Patient Satisfaction and Medication Adherence with Automated Multi-Dose Packaging: A National Cross-Sectional Evaluation of the Ez-Pill Service in Saudi Arabia

1. Introduction

The increasing prevalence of chronic diseases, such as hypertension, diabetes, and cardiovascular disease, often necessitates complex, long-term pharmacological regimens. Although effective therapies are available, treatment outcomes depend substantially on medication adherence [1,2,3,4,5,6]. The World Health Organization defines adherence as the extent to which a person’s behavior corresponds with agreed recommendations from a healthcare provider [7]. In Saudi Arabia, where cardiometabolic disorders are highly prevalent [8], improving medication adherence is a public health priority aligned with the Health Sector Transformation Program of Vision 2030 [9,10]. Nevertheless, nonadherence remains a persistent challenge, with approximately 66% of Saudi patients reporting difficulty taking medications on time [3,11]. Medication nonadherence is associated with poorer clinical outcomes, reduced quality of life, increased hospitalization, and substantial healthcare costs [6,12,13]. Medication adherence is influenced by multiple modifiable and non-modifiable factors, including socioeconomic status, health literacy, cognitive function, and regimen complexity [4,6,13].

Community pharmacies are highly accessible points of care and play an important role in public health promotion and medication education [14,15,16]. Globally, pharmacy practice is shifting from traditional dispensing toward patient-centered care and longitudinal patient relationships [17,18]. Although the scope of pharmacy practice in the Arab world has traditionally been limited, Saudi Arabia has expanded pharmacist-led clinical services, including structured diabetes management, immunization, and biomarker monitoring, as part of its national healthcare transformation [15,16]. Evaluating patient satisfaction with these services can help identify areas for improvement and inform health policy [19,20]

Treatment complexity and dosing inconvenience are recognized as modifiable barriers to medication adherence. Managing multiple concurrent medications can impose cognitive and practical burdens on patients, increasing the risk of confusion, missed doses, and medication administration errors [4,6,13]. Automated multi-dose medication packaging (MDMP) systems, such as automated pouch packaging, are designed to reduce this burden by organizing medications into chronologically arranged, easy-to-open pouches labeled with administration dates, times, and medication instructions while minimizing medication waste [21,22,23]. Reducing the complexity of medication organization and administration may improve dosing confidence and satisfaction and, in turn, support medication adherence [6,19,20].

In Saudi Arabia, where conventional medication packaging and manual pill organizers remain common, the Ez-Pill service provided by Nahdi Medical Company is an automated MDMP service [24]. The service replaces conventional medication packaging with personalized, easy-to-open pouch rolls labeled with specific dosing times. This approach is intended to support medication safety and streamline dispensing while allowing community pharmacists more time for patient counseling and medication reviews. Although a meta-analysis found that packaging interventions improved medication adherence, with a moderate effect size (d = 0.593) [25], evidence regarding their long-term effects on objective clinical outcomes, such as biomarker control or hospital readmissions, remains mixed [21,23].

Furthermore, many previous evaluations have relied on self-reported adherence measures, which are susceptible to recall and social desirability biases, rather than objective measures such as pharmacy refill records or electronic monitoring. Previous studies evaluating patient satisfaction and pharmacy services in Saudi Arabia have largely been limited to small, single-center, or regional cohorts. To the best of our knowledge, no published study has evaluated the national implementation of an automated community pharmacy MDMP service while concurrently assessing associations between demographic, operational, and clinical factors and user satisfaction and adherence in Saudi Arabia. This study therefore aimed to evaluate patient satisfaction and self-reported medication adherence among active Ez-Pill users across the national network of Nahdi Medical Company, one of the largest community pharmacy chains in Saudi Arabia. By evaluating patient satisfaction and self-reported medication adherence with an automated MDMP service, this study may provide evidence relevant to the Saudi Ministry of Health’s emphasis on patient satisfaction as an indicator of healthcare quality [9].

