The Awareness of Patients' Bill of Rights among Medical Interns and Medical Students at Tabuk University.

BACKGROUND: Incorporating patient priorities and preferences into their healthcare can improve desirable proximal outcomes related to communication such as the patient feeling heard, understood, respected and engaged in their care, which can soften the negative effects of the illness and can help clinicians in decision-making. AIM: To determine the level of awareness and knowledge of Patients' Bill of Rights and factors affecting it among undergraduate students and medical interns.
METHODS: This is a cross-sectional study carried out in Tabuk city among all medical interns doing their clinical rotations at Tabuk city (n = 70) as well as the 4th, 5th and 6th-year medical students, Tabuk University (n = 219). An English self-administered valid and reliable questionnaire, based on patients` Bill of Rights (PBR) document published by the Ministry of Health (MOH), Kingdom of Saudi Arabia (KSA) was utilised for data collection.
RESULTS: The study included 205 medical students and interns out of invited 289, giving a response rate of 70.9%. All were Saudis. Almost two-thirds (69.3%) reported hearing about patients` bill of rights. Among those who have heard about these rights, 40.2% gained their information from lectures whereas 16.2% gained the information from hospital posters. The total knowledge score about Patients` Bill of Rights ranged between 0 and 32 (out of a possible maximum of 34) with a mean ± SD of 24.6 ± 4.6 and median (IQR) of 25 (23-27). There was a significant positive correlation between student`s age and total score of knowledge of patients` bill of rights, Spearman`s correlation coefficient (r) = 0.18, p = 0.014. The mean rank of the total knowledge score was 83.98 among 4th-grade medical students and reached to 125.07 among medical interns, p = 0.003.
CONCLUSION: Overall awareness and Knowledge of the senior medical students and interns in the College of Medicine, Tabuk University regarding patients` rights age acceptable. However, some deficient issue needs to be improved. Copyright:

Introduction

Human rights are rights inherent to all human beings, regardless of race, sex, nationality, ethnicity, language, religion, or any other status [1].

The term “human rights” refers to those rights that have been recognised by the global community in the Universal Declaration of Human Rights (UDHR), adopted by the United Nations (UN) the Member States in 1948, and in other international legal instruments binding on States [2]. Human rights are not only a generic term representing a symbol of our contemporary society but are also the reflection of a common perception of human values [3]. Health is a major part of our human rights and our understanding of a life in dignity [4]. The World Health Organization (WHO) defined health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”.

WHO also states that “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, and political belief, economic or social condition [5]. Patients’ rights differ from country to another and from different authorities, also depending upon prevailing cultural and social norms [6]. Saudi Ministry of Health issued a Patient’s Bill of Rights (PBR) in 2006 and defined it as “Patient’s rights are policies and rules that must be preserved and protected by the Health facility toward patients and their families.”

In recent years, the concerns about the patients’ values and preferences of treatment have raised, to participate in the decision-making process. Incorporating patient priorities and preferences into their healthcare can improve desirable proximal outcomes related to communication such as the patient feeling heard, understood, respected and engaged in their care, which can soften the negative effects of the illness and can help clinicians in decision-making. This would enhance the medical and physiological outcomes, as well as result in decreased anxiety, greater confidence in and adherence to doctor’s treatment plans, increased satisfaction with care and higher levels of trust in healthcare providers [7]. Human rights principles that apply to patient’s care include the right to get the highest attainable standard of health, which covers both positive and negative guarantees in respect of health, as well as political rights ranging from the patient’s right to be free from torture and cruel treatment to liberty and security of person. They also brought to the attention the right of socially excluded groups to be free from discrimination when providing health care. Critical rights that relevant to health care providers involve the freedom of association and the enjoyment of decent work conditions [8]. 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 the 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 [9]. To make sure the rights of patients are protected requires more than educating policy measures and health providers; it requires educating people about what they should expect from their health care providers, about the kind of treatment they should receive [10]. Patients’ bills of rights are derived from the values and ethics of the medical profession. Like the right of informed consent, confidentiality, privacy, autonomy, safety, respect, treatment choice, refuse the treatment and participating in the treatment plan [11]. Patients must be competent to understand the relevant information and the decision choices and must not be enforced into accepting treatment against their wishes.

