Quality of Life Research

, Volume 16, Issue 7, pp 1107–1125 | Cite as

Measuring quality of health care from the user’s perspective in 41 countries: psychometric properties of WHO’s questions on health systems responsiveness

  • N. B. ValentineEmail author
  • G. J. Bonsel
  • C. J. L. Murray
Original Paper



To evaluate, for different populations, psychometric properties of questions on “health systems responsiveness”, a concept developed by World Health Organization (WHO) to describe non-clinical and non-financial aspects of quality of health care.

Data sources/study setting/data collection

The 2000–2002 WHO Multi-Country Study comprised 70 general population surveys. Forty-one surveys were interviewer-administered, from which we extracted respondent records indicating ambulatory and inpatient health services use (excluding long-term institutions) in the previous 12 months (50,876 ambulatory and 7,964 hospital interviews).

Study design

We evaluated feasibility, reliability, and construct validity using 33 items with polytomous response options, comparing responses from populations identified by countries, sex, age, education, health and income.

Principal findings

Average item missing rates ranged from 0 to 16%. Domain-specific alpha coefficients exceeded 0.7 in 7 (of 9) cases. Average intertemporal reliability was acceptable in 6 (of 10) sites, where Kappas ranged from 0.54 to 0.79, but low in 4 sites (K < 0.5). Kappa statistics were higher for male, educated and healthier populations than for female, less educated and less healthy populations. Factor solutions confirmed the domain structure of 7 domains (only 7 were operationalized for ambulatory settings). As in other studies, higher incomes and age was associated with more positive responsiveness reports and ratings.


Quality issues addressed by WHO’s questions are understood and reported adequately across diverse populations. More research is needed to interpret user-assessed quality of care comparisons across population groups within and between countries.


Quality of health care Health care surveys Quality indicators Patient-centred care Physician-patient relations Psychometrics 

List of Abbreviations


United States Agency for Healthcare Research and Quality


Consumer Assessment of Health Plans Survey



MCS Study

Multi-Country Survey Study on Health and Health Systems Responsiveness


Maximum Likelihood (factor analysis)


Quality of care through patients’ eyes


Correlation Coefficient (Pearson or Spearman, as specified)


United Nations Development Programme


United Nations Educational, Scientific and Cultural Organization


World Health Organization

Supplementary material


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Copyright information

© Springer Science+Business Media B.V. 2007

Authors and Affiliations

  • N. B. Valentine
    • 1
    • 2
    Email author
  • G. J. Bonsel
    • 2
  • C. J. L. Murray
    • 3
  1. 1.WHOGeneva 27Switzerland
  2. 2.Erasmus Medical CenterInstitute of Health Policy and Management (iBMG)RotterdamThe Netherlands
  3. 3.Harvard UniversityCambridgeUSA

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