Impact of findings on practice statements

  • Patient perception and satisfaction with pharmaceutical services is a useful factor in the assessment of pharmacist’s performance and consequently the health care outcomes.

  • Nigerian HIV patients in a HIV treatment centre, have negative perception regarding pharmacists’ communication and the pharmacists’ efforts to solve their medications related problems.

  • Interventions targeted at improving the communication and problem-solving skills of pharmacists are imperative for better treatment outcomes in this setting.

Introduction

Patients are essential source of information about accessibility and effectiveness of care [1, 2]. The patient’s perception is increasingly considered as a useful factor in the assessment of health care outcomes [1, 3, 4]. The patient’s perception of care has direct influence on treatment adherence [1]. Patient satisfaction is a primary outcome that may be defined as the extent to which an individual’s needs and wants are met [5]. It is a highly personal assessment of health care services and providers [6] that is greatly affected by the preferences and expectations of the patient [7]. The patient’s preferences and expectations may be viewed as the determinants of satisfaction, whereas the elements of care, such as technical and interpersonal aspects, are the components of satisfaction [7, 8]. Satisfaction reflects the realities of care [7], and it is based on the patient’s experience of both contacts with the organization and personal outcomes. Patient satisfaction can be conceptualized as patient’s evaluation of the pharmacist’s performance in a variety of patient care activities [7, 9].

Pharmaceutical care is defined as “the responsible provision of drug therapy for the purpose of achieving definite outcomes that improve the patient’s quality of life” [10]. It is a patient focused and outcome oriented pharmacy practice in which the pharmacist takes responsibility for a patient’s drug related needs and holds him or herself accountable for meeting the needs [11, 12]. Successful implementation of a pharmaceutical care practice model has the potential to increase both patients’ expectations and satisfaction with their pharmacists’ activities [13]. Pharmaceutical care has become a preferred mode of practice [14, 15] and the attitudes of pharmacists towards this practice are favorably high irrespective of the practice settings [16]. The pharmacy practice in Nigeria has remained focused largely on the products (drugs) even though many are aware of the changing role of the clinical pharmacist globally. Pharmaceutical care has not been fully integrated into professional pharmacy practice as a standard of care for patients in Nigeria [14]. However, pharmacists in Nigeria indicated willingness to implement pharmaceutical care but reported inadequate knowledge, professional skills and the pharmacy layout as the barriers to the practice of pharmaceutical care [17]. Recently, the pharmaceutical care education was included in the pharmacy training curriculum in Nigeria to promote pharmaceutical care as a philosophy and standard of provision of care for patients.

Pharmaceutical care is an individualized care and is more critical in pharmacotherapy for chronic conditions such as HIV. Personalized services are essential to patient satisfaction. In Bangladesh, the service quality factors identified as important for patients’ satisfaction were timeliness and convenience, personal attention, reliability and dependability, health worker competence and professionalism, empathy, responsiveness, assurance, availability, and tangibles such as physical facilities, environment, equipment and the appearance of the personnel [18]. Patients want not only a professional pharmacist but someone who is receptive and dispose to friendliness. Gauging patient sentiment with satisfaction scores is a useful way to point out deficiencies and improve the patient experience. However, these patient focused assessments are largely ignored by health care managers.

Patient satisfaction surveys are increasingly being used in hospitals to assess the competency of health care providers and the quality of care, particularly as satisfaction relates to continuity of care [9]. A study that assessed patient satisfaction with pharmaceutical services in Nigeria reported that patients experience low satisfaction with pharmaceutical services; 46 % rated the amount of time the pharmacist offered to spend with them as poor; and 49 % felt satisfied with the pharmaceutical services [19]. Perceived satisfaction was significantly higher in “friendly explanation” than in “managing therapy”. The socio-demographic characteristics of patients were found to have no association with their level of satisfaction [19]. Satisfaction surveys provide “actionable” data that reveal obvious steps for improvement. Satisfied patients have been defined as “ones who receive significant added value” to their bottom line [20]; they have a more positive relationship with their health care provider [13, 21], and are also more likely to continue to use health care services [13, 22, 23] and remain adherent to medical regimens [13, 24, 25]. In a study conducted in Ethiopia, majority of HIV-infected patients (82.5 %) were dissatisfied with long waiting time to get pharmacy services. As the waiting time to get pharmacy service increases, the level of satisfaction among HIV-infected patients decreases. Other areas of dissatisfaction included (45.2 %) lack of description about ART drugs, (22.4 %) impoliteness of pharmacy staffs, and (4.20 %) shortage of drugs [25]. The level of satisfaction was not associated with age, educational status, sex and monthly income of the patients [25]. There is paucity of data on patients’ perception and/or satisfaction about the pharmaceutical care-based services in HIV therapy in Nigeria.

