HEALTH STUDENTS' PERSPECTIVES ON PATIENT CONFIDENTIALITY AND RECORD-KEEPING ETHICS

Background: Various medical communities and associations have approved codes of ethics that place a significant emphasis on the importance of maintaining privacy and confidentiality. Students have been expected to respect patients’ rights. Aim: This study aimed to investigate health sector university students’ level of knowledge and attitudes toward the importance of patient confidentiality of information. Methods: The study utilized a convenient sampling method to select 402 health sector students from universities in Saudi Arabia. The study adopted a cross-sectional design, including all students studying health specialties at Saudi universities. The study was conducted for all students of health specialties at Saudi Universities. The study was performed from October 12, 2022, to February 20, 2023. The questionnaire consisted of three sections focusing on knowledge, attitudes, and demographic characteristics. Results: Overall, most participating students have good level of knowledge (66%) and positive attitudes (53%) toward maintaining patient confidentiality.


INTRODUCTION
Different medical communities and associations have approved codes of ethics that place a high emphasis on privacy and confidentiality 1,2 .Confidentiality is a fundamental aspect of legal health records and an ethical foundation for providing exceptional care 3 .Patients' rights to confidentiality are emphasized in religious texts, the Hippocratic Oath, and nearly all contemporary code of ethics 4 .The term "confidentiality" has a narrower meaning, referring specifically to the protection of personal information and the obligation of healthcare professionals not to disclose information without the patient's consent.Confidentiality is often used interchangeably with the term "informational privacy" 2 .
Confidentiality is a key virtue in building trust between healthcare providers and patients.Health professionals have a legal duty to ensure the handling of patient data in a private and secure manner 5 .Students in the healthcare field are expected to respect patients' rights to confidentiality, and they should also be aware of the consequences of breaching patient confidentiality 6 .Confidentiality refers to limiting access to personal information to authorized individuals and following authorized procedures at appropriate times and in approved manners 7,8 .Respecting patients' confidentiality means keeping privileged communication confidential and not disclosing it without the patient's consent 9 .The principle of respect for autonomy is commonly discussed in the context of health care interventions, but it is also relevant to issues such as confidentiality, fidelity, privacy, and truth-telling 10 .
Focusing too narrowly on decisions regarding health care interventions can cause other situations involving patient autonomy to be overlooked 11,12 .Recent studies have explored the attitudes of medical students and operating room nurses towards patient privacy, and the founding's indicated that both groups had negative attitudes towards privacy and confidentiality issues 13,14 .For that, the aim of the current study is to investigate health sector university students' level of knowledge and attitudes toward the importance of patient confidentiality of information.

STUDY DESIGN
Cross-sectional analytical study.The study conducted for all students of health specialties at Saudi Universities.The targeted sample composed of those who have completed

DATA COLLECTION METHODS
A survey was sent out to health students in various Saudi Arabian universities through different online platforms such as emails, Twitter, Facebook, and text messages.The Ministry of Higher Education reports that there are approximately 21,000 health sector students in all universities in Saudi Arabia.We used a nonprobability sampling method and determined that a minimum of 400 participants was necessary by calculating the sample size with a 95% confidence interval and a 5% margin of error.

DATA COLLECTION INSTRUMENT
The survey used in this study was selected after reviewing similar literature 6,3,15 The data collection instruments were a demographic questionnaire and a self-administered questionnaire created by Hosseini Ghavamabad et al. in 2019 13 , which was modified by Karasneh R in 2021 16 .The questionnaire consisted of two sections: Knowledge, which had seven multiple-choice questions, and Attitude, which had 14 statements on a 4-point Likert scale.In the knowledge section the participants could respond with "yes," "no," or "I don't know."Participants received two points for each correct answer and one point for each incorrect response, resulting to a total knowledge score of 14.The knowledge section was scored from 7 to 14, with a higher score indicating greater knowledge about patient data confidentiality.To analyze knowledge, the number of correct answers was calculated as the sum score for each respondents.A mean of seven questions regarding knowledge of patient confidentiality was calculated, and those who scored above the mean were classified as having "good" knowledge, while those who scored below were classified as having "poor" knowledge 16 .
The attitudes section of the questionnaire consisted of 14 questions, which were scored on a 4-point Likert scale ranging from "never" to "always."This section was scored from 14 to 56, with a higher score indicating greater confidentiality regarding patient data sharing.To analyze attitudes, the correct direction of the attitude for each question was determined.A mean of the 14 questions related to attitudes toward patient confidentiality was calculated, and those who scored above the mean were classified as having a "favorable" attitude, while those who scored below the mean were classified as having an "unfavorable" attitude, according to Entwistle VA in 2010.

