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ORIGINAL ARTICLE
Year : 2023 | Volume
: 67
| Issue : 1 | Page : 47-53
Institutional disrespect and abuse during health-care utilization in public health facilities of Tamil Nadu: A facility-based cross-sectional survey
Yuvaraj Krishnamoorthy1, Venmathi Elangovan1, Murali Krishnan2, Isha Sinha2, Gerald Samuel2, Krishna Kanth2
1 Assistant Professor, Department of Community Medicine, ESIC Medical College and PGIMSR, Chennai, Tamil Nadu, India
2 Research Assistant, Department of Community Medicine, ESIC Medical College and PGIMSR, Chennai, Tamil Nadu, India
Correspondence Address:
Yuvaraj Krishnamoorthy
Department of Community Medicine, ESIC Medical College and PGIMSR, K. K. Nagar, Chennai, Tamil Nadu
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/ijph.ijph_888_22
Abstract
Background: Disrespect and abuse have a negative impact on the quality of care provided in the public health facilities, thereby impacting the public health-care utilization of the patients. Objectives: This study aims to capture the burden and determinants of disrespect and abuse faced by the patients who seek care from public health facilities in Tamil Nadu. Methods: This study was conducted among 4917 participants at outpatient and inpatient levels in 18 public health facilities across six districts in Tamil Nadu. Institutional disrespect and abuse were reported as proportion with 95% confidence interval (CI). Logistic regression model was done to assess the determinants of institutional disrespect and abuse. Results: Overall, the proportion of participants facing some form of institutional disrespect and abuse was 9.8% (95% CI: 9.0%–10.6%). Elderly patients (≥60 years) (adjusted odds ratio [aOR] = 2.71; 95% CI: 1.27–5.76), widowed/separated/divorced (aOR = 1.99; 95% CI: 1.11–3.57), patients with higher educational qualification (aOR = 1.82; 95% CI: 1.25–2.64), patients belonging to the richest quintile in terms of socioeconomic status (aOR = 4.96; 95% CI: 3.59–6.84), and patients having some form of chronic disease (aOR = 1.37; 95% CI: 1.07–1.75) had significantly higher odds of facing institutional disrespect and abuse. Conclusion: Almost one in ten patients visiting secondary and tertiary care public health facilities in Tamil Nadu had faced some form of disrespect during their hospital visit/stay. The findings from our study should be taken up and further qualitative exploration to identify the reasons for such disrespectful care and corrective solutions should be suggested.
Keywords: Abuse, institutional disrespect, patient acceptance of health care
Introduction 
Health-care utilization is defined as obtaining the health care provided by the health-care services in the form of health-care contact.[1] Utilization of the health-care services has been linked to a variety of sociodemographic parameters such as age, gender, and socioeconomic level. It has also been linked to the organizational structure and financing of health care, as well as individual health condition.[2] In an ideal world, this would be solely determined by a person's or community's degree of health; unfortunately, the reality is considerably different. For decades, researchers have been studying the reasons why people's health-care consumption habits differ from one another. Various theoretical models of health-care usage have been developed in an attempt to explain which variables influence health-care utilization and to what extent from various perspectives (economic, psychological, behavioral, epidemiological, etc.).[3]
Physical abuse, nonconfidential care, nondignified care, nonconsented care, discrimination, detention, and abandonment/neglect of care are the seven primary forms of disrespect and abuse, according to Bowser and Hill.[4] Adverse events, errors, compromises in patient safety, and even patient mortality have all been related to disrespect and abuse. It harms the patients by creating fear, anger, shame, confusion, uncertainty, loneliness, self-doubt, sadness, and a variety of physical illnesses, such as sleeplessness, exhaustion, nausea, and hypertension.[5] Such disrespectful behavior of the health-care workers (HCWs) against the patients lowers the confidence and will make them hesitant in asking and disclosing information which are considered important. Therefore, disrespect and abuse have a negative impact on the quality of care provided in the public health facilities, thereby impacting the public health-care utilization of the patients. It can also act as a barrier for the patients to recommending it to their family members/neighbors/friends.[4] Evidence shows that in countries with high maternal mortality, women are discouraged from seeking maternity care at facilities because they are afraid of maltreatment or neglect, based on their own unpleasant experiences and the institutions' bad reputation. As a result, some women prefer to deliver at home with traditional birth attendants who may be more culturally competent or caring.[6]
Lack of communication between the health-care provider and patients often leads to the disrespectful environment. Health-care providers, nevertheless, are victims of ongoing health system issues and poor workplace environment.[7] Having a better knowledge of what contributes to, incites, or provokes such behavior may help the health-care facilities in developing suitable educational and training programs and decrease the chance of occurrence of such events and increase the overall quality of care provided by the health-care team in public health facilities.[8] Till now, the studies have focused on assessing the respectful maternity care, while the patients admitted/visiting the facility for other reasons are neglected from this area of research.[7],[9],[10] Thus, this study aims to capture the burden and determinants of disrespect and abuse faced by the patients who seek care from public health facilities in Tamil Nadu.
