Original Clinical Science
Knowledge, Attitudes, and Willingness Toward Organ Donation Among Health Professionals in China Dongmei Hu, MS1,2,3 and Hai Huang, PhD1,2
Background. The purposes of this study were to assess the knowledge, attitudes, and willingness toward organ donation among the health professionals in China. Methods. Questionnaires were delivered to 400 health professionals from 7 hospitals in Dalian and 1 hospital in Chaozhou of China between October 2013 and January 2014. Results. In all, 400 health professionals
were approached, 373 valid responses were returned. Over 90% of the participants knew about organ donation, but only 17.4% had taken part in some training courses or lectures about organ donation. Health professionals (64.9%) knew the shortage status of organ, and doctors knew more than nurses and nonclinical staffs (P < 0.01). Health professionals (97.3%) knew brain death, and 68.9% professionals thought brain death was the reasonable criteria to judge death. Doctors showed a higher knowledge level about brain death than nurses and nonclinical staffs (P < 0.01). Altogether, 60.1% approved deceased donation; however, only 48.5% approved living donation. Doctors' attitudes were more positive than nurses and nonclinical both in deceased donation (P < 0.01) and in living donation (P < 0.05). In all, 49.3% were willing to donate their own organs postmortem, and doctors had higher willingness to donation postmortem compared with nurses and nonclinical staffs (P < 0.01). The most (49.2%) commonly cited reason for refraining from donation was: “afraid that organs would be picked up inhumanely and body would be disfigured”. Conclusions. Health professionals showed lower favorable attitudes and willingness toward organ donation than Chinese general public. A proportion of Chinese health professionals' knowledge about organ donation was limited. (Transplantation 2015;99: 1379–1385)
O
rgan transplantation has become the most effective treatment for saving patients who have had organ failure. Despite these contemporary advances, there has been a relatively slow progress in the supply of organs for transplantation. Worldwide, there is a chronic imbalance between the number of donors and the numbers of patients on a waiting list in need for organ transplantation.1 The situation in China is of particular concern. Over one million end-stage organ failure patients need organ transplantations, whereas only 0.01 million of them receive transplants every year in China.2 A solution to the high demand and critical shortage is to increase the number of organs from donors. The numbers of donors per million population (pmp) are higher in Received 20 January 2015. Revision requested 10 March 2015. Accepted 18 March 2015. 1
Graduate School, South Medical University, Guangzhou, China.
2
Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, China.
3
Public Health School, Dalian Medical University, Dalian, China.
This project was supported by Science Plan Key Project of Guangdong Province in China. The authors declare no conflicts of interest. All authors conceived and designed the study. H.H. reviewed the article and approved the final version. D.H. provided data collection, data analysis and wrote the article. Correspondence: Hai Huang, PhD, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, China. ([email protected]). Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0041-1337/15/9907-1379 DOI: 10.1097/TP.0000000000000798
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the western countries. Some countries in Europe have rates between 6 pmp (in Greece, 2006) and 33 pmp (in Spain, 2006),3 as compared to lower rate in Asian countries, such as Iran (1.8 pmp, 2006),4 Japan (0.08 pmp, 2007),5 South Korea (0.97 pmp, 2007),5 especially in China, the organ donation rate is only 0.03 pmp.2 Thus, increasing organ donation rate is an important public health issue in China. Some researchers have reported that there is a positive correlation between knowledge toward organ donation and the donation behavior.6-9 In a study on a group of rural critical care nurses, McCoy and Bell10 concluded that knowledge and positive attitudes were important when providing support to families and care for potential donors, which could increase the supply of donors for transplants. On the other hand, health professionals play a pivotal role in the organ procurement process, based on their intimate relationship with patients and their families. They are well placed to identify a potential donor and to approach the bereaved family. It has been suggested that their knowledge, beliefs, and attitudes toward organ donation have been shown to influence public awareness and willingness to register.11,12 Insufficient knowledge and failure to identify possible donors are considered important contributing factors responsible for the shortage of available organs.9,13 Thus, knowing their knowledge, attitudes, and willingness toward organ donation is essential. Several analyses of health professional attitudes toward organ donation have been performed in other countries.11,14-18 However, few researches have been undertaken on knowledge, attitudes, and willingness of health professional about organ donation in China. www.transplantjournal.com
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The aim of this study was to determine the level of knowledge, attitude, and willingness toward organ donation among health professionals in China. In doing this, we hoped that the results would be helpful to improve attitudes and willingness of health professionals toward organ donation. At the same time, we hoped to provide useful information for the Chinese government to develop appropriate policies and laws.
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performed to test for differences in proportions of categorical variables between 2 or more groups. All statistical calculations were performed using SPSS13.0 (SPSS, Inc., Chicago, IL). Statistical tests were 2-sided, and a level of 0.05 was considered to indicate statistical significance.
RESULTS Demographics
MATERIALS AND METHODS Study Population and Questionnaire Distribution
October 2013 to January 2014, anonymous self-administered questionnaires were randomly distributed to health professionals in 7 hospitals of Dalian and 1 hospital in Chaozhou, China. The participants of this study consisted of doctors, nurses, and nonclinical staffs, including technical staff and managers, who came from various departments of the hospitals including medicine unit, surgical unit, pediatric unit, intensive care unit, renal unit, emergency ward, hematology unit, cardiac care unit, and administration section. Participants were asked to fill in the questionnaires during grand rounds of the individual departments, and the questionnaires were collected immediately afterward. The survey was approved by Dalian Medical University's ethics committee. Each questionnaire was accompanied with an information sheet describing back ground and purpose for survey. All participants were encouraged to participate without any undue pressure. To ensure the respondents' privacy, the study was voluntary and anonymous; we did not collect the content forms. Returning a completed questionnaire indicated informed consent for study participation. Instrument
We designed a questionnaire that was divided into 2 parts1: demographics, including sex, age, job category, educational level, marital status, and religion2; core questions related to health professional's knowledge (8 items), attitudes (4 items), and willingness regarding organ donation(4 items), which consisted of 14 single choice questions and 2 multiple choice questions. The questionnaire was pilot-tested on a random sample of 30 health professionals regarding wording and time needed for completion. The average time to complete the questionnaire was 3 minutes. After the pilot testing, 2 items that were misunderstood by most responders in the original questionnaire were modified. The content validity index of the questionnaire was determined by distributing the modified questionnaire to 2 experts who have experience in the area of organ donation. The testretest reliability was tested by 50 health professionals at a 2-week interval. The coefficient was 0.85, which reflecting a good test-retest reliability. Statistical Analysis
Measurement data were presented with mean values ± standard deviations ( x s ) after testing for normal distribution. Categorical data were summarized as counts and percentages (%). Student t test was used to ascertain the significance of differences between mean values of 2 continuous variables. Mann-Whitney U test was used for 2 ordinal variables comparisons and Kruskal-Wallis H test was used for 3 ordinal variables comparisons. The χ2 analysis was
A total of 400 questionnaires were distributed and returned, 5 of which had missing information about basic background, 22 of which had not completed the questionnaires. Those 27 questionnaires were taken as invalid and deleted, leaving 373 valid questionnaires (valid return rate was 93.2%) for analysis: 85 participants (22.8%) were men and 288 (77.2%) were women. Of all study participants, 134 (35.9%) were doctors, 173 (46.4%) were nurses, 66 (17.7%) were nonclinical medical staff. Table 1 shows the baseline characteristics of study participants. The mean age was 32.6 ± 8.3 years, ranging from 20 to 65 years. Approximately 85% of the participants did not have a religious belief. Nearly 60% of the participants were married. With regard to educational level, 29.3% had specialist qualifications or lower, 46.3% had a bachelor's degree, 20.1% had a master's degree, and 3.8% had a doctor's degree.
