October 2023
Volume 12, Issue 10
Open Access
Public Health  |   October 2023
Barriers and Facilitators to Ophthalmology Visit Adherence in an Urban Hospital Setting
Author Affiliations & Notes
  • Angelica C. Scanzera
    Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois Chicago, Chicago, Illinois, USA
  • R. McKinley Sherrod
    Institute for Healthcare Delivery Design, Office of Population Health Sciences, University of Illinois Chicago, Chicago, Illinois, USA
  • Archit V. Potharazu
    Institute for Healthcare Delivery Design, Office of Population Health Sciences, University of Illinois Chicago, Chicago, Illinois, USA
    College of Medicine, University of Illinois Chicago, Chicago, Illinois, USA
  • Diana Nguyen
    Institute of Design, Illinois Institute of Technology, Chicago, Illinois, USA
  • Cameron Beversluis
    Institute for Healthcare Delivery Design, Office of Population Health Sciences, University of Illinois Chicago, Chicago, Illinois, USA
  • Niranjan S. Karnik
    Institute for Juvenile Research, University of Illinois Chicago, Chicago, Illinois, USA
  • Robison V. P. Chan
    Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois Chicago, Chicago, Illinois, USA
  • Sage J. Kim
    Division of Health Policy, School of Public Health, University of Illinois Chicago, Chicago, Illinois, USA
  • Jerry A. Krishnan
    Institute for Healthcare Delivery Design, Office of Population Health Sciences, University of Illinois Chicago, Chicago, Illinois, USA
  • Hugh Musick
    Institute for Healthcare Delivery Design, Office of Population Health Sciences, University of Illinois Chicago, Chicago, Illinois, USA
  • Correspondence: Angelica C. Scanzera, Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, 1855 W. Taylor Street, Chicago, IL 60612, USA. e-mail: ascanz@uic.edu 
Translational Vision Science & Technology October 2023, Vol.12, 11. doi:https://doi.org/10.1167/tvst.12.10.11
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      Angelica C. Scanzera, R. McKinley Sherrod, Archit V. Potharazu, Diana Nguyen, Cameron Beversluis, Niranjan S. Karnik, Robison V. P. Chan, Sage J. Kim, Jerry A. Krishnan, Hugh Musick; Barriers and Facilitators to Ophthalmology Visit Adherence in an Urban Hospital Setting. Trans. Vis. Sci. Tech. 2023;12(10):11. https://doi.org/10.1167/tvst.12.10.11.

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Purpose: To explore barriers and facilitators to completing scheduled outpatient appointments at an urban academic hospital-based ophthalmology department.

Methods: Potential participants were stratified by neighborhood Social Vulnerability Index (SVI) (range, 0–1.0, higher scores indicate greater vulnerability), and semistructured interviews were conducted with individuals 18 years and older with an SVI of greater than 0.61 (n = 17) and providers delivering care in the General Eye Clinic of the University of Illinois Chicago (n = 8). Qualitative analysis informed by human-centered design methods was conducted to classify barriers and facilitators into three domains of the Consolidated Framework for Implementation Research: outer setting, inner setting, and characteristics of individuals.

Results: There were four main themes—transportation, time burden, social support, and economic situation—all of which were within the outer setting of the Consolidated Framework for Implementation Research; transportation was most salient. Although providers perceived health literacy as a barrier affecting motivation, patients expressed a high motivation to attend visits and felt well-educated about their condition.

Conclusions: A lack of resources outside of the health system presents significant barriers for patients from neighborhoods with high SVI. Future efforts to improve adherence should focus on resource-related interventions in the outer setting. Improving access to eye care will require community-level interventions, particularly transportation.

Translational Relevance: Understanding the barriers and facilitators within the Consolidated Framework for Implementation Research provides useful guidance for future interventions, specifically to focus future efforts to improve adherence on resource-related interventions.

