Objectives: We sought to assess the knowledge and attitudes of medical and nonmedical University students regarding eye donation and corneal transplant.

Materials and Methods: The study was a compa-rative, questionnaire-based, cross-sectional survey of fourth-year medical and environmental science students at the University of Nigeria conducted in October 2012. Participants’ demographics, know-ledge, and attitudes on eye donation and corneal transplant were analyzed using descriptive and comparative statistics. Values for P less than .05 were considered statistically significant.

Results: The participants (107 medical students, 75 environmental science students) were 117 men and 65 women aged 22.3 ± 2.2 years (range, 18-32 y). There were no significant intergroup differences regarding awareness of eye donation (OR 1.71; 95% CI: 0.92-3.17; P = .0924) and willingness to donate their own (OR 0.76; 95% CI: 0.33-1.76; P = .5260) or their relatives’ eyes (OR 0.76; 95% CI: 0.29-1.98; P = .6274). Significantly more medical students than environmental science students knew that donation consent is given by the donor while alive (OR 2.93; 95% CI: 1.56-5.4; P = .0005) and had good know­ledge of donor eye preservation (OR 2.43; 95% CI: 1.27-4.68; P = .007).

Conclusions: Among medical and nonmedical under-graduate students, there are crucial deficits in knowledge and attitudes on eye donation and corneal transplant. Tailored donation awareness campaigns and introduction of undergraduate course work on eye donation may reverse the trend.

Key words : Knowledge, Attitudes, Eye donation, Corneal transplant

Introduction

Corneal disease-related vision loss remains an important cause of blindness, accounting for 4.0% of the estimated 2010 global blindness burden of 39 million.¹ The prevalence of corneal blindness (the fourth cause of blindness globally) in low- and middle-income countries, ranges from 7% to 7.9%.^2-4 This is about 20 times greater than the reported prevalence in developed countries.⁵ Corneal transplant (ie, corneal grafting or keratoplasty), first performed by Eduard Zirm in 1905,6 is the most widely practiced^7,8 and most successful⁹ clinical allografting. The practice of keratoplasty has witnessed phenomenal advances owing to innovations in instrumentation, surgical techniques, and perioperative care, resulting in improved outcomes and cost-effectiveness.¹⁰

Despite these developments, widespread use of keratoplasty remains hindered by the relative scarcity of donor corneas in both developed,^7,11-14 and developing, countries.^9,15-18 This has been attributed to the unwillingness of potential donors to pledge their eyes,^9,15,16 and to the failure of health care personnel to educate potential donors on the process of eye donation.^{9,11,12,19,20} Donor unwillingness has been attributed to sociodemographic barriers,^7,8,18,21-24 poor awareness and knowledge,^12,16,17,22 erroneous spiritual/cultural beliefs,^{7,12, 16,17} and objections by family members.^9,16,17 However, it has been observed that good awareness/knowledge does not translate to a willingness to donate.^7,11 Also, a willingness to donate does not equal an irrevocable commitment to donation, that is, possession of organ donor card.^9,17,20,23 These discrepancies have been attributed to the donors’ ignorance of the donation process^7,9,25 or to end-stage medical care providers who educate relatives of terminally ill patients on the humanitarian need for donation or both.²⁴ This probably informed the adoption of presumed donor legislation,^9,24 whereby the state has the legal authority to recover an organ from a potential donor if the potential donor did not register any antemortem objection to eye donation. This policy ensures higher cornea donation rates compared with the consented donor alternative that requires a donor’s mandatory/documented antemortem ex-pression of intent to donate.⁹

Previous surveys on awareness and attitudes regarding eye donation and corneal transplant, especially in sub-Saharan Africa,^16,18,21 have been dominated by descriptive studies on the general population,^7,21,22 hospital outpatients,^8,26 medical students,^9,11,16,17 heterogeneous university students,^{12,15,18,24,25} and health care providers.^18,22 Consequently, there is a paucity of surveys that compare distinct student subpopulations differing in specific characteristics that can influence awareness, knowledge, and attitudes regarding eye donation.^9,20 To bridge this knowledge gap, the investigators, in October 2012, conducted a comparative cross-sectional survey of fourth-year undergraduate students of the Faculty of Medical Sciences and the Faculty of Environmental Sciences at the University of Nigeria, Enugu campus. The investigators hypothesized that general medical education enhances knowledge and attitudes on eye donation and corneal transplant. Thus, the study sought to investigate the influence of general medical education on awareness, knowledge, and attitudes on eye donation/corneal transplant. In addition to providing data for intra- and intercountry benchmark comparisons, the results would assist eye donation campaigners/organ procurement organizations, health educators, and health policy makers/implementers in Nigeria, and under similar settings elsewhere, in developing strategies to increase the procurement of donor corneas.