TABLE 1.
Demographic characteristics
Sex Male Female Age, y 20-24 25-29 30-39 40 and older Educational level Doctor Master Bachelor Specialist qualification or lower Job category Doctor Nurse Nonclinical staff Marital status Married Single Religion None Yes Buddhism Christianity Catholicism Muslim Others
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n
Constituent ratio, %
85 288
22.8 77.2
59 98 138 78
15.8 26.3 37.0 20.9
14 75 175 109
3.8 20.1 46.9 29.3
134 173 66
35.9 46.4 17.7
221 152
59.2 40.8
317 56 33 9 2 2 10
85.0 15.0 8.8 2.4 0.5 0.5 2.7
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Knowledge About Organ Donation of Health Professionals
Table 2 shows the results for each knowledge item in different job category health professionals. Although 93.8% of the participants knew about organ donation, only 19.6% knew the sector where to donate organ, and 13.7% knew the procedure of donation. Doctors knew more about organ donation than nurses and nonclinical staff (χ2 = 13.648, P < 0.001). Of all the participants, only 17.4% had taken part in some training courses or lectures about organ donation. Over half of (64.9%) the health professionals knew about the shortage of organs, and doctors knew more than nurses and nonclinical staff (75.4% vs 61.3% and 53.0%, χ2 = 11.531, P = 0.003). With regard to the reasons for organ shortage, the 2 top reasons were traditional views (75.6%) and scarce knowledge about organ donation (59.8%). Most (97.3%) health professionals knew about brain death, and over half of health professionals (68.9%) thought brain death was the reasonable criteria by which to judge
death. According to job category, doctors showed a higher knowledge level about brain death than nurses and nonclinical staff (χ2 = 18.548, P < 0.001). With respect to criteria of death, 76.1% doctors and 70.5% nurses believed that brain death was a reasonable criteria, comparing with 50.0% for nonclinical staff (χ2 = 18.543, P < 0.001) (Table 2). Attitude Toward Organ Donation of Health Professionals
Table 3 reveals the attitude toward organ donation of health professionals. Most of the participants (76.9%) considered that organ donation is a noble thing. About 60.1% approved the deceased donation; however, only 48.5% approved living donation. Doctors' attitudes were more positive than those of nurses and nonclinical staff members both in deceased donation (Z = 8.560, P = 0.014) and in living donation (Z = 6.835, P = 0.033). More than half of the participants (61.7%) agreed to register their willingness to
TABLE 2.
The comparison about current level of organ donation knowledge among different health professionals
(1) Know about organ donation Never heard Know a little Know more Know very well (2) Know the sector where to donate organ Yes No (3) Know the procedure of donation Yes No (4) Know the shortage status of organ Yes No (5) Take part in some training courses or lectures about organ donation Yes No (6) The reason for organ shortage Traditional view Economic level No effective system for organ donation and allocation Cope with the aftermath Mistrust to hospital No reasonable compensation Scarce knowledge about organ donation Indifference and lack of humanity (7) The knowledge about brain death Never heard Know a little Know more Know very well (8) The reasonable criteria to judge death Cardiopulmonary death Brain death Not sure
Doctors (n = 134)
Nurses (n = 173)
Nonclinical staffs (n = 66)
n (%)
n (%)
n (%)
2 (1.5) 81 (60.4) 42 (31.3) 9 (6.7)
6 (3.5) 133 (76.9) 30 (17.3) 4 (2.3)
6 (9.1) 54 (81.8) 6 (9.1) 0 (0.0)
34 (25.4) 100 (74.6)
29 (16.8) 144 (83.2)
10 (15.2) 56 (84.8)
22 (16.4) 112 (83.6)
22 (12.7) 151 (87.3)
7 (10.6) 59 (89.4)
101 (75.4) 33 (24.6)
106 (61.3) 67 (38.7)
35 (53.0) 31 (47.0)
30 (22.4)
27 (15.6)
8 (12.1)
100 (74.6) 46 (34.3) 71 (53.0) 53 (39.6) 35 (26.1) 54 (40.3) 82 (61.2) 35 (26.1)
137 (79.2) 59 (34.1) 53 (30.6) 54 (31.2) 32 (18.5) 58 (33.5) 110 (63.6) 33 (19.1)
45 (68.2) 19 (28.8) 17 (25.8) 18 (27.3) 13 (19.7) 13 (19.7) 31 (47.0) 16 (24.2)
2 (1.5) 61 (45.5) 51 (38.1) 20 (14.9)
3 (1.7) 96 (55.5) 68 (39.3) 6 (3.5)
5 (7.6) 44 (66.7) 15 (22.7) 2 (3.0)
30 (22.4) 102 (76.1) 2 (1.5)
40 (23.1) 122 (70.5) 11 (6.4)
25 (37.9) 33 (50.0) 8 (12.1)
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Z/χ2
P
13.648
0.000
4.551
0.103
1.515
0.469
11.531
0.003
3.981
0.137
18.548
0.000
18.543
0.001
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TABLE 3.
Attitudes regarding organ donation of health professionals Doctors (n = 134)
Nurses (n = 173)
Nonclinical staffs (n = 66)
n(%)
n(%)
n(%)
(9) Consider that organ donation is a noble thing Yes No Not sure (10) Agree to register organ donation willingness applying the ID card or driving license Yes No (11) Attitude to living organ donation Disagree at all Disagree a little Not sure Agree a little Agree at all (12) Attitude to deceased organ donation Disagree at all Disagree a little Not sure Agree a little Agree at all
101 (75.4) 10 (7.5) 23 (17.2)
137 (79.2) 5 (2.9) 31 (17.9)
P
9.296
0.054
2.378
0.305
6.835
0.033
8.560
0.014
49 (74.2) 0 (0.0) 17 (25.8)
89 (66.4) 45 (33.6)
100 (57.8) 73 (42.2)
41 (62.1) 25 (37.9)
3 (2.2) 37 (27.6) 20 (14.9) 53 (39.6) 21 (15.7)
7 (4.0) 48 (27.7) 37 (21.4) 66 (38.2) 15 (8.7)
10 (15.2) 16 (24.2) 14 (21.2) 21 (31.8) 5 (7.6)
6 (4.5) 14 (10.4) 21 (15.7) 60 (44.8) 33 (24.6)
4 (2.3) 18 (10.4) 54 (31.2) 75 (43.4) 22 (12.7)
1 (1.5) 14 (21.2) 17 (25.8) 25 (37.9) 9 (13.6)
donate their organs, during the application for an identification (ID) card or driving license.
z/χ2
Health Professionals' Willingness to Donation
donate their own organs based on traditional Chinese values that people should maintain physical integrity of their bodies after death. Figure 1 shows the reasons for refraining from organ donation.
