MooreandChaudharyBMCResearchNotes2013,6:31 http://www.biomedcentral.com/1756-0500/6/31 SHORT REPORT Open Access ’ Patients attitudes towards privacy in a Nepalese public hospital: a cross-sectional survey Malcolm Moore1* and Ritesh Chaudhary2 Abstract Background: Many people inwestern countriesassumethat privacy and confidentiality are features of most medical consultations. However, in many developing countries consultations take place ina public setting where privacy is extremely limited. This is often saidto be culturally acceptablebut there is littleresearch to determine if this is true. Thisresearch sought to determine the attitudes of patients ineastern Nepal towards privacy in consultations. A structured survey was administered to a sample of patients attendingan outpatientsdepartmentin eastern Nepal. It asked patients about their attitudes towards physical privacy and confidentiality ofinformation. Findings: The majorityof patients (58%) stated that they were not comfortable having other patients in the same room. Asimilarpercentage(53%) did not want other patients to knowtheirmedical information but more patients were happy for nurses and other health staff to know(81%). Females and younger patientswere more concerned to have privacy. Conclusion: The results challenge theconventional beliefs about patients’privacy concerns inNepal. They suggest that consideration should be given to re-organising existing outpatient facilities and planning future facilities to enable more privacy.The study has implicationsfor other countries where similar conditionsprevail. There is a need for more comprehensive research exploringthis issue. Keywords: Medical consultations, Nepal, Privacy Findings high [5]. In non-western settings expectations can be very Backgroundandresearchquestion different and the difficulties much greater. Many develop- Most people in western countries assume that privacy ing country consultations are conducted with several doc- and confidentiality are part of normal medical consulta- tors in the same room, often at the same desk. Theremay tions. The confidentiality of the doctor-patient relation- be medical students as well, separately seeing patients. ship dates back to antiquity. The Hippocratic Oath Patientseachhaveoneortwoattendantsandancillarystaff states,“WhatIseeorhearinthe courseofthetreatment walk in and out freely. Privacy might mean occasionally in regard to the life of men, which on no account one pullingascreenaroundtheexaminationbed.Thisscenario must spread abroad, I will keep to myself holding such is usually found in medical practice in Nepal. It is partly a things shameful to be spoken about”. Privacy is a result of high patient numbersand limited manpower and broader term including physical privacy, informational facilities.However,anecdotally,manyNepalesedoctorssay privacy, protection of personal identity and the ability to thatitisaculturalissueaswell:informationissharedand make choices withoutinterference [1]. patients want the support of friends and family at every These things can be difficult to achieve in western step.Thisemphasisonthegroupisoftentakentoindicate settings and may involve complex judgements [2,3]. The thatpeopledon’twantorexpectprivacy. knowledgeofmedicalstaffaboutprinciplesofconfidential- There is little research evidence about expectations of itycanbelacking [4]andtheexpectationsofpatientsvery privacy in developing countries. Most western evidence wasgathereddecadesago,probablybecauseexpectations *Correspondence:[email protected] of privacy are now assumed. It also focuses on younger 1BrokenHillDepartmentofRuralHealth,UniversityofSydney,POBox457, patients,whoarefound tobesensitivetoissuesofconfi- BrokenHill,NSW2880,Australia dentiality. Most adolescents consult a GP more than Fulllistofauthorinformationisavailableattheendofthearticle ©2013MooreandChaudhary;licenseeBioMedCentralLtd.ThisisanOpenAccessarticledistributedunderthetermsofthe CreativeCommonsAttributionLicense(http://creativecommons.org/licenses/by/2.0),whichpermitsunrestricteduse, distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited. MooreandChaudharyBMCResearchNotes2013,6:31 Page2of5 http://www.biomedcentral.com/1756-0500/6/31 once a year [6] but Ford et al. [7] found that this fell sig- items. (Appendix) It asked patients about their attitudes nificantly if it was related to pregnancy, HIV, or sub- towards physical privacy and confidentiality of informa- stance misuse. Around 25% would forego health care if tion using mostly closed questions, with the opportunity theyhadconcernsaboutconfidentiality.Finkenaueretal. for comments. This survey was piloted by the Nepalese [8] suggests that young women are unlikely to discuss researcher (RC), a doctor working in GOPD, and refined sexual behavior with a doctor if they are not sure that for use with patients from the target population. The their consultations will be confidential. Elsewhere, ado- population was all patients attending GOPD. A conveni- lescents have been found to consider confidentiality a ence sample of 100 individuals was chosen. This sample highpriority[9–13].Whiddetetal.