Objectives: Although there have been some case studies that measure the medical students’ know-ledge and attitude about organ donation, there is no such global survey in the literature.

Materials and Methods: An online questionnaire was prepared to measure the knowledge and attitudes about organ donation.

Results: A total of 1541 medical students from 104 different countries responded to the questionnaire. The participants who have received education before were more successful, had a higher self-donation rate, and showed a more-positive attitude toward organ donation than did those who did not receive an education, or a higher self-donation rate, or a more-positive attitude toward organ donation. Opposition against promotion of the organ donation by medical doctors was more widespread among men, preclinical students, African participants, and participants who did not support organ donation. The two most important decisions about increasing the level of organ donation involved in achieving support of the media and the education of the health care workers.

Conclusions: Educational programs would improve the knowledge and attitudes of medical students about organ donation and transplantation.

Key words : Organ donation, Transplantation, Medical student, Attitude, Knowledge

Introduction

Organ transplant is the principle –and in some cases– the only treatment for the quality and increased survival rates in the final stage organ failure.^1-9 Execution of organ transplant depends on the availability of viable organs.¹⁰ Success of transplant plans is directly related to the variety in the organ pool and the public awareness about organ transplant.¹¹ If organ donation increases, organ transplants also will increase, and we can save more lives.¹² Nevertheless, organ donation rates are well below the desired levels in most parts of the world^{.5-8, 13-16}

The main problem is the discrepancy between the number of potential donors and the number of current donors due to the shortage of deceased-donor organs.^17-19 The role of the physician in addressing this discrepancy is not limited to identifying suitable donors and informing the next of kin, but it also involves promoting a positive environment for organ transplant.^12,20,21 Regardless of the legislation or the socioeconomic status, the attitude and knowledge of the medical staff is the most crucial step for organ transplant.^4,6,21 Organ donation rates appear to be on rise as knowledge of physicians increase.^{7,16,17,22,23}

To give future physicians the necessary infor-mation and attitudes regarding organ donation and transplant; it is essential to use proper strategies in medical education.^1,13,17 The curricula of numerous medical schools are devoid of the necessary emphasis on the subject.^9,24,25 The first step in developing a proper education program is to specify medical students’ knowledge regarding organ donation and transplant.¹² There have been many country case studies that aim to assess the knowledge and attitudes of medical students regarding organ donation and transplant on the cases at hand.^{1,7,9,12,13,16,17,25,30} Nevertheless, there is no worldwide study of this phenomenon. We performed this study to assess the knowledge and attitudes of medical students from various countries regarding organ donation and transplant.

Materials and Methods

Questionnaire
The questionnaire was prepared online using Google Docs. It was shared with the participants via the Internet. The results were stored online. The participants were reached through social media groups that maintain global membership. The groups were searched at Facebook’s search engine with the key words “medical school,” “medical faculty,” “medical student,” and “medicine.” Administrators of the groups were informed about the study and asked to deliver the questionnaire to the members. Besides, executive boards of the respective country associations of International Federation of Medical Students’ Associations also were contacted and asked to deliver the questionnaire to the medical students in their country via the Internet in case they wished to participate. Criteria for participation in study were: a statement confirming their status as a medical student, voluntary participation, informed consent, and full response to each question in the questionnaire. The online questionnaire was open for response between March 26 and June 27, 2013. This research was approved by Hacettepe University Ethics Committee. All of the protocols conformed to the ethical guidelines of the 1975 Helsinki Declaration. Written informed consent was obtained from all subjects.

The questionnaire consisted of 15 questions; 4 of which related to demographics, 4 to attitudes toward self-donation and organ donation in general, 4 to knowledge level and self-assessment of knowledge, 1 to perceived problems regarding organ donation, 1 to suggestions to increase organ donation, and 1 to receiving training on organ donation (Table 1).

Participants were asked to choose from given list of the countries. The countries were classified according to the regions of the World Health Organization.31 Age variable was categorized for single age groups ranging from 18 to 30 years and an aggregate category for above 30 years. Years of medical school ranged from 1 to 8. The participants who were in their first 3 years of medical school were categorized as preclinical students, and those who were above their third year were categorized as clinical students.

Grading system
Questions that measured knowledge were assessed together. Expected responses were graded 1 and wrong responses were graded 0. This sum of the grades was categorized as the Total Score. The range for the total score was between 0 and 14.

Statistical analyses
Statistical analyses were performed with SPSS software (SPSS: An IBM Company, version 15.0, IBM Corporation, Armonk, NY, USA). The population was assessed by descriptive analyses and categorical variables were compared using the chi-squared test. Post-hoc comparisons were performed using the chi-squared test and Bonferroni correction. Kolmogorov-Smirnov and Shapiro-Wilk tests were used to assess normality. Numerical data were analyzed with a one-way analysis of variance test and a t test for independent samples. Post-hoc comparisons were performed using Duncan's new multiple range test. P < .05 was considered statistically significant.

