Patients Awareness of Their Rights: Insight from a Developing Country

Background: Considering the effect of human right observance on patients’ satisfaction from the treatment process, in Iran the Patient Rights Charter (PRC) was developed by the Ministry of Health and Medical Education (MOHME) in 2001 and enforced to all hospitals across the country. The purpose of the current study was to evaluate patients’ awareness of their rights based on PRC in two tertiary teaching hospitals affiliated with Shiraz University of Medical Sciences (SUMS) in Iran. Methods: Current study was a cross-sectional descriptive and analytical survey. The research sample consisted of 200 inpatients and data were gathered through questionnaires filled out during the interview. The rate of awareness of patients was measured on a Likert scale ranging from 1 to 4. Validity and reliability of the questionnaire were confirmed. Data were analysed by descriptive and analytical statistics. Results: In 30.5% of cases, the total awareness of patients was weak, in 59.4% was moderate, and in 10.1% of them was good. The most awareness was about trust and assurance to confidentiality of treatment team, and the least was about providing sufficient information about treatment options and their complications. There was a significant relationship between educational level and the place of residency with patients’ awareness (P<0.001). Conclusion: Total awareness of patients from their rights was medium. Although compared to similar studies this rate was not unsatisfactory, attempts should be made to improve it. Health care organizations are to deliver PRC to patients and make sure they have proper information about their rights. Assuring observance of patients’ rights requires not only informing healthcare policy makers and providers, but also educating citizens about what they must expect from their governments and health care providers. This will consequently improve the quality of services. Establishment of Patient Right Committee for supervision and monitoring of informing and observance of patients’ rights is also recommended.


Background
Since the introduction of the Human Rights Act by the United Nations in 1948, legislations on patients' rights have been passed all over the world (1). Examples of them are the 1968 Sydney Declaration on organ transplantations (2), the 1964 Helsinki Declaration on research subjects (3), and the 1978 Alma-Ata, Basic Health Services Declaration (4). The main reason of increasing in legislation is that observance of patients' rights is an essential part of quality improvement efforts in health services (5).
In many declarations, the purpose of patients' rights is to ensure the ethical treatment of all patients (6). Patients' rights are defined on the basis of patients' satisfaction with treatment process, confidentiality, informed consent and privacy (7). Patients have more necessary physical, mental, and social needs than other individuals. This is because of their specific situations and vulnerability that may make them unable to meet all requirements. As such, considering patients' rights is essential (6,8,9).
In most countries, health care organizations have established regulations or charters for patients' rights and announced and implemented them, in order to achieve patients' satisfaction (10). In Iran the Patient Rights Charter (PRC) was developed by the Ministry of Health and Medical Education (MOHME) in 2001 and enforced to all hospitals across the country (11). To increase the productivity, efficiency, effectiveness, and most importantly, patient satisfaction, it is indispensable that all health care organizations establish committees to observe patients' rights, as well as monitoring the work of staff and health care providers (10).
Awareness of patients from their rights can bring about a lot of advantages such as increased quality of health care services, decreased costs, more prompt recovery, decreased length of stay in hospitals, lower risk of irreversible physical and spiritual damages, and more importantly, increased dignity of patients through informing them about their rights to participate in decision making. On the other hand, lack of respect to patients' rights may lead to hazards to security and health situation of patients. Besides, it may ruin the relationship between the staff and patients that consequently decreases efficiency, effectiveness, and suitable care of patients (12).
There is a wealth of literature exploring patients' rights in Iran. Some studies have looked at the awareness of patients and providers from the components of PRC (11,13,14); and some have focused on observance of patients' rights from the patients and providers' view (15)(16)(17)(18)(19); role of education on students' awareness of patients' rights (20)(21)(22); and patients' rights in electronic health systems (23,24). One of the principles of clinical governance that leads to quality of health services improvement is the patients' participation in treatment process. This can be achieved only when patients are reasonably aware of their rights. However, with ever increasing complexity in the health systems and fast growing medical technologies and methods, the awareness of patients from their rights has been challenged. Given this, current study was performed to evaluate patients' awareness of their rights in two tertiary teaching hospitals, affiliated with SUMS in Iran.

