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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2021  |  Volume : 32  |  Issue : 6  |  Page : 1552-1561
Posthumous Organ Donation Decision: The Role of Empathy and Knowledge on the Attitude and Willingness to Donate among University Students in Pakistan

School of Business and Economics, Universiti Putra Malaysia, Serdang, Selangor, Malaysia

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Date of Web Publication27-Jul-2022


Organ transplantation is a common procedure in many countries, but it can still be hampered by a lack of donors. Many reasons exist for people’s hesitation to sign the donor card and this study explores the factors affecting posthumous organ donations motivation. The objectives of the study were to examine the role of knowledge, empathy, and attitude toward willingness to donate in posthumous organ donation decisions. We also examined whether education moderated the relationship between knowledge and attitude to donate. For this purpose, a survey was conducted among university students in public and private universities from Lahore, Pakistan. Structural Equation Modelling using the SmartPLS (3.0) was used to test the hypotheses proposed for this study. Empathy toward posthumous organ donation and the knowledge were positively related to the respondent’s attitude and attitude was positively related to willingness to donate organs posthumously. The results showed that education level did not moderate the relationship between attitude and knowledge. Future research may incorporate other factors such as religious affairs and cultural values for developing a socially appropriate model.

How to cite this article:
Umair S, Ho J, Waqas U. Posthumous Organ Donation Decision: The Role of Empathy and Knowledge on the Attitude and Willingness to Donate among University Students in Pakistan. Saudi J Kidney Dis Transpl 2021;32:1552-61

How to cite this URL:
Umair S, Ho J, Waqas U. Posthumous Organ Donation Decision: The Role of Empathy and Knowledge on the Attitude and Willingness to Donate among University Students in Pakistan. Saudi J Kidney Dis Transpl [serial online] 2021 [cited 2022 Sep 25];32:1552-61. Available from: https://www.sjkdt.org/text.asp?2021/32/6/1552/352415

   Introduction Top

One of the greatest success stories in the history of medicine is the transplantation of a living organ or tissue from one person to another to cure illness.[1] Organ transplantation has gained worldwide acceptance as a viable treatment since the first renal transplant in the USA in 1954[2] and the advances in immune-suppressive drugs have caused the demand for organs for transplantation to increase tremendously. It is now considered a common way to increase the life expectancy of people who would otherwise die from end-stage diseases.[3] As a result of the increased use of transplant therapy, there is a worldwide shortage of available organs and the scarcity of suitable organs is likely to continue to be a global problem.[4] The gap between the demand and availability of organs is one of the greatest hurdles preventing progress in the field of organ transplantation.[5] One way for this shortage to decrease would be through posthumous organ donation, that is, increasing donation after death.[6] Patients with irreversible loss of brain function are looked upon as one of the largest sources of organs.

Each year, about 130,000 people in Pakistan die because of kidney and liver failure;[7] many of them could have been saved by an organ transplant. As of 2018, only eight persons in Pakistan have so far donated their organs after death. The low rate is attributed to a general lack of knowledge and awareness about posthumous organ donation in the country.[8] Most people are unaware of the importance of being an organ donor and the benefits associated with it.[9] However, even those who are aware of organ donation have different levels of knowledge and views regarding the issue.[10] In previous organ donation studies, one of the major barriers to organ donation is the lack of knowledge[11],[12] and it has been observed that respondents with higher education levels were more aware of the importance of organ donation.[10] While there have been studies on organ donation intention, most of these studies were conducted on medical students,[13],[14] and it is not clear whether an increase in education level in other disciplines would strengthen the relationship between knowledge and attitude. Other than know-ledge, there can be certain factors that can motivate a person to donate organs after death. The increasing gap between demand and supply of the organs demands to find ways to reduce this gap. There is a need to find the factors that can increase the willingness to donate organs. Thus, the general objective of this study was to identify the actors that can increase the willingness to donate posthumous organs. Specifically, this study set out to investigate whether: (1) knowledge and empathy influenced attitude to donate; (2) a positive attitude translated into willingness to donate posthumous organ donation, and (3) education level moderated the relationship between knowledge and attitude to donate.