More than 93 million people in the United States were at high risk for vision loss in 2017, a 43% increase since 2002.1 Although screening for refractive error and early eye disease could prevent unnecessary vision loss or blindness,2,3 less than 60% of adults at high risk of vision loss reported receiving eye care in 2017.1 Minorities and individuals with limited socioeconomic resources have more barriers to care, resulting in the underuse of eye care and an increased risk of vision loss.48 Because the major causes of visual impairment and blindness are treatable, adherence to eye care services that detect and manage vision loss should be a national health priority.912 
The University of Illinois’ Hospital and Health system serves residents of communities who primarily identify as racial and ethnic minorities. These communities have higher rates of unemployment, large numbers of uninsured individuals, and greater levels of poverty than in Illinois and the United States.13 We previously applied the 2018 Centers for Disease Control and Prevention Social Vulnerability Index (SVI) to examine the association between neighborhood-level social vulnerability and adherence to scheduled ophthalmology office visits within our diverse urban hospital setting.14 Briefly, the SVI has been used since 2000 and has demonstrated the effects of neighborhood-level social vulnerability on individual patient access and outcomes.1521 We previously reported that nonadherence to attending ophthalmology visits in our health system was associated with higher SVI scores after controlling for demographic variables, new or established appointment type, and distance from clinic.14 Although our previous work may assist in identifying patients at risk of nonadherence, it cannot explain why a patient cannot adhere to a scheduled appointment or what specific interventions might be most helpful in promoting adherence. Such information is needed to guide the design and evaluation of interventions to improve the accessibility of eye care. 
Qualitative studies provide the opportunity to gain insights into how patients interact with the health care system. The widely used Consolidated Framework for Implementation Research (CFIR) comprises 39 constructs within 5 major domains: outer setting (e.g., patient needs and external policies), inner setting (e.g., culture and implementation climate), characteristics of individuals (e.g., self-efficacy), implementation process (e.g., strategies for planning, execution, and evaluation), and intervention characteristics. The CFIR is also an adaptable framework and can be customized for use in individual situations.22,23 The use of the CFIR in this work provides a heuristic to understand patient interactions in a more systematic way. Similarly, human-centered design (HCD)24 provides frameworks for characterizing elements of a health care delivery context. 
The objective of this study was, therefore, to use qualitative methods to engage patients from neighborhoods with high social vulnerability and their ophthalmology health care providers to identify barriers and facilitators to completing outpatient appointments for eye care and to situate these findings into CFIR, which would provide useful guidance for future interventions. 
This study had University of Illinois at Chicago Institutional Review Board approval (protocol 2022–0484) and adhered to the tenets of the Declaration of Helsinki. A research team with expertise in HCD (D.N., R.M.S., and H.M.), public health (D.N. and A.C.S.), and clinical care (A.C.S.) was established to conduct interviews and analysis. 
Participants were recruited from the General Eye Clinic (GEC). The GEC serves a patient population that is 44% non-Hispanic Black, 29% Hispanic, and 11% non-Hispanic White, and more than one-half of patients have Medicaid insurance. This site was selected because it has the highest nonadherence rate in the department and most patients come from neighborhoods with high social vulnerability. 
