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IJPP 2004, 12: 7–12

ß 2004 Int J Pharm Pract


Received April 11, 2003
Accepted January 4, 2004 Assessment of patient satisfaction with pharmaceutical
DOI 10.1211/0022357023204
ISSN 0961-7671 services in a Nigerian teaching hospital

Azuka C. Oparah, Ehijie F. O. Enato and Obehi A. Akoria

Abstract
Objective To assess patients’ satisfaction with pharmaceutical services using an ‘‘ideal referent’’
model, and to further explore the validity of an existing patient satisfaction instrument.
Method A cross-sectional survey was conducted with a sample of 500 outpatients recruited con-
secutively at the University of Benin teaching hospital, Nigeria. A self-completion questionnaire that
employed a Likert-type scale was used. Data were used to calculate scores on a scale that ranged from
20 to 100, with an assumed midpoint of 60. Descriptive statistics on the sample characteristics and
questionnaire items were computed including means, standard deviations and frequency distribu-
tions. Varimax rotation with Kaiser normalisation was employed in principal factor analysis. Student’s
t-test and one-way ANOVA were used for inferential statistics.
Key findings The instrument reliability was determined to be 0.9641 and was comparable to the
reference study. Nearly half of the patients (46%) rated the amount of time the pharmacist offered
to spend with them as poor. About one-third rated promptness of prescription service as poor. Only
49% felt satisfied with the pharmaceutical services. Overall, pharmacy services received a satisfaction
rating of 56.04 ± 24.49, below the midpoint. Perceived satisfaction was significantly higher in
‘‘friendly explanation’’ than in ‘‘managing therapy’’ (t = 3.916; P < 0.0001).
Conclusion The study provides evidence that patients experience low satisfaction with current
pharmaceutical services at the study hospital. The sociodemographic characteristics of patients were
not associated with their level of satisfaction. We further confirm the validity of the patient
satisfaction questionnaire in a Nigerian practice setting.

Introduction

Pharmaceutical care has become a dominant aspiration of pharmacy practice world-


wide in the past decade and aims to improve patient outcomes. Patient satisfaction is
one subjective outcome for which measures can be predetermined and levels assessed.
Patient satisfaction with pharmacy services is important for several reasons and is
becoming increasingly popular as an indicator of quality of health care services. 1±3
There is evidence that satisfaction with health services is closely related to the mental
health status of patients. 4 Patient patronage of a pharmacy department depends on
their satisfaction with services obtained. Patient satisfaction can be a predictive meas-
ure of the probability that a patient will continue to use the services of a particular
Department of Clinical Pharmacy provider. In a competitive health care market, it is important that pharmacists provide
and Pharmacy Practice, competent services with which the consumer is satisfied to ensure that patients will
University of Benin, Nigeria
continue to seek their services. 5
Azuka C. Oparah, lecturer Patient satisfaction is also likely to affect the image of the pharmacist and pharmacy
Ehijie F. O. Enato, lecturer
profession and, as such, efforts should not only be made to track patient satisfaction
Obehi A. Akoria, lecturer
with pharmacy services but also to improve it where needed.
Satisfaction can be conceptualised as performance evaluation, disconfirmation of
Correspondence: Mr Oparah, expectations, an affect-based assessment or an equity-based assessment. 6 Several meas-
Department of Clinical Pharmacy ures of patient satisfaction with pharmaceutical services have been developed and
and Pharmacy Practice,
University of Benin,
tested. An interviewer administered a Pharmacy Encounter Survey to patrons of
PMB 1154 Benin City, Nigeria randomly selected chain and independent pharmacies in Philadelphia County and
E-mail: oparaca@yahoo.com showed that respondents were most satisfied with pharmacy location and least satisfied

