Investigating Medical Students' Attitudes Towards Women's Patients' Rights: Implications for Ethical Gynecological Care

Introduction: The provision of ethical care is a critical component of the medical profession, and adherence to the patient's bill of rights is essential to ethical care. This study aimed to investigate medical students’ attitudes toward the provisions of the patient's ethical charter. 

Methods: A cross-sectional descriptive-analytical study was conducted between March 2022 to July 2022, in the gynecology department among several medical students in the 1st to 10th semesters at Mazandaran University of Medical Sciences. Data were collected using valid and reliable questionnaires containing 22 questions about the women's patient's bill of rights provisions. The questionnaire scoring scale was based on the five-point Likert scale. Students' views were classified into three levels: favorable, relatively favorable, and unfavorable. 

Results: 230 medical students participated in the study, with a mean age of 21.96±2.89, and 37% were women. The average student had a relatively favorable attitude toward the patient's Bill of Rights provisions. There were no significant differences between men and women or between students who had related programs about the patient's bill of rights and those who did not. The correlation between age and semester by attitude score towards the patient's right charter showed a significant relationship. With increasing age, the attitude toward patient rights standards worsened. Higher-semester students were more unfavorable toward the patients' bill of rights provision. 

Conclusion: The study findings suggest that implementing medical courses and programs related to women's patient's bill of rights could be more effective. Medical students' attitudes towards the patient's ethical charter worsen with increasing age and academic term. Further studies are required to identify the reasons behind this trend and improve the implementation of medical courses and programs related to the patient's bill of rights.

Patients' rights especially women patients right in medical research have long been recognized as an essential element of healthcare ethics [1]. Patient rights are fundamental principles enshrined in medical standards and laws, and the medical staff is responsible for ensuring they are implemented [2]. The Charter of Patients’ Rights aims to preserve human dignity and should be written based on the patient's perspective and stakeholders. However, the charter's provisions have shortcomings, including low executive power and guarantee. Despite an agreement between service providers and recipients about respecting patients' rights, discrepancies exist in their interpretation of some charter provisions [3]. Ancient traditional medical texts provide insight into the importance of medical ethics and the doctor-patient relationship. For instance, works such as "Al-Hassan al-Baqaratiyah" by Abul Hasan Tabari, "Al-Tab Ruhani" by Razi, and "Kamal al-Sanaa al-Tabieh" by Ali Ibn Abbas Ahwazi emphasize the importance of respecting patients' rights. Historical literature also highlights doctors' obligations to their patients. To improve patient rights in contemporary medicine, it is crucial to understand the awareness levels of service providers and recipients, as deficiencies in awareness may hinder the realization of patients' rights. Studies have shown suboptimal awareness levels regarding patients' rights. More than establishing guidelines and rules may be necessary for achieving desirable results [4]. To address this gap, this study investigates the attitudes and opinions of medical students at Mazandaran University of Medical Sciences concerning patients' rights and ethical charters.

Our study aims to explore the perspectives and attitudes of medical students from Mazandaran University of Medical Sciences toward adherence to women patients' rights and ethical principles. Our findings could inform the development of more effective programs focused on women's patients' rights and offer valuable insights for policymakers in their strategic planning efforts.

The present study is a cross-sectional descriptive-analytical investigation that aims to assess the attitudes and opinions of medical students at Mazandaran University of Medical Sciences toward patients' Bill of Rights provisions. The statistical population of the research comprises medical students enrolled in the first to tenth semesters of the university in 2022. The data were collected via a self-reported two-part questionnaire that contained 22 items related to the patient’s bill of rights provisions. The questionnaire was designed to measure attitudes using a five-point Likert scale ranging from deficient to very high. Accordingly, a score of 1 indicates the most increased positive tendency, while a score of 5 indicates the lowest favorable preference. The minimum score for completing the questionnaire is 2.2, and the maximum score is 110, with higher scores reflecting fewer positive attitudes toward patients' Bill of Rights provisions. The questionnaire also includes demographic questions at the beginning to collect background information. The data are classified into three categories based on the students' attitudes: favorable (22-51), relatively bright (52-81), and unfavorable (82-110). The questionnaire utilized in this study is valid and reliable, ensuring the accuracy and integrity of the obtained data. 

The questionnaire employed in this study was adapted from previous research by Mehrnoosh Abbasi et al. (2010), as well as from the charter of patients' rights endorsed by the Ministry of Health, Treatment, and Medical Education, which draws from the work of Parsapour (2006). Initially, medical ethics experts and professors assessed the questionnaire for content and form validity, followed by pilot testing. Ultimately, the medical ethics department of Tehran University reviewed and approved the questionnaire. The questionnaires will be administered confidentially and anonymously to comply with ethical principles. The study will span eight weeks, during which data will be collected and analyzed using descriptive statistics, parametric t-test, and non-parametric Mann-Whitney and correlation tests based on the normality of data distribution, with SPSS v19 software. Participants must be enrolled in a medical program and express a willingness to participate in the study. Dissatisfaction with participation will be grounds for exclusion. Quantitative variables will be summarized using mean (standard deviation), while qualitative variables will be outlined as numbers and percentages. The Kolmogorov-Smirnov test will verify normal data distribution, and the average (95% confidence interval) attitude score will be calculated. The proportion of individuals with favorable, relatively favorable, and unfavorable attitude levels and their respective 95% confidence intervals will be determined based on proposed cutoff points. The attitude levels of the study groups will be compared using a t-test and Mann-Whitney test, with a level of statistical significance set at 0.05. Statistical analyses will be conducted using SPSS software version 16. Participants will provide informed consent, and their data will remain confidential. Results will be published only in aggregate, and participants will be informed of the study's findings.

