Attitudes and Behaviours of Students From the Faculty of Theology Regarding Organ Donation: A Study From Turkey

Attitudes and Behaviours of Students From the Faculty of Theology Regarding Organ Donation: A Study From Turkey M. Naçar, F. Çetinkaya, Z. Baykan, and S. Poyrazog˘lu ABSTRACT The aim of this study was to investigate the knowledge and attitude of students from the Faculty of Theology of Erciyes University regarding organ donation. This study comprising all students (n ⫽ 264) showed that 51.6% of subjects to the kidney is an organ that may be donated; other organs were less known. 16.5% of the students thought that organ donation is not in accord with Islamic beliefs; 22.0% thought that it is permitted in Islam for Muslims to donate to non-Muslims, and 23.6% were willing to accept organs from non-Muslims. 23.6% of the students were willing to donate their organs, whereas 57.3% were undecided. None of the students had an organ donation card. Among students who did not consider donation or were undecided, 16.5% stated that it was “religiously inappropriate” and 13.3% stated that they did not “approve the loss of body integrity.” Students declared that they had little knowledge regarding organ/tissue donation: 67.9% about the religious aspect, 78.9% about the legal aspect, and 80.5% about the scientific aspect. Only 24.6% of the group noted school education as their source of information, with 51.2% stating that they had been questioned about organ donation by society. With this study, we concluded that the student’s knowledge regarding organ donation was not sufficient. HE MAGNITUDE of insufficient organ donation, is even worse in Turkey.1–3 In most Western countries, organ transplantations are primarily performed with organs from deceased donors; whereas in Turkey, they usually require live donors, especially close family members.4,5 Organ donation rates in developed countries is 20 –30 per million with 33.6 in Spain, 25.2 in Belgium, 14.1 in Canada, 16.2 in France, 4.5 in Greece, and 0.9 in Turkey.1–3 Although organ transplantation is a promising treatment method for many patients, it brings challenging problems that are not solely medical but also have religious, legal, and ethical aspects.6 In a country like ours, in which the majority is Muslim, the religious aspect must not be overlooked as documented by, almost every investigator.7–9 The social resistance created by religious beliefs or traditions in Islamic countries hampers the provision of deceased donor organs.9 The Department of Religious Affairs, Religious Affairs High Council, has declared that organ donation is acceptable according to the Islam religion, which accepts human beings as sacred.10,11 In Turkey, a law regarding organ donation was passed in 1979 which provides legal grounds for this act.12 Awareness of the knowledge level and attitudes regarding organ donation

T

among future officials of the religion may enable us to plan strategies to increase their effectiveness in this field. We did not encounter any other study performed upon students from a Faculty of Theology, either in our country or abroad. METHODS This study conducted in April 2009 comprised all students (n ⫽ 264) of the Faculty of Theology, Erciyes University, Kayseri. Kayseri is one of the biggest cities in Turkey, with a total population of one million, located in the central Anatolia region of Turkey; it is an important commercial and industrial center. The Faculty of Theology was established by the Ministry of Education in 1965 as the third Higher Islamic Institute of Turkey within the status of a four-year education program. Students who graduate from the Faculty of Theology can be employed as Religion Culture and Ethics teachers at the Ministry of Education or in Imam Hatip high schools or as imams, muftis, or preachers. The four-year From the Departments of Medical Education (M.N., Z.B.) and Departments of Public Health (F.Ç., S.P.), Erciyes University Medical Faculty, Kayseri, Turkey. Address reprint requests to Dr Melis Naçar, Departments of Medical Education, Erciyes University Medical Faculty, Kayseri, Turkey. E-mail: [email protected]

© 2009 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710

0041-1345/09/$–see front matter doi:10.1016/j.transproceed.2009.09.084

Transplantation Proceedings, 41, 4057– 4061 (2009)

