Knowledge, Attitude, and Practice Related to Health Care Ethics among Dental Students in Davangere City - A Cross-sectional Study

Introduction

Ethics has been defined as the branch of philosophy that deals with human conduct and moral principles. Dental ethics refers to dentist's moral obligations and duties to society, their patients, and other dental professionals. Even today, all medical graduates are required to make a symbolic promise to uphold the Hippocratic oath, demonstrating the long history of application of ethics to medical practice.¹ The Medical Council of India (MCI), which oversees medical education, has made medical ethics training a requirement for undergraduate students.^2,3 The current training emphasizes individual autonomy while the communities where the doctors are located are more accustomed to a communitarian approach, leading to a clash of norms.⁴

Public concern over the moral behavior of healthcare workers is on the rise.² These might be the result of the doctor's paternalistic behavior, a lack of comprehension, emotional outbursts, or both.³ Positive role models can provide examples of ethical behavior and inspire students to strive for high standards of ethical conduct. On the other hand, negative role models can illustrate the consequences of unethical behavior and the importance of avoiding such behavior.^1,5 By understanding these regulations and laws, doctors can ensure they are practicing in a way that is ethical and legal.^1-3 Hence, this study was conducted to assess the knowledge, attitude, and practices related to healthcare ethics among dental students in Davangere city.

Materials and Methods

Study design

The present study was a cross-sectional survey performed during the period between September and November 2021.

Study participants and study location

The study was conducted among the Dental undergraduates (Final years and Interns) of two colleges (College of Dental Sciences and Bapuji College of Dental Science) in Davangere city, Karnataka. Out of a total 221 students, 205 students took part in the study.

Pre-testing of the questionnaire

A close-ended structured questionnaire to assess the knowledge, attitude and practices related to healthcare ethics containing 15 questions was prepared. Before administering the questionnaire to the study participants, a pilot study was conducted among ten participants to test the validity and reliability of the questionnaire. The results of the pilot study were not included in the final analysis, as they were only used to test the questionnaire. The reliability of the questionnaire was assessed using Cronbach's alpha (Cronbach’s α=0.81).

Sampling method and Administration procedure

The convenience sample method was employed in this investigation. In the aforementioned colleges, we approached undergraduate students and distributed 221 survey questionnaires to them. Sufficient time was provided for the students to complete the survey questionnaire before collecting it.

The structured close-ended questionnaire proforma was designed in English. The questionnaire consisted of two parts. The first part collected general information from the participants such as their name, age, gender, year of studying, college name, and contact number. The second part of the questionnaire consisted of 15 questions related to knowledge, attitude, and practice of healthcare ethics. Specifically, six questions were related to knowledge, five were related to attitude, and four were related to practice.

Statistical analysis

The data obtained were collected, tallied, and entered onto a Microsoft Excel sheet. The IBM SPSS (Statistical Program for Social Sciences, software version 22.0) was used to perform frequency distribution and Pearson Chisquare statistical tests on the recorded data (p <0.05).

Ethics Statement

The Institutional Ethical Committee (IEC) at the College of Dental Sciences, Davangere authorized this study.

Informed Consent

A cover letter attached to the survey tool that included the key elements of informed consent was provided to participants. The cover letter informed participants about the purpose of the research study, potential benefits, and risks of participating, and emphasized that participation was voluntary and refusal to participate would not result in any academic penalty. IECs waived the requirement to sign a written consent form to protect their anonymity. Instead, completion of the survey implied the participant’s provision of informed consent.

Results

The study included a total of 221 participants, with a high response rate of 93.18% (n=205). The sample included 103 (50.2%) final-year students and 102 (49.8%) interns (Figure 1), among which 84 (41.0%) were males and 121 (59.0%) were females (Figure 2). The average age group was between 22-24 years. Table 1 presents the frequency of responses for each question, as well as the results of Chi-square test. About 73.7% of the students chose correct option for the term Ethics. About 66.3% of the students knew about the Hippocratic oath and Nuremberg code (Figure 3). A highly significant statistical difference with a p-value of 0.000 was observed. Nearly 77.6% of students knew the principles of ethics (Figure 4). On asking if there is an ethical committee in their institution, 44.9% students responded ‘Yes’, whereas 55.1% students responded as ‘Don’t know’ (Figure 5). Overall, interns had good knowledge regarding healthcare ethics compared to final year. The percentage of students giving correct responses was significantly higher in the internship of Dental studies.