Table 4 shows health professionals' willingness to donation. When asked whether they were willing to donate their own organs to family members awaiting organ transplantation, most participants (82.8%) said yes and only few of them (6.4%) said no. About 42.1% of the participants were willing to donate organs to their relatives or friends, 17.7% were not willing. However, some participants (15.0%) were willing to donate their own organs to someone unknown, and doctors showed higher willingness than nurses and nonclinical staff members (21.6% vs 10.4% and 13.6%, χ2 = 10.845, P = 0.028). Among the participants, 49.3% were willing to donate their own organs postmortem, and only 13.7% were unwilling to donate, 37.0% expressed uncertainty. Doctors had a higher willingness to donation postmortem (64.2%) compared with nurses (42.2%) and nonclinical staff (37.9%) (χ2 = 18.806, P = 0.001). Overall, 189 (50.7%) participants who were not willing to donate organ postmortem or uncertain about donation were allowed to cite multiple reasons for refraining from donation. The reasons for refraining from donation are presented in Figure 1. The most commonly cited reason for not wanting to donate organs was, “afraid that organs would be picked up inhumanely and body would be disfigured” (49.2%). The second most commonly cited reason was, “believed that the regulations and laws related to organ donation in China were far from complete” (45.0%). 40.2% participants reported they “distrusted the medical institutions and [were] afraid that donated organs might be sold on the black market” as an influencing factor. In addition, 32.3% said that they were unwilling to
DISCUSSION The potential role of health professionals in maximizing the limited organ donor pool is essential and deserves further study.19 Despite the critical importance of health professional support in this arena, there is a paucity of data in the literature regarding the attitudes of Chinese health professionals toward organ donation. This study is limited by its relatively small sample size and lack of geographic diversity. Nevertheless, as the first survey of Chinese health professional knowledge, attitudes, and willingness toward organ donation, this report provides a somewhat important perspective on organ donation. Questions 1 to 8 were designed to determine health professionals' basic knowledge about organ donation. The results showed that more than 93.8% of the participants possessed a degree of knowledge about organ donation, and 64.9% of the participants were aware of the shortage of organs for transplantation, which was lower than the results in a survey about physicians in the United States where approximately 86% of responders were aware about organ shortage problem.18 In all of the participants, only 19.6% knew the sector where to donate an organ and 13.7% knew the procedure of donation, which indicates there is still an immediate need to educate the health professionals with regard to basic knowledge about organ donation in China. Besides, most of the health professionals (82.6%) had not taken part in any training courses or lectures about organ donation, which is in agreement with the conclusion of a
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TABLE 4.
Health Professionals' willingness to donation
(13) Willing to donate some organs to my parents, children or spouse Yes No Uncertain (14) Willing to donate some organs to my relatives or friends Yes No Uncertain (15) Willing to donate some organs to someone unknown Yes No Uncertain (16) Willing to donate organs postmortem Yes No Uncertain
Doctors (n = 134)
Nurses (n = 173)
Nonclinical staff (n = 66)
n (%)
n (%)
n (%)
112 (83.6) 7 (5.2) 15 (11.2)
142 (82.1) 11 (6.4) 20 (11.6)
55 (83.3) 6 (9.1) 5 (7.6)
60 (44.8) 27 (20.1) 47 (35.1)
69 (39.9) 24 (13.9) 80 (46.2)
28 (42.4) 15 (22.7) 23 (34.8)
29 (21.6) 44 (32.8) 61 (45.5)
18 (10.4) 53 (30.6) 102 (59.0)
9 (13.6) 16 (24.2) 41 (62.1)
86 (64.2) 13 (9.7) 35 (26.1)
73 (42.2) 27 (15.6) 73 (42.2)
25 (37.9) 11 (16.7) 30 (45.5)
research in the United States that few physicians reported receiving formal training in donation, with most of them rating their knowledge as limited.20 The participants considered that the 2 top reasons for organ shortage were traditional views (75.6%) and scarce knowledge about organ donation (59.8%). These results demonstrate that the health professionals' knowledge about organ donation in Chinese hospitals is scarce. Research has shown that medical education positively influences knowledge and attitude toward organ donation and that better knowledge and a more positive attitude were associated with an increased readiness to donate an organ.11 Therefore, improving education efforts is essential in improving the health professionals' knowledge about organ donation. Brain death is used in many countries to determine death and is often the basis for removal of organs for transplantation. However, in China, brain death is not accepted by the public. Donation after brain death will replace donation after cardiac death in the future—this will be a substantial move toward a new era for organ transplantation in China.21 Researches had concluded that the understanding and acceptance of brain death as a valid determination of death was a factor that significantly influences attitudes toward donation.22,23 In our study, 97.3% health professionals knew the concept of brain death, and 68.9% thought brain death was reasonable criteria by which to judge death. Doctors showed a higher knowledge level about brain death than nurses and nonclinical staff members (χ2 = 18.548, P = 0.000). Similar results were found in other research: A survey about attitude of intensive care unit staff regarding organ donation in Kuwait showed 68% anesthetists and 51% nurses accepted brain death.24 A survey in Israel showed that 78.9% of health care professional had a positive attitude toward brain death.22 These results showed that brain death was not widely accepted by health professionals, especially nurses and nonclinical staff members. Thus, to increase the number of donors, more efforts should be done to promote health professionals' information and awareness of donation after brain death, such as more education and training among all
z/χ2
P
1.804
0.772
6.177
0.186
10.845
0.028
18.806
0.001
staff members, and more seminars about organ donation. On the other hand, over 80 countries recognize death in a patient determined to be brain dead; 14 countries have drafted legislation to support this notion; however, in China, the concept of brain death is still unclear and not widely accepted to be a determinant in the declaration of death.25 Therefore, legislation on brain death needs to be enacted to define the concept of brain death and publicity of brain death needs to be enhanced to improve the public's knowledge and acceptance of brain death. Questions 9 to 12 were designed to determine the health professionals' attitudes toward organ donation. In this survey, most of the participants (76.9%) considered that organ donation is a noble gesture. This result was slightly lower than other study on general population in China that 82.2% participants regarded every donor as a “hero.”26 Interestingly, previous research9,12 has concluded that health professionals hold a more favorable attitude than general population, whereas in our study, health professionals showed a lower support rate (60.1%) for deceased donation than the general Chinese population (89.1%).27 There demonstrates further need for studies to explain this difference of opinion.
FIGURE 1. The reasons for refraining from a donation.
