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Year : 2016  |  Volume : 19  |  Issue : 5  |  Page : 622-631

Ethical issues in knowledge, perceptions, and exposure to hospital hazards by patient relatives in a tertiary institution in North Western Nigeria

1 Department of Community Medicine, Kaduna State University, Kaduna, Nigeria
2 Department of Community Medicine, Ahmadu Bello University, Zaria, Nigeria

Date of Acceptance02-Jan-2016
Date of Web Publication19-Aug-2016

Correspondence Address:
AOM Oyefabi
Department of Community Medicine, Kaduna State University, Kaduna
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1119-3077.188705

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Introduction: Patient relatives are a significant part of the health care team in any hospital setting. This study determines their knowledge, perceptions, and factors responsible for their exposure to health hazards at the Ahmadu Bello University Teaching Hospital (ABUTH), Zaria, Kaduna State. The outcome of this study is intended to help the hospital managers to have a reference to make plans for the patient relatives' welfare and also address the ethical issues regarding patients' relatives safety while in the hospital.
Materials and Methods: This is a cross-sectional descriptive study involving 100 participants selected by systematic random sampling technique from the ten admission wards of the ABUTH. The data were analyzed using the Statistical Package for Social Sciences IBM 20 and STATA SE12.
Results: The mean age of the respondents was 35 years. They were mainly Hausa (58%), female (79%), and Muslims (76%). About 21%, 25%, and 54% of the respondents have poor, fair, and good knowledge, respectively, with a mean knowledge score of 33.3% while 24% perceived that blood urine and feces from patient relatives are safe to handle. Sexual harassment (13.3%), abusive insults from health care workers, (13.3%) and aggression from other patients were reported. Being the sole caregiver, type of illness, handling of patients' blood and feces, and length of hospital stay were significantly associated with exposure to hospital hazards (P < 0.05, χ2 > 1, odds ratio >1).
Conclusion: The participants' knowledge and perception of hospital hazard were poor. Abusive insults by health workers, sexual harassment, and indiscriminate handling of patients' specimen constitute major ethical challenges in this setting. The hospital management should have a guideline specifying the roles and responsibilities of patients and their relatives. There is a need for the health care workers' ethics education and safe accommodation for patient relatives.

Keywords: Admission, compliance, hazards, hospital ethics, patient relatives

How to cite this article:
Oyefabi A, Yahuza B S. Ethical issues in knowledge, perceptions, and exposure to hospital hazards by patient relatives in a tertiary institution in North Western Nigeria. Niger J Clin Pract 2016;19:622-31

How to cite this URL:
Oyefabi A, Yahuza B S. Ethical issues in knowledge, perceptions, and exposure to hospital hazards by patient relatives in a tertiary institution in North Western Nigeria. Niger J Clin Pract [serial online] 2016 [cited 2022 May 18];19:622-31. Available from:

   Introduction Top

A relative is a family member, friend, or neighbor looking after a person suffering from any kind of disability or illness.[1] Patients' relatives are important members of the health care team; they are important human resources for the sick family members.[2] These are usually the significant others who first recognized the need for the patients to seek medical help, advise him to do so, accompany the patients to the hospital, get him registered and bring him to the consulting room to see the medical experts.[3],[4] Sometimes, they explain the patient conditions to the medical practitioners, pay for his bill which is usually out of pocket and may even be catastrophic to the relative caregivers.[5] Usually, a family member is assigned to stay with the patient until the client is discharged from the hospital.[6],[7]

However, when an individual continues to stay in the hospital for long, they may be exposed to nosocomial infections such as Candida spp. Staphylococcus and Pseudomonas.[8] A very hazardous source of hospital hazard is the indiscriminate handling and disposal of hospital biomedical waste generated during diagnosis, treatment, nursing care, or immunization services.[9] The waste produced in the course of health care activities constitute a higher potential for infections and injury than any other type of wastes.[10] The sputum, blood, urine, feces, and any other bodily discharges of patients can be very dangerous as we have seen in the cases of Ebola virus epidemics in some West African nations recently.[11]

