Abstract

Key words : Attitudes Toward Organ Donation Scale, Transplant, Women

Introduction

Organ transplant is a treatment option for patients with chronic organ dysfunction and end-stage diseases. These patients may receive an organ donation from living donors or from donors in whom brain death is clinically diagnosed.¹ Brain death diagnoses and organ donation procedures are conducted in accordance with the Turkish Law No. 2238 under Harvesting, Storage, Grafting and Transplantation of Organs and Tissues, which was enacted in 1979 and revised in 2014.^1,2 The first deceased donor kidney transplant was performed by Haberal and colleagues in 1979, which was followed by the first deceased donor liver transplant in 1988 and the first pediatric living related segmental liver transplant and adult-to-adult living related liver transplant in 1990. The first combined liver-kidney transplant from a living related donor was performed in 1992.²

In 2001, the Turkish Health Ministry established the National Coordination Center as an umbrella organization to promote transplant activities, especially for deceased donor organ procurement.² The number of the patients awaiting organ donation is gradually increasing in our country and worldwide, with many patients dying before a donor is found. Donations from deceased donors are still below targeted rates despite an increase in organ transplant activities.^2,3 According to 2018 data from the International Registry on Organ Donation and Transplantation (IRODaT), although Turkey ranked high for organ transplant from living donors (52.01/1 million individuals), it ranked low with regard to organ donation from deceased donors (7.47/1 million individuals).⁴

Rate of refusal of organ donation by families of deceased organ donors is around 60% to 70% despite an increased number of brain death notifications, and this rate of family refusal has risen in recent years.^5,6 Rates for deceased donations of organs may be affected by legal and ethical factors, health system factors, religious factors, and sociocultural and psychosocial factors.⁷ Difficulties in brain death notification and obtainment of family approval are also factors that affect the low rates for organ donation from deceased donors.⁸

Determination of health-related attitudes and behaviors can help shape the adoption of modern health services. Despite the opinion that religious rules are an important factor for refusal of organ donation and transplant, there appears to be no basis for this assertion in the rules of various religions. Moreover, most religions support organ transplant as a positive initiative because it saves the life of a diseased person; however, gender, sociocultural factors, and education level have been reported as factors that may influence the perspective on organ donation.^9-12 Although females and housewives had a less positive perception of organ donation compared with males in some studies,^9,13 another study found that most living donors of kidneys were mothers, housewives, and other donors without formal education.¹⁴

Given the recent medical improvements, the rise in transplant activities, and the low number of deceased donors, the importance of efforts to improve education and awareness of families who would otherwise refuse organ or tissue donation is clear. Of similar importance are ongoing studies to investigate the factors that influence the decisions of family members and thereby increase the rate of organ donation by reduction of refusal rates.^15-17

In this study, we investigated the attitudes, knowledge, and beliefs of housewives who were attending courses at centers of the Directorate of Religious Affairs and at public education centers toward organ donation.

Materials and Methods

This cross-sectional study was conducted with women who had attended courses at Religious Affairs centers and public education centers in Seyhan Municipality in Adana, Turkey. Sociodemographic data of participants were recorded, and a questionnaire that included 5 Likert-type questions on their knowledge and beliefs was applied with face-to-face interviews. The questions were as follows: (1) Do you have sufficient knowledge about organ donation? (2) Do you think that our community has sufficient knowledge about organ donation? (3) What is the religious drawback of donating organs? (4) Are you aware that the organ donation-related procedures are conducted within the law? (5) Do you think that the promotions and campaigns about organ donation are sufficient in our country?

Attitudes of the participants were evaluated with the Attitudes Toward Organ Donation Scale (ATODS) developed by Kaça and colleagues, which is based on the conceptual and methodological recommendations of Ajzen.^18,19 The scale included fourteen 7-level Likert items, with higher scores indicating more positive attitudes toward organ donation.

Ethics committee approval was obtained from Adana Numune Training and Research Hospital Ethics Committee of Non-Interventional Studies (date: 28.02.2018/number:160), and the study was conducted in accordance with the principles of the 1975 Declaration of Helsinki. Written informed consent was obtained from the participants before the study commenced.