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In this study, similar to other studies of health professionals,28,29 doctors showed a higher level of favorable attitudes than nurses and nonclinical staff members, both in deceased donation (Z = 8.560, P = 0.014) and in living donation (Z = 6.835, P = 0.033). Research has showed that higher medical education was associated to positive attitude toward organ donation and increased willingness to donate.11,19,30 This helps to explain why, in our study population, doctors with more knowledge had higher positive attitude and willingness to organ donation than nurses and nonclinical staff members. This is important because not only do doctors have a direct responsibility to promote organ donation but also the rest of the staff have an important impact on the population. In this respect, if a person who works in a hospital has an unfavorable attitude, it is likely that this will create fear toward organ donation among the genuine population who listens to these people. On occasions, the hospital staff, whether or not they are a clinical staff, show opinions against donation that are heard by family members of a possible donor, it may negatively affect their decision.23 Thus, it is necessary to make efforts to improve attitude to organ donation not only in doctors but also in all the staff in the hospital, especially in nurses who are in close contact to patients and their relatives. It was common practice in some countries to supply applicants of driver's licenses with the necessary paperwork for organ donation. Eighty percent of Australians register for organ donations when getting their driver's licenses, and in Britain, the rate is 45%.31 In our study, however, when the participants were asked if they agree to register organ donation willingness at the time of applying an ID or driving license, only 61.7% gave a positive answer. Someone who did not agree commented they thought it would be ominous. Some others disliked the combined registration as they believe organ donation registration should follow voluntary principles strictly. In addition, there were some participants who thought applicants were not mature enough to make a prudent decision when applying for an ID card or driving license. All of these indicated that not all public in China accepted registered organ donation willingness at the time of applying for the ID card or driving license. Based on Chinese culture and traditional views, therefore, the registration ways should be discussed and should not be limited in the same way as in other countries. At the same time, a national education campaign about organ donation should be carried out, and promotion of public awareness about donation is necessary. Compared with 60.1% of participants who supported deceased organ donation, only 48.5% were in favor of living organ donation. This means that the promotion of living organ donation faces greater resistance than deceased organ donation. Interestingly, our results showed that most of the people (82.8%) would donate their organs regardless of physical harm if family members needed organs to save their lives. However, regarding donation to relatives or friends, only 42.1% were willing to donate their own organs to them, and 15.0% were willing to donate their own organs to someone unknown. This indicated that emotional factors played a role in decision making for living organ donation. The bonds between parents and their children are generally believed to be stronger in China than in Western countries. Family values are one of the core values in Chinese culture. Chinese people usually have a strong attachment to families.
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In Confucianism, filial piety takes priority over any other moralities. This sense of filial obligations and caring for parents is rooted in Chinese culture, influencing generations of Chinese people. Therefore, we were not surprised to note a high percentage of participants willing to donate a living organ to a close relative. This important finding suggests that relatives become a potential living organ source to increase organ donation and to save more lives. Thus, health professionals should make more efforts to encourage organ donation between relatives. The results of this cross-sectional survey showed that more than half of the respondents (50.7%) were unwilling to donate organs postmortem. The top 3 reasons for unwillingness to donate were disfigured corpse (49.2%), incomplete laws (45.0%), and distrust in medical institutions (40.2%). A similar result was found in a survey about American physicians' attitudes toward organ donation, showing that the unfair organ allocation system is one of reasons for declining to register as organ donor.18 Therefore, a legal system regulating organ donation should be quickly revised and reinforced to eradicate the illegal organ trading activities both in China and in other countries so as to eliminate fear of organ donation and change negative attitudes. In addition, 32.3% said that their unwillingness to donate their own organs were based on Chinese traditional values that people should maintain physical integrity of their bodies after death, which was also found by several other studies as a reason for not wanting to donate.26,32 On the other hand, in this study, 37.0% of the total participants answered “not sure” about their willingness for organ donation postmortem, which indicated that a part of health professionals had not been prepared for donation, but they were not against donation. Thus, efforts need to be made to motivate these potential donors to be bona fide donors. It is necessary to develop and implement effective educational campaigns to increase awareness, dispel myths, and modify attitudes about donation among the health professionals and the public. In conclusion, Chinese health professionals showed lower favorable attitudes and willingness toward organ donation than the Chinese general public. Knowledge about organ donation on the part of Chinese health professionals was limited. Therefore, constant effective education seminars in health professionals are needed to enhance knowledge and promote willingness toward organ donation. ACKNOWLEDGMENTS The authors thank the participants for their kind cooperation, and Guihua Li, Shu Jia, Haixia Liu, Yunying Zhang, Qiuyan, Sun, Nan Huang for collecting data in this study.
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6. Tokalak I, Kut A, Moray G, et al. Knowledge and attitudes of high school students related to organ donation and transplantation: a crosssectional survey in Turkey. Saudi J Kidney Dis Transpl. 2006;17:491–496. 7. Sander SL, Miller BK. Public knowledge and attitudes regarding organ and tissue donation: an analysis of the northwest Ohio community. Patient Educ Couns. 2005;58:154–163. 8. Figueroa CA, Mesfum ET, Acton NT, et al. Medical students' knowledge and attitudes toward organ donation: results of a Dutch survey. Transplant Proc. 2013;45:2093–2097. 9. Boey KW. A cross-validation study of nurses' attitudes and commitment to organ donation in Hong Kong. Int J Nurs Stud. 2002;39:95–104. 10. McCoy LK, Bell SK. Organ donation and the rural critical care nurse. Am J Crit Care. 1994;3:473–475. 11. Schaeffner ES, Windisch W, Freidel K, et al. Knowledge and attitude regarding organ donation among medical students and physicians. Transplantation. 2004;77:1714–1718. 12. Radunz S, Hertel S, Schmid KW, et al. Attitude of health care professionals to organ donation: two surveys among the staff of a German university hospital. Transplant Proc. 2010;42:126–129. 13. Shepherd L, O'Carroll RE, Ferguson E. An international comparison of deceased and living organ donation/transplant rates in opt-in and optout systems: a panel study. BMC Med. 2014;12:131. 14. Kim JR, Elliott D, Hyde C. Korean health professionals' attitudes and knowledge toward organ donation and transplantation. Int J Nurs Stud. 2004;41:299–307. 15. Foss S, Sanner M, Mathisen JR, et al. Doctors' attitudes to organ donation. Tidsskr Nor Laegeforen. 2014;134:1142–1145. 16. Reddy AV, Guleria S, Khazanchi RK, et al. Attitude of patients, the public, doctors, and nurses toward organ donation. Transplant Proc. 2003;35:18. 17. Erdogan O, Yucetin L, Tuncer M, et al. Attitudes and knowledge of Turkish physicians about organ donation and transplantation. Transplant Proc. 2002;34:2007–2008. 18. Alkhatib AA, Maldonado AQ, Abdel Jalil A, et al. Physicians' attitude toward organ donation and transplantation in the USA. Clin Transplant. 2014;28:149–151. 19. Symvoulakis EK, Tsimtsiou Z, Papaharitou S, et al. Kidney organ donation knowledge and attitudes among health care professionals: findings from a Greek general hospital. Appl Nurs Res. 2012;25:283–290.
