Stakeholder Perspectives on the Family Adoption Program in a Newly Established Rural Medical College, Odisha: A Qualitative Study

Abstract

Background:

The Family Adoption Program (FAP), introduced under India’s Competency-Based Medical Education (CBME) framework, aims to promote early community engagement, empathy, and contextual understanding among medical students. This study explored multi-stakeholder perspectives on FAP implementation in a newly established rural medical college in Odisha.

Materials and Methods:

A qualitative exploratory study was conducted using focus group discussions (FGDs), key informant interviews (KIIs), and in-depth interviews (IDIs) among first-year MBBS students (n = 20), faculty (n = 8), community health workers (n = 2), and community households (n = 10). Data were collected using semi-structured guides, audio-recorded, transcribed, and analyzed using Braun and Clarke’s thematic analysis approach with inductive coding and triangulation across stakeholder groups. Analytical approach: Manual coding and thematic analysis.

Results:

Five core themes emerged: emotional connection and trust, role expectations and identity confusion, communication and cultural barriers, learning and transformation through exposure, and program facilitation and orientation. Strong concordance across stakeholders highlighted rapid rapport-building and experiential learning, facilitated by frontline health workers. However, discordance was evident in role expectations, with communities often anticipating curative services, and in program facilitation, where gaps in orientation and preparedness were noted. Communication challenges extended beyond language to sociocultural and structural factors influencing engagement.

Conclusions:

FAP is an effective platform for early experiential learning and social accountability in rural settings. However, its implementation is shaped by context-specific challenges, including role misinterpretation and facilitation gaps. Strengthening community sensitization, continuous mentorship, and systematic integration of frontline health workers as community partners may enhance the social accountability and effectiveness of FAP.

INTRODUCTION

Medical education is increasingly oriented toward social accountability, which emphasizes aligning medical education, research, and service with the priority health needs of the communities served, and toward population health. Community-based medical education (CBME) enables this shift[1] by embedding learning in real-world settings. In India, the National Medical Commission introduced the Family Adoption Program (FAP) under CBME,[2,3,4] assigning MBBS students to longitudinally engage with families in field practice areas. The program aims to foster early community orientation, empathy, and contextual understanding through sustained interaction, supported by faculty and frontline health workers.[2,4,5,6]

MATERIALS AND METHODS

Aim

This study aimed to explore the perspectives of multiple stakeholders on the implementation of the Family Adoption Program (FAP) at a newly established rural medical college, focusing on experiences, perceived benefits, and operational challenges.

Study design

A qualitative exploratory study was conducted using focus group discussions (FGDs), key informant interviews (KIIs), and in-depth interviews (IDIs). The study was guided by a thematic analysis approach to capture stakeholder experiences and perspectives.

This project was undertaken as part of the Advanced Course in Medical Education (ACME), Batch 2025A, under the Nodal Center for Medical Education, Sri Ramachandra Medical College and Research Institute (SRMC), Chennai.

Study setting and timeline

The study was conducted in the rural field practice area of Matabad village, under the Jajpur block in Odisha, serving a predominantly rural, low- to middle-income population. Data collection was carried out over a one-month period, while the overall project, including planning, analysis, and reporting, was completed within the ACME program timeline (FEB-DEC 2025). Given the focused exploratory design, the study prioritized depth of interaction over prolonged duration.

Participants and sampling

Purposive sampling was used. The study included first-year MBBS students (n = 20/50, 10 boys and 10 girls in the two groups, from the Phase 1 MBBS class) selected through voluntary participation with gender representation via separate FGDs; faculty members (n = 8/10) from the Department of Community Medicine involved in FAP implementation; community health workers (n = 2/2) comprising one ASHA and one CHO; and community households (n = 10) previously engaged under FAP.

Participants were approached through face-to-face interactions. Students were recruited outside academic hours after being briefed about the study, while faculty, health workers, and households were contacted during routine academic or field visits. A total of 40 participants were included. Among households approached (n = 14), four declined to participate due to a lack of time and interest.

Data collection

Data collection was conducted by faculty members from the Department of Community Medicine, all of whom held at least an MD and were assistant professors and the Professor. The research team included six female and two male investigators with prior training and experience in qualitative research. FGDs were facilitated by the principal and co-investigators (with an observer and a note-taker), while KIIs and IDIs were conducted by trained faculty members (a single interviewer with one observer).

Semi-structured interview guides [Supplementary File: Annexure 1], aligned with the study objectives and refined through internal peer review, were pilot-tested with a few available stakeholders before the finalization of questions and probes. FGDs were conducted in a seminar hall, KIIs in faculty chambers and workplace settings, and IDIs in participants’ homes. Interviews lasted 20–45 minutes.

