08 November 2022: Original Paper
Organ Procurement, Donation, and Transplant Awareness in an Urban Eastern European Region: A General Population SurveyAlberto Emanuel Bacușcă12ABCDEF, Alexandru Burlacu12DE*, Grigore Tinică12AD, Mihail Enache12BF, Andrei Ţărus1BD, Cristina Gavriluţă3DF, Crischentian Brinza12DEF, Bianca Hanganu24DF, Beatrice Gabriela Ioan24ACD
Ann Transplant 2022; 27:e938016
BACKGROUND: Despite significant improvements in Romania’s transplantation system, actual donor numbers have paradoxically fallen, contrary to the European trend. With a donation rate of 3.44 donors per million inhabitants, Romania ranks near the bottom of European countries. This study aimed to identify several predictors of a positive attitude toward organ donation in the Romanian population that could aid in reshaping public policies to improve donation and transplantation rates.
MATERIAL AND METHODS: The study included a representative Iasi population. Data were collected by means of a questionnaire focused on revealing attitudes toward organ donation, importance of consent, willingness to donate a family member’s organs, and role of medical staff in the donation decision. A perception score was calculated as a methodological approach to validate attitudes toward organ donation.
RESULTS: Of all respondents, 55% agreed to donate their organs if declared brain-dead, while 20% opposed this idea; 72.7% considered consent necessary; 70% believed that consent must belong to the family when it comes to brain-dead organ donors; and 44.5% supported the idea of financial compensation. Higher monthly income was correlated with a positive attitude toward organ donation.
CONCLUSIONS: Even though the study population had a positive attitude toward organ donation, the willingness to donate was lower than in other European countries and did not translate into actual donations. The necessity of informed consent, lack of knowledge on the topic, bureaucratic aspects, and openness to financial compensation could explain the current situation of the Romanian transplantation system.
Keywords: Attitude, Health Policy, Perception, Humans, Tissue and Organ Procurement, Tissue Donors, Organ Transplantation, Brain Death, Informed Consent, Surveys and Questionnaires, Health Knowledge, Attitudes, Practice
The field of transplantation has gained popularity and interest in the scientific community due to the refinement of surgical techniques and long-term postoperative management [1,2]. Although organ transplantation is recommended in end-stage organ failure as a last resort to improve the survival rate, the population perception toward donating or receiving an organ is not as positive as expected .
With 157 301 solid organ transplants performed worldwide in 2019, transplantation activity increased steadily before being severely affected by the COVID-19 pandemic [4,5]. Between 2011 and 2019, the overall number of organ donors increased by 58.5% (from 25 776 to 40 858), with 78% brain-dead donors and 22% cardiac-activity donors .
With a donation rate of 3.44 donors per million inhabitants, Romania is ranked 42nd out of 82 states providing Global Observatory on Donation and Transplantation data on donation and transplantation activity in 2020 . Despite significant improvements in Romania’s healthcare system since joining the European Union (EU), including some in the transplantation system, the actual donor number has paradoxically fallen since 2014, contrary to the European trend [4,7,8].
Some factors were linked to the modest performance of the Romanian transplantation system, such as the underfunding of the national transplantation programs, lack of specialized medical staff, mandatory family consent, and poor communication between the different structures of the system. Nevertheless, population hesitation toward organ donation remains the most sensitive issue [9–11].
The Eastern European public perception of organ donation and transplantation is often based on social-demographic and cultural factors. In an analysis of social concepts and the dilemmas surrounding organ donation, Maloney and Walker (2002) found that although there is “a unanimous agreement on the noble idea of organ donation,” when people tried to elaborate on their beliefs, “a series of worries regarding cerebral death, mutilating the body of the deceased, human organ trafficking, and the role of the medical profession in the process of donating and transplanting organs” arose in their minds .
In a meta-analysis, which included a population from Middle Eastern countries, the authors reported several factors that interfere with donation acceptance, including educational status, being informed about the organ donation procedure, and family, spiritual, and religious factors . However, data regarding the prevalence of these factors in Romania are scarce and warrant further research.
Therefore, we conducted a cross-sectional survey study involving the general population of the municipality of Iasi to clarify the underlying reasons behind Romania’s low organ donation and transplantation rates. Iasi is a town near the Europe Union’s eastern border, with a population of 319 000. It provides healthcare services to a region with a population of 8 million people. We also intended to identify factors that could aid in reshaping public policies to improve donation and transplantation rates. In this study, we also attempted to mold the potential Romanian organ donor profile so that public health campaigns and media promotion, known to boost donation rates, could be better targeted.
