Health expectations in patients with diabetes mellitus and the factors affecting it: an integrative systematic review^†

This study has two questions:

What are the HE in patients with diabetes mellitus?

All searches were done by two researchers independently, and any inconsistencies were resolved by the third and fourth researchers. Also, any discrepancies between the researchers were discussed and a consensus was reached. Data were extracted based on a checklist prepared by researchers including the name of the first author, the year of publication of the article, the design of the study, the aims of the study, HE in patients with diabetes, and the factors affecting it. To examine the HE of patients with diabetes, available and valid electronic databases such as PubMed, Scopus, Science Direct, Google Scholar, ProQuest, CINAHL, Scientific Information Database (SID), Iran Doc, and Magiran with related keywords such as “expectation”, “experiences”, “perception”, “health”, “care”, “system”, “service”, “hospital”, “setting”, “diabetes”, “diabetes mellitus”, and their combination with the help of Boolean operators “OR”and/or “AND” without time limitation were searched. A sample of a search strategy using related keywords is shown in Table 1.

To be included for initial screening, articles were required to: (1) be written in English or Persian; (2) have access to the full text of the article; and (3) have keywords relevant to the review objectives in the title and abstract. Exclusion criteria include (1) lack of access to the full text of the article; (2) duplicate and unrelated articles; (3) articles published in languages other than English and Persian, and (4) editorial or commentarial articles. In addition, if an article investigated the expectations of patients with diabetes from issues other than health, it was excluded. This systematic review includes quantitative, qualitative, systematic review, and mixed-method articles.

After applying the inclusion and exclusion criteria, to assess the quality of quantitative articles, Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) tool²²; qualitative articles, Consolidated Criteria for Reporting Qualitative Research (COREQ) tool²³; review articles, PRISMA checklist²¹; and mixed method articles, Mixed Methods Appraisal Tool (MMAT)^24,25 were used. Also, a checklist was designed according to the inclusion criteria and the researchers evaluated the articles based on it. The STROBE tool used to evaluate the quality of quantitative articles consists of 22 items. The scoring of this tool was such that the met cases were counted and then divided into the maximum possible score (cohort = 84, case–control = 83, and cross-section = 77) and the percentage was obtained based on the formula.²⁶ Percentages >85 were considered excellent, between 70 and 85 good, 50–70 relatively good, and <50 poor. In this study, articles with a quality score >70 were included. The 32-item COREQ tool was used to evaluate the quality of qualitative articles. The qualitative ranking of this tool was such that if 66% or more of the items were met, they were of good quality, 33%– 65.9% of the cases were of medium quality, and 32% or less were of poor quality.²⁷ In this study, high-quality articles were included for systematic review. PRISMA 2020 checklist with 27 items was used to evaluate review articles. The tool covers seven modules with 27-items: title, abstract, introduction, methods, results, discussion, and other information. Each of the items were assessed as follows: “Yes” for total compliance, scored “1”; “partial” for partial compliance, scored “0.5”; and “No” for non-compliance, scored “0”; with a total maximum score of “27”. The review was considered to have major flaws if it received a total score of ≤15.0, minor flaws if it received a total score of 15.5–21.0, and minimal flaws if it received a total score of 21.5–27.0.²⁸ Finally, good-quality articles with a total score of 21.5–27.0 were included in this study. Also, the 2018 version of MMAT was used to assess the quality of mixed-method studies. The advantage of this tool is that it can be used to evaluate all research projects using a quality scoring system of 0, 25%, 50%, 75%, and 100%, where a higher score indicates a higher quality^24,25 In this study, articles with a quality of 50% and above were included in the final analysis.

The full text of the articles was investigated according to the designed checklist. According to the included criteria, only 17 articles remained in the research process.

In this step, the responses to the three initial questions were extracted from the retained articles in the review process. Data analysis was performed by conventional content analysis with MaxQDA 2010. By carefully reading the text of each resource, HE in patients with diabetes and the factors affecting it were extracted.

The combination of derived data to the response to the review questions was done in this step.

During the integrative systematic review, 1883 articles were identified; 151 articles were removed due to duplication and 868 articles were removed after reviewing the title and summary of the article due to lack of coordination with the objectives of the study; 864 articles were fully evaluated in terms of inclusion criteria, of which 847 original texts did not meet the required criteria, and in terms of method and results obtained were not consistent with the present study. Finally, after considering the inclusion and exclusion criteria and reviewing the full text of the articles and their qualitative evaluation, 17 studies were included in this systematic review (Figure 1). All articles were in English. Table 2 shows the specifications of the reviewed articles. Seven categories were identified after analyzing the data. Based on the findings, the HEs of diabetic patients were in four categories: “dynamism,” “consequentialism,” “comprehensive care,” and “access to facilities.” Also, the factors affecting the expectations of these patients were in three categories including “developments in societies,” “changing the conditions of healthcare systems,” and “individual factors.” In the following, the responses to questions are explained, respectively.

