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 Table of Contents  
Year : 2022  |  Volume : 6  |  Issue : 1  |  Page : 3-9

Impact of palliative care training on knowledge, beliefs, and attitudes of undergraduate physiotherapy students: A pilot study

Centre for Physiotherapy and Rehabilitation Sciences, Jamia Millia Islamia, New Delhi, India

Date of Submission12-Jul-2021
Date of Acceptance02-Sep-2021
Date of Web Publication26-Nov-2021

Correspondence Address:
Dr. Zubia Veqar
Centre for Physiotherapy and Rehabilitation Sciences, Jamia Millia Islamia, Jamia Nagar, Okhla, New Delhi 110025.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jsip.JSIP_7_21

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Background: In palliative care settings, patient comes with multiple symptoms. Hence, an interdisciplinary team is needed for effective management with physiotherapists being an essential part of the team. The level of knowledge, exposure, and practice in palliative care settings influence the extent of team participation and quality of care provided by the physiotherapy professionals. To the best of our knowledge, palliative care is not included in the undergraduate curriculum of physiotherapy in India till now. Hence, it is necessary to add palliative care to the undergraduate curriculum of physiotherapy students. Aim: The aim of this study was to evaluate the effect of education regarding palliative care on knowledge, beliefs, and attitudes of final-year physiotherapy studentsMaterials and Methods: Final-year physiotherapy students were recruited according to the exclusion and inclusion criteria after taking ethical approval from the university’s ethical committee. They are provided with three educational sessions regarding palliative care. They were made to fill all the questionnaires (i.e., Knowledge questionnaire, FATCOD-B Scale, and Belief questionnaire) before and after the completion of the educational program. Data analysis: Data were assessed by the Shapiro–Wilk test for normality and paired t test was used for comparing before- and after-session scores. The significance level was set at P < 0.05. Results: After taking educational sessions there is an enhancement in the level of knowledge (pre-session 9.65 ± 2.10 and post-session 16.59 ± 1.81), development of more positive attitudes (pre-session score 87.50 ± 7.29 and post-session score 118.94 ± 7.56), and amplification in the belief system of the subjects towards palliative care (pre-session score 3.56 ± 0.613 and post-session score4.91 ± 0.29) at significance level P < 0.05. Conclusion: Palliative care educational program had positively influenced the subjects by bringing about statistically significant changes in the level of knowledge, positive attitudes, and beliefs. Palliative care education must be added to the curriculum of physiotherapy undergraduate courses because of the necessity in society, and the upgradation of the physiotherapy profession.

Keywords: Attitude, belief, knowledge, palliative care, physiotherapy

How to cite this article:
Iram I, Veqar Z. Impact of palliative care training on knowledge, beliefs, and attitudes of undergraduate physiotherapy students: A pilot study. J Soc Indian Physiother 2022;6:3-9

How to cite this URL:
Iram I, Veqar Z. Impact of palliative care training on knowledge, beliefs, and attitudes of undergraduate physiotherapy students: A pilot study. J Soc Indian Physiother [serial online] 2022 [cited 2023 Feb 7];6:3-9. Available from: http://www.jsip.ac.in/text.asp?2022/6/1/3/331288

  Introduction Top

Palliative care as defined by World Health Organization (WHO) is “An approach that improves the quality of life of patients and their families facing the problems associated with life-limiting illness, through the prevention and relief of suffering using early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual”.[1] It is a system that delivers end-of-life care to the patients beginning from diagnosis till death and also offers bereavement care for the patient’s family after the patient’s death.[1] More than 9.8 million people die every year in India and the cause of approximately 60% of deaths are diseases that are noncommunicable like cancer.[2] According to the data from Worldwide Hospice Palliative Care Alliance, it is estimated that approximately 40 million people need palliative care every year in the world, including 5.9 million people in India.[3] Despite the passage of almost 25 years of initiation of palliative care services in India, till now, palliative care is available to merely approximately 1% of the Indian population.[4] It is imperative to mention here that under international human rights law warranting the availability of palliative care services is compulsory for health care systems.[5]

According to WHO, some major barriers need to be eradicated to meet the need for palliative care training, one of the important ones being an almost non-existent palliative care training for health professionals.[5] Some previous studies revealed that medical and allied healthcare professionals could not provide end-of-life care satisfactorily and the reason behind these results is the inadequate knowledge of palliative care among them. For achieving the purpose of providing a high quality of care and the avoidance of unnecessary suffering of palliative care patients, the healthcare professionals must have the necessary knowledge, exposure, and skills for doing so.[6] National health systems of all the countries have the responsibility of making policies for upliftment and enhancement of human resources, encompassing plans to provide palliative care training to existing health professionals and including palliative care in the core curriculum of all the health professional courses.[7] Hence, it is crucial for educational institutions to do the needful.

