Satisfaction among patients and caregivers receiving value-added services during the Covid-19 pandemic outbreak in a tertiary hospital in the Perak state of Malaysia

Lan-Sim CHEW Pharmacy Department, Hospital Raja Permaisuri Bainun Yee-Ling YEO Pharmacy Department, Hospital Raja Permaisuri Bainun Chee-Tao CHANG (  davidcct.crc@gmail.com ) Clinical Research Centre, Hospital Raja Permaisuri Bainun Chii-Chii CHEW Clinical Research Centre, Hospital Raja Permaisuri Bainun Doris GEORGE Pharmacy Department, Hospital Raja Permaisuri Bainun Philip RAJAN Clinical Research Centre, Hospital Raja Permaisuri Bainun


Introduction
According to the World Health Organization (WHO), patient satisfaction is de ned as patients' evaluation of the care provided relative to their expectations [1]. A better patients' satisfaction is associated with higher medication adherence [2], reduced medicolegal suits [3], and increase professionals job satisfaction [4]. In Malaysia, patient satisfaction was used as an indicator of service quality in the public hospitals [5,6].
In the conventional dispensing system, patients are required to re ll the medications using over-thecounter mechanism, which entails a long waiting time and thus affecting patients' satisfaction [7,8].
Hence, the pharmacy value-added services (VAS) was initiated to ease medication re lls. In Australia, medication home delivery services and drive-through services were preferred over the conventional dispensing method [9]. Additionally, patients who used drive-through pharmacy services reported better overall prescription re lling rate [10]. In the United States, patients who used mail order pharmacy had higher medication possession ratios, lower diabetes-related medical costs over time [11] and better satisfaction [12].
In Malaysia, the pharmacy VAS was introduced in the Ministry of Health to facilitate re ll of medications, reduce waiting time and improve patient satisfaction [13,14]. The most common pharmacy VAS includes Integrated Drug Dispensing System, drive through pharmacy, Prescribed Medication Courier Service and Appointment Card System. After clinic visits, patients obtain the rst 30-day medication supply from the hospital pharmacy counters. They can choose to use the conventional counter service or one of the valueadded services (mail, drive-through, appointment card, Integrated Drug Dispensing System) for their subsequent re lls.
The Integrated Drug Dispensing System enables patients to re ll their medications from any government health facilities that are listed under the Ministry of Health Malaysia [15]. The drive-through pharmacy allows patients to collect their partial supplies through a designated drive-through pharmacy counter within the hospital compound [16], while the Prescribed Medication Courier Service couriers re ll medication to the patient's location of choice [17]. In the Appointment Card System, medications -are prepacked and patients can collect their medications according to the dates speci ed on their appointment cards without queuing.
The Coronavirus disease (COVID-19) was announced as a pandemic on the 10th of March 2020. The Ministry of Health, Malaysia implemented various strategies to curtail the infection, including physical distancing [18]. One of the measures was to increase the use of pharmacy VAS, the aim of which was to reduce congestion in hospitals. This led to a marked increase in the utilization of this service, in which four out of ve patients re lled their medication using the pharmacy VAS in 2020, in comparison to two out of ve in year 2019 [19]. As the use of pharmacy VAS had substantially increased after the Covid-19 outbreak, it is imperative to study the satisfaction of the users.
This study aimed to assess the patients and caregivers' satisfaction towards the four primary valueadded services in the hospital and to explore their expectations for value-added service improvement.

Methods
This was a single-center, cross-sectional, web-based study in the outpatient pharmacy in a tertiary hospital in the Perak state of Malaysia. The outpatient pharmacy department has a patient load of 1000-1500 daily. Patients and caregivers aged 18 years and above, received at least one prescription re ll using the pharmacy VAS services from April to September 2020 were included in this study.
We used the pharmacy VAS patient registration database for convenient sampling purposes. The sample size was estimated according to a previous study, 85.7% of the patients were satis ed with the valueadded services [13]. Sample size was calculated using Raosoft Sample Size Calculator [20]. A minimum sample size of 187 was required, using 95% con dence interval, ± 5% precision with an in nite population size. To allow for a 20% incomplete response, a total sample of 234 was required.
The questionnaire was developed by the investigators by adapting a validated questionnaire [13]. The questionnaire was initially developed in the Malay language and subsequently translated to English and Mandarin. The adapted questionnaire then underwent face validation and content validation by two experts in the pharmacy eld. The questionnaire was subsequently pre-tested on ve respondents to ensure clarity. The nal version of questionnaire consisted of 3 major domains: i. demographic characteristics of participants; ii. satisfaction towards the pharmacy VAS (ten item measured based on a 5-point Likert scale from strongly disagree, disagree, neutral, agree to strongly agree); and iii. suggestions for service improvement (one open-ended question).
A link (URL) of the online questionnaire was created and disseminated to the targeted population through short messages service (SMS).
Once the respondent clicked the link, they were directed to the 'participant informed consent' page, respondents who selected the button 'I agree to participant' were then directed to the online questionnaire. On the other hand, those who clicked 'I do not agree to participate' were directed to an ending page.

