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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2014  |  Volume : 25  |  Issue : 1  |  Page : 196-205
Predictors of public attitude toward living organ donation in Kano, northern Nigeria

1 Department of Community Medicine, Aminu Kano Teaching Hospital and Bayero University, Kano, Nigeria
2 Alhassan Dantata Haemodialysis Unit, Department of Medicine, Aminu Kano Teaching Hospital and Bayero University, Kano, Nigeria

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Date of Web Publication7-Jan-2014


Organ shortage is a major public health challenge for transplant programs globally. The sustenance of such programs as an effective therapy for end-stage organ failure (ESOF) requires an exploration of public awareness and willingness to donate organs. This is imperative, especially in developing countries where ESOF is highly prevalent. We studied the awareness and predictors of public attitude toward organ donation in Kano city in northern Nigeria. Using interviewer-administered questionnaires, we assessed the awareness and willingness to donate solid organs among 400 adults in the Kano metropolis. Three hundred and five of the 383 respondents (79.6%) reported that they had heard about organ donation. There was a significant variation of awareness by education and ethnicity (P <0.05). Most respondents, 303 (79.1%), were willing to donate an organ. Gender [adjusted odds ratio (AOR) = 2.13; 95% confidence interval (CI): 1.40-4.95], educational attainment (AOR = 2.55; 95% CI: 1.35-5.88), marital status (AOR = 4.5; 95% CI: 2.97-9.1), religion (AOR = 3.40; 95% CI: 1.43-8.10) and ethnicity (AOR = 2.36; 95% CI 1.04-5.35) were significant predictors of willingness to donate an organ. Preferred organ recipients were parents (48.9%), children (21.3%), spouses (14.6%) and other relatives (13.4%). Reasons for willingness to donate organs included religion (51.2%), moral obligation (21.4%) and compassion (11.9%), among others. However, there was widespread ignorance of religious precepts concerning organ donation. The high level of awareness and willingness to donate organs in this society could be further enhanced by intensive information, education and communication strategies providing clear messages on societal benefits, religious aspects and bioethical guidance regarding organ donation.

How to cite this article:
Iliyasu Z, Abubakar IS, Lawan UM, Abubakar M, Adamu B. Predictors of public attitude toward living organ donation in Kano, northern Nigeria. Saudi J Kidney Dis Transpl 2014;25:196-205

How to cite this URL:
Iliyasu Z, Abubakar IS, Lawan UM, Abubakar M, Adamu B. Predictors of public attitude toward living organ donation in Kano, northern Nigeria. Saudi J Kidney Dis Transpl [serial online] 2014 [cited 2022 Oct 5];25:196-205. Available from: https://www.sjkdt.org/text.asp?2014/25/1/196/124577

   Introduction Top

Organ donation is the process of removal and transplantation of viable organs from a donor to a recipient, and this has become an effective therapy for end-stage organ failure (ESOF). [1] The World Health Organization reports that kidney transplants are carried out in 91 countries, and that around 66,000 kidneys, 21,000 livers and 6000 hearts were transplanted glo­bally in 2005 alone. [2] Organs used for trans­plantation are obtained from brainstem-dead, heart-beating cadaveric donors or living do­nors. There is a discrepancy between the num­ber of individuals requiring organ and tissue transplantation and the number of organs and tissues available. The increasing number of patients presenting with ESOF in hospitals in developing countries, including Nigeria, has prompted the establishment of a number of transplant centers. The prohibitive cost of renal dialysis and the cultural sensitivity to cada­veric organ donation has increased the reliance on living donors in our center. Transplantation raises a number of bioethical issues. These include the definition of death, consent for heart-beating cadaveric donors and compensa­tions for living donors. [3]

