Objectives: Our aim was to assess the knowledge and willingness to donate corneas among undergraduate dental students in Hyderabad city, India.

Materials and Methods: We conducted a cross-sectional study among undergraduate dental students of Panineeya Institute of Dental Sciences (Hyderabad, India). A pretested questionnaire was used to obtain information on demographic details, knowledge of cornea donation (7 questions), and willingness to donate corneas (3 questions). For analyses, we used chi-square and multivariate modeling tests. P < .05 was considered significant.

Results: Our study included 56 male (16.5%) and 284 female (83.5%) dental students. The overall mean number of correct answers for knowledge questions for this study population was 2.98 ± 1.43. A significant difference existed only for year of study (P < .001). Similar findings were noted when the study population was categorized into poor and good knowledge. The willingness to donate, which was referred to as a positive attitude, was expressed by 41%, with significance observed only for religion. The most common reason cited for unwillingness to donate was lack of sufficient information (52%). Regarding associations between ambiguity to donate and demographic factors, only religion was shown to be a significant factor.

Conclusions: Although approximately 66% of respondents had poor knowledge, 40% were willing to donate. When demographics were considered, year of study was significantly associated with knowledge and religion was significantly associated with willingness to donate.

Key words : Eye donation, India, Questionnaire

Introduction

Visual impairment and blindness are substantially attributed to corneal diseases, and the most cost-effective approach to ease the onus of corneal blindness and restoration of vision is corneal transplant. The rate of corneal procurement in India remains poor and insufficient to meet the demands of corneal transplant.^1,2 Bridging this gap would require motivation and willingness among the public to donate corneas. To understanding this need, studies have been conducted to find negative and positive factors associated with corneal procurement.^3,4

Across the globe, reasons for willingness and unwillingness to consider donating corneas are greatly varied.^5-7 Generalization are not possible due to skewness in populations based on country, religion, and race/ethnicity. Here, we considered a cohort of dental students from India to assess their knowledge and willingness to donate corneas. The uniqueness of this population is its young age, which is ideal for introducing the idea of organ and tissue donation and instilling a positive attitude toward cornea donation. Investigating their knowledge will also provide baseline data to understand the roadblocks for donation and the design strategies to enhance the willingness to donate and possibly create more corneal donors.

Materials and Methods

The questionnaire for this cross-sectional study was adapted from a previous study from Paraz and associates.8 Our study comprised 3 parts. First, demographic data were collected. The second part included using 7 questions to gather knowledge about corneal donation and recovery (questions 1-7). The third part used 3 questions (questions 8-10) to assess willingness to donate corneas. This self-reported questionnaire was pretested and validated (Cronbach alpha = 0.88). The study aimed to include all undergraduates and interns at the Panineeya Institute of Dental Sciences and Hospital. Participants were asked to refrain from discussion while answering. They were assured that anonymity and confidentiality would be maintained. Return of filled questionnaires signified consent to participate in the study. Ethical clearance to conduct the study was obtained from our Institutional Review Board (PMVIDS&RC/IEC/PHD/PR/0127-16).

Demographics of the study population are reported as number and percentage. We conducted a frequency distribution of responses to questions and comparison of correct knowledge scores, which are presented as percentages based on demographic variables. Comparisons of poor knowledge (< 50% correct answers) versus good knowledge scores were also done. Likewise, positive attitudes toward eye donation were evaluated. Data underwent chi-square tests and multivariate analyses. P < .05 was considered significant.

Results

From a total of 472 possible participants, 56 male (16.5%) and 284 female (83.5%) dental students participated in the study, making a response rate of 72% (340/472). Of these, 70 (20.6%) were in their first year of undergraduate study, 63 (18.6%)were in their second year, 75 (22%) were in their third year, 61 (17.9%) were in their fourth year, and 71 (20.9%) were interns. Most were Hindu (66.8%; n = 227), followed by Muslim (25%; n = 85); a small percentage followed Christianity (5.3%; n = 18) or other faiths like Jainism (2.9%; n = 10).

Table 1 illustrates the frequency distribution and correct responses to each question. Table 2 compares the correct knowledge in terms of number and percentage based on demographic variables (sex, year of study, and religion). Although more female participants answered all questions correctly, sig­nificant differences were only noted between female and male participants for questions 1, 2, and 6 (P < .05). On the contrary, religion did not reveal significant differences for answers, except for the question on facial appearance after corneal recovery (question 2), which was answered correctly by most Hindu participants. When the year of study was considered, questions 1, 3, 6, and 7 were answered correctly by a significantly higher proportion of first-year students. Another question that showed a significant difference based on year of study was question 5, which was answered correctly by significantly more third-year students.

The overall mean number of correct answers to knowledge questions for this study population was 2.98 ± 1.43. A significant difference existed only for the year of study (P < .001). A further post hoc analysis revealed that fourth-year students and interns had answered a significantly less number of questions correctly compared with other years (Table 3). Similar findings were noted when the study population was categorized into poor and good knowledge based on variables (Table 4). The willingness to donate, which was considered a positive attitude, was expressed by 41%, with significance observed only for religion (Table 5). The most common reason cited for unwillingness to donate was lack of sufficient information (52%) followed by religion (14.9%).

