Evaluation of Attitude toward Living Organ Donation among Adolescents in Southeast Spain

Evaluation of Attitude toward Living Organ Donation among Adolescents in Southeast Spain A. Ríos, B. Febrero, A. López-Navas, L. Martínez-Alarcón, J. Sánchez, D. Guzmán, P. Ramírez, and P. Parrilla ABSTRACT Introduction. The infant and youth population constitutes a sector in which early awareness is important to increase favorable attitudes toward donation. Objectives were as follows: (1) to analyze the attitudes of adolescents toward living organ donation; and (2) to determine the psychosocial variables affecting them. Materials and Methods. In Southeast of Spain a random sample was stratified according to Compulsory Secondary Education (CSO) school. In the 10 selected schools we performed a random sampling of each of the classes from the first to the fourth year of CSO. Attitudes were evaluated using a validated questionnaire lowering psychosocial aspects of donation. The self-administered questionnaire was completed anonymously. Statistical analyses employed Student t test and the ␹2 test. Results. Regarding living kidney donation, 89% (n ⫽ 3146) of adolescents favored it, although only 29% (n ⫽ 1035) in unrelated cases. For living liver donation, 78% (n ⫽ 2753) were in favor of related donation, but only 19% (n ⫽ 668) were in favor if it was unrelated. The favorable attitude toward living donation was mainly associated with the following variables: (1) being a woman; (2) having previous experience with the donationtransplantation process; (3) having spoken about the matter of donation and transplantation with family and friends; (4) a favorable attitude of one’s mother and father; (5) concern about possible bodily mutilation after donation; and (6) having performed pro-social type activities (P ⬍ .05). Conclusions. Related living donation is well accepted among adolescents on the Southeast of Spain. There was a high acceptance of unrelated living donation compared with studies published in other geographic areas.

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RGAN transplantation has gradually improved in terms of efficiency, providing a better quality of life. Given the ever-improving results, transplantation is indicated more frequently; therefore, the number of patients on waiting lists is ever increasing.1 This circumstance has made it necessary to develop other forms of organ procurement apart from deceased donation. Living organ donation

(LOD) is an ethically acceptable therapeutic option given the low level of risk to the donor and the good clinical results, although the situation is different for living kidney donation (LKD) versus living liver donation (LLD).2,3 Given that living donation is a theme of growing importance, it is important to determine the opinion of adolescents about this therapy and the factors affecting it, seeking

From the International Collaborative Donor Project (A.R., B.F., A.L.-N., L.M.-A., J.S., D.G., P.R.), Murcia, Spain; Regional Transplant Center (A.R., B.F., A.L.-N., L.M.-A., J.S., D.G., P.R.), Consejería de Sanidad y Consumo de la Región de Murcia, Spain; Transplant Unit (A.R., B.F., A.L.-N., L.M.-A., P.R., P.P.), General Surgery, Virgen de la Arrixaca University Hospital, Murcia, Spain, CIBEREHD; Department of Surgery (A.R., B.F.,

P.R., P.P.), University of Murcia, Murcia, Spain; Department of Psychology (A.L.-N.), UCAM, Universidad Católica San Antonio, Murcia, Spain. Address reprint requests to Dr. Antonio Ríos Zambudio, Avenida de la Libertad no. 208. Casillas, 30007, Murcia, Spain. E-mail: [email protected]

© 2012 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710

0041-1345/–see front matter http://dx.doi.org/10.1016/j.transproceed.2012.05.067

Transplantation Proceedings, 44, 1489 –1492 (2012)

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to increase future donation rates. The objectives of our study were as follows: (1) to analyze the attitudes of adolescents toward LOD, and (2) to determine the variables affecting these attitudes. MATERIALS AND METHODS Study Population Ten Compulsory Secondary Education (CSO) school in Southeast of Spain were stratified by geographic location. A random sample was obtained from classes in the first, second, third, and fourth year of CSO in each school.

about ODT (94% vs 86%; P ⬍ .001); (6) adolescents who had no fear of side effects (mutilation) after donation (93% vs 84%; P ⬍ .001); and (7) who believed that donation involved a low risk (95% vs 80%; P ⬍ .001). The results obtained upon multivariate analysis to assess the variables with most weight affecting attitude toward LKD showed the persistence of the following factors (Table 2): (1) attitude toward deceased donation; (2) conversations about ODT with family; (3) no fear of mutilation after donation; and (4) minimization of living donation risk. Attitudes Toward Related LLD

Instrument The measurement instrument was a validated questionnaire4 – 6 that was completed anonymously and self-administered.

Statistical Analysis The descriptive analysis applied Student t test and the ␹2 test together with an analysis of remainders.