Studies have been conducted among the gen­eral public in other parts of Nigeria regarding awareness and attitude toward organ donation. [4],[5] Responses were influenced by educa­tional, religious, cultural and ethical factors. For instance, a study conducted in Lagos found that 60% of the respondents were aware of organ donation, but that only 30% were willing to donate. [4] Positive attitude toward organ do­nation was significantly influenced by age, but not gender or educational status. A similar study among Nigerian health-care workers showed a positive perception of kidney dona­tion, and up to 75% of them were willing to donate. [5] ESOF contributes significantly to in-hospital mortality in our center. [6] The establish­ment of a renal transplant unit at this center brought the challenge of sourcing for kidney donors. Located in the commercial nerve cen­ter of northern Nigeria and the nation's most populous state, the catchment populace is predominantly Muslim and is averse to post­mortem examinations, including cadaveric do­nations. Hitherto, no known study explored the public perception and attitude toward organ donation in Kano and the surrounding areas. This study determined the awareness and wil­lingness of the public toward living organ donation in Kano city. It also identified predictors of such attitude. The information ob­tained could be used to create public aware­ness and mobilize organ donors, thereby in­creasing the pool of donors.

   Methods Top

We used a cross-sectional descriptive study design. A sample of 400 adults from the Kano metropolis was selected for the study. The sample size was calculated using Fisher's formula for estimating the minimum sample size for descriptive studies, [7] assuming a pre­valence of 30% (willingness to donate organ) obtained from a previous study. [4] The mini­mum sample size was inflated by 10% to com­pensate for non-response and incomplete responses. A multi-stage sampling method was used to select the study subjects. In the first stage, four localities (Tarauni, Fagge, Kano Municipal and Gwale) were randomly selected from the list of eight localities in Kano Metro­polis. The lists of settlements from the selected localities served as the sampling frame for the second stage. One settlement was selected ran­domly from each of the localities by drawing lots. The houses in all the selected settlements were then numbered and, proportionately, 106, 97, 114 and 83 houses were selected from the sampled settlements in Tarauni, Fagge, Kano Municipal and Gwale localities, respectively. Houses were selected using systematic random sampling. In houses with more than one house­hold, one was selected through a one-time ballot. Finally, one adult was selected from among the eligible adults in the selected house­hold using simple random sampling (by dra­wing lots), and this person was administered the survey instrument.

Instrument description/data collection

An interviewer administered the pre-tested semi-structured questionnaire, which was adap­ted from a previous survey instrument. [8] The first part elicited socio-demographic characte­ristics. The second part investigated awareness of solid organ donation and transplantation. The third section sought information on the attitudes toward organ donation and willingness to donate an organ for transplantation, where participants were requested to indicate their level of agreement on a three-point Likert-type scale (agree, undecided, disagree). Pre-testing of the instrument was conducted in another locality in Kano state (Kumbotso). Some of the questions were rephrased for cla­rity based on the observations made during pre-testing. The questionnaires were adminis­tered by eight Hausa-speaking Nigerian field assistants who were trained by the researchers on the tools and techniques of data collection and the study protocol. They worked in teams of two interviewers each (one male and one female). Each team had a female member so as to facilitate communication with the female respondents. The interviews were conducted in the local language (Hausa). Informed consent was obtained from all prospective respondents. The consent form was in the local language (Hausa), and literate respondents indicated acceptance by signing the consent form, while illiterate participants affixed their thumbprint. Ethical clearance for the study was obtained from the Institutional Review Board at Aminu Kano Teaching Hospital. The permission of authorities and traditional community leaders from the localities studied was obtained before commencement of data collection.

   Data Analysis Top

Data were analyzed using SPSS version 16. [9] Quantitative variables were summarized using appropriate measures of location and varia­bility. Categorical variables were presented as frequencies and percentages. Bivariate analysis involved the use of the Chi-square test for assessing the significance of associations bet­ween categorical variables. Logistic regression analysis was used to adjust for confounders and identification of predictors of willingness to donate organs for transplantation. The level of significance was set at P <0.05.

