Article Text

Knowledge and attitude regarding organ donation among medical students in Hong Kong: a cross-sectional study
  1. Steven Tsun-Wai Chu,
  2. Phoebe Pui Wun Chung,
  3. Yau Long Hui,
  4. Hing Chung Choi,
  5. Hiu Wai Lam,
  6. Ling Ling Sin,
  7. Chui Shan Law,
  8. Nga Ying Yan,
  9. Ka Yung Choi,
  10. Eric Yuk Fai Wan
  1. University of Hong Kong Faculty of Medicine, Hong Kong, Hong Kong
  1. Correspondence to Phoebe Pui Wun Chung ; ppwchung{at}hku.hk

Abstract

Objectives The rate of organ donation in Hong Kong is among the lowest in developed regions. Since medical students will play an important role in counselling patients for organ donation and identifying potential donors in the future, their knowledge, attitudes and action for organ donation are important. This study aims to understand knowledge, attitudes and actions with regard to organ donation among medical students and investigate the factors determining the knowledge and attitudes.

Design A cross-sectional study.

Setting and participants Medical students in Hong Kong were invited to complete a questionnaire. 377 medical students participated in the study.

Methods The questionnaire assessed their attitudes, knowledge, action of organ donation, belief and perception on organ donation, and other factors. Linear regression analyses and logistic regression were performed to analyse the effect of the variables on knowledge, attitudes and action for organ donation.

Results Almost all medical students (99.5%) held a positive attitude towards organ donation, but only 28.1% have signed up as organ donors. Determinants of knowledge of organ donation included belief in preservation of intact body after death (β = –0.14, 95% CI = –0.24 to –0.04) and perceived confidence and competence of organ donation discussion (β = –0.12, 95% CI = –0.22 to –0.02). Predictors of organ donor registration status included knowledge of organ donation (OR=1.03, 95% CI=1.00 to 1.06), perceived convenience of organ donation registration (OR=3.75, 95% CI=1.62 to 8.71), commitment to organ donation (OR=3.81, 95% CI=2.01 to 7.21) and exposure to organ donation (OR=4.28, 95% CI=2.37 to 7.74).

Conclusions Knowledge is positively associated with organ donation action. The above determinants of organ donation could be emphasised in medical education.

  • MEDICAL EDUCATION & TRAINING
  • MEDICAL ETHICS
  • TRANSPLANT MEDICINE

Data availability statement

Data are available on reasonable request.

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WHAT IS ALREADY KNOWN ON THIS TOPIC

  • Discrepancy between knowledge, attitude and action among medical students has been observed worldwide. Identifying the determinants of action of organ donation allows interventions to promote and facilitate organ donation.

WHAT THIS STUDY ADDS

  • This study used logistic regression analysis to control for confounds that could affect the results, which is superior to the bivariate correlation in most previous studies.

  • This study included variables not tested in the previous studies, including prosocial activities and exposure to organ donation, on knowledge and action of organ donation among medical students.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

  • Medical curriculum in the universities may enhance medical students’ confidence and competence on organ donation discussion, and improving their knowledge on organ transplantation to promote organ donation.

Introduction

The rate of organ donation in Hong Kong has been low in the past decade,1 despite numerous recent measures by the government attempting to facilitate and coordinate the process of organ donation, for example, by establishing a Committee on Promotion of Organ Donation in 20162 and establishing the Centralised Organ Donation Register allows the general population to register their wishes to donate organs after death in 2008.3 However, in 2017, there were only 6.0 donors per million populations, which were lower than most countries adopting either opt-in or opt-out organ donation system.4 Because of the shortage of organs from both deceased and living donors, there is a long waiting time for organ transplantation in Hong Kong, for example, 53 months in average for renal failure patients and 43 months for liver failure patients in 2019.5 This does not only increase the risk of complications but also creates adverse impacts on patients’ quality of life.4 The recent COVID-19 pandemic has severely slowed down organ donation process, with more than 50% decrease in organ transplant activity worldwide.6 7

It is widely agreed that healthcare professionals play a significant role in organ transplantation and donation, including the identification of potential donors and the transformation of potential donors into actual donor. The previous studies showed that healthcare professionals with positive attitudes towards organ donation are more likely to begin the organ donation process by seeking and obtaining consent from potential donor families.8 Recently, some reviews demonstrated that primary care interventions, for example, delivering organ donation information during practices and annual health check by trained general practitioners and staff, can significantly improve the organ donation registration rates,9 with more similar models were under trial.10 11 These indicated that doctors would play a more active role in organ donation promotion in the future, and they should be more prepared for it.

