Patient Satisfaction with Pharmaceutical Care Services in Selected Health Facilities in Delta State, South-South of Nigeria

Introduction: Patients who are satisfied with their overall care by a pharmacist are more likely to take medications rationally and less likely to change from one health care professional to another in an arbitrary manner. Objectives: This study evaluated patient satisfaction with pharmaceutical care services in some selected Hospitals in Delta State, South – South of Nigeria. Method: Patients who were visiting the outpatient pharmacy department of Two Tertiary Hospitals and Two Secondary Hospitals for prescription refills were investigated. The inclusion criteria were: patients aged 21years and above, and consent to participate in the study. A convenient sampling was done, of which a total of 400 questionnaires were distributed across the four health facilities. Result: In General Hospital Abraka, 21% were within the age group of 3135 years, 83% were females, 80% were married, 51% had postsecondary education and 35% were retired. In Central Hospital, Agbor, 94% out of which 22.3% were within the age group of 2630 years, 70.2% were females, 60.6% were married, 45.7% had postsecondary education and 44.7% were traders/self-employed. In Federal Medical Centre, Asaba, 32.2% were within the age group of 41-45 years, 53.3% were females, 48.9% were married, 38.9% had post-secondary education and 31.1% were civil servants. In Delta State University teaching Hospital, Oghara, 18.8% were within the age group of 41-45 years, 62.5% were females, 55.2% were married, 39.6% had post-secondary education and 37.5% were traders/self-employed. The study reported patient satisfaction with pharmaceutical care services in the four health facilities, but Oghara Teaching Hospital was rated highest on satisfaction with pharmaceutical care services. There was correlation between social demography and some of the items as p was <0.05 in some of the items. Regarding, availability of the pharmacists to answer your questions, the study reported no statistical correlation with p value<0.05.There was statistical correlation with friendly explanation with job occupation and marital status. Conclusion: This study reported patient satisfaction with pharmaceutical care services in the four health facilities. The study recommend more training for the health professionals on pharmaceutical care services and increase awareness of patient on expected pharmaceutical care services from their health care providers.


Introduction
Patient satisfaction is an integral component of the quality of healthcare [1,2]. Implementation of communication skills, convenience, rational use of medicines can lead to better use of medical services and ultimately better outcomes with improve quality of life for users. Patient satisfaction promotes positive health behaviors, such as compliance and continuity with providers [3]. Patients who are satisfied with their overall care by a pharmacist are more likely to take medications rationally and less likely to change from one health care professional to another [4]. Measuring satisfaction by provider setting is generally interpreted as a proxy for gauging patient perceptions of provider behavior [5]. Other studies have reported that patients place a high value on strong socio psychological and communicative relationships with their caregivers [6].

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The International Pharmaceutical Federation (FIP) in 1998, defined pharmaceutical care (PC) as the "responsible provision of pharmacotherapy for the purpose of achieving definite outcomes that improves or maintains a patient's quality of life" This is a collaboration process between the pharmacist and the patient who is aimed at preventing or identifying and resolving drug and health related problems. This is targeted at improving patient's quality of life [7]. This definition was a slight shift from [8]. It is the most widely used definition for pharmaceutical care. Changed the direction of Pharmacy practice worldwide with the paper published on Pharmaceutical Care; as patient oriented rather than the old product oriented focus.
The clinical pharmacy era, is loaded with rapid expansion of functions, professional transition and development of clinically oriented pharmacy practice. The notion of the pharmacy practice had shifted from compounding, and dispensing roles. Currently, emphasis is on clinical service delivery to their patients [9]. Clinical pharmacy is drug use "control" in which Donald Brodie [5] expounded and stated his theory: The ultimate goal of the service of pharmacy must be the safe use of drugs by the public. In this context, the mainstream function of pharmacy is clinical in nature that may be identified accurately as drug-use-control. By "drug-use-control" Brodie & Bemson (2007) reported the sum total of knowledge, understanding, judgments, procedures, skills, controls and ethics that assures safety in the distribution and use of medications is needed Brodie & Benson (1976). The overall goal of clinical pharmacy activities is to promote the rational and appropriate use of medicinal products and devices [10]. From the array of previous study, a lot have reported that patients were satisfied with pharmaceutical care services. In this study we will further evaluate patient satisfaction with pharmaceutical care services in some selected Hospitals in Delta State, South of Nigeria.

