RENAL DATA FROM THE ARAB WORLD
|Year : 2020 | Volume
| Issue : 3 | Page : 624-638
|Barriers in knowledge and attitudes regarding organ donation among Urban Jordanian population
Fayez Abdulrazeq1, Monica M Matsumoto2, Mohammad Zourob3, Abdulrahman Al-Dobai3, Khadega Zeyad3, Nemer Marwan3, Abdulrahman Qeshta3, Omar Aleyani3
1 Department of Community Medicine and Public Health Department, Faculty of Medicine, University of Science and Technology Yemen-Jordan Branch, Amman, Jordan
2 Pritzker School of Medicine, University of Chicago, Chicago, Illinois, USA
3 Department of Clinical Sciences, College of Medicine and Health Sciences, University of Science and Technology Yemen-Jordan Branch; Department of General Surgery, Islamic Hospital, Amman, Jordan
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|Date of Submission||04-May-2019|
|Date of Acceptance||06-Jun-2019|
|Date of Web Publication||10-Jul-2020|
| Abstract|| |
Low organ donation rates are a major obstacle to the expansion of transplant opportunities in the Middle East. Awareness and opinion about organ donation affect willingness to donate. This study aims to evaluate public attitudes and knowledge about deceased organ donation (DOD) in Jordan in support of larger efforts to increase donor rates. A mixed qualitative and quantitative approach was used. Qualitative, one-on-one interviews were used to create a quantitative survey, which was administered to randomly-selected individuals over a 5-month period. The questionnaire used series of statements to evaluate knowledge and attitude about DOD on a scaling system and converted to scores (0–4). A total of 15 qualitative interviews and 500 quantitative surveys (78.4% response rate) were completed. Only 78 (15.6%) knew they could donate their organs after death. Only 49 (9.8%) were registered as donors, although 373 (74.6%) knew about the registration process. Internet (52.2%) and social media (51.0%) were the most common sources of information. The overall knowledge score was moderately high at 68.8% (2.75 ± 1.31). Misconceptions persisted about body disfigurement, diagnostic accuracy of brain-death, and waiting list equity. The total attitude score was moderately positive at 65.8% (2.63 ± 0.02). Public awareness campaigns (85.3%, 3.42 ± 0.95) and regulatory legislation (78.8%, 3.15 ± 0.99) were considered especially positive, while negative attitudes about religious approval and paid donation were present. Female respondents had significantly higher scores on organ donation significance (P = 0.007) and overall attitude (P = 0.035) than males. The results of this study demonstrate knowledge gaps, misconceptions, and negative opinions on topics related to organ donation in Jordan. However, participants recognized the importance of educational campaigns and regulatory legislation and would likely benefit from information from health-care providers and religious leaders.
|How to cite this article:|
Abdulrazeq F, Matsumoto MM, Zourob M, Al-Dobai A, Zeyad K, Marwan N, Qeshta A, Aleyani O. Barriers in knowledge and attitudes regarding organ donation among Urban Jordanian population. Saudi J Kidney Dis Transpl 2020;31:624-38
|How to cite this URL:|
Abdulrazeq F, Matsumoto MM, Zourob M, Al-Dobai A, Zeyad K, Marwan N, Qeshta A, Aleyani O. Barriers in knowledge and attitudes regarding organ donation among Urban Jordanian population. Saudi J Kidney Dis Transpl [serial online] 2020 [cited 2021 Jan 25];31:624-38. Available from: https://www.sjkdt.org/text.asp?2020/31/3/624/289449
| Introduction|| |
The first successful human kidney transplant performed in 1954 demonstrated that organ transplantation was technically feasible in replacing a missing or damaged organ., Since then, the development of effective immunosuppressive regimens against organ rejection and improvements in surgical techniques and materials have allowed for advancements in the field of organ transplantation, providing the opportunity to cure conditions that may otherwise have limited treatment options. However, poor organ donation rates lagged behind medical advancements and continue to limit the number of transplants that can be performed.