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20. Thornton JD, Curtis JR, Allen MD. Primary care physicians' attitudes and practices regarding discussing organ donation with their patients. J Natl Med Assoc. 2010;102:52–58. 21. Wei X, Jiang H, Li Q. Organ transplantation in China—not yet a new era. Lancet. 2014;384:741. 22. Cohen J, Ami SB, Ashkenazi T, et al. Attitude of health care professionals to brain death: influence on the organ donation process. Clin Transplant. 2008;22:211–215. 23. Rios A, Conesa C, Ramirez P, et al. Attitude toward deceased organ donation and transplantation among the workers in the surgical services in a hospital with a transplant program. Transplant Proc. 2005; 37: 3603–3608. 24. Al-Mousawi M, Abdul-Razzak M, Samhan M. Attitude of ICU staff in Kuwait regarding organ donation and brain death. Transplant Proc. 2001;33:2634–2635. 25. Zhang L, Wang J, Kwauk S, et al. Preliminary analysis of factors influencing organ donation rates in China. Transplant Proc. 2011;43: 1421–1424. 26. Pan X, Liu L, Xiang H, et al. Current attitudes toward organ donation after cardiac death in northwest China. Chin Med J (Engl). 2014;127: 835–838. 27. Wang W, Tian H, Yin H, et al. Attitudes toward organ donation in China. Chin Med J (Engl). 2012;125:56–62. 28. Alsaied O, Bener A, Al-Mosalamani Y, et al. Knowledge and attitudes of health care professionals toward organ donation and transplantation. Saudi J Kidney Dis Transpl. 2012;23:1304–1310. 29. Wale J, Arthur A, Faull C. An analysis of knowledge and attitudes of hospice staff towards organ and tissue donation. BMJ Support Palliat Care. 2014;4:98–103. 30. Conesa C, Rios A, Ramirez P, et al. Multivariate study of the psychosocial factors affecting public attitude towards organ donation. Nefrologia. 2005;25:684–697. 31. Chinese to face organ donation choice in event of death when getting driver's license. Available at http://news.xinhuanet.com/english2010/ china/2011-04/25/c_13845134.htm. Accessed on April 25, 2011. 32. Chung CK, Ng CW, Li JY, et al. Attitudes, knowledge, and actions with regard to organ donation among Hong Kong medical students. Hong Kong Med J. 2008;14:278–285.
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Knowledge, Attitudes, and Willingness Toward Organ Donation Among Health Professionals in China Dongmei Hu, MS1,2,3 and Hai Huang, PhD1,2
Background. The purposes of this study were to assess the knowledge, attitudes, and willingness toward organ donation among the health professionals in China. Methods. Questionnaires were delivered to 400 health professionals from 7 hospitals in Dalian and 1 hospital in Chaozhou of China between October 2013 and January 2014. Results. In all, 400 health professionals
were approached, 373 valid responses were returned. Over 90% of the participants knew about organ donation, but only 17.4% had taken part in some training courses or lectures about organ donation. Health professionals (64.9%) knew the shortage status of organ, and doctors knew more than nurses and nonclinical staffs (P < 0.01). Health professionals (97.3%) knew brain death, and 68.9% professionals thought brain death was the reasonable criteria to judge death. Doctors showed a higher knowledge level about brain death than nurses and nonclinical staffs (P < 0.01). Altogether, 60.1% approved deceased donation; however, only 48.5% approved living donation. Doctors' attitudes were more positive than nurses and nonclinical both in deceased donation (P < 0.01) and in living donation (P < 0.05). In all, 49.3% were willing to donate their own organs postmortem, and doctors had higher willingness to donation postmortem compared with nurses and nonclinical staffs (P < 0.01). The most (49.2%) commonly cited reason for refraining from donation was: “afraid that organs would be picked up inhumanely and body would be disfigured”. Conclusions. Health professionals showed lower favorable attitudes and willingness toward organ donation than Chinese general public. A proportion of Chinese health professionals' knowledge about organ donation was limited. (Transplantation 2015;99: 1379–1385)
O
rgan transplantation has become the most effective treatment for saving patients who have had organ failure. Despite these contemporary advances, there has been a relatively slow progress in the supply of organs for transplantation. Worldwide, there is a chronic imbalance between the number of donors and the numbers of patients on a waiting list in need for organ transplantation.1 The situation in China is of particular concern. Over one million end-stage organ failure patients need organ transplantations, whereas only 0.01 million of them receive transplants every year in China.2 A solution to the high demand and critical shortage is to increase the number of organs from donors. The numbers of donors per million population (pmp) are higher in Received 20 January 2015. Revision requested 10 March 2015. Accepted 18 March 2015. 1
Graduate School, South Medical University, Guangzhou, China.
2
Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, China.
3
Public Health School, Dalian Medical University, Dalian, China.
This project was supported by Science Plan Key Project of Guangdong Province in China. The authors declare no conflicts of interest. All authors conceived and designed the study. H.H. reviewed the article and approved the final version. D.H. provided data collection, data analysis and wrote the article. Correspondence: Hai Huang, PhD, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, China. ([email protected]). Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0041-1337/15/9907-1379 DOI: 10.1097/TP.0000000000000798
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the western countries. Some countries in Europe have rates between 6 pmp (in Greece, 2006) and 33 pmp (in Spain, 2006),3 as compared to lower rate in Asian countries, such as Iran (1.8 pmp, 2006),4 Japan (0.08 pmp, 2007),5 South Korea (0.97 pmp, 2007),5 especially in China, the organ donation rate is only 0.03 pmp.2 Thus, increasing organ donation rate is an important public health issue in China. Some researchers have reported that there is a positive correlation between knowledge toward organ donation and the donation behavior.6-9 In a study on a group of rural critical care nurses, McCoy and Bell10 concluded that knowledge and positive attitudes were important when providing support to families and care for potential donors, which could increase the supply of donors for transplants. On the other hand, health professionals play a pivotal role in the organ procurement process, based on their intimate relationship with patients and their families. They are well placed to identify a potential donor and to approach the bereaved family. It has been suggested that their knowledge, beliefs, and attitudes toward organ donation have been shown to influence public awareness and willingness to register.11,12 Insufficient knowledge and failure to identify possible donors are considered important contributing factors responsible for the shortage of available organs.9,13 Thus, knowing their knowledge, attitudes, and willingness toward organ donation is essential. Several analyses of health professional attitudes toward organ donation have been performed in other countries.11,14-18 However, few researches have been undertaken on knowledge, attitudes, and willingness of health professional about organ donation in China. www.transplantjournal.com
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The aim of this study was to determine the level of knowledge, attitude, and willingness toward organ donation among health professionals in China. In doing this, we hoped that the results would be helpful to improve attitudes and willingness of health professionals toward organ donation. At the same time, we hoped to provide useful information for the Chinese government to develop appropriate policies and laws.
