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Synthesis and Characterization of Some Arylhydrazide derivatives
By Amanuel Tefera
Abstract
Insufficiency of existing drugs to fight the resistant infectious diseases synchronized by MDR strain challenges and the unpredictable outbreak of new diseases all in one concurrence have increased the demand for the search, design and synthesis of new chemical scaffolds possessing biological activity. As a result Hydrazone-Hydrazide was found to be very important compounds that satisfy this response. Hydrazone-hydrazide possess unique characteristic. They are significantly considered as building blocks in many products with interesting biological properties such as antiinflammatory, analgesic, anticonvulsant, antituberculosis, antitumor, anti-HIV and antimicrobial activities.
New hydrazone-hydrazide derivatives were synthesized by using 2, 4-DNPH as a central reactant reagent and reacted with methyl Salicylate and Formaldehyde Pharmaceutical reagent grade, in an acidic media. The complex was characterized by 1HNMR analysis and FT-IR Spectrophotometry.Based on the data the structure is elucidated. Finally it is proposed if the product is further biologically characterized it could be a good pathway to new biological active agent.








1. Introduction
1.1. Background of the study
Hydrazones constitute an important class of biologically active drug molecules which have attracted attention of medicinal chemists due to their wide range of pharmacological properties. These compounds are being synthesized as drugs by many researchers in order to combat diseases with minimal toxicity and maximal effects. These predictions has provided therapeutic pathway to develop new effective biologically active hydrazones [1].
Compounds with the structure of -C=N- (azomethine group) are known as Schiff bases, which are usually synthesized from the condensation of primary amines with compounds having active carbonyl groups [2].The hydrazides are very useful starting materials for the construction of several functionalized heterocycles with a broad spectrum of biological activities, and consequently they have been studied in considerable detail over the decades [3].
Generally, a number of hydrazones were tested by different researchers for their biological activity and were found to be important class of compounds. Many effective compounds, such as iproniazide 1 and isocarboxazide 2, are synthesized by reduction of hydrazide-hydrazones. Iproniazide, like INH, is used in the treatment of tuberculosis. It also displays an antidepressant effect and patients appear to have a better mood during the treatment. Another clinically effective hydrazide-hydrazone is Nifuroxazide, 3 which is used as an intestinal antiseptic [4].



  • 1.2. Statement of the problem

Since their introduction, antimicrobials (antibiotics) have played a vital role in decreasing morbidity and mortality caused by infectious diseases. However, over the past few decades, health related quality of human life benefits are under threat as many commonly used antibiotics have become less and less effective against certain illnesses due to the emergence of drug resistant microbes [5].
In recent decades various diseases threatened the world with their hazardous effects like Cancer, Malaria, AIDS and Tuberculosis. More than 50 million peoples are affected by malaria causing approximately 2 million deaths per year. Tuberculosis claims over 2 million lives worldwide each year. Researchers are involved in the business to synthesize the molecules of biological interest which can provide relief to the world from these hazardous diseases. Hydrazones have been emerged as one of the fruitful product of their efforts [6].
Many researchers evaluated that the spread of Mycobacterium tuberculosis and Plasmodium falciparum, are scaling up and the simultaneous presence with human immunodeficiency virus (HIV) infection, and severe opportunistic infections, have worsened the condition There will be one billion new active cases of a deadly contagious tuberculosis disease and if new anti-TB drugs are not developed, treatment of tuberculosis (TB) infection that has been caused by multidrug resistant (MDR) organisms would become a major concern worldwide [7].
Its synergy with (HIV) in immune-compromised patients would have worsened the situation. Cost of the drugs due to the emergence of resistant strains of M. tuberculosis would scale up the pathogenic synergy of the tubercular and non-tubercular mycobacterial infections. Therefore, there is urgent medical need to discover newer synthetic molecules and drugs for the treatment of tuberculosis and that will shorten the duration of therapy [8].
A study conducted in their veterinary medicine indicated that Staphylococcus aureus possess a wide array of virulence factors, including extracellular toxins and surface structures that facilitate immune evasion, tissue colonization and destruction. This isolate has an increased ability to colonize and cause tissular disruption and is resistant to all available antimicrobials including Linezolid-Methicillin in animal origin and outbreaks in human medical centers are becoming more frequently reported worldwide rising concerns about human and animal health safety [9].
According to World Health Organization (WHO) Disease outbreaks are inevitable, and often unpredictable, events. The environment surrounding an outbreak is unique in all of public health. Outbreaks are frequently marked by uncertainty, confusion and a sense of urgency. The existing antimicrobial agents seem to be insufficient to fight the resistant infectious diseases. This is due to the drive of evolution that leads to antimicrobial resistance. New emerging infections Human immunodeficiency syndrome (HIV), severe acute respiratory syndrome (SARS), (avian flu) is unpredictable. Therefore, discovery of new targets and pathways for drug development is essential. Beside the MDR strain challenge, growth of population and changes in climatic conditions have caused several new diseases like cancer, cardiovascular and psychosocial health problems and much more cases are rising every time [10].
The development of drug resistance towards the clinically used antibacterial agents has increased the demand for the design and synthesis of new chemical scaffolds possessing antimicrobial activity. The growing number of immuno-compromised patients as a result of cancer chemotherapy, organ transplantation, and HIV infection are the major factors contributing to this increase. Moreover, in some cases, especially in patients with impaired Liver or kidney functions, the use of antimicrobial drugs to treat infections causes several problems Thus; these trends have required the urgent need for new, more effective antibacterial agents with lack of side effects. Two attractive approaches have been developed. One of them involved the development of structurally new classes of antimicrobial agents with novel mechanism of action; secondly contained structural modification or optimization of the existing agents by improving both the binding affinity and spectrum of activity while retaining bioavailability and safety profile. Furthermore, in recent years, another strategy employing a combination of 2 different active fragments in 1 molecule has emerged. In this strategy, each drug moiety is designed to bind independently to 2 different biological targets and synchronously accumulate at both target sites. Such dual-action drugs, or hybrid drugs, offer the possibility to overcome the current resistance and reduce the appearance of new resistant strains. Therefore several researchers have concluded that the peculiar characteristic of Hydrazone-Hydrazides derivatives diverse pharmacological activities suitably fitted for these three potential possibilities of its [11].
Different chemical classes, including hydrazide-hydrazones, are on the pipeline to find new effective compounds against the alarmingly occurring resistant strains. Chemistry of hydrazine becomes known back in the 1863 by Hofmann when he synthesized the first Hydrazine derivative, by successfully converting Azobenzene to Hydrazobenzene. And this was succeeded by Emil Fischer (1877) who synthesized Phenyl Hydrazine which was used by his assistant to react with Acetoacetic acid ester. As a result of the continuing investigation by Stolz, Amidopyrine was produced which was antipyrine discovered during influenza epidemic in 1889/90 [12].
The resistance towards available drugs is rapidly becoming a major worldwide problem. The need to design new compounds to deal with this resistance has become one of the most important research areas of today. Hydrazone is a versatile moiety that exhibits a wide variety of biological activities. Therefore, as various researchers have indicate how attention should be given to the MDR Related health problem, the urgent need to discover newer drug, and peculiar characteristic of hydrazide derivatives & potential possibility of its diverse pharmacological activities [13]
  • 1.3. Significance of the study
The tremendous increase in development of multi-drug resistant microbial infections in the past few years has become a serious health hazard. This leads to search for new antimicrobial agents with improved biological activity A few hydrazones were synthesized and evaluated for antimicrobial activity against Gram positive bacteria Bacillus subtilis, Staphylococcus aureus. [14]
In a trace of search for new way of approach to tackle the whole health related problems, this research paper tried to state, hydrazone-hydrazide compounds play a very important role. The N-N linkage has been used as a key structural motif in various bioactive agents. Compounds of this group have a special feature that the amino-nitrogen has grater electron density and plays role for its greater affinity to react with other electrophile compounds on target biological molecules. As the other Ketone and Aldehyde groups have got a carbonyl group that has more affinity to electron donating group, an electrophile-nucleophile reaction takes place easily. In this reaction, electrons of the primary amino group are attracted by the partially positive carbon of the carbonyl functional group; a reaction is called Addition-elimination reaction or Condensation reaction [15].
These groups of compounds have varied activity in pharmaceuticals and biological preparations because of many reasons. They are good agents to combat diseases with minimal toxicity and maximal effects. It has been employed successfully as a starting material for the production of biologically active compounds. They are good coupling agents also. They are shown in several literatures used by many researchers to modify the existing drugs and to improve the efficiency and effectiveness On the other hand, Aldehydes and ketones are present in a number of low molecular weight molecules such as drugs, steroid hormones, and several bio molecules. The presences of these Aldehyde and Ketones in certain biomolecules have initiated the attention of researchers as a site of modification by these functional groups [16].
From most of the entire research, the researcher of this paper have learnt significant chemical characteristic of these compounds and the possible structural elucidation and characterization. The beneficiaries of this endeavor will be the pharmaceutical science industry and technology of the country, the Pharmaceutical Colleges & Universities future researchers, the publishing & Research development department of Universal University College, and the Ethiopian Community at large. The findings are open for further additional test and rechecking to find out the compounds’ biological activity.





2. Objectives
  • 2.1. General Objective
  • To synthesize and characterize some hydrazone-hydrazide Derivatives
  • 2.2. Specific Objectives
  • To synthesize the targeted compounds by condensation reaction;
  • To verify the Chemical Structures of the synthesized compounds using Spectroscopic Technique (1HNMR)
  • To draw Conclusions and put some recommendations
  • 3. Methods and Materials
    3.1. Materials
    3.1.1. Chemicals
    All chemicals used were of Analytical grade. Reagents used were formaldehyde, HCL, Methyl Salicylate, 2, 4-dinitrophenyl hydrazine, Solvents used were the solvents used were MeOH, EtOH, and diethyl ether, Benzene, Acetone, DMSO, CHCl3, H2O, HCl and (TLC) Solvent in 1:9 ratio of Polar to non-polar respectively.
    3.1.2. Equipments
    Tools were Thin Layer Chromatography (TLC) of silica coated aluminum plates, Condenser set, Heating mantle, round bottom flask, Electrical sensitive balance, Dropper, Measuring Cylinder, Micropipette, Test tube, Filter paper, Funnel (glass), Magnetic Stirrer, and Several other common laboratory equipment etc.
    • 3.1.3. Instruments
    Instrumentation and materials used were, UV Visible spectrophotometer, Proton NMR Spectroscopy, IR spectrophotometer:
    3.2. Methods
    The reaction of this experiment was done in condensation method of reaction. In this schematic outline the central 2, 4-DNPH in HCl as an acidic catalyst react with carbonyl compounds of two different kinds; Formaldehyde and Methyl Salicylate to form deferent hydrazide groups. This reaction can be described as a condensation reaction, with two molecules joining together with loss of methanol in methyl Salicylate derivative and H2O in Formaldehyde. It is also considered an addition-elimination reaction: nucleophilic addition of the -NH2 group to the C=O carbonyl group, followed by the removal of a small molecule, a yellow or red precipitate (known as a dinitrophenylhydrazone-hydrazide). The mechanism for the reaction between 2, 4-dinitrophenylhydrazine and an Aldehyde or ketone is shown below:

    SCHEME 1 the general reaction schemes of the experiments
    • 3.2.1. Synthesis of (2,4-dinitrophenyl)-2-hydroxybenzohydrazide

    The preparation was carried out according to a previously reported method of condensation reaction. 6.60g of A wet powder of 2,4-DNPH, was added to 4.33ml equimolar amounts of Methyl Salicylate in a round bottom flask containing 50mL of Absolute Ethanol. Then few drops of the catalyst HCL concentrate Solution were added to the content being stirred with magnetic stirrer first at STP for about16 hrs, later refluxed at moderate Temperature nearly 350 c by putting it on heating mantle and made up at 40 0c, the reflux continued with proper condenser setup totally for 4.30 hrs. The Completion of the reaction was physically observed by color change from yellowish to red and was checked by running TLC plates in 1:9 v/v ratio of DEE/Benzene solvent: After confirmation of the completion of the reaction, the product was allowed to cool slowly, and was carful sealed with Aluminum Foil. The compound was precipitated on standing in the refrigerator over two nights, then filtered and washed. After 48 hours the crystal was separated from the mother liquor by filtration process by using 90mcm diameter filter paper. The mother liquor was evaporated for further recrystallization.
    The yellowish red compound formed was then filtered, and washed repeatedly with cold ethanol. To ensure purity the product was recrystallized by weighing 200gm of the crystal was weighed and added to 50ml ethanol absolute and refluxed on the heating mantle until it got dissolved. Then it was filtered while it was hot in order to remove impurity. Then it was kept in the refrigerator Ice bath for another 48 hours. Then the crystallized was filtered; the filtrate was collected and sent for further 1HNMR and IR analysis procedure.

    Scheme 2 Reaction that results in formation of (2, 4-dinitrophenyl)-2-hydroxybenzohydrazide
    • 3.2.2. Synthesis of Methanal-2,4-Diphenylhydrazide

    The preparation was carried out according to a previously reported method. 14.31g of A wet powder of 2,4-DNPH, was added to equimolar amount of Formaldehyde (2ml) in to a round bottom flask containing 75mL of Absolute Ethanol and 2ml equimolar amounts of Formaldehyde. Then few drops of the catalyst HCL concentrate Solution were added to the content being stirred with magnetic stirrer first at STP for about16 hrs, later refluxed at moderate Temperature nearly 350 c by putting it on heating mantle and later made up at 40 0c, totally for 4.30 hrs: the reflux continued with proper condenser setup. The Completion of the reaction was physically observed by color change from yellowish to red and was checked by running TLC plates in 1:9 v/v ratio of DEE/Benzene solvent: After confirmation of the completion of the reaction, the product was allowed to cool slowly, and was carefully sealed with Aluminum Foil. The compound was precipitated on standing in the refrigerator overnight, then filtered and washed. After one day the crystal was separated from the mother liquor by filtration process by using 90mcm diameter filter paper. The mother liquor was evaporated for further recrystallization.
    The yellowish red compound formed was then filtered, and washed repeatedly with cold ethanol. To ensure purity the product was recrystallized by weighing 200gm of the crystal was weighed and added to 50ml ethanol absolute and refluxed on the heating mantle until it got dissolved. Then it was filtered while it was hot in order to remove impurity. Then it was kept in the refrigerator Ice bath for another 48 hours. Then the crystallized was filtered; the filtrate was collected and sent for further 1HNMR and IR analysis procedure.


    Scheme 3 reaction that result in formation of Methanal-2, 4-Diphenylhydrazide
  • 3.2.3. Determination of some physical constant of the Compounds

  • Some physical properties like percentage yield, Mol. Weight, appearance, and RF value were summarized under table -1. The RF value was achieved by TLC procedure. RF was measured and calculated to; Compound product # one was found to have the Rf value of 0.75 and compound product #two have got 0.85. From these result it was concluded that the product acquires major Non-polar and slight polar Functionality. The other physical constant measured was the percentage yield; thus Product of the reaction #one, was 55.36% and Product of Reaction # two is 55.72%. The rationale of reduction in yield could be concluded that because of some wastages, during the process and some inconveniencies. Solubility was tested in the ready available solvents stated under (Table-2). But all were not satisfactory so the only good solvent for both products is concluded to be (DMSO)

    Table 1 Physical Constant
    COMPOUNDYIELDMOL. WIEGHTMole. FormulaAPPEARANCERf
    (2,4-dinitrophenyl)-2-hydroxybenzohydrazide 55.36% 318.24g/mole C13H10N4O6 Red orange 0.75
    Methanal-2,4-Diphenylhydrazide 55.72% 210.15g/mole C7H6N4O4 Yellowish Orange 0.85




    2.1 Solubility
    No.CompoundSolubility
    DEEETOHMeOHAcetoneBenzeneDMSO
    1(2,4-dinitrophenyl)-2- hydroxy benzohydrazide +/= +/- = = = +++
    2Methanal-2,4-Diphenylhydrazide + + = = = +++
    Table 2Where, + = soluble, - = insoluble and +/- = slightly soluble
    • 3.2.4. Recrystallization

    The product Scheme 4 & Scheme 5 was weighed first to calculate the percentage yield. Then 200gm and 150gm of respective product was weighed & added to the Erlenmeyer flask dissolved in absolute EtOH at an elevated temperature; it was filtered while it was hot, to remove any impurity. Then the filtrate was discarded with the filter paper while the solution was allowed to be recrystallized in the Ice bath for 24 hours. The solution which was kept in the Ice bath was crystallized, and then the crystal was removed by filtration while the mother liquor was remained in the Erlenmeyer for further study in the future.
    Solubility test was checked by using four different standardized solvents, Benzene, DEE, Acetone and Chloroform. The derivative was found to be sparingly soluble in Acetone concentrate solution and hot Ethanol Absolute solution. Melting point was referred from the product label.
    The crystal collected is the ideal pure derivative obtained, and 15mg of each product was sent to HNMR analysis for further structural elucidation; and another 15mg of each was sent to EPHARM for ER analysis.
    • 4. NMR DATA And Analysis
    4.1. 1H-
    4.2. NMR Analysis of scheme 4
    Nuclear magnetic resonance 1H-NMR spectra of scheme 4 were recorded on a Bruker 400MHZ spectrometer using a DMNSO solvent. The chemical Shifts of each compound were expressed in parts per million (PPM) (δ values) with respect of tetramethylsilane (TMS) as internal reference standard and coupling constants (J value) in Hz. Splitting patterns are designated as follows: s, singlet; and d, doublet.

    Figure 1 (2, 4-dinitrophenyl)-2-hydroxybenzohydrazide
    1H-NMR (PPM): 6.844-6.871 (d, 1H, Phenyl C4-H); 7.618-7.683 (dd 2H, Phenyl C3, 5-H); 7.878-7.902(d,1H, Phenyl C6 H); 8.24-8.27,(d,1H,2,4-DNP C6 H); 8.35-8.384,(d,1H 2,4-DNP C5H); 8.808-8.848, (d,2H, NH-NH,); 10.013 (s,1H, 2,4-DNPH C3H,); 11.491(s,1H,OH)
    • 4.2.1. Result 1H-NMR result

    The 1H NMR of compound scheme 4 displayed a doublets peak at 6.844-6.871ppm, integrated for one proton and attributed to the Phenyl- C4H, a doublets- doublets peak at 7.618-7.683 ppm thus, was assigned for the Phenyl C3,5- 2H, 7.878-7.902, displayed doublet pick corresponding to 1H, assigned to Phenyl C6 H, doublet pick, for 1 proton assigned for 2,4-DNP C6 H; 8.35-8.384, doublet pick corresponding to 1H assigned to 2,4-DNP C5H and 8.808-8.848, doublet-doublet picks corresponding to 2H, attributed to NH-NH, groups; Moreover, two singlet pick far away from the central spectrum on 10.013 and 11.491 ppm attributing to proton on 2,4-DNP C3 and OH group phenyl respectively. The last singlet picks are due to their presence on the proximity of Electron Withdrawing groups EWG because they are deshielded and the spectrum will be shifted away. Figure 1-3b.

    Figure 2
    • 4.3. 1HNMR analyses of Scheme 5

    Nuclear magnetic resonance 1H-NMR spectra for compound scheme 5 was recorded on a Bruker 400MHZ spectrometer using a DMNSO solvent. The chemical Shifts of each spectrum were expressed in parts per million (PPM) (δ values) with respect of tetramethylsilane (TMS) as internal reference standard and coupling constants (J value) in Hz. Splitting patterns are designated as follows: s, singlet & d, doublet.

    Figure 3
    1H-NMR (PPM) of Compound #three; 5.043, (dd, 2H, N=C H); 7.654-7.679(d, 1H, 2,4-DNPC6 H); 8.232-8.263(d, 1H, 2,4-DNP C5H ); 8.799-8.806 (d,1H, 2,4-DNP C3H); 10.09 (s,1H, N-NH)
    • 4.3.1. 1HNMR result

    The 1H NMR of compound #2, Fig. 1 displayed a doublets peak at 5.04ppm, integrated for 2Hand attributed to the N=C two protons, a doublets peak at 7.654-7.679 ppm thus, was assigned for the 2,4-DNP C6- proton, 8.232-8.263, displayed one doublet pick corresponding to 1H, assigned to 2,4-DNP C5 H, 8.799-8.806, one doublet pick corresponding to 1H assigned to 2,4-DNP C3H and one singlet picks corresponding to 1H, attributed to NH-N=, groups; The last singlet picks are due to their presence on the proximity of Electron Withdrawing groups EWG because they are deshielded and the spectrum were shifted away.


    Figure 4 Methanal-2, 3-DNPH (ide)
    • 5. Discussion

    This synthesis and characterization of Novel Hydrazide compound which was commenced in the Universal University college has began with the derivatization of carbonyl compound of by using 2,4-Dinitrophenylhydrazine compound. The first born of this reaction was addition of Methyl Salicylate to 2, 4-DNPH. The amine group has a loan pair of electron density that it is highly is nucleophile, and interacts with electrophilic groups. In this case carbonyl groups act as an electrophile. Acidic media facilitates the forward reaction; the reaction is sensitive that hydrazine group can be easily degraded to Nitrogen molecule and Simple ammonia; and therefore close monitoring of temperature from ambient to moderate temperature was required.
    In the reaction the magnetic Steerer plays great role. It steers for a long time the solution so that the primary amino group will have access to the electrophilic functional group. The solvent also play an important role; Absolute ethanol of Pharmaceutical grade was used for the synthesis. Contamination with water was absolutely avoided so that Hydrazine functional group should be protected from degradation by hydrolysis. These were insured by washing all the tools properly, drying and rinsing it by Ethanol.
    In this procedure as indicated on “SCHEME TWO” the Amine group of 2, 4-DNPH was introduced to carbonyl group of methyl Salicylate. As the electron from the Amine group attack the carbonyl ester of methyl Salicylate, the ester bond loses its strength resulting in the cleaving away of methanol group in a few steps as a leaving group. Then carbonyl groups requirement of electron gets satisfied and stable product is formed. The reaction is called Addition Elimination Reaction. The product is collected and allowed in the Ice bath for 24hours to allow crystallized. Then the dry product was separated by filtration.
    In a similar manner to above reaction, the SCHEME three also reacts under an ambient to moderate temperature. 35-450 C. the solvent is the same and the reaction takes place in Acidic media. The principle of magnetic steering and Ice bathing for 24 hours is all the same. Though hydrazine groups have numerous medicinal significance, due to some human and animal hazards, so any leftover of the hydrazine and formaldehyde should be handled cautiously and properly disposed and this was done carefully.
    • 6. Conclusion
    The main objective of this procedure was to synthesize and characterize (2,4-dinitrophenyl)-2-hydroxybenzohydrazide and methanol-2,4-Dinitrophenylhydrazone; and To verify the Chemical Structures of the synthesized (2,4-dinitrophenyl)-2-hydroxybenzo-hydrazide and methanol-2,4-Dinitrophenylhydrazone by condensation reaction; verify them Using Spectrophotometric Techniques (H-NMR & IR); The synthetic derivatization was successfully done. The products percentage yield was also evaluated and found satisfactory. The data of product achieved was analyzed by 13C-NMR &1H-NMR as well as IR data. The product was confirmed to be consistent as forecasted.
    From the literature survey stated in this paper and many other one, this product has acquired a biological activity. There is no doubt that it has a pharmaceutical significance. The pure product attained is preserved in the laboratory of the institution for further biological characterization. The researcher of this project recommends that given the time and resource in the future any person who would like to pursue his research on this line the product of this two synthesis would be a starting material.
    • 7. References
    [1] Singh M. And Raghav N Biological Activities of Hydrazones International Journal Of Pharmacy And Pharmaceutical Sciences Vol 3, Issue 4, 2011
    [2] Gladiola Tantaru, Mihai Nechifor and Lenuta Profire; Synthesis and biological evaluation of some new Schiff bases and their Cu(II) and Mg(ІІ) complexes; African Journal of Pharmacy and Pharmacology, 2013 Vol.7(20), “pp.” 1225-1230
    [3] Hatem A. Abdel-Aziz, Tilal Elsaman Mohamed.I Attia and Amer M. Alanazi Molecules 2013, 18, 2084-2095
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    Assessment of attitudes and practices of physicians’ regarding generic drug prescribing in Girum, Hayat and St Gebrieal Hospitals, Addis Ababa, Ethiopia
    By: Diana G/Giorgis
    Abstract
    Background: Health care costs have been on the rise globally, and this trend is expected to continue. Expenditures on pharmaceuticals are considered a major driving factor for rising health care costs. The use of generic drugs can provide substantial savings in health care cost without affecting the quality or the therapeutic effect of the prescribed medicine.
    Objective: This study aimed to assess physicians’ attitudes and practices regarding generic drug prescribing in Girum, Hayat and St Gebreal Hospitals, Addis Ababa, Ethiopia.
    Methodology: A cross-sectional study design method was employed. The source populations for this study were all physicians whom were not in annual leave in Girum, Hayat and St Gebreal hospital. Data was collected through a self-administered questionnaire. A quota sampling method was used to select the respondents that were included in the inclusion criteria.
    Result: Out of the 30 physicians, 73.4% agreed on equivalency of both generic and brands approved by FMHACA. About 46.6% of physicians agreed that therapeutic failures are a serious problem with some generic products, and 60% of physicians agreed on equal effectiveness of most brand dugs and their generic alternatives and 39.9% disagreed. Forty percent of respondents felt sometimes pressurizes by patients to prescribe generics while 36.7 % of physicians rarely felt pressurized by patients.
    Conclusion: Physicians in this study support the use of generic substitutes for brand name drugs when it is available and appropriate for the patients. The finding of this study indicates that physicians faced multiple and sometimes competing forces to prescribe either brand name or generic drugs. In this study, the majority of physicians support generic drug substitution.



    • 1. Introduction
    • 1.1. Background of the study

    Health care costs have been on the rise globally, and this trend is expected to continue (1). Expenditures on pharmaceuticals are considered a major driving factor for rising health care costs. Spending on drug prescriptions has increased sharply in recent years with a growth rate faster than other major components of the health care system (2).
    Many countries have adopted cost-control strategies to slow drug spending growth such as drug utilization review and encouraging the use of less expensive generic drugs (3, 4).
    The use of generic drugs can provide substantial savings in health care cost without affecting the quality or the therapeutic effect of the prescribed medicine. A generic drug is identical, or bioequivalent, to a brand name drug in dosage form, safety, strength, route of administration, quality, performance characteristics and intended use (5).
    The adoption of generic drugs in medical practices is a complex phenomenon and many determinants can affect it. Physicians play a key role in controlling this phenomenon and their decision in prescribing generic drugs is likely to be affected by many factors. Although there is increasing local and international encouragement for physicians to prescribe generic products, some physicians are not in favor of prescribing generic drugs. Therefore, many studies have tried to find determinants of this practice (6, 7).
    • 1.2. Statement of the problem
    Physicians play a key role in generic drug prescribing, but their behavior is affected by many determinants. They face competing forces to prescribe either brand name or generic drugs (8). This decision making is based upon physicians’ knowledge regarding generic drug effectiveness (therapeutic value) and price differences between brand name and generic drugs. Due to lack of this knowledge, physicians tend to shift to brand name drugs prescribing.
    Patient attitudes are also a strong determinant affecting generics prescription among Physicians. They often yield to patient demand for brand name drugs even when generics are available. This generic typically costs 20 to 25 percent less than the brand-name drug (9). And so the patient thinks that it’s of low quality and ineffective.
    Other factors that influence prescribing are physicians’ personal preferences and authorities’ pressure. Most physicians are not extremely sophisticated about generic drug or drug costs. Their personal preferences are in terms of their specialty, field experience, case load, training level and type, will result in substantial reluctance to generic prescribing (10,11). Furthermore, lack of physicians’ confidence in regulatory authorities, like DACA, in ensuring quality, safety and efficacy of generic drugs.
    • 1.3. Significance of the study
    It seems that regardless of the knowledge provided about generic drug practice, the required behavior can be ensured. Proper education and training programs for practicing clinicians are recommended to raise the level of physicians’ knowledge of the benefits of generics. Pharmacists are source of information about generic drugs for physicians. Therefore, the pharmacist contribution in providing valid information to physicians should be improved through training programs, workshops, and other active methods of education and learning (12). Physicians should take their information about drugs from reliable sources. Probably the best source of information about marketed drugs in Ethiopia is the National Drug Formulary (NDF). It is available on-line and provides information and pricing on registered and marketed drugs in the country.
    This study intends to improve drug prescription in the clinical practice by mutual and active interaction between the physician and the patient. Both physicians and patients can be empowered by reliable information so that they both can place adequate pressure and influence on the other party to influence generic prescription (13). Interventions to reduce the practice of prescribing and patient demand for brand-name drugs might include giving pharmacies in health systems or hospitals the power to override prescriptions unless a patient was allergic to a generic alternative and proper patient education regarding their safety and effectiveness.
    Although physicians accepted generic substitution under policy and economic pressures, they still have concerns about overall generic drugs’ quality and reliability, and switchability of certain drug categories. These concerns prevent the full adoption of generic drugs prescribing and substitution by physicians, which can lead to escalation in health-care costs either on the governments or consumers directly (13). In order to eliminate these concerns, there should be full cooperation between governments, educators, professional organizations and consumers associations: regulatory authorities through assuring that generics are produced and kept according to the required standards; educators through teaching the concepts and values of generic medicines and disseminating knowledge on the standards required to register generics; professional bodies through declaring their views from generic practices in their policy statements; and consumers’ associations through demanding to be informed about the drugs they will pay for.
    • 2. Objectives
    • 2.1. General objectives
    • This study aims to assess physicians’ attitudes and practices regarding generic drug prescribing in Girum, Hayat and St Gebreal Hospitals, Addis Ababa, Ethiopia.
    • 2.2. Specific Objectives
    • To determine physicians’ attitude towards generic drug prescribing in relation to patient demand and personal preference in Girum, Hayat and St Gebreal Hospitals.
    • To identify physicians’ practices on the use of generic medicines based on their knowledge about generic drugs, in Girum, Hayat and St Gebreal Hospitals.
    • To identify the factors which influence physicians’ to prescribe generic drugs in Girum, Hayat and St Gebreal Hospitals.
    • 3. Methodology
    • 3.1. Study Area and Period
    The study was conducted in Addis Ababa city administration, which is established in November, 1887 by Emperor Menelik II and Empress Taitu, currently serves as the Federal Capital of Ethiopia, a chattered city having three layers of administration: city government at the top, 10 sub city administrations in the middle and 99 Kebele administrations at the bottom, covers an area of 540 square kilometers.
    This study assessed attitudes and practices of physicians’ regarding generic drug prescribing in Girum, Hayat and St Gebreal hospital, which is located in central Addis Ababa, Ethiopia.
    The study was conducted from April 1, 2013 to July 30, 2013 for the period of four consecutive months in Girum, Hayat and St Gebreal Hospitals, Addis Ababa, Ethiopia.

