nursing staff are important as autonomy is likely to be beneficial not only in improving the welfare of the individuals in their interactions with the health system but also in the health outcome of care due to better compliance.5,26 Fairly low scores in prompt attention and quality of basic amenities highlights the point that improvement of this domain is somehow re- source-dependent,27 however reengineering of patient admission process is undoubtedly effective in im- proving prompt attention. Evans et al. found a posi- tive relationship between prompt attention and per capita income of country, in a way that countries with higher per capita incomes received higher score in prompt attention domain.28 Comparison of the scores of responsiveness compo- nent of hospital services from this District in Tehran, Capital of Iran and other countries showed that the score in our study was better than South Africa in all aspects except quality of basic amenities and social support,7 and the scores were worse than Brazil in all aspects ex- cept prompt attention,29 and worse than European coun- tries in all aspects.30 For European countries, social sup- port was the best performing domain.30 In our study, out-patient responsiveness scores were better than South Africa7 in all domains, better than Brazil in prompt attention, communication and autonomy domains29 but worse than European coun- tries in communication, autonomy, confidentiality and quality of basic amenities.30 The relative rankings of domains among outpatient services were the same as other countries with the lowest scores given to prompt attention and the highest to dignity. Comparison of outpatient and inpatient respon- siveness indicated higher scores of outpatient services in all domains. It seems Iran health system should pay more attention to inpatient services and change the criteria of hospital evaluation in order to include re- sponsiveness domains. Clinical governance initiative, recently started in Iran, may play an important role in improving quality of care and responsiveness to pa- tient expectations.31 Using 0.4 as factor loading cutoff point in Prin- cipal Component Analysis to determine whether or not the domains should be considered a good factor showed that "communication, autonomy, confiden- tiality and choice" of inpatient services were loaded in one factor rather than being unique factor as proposed by WHO. Quality of basic amenities and access to social support were loaded in one factor; and lastly, prompt attention and dignity were load- ed in one factor. For outpatient services respon- Health system responsiveness siveness, the dignity, communication, and autono- my were load in one unique factor. It seems that in our sample of Iranians, talking respectfully, giving enough information, listening to patient and involv- ing him/her in decision making are interrelated and have less difference among the respondents. "Prompt attention" was loaded in one unique factor as proposed by WHO. Similarly, Peltzer (2009) found that communication, autonomy and confiden- tiality are the main factors.7 In Taiwan study, five factors including respect, access, confidentiality, basic amenities and social support were extracted.8 Considering the similarities, comparing results of Principal Component Analysis of this study, South- Africa and Taiwan studies with WHO responsive- ness domains highlights the importance of cultural specification of responsiveness aspects. Our study had some limitations. We collected self-reported subjective data rather than objective data. The long recall period of 5 years for inpatient services use, as proposed by the WHO proning to recall biases was the other limitation. In conclusion, responsiveness domains especially prompt attention and quality of basic amenities of outpatient/inpatient services were the priority area for improvement. As the type of provider was a main contributor to responsiveness and service users, soci- oeconomic variables had little effect on responsive- ness. It sounds that health policy should concentrate on provider performance,31 training them about re- sponsiveness issues and injecting more resources for improving responsiveness domains. Considering that this low income population used governmental ser- vices more on one hand, and gave lower scores to governmental services responsiveness on the other hand, further studies on the equity aspects of service use and responsiveness seem warranted. As respon- siveness is considered a health system goal, studies that monitor the performance of health system in re- sponsiveness and the effects of interventions on it will be of importance. Acknowledgment This research would not be done without the generous and patient cooperation of the residents of the District 17 of Tehran. We received financial support from the Deputy of Research of the Tehran University of Med- ical Sciences. Conflict of interest: None declared. WWW.ircmj.com Vol 13 May 2011 307