- Email: [email protected]
Knowledge and Opinions of Deceased Organ Donation Among Middle and High School Students in Korea
Knowledge and Opinions of Deceased Organ Donation Among Middle and High School Students in Korea J. Chunga, D. Choib, and Y. Parkc,* a Sookmyung Girl’s High School, Gangnam-gu, Seoul, Republic of Korea; bDaewon Foreign Language School, Gwangjin-gu, Seoul, Republic of Korea; and cDepartment of Applied Statistics and Institute of Natural Sciences, Graduate School of Hanyang University, Seongdong-gu, Seoul, Republic of Korea
ABSTRACT Background. Adolescents are an important target group for organ donation education. As yet, little is known about the attitude of Korean adolescents toward deceased organ donation, or the factors related to their decision. In this study, we explored the knowledge and opinions of deceased organ donation among middle and high school students in Korea. Methods. A self-reported survey was conducted among middle and high school students in Seoul, Korea. The questionnaire assessed knowledge, personal experience, and opinions of organ donation. Logistic regression analysis was performed to determine significant factors associated with willingness to become an organ donor. Results. Of the 323 students, 161 (49.8%) were willing to be a deceased donor, and the other 162 (50.2%) were unwilling or unsure. Neither level of knowledge nor experience of recent public information on organ donation affected students’ decisions. Instead, a cohesive family environment and family discussion were strong predictors of the willingness of Korean middle and high school students to be an organ donor. Conclusions. A donation education program that promotes family communication and discussion about organ donation could increase willingness to be an organ donor among Korean adolescents.
T
HE DEMAND for donated organs has risen rapidly over the past decade. However, the supply remains insufficient, and the shortage of donated organs poses a major obstacle to saving lives. The situation in Korea is of particular concern. The number of deceased organ donors in Korea is only 8.4 per million people, which is far less than in European countries (35.1 million per people) or the United State (25.9 million per people) [1]. Education is essential to solving the organ shortage problem, and education programs tailored to target audiences are more effective [2,3]. Adolescents are an important target group for organ donation education because adolescence is a key stage in the development of human values, and a positive attitude toward organ donation instilled in adolescence will last a lifetime. In addition, adolescent education can promote discussion with family members about organ donation [3,4]. Therefore, identifying the characteristics associated with willingness to become a deceased organ donor among Korean adolescents will allow a more
targeted education program for this population, and potentially increase deceased organ donation in Korea in the future. However, little is known about Korean adolescents’ attitudes toward deceased organ donation or the factors related to their decision. Thus, we explored the knowledge and opinions of Korean adolescents, particularly middle and high school students, toward deceased organ donation, using a self-reported questionnaire. METHOD The study population included students attending middle or high school in Seoul, Korea. The purpose of the survey was explained in the classroom, and only those who wanted to enroll in the study *Address correspondence to Young-Sun Park, PhD, Department of Applied Statistics and Institute of Natural Sciences, Graduate School of Hanyang University, 222 Wangsimni-ro, Seongdong-gu, Seoul, 133-791, Republic of Korea. E-mail: [email protected]
ª 2015 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/15 http://dx.doi.org/10.1016/j.transproceed.2015.09.057
Transplantation Proceedings, 47, 2805e2809 (2015)
2805
2806 participated. This study was exempt from Ethical Committee review, according to Korean regulations, because it used a survey procedure and the information obtained was recorded in such a manner that human subjects cannot be indentified [5].
Content of Questionnaire Based on previous studies, the questionnaire was designed to gather information on student demographics, knowledge of organ donation and transplantation, personal experience with organ donation or transplantation, and opinions regarding deceased organ donation. Student Demographics. Respondents were asked to indicate their gender, age, and religion. Race and ethnicity were not included because almost all middle or high school students in Seoul are of Korean ethnicity.
Knowledge Regarding Transplantation and Deceased Donation. To assess the students’ level of knowledge regarding organ donation and transplantation, questions were asked regarding knowledge of the following: (1) the concept of brain death; (2) the fairness of the organ allocation system; (3) disparities in waiting times; and (4) the illegality of organ selling and buying. The response format for the questionnaire items was “yes” or “no.” Personal Experience. Students were asked yes-or-no questions about whether they have: (1) received any type of public information or education about organ donation within the past year; (2) any neighbor, friend, or family member who experienced organ donation and/or transplantation; (3) prior experience with blood donation; (4) a cohesive family environment indexed by response to the following statement: “My family members really care and support one another”; and (5) discussed organ donation with family members. Willingness to Donate Organs. To examine the students’ willingness to donate organs, we asked them to choose from among the following statements regarding their organ donation decision: (1) “Yes, I would like to become an organ donor after death”; (2) “No, I would not like to become an organ donor after death”; or (3)” I am not sure.” In addition, respondents were asked whether they have indicated on any document that they will be an organ donor in the future.