Donor rates in countries in the Middle East, such as Jordan, are particularly low despite a relatively advanced health-care system. In Jordan, only 316 organ donors were registered in 2017: 251 were living donors [living donor rate: 26.14 per-million population (pmp)], and 65 were deceased donors (deceased donor rate: 6.91 pmp). While Jordan’s deceased donor rate is higher compared to other countries in the Middle East, such as Qatar (2.5 pmp), Lebanon (2.88 pmp), Saudi Arabia (3.33 pmp), and Bahrain (4 pmp), it is much lower compared to countries such as the United States (31.96 pmp) and United Kingdom (23.05 pmp). Furthermore, in the Middle- Eastern countries for which data is available, the deceased donor rates are lower than living donor rates. The scarcity of organ donors, especially deceased organ donors (DODs), in comparison with increasing numbers of the individuals on waiting lists highlight the principle obstacle facing organ transplantation today.
Reasons for shortage of DODs are multi-fold. These may include: gaps in knowledge regarding DOD,, brain-death,,, and the registration process; failure in conversion of potential donors into actual donors;, beliefs such as disfigurement of the body, recovery from brain-death, and fear of premature death;, lack of communication between health-care providers and potential donors regarding end- of-life and postmortem organ donation;, family nonauthorization in cases of brain-death;,, distrust of the medical system and concerns about social injustice in allocating donated organs to recipients; and concerns about organ trafficking. Other barriers to DOD in the Arab community may include: respecting parental authority, sensitivity of an emotionally-intense, religious convictions, and fear of losing body dignity. Similar barriers have been identified in other communities such as African-Americans and Hispanics.
Public knowledge, attitudes, and willingness toward organ donation have been a subject of interest for researchers worldwide. However, few studies have been conducted in Jordan and other Arab countries, especially about DOD, and those that have been done have identified that gaps in knowledge present barriers to donation., There is a need to further understand these issues so that they can be remedied. The purpose of this study was to evaluate organ donation in Jordan using both qualitative and quantitative approaches to elicit public perspectives, assess attitudes and beliefs, identify information sources, and measure public knowledge and misconceptions about DOD.
| Materials and Methods|| |
Study design, participants, and settings
This study involved a mixed study design using both qualitative and quantitative methodologies. For the qualitative approach, interviews were conducted with a convenience sample of transplant surgeons and organ donor recipients from the Islamic Hospital in Amman, Jordan, and members of the general public selected randomly from the area around the Islamic Hospital. Information generated was used to design the questionnaire for the quantitative approach. For the quantitative approach, a cross-sectional study was performed with randomly-selected individuals from five areas within the Al-Jami’ah District of the Amman Governorate, from November 2018 to April 2019. All individuals 18 years and older were eligible to participate. The study protocol was approved by the Ethics Committee of the University of Science and Technology Yemen, Jordan Branch. The purpose of the study was explained clearly to the study participants and verbal consent was obtained from them. Participation in the study was voluntary. Data generated from this study were undertaken with full confidentiality and for research purposes only.
Data collection and interviews
Two principle methods were used for data collection: (a) one-on-one interviews (qualitative), and (b) self-structured, self-administered questionnaires (quantitative). Each interview was performed by two trained, Arabic-speaking researchers. The first researcher was responsible for interviewing participants and guiding discussion on pre-identified themes based on a literature review and research team consensus. Points of discussion were presented as open-ended questions, and the researchers encouraged participants to express their thoughts and ideas freely without interruption. All interviews were digitally audio-recorded and transcribed separately by the two researchers, and then analyzed thematically by a third researcher.
The questionnaire was designed as a scoring system and presented as a 5-point Likert-type format (Suppl). The initial questionnaire was written in English, then translated to Arabic, and retranslated to English again to ensure consistency. A pilot of 20 participants identified ambiguous questions, acceptability of questions, and time needed to complete the questionnaire, and adjustments were made accordingly. The questionnaire was reviewed for content and validity by a transplant surgeon and three experts specialized in community medicine, sociology, and law and Faqih (Islamic jurisprudence). Internal consistency for overall scales and sub-scales was tested by using Cronbach’s alpha reliability coefficient (a). The questionnaire was classified into three sections: (a) demographic information; (b) willingness toward and knowledge of DOD using 16 statements to measure the level of knowledge (a = 0.63), sub-classified into three sections: (i) basic knowledge (5 statements, a = 0.36), (ii) significance (5 statements, a = 0.69), and (iii) misconceptions (6 statements, a = 0.51); and (c) attitudes and barriers concerning organ donation using 20 statements (a = 0.67). The internal consistency of all total and sub-total scales was found to be satisfactory, except for the organ donation basic knowledge scale, which was considered acceptable for a newly developed questionnaire.