Materials and Methods Study design and study setting
This cross-sectional survey was conducted as a part of large-scale mixed methods study on patient safety practices across public health facilities in Tamil Nadu. Health-care services in the state of Tamil Nadu are provided by a three-tier structure delivery system. At the primary level, subcenters and primary health centers are responsible for provision of health-care delivery. In secondary level, community health centers and district hospitals are responsible for providing specialist secondary services, and in tertiary level, medical colleges/hospitals are responsible for tertiary care services. We have conducted this survey among secondary and tertiary care facilities in Tamil Nadu.
Sampling strategy
A two-stage stratified random sampling was performed for the selection of public health facilities [Supplementary Figure 1].
Stage 1 – In the first stage, all the districts were stratified into three categories (low, medium, and high) based on their human development index scores.[11] Two districts from each of these strata were selected randomly. Selection of districts was done randomly using lottery method.
Stage 2 – In the second stage, a total of 18 public health facilities were selected covering the secondary and tertiary care levels of health-care delivery. One tertiary care hospitals/medical colleges and two government hospitals from each of the sampled districts were selected. This sums up to a total of 18 public health-care facilities in Tamil Nadu.
Sample size
Since the survey was conducted as a part of large-scale survey on patient safety assessment, the minimum sample size was estimated to be 800 patients from each of the districts based on the assumption on the response to patient safety domains. However, we tried to assess whether the sample size is enough to assess the burden of institutional disrespect and abuse based on the estimate from a previous study, which reported that 28.8% of patients have faced any form of abuse in any health-care facilities at Varanasi, North India.[12] Assuming 5% absolute precision, 95% confidence interval (CI), and design effect of 2, the minimum sample size was estimated to be 630 in each district. Since the sample size taken was 800 in each district, the sample taken in the survey was enough to determine the institutional disrespect and abuse.
To make the sample more representative of the distribution of outpatient department (OPD) and inpatient department (IPD) patients across the facilities, 500 patients from the OPD and 300 patients from the IPD were taken in each district. For OPD patients, 250 patients were selected from the medical college and 125 patients in each of the two GHs in the selected district. The total sample size to be taken from all the six districts was 3000 OPD patients (500 in each district). For IPD patients, 200 patients were selected from the medical college and 50 patients in each of the two GH in the selected district. The total sample size to be taken from all the six districts was 1800 IPD patients (300 in each district).
Data collection
Training of data collectors
A team of field assistants were recruited as data collectors for this survey. In total, 6 field assistants were recruited. Before starting the data collection process, a week-long training was provided to familiarize them on data collection methods, tools, and the patient safety implementation framework at the facility level. The field assistants were then asked to collect data from both secondary and tertiary care facilities. They were monitored periodically by the research assistants, the principal investigator, and co-investigators.
Data collection process
A consecutive sample of 250 OPD patients and 200 IPD patients from medical colleges and 125 OPD patients and 50 IPD patients from each of the two GHs were interviewed about the disrespect and abuse faced in the hospital during their visit. We had a semi-structured questionnaire and developed based on literature search and consultation with team of public health experts. The final form of questionnaire consisted of two sections:
Section I consisted of sociodemographic details of the patients (age, gender, education, occupation, marital status, socioeconomic status, reason for OPD/IPD visit, duration of hospitalization if applicable, and previous OPD/IPD visit to the same hospital).
Section II consisted of questions related to institutional disrespect and abuse faced by the patients during their visit to health-care facility.
Operational definition
Institutional disrespect and abuse
Patients answering “yes” to any one of the following questions were considered to have faced institutional disrespect and abuse during their visit to health-care facility:[13]
“Whether you are made to feel disrespected?”
“Whether the health provider shouted at or scolded you?”
“Whether the health providers made negative or disparaging comments about you?”
Statistical analysis
Data were entered into Epicollect5, and analysis was performed using STATA software version 14.2 (StataCorp, College Station, TX, USA). Continuous variables were summarized as mean and standard deviation and categorical variables as frequency and percentages. Point estimate was reported with 95% CI. Institutional disrespect and abuse were considered the dependent variables and age, gender, educational qualification, occupation (employed/unemployed), marital status, socioeconomic status (in terms of expenditure quintile), and type of hospital visit (OPD/IPD) were considered explanatory variables. Logistic regression model was done to assess the determinants of institutional disrespect and abuse. Factors with P < 0.20 in the univariable analysis were included in the multivariable analysis. The effect size was reported as adjusted odds ratio (aOR) with 95% CI. Variables with P < 0.05 were considered statistically significant.
