Impact of Single Classroom-based Peer-led Organ Donation Education Exposure on High-school Students and Their Families.

Summary

Deceased organ donation rate is poor in most parts of world but is abysmally low in India (0.8 per-million-population) leading to death of more than 500,000 patients per year awaiting organ transplantation.

We aimed to study the impact of single classroom-based peer-led organ donation education exposure on high-school students and their families. We also evaluated the impact on actual organ donor registrations after our intervention, which has not been studied till date.

In our study, organ donation education was provided by 30 minutes presentation in classrooms by the high school students (44) to the high school students (n=1583) of two schools. We collected pre-, post-intervention and family interaction feedback responses from the students 1-week before, on intervention day and 3-weeks after it, respectively.

There was statistically significant (p<0.05) improvement in students’ knowledge in all 18 questions resulting in an increase of mean score from 9.16 to 13.91. There was also significant increase in intent-to-donate (66.9% to 80.9%) and proportion, of students who wanted to encourage their family members for organ donation (72.6% to 87.2%) after our intervention.

1144 (84.2%) students reported discussion in family. 250 (18.4%) students’ families planned to take and 67 (4.9%) families (one or more person) actually took the donor pledge after intervention.

In our study, we successfully used a novel education program using peer high-school students, instead of healthcare personnel, leading to significant improvement in high-school students’ knowledge, intent-to-donate, family discussion and actual donor registrations. We recommend to include organ donation education in regular school curriculum.

Question / Proposal

Background

Deceased organ donation rate in India is just 0.8 per million population (pmp), which is very low to take care of lakhs of new patients added every year to the transplant waiting list.1,2 More than 500,000 patients of end stage organ failure die every year in India while awaiting organ for transplantation.2

Lack of awareness about deceased organ donation, religious beliefs and superstitions, and lack of faith in healthcare system are some of the important reasons for poor donation in India.3

A systematic review of various studies done on educational intervention by health experts on high school children in different countries have shown significant but variable improvement in knowledge, awareness, attitude and intent for deceased organ donation.4 However, adolescent education, especially by peers, leading to increase in actual donor registrations has not been adequately studied.

Questions

1. Will educating about organ donation by peers have significant impact on intent for organ donation by high-school students and their families?

2. Can this lead to actual organ donor registrations?  

Despite extensive search on internet, we could not find any such study done in India or any other low and middle-income country.

Hypothesis

We hypothesized that single, classroom-based education session, by high school students for high school students can improve the knowledge and intent-to-donate organs in the students and their families and will lead to family discussion which can be the catalyst to improve organ donation in society.

Research

Organ transplantation provides improved quality renewed life to end stage organ failure patients nearing death. But for transplantation we need organs which cannot be manufactured in labs and hence need to be donated. Deceased organ donation rate in India is 0.8 pmp which is abysmally low as compared to our needs as well as to other countries like US (26.6 pmp) and Spain (46.9 pmp).1,5 Unfortunately, this leads to preventable deaths of more than 500,000 end stage organ failure patients every year in India.2 It has been estimated that, out of all road accidental deaths occurring in India, if just 5-10% victims donate their organs, this huge unmet demand for organs for transplantation can be fully met.6

Panwar et al3 showed that lack of awareness (80.1%), religious beliefs and superstitions (63.4%) and lack of faith in healthcare system (40.3%) are important reasons for poor donation in India. 88.4% people reported that family’s opinion can influence their decision for deceased organ donation and 40.9% people would change their decision if not supported by their family.3

Educational interventions on adolescents (aged 12-19), who are the future youth of our society, have the potential to not only improve their knowledge but also trigger the family discussion on the forbidden topic of deceased organ donation in our society, which can have greater impact on actual organ donation rates.7-10  

Anantachoti et al,11 in their study on high school students, did 60 minute program on organ donation and transplantation presented by trained volunteers and got pre, post and 1 month later evaluations filled by students. They found that their intervention significantly improved the knowledge and attitude of the students towards organ donation (p <0.05) and 48% students also reported actual discussion with their family at 1 month follow up.