It is hoped that this study will contribute to a deeper understanding of the factors which will encourage posthumous organ donation, specifically in a predominantly Muslim context such as Pakistan. The findings of this study will be of interest to countries facing low organ donation rates and have a similar cultural and economic background as Pakistan. The present study incorporated a direct pathway between knowledge and empathy toward attitude, and from attitude to willingness to donate. The level of education was used as a moderator between knowledge and attitude. The research framework is shown in [Figure 1].

Figure 1. Research framework.

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Knowledge refers to the individuals’ association with the facts and truths about organ donation and usually, such knowledge can sometimes be gained from personal experiences or statements widely endorsed in the community.[15] Knowledge about organ donation is important to consider in determining the attitude toward organ donation. Having sufficient knowledge may shape the attitude toward organ donation. Empathy is used to refer to the shared feelings and thoughts between two individuals or two independent minds;[16] empathetic feelings may be considered sympathy, kindness, or being sensitive.[17] It has been noted that people who empathize with others are more likely to agree to organ donation[18] since empathetic individuals tend to see themselves in the place of others in need of help and this increases their desire to help them. Attitude describes a feeling which reflects a particular orientation of thought regarding organ donation.[15] It is expected that people who have previously expressed positive or negative attitudes toward posthumous organ donation, would behave consistently with their attitudes when they were asked to show willingness for becoming organ donors.[18] Finally, willingness which is closely linked to an individual’s behavior[19] has been described as a person’s motivation to carry out a certain behavior.[20] It is a fact that willingness to engage in a particular behavior can be affected by certain situational factors that intervene with the attitude-behavior relationship.[21] In general, the stronger a person’s willingness to engage in a particular behavior, the more likely his/her performance becomes a reality.[19] Hence, it is important to identify factors that can influence the individual’s willingness to engage in posthumous organ donation.

Based on the research objectives identified in this study, the following hypotheses were developed:

H1: Knowledge about posthumous organ donation is directly related to the positive attitude for posthumous organ donation.

H2: Empathy-related to posthumous organ donation is directly associated with a positive attitude for posthumous organ donation.

H3: Positive attitude toward posthumous organ donation and WTD are directly associated with each other.

H4: Education level moderates the relationship between attitude and knowledge about posthumous organ donation, where education level would strengthen the relationship.

   Methods Top

Study design and sample

Using a cross-sectional research design, an empirical investigation was employed in which a survey was conducted among 200 university students over the age of 18 from Lahore, Pakistan. Lahore is considered the largest city and the most advanced district of Punjab (Pakistan) with an expected population of more than 11 million. University students were used for the study as young, healthy donors can be important to target for promoting posthumous organ donation.[22] To ensure diversity in respondents, students from one public and one private university were included in the survey.


Face-to-face data collection method was used for data collection. Participants were approached in their classes after obtaining approval from their lecturers. For the ease of the respondents and the lecturers, this was done during break time or after class. Participants completed a questionnaire (Appendix) that was divided into two sections. Section I included an assessment of the participant’s knowledge about organ donation and transplantation, empathy, attitude, and WTD. These items were measured on a 7- point Likert scale that ranged from “1-strongly disagree” to “7-strongly agree.” Section II consisted of questions on the respondent’s demographic profile.

Knowledge about organ donation was measured by asking respondents to indicate their level of knowledge about different factual statements. We adapted Morgan and Miller’s[23] 8-item scale by replacing the “true/false” statements with the statements which could be measured on a seven-point Likert scale. Respondents were asked to rate their level of empathy with a scale developed by Davis[24] and Wang[25] (α = 0.86). Attitude toward organ donation was measured using the 6-item scale adapted from Morgan[26] (α = 0.88). To measure the respondent’s willingness to donate, four items were adapted from the scale developed by Charsetad[27] (α = 0.96).

