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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2018  |  Volume : 29  |  Issue : 5  |  Page : 1115-1127
Saudi medical students knowledge, attitudes, and beliefs with regard to organ donation and transplantation

1 Department of Internal Medicine, College of Medicine, Al Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia
2 Division of Medicine and Therapeutics, Ipswich Hospital NHS Trust and University of Suffolk, Ipswich, UK

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Date of Submission29-Sep-2017
Date of Acceptance23-Nov-2017
Date of Web Publication26-Oct-2018


A positive attitude to organ donation among doctors is key to increasing organ donation. Education of medical students is suggested to be central to achieving this. This study examined whether knowledge of organ donation and transplantation (ODT) correlates with attitudes and beliefs relevant to ODT among medical students in Saudi Arabia. Two hundred and thirty-three students completed a self-administered questionnaire. A knowledge score was calculated for each student and correlated with answers on attitudes and beliefs with regard to ODT. This study revealed a complex interaction between knowledge, attitudes, and beliefs to ODT. The majority of students support ODT in general, but a significant proportion have negative beliefs when asked about specific details of the process and concern for family members with regard to both deceased and live donation is evident. Despite almost all students believing that Islamic beliefs do not preclude ODT, 27.1% believe transplantation to be unacceptable in the Society in which they live. Education is an important strategy to improve donation rates. These findings can guide development of medical student education programs suggesting inclusion of open debate about views in society and the importance of discussion with family members to be essential.

How to cite this article:
AlShareef SM, Smith RM. Saudi medical students knowledge, attitudes, and beliefs with regard to organ donation and transplantation. Saudi J Kidney Dis Transpl 2018;29:1115-27

How to cite this URL:
AlShareef SM, Smith RM. Saudi medical students knowledge, attitudes, and beliefs with regard to organ donation and transplantation. Saudi J Kidney Dis Transpl [serial online] 2018 [cited 2021 Apr 15];29:1115-27. Available from: https://www.sjkdt.org/text.asp?2018/29/5/1115/243963

   Introduction Top

One of the major challenges still facing organ transplantation is the availability of donor organs.[1],[2] Awareness among young adults in general and medical students and doctors in particular has been suggested to be a key to achieving the required continued increase in organ donation.[1],[3],[4] Religious and cultural beliefs are a further potential barrier to organ donation and transplantation (ODT).[5] Awareness of and support for ODT has been studied in the general population in Saudi Arabia,[6],[7] Saudi students (nonmedical)[8],[9] and Saudi medical students.[10],[11]

This study explored the knowledge, attitudes, and beliefs of relevance to ODT among a group of 233 preclinical and clinical medical students attending a single Saudi College of Medicine. Specifically to explored attitudes underpinning commitment to ODT to understand better the level of commitment to the process and examined whether Islamic beliefs significantly impact on engagement of this group with ODT and was undertaken as it is believed that understanding of the complexities of the relationship of medical students with ODT is essential if education programs are to increase engagement.

The first renal transplant was performed in Saudi Arabia in 1979 with a progressive increase in organ transplantation overseen first by the National Kidney Foundation, and then from 1993 the Saudi Center for Organ Transplantation (SCOT).[12] The SCOT promotes deceased organ donation, deceased organ donation from brain-dead individuals and live-organ donation from relatives under specified guidelines covering the social, scientific, and ethical frameworks of the process.[13] An “Opt-in” system of donor registration is followed and a donor card is issued to individuals who intend to donate their organs after death. However, an organized registry of the donors is not maintained, which reduces the conversion of donor card holders to successful donors. Consent for live-organ donation is obtained from the donor, whereas family consent is required for retrieval of organs from deceased donors.

