Abstract
Purpose:
The Hospital Corneal Retrieval Program (HCRP) aims to counsel and encourage the family of a critically ill or deceased person in the hospital for eye donation. Adequately sensitized health-care workers (HCWs) may play a pivotal role in boosting HCRP.
Study Design:
Multicentric, cross-sectional, descriptive study.
Methods:
Study participants included all HCWs of three medical colleges, including one with eye bank and corneal transplant services. A pretested, structured questionnaire was used to record the awareness, knowledge, and attitude about eye donation among HCWs. The expected outcome was to seek differences in awareness, if any, among medical and paramedical workers of medical colleges with (group A) or without (group B) eye bank and corneal transplant facilities.
Results:
Of the 4060 study participants, 2100 HCWs were in group A and the rest (1960) were in group B. For eight out of 13 questions assessing awareness and perception, a statistically insignificant difference in responses was observed between the two groups. Regarding questions related to attitude, although the majority of HCWs in both groups were comfortable talking about eye donation, they did feel that counseling relatives of a terminally ill patient about eye donation was insensitive. Less than half of HCWs showed a willingness to donate eyes, and about half of the participants wanted to acquire more knowledge about eye donation.
Conclusion:
Awareness regarding eye donation among HCWs was mostly found to be at dismal levels, irrespective of whether they worked in an institute with or without eye bank and corneal transplant services. This warrants an accelerated effort at sensitizing HCWs as a strengthening measure for HCRP.
Keywords: Corneal blindness, corneal donation, eye donation, HCRP
Corneal blindness levies a substantial public health onus, affecting approximately 1.5 million people (4% of all cases of blindness) globally.[1] Ninety percent of the global cases of ocular trauma and corneal ulceration leading to corneal blindness occur in developing countries.[2] Further, in some parts of Africa and Asia, the incidence of cornea-related visual loss among children is 20 times higher than that in developed nations.[2] The burden of corneal blindness on the individual and the community, as a whole, may be enormous. The younger productive population is more prone to corneal infections and injuries compared to the elderly, who are mostly affected by cataracts; hence, the socioeconomic impact of corneal blindness is greater than cataracts in terms of the total blind-person years.[3]
Approximately 1.9 million corneal blind patients already exist across India, and about 20,000 get added to the tally each year.[4,5] A major treatment option for restoring sight in those with corneal blindness is corneal transplantation, which can only be accomplished through cornea donation. A recent global survey on eye banking and corneal transplantation reckoned the severe mismatch between the supply and demand of donor corneas worldwide, with only one cornea available for every 70 needed.[6] Since not each of the donated corneas is healthy enough to be transplanted, India needs about 2,77,000 donor eyes to perform 1,00,000 corneal transplants each year as per the current rate of requirement.[7] According to the Eye Bank Association of India (EBAI), about 56,000 corneas were procured in the year 2018–2019, while only 27,016 transplants were carried out in that same year.[8] Therefore, the collection of the donor’s eyes is the main concern in any organized effort to lessen corneal blindness. The establishment of robust eye bank and corneal transplant services as well as wilful corneal donation in ample numbers are required to tangibly combat corneal blindness.
Voluntary donation and Hospital Corneal Retrieval Program (HCRP) are the two modes of procuring donor corneas. Voluntary donations stand at negligible levels despite the rigorous efforts of National Program for Control of Blindness (NPCB), EBAI, and many nongovernment organizations at raising awareness of the general public and targeting social/religious taboos associated with corneal donations. HCRP, on the other hand, provides easy accessibility to potential donors and ready availability of a detailed medical history to assess the eligibility of the donor for corneal donation, enables swift procurement of tissues from younger donors, helps reduce death to corneal retrieval time, and improves cost-effectiveness. Hence, it improves both corneal collection and utilization rates in an eye bank. Literature suggests that awareness and training of health-care workers (HCWs) can appreciably increase the number of eye donations.[9,10] A well-aware health-care professional/paramedical or nursing staff can aid in increasing voluntary donations by educating the common man about the importance of corneal donation, dispelling common myths and misapprehensions, and providing information on the donation process. Moreover, HCRP can get a boost if adequately aware health-care providers can identify potential donors, sensitize and support their families, address their concerns, and help them make an informed decision. This study was designed to evaluate the awareness of HCWs of three medical colleges, including one with functional eye bank and corneal transplant services.