Results In total, 4917 participant data were included in the analysis. The sociodemographic characteristics of the participants are described in [Table 1]. There was almost equal distribution in terms of age groups, gender, and occupation. Almost one-third of the participants had no formal education. Almost three-fourth of the participants were currently married. The most common comorbidity was hypertension (14.4%) followed by diabetes mellitus (14%).
About 7.6% of the participants felt that they were made to feel disrespected; about 5.3% reported that the health provider shouted at or scolded them; about 2.9% reported that the health providers made negative or disparaging comments about them. Overall, the proportion of participants facing some form of institutional disrespect and abuse was 9.8% (95% CI: 9.0%–10.6%).
At OPD level, about 6.2% of the participants felt that they were made to feel disrespected; about 5.9% reported that the health provider shouted at or scolded them; about 3.8% reported that the health providers made negative or disparaging comments about them. At IPD level, about 10% of the participants felt that they were made to feel disrespected; about 4.3% reported that the health provider shouted at or scolded them; about 1.4% reported that the health providers made negative or disparaging comments about them [Table 2].
Table 2: Institutional disrespect and abuse across public health facilities in Tamil Nadu[Table 3] shows the determinants of institutional disrespect and abuse among study participants. Elderly patients (≥60 years) visiting the public health facilities (10.5%) had significantly higher odds of facing institutional disrespect and abuse (aOR = 2.71; 95% CI: 1.27–5.76; P = 0.01) when compared to patients aged <18 years (8.1%). Widowed/separated/divorced patients (12.2%) had almost two times higher odds of facing institutional disrespect and abuse (aOR = 1.99; 95% CI: 1.11–3.57; P = 0.02) when compared to unmarried patients (8.6%) and this association was statistically significant. Students/homemakers (11.9%) had significantly higher odds of having institutional disrespect and abuse (aOR = 2.35; 95% CI: 1.47–3.75; P < 0.001) when compared to unemployed individuals (8%). Patients with primary education (12.4%) and higher educational qualification (11.8%) had significantly higher odds of facing institutional disrespect and abuse (primary: aOR = 2.10, 95% CI: 1.55–2.84, P < 0.001; higher: aOR = 1.82, 95% CI: 1.25–2.64, P = 0.002) when compared to patients with no formal education (7.1%). Patients belonging to the richest quintile in terms of socioeconomic status (18.1%) had faced almost five times higher odds of institutional disrespect and abuse (aOR = 4.96; 95% CI: 3.59–6.84; P < 0.001) when compared to the poorest quintile patients (4.3%). Patients having some form of chronic disease (11.4%) had significantly higher odds of facing institutional disrespect and abuse (aOR = 1.37; 95% CI: 1.07–1.75; P = 0.01) when compared to patients without any chronic disease (9.2%).
Table 3: Determinants of institutional disrespect and abuse among patients visiting public health-care facilities in Tamil Nadu (n=4917) Discussion A growing body of evidence on the adverse patient experiences during health-care utilization paints a very disturbing picture of the facilities around the world. Many patients across the globe have reported to have experienced disrespectful, neglectful, or abusive form of treatment during their visit to health-care facilities.[4],[5],[6],[7] Such incidents constitute a violation of the trust between the patients and their respective health-care provider and can act as a powerful disincentive for the patients in seeking health-care services. Such practices might have a direct adverse consequence for the patients. Hence, we aimed to identify the extent and determinants of the institutional disrespect and abuse experienced by the patients during their visit to public health-care facilities.
Almost one in ten patients visiting secondary and tertiary care public health facilities in Tamil Nadu had faced some form of disrespect (felt disrespected/received shout or scold/received negative or disparaging comments) during their hospital visit/stay. However, the extent of disrespect and abuse was far lesser than the previous studies conducted in public health-care facilities across India. Previous studies conducted in northern part of the country such as Varanasi,[12] Gujarat,[14] and Uttar Pradesh[15] have reported the burden of disrespectful care ranging from 30% to 50%. A study in Manipur has even reported a burden of about 96.5%.[16] Similarly, studies conducted in other low-middle-income countries have reported a substantially higher level of disrespect and abuse among patients seeking care at public health facilities.[10],[13],[17],[18] However, most of these studies were conducted among pregnant women receiving care for institutional delivery. This pregnancy cohort might have influenced the finding as the structural and the gendered nature of disrespect and its embeddedness at intersection of health-care system and the sociocultural norms normalizing its manifestations as the “standards” of care during delivery.[19] However, conducting exit interviews to collect institutional disrespect and abuse has its own advantages and disadvantages. Although the exit interviews reduce the possibility of recall bias, it can also cause underreporting of the extent of disrespect and abuse faced by the patients, when compared to data collection at their own households.