The Islamic Jurisprudence Assembly Council in Saudi Arabia approved deceased and live donation in 1988.[8],[9] The Saudi Government and SCOT have promoted transplantation by facilitation of the brain death fatwa and introduction of innovative policies such as the incentive-based procurement system. This has resulted in 558 kidneys, 158 livers, 21 hearts, 31 lungs, six pancreases, and six corneas being transplanted in Saudi Arabia in 2013, from live and deceased donors.[14]

However, reluctance toward deceased organ donation still prevails among the public[13] with the number of Saudi donors historically being considerably lower than non-Saudi donors.[15] In predominantly Muslim countries such as Pakistan only 35.3% of the general public are “highly motivated” to donate organs.[16] In keeping with this, in Middle Eastern countries deceased donation typically accounts for no more than 25% of all transplants performed.[17] Thus, the demand for organ transplantation far exceeds transplant activity, with more than 10,000 patients undergoing dialysis in Saudi Arabia and 5–700 patients remaining on the waiting list for liver transplantation, with 20%-25% dying while waiting in the King Faisal Specialist Hospital and Research Center, Riyadh. Increase in deceased donation rates to achieve the proportions seen in the US and UK would significantly increase transplantation in Saudi Arabia.

Figuero et al[18] demonstrated self-reported medical knowledge to correlate with donor registration among Dutch medical students. Three studies have been conducted in Saudi Arabia, but only published in abstract. Alwably reported 42.5% of 355 students at Qassim University to be willing to sign organ donor cards and 46.6% to be willing to donate to relatives after death.[10] Majeed reported a positive correlation between knowledge and commitment to organ donation among nursing and medical students at the University of Dammam.[11] Almohsen reported 37.4% of students at Qassim University to be prepared to donate organs in the future and 68.2% being prepared to donate to a relative.[9] They comment that medical students had significantly higher knowledge but do not comment on whether this correlates with a greater commitment to ODT.[9],[10],[11]

This study describes in detail medical students’ level of knowledge of transplantation at a single center in Saudi Arabia and explores whether the level of knowledge correlates with attitudes to transplantation. It allows comment also on the influence of Islamic beliefs on ODT in this cohort of Saudi medical students.

   Materials and Methods Top

The study was approved by the Institutional Review Board of the College of Medicine, Al-Imam University, Riyadh. Medical education at the Saud Islamic University, Riyadh is a six years program with three preclinical years followed by two clinical years, before students’ progress to internship. The curriculum of the MBBS at Al-Imam University consists of the following:

- Phase I: Premedical program at college of science (1 year)

- Phase II: First year - The foundation of medicine

Second year - Foundation and system-based program

Third year- System-based program.

- Phase III: Fourth and Fifth Year: Clerkship-clinical rotations

• One year internship

Six hundred and forty-five pre-clinical and clinical students at the College were asked to complete an electronic, self-administered questionnaire between January and March 2016. Participation was voluntary, anonymous, and unpaid. There are 104 female students in total. Two hundred and thirty-three students responded of whom 72 were female.

The questionnaire was developed based on previous published questionnaires.[3],[19],[20],[21],[22],[23] The survey was carried out using methodology similar to Sobnach,[24] distributing the questionnaire to all medical students without prior notification. The questionnaire consists of 60 questions in seven sections allowing collection and evaluation of: (i) demographic data, (ii) medical knowledge about ODT, (iii) attitudes and beliefs toward ODT, (iv) training and exposure to information about ODT, (v) position of the participant with regard to their own organ donation, (vi) level of confidence about ODT, and (vii) opinions about reasons for shortage of organs and solutions. Three control questions assessing adequate engagement with the questionnaire were included ([Appendix I] for a copy of the complete questionnaire).

All analyses were conducted with Statistical Package for Social Sciences (SPSS) version 16.0 (SPSS Inc. Chicago, IL, USA). A knowledge score was calculated for each student and correlations between knowledge score and (a) demographic characteristics and stage of training, (b) attitudes and beliefs, (c) training and exposure, (d) own position with regard to organ donation, and (e) confidence with own knowledge were assessed by two-sided Chi-square test, with Ρ <0.05 considered statistically significant.

   Results Top

A complete questionnaire was received from 233 students. Three control questions were included asking the students to reply simply yes or no to exclude students answering randomly. Eight respondents were excluded as they answered incorrectly for at least one of the three control questions. Of the 225 included participants, 153 were male and 72 were female. One hundred and nine were preclinical students and 116 were clinical students. The mean age of the respondents was 23 years (range, 17–29) [Table 1].
Table 1: Demographic characteristics, year of the study of participants completing the questionnaire correctly and number of students registering for or considering organ donation.