Statistical analyses
We used a single-sample t test with a test value of 3 for assessment of the 5 Likert questions about attitudes and knowledge of the participants with regard to organ donation. Spearman correlation analysis was used to compare mean scores of the questions on organ donation knowledge and beliefs; Spearman correlation analysis was also used for sociodemographic variables and mean ATODS scores. Comparisons of ATODS scores according to sociodemographic data, family type, and course type of the participants were performed with the 2 independent samples t test, the chi-square test, and the Kruskal-Wallis test. A level of P < .05 was accepted as statistically significant.

Results

The study included 212 housewives with mean age of 42.9 ± 13.1 years (range, 19-76 years). Of these, 40 (18.9%) were single and unmarried, 147 (69.3%) were married, 68 (32.1%) were uneducated, and 125 (59.0%) were at a low level of income. Mean number of children of married women was 3.3 ± 1.9. Other demographic results showed that 36 participants (17.0%) were from a large family, 176 (83.0%) were from nuclear family, 108 (50.9%) were attending Quran courses, and 104 (49.1%) were attending public education courses.

Mean scores for questions regarding knowledge and attitude were compared with the test value of 3.0 (Table 1). Mean score of the answer to the question “Do you have sufficient knowledge about organ donation?” was 2.1 ± 1.0, and it was significantly lower than the test value of 3.0 (t = -11.208, P < .001) (Table 1).

The association among the answers to the questions on knowledge and attitudes of participants about organ donation was investigated with correlation analyses (Table 2). Mean score of the answers to the question “What is the religious drawback of donating organs?” was significantly lower in participants with marital status of single (1.45 ± 0.9) compared with participants who were married or divorced/widowed (2.2 ± 1.3 and 2.3 ± 1.6, respectively) (r = -0.178, P = .010).

Mean score of the answers to the question “Do you have sufficient knowledge about organ donation?” was significantly lower in participants without formal education (1.3 ± 0.6) and graduates of elementary school/intermediate school (2.1 ± 0.9) compared with graduates of high school (3.0 ± 0.9) and university (3.0 ± 0.9) (r = 0.610, P < .001). Mean score of the answers to the question “Do you think that our community has sufficient knowledge about organ donation?” was significantly lower in participants without formal education (1.78 ± 0.8) compared with graduates of elementary school/intermediate school (2.2 ± 0.7) and graduates of high school (2.3 ± 0.9) and university (2.1 ± 0.8) (r = 0.224, P = .001). Mean score of the answers to the question “What is the religious drawback of donating organs?” was significantly hig­her in participants without formal education (2.5 ± 1.5) and graduates of elementary school/intermediate school (2.3 ± 1.3) compared with graduates of high school (1.5 ± 0.9) and university (1.3 ± 0.8) (r = -0.302, P < .001). Mean score of the answers to the question “Are you aware that the organ donation-related procedures are conducted within the law?” was significantly lower in participants without formal education (1.8 ± 1.0) and graduates of elementary school/intermediate school (2.1 ± 1.1) compared with graduates of high school (2.9 ± 1.3) and university (2.7 ± 1.3) (r = 0.305, P < .001).

Mean score of the answers to the question “Do you have sufficient knowledge about organ donation?” was significantly lower in the participants with low income (2.0 ± 1.0) and moderate income (2.2 ± 0.9) compared with the participants with high income (3.1 ± 1.1) (r = 0.286, P < .001). Mean score of the answers to the question “What is the religious drawback of donating organs?” was significantly higher in the participants with low income (2.4 ± 1.4) compared with the participants with moderate income (1.6 ± 1.1) and high income (1.5 ± 0.9) (r = -0.305, P < .001). Mean score of the answers to the question “Are you aware that the organ donation-related procedures are conducted within the law?” was significantly lower in the participants with low income (2.1 ± 1.2) and moderate income (2.1 ± 1.1) compared with the participants with high income (3.1 ± 1.2) (r = 0.171, P = .013).

Mean score of the answers to the question “Do you have sufficient knowledge about organ donation?” was significantly lower in the participants from a large family (1.5 ± 0.6) compared with those from a nuclear family (2.3 ± 1.1) (r = -0.261, P < .001).