Data analysis
Data was initially recorded in the Google Sheets, subsequently transferred, coded and analysed using the IBM SPSS statistical software version 20.0 (SPSS Inc, Chicago, Illinois). Respondents' demographic characteristics and satisfaction scores were descriptively analyzed.
In the satisfaction domains, each "strongly disagree" response was given 1 point, and each "strongly agree" response was given 5 points. The minimum satisfaction score was 1 and the maximum satisfaction score was 5. The mean score for each item was calculated by averaging the scores with the total number of respondents.
The independent t-test and one-way analysis of variance (ANOVA) were used to analyze the differences of mean scores in the satisfaction domain across different demographic characteristics. Multiple linear regression was employed to evaluate the association between respondents' demographic characteristics with their satisfaction towards pharmacy VAS, presented with beta coe cients (β), standard errors, tvalue and P-value. Pearson correlation was performed to determine the relationship between total numbers of comorbidities with satisfaction scores. Multiple linear regression analysis was performed to determine the factors associated with the level of satisfaction. Statistically signi cant level was set at 5%. Thematic analysis was used in analysing open-ended question.
Out of a maximum score of 5, the overall mean satisfaction score was 4.42 (SD: 0.55), ranged from 1 to 5. Among all, the respondents were most agreeable to time saving bene ts of the pharmacy VAS (4.56 ± 0.63). Majority of the respondents felt that pharmacy VAS had made their life easier (290, 95.7%) with mean score of 4.51 ± 0.65 and planned to recommend the pharmacy VAS to others (292, 96.4%) by giving an average of satisfaction score of 4.51 ± 0.61 ( Table 2).
The mean satisfaction scores differed across age groups (p < 0.001), occupation (p < 0.001), residential area (p = 0.037) and type of VAS services used (p < 0.001). Patients aged > 60 years old, retiree, resided within the Kinta district and those who used the drive-through services reported higher satisfaction scores (Table 1).
Multiple linear regression was performed to identify signi cant predictors for satisfaction on pharmacy VAS. Respondents aged more than 60 (vs. age 18-35, β = 2.375, p < 0.001) and those who used drivethrough service (vs. SPUB, β = 2.272, p = 0.001) reported higher satisfaction scores (Table 3). There was no signi cant correlation between total number of comorbidities with the mean satisfaction scores (r = 0.040, p = 0.494).
Several suggestions were made for service improvement, including longer operating hours (18, 6.0%), upgraded communication system (9, 3.0%), smoother registration process (9, 3.0%), more polite staff (9, 3.0%), selection of preferred postage delivery time (6, 2.0%) and promotion of value-added services (4, 1.3%) ( Table 4). #Notes: Student's t-test and one-way ANOVA was performed to detect the differences of mean scores across different groupŝ combination of no formal education and primary school level  Stepwise multiple linear regression analysis. Multicollinearity and interaction term were checked and not found (tolerance < 1.00 and VIF < 10). Linear relationship between the independent and outcome variable was checked using scatter plot of residuals. Normality of response variable was checked using histogram and box-plot of residuals. Model assumptions are ful lled.

Discussion
To the best of our knowledge, this is the rst study reporting the satisfaction levels of patients and caregivers using the pharmacy VAS during the Covid-19 pandemic. The respondents demonstrated a high level of overall satisfaction towards the four types of VAS. Majority of them suggested extended hours of operation, more courteous staff, better communication system, and a smoother registration process when using VAS. While the previous studies evaluated a maximum of three types of VAS [13,[21][22][23], this study evaluated four different type VAS for satisfaction level among the users. This study describes the key factors affecting patients and caregivers' need with regards to pharmacy VAS, informing stakeholders on the possible gaps for improvement.
We also translated the questionnaire into Mandarin, providing a wider choice of language options for participants. The study was designed as a self-administering online questionnaire without the presence of interviewers that allows the respondent to freely provide their responses, and a semi-structured question at the end of questionnaire that allowed respondents to give their expectations on VAS in free text.
At least 77.2% of the respondents rated their satisfaction with mean scores of more than 4.0 out of a maximum of 5.0 irrespective of service types. Similar to the ndings of previous studies, a range of 74.5 to 100% of respondents rated high level of satisfactions to pharmacy VAS [10,13,21,23]. In contrast, patients satisfaction level with the outpatient pharmacy services varied between 1.5 and 87.5% [12,[24][25][26][27][28][29][30][31]. In the comparison of VAS against traditional counter service (TCS), a signi cant higher proportion of VAS users (77.8 to 96.2%) rated higher satisfaction scores than TCS users (63.1 to 89.4%) [13,21,22]. This implied that VAS users are satis ed with this innovative method of medication dispensing that offer them more exibilities to get their prescription re lls when compared to the conventional dispensing service that requires them to come to the counter and wait to get their medication prepared by pharmacy staff.
Being a retiree, more than 60 years of age, residing near to the hospital and utilisation of drive-through service were signi cant predictors for higher score of satisfaction to VAS. In contrast, a previous study showed that satisfaction level of older adults and female users were negatively correlated with VAS while users with higher income had their satisfaction level positively correlated with VAS [13]. Types of VAS selected by users were recognized as one of the factors affecting users' satisfaction level [21]. Another study showed that users of mail pharmacy services demonstrated a lower satisfaction level than drivethrough and call-and-collect service as users are required to pay for the mail service [13]. On the other hand, other studies study show that users of mail pharmacy demonstrated a better satisfaction compared to TCS [22] or other types of VAS such as integrated drug dispensing system [21]. It is postulated that the factors affecting the satisfaction level of VAS users could have been unique for geographical location, health institutions and types of VAS selected.
It is noteworthy that types of VAS evaluated in each study were limited by the availabilities of VAS offered by the respective health institution. In addition, as discussed by the previous study [21], patients could only select the VAS based on the availability of VAS, and the selection of VAS is also limited by the pharmaceutical dosage form of the medication. For instance, currently, mail pharmacy is not an option for patients prescribed with medications requiring storage at low temperatures, dangerous drugs or psychotropic medications. This has render di culties for researchers to compare the satisfaction level among different types of VAS in the presence of such limitations. There is no single standard measure of patient satisfaction applicable to all pharmacy situations.
Users who selected pharmacy drive-through service had positive correlation with the satisfaction levels of VAS after adjusting other factors. High satisfaction levels were seen in users of pharmacy drive-through services evaluated in a previous study, which indicated that as high as 69.2% of the users rating this service 'very satis ed' and 30.8% rated 'satis ed', mainly due to convenience, short waiting time and problem recti cation in a timely manner [23]. Insu cient parking lots, congested patients waiting area and long waiting time have been the major issues encountered by most of the tertiary hospitals globally.

