Level of satisfaction of clients of public pharmacies dispensing high-cost drugs in Espírito Santo, Brazil

The aim of this study was to evaluate the level of satisfaction of pharmaceutical services and to determine the socioeconomic profile of public pharmacy clients. This is a cross-sectional observational study using a quantitative approach. The sample was calculated from the monthly number of patients seen in pharmacies and was stratified for each pharmacy. Data were analysed using SPSS 11.5 software and by observing the simple relative frequencies for qualitative variables. For the quantitative variables, the analysis of variance (ANOVA) and post-hoc Fisher tests were performed. Data are expressed as mean ± standard deviation (SD). The results show that, in general, patients at “Farmácias cidadãs” are satisfied with the services. However, when stratified, we found that the greatest satisfaction was related only to structural and organizational aspects, while the pharmaceutical services are unsatisfactory. When relating satisfaction to the socioeconomic characteristics, a difference between waiting time (39.07 ± 19.53), attendance by pharmacist (8.91 ± 5.14) and education was observed. It is concluded that users are satisfied with the services of state “Farmácias cidadãs” of Espírito Santo, but there should be improvements in relation to pharmaceutical services and the interpersonal relationships between health professionals and users of the public health system in Brazil.


INTRODUCTION
The level of satisfaction reflects the quality of healthcare offered, as well as the preferences and expectations of users in relation to the health system (Halal et al., 1994;Kucukarlan, Schommer, 2002;Larson, Roves, MacKeigan, 2002).Therefore, it has become increasingly important to evaluate the level of user satisfaction in relation to services provided by health professionals, which could be used as a quality indicator to improve these services (Halal et al., 1994;Kucukarlan, Schommer, 2002;Larson, Roves, MacKeigan, 2002;Marin, 2003).
The user satisfaction can be considered a connection between users and professionals when aiming to correct or improve the work of the health professionals (Oliveira, Guirardello, 2006).Furthermore, the user satisfaction data may improve the work of managers of the public health system (Espiridião, Trad, 2005;Benazzi, Figueiredo, Banassi, 2010).Thus, the level of satisfaction of users of a health service could be converted into indicators of quality to promote an improvement in this service.
Recent studies show that users become more satisfied with the services of a pharmacy when the pharmacist interacts with them and gives clear explanations about the medications (Al-Arifi, 2012;Alturki, Khan, 2013).Alturki and Khan (2013) found that 61.2% of users expressed dissatisfaction, as they did not understand the information provided by the pharmacist.In addition, Catic, Jusufovic and Tabakovic (2013) showed that the features most appreciated by users about the pharmacist were the explanations and providing appropriate responses (79.1%), followed by consultation offered by these professionals who clearly informed the patient about the drugs proposed by the physician.In the present study, we evaluated the relationship between the user and the pharmaceutical services for potential improvements at the level of individual pharmaceutical care.This was already proven by the Association of Pharmacists in Bosnia and Herzegovina (Catic, Jusufovic, Tabakovic, 2013).
The Brazilian Unified Health System is recognized as one of the most extensive and comprehensive public health systems in the world.It ranges from simple queries to highly complex procedures, such as transplants (Portal da Saúde, 2013) and there is a law that ensure free universal access (Brasil, 1990).Health services in the Unified Health System aim to protect public health.Therefore, this law regarding pharmaceutical services has become an integral part of the system (Brasil, 1990), because drugs are considered the main instrument for treating diseases, and thus have a substantial impact on public health (Espírito Santo, 2012).
In 2004, by resolution of the National Health Council No. 338 of May 6, 2004, the Ministry of Health established the National Pharmaceutical Assistance Policy to ensure access to medicines, their rational use and to qualify the services provided by pharmaceutical sectors in Brazil (Brasil, 2004).In 2007, the Pharmaceutical Services (PS) was divided into three components: basic, strategic and specialized components, the latter regulated by decree GM/MS No. 2981 of November 26, 2009, in order to facilitate access to high cost drugs or for rare diseases (Brasil, 2010).In the state of Espírito Santo, these medications are dispensed by "Farmácias cidadãs".
The "Farmácias cidadãs" of the state of Espírito Santo were imposed by Decree No. 1956-R 7 in 2007, which promotes drug dispensing, i.e. high-cost drugs that are of great importance to the users are provided in the entire state (Espírito Santo, 2007).All over Espirito Santo, there are nine "Farmácias cidadãs" (Espírito Santo, 2012).These pharmacies have a whole aspect of internal environment aiming to provide proper care and there are drugs available for treatment of 335 different diseases (Espírito Santo, 2013).The entire project is geared towards the humanization of pharmaceutical care, in addition to providing specialized pharmacists and qualified services.
However, no study has been conducted to verify whether the "Farmácias cidadãs" fulfil the requirements for which they were founded.Therefore, assuming that the level of user satisfaction is an important tool for evaluation of health services, this study aimed to evaluate the satisfaction of citizens that attended "Farmácias cidadãs" and its relationship with certain selected socioeconomic data.

