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Knowledge, Attitude and Practices of Medical Undergraduates of Rawalpindi

Medical University Regarding Potential Organ Donation

Article  in  Journal of the Pakistan Medical Association · October 2020

DOI: 10.5455/JPMA.301449

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1  DOI: https://doi.org/10.5455/JPMA.301449
2 

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3  KAP Study Article

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4  Knowledge, attitude and practices of medical undergraduates of

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5  Rawalpindi medical university regarding potential organ donation

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6 

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7  Asfaa Ashfaq1, Sadia Tariq2, Sana Javed Awan3, Rehana Sarafraz4, Abida

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8  Sultana5, Lubna Meraj6
9  1,6 District Headquarter Hospital, Rawalpindi Medical University, Rawalpindi, Pakistan;

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10  2-4 Holy Family Hospital, Rawalpindi Medical University, Rawalpindi, Pakistan;

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11  5 Department of Community Medicine, Fauji Foundation Medical College, Rawalpindi,
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12  Pakistan.
13  Correspondence: Lubna Meraj. Email: lubnameraj@gmail.com
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14 
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15  Abstract
16  Objectives: To determine the knowledge, attitude and practices of medical
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17  undergraduates regarding potential organ donation.

18  Methods: The descriptive cross-sectional study was conducted from April to July
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19  2017 at Rawalpindi Medical University, Rawalpindi, Pakistan, and comprised

medical students of either gender selected from each of the five academic years.
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20 

21  Data was collected using a structured questionnaire on knowledge, attitude and
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22  practices. Data was analysed using SPSS 22.

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23  Results: Of the 400 subjects, there were 40(10%) male and 40(10%) female
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24  students from each of the five academic years. The mean age of the sample was
25  20.98+/-1.63 years (range: 18-27 years). Overall, 363(90.8%) students had
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26  knowledge of organ donation, and 96(24%) knew about potential organ donation.
27  Of the 184(46%) subjects willing for live donation, 86(46.7%) were males and
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28  98(53.2%) were females. Of the 245(61.5%) subjects willing for potential organ
29  donation, 62(77.5%) were from the 5th year and 30(37.5%) were from the 1st
30  year.

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31  Conclusions: Medical students were found to have good knowledge regarding

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32  live organ donation, but they had very little information about potential organ

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33  donation.

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34  Key Words: Potential organ donation, Organ transplant, Knowledge, Attitude,

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35  Practices, Medical students, KAP study, Transplant.

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36 

37  Introduction
38  Potential organ donor is a person, whose cell, tissue and organ can be recovered

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39  after the declaration of death if the organs are viable and there is no absolute
40  medical contraindication. The consent for donation is either given by the donor
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41  himself or by family after his death. On the basis of death declaration criteria,
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42  these donors can be divided into Deceased Heart Beating Donor (donor after brain
43  death) and Deceased Non-Heart Beating Donor (donor after cardiac death). The
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44  former can be kept alive by cardiopulmonary resuscitation (CPR) till the viable
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45  organ is recovered. 1

46  According to a rough estimate, around 50,000 people in Pakistan die each year
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47  from end-stage organ failure. According to the Sindh Institute of Urology and
48  Transplant (SIUT), these constitute around 15,000 from kidney failure, 10,000
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49  from liver failure and 6,500 from heart failure. Most of these lives can be saved
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50  if there are organs available for transplantation. Live donation can be done for
51  very limited range of organs, i.e. kidney, portion of the liver, lobe of a lung, part
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52  of pancreas, or intestine. However, in deceased donation, a single donor can

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53  donate up to 17 organs, including kidneys, liver, lungs, heart, pancreas, intestine,
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54  corneas, bone, bone marrow, and skin, and can save the lives of at least 8 patients
55  on an average. 2-3
56  Pakistan at present has a growing programme of live organ donations and
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57  transplantations with several transplant institutes throughout the country.

