- Email: [email protected]
Factors That Affect the Attitudes of the Bolivian Population in Spain With Regard to Organ Donation for Transplant
Factors That Affect the Attitudes of the Bolivian Population in Spain With Regard to Organ Donation for Transplant A. Ríosa,b,c,*, A.I. López-Navasa,d, Á. Sáncheza, M.A. Ayalaa,e, G. Garridof, M.J. Sebastiána,g, L. Martínez-Alarcóa,c, G. Ramisa,b,c, A.M. Hernándezh, P. Ramíreza,b,c, and P. Parrillaa,b,c a Proyecto Colaborativo Internacional Donante (“International Collaborative Donor Project”), Murcia, Spain; bDepartment of Surgery, Paediatrics, Obstetrics and Gynaecology, University of Murcia, Murcia, Spain; cTransplant Unit, Surgery Service, IMIBeHospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain; dDepartment of Psychology, Catholic University of Murcia, UCAM, Murcia, Spain; e Hospital Regional de Alta Especialidad del Bajío, León, Guanajuato, Mexico; fOrganización Nacional de Trasplantes, Madrid, Spain; g Coordinación de Trasplantes, UMAE Hospital de Especialidades No. 25 IMSS, Monterrey, Mexico; and hEndocrinology and Nutrition Service, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
ABSTRACT Background. The Bolivian population is an emerging Latin American immigrant group in Spain, several of whom have been transplanted or are awaiting transplant. We aimed to assess attitudes toward organ donation among Bolivians currently residing in Spain. Method. The population screened was born in Bolivia but living in Spain, stratified by gender and age. The appraisal tool used was a questionnaire that assesses attitudes toward organ donation for transplant (“PCID-DTO Ríos”). Support from immigration associations in Spain was needed for advice on locations of potential respondents. Survey participation was anonymized and the questionnaire was self-administered. Verbal consent was obtained before participation. Results. There were 206 respondents: 49% (n ¼ 101) in favor of donating their organs after death; 21% (n ¼ 44) against donation; and 30% (n ¼ 61) undecided. Their attitudes were found to be associated with level of education (P ¼ .008), previous experience with donation and transplant (P ¼ .011), concern regarding mutilation after donation (P ¼ .002), knowing the attitude of their religion toward transplant (P ¼ .001), the opinion of their partner (P < .001), and the possibility of needing a future transplant (P ¼ .050). In the multivariate study, the main factor was having a partner in favor of organ donation (odds ratio ¼ 16.129; P ¼ .003). Conclusion. Attitudes toward organ donation among Bolivians residing in Spain are far more negative compared with rest of the Spanish population, due to various factors.
O
RGAN transplantation is a fully acceptable therapy, limited mainly by the shortage of organs available [1]. To increase the availability of organs, it will be necessary to take action on several levels, both within organizations and by raising awareness in society. Immigration has increased greatly in Western Europe given the greater level of economic development in those countries. This development is having repercussions in the world of transplantation; consequently, most Western European countries are experiencing a considerable increase in the number of nonenative-born patients on the transplant waiting list, and requests for organs from non-native families also being ª 2017 Elsevier Inc. All rights reserved. 230 Park Avenue, New York, NY 10169
Transplantation Proceedings, 50, 319e322 (2018)
considered [2e5]. In Spain, this notable increase in the foreign population is creating a new social and demographic realities. The Latin American population shares important cultural, religious, and linguistic similarities with Spain, which makes their integration into Spanish society much easier. The Bolivian population is an emerging Latin American immigrant group in Spain. Currently, after the
*Address correspondence to Antonio Ríos-Zambudio, Avenida de la Libertad No. 208, Casillas, 30007 Murcia, Spain. E-mail: [email protected] 0041-1345/18 https://doi.org/10.1016/j.transproceed.2017.11.044
319
320
Ecuadorian population, Bolivians comprise one of the larger immigrant groups in Spain, and several have been transplanted or are awaiting transplantation. Our objective was to characterize the attitudes toward organ donation among Bolivians currently living in Spain. METHODS Population Screened The cohort studied consisted of those born in Bolivia but residing in Spain. To obtain an approximate number for this population, the latest census was used as a reference, which identifies the legal population of non-native residents, including those born in Latin American countries. According to the census, there are 11,311 legal resident Bolivians living in Spain. In addition, Spain has a large number of illegal residents from Bolivia, and thus various immigration organizations were consulted to estimate the size of this group. The total number of Bolivians living in Spain is estimated at 231,000.