Interviews were conducted in Odia, Hindi, or English, depending on participants’ preference (as all India-level students were also enrolled in the institute). All sessions were audio-recorded, and field notes were maintained to capture contextual details and non-verbal cues. Repeat interviews were not conducted. Care was taken to minimize external interruptions during interviews; however, minor disruptions occurred during household interviews due to natural home settings.

Data analysis

Audio recordings were transcribed and translated into English by an independent bilingual translator. Transcripts were cross-checked for accuracy by the research team and were not returned to participants due to time constraints. Data were analyzed using Braun and Clarke’s six-phase thematic analysis approach.[7] Manual inductive coding was performed using a Microsoft Excel coding matrix, with Microsoft Word used for transcript review and annotation. An illustrative thematic network was created using Genspark.ai. Initial coding was undertaken by one researcher and independently reviewed by the principal investigator and two co-investigators. Coding discrepancies were resolved through discussion and consensus. Codes were iteratively refined into subthemes and overarching themes, with the complete thematic framework provided in Supplementary Annexure 2. Data saturation was determined through iterative analysis when no new codes or themes emerged across successive interviews.

Reflexivity and Rigor: Interviews were conducted by faculty members affiliated with the institution, which may have introduced potential bias due to academic relationships, particularly with student participants. The possibility of social desirability bias is acknowledged. Bias was minimized through independent coding, peer debriefing, and consensus discussions. This study was conducted and reported in accordance with the COREQ (Consolidated Criteria for Reporting Qualitative Research) guidelines [Supplementary File: Annexure 3].

Ethical considerations

Ethical approval was obtained from the Institutional Ethics Committee (Approval number 13/25, date April 23, 2025). All stakeholder participation was voluntary, especially among the students and faculty. Written informed consent was obtained from all participants after providing study information in the local language. Confidentiality and anonymity were maintained throughout the study.

Data management

All interviews were audio-recorded with participants’ informed consent. Audio files and verbatim transcripts were stored on a password-protected computer accessible only to the research team. Personal identifiers were removed during transcription, and each participant was assigned a unique study identification code to maintain confidentiality. Audio recordings will be securely retained until five years post-publication, after which they will be permanently deleted in accordance with IEC guidelines. All reported quotations were anonymized to prevent participant identification.

RESULTS

This study generated rich qualitative insights into the implementation of the Family Adoption Program (FAP) through triangulated perspectives of students, faculty, community members, and frontline health workers. Household respondents were predominantly female, reflecting availability during home visits. Across stakeholder groups, there was strong convergence in recognizing FAP as a transformative platform for early community engagement. However, the data also revealed important tensions between expectations and delivery, highlighting the need for clearer role definition, structured facilitation, and context-sensitive implementation.

Thematic analysis revealed five core themes. The relationships among these themes and the central facilitative role of ASHA/CHO across stakeholder groups are illustrated in Figure 1. The thematic network demonstrates how ASHA/CHO functioned as the key bridging stakeholder, linking community engagement, communication, program facilitation, and experiential learning while mediating trust and role expectations.

Figure 1.

Thematic Network of the Family Adoption Programme (FAP): ASHA/CHO as the Central Bridging Stakeholder Across Stakeholder Perspectives. The figure illustrates the five overarching themes identified through triangulated qualitative analysis of interviews and focus group discussions with students, faculty, households, and ASHA/CHO. ASHA/CHO emerged as the central bridging stakeholder, facilitating communication, translation, rapport-building, family identification, health education, and community engagement. The network highlights the interrelationship between Emotional Connection and Trust, Role Expectations and Identity Confusion, Communication and Cultural Barriers, Learning and Transformation Through Exposure, and Programme Facilitation and Orientation, demonstrating how these themes collectively shape the implementation and perceived effectiveness of the Family Adoption Programme

Theme 1: Emotional connection and trust

A dominant and consistently reported finding across all stakeholder groups was the rapid development of emotional connection and trust between students and community members.

Community members expressed deep respect and acceptance of students, often extending familial warmth and trust. This perception was rooted in the symbolic value attached to the medical profession, with students being viewed as future doctors deserving of credibility and respect. One student reflected this dynamic:

“The villagers think we are real doctors and sometimes expect medicines.”

Similarly, frontline health workers noted that communities were more receptive when students were introduced through trusted intermediaries:

“People respect students as future doctors… they’ll listen.”

Community members described students in relational terms, indicating a sense of inclusion and acceptance:

“They’re like our daughters… we have made them our friends.”

Students themselves reported an emotional journey marked by initial apprehension, followed by increasing comfort and connection:

“I was a bit excited but nervous… we had never done this before, but as we went, it became easier.”

Faculty observations corroborated this transition, noting a visible shift from hesitation to active engagement within a short period.

Theme 2: Role expectations and identity confusion

While emotional connection emerged as a strength, it was closely accompanied by significant ambiguity about student roles, which formed the second major theme.

Community members frequently perceived students as healthcare providers or representatives of government services, leading to expectations that extended beyond the program’s intended scope. A student recounted:

“Some people thought we were from the government and asked us to get their pension released.”