Results

Demographics
The population comprised 1541 medical students. The distribution of the participants regarding the descriptive criteria of gender, preclinical/clinical education and regions is shown as Table 2. The youngest age group among the participants was 18 years. The oldest age group was participants above 30 years, which amounted to 17 students. When those 17 participants are excluded from the population; the mean age was 21.8 (standard deviation (SD): 2.252), and the mode of the age variable was 22 years. There were participants from 104 different countries. The distribution of the countries is shown at Table 3.

Willingness regarding organ donation
When asked about their willingness regarding organ donation, 94.4% of the participants (n = 1454) stated that they support organ donation while 4.3% (n = 66) were not sure, and 1.4% (n = 21) were not supportive of organ donation. There was no significant difference between the support rates for organ donation with regard to gender, region, and preclinical/clinical educational variables.

Only 12.4% of students (n = 191) stated that they had already consented to donation, while 87.6% of students (n = 1350) have not consented to donation yet. Among the students who had not consented to donation, 60.7% (n = 936) stated that they want to donate their organs in the future, 23.4% (n = 361) chose not sure, and 2.9% (n = 44) said that they do not want to donate their organs. Although they stated that they did not give consent for donation, 0.5% (n = 9) of the participants did not answer the question on the willingness to self-donate.

Regional distribution of the participants that had already consented to donation was as follows in a descending order of percentage: 16.2% in Europe (n = 142), 12.5% in the Western Pacific (n = 12), 10.7% in the Americas (n = 16), 6.1% in Africa (n = 2), 5.3% in Eastern Mediterranean (n = 17), and 3% in South-East Asia (n = 2) (P < .01). Post-hoc comparison revealed that the difference is caused by the figures in Europe. Self-donation rates are not significantly different in terms of gender and preclinical/clinical educational variables.

Knowledge
When asked about their knowledge about the current organ donation system in their countries; 59.8% (n = 922) of the participants stated that they have knowledge about the system, 20.2% (n = 312) responded “not sure” and 19.9% (n = 307) responded “no.” To the next question which asks the participants to assess the level of their knowledge; 18.7% (n = 288) responded that they have enough knowledge, 35.6% (n = 548) stated that their level of knowledge needs improvement, and 9.1% (n = 140) said that they find their knowledge not enough at all (P < .01). Those who did not claim knowledge about organ donation system were asked not to respond to that question; nevertheless, 55 of them responded. They were not excluded from the statistical analysis.

Questions to measure the knowledge of the participants about organ donation and transplant and their expected answers are shown in Table 4. The second, third, fourth, and fifth questions were about brain death. With regard to second question, clinic students were more successful with 56.5% correct response rate (n = 390), while only 43.5% of the preclinical students (n = 401) responded correctly (P < .01). The rate of correct answers for the third and fifth questions were 70.7% (n = 488) and 79.1% (n = 546) for clinical students and 62.3% (n = 530) and 69% (n = 587) for preclinical students (P < .01). No statistically significant difference was found for the fourth question.

The mean of total scores was 9.45 with standard deviation equating to 2.01. The median of the scores was 10. The minimum score was 2 and the maximum was 13.

The means of the total scores for each region are shown at Figure 1. The regions are ranged in descending order of mean total score as such: Europe with 9.87 (SD = 1.859), the Americas with 9.33 (SD = 2.055), the Western Pacific with 9.01 (SD = 1.774), the Eastern Mediterranean with 8.9 (SD = 2.086), Southeast Asia with 8.11 (SD = 2.199), and Africa with 8 (SD = 1.953). When the means of the total scores for each region are compared by post-hoc tests, Europe was statistically different from all the regions except for the Americas (P < .01). The Americas were, on the other hand, different from Africa and Southeast Asia but similar to the other 3 regions (P < .01). Lastly, Africa and Southeast Asia were different from all other regions (P < .01). No statistically significant differences were found between the total scores of female and male participants.

The mean for preclinical students was 9.21 (SD = 2079), while the mean total score for clinical students was 9.75 (SD = 1.886). The difference between preclinical and clinical students was statistically significant (P < .01).

Mean total score was 8.35 (SD = 2.296) for the participants who think that doctors should not promote organ donation, 8.61 (SD = 1.894) for the participants who think organ donation should be promoted only to the families of potential donors, and 9.65 (SD = 1.959) for the participants who advocate for public promotion of the organ donation by the doctors. The mean of the participants who support public promotion was significantly higher as compared with the other 2 groups (P < .01).