Recruitment and Eligibility
Individuals 18 years and older with an SVI of greater than 0.61 who were English speaking were eligible to participate in this study. Briefly, the SVI is a composite measure representing neighborhood relative vulnerability compared to all other communities nationally by census tract. U.S. Census data are used to create a percentile rank using 15 social factors organized into 4 themes (socioeconomic status, household composition/disability, minority status/language, and housing type/transportation). Percentile ranking values range from 0 to 1, with 1 representing the 100th percentile for extreme social vulnerability.15 Residential addresses were geocoded using ArcGIS, a geographic information systems software, to append the publicly available neighborhood-level SVI to each individual patient.14 A classification tree using binary recursive partitioning was used to determine the optimal cutoff of an SVI of 0.61 using the Youden index to prioritize both specificity and sensitivity. This cutoff provides a misclassification rate of 28% with an area under the curve of 0.62. In this study, adherence was defined as completing the scheduled ophthalmology visit during the enrollment period. We aimed to recruit 50% of patients who adhered to a scheduled eye visit during the recruitment period and 50% who did not. We used purposeful sampling, which is widely used in qualitative research to identify and select “information-rich cases for the most effective use of limited resources.”25,26 Subject eligibility was determined using multiple methods: (1) A report of patients (adherent and nonadherent) scheduled in the GEC between June 6 and 13, 2022, was pulled from the electronic health record. Eligible patients were mailed a letter informing them of the study. After 10 business days, a member of the study team called patients to determine interest, and interested participants were scheduled for an interview. (2) Additionally, providers recruited patients in the clinic. Eligibility was confirmed by the study team, and patients were called to schedule an interview. 
GEC providers, including resident as well as attending physicians, were recruited via email. Those who expressed interest were scheduled for an interview. Individuals were recruited on a voluntary basis. 
Data Collection
Demographic characteristics pulled from the medical record included age, gender, race/ethnicity, patient status (new or established), and insurance status. Interviews with patients focused on social context, patient experience of eye-related health care appointments, and possible solutions to improve adherence (see Appendix A for patient and provider interview guides). After the interview, participants voluntarily completed a demographic survey (Appendix B). Patient interviews were led by D.N. or R.M.S. A second investigator joined each interview to take field notes. Patients received a $40 gift card as compensation for their participation. A chart review of each patient was conducted after the interview to better understand the patient's medical history and journey to seeking care (i.e., disease, visit scheduling). 
Interviews with providers asked open-ended questions about clinic roles, perceived patient barriers and facilitators to eye visit adherence, and design requirements for future interventions. Provider interviews were led by A.C.S. A second investigator joined each interview to take field notes. Providers were not compensated for their participation. 
Semistructured interviews were conducted in English in person, by phone, or video platform based on participant preference. Upon obtaining verbal consent, interviews were audio recorded. Informed consent and protected health information were documented in REDCap, a Health Insurance Portability and Accountability Act of 1996–compliant web-based system. 
Rapid qualitative analysis is often selected in implementation research to establish provisional assessments of contexts, primary drivers, or considerations of stakeholders.2730 HCD is an approach to understanding real-world context and behaviors of individuals, engage stakeholders, and rapidly prototype and test solutions.24 Although historically comprising two distinct fields, combining implementation science31 and HCD methodologies may have a synergistic effect when conducting qualitative research. We implemented two inductive HCD methods to identify patterns within interview data and group themes into distinct categories: (1) rapid affinity diagramming and (2) modified recursive abstraction.29,32 To further characterize barriers and facilitators to adherence, as well as identify opportunities for intervention, interviews were then analyzed vis à vis CFIR. 
Affinity diagramming is a method frequently used within HCD in which researchers write down a single observation derived directly from the corresponding interview so that each observation may be considered on its own. Notes are then clustered based on their relatedness to one another and clusters are then reviewed and ascribed themes.32 A minimum of two team members conducted a debrief immediately after each interview during which they shared observations and discussed emergent findings. Each insight or quote was captured in Miro, a virtual white-boarding platform (Miro, 2022). Upon completion of all interviews, reflections that shared a theme were clustered into categories that researchers defined with a short title. Clusters were then arranged to visualize the salience of each theme and relationships between them. 
In parallel, interview transcripts were also analyzed using the following steps of a modified recursive abstraction method32: (1) organization of all interview responses by question, (2) condensation of responses into synthesized themes, and (3) definition of each theme. In many respects, this process is very similar to other qualitative methods, such as grounded theory.33 Findings from each analysis method yielded similar themes. In the case of a discrepancy, researchers defaulted to findings from the recursive abstraction method, which could be more directly traced to interview transcripts. 
