Level and Determinants of Patient Satisfaction with Pharmacy Services in Ethiopian Hospitals: A Systematic Review
Received: 06-Jun-2022 / Manuscript No. JCMHE-22-65930 / Editor assigned: 08-Jun-2022 / PreQC No. JCMHE-22-65930(PQ) / Reviewed: 22-Jun-2022 / QC No. JCMHE-22-65930 / Revised: 26-Jul-2022 / Manuscript No. JCMHE-22-65930(R) / Published Date: 02-Aug-2022
Abstract
Introduction: Patient satisfaction is a globally accepted healthcare quality indicator. It has a great impact on medication adherence and treatment outcomes. Therefore, the aim of this review is to assess the level and determinants of patient satisfaction with pharmacy services in Ethiopian hospitals.
Methods: To ensure inclusion of relevant studies, this review followed and used the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guideline and checklist. Comprehensive searches of electronic online databases such as Google Scholar, PubMed, Science Direct and Research Gate were accessed from inception of this review to December 20, 2021. The search by used the keywords: “patient satisfaction”, “hospital pharmacy services” and “Ethiopia” either alone or in different order of combinations limiting the language to English.
Results: Electronic online databases were searched and 2,480 records were identified. Ninety-nine duplicates were removed. Title and abstract screening resulted in the exclusion of 2,364 irrelevant articles. Two articles were excluded with justification. Finally, 15 articles were included in the review. The level of patient satisfaction in hospitals was varied based on hospitals APTS implementation. It ranged from 40.5% to 92.3%. There were variations in the determinants of patient satisfaction but socio-demographic factors, pharmacy setting and pharmacy service were the general determinants of patient satisfaction.
Conclusion: Patient satisfaction with pharmacy services in Ethiopian hospitals was generally found to be low. Patients served at APTS implemented hospitals were highly satisfied but further studies should be conducted to confirm consistence. Quality healthcare setting and service had positive impact on level of patient satisfaction. Satisfied patients adhere to medications which in turn improve treatment outcomes.
Keywords: Patient satisfaction; Hospital pharmacy service; Ethiopia
Abbreviations
APTS: Auditable Pharmaceutical Transaction and Services; ART: Antiretroviral Therapy; CS: Cross-sectional Study; IPD: Inpatient Department; OPD: Outpatient Department; PRISMA: Preferred Reporting Items for Systematic Review and Meta-analysis.
Introduction
The improvement of the quality of hospital pharmacy services indicates the betterment of pharmaceutical care services in hospitals. Healthcare quality is influenced by perception and satisfaction of patients. Pharmaceutical care has been adopted in complement for the national strategy of the Federal Ministry of Health for achieving development goals [1]. Ethiopian Federal Ministry of Health works towards providing quality health services. Auditable Pharmaceutical Transaction and Services (APTS) rollouts in more than 200 health facilities, introduction of clinical pharmacy and drug information services and an increased attention to anti-microbial resistance are among the initiatives [2].
Patient satisfaction is a globally accepted healthcare quality indicator that should be routinely studied for consistent quality assurance and proper functioning of the health system. Satisfaction of patients has great impact on medication adherence and treatment outcome [3]. Pharmacy being the last department to be visited, it has a direct link with patient satisfaction. Availability of medicines, waiting time and privacy in counseling affect patient satisfaction [4-7].
The pharmacy setting, location and cleanliness affects patients’ satisfaction. Lack of adequate drug information and noise in dispensing area dissatisfies patients. In many developing nations, main healthcare provider is government and the service suffers quality issue [8-12]. Patient satisfaction is difficult to measure and affects patient expectation. Communication of pharmacy professionals with patients increase satisfaction and affect adherence. Patient satisfaction is crucial for health facility survival. Patient satisfaction improves compliance, creates long lasting relationship and continuity of care especially in cases of chronic disease. Healthy pharmacist-patient interaction encourages compliance and adherence.
Adequate medication counseling, appropriate location of the pharmacy setting, adequate waiting area, prompt services, availability of prescribed medications, adequate number of pharmacists, politeness and attitudes of pharmacy professionals positively influence patient satisfaction. Patients’ perception of inadequate knowledge of pharmacists and lack of quality of the system resulted in dissatisfaction. Socio-economic status, perceived status and insurance also affect satisfaction [13-16].