Similarly, households often expected direct medical or material benefits:

“They said we can go to the medical college, and through them, maybe we’ll get medicines or other help.”

In several instances, the presence of students was interpreted as part of survey or welfare distribution activities:

“One person thought we came to do a survey for some scheme and was upset we didn’t give anything.”

These misconceptions created practical and emotional challenges for students, who found themselves navigating expectations they were neither equipped nor authorized to meet. The mismatch between perceived and actual roles contributed to discomfort and, at times, dissatisfaction among community members.

Frontline health workers played a critical mediating role in clarifying these misunderstandings, yet the persistence of such expectations indicated gaps in pre-engagement sensitization. Faculty also acknowledged the need for clearer communication strategies:

“We need to sensitize the community beforehand… otherwise there is confusion or disappointment.”

Theme 3: Communication and cultural barriers

Despite the early establishment of rapport, participants across all stakeholder groups highlighted persistent communication and sociocultural barriers that shaped the quality and depth of engagement.

Language emerged as one of the most immediate and tangible barriers, particularly during initial household visits. Students frequently encountered difficulties in communicating effectively due to linguistic diversity within rural communities:

“We faced a lot of language issues. Sometimes we had to ask ASHA to translate everything.”

These challenges often necessitated reliance on frontline health workers, especially ASHAs, who acted as critical linguistic and cultural intermediaries. Health workers themselves acknowledged this bridging role:

“Some people don’t know who the students are… language barriers exist.”

Beyond language, students also encountered cultural resistance and sensitivity around personal topics, particularly those related to health behaviors, income, and social practices. Many reported discomfort in initiating such conversations:

“It was difficult to ask personal questions like alcohol habits or illnesses. Some got irritated.”

These experiences reflect the intersection of cultural norms, privacy concerns, and power dynamics, which influenced the extent to which participants were willing to engage openly.

Faculty perspectives further highlighted logistical and environmental constraints affecting fieldwork implementation:

“Field logistics are challenging due to weather and scheduling.”

Such operational barriers, combined with communication gaps, often limited the continuity and effectiveness of interactions.

Importantly, underlying structural vulnerabilities, particularly poverty, shaped both communication and expectations. Community members expressed lived realities that framed their interactions with students:

“What can we really do? We don’t even have a proper house.”

Theme 4: Learning and transformation through exposure

A central strength of the Family Adoption Program, consistently emphasized across stakeholders, was its role in facilitating experiential learning and personal transformation among students.

Students reported that field exposure enabled them to move beyond theoretical knowledge, fostering a deeper appreciation of the human dimensions of healthcare:

“We learned how to treat everyone with empathy… we had to connect with people emotionally.”

Faculty echoed this transformation, observing significant growth in students’ attitudes and perspectives:

“FAP builds empathy, improves students’ ability to understand community needs.”

Exposure to real-life conditions—such as poverty, inadequate housing, and limited access to healthcare—allowed students to contextualize medical knowledge within the broader social determinants of health. This shift from abstract learning to lived experience was frequently described as impactful:

“Before this, medicine was theory and books. After this, I started to see health as something human.”

Health workers also recognized opportunities for students to contribute meaningfully through health education and counseling, suggesting areas where their engagement could be further strengthened:

“Students should counsel families more, like risks of an untreated cold becoming pneumonia.”

From the community perspective, interactions with students were not one-directional but involved reciprocal exchange and mutual learning. Community members expressed both appreciation and expectations:

“If they could check our health and provide medicines, that would be better.”

While these expectations sometimes contributed to role confusion, they also reflected the perceived value of student engagement and the community’s openness to interaction.

Theme 5: Program facilitation and orientation

The effectiveness of the Family Adoption Program was strongly influenced by the nature and quality of program facilitation and orientation processes, which emerged as a distinct theme across stakeholders.

Students reported that structured orientation sessions, including role plays and demonstrations, were helpful in preparing them for field engagement:

“We had role plays in orientation. That helped us understand how to talk and manage if people are uncooperative.”

Faculty also emphasized the importance of equipping students with communication and behavioral competencies prior to field exposure:

“Students should be trained in basic communication and behavior before fieldwork.”

However, despite these preparatory efforts, several participants indicated that orientation was insufficient in addressing real-world complexities, particularly in handling community expectations and emotionally challenging interactions:

“Orientation helped, but we felt unprepared to handle people who expected medical advice. We needed more guidance on that.”

Faculty acknowledged similar gaps, especially in communication training and situational preparedness:

“There are gaps in the communication training of students.”

Frontline health workers, particularly ASHAs and CHOs, played a pivotal facilitative role in program implementation. They were instrumental in identifying households, introducing students, and supporting communication:

“I help identify families during home visits and support with spreading health messages.”