Organ donation education intervention studies done in different countries on adolescent students have shown variable impact on intent for organ donation depending on the demography of participants, country or region of study and method of intervention.11-14 A review by Yip C et al15 showed that peer-led educational intervention has better response than non-peer-led intervention.

On extensive search on internet we could not find any interventional study done in India or any other low and middle-income country on high school students assessing intent for donation and impact on family discussion besides change in knowledge about deceased organ donation. Also we could not find any chapter on awareness about organ donation and transplantation in majority of high school curriculum in India including CBSE board, except Maharashtra board.

In this project, we aimed to study the impact of high school organ donation awareness education on knowledge and intent for deceased organ donation in students, discussion with their family members, and actual donor registrations. We planned a novel approach to impart education by the peer high school students in place of healthcare workers, which can have positive peer group impact and eliminate the negative bias towards healthcare system in India.

Method / Testing and Redesign

Study

Longitudinal, interventional study with a pre-post design.

Participants

All students of 9-12 grades of two private schools in Delhi, who were present on the day of intervention.

Core team

Four self-motivated high-school students (Lakshya, Shreet, Pranav and Aditya) under leadership of Lakshya, from school one.  

Materials

  • Questionnaire: consisting of 20 multiple-choice questions on demography (without names), awareness, knowledge, perception and beliefs on organ donation, transplantation, brain death and intent for organ donation was prepared. The same questionnaire was used for collection of pre- and post-intervention anonymous responses.

  • Presentation: of 42 slides was prepared to impart knowledge about various aspects of deceased organ donation in unbiased and non-convincing manner. The slides contained information about:

  1. Organ donation & transplantation,

  2. Difference between living and deceased organ donation,

  3. One short story of a donor and recipient,

  4. Brain stem death and its certification,

  5. Myths clearing and

  6. Organ donor registration.

Core-team students and group of volunteering students used this presentation to impart knowledge during intervention in first and second school, respectively.

  • FAQ booklet: based on the information given in presentation, was prepared for distribution to the participants after the presentation to help them discuss the subject matter with their family members, relatives and friends at home.

  • Form-7: Organ donor registration form of competent authority was provided to all participants.

  • Family interaction feedback form: containing 5 questions, to collect information about family’s response after interaction at home.

Methodology

  • The study was carried out with the permission of Principal and head of schools.

  • “Pre-intervention” questionnaire responses were collected 1-week prior to the intervention day, from the students of all 14 sections of classes 9-12 in school-1.

  • On intervention day, all 14 sections of 9-12 classes in school-1 were addressed individually by one core team member per section. The activity lasted about 55-60 minutes per classroom, consisting of the presentation lasting about 30 minutes, followed by questions and answers to address students’ queries. Thereafter students completed responses in the “Post-intervention” questionnaire. After that we distributed the FAQ booklet and one form-7 for family. Forty students from different classes volunteered to join our team to conduct further campaigns.

  • 3-weeks after the intervention day, we collected responses on the family interaction feedback forms from the students present on intervention day.

  • We conducted one hour workshop to train these forty student volunteers to do similar activity in second school.

  • Same educational activities as in school-1 were followed in the school-2. On the intervention day, all 40 volunteers carried out sessions individually or in a group of two in 31 sections of 9-12 classes.

In school-2 also we registered 180 student volunteers to carry out future such campaigns on organ donation awareness.

Analysis

In questionnaires one mark was awarded for each correct and zero for wrong responses. We used mean and standard deviations to represent continuous data, and percentages to describe categorical data. Unpaired student’s t-test was used to compare continuous variables in pre- and post-intervention data due to anonymous nature of our data. Proportions were compared with Chi-square test.

 

Activity Pictures

Results

Table 1

  • Out of Total 1538 students (400 and 1183 from school 1 & 2, respectively), who completed pre-intervention responses, 1421 students (383 and 1038 from school 1 & 2, respectively) were present on intervention days and completed post-intervention questionnaire.

  • Mean age of students, Gender, Religion and Class strengths in pre- and post-intervention data were not statistically different (p>0.05). 

Table 2

  • The proportion of correct responders for Question 1-20 except 15 and 16, increased significantly after the educational intervention (p-value <0.001). The proportion of students who scored >10 questions correctly increased from 46.1% to 95% after the intervention (p-value <0.001). The mean score also increased significantly from 9.16 to 13.91 (p-value <0.001). This showed that the educational intervention increased the knowledge and understanding of students significantly.

