Assessment of patients’ awareness of their rights in teaching hospitals in Iran

Abstract

Introduction

Respecting patients’ rights is an essential component in health care. Passing a regulation is not a guarantee for the protection of patients’ rights. This article aimed to assess patients’ awareness of the contents of the Patient’s Bill of Rights in Iran and to determine if they had received a service compatible with their rights charter.

Methods

This is a descriptive study in 202 hospitalised patients. A questionnaire was used, and associations between variables were examined using Pearson’s correlation test. The significance level was p < .05.

Results

The patients’ ages ranged from 18 to 87 years of age, 33% were male and 79% were married. Patients’ knowledge was lowest regarding the need for consent for the treatment process and was highest regarding the patient’s right to know the expertise of the treatment team. The mean of patients’ knowledge was 77.56%. As for patients’ exercising their rights, the highest score belonged to the patient’s right for attending doctors and treatment team’s confidentiality; the lowest score belonged to the right to receive necessary information about probable complications, other treatment options and participation in the final selection of treatment method. The mean score of patient satisfaction was 8.06 (out of 11). There was no significant relationship with their education level or the number of admissions.

Conclusion

Health-care professionals can provide care based on patients’ rights, and their knowledge of patients’ rights needs to be evaluated. Educational programmes, leaflets, booklets and posters can be helpful in this regard. In addition, professional organisations and the Ministry of Health need to be more sensitive to this issue.

Keywords

Patients’ rights awareness patient satisfaction

Introduction

As concerns about patient choice increase, respect for patients’ values and preferences become more pressing, and patients’ expectations become higher as they demand the best possible service. Patients’ rights have recently been introduced into the field of health and medical practice, and patients are now much more aware of what they can expect from their health-care professionals.^1,2 The fundamental reason for the importance of patients’ rights is that respecting such rights is an essential part of providing good health care.^3,4

Legislation on patient’s rights has been passed throughout the world since the Human Rights Act was published by the United Nations in 1948.⁵ However, there are many declarations on patients’ rights such as ‘The Declaration of Lisbon’ by the World Medical Association, and many developed countries, including Finland, the Netherlands, Lithuania, Denmark, Norway, France, the USA, the UK, Italy and New Zealand, have drawn up legislation covering patients’ rights.^3,4,6–10 It is obvious that passing a regulation is not a guarantee for the protection of patients’ rights. It seems that young professionals who work in education centres are much more familiar with patients’ rights. However, Yilmaz reported that teaching hospitals sometimes ignore patients’ rights, as they may expose a patient’s body in front of students without the patient’s consent and examine them multiple times for the purposes of teaching.¹¹

As one of the ethical aspects of patient care is paying attention to patients’ rights and requests, notifying patients of their rights is considered to be one of the main foundations of ethical practice. It is important to note that although instructions and charters related to patients’ rights are similar in different countries, as they contain general principles, there are certain variations in details according to cultural, religious and local differences. That is why the World Health Organization’s (WHO) research group, who are investigating the field of patients’ rights, recommends that each country defines a charter according to their own specific cultural requirements and social needs, and that the health system of each country adheres to the principles contained in their particular charter.

In Iran, physical, psychological, spiritual and social health are the most important dimensions of an individual’s existence, and their provision based on Article 29 of the Constitution is considered a major commitment in the Islamic Republic of Iran. The Ministry of Health and Medical Education is responsible for providing optimal health services for the whole of Iran.

The health system in Iran is composed of the National Health System and the private sector. In most parts of the country, including rural parts in the 33 different provinces across the country, public and national medical services are accessible, and are organised by the Ministry of Health and Medical Education.

Accordingly, the Patients’ Rights Charter, with its aim of explaining health-care recipients’ rights and promoting ethical standards, is one of the most important aspects of health-care services. The treatment of patients ethically was developed into a rights charter within a three-year period, with the participation of both experts and beneficiaries. After the approval of the Policy Council, Ministry of Health and Medical Education in 2002, it was sent to all health centres.¹²

The general principles of the Patients’ Rights Charter in Iran are:

‐ The patient has the right to expect prompt treatment and optimal, efficient and respectful care from the treatment group, regardless of ethnic, cultural or religious factors.

‐ The patient has the right to know, if desired, the hospital, physicians, nurses, and other members of the treatment group.

‐ The patient has the right to ask for necessary information from the attending physician in person or, if desired, by one of his/her relatives about the stages of diagnosis, treatment and his/her disease progression. In medical emergencies, this should not lead to delays in continuing treatment or a threat to the patient’s life.

‐ The patient is entitled to receive necessary information, according to his/her understanding, about the probable side effects of his/her treatment, or when using alternative methods before examination and initiation of treatment by the attending physician, and to participate in the final treatment method choice.

‐ The patient has the right, if desired and not a threat to public health according to law, to announce his consent or to go to another treatment centre.