The questions about knowledge were dichotomized into “true” or “false” categories, unknown to the respondents, and questions about attitudes were divided into “positive” or “negative” categories. Responses were scored as: “strongly agree” (4 or 0), “agree” (3 or 1), “neutral” (2), “disagree” (1 or 3), and “strongly disagree” (0 or 4), based on accuracy of knowledge statements and positivity of attitude statements. A higher score indicated a greater level of knowledge or a more positive attitude, respectively. The total knowledge score ranged from 0 to 64: 0–20 for both the first and second sections, and 0–24 for the third section. The total attitude score ranged from 0 to 80. In order to facilitate interpretation of the results, all overall scales and sub-scales were converted to a range of 0 to 4 by dividing each score within the scale by the total number of statements that comprise the scale. A mean score >2 associated with adequate knowledge/positive attitudes and a mean score <2 associated with inadequate knowledge/negative attitudes. Mean percentages were calculated by dividing the mean score by the highest number (i.e., 4).
| Statistical Analysis|| |
Data generated from the quantitative research approach were analyzed using IBM SPSS Statistics for Windows, Version 21.0 (IBM Corp., Armonk, NY, USA). Continuous variables were presented as means, standard deviations, and mean percentages. Categorical variables were presented as proportions and frequencies. Independent-sample t-test was used to examine mean gender differences in participants’ knowledge and attitude scores. A P <0.05 was considered statistically significant.
| Results|| |
For the qualitative component, 15 interviews were conducted with a 100% response rate (5/5) of the convenience sample (two transplant surgeons, three kidney transplant recipients), and 55.6% response rate (10/18) with members of the general public (6 males, 4 females). Selected quotations are summarized in [Table 1]. A total of 500 out of 638 (78.4%) randomly-selected participants completed the interview for the quantitative study. Socio-demographic characteristics of the respondents are summarized in [Table 2]. The majority of participants were female (297, 59.4%), Muslim (494, 98.8%), less than 30 years old (403, 60.6%), Jordanian (458, 91.6%), married (307, 61.4%), had a university degree or higher (380, 76.0%), and had a monthly income of ≤1000 Jordanian dinars (439, 87.8%).
As described in [Table 3], 389 (77.8%) respondents were familiar with the presence of the “Jordan Society for Organ Donation.” However, only 78 (15.6%) knew that they have the option to donate their organs after death. Similarly, 373 (74.6%) were familiar with the registration process to become an organ donor, but only 49 (9.8%) were currently registered as potential organ donors. One-hundred and twenty (24.0%) respondents knew a close family member or friend needing an organ transplant, and 150 (30.0%) knew somebody who died from a disease that might be cured by transplant. With regard to respondents’ willingness to donate organs after death, 159 (31.8%) were willing to donate to someone who needs it to live, 109 (21.8%) were willing to donate for scientific research, and 139 (27.8%) had already communicated with their families about their wishes regarding organ donation. Finally, 455 (89.0%) respondents would be grateful to accept an organ from a donor if they were suffering from organ failure.
|Table 3: Respondents' awareness about organ donation in Jordan and their willingness to donate organs after death (n = 500).|
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Knowledge regarding organ donation
The three most common sources of knowledge regarding organ donation were: internet (52.2%), social media (e.g., Facebook, Snapchat) (51.0%), and media (e.g., newspapers, television, radio) (35.6%), while school/education and health-care providers were the least common sources of knowledge (24.0% and 16.0% respectively) [Figure 1]. With regard to respondents’ knowledge about organs and tissues that can be donated after death, respondents chose kidneys (79.0%), corneas (76.8%) and hearts (65.6%) as the three most common organs and tissues, while skin (17.4%) and tendons (12.4%) were the least common [Figure 2]. As shown in [Table 4], the score for overall knowledge of organ donation was moderately high at 68.8% (2.75 ± 1.31). Respondents demonstrated a higher level of knowledge about the significance of organ donation (75.0%, 3.00 ± 0.62) than basic knowledge of organ donation (73.8%, 2.95 ± 0.62) or misconceptions about organ donation (54.0%, 2.16 ± 0.70).