[14]studiedprimary- consisted of all patients who consulted the researcher care patients in New Zealand to investigate their atti- during his rostered hours in the department and con- tudes toward sharing medical information. They found sented to inclusion. His weekly morning clinic usually three factors that influenced attitudes: the identity of the fell on the same day but was subject to variation. After recipient (e.g. health professional vs government body); explaining the study and receiving oral consent, the re- the level of anonymity; and the type of information searcher administered the survey. This was done orally (e.g.verypersonaldetails). due tothelow literacyofthe population.Wherepatients Some relevant research has been done in non-western were less than 18 years of age their caregiver was settings. A study in Egypt showed that one third of approached for inclusion inthe study. Interviews contin- patients interviewed in a hospital outpatients clinic ued over a three-month period in 2010 until the arbi- thoughtthelevelofprivacyintheconsultationroomwas trary target of 100 participants was reached. Ethics unsatisfactory [15]. Bhatia and Cleland [16] in Karnataka approval for the study was given by the Research and State, India, found that there was significantly less priv- ThesisCommitteeat BPKIHS. acy in public compared to private medical settings. In Most of the data were quantitative. SPSS software 17.0 family practice clinics at the Aga Khan University in using chi-square test for difference in proportions was Pakistan [17], patients recorded objections to the pres- used for analysis. There was a small amount of qualita- ence of medical and nursing students and other obser- tive data arising from the opportunity given to patients vers on the basis of a reduction in privacy. There were for comment on several questions. These data were ana- also concerns over privacy from diabetic patients in lysed using an iterative process of thematic analysis: ini- Oman[18],andhospitalpatientsinLahore[19],particu- tially by each researcher individually and then together larlyinthepublicsystem. untilagreementwasreached. The literature supports the contention that privacy and confidentiality are important to patients. It also Results shows that these concerns are not only found in western 100patientswereenrolledinthestudy,2patientsdeclin- settings.InNepalsomemedicalschools are beginningto ing to participate. There were 59 females and 41 males. emphasise principles of good communication and 38patientswerehousewives,19farmers,18studentsand patient-centred care, often assuming physical privacy in the remainder had diverse occupations including tea- the consultation. The authors of this paper worked and chers, labourers and shopkeepers or were unemployed. studiedtogetherinsuchamedicalschoolforthreeyears. The age and educational demographic data are shown in This research was prompted by the tension between Table1. what was being taught – based on western curricula – Patients were usually accompanied by one or two atten- and the reality of consulting in a busy Nepalese hospital dants (mean 1.1), all of whom came into the consultation. where privacy may notbe offered. Theresearch question arose: what expectations of privacy do Nepalese patients Table1Ageandeducationallevelofparticipants,n=100 have in this hospital? This question was broken down Age Number into questions about physical and informational privacy 16-25 41 which queried the assumption that the patients were 26-35 33 happy withthe current situation. >35 26 Methods Educationallevel Number The study was performed in the general outpatients de- Noschooling 23 partment (GOPD) of B.P. Koirala Institute of Health Primary(1–5) 14 Sciences (BPKIHS) in eastern Nepal. This is a 700-bed Highschool(6–10) 43 teaching hospital with a GOPD seeing around 100 Intermediate(−12) 14 patients a day. A cross-sectional study was done using a Bachelordegree 6 structured survey instrument in Nepalese, containing 13 MooreandChaudharyBMCResearchNotes2013,6:31 Page3of5 http://www.biomedcentral.com/1756-0500/6/31 75%ofpatientsstatedthattheypreferredalloftheiratten- Table3Confidentialityintheconsultingroom,n=100 dantstobepresent. Question:Areyoucomfortablewiththefollowinggroups Yes No There were 2 questions directly related to the number knowingyourmedicalinformation? ofconsultationsoccurringin each room (Table 2). These Q5....allofyour‘party’(attendants) 55 45 questionswereseparated inthe patient survey. Q6....nursesandhelpers 81 19 Several questions were asked about the confidentiality Q7....otherpatientsinGOPD 53 47 of medical information in the consulting room as shown in Table 3. Patients were much more comfortable with nurses and helpers knowing their information (81%) consultation”; 5 people stated there should be “one room than theirattendants(55%) orotherpatients(53%). for one patient in a consultation”; 3 people thought “it is There were several significant differences in responses important to reduce overcrowding”; 