Patient's Bill of Rights: Is it a Challenge for Quality Health Care in Saudi Arabia?

BACKGROUND: Increasing interest in patients' rights and the certainty of its impact on the quality of patient care has led to extensive research in both developed and developing countries. In 2006, the Government of Saudi Arabia publicized the Patient's Bill of Rights (PBR) that was aimed at improving patients' and health-care professionals' experience, with a focus on the quality of care provided.
OBJECTIVE: To determine the degree of awareness of rights among patients admitted to hospitals in Al-Madinah Al-Munawarah. The results would help policymakers understand the impact of patients' rights, and thus provide them with evidence to provide quality health-care service delivery and patient care through patients' rights.
METHODOLOGY: This is an observational, analytical, cross-sectional study implemented in Al-Madinah Al-Munawarah, Saudi Arabia, using a self-administered questionnaire.
RESULTS: The study had a response rate of 83.01% and found an association between gender and knowledge for the selected items of patients' rights. However, there was no statistically significant difference between the knowledge of males and females regarding the consent form, with an awareness rate of 90% among the total sample size. However, almost half had never heard about patients' rights.
CONCLUSION: This study shows that in Al-Madinah Al-Munawarah, Saudi Arabia, there is a low level of awareness among patients admitted to hospitals regarding their rights. Further, it was found that wall placards, mass media and health-care providers are important sources of knowledge regarding patients' rights. Health-care policymakers in Saudi Arabia should recognize the importance of patients' rights as means of providing better quality care and a higher rate of patient satisfaction by establishing measures to tackle obstacles that may impede the implementation of PBR.

INTRODUCTION

In the past few years, increasing public concern regarding the ethical conduct of health-care professionals has led to a stronger call for establishing patient's rights.[1]

Patients' rights differ across countries, based on cultural and social factors. In this term, the word “right” is firmly linked to the meaning and impact of “quality care.” If patients are aware of their rights, it would help in fostering a stronger doctor–patient relationship, and thus lead them to receive quality care with higher satisfaction.[2]

In fact, several patient–physician relationship models exist that focus mainly on patients' rights.[2] Patients have the right to accept standards of quality care, to treatment within the available resources and with a high level of personal dignity. They also have the right to receive all the necessary information regarding individual(s) responsible for their care, treatment and services. Patients have the right to receive complete details regarding their diagnosis, treatment, procedures and prognosis of illness in a way and language that is easily understood, and the same should be considered while drafting the informed consent form.[3]

Recently, several regulations have been implemented that highlight the importance of patients' rights in the provision of quality health care.[4] This close association between patients' rights and its impact on the quality of care has led to extensive research in both developed and developing countries.[5678910]

In 2006, the Government of Saudi Arabia publicized the Patient's Bill of Rights (PBR), which was aimed at improving patients' and health-care professionals' experience, with a special focus on the quality of care provided. The Saudi PBR defines patients' rights as “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.” Patients may change or refuse treatments and must be informed about possible complications.[1112]

This study aims to determine the degree of awareness of these rights among patients admitted to hospitals in Al-Madinah Al-Munawarah. These results would help policymakers understand the impact of patients' rights, and thus provide them with evidence to provide quality health-care service delivery and patient care through patients' rights. This study focused mainly on two important items, namely, the consent form and filing of a complaint. This is so because according to the author's personal observation, in Saudi hospitals, it is known that the primary causes of dissatisfaction among patients and their families regarding the quality of care are because of their unawareness of the treatment plans and the difficulty in understanding the consent form before signing it.[11] Consequently, the patient and their families also have rights to know how to file a complaint, if possible.[13]

METHODOLOGY

This is an observational, analytical, cross-sectional study implemented in Al-Madinah Al-Munawarah, Saudi Arabia. The study was conducted in randomly selected public hospitals and private hospitals (two each) between January 2014 and end of March 2014. Patients or their family members in the outpatient clinics of these hospitals were interviewed using a time-bound sampling technique (2–3 times a week).

Respondents were asked to complete a questionnaire if they had been admitted to a hospital or had accompanied relatives during a hospital stay within the past 3 months. Assistance was offered to participants who were not able to complete the questionnaire.

The inclusion criteria were, first, that the respondent should have been admitted to any public or private hospital in Al-Madina within the past 3 months (not necessarily the same hospital where the interview had taken place). Second, the patient or family member should complete the questionnaire only after reading and understanding the introductory paragraph explaining the objectives of the study. Finally, the respondent should voluntarily consent to participate in the survey.

