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Review Article| Volume 56, 103293, November 2021

The role of expectations and future-oriented cognitions in quality of life of people with multiple sclerosis: A systematic review

Open AccessPublished:September 30, 2021DOI:https://doi.org/10.1016/j.msard.2021.103293

      Highlights

      • MS is an unpredictable disease associated with much uncertainty. The expectations people with MS (PwMS) form about the future may influence their quality of life (QOL)
      • Positive thoughts about the future such as self-efficacy expectations appear to be particularly beneficial for the QOL of PwMS
      • There is inconclusive evidence regarding the possible impacts of negative expectations (e.g. fears or worries) on QOL in MS.
      • Interventions targeted at fostering positive thoughts about future capabilities may be effective in increasing QOL in PwMS.

      Abstract

      Purpose

      Multiple Sclerosis (MS) is a highly variable condition characterised by uncertainty of disease course which can make formation of expectations about the future difficult. This systematic review aimed to examine associations between expectations, or Future Oriented Cognitions (FOCs), and Quality of Life (QOL) in people with MS (PwMS).

      Methods

      Following PRISMA guidelines, literature up to October 2019 was searched using Medline, EMBASE, PsycINFO and Web of Science. Quantitative studies that investigated relationships between FOCs and QOL in PwMS (assessed using a standardised QOL assessment) were considered for inclusion. After data extraction, results were analysed using narrative synthesis, focusing on the valence of FOCs (positive, negative, unvalenced). Quality appraisal was conducted using the Mixed Methods Appraisal Tool (MMAT). All stages of the review were patient-led by a person with MS.

      Results

      A total of 13 studies met the review inclusion criteria, with a combined sample size of 4,179. Of these studies, 11 involved measures of positive FOCs, most commonly self-efficacy, one measured a negative FOC, with one FOC unclassified. Nine studies found significant associations between QOL and self-efficacy. Although other positively valenced constructs were less frequently reported, significant associations with higher QOL were also evidenced.

      Conclusions

      Identifying ways to foster positive FOCs, particularly self-efficacy, may have beneficial effects on QOL. More research is needed to understand the impacts of negative FOCs on QOL to determine whether these processes could be meaningfully targeted in interventions.

      Keywords

      1. Introduction

      Multiple sclerosis (MS) is a long-term neurological condition experienced by over 2 million people worldwide (
      • Wallin M.T.
      • et al.
      Global, regional, and national burden of multiple sclerosis 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016.
      ,
      • Magyari M.
      • Sorensen P.S.
      The changing course of multiple sclerosis: rising incidence, change in geographic distribution, disease course, and prognosis.
      ). While typically diagnosed in early adulthood, initial symptoms can occur at any stage of the lifespan, with women more than twice as likely to be affected as men (
      • Wallin M.T.
      • et al.
      Global, regional, and national burden of multiple sclerosis 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016.
      ,
      • Gilmour H.
      • Ramage-Morin P.L.
      • Wong S.L.
      Multiple sclerosis: Prevalence and impact.
      ). Symptoms of MS are highly variable and can include fatigue, pain, and problems with vision, cognition, bladder function and mobility (
      • Brownlee W.J.
      • et al.
      Diagnosis of multiple sclerosis: progress and challenges.
      ), with levels of impairment ranging from mild to moderate or severe (
      • Confavreux C.
      • et al.
      Relapses and progression of disability in multiple sclerosis.
      ). Although approximately half of people with MS (PwMS) require ongoing care and support (
      • Maguire R.
      • Maguire P.
      Caregiver Burden in Multiple Sclerosis: Recent Trends and Future Directions.
      ), advances in treatment in recent years have enabled many to live independently and manage their symptoms (
      • Brownlee W.J.
      • et al.
      Diagnosis of multiple sclerosis: progress and challenges.
      ). Conversely, some PwMS may continue to experience losses to quality of life (QOL) despite successful disease management (
      • Zwibel H.L.
      • Smrtka J.
      Improving quality of life in multiple sclerosis: an unmet need.
      ,
      • Benito-Leon J.
      • Morales J.
      • Rivera-Navarro J.
      Health-related quality of life and its relationship to cognitive and emotional functioning in multiple sclerosis patients.
      ,
      • Mitchell A.J.
      • et al.
      Quality of life and its assessment in multiple sclerosis: integrating physical and psychological components of wellbeing.
      ). In addition to clinical health status, a range of complex social, psychological and contextual factors influence QOL (
      • Benito-Leon J.
      • Morales J.
      • Rivera-Navarro J.
      Health-related quality of life and its relationship to cognitive and emotional functioning in multiple sclerosis patients.
      ,
      • Yamout B.
      • et al.
      Predictors of quality of life among multiple sclerosis patients: a comprehensive analysis.
      ,
      • Yalachkov Y.
      • et al.
      Determinants of quality of life in relapsing-remitting and progressive multiple sclerosis.
      ). Identifying these factors is an important goal when considering how best to support PwMS.
      One potentially significant set of factors that may influence QOL in MS is the expectations that people hold about the future, or more broadly what could be termed “future-oriented cognitions”
      Hereafter, we refer to Future Oriented Cognitions as FOCs
      (
      • Bubić A.
      • Abraham A.
      Neurocognitive bases of future oriented cognition.
      ). In a healthcare context, expectations may be formed in relation to the processes of treatment, the outcomes of treatment, or general management of illness (

      Crow, R., et al., The role of expectancies in the placebo effect and their use in the delivery of health care: a systematic review. 1999.

