How do we measure human sensitivity in healthcare?

Answers to questions about the sensitivity of the healthcare system

Nikolay Mihaylov, Doctor of Sociology, author of the monograph "Sensitivity of the Healthcare System in Bulgaria: Concept, Measurement, and Research," published by the Medical University – Varna, 2026.

How would you introduce yourself to our readers – what do you professionally engage in and how did you come to the topic of sensitivity in the healthcare system?

I am a researcher and lecturer – I deal with issues of public health and healthcare management from a sociological and psychological perspective. I work at the Medical University – Varna as a chief assistant in the Department of Health Economics and Management at the Faculty of Public Health. I conduct social research on communities, movements, specialist-patient relationships, evaluation of health interventions. Sensitivity is precisely a social, psychological, and organizational topic in healthcare – I entered this field thanks to a larger scientific project for the evaluation of the Bulgarian healthcare system, carried out between 2018 and 2023 by a team from our department. A system cannot be assessed solely by the number of doctors, beds, and the size of the budget. It is necessary to know how it is perceived and experienced by the people who should be at its center – the patients. In international practice, this dimension is called "sensitivity." We found that in our country, sensitivity has not been purposefully measured and with an appropriate tool, and this solidified the direction of my work.

When we talk about "sensitivity of the healthcare system," what does this actually mean for a patient?

The sensitivity of the system encompasses everything that happens around treatment, in the relationship between the system and the patient. Was I treated with respect? Was my condition explained to me in understandable language? Was I included in the decisions? Is my personal information protected? How long did I wait for attention? Could I choose treatment options? Were the conditions in the hospital acceptable, and did I have the opportunity to maintain contact with my loved ones? These are the eight elements I examine. Sensitivity is not the same as satisfaction. It does not ask "are you satisfied?" but rather "what actually happened to you?", which makes it a more objective indicator than satisfaction.

Why is it important for the healthcare system to respond not only to medical needs but also to the non-medical expectations and experiences of the patient?

There are two reasons. The first is that sensitivity directly contributes to the well-being of the patient. The World Health Organization places sensitivity among the three ultimate goals of the healthcare system, along with the health of the population and equitable financing. Respectful treatment, the ability to participate in decisions about oneself, and not waiting in anxiety are part of well-being, of human dignity regardless of diagnosis. The second reason is practical. When a patient feels heard and respected, they share more information about their condition, adhere better to prescriptions, use services more often, and delay seeking help less frequently. Thus, sensitivity also affects health.

What are the most important things that a patient expects from the healthcare system beyond treatment itself?

The priorities of Bulgarian patients are clearly outlined in the results of our research. First is the prompt response when help is needed. Second is dignified treatment. This is followed by clear communication, the possibility of choice, and participation in decisions. Last in the ranking are the conditions and connection with loved ones in the hospital, as well as confidentiality. An important clarification regarding these results is that the question about social support (the connection with loved ones) was asked during the pandemic when access to hospitals was limited, so the importance of this element should be interpreted cautiously.

You examine eight elements of sensitivity. Which of them are most important for patients and why?

As I mentioned earlier, the most important are the prompt response and respect for dignity. The first is understandable: when a person is ill or worried about their health, any delay increases anxiety. The second reflects the need to be treated as a person, not just another case. After these come the clarity of communication, choice of services, and autonomy. This ranking almost coincides with the results of a large international study on sensitivity by the WHO. The only significant difference between Bulgarian patients and participants in the international study is in confidentiality – here it ranks second to last in importance.

Can a patient receive medically correct treatment but still remain dissatisfied with the healthcare system?

Yes. In the study, we examined the relationship between perceived sensitivity of the healthcare system and the specific medical care provided, and patient satisfaction. The experience in contact with the system plays a very large role. In the models we statistically analyze, the assessment of sensitivity explains a significant portion of satisfaction with healthcare. A patient cannot evaluate everything the doctor has done for their treatment, but they very clearly feel whether they have been listened to, whether their condition has been explained, and how long they waited for attention and help.

How did you measure something as difficult to measure as the attitude, experience, and feelings of the patient?

