INTRODUCTION:
Organ
donation is the gift of one’s body parts after death, or from a living donor
for the purpose of transplantation. Transplantation is an operation which
involves the replacement of diseased and defective organs and tissues with
healthy ones from donors. This treatment helps save lives of people. Organ and
tissue donation is considered as the ultimate humanitarian act of service for
mankind. The commonly transplanted organs are kidney, heart, liver, lungs and
pancreas while the Transplantable tissues are eyes, bone, skin, and heart
valves. Thus, a single donor can save the lives of a number of people. The
practice of organ transplantation conforms to the rule outlined in Organ
Transplantation Etiquette 1991 was produced by the WHO. [1] Kidney
transplantation started in Malaysia in December 1975 while first heart transplant
surgery was successfully performed in December 1997. [2]
There
are three methods of obtaining consent for donation worldwide, “opting in”,
“opting out” and “required request.” “Opting in”: If a patient under
consideration carries a signed donor card or has otherwise recorded his wishes
to donate, there is usually no legal requirement to consult to relatives. If
the patient has not signed a donor card, it is necessary to approach the next
of kin in order to establish that during life the donor had expressed no
objection to organ donation. “Opting out”: An individual can register his
objection to organ donation during his lifetime. If the following death, no
objection is found, donation normally takes place without reference to the next
of kin. “Required request”: This system operates within a legal framework. The
physician in charge of the patients’ care is required to ensure that the
subject of organ donation is discussed with the next of kin before the support
systems are withdrawn. [2]
The
practice of organ transplantation in Malaysia is carried out based on “opting
in” system. The matter is highlighted in Human Tissue Act 1974; section 2(1)
which is: “If any person, either in writing at any time or orally in the
presence of two or more witnesses during his last illness, has expressed a
request that his body or any specific part of his body be used after his death
for therapeutic purposes, or for purposes of medical education or research, the
person lawfully in possession his body after his death away, unless he has
reason to believe that the request was subsequently withdrawn, authorize the
removal of the body of any part or, as the case may be, the specific part, for
use in accordance with the request.” [3-4]
Organ
transplantation saves thousands of lives worldwide. According to WHO, kidney
transplants are carried out in 91 countries. Around 66,000 kidney donations,
21,000 liver donations, and 6000 heart donations were transplanted globally in
2005 .[5] Organs for donation are procured from both livings donors
as well as cadavers. There is a universal shortage of cadaver organ donors,
which deeply affects organ transplantation program. [6] In the
United States in 2006 more than 6,000 patients on the waiting list-- one person
every 90 minutes—died while awaiting transplantation. [7] 400 people
die every year as they wait for a suitable transplant in the UK. [8] The
demand for an organ transplant in Asia is enormous. One study reported that
China’s waiting list for organ transplants holding 1.5 million people. [7]
Socio-cultural beliefs and customs in Asian countries make more
problematic to obtain organs for transplantation. [5, 9] Even with
so much scientific development through the world Asian countries still
inexplicably lower than Western countries in organ donations. [9] Donor
eligibility and compensation are the most crucial variables in defining living
organ transplantation policies. [7, 10-13] In Malaysia, a living-related donors
are defined as parents, siblings, or close relatives who are genetically
related to the recipients, or spouse and a very close friends who are
“emotionally related” to the recipients. [14] Living unrelated
donors are also legal in Malaysia. [15]
In
Malaysia, from the year 1997 until 1st August 2010, there are 300
organ donation cases recorded. [15] Out of the 300 cases, 20 cases
include a donation of multiple organs and tissues. For kidney transplant cases,
both from living donors and cadaverous, 1374 successful cases have been
recorded until July 2010. More than 10,000 patients are currently waiting for a
kidney transplant. [16] Whereas for other patients, 7 are still
waiting for the heart transplant, and 4 patients for the lung transplant. [16]
In
Malaysia, there is a huge gap between the number of transplants that are being
