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\def\RunningAuthor{Ganapathy Sankar U. et al.}
\firstPage{1433}
\articleType{Original Article}
\receivedDate{15.09.2019}
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\title{Evaluation of palliative care knowledge among health care students- A pilot study}
\author{Ganapathy~Sankar~U.\textsuperscript{1},  
            Monisha~R.\textsuperscript{*}\textsuperscript{1},  
            Christopher~Amalraj~Vallaba~Doss\textsuperscript{2}, 
            Palanivel~R.~M.\textsuperscript{3}~\\[5pt]{\textsuperscript{1}SRM College of Occupational therapy, SRM Institute of Science and Technology, Kattankulathur, Chennai ,Tamil Nadu 603203, India}~\\{\textsuperscript{2}College of Medicine, Imam Abdulrahman Bin Faisal University, P. O. Box 1982, Dammam 31441, Saudi Arabia}~\\{\textsuperscript{3}Deanship of Quality and Academic Accreditation, Imam Abdulrahman Bin Faisal University, P. O. Box 1982, Dammam 31441, Saudi Arabia }}

\begin{abstract}
Palliative care is given much importance in the curriculum of medical and health sciences. Before planning a new design and curriculum development, it is mandatory to test the knowledge and awareness of Occupational therapy students on palliative care. Thus, it will help the expert's panel to enhance the syllabus designing methods appropriate to the student's knowledge. Without paying much attention to enhance knowledge on palliative care among students might lead to failure in providing quality care. To evaluate the knowledge in palliative care among undergraduate occupational therapy students. The study population included BOT 1\ensuremath{^{ST}} Year and BOT Final year students and CRI from SRM College OF Occupational therapy, Kattankulathur. After obtaining informed consent signed from the participants, they have been instructed to fill in the questionnaire. The questionnaire has demographic data and 35 questions under nine groups, for which the students were instructed to answer (Yes, No, Don't know). A detailed instruction was there in the questionnaire to avoid leaving any questions blank. It was found that occupational therapy students were aware of palliative care. Knowledge in palliative care was not precise among occupational therapy students related to healthcare. Hence there is an emerging need to include palliate care in the curriculum for the development of knowledge in palliative care.
\end{abstract}\def\keywordstitle{Keywords}

\begin{keywords}Knowledge,\newline Questionnaire,\newline Undergraduate occupational therapy students,\newline Kattankulathur
\end{keywords}
\twocolumn[ \maketitle {\printKwdAbsBox}]
\makeatletter{\raggedright\textsuperscript{*}Corresponding Author\par Name:\ Monisha~R.~\\ Phone:\ 9940228679~\\  Email:\ dreamsfuture000@gmail.com 
        \par}\vspace*{-11pt}\hrulefill\par{\fontsize{12}{14}\selectfont ISSN: 0975-7538}\par% 
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\section{Introduction}
Palliative care is care given to a person as a whole, not just their disease; it improves the quality of patients with cancer and other ailments. The goal of the current study is to assess the knowledge in students of the health care delivery system and their knowledge will have an impact on the delivery of care to patients with chronic ailments\unskip~\citep{660558:15555854}.

Lag in the curriculum development will harm the students further. Without much knowledge of palliative care, they experience trouble in the long term delivery of the health care management process. Knowing about palliative care is to prevent or treat, as early as possible, the chronic ailments\unskip~\citep{660558:15555855}

Palliative care is commonly referred to as supportive care. But none of the researchers aimed to create awareness among students of the health care delivery system. Patients can benefit from palliative care management as inpatient and in an outpatient clinic, it will benefit the patient by serving as a long-term care facility\unskip~\citep{660558:15555856}. 

Within the modern advanced era, cancer and other chronic ailments continue to increase. The majority of the patients die because of chronic ailments; however, students left without proper guidance and knowledge regarding palliative care. Palliative care is the only method that improves the quality of life and provides a solution for numerous problems related to life-threatening illness for the patients and their family members\unskip~\citep{660558:15555857}. 