‐ The patient has the right to ensure confidentiality of the contents of his/her medical records, the results of clinical examinations and consultancy, except in cases in which an inquiry is made of the treatment team according to legal guidelines.

‐ The patient is entitled to have the physician’s and other health-care team members’ confidentiality. Therefore, the presence of people who do not take part directly in treatment procedures will be dependent upon the patient’s permission.

‐ The patient has the right to have accessibility to the attending physician and other significant members of the treatment team during hospitalisation, transportation and following discharge.

‐ The patient has the right to announce his/her willingness to participate in treatment or to refuse to continue cooperation at various stages of the research process by acquiring complete information about the educational and research activities of the hospital that are relevant to his/her health and treatment.

‐ If the patient needs to be transferred to another hospital, the patient has the right to be informed of the treatment team’s skills, rates and insurance coverage in the destination medical centre in advance.

Regarding the Legal Medicine Organization report, one of the main causes of complaint against physicians is professional misconduct and an unacceptable relationship between patients and their health care providers. Hence, we decided to assess patients’ awareness about the contents of the Patients’ Bill of Rights in Iran, and whether they received a service that was compatible with their rights charter.

Materials and methods

This study was a cross-sectional descriptive study aimed to assess patients’ awareness of their rights, and also their opinions about whether they exercised these rights during their hospitalisation. A convenience sample of 202 patients was recruited for this study. The subjects were selected by random sampling among patients in hospitals affiliated to Shahid Beheshti University of Medical Sciences (the second ranked university in Iran) who were admitted to different wards, including surgery, internal medicine, emergency, obstetrics and gynaecology. The inclusion criteria were the following: full consciousness, aged >18 years of age, able to give consent and not part of a health provider team. Participants were given sufficient information about the aims of the study, and verbal informed consent was obtained before gathering data. The subjects were assured of anonymity and confidentiality of their data.

For a prevalence of 75% awareness regarding patients’ rights with 6% error and a confidence level of 95%, the sample size was estimated as 200. A questionnaire was designed to collect the data. The questionnaire had three sections: the first part collected the patients’ demographic information, the second part asked about the patients’ awareness of the rights questionnaire designed according to elements of the Patients’ Rights Charter in Iran, and the third part concerned the patients’ opinion of whether they had received suitable care in accordance to their rights during hospitalisation. The answers to each question in part 2 were yes/no/no idea, and in part 3, a score of 1–11 was obtained. Data were gathered by two medical students within about eight months. The content validity of the questionnaire was assessed by a group of experts, and the reliability was 0.84. A pilot study was performed on 20 patients, and accordingly some changes were made to the questionnaire.

After coding, the data were analysed using SPSS software (v18), and the data were presented using descriptive statistics, such as frequencies and percentages. Interval and ratio variables were presented in the form of means and standard deviations. Mean comparison was performed by Student’s t-test for variables with two groups, and analysis of variance and Kruskal–Wallis test for variables with more than two groups. Significance level was chosen as p < .05

Results

This study aimed to assess patients’ awareness of their rights and also to assess if they had received care in accordance with their rights.

A total of 202 patients, who were hospitalised in the Shahid Beheshti University of Medical Sciences educational hospitals, were studied. However, it is not statistically significant. There are missing data because some questionnaires were not filled out completely by participants.

The patients’ demographic characteristics are shown in Table 1. The age of the patients ranged from 18 to 87 years. The mean age was 40.09 years. About one third of the sample group were male (33.67%). Approximately three-quarters (78.79%) of the patients were married, and more than half had an educational level higher than high school (58%). The education level of the sample group is shown in Table 1. In terms of the participants’ employment status, 10% were employees, 25.26% were self-employed, 50% were housewives and 14.74% were professionals.

Table 1.

Frequency distribution of demographic characteristics of the sample group.

Variables	Number	Percent
Sex
Male	66	33.67
Female	130	66.33
Marital status
Single	31	15.66
Married	156	78.79
Widowed	8	4.04
Divorced	3	1.52
Level of education
Illiterate	19	9.5
Elementary	25	12.5
Intermediate	26	13
High school	14	7
College	80	40
Master and higher	36	18
Job status
Employer	20	10
House keeper	100	50
Non-governmental jobs	51	25.26
Others	29	14.74
Number of hospital admissions
Once	68	34
Twice	57	28
Three times and more	77	38

The number of hospital admissions ranged from 1 to 30 times. The mean number of admissions was 3.12, as shown in Table 1. Patients’ awareness and their opinion about receiving suitable care in different items of the rights charter are shown in Table 2. The knowledge of patients was lowest (45.65%) regarding the need to obtain the patient’s consent for the presence of people who are not directly involved in the treatment process at the patient’s bedside, and it was highest (90.63%) regarding the patient’s right to know the expertise of the treatment team, tariffs and insurance coverage if the patient is required to be transferred to another hospital. The mean general knowledge of the Patients’ Rights Charter in this study was 77.56%.