Systematic review on the level of patient satisfaction with hospital pharmacy services was not conducted so far in Ethiopia. Therefore, this review attempted to assess the level and level of patient satisfaction determinants of patient satisfaction with pharmacy services in Ethiopian hospitals.
Literature Review
Study protocol and registration
Preferred Reporting Items for Systematic Review and Meta- Analysis (PRISMA) group guideline and checklist was followed to ensure inclusion of relevant studies. The checklist was applied during record identification, titles and abstracts screening, and eligibility evaluation of full texts. This review was registered on PROSPERO and granted identification number of 285219 with a title “level of patient satisfaction with pharmacy services in Ethiopian hospitals: a systematic review” [17].
Eligibility criteria
Inclusion criteria: Published articles in peer reviewed journals reporting level of patient satisfaction with pharmacy services in Ethiopian hospitals [18].
• Primary objective being assessed.
• Published from inception to December 20, 2021.
• Published in English language.
• Original researches.
Exclusion criteria
• Researchers conducted outside Ethiopia.
• Studies with full-text missing.
Search strategy and data sources: Google Scholar, PubMed, HINARI, Science Direct and Research Gate databases were accessed from inception of this review to December 20, 2021. Comprehensive searches was done using keywords: “patient satisfaction”, “hospital pharmacy services”, “systematic review” and “Ethiopia” either alone or in different order of combinations. Boolean connectors (and, or, not) were applied to obtain relevant articles. Studies reporting level of patient satisfaction with pharmacy services were identified limiting the language to english [19-21].
Data extraction and quality assessment: Microsoft Excel spreadsheet was prepared and used for data extraction. EndNote (version X9) software for Windows was used for citation and reference management. Author/s and year of publication, study region, study population, study design, data collection tools and sample size, prevalence of patient satisfaction level and health institutions were extracted [22-26].
Quality of included studies was evaluated by most commonly used quality assessment tool, Newcastle-Ottawa quality assessment scale for systematic reviews adapted for cross-sectional studies with 10 points (stars). The quality assessment tool is classified in to three categories for ease of measurement:
• Selection (methodological) of study with weight of maximum five stars.
• Comparability of the study subjects which takes a maximum score of two stars.
• Outcome measures with statistical analysis with a maximum score of three stars.
This critical appraisal was conducted to assess the internal (systematic error) and external validity of the studies and to reduce the risk of bias.
Sample representativeness, data measurement tool, response rate, comparability of study, statistical test used and its appropriateness for data analysis were the critical criteria evaluated. Three reviewers (TW, KM and WA) independently assessed qualities of the articles. Discrepancies were resolved with discussion.
Results
Search results and study characteristics: Electronic online databases were searched and 2,480 records were identified. Ninetynine duplicates were removed. Title and abstract screening resulted in the exclusion of 2,364 irrelevant articles. Two articles were excluded with justification. Finally, 15 articles were included in the review (Figure 1).
Figure 1: Flow diagram depicting article screening process by PRISMA group guidelines.
Fifteen studies met the eligibility criteria and were included. Details of the studies included in the review are presented in Table 1. All the studies included were original researches and used cross sectional study design. The study subjects were patients visiting hospital pharmacy units. Total participants from all the 15 studies were 6,001, sample size ranging from 189 to 810 (Table 1). The median value was 405 (interquartile range =135).