Three academic experts reviewed the items of the questionnaire to establish content validity. Before the actual distribution, the questionnaire was pretested on 10 university students to ensure that the respondents would be able to understand the questions and the instructions. Based on the pre-test comments, the font size was changed to make the questionnaire easy to read and the explanation of the term “posthumous organ donation” was added at the introduction part of the questionnaire to facilitate understanding of the term.

Ethical consideration

In compliance with the three authors’ university research guidelines, ethical approval was obtained from the authors’ university ethical committee before the survey was conducted. Permission was also obtained from the respective universities and verbal consent was taken from all the respondents before distributing the questionnaires.

   Statistical Analysis Top

PLS-Structural Equation Modelling (SEM) with SmartPLS (3.0) was used to test the hypotheses proposed for this study. Appropriate statistical tests including assessment of the measurement model, structural model, and the moderating effect were applied.

   Results Top

Response rate and participant characteristics

Of the 200 distributed questionnaires, 189 proved usable after eliminating those that were incomplete, indicating a response rate of 94.5%. Since the respondents were from a single source, it was deemed important to determine if common method bias was an issue in this study. We tested for the common method variance using Harman’s single-factor method.[28] The value for the largest variance explained by the first factor was 24.30% which was <40% as indicated by Podsakoff et al[28] indicating that common method variance was not a concern for this study.[29] Slightly skewed toward female respondents in this study, there were 83 males (43.90%) and 106 (56.10%) females. Based on age, the majority (91%) were between 18 and 24 years of age. Most of the respondents were Muslims (98.41%) while a small percentage (1.59%) were from other religions. The majority (84.13%) was in a bachelor’s degree and the remaining 15.87% were in a master’s degree program [Table 1].

Table 1. Respondents’ profile (n=189).

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Construct reliability and validity

The measurement model for both reflective and formative constructs was assessed. The reflective constructs were empathy, attitude, and WTD. The reflective measurement model items were assessed with composite reliability, and average variance extracted (AVE) to evaluate internal consistency and convergent validity. In PLS-SEM, composite reliability for all the constructs should be above the minimum threshold of 0.7.[29] As shown in [Table 2], the composite reliabilities for all reflective constructs, i.e., attitude, empathy, and WTD were 0.799, 0.812, and 0.921, respectively. All these values were greater than the minimum threshold indicating a high level of internal consistency between the constructs. An AVE of 0.50 or greater indicates that the construct explains half or more than half of the variance of its indicators.[30] For the present study, as shown in [Table 2], the AVEs for all three constructs were greater than 0.50. Next, we checked the discriminant validity of the items. The purpose of discriminant validity is to ensure that one construct is empirically distinct from the others.[30] According to Fornell and Larker[31] AVE of a latent factor should be greater than the variance shared between the latent factor and other latent factors (that is the square between two latent factors). This indicates that more variance is shared between the latent factor and its measurement items than with another latent variable representing different sets of measurement items.[32] For the present research, all reflective constructs exhibited sufficient discriminant validity because the square root of AVE (diagonal) was larger than the correlation (off-diagonal) for all reflective constructs.[30] This indicates that all the reflective constructs in the study were empirically distinct from each other.

Table 2. Composite reliability and convergent reliability.
Criteria: Composite Reliability ≥0.7 (Hair et al, 2017); AVE ≥0.5 (Hair et al, 2017)

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Assessment of the formative construct (knowledge) was performed. To validate the formative measures, multicollinearity between indicators was first assessed. In PLS-SEM, a variance inflation factor (VIF) value of 5.00 and above indicates potential collinearity problem.[30] VIF values for each knowledge item were less than 5, indicating collinearity was not an issue in this study.[29] While assessing the formative measurement items, the significance and relevance of the outer weight, t-statistic, and p-value of the formative constructs were examined. It was assessed that the four items of knowledge (KN2 (t = 1.286, p = 0.1), KN3 (t = 1.051, p-value 0.147), KN4 (t = 1.271, p = 0.102), KN5 (t = 0.033, p =0.487) were non-significant. However, as previous research and theory provided evidence for the relevance of these indicators in capturing the operationalized definition of knowledge, these indicators were retained in the formative constructs,[29] even though their outer weights were not significant.