Inclusion Criteria The population studied was >15 years old, and stratified by gender and age.
Appraisal Tool Attitude was assessed using a validated questionnaire of attitude toward Organ Donation and Transplantation (PCID-DTO Rios: A Questionnaire by the International Collaborative Donor Project About Organ Donation and Transplantation [Proyecto Colaborativo Internacional Donante sobre Donación y Trasplante de Organos], developed by Dr. Ríos). [6e8]. This questionnaire includes questions for subscales or validated factors in the Spanish population, with a total explained variance of 63.203% and a Cronbach’s a reliability coefficient of 0.834.
Fieldwork Research Participants were surveyed according to the stratification. The aforementioned support from immigration associations is Spain was needed to advise on the location of potential respondents. Study participation was anonymized and self-administered. Verbal consent was obtained prior to participation.
Statistics A descriptive statistic was performed, and Student’s t test, chisquare test, Fisher’s exact test, and logistic regression analysis were applied.
RESULTS Attitude Toward Donation of One’s Own Solid Organs
A total of 206 respondents were included in the study. Forty-nine percent (n ¼ 101) were in favor of donating their own organs after death, 21% (n ¼ 44) were against donation, and 30% (n ¼ 61) were undecided. Factors Affecting Attitude Toward Organ Donation
Among the sociopersonal variables, level of education was found to stand out, so those with a university education showed a more favorable attitude without education (57%
RÍOS, LÓPEZ-NAVAS, SÁNCHEZ ET AL
vs 28%; P ¼ .008) (Table 1). In the group of variables related to attitudes toward organ donation and transplantation, those with previous experience with the issue had a more favorable attitude (67% vs 45%; P ¼ .011), as did those who considered the possibility of future transplant versus those who had not (57% vs 39%; P ¼ .050). Among the social interaction and pro-social variables, those with a more favorable attitude toward organ donation of a family member also had it toward donation of own cadaveric organs (64% vs 38%; P ¼ .003). In addition, there was greater acceptance of donation among respondents who knew that their partners are in favor of donation compared with those against (85% vs 20%; P < .001). With regard to religious variables, those whose professed doctrine favors donation and transplant would also accept organ cadaveric donation compared with those whose religion did not accept this idea (59% vs 0%; P ¼ .001). Finally, among the variables related to attitude toward the body, the relationship between those who considered possible mutilation of the body after donation vs those who did not was also questioned, with the former group displaying a more positive attitude toward donation (66% vs 33%; P ¼ .002). Multivariate Analysis
In the multivariate study, it remained as an independent variable to have a partner who favors organ donation (odds ratio [OR] ¼ 16.129; P ¼ .003).
