Changing Attitude to Organ Donation and Transplantation in University Students During the Years of Medical School in Italy

Changing Attitude to Organ Donation and Transplantation in University Students During the Years of Medical School in Italy P. Burra, M. De Bona, D. Canova, M. C. D’Aloiso, G. Germani, R. Rumiati, M. Ermani, and E. Ancona ABSTRACT The shortage of organ donations is a major limiting factor in transplant programs. Since a favorable attitude of health professionals to organ donation can positively influence the decision of families of potential donors, educating physicians early in their careers may become crucial in this setting. The aim of this study was to compare medical student opinions on organ donation and transplantation at different stages in their undergraduate career. Methods. Medical students were prospectively surveyed in their first and fourth years by an anonymous 10-item questionnaire. Results. The 100 of 195 (51.3%) students completed both questionnaires including 29 men, of an overall cohort mean age 23.7 (range, 22–32 years). 91% of the students had attended classical or scientific high school and 83% were Catholic. Their attitude to transplantation remained strongly positive (96% vs 92%, fourth vs first year). 96% of the fourth year students would accept an human donor organ or an artificial organ (vs 95% of first year) and 91% would accept an animal organ (vs 84%). The students showed a positive attitude to organ donation (96% vs 91%, fourth vs first year). Most of them were prepared to donate their organs after death (88% vs 87%). 63% of the fourth year students signed a donor card. In conclusion, medical student attitudes to organ donation and transplantation are highly positive, but do not improve during the first 3 years of Medical School. An educational program is therefore needed.

I

N SPITE of improvements in graft and patient survival, the shortage of organ donations continues to be a major limiting factor in transplant programs. To increase the number of potential and actual donors, artificial and bioartificial organs, “non– heart-beating donors” and suboptimal donors have been used, but worldwide more than 20% of patients on waiting lists (mainly liver and heart) die every year because of the shortage of donor organs.1 Public attitudes to cadaveric organ donation and transplantation are influenced by many factors, including education, socio-economic status, culture and religion.2,3 Many studies have emphasized that young people generally have a more positive attitude to organ donation than other population groups.4,5 The majority of teenagers are aware of the scarcity of donations and recognize that ignorance of transplantation activities is an important reason for people’s unwillingness to donate organs.2–5 We have previously reported that first year university students in Italy are well informed about organ transplantation and the problem of organ donation.6 © 2005 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 37, 547–550 (2005)

Education programs have recently been suggested as a new approach to solving the organ shortage. The general population, and the student population in particular, need to be educated about transplantation and the need to accept the commitment to donate organs.1 However, information is still lacking on medical student opinions about organ donation and the educational role of medical studies in this setting. The aims of this study were therefore: to assess the knowledge of and attitude to organ donation and transplantation among medical students and to evaluate the impact of 3 year of medical studies on these opinions.

From the Department of Surgical and Gastroenterological Science University Hospital of Padua, Padua, Italy. Address reprint requests to Dr P. Burra, University Hospital of Padua Via Giustiniani 2, Padua 35128, Italy. 0041-1345/05/$–see front matter doi:10.1016/j.transproceed.2004.12.255 547

548

METHODS The study population consisted of medical undergraduates, who were prospectively surveyed in their first and the fourth years. A 10-item questionnaire with multiple-choice questions was structured into four sections evaluating (i) social and demographic data (gender, city, and year of birth) and information on previous schooling, religious beliefs and hobbies; (ii) attitude to organ transplantation; (iii) attitude to organ donation; (iv) knowledge of problems related to organ transplantation. Questionnaires were distributed to students at the end of lectures and were completed anonymously immediately after their distribution. No information was given to students who completed the first year questionnaire. The background and reasons for the survey were explained to students who completed the fourth year questionnaire. Statistical analysis: The data are expressed as percentages (%) of answers to each question. Since not all students answered all the questions, group sizes may vary slightly among questions. The chi-square test and Student “t” test were used when appropriate to assess the significance of the relationship between variables; Pvalues ⬍ .05 were considered significant.