      ). The benefits of positive expectations on patient satisfaction, through observation of the placebo effect, are well-established (
      • Stewart-Williams S.
      • Podd J.
      The placebo effect: dissolving the expectancy versus conditioning debate.
      ,
      • Thompson A.G.
      • Sunol R.
      Expectations as determinants of patient satisfaction: concepts, theory and evidence.
      ). Aside from treatment expectations however, there are a range of other FOCs experienced by PwMS that may potentially influence QOL. Given the unpredictable nature of the condition, it is not uncommon for PwMS to experience feelings of uncertainty about what the future may hold, in terms of their long-term prognosis, individual capabilities, or their likelihood of experiencing symptoms on a day-by-day basis (
      • Alschuler K.N.
      • Beier M.L.
      Intolerance of Uncertainty: Shaping an Agenda for Research on Coping with Multiple Sclerosis.
      ,
      • Boeije H.R.
      • Janssens A.C.J.
      It might happen or it might not’: how patients with multiple sclerosis explain their perception of prognostic risk.
      ). This may be exacerbated by a lack of support in the healthcare system, or through inadequate provision of information. For example, research from the UK indicates that while the vast majority of PwMS expressed desires to learn of their long-term prognosis, almost half reported never having a conversation about this with health care professionals (
      • Dennison L.
      • et al.
      How do people with Multiple Sclerosis experience prognostic uncertainty and prognosis communication? A qualitative study.
      ,
      • Dennison L.
      • et al.
      Do people with multiple sclerosis want to know their prognosis? A UK nationwide study.
      ). This uncertainty may lead to feelings of worry or anxiety about the future, which may in turn impact negatively on QOL. Furthermore, uncertainty regarding the effects of treatment has been cited as one of the main reasons for PwMS delaying starting on a disease modifying therapy (
      • Visser L.H.
      • van der Zande A.
      Reasons patients give to use or not to use immunomodulating agents for multiple sclerosis.
      ), with potential deleterious consequences for longer term health.
      Studies in other patient groups have demonstrated how expectations or FOCs may impact on patient wellbeing and QOL more generally (
      • Geurts J.W.
      • et al.
      Patient expectations for management of chronic non-cancer pain: A systematic review.
      ,
      • Janzen J.A.
      • et al.
      What is a health expectation? Developing a pragmatic conceptual model from psychological theory.
      ). It is clear that fostering accurate expectations about treatment and potential effects can be of benefit (

      Crow, R., et al., The role of expectancies in the placebo effect and their use in the delivery of health care: a systematic review. 1999.

      ). Conversely, negative FOCs can lead to poorer patient outcomes. For example, fear of recurrence (FoR), which has been extensively studied in cancer survivors, has been shown to impact QOL independently of clinical health status (
      • Crist J.V.
      • Grunfeld E.A.
      Factors reported to influence fear of recurrence in cancer patients: a systematic review.
      ,
      • Maguire R.
      • et al.
      Expecting the worst? The relationship between retrospective and prospective appraisals of illness on quality of life in prostate cancer survivors.
      ). Evidence suggests that interventions targeted at reducing FoR in this population can have positive implications for survivors (
      • Hall D.L.
      • et al.
      Mind-body interventions for fear of cancer recurrence: A systematic review and meta-analysis.
      ). Similar effects may be evident for PwMS in relation to worries over relapses or general progression, but the experience of fear in this group remains understudied.
      To our knowledge, there has been no attempt to review how expectations and FOCs are associated with QOL in the MS population. The present systematic review aims to address this gap. Building on existing theoretical frameworks (
      • Thompson A.G.
      • Sunol R.
      Expectations as determinants of patient satisfaction: concepts, theory and evidence.
      ,
      • Geurts J.W.
      • et al.
      Patient expectations for management of chronic non-cancer pain: A systematic review.
      ,
      • Kravitz R.L.
      Patients' expectations for medical care: an expanded formulation based on review of the literature.
      ), we hypothesise that a range of expectations or FOCs may be experienced by PwMS. Thoughts about the future may be unvalenced (e.g. simple predictions of likelihood of certain events or outcomes), positive (e.g. feelings of optimism, hope, or levels of confidence/self-efficacy in future capabilities), or negative (e.g. worries or fears in relation to future health or prognosis). While the distinction between unvalenced and positive FOCs is similar to that made previously between “predicted” and “value” expectations (
      • Geurts J.W.
      • et al.
      Patient expectations for management of chronic non-cancer pain: A systematic review.
      ), we also aim to capture associations between negative FOCs and QOL, given their known associations in other populations. As expectations and FOCs may be amenable to change, these factors merit investigation when considering interventions aimed at enhancing QOL in PwMS.

      2. Method

      The methods reported below adhere to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (see supplementary material for PRISMA checklist). The focus of the review was patient-led, having been conceptualised by the first author, who has MS. The protocol was presented at the MS Frontiers Conference in July 2019 (Maguire et al., 2019).

      2.1 Search strategy

      Search terms were identified relating to (1) MS, (2) Expectations/FOCs, and (3) QOL (see example of search in supplementary material). Given the lack of a clear consensus regarding the nature of expectations (
      • Geurts J.W.
      • et al.
      Patient expectations for management of chronic non-cancer pain: A systematic review.
      ,
      • Janzen J.A.
      • et al.
      What is a health expectation? Developing a pragmatic conceptual model from psychological theory.
      ,
      • Coulter A.
      Examining health expectations.
      ), a broad range of search terms relating to FOCs and patient expectations was developed based on previous research. PsycINFO, PubMed, EMBASE and Web of Science databases were initially searched from inception to April 2019, and subsequently searched up to October 2019. Searches involved a combination of free text words or exploded subject headings using MeSH, EMTREE, or PsycINFO thesaurus. Reference lists of included papers were later hand searched to identify other relevant studies.

      2.2 Eligibility criteria

      In order to be included in the review, studies were required to: (1) report primary quantitative data from an adult sample of PwMS, (2) include a standardised measure of QOL, (3) have at least one measure of an expectation or FOC, and (4) examine the relationship between the QOL and FOC measure(s). Studies with sample sizes of <30 participants, validation and feasibility studies, material published in outlets other than peer-reviewed journals, and reports in languages other than English were excluded.

      2.3 Screening

      Results from the database searches were imported into the systematic review software Rayyan (
      • Ouzzani M.
      • et al.
      Rayyan—a web and mobile app for systematic reviews.
      ) and duplicates were removed prior to screening. Titles and abstracts of studies were then screened by two reviewers (RM and BMcK or NK), with a third (DD) in cases of conflict. Any disagreements were discussed until consensus was reached. Full-texts of articles were then obtained and assessed against the eligibility criteria by two reviewers (RM, BMcK), with a third in case of conflict (DD).

      2.4 Data selection and extraction

      The following data were extracted (BMcK, RM) from the full-texts of included studies, where available: study aims, design, country setting, characteristics of sample including sample size, gender, age, and MS characteristics (e.g. proportion of those with Relapsing Remitting MS (RRMS), level of disability, or time since diagnosis (TSDX)), FOC or expectation measure(s) used, QOL measure used, and results obtained, including other contextual information that may be relevant to the interpretation of results.

