Assessing knowledge of the patient bill of rights in central Saudi Arabia: a survey of primary health care providers and recipients.

BACKGROUND AND OBJECTIVES: Little is known about the implementation of the patient bill of rights (PBR) in Saudi Arabia. Therefore, this study was conducted to explore to what extent health care recipients and providers know about the bill and its implementation. DESIGN AND
SETTING: A cross-sectional survey conducted on health care professionals and patients at Primary Health Care Centers in Riyadh, Saudi Arabia, during July 2010. PATIENTS AND METHODS: The study employed a self-administered questionnaire to collect data from 500 patients (aged 18 years or older) and 500 health care providers (physicians and nurses) in primary health care (PHC) centers in Riyadh. Data was collected on the respondents' knowledge of the existence and contents of the bill, the extent to which the bill is implemented, and the obstacles that may hinder bill implementation. The data was analyzed and presented in a descriptive fashion.
RESULTS: More than three quarters of patients and one third of PHC providers did not know about the existence of the bill. Among those who knew about its existence, about three quarters of patients and almost half of PHC providers had little (or very little) knowledge about the bill contents. In general, patients scored lower means of perception than PHC staff about the implementation of the bill's aspects. PHC staff reported several obstacles that may hinder the implementation of the PBR in Saudi Arabia.
CONCLUSIONS: Patients and health care providers lack necessary knowledge about the PBR. More dissemination of information about the bill, taking into account the particularities of the Saudi population is needed. Future research is required to establish measures that are effective in ensuring that patients rights are ensured.

Health as a fundamental human right is recognized in the World Health Organization’s (WHO) Constitution, which states that the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being.1 At present, there are many declarations defining the importance of patients’ rights in the provision of health care.2 However, the mechanism of their implementation and their real contents vary among countries,3 often depending upon prevailing cultural and social norms.4 Despite that patients’ rights are increasingly emphasized around the world, it is still an ambiguous concept for health care providers and patients alike.5

The increasing interest in the subject of patients’ rights have led to extensive research in developed6–8 and developing9–11 countries. However, the patients’ bill of rights (PBR), irrespective of the country it originates from, aims to reaffirm the importance of the relationship between patients and their health care providers, and also to ensure the critical role patients may play in safeguarding their own health. Various factors have enhanced the recognition of patients’ rights, including the values arising from human rights, reforms in health care systems, the continuing progress of medical science and biomedical technology, and the ease of access to medical information.12,13

In 2006, the government of Saudi Arabia promulgated the PBR with the aim of improving patients’ and health care professionals’ experience with health care receipt and delivery, and also improving the overall quality of health care given to the population. The intent of this bill is to serve as a blueprint for how systems and procedures that aim to protect patients and ensure quality of care could be improved. The Saudi PBR defines the patients’ rights to accessible health care that meets their needs, to be treated with respect, to receive understandable information, to be involved in treatment options and plans, to file a complaint, and to the inviolability of personal privacy. The bill states that patients may change or refuse treatments and must be told about possible complications. The bill also stipulates that patients must know the costs of treatment in advance (in the case of private sector treatment) and should not undergo any medical management without their consent. 14

While the objectives of this bill are very noble, its success will depend greatly on how patients and health care providers know about it and how well it is implemented. A successful implementation of this bill will result in a drastic improvement in the provision of health care, and will lead to a higher degree of patient satisfaction and involvement in their health care decisions. Therefore, the main aim of this study was to assess the implementation of the PBR in Saudi Arabia. Specific objectives were to examine the extent to which patients and PHC staff are aware of the existence and the contents of the bill, to examine the extent to which aspects listed in the bill are implemented, and to determine the obstacles that may impede the implementation of the bill.

PATIENTS AND METHODS

This was a cross-sectional study conducted to explore the implementation of the PBR that was introduced recently in the Saudi health care system. A stratified random sampling was used to represent patients and PHC staff from public and private health care sectors. In each sector, 500 patients (18 years or older) and 500 PHC staff (physicians and nurses, who had been in the profession for the past 2 years) were selected using systematic random sampling and requested to complete the survey questionnaires. The study took place in Riyadh, the capital of Saudi Arabia, during July 2010. The survey questionnaire consisted of four parts. The first focused on personal characteristics of respondents and included questions on gender, age, educational level, and occupation. In the second part, respondents were asked whether they had knowledge about the existence of the PBR, its contents, and whether they had observed any improvement in doctor-patient relationships in the past 2 years. Responses in this section were in “yes” and “no” form. The third part asked the respondents (patients and PHC staff) about the extent to which each aspect defined in the PBR was implemented. In this section, a 5-point Likert scale ranging from “1=strongly disagree” to “5=strongly agree” was used to assess respondents’ perception about the implementation. A reliability check showed that the scale has high internal consistency (Cronbach α=0.888). The fourth part requested PHC staff to identify possible obstacles to the implementation of PBR in Saudi Arabia. In this section, PHC staff were given a list of possible obstacles, based on a review of the relevant published studies, and were instructed to mark as many obstacles as applied.

To increase the content validity of the questionnaire, a review of the relevant published studies was carried out. Two academic staff and two physicians reviewed the draft questionnaire, and it was pilot-tested. On the basis of the suggestions of the reviewers and the outcome of the pilot survey, the final questionnaire was reformulated. The respondents were assured of confidentiality and provided with an explanation regarding the purpose of the study and the importance of their contribution. The subjects gave consent to participate in the study. All questionnaires were distributed by well-trained postgraduate students. While patients completed the questionnaire during their waiting times in the PHC clinics, PHC staff were requested to complete them at times of their convenience.

The data was analyzed and presented in a descriptive fashion. In making a comparison between patients and PHC staff, the chi-square test was used to test the difference between categorical variables, and the mean values of continuous variables were compared using the t test. The level P<.05 was considered as the cutoff value for significance. The data for this study was entered and analyzed using SPSS version 11 (IBM Corp, Armonk, NY USA).

RESULTS

Of the 1000 questionnaires, 799 (79.9%) were completed and valid for analyses. Of these, 433 (54.2%) were completed by patients and 366 (45.8%) were completed by PHC staff. The remaining 201 (20.1%) questionnaires were excluded because of incompleteness. Patients were predominantly young with an average age of 36.9 (13.1) years (range, 18–68 years), the majority of them were males (64.4%) having an educational level of high school or above (71.6%). The majority of PHC staff respondents were female (62.8%) and had an average age of 38.2 (10.9) years (range, 24–59 years). Among the PHC staff, a total of 147 (40.2%) were physicians and the remaining 219 (59.8%) were nurses.

The difference between patients and PHC staff on knowledge of the PBR is shown in Table 1. The results indicated that only 91 (21.9%) patients and 242 (66.1%) PHC staff knew about the existence of the PBR (P<.001). Of these, only 27 (29.7%) patients and 85 (35.1%) PHC staff reported that they had observed changes in the doctor-patient relationship in the past 2 years. A further analysis indicated that, among respondents who had heard about the existence of the bill, about three-quarters (73.6%) of patients and about half (48.8%) of PHC staff had “little or very little” knowledge about the bill contents (P<.001). Similarly, a significantly higher percentage of patients than PHC staff (39.6% and 12.0%, respectively) indicated that the bill would bring “little or very little” improvement in the provision of health care (P<.001).

Table 1

Respondent knowledge about the existence of the Patient Bill of Rights.

Patientsn (%)	Respondents		χ2	P
	Primary health care center staffn (%)
Have you heard about the existence of the Patient Bill of Rights?
Yesa	91 (21.0)	242 (66.1)	164.15	.001
No	342 (79.0)	124 (33.9)
Have you observed any changes in the doctor-patient relationship in the past two years?
Yesb	27 (29.7)	85 (35.1)	0.654	.419
No	64 (70.3)	157 (64.9)

N=All respondents

N= Only respondents who had heard about the PBR.

In this study, respondents were requested to indicate their perception about the extent to which each of the aspects (articles) listed in the bill was implemented (Table 2). In general, patients perceived lower mean scores for the implementation of all aspects listed in the PBR than PHC staff. In particular, patients reported significantly lower mean scores in the implementation of several aspects such as the provision of care that meets their needs, the encouragement to play roles in their health decisions, the provision of understandable information, obtaining information about treatment options and complications, and referrals to higher levels of care. Moreover, patients attending the private sector centers reported a significantly lower mean score of perception about the implementation of the aspect “obtaining information about costs of care” than PHC staff.

Table 2

The extent to which aspects of the Patient Bill of Rights were implemented as perceived by respondents by scores on a 5-point Likert scale.

Aspects of the Patient Bill of Rights	Mean scores		P
	Patients	PHC staff
Patients are provided with health care which meets their needs	3.72	4.06	.001
Patients are treated with respect	4.48	4.54	.335
Precautions are taken to ensure patients’ privacy	4.09	4.10	.832
Patients are encouraged to play roles in their health decisions	3.42	3.76	.001
Patients are provided with understandable information	3.43	3.75	.001
Patients can obtain information about the treating health staff	3.45	3.61	.037
Patients are informed about their treatment plans	3.71	3.91	.009
Patients are informed about options of treatments about their health conditions	3.45	3.91	.001
Patients are informed about complications/risks involved in their treatments	3.50	4.28	.001
Patients have continuous/follow up of their health problems	4.52	4.54	.691
Patients are transferred to other levels of care when necessary	3.84	4.10	.002
Patients’ approval is obtained before managing their health problems	4.32	4.37	.429
Information about patients’ condition is kept confidential	4.50	4.54	.472
Patients’ complaints are taken seriously	2.55	4.37	.001
Patients can refuse persons who are not involved in their care	3.92	4.00	.224
Patients are informed about costs of their health care in advance	3.06	4.39	.001
Patients can change their treating doctors if they wish	4.30	4.14	.063
Patients can obtain reports about their health conditions	3.29	3.43	.098

PHC staff reported a number of obstacles that may deter the implementation of the PBR in Saudi Arabia (Table 3). The lack of knowledge about the bill among patients and PHC staff were the most cited two obstacles in implementing the PBR and were reported by about half of respondents. Obstacles such as PHC staff dissatisfaction, shortage of staff, and lack of necessary facilities were reported by more than one third of PHC staff. About a quarter of PHC staff gave “heavy workload” and “inadequate resources” as other obstacles for the implementation of the PBR. Slightly more than 15% of respondents cited that “poor coordination with other levels of care” and “insufficient managerial support” as obstacles to the implementation of the bill. PHC staff specified “other” obstacles that impede the implementation of PBR, including “time constraint,” “improper staff/patient ratio,” and “unsafe environment.”

Table 3

Obstacles to the implementation of the Patient Bill of Rights as perceived by PHC staff (only for PHC staff who were aware of the existence of the bill.

Obstacles	Frequencya
	N	(%)
Lack of knowledge about the bill among patients	185	50.5
Lack of knowledge about the bill among	179	48.9
Staff dissatisfaction	133	36.3
Insufficient numbers of health staff	125	34.2
Lack of necessary facilities	124	33.9
Heavy workload	97	26.5
Inadequate resources	86	23.5
Inadequate coordination and cooperation with other levels of healthcare	58	15.8
Insufficient managerial support	56	15.3
Other obstacles	40	10.9

Respondents were instructed to select as many obstacles as applicable.

DISCUSSION

Despite the introduction of the PBR in the Saudi health care system more than 3 years ago, patients and PHC staff were not yet fully aware of the legislation. This may indicate that the process of informing health care providers and recipients about the bill has not been successfully implemented. In this study, a considerable percentage of patients and PHC staff were not aware of the PBR, its contents, and the improvements likely to occur in the delivery of health care as a result of implementing the bill. Comparing the results of the present study with those in other countries is difficult because of differences in legislation among health care systems, research methodologies used, and differences in values and norms among societies.