DISCUSSION
Bolivia is a Latin American country with a low economic development. Ethnically, the population is a mixture of the initial Spanish settlers and indigenous populations. Currently, Bolivia has a donation rate of <10 donors per cadaver per million population (pmp). This is due to 2 fundamental reasons: first, the high number of family refusals; and, second, the failure to detect brain death [1]. Our study data have shown that the attitude toward donation among Latin Americans residing in Spain is worse than that reported in the native Spanish population. This is illustrated by the population data reported by our group [9] using the same questionnaire, which showed that 63% of the native Spanish population is in favor of deceased organ donation, compared with 49% observed in the presented study. In Spain, the Bolivian population is young, with the mean age of our respondents being 30 years. This means that, in Bolivia, attitudes would be even less favorable because of the higher rate of older people, who tend to be less aware of issues related to organ donation and transplantation. Furthermore, in Spain, this is an exclusive population group within emigrant Latin Americans, due to the high costs associated with relocation, and this is reflected in the fact that 15% of respondents reported having completed university education. All of this leads us to believe that attitudes would be worse in the countries of origin of Latin
BOLIVIAN ORGAN DONATION ATTITUDES
321
Table 1. Variables Affecting Attitude Toward Deceased Organ Donation In Favor (n ¼ 101; 49%)
Bivariate analysis Sociopersonal variables Age (30 9 years) d Gender d Civil status d Have offspring d Level of education University studies Knowledge about and attitude toward organ donation and transplantation variables Personal experience with donation and transplant Yes Possibility of needing a transplant Yes Knowing concept of brain death d Social interaction and pro-social behavior variables Attitude toward organ donation of a relative In favor Family comment on donation and transplant d Opinion of couple toward donation and transplant In favor Performing pro-social activity d Religious variables Religion of respondent d Knowing attitude of religion toward transplant In favor Attitude toward the body variables Concern about mutilation after donation No Acceptance of incineration d Acceptance of burial d Acceptance of autopsy, if necessary d
Multivariate analysis Opinion of couple toward donation Against In favor Do not know No couple
Against (n ¼ 105; 51%)
P
d d d d Without studies
.925 .294 .469 .442 .008*
No Do not know d
.011* .050* .834
Against d Against d
.003* .063 <.001* .360
d Against
.157 .001*
Do not know d d d
.002* .160 .097 .253
(b)
SE
OR (95% CI)
2.788 0.988 0.791
0.941 0.851 0.922
1 16.129 (100e2.570) 2.688 (14.285e0.506) 2.207 (13.513e0.362)
.003* .246 .391
Abbreviations: b, regression coefficient; CI, confidence interval; OR, odds ratio; SE, standard error. *Statistically significant.
America, and also among Bolivians in more proximal countries such as the USA [10]. In Spain, a coordination system has been developed that has led to high donation rates, together with a quality control system that has reduced potential donor losses due to requests not being made for donation. The current tendency of Latin American governments is to promote organ donation and transplantation. Therefore, they work in close collaboration with the ONT (Spanish National Transplant Organization) with the aim of introducing the “Spanish model.” Consequently, there have been projects such as the Siembra and Alianza Project [1], in collaboration with the ONT, promoting the Spanish model and developing transplant programs for training professionals [1]. An analysis of the psychosocial profile of respondents found that most of the factors described in Western population studies also appear in the Bolivian population residing in Spain. The most important factor detected in this population relates mainly to the family. At the family level, it has been observed that discussing the matter in the family setting increases the chances of being in favor of donation and transplantation. In this context, the attitude of a
respondent’s partner toward donation is also fundamental: when the respondent knew that his/her partner was in favor, then the respondent clearly indicated a more favorable attitude. Therefore, it would seem beneficial to encourage dialog about matters of donation and transplantation within family circles and with one’s partner [11e19]. In conclusion, attitudes toward organ donation among Bolivians who reside in Spain is worse than that reported in the native Spanish population, and is determined by many psychosocial factors, mostly related to the family. REFERENCES [1] RedeConsejo Iberoamericano de Donación y Trasplante. Trasplante en Iberoamérica Newsletter 2016;10(1). monograph [in Spanish]. [2] Ríos A, Cascales P, Martínez L, et al. Emigration from the British Isles to south-eastern Spain: a study of attitudes toward organ donation. Am J Transplant 2007;7:2020e30. [3] Ríos A, Martínez L, Sánchez J, et al. German citizens in south-eastern Spain: a study of attitude toward organ donation. Clin Transplant 2010;24:349e57. [4] Ríos A, López-Navas A, Navalón JC, et al. The LatinAmerican population in Spain and organ donation. Attitude