The present study examines the attitudes of 230 medical students at Mazandaran University of Medical Sciences toward patients' rights, using a questionnaire-based survey conducted between March 2022 and July 2022. The mean age of the participants was 21.96±2.89, ranging from 18 to 45 years old. Of the participants, 85 (37%) were female, and 145 (63%) were male. Approximately 96.6% of the participants were aged between 18 and 26, while 5.7% were married. By the end of the study period, 31 (13.5%) participants had received related classes about acknowledging patients' rights. (Table 1).

Table 1: Demographic characteristics of participants (n=230).

The score of the student’s attitudes toward the patients' bill of rights showed a normal distribution, with a mean score of 58.06±15.74, ranging from 22 to 101. The average student had a relatively favorable attitude (the second level of our classification) toward the Bill of Rights of Patients. Specifically, 33.9% of students had good attitudes (score between 22 and 51), 60% had relatively good attitudes (score between 52 and 81), and 6.1% had unfavorable attitudes (score between 82 and 110) toward the patients' bill of rights. No significant differences were found between men and women or students who had related programs about patients' accounts of righteousness and those who did not. (Figure 1).

Figure 1: Students' attitude score histogram towards patients' bill of rights, favorable attitudes (22-51 score), favorable attitudes (52-81score), unfavorable (82-110 score) attitudes.

Spearman's test showed a significant relationship between age and attitude score toward patients' bill of rights (P=0.037, correlation coefficient =0.137), indicating that the attitude toward the standards of patient's rights worsens with increasing age. Additionally, a significant relationship was observed between the semester of students and attitude score toward patients' bill of rights (P=0.003, correlation coefficient =0.198), suggesting that students with higher semesters had a more unfavorable attitude toward the patients' bill of rights provision. (Figure 2).

Figure 2: Correlation between students' semester and attitude score toward patients' bills of rights according to questionnaire provision.

The results also revealed that the best score and favorable student attitude were observed for the second question, "Providing diagnostic-therapeutic services without discrimination (gender, ethnicity, type of insurance, income, etc.).” In contrast, the worst score was observed for the last question, "Expressing the error that occurred during the provision of services to the patient by the person committing the error." No significant differences were found between men and women students in the questionnaire's questions, except for the seventeenth question, "Providing sufficient information about the rare side effects of the treatment in a time understandable to the patient or his companion," where women had a significantly better attitude than men (P=0.037). Married and unmarried students also showed very different perspectives (P=0.003) toward the sixteenth question, "The possibility of leaving the hospital with the patient's consent against the opinion of the treatment team," with married students having a better attitude toward this provision. Finally, significant correlations were observed between age and four conditions of the questionnaire (questions 6, 10, 12, and 14), indicating that the attitude toward these provisions worsens as the age of the participants increases. Furthermore, a reverse correlation was observed between semester and attitude toward questions 1, 2, 3, 6, 12, 17, 18, 19, 20, and 22. This suggests that students with higher semesters were less favorable toward these charter standards of patients' rights.

Davarzani conducted a comparative study in the form of a documentary analysis to review the bill of rights of patients in different countries, international laws, and the domestic laws and bill of rights of Iran. This study compared and contrasted the legal framework surrounding patients' rights across various countries and jurisdictions [1]. Azodi and colleagues conducted a census-sampling-based research study among Bushehr University of Medical Sciences medical students. The study examined medical students' views regarding respect for patients' rights. The study found that the score of the student’s views on patient rights was lower among final-year students compared to first-year students [2].

A study similar to ours, conducted by Al Anazi, addressed the importance of incorporating patient rights and preferences into healthcare practices. While our research focused on medical students' attitudes toward the patient's bill of rights, this study investigated the level of awareness and knowledge among undergraduate students and medical interns in Tabuk City. The first similarity between the two studies was the acknowledgment that incorporating patient priorities and preferences into healthcare can improve outcomes, such as better communication, patient engagement, and informed decision-making. Both studies recognized the significance of considering patient rights in clinical practice. The findings from this study indicated room for improvement regarding awareness and knowledge of the patient's bill of rights among healthcare professionals. Our study reveals a decline in medical students' attitudes toward the provisions of the patient's bill of rights as they progress through higher semesters, suggesting improved educational strategies are needed. In contrast, Al Anazi’s study reports that around two-thirds of the participants have heard about the patient's bill of rights, with varying sources of information. The overall knowledge scores indicate a moderate level of knowledge, but there is room for improvement, particularly among medical interns [5].

