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Abstract

This article gives an elaborate description of the history of Nursing in India from 1500 BC. The evolution through different stages: Buddhist era, Mughal rule, British Empire and democratic India is depicted here. It answers a unique question in a country with a Hindu majority, why there a strong Christian domination in this profession? Does faith influence the choice of a profession? The article responds to those inquiries.
88 JCN / Volume 26, Number 2
According to Indian author Meera
Abraham (1996),“The link between
churches and missions and the
profession of nursing in modern
times is not found anywhere else
in the world” (p.19). Early medical
missionary activities were an impor-
tant influence, paving the way for the
nursing profession to be influenced
by Christianity.The professional
influence of the Catholic Nurses
Guild and the Christian Nurses
League has continued to elevate the
standardof the profession alongside
the Trained Nurses Association of
India (Harnar,1975).
The evolution of modern nursing
and its link to Christianity is a fasci-
nating study. It is inspiring to reflect
on the move of missionary nurses to
India and their long-lasting influence
on Indian-educated nurses.
byElizabeth B.Simon
and NURSING
in INDIA
CHRISTIANITY
modern education in India, especially
nursing education. In India, although
Christians represent only 3% of the
population, 30% of nursing graduates
arefrom traditional Christian families.
It is interesting to explore the reasons
behind the overwhelming Christian
presence in nursing.
CHRISTIANITY
has greatly influenced
AImpact
JCN/April-June 2009 89
HEALTHCARE IN ANCIENT INDIA
The history of nursing in India
dates to about 1500 B.C.Atharvaveda
(a sacred text of Hindus) contains the
earliest accounts describing the practice
of healthcare. In 700 B.C.,“halls of
healing” were founded, and Benares
(a city on the bank of River Ganges)
was the center of medical education.
The Ayurvedic (the science of life)
surgeon Sushruta (6th century B.C.)
and the physician Charaka (300 B.C.)
were famous in the ancient world
through their teachings in Samhita (a
collection of texts) about asepsis and
techniques of cesarean section, plastic
surgery, and eye and brain surgeries.
Sushruta asserted that cure rests on
four feet—the ideal relationships of
physician, patient, nurses, and medi-
cine. Charaka, in Samhita, chapter 9,
lists the four qualifications of the
attending nurse as knowledge of the
drugs to be compounded, cleverness,
devotedness, and purity of the mind
and body (Wilkinson, 1958).
During the rise of Buddhism with
its philosophyof mercy and compas-
sion, India witnessed the development
of medical education from 500 B.C.
to A.D. 300.The practice of surgery,
however,became extinct because
Ahimsa (the rule that bars injuring living
beings) forbade dissection of animals and
study of anatomy
.The establishment of
numerous hospitals for humans and
animals, famous medical schools with
hundreds of lecture rooms and thou-
sands of students, one doctor for every
10villages, pharmaceutical gardens, and
hostels for the physically challenged
were highlights of this period.
This glorious era for ancient
healthcare ended with the decline of
Buddhism and resurgence of Brahman
influence with its repugnance for
pollution from sickness. By A.D. 1000,
public hospitals vanished from India
until they were reestablished by the
Indian army in the 1880s. Qi
iThe inva-
sion of India by Moghul emperors and
Muslim rule in A.D. 1200 accelerated
the decline of healthcare.
CHRISTIAN INDIA
Christianity came to India with the
first-century missionary activity of
Thomas, the disciple of Jesus, and with
Western missionary activity from 1500
to 1975.The influence of the Roman
Catholic Church began in the 16th
century, and its role in healthcare is
vital today. Protestant missions all
across India were sponsored by many
Western organizations dating from
1701 (Warneck, 1901).
Unlikethose known as St.Thomas
Christians, who confined their reli-
gious beliefs to themselves, Protestant
missionaries undertook aggressive and
dedicated missionary work, experi-
encing great success between 1830
and 1880. Among the many effective
strategies that the missionaries adopted,
the medical mission was a favored
approach. Amajor contribution of the
Christians was the establishment of
social services through schools and
hospitals for the untouchables and
outcastes (Harnar, 1975).
