Association of pharmacy services with patient satisfaction in public and private tertiary care hospitals of Rawalpindi and Islamabad

The healthcare system in Pakistan is facing a shortage of human resources and appropriate and sustainable nancial measures and therefore fails to provide optimum services to the population of Pakistan. Furthermore, research is limited in the healthcare institutes; therefore, there is a scarcity of information about patient satisfaction with pharmacists and pharmacy services in Pakistan. As evident from the inadequate information in the literature, patients’ opinions about the pharmacy services in Pakistan are important [1]. Therefore, the current study was designed to assess patient satisfaction with the pharmacy performance of the outpatient pharmacy and its variation with socio-demographic characteristics in twin cities of Pakistan (Rawalpindi and Islamabad). study to assess the was and into for and inferential was to nd the association among different domain of satisfaction with different demographic characteristics of respondents. Furthermore No signicant difference (p ≥ 0.05) was observed in pharmacist’s approach with marital status and number of visits Current study concluded that overall patient had average satisfaction score. Patients shows a better satisfaction towards pharmacist behavior/ way of handling the patients, information provided by pharmacist regarding medicine. Patient had less satisfaction towards the location of pharmacy, Availability and affordability of medicine. Patient shows negative satisfaction regarding waiting area and counselling area at in door patient pharmacy. It has been observed that educated respondents shows high level of satisfaction towards pharmacist availability and information provided by the pharmacist.


Method
A cross-sectional study design was used to assess the patient satisfaction through convenience sampling technique. Minimum sample size of 250 respondents who visit pharmacy department of public and private hospital for pharmaceutical care were included in this study. A pre validated tool was used to assess the patient satisfaction. Data was clean coded and import into spss for analysis. Descriptive and inferential statistic was applied to calculate frequency, standard deviation, mean deviation and p value to nd the association among different domain of patient satisfaction with different demographic characteristics of respondents.

Result
Current study shows overall patients were satis ed from pharmacy services provided by government and private hospitals. Furthermore patient satisfaction towards pharmacist medication advice was very good however patient satisfaction towards pharmacist approach was good while patient perception with pharmacy setting, drug availability and cost were underrated. Signi cance difference (p ≤ 0.05) was observed in pharmacist's approach with different gender, age groups and quali cation. No signi cant difference (p ≥ 0.05) was observed in pharmacy setting drug availability and cost with different gender, age groups and marital status of respondents. However Signi cance difference (p ≤ 0.05) was observed in pharmacy setting drug availability and cost with different level of education patients with less education had better satisfaction as compared to highly educated respondents. Furthermore Signi cance difference (p ≤ 0.05) was observed in pharmacy setting drug availability and cost with occupation. Selfemployee and government employee had low satisfaction score while other had better satisfactory score.
Signi cance difference (p ≤ 0.05) was observed in pharmacist's approach with different gender, age groups and quali cation. Females had better satisfactory score as compared to female. Younger age group had better satisfaction as compared to elderly. Patients belong to higher educational groups had better satisfaction toward pharmacist approach as compared to low quali cation groups respondents.