Statistics Groups were defined according to the willingness to become a deceased organ donor. The “donor group” consisted of respondents who answered “I would like to be an organ donor after death,” and the “nondonor group” comprised those who answered “No, I would not like to become an organ donor after death” or “I am not sure.” Data are summarized as means and standard deviations (SD) or as frequencies and percentages. Wilcoxon-Mann-Whitney tests and Fisher exact tests were used to examine differences between the 2 groups. A logistic regression analysis was performed to identify factors that significantly influenced respondents’ willingness to donate organs after death. Covariates included age (middle school [12e14 years] vs high school [15e16 years]), gender (boys vs girls), blood donation experience (no vs yes), acquaintances with experience of donation or transplantation (no vs yes), recent experience of organ donationerelated public education or information (no vs yes), discussion with family member on donation (no vs yes), and level of knowledge or organ donation (low vs high; dichotomized at the median sample score, 2 vs >2 questions answered correctly). We
CHUNG, CHOI, AND PARK calculated multivariable-adjusted odds ratios (OR) and the corresponding 95% confidence intervals (CI). Statistical analyses were conducted using the SAS software, package (version 9.3, SAS Institute, Cary, NC, United States). All tests were two-tailed and a P value of .05 was taken to indicate statistical significance.
RESULTS
Among the 327 questionnaires gathered, we excluded 4 questionnaires with missing data; the remaining 323 valid questionnaires were analyzed. Table 1 shows the demographic data of the respondents. Of the 323 total respondents, 161 (49.8%) students were classified into the donor group. The other 162 (50.2%) were classified into the nondonor group, of which 88 (27.2%) answered “No, I would not like to become an organ donor after death” and the remaining 74 (22.9%) answered “I’m not sure.” Among all of the participants, only 3 (0.9%) students carry a donor card. The differences in demographic characteristics between the donor and nondonor groups are listed in Table 2. High school students (66.3%) were more willing to become deceased donors than middle school students (43.6%). More girls than boys were willing to be deceased organ donors. The donor and nondonor groups did not differ with regard to religion. Table 3 presents students’ knowledge about organ transplantation and donation. Students were correct on an average of 2.43 0.88 of 4 questions, and there was no group difference in the number of correct answers between the donor and nondonor group. The relationship between personal experience and the donation decision is shown in Table 4. No differences were found between the donor group and nondonor group with respect to recent public donation education experience, donation or transplantation experience of acquaintances, or blood donation experience. However, a cohesive family environment was significantly more prevalent in the donor group compared with the nondonor group, and the donor Table 1. Demographic Characteristics of Students (n [ 323) Characteristic
Age (y; mean SD) Educational level Middle school students High school students Gender Boys Girls Religion No religion Have a religion Protestant Catholic Buddhist Other
13.54 1.06 234 (72.4) 89 (27.6) 155 (48.0) 168 (52.0) 174 149 86 42 19 2
(53.9) (46.1) (26.6) (13.0) (5.9) (0.6)
Note: Values are expressed as numbers (%), unless otherwise stated.
KNOWLEDGE AMONG MIDDLE AND HIGH SCHOOL STUDENTS Table 2. Comparision of Demographic Characteristics Between Donor and Nondonor Groups Characteristics
Educational level Middle school (12e14 y) High school (15e16 y) Gender Boys Girls Religion (%) No religion Have a religion
Donor Group (n ¼ 161)
Nondonor Group (n ¼ 162)
132 (56.41) 30 (33.71)
64 (41.29) 97 (57.74)
91 (58.71) 71 (42.26)
73 (48.99) 88 (50.57)
76 (51.01) 86 (49.43)
.0038
.8236
Note: Values are expressed as numbers (%), unless otherwise stated.
group had significantly greater experience of family discussion of donation when compared with the nondonor group. Table 5 shows the results of the logistic regression assessing the predictors of willingness to become an organ donor. Students age and gender, cohesive family environment, and discussion with family members of the donation issue were all associated with willingness to donate. Cohesive family environment and having discussed organ donation with family members were independent, strong Table 3. Comparison of Responses to Knowledege-Related Questions Between Donor and Nondonor Groups Knowledge Questions
1. Brian death concept: “A brain dead person can wake up in some cases.” (F) Correct Incorrect 2. Fairness of organ allocation system: “Donated organs are allocated by the doctor (s) who harvested the organ, per his/her own wish.” (F) Correct Incorrect 3. Disparities in waiting time: “In Korea, organ donation falls short of organ need.” (T) Correct Incorrect 4. Organ selling: “It is illegal to sell or buy an organ.” (T) Correct Incorrect Number of correct answers (mean SD)
Donor Group (n ¼ 161)
Nondonor Group (n ¼ 162)
Table 4. Personal Experience and Willingness to Become an Organ Donor Donor Group Nondonor Group (n ¼ 161) (n ¼ 162)
P
.0003 102 (43.59) 59 (66.29)
2807
Cohesive family relationship No Yes Blood donation experience No Yes Acquaintance with experience of organ donation or transplantation No Yes Recent public information exposure No Yes Discussion with family member on donation issue No Yes
P
.0182 8 (27.59) 153 (52.04)
21 (72.41) 141 (47.96)
142 (48.97) 19 (57.58)
148 (51.03) 14 (42.42)
.3650
.5857
125 (49.02) 36 (52.94)
130 (50.98) 32 (47.06) .4893
105 (51.47) 56 (47.06)
99 (48.53) 63 (52.94) .0085
107 (45.34) 54 (62.07)
129 (54.66) 33 (37.93)
Note: Values are expressed as numbers (%).
predictors of willingness to donate. In contrast, level of knowledge, prior experience of blood donation, acquaintance’s experience of donation or transplantation, and recent public education exposure showed no effect on donation decision.
