed, and next visit dates). For the purposes of sampling, about 4952 patients who had missed their appointments for more than three consecutive months in the entire district were selected from the existing records. From this patient list, those who did not have telephone numbers were excluded. From the list of remaining patients, 300 patients were selected as a convenient sample.
The medical records were reviewed for the sample population obtained from a well-functioning digital health record. Data regarding the demographic characteristics of the patients (age, sex, facility type) were also obtained.
We targeted patients who had missed their appointments for at least three months. The tool used in this phase pretested and enabled us to obtain reasons for the most important factor of missed appointments and to contextualize patient behavior beyond the immediate reasons for missing appointments. As such, we profiled patients' illness experiences, access to services and/or information, self-treatment, treatment experience, social support, and financial constraints as any one or all of these factors might influence behavior. The tools were tested in a previous study and subsequently refined. Data were evaluated via both statistical analyses and textual descriptions.

| RE SULTS
Of the 300 selected patients, 206 participated in the interview (response rate = 69%). The major reasons behind unresponsiveness were invalid/incorrect telephone numbers (n = 29) and telephone numbers not reachable/switched off (n = 59), while others were death (n = 4) and unwillingness (n = 2). During the interview, it was found that for some patients, follow-up visits sometimes were not been recorded by the facility staff resulting in many patients being wrongly counted in "missed visit" category. Forty-nine (23%) patients were found in this category and were excluded from the analysis.
The characteristics of the study participants are presented in Table 1. Most of the patients enrolled in the present study were females (59.9%), which aligns well with the characteristics of the general registration of hypertensive patients in the state, in that the number of female patients exceeds that of their male counterparts. Most of the patients (52.2%) were older than 50 years, and the enrollment rates of patients were 29.9%, 46.5%, and 23.6%, respectively, in community health centers, district and sub-district hospitals, and primary health centers or similar facilities.
Among patients who missed appointments, the most important reason was the absence of perceived illness or feeling sick, which was the reason for missing the follow-up visit in 24.8% of patients (Table 2). Other factors were the distance between the patient's residence and the facility (22.3%) and the lack of proper guiding instructions by the facility staff, whereby patients were not properly instructed on when and where to come for a follow-up visit (15.3%).
Besides the above-mentioned reasons, some other factors reported as the cause of discontinuing follow-up visits were acute illness/disability (8.3%), long waiting periods at the facility (7%), medication quality (6.4%), and being demotivated by others (6.4%).
Although no significant differences were observed among male and female patients, it could be seen that the common reasons mentioned by the older age-group (such as the distance-to-facility factor, 69%) were relatively less common among their younger counterparts (31%). Participants in the younger age-group also did not consider hypertension as a serious illness or even as an illness (67%), compared to those in the older age-group (33%). Lack of proper guidance or instructions from the facility was most frequently reported by the younger age-group (58%) than the older age-group (42%), but there were no significant differences in these proportions (Table 3).
Another finding of the present study was that although the patients did not show up for the follow-up visits at the public health facilities, a majority of them (55.4%) claimed that they continued receiving their treatment from some other sources, which were mostly private health care providers (54%), non-registered practitioners (21%), local pharmacy shops (16%), and AYUSH practitioners (8%) (Figure 1). We also analyzed a variety of reasons among patients who continued treatment versus those who did not. The distance factor turned out to be the most important reason (34.4%) among those who were continuing treatment (n = 87), while the lack of perceived illness (65%) was the most important reason among those who did not continue treatment (n = 60). The frequencies of both factors were found to be significantly different between the two groups (Table 4).

| DISCUSS ION
The present study documented the major factors affecting adherence to medical appointments among hypertensive patients enrolled in the hypertension control program at public health facilities in Punjab, India. Missing follow-up visits are already known to be associated with poor blood pressure control, and our study explored the reasons why patients missed follow-up visits. 9 The major reason identified in our study was the lack of perceived illness by patients as hypertension is mostly an asymptomatic con- In our study, health facility factors, such as long waiting time (7%), perceived poor quality of medication (6.4%), and lack of other required medication (4.5%), were a reason why some patients opted for other avenues for collecting medicines rather than come to public health facilities. A long waiting time at the facility leading patients to avoid the visit has also been documented in other studies. 13,14 However, these factors can be avoided by managing patient flow at the facility and making the required medication available by properly calculating the demand beforehand.
Some patients also complained of not being able to take out the in previous studies. 13 Although the study was conducted at a time when the digital system was newly implemented, the issue of not recording information in the system was a gross finding at all levels; however, with the advancement of the program, this error is expected to be minimized.

| LI M ITATI O N S
The present study also had some limitations, as many of the patients could not be reached because their telephone numbers were inva-

| CON CLUS IONS
The present study was part of a service improvement process, and the findings are disseminated to relevant stakeholders for the implementation of effective actions. We highlighted the roles of social and system factors in contributing to the burden of missed followup appointments. There is a need for a more patient-centered care model to improve patient information collection, guide the patient properly at the health facility, save patients' time at the clinic, provide personalized care for acutely ill and older patients, and address distance barriers between a patient's home and the health facility.
Further, introducing a reminder system utilizing telephone calls/ short message service/home visits may help to increase the followup rate among patients. Based on our findings, we recommend the need to develop a model of care that reflects the local context with an easily accessible, reliable, and quality means of service delivery.
In addition, attention should be given to a more decentralized model of service delivery and strengthening information systems for early detection and management of missed visits among patients, thereby building a more reliable service delivery model. By so doing, we will be able to reduce out of the pocket expenditure and thus achieve our objective of blood pressure control.

CO N FLI C T O F I NTE R E S T
None.

AUTH O R CO NTR I B UTI O N S
BD and GS conceived and designed the study. BD and DN provided supports in designing the tools and making critical revisions. BD and DN wrote the manuscript, performed the data analysis, and critically revised the text. GS and SG provided guidance and technical inputs.
All authors approved the final version of the manuscript.

FU N D I N G I N FO R M ATI O N
None.