  • Students’ intent for organ donation (question 15) increased significantly from 66.9% to 80.9% after intervention (p-value <0.001).

  • The proportion of students, who wanted to encourage their family members for organ donation (Question 16), increased significantly from 72.6% to 87.2% after the intervention (p-value <0.001).

Table 3

  • The mean score improvement of students in question 1 to 20 except 15 & 16 after the intervention was statistically significant for all the classes separately also in class-wise split analysis and best response was seen for class 11.

  • The increase in proportion of students in intent for organ donation (Q15) after the intervention was significant for all the classes in class-wise split analysis and best odds ratio was seen for class 9.

  • The proportion of students, who wanted to encourage their family members for organ donation (Q16), increased significantly after intervention for all classes on class-wise split analysis and best odds ratio was seen for class 11.

  • Our study showed, educational intervention led to significant improvement in knowledge and intent for organ donation in all the studied classes and better response was seen in class 9 and 11.

Table 4

  • The demographic data of the students in post intervention responses and family interaction feedback was comparable (p>0.05).

Figure 1

  • 82 (6%) students reported that some family member in their family and friends had already taken the organ donor pledge before our activity.

Figure 2

  • 1144 (84.2%) students had discussion on organ donation at home after the intervention.

Figure 3

  • Family’s response to discussion was ‘very positive’ in 142 (10.5%), ‘positive’ in 485 (35.7%), ‘neutral’ in 600 (44.2%) and ‘negative’ in 113 (8.3%) student families.

Figure 4

  • 18.4% (250) students reported that one or more of their family member have planned to take organ donor pledge after the activity.

Figure 5

  • 67 students reported that one or more of their family member had taken organ donor pledge after our activity. Out of these 67 student families, 25 people of 18 families submitted their duly filled organ donor forms (form-7) with us for submission to authorities. Rest others filled their donor forms online.

Conclusion

Our study showed that educational intervention on deceased organ donation by peers for the high school students led to significant improvement in their knowledge as shown by increase in proportion of students answering correctly each of 18 questions, and increase in mean total score from 9.16 to 13.91 (p<0.001).

Intention for organ donation of the students also increased significantly from 66.9% to 80.9% after our intervention (p<0.001).

Significantly more number of students (72.6% to 87.2%) wanted to encourage their family members for organ donation after our intervention (p<0.001).

The response for all above parameters was better in class 9 and 11.

Our intervention led to discussion on organ donation in 84.2% student families and the response was reported to be very positive in 10.5% and positive in 35.7% student families.

Besides gain in knowledge, our study documented actual donor registrations after educational intervention to adolescents in a class room, as family members of 67 students actually pledged for organ donation after our intervention and 25 people submitted the donor registration forms with us for deposition to appropriate authority. Apart from this 18.4% students reported that one or more of their family member have planned to take organ donor pledge after the activity.

In this study, we successfully used the novel intervention of using a group of high school students, instead of healthcare personnel, for imparting the organ donation education to their peers, leading to significant family discussion and actual donor registrations. 

On the basis of our study we would like to recommend to educational authorities in India to include the topic of organ donation and transplantation in regular school curriculum in high school classes, which may serve as the catalyst for family discussion and has the potential to change the thinking of not only high school students but also their families and thus whole society for organ donation.

Limitations of our study:

1. We could not do one to one pairing of responses in pre-intervention, post-intervention and family interaction feedback due to anonymous response collection procedures.

2. We could not track all the donor registrations as most of them were reported to be done online.

3. Although we appealed and assumed the responses to be truly representing the responder’s feelings but, since our study was questionnaire based, there still remains a scope of bias.

Future Plan:

1. We have continued our campaign for organ donation awareness in other schools of Delhi with the help of our volunteers. We have already registered 220 volunteers to scale up this work.

2. We will carry out advocacy activities for inclusion of education about organ donation and transplantation in regular high school curriculum.