It has been noted in previous studies that exposure to physical hazards due to needle stick injury poses a great danger transmitting nosocomial bloodborne infections such as the HIV and viral hepatitis,[12] while airborne aerosols and droplets of washing and cleaning liquids may constitute chemical hazards resulting in chronic poisoning and allergic reactions.[13] Undue exposure to cytotoxic, antiviral drugs, hormones, bioengineered drugs, and other miscellaneous drugs have a potential for causing cancer, developmental or reproductive toxicity to the exposed organs.[14]

Common social and psychological hazards observed in hospital settings are verbal threats, physical assaults, significant depression, anxiety, and neurological deficits.[15],[16],[17],[18]

This study determines the prevalence, knowledge, nature, and risk factors associated with the exposure to hospital hazards by the respondents. It also examines the ethical issues in knowledge, perceptions, and pattern of exposure to these hazards. The outcome of this will help the hospital management to have a reference study to make plans for the patient relatives' welfare and also to address the ethical issues regarding patients' relatives' safety at the Ahmadu Bello University Teaching Hospital (ABUTH), North Western, Nigeria.

   Materials and Methods Top

Study location

The study was carried out the ABUTH, Shika, Zaria complex. The hospital offers health services not only to people residing in Zaria but also in surrounding districts and states. This ultra-modern complex also serves as a referral center for cases from all over the Nigeria federation to its various specialty clinics. It has been designated a center of excellence for radiotherapy and oncology for the treatment of cancer. It has a bed capacity of 1000 and a total patient admission turnover of more than 10,000 annually. The hospital has clinical departments, wards, Outpatient Department, Radiology Department, Accident and Emergency Unit (A and E), laboratories, operating theaters, clinics, Intensive Care Unit, and Administrative Departments. The study population comprises patient relatives in the hospital premises who have spent at least a day within the hospital.

Study design

This is a cross-sectional descriptive study involving 100 participants selected by the systematic sampling technique from the male medical, female medical, male surgical, female surgical, pediatric medical, emergency pediatric ward, A and E, psychiatry, obstetrics, and gynecology wards. Ten patients were equally allocated to each ward, and these were selected by systemic random sampling technique using the available number of patients' relatives in each ward who met the selection criteria as the sampling frame. The data were collected with structured questionnaires [Appendix 1] and [Appendix 2]. These were well-rehearsed by the researchers and the research assistants during the planning meeting to ensure accuracy and uniformity in questions to be asked the respondents. The questionnaires were administered by the second author assisted by two well-trained research assistants. The questionnaire design started with an introductory informed consent which the patients' relatives were requested to read before they respond to the questions. This was also carefully read to the illiterate respondents by the researcher to seek their consent before their responses to the questions. The permission to carry out the research was obtained from the Ethical Committee of the ABUTH, Shika, Zaria. The data collectors translated the questions to the Hausa language for the illiterate respondents who were mainly Hausa. The questionnaire contains three sections; Section A was on the sociodemographics, Section B was on the knowledge of the relative on hospital hazards, while Section C was on the exposure to of the participants to hospital hazards. The questionnaires were interviewer-administered. They were collated after the data collection; data cleaning were done each day before entry into the computer. Data analysis was done with the Statistical Package for Social Sciences (IBM SPSS) version 20 and the StataCorp STATA SE 12. Quantitative variables were summarized using appropriate measures of location and variability such as the mean and the standard deviations, whereas categorical variables were presented as frequencies and percentages. The Chi-square test was used to test for significant associations between categorical variables. The value P ≤ 0.05 was considered statistically significant. Binary logistic regression analysis was used to determine factors that were significantly associated with respondents' exposure to hazards and quantitative variables such as the age and number of days in the hospital. The minimum sample size calculated using the Cochran's formula was 66; this was however increased to 100, this was to increase the Power of the study.[19]

Ethical consideration

Approval for the study was obtained from the ABUTH, Zaria Research Ethical Committee. Inform verbal consents were obtained, and their names were not demanded to ensure confidentiality. [Appendix 3].