322 toward deceased organ donation and organ donation rates. Transpl Int 2015;28:437e47. [5] Ríos A, López-Navas A, García JA, et al. The attitude of Latin American immigrants resident in Florida (USA) toward deceased organ donation. Transplant Int 2017;30:1020e31. [6] Ríos A, López-Navas A, López-López A, et al. A multicentre and stratified study of the attitude of medical students towards organ donation in Spain. Ethn Health 2017;30:1e19. [7] Ríos A, López-Navas A, Ayala-García MA, et al. Estudio multicéntrico hispano-latinoamericano de actitud hacia la donación de órganos entre profesionales de centros sanitarios hospitalarios. Cir Esp 2014;92:393e403 [in Spanish]. [8] Ríos Zambudio A, López-Navas A, Ayala-García MA, et al. Level of awareness of personnel in hospital services related to the donation process: a Spanish and Latin-American multicenter study. J Heart Lung Transplant 2012;31:850e7. [9] Conesa C, Ríos A, Ramírez P, et al. Estudio multivariante de los factores psicosociales que influyen en la actitud poblacional hacia la donación de órganos. Nefrología 2005;25:684e97 [in Spanish]. [10] Frates J, Garcia Bohrer G. Hispanic perceptions of organ donation. Prog Transplant 2002;12:169e75. [11] Ríos A, Ramírez P, Rodríguez MM, et al. Attitude of hospital personnel faced with living liver donation in a Spanish center with a living donor liver transplant program. Liver Transpl 2007;13: 1049e56. [12] Ríos A, Ramírez P, del Mar Rodríguez M, et al. Attitude of ancillary personnel faced with living kidney donation in a hospital
RÍOS, LÓPEZ-NAVAS, SÁNCHEZ ET AL with a living donor kidney transplant program. Transplantation 2007;83:336e40. [13] Ríos A, Martínez-Alarcón L, Sánchez J, et al. The quest for favourable subgroups to encourage living kidney donation in Spain. An attitudinal study among British and Irish citizens resident in southeastern Spain. Nephrol Dial Transplant 2008;23:1720e7. [14] Ríos A, Martinez L, Sánchez J, et al. Factors that influence the attitude of East European residents in Spain toward living kidney donation. Transpl Int 2009;22:707e16. [15] Ríos A, Martínez L, Sánchez J, et al. Attitude of the population of German origin in the South East of Spain toward living kidney donation. In search of favourable sub-groups for promoting living kidney donation in Spain. Nephron Clin Pract 2008;110:c133e8. [16] Ríos A, López-Navas A, Ayala-García MA, et al. A multicenter study in Spanish, Mexican and Cuban hospitals of attitude toward living kidney donation. Ann Transplant 2014;19: 96e103. [17] Ríos A, López-Navas A, Martínez-Alarcón L, et al. LatinAmericans in Spain and their attitude toward living kidney donation. Clin Transplant 2015;29:1054e62. [18] Ríos A, Ramírez P, Rodríguez MM, et al. Personnel in cadaveric organ transplant-related hospital units faced with living liver donation. An attitudinal study in a Spanish hospital with a cadaveric and living liver transplant programme. Liver Int 2007;27: 687e93. [19] Ríos A. International Collaborative Donor Project. Cir Esp 2018; 96: in press.
ABSTRACT Background. The Bolivian population is an emerging Latin American immigrant group in Spain, several of whom have been transplanted or are awaiting transplant. We aimed to assess attitudes toward organ donation among Bolivians currently residing in Spain. Method. The population screened was born in Bolivia but living in Spain, stratified by gender and age. The appraisal tool used was a questionnaire that assesses attitudes toward organ donation for transplant (“PCID-DTO Ríos”). Support from immigration associations in Spain was needed for advice on locations of potential respondents. Survey participation was anonymized and the questionnaire was self-administered. Verbal consent was obtained before participation. Results. There were 206 respondents: 49% (n ¼ 101) in favor of donating their organs after death; 21% (n ¼ 44) against donation; and 30% (n ¼ 61) undecided. Their attitudes were found to be associated with level of education (P ¼ .008), previous experience with donation and transplant (P ¼ .011), concern regarding mutilation after donation (P ¼ .002), knowing the attitude of their religion toward transplant (P ¼ .001), the opinion of their partner (P < .001), and the possibility of needing a future transplant (P ¼ .050). In the multivariate study, the main factor was having a partner in favor of organ donation (odds ratio ¼ 16.129; P ¼ .003). Conclusion. Attitudes toward organ donation among Bolivians residing in Spain are far more negative compared with rest of the Spanish population, due to various factors.
