EXPERIMENTAL AND CLINICAL TRANSPLANTATION

Key words : Corneal transplant, Organ donation, Social awareness, Societal perceptions of organ donation, Student awareness

According to the estimates from the World Health Organization, 2.2 billion people worldwide live with vision problems, and almost half of these problems are caused by preventable or treatable causes. Also, 43.3 million people living with vision problems are blind, and this number will reach 61 million in 2050 with population growth, aging, changes in the environment, and lifestyle.^1,2 Corneal damage, which is a leading cause of vision loss and affects approximately 4.2 million people, occurs as a result of various factors such as congenital causes, trauma, infection, and infectious diseases. These factors are also generally considered to be preventable or treatable with methods such as corneal transplant.² Corneal blindness is a global public health problem that affects people living in different regions and countries at rates ranging from 0% to 27.5%.³ A corneal transplant is one of the most successful types of transplant. Approximately 12.7 million people worldwide are waiting for corneal transplants; however, it is estimated that only 1 of 70 people will become corneal donors.⁴ Factors such as socioeconomic status of countries, access to preventive health services, and environmental factors have caused this deficit of donors and resulted in the present failure of corneal transplantation to reach the desired level.³ In addition, other societal factors contribute to the scarcity of corneal donors, including religion, beliefs, and cultural values of potential corneal donors; the lack of knowledge and awareness of the transplant process, such as legal regulations regarding corneal donation and eye banks; and the negative attitudes of family, relatives, and society. All of these factors may affect the wishes and decisions of potential donors about corneal donation.⁵ University students are the educated adults of the future, and they have a key role to raise awareness and to develop and promote a positive attitude toward corneal donation. For this study, we aimed to measure and compare the awareness levels of corneal donation among university students in Turkey enrolled in health care versus nonhealthcare curriculums, both before and after receiving education on corneal donation. Through these students, our goal was to contribute to the development of a positive attitude toward corneal donation in society.

Materials and Methods

Research design and sample

This cross-sectional and descriptive study was conducted at a university in Turkey for 5 months, from January 2020 to May 2020. The study followed a 3-step process that included educational training to improve awareness of corneal donation. To evaluate and compare the effectiveness of the educational training to promote mindfulness, a questionnaire was given to the students before the educational training, immediately after the educational training, and 4 to 6 weeks after the educational training. This education on corneal donation was not a compulsory part of the curriculum at either school. The attendance of the participants was voluntary. The educational regimen consisted of a 30-minute presentation that was based on the present literature and was designed to provide comprehensive information regarding all of the points of inquiry listed in the questionnaire. We solicited 5 experts to review the content of the educational regimen. The education portion was presented face-to-face. The population of the research study consisted of 952 students enrolled in either the School of Health (nursing department) or the School of Physical Education and Sports (physical education and sports teaching and sports management department). The sample size for the nonhomogeneous popu-lation was calculated with the formula determined by Salant and Dillman (1994),⁶ with a 95% confi-dence interval and a sampling error of ±5%: n = Nt²pq/d²(N - 1) + t²pq, where N is number of individuals in the target audience; n is number of individuals to be sampled; p is the probability of occurrence of the investigated event; q is the probability of nonoccurrence of the investigated event; is the theoretical value found according to the t table at a certain significance level; and d is the sampling error (±) accepted according to the probability of occurrence of the event. According to this formula, 952(1.96)²(0.5)(0.5)/[(0.05)²(952 - 1)] + (1.96)²(0.5)(0.5) = 274. The sample of this study consisted of 179 students from the nursing department and 97 students from the physical education and sports department, comprising a total of 276 participants, all of whom completed the 3 stages of the study.

Data collection tools

The questionnaire used in the research consisted of 3 parts. In the first part, descriptive characteristics of the students were collected, such as age, sex, department, education year, knowledge of corneal donation, methods to seek information about corneal donation and the source of the information, self-assessment that the information is sufficient or insufficient, the willingness and desire to seek information, and the person most likely to be consulted for information. The second part consisted of 22 objective statements regarding corneal donation and the transplantation process. Each correct response was worth 1 point, and the highest possible score was 22. These questions were adapted from similar studies in the literature.^7,8 In the third part, attitudes toward corneal donation were evaluated, including the desire to donate a cornea, the reason for or against their decision to donate, the desire to donate a relative’s cornea, possession of an organ donation card, and social contact with a corneal transplant recipient or a candidate awaiting corneal transplant.