The mean total scores and standard deviations with regard to participation in educational programs are shown in Table 5. The post-hoc analyses revealed that the difference between the participants who did not receive education at all and those who received education at medical faculty was statistically significant (P < .01). There was also a statistically significant difference between the participants who did not receive education at all and those who received education at a program other than school (P < .01). No other statistically significant differences were found for other paired comparisons.

The distribution of self-donation and thoughts about doctors’ role in promoting organ donation variables in terms of whether or not the participants have received education before and where they received the education is given in Table 6.

Thoughts and suggestions
When asked about how the attitude of medical doctors should be about organ donation, 81.9% of the participants (n = 1262) stated that the doctors should promote organ donation to the whole public, 13.4% of the participants (n = 207) believed that the doctors should promote organ donation only to the families of donor candidates and 4.7% of the participants (n = 72) thought that the doctors should not promote organ donation at all. The rate of support for public promotion is highest in the Americas, whereas the rate of participants that thought organ donation should not be promoted at all is highest in Africa. The difference between the regions was statistically significant (P < .01). The results of post-hoc comparison showed that the Americas were different from all other regions. The differences between Europe and the Western Pacific, and Africa, Southeast Asia, and the Eastern Mediterranean were not statistically significant. The rate of preclinical students who did not support the promotion of organ donation was 5.9% (n = 50) while 80.4% (n = 684) of them were in favor of public promotion. The rates of no support for promotion and support for public promotion among clinic students were 3.2% (n = 22) and 83.8% (n = 690). The difference between preclinical and clinical students in this regard was statistically significant (P = .03).

The participants were asked about their thoughts on the most important problems that inhibit organ donation and their opinions on the highest priority resolutions to increase organ donation. Participants were allowed to choose more than 1 option (Tables 7 and 8).

Discussion

We set out to explore the knowledge levels and attitudes of 1541 medical students from 104 different countries about organ donation. In total, 94.4% of the participants declared that they support organ donation. Whereas, only 12.4% stated that they already consented to donation. What stood out was that there was significantly higher organ donation consent rate in Europe as compared with other regions. This can be attributed to an opt-out system for organ donation, which is widely present in European countries. In general, previous studies also show that although most of the medical students express their support for organ donation, few of them carry a donor card.^1,13,32

Alsaied and associates’ study regarding Qatar showed that despite the fact that 89% of the physicians expressed their support for organ donation, regarding self-donation, 53.2% of them said that they are “considering become an organ donor but need more time to think about it.”6 Akgun and associates’ study found that only 55.1% of Turkish physicians were willing to donate their organs.¹⁹ What inspires hope was that 60.7% of our participants who have not consented to donation, yet stated that they would like to do so.

A study regarding organ donation trends among South African medical students showed that the rate of clinical students who had already consented to donation was significantly higher as compared with the consent rate among preclinical students.1 In our study, we did not find a statistically significant difference between preclinical and clinical students regarding organ donation support and self-donation. Only 18.7% of the participants said that they found their knowledge sufficient. As most of the participants did not consider their knowledge sufficient; we may say that they would be willing to increase it in any way. Previous studies have shown that most of the medical students are willing to increase their knowledge.^1,27

So far, the surveys done publicly and among medical students have not found gender difference regarding their attitude toward organ donation.^1,32,33 Regarding the attitudes and total score, we did not find a statistically significant difference between the genders either.

The mean total score of the clinical students was significantly higher compared with preclinical students. Thus, we may argue that as the time spent for study and clinic experience increases, knowledge also increases. A similar study with medical students in Hong Kong showed there was a positive correlation between clinical exposure and knowledge.¹³ A survey among health care professionals also showed that knowledge increased with educational level.¹⁵

Europe was the only region that had a higher mean total score than that of the entire sample. Mean scores were lowest in Africa and Southeast Asia. This should be a warning signal for the authorities in these regions.

We discovered that only 51.3% of the participants had the correct knowledge about irreversibility of brain death, and 33.9% deemed coma and brain death to be the same. Sobnach and associates, in their survey on South African medical students, state that the participants struggled to make sense of the concept of brain death and low willingness for organ donation was related to this lack of knowledge.¹ The survey on Canadian medical students carried out by Bardell and associates remarked that 64% of the participants knew that brain death and coma were different and brain death meant actual death.¹⁷ In our study, clinical students were significantly more successful in identifying the concept of brain death. Thus, we can argue that the concept of brain death gets more comprehensible for medical students as the level of education and clinical experience increase.

The lowest rate of correct knowledge about the transplantability of organs was regarding uterus, small intestines, and face. The reason that knowledge level concerning the face and the uterus is low is most probably that first operations of the uterus and the face were just done recently.

