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IJHCQA
26,5 Measuring patients’ satisfaction
with pharmaceutical services at a
public hospital in Qatar
398
Imran Fahmi Khudair
Pharmacy Department, Hamad General Hospital, Doha, Qatar, and
Received 23 March 2011
Revised 19 July 2011 Syed Asif Raza
Accepted 15 August 2011
College of Business and Economics, Qatar University, Doha, Qatar

Abstract
Purpose – The aim of this paper is to study pharmacy service impact on patient satisfaction and to
determine what factors saliently link with pharmaceutical service performance at Hamad General
Hospital.
Design/methodology/approach – A patient satisfaction questionnaire was designed using the
literature and consultation with Hamad General Hospital medical experts. The questionnaire
contained 22 items that focused on five influencing factors: promptness; attitude; supply; location;
medication education; and respondent demographic aspects. A total of 220 respondents completed the
questionnaire. An exploratory factor analysis was used to group items and a structural equation model
was developed to test causality between five factors along with their influence on patient satisfaction.
Findings – The study establishes statistical evidence that patient satisfaction is positively
influenced by service promptness, pharmacist attitude, medication counseling, pharmacy location and
waiting area. Several socio-demographic characteristics have statistically different effect on
satisfaction, notably: gender; marital status; health status; age; educational level; and ethnicity.
However, medication supply did not influence patient satisfaction.
Practical implications – Pharmaceutical services are recognized as an essential healthcare-system
component. Their impact on customer satisfaction has been investigated in many countries; however,
there is no such study in Qatar.
Originality/value – The findings identify pharmaceutical service performance indicators and
provide guidelines to improve Qatari pharmaceutical services.
Keywords Patient satisfaction, Psychometric properties, Pharmaceutical services, Healthcare,
Structural equation modelling, Qatar, Customer satisfaction, Health services
Paper type Research paper

Introduction
Pharmacy services have been increasingly expanded beyond simple medication supply
to become a more patient-centered and caring service. Pharmacists work in harmony
with other healthcare providers to optimize patients’ quality of life and to achieve the
best clinical outcome. Good professional relationship and communication must be
established and maintained between the pharmacist and the patient to attain this goal.
International Journal of Health Care The pharmacist also should maintain an appropriate caring attitude and use his/her
Quality Assurance pharmacotherapy knowledge and skill as the medication expert to improve the
Vol. 26 No. 5, 2013
pp. 398-419 patients’ health and wellbeing.
q Emerald Group Publishing Limited Patient satisfaction is an integral healthcare-quality component. Improved
0952-6862
DOI 10.1108/IJHCQA-03-2011-0025 communication, convenience and courtesy can lead to better health service use and
ultimately better outcomes. High satisfaction promotes positive health behaviors, such Measuring
as compliance and continuity with providers. Patients who are satisfied with their patients’
overall care are likely to take medications properly and less likely to change from one
healthcare professional to another (Briesacher and Corey, 1997). According to satisfaction
Schommer and Kucukarslan (1997), patient satisfaction is about personally evaluating
or appraising a service or product perceived to be valuable and beneficial. Patient
satisfaction is becoming a popular healthcare quality indicator in which 399
pharmaceutical services are an essential part. Measuring patient satisfaction is an
approach to identifying and meeting patient needs (Lang and Fullerton, 1992).
Providing better access to quality pharmacies is a way to improve patient satisfaction
with healthcare. In a competitive healthcare market, pharmacists should provide
competent services in a satisfactory manner to ensure service continuity (Gourley et al.,
2001). As healthcare moves toward an outcomes-based (e.g., patient satisfaction) model
outcomes are important components to patients who may wish to see healthcare staff
who produce better outcomes or greater patient satisfaction. As a result, pharmacists
demonstrating greater patient satisfaction may be at a competitive advantage (Larson
et al., 2002). Patient satisfaction questionnaires have grown substantially over the last
decades as tools to measure healthcare from the patients’ view point (Quintana et al.,
2006). However, patient satisfaction had little attention in public or government
sponsored settings and in developing countries (Abd al Kareem et al., 1996).
Hamad Medical Corporation’s (HMC) Hamad General Hospital (HGH) is a
community teaching hospital with 600 beds and Doha’s main non-profit healthcare
provider in Qatar State (HMC web site, www.hmc.org.qa). Qatar, located on the
Arabian Gulf’s western coast, is on a 160 km, 11,493 km2 peninsula. In April 2010, the
Qatar Statistics Authority estimated Qatar’s population at 1,670,389 (76.1 percent
males) including around 70 percent expatriates (www.qsa.gov.qa). The country’s
healthcare has advanced greatly, which resulted in remarkable growth in peoples”
health and well-being. According to WHO, the per capita healthcare expenditure in
2005 was the highest among the Eastern Mediterranean regions (www.who.int/topics/
statistics/en/). In 2009, healthcare expenditure, excluding the private sector, was 3.1
percent of gross domestic product (www.qsa.gov.qa).

