What factors of drug distribution system affect the satisfaction of outpatient with health insurance at district 2 hospital

RESEARCH PROJECT BMBR5103 WHAT FACTORS OF DRUG DISTRIBUTION SYSTEM AFFECT THE SATISFACTION OF OUTPATIENT WITH HEALTH INSURANCE AT DISTRICT 2 HOSPITAL?... In other words, patient satisfa

RESEARCH PROJECT

(BMBR5103)

WHAT FACTORS OF DRUG DISTRIBUTION SYSTEM AFFECT THE SATISFACTION OF OUTPATIENT WITH HEALTH INSURANCE AT DISTRICT 2 HOSPITAL?

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EXECUTIVE SUMMARY

Improving the quality of patient care is always the highest goal of the health sector Especially in recent years, the policy for socialization of health care has facilitated a wide range of medical services, the competition has contributed to boosting the demand for service quality improvement The drug distribution system has been considered the most important and the most costly component of any health system and therefore it affects significantly the overall quality of health care As a result, evaluating the quality of this system is a vital part of the process of improving both the quality and efficiency of health care

Patient satisfaction is the "property" of hospital The patient satisfaction index is the criterion used

to measure the response of health facilities to the expectations of patients In other words, patient satisfaction is the highest measure of the quality of the operation of health facilities, not other forms of honor

Program 527/CTr-BYT (June 18, 2009) of the Ministry of Health on "Improving the quality of medical examination and treatment at medical facilities for the purpose of meeting the patient satisfaction with the health insurance" require: improve morale, patient service attitude; reform administrative procedures; reduce inconvenience in reception, medical examination, treatment and payment to patients; improve the quality of health services in hospitals and healthcare facilities; ensure the rights of patients with health insurance, avoid abusing medicine, technology and test in order to save health resources and costs (Ministry of Health, 2009) In addition, Ministry of Health Circular No 19/2013/TT-BYT dated July 12, 2013 guiding implementation of medical service quality management requires all hospitals to assess the effectiveness of criteria, standard and quality management model indicators by 2018 (Ministry of Heath, 2013)

Medicine supply is one of the important tasks that affect the quality of hospital treatment and is also a significant factor in assessing the quality of pharmacy's department

In fact, the distribution of drugs has many factors affecting to patient satisfaction such as: drug

quality, drug delivery process, waiting time, medicine consultation Therefore, it is necessary to

have sufficient research to find out what factors make the patient dissatisfied

In Vietnam, the issue of drug supply in hospitals still exist many inadequacies and receive social

attention This inadequacy can occur at all stages of the drug delivery process: from procurement

to delivery, from prescription to instructional use

Despite continuous efforts, the health sector has not yet met the needs and expectations of patients

There is always a gap between the current response and demand In order to measure and narrow

this gap, the quality of drug supply and quality improvement work needs to be concentrated on the

basis of a highly relevant assessment of patients

When the Health Insurance Law came into force on July 1, 2009, District 2 Hospital in Ho Chi

Minh City became the place of registration for primary healthcare for patients with health

insurance As a result, the number of outpatient with health insurance has increased from 800 to

1000 patients per day, leading to overload in some departments, especially in drug distribution

system

Therefore, the topic "What factors of drug distribution system affect the satisfaction of outpatient

with health insurance at District 2 Hospital ? " be done

Overall objective:

Providing factors of medicine dilivery activities affecting patient satisfaction

Specific objectives:

