Key words : Barriers to organ donation, Deceased donor, Knowledge level

Introduction

Kidney transplantation (KT) is the treatment of choice for patients with end-stage renal disease.¹ Nevertheless, organ shortage remains a demanding problem worldwide and in the Kingdom of Saudi Arabia (KSA).² Deceased organ donation and living organ donation were approved in KSA in 1982.³

The deceased organ donation rate in KSA is low compared with the need for organs for transplant. Despite an increase in the Saudi population from 24.9 million in 2004 to 35.3 million in 2021, the total number of brain dead donors during this period was 1552 (between 70 and 141 donors/year). Deceased donor KT represents about 20% of KTs in KSA during the past 2 decades. In KSA from 2004 to 2021, 11 221 KT procedures were performed, with 9014 (80.3%) from living donors (547-1121 cases/year) and 2207 (19.7%) from deceased donors (54-114 cases/year; average of 84 per year).⁴ Among deceased organ donors in KSA, 96.5% were foreign workers.

The main factors contributing to the paucity of deceased organ donors are the lack of awareness and accurate knowledge in the community, miscon-ceptions, family opinion, and confusion surrounding organ donation due to religious and cultural barriers.^5,6 Medical students (future physicians) and health care professionals with the proper perspective and understanding of organ donation are essential for fostering an environment that positively influences organ donation and procurement rates.^5,7 This study evaluated the knowledge, attitudes, and barriers surrounding organ donation among Southern Saudi Arabia medical students and health care professionals.

Materials and Methods

The study was conducted using quantitative met-hods among consented medical students (n = 200) who were in the third and fourth year of study in the largest medical college in Southern Saudi Arabia and health care professionals (n = 200) at the Armed Forces Hospitals Southern Region, Khamis Mushayte, (the largest tertiary military hospital in Southern Saudi Arabia). The period of study was from December 2022 to April 2023.

Anonymous questionnaires in a Google form were sent to participants via WhatsApp from Meta. Each participant was informed about the objective and informed that participation was anonymous and voluntary. The study was in accordance with the Declaration of Helsinki “Ethical Principles for Medical Research Involving Human Subjects.” The study was approved by the Armed Forces Hospitals Southern Region institutional review board (AFHSRMREC/2023/GENERAL SURGERY).

Data were collected from the structured questi-onnaire. The questionnaire included 33 questions. Two options (“Yes” or “No”) were provided for respondents’ answers to each question. Most statements to assess knowledge among respondents were adopted from previous research.^5,8,9

The questionnaire included the following: 5 questions to understand the sociodemographic profile, 15 questions to understand the knowledge of the respondents toward organ donation, 6 questions to assess attitudes on participant’s willingness on deceased donations, and 7 questions about reasons of donation refusal.

A cumulative knowledge score was developed by counting 1 point per correct answer and 0 points for incorrect answers on knowledge of organ donation. The median score was calculated, and then respon-dents were classified into 2 categories based on their scores. The participants who scored a summed knowledge equal to or higher than the median were classified as having an “above-average knowledge level,” whereas the other participants were identified as having “below-average knowledge level.”⁵

Statistical analyses

Data were entered and analyzed using IBM SPSS Statistics for Windows version 29.0 (IBM Corp). Descriptive statistics were used. We used the chi-square test to compare categorical variables, and P < 0.05 was considered significant.

Results

All sociodemographic data are summarized in Table 1. A questionnaire was completed by 200 of the 220 health care professionals and by 200 out of 205 medical students invited to participate (completion rates of 90.9% and 97.5%, respectively). The concept of organ donation, in general, was understood and accepted by 100% of group A and 97.5% of group B (P = .06). The median knowledge score was 7 in the study sample. Hence, a participant’s knowledge with a score of 7 or higher was identified as “above average.” The cumulative knowledge score was above average in both groups (66.4% and 56.9% of group A and group B, respectively).With regard to knowledge of severe organ shortage, 90% of group A and 60% of group B (P < .001) were aware. The legality of the organ donation process in KSA was understood by 100% of group A and 85% of group B. However, the process of deceased donor registration was known by 62.5% of group A and 45% of group B.

In general, 90% of group A and 75% of group B had awareness of brain death concepts (P < .001) and 67.5% of group A and 70% of group B had knowledge on discontinuation of ventilatory support. In addition, 40% of group A and 15% of group B understood the need for family consent for deceased organ donation (P < .001). Primary sources of information for both groups were the internet and social media. Other knowledge parameters are summarized in Table 2.

Regarding attitude toward deceased organ donation (Table 3), 91% of group A and 52% of group B were willing to donate after death. Furthermore, 53% of group A and 26% of group B would donate organs of their relative after brain death. Although 55.5% of group A and 34% of group B had thought about deceased organ donation, only 22% of group A and 14% of group B were already registered as donors. In both groups, the motives of donation were to save lives in 85% of group A and 83% of group B and to please Allah in 90% of group A and 85% of group B. Saving lives and satisfying God were the main motives in both groups.

In group A (health care professionals), the most common reasons for refusal were lack of knowledge about donation (85.7%), fear of body disfigurement after death (82.9%), and religious belief (64%). In group B (medical students), the main reasons for refusal were familial and social (90.9%), lack of knowledge about donation (86%), and fear of body disfigurement after death (78%). Barriers are summarized in Table 4.

Among the health care professional group (group A), consultants knew more about the donation process and residents had a more positive attitude and motivation for donation. Detailed comparisons are summarized in Table 5.