Many studies have been conducted internationally to assess the awareness and implementation of Patients’ Bill of Rights among undergraduate students, medical interns and physicians but only a few studies done locally and no single study has been done in Tabuk area. In a study done in Saudi Arabia in 2012 by Saad Abdullah Alghanim titled “Assessing knowledge of the patient bill of rights in central Saudi Arabia: a survey of primary health care providers and recipients” explore the implementation of the PBR that was introduced recently in the Saudi health care system and showed that 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 [12].

Another study done in Riyadh, Saudi Arabia in 2014 by Salwa B. El-Sobkey and her colleagues with a title “Knowledge and attitude of Saudi health professions’ students regarding patient’s bill of rights” was aimed to investigate the knowledge of health professions’ students at College of Applied Medical Sciences (CAMS) Riyadh Saudi Arabia regarding the existence and content of Saudi PBR as well as their attitude toward its ineffectiveness. The results showed that half (52.3%) of the students had perceptual knowledge regarding the existence of Saudi PBR and only 7.9% of them were knowledgeable about some items (1-4 items) of the bill. Privacy and confidentiality of the patient were the most common known patient’s rights. Students’ academic level was not correlated to neither their knowledge regarding the bill existence or its content nor to their attitude toward the bill. The majority of the students (93%) reported that only one course within their curriculum was patient’s rights-course related. About one quarter (23.4%) of the students reported that teaching staff used to mention the patient’s rights in their teaching sessions [6].

In a recent and local study done in 2017 in the Eastern Province of Saudi Arabia by Sarah A. Al-Muammar and her colleague to determine the doctors’ knowledge of patients’ rights at King Fahd Hospital of the University. The researchers found that about 44% of physicians had adequate knowledge about PBR and 55.56% had inadequate knowledge. Regarding physician’s response to each item of PBR, the majority (98.1%) gave the correct answer to Item 2: “Patients should know the identity and professional status of the healthcare providers responsible for their treatment” (98.1%). Item 25: “Doctors are entitled to withhold any procedures related to a patient’s condition if the patient refuses their choice of treatment” was the item with the least correct response (15.5%) and suggested that the institution should provide training and motivate physicians, especially younger doctors regarding PBR to ensure good health for all and safeguard the integrity of both the physician and the hospital [13].

Another study done in Mecca city, Saudi Arabia by Hager A. Saleh and her colleague titled “Physicians’ Perception towards Patients’ Rights in Two Governmental Hospitals in Mecca, KSA”, In this research paper the perception of physicians concerning patients’ rights and their fulfillment in two governmental hospitals in Mecca, Saudi Arabia is compared, using a self-administered questionnaire which examined the physicians’ knowledge, attitude and perception towards these rights. Results of this study demonstrated the physicians’ opinion about patients’ rights. Regarding hospital (A), the agreement of physicians on investigated rights to be a patient right in their working hospital ranged from 85.7% up to 100% for 6 rights investigated. Regarding hospital (B), the agreement ranged from 73.1% up to 100% for 4 rights investigated.

All physicians in both study hospitals indicated that the rights to know the name of attending physician, the right to be treated with caring and respect and the right to know treatment alternatives is considered an actual patient right. They concluded the study by saying that there is a similar discrepancy between physicians in both hospitals, most physicians are aware of patients’ rights and in particular of the basic human rights as respect, privacy and confidentiality and most of the physicians agreed on the importance of the patients’ rights in both hospitals while only a few percentages of them reported that patients’ rights were maintained in both hospitals [26].

A study done in 2012 in Iran aimed to assess the knowledge of students about patient Rights and its relationship with some factors. A survey was conducted on 270 medical and paramedical students of Hamedan in simple randomised sampling. Data collecting instruments were a questionnaire form that contains demographic information and educational questions regarding patient rights which its reliability and validity were made through the same measurement by two researchers.

Based on survey results mean of awareness were 10.3 with a standard division of 1.5%. Forty-seven percent of the students mentioned who are not familiar with the Bill of Rights. Low awareness was 31%, medium 53%, and high awareness was only 16%, in total. There was not any statistically significant relationship between awareness and any demographic variables. According to this study, awareness of most students about patient rights was low. So, promote awareness in the field of educational planning should be done [27].