P
.4613
DISCUSSION
49 (53.26) 112 (48.48)
43 (46.74) 119 (51.52) .9998
Our results show that cohesive family environment and family discussion are strong predictors of organ donation decisions among Korean middle and high school students. In contrast, level of knowledge of, and exposure to recent Table 5. Logistic Regression Assessing Predictors of Willingness to Become an Organ Donor Univariate Logistic Regression
94 (49.74) 67 (50.00)
Donation Characteristic
95 (50.26) 67 (50.00) .1978
136 (51.71) 25 (41.67)
127 (48.29) 35 (58.33) .7976
122 (50.41) 39 (48.15) 2.49 0.90
120 (49.59) 42 (51.85) 2.38 0.86
.2311
Note: Values are expressed as numbers (%) exept when otherwise stated. Abbreviations: F, false; T, true.
Gender Education level Cohesive family environment Blood donation Acquaintance’s experience of organ donation or transplantation Recent public education or information Discussion with family member on donation issue Knowledge level
OR
95% CI †
1.94 1.25, 3.02 2.55† 2.53, 4.24 2.85† 1.22, 6.62 NS NS NS NS
NS
NS
1.97† 1.19, 3.27 NS
NS
Multivariate Logistic Regression OR
95% CI
1.72* 1.08, 2.76 2.64† 1.56, 4.49 2.62* 1.07, 6.45 NS NS NS NS
NS
NS
1.90*
1.12, 3.22
NS
NS
Note: Referent ¼ gender (boy); education level (middel school); knowledge level (low: number of correct answers 2). Abbreviation: NS, not significant. *P < .05. † P < .01.
2808
public information on, donation did not affect the decision to donate of our sample of Korean teenagers. In the present study, 49.8% of the students answered that they would be willing to donate their organs after death. This is far less than the 99% of respondents with a positive attitude among medical students in the United States [6] or the 73% of teenagers in Spain [7]; this rate is also lower than that reported for mainland Chinese college students (64.1%) [8]. It has been reported that Asians are more reluctant to consent to organ donation compared with white people [2,9e11]. Asians’ negative attitude toward organ donation can be explained by the traditional Confucian culture, which includes a stronger concern about maintaining body integrity even after death [8,9,11,12]. The low rate of willingness to donate among our sample of Korean teenagers is in line with the previous studies of Asian subjects, and could also be due to the influence of the traditional Confucian culture. In this study, only 1% of the students had signed documents pertaining to donation consent. This is far less than 9.4% donor cardecarrying rate of US high school students [11]. The huge difference in donor card carrying rate between US and Korean teenagers can be explained with several reasons. First, unlike American teenagers, who are required to make a decision about organ donation when they apply for a driver’s license, Korean middle and high school students are not eligible to apply for a driver’s license. Thus, they do not have the same opportunity to confront the donation consent issue. Second, as explained above, the traditional Confucian culture remains a major influence in Korea. In the regions of Asia where the Confucian doctrine remains dominant, such as mainland China and Taiwan, the donor card carrying rate is around 3%, which is comparable with our results [8]. Concerning gender, some studies found no difference in donation decisions according to gender [7], but other studies, of US high school students [11] or Chinese university students [8], reported more favorable attitudes toward organ donation in female students. Our results are consistent with this latter result. High school students showed a more positive attitude toward organ donation than the middle school students in our study. Reports on the effect of age on donation decisions are inconsistent. While many studies have reported no correlation between age and donation decision, there have been some reports of a more favorable attitude toward donation among older students. A study of US high school students found that increased age was a significant predictor of organ donation [11]. Similarly, a study of Spanish teenagers reported a more positive attitude toward organ donation in those with secondary schooling or above (age >13 years) compared with those with primary schooling (<12 years) [7]. In this study, level of knowledge of organ donation or transplantation did not affect Korean middle and high school students’ donation decisions, which is contrary to many previous studies conducted in the United States or
CHUNG, CHOI, AND PARK
Europe [2,6,7,11] that have reported a positive relationship between level of knowledge and donation decision. However, a study by Bresnahan et al reported similar findings to our study: among the 426 college students from the United States, Japan, and Korea, only the Korean students failed to show any correlation between level of knowledge and organ donation decision [13]. These authors explained this lack of relationship between knowledge level and donation decision among Korean college students by referring to the traditional Confucian culture of Korea, which considers body integrity in terms of filial piety. In addition, recent exposure to public information about organ donation did not affect organ donation decisions among our sample of Korean middle and high school students. This may be explained partially by the traditional Confucian culture of Korea, but may also be explained by the paucity of donation education programs in Korea. Our results showed that only 36.9% (119/323) of Korean students had received public organ donationerelated information within the past year. In Korea, there are very few classroom-based donation education programs aimed especially at adolescents. This paucity of education programs could have been responsible for the low rate of exposure to organ donation information, which may have concealed the relationship between exposure to donationrelated public information and willingness to be a donor. Cohesive family environment and family discussion were strong predictors of organ donation decision among our sample of Korean middle and high school students. Students who had discussed donation with family members were more likely to donate their organs compared with those who had not. It has been consistently reported that family discussion is a strong predictor of organ donation in several different cultural areas [2,14e16]. The