Their involvement often determined the success of initial engagement, particularly in communities unfamiliar with the program. However, even among health workers, initial confusion regarding program structure and objectives was evident:

“I didn’t know initially. This is the first time we’re doing it here… a madam from the medical college explained it.”

Health workers also demonstrated a clear understanding of program expectations once oriented:

“Each student will adopt three to five households, collect data, and build community relationships.”

Triangulation and convergence of stakeholder perspectives

Table 1 presents triangulated stakeholder perspectives across the five core themes, with embedded subthemes reflecting the analytical depth of the thematic framework.

Table 1.

Triangulated perspectives on core themes across stakeholders

Theme (Subthemes)		Households (Community)		Field Workers (ASHA/CHO)		Faculty		Students
Emotional Connection and Trust (medical identity, emotional bonding, initial apprehension)		Developed trust; perceived students as family; expressed emotional closeness and acceptance		Facilitated rapport-building; observed strong community acceptance and respect for students		Noted transition from hesitation to engagement; recognized growth in empathy and relational skills		Experienced emotional bonding; initial nervousness followed by comfort and connection; valued interpersonal engagement
Role Expectations and Identity Confusion (misinterpretation of role, expectations of care, government linkage)		Expected medicines, healthcare services, or linkage to schemes; perceived students as doctors or officials		Clarified student roles; managed expectations; recognized persistent confusion in community		Identified need for pre-engagement sensitization; acknowledged gaps in role clarity		Faced pressure due to unrealistic expectations; struggled with inability to provide medical or material support
Communication and Cultural Barriers (language barriers, cultural sensitivity, structural constraints, field logistics)		Faced difficulty understanding purpose; discomfort discussing sensitive issues; influenced by poverty and living conditions		Acted as translators and cultural mediators; highlighted local communication gaps and contextual barriers		Identified sociocultural and logistical constraints affecting engagement and field implementation		Encountered language barriers; discomfort in asking sensitive questions; relied on ASHA/CHO support
Learning and Transformation Through Exposure (empathy development, contextual understanding, reciprocal learning)		Shared lived experiences; valued being heard; engaged in mutual interaction with students		Encouraged student engagement in counseling; observed behavioral and attitudinal change		Highlighted experiential learning; emphasized development of empathy and real-world understanding		Reported shift from theoretical to contextual learning; developed empathy, communication, and social awareness
Program Facilitation and Orientation (orientation quality, preparedness gaps, role of health workers, implementation clarity)		Desired continuity, clarity of program purpose, and repeated engagement		Identified households, facilitated introductions; initially required orientation themselves		Emphasized structured training, mentorship, and feedback systems; acknowledged training gaps		Found orientation useful but insufficient; reported lack of preparedness for real-world challenges

Triangulation of findings from students, faculty, community members, and frontline health workers revealed both strong convergence and meaningful divergence, enhancing the credibility and depth of the analysis.

There was clear agreement across all stakeholder groups on the central role of emotional connection and experiential learning. Students and faculty consistently described rapid rapport-building and personal transformation, while community members and health workers validated these observations through their own experiences of engagement and trust.

Similarly, role expectations and identity confusion emerged as a shared concern across all groups. Students frequently described pressure stemming from unrealistic expectations, while community members expressed anticipation of tangible benefits, such as medical care or access to services. Faculty and health workers acknowledged the need for improved community sensitization and clearer communication to address these gaps.

In contrast, some divergence was observed in perceptions of program facilitation. While faculty emphasized structured orientation and academic objectives, students highlighted practical challenges and gaps in preparedness. Community members and health workers focused more on continuity of engagement and clarity of purpose.

Frontline health workers consistently emerged as key intermediaries, bridging communication gaps, facilitating trust, and enabling smoother interactions. Their role was recognized across all stakeholder narratives as essential to effective program implementation.

The consistency of themes across multiple data sources, combined with complementary and contrasting perspectives, strengthens the robustness of the findings and demonstrates the value of a multi-stakeholder qualitative approach.

DISCUSSION

This qualitative exploratory study, conducted in a newly established rural medical college setting, used a triangulated design incorporating focus group discussions, key informant interviews, and in-depth interviews to capture perspectives across students, faculty, community households, and frontline health workers.[3] The inclusion of multiple stakeholder groups enabled a comprehensive understanding of FAP implementation, while thematic analysis provided a structured approach to identifying convergent and divergent experiences.[7] Notably, household respondents were predominantly female, reflecting the availability and central role of women in home-based interactions within rural settings, which may have influenced the nature of community perspectives captured. Consistent with the intent of CBME, FAP was perceived as a transformative platform that bridges theoretical knowledge and lived community realities, fostering the early development of empathy, communication skills, and social accountability, a core responsibility of medical schools as described by Boelen and Heck. Click or tap here to enter text.[1,2,8] Our findings reinforce existing evidence that community-based medical education enhances experiential learning and contextual understanding of health determinants, particularly in resource-constrained settings.[9,10,11] This may also reflect the smaller cohort size and closer student–community interaction compared to larger urban institutions

