In the present study, 3 Themes and 15 subthemes were identified, explaining the reasons relating to patient absconding behavior (Table 1).
Table 1
Themes and subthemes related to patients’ escape
Economic factors
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Lack of insurance coverage
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Lack of proper and complete insurance coverage
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Inability to pay costs
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illegal foreigner patients
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Patients’ social and behavioral factors
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Addiction
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Suicide and illegitimate pregnancies
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Free hospital services misconception
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Nonsupportive families
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Mental and psychological problems of patients
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Hospital-related factors
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The horizontal building structure of hospitals and insufficient supervision
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Not training and informing patients
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Absence of an established process for pursuing a patient escape
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Patients’ dissatisfaction with hospitals
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Difficulties in the discharge process of the patients
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First category: Economic factors
Lack of insurance coverage
Universal health insurance coverage means all citizens can access and afford proper services, including preventive, therapeutic, and rehabilitation services, when needed. This issue is helpful in the realization of the goals of the health system. Accordingly, one of the main aims of the Ministry of Health and Medical Education (MOHME) is health coverage and an increase in the population of base health insurance. This objective has been sought in the health system reform plan. Despite the presence of these governmental plans and policies, insurance coverage has not yet been implemented thoroughly. In this study, many interviewees posited insurance noncoverage as one of the challenges of patients escape from the understudy public hospitals. “Some patients had no insurance coverage” (P. 41).
On the other hand, some interviewees mentioned a lack of insurance coverage as well as a budget for the insurance of some patients like cardboard sleepers whose reception and settlement of therapeutic costs have brought about difficulties to hospitals. In this respect, one of the participants believed that: “some people, like cardboard sleepers, come to hospitals with false identities, and they aim to escape from the beginning so that their identities are not disclosed. These people comprise many numbers of escaping individuals. These individuals have no identities and are re-received by the hospital emergency. There is no budget for the insurance of these patients so that some part of the cost these patients undergo for hospital payment can be compensated by insurance coverage” (P. 63).
Lack of proper and complete insurance coverage
Despite the availability of health insurance coverage, patients cannot afford therapeutic expenses due to insufficient support and improper coverage, and they escape from the hospital without settling. Concerning this issue, participants said that: “some patients needed urgent and emergency cares, such as suicide and quarrel cases. They had to pay the costs themselves since their costs were not covered by insurance. Thus, they escaped from the hospital without settling, and, hence, making hospitals face difficulties. For accident patients with high costs and without any supportive insurance coverage, there is an extreme tendency for escape” (P. 42). The patients who had quarreled escaped when their statuses become stable since insurance does not cover these cases” (P. 40).
Inability to pay costs
Due to economic problems and lack of proper insurance coverage, some patients cannot afford the hospital costs and escape from the hospital after receiving therapeutic services. “inability to pay charges has the highest effect on the escaping patient. The expenses of these patients are high and make the hospitals encounter financial problems, especially our educational hospital that is trauma center” (P. 37). The main reason for the escape of patients is their unaffordability” (P. 1).
Receiving foreigners
The reception of foreigners in some hospitals leads to many problems owing to their high care costs and insurance noncoverage, and, in some cases, it results in their escape without settling. In this regard, the participants told that: “The majority of our runaway patients are foreigners whose therapeutic costs are high, and they cannot afford the payments” (P. 46). “Illegal foreigners with no identification cards are not covered by any insurance, and thus they have a high tendency to escape. Similarly, the runaway statistics of this community is high” (P. 42).
Second category: Patients’ social and behavioral factors
Addiction
Concerning the geographical conditions and situations of the understudy hospitals, one of the social problems they face is the patients’ addiction. Many of these individuals belong to low social class, and they cannot tolerate the hospital conditions when they are hospitalized and treated. They run away in some cases before their care processes are completed. “Some escaping patients are addicts and have social and familial problems” (P. 26). “The hospitalized addicts cannot tolerate the hospital at their hangover time, and they are compelled to escape.” (P. 1).