1 Describe and explain how each factor influence patient satisfaction

2 Find out which factors actually impact patient satisfaction

3 Provide recommendation to improve the quality of drug distribution system

CHAPTER 1 - INTRODUCTION 1

1.1 Introduction 1

1.2 Research Aims 3

1.3 Research Question 3

1.4 Context and Relevance 3

1.5 Scope of research 4

1.6 Structure 5

1.7 Conclusion 6

CHAPTER 2 - LITERATURE REVIEW 7

2.1 Introduction 7

2.2 What is the drug distribution system? 7

2.3 What is patient satisfaction? 10

2.4 What factors may affect patient satisfaction? 12

2.5 How to measure patient satisfaction? 14

2.6 Gap in liturature 15

2.7 Conclusion 16

CHAPTER 3 - METHODOLOGY 17

3.1 Introduction 17

3.2 Research approach 17

3.3 Research design 18

3.4 Data collection 19

3.5 Data analysis 20

3.6 Reliability 21

3.7 Validity 21

3.8 Ethical considerations 22

CHAPTER 4 - FINDINGS - DISCUSSION 24

4.1 Introduction 24

4.2 Descripting and explaining each factor 24

4.2.1 Personal question 24

4.2.2 Reliability 25

4.2.3 Responsiveness 26

4.2.4 Assuarance 29

4.2.5 Empathy 31

4.2.6 Tangible 32

4.3 Reliability analysis 33

4.4 Correlation analysis 35

4.5 Regression analysis 37

4.6 Conclusion 38

CHAPTER 5 - CONCLUSION 40

5.1 Introduction 40

5.2 The purpose of the research 40

5.3 Addressing the research question 41

5.4 Key findings 41

5.5 Limitation and Recommendation 42

5.6 Answering the Research question 43

REFERENCE 44

Apendices - Questionnaire 49

CHAPTER 1 - INTRODUCTION

1.1 Introduction

In this chapter, I will introduce the research, overview District 2 Hospital, outline the aims and discuss why it is relevant to quality of healthcare in Vietnam It will briefly measure the circumstance of the research and present the structure for this dissertation Firstly, I will sketch some highight of public hospitals in Vietnam and overview of District 2 Hospital Then we will discuss the study aims and this will help us to develop

a focused research question to investigate It will then state how this research is important and the relevance to the quality of healthcare in Vietnam Following which it will highlight what this dissertation will examine and the confines of it Finally it will finish

by outlining the structure for the rest of the research

Public hospitals play a crucial role in the healthcare system in Vietnam because they are the dominant provider of hospital care compared with private hospitals Among 1,099 hospitals national wide, there are 962 public hospitals, accounting for 87.5 per cent of the whole hospital system (Vietnam General Statistics Office, 2012) As a result, evaluating the quality of drug distribution system would help to better understand the current supply capacity and quality of supply and significantly contribute to the aim of improving the health outcomes for people in Vietnam

Figure 1.0 District 2 Hospital

District 2 Hospital was built in 1998 with the initial size of only 60 beds, but with the support of the state, District 2 Hospital has been raised to 150 beds since 2015 Besides upgrading advanced medical equipment and facilities, District 2 Hospital may also pay much attention to improving the level of medical staff, working principles, behaviors for physicians, nurses, technicians through training With a better goal of serving, the board

of directors, doctors and nurses have been constantly innovating and improving their capacity Since 2015, District 2 Hospital has attracted from 1,000 to 1,100 outpatients to medical examination and treatment every day, 2.5 times higher than in 2014 The number

of inpatients has also increased, beds were always filled with over 90% patients The rate

of referral to upper levels in 2015 decreased by 72% compared to 2014 In the first six months of 2017, the hospital has reduced the rate of referral to higher levels up to 82%

over the same period in 2016 due to technical advances, actually hospital currently owned about 650 complicatied techniques People now are gradually becoming more confident in the quality of medical examination and treatment of hospitals and this has contributed significantly to reducing the overload of such hospitals: Cho Ray, Binh Dan, Nhan Dan Gia Dinh,

1.2 Research Aims

This research aims to define what factors of drug distribution system affect outpatient satisfaction at District 2 Hospital Based on these factors, managers can find solutions to improve the efficiency of drug distribution system and enhance the quality of healthcare

in their hospital

1.3 Research Question

A research question is the core of a research, the overall purpose of the research is therefore to find an answer to the research question In this instance, the research question should be tightly focussed, that is, it should be extremely clear exactly what aspect of practice the researcher is investigating and with which population of patients

or clients So the study was conducted to answer the following research questions:

- What factors of drug distribution system affect the satisfaction of outpatient with health insurance at District 2 Hospital?