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4058 school includes 152 first-year, 36 second-year, 21 third-year, and 55 fourth-year students. Approval for this study planned to be performed by a questionnaire was obtained from the Ethical Committee of Erciyes University and from the school administration. The questionnaire was completed by all students (n ⫽ 246) who accepted to participate with their written consent. One student from first year, five students from second year, three students from third year, and four students from fourth year did not participate, because either they did not want to or they were not present at the time; the participation rate was 93.2%. Together with defining questions, the questionnaire included 30 questions about which organs could be transplanted and legal regulations; if they wanted to donate and the reason for the decision; whether it was religiously appropriate to donate; the status of organ donation; possession of a donation card; and the sufficiency of their knowledge regarding organ donation. The question about which organs can be transplanted was open ended. To prevent influence from each other, the questionnaire distributed to students was completed under the supervision of a research worker. The question “do you consider donating your organs” was a closed-end question. The persons who answered the question as “yes,” were grouped in terms of motivation about the topic the ones who gave “no” or “don’t know” as an answer were assumed to be not motivated. Family income state was asked as a 5-point Likert scale; students responded as they assessed it. Data from the study were transferred into an SPSS 13.0 program for analysis using chi-square tests.

RESULTS

The 246 students who answered the questionnaire showed a mean age of 21.2 years (range 17 to 45) with 78.5% women. The number of first-year students in the study was 146 (59.3%); second year 31 (12.6%); third year 18 (7.3%), and fourth year 51 (20.7%). 93.9% had graduated from Imam Hatip high schools. We observed that respondents showed better awareness of kidney (51.2%), heart (39.4%), and cornea (24.8%) transplantation among the commonly translated organs/tissues. Only 16.7% of students knew where to donate the organ. The percentage of students who were aware that brain death was necessary before taking the organs of a person was 65.4%, that personal verbal consent was not sufficient for organ donation was 48.8%, and that a person can decide which organ to donate was 62.6%. Among the entire group, 95.5% of students stated that they wanted to learn more about organ/tissue transplantation. 68.7% of the students had obtained information about organ/tissue transplantation from television/newspapers, 32.9% from class/school, 20.2% from religious publications, 15.6% from the internet, 6.6% from health personnel, and 2.8% from friends, family, and/or foundations/associations. There was no obvious difference between male and female students, but men were less willing to donate. There was no significant relationship between willingness of students for organ donation and year, gender, or economic status. The rate of organ donation, though not significant, was higher among students who had graduated from Imam Hatip than from normal high schools. Although there was no significant difference in the desire to donate among

NAÇAR, ÇETINKAYA, BAYKAN ET AL

students who were interested in organ donation and had researched religious aspects, the desire for organ donation was significantly greater among those that thought that they had sufficient knowledge about organ transplantation. Although the desire to donate organs was higher among students who had a relative or acquaintance awaiting an organ-tissue transplantation, there was no significant difference in the desire among students who knew someone who underwent organ tissue transplantation. DISCUSSION

Because organ donation is a social matter, it needs the thorough attention of health personnel as well as social, law, and media workers and especially religious officials. When attitudes toward organ donation are evaluated, it is frequently noticed that negativity is related to religious beliefs. But the Islamic religion has approved life-saving procedures, including organ transplantation.11,12 From this perspective, support of religious officials becomes important. Among the theology students in the present study, 51.6% knew that the kidney could be donated; the other organs were less well known. Studies performed in medical faculties and vocational health schools show slightly higher knowledge levels about organ donation.13,14 Even in a study that evaluated the knowledge level of the general population, the data were a bit higher than in the present study.15,16 The fact that the knowledge of students from health-related schools was greater is an expected one. But religious officials, who are expected to influence society in a positive way in the near future, should show better knowledge than the general population. The Islamic religion permits organ transplantation as long as the person is dead at the moment of removal of the tissue or organ. Knowledge about brain death was evident in 65.4% of students. Despite financial profit from tissue or organ donation being forbidden both by Turkish law and by Islam, only 38.6% of students were not aware of it and six students even stated that the possibility that you could sell your organs was “thought provoking.” Knowing where to donate the organ is important both for the transformation of attitudes into behaviors and to perform their roles as consultants. Only 16.7% of students knew where to refer individuals who desired organ donation although the rate was not high among medical and nursing school students either.13,14 These results again demonstrate the need for education in all field. In this study, 16.5% of students thought that organ donation was not religiously appropriate (Table 1). These results are consistent with similar studies conducted among the general Türkish population and among students,13–16 despite the Turkish Department of Religious Affairs stating that organ transplantation has no religious inconvenience.10 Whereas 23.6% of students were willing to donate their organs, 57.3% were undecided (Table 1). The rates among students in vocational health studies in Turkey were 36.%