Only 33.5% of the participants stated that they received organ donation education in the medical school. This shows that organ donation is devoid of the necessary emphasis and attention in the curricula of the medical schools. In a previous study done in Ohio in the United States, Edwards and associates noted that less than 25% of medical students received organ donation education in the medical school.¹² Sobnach and associates’ survey in South Africa showed that only 34% of the medical students took formal transplant coursework, while 31% of the participants declared that they obtained their knowledge through mass media.²⁵ Unfortunately, both previous studies and this study indicate that medical students graduate from medical school without receiving sufficient education about organ donation.

The participants who have received formal and/or informal education about organ donation were better regarding mean total score, support for organ donation, and self-donation as compared with their counterparts who have not received any kind of education. We may say, then, that participating in some kind of education organ donation strengthens the knowledge about and positive attitude toward the matter.

According to Akgun and associates’ study in a Turkish university, students in the departments with a curricula including health education were more likely to donate their organs and had better knowledge of the subject.¹⁸ However, it was observed that even receiving education about organ donation does not bring about the desired level of knowledge and positive attitude. Among the participants who had already received education about organ donation; only 17.8% consented to donation, and 6.1% advocated that the medical doctors should not promote organ donation in any way. Besides, there was no statistically significantly difference between the mean total scores of the participants who received education about organ donation before medical school and the participants who did not receive education. In the light of this information, we may claim that receiving education about organ donation is not enough for increasing awareness about organ donation by itself.

The quality and qualifications of the educational programs also should be assessed. Besides, one also should keep in mind that the attitude towards organ donation is shaped by multiple factors. It would be beneficial to carry out further research order to investigate the contribution of education received before medical school toward a positive attitude regarding organ donation and knowledge level about the issue.

When the participants were asked to identify the most important reasons for the shortage of organ donation, the 3 most popular responses were the “lack of knowledge of people,” “religious beliefs,” and “ethical problems.” According to the study of Daedavessis and associates, the medical students in Greece see the lack of knowledge in the public, Greek culture, and the inadequate number of transplant facilities as the most important reasons.³⁴ In Bapat and associates’ survey among postgraduate medical students, the 2 most important reasons for in unwillingness to donate were that they thought “donation has too many hassles,” and that they would decide when “the day” comes.⁷ Edwards and associates found that the most important obstacles before organ donation were the desire to be buried with all organs, personal conflicts with organ donation, and the fear that carrying an organ donation card could result in insufficient medical care.¹²

This study is the first global survey done regarding the knowledge and attitude of the medical students about organ donation. The larger sample size and the diversity of the participants from 104 different countries are the main strengths of this survey. Besides, it was a multifaceted research. We measured not only the attitudes toward organ donation, but also the knowledge level and self-assessment of the participants as well as where they got their information, what problems they considered, and what resolutions to the problems they suggested regarding organ donation.

The data collected allowed us to compare the students regarding education level and regions of origin, in addition to revealing the current situation in general. Nevertheless, there were some limitations that were faced during the study. To begin with, it was a challenge to devise a fully reflective questionnaire and create a fully representative sample for a global study. There are different organ donation systems in different corners of the world and no available categorization of the countries so as to reflect those differences. Thus, we chose to use the World Health Organization (WHO) regional distribution, which is widely accepted and used. The uneven distribution of the participants among regions, especially the low participation rate in Africa, damaged the representation of the sample. The fact that the questionnaire was responded to online prevented researchers from observing their participants. The questionnaire was shared on social media platforms whose membership was composed of medical students, and the participants who did not declare themselves “medical students” were denied response to the questionnaire. Nevertheless, some participants might not be medical students at the time they responded to the questionnaire. There also is a possibility of non-response bias. In addition, the questionnaire might have reached only students who frequently use the Internet and social media. Lastly, the participants might have received outside help or been referred to sources regarding organ donation for questions that measure knowledge.

In this study, we analyzed the knowledge and attitudes of medical students from different countries regarding organ donation. In light of this study, and the literature on the subject,^{1,7,12,13,16,17,23,25,27,29,34,35} we emphasize the need for appropriate education programs about organ donation and transplant. Such programs may be integrated into the curricula of medical schools. Practical sessions such as simulations of communication with the family of a donor candidate, in addition to theoretic information about the literature and the legislation, should be included in these programs. It may be more beneficial to carry out these programs in small study groups and encourage discussions.^25,29 Those who prepare such programs might benefit from similar surveys applied to local medical students. The biggest step toward the increase of organ donation rates globally at desired levels may be taken when future medical doctors possess appropriate knowledge about and attitudes toward organ donation. In this way, it may be possible to perform more organ transplants and to save more lives.

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