Introduction
Service quality is deliberated a substantial approach to satisfy the client and reassure frequent service which fascinates loyal clients. Thus, the persistent upgrading of service is desirable in order to strive with other companies in the healthcare industry. In the healthcare industry, most healthcare facilities deliver common services but contrast in service quality which is a pointer to gain a economical bene t in the business [2] At this time, there are many in rmaries in the market. This gives patients or clients more alternatives to choose the best one with the equitable price they require. Therefore, in rmaries have to expand their service excellence and other functions in every small detail to succeed. However the remedial service in emerging nations is often achieved by the government and faced with a limited budget, and also lacks human resources [3]. This leads to customers' dissatisfaction with the level of service quality. The hospital service industry has a perceived level of excellent service quality, and this leads clients to expect these levels of excellence. Customer satisfaction is found when the level of a customer's expectations is met by the actual quality of the service provided [4]. Thus, service quality is the actual service quality the customers or clients perceived when measured against their expectations before receiving a service [5].
Over modern decades, there has been considerable worldwide increase in the morbidity and mortality associated with chronic diseases. This has been linked with lack of individualized patient care and consequent medication-related issues. To this end, the World Health Organization (WHO) and the International Pharmaceutical Federation (FIP) have recognized the need to develop pharmacy services as a way to meet the fast-growing demand for safe and quality uses of medicines, alongside affordable healthcare service provision [6]. The European Society of Pharmacy and the Canadian Pharmacist Association have also stressed the need to expand the clinical services provided by pharmacists in both hospital and community settings [7,8]. As a result, the role of the pharmacist has shifted from productoriented services to patient-oriented services [9], and advanced pharmacy services are progressively becoming vital within developed healthcare systems [10]. Nevertheless, despite a signi cant body of international research reporting positive health and economic outcomes associated with the implementation of enhanced cognitive pharmacy services, there have been barriers to successful implementation in developing countries [11,12].
The healthcare system in Pakistan is facing a shortage of human resources and appropriate and sustainable nancial measures and therefore fails to provide optimum services to the population of Pakistan. Furthermore, research is limited in the healthcare institutes; therefore, there is a scarcity of information about patient satisfaction with pharmacists and pharmacy services in Pakistan. As evident from the inadequate information in the literature, patients' opinions about the pharmacy services in Pakistan are important [1]. Therefore, the current study was designed to assess patient satisfaction with the pharmacy performance of the outpatient pharmacy and its variation with socio-demographic characteristics in twin cities of Pakistan (Rawalpindi and Islamabad).