Literature review
In pharmaceutical context, many patient-satisfaction definitions are ambiguous.
Schommer and Kucukarslan’s (1997) early work contributed greatly to conceptualizing
patient satisfaction within a pharmaceutical services framework. They classified
pharmaceutical services based on four patient-satisfaction conceptualizations:
performance evaluation (a service’s salient characteristics); disconfirmation of
expectations (gap between expectation and actual experience); an individual’s
emotional response to a service and resulting actions (affect-based assessment); an
individual’s evaluation of what is gained compared to what it cost (equity-based
assessment). According to Schommer (2003), satisfaction can be viewed as an extent to
which an individual is able to execute a desired behavior based on a service.
Furthermore, research defines satisfaction as “an individual’s judgment about the
extent to which a product or service provides a pleasurable level of
consumption-related fulfillment” (Schommer, 2003, p. 317). It is an emotional
reaction resulting from a product or service evaluation, which is followed by a
IJHCQA judgment that is made by an individual on how perfectly the service was provided,
26,5 which results in either pleasure or displeasure (Schommer, 2003). Similarly,
satisfaction is assumed to include a cognitive evaluation of an emotional response to
the system’s structure, process and outcome (Gourley et al., 2001). In Larson et al. (2002,
p. 44), patient satisfaction is viewed as his/her “personal evaluation of healthcare
services and providers”. Satisfaction determinants can be considered as the patient’s
400 preferences and expectations, whereas technical and interpersonal care elements can
be its components (Larson et al., 2002).
No single patient-satisfaction measure is applicable to all pharmacy situations
(Schommer and Kucukarslan, 1997). A theoretical base is required for satisfaction
evaluation in which the measure’s validity can be assessed. The measure must fit an
overall research process framework and the researcher must have an apparent scheme of
what is to be measured (Schommer and Kucukarslan, 1997). Patient satisfaction is the
function underlying satisfaction constructs, which include satisfaction with the primary
provider’s staff and waiting time (Aragon and Edwards, 2004). By understanding these
components, pharmacy managers can work on improving those areas, produce more
satisfied patients and develop the pharmacy’s viability (Lang and Fullerton, 1992).
Patient satisfaction is a valuable humanistic outcome that should be measured. It is
important for determining healthcare service sustainability (Panvelkar et al., 2009). It
also reflects how pharmacy services influence patients’ lives. However, owing to its
subjective nature, it is difficult to assess and it is not a structure or process measure
(Gourley et al., 2001). Additionally, satisfaction is more subjective than reports of care,
which provide objective evidence about what occur in an encounter (Larson et al., 2002).
Self-reporting questionnaires include: mail; face-to-face interviewing; phone interviewing
or most recently by internet response. Although the internet has become an efficient way
to distribute and complete questionnaires, it is not feasible in many countries. Further, it
may be used only by people who are familiar with the internet (Quintana et al., 2006).
There are some benefits from having a satisfied patient. Aharony and Strasser
(1993), for example, found that satisfied patients are more likely to continue using
healthcare services, maintain a relationship with a specific healthcare provider, comply
with treatments (including medications), participate in their own treatment and
cooperate with their healthcare providers. Increasingly, patient satisfaction is
becoming a popular health-service quality indicator (Schommer and Kucukarslan,
1997). There has been a considerable increase in the attention paid to measuring
patient satisfaction. Searching “patient satisfaction” in the MEDLINE database
resulted in 51,395 publications at December 2010; rising from 152 in 1980. Measuring
patient satisfaction in the Arabic countries was further explored by searching
MEDLINE, EBSCO, ProQuest and Google Scholar databases using “patient
satisfaction” and each Middle East Arabic country name as key words. We found 67
articles: 30 Saudi Arabian; 11 Kuwaiti; eight Egyptian; eight Jordanian; four Qatari;
two United Arab Emirates and Lebanese; one from Oman and Yemen. Some included
pharmacy service factors that affect patient satisfaction. However, no study focused on
measuring patient satisfaction with pharmaceutical services. There were four studies
measuring patient satisfaction with the healthcare services conducted in Qatar. The
Abd al Kareem et al. (1996) work used an established self-administered questionnaire
developed by Ware et al. (1983) to measure patient satisfaction with medical care using
seven constructs in two governmental out-patient healthcare facilities. Constructs
included: general satisfaction; service availability and convenience; facilities; Measuring
humaneness; service-quality and continuity. Similarly, McGivern (1999) evaluated patients’
patient satisfaction with healthcare quality in 18 patient areas. The remaining two
studies assessed patient satisfaction in primary healthcare facilities. Almujali et al. satisfaction
(2009) focused on physician consultation effect on patient satisfaction in a public health
center. Al-Emadi et al. (2009)explored all 21 primary healthcare centers in Qatar using
a questionnaire developed by Makhdoom et al. (1997) in Saudi Arabia, which covered 401
six primary healthcare service aspects. Extending the search to other Gulf Cooperation
Council (GCC) countries, we found 45 articles that discussed patient satisfaction. Most
(40 percent) dealt with patient satisfaction in primary healthcare services; 11 percent
with specialized medical services, 11 percent surgical procedures, 7 percent dental
services, 18 percent hospital services, 4 percent hospital process improvements and 9
percent miscellaneous services.
Recently, there has been an increasing trend to calibrate patient satisfaction
questionnaires in Middle Eastern regions. Many researchers used up-to-date healthcare
research methods to measure service quality perceptions. Mostafa (2005) worked on
patient satisfaction and expectation in eight Egyptian public and private hospitals
involving 332 patients. The author concludes that quantitative methods are valuable
for establishing relationships between variables, but are considered weak when
attempting to identify the reasons for those relationships. Additionally, patients may
have multifaceted beliefs that cannot be acquired in the questionnaire and combining
qualitative and quantitative methods may enhance the findings. Al-Eisa et al. (2005)
measured patient satisfaction with primary healthcare services in Kuwait using an
Arabic language questionnaire that included socio-demographic characteristics,
overall and specific satisfaction questions with different services aspects in the facility,
such as: buildings; reception; physician; nurse; pharmacy; laboratory and X-ray
services. Convenience samples were used and 1,250 patients were included. Pharmacy
generated the highest satisfaction. The Alaloola and Albedaiwi (2008) Riyadh study
highlighted healthcare quality’s importance as a patient satisfaction predictor by
capturing other effects such as patient status. It involved 1983 inpatient, outpatient and
emergency care patients using a locally developed patient satisfaction questionnaire.
The authors recommended that service standards in the areas in which patients were
significantly dissatisfied should be raised by involving senior leaders. Areas for which
patients were significantly satisfied, on the other hand, will need to be sustained or
even improved. Badri et al. (2009) used structural equation modeling to test causality
relationships between healthcare quality and patient satisfaction Their questionnaire
was completed by 244 adult patients discharged from the United Arab Emirates public
hospitals. The proposed model included five main constructs. Three represented
service quality (care, administration and information). The fourth was patient status
and the fifth patient satisfaction with care. The model captured attributes that
characterize healthcare quality in developing countries, which can be used to evaluate
healthcare practices from patient viewpoints. Anbori et al. (2010) performed a similar
study in Sana’a, Yemen. It included 819 respondents and measured their satisfaction
and loyalty to private hospitals. The authors concluded that improvements were
required to achieve high quality healthcare services in the private hospitals and to
increase loyalty among patients.
IJHCQA Motivation and problem statement
26,5 As patient satisfaction is a health service quality indicator, assessing patient
satisfaction with pharmacy services is essential for improving Qatari public hospital
facilities and performance. No study focused on measuring patient satisfaction with
pharmaceutical services in Qatar or other GCC countries. Additionally, assessment
tools for measuring patient satisfaction with pharmacy services have not been
402 developed so far in this region. Regarding these shortcomings and a clear gap in the
literature, our purpose is to develop a reliable patient satisfaction instrument for
Qatar’s pharmaceutical services. We expect this study to help increase pharmacy
service viability and to help manages achieve internationally accredited public
healthcare service status and continuous quality improvement in Qatar’s public
healthcare system. The Joint Commission International (JCI) accreditation process
began in 2005 at HMC. This study is vital, therefore, for continuously improving HMC
facilities and for maintaining its accreditation standing. Among the major challenges
in our study is developing a patient satisfaction questionnaire, which should be
practical, not too lengthy or complex to suit the limited time patients have in the
out-patient pharmacy area. Lengthy questionnaires are likely to be partially completed
by respondents (Schommer and Kucukarslan, 1997) and a questionnaire with missing
information owing to difficult or improper question placement could severely impact
data collection (Aragon and Edwards, 2004). Thus, the questionnaire must include the
most relevant pharmacy service aspects that managers seek to understand. We focus,
therefore, on developing a survey-based on patient satisfaction methods; identifying
the dominant factors affecting patient satisfaction; developing conceptual models that
investigate and validate the relationship among these dominant factors and their
impact on patient satisfaction; determine patient satisfaction among different
socio-demographic groups and suggest ways to improve patient satisfaction with
pharmaceutical services in the Qatari public healthcare system.