Christian missions flourished in
India for a number of reasons.The
scientific contributions of Robert
Koch (1843–1910) and Louis Pasteur
(1822–1895) favored the establishment
ofWestern medical missions. In addi-
tion, the liberal administration of India’s
first prime minister, Jawaharlal Nehru,
from 1947 to 1964, and the Indian
constitution helped medical missions
to grow in a favorable soil. For example,
Article 25 of the Indian Constitution
provides the right to propagate one’s
faith, and Article 30 establishes the right
of minority groups to maintain their
own institutions.
It took enormous courage for
aHindu to convert to Christianity
because ostracism from Indian society
and being an outcaste from the family
were bitter experiences similar to a
living death. Despite the social perse-
cution, however, many elites and poor
people from different classes and castes
converted (Copley, 1997).
Currently, India has 27 million
documented traditional Christians,
who constitute 3% of the general
population. Despite their minority
status, Christians are seen as leaders
in the nursing profession,medical care,
and education. Early medical missionary
activities depict the sacrifices and contri-
butions of Wester n missionaries to India.
MEDICAL MISSIONS
The impetus for medical missions
originated in the Conference of
Mission convened at Liverpool in
1860.Attendees discussed the value
of medical missions in India under the
theme “healing of the sin-sick soul.
This vision encouraged many young
educated men and women to travel
to distant parts of the world to serve
people unknown to them.The famous
speech given by John Lowe (1887, p.
10) of the Edinburgh Medical Mission
Society—urging the “welfareof my
Elizabeth B. Simon PhD, RN,
CCRN, CEN, is Assistant Professor
at Hunter College,NewYork and
aconsultant for the Corporate
Nursing Services, NYCHHC.
She is a graduate of the College
of Nursing, Christian Medical
College, Punjab, India. Before
coming to the United States, she worked in Chr istian
Fellowship Hospital. She serves as a Visiting Professor
at The Faith Institutes of Nursing Sciences, Bangalore,
India, and attends Salem Assembly of God Church,
Elmont, NewYork.
90 JCN / Volume 26, Number 2
women spend most of
the daytime.The Zenana
Mission had a vision
focused on the welfare
of Indian women.As early
as 1872, medical education
for women was encour-
aged, but Indian women
physicians were few and
all were trained abroad.
The first class of female
physicians, started in 1875,
comprised women of European or
Anglo-Indian descent. By 1890, there
were many female medical students in
different parts of India, increasing the
need and desirefor helpers “who would
commend Christianity to the patients
by the example of their lives and by
helping the missionaries in teaching
and preaching” (Balfour & Young,
1929, p. 112).
Another productive work of
Christianity was the Arcott Mission
in southern India.This was the work
of the Scudder family for three gener-
ations. Dr. John Scudder, the son of a
pioneer missionary to south India,
became a physician and minister at
Arcott. His daughter, Dr. Ida Scudder,
moved by the death of two women
in childbirth, one Brahmin and one
Muslim, was drawn to train female
physicians. She introduced
W
estern
midwifery in India, and sent candidates
for nurse training. Dr. Edith Mary
Brown,pioneered similar work in
northern India at the only medical
school for women taught by women
(Balfour & Young, 1929).
In 1905, missionary nurses came to
India as members of the Missionary
Medical Association and laid the
foundation for formalized nursing
education in India. In 1910, Dr. Jenny
Muller of St. Stephen’s hospital in
Delhi stated,“In India the call for
nurses is much louder than the call
for women doctors” (Rafferty,1997,
p.75).The missionary nurses were well
educated to fulfill their call of duty.
In 1908, to differentiate missionary
nurses from missionaries who had some
nursing skills, the British Missionary
Directory for Nurses published quali-
fications for “missionary nurses”—a
3-year course of training in nursing
plus midwifery, drug dispensing, and
tropical diseases.
NURSING AND
THE BRITISH MILITARY
The influence of Christianity in
Indian nursing started with modern
nursing and Florence Nightingale
(1820–1910).Although military
hospitals and nursing services (mostly
performed by military men) had existed
earlier,in 1857 the British government
of India consulted with Nightingale. She
never visited India but provided strong
leadership to reform the Indian nursing
service (Wilkinson, 1958).
Nightingale sent questionnaires to
morethan 200 large military stations
controlled by the British government,
inquiring about rules and regulations
pertaining to health and sanitation.
