Abstract

Key words : Corneal transplantation, Coronavirus disease 2019, Severe acute respiratory syndrome coronavirus 2, West Bengal (India)

Introduction

Blindness is an important class of morbidity that affects the lives of millions of people worldwide. International health bodies, including the World Health Organization (WHO), have stressed efforts to reduce the burden of global blindness, with “VISION 2020” being one such effort. In its 2009 Action Plan, the WHO said it is an ongoing challenge of the global health communities to rapidly grow the worldwide eye care services at a time when life expectancy and demand for eye services is simultaneously increasing.¹ Corneal blindness can be caused by a variety of conditions, including infections, ulcerations, trauma, and congenital disorders, with these being the most common causes of blindness, as listed by the WHO.²

India shoulders the largest burden of global blindness, with 0.36% of its population being blind.^3,4 Corneal causes are the second most common cause of blindness in India,³ accounting for 37.5% of blindness among Indians aged less than 50 years, according to a report.⁴ Currently, there are estimated to be 1.2 million people with corneal blindness in India, to which 25 000 to 30 000 people with corneal blindness are added every year.⁵ As high as 50% of corneal blindness is treatable by corneal transplantation.⁶ As per the Ministry of Health and Family Welfare, Government of India, total cornea collection in the country in 2018-19 was 69 349.⁷ There is increasing demand for quality donor corneas, but the supply is limited.⁵ The COVID-19 pandemic has also had a negative effect on eye donation efforts, with decreases in both collection and transplant by 80% in 2020 compared with the previous year.⁸ These decreases may be explained by the fear that people may have developed toward donation and acceptance of donated eyes, with consideration of eyes as a critical point of entry for the virus.⁸ In addition, COVID-19 falls into the category of conditions that can be potentially hazardous to eye bank personnel who retrieve eyes from donors.⁹

Determination of the awareness of the general public is of utmost importance because inadequate public awareness is seen as a major hindrance toward eye donation and, hence, a difficult hurdle to cross to clear the backlog of cases that has grown larger with time.¹⁰ With an aim to address the lack of awareness, the Government of India conducts the “National Eye Donation Fortnight” (August 25 to September 8 of every year) and observes the “World Sight Day” (second Thursday of October annually).^11,12 Several state-of-art institutes of ophthalmology have been set up with facilities for eye donation and eye banking, including the Regional Institutes of Ophthalmology, which are also entrusted with the duty to raise public awareness. Supplementing the activities of the government are many private bodies and nongovernment organizations that actively undertake campaigns to raise public awareness.^13-16

The present study aimed to assess awareness on eye donation among adult members in an urban community of West Bengal (India) and its perception during the COVID-19 pandemic and to determine the sociodemographic factors affecting eye donation awareness.

Materials and Methods

This community-based, descriptive study of cross-sectional design was conducted among adult residents living in the urban field practice area of a medical college in the Indian state of West Bengal, with a study period of 3 months (July to September 2020).

There were 218 line-listed families with 638 adult members (aged 18 years or more) residing in the defined area. A similar Indian study reported that 62.3% of its participants had awareness about eye donation.¹⁷ Considering prevalence (p) of 62.3%,
q = 100 - p, and e = 5% of p, the sample size (n₀) was calculated as 929.49 per the formula n0 = z²pq/e². Because the population was finite, the sample size (n) was corrected to 378.56, applying the formula for finite population correction, n = n₀/[1 + {(n₀ - 1)/N}], where N = 638. With the assumption of a nonresponse rate of 20%, the derived sample size was determined to be 455. The required number of participants was randomly selected; however, only 423 could be included in the study, with the remaining either unavailable after 3 visits on 3 consecutive days of data collection or not willing to participate. In addition, those seriously ill at the time of data collection were also excluded.

The participants were interviewed using a predesigned and pretested data collection schedule, after informed consent was obtained. The data collection schedule had 2 parts. The first part contained questions on sociodemographic variables (including socioeconomic class), and the second part had questions to assess awareness and perception of the study participants toward eye donation. The socioeconomic class of the participants was assessed using the B.G. Prasad Scale, modified in June 2020.¹⁸ The B.G. Prasad Socioeconomic Scale has been used to classify the Indian population into 5 socioeconomic classes, based on their monthly per capita income, with class I being the upper most and class V being the lowest among the classes.