Suicide and illegitimate pregnancies
Illegitimate pregnancies and suicide are two social intricacies leading to the runaway of the patients more than the other factors: “The reason for the patients’ runaway is poisoning. Those patients that commit suicide and are transferable to psychological hospitals escape mainly due to social problems and difficulties” (P. 62). “Our main intricacy is illegitimate pregnancies. Patients leave their babies and run away. It gives rise to many legal and civil as well as cost problems for hospitals, and we spend a lot of time to pursue these individuals” (P. 63).
The free hospital service misconception
The patients of the studied hospitals were often from deprived areas or enjoyed lower social and economic statuses. They faced catastrophic care costs due to their lack of insurance or inappropriate insurance-service coverage, and they were worried about their received therapeutic service charges. After receiving care services, some individuals with false identities aimed to run away from the hospital without paying the costs. “Some think that hospital services are free; they come with false identities and aim to escape from the beginning so that their identities are not illuminated. These individuals comprise the main body of patients escaping from the hospital after receiving services.” (P.63). Some patients also refer to public hospitals to merely receive several paraclinical services since they are less costly than private hospitals, and they escape after they receive paraclinical services from the hospital. “Some patients come with a prior motivation, fulfill their paraclinical demands, and escape the hospital” (P. 42).
Nonsupportive families
Disease impresses both the patient and his family. Anxiety, stress, and inconvenience derived from a person’s illness are transferred to his family as well. For patients, a family is a defensive shield against problems; however, some families are incapable of supporting their patients owing to diverse reasons, such as economic and familial problems, such that some families were unaware of their patients in this study. Some escaping patients need their families’ approval for their discharge due to legal impediments. It is because they may aim to commit suicide, and they do not want their families to be informed” (P. 1). Some also run away due to familial problems. Perhaps, some cases of these individuals also had familial problems, and their families were unaware of their problems” (P. 2). “Many of these patients have no families” (P. 35).
In contrast, some cases of the patient escape, such as the runaway of infants, children, and adolescents are fulfilled by the support of their families, friends, or carers. “Friends and entourage can influence patients’ runaway” (P. 61). In some cases, it is families that scare away the patients, particularly infants and children (P. 61).
Mental and psychological problems of patients
The escape of a patient is a deflective behavior resultant from varying factors that might be associated with the behavioral and mental problems of the patient. These problems may have roots in disease diagnosis and treatment process, as well as dissatisfaction with hospitalization in the hospital. The research participants referred to such social and behavioral problems of the escaping patients and told that: “Many patients have mental and psychological problems and do not stand the treatment process” (I. 48).
On the other hand, some interviewees mentioned some different factors of the patients’ behavior for running away and declared that: “The reason for the escape of these individuals is that they think they have been cured, and they do not need to attend the hospital and continue their treatment. Some people are wicked, and they do not like to be in the hospital milieu and observe the laws and regulations” (P. 59). “The escape of the patient may be due to his disease diagnosis. The escaped individual may be among those who do not want to be hospitalized. These issues reflect the mental and familial problems of the patient. Those patients that are forced to be hospitalized run away more probably (P. 61).
Third category: hospital-related factors
Horizontal hospitals building structure and insufficient supervision
Due to the provision of a wide number of services and activities, hospitals enjoy numerous physical conditions. The presence of diverse and crowded wards, as well as numerous doors in the hospital environment, minimizes the possibility of control and supervision, and this issue paves the way for the escape of some patients from the hospital. In this respect, one of the participants believed that: “The dispersion of the wards and the availability of numerous doors can be the reason for the runaway of the patient” (P. 1).
In hospitals, the guardians and police forces have crucial roles in the establishment of order and observance of regulations. Owing to its environmental conditions and outnumbered clients, controlling and supervising hospitals is difficult, making these forces confront problems in the execution of their responsibilities. Likewise, the negligence and slumber of the guardians can sometimes trigger reduced control and supervision, as well. In this regard, some participants believed that: “The negligence of nurses and disregard of the guard forces can result in the escape of patients” (P. 51). “The entrance and exit of individuals to and from hospitals are not controlled, and they think that they can easily run away” (P. 26). Moreover, some other participants referred to the few numbers of guardians in wards and thus decreased control and supervision in hospitals and told that: “The shortage of the guard forces in hospitals is one of the main reasons for individuals’ escape. If they are more in number, more protection and care will be realized” (P. 8). “The number of guard forces in hospitals is few, and they do not properly accomplish their responsibilities” (P. 35).
