IJPP 2004, 12: 7–12
ß 2004 Int J Pharm Pract
Received April 11, 2003
Accepted January 4, 2004
DOI 10.1211/0022357023204
ISSN 0961-7671
Department of Clinical Pharmacy
and Pharmacy Practice,
University of Benin, Nigeria
Azuka C. Oparah, lecturer
Ehijie F. O. Enato, lecturer
Obehi A. Akoria, lecturer
Correspondence: Mr Oparah,
Department of Clinical Pharmacy
and Pharmacy Practice,
University of Benin,
PMB 1154 Benin City, Nigeria
E-mail: oparaca@yahoo.com
Assessment of patient satisfaction with pharmaceutical
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
provider. In a competitive health care market, it is important that pharmacists provide
competent services with which the consumer is satisfied to ensure that patients will
continue to seek their services. 5
Patient satisfaction is also likely to affect the image of the pharmacist and pharmacy
profession and, as such, efforts should not only be made to track patient satisfaction
with pharmacy services but also to improve it where needed.
Satisfaction can be conceptualised as performance evaluation, disconfirmation of
expectations, an affect-based assessment or an equity-based assessment. 6 Several meas-
ures of patient satisfaction with pharmaceutical services have been developed and
tested. An interviewer administered a Pharmacy Encounter Survey to patrons of
randomly selected chain and independent pharmacies in Philadelphia County and
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
A mail questionnaire sent to randomly selected outpa-
tients in a large university hospital revealed that of those
that received prescriptions but did not have them dis-
pensed in the hospital pharmacy, two-thirds were aware
of the existence of the pharmacy, but more than one-third
of these found the pharmacy inconvenient for refills while
about a quarter thought that the waiting time to fill pre-
scriptions was too long. Of those respondents that re-
ceived prescriptions, nearly half had them filled at the
university. Reasons given for this consumer behaviour
were mainly convenience, followed by availability of medi-
cation, and low prices. 8
Based on responses to a questionnaire survey of patient
demand for community pharmacies in Tokyo and Osaka,
patient satisfaction was influenced by the attitude of pharma-
cists and by specialised activities, such as providing infor-
mation and explanations, and convenience of opening
hours. Furthermore, comfortable facilities and availability
of over-the-counter drugs that the respondents rated low in
terms of importance influenced satisfaction while conveni-
ence of location did not.9 These studies reveal that while
there may be some general satisfaction indicators in phar-
macy services, there is a need to undertake site-specific stu-
dies in order to meet the expectations of the clientele served.
In another study that was undertaken to determine the
components of outpatient pharmacy services that impacted
on the patient’s perception of satisfaction, results of the
principal components analysis delineated two dimensions
of patient satisfaction. The authors concluded that phar-
macy managers could emphasise these to produce a more
satisfied patient, repeat patronage, and enhanced viability
for the pharmacy. 10 These components were defined as
``professional communication’’ and ``physical and emo-
tional well-being of the patient’’. This finding is similar to
the two dimensions of ``friendly explanation’’ and ``mana-
ging therapy’’ derived in another study. 11 Several studies
have found that patient satisfaction improved after provi-
sion of pharmaceutical care although not all studies have
found a positive association. 12±15
Several instruments are available to inform the pharma-
ceutical literature for evaluating patient satisfaction with
pharmacy services. Since there are technical and interperso-
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.
Larson, Rovers and Mackeigan 11 have developed and
updated a validated instrument for assessing patient satis-
faction with pharmaceutical care. This instrument provides
information on patients’ satisfaction with two dimensions
of pharmacy services: ``friendly explanation’’ and ``managing
therapy’’. The updated version has not been widely tested.
Kucukarslan and Schommer found that patients’ prior
experiences, ideal referents, or market-based expectations
affected patients’ satisfaction with pharmacy services.
They also concluded that satisfaction surveys should be
designed to specifically assess the type of services provided
by the pharmacy. 16
The pharmacy profession advocates that pharmacists
offer pharmaceutical care to improve patients’ health, in
addition to dispensing medications. 17 Pharmaceutical care
is poorly developed in many hospitals; hence standards of
care provided to patients vary.18 Pharmaceutical care is yet
to become an integral part of pharmacy practice in Nigeria.
Hospital pharmacy practice in Nigeria may be described as
under-developed in comparison with many other countries.
To date, few pharmacists have been attracted to the public
health sector because of poor remuneration and lack of job
satisfaction. Government hospitals widely use pharmacy
technicians, who have two years post secondary education
in a school of health technology, for the dispensing of drugs.
The role of the pharmacist in the hospital is limited to the
traditional dispensing of drugs and inventory management.
Only a few hospitals have a unit dose dispensing system.