- Why/How these factors affect the quality of drug distribution system at District 2 Hospital?

1.4 Context and Relevance

The Vietnamese public hospital system is overloaded, especially at the provincial and national levels, both in general and specialty public hospitals Further, the current shortage of experienced medical doctors, pharmacist and other professional staff has put

increasing burden on hospital capacity to meet healthcare needs of the population This situation therefore affects the quality of healthcare system (Le TP, 2014)

Decision No 68/QD-TTg dated January 10, 2014 of the Prime Minister approving the National Strategy on Vietnam pharmaceutical industry’s development to 2020 and with the vision to 2030 The overal objectives is to supply medicines adequately, timely with quality and rational prices according to the disease structure respectively with each socio-economical development stage and ensure medicine usage to be safe and rational

To attach special importance to medicine supply for subjects belonging to social

The current drug distribution model illustrates a complicated process can influence the quality of drug distribution system that is expressed by patient satisfaction Over the past

20 years, patient satisfaction surveys have gained increasing attention as meaningful and essential sources of information for identifying gaps and developing an effective action plan for quality improvement in healthcare organizations However the application of these findings is not the same in each healthcare center Each hospital should conduct its own patient satisfaction studies in order to improve the quality of healthcare

Why I choose District 2 Hospital? District 2 Hospital is a secondary hospital undercontrolled by Ho Chi Minh City Ministry of Health In the past, there was no systematic study to evaluate customer satisfaction about the quality of drug distribution system for outpatients at District 2 Hospital A number of surveys have been conducted

at other hospitals, however, those research could not apply to enhance the quality of healthcare for this hospital Therefore a systematic study is needed to discover and answer the research questions posed

1.5 Scope of research

The research involves the concepts of service quality in general and quality of drug distribution system in particular Quality of drug distribution system perceived by

patients has been considered the transformation of the most frequently-used term: patient satisfaction

The results of the research will provide evidence-based suggestions for applying the framework to identify factors affecting to patient satisfaction in Vietnam, contributing

to assess and improve the service quality of the drug distribution system in general and

of District 2 Hospital in particular

Due to time restraints, the sample will be limited to 174 participants This may mean that the results cannot be generalised to the whole population Due to limited time and budget, the research will ask participants to self evaluate their satisfaction levels and therefore it may have poor construct validity

The findings and the discussion will then be presented using tables and graphs to highlight the key points found Averages and correlations will be calculated to help form

an answer to the research question Each high-light will be explained and discussed what has been found and to relate it back to the existing literature This will allow the researcher to draw conclusions from the data

1.7 Conclusion

This chapter has introduced the research and discuss the aims and relevance of it It has outlined the scope of the research and created a research question that can be investigated The next chapter will present existing literature surrounding the question

“What factors of drug distribution system affect the satisfaction of outpatient with health insurance at District 2 Hospital ?” This will give background knowledge for the topic and will be informative about what has previously been investigated

CHAPTER 2 - LITERATURE REVIEW

2.1 Introduction

Drug distribution system are seen as the most prominent and vital component of any healthcare system This Chapter firstly examines the role of the drug distribution system within the healthcare system in Vietnam Some available drug distribution models that are provided by international advisory bodies such as the World Health Organization and the International Pharmacy Federation may be also discussed when seeking to describe the pharmaceutical system

Moreover, the concept of satisfaction and in particular, patient satisfaction as an important indicator of quality of care will be introduced and analysed through related worldwide studies

Patient satisfaction is an important and commonly used indicator for measuring the quality in healthcare Patient satisfaction affects clinical outcomes, patient retention, and medical malpractice claims It affects the timely, efficient, and patient-centered delivery

of quality healthcare Patient satisfaction is thus a proxy but a very effective indicator to measure the success of doctors and hospitals (Bhanu Prakash, 2010)