58  According to a 2007 survey, only 400 live kidney transplant procedures were
59  conducted, which is not enough to reduce mortality associated with end-stage renal

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60  disease (ESRD).4 There is only one specialised facility for liver transplantation in

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61  Pakistan and very limited number of surgeons are specialised in the field.5 In the

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62  case of deceased organ transplantation, only 7 had been carried out in Pakistan

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63  till 2005.6 Out of these, 6 organs were imported from international donors.6 No

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64  further countrywide surveys were carried out. In Pakistan, another major problem

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65  regarding organ donation is organ export or commercial sale of organs to foreign
66  recipients. This practice was prevalent to a much greater extent before the
67  formulation of a law against it in 2010.7

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68  According to the World Health Organisation (WHO), Global Activity in Organ
69  Transplantation estimates that total 119,873 solid organs were transplanted
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70  globally in 2014, which included 79,948 kidneys, 26,151 livers and 6,542 hearts.8
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71  In the United States, 30,849 kidney transplants were conducted, out of which 67%
72  were from deceased donors, while only 25.3% deceased donor contributed in the
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73  total 5,290 transplants conducted in South Asia. These statistics depict a huge
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74  role of potential donation in developed countries.9

75  Medical students who have to witness life-and-death situations are expected to
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76  have a better idea of the gravity of the situation, and, therefore, to have better
77  knowledge regarding the importance of donated organs. The current study was
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78  planned to find out the knowledge, attitudes and practices of medical
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79  undergraduates regarding potential organ donation, and to find changing trends,
80  if any, in terms of academic year and gender.
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81 
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82  Subjects and Methods

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83  The descriptive cross-sectional study was conducted from April to July 2017 at
84  the Rawalpindi Medical University, Rawalpindi, Pakistan, at its two campuses.
85  Campus-I has students of the first two academic years, while Campus-II has
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86  students of the remaining three years. After obtaining approval from the ethics
87  committee of the Rawalian Student Research Society (RSRS), the sample size
88  was calculated using the WHO calculator in line with literature4 at confidence

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89  level of 5% and absolute precision of 0.05. WHO sample size calculator was used

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90  to calculate the minimally required sample size10. Owing topotential non-

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91  response, the sample size was inflated by 10%. The sample was rasied using

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92  stratified random sampling, with equal number of male and female students who

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93  were randomly selected from each of the five academic years of the

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94  undergraduate medical programme.
95  After taking informed consent from the participants, data was collected using a
96  pre-tested questionnaire which had multiple choice questions (MCQs) and a few

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97  open-ended questions. It had three sections. The first section consisted of five
98  questions to assess knowledge about live and potential donation, side effects of
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99  organ donation, laws about organ donation, and transplantable organs. The
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100  second section inquired about any history of organ donation as a way of assessing
101  practices, and, if donated, which organ it was and what was the reason behind the
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102  donation. The third section assessed attitude of participants by inquiring whether
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103  they will willingly donate their organs during life or after death along with the
104  reason for their answer and which organs they will willingly or never donate.
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105  Also, the questionnaire had three questions related to gender, age and the
106  academic year of each subject. The questionnaire was administered among the
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107  students and collected the next day. Data was analysed using SPSS 22.
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108 

109  Results
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110  Of the 400 subjects, there were 40(10%) male and 40(10%) female students from
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111  each of the five academic years; a total of 200(50%) males and as many females.
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112  The mean age of the sample was 20.98+/-1.63 years (range: 18-27 years). Overall,
113  363(90.8%) students had knowledge of organ donation while 96(24%) students
114  knew about the basic concept of potential organ donation and the systematic
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115  programme required for its practical implementation. Also, 269(67%) knew about
116  the adverse effects on the health status of donor after live solid organ donation;
117  298(74.7%) had a rough idea regarding one or more basic laws of deceased organ

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118  donation, and, of these 298 subjects, 62(21%) knew that deceased donation

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119  without consent is illegal; 44(15%) knew that 18 is the lower age limit for

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120  donation; 69(23.3%) knew that organ trafficking is illegal; 18(6%) knew that

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121  donation without human leukocyte antigen (HLA) matching is illegal; 25(8.5%) knew that

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122  there is high penalty for illegal action; and 256(86%) knew that only heart, liver

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123  and kidney can be transplanted.
124  In terms of attitude, 184(46%) subjects were willing to donate an organ during
125  life; , 86(46.7%) males and 98(53.2%) females. A total of 245(61.5%) students

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126  were willing to donate their organs after their death. Among those who were
127  willing, 62(77.5%) were from the final year and 30(37.5%) from the 1st year
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128  (p=0.000). Similar trend for live donation was noted when going from first to
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129  final year (Figure 1). There was no significant correlation between gender and
130  willingness of donation (p>0.05). Kidney 90(22.5%) and liver 31(7.8%) were the
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131  top choices for donation.