students in China and Japan, who share Confucian culture with Koreans, also showed a positive relationship between family discussion about deceased organ donation and positive attitudes toward donation [14]. Because they are of the Confucian culture, Koreans ascribe high value to family. A recent survey performed in Korea showed that 87.5% of respondents regarded “family” as the most important thing in their life [16]. Taking into consideration the strong family culture in Korea, our finding that family discussion is a strong predictor of donation decisions among Korean students appears intuitive. Our data suggest that familyoriented donation education programs may be effective for Korean teenagers. On the other hand, despite the strong relationship between family discussion and donation decisions among Korean students, only 25.9% of our sample had discussed the issue of donation with their family. Our results are comparable with previous reports from college students in traditional Chinese society, of whom only 25.8% had talked to family members about donation [14]. Similarly, a study performed in urban high school students in America reported that only 16% of Asian students had spoken with family members about organ donation, in contrast with the
KNOWLEDGE AMONG MIDDLE AND HIGH SCHOOL STUDENTS
rate of 53% recorded for white students [10]. There is a tradition in China of not talking about matters related to death or dying; mentioning death for any reason is considered to be unlucky, even today [13], and Chinese people are reluctant to mention deceased organ donation to their families because of this death anxiety [17]. Both Korea and China share similar traditions; discussion of matters related to death is also taboo in Korea. The present findings again suggest that an education program that improves family communication and promotes family discussion of death and deceased donation may be necessary for Korean teenagers. The current law in Korea allows family members to veto consent for deceased organ donation, such that familial consent is essential with respect to harvesting organs from the deceased. It is well documented that family communication and knowing the intentions of the deceased regarding organ donation are positively correlated with familial consent for deceased organ donation [15,18e20]. In this regard, promoting family discussion about organ donation will be essential to increase deceased organ donation in Korea. In summary, our study showed that a cohesive family environment and family discussion are strong predictors of positive organ donation decisions among Korean middle and high school students. Our results and the current law in Korea indicate that a donation education program focusing on the family to promote family discussion about organ donation will be an important strategy to increase the organ donation rate among Korean adolescents, and ultimately to increase deceased organ donation in Korea. REFERENCES [1] International Registry in organ donation and transplantation 2013. http://www.irodat.org/img/database/grafics/newsletter/IRODaT% 20Newsletter%202013%20.pdf. IRODaT Newletter 2014;4 [accessed July 25, 2015]. [2] Weaver M, Spigner C, Pineda M, Rabun KG, Allen MD. Knowledge and opinions about organ donation among urban high school students: pilot test of a health education program. Clin Transplant 2000;14:292e303. [3] Li AH, Rosenblum AM, Nevis IF, Garg AX. Adolescent classroom education on knowledge and attitudes about deceased organ donation: a systematic review. Pediatr Transplant 2013;17:119e28. [4] Cantarovich F, Cantarovich D. Education and organ donation: ‘the unfinished symphony’. Transpl Int 2012;25:e53e4.
2809 [5] http://www.irb.or.kr/Home/html/menu03/commonDeliberation Exemption.aspx. [accessed July 25, 2015]. [6] Essman C, Thornton J. Assessing medical student knowledge, attitudes, and behaviors regarding organ donation. Transplant Proc 2006;38:2745e50. [7] Conesa C, Rios Zambudio A, Ramirez P, Canteras M, del Mar Rodriguez M, Parrilla P. Socio-personal profile of teenagers opposed to organ donation. Nephrol Dial Transplant 2004;19: 1269e75. [8] Chen JX, Zhang TM, Lim FL, Wu HC, Lei TF, Yeong PK, et al. Current knowledge and attitudes about organ donation and transplantation among Chinese university students. Transplant Proc 2006;38:2761e5. [9] Cheung AH, Alden DL, Wheeler MS. Cultural attitudes of Asian-Americans toward death adversely impact organ donation. Transplant Proc 1998;30:3609e10. [10] Spigner C, Weaver M, Cardenas V, Allen MD. Organ donation and transplantation: ethnic differences in knowledge and opinions among urban high school students. Ethn Health 2002;7: 87e101. [11] Thornton JD, Wong KA, Cardenas V, Curtis JR, Spigner C, Allen MD. Ethnic and gender differences in willingness among high school students to donate organs. J Adolesc Health 2006;39:266e74. [12] Zhang L, Wang J, Kwauk S, Wu Q, Nielson K, Zeng F, et al. Preliminary analysis of factors influencing organ donation rates in China. Transplant Proc 2011;43:1421e4. [13] Bresnahan M, Lee SY, Smith SW, Shearman S, Nebashi R, Park CY, et al. A theory of planned behavior study of college students’ intention to register as organ donors in Japan, Korea, and the United States. Health Commun 2007;21:201e11. [14] Liu S, Liu C, Cao X, Shang B, Chen A, Liu B. The difference in the attitude of Chinese and Japanese college students regarding deceased organ donation. Transplant Proc 2013;45: 2098e101. [15] Murray L, Miller A, Dayoub C, Wakefield C, Homewood J. Communication and consent: discussion and organ donation decisions for self and family. Transplant Proc 2013;45:10e2. [16] Lee SM. Korean’s cultural perspective and ethics of transplantation. J Ethics Education Studies 2005;8:241e58. [17] Wu AM. Discussion of posthumous organ donation in Chinese families. Psychol Health Med 2008;13:48e54. [18] Martinez JM, Lopez JS, Martin A, Martin MJ, Scandroglio B, Martin JM. Organ donation and family decisionmaking within the Spanish donation system. Soc Sci Med 2001;53: 405e21. [19] Siminoff LA, Gordon N, Hewlett J, Arnold RM. Factors influencing families’ consent for donation of solid organs for transplantation. JAMA 2001;286:71e7. [20] Kim HS, Yoo YS, Cho OH. Satisfaction with the organ donation process of brain dead donors’ families in Korea. Transplant Proc 2014;46:3253e6.
