Situational Analysis of the Health and Wellness Centers (HWCs) to Provide Palliative Care in Telangana, South India

Situational Analysis of the Health and Wellness Centers (HWCs) to Provide Palliative Care in Telangana, South India | 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 Situational Analysis of the Health and Wellness Centers (HWCs) to Provide Palliative Care in Telangana, South India Mousami Kirtania, Ajitha Katta This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5593288/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 04 Nov, 2025 Read the published version in Discover Public Health → Version 1 posted 6 You are reading this latest preprint version Abstract Background Palliative Care (PC) aims to provide holistic care encompassing physical, psycho-social, and spiritual well-being to improve the quality of life of the patients and their caregivers. In India, PC is practiced in a scattered manner contributing to myths, and misunderstanding. Thus, it is necessary to integrate PC into primary care through the Health and Wellness Centers (HWCs). For appropriate treatment and referrals, it is required that the Health Care Providers (HCPs) have adequate knowledge. Hence, this study aims to identify the resources available in the selected HWCs in Hyderabad and Ranga Reddy districts in Telangana. It also seeks to evaluate the knowledge and barriers of the HCPs. Materials and Method A cross-sectional observational study was performed in the randomly selected 30 HWCs in both districts. A checklist was used to assess the resources available to provide PC. Qualitative In-depth Interviews (IDIs) and Focus Group Discussions (FGDs) were executed with the HCPs at the centers. Atlas.ti software was used to analyze the IDIs and FGDs. Results The lack of staff nurses, missing essential drug kits, and absence of home-based PC screening were identified. The respondents were unaware of PC as they did not receive any training. The interviews revealed that the Mid-level Health Providers (MLHPs) had a higher level of knowledge than the other staff. Conclusion The HWCs are not yet well-equipped to provide PC at the centers and homes. New and modified training and sensitization programs must be implemented at the central and state levels. Health and Wellness Centers India Palliative Care Primary Health Care Universal Health Coverage Figures Figure 1 Figure 2 Figure 3 Key Message WHO has recommended integrating Palliative Care into Primary Health Care as one of its components to improve Universal Health Coverage. National Health Mission (NHM) provided operational guidelines to incorporate palliative care services at the HWCs, Sub-centers, and Primary Health Care centers (PHCs). The guidelines contain a checklist (used in this study) of essential resources to be present at various levels. INTRODUCTION Palliative Care (PC) is known to improve the overall quality of life of patients and their families through a holistic approach [ 1 ]. It is emerging as a medical specialty because the number of persons with long-term illness is on the rise due to longevity and morbidities [ 2 ]. The care resonates with the Primary Health Care components for achieving Universal Health Coverage, anytime, anywhere, and for anyone [ 3 ]. To attain this goal, it is necessary to integrate PC into public health care systems such as the Sub-Centers (SCs) and the Primary Health Centers (PHCs) which are transforming into Ayushman Bharat - Health and Wellness Centers (AB-HWCs) in India [ 4 ]. The operationalization of the HWCs requires several inputs that include expanding human resources, partnership for knowledge implementation, funding, medical supplies and equipment, and continuum care with appropriate referrals [ 5 ]. Since knowledge and skill are utmost necessary to ensure quality services at HWCs, an initiative called ‘SASHAKT - Systematic Assessment of Health Care Providers Knowledge and Training’ was launched by the National Health System and Resource Centre (NHSRC) in 2021 [ 6 ]. Through SASHAKT, Telangana integrates palliative care into primary healthcare, making it more patient-centric and accessible. The initiative ensures that those suffering from chronic, debilitating, or terminal illnesses receive compassionate, home-based, and holistic care, improving their quality of life. Although less than India’s 1.2 billion population has access to palliative care, most symptom management and psychosocial support can be done inexpensively, provided the health workers are trained effectively [ 7 ]. Capacity building at the primary healthcare level is essential to provide continuum care. At the primary level, palliative care is usually provided by general physicians, staff nurses, and grassroots workers. Allied health professionals such as psychologists, physiotherapists, and pharmacists might fit the desirable criteria of capacity building for HWCs [ 8 ]. At the HWC-SC level, a home-based palliative care team should consist of a Community Health Officer (CHO), a multi-purpose worker (MPW), an ASHA, and a volunteer. Drugs and consumables such as catheters and air cushions should be available, whereas oral morphine can be dispensed from the HWC-PHC [ 8 ]. However, for a comprehensive and community-based approach, the social workers require formal training so that PC services can reach remote areas without any underlying myths and misconceptions [ 9 ]. The community-based approach is also helpful for providing home-based PC through Primary Health Care settings [ 10 ]. According to the available evidence, most people prefer to be at home in the last phase of their lives which increases the demand for PC at home [ 11 ]. Home-based PC offers a twin advantage where it reduces the burden on the healthcare system by avoiding overcrowding and lessening the out-of-pocket expenditure for the patients and their families [ 12 ]. The barriers to providing PC services have been recognized at various levels. The first and foremost is at the policy and system level, followed by the organizational level, the healthcare provider’s level, and the patient and family level. A research-driven strategy can address all the barriers [ 13 ]. By conducting targeted research, health professionals and policymakers can systematically address barriers to palliative care and implement evidence-based strategies that improve patient outcomes and service delivery. As per WHO recommendations, if palliative care has to integrate with the primary healthcare system, the HECs at the primary level must be ready to provide palliative care. In Telangana, palliative care is available only at the district level. Hence, this study aims to perform a situational analysis of the SC-HWCs and compare the results between two selected districts. A situational analysis of the HWCs was conducted to assess the current state of services, identify gaps, and improve patient care. By conducting a situational analysis, HWCs can refine their approach to palliative care, ensuring that services are patient-centered, effective, and sustainable. Study Objectives The purpose of the study was threefold; To identify the essential resources and existing palliative care services provided at the selected Sub-center-HWCs. To evaluate the level of PC knowledge of the healthcare providers and the social workers posted at the HWCs. To identify the barriers and pitfalls related to the provision of PC at the community level. MATERIALS AND METHODS Research Ethics The study was performed according to the Helsinki Declaration and approved by the Institutional Ethics Committee (IEC), University of Hyderabad (UH/IEC/2022/360). A written informed consent was obtained from all the participants willing to participate in the qualitative survey. To preserve anonymity, personal details, such as sex, age, and designation were not collected. Permission to collect data was obtained from the respected district officials at various levels. Study Design A cross-sectional observational study design was used. A convenience sampling was used to select the two districts, namely Hyderabad and Rangareddy. A self-administrative checklist was used to assess the basic resources available in the centers. An exploratory study design was adopted for qualitative IDIs and FGDs. Sampling Process Out of 33 districts in Telangana, two major districts namely Hyderabad and Ranga Reddy were selected on convenience due to the time constraint of the study. A total of 30 HWCs were selected randomly by using the lottery method from both districts (Fig. 1 Study Design ). Study Setting and Participants The survey and interviews took place at the selected HWCs. The HWCs are the facilities at the grassroots level and act as first contact to the community (Fig. 1 ). So, 30 HWCs were selected from the state’s two districts to assess their resources and palliative care services. The interviews were conducted in a quiet room in the center to enhance the quality of the process. The study continued for 2 months from 1st August to 30th September 2023, each month dedicated to one district. The ASHAs, ANMs, Staff Nurses, and Medical Officers were selected conveniently for the interview and focus group discussion based on their availability at the centers. Hence, 22 participants from Ranga Reddy and 26 participants from Hyderabad districts respectively, were available during the study period. From the total of 48 participants, 20 were recruited for IDI and 28 were distributed equally for four FGD groups. Statistical Methods Demographic details of the participants and the mean scores of the HWCs were described using frequency distribution in SPSS v 29. The qualitative data analysis was done in the atlas. ti version 7.1 software. A thematic approach was used to derive the common codes and themes [ 14 ]. Procedures A total of 30 HWCs, 15 from each district were selected using simple random sampling. Each center was visited by the research team with the checklist. The contents of the checklist were included by referring to the ‘Operational Guidelines for Palliative Care at HWC’ provided by NHSRC [ 15 ]. The checklist containing 40 items was analyzed using Dichotomous scoring with ‘Yes’ or ‘No’ responses. Marking ‘Yes’ denoted that the resource is available at the center during the assessment and vice versa. The dichotomous scoring of all the 30 HWCs was combined and converted into