Perceived Adherence to Professional Ethics and Associated Factors Among Health Professionals in Bale Zone Public Hospitals, Oromia Regional State, South-East Ethiopia


 Introduction: Currently, hospitals not only have to contend with the dynamics of regulation but most importantly they have to deal with the issue of professional ethics.
Objective: The objective of this study is to assess perceived adherence the professional ethics and associated factors among health care professionals in hospitals found in Bale Zone, Oromia region, South East - Ethiopia.
Methods: A hospital based cross-sectional study was employed from April to May 2019in hospitals found in Bale Zone. All medical doctors, nurses and midwives who involved in patient treatment and care in the different units of the hospitals during data collection. The edited and cleaned data entered into a computer using SPSS version 20.0 software and a summary descriptive statistics and binary logistic regression was performed. Those variables which had significant association in bivariate logistic regression analyses were taken to multiple logistic regression models to identify variables which has independent association with the dependent variable (perceived adherence to professional ethics). All statistical tests were declared at p-value less than 0.05.
Results: From the total of 417 questionnaires distributed to different health care units in the hospitals, the analysis was done for 408 responses which give a response rate of 97.8%. Overall, 186(45.6%) respondents had good perceived adherence of ethical practice. Nurse profession (AOR) = 3; 95 % CI= 1.17–7.76),Midwife profession(AOR) = 4; 95 % CI= 1.19–11.40), negative attitude towards professional ethics (AOR = 2; 95% CI: 1.03, 2.52), insufficient information about professional ethics in the curriculum (AOR = 2; 95% CI: 1.08, 2.97) and those whose work experience less than three years (AOR = 2.5; 95% CI: 1.32, 4.75) were associated with poor adherence to professional ethical practice
Conclusions: This study highlight the overall ethical practice among Bale zone health professionals is low. Profession, work experience, perceived inadequacy of professional ethics curriculum and attitude had statistically significant association. Need staff’s attitude towards professional ethics, considering the intensity of CRC training for different professionals differently and revising the contents of professional ethics in the respective curriculums.

