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Abstract
Objectives To assess the patients’ awareness of their rights, associated factors and the practice of these rights by the medical team from the patients’ perspective at Tikur Anbessa Specialized Hospital.
Design
An institution-based prospective cross-sectional study was carried out.
Setting The research was conducted from January to May 2021 in a specialised hospital in central Ethiopia.
Participants 392 people who had elective surgery were included in this study; 217 men and 175 women responded. Systematic random sampling was employed to choose the research subjects, and K (skip interval) was calculated using the 3-month surgical waiting list at the hospital. Patients under the age of 18, those with severe illnesses, those who were not inpatients, and those who had diagnosable mental conditions were not eligible.
Primary and secondary outcome measures A structured questionnaire was administered in a face-to-face interview by trained data collectors after surgery at the surgical ward and analysed by using SPSS V.24. Bivariate and multivariable regression analyses were used to identify the associated factors. A p<0.05 was used to judge the significance of the association.
Result Patients’ awareness about their rights was 76%. Educational level, place of residency and the number of hospital admission were significantly associated with patients’ awareness. The majority (83.2%) of patients reported that health providers had poor practices regarding patient rights.
Conclusion Most patients were unaware of most of their rights, and the majority of patients reported that healthcare providers did a poor job of protecting their patients’ rights. To advance the application and understanding of patient rights, access to various facilities, patient and healthcare provider education programmes, and patient rights information technology must be improved.
- Adult anaesthesia
- ACCIDENT & EMERGENCY MEDICINE
- SURGERY
Data availability statement
Data are available on reasonable request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
This study used a standardised tool to assess the study’s outcome variable.
Using Cronbach’s alpha, the validity of the data collection method was examined in this study.
The sample size for this study is larger than average for a single-centre study.
Due to time and financial constraints, this is a single-centre study.
Introduction
The Universal Declaration of Human Rights which is established in 1948 recognises ‘the inherent dignity’ and the ‘equal and inalienable rights of all members of the human family’. It is on the basic concept of the fundamental dignity and equality of all human beings, that the notion of patient rights was developed.1 Patient rights are a basic human right and a quality assurance that measures and protects patients against abuse and promotes ethical practice.2 Therefore, improving the rights of patients is considered a priority in the provision of medical services and one of the medical indices in every society.3 According to WHO, each country should make its bill by its own cultural and social needs to promote and support patients’ rights.4 The WHO cautions that ‘the existence of patients’ charters without efforts to raise awareness among patients does not improve the quality of healthcare’’.5 In giving effective care, the patient generally demands their rights, while the hospital is responsible for fulfilling this particular expectation.6
In Ethiopia, every specialised hospital has standard requirements of patient rights. Patients in specialised hospitals have the following components of rights such as; healthcare and respect as a human being, informed consent, hygienic environment, and health education, choice of care, participation and representation, and the right to redress grievances.7
Patients awareness of their rights increase the quality of healthcare services, decrease costs, more prompt recovery, decrease the length of stay in hospitals, lower the risk of irreversible physical and spiritual damages, and more importantly, increased the dignity of patients through informing them about their rights to participate in decision making.8 Though there are bills, charters and hospital documents regarding patients’ rights available in different settings, the awareness among patients about these documents may be limited.9 Patients’ good level of awareness rates of their rights varied from 5.8% to 76.8% in a study done in Iran10 and 5% in a study done at Rawalpindi, Pakistan.4 Patients especially in the underdeveloped country remain submissive, had poor (30.5%) knowledge of their rights, and those even with good knowledge (10.1%)8 cannot claim their rights in a healthcare system and regard it as a favour from healthcare setting and staff rather than their right.11
Preserving these rights is vital to improving the quality of healthcare services,12 however, the right of a patient can be violated from the moment of admittance and affect the course of hospital stays.10 Lack of respect for patients’ rights may lead to hazards to the security and health condition of patients. It may ruin the relationship between the staff and patients that consequently decreasing efficiency, effectiveness and suitable care of patients.8 A study done in Egypt about the practice of patient rights by health providers is at a poor level. Fifty-three per cent of patients in Alexandria main university hospital and 71% of patients in Matrouh general hospital reported that health workers had poor practice.13
However, the level of awareness and practice of patient rights have not been studied in Ethiopia. Therefore, this study aims to assess the awareness status of patients about their rights and its practice by the health provider and helps to improve its practice according to the specialised hospital requirements of patient rights. Moreover, the information obtained from this study will help healthcare decision-makers, clinicians, health system leaders and policy makers to intervene to improve awareness of the rights of the patient and improve patient participation in the decision-making process, thereby improving the quality of healthcare services towards the medical ethics on the surgical procedure. The study also provides a basis for further studies for those interested intellectuals to perform a detailed search.
