Awareness of retinopathy of prematurity among pediatricians in a tier two city of South India.

PURPOSE: To analyze the level of awareness and knowledge about retinopathy of prematurity (ROP) among pediatricians in Coimbatore, which is a tier two city in South India.
MATERIALS AND METHODS: A questionnaire was framed on the knowledge attitude and practice (KAP) pattern. The questionnaire was given to 83 practicing pediatricians in government and private practice in Coimbatore and collected in person between November and December 2009. Answers were obtained on criteria like knowledge, prevention, screening, treatment and awareness of ROP.
RESULTS: Only 54 (65.1%) pediatricians were aware of ROP, while 29 (34.9%) were not aware of the disease. Thirty-three (39.8%) answered that ROP is preventable, while 24 (28.9%) responded that ROP is not preventable. Thirty-four (41%) pediatricians had no idea as to which part of the eye is affected in ROP, while 38 (45.8%) did not know when ROP screening should be started. Only 43 (51.8%) pediatricians were sure that ROP is treatable. Pediatricians in private hospitals were more aware of ROP compared to their counterparts in government hospitals (P = 0.006).
CONCLUSION: Awareness among pediatricians in Coimbatore about ROP is poor. Our study emphasizes the need to increase awareness of this avoidable cause of blindness.

Introduction

Retinopathy of prematurity is a fibrovascular proliferative disorder affecting the peripheral retinal vasculature in premature infants. It is a preventable cause of childhood blindness. With improving survival of very low birth weight infants, ROP emerged as a significant problem in India.[1-4] Although the exact prevalence in India is not known, the incidence reported is between 22 and 52%.[5-7]

The initial signs of ROP may be detected a few weeks after birth, and the condition progresses rapidly. This means that screening has to be timely as there is only a very narrow window of opportunity for treating these babies and the condition can quickly progress to blindness. Thus, awareness among pediatricians is a must to tackle this problem. Unfortunately, this is still lacking in India.[2] Many pediatricians refer to the ophthalmologist only when they or the parents notice white reflex, when it is too late to do anything as far as giving normal vision is concerned.[89]

We conducted this study to analyze the level of awareness and knowledge about ROP among pediatricians in Coimbatore, which is a tier two city of South India.

Materials and Methods

A questionnaire was framed on the knowledge attitude and practice (KAP) pattern, so as to gain a quick and effective response from the participants [Figure 1]. Answers were obtained on criteria like knowledge, prevention, screening, treatment and awareness on ROP. No personal questions were asked. The questionnaire was distributed and collected in person.

Figure 1

Knowledge attitude and practice questionnaire

The area of study and samples were chosen from various hospitals and nursing homes in the Coimbatore city. A sample size of 83 pediatricians was selected and the data were collected from them during November and December 2009. The samples contained pediatricians with a minimum of 5 years of experience in pediatrics and who were practicing in either government or private setup in Coimbatore city. The study was approved by the institutional review board of our hospital. Informed consent was taken from all participating pediatricians, and it was clearly mentioned that their identity would not be revealed.

Statistical analysis

The Chi-square test was used to test the association between different variables and a P value of <0.05 was interpreted as statistically significant.

Results

Eighty-three pediatricians were included in the study. The demographic details are given in Table 1. Fifty of the 83 (60.2%) were male pediatricians, while 33 (39.8%) were females. Fifteen (18%) were in government practice, while 68 (82%) were in private practice.

Table 1

Age distribution of the pediatricians

Only 54 (65.1%) were aware about ROP, while 29 (34.9%) were not aware of the disease. Thirty-three (39.8%) pediatricians said that ROP is preventable, 24 (28.9%) responded that ROP is not preventable, while 26 (31.3%) said that they have no idea if it was preventable or not. Table 2 gives percentage of the pediatricians with respect to their idea on risk factors for ROP.

Table 2

Awareness of pediatricians regarding causes of retinopathy of prematurity

While analyzing on how ROP is identified, 34 (41%) pediatricians had no idea, 16 (19.3%) of them mentioned that it is identified by examining the inside parts of the eye, whereas only 31 (37.3%) responded that it is identified by examining the retina. Two (2.4%) mentioned that it is identified by examining the vitreous. Table 3 shows the percentage of pediatricians with respect to their awareness about who performs the eye test.

