Background
Acceptability has become an increasingly important topic in healthcare. Patients’ preferences for and acceptability of different types of diagnostics, drug administration methods and disease management modes have been studied in various diseases as these can significantly influence patients’ agreement and compliance with, as well as uptake of and participation in care [
1‐
3]. Acceptability of health states and health changes, for instance in relation to progression of age, have been investigated less frequently, although these may also be relevant in the context of individual and societal decisions [
4‐
6].
In general, health of most individuals is not ‘perfect’ (i.e. most individuals have a certain degree of impairment in some dimensions of health) [
7], and deteriorates with age [
8]. Individuals may perceive some health problems and imperfect health states as ‘normal’, and experiencing increasing problems and poorer health states as a natural part of the ageing process [
9,
10]. This may cause certain imperfect health states to be considered ‘acceptable’. The number of imperfect health states considered acceptable may increase with age, both from an individual and a societal viewpoint. As an example, having some problems with mobility may be seen as unacceptable at the age of 30, but be considered fully acceptable at the age of 90. Whether or not something is seen as acceptable, likely depends on the health domain in which problems occur (e.g. pain may be judged differently than mobility), the level of problems, and the total health profile [
5]. Moreover, perceptions of acceptability may be related to how healthy people are at different ages, on average, as individuals may compare themselves to others in evaluating their health [
6,
11].
Experiencing acceptable health problems, or being in an acceptable, yet imperfect health state, may be associated with a lower probability of seeking health care or accepting treatments at the individual level. Moreover, at the societal level, priority may be given to treatments that are aimed at patients in ‘unacceptable’ health states, that is, below some threshold of acceptability [
6]. Hence, knowledge on which health problems and states people consider to be acceptable at different ages can be informative in different contexts. Knowledge on this issue is, however, scarce.
Acceptability of health problems at different ages was investigated in two empirical studies in The Netherlands [
4,
5]. Results of a first web-based survey in a relatively small convenience sample suggested that people often consider less than perfect health states acceptable, especially those involving moderate health problems. The acceptability of health problems varied per health domain and increased with the age of the person experiencing the problems [
4]. Recently, this study was repeated and expanded in a larger sample, aged 18–65 years, that was representative for the Dutch general public [
5]. Results of this study confirmed the previous findings, demonstrated the relevance of health profiles and identified some determinants of acceptability (like age of death of next of kin and having a healthy diet) [
5].
The fact that people hold age-specific reference points for acceptable health can have significant implications for health care. Shared decision making may be enabled by integrating issues of acceptability of health problems in the communication between clinicians and patients [
12]. A better understanding of patients’ views regarding the acceptability of health problems can modify treatment goals, may influence the evaluation of health gains and potentially patients’ compliance. Moreover, health gains above and below the acceptability level might be valued differently and receive different priority in health policy [
4‐
6].
Despite its relevance and potential importance, evidence on age-dependent acceptability of health problems is still scarce and not available for most countries [
13,
14]. One interesting question is the generizability of the Dutch findings to other populations. Especially since life expectancy as well as health expectancy differs between countries, one might expect inter-country variation in the evaluation of the acceptability of health problems in relation to age [
15]. While health deteriorates with age in all societies, the moments and degrees of decline as well as the domains of health affected may vary significantly across countries, which could affect views on acceptability of health states.
In this paper, we investigate the acceptability of imperfect health states in relation to age in Hungary. Life expectancy at birth in Hungary is about 6 years lower than in The Netherlands. Moreover, health surveys reported better health status of the Dutch population than the Hungarian population, especially for ages 65 and over [
8]. In addition, the quality of and access to health and social care services, as well as the cultural and socio-economic context, differs between the two countries. All these aspects might influence the age-dependent acceptability of health problems. The comparison of two countries that differ significantly in health indicators, health and social care systems, as well as in their economic development level, can add valuable knowledge regarding the impact of non-personal factors on acceptability of less than perfect health.
Hence, in this paper, we aim to assess the acceptability of imperfect health states in relation to age in Hungary. Since the same survey questions are used as in previous studies in The Netherlands [
4,
5], we also discuss the inter-country differences and highlight the relationship between acceptability levels and the population norms of health in the two countries.
Discussion
In this paper, we presented the results of a study on the acceptability of less than perfect health states at different ages in Hungary. Our results showed that certain health problems are acceptable for the Hungarian general public. The acceptability differed per health domain and with severity of the health problems, with severe problems in any domain considered to be unacceptable at any age by a majority of respondents. Moderate problems in ‘Anxiety/depression’ and ‘Pain/discomfort’ appeared to be acceptable earliest in life, and health problems were generally considered more acceptable in older ages. Respondents’ age, current health, and lifestyle were significant determinants of age-specific acceptability of health problems, although the influence of health and age appeared small. Those respondents who believed to be alive at a presented age (30–80) were also less likely to accept health problems at that age. This suggests that age-specific acceptable health problems and subjective life expectancy are related.