percentages to give an idea of the overall proportion of the available resources. Qualitative IDIs and FGDs were organized with the staff working at the selected HWCs to assess their level of knowledge about PC. A semi-structured questionnaire was used to ask basic questions such as, ‘What is Palliative Care?’, ‘Who Provides PC?’, ‘When is PC preferred for patients?’, etc., The IDIs were conducted in a quiet, comfortable setting. Interviews were recorded with permission and transcribed for analysis. The IDIs were terminated at the point of saturation. FGDs were arranged at the HWCs with a quiet room when the flow of the patients was low. Apart from IEC, we obtained permission from the state program officer and the district medical health officers to conduct the survey. The FGDs and IDIs were highly effective in assessing barriers to palliative care by allowing participants to share personal experiences and express their views on system-level challenges. By capturing individual and group perspectives, these methods uncovered various barriers, from access issues to provider concerns. The principal investigator and a moderator stimulated the process. An externally trained moderator (Master in Public Health) was hired, skilled in the local language and familiar with the research topic. The moderator played a role in the language translation process and transcribing the interviews. RESULTS The comparison of the human resources available in the selected SC-HWCs of both districts is shown below (Table 1 ). According to the NHSRC guidelines, the recommended human resources to be present at the HWCs are JAS/VHSNC, ASHA, ANM, Staff Nurse, and a Medical Officer [ 16 ]. The rural HWCs had Mid-level Health Providers (MLHPs) but no staff nurses available. JAS/VHSNC positions were found empty in both rural and urban HWCs. Whereas, the number of ASHAs/ANMs and Medical Officers were adequately present in rural and urban HWCs. Table 1 Availability of Human Resources in HWCs SI No Human Resources SC-HWCs Total (N = 30) Rural (N = 15) Urban (N = 15) Available N Available N Available N Available (%) 1. Medical Officer (PHC/UPHC) 15 15 30 100 2. Staff Nurse 0 15 15 50 3. ANM 15 15 30 100 4. ASHA 15 15 30 100 5. JAS/VHSNC 1 5 6 20 The essential healthcare services that should be available in the HWCs to provide PC is shown (Table 2 ). Talking about PC services, PC OPD did not exist in any of the HWCs. However, Home-based PC was provided by 53.3% (8 out of 15) of the rural HWCs compared to none of the urban HWCs. Symptom management, emotional and psychological support, and nursing care were given. The patients mostly belonged to the category of cancer, cardiovascular diseases, and debilitating conditions, including old age frailty. Whereas the services like training and sensitization programs, and referral of the PC cases were found to be better in the urban HWCs. Three days of training, for once, for all the ASHAs and ANMs. While the MLHPs did a one-month course. The training module included basic concepts of palliative care and how to identify palliative care patients in the community and report them to HWCs. The rural and urban HWCs had all the essential equipment except the tongue depressors, only 3 (20%) and 9 (60%) of the rural and urban HWCs had a tongue depressor. Drugs like Paracetamol and Diclofenac were present at all the 30 (100%) HWCs. While the drug like Tramadol was present only at 26.6% (8 out of 30) of the total HWCs. The drugs for psychological symptom management were not present in any of the centers. On the other hand, Iron, vitamin, and Mineral supplements were available at all 30 (100%) HWCs. Supplies like Catheters, Urine bags, and Feeding tubes were present in a few centers only. Table 2 Availability of Essential Services to Provide Palliative Care SI No Service Provision SC-HWCs Total (N = 30) Rural (N = 15) Urban (N = 15) Available N (%) Available N (%) Available N (%) 1. Palliative Care Services a) PC OPD 0 0 0 b) Home-based Care 8 (53.3) 0 0 c) Training & Sensitization Programs 5 (33.3) 7 (46.6) 12 (40) d) Referral 8 (53.3) 10 (66.6) 18 (60) 2. Equipment a) Stethoscope 15 (100) 15 (100) 30 (100) b) B.P Apparatus 15 (100) 15 (100) 30 (100) c) Lightweight stool 15 (100) 12 (80) 27 (90) d) Torch 13 (86.6) 15 (100) 28 (93.3) e) Thermometer 9 (60) 15 (100) 24 (80) f) Tongue Depressors 3 (20) 9 (60) 12 (40) g) Glucometer 13 (86.6) 15 (100) 28 (93.3) 3. Drugs for Pain Control a) Paracetamol 15 (100) 15 (100) 30 (100) b) Ibuprofen 7 (46.6) 12 (80) 19 (63.3) c) Tramadol 3 (20) 5 (33.3) 8 (26.6) d) Diclofenac 15 (100) 15 (100) 30 (100) e) Dexamethasone 6 (40) 10 (66.6) 16 (53.3) 4. Supplies a) Dressing supplies & trays 15 (100) 15 (100) 30 (100) b) Cottons & Scissors 15 (100) 15 (100) 30 (100) c) Gloves 12 (80) 15 (100) 27 (90) d) Gauze Piece & Bandage 10 (66.6) 15 (100) 25 (83.3) e) Syringes & Needles 15 (100) 15 (100) 30 (100) f) Catheters & Urine Bags 2 (13.3) 2 (13.3) 4 (13.3) g) Feeding tubes 1 (6) 3 (20) 4 (13.3) 5. Psychological Symptom Management a) Lorazepam 0 0 0 b) Amitriptyline 0 0 0 6. Iron, Mineral & Vitamin Supplements 15 (100) 15 (100) 30 (100) The socio-demographic characteristics of the study participants included in the IDI and FGDs are given (Table 3 ). A total of 20 IDIs and 4 FGDs were conducted with the health care staff in the two districts to assess the level of PC knowledge and perceived barriers to providing PC, respectively. The FGDs included a total of 28 members, each group containing 7. The majority of the participants were aged 30 and above and were females. The number of ASHA and Staff Nurses exceeded the other positions. Meanwhile, the participant’s education level was either till 10th grade or graduation. Most of them were Hindu and married. Almost half of them had an experience of more than 3 years in their respective fields. Table 3 Socio-demographic Details of the Participants (HCPs) S.I No Characteristics Category Total N = 47 N (%) 1. Age 25–30 16 (34) 30–35 13 (27.6) 35 or more 18 (38.2) 2. Gender Male 13 (27.6) Female 34 (72.3) 3. Designation Medical Officer 9 (19.1) Staff Nurse 12 (25.5) ASHA 15 (32) ANM 8 (17) MLHP 3 (6.3) 4. Education 8th − 10th grade 22 (46.8) 10th − 12th grade 4 (8.5) Graduate or more 21 (44.6) 5. Religion Hindu 38 (80.8) Muslim 9 (19.1) 6. Marital Status Married 41 (87.2) Unmarried 6 (12.7) 7. Years of Experience 3 Years 22 (46.8) Common Themes The thematic analysis led to the formation of five themes; i) Training & Education, ii) Myths & Misunderstandings, iii) Role of Caregiver, iv) Burden on the Grassroots Workers, and v) Inadequate Health Systems Approach. The themes and sub-themes generated from the interviews using the atlas. ti software are explained in (Table 4 ). To make it insightful, the themes are discussed in detail. Table 4 Thematic Framework S.I No. Analytic Framework Themes Sub-themes 1. Knowledge and Practice Training and Education Confusion in terms of Palliative and End-of-life Care, not sure about Hospice setting, No idea about the domains of Palliative Care Did not receive any formal training on PC, if received - only for 3 days, No discussion of PC with families 2. Knowledge Myths and Misunderstanding PC is given at the end-stage of illness, Reference to hospice when the patient is dying, Negative association of PC with death and dying 3. Attitude Role of Caregiver Importance of family in caregiving, Decision-making, and consent, Training to the family for basic care 4. Attitude Burden on Grassroots Workers Overburdened ASHAs and ANMs, PC Screening is an extra responsibility, Need for more vacancies and remuneration for extra work 5. Practice Inadequate Health System Approach No PC policy for the state, No separate funding for PC programs, Lack of PC education and promotion activities, Insufficient infrastructure Training and education The participants without any training in PC mentioned in the interview that they were not very aware of Palliative Care and its related terms. Though they heard about the terminology as a part of other National Program Training. Meanwhile, the participants who received training for 3 days were able to define palliative care but at the same time confused between the terms, ‘End-of-life Care’ and ‘Hospice Care’. Many participants who were not trained manifested anxiety and low levels of confidence while talking about PC. These consequences demand a dire need for PC training programs with a longer duration for all the staff engaged in providing primary health care. Developing proficiency in the field will improve the quality of care and patient satisfaction at the community level [ 17 ]. Myths and misunderstandings The lack of knowledge and training among the grassroots workers is contributing to several myths related to the principles and philosophy of PC [ 18 ]. Many of the respondents stated that palliative care is given only to cancer patients, who are at the end stage of illness. Some of them misunderstood PC with the Non-communicable Diseases (NCD) treatment. Most of the participants were not aware of Hospice care and those aware defined it as a pathway to death. Hospice was also related to despair in patient’s treatment at hospitals or homes. The existing myths among healthcare providers could lead to invalid dissemination of knowledge within the community [ 19 ]. Role of caregiver The participants mentioned the importance of the caregiver especially when the patient is receiving care at home. The ASHAs and ANMs educated the primary caregiver to take care of the basic requirements of the patient, such as positioning, bed rolling, diet, small wound cleaning, medicinal values, etc., The participants believed that caregivers might make their job easy if they are given proper training for patient care. Some of the participants who had adequate knowledge in palliative care spoke briefly on the caregiver’s role in the consent and decision-making for the patient receiving palliative care in any setting. The burden on the grassroots workers The ASHAs, ANMs, and Anganwadi Workers (AWWs) were appointed and expected to fulfill many responsibilities during the COVID-19 pandemic and the trend is continuing [ 20 ]. A lot of tasks such as screening patients for COVID-19, spreading awareness, making sure that the community people follow the quarantine guidelines, Vaccination, etc., were added in addition to the regular tasks that