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132  The most dominant reason for willingness was to help a random person in need,
133  204(83.6%) (Figure 2). The most dominant reason for unwillingness was family
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134  restrictions 54(35%) (Figure 3). In terms of practice, 1(0.25%) student had
135  donated a kidney to a relative; a male student of 4th year. Relation with gender
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136  was not statistically significant (p=0.082).

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137 

138  Discussion
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139  The findings showed that 90.8% of students had knowledge of organ donation,
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140  but surprisingly only 24% students had knowledge about potential organ
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141  donation. This shows that potential organ donation is quite an unfamiliar concept
142  in our setup. A study conducted among general population at Aga Khan
143  University (AKU) reported that 60% people had basic knowledge about organ
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144  donation.4 Another study conducted in Egypt showed that only 36% medical
145  students had good knowledge about organ donation.10 To our knowledge, no
146  study has yet been conducted for potential organ donation.

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147  The current study found that 74.7% participants had idea about the laws

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148  concerning deceased organ donation while the study in Egypt showed that 77.7%

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149  participants had not heard or read about any laws regulating organ donation10.

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150  A relatively low percentage of students were willing to donate their organs in

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151  their lifetime (46%) compared to those willing to donate after death (61%).

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152  However, other studies have reported up to 62% participants willing to donate
153  organs.4,10,11 The higher level of willingness for potential or cadevar donation in
154  our study is justifiable as there is no morbidity associated with it while live organ

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155  donation is associated with considerable morbidity and risks for the donor, and,
156  in addition, the cost of the procedures and post-operative care is unaffordable for
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157  a big majority. Yet again, no such study has been carried out for potential organ
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158  donation before in Pakistan. Our results also showed a slightly greater number of
159  females were willing for donation compared to males but the difference was not
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160  statistically significant.

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161  Medical students in Pakistan are given mostly theoretical knowledge in their
162  first two years, having near to none clinical exposure. Over the next three years,
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163  they are taught in an environment of increasing clinical exposure with each
164  academic year. Our results showed that our medical students had increasing
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165  willingness to donate their organs during life as well as after death when moving
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166  from the first to the final year. Another important analysis was that there was a
167  sudden increase in willingness noted in the first clinical year or the 3rd academic
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168  year, while there was a uniformly increasing trend in the rest of the academic
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169  years. This shows that exposure to clinical practice and facing life and death
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170  situations imparts a greater respect towards life and suffering of patients in the
171  minds of students.
172  When asked for the reasons for which they wanted to donate their organs after
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173  their death, the most prominent reason was to help a random person in need
174  (83.6%), while the second prominent reason was to gain virtues (12.2%). These
175  results contrast with the results of an earlier study4 that showed 51% participants

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176  willing to donate their organs only to family members. In a study in China 62.4%

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177  participants were willing to donate only to the relatives11. However, when asked

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178  the reasons for unwillingness from the students not willing to donate, the most

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179  prominent reason was that their family will not allow their bodies to be taken

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180  apart for donation (35.1%). The second common reason was fear of body

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181  disfigurement (25.7%). There were also a fair number of students who opted for
182  the fear of improper handling of their organs and some cited religious concerns.
183  In China11 a study showed value of life, relationship between body integrity and

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184  conventional culture to be important factors regarding decision-making in this
185  regard.
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186  From these results, one can infer that there is a general misconception among the
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187  students that their bodies will not be handled in a respectable way if they allow
188  their organs to be taken. As for religious aspect, there has been a lot of debate
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189  regarding religion and organ donation. The Al-Azhar University of Egypt has
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190  declared both potential and live organ donation as allowed and appreciated in
191  Islam.12 In fact, apart from Jehovah’s witnesses from one of the Christian
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192  dominations13 and some orthodox Jews, no religion formally disputes blood or
193  organ transplantation14,15.
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194  Most willingly potentially-donated organs ion the current study were kidneys,
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195  liver, heart and lungs. However, a significant number of students (44%) were
196  willing to donate all their organs after their death.
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197  In our study, only one student had donated a kidney to a family member
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198  (0.25%). A survey published in Pakistan in 2009 showed that 3.5% people had
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199  donated organs in their lives, and 35.3% of people expressed a high motivation
200  for organ donation. However, no survey has ever been conducted in Pakistan
201  regarding potential organ donation, but, according to a report,6 7 deceased donor
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202  tranplants were carried out at the SIUT, Karachi, in 2005, and 6 of them were
203  from international donors.
204  In Pakistan, there have been successful kidney and liver transplants, but apart