Research methodology
Survey design and data collection
The survey design process was started by searching the literature and the pooled results
went through a review process. They were examined and filtered to measure and
improve our pharmacy practice. Seven constructs and sub items were obtained from the
literature: pharmacist communication skills (Lang and Fullerton, 1992; Panvelkar et al.,
2009); service location (MacKeigan and Larson, 1989; Gourley et al., 2001; Kamei et al.,
2001; Larson et al., 2002; Panvelkar et al., 2009); patient education (Larson et al., 2002;
Panvelkar et al., 2009); service promptness (Gourley et al., 2001; Larson et al., 2002;
Panvelkar et al., 2009); staff empathy and attitude (Kamei et al., 2001; Larson et al., 2002);
medication supply (MacKeigan and Larson, 1989); and staff competence (Larson et al.,
2002). An expert panel (senior pharmacists and HGH quality assurance department
experts) reviewed the questionnaire’s appropriateness, simplicity and clarity. The panel
suggested modifications and recommended using the pilot study outcomes. Most
pharmacy users are Arabic speaking so the English-language questions were translated
into Arabic. Any discrepancies between the two versions were resolved by the expert
panel using the approach suggested in Al-Emadi et al. (2009). The final questionnaire
was based on a pilot study involving 30 patients visiting HGH pharmacies to determine
the most salient constructs (see the Appendix, Figure A1). They were asked to select
three constructs likely to be the most important for patient satisfaction. Five constructs Measuring
from seven constructs were finally selected (Table I), so we designed the questionnaire patients’
by taking these five constructs into consideration.
The items under each construct were positively phrased using a five-point satisfaction
Likert-scale ranging from strongly disagree (1) to strongly agree (5). There were 22
items/questions: service promptness (two); pharmacist attitude and empathy (five);
medication supply (five); pharmacy location (four); and teaching (six). An open-ended 403
question asked the respondent to suggest ways to improve HGH pharmacy services.
The questionnaire’s second part was about the respondent’s socio-demographic
characteristics, including nationality, gender, marital status, age, educational level,
income, medication intake and average visits to HGH pharmacies in the last year. The
questionnaire took approximately five minutes to complete. From 195 patient
satisfaction studies that we located, 80 percent used a new satisfaction assessment
instrument and 10 percent modified existing questionnaires. Most studies are
context-specific and authors felt that existing instruments included irrelevant and
excluded relevant or an unsuitable item and construct mix (Sitzia, 1999). The survey
was conducted between October and November, 2010, during the HGH out-patient
pharmacy working week (Sunday-Thursday).

Sampling
We included respondents 18 years or older, able to read and write either Arabic or
English, who had obtained at least one prescription from HGH out-patient clinic
pharmacies in the previous year, and willing to complete the questionnaire. Individuals
unable to answer the questionnaire owing to language barriers were excluded.
Respondents were asked to evaluate their experiences because studies show that the
person completing the questionnaire have an important effect on the results; that is,
negative satisfaction levels were recorded in those surveys answered by someone other
than the patient (Quintana et al., 2006). All respondents were HGH pharmacy users
including Qatari citizens and multi-ethnic expatriates.