    • 3.2. Study Design
    A cross-sectional study design was employed to assess the attitude and practice of physicians regarding generic drug prescribing in Girum, Hayat and St Gebreal hospitals in Addis Ababa.
    • 3.3. Study Population
    The source population for this study was all physicians that are currently working in Girum, Hayat and St Gebreal Hospitals.
    • 3.3.1. Inclusion Criteria
    • All physicians working in Girum, Hayat and St Gebreal hospital, whom weren’t on annual leave & those who consented to take part in the study.
    • 3.3.2. Exclusion Criteria
    • Those physicians whom weren’t willing to take part in the study.
    • 3.4. Sampling Procedures
    Quota sampling method was used to select the respondents that were included in the inclusion criteria.
    • 3.5. Data Collection Instrument
    Data was collected through a self-administered questionnaire. The questionnaire is divided into three sections.
    • v Demographics: Questions related to the respondents age, gender, marital status and year of service.
    • v Attitude test: this part of the questionnaire was related to examine physicians’ attitude towards product benefits that generic drugs have: cost effective, of high quality, and are as effective as the branded drugs.
    • v Practice test: related to the use of generic medicines by physicians’ based on their knowledge about generic drugs and factors that influence physicians’ generic drug prescribing.
    • 3.6. Data Entry and Analysis
    The participants’ response was encoded and the collected data was analyzed using SPSS version 16 software package. Descriptive statistics was used to calculate the proportion of each group of respondents whom agreed/disagreed with each statement in the questionnaire.
    • 3.7. Data Quality Assurance
    To establish reliability, simplicity and explicitly of the questions on the questionnaire a pre-test was performed among physicians in Girum, Hayat and St Gebreal Hospitals. Accordingly no irregularities or confusing questions were found.
    • 3.8. Study Variable
    Table 1: Study Variables
    Dependent VariablesIndependent Variables
    Attitude of physicians regarding generics Demographic factors: Age, Sex, and year of experience.
    Practice of prescribing generics by physicians
    Factors influencing physicians to prescribe generics

    • 3.9. Ethical consideration

    The proposal of this study was submitted to Universal medical College, research and publication office. The purpose of this study was explained to the respondents before consenting verbally. Participation of the respondents was on voluntary bases and their anonymity was maintained. Every received data was treated carefully and confidentially. The respondents had the right to refuse to join this study and no need to explain their reasons. The data, that were collected, were only used in this research and their information was fully confidential.
    • 4. Results
    • 4.1. Demographic characteristics

    All physicians who worked in Girum, Hayat and st. Gebrieal hospitals were included in this study. A total of 30 participants were incorporated in this study. The response rate was 100%. The median age of the respondents was 35. Most of the respondents, 93.3% (28) were males. This finding showed that majority (53%) of respondents was married. Most of the respondents, 60% (18) had longer experience, thus, finding shows that majority of the respondents had more than 10 years of experience. The socio- demographic characteristics of the participants in the study are shown in table 1 below.
    Table 1: Demographic characteristics of the respondents, in selected private hospitals in Addis Ababa
    CharacteristicsFrequency%
    Sex
    Male 28 93.3
    Female 2 6.7
    Age
    >35 15 50
    <35 15 50
    Marital status
    Married 16 53.3
    Unmarried 14 16.7
    Year of service
    <10 12 40
    >10 18 60

    • 4.2. Attitude of the respondents

    The assessment of the attitude of physicians regarding generic drug prescribing were scored as strongly agree, somewhat agree, neither agree nor disagree, somewhat disagree, strongly disagree. As depicted in table 2 below, out of the 30 physicians, 73.4% agreed on equivalency of both generic and brands approved by FMHACA. About 46.7% of physicians agreed that patients wanted them to prescribe generics while 53.3% of physicians disagreed that patients wanted them to prescribe generics. About 40% of physicians agreed on wider use of generics will result in less money for research and development of new pharmaceuticals and 59.9% of physicians disagreed. Close to half, 46.6% of physicians agreed that therapeutic failures are a serious problem with some generic products while 52.9% of physicians disagreed on therapeutic failures with some generic products. About 30% of physicians agreed to willingly support generic substitution for brands and 70% of physicians disagreed to willingly support generics substitution. Most of the physicians, 63.4% disagreed on whether most of physicians do support generics prescribing today. About 73.3% of physicians agreed on not substituting drugs with narrow therapeutic indices even when required by third parties while 26.6% of physicians disagreed. About 60% of physicians agreed on equal effectiveness of most brand dugs and their generic alternatives and 39.9% disagreed.
    Table 2: Attitude of the respondents in selected private hospitals in Addis Ababa
    Study variablesFrequency%
    All products approved by FMHACA as generic drugs can be considered therapeutically equivalent with brand name products.
    Strongly Agree 14 46.7
    Somewhat agree 8 26.7
    Neither agree nor disagree 5 16.7
    Somewhat disagree 2 6.7
    Strongly disagree 1 3.3
    Patients want me to prescribe generic drugs
    Strongly Agree 3 10.0
    Somewhat agree 11 36.7
    Neither agree nor disagree 6 20.0
    Somewhat disagree 4 13.3
    Strongly disagree 6 20.0
    Wider use of generic drugs will mean that less money will be
    used for research and development of new pharmaceuticals.
    Strongly Agree 1 3.3
    Somewhat agree 11 36.7
    Neither agree nor disagree 10 33.3
    Somewhat disagree 4 13.3
    Strongly disagree 4 13.3
    Therapeutic failures are a serious problem with some generic products
    Strongly Agree 7 23.3
    Somewhat agree 7 23.3
    Neither agree nor disagree 7 23.3
    Somewhat disagree 4 13.3
    Strongly disagree 5 16.3
    Willingly support generic substitution for brand name
    Strongly Agree 6 20
    Somewhat agree 3 10
    Neither agree nor disagree 9 30
    Somewhat disagree 12 40
    Strongly disagree - -
    Most physicians support the use of generics today.
    Strongly Agree 4 13.3
    Somewhat agree 7 23.3
    Neither agree nor disagree 14 46.7
    Somewhat disagree 5 16.7
    Strongly disagree - -
    There are some drugs with narrow therapeutic indices that should not be substituted even when required by third parties.
    Strongly Agree 13 43.3
    Somewhat agree 9 30.0
    Neither agree nor disagree 7 23.3
    Somewhat disagree - -
    Strongly disagree 1 3.3
    Most brand name drugs and their generic alternatives are equally effective.
    Strongly Agree 9 30.0
    Somewhat agree 9 30.0
    Neither agree nor disagree 4 13.3
    Somewhat disagree 4 13.3
    Strongly disagree 4 13.3
    • 4.3. Practice of the respondents

    This part of the assessment tried to look into the physicians’ practice of generics prescribing based on their knowledge and experience with generics. As indicated in the table 3 below, more than half, 56.7% (17) of the respondents expressed that they did support generic substitutions in most cases but there are some situations where it will not be appropriate and 33.3 %( 10) of physician support substitution in all cases. While 10 %( 3) of physicians didn’t support generic substitution. Majority of the respondents 63.3 %( 19) find information about availability of generic alternative to brands through electronic devices (internet, medical journals, drug company written information and informational literature) while 36.7% (11) of physicians gather their information through individuals (drug manufacturer representatives, pharmacists, colleagues and meetings or conferences). Almost all, 96.7 % of physicians in this study had knowledge about the price differences between brands and generics. And 3.3% of physicians had a little knowledge about price differences. About 40 %( 12) of respondents felt sometimes pressurizes by patients to prescribe generics. About 36.7 %( 11) of physicians rarely felt pressure by patients. While 23.3 %( 7) of physicians never been pressurizes by patients to prescribe generics.


    Figure 1: General Opinion Regarding Substitution of Generic Medications for Brand Name Drugs% Supporting Statement in selected private hospitals in Addis Ababa

    Table 3: Assessment of practice of the respondents in selected private hospitals in Addis Ababa
    Study VariablesFrequency%
    General opinion of substituting generics for brands.
    Support generic substitution in all cases 10 33.3
    Support generic substitutions in most cases 17 56.7
    Don’t support generic substitution for brands 3 10
    Availability of information regarding generic alternative to brands
    Electronic sources 19 63.3
    Individuals 11 36.7
    Physician’s knowledge about price differences between brands and generics.
    Very little 1 3.3
    Some 15 50
    A lot 14 46.7
    Patients pressurizing physicians to prescribe generics.
    Never 7 23.3
    Rarely 11 36.7
    Sometimes 12 40

    • 4.4. Reasons of physicians to prescribe brand name drugs over generics

    This part looks into the reasons for physicians to prescribe brand name drugs over generics. As observed from the table 4 below, out of 30 physicians, 60% said that switching a patient from brand name to generics may not change the outcome therapy while the rest, 40% reasoned somewhat effect may be noticed while switching brand to generics. More than half, 56.7% of physicians agreed that generic substitutions for brands are not available in the desired dosage while 43.3% didn’t agree that generic substitution for brands is not available in desired dosage. About 60% of physicians agreed that patients will be confused to take pills different in color and size and 40% of physicians didn’t agree at all. Majority of respondents, 76.7% did not agree at all that patients require medications with narrow therapeutic indexes. About 40 % of respondents had somewhat concerns about side effects from generics while 60.6% of physicians didn’t have concerns about side effects of generics. More than half, 56.7% of physicians agreed a great deal on the cost difference between brand name drugs and generics being minimal while the rest, 43.3% didn’t agree at all on the cost difference being minimal between brand name drugs and generics.
    Table 4: Reasons contributing physicians to prescribe brand name drugs over generics in selected private hospitals in Addis Ababa
    Study variablesFrequency%
    Switching patient from brand to generics may change Outcome of therapy.
    Not at all 6 20
    Not very much 12 40
    Somewhat 8 26.7
    A great deal 4 13.3
    Generic substitution for brands is not available in desired Dosage.
    Not at all 5 16.7
    Not very much 8 26.7
    Somewhat 17 56.7
    Patients may be confused to take pills different in size and color than
    Not at all 2 6.7
    Not very much 10 33.3
    Somewhat 11 36.7
    A great deal 7 23.3
    A patient requires medication with narrow therapeutic index.
    Not at all 14 46.7
    Not very much 9 30
    Somewhat 5 16.7
    A great deal 2 6.7
    Concerns about side effects from generics.
    Not at all 9 30.3
    Not very much 9 30.3
    Somewhat 11 36.7
    A great deal 1 3.3
    The cost differences between brand name drugs and generics may be minimal.
    Not at all 9 30
    Not very much 4 13.3
    Somewhat 6 20
    A great deal 11 36.7

    • 4.5. Factors influencing physicians to prescription of generic drug

    Factors that influence prescribing are personal preferences and patient and authorities’ pressure. As indicated in table 5 below, half of physicians felt pressurized by patients to prescribe generics. Majority of physicians, 73.3% (22) said government has a role in controlling and enforcing generics prescribing while 26.7% (8) of physicians said that government has no role. About 83.3% (25) of physicians felt pressurized from health care administrations to prescribe generics. Close to three forth, 70%(21) of physicians personally believed using generics saves health costs while the rest didn’t believe using generics will save health costs (table 4).

    Table.5 Factors influencing physicians to prescribe generics in selected private hospitals in Addis Ababa
    Study variablesFrequencies%
    Patient pressure to prescribe generics.
    Yes 15 50
    No 15 50
    Governmental role in controlling and enforcing physicians To prescribe generics.
    Yes 22 73.3
    No 8 26.7
    Pressure from health care administration to prescribe generics.
    Yes 5 16.7
    No 25 83.3
    Personally believe using generics saves health costs.
    Yes 21 70
    No 9 30





    • 5. Discussion

    The response rate of physicians to the questionnaire (100%) was satisfactory and comparable to other studies (16). Most physicians in this study were in their late thirties in age. They were mainly practicing clinicians for an average period of experience that exceeded 10 years. The result shows that the physicians had an overall good attitude and practice regarding generic prescribing in which other studies showed similar findings (16). As a survey done in Saudi Arabia, majority of the respondents (96%) reported that they knew enough about the therapeutic value of generic drugs (16) while this study showed that 73.4% of physicians knew enough about the therapeutic value of generics.
    Fifty six percent of the respondents expressed that they did support generic substitutions in most cases but there are some situations where it will not be appropriate and 33.3 % of physician support substitution in all cases while 10 % of physicians didn’t support generic substitution. Other studies in Slovene general practitioners reported that majority of physicians supported generic substitutions in most cases (7). The majority of physicians also reported that they knew about the price difference between brand name and generic drugs. Also, they strongly agreed that the price difference helped them to switch to a generic prescription; this is similar to findings in other studies (7).The purpose of this study was to assess the attitude and practice of physicians regarding generic drug prescribing in Girum, Hayat and St Gebreal hospitals and to identify factors that influence physicians to prescribe generic drugs so that the result of this study could be used to address the pressure that physicians experience and to encourage them to prescribe generic drug names.
    In this study the result showed that 50% of physicians felt pressurized by patients to prescribe generics. And 73.3 % of physicians agreed that the government has a role in controlling drug quality and assurance. While the study conducted in Saudi Arabia, 25% of physicians were more likely to report that they felt pressured to prescribe generics by patients and most physicians(82%). had a positive attitude towards the government role in controlling the drug industry (16).

  • 6. Conclusion and Recommendations
  • 6.1. Conclusion
  • Physicians in this study support the use of generic substitutes for brand name drugs when they are available and appropriate for the patient. While they say there are some drugs with narrow therapeutic indices that should not be substituted even when required by a third party, they also report feeling pressure from patients and health care administrators to prescribe generics. They do have positive attitude towards generic drug prescribing concerned with therapeutically equivalence with brand name drugs.
    The findings of this study indicate that physicians are faced by multiple and sometimes competing forces to prescribe either brand name or generic drugs. In this study, the majority of physicians support generic drug substitution. Supporting forces for generic prescription include physician knowledge about generic drug effectiveness and price differences, a positive attitude among physicians towards generic drugs, the influence of patients on prescribing generic drugs and the government role in supporting generic prescription. On the other hand, factors that work against generic prescription include the influence of the brand name drug companies and the use of drugs with a narrow therapeutic index.
    Further studies are needed to explore situations and factors where switching from brand to generic drugs may not be advised. Overall, it can be argued that the organizations to a moderate extent influence the prescription of drugs. Since the current study was based on respondents working at Girum, Hayat and St Gebreal hospitals, Addis Ababa the results might not be entirely representative. Therefore a much broader research should be conducted in other hospitals to determine whether the same results would be found.
    • 6.2. Recommendations
    From the above result and discussion I would recommend the basic suggestive points as follows:
    • ü Efforts to educate physicians early in their career about the benefits and the value of generic drug prescribing should be encouraged through pre service trainings, giving seminars.
    • ü Pharmacist contribution in providing valid information to physicians should be improved through training programs, workshops, and other active methods of education and learning.
    • ü Giving pharmacies in health systems or hospitals the power to override prescriptions unless a patient is allergic to a generic alternative.
    • ü Policy makers should continue to encourage generic prescribing when generic equivalent is available and suitable through post-marketing surveillance.
    • 7. References
    • 1. Borger C, Smith S, Truffer C, Keehan S, Sisko A, Poisal J, et al. Health spending projections through 2015: changes on the horizon. Health Aff. 2006; 25:W61–73.
    • 2. Steinwachs DM. Pharmacy benefit plans and prescription drug spending. JAMA. 2002;288:1773–1774. [PubMed]
    • 3. Ess SM, Schneeweiss S, Szucs TD. European healthcare policies for Controlling Drug Expenditure.Pharmacoeconomics. 2003;21:89–103. [PubMed]
    • 4. Rocchi F, Addis A, Martini N. Current national initiatives about drug policies and cost control in Europe: the Italy example. J Ambul Care Manage. 2004; 27:127–31. [PubMed]
    • 5. The U.S. Food and Drug Administration (FDA); Center for Drug Evaluation and Research (CDER) what are Generic Drugs? Available http://www.fda.gov/cder/ogd/#Introduction. (Accessed June 2, 2008)
    • 6. Bertoldi AD, Barros AJ, Hallal PC. Generic drugs in Brazil: known by many, used by few. Cad SaudePublica. 2005;21:1808–15. [PubMed]
    • 7. Kersnik J, Peklar J. Attitudes of Slovene general practitioners towards generic drug prescribing and comparison with international studies. J Clin Pharm Ther.2006; 31:577–83. [PubMed]
    • 8. Barrett, L. L. (2005) Physicians’ Attitudes and Practices Regarding Generic Drugs. Washington DC: AARPKnowledge Management, [updated 2005; cited 11 September 2008], pp. 1 – 33, http://assets.aarp.org/rgcenter/health/phys_generic.pdf.
    • 9. Ernst ME, Kelly MW, Hoehns JD, et al. Prescription medication costs: a study of physician familiarity. Arch FAM Med. 2000; 9:1002–1007.
    • 10. Bower, A. D. and Burkett, G. L. (1987) Family physicians and generic drugs: A study of recognition, information sources, prescribing attitudes, and practices. Journal of Family Practice 24 (6): 612 – 616.
    • 11. De Run, E. C. and Felix, M. -K. N. (2006) Patented and generic pharmaceutical drugs: Perception and prescription. International Journal of Business andSociety7 (2): 55.
    • 12. Mott DA, Cline RR.Exploring generic drug use behavior: the role of prescribers and pharmacists in the opportunity for generic drug use and generic substitution.Med Care. 2002;40:662–674. [PubMed]
    • 13. Ashworth M, Golding S, Majeed A. Prescribing indicators and their use by primary care groups to influence prescribing. J Clin Pharm Ther. 2002; 27:197–204. [PubMed]



















    Assessment job satisfaction of pharmacy professionals working in public hospitals in Addis, Ababa as a case study, Ethiopia
    By: Eden Tadesse
    Abstract
    Background: Job satisfaction is a worker’s sense of achievement and success on the job. It is generally perceived to be directly linked to productivity as well as to personal well-being. Job satisfaction implies doing a job one enjoys, doing it well and being rewarded for one’s efforts. Job satisfactionfurther implies enthusiasm and happiness with one’s work. Job satisfaction is the key ingredient that leads to recognition, income, promotion and the achievement of other goals and the achievement of other goals that lead to a feeling of fulfillment (Kaliski, 2007).
    Objective: to assess job satisfaction of pharmacy professionals working in public hospitals in Addis Ababa as a case study.
    Method: Non probability quota sampling method was used in the research
    Result: 105 public health pharmacist professional were taken for the study of the 49.5 % of them range in the age group of 20-26 4.8% of them to were in the age group of 34-40 58.1% of them were males and the rest were female 59 % of them are single.
    Conclusion: 77% of the respondents were dissatisfied in their job and two third of the subjects are not satisfied in their come while the fourth of them were dissatisfied with their promotion on the other hand participant agree with continues supervision and positive interaction enhance employees satisfaction and work performance.



    1. Introduction
    1.1. Background of the Study
    Health services are affected by several factors such as human resources, delivery system and health infrastructure. Among these, human resources are vital components that deliver health service. Job satisfaction of health workers is significantly important in building up employees’ motivation and efficiency as higher job satisfaction results to better employees’ motivation and efficiency. Higher job satisfaction and higher level of patient satisfaction is the bed rock for the overall high quality health services as Mowday, RT stated clearly. Fridrkinsx, etal clarified that job dissatisfaction results in burn out and turn over would exacerbate the current shortage and results in serious under staffing health care facilities. This has a potential negative repercussion on delivery of high standard and quality patient care. There is compelling evidence that suggests reduction in health professional staff below certain level is related to poor patient outcomes. In Ethiopia health service organizations and management has been decentralized, but still there is shortage of health professionals in different health service sectors. This has a great deal of undesirable impacts on rendering efficient services and resource allocation as Ethiopian Social Sector studies (mega 2004 1st edition) discussed in detail.
    In fact, human power is the bed rock for provision of quality health care for the people and high level of professional satisfaction among health workers earn, high dividends such as higher work force retention and patient satisfaction
    It is evident that the delivery of quality health services depends on the availability of a competent workforce and adequate number of professionals with the appropriate knowledge, experience and skills. With the increase in the demand for health services, health systems need to have the right number of workforce with required standard. This availability of health professionals ensures that there is the right number of health professionals put in place. The supply of healthcare workers is not always capable of meeting the demand for the health workers as stated vividly by World Health Organization (2006:101-104)
    As International Pharmaceutical Federation (2006:11) put it, pharmacists worldwide are viewed as the most accessible healthcare workers; hence they play a vital role in the delivery of health care services especially at primary health care levels. Pharmacists represent the third largest healthcare professional groups in the world.
    According to the International Pharmaceutical Federation, (2006:21-22) ,there is an internationally increase in the demand for pharmacists due to the ageing population with the subsequent increased use of prescription drugs, and the increased disease burden such as HIV&AIDS and TB.
    This picture is not different in Ethiopia in terms of the shortage of pharmacists which has put an immense pressure on both public and private health sectors. The number of pharmacists practicing in the private sector is smaller compared to those working in the public sector since the profession is concerned with accessibility which fails to connect public and private sector levels.
    With the growing increase in demand for pharmacists and the disproportionate production of qualified pharmacists in the country, it is important that pharmacist employers consider ways of attracting and retaining pharmacists into their organizations. This is particular vital for the public sector which has always struggled to attract and retain pharmacists. There is also constant competition for talented health professionals between the private and public sectors due to differences in payment packages and working conditions. The pharmacy workforce is very mobile so the country’s educational policy which is another contributor to the shortage of motivated personnel’s. There is also migration of health professionals including pharmacists who move between the public and private sectors, rural and urban areas. This is often referred to as an imbalance in the work force where the majority of professionals are found in the urban private sector while rural health care and rural public sectors are operating with critical shortage health professionals.
    In our context as bulk of health workers suggest there is low esteem and poor satisfaction of the work force that hinders in providing efficient and high quality health service. And when it comes to pharmacists, this lack of motivation can be seen as a big obstacle in giving effective patient care services Due to the lack of inherent self esteem and motivation from the health sector, the profession can be seen less used and lagging behind in service it provides. This situation contributes to the lion share of job dissatisfaction by the health care professionals. For this very reason, job dissatisfaction are: salary, work environment, future involvement in the health care, promotion and lack of incentives are some to mention among the problems.
    This problem has an adverse effect on the health employees as it has a magnitude ranging from work dissatisfaction to leaving the job or changing the field which results in poor patient care satisfaction. The problem is obviously observed while the clinical pharmacist has been in the attachment work experience.
    1.2 Statement of the Problem
    Ethiopia faces with serious human resource problems in terms of health service delivery. There is a shortage of skilled personnel in key areas of the health sector and the shortage of pharmacists has been acknowledged. Most importantly ,there is an uneven distribution of pharmacists between the public and private sectors, despite the public sector lacks the means of attraction and keeping pharmacists, and putting in place incentives to arouse self esteem . Hence Low job satisfaction can result in an increased staff turnover and absenteeism which adversely affect the efficiency of health services and patient care
    Therefore, this study attempts to uncover the extent of the problem under discussion.
    1.3 Significance of the study
    The aim of this study is to assess the factors influencing job satisfaction among pharmacy professionals working in public hospitals in Addis Ababa. Therefore, bringing in to light the problem under discussion and implementing the finding of study is hoped to help pharmacy professionals working currently in the hospitals where the researcher has taken the target population to understand influencing factors, the socio-demographic, economic and other related issues. The findings could also contribute worthwhile benefit to the quality of care that is given by pharmacy professionals to clients and contribute to patient satisfaction. It can also be used as a base line data for those who want to undertake further study on job satisfaction.

    2. Objectives of the study
    2.1. The general objective of this study is to assess job satisfaction of pharmacy professionals working in public hospitals in Addis Ababa as a case study.
    2.3. Specific Objectives
    To achieve the stated objectives above, the specific objectives are:
    • To examine the level of job satisfaction among the pharmacy professionals working in public hospitals in Addis Ababa
    • To identify the factors influencing job satisfaction
    • To suggest possible recommendations based on the findings to build up self esteem to bring job satisfaction.
    3. Methodology
    3.1. Study area and period
    Addis Ababa is the capital city of Ethiopia with an estimated population of three to four million. There are more public and private health facilities in Addis Ababa than any part of the country including 32 public and 60 private health facilities. The study was conducted in ten public hospitals under Addis Ababa health biro and ministry of health. The study period is from March to June 2013.
    3.2. Study Design
    A cross sectional study design was used to assess job satisfaction of pharmacy professionals working in public hospitals in Addis Ababa, Ethiopia
    3.3. Study population
    3.3.1. Target population

    All pharmacy professionals working in Addis Ababa are the target population

    3.3.2. Source population
    • All pharmacy professionals working at ten public hospitals under Addis Ababa health biro and ministry of health.
    3.3 3. Study /sample population
    The study population consisted of all the pharmacy professionals employed in the ten public hospitals. The main reason to embrace all professionals in this study is principally due to the small number of pharmacy professionals in the study area as a result the investigator decided to include all pharmacists found in the study area to ensure the representativeness of the information obtained from the professionals.
    3.3.4. Sample size determination
    The investigator decided to include all pharmacists who are willing and available at the time of data collection from the ten hospitals. The nature of work, working hours, study area and salary scale play a vital role in the satisfaction of employees and is found to be important to incorporate every pharmacist from the selected health facilities in to the research
    3.4. Inclusions
    The inclusion criteria were all pharmacist at five public hospitals, who were available.
    3.5. Sampling method
    Non - probability quota sampling method was used to select the study subjects and hospital.
    3.6. Data Collection Method
    A self-administered questionnaire was used to collect data from the participants. The questionnaire consists of three sections: comprised the socio-demographic characteristics, consist of job satisfaction in public hospital and strategies for retaining pharmacists.
    3.7. Quality control
    Data collection instrument was pre –tested on pharmacy professionals working in Black Lion hospital and adjustment was made based on the assessment of its appropriateness. After every data collection, the investigator checked for the completeness then the data entered using SPSS version 16.0 computer software package. If any error indentified at the time of data managing, the original questionnaire was revised
    3.8.Study variables
    3.8.1. Dependent variables
    • v Job satisfaction
    3.8.2. Independent variable
    • v Age, sex, marital status, qualification, experience, position
    • v Income, patient interaction, promotion, co-workers, supervisor and strategies for retaining pharmacists
    3.9. Operational definitions
    Job Satisfaction: It is an attitudinal variable that reflects how people feel about their jobs overall as well as various aspects of them. Simply, job satisfaction is the extent to which people like their jobs; job dissatisfaction is the extent to which people dislike them. Spector, (2006:217)
    Pharmacy professionals: a person licensed to prepare, compound, and dispense drugs up on written order (prescription) from a licensed practitioner such as a physician, dentist, or advanced practice nurse
    Public hospitals: hospitals (called Government Hospitals) provide health care free at the point of use for any citizen. These are usually individual state funded. However, hospitals funded by the central (federal) government also exist. State government hospitals are run by the state (local) government and may be dispensaries, peripheral health centers, rural hospital, district hospitals or medical college hospitals
    Retention: It is the percentage of employees remaining in the organization Phillips & Connell, (2003:2)
    Turnover: It is the opposite of retention and it refers to the percentage of employees leaving an organization for some reasons Phillips, et.al. (2003:2).

    3.10. Data entry and analysis

    Data were analyzed using SPSS version 16.0 computer software packages. The result were presented using a range of frequencies and percentage in the form of tables and association between the variables and drawn. Finally to ensure the quality of the analysis, adequate time would be spent.

    3.11. Ethical consideration

    • Ethical clearance and approval to conduct this study was obtained from Universal University College, Research and Publication Office. Permission was secured from the medical directors and pharmacy heads of each hospitals. A written consent describing the purpose of the study was prepared and provided to each respondent to obtain their willingness. The investigator ensured the study participants about the confidentiality and privacy of the data gathered.
    4. Result
    4.1. Socio-demographic characteristics of the respondents
    A total of 105 pharmacy professionals were included in the study. From the total study participants about half (49.5%) of them were in the age group of 20-26years while only 4(3.8%) were in the age group of 34-40years. The mean age of the study participants was 1.54 with a standard deviation of 0.596. More than half 58.1% of them were males while the rest are females and about 59.0% were single. Regarding their educational qualification, more than three forth 88.6% of them bachelor of pharmacy as shown in table1.

    Table 1: Socio-demographic characteristics of the respondents, in public hospitals in Addis Ababa, Ethiopia
    Variable Frequency Percent
    Age
    20-26
    52 49.5
    27-33 49 46.7
    34-40 4 3.8
    Total 105 100.0
    Sex
    Male

    61

    58.1
    Female 44 41.9
    Total 105 100.0
    Marital status
    Single

    62

    59.0
    Married 43 41.0
    Total 105 100.0
    Level of education
    Degree or diploma

    93

    88.6
    Master 10 9.5
    Master in business management 2 1.9
    Total 105 100.0



    4.2. Working history of the respondents
    More than two third 66.7% of them have less than five year working experience in public service and only 5(4.8%) of them has 11-15 years public service experience. From the total study subjects 51(48.6%) of them are senior pharmacist and 39(37.1%) were principal pharmacists as depicted in table 2 below.
    Table 2: Working history of the study participants, Public hospitals in Addis Ababa, Ethiopia
    Variable Frequency Percent
    Years of experience
    0-5

    70

    66.7
    6-10 30 28.6
    11-15 5 4.8
    Total 105 100.0
    Position you currently holding
    Senior pharmacist

    51

    48.6
    Principal pharmacist 39 37.1
    Chief pharmacist 7 6.7
    Manager pharmaceutical service 2 1.9
    Other 6 5.7
    Total 105 100.0

    4.3. Level of job satisfaction
    Regarding the level of job satisfaction, from the total study subjects 77.1% of them are not satisfied while the rest 22.9% of them are satisfied with their job as depicted in figure 1 below.

    Figure3: Shows the level of job satisfaction of the study subjects, Public Hospitals in Addis Ababa, Ethiopia
    4.4. Level of satisfaction with respect to certain characteristics
    From the total study subjects, about two third 63.8% of them are not satisfied with their income while the rest are satisfied. With respect to the interaction with patients, majority 80.0% of them are not satisfied. As to the promotion, 81.0% of them are not satisfied while the rest 19.0% are satisfied. About half 50.5% of them are not satisfied with the presence of staff/coworkers at the job and 58.1% of them are satisfied with the presence of supervisor on the job. Close to two third 61.0% of them are not satisfied with the way pharmacist are rated as shown in table 3 below.

    Table 3: Job satisfaction study participants in public service of the, Public Hospitals in Addis Ababa, Ethiopia
    VariableFrequencyPercent
    Income
    Not satisfied

    67

    63.8
    Satisfied 38 36.2
    Total 105 100.0
    Patient interaction
    Not satisfied

    84

    80.0
    Satisfied 21 20.0
    Total 105 100.0
    Promotion
    Not satisfied

    85

    81.0
    Satisfied 20 19.0
    Total 105 100.0
    Staff present at job
    Not satisfied

    53

    50.5
    Satisfied 52 49.5
    Total 105 100.0
    Supervisor present at job
    Not satisfied

    44

    41.9
    Satisfied 61 58.1
    Total 105 100.0
    Strategy for rating pharmacist
    Not satisfied

    64

    61.0
    Satisfied 41 39.0
    Total 105 100.0




    4.5. Factor association with job satisfaction and selected variables
    From the total study subjects in the age group of 20-26years, about three forth 76.9% of them are not satisfied and from the total males about 82.0% of them are not satisfied. The study tries to correlate age, gender, marital status, service year, position, income, patient interaction, promotion, presence of staff on job, presence of supervisor on job and strategy for rating pharmacists with level of job satisfaction. From all the above variables only service year (P = 0.002) and position (P = 0.048) seem to affect the level of job satisfaction while the rest fail to have a significant association as shown in table 4 below.