ATTITUDES OF THEOLOGY STUDENTS

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Table 1. Attitudes Toward Organ Donation Belief or Attitude

Stated organ donation is not in accord with Islamic belief Believing that it is permitted in Islam to donate Muslims to non-Muslims Willing to accept organs from non-Muslims when needed Willing to donate organs after death Yes No Undecided Has signed an organ donor card Willing to accept organs from other people when needed Willing to donate their organs to close relatives in their lifetime when it is necessary Wanting to donate dead relatives’ organs/tissues Believing characteristics of the person they were donating their organs to to be important Reported researching religious publications on donation Stated they were questioned about organ donation by the society Stated school education as a source of information Stated they never donated blood

n

%

31

12.6

54

22.0

58

23.6

58 47 141 0 146

23.6 19.1 57.3 0.0 59.3

189

76.8

101 108

41.1 43.9

101 126

41.1 51.2

80 186

32.5 75.6

and 52.4%, respectively,14 and in the last year of medical study were 72.3% and 1.5%, respectively.13 None of the subjects in our study had an organ donation card. Among 291 religious officials in Antalya, only one stated that he would donate his organs.3 This rate was 14.1% among students in the last medical year.13 In another study of health personnel, the rates were doctors 37.5% and nurses 55.1%.17 In a study conducted in England, 43% of medical students and 74.2% of nurses had expressed willingness toward donation.18 A study from Poland documented that people were unwilling to sign the donation cards because brain death was perceived to be a vague definition.19 When studies are evaluated in general, on the one hand thoughts about organ donation are positive but on the other hand the rates of donation are low.3,13 There is no doubt that a decision favoring organ donation is a stressful event for the relatives of a person with brain death. In the present study, 41% of the students stated that they would donate the organs of a relative with brain death; the rate among religious officials was 47%.3 In a study conducted in Bursa, there was a 53.6% rate among the general population.16 In our study, 43.9% of the students stated that the characteristics of the person to whom they were donating their organs was important. 28% of religious officials in Antalya feared that their organs would go to people of whom they did not approve.3 In a study conducted with English Muslims,20 most people did not want to donate or receive organs from non-Muslims, because they ate pork, drank alcohol, or smoked cigarettes. The question about whether organ donation is religiously appropriate is the most common issue that people ask

religious officials in the Islamic population. An insufficient or erroneous comment from a religious official can move the population in the wrong direction. 51.2% of students stated that they were questioned about organ donation by the society. Ten participants in an English study stated that they wanted to cancel their donor cards on account of the advice of their imam.21 Among the present students, 75.6% had never donated blood. In this study, 37.2% of students who stated that they would donate their organs, had decided to do so because “they wanted to save lives,” 28.6% because “it could happen to them,” and 20.6% because “they would acquire merit” (Table 2). Previous studies have shown that donations that were made without a family relationship or emotional reasons were based on religious beliefs.3,16 In the study from Antalya, 86.0% of religious officials stated that organ donation was a matter of human dignity based on a solid Muslim belief.3 Among students who did not consider donation or were undecided, 16.5% stated that it was “religiously inappropriate” and 13.3% that they did not “approve of the loss of body integrity.” In a study conducted among religious officials in Turkey, the reasons of refusing organ donation were 17% for the preservation of body integrity after death and 28% for the fear of their organs being transplanted into someone whom they did not like.3 In Bursa, 26.2% of the people stated that it was because of religious concerns they did not consider organ donation.16 Due to insufficient knowledge regarding the legal and religious aspects of organ donation, people approach the subject skeptically at first; they display a negative attitude based on religious reasons. It has been shown that instruction of society about organ donation and transplantation Table 2. Reasons for Considering and Objecting Organ Donation

