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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.
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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
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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
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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
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9. Aretheresome illnesses orproblems where, ifyou Received:15March2012Accepted:23January2013
hadthem, youwouldprefertoseethedoctorby Published:29January2013
yourself?
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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.