carried out and demand. [17] Awareness regarding organ donation lacks
among Malaysians. [18] The perception toward organ donation includes
many factors; mainly education, religion, and culture. [19-20] There
are ethical issues related to living organ donation as live donors suffer from
deteriorating physical health after donating organs and so organs taken from
people after their death would be more ethical. [21-23] Important
misconceptions and fears are: fear of death, the belief that the removal of organ
violates the sanctity of deceased, concern about being cut up after death,
desire to be buried whole, wrong concept of brain death, and the idea of
donation being against religious conviction. [9, 24] Many religious
experts such as Dr Abu Bakar Abdul Majeed (Senior Fellow Malaysian Institute of
Islamic Understanding), the late Venerable Dr K Sri Dhammananda Nayake Maha
Thera (Chief Buddhist High Priest of Malaysia and Singapore) and Mr R
Letchumanan (Propagation Officer of Malaysian Hindu Sangam) have emerged to
clear the air about organ donation. They have also stressed that organ donation
is a noble act and is encouraged by all faiths. [25]
Malaysia
is unique because of its diversity of races made up mainly of three large
ethnic groups; Malays, Chinese, and Indians. The current distribution of the
ethnic groups is as follows; Malays 65%, Chinese 26% and Indians 8%. [26-28]
Despite their vast differences in their cultural and religious beliefs
between three ethnic group in Malaysia but communities successfully maintained
harmony over the last few decades. In some cases, people of the same race tend
to practice the same religion. All Malays are Muslims whereas the main
religions for the Chinese and Indians are Buddhism and Hinduism respectively,
although other religions such as Christianity is also popular among the
non-Malay races. The fact that Malaysia has a large population of three very
different races therefore provides an interesting opportunity to examine
differences in attitude and perception towards cadaveric organ donation in
these three racial groups and its implications in terms of organ
transplantation. [19]
In
Malaysia, the demand for organs significantly surpasses the number of donors.
Therefore, many medical institutes face difficulties in getting organ donors. [17]
As organ donation is crucial to helping save lives, it is important to
determine the perception of RCMP students which includes attitude, knowledge
and practice regarding organ donation. RCMP students are future health care providers
for the community. They are from different educational backgrounds with a
scientific base and have an inherent to serve mankind. Well-informed medical
students, pharmacist, and radiologist are expected to influence organ donation
rates. Besides that, it is also important to find out why organ donation is not
popular and how to increase its popularity in the country. The objective of
this study is to find out the level of knowledge, attitude, and commitment to
the UniKL-RCMP students towards organ donation.
MATERIALS AND METHODS:
This is a prospective and
cross-sectional descriptive study. MBBS students of Phase 1A, 1B and 2, and
Pharmacy and Radiography students of Semester 1, 2, 3 and 4 will be included in
this study of UniKL-RCMP. The Phase 3A and 3B MBBS and Semester 5 and 6
Pharmacy and Radiography students and the students who decline to take part in
the study will be excluded. A sample size of 341 was calculated with a 99%
confidence interval assuming a prevalence of 50% for knowledge, attitude and
commitment towards organ donation. Stratified random sampling will be used to
draw the sample for this survey. All consenting individuals will be given a
questionnaire. University Kuala Lumpur-Royal College of Medicine Perak, Ipoh
(Main campus). Data was collected September 2012 to October 2012. A
questionnaire was prepared to cover the socio-demographic data, knowledge,
attitude and commitment of the respondents towards the organ. It will be
pretested before the study. After a short briefing about the purpose of the
study, all the Medical students of Phase 1A, 1B and Phase 2, and the semester
1, 2, 3 and 4 of Diploma in Pharmacy and Radiography students will be passed a
questionnaire with a consent form to take part in the study. The students will
then be requested to return the questionnaire and the consent form on the day
itself. Data collected from the completed questionnaires will then be analyzed
using the Statistical Package for Social Science (SPSS) 20. The researchers
will then establish and prepare a report on knowledge, attitude, and commitment
to the UniKL-RCMP students towards organ donation.