Consenting to organ donation (n ⫽ 58) Save others’ life Considering “it could happen to them” Thinking “they would acquire merit” Knowing a person waiting for organ/tissue transplantation Other reasons* Objecting to organ donation or undecided (n ⫽ 188) Stated that it was “religiously inappropriate” Did not “approve the loss of body integrity” Fear about obtaining tissue/organ before dead Obtaining financial profit from tissue or organ donation Fear Not to distribute organs Other reasons†

n

%

49 39 30 11

84.5 67.2 51.7 19.0

4

6.9

31 25 22 19

16.5 13.3 11.7 10.1

13 8 5

6.9 4.3 2.7

A student can give more than one answer. *Influenced by media and environment, human dignity. † I’m afraid of reaction society, I don’t have enough knowledge about this subject, I don’t know who will take my organ.

4060

NAÇAR, ÇETINKAYA, BAYKAN ET AL

positively affects their attitudes.2 Religious officials from Antalya stated that the low donation rate was due to wrong and insufficient knowledge.3 In the present study, the students acknowledged insufficient information: 67.9% in the religious aspects, 78.9% in the legal aspects, and 80.5% in the scientific aspects (Table 3). In a study conducted among medical students, 66.0% stated that their knowledge was insufficient.13 Religious scholars can raise social awareness only with the knowledge received during their education. In the Faculty of Theology where this study was conducted, lessons about this topic are taught in the fourth year; however, they are optional. Therefore, many students start their professional life without receiving sufficient education, with only 32.9% citing education as an information source. Only 24.6% of imams in Turkey stated that school education was these source of information.3 The rates of acceptance of organ donation were 22.6% among male and 22.8% among female students, an insignificant difference (Table 4). The rates of organ donation, though not statistically significant, were higher among students who had graduated from Imam Hatip compared with normal high schools. Although there was no significant difference in the desire to donate among students who were interested in this procedure and among those who had made some research about the religious aspects, the desire was significantly higher among those that thought that they had sufficient knowledge about organ transplantation. This result shows that one reason for a negative attitude may be a need to investigate the topic. Although the desire to donate their organs was higher among students who had a relative or acquaintance awaiting an organ-tissue transplantation, the lack of a significant difference among students who did or did not know someone who underwent organ/tissue transplantation is an interesting result. Knowing someone awaiting an organ increases experience about organ donation with development of a more positive attitude. A large-scale study performed nationwide in England revealed that people thought of donating their organs for the first time after the loss of a relative who was on the waiting list for an organ.22 Studies emphasize that, when people are reminded of the fact that someday they themselves or a relative may be in need of an organ, their fears and concerns about donation and transplantation are avilled and they gain a different point of view.2,15,22,23 In conclusion, this study allowed us to establish the low and insufficient level of knowledge about organ/tissue donation among theology students, who will be at the cornerTable 3. Knowledge Regarding Organ/Tissue Donation in Religious, Legal, and Scientific Aspects (%) Knowledge About Organ/ Tissue Transplantation

Religious aspects Scientific aspects Legal aspects

Fully Sufficient

Not Fully Sufficient

Insufficient

4.1 0.4 0.8

28.0 19.1 20.3

67.9 80.5 78.9

Table 4. Willingness to Donate Organs According to Some Variables Willingness

␹2

P Value

24.7 16.1 16.7 27.5

1.951

.583

12 46

22.6 23.8

0.033

.856

92 149 5

25 31 2

27.2 20.8 40.0

2.044

.360

15 231

1 57

6.7 24.7

2.535

.111

101 145

26 32

25.7 22.1

0.446

.504

10 69 167

5 20 33

50.0 29.0 19.8

6.345

.042

14 232

7 51

50.0 22.0

5.752

.016

27 219

10 48

37.0 21.9

3.049

.081

Variables

n

n

%

Total Year 1 2 3 4 Gender Male Female Economic status High Moderate Low High school Normal high school Imam Hatip high school Interested in organ donation and made some research about the religious aspects Yes No Knowledge about organ/tissue transplantation in the religious aspects Fully sufficient Not fully sufficient Insufficient Had relative or acquaintance waiting for organ/tissue transplantation Yes No Had someone they knew who underwent organ/tissue transplantation Yes No