7
8 The International Journal of Pharmacy Practice, March 2004

with time spent waiting for their prescription to be filled. 7 addition to dispensing medications. 17 Pharmaceutical care
A mail questionnaire sent to randomly selected outpa- is poorly developed in many hospitals; hence standards of
tients in a large university hospital revealed that of those care provided to patients vary.18 Pharmaceutical care is yet
that received prescriptions but did not have them dis- to become an integral part of pharmacy practice in Nigeria.
pensed in the hospital pharmacy, two-thirds were aware Hospital pharmacy practice in Nigeria may be described as
of the existence of the pharmacy, but more than one-third under-developed in comparison with many other countries.
of these found the pharmacy inconvenient for refills while To date, few pharmacists have been attracted to the public
about a quarter thought that the waiting time to fill pre- health sector because of poor remuneration and lack of job
scriptions was too long. Of those respondents that re- satisfaction. Government hospitals widely use pharmacy
ceived prescriptions, nearly half had them filled at the technicians, who have two years post secondary education
university. Reasons given for this consumer behaviour in a school of health technology, for the dispensing of drugs.
were mainly convenience, followed by availability of medi- The role of the pharmacist in the hospital is limited to the
cation, and low prices. 8 traditional dispensing of drugs and inventory management.
Based on responses to a questionnaire survey of patient Only a few hospitals have a unit dose dispensing system.
demand for community pharmacies in Tokyo and Osaka, The layout and the design of the pharmacies are often
patient satisfaction was influenced by the attitude of pharma- unsuitable for effective dispensing. Drugs are dispensed
cists and by specialised activities, such as providing infor- through pigeonholes in most hospitals, which forms a bar-
mation and explanations, and convenience of opening rier to patient counselling. Medication profiles are not kept
hours. Furthermore, comfortable facilities and availability as an essential component of the pharmaceutical service.
of over-the-counter drugs that the respondents rated low in The records kept in the pharmacy are those of stock, which
terms of importance influenced satisfaction while conveni- suggests product-oriented pharmacy practice. A drug revolv-
ence of location did not.9 These studies reveal that while ing fund scheme was introduced in the country some years
there may be some general satisfaction indicators in phar- ago to reduce the problem of ``out of stock’’. This is a cost
macy services, there is a need to undertake site-specific stu- recovery system of pricing drugs sold to patients in govern-
dies in order to meet the expectations of the clientele served. ment hospitals. Patients pay for their drugs, as the national
In another study that was undertaken to determine the health insurance scheme is yet to be fully established.
components of outpatient pharmacy services that impacted We undertook an assessment of patient satisfaction
on the patient’s perception of satisfaction, results of the with a hospital pharmacy service using the ideal referent
principal components analysis delineated two dimensions model in a health facility where pharmaceutical care does
of patient satisfaction. The authors concluded that phar- not yet exist. We selected the updated Larson instrument
macy managers could emphasise these to produce a more because its authors tested it in a setting where pharmaceut-
satisfied patient, repeat patronage, and enhanced viability ical care was to be implemented. Furthermore, it is logical
for the pharmacy. 10 These components were defined as to assess patient satisfaction with pharmaceutical services
``professional communication’’ and ``physical and emo- using this model since pharmaceutical care represents the
tional well-being of the patient’’. This finding is similar to accepted professional ideal for pharmacy.
the two dimensions of ``friendly explanation’’ and ``mana- The findings would provide useful baseline data for the
ging therapy’’ derived in another study. 11 Several studies introduction of pharmaceutical care in the health care
have found that patient satisfaction improved after provi- facility under study.
sion of pharmaceutical care although not all studies have The objectives of the study were to assess patient satis-
found a positive association. 12±15 faction with pharmaceutical services using the ideal refer-
Several instruments are available to inform the pharma- ent model, and to generate data to further evaluate the
ceutical literature for evaluating patient satisfaction with validity of the updated instrument developed by Larson
pharmacy services. Since there are technical and interperso- et al11 in a Nigerian practice setting.
nal elements of care that affect satisfaction, an assessment
of patient satisfaction should reflect changes in professional
practice or else the instrument would lack content validity. Methods
Larson, Rovers and Mackeigan 11 have developed and
updated a validated instrument for assessing patient satis- The study was undertaken at the University of Benin teach-
faction with pharmaceutical care. This instrument provides ing hospital, a 560-bed tertiary health facility. The hospital
information on patients’ satisfaction with two dimensions is located in an urban city with a population of over one
of pharmacy services: ``friendly explanation’’ and ``managing million people, of varied socioeconomic strata. The layout
therapy’’. The updated version has not been widely tested. of the pharmacy department is similar to other pharmacy
Kucukarslan and Schommer found that patients’ prior departments in the country, all of which share a common
experiences, ideal referents, or market-based expectations weakness of dispensing drugs through a pigeonhole, which
affected patients’ satisfaction with pharmacy services. obstructs pharmacist±patient interactions. The study was
They also concluded that satisfaction surveys should be undertaken between September and November 2002.
designed to specifically assess the type of services provided Approval was obtained from hospital management prior
by the pharmacy. 16 to the start of the survey. The objectives of the study were
The pharmacy profession advocates that pharmacists addressed using a 20-item self-completion questionnaire
offer pharmaceutical care to improve patients’ health, in with a Likert-type response scale. The item stems covered
March 2004, The International Journal of Pharmacy Practice 9