Mean score of the answers to the question “Do you have sufficient knowledge about organ donation?” was significantly lower in the participants attending Quran courses (1.6 ± 0.8) compared with those attending public education courses (2.8 ± 1.0) (r = -0.562, P < .001). Mean score of the answers to the question “Do you think that our community has sufficient knowledge about organ donation?” was significantly lower in the participants attending Quran courses (1.9 ± 0.8) compared with those attending public education courses (2.2 ± 0.7) (r = -0.229, P = .001). Mean score of the answers to the question “What is the religious drawback of donating organs?” was significantly higher in the participants attending Quran courses (2.5 ± 1.4) compared with those attending public education courses (1.6 ± 1.0) (r = 0.318, P < .001). Mean score of the answers to the question “Are you aware that the organ donation-related procedures are conducted within the law?” was significantly lower in the participants attending Quran courses (1.8 ± 1.0) compared with those attending public education courses (2.6 ± 1.2) (r = -0.319, P < .001) (Table 2).

Mean scores of ATODS increased as mean scores of the answers to the questions “Do you have sufficient knowledge about organ donation?” and “Are you aware that the organ donation-related procedures are conducted within the law?” increased (r = 0.360, P < .001 and r = 0.299, P < .001, respectively). Mean scores of ATODS decreased significantly as mean scores of the answers to the question “What is the religious drawback of donating organs?” increased (r = -0.258, P < .001).

Mean score of the ATODS was 52.7 ± 12.2. Comparisons of the participants with regard to sociodemographic data, family type, and course type are presented in Table 3. Mean score of unmarried, single participants (57.1 ± 10.3) was higher than the scores of married participants (51.7 ± 12.5) and divorced/widowed participants (51.7 ± 11.9) (χ2 = 6.742, P = .034). Mean ATODS scores were 48.5 ± 11.4 for the participants without formal education, 52.2 ± 12.5 for graduates of elementary/intermediate school, 55.2 ± 12.2 for graduates of high school, and 60.0 ± 9.71 for graduates of university, and the ATODS score linearly increased as education increased (χ2 = 21.499, P < .001).

Mean score of ATODS was 50.6 ± 11.5 for the participants with low income, 54.9 ± 12.4 for the participants with moderate income, and 58.1 ± 12.7 for the porticipants with high income, and the ATODS score increased as income increased (χ2 = 10.339, P = .001).
Mean score of the ATODS for the participants from a large family was significantly lower (48.7 ± 12.0) than the score for the participants from a nuclear family (53.5 ± 12.1) (t = -2.185, P = .030). Mean ATODS score for the participants who attended Quran courses was significantly lower (49.3 ± 11.7) than the score for the participants who attended courses at a public education center (56.3 ± 11.7) (t = -4.383, P < .001) (Table 3).

Discussion

Low rate of approval by families for organ donation is an important factor for the low rates of organ donation and transplant from deceased donors. The decisions of housewives may be important for obtaining family approval. Overall, in our study, the housewives who were attending Quran courses and public education courses perceived themselves and the public to have little knowledge of organ donation, did not find organ donation to be inconvenient, were unaware that organ donation procedures are conducted under law in our country, and found promotions and campaigns for organ donation to be insufficient. Higher scores of ATODS reflect positive attitudes toward organ donation. Mean ATODS scores significantly increased as education and income increased, and scores were higher for participants who were single (unmarried, not widowed/divorced), with a nuclear family, and attending public education courses. Mean ATODS scores were also higher in the participants with greater knowledge about organ donation, with awareness of lawful organ donation, and without perception of organ donation as inconvenient.