|Figure 1: Sources of knowledge among respondents regarding organ donation (n = 500). (Note that respondents were able to choose more than one option).|
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|Figure 2: Respondents' knowledge about organs and tissues that can be donated after death (n = 500). (Note that respondents were able to choose more than one option).|
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|Table 4: Knowledge about organ donation, its significance, and associated misconceptions, comparing male (n = 203) and female (n = 297) respondents. Mean (M) scores were based on a scale of 0-4, with a score >2 indicating adequate knowledge and <2 inadequate knowledge about organ donation. The higher the score, the higher level of knowledge.|
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In the first section (organ donation-basic knowledge), respondents were most knowledgeable regarding: determination of death with complete accuracy before organ donation (86.5%, 3.46 ± 0.91), selection criteria for organ recipients (83.5%, 3.34 ± 0.96), and acceptance of patients with human immunodeficiency virus or cancer as potential donors (76.8%, 3.07 ± 1.07). However, they showed lower levels of knowledge regarding: possibility to donate organs while still alive (62.0%, 2.48 ± 1.27) and acceptance of children and newborns as potential donors after death (59.8%, 2.39 ± 1.49). In the second section (organ donation-significance), 75.3% of study participants were aware of the scarcity of available organs for transplant and subsequent death of the individuals on the waiting list (3.01 ± 0.89). In addition, awareness of the significance of organ donation was 81.8% (3.27 ± 0.88) for curing patients with organ failure, 76.3% (3.05 ± 1.02) for saving lives of newborns with congenital diseases, 73.3% (2.93 ± 1.05) for improving quality of life of blind and deaf people, and 68.5% (2.74 ± 1.15) for helping burn victims. In the third section (organ donation-misconceptions), a majority of respondents were conscious that organ donation does not result in paying extra medical bills by donor’s family (66.8, 2.67 ± 1.23), disfigurement of the body (57.0%, 2.28 ± 1.25), or obligation to donate all organs after death (66.0%, 2.64 ± 1.37). On the other hand, less than half knew that patients will not recover from brain-death (49.8%, 1.99 ± 1.22), organ donation is not a reason for delay of funeral (45.5%, 1.82 ± 1.28), and there is social justice in the organ donation waiting list (39.8%, 1.59 ± 1.49).
Attitudes, perceptions and beliefs about organ donation
As shown in [Table 5], the total attitude score toward organ donation was moderately positive at 65.8% (2.63 ± 0.02). A majority of respondents thought that more campaigns were needed to increase public awareness about organ donation (85.3%, 3.42 ± 0.95), and that more laws and legislations were needed to regulate organ donation and prevent organ trafficking (78.8%, 3.15 ± 0.99). However, 53.8% (2.15 ± 1.45) were against automatic registration of deceased individuals as potential donors regardless of their desire to donate. With regard to willingness to donate while still alive, 77.3% (3.09 ± 1.14) would consider donating one of their kidneys to a close family member, which decreased to 66.0% (2.64 ± 1.15) when considering doing the same for a stranger.
|Table 5: Attitudes toward positive and negative statements about organ donation, comparing male (n = 203) and female (n = 297) respondents. Mean (M) scores were based on a scale of 0-4, with a score >2 indicating positive attitudes and <2 negative attitudes toward organ donation. The higher the score, the more positive the attitude.|
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Eighty percent (3.20 ± 0.97) of participants believed that donors’ families may find solace from the potential that their loss could improve the life of another person, and 81.0% (3.24 ± 0.97) thought that individuals should discuss their views on organ donation with their families. If the wishes of deceased persons regarding organ donation were unknown 71.3% (2.85 ± 1.06) thought that the decision should be made by families. In order to achieve that, 83.5% (3.34 ± 0.87) believed that families should be provided with adequate information about organ donation process, and 85.3% (3.41 ± 0.90) believed such a decision should be voluntary. Moreover, 76.8% (3.07 ± 1.10) indicated the importance of signing an informed consent by families prior to organ donation.
With regard to financial compensation of organ donors, 62.0% (2.48 ± 1.30) of participants were against receiving any financial compensation from recipients. However, only 37.3% (1.49 ± 1.23) disagreed that legalizing paid donation would contribute to stopping the illegal trade of organs. Regarding participants’ religious beliefs about organ donation, 66.0% (2.64 ± 1.25) believed that it was not against their religious faith to donate organs after death, and 63.3% (2.53 ± 1.41) thought that donors and recipients do not need to be within the same religion.
