PATIENTS IN INDIAN HOSPITALS: ENVIRONMENTAL STRESSES AND AFFECTIVE...
PATIENTS IN INDIAN HOSPITALS: ENVIRONMENTAL
STRESSES AND AFFECTIVE REACTIONS
MANJU AGRAWAL AND AJIT K. DALAL
Hospitals in India are characterised by urban bias, overcrowding, depersonalisation and routine
treatment procedures. Lack of proper communication with medical staff further heightens patients'
anxiety. Using an interview schedule, patients' affective reactions to the stressful hospital environment
were studied. The six reaction categories taken in this study were: anger, anxiety, depression, helpless-
ness, disengagement and rationalisation (in metaphysical terms). Data were collected on 122 hospital-
ised patients. It was found that the characteristic responses of both male and female patients were
depression, rationalisation and sense of helplessness. Gender differences in affective reactions were
observed. Male patients showed less anger and anxiety than females, but were higher on disengagement
Dr. Manju Agrawal is Research Associate, Department of Psychology, Lucknow University.
Dr. Ajit K. Dalai is in the Department of Psychology, University of Allahabad, Allahabad.
generally admitted to a hospital when an illness, disrupting one's normal
life activities, becomes acute, necessitating specialised treatment and close moni-
toring. Though a large proportion of patients get well as a result of hospitalisation,
hospitals are associated with suffering, pain and death. Hospitalisation is in itself a
major stressful event. The patients, trapped in an alien, impersonal environment,
are overawed by rigid hospital schedules, rules and regulations. Hospitalisation
uproots the patients from their familiar surrounding, strips them of their social roles
and identity, and renders their usual style of functioning ineffective. Western studies
show that only 40 per cent of the people who are ill, actually seek medical aid (Kosa
and Robertson, 1975), and still fewer are hospitalised. In India, though there are no
data, one can conjecture that the percentage of sick people getting hospitalised will
be very low.
Hospitals in India have an urban bias. According to the Health Information of India
(1987), out of the total number of 7765 hospitals, 6131 (nearly 79 per cent) are
located in big towns. Almost all medical colleges are located in cities, where doctors
and nurses are educated in the Western medicinal system. The lifestyle, language
and urban culture of the medical staff does not instil confidence and assurance in
the patients, who (at least in government hospitals) primarily come from the rural
and lower socio-economic strata of the society (Dalai and Singh, in press; Siva,
1989). The cultural and status differential between the patients and doctors often
results in patients meekly submitting to the authority of their doctors. The patients'
hopes and despairs are contingent on the pleasures and displeasures of their
attending doctor: their saviour. To a helpless patient, who is caught in the cobweb
of complex hospital system, even the lower down paramedical staff appears too
invincible to be disobeyed. In such an environment, the patients lose personal
control over their lives — all major decisions about them being taken by those who
are unfamiliar to them. The hospital ethos, thus, has no congruity with the patient's
life in the outside world.
42 Manju Agrawal and Ajit K. Dalai
The free-for-service medical colleges have usually qualified and technically more
competent doctors than the fee-for-service private and nursing home practitioners.
The latter service system is flourishing and proliferating because it lends its services
also towards satisfying the emotional needs of the patients (Freidson, 1961).
Two-thirds of all medical complaints are usually psychological in nature (Taylor,
1986) which are less attended to by the free-for-service doctors of medical hospitals.
They devote less time with patients and discourage patients from coming to them
again unless very necessary.
On hospitalisation, the patient's discomfort is aggravated by the depersonalised
treatment (s)he receives. In the hospital, a patient is just a number, or a case, or a
body to be medicated or operated upon. Patients are expected to remain passive,
cooperative and uninvolved in the treatment process. Such role expectations from
the patients are universal, but more apt in the Indian setup, due to the illiteracy and
rural background of a majority of patients and the heavy role demands on the medical
staff. In the perennially overcrowded Indian hospitals, the doctors have to attend to
a long array of in-door and out-door patients, besides fulfilling the role demands of
a teacher, an administrator and a clinician. Any attempt by doctors to be personal
in their approach makes the patients demand more of the doctors' time and energy,
with the possibility of leaving many patients unattended.
Such depersonalisation emanates from the hospital bureaucracy and routinisation
of treatment procedures in the allopathy system of medicine (Goffman, 1961).
Besides, constantly changing duties of junior doctors and nursing staff and shifting
of the patient from ward to ward does not allow any personal relationship to develop.