Materials and Methods

Established in 1960, and located in Nigeria’s southeast geopolitical zone, the University of Nigeria is one of the first-generation universities in Nigeria. The University, located in the Enugu state, operates a 2-campus system, Nsukka and Enugu campuses, and currently has 15 faculties. Of these, the Faculties of Medical Sciences, Environmental Sciences, Law, and Health Sciences and Technology are located at the Enugu campus. The duration of undergraduate medical training is 6 years, while the duration of training in the Faculty of Environmental Sciences ranges from 4 to 6 years, depending on the course of study. At the University of Nigeria and at other Nigerian universities, there is no formal undergraduate instructional coursework on organ donation/transplant. Students are predominantly Christians of Ibo ethnic origin, the dominant tribe in Nigeria’s southeast geopolitical zone.

Despite the promulgation of the enabling Corneal Grafting Decree No. 23 in 1973 in Nigeria, the practice of corneal transplant is still in its early stage. Nigeria’s only eye bank was established in Lagos in 2004,²⁶ and Nigeria’s only 2 corneal transplant centers (located at University College Hospital, Ibadan,²⁷ and Lagos State University Teaching Hospital) were established in 2008.²⁶ In Nigeria, there is widespread apathy toward organ donation, and having an organ donor card is almost nonexistent. The first Nigerian cornea donor pledged his eyes in 2010.

Before the study, ethics clearance compliant with the 1964 Helsinki Declaration (last revised in 2008) was obtained from the Health and Medical Research Ethics Committee of the University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria.

The study was a comparative cross-sectional, self-administered, questionnaire-based survey of fourth-year undergraduate students of the Faculty of Medical Sciences (MS4, group 1) and the Faculty of Environmental Sciences (ES4, group 2) of the University of Nigeria Enugu campus, conducted between October 1 and November 30, 2012. Data on the number of the fourth-year students was obtained from the faculty officer of each faculty. Informed written consent was obtained from each participant before the study. All fourth-year students at the faculties of Medical Sciences and Environmental Sciences were eligible for the study; those who declined were excluded from the study.

Eye donation was defined as antemortem pledging of one’s eye/cornea upon death for transplant to others in need. Awareness was defined as general knowledge of eye donation/corneal transplant derived from having heard or read about it. In addition to awareness, knowledge was defined as possessing specific factual information about eye donation/corneal transplant. And attitudes were defined as personal views, opinions, or feelings on eye donation/corneal transplant.

The study instrument, partly developed de novo and partly adapted from a review of related literature,^{11,15,16,20,25} was a 25-item open- and closed-ended questionnaire. To ascertain its construct validity, psychometric reliability, and ability to achieve the study objectives, the questionnaire was pretested on fourth-year undergraduate students of same course of study at another university in Nigeria’s southeast geopolitical zone. The questionnaire contained subsections on participants’ demographics, awareness, knowledge, attitudes, and barriers to eye donation and knowledge of corneal transplant.

Assuming a power of 90% (0.9), a β value of 0.1, a significance level (α) of 5% (.05), and using 79.1%¹⁶ (P1 = 0.79) reported prevalence of eye donation awareness among medical students and 47.7%²⁵ (P2 = 0.47) among nonmedical students , a minimum sample size of 42.55, in each group, was envisaged using sample size (n) = { [P1(1-p1) + P (1-P2)]/ (P2-P1) 2 } × f (α, β); f (α, β) was deduced from the data in Tables. However, 107 MS4s and 75 ES4s were recruited into the study.

Statistical analyses
Statistical analyses were performed with SPSS software (SPSS: An IBM Company, version 18.0, IBM Corporation, Armonk, NY, USA). During data analyses, neutral responses like undecided or not sure were taken as a negative answer, while blank responses were excluded from the analyses. Descriptive and comparative statistical analyses were performed. Comparative statistical tests for significance of observed intergroup differences were performed with the t test for metric variables, and with the chi-squared or Fisher exact test for categorical variables. In all comparisons, odds ratios (OR) and 95% confidence intervals (CI) associated with P < .05 were considered statistically significant.