Table 3

Awareness of pediatricians regarding who performs screening for retinopathy of prematurity

Table 4 shows percentage of the pediatricians with respect to their idea on the period of first eye test for ROP screening, that is, when to refer to ophthalmologist for ROP screening? Forty-three (51.8%) pediatricians were sure that ROP is treatable, while 15 (18.1%) were sure that ROP is not treatable, and 25 (30.1%) had no idea if ROP is treatable or not. Eighteen (21.7%) pediatricians mentioned that cryotherapy is the treatment for ROP, 28 (33.7%) mentioned that the laser is the treatment for ROP while 37 (44.6%) had no idea about the treatment for ROP. Only 17 (20.5%) pediatricians were satisfied with their current status on awareness and knowledge on ROP, while 41 (49.4%) were not satisfied, 15 (18.1%) were not sure and 10 (12%) had no idea about the current status on the awareness and knowledge. Pediatricians in private hospitals were more aware of ROP compared to their counterparts in government hospitals (P = 0.006).

Table 4

Awareness of pediatricians regarding timing of retinopathy of prematurity screening?

Discussion

In our study, we found that only 65.1% of the pediatricians were aware about ROP. Only 39.8% thought it was preventable and 42.2% had no idea on risk factors of ROP. 41% were not aware of which part of the eye is to be examined to identify ROP and 47% did not know who needs to perform the test. 45.8% of the pediatricians were not aware regarding the period of first eye test for ROP screening. In fact, 14.5% thought that first ROP screening should be done between 6 and 12 months of age. 44.6% of the pediatricians had no idea about the treatment modalities of ROP, while 18.1% thought that ROP is not treatable.

Till date, there is no study published on KAP for ROP among pediatricians in India. Rani and Jalali (Knowledge attitude practice study of retinopathy of prematurity amongst pediatricians attending a neonatal ventilation workshop in south India. Proceedings of World ROP Congress; 2009 November 21-23; New Delhi, India. New Delhi: Paras printers; 2009) did a similar study on 38 pediatricians attending a neonatology ventilation workshop in Hyderabad. In that study, they found that 100% of pediatricians knew about the risk factors of ROP compared to only 57.8% in our study. In that study, 68% knew about laser treatment compared to 55.4% in our study. In another study done in Pune by Kulkarni et al. (Knowledge attitude and practices of retinopathy of prematurity amongst various stakeholders in western Maharashtra. Proceedings of World ROP Congress; 2009 November 21-23; New Delhi, India. New Delhi: Paras Printers; 2009), 80% of the pediatricians knew about the risk factors of ROP compared to 57.8% in our study. 93% of the pediatricians knew that timely treatment can prevent ROP related blindness, compared to only 39.8% in our study.

Both these above studies were done in tier one cities of India. Although the level of ROP awareness may be high among pediatricians of metro cities, our study shows that it is very poor in tier two cities like Coimbatore and may even be worse in tier three cities. We regularly see babies with advanced stage four and five ROP which were born in tier three cities and periphery.[8] These babies have never had an eye exam and come to us only after the parents notice that child is not seeing well. When enquired, these parents were never informed by the treating pediatrician about the need for an eye examination for their child. The medico-legal implications are huge and should be kept in mind by the pediatrician.[10]

The first step in reducing blindness due to ROP is recognizing that the problem exists. Our study shows that awareness of ROP is poor among pediatricians. Reports from other developing countries like China,[11] Thailand[12] and Vietnam[13] also show a similar trend.

Apart from this, another unique problem that India and other developing nations face is that severe ROP is also seen in bigger preterm babies. This is mainly because supplemental oxygen is often given unnecessarily to infants who are stable even when they would be adequately oxygenated without it. Thus, it is advisable to have caution and use wider screening criteria and not to rely on the criteria published by developed countries.[14] There is also an increasing body of evidence that lower target oxygen saturations are protective and monitoring should aim to keep oxygen levels between 83 and 93% and not higher.[15]

In our study, 79.5% of the pediatricians were not satisfied about their current awareness and knowledge on ROP. In order to improve the awareness among pediatricians about ROP, we recommend publishing articles in medical magazines and medical journals, including ROP seminars in national pediatric conferences and have frequent continuous medical education programs in government and private hospitals. The Indian Academy of Pediatrics (IAP) should take the lead at the national level to see that ROP awareness is spread uniformly amongst the pediatricians in India. On the lines of joint statements given by American Academy of Pediatrics and American Academy of Ophthalmology,[16] the IAP along with the All India Ophthalmological Society (AIOS) should develop national guidelines for the control of ROP. This will not only help in increasing the awareness among pediatricians and ophthalmologists, but also give uniform guidelines on screening and treatment of ROP.