they used to carry out daily. ‘ These circumstances led to extra commitments for us ’, stated most of the participants during the interview. Hence, the staff already assigned with ample number of tasks, are unwilling to learn and practice palliative care at the homes. This reason is also one of the challenges to initiating a Home-based PC with insufficient and less capable human resources in the health system. Inadequate health system approach A few participants including the Medical Officers and the MLHPs discussed about functioning of the health system. One of the Medical Officers reluctantly stated, “ We don’t have a sweeper to clean our offices and maintain hygiene. This is a basic necessity that we do not get. So, it is very difficult to assign workers and OPDs, especially for Palliative Care. We have many issues regarding workload because many prime positions are vacant such as Staff Nurse. Until these basic issues are resolved, I don’t think our health system could progress any further .” “ If we talk about Palliative Care, we should try to follow the bottom-up approach where the patients first come to the sub-centers or primary health centers and then go to the higher level of care. But again, we need at least one palliative care specialist posted at the primary level so that the patients can be referred according to their needs ”, added the two MLHPs. Barriers to Providing Palliative Care The barriers and challenges identified at the patient and health system levels are shown in (Fig. 2 Barriers to Provide Palliative Care ). Barriers at both levels were reported by the healthcare providers who participated in the Focus Group Discussions. “The stigma surrounding the use of palliative care is the most likely factor to prevent patients from using the service as it is negatively associated with death and dying”, reported one of the community health officers during the interview. As observed by the HCPs, the patients often related palliative and end-of-life care with death, hopelessness, loss of control, and speeding up the dying process. The factor further demoted the patient and caregiver’s trust in the PC team. The lack of trust drove them towards the affordable and available nearby private services. In some cases, the caregivers did not wish to reveal the prognosis to the patient while on the contrary, the patient was keen to understand the situation. These cases left the HCPs in an ethical dilemma. At times, the patients and caregivers have already given up on the situation which made them reluctant to any type of care. Again, lack of knowledge, myths, and misconceptions related to palliative and end-of-life care act as an umbrella term for all the barriers reported. Lack of sufficient training, education, and discussion of PC among the HCPs stands as one of the extensive barriers to providing PC. As a result, the participants were least confident while talking about PC during the interviews. This hesitancy will be a challenge to address in the future to provide home-based care. Inadequate training resulted in late reporting of the cases that led to the death of the patient before receiving any type of care. The scarcity in resource allocation in terms of manpower, infrastructure, medicine, equipment, and funding has been a barrier to many of the healthcare programs in India. The ANMs are not included in the palliative care programs due to which the burden on the ASHAs increased. As there is no separate budget allocated to PC, there are a lot of issues such as the absence of essential medicines including Morphine, no separate blocks for PC, few mobile vans, etc., DISCUSSION Our study found that the rural and urban HWCs in the two districts had limited resources, little or no awareness, and very few training and sensitization programs for Palliative Care. The study also identified major barriers to providing PC at the patient and health system level described by the HCPs through the interviews. One of the reviews also reported the scarcity of human resources concerning the presence of healthcare specialists in the HWCs [ 21 ]. Another review found several gaps in the existing primary health care model such as the absence of beneficiary mapping data, a narrow range of services, very little or no health promotion activities with no proper referral mechanisms. A two-way referral was identified as a strength of the HWCs to have better monitoring and follow-up of the patients leading to the continuum of care [ 22 ]. Similar to our study, an observational study in the state of Gujarat found that the HWCs are well functioning according to the guidelines but there was a lack of training for the freshers and the technical staff [ 23 ]. Studies from sub-Saharan Africa and South Asia similarly report severe shortages in trained palliative care providers, often relying on community health workers to fill gaps. A study conducted in Assam tried to improve the quality of PC by integrating the cancer care initiatives of the state. The study had similar findings to ours - lack of skilled HCPs, inadequate funding, and under-utilization of PC services due to little or no awareness and misconceptions among the HCPs and the public. The study also revealed that the curriculum of the medical and nursing colleges did not incorporate PC concepts [ 24 ]. The Neighborhood Network in Palliative Care (NNPC) model in Kerala has gained international attention due to its sustainable community-owned service providing long-term palliative care in a resource-poor setting mainly through volunteers [ 25 ]. The HWCs are connected with the local government and civil society organizations for smooth operation and improved quality of palliative care. The model known as the ‘palliative version’ of a community initiative is eligible to be implemented in other resource-poor settings in India [ 26 ]. Similar findings have been reported in high-income countries, where interdisciplinary teams have been shown to enhance patient outcomes and satisfaction (Smith et al., 2018). The American Society of Clinical Oncology (ASCO) guidelines have given several recommendations to integrate palliative care in any resource-constrained settings. Some of the recommendations for the basic facilitated centers are developing a palliative care model, carrying out a needs assessment for the patients, knowledge and skill-based training for timely screening of the cases, and availability of oral morphine. One of the recommendations was based on providing spiritual care by social workers, mental health professionals, or community health workers. If the counselors are not available, the physicians and nurses can play the role after receiving training on psycho-social care [ 27 ]. The World Health Organization (WHO) operational framework [ 28 ] that covers the core concepts of Primary Health Care is believed to strengthen Care in countries like India. The framework includes continued comprehensive care, trustworthy relations between the provider and the public, empowerment of communities, and a strong political will. The WHO also recommends step-wise strategies to integrate palliative care into primary health care such as PC policy-making and updating, availability and safe access to palliative essential medicines, and adequate training to the professionals, including palliative home care under primary care [ 29 ]. Our study was able to identify the major barriers and list of essential resources available in the HWCs through an in-depth perspective of the HCPs. However, a small sample of the HWCs was one of the limitations of the study. The districts and study participants were selected conveniently due to the time limitations of our study. Therefore, the knowledge findings are not generalizable. However, future research should focus on covering the majority of HWCs in all the districts of the state for a panoramic view. CONCLUSION The rural and urban HWCs had a scarcity of resources, poor awareness among the HCPs, and a lack of training programs related to palliative care. The centers cannot yet provide palliative care at the center or in the homes. Appropriate training and sensitization programs need to be initiated expeditiously. According to WHO guidelines, key policies include training healthcare providers, ensuring access to essential medicines (such as opioids), and promoting public awareness to reduce stigma. Future research should focus on evaluating innovative care delivery models, assessing the impact of policy changes, and exploring patient and caregiver experiences to enhance palliative care services further. Declarations Author Contribution A.K. and M.K. worked on study conception and design. M.K. wrote the main text, collected data, and compiled the results. A.K. edited the manuscript. All authors reviewed the manuscript. Acknowledgement We would like to acknowledge the State NCD Cell and the District Health authorities for their support at various levels. 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Assessment of functioning of health and wellness Centers in a district of western Gujarat. Cureus. 2020;11(2):34–9. Vallath N, Rahul RR, Mahanta T, Dakua D, Gogoi PP, Venkataramanan R, et al. Oncology-based palliative care development: The approach, challenges, and solutions from North-East Region of India, a model for low-and middle-income countries. JCO Glob Oncol. 2021;7(1):223–32. Nair MS, Augustine A, Sreeraj VG. Social Interventions in Palliative Care in Kerala: A Study on Community Owned Home-Based Palliative Care Unit. IOSR – J Humanit Soc Sci. 2021;26(8):25–35. Laabar TD, Saunders C, Auret K, Johnson CE. Socially, Culturally and Spiritually Sensitive Public Health Palliative Care Models in the Lower-income Countries: An Integrative Literature Review. Indian J Palliat Care. 2023;29(1):15. Osman H, Shrestha S, Temin S, Ali ZV, Corvera RA, Ddungu HD, et al. Palliative care in the global setting: ASCO resource-stratified practice guideline. J Glob Oncol. 