Structural model analysis

After validating the measurement model, the inner model (structural model) was analyzed. Since the VIF values for Attitude (VIF = 1.00), Empathy (VIF = 1.08) and Knowledge (VIF = 1.08) were less than 5. Hence, there were no collinearity issues with the inner model. Next, an assessment of the path coefficients was used to evaluate the significance of the hypothesized relationships among the constructs. The results in [Table 3] prove that the three direct relationships were significant and provided support to all three direct hypotheses. Hence, H1, H2, and H3 were supported at p ≤ 0.05.

Table 3. Assessment of the path coefficients.

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R2 was used to assess the coefficient of determination. According to Cohen,[33] R2 values of 0.260, 0.130, 0.02 as a rule of thumb can be described as substantial, moderate, and weak, respectively. The R[2] value for attitude was 0.338 and WTD was 0.351. This indicates that 33.80% of the variance in attitude was explained by knowledge and empathy and 35.10% of the variance in WTD was explained by attitude. From this, we can postulate that the relationship of knowledge and empathy with attitude and the relationship of attitude with WTD is quite substantial.

In the present study, the exogenous constructs (attitude, empathy, knowledge) were categorized according to three degrees of exogenous effect – 0.35-Large, 0.15-Medium, 0.02-Small, <0.02-Trivial.[33] Attitude had a large effect (f2 = 0.541) on WTD, while empathy had a medium effect (f2 = 0.26) and knowledge had a small effect (f2 = 0.118) on attitude. The results show that increasing the positive attitude toward posthumous organ donation can help to increase the willingness for this donation. After identifying the effect size, the predictive relevance, Q2, allows us to examine and assess whether the exogenous constructs have predictive power over endogenous constructs. A value of Q[2] greater than 0 indicates that the exogenous constructs have the predictive ability over the endogenous constructs.[31] The endogenous constructs attitude (Q2 = 0.146) and WTD (Q2 = 0.243) have Q2 values which exceeded 0 and this demonstrated the predictive relevance and validity of the model. The results highlight that empathy and knowledge toward posthumous organ donation can predict a person’s attitude for donation and a positive attitude for organ donation can predict the WTD organs after death.

Assessment of the moderating effect of education level

In PLS-SEM, interaction terms between a potential moderator and the predicting variables were created to evaluate the moderating effect of a construct on the endogenous variables. As shown in [Table 4], the initial assessment of the moderating effect showed that it was not significant (t = 0.196, p =0.422). These results imply that education level does not moderate the relationship between attitude and knowledge and, therefore, in the present study, H3 was not supported at the p ≤0.05 level.

Table 4. Moderating effect.

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   Discussion Top

Previous research on posthumous organ donation has concentrated on understanding the various factors that can influence a person’s willingness to donate organs after death. Scholars have explored knowledge, values, religious beliefs, and attitude toward posthumous organ donation, but despite this, there is still a lack of understanding of the relationship between the different factors and how they are interconnected. The main objective of the study was to identify factors that can increase the willingness to donate posthumous organs among university students in Pakistan.

