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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 2  |  Issue : 2  |  Page : 97-104

Patients' rights in an underserved Nigerian environment: A cross-sectional study of attitude and practice orientation of medical professionals in Abia State


1 Department of Family Medicine, Federal Medical Centre, Umuahia, Abia State, Nigeria
2 Department of Public Health, School of Basic Medical Sciences, Federal University of Technology Owerri, Owerri, Imo State, Nigeria

Date of Submission28-Aug-2017
Date of Acceptance29-Nov-2017
Date of Web Publication15-Dec-2017

Correspondence Address:
Dr. Gabriel Uche Pascal Iloh
Department of Family Medicine, Federal Medical Centre, Umuahia, Abia State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/bjhs.bjhs_20_17

Rights and Permissions
  Abstract 


BACKGROUND: Globally, medical care have an age long history, but the rights of patients are more recent and occupy front burner in the quality of care metrics and medical jurisprudence and are on the rise, particularly in emerging and developing economies.
AIM: The study was aimed at describing the attitude and practice of patients' rights among medical professionals in Abia State, Nigeria.
MATERIALS AND METHODS: A descriptive study was carried out on a cross-section of 185 medical practitioners in Abia State, Nigeria. Data collection was done using pretested, self-administered questionnaire that elicits information on awareness, attitude, and practice of basic patients' rights. Each item of attitude and practice of patients' rights was scored on a five-point Likert scale ordinal responses of all-times, most-times, sometimes, rarely, and none. Attitude and practice of patient's rights were assessed in the previous 1 year.
RESULTS: The age of the participants ranged from 28 to 71 years. There were 166 males and 19 females. All the participants were aware of the patient's rights. The overall positive attitude to patients' rights was 87.3% with the most common positive attitudinal orientation being right to confidentiality (100.0%), and the least was right to know the identity/professional status of the physician (52.4%). The overall practice of patient rights was 85.8% with the most commonly practiced being right to confidentiality (100.0%) and the least was right to know the identity/professional status of the physician (51.4%). Attitude (P = 0.037) and practice (P = 0.048) of the right to know the identity/professional status of the physician were significantly associated with >10 years of medical practice.
CONCLUSION: The level of awareness of patient's rights was very high but did not translate to comparative overall positive attitude and practice orientation. Patient rights should be the focus of intensive continuing medical education and professional development in addition to greater administrative and governmental support, especially in developing economies where there are limited options to safeguard patients' rights.

Keywords: Abia State, attitude, medical practitioners, Nigeria, patient's rights, practice


How to cite this article:
Pascal Iloh GU, Amadi AN, Chukwuonye ME, Ifedigbo CV, Orji UN. Patients' rights in an underserved Nigerian environment: A cross-sectional study of attitude and practice orientation of medical professionals in Abia State. BLDE Univ J Health Sci 2017;2:97-104

How to cite this URL:
Pascal Iloh GU, Amadi AN, Chukwuonye ME, Ifedigbo CV, Orji UN. Patients' rights in an underserved Nigerian environment: A cross-sectional study of attitude and practice orientation of medical professionals in Abia State. BLDE Univ J Health Sci [serial online] 2017 [cited 2020 Aug 13];2:97-104. Available from: http://www.bldeujournalhs.in/text.asp?2017/2/2/97/220941



Health care is an issue of decades and the increasing expectations from medical professionals and anger with the health system fuels the pressure for rights of the patients charters, canons, covenants, bills, and laws.[1],[2],[3],[4],[5] As a member of the human family, the notions of rights of the patients were derived, developed, and enshrined in the Universal Declaration of fundamental or basic human rights which was formalized in 1948 by United Nations.[6] The United Nations Commission on Human Right has clarified the broader relationship between human rights and rights to health [6] while the World Health Organization stated that respect for rights of patients is vital for patients physical, mental, social, emotional, and spiritual well-being.[7] The right of patient is therefore one of the essential elements in defining norms related to the concept of clinical governance system and an important index for quality of care offered in the health-care industry. Despite advances in the field of medical science, patient's rights are under siege and patient's daily experience widespread violation and erosion of their rights in health facilities especially in resource-poor environment.[8],[9],[10]