Key words: adherence ,professional, Bale Zone,

Health care providers need an awareness of professional ethics more than ever before. Because adherence to professional ethics by health care workers is one of the most critical aspects of quality health service delivery as it involves the way service providers interact with service users (4,5,8). Unethical behaviors among health professionals affects the accessibility of quality health services as it creates con ict in the relationship between health workers and health service users (3,9).
In other words, non-adherence to professional ethics by health workers do not only affect the quality of services citizens receive but also erodes the reputation of health professionals and all other o cials in the health system. Such a negative perception may further hinder the people's access to public health services (3,10). Health care should be safe, effective, patient-centered, timely, e cient and equitable.
These requisites of quality care are not only synergistic with ethics, but ethical concepts and reasoning are the foundation behind most current de nitions of healthcare quality (4,8). A patient centered approach to healthcare means providing a respectful patient's preferences and values through a shared decision make process. Such an approach is based on the ethical principles of autonomy and selfdetermination and is delineated in most healthcare organizations' ethical standards of practice, an informed consent policy (3,11).
Encouraging health professionals to behave more empathically and less formally with their patients' needs identi cation of potential factors affecting their behavior in the health care setting. Therefore the primary objective of this study is to assess adherence of professional ethics among health professionals and identify factors associated with health professional ethics in hospitals found in Bale zone.
The patient has the right to self-determination, to make free decisions and the physician will inform the patient about the consequences of his/her decisions (2,8,20). Despite this most health care providers don't provide informed consent for their patient. For instance one cross sectional study conducted among Iranian midwives shows that 87% of the pregnant mothers never received any information about the type of the childbirth, the advantages/disadvantages of different childbirth methods, their rights during pregnancy and childbirth after delivery.(25) Providing the best possible care to the patients in the most ethical manner may nd it di cult to balance the right to information with the need to avoid information overload (11). One challenge is how much information is adequate and how should complex medical information be communicated to patients who may be frightened or feeling ill, and may have trouble assessing risks, bene ts and alternatives. Even, not all patients want a great deal of information. Some may prefer to trust their health provider to do what is best for them (12,21). It is also common for health care professionals to clash with the family of the patients for whom they care over treatment decisions(22). Con dentiality is also both an ethical and a legal issue. Keeping information about a patient con dential is a way of showing respect for the person's autonomy. Because there is wide agreement that people have the right to control who has access to their information about them (11,21,24). In another way, the ability to provide high quality medical care depends on patients feeling free to communicate fully and truthfully with their caregivers. Fur thermore, individuals could face stigmatization and discrimi nation if certain medical information, such as about sexually transmitted diseases or mental illness, is not carefully protected (12,14). Therefore, all identi able information about a patient's health status, medical condition, diagnosis, prognosis and treatment and all other information of a personal kind, must be kept con dential, even after death (11,26). A cross sectional study conducted among Nepalese nurses and a doctor shows that only 2.5 % doctors and 11.6 % nurses agreed that adhering to con dentiality of patients is important(27).
Therefore, medical ethics must be understood as an essential branch of general ethics, offers a valuable framework in which to de ne the norms for medical care(28). Thus, medical ethics is concerned with promoting health and medicine and clarifying norms for improving relationships between patients and health professionals (2,12). Because, the statements of medical ethics require the health professional to do what is best for the patient and place the patient's interests before their interests. Above all, the purpose of medical ethics is to protect and defend human dignity and patients' rights (13,14). Despite this a report in Tanzania health facilities shows that 1 of 4 people in need of health services in these areas are routinely asked to give bribes (5).
Just like other public servants in Ethiopia, health workers are also bound by the legal and and ethical requirements. Basically, the act and codes of Ethics urge all health workers to avoid unethical practices in their working environment (29).Despite the presence of the act and codes of Ethics, incidents of failure to observe professional ethics continue and are particularly pronounced in Ethiopia calling for an end to these malpractices. The government, on its part, has been vainly promising to address the problem through imposition of tough measures against anyone found misbehaving (3,29).
A Score Card Report on 45 Health Facilities in Tanzania reveals factors like unavailable or non-functional hospital ethics committee, weak supervision and poor management exacerbates poor adherence to professional ethics (5).
The problem of substance use has been common among health professionals due to their proximity to those drugs. It highly affects the medical practice and patient's safety. A study conducted in Jimma University among medical interns shows that 48.4% of them used substance in their life time (32,33). Another study in western Amhara region shows that Professionals who drank alcohol were more likely to be dissatis ed by their job (34).
Health professionals that are more knowledgeable and have favorable attitude tend to have good ethical practice. A study conducted among doctors in Addis Ababa showed that knowledgeable medical doctors were more likely to have good practice of code of ethics and having good practice of code of ethics Page 5/37 among medical doctors with favorable attitude were 7.404 times the odds of those with unfavorable attitude towards code of ethics(18).
For years, unethical behavior among health workers in Ethiopia has been reported and discussed by various stakeholders including the media, members of parliament, community leaders as well as institutions.
Generally Non-adherence to professional ethics among health workers, not only affect the whole process of accessibility and provision of quality health services to citizens, but also tarnishes the reputation of health professionals and all other o cials in the health system. This situation must not be tolerated any further and must be eliminated at all costs.

Study Area and Period
A hospital based cross sectional study was conducted in Bale zone from March 1 st to April 30th, 2019. Bale zone is the second largest zone in Oromia regional state located in the South-eastern part of

Study Design
A hospital based cross-sectional study was implemented in order to assess the perceived adherence to professional ethics among health care providersin four public hospitals found in Bale zone.

Source Population
All medical doctors, nurses and midwives who were on duty in patient treatment and care in the different units of the respective hospitals.

Study Population
All medical doctors, nurses and midwives who ful l the inclusion criteria in four public hospitals were employed in the study.
Inclusion criteria: Those medical doctors, nurses and midwives who had more than 6 months work experience were be included in the study.

Exclusion criteria
Medical doctors, nurses and midwives who were on annual leave during data collection time

Sample Size Determination
Since the number of health professional found in Bale zone public hospitals were manageable, all medical doctors, nurses and midwives that ful lled the inclusion criteria were employed in the study which is 417 in number.

Data collection tools and techniques
Survey instruments were adapted from Patient Safety Indicators (PSIs) survey tools for provider and arealevel indicators, and patient safety culture survey instrument of Agency of Healthcare Research and Quality (AHRQ) [11] .Some of the questions are adapted from Center for Ethics in Health Care (NCEHC) integrated ethics staff survey and also using different literatures (7,9,18,27,35) Data was collected using self-administered questionnaire. Well-structured and pretested questionnaire was given for health professionals as self-administered questionnaire. Respondents who give their written informed consent were given the questionnaire and were asked to complete and return it. The rst part of the questionnaire focuses on the respondents' socio-economic status. The second part of the questionnaire was assessing the knowledge of healthcare ethics and their perception toward it. In the third part, their experiences on health care ethics was assessed.

