Explanatory models of influences on the construction and expression of user satisfaction.

The paper asks why high levels of expressed satisfaction are recorded in settings where health care provision is manifestly inadequate. Qualitative interviews with 30 women aged 25-60 years from a rural district health system of Northeast Brazil were used to explore the applicability of three explanatory models of influences on the construction and expression of satisfaction: expectations; contextual dynamics; mediating filters. The first two of these models argue that a lack of information and a reluctance to be negative respectively lead to high expressed satisfaction that is artificial. The concept of mediating filters proposes that respondents construct an evaluation that takes account of wider issues, such that high levels of expressed satisfaction are, in this sense, real. All three models contribute towards answering the paper's question. However, our data suggest that it is an informed, but low, expectation of health care provision that leads to alternative strategies, including resort to patron-client networks, and success in gaining good health care that is important. Mediating filters identified in this study were culpability and the reference time-frame. We raise questions for practice and offer a combined explanatory model.