2. Materials and Methods

The study assessed two primary outcomes: patient satisfaction with the Ez-Pill service and self-reported medication adherence.

2.1. Study Design and Setting

A descriptive cross-sectional study was conducted from February to July 2026 to evaluate patient satisfaction and self-reported medication adherence among users of the Ez-Pill service across Nahdi Community Pharmacies in Saudi Arabia. The Ez-Pill service is an automated MDMP system designed to replace traditional retail medication bottles and commercial blister packaging. The system packages multiple oral solid medications into a continuous roll of sequential, easy-to-open pouches. Each pouch is arranged chronologically according to the patient’s prescribed day and time of administration and labeled to provide guidance on medication timing and dosing. By organizing medication administration, simplifying multi-drug regimens, and facilitating refill management, the service aims to reduce the practical and cognitive burdens associated with polypharmacy.

2.2. Participant Recruitment and Eligibility

The target population comprised individuals actively enrolled in the Ez-Pill service. Eligible participants were active Ez-Pill users at Nahdi Community Pharmacies in Saudi Arabia of any gender or nationality who provided electronic informed consent. Individuals who declined informed consent or had no prior experience using the service were excluded. Participants were recruited by convenience sampling from a centralized pharmacy administrative database. All active Ez-Pill users registered in the Nahdi database constituted the recruitment frame. An initial invitation containing a unique, single-use survey URL was sent via automated short message service. To prevent duplicate submissions, each survey link was deactivated after the first completed submission. To increase participation, nonresponders received automated short message service reminders followed by telephone follow-up by Guest Care Center personnel. Convenience sampling may have introduced selection bias because individuals who engaged with pharmacy outreach or had favorable experiences with the service may have been more likely to respond.

2.3. Sample Size Determination

Sample size requirements were assessed using two approaches. First, the RaoSoft online sample size calculator [26] indicated a minimum sample of 381 participants based on a population of 42,200 active Ez-Pill users enrolled during the preceding 12 months, a 95% confidence level, a 5% margin of error, and a 50% response distribution. Second, sample size adequacy for the multivariable models was assessed using the guideline of 10–15 observations per independent parameter. With 16 independent predictor variables, 160–240 complete responses were required. Thus, the final sample exceeded the minimum sample size requirement for both approaches.

2.4. Data Collection Instrument

Data were collected using a structured, bilingual (Arabic and English) self-administered online questionnaire hosted on Google Forms (Google LLC, Mountain View, CA). The survey required approximately 10–15 minutes to complete and included closed-ended questions across four domains: demographic characteristics; clinical characteristics, service utilization, and experience; medication adherence; and satisfaction and future intentions.

2.5. Instrument Content and Face Validation

Because the survey was developed specifically for this study based on a literature review rather than adapted from a standardized instrument, validation was limited to content and face validity. Content validity was assessed by two independent academic pharmacists. Face validity was assessed by five community pharmacists with research and practice experience, who evaluated item clarity, contextual appropriateness, and questionnaire structure. Minor wording adjustments were made based on expert feedback. Finally, the questionnaire was piloted among 15 active Ez-Pill users to assess comprehensibility and administration procedures; pilot responses were excluded from the final analysis. Construct validity was not evaluated against objective measures, such as pharmacy refill records or electronic pillbox monitoring; the outcomes were self-reported and therefore potentially subject to recall and social desirability biases.