| Author/s, year |
Region | Health facility | Pharmacy unit | Study design | Data collection instrument (tool) used | Sample size (n) | Level of satisfaction |
|---|---|---|---|---|---|---|---|
| (Abebe et al., 2016) |
Amhara | Gondar University Referral Hospital | ART | CS | Adopted validated tool (Larson et al., 2002 and Hovart et al., 2010: PSPP-Q). | 292 | 54.70% |
| (Adinew et al., 2021) |
National | 26 APTS implemented hospitals (national) | OPD | CS | Adapted structured questionnaire and standard observation checklist. | 650 | 90.00% |
| (Asamrew et al., 2020) |
Addis Ababa | Tikur Anbessa Specialized Hospital | IPD | CS | Developed structured questionnaire. | 398 | 46.20% |
| (Ayalew et al., 2017) |
Amhara | Gondar University Hospital | OPD | CS | Developed data collection questionnaire. | 287 | 51.90% |
| (Ayele et al., 2020) |
Eastern Ethiopia | 13 Eastern Ethiopian Hospitals | OPD | CS | Adapted validated tool (Larson et al., 2002 and Traverso et al., 2007). | 422 | 46.20% |
| (Beyene et al., 2020) |
SNNPR | 15 public hospitals in SNNP region | OPD | CS | Adapted structured data collection tool | 465 | 92.30% |
| (Fekadu et al., 2020) |
Oromia | Wollega University Referral Hospital | OPD | CS | Developed data collection tool | 200 | 63.60% |
| (Gidey et al., 2021) |
Afar | Dubti General Hospital | OPD | CS | Adapted structured questionnaire | 422 | 40.50% |
| (Karunamoorthi et al., 2009) | Addis Ababa | Alert, Black Lion, St. Paulos, St. Peter Hospitals | ART | CS | Adapted validated structured questionnaire (CSQ-8, VSSA). | 405 | 54.80% |
| (Kassa et al., 2021) |
Tigray | 7 hospitals in Tigray region | OPD | CS | Adapted validated data collection questionnaire (SERVQUL). | 810 | 3.10* |
| (Kebede et al., 2021) |
Amhara | Dessie Referral and Boru-Meda Hospitals | OPD | CS | Adapted validated data collection instrument (Larson et al., 2002). | 422 | 59.40% |
| (Semegn and Alemkere, 2019) | Addis Ababa | Tikur Anbessa Specialized Hospital | OPD | CS | Adapted structured interview questionnaire. | 250 | 51.60% |
| (Surur et al., 2015) |
Amhara | Gondar University Referral Hospital | OPD | CS | Adopted validated data collection instrument (Eshetu and Gedif 2011). | 405 | 2.48* |
| (Teshome Kefale et al., 2016) | SNNPR | Mizan-Tepi University Teaching Hospital | OPD | CS | Adapted semi-structured questionnaire. | 384 | 52.60% |
| (Woldeyohanes et al., 2015) | Oromia | Jimma University Specialized Hospital | IPD | CS | Developed standardized structured questionnaire. | 189 | 61.90% |
Table 1: General characteristics of the included studies.
Four studies were conducted in Amhara region, three in Addis Ababa and two in Oromia region, two in SNNP region and others nationally, in Afar region, in Tigray region and in Eastern Ethiopian hospitals [27-29].
All the studies were published from 2009 to 2021 and used facility based cross-sectional study design. Eleven studies were conducted at OPD pharmacy units, two at ART and the other two at in-patient pharmacy. Twelve studies collected data from general patients, while one from type II diabetes mellitus patients and the other two from patients living with HIV/AIDS. A total of 85 hospitals were addressed in all the 15 studies. Systematic random sampling technique was used for selecting study participants in 10 studies, simple random sampling in 4 studies and convenient sampling techniques in 1 study. Four of the studies used developed data collection tool, six used adapted structured data collection tool, three used adapted validated data collection tool and two used adopted validated data collection tool [30].
Level of patient satisfaction with pharmacy services in Ethiopian hospitals: Prevalence of level of patient satisfaction of 13 studies was presented by percentage and the other two by Likert scale 3.10 (1 most dissatisfied, 5 most satisfied) and 2.48. The level of patient satisfaction in hospitals without APTS was between 40.5% and 63.6% and in APTS implemented hospitals; the satisfaction was 90% and 92.3%.
Determinant factors of patient satisfaction with hospital pharmacy services
Socio-demographic factors: Patient satisfaction was affected by socio-demographic factors in 10 studies. Age, marital status, level of education, occupation and economic status were contributing factors. Five studies either did not addressed socio-demographic association with patient satisfaction or had no association [31,32].
Health facility setting and health service provision: All the fifteen studies showed that there was association between pharmacy setting and patient satisfaction. Waiting area, location and cleanliness were among the expectations. There was significant association between pharmacy service and satisfaction of patients. Waiting time, politeness, availability medicines, adequate drug information and privacy were among the pharmacy services subjected to assessment (Figure 2).
Figure 2: Factors affecting level of patient satisfaction with pharmacy services.