Results

The feedback from the pretest improved the content and construct validities of the questionnaire. The final version of the questionnaire had a Cronbach alpha coefficient (internal consistency reliability) of 0.8. There were 250 fourth-year students at the Faculty of Medical Sciences and Faculty of Environmental Sciences (150 MS4s, 100 ES4s). Of these, 182 students (107 MS4s, 75 ES4s) participated in the study. The survey participation rate was 72.8% (182/250) overall; 71.3% for the MS4s (107/150) and 75.0% for the ES4s (75/100).

Participant demographics
Overall, there were 182 study participants (117 [64.3%] men and 65 [35.7%] women; sex ratio, M:F = 1.8: 1; mean age, 22.3 ± 2.2 SD y; range, 18-32 y). Of these, 107 were MS4s (58.8%; 66 men, 41 women; sex ratio, M:F =1.6:1; mean age, 22.6 ± 1.9 SD y; range, 19-27 y) while 75 were ES4s (41.2%; 51 men, 24 women; sex ratio, M:F = 2.2:1; mean age, 21.9 ± 2.6 SD y; range, 18-32 y). There were no statistically significant differences between MS4s and ES4s regarding mean age (22.6 ± 1.9 vs 21.9 ± 2.6; t = 1.82; P = .07) or sex (OR 0.76; 95% CI: 0.41-1.41; P = .3813).

Awareness, attitudes, and barriers to eye donation
Although the observed intergroup differences were not statistically significant, more MS4s (51; 47.7%) than ES4s (25; 33.3%) were aware of eye donation (OR 1.71; 95% CI: 0.92-3.17; P = .094) and expressed willingness to donate their own (OR 0.76; 95% CI: 0.33-1.76; P = .5260) or a relative’s eyes (OR: 0.76; 95% CI: 0.29-1.98; P = .6274). In both groups, the leading sources of awareness on eye donation were the mass media (MS4, ES4) (20.6%, 20.0%), the questionnaire for this study (7.5%, 12.0%), and lectures/journals (5.6%, 2.7%). However, despite a similar religious background, significantly more MS4s than ES4s cited religion as their main barrier to eye donation (OR 0.42; 95% CI: 0.17-1.01; P = .0496). In both groups, none of the participants possessed an organ donor card (Table 1).

Knowledge of eye donation
A comparative assessment of the following specific eye donation knowledge parameters did not identify significant differences between the knowledgeable proportions of MS4s and ES4s, confidentiality of donor and recipient identities (OR 0.87; 95% CI: 0.42-1.80; P = .7138), presence of a donor age limit (OR 0.95; 95% CI: 0.45-2.16; P = .9734), ideal timing (OR 1.19; 95% CI: 0.45-3.21; P = .8081), place for removal of pledged eye (OR 1.09; 95% CI: 0.69-1.75; P = .7049), and donation eligibility of persons who had specific systemic or ocular conditions while alive (P > .05). Compared with ES4s, significantly more MS4s knew that donation consent is given by the donor while alive (OR 2.93; 95% CI: 1.56-5.4; P = .0005). The participants’ profile of eye donation knowledge is shown in Table 2.

Knowledge of corneal transplant
Beyond the MS4s significant knowledge advantage over ES4s on preservation of a donated eye (OR 2.43; 95% CI: 1.27-4.68; P = .0070), the investigators did not observe any other significant intergroup difference in the other aspect/specific knowledge parameters assessed (Table 3).

Discussion

The participants were predominantly men who were aged 18 years or older, with a mean age of 22.3 ± 2.2 years. The observed male gender dominance is consistent with the sex distribution from similar surveys in Nigeria,¹⁶ China,²⁰ and India^17,24; however, this differs from the gender-neutral distribution in an American survey¹¹ and female gender preponderance in Italy²⁸ and Hong Kong.²⁹ The participants’ mean age is higher than that reported in China,²⁰ India,¹⁷ and Italy,²⁸ but lower than those reported in Nigeria¹⁶ and United States.¹¹ The differences in study specificities for different years of study, interregional variations in sex-determined preferences for undergraduate course of study, and university entry age may explain the demographic similarities/differences.