Dependent Variables
Perceived adherence to professional ethics Independent Educational status, attitude, knowledge on professional ethics, monthly income, service year, types of profession, type of college/university, marital status, preference during department selection, substance use, satisfaction, type of hospital, violence

Data Quality Control
To assure the quality of the data the following activities were done. Four BSc nurses were recruited and trained for one day for facilitation and two BSc health o cers were assigned as supervisor. Before the actual data collection, the structured questionnaire was pre-tested at Dodola hospital. The pre-test was done on 20 health professionals, and at the end of every data collection day each questionnaire was examined and pertinent feedback was given to the data collectors and supervisor.

Data entry and analysis
Data entry was carried out by an experienced data entry clerk with close supervision by the principal investigator. Data cleaning and screening was conducted exclusively by the principal investigator. Before starting the analysis, the data needs to be prepared and cleaned. The edited and cleaned data was entered into a computer using SPSS version 20.0 software and a summary descriptive statistics and binary logistic regression and multivariate logistic regression were done.
Bivariate and multiple logistic regression analyses were done to identify the relationship between the dependent variables (adherence to professional ethics) and independent variables. Those variables which had signi cant association in bivariate logistic regression analyses was taken to multiple logistic regression models to identify variables which has independent association with the dependent variable. All statistical tests will be declared at p-value less than 0.05.

Ethical Clearance
Ethical clearance was obtained from Jimma University. Permission letter was obtained from Bale zone health department. Participation in the study was on voluntary bases and oral consent was obtained from study participants to con rm their willingness. All the information provided by the study participants were kept con dential. Data were collected in a way that makes it impossible or at least very hard to identify the respondent and question that contain information that could be used to identify the surveyed persons was removed.

Dissemination
This will be disseminated to Bale Zone health department, Jimma university and other pro t or non-pro t organizations/ parties in devising effective policies aimed at decreasing non-ethical practice in public hospitals. Attempts will be made to publish the article in peer reviewed journal and to make presentations in scienti c conferences.

Socio Demographic Characteristics
Total of 417 survey questionnaires distributed to different units in the hospitals from which nine incomplete questionnaires were excluded. Finally, 408 (262 male and 146 female) participants completed survey questioners and considered for the analysis which gives a response rate of 97.8%. The mean age of the participants was 30.5 (± 5.7 years). The majority health professionals 258(63.2%) were in the 25.34 years age group and most of respondents 295(72.3%) of the participants were Oromos, whereas 211(51.7) were 0rthodox Christians.
Regarding respondent's salary, 196(48%) of the participants' monthly salary was 3250-5414 birr per month. In addition, 1,916 and 11,722 Birr were the minimum and the maximum monthly salary of the respondents respectively, with the median monthly salary of 5006 Birr. Moreover, the minimum and maximum monthly allowances were 0 and 3500 Birr respectively.
The general characteristics of the study respondents are presented in (Table 1).

Professionalism and other factors
From the total respondents 94(23%) were not happy with their current profession and 120(29.4%) didn't choose their current profession when they joined the university. More than half of them 221 (54.2%) were not ready to recommend others to pursue their current profession.
Ethics committees are institutional structures that provide a deliberative forum in which ethical issues can be analyzed and addressed. Majority of participants 237(58 %%) did not know about the existence of the ethics committee in their hospitals. Among those who knew the existence of ethics committee in the hospital, more than half, 92 (53.8%) of them didn't know the function of the committee while around 31 (18.14%) replied correction measure as the main task of the committee. Regarding training opportunity, only 131 (32.1%) of the respondents were taken professional ethics training.
Most of the respondents 341 (83.6%) mentioned college/university as the main source of information for professional ethics. Regarding the professional ethics course in previous educational curriculum 284(69.6%) of the respondents replied that it was not adequate.
Majority of the respondents replied that they encounter ethical problems in their institutions from time to time 238(58.3%). About 143(35%) of them have been accused regarding issues related with professional ethics. Religious related issued mentioned as the most common ethical dilemma faced by health care providers 149(36.5%) followed by discharge against medical advice 137(33.6%). Workload was stated as the main reason for unethical behavior of care providers 298(73%).
More than half of hospital administrators don't communicate professional ethics as a priority issue 206(50.5%) and 222(54.4%) of the respondents said the promotion decision doesn't consider ethical practice. 92 (47.1%) of participants stated that their relationship with managers unfairly in uence their ethical practice. More than quarter of the professionals 152(37.3%) reported that there is frequent con ict among colleagues.
From the total respondents 75(18.4%) of them reported that were harassed by their clients while 56(13.7%) of them stated that they received gifts from their patients. About 88(21.6%) of study participants used substances in their life and more than half of them used alcohol 54(61.4%). (Table 2) Knowledge towards professional ethics Majority of the respondents 314(77%) said that they can't de ne professional ethics but most of them agreed 370(90.7) that professional ethics is an important subject. Signi cant number of participants 305(74.8%) stated that the right of patient should always be recognized but 180(44.1%) of them replied that disclosure of medical report is important. About 354(86.8%) of professionals reported that the patient has the right to know about his/her problem in person. From the total respondents 177(43.4%) of them mentioned that they disclose medical error only if it caused a major harm. More than half of the respondents 217(53.1%) reported that being unethical to patient leads to legal action. The mean score knowledge about professional ethics was 5.65(SD=1.7). Overall, more than half of the respondents 229(56.1) were knowledgeable (Table 3).