   Results Top

Socio-demographic characteristics Of the 400 individuals approached, 383 agreed to participate, giving a response rate of 95.8%. Most of the participants (78.3%) were males, Hausa-Fulani (75.7%) and Muslim (85.6%). Their ages ranged from 18 to 62 years, with a mean of 34.3 ± 2.8 years. The corresponding figures for males and females were 37.7 ± 3.2 and 26.5 ± 4.1 years. More than half of the participants (58.5%) were in the fourth decade of life. About one-third of the responders had secondary (36.8%) and tertiary (39.2%) edu­cation, respectively, while 14.4% had no for­mal education [Table 1].
Table 1: Socio-demographic characteristics of the respondents, Kano, Nigeria, 2011.

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Awareness of organ donation

Most of the participants [305 (79.6%)] had heard of organ donation. Their main sources of information included electronic media (radio/ television, 47.2%), health workers (17.7%) and print media (14.8%); others (20.3%) men­tioned friends and family as their sources. Thirty-six respondents (10.4%) knew of some­one who had donated an organ while 42 (12.2%) knew of a transplant recipient. Aware­ness of organ donation was significantly asso­ciated with increasing educational attainment and ethnicity (P <0.05), but not with gender, age, religion or marital status [Table 2].
Table 2: Awareness of organ donation by socio-demographic characteristics, 2011.

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Most of the participants (65.9%) said that organs for donation could come from living donors only, while 4.9% said it could be ob­tained from deceased donors who have brain-death. However, only 25.9% of the people knew that organs for donation can come from both living and deceased donors. Apart from the universal knowledge of blood donation, our study showed that 61.6% of the people knew that kidneys can be donated, followed by 26.2% who knew that the heart can be donated and 5.3% who knew that the liver can be do­nated. Similarly, 3.9% knew that the lungs can be donated while 2.9% mentioned eyes, skin and bone marrow.

Of the 383 respondents, 93 (24.3%) had never donated blood. When asked whether or not they were willing to donate organs to others, 303 (n = 79.1%) replied in the affirma­tive. For those willing to donate, the reasons included religious issues (51.2%), moral obligation (21.4%), compassion/sympathy (11.9%), anticipated reciprocity (9.4%) and just to save life (6.1%). On the other hand, unwilling res­pondents also cited religious reasons (7.8%), lack of incentives (24.7%) and fear of dying in the process (37.7%). The remaining respon­dents (29.8%) mentioned other reasons (an­xiety or that it was the government's responsi­bility) for their position on organ donation. The preferred recipients of the respondents to their organs included parents (48.9%), children (21.3%), spouses (14.6%), relatives (13.4%) and friends (1.8%). With regard to knowledge of risks associated with organ donation, 67.2% of the people were aware that organ donation is associated with some risk for the donor. The risks mentioned included reduced physical strength (34.1%), shortened lifespan (24.7%) and infection (12.3%). Others (28.9%) ment­ioned bleeding, pain and anxiety. Regarding the attitude of respondents to organ donation, 77.1% considered it to be a good practice and that it should be encouraged to save lives, while a mere 2.9% were sure that their religion allowed for organ donation while the majority (63.5%) was not sure of their religious injunc­tion on organ donation and transplant. Other opinions are shown in [Table 3]. The important considerations before organ donation among respondents included the recipient's religious faith and the assurance that their organs would not be sold or swapped.
Table 3: Attitude of respondents toward organ donation and transplantation.

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Predictors of willingness to donate organs

[Table 4] shows that willingness to donate organs varied with socio-demographic charac­teristics. A significantly higher proportion of male respondents indicated their willingness to donate compared with females (P <0.003). By ethnicity, a significantly higher proportion of the Hausa-Fulani and Igbo respondents were willing to donate organs compared with the Yoruba and other Nigerian ethnic groups (P <0.001). By marital status, a higher proportion of currently married and single respondents were willing to donate organs compared with divorcees and widows/widowers (P <0.001). Also, a higher proportion of Muslim respon­dents were willing to donate organs compared with Christians (P <0.001), and a higher pro­portion of respondents with formal education were willing to donate organs compared with their less well-educated counterparts (P = 0.004). However, age had no significant in­fluence on attitude toward organ donation (P >0.05).
Table 4: Willingness to donate an organ by socio-demographic characteristics, 2011.