ABSTRACT Background. Adolescents are an important target group for organ donation education. As yet, little is known about the attitude of Korean adolescents toward deceased organ donation, or the factors related to their decision. In this study, we explored the knowledge and opinions of deceased organ donation among middle and high school students in Korea. Methods. A self-reported survey was conducted among middle and high school students in Seoul, Korea. The questionnaire assessed knowledge, personal experience, and opinions of organ donation. Logistic regression analysis was performed to determine significant factors associated with willingness to become an organ donor. Results. Of the 323 students, 161 (49.8%) were willing to be a deceased donor, and the other 162 (50.2%) were unwilling or unsure. Neither level of knowledge nor experience of recent public information on organ donation affected students’ decisions. Instead, a cohesive family environment and family discussion were strong predictors of the willingness of Korean middle and high school students to be an organ donor. Conclusions. A donation education program that promotes family communication and discussion about organ donation could increase willingness to be an organ donor among Korean adolescents.
T
HE DEMAND for donated organs has risen rapidly over the past decade. However, the supply remains insufficient, and the shortage of donated organs poses a major obstacle to saving lives. The situation in Korea is of particular concern. The number of deceased organ donors in Korea is only 8.4 per million people, which is far less than in European countries (35.1 million per people) or the United State (25.9 million per people) [1]. Education is essential to solving the organ shortage problem, and education programs tailored to target audiences are more effective [2,3]. Adolescents are an important target group for organ donation education because adolescence is a key stage in the development of human values, and a positive attitude toward organ donation instilled in adolescence will last a lifetime. In addition, adolescent education can promote discussion with family members about organ donation [3,4]. Therefore, identifying the characteristics associated with willingness to become a deceased organ donor among Korean adolescents will allow a more
targeted education program for this population, and potentially increase deceased organ donation in Korea in the future. However, little is known about Korean adolescents’ attitudes toward deceased organ donation or the factors related to their decision. Thus, we explored the knowledge and opinions of Korean adolescents, particularly middle and high school students, toward deceased organ donation, using a self-reported questionnaire. METHOD The study population included students attending middle or high school in Seoul, Korea. The purpose of the survey was explained in the classroom, and only those who wanted to enroll in the study *Address correspondence to Young-Sun Park, PhD, Department of Applied Statistics and Institute of Natural Sciences, Graduate School of Hanyang University, 222 Wangsimni-ro, Seongdong-gu, Seoul, 133-791, Republic of Korea. E-mail: [email protected]
ª 2015 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/15 http://dx.doi.org/10.1016/j.transproceed.2015.09.057
Transplantation Proceedings, 47, 2805e2809 (2015)
2805
2806 participated. This study was exempt from Ethical Committee review, according to Korean regulations, because it used a survey procedure and the information obtained was recorded in such a manner that human subjects cannot be indentified [5].
Content of Questionnaire Based on previous studies, the questionnaire was designed to gather information on student demographics, knowledge of organ donation and transplantation, personal experience with organ donation or transplantation, and opinions regarding deceased organ donation. Student Demographics. Respondents were asked to indicate their gender, age, and religion. Race and ethnicity were not included because almost all middle or high school students in Seoul are of Korean ethnicity.
Knowledge Regarding Transplantation and Deceased Donation. To assess the students’ level of knowledge regarding organ donation and transplantation, questions were asked regarding knowledge of the following: (1) the concept of brain death; (2) the fairness of the organ allocation system; (3) disparities in waiting times; and (4) the illegality of organ selling and buying. The response format for the questionnaire items was “yes” or “no.” Personal Experience. Students were asked yes-or-no questions about whether they have: (1) received any type of public information or education about organ donation within the past year; (2) any neighbor, friend, or family member who experienced organ donation and/or transplantation; (3) prior experience with blood donation; (4) a cohesive family environment indexed by response to the following statement: “My family members really care and support one another”; and (5) discussed organ donation with family members. Willingness to Donate Organs. To examine the students’ willingness to donate organs, we asked them to choose from among the following statements regarding their organ donation decision: (1) “Yes, I would like to become an organ donor after death”; (2) “No, I would not like to become an organ donor after death”; or (3)” I am not sure.” In addition, respondents were asked whether they have indicated on any document that they will be an organ donor in the future.
Statistics Groups were defined according to the willingness to become a deceased organ donor. The “donor group” consisted of respondents who answered “I would like to be an organ donor after death,” and the “nondonor group” comprised those who answered “No, I would not like to become an organ donor after death” or “I am not sure.” Data are summarized as means and standard deviations (SD) or as frequencies and percentages. Wilcoxon-Mann-Whitney tests and Fisher exact tests were used to examine differences between the 2 groups. A logistic regression analysis was performed to identify factors that significantly influenced respondents’ willingness to donate organs after death. Covariates included age (middle school [12e14 years] vs high school [15e16 years]), gender (boys vs girls), blood donation experience (no vs yes), acquaintances with experience of donation or transplantation (no vs yes), recent experience of organ donationerelated public education or information (no vs yes), discussion with family member on donation (no vs yes), and level of knowledge or organ donation (low vs high; dichotomized at the median sample score, 2 vs >2 questions answered correctly). We
CHUNG, CHOI, AND PARK calculated multivariable-adjusted odds ratios (OR) and the corresponding 95% confidence intervals (CI). Statistical analyses were conducted using the SAS software, package (version 9.3, SAS Institute, Cary, NC, United States). All tests were two-tailed and a P value of .05 was taken to indicate statistical significance.