Methodology
Study design: The study was quantitative in nature. A descriptive cross sectional design was used to conduct this study.
Setting: The study was carried out in pharmacy departments of public and private healthcare facilities located in twin's cities of Pakistan (Rawalpindi and Islamabad). Two public and two private hospital were selected randomly and collect data from the patients visiting the hospital pharmacy.
Study Population: The study population included in this research was adult patients or attendant visiting pharmacy department at public and private hospitals of Rawalpindi and Islamabad.
Sampling Strategy: In this study public and private pharmacy department of hospitals were the sampling units and the observational units were adults who were visiting these hospitals for seeking health care. The data was collected through non-probability convenience sampling technique.
Sample size determination: Initially, the sample size was calculated using a single proportion population formula and determined to be 381. This was based on the assumption of p = 50%. This sample was planned to be addressed with a systematic random sampling method. However, the practical scenario could not allow applying this method. Therefore, the actual sample was collected using a purposive sampling technique. Then, a total of 250 patients were addressed based on the available time and resource. No more than 5 clients refused to take part in the study. The reasons for the refusal were related to the care urgencies. Though none of them discontinued, some of the clients felt reluctant close to the end of the survey. Patient who refuse to participate Data Collection Tool: A structured interview questionnaire was adapted from different related works of literature. The questionnaire includes the client socio-demographic factors, the satisfaction questions and system-related questions that can potentially affect clients' satisfaction to the pharmacist service (Appendices 2). The satisfaction questions cover two aspects. The rst 6 questions address study participants' satisfaction towards the pharmacist approach or communication skills. The second 7 questions address participant satisfaction on the medication guide provided by the pharmacists. In all the satisfaction questions, the clients were asked to rate their satisfaction on a ve-point scale (1-very satis ed, 2-satis ed, 3-neutral, 4-dissatis ed, 5-very dissatis ed). For descriptive interpretation the ve scales were converted into a three scale format by combining very satis ed and satis ed as satisfaction, and dissatis ed and very dissatis ed as dissatisfaction. The questionnaire was prepared in English and then translated to urdu language and then retranslated to English to ensure consistency. The data was collected through interviewer-administered face to face interview Rawalpindi. The formal letter was used to get permission from the Head of Quid e Azam International Hospital Shifa International Hospital and consider as private healthcare facility while a letter was received from ethical committee of polyclinic hospital and holy family hospital as public healthcare facility in this study. The letter included the required information e.g. name of researcher, institute, topic name etc. once permission was granted personal visits was made to both hospital for data collection. First of all the brief introduction of the researcher was given to the participants for the sake of rapport building. The purpose of the study and basic required information was given to the participants the consent from each participant. Questionnaire was lled by the mean of interview after taking the consent from each participant. Data was collected from only those participants who agreed to participate. By this way a total sample of 250 was completed from both public and private setting.
Pilot Testing: The questionnaire was pretested on 10 participants at the study site to assess acceptability, feasibility and validity. On the basis of response of pilot testing minor amendments were made to text and questions. After that the questionnaire was nally modi ed and ready for collecting data.
Validity: The questionnaire was pre validated tool however revalidation was performed for Urdu based questionnaire. Face to face and content validity were performed by the three experts, one from academia second from hospital pharmacy and third one from community.
Reliability: Reliability of the data was checked after entering the data into SPSS and reverse coding. The scale showed excellent internal consistency, the value of the cronbach's alpha was 0.885 for this study.
Data Management: Code book was generated to for all the variables in the questionnaire and data was entered and recorded Microsoft excel sheet. Data was rechecked for any error, discrepancies or completeness by spot checking method. Data was stored in a separate storage device to avoid any loss in future and the hard copied were discarded soon after the data entry. Upon complete data collection and coding data was import to Statistical package social sciences 26 (SPSS-26).
Data Analysis: Data was analyzed in SPSS version 26.0. Reliability and quality of data was cross checked by using range and frequency tables to nd out the missing values if any. After that the data was arranged according to requirement for analysis. The continuous variables e.g. age was summarized into categories. All the outcome variables were computed and then summarized into different categories for further analysis.
Descriptive Statistics: Data was analyzed in three phases. In rst phase descriptive was run for sociodemographic variables that were setting, age, occupation, Ethnicity, income, educational status, Number of visits at pharmacy department. All the sociodemographic factors were presented into percentage and frequencies and tables and bar chart were generated according to nature of variable. In second step the descriptive analysis was run for outcome variables.
To identify factors affecting satisfaction, the ve-point scale satisfaction score of each study participant was summed and a mean of the sum was calculated. Then, the satisfaction score was dichotomized into satisfaction (less than or equal to 30) and dissatisfaction (above 30). Binary logistic regression was used to identify factors associated with satisfaction. The enter method was applied. The categorical variables were de ned using the last variable as a reference. The association was tested kruskal wellis and Man Whitney test and p-value those variables with P (p ≤ 0.05) in the univariate analysis were included in the multivariate analysis.
Ethical consideration: IRB approval was taken from the ethical committee of Al Shifa School of public health after synopsis presentation. Before the start of data collection purpose of the research was explained to the participants and asked for their voluntary participation. They were informed that in case of participation no any incentive was provided to them, there was no any physical harm or risk associated with this research and they were free to withdraw at any time. Participants were assured that the collected information would keep con dential and used only for research purpose. Con dentiality was ensuring by putting number or code instead of their names on the data form.

Demographic Characteristics of respondents
Out of 250 respondents, 55.75% were males and 44.25% were females. Age between 18-25 years 25.75%, 19% from 29 to 39 year, 18.25% from 40-49y, 17.5% from 50-59 and 19.5% from more than 60 year of age group. 39.6% of the respondent were single however 52.8% were married and 7.6% were divorced/widow. Of the total respondents 36% were illiterate and 5.5% were master level education. Of all the respondent 12.75% were government employee while 15% were working in private organization and 10% were selfemployee. Majority of the respondent had more than 40,000 of monthly income. Of the total 37.5% of the respondents were sought medicine for self-care while 62.5% were sought medication for their families.
Majority of the respondents bear all expanses by themselves however only 18% get insurance claim for their healthcare expenses (Table 1).