RESULTS:
A total of 380 questionnaires were
distributed, but only 341 were completed and returned to us giving a response
rate of 90%. Details of socio-demographic characteristics of the study
population are described In Table 1.
|
Table
1: Socio-Demographic Characteristics of Study Population
|
|
Socio-Demographic
Variables
|
Frequency
(n=341)
|
%
|
|
Age
group
|
|
|
|
<20
|
157
|
46.1
|
|
20-24
|
174
|
51.0
|
|
>24
|
10
|
2.9
|
|
Gender
|
|
|
|
Male
|
111
|
32.6
|
|
Female
|
230
|
67.4
|
|
Ethnicity
|
|
|
|
Chinese
|
21
|
6.2
|
|
Indian
|
37
|
10.9
|
|
Malay
|
266
|
78.0
|
|
Others
|
17
|
5.0
|
|
Course
of Study
|
|
|
|
MBBS
|
155
|
45.5
|
|
Diploma
of Pharmacy
|
116
|
34.0
|
|
Diploma
of Radiography
|
70
|
20.5
|
|
Religion
|
|
|
|
Buddhism
|
14
|
4.1
|
|
Christianity
|
22
|
6.5
|
|
Hinduism
|
29
|
8.5
|
|
Islam
|
266
|
78.0
|
|
Others
|
10
|
2.9
|
|
Annual
Household Income
|
|
|
|
<RM50,000
|
276
|
80.9
|
|
RM50,000-RM100,000
|
47
|
13.8
|
|
>RM100,000
|
18
|
5.3
|
|
Table 2: The Score on
Knowledge, Attitude and Commitment on Organ Donation among RCMP students (n=341)
|
|
|
Frequency
|
%
|
|
Knowledge Score
|
|
|
|
Poor
|
0
|
0.0
|
|
Average
|
91
|
26.7
|
|
Good
|
250
|
73.3
|
|
Attitude Score
|
|
|
|
Poor
|
2
|
0.6
|
|
Average
|
140
|
41.1
|
|
Good
|
199
|
58.4
|
|
Commitment Score
|
|
|
|
Poor
|
138
|
40.5
|
|
Average
|
187
|
54.8
|
|
Good
|
16
|
4.7
|
UniKL-RCMP
students, 73% of the respondents have good knowledge, 27% with average
knowledge; 58% of them have a good attitude, 41% with an average attitude, and
0.6% with poor attitude; 55% of them have average commitment, 41% and 5% with
poor and good commitment regarding organ donation respectively. The scores were
calculated based on total scores achieved in each category. The maximum score
minus the minimum score was divided into three grades (poor, average, and good)
to categorize the respondents’ total scores (Table 2 and Figure 1). The leading source of information of current study
respondents on organ donation were television or radio. Only a minority of
respondents got information from medical professionals (Table 3 and Figure 1). Among all socio-demographic factors, the statistically significant (p=0.007)
association was observed in the course of study (Table 4). Similarly, only the course
of study had statistically significant (p=0.014) differences in good attitude
towards organ donation (Table 5). Regarding good commitment along with a course
of study (p=0.047); religion (p=0.014) and also ethnicity (p=0.002) show a
statistically significant difference (Table 6).
Although the
course of study shows statistically significant differences associated with good knowledge
and attitude, but, display no association with good commitment. Good knowledge
level regarding organ the donation was found to be statistically (p=0.002)
significantly associated with their attitude, but a good level of knowledge
plays no role regarding commitment (p=0.731). Similarly, good attitude towards
organ donation does not ensure commitment (p=0.142)
DISCUSSION AND CONCLUSIONS:
There have been a number of surveys about
the perception of people towards organ donation. [11, 18] The current study compared the knowledge,
attitudes and commitments towards organ donation among RCMP students, Ipoh,
Malaysia. Our analysis revealed MBBS students are more knowledgeable and have a
better attitude about organ donation compared to others. This study clearly
demonstrates that there are ethnic and religious differences in commitment towards
organ donation. Indians were more willing to donate their organs after death
compared to other ethnic group. Religious beliefs are a major factor deterring
many people from expressing a motivation to donate.