Indeed, sensitivity is difficult to measure, as it cannot be observed directly, and patients' perceptions are subjective. The solution is to ask people not for their opinion but for their specific experience, for what happened during the receipt of health services. For example, instead of "are you satisfied with the doctor?" the question is "how often did doctors and nurses treat you with respect?" When we ask about several behaviors or events during the provision of medical assistance that reflect respect for the patient, we obtain a precise and reliable measurement of this otherwise hidden and subjective characteristic. Thus, patients describe what has happened to them, rather than giving a general assessment. Responses for each element of sensitivity are summarized in numbers, allowing the elements to be compared with each other.

How did you develop and validate the tool for measuring the sensitivity of the healthcare system in Bulgaria?

The work went through several consecutive stages, according to the established psychometric approaches for systematically testing new tools. First, I reviewed 25 tools used worldwide with about 450 questions. From these, I selected, translated, or formulated 74 questions tailored to the Bulgarian context. Then, 11 experts in health management and public health evaluated each question. With the filtered questions, I conducted a pilot online survey with 203 respondents. With this data, we checked whether the questions grouped into the expected structures and whether they provided reliable and valid results. This led to a final version of 37 questions for the eight elements. Most of the scales show excellent reliability, but some I could not investigate with enough questions due to the pandemic, and therefore I define the tool as promising and at the same time subject to improvement.

What did the national survey show you – in which aspects does the Bulgarian healthcare system best meet the expectations of patients and where are the most serious deficiencies?

The survey is nationally representative, with 800 people up to 65 years old, interviewed face-to-face in 2021. The highest ratings from Bulgarian patients were for confidentiality (0.76 on a scale from 0 to 1) and respect for dignity (0.73). The lowest ratings were for autonomy (0.53), social support, and material comforts (both 0.52). The overall picture is that in direct contact with the doctor and nurse, the system performs better than in organizational aspects, in the conditions of hospital stay, and in the partnership participation of the patient. Weak points include involvement in treatment decisions, clear communication, and options for choice. Again, it should be noted that the survey was conducted during a pandemic, which affects the direction of the responses.

Is there a difference between what the healthcare system considers important and what patients actually define as important?

I examined the perspective of patients, not that of institutions, so I cannot claim what exactly the system "thinks." However, an indicator of the difference gives us a measure of the contrast between the importance of elements and the assessment of their current state. When the assessment is compared with importance, the greatest potential for improvement is in prompt response followed by autonomy. At the opposite end is confidentiality: it is rated highly and considered less important.

What is the relationship between the sensitivity of the healthcare system and patients' trust in healthcare?

The relationship is very close. Statistical analyses indicate that patients' perceptions of the level of sensitivity explain about 44% of the differences in trust towards doctors, 48% towards hospitals, and 23% towards the management of the system as a whole. Logically, the more direct the contact, the stronger the relationship. For trust in the doctor, the most significant factor is dignified treatment. For trust in the hospital, the leading factors are prompt response and material conditions. I clarify that we are talking about statistical relationships, not causal dependencies, as the study is cross-sectional and we are talking about correlations between sensitivity and trust, not causation.

Can improving communication, respect, confidentiality, and attitude towards the patient actually change their assessment of medical care?

The data suggest that yes, but we must be scientifically correct in our statements. The study is cross-sectional and cannot prove that changing one will cause a change in the other. However, it is clear that the experience in contact with the system is a very strong predictor of satisfaction and trust at all levels of patient-healthcare system relationships.

Are there groups of patients who feel less heard or less well-served by the healthcare system?

The data outline several groups. People in poor health rate the system the lowest, for example in terms of dignified treatment and autonomy. Patients who primarily pay out of pocket also give lower ratings on almost all elements, likely because these are people with already established negative attitudes towards the system, which is why they seek services in the private sector. Older patients rate the system higher, but the sample does not include people over 65 years old. For vulnerable groups such as Roma, the least educated, or residents of villages, the survey does not have a large enough sample for categorical conclusions.

What, according to your research, could be changed relatively easily without requiring huge financial resources?