Aim of the study

The aim of this study is to assess the perception and satisfaction of HIV-infected patients receiving antiretroviral therapy regarding pharmaceutical services in outpatient HIV treatment setting.

Methods

Research design

This involved a cross-sectional survey of patients on antiretroviral therapy (ART), who were provided pharmaceutical care in the selected health facilities.

Setting

This study was carried out in 17 secondary (15 public and 2 faith-based) health facilities in an urban setting. The health facilities offer comprehensive HIV care and treatment services. HIV-positive clients identified at the HIV counseling and testing service points are enrolled into a Pre-ART register for follow-up. Those who meet the eligibility criteria for starting antiretroviral therapy based on the Nigeria national ART guideline are enrolled into ART register and are commenced on treatment. Antiretroviral drugs and a number of drugs for the treatment of opportunistic infections and other related services are fully funded by President’s Emergency Plan for AIDS Relief (PEPFAR) through US Agency for International Development (USAID) and are provided at-no-cost to the patients.

Interventions

The interventions included the infrastructural upgrade of the pharmacies, provision of audio-visual privacy; and initial didactic training of pharmacists on pharmaceutical care in HIV. Some of the topics covered in the training included: concept of pharmaceutical care; pharmacotherapeutics of HIV/AIDS; clinical pharmacovigilance for antiretroviral drugs; laboratory parameters, interpretations and monitoring in HIV care; common opportunistic infections and its management; HIV prevention; effective delegation in pharmacy; monitoring and evaluation in pharmacy. This training was followed up with an onsite hands-on pharmacy best practices training that focused on the following elements namely: dispensing, patient counseling, medication refilling, patient adherence, referral process, education programs, interaction with other health team members, data production and collection, and control of drugs. The trainings curricula were developed by Howard University Pharmacists and Continuing Education (HU PACE) Center for the Global HIV/AIDS Initiative Nigeria (GHAIN) project. Standard operating procedures (SOP) for pharmaceutical care provision and the documentation tools were developed and deployed to the intervention sites. The capacity building interventions were provided prior to commencement of pharmaceutical services provision. There were ongoing follow-up monitoring and provision of technical assistance (as necessary) by HU PACE’s team of monitoring and evaluation pharmacists in the health facilities. Pharmaceutical care package provided to patients included active screening of patients and the prescriptions for all potential and/or actual drug therapy problems, the provision of interventions and follow-up monitoring of patients on therapy.

Population/sample

Seventeen study sites were selected from 125 GHAIN-supported comprehensive HIV care and treatment centers (as at December 2010) using simple random sampling techniques. From 26,319 HIV-positive patients that were currently on ART as at December 2010, a sample of 2,700 patients was selected using simple random sampling techniques. The sample size was determined based on the ‘rule of the thumb’ proposed by Nunnally, who suggested that the number of subjects should be at least 10 times the number of items [26].

Selection criteria

All HIV-positive patients who were currently receiving highly active antiretroviral therapy (HAART) as at December 2010; and were provided pharmaceutical services in the ART pharmacy of the selected health facilities were eligible for inclusion in the study. Only patients who were provided pharmaceutical services in the ART pharmacy of the selected health facilities for at least 6 months duration and consented to participate were eligible for inclusion in the study. It is assumed that patients who received pharmaceutical services for at least 6 months duration will be better placed for the assessment of services provision compared to those who received services for <6 months duration. All patients who did not meet these criteria were excluded from the study.