two broad dimensions of pharmaceutical care, namely Overall, the respondents rated their experience with
``friendly explanation’’ and ``managing therapy’’. pharmaceutical services as 56.04 § 24.49. This summary
Provision was made on the questionnaire for respond- score was below the assumed midpoint of 60. All the items
ents to state their gender, occupation, marital status, aver- had factor loadings of between 0.516 and 0.782 and were
age monthly income, and highest level of education therefore grouped together.
attained. The questionnaire contained an instruction to Principal factor analysis (Table 2) resulted in two fac-
patients to compare their encounter with the pharmacy tors similarly identified as ``friendly explanation’’ and
with what they felt it ought to be (ideal), with respect to ``managing therapy’’. A large first factor accounted for
the questionnaire items. 59.96 per cent of the variance obtained.
The responses were rated from ``poor’’ to ``excellent’’ The extraction yielded two items having low factor
(``1’’ to ``5’’). Persons other than a pharmacist (two final loading under ``friendly explanation’’. These were: ``how
year pharmacy students, who had been trained) intro- well the pharmacist answers your questions’’, and ``the
duced and explained the questionnaire to the patients to courtesy and respect shown you by pharmacy staff’’.
minimise bias. Patients self-completed the questionnaire. These were excluded and 18 items were included in the
A consecutive sample of 500 adults that had used the final list of the components. The summary score for the
pharmacy before were recruited following their consent. ``friendly explanation’’ component was 2.60 § 1.11, while
Inpatients, those filling prescriptions for someone else, that of ``managing therapy’’ was 2.33 § 1.07 on a mean
and people who were unable to understand the written summary score that ranged from ``1’’ to ``5’’. Cronbach’s
English language were excluded. Patients were approached alpha for the subscales was 0.9373 (friendly explanation),
until a target of 500 usable questionnaires were obtained. and 0.9318 (managing therapy). A significant difference
was found in the patient satisfaction level in terms of the
two components (t ˆ 3.916; P<0.0001).
Data analysis The frequency distribution of the questionnaire items is
shown in Table 3. The average patient satisfaction rating
Usable responses were entered into Microsoft Excel and
was: poor (22 per cent), fair (28 per cent), good (33 per
rechecked prior to sorting, and were then loaded into
cent), very good (10 per cent) and excellent (5 per cent).
SPSS version 7.5 or GraphPad Instat version 2.05a for
There was an overall 0.6 per cent non-response to the
descriptive and inferential statistical analyses. The lowest
questionnaire items, implying high understanding of the
possible score for the 20 items was 20 and the highest was
items posed to the respondents. Nearly half of the patients
100. While the true midpoint on the scale was unknown, it
(46 per cent) rated their pharmaceutical service provision
seemed logical to assume 60, a point midway between the
as poor in reference to their perceived ideal on the amount
``poor’’ to ``excellent’’ axis.
of time the pharmacists offered to spend with them. About
The scores were treated as interval measurements suit-
one-third (31 per cent) rated the promptness of their pre-
able for parametric analysis. Descriptive statistics on sam-
scription service as poor.
ple characteristics and questionnaire items were computed,
Further inferential statistical analysis could not detect
including means, standard deviations and percentage fre-
any association between patients’ perceived satisfaction
quency distributions. The internal consistency of the instru-
and their sociodemographic profile. The results of the
ment was explored by computing Cronbach’s alpha test
subanalysis were similar to the overall in the sense that
of reliability. Principal component analysis employed
in none of the subgroups was satisfaction rated above the
Varimax rotation with Kaiser normalisation and list-wise
mean on the scale (see Table 1).
deletion of missing data. Factors selected for rotation had
eigenvalues greater than 1.00 and items with factor loading
below 0.4 were excluded in summary scores. Possible asso-
ciations between sociodemographic variables and patient
Discussion
satisfaction were explored using Student’s t-test and one-
way ANOVA. These inferential statistical analyses were
The questionnaire achieved a high response rate and we
conducted using GraphPad Instat, which reports exact
speculate that this was probably because the study was the
P values, and P < 0.05 was interpreted as significant.
first of its kind where patients were given the opportunity
to express their experience with service satisfaction, and
most of them agreed to do so, perhaps hoping to obtain a
Results better service in future. The majority of our respondents
were educated up to tertiary level, and in this respect our
The questionnaire response rate was 89.3 per cent and sample was not representative of the Nigerian population.
Cronbach’s alpha was found to be 0.9641. Sociodemogra- The study was carried out in a university community
phic characteristics are summarised in Table 1. Males located in an urban city. The findings would be likely to
(54 per cent) and females (46 per cent) were almost equally be different in rural areas where over 70 per cent of
represented. Nearly half of the patients (44 per cent) were Nigerians live and work. Low literacy is itself a challenge
married, and over two-thirds (69 per cent) were educated for research into patient satisfaction. However, the large
up to tertiary level. The modal income group reported segment of respondents in the low income group indicates
earning less than 100 dollars per month. the poverty level in the country.
10 The International Journal of Pharmacy Practice, March 2004