Material and Methods
AIMS OF STUDY:
We aimed to identify several predictors of a positive attitude toward organ donation in an Eastern Romania population. In this regard, informed consent, knowledge level of organ transplantation, and psychological factors, such as altruism and motivation to save lives, were the main variables investigated in the present study.
The study was conducted on a layered, multistage, representative sample of 440 respondents for the studied population (319 000 citizens of Iasi). With a population of 3 712 396, Iasi is the largest and most developed city and the only college city in Romania’s northeast region. A 3-stage probability sampling technique was used to choose a representative sample of city residents.
The method of applying the questionnaire was straightforward. We used a systematic analysis to determine the sample size of the survey. The statements were edited as per the 14 informal criteria for the development of questionnaire statements of Likert  and Edwards . The collection of statements relevant to the perception scale was the initial phase in the questionnaire’s design and was done longitudinally, with voluntary respondent participation. The positive and negative items were carefully chosen to minimize the effects of social desirability and positive response bias. The items were chosen in such a manner that respondents replied consistently to the statements [15,16]. The respondents were asked to indicate their degree of agreement with each statement on a 6-point scale ranging from 6=always agree; 5=mostly agree; 4=somewhat agree; 3=somewhat disagree; 2=mostly disagree; and 1=strongly disagree.
The data were uploaded and processed using SPSS version 18.0. The ANOVA test was used to analyze the dependent variable dispersion. The coefficient of variation was used to highlight the percentage deviation between 2 averages, providing results on the homogeneity of the series of values. To determine the significant differences between 2 or more groups, depending on the distribution of values, a threshold of 95% was considered significant. We applied the
The intercorrelation matrix provided an image of the degree of association between the items. The values show that there were no problems in constructing the respective items, and there was not a high degree of similarity. The value of Cronbach’s alpha (0.868) was acceptable, considering the threshold required (0.700) to validate the application of this questionnaire.
The willingness to donate (WTD) a family member’s organs was the dependent variable, and respondents had to choose between 3 options: “most likely consent”, “unsure”, and “most likely refuse”. The following were the independent variables: (1) demographic (sex, age, education, marital status, and religion); (2) transplant-related knowledge; (3) concerns regarding the organizational and bureaucratic components of organ donation system, as well as the role of the medical team in the process; and (4) views or concerns that could have a substantial impact on people’s attitudes and intentions to donate their or their relatives’ organs.
Perception, according to Gibson, is the mechanism through which an individual maintains contact with the environment . In constructing the scale, the summarized rating approach proposed by Likert was used .
The principle of the perception score is that the same questionnaire is applied to all cases and that for each item, the answer is associated with a numeric value: 1=always disagree; 2=mostly disagree; 3=sometimes agree; 4=frequently agree; 5=mostly agree; and 6=always agree. A score is calculated for each participant, ranging in this case from 25 to 150. As for the attitude toward organ donation, a higher score was interpreted as a “higher willingness to donate” and a lower score was interpreted as the opposite.
INSTITUTIONAL REVIEW BOARD STATEMENT:
The study was conducted in accordance with the Declaration of Helsinki and was approved by the Research Ethics Committee of the University of Medicine and Pharmacy “Grigore T. Popa” of Iasi (no.114/15.10.2021).
INFORMED CONSENT STATEMENT:
Informed consent was obtained from all participants involved in the study.
The age of the participants (questionnaire respondents) ranged between 18 and 83 years with a mean of 43.55 years, close to the median of 44 years. The sex ratio was 1: 1. can be applied. We can rephrase it as follows: The skewness test result (P=0.072) suggested a normal distribution of the range of values, and thus a test of statistical significance could be applied. (Table 1).
Most responses were obtained from respondents aged 50 to 59 years (21.1%), and the fewest responses were obtained from respondents under 20 years (5%) and over 80 years (4.8%).
The educational status revealed that 41.8% of respondents had a high school diploma, and 32.7% had higher education; 15.9% of the respondents had completed a vocational program, while in 6.6% of cases, the respondents’ educational level was elementary school. According to the socio-occupational status, 44.1% of respondents were employed, 20.5% were retired, 16.8% were students, 15.9% were freelancers, 7.3% were housekeepers, and 4.8% were unemployed. Of those who were employed, 18.2% were employed in the public sector and 23.6% in the private sector; 0.7% were administrators of public institutions and 1.6% were private company managers.