Figure 1.

PRISMA flow diagram of the present study.

Note: PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

HE in these patients is dynamic and influenced by various factors. Patients’ expectations should be checked by healthcare providers at different times, and care and services should be provided based on that. Although in previous studies, the dynamicity of HEs in patients with diabetes was not clearly mentioned, but in our review study, this characteristic was clearly obtained. The results of our study showed that the expectations of these patients are dynamic and health staff should pay attention to this important issue in providing care. There is strong evidence that although initial expectations may be formed, but in the process of healthcare experiences, they are subject to constant change. These expectations may be general or specific, positive or negative, but by establishing a relationship with the nurse and the health team, it can change over time.⁵² In the conceptual model of HE by Janzen et al. (2006), the concept of expectation emerged as a combination of several longitudinal stages (precipitating phenomenon, prior understanding, cognitive processing, expectation formulation, outcome, post-outcome cognitive processing), which indirectly refers to the continuous and dynamic nature of the concept over time.⁵³

In this study, one of the expectations of diabetic patients was consequentialism, which refers to the outcome of the service. These outcomes can be in the form of receiving different physical, psychological and social support, health consequences, absence of disease complications, absence of restrictions caused by the disease, and achieving a normal life. In general, expectations are the stored links between behaviors and consequences that guide subsequent behaviors. According to various studies, the influence of outcome expectations on behavior may be the most compelling aspect of HE models. Behaviors are mainly purposeful and controlled by forethought.⁵³ According to studies, patients expect to achieve good health outcomes without increasing costs or requiring many visits to health centers.¹² In this regard, in the study by Liu et al. (2019)54 and Vachon et al. (2017),³³ expectations are expressed as receiving physical, psychological, economic, and social support. Silva et al. (2018) also presented the improved quality of life as HE in diabetic patients.¹⁶ The results of our study highlighted this feature.

In this study, another expectation of patients with diabetes was to provide comprehensive care, which refers to paying attention to the patient’s individual needs and respecting ethical professional values. Patients’ expectations evolve through interaction with healthcare based on knowledge, beliefs, and individual moral values and dynamic interaction with the therapist and experience of the patient.⁵⁰ In this regard, Yao et al. (2022) emphasized the proper communication between health professionals and patients.³⁰ Kurne (2020) mentioned in his study on value-ethical factors, including communication, choice, security, respectful and empathetic care, and continuity of services.⁵⁵ Najafi Kalyani et al. (2014) expressed the expectations of patients from nurses to improve moral performance (responsibility, respect for patient’s rights) and to have appropriate personal characteristics (appropriate behaviors and interest in work).⁵⁶ In fact, the need and personal belief of these patients to receive support and comprehensive care creates expectations before entering the health system and medical centers. In the study by Kurne (2020)⁵⁵ and Jacklin et al. (2017)³⁴ on the need to receive medical care in compliance with moral-value principles as the main expectations of these patients are emphasized. In the study of Van Eijk-Hustings et al. (2013)⁵⁷ the need to receive comprehensive and organized care along with compliance with ethical principles has been mentioned as the main expectations of patients with diabetes. In our study, the result was extracted more comprehensively in the form of receiving comprehensive care, which culture, and other social factors can be effective in this.

The last of HE in patients with diabetes in this study was “access to facilities,” which included ease of access to health service providers, professional and skilled health staff, medicine, equipment, and welfare services for the patient. Before entering health centers, patients with diabetes believe in full access to health services. In the study by Larson et al. (2019), the availability of services and resources and healthcare providers are mentioned as expectations of patients.⁵⁸ Also, access to quality health services, experts, and information in various studies are included in the study of Vachon et al. (2017)³³ and Taylor et al. (2014).⁵⁹

The expectations of patients with diabetes can be affected by various factors. In this study, factors affecting the expectations of patients with diabetes were included in three categories: “developments in societies,” “ changing conditions of healthcare systems,” and “individual factors.”

