Examining health expectations

Abstract

In the health-care context, patient and public expectations are often seen as problematic. For example, patients are sometimes accused of having ‘unrealistic expectations’ about services or treatment efficacy and policymakers’ difficulties in reconciling demand with resource availability are frequently attributed to ‘rising expectations’, with the implication that these are in some way unreasonable. But the positive effects of high expectations tend to be ignored. We are delighted to publish the article by Janzen et al.1 (page 37) on two counts: first, because it is entirely appropriate for this journal to publish an article entitled ‘What is a health expectation?’ and secondly, because we believe there is a pressing need for detailed theoretical and empirical examination of the concept. Understanding how expectations are formed and how they affect health attitudes, behaviours and outcome assessments is crucial for many of the topics that interest our contributors and readers: for example, consultation behaviour, health-related lifestyles, patient-assessed outcomes, patient satisfaction, patients’ preferences, informed choice, shared decision making, self-care and self-management, participation in service development and priority-setting, involvement in research, and so on. A particularly interesting aspect of expectations, or expectancies, is their effect on symptoms or recovery, the so-called placebo effect. In a review of studies of the placebo effect, Crow et al.2 defined expectancies as treatment-related outcome expectations (beliefs that treatments will have positive or negative effects on health status) and patient-related self-efficacy expectations (beliefs that one can carry out the actions necessary for successful management of a disease or coping with the treatment). They identified five types of expectancy: process expectancy, positive outcome expectancy, negative outcome expectancy, interaction self-efficacy and management self-efficacy and they examined evidence from 93 studies to see the extent to which each of these had an effect on preparation for medical procedures, management of illness, and treatment outcomes. They concluded that expectancies are an important part of the mechanism by which placebos have their effects, but there were numerous weaknesses in the studies they examined. In view of its importance, Janzen and her colleagues were surprised to find so little good quality research on the topic of health expectations. To help things along they have proposed a pragmatic conceptual model that should help to clarify thinking and direct further research effort. For example, we need to know if their model has validity in a variety of settings or whether it requires further adaptation; we need more data on the impact of experience, knowledge and beliefs on the development of expectations; and we need a better understanding of patient and public expectations themselves. How often are they unrealistic? If unrealistic expectations are a real problem, how can they be modified? What is the relationship between expectations and preferences? Could measurement of patient satisfaction be improved by paying greater attention to prior expectations? To what extent is there concordance, or dissonance, between patients’ expectations and those of health professionals? Do health professionals understand patients’ expectations and in what ways do their perceptions of these influence their behaviour? Are public expectations really rising, and if so, what problems does this cause? Could high expectations act as a catalyst for quality improvement? If so, should we be encouraging patients to have even higher expectations and to express these more forcefully? The authors of the paper published in this issue have approached the topic from the perspective of social psychology, but there should be plenty of meat here for researchers from a variety of disciplines to get their teeth into. Health Expectations would be delighted to receive more submissions on this topic.