Parsapour and colleagues conducted a descriptive, analytical, cross-sectional study in three general educational hospitals in Tehran. The study aimed to collect information on the necessity of patient rights from patients, doctors, and nurses. The study used a questionnaire about demographic information and the importance of patient rights. The results showed that all groups recognized the need to observe almost all patient rights. The main disagreement among the groups was related to the patient's right to access information and make decisions, but this difference of opinion was not generally significant [3]. A study by Davis explored nursing students' views, indicating more robust support for an active nursing role in disclosure, informed consent, expressing professional opinions, and patients' decision-making than medical students. These findings emphasize the significance of healthcare professionals' involvement in upholding patient rights and suggest the potential for nurses to contribute more actively to the disclosure process, promoting patient-centered care. Collectively, both our and Davis’s studies underscore the importance of continuous evaluation and improvement in medical education, interdisciplinary collaboration, and recognizing nurses' unique contributions to ensure the effective implementation of the patient's bill of rights throughout the healthcare system [4].

Bagheri and colleagues researched to determine the priorities of medical ethics in the country. They created a scientific approach to the issues and challenges of medical ethics at the national level based on the opinions of thinkers in this field. Bagheri identified patients' rights, doctor-patient relationships, justice in the distribution of health resources, autonomy, informed consent, doctor-patient financial relationship, and hospital ethics committees as the country's first ten priorities of medical ethics. Overall, these studies provide valuable insights into the issues surrounding patient rights and medical ethics in Iran and offer solutions to improve the current situation [6]. Another study conducted by El-Sobkey and colleagues aimed to investigate the knowledge and attitudes of health professions students at the College of Applied Medical Sciences (CAMS) in Riyadh, Saudi Arabia, regarding the Saudi Patient's Bill of Rights (PBR). The researchers aimed to assess the students' awareness of the existence and content of the Saudi PBR and examine their attitudes toward its ineffectiveness. The study also explored the correlation between students' academic level, knowledge, and attitudes regarding the PBR. The findings revealed limited knowledge among the students about the Saudi PBR, with only half aware of its existence and a small percentage knowing specific items in the bill. Despite this limited knowledge, most students held a positive attitude toward the ineffectiveness of patient rights [7].

Parsapoor and colleagues reported a cross-sectional study to compare the attitudes of patients, physicians, and nurses toward the importance of observing patients' rights in different hospital settings. The study showed general agreement among all groups regarding the necessity of most aspects of patients' rights, with some disagreements observed about patients' right to access information and make choices about their healthcare. They concluded that healthcare providers, particularly physicians, should be better acquainted with patients' rights to meet their expectations and ensure effective patient-centered care [8]. Overall, these studies highlight the need for increased awareness and compliance with patient rights in healthcare settings and the potential influence of religious teachings on the understanding and observance of these rights.

This study represents a significant contribution to the existing literature, as it is among the few investigations undertaken in the field of interest amongst Iranian medical students. Nonetheless, it is not without limitations, as the statistical population's gender distribution was unequal. Furthermore, relying on self-reported data in the form of completed questionnaires may have introduced recall biases and other potential inaccuracies.

The findings of this investigation yielded statistically significant outcomes. Nonetheless, exercising prudence in reaching definitive conclusions is crucial until the specific causal factors underpinning these results are identified. Consequently, we suggest that future research endeavors concentrate on ascertaining potential determinants for these negative trends. Furthermore, the clinical ramifications of these findings extend to healthcare administrators and policy-makers, who should consider implementing strategies to address the underlying issues responsible for the identified trends.

In conclusion, this study examined medical students’ attitudes at Mazandaran University of Medical Sciences toward the women's patients' ethical charter. The findings suggest that, on average, the students held a relatively favorable attitude toward the Bill of Rights of Patients, which falls within the second level of our classification. Moreover, there were no significant differences in attitudes between male and female students, nor between those who had undergone related programs and those who had not. However, a negative correlation was observed between age and attitude score toward patients’ rights, indicating that the attitude towards the standards of patients’ rights worsened with age. Similarly, a negative correlation was seen between semester and attitude scores toward specific charter standards of patients' rights. These results imply that current medical courses and programs relating to the patients' charter may need to be more effective in shaping students' attitudes. Further research is required to identify the reasons for this phenomenon, and decision-makers in this field should reconsider their previous plans and decisions.

Acknowledgments

The researchers express their sincere gratitude to the Ethics and Research Committee and Gynecology Department of Mazandaran University of Medical Sciences, the affiliated colleges and medical centers, the students and staff of the university, and the medical centers affiliated with Mazandaran University of Medical Sciences.

Authorship 

all authors meet the ICMJE authorship criteria.

Conflicts of interest 

No potential conflict of interest relevant to this article was reported.

Funding

The authors received no financial support for this article's research, authorship, and publication.

Ethical approval 

This study was approved by Mazandaran University of Medical Sciences (IR. MAZUMS.REC.1400.8603). The analysis was performed by the principles of the Declaration of Helsinki.