Key words : Attitude, Iraq, Knowledge, Transplantation

Introduction

Organ donation and transplant is a success story in the history of medicine and humanity. Greater under­standing and improvements in immunobiology and surgical techniques are saving thousands of lives each year through organ transplant.^1,2

Organ donation is the cornerstone in the process of transplant. There is a worldwide shortage of donor organs compared with the need for transplant.³ Asia, the Middle East, and the Arab region are lagging behind much of the rest of the world with regard to organ donation.⁴ Social, religious, and economic factors may contribute to this low rate of transplant; also, inefficiencies in health systems may be a factor.

In Iraq, as in other Arab countries, a living donor program is the only source for organ donation. There are about 6000 Iraqi patients on hemodialysis, and there are 4500 renal transplant recipients, with a rate of 16.6 donations per million population per year.⁵ According to recently published data, the overall 3-year graft and patient survival rates were 91% and 90%, respectively, and 5-year graft and patient survival rates were 87.1% and 88%, respectively.⁶ With an ever-increasing aged population and advances in techno­logy and immunosuppression, we expect there will be an increased need for organ donation and transplant.⁷

Organ donation has 2 potential sources, ie, living donors and deceased donors. A supply of deceased donor organs is especially crucial for heart, lung, and liver recipients because these patients cannot be maintained long-term on mechanical devices, unlike patients with end-stage renal disease, who can be maintained on dialysis for long periods of their lives.^2,8

In all countries, the concept of organ donation and the associated rate of transplant are largely dependent on legislation and the attitude of the general public and health care professionals, as well as levels of organization and coordination of existing transplant units.⁹

Socioeconomic status, religion, gender, age, and education are important factors that affect the decision to volunteer for organ donation. Among these factors, beliefs against donation and transplant are great obstacles. It may be difficult to change such attitudes, but it is possible to provide accurate information about organ donation. Improved knowledge via proper targeting of the population and increased awareness may improve attitudes among the public at large toward donation and transplant.¹⁰

Health care professionals at different levels of health services are the most decisive link in the organ procurement process because they are the first people to set up a relationship with the potential living donors or families of deceased donors, and, as such, these health care workers have the opportunity to trigger the response to volunteer for organ donation. Education of health care professionals with regard to these obstacles has been shown to increase donation requests and procurement.^10,11

The altruistic act of donation provides a precious resource for organ transplant. Thus, public awareness of organ donation will fundamentally affect the success of transplant programs. Introduction of programs that succeed to inform people of various educational backgrounds may improve the rate of transplant.¹²

In this study, we investigated the attitudes toward organ donation and transplant in the Iraqi popu­lation, including their intention to donate after death.

Materials and Methods

This cross-sectional study included 400 adults (≥18 years old) Iraqis in the capital city of Baghdad.

The participants were categorized into 2 groups according to stratified quota sampling. The first group included 200 medically educated personnel (ME), and the second group consisted of 200 adults from educational backgrounds without a medical component (NME). The ME group included 50 intensive care unit (ICU) nurses, 50 staff nurses, 50 medical students (final year), and 50 senior house officers.

Inclusion criteria
We used the following criteria to determine inclusion for all candidates. (1) The age requirement was ≥ 18 years old. (2) The minimum acceptable level of education for the NME group was primary school, and we excluded those below it. The primary school study in Iraq ends by the age of 12 years. (3) Nurses were defined as graduates of a nursing college. (4) Nurses working in nephrology wards, dialysis units, or transplant centers were excluded.

Setting
The study was conducted from December 1, 2018, to March 1, 2019. The ME group was tested at The Medical City Teaching Hospital. The NME group was tested at 2 primary health centers in Baghdad.

Ethical approval
The study was conducted according to the Iraqi research ethics code, and verbal consent was obtained from all participants before participation in the study. The study was approved by the ethical committee and the nephrology council of the Arab Board for Health Specializations in Iraq.

Study design
The study was based on a structured, interviewer-administered questionnaire consisting of the following 2 aspects: (1) knowledge of organ donation and transplant; (2) attitudes and barriers toward organ donation and transplant. The questionnaire included 14 questions for the NME group, and there was an additional question for the ME group. The additional question asked whether or not their medical education curricula included adequate data about organ donation and transplant. The research team used quota sampling to distribute the questionnaires to the corresponding study groups.

The responses were categorized as either (1) “yes,” (2) “no,” or (3) “I don’t know.” One point was assigned for each favorable response, and then all scores were added together and reweighted out of 10 points for the questions about knowledge and attitude. A favorable response indicated positive, advantageous, or approval for knowledge and attitude.

This self-prepared questionnaire was developed after a review of the existing literature. A linguistic professional reviewed the wording and content and translated the questionnaire to Arabic so that the content was understandable to the study participants. Other questions were added but not included in the score; these ancillary questions requested the recipient’s gender and the relation to the donor.