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performed to test for differences in proportions of categorical variables between 2 or more groups. All statistical calculations were performed using SPSS13.0 (SPSS, Inc., Chicago, IL). Statistical tests were 2-sided, and a level of 0.05 was considered to indicate statistical significance.
RESULTS Demographics
MATERIALS AND METHODS Study Population and Questionnaire Distribution
October 2013 to January 2014, anonymous self-administered questionnaires were randomly distributed to health professionals in 7 hospitals of Dalian and 1 hospital in Chaozhou, China. The participants of this study consisted of doctors, nurses, and nonclinical staffs, including technical staff and managers, who came from various departments of the hospitals including medicine unit, surgical unit, pediatric unit, intensive care unit, renal unit, emergency ward, hematology unit, cardiac care unit, and administration section. Participants were asked to fill in the questionnaires during grand rounds of the individual departments, and the questionnaires were collected immediately afterward. The survey was approved by Dalian Medical University's ethics committee. Each questionnaire was accompanied with an information sheet describing back ground and purpose for survey. All participants were encouraged to participate without any undue pressure. To ensure the respondents' privacy, the study was voluntary and anonymous; we did not collect the content forms. Returning a completed questionnaire indicated informed consent for study participation. Instrument
We designed a questionnaire that was divided into 2 parts1: demographics, including sex, age, job category, educational level, marital status, and religion2; core questions related to health professional's knowledge (8 items), attitudes (4 items), and willingness regarding organ donation(4 items), which consisted of 14 single choice questions and 2 multiple choice questions. The questionnaire was pilot-tested on a random sample of 30 health professionals regarding wording and time needed for completion. The average time to complete the questionnaire was 3 minutes. After the pilot testing, 2 items that were misunderstood by most responders in the original questionnaire were modified. The content validity index of the questionnaire was determined by distributing the modified questionnaire to 2 experts who have experience in the area of organ donation. The testretest reliability was tested by 50 health professionals at a 2-week interval. The coefficient was 0.85, which reflecting a good test-retest reliability. Statistical Analysis
Measurement data were presented with mean values ± standard deviations ( x s ) after testing for normal distribution. Categorical data were summarized as counts and percentages (%). Student t test was used to ascertain the significance of differences between mean values of 2 continuous variables. Mann-Whitney U test was used for 2 ordinal variables comparisons and Kruskal-Wallis H test was used for 3 ordinal variables comparisons. The χ2 analysis was
A total of 400 questionnaires were distributed and returned, 5 of which had missing information about basic background, 22 of which had not completed the questionnaires. Those 27 questionnaires were taken as invalid and deleted, leaving 373 valid questionnaires (valid return rate was 93.2%) for analysis: 85 participants (22.8%) were men and 288 (77.2%) were women. Of all study participants, 134 (35.9%) were doctors, 173 (46.4%) were nurses, 66 (17.7%) were nonclinical medical staff. Table 1 shows the baseline characteristics of study participants. The mean age was 32.6 ± 8.3 years, ranging from 20 to 65 years. Approximately 85% of the participants did not have a religious belief. Nearly 60% of the participants were married. With regard to educational level, 29.3% had specialist qualifications or lower, 46.3% had a bachelor's degree, 20.1% had a master's degree, and 3.8% had a doctor's degree.
TABLE 1.
Demographic characteristics
Sex Male Female Age, y 20-24 25-29 30-39 40 and older Educational level Doctor Master Bachelor Specialist qualification or lower Job category Doctor Nurse Nonclinical staff Marital status Married Single Religion None Yes Buddhism Christianity Catholicism Muslim Others
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n
Constituent ratio, %
85 288
22.8 77.2
59 98 138 78
15.8 26.3 37.0 20.9
14 75 175 109
3.8 20.1 46.9 29.3
134 173 66
35.9 46.4 17.7
221 152
59.2 40.8
317 56 33 9 2 2 10
85.0 15.0 8.8 2.4 0.5 0.5 2.7
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Knowledge About Organ Donation of Health Professionals
Table 2 shows the results for each knowledge item in different job category health professionals. Although 93.8% of the participants knew about organ donation, only 19.6% knew the sector where to donate organ, and 13.7% knew the procedure of donation. Doctors knew more about organ donation than nurses and nonclinical staff (χ2 = 13.648, P < 0.001). Of all the participants, only 17.4% had taken part in some training courses or lectures about organ donation. Over half of (64.9%) the health professionals knew about the shortage of organs, and doctors knew more than nurses and nonclinical staff (75.4% vs 61.3% and 53.0%, χ2 = 11.531, P = 0.003). With regard to the reasons for organ shortage, the 2 top reasons were traditional views (75.6%) and scarce knowledge about organ donation (59.8%). Most (97.3%) health professionals knew about brain death, and over half of health professionals (68.9%) thought brain death was the reasonable criteria by which to judge
death. According to job category, doctors showed a higher knowledge level about brain death than nurses and nonclinical staff (χ2 = 18.548, P < 0.001). With respect to criteria of death, 76.1% doctors and 70.5% nurses believed that brain death was a reasonable criteria, comparing with 50.0% for nonclinical staff (χ2 = 18.543, P < 0.001) (Table 2). Attitude Toward Organ Donation of Health Professionals
Table 3 reveals the attitude toward organ donation of health professionals. Most of the participants (76.9%) considered that organ donation is a noble thing. About 60.1% approved the deceased donation; however, only 48.5% approved living donation. Doctors' attitudes were more positive than those of nurses and nonclinical staff members both in deceased donation (Z = 8.560, P = 0.014) and in living donation (Z = 6.835, P = 0.033). More than half of the participants (61.7%) agreed to register their willingness to
TABLE 2.
The comparison about current level of organ donation knowledge among different health professionals
(1) Know about organ donation Never heard Know a little Know more Know very well (2) Know the sector where to donate organ Yes No (3) Know the procedure of donation Yes No (4) Know the shortage status of organ Yes No (5) Take part in some training courses or lectures about organ donation Yes No (6) The reason for organ shortage Traditional view Economic level No effective system for organ donation and allocation Cope with the aftermath Mistrust to hospital No reasonable compensation Scarce knowledge about organ donation Indifference and lack of humanity (7) The knowledge about brain death Never heard Know a little Know more Know very well (8) The reasonable criteria to judge death Cardiopulmonary death Brain death Not sure
Doctors (n = 134)
Nurses (n = 173)
Nonclinical staffs (n = 66)
n (%)
n (%)
n (%)
2 (1.5) 81 (60.4) 42 (31.3) 9 (6.7)
6 (3.5) 133 (76.9) 30 (17.3) 4 (2.3)
6 (9.1) 54 (81.8) 6 (9.1) 0 (0.0)
34 (25.4) 100 (74.6)
29 (16.8) 144 (83.2)
10 (15.2) 56 (84.8)
22 (16.4) 112 (83.6)
22 (12.7) 151 (87.3)
7 (10.6) 59 (89.4)
101 (75.4) 33 (24.6)
106 (61.3) 67 (38.7)
35 (53.0) 31 (47.0)
30 (22.4)
27 (15.6)
8 (12.1)
100 (74.6) 46 (34.3) 71 (53.0) 53 (39.6) 35 (26.1) 54 (40.3) 82 (61.2) 35 (26.1)
137 (79.2) 59 (34.1) 53 (30.6) 54 (31.2) 32 (18.5) 58 (33.5) 110 (63.6) 33 (19.1)
45 (68.2) 19 (28.8) 17 (25.8) 18 (27.3) 13 (19.7) 13 (19.7) 31 (47.0) 16 (24.2)
2 (1.5) 61 (45.5) 51 (38.1) 20 (14.9)
3 (1.7) 96 (55.5) 68 (39.3) 6 (3.5)
5 (7.6) 44 (66.7) 15 (22.7) 2 (3.0)
30 (22.4) 102 (76.1) 2 (1.5)
40 (23.1) 122 (70.5) 11 (6.4)
25 (37.9) 33 (50.0) 8 (12.1)
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Z/χ2
P
13.648
0.000
4.551
0.103
1.515
0.469
11.531
0.003
3.981
0.137
18.548
0.000
18.543
0.001
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TABLE 3.