Study Design
A cross sectional randomized sampling study was carried out in four hospitals located in different Local Government Areas (LGA) in Delta State. These four hospitals were selected from the government hospitals (two Secondary and two Tertiary Health Institutions) in Delta state. Among the four hospitals is a teaching hospital located in Oghara, a Federal Medical Centre in Asaba, a general hospital in Abraka and a Central Hospital located in Agbor.

Study Setting
This research was carried out in four hospitals located in different Local Government Areas (LGA) in Delta State, Nigeria. Delta State was carved out of the former Bendel State on August 27th, 1991. Delta state is a state in Nigeria, populated by the Urhobos, which comprises the majority ethnic group, Enuaniigbos (Aniocha/Oshimili), Ukwuani/Ndokwa and Ika ethnic nationalities which are collectively referred to as Anioma people, Isoko, Itsekiri, and Ezon ethnic nations. The ethnic groups are grouped into three senatorial districts, namely Delta North, Delta South, and Delta Central, for administrative purposes. Delta is an oil producing state of Nigeria situated in the region known as the Niger Delta, South-South Geo-political zone with a population of 4,098,291 (Males: 2,674,306 Females: 2,024,08 [11].

Patients/Participants
Patients who were visiting the outpatient pharmacy department of the various health facilities listed above for prescription refills were investigated. The inclusion criteria were: patients aged 21 years and above, and consent to participate in the study.

Sample Size
A Convenient sampling was done, of which a total of 400 questionnaires were distributed across the four health facilities. 100 questionnaires were used for each of the health facilities [12].

Data Collection Procedures
The data collected included socio demographic such as age, sex, and marital status, level of education, occupation and patient satisfaction. Patient satisfaction with pharmaceutical care services was assessed as humanistic outcome. This assessment was based on the twenty-item questionnaire developed by Larson et al. and also validated in a Nigerian study. The patient satisfaction questionnaire was anchored on; excellent=5, very good =4, good =3, fair =2, and poor=1. The purpose of the questionnaire was explained to the respondents before administering the questionnaires.

Data analysis
Data collected were entered into Microsoft Excel, rechecked for accuracy and loaded into the Statistical Package for Social Sciences (SPSS) software (version 21). Descriptive Statistics such as mean, percentage as well as inferential statistical analysis were conducted.

Ethical Approval
Ethical approval was obtained from ethics committee in the different health facilities used. Respondents were sure of confidentiality of information provided and names were not included in the questionnaire.

Socio Demographic characteristics
In General Hospital Abraka, after retrieving and sorting out, all the 100 questionnaires distributed were well filled, out of which 21% were within the age group of 31-35 years, 83% were females, 80% were married, 51% had postsecondary education and 35% were retired. In Central Hospital, Agbor after retrieving and sorting out, only 94 out of the 100 questionnaires distributed were well filled giving a response rate of 94% out of which 22.3% were within the age group of 26-30 years, 70.2% were females, 60.6% were married, 45.7% had postsecondary education and 44.7% were trader/self-employed.
In Federal Medical Centre, Asaba, after retrieving and sorting out, only 90 out of the 100 questionnaires distributed were well filled giving a response rate of 90% out of which 32.2% were within the age group of 41-45 years, 53.3% were females, 48.9% were married, 38.9% had post-secondary education and 31.1% were civil servants. In Delta State University teaching Hospital, Oghara, after retrieving and sorting out, only 96 out of the 100 questionnaires distributed were usable giving a response rate of 96% out of which 18.8% were within the age group of 41-45 years, 62.5% were females, 55.2% were married, 39.6% had post-secondary education and 37.5% were traders/selfemployed (Table 1).   The patients' satisfaction questionnaire was grouped into 2 sub scales, namely: Friendly explanation item and managing therapy item scale (drug management scale). Patients' satisfaction with pharmaceutical care services was above average in these two components for all the four health facilities visited. Delta State University Teaching Hospital received the highest satisfaction with a mean score of 3.82± 0.99 for the friendly explanation items and 3.75± 0.92 for the managing therapy items (midpoint 3.0, range 1-5) ( Table 2), ( Figure 1).