The monthly income was low: two-thirds of respondents earned below €400 per month; 34.1% had monthly income of less than €200; and 32.5% had a monthly income between €200 and €400. The monthly income was between €500 and €700 for 19.1% of respondents; between €700 and €900 for 13.3% of respondents; and more than €900 per month for 7.7% of respondents.
A total of 97.7% of the respondents were Christians; however, 43% of respondents had a moderate approach to religion: they did not consider themselves to be religious, but were also not unconcerned with religion.
ATTITUDES TOWARD ORGAN DONATION AND TRANSPLANTATION:
Of the total respondents, 48.4% always agreed, and 20.5% mostly agreed that organ transplantation is a cutting-edge medical procedure that saves lives, while 6.9% mostly disagreed, and 1.8% did not agree with this statement. Sixty-two percent agreed that people willing to donate organs for transplant are altruistic people who love their fellow human beings.
Fifty-five percent of the respondents would agree to donate their organs if declared brain-dead, while 20% opposed this idea. The exact proportions were valid regarding donating a family member’s organs. If a relative needed a transplant, 72.3% of those asked said they would donate one of their organs
CONSENT IN THE CONTEXT OF ORGAN DONATION:
Of the total, 72.7% of respondents mostly or always agreed that consent is necessary during a lifetime when it comes to organ donation, while 9% opposed this idea. The share of positive responses was in the range of 46% to 65% in male respondents, which was a statistically significantly different percentage compared to that of women (
Eighty percent of respondents agreed that no person could be compelled in any way to donate organs, and 76.6% of respondents affirmed that the donor should have the right to refuse donation until harvest, while 7.2% opposed this idea. The distribution by age groups showed significant differences (
Of the total, 47.5% of respondents rejected the idea of procurement of organs in the absence of expressed consent during a lifetime. Only 23% would embrace such concepts as presumed consent.
Regarding brain-dead organ donors, nearly 70% of respondents agreed that the responsibility for consent should be given to the family of the deceased, with only 11% disagreeing. The age of the respondents made a big difference for this item as well. Younger respondents (those under 45 years) were firmer in agreeing with this assertion than older respondents (
MEDICAL TEAM INVOLVEMENT:
The doctor’s role in deciding whether a brain-dead person should be a donor or not was denied. More than 55% of respondents did not believe that doctors should be involved in decision-making. Regarding the medical team’s role in the informational process on this matter, 82.5% of respondents agreed that the team should carry the responsibility of informing the donor in advance about the physical, mental, family, and professional risks. The need for the donor’s psychological evaluation before consenting to donation was expressed by 72.3% of respondents.
ORGANIZATIONAL AND BUREAUCRATIC ASPECTS OF ORGAN DONATION SYSTEM:
Concerning having a single national donor register, 63% of respondents agreed with the register, while 47.3% would agree to have a donor card. Of the total, 56.5% of respondents expressed that individuals wishing to donate organs for transplantation must give their written consent to a notary or family doctor during their lifetime. Regarding formalizing their disagreement with organ donation with a notary or the family doctor while they are still alive, opinions of respondents were split in half. In the context of organ donation, 44.5% of respondents supported financial compensation, while 38.9% rejected it.
KNOWLEDGE OF ORGAN DONATION:
Twenty-two percent of respondents believed that the Romanian population was well informed about organ donation and transplantation and what it means to be a donor or a recipient, while 52.1% believed the opposite to be true. According to 66% of respondents, more information regarding organ donation and transplantation would result in a considerable increase in the number of lives saved.
From all respondents, 44.6% mostly agreed that the church should be involved in informing the public about organ donation, while almost 80% would assign this role to the physician. Only 4% of respondents opposed physician involvement in the education of organ donation.
VARIABLES ASSOCIATED WITH THE WTD A FAMILY MEMBER’S ORGANS:
We observed no demographic characteristics that correlated with the WTD a family member’s organs when comparing demographics in respondents who indicated approval to donate a family member’s organs with those who stated they would refuse. Participants who considered that organ donation should be performed with the family’s approval were more likely to consent than those who believed that organ donation should be done with the donor’s or doctor’s consent (P<0.001). There was also a significant relationship between the WTD (the dependent variable) and 1 of the belief-related items: participants who believed that the body’s integrity should be preserved after death were less willing to give an organ from a family member (P<0.001). The association between the WTD one’s own organs after death and the WTD a family member’s organs was statistically significant (P<0.001; Table 2).
The results of the multivariate analysis indicated that the following remained as significant factors of one’s WTD a family member’s organs after death: not believing that organ donation should be done with the consent of the family; not believing that body integrity should be preserved after death; and willingness to donate the organs of a brain-dead family member (Table 3).