2018;4:1–24. World Health Organization. Essential public health functions, health systems and health security: developing conceptual clarity and a WHO roadmap for action 2018. Integrating Palliative Care and Symptom Relief into Primary Health Care [homepage on the internet]. Geneva: World Health Organization [updated 2018; cited 2024 Mar 15]. Available from: https://www.who.int/publications/i/item/integrating-palliative-care-and-symptom-relief-into-primary-health-care Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 04 Nov, 2025 Read the published version in Discover Public Health → Version 1 posted Editorial decision: Revision requested 18 Jul, 2025 Editor assigned by journal 04 Jul, 2025 Reviewers agreed at journal 17 Apr, 2025 Reviewers invited by journal 14 Apr, 2025 Submission checks completed at journal 08 Apr, 2025 First submitted to journal 23 Feb, 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5593288","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":447581290,"identity":"0e0ddcae-dfdd-4b05-ab50-8ec9cbcc730c","order_by":0,"name":"Mousami Kirtania","email":"","orcid":"","institution":"University of Hyderabad","correspondingAuthor":false,"prefix":"","firstName":"Mousami","middleName":"","lastName":"Kirtania","suffix":""},{"id":447581291,"identity":"c1820930-f2bc-4f77-ab47-bac15cf0d948","order_by":1,"name":"Ajitha Katta","email":"data:image/png;base64,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","orcid":"","institution":"University of Hyderabad","correspondingAuthor":true,"prefix":"","firstName":"Ajitha","middleName":"","lastName":"Katta","suffix":""}],"badges":[],"createdAt":"2024-12-06 11:23:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5593288/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5593288/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12982-025-01057-9","type":"published","date":"2025-11-04T15:57:51+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":82064495,"identity":"113cce89-12d6-4e6b-9608-b31db4d8af35","added_by":"auto","created_at":"2025-05-06 12:24:04","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":394720,"visible":true,"origin":"","legend":"\u003cp\u003eStructure of Indian Healthcare System\u003c/p\u003e","description":"","filename":"Figure1StructureofIndianHealthcareSystem.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5593288/v1/2909006808b0cc42938570a3.jpg"},{"id":82064490,"identity":"41c6ec8c-66a9-4ca6-95f7-fad7f8c9a791","added_by":"auto","created_at":"2025-05-06 12:24:03","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":483868,"visible":true,"origin":"","legend":"\u003cp\u003e(Figure 1) Study Design\u003c/p\u003e","description":"","filename":"Figure2StudyDesign.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5593288/v1/fbe55a9d43df10053077df54.jpg"},{"id":82064538,"identity":"7b6ebd2d-a8ba-4c2a-9b2c-e1de1f7bd8a7","added_by":"auto","created_at":"2025-05-06 12:24:06","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":187390,"visible":true,"origin":"","legend":"\u003cp\u003e(Figure 2) Barriers to Palliative Care\u003c/p\u003e","description":"","filename":"figure3BarrierstoPalliativeCare.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5593288/v1/afe615ff4319b958cb73c93a.jpeg"},{"id":95564228,"identity":"7074a477-efd4-4f02-b8c6-e1ec17115b53","added_by":"auto","created_at":"2025-11-10 16:09:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2020664,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5593288/v1/dda619ae-9d7a-4285-bb03-f724dd323824.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Situational Analysis of the Health and Wellness Centers (HWCs) to Provide Palliative Care in Telangana, South India","fulltext":[{"header":"Key Message","content":"\u003cul\u003e\n \u003cli\u003eWHO has recommended integrating Palliative Care into Primary Health Care as one of its components to improve Universal Health Coverage.\u003c/li\u003e\n \u003cli\u003eNational Health Mission (NHM) provided operational guidelines to incorporate palliative care services at the HWCs, Sub-centers, and Primary Health Care centers (PHCs). The guidelines contain a checklist (used in this study) of essential resources to be present at various levels.\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"INTRODUCTION","content":"\u003cp\u003ePalliative Care (PC) is known to improve the overall quality of life of patients and their families through a holistic approach [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. It is emerging as a medical specialty because the number of persons with long-term illness is on the rise due to longevity and morbidities [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The care resonates with the Primary Health Care components for achieving Universal Health Coverage, anytime, anywhere, and for anyone [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. To attain this goal, it is necessary to integrate PC into public health care systems such as the Sub-Centers (SCs) and the Primary Health Centers (PHCs) which are transforming into Ayushman Bharat - Health and Wellness Centers (AB-HWCs) in India [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The operationalization of the HWCs requires several inputs that include expanding human resources, partnership for knowledge implementation, funding, medical supplies and equipment, and continuum care with appropriate referrals [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Since knowledge and skill are utmost necessary to ensure quality services at HWCs, an initiative called \u0026lsquo;SASHAKT - Systematic Assessment of Health Care Providers Knowledge and Training\u0026rsquo; was launched by the National Health System and Resource Centre (NHSRC) in 2021 [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Through SASHAKT, Telangana integrates palliative care into primary healthcare, making it more patient-centric and accessible. The initiative ensures that those suffering from chronic, debilitating, or terminal illnesses receive compassionate, home-based, and holistic care, improving their quality of life. Although less than India\u0026rsquo;s 1.2\u0026nbsp;billion population has access to palliative care, most symptom management and psychosocial support can be done inexpensively, provided the health workers are trained effectively [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCapacity building at the primary healthcare level is essential to provide continuum care. At the primary level, palliative care is usually provided by general physicians, staff nurses, and grassroots workers. Allied health professionals such as psychologists, physiotherapists, and pharmacists might fit the desirable criteria of capacity building for HWCs [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. At the HWC-SC level, a home-based palliative care team should consist of a Community Health Officer (CHO), a multi-purpose worker (MPW), an ASHA, and a volunteer. Drugs and consumables such as catheters and air cushions should be available, whereas oral morphine can be dispensed from the HWC-PHC [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. However, for a comprehensive and community-based approach, the social workers require formal training so that PC services can reach remote areas without any underlying myths and misconceptions [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The community-based approach is also helpful for providing home-based PC through Primary Health Care settings [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. According to the available evidence, most people prefer to be at home in the last phase of their lives which increases the demand for PC at home [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Home-based PC offers a twin advantage where it reduces the burden on the healthcare system by avoiding overcrowding and lessening the out-of-pocket expenditure for the patients and their families [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe barriers to providing PC services have been recognized at various levels. The first and foremost is at the policy and system level, followed by the organizational level, the healthcare provider\u0026rsquo;s level, and the patient and family level. A research-driven strategy can address all the barriers [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. By conducting targeted research, health professionals and policymakers can systematically address barriers to palliative care and implement evidence-based strategies that improve patient outcomes and service delivery.\u003c/p\u003e \u003cp\u003eAs per WHO recommendations, if palliative care has to integrate with the primary healthcare system, the HECs at the primary level must be ready to provide palliative care. In Telangana, palliative care is available only at the district level. Hence, this study aims to perform a situational analysis of the SC-HWCs and compare the results between two selected districts. A situational analysis of the HWCs was conducted to assess the current state of services, identify gaps, and improve patient care. By conducting a situational analysis, HWCs can refine their approach to palliative care, ensuring that services are patient-centered, effective, and sustainable.\u003c/p\u003e\n\u003ch3\u003eStudy Objectives\u003c/h3\u003e\n\u003cp\u003eThe purpose of the study was threefold;\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTo identify the essential resources and existing palliative care services provided at the selected Sub-center-HWCs.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTo evaluate the level of PC knowledge of the healthcare providers and the social workers posted at the HWCs.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTo identify the barriers and pitfalls related to the provision of PC at the community level.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eResearch Ethics\u003c/h2\u003e \u003cp\u003e The study was performed according to the Helsinki Declaration and approved by the Institutional Ethics Committee (IEC), University of Hyderabad (UH/IEC/2022/360). A written informed consent was obtained from all the participants willing to participate in the qualitative survey. To preserve anonymity, personal details, such as sex, age, and designation were not collected. Permission to collect data was obtained from the respected district officials at various levels.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy Design\u003c/h3\u003e\n\u003cp\u003eA cross-sectional observational study design was used. A convenience sampling was used to select the two districts, namely Hyderabad and Rangareddy. A self-administrative checklist was used to assess the basic resources available in the centers. An exploratory study design was adopted for qualitative IDIs and FGDs.