5 people felt that accordingtodemographics. “privacy isnot important inconsultations”. More females than males did not want other patients to know their medical information (57.6%, 31.7% chi- Discussion square test, p=0.011). Younger patients had more con- Thisstudywasdesignedtodiscoverwhatpatientsthought cerns about confidentiality. More patients aged from about privacy and confidentiality in this hospital outpati- 16–25 than those over 35 did not want their attendants ents setting. The results suggest that privacy is a big con- to know their medical information (56.1%, 23.1%, cern for people in this setting where privacy is often not p=0.027). The difference was similar concerning other available. Detailed comparison with previous studies from patients knowing but just failed to reach significance SouthAsiaandtheMiddleEastisnot possiblebut similar (58.5%, 30.8%, p=0.08). In contrast more patients aged concernswerereportedinthosesettings. over 35 than those aged 16–25 did not want nurses and There was consistency between the two key privacy other helpers to know their information (34.6%, 17.1%, questions - q4 and q11. It is striking that more than half p=0.04) The main reason for not wanting their atten- of the patients wanted one consultation per room, given dants to know their information was reported as ‘feeling the usual conditions in Nepalese consultations described shy’ (29 patients). 12 patients said that information above. Despite this, only 18% cited specific situations ‘shouldbeprivate’. wheretheywouldwanttoconsultprivately.Patientsmay 49%ofpatientsdidnotwanttheirmedicalinformation have been reluctant to specify the areas of concern – to be made available to other official people outside the mostly citing ‘abdominal’ conditions. This might also consultation(q8,e.g.employer,police). be a product of unfamiliarity with doing surveys. A Patients were asked if there were some specific situ- small number of patients (5%) reported having with- ation or illnesses where they wanted tosee the doctor by held information due to privacy concerns. The strong, themselves (q9). 18% said yes, citing abdominal pain or consistent responses to q4 and q11 suggest that these ‘general check-up’ as the most common situations. reflect ‘real’ preferences. Females were more likely than males to want to be seen Patients were discriminating in answering questions on their own for some specific illnesses (25.4%, 7.3%, about confidentiality of information. Most (81%) were p=0.02). Patients were also asked if they had ever not happy for nurses and helpers to know their informa- told the doctor information because they thought it tion but they didn’t differentiate significantly between would not be kept private (q10). Only 5% said that they their own attendants (55%) and other patients (53%) in hadwithheldinformation. terms of confidentiality. This is a surprising result in the Theoverall satisfaction rate with privacy inthe depart- Nepalese context, given the huge role played by patients’ mentwasstated tobe99%. attendants in medical care. In addition, around half of The final question invited general comments and 78 the patients (49%) did not want information released to patients responded: 67 people reiterated the place of ‘official’ people. These findings further indicate that atti- privacy, “privacy is very important during a medical tudes of Nepalese patients differ from what has been assumedpreviously. Males were less concerned than females with other Table2Numberofconsultationsperroompreferredby patients knowing their medical details (68.3%, 42.4%, participants,n=100 p=0.01). There was a general tendency for younger and Question Yes No female patients to be more concerned with confidential- Q4.Areyoucomfortablewithhavingotherpatientsinthe 42 58 ity. Previously cited papers from westernsettingssuggest sameroomasyou,consultingwithotherdoctors? possible reasons for this. Younger people may have been Q11.Wouldyoupreferiftherewasonlyonedoctorineach 56 44 concerned that information about drug, alcohol and sex- consultingroom? ual issues be kept from their families. Female patients MooreandChaudharyBMCResearchNotes2013,6:31 Page4of5 http://www.biomedcentral.com/1756-0500/6/31 mayhavebeenmoreembarrassedabout strangersknow- be conducted locally to discover what is appropriate ingintimatemedicaldetails. nowandinthefuture. Patients did not offer detailed comments when given the opportunity. However, the remarks that they made Appendix supported the quantitative data, underlining the evi- dence that patients in this context are concerned with 1. How manypeoplehave come with youtodaytosee confidentialityandprivacy. thedoctor? Number ofpeople: ______. Limitations Therearelimitationstothestudy.Patientswereunfamiliar 2. Whoarethey? with surveys and low literacy levels necessitated that sur- veys be administered orally. There was only one inter- a.Parent, viewer, a junior male doctor. It is not clear if this would b.Son/daughter,brother/sister, skew responses and in which direction, however patients