|Year : 2019 | Volume
| Issue : 1 | Page : 83-96
|Survey of medical students to assess their knowledge and attitudes toward organ transplantation and donation
Amgad E El-Agroudy, Ahmed Jaradat, Mona Arekat, Roba M Hamdan, Noura AlQarawi, Zainab K AlSenan, Abdullah Alnama, Ebrahim Almahmeed, Ahmad S AlShammari, Reem M Alanazi, Hamza O Juhmani, Abrar Y Almarzooq
Department of Medicine, Faculty of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain
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|Date of Submission||03-Dec-2017|
|Date of Decision||16-Jan-2018|
|Date of Acceptance||24-Jan-2018|
|Date of Web Publication||26-Feb-2019|
| Abstract|| |
Kidney transplantation is the most preferred treatment modality for patients with end-stage renal disease (ESRD). This study aims at understanding the awareness, attitudes, and beliefs among the medical and nonmedical students. The study population consisted of 500 medical students and 39 nonmedical controls, who were surveyed using a reliable questionnaire that examined their knowledge and attitudes. A 24-item self-administered questionnaire, which assessed the levels of knowledge, attitude regarding organ donation with dichotomous scale and demographic data were used. Of the 500 medical students who received the questionnaire, 376 (75.2%) with a mean age of 22.1 ± 2.5 years responded; 39% were male, 43.6% were Bahraini, and 32.2% were from Saudi Arabia, 51.3% were in Grades-5 and 6 and 58.8% resided in big cities. The medical students had a highly positive attitude and great willingness toward organ donation. Majority of them (75.3%) knew the treatment of ESRD, and 70.7% recognized correctly that kidney transplantation is the optimal treatment for ESRD. However, only 10.4% knew that it is performed in Bahrain since 1995. A total of 241 participants (64.3%) reported positive attitude toward living kidney donation and 71.8% expressed their agreement to donation after death. More than half (66.8%) believed that their religion permits organ donation, although 56.6% of the participants believed that there is a danger after donating a kidney. When compared to nonmedical students, there was no statistically significant difference in the attitudes toward living kidney donation (P = 0.823) or organ donation after death (P = 0.066).
|How to cite this article:|
El-Agroudy AE, Jaradat A, Arekat M, Hamdan RM, AlQarawi N, AlSenan ZK, Alnama A, Almahmeed E, AlShammari AS, Alanazi RM, Juhmani HO, Almarzooq AY. Survey of medical students to assess their knowledge and attitudes toward organ transplantation and donation. Saudi J Kidney Dis Transpl 2019;30:83-96
|How to cite this URL:|
El-Agroudy AE, Jaradat A, Arekat M, Hamdan RM, AlQarawi N, AlSenan ZK, Alnama A, Almahmeed E, AlShammari AS, Alanazi RM, Juhmani HO, Almarzooq AY. Survey of medical students to assess their knowledge and attitudes toward organ transplantation and donation. Saudi J Kidney Dis Transpl [serial online] 2019 [cited 2021 Mar 1];30:83-96. Available from: https://www.sjkdt.org/text.asp?2019/30/1/83/252936
| Introduction|| |
The burden of chronic diseases such as chronic kidney disease (CKD), leading to organ failure, is high. The most suitable effective treatment of end-stage kidney disease (ESRD) is transplantation. The incidence of CKD from community studies in the Gulf region ranges between 78 PMP and 136 PMP., The current state of ESRD management in Bahrain is grave. The annual incidence of ESRD in the country is increasing, whereas the number of kidney transplants performed is about 10–20 per year. Worldwide, there is a chronic imbalance between the number of donors and the numbers of patients in the waiting list for kidney transplantation and this deficit has become a major limiting factor in most transplant programs.,
The transplant community has looked at ways to tackle the problem of organ donor shortage. It has been identified that health professionals can positively affect the decision of families of potential donors. Therefore, targeting the education of medical students and improving their awareness may be a crucial approach to tackle this problem. To develop effective educational interventions for medical students, it is important to evaluate their existing level of knowledge and comfort with the topic of organ donation. Knowledge and attitude toward organ donation among medical students has been researched extensively, and studies have been conducted world-wide;,,,,,,,,,,,,,,,,, however, there is limited research regarding medical students in the Arab countries.,,,,,,
Students are regarded as a group displaying a high level of social involvement; many of them work as volunteers for different institutions and organizations., This willingness to help others may have a significant impact on their family members and friends, who may contribute to major social changes and affect the future of transplantation programs. Their knowledge and beliefs concerning transplantation may be among the most important factors affecting individual preferences regarding organ donation.,,,,,,,,,,,,,,,,,,,,
The objective of the present study was to understand the awareness and beliefs about organ donation and transplantation among the medical graduate students and to study their attitudes toward organ donation.