Objective
General objective
To assess patients’ awareness of their rights, the practice of these rights by health workers from the patients’ perspective, and factors affecting patients’ awareness of their rights among elective surgical patients at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia.
Specific objectives
To determine the surgical patients’ awareness about their rights.
To assess the practice of health workers towards patient rights from the patients’ perspective.
To identify factors affecting patients’ awareness of their rights.
Method and material
An institutional based cross-sectional study was conducted from January to May 2021. The study was conducted at Tikur Anbessa Specialized Hospital, in Addis Ababa, Ethiopia. Tikur Anbessa Specialized Hospital is the largest referral hospital in the country. It is the main teaching hospital for both clinical and preclinical training of most disciplines. It is also an institution where specialised clinical services that are not available in other public or private institutions are rendered to the whole nation. The various departments, faculties and residents under specialty training in the school of medicine provide patient care in the hospital. All adult patients who were admitted to undergo elective surgery at Tikur Anbessa Specialized Hospital were the source of the population. All patients who undergo elective surgery were included in the study. Patients below the age of 18 years, critically ill patients, outpatients and patients with known psychiatric disorder such as (schizophrenia, depression, obsessive–compulsive disorder) were excluded from the study. This study was reported in line with Strengthening the reporting of cohort cross-sectiona, and case-control studies in surgery (STROCSS)criteria and registered on www.researchregistry with research registry 7442 which is available at Browse the Registry—Research Registry.
Sampling technique
Systematic random sampling was used to select study participants by using a skip interval of K=N/n. There were 806 patients on the operation waiting list in the Hospital for the coming 3 months. Therefore, K=806/403=2 (skip interval) and the first study participant (randomly start) were selected using the lottery method from the daily elective surgery. Then, every two cases from the daily surgery were included in the study.
Data collection
A validated tool and the Ethiopian Patient Right Policy were used to develop a pretested questionnaire that was used to collect the data between 27 January 2021 and 10 May 2021 (online supplemental file 1). The data collection was done by four trained BSc level nurses using a structured questionnaire which was developed based on Ethiopian standard comprehensive specialised hospital requirements of patient rights.7 and adopted from previously published studies.12 It consists of three parts: the sociodemographic characteristics of the patient, awareness of patients towards their rights using a four-point Likert scale from 1 (not at all aware) to 4 (completely aware), and the practice of patient rights by health workers from the patient’s perspective using 3-point scale (yes, no and do not know) question. Consent was given for the patient after detailed information on the study topic and the objectives of the study, then the questionnaire was administered to patients who were included in the study after surgery at the surgical ward after the patient cooperated to communicate. The principal investigator and supervisor were checked the completeness of data every day.
Supplemental material
Data processing and analysis
After collection, data were summarised and coded. Data were entered into SPSS Windows V.24 for data cleaning up and analysing. Data cleanup was performed by checking for frequencies and missed values and variables. A descriptive statistical analysis was used to show the characteristics of the participants. Binary logistic regression was used to identify factors associated with the patient’s level of awareness of patients' rights. The cut point used during bivariate analysis was a p<0.2 considered as fit for multivariable analysis. The crude and adjusted ORs (AORs) with their corresponding 95% CIs were computed. P values of less than 0.05 were considered significant. The variance inflation factor was used to test for collinearity between independent variables, and association was performed for variables that were not collinear with each other. The analysis result was presented as frequencies, means, SD and percentages using tables and pie charts.