Another study was done in 2011 in South Africa to elicit South African medical students’ experiences of witnessing patient rights abuses and professional lapses during their clinical training. Of 223 students surveyed, 183 (82%) responded, 130 (71%) of whom reported witnessing patient rights abuses and professional lapses, including physical abuse (38%), verbal abuse (37%), disrespect for patients’ dignity (25%), and inadequately informing patients about their treatment (25%). Students attributed abuse to stressed health workers, overburdened facilities, and disempowered patients. Most students who witnessed abuse (59%) did not actively respond, and 64% of survey respondents felt unprepared or uncertain about challenging abuses in the future. Interviews with 28 students yielded detailed accounts of the abuses witnessed and of students’ emotional reactions, coping strategies, and responses.

Most students did not report abuses; they feared reprisal or doubted; it would make a difference. These results highlight the need to align medical ethics and human rights with medico-legal protocols in theory and clinical practice [28].

Material and Methods

This is a cross-sectional study; it was carried out in Tabuk city, which is the capital city of the Tabuk Region in northwestern Saudi Arabia. This study concentrated on two subjects: Medical interns doing their clinical rotations at Tabuk city and the 4th, 5th and 6th-year medical students at Tabuk University. The total number of participants is 289 participants.

An English self-administered questionnaire was given to all participants. It was used previously in a Saudi study and proved that it was valid and reliable [13]. It is based on PBR document published in 2007 by the Ministry of Health (MOH), Kingdom of Saudi Arabia (KSA) [14]. It consists of three sections. Section 1 includes the demographics of the participants (age, gender and professional status). Section 2 inquiries about the experience with patients` rights (History of hearing about patients’ bill of rights, Source of hearing about patients’ bill of rights and history of reading the bill and knowing its contents). The third section includes 34 statements to explore participant`s knowledge regarding PBR. All items have three possible responses; “Agree”, “Disagree”, and “Do not know”. Each correct answer was assigned a score of 1 and for every incorrect or “don`t know” responses, a score of “0” was assigned. The total score was computed for each participant, tested for normality of distribution and utilised for comparisons

Approval of the research proposal was obtained from the Regional Research and Ethics Committee. Administrative approvals from the Dean of College of Medicine, Tabuk University, was obtained. Verbal consents were taken from all participants before data collection. Confidentiality of information was assured.

The collected data were analysed with the help of a biostatistician using Statistical Package for the Social Sciences (SPSS) program version 25 developed by International Business Machines (IBM®) Corporation.

Descriptive analysis like frequencies, percentages, mean, range and standard deviation were used. Since the total PBRs knowledge score was abnormally distributed as seen by significant Shapiro-Wilk test, non-parametric statistical tests were applied; Mann-Whitney test to compare two groups and Kruskal-Wallis test to compare more than two groups. Spearman`s correlation test was utilised to correlate between two continuous variables. P-values of less than 0.05 were considered significant.

Results

The study included 205 medical students and interns out of invited 289, giving a response rate of 70.9%. The age was available for 193 participants and ranged between 21 and 29 years with a mean±SD of 23.3±1.4 years. All were Saudis. Table 1 shows their gender and professional status distribution. About two-thirds (68.3%) were females, and 30.2% were recruited from the 4th year medical students, whereas 22.4% were interns.

Table 1

Gender and professional status of the participants (n = 205)

	Frequency	Percentage
Gender
Male	65	31.7
Female	140	68.3
Professional status
4th-year medical student	62	30.2
5th-year medical student	45	22.0
6th-year medical student	52	25.4
Medical Intern	46	22.4

Experience with patients’ bill of rights

A group of 69.3% of the participants reported hearing about patients` bill of rights. Among those who have heard about these rights, 40.2% gained their information from lectures, whereas 16.2% gained the information from hospital posters, Figure 1.

Figure 1

Source of hearing about patients’ bill of rights among the participants (n = 142)

Among those who have heard about PBRs, 54.2% have read the bill and knowing its contents.