These findings were then situated within three domains of the CFIR framework: outer setting, inner setting, and characteristics of individual.34 Although CFIR is traditionally used to evaluate the readiness of an organization or environment for the implementation of a specific intervention, we used this framework to identify the setting in which an intervention to improve adherence would be most impactful. This novel use of CFIR necessitated slight modifications to the framework; therefore, the research team aligned upon a definition for each domain. Outer setting included economic, political, and social contexts, as well as patient needs and resources. The latter included social support for physical needs (e.g., a ride to appointment) and mental health (e.g., someone to talk to). Inner setting included both ophthalmology department and health system culture (i.e., norms, values, and basic assumptions of the given organization),34,35 availability of resources (i.e., level of resources devoted to implementing an intervention such as money, training, education, physical space, and time),34 and readiness for implementation of interventions to support adherence. Finally, characteristics of individuals included patient-specific barriers and facilitators to accessing health care, knowledge, self-efficacy, and outcomes expectancy about eye care. Initial analysis of the first three interviews was performed independently by each research member (D.N., R.M.S., and A.C.S.) using the CFIR template to evaluate concordance. Once consensus was achieved, two researchers coded each transcript independently with discrepancies resolved through discussion among all three researchers. 
A total of 17 of 85 patients and 8 of 12 providers invited to participate agreed to join the study. Patient sociodemographic characteristics are summarized in Table 1. Of the eight providers, four were attending physicians and four were residents with at least 2 years of experience working in the GEC. Interview length averaged 37 minutes (range, 23–56 minutes) for patients and 27 minutes (range, 21–36 minutes) for providers. There were four clear themes, which included transportation, time burden, economic situation, and social support (Fig.). 
Table 1.
Demographic Characteristics of Recruited Study Participants
Table 1.
Demographic Characteristics of Recruited Study Participants
Four primary themes organized within the outer setting, inner setting, and characteristics of individual domains of the CFIR. Multifactorial nature of barriers and facilitators is illustrated by the overlap between the four primary themes. COVID-19, coronavirus disease 2019.
Four primary themes organized within the outer setting, inner setting, and characteristics of individual domains of the CFIR. Multifactorial nature of barriers and facilitators is illustrated by the overlap between the four primary themes. COVID-19, coronavirus disease 2019.
Patients and providers identified transportation as both a facilitator and barrier, fitting under both the outer setting and characteristics of individuals using the CFIR framework (Table 2). 
Table 2.
Patient and Provider Quotes Aligned With Themes Within the CFIR
Table 2.
Patient and Provider Quotes Aligned With Themes Within the CFIR
Outer Setting
In this population, many patients had the ability to schedule transportation through their health insurance carrier. Some transportation companies available to these patients offered to send a text message or call with reminders before pick up. Although this practice was seen as an overall facilitator to care, several barriers were found to exist. Patients reported that scheduling transportation through insurance carriers was difficult or inconvenient because paperwork was required to determine eligibility, and, for those with questions, few resources were available to help them navigate the paperwork. Additionally, insurance programs usually require at least 3 days advance notice, so patients whose primary mode of transportation fell through were unable to use this program as a backup option. Transportation services through insurance carriers may also be unreliable; multiple patients reported missing at least one visit because the service never arrived for the pickup. One patient stated the inconvenience of scheduling and poor reliability of the transportation service made public transportation his mode of choice. Although visually impaired and reliant on other passengers to inform him when he was at his stop, he elected to spend more than 4 hours round trip (i.e., 30-minute walk, 2 buses, 1 train) to avoid the transportation service provided by his insurance carrier. Although several patients reported living near public transportation, few reported using it as a primary method of getting to their appointments. Additionally, one patient reported avoiding the use of public transit owing to use of a walker. Providers also identified these barriers. 
Patients who described having a social support system, including friends or family, often relied on their “people” to give them a ride. A social support system in general was seen by patients as a facilitator, but could not solve all transportation-related concerns reliably, as noted further elsewhere in this article. 