VALIDITY AND RELIABILITY OF THE INSTRUMENT
The questionnaire's knowledge and attitude sections had face, content, and construct validity, and confirmatory factor analysis confirmed the appropriateness of all questions to collect data.The survey was pilot tested on 21 participants who were not part of the study sample.The Cronbach's alpha values were calculated to be 0.79 and 0.89 for the knowledge and attitude sections, respectively, indicating acceptable internal consistency and reliability.
For the whole questionnaire, the Cronbach's alpha value was 0.83, further indicating acceptable internal consistency and reliability.

ETHICAL CONSIDERATIONS
The study adhered to the Helsinki Declaration and received ethical approval from the authors' Institutional Review Board (IRB) (Ref.No. KFU-REC-2022-OCT-ETHICS209).No identifying personal information such as names or addresses was collected from the participants.

RESULTS
The study survey was completed by 402 students from seventeen Saudi universities with varying study levels in the health sector.As for the time of admission, 86 (21.4%) students joined the university in 2018-2019, while 102 (25.4%) joined in 2019-2020.In terms of specialization, 191 (47.5%) students came from colleges of medicine, and 127 (31.6%) from colleges of nursing.In terms of universities, most of the kingdom's universities are represented.In terms of gender, 274 (68.2%) of the participants were females, while 128 (31.8%) were males.Of the participants, 108 (30.1%) had GPAs between 4 and 4.49, while 121 (30.1%) had GPAs between 4.5 and 5. Three hundred and sixty-eight (91.5%) of the students were single.Direct contact with patients was experienced by 331 (82.3%).The number of students who received ethics courses in dealing with patients is 346 (86.1%).A total of 205 (51%) attended private courses related to ethics.A total of 14 (53.2%)participants had experience with ethical dilemmas.Table 2 illustrates the students' knowledge about confidentiality of patient information.
Among the seven questions, the highest score was obtained in the first question about "Does confidentiality governed by low?".The majority of participants (66.7%) said "yes" giving a mean score of 1.67 ± 0.47 out of 2. The following question was "Does non-medical information considered confidential?"where the majority (61.7) answered "yes" giving a mean score of 1.62 ± 0.49out of 2. In general, the results show that the percentages of participants who were able to answer each question correctly were higher than those who gave wrong answers, except for question six "Can patient confidentiality be breached if the disease contagious?".The majority (55.5%) of participants answered "yes" which lowered the mean score of that question to 1.29 ± 0.45.The mean score of the knowledge subscale was 10.51± 1.77 out of 14, which indicates that participants have above average level of knowledge about patient confidentiality.
Overall, as shown in table 3, from all sample, 66% have good level of knowledge, while 34% have poor knowledge about the patient confidentiality.Overall, for each question in the scale, the percentage of participants who were able to answer correctly was higher than those who failed to answer.The highest score was obtained for the question "I allow non-medical personnel (eg, cleaning staff) to enter the examination room whilst I am providing care to patients", which was 3.05 ± 1.05 out of 4, followed by "I make and receive phone calls about patients' conditions when I am near other patients" with a mean score of 3.02 ± 1.07 out of 4. On the other hand, the lower scored item was "I use virus   Additionally, students' GPA has significant but weak negative correlation with students' attitude toward patient confidentiality (r=--0.100-,P-value= 0.045).