Domain of Pharmacy Services
Current study shows overall patients were satis ed from pharmacy services provided by government and private hospitals. Furthermore patient satisfaction towards pharmacist medication advice was very good however patient satisfaction towards pharmacist approach was good while patient perception with pharmacy setting, drug availability and cost were underrated ( Table 2). Association of different domains of patient satisfaction with demographic characteristics of respondents Signi cance difference (p ≤ 0.05) was observed in pharmacist's approach with different gender, age groups and quali cation. Females had better satisfactory score as compared to female. Younger age group had better satisfaction as compared to elderly. Patients belong to higher educational groups had better satisfaction toward pharmacist approach as compared to low quali cation groups respondents. Furthermore No signi cant difference (p ≥ 0.05) was observed in pharmacist's approach with marital status and number of visits. No signi cant difference (p ≥ 0.05) was observed in pharmacy setting drug availability and cost with different gender, age groups and marital status of respondents. However Signi cance difference (p ≤ 0.05) was observed in pharmacy setting drug availability and cost with different level of education patients with less education had better satisfaction as compared to highly educated respondents. Furthermore Signi cance difference (p ≤ 0.05) was observed in pharmacy setting drug availability and cost with occupation. Self-employee and government employee had low satisfaction score while other had better satisfactory score. Signi cance difference (p ≤ 0.05) was observed in Pharmacist medication advice with different level of quali cation and Occupation. Patient with higher level of education had better satisfaction as compared to low educational age groups. Patient with higher level of education had a better satisfactory score as compared to low educational groups. However No signi cant difference (p ≥ 0.05) was observed in age, gender, marital status and number of visits. reported in a study conducted in korea which stated that Of the patients who visited the pharmacy, 74.6% reported to be either "very satis ed" or "satis ed," and 25.4% responded as being "neutral," "dissatis ed," or "very dissatis ed." [13].
One third respondent said that pharmacy is located on more convenience location while one third said pharmacy was not located at convenient location. The results of the current study a line with another study conducted in japan declared that the location is utmost important for an ideal pharmacy [14]. Most of the patient reported that counselling area was not appropriate. Patients were hesitating to discuss their problems in the presence of other clients and pharmacy staff. The results of the current study a line with a study conducted in dubai that the majority of pharmacists cited the non-availability of a counselling room as the main barrier they encountered when counselling patients [15]. Less than half of the respondents reported that price of medications were affordable. In the support of this study a study conducted in Lahore Pakistan reported that On an average, the cost of standard treatment was equivalent to Near half of the patient agree that pharmacist spend su cient time to counsel the patient. The results of the current study was a line with another study conducted in Finland, which reported that that counselling by pharmacists is bene cial for their medication. Furthermore, pharmacists seem to be more active with the patients receiving prescription drugs. According to our results pharmacists should adjust more counselling to every patient's needs. Thus, pharmaceutical information and support of self-care were found to be important areas in patient counselling [17].
Most of the patient satis ed with all the information provided by the pharmacist regarding how to use medicine, storage of medicine and side effects. A study conducted in Finland reported that Counselling had a positive effect on medication behavior (by 31%), 36% of respondents understood their medication better, i.e. why and how to use their medication drugs, although they did not change their behavior. A total of 30% felt that the counselling had no effect on their medication taking [17]. Another study explain the patient counseling by four approaches are considered within the broader frameworks of delicacy, morality and competence which impact upon the giving and receiving of advice and information more generally, as well as in this setting, and in the light of the continued development of the 'extended role' [18]. Another study conducted in Dubai support the results of current study through a statement that the overall mean patient satisfaction score was 4.71 (a score of 5 indicated most satis ed and 1 indicated least satis ed). Men, older patients and patients who considered the pharmacist to be competent and skilled were generally more satis ed with the consultations. Among patients with chronic conditions who came for medication re lls, 41.8% believed that, although they needed counselling, it was not provided by the pharmacist [15].

Conclusion
Current study concluded that overall patient had average satisfaction score. Patients shows a better satisfaction towards pharmacist behavior/ way of handling the patients, information provided by pharmacist regarding medicine. Patient had less satisfaction towards the location of pharmacy, Availability and affordability of medicine. Patient shows negative satisfaction regarding waiting area and counselling area at in door patient pharmacy. It has been observed that educated respondents shows high level of satisfaction towards pharmacist availability and information provided by the pharmacist.

Availability Of Data And Materials
The data used and analysed during the current study are available from the corresponding author on reasonable request.
Abbreviations PA pharmacist's approach PMA pharmacist medication advice DAC drug availability, and cost