The era of superspecialisation in the allopathy system is further enhancing the sense
of depersonalisation. Depersonalisation of patients does not fit within the dominant
Indian cultural ethos, where most of the social interactions are very personalised
(Sinha, 1981). People tend to feel very anxious in an impersonal situation.
Another issue which merits careful consideration in the study of hospital environment
is doctor-patient communication. An observation commonly shared by patients is
that the doctors have neither time nor inclination to inform them about the diagnosis
and treatment course. Doctors believe that the correct information may increase a
patient's anxiety, particularly in case of a serious disease. Because of the status
differential patients are generally afraid of asking their doctors questions and are
thus ill-informed about their illness. Language, at times, becomes a barrier in
doctor-patient communication when patients are illiterate. From the patient's point
of view, the information provided is often vague and incomprehensible which further
enhances his/her anxiety. In one study of surgical patients, Dalai and Singh (in
press) found that 60 per cent of the patients in government hospitals did not have
even the basic information about the kind of surgery they were undergoing. Doctors
seem to underestimate patients' ability to comprehend information about their
diagnosis and treatment.
Since the doctors are primarily educated to deal with the biological aspects of the
disease, psycho-cultural aspects of the disease are either ignored, or very superfi-
cially dealt with. The doctors do not receive any formal training to deal with the
anxieties, fears and emotional crises of patients. This further mars the doctor-patient
Patients in Indian Hospitals 43
communication. Carstairs and Kapur (1976) observed that the Indian patients
primarily look for symptom relief and alleviation of their anxieties. Since the doctors
are unable to attend to patients' anxieties, most of the times patients are dissatisfied
with their communication with the doctors.
Another barrier in the doctor-patient communication is divergent beliefs about the
illness, its meaning, causes and recovery process. Patients frequently attribute their
illness to metaphysical factors and resort to traditional health practices. While visiting
a hospital, patients are usually not so much interested in the technical details of their
disease. Their interest is in knowing about the correct diagnosis, seriousness of the
disease, causes of the disease, side effects of medicines and the course of
medicine. The information they receive from doctors is usually about the organic
malfunctioning and the treatment regimen. Patients are very much inhibited to
discuss their fears and anxieties with the doctor. Such faulty doctor-patient commu-
nication often results in imprecise diagnosis and low compliance.
How do patients react to the stressful hospital environment? There could be large
variations in the way patients affectively react to hospital stressors depending on
their dominant behaviour pattern, socio-economic and educational background and
the nature of disease. However, studies suggest that people show some consistency
in responding to an unpleasant environment characterised by loss of control,
depersonalisation and lack of proper communication.
In our recent study conducted on 122 patients; 88 males and 34 females, from one
of the government hospitals located at Allahabad, the patients' affective reactions
to the stressful hospital environment were investigated. These patients were admit-
ted either for orthopaedic, respiratory or stomach problems. The average educa-
tional level of the patients was below primary level. Their age ranged between
25-55 years, the average age being 38 years. The reactions of the patients were
classified into six categories: Anxiety, anger, depression, helplessness, disengage-
ment and rationalisation (in the metaphysical sense). Among these, disengagement
refers to withdrawing one's attention from the immediate surrounding and engaging
in some other activities like music, day dreaming and so on. Rationalisation, on the
other hand, refers to interpreting the crisis within a larger cosmic perspective, e.g.,
'happiness and sadness are part of life'; 'there is someone bigger than mankind', 'it
is a result of my own karma'
(see Appendix). Table 1 given below displays means
and standard deviations along these six categories (on 4-point scale), both for male
and female patients and the results of t-test.
Table 1 shows that the most characteristic affective reactions to hospital environ-
ment in case of both males and females were rationalisation, helplessness and
depression. On the contrary, the mean rating on anger was the lowest in both the
groups, implying that anger is the least probable response among Indian hospita-
lised patients. Many studies (Taylor, 1983, Thompson, 1981) have shown that
helplessness and depression are the expected reactions to loss of personal control
in a crisis situation. Similarly patients' lowest response on anger is not surprising in
view that the most urgent need of a hospitalised patients is to make himself
44 Manju Agrawal and Ajit K. Dalai
acceptable in the surrounding so that needed services are not withheld. Their major
task is to please the physicians and the nursing staff. Even in Western hospitals,
which have supposedly much more efficient patient services, and a culture in which
a patient can sue the doctor for being negligent, similar patterns of reactions have
been observed (Tagliacozzo and Mauksch, 1972). According to Lorber (1975) about
75 per cent of all patients are cooperative, compliant, and they passively participate
in the treatment process. In an ongoing project by the authors the percentage of
such patients was found to be about 98 per cent. However, interviews of some
patients and their relatives revealed that they often suppressed their anger for the
fear of it affecting their treatment and care by hospital staff.