DISCUSSION
Healthcare professionals encounter many ethical dilemmas during their clinical practice.
Preparing them when they are students with the appropriate ethical and legal principles is vital to build their knowledge and influence their attitudes toward maintaining patient's confidentiality, and to prevent any legal or ethical risks in their future practice 5 .This study was conducted to assess the level of knowledge and attitudes of health sector students in maintaining the confidentiality of patient information and patients' records.The study sample included males and females students from different health specialties from 17 colleges and universities in all regions in Saudi Arabia.
The study results revealed that approximately 66% of the participated students have good level of knowledge about the confidentiality of patients' information.This result is higher than the results from similar studies done in Ethiopia (59.8%) 9 , and in Iran (56.5%) 13 .Likewise, the mean score of knowledge domain was 10.51out of 14 (SD=1.77),which was higher than the results by Karasneh et al., 2021 16 that surveyed physicians from public and private healthcare institutions in Jordan and reported a mean of 7.34 (SD=2.92).Students' attitudes toward maintaining patient confidentiality was positive for the majority of the students (53%), which raised the mean score of attitude scale to 40.64 out of 56 (SD= 8.63).
According to our results, receiving ethics courses during undergraduate study by 86% of the students could be a factor that contributed to raise participants' level of knowledge.12 Furthermore, several factors can be considered as contributing factors that influenced participants' attitude such as attending training courses about medical ethics by 51% of the participants; having clinical experience of direct contact with patients by 82% of them; and having previous experience with ethical dilemmas which all are essential for enriching and shaping the attitude toward patient confidentiality.
The majority of participants were able to answer some of the knowledge questions correctly.For example, they agreed that patient confidentiality is governed by low, and they agreed that non-medical information considered confidential.However, two items were considered weak areas where participants were not confident in answering them correctly.
These questions were about breaching confidentiality when the patient dies and when the disease is contagious which were answered correctly by only 46% and 29% respectively.This could be due to the limited clinical experience for students with these two patients categories.
Instructors, and/or supervisors usually assign students to be exposed to active patients to maximize their benefits of interacting with patients, and do not assign them to dying patients.
Additionally, for students' safety, supervisors are often trying to keep students away from infected cases especially during COVID-19 pandemic.These reasons might minimize students' exposure to such cases and affect their responses in these specific questions.
In our study, participants' perceived attitude toward maintaining patient confidentiality was generally positive as reflected by the positive responses of 53% of them.Although this percentage is considered good as compared to other studies 9,16 .There are some questions in the attitude scale that assess the frequency of breaching patient confidentiality by conducting specific actions were answered by "always", or "sometimes" by considerable percentage of participants.For instance, more than third of the participants answered the question about sending patient information online by either "always", or "sometimes".Similar proportion also applied to questions regarding discussing patients' conditions with colleagues during break; and discussing patients' conditions with friends outside the workplace.A vigilant assessment of responses is important to gain insight about the extent to which patient confidentiality might be breached by students.These findings mandate closer supervision and guidance to students when dealing with real patients.
The correlations between demographic characteristics and knowledge and attitude of health professionals were reported in some studies 9,16 but in our study, the analysis did not show significant correlations except for the university and the GPA, which are both weak correlations.The university is positively correlated with the level of knowledge and attitude.
The correlations can be explained by the variety of universities in our sample that included 17 14 a constructive feedback to students to encourage good practices and highlight the unethical practice that may harm the patients with or without intention, and to correct their future practice.
Graduating qualified health professionals is pivotal goal for educational institutions that worth huge efforts from educators, program directors and hospital leaders to ensure having a safe and ethical practice in the future.

Limitations
Using a self-report questionnaire is a limitation for the current study.