Data collection

A study-specific and semi-structured questionnaire that employed a Likert-type scale was used to interview the study participants at the point of exit from the ART pharmacy. The interview was conducted by independent and trained research assistants over 1 month period. Local vernacular was used to interpret the questions for few participants who had limited ability in reading, writing or understanding of English language. The questionnaire consisted of 34 questions in 7 different domains.

Domains

No. of items

Pharmacists’ communication

7

Medication use information

10

Pharmacists’ commitment and respect for patients

5

Pharmacists’ availability to attend to you

3

Confidentiality and waiting time

3

Pharmacists’ efforts to solve your medications related problems

3

Infrastructure and appearance of the pharmacy

3

Ethical consideration

Ethical approval was obtained from National Health Research Ethics Committee (NHREC), Abuja Nigeria (NHREC/01/01/2007-10/05/2012b). Informed consent was obtained from the participants and they were assured of the confidentiality of the information.

Pre-testing of study instrument

The study instrument was field tested in HIV-positive patients who were currently receiving highly active antiretroviral therapy (HAART) and were provided pharmaceutical care for at least 6 months in the ART pharmacy of two health facilities. The responses were used to review the questionnaire by the researchers and expert colleagues for content validity; and reliability tested using test–retest technique. The characteristics of the participants used in the field testing were similar to the study sample and they were not included in the main study.

Data analysis

The data were analyzed using Predictive Analytical SoftWare (PASW) Statistics 18. Descriptive statistics was used for sample characteristics including responses on Likert rating scales. All negatively worded items in the Likert rating scale were reverse coded; and the scale was anchored in manner that higher scores indicate better perception or higher satisfaction with the questionnaire items. To determine the internal consistency of the instrument, reliability analysis was performed using Cronbach’s alpha. The intraclass correlation coefficients (ICCs) with a two-way mixed model were also determined. A Kaiser–Meyer–Olkin (KMO) measure of sampling adequacy was calculated to determine the appropriateness of the variables for factor analysis. The sample is adequate if KMO value is >0.5 [27]; values >0.90 are rated as “marvelous” for factor analysis [28]. The Bartlett’s test of sphericity was also performed; and a value <0.05 indicate statistical significance. Factor analysis was performed using principal components extraction and Varimax rotation with Kaiser normalization. Missing values in the factor analysis was handled using listwise deletion. Factors selected had eigenvalues >1. Items with factor loadings ≥0.40 were considered significant, and loadings ≥0.50 were considered “very significant” [29]. The mean item scores were computed for the individual items. SD was also determined. A midpoint of the 5-point scale was determined by adding all the scores and computing the average. Mean scale scores above the midpoint were regarded as positive perception and satisfaction while below the mid-point were considered as negative perception and satisfaction. Chi-square was used for inferential statistics. All reported p values were two-tailed and p < 0.05 indicated statistical significance, except where otherwise indicated.

Results

Socio-demographic characteristics of participants

Of the 2,700 patients sampled, data from 1,617 (59.9 %) were valid for analysis. The data from 1,083 (40.1 %) patients were excluded in the analysis due to incomplete responses to key variables of interest. Of the 1,617 participants, 62.3 % were aged 26–40 years; 65.4 % females; 56.1 % attained secondary level education; 47.3 % were self-employed; 60.2 % were married and living together; and 25.0 % had average monthly income <5,000 naira (Table 1). The participants had received pharmaceutical care in the outpatient ART pharmacy for a mean duration of 25.2 (95 % CI 24.3–26.1) months. The average number of clients provided pharmaceutical care per clinic day at the pharmacy was 94 (95 % CI 57–131) clients; and these clients were served by an average of two pharmacists.

Table 1 Socio-demographic characteristics of the participants, n = 1,617
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Patients’ perception of pharmacy and pharmaceutical services received

The midpoint of the 5-point scale for patients’ perception of the pharmacy and pharmaceutical services received was 3.0. Mean scale scores above this midpoint were regarded as positive perception while below were considered as negative perception. The perception of the patients regarding the infrastructure and appearance of the pharmacy was positive while that regarding the pharmacists’ communication and pharmacists’ efforts to solve patients’ medication related problems were negative (Table 2). Over 40.0 % of the participants reported waiting for >20 min before been attended to by the pharmacists; and about 25.0 % participants reported 15–20 min duration of the pharmacist–patient interpersonal interaction (Fig. 1).