When questioned about how often they discuss their daily cases with their colleagues, 75.1% of students said seldom and only 20.5% of students said always (Figure 6). Almost 91.2% of students agreed that confidentiality is important (Figure 7). When asked if the patient’s confidentiality be breached if he/she dies, only 47.3% of students responded ‘No’, while 52.7% students responded ‘Don’t know’ (Figure 8) (p= 0.000).

Only 53.7% of students disagreed with the statement that consent should only be required for surgeries and not for testing and medications, while 46.3% of students agreed (Figure 9; p=0000). When a patient declines treatment because of particular religious convictions, only 45.9% of students stated that they would refer them to another doctor who shares those beliefs (Figure 10)

Frequency distribution of responses of chi square distribution

Discussion

The present study was conducted to assess the knowledge, attitude and practices related to healthcare ethics among dental students in Davangere city. Majority of students in the study had awareness of ethics (73.7%) and its principles (77.6%). Most participants returned the completed survey questionnaires within 48 hours. About 66.3% of students reported having “heard” and even “read” the Code of Ethics. Hariharan S et al. in 2006 in their study found that more than 90% of participants were unaware of the Nuremberg Code. According to Brogen AS et al. in 2009, 98.7% had heard and only 188 people (59.7%) were reported to have studied the Code of Medical Ethics.1 Shirazi B et al. (2005) in their study reported that more than half of the respondents had heard of the Code of Ethics published by the Pakistan Medical and Dental Council. Mere 44 out of 101 had read the code completely or partially. Seven were completely unaware of its existence.⁶

Majority of the participants in the study stated that undergraduate students were taught the Code of Ethics through seminars and lectures. In their study, Seetharaman Hariharan et al. (2006) reported that more than 70% of participants indicated to have learnt about ethics at work.² Only 11 participants received ethical instructions in medical school as reported by Shirazi et al. (2005). Four subjects did not believe that ethics education at the college level was necessary.⁶

Over 86.3% of the participants in the survey believed that knowledge of ethics is crucial for their profession, compared to almost 90% as reported by Seetharaman Hariharan et al. in 2006. Only one participant believed that knowledge of ethics was "not at all important."²

Despite 44.9% of students being aware that their institution had an ethics committee, very few were aware of the committee's function. In 2015, Chandrashekar Janakiram et al. found that 52.5% of participants were unsure if their institute had an ethics committee or not.³

In the present study, about 91.2% of the students believed that confidentiality is crucial. Shirazi B et al. (2005) in their study reported that 42 out of 101 respondents gave accurate responses to questions about confidentiality and the law pertaining to trauma victims.⁶

Although there are many arguments regarding confidentiality, such as confidentiality versus the law, confidentiality regarding communicable diseases versus spouse knowledge of the disease, and whether to provide police with information regarding trauma or assault of any kind versus treating the injured, it is highly unethical for a doctor to violate patient confidentiality. Except in cases when there is a threat to another person's life, confidentiality is preferred; in those cases, police enforcement must be notified. In our study, 52.7% of students reported not knowing about it, compared to 47.3% who disagreed. Shirazi B et al. (2005) in their study reported that majority of the respondents were unclear on these problems.⁶

In the current study, 86.8% of participants stated it was important to inform close family members of the patient's health all the times. Akoijam Brogen S et al. (2009) in their study noted that there was a clear lack of trust between patients and doctors, as evidenced by the respondents' opinions that medical records are frequently requested by patients' parties to file lawsuits (37.1%) and consult with other doctors (44.4%).¹ This study provided information from student evaluations and described an example of implementation. According to a study by Dhanappa KB et al., several essential and crucial issues for law school and the maintenance of professional ethics in healthcare are required.^7,8 The fact that only dental students from two institutions were included in this study represents a serious limitation of this study. Despite the high response rate, sampling bias still exists.

Conclusion

During their training, dental students commonly face moral conundrums but lack the awareness to resolve them. Being taught how to be a professional is one of the most crucial lessons taught in dental schools. The study emphasizes the significance of evaluating students' knowledge, attitudes, and practices about ethical and legal issues to develop strategies for raising their awareness on these issues and providing them with the necessary instructions. It would be advantageous to include an ethics curriculum in the starting phases of pre- and post-graduate programs.

Source of support in the form of grants, equipment

Nil

Conflict of interest

Nil

Acknowledgements

Nil