Benign paroxysmal positional vertigo (BPPV) represents the most prevalent peripheral vestibular disorder encountered in clinical practice, characterized by brief episodes of rotational vertigo triggered by specific changes in head position relative to gravity.(1) First noted by Bárány (1921) and later defined by Dix–Hallpike (1952), it causes about 17–42% of vertigo cases in specialty clinics.(2) Studies show a 2.4% lifetime prevalence and 0.6% annual incidence, rising to 4.5% in those ≥75 years.(3) (4)

It shows a female predominance (1.5–3:1), especially after menopause, suggesting hormonal effects on otoconia metabolism.(5) Peak incidence occurs in the sixth decade of life, though presentations span all age groups.(6) Dislodged otoconia migrate into a semicircular canal, where their gravity-driven movement disrupts endolymph flow and abnormally stimulates the cupula.(7) (8)

The posterior semicircular canal is affected in 60-90% of cases, followed by the horizontal canal (5-30%), while anterior canal involvement remains rare (1-2%).(2) This pattern reflects the posterior canal’s dependent position. Although 50–70% of cases are idiopathic, risk factors include older age, head trauma (7–23%), inner-ear disease, migraine (twice as prevalent in affected patients), osteoporosis, and cardiovascular risks like hypertension and hyperlipidemia.(3) (9) (10)

Clinically, patients experience brief episodes of spinning vertigo, usually lasting less than one minute, after positional head movements.(1) Characteristic findings include a short latency after movement, crescendo–decrescendo intensity, spontaneous resolution and fatigability with repetition.(2) The Dix–Hallpike test is the principal diagnostic test for posterior canal BPPV and typically elicits torsional upbeating nystagmus with vertigo.(2) For lateral canal involvement, the supine roll or Pagnini–McClure test is the primary diagnostic procedure.(11,12)

Figure 1: Dix-Hallpike Test demonstrated for the right side (12)

Despite its "benign" nomenclature, the condition imposes substantial burden on patients and healthcare systems. Quality-of-life assessments reveal moderate-to-severe functional impact in approximately 70% of patients at presentation.(13) The DHI consistently demonstrates significant disability scores across physical, emotional and functional domains.(14) BPPV increases fall risk 1.8-fold in the elderly, leading to fractures, hospitalizations and loss of independence.(3) Epidemiological data indicate that 86% of affected individuals seek medical consultation, interrupt daily activities, or require sick leave, with European economic analyses estimating annual costs approaching €1.8 billion.(3)

Management has shifted from pharmacological symptom suppression toward evidence-based particle repositioning maneuvers.(15) These procedures use sequential, gravity-assisted head positions to return displaced otoconial debris from the involved semicircular canal to the utricle.(7,8) The Epley maneuver is the most extensively studied treatment for posterior canal BPPV and has demonstrated substantial improvement in vertigo and conversion of the Dix–Hallpike test to negative in evidence syntheses.(15,16) For lateral canal BPPV, the Guffoni maneuver is a commonly employed treatment, whereas the Pagnini–McClure test is used diagnostically to identify lateral canal involvement and characterize the direction of nystagmus.(11,12)

Figure 2: Epley's Maneuver for Right Posterior Semicircular Canal-Canalolithiasis (12)

Figure 3: Gufoni Maneuver for Geotropic Right Lateral Semicircular Canal BPPV(12)

Figure 4: Pagnini-McClure Test (12)

Despite well-established short-term efficacy, several aspects require investigation. The temporal relationship between objective nystagmus resolution and subjective symptom improvement remains incompletely characterized, with implications for patient counseling.(15) Long-term outcomes beyond several weeks remain limited, yet are crucial for understanding recurrence patterns and treatment durability.(16) Furthermore, comprehensive quality-of-life assessment across extended follow-up periods requires standardized evaluation using validated instruments.

Accordingly, this prospective observational study evaluated the effect of canal-specific particle repositioning maneuvers in patients with single-canal BPPV. Subjective symptom grades, objective positional-test findings and DHI scores were assessed over six months to characterize the timing, magnitude and sustainability of treatment-associated improvement.