    Table 4: Shows cross-tabulation between job satisfaction and certain selected variables of the study subjects, public hospitals in Addis Ababa, Ethiopia
    Variable Job satisfaction
    Satisfied
    [No, %]

    Not satisfied
    [No, %]

    X2

    P –value
    Age
    20-26
    27-33
    34-40
    Total

    12(23.1)
    12(24.5)
    0(0.0%)
    24(22.9)

    40(76.9)
    37(75.5)
    4(100.0)
    81(77.1)


    1.261



    0.676
    Gender
    Male
    Female
    Total

    11(18.0)
    13(29.5)
    24(22.9)

    50(82.0)
    31(70.5)
    81(77.1)


    1.921


    0.239
    Marital status
    Single
    Married
    Total

    11(17.7)
    13(30.2)
    24(22.9)

    51(82.3)
    30(69.8)
    81(77.1)


    2.247


    0.160
    Service year
    0-5years
    6-10years
    11-15years
    Total

    12(17.1)
    7(23.3)
    5(100.0)
    24(22.9)

    58(82.9)
    23(76.7)
    0(0.0)
    81(77.1)


    18.175


    0.002*
    Position you currently holding
    Senior pharmacist
    Principal pharmacist
    Chief pharmacist
    Manager Pharmaceutical service
    Other
    Total

    16(31.4)
    6(15.4)
    2(28.6)
    0(0.0)
    0(0.0)
    24(22.9)

    35(68.6)
    33(84.6)
    5(71.4)
    2(100.0)
    6(100.0)
    81(77.1)


    5.832


    0.048*
    Income
    Not satisfied
    Satisfied
    Total

    14(20.9)
    10(26.3)
    24(22.9)

    53(79.1
    28(73.7)
    81(77.1)

    0.404

    0.630
    Patient interaction
    Not satisfied
    Satisfied
    Total

    22(26.2)
    2(9.5)
    24(22.9)

    62(73.8)
    19(90.5)
    81(77.1)


    2.647


    0.148
    Promotion
    Not satisfied
    Satisfied
    Total

    22(25.9)
    2(10.0)
    24(22.9)

    63(74.1)
    18(90.0)
    81(77.1)


    2.316


    0.152
    Supervisor present at work
    Not satisfied
    Satisfied
    Total


    10(22.7)
    14(23.0)
    24(22.9)


    34(77.3)
    47(77.0)
    81(77.1)


    0.001


    1.000

    5. Discussion
    It is evident that the delivery of quality health services depends on the availability of a competent workforce, available in adequate numbers with the appropriate skills. With the increases in the demand for health services, health systems should have the right workforce at the right time in the right quantity. This availability must ensure that those that are in the workforce remain longer and are satisfied with their work. The supply of healthcare workers is not always able to meet the demand for the health workers World Health Organization, (2006:101-104).
    Job satisfaction is a very important, multi-dimensional, enduring, and much researched concept in the field of organizational behavior. This is as a result of the human relations movement that began with the Hawthorne studies in the late 1920’s. It states that an employee’s perception is that their job allows the fulfillment of important values and needs Petersen, (2005:19). It is described, by Hertzberg (1966), as the pleasure one derives from one’s current job and working conditions.
    The overall purpose of the study was to determine the level of current job satisfaction among pharmacists working in different settings. The basic socio-demographic characteristics of the respondents are not different from other similar studies done in different areas. From the total study participants half (49.5%) of them were in the age group of 20-26years while only (3.8%) were in the age group of 34-40years. The mean age of the study participants was 1.4 with a standard deviation of 0.596 (1.54+0.596).
    A discontented and less motivated workforce leads to low productivity, low organizational effectiveness, absenteeism and a high turnover. For the individual, it can lead to poor mental health, in particular stress and anxiety, and in the end it has an impact on the delivery of health care services as well as the experience of patients in the receipt of care Hassel et al., (2007:259).
    This study found that from the total study subjects, 77.1% of them are not satisfied while the rest 22.9% of them are satisfied with their job. This may be related to a number of factors like working environment, years of experience, income, etc.
    Pay is a hygiene factor according to Herzberg’s theory Lyons, (2003:11) and an extrinsic job factor. This is about the employee’s perception of the pay received from the current employer. There is sufficient literature to suggest that the level of earnings exerts a substantial and significant effect on job satisfaction Carvajal, et.al. (2000:422). For any employee, his/her occupation is a main source of income; it also takes up a large part of the day and contributes to their social standing. Since the role of an occupation is central in many people’s lives, job satisfaction is an important component of overall well-being Sharma & Jyoti,( 2009:51). This study found that about two third 63.8% of them are not satisfied with their income and benefit they get from their organization.
    Different theories explain that promotion or recognition of work performance is a central matter to increase job satisfaction of the respondents. Promotion is the assignment of an employee to a higher-level job and is recognition of person’s past performance and future promise Grobler, et.al. (2006:235). In an organization, the promotion system tends to satisfy the need to achieve according to Maslow’s hierarchy of needs. Promotion is a motivator according to Herzberg’s theory. In this study, the study subjects also believe that promotion increases job satisfaction. In this study, 81.0% of them are not satisfied with the promotion and staff motivation in the organization.
    Continuous supervision and positive interaction with supervisors increases employees’ satisfaction and hence work performance. This aspect was measured to determine how the respondent perceived the supervision or management in the present job. The relationship between supervisor and an employee can be an important indicator of whether an employee is satisfied with the job or not Levy, (2003:250). This study find out that about half 50.5% of them are not satisfied with the presence of staff/coworkers at the job and 58.1% of them are satisfied with the presence of supervisor on the job. Close to two third 61.0% of them are not satisfied with the way pharmacists are rated.
    In the book, The Motivation to Work (1959), Herzberg did interviews with 200 engineers and accountants. They were asked to describe “any kind of story you like, either a time when you felt exceptionally good or a time when you felt exceptionally bad about your job”. This was conducted in twelve similar organizations Smerek, Peterson,( 2007:230). This theory, 'shown in distinguishes between intrinsic and extrinsic motivators. The common aspects of job satisfaction is pay, promotions, recognition, benefits, working conditions, supervision, co-workers, company, and management. This study tries to correlate age, gender, marital status, service year, position, income, patient interaction, promotion, presence of staff on job, presence of supervisor on job and strategy for rating pharmacists with level of job satisfaction. But this study found that only service year and position are statistically related or seem to job satisfaction level. There is no statistically significant relation between the above characteristics and level of job satisfaction except with income and promotion.

    6. Conclusion
  • From the total study subjects 77.1% of them are not satisfied while the rest of them are satisfied with their job.
  • This study also found that two third of the study subjects are not satisfied with their income
  • In this study, the study subjects also believe that promotion increases job satisfaction. More than three forth, 81.0% of them are not satisfied with promotion in their organization
  • Continuous supervision and positive interaction with supervisors increases employees’ satisfaction and hence work performance. This study found that about half 50.5% of them are not satisfied with the presence of staff/coworkers at the job and 58.1% of them are satisfied with the presence of supervisor on the job
  • A number of factors may affect job satisfaction. The study tries to correlate age, gender, marital status, service year, position, income, patient interaction, promotion, presence of staff on job, presence of supervisor on job and strategy for rating pharmacists with level of job satisfaction but no statistically significant result was found except for service year and position.


    • 7. Recommendation

    Considerable proportions of pharmacists working in public hospitals are dissatisfied with their job. Therefore, authorities should find a way to increase the level of job satisfaction of the pharmacists.
    The salaries are an issue that is always alluded to whenever there is a discussion involving how to attract and retain professionals. Salaries for pharmacists in the public sector are determined centrally and in the case of provincial authority facilities, this decision is taken at provincial level. The employer should engage in discussions with pharmacists’ forum to ensure pay equity, and to make sure that the benefits structure for pharmacists is acceptable and competitive.
    The employer should consider ways of promoting and improving employee relations with their supervisor because good interaction and supervision are central to job satisfaction and hence work performance.
    Promotion or recognition of work performance is a central matter to increase job satisfaction of the respondents. So the employer should improve the promotion and recognition of work performance of the employee by close discussion with them.

    8. Reference
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  • Assessment of the prescribing and dispensing practices of public health facilities in yeketit 12 hospitals, Addis Ababa, Ethiopia.
    By: Bandira Amedo
    Abstract
    Background: WHO estimates that more than half of all medicines are prescribed, dispensed inappropriately, and that half of all patients fail to take them correctly. Examples of irrational use of medicines include use of poly-pharmacy; inappropriate use of antimicrobials, over-use of injections when oral formulations would be more appropriate; failure to prescribe in accordance with clinical guidelines; non-adherence to dosing regimes.
    Objective: The main objective of the study is to assess the prescribing and dispensing practices of public health facilities in yekatit 12 hospitals, Addis Ababa, Ethiopia.
    Methodology: Thestudy was cross-sectional in nature using WHO study guide. Prescriptions will be selected by non probably quota sampling method, from those prescriptions prescribed from June1- 30,2013 form out patients in yekatit 12 hospital
    Results: The mean number of drugs per prescriptions was 1.67. Percentage of drugs prescribed by generic name was 91.8%. Antibiotics were prescribed in 38.3% of prescriptions and injections were prescribed in 23.3% of prescriptions. Percentage of drug prescribed from EDL was 93.3%. 85% of patients interviewed. From all drugs prescribed the number of drug actual dispensed was 73.54% and percentage of patients adequate know how to take the medication prescribed was 85%.from all drugs received by the patients only 42.9% were adequately labeled. The average counseling and dispensing time was 4.78minit and 40.78second.Copy of STG/formulary were available in the facility and percentage of key drugs indicators was 73%.
    Conclusion: Out of the 13 indicators, the study showed that the facilities were doing well on nine i.e. average number of drugs prescribed; encounters with an injection prescribed; drugs prescribed by generic names; drugs actually dispensed; correct patient knowledge of dosage; availability of key indicator drugs, availability of STG/formulary and drugs prescribed on EDL. The facilities did not do well on four (4) i.e. encounters with an antibiotic prescribed; average consultation time (min); average dispensing time (min); drugs adequately labeled.So there is a
  • 1. Introduction
  • 1.1. Background of the study
  • In 1985 WHO convened a major conference in Nairobi on the rational use of drug (1).since that effort has increased to improve drug use practice (2, 3).an essential tool for such work is an objective method to measure drug use in health facilities that will describe drug use patterns and prescribing behavior .haw ever the lack of agreement on such a method has been a recurrent problem.
    WHO estimates that more than half of all medicines are prescribed, dispensed or sold inappropriately, and that half of all patients fail to take them correctly (4). The overuse, underuse or misuse of medicines results in wastage of scarce resources and widespread health hazards. Examples of irrational use of medicines include use of too many medicines per patient ("poly-pharmacy"); inappropriate use of antimicrobials, often inadequate dosage; over-use of injections when oral formulations would be more appropriate; failure to prescribe in accordance with clinical guidelines; inappropriate self-medication, often of prescription-only medicines; non-adherence to dosing regimes. In-order to evaluate prescribing and dispensing patterns, WHO uses 12 core indicators. (See Appendix 1)
    The basic principles of prescribing are: - To make accurate diagnosis, to decide whether the drug treatment is necessary, to choose the best available drug, to choose the most appropriate dosage form , to prescribe the drug in adequate quantity, to monitor the treatment, and to inform and involve the patient.
    The prescribing practices measure aspect of outpatient treatment and are measured by: the first is average number of drugs per encounter, which measures the degree of poly-pharmacy (more than two drugs per encounter). Second, Percentage of drugs prescribed by generic name (the drug’s international nonproprietary name given by WHO regardless of who manufactures or markets it) which measures the tendency to prescribe by generic name which measures the cost-effectiveness of a health system to procure and use drugs. Third, Percentage of encounters with an antibiotic and an injection prescribed. This measures the overall level of use of two important, but commonly overused and costly forms of drug therapy.
    The purpose of dispensing is to ensure that an effective form of the correct drug is given to the right patient in the prescribed dosage and quantity with clear instructions and in a container, which maintains the potency of the drug. This can be achieved by: Reading and understanding the prescription, retrieval (collecting the correct drug), formulation (counting or pouring out the drug), processing (correct packing and labeling the drug) and delivering (giving the drug to the patient).
    The dispensing practices are measured by: Average consultation time measures the time that medical personnel spend with patients in the process of consultation and prescribing, average dispensing time, measures the average time that personnel dispensing drugs spend with patients, percentage of drugs actually dispensed measure the degree to which health facilities are able to provide the drugs, which were prescribed, percentage of drugs adequately labeled measures the degree to which dispenser’s record essential information such as name of patient, description of drug, dosage regimen, strength of the drug, precautions and total quantity dispensed on the drug packages they dispense and patients’ knowledge of correct dosage measures the effectiveness of the information given to patients on the dosage schedule of the drugs they receive.
    In 1981, WHO’s Action Program on Essential Drugs (DAP) was established to provide operational support to countries in the development of National Drug policies based on essential drugs and to work towards the Rational Drug Use. In 1985, WHO convened a major conference in Nairobi on the rational use of drugs. In order to encourage a standard approach to measuring problems in drug use, INRUD coordinated the development of standard drug use indicators (Appendix1) and encouraged indicator studies in a number of developing countries during the period 1990-1992. An essential tool for such work is an objective method to measure drugs in health facilities that will describe drug use patterns and prescribing behavior. (5).
    1.2. Statement of the problem
    Increasing drug cost is a burden to many healthcare delivery systems in both developed and developing countries. When physicians have a financial incentive to prescribe medications, they are likely to prescribe more drugs, brand drugs and also they are prescribing a drug for every problem which does not need medication. thus Irrational drug prescribing leads to reduction in the quality of drug therapy, wastage of resources, increased treatment cost, increased risk for adverse drug reactions, and emergence of drug resistance.
    Dispensing the drug without checking the appropriateness of the prescription, they do not labeling same important information, and also they are not giving important information on the use of the medication. Lack of enforcement in most developing countries, has lead to availability of many drug formulations of different brands in most drug outlets.
    Antimicrobial resistance is an increasing problem worldwide, impacting infection control efforts and costs of antimicrobial treatment. Numerous factors contribute to the problem, including unnecessary antimicrobial prescribing by trained and untrained health workers, uncontrolled dispensing by drug vendors, poor antibiotic prophylaxis in surgery, and poor infection control practices.
    The inappropriate drug use is characterized by the use of drugs when no therapy is indicated, the use of the wrong drug for a specific condition requiring drug therapy, the use of drugs with doubtful/ unproved efficacy, the use of drugs of uncertain safety status, failure to provide availability of safe and effective drugs, and the use of correct drugs with incorrect administration, dosages and duration.
  • 1.3. Significance of the study

  • The study conducted to improve the prescribers and dispensing practice by delivering the most commonly errors that occur on prescribing and dispensing practice. The result of this study used as a base line data for planners and researchers for further study about prescribing and dispensing practice.
    In addition, the result of the study important to deliver some information about standard prescribing and dispensing format that should be used in health institutions. The other important point is there is poly pharmacy, inappropriateness in dispensing of the medication which leads to drug resistance, unnecessary cost wastage of resource in this suggests that there is a need for better cooperation between these two bodies (physicians and pharmacists) in improving the prescribing and dispensing practice. Generally, the study is helpful for developing appropriate drug and health care delivery system for achieving accurate therapeutic significance.
    The study may inform the Ministry of Health, health planners, health providers, medical training institutions and other health related non-governmental organizations, the shortfalls in the prescribing and dispensing practices in Yeketit 12 hospital so that the health providers can improve these practices by modifying the existing weaknesses and malpractices.
  • 2. Objectives
  • 2.1. General Objective
  • The main objective of the study is to assess the prescribing and dispensing practices of public health facilities in yeketit 12 hospitals, Addis Ababa, Ethiopia.
    • 2.2. SpecificObjective
    • v To assess the prescribing practice,
    • ü Average number of drugs per encounter
    • ü Percentage of drugs prescribed by generic name
    • ü Percentage of encounters with an antibiotic prescribed
    • ü Percentage of encounters with an injection prescribed
    • ü Percentage of drugs prescribed from essential drugs list or formulary
    • v To evaluate the dispensing practice,
    • ü Average consultation time
    • ü Average dispensing time
    • ü Percentage of drugs actually dispensed
    • ü Percentage of drugs adequately labeled
    • ü Patients know ledge of correct dosage
    • v To assess the Availability of copy of essential drugs list or formulary And Availability of key drugs
    • v To identify weaknesses and make recommendations on how to improve the prescribing and dispensing practices in the public health facilities.
    • 3. Methodology
    3.1. Study Area and Period.
    The study would be conducted in Addis Ababa town. Addis Ababa is the capital city of Ethiopia. The total population of Addis Ababa is around four million. Yekatit 12 is the study area found in Arada sub city. To briefly locate yekatit 12 hospitals when you go from 4 kilo to 6 kilo as you walk around 500m there is a circle which has a historical building, then before crossing the circle you turn to the left and walk 20m so that you will found the main get to the hospital.
    The study would be conducted from April 1/2013 to august 10/2013 for FIVE consecutive months in the specified study location. To further explain: the proposal will be submitted on may middle then soon after that the study will take around four months (May to august).
    3.2. Study Design
    A cross sectional document review (prescription review) and observation will be conducted based on the outpatient prescriptions prescribed during a period from April 1, 2013 to august 20, 2013.both retrospective and prospective data will be used.
    3.3. Study Population.
    The study subjects were randomly selected from all out patient pharmacy prescriptions which contain drugs from June 1-30, 2013 for retrospective study and people who were coming with their prescriptions to the outpatient pharmacy to receive their drugs on that day.
    • 3.3.1. Source population
    The samples for the study were taken from yeketit 12 hospital Out- Patient Pharmacy (OPP) prescriptions which were written and dispensed from June 1-30, 2013 for retrospective study and all patients visited outpatient pharmacy with their prescriptions for taking their drugs.
    • 3.3.2. Study population
    Inclusion Criteria
    • A prescription that can fulfill the requirement of a prescription format in a given country.
    • 3.4. Sample Size Determination
    From prescription prescribed from June 1-30 2013 a total of 60 prescription and 60 patients (for patient care indicator) would be taken by non-probably quota sampling method to be analyzed. After the sample size determined, prescriptions will be selected by quota sampling method during the study period.
    • 3.5. Sampling Procedures
    Non-probably quota sampling method is used to collect data from records that can be included in the inclusion criteria. The data will be collected by the pharmacy technician.
    • 3.6. Data Collection procedure
    • 3.6.1. Data collection instrument
    Deferent data collection instrument would be used such as WHO drug use indicators form and other material like pen ,Pencil, Eraser ,Sharpener, watch, calculator. Record review and observation would be included during observation both the physician and pharmacists will not be informed to avoid bias in the results.
    • 3.6.2. Data collection procedure
    • Data collection checklist would be used to collect the required Information which contains those variables to be assessed.
    • Average number of drugs per encounter: Combination drugs are counted as one drug.
    • Percentage of drugs prescribed by generic name: Investigators must be able to observe the actual names used in the prescription rather than only having access to the names of the products dispensed.
    • Percentage of encounters with an antibiotic prescribed and Percentage of encounters with an injection prescribed: Antifilarials, Antischistosomals, Antifungal drugs, Antiamoebic, antigiardiasis drugs (except metrondazole), Antileishmaniasis drugs, Antimalarial drugs, Antitrypanosomal drugs, some immunizations are not to be counted as antibiotic and injections.
    • Average consultation time:Procedures for accurately recording the time spent during the Consultation, that is, the time between entering and leaving the consultation room. Waiting time is not included.
    • Average dispensing time: Procedures for accurately recording the average time patients spent With pharmacists or drug dispensers, that is, the time between arriving at the dispensary counter and leaving. Waiting time is not included.
    • Percentage of drugs actually dispensed: Information on which drugs were prescribed, and whether these drugs were actually dispensed at the health facility.
    • Percentage of drugs adequately labeled: Investigators must be able to examine the drug packages as they are actually dispensed at the health facility.
    • Patients' knowledge of correct dosage: to evaluate patient knowledge during the interview, or to record patient responses for later evaluation.
    • Availability of key drugs: A short list of 10-15 essential drugs must be compiled that should always be available.
    • Included to measure the availability of a more complete range of essential drugs Data collectors will then check the drugs on this list for availability in the facility. The quantity in stock should not be considered. Even if only one bottle or a few tablets are available, the drug should be recorded as being in stock.
    • 3.7. Study variable
    • 3.7.1. Outcome of interest
    Prescribing practice
    Dispensing practice
    • 3.7.2. Predicators
    Prescribing indicators
    • Average number of drugs per encounter.
    • Percentage of drugs prescribed by generic name.
    • Percentage of encounters with an antibiotic prescribed.
    • Percentage of encounters with an injection prescribed.
    • Percentage of drugs prescribed from essential drugs list or formulary.
    Patient care indicators
    • Average consultation time.
    • Average dispensing time.
    • Percentage of drugs actually dispensed.
    • Percentage of drugs adequately labeled.
    • Patients' know ledge of correct dosage.
    Facility indicators
    • Availability of copy of essential drugs list or formulary.
    • Availability of key drugs.
    3.8. Data Entry and Analysis
    After data is being collected using, observation and record reviewing the information on the data collection will be coded and during data entry the information of each study subject will be fed in to the computer according to its relevant genuine code. In this study data entry and clearing will be done using spss version 16 statistic soft ware and it will be described in the form of table, graph, and charts.
    3.8. Data quality assurance and management
    The data quality will be assured by capturing picture of the hospital, the data collector while they are collecting the data. The data collected, organized and presented with suitable data presentation method and the variable was processed and analyzed by using scientific calculator.
    • 3.9. Ethical consideration
    The following ethical issue is emphasized while under taking the study. Formal later will be written and has to be given from universal university collage research and publication office in order to get permission and to show its legality for collection of data will be given to yeketit12 hospital medical director and the information required will be assured for academic purpose.
    • 4. Result
    • 4.1. Prescribing indicators

    The study was conducted on 60 prescriptions Prescribed in Yeketit 12 hospital from April 1, 2013- august 20, 2013 and the following results were obtained. The average number of drugs per encounter was 1.76 drugs.

    Table 1: Distribution of the core drug use indicators based on the prescribing, patient care and health facility indicators of the Yeketit 12 hospital

    Core indicators IndicatorsY-12-HGUHWHO Standard
    Prescribing indicators Average number of drugs per prescription 1.67 1.77 ≤2
    % of drugs prescribed by generic name 91.8 99.16 100
    Percentage of encounters with an antibiotic prescribed 38.3 29.14 25
    Percentage of encounters with an injection prescribed 23.3 28.50 13.4-24.1
    Percentage of drugs prescribed from essential drugs list or formulary 93.3 98.89 100
    Patient
    Care
    Indicators
    Average consulting time (in minutes) 4.78 - >10
    Average dispensing time (in minutes) .68 4.3 >5
    Percentage of drugs actually dispensed 73.54 89.39 100
    Percentage of drugs adequately labeled 42.9 8.48 100
    Percentage knowledge of correct dosage 85 - 100
    Health
    Facility
    Indicators
    Availability of copy of STG/formulary YES yes Yes
    Availability of key drugs 73 66 100

    The average percentage of generic drugs prescribed was 91.8%. The percentage of patients receiving antibiotic was 38.3%.


    Figure 1: A graph showing generic name, antibiotic and injection usage in Yeketit 12 hospitals
    The average percentage of patients receiving one or more injections at the facilities was found to be 23.3 %. But overall injection use (23.3%) was the same with WHO standard of (13.4-24.1%).









    Figure 2: graph showing number of drug son each prescription in Yeketit 12 hospitals from April 1,2013to august 15, 2013.
    In addition, we were analyzed the number of drugs per prescription, as a result number of drug prescribed per prescription ranges from one to four. Accordingly, from 60 prescription, 28 prescriptions (46.6%) were contain only one drugs, 22 (36.67%) prescriptions were contain two drugs, 6 (10%) prescriptions were found to contain 3 drugs and 4 (6.67%), prescriptions were found to contain 4 drugs per prescription.
    The study showed that adherence of prescribers to prescribe drugs from national drug List (NDL). The study analyzed percentage of drugs from NDL. Accordingly 93.3% drugs were from NDL the rest 6.7% was out of NDL.
    • 4.2. Patient care indicators
    The average consultation time was 4.76 minutes. The average dispensing time for facilities was 40.76 seconds. 38.33% of the prescription were dispensing in more than 40 seconds while almost greater than half (61.67%) of the prescription were dispensing in less than 40 seconds.
    Figure 3: A graph showing adequacy of dispensing drugs, labeling of drugs and dosage knowledge of the patients.
    In Table 1, the facility dispensed greater than half of the drug prescribed haw ever which is not satisfactory. In Table 1 and Figure 3, the average adequacy of labeling of drugs was 42.9%. However, the average adequacy of patient knowledge at the facilities was 85%.



    4.3. Health facility Indicators
    In Table 1 and Figure 4, the percentage of available key drugs was 72.7%. This availability was not significantly considered for the health facility.


    Figure 4: A pie chart showing the availability essential drug in the facility.
    5. Discussion
    Prescribing and dispensing practices influence the patient’s compliance and thereby therapeutic success or failure.
    The result of this research described that the total number of drugs prescribed per prescription ranges from one to four, and the average number of drugs per prescription in this study was 1.76, WHO recommended that the average number of drugs per prescriptions should be below 2. Therefore, the result 1.76 is below 2 that can matches with WHO recommendations and therefore the problem of poly pharmacy is not considerable based on this study. the study conducted on pattern of prescribing practices in Madhya Pradesh, India result the Overall average number of drugs prescribed per prescription was 2.8.(18).
    Percentage of Drugs prescribed by Generic Name: in wolkite town south west Ethiopia and Gonder university of teaching referral hospital the present of drug prescribed by generic name was 92% and 99.16% respectively (25, 26). It was found that (91.8%) of drugs were prescribed by generic name at yeketit 12 Hospital. Therefore, it was found to be very encouraging and almost some result with the study conducted in gondre and wolkite town. Ethiopia Government policy through the National Drug Policy that all drugs procured by Central Medical Stores should be generic in order to capitalize on their cheaper cost. The high percentage of drugs prescribed by generic name and from EDL clearly shows that the procurement and utilization of drugs in the facility may be cost-effective. If product quality can be assured, then efforts to promote generic prescribing and generic substitution at the point of dispensing will result in more cost-effective care.
    The antibiotic prescriptions % in China was about 39% and the indicator was different in many countries. As shown above table 1, the antibiotic % in the hospital was (38.3%). This figure shows that the use of antibiotics was somewhat higher than the WHO standard and Brazil (19) but less than other hospitals in African countries. However, this could be attributed to the HIV/AIDS since opportunistic infections are mostly treated by antibiotics. There was slightly high use of antibiotics (38.3%) and same measures should be taken to improve the prescribing habits and the use of these types of drugs, there is little doubt that country will face serious problems of increasing resistance to currently cost-effective antibiotics and increased costs and risk to the patient from the overuse of injections.
    The injection percent, in table 1, was 23.3%, while the indicator was higher in some countries. In Gonder university of teaching referral hospital and wolkite town south west Ethiopia % of encounter with injection was 23% and 28.5%respectively (25, 26). According to WHO standard (13.4-24.1%), use of injections was good in this hospital, even its better than countries like Yemen 46% 22 and far lesser from other countries like Sudan (10.15%) 20 and India (3.9%) 21. Comparatively, on the use of injection all prescribers of the yeketit hospital have to be appreciated because there was no difference in the prescribing of injection as compared with the WHO standard.
    Percentage of Drugs prescribed from Essential Drug List:The WHO recommended that 100% of drugs should be prescribed from EDL. The study shown in Yemen and Tanzania, 78.9 %( 22), 70 %( 23) were prescribed from EDL respectively. But when we came to our study, 93.3% were prescribed from EDL. So, in this study, almost all drugs were prescribed from EDL and it is encouraging.
    The average consultation time of 4.76 minutes which shows that it is still less than the WHO standard (>10minits).therefore this consultation time turned to be short to enable physicians to communicate with their patients regarding their therapy and illness. During this consultation, the physician has to make a complete patient evaluation, select the appropriate medications, and enable for proper patient- physicians interaction. The short consultation time for this facility could be due pressure of workload since in yeketit 12 hospital serve both outpatients and in patients.
    Based on WHO standard, the average dispensing time should be > 5 minutes. The average dispensing time was found to be 40.76 second in this hospital. When we compared to other studies like Sudan 46.3 second (20) and Brazil 18.4 second (19), the dispensing time was almost the same but compared to WHO standard and study made in India 3.1 minutes (13) it is too different. We believe that this time still too short for patient pharmacist interaction and to give more time for pharmacists to explain all drug details with regard to its use, dosage frequency and possible adverse events and other information needed to be delivered to the patient which may affect patient compliance.
    Each dispensed drug must be appropriately labeled to comply with legal and professional requirements (24). According to this study, the hospital average percentage of drugs adequately labeled was (42.9%). In Sudan and India it was 37.6% (20) and 43.8% (21). These results have shown deviation from the ideal value of 100%. There were a few labels on the strip, insulin, bottle which contains syrup but was on the paper bag. So, that was the reason that the result shows inadequate labeling value. Therefore, there is an urgent need for managerial interventions to equip the dispensary with the necessary dispensing aid and enforce practitioners to put label on each and every dispensed drug to patients.
    The percentage of drugs actually dispensed was different from the drugs being prescribed because some of the drugs are stock out, other are not requested from the main store and some are prescribed by brand name. In this hospital (73.54%) of drugs was dispensed.haw ever % of drug dispensed in this hospital as compared to Gonder University of teaching referral hospital and WHO standard it is less.
    As shown in table1, in Yeketit 12 Hospital, 85 % of patients were able to repeat the correct dosage schedule of the drugs they had received and it was good as compared to the expected value of 100% and was better than studies conducted in other countries (India and Tanzania 64.5%, 70%) (19, 23). Many people have become reasonably knowledgeable in many issues including medication. In addition to this, the media (both electronic and print) may have also contributed considerably by informing the public through the radio, newspapers and television on the issue of medication. Many factors that contribute to inadequate patient knowledge, among them language difference between patient and health provider, information about drugs would not offered voluntarily by the health worker rather they depends on the patient to ask specific question.
    Availability of EDL/Formulary and STG:The purpose is to indicate the extent to which copies of the national essential drugs list or local formulary are available at health facility. These materials were available in the facility. But the problem was non of the book were found at the prescribing and dispensary level. In my opinion those book has to be available at the prescriber and dispensary level, so that they may used as a reference if there is any confusion related to prescribing and dispensing process
    The percentage availability of key indicator drugs was 72.7% and this shows that some of the critical items for acute respiratory tract infection, skin disinfection, conjunctivitis and prophylactic drugs were out of stock at the time of the studies. Thus contribute to prescribers respond to the absence of a drug by continuing to prescribe it and expecting patients to purchase the product in the private sector rather than switching to a therapeutic alternative. However, the limited number of key drugs could not give a true impression.

    6. Conclusion and recommendations

    6.1. Conclusion
    Drugs were being procured and prescribed in adequate quantities and in the most cost-effective way though antibiotics were being prescribed in an irrational manner. There was a drastic increase of patient knowledge on how to take medication by patients despite poor labeling by the dispensers. Out of the 13 indicators, the study showed that the facilities were doing well on nine i.e. average number of drugs prescribed; encounters with an injection prescribed; drugs prescribed by generic names; drugs actually dispensed; correct patient knowledge of dosage; availability of key indicator drugs, availability of STG/formulary and drugs prescribed on EDL. The facilities did not do well on four i.e. encounters with an antibiotic prescribed; average consultation time (min); average dispensing time (min); drugs adequately labeled.
    Moreover, the prescribers and dispensers should work in a congenial environment with rational workload and regular supply of logistics. Short (40.76sec) dispensing time culminated inadequate patients’ knowledge regarding medicines use and short supply created some patients’ dissatisfaction. Finally, to measure the pattern of medicine use, the very system specific, physicians specific and disease specific approach should be under-taken in controlled situation for intervention.
    Drug use studies are a necessary tool for assessing prescribing and dispensing problems in hospitals, recognizing areas for improvement and improving drug prescribing and dispensing
    practices in these facilities. The prescribing practices of the yekatit 12 are more of rational type
    however there is an irrational overuse of antibiotics, in adequate drugs labeling, short counseling and dispensing time are observed by the study.

    6.2. Recommendations
    In view of the above findings and discussions, the following recommendations are made:
    1.Ensure that antibiotic prescribing is in line with the Ethiopian Standard Treatment Guidelines. Identify and develop interventions for implementation to address the significant increase in the number of antibiotics prescribed per patient. This may be achieved through:
    ü Promotion on the use of EEDL through regular distribution and training of all relevant health workers.
    ü Treatment guidelines and training courses should emphasize on the importance of correct labeling and instructions to patients when antibiotics are prescribed.
    ü Institutionalizes Continuing Pharmaceutical and Medical Education activities.
    2. Ensure that patients are diagnosed and assessed adequately. This may be achieved through:
    ü Intensify disease prevention and control campaigns in order to sensitize the general public on good hygiene practices.
    ü Hence, this may reduce disease burden and in turn lessen congestion in the health facilities. Conduct frequent refresher courses for clinicians on proper prescribing and counseling of patients.
    3. Ensure that all the medicines dispensed are adequately labeled and that all the information on dosage regimen, side effects and refill are effectively conveyed to the patient or caretaker.
    ü Develop, disseminate and enforce clear guidelines and training on the importance of labeling for dispensed medicines on good dispensing practices for all dispensing personnel.
    ü The Ethiopian College of Health Sciences should resume the training of Pharmacy Assistants to increase the numbers of pharmacist and Pharmacy Technicians.
    ü Ensure the regular inspections, evaluation and monitoring of premises and personnel where dispensing operations are performed.
    7. Reference
    1. The rational use of drug .report of conference of experts, Nairobi, 25-29 November 1985 Geneva, world health organization, 1987.
    2. walker GJ, Hogerzeil HV, salami AO, Alwan AA, Fernando G, Kassem FA. Evaluation of rational drug prescribing in democratic yemen. Soc sci Med1990:31:823-828.
    3. Laing RO. rational drug use: an un solved problem .trop dect 1990:20:101-3.
    4. Ross-Degnan D, Laing R, Santoso B et al; Improving pharmaceutical use in primary care in developing countries: a critical review of experience and lack of experience. Presented at the International Conference on Improving the Use of Medicines, 1997, Chiang Mai, Thailand.
    5. WHO/DAP; How to investigate Drug use in health facilities, 1993, Geneva.