Nonetheless, compared to all these studies, our study finding shows that the disrespectful care faced by the patients receiving care in the public health facilities of Tamil Nadu was substantially lower when compared to other parts of the country or similar setting outside the country. Tamil Nadu is one of the best-performing states in terms of health indicators and health-care delivery in India. Hence, there is always a scope for improvement to reduce this burden to almost nil and lead by example for the country.
We also identified a set of determinants of institutional disrespect and abuse. We found that elderly and comorbid patients had significantly higher odds of facing the disrespectful care when compared to younger patients without any comorbidity. Possible reason for such finding could be that elderly patients who have some form of comorbidity have to visit the noncommunicable disease (NCD) to gather their regular prescription of drugs. NCD clinics in public health facilities are usually overcrowded, creating a hectic environment for the HCWs. In addition, lack of compliance to medications or lifestyle practices by these patients might also aggravate the already overworked HCWs, ultimately making the patients to face the wrath. However, this is in no way an excuse for such disrespectful behavior. Hence, further steps should be taken to create a positive environment for the HCWs, by regulating the overcrowded OPDs and lessening the burden of staffs. We also found that the patients who visited the facility before the current visit were less likely to face disrespectful care compared to patients visiting the facility for the first time. This finding might be influenced by the fact that the patients who did not face any form of disrespect tend to visit the facility more often, while those who might have faced some form of disrespect would have skipped out from visiting the respective facility and would have sought alternate facilities.
Another interesting finding found in our study was that the patients having higher education qualification and belonging to the richest quintile reported to have faced higher burden of institutional disrespect and abuse. Any increase in income quintile was statistically significant and the significance is much greater than any other determinants assessed in the study with clear gradient. This was in contrast with the previous study findings which has reported that the lower income and low-educated patients were more likely to be disrespected.[20],[21] The possible reason for such finding could be that the perception of disrespect is more in the less marginalized either because of a higher expectation of the interaction quality or a different interpretation of the features in public health-care facilities. Hence, doctors consider it appropriate when they are scolding a patient for noncompliance toward lifestyle changes or medication adherence among patients with chronic illness. They consider it as a part of their role with no implied disrespect. However, this can be accepted by people with weaker relationship of power but may arouse resentment in the richer quintile. Even the longer waiting times can be interpreted differently between different social classes. Hence, further qualitative exploration of these findings might provide some fruitful explanations and interpretations.
This study has certain strengths. This is one of the largest facility-based surveys in the country assessing the institutional disrespect and abuse across public health facilities. Our study also adds to the limited evidence from India that assesses the extent and determinants of institutional disrespect and abuse faced by both outpatients and inpatients in public health facilities. The chances of recall bias were almost nil as the patients were interviewed immediately after seeking the care in the respective facility. Random selection of districts and facilities with geographical representation enhances the external validity of the study finding to the entire Tamil Nadu state. The use of validated questions to assess institutional disrespect and abuse based on previous literature adds to the credibility of the evidence.
However, the study has some limitations. First, the self-reporting nature of the survey might have underestimated the burden of disrespectful care, as the study might not have captured all the cases of institutional disrespect and abuse. However, given the negative consequences of the disrespectful care and abuse for the patients were mediated by their own view of what is disrespectful and abusive, self-reported data were considered to be the most appropriate way of data collection. Second, we have only performed quantitative assessment of disrespect and abuse and did not attempt to do qualitative exploration of the findings due to time and logistic constraints. Third, cross-sectional nature of the survey makes it difficult to infer causal inferences for the determinants of institutional disrespect and abuse obtained in the study. Finally, we did not cover any private health-care facilities during our survey to compare and contrast the findings between the public and private facilities.
Despite these limitations, our study has certain important implications for public health professionals, researchers, and policymakers. Although minor proportion has felt such disrespect or abuse, it is a burning issue that has been widely discussed all over the world.[22] This can negatively impact the patient outcomes and delay the recovery time. These factors further burden the patients, HCWs, and facilities. However, till now, the studies have focused on assessing the respectful maternity care, while the patients admitted/visiting the facility for other reasons are neglected from this area of research.[9],[10],[23],[24] Hence, the findings from our study should be taken up and further qualitative exploration to identify the reasons for such disrespectful care and corrective solutions should be suggested.
Acknowledgments
The authors would like to acknowledge the Operational Research Programme (ORP) team and IIT-Madras for their continued support throughout the study.
Financial support and sponsorship
This study was conducted as a part of an Operations Research Project with grant from the Tamil Nadu Health System Reform Program administered by IIT-Madras, to study the patient safety practices in public health facilities of Tamil Nadu. The grant was awarded to Dr. Yuvaraj Krishnamoorthy.
Conflicts of interest
There are no conflicts of interest.
References 
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