c.Friend, etc___________. mayhavebeenlesslikelytocriticizeadepartmentinwhich he was seen as an authority figure. The phenomenon of 3. Doyoupreferthem allto bewithyouinthe ‘courtesybias’–subjectstendingtoagreewithinterviewer’s consultation? statements – has been much discussed in relation to re- search in Asia [20]. This should be considered here al- a.Yes though there was agreement between reverse-worded b.No questions (q4, q11). It is likely to have influenced the very c.Ifnot,whynot? highrateofsatisfactionwithprivacy(99%)giventheresults inallotherquestions.Therewasarelativelylownumberof 4. Areyoucomfortablewithhavingother patientsin attendantsaccompanyingthepatientsinthissample(mean thesame roomasyou, consultingwith other 1.1). The sample may have contained a greater number of doctors? ‘independent’individualsthanisthenorminthiscontext. A convenience sampling method was used and this a.Yes increased the likelihood that patients had seen the b.No researcher/doctor previously or had chosen to see him. This selection bias may have affected the results 5. Areyoucomfortablewithallofyour partyknowing in at least two ways. Patients may have been more con- themedicalinformation inyour consultation? cernedwithprivacyinseeingtheirchosendoctor.They mayalsohavefeltlessfreetoexpresscriticalopinions. a.Yes b.No Implications c.Ifnot,whynot? Further research is required to determine the validity of these results. There are implications for the planning of 6. Areyoucomfortablewithhavingnursesandhelpers health services in Nepal. The preferences of patients for knowing your medical information? privacy and confidentiality should be acknowledged in the design and staffing of facilities. There are significant a.Yes constraints imposed by lack of resources and high pa- b.No tient numbers. However, these results challenge the as- sumption that Nepalese patients are comfortable with 7. Areyoucomfortablewithother patientsinGOPD the public nature of their medical care. The implication knowing your medical information? is that provision should be made for private consulta- tionswhereverpossible. a.Yes These issues should be raised as medical education b.No evolves in Nepal and other parts of South Asia. Western teaching about patient-centred communication is being 8. Doyoumind ifyour medical informationis more widely taught, especially in departments of general availabletootherofficialpeople practice and psychiatry. This is difficult to implement where the design of facilities and high patient numbers a.Employer? Y/N make physical privacy hard to achieve. These issues are b.Insurance companiesY/N very dependent on cultural factors so research needs to c.Police?Y/N MooreandChaudharyBMCResearchNotes2013,6:31 Page5of5 http://www.biomedcentral.com/1756-0500/6/31 9. Aretheresome illnesses orproblems where, ifyou Received:15March2012Accepted:23January2013 hadthem, youwouldprefertoseethedoctorby Published:29January2013 yourself? References 1. SeiglerM:ConfidentialityinMedicine–adecrepitconcept.NEnglJMed a.Yes 1982,307:1518–21. 2. MendelsonD:‘MrCruel’andthemedicaldutyofconfidentiality.JLaw b.No Med1993,1:120–9. c.Ifso,whatthey are? 3. BergerJT,RosnerF,KarkP,BennettAJ:Reportingbyphysiciansof impaireddriversandpotentiallyimpaireddrivers.JGenIntMed2000, 15:667–672. 10.Haveyouevernottoldinformationtoadoctor 4. ShrierI,GreenS,SolinJ,etal:Knowledgeofandattitudetowardspatient because youthoughtthatinformation wouldnotbe confidentialitywithinthreefamilymedicineteachingunits.AcadMed kept private? 1998,73(6):710–2. 5. 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AbdulhadiN,AIShafeeM,FreudenthalS,OstensonCG,WahlstromR: Competinginterests Patient-providerinteractionfromtheperspectivesoftype2diabetes Theauthorsdeclarethattheyhavenocompetinginterests. patientsinMuscat,Oman:aqualitativestudy.BMCHealthServRes2007, Authors’contributions 19. 7H:u1m62a.yunA,FatimaN,NaqqashS,etal:Patients’perceptionandactual MMmadesubstantialcontributionstothestudyconceptionanddesignand practiceofinformedconsent,privacyandconfidentialityingeneral interpretationofresults;thedraftingandrevisionofthemanuscript;and outpatient departments oftwo tertiary care hospitals of Lahore. gaveapprovaltothefinalversion.RCmadesubstantialcontributionstothe BMCMedEthics2008,9:14. studyconception,acquisitionofdataandtheinterpretationofresults;the 20. JonesE:Thecourtesybiasinsouth-eastAsiansurveys.InSocialresearch draftingandrevisionofthemanuscript;andgaveapprovaltothefinal indevelopingcountries.EditedbyBulmerM,WarwickD.London:JohnWiley version. andSons;1983:253–9. Acknowledgement doi:10.1186/1756-0500-6-31 TheauthorswishtothankthefacultyandstaffatBPKoiralaInstituteof Citethisarticleas:MooreandChaudhary:Patients’attitudestowards HealthSciences,Dharan,Nepalforinvaluablesupport.Inparticular,thanksto privacyinaNepalesepublichospital:across-sectionalsurvey.BMC DrSuryaNiroulaandMrDharanidharBaralforhelpwithdatagatheringand ResearchNotes20136:31. analysis. Authordetails 1BrokenHillDepartmentofRuralHealth,UniversityofSydney,POBox457, BrokenHill,NSW2880,Australia.2BPKoiralaInstituteofHealthSciences, Dharan,Nepal.