Knowledge and attitude of law, medicine, and mass-communication students towards deceased organ donation: a cross-sectional study from Kathmandu, Nepal

INTRODUCTION

Organ donation is defined as the removal of tissues from the human body, from a living or dead person, for the purpose of transplantation as a treatment.¹ Today, transplanting solid organs is a common therapeutic strategy for patients with end-stage organ failure with promising effects for survival and quality of life.² However, increase in the incidence of organ failure and relatively constant organ donation rates has widened discrepancy between the number of patients on the waiting list for organ transplantation and the available number of organ donors.³

The shortage of organs is a global public health problem. Even in developed countries, where rates of deceased organ donation is relatively satisfactory, it is still struggling to meet the required demand.⁴

Although there is no recent robust data, it is estimated that, in Nepal, about 3000 people develop kidney failure annually, while the incidence of liver failure is 1,000. Similarly, an estimated 30% of the diabetic population in Nepal might benefit from pancreas transplantation.2 Solid organ transplantation started in Nepal with a kidney transplant in 2008 at the Tribhuwan University Teaching Hospital.⁵ Subsequently, few other government and private hospitals instigated kidney transplantation to meet the need. Nevertheless, the annual number of kidney transplantation is relatively low as compared to approximately 3,000 people requiring kidney transplantation each year. The Human Organ Transplantation Centre in Bhaktapur alone conducts nearly 150 kidney transplants per year.⁶ The first ever liver transplant from a live donor and also first kidney transplant from a brain-dead donor in Nepal was conducted in the same center not too long ago in 2016 and 2017 respectively.^7,8

The problem of organ shortage and organ trafficking can be solved by promoting cadaveric organ transplantation.⁹ Although, brain dead donor organ transplant has already been introduced in Nepal, the rate of transplantation from deceased organ donors is not satisfactory; thus, almost all kidneys and liver come from living donors. Young deaths due to road traffic accident or cardiovascular event provide a best option for high-quality organ yield.¹⁰ In Kathmandu alone, road accidents leave around 1000 people brain-dead annually, whose organs, if procured could save thousands of lives. It would also help curb organ trafficking, gender biasness, donor risk as seen in live donor organ transplantation.¹¹

Though, Nepal has swiftly paved its way in kidney transplantation, organ donation, especially cadaveric organ donation is yet to get momentum in Nepal. The prerequisites for the success of a transplantation program include awareness, positive attitude towards organ donation and consent by relatives for organ donation in the event of brain death.¹²

Many studies have shown that knowledge, attitude, and behavior are the key factors that influence rates of organ donation.¹³ Most of the studies from developed countries show that motivation to donate organs is associated with the appropriate awareness on the subject.¹⁴

There are not even a handful of research articles published on this public health issue in Nepal. Medical, law and mass-communication professionals can play pivotal role in promoting atmosphere for enhancing organ donation and procurement rates. Assessment of knowledge, attitude and practices on organ donation is essential for better understanding of the community on different aspects of organ donation. It will further help us in improving health education initiatives thereby removing the hurdles behind organ donation. Thus, this study aims to assess knowledge and attitude of post-graduate students from medical, law and mass communication fraternities towards cadaveric organ donation.

METHODS

This cross-sectional study was conducted among Medicine, Law and Mass communication students selected conveniently from a total of 9 colleges which were selected via lottery method, namely: Medical Colleges: National Academy of Medical Sciences (NAMS), Tribhuwan University Teaching Hospital (TUTH), and Kathmandu University (KU), Law colleges: Nepal Law campus (NLC), National Law College (NaLC), and Chakraborty Habi Law College. Mass Communication colleges: Ratna Rajya Campus (RR), Madan Bhandari Memorial College (MBM), and Kantipur City College (KCC).

The study was conducted from December 2016 to May 2017. The initial sample size was 440 with a response rate of 10%, which was calculated based on a similar study conducted in Turkey.¹⁵ A self-administered questionnaire with 10 questions each was used to measure knowledge and attitude towards decreased organ donation. The number of questionnaires distributed in medicine, law and mass communication was 140, 170 and 130, respectively. The respondents were further screened to get the final sample size for analysis based on the responses to the following questions.

1. Can organs be donated? Yes or No.

2. If “Yes”, when can the organs be donated? While alive/ After death/Both (Before and after death)

They were taken for further analysis only if the response to the first question was “Yes” and “both” to second question.

To assess knowledge level, for each correct answer, respondent was awarded with score “1” and for the wrong answer or “Don’t know” response, “0” score was given. There were three multiple choice questions. Hence, the knowledge scores were aggregated and ranged from 0-20. The respondent’s obtained total score was rated as following ¹⁶

Low level of knowledge: <or equal to 50% (0-10); Medium level of knowledge: 51%-75% (11-15); High level of knowledge: >75% (16-20)

To measure the attitude towards deceased organ donation, a 5-point Likert scale was used ranging from strongly disagree to strongly agree which was later changed to dichotomous outcome. The total score ranged from 10 to 50. The median value “3” on the 5-point Likert scale was taken as a cut off value, which in percentage is 60%.

