Saudi Journal of Kidney Diseases and Transplantation

: 2018  |  Volume : 29  |  Issue : 6  |  Page : 1358--1365

Knowledge, attitudes, and practice of organ donation in Morocco: A cross-sectional survey

Abdelkader Jalil El Hangouche1, Oumaima Alaika2, Hanan Rkain3, Adil Najdi4, Leila Errguig3, Nawal Doghmi2, Souad Aboudrar3, Mohammed Cherti2, Taoufiq Dakka3,  
1 Department of Physiology, Faculty of Medicine and Pharmacy of Tangier, Abdelmalek Essaadi University, Tangier; Department of Cardiology B, Ibn Sina Hospital; Exercise Physiology and Autonomic Nervous System Team “EPE-SNA”, Department of Physiology, Faculty of Medicine and Pharmacy of Rabat, Mohammed V University, Rabat, Morocco
2 Department of Cardiology B, Ibn Sina Hospital, Faculty of Medicine and Pharmacy of Rabat, Mohammed V University, Rabat, Morocco
3 Exercise Physiology and Autonomic Nervous System Team “EPE-SNA”, Department of Physiology, Faculty of Medicine and Pharmacy of Rabat, Mohammed V University, Rabat, Morocco
4 Department of Epidemiology and Clinical Research, Faculty of Medicine and Pharmacy of Tangier, Abdelmalek Essaadi University, Tangier, Morocco

Correspondence Address:
Dr. Abdelkader Jalil El Hangouche
Department of Physiology, Faculty of Medicine and Pharmacy of Tangier, Abdelmalek Essaadi University, Tangier


In any health system, public awareness of organ donation fundamentally affects the organ transplantation programs. The aim of this study was to evaluate the knowledge and perception of the people in Morocco toward organ donation as well as to identify the reasons and determinants for refusal of organ donation. This opinion survey included a representative sample of 2000 participants in Morocco, and data related to sociodemographic characteristics, knowledge and self-opinion about organ donation, and reasons behind refusal were collected. Statistical analysis showed that 55.2% of the participants were women, the median age was 21 years, and 60.8% of included participants had secondary education. Almost two-thirds of surveyed participants (62.3%) showed a low to mid-level of knowledge about organ donation and transplantation in Morocco. About half of the interviewed participants (48.8%) refused to donate their organs. Concern about risk of medical error and the belief in trafficking of procured organs were the main reasons for refusal, seen in 66% and 62% of the interviewees, respectively. Univariate and multivariate logistic regression models showed that the older, the less educated and the less informed a person is, the less he accepted organ donation. Therefore, promotion of organ donation in Morocco should involve a regular information and awareness among the general population.

How to cite this article:
El Hangouche AJ, Alaika O, Rkain H, Najdi A, Errguig L, Doghmi N, Aboudrar S, Cherti M, Dakka T. Knowledge, attitudes, and practice of organ donation in Morocco: A cross-sectional survey.Saudi J Kidney Dis Transpl 2018;29:1358-1365

How to cite this URL:
El Hangouche AJ, Alaika O, Rkain H, Najdi A, Errguig L, Doghmi N, Aboudrar S, Cherti M, Dakka T. Knowledge, attitudes, and practice of organ donation in Morocco: A cross-sectional survey. Saudi J Kidney Dis Transpl [serial online] 2018 [cited 2021 Sep 22 ];29:1358-1365
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Full Text


Organ transplantation is considered as the definitive and the most cost-effective treatment for end-stage organ failure.[1] However, transplantation programs are completely dependent on donor organ pools, and public attitude toward organ donation is the most significant determinant of donation activity.[2]

In Morocco, organs for transplantation are procured from both living and deceased donors; however, with the increasing scarcity of deceased donors, almost all organ donations come from living donors.[3] For instance, the expected need for renal transplants in Morocco was estimated at 7410 among 13,000 chronic renal failure patients on dialysis, while the number of transplants performed in Morocco does not exceed 10 transplants/year/million inhabitants (with 286 kidney transplants).[4],[5] In this context, we carried out this survey to describe the Moroccan population’s perception of organ donation and to highlight and to better understand the reasons for refusal in order to encourage organ donation in Morocco.