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Using a logistic regression model with gen­der, ethnicity, marital status, religion and education as independent variables, we found that all these variables remained significant predictors of willingness to donate after adjus­ting for each other. Specifically, males were more than twice likely to be willing to donate organs compared with their female counter­parts [adjusted odds ratio (AOR) = 2.13; 95% confidence interval (CI): 1.40-4.95]. Respon­dents with primary education were more than 30% likely to want to donate organs compared with those with no formal education. Simi­larly, those with secondary or post-secondary education had more than twice the likelihood of being motivated to donate organs (AOR = 2.55; 95% CI: 1.35-5.88). Compared with di­vorcees or widows/widowers, married respon­dents were more than twice as likely to want to donate. Also, single respondents were more than four-fold likely to be willing to donate (AOR = 4.5; 95% CI: 2.97-9.1). Muslim res­pondents were more than three-times likely to want to donate organs compared with non-Muslims (AOR = 3.40; 95% CI: 1.43-8.10). Finally, by ethnicity, Hausa-Fulani respondents were more than twice as likely to be willing to donate organs compared with the other Nigerian tribes (AOR = 2.36; 95% CI: 1.04-5.35) [Table 5].
Table 5: Predictors of willingness to donate organ for transplant among adults in Kano city, northern Nigeria.

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   Discussion Top

The level of awareness of organ donation among our respondents (79.6%) was compa­rable with the figure reported from Enugu [10] (79.4%), but higher than that obtained in Lagos (60%). [4] Researchers in other African countries have reported awareness levels of 76% and 96% in Morocco [11] and South Africa, [12] respec­tively. In Europe, the figure was 60.1%, [13] while in the United States of America, [14] 86% of the respondents were reported to be aware of organ donation and transplantation. These differences could be due to variations in methodology, population characteristics, timing as well as availability of local transplant services. The association observed between awareness and education is consistent with previous studies. [15],[16] Educated respondents have the advantage of being able to read and understand information regarding organ dona­tion from various sources. Most of our parti­cipants (65.9%) said that organs for donation came from the living, with a few knowing that it could come from brain-dead deceased do­nors as well. This concurs with a previous study from Pakistan [15] but contrasts with ano­ther study, [17] where up to 84% of the people knew that organs could come from cadavers while 71.1% said that it could be carried out during one's lifetime. The low acceptance of post-mortem examinations in the study area [18] could explain the ignorance about cadaveric donations.

The preponderance of electronic media as a source of information concurs with reports of earlier studies in Nigeria [4],[10] and elsewhere. [15] The relatively low acquaintance of our respondents with prior organ donors is in tandem with reports from other developing countries. [9],[15] Nevertheless, the exceptional relative fami­liarity with kidney donors could be due to the new renal transplant center in the study area. Also, the universal knowledge of blood do­nation and appreciable personal experience shows that this practice is common place.

The proportion of willing organ donors among our respondents (79.1%) was much higher than the responses from Lagos (30%) [4] and Enugu (33.6%) [10] in Nigeria. It was also higher than the figures from South Africa (8%) [12] and Turkey (47%). [19] In Asia, the corresponding figures were 35.2%, 35.3% and 49.8% in

Malaysia, [8] Pakistan [15] and China, [20] respectively. In Europe, the figure was 60.1%, [13] while in the USA, a much higher figure of 96% was re­ported in Ohio. [14] The choice of parents, spouses, children and relatives as preferred recipients of organs is in keeping with observations from other parts of Nigeria, [4],[10] Africa [12] and Asia. [15],[20] Specifically in Pakistan, [15] more than half of the respondents preferred to donate to a family member. Also, in Saudi Arabia [21] and Qatar, [22] potential donors preferred to donate their organs to close relatives and friends. These fin­dings could be a reflection of man's membership of a social system and variations in strength of family ties in the different socie­ties. The extended family system is still very strong in the study area and members are expected to be their brother's keeper. This may differ from the situation in industrialized coun­tries where the nuclear family concept pre­dominates and the benevolence to extended family members becomes relatively weaker. The level of trust between individuals and the health system may affect their motivation to donate organs for public good. Suspicion of commercialization of donated organs may dis­courage some potential donors from actua­lizing the gift of life. Also, a study in the USA reported concerns of potential donors regar­ding the removal of organs before they are truly dead and the perception that they may be denied optimal health-care on the basis of their prior intent to donate their organs after death. [23] Although these reasons were not given in the present study, such notions could discourage a number of potential donors, thereby reducing the pool of donors.