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The introduction of drive-through pharmacy is able to ease these problems among the elderly, working adults and parents with young children who require to re ll their medication on long-term basis [32]. In line with the WHO guidelines during the outbreak of COVID-19 pandemic in 2020 [33], elderly patients, who are associated with higher risks of mortality with coronavirus infection [34], are encouraged to select drive-through services in order to avoid the crowds and limit the contact with others [35]. Drive-through pharmacy also has been encouraged locally and in Australia during the on-going pandemic of COVID-19 as a safety measure for the public especially the elderly to get their medication because the nature of this service enables the practice of physical distancing and it has been a proven e cient and safe method of medication dispensing [35,36]. In spite of many advantages of drive-through services, it is important to note that this service would be of maximum bene t for citizens who own a vehicle and when the hospital is faced with inadequate carparks [37][38][39][40].
Respondents expect pharmacy staff to be more polite and courteous. Evidence showed that pharmacist attitude is positively correlated with patients' satisfaction visiting pharmacy department of public hospitals [41][42][43]. The patients receiving pharmaceutical care service would expect the pharmacy personnel to be pleasant and courteous [42], and show good attitude to them [44]. Previous study proposed that satisfactions of VAS users might be affected by the attitudes of pharmacists and questions assessing this context can be explored in future surveys [13]. Meanwhile, researchers could consider exploring factors affecting the attitude of pharmacy personnel when delivering VAS to the users.
The need to upgrade communication systems was suggested by respondents to improvise VAS. Effective communication was identi ed as one of the important elements to improve customer satisfaction in outpatient pharmacy service [21,45]. Establishing a single point of contact for all incoming queries can be adapted such that it serves as a centralised system to streamline the registration process, real-time communication between pharmacy personnel should any issue arise and alert the users to collect their medication based on the types of VAS they selected. The communication can be leveraged including creating service desk automation software [46], such as mobile application, that are equipped with the capabilities of voice calling, video conferencing, text, e-mail, and social media, suited to the preference of the customers [47].
The limitations of this study include ndings of a single-centre study may not be generalizable to other centres as the types of VAS services may vary between health institutions. In addition, our study did not compare the satisfaction level between VAS and TCS users, the satisfaction of existing TCS users especially among the elderly is therefore unknown. The timing of data collection would affect the satisfaction of the users [41], this survey was conducted during the pandemic in which the use of VAS could be a preferred option as it allowed the users to practice physical distancing and this factor could have contributed to high satisfaction levels. Future research should consider assessing the satisfaction level of TCS users and the reasons of not selecting VAS in which the ndings could be used as a reference for VAS improvement as well as the overall ow of out-patient dispensing activities. Other limitations are recall-bias among the users of VAS and the use of convenient sampling may lead to selection bias of the study population. Guidelines Good Clinical Practice (4 th edition) and other relevant guidelines for research. Only subjects above 18 were included, all participants informed consent were obtained prior to collecting their data.
Consent for publication: All authors agreed to submit to BMC Health Services Research for publication.
Availability of data and materials: The datasets generated and/or analysed during the current study are not publicly available due to con dentiality of patients, but are available from the corresponding author on reasonable request.
Competing Interest: The authors declare no con ict of interest.
Funding: This is a self-funded work.
Authors' contributions: LS and YL initiated the idea of this research work and nalised the proposal. CT drafted proposal collected and analysed data and draft the manuscript. CC contributed to the proposal drafting, data analysis and rst draft of the manuscript. DG and PR provided administrative support and supervision. All authors proofread and approve the nal version of this manuscript.