Methods
This research was a cross-sectional descriptive and analytical survey on patients' awareness of their rights in two tertiary teaching hospitals affiliated with SUMS, Iran, in 2012.
Research population was inpatients of two selected hospitals except patients of ICU and Pediatrics wards (because of critical and immature situations of patients). Sample size was calculated using n = z 2 p(1-p)/d 2 formula with considering z = 1.96, p = 50%, and d= 7% that yielded 200 patients. Given the similar number of admissions for two hospitals, equal numbers of patients were simple randomly selected from each (i.e. 100 patients from either hospital).
The questionnaire validity was confirmed using content validity by receiving the ideas of 10 faculty members of SUMS, and applying them in questionnaire. Reliability was calculated as 86%, using Alfa-Cronbach coefficient.
Interviews were conducted with patients after informing them of the study objectives and receiving their written consent at the point of discharge. The data was analysed using SPSS 15 (SPSS Inc., Chicago, IL, USA). Descriptive statistics were used including frequency, average and standard deviation to achieve the research objectives and variables were compared using analytical statistics including Kruskal-Wallis, and Mann-Whitney tests.
Results Table 1 shows demographic information of the study sample. The majority of participants were female (63.5%), aged between 10-25 years (42.5%). The educational level  Table 2). There were significant relationships between each element of PRC (i.e. 10 elements) and the total awareness (P<0.001).
The study results illustrated no significant relationship between age (P= 0.09) and gender (P=0.35) with awareness of patients. However, there were significant relationship between patient awareness with educational level and the place of residency (P<0.001), as with increasing the educational level, the awareness of patients is improved. Also, patients inhabited in urban areas had a higher awareness than rural residents.

Discussion
The results of this research revealed that dominant rate of patient awareness of their rights was in medium level (59.4%). This result is confirmed by Mosadegh Rad's and Joolaee's studies (16,25). This is also an issue of concern in developed countries as Fotaki showed that after the health care reform, patients knew more about some rights, and had little or no information about other rights. Patient awareness of their rights differed greatly among the regions of the Russia. Fotaki concluded that to overcome the information gap among patients, all health care actors should provide adequate information in all regions (26). Also, in present study, patients had high awareness in some rights rather than others. One reason for this could be that some right are embedded in treatment processes so patients are fully aware of them.
In present study, the most and least awareness were respectively about trust and assurance to confidentiality of treatment team, and, providing sufficient information about treatment options and their complications. These results confirm that there may be problems in correct perception and practical implementation of all elements of the PRC, as there was clear differences in awareness of patients from each element.
Near to the result of current study in awareness of patients from right of receiving non-discriminatory health services, results of Ducinskiene's study in Lithuania showed that only small part of health care providers have considered nationality, language, and social position of patients in health services delivery (27). Based on the World Medical Association, every person is entitled without discrimination to appropriate medical care (28). As such respect to human dignity is necessary.
In Kuzu's study, 69.6% of patients did not request to know health care providers, as they were afraid of receiving negative reactions such as scolding (29). In current study, patients' awareness of their right about getting to know health care professionals was in low level. Health care professionals should respect this right if they want a better communication with patients.
Providers, especially physicians, know about the right of providing sufficient information about patients' disease and its progress, but they withhold information from patients as they think it can limit the authority of them. Patients' awareness of this right, however, was in moderate level. Good providers' awareness compared to weak patient awareness of this right could be due to the dominant paternalistic medicine in which medical professionals hold the authority to make every decision on behalf of their patients.
The Iranian PRC indicates that contents of medical records should be accessed only for authorized individuals and patients have the right to access this information. However, in the present study, awareness of patients of this right was weak, which is in line with Parsapoor study (17). We hypothesize that this could be again the result of paternalistic medicine, which is dominant in Iran. Lack of patients' medical knowledge and an asymmetry of information between medical professionals and patients could also lead to medical professionals refusing to grant this right to patients.
The PRC in Iran also states that before performing educational and research programs on patients, they should be informed about the aims of these programs. In Almoajel study in 2012 (5), and the present study, the awareness of patients from this right was in moderate level.
Results of current study showed no significant relationship between age, and gender with awareness of patients. This situation for educational level and the place of residency was converse. As with promoting the educational level, patient's awareness has increased. Also, patients from urban regions had higher awareness about their rights than patients from rural areas. Ansari's and Dadkhah's studies confirmed these results (15,30). Given the fact that knowledge can improve the awareness of people about their rights, media plays a pivotal role in informing public of their rights especially patient's rights.

Limitations
The main limitation of this study is inability to make comparisons among studies, as different legislations and values in individual countries generate different perceptions from patients' rights, and their observance. Another limitation is the small sample size that included only two hospitals.

Conclusion
Total awareness of patients from their rights was medium. Although compared to similar studies this rate was not unsatisfactory, attempts should be made to improve it. Health care organizations are to deliver PRC to patients and make sure they have proper information about their rights. Observance of patients' rights is a reasonable answer by health care organizations for responding to patients' needs. Assuring observance of patients' rights requires not only informing healthcare policy makers and providers, but also educating citizens about what they must expect from their governments and health care providers. This will consequently improve the quality of services. Establishment of Patient Right Committee for supervision and monitoring of informing and observance of patients' rights is also recommended.

Ethical issues
This study was approved by the ethics committee of Shiraz University of Medical Sciences.