RESULTS Socio-demographic data

Of the 195 students who had completed the first year questionnaire, only 100 (51.3%) also completed the fourth year questionnaire (29 men, 71 women; mean age 23.7 years, range 22–32). Data on socio-demographic aspects, hobbies, religious beliefs and previous schooling are shown in Table 1. Attitude to transplantation

Among the fourth year students, transplantation was considered a life-saving procedure for end-stage organ disease by 96% of the students (92% in first year). If necessary for themselves, 96% of the students would accept an organ from a human donor (97% in the first year) and 96% would accept an artificial organ (95% in the first year). More fourth than first year students would accept an animal organ (91% vs 84%, respectively). The idea of transplantation was rejected by 4% of the students, who justified their attitude mainly on ethical-moral (34%) and immunological-infectious grounds (28%), as compared to 37% and 29% in the first year, respectively. Gender, education, town or country upbringing, hobbies and religious beliefs did not correlate with a positive opinion of transplantation in either the first or the fourth year evaluations. Attitude to organ donation

At both the time points, most students were prepared to donate their organs after death (fourth vs first years students, 88% vs 87%) and 78% of them would donate any organs, without preference or restriction. Female students had a more positive attitude to organ donation than males, in both the first and the fourth year evaluation (P ⫽ .03 and P ⫽ .04, respectively). A town or country upbringing, hobbies and religious beliefs did not correlate with the attitude to organ donation.

BURRA, DE BONA, CANOVA ET AL Table 1. Main Characteristics of the Study Population Characteristics

Gender Males Females Age (ys) Mean Range Coming from Village Small town (⬍ 100.000 inhabitants) City (⬎ 100.000 inhabitants) Hobbies* Music Sport Reading Informatics Painting Previous education High school Classical Scientific College Technical Language Teacher training Other Religious beliefs Catholic Muslim Protestant No religion Other/did not specify

N

29 71 23.7 22–32 35 29 36 87 43 41 53 34 91 34 57 7 3 2 2 2 83 1 2 11 3

*Total ⬎ 100 because students could indicate more than one hobby.

About 12% of students had a negative attitude to organ donation. They did not change their minds during the 3 years of medical studies: 6% expressed doubts about the validity of the criteria used to ascertain brain death, while 3% and 3% justified their opinion on philosophical or ethical-moral grounds, respectively. Sixty-three percent of fourth year students had signed a donor card. No donor card data were available on the first year students for comparison because donor cards had not yet been introduced in Italy. Problems with transplantation

The students were questioned on three different aspects. When queried whether they knew that some people need a transplant to stay alive, 94% of the fourth year students and 92.1% of the first year students knew that organ transplantation is sometimes the only therapeutic option. When queried whether they knew of the paucity of donations in Italy, more fourth year students than first year students (96% vs 91%) recognized this fact. Asked whether they knew that patients on the waiting list often die before an organ becomes available: 96% of the fourth year students and 91% of the first year students were

CHANGING ATTITUDE TO ORGAN DONATION

aware that the waiting lists are so long that people often die before being transplanted. About 7% of the first year students, but only 2% of the fourth year students failed to answer these questions. DISCUSSION