The present study aimed to evaluate the clinical effectiveness of canal-specific particle repositioning maneuvers in patients with single-canal benign paroxysmal positional vertigo. The primary objectives were to assess changes in subjective giddiness and objective positional nystagmus at day 4, one month and six months after treatment and to quantify the change in dizziness-related handicap using the Dizziness Handicap Inventory between presentation and six months. The secondary objectives were to describe the demographic profile, affected canal and laterality, examine the temporal relationship between subjective and objective recovery, and determine whether improvement was sustained throughout the six-month follow-up period.

Study Design and Setting This prospective observational study was conducted in the Department of Otorhinolaryngology at tertiary medical college and hospital, of southern India, from June 2023 to May 2025. Approval was obtained from the Institutional Ethics Committee, and written informed consent was obtained before enrolment. For participants aged 10–18 years, assent was obtained together with consent from a parent or legal guardian. Study Population and Sample Size The study enrolled 96 consecutive eligible patients. The sample size was based on an expected treatment success proportion of 80%, a 95% confidence level and relative precision of 10.5% of the expected proportion. The initial estimate was 87 participants; after allowing 10% for potential attrition, the required sample size was 96.(17) Inclusion Criteria Patients were included in the study if they met the following criteria: • Patients above 10 years of age • Patients presenting with positional vertigo irrespective of duration and demonstrating a positive canal-appropriate positional test (Dix–Hallpike test for posterior canal BPPV or supine roll test for lateral canal BPPV) • A positional test was considered positive when it provoked characteristic canal-specific nystagmus lasting less than 60 seconds • Posterior canal BPPV was confirmed if torsional nystagmus was present in the Dix-Hallpike test • Patient willingness to participate in the study Exclusion Criteria Patients were excluded from the study if they met any of the following criteria: • Patients on labyrinthine sedative medications • Patients with multicanal pathology • Patients with acute illness such as fever or hypoglycaemia • Patients with neck problems such as cervical spondylosis • Patients with neurological causes of vertigo • Patients unwilling to participate in the study Diagnostic Procedures All patients received a thorough clinical workup, including detailed vertigo history, full otolaryngological exam to rule out other pathology, and standardized positional vestibular testing. The Dix-Hallpike test was performed as the primary diagnostic procedure for posterior canal BPPV. Patients were positioned sitting with the head turned 45 degrees toward the tested side, then rapidly moved to supine position with the head extended approximately >20 degrees below horizontal. The examiner observed for latency period, nystagmus characteristics including direction, duration, and fatigability, while assessing subjective vertigo. The test was repeated on the contralateral side after adequate recovery time.(12) For suspected horizontal canal involvement, the supine roll test was employed. Patients were positioned supine with head elevated 30 degrees, then the head was rapidly rotated 90 degrees to one side and held for 30-60 seconds while observing for nystagmus. The procedure was repeated with head rotation to the opposite side. Nystagmus direction (geotropic or apogeotropic), intensity and duration were documented. Treatment Protocols Patients received canal-specific repositioning maneuvers by trained vestibular clinicians, initiated immediately after diagnosis. For posterior canal BPPV, the Epley maneuver was employed. The procedure consisted of five sequential head positions, each maintained for 30-60 seconds. Starting from the diagnostic Dix-Hallpike position with the affected ear down, the head was rotated 90 degrees toward the unaffected side, followed by rotation of head and body together 90 degrees to achieve face-down position, then sitting upright with chin tucked. Patients received instructions regarding post-treatment precautions. For lateral canal BPPV, the Guffoni maneuver was the principal repositioning procedure. Patients were moved rapidly from sitting to the appropriate side-lying position, followed by a 90-degree head rotation toward the undermost shoulder before returning to sitting. One right lateral canal case was managed with a Semont maneuver, as recorded in the treatment distribution. Outcome Measures Treatment efficacy was evaluated through three complementary approaches: Subjective Symptom Assessment: Symptom status was recorded using four ordered categories: Grade 0, complete absence of positional giddiness; Grade I, mild symptoms with occasional brief episodes that did not limit daily activities; Grade II, moderate and more frequent positional symptoms requiring activity modification; and Grade III, severe or persistent symptoms. Assessments were performed at baseline, day 4, one month and six months. Objective Nystagmus Assessment: Canal-appropriate provocative positional testing was repeated at each follow-up. Grade 0 denoted complete absence of positional nystagmus; Grade I represented a mild response with brief, low-intensity nystagmus; and Grade II represented persistent characteristic positional nystagmus of greater severity. Quality of Life Assessment: The DHI was administered at baseline and 6-month follow-up. This validated 25-item questionnaire assesses self-perceived handicap across functional (9 items), emotional (9 items), and physical (7 items) domains. Each item is scored as 0 (no), 2 (sometimes), or 4 (yes), yielding total scores of 0-100, with higher scores indicating greater disability. Follow-up Protocol Patients were assessed at day 4, one month and six months after the initial maneuver. Subjective grade and canal-appropriate positional-test findings were recorded at each visit, while the DHI was reassessed at six months. Additional maneuvers could be performed for persistent findings according to the clinical protocol; however, repeat-treatment frequency and recurrence were not analysed as study outcomes. Statistical Analysis Data were entered in Microsoft Excel and analysed using IBM SPSS Statistics version 22. Categorical variables were summarized as frequencies and percentages, while continuous variables were summarized as mean and standard deviation. Changes in categorical outcomes were examined using the chi-square or Fisher exact test, with McNemar testing used for applicable paired categorical comparisons. Baseline and six-month DHI scores were compared using a paired t test. A two-sided p value <0.05 was considered statistically significant.