      2.5 Quality Appraisal

      In order to assess the methodological quality of the included studies, each was assessed using the Mixed Methods Appraisal Tool (MMAT) by RM and DD, which includes appraisal criteria for a variety of study designs (
      • Hong Q.N.
      • et al.
      Mixed methods appraisal tool (MMAT), version 2018.
      ). The MMAT comprises two initial screening questions, followed by five design-specific questions (which differ for quantitative descriptive studies, randomised control trials, non-randomised control trials etc.). While it is not advised to use the MMAT to produce scores (
      • Hong Q.N.
      • et al.
      Mixed methods appraisal tool (MMAT), version 2018.
      ), we adopted the following approach as a proxy for methodological strength: 4-5 criteria met = high quality, 2-3 criteria met = moderate quality, and 0-1 criteria met = low quality. MMAT scores were not used as a basis to exclude studies, but rather to indicate methodological quality.

      2.6 Synthesis of findings

      Following data extraction and quality appraisal, the results were analysed using a process of narrative synthesis (RM). Due to the observed heterogeneity of QOL measures and designs employed, a meta-analysis was not deemed appropriate. The process of narrative synthesis first involved categorising the FOC measures as being either, (1) an unvalenced expectation, such as judgement of likelihood about the future, (2) a negative expectation, such as fears or worries about the future, or (3) a positive expectation, such as hope, optimism or confidence in capabilities. In certain cases, these categories were subdivided further to capture subtle differences in measures (e.g. measures of MS specific vs. generalised self-efficacy). Each set of factors was assessed in terms of its relationships with QOL.

      3. Results

      Database searches gave rise to 3,952 articles; removing duplicates (n=848) left 3,104 to screen. Of these, a further 2,993 were excluded. Full-texts of the remaining 111 were assessed for eligibility, with 11 meeting the inclusion criteria (see PRISMA diagram, Figure 1). The most common reasons for exclusion were failure to assess the relationship between an FOC and QOL or the absence of a peer-reviewed full text. Reference sections of the 11 included studies were examined, leading to the identification of two additional studies. Thirteen studies were therefore included in the final narrative synthesis, with summary information displayed in Table 1.
      Table 1Studies included in review
      StudyAimDesignCountryN PwMS (% female)Age (M years)MS characteristicsFOC measure(s)QOL measureMMAT score
      (
      • Arnoldus J.H.
      • et al.
      Quality of life during the first 6 months of interferon-B treatment in patients with MS.
      )
      To determine QOL of MS patients during initial 6 months of treatment with IFJN-b.LongitudinalNether-lands51 (76%)35.1100% RRMS; EDSS 3.7Therapeutic expectation score (seven item)Health status questionnaire (SF-36)3
      (
      • Calandri E.
      • et al.
      Depression, positive and negative affect, optimism and health-related quality of life in recently diagnosed multiple sclerosis patients: The role of identity, sense of coherence, and self-efficacy.
      )
      To describe levels of depression, positive and negative affect, optimism and HRQOL in a group of recently diagnosed PwMS.Cross-sectionalItaly60 (61%)3795% RRMS; EDSS 1-4; TSDX <3 yearsLife Orientation Test-Revised

      Self-efficacy in MS scale
      Health status questionnaire (SF-12)2
      (
      • Goodworth M.C.
      • et al.
      Variables associated with patient activation in persons with multiple sclerosis.
      )
      To examine the contributions of patient demographic and psychosocial variables to activation levels in PwMS.Cross-sectionalUSA163 (82%)46.2469% RRMS; TSDX (M)=8.3 yearsPatient Activation Measure–13

      MS Self-Efficacy Scale
      Leeds MS QOL scale3
      (
      • Hayter A.L.
      • et al.
      The impact of health anxiety in patients with relapsing remitting multiple sclerosis: Misperception, misattribution and quality of life.
      )
      To examine the effect of health anxiety on MS patients’ QoL.Cross-sectionalUK84 (% F not reported)not reported100% RRMS;TSDX<10 years; low disabilityModified version of Health Anxiety inventoryQOL index3
      (
      • Messmer Uccelli M.
      • Traversa S.
      • Ponzio M.
      A survey study comparing young adults with MS and healthy controls on self-esteem, self-efficacy, mood and quality of life.
      )
      To assess self-esteem, self-efficacy, mood and quality of life in a group of young adults with MS.Cross-sectionalItaly89 (84%)24.2TSDX (M) 5.3 years; minimal disabilityGeneral self-efficacy scaleWHO-5 well-being index3
      (
      • Motl R.W.
      • et al.
      Physical activity, self-efficacy, and health-related quality of life in persons with multiple sclerosis: analysis of associations between individual-level changes over one year.
      )
      To examine associations between individual-level changes in physical activity, self-efficacy and HRQOL over one-year period.LongitudinalUSA254 (88%)45.9100% RRMS; TSDX (M) 10 years; Mean EDSS 2MS Self-Efficacy ScaleMS Impact scale4
      (
      • Motl R.W.
      • et al.
      Physical activity and quality of life in multiple sclerosis: intermediary roles of disability, fatigue, mood, pain, self-efficacy and social support.
      )
      To examine variables that might account for relationship between physical activity and QOL in PwMS.Quasi/cross-sectionalUSA292 (87%)4884% RRMS; TSDX (M) = 10.3 yearsMS Self-Efficacy Scale Exercise self-efficacy scaleLeeds MS QOL scale4
      (
      • Penwell-Waines L.
      • et al.
      Testing the health promotion model for adherence and quality of life in individuals with multiple sclerosis.
      )
      To test the Health promotion model in explaining self-reported adherence and MS QOL.Cross-sectionalUSA121(85%)45.475% RRMS; TSDX (M) = 10 yearsSelf-efficacy for managing chronic diseaseLeeds MS QOL scale3
      (
      • Riazi A.
      • Thompson A.
      • Hobart J.
      Self-efficacy predicts self-reported health status in multiple sclerosis.
      )
      To examine the role of self-efficacy in predicting self-reported health status in MS among two groups.LongitudinalUK89 (70%)45.480% RRMS (EDSS=5.8) in steroid group & 23% (EDSS=7.2) in rehab group; TSDX 12 years in both groupsMS Self-Efficacy ScaleMS Impact scale5
      (
      • Spain L.
      • et al.
      Illness perception and health-related quality of life in multiple sclerosis.
      )
      To determine the relative importance of individual factors in HRQoL, in particular the role of illness perception.Cross-sectionalAustralia580 (79%)46.754% RRMS; TSDX (M) =8.5 yearsIllness Perception Questionnaire (treatment and personal control subscales)Health status questionnaire (SF-36)3
      (
      • Stuifbergen A.K.
      • Seraphine A.
      • Roberts G.
      An explanatory model of health promotion and quality of life in chronic disabling conditions.
      )
      To test an explanatory model of variables influencing health promotion and QOL in PwMSCross-sectionalUSA786 (80%)4745% RRMS; TSDX (M) = 10.6 yearsSelf-Rated Abilities for Health Practices scaleQOL index4
      (
      • Wilski M.
      • Tasiemski T.
      Health-related quality of life in multiple sclerosis: role of cognitive appraisals of self, illness and treatment.
      )
      To examine the role of cognitive appraisals as correlates of HRQoL in MSCross-sectionalPoland257 (67%)4837% RRMS; TSDX (M)=13 years; moderate disabilityBrief Illness Perception Questionnaire (treatment and personal control subscales)