 Materials and Methods

Study design and sampling method

A national cross-sectional survey was conducted between October 2016 and April 2017 in several regions of Morocco. We used stratified random sampling method from the 12 administrative regions of Morocco,[6] five regions were randomly selected (Tangier-Tetouan-Al Hoceima, Oriental Region, Rabat-Sale-Kenitra, Grand Casablanca-Settat, Souss-Massa, [Figure 1], and from each region, one province or prefecture was randomly selected; from each province or prefecture, two communities were randomly selected, 220 participants of each communities were randomly recruited between 10 am and 7 pm from local malls and community places, open to the general public. In total, a representative sample of 2200 Moroccan people was approached of whom, 2000 participants (91%) gave consent to participate in the study.{Figure 1}

Method of data collection

Data were collected using a face-to-face questionnaire. The tool was prepared and written in Arabic and French by the research team of the Laboratory of Physiology of the Faculty of Medicine and Pharmacy of Rabat. The language of the questionnaire was chosen on the basis of the preference of the respondent.

Pretesting was performed in a similar setting, to screen for potential problems in the questionnaire. The interviewers discussed the questionnaire carefully among themselves before data collection to decrease interviewer bias.

During interviews, the investigators defined organ donation as “the removal” of the tissues or organs of the body (e.g., a kidney or a heart) from a cadaver or from a living donor, for the purpose of transplanting or grafting them into other person.”


The questionnaire was divided into four sections, and each section included several questions to assess the following items:

The sociodemographic profile of the respondents (age, sex, marital status, and educational level)Evaluation of knowledge regarding organ donation, which was evaluated by the rate of correct answers to the four questions assessing the basic knowledge about organ donation that each Moroccan citizen is supposed to know. In this study, we have considered that a participant who had three or four correct answers had high knowledge on this topic, whereas a respondent who had two correct answers is considered to have mid-knowledge; while, the participant who had none or only one correct answer is considered to have a low knowledge regarding organ donationAttitude toward organ donation in general and organ donation to a family member by giving an example of kidney donationReason(s) for refusing to donate organ for transplant (risk of medical error, risk of organ trafficking, religious reasons, and violation of body integrity).

The questionnaires were filled out anonymously after obtaining an informed consent from each participant.

 Statistical analysis

The data were collected and transposed on an Excel table and analyzed by the Statistical Package for the Social Sciences (SPSS) software version 20.0 (SPSS Inc., Chicago, IL, USA).

The quantitative variables in asymmetric distributions were expressed as median [inter-quartile range (IQR) ]. Categorical variables were summarized as numbers (percentages). Comparisons between the two groups “supporters” and “opponents” of organ donation were performed through the Mann–Whitney test for quantitative variables in asymmetric distributions and by the Pearson Chi-square test for categorical variables.

Univariate logistic regression models were employed to identify the determinants associated with refusal of organ donation. All P-values were considered significant at <0.05.

Variables with a significant P value were further evaluated using multiple logistic regression analysis to determine their adjusted association with refusal of organ donation. All odds ratios were reported with a 95% confidence interval.

The descriptive and analytical results obtained were presented in the form of tables and figures and compared with the results of other similar surveys carried out in other countries.


The survey included 2000 people randomly recruited from the Moroccan population. The sociodemographic characteristics of the respondents showed that 55.2% were women. The median age was 21 years, with IQR of 19–30. The educational level varied with 22.9% of the interviewees having attended higher education [Table 1].{Table 1}

Concerning the assessment of the knowledge of transplant and organ donation in Morocco, only 1328 people interviewed (66.4%) were aware of the feasibility and the practice of organ transplantation in Morocco. Almost two-thirds of all respondents (62.3%) had a low to mid-level of knowledge about the legislation regulating organ donation and transplantation and the practical procedures of expressing during their lifetime and their willingness to donate organs. Furthermore, 985 interviewees (49.2%) already had a discussion and thought about organ donation and transplantation. Only 4.1% of interviewees knew at least one transplant recipient or one person waiting for transplant.

In terms of assessing respondents’ attitude to organ donation, 51.2% of respondents agreed to donate their organs; this percentage increased to 91.3% when it was about organ donation to relatives. The main reasons for refusal to donate their organs are given in [Figure 2].{Figure 2}

In order to define the determinants associated with refusal of organ donation, a comparison was performed between the two groups “supporters” and “opponents” of organ donation concerning age, sex, educational level, and knowledge of this issue. The results of this univariate analysis showed that the difference of all those factors was statistically significant [Table 2].{Table 2}

