Patient Satisfaction and Perception of Community Pharmacy Services in Sidama, Ethiopia: A Mixed-Methods Study Using an Adapted SERVQUAL Framework

Patient Satisfaction and Perception of Community Pharmacy Services in Sidama, Ethiopia: A Mixed-Methods Study Using an Adapted SERVQUAL Framework | medRxiv /* */ /* */ <!-- <!-- /*! * yepnope1.5.4 * (c) WTFPL, GPLv2 */ (function(a,b,c){function d(a){return"[object Function]"==o.call(a)}function e(a){return"string"==typeof a}function f(){}function g(a){return!a||"loaded"==a||"complete"==a||"uninitialized"==a}function h(){var a=p.shift();q=1,a?a.t?m(function(){("c"==a.t?B.injectCss:B.injectJs)(a.s,0,a.a,a.x,a.e,1)},0):(a(),h()):q=0}function i(a,c,d,e,f,i,j){function k(b){if(!o&&g(l.readyState)&&(u.r=o=1,!q&&h(),l.onload=l.onreadystatechange=null,b)){"img"!=a&&m(function(){t.removeChild(l)},50);for(var d in y[c])y[c].hasOwnProperty(d)&&y[c][d].onload()}}var j=j||B.errorTimeout,l=b.createElement(a),o=0,r=0,u={t:d,s:c,e:f,a:i,x:j};1===y[c]&&(r=1,y[c]=[]),"object"==a?l.data=c:(l.src=c,l.type=a),l.width=l.height="0",l.onerror=l.onload=l.onreadystatechange=function(){k.call(this,r)},p.splice(e,0,u),"img"!=a&&(r||2===y[c]?(t.insertBefore(l,s?null:n),m(k,j)):y[c].push(l))}function j(a,b,c,d,f){return q=0,b=b||"j",e(a)?i("c"==b?v:u,a,b,this.i++,c,d,f):(p.splice(this.i++,0,a),1==p.length&&h()),this}function k(){var a=B;return a.loader={load:j,i:0},a}var l=b.documentElement,m=a.setTimeout,n=b.getElementsByTagName("script")[0],o={}.toString,p=[],q=0,r="MozAppearance"in l.style,s=r&&!!b.createRange().compareNode,t=s?l:n.parentNode,l=a.opera&&"[object Opera]"==o.call(a.opera),l=!!b.attachEvent&&!l,u=r?"object":l?"script":"img",v=l?"script":u,w=Array.isArray||function(a){return"[object Array]"==o.call(a)},x=[],y={},z={timeout:function(a,b){return b.length&&(a.timeout=b[0]),a}},A,B;B=function(a){function b(a){var a=a.split("!"),b=x.length,c=a.pop(),d=a.length,c={url:c,origUrl:c,prefixes:a},e,f,g;for(f=0;f<d;f++)g=a[f].split("="),(e=z[g.shift()])&&(c=e(c,g));for(f=0;f<b;f++)c=x[f](c);return c}function g(a,e,f,g,h){var i=b(a),j=i.autoCallback;i.url.split(".").pop().split("?").shift(),i.bypass||(e&&(e=d(e)?e:e[a]||e[g]||e[a.split("/").pop().split("?")[0]]),i.instead?i.instead(a,e,f,g,h):(y[i.url]?i.noexec=!0:y[i.url]=1,f.load(i.url,i.forceCSS||!i.forceJS&&"css"==i.url.split(".").pop().split("?").shift()?"c":c,i.noexec,i.attrs,i.timeout),(d(e)||d(j))&&f.load(function(){k(),e&&e(i.origUrl,h,g),j&&j(i.origUrl,h,g),y[i.url]=2})))}function h(a,b){function c(a,c){if(a){if(e(a))c||(j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}),g(a,j,b,0,h);else if(Object(a)===a)for(n in m=function(){var b=0,c;for(c in a)a.hasOwnProperty(c)&&b++;return b}(),a)a.hasOwnProperty(n)&&(!c&&!--m&&(d(j)?j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}:j[n]=function(a){return function(){var b=[].slice.call(arguments);a&&a.apply(this,b),l()}}(k[n])),g(a[n],j,b,n,h))}else!c&&l()}var h=!!a.test,i=a.load||a.both,j=a.callback||f,k=j,l=a.complete||f,m,n;c(h?a.yep:a.nope,!!i),i&&c(i)}var i,j,l=this.yepnope.loader;if(e(a))g(a,0,l,0);else if(w(a))for(i=0;i (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0];var j=d.createElement(s);var dl=l!='dataLayer'?'&l='+l:'';j.src='//www.googletagmanager.com/gtm.js?id='+i+dl;j.type='text/javascript';j.async=true;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-P4HH5NV'); Skip to main content Home About Submit ALERTS / RSS Search for this keyword Advanced Search Patient Satisfaction and Perception of Community Pharmacy Services in Sidama, Ethiopia: A Mixed-Methods Study Using an Adapted SERVQUAL Framework View ORCID Profile Daniel Mengistu Kejela , Zerai Hagos doi: https://doi.org/10.1101/2025.08.10.25333113 Daniel Mengistu Kejela 1 Department of Community Development, Leadstar