O
RGAN transplantation is a fully acceptable therapy, limited mainly by the shortage of organs available [1]. To increase the availability of organs, it will be necessary to take action on several levels, both within organizations and by raising awareness in society. Immigration has increased greatly in Western Europe given the greater level of economic development in those countries. This development is having repercussions in the world of transplantation; consequently, most Western European countries are experiencing a considerable increase in the number of nonenative-born patients on the transplant waiting list, and requests for organs from non-native families also being ª 2017 Elsevier Inc. All rights reserved. 230 Park Avenue, New York, NY 10169
Transplantation Proceedings, 50, 319e322 (2018)
considered [2e5]. In Spain, this notable increase in the foreign population is creating a new social and demographic realities. The Latin American population shares important cultural, religious, and linguistic similarities with Spain, which makes their integration into Spanish society much easier. The Bolivian population is an emerging Latin American immigrant group in Spain. Currently, after the
*Address correspondence to Antonio Ríos-Zambudio, Avenida de la Libertad No. 208, Casillas, 30007 Murcia, Spain. E-mail: [email protected] 0041-1345/18 https://doi.org/10.1016/j.transproceed.2017.11.044
319
320
Ecuadorian population, Bolivians comprise one of the larger immigrant groups in Spain, and several have been transplanted or are awaiting transplantation. Our objective was to characterize the attitudes toward organ donation among Bolivians currently living in Spain. METHODS Population Screened The cohort studied consisted of those born in Bolivia but residing in Spain. To obtain an approximate number for this population, the latest census was used as a reference, which identifies the legal population of non-native residents, including those born in Latin American countries. According to the census, there are 11,311 legal resident Bolivians living in Spain. In addition, Spain has a large number of illegal residents from Bolivia, and thus various immigration organizations were consulted to estimate the size of this group. The total number of Bolivians living in Spain is estimated at 231,000.
Inclusion Criteria The population studied was >15 years old, and stratified by gender and age.
Appraisal Tool Attitude was assessed using a validated questionnaire of attitude toward Organ Donation and Transplantation (PCID-DTO Rios: A Questionnaire by the International Collaborative Donor Project About Organ Donation and Transplantation [Proyecto Colaborativo Internacional Donante sobre Donación y Trasplante de Organos], developed by Dr. Ríos). [6e8]. This questionnaire includes questions for subscales or validated factors in the Spanish population, with a total explained variance of 63.203% and a Cronbach’s a reliability coefficient of 0.834.
Fieldwork Research Participants were surveyed according to the stratification. The aforementioned support from immigration associations is Spain was needed to advise on the location of potential respondents. Study participation was anonymized and self-administered. Verbal consent was obtained prior to participation.
Statistics A descriptive statistic was performed, and Student’s t test, chisquare test, Fisher’s exact test, and logistic regression analysis were applied.
RESULTS Attitude Toward Donation of One’s Own Solid Organs
A total of 206 respondents were included in the study. Forty-nine percent (n ¼ 101) were in favor of donating their own organs after death, 21% (n ¼ 44) were against donation, and 30% (n ¼ 61) were undecided. Factors Affecting Attitude Toward Organ Donation
Among the sociopersonal variables, level of education was found to stand out, so those with a university education showed a more favorable attitude without education (57%
RÍOS, LÓPEZ-NAVAS, SÁNCHEZ ET AL
vs 28%; P ¼ .008) (Table 1). In the group of variables related to attitudes toward organ donation and transplantation, those with previous experience with the issue had a more favorable attitude (67% vs 45%; P ¼ .011), as did those who considered the possibility of future transplant versus those who had not (57% vs 39%; P ¼ .050). Among the social interaction and pro-social variables, those with a more favorable attitude toward organ donation of a family member also had it toward donation of own cadaveric organs (64% vs 38%; P ¼ .003). In addition, there was greater acceptance of donation among respondents who knew that their partners are in favor of donation compared with those against (85% vs 20%; P < .001). With regard to religious variables, those whose professed doctrine favors donation and transplant would also accept organ cadaveric donation compared with those whose religion did not accept this idea (59% vs 0%; P ¼ .001). Finally, among the variables related to attitude toward the body, the relationship between those who considered possible mutilation of the body after donation vs those who did not was also questioned, with the former group displaying a more positive attitude toward donation (66% vs 33%; P ¼ .002). Multivariate Analysis
In the multivariate study, it remained as an independent variable to have a partner who favors organ donation (odds ratio [OR] ¼ 16.129; P ¼ .003).