In a study from Çetin and Harman, about 30% of the high school students stated they had sufficient knowledge about organ donation.²⁰ Of these, 43% stated they did not find organ donation religiously objectionable, and 56% stated they would freely volunteer for organ donation to a family members in need.²⁰ In a study conducted with nursing school students, 75.5% of the students stated they had sufficient knowledge about organ donation, 71.7% stated they did not have religious objections to organ donation, and 64.2% stated they would volunteer for organ donation.²¹ In another study that investigated knowledge and opinions of medical students about organ donation, 89.5% of students stated they had knowledge about organ donation; however, only 39.2% found their knowledge sufficient, and 94.2% stated awareness that organ donation procedures are lawful. The percentage of individuals who believed people of the general public are not sufficiently aware about organ donation was 95.3%. The percentage of individuals who believed organ donation is religiously objectionable was 77.8%, and percentage of individuals who would volunteer for organ donation was 56.1%.²² In a study that investigated knowledge and attitudes toward organ donation in 414 individuals in Nevsehir, knowledge was greater in those who had higher education and who were students/officers and between 20 and 35 years of age (P < .05). However, gender and marital status did not affect knowledge of organ donation. Participants having greater knowledge had higher rates of being willing to donate their organs; however, the association among these variables was not statistically significant (P > .05).²³ In our study, mean scores of the answers to the questions “Do you have sufficient knowledge about organ donation?” and “Do you think that our community has sufficient knowledge about organ donation?” were low compared with test value 3.0 (2.1 ± 1.0 and 2.0 ± 0.7, respectively) (P < .001). The score was also low with regard to the question on awareness of lawful organ donation (2.2 ± 1.2) (P < .001). Knowledge of organ donation was significantly greater among graduates of high school/university compared with the less educated participants (r = 0.610, P < .001). Mean ATODS scores significantly increased as mean scores of knowledge level and awareness of lawful organ donation increased (P < .001).

In addition to insufficient knowledge, religion and beliefs are important factors that affect rates of organ donation. Although religion generally does not proscribe against organ donation, people may interpret religious rules in a manner that affects attitudes toward donation.²⁴ In a study of 730 adults who expressed concern about organ donation, 25% stated that organ donation conflicted with their religious beliefs.²⁵ Similarly, in the community-based study of Yazar and Açikgöz, 22.9% of the participants were not willing to donate organs because of their religious beliefs.²³ In our study, the participants did not have religious objection to organ donation (2.1 ± 1.3) (P < .001). Participants who were single, who had higher education status and income level, and who were attending public education courses had less religious objection to organ donation. Also, higher mean ATODS scores indicative of positive attitudes toward organ donation were associated with less religious objection (r = -0.258, P < .001).

Difficulties impede the fulfilment of worldwide transplant demands. Although Turkey is among the leading countries for organ donation, the rate of transplants from deceased donors is low. It is vital to conduct research and to fund education activities to facilitate improvement in the rates of family approval, which has a major effect on rates of organ donation. We suggest that efforts to improve community knowledge of organ donation and organ donation-related legal procedures in our country and efforts to promote campaigns for organ donation that include women would help facilitate higher rates of organ donation. Data from the present study provide insight on future education activities to improve knowledge and attitudes of housewives for organ donation.

References:

1. Karakoc E, Ayyildiz A, Yelken B. Cases of brain death and organ donation rates in Eskisehir. Transplant Proc. 2019;51(7):2192-2194. doi:10.1016/j.transproceed.2019.01.188
   CrossRef - PubMed
   
2. Haberal M. Transplantation in Turkey. Clin Transpl. 2013:175-180.
   CrossRef - PubMed
   
3. NHSBT Organ Donation and Transplant Activity Report 2015/2016. Accessed November 6, 2018. https://www.odt.nhs.uk/statistics-and-reports/annual-activity-report/
   CrossRef - PubMed
   
4. International Registry in Organ Donation and Transplantation (IRODaT) Newsletter, Final Numbers 2018; March 2019. Accessed November 6, 2019. www.irodat.org
   CrossRef - PubMed
   
5. Tepehan S, Elmas I. [An issue of trust for diagnosis of brain death and its effects on organ donation in Turkey.] J Intensive Care Nurs. 2014;18(1):8-14.
   CrossRef - PubMed
   
6. Durur F, Akbulut Y. Evaluation of policies for organ transplantation in Turkey. BMIJ. 2017;5(3):570-585. doi:10.15295/bmij.v5i3.150
   CrossRef - PubMed
   
7. Topbas E, Bingöl G. [The factors that influence organ transplant from cadaveric donors in Turkey.] J Nephrol Nursi. 2016;11(2):77-88.
   CrossRef - PubMed
   