The layout and the design of the pharmacies are often
unsuitable for effective dispensing. Drugs are dispensed
through pigeonholes in most hospitals, which forms a bar-
rier to patient counselling. Medication profiles are not kept
as an essential component of the pharmaceutical service.
The records kept in the pharmacy are those of stock, which
suggests product-oriented pharmacy practice. A drug revolv-
ing fund scheme was introduced in the country some years
ago to reduce the problem of ``out of stock’’. This is a cost
recovery system of pricing drugs sold to patients in govern-
ment hospitals. Patients pay for their drugs, as the national
health insurance scheme is yet to be fully established.
We undertook an assessment of patient satisfaction
with a hospital pharmacy service using the ideal referent
model in a health facility where pharmaceutical care does
not yet exist. We selected the updated Larson instrument
because its authors tested it in a setting where pharmaceut-
ical care was to be implemented. Furthermore, it is logical
to assess patient satisfaction with pharmaceutical services
using this model since pharmaceutical care represents the
accepted professional ideal for pharmacy.
The findings would provide useful baseline data for the
introduction of pharmaceutical care in the health care
facility under study.
The objectives of the study were to assess patient satis-
faction with pharmaceutical services using the ideal refer-
ent model, and to generate data to further evaluate the
validity of the updated instrument developed by Larson
et al11 in a Nigerian practice setting.
Methods
The study was undertaken at the University of Benin teach-
ing hospital, a 560-bed tertiary health facility. The hospital
is located in an urban city with a population of over one
million people, of varied socioeconomic strata. The layout
of the pharmacy department is similar to other pharmacy
departments in the country, all of which share a common
weakness of dispensing drugs through a pigeonhole, which
obstructs pharmacist±patient interactions. The study was
undertaken between September and November 2002.
Approval was obtained from hospital management prior
to the start of the survey. The objectives of the study were
addressed using a 20-item self-completion questionnaire
with a Likert-type response scale. The item stems covered
 March 2004, The International Journal of Pharmacy Practice
two broad dimensions of pharmaceutical care, namely
``friendly explanation’’ and ``managing therapy’’.
Provision was made on the questionnaire for respond-
ents to state their gender, occupation, marital status, aver-
age monthly income, and highest level of education
attained. The questionnaire contained an instruction to
patients to compare their encounter with the pharmacy
with what they felt it ought to be (ideal), with respect to
the questionnaire items.
The responses were rated from ``poor’’ to ``excellent’’
(``1’’ to ``5’’). Persons other than a pharmacist (two final
year pharmacy students, who had been trained) intro-
duced and explained the questionnaire to the patients to
minimise bias. Patients self-completed the questionnaire.
A consecutive sample of 500 adults that had used the
pharmacy before were recruited following their consent.
Inpatients, those filling prescriptions for someone else,
and people who were unable to understand the written
English language were excluded. Patients were approached
until a target of 500 usable questionnaires were obtained.
Data analysis
Usable responses were entered into Microsoft Excel and
rechecked prior to sorting, and were then loaded into
SPSS version 7.5 or GraphPad Instat version 2.05a for
descriptive and inferential statistical analyses. The lowest
possible score for the 20 items was 20 and the highest was
100. While the true midpoint on the scale was unknown, it
seemed logical to assume 60, a point midway between the
``poor’’ to ``excellent’’ axis.
The scores were treated as interval measurements suit-
able for parametric analysis. Descriptive statistics on sam-
ple characteristics and questionnaire items were computed,
including means, standard deviations and percentage fre-
quency distributions. The internal consistency of the instru-
ment was explored by computing Cronbach’s alpha test
of reliability. Principal component analysis employed
Varimax rotation with Kaiser normalisation and list-wise
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
satisfaction were explored using Student’s t-test and one-
way ANOVA. These inferential statistical analyses were
conducted using GraphPad Instat, which reports exact
P values, and P < 0.05 was interpreted as significant.
Results
The questionnaire response rate was 89.3 per cent and
Cronbach’s alpha was found to be 0.9641. Sociodemogra-
phic characteristics are summarised in Table 1. Males
(54 per cent) and females (46 per cent) were almost equally
represented. Nearly half of the patients (44 per cent) were
married, and over two-thirds (69 per cent) were educated
up to tertiary level. The modal income group reported
earning less than 100 dollars per month.
9
Overall, the respondents rated their experience with
pharmaceutical services as 56.04 § 24.49. This summary
score was below the assumed midpoint of 60. All the items
had factor loadings of between 0.516 and 0.782 and were
therefore grouped together.
Principal factor analysis (Table 2) resulted in two fac-
tors similarly identified as ``friendly explanation’’ and
``managing therapy’’. A large first factor accounted for
59.96 per cent of the variance obtained.
The extraction yielded two items having low factor
loading under ``friendly explanation’’. These were: ``how
well the pharmacist answers your questions’’, and ``the
courtesy and respect shown you by pharmacy staff’’.