2.2 What is the drug distribution system?

People are constantly looking for quality products and services The existence of this desire for quality has caused firms and organisations throughout the world to consider it

as an essential component of any service and production process Quality is a strategic differentiator tool for sustaining competitive advantage Improving quality through improving structures and processes leads to a reduction of waste, rework, and delays, lower costs, higher market share, and a positive company image (Lagrosen, 2005), (Rahman, 2001) As a result, productivity and profitability improve (Alexander, 2006) Therefore, it is very important to define, measure and improve quality of healthcare services in general and drug distribution system in particular

According to World Health Organization, drugs may be widely distributed through shops, drug sellers of various sorts and other informal channels However, the range, quality and storage conditions of drugs distributed in these ways are highly variable (WHO, 1997)

In any hospital, a drug distribution system is required to supply the medication prescribed for each inpatient The drug distribution system includes all the processes that occur between the prescription of a drug and the administration of that drug to the patient There are many varieties of drug distribution system in use throughout the world, but all have the same goal: to ensure that each dose of medication administered to each patient

is exactly that which was intended by the prescriber (Katja, 1999)

In less developed countries with large, medically underserved populations, pharmacists’ major responsibility remains providing or managing drug distribution systems In some countries, government at all levels may be actively involved in selecting which medications will be available, choosing a source of supply, maintaining integrity of that supply, ensuring quality and stability of medications, arranging for storage and shipping

of medicines, paying for them and, indeed, creating much of the infrastructure necessary

to provide medication to their citizens (Kohler, 2014)

WHO has developed extensive guidelines for the drug procurement process in developing countries The guidelines describe four strategic objectives for good pharmaceutical procurement: procure the most cost e ective drugs in the right quantity; select reliable suppliers of high quality products; ensure timely delivery; achieve the lowest possible cost Twelve operational principles are suggested to meet these objectives including using a transparent drug tendering process, having appropriate audit processes for drug procurement, using appropriate accounting and payment procedures, and assuring that all medications are of suitable quality (WHO, 1999) The chart below

is one of drug distribution models that WHO suggest for developing countries

Chart 2.0 Distribution network for essential medicines in the public, private and NGO

channels in developing countries

Since 2008, the hospital board has relied on WHO's drug distribution model to build a appropriate model for itself This model did not mimic exactly WHO’s, but it was well suitable to the disease pattern and epidemiological situation at the hospital The chart below illustrates current drug distribution model for outpatients in District 2 Hospital It will help us to build a suitable questionnaire to evaluate patient satisfaction

Chart 2.1 Current drug distribution system at District 2 Hospital

2.3 What is patient satisfaction?

Outpatient with health insurance

Outpatients are patients who have examined and analyzed the disease but no threatening illness, so these patients are referred to treated at home (outside the hospital) Health insurance is insurance that covers the whole or a part of the risk of a person incurring medical expenses, spreading the risk over a large number of persons By estimating the overall risk of healthcare and health system expenses over the risk pool,

life-an insurer clife-an develop a routine finlife-ance structure, such as a monthly premium or payroll tax, to provide the money to pay for the healthcare benefits specified in the insurance agreement The benefit is administered by a central organization such as a government

cash Change

Prescription filled Prescription Payment

Static and report

Prescription file

Narcotic Prescription file

agency, private business, or not-for-profit entity According to the Health Insurance Association of America, health insurance is defined as "coverage that provides for the payments of benefits as a result of sickness or injury It includes insurance for losses from accident, medical expense, disability, or accidental death and dismemberment" (Gary, 2002)

In this dissertation, outpatient with health insurance are called patient

Patient satisfaction

Oliver (1981) summarizes current thinking on satisfaction in the following definition:

“(satisfaction is a) summary psychological state resulting when the emotion surrounding disconfirmed expectations is coupled with the consumer’s prior feelings about the con-sumption experience” This and other definitions (Howard and Sheth, 1969), (Hunt, 1979) and most all measures of satisfaction relate to a specific transaction

Parasuraman (1985) explained satisfaction in relation to service quality He argued that service quality is defined as the gap between predicted or expected service (customer expectations) and perceived service (customer perceptions) If customers’ expectation is greater than performance, then perceived quality is regarded less than satisfactory and a service quality gap arises

