Evaluation of training effectiveness and patient referral patterns in palliative care by ASHAs and ANMs in Jodhpur

Bhargaviba Jadeja; Srikanth Srinivasan; Manoj Kamal; Pankaj Bhardwaj; Manoj Kumar Gupta; Anjum Khan Jaod; Bharat Paliwal; Latha A.

doi:10.18203/2394-6040.ijcmph20263595

Authors

Bhargaviba Jadeja Department of Community Medicine & Family Medicine, AIIMS, Jodhpur, India
Srikanth Srinivasan Department of Community Medicine & Family Medicine, AIIMS, Jodhpur, India
Manoj Kamal Department of Anaesthesiology & Critical Care, AIIMS, Jodhpur, India
Pankaj Bhardwaj ICMR-NIIRNCD, Jodhpur, Rajasthan, India
Manoj Kumar Gupta Department of Community Medicine & Family Medicine, AIIMS, Jodhpur, India
Anjum Khan Jaod Palliative Care, Bhagwan Mahaveer Cancer Hospital and Research centre, Jaipur, Rajasthan, India
Bharat Paliwal Department of Anaesthesiology & Critical Care, AIIMS, Jodhpur, India
Latha A. Department of Pediatric Nursing, College of Nursing, AIIMS Jodhpur, India

DOI:

https://doi.org/10.18203/2394-6040.ijcmph20263595

Keywords:

ASHA, ANM, Patient referral, Community health workers, Primary healthcare

Abstract

Background: Access to palliative care is still limited in India with Rajasthan and this is accompanied by a lack of awareness and trained personnel. Frontline workers like ASHAs and ANMs can help to improve early identification and referral of patients in need of palliative care. To assess effectiveness of palliative care training of ASHAs and ANMs and its effect on the pattern of referrals to patients in Jodhpur.

Methods: A quasi-experimental study was carried out in selected 21 Urban Primary Health Centres in the period from before (Sept-2024 to Jun-2025). The participants went through a two-day structured training programme. Knowledge was evaluated by a validated 18-item questionnaire in pre- and post-tests and referrals were followed for 6 months. Data were analysed with paired t-test and descriptive statistics.

Results: Significant improvement of knowledge scores was noted post training (P<0.05) with similar improvement among ASHAs and ANMs. A total of patients were identified and referred with a steady increase in referrals over time. Field exposure through home visits increased use of referral activity.

Conclusions: Structured training has been effective in improving knowledge and referral practices. Integrating trained frontline workers with supportive supervision and referral systems in community-based palliative care in resource limited settings.

References

Johnston BM, Ní Chéileachair F, Burke S, McQuillan R, May P, Davis L, et al. Review of the Implementation of the 2001 Report of the National Advisory Committee on Palliative Care as it relates to Adult Palliative Care. Dublin: Department of Health. 2022;3:67.

Clark J. Palliative care as a global health issue. inresearch handbook on end-of-life care and society. 2025: 537-544.

Bolton P, West J, Whitney C, Jordans MJ, Bass J, Thornicroft G, et al. Expanding mental health services in low-and middle-income countries: A task-shifting framework for delivery of comprehensive, collaborative and community-based care. Cambridge Prisms: Global Mental Health. 2023;10:16.

Tripodoro VA, Fidalgo JF, Pons JJ, Connor SR, Garralda E, Bastos F, Montero Á, Llamas LM, Béjar AC, Suárez D, Centeno C. First-ever global ranking of palliative care: 2025 World Map under the new WHO framework. J Pain Symp Man. 2025;2:76..

Vijay D. Plural imaginaries: reflections on end of life care from India. InResearch Handbook on End of Life Care and Society 2025 Sep 16 (pp. 113-128). Edward Elgar Publishing.

Varkey BP, Ghoshal A, Salins N, Mayland CR. Mapping end-of-life care in India: a scoping review to identify gaps in policy, practice and psychosocial support. BMC Palliative Care. 2025;24(1):189.

Phan HH, Gandhi I. Strategies to enhance palliative care access in rural populations and increase awareness of life-limiting illnesses in India: A scoping review. J Cancer Policy. 2025;11:100612.

Chandra A, Kumar R, Bhatnagar S, Nongkynrih B, Bhatnagar Sr S. Assessing awareness and palliative care needs in rural Haryana, North India: a community-based study. Cureus. 2023;15:10.

Naryanan P, Sinha M, Bharadwaj S. Participation, social accountability and intersecting inequalities: challenges for interventions to build collective identity with De-notified, Nomadic and Semi-Nomadic Tribal communities in India. Community Development J. 2020;55(1):64-82.