DISCUSSION
Bolivia is a Latin American country with a low economic development. Ethnically, the population is a mixture of the initial Spanish settlers and indigenous populations. Currently, Bolivia has a donation rate of <10 donors per cadaver per million population (pmp). This is due to 2 fundamental reasons: first, the high number of family refusals; and, second, the failure to detect brain death [1]. Our study data have shown that the attitude toward donation among Latin Americans residing in Spain is worse than that reported in the native Spanish population. This is illustrated by the population data reported by our group [9] using the same questionnaire, which showed that 63% of the native Spanish population is in favor of deceased organ donation, compared with 49% observed in the presented study. In Spain, the Bolivian population is young, with the mean age of our respondents being 30 years. This means that, in Bolivia, attitudes would be even less favorable because of the higher rate of older people, who tend to be less aware of issues related to organ donation and transplantation. Furthermore, in Spain, this is an exclusive population group within emigrant Latin Americans, due to the high costs associated with relocation, and this is reflected in the fact that 15% of respondents reported having completed university education. All of this leads us to believe that attitudes would be worse in the countries of origin of Latin
BOLIVIAN ORGAN DONATION ATTITUDES
321
Table 1. Variables Affecting Attitude Toward Deceased Organ Donation In Favor (n ¼ 101; 49%)
Bivariate analysis Sociopersonal variables Age (30 9 years) d Gender d Civil status d Have offspring d Level of education University studies Knowledge about and attitude toward organ donation and transplantation variables Personal experience with donation and transplant Yes Possibility of needing a transplant Yes Knowing concept of brain death d Social interaction and pro-social behavior variables Attitude toward organ donation of a relative In favor Family comment on donation and transplant d Opinion of couple toward donation and transplant In favor Performing pro-social activity d Religious variables Religion of respondent d Knowing attitude of religion toward transplant In favor Attitude toward the body variables Concern about mutilation after donation No Acceptance of incineration d Acceptance of burial d Acceptance of autopsy, if necessary d
Multivariate analysis Opinion of couple toward donation Against In favor Do not know No couple
Against (n ¼ 105; 51%)
P
d d d d Without studies
.925 .294 .469 .442 .008*
No Do not know d
.011* .050* .834
Against d Against d
.003* .063 <.001* .360
d Against
.157 .001*
Do not know d d d
.002* .160 .097 .253
(b)
SE
OR (95% CI)
2.788 0.988 0.791
0.941 0.851 0.922
1 16.129 (100e2.570) 2.688 (14.285e0.506) 2.207 (13.513e0.362)
.003* .246 .391
Abbreviations: b, regression coefficient; CI, confidence interval; OR, odds ratio; SE, standard error. *Statistically significant.
