Adult HIV/AIDS Patients’ Level of Satisfaction on Pharmaceutical Service: Institutional Prospective Cross Sectional Study

Objective : Patients are essential sources of information to assess the accessibility and effectiveness of pharmaceutical care. Patients’ perception and satisfaction on the care they received has direct in�uence on treatment adherence. This study was thus aimed to assess HIV/AIDS patients’ level of satisfaction on the pharmaceutical services provided in Zewditu Memorial Hospital, Addis Ababa, Ethiopia. An institution based cross sectional study was conducted from April 16, 2018 to May 16, 2018 in Zewditu Memorial Hospital. Result: Among the total 285 participants enrolled in the study, 172(60.4%) of them were females and the mean age of the participants was 42.5±9.8. The participants of this study received ART service for a mean duration of 7.3±3.5 years. In this study, 26.7%, 13.7%, 38.6%, 13% and 8.1% of the study participants rated the overall satisfaction to the ART pharmaceutical service as excellent, very good, good, fair, and poor, respectively. Participants who were provided information about drug-drug and drug-food interaction were 2.72 times more likely to be satis�ed than those who weren’t provided (AOR=2.72, 95%CI : 1.13-6.54).


Introduction
HIV infection has remained a serious disease of public health importance since 1981.Since the start of the epidemic, it is claimed that more than 35.0 million people have died from AIDS related illnesses.
Globally, it is estimated that approximately 36.7 million [34.0 million-39.8 million] people are living with HIV by the end of 2016 with 1.8 million new HIV infections, and 1 million AIDS related deaths [1].
Sub-Saharan Africa (SSA) countries continue to bear huge burden of HIV infection.The region is home to 25.7 million people living with HIV (PLWH) or 70% of world's PLWH [2].Moreover, 75% of the total HIV/AIDS deaths in 2015 were from SSA [3].Ethiopia is one of the sub-Saharan African countries with high burden of HIV [4].In 2016, there were 720,000 PLWH and 27,104 newly diagnosed cases in Ethiopia.
More than half (59%) of them were enrolled in highly active antiretroviral therapy (HAART) program [5].Evidences suggest that improved access to antiretroviral therapy (ART) is helping to drive a decline in HIV related mortality [6].In Ethiopia, ART service is available in 1047 health facilities [7].
Patient satisfaction on pharmaceutical care can be conceptualized as patient's evaluation of the pharmacist's performance in a variety of patient care activities [8].It is one of the imperative components for the great success of any healthcare services, especially in the ART units [9].Patient satisfaction has direct effect on adherence to HAART [10].Certain patient characteristics are known to correlate with the global patient satisfaction rating.Older patients were signi cantly more satis ed than younger patients [11].However, information provided pharmacist such as drug interaction were not known to be associated with patient satisfaction.
Patient's satisfaction is essentially an important issue in Africa particularly for countries like Ethiopia, where there is a dearth of adequate resources and skilled human capital to provide e cient health care services to the HIV/AIDS patients [9,12].We hypothesized that level of satisfaction in Ethiopia is low.
Hence, assessing the HIV/AIDS patients' level of satisfaction towards the pharmaceutical service in ART clinic is crucial for improving treatment outcome.This study is hence designed to identify the level of satisfaction of HIV/AIDS patients towards the pharmaceutical service provided at the ART clinic and its associated factors in Zewditu Memorial Hospital (ZMH), Addis Ababa, Ethiopia.

Methods
An institution-based prospective cross sectional study, using a quantitative data collection and key informant interview method, was conducted in ZMH, Addis Ababa, Ethiopia.The study setting was selected based on the virtue of being leading medical center in Ethiopia, for the treatment of HIV/AIDS.
Currently, it provides ART pharmaceutical care for more than 7,000 PLWH.This study was carried out from April 16, 2018 to May 16, 2018.
In selecting the study participants, patients who were ART care bene ciaries for more than 1 year and above the age of 18 were included.The number of patients to be involved in the study was determined using the single proportion formula [13] considering the prevalence data (78.5%)taken from previous similar study done in Ethiopia [14].Margin of error was set to be 5% (95% con dence interval).
For obtaining a representative of the population who has been visiting the ART pharmacy, a systemic random sampling technique was used.The average daily ow of patients to the hospital is approximately 100 patients.We had a 22 working days to collect data in the given study period.We expected to interview 13 patients per day.Accordingly, every eighth patient was approached to participate in the study.The rst participant of the day was selected using a simple random sampling from one to eight.In place of patient refused to participate in the study, the next patient was enrolled in the study.None of the participants discontinued the study.Data was collected using a tool adopted from Larson et al., [15].Questionnaire was designed and modi ed appropriately after it was pretested on 25 clients prior to the actual data collection.Moreover, the content validity of the data collection tool was con rmed by team of expert including senior infectious disease physician in Zewditu memorial hospital and a public health personnel and clinical pharmacist from Addis Ababa University.Based on the pre-test we found that some of the information needed such as drug interaction was not included in the tool was modi ed.The aim of the study and the potential risk it might pose was explained to patients prior to data collection and their written consent was con rmed.
In collecting data on the patients' satisfaction towards the ART pharmaceutical service, study participants were asked to respond to a number of assessment questions classi ed on a Likert scale of 1-5, with"1" stood for rating of the item as "poor", while "2", "3", "4", and "5" stood for "fair", "good", "very good", and "excellent", respectively.These satisfaction assessment questions are regrouped in 8 themes.
Following checking its completeness and consistency, the data collected were entered to and analyzed using SPSS Statistics for Windows, version 20.0.Frequencies, percentages, t-test, and ANOVA with post hoc test were used to analyze different variables.P-value less than 0.05 were used as cut off points for determining statistical signi cance of associations among different variables.