Knowledge about patients` bill of rights

Majority of the participants could recognize that patient should be notified about the diagnosis and all treatments updates in an understandable language (98.5%), consent must be written in a language understandable by the patient (97.1%), the medical team should report any violence against children to the concerned authority (95.1%), patient has the right to know in advance about his treatment cost and insurance coverage (95.1%), patients should be examined in a private examination room (94.8%), in order to get the patient participation in a research he must be provided with clear and comprehensive information (91.2%), patient should be aware of both common and rare complications (91.2%), patients have the right to complain to the administration (90.7%) and patients are required to be treated with courtesy and respect during times of emergency (90.2%).

On the other hand, less than half of them could recognize that the patient’s medical record cannot be accessed by health care team, researchers or other hospital staff (49.3%), patient should not be provided by one consent for different interventions like surgery, anaesthesia, radiology (46.8%), treatment options should not be discussed within the health team, patients are only entitled to know the treatment plan (45.4%), a doctor cannot disclose a patients information to judicial department only with his permission (27.3%), doctors are entitled not to withhold any procedures related to a patient condition if patient refuses their choice of treatment (26.8%) and patient have the right to choose his statements to be written in the medical report (23.9%).

The total knowledge score about Patients` Bill of Rights was abnormally distributed as shown by significant Shapiro-Wilk test (p < 0.001). It ranged between 0 and 32 (out of a possible maximum of 34) with a mean ± SD of 24.6 ± 4.6 and median (IQR) of 25 (23-27), Figure 2.

Figure 2

Knowledge score of the medical students and interns in Tabuk University regarding Patients` Bill of Rights

Factors associated with knowledge about the Patients` Bill of Rights

- Participants` age

There was a significant positive correlation between student`s age and total score of knowledge of patients` bill of rights as shown in Figure 3, Spearman`s correlation coefficient (r) = 0.18, p = 0.014.

Figure 3

Correlation between student`s age and total knowledge score of Patients` Bill of Rights

- Participant`s gender

As clear from Table 3, there was no statistically significant association between participants` gender and total knowledge score about patients` bill of rights.

Table 3

Association between participant`s gender and total knowledge score about patients` bill of rights.

Gender	Total knowledge score about patients` bill of rights
	Median	IQR	Mean rank
Male (n = 65)	25	22.5-27	99.05
Female (n = 140)	25	23-27	104.84

IQR: Inter-quartile range; P value of Mann-Whitney test = 0.513.

- Professional status

It is evident from table 4 that there was a statistically significant increase in the level of knowledge regarding PBR with advancing in the professional status as the mean rank of the total knowledge score was 83.98 among 4th-grade medical students and reached to 125.07 among medical interns, p = 0.003

Table 4

Association between participant`s professional status and total knowledge score about patients` bill of rights.

Professional status	Total knowledge score about patients` bill of rights
	Median	IQR	Mean rank
4th year medical student (n = 62)	24	22-26	83.98
5th year medical student (n = 45)	26	23-26	97.46
6th year medical student (n = 52)	25.5	23.25-27.75	110.95
Medical Intern (n = 46)	26	25-29	125.07

IQR: Inter-quartile range; P value of Kruskal-Wallis test = 0.003.

- Source of hearing about Patients` Bill of Rights

Although the highest level of knowledge was observed among those who had their information about PBR from hospital posters (mean rank was 85.59), compared to other sources (lecture, internet and self-interest), the association between source of hearing about PBR and knowledge about it was not statistically significant.

- History of reading the bill and knowing its contents

There was no statistically significant association between history of reading the bill and knowing its contents and total knowledge score about it among the participants, as shown in Table 6.

Table 6

Association between the history of reading the bill and knowing its contents and total knowledge score about it among the participants.

History of reading the bill and knowing its contents	Total knowledge score about patients` bill of rights
	Median	IQR	Mean rank
No (n=65)	25	23-27	68.08
Yes (n=77)	26	23-27.5	74.38

IQR: Inter-quartile range; P value of Mann-Whitney test = 0.361.

Discussion

The patients’ bill of rights (PBR) has been introduced in the Saudi health care system several years ago, despite that, awareness about it is not adequate as evidenced by previous studies carried out among different categories and different places such as primary health care providers and recipients in central Saudi Arabia [12], physicians working at a university hospital in the Eastern Province of Saudi Arabia [13], patients admitted to hospitals in Al-Madinah Al-Munawarah [15], patients attending outpatients `clinics in Taif [16], and students of College of Applied Medical Sciences in Riyadh [6].