2.6. Outcome Measurement and Variable Classification

The two primary continuous outcome measures were the Total Medication Adherence Score and the Total Ez-Pill Satisfaction Score. Both outcomes were calculated as mean domain mean scores ranging from 1.00 to 5.00 based on 5-point Likert-scale items, with higher scores indicating greater self-reported adherence and satisfaction. Negatively worded items were reverse-scored before domain aggregation, and mandatory response fields prevented missing item-level data in completed questionnaires. Chronic medical conditions were categorized into three non-overlapping groups based on documented diagnoses. The first group, cardiometabolic disorders alone, included patients with essential hypertension, type 2 diabetes mellitus, dyslipidemia, coronary artery disease, or heart failure only. The second group, non-cardiometabolic disorders alone, included patients with conditions such as osteoarthritis, rheumatoid arthritis, major depressive disorder, generalized anxiety disorder, gastrointestinal disorders (e.g., gastroesophageal reflux disease or inflammatory bowel disease), asthma, or chronic obstructive pulmonary disease. The third group, cardiometabolic disorders with systemic involvement, included patients with both cardiometabolic and non-cardiometabolic conditions. The 14 participant cities were grouped into four regions: Central (Riyadh), Eastern (Dammam, Khobar, Jubail, and Industrial Jubail), Southern (Khamis Mushait, Abha, Ohod Rofaida, and Najran), and Western (Jeddah, Makkah, Taif, Madinah, and Yanbu). The Northern Region was excluded because the Ez-Pill service was not available there during the study period.

2.7. Operational Coding and Reference Baselines

Multicategory nominal and ordinal independent variables were dummy-coded for multivariable analysis using pre-defined reference categories. Saudi nationality, married status, and employment status were used as the reference categories for nationality, marital status, and employment status, respectively. The Western Region was the reference category for geographic region. A medication burden of ≥6 medications was the reference category, compared with less than six medications. Cardiometabolic disorders alone was the reference category for clinical profile. Original medication packaging was the reference category for prior medication organization, compared with no systematic organization and pill boxes or manual organizers. For pharmacy loyalty, <1 year was the reference category, compared with 1–3 years and >3 years; for Ez-Pill use, <6 months was the reference category, compared with 6–12 months and >12 months.

2.8. Descriptive Statistics and Reliability Analysis

Statistical analyses were performed using IBM SPSS Statistics (Version 28.0; IBM Corp., Armonk, NY) and Microsoft Excel 2016 (Microsoft Corp., Redmond, WA). Descriptive statistics, including means, standard deviations, frequencies, and percentages were used to summarize demographic and clinical characteristics and adherence and satisfaction scores. Internal consistency was evaluated using Cronbach’s alpha (α), McDonald’s omega (ω), and corrected item-total correlations. The Ez-Pill satisfaction domain demonstrated excellent internal consistency (α = 0.965, 95% confidence interval [CI] [0.960, 0.970]; ω = 0.965, 95% CI [0.954, 0.975]), with corrected item-total correlations ranging from 0.708 to 0.902. The Ez-Pill adherence domain similarly exhibited high internal consistency (α = 0.965, 95% CI [0.953, 0.977]; ω = 0.966, 95% CI [0.961, 0.971]), with item-total correlations ranging from 0.843 to 0.923. Item-deletion sensitivity analyses were performed for both domains; removing any individual item did not meaningfully alter internal consistency, with all resulting α and ω coefficients remaining above 0.955.

2.9. Regression Modeling and Diagnostics

To examine factors associated with self-reported adherence and patient satisfaction, two multiple linear regression models were constructed using continuous mean domain scores ranging from 1.00 to 5.00 as the dependent variables. Linear regression was used because the composite domain scores were treated as continuous variables and met the relevant model assumptions. Missing data were precluded by mandatory electronic survey field validation, while potential selection bias from online convenience sampling was acknowledged. Before the multivariable analyses, 16 sociodemographic, geographic, and clinical predictors underwent univariable screening; variables without statistically significant associations with the outcomes were excluded, while clinically relevant covariates were retained. Following variable selection, the final regression models were fitted. Model 1 evaluated associations between sociodemographic, geographic, and clinical factors and total adherence score (mean = 4.53, standard deviation = 0.97). Model 2 evaluated associations between the same predictors and the total satisfaction score (mean = 4.56, standard deviation = 0.85). Standard regression diagnostics, including residual P–P plots for normality, scatterplots for homoscedasticity, and Cook’s distance for influential observations, were performed for both models to assess model assumptions. Multicollinearity was evaluated using variance inflation factors and tolerance values. Given the hypothesis-driven design, multiple testing adjustments were not applied. Model results were reported as unstandardized coefficients (B) with 95% CIs, standardized coefficients (β), t-statistics, p values, and coefficients of determination (R2). All statistical comparisons were two-tailed, with p<0.05 considered statistically significant.