There is no consensus between the literatures on how to define the concept of patient satisfaction in healthcare Most of researcher are familiar with customer satisfaction, so can we see patient as a consumer or not? The word “consumer” is derived from the Latin word “consumere” which literally means one who acquires commodities or services Similarly, the word customer is also defined as “a person who purchases goods or services.”( Brown, 1993) Today the patient sees himself as a buyer of health services Once this concept is accepted, then there is a need to recognize that every patient has certain rights, which puts a special emphasis on to the delivery of quality healthcare In

Donabedian's quality measurement model, patient satisfaction is defined as reported outcome measure while the structures and processes of care can be measured

patient-by patient-reported experiences (Oyvind, 2011)

Many authors tend to have different perceptions of definitions of patient satisfaction Jenkinson C et al (2003) and Ahmed et al (2011) pointed out that patient satisfaction mostly appears to represent attitudes towards care or aspects of care (Jenkinson, 2003) (Iftikhar, 2011)

While Rama et al (2011) referred to patient satisfaction as patients’ emotions, feelings and their perception of delivered healthcare services On the other hand, other authors defined patient satisfaction as a degree of congruency between patient expectations of ideal care and their perceptions of real care received (Iftikhar, 2011)

In this dissertation, Parasuraman’ theory will be used as core concept to built the

questionnaire

2.4 What factors may affect patient satisfaction?

In order to understand various factors affecting patient satisfaction, researchers have explored various dimensions of the perceived service quality, as meaningful and essential measures of patient perception of healthcare quality Kane et al (1997) stated that measuring satisfaction should "incorporate dimensions of technical, interpersonal, social, and moral aspects of care" (Kathryn, 2004) Research of patient satisfaction in advanced as well as developing countries has many common and some unique variables and attributes that influence overall patient satisfaction (Iftikhar, 2011)

Most of the studies in the literature review examined the correlation between demographic factors such as age, gender, health status and level of education with patient satisfaction; however, the findings from these studies are conflicting Two studies, one conducted in Scotland whereby 650 patients discharged from four acute care general

hospitals during February and March 2002, and the second study was conducted in 32 different large tertiary hospitals in the USA; both showed that male patients, patients older than 50 years of age, patients who had a shorter length of stay or better health status and those with primary level education had higher scores related to variable health service-related domains (José, 2006), (Otani, 2011)

On the other hand, a national survey performed in different accredited hospitals of Taiwan found that patient characteristics such as age, gender and education level only slightly influenced patient satisfaction but that the health status of patients is an important predictor of a patient’s overall satisfaction (Shou-Hisa, 2003) In addition, Nguyen et al (2002) and Jenkinson et al (2002) declared from their studies that the two strongest and most consistent determinants of higher satisfaction are old age and better health status

While two studies reported contrary results regarding the influential effect of the two controlled variables (age and gender) on overall patient satisfaction in different aspects

of healthcare services (Tonio, 2011), (Rama, 2011) In contrast, a 2006 national survey

of 63 hospitals in the five health regions in Norway showed that age, gender, perceived health and education level were not significant predictors of overall patient satisfaction (Oyvind, 2011)

A remarkable outcome of four studies conducted in tertiary hospitals in different countries revealed that the nurses' courtesy, respect, careful listening and easy access of care was particularly the strongest driver of overall patient satisfaction These aspects of nursing care are highly ranked by patients compared to other independent factors such

as physician care, admission process, physical environment and cleanliness (Tonio, 2011), (Forough, 2007), (Yogesh, 2011), (Kui-Son, 2005) In addition, a study carried out in 430 hospitals in the USA found the nurse work environment and patient-nurse

staffing ratio had statistically significant effects on patient satisfaction and recommendations (Ann, 2009)

While three other studies found that interpersonal communication skills of physicians in terms of their attitude, explanation of conditions, level of care, emotional support, respect for patient preferences and involving patients in decision making were more influential factors than clinical competence and hospital tangibles on patient satisfaction (Shou-Hisa, 2003), (Sung Soo, 2004) (Andrabi, 2012)