Christian University College , Addis Ababa, Ethiopia Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Daniel Mengistu Kejela For correspondence: danielmengistu33{at}gmail.com Zerai Hagos 1 Department of Community Development, Leadstar Christian University College , Addis Ababa, Ethiopia Find this author on Google Scholar Find this author on PubMed Search for this author on this site Abstract Full Text Info/History Metrics Data/Code Preview PDF Abstract Background Community pharmacies are vital for healthcare access in Ethiopia’s Sidama Region, yet patient satisfaction and perceptions of service quality remain understudied. This study evaluates patient satisfaction with pharmaceutical services in urban (Hawassa) and rural (Bensa, Aroresa) settings using a mixed-methods approach and an adapted SERVQUAL framework, incorporating six dimensions: reliability, responsiveness, assurance, empathy, tangibles, and accessibility. Methods A cross-sectional survey of 400 patients and in-depth interviews with 20 participants were conducted in 2025. Quantitative data were analyzed using descriptive statistics and regression analysis, while qualitative data underwent thematic analysis. Results Urban patients reported higher satisfaction (M = 4.31, SD = 0.74) than rural patients (M = 3.12, SD = 0.88). Reliability (β = 0.326, p < 0.001) and accessibility (β = 0.244, p < 0.001) were significant predictors of satisfaction. Qualitative findings highlighted challenges such as medicine stockouts, language barriers, and gender-based discomfort, particularly in rural areas. A Sidama-specific SERVQUAL model was developed, emphasizing culturally and linguistically sensitive services. Conclusions The study reveals urban-rural disparities in pharmacy service satisfaction and underscores the need for targeted interventions to enhance medicine availability, cultural sensitivity, and accessibility in Sidama. The adapted SERVQUAL framework provides a robust tool for evaluating pharmacy services in similar low-resource settings. Background Community pharmacies serve as critical healthcare access points in resource-limited settings, particularly in sub-Saharan Africa, where physician shortages are prevalent [ 1 ]. In Ethiopia’s Sidama Region, 62% of residents rely on community pharmacies as their primary source of medical care [ 2 ]. However, systemic challenges, including medicine stockouts, limited infrastructure, and communication barriers, undermine service quality, particularly in rural areas [ 3 ]. The World Health Organization (WHO) emphasizes patient satisfaction as a key indicator of health system performance and patient-centered care [ 4 ]. Ethiopia has implemented reforms like the Auditable Pharmaceutical Transactions and Services (APTS) system to improve pharmacy efficiency [ 5 ]. Despite these efforts, disparities persist between urban and rural settings, with rural pharmacies facing frequent stockouts and linguistic barriers [ 6 ]. The SERVQUAL model, widely used to assess service quality, has been adapted in low- and middle-income countries (LMICs) to include accessibility and cultural sensitivity [ 7 ]. However, its application in Ethiopia, particularly in Sidama, remains limited. This study assesses patient satisfaction and perceptions of community pharmacy services in Sidama using an adapted SERVQUAL framework, incorporating accessibility as a sixth dimension. By combining quantitative and qualitative methods, it aims to provide actionable insights for improving pharmaceutical care in Ethiopia. Conceptual Framework The conceptual framework for this study adapts the SERVQUAL model to the Sidama context, incorporating six dimensions: reliability, responsiveness, assurance, empathy, tangibles, and accessibility. These dimensions are