Table 1 Patients’ sociodemographic profile and questionnaire scores.

Item Number reporting Score SD

Gender
Female 230 48.84 21.31
Male 270 50.06 22.47
t ˆ 0.6196; P ˆ 0.5358
Occupation
Civil servant 120 47.85 20.70
Businessman 64 50.72 25.07
Trader 29 50.76 20.72
Teacher 110 50.19 22.29
Student 135 49.30 21.70
Not working 31 51.55 20.33
F ˆ 0.2721; P ˆ 0.9283
Marital status
Single 191 49.45 22.15
Married 220 48.89 21.86
Divorced 36 50.88 17.90
Widowed 14 46.71 23.53
F ˆ 0.1560; P ˆ 0.9258
Monthly income (Naira)*
<10,000 186 50.03 23.31
10,000±19,000 99 44.72 20.28
20,000±29,000 96 52.28 20.45
30,000±39,000 50 49.12 17.69
40,000±49,000 21 46.76 20.64
>49,000 28 52.29 24.85
F ˆ 1.720; P ˆ 0.1445
Level of education
No formal education 36 49.49 17.71
Primary 40 48.60 23.02
Secondary 63 52.08 22.78
Tertiary 343 48.97 21.87
F ˆ 0.3796; P ˆ 0.7678

*100 Naira ˆ US$1.

Only the professional appearance of the pharmacy professionals need to increase patients’ awareness of the
received a satisfactory rating out of the 20 satisfaction value of pharmaceutical care services and make it important
items investigated. The study used an ideal reference point, to their judgment of satisfaction. 20,21
asking patients to compare their own experience with that Although the present study did not find any significant
ideal. Tools measuring patient satisfaction with pharma- association between sociodemographic variables and per-
ceutical care employ outcome measures, unlike those used ceived level of satisfaction, this would be difficult to gen-
in traditional pharmacy patient satisfaction studies that eralise as there was disproportionate representation of
utilise structure and process elements. It is possible that groups in terms of level of education and income.
the patients we surveyed, being literate, had relatively Our testing of the validity of the questionnaire develop-
higher expectations of pharmacy and hence low satisfac- ed by Larson et al11 shows comparable results to those of
tion with current provision. A study in hospitals in Jordan the original authors. Both studies were carried out prior to
showed that patient satisfaction was mainly influenced by implementation of pharmaceutical care, although phar-
patients’ expectations of received care even after adjusting macy practice in the US is far ahead of that of Nigeria.
for sociodemographic variables. 19 In the current study, The internal consistency of the instrument, computed as
nearly half of the patients felt the amount of time the Cronbach’s alpha, in our local environment gave compar-
pharmacist offered to spend with them was inadequate. able results to the reference, ie, 0.9373 and 0.9318 versus
Pharmaceutical care is patient-centered and hence pharma- 0.957 and 0.962 for the subscales.
cists providing pharmaceutical care have high contact time Although we identified two principal component fac-
with patients. Patients may be less able to judge the tech- tors of patient satisfaction as in the reference study, our
nical quality of the care they receive, but they do judge results placed two items under ``friendly explanation’’
their social interaction with the pharmacist. Pharmacy rather than ``managing therapy’’. This indicates that
March 2004, The International Journal of Pharmacy Practice 11