The self-administered questionnaire was drafted in Arabic and comprised three parts. The first part comprised an introduction to the study, the inclusion criteria and details on voluntary participation and privacy of information. The second part comprised questions to collect sociodemographic and general data, including gender, age, educational level, type of hospital, duration of admission and the main reason for admission. The final part comprised questions pertaining to information on selected items of patients' rights such as the consent process of any medical intervention, reading the consent form before signing it, awareness about patients' rights and source of knowledge in addition to participant's response in case of having any complaint against the treatment or the health-care team. This questionnaire was pretested, following which a pilot test was conducted. Content validity was justified by reviewing the literature.[1112]

Ethical approval for this study (Protocol number: TUCDREC/9122013/Mahrous) was provided by the Research Ethics Committee of the College of Dentistry, Taibah University, Madinah, on December 5, 2013. The waiver of written informed consent process was approved because the nature of the questionnaire was anonymous, self-administered and contained no hospital identifier, except for public or private hospitals.

The data were coded and keyed into the Statistical Package for the Social Sciences version 19 for Windows 7 (SPSS Inc., Chicago, IL, USA). Descriptive analysis followed by inferential statistics was done. The mean percentages and standard deviations were calculated for qualitative and quantitative data, respectively. Chi-square and Fisher's exact tests were performed to statistically analyze the qualitative data. A P = 0.05 was considered as a cutoff point for statistical significance.

RESULTS

Of the 212 questionnaire distributed, 176 legible responses were obtained from respondents who consented to participate in the study, providing a response rate of 83.01%.

The mean age of the respondents (patients or their family members) was 34.23 ± 9.34 years. In total, 46.6% of the questionnaires were completed by the patients themselves, while 53.4% of the questionnaires were completed by their family members in case the patient was a child or disabled and unable to complete the questionnaire. As shown in Table 1, there is a slight preponderance of female participants (60.2%) in the sample. About 60% of the participants are university graduates.

Table 1

General and demographic characteristics (n = 176)

Item	Total number (%)
Gender
Male	70 (39.8)
Female	106 (60.2)
Educational level
School	58 (33)
University	104 (59)
Postgraduate	14 (8)
Type of hospital
Governmental	112 (63.6)
Private	64 (36.4)
Reason for admission
Nonsurgical	66 (37.5)
Surgical	64 (36.4)
Obstetrics/gynecology	46 (26.1)
Reason for selecting the hospital*
Health insurance	18 (10.2)
Geographic accessibility	52 (29.5)
Reputation of physician	50 (28.4)
Reputation of the hospital	26 (14.8)
Other factors	34 (19.3)

*Multiple answers were allowed

In the sample, public hospitals had more admissions, accounting for about 63% as compared with 37% for private hospitals. There was an almost equal distribution of “reasons for admission” between nonsurgical, surgical and obstetrics/gynecological causes at 37.5%, 36.4% and 26.1%, respectively. Geographic accessibility and physician reputations were found to be the most attractive items for selecting a hospital where patients receive health services. Other reasons for admission to a hospital were familiarity to the hospital, trust, system of management and comfortable waiting areas.

Table 2 shows the association between gender and knowledge about the selected patients' rights variables. No statistically significant difference was found between males and females regarding the existence of a consent form, with about 90% of the total respondents being aware of it. Interestingly, a significant difference was observed between male and female regarding the signature of the consent on hospital admission, with a higher response among males (79.3% as compared with 54% among females). Among those who signed the consent form, only 74% had read and understood its contents, with the percentage nonsignificantly being higher among females.

Table 2

Differences between gender and knowledge about patient rights among the selected sample

Item	Gender		Total number (%)	P
	Number of males (%)	Number of females (%)
Having previous knowledge about the existence of a consent form to be signed on hospital admission	58/70 (82.9)	100/106 (94.3)	158/176 (89.9)	0.082
Signed a consent on hospital admission	46/58 (79.3)	54/100 (54)	100/158 (63.3)	0.024*
Read and understood the content of the consent form	32/46 (69.6)	42/54 (77.8)	74/100 (74)	0.51
Agree that there is an importance for the consent form	50/58 (86.2)	88/100 (88)	138/158 (87.3)	0.82
Heard about patients’ rights in hospitals?	28/70 (40)	64/106 (60.4)	92/176 (52.3)	0.61
Agree that patients’ rights are important	26/28 (92.9)	58/62 (93.5)	84/90 (93.3)	0.21
Aware about the existence of a complaint box	26/70 (37.1)	40/106 (37.7)	66/176 (37.5)	0.23

*Significant at the 0.05 level

Although only 52.3% (92/176) of the respondents were aware about patients' rights, almost 93.3% stated that patients' rights are important. The main sources of knowledge of patients' rights were found to be posters in the hospitals (40/92; 43.5%), mass media (32/92; 34.8%) and staff members of health-care facilities (6/92; 6.5%).