Socio-demographics Characteristics of Participants
Of the total 285 participants enrolled (100% response rate) in the study, majority (172; 60.4%) of them were females.More than half (53.3%) of the respondents were married.The mean age (±SD) of the participants was 42.5±9.8and the highest proportion was found between the age group of 31 and 40 years.More than one-third (34.4%) of them had attended secondary level education.Occupationally, 28.8% of them were self-employed.The participants had received the ART service for a mean duration of 7.3±3.5 years (Table 1).Patients' Satisfaction towards the Service More than half of the patients rated the time given by the pharmacist to listen what they are in need of as excellent (123; 43.2%) and very good (27; 9.5%).Moreover, majority (70.2%) of them claimed that there is excellent use of easy and understandable language by pharmacist for communication.Most participants (55.1%), however, rated the provision of written information by pharmacists as poor (Table 2).
As it is indicated in table 2 below, 156 (54.7%) of the participants rated the service provided about medication precaution and side effect by the pharmacist as poor.Similarly, more than half of the participants indicated that they are not satis ed with pharmacist effort to give information about drugdrug and drug-food interactions.
The arrangement of medication and the cleanliness of the environment was rated as excellent by 192 (67.4%) and 189(66.3%)participants, respectively.Of the total participants, 138(48.4%) of them rated the availability of medication as excellent and the overall appearance of the pharmacy was rated as excellent by 68.4% of the participants.As the overall satisfaction of the patients is indicated in table 2, more than a quarter (26.7%) of them rated the overall satisfaction as excellent; whereas, 13.7% , 38.6% ,13% and 8.1% of them rated their satisfaction as very good, good, fair and poor, respectively.

Factors Affecting Patient Satisfaction towards the Pharmaceutical service
Binary logistic regression analysis that there is signi cant (p<0.05)association between provision of information about drug-drug/drug-food interaction and overall satisfaction of participants.Participants' who were provided information related to drug-drug and drug-food interaction were 2.72 times more likely to be satis ed than those who didn't receive information (AOR=2.72,95% CI: 1.13-6.54).Participants who reported shorter time to receive service were 4.06 times more likely to be satis ed than those who did not (AOR=4.06,95% CI: 1.69-9.74).However, no association was found between patients' socio-demographics variable and overall satisfaction (Table 3).

Discussion
In recent decades, determining patients' level of satisfaction is found to be the most useful tool for getting their views on how to provide them a care [16].This is due to its ability to re ect the quality of health care delivery and provider's ability in successful delivery of care that meets patients' expectations and needs [17,18].A satis ed patient is more likely to develop a longer lasting rapport with their health care provider.An individual who fails to take the ART due to dissatisfaction will end up in developing resistant strains to the drugs in a matter of few minutes [19].
Present study showed that the overall mean satisfaction of the participants on ART pharmaceutical services provided at ZMH was 3.38±1.23.This nding is in line with a similar study done in Gondar on expectation and satisfaction of ART clients towards the pharmaceutical service [14].This indicates the similarity of pharmacy practice in the settings.
In our study, 43.1% of participants rated the time taken by the pharmacist to listen to what they need as excellent; this was higher when compared with another study done in ART special unit in Addis Ababa [20].This might be due to the effort exerted by the hospital to modernize the pharmacy service in recent years.The easy and understandable language utilization by the pharmacists was rated excellent (4.29).This was slightly higher compared to the report of the study in Gondar (3.90) by Abebe et al., [14].
The effort of pharmacists to solve patients' medication related problem was rated poor by majority of the participants.This nding is supported by a study done in Nigeria, where perception of patients regarding the pharmacists' efforts to solve patients' medication related problems were negative [21].This could be because of lack of knowleadge or willingness by the pharmacists side.
Several factors including patient's age, educational level, health status and the severity of illness in uence satisfaction on care ART services [22].However, in this study no signi cant association was found between patients' socio-demographics variable and overall satisfaction.This could be because the ART service is free of charge so could not be altered by of socio-demographic factors.In addition the chronicity of the disease might make patient to have similar level of understanding about the service.
Present study rather revealed that provision of information about ARV drug-drug and drug-food interaction, and shorter time to receive service in uenced participants overall satisfaction towards the pharmaceutical service provided in the hospital.This indicate that improving the pharmaceutical service and develop pharmacist knowledge and skill can improve HIV/AIDS patients' satisfaction.

Conclusions
The adult HIV/AIDS patients' satisfaction with the overall ART pharmaceutical service was rated positively by participants with a mean value of 3.38.Patients claimed that they were better satis ed with infrastructure and the appearance of the pharmacy.In addition, the participants were better satis ed with the pharmacists' availability, commitment, con dentiality and for using easy and understandable language in the service.However, majority of the participants were not satis ed with the provision of medication related information and on the pharmacists' efforts to solve medications related problems.

Limitations
As the respondents were interviewed in the compound of the hospital, study bias could have occurred.
Moreover, the study was conducted in a governmental hospital that provides care to the certain group of the population in the city and the sample size used is not that large enough.As such, the result may not be a re ective of the situation in the general population.The hospital manly provide service for patients who cannot afford to attend private hospitals.The nding of this study is interpreted in light of several limitations.The cross-sectional design gives only a snap shot of events.To ensure con dentiality, participants' data were linked to a code number and registered.The right was given to the study participants to refuse or discontinue participation at any time they want and the chance to ask any thing about the study.
Abbreviations AOR: Adjusted Odds Ratio

Table - 3
Factors affecting overall satisfaction of patients attending ART service in ZMH,