Health systems' responsiveness and reporting behaviour: Multilevel analysis of the influence of individual-level factors in 64 countries

Health systems' responsiveness encompasses attributes of health system encounters valued by people and measured from the user's perspective in eight domains: dignity, autonomy, confidentiality, communication, prompt attention, social support, quality of basic amenities and choice. The literature advocates for adjusting responsiveness measures for reporting behaviour heterogeneity, which refers to differential use of the response scale by survey respondents. Reporting behaviour heterogeneity between individual respondents compromises comparability between countries and population subgroups. It can be studied through analysing responses to pre-defined vignettes - hypothetical scenarios recounting a third person's experience in a health care setting. This paper describes the first comprehensive approach to studying reporting behaviour heterogeneity using vignettes. Individual-level variables affecting reporting behaviour are grouped into three categories: (1) sociodemographic, (2) health-related and (3) health value system. We use cross-sectional data from 150 000 respondents in 64 countries from the World Health Organization's World Health Survey (2002-03). Our approach classifies effect patterns for the scale as a whole, in terms of strength and in relation to the domains. For the final eight variables selected (sex; age; education; marital status; use of inpatient services; perceived health (own); caring for close family or friends with a chronic illness; the importance of responsiveness), the strongest effects were present for education, health, caring for friends or relatives with chronic health conditions, and the importance of responsiveness. Patterns of scale elongation or contraction were more common than uniform scale shifts and were usually constant for a particular factor across domains. The dependency of individual-level reporting behaviour heterogeneity on country is greatest for prompt attention, quality of basic amenities and confidentiality domains.