During clinical training, medical students and interns are in direct contact with patients; therefore, they should be aware of patients’ rights and also should respect patients and keep their information confidential [17]. The awareness and knowledge of patient right is the initial step for doing work in the right way, so it is impossible to implement it without having sound knowledge about it [18]. Since the awareness and knowledge of patients’ rights in medical practice service is important for future physicians, it is important to investigate clinical years` medical students and interns` knowledge about patient`s bill of rights. Therefore, this study aimed to explore their knowledge about PBRs in Tabuk.

The overall knowledge score about Patients` Bill of Rights in the present study ranged between 0 and 32 (out of a possible maximum of 34) with a median (IQR) of 25 [23], [24], [25], [26], [27], which indicates an intermediate level of knowledge. In a similar study conducted by Saeede et al. (2016) [19], the knowledge score of medical students regarding patients` rights in operation room was 20.06 ± 3.41, keeping in mind that different tools were utilised in both studies. In Iran [20], about 53% of the medical students had an inadequate awareness about patient’s bill of rights with a mean of awareness of 10.3% with a standard division of 1.5%. In another Iranian study [21], 35.6% of the students had poor knowledge, and 27.7% and 36.7% had moderate and good knowledge, respectively. Khodamorad et al. [22] reported that 68.4% of students were satisfactorily knowledgeable of the patients’ right to have access to medical services. Also observed that 71.5% of them had a sufficient knowledge of a patient’s right to accept or refuse treatment and 69.8% were aware of the confidentiality of a patient’s information. However, Rangrazjedi and Rabee reported that only 23% of the students had a satisfactory awareness of patients’ rights in the area of access to medical services [23] Yaghoubi reported in his study that the majority of the medical and nursing students had sufficient knowledge regarding patients’ rights [24]. Almost half (52.3%) of students of College of Applied Medical Sciences in Riyadh were knowledgeable about the existence of Saudi PBR, and only 7.9% were able to recognise some items (1–3) of the bill [6]. Comparison of various studies in this regard is impossible due to using different tools and methods to assess the knowledge regarding PBRs.

In the present study, almost two-thirds of the students and interns were aware of the patients’ rights, and the majority of them were knowledgeable concerning patients` rights in different aspects regarding diagnosis, treatment, privacy, respect and confidentiality. The same has been observed in other studies carried out among physicians and students. [6], [12], [13]. However, low rate of knowledge was observed regarding some important issues such as accessing of patient’s medical record cannot be done by health care team, researchers or other hospital staff, providing consent for each of different interventions, discussion of treatment options within the health team, a doctor cannot disclose a patients information to judicial department only with his permission and are entitled not to withhold any procedures related to a patient condition if patient refuses their choice of treatment and patient have the right to choose his statements to be written in the medical report. In a similar study carried out in Iran, most of the medical students were aware of freedom of the individual patient while the lowest level of awareness was observed regarding the right of access to health care [20].

The main source of knowledge about patients` rights in the present study was lectured. This finding necessitates organising an educational session to senior medical students and interns regarding patients` rights.

In the present study, no gender difference was observed regarding the knowledge of patients` rights. In another study carried out by Saeede et al. in Iran [19], female students` knowledge was higher than male students`. In another Iranian study, Rangrazjedi et al. observed the same [23].

A significant relationship was found between age and academic level of the students and interns and their knowledge regarding patients’ rights as the highest level was observed among interns and those with advancing age. In another Saudi study carried out among students of the College of Applied Medical Sciences in Riyadh [6], students’ academic level was not correlated to their knowledge regarding patients` rights. However, in the present study, we included interns besides students. In Iran, awareness of patients` rights was not significantly associated with any studied socio-demographic factor [20]. In another study carried out in Iran, knowledge of patients` rights was significantly associated with age, gender, educational level and health education [21].

It has been documented that awareness of patient right among medical students is essential, but its application in the future is more essential [25].