     
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    Universal Medical College
    Research and Publication Office







    Annual Health Research Journal of Universal Medical College Volume IV












    January, 2015
    Addis Ababa, Ethiopia


    Editor in chief:
    Tadesse Alemu [MPH]




    Editorial Team
    Abreham Kassahun [MPH]
    Efrem Tilahun [MPH]
    Sr. Eleni Belachew [MPH]
    Hailemariam Abrha [M.Sc]








    Contact Address:
    Universal Medical College
    Research and Publication office
    Tel: (251) 116-625-841/42
    Email: umec@ethinet.et
    P.O.BOX: 13954
    Website: www.universaluniversitycolleges.com
    Addis Ababa, EthiopiaTable of Contents

    Contents Page
    Table of contents …………………………………………………..…….…………………..…...I Acknowledgment……………………………………………………………………..…………..II
    Acronym ………………………………………………………………………………………...III
    Message from the Research and Publication Office …………………………………………......V
    Assessment of Factors Affecting Utilization of Maternal Health Care Services in Lideta Health Center, Addis Ababa, Ethiopia…………………………………………………………………....1
    Assessment on Level of Client Satisfaction and Determinants in Yekatit 12 Teaching Hospital Outpatient Department Addis Ababa, Ethiopia ………………………………………………...27
    Assessment on Adult Patient Satisfaction with Nursing Care in Selected Public/Private Hospitals, Addis Ababa, Ethiopia……………………………………………………………………….….53
    Literature Review on the Biological and Chemistry of Moringa Species………………………78




















    Acknowledgment
    The Research and Publication Office passes its gratitude toward Universal Medical College for providing financial support for the publication of this journal.

    The office also extends its sincere thanks to the investigators and their advisors, study supervisors and data collectors who have been instrumental to come up with the compilation of these studies.

    Of course, last but not the least, the office expresses its sincere appreciation to the editorial team who dedicated their precious time and knowledge in editing this journal without which this journal couldn’t be real.
























    List of Acronyms Abbreviations
    AACN: American Association of Critical-Care Nurses
    AIDS: Acquired Immune Deficiency Virus
    ALKP: Alkaline phosphate
    ANC: Ante Natal Care
    ART: Anti Retroviral Therapy
    BMI: Body Mass Index
    CAT Catalase
    DMBA 7, 12-dimethyl benzy(a)antracene
    ENT: Ear Nose Throat
    Fig.: Figure
    FMoH Federal Ministry of Health
    FPG Fasting plasma glucose
    FTIR Fourier Transform Infrared
    Hb Hemoglobin
    HCD High Cholestrol diet
    HDL High-density lipoprotein
    HFD High-fat diet
    HIV: Human Immune Deficiency Virus
    1HNMR Nuclear Magnetic resonance Spectroscopy with respect to hydrogen -1 nuclei
    HPLC High-Performance Liquid Chromatography
    IFA: Iron and Folic Acid
    IL-2 Interleukin-2
    LPO Lipid per oxidase
    ITN: Insecticide Treated Net
    LDL Low-density lipoprotein
    M Moringa
    MCF Michigan Cancer Foundation
    MDGs: Millennium Development Goals
    MH: Maternal Health
    MHC: Maternal Health Care
    MHCS: Maternal Health Care services
    HUSM Hospital Universiti Sains Malaysia
    MMR: Maternal Mortality Rate
    NGOs NonGovernmental Organizations
    NP Nurse Practitioner
    OGTT Oral Glucose Tolerance Test
    OPD: Out-Patient Department
    PNC: Post Natal Care
    PPBG Postprandial Blood Glucose
    P PPG Postpradial Plasma Glucose
    RBC Red Blood cells
    RSC Radical Scavenging Capacity
    SBAs: Skilled Birth Attendants
    SD Standard Deviation
    SGOT Serum Glutamic Oxaloacetate Transaminase
    SGPT Serum Glutamic Pyruvic Transaminase
    SOD Super Oxide dismutase
    SPSS: Statistical Package for Social Science
    SSA: Sub Saharan Africa
    St. Saint
    STZ Streptozotocin-induced
    TBAs: Traditional Birth Attendants
    T2DM Type2 Diabetes mellitus
    TNF Tumor Necrosis Factor
    TPA 12-teteradecanoylphorbol-13-acetate
    TT: Tetanus Toxoid
    USA United States of America
    UV Ultra violet
    WBC White Blood cells
    WHO: World Health Organization

    Message from the Research and Publication Officer
    Dear Colleagues;
    For the past four years, Universal Medical College’s publication has played a critical role in conveying an overview of research activities at the Medical College.

    Excelling in advancement and transfer of knowledge is only possible through maintaining a strong research culture. An academic institution can achieve a competitive status if and only if it has a significant presence in the research community. The aim of UMC’s Research and Publication Office will be to keep its readers widely interested in basic and applied research, and to promote interaction and collaboration among researchers from different fields. We are seeking to move away from the formal and structured presentation of research activities; instead, we would like to provide the researchers with an opportunity to actively contribute to the publication.

    Starting with this issue, the publication is getting a new ‘look’ as well as a new ‘inside’. The featured articles of the present publication cover four selected research papers of Health officer, Pharmacy and Nursing graduating students. All of these papers and the publication are funded by the medical college. I expect that these articles will give an in-depth description of some of the exciting research projects that are currently underway and will provide an insight into the potential impact of the projects described. The importance of student involvement in research activities cannot be underestimated. The main goal of this section is to reveal some of the research opportunities offered to medical college students.

    Currently the office is facilitating a conducive environment to well come instructors working in the medical college in order to undertake research works that benefit the community of the college in particular and the community at large. I hope you will enjoy reading this journal and the officer welcomes your feedback on any aspect of the publication.

    With best regards,
    Tadesse Alemu [MPH]
    Research and Publication Office, Universal Medical College
    Assessment of Factors Affecting Utilization of Maternal Health Care Services in Lideta Health Center, Addis Ababa, Ethiopia
    1Meaza Abebayehu, 2Abreham Kassahun
    1Universal Medical College, Public Health Department
    2Universal Medical College, Public Health Department Abstract
    Introduction: Maternal mortality rate remains to be challenging to health system worldwide. Most maternal deaths do occur in poor countries and it is well known that poor countries are also the ones with highest MMR. The available information about the rates and trends in maternal mortality is essential for resource mobilization, and for planning and evaluation of progress towards Millennium Development Goal 5, the target for which is a 75% reduction in the maternal mortality rate from 1990 to 2015. Maternal health, therefore, becomes a very important issue as this is also their most productive time when they strive to fulfill their potential as individuals, mothers and family members, and also as citizens of a wider community.
    Objective: To assess factors affecting the utilization of maternal healthcare services in Lideta health center Addis Ababa, Ethiopia.
    Methodology:Institutional based descriptive cross-sectional study design that employed. A total of 178 pregnant women and women who gave birth in the last 12 months were included. Quota, non probability sampling technique was applied. Quantitative and qualitative data collection method was used. Data was collected by pretested questionnaires through interview and FGD. After completion of data collection, data was entered and analyzed using SPSS version 16.0 computer software package. Finally the result was presented by tables and graphs.
    Result: The study recruited 178 study subjects. Regarding the age of 1st pregnancy, about 3/4th of 134(75.3%) the women were pregnant aged 21-30. Out of the women included in the study 89(50%) went to health institution. The reasons for not to attending was distance of the health facility, cost lack of awareness, apparently healthy and work overload.

    1.Introduction

    1.1. Background of the Study

    Economic slowdown and food security crisis are the main challenging problems that almost all countries of the world faced and they have become the burning issues at both national and international levels. The economic slowdown will diminish the incomes of the poor; the food crisis will raise the number of hungry people in the world and push millions people into poverty. The poor are not only those with the lowest incomes but also those who are the most deprived of health, education and other aspects of human well-being. The poor health and nutrition of women and the lack of care that contributes to their death in pregnancy and child birth also negatively affect the health and survival of infants and children they leave behind. Most maternal deaths do occur in poor countries and it is well known that poor countries are also the ones with highest maternal mortality rates (MMR) (1). Childbearing is a key part of women's lives and occurs mainly in the adolescent and adult years. Maternal health (MH), therefore, becomes a very important issue as this is also their most productive time when they strive to fulfill their potential as individuals, mothers and family

    members, and also as citizens of a wider community. At the individual level, women's poor health causes lack/loss of employment, leading to poor income. This contributes to women's persistent poverty and lack of empowerment. Poor MH can also have huge costs on families in emotional, health and economic terms. It is well documented that maternal morbidities and mortalities directly affect the survival and well-being of children (2).

    MMR remains to be challenging to health system Worldwide. The available information about the rates and trends in maternal mortality is essential for resource mobilization, and for planning and evaluation of progress towards Millennium Development Goal (MDG) 5, the target for which is a 75% reduction in the MMR from 1990 to 2015(3).Women play a major role in the rearing of children and the management of family affairs and their loss from maternity-related causes is a significant social and personal disastrous event(4).According to World Health Organization (WHO) maternal death is defined as death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy from


    any cause related to or aggravated by the pregnancy or its management, but not from accidentalor incidental causes. The tragedy is not only of mortality but for every pregnant woman that dies around 20-30 more mothers will have short and long term complications related to pregnancy and child birth that leads to disability of the woman in the reproductive age(15-49). These disabling complications include obstetric fistulas, ruptured uterus and pelvic inflammatory diseases (5).
    Of the nearly 600,000 women who die each year due to pregnancy-related causes, over 99% of these deaths occur in sub-Saharan Africa (SSA). Additionally 300 million women suffer from short and long-term illness related to childbearing. The ratio of maternal mortality in the region is one of the highest in the world, reaching to the levels of 2000 deaths per 100,000 live births. Direct obstetric causes (hemorrhage, obstructed labour, hypertensive disorders, unsafe abortion, and infection) contribute for up to 80% of maternal deaths with increased fetal loss, prenatal mortality and poor survival of small children (6).
    In Ethiopia, the levels of maternal and infant mortality and morbidity are among the highest in the world. The MMR was 673 per 100,000 live births, and the infant mortality rate was 77 per 1,000 (7). One explanation for poor health outcomes among women and children is the non use of modern health care services by a sizable proportion of women in Ethiopia. Previous studies have clearly demonstrated that the utilization of available MH care services is very low in the country. Several studies in the 1990s have shown that about 25 percent of Ethiopian women received antenatal care and less than 10 percent received professionally assisted delivery care. Despite the fact that MH care utilization is essential for further improvement of maternal and child health little is known about the current magnitude of use and factors influencing the use of these services in Ethiopia (8).
    MH care refers to care given to women during pregnancy, child birth and postpartum periods to ensure good health outcomes of the woman and baby. They comprise Antenatal care (ANC), labour and delivery (maternity) care and postnatal care (PNC).The international guidelines for utilization of MH care stipulate that; utilization of ANC should be a minimum of 4 visits and the first visit should be done during first three months of pregnancy, maternity care should be provided by skilled birth attendants [SBA] and PNC

    should be done to both the woman and baby immediately after delivery and within two weeks after birth and, throughout 42 days after delivery (9).

    1.2. Statement of the Problem

    The study of maternal health care service utilization becomes one of the most important research areas in developing countries because of the serious damage to the societal wellbeing. Despite the fact that maternal health care utilization is essential for further improvement of maternal and child health little is known about the current magnitude of use and factors influencing the use of these services among Lideta health center pregnant women and women who gave birth in the last 12 months. Around Lideta health center many women delivered in their home by using traditional birth attendants (TBAs). Low delivery in health facilities as a result of many factors leads to high morbidity and maternal mortality. Home delivery if not conducted by professionals or by SBA, it increases the risk of transmission of human immune deficiency virus/acquired immune deficiency syndrome (HIV/AIDS) to relatives or TBAs who conduct deliveries without protective equipment’s.

    This problem was also seen in Lideta health center. In developing countries, the use of modern health care such as MH services can be influenced by socio demographic characteristics of women, the cultural context, and the accessibility of these services. A number of socio demographic characteristics of the individual affect the underlying tendency to seek care. In this regard, good examples are maternal age and parity, which have been examined as determinants of health care use repeatedly. The greater confidence and experience of the older and higher parity women together with greater responsibilities within the household and for child care have been suggested as explanatory factors for their tendency to use services less frequently. Maternal education has also been shown repeatedly to be associated with the utilization of maternal care services. Although, women in higher socioeconomic groups tend to exhibit patterns of more frequent use of maternal health services than women in the lower socioeconomic groups, factors such as education appear to be important mediators.


    1.3. Significance of the Study

    Though women comprise a large proportion of a given society, still many women in developing countries are at greater disadvantage. A large number of women are needlessly dying due to factors related to pregnancy and childbirth. Experiences from both developed and some developing countries have shown that these deaths could have been prevented if women had access to basic maternity care services. Studies that have been done to explore the determinants of maternal health service utilization (MHCS) in Ethiopia have shown that a variety of factors affect MHCS utilization. This is true in case of Lideta health center. The study will clarify the situation of utilization of MHCS in this health center and finds the problems that hinder mothers’ uses these services and give strategies to solve the problems. Proper interventions must be taken to increase delivery in health facilities. If there are a good interventions and clear strategies around delivery in health facilities, maternal morbidity and mortality will be decline. Additionally if there is high rate of delivery by SBA in the health facility, the risk of transmission of HIV/ADIS and other infection which associated with unprotected delivery requirements which used by TBA will

    decrease. So, this study will insure to identify the main factors that influence delivery in health facilities. It is expected that this study would appraise the current understanding of the MHCS utilization. The results of the study will appraise understanding of policymakers by elucidating the main determinant factors such as socio demographic characteristics of a women, cultural context and accessibility of the services which affects the maternal health care utilization in the health center. Additionally if maternal education and socioeconomic characteristics of women increases, the gap between utilization of the services will become decrease. The results can serve as an important input for any possible intervention aimed at improving the MHCS utilization which will help to reduce MMR. It is hoped that the result of the study will help to identify the main demographic and socioeconomic factors affecting MHCS utilization in Ethiopia.





    2.Objectives of Study

    2.1. General Objectives

    To assess factors affecting the utilization of maternal health care service in Lideta health center Addis Ababa, Ethiopia.

    2.2. Specific Objectives

    To identify factors that affect women’s attendance of antenatal care, institutional delivery care and postnatal care services in Lideta health center.
    To assess the knowledge, attitude and practices of pregnant women regarding antenatal care in Lideta health center.
    To identify the sources and place of delivery care available in Lideta health center.

    3. Methodology and Materials

    3.1. Study Area and Period

    The study was conducted in Lideta health center which is found in Lideta sub-city Addis Ababa Ethiopia. The study period was conducted from February to June 2014.

    3.2. Study Design

    Institutional based descriptive cross-sectional study design that employed qualitative and quantitative data collection methods were used to assess factors affecting utilization of MH care services in Lideta health center. The study was done by interviewing pregnant women’s and women who gave birth in the last 12 months based on the inclusion criteria using pre-tested questionnaires.

    3.3. Population

    3.3.1. Target Population

    The target populations were all women who attending the health care services in Lideta health center in reproductive age group (15-49).

    3.3.2. Study Population


    The Study populations were all pregnant women and women who gave birth in the last 12 months attending the health care services in Lideta health center.

    3.3.3. Sample Population


    Sample populations were 178 pregnant women and women who gave birth in the last 12 months attending the health care services in Lideta health center.

    3.4. Sampling Criteria

    4.4.1. Inclusion Criteria

    All women in their third trimester of pregnancy
    All women within 12 months of post delivery and those who terminated pregnancy beyond six months preceding the date of interview regardless of outcomes of Pregnancy.
    Women, who were mentally and physically capable of being interviewed
    Permanent resident of the study area

    3.4.2 Exclusion Criteria

    Women, who were not in their second or third trimesters, critically ill, could not talk or listen, and those who lived less than one year at the time of the interview were excluded from the Study.

    3.5 Sample Size Determination

    The sample size for the study was calculated by using single population proportion formula by 86.6% of pregnant women and women who gave birth in the last 12 months who use MH care services with 95% confidence interval and 5% degree of precision. Sample size (n) was computer based on single population proportion formula.
    n = (Zα/2)2 P (1-P)
    d2
    Where
    n = sample size
    Zα/2= Z score value at 95% confidence interval i.e. 1.96
    P= Prevalence is estimated to be 86.6% [22]
    d = Margin of error (5%)
    n = (1.96)2 0.866(0.134) = 178
    (0.050)2
    Therefore, the sample size was 178

    3.6 Sampling Procedure

    By using quota non probability sampling method one hundred seventy eight pregnant women and women who gave birth in the last 12 months in Lideta health center during the study period and are voluntary and mentally sound were selected.

    3.7 Study Variables

    3.7.1. Dependent Variables

    Factors affecting utilization of maternal health care services

    3.7.2. Independent Variables

    Knowledge, Attitude, Practice

    Socio-demographic characteristics, Economical characteristics

    3.8. Data Collection Procedure

    3.8.1. Data Collection Instrument

    Questionnaires were used to collect the data. Questionnaires were prepared in English and translated to Amharic language. Data was collected through interview method among pregnant women and women who gave birth in the last 12 months.

    3.8.2. Data Collectors

    The data was collected by three data collectors who were 4th year Health Officer Students were trained and supervised by the investigator.

    3.9. Data processing and Analysis

    After completion of data collection, data was cleaned, entered and analyzed using SPSS version 16.0 computer software package. Finally the result was presented by tables, graphs, chi-square(x2) and correlation.

    3.10. Validity and reliability

    To check validity and reliability of the study, questionnaires were adapted from previously done similar studies. The questionnaires were pretested before the initiation of the main study on five selected pregnant women and women who gave birth in the last 12 months. During this time some questions were not understandable by the respondents. Therefore important correction was be made and the questions were simplified based on pretest finding .Proper monitoring and evaluation of the data collection procedure was done by the investigator. The collected data was checked by the investigator for accuracy, completeness, inconsistencies or errors.


    3.11. Ethical Consideration

    Ethical clearance was obtained from Universal Medical College Research and Publication Office to the study area. Permission was secured from the principals of the study area.

    The purpose of the study was explained to the study subjects and a verbal consent was taken from the participants to confirm whether they were willing to participate. Confidentiality of responses was ensured throughout the research process.

    3.12. Dissemination of the result

    The finding of this study will be disseminated to Universal Medical College, Lideta sub-city Health Office and to different organizations that will to improve utilization of maternal health care services in sub-city. The findings will be also presented at different workshops and seminars.







    4. Result
    Socio demographic and obstetrics characteristics
    The study recruited 178 study subjects of which majorities of the respondents 48(27%) were aged between 22-25 and 47(26.4%) were aged between 26-29 followed by 31(17.4%) were aged between 30-33.Out of the total respondents majorities of 68(38.2%) were attended secondary high school and 59(33.1%) were attended elementary school followed by 31(17.4%) were diploma and above diploma. The majorities were Amhara 79(44.4%) followed by Oromo 40(22.5%). Out of the total respondents 155(87.1%) were married followed by 16(9) were single (Table1).

    According to the respondents’ age at 1st pregnancy almost above half of 134(75.3%) the women were pregnant aged 21-30 followed by 37(20.8%) were aged below (<) 21. Of all respondents 71(39.9%) women had one pregnancy, 52(29.2%) women had two pregnancy. According to their number of delivery 51(28.7%) women had one delivery followed by 36(20.2%) women had two delivery. 52(29.2%) of the respondents had one child followed by 34(19.1%) women had two children. According to the number of abortion 35(19.5%) of women had one abortion, 6(3.4%) had two abortions and 1(0.6%) had three abortions. None of the respondents had still births. Of all the respondents 1(0.6%) woman had one infant death and only 1(0.6%) woman had >3 infant deaths (Table 1).























    Table 1: Socio demographic and obstetrics characteristics of the respondents in Lideta health center 2014
    VariableFrequencyPercent
    Age 18-21 23 12.9
    22-25 48 27.0
    26-29 47 26.4
    30-33 31 17.4
    34-37 21 11.8
    >37 8 4.5
    Educational status Never attended 11 6.2
    Only read and write 9 5.1
    Elementary school 59 33.1
    Secondary high School 68 38.2
    Diploma and above diploma 31 17.4
    Marital status Married 155 87.1
    Divorced 2 1.1
    Widowed 5 2.8
    Never married 16 9.0
    Age at 1st pregnancy


    <21 37 20.8
    21-30 134 75.3
    31-40 6 3.4
    >40 1 .6
    No. of pregnancy 1 71 39.9
    2 52 29.2
    3 30 16.9
    >3 25 14.0
    No. of delivery 1 51 28.7
    2 36 20.2
    3 13 7.3
    >3 9 5.1
    None 69 38.8
    No. of live births 1 52 29.2
    2 34 19.1
    3 14 7.9
    >3 9 5.1
    None 69 38.8
    No. of abortion 1 35 19.7
    2 6 3.4
    3 1 .6
    None 136 76.4
    No. of stillbirths None 178 100.0
    No. of infant deaths 1 1 .6
    >3 1 .6
    None 176 98.9
    Total 178 100%



    Antenatal Care characteristics
    Out of the total women majority of the respondents 107(60.1%) women had 1-3 family size in their house hold followed by 66(37.1%) women had 4-6 family size. Majority of the women 142(79.8%) reported that their last pregnancy or delivery has been planned; whereas 36(20.2%) said that it was not planned. Out of the women included in the study almost all 174(97.8%) of women get ANC service from health institution. Among ANC users and non-users the majority 160(89.9%) reported that ANC check-up has benefits to the health of both the mother and child, while 8(4.5%) mentioned its benefit only for the health of the child, another 4(2.2%) mentioned that it is beneficial for the health of mother only and 6(3.4%) of them don’t know the benefit of ANC (Table 2).
    Out of the women included in the study 89(50%) went to health institution during the 2nd trimester (4-6 months), 80(44.9%) were went to health institution during the 1st trimester (1-3 months), while 5(2.8%) were went during the third trimester (7-9 months).Among the prenatal service users 16(9%) had at least one prenatal visit during their Pregnancy ,25(14%) had two visits, 81(45.5%) had three visits and 53(29.8%) had four or more visits. From ANC users most of the respondents 164(92.1%) had TT injections during the service, while 11(6.2%) had no TT injection during their visit. Two or more injections of tetanus toxoid were reported by the majority 127(71.3%) of antenatal care attendees. Almost all 170(95.5%) of the respondents had BP measurement during their visit. Majority of the respondents 169(94.9%) had Weight, Height, Laboratory and Physical Examination measurement (Table 2).
    Regarding the health service factors of all the ANC attendees 115(65.7%) women were not paid for ANC Services, while 58(32.6%) women were paid for ANC and 44(22.5%) reported very small with the payment while 19(4.5%) of respondents said fair of the payment. 129(72.5%) of women who mentioned waiting time was not a problem while 46(26.8%) of women mentioned waiting time was a problem .Of all the respondents 115(64.6%) waited for 2-16 minutes followed by 46(25.8) waited for 17-31 minutes. From ANC users the majority 132 (74.2%) of the respondents had received health education during any visit while only 43(24.2%) reported had never received health education and from health education receivers majority of 133(74.3%) of the respondents received health education around all topics. The majority 154(86.5%) of husbands had positive attitude towards ANC and maternity care services while only 3(1.7%) had negative attitude towards the service and also 21(11.7%) didn’t know their husband attitude around the service. On the other hand, women indicated the primary reasons for not attending ANC during their pregnancy to be that 3(1.7%) of the respondents said because of time or work overload while 1(0.6%) of the respondents said because of distance of the health facility and 1(0.6%) of the respondents said because of cost and also from the FGD results the main reasons by the most of the focus group discussants were lack of awareness, apparently healthy and work overload (Table 2).
    Both ANC users and non-users were asked about the perception of distance from health facility, and majority of the respondents 128(71.9%) reported it took <30 minutes followed by 48(27%) of said it took one hour. From ANC users majority of the respondents 161(90.4%) were took iron supplementation. According to vitamin supplementation most of the respondents 107(60.1%) were not took the supplements, while 66(37.1%) were took vitamin A supplements.109 (61.2%) of women said there was good quality of services, 55 (30.9%) of said satisfactory, while only 11(6.2%) of women said poor. Women also were questioned to rank the behavior of health workers at ANC unit 33(17.5%) of said very good, 71 (39.9%) said good, 67(37.6%) said somehow they are good, and only 3(1.7%) reported poor (Table 2).
    Table 2: Antenatal Care characteristics of the respondents in Lideta health center 2014
    VariableFrequencyPercent
    No. of people in the HH 1-3 107 60.1
    4-6 66 37.1
    7-9 5 2.8
    Plan of pregnancy Yes 142 79.8
    No 36 20.2
    Place of ANC Health institution 174 97.8
    Relatives/friends 1 .6
    Don't know 3 1.7
    Benefit of ANC Maternal health 4 2.2
    Child health 8 4.5
    Both 160 89.9
    Don't know 6 3.4
    At what gestational age while you go 1-3 months 80 44.9
    4-6 months 89 50.0
    7-9 months 5 2.8
    Don't know 4 2.3
    Total no. of visit Once 16 9.0
    Two 25 14.0
    Three 81 45.5
    Four and more 53 29.8
    Don’t Know 3 1.7
    TT injection Yes 164 92.1
    No 11 6.2
    Don’t know 3 1.7
    Quantity of TT injection Once 38 21.3
    Two or more 127 71.3
    BP measurement Yes always 170 95.5
    No 3 1.7
    Wt,Ht,Lab and PE done Yes 169 94.9
    No 4 2.2
    Payment of ANC Yes 58 32.6
    No 117 65.7
    Feeling about the payment Fair 19 10.7
    Very small 40 22.5
    Waiting time Yes 46 25.8
    No 129 72.5
    Adjusted waiting time 2-16 115 64.6
    17-31 46 25.8
    32-46 6 3.4
    47-61 6 3.4
    107-121 5 2.8
    Health Education given Yes 132 74.2
    No 43 24.2

    Topic of health education All 133 74.7
    Don’t know 43 24.2
    Attitude of husband Positive 154 86.5
    Negative 3 1.7
    Reason of not attend ANC B/c of time 3 1.7
    B/c of distance 1 .6
    B/c of cost 1 .6
    Distance of the health center from the house <30 minutes 128 71.9
    1hr 48 27.0
    2hrs 1 .6
    Iron tablets supplementation Yes 161 90.4
    No 13 7.3
    don't know 1 .6
    Vitamin A supplementation Yes 66 37.1
    No 107 60.1
    Feeling about quality of ANC Good 109 61.2
    Satisfactory 55 30.9
    Poor 11 6.2
    Feeling about the level of Health workers

    very good 33 18.5
    Good 71 39.9
    somehow they r good 67 37.6
    Bad 3 1.7
    Delivery and postnatal care services characteristics
    Concerning place of last delivery, 131 (73.6%) of the deliveries took place at health center, 31(13.6%) at hospital, 2(1.1%) in the clinic and 5(2.8%) in home. According to reasons of home delivery 2(1.1%) because of cost, 2(1.1%) because of to deliver relatives nearby and 1(0.6%) because of other reason. 2(1.1%) of home deliveries were attended by friends, 2(1.1%) of attended by neighbors and 1(0.6%) of attended by TBAs.Of all the respondents above half of the respondents 96(53.9%) were delivered by SVD, 8(4.5%) by C/S and 5(2.8%) by vacuum extraction. 88(49.45%) of women had average weight of baby,11(6.2%) of had large weight of baby,8(4.5%) of had small weight of baby and 2(1.1%) of didn’t know the weight of the baby (Table 3).
    95(53.4%) of the respondents had no danger symptoms after delivery while 14(7.9%) of the respondents had all symptoms after delivery. Majority of the respondents 103(57.9%) had checkup after delivery followed by 5(2.8%) of had no checkup.105 (59.8%) of the respondents had information about the routine follow up while, 3(1.7%) of had no information.61 (34.3%) of women came back to the health institution with in 1week, 44(24.7%) of women came back within 6 weeks while 1(0.6%) didn’t back. (Table 3)
    According to breast feeding 107(60.1%) fed their child, from this majority 78(43.8%) of them feed their child above 6 months. Of all the respondents most 144(80.9%) of them had knowledge about family planning methods. 42(23.6%) of them used injectable family planning methods, 40(22.5%) of them used pills.104 (58.4%) of the respondents didn’t get information about the side effects of the family planning methods from the health workers while 74(41.6%) of the respondents got information.(Table 3).











    Table 3: Characteristics during delivery and postnatal care services in Lideta health center
    VariableFrequencyPercent
    Place of delivery


    Hospital 31 17.4
    Health center 131 73.6
    Clinic 2 1.1
    Home 5 2.8
    Reason of home delivery Cost 2 1.1
    To deliver relatives Near by 2 1.1
    Others 1 .6
    In home delivery who assisted TBAs 1 .6
    Friends 2 1.1
    Neighbors 2 1.1
    How was deliver your baby SVD 96 53.9
    C/S 8 4.5
    Vacuum extraction 5 2.8
    Weight of the baby Large 11 6.2
    Average 88 49.4
    Small 8 4.5
    Don't know 2 1.1
    Symptoms after delivery All 14 7.9
    None 95 53.4
    Check up after delivery Yes 103 57.9
    No 5 2.8
    Information about routine check up Yes 105 59.0
    No 3 1.7
    After how many days do you come for routine check up Within 1wks 61 34.3
    6wks after delivery 44 24.7
    Didn't go 1 .6
    Did you breast feed Yes 107 60.1
    No 2 1.1
    Mechanism of breast feeding Exclusive<6 months 8 4.5
    Exclusive up to 6 months 21 11.8
    >6 months 78 43.8
    Knowledge about family planning Pills 15 8.4
    Injectables 11 6.2
    Implant 1 .6
    All 144 80.9
    None 6 3.4
    Others 1 .6
    Choice of family planning methods Pills 40 22.5
    Injectables 42 23.6
    IUD 18 10.1
    Implant 20 11.2
    All 1 .6
    None 55 30.9
    Others 2 1.1
    Information about the side effects Yes 74 41.6
    No 104 58.4
    Total 178 100.0
    Chi-square Analysis of socio-demographic characteristics on ANC
    Bivariate chi-square analysis is done for 5 variables and two of them are statistically significant at (since, p<0.05) significance level for ANC. These are educational status and income per month but occupation, religion and number of live births are not statistically significant because p>0.05.The chi-square test shows ANC services have association with different predictor variables, according to the result presented in Table 4 like educational status and income per month.
    Table 4: Chi-square Analysis of ANC services by selected socio -demographic characteristics in Lideta health center 2014
    CharacteristicsAntenatal careX2P value
    Variables Frequency%
    Educational status
    Never attended

    11

    6.2
    Only read and write 9 5.1
    elementary school 59 33.1
    secondary high school 68 38.2
    diploma and above diploma 31 17.4
    Total 178 100.0 30.969a .000
    Occupation
    house wife

    95

    53.4
    maid servant 15 8.4
    civil servant 32 18.0
    Merchant 15 8.4
    Student 3 1.7
    Private 18 10.1
    Total 178 100.0 4.297a .508
    Income per month
    <500 8 4.5
    500-1000 31 17.4
    1001-5000 129 72.5
    >5000 10 5.6
    Total 178 100.0 42.466a .000
    Religion
    Muslim 27 15.2
    Orthodox 125 70.2
    Catholic 5 2.8
    Protestant 21 11.8
    Total 178 100.0 15.091a .237
    No. of live births
    1 52 29.2
    2 34 19.1
    3 14 7.9
    >3 9 5.1
    None 69 38.8
    Total 178 100.0 2.451a .653
    A.education-1.82, occupation-0.08, income-0.04, religion-0.03, No. of children-0.25
    Correlation between selected socio-demographic characteristics and PNC services

    Table 5 shows correlation of selected socio-demographic variables with PNC services. The occupation has p>0.01 which means there is no relationship between the occupation and PNC services in the health center. When we see the respondents marital status, number of pregnancy and their age have p<0.01, these shows the variables have a relationship with PNC services and also the other one which is the educational status has p<0.05 so it is also has a relationship with the PNC services given in the health center.
    Table 5: Correlation of PNC services by selected socio-demographic characteristics in Lideta health center 2014
    CharacteristicsPostnatal carePearson correlationP value
    VariablesFrequency%
    Occupation
    house wife 95 53.4
    maid servant 15 8.4
    civil servant 32 18.0
    Merchant 15 8.4
    Student 3 1.7
    Private 18 10.1
    Total 178 100.0 .061 .416
    Marital status
    Married 155 87.1
    Divorced 2 1.1
    Widowed 5 2.8
    never married 16 9.0
    Total 178 100.0 .330** .000
    Age
    18-21 23 12.9
    22-25 48 27.0
    26-29 47 26.4
    30-33 31 17.4
    34-37 21 11.8
    >37 8 4.5
    Total 178 100.0 .581** .000
    Number of pregnancy
    1 71 39.9
    2 52 29.2
    3 30 16.9
    >3 25 14.0
    Total 178 100.0 -.635** .000
    Educational status
    Never attended 11 6.2
    Only read and write 9 5.1
    elementary school 59 33.1
    secondary high school 68 38.2
    diploma and above diploma 31 17.4
    Total 178 100.0 .163* .030
    *-correlation is
    **-correlation is
    significant at
    significant at
    0.05 Level
    0.01 level

    Focus group discussion results
    A total of 5 participants were involved in pregnant women and health workers. Nine specific questions were prepared. The group discussion started with general questions whether they had the knowledge on antenatal, delivery care services and postnatal care or not. Almost all of the groups defined ANC as a care provided during pregnancy to prevent any problems related to pregnancy and childbirth. ANC was also important for the well being of both the women and the fetus. Regarding delivery care services, most of the discussants agreed that delivery care and postnatal care is the care provided for women by trained health professional in the health institution. Majority of the group discussants able to name the danger signs of pregnancy related health problems. Such as sever hypertension, severe headache, severe anemia, vaginal bleeding, etc.
    The group discussants were asked the barriers that affect the utilization of maternal health care services. The main reasons by the most of the focus group discussants were lack of awareness, apparently healthy and work overload.
    The group were also interviewed the choice of delivery site. The majority of the discussants agreed that the best place to deliver a child is a health institution.
    They recommend that to increase maternal health care utilization are to educate the community, priority to train female midwifes, training and refreshment of traditional birth attendants.