      General Self-efficacy scale
      MS Impact scale4
      (
      • Wollin J.A.
      • et al.
      Longitudinal changes in quality of life and related psychosocial variables in australians with multiple sclerosis.
      )
      To explore changes in QOL and psychosocial variables in a large cohort of PwMSLongitudinalAustralia1287 (79%)55TSDX 13.5 years; 70% did not report change in illness over 2 years; 15% worsened and 5% improvedMS Self-efficacy scaleWHO QOL-1005

      3.1 Quality Appraisal

      MMAT scores for included studies ranged from 2 to 5, and are provided in Table 1. The majority of studies were of moderate quality (n=7), with common limitations relating to sample representativeness and risk of response bias.

      3.2 Sample characteristics

      A total of 4,179 PwMS participated in the studies reviewed, with sample sizes ranging from 51 – 1,287. The majority of participants across studies were female (79%; range 61-88%), which is broadly consistent with population norms (
      • Gilmour H.
      • Ramage-Morin P.L.
      • Wong S.L.
      Multiple sclerosis: Prevalence and impact.
      ). Participants came from a range of ages, with mean ages from 24-55 years old across studies, although most (n=8; 67%) reported a mean age of 45-48 years. One study failed to report age or gender breakdown. Studies came from various countries, including the USA (n=5), UK (n=2), Italy (n=2), Australia (n=2), Poland (n=1), and The Netherlands (n=1).
      In terms of MS characteristics, samples included different patient profiles. Three studies focused on those recently diagnosed (
      • Calandri E.
      • et al.
      Depression, positive and negative affect, optimism and health-related quality of life in recently diagnosed multiple sclerosis patients: The role of identity, sense of coherence, and self-efficacy.
      ,
      • Hayter A.L.
      • et al.
      The impact of health anxiety in patients with relapsing remitting multiple sclerosis: Misperception, misattribution and quality of life.
      ,
      • Messmer Uccelli M.
      • Traversa S.
      • Ponzio M.
      A survey study comparing young adults with MS and healthy controls on self-esteem, self-efficacy, mood and quality of life.
      ), which meant a high prevalence of people with relapsing-remitting multiple sclerosis (RRMS) with typically low levels of disability. One study focused on those commencing a particular treatment (
      • Arnoldus J.H.
      • et al.
      Quality of life during the first 6 months of interferon-B treatment in patients with MS.
      ), another involved comparison of groups undergoing rehabilitation versus steroid treatment (
      • Riazi A.
      • Thompson A.
      • Hobart J.
      Self-efficacy predicts self-reported health status in multiple sclerosis.
      ), with higher levels of disability evident in the former group. Other studies incorporated a mixture of patients with RRMS, primary-progressive MS (PPMS), and secondary-progressive MS (SPMS), with mean disease duration varying from less than 3 years to 14 years. Expanded Disability Status Scale (EDSS) scores (
      • Kurtzke J.F.
      Rating neurologic impairment in multiple sclerosis: an expanded disability status scale (EDSS).
      ) were commonly reported as measures of disability, with mean scores ranging from 2 (mild disability) to 7.5 (severe disability).

      3.3 Study characteristics

      Most of the studies involved cross-sectional research designs, with four involving longitudinal designs (
      • Arnoldus J.H.
      • et al.
      Quality of life during the first 6 months of interferon-B treatment in patients with MS.
      ,
      • Riazi A.
      • Thompson A.
      • Hobart J.
      Self-efficacy predicts self-reported health status in multiple sclerosis.
      ,
      • Motl R.W.
      • et al.
      Physical activity, self-efficacy, and health-related quality of life in persons with multiple sclerosis: analysis of associations between individual-level changes over one year.
      ,
      • Wollin J.A.
      • et al.
      Longitudinal changes in quality of life and related psychosocial variables in australians with multiple sclerosis.
      ). Almost all measured additional variables beyond those of interest in the current study.

