Our study aimed to determine the depth of knowledge and awareness of medical students across Pakistan concerning palliative care. Our findings reveal a predominance of female respondents, suggesting potential gender-based variations in interest levels toward this critical healthcare facet. Our findings are consistent with previous studies, which have shown similar trends in interests varying among both genders(9)(10)(11)(12). This observation prompts a critical appraisal of the efficacy of medical institutions nationwide in instilling a uniform appreciation for palliative care among their student cohorts.
Our study, which was conducted at Aga Khan University in Karachi, which is located in the province of Sindh, might have naturally attracted substantial attention from this region. However, it is important for us to acknowledge the inherent limitations of this regional focus, as the disproportionately high response rate from Sindh may not faithfully represent the awareness levels of medical students from other provinces, particularly Balochistan and the KPK. Punjab, the region with the highest proportion of medical students nationwide (MDCAT 2021 Data Analysis Report), provided a mere 17.9% of the responses. Furthermore, the markedly lower response rates from these regions, at 3.3% and 5.3%, respectively, underscore the imperative for more comprehensive, geographically inclusive research projects to capture a holistic understanding of Palliative Care awareness nationwide.
An intriguing demographic trend emerges from our data, with the majority of respondents consisting of students from the third and fourth years of medical school. This phenomenon suggests a burgeoning interest in palliative care as students progress through their academic journey. However, despite this apparent trajectory of increased familiarity, our analysis reveals a consistency in the mean packs score across different academic years, as the level of knowledge of more senior students did not differ significantly from that of juniors, while previous research suggests that as students advance through higher grades, their knowledge scores tend to improve, indicating a positive trend. (13)(14). This signals a deeper examination of the educational approaches employed within medical curricula nationwide. Are current instructional methodologies adequately equipping students with the requisite knowledge and skills to navigate the complexities of palliative care? Or does the static nature of knowledge acquisition as students advance through their studies hint at systemic inadequacies in curriculum design and implementation?
Our study revealed a mean score of 9.699, with a standard deviation of 2.76 among medical students in Pakistan, indicating a solid understanding of palliative care. Kozlov's community-based sample reported a mean score of 5.25 (SD = 4.77, range = 0–13), highlighting that Pakistani medical students outperform the general public in terms of palliative care knowledge. Furthermore, compared to a cross-sectional study by Mallon et al. among undergraduate students at a UK university, our findings show a higher mean score. Given that the PACKS is a recently developed tool, the only comparable score available is from the study by (12), which evaluated undergraduate students at a university in the UK. Among the various student groups, those enrolled in the faculty of life and health sciences department achieved a mean score of 9.5 with a standard deviation of 3.2, the highest among the three types of faculties studied. According to our study, Pakistani medical students still demonstrate a superior understanding of palliative care concepts.
Our study pinpointed familiarity with palliative care prior to the questionnaire as the sole variable significantly impacting the mean packs score. Consequently, we delved into the factors influencing this familiarity.
Institutional affiliation emerged as a notable determinant, with students from private institutes reporting higher levels of prior familiarity with the topic. Similarly, a positive correlation was observed between monthly family income and prior awareness of palliative care. This observation could be rationalized by Pakistan's status as a low-middle income country(15), where limited resources may restrict access to services such as palliative care to households with higher incomes. Moreover, higher income levels may be associated with greater levels of family literacy(16), thus facilitating awareness through research or word of mouth. However, despite these correlations, none exerted a significant direct impact on the mean packs score, suggesting a deficiency in understanding, leaving students potentially misinformed rather than uninformed.
Interestingly, when queried about prior experience in caring for a person at the end of life, a greater proportion of male respondents answered affirmatively—a finding that was both surprising and expected. This is surprising considering the prevailing patriarchal norms in Pakistani society, where caregiving duties typically fall to females who oversee tasks such as bathing, dressing, and cooking for sick relatives(17). However, this is also expected, as our results align with those of prior studies indicating a high incidence of similar experiences among males(18). This trend could be indicative of a growing male inclination toward healthcare professions and could also be reflective of common practices in Pakistan, where a greater sense of responsibility is bestowed upon men in household matters, particularly those of a more serious nature, where they often assume decision-making roles(19). In future research projects, this aspect could further be explored by inquiring about the nature of tasks that were assigned to them.