Before distribution, this questionnaire was pre­tested on 15 people to discover any ambiguity in the questions, and we solicited comments from these 15 pretest participants. Two members of the acade­mic staff reviewed the questionnaire, and their suggestions were incorporated into the final questionnaire to stren­gthen the presentation of the questionnaire (Table 1).

Statistical analyses
All statistical analyses were conducted with SPSS software (version 24.0, released 2016; IBM SPSS Statistics for Windows). The descriptive statistics of the studied sample were presented as mean, standard deviations, frequency, and percentage. For analysis of the difference between mean values in the ME group, 1-way analysis of variance was conducted. We used the post hoc test (Bonferroni test) to discover differences among specific groups’ mean values. Analysis of quantitative data between the 2 groups was conducted by t test. P < 0.05 was considered statistically significant.

Results

The study included 400 Iraqi adults (235 women [58.75%] and 165 men [41.25%]) with a mean age of 33.73 ± 10.38 years. The participants were categorized into 2 groups; the first group included 200 ME participants, whereas the second group included 200 NME Iraqi adults with a minimum education level of primary school (Table 2).

Group 1 of ME personnel included the following 4 levels of medical education: 50 staff nurses, 50 ICU nurses, 50 medical students of 6th grade, and 50 senior house officers. The participants of the NME group were older than those in the ME group (39.77 ± 10.33 vs 27.7 ± 6.03 years, respectively). The independent t test showed statistically significant differences in both knowledge and attitude scores between the people with or without a medical education (P < .001).

Among the ME participants, we used the Bonferroni post hoc test to discover which specific groups’ mean values (compared with each other) were different. Here, the senior house officers subgroup and the medical students subgroup showed a statistically significant difference (P < .05) versus the other subgroups (staff nurses and ICU nurses).

Only 94 participants (47%) of the ME group indicated that they received adequate information about organ donation and transplant in their medical education curricula. Survey results are shown in Figures 1, 2, and 3.

In this study, 52.5% of the ME group and 40.5% of the NME group accepted the concept of incenting living donors or families of deceased donors (Figure 4).

Discussion

Continuous provision of organs through the process of organ donation is crucial for a successful transplant program. There are widely recognized disparities in the rates of organ donation and transplant, which may be the result of limited knowledge and variable attitudes toward organ donation, which in turn may lead to greater disparity in access to transplants.¹³ In this study, it is apparent that Iraqi public attitudes toward organ donation and transplant may be improved with greater access to knowledge of these concepts.

The importance of well-educated health care professionals in the field of organ donation and transplant is paramount. The main source of informa­tion about organ donation was from medical staff (physicians and nurses), and this was true for the NME group as well as the ME group. Thus, the imple­mentation of transplant advocacy missions in Iraqi society via well-educated health care profes­sionals will facilitate enhanced rapport with the community.¹⁴ Nurses are the largest group of health care professionals, and yet they are not uniformly educated with regard to transplant and organ donation. The future success of transplant programs hinges on education of this group (nurses).¹⁵ The adoption of registered transplant nurses in the Iraq health system may positively affect the rate of organ donation.

These concepts may be promoted through well-structured educational curricula at all levels of medical education. In this study, only 39% of the ME group thought that their education provided adequate information regarding transplant and donation. Lessons on donation and transplant should be incorporated in the curricula of early education programs. Eighty percent of the study participants accepted the idea to apply such lessons in Iraqi schools. This would contribute to health literacy on this topic and provide children and their families with appropriate information with which to make informed decisions about donation.¹⁶

Saleem and colleagues, in Pakistan, revealed a direct correlation between education level and the knowledge of organ donation. This was consistent with results from a study conducted at a large academic center in Germany.^12,17

In Iraq, the legislation and regulation of brain-death donation have existed since the 1980s.¹⁸ Lack of knowledge about such issues may be the result of inadequate education and awareness of the policy makers, which may thus be reflected in the poor implementation at lower levels of the health system and the community. These data are not different from a study that showed a lack of awareness of the presence of the Saudi Centre of Organ Transplantation among the adult population in Riyadh city.¹⁹

Health care professionals at any level of health services are essential to the success of organ donation programs. A positive attitude among people will vary according to personal experiences, which may result in differences in donation legislation in different legal jurisdictions.²⁰

In the NME group, 30% of participants were willing to donate after death compared with 69% of the ME group. This is not a small number, with respect to Iraqi cultural background. Iraq is similar to other Arab countries in that there is confusion among the population with regard to religious conformity and organ donation and transplant; this has a negative effect on rates of organ donation, particularly from deceased donors. A partnership between health departments and religious leaders may promote awareness and increase the willingness for deceased donation.21 Muslims may not be given sufficient information regarding religious legitimacy of organ donation, and improvement may be achieved through liaison with faith leaders and through information campaigns at mosques and religious sermons.²² Spreading the concept of altruism, which is a concept well-rooted in the Arab and Islamic culture, could be a crucial factor in the success of such activities.