This vast survey
, together with indi-
vidual communications to medical and
militaryofficers, provided Nightingale
with information about the health
and sanitation practices of the previous
10 years. She wrote a paper suggesting
that Hindu religious teachers could
be used in the community as “health
missioners,” liaisons between the
villagersand the sanitation officer,
because the Hindu religion emphasized
purity and cleanliness (Nightingale,
brother,his body, his soul, for time, for
eternity”—in 1871 encouraged more
Westerners to set sail to India.
The American medical missionary,
Dr. Samuel Green, who worked in
India during the mid-1800s, echoed
the same vision bystating that his
“growing hope” was to spread the
“Gospel” and “Science”at the same
time (Abraham, 1996).This new vision
of the medical missionary movement
overpowered the initial work and
influence of evangelical missionaries
focused only on religious work.
The first female medical missionary
to any non-Christian country was
Clara Swain, an American physician
connected with the Women’s Foreign
Missionary Society of the Methodist
Episcopal Church. Swain landed in
India on January 2, 1870 and began
teaching classes to 14 women with
regard to nursing,compounding drugs,
and medicine. In 1877 these ladies were
examined by a board of three physicians
and pronounced competent (Balfour &
Young, 1929).
In 1880, after her graduation, Fanny
Butler, the first female student at the
London School of Medicine, left
Britain for the Zenana Mission in
India. Zenana is an Urdu word that
stands for an exclusive place where
JCN/April-June 2009 91
1896). It is understood from her
writings that religion influenced the
healthcare in India and that these
health missioners were men.
Thanks to Nightingale’s work, the
Royal Sanitary Commission of the
army in India was appointed in 1859
and established in 1861.The first
nursing class consisted of six midwives
who were Europeans or Anglo-Indians.
On March 28, 1888, the arrival of 10
fully qualified British nurses in Bombay
laid a foundation for the Indian army
nursing service.As women, they faced
opposition from male orderlies and
medical officers alike. However, their
dedicated service during a severe
outbreak of cholera gradually changed
these attitudes.
In 1914, British colonial forces
recruited Indian nurses, who were
organized into the Indian Military
Nursing Service (IMNS) in 1927.
Nurses were recruited from two
cultural groups: Indian Christian
communities in the state of Kerala
and Anglo-Indian communities.These
communities were open to allowing
women to work, even in low-status
jobs such as nursing, due to the active
role of Western missionaries and the
Christian nature of the Nightingale
model. Many civil hospitals were built
throughout India after the establish-
ment of the IMNS, but they offered
training in nursing only to Europeans
and Anglo-Indians. It was the mission
hospitals throughout India that started
training Indian nurses.
Currently, more than 330 Protestant
mission hospitals exist throughout India,
with more than 150 located in southern
states of Andhra Pradesh, Karnataka,
Tamil Nadu, and Kerala.Training nurses
was an important goal of the medical
missions. But because of the difficulty
recruiting Hindu and Muslim women,
the missionaries’ hope rested on
recruiting Christian girls from schools
to serve others through nursing.
OVERCOMING PREJUDICE
The prime goal of Western medical
and nursing missionaries in the 19th
century was to teach and train
“indigenous” physicians and nurses in
aChristian atmosphere with an ethos
of selfless service and devotion.Training
nurses of Indian origin faced many
obstacles, mainly because Hindu parents
were obsessed with caste prejudices and
Muslims with the inhibitions of the
purdah system, which required women
to be secluded from the public.The
lowstatus of nursing among Hindus
was mainly because of the caste system.
Nurses need to touch their patients,
and sickness was considered unclean
for Hindus. In addition, low-caste and
high-caste Hindus were not allowed to
mingle or touch each other.
In 19th-century India, female
missionaries were more productive than
their male counterparts because of their
access to local women.Yet the process of
providing care was difficult because of
cultural practices. Despite their influ-
ence, white women were the cultural
other, without caste and therefore
unclean for basic contact. Dr.Anna
Kugler,who worked as a medical
missionaryin India for 47 years
starting in 1883, wrote about her
experience with caste prejudices. It
was uncomfortable to be reminded
that she was considered unclean and
would make the household objects
unclean in a high-caste Hindu home.
During home visits, patients were
brought outside to prevent the physician
from polluting their Brahman homes.
Medicine bottles were kept on the
floor and had to be picked up by
the physician to avoid touching a
Brahman.This prejudice was based on
religion and caste, not on gender. Male
missionaries faced similar prohibitions.