The results of this prospective survey show that most medical students have a positive attitude to organ transplantation and donation, however, their understanding on the topic did not improve significantly during medical school. Medical student opinions were strongly positive already at the beginning of their university course: more than 95% of first year students approved of organ transplantation and 87% of them would donate their organs after death. These findings are better than what might have been expected, although recent reports have shown that the younger generation has a more positive attitude to organ donation than other population groups.4,5 In Spain, three out of four teenagers would be prepared to donate, compared with 65% in the rest of the population.7,8 We previously reported that 87% of university students in five different courses (Medicine, Agriculture, Veterinary Medicine, Psychology and Educational Sciences) were prepared to donate their organs after death. Most of them would accept transplantation as a life-saving procedure for themselves or a loved one from a human donor (97%), an artificial source (95%) or an animal donor (76%).6 On the whole, however, findings on this topic are disappointing: a survey in Turkey showed that 49.5% of university students were apparently willing to donate their organs after death, but a much smaller percentage (13.8%) had already formally indicated their will to do so.9 In Italy, about 80% of high school students reported a positive opinion on living kidney donation, but their opinion on cadaveric grafts was less positive: only 37% of students would consent to organ donation, if they had to choose for a brain-dead close relative and about 25% of them rejected organ donation.10 This survey focused on medical students because how physicians see organ donation may be a crucial factor in organ procurement rates. It has been suggested that a favorable attitude of health professionals to organ donation can positively influence the decision of the family of a potential donor.11,12 Educating physicians early in their careers may be fundamental to solve the problem of the chronic organ shortage. When students’ opinions were reassessed after 3 years of medical school, no significant differences emerged in their attitude toward transplantation and organ donation. Well-educated individuals with good social support systems, strong emotional support and social involvement more often take a positive stand on questions regarding organ donation after their own or a relative’s death,13 as confirmed by the high percentage of students prepared to donate their organs after death. Moreover, the impact of a successful organ transplantation activity at our institution since 1985, and the introduction of the Italian

549

law on tacit consent in April 1999 may help to explain the large proportion of students reporting a positive attitude to organ transplantation and donation. In fact, the organ donation rate has increased in Italy from 14.3 donors per million inhabitants (range, 3.1–31.4) in 2000 to 17.1 in 2001, a rise of 12.3% over the previous year.14 As to the influence of social and educational background on people’s opinions on transplantation and organ donation, female gender emerged as being more strongly associated with a positive attitude than male gender, confirming the previous findings that women generally have a more positive attitude to donating their own or a close relative’s organs after death, and to the idea of accepting a cadaveric graft.4,13 A town country upbringing, hobbies and schooling did not correlate with the attitude regarding organ donation and transplantation in our first and fourth year medical students. In particular, religious beliefs had no influence on students’ attitudes to transplantation and organ donation, though our survey only considered Catholics and nonreligious students. The main monotheistic religions accept allo-transplantation, leaving the potential donor free to decide for himself.15 However, religious beliefs are an important reason why people refuse to donate. A survey on 5600 Swedish inhabitants aged 18 to 75 years found a negative correlation between religious beliefs and willingness to donate organs after death: those who believed in God or an after-life were less prepared to donate their organs. People who chose cremation were more in favor of giving up their organs after death than those who preferred to be buried.16 People with religious beliefs associated with an intact body on with respect for ancestors or nature (Confucian and Buddhist values) consider the problem of bodily integrity after death a significant impediment to organ donation.17,18 In our survey, the majority of students preferred to receive an organ from a human or an artificial source than from an animal donor, a finding consistent with the tendency of the general population.3,19 The fourth year students reported greater acceptance of animal donors than first year students, probably due to their better knowledge of the use of animals in biomedical research. Only a minority of students reported a negative attitude to organ donation, usually because they were doubtful about the criteria for ascertaining “brain death.” This finding confirmed previous reports of an inadequate understanding (even among medical students) of the concepts of brain death and organ procurement.20 –22 The psychological difficulty to accept the idea of a heartbeat in a brain-dead individual was especially great for people with a lower cultural background.4,17,23 The three questions dealing with problems of organ transplantation and the waiting list were the most likely to go unanswered. This observation could indicate uncertainty or ignorance of these specific topics, despite the student’s being aware that organ transplantation is the only thera-