Methods
A cross-sectional descriptive study was conducted among HCWs of three government medical colleges in northern India, including one medical college with functional eye bank and corneal transplant services for more than 10 years. The study population included all HCWs of the three medical colleges (interns, residents as well as consultant doctors, nursing and paramedical staff) who had been working in the hospital for more than 2 years. Residents and consultants from the ophthalmology department were excluded from the study. A prevalidated, structured questionnaire was prepared using Google Form, in English as well as vernacular language, to record the sociodemographic details and assess the awareness, knowledge, and attitude about eye donation. After seeking approval from the respective ethics committees of the three participating medical colleges, the link to the Google Form questionnaire was shared with all HCWs and was closed for responses after 7 days with two repeated reminders. The data was collected and compiled in MS Excel and analyzed by using Statistical Package for the Social Sciences (SPSS; version 20.0) software. Descriptive statistics were used as necessary, and all qualitative variables were presented as frequency and percentages. Quantitative variables were presented as mean and standard deviation. A Chi-square test of significance was applied. The expected outcome was to seek differences in awareness, if any, among medical and paramedical workers of medical colleges, with or without eye banks and corneal transplant facilities.
Results
All participants were categorized into two groups: group A, comprising HCWs in a medical college with functional eye bank and corneal transplant services, and group B, which consisted of health workers in medical colleges without transplant services.
Total number of study participants was 4060, with 2100 HCWs in group A and the remaining 1960 in group B. Table 1 shows the participant characteristics in the two groups. About one-fourth of the respondents in group A and one-fifth of the respondents in group B were medical, paramedical, or nursing students. Nursing staff formed the largest subgroup in both the study groups. Designation-wise distribution of study participants is shown in Fig. 1.
Table 1.
Demographic characteristics of study participants
| Characteristic | Group A n=2100 (%) | Group B n=1960 (%) | Total n=4060 (%) | |||||
|---|---|---|---|---|---|---|---|---|
| Age, n (%) | <30 | 1158 (55.14) | 1056 (53.88) | 2214 (54.53) | ||||
| >30 | 942 (44.86) | 904 (46.12) | 1846 (45.47) | |||||
| Gender, n (%) | Male | 886 (42.19) | 1033 (52.7) | 1919 (47.27) | ||||
| Female | 1214 (57.81) | 927 (47.29) | 2141 (52.73) | |||||
| Designation | Studenta | 542 (25.80) | 386 (19.69) | 928 (22.86) | ||||
| Resident/faculty | 313 (14.9) | 293 (14.94) | 326 (14.93) | |||||
| Nursing staff | 583 (27.7) | 614 (31.32) | 1197 (29.48) | |||||
| Paramedical staff | 556 (26.47) | 464 (23.67) | 1020 (25.12) | |||||
| Others | 106 (5.04) | 203 (10.33) | 309 (7.61) | |||||
aMedical/nursing/paramedical student
Figure 1.
Designation-wise distribution of study participants
Table 2 presents the information regarding knowledge and perception of the participants about eye donation. For eight out of 13 questions assessing awareness and perception about eye donation, statistically insignificant difference in responses was observed between the two groups.
Table 2.
Awareness and knowledge regarding eye donation among HCWs
| Knowledge and perception | Group A n=2100 (%) | Group B n=1960 (%) | Chi2 (P) | Total n=4060 (%) | ||||
|---|---|---|---|---|---|---|---|---|
| Eyes can be donated | 2022 (96.3) | 1817 (92.7) | 3.94 (0.139) | 3839 (94.5) | ||||
| Eyes can be pledged anytime during life and/or donated after death | 138 (6.57) | 130 (6.63) | 2.42 (0.488) | 268 (6.60) | ||||
| Donated eyes should be removed within 6 h of death | 251 (11.95) | 182 (9.28) | 4.94 (0.176) | 433 (10.66) | ||||
| Close relative/kin can permit removal of eye of the dead | 1658 (78.95) | 1389 (70.87) | 8.87 (0.012) | 3047 (75.05) | ||||
| Person with communicable disease cannot donate eyes | 990 (47.14) | 1071 (54.64) | 1.8 (0.396) | 2061 (50.76) | ||||
| Person with noncommunicable disease can donate eyes | 1169 (55.67) | 1033 (52.7) | 2.32 (0.321) | 2202 (54.24) | ||||
| Only cornea is removed | 1476 (70.28) | 1245 (63.52) | 10.51 (0.005) | 2721 (67.02) | ||||
| Eye donation cures only corneal blindness | 992 (47.24) | 531 (27.09) | 16.65 (<0.001) | 1523 (37.51) | ||||
| Eye donation and removal does not cause disfigurement | 1740 (82.86) | 1441 (73.52) | 14.88 (0.001) | 3181 (78.35) | ||||
| Eye can be retrieved in the hospital or from home of the dead | 1218 (58.0) | 709 (36.17) | 36.67 (<0.001) | 1927 (47.46) | ||||
| Donated eyes can be preserved in eye bank | 1249 (59.48) | 1381 (70.46) | 5.40 (0.066) | 2630 (64.78) | ||||
| Identity of donor and recipient is kept confidential | 1303 (62.05) | 1265 (64.54) | 4.84 (0.089) | 2568 (63.25) | ||||
| Eye donation is not against religion | 1976 (94.1) | 1837 (93.72) | 0.04 (0.519) | 3813 (93.92) |
*Statistically significant p-value (<0.05) is in bold
Majority of the participants knew that the eyes can be donated and no statistically significant difference was noted between the two groups. Very few respondents, with no statistical difference between the groups, knew that eyes could be pledged anytime during life or after death and that donated eyes must be retrieved within 6 h of death.