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205  from that no other transplant has yet been done3. Even though Pakistan has high

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206  endemicity of hepatitis B and C16, and the gold standard and cost-effective

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207  treatment modality for chronic liver diseases is liver transplant, only one such

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208  facility is fully operational.5

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209  In the light of findings, it is recommended that more transplant units in

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210  government and private sectors should be set up, healthcare to guarantee
211  successful transplantation should be improved, and a system for registering
212  potential organ donors and carrying out transplantation, similar to foreign

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213  programmes, must be developed. Besides, awareness should be raised through
214  seminars etc. to educate the general public and remove misconceptions regarding
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215  live and potential organ donation. Steps should also be taken to ensure organ
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216  safety and proper handling of bodies after death.
217 
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218  Conclusion
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219  Knowledge regarding potential organ donation was less than that of live donation,
220  but, once educated about potential organ donation, there was more willingness
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221  for it. There was a fear of adverse effects and increased morbidity associated with
222  live donations, while the main concern for potential organ donation was the
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223  reluctance of family members and the fear of body disfigurement. The practice
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224  of live organ donation was minimal while that of potential organ donation was
225  essentially absent.
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226 
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227  Disclaimer: None.

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228  Conflict of Interest: None.

229  Source of Funding: None.
230 
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231 

232  References
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234  transplantation.; 2009 : cited 2016 September 19.  Available from:

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235  http://www.who.int/transplantation/activities/en/ 

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236  2. Dr Adeebul Hassan Rizvi, A.H.R. DAWN NEWS. Need for more organ

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237  donations in Pakistan stressed. Jan 24 2014

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238  http://www.dawn.com/news/1082005/need-for-more-organ-donations-in-

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254  8. Global Observatory on Donation and Transpantation. Organ Donation and
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264  11. Hamed H, Awad ME, Youssef KN, Fouda B, Nakeeb AE, Wahab MA.

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268  12. Zhang L, Li Y, Zhou J, Miao X, Wang G, Li D, et al. Knowledge and
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282  Consensus Statement on management of Hepatitis C Virus Infection - 2003.

283  J Pak Med Assoc. 2004 [cited 2018 Mar 12] ;54(3):146-50.
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284 
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285  ----------------------------------------------------------
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286 
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77.5

Willingness for potential organ 
73.8
80 66.3
62.5
60 51.3 48.8
donation 37.5
33.8
40 26.3

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22.5
20

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0
1st Year 2nd Year 3rd Year 4th Year 5th Year

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Academic year of participants
YES NO

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287 
288  Figure 1: Relation between willingness of donation with academic year of participants.
289 

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290  --------------------------------------------------------------------
291 

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90.0 83.6%
Percentage of Participants

80.0
70.0
60.0

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50.0

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40.0
30.0
20.0
ed 12.2%
10.0 3.1% 1.1%
0.0
To help a random For financial help of To gain virtues Other reasons
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person in need family
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Reasons for willingness of Potential Organ Donation
Percentage of participants
292 
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293  Figure 2: Reasons for willingness of participants for potential organ donation.
294 
295  --------------------------------------------------------------------
296 
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40.0 35.1%
35.0
30.0 25.7%
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22.3%
Percentage of Participants

25.0
20.0
15.0 9.5% 7.4%
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10.0
5.0
0.0
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Family Religious Fear of body

Fear of organ Fear of donation
restriction restriction disfigurement
abuse to mentally
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unsound people
Reason for unwillingness of Potential Organ Donation
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Percentage of particpants

297 
298  Figure 3: Reasons for unwillingness of participants for potential organ donation.
299 

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