Data quality assessment: All the 15 studies were evaluated. The quality of included studies was ranged 7 to 9 (Table 2).
| Studies included in this systematic review | Selection (methods) | Comparability of the subjects | Outcome measures | Total score |
|---|---|---|---|---|
| (Abebe et al., 2016) | 5 | 2 | 2 | 9 |
| (Adinew et al., 2021) | 4 | 2 | 2 | 8 |
| (Asamrew et al., 2020) | 4 | 2 | 2 | 8 |
| (Ayalew et al., 2017) | 4 | 2 | 2 | 8 |
| (Ayele et al., 2020) | 5 | 2 | 2 | 9 |
| (Beyene et al., 2020) | 4 | 2 | 2 | 8 |
| (Fekadu et al., 2020) | 4 | 2 | 1 | 7 |
| (Gidey et al., 2021) | 4 | 2 | 2 | 8 |
| (Karunamoorthi et al., 2009) | 5 | 2 | 2 | 9 |
| (Kassa et al., 2021) | 5 | 2 | 2 | 9 |
| (Kebede et al., 2021) | 5 | 2 | 2 | 9 |
| (Semegn and Alemkere, 2019) | 4 | 2 | 2 | 8 |
| (Surur et al., 2015) | 5 | 2 | 2 | 9 |
| (Teshome Kefale et al., 2016) | 4 | 2 | 2 | 8 |
| (Woldeyohanes et al., 2015) | 4 | 2 | 2 | 8 |
Table 2: Quality assessment results of included studies.
Discussion
Quality pharmacy service increases satisfaction which improves health outcome of patients by encouraging medication and treatment adherence. Pharmacy setting is the last stop in a healthcare setting where patients collect prescribed medicines and it is a key determinant of healthcare service quality. Patient satisfaction with hospital pharmacy services is an indicator of quality healthcare and determines the health outcomes of patients. There are different factors which affect the level of patient satisfaction with hospital pharmacy services in Ethiopia. Demographic and socio-economic and healthcare setting related factors can be mentioned. There was a positive association these factors and patient satisfaction.
Age, education level, occupation, paying capacity and marital status were found to be associated with patient satisfaction. Educated patients were less satisfied than illiterate. Married patients were more satisfied than unmarried or divorced. Older population with age (>60 years) were more satisfied than younger adults (18-30 years). Out-ofpocket payment is negatively associated with patient satisfaction and insured patients and those whose healthcare costs are covered with employing companies showed positive association.
Satisfaction of patients visiting hospital pharmacies was low (40.5%) where the health facilities lack adequate infrastructure, personnel and poor availability of essential medicines and healthcare setting with improved infrastructure, personnel and availability of medicines achieved satisfaction level of up to 90% and 92.3%. Healthcare setting and service were significantly associated with patient satisfaction. Uncomfortable and inconvenient waiting area and counselling room dissatisfied patients. Lack of information on drugs was another source of dissatisfaction.
Location of the pharmacy in a facility setting affects patient satisfaction. Convenient location is positively associated with patient satisfaction. There is a statistically significant correlation between the length of waiting time and patient satisfaction. Longer waiting time discourages patients and hence decreases satisfaction. Inadequate waiting space was also a source of dissatisfaction for patients.
Availability of medicines has strong association with level of patient satisfaction. Patients accessing prescribed medicines were satisfied. Lack of adequate description of the prescribed medications such as side effects, drug-drug interactions and drug-food interactions, staff impoliteness and shortage of drugs resulted in dissatisfaction.
There are some limitations for this systematic review. There was difference in association of socio-demographic variables and the level of patient satisfaction with pharmacy services. This is one limitation of the review. Majority of the studies reported the association but others didn’t. Since all the studies were cross-sectional, it was difficult to be certain of the direction of true temporal relationship. This is another limitation of this review.
Conclusion
Patient satisfaction with pharmacy services in Ethiopian hospitals was generally found to be low. Patients served at APTS implemented hospitals were highly satisfied but further studies should be done to confirm its consistence. Majority of the studies revealed that the level of patient satisfaction was less than 65%.
