Public evaluation of health services across 21 European countries: The role of culture

Abstract

Aim. This paper examines role of cultural values in understanding people's satisfaction with health services across Europe.Methods. We used multilevel linear regression analysis on the 7 th round of the European Social Survey (ESS) from 2014, including approximately 40,000 respondents from 21 countries. Preliminary intraclass correlation analyses lead us to believe that some explanations of variance in the dependent variable were to be found at the country level. In search of country-level explanations, we attempted to account for the role of national culture in influencing citizens' attitudes towards health systems. This was done by using Hofstede's dimensions of power distance (PDI), individualism (IDV), masculinity (MAS), and uncertainty avoidance (UAI), giving each country in the survey a mean aggregated score.Results. In our first model with individual level variables, being female, having low or medium education, experiencing financial strain, and reporting bad health and unmet medical needs were negatively associated with individual satisfaction with national healthcare systems, with the latter variable showing the strongest effect. After including Hofstede's cultural dimensions in our multilevel model, we found that the power distance index variable had a negative effect on the dependent variable, significant at a 0.1 level. Conclusions.It is possible that in national cultures associated with autocracy and hierarchy, citizens are likely to evaluate their national health system more negatively.

Beyond endogeneity in analyses of public opinion: Evaluations of healthcare by the foreign born across 24 European countries

“…Overall, results indicate some institutional characteristics of the country of residence determine how the foreign born rate healthcare services. In line with research on native populations [11,12,20,21], this study finds a strong and positive association between healthcare evaluations, the amount of total healthcare expenditure and the density of general practitioners. Also in line with previous research on native populations [11,20], there is no significant association between other institutional characteristics and healthcare ratings, with one exception: contrary to the initial hypothesis (H1a), the foreign born evaluate healthcare services more positively if they live in a country which limits the choice of primary care providers to the local area or to providers contracted by the health insurance within the area.…”

“…As stated above, a robust and positive relationship could only be established for healthcare evaluations and the amount of total and public health expenditure as well as the density of primary care services. Surprisingly, the amount of out-of-pocket payments, the density of specialists, the number of hospital beds, and access regulations have no robust effects on the public's opinion of healthcare [11,12,20,21]. These results could be hampered by socialization and adaptation effects within specific institutional settings.…”

“…We can say with some confidence that the amount of financial resources and the density of primary healthcare services are associated with the public's opinion of healthcare, i.e. how people think and feel about the healthcare system in the country where they live [11,12,20,21]. Other characteristics seem to be of less relevance for healthcare ratings if individuals do not know better and have no knowledge or experience of alternative healthcare arrangements.…”

“…For example, countries with higher total health expenditure tend to report higher healthcare ratings [20], as do countries with higher public health expenditure [12]. Interestingly, out-of-pocket payments are not always related to healthcare evaluations [20,21]. Research also suggests the density of primary care services can have a positive and significant effect [11,20,21], but the density of specialists and the number of hospital beds may not [20].…”

“…Interestingly, out-of-pocket payments are not always related to healthcare evaluations [20,21]. Research also suggests the density of primary care services can have a positive and significant effect [11,20,21], but the density of specialists and the number of hospital beds may not [20]. Surprisingly, and despite growing research efforts, empirical studies find no empirical association between healthcare evaluations and institutions that regulate access to medical care [11,20]-factors that are closely related to the individual's healthcare seeking behaviour and directly shape his or her experiences [22].…”