A logistic regression analysis to ascertain pre­dictors of good knowledge scores using unadjusted odds ratio showed that female participants were 0.5 times more likely to have good knowledge regarding donation (P < .001). Likewise, based on year of study, fourth-year students and interns were significant predictors of correct knowledge, and, based on religion, Hindu and Muslim followers were significant predictors of correct knowledge (P < .001). On the other hand, only fourth-year students and interns were predictors in the adjusted odds ratio analyses (Table 6).When we considered ambiguity to donate versus demog­raphics factors, all variables were significantly associated in the unadjusted odds ratio analyses. However, only religion proved to be a significant factor when variables were adjusted (Table 7).

Discussion

Blindness, a condition in which individuals lack visual perception, can result from corneal diseases or trauma that can cause corneal scarring; for these cases, visual impairment can be successfully treated with corneal transplant.⁴ Despite developments, there is a scarcity of donor corneas, which has been attributed to the unwillingness to donate due to socio-demographic barriers,^7,9 poor awareness and knowledge,^9,10 cultural beliefs,^7,10 and failure of health care personnel^11,12 to educate donors on the process of corneal donation.

Earlier studies have shown that knowledge, attitudes, and behaviors are essential factors in fostering an environment that positively influences organ donation rates, especially among health care profesionnals.¹³ Most studies on knowledge and attitudes regarding corneal donation have been among medical students^10,14,15 or nursing students.^16,17 However, no studies have been conducted among dentists, a major group among health care professionals.

In this study, we focussed on a cohort of dental students due to the homogeneity of the sample; their young age would suggest that they would be more receptive to new ideas and thus could potentially motivate patients and connect with the community at large.

In our study, only 33.8% of participants had adequate knowledge on corneal donation, a level that is much less than reported in other studies. Other studies have shown a knowledge prevalence of 96.8% among nursing college students of Dehradun hill city,16 86% among university students,¹⁸ 73.8% in an urban population in India,¹⁹ and 80.7% in adults from Singapore.⁷ These differences could be attributed to cultural differences, education levels, socioeconomic status, or family members who have donated eyes.

Although the level of knowledge was low in our study, more than half of the participants knew that the part of the eye removed during corneal recovery is the cornea rather than the whole eyeball (67.9%) and that corneal donation does not cause any disfigurement to the face (71.2%). These findings were similar to results in a population in the Srikakulam district,¹ health science students at Jimma University,²⁰ and youth in Singapore.8 In contrast, a study in an Asian population in the United Kingdom showed that participants had concern for face disfigurement.21 Similar to that shown by Paraz and associates,⁸ a higher number of participants in our study did not know about the duration of corneal recovery and the type of individual who can donate eyes or corneas. This lack of knowledge could result in unnecessary loss of potential donors.

When we compared demographics versus knowledge, female students, first-year students, and those who followed Christianity had higher mean scores for correct knowledge. However, when factors were adjusted for regression analyses, only the year of study was a significant predictor for good knowledge. In addition, few studies^10,22,23 have shown that age, sex, education, socioeconomic status, and religion were significant factors associated with knowledge.

In the present study, only 41.2% of the population stated a willingness to donate their corneas compared with 67% of Singaporean adults.⁷ In other studies, willingness to donate was 87.8% among Indian medical students¹⁵ and 85% among Indian nursing students,¹⁶ with Nigerian medical students²⁴ and Malaysian university students¹⁸ having lower willingness to donate (33.6% and 27%, respectively). These differences can be attributed to high social engagement because of their professional affiliations with non-governmental organizations or schools.¹

Bhandary and associates²² and Krishnaiah and associates²³ showed that female individuals were more reluctant to donate eyes because of their family ties and concern about their personality after donation. However, in our present study, female dental students were more willing to donate (42.3%) than male dental students (35.7%). In contrast, Ronanki and associates1 observed that female individuals were no less willing than male individuals to donate eyes. Although year of study did not have a significant effect on willingness to donate, Yew and associates⁷ found that the greater knowledge and willingness among Singaporean adults were likely due to high education status.

The only factor that was significantly associated with willingness to donate was religion; in our study, Muslim students were 0.32 times more unlikely to donate eyes; this could be due to their customs, such as burial to be carried out as soon as possible after death and the body being kept whole.8 In other studies, factors other than religion that influenced willingness to donate included good knowledge, age, sex, occupation, education level,^7,8,20 and being engaged in social services.¹

Similar to the study in Singaporean youth,8 a lack of adequate information was considered as the main reason (52.8%) for not willing or undecided to donate corneas among our study participants. Few studies have shown that ethnicity, cultural-specific issues, fear of illegal trade in organs, unsupportive family, and disfigurement of face are reasons for being unwilling to donate.^5,7,10,16

We acknowledge several limitations in our study, including it being a single-center study and the use of a questionnaire adapted from a previous study. Therefore, comparisons with other population groups should be done with extreme caution. Furthermore, the self-reporting nature of the questionnaire may not fully reflect the student’s real knowledge.

Conclusions

Our study showed that about 66% of our dental student participants had poor knowledge and only about 40% were willing to donate. When demographics were considered, the factor that was significantly associated with knowledge was year of study and the factor significantly associated with willingness to donate was religion. The most common reason for not being willing or undecided to donate was lack of adequate information. This finding suggests an urgency to deliver specific and tailored programs to increase knowledge and thereby donor rates, which should include the combined efforts of government and private organizations.

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