Study population

A total of 96 patients with single-canal benign paroxysmal positional vertigo (BPPV) were included in the analysis. The mean age was 43.8 years. The categorical age distribution demonstrated that BPPV was most frequent in middle adulthood, while both younger and older age groups remained represented in the cohort.

Table 1. Distribution of patients according to age group (n=96)

The largest age group was 41–50 years, comprising 25 patients (26.0%), followed by 31–40 years with 23 patients (24.0%). Thus, exactly one-half of the cohort (48/96; 50.0%) was aged 31–50 years. Patients aged 51–60 years accounted for 17.7%, whereas 13.5% were older than 60 years. Patients younger than 20 years and those aged 21–30 years constituted 8.3% and 10.4%, respectively.

Table 2. Distribution of patients according to sex (n=96)

There was a clear female predominance: 59 patients (61.5%) were female and 37 (38.5%) were male. The female-to-male ratio was approximately 1.59:1.

Distribution of the affected canal and side

Table 3. Distribution according to the affected semicircular canal and laterality (n=96)

SCC: semicircular canal. Percentages may not total exactly 100.0 because of rounding.

Posterior semicircular canal involvement was overwhelmingly predominant, occurring in 91 patients (94.8%). Only five patients (5.2%) had lateral canal BPPV. The right posterior semicircular canal was the single most frequently involved site, affecting 56 patients (58.3%), followed by the left posterior canal in 35 (36.5%). Overall right-sided disease was present in 60 patients (62.5%), whereas left-sided disease occurred in 36 (37.5%). No anterior canal involvement was reported.

Figure 5. Distribution of BPPV according to the affected canal and laterality.

Distribution of particle repositioning maneuvers

Table 4. Distribution of canal-specific particle repositioning maneuvers (n=96)

*Percentages may not total exactly 100.0 because of rounding.

The maneuver distribution closely reflected the pattern of canal involvement. Epley maneuvers were performed in 91 patients (94.8%): 56 right-sided and 35 left-sided. Four patients (4.2%) underwent a Guffoni maneuver, and one patient (1.0%) underwent a right Semont maneuver. All posterior canal cases were therefore managed with an Epley maneuver, while the five lateral canal cases were managed with either a Guffoni or Semont maneuver.

Subjective outcome assessment

Table 5. Subjective grading of giddiness across follow-up assessments (n=96)

Grade 0 denotes absence of subjective giddiness; increasing grades represent increasing symptom severity.

At baseline, 87 patients (90.6%) had Grade I symptoms, seven (7.3%) had Grade II symptoms and two (2.1%) had Grade III symptoms. No patient was symptom-free. The day-4 distribution was almost unchanged: 88 patients (91.7%) were Grade I, six (6.3%) were Grade II and two (2.1%) remained Grade III. This early subjective change was not statistically significant (p=0.317).

A statistically significant improvement was apparent at one month (p<0.01). Seven patients (7.3%) were completely symptom-free, 84 (87.5%) had Grade I symptoms and five (5.2%) had Grade II symptoms; no patient remained in Grade III. By six months, complete subjective resolution had increased markedly to 60 patients (62.5%), and the remaining 36 patients (37.5%) had only Grade I symptoms. No patient had Grade II or Grade III symptoms at the final follow-up (p<0.01).