The set of values of the organ donation perception assessment score was homogeneous, suggesting that tests of statistical significance could be applied (Table 4, Figure 1): variations in scores in the range of 32 to 150; group average score of 108.80±20.35; median score of 112; and skewness of test result P=−0.641.
Perception score did not correlate with age (r=0.029; P=0.551) (Figure 2). The average score was slightly lower in men, but no statistically significant difference was observed (108.41±20.66 vs 109.20±20.07; P=0.677; Figure 3).
The perception score was lowest in respondents with primary education (69±0.3) and highest in respondents with vocational school (113.16±19.42), but there was also no statistically significant difference between groups (P=0.125; Figure 4).
The lowest average perception score was obtained in respondents employed in the private sector (105.64±22.85) and the highest in respondents with other occupations (129.0±5.66), but the difference was not statistically significant (P=0.244; Figure 5).
The correlation between average perception score and monthly income was significant. The lowest average score was in respondents with an average income between €300 and €400, and the highest in respondents with an average income over €900 (P=0.027; Figure 6).
Perception score was not significantly correlated with religious affiliation; the lowest average level was recorded for respondents with Christian affiliation (108.64±20.46) and the highest for those with Muslim affiliation (121.33±4.04, P=0.772; Figure 7).
As a limitation of this study, the sample included only people who were met in highly frequented urban public spaces, resulting in potential selection bias. Also, the city of Iasi is the second largest and one of the most developed areas in Romania, as well as an important university town, and therefore may not be representative of the entire country. Another limitation was the non-response errors that occurred when respondents did not answer one or more questions.
Even though the study population had a positive attitude toward organ donation, the WTD in Romania is lower than in other European countries and does not translate into actual donations. The necessity of informed consent, lack of knowledge on the topic, bureaucratic aspects, and openness to financial compensation could explain the current situation of the Romanian transplantation system. The act of donation was associated with the idea of sacrifice, altruism, and love, but our research highlights a remarkable contradiction. There is a fragile equilibrium between those open to the possibility of having some monetary reward in exchange for organ donation and those who would refuse any kind of monetary reward for donating an organ. In other words, accepting the donation of an organ is an indicator of a person’s altruism, but this does not rule out the idea of receiving a reward for this gesture.
FiguresFigure 1. Perception score histogram. Figure created with SPSS 18.0, IBM SPSS Statistics. Figure 2. Correlation between age and perception score. Figure created with SPSS 18.0, IBM SPSS Statistics. Figure 3. Correlation between sex and perception score. Figure created with SPSS 18.0, IBM SPSS Statistics. Figure 4. Correlation between educational status and perception score. Figure created with SPSS 18.0, IBM SPSS Statistics. Figure 5. Correlation between socio-occupational status and perception score. Figure created with SPSS 18.0, IBM SPSS Statistics. Figure 6. Correlation between monthly income and perception score. Figure created with SPSS 18.0, IBM SPSS Statistics. Figure 7. Correlation between religion and perception score. Figure created with SPSS 18.0, IBM SPSS Statistics.
TablesTable 1. Age as a statistical indicator. Table 2. Variables associated with the willingness to donate a family member’s organs. Table 3. Variables influencing the willingness to donate a family member’s organs. Multivariate logistical regression analysis. Table 4. Statistical indicators of the perception score.