RESULTS Study Completion

Among 3633 selected adolescents, the questionnaire completion rate for LKD was 98% (n ⫽ 3545) and for LLD it was 97% (n ⫽ 3535). Attitudes Toward Related LKD

In this study, 89% (n ⫽ 3146) of adolescents were in favor, 2% (n ⫽ 61) against, and 10% (n ⫽ 344) had doubts (Table 1). The attitude toward related LKD was more positive among the following: (1) women (90% vs 87%; P ⫽ .021); (2) adolescents who believe that they may need a transplantation at some point (92% vs 84%; P ⬍ .001); (3) a favorable attitude toward deceased donor organ donation transplantation (ODT; 95% vs 83%; P ⬍ .001); (4) those who had spoken about the subject with friends (91% vs 88%; P ⫽ .007) or family (92% vs 87%; P ⬍ .001); (5) adolescents who knew a positive opinion of their parents

In this study, 78% (n ⫽ 2753) were in favor, 3% (n ⫽ 115) against, and 19% (n ⫽ 680) unsure. The following variables affected attitudes toward related LKD: (1) a belief that one might need a transplant in the future (81% vs 74%; P ⬍ .001); (2) personal experience with transplantation (81% vs 77%; P ⫽ .024); (3) a favorable attitude toward deceased donation (85% vs 71%; P ⬍ .001); (4) conversations about ODT with friends (81% vs 77%; P ⫽ .022) or family (83% vs 75%; P ⬍ .001); (5) favorable opinions of parents (82% vs 76%; P ⬍ .001); (6) lack of fear of side effects after donation (84% vs 71%; P ⬍ .001); and (7) belief that donation involved a low risk (91% vs 70%; P ⬍ .001). The results obtained upon multivariate analysis showed the factors with most weight affecting attitudes toward LLD (Table 2): (1) attitudes toward deceased donation; (2) lack of fear of mutilation after donation; and (3) minimization of living donation risk. Attitude Toward Unrelated Living Donation

If the LKD was unrelated, 29% (n ⫽ 1035) were in favor, 17% (n ⫽ 609) against, and 54% (n ⫽ 1901) undecided. If the LLD were unrelated, 19% (n ⫽ 668) were in favor, 27% (n ⫽ 965) against, and 54% (n ⫽ 1902) with doubts. A favorable attitude toward both unrelated LOD was related to the following: (1) female gender; (2) a belief that one might need a transplant in the future; (3) personal experience with transplantation; (4) attitude toward deceased

Table 1. Attitude Toward Related LKD/LLD and Associated Psychosocial Variables Related LKD In Favor

Gender Age Possibility of needing a transplant Personal experience of transplantation and/or donation Attitude toward deceased donation Family discussion about ODT Talking about the matter with friends Parent’s opinion Religious attitude Fear of side effects after donation Risk of donation

Not in Favor

Related LLD P

In Favor

Not in Favor

P

Woman — Yes —

Man — No —

.021 .064 ⬍.001 .184

— — Yes Yes

— — No No

.135 .231 ⬍.001 .024

In favor Yes Yes In favor — No Low

Against - undecided No No Against - undecided — Yes High

⬍.001 ⬍.001 .007 ⬍.001 .146 ⬍.001 ⬍.001

In favor Yes Yes In favor — No Low

Against - undecided No No Against - undecided — Yes High

⬍.001 ⬍.001 .022 ⬍.001 .125 ⬍.001 ⬍.001

Note: P ⬍ .05 was considered statistically significant.

ATTITUDE TOWARD DONATION AMONG ADOLESCENTS

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Table 2. Analysis of the Factors Related to LOD Among Selected Adolescents in the Southeast of Spain: Multivariate Analysis Variable

LKD Attitude toward deceased donation Not in favor In favor Speak about ODT with family: No Yes Concern about mutilation after donation: I am concerned I am not concerned DK/NA Risk of LKD High Quite A little Low I do not know it LLD Attitude toward deceased donation Not in favor In favor Concern about mutilation after donation: I am concerned I am not concerned DK/NA Risk of LLD High Quite A little Low I do not know it

Regression Coefficient (␤)

Standard Error

Odds Ratio (Confidence Intervals)

P*

1.546

0.100

1 4.694 (5.714–3.861)

⬍.001

0.190

4.053

1 1.209 (1.455–1.005)

.044

0.549 0.328

0.101 0.259

1 1.730 (2.109–1.422) 1.388 (2.304–0.835)

⬍.001 .205

0.204 1.042 0.403 0.523

0.223 0.205 0.190 0.185

1 1.227 (0.792–1.901) 2.832 (4.237–1.897) 1.497 (2.169–1.030) 1.686 (2.427–1.175)