Seaman S, Elwell C, Kitzinger J. Nicola Jane Frances Pease International Online Learning for a Novel Area of Palliative Care: Prolonged Disorders of Consciousness Patients Dying following Withdrawal of Clinically-assisted Nutrition and Hydration. Indian J Palliative Care. 2025;31(2):119.

Gadapani Pathak B, Sandøy IF, Nisar YB, Singh M, Kumar M, Madhur T, et al. Assessing the feasibility of implementing the national childhood pneumonia management program within existing health systems: a mixed-methods study. BMC Health Services Res. 2025;19;25(1):277.

Abel J, Kellehear A, Karapliagou A. Palliative care—the new essentials. Ann Palliative Med. 2018;7(2):3-14.

Chaudhary SR, Thomas A. Palliative care models in primary health care system of India: a scoping review. BMC Palliative Care. 2025;24(1):221.

Khatri RB, Endalamaw A, Erku D, Wlka E, Nigatu F, Zewdie A, et al. Enablers and barriers of community health programs for improved equity and universal coverage of primary health care services: A scoping review. BMC primary care. 2024;25(1):385.

Hewitt S, McNiesh S, Fink L. Barriers to primary care access in rural medically underserved areas: immediate care: a simple solution to a complex problem. Online J Rural Nursing and Health Care. 2019;4:127-55.

MacRae MC, Fazal O, O'Donovan J. Community health workers in palliative care provision in low-income and middle-income countries: a systematic scoping review of the literature. BMJ Global Health. 2020;25;5(5):569.

Fradgley EA, Paul CL, Bryant J. A systematic review of barriers to optimal outpatient specialist services for individuals with prevalent chronic diseases: what are the unique and common barriers experienced by patients in high income countries?. International J Equity Health. 2015;9;14(1):52.

Malichewe CV, Yoram F, Lyamai J, Mkusa V, Kiwango G, Nyongole O, et al. Struggles for provision of palliative care services at the primary healthcare setting in Tanzania; Experiences from health facility in-charges in Dar es Salaam; A qualitative study. PLoS One. 202621(2):342485.

Biswas DK, Deb LM, Dasgupta P, Maity S, Mukherjee A, Manna S. Assessment of knowledge on palliative care among the community health officers in rural area of Purba Medinipur District, West Bengal, India. Indian J Palliative Care. 2024;16;30(1):65.

Gbeminiyi OT, Oyeneye AI. Evaluation of immunization service delivery in primary healthcare centers in Akinyele and Lagelu local government areas, Oyo State, Nigeria. SAGE Open Medicine. 2025;13:22974.

Nayak MG, Pai RR, Nayak BS, Salins N. Improving symptom assessment and management in the community through capacity building of primary palliative care: A study protocol of exploratory research. F Research. 2022;11:733.

Gupta M, Rai V, Kanaria A, Marcus S, Joshy LE, Kaur J, et al. Training Improves Community Health Workers’ Knowledge and Perception of Palliative Care: A Quasi-experimental Study. Indian J Palliative Care. 2026;32(1):65-71.

Morrow A, Chan P, Tucker KM, Taylor N. The design, implementation and effectiveness of intervention strategies aimed at improving genetic referral practices: a systematic review of the literature. Genetics in Medicine. 2021;23(12):2239-49.

Ringborg U, von Braun J, Celis J, Baumann M, Berns A, Eggermont A, et al. Strategies to decrease inequalities in cancer therapeutics, care and prevention: Proceedings on a conference organized by the Pontifical Academy of Sciences and the European Academy of Cancer Sciences, Vatican City. 2023.

Babu BV, Kusuma YS. Health Care of the Elderly in the Context of Universal Health Coverage: An Overview of Policies and Programs in India. Handbook of Aging, Health and Public Policy: Perspectives from Asia. 2025;1:955-70.

Sood N. Management of delivery of community health services. comprehensive textbook of community health nursing including environmental science (Two Volume Set), -E-Book. 2025;7:444.

Bhatnagar S, Patel A. Effectiveness of the certificate course in essentials of palliative care program on the knowledge in palliative care among the participants: A cross-sectional interventional study. Indian J Palliative Care. 2018;24(1):86.

Singh T, Harding R. Palliative care in South Asia: a systematic review of the evidence for care models, interventions and outcomes. BMC Res Notes. 2015;8(1):172.

Potts M, Cartmell KB, Nemeth LS, Qanungo S. A qualitative evaluation of a home-based palliative care program utilizing community health workers in India. Indian J Palliative Care. 2019;25(2):181.

Gupta M, Kankaria A, Garg L, Bhatty SM, Lal B, Singh S, et al. Barriers and facilitators to accessing and providing palliative care to people with cancer in the Bathinda district in Punjab: a qualitative study. BMC Health Serv Res. 2025;25(1):1565.