CONCLUSION
Up to our knowledge, this study is the first in the country that assessed the level of knowledge and attitudes of healthcare professionals toward maintaining patient confidentiality that targeted almost all universities in all regions in Saudi Arabia.The study highlights the importance of assessing these variables to gain insight about the current level, Overall, the majority of participating students have good level of knowledge and positive attitudes toward maintaining patient confidentiality.However, based on the response, there are portions of students who breached the confidentiality of patients.Although this category of students is not large, paying more attention to students' ethical practice is vital to prevent patients' harm and to ensure safe and ethical practice from all healthcare professions students in Saudi Arabia.
Some strategies were given to help educators and hospital leaders to build good knowledge and clinical training for students, which eventually can enhance the level of knowledge and build positive attitudes for all students.Future research should be done to investigate which educational strategies and clinical training is more successful in enhancing students' ethical knowledge and practice.
Health Students' Perspectives on Patient Confidentiality and Record-Keeping Ethics ___________________________________________________________________________ Rev. Gest.Soc.Ambient.| Miami | v.18.n.1 | p.1-16 | e06188 | 2024.13 universities from all regions in Saudi Arabia.Universities offer different programs and courses to health professional students.In Saudi Arabia, universities do not offer unified programs even for the same specialties.Some universities focus on ethical and legal issues while others vary based on their curricula.The teaching methods also vary based on the programs' goals and content.Furthermore, the clinical training to students and their level of exposure to patients also vary based on the programs and the universities as well.All these variances among universities and how they deliver their programs may contribute to the correlations we found between universities and the level of knowledge and the attitude of their students.It is expected that the more clinical exposure to clinical cases and to ethical dilemmas, the more the student would understand and apply ethical principles among which is maintaining patient confidentiality.Contrary to our expectations, another correlation in this study was, (r= -0.1, p-value= 0.045) which indicates a weak negative correlation between the students' GPA of last academic year and the students' attitude toward patient confidentiality.Against what we expected, this correlation indicates that having high GPA actually does not correlate with practicing high level of maintaining patient confidentiality.However, this result might be statistically influenced by low variance among the GPAs because the majority of our sample (57%) have a high GPAs that range between 4 to 5. The study results highlight the importance of assessing the level of knowledge and attitudes toward maintaining patient confidentiality.Although the general results are positive, health care professionals and educators needs to pay more attention toward helping all health professions students gain the necessary knowledge and skills before they move to the work life to prevent any breach of patient confidentiality.This can be achieved by different strategies such as by adding more focus and time on teaching students the ethical principles as part of their undergraduate curricula either by designing a whole course about medical ethics, or at least having different lectures distributed in different courses/ blocks in the curricula.Another strategy is by revising the teaching methods they use in delivering the material and make evidence-based decision about the best method that serve better in delivering this content.Using Problem-based learning or team-based learning, clinical scenarios, simulation labs are all examples of alternatives that can be utilized in delivering medical ethics content and training 17 .Revising the clinical training plans is another approach that can help in ensuring that each student gets enough exposure to different cases and be able to maintain patient confidentiality.Delivering the content in theory and practice should be followed by in depth assessment of whether the students really gained the knowledge and became able to handle ethical dilemmas and able to maintain patient confidentiality.Part of students' assessment should include giving Health Students' Perspectives on Patient Confidentiality and Record-Keeping Ethics ___________________________________________________________________________ Rev. Gest.Soc.Ambient.| Miami | v.18.n.1 | p.1-16 | e06188 | 2024.

Table 2
Knowledge about patient confidentiality among the students

Table 3
Students' distribution of level of knowledge about confidentiality Table 4 presents the participants' perceived attitudes toward maintaining confidentiality.
protection and encryption software on the devices on which I store patient information" which obtained a mean score of 2.59 ± 1.19 out of 4. The mean score of the Attitude subscale was 40.64± 8.63 (Out of 56), which is equivalent to 72.57% of 100.Overall, 53% of participants have positive attitude toward maintaining patient confidentiality, while 47% have negative attitude, as shown in table 5.

Table 4
Perceived attitudes toward maintaining confidentiality among the students

Table 6
Predictors of students' knowledge and attitudes toward Patient Confidentiality