A statistically significant difference in the responses was recorded between the two groups when they were interrogated for the kind of blindness that can be ameliorated by eye donation, if only cornea or whole eyeball is retrieved, and if eye retrieval causes facial disfigurement. Group A participants, that is those who belonged to the medical facility with functional transplant services, exhibited better response rate to these questions. Similarly, compared to group B, statistically significant number of group A HCWs knew that the corneal retrieval can be carried out at the hospital as well as donor’s home [Fig. 2].
Figure 2.
Difference in Knowledge and awareness between Group A and Group B. (P-value <0.05 for all the statements depicted in the bar graph)
Regarding questions related to attitude and practice [Table 3], although majority of HCWs in both the groups were comfortable to talk about eye donation, they did feel that counseling relatives of a terminally ill patient about eye donation was inhuman. Ironically, more group A HCWs were uncomfortable in counseling terminally ill patients for eye donation compared to group B participants and the difference was statistically significant. Less than half of HCWs showed willingness to donate eyes and about half of the participants wanted to acquire more knowledge about eye donation [Fig. 3].
Table 3.
Preferred practice regarding eye donation among HCWs
| Practice | Group A n=2100 (%) | Group B n=1960 (%) | Chi2 (P) | Total n=4060 (%) | ||||
|---|---|---|---|---|---|---|---|---|
| Comfortable to talk about eye donation | 1850 (88.09) | 1629 (83.11) | 1.47 (0.146) | 3479 (85.69) | ||||
| Counseling family of terminally ill patients regarding eye donation is inhuman | 1048 (49.90) | 679 (34.64) | 7.44 (0.006) | 1727 (42.54) | ||||
| Want to acquire more information about eye donation | 1254 (59.71) | 1034 (52.75) | 1.50 (0.133) | 2288 (56.35) | ||||
| Willing to pledge/donate eyes | 1061 (50.52) | 800 (40.82) | 4.47 (0.107) | 1861 (45.84) |
*Statistically significant p-value (<0.05) is in bold. HCW=health-care worker
Figure 3.
Difference in practice pattern between Group A and Group B
For most of the study participants in both the groups, source of information about eye donation was medical campaigns, medical personnel, or hospitals [Fig. 4]. Only a small role was played by electronic/print media and internet as the means of raising awareness among HCWs.
Figure 4.
Frequency distribution of the preferred source of information about eye donation
Discussion
The knowledge and attitude regarding eye donation among HCWs plays a primary role in promoting eye donation and thus ameliorating corneal blindness. Many opportunities of prospective eye donations may be lost if HCWs fail to counsel family members about the possibility of eye donation. Moreover, if the health personnel are not aware enough to answer the questions and concerns of public and family members of terminally ill patients, the eye donation drive remains hindered. HCRP, particularly, suffers a major setback in case of unaware and undersensitized HCWs.
A comparative analysis of awareness and attitude was undertaken among HCWs of two kinds of medical facility, one with and the other without functional corneal transplant and eye bank services. Contrary to our expectation of having a better sensitized cohort of HCWs in group A, the awareness levels were mostly similar in both the groups. On the other hand, Robert et al. observed significantly better knowledge and practice levels regarding eye donation among fresh graduates from institutions with eye banks.[11]
Awareness that the eyes can be donated was found to be fairly good at 94.5% among the total study participants (96.3% in group A and 92.7% in Group B), but it still lagging behind a perfect score as was reported in a study from India among a sample of medical students.[12] Lowest awareness level has been reported as 8.4% among eye patients of Ghana.[13] Despite substantial awareness in our study participants that eyes can be donated, very few (6.60%) of them, with no significant difference between the two groups, knew that eyes could be pledged during life as well as can be donated after death with the consent of family. Knowledge that pledging is not mandatory and that cornea can be donated after death with the consent of kin was found among very few HCWs. It is imperative for HCWs to know that consent for donation is legally granted by any next of kin or close family member as detailed in the Transplantation of Human Organ and Tissue Act.[14] Even if the eyes had been pledged by the deceased during his/her life, it is entirely the family’s inclination and willingness to contact the eye bank for corneal donation.