Objective outcome assessment

Table 6. Objective positional-test grading across follow-up assessments (n=96)

Grade 0 denotes absence of positional nystagmus.

At baseline, all patients had objective evidence of positional nystagmus: 51 (53.1%) had Grade I findings and 45 (46.9%) had Grade II findings. By day 4, the number with Grade I findings increased to 59 (61.5%), while Grade II findings decreased to 37 (38.5%). Although no patient had yet achieved Grade 0, the shift from Grade II to Grade I was reported as statistically significant (p<0.01), demonstrating an early reduction in the severity of objective findings.

At one month, six patients (6.3%) had no demonstrable positional nystagmus, 70 (72.9%) had Grade I findings and 20 (20.8%) had Grade II findings (p<0.01). By six months, 62 patients (64.6%) achieved Grade 0, 21 (21.9%) had Grade I findings and 13 (13.5%) continued to show Grade II findings (p<0.01). Thus, 83 patients (86.5%) had either no nystagmus or only Grade I findings at six months, while 13.5% retained Grade II objective findings.

Figure 6. Temporal distribution of subjective and objective outcome grades from baseline to six months.

Paired change between one and six months

Table 7. Paired transition in subjective grade from one month to six months (n=96)

Paired assessment showed continuing subjective recovery between one and six months. Fifty-three patients (55.2%) improved from Grade I to complete symptom resolution, and five (5.2%) improved from Grade II to Grade I. Therefore, 58 patients (60.4%) improved by at least one subjective grade during this interval. Seven patients (7.3%) maintained complete resolution and 31 (32.3%) remained in Grade I. No subjective worsening was recorded between one and six months.

Table 8. Paired transition in objective grade from one month to six months (n=96)

Objective paired transitions also demonstrated substantial late improvement. Fifty-six patients (58.3%) improved from Grade I to Grade 0 and ten (10.4%) improved from Grade II to Grade I. Accordingly, 66 patients (68.8%) improved by at least one objective grade between one and six months. Six patients (6.3%) maintained Grade 0, 21 (21.9%) remained in the same Grade I or Grade II category, and three patients (3.1%) worsened from Grade I to Grade II.

Dizziness Handicap Inventory outcomes

Table 9. Comparison of mean Dizziness Handicap Inventory score at presentation and six months (n=96)

DHI: Dizziness Handicap Inventory.

The mean DHI score declined from 17.17±9.406 at presentation to 4.83±3.597 at six months. The absolute mean reduction was 12.34 points, corresponding to a 71.9% decrease from baseline. This improvement was highly statistically significant (p<0.001). In addition to the lower mean score, the standard deviation decreased from 9.406 to 3.597, indicating less variability in dizziness-related handicap at the final assessment.

Figure 7. Mean Dizziness Handicap Inventory score at presentation and six months. Error bars represent standard deviations.

Integrated summary of treatment response

The results demonstrate progressive improvement following canal-specific particle repositioning maneuvers. Subjective improvement was limited during the first four days and did not reach statistical significance at that assessment. Objective severity, however, shifted significantly from Grade II toward Grade I by day 4, even though complete objective resolution had not yet occurred. At one month, both subjective and objective distributions had improved significantly. Improvement continued between one and six months, as confirmed by the paired transition tables.

At the six-month assessment, 60 of 96 patients (62.5%) were completely free of subjective giddiness, while 62 (64.6%) had complete disappearance of positional nystagmus. All remaining patients had only Grade I subjective symptoms; however, objective Grade II findings persisted in 13 patients (13.5%). The DHI reduction of 12.34 points (71.9%; p<0.001) provided a complementary patient-reported measure of sustained improvement in dizziness-related functional limitation. Taken together, the categorical outcomes, paired transitions and DHI results consistently demonstrated substantial and sustained benefit over six months.