Regarding barriers to organ donation, 39.3% (1.57 ± 1.30) of respondents thought that they should be able to decide who will receive their organs, while 46.5% (1.86 ± 1.36) would refuse to donate their liver to a patient with alcoholic liver disease. Only 53.8% (2.15 ± 1.26) had faith and trust in the health-care system, and only 53.7% (2.15 ± 1.34) were sure that their bodies would be treated with respect and dignity. Finally, 54.8% (2.19 ± 1.35) of respondents believed that individuals with a criminal record should not be organ donors.
As shown in [Table 4] and [Table 5], female respondents had significantly higher total scores of organ donation-significance (P = 0.007) and attitude (P = 0.035) than males. No significant differences were found with total knowledge score (P = 0.056), organ donation-basic knowledge (P = 0.094) or misconceptions (P = 0.214). Moreover, females scored significantly higher than males with regard to determination of death with complete accuracy before organ donation (P = 0.022) and significance of organ donation in saving lives of newborns with congenital diseases (P <0.001). Females were more aware than males that organ donation does not result in disfiguration of the body (P = 0.023). With regard to attitudes, females were more supportive of providing adequate information to families about organ donation process (P = 0.014), and they showed significantly more positive attitudes toward acceptance of donors from other religions (P = 0.006).
| Discussion|| |
Overall, these data demonstrate that knowledge gaps and negative attitudes about organ donation remain in Jordan and are generally more pronounced among males. Nearly a quarter of respondents were not familiar with the presence of the “Jordan Society for Organ Donation.” While not as high as what was found in a Saudi Arabia study, room for improvement in knowledge and awareness about organ donation in Jordan remains. Increasing knowledge about such organizations is critical to promote organ donation and to encourage altruism among citizens. For example, the gap between respondents’ familiarity with the organ donor registration process and the number who are actually registered as potential donors, can be targeted. Furthermore, a disconnect exists between the large percentage of respondents who would accept an organ from a donor compared to the low number who would be willing to donate their organs after death. This study also revealed that nearly three-quarters of respondents had not communicated with their families about their wishes regarding organ donation. Such communication is essential to avoid future conflict that may arise between family and organ procurement organizations, and can document an individual’s wishes through donor designation. In order to widen the organ donor pool, several strategies and approaches can be implemented such as launching public awareness campaigns about DOD, streamlining the donation process, creating laws for paired organ donation, and considering donation after circulatory death, especially in patients who have irreversible, severe brain injuries but do not meet the criteria for brain-death.
The most common sources of knowledge on organ donation were the internet and social media, while school/education and health-care providers were the least common. Previous studies have supported that media campaigns have the potential to promote organ donation, but this also poses the risk of exposing people to inaccurate and biased information that can be found on these platforms. Health-care providers in Jordan need a larger role in providing information since they not only are a more trusted source of information, but are also involved in the delivery of end-of-life care to patients with serious illnesses and their families. Therefore, health-care providers should have access to updated guidelines and best practices so they can discuss difficult topics such as prognosis, end-of-life, and DOD with their patients.,
Encouragingly, respondents showed an overall high level of knowledge about organ donation, which is consistent with studies performed in other countries.,,, However, knowledge about specific topics, such as pediatric donation, indications for transplant, and donatable tissue types, is lacking. For example, addressing factors that influence parenteral donation decisions will be crucial to compensate for the scarcity of donated pediatric organs and increase the recipient rate of younger children in need of transplants. Unfortunately, several misconceptions remain prevalent, which has also been reported in other studies., The issue of body disfigurement appears more widespread than what was found in a study performed in a U.S. community and may require additional attention.
Only a few studies about organ donation have been performed in Jordan. Haddad et al assessed awareness and attitudes toward corneal donation among 500 respondents, and found over 80% were aware of corneal donation and would encourage corneal donation among other people, although only two-thirds were willing to donate their corneas after death. The main reasons for this unwillingness were fear that their bodies would not be treated respectfully and that other organs might be taken. Hammad et al analyzed attitudes toward brain-death and organ procurement in Jordan through over 2500 questionnaires and found that nearly three-quarters of the participants were aware of the concept of brain-death, but less than half agreed to give informed consent for organ donation if a relative was diagnosed with brain-death. In addition, about half believed that their religion was against brain-death. The main reason for rejecting donation of organs after brain-death was fear of organs being taken before confirming death. These studies reveal key issues in Jordan that may be contributing to the current dearth of organ donors and demonstrate the need for increased understanding of these barriers.