    5. Discussion

    Lower rates of use of ANC, delivery assistance and postnatal care services have been established as contributing factors for higher rate of maternal mortality. In developing regions of the world like Ethiopia where such service are poorly developed, maternal mortality remained to be a big challenge in public health. To address these issues different stakeholders at international, national and regional levels have been implementing different strategies. The MDG has been one of the internationally coordinated biggest initiatives.
    In this study majorities of the respondents 48(27%) were aged between 22-25 and 47(26.4%) were aged between 26-29 followed by 31(17.4%) were aged between 30-33.Out of the total respondents majorities of 68(38.2%) were attended secondary high school and 59(33.1%) were attended elementary school followed by 31(17.4%) were diploma and above diploma. In other study likeAyssaita and Dubti towns, Afar regional state ,North east Ethiopia four hundred eighty six (76.7%) of the respondents were in the age group of 20-34 years, with a mean age of 25.3+(5.6) year. Almost half 313(48.8%) of the respondents were unable to read and write, 225 (35%) attended primary school and 104(16.5%) had completed secondary high school and higher education. So, when we see the difference in this study it had some variation among age and educational status compare to the other study. And also according to ethnicity and occupation in this study the majorities were Amhara 79(44.4%) followed by Oromo 40(22.5%).the same result as in Ayssaita and Dubti towns almost above half of the respondents 95(53.4%) were house wives followed by 32(18%) were civil servants. The majorities were Amhara 426(66.4%) followed by Afar ethnic group 161(25%) (6).
    In this study majorities of the respondents 125(70.2%) were Orthodox follower followed by 27(15.2%) were Muslims and 21(11.8%) were protestant follower. The same as in rural Ethiopia it was observed that orthodox women received delivery care service more when compare with those who follow other religion. Similar to this we observed that women who follow orthodox religion receive PNC service more when compare with those who follow other religious beliefs. In this study religion is found to be significantly related with use of delivery care and PNC services but not with use of ANC services (1).
    In this study the factors: mother age at birth, mother’s education, religion,husband attitude, family size, income, and mother’s work status is significantly associated with improved utilization of maternal healthcare services. And also in Afar regional state of north east Ethiopia, in Hadya and in Arsi zone the factors are absences of a health problem, lack of awareness, work overload and distant health service were the main reasons for no ANC attendance this study has some similar factors compare to the others (6, 25, and 27).
    Maternal age is strongly correlated with maternal health care utilization. Since the younger and the older women differ in their experience and influence of the health seeking behavior is likely to vary between younger and older women. In general, younger women is more likely to accept modern health care as they are likely to have greater experience to modern medicine and have greater amount of schooling than older women. Another possible explanation for this is that women pregnant with their first child were more cautious about their pregnancies and therefore sought out trained professionals. Older women on the other hand, tend to believe that modern health care is not as necessary due to experiences and accumulated knowledge from previous pregnancies and births and therefore likely to have more confidence about pregnancy and childbirth and thus may give less importance obtaining ANC.
    Out of the women included in the study almost all 174(97.8%) of women get ANC service from health institution, concerning place of last delivery, 131 (73.6%) of the deliveries took place at health center, 31(13.6%) at hospital, 2(1.1%) in the clinic. Majority of the respondents 103(57.9%) had PNC. In North West Ethiopia about 32.3%, 13.8% and 6.3% of the women had the chance to get skilled providers for their antenatal, delivery and postnatal care, respectively. So the new study showed that there was highly improvement in utilization of the services. A significant heterogeneity was observed among clusters for each indicator of skilled maternal care utilization. At the individual level, variables related to awareness and perceptions were found to be much more relevant for skilled maternal service utilization. Preference for skilled providers and previous experience of antenatal care were consistently strong predictors of all indicators of skilled maternal health care utilizations. Birth order, maternal education, and awareness about health facilities to get skilled professionals were consistently strong predictors of skilled antenatal and delivery care use. Communal factors were relevant for both delivery and postnatal care, whereas the characteristics of a health facility were more relevant for use of skilled delivery care than other maternity services (30).
    The major objective of this report was to examine factors that significantly shape the use of maternity care services in Ethiopia. Most of the factors investigated are related to the demographic and socio cultural characteristics of women. The study has identified several factors that have important influence on utilization of maternal health services in Lideta health center. These include place of residence, women’s education, marital status, religion, parity, and number of children. Place of residence and education are common predictors for the utilization of all the three maternity care services. Marital status and religion are important only for the utilization of antenatal care. On the other hand, parity is an important predictor of antenatal care only for the urban areas, while it is important for the utilization of delivery care for the entire country. Most of these findings are consistent with previous studies like studies done in Ethiopia (30).
    The results of the chi-square analysis presented in this study identified factors that are significantly associated with utilization of ANC services. These are educational status and income per month but occupation, religion and number of live births are not statistically significant because p>0.05.The chi-square test shows ANC services have association with different predictor variables, according to the result presented like educational status and income per month. And also in other study in Afar regional state of north Ethiopia the bivariate statistical analysis addresses the marginal effect of a predictor variable on the response without taking into account other predictors. And it shows the association between the outcome variable and other predictor variables, obtained by cross tabulation of the response variables, maternal healthcare (i.e. ANC, delivery care and PNC) usage to the other predictor variables independently. The chi-square test shows utilization of maternal healthcare have association with different predictor variables, the three maternal health care’s (i.e. ANC, delivery care and PNC) utilization have association with region, sex of household head, mother’s education, religion, husband education, mothers age at birth, birth order, employment status of mothers and wealth index. Some of the results similar with this study. The results could be useful in improving utilization of maternal healthcare services (6).
    In this study shows correlation of selected socio-demographic variables with PNC services. The occupation has p>0.01 which means it has no relationship with PNC services in the health center. When we see the respondents marital status, number of pregnancy and their age have p<0.01, these shows the variables have a relationship with PNC services and also the other one which is the educational status has p<0.05 so it is also has a relationship with the PNC services given in the health center. And also a similar study done in Uganda, Kampala the section presents information concerning the relationship between some of the socio-demographic factors, awareness and utilization of postnatal services. The variables addressed are mothers’ age, husbands’ occupation, number of live births, level of education, employment of a mother and cultural influence (19).


    6. Conclusion and Recommendation
    Conclusion
    In conclusion, this study demonstrated that utilization of maternal health service is inadequate in general, as clearly depicted by the major maternal health indicators (antenatal, delivery services and post natal) during the period of the survey. The most important factors influencing utilization of maternal health care services were demographic and socio-cultural in nature. The major factors identified in this study include mother’s education, mother’s work status, birth order and economic status. Mothers with primary or above education are more likely to utilize maternal healthcare services than mothers with no formal education. Also mothers who work as employee use health services more than mothers who are not employed. The main reasons given by the individual women for not to use the services were lack of awareness, apparently healthy, distant health facility, and work overload.
    The present study revealed that the majority of women sought at least one prenatal visit from modern health care providers during their recent pregnancy. So, more than half of the women who attended antenatal care services. Number of previous pregnancies and parities were found to be positive predictors of antenatal care attendance. Mothers use healthcare services more at their first birth than second and more birth. Muslim women were generally less likely to attend ANC check up and seek delivery assistance.
    Some positive achievements in the implementation of the program of skilled birth attendance, delivery place, availability of basic infrastructure at the facility. The choice of delivery site while ANC non- attendance and age of the women 35+ years were found to be barriers of institutional delivery care services. Some of the deliveries were attended by TBAs (untrained TBAs, Close relatives\neighbors). Users’ complaints of poor services in the health center were well documented. However no tangible solutions have been achieved.

    Recommendations
    The findings of this study have important policy implications. The identification of factors those are significantly associated with a mother’s decision to use healthcare services. This knowledge now needs to be converted into development of adequate interventions that aim to increase service use.
    This study identifies that though positive trends were observed in service utilization, the current utilization patterns of ANC services in the study areas are still below the targets. Most women did not make the recommended number of antenatal care. Female education is associated with patterns of ANC service use, that is, the higher the level of education of a mother the higher utilization pattern. Education levels in Ethiopia need to be improved. In the sample studied, most of the women had either no or just primary education. Education affects maternal healthcare service use by exchanging ideas and knowledge about maternal health and attitudes toward risk prevention by using the maternal healthcare services. Improving family planning and child spacing and also since pregnancy related complications are the main reasons for utilization of health facilities, community awareness program must focus on the danger signs surrounding pregnancy and childbirth. Muslim women should be oriented towards modern culture and more open to accept ANC services. In addition, policies and efforts have to be put in place to create job opportunity to mothers in Ethiopia. Increasing the economic situation of the population is a long term national objective and goes beyond the responsibility of the Ministry of Health. Nevertheless, the Ministry of Health could align its plan of actions to meet the objectives of the poverty reduction strategy and of the Ethiopian vision 2025.
    Good management systems could ensure maximization of the current capacity to deliver better health care services. Users’ satisfaction with care has increasingly been recognized as an important outcome of care. Provide supportive supervision and monitoring of TBAs post training, help them publicize their improved skills and receive compensation for their services. Priority training for female skilled delivery attendants. Health facilities should be implementing comprehensive service delivery approach and that the services time should be expanded to the whole working hours.

    9. References

    • 1. Kassu Mehari, (2012). Determinant factors affecting utilization of maternal health care services in rural Ethiopia PP 1
    • 2. Hauwa Suleiman, (2011).Utilization of maternal health care services in Nigeria;Analysis of regional differences in the patterns and determinants of maternal health care use.PP 1
    • 3. Gwamaka Samson (2013). Utilization and factors affecting delivery in health facility among recent delivered women in Nkasi district .PP1
    • 4. Gurmesa Tura(2009).Antenatal care service utilization and associated factors in Metekel zone, northwest Ethiopia .Ethiopia J.Health Science vol.19(2)PP 111
    • 5. Eyrusalem Dagne (2010).Role of socio-demographic factors on utilization of maternal health care services in Ethiopia.PP1
    • 6. Melkamu Fenta(2005).Assessment of factors affecting utilization of maternal health care services in Ayssaita and Dubti towns, Afar regional state ,North east Ethiopia.PP1
    • 7. Behailu et.al (2009).Factors affecting Antenatal care utilization in Yem special woreda, south western Ethiopia. Ethiopia Journal Health science 19(1) PP45
    • 8. Yared and Asnaketch (2002).utilization of maternal health care services in Ethiopia.PP1
    • 9. Lillian Z.Katenga(2010).Utilization of skilled attendance for maternal health care services in Northern Malawi:rural health centers perspectives.pp45-45
    • 10. Yuba et.al (2012).Maternal health services utilization in Nepal; progress in the new millennium. Health science Jornal 6(4) PP621-627
    • 11. Tej et.al (2011).Factors affecting the use of maternal health services in Madhya Pradesh state of India: A multilevel analysis Int.J. equity health 10(59)
    • 12. Alok Chauhan (2012).Antenatal care among currently married women in Rajasthan,India.Asian pacific Jornal of Tropical disease.PPS617-S622
    • 13. Anita Gupta et.al (2010).Determinants of utilization pattern of antenatal and delivery services in urbanized village of East Delhi.indian Journal prev.soc.med.41 (3&4)
    • 14. Tang J (2008).Use of maternal health care services in poor regions in Sichuan. Sichuan Daxue 39(16) pp1004-6
    • 15. Manuela valery et.al (2010).Determinants of utilization of maternal care services after the reduction of user fees: A case study from rural Burkinafaso.Article in press PP4-7
    • 16. Judith ea.al (2013).Male involvement in maternal health care as a determinant of maternal health care as a determinant of utilization of skilled birth attendants in kenya.DHS 93 PP10-13
    • 17. Anuja et.al (2008).Factors affecting maternal Health care seeking behavior in Rwanda.DHS No 59 PP7-1
    • 18. Okechukwu O.Ajaegbu(2013).Percived challenges of using maternal health care services in Nigeria.Arts&social sciences Journal vol.65 pp5
    • 19. Nankwanga Annet (2004).Factors influencing utilization of postnatal services in Mulago and Mengo hospitals Kampala, Uganda.PP41-62
    • 20. Moore, Alex and George (2011).Utilization of health care services by pregnant mothers during delivery in Nigeria: A community based study in Nigeria.Jornal of Medicine and medical science 2(5) PP865-866
    • 21. Sinkhada, Teijlingen, porter and simkhada (2008).Factors affecting the utilization of antenatal care in developing: systematic review of the literature.Jornal Adv.Nurse 61(3):PP244-260
    • 22. Trends in maternal health in Ethiopia.In depth analysis of EDHS 2000-2011 pp35-44
    • 23. Asmeret Moges Mehari(2013).Levels and determinants of use of institutional delivery care services among women of child bearing age in Ethiopia. Analysis of EDHS 2000&2005 data.DHS working papers No.83pp13
    • 24. Kalayou Berhe et.al (2012/2013).Assessment of Antenatal care utilization and its associated factors among 15-49 years of age women in Ayeder Krbelle,Mekelle city.American journal of advanced drug delivery 2(1)pp062-075
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    • 26. Kebebe et.al (2012).Determinants of community based maternal health care service utilization in South omo Pastorial areas of Ethiopia.jornal of medicine and medical science 3(2) PP115-120
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    • 28. H.Berhe et.al (2013).Utilization and associated factors of post natal care in Adwa town, Tigray, Ethiopia.Advance research in pharmaceuticals and biologicals 13(1) pp354
    • 29. Worku Awoke et.al (2013).Institutional delivery service utilization in Woldia,Ethiopia.Science journal of puplic health 1(1)pp18-23
    • 30. Abebaw, Alemayehu and Mesganaw (2013).Factors affecting utilization of skilled maternal care in Northwest Ethiopia: a multilevel analysis.













    Assessment on Level of Client Satisfaction and Determinants in Yekatit 12 Teaching Hospital Outpatient Department Addis Ababa, Ethiopia
    1 Zemichael Getachew, 2Tadesse Alemu
    1Universal Medical College, Public Health Department
    2Universal Medical College, Public Health Department
    Abstract
    Back ground: Client satisfaction is the level of satisfaction that clients experience having used a service. Patient satisfaction is one of the important studied aspects of health care. It can be an especially valid indicator of quality care and measurement of patient satisfaction in the health care field has been shown to be an increasingly important determinant of overall patient outcomes (6).
    Objective: To assess level of client satisfaction and its determinants in Yekatit 12 Teaching public hospital outpatient department in Addis Ababa, Ethiopia
    Methodology: An institutional based cross sectional study design was employed to assess the level of client satisfaction and determinants in Yekatit 12 teaching hospital OPD. Non probable quota sampling method was used to select two hundred twenty seven patients. Data was collected through structured questioner. Data entry and analysis was done by using SPSS version 16.0 computer soft ware package.
    Result: This study has revealed that the overall satisfaction level of the clients with the services given at Yekatit Teaching Hospital was 68.2%. Majority of the respondents 74.4% of them do not think the toilet for clients is not comfortable. A significant relation was observed between clients’ suggestion for others to get a service in this hospital and waiting time for the physician (p=.000).
    Conclusion and Recommendation: Determent factors like physical environments, times spent to get service and approach of care giver had a significant association and relation with overall satisfaction level as reviled in this study.Fixing miner infrastructural problems, respecting clients’ precious time and dedicated enough to serve their clients were recommended.

    1. Introduction

    • 1.1. Background of the study
    Health care has seen many changes over the time. When it is looked back to know the history of evolution of health care, and it comes to know that objective of health care changed with requirement of society and availability of resource and technology. The 19th century (1850) was an era which was “symptom centered”. Health was being referred to the elements of empirical perception/local understanding without any scientific examination. Early 20th century (1900) was basic science or disease centered era. Health was being referred to scientific reasoning and experimenting disease. It included diagnosis and treatment of diseases. Mid of the 20th century (1950) experienced clinical science or patient centered era. Health was centered mainly in hospital and clinics and diagnosis and treatment of individuals was preferred. End of 20th century (2000) saw political health science or people-centered era. Health has become people’s matter and need public participation, including proper allocation of resources responding to public need. The World Health Organization conference, supporting health for all, held in 1990 defined future development in health to be human centered. A lot of stress has been made on investment in health, patient care and patient’s right to delivery of quality health care leading to patient satisfaction (1).
    Health care quality is a global issue. The health care industry is undergoing a rapid transformation to meet the ever-increasing needs and demands of its patient population. Hospitals are shifting from viewing patients as uneducated and with little health care choice, to recognizing that the educated consumer has many service demands and health care choices available. Respect for patient’s needs and wishes, is central to any humane health care system (2). Client satisfaction is the level of satisfaction that clients experience having used a service. It therefore reflects the gap between the expected service and the experience of the service, from the client's point of view. Measuring client or patient satisfaction has become an integral part of hospital/clinic management strategies across the globe. Moreover, the quality assurance and accreditation process in most countries requires that the satisfaction of clients be measured on a regular basis. Asking patients what they think about the care and treatment they have received is an important step towards improving the quality of care, and ensure local health services are meeting patients' needs. It is an established fact that satisfaction influences whether a person seeks medical advice, complies with treatment and maintains a continuing relationship with practitioners (3).
    Patient satisfaction is one of the important studied aspects of health care .It can be an especially valid indicator of quality care and measurement of patient satisfaction in the health care field has been shown to be an increasingly important determinant of overall patient outcomes. Measuring satisfaction reliably, however, is an ongoing challenge .Individual patient attitude, expectations, and demographics clearly influence patient satisfaction levels. Given the same quality of care, two individuals may have radically different perceptions and, thus, different satisfaction levels (4). Hence determination of patient real feeling is very difficult. It is the responsibility of the administrator team. “Put yourself in your patient’s shoes,” was a proverb that explains how to proceed with a patient (5). Patients have explicit desires or requests for services when they visit hospitals. However, many cases of patient dissatisfaction can occur due to inadequate discovery of their needs. In a study conducted amongst seven developing countries, researchers who directly observed the clinical practice, found that 75% of cases were not adequately diagnosed, treated or monitored, though the most frequent explanation for the variation and low-quality care in the developing world was lack of resources (6).
    Patients’ perceptions about healthcare systems seem to have been largely ignored by the health care managers in developing countries. This is despite the fact that patient satisfaction surveys are one of the established yardsticks to measure success of the service delivery system, functional at hospitals. Awareness about patient satisfaction is relevant in the sense that satisfied patients are more likely to abide by the treatment advised, to continue using medical services and to promote referrals, thereby increasing the service volumes (7).
    • 1.2. Statement of the problem
    Ethiopia is one of the developing countries located in the northeastern part of Africa that currently trying to cope with the increasing population and its disproportionate health service delivery. Though the government is trying to address acceptable, accessible and affordable health service, there is still a gap between the desired goal and the current situation. Attentions given for the clients or patients presenting in public hospitals is somehow very poor which adds up the major opening in that gap. This problem is seen in the major public hospitals in Addis Ababa a capital city of Ethiopia. Understanding each patient needs is seems to be very difficult specially when there is a limited resource but it’s a fact that providing poor basic needs of a patient is not acceptable. Greeting with a calm face, talking with full attention, taking a detailed history, giving a clear information and reassurance are mite be some of the basic needs that all patients at least wants to get. But due to many reasons those patient needs are routinely ignored leading to dissatisfaction by the service provided and so decreased utilization.
    Like any other public institutions, hospital setup should be easy to use. Reception room, cafeteria, clean toilets and information desk are some of the places the hospital should have. Though it’s mandatory to have such places, it’s also an important thing to set them just the way the client or patient expects them to be. The environment of a hospital can highly affect the level of satisfaction of a patient. With easy access to pharmacy, laboratory, radiological rooms and other offices are also the important places, a patient want to get an organized, clear and short time consuming service. But the reality in the public hospitals found in Addis Ababa starts with uncomfortable rest room, broken toilets and confusing environment that patient mostly kill their time of wandering and so on. These problems are most seen in the outpatient departments where the patient first contacts the hospital.
    • 1.3. Significance of the study
    Quality assurance in the hospital can be done by assessing patient satisfaction level. This satisfaction levels are assessed by searching the needs of a patient in that hospital. Considering the limited resources and other detailed problems which should be solved through time, public hospitals at list should explore the cause of the obvious and simple problems to find a solution and assure quality of care. Patients from different socio demographic back ground will give their opinion, experience and level of satisfaction based on general approach by the service providers along with the setup. The received information from the patients will be analyzed and measured. The result from the study will serve as basic information in deciding solutions to fill the gap between the desired goal and the current status of the hospital.
    Other staffs and places like pharmacy, laboratory, x-ray room etc. in the hospital have a great influence on the satisfaction level of the patient which in turn affects the quality of care. Problems in those places can also be determinate factors, identifying these problems in this particular study area by asking patients and putting them as a measured data is the aim of the study. Thus information obtained after completion of the study will help the managerial board to reach major decisions in solving the problems.




















    Fig.1: Conceptual Frame work for the study
    Independent variables





















    2. Objective

    2.1. General Objective

    To assess level of client satisfaction and its determinants in Yekatit 12 Teaching public hospital outpatient department in Addis Ababa, Ethiopia

    2.2. Specific Objective

    • To assess the level of client satisfaction among patients attending Yekatit 12 Teaching public hospital outpatient department in Addis Ababa, Ethiopia
    • To assess determinants for the patient satisfaction among patients attending Yekatit 12 Teaching public hospital outpatient department in Addis Ababa, Ethiopia

    3. Material and Methodology

    3.1. Study area and Period

    Yekatit 12 teaching hospital is one of the five public hospitals in Ethiopia and it belongs to the Addis Ababa administrative region. The hospital provides services for a population of approximately 4 million. It is made up of nine departments and six units and has 265 beds. Yekatit 12 has laboratory and x-ray room facilities that perform most categories of routine diagnostic prosidures. It is located around Sidist kilo in front of Addis Ababa University main cumpus on the side of St.Piters and Powlos church or on the left side of Sematat Avenue when you came from Four kilo behind Federal higher court compound. The study was held starting from March up to June, 2014.

    3.2. Study Design

    An institutional based cross sectional study design was used to assess the level of client or patient satisfaction and determinants in Yekatit 12 teaching hospital outpatient department in Addis Ababa, Ethiopia

    3.3. Population

    3.3.1. Source population

    All patients presenting in Yekatit 12 teaching public hospital

    3.3.2. Sample population

    All patients presenting in Yekatit 12 teaching public hospital outpatient departments

    3.3.3. Study population

    A total of 227 patients aged greater than 18 presenting in outpatient department

    3.4. Criteria for Inclusion and Exclusion

    3.4.1. Inclusion Criteria

    All voluntary patients aged greater than 18 presenting in the outpatient department during the study period

    3.4.2. Exclusion Criteria

    All patients presenting severely sick and mentally not sound
    All patients who are not presenting within the study period
    All patients getting service other than outpatient department
    All patients presenting hearing problem

    3.5. Sample Size Determination

    This study calculated the sample size by using single population proportion formula by 18%[20] of prevalence of patient satisfaction in public hospitals with 95% confidence interval and 5% degree of precision.
    n = (zα/2)2 p (1-p)
    d2
    Where
    n= sample size
    zα/2 = Z score value at 95% confidence interval that is 1.96
    P = prevalence estimated to be 18% (20)
    d = margin of error (5%)

    n= (1.96)2 0.18 (1-0.18) = 227
    (0.050)

    3.6. Sampling Procedure

    Non probability quota sampling method was used to select two hundred twenty seven patients presenting in outpatient department of Yekatit 12 teaching hospital.

    3.7. Data Collecting Technique

    3.7.1. Data collection method

    A structured questioner adapted from previous studies on this title was prepared by investigator.

    3.7.1.1. Qualitative data

    A qualitative data collection was done by the investigator through observation. A structured questioner at least containing eight close ended questions was prepared to be marked at the time of observation by the investigator. Around 40 selected interactions between patient and care provider like doctors, nurses and other personal was observed.

    3.7.1.2. Quantitative data

    A quantitative data was collected through structured questioner holding three parts (socio demographic, physical environment and client-service provider interaction). The questioner was included open and closed ended question, focusing on the objective of the study. Data collectors were interview 227 selected subjects in the OPD, laboratory and other areas.

    3.7.2. Data Collectors

    Three selected individuals at least who have finished secondary high school were trained on how to collect the data prior data collection date.

    3.8. Data Processing and analysis

    Completeness of the data was checked after data collection. Data entry and analysis was done by using SPSS version 16.0 computer soft ware package. The data entered was cleaned and analysis was made on the set of variables. The final data was presented in graphs, tables and statements.

    3.9. Study Variables

    3.9.1. Dependent variables

    • o Level ofClient or patient satisfaction
    • o Determinants of client satisfaction

    3.9.2. Independent variables

    • o Socio demographic factors
    • o Physical environment
    • o Care provider-patient relation

    3.10. Data Quality Assurance

    To ensure quality, questionnaires were adapted from previous similar studies. The structured questionnaire was pretested on the study area, but subjects used for this purpose was not be included in the study sample. This is done to identify the clarity of question, their sensitiveness as well as gap on data collector. Correction was made based on the result of the pre-test. Questions was grouped and sequenced in terms of their sensitivity and objectives they focus on. The investigator properly monitored and evaluated the data collection procedure. At the spot on daily basis data was checked for completeness, accuracy, clarity and consistency by the Investigator.

    3.11. Ethical Considerations

    A written ethical clearance letter from Universal University College to the study area was forwarded to the concerned party. By contacting the officials permission was secured at the Study area. After The necessary explanation about the purpose of the study and its procedure, permission and verbal consent from the respondents was asked before data collection begins. Only volunteers who are mentally sound were taken. Privacy and confidentiality was maintained throughout the process of the study. The materials used for data collection was not have the name of the respondent and was destroyed after finalizing the study.

    3.12. Dissemination of the Result

    The final result of this study will be disseminated to the relevant bodies such as Universal University College, for the hospital where the study were conducted and for those who will benefit from the research or study outcome.

    • 4. Result
    Socio-demographic characteristics
    Of the total 277 outpatient department service users interviewed in Yekatit 12 Teaching Hospital, 56 (24.7%) were within the age group of 25-31, 35 (15.4%) of them between 39-45 and 32 (14.1%) of them were between 18-24 and 32-38. There were almost equal proportion 114 (59.2%) of male and 113 (49.8%) female respondents. Majority 155 (68.3%) were married and 67(29.8%) of them unmarried. Considerable number 165 (72.7%) of respondents were literate and 44 (19.4%) were illiterate. Concerning the occupation 76 (33.5%) of the respondent have no job, 61(26.9%), 48(21.1%), 33(14.5%) were private workers, governmental workers and merchants respectively. Majority 194(85.5%) of them live in urban area. Most 160(70.5%) of them pay for the service they get while 67(29.5%) of them gets free service. Reason for follow up accounts 144(63.4%) while illness 49(21.6%) and attendant 34(15%) (Table1).



















    Table 1: Socio-demographic characteristics of the respondents, Yekatit 12 Teaching Hospital, Addis Ababa, 2014
    Variable Frequency Percent
    Age
    18-24

    32

    14.1
    25-31 56 24.7
    32-38 32 14.1
    39-45 35 15.4
    46-52 31 13.7
    53-59 19 8.4
    60-66 14 6.2
    67-73 5 2.2
    74-80 3 1.3
    Total 227 100.0
    Sex
    Male 114 50.2
    Female 113 49.8
    Total 227 100.0
    Marital Status
    Unmarried 67 29.5
    Married 155 68.3
    Widowed 3 1.3
    Divorced 2 .9
    Total 227 100.0
    Educational Status
    Illiterate 18 7.9
    Can read and write 44 19.4
    Literate 165 72.7
    Total 227 100.0
    Occupation
    Governmental worker 48 21.1
    Merchant 33 14.5
    Farmer 9 4.0
    No job 76 33.5
    Private work 61 26.9
    Total 227 100.0
    Lives
    Urban 194 85.5
    Rural 33 14.5
    Total 227 100.0
    Payment Status
    Paying 160 70.5
    Free service 67 29.5
    Total 227 100.0
    Reason for visit
    Illness 49 21.6
    Follow up 144 63.4
    Attendant 34 15.0
    Total 227 100.0
    How frequent do you come
    New visit 33 14.5
    Repeated visit 194 85.5
    Total 227 100.0
    Physical Environment of the hospital
    Majority of the respondents 160(70%) do not think that there is proper ventilation in the waiting Room while 50(22%) and 17(7.5%) of them think there is proper ventilation and somehow good ventilation in the waiting room respectively. Sitting arrangement in the waiting room is one aspect were 144(63%) of the respondents do not think it’s comfortable followed by 53(23.3%) of them thinking it’s comfortable and 30(13.2%) of them think somehow it’s comfortable. The other aspect is toilet for the clients, were by 169(74.4%) of the respondents do not think it’s comfortable, which makes the value significant. Getting only some of the requested drugs all the time was score for 59(26%) of the respondents while 64(28.2%) think they have got drugs all the time (table 2).

