Knowledge of Patient’s Health Rights among Medical Students in Jeddah, Saudi Arabia 2020 – A Cross Sectional Study

Background: Saudi Arabia aims to arm the basic human rights for all its citizens. The medical students need to be aware about globally recognized rights in their study and career. Only few studies have measured the knowledge of medical students about public health rights (PBR) in Saudi Arabia. The present study aims to assess the current knowledge of medical students in Jeddah, Saudi Arabia concerning health empowerment issues and health rights. Methods: Descriptive cross-sectional study was conducted at Jeddah, Saudi Arabia among the medical students of Ibn Sina National College (ISNC), Batterjee Medical College (BMC), King Abdul-Aziz University (KAU) and King Saud bin Abdul-Aziz University (KSAUHS) Jeddah branch, between July and August 2020. Questionnaire was used to collect demographic data, along with knowledge of the rights of female patients, laws and rights of patients with disabilities, special needs and senility, reproductive health rights, and health rights of cancer patients. The data were analyzed using statistical package of social science (SPSS) version 25. Results: Of the 393 participants, 58.3% were females and 41.7% were males. Regarding consent, 72.3% and 65.1% of the participants responded that a male guardian was not required to give consent for hospital admission and discharge, respectively, and only 46.1% knew that a female patient could provide consent for a caesarean section. Only 51.7% of the students were aware about Saudi Arabian health rights including the disabled individuals; while, 44.0% did not know. About half (53.2%) knew that that special needs patients have health rights, and 25.2% believed that abortion is never allowed in Islam. Concerning the woman’s right to attain contraception, 51.1% stated that the consent was not required; while, 25.7% responded that consent from a male guardian/partner is rst required. Approximately half (49.6%) were aware that cancer patients have the right to free medical treatment, and 52.9% knew that cancer patients have the right to free surgical treatment. Conclusions: The knowledge of medical students regarding health rights of certain patient populations was not satisfactory in Saudi Arabia, which highlights the importance of health rights education in medical school.

have the right to free surgical treatment.
Conclusions: The knowledge of medical students regarding health rights of certain patient populations was not satisfactory in Saudi Arabia, which highlights the importance of health rights education in medical school.
Trial registration: 95/IRB/2020 Background Human rights, the fundamental standards of mankind re ect a common understanding towards human values, without considering human differences [1]. Health is considered as a major part of human rights and standard of quality of life [2]. The World Health Organization (WHO) referred health as not only the absence of disease or inability, but as a condition of complete physical, intellectual, and social well-being [3]. The conception of patient's right was expanded based on the standards. The rights vary from country to country depending upon widespread cultural and social norms in each country, and the standard to maintain the dignity and equality among the patients [4,5].
The World Federation for Medical Education (WFME) establishes the need to balance the academic and behavioral skills of medical students [6]. In 2006, the Ministry of Health (MOH) in Saudi Arabia issued the Patient Bills Rights (PBR) and stated about all the required rights to health care to highlight the need medical care for every citizen. These rights to health care are available in their policy, procedure manual, and regular circulars [7]. Regarding patients' values and preferences of treatment, the sustainable development purposes included many purposes and targets for promoting health. For instance, it includes incorporating patient priorities and preferences into their healthcare to enhance desirable proximal outcomes linked to communication. Appropriate understanding of patients towards care ease the impact of drawbacks of this disease and may support physicians in decision-making [8,9].
Declaration of patient's rights is still vague concept for health care workers and patients; although, nowadays there are many declarations regarding this aspect across the world [10]. Medical students as well as health care workers need to understand and accommodate the patient's health rights to insure a healthy and high-quality lifestyle for human beings and achieve professional objectives [11,12]. One of the previous studies evaluated the extent of knowledge medical students, health care workers, and patients about PBR, which showed that 39.7% of female patients had no such right to make the decision and 45.7% had no knowledge. Moreover, 32.6% and 42.3% of the respondents believed that a male guardian was required to give an approval for women's medical treatment and surgery, respectively [7]. Another cross-sectional study done in Tabuk showed that majority of participants (98.5%) noti ed about diagnosis and treatments updates in understandable language and 95.1% knew that therapeutic group ought to report any savagery against children to the specialist [3]. Considering the notable shortage of studies that measure the knowledge of medical students about PBR Saudi Arabia, medical students should be introduced to these globally recognized rights as early as possible in their study and career. The aim of this study was to assess the current knowledge of medical students in Jeddah, Saudi Arabia concerning health empowerment issues and health rights.