Surprisingly, we found that the main barriers against donation (living and deceased) were not religious beliefs or social judgments, as these factors were measured at only 7% for both groups. Rather, the main barriers against donation were fear of future health risks and fear of body disfigurement. Islamic juristic academies and fatwa (juristic opinion) bodies in the Muslim world, including the Islamic Organization for Medical Sciences based in Kuwait, are in agreement with regard to the permissibility and lawfulness of donating organs to patients whose survival or cure vitally depends on transplant.^23,24

For living donation, the barriers are nearly the same worldwide. Fear of surgical and health risks are important causes for the low rates of donation, as in our study. There is also a fear of financial loss, and a provision of a financial stability factor after donation could be a solution to mitigate these fears. This may include reimbursement for out-of-pocket expenses, paid leave, wait list priority, health insurance, and donor acknowledgment.^23,25

The results of this study show that the knowledge and attitude of Iraqi people toward the concepts of organ donation and transplant were comparable to those in neighbor countries known for successful donor programs (living and deceased), namely Saudi Arabia, Iran, and Turkey.^19,26,27 To facilitate successful acceptance of donation and transplant, the concept of altruism should be emphasized, and the concept of death should be clarified within the context of organ donation; also, support should be solicited from faith leaders, the media, and government. We may benefit from the expertise and knowledge of such leading countries to start our deceased donor program.²⁸

Trust in the medical system may affect patient preferences and access to renal transplant, especially in the setting of deceased donation. Only 57% of the ME group trusted the health system. The application of proper ICU settings and accurate diagnosis of brain death may improve the rate of donation. Efforts to enhance public trust should encompass beliefs about honesty, motives, and equity of the health care system.²⁹

Gender is an intrinsic, nonimmunologic factor and plays a pivotal role in the field of transplant. Previous Iraqi data revealed that donors were women in about two-thirds of the organ donations.^7,30 In the developing countries, there is often gender segregation, and women are consis­tently overrep­resented among living donors.31 In this study, about 90% of participants accepted the idea of either type of donation (living or deceased) with no difference according to the participant’s gender. This lack of gender difference can be explained in the educated sample in the capital city, but women may experience a higher degree of exploitation in peripheral areas, tribal communities, and poor socioeconomic profiles.³² Nondirected living kidney donation provides unique opportunities to reduce factors such as emotional distress, empathy, and impulsiveness.³³

In this study, 52.5% of the ME group and 40.5% of the NME group accepted the concept of incenting living donors or families of deceased donors. It has been argued that incentivizing donors will promote altruism in organ donation. Now may be the time to test incentives in our health system. In the absence of a deceased donor program, this may persuade more people to volunteer as living donors and help alleviate the growing gap between donors and the wait list. Also, this may lead to fewer channels for organ trafficking. Organ procurement and delivery require a regulated model to prevent illegal brokering of organs. The implementation of a deceased donor program would substantially inhibit these illegal actions.^34-36

About 60% of the study population preferred that, in the event of a potential brain-dead candidate donor, a multidisciplinary team should approach the family of a brain-dead donor at the ICU, to initiate a conversation regarding organ donation. This may not be the standard approach worldwide. Usually, an intensivist or an organ donation coordinator is designated to approach the family of a deceased donor; however, this is not the case from the perspective of the Iraqi people because of limited knowledge and lack of a proper training program for coordinators even in living donor programs. Education of the public regarding a positive attitude toward organ donation and education of health professionals are key factors in the success of organ donation programs. The approach to facilitating this success should include meticulous preparation, organized direction, and fulfillment of the required conditions and close support for the family.³⁷

This study is limited by a small sample size and possible inhomogeneity of the study participants. Another limiting factor is that this study was conducted in the urban districts of the capital city of Baghdad and did not recruit people from suburbs or rural areas, and so the perspectives of people in these outlying areas remain unknown.

In conclusion, Iraqi people are moderately infor­med about organ donation and transplant. Among Iraqis, educated people have a more receptive attitude toward organ donation and transplant than do less-educated people. Religion and social beliefs were not barriers to organ donation in the study sample. Adoption of educational programs at different levels of education should be mandatory. Regulated gover­nmental application of an incentives program may be a useful strategy for the present. Implementation of deceased donor programs should become a high priority. A larger study including other Iraqi governorates (urban and rural areas) and people from different cultural and educational backgrounds will inform further actions and policies of organ donation and transplant in Iraq.

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