Limitation of the study

Berksonian bias might occur in the hospital-based study and oral reports from the participants is liable to information bias.[19]

   Results Top

The mean age of the respondents was 35 years, the ages range from 11 to 70 years, they were mostly Muslim (76%), female (79%), Hausa (58%), and unemployed homemakers (67%); about 69% of them were from Kaduna state, while others were from the neighboring North Western states in Nigeria, most had no formal education (34%). Overall, 43% of the respondents experienced, at least, one type of hospital hazard during the hospital stay. Approximately, 21%, 25%, and 54% of the respondents have poor, fair, and good knowledge, respectively, with a mean knowledge scores of health hazards (HHs) being 33.3%. The main sources of information were the medical personnel 47%, media 41%, school 31%, television (21%), and radio (17%). The major known route of transmission of hospital hazards were ingestion (75%), inhalation (77%), skin contact (72%), and sexual contact (48%) [Table 1]. The sources of hospital accidents includes falls (75%), electric shocks (68%), fire (69%), and food poisoning (65%), while hospital wastes (76%), drugs (41%), radiation (24%), hospital environment (62%), stress of caregiving (62%), and sharps (71%) were known by the participants to be the factors constituting HH in the hospital environment [Table 1]. The respondents mentioned personal protective devices useful during hospital stay to include hand gloves (82%), work cloth (68%), goggle (66%), facemask (73%), vaccination (67%), hand washing (68%), footwear (47%), personal hygiene (24%), and the use of disinfectants (21%) [Table 2].
Table 1: Knowledge of the routes of transmission, sources, and risk factors of hospital hazards

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Table 2: Knowledge of methods of personal protection from hospital hazards

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Majority of the respondents (66.7%) believed that the knowledge of the hospital hazard was very important, other believed that sleeping in the hospital was very appropriate (42%), while 24% of the respondents perceived that their sick relatives' bodily specimen such as the blood, urine, and feces were safe for the to handle, only 70% believed that they can get infection from the ward, while another 69.7% opined that the patient care is stressful. Three-third (75%) of the respondents noted that the patient care affected their work and study. About 2/5th (39%) were satisfied with the quality of the hospital care [Table 3]. However, 90% of the respondents slept in the hospital wards to take care of their patients. They preferred to do this because their sick relatives required intensive care (60%), their homes were far from the hospital (22%), and there were not enough accommodation facilities for the sick relatives within the hospital environment (18%) [Figure 1].
Table 3: Perception of the respondents about hospital hazards

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Figure 1: Patients' relatives reasons for sleeping in the hospital admission wards

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The nature of hospital hazards experienced by these caregivers were aggression from other relatives (4%), stealing of their personal properties (3%), diarrhea and vomiting (5%), sexual harassment (6%), verbal aggression from health workers (6%), stress headache (9%), respiratory illness (23.9%), and febrile illness (47.8%). The median number of days spent in the hospital was 12 days during which time the respondents came in contact with their sick relatives' blood (37%), urine (67%), and sputum (14%) specimen.

The hospital procedures this group of caregivers believed would require personal protections include ward cleaning (79%), changing of bed sheets (71%), collecting blood, urine or stool samples from patients (71%), setting up of the intravenous line (61%), surgical procedures (69%), and drug dispensing (56%). They wanted the hospital management to provide accommodation within the hospital premises (52%), while 64.6% wanted to be educated on the hospital HHs. Some of the respondents also wanted the management to provide improved security services for them (51%), while 2/5th (19%) wanted the hospital to train the health workers on good human relations.