Attitudes regarding organ donation of health professionals Doctors (n = 134)
Nurses (n = 173)
Nonclinical staffs (n = 66)
n(%)
n(%)
n(%)
(9) Consider that organ donation is a noble thing Yes No Not sure (10) Agree to register organ donation willingness applying the ID card or driving license Yes No (11) Attitude to living organ donation Disagree at all Disagree a little Not sure Agree a little Agree at all (12) Attitude to deceased organ donation Disagree at all Disagree a little Not sure Agree a little Agree at all
101 (75.4) 10 (7.5) 23 (17.2)
137 (79.2) 5 (2.9) 31 (17.9)
P
9.296
0.054
2.378
0.305
6.835
0.033
8.560
0.014
49 (74.2) 0 (0.0) 17 (25.8)
89 (66.4) 45 (33.6)
100 (57.8) 73 (42.2)
41 (62.1) 25 (37.9)
3 (2.2) 37 (27.6) 20 (14.9) 53 (39.6) 21 (15.7)
7 (4.0) 48 (27.7) 37 (21.4) 66 (38.2) 15 (8.7)
10 (15.2) 16 (24.2) 14 (21.2) 21 (31.8) 5 (7.6)
6 (4.5) 14 (10.4) 21 (15.7) 60 (44.8) 33 (24.6)
4 (2.3) 18 (10.4) 54 (31.2) 75 (43.4) 22 (12.7)
1 (1.5) 14 (21.2) 17 (25.8) 25 (37.9) 9 (13.6)
donate their organs, during the application for an identification (ID) card or driving license.
z/χ2
Health Professionals' Willingness to Donation
donate their own organs based on traditional Chinese values that people should maintain physical integrity of their bodies after death. Figure 1 shows the reasons for refraining from organ donation.
Table 4 shows health professionals' willingness to donation. When asked whether they were willing to donate their own organs to family members awaiting organ transplantation, most participants (82.8%) said yes and only few of them (6.4%) said no. About 42.1% of the participants were willing to donate organs to their relatives or friends, 17.7% were not willing. However, some participants (15.0%) were willing to donate their own organs to someone unknown, and doctors showed higher willingness than nurses and nonclinical staff members (21.6% vs 10.4% and 13.6%, χ2 = 10.845, P = 0.028). Among the participants, 49.3% were willing to donate their own organs postmortem, and only 13.7% were unwilling to donate, 37.0% expressed uncertainty. Doctors had a higher willingness to donation postmortem (64.2%) compared with nurses (42.2%) and nonclinical staff (37.9%) (χ2 = 18.806, P = 0.001). Overall, 189 (50.7%) participants who were not willing to donate organ postmortem or uncertain about donation were allowed to cite multiple reasons for refraining from donation. The reasons for refraining from donation are presented in Figure 1. The most commonly cited reason for not wanting to donate organs was, “afraid that organs would be picked up inhumanely and body would be disfigured” (49.2%). The second most commonly cited reason was, “believed that the regulations and laws related to organ donation in China were far from complete” (45.0%). 40.2% participants reported they “distrusted the medical institutions and [were] afraid that donated organs might be sold on the black market” as an influencing factor. In addition, 32.3% said that they were unwilling to
DISCUSSION The potential role of health professionals in maximizing the limited organ donor pool is essential and deserves further study.19 Despite the critical importance of health professional support in this arena, there is a paucity of data in the literature regarding the attitudes of Chinese health professionals toward organ donation. This study is limited by its relatively small sample size and lack of geographic diversity. Nevertheless, as the first survey of Chinese health professional knowledge, attitudes, and willingness toward organ donation, this report provides a somewhat important perspective on organ donation. Questions 1 to 8 were designed to determine health professionals' basic knowledge about organ donation. The results showed that more than 93.8% of the participants possessed a degree of knowledge about organ donation, and 64.9% of the participants were aware of the shortage of organs for transplantation, which was lower than the results in a survey about physicians in the United States where approximately 86% of responders were aware about organ shortage problem.18 In all of the participants, only 19.6% knew the sector where to donate an organ and 13.7% knew the procedure of donation, which indicates there is still an immediate need to educate the health professionals with regard to basic knowledge about organ donation in China. Besides, most of the health professionals (82.6%) had not taken part in any training courses or lectures about organ donation, which is in agreement with the conclusion of a
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TABLE 4.