Ethics
The research questionnaire was approved by the hospital medical research center
(Research proposal no. 10154/10, www.hmc.org.qa/mrc) and informed consent was
obtained from each respondent.

Constructs Frequencya %

Pharmacist communication skills 6 6.7

Pharmacy location 8 8.9
Medication teaching 16 17.8
Service promptness 22 24
Pharmacist attitude and empathy 18 20
Medication availability, quality and quantity 14 15.6
Pharmacist work skills and competence 6 6.7 Table I.
Pharmacy users’ most
Notes: n ¼ 30; aEach respondent was asked to nominate his/her three most important choices important constructs
IJHCQA Preliminary studies and exploratory analysis
26,5 A total of 220 completed forms from 400 distributed were returned – a 55 percent response
rate. Reasons for declining were poor sight (14), questionnaire too long (35), no time (42) or
not willing to participate (89). Non-respondents (180) included 81 males (45 percent).
Almost 190 (85 percent) said the questionnaire was appropriate and had included all the
pharmaceutical service elements; 6.4 percent did not comment. Most respondents were
404 female (59 percent), between 18-45 years (74 percent). Most were married (71 percent), had
obtained a university degree or higher (79 percent), with a monthly income between 5,001
to 20,000 Qatari Riyals (60 percent). Most were Arabic speaking (75 percent), middle
easterners and North African (73 percent). More than half (55 percent) took medication
daily. Average visit to any HGH pharmacies during the previous year was six (SD ¼ 4:6).
Average medication items were three (SD ¼ 1:7). Dispensing medication took around 34
minutes (SD ¼ 30). Table II describes the sample’s demographics and characteristics
(n ¼ 220). Missing items were replaced using the mean imputation method – estimating
the missing values from the mean value. We only used this missing-items method if
respondent has completed at least half the items in that construct (González et al., 2005).
Next, we did an exploratory analysis (Table III). Satisfaction levels determined by
the survey were compared among different groups and categories. The Shapiro-Wilk
normality test indicated that our data were not normally distributed; the
Mann-Whitney U and Kruskal Wallis non-parametric tests, therefore, were deployed.
Like other studies, males were more satisfied (Al-Eisa et al., 2005; Quintana et al., 2006;
Abd al Kareem et al., 1996). Married respondents were more satisfied than single users.
Almost equal satisfaction was noted regarding Arabic or English speakers, unlike the
Abd al Kareem et al. (1996) findings in which English speakers were more satisfied that
Arabic speaking patients. Nationality was not associated with significantly different
satisfaction levels. Al-Emadi et al. (2009) found that non-Qatari respondents were more
satisfied with healthcare services than Qatari patients. Similarly, Abd al Kareem et al.
(1996) found that non-Qatari nationals were consistently more satisfied than Qatari
nationals in governmental healthcare services. Respondents’ physical health status,
measured indirectly by medication usage, was included in our analysis. Our data
revealed that respondents with chronic disease requiring daily medication were more
satisfied than respondents who take mediations when needed (i.e., not having chronic
disease). Johnson et al. (1999) showed a significant positive relationship between
mental health status and satisfaction with pharmacy services. However, this
relationship was not found with the physical health status.
Satisfaction was significantly lower in the younger compared to elderly
respondents. This finding is consistent with previous studies (Al-Eisa et al., 2005;
González et al., 2005; Quintana et al., 2006), which could be explained by older
patients getting less demanding (Al-Emadi et al., 2009). Those with high school or
less education were more satisfied than university or higher education respondents
(Al-Eisa et al., 2005; Quintana et al., 2006). Generally, satisfaction rises as monthly
income increases, but the difference is statistically insignificant. There was a
statistically significant difference between ethnic group satisfaction scores (Table IV).

Factor analysis
Factor analysis (FA) is different from other statistical techniques since it is not a
confirmatory technique that tests hypotheses or determines whether one group is
 Measuring
Characteristics Number %
patients’
Gender satisfaction
Female 130 59

Marital status
Married 157 71 405
Single 59 27
No response 4 2
Age group (years)
18-25 24 11
26-35 98 45
36-45 40 18
46-55 32 15
Above 56 24 11
No response 2 1

Education
Primary/secondary 2 1
High school 40 18
University 122 56
Higher education 50 23
No response 18 8

Language
Arabic 165 75
English 55 25

Ethnicity
Middle Easterners 132 60
South Asian 36 16
North African 28 13
Southeast Asian 8 4
American/Canadian 4 2
European 2 1
No response 10 5

Monthly income (Qatari Riyals) a

Less than 5,000 47 21
5,001-10,000 59 27
10,001-20,000 72 33
Above 20,001 24 11
No response 18 8

Medication usage
Daily 121 55
When needed 93 42
No response 6 3
Average HGH Pharmacies visits last yeara 6 ^ 4.6
Average of service waiting time in the last visit (minutes)b 34 ^ 30
Average medication number in the last visit (items)b 3 ^ 1.7 Table II.
Demographics and
Notes: n ¼ 220; a1 US Dollar ¼ 3:65 Qatari Riyals; bMean^ ¼ SD characteristics
IJHCQA
Characteristics Number Mean SD p-value
26,5
Gender (n ¼ 220) , 0.001
Male 90 4.09 0.816
Female 130 3.49 1.086
Marital status (n ¼ 216) 0.023
406 Married 157 3.82 0.990
Single 59 3.46 1.088
Language (n ¼ 220) 0.763
Arabic 165 3.73 1.043
English 55 3.74 0.984
National (n ¼ 210) 0.086
Citizen 36 3.89 1.260
Noncitizen 174 3.71 0.984
Medication use (n ¼ 214) , 0.001
Table III. Daily 121 3.95 0.995
Satisfaction levels When needed 93 3.39 0.978