Study design and sampling
This is a cross-sectional observational study using a quantitative approach, in which data were collected using a structured questionnaire.Moreover, socioeconomic data were evaluated using variables, including age, gender, median household income, education, and monthly family income.Other estimated variables, including waiting time, attendance time by the pharmacist, source of the prescription and the drug-dispensing service, were also assessed to evaluate the satisfaction of the users of the "Farmácias cidadãs".
The sample size was calculated taking into account the number of monthly visits (23,167) in 2010 in the nine surveyed pharmacies (Espírito Santo, 2012).Then, through EpiInfo version 7.0 and with a confidence level of 95% and a margin of error of 5%, the calculated sample size was 376 individuals.Considering a possible loss of 20%, the amount of participants was increased to 451 users (Benazzi, Figueiredo, Banassi, 2010).Subsequently, data were stratified for pharmacies.A sample of each pharmacy was stratified based on the local population of each municipality.
The way the present research was carried out can be considered biased, as the recruitment of patients was not randomized because patients participated only when they agreed to take part.

Sample Selection
Convenience sampling was adopted for patients and caregivers who sought care in "Farmácias cidadãs" of their respective municipality.Users or carers who attended a "Farmácia cidadã", residents in the state of Espírito Santo, aged at least 18 years and who could respond to the proposed questionnaire were included.Patients were addressed upon arrival at the pharmacy and informed about the research.Those who agreed to participate received a questionnaire and the instructions.At the end of the documentation, the participants returned the questionnaires and consent forms.

Local service evaluation
"Farmácias cidadãs" of Espírito Santo are located in nine different cities.Each pharmacy was visited in the first week of a given month in order to assess the highest number of users.The users in the pharmacies were invited to participate in the study.After accepting the invitation and signing the consent form, the questionnaire was presented to users and/or their guardians.The same researcher distributed the questionnaires in all pharmacies.To analyse the variables of waiting time and attendance by the pharmacist, patients were asked about the time of arrival and attendance.

Analysis of the level of satisfaction
To assess the satisfaction of users, a structured questionnaire was applied, i.e. the "Satisfaction Questionnaire with Pharmacy Services", which was designed and implemented primarily by Kucukarslan and Schommer (2002) and adapted, translated and validated for the Portuguese language by Correr et al. (2009).
This questionnaire assessed both the services provided by the pharmacist and the pharmacy services in general.The intensity scale had a five-point Likert-type scale for each question (total of 20), where the lower number represents the "very bad" option and the higher number the "very good" option.The respondents then chose the answer that best represented their opinion.The level of satisfaction is expressed as the mean ± standard deviation (SD) for each question and the questionnaire as a whole, both in each pharmacy and as the sum of all pharmacies.The users were also classified as satisfied (score equal to or greater than 4) and not satisfied (score less than 4).

Ethical criteria
The study was approved by the Ethics and Human Research Board of the University Vila Velha (UVV-CEP), process number 46,148 in June 2012.

Statistical analysis
Statistical analyses were performed using the Statistical Package for Social Sciences (SPSS 17.0).Satisfaction data, standby time and attendance were expressed as mean ± standard deviation (SD).The Kolmogorov-Smirnov normality test was used to evaluate the continuous variables (Table I).To evaluate the distribution of the data, descriptive statistics were applied, and analysis of variance (ANOVA) to detect differences between the means of questions and questionnaires, followed by Tukey's test.The Chi-square test was used to compare frequencies of socioeconomic variables with the percentage of satisfied and dissatisfied users.When the correlation of the variables had less than five members, the Fisher test was used to compare frequencies.The level of significance for the tests was p < 0.05.

Socioeconomic data
Of all participants, 408 met the inclusion criteria.The most frequent reason for exclusion was a missing signature on the informed consent or incorrect completion of the questionnaire of pharmaceutical services.Of the users, 250 (62%) were female and 158 patients (38%) male.Several studies have shown that healthcare is more important for women than men, which may explain the higher frequency of women (Mendoza-Sassi, Beria, 2001;Ribeiro et al., 2006;Benazzi, Figueiredo, Banassi, 2010;Catic, Jusufovic, Tabakovic, 2013).
The majority of former studies showed a predominance of users and/or carers with low education (Castellano et al., 1999;Colossi, 2004).However, as in the present work, there are reports of a prevalence of individuals with higher-level education (Herc, Berezovsky, 2006;Benazzi, Figueiredo, Banassi, 2010).These data show a change in the profile of patients that attended public pharmacies, what had been considered only for the disadvantaged clients, according to Benazzi, Figueiredo and Banassi (2010).
Table II shows the average waiting times of the users (39.07 ± 19.53 min) and the time they were effectively attended to by the pharmacist (8.91 ± 5.14 min).Three pharmacies (A, F and I) had waiting times above the average (p < 0.01).
Of all users surveyed, 385 (95.5%) received medications.The other users had no medication dispensed mainly due to incomplete documentation (66.7%).In relation to the prescriptions, 225 (56%) were from the Public Health System and 44% were from Privates Health Systems.