3. Results

3.1. Sociodemographic Characteristics of the Respondents

A total of 498 questionnaires were distributed, yielding 443 completed responses and a response rate of 89.0%. The baseline sociodemographic characteristics of the cohort are presented in Table 1. The study population had a mean age of 53.22 ± 12.36 years. The sample was predominantly male (n = 347, 78.30%) and a slight majority were Saudi nationals (n = 249, 56.20%). In terms of educational attainment, more than half of the participants held a higher education degree, with 42.20% (n = 187) possessing a Bachelor’s degree and 11.70% (n = 52) having completed postgraduate studies. Regarding employment status, more than half of the respondents were employed full-time (n = 255, 57.60%), followed by retirees, who constituted 22.10% (n = 98) of the cohort. The vast majority of participants were married (n = 385, 86.90%). Geographically, participants predominantly resided in the Western Region (n = 292, 65.90%), while the remaining respondents were distributed across the Central (n = 67, 15.10%), Eastern (n = 47, 10.60%), and Southern (n = 37, 8.40%) regions of Saudi Arabia.

3.2. Clinical Profiles and Service Utilization Patterns Among Ez-Pill Users

The clinical profiles and service utilization patterns of the respondents are presented in Table 2. In terms of daily medication management prior to adopting the service, 79.90% of participants managed their own medications (n = 354), while family members or caregivers managed medications for 18.10% (n = 80). Most participants reported a relationship with Nahdi Community Pharmacies exceeding 3 years (n = 287, 64.79%), whereas relationships of 1–3 years and <1 year accounted for 20.99% (n = 93) and 14.22% (n = 63), respectively. Regarding initial awareness of the Ez-Pill service, Nahdi pharmacists or pharmacy staff were identified as the primary source of information (n = 408, 92.10%), followed by family or friends (n = 12, 2.70%) and pharmacy digital applications or websites (n = 10, 2.30%). More than half of respondents had used the Ez-Pill service for more than 1 year (n = 242, 54.60%). Conversely, intermediate-term users (6–12 months) comprised 23.30% (n = 103) of the sample, and short-term users (<6 months) represented 22.10% (n = 98). Most respondents were prescribed multiple chronic medications, with 43.12% (n = 191) taking ≥6 medications and 36.30% (n = 161) taking 4–5 medications. Cardiometabolic disorders alone were the most prevalent chronic conditions among Ez-Pill users (n = 294, 66.40%), followed by cardiometabolic disorders presenting with systemic involvement (n = 133, 30.00%), while non-cardiometabolic disorders alone were reported by 3.60% of participants (n = 16). Prior to adopting the Ez-Pill service, the most common method of medication organization was the use of original retail bottles or commercial packaging (n = 196, 44.20%), followed by manual pill boxes or organizers (n = 141, 31.80%), while 23.90% (n = 106) of respondents reported no systematic method of organization.

3.3. Self-Reported Medication Adherence and Confidence

The descriptive findings indicate high levels of self-reported medication adherence and dosing confidence across the study cohort (Table 3). High scores were observed for confidence-related items, specifically taking the correct medication (4.54 ± 1.04), taking the correct dose (4.56 ± 1.04), and taking medications at the appropriate time (4.55 ± 1.03). Across all seven adherence-focused items, the composite total adherence score had a mean of 4.53 ± 0.79 out of 5.00, with 88.30% of responses indicating positive agreement. These consistently high descriptive scores indicated high self-reported adherence, although the concentration of responses at the upper end of the scale suggests a potential ceiling effect.