Table 2 Frequency distribution of the participants’ responses to the questionnaire items
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Fig. 1
figure 1

Waiting time and the duration of pharmacist–patient interpersonal interactions

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The Kaiser–Meyer–Olkin (KMO) measure of sampling adequacy for factor analysis was 0.933; and the Bartlett’s test of sphericity was statistically significant (p = 0.000) indicating that factor analysis was useful for the data. The internal consistency of the 34-items scale based on standardized items as measured by Cronbach’s alpha was 0.9050; and the average measures of ICC was 0.9050 (95 % CI 0.8983–0.9115), p = 0.000). Following the listwise deletion of missing values, 1,298 cases were left for factor analysis. Using the criterion of an eigenvalue >1.0, seven factors were extracted which accounted for 57.9 % of variance. The large first factor accounted for 26.3 % of the variance. The second to seventh factors accounted for 10.7, 6.9, 4.9, 3.5, 2.9, and 2.7 % of the variance, respectively. However, the scree plot indicated a break after the seventh factor (eigenvalue = 0.900). All except one item had one factor loading of 0.40 or greater (Table 3).

Table 3 The factor loading the question items, N = 1,298
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Patients’ satisfaction

The midpoint of the 5-point scale for patients’ satisfaction of the pharmacy and pharmaceutical care received was 3.5. The participants rating of satisfaction with the waiting time before been attended to was negative while the overall quality of services received was rated as positive (Table 4). The majority of participants (about 90 %) reported that they got the kind of pharmacy services they wanted and would recommend them to others in need of similar service (Fig. 2). Of the participants, 861 (56.2 %) reported that almost all of their needs were met by the services they received in the pharmacy, 573 (37.4 %) reported that most of their needs were met, 66 (4.3 %) reported that only a few of their needs were met, while 31 (2.0 %) participants reported that none of their needs were met.

Table 4 Participants rating of the services they received from the pharmacies
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Fig. 2
figure 2

Participants’ overall perception about the pharmacy services

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Of the participants, 1,010 (62.9 %) reported that they got all the medications they needed from the pharmacy all of the time, 472 (29.4 %) of them reported most of the time, 74 (4.6 %) reported sometimes, 15 (0.9 %) reported rarely; and 36 (2.2 %) reported that they never got all the required medications from the pharmacy. Of the participants, 1,445 (98.2 %) of them reported that they would come back to the pharmacy if they were to seek help again whereas 27 (1.8 %) participants reported otherwise. However, the overall rating of the participants’ level of satisfaction with the services they received in the pharmacy was 845 (55.7 %) very satisfied, 286 (18.8 %) mostly satisfied, 63 (4.2 %) indifferent or mildly satisfied, 277 (18.2 %) mostly dissatisfied, and 47 (3.1 %) quite dissatisfied. The level of satisfaction was found to be associated with educational status of the participants (p = 0.006) unlike age, monthly income, sex, marital and employment status (p > 0.05). The increasing educational status of participants was associated with decreasing level of satisfaction.

Discussion

The participants’ rating of satisfaction with the waiting time to access pharmaceutical care-based services was negative. The level of satisfaction among participants decreases with increasing waiting time to access pharmaceutical services. This is consistent with previous reports that patient satisfaction with health care was associated with organizational factors particularly waiting time, and the availability of drugs [25, 30, 31]. The physical appearance of the pharmacy was perceived by participants as positive. This may be expected as the study interventions included infrastructural upgrades of these pharmacies.

The satisfaction with the overall quality of pharmaceutical services received by participants was rated as positive. Majority of the participants (about 90 %) got the kind of pharmaceutical services they wanted and would recommend them to others in need of similar service. This is contrary to a previous report of low satisfaction with pharmaceutical services in Nigeria [19].