Sample size determination
The sample size of the study was determined by using a single population proportion formula, n=z2p (1−p)/d2. We did not find similar study in Ethiopia, so we took p=50% which is proportion for unknown prevalence. With 95% confidence level and Z=1.96, 5% margin of error (d). n=384, n=384+19 (allowed 5% for non-respondent rate); n=403.
Where n=required sample size.
Z=level of confidence (1.96 for 95% confidence level).
p=expected proportion 50%.
d=margin of error 5%.
Patient and public involvement
No patient involved
Operational definitions
Awareness
Refers to the knowledge of and ability to recognise the patients’ rights; it can be determined by using the questioner’s cumulative score of response. The percentage score is categorised as a dichotomous variable.11 12 14
In total, 14 questions with four possible answers each were asked, adding up to a total score of 56. The outcome variable awareness was categorised as follows: if the participant received a score below 28 (or 50%), it was assumed they were ‘unaware of patient rights’; if they received a score ≥28 (50%), it was assumed they were ‘well aware’ of them, in accordance with previous studies.8
Practice
Refers to behaviours regarding patients’ rights during a health worker-to-patient health interaction.11 According to prior research, out of a total of 14 practice items contained in the questionnaire, a practice is classified as ‘good practice’ if the practitioner practices ≥7 (50) and ‘poor practice’ if the practitioner practices <7 (50%).13
Elementary occupation’s
According to the International Labour Organization’s definitions, elementary occupations include cleaners and helpers who perform a variety of tasks in private homes, hotels, offices, hospitals and other establishments, as well as in airplanes, trains, coaches, trams and other similar vehicles, to keep the interiors and fixtures clean, and who hand-launder and press clothing and textiles.
Result
Sociodemographic characteristics of study population
A total of 392 patients participated in this study (general surgery—126, gynaecology—57, orthopaedics—115, urology—42, gastroenterology—22, Ear Nose and Throat (ENT)—18, cardiothoracic—12) with a 97.27% response rate. Overall, 217 respondents (55.4%) were male. The study participant’s ages ranged from 18 to 78 years with a mean of 40.21±16.05. In terms of marital status, 243 (62%) of respondents were married. About 261 people (66.6%) lived in cities. A quarter of the 102 respondents (26%) were farmers. About 188 (48%) patients knew the existence of a charter of patient rights. Mass media was the main source of knowledge for the charter of patient rights 111 (28.3%) (table 1).
Demographic and baseline characteristics of the study participants and their source of knowledge about patient rights, Addis Ababa, Ethiopia, 2021
Patients’ awareness of their rights
In this study, patient’s knowledge of their rights was examined. A total of 298 (76%) were aware of their rights, while 94 (24%) were not (figure 1).
Awareness status of the patients about their rights, Addis Ababa, Ethiopia, 2021.
As shown in table 2, 90.5% of respondents were aware of their right to receive medical care without being subjected to discrimination, 80.4% were aware of their right to respectful treatment, 74.5% were aware of their right to know the name and position of the medical team, 71.7% were aware of their right to medical report confidentiality and 70.4% were aware of their right to privacy during examinations and procedures. Patients were less aware of their rights to obtain a copy of their medical records (10.8%), to receive an explanation of their complaint and any unexpected results of the treatment they received (10.0%), to participate in care decisions, and to select the course of treatment (8.1%).
Patients' awareness about different items of the charter of their rights, Addis Ababa, Ethiopia, 2021
The practice of patient rights
Out of 392 patients, 83.2% made a point of saying their healthcare providers had poor practices, and 16.8% said they had good practices (figure 2).
The practice of patient rights among health providers from patients’ perspective, Addis Ababa, Ethiopia.
As shown in table 3, the most commonly observed patient rights are to receive information about the financial costs of healthcare services (87.2%) and to consent to a procedure in writing before receiving treatment (70.9%). On the contrary, only 20.7% of participants said that healthcare providers introduced themselves, 19.6% said that they were informed of their options before finishing the treatment plan, 6.6% received the necessary personal items, 3.6% were asked for permission to use their data for research and 1.8% said that they were given information about grievance redress. Only 1% of patients reported receiving a summary of their rights.