Attitude Towards Professional Ethics
From the total respondents, 149(36.5) agreed to the view that 'ethical conduct is important only to avoid legal action' and 215(52.7%) of the respondents agreed that the patients' wishes should be adhered. About 195(47.8%) of the respondent agreed that 'patient should always be told if something is wrong' while 119(29.2%) of them disagreed that close relatives must always be told about a patient's condition. Also 152(37.3%) of the respondents agreed to the view that health professionals should do what is best irrespective of patient's opinion and 161(39.5%) of the respondents disagreed to the view that patient's only need to consent for operations but not for tests or medications while 127(31.1) of the respondents disagreed that children should never be treated without the consent of their parents or guardians. Regarding non-compliant and violent patients, 115(28.2%) disagreed that health professionals should refuse to treat patients who behave violently' and 154(37.7%) disagreed that 'if patients refuse to undergo treatment due to their beliefs, they should be instructed to nd another health profession'.
Regarding social clients, 138(33.8%) of the respondents disagreed treat social that treating social client rst is correct and 173(42.4%) of them agreed that health professionals should resolve con ict with other health care providers (Table 3) The mean score of attitude towards professional ethics was 46.03(SD=5.8). Overall about 184(45.1%) had a positive attitude towards professional ethics.

Ethical Practice of health professionals towards professional ethics
The degree to which health professions demonstrate behavior consistent with ethical practices in health care was measured using 15 questions. Those whose choice is 'always' earned score of 2, sometimes earned 1 and never earned 0 with a total of 30 marks. Participants who score equal or above the mean are considered had good practice and below the mean had poor practice.
The mean score of ethical practice was 17.18 (SD = 3.24).