Study Design and Setting
This descriptive cross-sectional study was conducted at Jeddah, Saudi Arabia among the medical students of Ibn Sina National College (ISNC), Batterjee Medical College (BMC), King Abdul-Aziz University (KAU) and King Saud bin Abdul-Aziz University (KSAUHS) Jeddah branch, from July to August 2020.

Ethical Approval
The approval was obtaining from Dr. Soliman Fakeeh Hospital Scienti c Research Review Committee (DSFH IRB).

Study Sample
The targeted sample was selected from 2 nd year internship medical students by random sample selection. The students who had a previous bachelor degree in the medical eld, were excluded.

Data Collection
A validated questionnaire was used from a previous study [7] for the purpose of data collection. The questions were divided into 5 sections with total of 24 questions survey sections as following: First section was about demographic data: gender, academic year, college/ university, and previous bachelor's degree (4 questions) Second section was related to the knowledge of the rights of female patients (yes, no or I do not know) (5 questions) Third section was about the knowledge of the laws and rights of patients with disabilities, special needs and senility (yes, no, or I do not know) (3 questions) Fourth section was about the knowledge of the reproductive health rights (yes, no or I do not know) (5 questions) The last section was about the knowledge of the health rights of cancer patients (yes, no or I do not know) (7 questions)

Data Analysis
All data were analyzed using statistical package of social science (SPSS) version 25. Any signi cant differences were assessed by frequency, means, and chi square test. Data were considered signi cantly different when p < 0.05.

Results
A total of 393 participants were recruited in this study, among which 58.3% were females and 41.7% were males. Further, 21.8% of the participants were from KAU, 43.5% were from ISNC, 21.8% were from BMC, and 12.7% from KSAUHS. The total mean age of the participants was 22.22 ± 1.86 ( Table 1).
The results of assessing the knowledge toward the rights of female patients showed that 72.3% and 65.1% of the participants responded that a male guardian was not required to give consent for hospital admission and discharge, respectively. Similarly, 71.2% and 60.6% of the participants responded correctly that hospital rules do not need female patients to acquire a male guardian's consent for medical treatment and surgery, respectively. However, a caesarean section showed that only 46.1% of the medical students had knowledge that women can make their decision for herself and provide consent; whereas, 21.6% believed that female patients did not have this right, and 32.3% did not know about this at all ( Table 2). Table 3 shows the analysis of knowledge of medical students towards the law and rights of patient with disabilities, special needs and senility. It shows that only 51.7% of the students knew that Saudi Arabian health rights law includes those with disability; while, 44.0% did not know. Approximately, half of the participants 53.2% knew that special needs patients have health rights. More than half of the participants (56.7%) knew that senility people have health rights; whereas, 36.1% did not know (Table 3).
Regarding perceptions of reproductive health rights, approximately 25.2% of the participants believed that abortion is completely forbidden in Islam; whereas, the majority 63.1% of them knew that abortion is allowed in exceptional cases. When asked about a woman's right to attain contraception, 25.7% responded that consent from a male guardian/partner is rst required and 51.1% stated that the consent was not required. Further, 65.4% of the participants knew that screening includes human immunode ciency virus (HIV) testing. Regarding HIV/acquired immunode ciency syndrome (AIDS) patients in Saudi Arabia, 53.2% knew that these patients have health rights; while, 41.0% did not know. Concerning sexual/reproductive information, 45.8% of the participants were knowledgeable of this; whereas, 35.9% were not aware about this (Table 4).
Majority the participants (74.3%) agreed that disclosure of full information regarding their illness is a patient right, and most of them agreed (78.9%) that newly diagnosed cancer patient must get full information about their disease. Most participants (75.6%) also believed that a patient had the right to withhold information from his/ her family. About half of the participants (55.5%) were knowledgeable that cancer patients in Saudi Arabia have the right to free medical treatment. About 52.2% of the participants responded that cancer patients have the right to free chemotherapy treatment. However, 49.6% of the participants also responded that cancer patients have the right to free radiotherapy treatment. Only half of the participants (52.9%) knew that cancer patients have the right to free surgical treatment; whereas, 41.2% did not know about it (Table 5).