| Materials and Methods|| |
The present study is a secondary analysis of a survey conducted at the College of Medicine and Medical Sciences, Arabian Gulf University and business faculty (who served as control group), Manama, Bahrain, in 2017, about the knowledge and attitudes toward brain-death, organ donation, and transplantation in a sample of university students. The study sample comprised 1st, 2nd, 3rd, 4th, 5th, and 6th-year medical students. Anonymity and confidentiality of respondents were maintained, and participation was voluntary. Ethical approval for this study was obtained from the Ethical Committee of the Institutional Review Board and verbal consent was obtained from all participants. A nonrandom sampling method was used.
A specially designed self-administered questionnaire was used and consisted of 24 items: 4 items assessing demographics, 10 items measuring knowledge, and 10 items measuring attitudes. The first part comprised demographic information (age, sex, residence, and nationality). The second part consisted of questions on knowledge about renal failure and its treatment, transplantation in Bahrain, brain-death, organ donation, whether a family member or friend had renal failure or undergone a transplant and religious and other beliefs toward donation. These items required dichotomous “yes/no/I don't know” responses. The last part comprised questions about willingness to donate or to receive a transplant, attitudes toward organ donation after brain-death and a few specific reasons for refusing to donate (fear from surgery, religious reasons, not confident about results), their attitudes regarding the acceptability of potential monetary incentives for living donation or to buy kidney to their families. The respondents had to indicate their responses as either agree/disagree/don't decide.
The questionnaires were administered to the students with no prior information or announcements to minimize response bias. They were collected back immediately after anonymous completion.
| Statistical Analysis|| |
Measurement data were presented with mean values ± standard deviation after testing for normal distribution. Categorical data were summarized as counts and percentages (%). Student's t-test was used to ascertain the significance of differences between mean values of two continuous variables. Mann–Whitney U-test was used for two ordinal variables comparisons and Kruskal–Wallis H test was used for three ordinal variables comparisons. The Chi-square analysis was performed to test for differences in proportions of categorical variables between two or more groups. All statistical calculations were performed using SPSS 20.0 (SPSS, Inc., Chicago, IL, USA). Statistical tests were two-sided, and a level of 0.05 was considered to indicate statistical significance.
| Results|| |
About 600 questionnaires were distributed to volunteer students in various majors, and 557 were returned. We eliminated 142 questionnaires with missing information. A completed questionnaire was obtained from 376 (75.2%) medical students and 39 (39%) business faculty. The mean age of all students was 22.3 years ranging from 17 to 25 years. [Table 1] shows the demographic data of the respondents. Among the medical students who completed all questions, 64.8% were Bahrainis, 79.8% were Saudi students, and 76.8% were Kuwaiti students.
Knowledge about transplantation and organ donation
The level of knowledge among the medical and business students about transplantation is shown in [Table 2]. As expected, the percentages of the medical students who knew the meaning of chronic renal failure, treatment of chronic renal failure and, transplantable organs were significantly higher in medical students than that of the business students as shown in [Table 2]. It was found that 75.2% of the study group considered that organ transplantation was an important therapeutic method; the frequency was 70.7% for medical students and 46.2% for business students (P = 0.001). Regarding the knowledge that kidney transplantation was performed in Bahrain since 1995, 43 (10.4%) were aware, whereas 301 (73.1%) never heard of it; there was no statistical significance between the two groups (P = 0.884). Overall, only a few of the respondents (12.5%) had never heard of the concept of brain-death. The frequency was 13% for the medical students and 12.8% for the business students (P = 0.417). Regarding awareness of the value of organ donation after death, 276 students (66.5%) knew about donation after death, whereas 77.8% believed that it could save only critically ill patients; there was no statistically significant difference between the two groups (P = 0.546 and 0.346, respectively).
|Table 2: Frequency of students toward knowledge on organ donation and transplantation.|
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As shown in [Table 2], more than two-thirds of the respondents, 251 of the medical (66.8%) and 27 (69.2%) of the business students were not aware of the current legislation (Fatwa) concerning transplantations and organ donation in Bahrain. Two-hundred and ninety-seven (71.6%) of all studied students said that they would accept the concept of brain-death if one of their relatives had it with no statistical significance between the groups (P = 0.609).