The satisfaction level ranged from 40.5% to 63.6% in non-APTS hospitals and 90% to 92.3% in APTS implemented hospitals. Sociodemographic factors and facility settings and services were determinants of the level of patient satisfaction. Quality healthcare setting and service had positive impact on the level of patient satisfaction. Satisfied patients adhere to medications which in turn improve treatment outcome. Therefore, qualities of healthcare setting and services should be improved to increase patient satisfaction.
References
- Abebe TB, Erku DA, Gebresillassie BM, Haile KT, Mekuria AB, et al. (2016) Expectation and satisfaction of HIV/AIDS patients toward the pharmaceutical care provided at Gondar University Referral Hospital, Northwestern Ethiopia: a cross-sectional study. Patient Prefer Adherence 10:2073-2082.
- Adinew A, Feyissa M, Tadesse B, Demeke B, Assefa T, et al. (2021) Assessment of patient satisfaction towards auditable pharmaceutical transactions and services implemented in outpatient hospital pharmacy in Ethiopia. J Pharm Policy Practice 14:1-8.
- Afolabi MO, Afolabi ER, Faleye BA (2012) Construct validation of an instrument to measure patient satisfaction with pharmacy services in Nigerian hospitals. Afr Health Sci 12:538-544.
- Agu KA, Oqua D, Agada P, Ohiaeri SI, Adesina A, et al. (2014) Assessment of satisfaction with pharmaceutical services in patients receiving antiretroviral therapy in outpatient HIV treatment setting. Int J Clin Pharm 36:636-647.
- Alharbi A, Stevenson M (2020) Refining Boolean queries to identify relevant studies for systematic review updates. Journal of the American Medical Informatics Association 27:1658-1666.
- Alodan A, Alalshaikh G, Alqasabi H, Alomran S, Abdelhadi A, et al. (2020) Studying the Efficiency of Waiting Time in Outpatient Pharmacy. MethodsX 7: 100913.
- AlShayban DM, Naqvi AA, Islam MA, Almaskeen M, Almulla A, et al. (2020) Patient Satisfaction and Their Willingness to Pay for a Pharmacist Counseling Session in Hospital and Community Pharmacies in Saudi Healthcare Settings. Front Pharmacol 11:138.
- Alturki M, Khan TM (2013) A study investigating the level of satisfaction with the health services provided by the Pharmacist at ENT hospital, Eastern Region Alahsah, Kingdom of Saudi Arabia. Saudi Pharm J 21:255-260.
- Amorha KC, Okonta MJ, Ukwe CV (2021) Patients' Satisfaction with Pharmaceutical Care Services in Asthma: An Intervention Study in 2 Nigerian Hospitals. J Patient Exp 8:23743735211034339.
- Asamrew N, Endris AA, Tadesse M (2020) Level of patient satisfaction with inpatient services and its determinants: A study of a specialized hospital in Ethiopia. Hindawi 2020.
- Ayalew MB, Taye K, Asfaw D, Lemma B, Dadi F, et al. (2017) Patients'/Clients' Expectation Toward and Satisfaction from Pharmacy Services. J Res Pharm Pract 6:21-26.
- Ayele Y, Hawulte B, Feto T, Basker GV, Bacha YD, et al. (2020) Assessment of patient satisfaction with pharmacy service and associated factors in public hospitals, Eastern Ethiopia. SAGE Open Med 8.
- Azeredo TB, Oliveira MA, Luiza VL, Esher A, Campos MR, et al. (2009) User satisfaction with pharmacy services in the Brazilian National STD/AIDS Program: validity and reliability issues. Cad Saude Publica 25:1597-1609.
- Berehe TT, Bekele GE, Yimer YS, Lozza TZ (2018) Assessment of client’s satisfaction with outpatient services at Yekatit 12 Hospital Medical College, Addis Ababa, Ethiopia. BMC Res Notes 11:507.
- Beyene D, Abuye H, Tilahun G (2020) Effect of Auditable Pharmaceutical Services and Transaction System on Pharmaceutical Service Outcomes in Public Hospitals of SNNPR, Ethiopia. Integr Pharm Res Pract 9:185-194.
- Emeka PM, AlMunjem MF, Rasool ST, Kamil N (2020) Evaluation of Counseling Practices and Patient's Satisfaction Offered by Pharmacists for Diabetics Attending Outpatient Pharmacies in Al Ahsa. J Patient Exp 7:338-345.