A study conducted in a public hospital in France found the most common problems experienced by patients were related to hospital living arrangements and amenities (Nguyen, 2002) A similar result was reported in a study conducted at five hospitals served under the BJC Healthcare System (Koichiro, 2009) Furthermore, in 2012 Andrabi et al reported that the major dissatisfaction in an outpatients department was the long waiting time and overcrowded registration (Andrabi, 2012) In contrast, a study carried out in five different hospitals in Scotland found that physical comfort had the highest satisfaction rate compared to other core dimensions: information, coordination

of care and emotional support (Jenkinson, 2003)

2.5 How to measure patient satisfaction?

In this research, the scientific questionnaire will be built based on Parasura man’ model

Parasuraman et al., (1988) designed the SERVQUAL instrument to specifically measure functional service quality using both the gap concept and service quality dimensions The SERVQUAL instrument, in its original form, contains twenty-two pairs of Likert scale statements structured around five service quality dimensions: These dimensions are:

(i) Reliability: deals with the ability to perform the promised service dependably and

accurately

(ii) Responsiveness: considers the willingness to help customers and provide prompt

service

(iii) Assurance: talks about the knowledge and courtesy of employees and their ability

to inspire trust and confidence

(iv) Empathy: ability to provide caring and individualized attention to customers (v) Tangible: describes the appearance of physical facilities, personnel and equipment

In this dissertation, the questionnaire survey was based on the content and structure of

the SERVQUAL scale and the questionnaire survey of previous studies in the health

sector (Diem Vo Thi Ngoc 2012, Thanh Nhu Ngoc, 2103)

2.6 Gap in liturature

When conducting this literature review and reading many articles on patient satisfaction,

it has been apparent that it is quite difficult to apply these results to Vietnam public hospital system in general and District 2 Hospital in particular As mentioned above, there is no standard drug delivery model can be applied to all hospitals An effective model must be appropriated to the patient's characteristics, disease pattern, capacity of the medical staff and facilities of each hospital Now in the world, there are few studies about the effectiveness of drug delivery systems at hospital, most of them are conducted

in developed countries In Vietnam, there are about 5-10 studies per year conducted in relation to drug distribution system and most of these researchs are guided by experts from two major pharmaceutical universities (Hanoi and Ho Chi Minh City) Therefore, those researchs are not high quality and very difficult to apply

When reading worldwide articles, I find out some problems such as: In regard to health insurance discount, most previous studies have said that patients are satisfied but it did not mention exactly how they satisfied Another factor is often overlooked when examining the patient satisfaction was the waiting time to receive the drug In this study,

all questions will be adjusted to better suitable with current drug distribution model at District 2 Hospital and this will help patients to evaluate accurately

2.7 Conclusion

In this chapter, the literature review has discussed many aspects of patient satisfaction

so as to gain a whole view of the issue and gain more knowledge on it Throughout the review, many experts have contradicted each other and therefore each term and concept within the topic of patient satisfaction, may not be able to be clearly defined Besides, the concept of drug distribution system has been introduced in various respects However, there are few researchs about the quality of drug distribution system in the world in general and Vietnam in particular Nevertheless, the review has showed the author with wider background knowledge on the topic which will allow a deeper discussion of findings after the study has been completed Dissertation – “What factors

of drug distribution system affect the satisfaction of outpatient with health insurance at District 2 Hospital?”

In conclusion, this literature has discussed and analysed existing literature surrounding the topic of patient satisfaction This has given background knowledge of the topic and therefore will help in answering the question “What factors of drug distribution system affect the satisfaction of outpatient with health insurance at District 2 Hospital?” The literature has built a strong foundation for the dissertation and will help when discussing the findings The next chapter will outline the methodology that will be used in the study that will be conducted

CHAPTER 3 - METHODOLOGY

3.1 Introduction

The previous chapter discussed the existing research on the topic of patient satisfaction, including what healthcare quality is, what satisfaction is, the factor affecting to patient satisfaction Now that the current research has been analysed, this chapter will go on to discuss the research approach that was used during this dissertation The approach and design will be analysed to decide what the best method of data collection will be to answer the question “What factors of drug distribution system affect the satisfaction of outpatient with health insurance at District 2 Hospital? This chapter will cover the method of data collection and analysis, as well as the validity and reliability of the study being conducted