Characteristics of Individual
Patients who had the ability to drive themselves with a personal car often described this as a facilitator for adhering to visits. However, the cost of parking was mentioned as a barrier. For example, one patient reported having to refill her parking meter owing to the extended length of her visit. Providers described similar barriers and facilitators as noted elsewhere in this article. One additional barrier reported by providers that was not mentioned by patients was that temporary disability or visual impairment made travel to and from appointments more difficult. 
Time Burden
Inner Setting
Patients expressed significant dissatisfaction with wait times in the clinic. Although some patients reported getting in and out in less than 1 hour, others expressed frustration with wait times extending beyond 3 hours. Although this wait time was not a direct barrier, there was an interaction between the effects of wait time and other factors affecting the patient, such as using up all approved paid time off work or issues with transportation. Regarding transportation, some transportation services provided by the patient's insurance had an agreed upon window for pick-up, usually 3 hours, or limited hours of operation. Because transportation services had to be scheduled 3 days in advance, patients reported that if their visit time went over the scheduled pickup time, there was no way to reschedule their transportation. As a result, one patient even reported leaving before being seen by a provider to decrease the risk of being left without transportation after an appointment. Providers acknowledged an interaction between long wait times and other themes, including transportation and paid time off. The GEC is the only dedicated walk-in clinic for immediate eye care in Chicago.36 Providers offered that a reason for long wait time for scheduled visits was due to the need to, in some cases, prioritize walk-in patients who are frequently coming for urgent and emergent issues. 
Social Support
Outer Setting (Patient Needs and Resources)
Patients reported that having a social support system, such as family or friends, served as a facilitator. Specifically, as noted elsewhere in this article, patients relied on others to drive them to and/or attend appointments with them. Although this factor generally served as a facilitator, patients also stated that their ability to attend a visit depended on whether the appointment time and day also worked for the person driving them to the appointment. One patient shared that she missed an appointment owing to a family member's work schedule. Although providers agreed that reliance on another person for transportation to appointments could be a facilitator, they reiterated concerns that it could also be a barrier because it depended on fitting with two individuals’ schedules. 
Those who brought a companion to their visit also found it helpful for this other person to learn about their eye condition. Several providers described that patients coming with family or friends often served as a facilitator who could assist with reinforcing the care plan and education. 
However, providers found that caretakers who attended visits with patients coming from facilities such as nursing homes served mostly as transportation to the visit and were less frequently able to provide additional details about the patient's medical history. 
Inner Setting
Some providers reported that early coronavirus disease 2019 policies, which limited visits to the patient only in many cases and have since been lifted, were a barrier to patient education and facilitation of follow-up visits. Several providers felt a responsibility to assist the patient with accessing resources. Examples included providing information on financial assistance or personally facilitating transportation. Another facilitator described by providers was their experience referring patients to social work for additional resources and a trained professional to assist with social support. Many felt that they had an overall positive experience with social work, but saved referrals for patients at highest risk of missing a visit, even though they felt most patients would benefit from this type of referral. One provider specifically noted that a majority of patients seen in the GEC would benefit from a social work referral, but that limited availability of social work caused the provider to have to strategically decide who to refer. The decision of who to refer to social work varied from provider to provider. 
Economic Situation
Outer Setting
Most patients interviewed had Medicaid insurance. Medicaid provides visit coverage and offers transportation through contracted services for patients with no other way to get to and from their visits. Although these factors serve as facilitators to care, patients did report that having this insurance type limited where they could get their care as well as their transportation options. Although not a direct barrier to adherence, this factor often affected the distance to a covered provider, creating additional patient barriers. Those reporting working full time discussed that their employer determines their ability to take time off for visits. Although paid time off was available for some patients, many discussed the increased wait time interacting with approved time off. 
Characteristics of Individual
Transportation and economic situation were seen to overlap in several ways. For example, patients expressed cost of parking as a financial concern affecting their decision whether to drive to the clinic. Similarly, as noted in the outer setting, several patients reported their fixed income factoring into transportation options. 
