Patients’ evaluations of the quality of care: influencing factors and the importance of engagementAims. This paper reports a study exploring the process of patient evaluation and identifying the factors which influence this. Background. Patient experiences of health care have become a central focus for researchers, policymakers, clinicians and patient groups in many countries. While surveys of patient experiences have become increasingly common internationally, concerns about the validity of concepts such as satisfaction have cast doubt on the utility of their findings. These concerns reflect our limited understanding of patient evaluation and the factors that can influence this process. Methods. A qualitative design was adopted, using semi- structured interviews with a sample of outpatients in their homes in one county in England. In total, 41 patients participated in the study and were interviewed before their appointment. Of these patients, 37 were interviewed again after their appointment. Six of the latter were then re-interviewed 6 weeks after the appointment to explore whether evaluations had changed. Findings. Patient evaluation was influenced by a number of factors, including gratitude, faith, loyalty, luck and equity. The overall effect was to prompt positive evaluation, even when care was poor. These factors should be accounted for in the interpretation of patient experiences surveys. Patient experiences were further influenced by their sense of engagement with the system. A negative sense of engagement could have a major impact on the patient, resulting in disappointment or fear and a desire to leave the health care system, and in a negative evaluation of a specific aspect of care. Conclusions. Engagement may provide a more appropriate indicator of negative experience than dissatisfaction. The influence of these factors should be considered in future attempts to develop more sensitive and appropriate methods of eliciting patient experiences. Grant information: PPP Health Care Medical Trust Millennium Fellowship Grant.