In conclusion, overall awareness and Knowledge of the senior medical students and interns in the College of Medicine, Tabuk University regarding patients` rights age acceptable. However, some deficient issue needs to be improved such as accessing of patient’s medical record by health care team, researchers or other hospital staff, providing consent for each of different interventions, discussion of treatment options within the health team, a doctor cannot disclose a patients information to judicial department only with his permission and are entitled not to withhold any procedures related to a patient condition if patient refuses their choice of treatment and patient have the right to choose his statements to be written in the medical report. There was age, and the academic level difference between the participants in this regard as older students and interns were more knowledgeable of patients` rights. The main source of information regarding the Patients` Bill of Rights was lectured.

Table 2

Knowledge of the participants about different elements of the Patients` Bill of Rights

	Right response
	No.	%
1. Patients are not required to be treated with courtesy and respect during times of emergency (Disagree)	185	90.2
2. The patient should know the identity and professional status of the health care providers responsible for his treatment (Agree)	168	82.0
3. A patient is entitled to know the name of the physician performing the procedure except in emergency case (Agree)	131	63.9
4. Patients are entitled to know a method of contacting his treating physician (Agree)	121	59.0
5. The patient should be notified about the diagnosis and all treatments updates in an understandable language (Agree)	202	98.5
6. patient’s culture & beliefs should be respected even if it was against medical advice (Agree)	151	73.7
7. A patient may have the possibility of obtaining a second opinion within the same hospital or another (Agree)	171	83.4
8. Patients should be examined in a private examination room (Agree)	194	94.8
9. When examining a patient, a third party should be present (Agree)	156	76.1
10. Treatment options should be discussed within the health team; patients are only entitled to know the treatment plan (Disagree)	93	45.4
11. The patient’s medical record can be accessed by the health care team – Researchers – other hospital Staff (Disagree)	101	49.3
12. A doctor can disclose an adult patient information to anyone upon his permission (Agree)	134	65.4
13. A doctor can disclose patients information to a research team without his permission (Disagree)	158	77.1
14. A doctor can disclose adult patients information to a specific family member (Father-Husband-Wife) without his permission (Disagree)	179	87.3
15. A doctor can disclose patients information to the judicial department only with his permission (Disagree)	56	27.3
16. A doctor can disclose patients information in case of communicable diseases (Agree)	156	76.1
17. Visitors have the right to know about the patient’s condition (Disagree)	171	83.4
18. Procedures or interventions should be briefly discussed with the patient (Agree)	116	56.6
19. A consent form is required for both routine and emergent lifesaving procedures (Agree)	131	63.9
20. Written consent is required in all procedures even if a verbal consent was acquired (Agree)	171	83.4
21. Consent must be written in a language understandable by the patient (Agree)	199	97.1
22. The patient should be provided by one consent for different interventions like surgery, anaesthesia, radiology (Disagree)	96	46.8
23. The patient should be aware of both common and rare complications (Agree)	187	91.2
24. Treatment procedure should be done even if refused by the patient (Disagree)	175	85.4
25. Doctors are entitled to withhold any procedures related to a patient condition if the patient refuses their choice of treatment (Disagree)	55	26.8
26. To get the patient participation in research, he must be provided with clear and comprehensive information (Agree)	187	91.2
27. Patient in governmental hospitals doesn’t have the right to refuse participation in any research done by the hospital (Disagree)	160	78.0
28. The patient doesn’t have the right to quit after agreeing to participate in research (Disagree)	135	65.9
29. The patient has the right to know in advance about his treatment cost and insurance coverage (Agree)	195	95.1
30. The patient doesn’t need to know about treatment cost if he was covered by insurance (Disagree)	124	60.5
31. The patient has the right to request a medical report at any time (Agree)	144	70.2
32. The patient has the right to choose his statements to be written in the medical report (Agree)	49	23.9
33. Patients have the right to complain to the administration (Agree)	186	90.7
34. The medical team should report any violence against children to the concerned authority (Agree)	195	95.1

Table 5

Association between the source of hearing about Patients` Bill of Rights and total knowledge score about it among the participants.

Source of hearing about patients’ bill of rights	Total knowledge score about patients` bill of rights
	Median	IQR	Mean rank
Lecture (n=57)	25	23-28	69.98
Internet (n=31)	24	21-26	60.42
Self-interest (n=31)	26	23-28	74.92
Hospital poster (n=23)	26	25-27	85.59

IQR: Inter-quartile range; P value of Kruskal-Wallis test = 0.152.