Our study has several strengths. This is the first study in Hungary (and also in the Central Eastern European region) to assess age-related acceptability of health problems. Our results can be used as country-specific reference points for acceptable health and provide some first insights into their determinants. Moreover, given that we used a similar methodology, we were able to compare the Hungarian findings to previous Dutch findings [
5], although only in a descriptive manner. This comparison is however still interesting since both countries have quite different characteristics in terms of population health, health and social care systems and economic development levels. Considering that age-specific acceptable health problems were quite similar between these two fairly distinct countries suggests that views on acceptability of health problems may not differ substantially between (European) countries. We do note some differences as well. For instance, compared to the Netherlands, in Hungary a somewhat higher proportion of respondents indicated that moderate problems were acceptable under the age of 70. This difference mainly originated from differences in acceptability of moderate problems in the ‘Anxiety/depression’ dimension (see Fig.
2a, b). This may be related to the fact that the prevalence of problems in the ‘Anxiety/depression’ dimension among the Hungarian general population is much higher than that in The Netherlands (see Fig.
2), also in younger people [
8]. One might also suspect both findings to be related to the wording of the validated Hungarian EQ-5D-3L questionnaire, in which ‘depression’ is translated as ‘lehangoltság’ (feeling down). However, high prevalences of problems in the ‘Anxiety/depression’ dimension were also reported for other Central and Eastern European countries [
8,
22,
23]. This would support the validity of the Hungarian data. While this would also support that commonness of health problems may lead to higher acceptability of those problems, we emphasise that this is especially observed for anxiety and depression. For instance, we observed that a gap between the acceptability of health problems and the prevalence of actual problems in both the Dutch and Hungarian general population for the ‘Pain/discomfort’ dimension (see Fig.
2a, b). For that dimension, more problems were experienced than considered acceptable and higher prevalence seemingly did not translate into higher acceptability. On the other hand, the rate of citizens aged 64–75 reporting some problems in ‘Mobility’ was much higher in Hungary than in the Netherlands (37.7% vs. 17.1%), whilst acceptability rates at age 70 differed only slightly between the two countries (cumulative %: 69.1 vs 65.9). Overall, the association between prevalence of health problems of a population and the acceptability of these problems was limited. The acceptable health curves indicated that aggregated acceptability levels were close to population health status EQ-5D-3L index scores up to age 60 but diverge from age 70 onward in both countries, with aggregate acceptability profiles being below observed average health states.
Before highlighting some implications of our findings, we highlight some limitations of our study. First, our sample was not representative for the Hungarian population given our recruitment strategy and response rates. Young male respondents were overrepresented. This may have influenced our results and limits the comparability to the findings from The Netherlands in which a sample reasonably representative for the Dutch general public between the ages of 18 and 65 in terms of age, gender and education level were involved. Future studies are encouraged to include representative samples, also including respondents over 65 years old. Second, we had a limited set of ages for which we asked about acceptability of health problems. Including a broader range could provide important additional information (e.g. about how acceptable anxiety/depression would be in children and early adulthood) [
24]. Third, we assumed that when a problem level was indicated to be acceptable at a certain age, it would be acceptable at older ages as well. This might be investigated further, for instance in relation to anxiety and depression. Fourth, the 3L version of the EQ-5D was used in both studies, not the more recent 5L. It could be interesting to see how people would respond to health problems described on a more sensitive instrument like the EQ-5D-5L [
25]. Using other instruments that have different approach to health and well-being (e.g. ICECAP-A and ICECAP-O measures) could reveal additional new aspects [
26]. Fifth, given the absence of Hungarian tariffs for the EQ-5D, we applied the UK tariffs to calculate AHC scores. Clearly, this UK data set need not necessarily reflect the preferences of the Hungarian population. Future studies are encouraged to use country specific tariffs, whenever available. Sixth, the gap between the AHC
AGGREGATE and AHC
WORST reflects the uncertainty about how to aggregate dimension-specific answers into a full health profile and EQ-5D-3L index scores. Future studies could include descriptions of full health states, in order to directly assess their acceptability. It was done in the Dutch study, but only for three profiles [
5]. This provides information about the way in which people perceive combinations of health problems in several domains. Feasibility issues, also in relation to the more complex task and the high number of possible combinations, prevented us from doing this in this study. Using the EQ VAS to assess the acceptability of health states could be an interesting alternative approach. A recent pilot provided promising results regarding its applicability [
27]. Seventh, patients with chronic diseases might have different views on the acceptability of health problems [
12], hence further studies are suggested involving specific patient groups. Eigth, we emphasize that we considered only one aspect, namely the age, for the assessment of acceptability of health problems. Other relevant aspects could also be studied (for instance in relation to lifestyle), which may be relevant in the context of healthcare policies.
In terms of implications of our research, we highlight the following points. First, our results indicate that acceptability of health problems is common across countries, and increases with age. Moreover, severe problems in any health domain were acceptable for fewer individuals than moderate problems at all ages, and the great majority indicated that severe health problems were never acceptable. While general patterns between countries are similar, important differences (also for specific dimensions) can exist, which emphasises the value of country specific studies. Second, the fact that certain health problems may be seen as acceptable could have implications for how individuals perceive these problems (also at different ages) and whether they will seek care given the problems. Moreover, health care professionals may be more inclined to treat unacceptable problems than acceptable ones.
An interesting avenue for future research would be to see which problems medical professionals see as acceptable at different ages and whether this is associated with treatment choices. Moreover, at a societal level, priority may be given to treatments of those problems that are considered unacceptable. Whether such a way of setting priorities is in line with public preferences or normative ‘acceptable’ is another area for future research.
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.