      3.4 Measures employed

      Various QOL measures were used, the most common being the Leeds MS QOL Scale (
      • Ford H.
      • et al.
      Developing a disease-specific quality of life measure for people with multiple sclerosis.
      ) (n=3), the MS Impact scale (MSIS-29) (
      • Hobart J.
      • et al.
      The multiple sclerosis impact scale (MSIS-29) a new patient-based outcome measure.
      ) (n=3), the QOL Index (QLI)–MS version (
      • Ferrans C.E.
      • Powers M.J.
      Psychometric assessment of the Quality of Life Index.
      ) (n=2), and the SF-36 (
      • Ware Jr, J.E.
      SF-36 health survey update.
      ) (n=2). Single studies also included the SF-12 (
      • Gandek B.
      • et al.
      Cross-validation of item selection and scoring for the SF-12 Health Survey in nine countries: results from the IQOLA Project.
      ), the WHO-5 (
      • Topp C.
      • et al.
      The WHO-5 Well-Being Index: A Systematic Review of the Literature.
      ), and the WHOQOL-100 (
      • Power M.
      • Bullinger M.
      • Harper A.
      The World Health Organization WHOQOL-100: Tests of the universality of quality of life in 15 different cultural groups worldwide.
      ). It should be noted that, while all these are measures of QOL, they vary in the number of items and/or QOL domains measured; some include subscales (e.g. of mental/psychological and physical health), while others capture a single QOL index.
      The FOC construct most frequently measured was self-efficacy, with almost all studies including one measure of this (n=10), including all those studies which were based in the USA. Of the studies measuring self-efficacy, specific measures of MS self-efficacy were used in 5 studies, including use of the MSSE (
      • Schwartz C.E.
      • et al.
      Measuring self-efficacy in people with multiple scleoris: a validation study.
      ) (n=3), the SEMS (
      • Bonino S.
      • et al.
      The Self-Efficacy in Multiple Sclerosis (SEMS) Scale: Development and validation with Rasch analysis.
      ) (n=1), and the MSSS (
      • Rigby S.A.
      • et al.
      Development and validation of a self-efficacy measure for people with multiple sclerosis: the Multiple Sclerosis Self-efficacy Scale.
      ) (n=1). Two studies included the General Self-Efficacy Scale (
      • Schwarzer R.
      • Jerusalem M.
      Generalized self-efficacy scale. Measures in health psychology: A user's portfolio.
      ); one used the Self-Efficacy for Managing Chronic Illness Scale (
      • Lorig K.R.
      • et al.
      Chronic disease self-management program: 2-year health status and health care utilization outcomes.
      ). Two studies employed self-efficacy measures in specific contexts, namely the Self-Rated abilities for Health Practices Scale (
      • Becker H.
      • et al.
      Self-rated abilities for health practices: A health self-efficacy measure. Health Values: The Journal of Health Behavior.
      ) and the Exercise Self-Efficacy Scale (
      • McAuley E.
      Self-efficacy and the maintenance of exercise participation in older adults.
      ).
      Other FOC measures included the “control” subscales of the Illness Perception Questionnaire (
      • Leventhal H.
      • Meyer D.
      • Nerenz D.
      The common sense representation of illness danger.
      ) and the Brief-Illness Perception Questionnaire (
      • Broadbent E.
      • et al.
      The brief illness perception questionnaire.
      ); the Patient-Activation Measure-13 (
      • Hibbard J.H.
      • et al.
      Development and testing of a short form of the patient activation measure.
      ); the Life-Orientation Test (
      • Scheier M.F.
      • Carver C.S.
      • Bridges M.W.
      Distinguishing optimism from neuroticism (and trait anxiety, self-mastery, and self-esteem): a reevaluation of the Life Orientation Test.
      ); an adapted version of the Health-Anxiety Questionnaire (
      • Salkovskis P.M.
      • RIMES K.A.
      • WARWICK H.M.C.
      The Health Anxiety Inventory: development and validation of scales for the measurement of health anxiety and hypochondriasis.
      ); and a bespoke seven-item measure of treatment expectations regarding beta interferon (IFN-b1). Studies employing these measures were all based in Europe, with the exception of one study based in Australia which examined illness perceptions (
      • Spain L.
      • et al.
      Illness perception and health-related quality of life in multiple sclerosis.
      ). Four studies reported more than one FOC measure (
      • Calandri E.
      • et al.
      Depression, positive and negative affect, optimism and health-related quality of life in recently diagnosed multiple sclerosis patients: The role of identity, sense of coherence, and self-efficacy.
      ,
      • Messmer Uccelli M.
      • Traversa S.
      • Ponzio M.
      A survey study comparing young adults with MS and healthy controls on self-esteem, self-efficacy, mood and quality of life.
      ,
      • Goodworth M.C.
      • et al.
      Variables associated with patient activation in persons with multiple sclerosis.
      ,
      • Motl R.W.
      • et al.
      Physical activity and quality of life in multiple sclerosis: intermediary roles of disability, fatigue, mood, pain, self-efficacy and social support.
      ).