Table 2.

Patients’ awareness and their opinion about receiving suitable care in different items of their right charter.

Item	Awareness	Opinion about receiving suitable care (score 1–11)
– The right to expect prompt treatment and optimal, efficient and respectful care from the treatment group regardless of ethnic, cultural and religious factors.	Total: 197	Total answers: 180
	Yes: 88.32%	Mean: 8.15
	No: 2.54%	SD: 3.01
	No idea: 9.14%	SE: 0.22
– The right to know, if desired, the hospital, physicians, nurses and other members of the treatment group.	Total: 200	Total answers: 183
	Yes: 85.5%	Mean: 7.89
	No: 4%	SD: 3.32
	No idea: 10.5%	SE: 0.24
– The right to ask necessary information from attending physician personally or, if desired, by one of his/her relatives about stages of diagnosis, treatment and his/her disease progression. In medical emergencies, this should not lead to delay in continuing treatment or a threat to patient’s life.	Total: 199	Total answers: 184
	Yes: 88.44%	Mean: 8.13
	No: 3.52%	SD: 3.17
	No idea: 8.05%	SE: 0.23
– The right to receive necessary information according to his/her understanding about the probable side effects of treatment or using other methods before the examinations and initiation of treatment from attending physician and to participate in choosing the ultimate treatment method.	Total: 190	Total answers: 184
	Yes: 78.42%	Mean: 7.41
	No: 8.95%	SD: 3.61
	No idea: 2.63%	SE: 0.28
– The right to ensure confidentiality of the contents of his/her medical record, the results of clinical examinations and consultancy, for privacy, except in cases in which an inquiry is made of the treatment team according to the legal duties.	Total: 191	Total answers: 165
	Yes: 80.1%	Mean: 8.93
	No: 4.19%	SD: 3.15
	No idea: 15.71%	SE: 0.24
– The right, if desired and not a threat to public health according to law, to announce his/her consent at the end of treatment or go to other treatment centres.	Total: 190	Total answers: 147
	Yes: 66.84%	Mean: 8.46
	No: 8.95%	SD: 3.25
	No idea: 24.21%	SE: 0.26
– The right to ensure accessibility to attending physician and other main members of treatment team during hospitalisation, transportation and after discharge.	Total: 184	Total answers: 158
	Yes: 88.04%	Mean: 7.95
	No: 5.43%	SD: 3.36
	No idea: 6.52%	SE: 0.27
– The right to have physicians’ and other health-care team members’ confidentiality.	Total: 190	Total answers: 159
	Yes: 77.89%	Mean: 9.01
	No: 11.05%	SD: 3.07
	No idea: 11.05%	SE: 0.24
– The presence of other people who do not directly take part in treatment procedure will depend upon patient’s permission.	Total: 184	Total answers: 146
	Yes: 45.65%	Mean: 7.55
	No: 24.64%	SD: 3.88
	No idea: 29.89%	SE: 0.32
– The right to announce his willingness and personal satisfaction to participate in treatment or refuses to continue his/her cooperation in various stages of the research by acquiring complete information about educational and research activities of the hospital that are effective on his/her health and treatment.	Total: 191	Total answers: 154
	Yes: 63.35%	Mean: 7.96
	No: 16.23%	SD: 3.40
	No idea: 20.42%	SE: 0.27
– If the patient should be transferred to another hospital, the patient has the right to be informed of treatment team’s skills, rates and insurance coverage of health services in destination medical centres in advance.	Total: 192	Total answers: 161
	Yes: 90.63%	Mean: 8.15
	No: 3.13%	SD: 3.52
	No idea: 6.25%	SE: 0.28

According to this study, the rights that >85% of subjects were aware of are:

‐ Right to be informed of treatment team skills, rates and insurance coverage in destination medical centres, if the patient needs to be transferred (90.63%).

‐ Right to ask necessary information of the attending physician (88.44%).

‐ Right to expect prompt treatment and optimal, efficient and respectful care from the treatment group (88.32%).

‐ Right to ensure accessibility to attending physician and other treatment team members during hospitalisation, transportation and after discharge (88.04%).

‐ Right to know, if desired, the hospital physicians, nurses and other members of the treatment group (85.5%).

Full details are shown in Table 2. As for patients exercising their rights, the highest score belonged to their right for attending doctors’ and treatment team’s confidentiality (9.01/11), and the lowest belonged to their right to receive necessary information about probable complications, other treatment options and participation in the final selection of treatment method (7.41/11). The mean score of patient satisfaction for all the items in the questionnaire was 8.06 (out of 11), with a standard deviation of 2.36, mean error of 0.17 and median of 8.45. The scores of 90% of the subjects ranged from 2.27 to 11.