America, and also among Bolivians in more proximal countries such as the USA [10]. In Spain, a coordination system has been developed that has led to high donation rates, together with a quality control system that has reduced potential donor losses due to requests not being made for donation. The current tendency of Latin American governments is to promote organ donation and transplantation. Therefore, they work in close collaboration with the ONT (Spanish National Transplant Organization) with the aim of introducing the “Spanish model.” Consequently, there have been projects such as the Siembra and Alianza Project [1], in collaboration with the ONT, promoting the Spanish model and developing transplant programs for training professionals [1]. An analysis of the psychosocial profile of respondents found that most of the factors described in Western population studies also appear in the Bolivian population residing in Spain. The most important factor detected in this population relates mainly to the family. At the family level, it has been observed that discussing the matter in the family setting increases the chances of being in favor of donation and transplantation. In this context, the attitude of a
respondent’s partner toward donation is also fundamental: when the respondent knew that his/her partner was in favor, then the respondent clearly indicated a more favorable attitude. Therefore, it would seem beneficial to encourage dialog about matters of donation and transplantation within family circles and with one’s partner [11e19]. In conclusion, attitudes toward organ donation among Bolivians who reside in Spain is worse than that reported in the native Spanish population, and is determined by many psychosocial factors, mostly related to the family. REFERENCES [1] RedeConsejo Iberoamericano de Donación y Trasplante. Trasplante en Iberoamérica Newsletter 2016;10(1). monograph [in Spanish]. [2] Ríos A, Cascales P, Martínez L, et al. Emigration from the British Isles to south-eastern Spain: a study of attitudes toward organ donation. Am J Transplant 2007;7:2020e30. [3] Ríos A, Martínez L, Sánchez J, et al. German citizens in south-eastern Spain: a study of attitude toward organ donation. Clin Transplant 2010;24:349e57. [4] Ríos A, López-Navas A, Navalón JC, et al. The LatinAmerican population in Spain and organ donation. Attitude
322 toward deceased organ donation and organ donation rates. Transpl Int 2015;28:437e47. [5] Ríos A, López-Navas A, García JA, et al. The attitude of Latin American immigrants resident in Florida (USA) toward deceased organ donation. Transplant Int 2017;30:1020e31. [6] Ríos A, López-Navas A, López-López A, et al. A multicentre and stratified study of the attitude of medical students towards organ donation in Spain. Ethn Health 2017;30:1e19. [7] Ríos A, López-Navas A, Ayala-García MA, et al. Estudio multicéntrico hispano-latinoamericano de actitud hacia la donación de órganos entre profesionales de centros sanitarios hospitalarios. Cir Esp 2014;92:393e403 [in Spanish]. [8] Ríos Zambudio A, López-Navas A, Ayala-García MA, et al. Level of awareness of personnel in hospital services related to the donation process: a Spanish and Latin-American multicenter study. J Heart Lung Transplant 2012;31:850e7. [9] Conesa C, Ríos A, Ramírez P, et al. Estudio multivariante de los factores psicosociales que influyen en la actitud poblacional hacia la donación de órganos. Nefrología 2005;25:684e97 [in Spanish]. [10] Frates J, Garcia Bohrer G. Hispanic perceptions of organ donation. Prog Transplant 2002;12:169e75. [11] Ríos A, Ramírez P, Rodríguez MM, et al. Attitude of hospital personnel faced with living liver donation in a Spanish center with a living donor liver transplant program. Liver Transpl 2007;13: 1049e56. [12] Ríos A, Ramírez P, del Mar Rodríguez M, et al. Attitude of ancillary personnel faced with living kidney donation in a hospital
RÍOS, LÓPEZ-NAVAS, SÁNCHEZ ET AL with a living donor kidney transplant program. Transplantation 2007;83:336e40. [13] Ríos A, Martínez-Alarcón L, Sánchez J, et al. The quest for favourable subgroups to encourage living kidney donation in Spain. An attitudinal study among British and Irish citizens resident in southeastern Spain. Nephrol Dial Transplant 2008;23:1720e7. [14] Ríos A, Martinez L, Sánchez J, et al. Factors that influence the attitude of East European residents in Spain toward living kidney donation. Transpl Int 2009;22:707e16. [15] Ríos A, Martínez L, Sánchez J, et al. Attitude of the population of German origin in the South East of Spain toward living kidney donation. In search of favourable sub-groups for promoting living kidney donation in Spain. Nephron Clin Pract 2008;110:c133e8. [16] Ríos A, López-Navas A, Ayala-García MA, et al. A multicenter study in Spanish, Mexican and Cuban hospitals of attitude toward living kidney donation. Ann Transplant 2014;19: 96e103. [17] Ríos A, López-Navas A, Martínez-Alarcón L, et al. LatinAmericans in Spain and their attitude toward living kidney donation. Clin Transplant 2015;29:1054e62. [18] Ríos A, Ramírez P, Rodríguez MM, et al. Personnel in cadaveric organ transplant-related hospital units faced with living liver donation. An attitudinal study in a Spanish hospital with a cadaveric and living liver transplant programme. Liver Int 2007;27: 687e93. [19] Ríos A. International Collaborative Donor Project. Cir Esp 2018; 96: in press.