This prospective observational study demonstrated progressive improvement in subjective giddiness, positional nystagmus and dizziness-related handicap following canal-specific particle repositioning maneuvers in 96 patients with single-canal BPPV. The principal findings were the predominance of posterior canal disease, significant early improvement in the severity of objective findings without immediate complete resolution, later subjective recovery, continued improvement between one and six months, and a substantial reduction in mean DHI score. Demographic and clinical profile The mean age was 43.8 years, and exactly half of the cohort was aged 31–50 years. Although BPPV is often associated with older age, it occurs across adulthood, and differences in referral patterns, population structure and healthcare-seeking behaviour may influence the age profile of hospital-based cohorts.(3,4,6) Female patients constituted 61.5% of the cohort, producing a female-to-male ratio of 1.59:1. This accords with the recognized female predominance in BPPV and may be related to age-dependent hormonal and metabolic influences on otoconial integrity.(5,9) Posterior semicircular canal involvement accounted for 94.8% of cases, while lateral canal disease constituted 5.2%. The posterior canal is anatomically predisposed to retain dislodged otoconial debris in gravity-dependent positions, explaining its predominance in clinical series.(2,6) Right-sided disease was more frequent than left-sided disease, with the right posterior canal alone accounting for 58.3% of the cohort. Although sleeping posture and anatomical orientation have been proposed as possible explanations for right-sided predominance, laterality was not examined analytically in the present study and therefore remains descriptive. Treatment distribution and clinical response The distribution of maneuvers closely reflected canal involvement. Epley maneuvers were performed in 91 patients (94.8%), corresponding to the 91 posterior canal cases. Four patients underwent Guffoni maneuvers and one underwent a right Semont maneuver. Because lateral canal BPPV represented only five cases, the study was not designed to compare the relative effectiveness of different lateral canal maneuvers. The findings should therefore be interpreted primarily as outcomes of a canal-specific repositioning strategy dominated by the Epley maneuver rather than as comparative evidence between maneuver types. Subjective symptoms changed little during the first four days. No patient had achieved Grade 0 by day 4, and the distribution of Grades I–III was not significantly different from baseline (p=0.317). In contrast, objective findings showed a significant early shift from Grade II toward Grade I (p<0.01): Grade II decreased from 46.9% at baseline to 38.5% at day 4, although no patient had yet achieved complete objective resolution. This distinction is important. The day-4 finding represents an early reduction in objective severity rather than disappearance of positional nystagmus. At one month, both outcome distributions had improved significantly. Subjectively, seven patients (7.3%) were symptom-free, 84 (87.5%) had Grade I symptoms and five (5.2%) had Grade II symptoms; no Grade III symptoms remained. Objectively, six patients (6.3%) had no positional nystagmus, 70 (72.9%) had Grade I findings and 20 (20.8%) had Grade II findings. These results indicate that clinically meaningful improvement had become apparent in both patient-reported and examination-based measures, while complete resolution remained uncommon at this intermediate assessment. Six-month outcomes and subjective–objective relationship Improvement continued substantially between one and six months. Paired subjective transitions showed that 58 patients (60.4%) improved by at least one grade, with no subjective worsening. Paired objective transitions showed improvement in 66 patients (68.8%), while three (3.1%) worsened from Grade I to Grade II. These transition data demonstrate that the final outcomes were not explained solely by early response; recovery continued throughout follow-up. At six months, 60 patients (62.5%) had complete subjective resolution, and the remaining 36 (37.5%) had only Grade I symptoms. Objective Grade 0 was achieved by 62 patients (64.6%), whereas 21 (21.9%) retained Grade I and 13 (13.5%) retained Grade II findings. Thus, the proportions achieving complete subjective and objective resolution were similar, but the distribution among patients without complete resolution differed. The persistence of Grade II nystagmus in 13.5% despite the absence of Grade II or III subjective symptoms suggests incomplete concordance between perceived recovery and positional-test findings. Central compensation, reduced sensitivity to residual vestibular signals and persistence of low-salience nystagmus may contribute to such dissociation, although these mechanisms were not directly evaluated.(15,16) Dizziness-related handicap The mean DHI score decreased from 17.17±9.406 at presentation to 4.83±3.597 at six months, an absolute reduction of 12.34 points and a relative reduction of 71.9% (p<0.001). The lower standard deviation at six months also indicates that scores became more tightly concentrated at the lower end of the scale. The DHI complements symptom grading and positional testing by capturing the broader functional, emotional and physical consequences of dizziness.(13,14) Accordingly, the observed reduction supports a sustained patient-centred benefit in addition to improvement in clinical signs. Comparison with existing evidence The direction of the present findings is consistent with evidence supporting repositioning maneuvers as first-line treatment for BPPV.(2,15,16) Evidence syntheses have shown that the Epley maneuver improves vertigo resolution and conversion of the Dix–Hallpike test to negative compared with sham or control management.(15,16) The present study adds a detailed six-month trajectory in a routine clinical cohort, demonstrating limited early subjective change, significant early reduction in objective severity and continued improvement after one month. The substantial DHI reduction is also consistent with studies showing improvement in dizziness-related quality of life following appropriately performed repositioning maneuvers.(14,19) Evidence regarding adjunctive medication does not alter the central interpretation of these findings. A systematic review of Epley maneuver combined with betahistine reported improvement in DHI outcomes, but repositioning remains the mechanistically targeted intervention for displaced canaliths.(20) Because the present study did not include a pharmacological comparator, it cannot determine whether adjunctive medication would have modified the timing or magnitude of recovery. Clinical implications These findings support prompt canal identification and performance of a canal-appropriate repositioning maneuver after diagnostic positional testing. Counselling should distinguish early reduction in nystagmus severity from complete resolution and should explain that subjective improvement may be limited during the first few days. Follow-up remains clinically relevant because improvement continued through six months and a proportion of patients retained objective positional findings despite relatively mild or absent subjective symptoms. Strengths and limitations The principal strengths were the prospective design, standardized follow-up at four time points, inclusion of both subjective and objective measures, use of paired transition tables, and assessment of dizziness-related handicap with a validated instrument. The six-month follow-up provided information beyond the immediate post-maneuver period and allowed evaluation of continued recovery after one month. Several limitations should be acknowledged. The study was conducted at a single centre without a control or sham-treatment group; therefore, improvement cannot be separated completely from spontaneous resolution, regression to the mean or other time-related effects. Direct observation was used instead of video-oculography, and subtle nystagmus may have been missed. The cohort was dominated by posterior canal BPPV, limiting inference regarding lateral canal maneuvers. DHI was measured only at presentation and six months, preventing assessment of its early trajectory. Potential predictors of incomplete recovery were not analysed. Repeat-maneuver frequency, recurrence and adverse events were not reported as study outcomes, so no conclusions can be drawn regarding these endpoints. Finally, follow-up ended at six months and cannot establish longer-term durability or recurrence. Overall interpretation Within these limitations, canal-specific particle repositioning maneuvers were associated with substantial improvement across complementary outcome measures. The temporal pattern—early reduction in objective severity, later subjective improvement and continued recovery through six months—provides clinically useful information for follow-up and patient counselling. The findings reinforce repositioning maneuvers as the principal non-pharmacological treatment for appropriately diagnosed single-canal BPPV while highlighting the value of assessing both symptoms and positional nystagmus.