In 1981, the World Medical Association adopted a statement on the rights of patients known as the Declaration of Lisbon in recognition of the practical, ethical, or legal difficulties as related to rights of patients, a physician should always act according to his or her conscience and always in the best interest of the patients.[11] The International Code of Medical Ethics by the World Medical Association emphasizes that a physician shall maintain the highest standard of professional conduct, respect rights of patients, owes his patients complete loyalty and all the resources of his sciences and safeguard patient confidence while Physicians Oath now called Physician Pledge as amended in 2017 pledges that physicians shouldn't use medical knowledge to violate human rights and civil liberties even under threat. Although the rights of patients vary in different countries and jurisdictions often depending on the prevailing sociocultural and moral norms,[4],[5],[11] the Declaration of Lisbon by the World Medical Association provides some of the principal rights which medical profession seeks to provide to the patients and whenever legislation or government action denies these rights, physician should seek by appropriate means to assure and restore them.[11]

Globally, rights of patients are derived from the principles of fundamental human rights, health rights, and professional obligations of the physician toward his patients as contained in the code of medical ethics and declarations which are applicable worldwide.[4],[5],[6],[11] Patient rights refer to legal interests of persons who submit to medical care and set out the ways in which patients and health professionals can work as partners in an open and positive relationships to improve the effectiveness of health-care process and standard of care. Despite enormous debate on the rights of patients, there is growing national and international consensus that all patients have a basic rights to privacy and confidentiality of medical information, informed consent for surgery, medications and invasive procedures, consent or refuse treatment, refuse or participate in research, and be informed about relevant risks of medical interventions.

The rights of patients vary in different countries depending on the prevailing ethical, legal, and morality which informed the specific rights to which patients in health facilities are entitled and have been reported within and across global medical populations in United States of America,[1],[12] United Kingdom,[3],[12] India,[13],[14] Saudi Arabia,[15] Iran,[16] Malaysia,[17] Pakistan,[18] Lithuania,[19] Georgia,[20] South Africa,[21] Egypt,[22] Uganda,[9] Ghana,[10] and Nigeria.[23] Although rights of patients are now accepted as the cornerstone of standard patient care, it is still being challenged in many developing and emerging economies.[5],[8],[13],[23] The observance of rights of patients in any global health society is an essential part of quality improvement efforts in quality of care that ensure ethical, legal, and social delivery of health-care goods and services with the purpose of improving efficiency, effectiveness, and of patient care and satisfaction.[24]

Nigeria is a federation consisting of federal, state, and local tiers of government, and health is a social service on the concurrent list in the constitution of Federal Republic of Nigeria and some of the rights of patients have been enshrined in federal policies and laws and if violated may result in fines or prison terms or both.[25],[26],[27],[28] However, there remains a great deal of work to clarify the relationships between human rights and rights to health including rights of patients in the region.[29] Of great interest in Nigeria is that patients in our health-care facilities consider physicians opinion as the final.[30],[31],[32],[33] Often times, they do not know their rights and are not bothered in knowing them. However, the increasing litigations arising from the abuse of rights of patients [29] is eroding the age-old paternalistic and absolute power enjoyed by Nigerian physicians who wittingly or unwittingly, knowingly or unknowingly infringe on the rights of patients which impinge on satisfaction with the quality of care.[32],[33] The increasing health literacy in Nigeria,[31] National Health Act,[27] service compact with all Nigerians (SERVICOM charter),[28] and easy access to medical information on the internet have ushered in more knowledge on rights of patients among the populace as they navigate the health-care pathway and Nigerian patients have the right to be served right.[28] Patients right issues in Nigeria have been a persistent problem and a large gap exists among medical practitioners beliefs, attitude, and practice, and there is the need to study the orientation of medical professionals toward rights of patients to make imperative improvement on the outcome of care such as patient satisfaction with care [31],[32],[33] and patient safety.[30] The creation of positive attitude and all-times practice of patients' rights preeminently rely on medical practitioners' orientation to the practice of right issues surrounding patient care. It is based on this premise that researchers were motivated to study the awareness, attitude, and practice of patient's rights in a cross-section of medical professionals in Abia State, Nigeria.


  Materials and Methods Top


This was a cross-sectional descriptive study carried out on 185 private and public medical practitioners who participated in continuing professional development program organized by Directorate of Postgraduate Studies of Federal Medical Centre Umuahia, Nigeria, for medical professionals in Abia State, on third and fourth May 2017 as well as during the General Meeting of Nigerian Medical Association, Abia State Branch held on May 7, 2017.