Early diagnosis and detailed assessment help to prevent psychological and social ailments. However, there is a misconception among students that palliative care is associated with the management of patients with cancer. But knowledge of Palliative care will make them realize that it is not restricted to cancer or terminally ill patients alone. Thus there is an increasing demand to include palliative care in the curriculum for creating awareness among occupational therapy students as they belong to the health care delivery system\unskip~\citep{660558:15555858}. 

Palliative care includes treatment of life-threatening conditions. Health professionals work for the well being of the population who are within the demand for a cure from pain. However, many will avoid the patient who is with end-of-life illnesses. The importance of palliative care is well recognized in the western world; however, the curriculum in our country is gradually developing in its way, with much attention paid by the health care delivery system team members on the palliative care\unskip~\citep{660558:15555858}. 

Palliative care should be added to the curriculum of the Academy of Health Sciences. Palliative care education in medical schools has been improved. However, undergraduate education in palliative care is not well established and there is no standardized curriculum that involves palliative care. There is a considerable gap in the knowledge of palliative care among undergraduate students in our country, hence to establish the defined curriculum for Occupational therapy students in Kattankulathur, there is a need to understand the student's knowledge and awareness on palliative care\unskip~\citep{660558:15555859}.

In order to improve the quality of life and to provide effective care, the members of the rehabilitation team need to have a common ideal and understanding of the role and contribution each of them has to make an order to achieve successful outcomes. This study may thus be an eye-opener to provide a way to include palliative care in the syllabus of undergraduate health care students\unskip~\citep{660558:15555859}.
    
\section{\textbf{Methodology}}
The study was conducted between 1st October 2018 and 30\ensuremath{^{th}} October 2018. After obtaining approval from the Head of the department, questionnaires have been loaded up into goggle forms and the link has been forwarded in WhatsApp groups of first and final year students of Occupational therapy in SRM College of Occupational therapy, Kattankulathur, India. A written informed consent form was collected from all the participants, who were willing to participate in the study, were included in the study and those not willing to participate were excluded. 

The questionnaire contains basic questions on philosophy, communication issues, non-pain symptoms, medications use and context of the application of palliative care. A total of 35 questions answered with three options (Yes, No, Don't know) were included in the online survey. The groups of statements deal with palliative care are its definition, its philosophy, people who were in need of palliative care, Common non-pain symptoms encountered in palliative care, Community prognosis in palliative care, multidisciplinary team members of Palliative care, Components of good death, Morphine in palliative care, Common side effects of morphine in palliative care setting

This pilot study conducted on BOT final year students and CRRI will provide a way for analyzing the knowledge of palliative care among health care professionals. Detailed instructions and demographic data were included in the online questionnaire to identify each student's response in isolation and to avoid missing data in the outcome; the instructions were framed with caution.

 A total of 120 students participated in the study. The questionnaire contained the sociodemographic profile, Educational profile \& 35 statements under nine groups for which the respondents were expected to answer one of three options. The sample size calculation was done according to the formula 4pq/d\ensuremath{^{2}}. (p-prevalence of awareness of palliative care from previous studies; q-100 minus prevalence percentage; d-precision which can range from 10\%-20\%). The prevalence of awareness of palliative care from previous studies was around 60\%.

\textbf{Statistical analysis}

Statistical analysis was done using SPSS version 19.0 and the results were expressed in frequencies and percentages.