Canal-specific particle repositioning maneuvers were associated with substantial improvement in the clinical and functional outcomes of patients with single-canal benign paroxysmal positional vertigo. Objective improvement in positional nystagmus was evident as early as day 4 (p<0.01), whereas subjective symptom improvement was initially limited (p=0.317) and became significant at one month (p<0.01). This temporal difference indicates that objective vestibular recovery may precede the patient’s perception of symptomatic relief.

Treatment benefits continued to increase throughout the six-month follow-up. At six months, 60 patients (62.5%) achieved complete subjective resolution of giddiness, while 62 patients (64.6%) demonstrated complete disappearance of positional nystagmus. All remaining patients had only Grade I subjective symptoms, with no Grade II or Grade III subjective symptoms recorded at the final assessment. The mean Dizziness Handicap Inventory score decreased from 17.17 ± 9.406 at presentation to 4.83 ± 3.597 at six months, representing a 12.34-point or 71.9% reduction in dizziness-related handicap (p<0.001).

These findings support canal-specific particle repositioning maneuvers as a clinically valuable, non-invasive first-line treatment for single-canal BPPV. The sustained improvement in symptoms, positional nystagmus and dizziness-related quality of life supports their routine clinical use. Patients should nevertheless be counselled that subjective recovery may lag behind early objective improvement and that structured follow-up remains important for identifying persistent clinical or positional findings.

Take-Home Message

Canal-specific particle repositioning maneuvers were associated with progressive and sustained improvement in subjective giddiness, positional nystagmus and dizziness-related handicap over six months. Early objective improvement preceded significant subjective recovery, emphasizing the importance of counselling and structured follow-up.

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