The responsiveness domains were derived from existing patient questionnaires and studies as reported in the extensive literature review conducted by de Silva.18 This review profiled the questionnaire work undertaken by the Agency for Healthcare Research and Quality (AHRQ), Harvard Medical School, the Research Triangle Institute and the RAND Corporation. None of the existing questionnaires and studies captured all the dimensions that they covered collectively.
WHO developed an instrument (questionnaire) that covered the collection of dimensions (de-scribed in the literature review) related to non-technical aspects of the process of care: dignity, autonomy, communication, confidentiality, prompt attention (related to convenience and peace of mind rather than urgent medical attention), quality of basic amenities, access to social support networks during treatment (labelled “social support” in the MCS Study and “access to family and community support” in the World Health Survey), and choice (of health care providers).
WHO’s responsiveness questionnaire has been developed and refined. Questions (items) were initially fielded in a key informants’ survey of 35 countries and the results described in the World Health Report 2000.4 A household survey instrument which included pre-testing was then developed as part of the MCS Study covering 60 countries.19,20 Following the launch of the MCS Study, the concept of responsiveness and the questionnaire were refined and a revised instrument was included in the World Health Survey (WHS) which was administered across 70
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countries in 2002-2003. The WHS basic survey mode used an in-person interview conduct-ed in one of three possible forms: ninety-minute in-household interview (53 countries) (long form), thirty-minute face-to-face interview (short form) (13 countries); or computer-assisted telephone interview. Samples were randomly selected (those above 18 years) resulting in sizes of between 600 and 10,000 for each country surveyed. Descriptive statistics about individuals sampled in each country are reported in Appendix 3.2.
Figure 3.3 Responsiveness questionnaire as a module in the World Health Survey questionnaire: interview structure and timing
Data collection was performed on a modular basis, addressing different aspects of health and the health system and including information on health insurance, health expenditures, socio-de-mographics and income, health state valuations, health system responsiveness, and health sys-tem goals.21 Figure 3.3 provides an overview of the responsiveness module in the WHS. The measurement of responsiveness was obtained by asking respondents to rate their most recent experience of contact with the health system within each of the 8 domains by responding to the set of questions listed in Figure 3.4. The response categories available were: very good, good, moderate, bad and very bad.
Like health, responsiveness is viewed as a multidimensional concept. Each domain is measured as a categorical variable for which there is an assumed underlying latent scale. Certain domains are more suited to patient evaluation e.g., quality of basic amenities and prompt attention. It is
more difficult to evaluate whether full details of the nature of the illness and all relevant treat-ments and available options have been disclosed as this requires specialist knowledge. Accord-ingly, it is more problematic to maintain objectivity in the evaluation of some domains. Samples have undergone extensive quality assurance procedures both at data collection stage at country and inter-country levels.
The MCS Study and WHS modules on responsiveness have strong similarities. However, they have a number of different ways of expanding and alleviating the burden on survey respond-ents. More notable changes in the WHS include: more face-to-face interviews or computer as-sisted telephone interviews (the MCS Study included 28 postal surveys); eliciting the experienc-es of children up to twelve (reported through a parent); and reducing the number of items that individuals are required to respond to on each domain. The WHS module also tried to identify barriers to access by asking people if they needed care and, if so, whether they sought care or why they did not (Figure 3.3 section 1). The analyses that follow focus on the questions asked in sections four and five of the responsiveness module and cover ambulatory and hospital (inpa-tient) experiences of adult and children populations.
Responsiveness domain label (Short
description) Item questions
Prompt attention
(Convenient travel and short waiting times)
How would you rate:
1- the traveling time to the hospital
2- the time you waited before being attended to b Dignity
(Respectful treatment and communi-cation)
How would you rate:
1- being greeted and talked to respectfully a
2- the respect for privacy during physical examinations and treatments a b Communication
(Clarity of communication) How would you rate:
1- how clearly health care providers explained things to you a
2- the time you get to ask questions about your health problems or treatment ab Autonomy
(Involvement in decisions) How would you rate:
1- being involved in making decisions about your health care or treatment a 2- the information you get about other types of treatments or tests b Confidentiality
(Confidentiality of personal information) How would you rate the way:
1- the health services ensured you could talk privately to health care providers a 2- your personal information was kept confidential a b
Choice
(Choice of health care provider) How would you rate:
1- the freedom you had to choose the health care providers that attended to you Quality of basic amenities
(Surroundings/facilities) How would you rate:
1- the cleanliness of the rooms inside the facility, including toilets a 2- the amount of space you had a b
Access to family and community support
(Contact with outside world and maintenance of regular activities/ social support)
How would you rate:
1- the ease of having family and friends visit you
2- the experience of staying in contact with the outside world when you were in hospital a b
Figure 3.4 Operationalization of the responsiveness domains in the WHS
a Similar items appear in the Multi-Country Survey Study; b Item dropped for the short version of the World Health Survey
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