Frequency statistics for patients' satisfaction
About 34.4% of respondents perceived the professional appearance of the pharmacy to be excellent in Delta State University Teaching Hospital, 33.3% of the respondents feel that the professional appearance of the pharmacy is excellent in Federal Medical Centre, Asaba, 11.0% of the respondents perceived the professional appearance of the pharmacy to be excellent in General Hospital, Abraka, while 8.5% respondents perceived the professional appearance to be excellent in Central Hospital, Agbor (Tables 3-6).       All the values were de-aggregated into positive and negative response, of which poor and fair represent negative response while good, very good and excellent represent positive response. Central Hospital Abraka had a positive response of 87.3%, Delta state University Teaching Hospital Oghara had a positive response of 93.2%, summary of all secondary was 88.8%, and summary of all tertiary was 92.6% (Table 7). Oghara which is the teaching Hospital had the highest positive response while Abraka health facility had the least (Figures 2 & 3).

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The availability of the pharmacists to answer your questions Correlation / Cross-tabulation of satisfaction assessment with social demography. There was correlation or statistical significance between social demography, how well the pharmacists instruct you on how to take your medications and the courtesy and respect shown to you by the pharmacy staff asp was <0.05. But there was no statistical correlation in availability of the pharmacists to answer your questions (Table 8). There was no statistical correlation on managing therapy with gender except for privacy of your conversation with the pharmacist (Table 9).

Educational Level
There was no statistical correlation with education except for how well the pharmacists instruct you about how to take your medications and availability of the pharmacists to answer your questions (Table 10).

Correlations/Cross-Tabulations of Some Friendly Explanation Items with Marital status
About 39.1%, 37.2% , 35% of single, married and divorced respectively, respondents reported that the professional appearance was good, availability of the pharmacist to answer your questions was good, Also, 46.7%, 40.2%, 80% and 61.8% respectively, of single, married and divorced respondents reported that how well the pharmacists instructs you about how to take your medication was very good. Likewise, the courtesy and respect shown to patients by pharmacy staff was reported very good. There was statistical correlation with friendly explanation and marital status, the professional appearance of the pharmacy, the availability of the pharmacist to answer your questions, how well the pharmacists instructs you about how to take your medication and the courtesy and respect shown to you by pharmacy staff (Table 11).

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There was statistical correlation with friendly explanation with job occupation (Table 12).

Demography
The study revealed that more female participated in the study carried out in the four Health facilities. Although, they were more of married women, civil servant, mostly within the age group of 41-45 years with post-secondary education. The high number of female is expected. Studies have shown that more female visit health facility for medical problems [13].

Satisfaction Assessment
The patients' satisfaction was grouped into 2 sub scales. They are friendly explanation item and managing therapy item scale (drug management scale). Patients' satisfaction with pharmaceutical care services was rated above average in these two components for all the four health facilities. This shows that Pharmaceutical care is well integrated in all pharmacy departments in the Health facility. This is in line with other studies. Pharmacists are living up to their responsibility as prescribed by world Health Organization (WHO) and international pharmaceutical federation [7,8]. This reported patient satisfaction is basically assessed by patient's perception and attitude of service providers [1], [14][15][16][17][18][19]. Also another indicator of patient satisfaction with pharmaceutical care services is that patients take their medications rationally and pharmacists of late have improve in their communication skills [4,5].
However, Delta State University Teaching Hospital had the highest satisfaction with a mean score of 3.82± 0.99 for the friendly explanation items and 3.75± 0.92 for the managing therapy items (midpoint 3.0, range [1][2][3][4][5]. This reported patient high satisfaction may be due to the high standard of health professionals and structural out-fit in the pharmacy department in the teaching Hospital. High level of pharmaceutical care delivery does not depend on just the quality of personnel but the structural outfit or layout of the pharmacy unit has a major impact in boosting service delivery. The result showed that respondents had post-secondary education; this means that they are literate and are exposed to pharmaceutical care services to be provided with high expectations. Also patient expectation may be very high in pharmaceutical care services they are expecting to get from the pharmacy [20].
This study has shown that in spite of their high expectations, pharmacist is meeting up to patients expectations with quality pharmaceutical care services they render to them. Several studies have reported that patients were provided with pharmaceutical care services and were satisfied with the services provided. Also patients were willing to receive drug information from pharmacists. Their satisfaction is likely associated with the provision of Pharmaceutical care services, promptness in service delivery, pharmacist attitude/ communication skills, medication counseling, pharmacy physical structure, and reduced waiting time in the pharmacy [21][22][23][24][25][26][27].