Another notable finding relates to students' interest in pursuing palliative care as a profession. Interestingly, students from lower-income households showed more enthusiasm for this career path. We speculate that those hailing from less affluent backgrounds might be more aware of the ground reality of patients and have a better idea of suffering that ensues due to lack of resources, fostering a stronger sense of empathy and a desire to help others in similar situations. Moreover, cultural and community values might place a high emphasis on caregiving and supporting the elderly and the ill, influencing career choices, especially in communities where such roles are highly respected.
Upon scrutinizing the responses from students to our questionnaire, we directed our attention toward examining three specific items: items 5, 10, and 11.
Item 5 sought to gauge students' understanding of the notion that "Palliative care is only for people in their last six months of life." While a majority of respondents answered correctly, a notable portion (31.3%) admitted uncertainty by selecting "I do not know," and a significant fraction (17.5%) provided incorrect responses. This observation suggests a lack of clarity among students regarding the scope of palliative care, with many possibly assuming that palliative care is only applicable in the final stages of life. Moving on to item 11, which inquired whether "Palliative care means stopping treatments aimed at curing the illness," approximately 70% of respondents answered correctly. However, the remaining participants were divided between selecting "I do not know" and incorrectly affirming the statement as "true." Notably, both items 5 and 11 touch upon criteria commonly associated with hospice care. The fact that a considerable number of students struggled with these questions implies a degree of confusion between palliative and hospice care, possibly stemming from the interchangeable use of these terms despite their distinct purposes and practices.
Turning our attention to item 10, which posited that "Palliative Care helps people understand their treatment options better," it is notable that a quarter of respondents expressed uncertainty about this statement. This uncertainty may stem from the misconception that palliative care is exclusively reserved for end-of-life scenarios, where treatment options may be perceived as limited. This lack of clarity may also contribute to the observed difficulties in correctly answering item 11. Kozlov’s study(20), though focused on community-dwelling adults rather than students, revealed similar patterns in awareness and knowledge about palliative care. In her research, items 5, 10, and 11 also had a significant number of incorrect responses. However, her study showed a much greater percentage of “don’t know” individuals than did our study. This suggests that while many of our respondents were uncertain about the correct answers, they were still more aware of and had a better understanding of the differences between palliative care and hospice. This is particularly notable compared to a community-based sample of educated adults in a developed country.
In light of these findings, it becomes evident that there is a need for greater clarity and understanding regarding the nuances of palliative care among medical students. Addressing this knowledge gap could be achieved through comprehensive education that encompasses both palliative and hospice care topics, elucidating the appropriate contexts for each type of care.
Strengths:
This study represents a pioneering effort in Pakistan and is the first of its kind to explore palliative care awareness among undergraduate medical students. Unlike the previous literature limited to healthcare workers, our study casts a wider net, gathering responses from across Pakistan rather than from a few select institutes. In contrast to existing studies focusing solely on undergraduate medical students, ours encompasses a broader demographic, providing a more representative snapshot of the country's student population. Moreover, given the dearth of recent literature on this topic in Pakistan, our study fills a critical gap by offering an updated perspective on palliative care awareness among students. A recent scoping literature review by Patel et al. highlights the urgent need for more studies on knowledge, attitudes, and practices (KAPs) related to palliative care in developing countries. This review highlights a significant gap in the literature from these regions, highlighting the necessity for more comprehensive research to understand and improve palliative care awareness and practices in developing nations.(21) Hence, our study contributes to addressing this gap by providing valuable insights and data from a developing country context, thereby adding to the limited but growing body of research in this area. Additionally, our utilization of the Packs questionnaire, a validated tool for assessing knowledge of palliative care, adds robustness to our findings. Its proven efficacy in accurately gauging knowledge levels, coupled with our study's demonstration of construct validity and potential for educational interventions, underscores its utility in both research and practice.
Limitations:
Despite extensive dissemination efforts via social media, the response rate remained relatively low, as evidenced by the varying number of respondents from each province. This discrepancy in response rates among provinces underscores a limitation in the generalizability of our findings to the entire population of undergraduate medical students in Pakistan.