There were positive as well as negative statements. Positive statements were marked as 5, 4, 3, 2, 1 for strongly agree, agree, neutral, disagree and strongly disagree respectively, while for negative statements, reverse markings were done. Based on the cumulated score, which was converted into percentage, respondents who scored above 60% were considered as having “Positive” attitude, while those scoring below 60% were considered as having “Negative” attitude.

Before starting data collection, a written informed consent was obtained from all the participants after explaining them about the research topic and its importance. Respondents spent 30 minutes, on an average, to complete the questionnaire.

Ethical approval

Ethical approval was obtained from the Institutional Review Committee of B.P. Koirala Institute of Health sciences, Dharan, Nepal.

Statistical analysis

The collected data was, it was entered in Microsoft Excel 2007 which and was subsequently converted into Statistical Package for Social sciences (SPSS) version 11.5 for further analysis. Frequency, percentage, mean, and standard deviation were calculated. Graphical and tabular presentations were used wherever required. Pearson correlation test was used to test association at 95% confidence interval (C.I.).

RESULTS

Out of 440 questionnaires, all the respondents were aware that organs can be donated. However, only 299 respondents could correctly answer that organs can be donated both- before and after death. Thus, the final sample size taken for further analysis was 299.

Socio-demographic characteristics of the respondents

Most of the respondents (37.5%) were from medicine, followed by law (35.5%) and Mass communication (27.1%). Majority (78.3%) of them were in between the age group of 20-30 years. More than half (54.8%) of the respondents were male. Majority (89%) of the respondents followed Hinduism. 68.2% were single. Likewise, nearly three-fourth (73.9%) of the respondents lived in nuclear family and most of them (70.5%) had adequate monthly income (Table 2).

Knowledge regarding organ donation and transplantation

Out of initial 440 respondents, most (68%) knew that organs could be donated both, before and after death. These people were selected as the final sample. Nearly 42% correctly answered that our law permits only close relatives to be a living organ donor. 64.2% were unaware of the recent amendment in the old transplant act of Nepal. Majority (77%) reported that buying and selling organs for the purpose of organ transplantation is illegal in Nepal (Table 3). When asked about organs that can be donated while alive, 94.6% of respondents opted for kidney, followed by liver (50.2%). Similarly, for open-ended questions on organs that can be donated after death, most responses were for cornea (90%) followed by heart (70.2%), kidney (63.2%) and liver (54.8). For question related to organs transplantable in Nepal, majority (78.9%) of responses were for cornea followed by kidney (86.9%) and liver (37.8%). 45.2% of the respondents correctly mentioned at least one hospital conducting organ donation and transplantation in Nepal (Table 3).

Classification of knowledge level of the respondents

Almost half (48.8%) of the respondents had low level of knowledge, while 44.1% had moderate level of knowledge and only 7% had high level of knowledge on organ donation (Table 4).

Attitude of the respondents towards deceased organ donation

More than nine-tenth (93.3%) of the respondents felt that deceased organ donation can help reduce organ scarcity for organ transplantation. Regarding health care system of Nepal, 41.1% respondents found it trustworthy, while 38.8% were ambivalent. Nearly 61% think that there are lesser risks associated with deceased organ donation. The idea of providing monetary incentives to promote deceased organ donation was declined by 40.5%. The idea of adding organ donation chapters in curriculum to promote awareness regarding organ donation was backed up by 92% of respondents. Similarly, the concept to initiate the provision of facility for voluntary registration for deceased organ donation on issuing driving license was supported by 72.9%. More than nine-tenth (93%) of the respondents agreed to the concept of bestowing full rights of making decision for organ extraction from a deceased organ to the family members and not the doctors (Table 5).

Classification of respondents’ attitude towards deceased organ donation

Majority (95%) of respondents had positive attitude towards deceased organ donation (Table 6).

Co-relation between knowledge and attitude score

The Pearson co-relation coefficient (r) was 0.251 showing a weak positive co-relation between knowledge and attitude of the respondents, and was statistically significant (Table 7).

Sources of information on organ donation and transplantation

Majority (80.6%) of the respondents reported that their source of information were Tv/Radio/Internet followed by Newspapers (51.8%), Health Care Personnel (29.4%), Relatives/Friends (16.1%) and Organ Transplant Centers (7.7%) (Figure 1).

Almost half (50.5%) of the respondents reported that they had heard the term “brain death”, and most of these were from the medical stream followed by law and mass-communication (Figure 2).

Familiarity with deceased organ donation registration procedure

Only 3% of the respondents reported of being familiar of the procedure of registering their names for deceased organ donation (Figure 3).