\u003c/p\u003e\n\u003ch3\u003eSampling Process\u003c/h3\u003e\n\u003cp\u003eOut of 33 districts in Telangana, two major districts namely Hyderabad and Ranga Reddy were selected on convenience due to the time constraint of the study. A total of 30 HWCs were selected randomly by using the lottery method from both districts (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e \u003cb\u003eStudy Design\u003c/b\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eStudy Setting and Participants\u003c/h3\u003e\n\u003cp\u003eThe survey and interviews took place at the selected HWCs. The HWCs are the facilities at the grassroots level and act as first contact to the community (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). So, 30 HWCs were selected from the state\u0026rsquo;s two districts to assess their resources and palliative care services. The interviews were conducted in a quiet room in the center to enhance the quality of the process. The study continued for 2 months from 1st August to 30th September 2023, each month dedicated to one district.\u003c/p\u003e \u003cp\u003eThe ASHAs, ANMs, Staff Nurses, and Medical Officers were selected conveniently for the interview and focus group discussion based on their availability at the centers. Hence, 22 participants from Ranga Reddy and 26 participants from Hyderabad districts respectively, were available during the study period. From the total of 48 participants, 20 were recruited for IDI and 28 were distributed equally for four FGD groups.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Methods\u003c/h2\u003e \u003cp\u003eDemographic details of the participants and the mean scores of the HWCs were described using frequency distribution in SPSS v 29. The qualitative data analysis was done in the atlas. ti version 7.1 software. A thematic approach was used to derive the common codes and themes [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eProcedures\u003c/h3\u003e\n\u003cp\u003eA total of 30 HWCs, 15 from each district were selected using simple random sampling. Each center was visited by the research team with the checklist. The contents of the checklist were included by referring to the \u0026lsquo;Operational Guidelines for Palliative Care at HWC\u0026rsquo; provided by NHSRC [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The checklist containing 40 items was analyzed using Dichotomous scoring with \u0026lsquo;Yes\u0026rsquo; or \u0026lsquo;No\u0026rsquo; responses. Marking \u0026lsquo;Yes\u0026rsquo; denoted that the resource is available at the center during the assessment and vice versa. The dichotomous scoring of all the 30 HWCs was combined and converted into percentages to give an idea of the overall proportion of the available resources.\u003c/p\u003e \u003cp\u003eQualitative IDIs and FGDs were organized with the staff working at the selected HWCs to assess their level of knowledge about PC. A semi-structured questionnaire was used to ask basic questions such as, \u0026lsquo;What is Palliative Care?\u0026rsquo;, \u0026lsquo;Who Provides PC?\u0026rsquo;, \u0026lsquo;When is PC preferred for patients?\u0026rsquo;, etc., The IDIs were conducted in a quiet, comfortable setting. Interviews were recorded with permission and transcribed for analysis. The IDIs were terminated at the point of saturation. FGDs were arranged at the HWCs with a quiet room when the flow of the patients was low. Apart from IEC, we obtained permission from the state program officer and the district medical health officers to conduct the survey. The FGDs and IDIs were highly effective in assessing barriers to palliative care by allowing participants to share personal experiences and express their views on system-level challenges. By capturing individual and group perspectives, these methods uncovered various barriers, from access issues to provider concerns. The principal investigator and a moderator stimulated the process. An externally trained moderator (Master in Public Health) was hired, skilled in the local language and familiar with the research topic. The moderator played a role in the language translation process and transcribing the interviews.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThe comparison of the human resources available in the selected SC-HWCs of both districts is shown below (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). According to the NHSRC guidelines, the recommended human resources to be present at the HWCs are JAS/VHSNC, ASHA, ANM, Staff Nurse, and a Medical Officer [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The rural HWCs had Mid-level Health Providers (MLHPs) but no staff nurses available. JAS/VHSNC positions were found empty in both rural and urban HWCs. Whereas, the number of ASHAs/ANMs and Medical Officers were adequately present in rural and urban HWCs.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAvailability of Human Resources in HWCs\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSI No\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHuman Resources\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eSC-HWCs\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTotal (N\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRural (N\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUrban (N\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAvailable N\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAvailable N\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAvailable N\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAvailable (%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedical Officer (PHC/UPHC)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStaff Nurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eANM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eASHA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJAS/VHSNC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe essential healthcare services that should be available in the HWCs to provide PC is shown (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Talking about PC services, PC OPD did not exist in any of the HWCs. However, Home-based PC was provided by 53.3% (8 out of 15) of the rural HWCs compared to none of the urban HWCs. Symptom management, emotional and psychological support, and nursing care were given. The patients mostly belonged to the category of cancer, cardiovascular diseases, and debilitating conditions, including old age frailty. Whereas the services like training and sensitization programs, and referral of the PC cases were found to be better in the urban HWCs. Three days of training, for once, for all the ASHAs and ANMs. While the MLHPs did a one-month course. The training module included basic concepts of palliative care and how to identify palliative care patients in the community and report them to HWCs. The rural and urban HWCs had all the essential equipment except the tongue depressors, only 3 (20%) and 9 (60%) of the rural and urban HWCs had a tongue depressor. Drugs like Paracetamol and Diclofenac were present at all the 30 (100%) HWCs. While the drug like Tramadol was present only at 26.6% (8 out of 30) of the total HWCs. The drugs for psychological symptom management were not present in any of the centers. On the other hand, Iron, vitamin, and Mineral supplements were available at all 30 (100%) HWCs. Supplies like Catheters, Urine bags, and Feeding tubes were present in a few centers only.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAvailability of Essential Services to Provide Palliative Care\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSI No\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eService Provision\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eSC-HWCs\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTotal (N\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eRural (N\u0026thinsp;=\u0026thinsp;15)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eUrban (N\u0026thinsp;=\u0026thinsp;15)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eAvailable N (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eAvailable N (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eAvailable N (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ePalliative Care Services\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ea)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePC OPD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eb)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHome-based Care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (53.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ec)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTraining \u0026amp; Sensitization Programs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (46.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12 (40)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ed)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReferral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (53.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (66.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18 (60)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eEquipment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ea)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStethoscope\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e30 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eb)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB.P Apparatus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e30 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ec)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLightweight stool\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27 (90)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ed)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTorch\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (86.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28 (93.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ee)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThermometer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24 (80)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ef)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTongue Depressors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12 (40)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGlucometer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (86.