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Knowledge scores

The questionnaire contained 20 questions assessing knowledge of ODT [Table 2]. Matching two questions; general knowledge eight questions; brain stem death six questions; Stem cell transplantation in Saudi Arabia two questions and the Saudi donation process two questions). The overall mean score was 61%, with a mean score of 81% for questions on brain stem death, but a mean score of only 20% for the two matching questions [Table 2]. No significant difference was seen between pre-clinical and clinical students or between male and female students.
Table 2: Knowledge scores by topic.

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Mean knowledge scores were calculated for students answering, for example, yes/no or agree/neutral/disagree for each subsequent question, allowing any association between knowledge scores and these answers to be determined.

Students were asked also from where they had obtained most knowledge about transplantation: television, radio, newspapers, medical school lectures, religious leaders, family, colleagues, or other. Medical school lectures (36%), television (25.8%) and social media (20%) were the major primary sources of information.

Attitudes and beliefs toward organ donation and transplantation

Students’ attitudes and beliefs toward ODT were explored first by documenting whether they had donated blood, whether they would be willing to be a live organ donor and whether they would be prepared to receive a deceased or live donor transplant [Table 3]. Overall 44% of students had donated blood, with 60% of male students, but only 26% of female students having donated (P = 0.0001).
Table 3: Attitudes and beliefs: Blood donation and willingness to donate and receive transplant. Mean knowledge score ± standard deviation is shown for students answering yes or no to each question.

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Interestingly, almost all students (92%) would be willing to be a live organ donor to a family member, but only 76% would be prepared to receive a transplant from a family member after live donation. However, 90% of students would be prepared to accept a deceased organ transplant. The 22 students who would not be prepared to accept a deceased kidney scored the lowest knowledge score of all groups analyzed (10.68 ± 1.25) which was significantly different to the score for the 203 students prepared to accept a deceased organ (12.33 ± 2.04, P <0.05). Seventy-six percent of students were prepared to donate stem cells.

More general attitudes and beliefs were then explored [Table 4]. The majority of students (81.8%) supported organ donation in general, with a similar percentage (81.3%) believing doctors should promote ODT to the public and the majority believing that donating one’s organs would add meaning to life (88.9%). These responses would suggest the majority of these students would play a positive role in the promotion of organ transplantation in their future career.
Table 4: General attitudes and beliefs to organ donation and transplantation.

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However, when asked more specific questions, only 33% agreed with transplantation from brain dead patients and 30.2% believed that there may be premature termination of medical treatment for registered organ donors, to allow donation. Furthermore, only 29.8% of students believed that “organ donation does not usually add to a family’s grief, 24.9% of students disagreeing with this statement and 45.3% recording a neutral response. Perhaps partly explaining this, 20.9% of students believed the body to be mutilated by the donation process with 48.9% believing preservation of an intact body after death to be important. Accordingly, only 32.4% of students believed transplantation to be acceptable in the society in which they lived, 40% of students being neutral and 27.1% disagreeing with this statement. However, only 7.6% of students believed that Islamic beliefs prohibit human organ transplantation. 15.6% of students believed that organs should go to someone of the same religion. Importantly, 53.3% of students believed that their family would object if they agreed to donate their organs and 42.7% thought that family wishes should be able to override wishes expressed on an organ donor card. About 26.7% of students agreed that organs should be retrieved if the donor has not pledged them for donation when alive, 35.1% of students disagreeing with this statement.

Finally, 51.1% of students believed it to be acceptable to transplant animal tissues into humans.

Training and exposure to organ donation and transplantation

Students were asked also about exposure to transplantation [Table 5]. Only 70 out of 225 students had participated in a formal education program. The mean knowledge score for students who had participated in an education program about ODT was significantly higher than the score for students who had not participated in a formal program (12.79 ± 2.01 versus 11.89 ± 1.99 P <0.05). One hundred and seventy students (76%) had discussed transplantation with friends or colleagues. Only 14% had discussed transplantation on social media. Importantly, a minority of students (36%) had discussed donation decisions with family. Twenty-three percent had discussed transplantation with religious leaders. A minority of students had contact with or engaged with transplantation at a more practical level, 38% knowing someone who had donated or received an organ and only 25% knowing that family members or close friends had signed a donor card. There was no correlation between engagement with donation and transplantation, in these varied ways, and knowledge score.
Table 5: Exposure to organ donation and transplantation.