About me

Hi, my name is Lakshya Aggarwal. I live in Delhi-NCR and my team is from Arwachin International School, Dilshad Garden, Delhi. I like reading detective fiction, understanding and making algorithms for day-to-day problems, love to solve cubes and play table tennis.

When I was 6 years old, my grandfather underwent liver transplantation due to liver cancer and my mother was his living donor (as she only matched the requirements within my family). They both are healthy now. This incident inspired me to come up with this project to increase deceased organ donation awareness so that no one needs to be a living donor. Winning this Google Science Fair will bring limelight to our project and help in increasing awareness about deceased organ donation.

Isaac Newton has inspired me not only because of his immense contribution in the field of physics and mathematics, but also of his tenacious attitude towards life.

Hi, I am Shreet Aggarwal of class 11th.  I love exploring things. At an age of 7, I started working on computer and exploring the cyber world. I believe technology can take education to new heights. My greatest inspiration is Albert Einstein due to his valuable contribution in physics.

Hi, I am Pranav Parashar of class 10th. I love reading fiction-novels. I love listening to music and traveling. I got interested in this when I realized how much difference organ transplantation could make in one’s life. This project has inspired me to take medicine and become a transplant surgeon.

Health & Safety

Our research was done under the mentorship of Dr Smita Mishra, Consultant Pediatric Cardiology, Manipal Hospitals, Palam Vihar, Sector 6 Dwarka, New Delhi, 110075. Contact Information

In-school activities of our project were done under the guidance of Mrs Sangita Sharma, Headmistress and Coordinator, Arwachin International School, Dilshad Garden, Delhi 110095. Contact Information

The study was carried out with the permission and clearance of Director, Principal and Head-teacher of both the schools.

Educational intervention activities were done in the presence of class teachers of the respective classes.

Our project did not require use of any laboratory, research centre or school laboratory, any animal or biological product, any hazardous chemical, and any chemical or tissue that might require specific safety and health guidelines.

So, personally we did not have to follow any special safety procedures.

Bibliography, references, and acknowledgements

Acknowledgements

We are thankful to Dr Smita Mishra, our mentor, an astute clinician and academician. She has kindly mentored us on designing, logistic supports, and literature search for our project, despite her busy schedule. She also helped us in arranging sponsorships for the printed material used during the project activity like questionnaires, feedback forms, form-7 and FAQ booklets. We could not have completed this project without her valuable guidance and support throughout the project.

We are thankful to Mrs Sangita Sharma, our Headmistress and coordinator at Arwachin International School (AIS), Dilshad Garden. We are grateful to her for giving us full support in actual execution of the project in the schools. She gave us crucial support, guidance and help in conducting pre-intervention, intervention and family feedback collection days’ activities in both the schools. Her invaluable support in motivating volunteering students’ confidence in themselves and fine tuning their presentation skills was critical for our project.

We are thankful to Aditya Bhatt for being the invaluable part of our core team. He is the forth pillar of our project. We appreciate him for understanding our limitation in not able to officially include him as our forth team member in Google Science Fair.

We are thankful to our volunteering students without whom it would have been difficult to execute activities in ABBS.

We are thankful to Ms Megha, Senior teacher at Arwachin Bharti Bhawan Senior Secondary School (ABBS), Vivek Vihar, for her valuable support in conducting pre-intervention, intervention and family feedback collection days’ activities in ABBS.

We are thankful to Mr Arun Sharma (Director, AIS), Mr Anurup Sharma (Director, ABBS), Mrs Swapna Nair (Principal, AIS), Mrs Urmila Sharma (Principal, ABBS), Mrs Leeja Srigil (Senior Chemistry Teacher, AIS), and all the teachers of AIS and ABBS for extending their encouragement and support in execution of the project.  

We are thankful to Dr Dheeraj Shah, Professor, Department of Pediatrics, UCMS and GTB Hospital, Dilshad Garden, for his invaluable help and guidance in statistical analysis of our data.

We are thankful to Dr Yugal K Mishra (Chairman, Payasuni Charitable Trust), Dr GP Kaushal (President, IAP Delhi), Dr Peeyush Khanna (Secretary, IAP Delhi), Payasuni Charitable Trust and Indian Academy of Pediatrics Delhi State Branch for supporting the project and providing required sponsorship for the materials used.