\textbf{Assessment of Palliative care awareness}

\textbf{Palliative care}


  
  \begin{enumerate}
  \item \relax Pain medicine
  \item \relax Geriatric medicine
  \item \relax Rehabilitation medicine
  \item \relax Active care of the dying (Answers were provided in Figure~\ref{f-2eda6ce7f33a})
  \end{enumerate}
  \textbf{Philosophy of palliative care}


  
  \begin{enumerate}
  \item \relax Affirms life
  \item \relax Recognizes dying as a normal process
  \item \relax Hastens death
  \item \relax Prolongs life
  \end{enumerate}
  \textbf{Palliative care is needed for}


  
  \begin{enumerate}
  \item \relax All dying patients
  \item \relax Metastatic cancer with uncontrolled pain
  \item \relax End-stage heart failure
  \item \relax Debilitating illnesses like rheumatoid arthritis
  \end{enumerate}
  \textbf{Common non-pain symptoms encountered in palliative care}


  
  \begin{enumerate}
  \item \relax Delirium
  \item \relax Vomiting
  \item \relax Constipation
  \item \relax Breathlessness
  \end{enumerate}
  \textbf{Communicating prognosis in palliative care}

 Prognosis should always be clearly communicated


  
  \begin{enumerate}
  \item \relax Prognosis should only be informed to family members
  \item \relax Not communicating prognosis could lead to lack of trust
  \item \relax Patient's wishes and choices should be clearly communicated
  \end{enumerate}
  \textbf{Palliative care multidisciplinary team consists of}


  
  \begin{enumerate}
  \item \relax Medical social worker
  \item \relax Nurse
  \item \relax Radiotherapist
  \item \relax Occupational therapist
  \end{enumerate}
  \textbf{Components of a good death}


  
  \begin{enumerate}
  \item \relax Pain and symptom management
  \item \relax Clear decision making
  \item \relax Preparation for death
  \end{enumerate}
  \textbf{Morphine}


  
  \begin{enumerate}
  \item \relax Causes death in all dying patients
  \item \relax Improves quality of life
  \item \relax Relieves all kinds of pain
  \item \relax Relieves breathlessness in heart failure
  \end{enumerate}
  \textbf{Common side effects of morphine in the palliative care setting}


  
  \begin{enumerate}
  \item \relax Nausea and vomiting
  \item \relax Constipation
  \item \relax Drowsiness
  \item \relax Addiction
  \end{enumerate}
  
\bgroup
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\centering \makeatletter\IfFileExists{images/65bd44a1-6e21-42d0-bf18-b18f293c920f-ucapture.png}{\includegraphics{images/65bd44a1-6e21-42d0-bf18-b18f293c920f-ucapture.png}}{}
\makeatother 
\caption{\boldmath {Answers}}
\label{f-2eda6ce7f33a}
\end{figure*}
\egroup

    
\section{Results and Discussion}
A total of 120 students of BOT Final year and CRRI have been included in the study from SRM College of Occupational therapy, SRM Institute of Science and technology. The questionnaire on the assessment of palliative care knowledge has been sent to all by forwarding a link through Google forms. Table 1 gives a frequency of the entire study population of 1200, female (72.5\%) while males occupied (24.5\%). Occupational therapy students were not aware that palliative care is an active care of dying. 55 \% had given the correct response, while others didn't have knowledge of the definition of palliative care. 50\% had no knowledge of palliative care. More than 75\% of the Occupational therapy assumed that palliative care was about pain. 85\% of students were having a wrong perception that palliative care is needed for deliberating illness like rheumatoid arthritis and the majority of students wrongly assumed that palliative care prolongs life. The majority of the Occupational therapy students falsely agreed that all dying patients require palliative care and it has been proved that students had no knowledge of those who were in need of palliative care. 16\% of the Occupational therapy students had no idea about delirium on palliative care. Delirium and vomiting, as non-pain symptoms, were rightly known to more than 85\% of students. Among them, the occurrence of delirium and vomiting was known to 72\%, while constipation and breathlessness were known to 52\% of students. About 70-80\% of Occupational therapy students correctly stated that the consequence of lacking trust due to poor communication. But however, 18\% of students never realized the fact that communicating with patients will facilitate treatment participation at a higher rate. About 92\% of Occupational therapy students were correctly stated that medical social workers, nurses and occupational therapists form the team of palliative care while only less than 10-18\% were not aware. Approximately 60\% of Occupational therapy students had a false statement that morphine relieves all kinds of pain. 