tailored to reflect local cultural, linguistic, and structural factors influencing patient satisfaction in community pharmacies. The framework posits that service quality directly influences patient satisfaction, moderated by contextual factors such as urban/rural residence, insurance coverage, and cultural practices. The adapted framework is visualized below to illustrate the relationships between service quality dimensions, patient satisfaction, and contextual moderators. Methods Study Design and Setting A mixed-methods, cross-sectional study was conducted in Sidama National Regional State, Ethiopia, from January to March 2025. Data were collected from public and private community pharmacies in Hawassa City (urban), Bensa Woreda (semi-rural), and Aroresa Woreda (rural), selected purposively for their socioeconomic and geographic diversity. Participants The study included 400 adult patients (≥18 years) who accessed community pharmacy services during the study period. Participants were selected using systematic random sampling from pharmacy logs. For qualitative component, 20 key informants (10 patients, 10 staff) were purposively selected. Data Collection Quantitative Data A structured questionnaire, adapted from the SERVQUAL framework, assessed six dimensions: reliability, responsiveness, assurance, empathy, tangibles, and accessibility. The questionnaire, translated into Amharic and Sidamigna, used a 6-point Likert scale (1 = Strongly Disagree, 6 = Strongly Agree). Socio-demographic data were also collected (Appendix A). Qualitative Data Semi-structured interviews explored patient and staff experiences, focusing on service delivery, cultural sensitivity, and access barriers. Interviews were audio-recorded with consent and conducted in participants’ preferred languages (Appendix B). Data Analysis Quantitative Analysis Descriptive statistics (means, standard deviations) and multiple linear regression were performed using SPSS v26 to identify predictors of satisfaction. The regression model included SERVQUAL dimensions, urban/rural residence, and insurance coverage as predictors. Qualitative Analysis Interview transcripts were analyzed thematically using NVivo v12, following a six-step process: familiarization, coding, theme generation, review, definition, and reporting [ 8 ]. Themes were triangulated with quantitative findings to ensure robustness. Ethical Considerations Ethical clearance was obtained from Leadstar Christian University College (LCU-2025-014) and the Sidama Regional Health Bureau (SRHB-PH-2025). Informed consent was secured from all participants, with confidentiality and voluntary participation ensured (Appendix C, D). Results Respondent Characteristics The sample (N=400) was 54% male and 46% female, with 50% urban and 50% rural residents. Age distribution included 18.5% (18–25 years), 35.3% (26–35 years), 23% (36–45 years), 15.8% (46–60 years), and 7.5% (>60 years). Only 34.8% had health insurance ( Table 1 ). View this table: View inline View popup Download powerpoint Table 1. uantitative Findings Mean satisfaction scores were higher in urban areas (M = 4.31, SD = 0.74) than rural areas (M = 3.12, SD = 0.88). Assurance (M = 4.21, SD = 0.82) and reliability (M = 3.67, SD = 0.81) scored highest overall, while accessibility (M = 3.12, SD = 1.02) scored lowest ( Table 2 ). Regression analysis identified reliability (β = 0.326, p < 0.001) and accessibility (β = 0.244, p < 0.001) as the strongest predictors of satisfaction, followed by assurance (β = 0.173, p = 0.001) and empathy (β = 0.087, p = 0.027). Urban residence (β = 0.119, p = 0.011) and insurance coverage (β = 0.128, p = 0.007) also significantly predicted satisfaction ( Table 3 ). View this table: View inline View popup Table 2. View this table: View