These were excluded and 18 items were included in the
final list of the components. The summary score for the
``friendly explanation’’ component was 2.60 § 1.11, while
that of ``managing therapy’’ was 2.33 § 1.07 on a mean
summary score that ranged from ``1’’ to ``5’’. Cronbach’s
alpha for the subscales was 0.9373 (friendly explanation),
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).
The frequency distribution of the questionnaire items is
shown in Table 3. The average patient satisfaction rating
was: poor (22 per cent), fair (28 per cent), good (33 per
cent), very good (10 per cent) and excellent (5 per cent).
There was an overall 0.6 per cent non-response to the
questionnaire items, implying high understanding of the
items posed to the respondents. Nearly half of the patients
(46 per cent) rated their pharmaceutical service provision
as poor in reference to their perceived ideal on the amount
of time the pharmacists offered to spend with them. About
one-third (31 per cent) rated the promptness of their pre-
scription service as poor.
Further inferential statistical analysis could not detect
any association between patients’ perceived satisfaction
and their sociodemographic profile. The results of the
subanalysis were similar to the overall in the sense that
in none of the subgroups was satisfaction rated above the
mean on the scale (see Table 1).
Discussion
The questionnaire achieved a high response rate and we
speculate that this was probably because the study was the
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
better service in future. The majority of our respondents
were educated up to tertiary level, and in this respect our
sample was not representative of the Nigerian population.
The study was carried out in a university community
located in an urban city. The findings would be likely to
be different in rural areas where over 70 per cent of
Nigerians live and work. Low literacy is itself a challenge
for research into patient satisfaction. However, the large
segment of respondents in the low income group indicates
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
received a satisfactory rating out of the 20 satisfaction
items investigated. The study used an ideal reference point,
asking patients to compare their own experience with that
ideal. Tools measuring patient satisfaction with pharma-
ceutical care employ outcome measures, unlike those used
in traditional pharmacy patient satisfaction studies that
utilise structure and process elements. It is possible that
the patients we surveyed, being literate, had relatively
higher expectations of pharmacy and hence low satisfac-
tion with current provision. A study in hospitals in Jordan
showed that patient satisfaction was mainly influenced by
patients’ expectations of received care even after adjusting
for sociodemographic variables. 19 In the current study,
nearly half of the patients felt the amount of time the
pharmacist offered to spend with them was inadequate.
Pharmaceutical care is patient-centered and hence pharma-
cists providing pharmaceutical care have high contact time
with patients. Patients may be less able to judge the tech-
nical quality of the care they receive, but they do judge
their social interaction with the pharmacist. Pharmacy
professionals need to increase patients’ awareness of the
value of pharmaceutical care services and make it important
to their judgment of satisfaction. 20,21
Although the present study did not find any significant
association between sociodemographic variables and per-
ceived level of satisfaction, this would be difficult to gen-
eralise as there was disproportionate representation of
groups in terms of level of education and income.
Our testing of the validity of the questionnaire develop-
ed by Larson et al11 shows comparable results to those of
the original authors. Both studies were carried out prior to
implementation of pharmaceutical care, although phar-
macy practice in the US is far ahead of that of Nigeria.
The internal consistency of the instrument, computed as
Cronbach’s alpha, in our local environment gave compar-
able results to the reference, ie, 0.9373 and 0.9318 versus
0.957 and 0.962 for the subscales.
Although we identified two principal component fac-
tors of patient satisfaction as in the reference study, our
results placed two items under ``friendly explanation’’
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
should be reinforced with intuitive grouping.
There was a low non-response to questionnaire items
(0.62 per cent). This finding and the high reliability found
indicate that the instrument is valid in assessing patient
satisfaction in Nigerian pharmacy practice.
Reports show that, in general, patient satisfaction rat-
ings tend to be high. 1 Our study, in which patients gave
low satisfaction ratings, has identified areas where the
current service could be improved, as well as an opportu-
nity for pharmaceutical care to demonstrate its value.
A follow-up investigation would be needed to measure
patient satisfaction after pharmaceutical care services
have been implemented.
Since patient satisfaction is a measure of quality of
health care, this study points to some shortcomings which
may have an overall impact on the quality of Nigerian
health care services. The findings were obtained from a
tertiary health care centre and the situation could be
worse in lower levels of health care. Future research should
also consider patient satisfaction in community pharmacy
and primary health care centres in Nigeria.
Conclusion
The study provides evidence that patients experience low
satisfaction with pharmacy services in a Nigerian hospital.
Patients’ perceived satisfaction was significantly higher in
terms of ``friendly explanation’’ than ``managing therapy’’.
The sociodemographic characteristics of patients were not
associated with their level of satisfaction. We further con-
firm the validity of the patient satisfaction questionnaire
developed by Larson et al in a Nigerian practice setting.
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