Many health care professionals are involved in the multidisciplinary palliative care team.[8] Physiotherapists play a crucial role in this team, beginning from controlling pain and other related symptoms to enhancing the patient’s quality of life.[8] The capability of disseminating knowledge and changing the patient’s attitude and behaviors towards palliative care exclusively depends upon the physiotherapist’s beliefs and behaviors.[9] According to Sobush and Fehring, for the achievement of maximum output from the treatment, the physiotherapist should assess patient’s attitudes, appearances, and behavior and must influence them by their attitudes, behaviors, and knowledge.[10]

There are enough studies that describe the knowledge and awareness of doctors, nurses, patient, and their caretakers about palliative care on different scales and questionnaires especially made for them but surprisingly there are very few studies that describe the extent of knowledge and awareness of the physiotherapists about the end of life care on questionnaires which are tailor-made for them.[8],[11] The knowledge, belief, and attitude of physiotherapy students have not been studied extensively. Hence, we have designed this study to assess the level of knowledge, attitude, and belief of physiotherapy students and evaluate if a training module improved them.

  Material and Methods Top

This study was duly approved by the institutional ethical committee (IEC). We had done this study as a pilot study to test the effect of our intervention and make improvements in the educational program to be used in a study with a larger sample size. All the subjects gave oral and written consent before their recruitment in the study as per the Declaration of Helsinki 2012.[12] They were duly informed about their right to withdrawal from the study at any given point in time. All identifying information on the consent form, demographic history, and questionnaires were kept confidential. Pre–post intervention design was used in the study.

We have taken a convenience sample of final-year bachelor of physiotherapy (4 years of academic training followed by 6 months of internship) students. Forty students were eligible for our study. Two of them did not give consent. Hence, we have included (n = 38), have had exposure to patients during clinical postings, and had a working knowledge of English voluntarily completed the study. Their age ranged between 21 and 26 years (22.03 ± 0.834) and both the sexes (male = 14; female = 24) were recruited. They were excluded if they had undergone any previous training in palliative care of any duration other than what was covered in their Bachelor of Physiotherapy curriculum. A first introductory session was given by the senior researcher working in the area of palliative care; further sessions were taken by the researcher only.


Before the commencement of the study, the purpose and methodology were explained to the subjects. The subjects filled all the scales mentioned in the outcome measures below before the first session of the educational program on palliative care. These readings were recorded as prescores. The educational program was created based on the suggestions given by Veqar et al.[13] It was given to the subjects in three sessions of 2 h each with 15 min break after 1 h. After the closing session of the palliative care educational program on day 3, the subjects were made to fill the same outcome measures again [Figure 1]. These were recorded as post-scores. Teaching sessions included blackboard teaching, PowerPoint presentations, and discussion on case studies.
Figure 1: Depiction of study flow from enrolment through analysis (attached separately)

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  Outcome Measures Top

Knowledge questionnaire

A self-administered questionnaire was used to assess the knowledge of subjects toward palliative care. This questionnaire had 20 multiple-choice questions: one point was given for each correct answer and zero for the incorrect one. The total score was out of 20.

Belief questionnaire

This questionnaire was used to assess the beliefs of final-year physiotherapy students towards palliative care both before and after the short-term educational program on palliative care. The questionnaire had five questions, responses were given as true or false, one point was given for each correct answer, and zero for each incorrect one. The total score was out of five.