    Table 2: Results of respondents on the physical environment of Yekatit Teaching Hospital, Addis Ababa 2014 (N=277).
    Variable frequency percent
    Proper ventilation in the waiting room
    Yes 50 22.0
    No 160 70.5
    Somehow good 17 7.5
    Comfortable Sitting arrangements in the waiting room is
    Yes 53 23.3
    No 144 63.4
    Somehow comfortable 30 13.2
    Cline and comfortable toilet for client
    Yes 13 5.7
    No 169 74.4
    Somehow good 10 4.4
    I don’t know 35 15.4
    Getting any drug you Requested All the time
    Yes 64 28.2
    No I don’t get 34 15.0
    I don’t know 9 4.0
    Yes but some of them 59 26.0
    Suggest Others to get service in this hospital
    Yes 151 66.5
    No 76 33.5

    Time spent to get various services
    The highest (63.95%) value was scored for those who responded waiting the physician greater than 180 minute. Waiting for the result on the laboratory area took 61-180 minute for 18.55% of the respondents. Registration time took 16-30 minute for 24.7% of the respondents while 33.05% of them spent less than10 minute in the pharmacy and on the other examination areas like ultrasound, x-ray and endoscopy result took greater than 180 minute for 19.45% of the respondents (table3).
  • Table 3: percentage distribution of time spent to get various services in Yekatit Teaching Hospital, Addis Ababa 2014 (N=277) .
    Variable Time spent in Minute
    less than 10 10-15 16-30 31-60 61-180 greater than 180
    In the registration office 18.5% 18.95% 24.75% 15.05% 15.05% 15.05%
    In the Laboratory area for a Result 5.35% 11.55% 22.05% 11.95% 18.55% 17.25%
    In other examination areas(ultrasound, x-ray etc) 4.45% 6.65% 11.05% 10.15% 8.85% 19.45%
    In the Pharmacy area 33.05% 18.15% 15.05% 5.35% 1.85%
    Waiting For a Physician 4.45% 2.65% 7.05% 10.15% 11.95% 63.95%
    Client-services provider relation and client satisfaction level
    Attention given by the physician and nurses were the highest (26%) value that respondents were very satisfied with. Unsatisfied respondents by the waiting room ventilation, setting arrangement, toilet and compound cleanness were 48.5%. Neutrally satisfied respondents by the service provided on the laboratory were the highest among neutral satisfaction level scoring 22%. Respondents were satisfied 48.5% by the attention physicians and nurses give (table4).

    Table 4: percentage distribution satisfaction levels of client on differs variables in Yekatit 12 Teaching Hospital, Addis Ababa 2014 (N=277)
    Variables Satisfaction level
    V. Satisfied Satisfied Neutral Unsatisfied V. Unsatisfied
    Waiting room ventilation & setting arrangement, toilet & compound cleanness 3.5% 10.1% 18.1% 48.5% 19.8%
    Service provided on the Laboratory 6.2% 43.6% 22.0% 11.5% 3.1%
    Service provided on other examination areas (Ultrasound, X-ray & endoscopy) 4.8% 23.8% 15.9% 15.4% .4%
    Information given by the Pharmacist 8.4% 43.2% 9.7% 10.6% 1.3%
    Pharmacy service Provided 5.3% 41.9% 16.3% 8.8% .9%
    Attention Physician and Nurses give 26.0% 48.5% 13.2% 11.9% .4%
    Privacy and Confidentiality kept by the Physicians and nurses 5.7% 53.7% 21.6% 18.1% .9%
    Respect and Courtesy you get from any service providers 10.6% 43.2% 17.2% 27.3% 1.8%
    time you spent with the Physician 20.7% 48.0% 21.1% 9.3% .9%
    Completeness of the Information you get from the Physician about your problem 17.6% 41.9% 17.6% 22.5% 1%
    Examination Room cleanness 6.6% 30.0% 32.2% 30.0% 1.3%
    Registration room and Other Staffs of the Hospital giving any service 6.2% 33.5% 30.8% 25.6% 4.0%
    Client satisfaction level
    More than half (68.3%) of the respondents were unsatisfied by the waiting room ventilation and setting arrangement, toilet and compound cleanness. Only 9.7 and 10.1 presents of the respondents were unsatisfied with pharmacy service and time spent with the physician respectively. Satisfaction level was score high in which 89.9% of the respondents were satisfied by the time they spent with the physician followed by physicians attention, privacy and confidentiality, completeness of the information about the problem physicians give for their patients and laboratory service 87.7%, 81.1%, 77.1% and 71.8% respectively (table5).
    Table 5: arranged client satisfaction level (very satisfied, satisfied and neutral merged in satisfied and unsatisfied and very unsatisfied merged in unsatisfied) in Yekatit 12 Teaching Hospital, Addis Ababa 2014 (N=277)
    Variables Satisfaction level in %
    Satisfied Unsatisfied
    Waiting room ventilation & setting arrangement, toilet & compound cleanness 31.7 68.3
    Laboratory Service 71.8 14.5
    other examination areas Service 44.5 15.9
    Pharmacist Information 61.2 11.9
    Pharmacy service Provided 63.4 9.7
    physician Attention 87.7 12.3
    Privacy & confidentiality 81.1 18.9
    Respect & courtesy 70.9 29.1
    Time spent with physician 89.9 10.1
    Completeness of the Information Physician give about the problem 77.1 22.9
    Examination Room cleanness 68.7 31.3
    Registration room and Other Staffs of the Hospital giving any service 70.5 29.5
    Comparison of level of client satisfaction on compound cleanness and comfort by selected socio– demographic characteristics
    Table 6 shows comparisons of level of satisfaction on compound cleanness and comfort with selected socio-demographic characteristics of the respondents. Accordingly, those between the age group of 39-45 were highly unsatisfied but no association was observed between level of satisfaction of client on compound cleanness and comfort (p=0.116). Level of satisfaction had statistically significant associated with sex (p=0.004) and males were highly unsatisfied than females. No association was also observed in educational states and level of satisfaction but literates were highly unsatisfied. Significant association was there on clients who pay for the service they get and satisfaction level client on compound cleanness and comfort (p=0.002). Clients who pay for the service were highly unsatisfied than that of getting free service. Association was also observed on clients’ reason for visit and level of satisfaction on compound cleanness and comfort (p=0.007). Those who were on follow up were highly unsatisfied (table6).

    Table 6: Comparison of level of client satisfaction on compound cleanness and comfort by selected socio– demographic characteristics in Yekatit 12 Teaching Hospital, Addis Ababa, 2014
    VariablesSatisfiedUnsatisfiedTotalX2p-value
    Age (in year)
    18-24 13 19 32







    12.882








    .116
    25-31 24 32 56
    32-38 9 23 32
    39-45 6 29 35
    46-52 9 22 31
    53-59 5 14 19
    60-66 6 8 14
    67-73 0 5 5
    74-80 0 3 3
    Sex
    Male 26 88 114
    8.396

    .004
    Female 46 67 113
    Educational Status
    Illiterate 8 10 10


    2.310



    .315
    Can Read And Write 16 28 28
    Literate 48 117 117
    Payment Status
    Paying 41 119 160
    9.292


    .002
    Free Service 31 36 67
    Reason for visit
    Illness 19 30 49

    9.956


    .007
    Follow Up 50 94 144
    Attendant 3 31 34
    Repeated Visit 61 133 194
    Multivariate analysis

    A significant relation was observed between clients’ suggestion for others to get a service in this hospital with satisfaction level of compound cleanness (p=0.002) as well as respect & courtesy by health provider (p=.000) also waiting time for the physician (p=.000). Significant relation was there between satisfaction level of compound cleanness and waiting time for the physician (p=.000), satisfaction level of respect and curtsy by health providers (p=.000), client satisfaction on all staff and registration service (p=.004). Satisfaction level of respect & courtesy given and satisfaction level of client on all staff as well as registration office service were also significantly related (p=0.000). Also satisfaction level of client on all staff and registration office and client suggest others to get service in this hospital had a significant relation (table7).

    Table 7: Relations between multiple variables in the study in Yekatit 12 Teaching hospital, Addis Ababa 2014
    Suggest Others to get service in this hospital Compound cleanness satisfaction Waiting time For a Physician Respect & courtesy given Satisfaction All staff & registration office service Satisfaction
    Suggest others to get service in this hospital X2 1 .203** .243** .491** .482**
    p-value .002 .000 .000 .000
    Compound cleanness satisfaction X2 .203** 1 .313** .290** .192**
    p-value .002 .000 .000 .004
    Minutes spent Waiting For a Physician X2 .243** .313** 1 .241** .198**
    p-value .000 .000 .000 .003
    Respect & courtesy given Satisfaction X2 .491** .290** .241** 1 .351**
    p-value .000 .000 .000 .000
    All staff & registration office service Satisfaction X2 .482** .192** .198** .351** 1
    p-value .000 .004 .003 .000
    **. Correlation is significant at the 0.01 level (2-tailed).

    Shows the comparisons of time spent to receive various services in the hospital and level of satisfaction
    Table 6 shows the comparisons of time spent to receive various services in the hospital and level of satisfaction. Time spent to get lab result had statistically significant association with lab service satisfaction (p= .000). Those who spent 16-30 minutes were more satisfied. In the same way there was a statistically significant association observed between times spent to get service on the registration office along with the other staffs and clients satisfaction level (p=0.000). Those who spent 16-30 minutes to get the service were highly satisfied. Waiting for the result in other examination areas were significantly associated with satisfaction, clients who spent greater than 180 minutes were more satisfied in this case (p=0.000). Satisfaction by the service provided in the pharmacy area was also significantly associated with the time spent to get the service. Clients who spent less than 10 minuet to get the service were highly satisfied than those who spent more than 10 minuet (p=0.000). on the other hand clients who were highly satisfied by the time they spent with the physician waited to get the service for more than 180 minutes, though there was no strong association (p=0.072) (table8).

    Table 8: shows the comparisons of time spent to receive various services in the hospital and level of satisfaction in Yekatit 12 Teaching Hospital, Addis Ababa 2014
    variables Minutes spent in lab, other examination areas, pharmacy, waiting for physicians & registration room respectively X2 p-value
    less than 10 10-15 16-30 31-60 60-180 greater than 180
    Laboratory service
    Satisfied

    12

    24

    46

    23

    33

    25



    2.474



    .000
    Unsatisfied 0 2 4 4 9 14
    Other examination service
    Satisfied



    10



    15



    22



    11



    14



    29




    2.619




    .000
    Unsatisfied 0 0 3 12 6 15
    Pharmacy service
    Satisfied


    72


    36


    28


    7


    -


    1



    2.651



    .000
    Unsatisfied 3 5 6 5 - 3
    Time with physician Satisfied

    10


    5


    16


    22


    27


    124



    10.116



    .072
    Unsatisfied 0 1 0 1 0 21
    All staff & registration service
    Satisfied


    37


    33


    43


    21


    17


    9




    19.871




    .001
    Unsatisfied 5 10 13 13 17 9
    Findings of the observation

    A principal investigator have observed a general approach and activity’s of a care providers on 44 patient examinations in various outpatient study setting or rooms like medical, surgical and ENT departments using a checklist after getting permission from those facility heads and examining professionals to simply observe the examination process wearing a professionals uniform. Accordingly, 25(56%) of the care providers called their patients by names when they start conversation and to come into examination room. On the first contact with the care provider 31(70.5%) of the care providers greet patients in a socially acceptable manner. All 44(100%) care providers were polite enough, keep patient privacy, take history as expected and give a chance to talk enough to their patients but only 11(25.0%) of the care providers perform physical examinations to their patients(table9).
    Variable Response Response rate
    Does the provider call a patient by name Yes 25(56.8%)
    No 19(43.2%)
    Total 44
    Does the provider greet a client Yes 31 (70.5%)
    No 13 (29.5%)
    Total 44
    Is the provider polite enough to patients Yes 44(100.0%)
    Does provider take history as expected Yes 44(100.0%)
    Does provider give patient chance to talk enough Yes 44(100.0%)
    Does provider perform physical examination Yes 11(25.0%)
    No 33(75.0%)
    Total 44
    Does the provider try to keep patient privacy Yes 44(100.0%)
    Table 9: Shows quantified qualitative findings of observation on cases or interaction of care giver and client in Yekatit 12 Teaching Hospital, Addis Ababa 2014
    Suggestion given to improve the service and summarized
    Thoughts by the respondents: clients were asked to give any suggestion, filling and thoughts they believed are important for improving the services. Most of them gave more than one suggestion while others reserved to say nothing. The suggestions forwarded based on the situations and fillings were almost similar. Accordingly, the main ones were; concerning the physical environment this was forwarded, toilet for client were the most unexpected, uncomfortable and even considered to be as if it’s not there. Suffocation and uncomfortable sitting arrangement should be fixed along with a dirty cafeteria, broken and insufficient water supplies. The other one is concerning the time spent to get any service along with inappropriate appointment giving. Waiting time for the physicians were the most frustrating one which should be managed soon. Finally health care providers approach should be some how good despite the enormous different behaviors’ shown by the clients. Positive feedbacks were also given on laboratory, pharmacy services and physicians approach saying that they should keep up the good work.


    • 5. Discussion
    This study has revealed that the overall satisfaction level of the clients with the services given at Yekatit Teaching Hospital was 68.2%. This result is the highest among researches done in Tigray zone Ethiopia with the result 43.6 % [15] and other research done in Addis Ababa, Ethiopia (2012) showing a result of 18.0% [20]. The finding is higher than research done, Kolkata, India which showed 36% [4] and study done in Islamabad, Pakistan showing a result of 54% [1]. The difference might be attributed to the fact that this study was conducted in a specialized teaching hospital where there are relatively adequate number of health professionals and better diagnostic facilities.

    As it has been indicated in the result, majority of the respondents (70%) do not think that there is proper ventilation in the waiting room, 63 and 74 percent of the respondents do not think there is comfortable setting arrangement and toilet respectively, supported with suggestions given by the respondents saying that suffocation and uncomfortable sitting arrangement along with a dirty cafeteria, broken and insufficient water supplies should be fixed. This finding is agreed with the study done in Kolkata, India were majority of the total respondents (84%) agreed/strongly agreed regarding the inadequacy of facilities like toilet, drinking water, sitting arrangement in the dispensaries [4]. This might be due to lack of attention and resource to fix the problem despite the big project that the hospital was involved in building up a specialized and teaching institution.
    In the analysis of client satisfaction the very satisfied and very dissatisfied groups were categorized to satisfied and dissatisfied groups respectively because the numbers of respondents in those groups were small. Similarly neutral responses were classified as satisfied considering that they may represent a positive way of expressing an agreement. A statistically significant association was observed between level of satisfaction and sex (p=0.004), payment status (p=0.002) and clients’ reason for visit but no statistical association was observed for age and educational status which oppose research done in Cambodia reviling a significant association of education and level of satisfaction [8].
    Statistical analysis in this study has shown that the level of satisfaction decreased with an increase in length of waiting time (p=.000) in laboratory, pharmacy and other examination areas, it is similar with other study done in eastern Ethiopia showed a statistical analysis of the level of satisfaction decreased with an increase in perceived length of waiting time p< 0.01[19].
    Registration time took 16-30 minutes for 24.75% of the clients, 70.5% of the respondents were satisfied by the service and statistically significant association was observed between times spent to get service on the registration office and clients satisfaction level (p=0.000). The result is similar to a study showing satisfaction level of service given on registration in institute of medical science, Islamabad, Pakistan having a result of 77.5% [1]. But the result is higher than research done in Cambodia which reveled that the majority of the respondents were relatively less satisfied with registration service at 64% [8]. The reason for this difference might be the application of an organized and fast service that has been implemented starting resent years back.
    In this study 26% of the respondents were clamed to get only some of the drugs all the time and 33.05% of them spend less than 10 minutes to get the service. 63.4% of the respondents were satisfied by the service provided on the pharmacy. This finding was lower than research done in Tigray zone Ethiopia showing, of those with the prescription paper, only one third (32 %) got all the prescribed drugs and supplies [15]. The reason for this might be shortage of drug supplies despite the large patient out flow.
    Result in this study showed 71.8% of the respondents were satisfied with the service provided in the libratory which is lower than other research done in eastern Ethiopia showing 87.6% were satisfied with the laboratory services [18]. Also statistically significant association was observed between level of satisfaction on this area and time spend to get the service (p= .000) this result was also similar to another study done in Addis Ababa which revealed, statistical significant associations between the overall patients’ satisfaction with waiting time to get blood drawing service, availability of ordered laboratory tests and waiting time to get laboratory result with (p<0.05) [21].
    Some determinants observed in this study were waiting time to get various services, payment status (p=.002), compound cleanness (0.000), respect & courtesy given and sex which somehow has a similarity with other research done in Calabar, Nigeria showing determinants of satisfaction were total clinic wait time (p=0.001), clinic wait time (p=0.007) and age (p=0.001) [12].
    Quantified qualitative result in this study showed that physical examination was not done in 75% of the cases. This finding is very higher compared to research done in Muhimbili National Hospital, Tanzania showing Only 38 (2.3%) of patients voiced some dissatisfaction with the medical examination done on them [10]. The reason for this might be the fact that there is large number of patient out flow and individual physician was expected to see more than 40 patients per half a day in this study set up which in turn might affect the proper examination time.
    Satisfaction level of client with all staff, registration office and clients suggesting others to get service in this hospital had a significant relation. 66.5% of the respondents suggest others to get service in this hospital which is lower compared to other study in Hawasa university teaching hospital showing 87.6% of them would like to recommend the hospital to their friend [17].

    • 6. Conclusion
    Based on the finding of this study the following conclusion can be drawn.
    Many clients seemed to be unsatisfied with the services provided in general physical environment; time spends to get any service in outpatient department like:
    • ü Waiting room ventilation & setting arrangement, toilet & compound cleanness.
    • ü Time spend waiting for the physician.
    • ü Time spend to get the results of various examinations.
    Many clients were satisfied with some of the services provided in the OPD as well as health care providers like:
    • ü Services provided in the laboratory and pharmacy.
    • ü Time they spent with the physician, attention given by the physician, privacy and curtsy given by care givers.
    Observational quantified finding showed that many of the cases were scored with the good approach by the care providers and many of suggestions give by the respondents support the quantitative data on physical environment of the hospital.
    Determent factors like physical environments, times spent to get service and approach of care giver had a significant association and relation with over all satisfaction level as reviled in this study.
    There for from the stamens above though there are significant problems to be solved client satisfaction is high in outpatient department of Yekatit 12 Teaching Hospital.
    • 7. Recommendation
    Concerning the management:
    It could be important to solve and fix miner infrastructural problems like toilet, sitting arrangements, clean and simple environment and water supplies as fast as possible in the hospital that dose seems to affect emotions of the client, though situations forced the management to focus on the beiger problems they should not forget client satisfaction matters a lot after all.
    New and organized services delivery system with regular provision of job training for all health workers should be in place to help them change their attitudes in order to provide their clients with all relevant information.
    Assignment of the right staffs in the right place for the provision of appropriate and relevant information.
    Concerning the health care providers:
    Tough it’s too difficult to satisfy the needs in an individual level despite the enormous patient outflow, health care providers should be dedicated enough to serve their clients as much as possible which begins with change in attitude and behavior.
    Respecting clients’ precious time and treating them equally by considering shortage of time despite the flow of the patient giving them appropriate appointment as much as possible also recommended, though this also need managerial systematic approach.

    10. Reference

    • 1. Anjum Javed Patient satisfaction towards outpatient department services in Pakistan institute of medical science, Islamabad: 2oo5 p 2,3
    • 2. Syed Shuja Qadr Rombha Pathak et al An assessment of patients satisfaction with services obtained from a tertiary care hospital in rural Haryana: 2012; International Journal of collaborative research on internal medicine and public health vol.4(8) p 1525
    • 3. Fekadu Assefa et al Assessment of clients satisfaction with health service deliveries at Jimma university specialized hospital:2011; Ethiopian journal of health science vol. 21(2) p 101
    • 4. Amitabra Chattopadhyay et al Patient satisfaction evaluation in CGHS dispensaries in Kolkata: 2013;IOSR journal of dental medical sciences (IOSR-JDHS) vol.16(4) p 13-19
    • 5. Asma Ibrahim Patient satisfaction with health services at the outpatient department of Indira Gandhi Memorial hospital, Male Maldives: 2008 p 1
    • 6. Tayue Tateke et al Determinants of patient satisfaction with outpatient health service at public and private hospitals in Addis Ababa, Ethiopia:2012; AOSIS open journals p 2
    • 7. Nirmalya Manna et al A study on client satisfaction as per standard treatment guidelines in a rural hospital of west Bengal, India: 2013 Global journal of medicine and public health vol.2(6) p 1
    • 8. Moavad Hana Assessment of patient satisfaction in an outpatient department of an autonomous hospital in Phnompenh, Cambodia:2012 p 47-66
    • 9. Iftikhar Ahmad et al Predictors of patient satisfaction:2011; Gomal journal of medical science vol.9(2) p 185
    • 10. E.P.Y Muhondwa et al Patient satisfaction at the muhimbili national hospital in Dare selam, Tanzania:2008; East African journal of public health vol.5(2) p 69-71
    • 11. Ndifreke et al Patient-Related factors influencing satisfaction in the patient-doctor encounters at the general outpatient clinic of university of calabar teaching hospital, calabar, Nigeria:2012; International journal of family medicine p 3
    • 12. H.Adamu et al Patient satisfaction with service at a general outpatient clinic of tertiary hospital in Nigeria:2014; British journal of medicine and medical research vol.4(11) p 2182
    • 13. P.K.Turkson Perceived quality of health care delivery in rural district of Ghana:2009; Ghana medical journal vol.43(2) p 65-67
    • 14. Juliet Nahbuye-sekand et al Patient satisfaction with services in outpatient clinics at Mullago hospital, Uganda:2011; International journal for quality in health care p 1-8
    • 15. Girmay Adane Assessment of clients satisfaction with outpatient services in Tigray Zonal hospitals:2006 p17-37
    • 16. Fekadu Assefa et al Assessment of clients satisfaction with health service deliveries at Jimma University specialized hospital:2011; Ethiopian journal of health science vol.2192) p 101
    • 17. Anteneh Asefa et al patient satisfaction with outpatient health services in Hawassa university teaching hospital, southern Ethiopia:2014; Journal of public health and epidemiology p 103-105
    • 18. Zelalem Telemariam et al Clients and clinician satisfaction with laboratory services at selected governmental hospitals in eastern Ethiopia:2013; BMC research note vol.6(15) p 1
    • 19. Birna Abdosh The quality of hospital service in eastern Ethiopia: patients perspective:2006; Ethiopian journal of health development vol.20(3) p 200
    • 20. Taye Tateke et al Determinants of patient satisfaction with outpatient health services at public and private hospitals in Addis Ababa, Ethiopia:2012; p 1
    • 21. Tedla Mindaye et al Patient satisfaction with laboratory services at antiretroviral therapy clinics in public hospitals Addis Ababa, Ethiopia:2012; BMC research Note vol.5(184) p 1




    Assessment on Adult Patient Satisfaction with Nursing Care in Selected Public/Private Hospitals, Addis Ababa, Ethiopia
    1Feleke Haile, 2Sr. Elleni Belachew
    1Universal Medical College, Public Health Department
    2Universal Medical College, Public Health Department
    Abstract
    Introduction: - Measuring quality of care in the hospital setting has become very important in evaluating healthcare services. One of the major criterions that used as a tool is adult patient satisfaction with nursing care. Nursing care is one of the major health care services that contribute significantly to the patient healing process.
    Objective: - To assess Adult patient satisfaction with nursing care in selected Public/Private Hospitals.
    Methodology: - A descriptive Cross-Sectional design was conducted in 164 admitted adult patients in Tikur Anbessa and St. Gabriel hospital who were selected through stratified probability sampling method. Data was collected using structured questionnaires designed for interview and the study was implemented by face-to-face interview. Quantitative and qualitative study was undergone. Data analysis was made on the set of variables by using SPSS and the data were presented in tables, graphs and cross-tabulation.
    Results: - Age and gender were the significant predictors of patient satisfaction with nursing care (p<0.05).
    Conclusion and Recommendation: -The study also analyzed the socio-demographic-patient satisfaction relationship and showed the association between adult patients’ satisfaction and gender and age. Additionally, it assessed the organizational factors that affected the nursing care process and as a result tightened the nurses to not work at their best. Based on these findings recommendations were forwarded for the nurses and also for the organization.









    1. Introduction
    • 1.1. Background
    Measuring quality of care in the hospital setting has become very important in evaluating healthcare services. The United States National Center for Health Services Research and Development (NCHSRD 1970), for instance has assessed the degree of system efficiency and effectiveness in meeting the demands and needs of patients. Their criteria for the evaluation of the performance of the healthcare system were classified into three categories: mortality, morbidity, and patient satisfaction. Patient satisfaction is probably the most difficult to measure among the three, but its importance in determining quality of care cannot be set aside (1).
    The factors contributing to patient satisfaction have been widely studied and discussed within several disciplines, including nursing, but the definition still varies from person to person and from time to time (2).
    The word “satisfaction” is derived from the Latin (satis=enough and faction=to do or make). These terms illustrate the point that satisfaction implies the fulfillment of response, as stated by Oliver in 1993. Patient’s satisfaction is “the individual’s positive evaluations of distinct dimensions of healthcare” as described by Linder-Pelz in 1982. Expression of satisfaction is an expression of attitude, an effective response, which is related to both the belief that the care possesses certain attributes (3).
    In another definition satisfaction is the psychological state that results from confirmation or disconfirmation of expectations with reality. Stimson and Webb have suggested that satisfaction is related to perception of the outcome of care and the extent to which it meets patient expectations. Pascoae (1983) defined patient satisfaction as “a health care recipient’s reaction to salient aspects of the context, process, and result of their service experience” (4).
    In the health care sector, patient satisfaction has emerged as an important component of the quality of care, and has been used as a means to attain, maintain and monitor it. Despite its popularity and wide acceptability, through time it sparked debates among users and providers of health care services. Mainly these were concentrated on the conceptualization of the term. Therefore, quality of care has often been defined differently among stakeholders, such as employers, insurance companies, health care managers, physicians, nurses and patients. Few clinicians would debate that clients are the central focus of both service delivery and quality measurement. Yet, the client's perspective on quality care largely has been considered external to the service delivery process. Donabedian (1988), a noted authority in quality measurement states that patient satisfaction may be considered to be one of the desired outcomes of care, even an element in health status itself…It is futile to argue about the validity of patient satisfaction as a measure of quality. Whatever its strengths and limitations as an indicator of quality, information about patient satisfaction should be as indispensable to assessments of quality as to the design and management of health care systems (5, 6).
    The dimensions of patient satisfaction include art of care (caring attitude), technical quality of care, accessibility and convenience, finances (ability to pay for services), physical environment, availability, continuity of care, efficacy and outcome of care. A working definition is the degree to which the patient’s desired expectations, goals and/or preferences are met by the health care provider and or service (7).
    Patient outcomes of care are further affected by rapport and interpersonal quality of practicing professional nurses. The relationship the nurse has with the patient has much impact unlike the outcomes regarding normalizing serum biochemical values. This puts emphasis on the point that the nurse has to achieve therapeutic and humanistic outcomes appropriate for each individual patient. Dissatisfied patients tend to launch complaints to the establishment or seek redress from it more often and dissuade others from seeking health care services from the system if the systems do not favor them (8).
    Patients’ satisfaction with nursing care has been reported as the most important predictor of the overall satisfaction with hospital care and an important goal of any health care organization. Patient satisfaction is often determined by the nursing care in any health setup (9).
    • 1.2. Statement of the Problem
    In Ethiopia health care is delivered mainly by the government. However, the private sector and voluntary organizations also play a significant role in general health care delivery. Nurses constitute the largest human resource element and have a great impact on quality of care and patient outcomes in health care organizations. As it is stated before, patient satisfaction with nursing care is strongly dependent on their perception which encompasses mixture of diverse thoughts on the time they experience the incident (the nursing care). Even though public and private hospitals are in two different corners on the provision of health services (specifically nursing care), the patients they serve have unmet satisfactory levels on the subject of care given by the nurses. Factors contributing to patient satisfaction are complex and there is no consensus on this issue, but, finding these factors as much as possible and achieving the needed satisfaction for the patients is central. Considering this as a fact, in Ethiopia the core factors that upset patients and make them depreciate the nursing care are not elucidated well.
    As it is grounded and proved by plenty of studies, nurses are one of the main stakeholders in the process of providing health care services with other professionals in health institutions. Health systems worldwide are increasingly challenged – faced with a growing range of health needs and financial constraints that limit services’ potential to strengthen health sector infrastructures and workforces. Nurses’ disappointment with their work and as a result impeding the quality of care they give is one of the main challenging things in the health system. The reasons for the disappointment are varied and complex, but key among them are unhealthy work environments that weaken performance or alienate nurses and, too often, drive them away – from specific work settings or from the nursing profession itself. And this is a colossal jeopardy for a health organization; losing its main stakeholders in addition to being dysfunctional of them due to the circumstances that mentioned above.

    • 1.3. Significance of the Study
    Nursing care is one of the major health care services that contribute significantly to the patient healing process. Nurses have 24 hour contact with patients. Thus, as they are the frontline, the patients expect more from them and nurses should also fulfill patients’ needs with competence and a compassionate approach. On this line, assessing the level of satisfaction of patients with nursing care is crucial in order to identify the area of dissatisfaction and at the same time improve the nursing services. This study is, therefore, aimed on assessing the current prevalence of patient satisfaction with nursing care in both hospitals and indicating strategies for improving the services. It also intended to bridge the information gap, elaborate different factors that distort the patients’ perception with nursing care and put practicable solutions from different point of views for the improvement of the nursing care and better prevalence of patient satisfaction.
    This study also targeted to clearly identify the basic areas of nurse complaints related with their work environment which strongly affect patient outcome. The study intended to explain interventions for the identified problems on nurses’ side which (the interventions) make nurses function in a better way and as a result fulfill the needs of their clients. The results of this study can be used as a baseline on this area and also a reference for future studies that focus on patients’ satisfaction with nursing care.
    • 2. Objectives of The Study
    • 2.1. General Objective
    This study aimed to assess adult patient satisfaction with nursing care in selected public/private hospitals in Addis Ababa, Ethiopia.

    • 2.2. Specific Objectives
    • v To find out prevalence of patient satisfaction with nursing care.
    • v To examine factors leading adult patients to dissatisfaction by the care they get from nurses.
    • v To identify barriers those encumber nurses from giving the intended care for patients.
    • 3. Methods and Materials
    • 3.1. Study Area and Period
    The study assessed adult patient satisfaction with nursing care in Tikur Anbessa Specialized Hospital which is located between Migration Office and National Bank of Ethiopia and in Saint Gabriel General Hospital, established in October 19, 1988 E.C (Ethiopian Calendar) and found in Bole Sub city about 1 Km from 22 Mazoria to Bole International Airport on the left side. Tikur Anbessa (Black Lion) hospital is the country’s biggest and specialized governmental referral hospital and established in 1964 E.C. It is a specialized referral teaching hospital. The hospital has more than 201 staff Physicians and 473 Nurses. On the other hand, Saint Gabriel General Hospital is one of the highest NGOs (Non Governmental Organizations)/ private hospitals in the city. It has 12 staff Physicians and 37 Nurses with 65 beds. The study was conducted within the period of March 30 to June 15, 2014.

    • 3.2. Study Design
    A descriptive Cross-Sectional design was adopted and used to assess adult patient satisfaction with nursing care in selected public/private hospitals in Addis Ababa, Ethiopia. The study was conducted based on the inclusion criteria using pre-tested questionnaires.
    • 3.3. Study Population
    • 3.3.1. Target Population
    The target population for this study was all patients that were getting health services from Tikur Anbessa Specialized Hospital and St. Gabriel General Hospital during the time the study was conducted.
    • 3.3.2. Source Population
    The source population was adult patients who were admitted in respective wards in each hospital with in the period of the study.
    • 3.3.3. Sample Population
    • 3.3.3.1. Inclusion Criteria
    Patients aged 18 years and above;
    Conscious, coherent, oriented to time, person and place
    Patients admitted in the respective wards for at least four days and
    Patients willing to give informed consent.
    • 3.3.3.2.Exclusion Criteria
    Patients aged less than 18 years.
    Patients in critical condition; severely ill and comatose.
    Patients not admitted in respective wards with in the period of the study time. (Patients who get services in outpatient setting).
    Patients who don’t have willingness to participate in the study.
    • 3.4. Sample Size Determination
    The sample size for the study was calculated using single population proportion formula and by 67% prevalence which was taken from a similar study conducted in Addis Ababa within selected governmental hospitals (4) with 95% confidence interval taking the margin of error as 5%. Sample size (n) is computer based on single population proportion formula.