Although generally poor, the MS4s have a marginally higher awareness of eye donation; however, they were less willing to donate their own or a relative’s eyes. The influence of religion, the most frequently cited barrier to eye donation, on donation decision did not significantly differ between MS4s and ES4s. The 41.7% awareness in the present study is lower than a study of medical students by Okoye and associates¹⁶ (79.1%) and of a study of the general population by Odusanya and associates,²¹ (60.0%) both in Nigeria. Also, the present awareness figure is lower than those from similar surveys of university students in India (73.8% to 96%),^15,24 Malaysia (97.6%),¹⁵ and China (96.6%).²⁰ One survey found that sixth-year medical students were likely more knowledgeable regarding eye donation issues compared with MS4s.^{16, 29} Odusanya and associates²¹ studied a heterogeneous group of adult residents in Lagos, Nigeria, where the country’s only eye bank is located, thus likely conferring awareness and knowledge advantage on them. Whereas in India and Singapore, eye banking/corneal transplant has been practiced for decades. In Nigeria, this practice began in late twenties. This probably accounts for the marked knowledge advantage of Indian and Singapore students over their Nigerian counterparts. The present data reinforce the need suggested in other studies to include formal instruction on eye donation/corneal transplant in undergraduate medical and nonmedical training curricula.^{9,11,15,20,30}

The mass media was the leading source of awareness for most participants who reported awareness of eye donation. This is consistent with the findings in Nigeria¹⁶ and India²⁶ and support the established necessity for a rigorous mass media-based campaign, targeting the general population, to increase eye donation awareness.^8,12,17

Across both study subgroups, awareness did not translate to willingness to donate, nor did willingness translate to irrevocable commitment to donate one’s own eyes. Additionally, more ES4s than MS4s were willing to donate their own eyes (16.0% vs 13.1%). This pattern of mismatch provides suggestive evidence that critical barriers issues exist between awareness and willingness, and between willingness and actual pledging of one’s own eyes.^{7,9,11,17,20,23,26} Therefore, formulating evidence-based strategies that overcome these barriers are indispensable precursors that will enhance eye donation rates. As suggested by Essman and associates, the higher tendency of ES4s, who were comparatively less aware than MS4s (33.3% vs 47.7%), to donate could be attributed to greater intrinsic altruism among ES4s.¹¹

Religion, lack of awareness, and family objections were the participants’ leading barriers to eye donation. The present data corroborate previous findings that identified religion,^7,23,24 family-related barriers,^16,17 and poor awareness^13,22 as significant barriers to eye donation. To overcome these barriers, the eye donation community organizations should intensify their donation awareness creation efforts and extend the reach of eye donation campaigns to the general population, especially the clergy. The clergy, despite their vantage position in transmitting strategic health-related information to their congregations, has been shown to have inadequate knowledge and suboptimal attitudes regarding organ donation/transplant.^31,32 Furthermore, adop-ting presumed consent approach to eye donation would provide the legal enforcement framework to specifically overcome family objections.

On eye donation knowledge, significantly more MS4s knew that donation consent is given by donor while alive, but not that presence of communicable disease contraindicates one as a donor. Similar patterns of misconceptions among medical students regarding eye donation knowledge have been reported from comparative surveys in India, Malaysia, and China.^9,15,20 These findings further underscore the need for undergraduate curricular modification, across all undergraduate study fields, to include mandatory formal instructions on eye donation/corneal transplant. The change in curricula would give university graduates (especially medical graduates) the necessary knowledge to educate, motivate, and recruit potential organ donors from the general population.^9,11,33

Of the 5 specific corneal transplant knowledge parameters assessed in this survey, significantly more MS4s knew the method of preserving/storing donor eyes compared with ES4s. A similar pattern of marginal knowledge advantage of medical students over nonmedical students has been reported by Bharti and associates¹⁵ in Malaysia and by Dhaliwal⁹ in India. Further valid comparisons with the findings of other previous comparative surveys were precluded by their “non” specificities for eye donation/corneal transplant or nonreporting of equivalent comparative data.^20,24,25 Deficiencies in absolute and comparative factual knowledge that MS4s possess regarding corneal transplant further justifies introducing an organ donation/transplant course (with an emphasis on corneal transplant) into undergraduate medical training. This has been shown by Caban and associates,³⁴ Feeley and associates,³⁵ and Manyalich and associates36 to effectively enhance trainees’ attitudes and knowledge and positively affect the public’s rate of eye donations.

