Patient satisfaction surveys are an increasingly common element of efforts to evaluate the quality of healthcare. Many patient satisfaction surveys in low/middle-income countries frame statements positively and invite patients to agree or disagree, so that positive responses may reflect either true satisfaction or bias induced by the positive framing. In an experiment with more than 2200 patients in Nigeria, we distinguish between actual satisfaction and survey biases. Patients randomly assigned to receive negatively framed statements expressed significantly lower levels of satisfaction (87%) than patients receiving the standard positively framed statements (95%—p<0.001). Depending on the question, the effect is as high as a 19 percentage point drop (p<0.001). Thus, high reported patient satisfaction likely overstates the quality of health services. Providers and policymakers wishing to gauge the quality of care will need to avoid framing that induces bias and to complement patient satisfaction measures with more objective measures of quality.
- patient satisfaction
- quality of care
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Handling editor Seye Abimbola
Contributors All authors contributed equally to this manuscript.
Funding The data collection for this research was funded through a grant by the Bill and Melinda Gates Foundation.
Competing interests None declared.
Patient consent For this non-invasive survey of patient satisfaction, the IRB allowed verbal consent.
Ethics approval This research was approved by the Institutional Review Boards (IRB) of the Government of Nigeria and Johns Hopkins University (HIRB 00001960).
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement All data from the study are available upon request from the authors.
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