Lack of training and informing patients
In health-promoting hospitals, training and informing patients are introduced as one of the conditions and infrastructures of health promotion. This training and informing in hospitals can involve some cases such as training about the disease and its treatment process and informing about therapeutic costs, disease management, and lifestyle development in such a way that this awareness enhances the post-discharge health. Therefore, one of the standards of the health-promoting hospitals associates with patient’s interventions and information and refers to training and informing patients and their families. Unfortunately, this issue is not well executed in the majority of hospitals. In this respect, according to the prospects of the many participants, one of the factors of patient escape is the lack of patient and carer training and informing. “Not informing and training patients is the reason for their escape (P. 27). “It is the unawareness and culture of the patient who should be involved and in contact with the hospital for the continuation of his therapy.” (P. 2).
On the other hand, some participants perceived the non-training and non-informing of patients from the official processes of the hospitals and therapeutic costs as the reasons for their escape: “Many individuals run away due to being unaware of the expenses as well as the official and discharge processes.” (P. 32). “It is due to patients’ unawareness of costs.” (P. 31). “They escape mostly owing to not being informed about costs.” (P. 53). “Individuals are unaware. If we inform the patient and his carers, it will decrease the dissatisfaction and runaway of the patient. Some part of it relates to the nonpayment of the costs; however, it can be solved by social-aid counseling, informing, and explaining the cost discounts.” (P. 28).
Absence of a certain process pursuing patient escape
Concerning the opinions of the participants, there is no specific process in hospitals for pursuing the patient escape. Thus, no helpful coordination, planning, and practice are carried out for the minimization of this intricacy. In this regard, some participants expressed that: “There should be a law, which makes it easy how to behave and pursue these patients” (P. 46). “There is no proper process for the pursuance of escape, and no guardian and ward takes responsibility. Furthermore, there is a lack of cooperation and coordination between guardians and nurses concerning the patient’s escape” (P. 62).
Patients’ dissatisfaction with hospitals
The problems of patient satisfaction and the observance of his rights are significant. They are the results of a wide group of varied tasks that should be prioritized by the hospital management. The healthcare employees and personnel of hospitals should attempt to attract patients’ satisfaction with services. The dissatisfaction of patients gives rise to some problems like noncooperation with the healthcare personnel as well as probable complaints and skirmishes, and sometimes patients leave the hospital or run away. The interviewees referred to some dissatisfaction-related problems, which can have parts in the escape of patients from the understudy hospitals. In this regard, they noted that: “A patient may be dissatisfied with the current practices and conditions of the hospital.” (P. 15). “Dissatisfaction with the hospital personnel and their cares, dissatisfaction with the facilities present in the hospital, and bad treatments with patients play roles in the escape of patients” (P. 34). “Lack of effective communication of the healthcare personnel with the patient can be a reason for the patient’s escape.” (P. 53). “The reason for escape stems from the incoordination of extra-organizational institutions.” (P. 49).
Some patients expect further care from the hospital personnel, and the non-realization of this expectation triggers dissatisfaction, and sometimes the abandonment of the hospital by the patient. Some interviewees also posed: “Perhaps, another factor for dissatisfaction is the treatment process. The patient may think that the personnel have not embarked on his treatment, and thus he gets into trouble with the personnel and physician” (P. 27). “No proper therapeutic action is performed, and the nurse does not stand beside the patient’s bed” (P. 63).
Difficulties in the discharge process of the patient
The discharge process starts from the time the patient is allowed to be discharged to the time he leaves the hospital. This is one of the main processes of the hospital and also a fundamental challenge in hospital management. The long discharge time leads to reduced service quality as well as patients’ dissatisfaction, and, in some cases, patients leave the hospital without finishing the phases of this process and receiving the discharge sheet. In this regard, some participants believed that: “The discharge bureaucracy (we cannot do anything about it) triggers to the runaway of individuals who do not have the patience for official processes as well as official reception and discharge tasks” (P. 1 & 12). The long process of the service provision and discharge leads to the impatience and escape of patients” (P. 46).