The conclusions drawn from this study and the generalizability of its findings are limited by its single-center design, study specificity for undergraduate students, and the questionable reliability inherent in self-reported knowledge surveys. Additionally, respondents may express increased willingness to donation when directly asked by an interviewer.

In conclusion, at the University of Nigeria, both medical and environmental science undergraduate students have poor awareness, knowledge, and attitudes on eye donation and corneal transplant. Medical students have a marginal knowledge advantage over their environmental science counterparts. To reverse the trend, mass media-based awareness campaigns and inclusion of mandatory instructional course work on eye donation and corneal transplant in undergraduate medical and nonmedical training curriculum are instructive. Future multicenter studies as well as population-based surveys are needed.

References:

1. Pascolini D, Mariotti SP. Global estimates of visual impairment: 2010. Br J Ophthalmol. 2012;96(5):614-618.
   CrossRef - PubMed
2. Report of the Nigerian National Blindness and Visual Impairment Survey: 2005-2007 Web site. http://pbunion.org/Countriessurveyresults/Nigeria/Nigeria_survey_Summary_report.pdf. Accessed March 19, 2014.
3. Ophthalmic Research in ICMR Web site. http://icmr.nic.in/oph-icmr.pdf. Accessed March 19, 2014.
4. WHO Web site. Prevention of Blindness and Visual Impairment: Priority eye diseases. http://www.who.int/blindness/causes/priority/en/index9.html. Accessed March 19, 2014.
5. Whitcher JP, Srinivasan M, Upadhyay MP. Corneal blindness: a global perspective. Bull World Health Organ. 2001;79(3):214-221.
   PubMed
6. An Ophthalmologist’s journey. Dr. Eduard Konrad Zirm - 1863 bis 1944 Web site. http://www.drzirm.org/ehistory.html. Accessed March 19, 2014.
7. Yew YW, Saw SM, Pan JC, et al. Knowledge and beliefs on corneal donation in Singapore adults. Br J Ophthalmol. 2005;89(7):835-840.
   CrossRef - PubMed
8. Palamar M, Durusoy R, Egrilmez S, Salis O, Yagci A. Public opinion concerning corneal donation and transplant: a survey from Izmir, Turkey. Exp Clin Transplant. 2011;9(2):134-138. Erratum in: Exp Clin Transplant. 2011;9(4):286. Palamar Onay, Melis [corrected to Palamar, Melis].
   PubMed
9. Dhaliwal U. Enhancing eye donation rates. Training students to be motivators. Indian J Ophthalmol. 2002;50(3):209-212.
   PubMed
10. Coster DJ. A century of corneal transplantation. Clin Experiment Ophthalmol. 2005;33(6):557-558.
    CrossRef - PubMed
11. Essman C, Thornton J. Assessing medical student knowledge, attitudes, and behaviors regarding organ donation. Transplant Proc. 2006;38(9):2745-2750.
    CrossRef - PubMed
12. D'Alessandro AM, Peltier JW, Dahl AJ. A large-scale qualitative study of the potential use of social media by university students to increase awareness and support for organ donation. Prog Transplant. 2012;22(2):183-191.
    CrossRef - PubMed
13. Rey JW, Grass V, Barreiros AP, et al. Organ procurement in Germany: a regional survey among students [in German]. Dtsch Med Wochenschr. 2012;137(3):69-73.
    PubMed
14. Muraine M, Toubeau D, Menguy E, Brasseur G. Analysing the various obstacles to cornea postmortem procurement. Br J Ophthalmol. 2002;86(8):864-868.
    CrossRef - PubMed
15. Bharti MK, Reddy SC, Tajunisah I, Ali NA. Awareness and knowledge on eye donation among university students. Med J Malaysia. 2009;64(1):41-45.
    PubMed
16. Okoye OI, Maduka-Okafor FC, Eze BI. What does the medical student know about eye donation/corneal transplant? The University of Nigeria scenario. West Indian Med J. 2010;59(1):41-44.
    PubMed
17. Singh MM, Rahi M, Pagare D, Ingle GK. Medical students' perception on eye donation in Delhi. Indian J Ophthalmol. 2007;55(1):49-53