The establishment and maintenance of professional relationship between the pharmacist and the patient is an essential step in the provision of pharmaceutical care. This relationship is based upon trust, caring, open communication, mutual respect, cooperation, and mutual decision making; and the patients’ welfare is paramount [32, 33]. This is consistent with the study findings in many instances. However, there are some findings that were contrary to this standard practice. For example, majority of the participants reported that the pharmacists neither accorded them the desired respect nor correct their mistakes, misconceptions or myths with respect; and also were not allowed to ask questions. Pharmacists’ communication was rated very low although good communication is extremely important factor in providing pharmaceutical care. These are some areas of gap needing further intervention for improvement by the pharmacists. Effective communication is an important subject that must be included in continuing pharmacy educational programs aimed at improving pharmaceutical care in this setting. Satisfied patients have a more positive relationship with their health care provider, and are also more likely to continue to use health care services and remain adherent to medical regimens [13, 21–25]. Almost all the participants reported that they would come back to the pharmacy if they were to seek help again.

The provision of medication use information is among the fundamental professional responsibilities of pharmacists in health systems; and is an integral part of pharmaceutical care [34]. The perception of the participants regarding the medication use information provided by pharmacists was positive except for demonstration of how to open or close medication containers, information regarding missed doses and the medication refill process. This is contrary to previous report that patients’ areas of dissatisfaction with pharmaceutical services included lack of description about ART drugs [25]. The pharmacists must perceive and evaluate the medication information needs of the patients, effectively address them, appropriately communicate and apply the information to the patient care situation [34, 35]. The three major pharmaceutical care functions included: identifying potential and actual medication related problems; resolving actual medication related problems; and preventing potential medication related problems [33]. However, the perception of the participants regarding the pharmacists’ efforts to solve patients’ medication related problems were negative. Interventions targeted at improving the pharmacists’ knowledge and skills needed to effectively perform this function are very imperative. Over one-half of the participants were dissatisfied by the duration of interaction with the pharmacist (<10 min). This is consistent with previous reports in Nigeria [19] and in Ethiopia [25]. High patient load may be the cause of long waiting time to receive pharmaceutical care-based services; and may adversely affect the duration of interaction between pharmacist and the patient. In addition, the pharmacy is often times the last service delivery point that patients will access in the hospital. Long waiting times in other service delivery points in the hospital will tend to build up stress such that by the time the patient meets the pharmacist he/she is often times ill-tempered, impatient and only just wants to pick up his medication. This may adversely affect the quality of pharmaceutical care-based services rendered to the patients. Majority of the participants reported receiving all the medications they needed from the pharmacy. This has been reported previously in HIV treatment setting in Ethiopia [25]. The level of satisfaction was found to be associated with educational status of the participants unlike age, marital and employment status, sex, and monthly income. The study findings showed that the higher educational status of the participants the lesser the level of satisfaction. The level of expectations from the healthcare system by patients who are highly educated may be higher than those who are less educated and probably less informed. This is contrary to previous reports that socio-demographic characteristics of patients had no association with their level of satisfaction [19, 25].

The internal consistency of the 34-items scale was excellent [36] and superior to 0.70 indicating that the items are sufficiently correlated to constitute a scale [37]. This was corroborated by ICC value that indicated good agreement of items in the scale [38]. Reliabilities of 0.95 or greater are not necessarily desirable, as this indicates that the items may be entirely redundant [39]. All items in the scale (except one item) had significant loadings of 0.40 or greater which may indicate that the extracted factors represented the variables well [29].

There were limitations to this study. Some participants may falsely report high/low level of satisfaction to pharmaceutical care-based services to impress/despise the pharmacist (response bias). This may overestimate/underestimate the effects been measured in this study. There may be recall bias when responding to the questionnaire items in the instrument. This has the potential to either overestimate or underestimate the patients’ perception and satisfaction with pharmaceutical services. Only patients who received pharmaceutical care-based services for at least 6 months duration were selected for the study. The exclusion of patients who received pharmaceutical care-based services for <6 months duration may be a source of potential bias which may overestimate/underestimate the effects been measured in this study.

Conclusion

The satisfaction with the overall quality of pharmaceutical services received by participants was rated as positive. Patients were satisfied with the appearance of the pharmacy in the health facilities and would come back to the pharmacy if they were to seek help again. However, longer waiting times resulted in lower patient satisfaction; and patients were dissatisfied by the duration of interaction with the pharmacist. High patient load may be the cause of long waiting time to receive pharmaceutical services; and may adversely affect the duration of interaction between pharmacist and the patient.