The inclusion criteria were private and public medical practitioners in Abia State who participated in the continuing professional development program and General Meeting of Nigerian Medical Association, Abia State Branch.

Sample size estimation was determined using the formula for estimating minimum sample size for descriptive studies [34] using the formula n = Z 2 pq/d 2 and nf = n/1 + n/N where n = Desired sample size when population is more than 10,000; nf = Desired sample size when population is <10,000; Z = standard normal deviate set at 1.96 which corresponds to 95% confidence limit; P= since attitude and practice orientations are multivariate concepts, the authors assumed that 50% (0.50) of the participants would have positive attitude and adequate practice of rights of patients; d = desired level of precision set at 0.05. When studying population <10,000 using an estimated population size of 200 medical practitioners based on the previous medical practitioners continuing professional development attendance records at the Directorate of Postgraduate Studies, Federal Medical Centre, Umuahia. This gave a sample size estimate of 132 patients. However, the sample size of 185 medical practitioners was used to improve the precision of the study

The eligible medical professionals for the study were consecutively recruited for the study based on the inclusion criteria until the sample size of 185 was achieved.

The study instrument consisted of sections on sociodemographic data such as age, sex, years of practice, place of work, and information on awareness, attitude, and practice of rights of patients.

The data collection tool was designed by the researchers to suit Nigerian environment through robust review of the appropriate literature on rights of patients.[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[29] The specific domains of rights of patients examined were right to confidentiality of all medical information and records; informed consent for surgery, drugs, and invasive procedures; dignity and respect for personal values; free choice of physician; information about medical conditions; complaints and justice about health service they receive; to know the identity/professional status of physicians; and refuse or participate in research. Each item of rights of patients was scored on a five-point Likert ordinal scale of all-times, most-times, sometimes, rarely, and none. All-times response to each attitude-based question indicated positive attitude while most-times, sometimes, rarely, and none responses meant negative attitude. Similarly, all-times response to each practiced-based question indicated the adequate practice of rights of patients while most-times, sometimes, rarely, and none responses to practice question meant the inadequate practice of rights of patients. The assessment of attitude and practice of rights of patients was inquired in the 12 months preceding the study.

The questionnaire was pretested using 10 medical doctors at Federal Medical Centre, Umuahia. The pretesting was done to find out how the questions would interact with the respondents and ensure there were no ambiguities. However, no change was necessary after the pretesting as the questions were interpreted with the same meaning as intended. The questionnaire was self-administered since the participants are health literate.

Operationally, patient rights referred to ethical, legal, and social principles of freedom or entitlements to patients as recipients of medical care. Attitude to patients' rights referred to the feeling of the medical practitioner toward patients' rights during doctor–patient encounter in the past 12 months while the practice of rights of patients referred to the habits regarding patients' rights during doctor–patient interaction in the past 12 months. Specifically, positive attitude and adequate practice of patients' rights, respectively, referred to compliance to specific items of the rights of patients as defined by all-times response to each domain of rights of patients.

The data generated were analyzed using software International Business Machines Corporation, Statistical Package for the Social Sciences (IBM SPSS) version 21, New York, USA. Categorical variables were described by frequencies and percentages. Bivariate analysis involving Chi-square test was used to test for significance of association between categorical variables. In logistic regression analysis, the dependent (outcome) variables were the attitude and practice of right to know the identity and professional status of the physicians, respectively, and the independent variables were age, sex, years of practice, and place of work. In all cases, a P < 0.05 was considered statistically significant. Odds ratio (OR) which is an indicator of the degree of association of attitude and practice of right to know the identity and professional status of the physicians with a predictor demographic variable was estimated at 95% confidence limit.


  Results Top


Of the 185 medical practitioners who participated in the study, 131 (70.8%) were middle-aged adults (40–59 years), 46 (24.9%) were young adults (18–39 years), and 8 (4.3%) were aged 60 years and above. The age of the participants ranged from 28 to 71 years with mean age of 34 ± 5.4 years. There were 166 male (89.7%) with 19 female (10.3%) with female-male ratio of 1: 8.7. Other demographic characteristics of the study participants are shown in [Table 1].
Table 1: Demographic profile of the study participants