RESULTS
Among the 327 questionnaires gathered, we excluded 4 questionnaires with missing data; the remaining 323 valid questionnaires were analyzed. Table 1 shows the demographic data of the respondents. Of the 323 total respondents, 161 (49.8%) students were classified into the donor group. The other 162 (50.2%) were classified into the nondonor group, of which 88 (27.2%) answered “No, I would not like to become an organ donor after death” and the remaining 74 (22.9%) answered “I’m not sure.” Among all of the participants, only 3 (0.9%) students carry a donor card. The differences in demographic characteristics between the donor and nondonor groups are listed in Table 2. High school students (66.3%) were more willing to become deceased donors than middle school students (43.6%). More girls than boys were willing to be deceased organ donors. The donor and nondonor groups did not differ with regard to religion. Table 3 presents students’ knowledge about organ transplantation and donation. Students were correct on an average of 2.43 0.88 of 4 questions, and there was no group difference in the number of correct answers between the donor and nondonor group. The relationship between personal experience and the donation decision is shown in Table 4. No differences were found between the donor group and nondonor group with respect to recent public donation education experience, donation or transplantation experience of acquaintances, or blood donation experience. However, a cohesive family environment was significantly more prevalent in the donor group compared with the nondonor group, and the donor Table 1. Demographic Characteristics of Students (n [ 323) Characteristic
Age (y; mean SD) Educational level Middle school students High school students Gender Boys Girls Religion No religion Have a religion Protestant Catholic Buddhist Other
13.54 1.06 234 (72.4) 89 (27.6) 155 (48.0) 168 (52.0) 174 149 86 42 19 2
(53.9) (46.1) (26.6) (13.0) (5.9) (0.6)
Note: Values are expressed as numbers (%), unless otherwise stated.
KNOWLEDGE AMONG MIDDLE AND HIGH SCHOOL STUDENTS Table 2. Comparision of Demographic Characteristics Between Donor and Nondonor Groups Characteristics
Educational level Middle school (12e14 y) High school (15e16 y) Gender Boys Girls Religion (%) No religion Have a religion
Donor Group (n ¼ 161)
Nondonor Group (n ¼ 162)
132 (56.41) 30 (33.71)
64 (41.29) 97 (57.74)
91 (58.71) 71 (42.26)
73 (48.99) 88 (50.57)
76 (51.01) 86 (49.43)
.0038
.8236
Note: Values are expressed as numbers (%), unless otherwise stated.
group had significantly greater experience of family discussion of donation when compared with the nondonor group. Table 5 shows the results of the logistic regression assessing the predictors of willingness to become an organ donor. Students age and gender, cohesive family environment, and discussion with family members of the donation issue were all associated with willingness to donate. Cohesive family environment and having discussed organ donation with family members were independent, strong Table 3. Comparison of Responses to Knowledege-Related Questions Between Donor and Nondonor Groups Knowledge Questions
1. Brian death concept: “A brain dead person can wake up in some cases.” (F) Correct Incorrect 2. Fairness of organ allocation system: “Donated organs are allocated by the doctor (s) who harvested the organ, per his/her own wish.” (F) Correct Incorrect 3. Disparities in waiting time: “In Korea, organ donation falls short of organ need.” (T) Correct Incorrect 4. Organ selling: “It is illegal to sell or buy an organ.” (T) Correct Incorrect Number of correct answers (mean SD)
Donor Group (n ¼ 161)
Nondonor Group (n ¼ 162)
Table 4. Personal Experience and Willingness to Become an Organ Donor Donor Group Nondonor Group (n ¼ 161) (n ¼ 162)
P
.0003 102 (43.59) 59 (66.29)
2807
Cohesive family relationship No Yes Blood donation experience No Yes Acquaintance with experience of organ donation or transplantation No Yes Recent public information exposure No Yes Discussion with family member on donation issue No Yes
P
.0182 8 (27.59) 153 (52.04)
21 (72.41) 141 (47.96)
142 (48.97) 19 (57.58)
148 (51.03) 14 (42.42)
.3650
.5857
125 (49.02) 36 (52.94)
130 (50.98) 32 (47.06) .4893
105 (51.47) 56 (47.06)
99 (48.53) 63 (52.94) .0085
107 (45.34) 54 (62.07)
129 (54.66) 33 (37.93)
Note: Values are expressed as numbers (%).
predictors of willingness to donate. In contrast, level of knowledge, prior experience of blood donation, acquaintance’s experience of donation or transplantation, and recent public education exposure showed no effect on donation decision.
P
.4613
DISCUSSION
49 (53.26) 112 (48.48)
43 (46.74) 119 (51.52) .9998
Our results show that cohesive family environment and family discussion are strong predictors of organ donation decisions among Korean middle and high school students. In contrast, level of knowledge of, and exposure to recent Table 5. Logistic Regression Assessing Predictors of Willingness to Become an Organ Donor Univariate Logistic Regression
94 (49.74) 67 (50.00)
Donation Characteristic
95 (50.26) 67 (50.00) .1978
136 (51.71) 25 (41.67)
127 (48.29) 35 (58.33) .7976
122 (50.41) 39 (48.15) 2.49 0.90
120 (49.59) 42 (51.85) 2.38 0.86
.2311
Note: Values are expressed as numbers (%) exept when otherwise stated. Abbreviations: F, false; T, true.