Characteristics of Individual
Providers often spoke of health literacy, described by providers as the “patient's understanding of diagnosis or disease,” as a motivating factor for attending ophthalmology visits. Most providers who participated in this study discussed an association between health literacy (or lack thereof) as a potential facilitator (and/or barrier) to attending visits; however, most patients who were interviewed did express a motivation to attend their visits for several reasons. Patients reported that their vision or eye health is important to them because it plays a major role in activities of daily living (e.g., taking medications, completing paperwork, caring for family member). Patients also reported that they felt they had a good understanding of the risk of inaction, either from the education they were provided during a visit or from seeing a friend or family member experiencing health complications or vision loss. 
Moreover, patients showed a high level of self-advocacy and even created workarounds to avoid barriers from the inner and outer settings. Examples included scheduling a later pickup time with the transportation service in case a visit ran late, scheduling visits early in the day to avoid the long wait times in the clinic, or creating a unique personal scheduling system. Two patients reported leaving an outside provider and working with a new insurance company to ensure they could be seen. One patient even reported paying for a copy of their medical records from an outside provider when transferring care to our health system. This self-advocacy was seen across all patients. 
Additional Themes
Several additional factors within the inner setting were found to influence attitudes toward adherence, including scheduling, trust, and care provided. 
Scheduling (Inner Setting)
Patients and providers both expressed concerns with appointment scheduling. Some patients stated that their appointment lead time, the time between when the appointment is scheduled and when it occurs, was short, less than 1 week. Others reported lead times between a few weeks and 5 months. In addition, those who cancelled found it difficult to reschedule a visit in a timely manner. Providers similarly described longer lead times, increasing the risk of no shows. Patients and providers agreed that leaving with a follow-up appointment in hand served as a great facilitator that helped to avoid having to call and schedule visits and decreased the risk of follow-up visits being scheduled incorrectly (e.g., missing additional linked visit for imaging). Patients and providers also reported that reminder calls and messages assisted with adherence; however, both noted that automated calls had less of an effect compared with having a person call, especially in the case of needing to reschedule. Providers also reported that reminder calls work only when the phone number in the system is correct, and they noted this was often not the case. 
Trust (Characteristics of Individual/Inner Setting)
Regarding trust, patients often felt a loyalty to and reported getting all their care within the health system. Trust in the overall health system served as a facilitator and was not mentioned as a barrier. 
Care Provided (Inner Setting)
Finally, patients expressed a very positive experience with the quality of care they received during their visits. Despite some patients reporting long wait times, many patients remarked that the staff were friendly and welcoming, the examination thorough, and doctors took the time to educate them on their condition. 
Suggested Interventions
Providers were asked about potential interventions that could assist in improving adherence to visits. Recommendations varied and encompassed refining patient education (e.g., educational videos, handouts), reducing time burden (e.g., reducing patient volumes, improving efficiency), and addressing patient needs (e.g., counseling visits to address social determinants of health, adequate social work staffing, transportation assistance center). 
In this study, we engaged patients from neighborhoods with high social vulnerability and providers to evaluate barriers and facilitators to ophthalmology visit adherence. Key findings of this study are that (1) eye care providers and patients coming from neighborhoods with high socially vulnerability agreed on four key themes among barriers and facilitators to ophthalmology visit adherence—transportation (barrier and/or facilitator), time burden (barrier), economic situation (barrier and/or facilitator), and social support (barrier and/or facilitator). (2) Although providers perceived health literacy as a barrier affecting motivation, patients expressed a high motivation to attend visits and felt well-educated about their condition. (3) Combining implementation and HCD methods, such as CFIR and rapid affinity diagramming, respectively, helps to organize themes into possible intervention strategies. 