Reverse acculturation also occurred as
female medical missionaries were influ-
enced by the local culture (Singh, 2005).
However, early missionaries’ efforts
to overcome cultural difficulties opened
apath for those who came later.As a
result, a group of missionaries serving
in India started the Medical Missionary
Association (MMA). In 1926, it was
renamed the Christian Medical Asso-
ciation of India (CMAI).Affiliated
with more than 16 Protestant sects,
the CMAI oversees morethan 330
healthcare institutions and thousands
of Christian professionals.The nurses’
wing, named the Nurses League of
CMAI, functions to “ensure the highest
standard of nursing education consistent
with Christian principles.” Numerous
nursing textbooks are published by the
Nurses League.
From the early days of nursing
education, church-related schools were
committed to innovation with new
programs and improvement of the old
ones (CMAI, 2008). In addition to
CMAI institutions, therearemorethan
400 hospitals and 1,000 health centers
for the Catholic Health Association of
India (CHAI, 2008).
In 1953, an American nurse, Rebecca
Glanzer, was sent by Nurses Christian
Fellowship USA to India to establish a
work among nurses.The emerging
movement became the Evangelical
Nurses Fellowship of India, currently
part of Nurses Christian Fellowship
International (Shelly, 2005).
92 JCN / Volume 26, Number 2
CHRISTIAN
NURSING EDUCATION
Service and devotion were the
dictum of missions, influencing nursing
education more than medical education.
At the time of World War II, 90% of
Indian nurses came from the Indian
Christian community, and 80% of
these were trained in mission hospi-
tals. Nursing as a profession was not
restricted to women. Miss Schafer came
to Miraj Mission Hospital at Bombay in
1921 and devoted her service to training
men in nursing. In 1927, the Missionary
Nursing Association allowed men to
take its examinations. In 1930, male
nurses took the Bombay Presidency
Examinations. Until 1940, all male
nurses were Christians. From 1944,
men were admitted to other reputable
schools, such as the nursing program at
Christian Medical College,Vellore.
By 1940, the predominance of
European and Anglo-Indian nurses
had declined, and Indian Christians
from Kerala dominated the nursing
profession. Compared with the other
states in India, this southern state with
its powerful Christian political clout
gave nursing its needed recognition and
support. In 1950, the state of Kerala
encouraged nurses to get a bachelor’s
degree in nursing, and the Keralite
nurses were encouraged to return to
their home state to become leaders in
their profession. Since then, in Kerala
and other parts of India and abroad,
Christian nurses from Kerala mark
their presence in clinical and adminis-
trativesettings.
Christian missions have played a
major role in shaping nursing as a
modern profession in Kerala (Abraham,
1996; George, 2005b).The missions,
facing major challenges after British
colonial rule ended in India and
Pakistan in 1947, restricted access to
foreigners for medical missions (Singh,
2005). Most of the pioneer missions
still exist today, flourishing as degree-
granting institutions managed by
Indian Christians.
Many prominent women in India
were influenced by the Christian reli-
gion and committed their service to
nursing. Pandita Ramabai (1858-1922)
was one well-known social reformer
who converted to Christianity.She
advanced women’s education, starting
Seva Sadan nursing (an Indian version
of modern nursing), the Hindu Ladies’
Social and Religious Club,and Arya
Mahila Samaj (Women’sClub).Along
with her friend Ramabai Ranade (wife
of then Judge Ranade), she promoted
nursing as a service-oriented profession
among high-caste Hindus.Thousands
of medical and nursing students were
housed in Ranade’s dor mitory, where
she influenced them in their education
and value systems (MacNicol &
Mangalwadi, 1996).
Another prominent reformer, Raj
Kumari Amrit Kaur,despite the Sikh
sound of her name, was a Christian, a
follower of Gandhi’s pr inciples, and
the first female cabinet minister. She
headed the Ministry of Health in India
in 1947 and became the president of
the World Health Assembly in 1960.
She gave nursing enviable social status
through her influence.She started a
reputable college of nursing in New
Delhi, which is named after her in
recognition of her valuable contribu-
tions elevating the status of the
profession during her political tenure.
The Indian Nursing Council (INC)
reports that India has 1,570 diploma
programs, 808 Bachelor of Science
programs, 88 Master of Science
programs, and 76 post-basic Bachelor
of Science programs in India. In addi-
tion, 57 students are attending a PhD
program in nursing under the INC.
Among the names listed on the INC
Web site, 475 programs carry distinctive
Christian names. It is impossible to iden-
tify individual nurses’ religious affiliation
from government publications, but an
estimated 30% or more of the nursing
graduates are Christians from Kerala.
Indeed, the demographics of participants
in studies conducted in the United
States and the United Kingdom indicate
that the percentage of Christian nurses
is much higher (DiCicco-Bloom, 2004;
George,2005a; Jose, 2006).
THE KERALA PHENOMENON
The southern state of Kerala has
had a unique influence on Christianity
and nursing in India. Kerala is the seat
of ancient Christianity,dating back
to A.D. 52.Traditions and historians
supportthat St.Thomas, Chr ist’s
disciple, came to the region. Conse-
quently, the descendants of the
Christians from those days are called
the St.Thomas Christians or Syrian
Christians.They belong to Orthodox,
Catholic, and Protestant traditions. In
addition, 400 people migrated from
Syria in A.D. 345 and joined this
Kerala Church. Later, Portuguese
tradersin 1498 converted coastal
residents and connected them to
Rome.They were therefore called
Latin Catholics. Most of the British
mass converts were from the lower
castes, with the exception of the high-
caste elite in major cities.They form
the majority of the Protestant group.
Despite their minority status in India,
Kerala Christians constitute prosperous
JCN/April-June 2009 93
communities commanding extraordi-
nary political clout. However, religion
in India is the basis of social life and may
not be a deep-rooted conviction of indi-
vidual faith. Religion influences many
everyday aspects of Indian life:marriage
choices, career selection, food habits,
education, festivals, general appearance
(choice of clothing, jewelry, and colors),
attitudes toward women and children,
recreation,and more.In essence, Indians’
cultural practices are deeply rooted in
their religion.
This interplay of religion and social
life in India has influenced education
and career choices among Kerala
Christians. Kerala has the largest
Christian population of any Indian state.
The importance of education, especially
female education, has been influenced
by the large number of Christians.
The adult literacy rate of 91%, with the
highest female literacy index and human
development index,is the highest in
the country.There are 2,700 govern-
ment medical institutions in Kerala,
with 160 beds per 100,000 population.
The indicators of material well-being
in Kerala, such as the infant mortality
and birth rates, are comparable with
U.S. standards. In 2007, Kerala was
declared the world’s first baby-friendly
state by the World Health Organization
and UNICEF.The baby-friendly
hospital initiative (BFHI),launched
in 1991, is a UNICEF designation
for maternity hospitals based on their
breast-feeding policies. More than 90%
of the hospitals in Kerala qualified for
this designation.The high female literacy
rate and health awareness contributed
to that designation.
According to anthropologist Bill
McKibben (2006, p.1),“Though a land
of paddy-covered plains, Kerala stands
out as the Mount Everest of
social development;there’s
truly no place like it.
However, Kerala is an
agrarian society, and educated
men and women must move
out of Kerala to get a decent,
well-paid job.They travel all
over India and to different
countries and continents.
In spite of social and human
development comparable with first-
world nations, Kerala is poor even
by the standards of India, whereas
the inhabitants are enjoying a middle-
class social life comparable with that
of the first world. Lack of industrial
development,demographics,and histor-
ical factors are seen as contributors to
this situation.This “Kerala phenom-
enon” or Kerala model, denoting poor
economic development in the midst
of commendable human development,
high female literacy coupled with poor
job opportunities, and a high percentage
of Christians in Kerala, causes a large
number of young women to choose
nursing as a profession.
The socially conservative parents of
young women find that professional
nursing has the structure to offer their
daughters a safe haven outside their
secure homes in Kerala.The hospitals
in India provide hostels (dormitories)
similar to their home settings, a decent
employment, and salaries that Kerala
cannot offer. In addition, the Christian
ethos of service and healing is more
acceptable to Christian parents than to
Muslims or Hindus. It is said that Kerala
nuns and nurses are found everywhere
in India and various parts of the world.
For the young women who move
to different parts of India from this
southernstate, it is an opportunity to
negotiate the patrifocal nature of the
community and family (Nair, 2007).The
Kerala phenomenon contributes to their
professional choices.
Kerala, nursing, and nuns are inter-
twined. In 1906, eight Swiss nuns began
work as nurses in Kerala.In 1920,formal
nursing courses were organized, often
with Christian students. During the
1950s, the number of nursing schools
in the private sector increased to meet
the demands of the growing profession
(Jeffrey, 1992). Currently, 257 recognized
nursing schools and colleges are found
in Kerala (Nair,2007). Nevertheless,
a large number of educated men and
women move to larger cities such as
Mumbai and Bangalore for nursing
education. Because of the job opportu-
nities for nursing in a global market,
even small village bank branches are
getting a 1,000% increase in deposits
from nurses working abroad. Nursing is
changing the villages of India, especially
in the more Christian-influenced state
of Kerala.
Most of the Indian immigrants to the
United States come from central Kerala,
where the majority of Christians reside.
The unique and most important aspect
of immigration is the role of nurses.
Williams aptly states,“Christians are the
only Asian-Indian group coming on the
shoulders of women” (Williams, 1996,
94 JCN / Volume 26, Number 2
p. 18).Women of other immigrant
groups (Hindus, Muslims, Jains, Sikhs)
follow men. It is interesting to note
that 85% of the Kerala immigrants
in the United States are Christians,
although Christians are only 20% of
Keralas population.This discrepancy
is related to the disproportionate
presence of Christian nurses.
REACHING THE
ENDS OF THE EARTH
Indian nurses remember with grati-
tude the contributions and sacrifices
of missionary and indigenous nurses
who paved the way for them to enjoy
the expansion of their professional
services and goals.The cur rent
migration of Indian nurses to other
countries parallels the earlier exodus
of nurses from Western nations to
India.Western nurses undertook this
earlier exodus out of selfless devotion,
in search of an opportunity to serve
their unknown brothers and sisters,
to heal their sin-sick souls for time
and for eternity. Neglecting their
own personal gain and comfort, the
missionary nurses, likeSt. Paul in the
New Testament, were compelled by
Christian love to reach out to others
far away, to “turn them from darkness
to light” (Acts 26:18).They obeyed
Christ’s command to “go and teach
all nations” (Matthew 28:19) with a
single goal in life:“for
to me, to live is Christ
and to die is gain”
(Philippians 1:21).
The Macedonian call
to the missionary nurses
from India (Acts 16:9)
was so strong that most
spent their entire life
on Indian soil. Such
dedication and altruism in nursing
may not be visible currently at the
bedside. However, the opportunity
to minister to the spirit is multiplied
when the body is in need of healing.
Jesus dealt with spiritual problems
through physical healing.
Currently, missionary nursing in
India is restricted by government poli-
cies.Yet there are opportunities for
short-term missions in both local and
global communities. Missions encourage
new nursing graduates to spend the first
year of their professional life in a medical
mission field.This strategy of bringing
the first fruit of labor (Deuteronomy
18:4; Leviticus 2:12) for healthcare
missions is workable for most young
people in India. Before entering married
life, traditional nursing graduates in their
early twenties maybe able to work for
the low pay that missions offer.
After graduating from a leading
Christian medical center, I spent the
first year of my professional life in a rural
mission hospital in India.That nursing
life and recent, sporadic missions have
been gratifying experiences.
Everyone cannot reach to the ends of
the earth. However, we are missionaries
of the Kingdom of God to a hurting
and lost world.The spirit of Christian
love that inspired the early missionaries
in India should be the philosophyof
nursing practice in this era.
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... Kerala's position as the leading Indian state for the training and 'export' of nurses for the international market is well known. Kerala is distinct from many other states in India because it has a long tradition of female education, nurse training and migration rooted in the state's history of Christianity (Aravamudan, 1976; Simon, 2009; Percot and Rajan, 2007). Historically since the 1970s mostly Christian women from Kerala have trained as nurses in order to emigrate to the GCC and OECD nations (George, 2006). ...
... This research intends to go further, however, and examine this at the regional scale. Kerala is distinct from many other states in India because it has a long tradition of female education, nurse training and migration rooted in the state's history of Christianity (Aravamudan, 1976;Simon, 2009;Percot, 2006;Mathew, 2005;Thomas, 2006;. But, despite Kerala's high gender-based human development indicators, in the case of nursing, there is evidence that societal norms diminish their status and social capital, especially in terms of the marriage process (George, 2005;Abraham, 2004). ...
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