The knowledge of the respondents about the hospital hazard (χ2= 5.64, P = 0.018), handling of blood specimen (χ2 = 6.44, P = 0.011), contact with patients' fecal matter (χ2 = 1.647, 0.011), and being a sole caregiver (χ2 = 5.369 P = 0.02) were observed to be significantly associated with occurrence of a hospital hazard [Table 4].
Table 4: Determinants for experiencing hospital hazards by the patients' relatives (n=100)

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   Discussion Top

The patient relatives in this study were relatively older homemakers, 2008 Nigeria National Demographic and Health Survey revealed that the median age at marriage in North Western Nigeria is 15.2 years.[19] The women in this study, therefore, would have married for more than 10 years at the time of this study. These experienced homemakers were preferred by their family members to stay with the patients because of the believe that this older relative can better care for the sick persons.[20] Previous studies in Africa had also reported the predominant female relative caregivers.[21],[22] Most of the respondents were from Kaduna state, but some came from Katsina, Zamfara, Sokoto, and from some nearby villages. Majority of the patients had more than one relative caregivers due to the extended family system in Africa.[23],[24] Previous studies have also shown that the patients recover faster and interact better with the clinicians when patient relatives are available.[25],[26]

The mean knowledge score of 33.3% in this study revealed the limited knowledge of patient relative caregivers. Previous studies have shown that this problem of lack of awareness of hospital potential hazards by patient relatives and indeed by any other persons in the hospital environment could be associated with the hospital management practices of giving inadequate information to the patients and their relatives.[27],[28] However, the Nigeria Medical Association has clearly stipulated the fundamental right of a patient to include the right to necessary information about the name and status of the health care workers in charge of a patient and the right to information on the diagnosis, treatment, and prognosis.[29] Therefore, the inability of a patient or the relative to assess basic health information regarding their safety during the hospital stay contravenes the fundamental right of such a patient.[29]

The handling of patient urine, feces, and blood specimen was also due to lack of adequate information on the danger of such specimen. It should be noted that more than 40% of the patients' relatives in this study thought that the bodily specimen of their sick family member could not harm them. However, Dowell et al. observed that 16% family members developed Ebola hemorrhagic fever with exposure to body fluids such as feces or urine conferring additional risk with relative a risk of 3.6.[30] Based on a limited number of studies, it is believed that human-to-human transmission of the Ebola disease occurs only by the direct contact with blood or bodily fluids from an infected person who is showing signs of infection or by contact with objects recently contaminated by an actively ill infected person.[31],[32] Similarly, an infectious disease such as the cytomegalovirus infection is spread when urine is transferred from the soiled hands or objects to the mouth while gastroenteritis, hookworm infection, cholera, hepatitis A, Campylobacter, cryptosporidiosis, giardiasis, hand, foot and mouth disease, viral meningitis, Rotavirus, Salmonella, Shigella, and yersiniosis infections are transmitted via the feco-oral-route.[33] Bloodborne infections such as the HIV, hepatitis B, cytomegalovirus, and other viral hemorrhagic fever such as Lassa fever are well-documented in literatures.[34] Therefore, it is not right for the untrained patients' relatives to handle these specimens considering their potential for HHs. The Nigeria National Health Bill recently accorded the presidential assent, includes several patients and caregiver rights, including rights to emergency care, information about treatment, and right to have information about a patient. It is hoped that the implementation of this bill will address the problem of inadequate information about the patient management in Nigeria hospital.[35]

The patient bill of right stipulated also that the patient has the right to be informed about the hospital policies and practices that relate to patient care, treatment, and responsibilities. The sick person or their significant others also have the right to be informed for the available resources for resolving disputes, grievances conflicts such as the ethic committee, patient representatives, or other mechanisms available within the hospital. The collaborative nature of the health care requires that the patient families or surrogate participate in their care, and they should be accorded necessary information to perform their caregiving role effectively and without harm to the patient and themselves.[36]

Majority (34%) of the respondents in this study were not formally educated. It has been noted that higher level of education promotes access to information and better understanding of the modes of transmission, possible risk factors, and methods of disease prevention.[37]