We are thankful to National Organ and Tissue Transplant Organization (NOTTO) and Professor (Dr) Vimal Bhandari (Director, NOTTO) for their encouraging words and for providing soft copy of Form-7 for the project.

We are thankful to our parents for their support in the project.

References

1. https://sites.ndtv.com/moretogive/expert-blog-steps-ensure-steady-rise-organ-donation-rate-india-2160/

2. https://sites.ndtv.com/moretogive/lack-organ-donation-india-half-million-people-die-annually-india-due-unavailability-organs-2107/

3. Rajesh Panwar, Sujoy Pal, Nihar R. Dash, Peush Sahni, Aarti Vij, Mahesh C. Misra. Why are we poor organ donors: A survey focusing on attitudes of the lay public from northern India. Journal of Clinical and Experimental Hepatology. 2016 Jun; 6(2): 81–86.

4. Li AH-T, Rosenblum AM, Nevis IF, Garg AX. Adolescent classroom education on knowledge and attitudes about deceased organ donation: A systematic review. Pediatric Transplantation. 2013; 17: 119–128.

5. https://www.thelocal.es/20180111/spain-is-the-undisputed-world-leader-in-organ-transplants

6. Shroff S. Legal and ethical aspects of organ donation and transplantation. Indian Journal of Urology. 2009; 25(3): 348–355.

7. Salim A, Berry C, Ley EJ, Liou DZ, Schulman D, Navarro S, Zheng L, Chan LS. Increasing intent to donate in Hispanic American high school students: results of a prospective observational study. Transplantation Proceedings. 2013; 45: 13–19.

8. Cantarovich F, Cantarovich D. Education and organ donation: ‘the unfinished symphony’. Transplant International. 2012; 25: e53–54.

9. Cantarovich F. The role of education in increasing organ donation. Annals of Transplantation. 2004; 9: 39–42.

10. Rosenblum AM, Horvat LD, Siminoff LA, Prakash V, Beitel J, Garg AX. The authority of next-of-kin in explicit and presumed consent systems for deceased organ donation: An analysis of 54 nations. Nephrology, Dialysis, Transplantation. 2012; 27: 2533–2546.

11. Anantachoti P, Gross CR, Gunderson S. Promoting organ donation among high school students: An educational intervention. Progress in Transplantation. 2001; 11: 201–207.

12. Weaver M, Spigner C, Pineda M, Rabun KG, Allen MD. Knowledge and opinions about organ donation among urban high school students: Pilot test of a health education program. Clinical Transplantation. 2000; 14: 292–303.

13. Waldrop DP, Tamburlin JA, Thompson SJ, Simon M. Life and death decisions: Using school-based health education to facilitate family discussion about organ and tissue donation. Death Studies. 2004; 28: 643–657.

14. Smits M, Van Den Borne B, Dijker AJ, Ryckman RM. Increasing Dutch adolescents’ willingness to register their organ donation preference: The effectiveness of an education programme delivered by kidney transplantation patients. European Journal of Public health. 2006; 16: 106–110.

15. Yip C, Gates M, Gates A, Hanning RM. Peer-led nutrition education programs for school-aged youth: a systematic review of the literature. Health Education Research. 2016; 31: 82-97.

Research on Deceased Organ Donation

We also used online resources to update our knowledge and understanding on deceased organ donation, transplantation, brain death, donor and recipeint experiences for development of materials for our project under the guidance of our mentor. 

Online Resources also used were:

1.      https://www.notto.gov.in/faqs.htm

2.      https://tendaily.com.au/news/good-news/a180601ogh/double-transplant-recipient-to-make-ironman-history-20180601

3.      https://timesofindia.indiatimes.com/city/mumbai/7-yr-old-NRIs-organs-help-4-get-a-fresh-shot-at-life/articleshow/50799966.cms

4.      http://www.mohanfoundation.org/

5.      http://www.organindia.org/ngos-in-organ-donation/

Data analysis tools

We used IBM SPSS Statistics 25.0 software and online statistical calculator 'https://www.medcalc.org/' for statistical analysis of our data under the able guidance of Dr Dheeraj Shah.