- Eshetu E, Gedif T (2011) Quality of pharmacy services in government hospitals in Addis Ababa, Ethiopia. Ethiopian Pharmaceutical Journal 29:108-120.
- Fekadu G, Dereje S, Dugassa D, Bekele F, Simegnew D, et al. (2020) Type 2 diabetes mellitus patients’ satisfaction with pharmacy services in Wollega University Referral Hospital, Western Ethiopia. International Journal of Surgery - Global Health 3:e28.
- Garjani A, Rahbar M, Ghafourian T, Maleki N, Garjani AF, et al. (2009) Relationship of pharmacist interaction with patient knowledge of dispensed drugs and patient satisfaction. East Mediterr Health J 15:934-943.
- Gidey AB, Yazie TS, Bogale T, Gulente TM (2021) Magnitude of client satisfaction and its associated factors with outpatient pharmacy service at Dubti General Hospital, Afar, North East Ethiopia: A cross sectional study. PLoS One 16: e0260104.
- Kabba JA, Bah AJ, James PB, Chang J, Kitchen C, et al. (2021) Patients satisfaction with free healthcare pharmaceutical services in Sierra Leone: a national cross-sectional study. Int J Clin Pharm 43:556-565.
- Karunamoorthi K, Rajalakshmi M, Babu SM, Yohannes A, et al. (2009) HIV/AIDS patient's satisfactory and their expectations with pharmacy service at specialist antiretroviral therapy (ART) units. Eur Rev Med Pharmacol Sci 13:331-339.
- Kassa DG, Xiang C, Hu S, Hayat K, Andegiorgish AK, et al. (2021) Patients' perception of the outpatient pharmaceutical service quality in hospital pharmacies with auditable pharmaceutical transactions and services in Ethiopia: a cross-sectional study. BMJ Open 11:e042853.
- Kebede H, Tsehay T, Necho M, Zenebe Y (2021) Patient Satisfaction towards Outpatient Pharmacy Services and Associated Factors at Dessie Town Public Hospitals, South Wollo, North-East Ethiopia. Patient Prefer Adherence 15:87-97.
- Khudair IF, Raza SA (2013) Measuring patients' satisfaction with pharmaceutical services at a public hospital in Qatar. Int J Health Care Qual Assur, 26, 398-419.
- Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, et al. (2009) The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med 6:e1000100.
- Modesti PA, Reboldi G, Cappuccio FP, Agyemang C, Remuzzi G, et al. (2016) Panethnic differences in blood pressure in Europe: a systematic review and meta-analysis. Plose One 11:e0147601.
- Nigussie S, Edessa D (2018) The Extent and Reasons for Dissatisfaction From Outpatients Provided With Pharmacy Services at Two Public Hospitals in Eastern Ethiopia. Front Pharmacol 9:1132.
- Semegn S, Alemkere G (2019) Assessment of client satisfaction with pharmacist services at outpatient pharmacy of Tikur Anbessa Specialized Hospital. PLoS One 14:e0224400.
- Surur AS, Teni FS, Girmay G, Moges E, Tesfa M, et al. (2015) Satisfaction of clients with the services of an outpatient pharmacy at a university hospital in northwestern Ethiopia: a cross-sectional study. BMC Health Serv Res 15:229.
- Kefale AT, Atsebah GH, Mega TA. (2016) Clients' perception and satisfaction toward service provided by pharmacy professionals at a teaching hospital in Ethiopia. Integr Pharm Res Pract 5:85-94.
- Woldeyohanes TR, Woldehaimanot TE, Kerie MW, Mengistie MA, Yesuf EA, et al. (2015) Perceived patient satisfaction with in-patient services at Jimma University Specialized Hospital, Southwest Ethiopia. BMC Res Notes 8:285.
Citation: Wakjira T, Mesele K, Ayenew W (2022) Level and Determinants of Patient Satisfaction with Pharmacy Services in Ethiopian Hospitals: A Systematic Review. J Comm Med Health Educ 12: 771.
Copyright: © 2022 Wakjira T, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited.
Share This Article
Recommended Journals
Open Access Journals
Article Usage
- Total views: 1670
- [From(publication date): 0-2022 - Dec 23, 2024]
- Breakdown by view type
- HTML page views: 1414
- PDF downloads: 256