The overall attitude toward DOD was positive, although important areas of negativity were found. Respondents favored respecting individual autonomy, which may be higher than other countries, with the majority disagreeing with automatic registration of deceased individuals as potential donors. Similarly, most respondents were against transplant recipients giving any financial compensation to donors and did not believe that paid donation could contribute to stopping the illegal trade of organs. Paid organ donation is a controversial subject in the transplant community, since the line between paid donation and transplant tourism is often blurred, and vulnerable groups are at risk of being victims of organ trafficking., However, these results suggest that increasing awareness about the arguments behind these issues can positively affect attitudes toward donation.
Respondents endorsed discriminatory attitudes in regard to who deserved to be a transplant recipient. One of negative attitudes that was detected in our study was the refusal to accept patients with alcoholic liver disease as transplant recipients, although similar finding was reported in a United Kingdom study. Alcoholic liver disease as an indication for liver transplantation has been a contentious topic even in the medical community, and many transplant centers do not accept alcoholic patients because of compliance issues with immunosuppressive regimens, the potential for recidivism, and disease recurrence. However, transplantation has proven to be highly successful in abstinent alcoholics with a survival rate comparable to those with other causes of liver disease. In addition, a majority of respondents were against accepting individuals with criminal record as potential donors, although more studies are needed to investigate this attitude.
Religious considerations did not appear to be a major barrier to organ donation in the majority of the respondents, although it remains a factor for a sizeable percentage. Most respondents identified with Islam, and the majority believed it was not against their religious faith to donate organs after death. Similar findings have been reported in studies performed in other Islamic countries, such as Palestine and the United Arab Emirates,, and may indicate overall positive perceptions in Islam compared with other studies from Christian-majority groups. Most participants also believed that donors and recipients did not have to be from the same religion. Prior studies investigating the relationship between Islamic religiosity and attitude toward DOD revealed that adherence to Islamic ethics does not appear to be associated with negative attitudes toward DOD. Nevertheless, a brief religious educational intervention by sharing the decrees from Islam about organ donation may positively impact the willingness for donation in Jordan and other Muslim-majority countries..,
| Limitations|| |
Limitations of this study include selection bias and generalizability to other populations outside of Jordan that may have differing demographic characteristics, awareness levels, and opinions about organ donation. In the qualitative portion, transplant surgeons and organ recipients were selected from a single, private hospital (Islamic Hospital) and hence, participants’ experience may not reflect the situation in other hospitals. The sample population was also selected from a single district in the Amman governorate, and may not apply to other populations within Jordan, such as rural communities or those without advanced degrees, who may have a lower level of knowledge of these issues compared to urban populations., In addition, Al-Jami’ah District contains tertiary hospitals and cancer center, so residents may have greater awareness of these topics in comparison with other districts. However, the majority of Jordanians live within the Amman governorate, and the study was designed to be cross-sectional in order to account for variations. All responses were self-reported, and hence cannot necessarily be validated, although the questions for assessing respondents’ knowledge about organ donation are used as a measuring tool.
| Conclusion|| |
Organ transplantation is a potentially curative option for patients with end-stage organ failure. Organ donation is an altruistic deed that can save lives, prolong survival, and improve quality of life. Unfortunately, the scarcity of DODs is the principle obstacle facing organ transplantation opportunities in Jordan, underscoring a need to increase awareness about donor registration, transplant opportunities, and misconceptions. This study aimed to assess public perspectives and to measure knowledge and attitudes toward DOD, in order to inform methods for widening the organ donor pool. This study revealed several misconceptions, gaps in knowledge, and negative attitudes toward organ donation that remain in Jordan. However, participants recognized the importance of educational campaigns and regulatory legislation to prevent organ trafficking, and would likely benefit from information from health-care providers and religious leaders. Future research should be directed to investigate associated causes and barriers to organ donation, as well as the effect of informational campaigns. Moreover, more health-care provider-directed educational programs are needed to increase public awareness and acceptance of organ donation in Jordan.
Conflict of interest: None delared.
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Department of Community Medicine and Public Health, Faculty of Medicine, University of Science and Technology, Yemen-Jordan Branch, Amman
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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