Discussion

Medical students and health care professionals substantially affect the public attitudes and pro-pensity on organ donation and transplantation; thus, these groups can help eliminate barriers and promote organ donation.^5,10

Awareness of deceased donor organ donation and the brain death principles is essential for progress on deceased donor transplantation. Therefore, a lack of knowledge in health care professionals on brain death can be a main reason for delays in this progress.¹¹ Ríos and colleagues reported a positive influence of perception of the concept of brain death among health care professionals on attitudes toward deceased organ donation.¹¹ Our study revealed that most participants (90% of group A and 75% of group B) knew that patients after brain death could donate organs. About 30% of both groups understand the need for family consent before discontinuation of ventilatory support of brain-dead donors. Our study revealed that the overall knowledge among the study participants was satisfactory. Akgün and colleagues revealed that 75.5% of physicians and 67.2% of nurses had a good understanding of the legislation surrounding deceased organ donation in their country.¹² Moreover, in our study, the awareness level among consultants was better (81.5%) compared with that of the residents (71.4%) and nurses (45%).

People receive information about organ donation through several sources. Figueroa and colleagues reported that newspapers (44.8%) were the most common source of information on deceased organ donation, followed by television (40.5%), continuing medical education (36.8%), advertisements on posters and billboards (30.5%), friends/family (21%), and Bachelor of Medicine/Bachelor of Science and nursing courses (15.5%).13 In our cohort, we found that social media (22% and 32% in groups A and B, respectively) was the most common source of information.

Overall, the attitude of all health care workers on willingness to donate organs has been reported to be favorable. We reported a significant difference between the different categories of health care professionals for willingness to donate organs after brain death, with 57.5% of consultants, 48.6% of nurses, and 29% of residents willing to donate. In our cohort, the most important motivation for donation was pleasing God in 90% and 85% of groups A and B, respectively. Akbulut and colleagues reported that the main motives were saving lives (80.5%), social reasons (66.7%), and the potential need for a future organ transplant for a relative (33.3%).²

There are many indicators of a favorable attitude toward organ donation. Willingness to attend lectures or symposiums is one such indicator. Our study revealed that 85% of group A and 45% of group B were interested in attending a presentation or lecture on deceased donor organ donation. This result was significantly higher than the results of a similar study from Ahlawat and colleagues, which found that approximately 41% of participants desired more information on organ donation.¹⁴

In their study, Saleem and colleagues reported a direct correlation between education level and knowledge of organ donation. About 42.6% of precollege students and 52.2% of college and university students had a higher level of knowledge on organ donation.¹⁵ Multiple studies have also demonstrated that nurses who donate their organs are more knowledgeable about the irreversibility of brain death, the relevant legal regulations for organ donation, and the compatibility of organ donation with religious beliefs. Other previous studies^16-18 indicated that education on organ and tissue donation positively influences donation and transplant rates. Similar to the findings of Adithyan and colleagues,⁵ unfortunately, we found a discrepancy between organ donation knowledge and propensity to donate among medical students and health care professionals.

Several barriers to deceased organ donation include inaccurate knowledge of donation criteria, unfamiliarity with the procedure, and difficulty in obtaining consent from family members, resulting in decreased donation rates.⁹ Understanding the reasons for organ donation refusal is the most significant starting point for planning and implementing strategies to increase the donation rate.^19,20 Cultural and religious beliefs are 2 of the most significant obstacles to organ donation. Chen and colleagues reported specific local cultural reasons to refuse organ donation in the Far East, such as the fear of not being forgiven by ancestors and tribal elders who may not accept the concept of organ donation, the need for intact bodies during rituals and earth burials, bad-shaped bodies resulting from accidental deaths, and the fear of possession by the donor’s spirit.²¹ In contrast, according to a European study from Kobus and colleagues,²² 83% of participants consented to organ donation after death.

Several local studies have verified the low religious barriers in the KSA. Alsharidah and colleagues discovered that only 5% of the Saudi population viewed their religious beliefs as an impediment and refusal reason for organ donation. Similarly, 68.6% of participants in a study by Mohamed and colleagues viewed organ donation as permissible in Islam, compared with 26.2% who viewed it as forbidden.^23,24 Conversely, in our study, religious beliefs were the reason why 64.3% of group A and 27.3% of group B refused organ donation. A Taiwanese study by Weng and colleagues found that views from religious leaders on organ donation did not influence 48.4% of participants. In contrast, it only partially influenced 36.7% of participants.²⁵

In addition to the previously mentioned barriers, the fear of disfigurement after death is one of the primary obstacles to organ donation. The highest percentage of participants (13%), according to Tumin and colleagues26 believed their corpses should be preserved after death. This is consistent with the findings of our study; in 82.9% and 78% of groups A and B, respectively, concern about disfigurement was the primary reason for refusal.

Several strategies have been proposed to increase the awareness of organ donation among medical students by incorporating more organ donation lessons into the medical curriculum.^27,28 In addition, numerous studies^2,5,29-33 found that a lecture on organ donation significantly altered the attitudes of medical students and health care professionals toward organ donation. Locally, Alsharidah and colleagues repor-ted the need for regular programs, lectures, and campaigns to enhance the knowledge of Saudi health workers on organ donation. Furthermore, it is essential to interpret the definition of a healthy organ and the screening stages before accepting a donation, as some individuals believe they are not fit enough to donate organs.²³

Limitations
Our study had a limitation of being a single-center study. A multicenter study is needed to authenticate the findings further.

Conclusions

Among health care professionals who responded to a questionnaire, consultants knew more about the donation process but residents had a more positive attitude and motivation for donation. Awareness among health care professionals and medical students is essential to increasing the organ donor pool. Improving awareness could be achieved by giving health care professionals and medical students proper knowledge and orientation and increasing the importance of organ donation in the medical curricu-lum through campaigns and continuous medical education. This study reiterates the need for education interventions that should stress brain death irrever-sibility, national legal regulations for organ donation, the compatibility of organ donation with religious values, and the explanation of inaccurate beliefs.

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