Statistically, our study showed that most
socio-demographic factors were independently associated with good knowledge and
attitude towards organ donation except for the course of study of respondents.
As for the commitment level of respondents, most socio-demographic factors
appear to be independently associated with it except for the ethnicity and
religion of respondents. Our study showed a slightly higher prevalence of good
knowledge (73%) on organ donation when compared to 60% reported in an earlier
study in Pakistan. [11] This is because our study population
consisted of medical and health care students from a medical college in Ipoh
whereas the previous survey was done on a non-medical population encountered in
the marketplaces of Karachi. Besides that, different variables were used to
assess the depth of knowledge of the students towards organ donation.
86% of the current survey respondents
understood that the term ‘Organ Donation’ means the removal of the tissues of
the human body for the purpose of transplantation to another person. The Majority
(77%) of the respondents were aware that organs can be taken from living or
deceased donors. This is significantly different from the previous study where
a minority of the respondents knew that organs for donation could come from
both living persons and cadavers. [11] 77% of respondents know which
human organs can be donated, according to our National Organ Donation Program
in Malaysia. 67% of our respondents know that a person with brain death cannot
recover and lead a normal life. This is significantly higher than a previous
study on the opinion of secondary school students on organ donation which
reported 58% which is unsure of the term brain death. [29] The
reason being the lack of exposure of the secondary school students to this
issue. This indirectly brings fear in
them and creates an obstacle for them to donate organs. 72% of them agreed that
organ donation is taught and encouraged in Medical and Health Sciences. Another
research report suggested that only II% of students received training on organ
donation before attending medical school and 22% received training during the
attendance at medical school.[30] Therefore, educated individuals
are more likely to be organ donors themselves. A significant number of the
subjects (89%) agreed that a life can be saved through organ transplantation.
The current study found that 64% of the
respondents agreed that organ donation is not prohibited in their religion. In
fact, all major religions have come out in open support of organ donation. A
study stated that ‘better to use human organs to save lives rather than waste
them’. [31] Religion is one vehicle that can be used to encourage
the society in the direction of organ donation. [11, 32] 69% of the
respondents realize the existence of the National Organ Donation Program in
Malaysia. However, only 53% of the respondents know what to do if they decide
to donate any of their organs. A number studies reported that students suffer
from a lack information on organ donation. [33-34] Adequate
information input to future health care professionals would help improve the
dedicated attitude towards organ transplant. [35-38] It is to note
that only 48% of the study respondents had heard about organ donation through
medical professionals. The majority of them got information regarding organ
donation from the mass media. Other studies also found publicity campaigns and
the media to be the major sources of information strengthens attitude and
commitment towards organ donation. [39-40] Publicity plays an
important role in order for the community to realize and understand the
procedure to be an organ donor. Another study reported that educational
programs related to organ donation could result in increased rates of donors
and reduction in waiting lists for organ transplants. [41] Thus, the
medical and other health professionals curriculum should promote organ donation
issues to create more humanistic doctors and related healthcare professionals
in promoting organ donation.[35-38]
The attitudes towards organ donation, 97%
of the respondents appeared to be in favor of organ donation and agreed that
everyone should be educated regarding the benefit of organ donation. This is
significantly higher when compared to data from a study done in Pakistan, where
only 57% of respondents were in favor of organ donation. [11] 74%
agreed that selling or buying organs should not be encouraged. In India, “The
Transplantation of Human Organs Act” of 1994 was enacted to regulate organ
procurement and transplantation and to prohibit the sale of organs. [6] In
Malaysia, the “Human Tissues Act”, enacted in 1974, does not ban the purchase
of organs and that donations are legally permissible under a valid consent from
the donor. [7, 14] The Ministry of Health has been trying to make
amendments to the Act to stop commercial transactions and advertisements of
human organs. [1, 7] In certain countries, organ selling and buying
is widely practiced illegally due to low household incomes and poverty. [5]
In Pakistan, 93% of donors sold a kidney to repay a debt and out of
those, 85% reported no economic improvement in their lives as they are still in
debt. [11, 42] Our study participant’s view was similar to mentioned
studies. [5-7, 14]
The present study found that 62% were
willing to donate their organs to any individual, and 34% of the respondents
mentioned that they would like to donate their organs only to their relatives.