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28 (93.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eDrugs for Pain Control\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ea)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eParacetamol\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e30 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eb)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIbuprofen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (46.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19 (63.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ec)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTramadol\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8 (26.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ed)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiclofenac\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e30 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ee)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDexamethasone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (66.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16 (53.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eSupplies\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ea)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDressing supplies \u0026amp; trays\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e30 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eb)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCottons \u0026amp; Scissors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e30 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ec)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGloves\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27 (90)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ed)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGauze Piece \u0026amp; Bandage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (66.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e25 (83.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ee)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSyringes \u0026amp; Needles\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e30 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ef)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCatheters \u0026amp; Urine Bags\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (13.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (13.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (13.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFeeding tubes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (13.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ePsychological Symptom Management\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ea)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLorazepam\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eb)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAmitriptyline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eIron, Mineral \u0026amp; Vitamin Supplements\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e30 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe socio-demographic characteristics of the study participants included in the IDI and FGDs are given (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). A total of 20 IDIs and 4 FGDs were conducted with the health care staff in the two districts to assess the level of PC knowledge and perceived barriers to providing PC, respectively. The FGDs included a total of 28 members, each group containing 7. The majority of the participants were aged 30 and above and were females. The number of ASHA and Staff Nurses exceeded the other positions. Meanwhile, the participant\u0026rsquo;s education level was either till 10th grade or graduation. Most of them were Hindu and married. Almost half of them had an experience of more than 3 years in their respective fields.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSocio-demographic Details of the Participants (HCPs)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eS.I No\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal N\u0026thinsp;=\u0026thinsp;47\u003c/p\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e1.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25\u0026ndash;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (34)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30\u0026ndash;35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (27.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 or more\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18 (38.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e2.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (27.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34 (72.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e3.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eDesignation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMedical Officer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (19.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStaff Nurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (25.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eASHA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (32)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eANM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (17)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMLHP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (6.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e4.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eEducation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8th \u0026minus;\u0026thinsp;10th grade\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22 (46.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10th \u0026minus;\u0026thinsp;12th grade\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (8.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGraduate or more\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21 (44.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e5.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eReligion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHindu\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38 (80.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMuslim\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (19.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e6.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eMarital Status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41 (87.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnmarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (12.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e7.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eYears of Experience\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;1 Year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (17)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u0026ndash;3 Years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17 (36.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;3 Years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22 (46.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eCommon Themes\u003c/h2\u003e \u003cp\u003eThe thematic analysis led to the formation of five themes; i) Training \u0026amp; Education, ii) Myths \u0026amp; Misunderstandings, iii) Role of Caregiver, iv) Burden on the Grassroots Workers, and v) Inadequate Health Systems Approach. The themes and sub-themes generated from the interviews using the atlas. ti software are explained in (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). To make it insightful, the themes are discussed in detail.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThematic Framework\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eS.I No.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAnalytic Framework\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThemes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSub-themes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKnowledge and Practice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTraining and Education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eConfusion in terms of Palliative and End-of-life Care, not sure about Hospice setting, No idea about the\u0026nbsp;domains of Palliative Care\u003c/p\u003e \u003cp\u003eDid not receive any formal training on PC, if received - only for 3 days, No discussion of PC with families\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKnowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMyths and Misunderstanding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePC is given at the\u0026nbsp;end-stage of illness, Reference to hospice when the\u0026nbsp;patient is dying, Negative association of PC with death and dying\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAttitude\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRole of Caregiver\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eImportance of family in caregiving, Decision-making, and consent, Training to the\u0026nbsp;family for basic care\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAttitude\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBurden on Grassroots Workers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOverburdened ASHAs and ANMs, PC Screening is an extra responsibility, Need for more vacancies and remuneration for extra work\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePractice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInadequate Health System Approach\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo PC policy for the\u0026nbsp;state, No separate funding for PC programs, Lack of PC education and promotion activities, Insufficient infrastructure\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eTraining and education\u003c/h2\u003e \u003cp\u003eThe participants without any training in PC mentioned in the interview that they were not very aware of Palliative Care and its related terms. Though they heard about the terminology as a part of other National Program Training. Meanwhile, the participants who received training for 3 days were able