550

peutic option for many people who risk of dying while waiting for an organ. The results of the survey show that, despite an initially good awareness about transplantation and organ donation, the students knowledge in this setting did not significantly improve during the first three years of medical school. Their understanding was still lacking in some areas. These findings support the need to expand the content of education and expand discussion on the clinical and conceptual aspects of organ recruitment during a medical student’s formal education. An education program is needed, strongly focusing on medical students (as the future health care professionals who will be the first people to establish a relationship with the potential donor’s family) in order to improve their knowledge about transplantation and organ donation issues. REFERENCES 1. Cantarovich F: Improvement in organ shortage through education. Transplantation 73:1844, 2002 2. Boulware LE, Ratner LE, Sosa JA, et al: Determinants of willingness to donate living related and cadaveric organs: identifying opportunities for intervention. Transplantation 73:1683, 2002 3. Sanner MA: Giving and taking - to whom and from whom? People’s attitudes toward transplantation of organs and tissue from different sources. Clin Transplantation 12:530, 1998 4. Sanner MA: A Swedish survey of young people’s views on organ donation and transplantation. Transpl Int 15:641, 2002 5. Keiding S, Jensen SL, Vilstrup H: Attitude of the population to organ transplantation. Ugeskr Laeger 156:2869, 1994 6. Canova D, De Bona M, Rupolo G, et al: Italian university students’ attitude to transplantation and organ donation. 11th Congress of the European Society for Organ Transplantation (ESOT), Venice, Italy, September 20 –24, 2003 (Abstract) 7. Perkins KA: The shortage of cadaver donor organs for transplantation: can psychology help? Am Psychol 42:921, 1987 8. Martinez JM, Martin A, Lopez JS: La opinion publica espagnola ante la donacion y el trasplante de organos. Med Clin 105:401, 1995

BURRA, DE BONA, CANOVA ET AL 9. Kececioglu N, Tuncer M, Yucetin L, et al: Attitudes of religious people in Turkey regarding organ donation and transplantation. Transplant Proc 32:629, 2000 10. Soragna G, Carrano R, Putaggio S, et al: Opinions on renal transplantation and organ donation in high school students in two large Northern (Torino) and Southern (Napoli) Italian cities. Transplant Proc 36:428, 2004 11. Bartucci MR: Organ donation: a study of the donor family perspective. J Neurosci Nurs 19:305, 1987 12. Stocks LC, Kress T, Lewino D: Dispelling myths regarding organ donation: the donor family experience. J Transpl Coord 2: 147, 1992 13. Östergren PO, Gäbel H: Influence of social support and study course on attitudes of 18-year-old students toward cadaveric organ donation and transplantation. Transpl Proc 25:1702, 1993 14. http://www.ministerosalute.it/trapianti/ (accessed: August 20, 2004) 15. Gillman J: Religious perspectives in organ donation. Crit Care Nurs 22:19, 1999 16. Sanner MA, Hedman H, Tufveson G: Evaluation of an organ-donor-card campaign in Sweden. Clin Transplantation 9: 326, 1995 17. La Spina F, Sedda L, Pizzi C, et al: Donor-families’ attitude toward organ donation. Transpl Proc 25:1699, 1993 18. Lam WA, McCullough LB: Influence of religious and spiritual values on the willingness of Chinese-Americans to donate organs for transplantation. Clin Transplantation 14:449, 2000 19. Ward E: Attitudes to xenotransplantation. Lancet 349:1775, 1997 20. Bardell T, Hunter DJ, Kent WD, et al: Do medical students have the knowledge needed to maximize organ donation rates? Can J Surg 46:453, 2003 21. Afonso RC, Buttros DA, Sakabe D, et al: Future doctors and brain death: what is the prognosis? Transplant Proc 36:816, 2004 22. Dutra MM, Bonfim TA, Pereira IS, et al: Knowledge about transplantation and attitudes toward organ donation: a survey among medical students in northeast Brazil. Transplant Proc 36: 818, 2004 23. Martin A, Rossaro L: Liver transplantation in Italy and scarcity of donors: causative factors and ethical consideration. Gastroenterol Jpn 28:S34, 1993