3.2 Research approach

Research approaches fall into two categories: inductive and deductive Inductive approach, also known in inductive reasoning, starts with the observations and theories are proposed towards the end of the research process as a result of observations (Goddard, 2004) Inductive research “involves the search for pattern from observation and the development of explanations – theories – for those patterns through series of hypotheses” ( Bernard, 2011) Whereas a deductive approach is concerned with

“developing a hypothesis (or hypotheses) based on existing theory, and then designing a research strategy to test the hypothesis” ( Wilson, 2010) Each of these approaches has advantages and it can be said that “any research effort uses both inductive and deductive thinking”

To keep the study unbiased and reliable, an inductive approach was used This was so that findings were not swayed by a leading research question as the researcher had not previously decided what the outcome should be This approach aims to generate meanings from the data set collected in order to identify patterns and relationships to

build a theory; however, inductive approach does not prevent the researcher from using existing theory to formulate the research question to be explored (Saunders, 2012) By using an inductive approach, this dissertation was able to analyse which factors affecting

to patient satisfaction

Data can be split into two main categories: quantitative and qualitative Quantitative data

is any data that is in numerical form such as statistics, percentages, etc (Given, 2008) Qualitative research is a method of inquiry employed in many different academic disciplines, including in the social sciences and natural sciences, but also in non-academic contexts including market research, business, and service demonstrations by non-profits (Denzin, 2005)

To ensure that the research being conducted was scientific, quantitative data was used throughout the data collection as it can then be clearly analysed in the form of tables and graphs This was helpful when trying to draw conclusions from the data and presented trends and correlations in clear format

3.3 Research design

In terms of data collection methods, a questionnaire was used for this research They are

a valuable method of collecting a wide range of information from a large number of individuals, often referred to as respondents This therefore means that it was an appropriate form of data collection for this dissertation as it allowed the results to be easily analysed in a scientific format

There are many benefits of using a questionnaire to collect data One of the main positives is that data can be collected quickly, at little cost when compared to face-to-face interviews Questionnaires are easy to analyze and reduce bias Data entry and tabulation for nearly all surveys can be easily done with many computer software packages Moreover, they are familiar to most people and less intrusive than telephone

or face-to-face surveys Nearly everyone has had some experience completing

questionnaires and they generally do not make people apprehensive Therefore, this was the chosen method for this research as it suits its needs well

However, there are also many disadvantages to using questionnaires and these may mean that the research has limitations Questionnaires are not always the best way to gather information For example, if there is little previous information on a problem, a questionnaire may only provide limited additional insight On one hand, the investigators may not have asked the right questions which allow new insight in the research topic

On the other hand, questions often only allow a limited choice of responses If the right response is not among the choice of answers, the investigators will obtain little or no valid information Another setback of questionnaires is the varying responses to questions Respondents sometimes misunderstand or misinterpret questions If this is the case, it will be very hard to correct these mistakes and collect missing data in a second round

In conclusion, even though there are limitations to this research method, there will be limitations to all methods and therefore questionnaires were still used as the source of data collection

3.4 Data collection

The data for this dissertation was collected in random sampling Simple random sampling (also referred to as random sampling) is the purest and the most straightforward probability sampling strategy It is also the most popular method for choosing a sample among population for a wide range of purposes In simple random sampling each member of population is equally likely to be chosen as part of the sample (Gravetter, 2011)

A trained data-collection team of 2 people went to District 2 Hospitals to conduct to-face interviews with the patients In most cases the interviewers asked questions and filled in the questionnaire Necessary explanations were provided to the respondents

face-during the interviews Each interview took about 15 to 20 minutes The study lasted over