Health Professionals' willingness to donation
(13) Willing to donate some organs to my parents, children or spouse Yes No Uncertain (14) Willing to donate some organs to my relatives or friends Yes No Uncertain (15) Willing to donate some organs to someone unknown Yes No Uncertain (16) Willing to donate organs postmortem Yes No Uncertain
Doctors (n = 134)
Nurses (n = 173)
Nonclinical staff (n = 66)
n (%)
n (%)
n (%)
112 (83.6) 7 (5.2) 15 (11.2)
142 (82.1) 11 (6.4) 20 (11.6)
55 (83.3) 6 (9.1) 5 (7.6)
60 (44.8) 27 (20.1) 47 (35.1)
69 (39.9) 24 (13.9) 80 (46.2)
28 (42.4) 15 (22.7) 23 (34.8)
29 (21.6) 44 (32.8) 61 (45.5)
18 (10.4) 53 (30.6) 102 (59.0)
9 (13.6) 16 (24.2) 41 (62.1)
86 (64.2) 13 (9.7) 35 (26.1)
73 (42.2) 27 (15.6) 73 (42.2)
25 (37.9) 11 (16.7) 30 (45.5)
research in the United States that few physicians reported receiving formal training in donation, with most of them rating their knowledge as limited.20 The participants considered that the 2 top reasons for organ shortage were traditional views (75.6%) and scarce knowledge about organ donation (59.8%). These results demonstrate that the health professionals' knowledge about organ donation in Chinese hospitals is scarce. Research has shown that medical education positively influences knowledge and attitude toward organ donation and that better knowledge and a more positive attitude were associated with an increased readiness to donate an organ.11 Therefore, improving education efforts is essential in improving the health professionals' knowledge about organ donation. Brain death is used in many countries to determine death and is often the basis for removal of organs for transplantation. However, in China, brain death is not accepted by the public. Donation after brain death will replace donation after cardiac death in the future—this will be a substantial move toward a new era for organ transplantation in China.21 Researches had concluded that the understanding and acceptance of brain death as a valid determination of death was a factor that significantly influences attitudes toward donation.22,23 In our study, 97.3% health professionals knew the concept of brain death, and 68.9% thought brain death was reasonable criteria by which to judge death. Doctors showed a higher knowledge level about brain death than nurses and nonclinical staff members (χ2 = 18.548, P = 0.000). Similar results were found in other research: A survey about attitude of intensive care unit staff regarding organ donation in Kuwait showed 68% anesthetists and 51% nurses accepted brain death.24 A survey in Israel showed that 78.9% of health care professional had a positive attitude toward brain death.22 These results showed that brain death was not widely accepted by health professionals, especially nurses and nonclinical staff members. Thus, to increase the number of donors, more efforts should be done to promote health professionals' information and awareness of donation after brain death, such as more education and training among all
z/χ2
P
1.804
0.772
6.177
0.186
10.845
0.028
18.806
0.001
staff members, and more seminars about organ donation. On the other hand, over 80 countries recognize death in a patient determined to be brain dead; 14 countries have drafted legislation to support this notion; however, in China, the concept of brain death is still unclear and not widely accepted to be a determinant in the declaration of death.25 Therefore, legislation on brain death needs to be enacted to define the concept of brain death and publicity of brain death needs to be enhanced to improve the public's knowledge and acceptance of brain death. Questions 9 to 12 were designed to determine the health professionals' attitudes toward organ donation. In this survey, most of the participants (76.9%) considered that organ donation is a noble gesture. This result was slightly lower than other study on general population in China that 82.2% participants regarded every donor as a “hero.”26 Interestingly, previous research9,12 has concluded that health professionals hold a more favorable attitude than general population, whereas in our study, health professionals showed a lower support rate (60.1%) for deceased donation than the general Chinese population (89.1%).27 There demonstrates further need for studies to explain this difference of opinion.
FIGURE 1. The reasons for refraining from a donation.
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In this study, similar to other studies of health professionals,28,29 doctors showed a higher level of favorable attitudes than nurses and nonclinical staff members, both in deceased donation (Z = 8.560, P = 0.014) and in living donation (Z = 6.835, P = 0.033). Research has showed that higher medical education was associated to positive attitude toward organ donation and increased willingness to donate.11,19,30 This helps to explain why, in our study population, doctors with more knowledge had higher positive attitude and willingness to organ donation than nurses and nonclinical staff members. This is important because not only do doctors have a direct responsibility to promote organ donation but also the rest of the staff have an important impact on the population. In this respect, if a person who works in a hospital has an unfavorable attitude, it is likely that this will create fear toward organ donation among the genuine population who listens to these people. On occasions, the hospital staff, whether or not they are a clinical staff, show opinions against donation that are heard by family members of a possible donor, it may negatively affect their decision.23 Thus, it is necessary to make efforts to improve attitude to organ donation not only in doctors but also in all the staff in the hospital, especially in nurses who are in close contact to patients and their relatives. It was common practice in some countries to supply applicants of driver's licenses with the necessary paperwork for organ donation. Eighty percent of Australians register for organ donations when getting their driver's licenses, and in Britain, the rate is 45%.31 In our study, however, when the participants were asked if they agree to register organ donation willingness at the time of applying an ID or driving license, only 61.7% gave a positive answer. Someone who did not agree commented they thought it would be ominous. Some others disliked the combined registration as they believe organ donation registration should follow voluntary principles strictly. In addition, there were some participants who thought applicants were not mature enough to make a prudent decision when applying for an ID card or driving license. All of these indicated that not all public in China accepted registered organ donation willingness at the time of applying for the ID card or driving license. Based on Chinese culture and traditional views, therefore, the registration ways should be discussed and should not be limited in the same way as in other countries. At the same time, a national education campaign about organ donation should be carried out, and promotion of public awareness about donation is necessary. Compared with 60.1% of participants who supported deceased organ donation, only 48.5% were in favor of living organ donation. This means that the promotion of living organ donation faces greater resistance than deceased organ donation. Interestingly, our results showed that most of the people (82.8%) would donate their organs regardless of physical harm if family members needed organs to save their lives. However, regarding donation to relatives or friends, only 42.1% were willing to donate their own organs to them, and 15.0% were willing to donate their own organs to someone unknown. This indicated that emotional factors played a role in decision making for living organ donation. The bonds between parents and their children are generally believed to be stronger in China than in Western countries. Family values are one of the core values in Chinese culture. Chinese people usually have a strong attachment to families.
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In Confucianism, filial piety takes priority over any other moralities. This sense of filial obligations and caring for parents is rooted in Chinese culture, influencing generations of Chinese people. Therefore, we were not surprised to note a high percentage of participants willing to donate a living organ to a close relative. This important finding suggests that relatives become a potential living organ source to increase organ donation and to save more lives. Thus, health professionals should make more efforts to encourage organ donation between relatives. The results of this cross-sectional survey showed that more than half of the respondents (50.7%) were unwilling to donate organs postmortem. The top 3 reasons for unwillingness to donate were disfigured corpse (49.2%), incomplete laws (45.0%), and distrust in medical institutions (40.2%). A similar result was found in a survey about American physicians' attitudes toward organ donation, showing that the unfair organ allocation system is one of reasons for declining to register as organ donor.18 Therefore, a legal system regulating organ donation should be quickly revised and reinforced to eradicate the illegal organ trading activities both in China and in other countries so as to eliminate fear of organ donation and change negative attitudes. In addition, 32.3% said that their unwillingness to donate their own organs were based on Chinese traditional values that people should maintain physical integrity of their bodies after death, which was also found by several other studies as a reason for not wanting to donate.26,32 On the other hand, in this study, 37.0% of the total participants answered “not sure” about their willingness for organ donation postmortem, which indicated that a part of health professionals had not been prepared for donation, but they were not against donation. Thus, efforts need to be made to motivate these potential donors to be bona fide donors. It is necessary to develop and implement effective educational campaigns to increase awareness, dispel myths, and modify attitudes about donation among the health professionals and the public. In conclusion, Chinese health professionals showed lower favorable attitudes and willingness toward organ donation than the Chinese general public. Knowledge about organ donation on the part of Chinese health professionals was limited. Therefore, constant effective education seminars in health professionals are needed to enhance knowledge and promote willingness toward organ donation. ACKNOWLEDGMENTS The authors thank the participants for their kind cooperation, and Guihua Li, Shu Jia, Haixia Liu, Yunying Zhang, Qiuyan, Sun, Nan Huang for collecting data in this study.
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