Overall, few medical students had personal experience with a family member or friend having chronic renal failure, having undergone a transplant or donated an organ. However, differences between the medical and non-medical students showed no statistical significance (P = 0.825).
We studied the sociodemographic data of the medical students regarding the knowledge and attitude of respondents toward organ donation [Table 3]. There was no significant difference in the level of knowledge regarding transplantable organs between all nationalities. Level of awareness was uniform in both genders except that male students knew that a person with brain-death can donate organs to sick people (P = 0.040). As expected, the level of awareness regarding the knowledge of chronic renal failure and its optimum treatment and the value of donating organs to sick people was statistically higher in students above the age of 20 years. Furthermore, the level of education showed a significant association with the awareness of these issues. [Table 3] shows that there was no significant difference in the awareness regarding organ donation and transplantation, between students from urban (big or small cities) and rural areas.
|Table 3: Sociodemographic characteristics and positive knowledge and attitude of medical students toward donation.|
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[Table 3] shows the attitude toward organ donation of the students. The difference between the medical and nonmedical students toward organ donation was insignificant. Overall, most of the respondents were willing to donate a kidney to a close relative in their lifetime. When asked whether they were willing to donate their kidneys to family members awaiting organ transplantation, most students (64.3% and 69.2% of medical and business students, respectively) said “yes” and only a few of them (26.7%) said “no.” The attitude of medical students was less positive than that of business students regarding living donation, although it was not significant (P = 0.823). A total of 241 (58.1%) students were willing to donate kidneys to their friends, 14.9% were not willing. The reasons for refraining from donation were that their body would be disfigured (58.1%) or lack of religious legalization (Fatwa) (14.9%). On the other hand, 165 of the medical students (43.9%) and 17 (43.6%) of the business students preferred to undergo kidney transplant in Bahrain, in case it was required.
As to their willingness for organ donation after death, 69.2% consented, 15.9% objected, and 12.3% chose the alternative “not sure.” Among the respondents, 71.8% of the medical students and 69.2% of the business students were willing to donate their organs after death, which was not statistically significant (P = 0.066).
Overall, the attitude regarding incentives for living kidney donors was good. Of the students, 35.4% supported compensation and more than half of them (50.4%) agreed on no payment for kidney donation; there was no statistical significance between the groups (P = 0.351). Medical students (63.3%) were less likely than business students (69.2%) to believe that they could buy kidneys for their families if they needed kidney transplantation; although, it was not statistically significant (P = 0.551).
The relation of sociodemographic data of the medical students and their attitude toward donation is shown in [Table 4]. Bahraini medical students reported a less positive attitude than Saudi, Kuwaiti and others with a significant difference in terms of motivation for kidney donation to their family members (P = 0.029) or to agree for their families to become living kidney donors (P = 0.038). Male students (74%) showed higher optimism than female students (58%) toward kidney donation to their family members (P = 0.003). Students aged >20 years (68%) had a significantly (P = 0.002) more positive attitude toward accepting kidney donation in their families than younger students (52%). Furthermore, based on the education level, the percentage of the positive attitude toward acceptance of their families as kidney donors was significantly higher (P = 0.041) among the higher grade medical students.