    CrossRef - PubMed
18. Gelaw Y, Ambaw F. Sociodemographic correlates of attitude towards corneal donation among health science students and academic staff of Jimma University. Ethiop Med J. 2010;48(1):41-47.
    PubMed
19. El-Shoubaki H, Bener A. Public knowledge and attitudes toward organ donation and transplantation: a cross-cultural study. Transplant Proc. 2005;37(5):1993-1997.
    CrossRef - PubMed
20. Chen JX, Zhang TM, Lim FL, et al. Current knowledge and attitudes about organ donation and transplantation among Chinese university students. Transplant Proc. 2006;38(9):2761-2765.
    CrossRef - PubMed
21. Odusanya OO, Ladipo CO. Organ donation: knowledge, attitudes, and practice in Lagos, Nigeria. Artif Organs. 2006;30(8):626-629.
    CrossRef - PubMed
22. Rokade SA, Gaikawad AP. Body donation in India: social awareness, willingness, and associated factors. Anat Sci Educ. 2012;5(2):83-89.
    CrossRef - PubMed
23. Golchet G, Carr J, Harris MG. Why don't we have enough cornea donors? A literature review and survey. Optometry. 2000;71(5):318-328.
    PubMed
24. Manjunath SN, Lokare L, Gokhale SA, Godbole M, Mulkipatil SY, Mahesh V. Awareness of eye donation among college students of Hubli city, Karnataka. Int J Biomed Res. 2012;3(12): 201-204.
25. Peron AL, Rodrigues AB, Leite DA, et al. Organ donation and transplantation in Brazil: university students' awareness and opinions. Transplant Proc. 2004;36(4):811-813.
    CrossRef - PubMed
26. Eko Ni Baje O. First Eye Transplant @lagos State University Teaching Hospital. - Politics – Nairaland. Nairaland Forum Web site. http://www.nairaland.com/537204/eko-ni-baje-o-first. Accessed March 19, 2014.
27. UCH Carries Out Cornea Transplants. Topix Ibadan, Nigeria Web site. http://www.topix.com/forum/ng/ibadan/TRH3M8K0EN1B7979B. Accessed March 19, 2014.
28. Canova D, De Bona M, Ruminati R, Ermani M, Naccarato R, Burra P. Understanding of and attitudes to organ donation and transplantation: a survey among Italian university students. Clin Transplant. 2006;20(3):307-312.
    CrossRef - PubMed
29. Tam WW, Suen LK, Chan HY. Knowledge, attitudes and commitment toward organ donation among nursing students in Hong Kong. Transplant Proc. 2012;44(5):1196-1200.
    CrossRef - PubMed
30. Najafizadeh K, Shiemorteza M, Jamali M, et al. Attitudes of medical students about brain death and organ donation. Transplant Proc. 2009;41(7):2707-2710. Erratum in: Transplant Proc. 2010;42(3):999. Assan, S [corrected to Assari, S].
    CrossRef - PubMed
31. Wejda SC, Kosieradzki M, Jakubowska-Winecka A, et al. Survey on attitudes and knowledge on the organ recovery from deceased donors in Roman Catholic nuns and priests. Transplant Proc. 2012;44(7):2173-2175.
    CrossRef - PubMed
32. Michalska E, Kołodziej K, Szymański D, Strzelczyk J. Students of the Polish catholic theological seminars and the issue of organ transplantation. Ann Transplant. 2010;15(4):56-60.
    PubMed
33. Essman CC, Lebovitz DJ. Donation education for medical students: enhancing the link between physicians and procurement professionals. Prog Transplant. 2005;15(2):124-128.
    PubMed
34. Caban A, Ziaja J, Budziński G, et al. Evaluation of transplantation procedures acceptance among students of Thai, American, and Polish origin who finished a basic didactic course. Transplant Proc. 2011;43(8):2879-2881.
    CrossRef - PubMed
35. Feeley TH, Tamburlin J, Vincent DE. An educational intervention on organ and tissue donation for first-year medical students. Prog Transplant. 2008;18(2):103-108.
    PubMed
36. Manyalich M, Paredes D, Ballesté C, Menjívar A. The PIERDUB project: International Project on Education and Research in Donation at University of Barcelona: training university students about donation and transplantation. Transplant Proc. 2010;42(1):117-120.
    CrossRef - PubMed