A key contribution of this study lies in highlighting the rapid development of emotional connection and trust, which appeared to occur earlier than reported in several prior studies. While previous literature suggests that rapport-building in community-based programs often requires sustained engagement over time, Click or tap here to enter text.[8,10] Our findings indicate that, in rural settings, relational trust may develop more quickly. This may be attributed to the collectivist social structure, cultural openness, and the facilitative role of frontline health workers, particularly ASHAs and CHOs. These intermediaries played a crucial role in legitimizing student presence and fostering initial acceptance, aligning with studies that emphasize the importance of community linkage mechanisms in CBME implementation.[11,12] This finding aligns with Blanchard et al.,[13] who demonstrated that community health workers serve as trusted intermediaries, facilitating communication, strengthening community trust, and improving equitable engagement with health services in rural India. At the same time, the study identifies role expectations and identity confusion as persistent, structurally embedded challenges. As findings reported across Indian settings[12,14] Community members often perceived students as healthcare providers or representatives of government services, leading to expectations of direct medical care or material support. This mismatch between program intent and community perception not only created pressure for students but also risked dissatisfaction among households. These findings underscore the need for systematic pre-engagement sensitization of both students and the community, and for clearer communication strategies, as emphasized in national implementation guidelines.[4,12]

Another important insight concerns communication and cultural barriers, which extend beyond language differences to encompass deeper sociocultural and structural dimensions. Students reported discomfort in discussing sensitive topics, while community responses were shaped by cultural norms, privacy concerns, and socio-economic vulnerabilities. These findings are consistent with prior qualitative work, indicating that CBME implementation in diverse settings requires not only linguistic competence but also cultural sensitivity and contextual awareness.[15,16] Importantly, the study highlights that frontline health workers function as critical cultural mediators, enabling more effective engagement and bridging gaps between academic and community contexts.[13]

The theme of learning and transformation through exposure further reinforces the pedagogical value of FAP. Students described a clear shift from theoretical learning to contextual understanding, particularly regarding social determinants such as poverty, sanitation, and access to care. This aligns with global CBME evidence demonstrating improved empathy and contextual learning through community immersion.[17,18]

An important insight from this study is the context-driven adaptation observed during program implementation. Student interactions were often shaped by on-ground realities, including language barriers, participant comfort with sensitive topics, and household availability, rather than strictly following predefined protocols. Frontline health workers, particularly ASHAs and CHOs, played a critical role in facilitating these interactions by introducing students, mediating communication, and supporting engagement in settings where direct interaction was initially challenging. These observations indicate that, in this newly established rural setting, FAP implementation was responsive, adapting to local sociocultural and logistical conditions. Such findings highlight the need for program designs that explicitly accommodate field-level variability, rather than relying solely on standardized approaches.[16]

However, the effectiveness of FAP was significantly influenced by program facilitation and orientation processes. While initial orientation sessions provided a useful foundation, they were often insufficient in preparing students for the complexities of real-world interactions, particularly in managing expectations and navigating challenging conversations. Similar gaps in training and preparedness have been reported in other CBME implementation studies. Click or tap here to enter text.[11,15] The findings emphasize the need for iterative training, structured mentorship, and continuous feedback mechanisms, rather than one-time orientation sessions. Additionally, the initial lack of clarity among frontline health workers about the program structure highlights the importance of inclusive, comprehensive stakeholder orientation.

Limitations- This study has several limitations that should be considered while interpreting the findings. First, the study was conducted in a single rural medical college, which may limit the generalizability of the findings to other institutional or urban contexts. Second, the inclusion of only two community health workers, while reflective of the local implementation structure, limits the depth of insights from this stakeholder group; thematic saturation was therefore achieved at the overall dataset level rather than within individual subgroups. Third, the study involved first-year MBBS students, whose experiences may reflect early-stage engagement and not capture the program’s longitudinal impact. Fourth, the involvement of faculty members as interviewers introduces the possibility of social desirability bias, particularly among student participants; however, this was mitigated using semi-structured guides, independent coding, and peer debriefing. Additionally, as with most qualitative studies, findings are based on self-reported experiences and may be influenced by participant recall and perception. A standardized sociodemographic profile was not collected uniformly across all stakeholder groups as participant selection was based on stakeholder role rather than demographic characteristics. Consequently, comparisons by demographic variables were not possible. Future studies should incorporate a standardized participant characteristics form across all stakeholder groups to improve contextual reporting. Finally, the relatively short duration of data collection, conducted within an academic program timeline, may have limited the exploration of evolving program dynamics over time.