The confidence interval (CI) was determined at 95% with the mean 7.72–8.40. A non-parametric Wilcoxon signed–rank test was significant compared with the constant number 6. Patients’ awareness and their opinions about receiving suitable care in different items of their rights charter are shown in Table 2.

Analysis of variance showed that the mean score of patient’s satisfaction of the previously mentioned questions did not show any significant relationship (p = .367) with their education. A Kruskal–Wallis non-parametric test did not find any significant difference either. Analysis of variance showed that the mean score of patient’s satisfaction of the previously mentioned questions did not show a significant relationship (p = .09) with the number of admissions. In addition, a Kruskal–Wallis non-parametric test did not find any significant difference.

Discussion

Patients’ rights have recently become the centre of national attention in the practice of medicine, and these are different in various countries and jurisdictions according to cultural and social norms. It would seem that it is both important and informative to assess patients’ awareness of their rights and if they have received a service compatible with their rights charter. In other similar studies, for example in Malaysia and Saudi Arabia, the majority of subjects were young or middle-aged as was the case in the present study.^2,8

The number of hospital admissions and the mean number of admissions in our study was the same as comparable studies, but in one study in Saudi Arabia, a positive relationship was determined between the awareness score and education level and income, and a negative association between awareness and age, which is different from this study.² Only 4% of subjects were aware of all the items in the charter, and that is comparable to findings in other studies conducted in Saudi Arabia and Lithuania.^1,13About 10% of subjects were illiterate and related studies showed the same results.¹⁴

In one study, the three rights that >80% of the subjects were aware of included: the right to have personal data secured, the right to be informed about their rights and responsibilities in a manner in which they can understand, and the right to be respected by the hospital staff.² These results are comparable with the present study.

In a study conducted in Greece, the right to confidentiality was not considered as a right of privacy. Many patients allowed their doctors to make decisions, and 85% of patients were not even aware of the legislation. It was also stated that 60% of patients did not have any idea of their rights.¹⁵ In another study, it was demonstrated that 60% of patients were not aware of the European Convention on Human Rights.¹⁶ In a study by Changole et al., half of the patients who participated in the study had never heard of patients’ rights anywhere.¹⁷ A study in Turkey showed that only 9% of patients were aware of the regulations concerning patients’ rights, and other studies have shown similar results.^5,18–20

Most of the patients in the present study were given equal access to health care (91%), benefitted from the capabilities of their selected health-care institutions (86.7%), and their privacy was protected (86.1%). In addition, there were similarities between this and other studies.^21,22 Those patients who stated that they had not received care in accordance with their rights identified the shortcomings as not receiving written (95.2%) or verbal (53%) information from health-care professionals and the failure of health-care personnel to introduce themselves (73.3%).⁵ One study in Turkey showed that only 27.7% of patients gave informed consent,²³ and another study showed that only 65% of patients who requested care in hospital were given access to that care, 20% of nurses and physicians introduced themselves to their patients, and 47% of patients indicated that they received verbal information from health-care professionals.²⁴ In another study, when patients were asked why they did not request information about hospital regulations, they stated that they did not know that this was their right, and they expected that the health-care professionals would inform them.²⁴

One limitation of this study was that only self-reported data obtained from the patients were used to assess awareness. In future studies, it would be useful to collect data from health-care professionals, and to observe the services in the ward in order to evaluate the quality, instead of relying on a single interview for collecting data. In this study, verbal rather than written consent was obtained, which could be considered a weak point of the study.

Conclusion

This study investigated patients’ rights in Iran. According to the results of this study, it appears that since the passage of the Patients’ Rights Charter in Iran in 2002, there has not been any obvious official activity to improve patient awareness. Many studies have shown that written information, as part of regular educational programmes, is strengthened when combined with verbal information.^25,26 Educational leaflets, booklets and posters about patients’ rights should be placed on public bulletin boards in all hospitals and health centres, so that they are visible to patients. Performing future questionnaire studies, combined with observation, will help us to understand and elucidate patients’ rights.

The results of this study suggest that health-care professionals can provide care based on patients’ rights, and that health-care professionals’ knowledge of patients’ rights needs to be evaluated and, if required, educational programmes should be prepared. Professional organisations and the Ministry of Health need to be more sensitive to the issue of patients’ rights.

It must be mentioned that the present study is a starting point for working on the Patients’ Rights Charter in Iran. In future studies, it will be helpful to focus on special groups such as the illiterate, patients with learning difficulties and older adult patients about their awareness of their rights or to find out if there is any difference in the result by considering different health systems (e.g. national vs. private).

Footnotes

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Conflict of interest

None declared.

Acknowledgements

The authors thank the Shahid Beheshti University Medical Sciences hospital staff and patients for their collaborations in this project.

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