Table 3 shows that there is no significant association between the level of education and knowledge about the selected patients' rights variables. Further, there was no significant association between being admitted to a public or private hospital and knowledge about patients' rights [Table 4].

Table 3

Association between educational level and knowledge about patient rights among the selected sample

Item	Educational level			Total (%)	P
	School (%)	University (%)	Postgraduate (%)
Having previous knowledge about the existence of a consent form to be signed on hospital admission	48/58 (82.8)	96/104 (92.3)	14/14 (100)	158/176 (89.8)	0.257
Signed a consent on hospital admission	34/48 (70.8)	56/96 (58.3)	10/14 (71.4)	100/158 (63.3)	0.523
Read and understood the content of the consent form	30/48 (62.5)	44/96 (45.8)	4/14 (28.6)	78/158 (49.4)	0.212
Agree that there is an importance for the consent form	46/48 (95.8)	80/96 (83.3)	6/14 (85.7)	132/158 (87.3)	0.32
Heard about patients’ rights in hospitals?	26/58 (44.8)	54/104 (51.9)	12/14 (85.7)	92/176 (52.3)	0.151
Agree that patients’ rights are important	22/24 (91.7)	50/54 (92.6)	12/12 (100)	84/90 (93.3)	0.843
Aware about the existence of a complaint box	24/58 (41.4)	38/104 (36.5)	4/14 (28.6)	66/176 (37.5)	0.975

Table 4

Association between the type of hospital and knowledge about patient rights among the selected sample

Item	Hospital		Total (%)	P
	Governmental (%)	Private (%)
Having previous knowledge about the existence of a consent form to be signed on hospital admission	98/112 (87.5)	60/64 (93.8)	158/176 (89.8)	0.294
Signed a consent on hospital admission	66/92 (67.3)	34/60 (56.7)	100/158 (63.3)	0.237
Read and understood the content of the consent form	44/98 (44.9)	34/60 (56.7)	78/158 (49.4)	0.217
Agree that there is an importance for the consent form	84/98 (85.7)	54/60 (90)	138/158 (87.3)	0.427
Heard about patients’ rights in hospitals?	64/112 (57.1)	28/64 (43.8)	92/176 (52.3)	0.162
Agree that patients’ rights are important	58/62 (93.5)	26/28 (92.9)	84/90 (93.3)	0.21
Aware about the existence of a complaint box	40/112 (35.7)	26/64 (40.6)	66/176 (37.5)	0.736

Reason of admission also did not affect the knowledge status regarding the selected variables of patients' rights [Table 5], except for the importance of the consent form, which was significantly lower among those admitted for surgical and obstetric/gynecological treatment than among those admitted for nonsurgical treatment (76.7%, 86.4% and 100%, respectively; P = 0.03).

Table 5

Association between educational level and knowledge about patient rights among the selected sample

Item	Reason of admission			Total (%)	P
	Nonsurgical (%)	Surgical (%)	Obstetrics/gynecological (%)
Having previous knowledge about the existence of a consent form to be signed on hospital admission	54/66 (81.1)	60/64 (93.8)	44/46 (95.7)	158/176 (89.8)	0.158
Signed a consent on hospital admission	32/54 (59.3)	42/60 (70)	26/44 (59.1)	100/158 (63.3)	0.626
Read and Understood the content of the consent form	26/54 (48.1)	30/60 (50)	22/44 (50)	78/158 (49.4)	0.988
Agree that there is an importance for the consent form	54/54 (100)	46/60 (76.7)	38/44 (86.4)	138/158 (87.3)	0.03*
Heard about patients’ rights in hospitals?	34/66 (51.5)	26/64 (40.6)	32/46 (69.6)	92/176 (52.3)	0.105
Agree that patients’ rights are important	30/32 (93.8)	24/26 (92.3)	30/32 (93.8)	84/90 (93.3)	0.566
Aware about the existence of a complaint box	24/66 (36.4)	22/64 (34.4)	20/46 (43.5)	66/176 (37.5)	0.606

*Significant at the 0.05 level

About two-thirds of the study sample was not aware of the existence of a complaint box within the hospital where they were admitted.

Only 22 of 176 (12.5%) respondents have used the suggestion/complaint box to register a complaint, while 26 (14.8%) chose to register their complaints with the treating physician, with no statistically significant difference between private and public hospitals. Further, 96 (54.5%) chose to register their complaints with the responsible manager, with the percentage being higher among those admitted to private hospitals (65.6% vs. 48.2% admitted to public hospitals; P = 0.19). Interestingly, 34 (19.3%) chose to “do nothing” when having a complaint, with the percentage being significant higher among those admitted to public hospitals (28 [82.3%] vs. 6 [17.6%] admitted to private hospitals).