A high proportion of this predominantly Muslim populace was willing to donate. Des­pite this level of motivation, many were not sure of the Islamic opinion on organ donation. An important factor may be the uncertainty of the theological position on the issue. This is further complicated by conflicting legal ru­lings from Islamic scholars concerning the legality of brain-death criteria, donation and transplantation per se. [24] While a number of Islamic organizations and institutions around the globe have issued fatwas and edicts in fa­vor of organ donation, describing it as "an act of merit," [25] the awareness among adherents of the religion is poor. This underscores the im­portance of partnering with religious leaders to enlighten their subjects on the injunctions of the different faiths regarding organ donation and transplantation.

While most developed nations have a legal system of oversight for organ transplantation, the same cannot be said of developing coun­tries, and the fact remains that the demand for organs far outstrips the supply. [26] Consequently, there has been a black market referred to as transplant tourism raising serious bioethical concerns. Because most of those offering their organs for sale do so out of economic despe­ration, they are often exploited by middlemen who procure these organs for the rich. [15]

The significant role of gender, ethnicity, marital status, religion and education has also been observed previously. [4],[15] A European study [13] showed that individual and family de­cisions to donate organs are affected by aware­ness and social interactions such as the ability to count on others in case of a serious problem (reciprocity). The apparent influence of religion in our study needs to be cautiously inter­preted, given that non-Muslims were a mino­rity in the study area. The true effect of religion could be found in settings where the proportion of Muslim and non-Muslim respon­dents are similar. Furthermore, education (more educated), age (younger) and political affi­liation determined willingness to donate one's own organs and consent to the donation of those of a relative. It suggests that opinions about organ donation are molded by indivi­dual, family, community influences as well as spiritual inclinations among other factors. Therefore, strategies for encouraging organ donation should be directed at personal, house­hold and ecological levels. Targeted informa­tion packages should be produced and socio-culturally appropriate channels of delivery should be used to maximize the availability of organs to address the existing gap between those that need organs and the donors. The positive effect of education is also consistent with other studies. [4],[15] This suggests that efforts to increase knowledge and promote supportive attitudes toward organ donation and transplan­tation should focus on the general public with a low level of education. Another issue that needs attention is the religious and cultural sensitivity about manipulation of the body of the deceased donor.

In evaluating our results, several limitations should be considered. First, self-reported infor­mation on willingness to donate organs is prone to social desirability bias because attitudes do not necessarily reflect one's actual behaviors when confronted with a real-life scenario. Secondly, northern Nigeria is by no means homogenous and, therefore, findings from one community need to be extrapolated with caution. The inclusion of a subsection on attitude toward organ donation in subsequent demographic and health surveys could provide more representative data. Despite these caveats, the issues highlighted by this study are of considerable importance for the understanding of public view on organ donation and trans­plantation, and could inform public campaign programs.

We found a high level of awareness and willingness to donate solid organs, and these were modulated by education, ethnicity, mari­tal status and religion. Measures should be taken to educate people with relevant infor­mation, including the benefits of organ dona­tion and possible risks as well such that people can make informed choices. Policy makers should involve religious scholars for the mo­bilization of a favorable public opinion to­ward organ donation in a community that is highly religious. In addition, hospitals should introduce organ donor card systems and the government should legislate for the protection of donors, health workers and organ recipients from commercial interests.

   References Top

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Correspondence Address:
Zubairu Iliyasu
Medical Research Consultancy Unit, Department of Community Medicine, Mohammed Kabir Building, Aminu Kano Teaching Hospital, PMB 3452 Kano
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-2442.124577

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]

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