Only those participants who had heard about eye donation were asked the following questions to assess awareness toward eye donation (contained in the second part of the questionnaire): when can eyes be donated, formalities needed for eye donation, can eyes be donated at home, time limit within which eyes can be donated after death, can donated eyes be preserved, part of the eye that is actually transplanted, and awareness about any organization that works in the field of eye donation. Correct responses to each of the above questions gave the participants a positive 1 score, whereas a wrong answer yielded no score. The total individual score obtained for each study subject was calculated by adding up the scores from each question. The scores obtained by all participants were arranged in ascending order, and a median score was calculated. An individual who had a total score below the median score was classified as having “poor” awareness toward eye donation, whereas an individual who scored equal to or above the median score was classified as having “good” awareness. COVID-19-related questions, which were also asked, were not scored because the effects of the virus on blood transfusions or cell or tissue transplants, including cornea donation, are still under research. Although current evidence does not suggest that corona viruses can be transmitted by any of the above, ophthalmologists opine that the possibilities of transmission via ocular surface to the recipient remain.^9,19

For data entry and analysis, we used the Statistical Packages for Social Science (SPSS Inc) version 16.0. Results were obtained based on predefined objectives. For descriptive statistics, simple proportions were used. Sociodemographic variables showing significant statistical predictability with eye donation awareness (P < .1) by univariate logistic regression analysis were further tested with the help of multivariable logistic regression for significance.

Guidelines of the Declaration of Helsinki were adhered to. Permission for conduction of the study was granted by the Institutional Ethics committee of the Medical College, Kolkata (no. MC/Kol/IEC/Non-spon/723/12-2017). Identity of the study subjects was not disclosed, and study subjects were interviewed only after their written informed consent.

Results

The study included 423 participants, with 34.0% (144/423) in the age group of 18 to 30 years. Most of the participants were males (52.0%, 220/423) and spoke Bangla as mother tongue (69.5%, 294/423); all were Hindus (100.0%, 423/423). Most were presently married (77.5%, 325/423) and educated up to the secondary level (38.3%, 162/423); 39.2% (166/423) were engaged in financially gainful employment outside the home, and 9.7% (41/423) were students. Most (34.5%, 146/423) belonged to class IV of the Modified BG Prasad Scale, with a monthly per capita income ranging between 1137 and 2273 Indian rupees (Table 1). Of 423 participants, 85.6% either had a form of eye morbidity and/or had the same in their family member(s) or relatives: 253/362 (69.9%) had refractive errors requiring glasses, 46/362 (12.7%) had cataracts, 63/362 (17.4%) had history of frequent watering or redness of eyes, 11/362 (3.0%) had glaucoma, 4/362 (1.1%) had squint complications, 2/362 (0.6%) had blindness, 25/362 (6.9%) had dryness of eyes, and 22/362 (6.1%) had history of infections like conjunctivitis. Of 423 participants, 87 (20.5%) visited an ophthalmologist at least once in the previous 3 months for themselves or accom­panied someone else.

Of total participants, 70.2% (297/423) knew about eye donation, whereas the rest were unaware. Among these 297 participants, 40.7% (121/297) had gained information about eye donation from health care personnel like physicians, nurses, and other health care workers; television served as a source of information for 38.0% (113/297). Among 297 participants with knowledge, 59.9% (178/297) responded that eye donation is only possible after death. Among answers to multiple response questions, 52.2% (155/297) stated that a concerned living person needed to pledge for eye donation in order to facilitate donation of eyes, whereas 25.9% (77/297) stated that permission from family members after a person’s death can facilitate donation. Among 297 participants with knowledge, 52.9% (157/297) were aware about donation from home and 30.6% (91/297) knew about an organization that facilitates eye donation. In addition, 57.9% (172/297) were aware that eyes can be donated within 6 hours of a person’s death; however, only 30.6% (91/297) could correctly answer that the cornea (black part of the eye) is transplantable; 52.2% (155/297) said the donated eye can be preserved (Figure 1 and Table 2).

With regard to the effects of COVID-19 on eye donation, 32.0% (95/297) stated that COVID-19 can be transmitted from a donor to the recipient through eye donation, 12.8% (38/297) denied such a possibility, and 55.2% (164/297) did not have any ideas on this topic. Although 73.1% (217/297) of participants had a favorable perception toward eye donation, 58.2% (173/297) of participants opined that the pandemic was not the suitable time to consider eye donation. Of those who said eye donation should continue during the pandemic, 69.3% (86/124) stated that extra precautions need to be taken by concerned health authorities to ensure that the infection does not spread from the donor.

Participants with scores equal to or above the median awareness score of 3.50 were classified as having “good” awareness toward eye donation. Predictability of good awareness with mother tongue, marital status, education, occupation, and socioeco­nomic status was found to be statistically significant (P < .10) using univariate regression analysis; presence of eye-related morbidities in self/family/relatives was not found to be a significant predictor. Multivariable logistic regression was performed on the variables showing significance to further ascertain their statistical predictability with eye donation awareness. Results of multivariable regression analysis revealed a statistically significant predictability of good eye donation awareness with better education (adjusted odds ratio [AOR] of 2.033; 95% CI, 1.130-3.658; P = .018), outdoor occupational engagement (AOR of 2.946; 95% CI, 1.732-5.012;P < .001), and higher socioeconomic class (AOR of 2.655; 95% CI, 1.512-4.660; P = .001) (Table 3).