DISCUSSION

To demonstrate the relation between patients' rights and quality care, this study answered the following questions: Are patients admitted to hospitals aware of their rights? Are there any differences in the level of awareness between genders, educational level or being admitted to the public/private hospital?

In this study, it was found that the consent form followed by complaint registration against a service provided was the best-known patients' rights variables, both of which are indicators of good quality patient care.

The study had a young population, with a mean age of 34.23 ± 9.34 years. Further, in addition to the two-thirds of the study participants who had a university-level education and above, surprisingly, the results of this study show that even the one-third lower educated young population are aware of important variables of patients' rights. This result can have a great impact on planning and assessing the quality of care provided in Saudi hospitals, which in turn may help in reshaping services and preadmission procedure. Therefore, these results indicate the need for strengthening points of patients' rights, similar to results found by another study conducted in Jeddah, Saudi Arabia.[11]

According to Leon, people belonging to the low social class have a low awareness of patients' rights and pay attention only to their basic needs. A concern for health-care rights seems to be beyond their scope, which in turn may affect their perceptions to details regarding health-care delivery. This could possibly be a reason that may lead a health-care facility to provide low-quality patient care. Therefore, although these low social class patients may perceive the need for receiving improved quality of health care, their lack of patients' rights awareness may result in them not obtaining the desired changes.[14]

About half of the study population had never heard about patients' rights, although the majority stated that it is a critical issue, which is in accordance with the findings of similar studies conducted in Saudi Arabia and Egypt.[81113]

About two-thirds of our study population was not aware of the existence of a complaint/suggestion box. In this study, less than one-third of patients or their accompanying family members (19.3%) would prefer to do nothing when faced with problems or harm in the hospital, which is in contrast with the findings of Abou Zeina et al., who found that patients preferred to raise complaints with the administrative authorities.[1315] The high percentage of patents who chose to complaint in our study could be due to their awareness of their rights or the mode of complaint, as was evident by 54.5% of the study population choosing to register their complaint with the responsible manager. The statistically significant difference when comparing the negative attitude toward presenting their complaint between public (82.3%) and private hospitals (17.6%) may be attributed to the prompt response of private hospitals in resolving issues their patients face. However, the negative attitude toward complaints in public hospitals is alarming and highlights the need of making patients completely aware of their rights to ensure the commitment of hospitals to quality care.

The main source of knowledge about patients' rights is wall placards (43.5%), followed by mass media (34.8%). These results are in accordance with the results of a study conducted in South Egypt.[13] Therefore, to increase patients' rights awareness, it may be crucial to focus on and give attention to placards and their placement in hospitals. Similarly, it would be valuable to strategize a new method to spread patients' rights awareness among patients and their accompanying family members. Research has indicated that mass media also plays a significant role in making people aware of their legal and social rights, which in turn help them be knowledgeable and informed about everything related to their care plan. However, usage of media requires elaborate planning, beginning from the higher-level management of the hospital.[1116]

Although patients' rights have an increasing emphasis around the world, they are relatively less known in Saudi Arabia and are often recalled only when health-care providers make mistakes that result in death or disability, reflecting bad quality patient care.[51016]

When considering the cause of admission, it was found that there was no statistically significant difference between the variables studied, except for the importance of consent form, which was higher among those admitted for nonsurgical treatments as compared with those admitted for surgical and obstetric/gynecological treatments. This finding is in contrast to the findings of Abou Zeina et al.[13] Perhaps, the findings of this study may be attributed to the fact that signing a consent form is mandatory for surgical and obstetric/gynecological treatments, and possibly the study population indicated the need and importance of also applying the consent form for nonsurgical treatments.

This study found that about 80% males, compared with 54% females, signed a consent form on hospital admission, which may be attributed to social factors related to the Saudi culture where a male can sign on behalf of female family members he is accompanying during a hospital stay. Interestingly, among those who signed the consent form, the percentage of females who read and understood the contents of the consent form were higher than that of male, thereby signifying the need for future studying gender-based accurateness and meticulous nature when signing the consent form.

CONCLUSION

Although the study sample does not claim to be representative, the findings reflect an insight into the situation in Saudi Arabia. The study demonstrated that there is a low level of awareness of patients' rights in Al-Madinah Al-Munawarah. Wall placards, mass media and health-care providers are important sources of spreading knowledge pertaining to patients' rights.

The introduction of PBR in Saudi Arabia is a valid and reliable tool in ensuring the quality of health service and protection of patients' rights. Health-care policymakers should recognize the importance of patients' rights as means of providing better quality care and a higher rate of patient satisfaction. This can be established through measures to tackle obstacles that impede the implementation of PBR.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest