Practice-Informed Barriers and Contextual Solutions in Neonatal Habilitation Across Indian Neonatal Intensive Care Units: A Qualitative Exploration of Therapists’ Perspectives 

Practice-Informed Barriers and Contextual Solutions in Neonatal Habilitation Across Indian Neonatal Intensive Care Units: A Qualitative Exploration of Therapists’ Perspectives | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Practice-Informed Barriers and Contextual Solutions in Neonatal Habilitation Across Indian Neonatal Intensive Care Units: A Qualitative Exploration of Therapists’ Perspectives Abishek J R, Vadivelan Kanniappan This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7360302/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 31 Jan, 2026 Read the published version in BMC Pediatrics → Version 1 posted 13 You are reading this latest preprint version Abstract Background: Preterm infants are at high risk for neurodevelopmental delays, and hence habilitation in the Neonatal Intensive Care Unit (NICU) in a timely manner is a priority. In India, however, standardized habilitation pathways are underdeveloped, and the role of neonatal therapists, particularly physiotherapists is discrepant and ill-defined. There is scarce literature from the ground-level perception of therapists on providing structured development care, especially in resource-limited NICU settings. This study aims to explore therapist-informed barriers and context-specific solutions affecting the provision of habilitation services for preterm infants in Indian NICUs. Methods: This qualitative study follows a constructivist paradigm. In-depth semi-structured interviews were conducted with 16 NICU physiotherapists from diverse backgrounds across India. Thematic analysis was performed with Braun and Clarke's six-phase reflexive framework. Codes were inductively established and themes iteratively refined. Results: The two overall themes were: (1) Practice-Informed Barriers, including fractured professional identity, institutional bounds, poor training, and maternal disempowerment; and (2) Therapist-Driven Solutions, consisting of mother-inclusive graduated engagement, culture-congruent approaches, streamlined gestational protocols, and urgent appeals for curriculum and policy change. The therapists portrayed the necessity for habilitation practices to be salient, collaborative, and consistent with Indian contextual realities. Conclusion: Despite systemic constraints, Indian NICU physiotherapists reflect adaptive, culturally appropriate approaches to facilitate early habilitation. Overcoming structural barriers and institutionalization of therapist roles in interdisciplinary NICU teams are essential steps toward equitable and developmentally beneficial care for preterm infants. These findings provide a foundational input into the development of India-specific early stimulation protocols based on practice realities. Trial registration: The trial has been registered under Clinical Trials Registry—India (CTRI/2025/02/081483) on February 28 2025. India NICU Therapist Neonatal Care Stimulation Preterm Infant Introduction India bears the largest preterm birth burden globally, with over 3.5 million preterm infants born every year( 1 , 2 ). Despite the fact that there has been a boost in neonatal care infrastructure, the children are still prone to developmental impairment due to both biological vulnerability as well as a lack of enough sensory and neuromotor stimulation in the NICU environment.( 3 , 4 ) Particularly, Indian NICUs lack well-organized habilitation protocols to explain lost early developmental intervention opportunities within a window of brain plasticity( 5 ). The country grapples with a significant number of infant deaths and preterm births, but studies explicitly linking preterm birth to infant mortality remain scarce, failing to account for unobserved heterogeneity( 6 ). Neonatal habilitation refers to the process of facilitating sensory, motor, and behavioral organization for preterm infants starting from early days of life, often while the infant is still in intensive care. Global models emphasized the necessity of early stimulation towards better neurodevelopmental outcomes, yet most frameworks, e.g., SENSE and NIDCAP, are derived from high-resource contexts with robust multidisciplinary staffing. ( 7 – 10 ) But habilitation practice in India is heterogeneously administered, typically on an ad hoc basis depending upon individual clinician preference, institution-based tradition, or parental convenience, with minimal guidance through standardized regimens. Considering that the majority of preterm births globally occur in low- and middle-income countries, it is thus imperative to contextualize habilitation protocols for resource-constrained settings( 11 , 12 ). Among clinical staff that provide habilitation care, Indian physiotherapists are often the first-line providers of positioning, sensory stimulation, and early motor facilitation. But their function is vaguely defined, sporadically acknowledged, and widely unprovided for by hospital policies or systematic education. Therapists are involved in developmental care, but they too often have their work go unrecorded or unvalued. This situation shows not only institutional limitations but also a more general difficulty of fractured professional identity among Indian NICU teams.( 13 – 15 ) Current literature either focuses on the parental preparation for NICU care or on protocol-based interventions at the expense of practice conditions that therapists encounter in reality( 16 , 17 ). As a result, relatively little is known about ground-level obstacles therapists confront in delivering habilitative care such as limitations set by institutional workflows, training gaps, absence of interdisciplinary coordination, or cultural patterns affecting mother-infant interaction. Unless these practice-informed obstacles are identified and addressed, efforts to establish or put in place formalized habilitation protocols will be short of feasibility, sustainability, or cultural salience.( 18 , 19 ) This research was aimed at bridging this important lacuna. Based on the lived clinical experiences of physiotherapists providing services in NICUs in India, it identifies practice-informed problems and grassroots-level solutions for early habilitation among preterm infants. This question constitutes the foundation T0 phase of a broader translational research program whose objective is to design culturally appropriate, evidence-based early stimulation protocols. In this therapist-focussed light, the study seeks to bring into view context-sensitive understanding that can inform subsequent interventions and policy adjustments in neonatal habilitative care. Methods Study Orientation and Rationale This manuscript represents the first analytical phase of a larger multiphase PhD study investigating neonatal habilitation in Indian NICUs. While the findings were derived from the same interview dataset as a previously submitted manuscript focusing on systemic patterns of practice, this paper specifically centers on practice-informed barriers and therapist-generated solutions. Although the methodological framework, design, and participants were common to both outputs, this second submission (chronologically the first in design) explores a distinct analytical angle, justified by the richness and multidimensionality of the original data. This approach aligns with contemporary qualitative research practice where large, in-depth datasets are mined for separate yet thematically linked outputs, provided transparency is maintained. Positioned within the earliest phase of translational inquiry (T0), this study prioritizes the contextual realities and practice-level obstacles to habilitation within Indian NICUs, with the aim of guiding protocol development attuned to real-world clinical constraints. Given the limited formal guidelines and the high variability in habilitation practices across Indian NICUs, this foundational phase sought to generate empirical insights directly from therapists’ experiences. Philosophical and Theoretical Orientation The research took a constructivist epistemology, acknowledging that knowledge is co-constructed between participants and researchers. A phenomenological perspective was used to investigate how NICU physiotherapists experience and interpret their roles in early habilitation. A descriptive-exploratory method was utilized to gain genuine insights into clinical decision-making, organizational structures, and the sociocultural dynamics informing habilitative care. Participants and Sampling 16 NICU physiotherapists were recruited from diverse healthcare contexts in India, such as tertiary hospitals, private institutions, and government hospitals. Purposive and snowball sampling techniques were employed to achieve maximum representation of views. Eligible participants had a minimum of two years of NICU experience and were directly involved in developmental care. Out of the 20 therapists who were contacted, four were unable to participate because of scheduling conflicts. The resultant sample consisted of professionals with varying years of experience (between 2 and >10 years) and educational backgrounds (undergraduate, postgraduate, doctoral) and included three board-certified neonatal therapists. These demographics are listed in Table 1. Table 1: Baseline Characteristics of the participants Participant Characteristics Frequency percentage Baseline Characteristics of Therapists Experience 2- 5 years 6-10 years More than 10 years 7 5 4 43.75% 31.25% 25% Educational Qualification Undergraduate Postgraduate Doctoral 7 7 2 43.75% 43.75% 12.5% Board Certified Neonatal therapist 3 18.75% Rapport Building and Consent The interviewer established rapport-building through an opening telephone call that disclosed the rationale, voluntary status, and confidentiality guarantees of the study. Only after securing verbal agreement and comfort from the therapist was the formal interview scheduled. Data Collection Interviews was conducted by the principal investigator (AJR), who is research scholar in the field of physiotherapy and has an experience of conducting and publishing qualitative studies, All interviews took place over one-on-one audio calls, arranged at participants' convenience and outside standard clinical time. Participants selected quiet, secluded spaces to be interviewed, with express requests to be free from interruptions and protected from overheard listening. Phone calls were selected for practicality due to participants' professional commitments and geographic distances. All interviews lasted 45 to 90 minutes with a mean of 60 minutes. Interviews were semi-structured and employed a flexible format to explore in depth issues such as perceived habilitation barriers, clarity of role, team integration, support from the institution, training deficits, and mother-infant interaction. Questions were open-ended, and interviewers utilized dynamic probing on the basis of participant response to prompt greater reflection. The questionnaire is added as supplementary file. Consent interviews were audio recorded. Real-time field notes were taken to observe and record non-verbal responses, contextual information, and interviewer comments. Field notes were invaluable in informing follow-up questions and referencing areas for further probing in future interviews. No repeat interviews were necessary; this was understandable by the rich, detailed information gathered within a single interview, and pre-established rapport allowing participants to respond openly and exhaustively during the first interview. Data saturation was decided based on the failure of new codes to emerge in two consecutive interviews, ensuring thematic completeness and analytical adequacy. Data Handling and Transcription All of the interviews were verbatim transcribed. The local language interviews were translated into English by the researchers themselves, who were bilingual and well-versed in NICU slang and contextual connotations. This minimized meaning loss in translation. The transcripts were anonymized via participant codes and stored on encrypted devices available to the research team. Transcript returns were not done, a choice defended by the professional character of the interviews, where respondents were assured in their reporting, and the content mostly represented structured professional experiences as opposed to private or affective revelations. Additionally, real-time validation of answers was built into the interview process through clarifying questions and restatements. Data Analysis Thematic analysis was conducted by Braun and Clarke's six-step reflexive approach, which entailed data familiarization, initial coding, theme development, review of the themes, defining the themes, and final narrative synthesis. The transcripts were coded independently by two researchers who had qualitative methodology experience and neonatal physiotherapy background. Coding was done manually in Microsoft Excel 2021Following coding at the initial stage, the researchers sat down to compare and contrast the codes and reconcile them through discussion. Disagreements over coding were resolved by discussion until consensus. Themes were inductively generated, following grounded wisdom in preference to preconceived categories. Themes were each substantiated by a matrix of open codes, extended quotes, and interpretive summaries. Analytic rigor was guaranteed by regularly checking emerging themes against original transcripts to verify their validity and richness. A practice-informed interpretive perspective was employed to place the participants' clinical reasoning, emotional labor, and cultural negotiations in care at the center. Analytical memos were employed throughout to document conceptual connections, unfolding theoretical considerations, and cross-case contrasts. Reflexivity, context sensitization, and commitment to participants' terminology were privileged during theme building. Researcher Reflexivity and Ethical Considerations The research was conducted by a pediatric and neonatal-trained physiotherapist with previous experience of qualitative research in NICU settings. As a precaution against insider bias, the principal investigator maintained reflexive field notes throughout the research to document assumptions, affective reactions, and interpretative choices. Reflexive practice was augmented by peer debriefing with a co-researcher at the coding and analysis phases. All the participants received a clear verbal description of the purpose of the study, their voluntary participation, confidentiality of the information, and their right to withdraw at any time. Rapport was created in a pre-interview call during which the researcher provided a self-introduction, described the intent of the study, and answered participant questions. An interview was scheduled only once participants were at ease and cooperative. These initial discussions facilitated familiarity and trust, bringing about wider openness during the formal interview. Publication Sequence and Dataset Justification This paper is the inaugural sequential output from a larger dataset garnered during these 16 interviews. While this paper was authored and completed following the submission to a peer-reviewed journal of a second paper entitled "Experience-Informed Practices in Preterm Infant Habilitation in Neonatal Intensive Care Unit: Integrating Therapists' Expertise and Mothers' Lived Experiences," the present manuscript sequentially follows it in logic. The original dataset was re-examined and re-analyzed with additional eye for the present study, with attention given to barriers and solutions brought about by therapists, while the originally submitted paper focused on more general practice patterns and evidence-informed approaches. While a second manuscript from this dataset has already been submitted, this paper represents the foundational analysis in the research chronology. It focuses specifically on the structural, educational, and cultural impediments to neonatal habilitation as interpreted through therapist narratives. The other manuscript explores practice applications from a different analytic lens. This sequential publication approach is methodologically justified and common in qualitative health research, especially when datasets are rich and multiperspectival. This strategy was transparently declared to the current journal, and great care has been taken to ensure that no textual duplication or conceptual redundancy occurs between the manuscripts. Results Thematic analysis yielded two overarching themes based on the interviews with neonatal therapists: (1) Barriers to Delivering Early Habilitation in Indian NICUs, and (2) Practice-Informed Strategies for Developmental Care with nine subthemes combined. Together, they reveal how therapists navigate fragmented roles, institutional challenges, cultural complexity, and training gaps, while simultaneously developing adaptive, parent-centered solutions in practice. The coding tree is depicted in table 2. Table 2: Coding of responses Theme Subtheme Open Codes Barriers to Delivering Early Habilitation in Indian NICUs Fragmented Professional Identity Role seen primarily as respiratory care; Limited involvement in care planning; Under-recognition of developmental contributions; Gradual acceptance through outcomes; Scope not well understood by team Institutional and Operational Restrictions NICU schedules dominated by medical routines; Insufficient time for habilitation; No formal protocols; No documentation channels; Practice is different in different hospitals Curriculum Gaps and Training Shortfalls Limited NICU exposure during training; Learning through observation and workshops; Initial reluctance with fragile infants; Requirement for structured mentorship; On-the-job skill building Maternal Disempowerment and Cultural Hesitancy Fear of harming the baby; Cultural beliefs limit early touch; NICU environment overwhelms families; Misunderstanding about wires and equipment; Need for repeated emotional orientation Practice-Informed Strategies for Enhancing Developmental Care Empowering Mothers through Graduated Involvement Stepwise inclusion based on readiness; Observation-first approach; Building confidence through guided touch; Framing mother as the baby’s co-therapist; Respecting emotional pace of families Culture-Compatible Interventions Using familiar caregiving terms; Avoiding clinical jargon; Promoting accepted techniques (Yakson touch, singing); Aligning with family comfort zones; Blending therapy into parenting Visual and Simplified Protocols Easy-to-use visual charts; Pictorial guidance for low-literacy caregivers; Gestational age-based checklists; Tools usable without extra training; Protocols that support team consistency Curriculum and Policy Reforms Integration of habilitation into syllabus; Need for India-specific protocols; Structured NICU certification; Addressing gaps in senior-level training; National guidance for standardization Building Respectful Partnerships with NICU Teams Gaining trust through outcomes; Demonstrating contribution to discharge readiness; Using case sharing and education sessions; Positioning therapy as collaborative; Inclusion through team rapport Theme 1: Barriers to Delivering Early Habilitation in Indian NICUs Subtheme 1.1: Fragmented Role Identity Therapists reported that their professional identity in the NICU was often reduced to respiratory care. Even with skills in positioning, sensory stimulation, feeding assistance, and neurodevelopmental evaluation, they were usually summoned only to suction or perform chest physiotherapy. The constrained definition of their role restricted interdisciplinary interaction and kept them out of significant decision-making regarding developmental care. “In most NICUs, the first thing that comes to people's minds when they hear 'physiotherapist' is that we are only here to clear secretions or do suction. That's not all we do, though. We are involved in positioning, sensory readiness, and early developmental transitions support, but these services aren't always recognized or requested." - Therapist Therapists indicated that they did not perceive this as intentional exclusion, but rather as a consequence of a lack of knowledge about the complete range of physiotherapy in NICU environments. They felt that realistic inclusion could only be realized through demonstrated performance and by presenting themselves as complementary to medical objectives, rather than disrupting them. "First, they would tell us not to do therapy. But as time passed, when they could see babies calm down, feed well, and get discharged sooner, they began asking us to do more on a regular basis." - Therapist Subtheme 1.2: Institutional Gaps and Operational Constraints Therapists emphasized noteworthy heterogeneity between hospitals in terms of habilitation practice. Certain NICUs provided more room for variation in developmental care, whereas others were rigidly timetabled around medical and nursing procedures, with little scope left for sensory or postural interventions. Time, space, and staff were identified as central constraints on the delivery of stimulation protocols. "The unit is constantly full of feedings, rounds, procedures, etc., there's scarcely a minute when you can insert habilitation. You must wait and catch your moment in between." - Therapist Therapists most frequently worked without systematic protocols to direct their activity, relying on their own clinical judgment or their senior colleagues' recommendations. This variability produced unequal care across units and among therapists. Furthermore, developmental care was rarely documented formally, which reduced its visibility and continuity. “There is no documentation format for what we do. Even if we spend time positioning, giving stimulation, it’s not recorded. It feels like it never happened .” – Therapist Therapists viewed lack of structural support as a major constraint to standard habilitation delivery, particularly in high-volumes or government hospitals. Subtheme 1.3: Curriculum Gaps and Training Shortfalls Members indicated that habilitation was not a strong emphasis in their academic programs. Although a few had some exposure within NICU rotations, it was typically observational and did not involve structured instruction. The shift from learning in the classroom to NICU care was a sudden one, and most therapists reported feeling unprepared to manage vulnerable neonates, especially high-risk or ventilated ones. "PG time, we posted NICU for 2 weeks. We did a lot of following behind others though. I was afraid to even touch a preterm infant because I had no idea what was safe and what wasn't." – Therapist This restricted exposure frequently resulted in initial reluctance, particularly in environments that lacked an elder therapist to supervise or guide. Therapists were keen to point out that this was not an issue of failing educators, but a deficiency in how the curriculum translated into NICU realities. Competence was gained by many through workshops, observation, and practice, frequently acquiring experience "on the job" with support from nursing staff or other members of the team. “Everything I know about developmental care came after my degree. I had to attend workshops, observe seniors, and slowly practice on stable babies to get comfortable .” – Therapist Subtheme 1.4: Maternal Disempowerment and Cultural Hesitancy Therapists found that most mothers reported feeling emotionally removed or threatened when approaching the NICU. This was both influenced by the sterile clinical environment and by cultural prohibitions against early handling of delicate or premature infants. Some saw handling or stimulation as dangerous, particularly during the first month of life. “One mother told me her elders said not to touch the baby for the first month. She would just sit in a chair nearby but never approach the incubator. It took repeated reassurance before she even held the baby’s hand.” – Therapist The beeping machines, oxygen tubes, and clinical sterility further amplified maternal anxiety, leaving many unsure about their role in care. Without proper orientation, they often assumed that their presence was not needed — or even harmful. “Mothers would say, ‘What if I do something wrong? What if I disturb the machine?’ The NICU is overwhelming, and without someone to tell them, they believe they shouldn't touch or engage". – Therapist Therapists stressed that consistent, empathetic orienting — emotional and functional — was essential for supporting mothers as they moved from being passive spectators to active participants in their baby's development. Theme 2: Practice-Informed Strategies for Developmental Care Therapists discussed a rich array of methods they have developed and honed over years to facilitate early habilitation in neonatal intensive care units. These strategies did not come out of formal education or set protocols, but rather from experience, observation of culture, and affective sensitivity to the requirements of infants and caregivers. Their practices illustrate how, even in resource-scarce systems, physiotherapists are innovatively working to provide safe, developmentally friendly care through authentic collaboration with families. Four subthemes describe these strategies: Empowering Mothers through Graduated Involvement, Culture-Compatible Interventions, Visual and Simplified Protocols, and Curriculum and Policy Reforms. Subtheme 2.1: Progressive Parental Involvement Based on Emotional Readiness Rather than giving instructions or tasks immediately, therapists adopted a layered, emotionally attuned approach to involving mothers. They began with non-threatening forms of interaction such as silent observation or gentle presence and progressed to touch, voice, and stimulation only when the mother expressed readiness. “We never start with, ‘Do this or do that.’ First, we ask them to just stand by the incubator and observe. Once they feel comfortable, we suggest they speak softly or make eye contact. After that, we move to holding the hand, then touching the chest or back. It’s a slow, respectful process.” – Therapist This progression allowed the mother to rebuild confidence and bond with the baby without fear. Therapists found that emotional readiness was the foundation of effective habilitation, even more than technical skill. “It’s not just about the baby’s stimulation — it’s about making the mother believe, ‘I can do this.’ That shift doesn’t happen overnight. It builds day by day, with small victories.” – Therapist Therapists introduced practical caregiving skills gradually, based on each mother’s emotional state and the infant’s medical condition. They taught techniques such as passive movement, hand containment, visual tracking, and safe handling positions, all while emphasizing emotional connection. “We teach mothers how to hold the baby, how to offer a finger for grasp, how to gently stroke the head or chest. It’s not just about doing it right, it’s about helping them believe they can do it.” – Therapist Care was taken not to assign complex or invasive tasks. The focus was on building confidence and sensitivity, allowing mothers to understand both what to do and why it matters. “We never leave them alone on the first day. We stand with them, guide them. Once they see that the baby is okay, they relax. Then they start doing it on their own.” – Therapist Subtheme 2.2: Culturally Sensitive Adaptation of Stimulation Practices Therapists frequently modified their language and methods to fit cultural expectations. Instead of calling interventions "therapy," they redefined them as intimate caregiving procedures like blessing, soothing, or bonding. This served to diminish fear and enabled families to bond with the baby in emotionally significant ways. “We don’t say, ‘We are doing visual stimulation.’ We say, ‘Let the baby look at you, your face is the best thing for them to see.’ That makes it feel like parenting, not a clinical task.” – Therapist Such adaptations also allowed therapists to introduce stimulation earlier, even in families that initially resisted. Techniques like yakson touch or face-regard were easy to teach, safe for fragile infants, and culturally resonant. “Some families are afraid of structured therapy. But when we say, ‘This is like blessing the baby,’ they’re more open. That way, the baby gets the care, and the family feels involved without fear.” – Therapist They also found that simpler, intuitive techniques such as Yakson touch were welcomed more easily than structured Western methods. For example, contrast cards and stimulation kits were often met with confusion, while gentle, familiar acts like stroking or humming were quickly embraced. “Sometimes yakson touch is accepted while contrast cards are not. When I show a mother how to stroke her baby’s head gently, she responds emotionally. But if I give her a card or tool, she freezes.” – Therapist This sensitivity extended beyond technique to communication. Therapists frequently assessed what methods would emotionally connect with each family and adapted their approach accordingly. “We match intervention to cultural comfort. That way, it feels natural and not imposed. If they already sing to their babies at home, we encourage that here too.” - Therapist Even auditory stimulation was reframed to match what caregivers already understood and did in daily life, allowing therapy to blend seamlessly with family culture. “Singing or talking is more accepted than structured sound therapy. We tell people, 'Speak to your baby as you would at home,' and that is more effective than any formal teaching". – Therapist These culturally matched interventions not only promoted participation but also supported the family's affective connection with the baby, making habilitation more maintainable after discharge. Subtheme 2.3: Visual, Modular Protocols that Simplify Care for All Therapists identified the need for practical, accessible tools that simplify the delivery of early stimulation, especially in units where time is limited and documentation burdens are high. They strongly advocated for pictorial or chart-based protocols tailored by gestational age, allowing both families and staff to follow safe, developmentally appropriate interventions without the need for extensive verbal instruction. These tools would provid clear, concise guidance that could be used across shifts, helping maintain consistency even when therapists were unavailable. “We need a visual guide that says, for example ’28 weeks: nesting and voice. 31 weeks: massage. 34 weeks: face regards’ That way, even if the therapist isn't around, others can safely follow.” – Therapist Visuals proved to be very helpful for mothers with lower literacy and higher stress, finding verbal instructions too overwhelming. A printed or pictorial checklist served as a reference that they could return to confidently. “One mother kept asking if she could talk to her baby. Then we gave her a chart that said ‘28 weeks - voice stimulation: Yes.’ She was so relieved. From that day, she would sing softly every time she visited.” – Therapist They also noted that complex guidelines were rarely followed in practice due to time pressure. A visual reference that required minimal reading was far more usable during clinical care or caregiver counseling. “We don’t have time to read 20 pages. A quick, visual guide that shows what is allowed at each week is more useful during rounds or parent counseling.” – Therapist Therapists found such tools particularly useful for mothers who were either illiterate or highly anxious. These visuals reassured families and gave them stepwise guidance they could follow at their own pace. “Mothers can follow pictures better than text. Sometimes they’re too scared or emotional to remember what we say. But when they see a visual guide, they relax and follow it step by step.” – Therapist In busy units with rotating staff, therapists saw such tools as essential for continuity of care and standardization of practice. “We need tools that don’t need extra training to use. Something simple enough that any caregiver or new staff member can use it without second-guessing.” – Therapist These protocols were seen not just as teaching aids, but as vital supports for equity — allowing habilitation to reach more babies, even when therapists weren’t present every day. 2.4 Curriculum and Policy Reforms While therapists have innovated their own solutions in practice, they strongly voiced the need for formal integration of habilitation into training and policy. Many reported that habilitation was absent or minimally addressed in their academic programs. This led to confusion among graduates, who often assumed physiotherapy in NICU was limited to respiratory work. “Put habilitation in the syllabus, not just chest PT. Most students come out not knowing that we have a role beyond suction.” – Therapist Even senior therapists, due to a lack of structured exposure or continuing education, expressed uncertainty at times in applying habilitative strategies consistently. “Even our seniors feel lost sometimes. If there was a national guideline or a core module, then everyone would be speaking the same language." – Therapist The participants underlined the necessity of designing national or regional protocols based on the Indian context. These would consider cultural diversity, staffing shortages, and variability in hospital infrastructure. “We need India-specific protocols. What works abroad might not always work here, especially when families, beliefs, and systems are so different.” – Therapist Therapists also called for hands-on, certified training to bridge the gap between theory and NICU-specific care. Many had relied on workshops or senior mentorship to gain practical skills, but they hoped future therapists would have structured pathways to learn safely and confidently. “We need more hands-on certification and exposure. Theory alone doesn’t prepare you to hold a baby on a ventilator or teach a scared mother how to connect.” – Therapist These reflections suggest a strong readiness within the profession to expand its role, provided institutional and policy-level support is available. Subtheme 2.5: Building Respectful Partnerships with NICU Teams Therapists described how trust with medical and nursing staff developed gradually through mutual respect and proof of benefit. Rather than asserting their presence, therapists focused on supporting unit goals and showing how habilitation could improve stability, feeding, and discharge readiness. “Initially, they were not sure about us being there. But when they saw that babies settled better, started feeding better after therapy, they began calling us on their own. That’s how collaboration grows — through outcomes, not arguments.” – Therapist Therapists also used staff meetings, case updates, and informal presentations to increase visibility and encourage interdisciplinary conversation. These efforts slowly shifted perceptions and helped integrate habilitation into standard care. “We presented what we do in habilitation. Those changed things. The staff realized we’re not interrupting, we’re contributing.” – Therapist Discussion The qualitative research examined the experiences of neonatal physiotherapists providing habilitation care in Indian NICUs. Using unstructured interviews with therapists in various geographical regions, the research both explored the systemic impediments that confront them and how they go about incorporating developmental care into standard NICU practice. Findings indicate that although physiotherapists frequently face difficulties pertaining to role identity, institutional support, and formal training, they are equally capable of expressing adaptability, emotional intelligence, and cultural responsiveness in facilitating family-centred habilitation. One of the central outcomes of this research was the continuity of a disgregated professional identity for physiotherapists working in the neonatal environment. The participants regularly indicated that their work was generally thought of as being mostly in the domain of chest physiotherapy, with little acknowledgement of developmental support, positioning, sensory stimulation, and parent training. This narrow perception not only restricted referrals for habilitation but also interfered with interdisciplinary practice. These results resonate with previous reports from high- and low-resource contexts alike, wherein allied health professionals' involvement in NICU care is narrowly defined unless specifically designed into models of care( 20 – 22 ). Here, it is significant that physiotherapists in this study did not explain this exclusion in terms of active medical team resistance but instead as lack of awareness and systemic design. Several highlighted that trust and inclusion increased when medical personnel witnessed the calming or functional effects of habilitation. This speaks to the requirement for role clarification among NICU teams, as well as to physiotherapy being not an "add-on" but an integral part of developmental care from admission to discharge ( 13 , 23 , 24 ). Another key barrier was that there were no standardised habilitation protocols in place among NICUs. All these stakeholders explained how time pressures, dense patient loads, and dense schedules allowed no space for developmental interventions. ( 25 , 26 ) This was further exacerbated by the absence of documentation formats to use in recording habilitative care, lack of clinical records and frequently not rewarding them in performance measures. The heterogeneity in the conceptualization and provision of habilitation across institutions from ad hoc practices to formal programs is consistent with other LMICs, where resource constraints and top-down decision-making tend to exclude non-medical professionals ( 27 ). The fact that many therapists had been working in the lack of guidance and developed their own de facto routines attests both to their resourcefulness and to a systemic failure to integrate habilitation into standard care pathways. Institutionalization of habilitation in optimized, evidence-based, gestational-age-specific protocols could enable standardization while empowering not only physiotherapists but nurses and families too( 28 , 29 ). One of the persistent problems was insufficient neonatal habilitation exposure in physiotherapy education. The majority of respondents stated that undergraduate or postgraduate training did not prepare them with the clinical competence and manual skills required in the NICU setting. A number expressed anxiety or discomfort during first-time clinical placements, particularly while managing fragile, ventilated, or medically unstable neonates. Many therapists reported to learn neonatal care primarily from informal peer learning or continuous education workshops( 17 , 30 ). Such learning, while valuable, comes at a steep learning curve, particularly in the absence of formalized mentoring or competency-based assessment. Despite this lack, a commitment to learning and innovation was demonstrated by the majority of therapists using peer observation, self-study, and collaborative work with nurses to develop their practice. This highlights the urgent need for curriculum updating with formal NICU postings, competency-based certification, and interdisciplinary simulation-based education. Incorporating habilitation-specific modules within postgraduate physiotherapy courses may also normalize early exposure to NICU dynamics and reduce practitioner anxiety( 31 , 32 ). Such comprehensive preparation can enhance confidence, competency, and job satisfaction among neonatal physiotherapists while improving the quality of care( 20 ). Mothers' emotional state and their beliefs were found to be the key determinants of habilitation uptake. Mothers were often said to be reluctant to touch or engage with their babies, particularly when preterm or medically fragile. Culture, for example, delayed contact for the first month and fear of the equipment helped to account for this distance. These findings are consistent with research highlighting parent preparation and orientation in NICUs, especially in resource-limited and heterogeneous contexts( 17 , 19 , 33 ). Therapists in this research reacted with a graduated, affectively responsive strategy of parent involvement. They started with presence and observation and progressed to gentle touch and finally active engagement. The step-by-step participation fostered maternal confidence and facilitated bonding. The re-labelling of therapy in culturally recognizable terms (e.g., "blessing touch") was especially useful in obtaining parents' trust. These practices are in harmony with global standards for family-centered care, where parents' emotional preparation is given more importance compared to the completion of work( 19 , 34 ) Lacking formal systems, therapists developed their own pragmatic aids to aid developmental care. Most promoted reduced visual protocol e.g., gestational age-based charts that might assist professionals and parents alike. Visual aids were particularly valuable in staff-intensive units with frequent turnover or where caregiver literacy was an issue. The focus on usability, flexibility, and cultural compatibility is reflective of a grounded awareness of actual NICU limitations.( 16 , 35 , 36 ) Participants also explained modifying standard procedures to suit family taste, opting for gentle, familiar actions such as Yakson touch, singing, or face regard rather than untried interventions such as contrast cards or protocolized auditory approaches. Such adaptive practice shows the strength infrequently reported in neonatal literature: the therapist's cultural intuition and emotional intelligence. Although such practices are not documented, they are potentially key to the effectiveness and durability of habilitation in Indian settings.( 37 – 39 ) Therapists eagerly articulated a need for official acknowledgment of habilitation in national practice and training guidelines. Most called for habilitation to be included in postgraduate curricula, developing India-specific protocols, and offering formal certifications for neonatal care. Notably, therapists cited that even experienced clinicians felt unprepared, which highlighted a systemic intergenerational training gap. This discovery reverberates with others in other LMICs, in which segmented systems, variability in resources, and lack of interprofessional education have hindered universal implementation of early intervention( 40 , 41 ). For India, professionalization of habilitation would improve care as well as confer legitimacy on the therapist's role as an esteemed member of the NICU team. This process of earning interprofessional trust through demonstrated clinical benefit such as improved feeding or discharge readiness, reflects the bottom-up advocacy required in hierarchical NICU environments.( 20 , 23 , 35 , 42 ) Therapists in this study did not seek recognition through assertion but through collaborative outcomes, which gradually reshaped their standing within the medical team. Such relational strategies underline the importance of visibility, informal advocacy, and shared clinical goals in embedding habilitation into routine NICU workflows. Strengths and Limitations One of the real strengths of this study is the focus on the lived experience of neonatal physiotherapists throughout India, giving a grounded, context-sensitive image of how habilitation is being put into practice in varying institutional and cultural contexts. Yet, the research does have its own limitations. The evidence comes only from physiotherapists' views and did not incorporate contributions from neonatologists, nurses, or families. Triangulation between disciplines might have provided more richness to the understanding. Besides that, the lack of structure during the interviews, although opening up rich information, might have resulted in variable depth in participants. Implications for Practice and Policy The results have a number of implications. First, they emphasize that habilitation needs to be formally incorporated into physiotherapy education through competency-based models and NICU experience during internships. Second, policy and documentation systems would have to be reconfigured so that stimulation, positioning, and training parents became routine, not optional, parts of NICU treatment. Third, interdisciplinary workshop sessions have the potential to better acquaint therapists, neonatologists, and nurses with each other — silos are dismantled, and care coordination is facilitated. Lastly, parent engagement needs to be reimagined as a graduated, emotionally safe process, rather than an orientation. Future Directions Further studies are suggested to develop and validate India-specific habilitation protocols for gestational age, medical stability, and caregiver readiness. Mixed-methods studies across neonatologists, nurses, and parents will give a more nuanced view on implementation issues. Intervention studies can also pilot the efficacy of visual stimulation charts, caregiver training modules, or interdisciplinary rounds with therapists in outcome improvement. There is also scope for policy-making. Guidelines at the national level, like those of the Indian Academy of Pediatrics or National Health Mission might make room for habilitation as an identified field of care. With formal training and support from institutions, activity that is currently performed on an ad-hoc basis by therapists can become part of a more regular, uniform system of care. Conclusion This study highlights the real-world challenges and adaptive practices of physiotherapists delivering early habilitation in Indian NICUs. Despite systemic constraints, such as limited role clarity, absence of structured protocols, inadequate training, and cultural hesitancy among caregivers, therapists demonstrated strong professional agency through context-sensitive strategies, including graduated parental engagement, culture-aligned interventions, and simplified visual tools. These insights affirm the critical role of physiotherapists not only as clinicians but also as innovators and collaborators in neonatal care. To translate this practice-informed wisdom into sustainable impact, there is a pressing need to integrate habilitation into physiotherapy curricula, institutional protocols, and national neonatal health policy, ensuring equitable, developmentally supportive care for every infant. Declarations Conflict of interest: Authors declare no conflict of interest to disclose Ethical Considerations The study was conducted in accordance with Helsinki’s declaration. The study was approved by Institutional Ethics Committee of SRM Medical College Hospital and Research and Centre, Kattankulathur.( Reg. No: ECR/8972/INST/TN/2013/RR-19) Confidentiality was strictly maintained, with all data anonymized before analysis. Informed consent was obtained from all participants before participation, and they had the right to withdraw from the study at any stage without consequences. Participants were recruited to the study following the voluntary willingness to participate. Consent for publication: All the participants gave consent to publish Funding statements The project is funded by Researcher Starter Grant – “Growth & Advancement Towards Excellence”, SRM Institute of Science and Technology, Kattankulathur, India Availability of data and materials The datasets used and/or analysed during the current study are available from the PI on reasonable request. Competing interests Authors declare no competing interests. Author Contributions: AJR: Conceptualization, conducting interviews, transcribing and translations, coding of responses and theme identification and Interpreting results KV: Conceptualization, coding of responses, drafting results, proof corrections, drafting manuscript All authors contributed to the revision of the protocol and read and approved the final manuscript Acknowledgements: Authors would like to extend heartfelt thanks to all the participants for spending their valuable time for the interview sessions Disclosure This manuscript is based on a distinct reanalysis of a qualitative dataset already used for a separate publication. The present paper explores a different thematic focus (barriers and practice-informed solutions), while the previously submitted paper focuses on system-level practice patterns. There is no textual or conceptual overlap between the two manuscripts, and the reuse of data is transparently declared in the Methods section. 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Supplementary Files Semistructuredinterviewtounderstandpracticeinformedbarriers.docx Cite Share Download PDF Status: Published Journal Publication published 31 Jan, 2026 Read the published version in BMC Pediatrics → Version 1 posted Editorial decision: Revision requested 01 Dec, 2025 Reviews received at journal 25 Nov, 2025 Reviews received at journal 22 Nov, 2025 Reviewers agreed at journal 13 Nov, 2025 Reviewers agreed at journal 12 Nov, 2025 Reviews received at journal 03 Oct, 2025 Reviewers agreed at journal 17 Sep, 2025 Reviewers agreed at journal 15 Sep, 2025 Reviewers invited by journal 12 Sep, 2025 Editor invited by journal 24 Aug, 2025 Editor assigned by journal 23 Aug, 2025 Submission checks completed at journal 23 Aug, 2025 First submitted to journal 12 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Despite the fact that there has been a boost in neonatal care infrastructure, the children are still prone to developmental impairment due to both biological vulnerability as well as a lack of enough sensory and neuromotor stimulation in the NICU environment.(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) Particularly, Indian NICUs lack well-organized habilitation protocols to explain lost early developmental intervention opportunities within a window of brain plasticity(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). The country grapples with a significant number of infant deaths and preterm births, but studies explicitly linking preterm birth to infant mortality remain scarce, failing to account for unobserved heterogeneity(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eNeonatal habilitation refers to the process of facilitating sensory, motor, and behavioral organization for preterm infants starting from early days of life, often while the infant is still in intensive care. Global models emphasized the necessity of early stimulation towards better neurodevelopmental outcomes, yet most frameworks, e.g., SENSE and NIDCAP, are derived from high-resource contexts with robust multidisciplinary staffing. (\u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) But habilitation practice in India is heterogeneously administered, typically on an ad hoc basis depending upon individual clinician preference, institution-based tradition, or parental convenience, with minimal guidance through standardized regimens. Considering that the majority of preterm births globally occur in low- and middle-income countries, it is thus imperative to contextualize habilitation protocols for resource-constrained settings(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAmong clinical staff that provide habilitation care, Indian physiotherapists are often the first-line providers of positioning, sensory stimulation, and early motor facilitation. But their function is vaguely defined, sporadically acknowledged, and widely unprovided for by hospital policies or systematic education. Therapists are involved in developmental care, but they too often have their work go unrecorded or unvalued. This situation shows not only institutional limitations but also a more general difficulty of fractured professional identity among Indian NICU teams.(\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eCurrent literature either focuses on the parental preparation for NICU care or on protocol-based interventions at the expense of practice conditions that therapists encounter in reality(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). As a result, relatively little is known about ground-level obstacles therapists confront in delivering habilitative care such as limitations set by institutional workflows, training gaps, absence of interdisciplinary coordination, or cultural patterns affecting mother-infant interaction. Unless these practice-informed obstacles are identified and addressed, efforts to establish or put in place formalized habilitation protocols will be short of feasibility, sustainability, or cultural salience.(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eThis research was aimed at bridging this important lacuna. Based on the lived clinical experiences of physiotherapists providing services in NICUs in India, it identifies practice-informed problems and grassroots-level solutions for early habilitation among preterm infants. This question constitutes the foundation T0 phase of a broader translational research program whose objective is to design culturally appropriate, evidence-based early stimulation protocols. In this therapist-focussed light, the study seeks to bring into view context-sensitive understanding that can inform subsequent interventions and policy adjustments in neonatal habilitative care.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy Orientation and Rationale\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis manuscript represents the first analytical phase of a larger multiphase PhD study investigating neonatal habilitation in Indian NICUs. While the findings were derived from the same interview dataset as a previously submitted manuscript focusing on systemic patterns of practice, this paper specifically centers on practice-informed barriers and therapist-generated solutions. Although the methodological framework, design, and participants were common to both outputs, this second submission (chronologically the first in design) explores a distinct analytical angle, justified by the richness and multidimensionality of the original data. This approach aligns with contemporary qualitative research practice where large, in-depth datasets are mined for separate yet thematically linked outputs, provided transparency is maintained.\u003c/p\u003e\n\u003cp\u003ePositioned within the earliest phase of translational inquiry (T0), this study prioritizes the contextual realities and practice-level obstacles to habilitation within Indian NICUs, with the aim of guiding protocol development attuned to real-world clinical constraints. Given the limited formal guidelines and the high variability in habilitation practices across Indian NICUs, this foundational phase sought to generate empirical insights directly from therapists\u0026rsquo; experiences.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePhilosophical and Theoretical Orientation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research took a constructivist epistemology, acknowledging that knowledge is co-constructed between participants and researchers. A phenomenological perspective was used to investigate how NICU physiotherapists experience and interpret their roles in early habilitation. A descriptive-exploratory method was utilized to gain genuine insights into clinical decision-making, organizational structures, and the sociocultural dynamics informing habilitative care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipants and Sampling\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e16 NICU physiotherapists were recruited from diverse healthcare contexts in India, such as tertiary hospitals, private institutions, and government hospitals. Purposive and snowball sampling techniques were employed to achieve maximum representation of views. Eligible participants had a minimum of two years of NICU experience and were directly involved in developmental care.\u003c/p\u003e\n\u003cp\u003eOut of the 20 therapists who were contacted, four were unable to participate because of scheduling conflicts. The resultant sample consisted of professionals with varying years of experience (between 2 and \u0026gt;10 years) and educational backgrounds (undergraduate, postgraduate, doctoral) and included three board-certified neonatal therapists. These demographics are listed in Table 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1: Baseline Characteristics of the participants\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"601\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParticipant\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003epercentage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline Characteristics of Therapists\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExperience\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e2- 5 years\u003c/p\u003e\n \u003cp\u003e6-10 years\u003c/p\u003e\n \u003cp\u003eMore than 10 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e43.75%\u003c/p\u003e\n \u003cp\u003e31.25%\u003c/p\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducational Qualification\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eUndergraduate\u003c/p\u003e\n \u003cp\u003ePostgraduate\u003c/p\u003e\n \u003cp\u003eDoctoral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e43.75%\u003c/p\u003e\n \u003cp\u003e43.75%\u003c/p\u003e\n \u003cp\u003e12.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBoard Certified Neonatal therapist\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e18.75%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eRapport Building and Consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe interviewer established rapport-building through an opening telephone call that disclosed the rationale, voluntary status, and confidentiality guarantees of the study. Only after securing verbal agreement and comfort from the therapist was the formal interview scheduled.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInterviews was conducted by the principal investigator (AJR), who is research scholar in the field of physiotherapy and has an experience of conducting and publishing qualitative studies,\u003c/p\u003e\n\u003cp\u003eAll interviews took place over one-on-one audio calls, arranged at participants\u0026apos; convenience and outside standard clinical time. Participants selected quiet, secluded spaces to be interviewed, with express requests to be free from interruptions and protected from overheard listening. Phone calls were selected for practicality due to participants\u0026apos; professional commitments and geographic distances.\u003c/p\u003e\n\u003cp\u003eAll interviews lasted 45 to 90 minutes with a mean of 60 minutes. Interviews were semi-structured and employed a flexible format to explore in depth issues such as perceived habilitation barriers, clarity of role, team integration, support from the institution, training deficits, and mother-infant interaction. Questions were open-ended, and interviewers utilized dynamic probing on the basis of participant response to prompt greater reflection. The questionnaire is added as supplementary file.\u003c/p\u003e\n\u003cp\u003eConsent interviews were audio recorded. Real-time field notes were taken to observe and record non-verbal responses, contextual information, and interviewer comments. Field notes were invaluable in informing follow-up questions and referencing areas for further probing in future interviews. No repeat interviews were necessary; this was understandable by the rich, detailed information gathered within a single interview, and pre-established rapport allowing participants to respond openly and exhaustively during the first interview.\u003c/p\u003e\n\u003cp\u003eData saturation was decided based on the failure of new codes to emerge in two consecutive interviews, ensuring thematic completeness and analytical adequacy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Handling and Transcription\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll of the interviews were verbatim transcribed. The local language interviews were translated into English by the researchers themselves, who were bilingual and well-versed in NICU slang and contextual connotations. This minimized meaning loss in translation. The transcripts were anonymized via participant codes and stored on encrypted devices available to the research team.\u003c/p\u003e\n\u003cp\u003eTranscript returns were not done, a choice defended by the professional character of the interviews, where respondents were assured in their reporting, and the content mostly represented structured professional experiences as opposed to private or affective revelations. Additionally, real-time validation of answers was built into the interview process through clarifying questions and restatements.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThematic analysis was conducted by Braun and Clarke\u0026apos;s six-step reflexive approach, which entailed data familiarization, initial coding, theme development, review of the themes, defining the themes, and final narrative synthesis. The transcripts were coded independently by two researchers who had qualitative methodology experience and neonatal physiotherapy background. Coding was done manually in Microsoft Excel 2021Following coding at the initial stage, the researchers sat down to compare and contrast the codes and reconcile them through discussion. Disagreements over coding were resolved by discussion until consensus.\u003c/p\u003e\n\u003cp\u003eThemes were inductively generated, following grounded wisdom in preference to preconceived categories. Themes were each substantiated by a matrix of open codes, extended quotes, and interpretive summaries. Analytic rigor was guaranteed by regularly checking emerging themes against original transcripts to verify their validity and richness.\u003c/p\u003e\n\u003cp\u003eA practice-informed interpretive perspective was employed to place the participants\u0026apos; clinical reasoning, emotional labor, and cultural negotiations in care at the center. Analytical memos were employed throughout to document conceptual connections, unfolding theoretical considerations, and cross-case contrasts. Reflexivity, context sensitization, and commitment to participants\u0026apos; terminology were privileged during theme building.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResearcher Reflexivity and Ethical Considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research was conducted by a pediatric and neonatal-trained physiotherapist with previous experience of qualitative research in NICU settings. As a precaution against insider bias, the principal investigator maintained reflexive field notes throughout the research to document assumptions, affective reactions, and interpretative choices. Reflexive practice was augmented by peer debriefing with a co-researcher at the coding and analysis phases.\u003c/p\u003e\n\u003cp\u003eAll the participants received a clear verbal description of the purpose of the study, their voluntary participation, confidentiality of the information, and their right to withdraw at any time.\u003c/p\u003e\n\u003cp\u003eRapport was created in a pre-interview call during which the researcher provided a self-introduction, described the intent of the study, and answered participant questions. An interview was scheduled only once participants were at ease and cooperative. These initial discussions facilitated familiarity and trust, bringing about wider openness during the formal interview.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePublication Sequence and Dataset Justification\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis paper is the inaugural sequential output from a larger dataset garnered during these 16 interviews. While this paper was authored and completed following the submission to a peer-reviewed journal of a second paper entitled \u0026quot;Experience-Informed Practices in Preterm Infant Habilitation in Neonatal Intensive Care Unit: Integrating Therapists\u0026apos; Expertise and Mothers\u0026apos; Lived Experiences,\u0026quot; the present manuscript sequentially follows it in logic. The original dataset was re-examined and re-analyzed with additional eye for the present study, with attention given to barriers and solutions brought about by therapists, while the originally submitted paper focused on more general practice patterns and evidence-informed approaches.\u003c/p\u003e\n\u003cp\u003eWhile a second manuscript from this dataset has already been submitted, this paper represents the foundational analysis in the research chronology. It focuses specifically on the structural, educational, and cultural impediments to neonatal habilitation as interpreted through therapist narratives. The other manuscript explores practice applications from a different analytic lens. This sequential publication approach is methodologically justified and common in qualitative health research, especially when datasets are rich and multiperspectival. This strategy was transparently declared to the current journal, and great care has been taken to ensure that no textual duplication or conceptual redundancy occurs between the manuscripts.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThematic analysis yielded two overarching themes based on the interviews with neonatal therapists: (1) Barriers to Delivering Early Habilitation in Indian NICUs, and (2) Practice-Informed Strategies for Developmental Care with nine subthemes combined. Together, they reveal how therapists navigate fragmented roles, institutional challenges, cultural complexity, and training gaps, while simultaneously developing adaptive, parent-centered solutions in practice. The coding tree is depicted in table 2.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Coding of responses\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTheme\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSubtheme\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 318px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOpen Codes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBarriers to Delivering Early Habilitation in Indian NICUs\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eFragmented Professional Identity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 318px;\"\u003e\n \u003cp\u003eRole seen primarily as respiratory care; Limited involvement in care planning; Under-recognition of developmental contributions; Gradual acceptance through outcomes; Scope not well understood by team\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eInstitutional and Operational Restrictions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 318px;\"\u003e\n \u003cp\u003eNICU schedules dominated by medical routines; Insufficient time for habilitation; No formal protocols; No documentation channels; Practice is different in different hospitals\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eCurriculum Gaps and Training Shortfalls\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 318px;\"\u003e\n \u003cp\u003eLimited NICU exposure during training; Learning through observation and workshops; Initial reluctance with fragile infants; Requirement for structured mentorship; On-the-job skill building\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eMaternal Disempowerment and Cultural Hesitancy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 318px;\"\u003e\n \u003cp\u003eFear of harming the baby; Cultural beliefs limit early touch; NICU environment overwhelms families; Misunderstanding about wires and equipment; Need for repeated emotional orientation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePractice-Informed Strategies for Enhancing Developmental Care\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eEmpowering Mothers through Graduated Involvement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 318px;\"\u003e\n \u003cp\u003eStepwise inclusion based on readiness; Observation-first approach; Building confidence through guided touch; Framing mother as the baby\u0026rsquo;s co-therapist; Respecting emotional pace of families\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eCulture-Compatible Interventions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 318px;\"\u003e\n \u003cp\u003eUsing familiar caregiving terms; Avoiding clinical jargon; Promoting accepted techniques (Yakson touch, singing); Aligning with family comfort zones; Blending therapy into parenting\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eVisual and Simplified Protocols\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 318px;\"\u003e\n \u003cp\u003eEasy-to-use visual charts; Pictorial guidance for low-literacy caregivers; Gestational age-based checklists; Tools usable without extra training; Protocols that support team consistency\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eCurriculum and Policy Reforms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 318px;\"\u003e\n \u003cp\u003eIntegration of habilitation into syllabus; Need for India-specific protocols; Structured NICU certification; Addressing gaps in senior-level training; National guidance for standardization\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eBuilding Respectful Partnerships with NICU Teams\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 318px;\"\u003e\n \u003cp\u003eGaining trust through outcomes; Demonstrating contribution to discharge readiness; Using case sharing and education sessions; Positioning therapy as collaborative; Inclusion through team rapport\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 1: Barriers to Delivering Early Habilitation in Indian NICUs\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSubtheme 1.1: Fragmented Role Identity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTherapists reported that their professional identity in the NICU was often reduced to respiratory care. Even with skills in positioning, sensory stimulation, feeding assistance, and neurodevelopmental evaluation, they were usually summoned only to suction or perform chest physiotherapy. The constrained definition of their role restricted interdisciplinary interaction and kept them out of significant decision-making regarding developmental care.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;In most NICUs, the first thing that comes to people\u0026apos;s minds when they hear \u0026apos;physiotherapist\u0026apos; is that we are only here to clear secretions or do suction. That\u0026apos;s not all we do, though. We are involved in positioning, sensory readiness, and early developmental transitions support, but these services aren\u0026apos;t always recognized or requested.\u0026quot;\u003c/em\u003e - Therapist\u003c/p\u003e\n\u003cp\u003eTherapists indicated that they did not perceive this as intentional exclusion, but rather as a consequence of a lack of knowledge about the complete range of physiotherapy in NICU environments. They felt that realistic inclusion could only be realized through demonstrated performance and by presenting themselves as complementary to medical objectives, rather than disrupting them.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;First, they would tell us not to do therapy. But as time passed, when they could see babies calm down, feed well, and get discharged sooner, they began asking us to do more on a regular basis.\u0026quot;\u0026nbsp;\u003c/em\u003e- Therapist\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSubtheme 1.2: Institutional Gaps and Operational Constraints\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTherapists emphasized noteworthy heterogeneity between hospitals in terms of habilitation practice. Certain NICUs provided more room for variation in developmental care, whereas others were rigidly timetabled around medical and nursing procedures, with little scope left for sensory or postural interventions. Time, space, and staff were identified as central constraints on the delivery of stimulation protocols.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;The unit is constantly full of feedings, rounds, procedures, etc., there\u0026apos;s scarcely a minute when you can insert habilitation. You must wait and catch your moment in between.\u0026quot;\u0026nbsp;\u003c/em\u003e- Therapist\u003c/p\u003e\n\u003cp\u003eTherapists most frequently worked without systematic protocols to direct their activity, relying on their own clinical judgment or their senior colleagues\u0026apos; recommendations. This variability produced unequal care across units and among therapists. Furthermore, developmental care was rarely documented formally, which reduced its visibility and continuity.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;There is no documentation format for what we do. Even if we spend time positioning, giving stimulation, it\u0026rsquo;s not recorded. It feels like it never happened\u003c/em\u003e.\u0026rdquo; \u0026ndash; Therapist\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTherapists viewed lack of structural support as a major constraint to standard habilitation delivery, particularly in high-volumes or government hospitals.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSubtheme 1.3: Curriculum Gaps and Training Shortfalls\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMembers indicated that habilitation was not a strong emphasis in their academic programs. Although a few had some exposure within NICU rotations, it was typically observational and did not involve structured instruction. The shift from learning in the classroom to NICU care was a sudden one, and most therapists reported feeling unprepared to manage vulnerable neonates, especially high-risk or ventilated ones.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;PG time, we posted NICU for 2 weeks. We did a lot of following behind others though. I was afraid to even touch a preterm infant because I had no idea what was safe and what wasn\u0026apos;t.\u0026quot;\u0026nbsp;\u003c/em\u003e\u0026ndash; Therapist\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis restricted exposure frequently resulted in initial reluctance, particularly in environments that lacked an elder therapist to supervise or guide. Therapists were keen to point out that this was not an issue of failing educators, but a deficiency in how the curriculum translated into NICU realities. Competence was gained by many through workshops, observation, and practice, frequently acquiring experience \u0026quot;on the job\u0026quot; with support from nursing staff or other members of the team.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Everything I know about developmental care came after my degree. I had to attend workshops, observe seniors, and slowly practice on stable babies to get comfortable\u003c/em\u003e.\u0026rdquo; \u0026ndash; Therapist\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSubtheme 1.4: Maternal Disempowerment and Cultural Hesitancy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTherapists found that most mothers reported feeling emotionally removed or threatened when approaching the NICU. This was both influenced by the sterile clinical environment and by cultural prohibitions against early handling of delicate or premature infants. Some saw handling or stimulation as dangerous, particularly during the first month of life.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;One mother told me her elders said not to touch the baby for the first month. She would just sit in a chair nearby but never approach the incubator. It took repeated reassurance before she even held the baby\u0026rsquo;s hand.\u0026rdquo;\u003c/em\u003e \u0026ndash; Therapist\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe beeping machines, oxygen tubes, and clinical sterility further amplified maternal anxiety, leaving many unsure about their role in care. Without proper orientation, they often assumed that their presence was not needed \u0026mdash; or even harmful.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Mothers would say, \u0026lsquo;What if I do something wrong? What if I disturb the machine?\u0026rsquo; The NICU is overwhelming, and without someone to tell them, they believe they shouldn\u0026apos;t touch or engage\u0026quot;.\u003c/em\u003e \u0026ndash; Therapist\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTherapists stressed that consistent, empathetic orienting \u0026mdash; emotional and functional \u0026mdash; was essential for supporting mothers as they moved from being passive spectators to active participants in their baby\u0026apos;s development.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 2: Practice-Informed Strategies for Developmental Care\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTherapists discussed a rich array of methods they have developed and honed over years to facilitate early habilitation in neonatal intensive care units. These strategies did not come out of formal education or set protocols, but rather from experience, observation of culture, and affective sensitivity to the requirements of infants and caregivers. Their practices illustrate how, even in resource-scarce systems, physiotherapists are innovatively working to provide safe, developmentally friendly care through authentic collaboration with families. Four subthemes describe these strategies: Empowering Mothers through Graduated Involvement, Culture-Compatible Interventions, Visual and Simplified Protocols, and Curriculum and Policy Reforms.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSubtheme 2.1: Progressive Parental Involvement Based on Emotional Readiness\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRather than giving instructions or tasks immediately, therapists adopted a layered, emotionally attuned approach to involving mothers. They began with non-threatening forms of interaction such as silent observation or gentle presence and progressed to touch, voice, and stimulation only when the mother expressed readiness.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We never start with, \u0026lsquo;Do this or do that.\u0026rsquo; First, we ask them to just stand by the incubator and observe. Once they feel comfortable, we suggest they speak softly or make eye contact. After that, we move to holding the hand, then touching the chest or back. It\u0026rsquo;s a slow, respectful process.\u0026rdquo;\u003c/em\u003e \u0026ndash; Therapist\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis progression allowed the mother to rebuild confidence and bond with the baby without fear. Therapists found that emotional readiness was the foundation of effective habilitation, even more than technical skill.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;It\u0026rsquo;s not just about the baby\u0026rsquo;s stimulation \u0026mdash; it\u0026rsquo;s about making the mother believe, \u0026lsquo;I can do this.\u0026rsquo; That shift doesn\u0026rsquo;t happen overnight. It builds day by day, with small victories.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u0026ndash; Therapist\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTherapists introduced practical caregiving skills gradually, based on each mother\u0026rsquo;s emotional state and the infant\u0026rsquo;s medical condition. They taught techniques such as passive movement, hand containment, visual tracking, and safe handling positions, all while emphasizing emotional connection.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We teach mothers how to hold the baby, how to offer a finger for grasp, how to gently stroke the head or chest. It\u0026rsquo;s not just about doing it right, it\u0026rsquo;s about helping them believe they can do it.\u0026rdquo;\u003c/em\u003e \u0026ndash; Therapist\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCare was taken not to assign complex or invasive tasks. The focus was on building confidence and sensitivity, allowing mothers to understand both what to do and why it matters.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We never leave them alone on the first day. We stand with them, guide them. Once they see that the baby is okay, they relax. Then they start doing it on their own.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u0026ndash; Therapist \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSubtheme 2.2: Culturally Sensitive Adaptation of Stimulation Practices\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTherapists frequently modified their language and methods to fit cultural expectations. Instead of calling interventions \u0026quot;therapy,\u0026quot; they redefined them as intimate caregiving procedures like blessing, soothing, or bonding. This served to diminish fear and enabled families to bond with the baby in emotionally significant ways.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We don\u0026rsquo;t say, \u0026lsquo;We are doing visual stimulation.\u0026rsquo; We say, \u0026lsquo;Let the baby look at you, your face is the best thing for them to see.\u0026rsquo; That makes it feel like parenting, not a clinical task.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u0026ndash; Therapist\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSuch adaptations also allowed therapists to introduce stimulation earlier, even in families that initially resisted. Techniques like yakson touch or face-regard were easy to teach, safe for fragile infants, and culturally resonant.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Some families are afraid of structured therapy. But when we say, \u0026lsquo;This is like blessing the baby,\u0026rsquo; they\u0026rsquo;re more open. That way, the baby gets the care, and the family feels involved without fear.\u0026rdquo;\u003c/em\u003e \u0026ndash; Therapist\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThey also found that simpler, intuitive techniques such as Yakson touch were welcomed more easily than structured Western methods. For example, contrast cards and stimulation kits were often met with confusion, while gentle, familiar acts like stroking or humming were quickly embraced.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Sometimes yakson touch is accepted while contrast cards are not. When I show a mother how to stroke her baby\u0026rsquo;s head gently, she responds emotionally. But if I give her a card or tool, she freezes.\u0026rdquo;\u003c/em\u003e \u0026ndash; Therapist\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis sensitivity extended beyond technique to communication. Therapists frequently assessed what methods would emotionally connect with each family and adapted their approach accordingly.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We match intervention to cultural comfort. That way, it feels natural and not imposed. If they already sing to their babies at home, we encourage that here too.\u0026rdquo;\u003c/em\u003e - Therapist\u003c/p\u003e\n\u003cp\u003eEven auditory stimulation was reframed to match what caregivers already understood and did in daily life, allowing therapy to blend seamlessly with family culture.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Singing or talking is more accepted than structured sound therapy. We tell people, \u0026apos;Speak to your baby as you would at home,\u0026apos; and that is more effective than any formal teaching\u0026quot;.\u0026nbsp;\u003c/em\u003e\u0026ndash; Therapist\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThese culturally matched interventions not only promoted participation but also supported the family\u0026apos;s affective connection with the baby, making habilitation more maintainable after discharge.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSubtheme 2.3: Visual, Modular Protocols that Simplify Care for All\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTherapists identified the need for practical, accessible tools that simplify the delivery of early stimulation, especially in units where time is limited and documentation burdens are high. They strongly advocated for pictorial or chart-based protocols tailored by gestational age, allowing both families and staff to follow safe, developmentally appropriate interventions without the need for extensive verbal instruction. These tools would provid clear, concise guidance that could be used across shifts, helping maintain consistency even when therapists were unavailable.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We need a visual guide that says, for example \u0026rsquo;28 weeks: nesting and voice. 31 weeks: massage. 34 weeks: face regards\u0026rsquo; That way, even if the therapist isn\u0026apos;t around, others can safely follow.\u0026rdquo;\u003c/em\u003e \u0026ndash; Therapist\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eVisuals proved to be very helpful for mothers with lower literacy and higher stress, finding verbal instructions too overwhelming. A printed or pictorial checklist served as a reference that they could return to confidently.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;One mother kept asking if she could talk to her baby. Then we gave her a chart that said \u0026lsquo;28 weeks - voice stimulation: Yes.\u0026rsquo; She was so relieved. From that day, she would sing softly every time she visited.\u0026rdquo;\u003c/em\u003e \u0026ndash; Therapist\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThey also noted that complex guidelines were rarely followed in practice due to time pressure. A visual reference that required minimal reading was far more usable during clinical care or caregiver counseling.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We don\u0026rsquo;t have time to read 20 pages. A quick, visual guide that shows what is allowed at each week is more useful during rounds or parent counseling.\u0026rdquo;\u003c/em\u003e \u0026ndash; Therapist\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTherapists found such tools particularly useful for mothers who were either illiterate or highly anxious. These visuals reassured families and gave them stepwise guidance they could follow at their own pace.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Mothers can follow pictures better than text. Sometimes they\u0026rsquo;re too scared or emotional to remember what we say. But when they see a visual guide, they relax and follow it step by step.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u0026ndash; Therapist\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn busy units with rotating staff, therapists saw such tools as essential for continuity of care and standardization of practice.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We need tools that don\u0026rsquo;t need extra training to use. Something simple enough that any caregiver or new staff member can use it without second-guessing.\u0026rdquo;\u003c/em\u003e \u0026ndash; Therapist\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThese protocols were seen not just as teaching aids, but as vital supports for equity \u0026mdash; allowing habilitation to reach more babies, even when therapists weren\u0026rsquo;t present every day.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.4 Curriculum and Policy Reforms\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhile therapists have innovated their own solutions in practice, they strongly voiced the need for formal integration of habilitation into training and policy. Many reported that habilitation was absent or minimally addressed in their academic programs. This led to confusion among graduates, who often assumed physiotherapy in NICU was limited to respiratory work.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Put habilitation in the syllabus, not just chest PT. Most students come out not knowing that we have a role beyond suction.\u0026rdquo;\u003c/em\u003e \u0026ndash; Therapist\u003c/p\u003e\n\u003cp\u003eEven senior therapists, due to a lack of structured exposure or continuing education, expressed uncertainty at times in applying habilitative strategies consistently.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Even our seniors feel lost sometimes. If there was a national guideline or a core module, then everyone would be speaking the same language.\u0026quot;\u0026nbsp;\u003c/em\u003e\u0026ndash; Therapist\u003c/p\u003e\n\u003cp\u003eThe participants underlined the necessity of designing national or regional protocols based on the Indian context. These would consider cultural diversity, staffing shortages, and variability in hospital infrastructure.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We need India-specific protocols. What works abroad might not always work here, especially when families, beliefs, and systems are so different.\u0026rdquo;\u003c/em\u003e \u0026ndash; Therapist\u003c/p\u003e\n\u003cp\u003eTherapists also called for hands-on, certified training to bridge the gap between theory and NICU-specific care. Many had relied on workshops or senior mentorship to gain practical skills, but they hoped future therapists would have structured pathways to learn safely and confidently.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We need more hands-on certification and exposure. Theory alone doesn\u0026rsquo;t prepare you to hold a baby on a ventilator or teach a scared mother how to connect.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u0026ndash; Therapist\u003c/p\u003e\n\u003cp\u003eThese reflections suggest a strong readiness within the profession to expand its role, provided institutional and policy-level support is available.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSubtheme 2.5: Building Respectful Partnerships with NICU Teams\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTherapists described how trust with medical and nursing staff developed gradually through mutual respect and proof of benefit. Rather than asserting their presence, therapists focused on supporting unit goals and showing how habilitation could improve stability, feeding, and discharge readiness.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Initially, they were not sure about us being there. But when they saw that babies settled better, started feeding better after therapy, they began calling us on their own. That\u0026rsquo;s how collaboration grows \u0026mdash; through outcomes, not arguments.\u0026rdquo;\u003c/em\u003e \u0026ndash; Therapist\u003c/p\u003e\n\u003cp\u003eTherapists also used staff meetings, case updates, and informal presentations to increase visibility and encourage interdisciplinary conversation. These efforts slowly shifted perceptions and helped integrate habilitation into standard care.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We presented what we do in habilitation. Those changed things. The staff realized we\u0026rsquo;re not interrupting, we\u0026rsquo;re contributing.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u0026ndash; Therapist\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e The qualitative research examined the experiences of neonatal physiotherapists providing habilitation care in Indian NICUs. Using unstructured interviews with therapists in various geographical regions, the research both explored the systemic impediments that confront them and how they go about incorporating developmental care into standard NICU practice. Findings indicate that although physiotherapists frequently face difficulties pertaining to role identity, institutional support, and formal training, they are equally capable of expressing adaptability, emotional intelligence, and cultural responsiveness in facilitating family-centred habilitation.\u003c/p\u003e\u003cp\u003eOne of the central outcomes of this research was the continuity of a disgregated professional identity for physiotherapists working in the neonatal environment. The participants regularly indicated that their work was generally thought of as being mostly in the domain of chest physiotherapy, with little acknowledgement of developmental support, positioning, sensory stimulation, and parent training. This narrow perception not only restricted referrals for habilitation but also interfered with interdisciplinary practice. These results resonate with previous reports from high- and low-resource contexts alike, wherein allied health professionals' involvement in NICU care is narrowly defined unless specifically designed into models of care(\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eHere, it is significant that physiotherapists in this study did not explain this exclusion in terms of active medical team resistance but instead as lack of awareness and systemic design. Several highlighted that trust and inclusion increased when medical personnel witnessed the calming or functional effects of habilitation. This speaks to the requirement for role clarification among NICU teams, as well as to physiotherapy being not an \"add-on\" but an integral part of developmental care from admission to discharge (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAnother key barrier was that there were no standardised habilitation protocols in place among NICUs. All these stakeholders explained how time pressures, dense patient loads, and dense schedules allowed no space for developmental interventions. (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eThis was further exacerbated by the absence of documentation formats to use in recording habilitative care, lack of clinical records and frequently not rewarding them in performance measures. The heterogeneity in the conceptualization and provision of habilitation across institutions from ad hoc practices to formal programs is consistent with other LMICs, where resource constraints and top-down decision-making tend to exclude non-medical professionals (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe fact that many therapists had been working in the lack of guidance and developed their own de facto routines attests both to their resourcefulness and to a systemic failure to integrate habilitation into standard care pathways. Institutionalization of habilitation in optimized, evidence-based, gestational-age-specific protocols could enable standardization while empowering not only physiotherapists but nurses and families too(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOne of the persistent problems was insufficient neonatal habilitation exposure in physiotherapy education. The majority of respondents stated that undergraduate or postgraduate training did not prepare them with the clinical competence and manual skills required in the NICU setting. A number expressed anxiety or discomfort during first-time clinical placements, particularly while managing fragile, ventilated, or medically unstable neonates. Many therapists reported to learn neonatal care primarily from informal peer learning or continuous education workshops(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Such learning, while valuable, comes at a steep learning curve, particularly in the absence of formalized mentoring or competency-based assessment.\u003c/p\u003e\u003cp\u003eDespite this lack, a commitment to learning and innovation was demonstrated by the majority of therapists using peer observation, self-study, and collaborative work with nurses to develop their practice. This highlights the urgent need for curriculum updating with formal NICU postings, competency-based certification, and interdisciplinary simulation-based education. Incorporating habilitation-specific modules within postgraduate physiotherapy courses may also normalize early exposure to NICU dynamics and reduce practitioner anxiety(\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Such comprehensive preparation can enhance confidence, competency, and job satisfaction among neonatal physiotherapists while improving the quality of care(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eMothers' emotional state and their beliefs were found to be the key determinants of habilitation uptake. Mothers were often said to be reluctant to touch or engage with their babies, particularly when preterm or medically fragile. Culture, for example, delayed contact for the first month and fear of the equipment helped to account for this distance. These findings are consistent with research highlighting parent preparation and orientation in NICUs, especially in resource-limited and heterogeneous contexts(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eTherapists in this research reacted with a graduated, affectively responsive strategy of parent involvement. They started with presence and observation and progressed to gentle touch and finally active engagement. The step-by-step participation fostered maternal confidence and facilitated bonding. The re-labelling of therapy in culturally recognizable terms (e.g., \"blessing touch\") was especially useful in obtaining parents' trust. These practices are in harmony with global standards for family-centered care, where parents' emotional preparation is given more importance compared to the completion of work(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eLacking formal systems, therapists developed their own pragmatic aids to aid developmental care. Most promoted reduced visual protocol e.g., gestational age-based charts that might assist professionals and parents alike. Visual aids were particularly valuable in staff-intensive units with frequent turnover or where caregiver literacy was an issue. The focus on usability, flexibility, and cultural compatibility is reflective of a grounded awareness of actual NICU limitations.(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e Participants also explained modifying standard procedures to suit family taste, opting for gentle, familiar actions such as Yakson touch, singing, or face regard rather than untried interventions such as contrast cards or protocolized auditory approaches. Such adaptive practice shows the strength infrequently reported in neonatal literature: the therapist's cultural intuition and emotional intelligence. Although such practices are not documented, they are potentially key to the effectiveness and durability of habilitation in Indian settings.(\u003cspan additionalcitationids=\"CR38\" citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e Therapists eagerly articulated a need for official acknowledgment of habilitation in national practice and training guidelines. Most called for habilitation to be included in postgraduate curricula, developing India-specific protocols, and offering formal certifications for neonatal care. Notably, therapists cited that even experienced clinicians felt unprepared, which highlighted a systemic intergenerational training gap.\u003c/p\u003e\u003cp\u003eThis discovery reverberates with others in other LMICs, in which segmented systems, variability in resources, and lack of interprofessional education have hindered universal implementation of early intervention(\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). For India, professionalization of habilitation would improve care as well as confer legitimacy on the therapist's role as an esteemed member of the NICU team.\u003c/p\u003e\u003cp\u003eThis process of earning interprofessional trust through demonstrated clinical benefit such as improved feeding or discharge readiness, reflects the bottom-up advocacy required in hierarchical NICU environments.(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e) Therapists in this study did not seek recognition through assertion but through collaborative outcomes, which gradually reshaped their standing within the medical team. Such relational strategies underline the importance of visibility, informal advocacy, and shared clinical goals in embedding habilitation into routine NICU workflows.\u003c/p\u003e\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\u003ch2\u003eStrengths and Limitations\u003c/h2\u003e\u003cp\u003eOne of the real strengths of this study is the focus on the lived experience of neonatal physiotherapists throughout India, giving a grounded, context-sensitive image of how habilitation is being put into practice in varying institutional and cultural contexts.\u003c/p\u003e\u003cp\u003eYet, the research does have its own limitations. The evidence comes only from physiotherapists' views and did not incorporate contributions from neonatologists, nurses, or families. Triangulation between disciplines might have provided more richness to the understanding. Besides that, the lack of structure during the interviews, although opening up rich information, might have resulted in variable depth in participants.\u003c/p\u003e\u003cdiv id=\"Sec25\" class=\"Section3\"\u003e\u003ch2\u003eImplications for Practice and Policy\u003c/h2\u003e\u003cp\u003eThe results have a number of implications. First, they emphasize that habilitation needs to be formally incorporated into physiotherapy education through competency-based models and NICU experience during internships. Second, policy and documentation systems would have to be reconfigured so that stimulation, positioning, and training parents became routine, not optional, parts of NICU treatment. Third, interdisciplinary workshop sessions have the potential to better acquaint therapists, neonatologists, and nurses with each other \u0026mdash; silos are dismantled, and care coordination is facilitated.\u003c/p\u003e\u003cp\u003eLastly, parent engagement needs to be reimagined as a graduated, emotionally safe process, rather than an orientation.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec26\" class=\"Section3\"\u003e\u003ch2\u003eFuture Directions\u003c/h2\u003e\u003cp\u003eFurther studies are suggested to develop and validate India-specific habilitation protocols for gestational age, medical stability, and caregiver readiness. Mixed-methods studies across neonatologists, nurses, and parents will give a more nuanced view on implementation issues. Intervention studies can also pilot the efficacy of visual stimulation charts, caregiver training modules, or interdisciplinary rounds with therapists in outcome improvement.\u003c/p\u003e\u003cp\u003eThere is also scope for policy-making. Guidelines at the national level, like those of the Indian Academy of Pediatrics or National Health Mission might make room for habilitation as an identified field of care. With formal training and support from institutions, activity that is currently performed on an ad-hoc basis by therapists can become part of a more regular, uniform system of care.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study highlights the real-world challenges and adaptive practices of physiotherapists delivering early habilitation in Indian NICUs. Despite systemic constraints, such as limited role clarity, absence of structured protocols, inadequate training, and cultural hesitancy among caregivers, therapists demonstrated strong professional agency through context-sensitive strategies, including graduated parental engagement, culture-aligned interventions, and simplified visual tools. These insights affirm the critical role of physiotherapists not only as clinicians but also as innovators and collaborators in neonatal care. To translate this practice-informed wisdom into sustainable impact, there is a pressing need to integrate habilitation into physiotherapy curricula, institutional protocols, and national neonatal health policy, ensuring equitable, developmentally supportive care for every infant.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of interest:\u0026nbsp;\u003c/strong\u003eAuthors declare no conflict of interest to disclose\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in accordance with Helsinki\u0026rsquo;s declaration. The study was approved by Institutional Ethics Committee of SRM Medical College Hospital and Research and Centre, Kattankulathur.( Reg. No: ECR/8972/INST/TN/2013/RR-19)\u003c/p\u003e\n\u003cp\u003eConfidentiality was strictly maintained, with all data anonymized before analysis. Informed consent was obtained from all participants before participation, and they had the right to withdraw from the study at any stage without consequences.\u003c/p\u003e\n\u003cp\u003eParticipants were recruited to the study following the voluntary willingness to participate.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e All the participants gave consent to publish\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding statements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe project is funded by Researcher Starter Grant \u0026ndash; \u0026ldquo;Growth \u0026amp; Advancement Towards Excellence\u0026rdquo;, SRM Institute of Science and Technology, Kattankulathur, India\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the PI on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuthors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAJR: Conceptualization, conducting interviews, transcribing and translations, coding of responses and theme identification and Interpreting results\u003c/p\u003e\n\u003cp\u003eKV: Conceptualization, coding of responses, drafting results, proof corrections, drafting manuscript\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the revision of the protocol and read and approved the final manuscript\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e Authors would like to extend heartfelt thanks to all the participants for spending their valuable time for the interview sessions\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis manuscript is based on a distinct reanalysis of a qualitative dataset already used for a separate publication. The present paper explores a different thematic focus (barriers and practice-informed solutions), while the previously submitted paper focuses on system-level practice patterns. There is no textual or conceptual overlap between the two manuscripts, and the reuse of data is transparently declared in the Methods section.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLawn JE, Davidge R, Paul VK, Xylander S von, de Graft Johnson J, Costello A, et al. Born Too Soon: Care for the preterm baby. Reproductive Health. 2013 Nov 15;10(1):S5. \u003c/li\u003e\n\u003cli\u003ePhilip T, Thomas P. A prospective study on neonatal outcome of preterm births and associated factors in a South Indian tertiary hospital setting. International Journal of Reproduction, Contraception, Obstetrics and Gynecology. 2018 Nov 26;7(12):4827\u0026ndash;32. \u003c/li\u003e\n\u003cli\u003eJain S, Patel P, Pandya N, Dave D, Deshpande T, Jain S, et al. 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Available from: https://publications.aap.org/pediatrics/article/132/4/e1073/64821/Early-Intervention-IDEA-Part-C-Services-and-the?autologincheck=redirected\u003c/li\u003e\n\u003cli\u003eCulture and Development in Children and Youth - ClinicalKey [Internet]. [cited 2025 Jul 28]. Available from: https://www.clinicalkey.com/#!/content/playContent/1-s2.0-S1056499310000660?returnurl=https:%2F%2Flinkinghub.elsevier.com%2Fretrieve%2Fpii%2FS1056499310000660%3Fshowall%3Dtrue\u0026amp;referrer=\u003c/li\u003e\n\u003cli\u003eCulturally Relevant Family Therapy Practice with Parents of Children and Adolescents - Tania Roy, A. Thirumoorthy, R. Parthasarathy, 2017 [Internet]. [cited 2025 Jul 28]. Available from: https://journals.sagepub.com/doi/10.4103/0253-7176.203122\u003c/li\u003e\n\u003cli\u003eFull article: Knowledge and training in paediatric medical traumatic stress and trauma-informed care among emergency medical professionals in low- and middle-income countries [Internet]. [cited 2025 Jul 28]. Available from: https://www.tandfonline.com/doi/full/10.1080/20008198.2018.1468703\u003c/li\u003e\n\u003cli\u003eExperiences of Early and Enhanced Clinical Exposure for Postgraduate Neonatal Nursing Students at the University of Zambia, School of Nursing Sciences: Lessons and Implications for the Future [Internet]. [cited 2025 Jul 28]. Available from: https://www.scirp.org/journal/paperinformation?paperid=125491\u003c/li\u003e\n\u003cli\u003eBurrows A. Developmental Care in the NICU: Best Practices for Preterm Infants, Expectations of Healthcare Providers, and Impact on Parents and Families. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"India, NICU, Therapist, Neonatal Care, Stimulation, Preterm Infant","lastPublishedDoi":"10.21203/rs.3.rs-7360302/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7360302/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePreterm infants are at high risk for neurodevelopmental delays, and hence habilitation in the Neonatal Intensive Care Unit (NICU) in a timely manner is a priority. In India, however, standardized habilitation pathways are underdeveloped, and the role of neonatal therapists, particularly physiotherapists is discrepant and ill-defined. There is scarce literature from the ground-level perception of therapists on providing structured development care, especially in resource-limited NICU settings. This study aims to explore therapist-informed barriers and context-specific solutions affecting the provision of habilitation services for preterm infants in Indian NICUs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis qualitative study follows a constructivist paradigm. In-depth semi-structured interviews were conducted with 16 NICU physiotherapists from diverse backgrounds across India. Thematic analysis was performed with Braun and Clarke's six-phase reflexive framework. Codes were inductively established and themes iteratively refined.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe two overall themes were: (1) Practice-Informed Barriers, including fractured professional identity, institutional bounds, poor training, and maternal disempowerment; and (2) Therapist-Driven Solutions, consisting of mother-inclusive graduated engagement, culture-congruent approaches, streamlined gestational protocols, and urgent appeals for curriculum and policy change. The therapists portrayed the necessity for habilitation practices to be salient, collaborative, and consistent with Indian contextual realities.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDespite systemic constraints, Indian NICU physiotherapists reflect adaptive, culturally appropriate approaches to facilitate early habilitation. Overcoming structural barriers and institutionalization of therapist roles in interdisciplinary NICU teams are essential steps toward equitable and developmentally beneficial care for preterm infants. These findings provide a foundational input into the development of India-specific early stimulation protocols based on practice realities.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration:\u003c/strong\u003e The trial has been registered under Clinical Trials Registry—India (CTRI/2025/02/081483) on February 28 2025.\u003c/p\u003e","manuscriptTitle":"Practice-Informed Barriers and Contextual Solutions in Neonatal Habilitation Across Indian Neonatal Intensive Care Units: A Qualitative Exploration of Therapists’ Perspectives ","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-22 13:20:12","doi":"10.21203/rs.3.rs-7360302/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-01T15:45:12+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-25T16:19:32+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-22T09:34:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"208396432462760461098506012674999274387","date":"2025-11-13T16:41:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"3284495152398796438944134611887472982","date":"2025-11-12T11:07:13+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-03T08:26:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"166895951033866708640071027858760942119","date":"2025-09-17T06:54:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"298233120179274711435083600543979920114","date":"2025-09-15T05:32:28+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-12T20:12:14+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-24T18:50:26+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-23T08:42:38+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-23T08:41:37+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2025-08-13T03:08:19+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8792ebca-9578-4efc-be9f-194366185c26","owner":[],"postedDate":"September 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-02T16:00:45+00:00","versionOfRecord":{"articleIdentity":"rs-7360302","link":"https://doi.org/10.1186/s12887-026-06533-y","journal":{"identity":"bmc-pediatrics","isVorOnly":false,"title":"BMC Pediatrics"},"publishedOn":"2026-01-31 15:58:11","publishedOnDateReadable":"January 31st, 2026"},"versionCreatedAt":"2025-09-22 13:20:12","video":"","vorDoi":"10.1186/s12887-026-06533-y","vorDoiUrl":"https://doi.org/10.1186/s12887-026-06533-y","workflowStages":[]},"version":"v1","identity":"rs-7360302","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7360302","identity":"rs-7360302","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}