10 days with seventeen questionnaires collected in District 2 Hospital from 200 participants (patients) This type of sampling means that “the selection of people or events is literally ‘at random’” (Denscombe, 2007) The smaller amount of participants was due to the limited amount of time, as well as people being tired to answer questionnaires Most questionnaire were done from 08:30 am to 10:30 am when people tend to have more time to talk Due to the time restraints and limited budget, the sample size was relatively small If the research was done on a larger budget in the future, ideally there would be a larger sample This would help to rule out any bias results and help the external validity to remain high

After collecting and processing data, there were 26 unsuitable patient responses due to wrong understanding, 2 choices for one question, one answer to all questions Therefore the sample used for analysis was 174 participants

by using a code book

The code book transformed each questionnaire in to a series of numbers so that it could

be compared to others By using quantitative data, this was easily done and therefore the data could be easily analysed to find factors affecting to patient satisfaction

It was important to ensure that each set of answers stayed with the number of the questionnaire that they had come from so that if a participant (patients) wished to withdraw their data, this could easily be done

3.6 Reliability

Together, validity and reliability are at the core of what is accepted as scientific proof,

by scientist and philosopher alike

Reliability is a concern every time a single observer is the source of data, because we have no certain guard against the impact of that observer’s subjectivity” (Babbie, 2010)

On the other hand, Wilson (2010) argued that reliability issues are most of the time closely associated with subjectivity and once a researcher adopts a subjective approach towards the study, then the level of reliability of the work is going to be compromised The sample that was used has been collected during 10 days to ensure that it is more reliable Participants were randomly selected: handed out the questionnaire during 10 consecutive days (20 samples per day) Invalid samples were the samples that were not enough information or patient answers the same for all questions, or give multiple answers to one question or do not answer all questions fully When the sample was invalid, the sample will be destroyed and new samples will be investigated

3.7 Validity

Validity of research can be explained as an extent at which requirements of scientific research method have been followed during the process of generating research findings Oliver (2010) considers validity to be a compulsory requirement for all types

of studies The questionnaire survey was based on the content and structure of the SERVQUAL scale and the questionnaire survey of previous studies in the health sector (Diem Vo Thi Ngoc 2012, Thanh Nhu Ngoc, 2103)

Likert scale is the most widely used approach to scaling responses in survey research, such that the term is often used interchangeably with rating scale, although there are other types of rating scales (Wuensch, 2005) The answers in this study uses the Likert scale because its advantage is to use a positive sequence of five value: very disatisfied (1), disatisfied (2), neutral (3), satisfied (4), very satisfied The questionnaire consisted

of two parts: personal information (2 questions), factors that could affect patient satisfaction (5 groups of factor with 14 questions) and general satisfaction (1 question)

3.8 Ethical considerations

Ethical considerations in research are critical Ethics are the norms or standards for conduct that distinguish between right and wrong They help to determine the difference between acceptable and unacceptable behaviors Before taking this survey, I have consulted with hospital director, drug & treatment councils, staffs of the pharmacy on outpatient health insurance at District 2 Hospital

Investigators would be trained on the content and meaning of the questionnaire After the patient received the medication, the investigator contacted the patient directly, explained the meaning of the survey and the meaning of each questionnaire to ensure that the patient understands and responds well We commited to investigate with the shortest time so as not to compromise the patient health All these processes were taken seriously during the servey in order to create a reliable database

Furthermore, in order to ensure confidentiality, all data collected were locked and stored away and was only utilised by the researcher to maintain privacy Moreover, a statement

at the start of the questionnaire included and during the interview, the statement was read out loud to the manager to receive acceptance of copyright to the described material Additionally, names, addresses and diagnosis of participants (patient) were not recorded

at any circumstance in the questionnaires to maintain privacy and data protection

3.9 Conclusion

The third chapter has identified and analysed different methods of data collection to release the reason why we choose this method It has clearly sketched exactly what was done in this dissertation so that there was no difficulty if any researcher wanted to Validity and reliability of the research has seen discoursed and blemishes in these have been delineated The research approach and design have been sketched so that the researcher can identify a clear interpretation as to how the research was completed This chapter discussed the methodology used to answer the question “What factors of drug distribution system affect the satisfaction of outpatient with health insurance at District

2 Hospital” The next chapter will go on to discuss the findings from this research