In contrast with a study done in China, 50% of the respondents were willing to
be living organ donors in which 62% preferred donating organs to their close
relatives. [20, 43] Research report indicated that more than 91%
students showed a positive attitude towards organ donation. [44] In
another study carried out 91% would donate a kidney to their relatives and only
38% are willing to donate their organs to unrelated patients. [45] 69%
of the current study respondents were willing to encourage their relatives and
friends for organ donation. As future healthcare providers, they are more prone
to encourage organ donation as it is taught and encouraged in Medical and
Health Sciences. Giving blood is considered to indicate a self-sacrificing view
of life and predisposes to organ donation [46] and therefore, serves
as an appropriate measure of the level of commitment towards organ donation. [47-52]
It is reported that 82% of the individuals have a favorable attitude
towards blood donation. [46] However, in the current study 24% were
regular blood donors. Muslim countries like Malaysia and Indonesia, kidney
donation has to be by consent. [51] The present study found that
only 5.9% of the respondents have already pledged their kidney for
donation.
42% of the study participants would
consider donating their transplantable organs after their death. However, 39% were unsure and 20% would not
consider donating their organs after their death. In another study, only 27%
were opposed to organ donation or undecided [46] possible reasons as
mentioned in different reports for not wanting to donate their organs may be
due to social and cultural issues. [21, 52] As Asians are
superstitious and they believe that removing an organ after death violates the
sanctity of the deceased. [53-55] Moreover there is general thought
among the donor of a kidney that doctors will be more concern about the
transplant patient not to the donors thus they will not survive due to
negligence after donation. [9] These may be the reasons; therefore, the
majority of our respondents (64%) would not consider donating their body after
their death for scientific research and learning in medical school. As compared
to a study done in Hong Kong, 18.8% were reluctant to donate organs after death
because of the fear that organs might be used for medical research. [19]
In conclusion, the overall findings of our
study showed an inconsistency in the knowledge, attitude and commitment of
students towards organ donation as they possess good knowledge and attitude
towards organ donation, but display poor commitment. Measures should be taken
to educate people with information, such as the benefits and possible risks
associated with organ donation so that people can make informed choices in the
future. Televisions, newspapers and healthcare providers have the capability in
inspiring people to improve their attitudes and commitment towards organ donation.
Therefore, the communication gap between the public and health care providers
should be bridged. This can be done by organizing appropriate education
programs directed to both the medical professions and to the general public.
The younger generation should be actively involved in organ donation campaigns.
Our study revealed that students were well aware of organ donation with a
considerable number of them willing to donate their organs. The perceived
reasons for not wanting to donate organs need to be considered while creating
awareness about organ donation in the community. The study helps to identify
potential areas for improvement to overcome the shortage of organs required for
organ donations.
LIMITATIONS:
There are several limitations to the study.
The questionnaires were not accurate measures of their knowledge, attitude and
commitment because the questionnaires only covered certain aspects. Besides
that, by computation of knowledge score based on Likert scale is somewhat
subjective. We feel that the scores only provide a fairly reasonable estimate
of the depth of knowledge, attitudes and commitments of individuals. Besides
that, the large sample size made it difficult for the collection of data. Not
all questionnaires were returned to us. Furthermore, the reasons causing the
lack of participation in organ donation were not identified in this study.
Limited funds were available for the survey because of the lack of sponsors.
ACKNOWLEDGEMENT:
Our deepest gratitude to all students
participated in the study. We are also
much grateful to the Dean of the faculty of Medicine, Universiti of Kuala
Lumpur, Malaysia. Authors do not possess
any conflict of interest.
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