inline View popup Download powerpoint Table 3. Qualitative Findings Five key themes emerged from interviews: stockouts, gender sensitivity, accessibility, cultural practices, and language barriers ( Table 4 ). Rural patients frequently reported medicine unavailability, with one respondent stating, “I came three times and still didn’t get the antibiotic” (Male, Aroresa). Women expressed discomfort discussing reproductive health with male pharmacists, particularly in rural settings. Accessibility challenges included long travel times, with a female respondent from Aroresa noting, “It takes me two hours to reach the pharmacy.” Language barriers were prominent, with elderly rural patients struggling to understand Amharic-speaking staff. Suggestions included mobile pharmacy services, female staff, and enhanced privacy measures. View this table: View inline View popup Download powerpoint Table 4. Download figure Open in new tab Figure 1. Comparison of Mean SERVQUAL Dimension Scores in Urban and Rural Community Pharmacies, Sidama Region (2025). Download figure Open in new tab Figure 2. Adapted SERVQUAL Conceptual Framework for Community Pharmacy Services in Sidama, Ethiopia (2025). Discussion This study highlights significant urban-rural disparities in patient satisfaction with community pharmacy services in Sidama, consistent with prior research in Ethiopia [ 9 , 10 ]. Higher urban satisfaction scores reflect better infrastructure, staffing, and medicine availability, aligning with findings from Addis Ababa [ 11 ]. Reliability and accessibility as key predictors underscore the importance of consistent medicine supply and geographic access, particularly in rural areas where stockouts and travel barriers are prevalent [ 12 ]. Qualitative findings emphasize cultural and gender-specific challenges. Language barriers, particularly the lack of Sidamigna-speaking staff, align with studies in multilingual African settings [ 13 ]. Gender-based discomfort, especially among rural women, highlights the need for gender-sensitive care, as noted in Uganda [ 14 ]. The integration of traditional medicine use, often undisclosed to pharmacists, suggests a need for culturally responsive counseling [ 15 ]. The adapted SERVQUAL model, incorporating accessibility, proved effective in capturing Sidama-specific service quality nuances. This aligns with adaptations in other LMICs, where accessibility is critical [ 7 ]. The proposed Sidama-specific SERVQUAL framework (Table 5) offers a practical tool for evaluating and improving pharmacy services in similar contexts. Limitations: The cross-sectional design limits causal inference, and purposive sampling may reduce generalizability. The small number of qualitative interviews may not fully capture all perspectives. Future studies should include longitudinal designs and broader samples, including non-users of pharmacy services. Conclusions and Recommendations This study provides evidence of urban-rural disparities in pharmacy service satisfaction in Sidama, driven by differences in reliability, accessibility, and cultural sensitivity. To enhance pharmaceutical care, we recommend: Strengthen Medicine Supply Chains: Address stockouts through improved coordination with the Ethiopian Pharmaceutical Supply Service (EPSS). Enhance Cultural Competence: Train pharmacists in Sidamigna and cultural sensitivity to improve communication and trust. Promote Gender-Sensitive Services: Increase female pharmacy staff and private counseling spaces, particularly in rural areas. Expand Accessibility: Pilot mobile pharmacy services and extend operating hours to accommodate rural patients. Adopt the Sidama-Specific SERVQUAL Framework: Use this model for ongoing service quality assessments and policy development. These interventions