Characteristics Number Mean SD p-value

Age group (years) (n ¼ 218) , 0.001

18-25 24 3.583 1.283
26-35 98 3.423 0.882
36-45 40 3.800 1.224
46-55 32 4.063 0.759
Above 56 24 4.500 0.659
Educational level (n ¼ 214) 0.002
Primary/secondary 2 4.000 0.000
High school 40 4.200 0.758
University 122 3.656 1.089
Higher education 50 3.440 0.951
Ethnicity (n ¼ 210) 0.014
Middle Easterners 132 3.833 1.071
South Asian 36 3.707 1.109
North African 8 4.250 0.463
Southeast Asian 28 3.286 0.810
American/Canadian 2 3.000 0.000
European 4 3.500 0.577
Monthly income (Qatari Riyals) (n ¼ 202) 0.063
Less than 5,000 47 3.776 1.061
Between 5,001-10,000 59 3.847 0.979
Table IV. Between 10,001-20,000 72 3.417 1.071
Satisfaction levels Above 20,001 24 3.917 0.881

significantly different from another (Tabachnick and Fidell, 2007). It is a data reduction
procedure, which takes large variable-sets and looks to reduce or summarize them
using smaller factors or components. It does this by looking for clumps or groups
among the inter-correlations amid variables/items. This is an almost impossible task to
do by eye with anything more than a few variables. Factor analysis techniques have Measuring
several uses, which are used extensively by researchers who are developing and patients’
evaluating tests and scales. The scale (factor) developer starts with several individual
scales (items) and questions. By using FA techniques, they can refine and reduce these satisfaction
items to form smaller, coherent subscales, more commonly referred as factors. Factor
analysis can also be used to reduce several related variables to a more manageable
number prior to using them in other analyses such as multiple regression, multivariate 407
analysis of variance, structural equation modeling, etc. There are two main FA
approaches – exploratory and confirmatory. Exploratory FA is often used in the early
stages to gather information about exploring the interrelationships among variables.
Confirmatory FA, on the other hand, is a more complex and sophisticated technique
used later in the research process to test hypotheses concerning the structure
underlying variables. There are three main steps when conducting FA: assessing data
suitability for factor analysis; extracting factors; factor rotation and interpretation. All
22 items in our study were included in the FA. Two performance measures,
Kaiser-Meyer-Olkin (KMO) sampling adequacy and Bartlett’s sphericity test
(Tabachnick and Fidell (2007) were used to check data suitability. The KMO result
should range from 0 to 1 with 0.6 suggested as the minimum value for a good FA, and
Bartlett’s test should be significant. In our FA, the KMO value is 0.875 and also
Bartlett’s p value was , 0.001. Factor extraction, which involves determining the least
factors that can be used to best represent the interrelationships among the variables, is
done next. Although there are several approaches to factor extraction, the most
commonly used approach is principal component analysis (Tabachnick and Fidell,
2007). Kaiser’s criterion is used to determine the right factors. Using this rule, only
factors with an Eigenvalue of 1.0 or more are retained for investigation. Thus, five
components/factors were retained, which represent our construct number. The scree
plot in Figure 1 shows that Eigenvalues above 1 generate five factors. The variation
explained by five factors is about 73 percent of the total.
Once the factors have been determined, the next step is to interpret them by rotating
the factors. Rotation does not change the underlying solution; it presents loadings in a
manner that is easier to interpret. There are two approaches to factor rotation resulting in
either orthogonal (uncorrelated) or oblique (correlated) factor solutions. According to
Tabachnick and Fidell (2007), orthogonal rotation results in solutions that are easier to
interpret and to report; however, they require the researcher to assume that the
underlying constructs are not correlated, which may not be the case. We use the
orthogonal rotation approach. In the PASW (formerly SPSS) 18 software, the most
commonly used orthogonal approach (Varimax) is adapted. Table V presents the
Varimax rotation results. Additionally, the 22 items are listed in Table VI. All items
loaded well among factors representing the five constructs except item S5 and T6 (their
higher loading was in different factor). However, all factor loadings, ranging from
0.482-0.854 were significant (higher than 0.4, Larson et al., 2002), demonstrating the scale
items” convergent validity. All items in Table VI are distributed among the five factors.
Reliability (the scale’s internal consistency) was measured using Cronbach’s a
coefficient (Table V). Reliability coefficients above 0.9 are excellent (such as Attitude and
Teaching); those above 0.8 are very good (such as Promptness and Place) and values
above 0.7 are acceptable (such as Supply) (Heidegger et al., 2006). Cronbach’s a
coefficient ranged from 0.786-0.918 for the subscales and 0.941 for the total scale.
IJHCQA
26,5

408

Figure 1.
Scree plot

Sitzia (1999) reported 17 studies that measured patient satisfaction. The median a
coefficient value was 0.82 for the subscale and 0.93 for the total scale in another 15
studies. Content validity was assured by first involving pharmacy user views when we
selected the most relevant constructs that steer their satisfaction. Experts also selected
appropriate items that best measured each construct. Adding an open-ended question,
which asks for ways to improve the service, gave a dynamic aspect to the questionnaire
that helped to detect pharmacy user perceptions and create an on-going instrument that
tracks satisfaction with pharmacy services over time (Lang and Fullerton, 1992).