Political–social developments and access to higher education among the population mean that society’s expectations regarding health have increased.^33,38,59 Internet and social media have facilitated this to some extent. Undoubtedly, the expectations of patients with diabetes have increased due to the availability of health information on the Internet. Due to the involvement of multiple physical systems, frequent visits to medical centers, and access to the Internet and various resources, these patients have differentiated and high-level expectations, all of which are aimed at meeting their individual needs.^30,33,38,59 In their study, Taylor et al. (2014) stated that access to the Internet and social media are factors influencing the formation of HEs.⁵⁹ In their study, Vachon et al. (2017) mentioned the access of patients with diabetes to the Internet and information related to the disease as effective factors in the formation of HEs.³³

With the change in the conditions of health service provider systems toward patient-centeredness and organizational ideology changes in line with the movement toward continuous quality improvement, patients’ expectations of health have been affected and changed. In this regard, in the 1990s, the patient’s expectation was placed at the core of the mission of treatment.⁴⁹ Also, other factors such as the features and quality of services, economic facilities, environmental factors, existing medical institutions, and social insurances are factors influencing the formation of the expectations of these patients.⁶⁰ In this regard, Alazari et al. (2006) also stated in their study the conditions of service provider organizations and their structures as effective factors in forming expectations.³⁸

The last factor affecting HE in patients with diabetes in this study was “individual factors.” Individual factors of the client refer to the contextual factors and personal characteristics of the client and his/her previous experiences of health services. According to the results of the studies, the expectations of patients with diabetes are subjective; therefore, it may change in different situations. The expectations of these patients are created through interaction with health based on the person’s cognitive and psychological beliefs and values.⁶¹ According to the study by Lakin et al. (2022), expectations are subject to social and cultural factors and individual characteristics such as race, gender, social and economic class, level of education, political position, social rewards, and behavioral exchange patterns. Based on the model of Larson et al. (2019), the expectations of patients are not only influenced by factors related to the health system, but also by the influence of social contexts, society and family, socio-economic status, age, health status, and past experiences of interaction with the health system.⁵⁸ Expectations allow us to use previous possible conditions to adjust subsequent actions.⁶² The previous experience of receiving health services and social education can influence the formation of expectations of diabetic patients from health.^14,30,34 Psychologists also defined expectation as a conscious prediction of future events based on previous experience.⁵² In this regard, Pavlov (1927, 1960) defined a conditioned response as a response that can be predicted based on previous experience.⁶³ The premise of the stimulus–response psychologist Skinner’s theory was that new behavior is formed by old behavior.^52,63 Therefore, according to these theories, the previous experiences of a person with diabetes and its complications can be effective in forming his/her expectations of health. The results of the present study are almost in line with the results of similar studies, but in the present study, individual factors include wider dimensions. Therefore, according to the results of the present study and other studies conducted in this field, it can be concluded that individual factors have a high impact on the formation of expectations from health, but it is mostly influenced by culture and ethnicity and can be expressed in different ways in different studies.

The results of these studies are very consistent with the results of the present study. These slight differences in the results of different studies can confirm the effect of different factors on HE in patients with diabetes and its dynamics and multidimensionality; as mentioned in the present study. Therefore, due to the variability and dynamism of HE in these patients, emphasis is placed on examining expectations in service delivery and patientcentered care in order to increase the satisfaction and effectiveness of services. In addition to highlighting the expectations and needs of patients with diabetes, this study highlighted the shortcomings of the health system. By identifying the needs of these patients and discovering the obstacles in the system, useful measures can be taken to remove the obstacles and meet the needs of patients with diabetes. These measures can be useful for improving the quality of healthcare and customer orientation. In conclusion, this study provides valuable insights into the expectations of patients with diabetes. These findings highlight the need for healthcare providers to address patient expectations and adjust their approach accordingly to ensure optimal patient satisfaction and care. The findings of our study have important implications for research and documenting diabetes patients’ expectations of healthcare.

One of the limitations of this study was the comprehensive review of articles in Persian and English. Articles on health expectancy in patients with diabetes mellitus may have been published in other languages that researchers have not included in the study due to their lack of proficiency in other languages. Therefore, it is suggested that a comprehensive study be conducted by reviewing all articles in other languages. Because patient expectations are influenced by various factors such as cultural and individual factors, it is recommended to use other study methods to assess the HEs of these patients. It is also recommended to conduct a variety of quantitative studies to investigate the impact of factors affecting the expectations of these patients to confirm the results of the present study to use these factors to improve the quality of services.

Similar studies in different fields are needed to further understand patient expectations and the transferability of our findings. This may include a greater variety of experiences and patient demographics (e.g., pediatric patients) and clinical contexts such as intensive care units. We hope that this can lead to the development of more accurate and feasible methods for measuring patient expectations. A better understanding of patient expectations can also inform the planning of healthcare services and the design and delivery of healthcare education programs.¹³ With such measures, physicians and healthcare providers can be enabled to deliver and monitor patient-centered care with outcomes tailored to patients’ desires.