Discussion
Adherence to professional ethics by health care workers is the core aspects of quality health care delivery as it involves the way service providers interact with service users. But, only 45.6% of the professionals had good perceived practice towards professional ethics which is nearly similar with study conducted among Egyptian residents which is 48%(16) and greater than other similar studies conducted in Ambo town and Addis Ababa city which showed 24% and 30.4% adherence level to professional ethics respectively (18, 37) .The discrepancy might be due to the small sample size and the implementation of CRC program by the federal ministry of health. Another nationwide study on respectful maternity care in public facilities reported 36% of the health professionals committed at least one form of mistreatment of women (38). For instance, though informed consent is a vital component of present-day health care ethics and a means of exercising patients right to self-determination, only 41.4% of professionals always obtain informed consent before rendering any service. This is nearly similar with study conducted in Addis Ababa which is 34% (18). Breaches of patient con dentiality or right to privacy and end-of-life decision-making are common ethical problems reported by other study (39).
Though knowledge towards professional ethics is very important asset for ethical practice, overall only 56.1% had good knowledge towards professional ethics. The result is similar to the study in Mexico (40). Similar study in Ghana showed that 74% of the study participants had good knowledge towards health care ethics (41) which is relatively greater than this research result. The difference might be due to socio economic and cultural difference among health care professionals. But, the result from another study in ambo town revealed good knowledge level of 31% which is less than this research result (37). This difference might be the impact of CRC training provided all over the country regarding ethical practice and awareness for health professionals. Another study which is conducted in Addis Ababa among medical doctors showed that 75% of the study participants had good knowledge towards professional ethics (18) which is higher than this study. The difference might be because study was limited on doctors and conducted in capital city where information regarding professional ethics is easily accessible.
In relating to knowledge, in this study, about 77% of participants reported that they can't de ne professional ethics properly. In the contrary, about 86.7% Egyptian health professionals were able to de ne it which is very high (16). The discrepancy might be due to difference in study setting and study subjects. From the total respondents of this study, 61.5% of them were against the idea of physician assisted dying which is lower than study in Nepal which is 90%(27). Similar study in Ambo Town revealed that about 46% of the study participants were disagreed with assisting a patient who wants to die (37).
Almost consistent result is reported from another study in Addis Ababa where 67.1% participants disagreed that it is possible for nurses to help patients prepare for death using various psychological mechanisms (42).
The poor attitude towards professional ethics itself affects the ethical practice of health care professionals. Overall, only 45.1% of study participants had positive attitude towards professional ethics which is nearly similar with study in Ambo and Gondar towns which accounts 48%and 49.2% respectively (37,43). The result is slightly lower than the study conducted in Egypt which is 60% (16). The inconsistency with study in Egypt might be due to difference in study setting and study subjects. For instance, in this study about 36.5% of participants agreed that ethics is only important to avoid legal action. Similar study conducted in sub-Saharan African countries revealed 41.7% which is nearly similar to this study agreed (13). In this regard, paternalistic attitude toward patient this study shows 47.8% of them disagreed for statement provider should do what is best for patient irrespective of patient opinion and about 52.7% disagreed to the view that patient wishes must always be adhered. The result is consistent with study conducted in India and sub-Saharan African countries (13,44,45).
Con dentiality is both ethical and legal issue. It is crucial to maintain trust in client provider relationship.
The maintenance and breach of con dentiality under certain speci c circumstances is extensively discussed and stressed upon in medical code of ethics. However, this study revealed about 41.7% of respondents disagreed with the statement 'con dential information can only be disclosed if the patient gives explicit consent'. About 31.9% agreed that the patient information must be revealed for close a relative which is Similar with study in Ambo town (37). But different from Nepal that shows 77.1% which is higher (27), the difference might be due to the difference in sample size and sociocultural context in the study area.
In this study, the overall level of job satisfaction among health care professionals was 49.3%. This nding is comparable with previous studies conducted in Ethiopia 54% in Gondar (46) and 54.2% in East Gojjam Zone (47). But, this result is lower than satisfaction rate reported in Nigeria and Nepal where the satisfaction level was 90.4% and 76% respectively (48), (49).The possible explanation for the above difference could be due to the difference in socio-economic status of the countries. Another nationwide qualitative study among healthcare workers in rural Ethiopia also concluded that healthcare workers experienced job dissatisfaction(50).
In this study, the socio-economic factors; respondents' educational status and work experience and other independent variables; attitude towards professional ethics, perceived adequacy of professional ethics in the curriculum, current profession, presence of ethics committee, receiving gifts from patients and love for the profession were showed signi cant association with professional ethics in the bivariate logistic regression analysis. From these independent variables, attitude toward professional ethics, current profession, perceived adequacy of ethics information from the curriculum and work experience were persistently associated with professional ethics in multiple logistic regressions analysis.
Similarly, unfavorable attitude is in uencing the ethical practice in another study (18). But in contrast to this study, higher likelihood of performing high level ethical practice is found among midwives than other cadres (38). It is also reported that health professionals with fewer years of experience encountered ethical issues more frequently than others (39) Another systematic review identi ed increased workload, lack of organizational support, training workshops, patient behavior, inappropriate role modelling as in uencing factors for poor ethical practice (51).

Conclusion
The overall ethical practice of health care workers was low. Negative attitude toward professional ethics, perceived inadequacy of professional ethics curriculum, work experience and current profession have statistically signi cant association with ethical practice among health care workers in public hospitals of Bale Zone.

Recommendation
Depending on the result of this study the following recommendation were forwarded Government should give more emphasis and work on CRC training.
Hospitals should avail professional code of ethics documents to enhance knowledge of the employees, facilitate and give training educational opportunities and also, they should strengthen their Ethics committees.
Universities should revise the content of professional ethics course in the curriculum.
Finally, other researchers are recommended to conduct further investigation particularly the qualitative one to dig out more information regarding this issue.

Strengths of this study
It is primary study

Professional ethics is burning issue right now in all professions especially in health sector
There was no similar study done in the study area

Weakness of this study
Providers' practices were self-reported and their responses may have been tailored according to what they believed were appropriate.
The attitude of health professionals towards health care ethics would be better investigated with qualitative study design.

Declarations
Ethics approval and consent to participate The research proposal was approved by institutional review board of Jimma University, Jimma University Institute of Health. A permission letter was obtained from Bale zone health department.

Consent to publish
Not applicable

Availability of data and materials
All the data included in the manuscript has been included in the form of tables and gures. The deidenti ed raw data is not publicly available. But the de-identi ed raw data can be requested from the corresponding author after providing the necessary justi cation for request.

Competing interest
The authors declare no competing interest.

Funding
The study was funded by Jimma University Institute of Health (JIH) throughout inception, data collection and analysis.

Authors' contribution
Abiru Neme , Bethlem Getachew and Desta Workneh contributed on data analysis, and checked the draft. Abiru Neme and Bethlem Getachew prepared manuscript. All authors read and approved the nal paper.