The findings demonstrate that FAP is both feasible and effective in enabling early experiential learning and rapid rapport-building among first-year MBBS students. The accelerated development of trust—facilitated by ASHAs and CHOs—highlights its potential to embed social accountability early in training. However, important implementation gaps persist, including misalignment between community expectations and student roles, language barriers, and limited preparedness for real-world interactions. These findings suggest that current orientation and engagement strategies are insufficient for the realities of the field in resource-constrained settings. Strengthening FAP will require a shift from one-time orientation to continuous, competency-based mentorship, along with structured community sensitization and stronger integration of frontline health workers. Ensuring continuity of engagement and incorporating feedback-driven adaptations will be critical to sustaining impact and enhancing both educational outcomes and program relevance. Scaling FAP to larger cohorts will also require structured scheduling and increased faculty and health worker support to maintain depth of engagement.

CONCLUSIONS

This study provides a triangulated, multi-stakeholder perspective on FAP implementation in a newly established rural medical college in Odisha. There was strong concordance across stakeholders on rapid trust-building and experiential learning, while discordance persisted around role expectations and program facilitation. A key insight was the early development of rapport in this rural setting, mediated by ASHA/CHO involvement, alongside ongoing role confusion and preparedness gaps. These findings highlight the need for structured community sensitization, continuous mentorship, and stronger integration of frontline health workers to align program intent with field realities.

Key messages

• FAP enables rapid trust-building and experiential learning in rural contexts

• Misalignment between community expectations and student roles remains a key challenge

• Frontline health workers are critical facilitators of program implementation

Conflicts of interest

The Principal Investigator and some members of the research team were faculty members involved in implementing the Family Adoption Programme at the study institution and therefore constituted one of the stakeholder groups examined. To minimize potential bias arising from this dual role, data collection was conducted using standardized, semi-structured tools, and reflexive safeguards were applied throughout the study. Transcription and thematic analysis were independently performed by a researcher from a different institution who was not involved in the program’s implementation or data collection. The authors declare no financial or other competing interests.

SUPPLEMENTARY FILE: ANNEXURE 1

Interview Guides:

I. Focus Group Discussion Guide for MBBS Students

Introduction: Explain study objectives, obtain informed consent, and assure confidentiality and anonymity.

Key Questions and Probes

1. What has been your experience with the Family Adoption Programme (FAP)?

   Probes: Initial reaction; understanding of FAP; orientation received; experience during first and subsequent visits.

2. How has FAP influenced your understanding of community health and medical practice?

   Probes: Empathy; communication skills; social determinants of health; linking theory with real-life situations.

3. What challenges did you face while interacting with adopted families?

   Probes: Language barriers; sensitive questions; cultural differences; community reluctance; logistics.

4. How did community members respond to your visits?

   Probes: Acceptance; trust; expectations; perception of students as doctors or government representatives.

5. How useful was the orientation before field visits?

   Probes: Role plays; communication training; preparedness for difficult situations; areas needing more guidance.

6. What aspects of FAP should be improved?

   Probes: Faculty support; ASHA/CHO involvement; field logistics; follow-up; health education or referral support.

7. What additional support would help improve implementation?

   Probes: Training; mentoring; equipment; transport; digital documentation.

II. Key Informant Interview Guide for Faculty Members

Introduction: Explain study objectives, obtain informed consent, and assure confidentiality. Key Questions and Probes

1. How do you perceive the objectives of FAP in undergraduate medical education?

   Probes: Community orientation; empathy; communication; experiential learning; social accountability.

2. What is your role in implementing and mentoring students during FAP?

   Probes: Planning; supervision; rapport building; field guidance; evaluation.

3. How do you assess student participation and learning?

   Probes: Field observation; logbooks; presentations; feedback; communication skills.

4. What major challenges have you encountered during implementation?

   Probes: Logistics; manpower; student preparedness; family availability; language or cultural barriers.

5. What feedback have you received from students and community members?

   Probes: Acceptance; expectations; role confusion; benefits; dissatisfaction.

6. What role can frontline health workers and the district health system play?

   Probes: Community mobilisation; family identification; translation; referrals; coordination.

7. What improvements would strengthen FAP?

   Probes: Standardised orientation; mentorship; logistics; digital records; feedback systems; institutional support.

III. Semi-Structured Interview Guide for Community Members

Introduction: Explain study objectives, obtain verbal informed consent, and assure confidentiality and anonymity.

Key Questions and Probes

1. What do you understand about the Family Adoption Programme?

   Probes: Who explained the programme; purpose of student visits; expectations before participation.

2. What has been your experience with students visiting your household?

   Probes: Frequency of visits; activities performed; communication; behaviour; follow-up.

3. Have the visits influenced your health awareness or access to care?

   Probes: Advice received; changes in health practices; referrals; perceived usefulness.

4. What challenges have you experienced during student visits?

   Probes: Privacy; time; communication; financial or social constraints; living conditions.

5. What did you expect from the programme?

   Probes: Medicines; health check-ups; treatment; government schemes; follow-up.