1. Matevossian E, Kern H, Hüser N: Transpl Int, 2009; 22(12); 1132-39
2. Nordham KD, Ninokawa S, The history of organ transplantation: Proc (Bayl Univ Med Cent), 2022; 35(1); 124-28
3. Mithra P, Ravindra P, Unnikrishnan B, Perceptions and attitudes towards organ donation among people seeking healthcare in tertiary care centers of coastal South India: Indian J Palliat Care, 2013; 19(2); 83-87
4. Valentini L, Schaper L, Buning C, Malnutrition and impaired muscle strength in patients with Crohn’s disease and ulcerative colitis in remission: Nutrition, 2008; 24(7–8); 694-702
5. Putzer G, Gasteiger L, Mathis S, van Enckevort A, Solid Organ donation and transplantation activity in the Eurotransplant area during the first year of COVID-19: Transplantation, 2022; 106(7); 1450-54
6. Nguyen DL, Parekh N, Bechtold ML, National trends and in-hospital outcomes of adult patients with inflammatory bowel disease receiving parenteral nutrition support: JPEN J Parenter Enteral Nutr, 2016; 40(3); 412-16
7. Vladescu C, Scintee SG, Olsavszky V, Romania: Health system review: Health Syst Transit, 2016; 18(4); 1-170
8. Arredondo E, López-Fraga M, Chatzixiros E, Council of Europe Black Sea Area Project: International cooperation for the development of activities related to donation and transplantation of organs in the region: Transplant Proc, 2018; 50(2); 374-81
9. Holman A, Beatrice I, The malfunctions of a national transplantation system: Multi-layered explanations from within: Rev Med Chir Soc Med Nat Iasi, 2016; 120(1); 62-69
10. Grigoraş I, Blaj M, Florin G, The rate of organ and tissue donation after brain death: Causes of donation failure in a Romanian university city: Transplant Proc, 2010; 42(1); 141-43
11. Grigoras I, Condac C, Cartes C, Presumed consent for organ donation: Is Romania prepared for it?: Transplant Proc, 2010; 42(1); 144-46
12. Mekkodathil A, El-Menyar A, Sathian B, Knowledge and willingness for organ donation in the Middle Eastern Region: A meta-analysis: J Relig Health, 2020; 59(4); 1810-23
13. Likert R, A technique for the measurement of attitudes: Arch Psychol 22, 1932; 140; 55-55
14. Edwards AL: Techniques of attitude scale construction, 1957, Appleton-Century-Crofts
15. Lal S, Kadian K, Jha S, a resilience scale to measure farmers’ suicidal tendencies in national calamity hit region of India: Curr World Environ, 2014; 9; 1001-7
16. Lal S, Mohammad A, Ponnusamy K, Divulging magnitude of perceptual levels of participants in National Dairy Mela (Fair) of India: A farmers’ perspective: J Glob Commun, 2015; 8; 158
17. Koch SE: Psychology: A study of a science, 1959, McGraw-Hill
18. Falomir-Pichastor JM, Berent JA, Pereira A, Social psychological factors of post-mortem organ donation: A theoretical review of determinants and promotion strategies: Health Psychol Rev, 2013; 7(2); 202-47
19. Radecki CM, Jaccard J, Psychological aspects of organ donation: A critical review and synthesis of individual and next-of-kin donation decisions: Health Psychol, 1997; 16(2); 183
20. Radecki CM, Jaccard J, Signing an organ donation letter: The prediction of behavior from behavioral intentions 1: J Appl Soc Psychol, 1999; 29(9); 1833-53
21. Saunders B, Normative consent and opt-out organ donation: J Med Ethics, 2010; 36(2); 84-87
22. Johnson EJ, Goldstein D, Medicine Do defaults save lives?: Science, 2003; 302(5649); 1338-39
23. Steffel M, Williams E, Tannenbaum D, Does changing defaults save lives? Effects of presumed consent organ donation policies: Behav Sci Policy, 2019; 5; 68-88
24. Domínguez J, Rojas JL, Presumed consent legislation failed to improve organ donation in Chile: Transplant Proc, 2013; 45(4); 1316-17
25. Živčić-Ćosić S, Bušić M, Župan Ž, Development of the Croatian model of organ donation and transplantation: Croat Med J, 2013; 54(1); 65-70
26. Orlić P, Andrasević D, Zeidler F, Cadaver kidney harvesting in the region of Rijeka, Yugoslavia: Transplant Proc, 1991; 23(5); 2544
27. Danica Avsec JS, Twenty years of deceased organ donation in Slovenia: Steps towards progress in quality, safety, and effectiveness: Am J Health Res, 2021; 9(3); 82-88
28. Chouhan P, Draper H, Modified mandated choice for organ procurement: J Med Ethics, 2003; 29(3); 157-62
29. Harish A, George T, Kurian V, Mullasari Ajit S, Arteriovenous malformation after transradial percutaneous coronary intervention: Indian Heart J, 2008; 60(1); 64
30. Spital A, Mandated choice. The preferred solution to the organ shortage?: Arch Intern Med, 1992; 152(12); 2421-24
31. Albertsen A, Against the family veto in organ procurement: Why the wishes of the dead should prevail when the living and the deceased disagree on organ donation: Bioethics, 2020; 34(3); 272-80
32. Downie J, Shea A, Rajotte C, Family override of valid donor consent to postmortem donation: Issues in law and practice: Transplant Proc, 2008; 40(5); 1255-63
33. Martínez-Soba F, Miñambres E, Martínez-Camarero L, Results after implementing a program of intensive care to facilitate organ donation: Transplant Proc, 2019; 51(2); 299-302
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