Gender Education level Cohesive family environment Blood donation Acquaintance’s experience of organ donation or transplantation Recent public education or information Discussion with family member on donation issue Knowledge level
OR
95% CI †
1.94 1.25, 3.02 2.55† 2.53, 4.24 2.85† 1.22, 6.62 NS NS NS NS
NS
NS
1.97† 1.19, 3.27 NS
NS
Multivariate Logistic Regression OR
95% CI
1.72* 1.08, 2.76 2.64† 1.56, 4.49 2.62* 1.07, 6.45 NS NS NS NS
NS
NS
1.90*
1.12, 3.22
NS
NS
Note: Referent ¼ gender (boy); education level (middel school); knowledge level (low: number of correct answers 2). Abbreviation: NS, not significant. *P < .05. † P < .01.
2808
public information on, donation did not affect the decision to donate of our sample of Korean teenagers. In the present study, 49.8% of the students answered that they would be willing to donate their organs after death. This is far less than the 99% of respondents with a positive attitude among medical students in the United States [6] or the 73% of teenagers in Spain [7]; this rate is also lower than that reported for mainland Chinese college students (64.1%) [8]. It has been reported that Asians are more reluctant to consent to organ donation compared with white people [2,9e11]. Asians’ negative attitude toward organ donation can be explained by the traditional Confucian culture, which includes a stronger concern about maintaining body integrity even after death [8,9,11,12]. The low rate of willingness to donate among our sample of Korean teenagers is in line with the previous studies of Asian subjects, and could also be due to the influence of the traditional Confucian culture. In this study, only 1% of the students had signed documents pertaining to donation consent. This is far less than 9.4% donor cardecarrying rate of US high school students [11]. The huge difference in donor card carrying rate between US and Korean teenagers can be explained with several reasons. First, unlike American teenagers, who are required to make a decision about organ donation when they apply for a driver’s license, Korean middle and high school students are not eligible to apply for a driver’s license. Thus, they do not have the same opportunity to confront the donation consent issue. Second, as explained above, the traditional Confucian culture remains a major influence in Korea. In the regions of Asia where the Confucian doctrine remains dominant, such as mainland China and Taiwan, the donor card carrying rate is around 3%, which is comparable with our results [8]. Concerning gender, some studies found no difference in donation decisions according to gender [7], but other studies, of US high school students [11] or Chinese university students [8], reported more favorable attitudes toward organ donation in female students. Our results are consistent with this latter result. High school students showed a more positive attitude toward organ donation than the middle school students in our study. Reports on the effect of age on donation decisions are inconsistent. While many studies have reported no correlation between age and donation decision, there have been some reports of a more favorable attitude toward donation among older students. A study of US high school students found that increased age was a significant predictor of organ donation [11]. Similarly, a study of Spanish teenagers reported a more positive attitude toward organ donation in those with secondary schooling or above (age >13 years) compared with those with primary schooling (<12 years) [7]. In this study, level of knowledge of organ donation or transplantation did not affect Korean middle and high school students’ donation decisions, which is contrary to many previous studies conducted in the United States or
CHUNG, CHOI, AND PARK
Europe [2,6,7,11] that have reported a positive relationship between level of knowledge and donation decision. However, a study by Bresnahan et al reported similar findings to our study: among the 426 college students from the United States, Japan, and Korea, only the Korean students failed to show any correlation between level of knowledge and organ donation decision [13]. These authors explained this lack of relationship between knowledge level and donation decision among Korean college students by referring to the traditional Confucian culture of Korea, which considers body integrity in terms of filial piety. In addition, recent exposure to public information about organ donation did not affect organ donation decisions among our sample of Korean middle and high school students. This may be explained partially by the traditional Confucian culture of Korea, but may also be explained by the paucity of donation education programs in Korea. Our results showed that only 36.9% (119/323) of Korean students had received public organ donationerelated information within the past year. In Korea, there are very few classroom-based donation education programs aimed especially at adolescents. This paucity of education programs could have been responsible for the low rate of exposure to organ donation information, which may have concealed the relationship between exposure to donationrelated public information and willingness to be a donor. Cohesive family environment and family discussion were strong predictors of organ donation decision among our sample of Korean middle and high school students. Students who had discussed donation with family members were more likely to donate their organs compared with those who had not. It has been consistently reported that family discussion is a strong predictor of organ donation in several different cultural areas [2,14e16]. The students in China and Japan, who share Confucian culture with Koreans, also showed a positive relationship between family discussion about deceased organ donation and positive attitudes toward donation [14]. Because they are of the Confucian culture, Koreans ascribe high value to family. A recent survey performed in Korea showed that 87.5% of respondents