Four key themes emerged in interviews with patients and providers: transportation (barrier and facilitator), time burden (barrier), economic situation (barrier and facilitator), and social support (barrier and facilitator). Each of these themes are associated with social determinants of health, nonmedical factors in communities that affect health, functioning, and quality-of-life outcomes and risks.37,38 Eye visit adherence is a challenge exhibited across the United States.11,3950 Analogous research identifies similar themes in barriers and facilitators to eye visit adherence. For example, community interviews with providers and uninsured or underinsured patients in Michigan indicated priorities, knowledge, transportation, cost, and access as key themes.51 Similarly, focus groups among high-risk patients across multiple socioeconomic strata indicated cost, trust, communication, access, race, and the patient–doctor relationship as key themes.52 Other studies report similar barriers including lower income or cost of care, lack of insurance or public insurance, trust, communication, transportation, health literacy, patient or escort difficulty getting time off work for appointments, and access to care.4850,52,53 
There was a noticeable difference in the perceptions providers and patients felt health literacy played in motivating patients to adhere to visits. Specifically, providers indicated they believed patients need more education about their condition to motivate them to attend ophthalmology visits. However, in this study, most patients expressed an understanding of the importance of eye care and a high desire to attend eye care appointments. This divergence—providers concerns regarding a potential lack of patient motivation owing to lack of understanding about their condition versus patients emphasizing their own highly motivated state—has been similarly identified in a Delphi study of patient and provider perspectives in glaucoma treatment adherence conducted in urban Alabama.54 This situation indicates a misunderstanding as to the motivation component underpinning patient adherence to eye care visits. The previously mentioned study, however, differed in that patients recognized sociobehavioral treatment facilitators such as social support, whereas providers focused on socioeconomic treatment barriers, such as cost or transportation.54 In contrast, patients and providers in our study aligned on the presence of ability-related facilitators (social support) and barriers (socioeconomic factors) to visit adherence. One must further consider that the term “adherence” naturally frames the situation as a behavioral (and motivational) problem; this health system perspective does not assess all the variables impacting difficult decisions made by patients to receive or not receive care. 
An interesting observation in this study was the interaction among themes as illustrated in Figure. For example, transportation was seen as a theme in and of itself, but also interacted with time burden (e.g., visit wait times putting patients at risk of missing their scheduled transportation home), economic situation (e.g., cost of parking), and social support (e.g., reliance on family or friends for transportation). Although this finding in unsurprising, we must understand that, for patients coming from neighborhoods with high social vulnerability, these interactions among themes may be stronger and need to be considered when creating an intervention. 
Use of the CFIR framework helps to inform where across the health care and social ecosystem these barriers and facilitators reside and impact adherence to appointments. For example, potential interventions may be situated within the inner setting (e.g., adjustments to scheduling processes, parking fees, and social work support). However, it is also apparent that each of these four themes have impacts outside health care’s traditional scope (e.g., outer setting—paid time off, characteristics of individuals—visual impairment affects ability to drive to visit). For example, owing to a “lack of slack” in interventions such as insurance-based transportation, patients could not make a reliable backup plan should the initial intervention fail for whatever reason. An important implication is that if ability-related barriers to a behavior are sufficiently high, no amount of motivation will be able to successfully empower change. Therefore, although providers may believe patients require education-related interventions to increase motivation, and therefore improve adherence, socially vulnerable patients may lack the choice infrastructure necessary to allow high motivation to empower behavior change. 
A potential implication is that social determinants of health may impact the coding of a barrier or facilitator as a motivation-related or ability-related issue. Consider long wait times; although this factor may be seen as a motivation-related barrier to adherence (e.g., wishing to avoid long wait times, a patient decides to not complete an appointment), patient interviews indicate this to be an ability-related barrier. Long wait times disrupt transport plans, jeopardizing patients scheduled transportation service or family and friend pickups. This well-known issue emphasizes the importance of an ability-related framing when investigating eye visit adherence interventions for socially vulnerable populations. 