8. Karakayali H, Haberal M. The history and activities of transplantation in Turkey. Transplant Proc. 2005;37(7):2905-2908. doi:10.1016/j.transproceed.2005.07.025
   CrossRef - PubMed
   
9. Tanriverdi G, Bedir E, Sevig Ü. [The effect of gender on health related attitudes and behaviors.] TAF Prev Med Bull. 2007;6(6):435-440.
   CrossRef - PubMed
   
10. Demircioglu N. Dini farkliliklarin organ bagisina etkisi. Doctoral dissertation; Saglik Bilimleri Enstitüsü.
    CrossRef - PubMed
    
11. Murat TA. [The importance of tissue and organ transplantation in Turkey.] Health Care Acad J. 2016;3(3):106-110. doi:10.5455/sad.13-1477691139
    CrossRef - PubMed
    
12. Yücetin L, Keçecioglu N, Ersoy FF. [Organ donation and transplantation in Turkey at a glance.] Dialysis Transplant Burns. 2003;14(2):115-118.
    CrossRef - PubMed
    
13. Tarhan M, Dalar L, Yildirimoglu H, Sayar A, Altin S. [Relationship between attitudes and social profiles of patients’ relatives about organ donation and transplantation.] Bakirköy Med J. 2013;9(4):152-158.
    CrossRef - PubMed
    
14. Kaya B, Erturk D, Paydas S, Demir E, Balal M, Gocum H. Evaluation of living kidney donor and recipient candidates: the experience of our center. Transplant Proc. 2019;51(7):2205-2209. doi:10.1016/j.transproceed.2019.04.071
    CrossRef - PubMed
    
15. Kahveci E, Bozoklar CA, Topçuoglu MA, eds. [From Brain Death To Organ Transplantation - Basic Principles And Practical Practices.] Ankara: Özyurt Matbaacilik; 2015.
    CrossRef - PubMed
    
16. Altinanahtar A. [Organ procurement and transplantation in the world and Turkey: economic perspectives, problems and proposed solutions.] Socioecon J. 2016;24(28):11-30.
    CrossRef - PubMed
    
17. Moraes EL, Massarollo MC. Family refusal to donate organs and tissue for transplantation. Rev Lat Am Enfermagem. 2008;16(3):458-464. doi:10.1590/s0104-11692008000300020
    CrossRef - PubMed
    
18. Ajzen I. The theory of planned behavior. Organ Behav Hum Decis Process. 1991;50(2):179-211. doi:10.1016/0749-5978(91)90020-T
    CrossRef - PubMed
    
19. Kaça G, Amado S, Kikici I, et al. [Investigation of attitudes towards organ donation within the framework of planned behavior theory.] Turk J Psychol. 2009;24(64):78-94.
    CrossRef - PubMed
    
20. Çetin G, Harman Ö. [High school students’ knowledge and attitudes of organ transplantation and organ donation.] J Res Educ Teach. 2012;1(2):172-177.
    CrossRef - PubMed
    
21. Özer FG, Karamanoglu AY, Beydag KD, et al. [Effect of education on a group of university school for health sciences students’ opinions and knowledge level about organ transplantation and donation.] TAF Prev Med Bull. 2008;7(1):39-46.
    CrossRef - PubMed
    
22. Koçak A, Aktas EÖ, Senol E, Kaya A, Bilgin UE. [Ege University Faculty of Medicine undergraduates’ knowledge level regarding organ donation and transplantation.] Ege J Med. 2010;49(3):153-160.
    CrossRef - PubMed
    
23. Yazar MA, Açikgöz MB. Knowledge levels and attitudes of people living in the city centre of Nevsehir on organ donation and transplantation. Turk J Anaesthesiol Reanim. 2016;44(5):250-257. doi:10.5152/TJAR.2016.87094
    CrossRef - PubMed
    
24. Messina E. Beyond the officially sacred, donor and believer: religion and organ transplantation. Transplant Proc. 2015;47(7):2092-2096. doi:10.1016/j.transproceed.2015.06.031
    CrossRef - PubMed
    
25. Okka B, Demireli O. [Evaluation of people’s perspectives on organ donation in Konya Province: the public attitudes towards organ donation in Konya.] Turkey Clin J Med Ethics. 2008;16:148-158.
    CrossRef - PubMed