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Registration for organ donation

The attitudes documented above reveal a complex scenario. It is perhaps therefore not surprising that only 34 students (15%) had registered for organ donation [Table 1]. Students in the clinical phase of their studies were significantly more likely to have registered as compared to those in the preclinical phase (9% vs. 21%; P = 0.02). Almost half of the students were considering donation with no significant difference between preclinical and clinical students (45% vs. 41%, respectively). Twenty-five percent of preclinical students and 21% of clinical students had never considered becoming a donor. No significant gender differences were seen. A clear trend was seen between knowledge score and personal engagement with donation although this did not reach statistical significance [Table 6].
Table 6: Engagement with transplantation and knowledge score.

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Level of confidence about organ donation and transplantation and opinions about reasons for shortage of organs and solutions

Only 41 out of 225 students felt that they had enough knowledge with 209 wanting to learn more, 181 wanting to add ODT to the formal medical school curriculum and 188 believing that this would increase organ and tissue donation in the future [Table 7].
Table 7: Confidence and further learning

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Our students think that lack of public awareness is the primary reason for the shortage of donor organs (92%), with social issues (77.3%), religious beliefs (64%), and lack of knowledge among healthcare professionals (64%) also perceived to be important factors. Solutions suggested by respondents to address the shortage of donated organs complement the above. Creating public awareness of organ transplantation by media (96.9%) and further education of healthcare professionals (95.1%) were proposed by almost all respondents. Other important suggestions include support from “society” (91.1%) involvement of religious leaders (88%) and addressing ethical issues (84.4%).

   Discussion Top

As well as defining knowledge and attitudes to transplantation among pre-clinical and clinical medical students, this study has specifically addressed the correlation between levels of knowledge and attitudes toward and engagement with ODT.

Thirty-one percent of students perceived themselves as having received formal education in organ donation and transplantation, with knowledge scores significantly higher for those who had. Although only two questions were asked on matching, they are perhaps most revealing. Medical students might reasonably be expected to know that HLA matching correlates with transplant outcome, inherent in this being recognition that grafts differ in the degree of mismatch. Thus, it might be expected that students would know that exact matching is not needed. The requirements for blood group matching might be less obvious. However, a mean score of 20% for these two questions is particularly low.

Most importantly, significant conflict is suggested with regard to beliefs and attitudes to ODT. Overall students expressed support for donation and transplantation with >80% of students supporting donation in general, believing doctors should promote donation and believing that live organ donation added meaning to life. This is as reported by other authors both in KSA and worldwide.[4],[7],[8],[9],[10],[16],[18],[24],[25],[26] However, this reported support was in contrast to views on specific aspects of donation. A minority of students agreed with deceased donation from brain dead patients, with 30.2% believing life may be terminated prematurely. Edwards found concern that donation may impact negatively on the care received by a potential donor to be a significant factor inhibiting support for donation among medical students.[20] Thus, despite “superficial” support for ODT, such concerns may significantly impair engagement with the process. A similar percentage believed that donation added to a family’s grief with almost half of students believing that preservation of the intact body after death was important. This latter belief is in keeping with the fundamental principle of Islam that violating the human body, whether living or dead, is forbidden. However, this view does not take account of the Islamic Jurisprudence Assembly Council in Saudi Arabia ruling that, in keeping with the highest priority placed on saving a life in the Qur’an and the principle that necessity overrides prohibition, organ transplantation is not precluded by Islamic beliefs.[27] It is perhaps therefore not surprising that despite the general support indicated in initial questions, only 32.4% of students believed transplantation to be acceptable in the society in which they lived. Importantly, when specifically asked, only 7.6% believed Islamic beliefs to preclude transplantation. However, 64% of students cited religious beliefs as a cause of the shortage of donor organs. There are thus many contradictions in student’s commitment to ODT when attitudes and beliefs are explored in detail. This is similar to the attitudes of “Western Muslim” individuals to donation documented by Sharif et al,[28] where many people interviewed supported donation, but believed it to be incompatible with Islam. Importantly, Edwards et al[20] found a desire to be buried with organs intact to be a barrier to donation in non-Muslim individuals also. Thus, this complex situation may be reconciled if students’ own religious beliefs are not the main reason for their hesitancy with regard to transplantation, but rather a belief that the general public may be less clear about the position of Islam with regard to transplantation. Accordingly, 92% of students in this study believe a lack of public awareness to be the major reason for the lack of donor organs. This is challenged by the findings of Jabri et al,[7] who documented only 21.7% of Saudi citizens visiting a shopping mall in Madinah City to be unaware of donation with 74.1% being prepared to donate organs. Interestingly, only 2.7% of participants reported having a donation card. This misunderstanding may significantly inhibit a students’ future willingness to engage in discussions about organ donation and is easily addressed by education programs. However, this education should focus on discussion of attitudes and beliefs, including the findings of such studies, and not “medical” facts about ODT.