246

58

23.6

146 31 18 51

36 5 3 14

53 193

stones of education and attitude transformation of the general population. REFERENCES 1. Shaheen FA: Organ donation in the Middle East countries. Ethn Dis 19(1 Suppl 1):16, 2009 2. Gäbel H, Ahonen J, Södal G, Lamm L: Cadaveric organ donation in Scandinavia, 1992. Transplant Proc 26(3):1715, 1994 3. Keçeciolu N, Tuncer M, Yücetin L, Akaydin M, Yakupolu G: Attitudes of religious people in Turkey regarding organ donation and transplantation. Transplant Proc 32:629, 2000 4. Simpkin AL, Robertson LC, Barber VS, Young JD: Modifiable factors influencing relatives’ decision to offer organ donation: systematic review. BMJ 338:b991, 2009 5. Haberal MA: Living donor kidney transplantation: how far should we go? Urol J 1:148, 2004 6. Golmakani MM, Niknam MH, Hedayat KM: Transplantation ethics from the Islamic point of view. Med Sci Monit 11:105, 2005 7. Rady MY, Verheijde JL: Islam and end-of-life organ donation. Asking the right questions. Saudi Med J 30:882, 2009

ATTITUDES OF THEOLOGY STUDENTS 8. Odell J, Boyce S, Siddall S: Tissue donation: the benefit of a positive approach. Nurs Stand 13:66 – 8, 70 –1, 1998 9. Woo KT: Social and cultural aspects of organ donation in Asia. Ann Acad Med Singapore 21:421, 1992 10. Düzenli Y: Organ transplantation on basis of Islamic resources. Turkiye Klin J Med Ethics 13:125, 2005 11. el-Shahat YI: Islamic viewpoint of organ transplantation. Transplant Proc 31:3271, 1999 12. Dontlu AÇ: Organ bag˘ıs¸ı naklinde etik, dinsel ve yasal yaklas¸ımlar. Dialysis Transplant Burns 15:69, 2004 13. Naçar M, Çetinkaya F, Kanyımaz D, Tokgöz B, Utas¸ C: Hekim adaylarnn organ nakline bakıs¸ açıar. J Turkish Soc Nephrol 10:123, 2001 14. Özmen D, Çetinkaya AÇ, Sarızeybek B, Zeybek A. Knowledge and views of students of the Celal Bayar University Manisa School of Health towards organ donation. Turkiye Klin J Med Sci 28:311, 2008 15. Ozdag N: Public awareness and acceptance of tissue and organ donation. EDTNA ERCA J 30:188, 2004 16. Bilgel H, Bilgel N, Okan N, Kilicturgay S, Ozen Y, Korun N: Public attitudes toward organ donation. A survey in a Turkish community. Transpl Int 4:243, 1991

4061 17. Akgün HS, Bilgin N, Tokalak I, Kut A, Haberal M: Organ donation: a cross-sectional survey of the knowledge and personal views of Turkish health care professionals. Transplant Proc 35: 1273, 2003 18. Cantwell M, Clifford C: English nursing and medical students’ attitudes towards organ donation. J Adv Nurs 32:961, 2000 19. Rowin ´ski W, Lao M, Wałaszewski J, Lisik W: Social, legal and medical limitations of organ transplantation in Poland. Ann Transplant 1:36, 1996 20. Aslam M, Hameed W: UK Muslim graduates need more information about organ donation and transplant. Transpl Int 21:92, 2008 21. Alkhawari FS, Stimson GV, Warrens AN: Attitudes toward transplantation in U.K. Muslim Indo-Asians in west London. Am J Transplant 5:1326, 2005 22. Passey S: The ultimate gift. Nurs Times 93:26, 1997 23. Davis C, Randhawa G: The influence of religion on organ donation and transplantation among the Black Caribbean and Black African population—a pilot study in the United Kingdom. Ethn Dis 16:281, 2006