    Where
    = sample size
    = Z score value at 95% confidence interval i.e. 1.96
    = the proportion of patients that were satisfied with nursing care which is 0.67, as it is taken from similar study.
    = Margin of error (5%)

    339.75
    Since the above sample was taken from a relatively small population (N=318), sample size correction was made; or population reduction formula was used:-
    = 164.257≈164
    So, the sample size for this study was 164.
    • 3.5. Sampling Procedure (Technique)
    164 adult patients who fulfilled the inclusion criteria and were available during the study period were chosen through stratified probability sampling method.
    • 3.6. Data Collection Tools
    • 3.6.1. Data Collection Instrument and Technique
    Data was collected using questionnaires designed for interview. Questionnaires for adult patients were used in English and translated in to Amharic and then the study was implemented by face-to-face interview. Questionnaires for Nurses were prepared and used in English and implemented by face-to-face interview.
    • 3.6.2. Data Collectors
    Three data collectors; third year Public Health Officer Students were selected, trained for three days on how to collect the data and communicate with the study subjects and supervised by the investigator throughout the data collection process.
    • 3.7. Data Quality Assurance and Management
    The investigator conducted the research by being on both sides of the parties meaning addressing both adult patients and nurses to find out the problems from each party (quantitative and qualitative study was conducted). In order to ensure the validity and reliability of the study, questionnaires were adopted from previous similar studies. The questionnaires were pretested on ten selected adult patients and then correction was considered accordingly. Proper monitoring and evaluation of the data collection procedure was done by the principal investigator. Finally, the collected data was checked for completeness and consistency.
    • 3.8. Study Variables
    • 3.8.1. Dependent Variables
    • ¨ Adult Patient Satisfaction with nursing care
    • ¨ Implementation of nursing process
    • 3.8.2. Independent Variables
    • ¨ Age
    • ¨ Gender
    • ¨ Religion
    • ¨ Socio-economic status
    • ¨ Education
    • ¨ Organizational and environmental factors
    ¨ Nurse to patient ratio
    ¨ Hospital organizational structure

    • 3.9. Data entry and Analysis
    • After data collection the data was checked for completeness. SPSS (Statistical Package for Social Science) version 16.0 computer software package was used for data entry and analysis. After data entry, it was cleaned and analysis was made on a set of variables. Transformation of set of variables is done for the sake of putting results to the ease. Finally the data is presented in graphs, tables, statements, cross tabulation and chi-square.
    • 4.10. Ethical Consideration
    Ethical clearance letter was written from Universal Medical College to the study area and forwarded to the concerned body. Permission was granted from the head managers of the study area. Permission and verbal consent from the respondents was asked before data collection began and only volunteers who can fulfill the inclusion criteria were taken for the study. Privacy and confidentiality was maintained throughout the process of the study. Finally, the materials used for data collection were destroyed after finalizing the study.

    • 4. Results
    Socio-Demographic Characteristics
    A total of 164 adult patients who were admitted in the respective hospitals (Tikur Anbessa and St. Gabriel) participated in this study and gave information regarding their perception levels of nursing care. More than half of patients under the study were females 89(54.3%) followed by males 75(45.7%) from which Tikur Anbessa Hospital took 75(55.6%) females and 60(44.4%) males and St. Gabriel contained 15(51.7%) males and 14(48.3%) females based on their strata. The greatest number of 87(53%) subjects’ age ranged from 18-35 followed by 48(29.3%), 23(14%) and 6(3.7%) of them ranged from 36-50, 51-65 and 66-80 respectively. The data presented in table 1 show that 98(59.8%) of patients were married and 55(33.5%) of them were single. From the total participants 94(57.3%) of adult patients reside in urban and 61(37.2 %) and 9(5.5 %) reside in rural and foreign respectively (Table 1).

    The majority of the responding patients had an income ranged up to 1000 birr (n=112, 68.3%) and got the hospital service by paying (n=100, 61%). From the respondents 65(39.6 %) of participants had a secondary school level (Table 1). As for days spent in the ward, most of the respondents (n=74, 45.1%) had spent >10 days in the wards they were admitted (see figure 1).




























    Table 1:- Distribution of patients according to frequency and percentage of demographic variables, n=164, Addis Ababa Ethiopia, 2014
    VariablesSaint Gabriel(n=29) Tikur Anbessa(n=135)Total
    Freq%Freq%Freq%

    Gender
    Male 15 51.7 60 44.4 75 45.7
    Female 14 48.3 75 55.6 89 54.3

    Age
    18-35 11 37.9 76 56.3 87 53.0
    36-50 5 17.2 43 31.9 48 29.3
    51-65 9 31.0 14 10.4 23 14.0
    66-80 4 13.8 2 1.5 6 3.7

    Religion
    Orthodox 16 55.2 97 71.9 113 68.9
    Muslim 7 24.1 21 15.6 28 17.1
    Protestant 4 13.8 14 10.4 18 11.0
    Catholic 2 6.9 3 2.2 5 3.0
    Residence Urban 18 62.1 76 56.3 94 57.3
    Rural 5 17.2 56 41.5 61 37.2
    Foreign 6 20.7 3 2.2 9 5.5

    Marital Status
    Single 6 20.7 49 36.3 55 33.5
    Married 16 55.2 82 60.7 98 59.8
    Widowed 1 3.4 3 2.2 4 2.4
    Divorced 6 20.7 1 .7 7 4.3


    Educational Level
    Illiterate 4 13.8 26 19.3 30 18.3
    Reads and writes - - 9 6.7 9 5.5
    Primary & Intermediate 6 20.7 23 17.0 29 17.7
    Secondary 11 37.9 54 40.0 65 39.6
    Diploma 4 13.8 18 13.3 22 13.4
    First Degree and above 4 13.8 5 3.7 9 5.5



    Occupation
    Service - - 27 20.0 27 16.5
    Self employed 11 37.9 45 33.3 56 34.1
    House Wife - - 21 15.6 21 12.8
    Retired 7 24.1 1 0.7 8 4.9
    Student - - 12 8.9 12 7.3
    Unemployed 11 37.9 29 21.5 40 24.4

    Monthly Income
    Up to 1000 Birr 12 41.4 100 74.1 112 68.3
    1000-5000 Birr 4 13.8 32 23.7 36 22.0
    5000-10000 Birr 6 20.7 3 2.2 9 5.5
    >10000 Birr 7 24.1 - - 7 4.3
    Ward Service
    Type
    Pay 23 79.3 77 57.0 100 61.0
    For free - - 53 39.3 53 32.3
    Charity 6 20.7 5 3.7 11 6.7




    Figure 1:- Bar graph Diagram showing distribution of patients on how much days they spent in the respective wards
    Nursing care satisfaction scores
    Aspects of care given the highest satisfaction ratings among fully satisfied versus not fully satisfied. (Fully satisfied refers to very or completely satisfied and notfully satisfied refers to not at all / barely / quite satisfied)
    Tikur Anbessa Hospital
    The nurses check patients’ ID prior to administering medications (76.3%), the amount of freedom patients were given on the ward (59.3%) and there always being a nurse around if patients needed one (58.5%) were aspects of care given the highest satisfaction ratings.
    St. Gabriel Hospital
    The checking of patient’s ID by the nurses prior to administering medications (96.6%), how quickly nurses came when patients called for them, how often nurses checked to see if patients were ok and the amount of freedom patients were given on the ward (93.1%) and how willing nurses were to respond to patients’ request (89.7%) were aspects of care given the highest satisfaction ratings (Table 2).
    Aspects of care given the lowest satisfaction ratings among fully satisfied versus not fully satisfied. (Fully satisfied refers to very or completely satisfied and notfully satisfied refers to not at all / barely / quite satisfied)
    Tikr Anbessa Hospital
    The amount of information nurses gave to patients about their condition and treatment (35.6%), how often nurses checked to see if patients were ok, the type of information nurses gave to patients about their condition and treatment and Nurses' awareness of patients’ needs (41.5%) and the amount of privacy nurses gave to patients (44.4%) were aspects of care given the lowest satisfaction ratings.
    St. Gabriel Hospital
    How capable nurses were at their job (62.1%), the type of information nurses gave to patients about their condition and treatment (65.5%) and the amount of time nurses spent with patients and Nurses manner in going about their work (69.0%) were aspects of care given the lowest satisfaction ratings (Table 2)

































    Table 2:- Criteria for satisfaction of in-patients respondents, Addis Ababa Ethiopia, 2014
    Criteria for satisfactionTikur Anbessa
    Hospital; n=135
    St. Gabriel Hospital
    n=29
    Not fully
    Satisfied (%)
    Fully
    Satisfied (%)
    Not fully
    Satisfied (%)
    Fully
    Satisfied (%)
    The amount of time nurses spent with you 48.9 51.1 31.0 69.0
    How capable nurses were at their job 50.4 49.6 37.9 62.1
    There always being a nurse around if you needed one41.558.513.886.2
    The amount nurses knew about your care 52.6 47.4 24.1 75.9
    How quickly nurses came when you called for them48.151.96.993.1
    The way the nurses made you feel at home48.951.124.175.9
    The amount of information nurses gave to
    you about your condition and treatment
    64.4 35.6 27.6 72.4
    How often nurses checked to see if you were ok 58.5 41.5 6.9 93.1
    Nurses helpfulness 50.4 49.6 27.6 72.4
    The way nurses explained things to you 54.8 45.2 27.6 72.4
    How nurses helped put your relatives or friends minds at rest 52.6 47.4 24.1 75.9
    Nurses manner in going about their work 48.1 51.9 31.0 69.0
    The type of information nurses gave to you about your condition and treatment 58.5 41.5 34.5 65.5
    Nurses treatment of you as an individual 50.4 49.6 20.7 79.3
    How nurses listened to your worries and concerns 54.1 45.9 20.7 79.3
    The amount of freedom you were given on the ward40.759.36.993.1
    How willing nurses were to respond to your request 52.6 47.4 10.3 89.7
    The amount of privacy nurses gave you 55.6 44.4 24.1 75.9
    Nurses' awareness of your needs 58.5 41.5 20.7 79.3
    The nurses check your ID prior to administering medications23.776.33.496.6
    Overall Satisfaction Mean 49.378.8




    Patients’ experience on the organizational and environmental effects
    From the 135 participants of the study from Tikur Anbessa Hospital; when asked whether there was one particular nurse in charge of their care in the ward 93(68.9%) of them said yes, 36(26.7%) of the participants said no and the remaining 6(4.4%) patients showed uncertainty. For the question whether they were told to go back to their home before they get good relief because of patient turnover 8(5.9%) patients answered yes and 127(94.1%) of the participants said no. And when they were asked if they experienced fragmented care or lack of time available for individual care because the organization gave a reason that there is shortage of staff nurses 24(17.8%) of the participants said yes and 111(82.2% ) of them told no (Table 3).
    In case of St. Gabriel Hospital from the 29 respondents; when they were asked whether there was one particular nurse in charge of their care in the ward 25(86.2%) of them said yes, 3 (10.3%) of the participants said no and the remaining 1 (3.4 %) patient answered not sure. For the question whether they were told to go back to their home before they get good relief because of patient turnover 1 (3.4%) patient answered yes and 28(96.6%) of the participants said no. And when they were asked if they experienced fragmented care or lack of time available for individual care because the organization gave a reason that there is shortage of staff nurses 1 (3.4%) of the participants said yes and 28(96.6%) of them told no (Table 3).
















    Table 3:- Distribution of frequency and percentage of patients’ experience on the organizational and environmental effects, Addis Ababa Ethiopia, 2014

    Category
    Tikur Anbessa
    Hospital; n=135
    St. Gabriel
    Hospital; n=29
    Freq%Freq%
    Have you told to go back to your home before you
    get good relief because of patient turnover?
    Yes 8 5.9 1 3.4
    No 127 94.1 28 96.6
    Have you experienced fragmented care or lack of time available for individual care because the organization gave a reason that there is shortage of staff nurses?
    Yes 24 17.8 1 3.4
    No 111 82.2 28 96.6


    Figure 2:- Was there one particular nurse in charge of your care in this ward? Showing for Tikur Anbessa Hospital

    For the question regarding overall rating of nursing care received on a specific ward 76(56.3%) of participants from Tikur Anbessa hospital and 25(86.2%) respondents from St. Gabriel hospital showed full satisfaction (See Figure 3).



    Figure 3 – Overall how would you rate the nursing care you received in this ward?
    (Fully satisfied= Excellent/very good; Not fully satisfied= Dreadful/Very poor/Poor/Fair/Good)
    The Relationship between the Patients’ Level of Satisfaction and Independent variables
    The chi-square of independence was conducted for Tikur Anbessa Hospital to assess whether the level of adult patients’ satisfaction had a relationship with gender, age group, religion, place of residence, educational level and monthly income. The results from the cross-tabulations analysis showed that there were no significant relationship between religion, place of residence, educational level and monthly income with adult patients’ satisfaction (P value>0.05). However, there were significant relationship between gender with level of adult patients’ satisfaction (p=0.044, n=135). Furthermore, there was significant relationship between age with level of adult patients’ satisfaction (p=0.003, n=135) (Table 4).





    :- Relationship between level of patients’ satisfaction with independent variables
    Level of Satisfaction
    VariablesFully SatisfiedNot fully
    Satisfied
    X2P-value
    Freq. %Freq. %
    Gender
    Male 28 46.7 32 53.3 4.07 *0.044
    Female 48 64 27 36
    Total 76 56.3 59 43.7
    Age
    18-35 38 50 38 50 14.106 *0.003
    36-50 22 51.2 21 48.8
    51-65 14 100 0 0
    66-80 2 100 0 0
    Total 76 56.3 59 43.7
    Religion
    Orthodox 55 56.7 42 43.3 2.982 0.394
    Muslim 10 46.6 11 52.4
    Protestant 8 57.1 6 42.9
    Catholic 3 100 0 0
    Total 76 56.3 59 43.7
    Residence
    Urban 43 56.6 33 43.4 0.662 0.718
    Rural 32 57.1 24 42.9
    Foreign 1 33.3 2 66.7
    Total 76 56.3 59 43.7
    Educational Level
    Illiterate 16 61.5 10 38.5 7.969 0.158
    Reads and writes 8 88.9 1 11.1
    Primary & Intermediate 13 88.9 10 11.1
    Secondary 28 51.9 26 48.1
    Diploma 7 38.9 11 61.1
    First Degree and above 4 80 1 20
    Total 76 56.3 59 43.7
    Monthly Income
    Up to 1000 Birr 57 57 43 43 0.282 0.868
    1000-5000 Birr 17 53.1 15 46.9
    5000-10000 Birr 2 66.7 1 33.3
    >10000 Birr 0 0 0 0
    Total 76 56.3 59 43.7
    *P<0.05




    Quantitative Study Results
    Organizational Factors Affecting Implementation of Nursing Process
    Nurses from both hospitals were assessed regarding work related problems that might hinder them from giving the expected nursing care for patients. The assessment showed that much of the respondents in Tikur Anbessa Hospital worked for 12 or more hours per day. The situation in St. Gabriel Hospital was similar with that of Tikur Anbessa Hospital. A large amount of nurses in Tikur Anbessa gave nursing care for more than 16 patients per day. When asked about the equipments in hand for giving nursing care, all the participants in Tikur Anbessa Hospital explained that they didn’t have all the equipments to do their nursing care. This was totally opposite to St. Gabriel Hospital. All the nurses in both hospitals worked overtime. Unlike the participants in St. Gabriel, those in Tikur Anbessa Hospital were not satisfied with the overtime payment.
    All the components; rude Physicians, harassing coworkers, demanding patients, the nurse to patient ratio, dealing with abusive family members, unsympathetic managers and poor work habit were the great strains or anxieties that nurses had in their working time. Of the above mentioned components the nurse to patient ratio was a reason that was mentioned repeatedly than the other components by nurses who worked in Tikur Anbessa Hospital. In St. Gabriel Hospital the causes for anxiety were the nurse to patient ratio and dealing with abusive family members.
    In mentioning the dissatisfying aspects of their job, respondents from both hospitals shared the following once; having to care for so many patients and the shift program that they had. In the case of Tikur Anbessa, the monthly salary that the nurses earned was an additional disappointing aspect. When respondents were describing the atmosphere/culture of their workplace, most of Tikur Anbessa’s respondents explained it as stressful at times and disorganized. In contrary, much of St. Gabriel’s respondents described their atmosphere as well organized. From conditions that influenced the nursing care delivery; inability to collect the required material for care was the top problem mentioned by Tikur Anbessa Hospital respondents. For St. Gabriel Hospital respondents the condition that influenced their nursing care delivery was patients discharge before completing planed interventions. From the above findings, it can be concluded that these work related dissatisfying aspects with in nurses were one of the main factors for low nursing care satisfaction scores by patients.
    • 5. Discussion
    • From the main findings, patients’ satisfaction and perception of nursing services have been rated in terms of percentages. Parametric; chi-square test was carried out to determine the possibility of demographic predictors of patient satisfaction and perception with the nursing services. Overall the rating of satisfaction in Tikur Anbessa Hospital for this study was 49.3% which was low when it is compared to the previous study that was done in this hospital with other two governmental hospitals 63% (4). It also had the lowest adult patient satisfaction score for all nursing care satisfaction scores when compared with the results of the study done in Malaysia (17) in which the overall moderate satisfaction of the patients was 82.7%. The reason for this could be explained by the low ranking scores of individual nursing care satisfaction in the current study.
    Even though all nursing care satisfaction scores were high ranking in the case of St. Gabriel Hospital when compared with Tikur Anbessa Hospital, both Hospitals ranked high on some features too. These were the fact that nurses check patients’ ID prior to administering medications, the amount of freedom patients were given on the ward, the presence of a nurse around if patients needed one, the speed with which nurses came when patients called for them and the way the nurses made patients feel at home.
    The top aspects that patients scored highest for their satisfaction with nursing care in Tikur Anbessa Hospital were the fact that the nurses check patients’ ID prior to administering medications (76.3%), the amount of freedom patients were given on the ward (59.3%) and the presence of nurses when needed (58.5%). The first satisfaction score component; the checking of patients’ ID prior to administering medications scored high and has a similarity with the study that was done in Egypt on three hospitals(King Faisal Hospital(92%), Al-Noor Hospital (100%) and Al-Ahly Hospital (100%)) (20) even though there is a big gap between the percents and these may contribute to the fact that Egyptians’ hospitals structure is totally different with the Ethiopian ones. The second one; the amount of freedom patients were given on the ward also goes with Bekele Chaka’s study on governmental hospital which was 83% (4).
    • When it comes to the satisfaction ratings that adult patients gave low satisfaction rating, Tikur Anbessa Hospital received low score in regards to these components; the amount of information nurses gave to patients about their condition and treatment (35.6%), how often nurses checked to see if patients were fine, the type of information nurses gave to patients about their condition and treatment, Nurses' awareness of patients’ needs (41.5%) and the amount of privacy nurses gave to patients (44.4%). The amount and type of information about their condition and treatment ( 35.6% and 41.5%), how often nurses checked to see if patients were ok and Nurses' awareness of patients’ needs (41.5%) were similar with the study that was done in Ghana (19) which were 14% , 27% and 28% respectively although the numbers are not that much near each other.
    • The first components (the amount and type of information (35.6% and 41.5%)) nurses gave to patients about their condition and treatment were ranked low like the study done in Kenya (Kenyatta National Hospital, Nairobi) (8) which was 11.1% but opposite to that of Indonesia (64.9%) (15), taking into account the fact that the variables scored low as a result of poor nurse-patient communication. In case of patients’ satisfaction about the amount of privacy nurses gave to patients, the current study was opposite to the study in Ghana (19) which was low. This could be explained as most of the beds in Tikur Anbessa Hospital didn’t have a screen which could provide privacy for the patient. Even though it is generally believed that elements of privacy, respect and advocacy which nurses consider through their practice enhance patients’ satisfaction with care the situation here was different. The reason for low rating of the former two components could be as Tikur Anbessa hospital is a center for the country’s high patient flow, this resulting frustration among nurses and failure to update and follow up patients frequently.
    • In case of St. Gabriel Hospital the overall satisfaction rate was 78.8% and this finding was in accordance with a study done in Egypt (20). In St. Gabriel Hospital the aspects that got high score were the checking of patient’s ID by nurses prior to administering medications (96.6%), the speed at which the nurses came when patients called for them, how often nurses checked to see if patients were ok, the amount of freedom patients were given on the ward (93.1%) and how willing nurses were to respond to patients’ request (89.7%). Also these findings agreed with the previous mentioned hospitals in Egypt (20). The high score for the satisfaction scales might be because as the hospital is private oriented the organization tried its best to fulfill the client’s need to be competitive.
    • In this study the investigator found out that gender had a strong correlation with adult patient satisfaction with P-value of 0.044. Likewise age was the other independent variable that determined the adult patient’s satisfaction with nursing care with P-value of 0.003. However, a study that was done in Tehran stated that there were no significant relationship between gender and age group with patient satisfaction (9). But the above chi-square result agreed with a study in Ghana (19). For instance 64% of female patients were fully satisfied with the nursing care they got from Tikur Anbessa Hospital.
    • The study additionally tried to assess organizational factors that affect implementation of nursing process and found out the following problems. Rude Physicians, harassing coworkers, demanding patients, the nurse to patient ratio, dealing with abusive family members, demanding patients, unsympathetic managers and poor work habit were among the reasons that cause great anxiety in work place. As to the dissatisfying aspects of their job having to care for so many patients, the shift program that they had and the monthly salary that the nurses earned were mentioned. While talking about the atmosphere of their work environment, they described it as stressful at times and disorganized. From conditions that influenced the nursing care delivery, there were different reasons for each organization. For Tikur Anbessa Hospital inability to collect the required material for care was the number one constraint that encumbers good nursing care delivery. On the other side in St. Gabriel Hospital patients discharge before completing planed interventions was the situation. The above findings on nurses’ side agreed with the previous study by Mulugeta Aseratie (21). By mentioning these organizational effects on nurses, it could be clearly seen that the listed problems on nurses’ side tightened the nurses to not work at their best and as a result caused low nursing satisfaction score by the patients.
    Conclusion
    • In conclusion, the findings of this study show that all the nursing care satisfaction score labels in Tikur Anbessa Hospital were low and that reflected the communication gap between the adult patients and nurses. Furthermore, the study identified the main elements that caused dissatisfaction to the patients which were the amount of information nurses gave to patients about their condition and treatment (35.6%), how often nurses checked to see if patients were ok, the type of information nurses gave to patients about their condition and treatment, Nurses' awareness of patients’ needs (41.5%) and the amount of privacy nurses gave to patients (44.4%). On the other way the nursing care score labels in St.Gabriel Hospital were high which clearly putted that socio-demographic status of the patients and the setting of the organization had an effect on adult patients’ satisfaction.
    • The study also analyzed the relationship between the socio-demographic characteristics of adult patients and their level of satisfaction by chi-square test and got a significant relationship between adult patients’ satisfaction and gender and age of patients respectively. Additionally, the current research conducted quantitative study on nurses’ side and found out the following organizational factors to affect implementation of nursing process. These were reasons that caused great strains or anxieties in work place, dissatisfying aspects of the nurses’ job, conditions that influenced the nursing care delivery and the type of atmosphere or culture that made nurses non-functional.
    Recommendations
    Based on the findings of the study the investigator recommended the following:-
    For the professionals (Nurses) in Tikur Anbessa Hospital:- to increase the patient satisfaction level from its current lowest score nurses can take the following simple measures
    • v Listen and answer all your patient's questions:-The first step in making your patient happy and comfortable is simply to listen. Always explain things carefully and then ask if your patient has questions. It is a solution for the communication gap between you and your clients.
    • v Treat your patient like a customer:-It is important to remember that if there were no patients, there would be no health-care providers. Patients keep us in business! Considering your patients as your customer will answer the satisfaction compliant from every angle of point.
    • v Walk a mile in your patient's shoes:-As health-care providers, it is easy to forget what it is like to be a patient. Patients are often scared, anxious and uncomfortable. They're often made to wear immodest gowns, undergo frightening procedures, and trust everyone in charge of their care. Keep this in mind when you feel a patient is being difficult or unreasonable.
    • I. For the Organization (Tikur Anbessa Hospital):- To make nurses function in a better way and achieve patients’ satisfaction through them as they are vital in the process of care giving, the organization has to try to implement the following suggestions.
    • Ø Giving financial and non-financial incentives for nurses. This will solve the problem of nurse burnout.
    • ü Financial incentives; wages and conditions, Performance-linked payments and others like Fellowships and Loans, approval, discounting.
    • ü Non-financial incentives; Positive work environment, flexibility in employment arrangements, support for career and professional development, access to services such as health, child care and schools, recreational facilities, housing and transport and intrinsic rewards.
    • Ø Work in collaboration with the private sectors to exchange experiences on the side of adult patient satisfaction.
    • 6. References
    • 1. Maria Vanessa C. Villarruz-Sulit, Antonio L. Dans and Mark Anthony U. Javelosa. “Measuring Satisfaction with Nursing Care of Patients Admitted in the Medical Wards of the Philippine General Hospital”. ACTA MEDICA PHILIPPINA. 2009. Vol. 43 N0. 4: 53
    • 2. Felesia Samuel Chawani. “Patient satisfaction with nursing care: a meta synthesis”; JOHANNESBURG. 2009: 1,4, 88-90
    • 3. Asma Hasan. “Patient satisfaction towards maternal and child health services among mothers attending at maternal and child health training institute in Dhaka, Bangladesh”. 2007: 22
    • 4. Bekele Chaka. “Adult patient satisfaction with nursing care”. June, 2005: Pg 2, 16, 24
    • 5. Andreas Charalambous and Theodoula Adamakidou. BMC Nursing. “Risser patient satisfaction scale: a validation study in Greek cancer patients”; 2012
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    Literature Review on the Biological and Chemistry of Moringa Species
    Adanech T. 1, Genet Minale 2
    1 Universal medical college, Department of Pharmacy
    2 Ambo University, CHS, Department of pharmacy
    ABSTRACT

    Medicinal plants are the most exclusive source of life saving drugs for the majority of the world's population, one of such plant is Moringa. Moringa is cultivated all over the world due to its multiple utilities. Every part of Moringa is used for certain nutritional and/or medicinal purpose.
    It has been reported as ant hyperglycemic, antidyslipidemic,antiinflammatory,analgesic,antipyretic antimicrobial,antioxidant,antinephrotic,antihypertensive,cancerpreventive,hepatoprotective,wound healing, anti-ulcer, anti implantation, anti plasmodia and anti-trypanosome. It is a good source of protein, vitamins, oils, fatty acids, minerals. Glucosinolates, flavonoids, and phenolic acids are the main phyto chemicals in Moringa species. Its multiple pharmaceutical effects are capitalized as therapeutic remedy for various diseases in traditional medicinal system. Further research on this charismatic healer may lead to the development of novel agents for various diseases. This review provides a brief overview about medicinal potential of Moringa and its future as a component of modern medicinal system.








    Plants which produce constituents mostly as secondary metabolites having medicinal values are called medicinal plants. Medicinal plants are the most common source of life saving drugs for the majority of the world's population (1)Over centuries, cultures around the world have learned how to use plants to fight illness and maintain health. These readily available and culturally important traditional medicines form the basis of an accessible and affordable health-care regime and are an important source of livelihood for indigenous and rural populations. One of such plant is .The name is derived from the word Murungai(2). The family represented only by a single genus and 13 species (3). In fact, it is stated that the taxonomic position of the family is not clear. It has some features similar to those of and but the seed structure does not agree with either of the above families. Pollen studies have not provided any other suggestions and recent molecular studies have pointed a relationship with the . These indicate that the taxonomic position of the family is not yet settled and is open for further study (4). The tree is native to northern India, western Bangladesh and into eastern Pakistan. It grows from sea level to around 4,000 feet in elevation. Most commonly found near riverbeds, humans have cultivated it in such regions as Nepal, Afghanistan, Sri Lanka, Southeast Asia and West Asia, countries throughout the Arab world, East and West Africa, the West Indies, southern Florida, and all countries from Mexico south to Peru, Brazil and Paraguay(5).

    1. Introduction

    . MoringaMoringa Tamil
    MoringaceaeMoringa BrassicaceaeCapparidaceaeCarricaceae
    Moringa grows up to 20 ft (6.1 m) tall, with a straight trunk with corky, whitish bark. It grows well in hot, semi-arid and humid regions and in well-drained sandy or loamy soils. The tree has tuberous taproot and brittle stem is with corky bark. The leaves are pale green, compound, tripinnate, with many small leaflets. The fruit pods are pendulous, green turning greenish brown, triangular and split lengthwise into 3 parts when dry. The pods contain about 10 to 20 seeds embedded in the fleshy pith. The seeds are dark brown and the kernel is surrounded by a lightly wooded shell (6).
    Moringa
    Table-1 The origin and species of
    Moringa(7)
    Species OriginMoringa oleifera IndiaM. drouhardii MadagascarM. cocanensis IndiaM. arborea North Eastern KenyaM. hildebrandtii MadagascarM. borziana Kenya and SomaliaM.Ovalifolia Namibia and AngolaM. peregrine Horn of Africa, Red sea, ArabiaM. longituba Kenya, Ethiopia, SomaliaM. stenopetala Kenya, EthiopiaM. pygmaea Northern SomaliaM. rivae Kenya, EthiopiaM. ruspoliana Kenya The aqueous extract of the leaves of possesses hypoglycemic and anti hyperglycemic activity in normal and alloxan induced diabetic rabbits respectively (8). Prediabetes and diabetes were induced in Wistar rats, treatment lowered FPG in concentration-dependent manners. According to the study on a group of 60 T2DM patients, age 40–58years, BMI 20–25kg/m, on sulfonylurea medication and a standardized calorie-restricted diet, after giving leaf tablets/day for 90 days, PPPG progressively decreased with treatment duration, by 9% after 30days, 17% after 60days, and 29% after 90days (9). The aqueous leaf extract of is shown to increase body weight and reduce serum glucose and cholesterol level in Swiss albino male mice (10). Both aqueous and ethanol extracts of showed antihyperglycemic effects on streptozitocin induced diabetes in rats by causing a significant decrease in blood glucose levels (11).

    2. Biological Activity of

    Moringa

    2. 1 Anti-hyperglycemic propertiesMoringa oleiferaM. oleifera  2M. oleifera   M. stenopetala M. peregrine
    Aqueous extract of leaves prevented atherosclerotic plaque formation in artery and also possess lipid lowering activity in rabbits fed with high cholesterol diet (12). Similar result is also obtained with HCD rabbits fed an aqueous extract of fruits. The hydroalcoholic extract of leaves exert notable cardio protective effects on myocardial infarction and possess myocardial preservative actions. The crude extract of leaves has been reported to exhibit cholesterol lowering effect in high fat diet fed and iron deficient rats and in hyperlipedemics (13). The aqueous leaf extract of is shown to decrease cholesterol level in Swiss albino male mice (10).

    Effects

    2.2. Anti-dyslipidemic M. oleiferaM. oleiferaM. oleiferaMoringaM. stenopetala In rodents treated with leaves,a decrease of plasma cholesterol and an increase in fecal cholesterol was observed . leaf powder contain about 12% (w/w) fibers, dietary fibers which reduce gastric emptying. The detected anti nutrientsin are alkaloids, tannins, phenolics, saponins, flavonoids and steroids (14). The alcoholic leaves extract ofLam. has shown ulcer protective effect as dose dependently against pylorus-ligation, ethanol, cold restraint stress, and aspirin induced gastric ulcer in rats. The extract of Lam. was found to decrease ulcer and acid pepsin secretion. A change was also seen in SOD, CAT, and LPO levels in rat gastric mucosa due to antioxidant property of alcoholic leaves extract of Lam. Antioxidant defense mechanism of the extract was probably due to metabolising lipid peroxides and scavenging property of HO(15). The acetone extract and methanol extract of the leaves of produced gastric anti secretory effect in pylorus-ligated rats and showed gastric cytoprotective effect in ethanol-induced and indomethacin- induced gastric ulcers (16).

    2.3 Anti-nutrient propertiesM. oleiferaM. oleifera M. oleifera

    2.4. Anti ulcer property Moringa oleifera Moringa oleifera Moringa oleifera 22 Moringa oleifera Researchers at the Asian Vegetable Research and Development Center (AVRDC) showed that leaves of four species ( , . , and ) contained high levels of nutrients and antioxidants (17) The antioxidant activity of ethanolic and saline extracts from flowers, inflorescence rachis, seeds, leaf tissue, leaf rachis and fundamental tissues of stem was determined using thin layer chromatography stained with a 0.4 mM 1,1-diphenyl-2-picrylhydrazyl radical (DPPH) solution. Antioxidant components were detected in all .The best RSC was obtained with saline extract of leaf rachis (18). Antioxidant activity of, was determined by analysing the total phenolics content, total flavonoids content, reducing power and radical scavenging activity using the 2,2-diphenyl-1-picrylhydrazyl free radical method. The total phenolics content of was almost twice that of the selected vegetables (cabbage, spinach, broccoli, cauliflower and peas) and the total flavonoids content was three times that of the selected vegetables. The reducing power of was higher than that of the vegetables and the percentage of free radicals remaining was lower compared with the vegetables. These results showed that, is a good source of antioxidants (19). The seed oil , showed higher anti-oxidant activity comparable to that of known anti-oxidants, tocopherol, butylatedhydroxyanisole (BHA) and butylated hydroxytoluene (11).