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The overall positive attitude to patients' rights was 87.3% with the most common positive attitudinal orientation being right to confidentiality of medical information and records (100.0%) and the least was right to know the identity/professional status of the physician (52.4%). The frequencies of attitude to other rights of patients' items are shown in [Table 2].
Table 2: Distribution of the study participants by attitude to specific right of patients and overall attitude to patients' rights

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The overall practice of patient rights was 85.8% with the most commonly practiced being right to confidentiality of medical information and records (100.0%), and the least was right to know the identity/professional status of the physician (51.4%). The frequencies of practice of other rights of patients' items are shown in [Table 3].
Table 3: Distribution of the study participants by practice of specific right of patients and overall practice status

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Bivariate Chi-square analysis of the demographic characteristics of the study participants as related to attitude and practice of knowing the identity/professional status of the physician showed that years of practice was significantly associated with attitude (χ2 = 5.16; P= 0.037) and practice orientation (χ2 = 5.79; P= 0.048) of knowing the identity/professional status of the physician while other demographic factors were not statistically significant [Table 4] and [Table 5].
Table 4: Association between demographic variables and attitude to right to know the identity and professional status of the physician

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Table 5: Association between demographic factors and the practice of right to know the identity and professional status of the physician

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On logistic regression analysis of demographic variables as related to attitude and practice of knowing the identity/professional status of the physician showed that years of practice remained statistically significant for attitude (OR = 3.01 (1.94–8.77); P= 0.026); and practice (OR = 2.46 (1.88–7.04); P= 0.031), whereas other demographic factors were not statistically significant [Table 6] and [Table 7]. The most significant demographic predictor of positive attitude to knowing the identity/professional status of the physician was years of practice. A significantly higher proportion of medical practitioners who had years of practice more than 10 years (78.4%) had positive attitude compared to their counterparts whose years of practice were 10 years and less (21.6%). Medical practitioners with years of practice more than 10 years were three times more likely to have positive attitude to knowing the identity/professional status of the physician (OR = 3.01 (1.94–8.77); P= 0.026). Similarly, the most significant demographic predictor of practice orientation of knowing the identity/professional status of the physician was years of practice. A significantly higher proportion of medical practitioners who had years of practice more than 10 years (75.8%) had adequate practice of knowing the identity/professional status of the physician compared to their counterparts whose years of practice were 10 years and less (24.2%). Medical practitioners who had years of practice more than 10 years were two and half times more likely to have adequate practice of knowing the identity/professional status of the physician (OR = 2.46 (1.88–7.04); P= 0.031).
Table 6: Logistic regression analysis of demographic variables as related to attitude to right to know the identity and professional status of the physician

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Table 7: Logistic regression analysis of demographic variables as related to practice of right to know the identity and professional status of the physician

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  Discussion Top


This study has shown that 100% of the study participants were aware of the rights of patients in healthcare facilities. This finding has corroborated the general acceptance and international consensus by the World Medical Association that what is owed to the patients as a human being by physicians is their rights in health-care environment [11] and physician–patient relationship can be likened to citizens–State relationships.[5],[6],[35] Accordingly, duty to treat exist when a physician–patient relationship is established, the contract to provide care is exercised by the medical doctor and the patient.[11] The physician invariably owes each patient the duty to recognize and respect rights of patients given current medical knowledge and available ethical and legal resources. The patient should therefore receive health care that is consistent with the dignity and respect they are owed as human beings. Of great interest in Nigeria is that the SERVICOM charter on service delivery by the SERVICOM office of the Federal Government of Nigeria has emphasized the slogan of “The Patient First and Always” and that Nigerian patients have the right to be served right in health-care facilities.[28] Widespread awareness of medical practitioners on inalienable rights of patients can lead to fruitful advancement of patients' rights for broader and diverse health service benefits. This will ensure quality health care for patients and safeguard the integrity of the physicians, health facility, and health profession. It is therefore quintessential that every practitioner of the noble art and science of medicine be aware of the policies, precepts, principles, and practice of patients' rights. This will go a long way to improve quality of care received by the consumers of health-care goods and services.