Primarily what depends on interpersonal and management practices and the organization of service delivery, rather than on investments in material conditions or additional personnel. Direct examples are respect for dignity, clear communication, and autonomy: better treatment of patients, involving the patient in decisions, and providing information more carefully and clearly. Improvement requires a change in attitudes among some specialists, in organizational culture, and in the training of future medical professionals, rather than new techniques or buildings. Of course, changing relationships is not "expensive," but that does not mean it is easy given the layered professional and social relations. We must not overlook the fact that some of the problems in relationships are due to the high level of uncertainty and stress in the system.

How can healthcare managers and institutions practically use the results of your research?

The book allows managers to relatively easily measure the sensitivity or some of its elements concerning their organization. The questionnaire of 37 questions is ready for use on paper or in digital form and can be shortened or supplemented according to the goals, with instructions at the end of the book on how to use the questionnaire, how to assess its exact composition according to the goals of the study. Each scale can also be applied independently. Managers can also add a proposed question about the importance of the elements to direct efforts towards what patients value most. The data are most useful at the level of healthcare institutions, where sensitivity is most closely related to satisfaction and trust. The results of measuring sensitivity show where to direct the limited resources of a healthcare organization. Of course, managers can also read the book to gain insights and understanding of general trends in patient preferences and the state of the offered health services. From there, they can better plan their organization's strategy.

If you had to point out one indicator that every hospital should regularly measure to understand how patients experience the system, what would it be?

The most important for patients is prompt response. In the analyses, it is the most influential element for trust in the hospital and proves to be a significant predictor in analyses of satisfaction and trust. If this indicator cannot be a priority for the hospital, for example, because it requires additional human resources, I would recommend as a backup the respect for dignity. It is the second most important element for patients and the strongest predictor of trust in doctors. One indicator is never enough, but these two provide a good starting point. Of course, confidentiality is also related to certain regulatory standards for the operation of healthcare institutions, so it is also an important indicator.

What would you like to see change in Bulgarian healthcare as a result of this research?

First and foremost, sensitivity should become part of the discussion about the quality of the healthcare system. Second, practices for standardized, routine measurement of sensitivity at all levels of the system should be introduced. I would also like attention to be paid to the two biggest deficiencies: prompt response, which requires comprehensive measures and more human and material capacity, and respect for autonomy, which depends more on the culture and training of specialists. Special attention is also needed for vulnerable groups. Finally, measurement should be conducted periodically at the system level by expert teams that are not part of the governing bodies of the system, so that the assessment can serve as an evidential basis for better policies.

What are the next steps – can measuring sensitivity become a permanent part of the quality assessment of the healthcare system?

I hope this will happen. Not as continuous monitoring, which would be too burdensome for the system and those working in it. I recommend systematic national surveys every three years. If the surveys inform reforms, sufficient time should be allowed before expecting a reflection in patients' perceptions. Data collection and analysis should be done by independent expert teams to ensure transparency and trust in the results. Next steps in researching sensitivity would be to conduct a fully representative national survey that includes people over 65 years old, qualitative studies with interviews and focus groups for a better understanding of Bulgarian expectations, comparative norms for healthcare institutions, and more detailed studies by groups: general practitioners and specialists, public and private sectors, hospital and outpatient care.

If medicine treats the disease, but the healthcare system must also care for the person, what do you think we still have not learned to measure well enough?

Human relationships and perceptions. An important and unexplored question is how the Bulgarian patient understands "good treatment" – whether they are demanding or have low expectations? It is not enough for our standards to correspond with international concepts – we need to check the national context with qualitative methods. Another question is the experiences in the most critical moments, such as emergency care, intensive care unit stays, serious illness. These situations are harder to measure but are of utmost importance. Third, it is difficult to capture the voice of the most vulnerable: people in serious health conditions, the poorest, and the most isolated, who are the hardest to include in samples. Finally, the relationship between sensitivity and health outcomes – to convince professionals and managers in the system with evidence that the relationship is very significant and that sensitivity is not a "luxury." Increasing sensitivity would also contribute to more favorable, more humane working conditions for those working in the healthcare system – and we know that this is sometimes a bigger problem than material shortages. Sensitivity can be a cornerstone for the overall improvement of the healthcare system. I take this opportunity to thank you for the opportunity to speak on the topic and to invite interested readers to download the entire book for free from the web portal of the Medical University – Varna.