| Discussion|| |
Organ transplantation is the most preferred treatment for ESRD and organ failure. It offers a better quality of life with better survival benefits. However, while the number of organ donations has not significantly increased, there has been an increase in the number of patients waiting for organ or tissue transplantation, not only in Bahrain but also worldwide., Encouraging organ donation requires information about the population's awareness and attitude toward donation by identifying and assessing the barriers against donation. It has been documented that insufficient knowledge is considered to be an important contributing factor responsible for the shortage of available organs. Lack of knowledge about legal and procedural aspects of organ donation, especially among health-care providers, who should be the most knowledgeable, has previously been identified as one of the main factors that may contribute to the limited availability of donor organs., Medical students are a group of particular interest. Medical students are among the future healthcare providers who can influence the willingness of the general public to register as donors. Furthermore, as medical students are expected to gain increasing medical knowledge each year of study; they are an important group to empirically assess the effect of increasing knowledge on the subject of organ donation or willingness to donate. Surveys on the attitudes toward organ donation among medical students have been carried out in many countries,,,,,,,,,,,,,,,,,, including some studies in countries.,,,,,,
In this study, the knowledge of transplant terminology was fairly good. The level of knowledge among medical students was higher than among business students in Bahrain. As seen in our study, medical students had a higher level of knowledge compared with other students, as reported in another study in central Saudi Arabia, where they found that only 50.8% of medical students had good knowledge about transplantation. Medical students in other countries such as Ireland, India, and Nigeria have an adequate level of knowledge, and the majority is willing to donate.,, Knowledge about organ donation and transplantation was highly associated with year of medical education as shown in [Table 3]. These differences may be due to the presence of topics in the third and fourth years of medical curriculum and the higher likelihood that a 5th year medical student meets a patient with organ failure or transplant. In a study conducted on medical students in Brazil, it was found that knowledge of the students about transplantable organs was higher during the later years of the study. Although, in another study performed in France, it was found that 1st year medical students had a good level of knowledge regarding organ donation and transplantation before their medical course. Also, no difference was seen in a study, which compared 1st- and 6th-year medical students and determined that although many variables on this subject change by the 6th year, and found that 6th-year students had not gained sufficient positive attitudes and behaviors toward organ transplantation.
In this study, 74.5% of students who participated in the study were aware of the concept of brain-death, and that organ donation after death can save lives (77.9%), which is almost similar to various other studies reported in literature among medical students.,, Most of these studies have shown a relative lack of knowledge regarding the subject among medical students.,,, In one study, there was a positive correlation between the level of knowledge about brain-death and transplantation and the level of seniority of students, indicating that they gained their knowledge during the progress of their curriculum. This observation gives us essential information regarding the learning outcomes of students and can be used as a tool to modify the curriculum of students and to include a short course regarding the subject early in the curriculum.
In this study, most of the participants (66.8%) knew about the religious aspects of organ donation or any existing religious law in Bahrain regarding organ donation and transplantation. However, only 10.4% had heard about kidney transplant being performed in Bahrain since 1995. The awareness about religious law and Fatwah seems to have a great influence on the willingness of organ donation. No religion formally forbids principles of organ donation as a way to save life. but many controversies exist. Many studies have emphasized the importance of religion.,, A study from Tabuk, Saudi Arabia, revealed that more than 58% of the medical students reported that Islamic religion allows organ donation. Several Islamic organizations and institutions around the world have issued regulations in favor of organ donation; describing it as “an act of merit.”,,, The Council of the Islamic Fiqh Academy of the Muslim World League (Makkah, Saudi Arabia) in 1985, and the Council of the Islamic Fiqh Academy of the Organization of Islamic Conference (Jeddah, Saudi Arabia) in 1988 have concluded that it is permissible within Islamic law (Shari'ah) to remove organs from the deceased.
A study comparing the level of knowledge and attitude in rural and urban areas in Saudi Arabia found that the urban population had a higher level of knowledge and more positive attitude compared with those of rural areas. When gender comparison was performed, both genders had adequate level of knowledge; however, a higher knowledge (P = 0.040) that donating organs after death can save lives of sick people was observed among males (74%) as compared to females (62%). These findings concur with the results reported by Marqués- Lespier et al, on medical students attending University of Puerto Rico School of Medicine where almost half (49.6%) of the male participants had adequate knowledge (>50%) compared to females (41.9%). In this study, males had a significantly (P = 0.003) higher mean positive attitude than females toward donation to their family members. This finding contradicts with the studies by Burra et al, and Mekahli et al, on European medical students where females had a higher positive attitude, as they may have more emotional values compared to males.