Statistical analyses

We used SPSS statistical software (version 22.0) for data analyses. Frequency and percentage were used to analyze the descriptive characteristics of the students participating in the research, and mean and standard deviation statistics were used to analyze the scores. Kurtosis and skewness values were examined to determine whether the research variables showed a normal distribution. The t test, 1-way analysis of variance, and post hoc (Tukey, least significant difference) analyses were used to examine student awareness levels according to their respective descriptive characteristics. Changes in awareness levels were analyzed with the repeated measures analysis of variance test. The Cohen coefficient (d) and eta-square coefficient (?²) were used to calculate the effect size. The effect size indicates whether the difference between the groups is sufficiently large to be considered significant, according to the following scale of Cohen values and eta-square values: Cohen 0.2 = small, 0.5 = medium, 0 = large; and ?² 0.01 = small, 0.06 = medium, 0.14 = large.⁹

Ethical approach

This study complied with the principles of the Declaration of Helsinki and the Declaration of Istanbul. The study was approved by the Tekirdag Namik Kemal University Non-Interventional Clinical Research Ethics Committee (December 26, 2019; no. 2019.240.12.15). Institutional permission was obtained from the Tekirdag Namik Kemal University Health School Directorate and the Tekirdag Namik Kemal University Physical Education and Sports School Directorate. Written informed consent (via the Informed Voluntary Consent Form) was obtained from the students who agreed to participate in the study.

The average age of the students participating in the research was 20.7 years; 66.3% (n = 183) were female students; 64.9% (n = 179) were enrolled in the nursing department; and 35.1% (n = 97) were enrolled in the physical education and sports curriculum. Also, 33.7% (n = 93) of the students were in year 1 of their respective curriculum, 25.4% (n = 70) were in year 2, 22.1% (n = 61) were in year 3, and 18.8% (n = 52) were in year 4. Of the nursing students, 73.2% (n = 131) had been previously aware of the notion corneal donation, but 86% (n = 154) had not previously received specific information about corneal donation. On the other hand, 56.70% (n = 55) of physical education and sports department students were previously unaware of corneal donation, and 91.8% (n = 89) had not received information about corneal donation before our study. In total, 62.7% (n = 173) of the students were aware of corneal donation, but 88% (n = 243) had not received information about corneal donation. For students who had previously received information, 39.4% (n = 13) stated that their source of information was social media/television/radio; 98.32% (n = 176) of nursing students and 99% (n = 96) of physical education and sports students considered their personal knowledge to be insufficient. In addition, 98.3% (n = 176) of the nursing students and all of the physical education and sports students (n = 97) wanted to receive information about corneal donation. In total, 98.6% (n = 272) of the students judged the information to be insufficient, and 98.9% (n = 273) wanted to receive information about corneal donation. In addition, 65.9% (n = 180) stated that they would consult a doctor for information, whereas 27.5% would consult a nurse (Table 1). When questions with information about corneal donation and the transplant process were compared with results before education; higher correct answers were shown immediately after the educational training and also 4 to 6 weeks later (Table 2). Total scores before the educational training were also lower. Although the average score before the education was 10.93, we observed an average score of 20.79 points immediately after the education and an average score of 19.65 points 4 to 6 weeks after the education, which demonstrated a significant increase in knowledge level ((Table 3) and (Figure 1)). We examined the relationship between the descriptive characteristics of the students and their level of knowledge. Accordingly, the knowledge levels before, immediately after, and 4 to 6 weeks after the educational training for female students were significantly higher than for male students. With respect to the 2 different curriculums, the knowledge levels before and immediately after the training were higher for the students in the nursing department than for students in the physical education and sports department. According to the years of education, the level of knowledge before and immediately after the training was higher for the students in year 4 and year 3 than for students in year 1. There was a higher level of knowledge before and immediately after education for students who were aware of corneal donation versus students who were unaware of corneal donation. Although the level of knowledge before the educational training was higher in students who had previously received information about corneal donation versus students who had not had previously received information, no significant difference was found after the training. Similarly, there was a higher level of knowledge before the educational training for students who perceived they had sufficient information about corneal donation versus students who reported that their information was insufficient, but no significant difference was found after the educational training (Table 4). Before the educational training, 59.1% (n = 163) of the students had stated a desire to donate their corneas; however, this rate was 88.4% (n = 244) immediately after and 94.6% (n = 261) at 4 to 6 weeks after educational training. In addition, 51.8% (n = 143) of students had a desire to donate a relative’s cornea; this rate was 77.9% (n = 215) immediately after the educational training and 88.6% (n = 239) at 4 to 6 weeks after the training. Regarding the reason for the desire to donate, the responses mainly indicated a willingness to do good (ie, altruistic motive). The results from the interviews before and immediately after the educational training showed that the main reason against donation was the fear of change in body integrity; however, at 4 to 6 weeks after the training, the main reason was family response (Figure 2). Although the results before and immediately after the educational training showed that the desire to donate corneas was significantly higher in nursing students versus physical education and sports students, no significant difference was found 4 to 6 weeks after the training. Also, although the pretraining results showed that the desire to donate a relative’s cornea was higher in nursing students versus physical education and sports students, no significant difference was found immediately after the educational training and 4 to 6 weeks after the educational training (Figure 3).

