Level of confidence in and endorsement of the health system among internet users in 12 low-income and middle-income countries

Introduction People’s confidence in and endorsement of the health system are key measures of system performance, yet are undermeasured in low-income and middle-income countries (LMICs). We explored the prevalence and predictors of these measures in 12 countries. Methods We conducted an internet survey in Argentina, China, Ghana, India, Indonesia, Kenya, Lebanon, Mexico, Morocco, Nigeria, Senegal and South Africa collecting demographics, ratings of quality, and confidence in and endorsement of the health system. We used multivariable logistic regression to assess the association between confidence/endorsement and self-reported quality of recent healthcare. Results Of 13 489 respondents, 62% reported a health visit in the past year. Applying population weights, 32% of these users were very confident that they could receive effective care if they were to ‘become very sick tomorrow’; 30% endorsed the health system, that is, agreed that it ‘works pretty well and only needs minor changes’. Reporting high quality in the last visit was associated with 4.48 and 2.69 greater odds of confidence (95% CI 3.64 to 5.52) and endorsement (95% CI 2.33 to 3.11). Having health insurance was positively associated with confidence and endorsement (adjusted odds ratio (AOR) 1.68, 95% CI 1.49 to 1.90 and AOR 1.34, 95% CI 1.22 to 1.48), while experiencing discrimination in healthcare was negatively associated (AOR 0.67, 95% CI 0.56 to 0.80 and AOR 0.63, 95% CI 0.53 to 0.76). Conclusion Confidence and endorsement of the health system were low across 12 LMICs. This may hinder efforts to gain support for universal health coverage. Positive patient experience was strongly associated with confidence in and endorsement of the health system.

Thinking about your last visit to a health care facility (not including overnight stays), how would you rate the following: There are some good things in our health care system, but major changes are needed to make it work better. On the whole, the system works pretty well and only minor changes are necessary to make it work better.

Question 25.
Do you have health insurance? (Any service, either from the government or a private company, that pays for some or all of your health care costs)

Yes No
End survey with note below: Thank you for participating in this survey. We appreciate your time.

Reproducibility
In a study of global mental health stigma 1 , researchers tested the reproducibility of responses produced by RDIT tm sampling methods. A short survey was fielded every month for 21 consecutive months in India. Responses were very similar across the survey months; 31.1 +/-.18% s.e. replied yes to the question, "is there someone you interact with every day who suffers from mental illness?" An average of 10.1 +/-.11% s.e. said that "people who suffer from mental illness are more violent." The group also compared global responses excluding India between June and July of 2014 and June and July of 2015 and found no statistically significant differences for any of their questions.

Habitual respondents
A study of RDIT tm in 2014 2 asked 50,313 respondents the following question: "prior to this survey when was the last time you answered survey questions?" 72% of respondents had not taken a survey in the last month and 47% of respondents had never taken a survey before.

Representativeness
An independent research group analyzed the cookies produced by the RDIT tm sample over the course of one week in 2013 3 and found highly statistically significant correlations with characteristics of the U.S. internet using population. The group matched a total of 115,000 unique cookies. Almost complete convergence (correlations between .915 and .997) was found between the two samples when looking at the internet service providers, geographic distribution, number of cookie hits and age of the cookies.

Anchor vignettes
Anchoring vignettes can be included in surveys that compare self-reported health across countries or groups of people that are likely to have differing norms and expectations. The anchoring vignette allows researchers to control for these factors, identify comparable cut-off points between ordinal response categories, and make interpersonal comparisons despite social difference in response characteristics.

Sampling weight construction
The age and gender weight targets were created based on the Census Bureau's 2017 Population Estimates of the country's population. The urban and rural targets were created based on the Central Intelligence Agency database. The education targets for most countries were created based on educational attainment data from the UNESCO Institute for Statistics. Education targets for Nigeria were created based on data from the Demographic and Health Survey conducted by the National Population Commission of Nigeria and education targets for Morocco were based on educational enrolment data from the High Commission for the Plan of Morocco.