3.3.1. Multivariable Regression Analysis of Medication Adherence

The multivariable linear regression model for medication adherence was statistically significant but explained a modest proportion of the outcome variance. After controlling for all sociodemographic, clinical, and geographic covariates, two factors were significantly associated with medication adherence. First, residence in the Eastern region was significantly and negatively associated with total adherence scores compared to the Western Region baseline (B = −0.396, 95% CI: [−0.710, −0.082], β = −0.126, t = −2.477, p=0.014). This corresponded to a lower mean adherence score of approximately 0.40 points on a 5-point scale compared with Western Region residents. Second, long-term Ez-Pill use was positively associated with adherence scores. Participants who sustained their Ez-Pill utilization for more than 1 year exhibited significantly higher adherence scores compared to short-term users of less than 6 months (B = 0.276, 95% CI: [0.026, 0.526], β = 0.142, t = 2.172, p=0.030). This corresponded to a 0.28-point higher adherence score among long-term users. A similar association was observed among intermediate users (6–12 months), although it did not reach statistical significance (B = 0.254, p=0.067) (Table 4).

3.4. Patient Satisfaction and Service Experience

Descriptive findings indicated high levels of satisfaction with the Ez-Pill service (Table 5). The highest overall mean scores were observed for guests’ likelihood to recommend the service to family or friends (4.67 ± 0.93) and their clear understanding of how to use the packaging based on instructions (4.64 ± 0.93). High ratings were also observed for fast medication management (4.62 ± 1.01) and collection convenience (4.62 ± 0.96). Across all 12 items spanning quality, usability, and future retention, the composite total satisfaction score had a mean of 4.55 ± 0.77 out of 5.00, with 89.4% of responses falling into the positive agreement or likelihood categories. As observed with the adherence domain, the concentration of satisfaction scores at the upper end of the scale suggests a potential ceiling effect.

3.4.1. Multivariable Regression Analysis of Patient Satisfaction

The multivariable linear regression model for patient satisfaction was statistically significant but explained a modest proportion of the outcome variance. After controlling for all sociodemographic, clinical, geographic, and prior routine covariates, two factors were significantly associated with patient satisfaction. First, residence in the Eastern region was significantly and negatively associated with total satisfaction scores compared with the Western Region baseline (B = −0.295, 95% CI: [−0.571, −0.019], β = −0.107, t = −2.100, p=0.036), corresponding to a different of approximately 0.30 points on the 5-point satisfaction scale. Second, long-term Ez-Pill use was positively associated with satisfaction scores. Participants who used Ez-Pill utilization for more than 1 year exhibited significantly higher satisfaction scores compared with short-term users of less than 6 months (B = 0.278, 95% CI: [0.058, 0.498], β = 0.162, t = 2.487, p=0.013), corresponding to a 0.28-point difference in user-reported satisfaction. A similar association was observed among intermediate users (6–12 months), although it did not reach statistical significance (B = 0.229, 95% CI: [−0.010, 0.468], β = 0.114, t = 1.886, p=0.060) (Table 6).

4. Discussion

This study evaluated user satisfaction and self-reported medication adherence with the Ez-Pill automated MDMP service within a major community pharmacy chain in Saudi Arabia. The primary finding was the high level of self-reported adherence confidence and dosing safety, reflected in the composite adherence score. The highest scores were observed for confidence in taking the correct medication, taking the correct dose, and taking medications at the appropriate time. These findings are consistent with previous studies of MDMP services. For instance, Nair et al. [22] reported higher perceived medication adherence among primary care patients using a similar automated service over 6 and 12 months.

The high levels of confidence expressed by Ez-Pill users indicate that organizing oral medications into ready-to-administer, customized packages is associated with reduced self-reported regimen confusion and high self-efficacy. Nair et al. [22] attributed this behavioral shift to the simplification of the medication administration process. Rather than requiring patients or caregivers to coordinate instructions from multiple medication labels or packages, MDMP organizes complex regimens into unit-of-use pouches labeled with designated dosing times. This simplification may reduce the cognitive burden of complex medication regimens [4,27]. However, the broader literature presents mixed evidence regarding the clinical effects of MDMP. Systematic reviews, including those by Boeni et al., [21] note that while user satisfaction is consistently high, objective adherence improvements across diverse trial designs remain variable. Furthermore, real-world implementation of automated packaging frequently faces operational barriers, such as technical equipment maintenance, high upfront capital costs, increased pharmacy workflow demands, and the risk of packaging errors during manual intervention steps.