Causal model development using structural equation modeling

The structural equation modeling (SEM) technique is used to develop models. It is a
statistical method that takes a confirmatory (i.e., hypothesis testing) approach to
analyzing structural relationships bearing on some phenomenon (Byrne, 2001).
Typically, this theory represents “causal” processes that generate observations about
multiple variables (Bentler, 1989; Bollen, 1989). SEM conveys two important
procedures: causal processes under study are represented by structural (i.e., regression)
equations and that these structural relationships can be modeled pictorially for a
clearer conceptualization. The hypothesized model can then be tested statistically by
simultaneously analyzing the entire system variables to determine the extent to which
the model is consistent with the data for inferential purposes. If goodness-of-fit is
adequate then the model postulated relations between the variables are confirmed. If
goodness-of-fit is inadequate then the plausibility is rejected. SEM has several aspects
 Factor loadings
Reliability 1 2 3 4 5
Construct Items coefficientsa Items n Mean SD Prompt Attitude Supply Place Teach

Promptness 2 0.896 P1 214 3.46 1.295 0.597

P2 192 3.24 1.316 0.754
Attitude 5 0.918 A1 216 4.06 0.903 0.780
A2 210 3.93 0.941 0.756
A3 213 4.01 0.898 0.824
A4 218 3.87 0.980 0.772
A5 214 4.30 0.825 0.697
Supply 5 0.786 S1 218 4.23 0.674 0.759
S2 216 4.01 0.969 0.678
S3 218 4.28 0.745 0.482
S4 216 4.44 0.550 0.640
S5 216 4.49 0.618 0.521 0.577
Place 4 0.846 C1 218 4.13 0.951 0.812
C2 216 3.82 1.219 0.803
C3 218 4.07 0.986 0.686
C4 216 3.98 0.993 0.673
Teaching 6 0.915 T1 214 3.38 1.223 0.854
T2 213 3.55 1.193 0.778
T3 206 2.83 1.202 0.754
T4 210 2.95 1.248 0.634
T5 216 3.06 1.264 0.706
T6 202 2.78 1.290 0.624 0.336
Scale reliability 0.941
Note: aCronbach’s a coefficient, only factor-loadings above 0.3 are presented
Measuring

satisfaction

The five-construct scale

patients’

Table V.
409
IJHCQA
Construct Item Description
26,5
Promptness P1 Receive medications within a reasonable time
P2 Waiting time is acceptable considering the quantity of
prescription medication
Attitude A1 Pharmacist helped me to get the medications
410 A2 Pharmacist helped to solve any problem getting the medication
A3 Pharmacist answered my questions
A4 Pharmacist understood the medical case
A5 Pharmacists treat me with respect
Supply S1 Medication quantity was sufficient
S2 All my medications were available in the pharmacy
S3 Medication name was clear and easy to read
S4 Medication label/sticker instructions were clear
S5 Medication appearance and quality was good
Place C1 The pharmacy was easily found
C2 The waiting area was comfortable
C3 The pharmacy area was clean and acceptable
C4 The pharmacy working hours are suitable to me
Teaching T1 Pharmacist explained the reason for my medication
T2 Pharmacist told how to take the correct medication dose
T3 Pharmacist explained my medication’s possible side effects
T4 Pharmacist explained how to store my medication
T5 I had enough time with the pharmacist
T6 Pharmacy had a private place for teaching medication use
Table VI.
Construct descriptions Satisfaction SAT I am satisfied with HGH pharmaceutical services

that set it apart from older multivariate procedures. It takes a confirmatory rather than
an exploratory approach (Kutner et al., 2005). Moreover, by demanding that the
inter-variable relations are specified a priori, SEM lends itself well to data analysis for
inferential purposes. In contrast, most other multivariate procedures are essentially
descriptive (e.g., exploratory factor analysis), so that hypothesis testing is difficult, if
not impossible. Traditional multivariate procedures are incapable of either assessing
or correcting measurement error, while SEM explicitly estimates error variance
parameters. Alternative methods, such as linear regression (Kutner et al., 2005) assume
that error(s) is the exploratory (i.e., independent), and normally distributed with zero
mean. Applying methods, when there is error in the exploratory variables, is
tantamount to ignoring errors, which may lead to inaccuracies, especially when errors
are sizeable. Such mistakes are not encountered normally when SEM analyses are
used. Although exploratory data analyses methods based on observed measurements
only are reported, whereas those using SEM procedures can incorporate both
unobserved (latent) and observed variables. Lastly, there are no widely and easily
applied alternative methods for modeling multivariate relations, or for estimating point
and/or interval indirect effects. These important features are available using SEM.
Given, these highly desirable characteristics, SEM has become popular for
non-experimental research, when methods for testing theories are not well developed
and ethical considerations make experimental design infeasible (Bentler, 1989). Thus,
SEM can be used effectively to address numerous research problems involving Measuring
non-experimental research. patients’
In behavioral sciences, researchers are often interested in studying theoretical
constructs that cannot be observed directly. These abstract phenomena (latent variables or satisfaction
factors) are not observed directly; thus, a researcher must operationally define the latent
variable behaviorally, which s/he believe represents it. A latent or unobserved variable is
linked to one that is observable and thus measurable. Assessing behaviors constitutes 411
directly measuring an observed variable, albeit indirectly measuring an unobserved
variable. In SEM, these measurements are termed observed or manifest variables. They
indicate underlying constructs presumed to represent. Given this necessary bridging
process between observed variables and unobserved latent variables, it is important that
SEM requires researchers to be circumspect when selecting assessment measures. The
proposed SEM-based conceptual model is presented in Figure 2, which describes five
construct’s impact: service promptness; pharmacist attitude; medication supply; pharmacy
location; and teaching on patient satisfaction and their inter-relationships.
All five (exogenous) constructs were measured using observed (endogenous)
variables. Observed variables relating to each construct are measured using our
questionnaire data. Exogenous constructs and endogenous items used in the
questionnaire with their codes and description displayed in Table VI. In AMOS
(Analysis of MOment Structures) software, the variables send out arrowheads
denoting which variable it is predicting. Using AMOS, SEMs are schematically