      3.5 Narrative synthesis

      We categorised FOCs by their valence (specifically whether they measured positive, negative or unvalenced FOCs/expectations). Table 2 illustrates that most studies (n=11) measured positively valenced FOCs, including self-efficacy, optimism, patient-activation, or personal/treatment control. Nine out of the 11 studies measuring positive FOCs demonstrated significant relationships with QOL. In contrast, one study (
      • Calandri E.
      • et al.
      Depression, positive and negative affect, optimism and health-related quality of life in recently diagnosed multiple sclerosis patients: The role of identity, sense of coherence, and self-efficacy.
      ) found both optimism and self-efficacy to relate to mental health, but the association was not evident with physical health, and self-efficacy did not predict QOL when controlling for other known associates. There was mixed evidence for the role of perceptions of treatment control in QOL. While positive relationships were found in one study (
      • Wilski M.
      • Tasiemski T.
      Health-related quality of life in multiple sclerosis: role of cognitive appraisals of self, illness and treatment.
      ), another reported control as a significant predictor of only two subscales of the SF36, specifically vitality and emotional role functioning (
      • Spain L.
      • et al.
      Illness perception and health-related quality of life in multiple sclerosis.
      ), although these differing results may be attributed to the different measures used.
      Table 2Results summary
      FOC ValenceSpecific FOCSignificant relationships with QOL (p <0.05)No relationships with QOL (p>0.05)
      Not classifiedTherapeutic expectations
      • (
        • Arnoldus J.H.
        • et al.
        Quality of life during the first 6 months of interferon-B treatment in patients with MS.
        ) – no relationship with therapeutic expectations for beta interferon and SF36 scores.
      Positive FOCsSelf-efficacy (general)
      • (
        • Messmer Uccelli M.
        • Traversa S.
        • Ponzio M.
        A survey study comparing young adults with MS and healthy controls on self-esteem, self-efficacy, mood and quality of life.
        ) – SE correlated with WHO-5 (r=.53)
      • (
        • Wilski M.
        • Tasiemski T.
        Health-related quality of life in multiple sclerosis: role of cognitive appraisals of self, illness and treatment.
        ) – SE correlated with MSIS-29 (-0.419) and, in regression model controlling for other known associates, predicted general HRQoL (beta=-0.22), physical (beta = -0.3) and psychological (beta= -.02) domains of MSIS-29.
      Self-efficacy (MS specific)
      • (
        • Calandri E.
        • et al.
        Depression, positive and negative affect, optimism and health-related quality of life in recently diagnosed multiple sclerosis patients: The role of identity, sense of coherence, and self-efficacy.
        ) – SE correlated with mental health domain of SF12 (r=.26).
      • (
        • Goodworth M.C.
        • et al.
        Variables associated with patient activation in persons with multiple sclerosis.
        ) – SE correlated with LMSQL (r=.62)
      • (
        • Motl R.W.
        • et al.
        Physical activity, self-efficacy, and health-related quality of life in persons with multiple sclerosis: analysis of associations between individual-level changes over one year.
        ) – Baseline MSSE functioning and control correlated with MSIS-29 physical (r=.616; r=.615) and psychological (r=.427; r=.602) domains at follow up.
      • (
        • Motl R.W.
        • et al.
        Physical activity and quality of life in multiple sclerosis: intermediary roles of disability, fatigue, mood, pain, self-efficacy and social support.
        ) – SE correlated with LMSQL (r=.73) + predicted LMSQL in regression analysis (ybeta=.07).
      • (
        • Riazi A.
        • Thompson A.
        • Hobart J.
        Self-efficacy predicts self-reported health status in multiple sclerosis.
        ) – Baseline MSSE function and control associated with physical (r=-.56; r=0.61) and psychological (r=-0.41; r=0.61) domains of MSIS-29 at follow up. Regression analyses showed both baseline and MSSE changes to independently predict MSIS-29 scores.
      • (
        • Wollin J.A.
        • et al.
        Longitudinal changes in quality of life and related psychosocial variables in australians with multiple sclerosis.
        ) – SE at baseline correlated with overall WHOQOL-100 at follow up (r=.71), as well as with the psychological (r=0.71), independence (r=.72) and environment (r=63) domains. Along with perceived stress and social support, SE predicted WHOQOL-100 in regression model (beta = .18).
      • (
        • Calandri E.
        • et al.
        Depression, positive and negative affect, optimism and health-related quality of life in recently diagnosed multiple sclerosis patients: The role of identity, sense of coherence, and self-efficacy.
        ) – SE not correlated with physical health domain of SF12. Also SE was not a predictor of either mental or physical health when controlling for other factors in regression analysis.
      Self-efficacy for illness management
      • (
        • Penwell-Waines L.
        • et al.
        Testing the health promotion model for adherence and quality of life in individuals with multiple sclerosis.
        ) - SE predictor of LMSQL after controlling for known associates including anxiety, depression and stigma (beta=-.19)
      Self-Rated abilities for Health practices
      Exercise self-efficacy
      • (
        • Motl R.W.
        • et al.
        Physical activity and quality of life in multiple sclerosis: intermediary roles of disability, fatigue, mood, pain, self-efficacy and social support.
        ) – EXSE correlated with LMSQL (r=.38)
      Optimism
      • (
        • Calandri E.
        • et al.
        Depression, positive and negative affect, optimism and health-related quality of life in recently diagnosed multiple sclerosis patients: The role of identity, sense of coherence, and self-efficacy.
        ) – optimism correlated with mental health domain of SF12 (r=.33)
      • (
        • Calandri E.
        • et al.
        Depression, positive and negative affect, optimism and health-related quality of life in recently diagnosed multiple sclerosis patients: The role of identity, sense of coherence, and self-efficacy.
        ) – optimism not correlated with physical health domain of SF12.
      Patient activation
      Illness perception (Treatment control)
      • (
        • Spain L.
        • et al.
        Illness perception and health-related quality of life in multiple sclerosis.
        ) – regression analysis controlling for known associates showed small effect on vitality (beta = 0.099) and emotional role functioning (-0.10) subscales of SF36
      • (
        • Wilski M.
        • Tasiemski T.
        Health-related quality of life in multiple sclerosis: role of cognitive appraisals of self, illness and treatment.
        ) – treatment control related to MSIS-29 (r=-.154).
      • (
        • Spain L.
        • et al.
        Illness perception and health-related quality of life in multiple sclerosis.
        ) – regression analysis did not show effect of control on any other SF36 subscales than those reported.
      Negative FOCsHealth anxiety
      • (
        • Hayter A.L.
        • et al.
        The impact of health anxiety in patients with relapsing remitting multiple sclerosis: Misperception, misattribution and quality of life.
        ) – difference in QLI scores in low vs. high HAI groups after controlling for disability.
      Generally, however, scores indicative of more positive FOCs were associated with better patient QOL in both physical and psychological domains (
      • Wollin J.A.
      • et al.
      Longitudinal changes in quality of life and related psychosocial variables in australians with multiple sclerosis.
      ,
      • Wilski M.
      • Tasiemski T.
      Health-related quality of life in multiple sclerosis: role of cognitive appraisals of self, illness and treatment.
      ,
      • Motl R.W.
      • McAuley E.
      • Sandroff B.M.
      Longitudinal change in physical activity and its correlates in relapsing-remitting multiple sclerosis.
      ,
      • Casey B.
      • et al.
      Do multiple sclerosis symptoms moderate the relationship between self-efficacy and physical activity in people with multiple sclerosis?.
      ). While the majority of studies involved cross-sectional designs, those employing longitudinal designs suggest that positive expectations, specifically MS self-efficacy, are predictive of later higher QOL (
      • Riazi A.
      • Thompson A.
      • Hobart J.
      Self-efficacy predicts self-reported health status in multiple sclerosis.
      ,
      • Wollin J.A.
      • et al.
      Longitudinal changes in quality of life and related psychosocial variables in australians with multiple sclerosis.
      ,
      • Motl R.W.
      • et al.
      Physical activity and quality of life in multiple sclerosis: intermediary roles of disability, fatigue, mood, pain, self-efficacy and social support.
      ,
      • Motl R.W.
      • McAuley E.
      • Sandroff B.M.
      Longitudinal change in physical activity and its correlates in relapsing-remitting multiple sclerosis.
      ), and studies employing regression analyses suggest that self-efficacy is an independent predictor of higher QOL when controlling for other known associates (
      • Penwell-Waines L.
      • et al.
      Testing the health promotion model for adherence and quality of life in individuals with multiple sclerosis.
      ,
      • Wilski M.
      • Tasiemski T.
      Health-related quality of life in multiple sclerosis: role of cognitive appraisals of self, illness and treatment.
      ).
      Only one study in the review examined a negative FOC in relation to QOL (
      • Hayter A.L.
      • et al.
      The impact of health anxiety in patients with relapsing remitting multiple sclerosis: Misperception, misattribution and quality of life.
      ); those with higher levels of health anxiety had lower QOL after controlling for degree of disability.
      We were unable to obtain the full seven-item measure of therapeutic expectations in relation to beta interferon (IFN-b1) treatment (
      • Arnoldus J.H.
      • et al.
      Quality of life during the first 6 months of interferon-B treatment in patients with MS.
      ), so cannot make an assessment of its valence. No significant association between this measure and QOL was found.