can support Ethiopia’s goal of equitable universal health coverage by improving patient-centered pharmaceutical care in Sidama and similar regions. Data Availability https://github.com/HAWASSA2016 https://github.com/HAWASSA2016 Footnotes This likely refers to Figure 2, “Adapted SERVQUAL Conceptual Framework for Community Pharmacy Services in Sidama, Ethiopia (2025),” which illustrates the relationships between service quality dimensions, patient satisfaction, and contextual moderators. References 1. ↵ Nyamuzihwa , T. , et al. ( 2023 ). Community pharmacy services in sub-Saharan Africa . Journal of Global Health , 13 , 04012 . OpenUrl PubMed 2. ↵ Vemuru , V. , et al. ( 2020 ). Healthcare access in Ethiopia . Ethiopian Journal of Health Sciences , 30 ( 4 ), 567 – 574 . OpenUrl PubMed 3. ↵ Winchester , M. S. , et al. ( 2018 ). Global health collaboration . SpringerBriefs in Public Health . doi: 10.1007/978-3-319-77685-9 OpenUrl CrossRef 4. ↵ Barraza-Lloréns , M. , et al. ( 2025 ). Measures of hospital efficiency and quality . doi: 10.18235/0013359 OpenUrl CrossRef 5. ↵ Beyene , D. , et al. ( 2020 ). Effect of auditable pharmaceutical services on outcomes in Ethiopia . Integrated Pharmacy Research and Practice , 9 , 185 – 194 . doi: 10.2147/iprp.s277080 OpenUrl CrossRef 6. ↵ Tadesse , T. , et al. ( 2020 ). Sexual and reproductive health service barriers in Sidama . BMC International Health and Human Rights , 20 ( 1 ). doi: 10.1186/s12914-020-00223-1 OpenUrl CrossRef 7. ↵ Coombs , C. , et al. ( 2022 ). Adapting SERVQUAL for healthcare in LMICs . Health Policy and Planning , 37 ( 3 ), 412 – 420 . OpenUrl 8. ↵ Peel , K. ( 2020 ). A beginner’s guide to thematic analysis . Practical Assessment, Research, and Evaluation , 25 ( 1 ), 1 – 15 . OpenUrl 9. ↵ Kassa , D. G. , et al. ( 2021 ). Patients’ perception of pharmaceutical service quality in Ethiopia . BMJ Open , 11 ( 5 ), e042853 . doi: 10.1136/bmjopen-2020-042853 OpenUrl Abstract / FREE Full Text 10. ↵ Getahun , A. , et al. ( 2020 ). Patient satisfaction with pharmacy services in Southern Ethiopia . Journal of Multidisciplinary Healthcare , 13 , 1531 – 1540 . OpenUrl 11. ↵ Mekonnen , A. B. , & Fekadu , G. ( 2018 ). Patient satisfaction in Addis Ababa health centers . Ethiopian Pharmaceutical Journal , 34 ( 2 ), 127 – 136 . OpenUrl 12. ↵ Dumessa , E. , et al. ( 2025 ). Inequity in medication access in Eastern Ethiopia . BMC Health Services Research , 25 ( 1 ). doi: 10.1186/s12913-025-12963-8 OpenUrl CrossRef 13. ↵ Taylor , A. , & Kazembe , P. ( 2024 ). Language barriers in Malawi health facilities . BMC Health Services Research , 24 ( 1 ). doi: 10.1186/s12913-024-11901-4 OpenUrl CrossRef 14. ↵ Nsabagasani , X. , et al. ( 2019 ). Cultural appropriateness in pharmaceutical care in Uganda . Health Policy and Planning , 34 ( 5 ), 349 – 357 . OpenUrl 15. ↵ Tuasha , N. , et al. ( 2023 ). Prevalence of traditional medicine in Ethiopia . Systematic Reviews , 12 ( 1 ), 232 . doi: 10.1186/s13643-023-02398-9 OpenUrl CrossRef PubMed View the discussion thread. Back to top Previous Next Posted August 15, 2025. Download PDF Data/Code Email Thank you for your interest in spreading the word about medRxiv. NOTE: Your email address is requested solely to identify you as the sender of this article. Your Email * Your Name * Send To * Enter multiple addresses on separate lines or separate them with commas. You are going to email the following Patient Satisfaction and Perception of Community Pharmacy Services in Sidama, Ethiopia: A Mixed-Methods Study Using an Adapted SERVQUAL Framework Message Subject (Your Name) has forwarded a page to you from medRxiv Message Body (Your Name) thought you would like to see this page from the medRxiv website. 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