Discussion
The results of present study showed that participants have an acceptable knowledge regarding the rights of female patients. However, there is a lack of knowledge about the right of consenting herself for cesarean section, because they believed that female need a consent from a male guardian. Only few of the participants knew about such right (32.3%); while, 46.1% knew that they can consent for herself. In contrast, study done in KAU on medical students found that the participants were not well informed generally about rights of female. However, a similar nding to the present study concerning the right of female to consent a caesarian section for herself showed that more than half of the students had poor knowledge [7]. The misconception that male guardian should be informed started to disappear due to the increased awareness of female rights, empowerment, and acknowledgment in Saudi Arabia [13].
Abortion is never allowed in Islam except in some exceptional cases, where it might threat the mother or the fetus. This decision should consider the gestational age at time of termination [14]. The results of the present study showed that understanding of the patients towards this right was satisfactory (63.1%), as compared to another which showed that there is poor knowledge among medical students concerning abortion in Saudi Arabia [5]. It is assumed that participants in the present study has good knowledge due to including the abortion topic in the curriculum in medical colleges.
Regarding HIV/AIDS patients' rights, 41.0% of participants failed to recognize that right. One third of the study participants were unknowledgeable of sexual/reproductive information. Previous study has also shown that the level of knowledge on sexual health among adolescents and youth in Saudi Arabia is poor [3]. It is not surprising that knowledge of sexual health rights among these students is especially low because the traditional Saudi culture discourages discussion of this subject. Half of the individuals with disabilities, special needs, and senility patients can comprehend about their rights. In contrast, more than one third do not know if they have rights. This is comparable to another study which concluded that almost half of the participants had knowledge about those rights [7]. This increase in knowledge is due to current curriculums mentioning a lot of scenarios about those vulnerable patients.
Concerning the rights of cancer patients in the present study, it is shown that 74.3% of participants understand that full disclosure of information is a patient's right, which is similar to the results of a study done on medical students in University of Dammam [4]. Majority of our participants (78.9%) believed that the patient has the right to have full information to a newly diagnosed cancer. Most of the participants (75.6%) agree that the patient has the right to hide this information from his/her family. Similar results were observed towards providing full information to a newly diagnosed cancer patient about his/her disease. However, half of the participant were knowledgeable, concerning the right of patient withholding information from their family [7].
Cancer patient's rights represent an essential part; therefore, medical ethics place a high value on providing truthful information to the patients. The results of present study have shown that half of the participants have positive knowledge about cancer patients' rights to free medical, chemotherapy, radiotherapy, and surgical treatment; whereas, more than one third of them do not know about such right. These results are in agreement with the previous study by Al-Amoudi et al [2]. The present study showed lack in knowledge in medical students concerning the rights of patients. However, some limitations of this study include participation of unequal number of students from the four colleges and no interns from recruited from KSAUHS.

Conclusions
The results of present study con rm that majority of the study participants had poor knowledge regarding the rights of female, reproductive, elderly, special needs, disabled, and cancer patients. Concerning the future doctors, it is important to transform and enhance knowledge of the existing laws and regulations considering the health rights of all patient groups for delivering optimal health care. Therefore, it is recommended that curriculum of medical colleges must include patients' health rights as a subject to improve the health outcomes of all medical students. The approval was obtaining from Dr. Soliman Fakeeh Hospital Scienti c Research Review Committee (DSFH IRB) with approval number: 95/IRB/2020. All methods were performed in accordance with the relevant guidelines and regulations. The authors approve their consent to publish. Written informed consent was obtained from all subjects or, if subjects were under 18, then from a parent and/or legal guardian.

Availability of data and materials
The data will be available for review from the corresponding author, on request.

Informed Consent
Informed consent was taken and institutional approval was obtained from Dr. Soliman Fakeeh Hospital Scienti c Research Review Committee (DSFH IRB) with approval number: 95/IRB/2020. Written informed consent was obtained from all subjects or, if subjects were under 18, then from a parent and/or legal guardian.

Competing interests
The authors declare no con ict of interest Funding This research received no funding.
Authors' contributions HA conceptualized the manuscript and completed the rst draft with ZN. HA, AA, SA, SE, SS, MB, MA and ZN assisted with information acquisition and interpretation; revised the manuscript; approved its nal content; and agree to be personally accountable for their contributions.
14. Kiong TW, Sakarai VN, Dissanayake N, Ravendaran ME. A Cross Sectional Study on the Awareness and