Frequency statistics for patient's satisfaction
Regarding Pharmacy professional appearance, the four hospitals were rated excellent. This implies that the pharmacies were neat and pharmacists were in their best professional conduct. Also pharmacists showed competency in their job. This connotes that patients were satisfied with the pharmaceutical care services provided [28].
In the four health facilities, about 50% of single, married and divorced respondents reported that the professional appearance was satisfactory. Pharmacists are the most accessible health care professionals and play a key role in the delivery of health care services, particularly in ensuring effective and safe treatment with drugs. Pharmacist's role in the medical industry will continue to revolve towards patient oriented services to achieve optimal safe use of medicines. Pharmacists are the most trusted and highly rated professionals. Their professional appearance before patients is crucial in patient building confident in them and their services they will and about to deliver to their patients. This will raise patient confident with expression of satisfaction which will translate to compliance. Hence, the drug use policy has been met with rational use of drug, clinical and humanistic outcomes will be achieved. Other studies have equally reported satisfaction with pharmacist professional appearance [22].
Regarding availability of the pharmacist to answer your questions over 50% of respondents reported that they were satisfy. Pharmacists are the most trusted and accessible health professional. They are always available to render their legal responsibility of dispensing, clerking patients and giving drug information to patients. This has drastically reduced irrational use of drug among patient with evidence of better clinical and humanistic outcomes. Other studies have reported that pharmacists are always available to answer questions from patients and other health care professionals; regarding drugs use and their health [22].
In the same vein over 50% of respondents that were single, married and divorced respondents reported that, how well the pharmacists instructs patient about how to take your medication was very good. Likewise, the courtesy and respect shown to patients by pharmacy staff was reported very good. This is clearly seen in majority of the patients. The pharmacist intervention in instructing patients how and when to take their medications has of late improve patient response to their health with evidence of excellent clinical outcomes, humanistic outcomes and improve quality of life. Several studies have reported that intervention of pharmacist in patient medication and Health team have raised standard of patient care and they help the health team on therapy related issues since they are the only recognised specialist on drug related issue.

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Pharmacists are trained from their undergraduate days to be respective, discipline and to be honest in their practice. Studies have reported that they are one of the most trusted health professionals. Dishonesty in service delivery by the pharmacist can destroy millions of life. It is eminent on the pharmacist to remain honest, respectful to their patients to deliver the best pharmaceutical care services to their patients. This connotes that pharmacists are doing their job as prescribed and patients are satisfied with their services. This shows that pharmacists are always on their duty post. Hence, they have met the expected standard required in their conduct and professionalism. Pharmacists, there for have met their legal responsibility, by providing advice about medications use, screening prescriptions, dispensing and any other management work related to the stocking of medications [22,29,30].

Correlation / Cross-tabulation of Satisfaction Assessment with Social Demography
There was correlation or statistical significance between social demographic data on professional appearance, availability of pharmacist to answer questions, how well the pharmacists instruct you on how to take your medications and the courtesy and respect shown to you by the pharmacy staff as p was <0.05. There was no correlation with availability of the pharmacists to answer your questions. This might be due to the setting of the pharmacy department at the time of this study. Regarding managing therapy, there was no statistical correlation with gender except for privacy of your conversation with the pharmacist. This is expected because Pharmacists are expected to maintain high level of confidentiality with patient's medical problems. There was also no statistical correlation with education except for how well the pharmacists instruct the patient about how to take their medications and availability of the pharmacists to answer patient's questions. This is expected as pharmacists are the best trained on drug related issue. Patient knowledge on drug cannot be correlated as they were fed with the information given by the pharmacists. For marital status there was statistical correlation with friendly explanation and marital status.

Conclusion
The study revealed that more female participated, majority were married with higher education qualification. Patients reported satisfaction with pharmaceutical care services. However, Delta State University Teaching Hospital was rated highest with patient satisfaction with pharmaceutical care services provided for friendly explanation and managing therapy. For managing therapy, there was no statistical correlation with gender except for privacy of your conversation with the pharmacist. Also there was no statistical correlation with education except for how well the pharmacists instruct you about how to take your medications and availability of the pharmacists to answer your questions. However, more training for the health care professionals and awareness programmers of pharmaceutical care service for patients is required.