to define palliative care but at the same time confused between the terms, \u0026lsquo;End-of-life Care\u0026rsquo; and \u0026lsquo;Hospice Care\u0026rsquo;. Many participants who were not trained manifested anxiety and low levels of confidence while talking about PC. These consequences demand a dire need for PC training programs with a longer duration for all the staff engaged in providing primary health care. Developing proficiency in the field will improve the quality of care and patient satisfaction at the community level [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eMyths and misunderstandings\u003c/h2\u003e \u003cp\u003eThe lack of knowledge and training among the grassroots workers is contributing to several myths related to the principles and philosophy of PC [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Many of the respondents stated that palliative care is given only to cancer patients, who are at the end stage of illness. Some of them misunderstood PC with the Non-communicable Diseases (NCD) treatment. Most of the participants were not aware of Hospice care and those aware defined it as a pathway to death. Hospice was also related to despair in patient\u0026rsquo;s treatment at hospitals or homes. The existing myths among healthcare providers could lead to invalid dissemination of knowledge within the community [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eRole of caregiver\u003c/h2\u003e \u003cp\u003eThe participants mentioned the importance of the caregiver especially when the patient is receiving care at home. The ASHAs and ANMs educated the primary caregiver to take care of the basic requirements of the patient, such as positioning, bed rolling, diet, small wound cleaning, medicinal values, etc., The participants believed that caregivers might make their job easy if they are given proper training for patient care. Some of the participants who had adequate knowledge in palliative care spoke briefly on the caregiver\u0026rsquo;s role in the consent and decision-making for the patient receiving palliative care in any setting.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eThe burden on the grassroots workers\u003c/h2\u003e \u003cp\u003eThe ASHAs, ANMs, and Anganwadi Workers (AWWs) were appointed and expected to fulfill many responsibilities during the COVID-19 pandemic and the trend is continuing [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. A lot of tasks such as screening patients for COVID-19, spreading awareness, making sure that the community people follow the quarantine guidelines, Vaccination, etc., were added in addition to the regular tasks that they used to carry out daily. \u0026lsquo;\u003cem\u003eThese circumstances led to extra commitments for us\u003c/em\u003e\u0026rsquo;, stated most of the participants during the interview. Hence, the staff already assigned with ample number of tasks, are unwilling to learn and practice palliative care at the homes. This reason is also one of the challenges to initiating a Home-based PC with insufficient and less capable human resources in the health system.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eInadequate health system approach\u003c/h2\u003e \u003cp\u003eA few participants including the Medical Officers and the MLHPs discussed about functioning of the health system. One of the Medical Officers reluctantly stated, \u0026ldquo;\u003cem\u003eWe don\u0026rsquo;t have a sweeper to clean our offices and maintain hygiene. This is a basic necessity that we do not get. So, it is very difficult to assign workers and OPDs, especially for Palliative Care. We have many issues regarding workload because many prime positions are vacant such as Staff Nurse. Until these basic issues are resolved, I don\u0026rsquo;t think our health system could progress any further\u003c/em\u003e.\u0026rdquo;\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eIf we talk about Palliative Care, we should try to follow the bottom-up approach where the patients first come to the sub-centers or primary health centers and then go to the higher level of care. But again, we need at least one palliative care specialist posted at the primary level so that the patients can be referred according to their needs\u003c/em\u003e\u0026rdquo;, added the two MLHPs.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eBarriers to Providing Palliative Care\u003c/h2\u003e \u003cp\u003eThe barriers and challenges identified at the patient and health system levels are shown in (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e \u003cb\u003eBarriers to Provide Palliative Care\u003c/b\u003e). Barriers at both levels were reported by the healthcare providers who participated in the Focus Group Discussions.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e\u0026ldquo;The stigma surrounding the use of palliative care is the most likely factor to prevent patients from using the service as it is negatively associated with death and dying\u0026rdquo;, reported one of the community health officers during the interview. As observed by the HCPs, the patients often related palliative and end-of-life care with death, hopelessness, loss of control, and speeding up the dying process. The factor further demoted the patient and caregiver\u0026rsquo;s trust in the PC team. The lack of trust drove them towards the affordable and available nearby private services. In some cases, the caregivers did not wish to reveal the prognosis to the patient while on the contrary, the patient was keen to understand the situation. These cases left the HCPs in an ethical dilemma. At times, the patients and caregivers have already given up on the situation which made them reluctant to any type of care. Again, lack of knowledge, myths, and misconceptions related to palliative and end-of-life care act as an umbrella term for all the barriers reported.\u003c/p\u003e \u003cp\u003eLack of sufficient training, education, and discussion of PC among the HCPs stands as one of the extensive barriers to providing PC. As a result, the participants were least confident while talking about PC during the interviews. This hesitancy will be a challenge to address in the future to provide home-based care. Inadequate training resulted in late reporting of the cases that led to the death of the patient before receiving any type of care. The scarcity in resource allocation in terms of manpower, infrastructure, medicine, equipment, and funding has been a barrier to many of the healthcare programs in India. The ANMs are not included in the palliative care programs due to which the burden on the ASHAs increased. As there is no separate budget allocated to PC, there are a lot of issues such as the absence of essential medicines including Morphine, no separate blocks for PC, few mobile vans, etc.,\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eOur study found that the rural and urban HWCs in the two districts had limited resources, little or no awareness, and very few training and sensitization programs for Palliative Care. The study also identified major barriers to providing PC at the patient and health system level described by the HCPs through the interviews.\u003c/p\u003e \u003cp\u003eOne of the reviews also reported the scarcity of human resources concerning the presence of healthcare specialists in the HWCs [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Another review found several gaps in the existing primary health care model such as the absence of beneficiary mapping data, a narrow range of services, very little or no health promotion activities with no proper referral mechanisms. A two-way referral was identified as a strength of the HWCs to have better monitoring and follow-up of the patients leading to the continuum of care [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Similar to our study, an observational study in the state of Gujarat found that the HWCs are well functioning according to the guidelines but there was a lack of training for the freshers and the technical staff [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Studies from sub-Saharan Africa and South Asia similarly report severe shortages in trained palliative care providers, often relying on community health workers to fill gaps.\u003c/p\u003e \u003cp\u003eA study conducted in Assam tried to improve the quality of PC by integrating the cancer care initiatives of the state. The study had similar findings to ours - lack of skilled HCPs, inadequate funding, and under-utilization of PC services due to little or no awareness and misconceptions among the HCPs and the public. The study also revealed that the curriculum of the medical and nursing colleges did not incorporate PC concepts [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe Neighborhood Network in Palliative Care (NNPC) model in Kerala has gained international attention due to its sustainable community-owned service providing long-term palliative care in a resource-poor setting mainly through volunteers [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The HWCs are connected with the local government and civil society organizations for smooth operation and improved quality of palliative care. The model known as the \u0026lsquo;palliative version\u0026rsquo; of a community initiative is eligible to be implemented in other resource-poor settings in India [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Similar findings have been reported in high-income countries, where interdisciplinary teams have been shown to enhance patient outcomes and satisfaction (Smith et al., 2018).