Practice of patient’s rights among health professionals from patients’ perspective Addis Ababa, Ethiopia, 2021
Factors affecting patients’ awareness of their rights
A multivariable regression analysis revealed a significant relationship between patients’ knowledge of their rights and their educational status, place of residence and the number of hospital admissions. Patients with a university or college education had better awareness than illiterate patients with the odds of 16.66 (AOR 16.66, 95% CI 3.00, 92.47). Patients with a secondary school education were 3.88 times more aware than patients who could not read or write (AOR 3.88, 95% CI 1.47 to 10.20). Patients in urban areas were 3.43 times more aware than those in rural areas (AOR 3.43, 95% CI 1.54 to 7.65). Patients admitted three or more times had 10.13 times more awareness than patients admitted only once (AOR 10.13, 95% CI 2.24 to 45.76) (table 4).
Factors affecting patients’ awareness about aspects of patient rights Addis Ababa, Ethiopia, 2021
Discussion
Patients’ awareness of their right
In this study, patient’s knowledge of their rights and healthcare professionals’ practice of those rights were evaluated. The results of this study revealed that 59.6% of respondents had a good awareness of their rights with the overall awareness score of patients 33.37±8.618 (59.6%) out of the maximum score of 56. In terms of the practice of patients’ rights, the majority of patients (83.2%) reported that healthcare providers' practice of patients’ rights was poor.
In our study, 48% of the respondents knew about the patient rights charter which was in line with the study done in Matrouh general hospital in which patient rights charter awareness was 47%.15 On contrary, the prevalence of patient rights charter awareness in our study was higher than those of an Egyptian study in which 23.7% of patients were aware of patient rights charter,12 and only 4.6% of patients were aware in research done in Sudan.16 This could be because, in our study, participants in urban areas (66.6%) outnumbered those in rural areas.17 However, in a study conducted in Sudan, approximately (71.5%) and Egypt, approximately (63.6%) of respondents lived in rural areas. Another factor that could be considered is the patients’ educational level. In our study, (17.1%) of patients had a higher education, compared with (5.5%) in Egypt and (9.2%) in Sudan.
Mass media was the main source of information about patients’ rights charter in our study, which is supported by a study done in India which covered about 58%,18 and a study in south Egypt 89.4%.19 However, our study was contrasted with the study in Riyadh, Saudi Arabia,20 and the study in upper Egypt, where a higher proportion of patients received information from physicians and nurses.12
Our study found that the majority of the study participants were aware of their rights, including the right to receive impartial medical care, the right to be respected by the medical staff, the right to privacy during examinations, the right to the confidentiality of their medical records, and the right to know the identity and name of their doctors. The findings correspond to those of a study carried out in Egypt,12 Iran8 and India.21 On the contrary, patients were less aware of the right to participate in healthcare decisions and choosing the treatment plan, the right to be provided sufficient information about patients’ illness, and any unanticipated outcomes of the treatment process. These findings are supported by a similar study conducted in Pakistan,4 Iran,8 Egypt12 and Iraq.22 This may be due to the paternalistic relationship between the healthcare providers and the patients.23
In this study, patients’ awareness of their right to obtain their medical records is low (10.8%), which is consistent with Mastaneh and Mouseli study.8 This could also be attributed to the paternalistic model. Healthcare providers may believe that the right to access a patient’s medical record confers authority on them, and they may refuse to inform the patient of this right.
According to multivariable analysis, educational level is significantly related to patient awareness of their rights which is in line with a study done in Iran.24 Given that as one’s educational status improved, so did one’s knowledge of various topics. Furthermore, because they have knowledge pursuing behaviour, educated people are close to information from media and searches.
Patients living in rural areas had lower awareness than urban residents, which is comparable to a study conducted in Iran.8 This could be due to people living in rural areas having less access to information technology and media, as these are critical in informing the community about patients’ rights.