Transportation as a barrier to accessing eye care is well-documented.55 Although Medicaid offers access to transportation services, our study shows barriers that exist even within this offering. Ride share transportation services have been proven effective in improving adherence to visits and found to be economically feasible in cancer care.56,57 This type of community-level intervention requires further evaluation within eye care. 
Our study has several limitations. Only 17 of 85 patients agreed to participate in this research study. Because we were looking to recruit patients with a history of nonadherence to visits, we expected challenges in recruitment and, therefore, reached out to a larger number of patients. Although this practice may have resulted in participation bias, we were able to interview a diverse population coming from neighborhoods with high social vulnerability, more than one-half (11 of 17 patients) of whom were nonadherent to previous visits and the specific population we aimed to interview. We also aimed to minimize response bias by assuring anonymity of responses and conducting interviews in private. Further research may be helpful in understanding effective strategies for recruiting historically marginalized communities for qualitative research. Although confirmation bias is always possible in qualitative research, we actively worked to decrease this by establishing concordance among the researchers. Finally, CFIR is a race-neutral tool that can reduce the ability to recognize how structural racism affects interventions designed to address health disparities.58 The CFIR framework was revised in October 2022, after study completion.23 The revised CFIR framework attempts to assess determinants related to equity in implementation and may be used for future research. Design and prototyping of implementation strategies must embody an antiracist perspective and actively engage representative stakeholders. 
Visit nonadherence is often attributed to a lack of health literacy affecting motivation to attend visits.5154 Our findings indicate that absence of ability, specifically owing to lack of resources, presents more significant barriers for patients from neighborhoods with high social vulnerability. Understanding factors within CFIR can provide useful guidance for where future interventions should be located, and looking at motivation versus ability can help to further refine the purpose of such interventions. Our research points to focusing future interventions on ability- or resource-related barriers away from patient education and in the outer setting, such as transportation. Such interventions may reside outside the four walls of the clinic; hence, new policies are needed to address these barriers and broaden the scope of assistance provided to vulnerable populations. 
The authors thank the Center for Dissemination and Implementation Science (CDIS) at UIC for their assistance in assuring sound methodology and Lauren Kalinoski, MS, CMI on her assistance with illustrations. 
Funded by NIH/NEI K12 EY021475 (Scanzera), NIH/NEI P30 EY001792, and an unrestricted grant to the Department of Ophthalmology and Visual Sciences from Research to Prevent Blindness. The funding organizations had no role in the design or conduct of this research. 
Disclosure: A.C. Scanzera, None; R.M. Sherrod, None; A.V. Potharazu, None; D. Nguyen, None; C. Beversluis, None; N.S. Karnik, research funding – National Institute on Drug Abuse and National Center for Advancing Translational Sciences; R.V.P. Chan, Owner/Equity – Alcon, Genentech, Ocular Therapeutix, Siloam Vision; Research funding – National Institutes of Health and Research to Prevent Blindness; S.J. Kim, None; J.A. Krishnan, research funding – National Institutes of Health, the Patient Centered Outcomes Research Institute, the American Lung Association, Regeneron, and consulting fees – GlaxoSmithKline, AstraZeneca, Bdata, Inc., and CereVu; H. Musick, None 
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Four primary themes organized within the outer setting, inner setting, and characteristics of individual domains of the CFIR. Multifactorial nature of barriers and facilitators is illustrated by the overlap between the four primary themes. COVID-19, coronavirus disease 2019.
Four primary themes organized within the outer setting, inner setting, and characteristics of individual domains of the CFIR. Multifactorial nature of barriers and facilitators is illustrated by the overlap between the four primary themes. COVID-19, coronavirus disease 2019.
Table 1.
Demographic Characteristics of Recruited Study Participants
Table 1.
Demographic Characteristics of Recruited Study Participants
Table 2.
Patient and Provider Quotes Aligned With Themes Within the CFIR
Table 2.
Patient and Provider Quotes Aligned With Themes Within the CFIR

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