6. Do you feel the programme has been beneficial? Why or why not?

   Probes: Trust; relationship with students; health knowledge; unmet expectations.

7. How could the programme be improved?

   Probes: More frequent visits; health camps; clearer explanation of objectives; involvement of local health workers.

IV. Semi-Structured Interview Guide for ASHA/Community Health Officer (CHO)

Introduction: Explain study objectives, obtain verbal informed consent, and assure confidentiality and anonymity.

Key Questions and Probes

1. What is your understanding of the Family Adoption Programme?

   Probes: How you learned about it; programme objectives; expected student activities.

2. What role have you played in supporting FAP?

   Probes: Identifying households; introducing students; accompanying visits; translation; health education.

3. How have community members responded to student visits?

   Probes: Acceptance; trust; reluctance; expectations; misunderstanding of student roles.

4. What challenges have you observed during implementation?

   Probes: Language; cultural barriers; household availability; logistics; coordination.

5. What benefits do you perceive for students and the community?

   Probes: Communication skills; empathy; health awareness; behaviour change; linkage to care.

6. How can collaboration with the medical college and health system be strengthened?

   Probes: Joint planning; community mobilisation; referrals; health education; follow-up.

7. What improvements would you suggest?

   Probes: Better orientation; stronger field-worker involvement; health camps; digital records; community sensitization.

V. Observation Guide

• Recording field visits, interactions, and general community response.

• Documenting any logistical challenges faced by students and faculty.

• Identifying emergent themes not covered in structured tools.

ANNEXURE 2

Comprehensive Thematic Analysis

Theme	Sub-theme	Stakeholder	Quote
Emotional Connection & Trust	High Regard for Medical Identity	Student	“The villagers think we are real doctors and sometimes expect medicines. One person even asked me to prescribe something.”
		Health Worker	“People respect students as future doctors... they'll listen.”
		Community	“They're good children. Why would I say anything false? We treat them like our own kids.”
	Emotional Bonding	Community	“They're like our daughters... we have made them our friends.”
	Mixed Emotions, Nervousness	Student	“I am a bit excited, but nervous because initially I thought like how will we handle family members, like we have never done this before, but as we went it was good.”
Role Expectations & Identity	Misinterpretation of Role/Responsibility	Student	“Some people thought we were from the government and asked us to get their pension released.”
		Community	“They said we can go to the medical college, and through them maybe we'll get medicines or other help.”
	Survey, Scheme, Government	Student	“One person thought we came to do a survey for some scheme and was upset we didn't give anything.”
		Student	“One of the families asked if we were taking down names for ration distribution.”
		Community	“IDI_ACME 9: Sometimes we have to go to the government hospital.”
		Community	“IDI_ACME 6: We're getting some free medicines from the government. But will that solve everything?”
Communication & Cultural Barriers	Language/Translation Challenges	Student	“We faced a lot of language issues. Sometimes we had to ask ASHA to translate everything.”
		Student	“In one household they didn't understand Hindi or Odia. We couldn't do anything without help from the ASHA.”
	Logistics, Field Barriers	Faculty	“Field logistics are challenging due to weather and scheduling.”
		Health Worker	“Some people don't know who the students are... language barriers exist.”
	Cultural/Topic Sensitivity	Student	“It was difficult to ask personal questions like alcohol habits or illnesses. Some got irritated.”
		Student	“One of the families avoided questions on income and health topics. We felt like intruding.”
	Poverty, Structural Constraints	Community	“We live in such broken homes... If we don't earn, we can't eat.”
		Community	“What can we really do? We don't even have a proper house.”
Learning & Transformation	Empathy & Human Connection	Student	“We learned how to treat everyone with empathy. Like we were talking about respect and all that... we had to connect with people emotionally.”
		Faculty	“FAP builds empathy, improves students' ability to understand community needs.”
		Community	“They're like our daughters... we have made them our friends.”
	Gaining Knowledge/Context	Student	“The villagers think that we are real doctors and sometimes expect medicines, which shows their trust but also creates pressure.”
		Health Worker	“Students should counsel families more - like risks of untreated cold becoming pneumonia.”
		Community	“If they could check our health and provide medicines, that would be better.”
Program Facilitation & Orientation	Orientation Content/Delivery	Student	“We had role plays in orientation. That helped us understand how to talk and manage if people are uncooperative.”
		Faculty	“Students should be trained in basic communication and behavior before fieldwork.”
		Health Worker	“I help identify families during home visits and support with spreading health messages.”
	Gaps in Preparation/Feedback	Student	“Orientation helped, but we felt unprepared to handle people who expected medical advice. We needed more guidance on that.”
		Faculty	“There are gaps in the communication training of students.”
	Initial Confusion/Role Clarification	Health Worker	“I didn't know initially. This is the first time we're doing it here... A madam from the medical college explained it.”
	Knowledge of Student Activities	Health Worker	“Each student will adopt five households, collect data, and build community relationships.”