Table 2 Principal component analysis of the questionnaire items.

Item Mean score SD Factor loading

``Friendly explanation’’ items


The professional appearance of the pharmacy (1) 3.02 1.13 0.819
The availability of the pharmacist to answer your questions (2) 2.85 1.14 0.863
The pharmacist’s professional relationship with you (3) 2.80 1.15 0.849
The pharmacist’s ability to advise you about problems that you might have 2.58 1.09 0.776
with your medications (4)
The promptness of the prescription drug service (5) 2.29 1.14 0.575
The professionalism of the pharmacy staff (6) 2.69 1.08 0.815
How well the pharmacist explains what your medications do (7) 2.48 1.09 0.622
How well the pharmacist instructs you about how to take your medications (12) 2.55 1.15 0.581
Your pharmacy services overall (13) 2.56 1.05 0.523
How well the pharmacist answers your questions (14) 2.45 1.08 0.363*
The courtesy and respect shown you by the pharmacy staff (16) 2.28 1.09 0.213*
Subtotal mean 2.60 1.11
``Managing therapy’’ items
The pharmacist’s interest in your health (8) 2.56 1.09 0.406
How well the pharmacist helps you to manage your medications (9) 2.47 1.07 0.573
The pharmacist’s efforts to solve problems that you have with your medications (10) 2.44 1.05 0.626
The responsibility that the pharmacist assumes for your drug therapy (11) 2.39 1.08 0.606
The pharmacist’s efforts to help you improve your health and stay healthy (15) 2.38 1.05 0.792
The privacy of your conversations with the pharmacist (17) 2.18 1.05 0.787
The pharmacist’s efforts to ensure that your medications do what they 2.29 1.02 0.788
are supposed to (18)
How well the pharmacist explains possible side effects (19) 2.28 1.13 0.756
The amount of time the pharmacist offers to spend with you (20) 1.99 1.11 0.729
Subtotal mean 2.33 1.07

*Items with low factor loading (<0.40) and not included in the summation.

Table 3 Percentage frequency distribution of responses to the questionnaire items.*

Item Poor Fair Good Very good Excellent

The professional appearance of the pharmacy 9.6 20.2 38.9 19.4 11.4
The availability of the pharmacist to answer your questions 12.4 22.6 38.9 16.2 9.2
The pharmacist’s professional relationship with you 13.4 25.9 36.1 15.0 9.2
The pharmacist’s ability to advise you about problems that you might have 17.2 30.1 36.3 9.6 6.6
with your medications
The promptness of the prescription drug service 30.7 27.9 26.9 10.2 4.2
The professionalism of the pharmacy staff 14.6 26.5 39.5 12.6 6.4
How well the pharmacist explains what your medications do 18.8 32.1 33.1 10.2 5.0
The pharmacist’s interest in your health 19.2 26.5 38.1 10.4 5.6
How well the pharmacist helps you to manage your medications 19.0 33.3 31.5 11.4 4.2
The pharmacist’s efforts to solve problems that you have with your medications 20.0 31.9 33.1 11.0 3.4
The responsibility that the pharmacist assumes for your drug therapy 21.2 32.3 32.3 9.0 4.0
How well the pharmacist instructs you about how to take your medications 18.8 28.3 34.3 10.4 7.0
Your pharmacy services overall 15.0 32.7 36.7 9.8 5.0
How well the pharmacist answers your questions 20.0 30.1 34.9 9.6 4.4
The pharmacist’s efforts to help you improve your health and stay healthy 22.6 31.3 33.3 9.0 3.4
The courtesy and respect shown you by the pharmacy staff 28.3 28.5 30.7 8.2 3.6
The privacy of your conversations with the pharmacist 31.5 28.7 29.1 8.2 1.8
The pharmacist’s efforts to ensure that your medications do what they are 24.8 31.9 31.5 9.4 1.6
supposed to
How well the pharmacist explains possible side effects 29.7 26.5 29.7 9.2 4.0
The amount of time the pharmacist offers to spend with you 45.7 21.0 23.0 7.0 2.8
Mean 21.6 28.4 33.4 10.8 5.1

*Values may not add up to 100 because of non-response to an item.