Figure 2.
Proposed structural
equation model
IJHCQA portrayed using a four geometric symbols-a circle (or ellipse) configuration, a square
26,5 (or rectangle), a single-headed arrow and a double-headed arrow. By convention, circles
(or ellipses) represent unobserved latent factors. Squares (or rectangles) represent
observed variables, single-headed arrows represent one variable’s impact on another
and the double-headed arrows represent co-variances or correlations between variable
pairs. Our motive was to study the conceptual model presented in Figure 2.
412 Determining fitness is a basic task in SEM modeling. The data analyzed by SEM
programs include a matrix of estimated relationships between model variables.
Assessment of fit calculates how similar the predicted data are to matrices containing the
relationships in the model’s data. The AMOS model fitness was tested and the results are
summarized in Table VII. The x 2/df ratio should be less than five, which is used as an
appropriate measure of model fit. The NFI, NNFI, and CFI values should be on the higher
side of a 0-1 scale to indicate a model with good fit (Bentler, 1989). Additionally, for an
adequate model fitness, SRMR should be lower than 0.1 (Sivo et al., 2006) and the present
model fitness results show that SRMR ¼ 0:067 , 0:1, which meets another model
fitness criterion. By looking at these results, we might conclude that this model
reasonably satisfies the fitness criteria. As mentioned previously, the proposed model
presented in Figure 2 is implemented using AMOS, which tests the hypotheses listed in
Table VIII. The covariance relationships derived from the AMOS output are presented in
Table IX and the regression relationships are presented in Table X.

Hypothesis interpretations
Hypothesis test results were interpreted as follows:
H1-H4. Service promptness is positively correlated with pharmacist attitude;
medication supply, pharmacy location and teaching. Covariance
estimates for service promptness are statistically significant
(p , 0:001). Thus, H1-H4 are supported.
H5-H7. Pharmacist attitude is positively correlated with medication supply;
pharmacy location and medication teaching. The covariance estimates
for pharmacist attitude in Table IX are statistically significant
(p , 0:001). Therefore, H5-H7 are supported.
H8 and H9. Medication supply is positively correlated with pharmacy location and
teaching. Covariance estimates for medication supply are also
statistically significant for these two hypothesis (p , 0:001). H8 and
H9, therefore, are supported.

Fitness indices Values

2
x /df 3.74
Goodness of fit index (GFI) 0.77
Adjusted GFI 0.71
Normed fit index (NFI) 0.82
Table VII. Non normalized fit index (NNFI) 0.82
Structural model Comparative fit index (CFI) 0.85
goodness of fit indices Standardized root mean square residual (SRMR) 0.067
 Measuring
Hypothesis Label
patients’
Service promptness influences pharmacist attitude H1 satisfaction
Service promptness is related to medication supply H2
Pharmacy location influences service promptness H3
Service promptness is related to teaching H4
Pharmacist attitude is related to the medication supply H5 413
Pharmacist attitude is related to pharmacy location H6
Pharmacist attitude influences teaching H7
Pharmacy location influences the medication supply H8
Medication supply is related to teaching H9
Pharmacy location influences teaching H10
Service promptness influences patient satisfaction H11
Pharmacist attitude influences patient satisfaction H12
Medication supply influences patient satisfaction H13
Pharmacy location influences patient satisfaction H14 Table VIII.
Teaching influences patient satisfaction H15 Hypotheses

Relationship Estimate Standard error t p value Hypothesis Result

Promptness $ Attitude 0.35 0.057 6.16 , 0.001 H1 Supported

Promptness $ Supply 0.24 0.043 5.56 , 0.001 H2 Supported
Promptness $ Place 0.37 0.066 5.63 , 0.001 H3 Supported
Promptness $ Teaching 0.46 0.08 5.77 , 0.001 H4 Supported
Attitude $ Place 0.22 0.039 5.70 , 0.001 H5 Supported
Attitude $ Supply 0.17 0.028 6.18 , 0.001 H6 Supported
Attitude $ Teaching 0.27 0.047 5.74 , 0.001 H7 Supported Table IX.
Supply $ Place 0.21 0.034 6.12 , 0.001 H8 Supported Covariance estimates
Supply $ Teaching 0.23 0.039 5.83 , 0.001 H9 Supported among the exogenous
Place $ Teaching 0.32 0.057 5.57 , 0.001 H10 Supported variables

H10. Pharmacy location is positively correlated with teaching. Covariance

estimates for service promptness are statistically significant
(p , 0:001), therefore the hypotheses is supported.
H11. Service promptness influences general satisfaction. From Table X, the
regression weight estimate for service promptness has a statistically
significant (p , 0:001) positive impact on patient satisfaction. Thus,
this hypothesis is supported. This finding is consistent with earlier