To the best of our knowledge, 2 population-based studies on corneal donation and transplantation have been conducted in Turkey.^10,11 In those studies, only the general view of the society was examined, and the authors did not aim to increase the level of knowledge. In this study, the knowledge level and attitudes regarding corneal donation were examined in students from 2 different departments at a university in Turkey. The education provided as the strength of our research aimed to increase the level of knowledge about corneal donation and develop a positive attitude. We examined the literature for studies on students in different age groups and from different departments regarding their knowledge and perception of corneal donation and transplantation. In a study by Hameed and Jadidy (2015), the levels of knowledge and awa-reness regarding corneal donation and transplantation were found to be higher for female students than for male students.¹² In their study published in 2014, Eze and colleagues observed medical and nonmedical students and concluded that the level of knowledge of corneal donation and transplantation was higher among the medical students versus the nonmedical students and that the source of information for both groups was social media.⁷ In the study of Lartey and colleagues from 2019, the corneal transplant awareness level was found to be higher among the students in year 3 and year 4 of their curriculum versus students in earlier years.¹³ Gupta and colleagues reported in 2017 that 87% of the students in their study had heard of corneal donation, but only 44% wanted to donate their corneas. The reason against personal cornea donation was the concern for maintaining body integrity, similar to our study.¹⁴ In a study by Chowdhury and colleagues from 2021, 88.4% of medical students and 79.1% of nursing students reported that they wanted to donate their corneas. The basis of this willingness to donate was to cure blindness, similar to our research results in which the reason was a desire to do good (altruism). An important reason against donation was the lack of awareness.¹⁵ The findings from our study are consistent with and similar to other studies in the literature. In our study, the total scores before and immediately after the educational training were significantly higher for students in the nursing department, students who knew about corneal donation before education, and students in year 4 and year 3. No significant difference was found in the scores of these students at 4 to 6 weeks after the educational training. In addition, there was no significant difference in the total scores of the students who received information about corneal donation and found their knowledge sufficient. Although approximately 62% of the students claimed personal awareness of corneal donation, overall, they had provided correct responses to only half of the questionnaire items and achieved a low average score of 10.93, which demonstrated their lack of knowledge. The average score of 20.79 immediately after the educational training and 19.65 points at 4 to 6 weeks after the educational training demonstrated a significant increase in their level of knowledge versus the pretraining score. We concluded that the educational training given in the study increased the desire to donate one’s own cornea and the desire to donate the cornea of a relative. These results showed that education had positive results on the students’ level of knowledge on corneal donation and willingness to donate. In this research, student awareness about corneal donation and transplantation increased after the educational training, and we conclude that the students and their relatives developed a positive attitude toward donating their corneas. The most often cited sources for information were tools such as social media/television/radio, and the participants most frequently sought consultation from doctors, followed by nurses. We suggest that awareness about corneal donation will increase and will be facilitated by health professionals.

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