12 The International Journal of Pharmacy Practice, March 2004

principal factor analysis of patient satisfaction items 5 Marshall GN, Hays RD, Sherbourne CD, Wells KB. The
should be reinforced with intuitive grouping. structure of patient satisfaction with outpatient medical
There was a low non-response to questionnaire items care. Psychol Assess 1993;3:477±83.
(0.62 per cent). This finding and the high reliability found 6 Schommer JC, Kucukarslan SN. Measuring patient satisfac-
tion with pharmaceutical services. Am J Health Syst Pharm
indicate that the instrument is valid in assessing patient
1997;54:2721± 32.
satisfaction in Nigerian pharmacy practice. 7 Briescher B, Corey R. Patient satisfaction with pharmaceut-
Reports show that, in general, patient satisfaction rat- ical services at independent and chain pharmacies. Am J
ings tend to be high. 1 Our study, in which patients gave Health Syst Pharm 1997;54:531±6.
low satisfaction ratings, has identified areas where the 8 Somani SM, Daniels CE, Jermstad RL. Patient satisfaction
current service could be improved, as well as an opportu- with outpatient pharmaceutical services. Am J Hosp Pharm
nity for pharmaceutical care to demonstrate its value. 1982;39:1025± 7.
A follow-up investigation would be needed to measure 9 Kamei M, Teshima K, Fukushima N, Nakamura T. Investi-
patient satisfaction after pharmaceutical care services gation of patients’ demand for community pharmacies: rela-
have been implemented. tionship between pharmacy services and patient satisfaction.
Yakugaku Zasshi 2001;121:215± 20.
Since patient satisfaction is a measure of quality of
10 Lang JR, Fullerton SD. The components of satisfaction
health care, this study points to some shortcomings which with outpatient pharmacy services. Health Mark Q 1992;
may have an overall impact on the quality of Nigerian 10:143±54.
health care services. The findings were obtained from a 11 Larson LN, Rovers JP, Mackeigan LD. Patient satisfaction
tertiary health care centre and the situation could be with pharmaceutical care: update of a validated instrument.
worse in lower levels of health care. Future research should J Am Pharm Assoc 2002;42:44± 50.
also consider patient satisfaction in community pharmacy 12 Volume CI, Farris KB, Kassam R, Cox CE, Cave A.
and primary health care centres in Nigeria. Pharmaceutical care research and education project (PREP):
patient outcomes after provision of pharmaceutical care. J
Am Pharm Assoc 2001;41:411±20
Conclusion 13 Nicholas-English G, Poirier S. Optimizing adherence to
pharmaceutical care plans. J Am Pharm Assoc 2000;40:
The study provides evidence that patients experience low 475±85.
satisfaction with pharmacy services in a Nigerian hospital. 14 Gourley GA, Portner TS, Gourley DR, Rigolosi EL,
Patients’ perceived satisfaction was significantly higher in Holt JM, Solomon DK et al. Humanistic outcomes in the
terms of ``friendly explanation’’ than ``managing therapy’’. hypertension and COPD arms of a multicenter outcomes
study. J Am Pharm Assoc 1998;38:586±97.
The sociodemographic characteristics of patients were not
15 Spalek VH, Gong WC. Pharmaceutical care in integrated
associated with their level of satisfaction. We further con- health system. J Am Pharm Assoc (Wash) 1999;39:
firm the validity of the patient satisfaction questionnaire 553±7.
developed by Larson et al in a Nigerian practice setting. 16 Kucukarslan S, Schommer JC. Patients’ expectations and
their satisfaction with pharmacy services. J Am Pharm
Assoc 2002;42:489± 96
17 Hepler CD, Strand LM. Opportunities and responsibil-
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