The clinical profile of the current cohort indicates a substantial medication burden, with most respondents taking four or more chronic medications and a large proportion taking six or more. Furthermore, cardiometabolic disorders alone or with systemic involvement accounted for the majority of chronic conditions. In patients managing complex medication regimens, unintentional nonadherence is associated with medication regimen complexity. As discussed by Lee et al. [23] medication regimen complexity is influenced not only by the number of medications but also diverse dosage forms, frequent dosing, and complex administration instructions. Lee et al. [23] utilized the Medication Regimen Complexity Index to show that pharmacy-led automated MDMP is associated with reduced baseline complexity scores, primarily by collapsing independent dosing schedules into shared, automated administration intervals. In our study, the fact that almost half of participants previously relied on original retail bottles and nearly a quarter had no systematic organization suggests that Ez-Pill was adopted by patients transitioning to more structured medication packaging.

When interpreting these elevated adherence and confidence scores, caution is warranted. Because the cohort exhibited high ratings across all items, these findings may reflect a ceiling effect commonly observed in self-reported voluntary surveys. Furthermore, reliance on self-reported measures rather than objective measures, such as electronic pill monitoring or longitudinal pharmacy refill records, may introduce social desirability and recall biases. Because the survey included only active users, survivor bias should also be considered: patients who found the service unhelpful or difficult to use may have discontinued it before data collection, potentially resulting in higher observed satisfaction and adherence.

Another important finding was the high level of patient satisfaction with the service. Patient satisfaction is relevant because it may be associated with medication adherence and long-term service retention. In our study, most participants reported high satisfaction with the automated system. This finding is consistent with Nair et al. [22] in which at least half of surveyed patients reported high satisfaction with the product and service and noted that it reduced the time required for daily medication management. Boeni et al. [21] emphasized that capturing humanistic outcomes, such as user opinion and satisfaction, provides an essential complement to clinical metrics when evaluating drug reminder packaging programs. The high satisfaction scores observed in our study indicate good acceptability of the service among surveyed users.

A key finding from our multivariable regression analysis is that long-term users who sustained their Ez-Pill utilization for more than a year exhibited significantly higher total adherence scores compared to short-term users of less than six months. This positive association may reflect greater familiarity with the service over time. Sustained use of pre-sorted pouch packaging may become incorporated into daily medication routines and reduce the cognitive effort required for medication management. Furthermore, prolonged enrollment may provide repeated interactions with community pharmacists, increase familiarity with the packaging, and strengthen trust in the service. Conversely, this longevity association may also reflect survivor bias, as satisfied users are inherently more likely to remain enrolled long-term.

In contrast, multivariable analysis revealed that residence in the Eastern region was negatively associated with total adherence and satisfaction compared to the Western Region baseline. Although speculative, these geographic differences may reflect regional variation in pharmacy staffing, delivery logistics, service implementation, or patient characteristics. Further investigation of these regional differences may help identify opportunities for service standardization.

Statistical significance should be distinguished from practical or clinical significance when interpreting these regression findings. While service tenure and geographic region reached statistical significance, the observed effect sizes were modest, reflecting scale changes of approximately 0.28 to 0.40 points on a 5-point Likert continuum. Furthermore, the overall regression models explained a modest proportion of total outcome variance (R2 < 10%). This limited explanatory power suggests that adherence and satisfaction are multifactorial and may be influenced by unmeasured variables, such as health literacy, socioeconomic status, family support, disease severity, and patient-clinician communication, which warrant future investigation.