In our study, medical students did not appear to have a significantly different attitude toward deceased organ donation. More than two-thirds of the medical students and business students stated that they considered living kidney donation (P = 0.823) or organ donation after death (P = 0.066) as acceptable. On the other hand, 60.6% of medical students and 83.8% of business students agreed that their family members can donate kidneys to another person if they needed. In one study on medical and law students, the authors reported that medical students (48%) had a significantly higher positive attitude toward organ donation when compared with law students (36%). There were varying reports of willingness to donate organ among medical students.,,,,,,,,,,,,,,,,,, Anochie and Ofori reported that <50% of medical students studied would be willing to donate kidneys for transplantation. In a prospective cohort study of medical students in Italy, Burra et al reported that medical students' attitudes toward organ donation and transplantation were highly positive but did not improve during the first three years of medical school. Another study from Turkey reported that there was greater motivation for organ donation. They found that 94.5% of the medical students and 85.3% of technology students would agree to have their own organs removed after death.
Regarding donation to friends, only 56.6% of the medical students and 71.8% of the business students were willing to donate their own kidneys. This indicated that emotional factors played a role in decision making for living organ donation. The bonds between families are generally believed to be stronger in the Gulf region than in Western countries. Family values are one of the core values in Islamic culture. Similar results were found in Chinese people who have a strong attachment to families. This important finding suggests that relatives become a potential living organ source to increase organ donation and to save more lives. Thus, health professionals should make more efforts to encourage organ donation between relatives and friends.,
In our study, when the reasons of the medical students who did not want to donate were asked, it was found that 56.6% of the students were afraid of the surgical complications whereas only 15.3% found organ donation religiously appropriate, 16.0% found organ donation religiously inappropriate, and 16.0% were not confident about the results. Culture and religion played a much lesser prohibitive part in determining the level of organ donation than other studies. None of the religions object to organ donation in principle although, in some, there is varying thought. Ninety-six percent of the respondents in one study in India agreed that religion does permit donation. In another study, almost two-thirds of the respondents thought that the fear of side effects could influence their decision toward organ donation. Therefore, it is possible that establishing legislation that will guarantee the donors better healthcare and easy access to health facilities might encourage them to donate organs during their lifetimes. These results were confirmed in other study by Boulware et al who showed that donors are significantly influenced by the prospect of preoperative anxiety and fear about possible postoperative complications; this decreased willingness to donate.
Paid organ donation is a debatable topic with strong ethical arguments from both proponents and opponents. This issue is not sufficiently explored by studies around the world while investigating knowledge, perceptions, and attitudes of medical students. Our study shows that nearly 50% of the medical students did not agree for financial compensate to the organ donor. In Brazil, students were mostly against paid organ donation (76.8%) and even when explained that mutual benefits could be gained from organ donation, their views remained unchanged. Almost 73% of the 1000 participants in an Iranian study in Ahwaz city disagreed to any type of compensation for donation. Paid transplants negatively affect the living-related and cadaver transplant activities in developing countries and those who can afford to pay, opt for a paid organ rather than subject a loved one to the risk of donor nephrectomy. In a way, if the option of buying organs were not available, the pressure on the health-care administrators to breathe some life into the cadaver transplant program would increase.
The study has some limitations. First, the study was performed in a single university and thus, the results must be taken with caution to be generalized to all medical and nonmedical students in Bahrain or Gulf countries with the same culture. Second, the control group in our study was small. However, our survey was directed mainly towards medical students and in addition, the response rate from nonmedical students was poor. Third, the assessment of students' understanding of terminology was based on a self-report of either “yes” or “no.” We did not test their understanding by asking students to select from a series of options. Therefore, this self-reporting may not have been wholly truthful. Nevertheless, this study forms an important baseline step for future studies.
In conclusion, the knowledge of transplant terminology was fairly good among medical students. The results of the our study give us an idea that, despite initially positive personal beliefs and knowledge about transplantation and organ donation, students' attitudes in this setting remain unacceptable and in need of significant improvement during medical education. Their perception and fear was still deficient in some areas of organ donation. These results support the need to develop a satisfactory program in medical education. An organized educational program about all aspects of organ donation, particularly from cadavers, seems necessary.
Conflict of interest:
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Amgad E El-Agroudy
Department of Medicine, Faculty of Medicine and Medical Sciences, Arabian Gulf University, Manama
[Table 1], [Table 2], [Table 3], [Table 4]
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