    2.5. Antioxidant propertiesMoringaM.oleiferaMperegrinaM. stenopetala M. drouhardii.M. oleifera M. oleiferaMoringa Moringa Moringa oleiferaperegrina The ethanolic extract of the flowers ofwas tested for phytochemicals, anti-inflammatory activity. The studies indicate that the ethanolic extract showed significant anti-inflammatory activity (20)Under the same experimental conditions, nimuslide (50 mg/kg; p.o.) potentiates the anti-inflammatory activity of . Oral administration of an ethanolic extractpod-like fruits showed a tendency to reduce the elevated levels of the lysosomal enzymes (acid phosphatase and N-acetyl glucosaminidase) significantly and they reverted to near normal values, which may be due to stabilization of the lysosomal membrane. The glycoprotein (total hexose and sialic acid) contents were increased following treatment of in liver and stomach homogenate of rats with adjuvant–induced arthritis. The results show that possess significant analgesic and anti-inflammatory activity (21).Extracts from leaves have been shown to modulate humoral and cellular immunity in rats and mice (22). The crude methanol extract of the root of inhibits carrageenan induced rat paw oedema in a dose dependent manner after oral administration. Moreover, n-butanol extract of the seeds of shows anti inflammatory activity against ovalbumin-induced airway inflammation in guinea pigs. Amelioration of inflammation associated chronic diseases can be possible with the potent anti-inflammatory activity of sbioactive compounds (23).

    2.6. Anti-inflammatory properties Moringa concanensis . M. concanensis M. concanensis M. concanensis Moringa concanensis M. oleiferaM. oleiferaM. oleiferaM. oleifera

    The ethanolic extract of tender pod-like fruits was administered orally showed a significant analgesic activity in mice; 22.53 % and 51.47 % protection against mechanical pain, 22.73 % and 51.63 % protection against acetic acid-induced writhing and 62.20 % and 125.59 % protection against thermal-induced pain. Aspirin and pentazocine potentiated the analgesic effect of (21)The alcoholic extract of seeds ofseed was found to be a potent analgesic when study was carried out in wistar male albino rats using hot plate and tail immersion method. It was found that methanolic extract of the root not only produced analgesia in mice but also potentiated the analgesic action morphine and pethidine (24). The antipyretic effect of ethanol, petroleum ether, ether and ethyl acetate extracts of seeds was assessed using yeast induced hyperpyrexia method, Paracetamol was used as control during the study. Ethanol and ethyl acetate extracts of seeds showed significant antipyretic activity in rats (25). The ethanolic extract offlower showed a significant antipyretic activity when compared with standard drug (21).

    2.7Anaglesic activityM. concanensis M. Concanensis . M. oleifera

    2.8. Antipyretic activityM. oleifera Moringa concanensis The antibacterial activity of leaf extracts against four microorganisms, and was analysed.The ethanolic extract of was active against and where as the aqueous extract exhibited an inhibitory effect on And but was resistant at all test Concentrations (26). The molecular mechanism of action of the essential oil of is unknown, but the essential oil can probably inhibit the generation of adenosine triphosphashote from dextrose and disrupt the cell membrane. The high amount of hydrocarbons and the concurrent presence of quercetin and luteolin could also contribute to inhibit the microbial DNA gyrase (27). The seed oil of displayed significant antibacterial activity against , s, , and (11). Antibacterial activity of aqueous and solvent extracts of was determined by cup diffusion method on nutrient agar medium. The antimicrobial activitywas more in chloroform, aqueous extract than the acetone extract (28). Isolated compounds from root wood of was evaluated for antibacterial activities on four different strains ( and Typhimurium) using agar disc diffusion technique. Among the five crude extracts evaluated (petroleum ether, chloroform, acetone, methanol and water), the acetone extract was found to be the most active against the tested strains (29).

    2.9. Antibacterial and Antifungal ActivityMoringa oleifera Escherichia Coli, Pseudomonas aeroginosa, Staphylococcus aureus Salmonella typhii M. oleferiaS. typhii, S. aureus E. ColiS. TyphiP. aeruginosa M. oleifera M. peregrinaCandida albicansEcherichiacoliEnterobacter cloacaeKlebsiella pneumoniae Pseudomonas aeruginosaMoringa concanensis leaves Moringa stenopetalapathogenic bacterial Staphylococcus aureus, Escherichia coli, Pseudomonas aeruginosaSalmonella Antifungal activity of aqueous leaves extractsof and solvent extracts was determined by disc diffusion method on Sabouraud Dextrose agar medium. Anti fungal activity of aqueous extract showed maximum zone of inhibition against and the minimum inhibitory zone against , and (30).The antifungal activity of essential oil of seed was evaluated against , , , and and showed inhibitory activity against all tested strains (31). Ethanol extracts showed anti-fungal activities against dermatophytes such as , , and 32).
    Moringa concanensisA. oryzae, A. on flavusC. albicans, A.sojae M. oliferaP. aurantiogriseumP. expansumP. citrinumP. digitatum A. niger M. oliferain vitroTrichophyton rubrumTrichophyton mentagrophytes, Epidermophyton XoccosumMicrosporum canis ( The chemo preventive property of hydro-ethanolic extract of was evaluated on DMBA induced renal carcinogenicity, after extract treatment the results suggested that . extract could act against DMBA-induced kidney injury in mice by a mechanism related to its antioxidant properties (33). Crude aqueous leaf extract of caused significant fall in systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial blood pressure (MABP) at doses of 10, 20, 30 and 40 mg/kg in normotensive anaesthetized guinea pigs (n = 12) (34). leaf juice exerts a stabilizing effect on blood pressure. A variety of glycosides viz. nitrile, mustard oil glycosides, thiocarbamate and isothiocyanate, isolated through bioassay – directed fractionation of ethanolic extract of leaves and pods of this plant showed blood pressure lowering effect. Presence of methyl phydroxybenzoate and beta sitosterol confer hypotensive potency to the pods. Lyophilized hydroalcoholic extract of showed myocardial preservative effect in isoproterenol (ISP)-induced model of myocardial infarction. The alkaloids obtained by the fractionation of the water extract of the leaves of , converted into their salt form, were tested for their activity on the isolated frog heart. The total alkaloidal salts were found to have a negative inotropic effect on the frog heart (35).

    2.10. Anti-nephrotoxic effect M. oleiferaM oleifera

    2.11. Anti hypertensive effect

    M. stenopetala M. oleiferaM. oleiferaM. oleifera The hepatoprotective effect of an ethanolic extract of leaves on liver damage induced by antitubercular drugs such as isoniazid (INH), rifampicin (RMP), and pyrazinamide (PZA) in rats was evaluated. Oral administration of the leaves extract showed a significant protective action (36). This observation was supplemented by histopathological examination of liver sections. The results of this study showed that treatment with extracts appears to enhance the recovery from hepatic damage induced by antitubercular drugs (37).

    2.12. Hepatoprotective effectM. oleiferaM. oleifera According to the investigation on aqueous extract of bark of for normal wound healing and dexamethasone suppressed wound healing using incision, excision and dead space wound models in Wistar rat, the extract significantly increased the wound breaking strength in incision wound model. The aqueous extract treated wounds were found to epithelize faster and the rate of wound contraction was significantly increased as compared to control wounds. Significant increase in granulation breaking strength and hydroxyproline content in dead space wound was observed. The aqueous extract significantly decreased the antihealing activities of dexamethasone in all the wound models (38). The aqueous extract of leaves of was investigated for its wound healing activity at dose level of 300 mg/kg body weight using restored incision, excision, and dead space wound models in rats. The prohealing actions seem to be due to increased collagen deposition as well as better alignment and maturation. has significant wound healing property (39).

    2.13. Wound healingM. oleiferaM. oleifera M. oleifera The oil showed high growth inhibition against three human cancer cell lines, breast adenocarcinoma , hepatocellular carcinoma , and colon carcinoma(6).Since species have long been recognized by folk medicine practitioners as having value in tumor therapy , compounds 4-(4'-acetyl-a-L-rhamnopyranosyloxy)benzyl isothiocyanate and 4-(aLrhamnopyranosyloxy) benzyl isothiocyanatewere examined for their cancer preventive potential . 4-(4'-acetyl-a-L-rhamnopyranosyloxy)benzyl isothiocyanateand the related compound niazimicinwere shown to be potent inhibitors of phorbol ester (TPA)-induced Epstein-Barr virus early antigen activation in lymphoblastoid cells (3). In one of these studies, niazimicinalso inhibited tumor promotion in a mouse two-stage DMBA-TPA tumor model; skin tumor was examined following ingestion of drumstick (Moringa seedpod) extracts. In this mouse model, which included appropriate positive and negative controls, a dramatic reduction in skin papillomas was demonstrated (40). During a study to analyze efficacy and safety of seed kernels of for the management of asthmatic patient, the study showed a significant decrease in the severity of asthma symptoms and also concurrent respiratory functions improvement. The alkaloid moringine relaxes bronchioles (41). Ethanolic seed extract of significantly decreases histamine secretion and de-granulation of mast cells in rats. The glycoside saponin was reported to possess mast cell degranulation inhibiting and antihistaminic activity (42).

    2.14. Cancer PreventionM. peregrinaMoringa O-O-

    2.15. Anti histaminic activityM. oleifera M. oleifera Various extracts of the different parts of Lam. and Nimmo have been investigated for their antifertility activity in rats. Aqueous extracts of the roots of both plants and of the bark of Lam. are effective in preventing implantation. The results also show that the anti-implantation activity of (root) was consistent regardless of its time and place of collection (43).

    2.16. Anti implantation activityM. oleiferaM. coneanensisM. oleiferaM. oleifera Leaf and root extracts of were tested against the infectivestages of an ,ethanol extract offresh root wood and an acetone extract ofdried leaves both showed activity against (44).The anti-trypanosomal effect observed under condition following administration of extracts of is attributable to the extracts, appears to be confirmed by the death of all members of the control group that were infected with the parasite but left untreated within 10 days of infection, while most others survived for more than 7 days after the extract administration was terminated. The results for the methanol and aqueous extracts are consistent with the results which show that both extracts of the various parts were highly active compared to the control (45). The antiplasmodial activity of crude n-hexane and ethanolic seed extracts of using cold extraction method on albino mice () induced intraperitoneally with chloroquine sensitive was determined. n-hexane extract of the seeds of plasmodial inhibition rate of 61% was observed at concentration 50 ml/kg, 70% at concentration 100 ml/kg and 97% at concentration 200 ml/kg after treatment for 72 h. A 100% inhibition rate was observed for mice treated with 25 mg/kg of standard chloroquine diphosphate after day 3 of treatment. Overall, crude ethanolic extract of seed showed higher parasite inhibition than the crude n-hexane extract (46).

    2.17. Anti-trypanasomal effectM. stenoetala pTrypanosoma bruceiT. bruce in vivo M. oleifera in vivo in vitro

    2.18 Anti plasmodial effectM. oleifera Mus musculusPlasmodium berghei M. oleifera, M. oleifera Phytochemicals are non-nutritive chemicals produced by plants which may have an impact on health, or on flavor, texture, smell or color of the plants. Plants produce these chemicals to protect themselves but research demonstrates that they can alsoprotect humans against diseases. The phytochemicals include the alkaloids, anthocyanins,carotenoids, coumestans, flavan-3-ols, flavonoids, hydroxycinnamicacids, isoflavones, lignans, monophenolsmonoterpenes, organosulfides, phenolic acids, phytosterols and saponins (25).

    3. Review on the Chemistry Of Moringa species are rich sources of various phytochemicals including uncommon sugar-modified glucosinolates. However details on quantity and profiles are widely found in literature only for , andThe predominant glucosinolate is 4-O-(α-Lrhamnopyranosyloxy)-benzylglucosinolate (glucomoringin) and depending on the tissues three mono-acetylrhamnose isomers of this glucosinolate have also been detected. Chlorogenic acids and flavonols have been reported in different tissues of and but there isno information for other species. The flavonoid profile was found to be quite complex and was predominated by flavonol glycosides (glucosides, rutinosides andmalonylglucosides of quercetin, kaempferol and isorhamnetin).The predominant core aglycones are flavonols: quercetin > kaempferol > isorhamnetin. The leaves had the highest and most complex flavonoid contents, and no flavanoids were detected in roots or seeds. Theantioxidant activity of leaves from was shown to be very high due to the high concentrations of polyphenolics (7, 26).
    Moringa M. oleiferaM. peregrine M. Stenopetala. M. oleifera M. stenopetala Moringa M. oleifera specific components of preparations that have been reported to have hypotensive, anticancer, and antibacterial activity include 4-[4’-O-acetyl- α -L-rhamnosyloxy) benzyl] isothiocyanate, [1], 4-( α -L-rhamnopyranosyloxy)benzyl isothiocyanate [2], niazimicin [3], pterygospermin [4], benzyl isothiocyanate [5], and 4-( α -L-rhamnopyranosyloxy)benzyl glucosinolate [6], While these compounds are relatively unique to the Moringa family (47).
    Moringa
    http://www.tfljournal.org/images/articles/20051201124931586_10_original.gif
    structure of selected phytochemicals from Moringa species(47).
    Fig.1

    From GC-MS Analysis of methanoic leaf extract of oleiferasixteen compounds were identified. These compounds comprise mainly hydrocarbons, fatty acids, alcohols, esters and phenols. The composition of the extract comprises; 9-Octadecenoic acid (20.89%), L-(+) - Ascorbic acid- 2, 6- dihexadecanoate (19.66%), 14 –methyl -8- Hexadecenal (8.11%), 4- hydroxyl-4-methyl- 2-pentanone (7.01%), 3-ethyl-2, 4-dimethylpentane (6.14%) and phytol (4.25%) , 3, 4-epoxyethanone (1.78%) , N-(-1-methylethyllidene)- benzene ethanamine (1.54%,), 3-5-bis (1, 1-dimethylethyl)-phenol 2.55% , hexadecanol (1.23% ), 3, 7, 11, 15-tetramethyl-2 hexadecene-1-ol ( 1.17% ),4, 8, 12, 16-tetramethyl heptadecan-4-olide (2.77%), 1, 2, 3-propanetriyl ester-9 octadecenoic acid. (1.23%), 1, 2 benzenedicarboxylic acid, (2.46%) and octademethyl cyclononasiloxane (1.23% ) of the extract (48).
    M. The chromatogram of the methanolic extract of the seeds of showed five peaks which indicate the presence of five compounds in the extract .These compounds comprise mainly hydrocarbons, fatty acids, alcohols and esters (1).The phytochemicals identified in the leaf powder of included tannis, saponins, alkaloids, phenols flavonoids and glycosides. The nutritional investigations revealed the presence of carbohydrates (29.08%), ascorbic acid (140mg/100g); fibre (2.1%), protein (6.88%) as well as iron (70mg/100g), calcium (1530 mg/100g)), vitamin C (17.8 mg/100g) potassium (255 mg/100g), magnesium (250 mg/100g) and vitamin A (19.9 mg/100g) (49).
    M. oleiferaM. oleifera Phytochemical investigation of the stem bark of Lam. (Moringaceae) furnished two new phytoconstituents identified as n-heptacosanyl n-octadec-9,12,15 trieneoate (moringyl linoleneate) and n- docas- 4-en-11-one-1-yl n-decanoate (oleiferyl capriate) along with the known compounds -sitosterol, epilupeol, glyceropalmityl phosphate and glycerol-oleiostearyl phosphate (50).
    M. oleifera The seed oil of Egyptian (Forssk) was extracted with a mixture of dichloromethane/methanol. oil was found to contain high amounts of hydrocarbon fraction C12 to C32 and phytoesterol fractions rich in campesteol, clerosterol and sitosterol compounds. The major fatty acids were identified as oleic and linoleic acids. Tocopherols and phenolic in oil accounted for 20.35 and 48.31 mg/100 g (51).
    M. peregrinaMoringa peregrine had 26.6% crude protein (CP), 3.36% fat, 17.9 KJ/kg DM gross energy, 45% nitrogen free extract (NFE), and 38.4% non fiber carbohydrate (NFC). In , the contents of CP, fat, NFE, NFC and gross energy were 28.9%, 6.73%, 45%, 38.4% and 17.9 MJ/kg DM, respectively. leaves contained significantly higher crude fiber, acid detergent fiber (ADF) and cellulose than those of . However, the acid detergent lignin (ADL) and hemicelluloses contents of were significantly higher than those of (52).On the other hand, the raw leaves of are also known to contain isothiocyanates (cyanogenic glucosides), which is a known goitrogenic factor that can be detrimental to humans(53).
    M. stenopetala M. oleiferaM. stenopetala M.oleiferaM. oleiferaM. stenopetala M. stenopetala The fixed oil of the seed Fam. was analyzed using GC-MS. Nine compounds from fixed oil was characterized. Methyl ester 9-Hexadecanoic acid (55.23%), hexadecanoic acid (29.90%), Eicosanoic acid (9.64%) was found to be the major compounds of while Pentadeconic acid (55.60%), 11- octadecenoic acid (10.40%), docosanoic acid (7.24%) were found to be the major compounds of oil(54).
    M. concanensis Nimmo M. Concanensis Nimmo M. oleifera L M. Concanensis Nimmo phytochemical screening of ethanolic extract of revealed the presence of alkaloids, flavonoids, carbohydrate, phytosterols, fixed oils and fat , tannin, amino acids reducing sugar and cardiac glycosides (30). The phytochemical analysis ofbark revealed the presence of alkaloids, carbohydrates, terpenoids, tannins, cardiac glycosides, reducing sugar and amino acid (28). The major medicinal interests of Moringa are three structural classes of phytochemicals: glucosinolates, flavonoids, and phenolic acids (53)
    M.concanensis M. concanensis Glucosinolate contents in leaves of five three species (, and ) ranged from 2.65 μmol/g in old leaves of to 28.62 μmol/g in young leaves of . An Indian gave maximum leaf yield. In leaves, most phytochemicals of this class carry a benzyl-glycoside group linked to the single carbon of the motif. The most abundant of them is 4--(α-

    3.1 GlucosinolatesMoringa M. oleiferaM. stenopetala M.peregrinaM. stenopetala M. oleifera M. oleiferaM. oleiferaOl-rhamnopyranosyl-oxy)-benzylglucosinolate, otherwise known as glucomoringin. Enzymatic hydrolysis of the glucosinolate motif of members of this class leads to the formation of corresponding isothiocyanates, thiocyanates, or nitriles (55).contain low amounts of 4- monoacetyl-4-(R-Lrhamnopyranosyloxy)-benzylglucosinolate isomers, but significant amounts of 4-(R-L rhamnopyranosyloxy)-benzylglucosinolate and benzylglucosinolate in the stem tissue. The root tissues were found to contain both 4-(R-Lrhamnopyranosyloxy)-benzylglucosinolate and benzylglucosinolate while the contained quercetin 3-rhamnosylglucoside (rutin)(53). M. stenopetala M. stenopetala O
    Benzyl glucosinolate(53) Hydroxy benzyl Glucosinolate (53).

    FIG.3FIG.2.
    Flavonoids and phenolic acidsare collectively referred to phenolic compounds. Quercetin and kaempferol, in their as 3′--glycoside forms, are the predominant flavonols in leaves. The sugar moieties include, among others, rhamnoglycosyl (rutinosides), glucosyl (glucosides), 6′ malonyglucosyl, and 2′-galloylrutinoside groups. Based up on UV and MS analyses of leaves extract, 12 flavonoids were simultaneously identified as quercetin and kaempferol glycosides, including malonyl glycosides, acetyl glycosides and succinoyl glycosides. Of these identified compounds, quercetin and kaempferol glucosides and glucosides malonates are the major constituents. The qualitative analysis revealed that leaves contained large amounts of flavonoids including that of quercetin and kaempferol with quercetin being the higher of the two (56). Flavonoids demonstrate a wide range of biochemical and pharmacological effects including anti-oxidation, anti-inflammation, anti-platelet, anti-thrombotic action and anti inflammation (57).

    3.2 Phenolic compoundsOM. oleiferaMoringaM. oleifera
    Caffeoylquinic Acid 3-CQA (Chlorogenic Acid)(57)
    Fig .4. Isoflavones are some of the phytochemicals found leaves as well as in other legumes, parsley and grains. They elevate HDL cholesterol (good cholesterol) and lower LDL cholesterol (bad cholesterol). Also, they are potent antioxidants against superoxide and hydrogen peroxide, have estrogenic-like qualities (phytoestrogen), may reduce menopausal symptoms, prevent bone resorption (osteoporosis) in post-menopausal women, may prevent breast cancer, inhibit prostate cancer cells by 30%, and inhibit tyrosine kinases involved in tumorigenesis.(3) The amount of quercetin in the leaves of ranged from 1.62 to 0.066 % predominantly as quercetin-3--β-(LC-MS/MS) method to analyze quercetin (QU), rutin (RU) and kaempferol (KA) simultaneously in the leaf extracts of Lam show that the lower limit of quantitation achieved for QU, RU and KA was 5 ng/(58).

    3.2.1 IsoflavonesMoringa

    3.2.2QuercetinMoringa oleiferaOd-glucoside also known as isoquercitrin or isotrifolin while for kaemperol the percentage was lower ranging from 0.673 to 0.054 %, but traces of quercetin 3-glucoside is found in Quercetin is a potent antioxidant with multiple therapeutic properties. It can reduce hyperlipidemia and atherosclerosis in HCD or HFD rabbits. It has shown anti-dyslipidemic, hypotensive, and anti-diabetic effects in the obese Zucker rat model of metabolic syndrome. It can protect insulin-producing pancreatic β cells from STZ-induced oxidative stress and apoptos. O-M. stenopetala. Moringa oleifera
    The structure of Kaempferol, Quercetin(58).
    FIG.5. Chlorogenic acid, which is an ester of dihydrocinnamic acid (caffeic acid) and quinic acid, is a major phenolic acid in leaves The discovery of chlorogenic acid analogs in the leaves of M. oleifera give a promising indication that the leaves have medicinal use in maintaining a healthy liver and gall bladder function as well as for other medicinal applications. Chlorogenic acid can beneficially affect glucose metabolism. It has been shown to inhibit glucose-6-phosphate translocase in rat liver, reducing hepatic gluconeogenesis and glycogenolysis. It was found to lower PPBG in obese Zucker rats. In OGTT experiments performed on rats or humans, it reduced the glycemic response in both species, in rodents; it also reduced the glucose AUC. Its anti-dyslipidemic properties are more evident as its dietary supplementation has been shown to significantly reduce plasma TC and TG in obese Zucker rats or HFD mice and to reverse STZ-induced dyslipidemia in diabetic rats. Recent reports have associated consumption of the analog forms of chlorogenic acid to have protective benefits to the central nervous system (13).
    3.2.3 Chlorogenic acid
    M. oleifera
    CaffeoylquinicAcid 5-CQA (Chlorogenic Acid)(13)
    FIG.6 The alkaloid moringinine was initially purified from root bark and later chemically identified as benzylamine . It is also present in leaves. This substance was suspected to mediate the hypoglycemic effect of the plant. From 100 g of leaves, 0.0956 to 0.148 mg/100 g DW of alkaloids was obtained. Moringa leaves contained low levels of alkaloids; the alkaloids are not a major contributor to the antioxidant capacity (59).

    3.3 Alkaloids

    M. oleiferaM. oleifera The phytochemicals identified in the leaf powder of include saponins (49). saponin also extracted from benzene extract ofdried pod of and then separated and characterized by thin layer chromatography, HPLC, FTIR and H NMR, from the analysis on saponins the presence of 13 saponin components was reported. Phytochemicals such as tannins, saponins, glycosides and terpenoids were found to be relatively low in concentration. Tannins could be an effective ameliorative agent of the kidney. Tannins have also shown to be a potential anti-viral, anti-bacterial and anti-parasitic agents (60).

    3.4 Saponins Moringa oleiferaMoringa oleifera1M. oleifera

    3.5 Glycosides3.5.1 Niaziminin Niaziminin is a mustard oil glycoside initially isolated (along with other glycosides such as niazinin and niazimicin) from ethanolic extracts of leaves, based on their hypotensive properties on Wistar rats. At 1mg and 3mg/kg-bw, these compounds caused a 16–22 and a 40–65% fall of mean arterial blood pressure (MABP), respectively.Niazimicinhave also been reported to have potent anti tumor promoting activity in two stagecarcionogenesis in mouse skin using 7,12-dimethylbenz (a) anthracene [DMBA] as an initiator and 12-O-tetradecanoyl-phorbol-13-acetate [TPA] as a tumor promoter (61). Anthocyanins are water-soluble glycosides and acyl-glycosides of anthocyanidins. Anthocyanins have anti oxidant and anti-inflammatory effects and protect endothelial cells from oxidative damage (62). This compound was isolated from roots and structurally identified as -benzoyl phenyl alanyl phenylalinol acetate at 25μM, this unusual dipeptide derivative inhibited by nearly 90% the secretion TNFα and IL-2 from lipopolysaccharide-stimulated peripheral blood lymphocytes in culture. It had no effect on IL-6 secretion .This inhibitory activity may contribute to the anti-inflammatory properties of the plant (63). In the experiment, the scientists found that the seed protein forms dense layers thicker than a single molecule even at concentrations as low as 0.025 wt% – so the binding is very efficient. protein has a strong tendency to bind both to mineral surfaces and to other protein molecules, even at very low protein concentrations, due to hydrophobic regions and to the fact that, even when the overall protein is electrically neutral, different subgroups of opposite charge will be ionised. Work on proteins continues to develop a non-toxic, biodegradable water purification treatment for which materials are available locally and at a much lower cost than aluminium salts (64).
    M. oleifera

    3.5.2 Anthocyanins

    3.6 Aurantiamide acetateM. oleiferaN

    3.7. ProteinsM. oleifera M. oleifera M.oleifera M. oleifera The oil from the seed of was found to contain high levels of β-sitosterol (up to 45.58%), stigmasterol (up to 23.10%) and campesterol (up to 15.81%). alph, gama and delta tocopherols were detected up to levels of 15.38, 25.40 and 15.51 mg/kg of oil, respectively(65) various sterols were identified in the seed oil of n-hexane extract, among the sterols, stigmasterol has the highest percentage (18.8%).The identification and determination of sterols by GLC revealed the presence of corposterol and desmosterol) (66).

    3.8. Sterol CompositionM. oleifera The vitamin C content of fresh leaves ranges around 204 mg/100 g of fresh weight Vitamin C or ascorbic acid acts as an antioxidant that, along with other vitamins,protects the body from oxidative stress, maintains the immune system and aids in theabsorption of iron. Additionally, ascorbic acid neutralizes any radicals, damaged lipidsand DNA in the blood that may cause illnesses to emerge while regenerating the activeantioxidant capacity from vitamin E (59).

    3.9. Vitamins

    3.9.1 Vitamin CM. oleifera The tocopherol profile of seed oil, consisted of alpha, gama- and delta-tocopherol. The oil extracted with n-hexane had the highest content of alpha- and delta-tocopherol and the lowest of gama-tocopherol. The leaves of were shown to provide a considerable source of vitamin E the amount varied from 7.11 to 112.04 mg/100 g DW (66).

    3.9.2 The tocopherolesM. oleifera Moringa Results from the analysis showed that leaves contain 16.32 mg/100 g DW both beta and alpha carotene with consistently higher amounts of beta carotene. Beta-carotene is strong against singlet oxygen, can stimulate DNA repair enzymes, gives better cornea protection against UV light than lycopene and can boost the activity of Natural Killer (NK) immune cells. Alpha –carotene is ten times more anti-carcinogenic than beta-carotene, enhances release of immunogenic cytokines and helps in improvement of vision (zz).Lycopene: it is classified as one of the powerful antioxidant which reduces damage to DNA and proteins and gives better skin protection against UV light than beta-carotene. (3) The contents of calcium, phosphorous, magnesium, potassium and sodium in were 2.47%, 0.57%, 0.76%, 2.45% and0.11%, respectively. Moringa was found to be good source of calcium (1.61 %), potassium (0.52 %), magnesium, (0.60 %), iron (40.65 mg/100 g) Manganese (14.60 mg/100 g) and copper (0.95 mg/100 g) all of which are minerals essential to the diet (58).

    3.9.3. CarotenoidsM. oleifera

    3.10 Elemental analysis

    M. stenopetala oleifera The hydro distillation of the leaves of produced pale yellow oil in 0.05% yield on a dry mass basis. 29 compounds were identified, accounting for 92.3% of the total oil, and hydrocarbons represented the 91.1% of the oil. Hexacosane (13.9%), pentacosane (13.3%) and heptacosane (11.4%) were the most abundant compounds. Nonacosane (18.6%), 1,2,4-trimethyl-benzene (16.9%) and heptacosane (7.4%) were the major components in the essential oil of obtained by Soxhlet extraction, while nonacosane (13.4%–60.1%), heptacosane (5.0%–22.6%) and pentacosane (1.0%–6.3%) were among the most abundant components in the essential oil obtained by Supercritical Fluid Extraction under different conditions(68).

    3.11 Chemical Composition of the Essential OilsM. oleifera M. oleifera In the toxicity study of ethanolic and aqueous extract of leaves and fruit, animals were challenged with different amount of the extract ,the biochemical parameters ALKP, SGPT, and SGOT showed no significant changes, even increase in the dose of the extract was well tolerated and nontoxic . The hematological parameters RBC, WBC, Hb were also analyzed, no change was observed among the different extracts in the haematological studies. Even the value of RBC count is similar to that of vehicle control studied with same extract (37). In the treatment with aqueous leaf extract of different doses of the extract was well tolerated by all animals.. No significant change in the weight of liver and kidney was observed in the entire group (10).

    4. ACUTE TOXICITY STUDIESM. oleiferaM. stenopetala, Medicinal plants are widely used throughout the world to fight illness and to maintain health due to their natural origin, cost effectiveness and less side effect. One of such plant is Leaves ,seeds, flowers and root of plant are known to have various biological activities, including, anti-hyperglycemic effect anti-nutrient properties, antioxidant properties ,anti-inflammatory properties, antibacterial and antifungal activity, anti-nephrotoxic effect , antihypertensive,hepatoprotective effect ,wound healing,anti-implantation activity, antiplasmodial activity and anti-trypanasomal effect. According to toxicity study the extracts were well tolerated with no toxicity. This plant family is rich in compounds containing the simple sugar, rhamnose, and it is rich in a fairly unique group of compounds called glucosinolates and isothiocyanates. The major medicinal interest of is three structural classes of phytochemicals: glucosinolates, flavonoids, and phenolic compounds. Quercetin ,Chlorogenic acid ,Moringinine , Niaziminin ,Anthocyanins, Aurantiamide acetate, Alkaloids, phenols, proteins, Sterol ,Vitamin c,Isoflavones, tocopheroles, Carotenoids are some of the phytochemicals with therapeutic potential. (www.biologicaldiversity.org/publications/papers/Medicinal_Plants_042008_ lores.pdf)

    5. SUMMARYMoringa. Moringa of MoringMoringa
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      • Moringa oleifera





         
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        Universal Medical college
        Revised program for1st-year pharmacy regular degree students
        2019/2020 A.Y

         
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        Contact Us

         
         
        Universal medical college
        Address: around 22 mazoria, behind Dinbruwa hospital
        Tel: +251116667366
        +25111666 7354
        Mobile: +251911523053
        +251922470000
        p.o.box: 13954
        Email: admin@universaluniversitycolleges.com
        Facebook:
        umc2011@gmail.com

         
         
         
         
         
         
         
         
         

        Working Hours

         
        • Throughout the week, Monday to Friday from 8:30am-5:30pm (Regular classes), Saturday 8:30am-12:30pm
        • Extension classes Monday to Friday from 6pm-8:00pm; Saturday and Sunday from 8:30am-11:30am
         
         
         
         
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