Relationship Estimate Standard error t p value Hypothesis Result

SAT ˆ Promptness 0.34 0.07 4.83 , 0.001 H11 Supported

SAT ˆ Attitude 0.33 0.126 2.57 0.01 H12 Supported
SAT ˆ Supply 0.06 0.133 0.42 0.672 H13 Not supported Table X.
SAT ˆ Place 0.38 0.111 3.38 , 0.001 H14 Supported Regression weight
SAT ˆ Teaching 0.28 0.093 2.94 0.003 H15 Supported estimates
IJHCQA studies such as prescription filling time, which has a negative effect on
26,5 patient satisfaction (Panvelkar et al., 2009).
H12. Pharmacist attitude has a positive impact on patient satisfaction
(Table X). Using AMOS output, the relationship is positive and
statistically significant (p , 0:001) and thus, hypothesis 12 is
supported, which is consistent with other studies (Panvelkar et al.,
414 2009; Kamei et al., 2001).
H13. Medication supply influences patient satisfaction. The regression
weight estimate for medication supply in Table X shows an
insignificant impact on patient satisfaction (p ¼ 0:672 . 0:05), so this
hypothesis is not supported. Pharmacy services are now extended to
more than medication supply and patients are now looking to other
factors when they visit HGH pharmacies. Gourley et al. (2001) also
found pharmacy service foci have expanded beyond medication
dispensing to a more specialized pharmaceutical care. However,
MacKeigan and Larson (1989) found a positive relationship between
patient satisfaction and medication supply.
H14. Pharmacy location influences patient satisfaction. Table X shows that
pharmacy location is statistically significant (p , 0:001). This
hypothesis, therefore, is supported. Pharmacy location, facilities,
convenience and working hours were also found to influence patient
satisfaction positively in the Panvelkar et al. (2009) and Kamei et al.
(2001) studies.
H15. Teaching influences patient satisfaction. The regression weight
estimate for teaching reported in Table X is statistically significant
(p ¼ 0:003); this hypothesis, therefore, is supported and consistent
with earlier studies (Larson et al., 2002; Panvelkar et al., 2009). Patients
at HGH value healthcare staff contributions to help them understand
medication benefits and risks (Khudair and Hanssens, 2010).

Conclusions and recommendations

Our survey and analyses have several applications; for example, if pharmacy staff
modify or implement new dispensing processes then our questionnaire can be used as a
“before and after” patient-satisfaction measure. A second use is a quality assurance
tool for detecting weaknesses and monitoring improvements. For health professionals
and authorities, patient satisfaction can be considered a valuable indicator for defining
better strategies, management procedures, training priorities and resource allocation
options (Fitzpatrick, 1991). Our results indicate that patient perceptions about how
pharmacy staff meet their expectations can be measured. A satisfied patient is
expected to return for follow-up care, cooperate with the caregiver and adhere to
regimens. Good quality care is suggested by high satisfaction ratings (Briesacher and
Corey, 1997). Our results, therefore, are vital for public and private pharmacy staff to
help them improve Qatari services.
Several social-psychological characteristics are inherited in patient satisfaction
measurement processes, which need to be taken into account and controlled wherever
possible (Heidegger et al., 2006). Those biases should be maintained to the lowest possible Measuring
effect. Social desirability response bias may mean that patients report greater satisfaction patients’
than they actually feel because they believe positive comments are more acceptable
(Heidegger et al., 2006). Ingratiating response bias can lead to high satisfaction ratings. satisfaction
Patient satisfaction survey timing may influence satisfaction ratings (Stevens et al., 2006).
Response rates in the literature range from 66 percent to 77 percent, depending on data
collection procedures (Sitzia and Wood, 1998; Panvelkar et al., 2009) and non-responders 415
were not contacted to clarify reasons for non-response. Falling response rates can lead to
non-response bias and being aware is important, as some evidence suggests that satisfied
patients are more likely to reply (Stevens et al., 2006). Selection in most studies, usually
performed by the pharmacist provider, leads to selection bias, which can occur owing to
patient selection processes (i.e., convenience sample). Social desirability may emerge as an
issue as patients habitually tend to rate responses to go with what they think the provider
would find pleasing (Heidegger et al., 2006). Finally, the time between service experience
and evaluation may lead to recall bias (Panvelkar et al., 2009).
Our study is among the first to explore patient satisfaction in the HMC
pharmaceutical services and it establishes patient satisfaction measurement criteria
offered in HGH, HMC’s largest member. Our results show that our questionnaire is a
reliable tool for measuring outpatient satisfaction with pharmacy services. The survey
captured the important information about patient satisfaction and the factors that
influence it. Our study is the first to calibrate patient satisfaction resulting from
pharmacy service at a major public hospital in Qatar. It provides a quantitative
measure of pharmacy performance and factors that significantly affect patient
satisfaction. It uses statistical tools to identify avenues through which patient
satisfaction could be improved. We designed a questionnaire containing 22 items that
focused on the five most dominant factors: service promptness; attitude; supply;
location; education and respondent demographic. Questionnaire items were grouped
into five factors using exploratory factor analysis. In an exploratory study, statistical
evidence shows that patient satisfaction was significantly different among
socio-demographic groups such as gender, marital status, health status, age,
educational level and ethnicity influence satisfaction. We used SEM to study five
dominant factors’ impact on patient satisfaction. The SEM model also establishes
causality tests to study the correlation among factors. It establishes statistical evidence
that patient satisfaction is positively influenced by service promptness, pharmacist
attitude, medication counseling, physical location and comfort in the pharmacy
waiting area. However, medication supply did not influence patient satisfaction.
Results derived from these studies should be constantly revisited and used by
pharmacy managers for continuous quality improvement (CQI) purposes. We
recommend that pharmacy managers use our findings to allocate resources for
improving patient satisfaction by looking into the dominant factors. Additionally,
healthcare staff need to be more sensitive about improving patient satisfaction. We
recommend that future research extends the study to the Qatari public and private
healthcare providers. Another logical extension would be to conduct similar studies
across different GCC and Middle-Eastern countries. Improving respondent
participation means developing dynamic and ongoing assessment for CQI purposes.
Using electronic surveys that are completed by patients in pharmacy waiting areas or
via an internet are likely to improve the response rate and strengthen the findings.
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418 Appendix

Figure A1.
Patient satisfaction
questionnaire
 Measuring
patients’
satisfaction

419

Figure A1.

Corresponding author
Syed Asif Raza can be contacted at: syedar@qu.edu.qa

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