Community pharmacists played an important role in service uptake, with most participants identifying a pharmacist or pharmacy staff member as their primary source of information about the service. This finding reflects the expanding patient-facing role of community pharmacists beyond traditional dispensing. A recent systematic review by Almontashiri et al. [28] confirms that the transition of pharmacists toward patient-centered community interventions is associated with improved medication adherence and patient satisfaction. In community settings, close proximity to patients equips pharmacists to screen and identify individuals suffering from extensive, complex therapies who stand to gain the most from immediate MDMP enrollment.

The positive adherence, safety, and satisfaction outcomes associated with the Ez-Pill service carry relevant implications for the ongoing healthcare sector transformation under Saudi Vision 2030. A core mandate of the Vision 2030 Quality of Life Program and the Health Sector Transformation Program is to shift the national healthcare framework from a reactive, acute-care model to a proactive, preventive, and value-based model. By supporting regimen organization and compliance among chronic cardiometabolic patients, community-based MDMP services can serve as an accessible supportive tool alongside primary care interventions. Poor medication adherence is a driver of unnecessary healthcare resource exploitation, including emergency department visits and avoidable hospital readmissions. As supported by the economic data syntheses of Boeni et al. [21] improving patient adherence levels within specific chronic disease cohorts is associated with reduced overall healthcare facility costs. In the context of healthcare restructuring in Saudi Arabia, scaling automated MDMP services like Ez-Pill across community pharmacy networks complements state-led digital initiatives, most notably the national e-prescribing platform, Wasfaty. Studies have shown that Wasfaty improves access to medication, facilitates accurate tracking of patient prescriptions, and reduces dispensing errors [29,30]. While the Wasfaty platform decentralizes prescription fulfillment from public clinics to private community pharmacies, layering automated MDMP solutions onto this digital infrastructure offers a supportive mechanism to help transitioned patients remain engaged with their long-term therapies. Ultimately, this collaborative approach leverages private-sector pharmacy networks to support public health objectives, aligning with the preventive care goals of Saudi Vision 2030.

This study has several strengths. To our knowledge, it is among the first to evaluate the real-world use of an automated MDMP system across multiple regions of Saudi Arabia, extending beyond localized or city-specific cohorts. The study achieved a high response rate and exceeded the prespecified minimum sample size. The survey domain scales demonstrated high internal consistency, with both satisfaction and adherence measures exceeding commonly used psychometric thresholds. Multivariable linear regression models were also used to examine associations while adjusting for sociodemographic, geographic, and clinical covariates. Ultimately, this work bridges private-sector pharmacy innovations with the public health mandates of Saudi Vision 2030, specifically aligning with the Quality of Life Program and integration with the national Wasfaty e-prescribing ecosystem.

The study also has some limitations. First, the cross-sectional design precludes inferring causality, and relying on self-reported online survey data, rather than objective measures like pharmacy refill records or standardized clinical scales may introduce recall bias, social desirability bias, and ceiling effects. Second, restriction of the sample to active users introduces selection and survivor biases and may overestimate satisfaction by excluding former users who discontinued the service. Third, generalizability is limited by convenience sampling, the concentration of participants in the Western Region, exclusion of the Northern Region, the male-predominant sample, and the potential underrepresentation of older or less digitally literate individuals. Finally, the absence of a non-automated control group limits comparative effectiveness evaluations, and residual confounding from unmeasured variables cannot be fully ruled out despite multivariable adjustments.

5. Conclusions

This cross-sectional study demonstrates positive associations between the use of the automated Ez-Pill service and high self-reported satisfaction, adherence, regimen clarity, and dosing confidence among active users in Saudi Arabia. Frontline community pharmacists played a key role in driving service adoption, reinforcing their value in patient-centered digital care. However, because the study relied on self-reported survey data from current service users rather than standardized clinical adherence tools or objective metrics, these findings reflect perceived user experiences and statistical associations rather than proven causal effects, clinical effectiveness, or broad nationwide acceptance. Future longitudinal or controlled studies utilizing objective adherence metrics, such as longitudinal pharmacy refill data or electronic pill counts, are recommended before drawing definitive conclusions regarding the clinical or economic impact of scaling such services.