      4. Discussion

      In this review, we aimed to systematically investigate associations between FOCs/expectations and QOL in PwMS. The current weight of evidence suggests that thoughts about the future play a role in QOL, although there is still some uncertainty regarding the precise nature of these associations. As we discuss below, shedding light on these processes may aid the development of supports for those living with MS.

      4.1 Positive expectations and self-efficacy

      The most robust finding from studies included in our review is the strong associations uncovered between positive FOCs and QOL. In particular, published research provides good evidence for links between QOL and self-efficacy, including both general and disease-specific self-efficacy (
      • Calandri E.
      • et al.
      Depression, positive and negative affect, optimism and health-related quality of life in recently diagnosed multiple sclerosis patients: The role of identity, sense of coherence, and self-efficacy.
      ,
      • Messmer Uccelli M.
      • Traversa S.
      • Ponzio M.
      A survey study comparing young adults with MS and healthy controls on self-esteem, self-efficacy, mood and quality of life.
      ,
      • Riazi A.
      • Thompson A.
      • Hobart J.
      Self-efficacy predicts self-reported health status in multiple sclerosis.
      ,
      • Motl R.W.
      • et al.
      Physical activity, self-efficacy, and health-related quality of life in persons with multiple sclerosis: analysis of associations between individual-level changes over one year.
      ,
      • Wollin J.A.
      • et al.
      Longitudinal changes in quality of life and related psychosocial variables in australians with multiple sclerosis.
      ,
      • Goodworth M.C.
      • et al.
      Variables associated with patient activation in persons with multiple sclerosis.
      ,
      • Wilski M.
      • Tasiemski T.
      Health-related quality of life in multiple sclerosis: role of cognitive appraisals of self, illness and treatment.
      ,
      • Motl R.W.
      • et al.
      Physical activity and quality of life in multiple sclerosis: intermediary roles of disability, fatigue, mood, pain, self-efficacy and social support.
      ). Broadly speaking, self-efficacy is an example of an outcome expectation relating to an individual's confidence in their own abilities, and involves physical, social and self-evaluative components (
      • Morrison J.D.
      • Stuifbergen A.K.
      Outcome expectations and physical activity in persons with longstanding multiple sclerosis.
      ,
      • Motl R.W.
      • et al.
      Physical activity and quality of life in multiple sclerosis: intermediary roles of disability, fatigue, mood, pain, self-efficacy and social support.
      ). This confidence may be generalised or domain specific, both forms of which were captured in our review.
      In MS, self-efficacy has been researched most frequently in the context of physical exercise (
      • Morrison J.D.
      • Stuifbergen A.K.
      Outcome expectations and physical activity in persons with longstanding multiple sclerosis.
      ), but more broadly has been shown to predict self-reported functioning in relation to physical, social and cognitive domains (
      • Schmitt M.M.
      • et al.
      Self-efficacy as a predictor of self-reported physical, cognitive, and social functioning in multiple sclerosis.
      ). Papers included in the review used a variety of measures of self-efficacy, suggesting that confidence in a range of future abilities in different domains and at different levels of specificity have an influence on the QOL of PwMS. This is also consistent with early research showing that self-efficacy predicts adjustment to MS more strongly than other outcome expectations (
      • Wassem R.
      Self-efficacy as a predictor of adjustment to multiple sclerosis.
      ), as well as being consistent with the patterning of relationships between self-efficacy and QOL in other patient groups (
      • Bentsen S.B.
      • et al.
      Self-efficacy as a predictor of improvement in health status and overall quality of life in pulmonary rehabilitation—An exploratory study.
      ,
      • Mancuso C.A.
      • Sayles W.
      • Allegrante J.P.
      Knowledge, attitude, and self-efficacy in asthma self-management and quality of life.
      ,
      • Cramm J.M.
      • et al.
      The importance of general self-efficacy for the quality of life of adolescents with chronic conditions.
      ).
      Other positive FOCs associated with QOL in MS share some overlap with self-efficacy, as they relate to patients’ perceptions of control, which may be particularly important in PwMS given the uncertainty of disease course and symptom variability. These may include illness perceptions (
      • Spain L.
      • et al.
      Illness perception and health-related quality of life in multiple sclerosis.
      ,
      • Wilski M.
      • Tasiemski T.
      Health-related quality of life in multiple sclerosis: role of cognitive appraisals of self, illness and treatment.
      ), and patient activation (
      • Goodworth M.C.
      • et al.
      Variables associated with patient activation in persons with multiple sclerosis.
      ), for example, a patient's expected engagement in their own healthcare management. Two studies (
      • Calandri E.
      • et al.
      Depression, positive and negative affect, optimism and health-related quality of life in recently diagnosed multiple sclerosis patients: The role of identity, sense of coherence, and self-efficacy.
      ,
      • Spain L.
      • et al.
      Illness perception and health-related quality of life in multiple sclerosis.
      ) reported inconclusive findings, which might be explained by differences in the measures used. However, taken together, the review's findings suggest that fostering positive expectations in one's ability to manage the effects of MS and treatment may enhance QOL.
      Previous reviews of psychosocial interventions in MS have found evidence for the benefits of patient education and goal setting on wellbeing (
      • Malcomson K.
      • Dunwoody L.
      • Lowe-Strong A.
      Psychosocial interventions in people with multiple sclerosis.
      ), both of which might offer ways of increasing self-efficacy. Indeed, increases in positive efficacy expectations could be a key mechanism through which these interventions operate. Further research is needed to understand the optimal delivery of supports in terms of timing and duration, particularly in light of the evolving challenges encountered in MS. Our review suggests that self-efficacy is an important predictor of QOL regardless of disease duration or progression, with associations between QOL and self-efficacy found in studies which varied in the proportion of people with RRMS and progressive MS respectively. In light of these findings, we suggest that identifying ways of (1) encouraging positive efficacy expectations at diagnosis, and (2) maintaining positive expectations throughout the disease trajectory, may be beneficial in helping patients cope with the wide-ranging challenges encountered at different stages of the disease.
      Only one study included in our review investigated optimism, with associations between mental, but not physical, QOL domains reported (
      • Calandri E.
      • et al.
      Depression, positive and negative affect, optimism and health-related quality of life in recently diagnosed multiple sclerosis patients: The role of identity, sense of coherence, and self-efficacy.
      ). Previous work has pointed to the benefits of optimism in aiding adaptive coping strategies in MS (
      • de Ridder D.
      • Schreurs K.
      • Bensing J.
      The relative benefits of being optimistic: Optimism as a coping resource in multiple sclerosis and Parkinson's disease.
      ). Other work suggests that the physical health of PwMS depends strongly on positive expectations, including optimistic beliefs (
      • Fournier M.
      • de Ridder D.
      • Bensing J.
      Optimism and adaptation to chronic disease: The role of optimism in relation to self-care options of type 1 diabetes mellitus, rheumatoid arthritis and multiple sclerosis.
      ). This, however, may depend on the controllability of disease. Specifically, when self‐care options for controlling disease are limited, positive unrealistic thinking may be of benefit. In contrast, positive efficacy expectations may be more useful when self-care is possible (
      • Fournier M.
      • de Ridder D.
      • Bensing J.
      Optimism and adaptation to chronic disease: The role of optimism in relation to self-care options of type 1 diabetes mellitus, rheumatoid arthritis and multiple sclerosis.
      ). Similar effects have been observed in other chronic illness populations, with optimism showing stronger associations with QOL in those limited by disease, compared to those who are not (
      • Maguire R.
      • Hanly P.
      • Maguire P.
      Living well with chronic illness: How social support, loneliness and psychological appraisals relate to well-being in a population-based European sample.
      ). While our review found similar benefits for self-efficacy expectations in a range of PwMS, including those with progressive forms of the disease, examination of the broader literature implies that the benefits of fostering positive expectations may depend on individual health-related characteristics and other contextual factors.