ANNEXURE 3

Domain	Item No.	Guide Questions / Description	How addressed in this study	Page No.
Domain 1. Research team and reflexivity
Interviewer/facilit ator	1	Which author(s) conducted the interview or focus group?	FGDs, KIIs and IDIs were conducted by faculty members from the Department of Community Medicine (Principal Investigator and Co-investigators).	3
Credentials	2	What were the researchers' credentials?	All interviewers possessed MD qualifications in Community Medicine.	3
Occupation	3	What was their occupation at the time of the study?	Assistant Professors and Professor, Department of Community Medicine.	3
Gender	4	Was the researcher male or female?	Research team comprised six female and two male investigators.	3
Experience and training	5	What experience or training did the researcher have?	Investigators had prior qualitative research training and experience.	3
Relationship established	6	Was a relationship established prior to study commencement?	Faculty had routine academic relationships with students and professional interactions with faculty and health workers; interviews with households were established during field visits.	4
Participant knowledge of interviewer	7	What did participants know about the researcher?	Participants were informed that interviewers were faculty conducting an ACME research study on the Family Adoption Programme.	3-4
Interviewer characteristics	8	What characteristics were reported about the interviewer/facilitator?	Potential academic relationship and social desirability bias were acknowledged. Independent coding, peer debriefing and consensus discussions were used to minimise bias.	4
Domain 2. Study design
Methodological orientation and theory	9	What methodological orientation underpinned the study?	Qualitative exploratory study using Braun and Clarke's six-phase thematic analysis.	2,4
Sampling	10	How were participants selected?	Purposive sampling across four stakeholder groups.	3
Method of approach	11	How were participants approached?	Face-to-face recruitment during academic sessions and field visits.	3
Sample size	12	How many participants were included?	Forty participants: 20 students (2 FGDs of 10 each), 8 faculty, 2 health workers and 10 households.	3
Non-participation	13	How many refused? Why?	Four households declined participation because of lack of time or interest.	3
Setting of data collection	14	Where was data collected?	Seminar hall (FGDs), faculty chambers/workplaces (KIIs) and participant homes (IDIs).	3
Presence of non-participants	15	Was anyone else present?	FGDs included an observer and note- taker; KIIs/IDIs included one interviewer and one observer. Household interviews occasionally had family members present due to natural settings.	3
Description of sample	16	Important characteristics of sample	Participant groups, stakeholder roles and recruitment described. Household respondents were predominantly female. Limitation regarding absence of standard demographic data acknowledged.	5,13
Interview guide	17	Were guides provided? Pilot tested?	Semi-structured interview guides were used, refined by peer review and pilot- tested before finalization (Supplementary Annexure 1).	3; Supplementary Annexure
Repeat interviews	18	Were repeat interviews conducted?	No repeat interviews were conducted.	3
Audio/visual recording	19	Audio or visual recording?	All interviews were audio-recorded with informed consent.	3,5
Field notes	20	Were field notes made?	Yes. Field notes documented contextual information and non-verbal observations.	3
Duration	21	Duration of interviews	Interviews lasted approximately 20-45 minutes.	3
Data saturation	22	Was data saturation discussed?	Saturation assessed iteratively; no new themes emerged and consensus was reached by the research team.	4
Transcripts returned	23	Were transcripts returned?	No. Transcripts were not returned due to time constraints; cross-checked internally for accuracy.	4
Domain 3. Analysis and findings
Number of data coders	24	How many coded the data?	One primary coder performed initial coding; validation undertaken by the Principal Investigator and two co-investigators.	4
Description of coding tree	25	Was coding tree described?	Inductive coding framework with themes and subthemes presented in Supplementary Annexure 2.	4; Supplementary Annexure
Derivation of themes	26	Were themes derived from data?	Themes were inductively derived through iterative thematic analysis.	4
Software	27	Software used?	Manual coding using Microsoft Excel coding matrix and Microsoft Word for transcript review.	4
Participant checking	28	Did participants provide feedback?	No participant/member checking was undertaken.	4
Quotations presented	29	Were quotations presented?	Representative quotations from each stakeholder group are presented throughout the Results and Supplementary Annexure 2.	5-10; Supplementary Annexure
Data and findings consistent	30	Consistency between data and findings?	Yes. Themes were triangulated across stakeholder groups and summarised in Table 1 and Figure 1.	10-18
Clarity of major themes	31	Were major themes clearly presented?	Five major themes are described in detail, illustrated in Figure 1 and summarised in Table 1.	5-18
Clarity of minor themes	32	Were diverse cases/minor themes described?	Subthemes and triangulated stakeholder perspectives are presented in Table 1 and Supplementary Annexure 2.	10-18; Supplementary Annexure

Funding Statement

Nil.