The present study was an attempt to understand the influence of empathy, knowledge on attitude and willingness for posthumous organ donation and transplantation among university students of Pakistan. In this study, it was found that knowledge about organ donation was positively related to attitude toward posthumous organ donation. The results of this study further confirm the association between knowledge and attitude toward posthumous organ donation and were consistent with that of many other studies.[13],[34],[35],[36] People would have a more favorable attitude toward the donation if they knew about donation after death, specifically knowledge on the donation procedures and organ donation laws.[12]

The findings of the present study also found that empathy was positively related to attitude toward posthumous organ donation. The results of the present study were in support of the previous studies,[37],[38],[39] as empathy demonstrated a significant influence on the positive attitude toward donating organs after death suggesting that empathetic concerns can play an important part in shaping positive attitudes toward posthumous organ donation. Empathy is a response to another person’s feelings and emotions or a particular situation,[38] and hence can be an important predictor of attitude toward a specific behavior. In previous studies, there has been a limited discussion on the role of empathy toward posthumous organ donation.[40]

The results for the hypothesis between attitude and WTD highlighted that favorable attitude toward posthumous organ donation was positively related to willingness to donate organs after death and thus indicated that attitude could positively influence willingness to donate. The consistent influence of attitude on the willingness to perform a behavior was in accordance with past theories on donation research.[21],[41],[42] The findings of this study suggest that university students with positive attitudes toward posthumous organ donation are more willing to donate their organs after death.

The findings of the present study suggest that to increase the pool of donors, particularly in Pakistan, the policies can use empathy as the primary target for public education to increase favorable attitudes toward posthumous organ donation. Future policies of the health ministry and the organizations working for posthumous organ donation in Pakistan can focus on promoting the concept of being empathetic toward the recipient. They can use media stories to increase awareness, empathetic concerns and knowledge about posthumous. There needs to keep on promoting the messages that every person has a chance to be in a need of an organ instead of donation in their life. The promotional campaigns can also highlight the importance of an organ to the potential recipient and that the potential organ recipients may also have an equal chance to live a healthy life. Particularly, to target young adults the universities can conduct seminars on the importance of organ donation and being an organ donor. Such seminars can also highlight information about different types of donations, the procedures of donation and the ways to become an organ donor. This can help to increase the potential donor.

One of the limitations of the study is that we employed convenience sampling as the study’s research design. Even though we tried to recruit respondents across a range of different programs, this group may still be fairly homogeneous in their thoughts and feelings towards posthumous organ donation. However, the sampling technique could potentially cause a problem of generalizability. Another potential limitation of the study was the use of a self-administered survey which can be biased. Future studies can include measures of social desirability. This way, it would be easy to assess the degree of positive bias in such studies. Future studies may utilize multi-group analysis to make a comparison between medical and non-medical students to get a better idea of the intrinsic differences in their feelings toward posthumous organ donation. Future research can also extend the model by incorporating other factors such as religious affairs and cultural values for developing a socially appropriate extended model. Next, despite the attempt to obtain respondents from different departments of the sampled universities, respondents in this study were predominantly comprised of Muslims. Future studies can be conducted with a comparison of different religions to make the results more generalizable.

   Conclusion Top

At a global level, there is a serious need to bridge the gap between demand and the available supply of organs. In Pakistan, like in many other countries, the need for organs calls for a national-level communication strategy that increases the awareness, knowledge, and willingness of people to donate organs posthumously. This will help increase the organ donor rate and ultimately prolong the lives of people through organ transplantations. The present study was an attempt to answer this call by examining the antecedents to attitude and willingness to posthumous organ donation decisions with family. We discovered that, among our Pakistani students, the level of education was not an important factor in creating a positive attitude towards donating organs. Increasing the knowledge and motivation of other people may enhance their sympathetic attitude and eventually, they will be more willing to donate organs after death.

   Acknowledgment Top

We thank all the participants of this study for taking the time to participate in our study. We are also grateful to the four universities that allowed us to conduct these interview sessions.

Conflicts of interest: None declared.

   References Top

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Correspondence Address:
Jo Ann Ho
School of Business and Economics, Universiti Putra Malaysia, Serdang, Selangor, 43400 Malaysia.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-2442.352415

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