This study also showed that patients’ right awareness levels increased along with the number of hospital admissions. A study conducted in Egypt backs up the findings.12 This might be because as the number of hospital admissions rises, patients may become more familiar with the facility’s policies and procedures. The total awareness score and the number of hospital admissions did not, however, appear to be statistically associated in studies conducted in Iran10 and Saudi Arabia.22
The practice of patient right by health professionals
Regarding the exercise of patient rights, approximately 12.8% of patients claimed that medical staff failed to inform them of the financial cost of medical services, which is consistent with a study conducted in Upper Egypt, which discovered that 10.3% of patients were not informed of the cost of medical care.12
Concerning informed consent, only 48.2% of patients received all the essential information about illness and treatment process, which is comparable with the study conducted in Uganda,11 and a study done in Egypt found that about 48.8% were received all necessary information before signing the consent form.12 A study done in India found that 60% of patients said that the medical team provides information on illness and treatment process, which is higher than the current study.14
This study showed that 55.4% of the respondents reported that their privacy was protected which is lower in comparison with a study done in Uganda, which was about 82.4%,11 and a study done in India, which was 88.3%.3 One possible explanation is that Tikur Anbessa is a teaching hospital, and when healthcare providers teach their students, they may unintentionally reveal patients’ privacy.
The study showed about 60.7% of patients said that the health professionals treated them with respect which was in line with a study done in Sudan in which 60.5% of the patients were treated with respect,16 and in Egypt 59.7%.12 On the contrary in a study done in India 90% of patients said that they receive medical care with respect and dignity which is a little more than our finding.25 This difference could be due to an increased workload on medical staff in Tikur Anbessa Specialized Hospital.
In this study, only 20.7% of patients said that the health caregivers introduce themselves which is less than the finding of a study done in Egypt in which about 85% of patients.12 This finding is much lower than the result of a study done at Alexandria university hospital and Matrouh general hospital, Egypt which found that 94%–89% of patients indicated that the health workers introduce themselves, respectively.13 This difference could be due to an increase in the workload of Tikur Anbessa Specialized Hospital. The other reason also may be healthcare providers withhold information from patients as they think it can limit their authority.
This study showed that the practice to submit complaints regarding healthcare (1.8%) and a summary is given about patient rights (1%). This result was in line with a study conducted in Egypt, which found that only 1.9% of people used their right to a remedy for grievances.12 A study conducted in India,21 which was higher than our study, also discovered a low practice rate of 24%.15 This might be due to a deficiency of awareness and attitude of the health professional towards these rights.
Conclusion and recommendation
Most of the participants in the study were aware of their right to receive healthcare free from discrimination and to be treated with respect. However, the majority of patients were unaware of their rights to medical record access, access to information about their illness, and participation in treatment decision-making. The number of hospital admissions, the place of residence and the level of education all had an impact on awareness.
Most patients reported that healthcare providers did a poor job of upholding their patients’ rights. The rights to full care and to know the price of medical services were the ones that were most frequently exercised. Less frequently exercised were the rights to grievance redress, involvement in illness-related decision-making, request for permission to participate in research and receipt of a list of patient rights. To advance the application and understanding of patient rights, it is necessary to improve access to various facilities, patient and healthcare provider education programmes, and information technology about patient rights.
Data availability statement
Data are available on reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
Ethical clearance and permission were obtained from Addis Ababa University College of health science Institutional review board before the start of the study.Ethics ID/approval number AAUMF 12/2021. Participants gave informed consent to participate in the study before taking part.
Acknowledgments
We would like to give credit to study participants, Addis Ababa University and facilitators for their unreserved cooperation in the process of this study.
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors KD: conceptualisation, methodology, formal analysis, investigation, resources, data curation, writing—original manuscript draft, writing—review and editing, visualisation, supervision, project administration. BG: took part in methodology, formal analysis, investigation, writing review and editing, visualisation. KEO: manuscript writing, paper revision, editing, methodology. KGB: manuscript writing, paper revision, editing, methodology. MH: took part in methodology, formal analysis, investigation, writing review and editing, visualisation. From now on Kumlachew Geta the coresponding author will act as a guarantor for the overall content of this paper.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.