Affective Reactions of Hospitalised Male and Female Patients
Females (n = 234)
1.56 .60 1.87 .60
2.44 .93 2.66 .90
2.30 .49 1.95 .54
2.83 .50 2.56 .47
** P < .01
Low anger and high rationalisation can be explained in terms of patients' efforts to
adapt to the environmental stress by bringing changes in one's affective reactions
and cognitions instead of changing the situation which they perceive as beyond
control. Explaining the crisis as part of life, God's desire or result of one's own karma
facilitates in the process of adjustment to the disease (Agrawal and Dalai, in press).
The indigenous theory of karma
helps in explaining a host of undesirable experi-
ences without arousing a feeling of anger or guilt (Paranjpe, 1984).
Although the dominant reaction categories were found to be the same in males and
females, yet males and females differed significantly on magnitude of reaction to
four of the six reaction categories. Whereas female patients were higher on anger
and anxiety, male patients were higher on disengagement and rationalisation. It
appears that females are less inhibited in expressing their affective reactions
whereas male patients tend to control their affective reactions by disengaging
attention from the crisis and philosophising about it.
This is a preliminary report of empirical findings of reactions to hospital environment,
needing further support in subsequent work. Study of reactions is important because
they have significant consequences in recovery from the disease (Kamen, Rodin
and Seligman, 1987).
A preference for the psychomedical approach to the treatment was advocated in a
seminar on Psychology as a Policy Science for Eighth Five Year Plan (Dalai, 1989).
It was argued that patient's recovery is much faster if his/her psycho-social needs
Patients in Indian Hospitals 45
are also taken care of in the treatment process. It was suggested that social
scientists may play an important role in alleviating patients' suffering by generating
a positive mental state which not only buffers the deleterious impact of environ-
mental stresses but also facilitates recovery and rehabilitation (Agrawal and Dalai,
During hospitalisation one undergoes a number of thoughts and experiences. Below are listed
some of experiences and thoughts which often occur to patients. Kindly think and reply how many
times each happens with you these days.
46 Manju Agrawal and Ajit K. Dalai
Agrawal, M. and
Positive Life Orientation and Recovery from Myocardial Infarction
(Unpublished manuscript). M.L.N. Medical College, Allahabad.
Agrawal, M. and
"Beliefs about the 'World' and Recovery from Myocardial In-
farction", Journal of Social Psychology.
Carstairs G.M. and
The Great Universe of Kota: Stress, change and mental disorder
in an Indian Village.
London: Hogarth Press.
"Psychomedical Model of Patients Care: Empirical evidence and
applications". Paper presented at the conference on Psychology
a Policy Science,
held in the Department of Psychology,
Allahabad University, Allahabad.
Dalai, A.K. and
"Role of Casual and Recovery Beliefs in the Psychological Adjust-
ment to a Chronic Disease", Health and Psychology: An Interna-
Patients' Views of Medical Practice,
New York: Russell Sage
New York: Garden City, Doubleday.
Government of India
Health Information of India,
Ministry of Health, Government of
India Publications, India.
Kamen, LP., Rodin, J.
Explanatory Style and Immune Functioning.
and Seligman, M.E.P.
script), University of Pennsylvania, Philadelphia.
"The Social Aspects of Health and Illness". In J. Kosa and I. Zola
(eds.), Poverty and Health: A Sociological Analysis,
Mass: Harvard University Press.
"Good Patients and Problem Patients: Conformity and Deviance
in a General Hospital", Journal of Health and Social Behaviour,
Theoretical Psychology: The Meeting of East and West,
"Human Assessment in the Indian Context", Human Assessment
and Cultural Factors,
Queens University, Kingston, Canada.
"We have Failed Them All", The Sunday Observer,
17, p. 21.
"The Patient's View of the Patient's Role", In E.G. Jaco (ed.),
and Mauksch, H.O.
Patients, Physicians and Illness
(2nd ed.), New York: Free Press.
"Adjustment to Threatening Events: A Theory of Cognitive Adap-
tation", American Psychologist,
New York: Random House.
"Will it Hurt Less if I Can Control It? A complex answer to a simple
question", Psychological Bulletin,
The Indian Journal of Social Work, Vol. LV, No. 1 (January 1994)