The incidence of occurrence of hospital hazard among patient relatives was 43%. The major HHs reported in this study were mainly infectious diseases such as febrile illness (47.8%), respiratory illness (23.9%), stress headache (9%), and diarrhea and vomiting (5%). This observation is comparable to an aggregate of nosocomial infection rate of 26.8% observed by Ding et al. in China.[38] The complaint of headache may also be due to stress involved in patient care. Okoye and Asa in Nigeria had stated in their studies some of the stressful consequences of caregiving.[39]

Verbal aggression from the health care workers, sexual harassment of patient relatives, patient aggression, and undue handling of patient specimen constitute major ethical issues in this study.[40] Aggression either from the health care worker, the patient or his relative can disrupt cordial relationship with an attendant negative effect on the patients on admission.[39] Public commentators have observed that the impact of the negative attitude to work by health care providers in public and private hospitals in Nigeria is particularly worrisome. Years of the poor attitudinal problem, particularly in the public sector, has further endangered lives of many patients negating the principle of non-maleficence.[41]

Furthermore, negative attitude of the health care providers has been reported in previous studies to affect the uptake of essential hospital services.[42],[43] Studies have reported increasing home deliveries in African countries due to poor attitude of the health care providers.[44] Most pregnant women lack confidence in some health care professionals because they considered them undertrained, incompetent, and inexperienced.[45] Some women have described health providers as verbally and physically abusive, rude, bossy, disrespectful, insulting, easily angered, having poor attitudes, and lacking compassion.[46],[47],[48]

This kind of attitude constitutes malpractice described by the Nigeria code of medical ethics under rule 33. Verbal abuse and physical assaults on patients that the health worker owes a duty of care to is by no means a practice, that is, without medical ethics.[49] The Medical and Dental Council of Nigeria's Code of Medical Ethics requires medical doctors, among other things, to give due respect and honor to patients.[49] Desmarais et al. reported that the patient can also be aggressive to the health care provider.[50],[51] Therefore, it is very pertinent for the hospital management to emphasize the need for courtesy from both parties.

The incidence of sexual harassment in this study was 13.3%. Sexual gratification is a major issue in many organizations setting although cases of sexual misconducts and rape are highly under reported.[51] The reported cases of rape and other form of sexual harassment are on the increase in Nigeria.[52] These cases of sexual misconduct need to be reported to the hospital management for appropriate disciplinary action since the law of the federal republic of Nigeria has stipulated strict sanctions against offenders.[53]

We also observed a significant association between the occurrence of hospital hazard and patients' relatives' contact with blood (χ2 = 6.44, P = 0.011, odds ratio [OR] =3), feces (χ2 = 1.65, P = 0.011, OR = 1.47), prior knowledge of the hospital hazard (χ2 = 5.64, P = 0.018, OR = 3.35), and when there was a sole patient's relative caregiver (χ2 = 5.37, P = 0.02, OR = 2.72). Handling of patient urine, length of stay in the hospital, sex of the relatives, and sleeping in the ward were not significantly associated with experiencing hospital hazards (P > 0.05) [Table 4]. There is a need to make sure that in every hospital in the subregion there is a high level of personal hygiene and that universal precautions are maintained by all health care providers, patients, and their relatives and other persons within the hospital environment to protect them from nosocomial infections and other potential hospital hazards, especially now that the highly infectious disease with high case fatality such as the Ebola hemorrhagic virus disease is ravaging the west African coast.[54],[55],[56]

   Conclusion and Recommendation Top

The prevalence of hospital hazard among the respondent is high in this study 33.3%. This is due to poor knowledge and wrong perception of potential hospital hazards by the respondents. Furthermore, abusive insults from health workers, sexual harassment, and undue handling of patients' specimen constitute major ethical challenges in this setting. The patient relatives need basic health education while in a hospital environment. The hospital should have a manual specifying the roles and responsibilities of patients and their relatives. There should be a functional disciplinary committee to enforce ethical practices in the hospital. The health care workers also need to continue hospital ethics education. The management should provide more accommodation facilities for patient relatives within the hospital.


The author wishes to thank the patient relatives who gave us the needed cooperation during data collection.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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