This study has shown that 87.3% of the medical practitioners had a positive attitude to rights of patients with the most common positive attitudinal orientation being right to confidentiality of medical information and records and the least was right to know the identity and professional status of the physicians. Admittedly, open and honest positive attitude to patients right is an integral part of patient-doctor relationship [36],[37] and is a fundamental ethical requirement from medical practitioners at all times.[11] The patient-physician relationship is of fiduciary nature that is based on trust and should be observed with utmost good faith in the best interest of the patients.[38] This relationship obliges the physician to show positive attitude to patients' rights in accordance with ethical and legal principles and justice. Developing positive attitude to patients' rights leads to active patient engagement which helps the patients to make informed decisions on all aspects of physician-patient encounters in health facilities. Failure to recognize and respect these patients' rights canons exposes the medical practitioner to legal liability and aggravated damages may be awarded when convicted.[35] It is therefore imperative that medical practitioners develop positive attitude to rights of patients as well as being carefully informed of the ethical, legal, and social implications of protecting and preserving the rights of patients.

This study has shown that 85.8% of the medical practitioners had adequate practice orientation to rights of patients with the most commonly practiced patients' rights being right to confidentiality of medical information and records and the least was right to know the identity and professional status of the physician. This finding has demonstrated the practice orientation of the study participants to the doctrine of confidentiality of patients' medical information and records as articulated and enshrined in Physicians Oath which remains a rite of passage for medical graduates into the medical profession. Accordingly, the law and medical ethics state that physician–patient interaction should remain confidential. The physician should not reveal patient confidential information and records unless at the requests of the patient or required by law because the State owns the patient and the physician. Although patients' rights are evolving globally with links to advances in medicine and changing government policies and laws, failure to respect these rights could lead to medical litigation with penalties.[29] However, some medical practitioners may not be comfortable with the observance and practice of the canons of patients' rights for fear of litigation, but this notion should change as it negates the principles and practice of patient-centered care [38] and covenant of trust.[39] Of great concern in Nigeria is that there is no clear policy on the disclosure of the identity of attending medical practitioner and patients are left at their discretion to discern the professional status of their medical doctors. The patients who are inquisitive of their right to know the professional status of their physicians are often misinterpreted by medical doctors as doubting their clinical competence and want to know more that they deserve. Revealing the professional status and identity of medical practitioners aids accountability and build trust in the health system. Assuring patients that their rights are protected during the process of care have an important role in improving the standard of care especially when patients' expectations of care are raised.[40],[41] However, when there are mutual respect and trust between medical practitioner and the patient, there are seldom any infringements on the rights of the patients.[35],[36],[42] This will reinforce shared decision-making for patient-centered care and trusting relationship with the patients.[35],[36],[43] As the world has become a global village with internet changing health care,[44] it is essential for medical practitioners to embrace the rights of patients in line with the United Nations Declaration [6] and Declaration of Lisbon.[11] Medical practitioners should be aware of the fact that as health-care role models, they need to observe the rights of the patients regardless of their own personal idiosyncrasies. Role modeling on rights of patients will positively influence physicians' attitude and practice of patients' rights and other aspects of clinical governance. By changing our attitude appropriately, the patient will also change their own because patients' rights also come with patient responsibilities to their physicians.

Attitude and practice of patients' rights as related to right to know the identity and professional status of the physicians were significantly associated with years of practice of more than 10 years. The finding of relatively higher positive attitude and adequate practice of right to know the identity and professional status of the physicians among medical practitioners with years of practice of more than 10 years is probably because longer years of practice influences receptivity and acceptability of information on national and international code of medical ethics and affords a wider scope for interactions and information exchange among medical professionals. Medical professionals irrespective of the years of practice should serve as advocate for patients through approaches that protect and promote the inalienable rights of the patients, especially at the point of care encounters.[11] This will help to position the health facility for international accreditation and other diverse global recognition.

Limitations of the study

The limitations of this study are recognized by the researchers. First and foremost, the study was focused on basic rights of the patients which are not an exhaustive list of rights of patients. Second, the attitude and practice of patients' rights were based on respondents' subjective responses and were not verified. However, there is a tendency to underreport episodes of patients' rights violation in addition to socially desirable responses.


  Conclusion Top


This study has shown that the level of awareness of patient's rights was very high but did not translate to comparatively overall positive attitude and practice of patients' rights. The most common positive attitudinal orientation and adequately practiced right of patients was the right to confidentiality of medical information and records and the least was right to know the identity and professional status of the physicians. The most significant predictor of positive attitude and adequate practice of right to know the identity and professional status of the physicians was years of practice of more than 10 years. Patient rights should be the focus of intensive continuing medical education and professional development in addition to greater administrative and governmental support, especially in developing economies where there are limited options to promote and protect the rights of the patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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