Interestingly, the study found that more than one-third of PHC staff were not aware of the inception of the PBR and that only half of those who were aware, knew about its contents as well. It was expected that health personnel had a comprehensive awareness about the existence of the bill and its contents; however, the results contradict this expectation. In the published studies, there is a general notion that health care providers possess higher levels of awareness about patient rights and other ethical health issues.15 However, the results of this study imply that more efforts are needed to promote the knowledge of health care providers about the bill and its contents.

In this study, the PHC staff cited several obstacles that may hinder the implementation of the PBR, such as the lack of knowledge about the bill among patients and health care providers. This is in line with other research which indicated that assuring the rights of patients are protected requires more than educating policy makers and health providers; it requires educating citizens about what they should expect from their health care providers.4 Other research indicated that the media plays a significant role in making people aware of their legal and social rights; however, this requires planning at a high level of health care management systems.12

PHC staff indicated that health personnel dissatisfaction, insufficient number of health staff, and lack of necessary facilities in PHC centers are among the important obstacles in implementing the PBR. These results confirm previous research studies conducted in Saudi Arabia which identified that many PHC centers lack necessary resources,16 have a shortage of qualified health personnel,17 and are overcrowded.18 These issues require urgent solution if the PBR is to be implemented successfully. Previous research studies indicated that where patients’ rights are not protected, they look for alternative advocacy mechanisms to meet their needs and protect their rights.12 One of these mechanisms commonly used in Saudi Arabia is that many patients turn to emergency departments with primary health care problems19 or rely on over-the-counter medication. 20 Such health-seeking behavior has been described as “inappropriate,”21 not only for patient health, but also for the health care system as a whole. Overcoming these issues might be a prerequisite to a successful implementation of the PBR. The impact of these issues on the implementation of the PBR could be examined in further research.

In summary, although patient rights are increasingly emphasized around the world, they are relatively lesser known in Saudi Arabia and are often recalled only when the health care providers make mistakes, which cause death or disability. Implementation of patient rights only seems possible when health care providers, recipients, and institutions have reached the desired levels of information and consciousness about the bill. Implementing and maintaining the PBR is the responsibility of all stakeholders of the health care system, including patients, health care providers, and policy makers.

Several limitations should be considered when interpreting the results of this study. First, the study was limited to PHC centers. Nevertheless, the findings have implications for other health care facilities as well. Second, because of time and financial constraints, the study was limited to Riyadh. Therefore, the study does not claim to be representative and the results cannot be generalized. Third, the results reported here were based on information collected by questionnaires and were subjected to the disadvantages of using such a data collection tool. Using a qualitative approach with health care stakeholders is recommended to further explore this national topic. Finally, most of the questions used in this study were nonspecific in nature and general in approach. Addressing more specific questions about the bill, its contents, and obstacles that may hinder its implementation will lead to a better understanding about the topic. Future research should attempt to address some of the concerns indicated in these limitations. Despite these limitations, it is expected that the findings are of benefit to all stakeholders of the health care system in terms of increasing awareness about the newly introduced PBR and obstacles that may hinder its implementation.

In conclusion, introducing the PBR in Saudi Arabia is a major step toward ensuring quality of health service and protection of patients’ rights. However, the results that emerged from this study indicate that a considerable percentage of patients and health staff lack necessary knowledge about the bill. This suggests that health decision makers, health institutions, and the media should work together to increase the level of knowledge about the PBR and its contents. Health care policy makers should establish measures to tackle obstacles that may delay the implementation of the PBR. If appropriate strategies for increasing the level of awareness about the PBR are to be developed, more dissemination of information about patients’ rights, taking into account the particularities of the Saudi population, is needed. Future research is required to establish measures that are effective in ensuring patient rights.