Concerns about the impact on family members seem to be a dominant theme with 53.3% believing that their family would object to them being organ donors and 42.7% believing that family wishes should override those of the donor. However, a minority of students had discussed donation with family members. Hesitancy about receiving a live donor kidney from a relative was evident also, with more students being prepared to donate a kidney than to receive a living donor (LD) kidney. Most students were prepared to receive a deceased kidney but significantly fewer were prepared to receive a LD kidney from a family member, suggesting this concern was specifically about receiving a transplant from a relative. Given the importance of LD transplantation to overall transplant activity in Saudi Arabia, it is essential that these concerns are addressed if these students are to engage positively in transplantation in their future careers. This hesitancy perhaps reflects a lack of understanding of the live donor process and overall how safe it is.

In general, it seems that students’ attitudes and beliefs with regard to transplantation demonstrate significant hesitancy when specifics are explored. This may limit how positively students engage with support for transplantation later in their careers. It is perhaps therefore not surprising that very few students (15%) had signed up to be organ donors. This is similar to reports from South Africa (8%)[24] and Hong Kong (23%),[21] but is significantly less than found in Germany (67%)[1] and New Zealand (72%).[4]

These findings may be explained further by the orthodox and educationally conservative nature of Saudi society. However, Zuidema[29] found only 35% of the Dutch population to be prepared to consider deceased donation, demonstrating reticence with regard to donation to be common to many societies, perhaps representing a misunderstanding of many aspects of donation and transplantation that might be addressed by education and open debate. The positive approach adopted by the Saudi government with regard to promotion of organ transplantation should be acknowledged in this regard. The establishment of the SCOT for coordination of organ transplantation, facilitation of the brain-death fatwa and introduction of innovative policies such as the incentive-based procurement system are some of the strategic moves implemented by the Saudi Government. This study suggests that education of students with regard to this stance and engagement of students with society in general to discuss these issues is a particularly important educational approach.

Bardell et al[3] have demonstrated the need for and benefits of inclusion of ODT in medical education programs. Sixty-four percent of students in the study cited a lack of knowledge among healthcare professionals as an important factor limiting donation rates. Therefore, adoption of improved education strategies should be considered in Saudi Arabia to motivate medical students to engage positively with organ donation and transplantation, furthering the progress already made by the government initiatives.

Overall, this study, in keeping with others, supports more formal education for medical students as a measure to increase ODT in Saudi Arabia. It suggests that challenging attitudes and beliefs, that are not necessarily aligned with beliefs of family members, society and religion, should be an important part of such education programs. Previous studies have shown a strong correlation between awareness of the allowance of organ donation in Islam and willingness to donate.[20],[25] It is perhaps particularly relevant that 48.9% of students in this survey believed preservation of the intact body after death to be important. Education programs should encourage students to discuss donation and transplantation with family members and explore attitudes in wider society, as documented by Jabri et al,[7] rather than simply imparting knowledge.

   Acknowledgment Top

The authors would like to thank all the students that participated in this study by responding to the questionnaire. The authors received no financial support for this research and authorship of this article and there are no conflicts of interest.

Conflict of interest: None declared.

   References Top

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Correspondence Address:
Dr. Saad M AlShareef
Department of Internal Medicine, College of Medicine, Al Imam Mohammad Ibn Saud Islamic University, P. O. Box 7544, Riyadh
Saudi Arabia
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DOI: 10.4103/1319-2442.243963

PMID: 30381508

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