The reliability of both these questionnaires was established before the commencement of the study and has been under review for publication. For knowledge questionnaire ICC (intraclass correlation coefficient) was 0.88,95% CI (0.73–0.94), and for belief questionnaire ICC was 0.70,95% CI (–0.09 to –0.80)

Frommelt’s Attitude towards Caring for the Dying scale

To measure the final-year physiotherapy student’s attitude toward palliative care, Frommelt’s Attitude towards Caring of the Dying (FATCOD)B scale was used. This scale has 30 items that aim to measure the subject’s attitudes towards providing care to people at the end of life. For each item scoring is done from 1 to 5 (1 = strongly disagree to 5 = strongly agree) scores are reversed for negative items. Maximum and minimum scores are 150 and 30, respectively. A higher score indicates a more positive attitude towards palliative care.[14] Reliability of the FATCOD scale has been established multiple times. The computed Pearson coefficient was found to be 0.94. The content validity index (CVI) of the FATCOD in 1988 was 1.00 with a computed inter-rater agreement of 0.98. The CVI was repeated in 1998 with an inter-rater agreement of 1.00.[15]

  Data Analysis Top

Data were assessed by a Shapiro–Wilk test for the normality of the distribution scores and paired t test was used for comparing pre-educational session and post-educational session scores of Knowledge questionnaire belief, knowledge, and FATCOD scales. The significance level was set at P < 0.05.

  Results Top

A total of 38 subjects participated in the study to determine the impact of palliative care educational programs on knowledge, beliefs, and attitudes. Pre-session scores were collected before the educational session and post-session scores were collected after completion of all three sessions of the educational program. There were four dropouts (absence in any session or incomplete filling of forms during the study). Thirty-four subjects were included for the data analysis.

Knowledge questionnaire

It was used to test the knowledge of the subjects about palliative care. There was a statistically significant improvement in the post-session mean scores of the questionnaire [Figure 2]; [Table 1] and [Table 2].
Figure 2: Pre–post comparison of total scores of knowledge questionnaire among the study group

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Table 1: Comparison of pre-session and post-session scores using paired t test

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Table 2: Paired sample t test (paired differences)

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Belief questionnaire

It was used to evaluate the beliefs of subjects for palliative care. There was an amplification of the belief system in the post-session mean scores of the questionnaire [Figure 3]; [Tables 1] and [2].
Figure 3: Pre–post comparison of total scores of belief questionnaire among the study group

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Frommelt’s Attitudes towards Caring of Dying-B scale

It was used to assess the attitudes of the subjects toward palliative care. Statistically, significant improvement was seen in the post-session mean scores of the scale [Figure 4]; [Table 1] and [Table 2].
Figure 4: Pre–post comparison of total scores of FATCOD scale among the study group

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  Discussion Top

This pilot study aimed to assess the impact of educational programs regarding palliative care of short duration on the knowledge, beliefs, and attitudes towards palliative care on the final-year physiotherapy students using knowledge questionnaire for assessing knowledge, belief questionnaire for testing beliefs, and FATCOD-B scale for checking attitudes as outcome measures. Scoring of knowledge was done based on the subject’s awareness about the term palliative care, its aims and methods used to deliver this care, and knowledge about other requirements of patients along with medical treatment like emotional, psychological and spiritual support. Belief scores were based on the understanding of palliative care and their thinking about palliative care. The scores of attitude scale scores were based on the subject’s point of view on the support and care provided to patients who are suffering from life-threatening diseases, and also the viewpoint on the fact that, whether the patients can be allowed to express emotions like anger, grief during palliative care treatment

In the pre-session scores of knowledge questionnaire, 56% of subjects scored less than 50% which indicates that there are gaps in palliative care knowledge among them. This is a significant result which points out a lacuna in our curriculum design and the non-preparedness of our young professionals to deal with palliative care patients. The results of the pre-session of our study were in line with the one done by Sadhu et al.,[16] whose results showed extensive deficiencies among undergraduate health care students regarding the understanding of palliative care. The results are also supported by another recent study done by Sujatha et al.[17] who concluded that basic knowledge about palliative care was inadequate among the undergraduate healthcare students.