regarded “family” as the most important thing in their life [16]. Taking into consideration the strong family culture in Korea, our finding that family discussion is a strong predictor of donation decisions among Korean students appears intuitive. Our data suggest that familyoriented donation education programs may be effective for Korean teenagers. On the other hand, despite the strong relationship between family discussion and donation decisions among Korean students, only 25.9% of our sample had discussed the issue of donation with their family. Our results are comparable with previous reports from college students in traditional Chinese society, of whom only 25.8% had talked to family members about donation [14]. Similarly, a study performed in urban high school students in America reported that only 16% of Asian students had spoken with family members about organ donation, in contrast with the
KNOWLEDGE AMONG MIDDLE AND HIGH SCHOOL STUDENTS
rate of 53% recorded for white students [10]. There is a tradition in China of not talking about matters related to death or dying; mentioning death for any reason is considered to be unlucky, even today [13], and Chinese people are reluctant to mention deceased organ donation to their families because of this death anxiety [17]. Both Korea and China share similar traditions; discussion of matters related to death is also taboo in Korea. The present findings again suggest that an education program that improves family communication and promotes family discussion of death and deceased donation may be necessary for Korean teenagers. The current law in Korea allows family members to veto consent for deceased organ donation, such that familial consent is essential with respect to harvesting organs from the deceased. It is well documented that family communication and knowing the intentions of the deceased regarding organ donation are positively correlated with familial consent for deceased organ donation [15,18e20]. In this regard, promoting family discussion about organ donation will be essential to increase deceased organ donation in Korea. In summary, our study showed that a cohesive family environment and family discussion are strong predictors of positive organ donation decisions among Korean middle and high school students. Our results and the current law in Korea indicate that a donation education program focusing on the family to promote family discussion about organ donation will be an important strategy to increase the organ donation rate among Korean adolescents, and ultimately to increase deceased organ donation in Korea. REFERENCES [1] International Registry in organ donation and transplantation 2013. http://www.irodat.org/img/database/grafics/newsletter/IRODaT% 20Newsletter%202013%20.pdf. IRODaT Newletter 2014;4 [accessed July 25, 2015]. [2] Weaver M, Spigner C, Pineda M, Rabun KG, Allen MD. Knowledge and opinions about organ donation among urban high school students: pilot test of a health education program. Clin Transplant 2000;14:292e303. [3] Li AH, Rosenblum AM, Nevis IF, Garg AX. Adolescent classroom education on knowledge and attitudes about deceased organ donation: a systematic review. Pediatr Transplant 2013;17:119e28. [4] Cantarovich F, Cantarovich D. Education and organ donation: ‘the unfinished symphony’. Transpl Int 2012;25:e53e4.
2809 [5] http://www.irb.or.kr/Home/html/menu03/commonDeliberation Exemption.aspx. [accessed July 25, 2015]. [6] Essman C, Thornton J. Assessing medical student knowledge, attitudes, and behaviors regarding organ donation. Transplant Proc 2006;38:2745e50. [7] Conesa C, Rios Zambudio A, Ramirez P, Canteras M, del Mar Rodriguez M, Parrilla P. Socio-personal profile of teenagers opposed to organ donation. Nephrol Dial Transplant 2004;19: 1269e75. [8] Chen JX, Zhang TM, Lim FL, Wu HC, Lei TF, Yeong PK, et al. Current knowledge and attitudes about organ donation and transplantation among Chinese university students. Transplant Proc 2006;38:2761e5. [9] Cheung AH, Alden DL, Wheeler MS. Cultural attitudes of Asian-Americans toward death adversely impact organ donation. Transplant Proc 1998;30:3609e10. [10] Spigner C, Weaver M, Cardenas V, Allen MD. Organ donation and transplantation: ethnic differences in knowledge and opinions among urban high school students. Ethn Health 2002;7: 87e101. [11] Thornton JD, Wong KA, Cardenas V, Curtis JR, Spigner C, Allen MD. Ethnic and gender differences in willingness among high school students to donate organs. J Adolesc Health 2006;39:266e74. [12] Zhang L, Wang J, Kwauk S, Wu Q, Nielson K, Zeng F, et al. Preliminary analysis of factors influencing organ donation rates in China. Transplant Proc 2011;43:1421e4. [13] Bresnahan M, Lee SY, Smith SW, Shearman S, Nebashi R, Park CY, et al. A theory of planned behavior study of college students’ intention to register as organ donors in Japan, Korea, and the United States. Health Commun 2007;21:201e11. [14] Liu S, Liu C, Cao X, Shang B, Chen A, Liu B. The difference in the attitude of Chinese and Japanese college students regarding deceased organ donation. Transplant Proc 2013;45: 2098e101. [15] Murray L, Miller A, Dayoub C, Wakefield C, Homewood J. Communication and consent: discussion and organ donation decisions for self and family. Transplant Proc 2013;45:10e2. [16] Lee SM. Korean’s cultural perspective and ethics of transplantation. J Ethics Education Studies 2005;8:241e58. [17] Wu AM. Discussion of posthumous organ donation in Chinese families. Psychol Health Med 2008;13:48e54. [18] Martinez JM, Lopez JS, Martin A, Martin MJ, Scandroglio B, Martin JM. Organ donation and family decisionmaking within the Spanish donation system. Soc Sci Med 2001;53: 405e21. [19] Siminoff LA, Gordon N, Hewlett J, Arnold RM. Factors influencing families’ consent for donation of solid organs for transplantation. JAMA 2001;286:71e7. [20] Kim HS, Yoo YS, Cho OH. Satisfaction with the organ donation process of brain dead donors’ families in Korea. Transplant Proc 2014;46:3253e6.