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Bias in patient satisfaction surveys: a threat to measuring healthcare quality
  1. Felipe Dunsch1,
  2. David K Evans2,
  3. Mario Macis3,
  4. Qiao Wang4
  1. 1 Development Research Group, World Bank, Washington, District of Columbia, USA
  2. 2 Africa Chief Economist’s Office, World Bank, Washington, District of Columbia, USA
  3. 3 Carey Business School, Johns Hopkins University, Baltimore, Maryland, USA
  4. 4 Water Global Programs, World Bank, Washington, District of Columbia, USA
  1. Correspondence to Dr David K Evans; devans2{at} and Dr Mario Macis; mmacis{at}


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.

  • health
  • patient satisfaction
  • quality of care
  • measurement
  • Nigeria

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

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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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