If your company operates across multiple countries, you already know that customer expectations, communication styles and feedback habits are not the same everywhere.
That also affects how people answer surveys. And that matters when your organization uses Net Promoter Score (NPS) to measure loyalty, advocacy or market sentiment. In international settings, NPS is influenced not only by the customer experience itself, but also by the way different cultures use rating scales, interpret recommendation questions and respond to feedback requests [1][2].
That does not make NPS useless. It does mean that international organizations should interpret it with more care.
Rather than asking why one country scores higher than another, a more useful question is: which cultural factors may be influencing the result?
1. People in different countries use rating scales differently
One of the clearest findings in recent cross-country survey research is that respondents in different countries do not use response scales in the same way. Differences in response-scale usage are widespread and can distort international comparisons, even when the underlying attitudes are not fundamentally different [2].
That matters for NPS because the metric depends on strict thresholds: respondents are classified as promoters, passives or detractors based on where their score falls. If one culture is more likely to use the top end of the scale and another is more likely to avoid it, the same real-world experience may produce different NPS outcomes [1][2].
For international companies, this means a lower score in one market does not automatically signal weaker customer loyalty. It may partly reflect how respondents in that market use numeric scales.
2. The meaning of a “high score” is not universal
In some cultures, giving the highest possible score is relatively normal. In others, top scores are reserved for truly exceptional performance. That difference can have a direct impact on NPS outcomes.
Ipsos recently highlighted that cultural response bias can make it difficult to know whether differences between markets reflect true differences in performance or simply different cultural response styles [1]. In other words, a score of 8 may be seen as very positive in one setting, while another market may use 9 or 10 more freely for a similar experience [1][2].
This is especially important in markets where expectations tend to be shaped by local systems, professional norms and trust dynamics, such as healthcare or technologically complex environments. A score should therefore be interpreted in its local context, not only against a global benchmark.
3. Comfort with criticism varies across cultures
NPS assumes that respondents feel equally comfortable expressing criticism. In practice, that is not always the case.
Cultural norms influence how directly people communicate dissatisfaction, how comfortable they feel challenging an organization, and how they respond to authority or expertise [1][2]. In healthcare and technologically complex environments, this effect may be even stronger, because relationships often involve professional hierarchy, clinical trust and high perceived stakes.
That does not mean people are less honest in one country than another. It means that the social meaning of criticism may differ. A restrained score may reflect politeness, caution or communication style as much as dissatisfaction.
For that reason, international NPS data should never be read in isolation. Qualitative context matters.
4. Language and translation can change survey outcomes
If your survey runs across several countries, language is not a technical detail. It is a measurement issue.
Recent survey methodology literature stresses that translation and cross-cultural adaptation are critical for multinational survey studies [3]. A literal translation is often not enough. If words such as recommend, satisfaction or likelihood are interpreted differently across languages, then respondents may not actually be answering the same question [3].
That is especially relevant in healthcare. KFF’s 2024 findings on language barriers in healthcare show that language differences materially affect care experiences and communication quality, which reinforces the need for linguistic precision when gathering feedback [4].
For healthcare marketers and insight teams, this means that survey design should be culturally adapted, not just translated.
5. Recommendation behaviour is shaped by local norms of trust and advocacy
NPS is built around a recommendation question: How likely are you to recommend us? But recommendation behaviour is itself culturally shaped.
In some markets, recommending a company or solution is a strong personal endorsement. In others, it is a lighter expression of approval. That matters in markets where trust, peer influence, professional reputation and system context all shape how comfortably people recommend a supplier, partner or provider [1][4].
So when NPS differs across countries, the gap may reflect more than service quality alone. It may also reflect different cultural meanings attached to endorsement, advocacy and trust.
What organizations should do with international NPS data
The answer is not to abandon NPS. The answer is to use it more intelligently.
Track trends within each market
NPS is often more useful as a within-market trend measure than as a blunt instrument for direct country-to-country comparison. Recent cross-country research supports the idea that response-style differences can distort simple international benchmarking [1][2].
Combine NPS with open-text feedback
A number on its own rarely tells the full story. Open comments help explain whether respondents are reacting to onboarding, service responsiveness, account support, product experience or communication quality.
Adapt surveys culturally, not just linguistically
If a survey is translated without proper cross-cultural adaptation, comparability suffers. Recent methodology guidance makes clear that translation quality, conceptual equivalence and local relevance all matter [3].
Treat NPS as one signal, not the whole picture
In healthcare, customer sentiment should ideally be interpreted alongside qualitative feedback, referral behaviour, retention patterns and market-specific context.
A better way to think about international NPS
For international organizations, the real question is not: Which country has the highest NPS?
A better question is: Are we interpreting customer loyalty accurately within each market?
Culture does not make NPS irrelevant. But it does make simplistic comparisons risky. The more international your footprint, the more carefully you need to interpret what the score actually means.
If your organization wants to use customer feedback more strategically across markets, it helps to treat NPS not as a universal truth, but as a context-sensitive signal that needs interpretation.
FAQ
Can you compare NPS across countries?
Only with caution. NPS scores are shaped not just by customer experience, but also by cultural differences in scale use, communication style and willingness to give very high or very low ratings.
Why does culture affect survey results?
Because people across cultures do not interpret rating scales, criticism and recommendation questions in the same way. Survey results can therefore reflect both actual experience and cultural response style.
What is the significance of culture for NPS in healthcare and complex technology markets?
In these environments, respondents are often judging trust, expertise, clarity and risk, not just satisfaction. That makes cultural context especially important when interpreting NPS
If you’d like to learn more about using Net Promoter Scores to better understand your customers, and how you can use NPS results to boost your marketing programs, we can help. Contact Anne-Mie Vansteelant at Living Stone, at +32 55 591 007 or anne-mie.vansteelant@livingstone.eu.
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Resources
[1] Ipsos Views. When Difference Doesn’t Mean Different: Understanding cultural response bias in global CX programmes. 2026.
[2] Ulitzsch E, Henninger M, Meiser T. Differences in response-scale usage are ubiquitous in cross-country comparisons and a potential driver of elusive relationships. Scientific Reports. 2024.
[3] Benlidayi IC, Gupta L. Translation and Cross-Cultural Adaptation: A Critical Step in Multi-National Survey Studies. Journal of Korean Medical Science. 2024.
[4] KFF. Language Barriers in Health Care: Findings from the KFF Survey on Racism, Discrimination, and Health. 2024.
COO | Managing Partner at Living Stone