Surprisingly, only about one-tenth of our study participants, irrespective of the study group, were aware of the ideal time of corneal retrieval after death. Previous studies conducted on medical students and HCWs have reported better cognizance of ideal time of corneal retrieval. Dave et al.[15] recently found that 84.8% of medical and paramedical staff were aware of the ideal time of corneal retrieval, while Singh et al.[16] reported that 44.1% of the medical students were aware of the same. Among HCWs, the knowledge of ideal time of eye donation is crucial, as a boost to HCRP as well as for procurement of usable corneas. Poor awareness related to ideal time of eye retrieval in our study participants may be seen as another setback to HCRP in the region.
Khandelwal and Katre[17] found that only half of their participants were aware that corneal donation does not cause disfigurement, but this awareness was significantly less in paramedical staff compared to interns and residents. In the present study, considerable number of HCWs (78.35%) were aware that eye donation does not lead to disfigurement and this awareness was statistically better among HCWs belonging to facility with eye bank. In addition, awareness that only cornea is retrieved from donors, only corneal blindness can be treated with eye/corneal donation, and cornea can be retrieved from either hospital or home of the deceased was found to be significantly better in group A participants. But still, the difference in awareness of the two groups was not as strong as reported by a previous study from South India. Narendran et al. had observed that having an eye bank or collection center in the hospital campus had a significant impact of 6 times higher knowledge scores than in those hospital staff who did not have an eye bank or a collection center in the campus.[18]
About 85.69% of our total study participants, with no significant difference between the study groups, responded that they were comfortable to talk about eye donation. This may be attributed, partly, to their conscientiousness as health-care professionals. Also, since the question did not specify the target group and the expected outcome, the response was favorably good. At the same time, about 42% of participants regarded counseling the family of terminally ill patients about eye donation as inhuman, with ironically stronger feeling of inhumanity among participants of center with eye bank than those of center without eye bank. Literature suggests that HCWs’ perception that discussing eye donation will cause distress to patients and kins is a major barrier to eye donation.[19,20] A recent scoping review by Madi-Segwagwe et al.[20] revealed that majority of HCWs, across the retrieved dataset, avoided discussions about eye donation unless the issue was primarily brought up by the patient or the kins. However, it is generally accepted that most of the families who give consent to donation consider this as a positive experience.[21] A survey of in-patients found that it was not distressing to discuss eye donation for the majority (73%) of participants and that knowing about donation enabled them to make an informed decision about donation.[22] Thus, a discrete discrepancy exists between the perception of service providers and that of services users.
Willingness to donate eyes in the present study was calculated to be 45.84%, with no statistical difference across the study groups. Williams and Muir, in their review analysis, mentioned that willingness to donate ranged from 7.3% among urban Pakistanis to 90% of patients at a tertiary eye institute in the USA, averaging 52% across all studies.[23] However, it cannot be overemphasized that a disparity exists between having an interest in donation and being actually registered for the same. Further, not all the pledged eyes transform into actual donations, without robust eye banking services and effective HCRP. One of the commonly cited reasons for being unwilling to donate is lack of enough awareness regarding eye donation.[23,24,25] Slightly more than half of HCWs in our study indicated that they were interested to acquire more information about eye donation.
In the present study, medical campaigns and hospital sources emerged as the preferred sources to acquire information about eye donation. This is in congruence to the findings of other awareness surveys conducted among HCWs.[9,15,24]
To combat corneal blindness, HCRP plays a fundamental role in meeting the corneal demands in a country like India, where majority of deaths occur in a hospital setting. EBAI further emphasizes on HCRP as approximately 72% of utilization of donated corneas is through HCRP model and 38% is through voluntary donation in eight eye banks of the country.[26] An efficient HCRP ensures lesser death to enucleation time and preservation time, thereby improving the visual outcome after keratoplasty.[27,28] Apart from raising awareness regarding corneal donation among HCWs, other measures to boost HCRP may include putting up posters and digital display units featuring eye donation information, in vernacular language, in intensive and critical care wards. Showing short videos of the experiences of the actual donor families and recipient patients in the waiting lounges can be another impactful measure. Further, organ donation sensitization can be made a “routine” inclusion in admission formalities in critical care and trauma units.
Conclusion
Frequent awareness lectures and campaigns, elaborating on the technical aspects of corneal donation and retrieval process, will result in better informed HCWs. A well-coordinated approach among the medical officers, nursing staff eye donation counselors, and technicians is warranted for an effective implementation of HCRP.
Financial support and sponsorship:
Nil.
Conflicts of interest:
There are no conflicts of interest.
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