title: Public evaluation of health services across 21 European countries: The role of culture.
abstract: OBJECTIVE
  This work examined the role of cultural values in understanding people's satisfaction with health services across Europe.
  
  
  METHODS
  We used multilevel linear regression analysis on the seventh round of the European Social Survey from 2014, including c. 40,000 respondents from 21 countries. Preliminary intraclass correlation analyses led 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, individualism, masculinity and uncertainty avoidance, 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 poor 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 the 0.1 level.
  
  
  CONCLUSIONS
  Citizens are likely to evaluate their national health system more negatively in national cultures associated with autocracy and hierarchy.
authors.affiliation: 1 Department of Sociology, Uppsala University, Sweden.
authors.forename: Liubov V
authors.initials: LV
authors.lastname: Borisova
authors.affiliation: 2 Department of Sociology and Political Science, Norwegian University of Science and Technology, Norway.
authors.forename: Pål E
authors.initials: PE
authors.lastname: Martinussen
authors.affiliation: 2 Department of Sociology and Political Science, Norwegian University of Science and Technology, Norway.
authors.forename: Håvard T
authors.initials: HT
authors.lastname: Rydland
authors.affiliation: 2 Department of Sociology and Political Science, Norwegian University of Science and Technology, Norway.
authors.forename: Per
authors.initials: P
authors.lastname: Stornes
authors.affiliation: 2 Department of Sociology and Political Science, Norwegian University of Science and Technology, Norway.
authors.forename: Terje A
authors.initials: TA
authors.lastname: Eikemo
mesh_terms: D000328:Adult; D000368:Aged; D003466:Cultural Characteristics; D005060:Europe; D005260:Female; D019538:Health Care Surveys; D006801:Humans; D008297:Male; D008875:Middle Aged; D055361:Multilevel Analysis; D009313:National Health Programs; D017060:Patient Satisfaction / Q000706:statistics & numerical data*; D055815:Young Adult
keywords: Europe; European Social Survey (ESS); Hofstede’s cultural dimensions; Public evaluation of healthcare; multilevel analysis; satisfaction with healthcare