The level of knowledge increased after the educational program, as indicated by the statistically significant difference which was observed between pre and post-session scores. The reason behind that may be a lack of understanding among subjects about palliative care before the educational session because of a deficiency of emphasis on the topic in the current undergraduate physiotherapy curriculum. The study was done by Divyalasya also supports our findings, they showed the positive impact of the educational session on knowledge of second-year physiotherapy, nursing as well as medical students on a single 20-point knowledge and attitude scale. They did not use belief as their outcome measure.[9]

There were some deficiencies in the belief system of the subjects at the time of recording pre-session scores but after the educational sessions, a significant difference was noticed. There is amplification in their belief system post-training. This may be attributed to the fact that they have not studied it as a separate subject rather it has been a non-existent subtopic in some other subjects. It is also worth mentioning that there is a lack of exposure to the palliative care settings in the clinical setting hence the clinical exposure to these subjects is very minimal. As a result of this their belief system has deficiencies regarding palliative care. For the support of our results, there is clear evidence from the results of the study done by Kumar et al.[8] examining the changes in knowledge, attitudes, beliefs, and experiences among them before and after an educational session on palliative care using a single scale, they also determined improvement in positive attitudes basic knowledge and beliefs regarding palliative care in the students after receiving an educational session.

Before the session, there was a lack of positive attitudes among subjects towards palliative care, we found that there is a scarcity of exposure to palliative care patients during the clinical postings, hence subjects are not aware of handling the palliative care patients which ultimately leads to the development of lack of positive attitudes. These findings are consistent with the results of Kulkarni et al.[11] who concluded that there is a lack of awareness among physiotherapy students before the educational program and there is a need to integrate palliative care education into the physiotherapy curriculum.

For improving the access to palliative care in India, education of health care professionals is a must.[6] According to previous researches, physiotherapist is an important member of the interdisciplinary palliative care team Physiotherapist works include the management of pain and other symptoms and enhancing the quality of life of people having terminal illnesses.[8] Hence, providing them the necessary knowledge about their roles and work is a must. Veqar Z has described the details of the importance of the role of physiotherapy in palliative care and also written about the perspectives of including palliative care in their curriculum.[4],[8] Our study also establishes the need for including palliative care in the curriculum of physiotherapists.

Therefore, in light of the results of our study and the past studies, there is clear evidence that there is a lack of knowledge of palliative care in health professionals as our study is on physiotherapy students we recommend that it must be included in the undergraduate curriculum of physiotherapy. There must be a standardized curriculum throughout the country. This will help the students in handling the patients in palliative care setups and teach them the need for support and planned strategies for terminally ill patients and in bereavement management. Though our intervention was a short program of three sessions of 2 h, there were significant differences in all variables we can say that educational training focused on palliative care can bring about a positive change eventually in the students. As it was a pilot study there were few limitations. First, the number of hours can be increased and incorporated into the curriculum. Second, palliative care is Interdisciplinary; hence, classes should be conducted in that manner. Furthermore, this study was based on a single university comparison between undergraduate physiotherapy students of different universities/colleges can help to substantiate the data.

  Conclusion Top

Palliative care educational program had positively influenced the subjects by bringing about statistically significant changes in the level of knowledge, positive attitudes, and beliefs. Palliative care education must be added to the curriculum of physiotherapy undergraduate courses because of the necessity in society, and the up-gradation of the physiotherapy profession.


The authors gratefully thanks Tarushi Tanwar, Mosab Aldabas, and all the participants involved in the present study.

Conflicts of interest

There are no conflicts of interest.

Financial support and sponsorship


Authors’ contribution

Study design: Zubia Veqar and Iram Iram.

Data collection: Iram Iram.

Data analysis: Iram Iram.

Paper writing: Zubia Veqar and Iram Iram.

Paper revision: All authors have revised and approved the final manuscript.

Study supervision: Zubia Veqar.

All authors gave substantial contribution to manuscript revision and editing.

  References Top

WHO Definition of Palliative Care. Geneva: World Health Organization; 2010. Available from: http://www.who. int/cancer/palliative/definition/en. [Last accessed on 2020 Mar 3].  Back to cited text no. 1
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Press Trust of India, ‘Kerala Population Ageing Fast: Survey,’ Business Standard; 2018. Available from: https://www.business-standard.com/article/pti-stories/kerala-population-ageing-fast-survey114091800463_1.html. [Last accessed on 2020 Jan 22].  Back to cited text no. 3
Veqar Z. The perspectives on including palliative care in the Indian undergraduate physiotherapy curriculum. J Clin Diagn Res 2013;7:782-6.  Back to cited text no. 4
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2]


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