Discussion

Corneal blindness is a major public health issue globally, and corneal transplantation has great potential to curb the burden. All around the world and especially in developing countries like India, as shown by Gupta and colleagues, there is a significant shortfall in the number of corneas collected and the number needed to cure all cases, resulting in an ever-increasing backlog.⁵ The COVID-19 pandemic has caused a significant negative effect as well.^8,9 Increasing public awareness toward eye donation is therefore crucial to meet the increasing demand for corneas.

Our present study found that 70.2% of parti­cipants heard about eye donation. Similar findings were reported in other Indian studies. A similar Indian study found that 62.3% of their study subjects had eye donation awareness.¹⁷ As per a Pondicherry (India)-based study, 80.6% subjects were aware of eye donation, and another study from South India revealed that 50.9% of its participants were aware of eye donation.^20,21 A study from Malaysia and another study from Ethiopia reported similar results with 69% and 56.4% of their participants being aware of eye donation, respectively.^22,23 A study from India’s Andhra Pradesh reported that awareness of eye donation was 30.7%; the difference in findings from our study could have been because of a better educational status among our participants.²⁴

Health care workers and television have contributed as vital sources of information on eye donation, as shown in our study (40.7% and 38.0% responses, respectively, among those who had heard about eye donation). Similarly, studies from India and Malaysia have credited mass media as the main source.^22,24,25 Publicity campaigns were the major source of information in a study done in India’s Tamil Nadu state.²¹

To retrieve a viable cornea for transplantation, it needs to be enucleated within 6 hours of a person’s death; our study showed that 57.9% of study participants who were aware about eye donation were also aware of this critical time period. This rate is similar to rates shown in studies from other parts of India (50.0% and 53.2%).^17,25

Among those with eye donation awareness, a large proportion of study subjects were unaware about how donated eyes are used. Only 30.6% of our study participants knew about the black part of the eye (ie, the cornea) being transplantable. This lowrate of awareness of this aspect was also shown in a Gwalior-based study (18.48%) and in a South Indian study (20.0%). These rates indicate the need for community-based campaigns designed to address such knowledge discrepancies.^17,21

It is also clear from the findings of our study that COVID-19 has had a negative effect on how the general public perceives eye donation, as a large proportion of our study participants were concerned about the possibility of transmission of COVID-19 through eye donation and many opined that the pandemic was not a suitable time to consider eye donation.

Conclusions

From the present study, it is evident that, although many of our participants had heard about eye donation, there were major shortfalls with respect to their knowledge on different practical aspects of eye donation. The COVID-19 pandemic has also affected perceptions about eye donation. Similar studies in both India and other countries also reflect this major shortfall in knowledge. Loopholes in public awareness eventually prove to be potential barriers against efforts made to promote eye donation. This demands a more focused approach, which should also be malleable enough to address various sections of the population, depending on the varied factors that influence their awareness. Our study found that lack of education was a significant barrier toward eye donation. Promoting knowledge among members of communities, especially when they are young, can be a strategy adopted to address the concern. School and college students can be effectively informed about eye donation and its benefits through a specifically designed curriculum. Regular community-based cam-paigns to promote eye donation can be undertaken, with special focus on allaying the dilemma presented by the COVID-19 pandemic.

Awareness was not found to be significantly different in the 2 groups of participants with or without ophthalmological morbidities. Because participants in the former group are expected to visit eye care facilities more often, health care providers can take the opportunity of patient contact to inform them on aspects of eye donation. Information kiosks may be built in outpatient and inpatient units of ophthalmology departments to spread awareness on eye donation and eye banking services. Information education communication materials like posters and leaflets may also be used to spread necessary information to patients and their relatives.

Participants belonging to lower socioeconomic classes tend to be less aware about eye donation, as per the significant findings of our study. Sensitizing local and religious leaders who influence people across all classes can help the cause as they could further educate these members of the community about eye donation and its benefits. Our participants who stayed at home tended to be less aware of eye donation. In this regard, use of mass media can be made by publicizing eye donation on television and radio. These mass media instruments are found in almost every household and therefore can be an effective way to deliver this important awareness.

Adaptation of community education strategies to make people aware about the social benefits of eye donation, as well as to address any stigmas that might be associated with donation, is therefore the need of the hour. Although efforts are underway, both from the government and private sectors, further efforts are needed.

Our present study was conducted only on residents of the urban field practice area of a medical college, which could be considered as a limitation of the study. Living in the vicinity of a medical college and exposure to regular health campaigns could have contributed to better awareness on eye donation in our residents versus those living elsewhere.

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