Satisfaction
The overall satisfaction level was 3.80 ± 0.3, indicating a medium level of satisfaction.The general satisfaction data are shown in Figure 1, and the scores for each question of the satisfaction questionnaire are shown in Table II.
The results show that most users were satisfied with the services provided in the "Farmácias cidadãs".Cerdá et al. (2005) described that there is an interaction between user satisfaction and their health condition.However, according to Benazzi, Figueiredo and Banassi (2010) a satisfaction survey is a complex issue because of the use of the client opinion as a tool of the study to evaluate a health service.Cerdá et al. (2005) stated that variables related to the dispensing and organization of the health sector could also help to improve customer satisfaction.
Indeed, despite an overall score that can be considered good, when analysing the questionnaire items separately, it can be observed that the lowest scores were related to aspects involved with the pharmacist (items 7, 8, 9, 10, 11, 12, 15, 18 and 19 of the questionnaire, Table III), i.e. related to the pharmaceutical management of the therapy.This is in agreement with data regarding the USA (Larson, Roves, MacKeigan, 2002) and Brazil (Correr et al., 2009).In the work of Alturki and Khan ( 2013), users  were satisfied with the service provided by the pharmacist, but often did not understand the information that was provided to them.Andrade et al. (2009) demonstrated that the satisfaction level with the pharmaceutical services was improved with the presence of specialized pharmaceutical care services.Thus, the results of this study indicate that the organization of the pharmacy, physical space and the professionalism of the staff may have been relevant to the overall average factors.
Additionally, one can infer the need for training of the pharmacists in clinical care so that the user satisfaction evaluation can achieve a level of excellence.

Satisfaction and socioeconomic variables
The results expressed in scatter plots that relate the waiting time to the satisfaction demonstrate that the higher the waiting time, the lower the satisfaction of the clients (Figure 2).The longer the clients were attended to by the pharmacists, the less they were satisfied (Figure 3).Cerdá et al. (2005) also found that the longer the waiting time of the user, the lower the satisfaction, even with the public health services, corresponding to the lowest scores of their work.
There was a weak negative correlation between waiting time and user satisfaction (Figure 2).These data indicate that these parameters may not be the most important factor in determining the level of satisfaction.Likewise, the weak negative correlation between attending time and user satisfaction could be explained by the high variation in results between different pharmacies.
Moreover, when data were categorized, a significant correlation between satisfaction and waiting time was observed (Table II).The same occurred with the attending time by the pharmacist.Clients that were attended to for more than 15 minutes were less satisfied.Although it seems paradoxical that the time with the pharmacist should reduce the level of satisfaction, it is possible that this time is being interpreted only as an additional waiting time for obtaining medication, since the dispensation may not be carried out with proper patient education.
The general satisfaction data related to the variables of the questionnaire are shown in Table III.It can also be observed that satisfaction is also related to higher education.This may be related to better understanding about drugs and/or better access to information other than the pharmacist, such as physicians, thus improving treatment adherence (Dewulf et al., 2006).
Variables such as family income may directly affect user satisfaction (Silva, Muccioli, Belfort Jr., 2004).Previous studies have shown that satisfaction surveys of users of the Unified Health System mostly involve lowincome users who cannot afford private health insurance (Silva, Muccioli, Belfort Jr., 2004;Gomes et al., 2008).However, this factor was not important in determining the level of satisfaction in this study, given that the percentage of satisfied users did not change significantly with increasing income (Table IV).This fact may be related to the differentiated service that is offered by "Farmácias cidadãs" in which the user, even with a better financial situation, cannot afford the high cost of drugs.
For further studies, it would be interesting to assess  the patient's understanding of the pharmacist's role in the Public Health System because it was one of the limitations faced in the initial interview.Many patients do not understand the role of this professional in the public system, a fact that may have caused difficulties in answering the questionnaire.
The data gathered for the present study demonstrate the importance of the pharmacist in the health system and can be extrapolated to other regions of the country where the distribution system and organization are similar to Espírito Santo.

CONCLUSION
We conclude that the model of pharmaceutical services provided in "Farmácias cidadãs" in the state of Espírito Santo is satisfactory for users, especially in regard to structural and organizational issues.There should be an improvement in the pharmaceutical services provided by the pharmacists.This would improve the rational use of medicines, thus avoiding negative clinical outcomes associated with them, as well as contributing to achieving a better health service.

FIGURE 3 -
FIGURE 3 -Scatter plot of the time with the pharmacist (min) vs. user satisfaction of the "Farmácias cidadãs" in Espírito Santo (p < 0.001).

FIGURE 2 -
FIGURE 2 -Scatter plot of the waiting time (min) associated with the satisfaction level of the users of the "Farmácias cidadãs" in Espírito Santo (p < 0.001).

TABLE III -
Mean of overall satisfaction level for each item of the Satisfaction Questionnaire with Pharmacy Services

TABLE IV -
General correlation between socioeconomic variables, attendance data and dispensing of medications with the satisfaction of the users of the "Farmácias cidadãs"