\u003c/p\u003e \u003cp\u003e The American Society of Clinical Oncology (ASCO) guidelines have given several recommendations to integrate palliative care in any resource-constrained settings. Some of the recommendations for the basic facilitated centers are developing a palliative care model, carrying out a needs assessment for the patients, knowledge and skill-based training for timely screening of the cases, and availability of oral morphine. One of the recommendations was based on providing spiritual care by social workers, mental health professionals, or community health workers. If the counselors are not available, the physicians and nurses can play the role after receiving training on psycho-social care [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe World Health Organization (WHO) operational framework [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] that covers the core concepts of Primary Health Care is believed to strengthen Care in countries like India. The framework includes continued comprehensive care, trustworthy relations between the provider and the public, empowerment of communities, and a strong political will. The WHO also recommends step-wise strategies to integrate palliative care into primary health care such as PC policy-making and updating, availability and safe access to palliative essential medicines, and adequate training to the professionals, including palliative home care under primary care [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur study was able to identify the major barriers and list of essential resources available in the HWCs through an in-depth perspective of the HCPs. However, a small sample of the HWCs was one of the limitations of the study. The districts and study participants were selected conveniently due to the time limitations of our study. Therefore, the knowledge findings are not generalizable. However, future research should focus on covering the majority of HWCs in all the districts of the state for a panoramic view.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe rural and urban HWCs had a scarcity of resources, poor awareness among the HCPs, and a lack of training programs related to palliative care. The centers cannot yet provide palliative care at the center or in the homes. Appropriate training and sensitization programs need to be initiated expeditiously. According to WHO guidelines, key policies include training healthcare providers, ensuring access to essential medicines (such as opioids), and promoting public awareness to reduce stigma. Future research should focus on evaluating innovative care delivery models, assessing the impact of policy changes, and exploring patient and caregiver experiences to enhance palliative care services further.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eA.K. and M.K. worked on study conception and design. M.K. wrote the main text, collected data, and compiled the results. A.K. edited the manuscript. All authors reviewed the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe would like to acknowledge the State NCD Cell and the District Health authorities for their support at various levels. We are also grateful to the Institutional Ethics Committee, University of Hyderabad, for supporting our study.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data that support the findings of this study are available from Ayushman Bharat - Health and Wellness Centers - National Health Portal (AB-HWCs-NHP).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKassianos AP, Ioannou M, Koutsantoni M, Charalambous H. The impact of specialized palliative care on cancer patients\u0026rsquo; health-related quality of life: a systematic review and meta-analysis. Supportive Care Cancer. 2018;26:61\u0026ndash;79.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJeba J, Atreya S, Chakraborty S, Pease N, Thyle A, Ganesh A, et al. 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Assessment of Functioning of Health and Wellness Centers of Western Odisha: A Cross-Sectional Study. Cureus. 2023;15(4):e37665.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi WW, Chhabra J, Singh S. Palliative care education and its effectiveness: a systematic review. Public Health. 2021;194:96\u0026ndash;108.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFang ML, Sixsmith J, Sinclair S, Horst G. A knowledge synthesis of culturally-and spiritually-sensitive end-of-life care: findings from a scoping review. BMC Geriatr. 2016;16:1\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKubi B, Enumah ZO, Lee KT, Freund KM, Smith TJ, Cooper LA, et al. Theory-based development of an implementation intervention using community health workers to increase palliative care use. J Pain Symptom Manag. 2020;60(1):10\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKrishnan S. Exploring female frontline health workers\u0026rsquo; role and capacities in COVID-19 response in India. Int J Disaster Risk Reduct. 2022;75:102962.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZodpey S, Negandhi H, Tiwari R. Human resources for health in India: strategic options for transforming health systems towards improving health service delivery and public health. J Health Manag. 2021;23(1):31\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSolanki HK, Rath RS, Silan V, Singh SV. Health and wellness centers: a paradigm shift in health care system of India? Int J Community Med Public Health. 2020;7(2):799\u0026ndash;805.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRathod H, Pithadia P, Patel D, Goswami M, Parmar D, Kotecha I. Assessment of functioning of health and wellness Centers in a district of western Gujarat. Cureus. 2020;11(2):34\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVallath N, Rahul RR, Mahanta T, Dakua D, Gogoi PP, Venkataramanan R, et al. Oncology-based palliative care development: The approach, challenges, and solutions from North-East Region of India, a model for low-and middle-income countries. JCO Glob Oncol. 2021;7(1):223\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNair MS, Augustine A, Sreeraj VG. Social Interventions in Palliative Care in Kerala: A Study on Community Owned Home-Based Palliative Care Unit. IOSR \u0026ndash; J Humanit Soc Sci. 2021;26(8):25\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLaabar TD, Saunders C, Auret K, Johnson CE. Socially, Culturally and Spiritually Sensitive Public Health Palliative Care Models in the Lower-income Countries: An Integrative Literature Review. Indian J Palliat Care. 2023;29(1):15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOsman H, Shrestha S, Temin S, Ali ZV, Corvera RA, Ddungu HD, et al. Palliative care in the global setting: ASCO resource-stratified practice guideline. J Glob Oncol. 2018;4:1\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Essential public health functions, health systems and health security: developing conceptual clarity and a WHO roadmap for action 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIntegrating Palliative Care and Symptom Relief into Primary Health Care [homepage on the internet]. Geneva: World Health Organization [updated 2018; cited 2024 Mar 15]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/publications/i/item/integrating-palliative-care-and-symptom-relief-into-primary-health-care\u003c/span\u003e\u003cspan address=\"https://www.who.int/publications/i/item/integrating-palliative-care-and-symptom-relief-into-primary-health-care\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\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":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Health and Wellness Centers, India, Palliative Care, Primary Health Care, Universal Health Coverage","lastPublishedDoi":"10.21203/rs.3.rs-5593288/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5593288/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePalliative Care (PC) aims to provide holistic care encompassing physical, psycho-social, and spiritual well-being to improve the quality of life of the patients and their caregivers. In India, PC is practiced in a scattered manner contributing to myths, and misunderstanding. Thus, it is necessary to integrate PC into primary care through the Health and Wellness Centers (HWCs). For appropriate treatment and referrals, it is required that the Health Care Providers (HCPs) have adequate knowledge. Hence, this study aims to identify the resources available in the selected HWCs in Hyderabad and Ranga Reddy districts in Telangana. It also seeks to evaluate the knowledge and barriers of the HCPs.\u003c/p\u003e\u003ch2\u003eMaterials and Method\u003c/h2\u003e \u003cp\u003eA cross-sectional observational study was performed in the randomly selected 30 HWCs in both districts. A checklist was used to assess the resources available to provide PC. Qualitative In-depth Interviews (IDIs) and Focus Group Discussions (FGDs) were executed with the HCPs at the centers. Atlas.ti software was used to analyze the IDIs and FGDs.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe lack of staff nurses, missing essential drug kits, and absence of home-based PC screening were identified. The respondents were unaware of PC as they did not receive any training. The interviews revealed that the Mid-level Health Providers (MLHPs) had a higher level of knowledge than the other staff.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe HWCs are not yet well-equipped to provide PC at the centers and homes. New and modified training and sensitization programs must be implemented at the central and state levels.\u003c/p\u003e","manuscriptTitle":"Situational Analysis of the Health and Wellness Centers (HWCs) to Provide Palliative Care in Telangana, South India","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-06 12:23:43","doi":"10.21203/rs.3.rs-5593288/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-18T10:03:44+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-04T15:01:27+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"2107385851866904571510236695611911310","date":"2025-04-17T15:19:37+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-14T15:41:37+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-08T14:14:07+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Public Health","date":"2025-02-23T17:49:20+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"00f7098e-f22d-4c9f-8b8a-153dc537b1a1","owner":[],"postedDate":"May 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-11-10T16:05:23+00:00","versionOfRecord":{"articleIdentity":"rs-5593288","link":"https://doi.org/10.1186/s12982-025-01057-9","journal":{"identity":"discover-public-health","isVorOnly":false,"title":"Discover Public Health"},"publishedOn":"2025-11-04 15:57:51","publishedOnDateReadable":"November 4th, 2025"},"versionCreatedAt":"2025-05-06 12:23:43","video":"","vorDoi":"10.1186/s12982-025-01057-9","vorDoiUrl":"https://doi.org/10.1186/s12982-025-01057-9","workflowStages":[]},"version":"v1","identity":"rs-5593288","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5593288","identity":"rs-5593288","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}