.361 ⬍.001 .034 .005

1.336

0.115

1 3.802 (4.761–3.039)

⬍.001

0.443 0.122

0.115 0.330

1 1.557 (1.949–1.243) 1.130 (0.591–2.159)

⬍.001 .712

0.254 0.309 1.371 0.354

0.183 0.162 0.231 0.160

1 1.289 (0.901–1.843) 1.362 (1.872–0.991) 3.937 (6.172–2.506) 1.424 (1.949–1.041)

.165 .056 ⬍.001 .027

Abbreviations: DK/NA, don’t know/not available. *P ⬍ .005 was considered statistically significant.

donation; (5) speaking about the matter with family or friends; (6) one’s mother and father’s opinion favoring ODT; and (7) lack of fear about side effects after donation (P ⬍ .05). DISCUSSION

Attitudes toward related LKD/LLD among Spanish adolescents were similar to those reported in the overall population.4,7 This aspect is of great relevance, given that adolescents of today represent the adults of tomorrow. They were well disposed to accepting LOD as well as other kinds of donation. When dealing with unrelated LOD, favorable attitudes ranged between 19% and 29%, which were favorable compared with those reported among the public at large.1,8,9 Kidney donation carries a low risk of morbidity and better transplant results compared with liver procedures; adolescents were aware of this difference. An analysis of the factors affecting better attitudes toward related LOD revealed 3 large groups of variables: those generally related to ODT, family factors, and fear of side effects as a consequence of LOD.9 There was a notably close relationship between LOD and factors of knowledge about and

attitude toward ODT.10 –12 A favorable attitude toward deceased ODT, a factor also reported among the public, encourages a favorable attitude toward LOD.4,7 Finally, among this group of factors the most noteworthy were those related to feelings of reciprocity; that is, doing to others what we would like to be done to ourselves if we were in such a situation. In this sense, it is more common to have a favorable attitude if the respondent believes that he or she might need a transplantation in the future.9 Another large group related to attitudes toward related LOD included variables of socio-familial interactions. To this effect, discussing the subject in the family and with one’s partner are factors that closely condition attitudes toward donation. These are factors that have been classically described in attitudes toward deceased organ donation10 –12; we have observed them repeated in LOD. In this sense, as indicated in the population, it is fundamental to encourage family dialogue about matters of ODT, given that this usually has a positive effect on attitudes toward LOD. To conclude, adolescents showed quite favorable attitudes toward related LKD/LLD. This favorable attitude is important to increase donation rates in the future. How-

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ever, most adolescents are unsure about unrelated LKD/ LLD. The attitudes were influenced by many psychosocial factors about which action should be taken so that adolescents develop more favorable attitudes in the future. REFERENCES 1. 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 13:1049, 2007 2. Chen PX, Yan LN: Health-related quality of life in living liver donors after transplantation. Hepatobiliary Pancreat Dis Int 10: 356, 2011 3. Mjøen G, Øyen O, Holdaas H, et al: Morbidity and mortality in 1022 consecutive living donor nephrectomies: benefits of a living donor registry. Transplantation 88:1273, 2009 4. Ríos A, Martínez 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 23:1720, 2008 5. Ríos A, Martínez L, Sánchez J, et al: Factors that influence the attitude of East European residents in Spain toward living kidney donation. Transplant Int 22:707, 2009

RÍOS, FEBRERO, LÓPEZ-NAVAS ET AL 6. Ríos A, Conesa C, Ramírez P, et al: Attitude survey of hospital workers in the surgical services towards living kidney donation. Transplant Proc 37:3621, 2005 7. Conesa C, Ríos A, Ramírez P, et al: Attitude of primary care nurses toward LKD. Transplant Proc 37:3626, 2005 8. Ríos A, Ramírez P, Rodríguez MM, et al: Personnel in cadaveric organ transplant-related hospital units faced with LLD: an attitudinal study in a Spanish hospital with a cadaveric and living liver transplant programme. Liver Int 27:687, 2007 9. Ríos A, Ramírez P, Rodríguez MM, et al: Attitude of ancillary personnel faced with living kidney donation in a hospital with a living donor kidney transplant program. Transplantation 83:36, 2007 10. Ríos A, Ramírez P, Martínez L, et al: Are personnel in transplant hospitals in favor of cadaveric organ donation? Multivariate attitudinal study in a hospital with a solid organ transplant program. Clin Transplant 20:743, 2006 11. 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 7:2020, 2007 12. Ríos A, Martínez L, Sánchez J, et al: German citizens in southeastern Spain: a study of attitude toward organ donation. Clin Transplant 24:349, 2010