DISCUSSION

The respondents in this study are the post graduate students from medical (37.5%), law (35.5%) and mass communication (27.1%). This composition corresponds to a study done in Turkey, where the composition of respondents was, medical (26%), law (35%), nursing (9.6%) and communication (10.26%).¹⁵

In the present study, nearly half (48.8%) of the respondents had low level of knowledge on organ donation. The knowledge level of respondents in similar kind of sample characteristics differs across various studies based on the scoring system used to assess knowledge level and type and country where study was conducted.^9,17,18 Not having a well validated universal tool to assess knowledge on organ donation is a limitation.

All participants (100%) were aware that organs can be donated and of this, nearly 68% said that organs can be donated both, before and after death. These results fairly correspond with the study done in South India where all the respondents cited that they knew about organ donation and 60.5% of these reported that organs can be donated before and after death.¹⁷

In the present study, kidney and liver were the most common responses to the question when asked about organs that can be donated before death, while cornea, heart, kidney, liver respectively were common responses for organs that can be donated after death. These results correspond fairly with other studies done where cornea and kidney were the most common responses followed by either liver or heart.^1,10,19-23 Thus, there was high level of awareness regarding donation of eye, kidney, heart, and liver as compared to other organs.

In our study, 64.2% were admitted that they did not know about the recent revision of transplant act of Nepal. This is in line with a study done among medical staff in Morocco where 68.2% admitted to have no knowledge about the existing organ donation laws in their country.¹⁴ Likewise, a study done in Ahmedabad, India, despite having a good sample of highly educated respondents, 74.41% were unaware of the Transplant Act of India.²⁴ Contrary to this, another study done in Chennai, India, only 43.4% were unaware of the same.¹⁹

In the present study, 95% of the respondents had a positive attitude towards cadaveric organ donation. A study done in India among Nurses, 78.33% had positive attitude towards organ donation.²⁵ In the present study, a vast majority (95%) had a positive attitude towards organ donation. This is quite high as compared to reports from India, 37%, and Pakistan, 75.2%.^22,26

In the present study, 94.3% of the respondents agreed that organ donation is a noble act. This is in line with a study done in Iran where 94.2% of the respondents had the same view.²⁷

In the present study, 41% of the respondents said that they do not find health care system of Nepal trustworthy. A study done among 341 participants from different faculties in Turkey showed that 37.3% did not have confidence in health care policy of their country.¹⁵

Vast majority (92%) of the respondents in our study felt that organ donation chapters should be made the part of school curriculum to promote organ donation. Similar results were replicated in studies done in Kerala and Telangana, all situated in India, where 91%, 82.4% and 88.7% of the respondents respectively reported the same.^9,17,18

Only 3% of the respondents in this study agreed that doctors should be given full rights to make decision about organ donation after patient’s death. Similar findings were found in studies done in Turkey and Pakistan where respondents least supported the idea of giving power to the doctors to make decision on organ donation upon someone’s death and believed that the person himself should make this decision, and if this is not applicable, the decision power should be entitled to his family.^22,23

In the present study, there was a weak correlation between the knowledge and attitude score which was statistically significant. This corresponds with the study done in Nepal among nursing students where knowledge and attitude were weakly associated.² A study done in Iran showed that there was a negative correlation between attitude and awareness.²⁷ Similarly, a study in India also showed that although the knowledge level was high, attitude was quite poor among the respondents.²⁸

In this study, TV, radio including internet were the major sources of information on organ donation and transplantation. Media has been the major source of information as reported by respondents from different countries around the world.^{1,19,21,22,29}

Similarly, 29.40%. of the respondents reported health care professionals as the source of information. Similar result was found in studies done in Pakistan and South India.^17,29 Contrastingly, a study done among general population in Ahmedabad, India about 48% of the people cited medical fraternity as the source of information on organ donation and transplantation.²³

Only 3% of the respondents in this study were aware of the procedure to register their names for cadaveric organ donation. While a study done among students from various specialties in Chennai, India, 35% of the respondents reported of having knowledge on organ donation card.¹⁹ This might be due to the wide variation in sample size and because of the wider development of organ donation and transplantation in India in comparison to Nepal.

CONCLUSION

Most respondents in this study had a positive attitude towards organ donation. However, there was a weak correlation between knowledge and attitude score and none of the respondents carried an organ donation card. This may mean that though people have positive outlook towards organ donation, they lack sufficient knowledge on the topic to make a rationale decision to register their names as a potential donor after death. Similarly, not having enough idea on organ donation registration process could also be a hindering factor. Thus, massive awareness, knowledge, and exploration of other influencing factors in other studies is a must.

ACKNOWLEDGEMENTS

The authors would like to thank Ms. Sarah Rasmussen and Senior Transplant Surgeon Dr. Pukar Chandra Shrestha for their insightful comments in questionnaire construction and manuscript refinement.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Review Committee, B.P. Koirala Institute of Health Sciences, Dharan, Nepal

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