For further study of the relationship between willingness to donate organs and age, sex, educational level, and the knowledge of this issue, respectively, univariate and multivariate logistic regression analysis found as adjusted determiners of refusal of organ donation, old age [odds ratio (OR) = 2.57 (1.61–4.13), P <0.001], male sex [OR = 1.25 (1.02–1.51), P = 0.02], low educational level [OR = 2.14 (1.53–3.01), P <0.001], and low knowledge about this therapy [OR = 2.75 (2.04–3.72), P <0.001] to be determinants [Table 3], [Table 4] and [Figure 3].{Table 3}{Table 4}{Figure 3}


Organ donation in Morocco has existed since 1985 when the first transplant was performed from a living donor.[7] The regulation of organ donation in Morocco has been passed with the Law no. 16-98 on the donation, removal, and transplantation of organs and tissues promulgated on September 16, 1999, which authorizes the removal for the benefit of the recipients under two conditions: the donation must be free and the aim must be therapeutic.[8]

Three decades later, our survey reveals limited knowledge of organ donation and transplantation in the Moroccan population. In fact, in our survey, 33.6% of the 2000 interviewees were not aware of the existence of the practice of organ transplant in Morocco versus 19.3% (902 respondents) found in a similar survey conducted in Tunisia, a neighboring country.[9] This finding is important since knowledge on this issue determines a person’s attitude toward organ donation which, in turn, influences the practice of this therapy.[10] Indeed, insufficient knowledge about legal and procedural aspects of organ donation is considered by many studies to be an important contributing factor responsible for the scarcity of available organs.[11],[12],[13],[14]

In our survey, 51.2% of the respondents agreed to donate their organs which is similar to the finding in a similar survey conducted in Saudi Arabia (51%) in 2016[1],[5] and slightly lower than the finding in Tunisia (53.9%) in 2010[9] and in China (53.5%) in 2016.[16] Consequently, the rate of organ transplantation in Morocco remains till today much lower compared to what it is needed, despite the fact that the resources requested to perform transplantations are not scarce and the technical performance level is globally quite acceptable. Nonetheless, some studies indicate that positive attitudes toward organ donation do not reflect reliably the number of organ donor registrations.[17]

Almost two-thirds of those who refused organ donation gave these reasons: the risk of medical error during organ procurement (66%) and the risk of trafficking of procured organs (62%). These reasons were given in 31% and 13.4% of interviewees, in similar surveys conducted, respectively, in Egypt[18] and France.[19] In a systematic review of the qualitative literature, participants expressed a distrust of organ donation system and process, based on previous negative experiences with the health-care system.[14] This fact should lead one to consider the problem of mistrust in the medical health community in Morocco; both fairness and transparency are imperative to ensure public trust in the Moroccan organ procurement system.

The violation of body integrity as justification for refusal for organ donation was given in 42.7% of cases in our survey, in 56% in a similar Rumanian survey,[20] and in 14.9% in a Chinese survey.[16] These differences may be explained by the sociocultural and religious specificities of each country and also by the difference in the efforts for communication of the public health officials about organ donation.

An interesting finding of the present study was that 37.5% of the interviewees considered that organ donation is prohibited by their religion (Islam). Yet, the religious authorities of many Islamic countries support the donation and transplantation of organs.[4],[21],[22] In our context, it is strongly recommended to involve the religious leaders in public communication in order to correct the popular misconceptions related to organ donation.

In our study, the attitude toward living donation to relatives was favorable in 91.3%. This result is consistent with the observations made in other studies reporting that resistance to donation tended to be less in the case of living donation for family.[23] This fact could be explained by the strength of family relation-ship that sometimes outweighs all reasons for refusal. This type of organ donation should thus be encouraged and facilitated in addition to the donation of organs after death.

The awareness of the population should be constantly increased over time by organizing national awareness-raising campaigns and by soliciting regular media programs, television movies, and networks. Indeed, several studies have clearly demonstrated the beneficial effects of such interventions aimed at improving the perception and attitudes toward organ donation.[13],[24],[25],[26],[27]


The number of patients waiting for organ transplant is rapidly increasing worldwide. Therefore, the gap between the demand for available organs and the supply is becoming wider every year. An improvement of perception and knowledge will be useful for the improvement of transplantation in Morocco and other Arab countries.


The authors would like to thank Mrs. Oumaima Outani and Fatima Zahra Abouzahir, Mr. Omar Azizi and Mohammed Dahbi, and all the other students of the Faculty of Medicine and Pharmacy of Rabat and Tangier for their kind cooperation.

Conflict of interest: None declared.


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