      4.2 Negative FOCs

      Only one study which met the review inclusion criteria examined negative FOCs, specifically, the effects of health anxiety on MS QOL (
      • Hayter A.L.
      • et al.
      The impact of health anxiety in patients with relapsing remitting multiple sclerosis: Misperception, misattribution and quality of life.
      ). This contrasts with research in other conditions such as cancer, where fears and worries about the future are extensively researched in relation to QOL. While MS is a very different illness, patients may experience a range of fears regarding their symptoms and prognosis (
      • Finlayson M.
      Concerns about the future among older adults with multiple sclerosis.
      ), which could potentially be alleviated through the provision of information and support. Although some studies examine such experiences, for example fear of falling (
      • Peterson E.W.
      • Cho C.C.
      • Finlayson M.L.
      Fear of falling and associated activity curtailment among middle aged and older adults with multiple sclerosis.
      ), more general worries appear to be under-investigated in relation to MS QOL.
      We could not classify the valance of one FOC measure (
      • Arnoldus J.H.
      • et al.
      Quality of life during the first 6 months of interferon-B treatment in patients with MS.
      ), and no studies in the review examined patients’ predictions of prognosis in relation to QOL. This is an issue which is worthy of further investigation as qualitative research suggests that many PwMS form expectations about their prognosis without HCP input (
      • Dennison L.
      • et al.
      How do people with Multiple Sclerosis experience prognostic uncertainty and prognosis communication? A qualitative study.
      ). A large scale study suggests that preferences for prognostic information may influence QOL (
      • Dennison L.
      • et al.
      Do people with multiple sclerosis want to know their prognosis? A UK nationwide study.
      ), suggesting again that the provision of appropriate information may facilitate adjustment for some, but not all, PwMS. Patient preferences are likely to be important in this context. While it has been suggested that delivery of prognostic information may lead to nocebo effects (
      • Heesen C.
      • Scalfari A.
      • Galea I.
      Prognostic information for people with MS: Impossible or inevitable?.
      ), we found no studies in our review to support this assumption, at least in terms of QOL impacts.

      4.3 Limitations

      While we attempted to capture as broad a range of measures of expectations and FOCs as possible, our search terms may have excluded some constructs that could potentially be viewed as FOCs. Our review only focused on the relationships between FOCs and QOL, and did not examine other measures of psychological wellbeing (e.g. depression and general anxiety). Given that these are commonly reported problems in PwMS (
      • Boeschoten R.E.
      • et al.
      Prevalence of depression and anxiety in multiple sclerosis: a systematic review and meta-analysis.
      ,
      • Jones K.H.
      • et al.
      A large-scale study of anxiety and depression in people with Multiple Sclerosis: a survey via the web portal of the UK MS Register.
      ), it is possible that FOCs may also influence these experiences. For example, those with higher risk perceptions have been found to be more bothered by MS-related thoughts, which relates to increased anxiety and depression independently of disease status (
      • Janssens A.C.J.
      • et al.
      Perception of prognostic risk in patients with multiple sclerosis: the relationship with anxiety, depression, and disease-related distress.
      ). The heterogeneity of methodologies, sample characteristics and measurement tools employed means that any comparisons made between findings should be interpreted with caution. Our review focussed on quantitative research studies; examination of findings from qualitative research designs may provide a more in-depth insight into the processes involved. Finally, the majority of the studies included involved cross-sectional designs, with only four longitudinal studies. Caution is needed in interpreting possible directionality of these results. While methodological quality was generally high, some studies may have been at risk of bias, particularly relating to the composition of samples.

      4.4 Conclusions

      Currently, the treatment of MS tends to focus on clinical aspects of the disease and symptom management, with less attention paid to psychological experiences of coping with disease. There is a growing recognition that the expectations patients form about illness may influence a range of outcomes, including health attitudes and behaviours, as well as treatment satisfaction, adherence and decision making (
      • Coulter A.
      Examining health expectations.
      ). Our review suggests that thoughts about the future may also influence many aspects of QOL in MS, and that recognising this is an important aspect of MS care, especially given the unpredictable nature of the disease. In particular, our findings highlight the importance of fostering positive expectations in patients, including self-efficacy in one's abilities to manage the effects of MS and treatment. These findings have implications for both clinicians and PwMS. For example, based on these results, we recommend that clinicians acknowledge the feelings of uncertainty that may be experienced by PwMS and carefully consider how to foster positive FOCs regarding treatment and symptom management during consultations, without setting unrealistic expectations. Similarly, we recommend that PwMS identify ways in which they may be empowered to feel in control over aspects of their condition while also learning to accept their diagnosis. While the development of such expectations may be aided by the provision of education and support, needs for these supports continue to be unmet (
      • McCabe M.P.
      • et al.
      Unmet education, psychological and peer support needs of people with multiple sclerosis.
      ). More research into the influence of other forms of expectations, such as negative or unvalenced FOCs, may give further insight into how best to develop interventions tailored at supporting PwMS.

      Declaration of Competing Interest

      Authors have no conflicts of interest to declare.

      Appendix. Supplementary materials

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