As a rehabilitation team member, Occupational therapy students must be aware of the need to gather knowledge of palliative care. The team of palliative care includes doctors, nurses, pharmacists and physiotherapists. Effective rehabilitation can only be achieved when the awareness of their individual roles in the team has to be inculcated into the curriculum of the undergraduate education system\unskip~\citep{660558:15555860}. In the baseline, before the inclusion of curriculum designs into practice, it is mandatory to test the knowledge among students whether they were aware of the course and their interest to learn and gather knowledge on the same. So we included the student's Occupational therapy colleges of our institution. The students were from the final years as they were completed the course duration and finished with the credit hours of learning undergraduate Occupational therapy programs. Hence, they were included in the study, and they are the people emerging and getting ready to practice the learned out theory part of the curriculum into practice in a lively environment. They should have basic knowledge of these issues in order to understand their roles played in a palliative care setting and they should be familiar with the rehabilitation process. The results proved that a gap exists in palliative care knowledge among undergraduate Occupational therapy students. A study by \unskip~\citep{660558:15555859} showed that nearly 76\% of the nurses had a favorable attitude towards palliative care. This knowledge of nursing students towards palliative care may be associated with frequent contact of the nursing students with sick patients and also training programs for them to deal with ill-patients. \unskip~\citep{660558:15555862} found insufficient knowledge about palliative care among final year medical students. \unskip~\citep{660558:15555856} has described the details of the importance of the role of Occupational therapy in palliative care and also written about the perspectives of including palliative care in their curriculum\unskip~\citep{660558:15555861,660558:15555862,660558:15555863}. Occupational therapy plays an integrated role in a multidisciplinary palliative care team from symptom control to improving quality of life in patients with terminal illnesses, as reported by Kumar SP and Jim A. Dr. Rajaragupathy Sujatha, Assistant Professor, Department of Biochemistry, PSG Institute of Medical Sciences and Research, Peelamedu, conducted a research at PSG Institute of science and technology, Coimbatore conducted a cross-sectional questionnaire-based study between November 2016 and March 2017 to assess the knowledge on palliative care among Occupational therapy, nursing, pharmacy and medical students and concluded that Basic knowledge about palliative care was inadequate among the undergraduate students related to healthcare \unskip~\citep{660558:15555864,660558:15555865}. This current study results focused only on Occupational therapy students as they play a major role in the rehabilitating process. A study by \unskip~\citep{660558:15555865} had also demonstrated the importance of strengthening the need to include palliative care in medical curriculum\unskip~\citep{660558:15555865}. 
    
\section{Conclusion }
Palliative care knowledge must be given importance in the curriculum of medical and Paramedical sciences. It is mandatory that Occupational therapy students must be aware of knowledge regarding palliative care and apply the best principles of palliative care. The current study concludes that 50\% of Occupational therapist was unaware of palliative care. There is an emerging need to create course content on palliative care among Occupational therapy students all over India. Future studies are needed to by testing the knowledge acquisition among Occupational therapy students followed by seminars, symposium and workshops with conferences highlighting the importance of palliative care. 

\textbf{Limitation}

The major limitations of the study are in completing the questionnaire. This study includes respondent's bias toward certain issues like discussed questions with friends, inaccurate responses and skipped questions and the questionnaire has been circulated in WhatsApp thus, it has given access to Postgraduate, doctorate and undergraduate first-year students. Access to fill up the questionnaire and to participate in the study is not controlled.
\section*{Acknowledgement}The authors thank the management SRMIST for offering the platform to conduct the research and the authors thank Occupational therapy students for their active participation in the study.

\textbf{Conflict of Interest}

Authors declare no conflict of interest

\textbf{Funding Source}

Self.
    

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