Identifying the determinants of action of organ donation allows interventions to promote and facilitate organ donation effects. Knowledge about organ donation has been regarded as a key element in predicting of medical students’ attitude to and action of organ donation.12–15 A study showed that only less than half of medical students in Hong Kong recognised brainstem death was medically and legally accepted as death.16 Lack of knowledge about organ donor registration is one of the factors to explain the low rate of action.17

However, knowledge is not a sufficient factor leading to positive attitude or action. There is a discrepancy between knowledge, attitude and action among medical students observed worldwide, including China,18 Poland,19 Greece20 and India,21 and Hong Kong.17 For example, a Hong Kong study in 2006 showed that although 85% of medical students showed a positive attitude towards organ donation, only 23% of them had signed the organ donation card.17 Other factors identified include family opinion and religion.22 23 Identifying other determinants of organ donation opens up the gateway for targeted promotion strategies for organ donation.

Since medical students are the future practitioners who will play a major role in organ donation counselling and medical treatment termination, it is of utmost importance to understand how their knowledge and attitude affect their action of organ donation. Previous studies also suggested that health professionals’ favourable attitude towards organ donation played a role in positively determining the decision of potential donor family.24 25 Identifying the determinants of action of organ donation allows interventions to promote and facilitate organ donation effects. There is a research gap in Hong Kong as the latest similar study was conducted in 200817 while organ donation promotion and medical education have undergone dramatic changes in terms of the content of curriculum and teaching method and activities in recent years. An updated understanding in this aspect enables comparison between the action, attitude and constraints about organ donation among medical students and potentially impact the future development in organ donation promotion strategies.

Methodology

Aim

This study aims to understand knowledge, attitudes and actions with regard to organ donations among Hong Kong medical students and investigate the associated factors determining the knowledge and attitude.

Setting and participants

In this cross-sectional study, medical students in Hong Kong were recruited physically in the campuses as well as online in social media platform during December 2020 and March 2021. Only medical students currently studying in the universities in Hong Kong, that is, The University of Hong Kong and The Chinese University of Hong Kong, were included while graduates and medical students who were taking gap year from medical study or enrolled in medical schools outside Hong Kong were excluded. All students were invited to do the self-administered English questionnaire in an online survey platform without undue pressure and no benefits were provided to students who have completed the survey. Participants were encouraged to provide their student numbers for the research team to check for duplication. Background of this study was well explained in the first page of the questionnaire and informed consent was obtained from all participants at the beginning of the survey. All methods were carried out in accordance with relevant guidelines and regulations

Sample size estimation

The target population is medical students from studying in Hong Kong. The population for our study is around 3000 people. At the confidence level of 95% and the margin of error as 5%, the calculated sample size is that at least 341 respondents from medical students studying either in The University of Hong Kong or The Chinese University of Hong Kong are needed.

Instruments

The survey consisted of 54 items covering demographic characteristics, and three main outcomes that were the knowledge of organ donation, attitude and action about organ donation, and potential factors associated with organ donation. The whole set of questionnaire is attached in online supplemental appendix I.

Supplemental material

The knowledge of organ donation was measured by 15 questions, adapted from a previous study.17 The items assessed five aspects of knowledge—organ transplantation, brain death, supply and demand of cadaveric organ, donor registration and medicolegal issues. Participants were required to provide dichotomous responses (‘yes’ or ‘no’) and the score was averaged to subscale scores and a composite score. The score refers to the percentage of questions answered correctly.

Three dichotomous questions assessed the participants’ attitude and action concerning organ donation, including their acceptance to organ donation, willingness to register as organ donor and action of organ donation registration.

Regarding the potential determinants influencing attitude and action of organ donation, 26 items, adapted from previous studies,17 26 27 were used to assess five areas of interest—(1) belief and perception on death and organ donation (nine items), (2) commitment towards organ donation (six items), (3) perceived confidence and competence on discussing organ donation (three items), (4) exposure to registered organ donors and potential organ recipients (two items) and (5) self-competence in death work (six items) from adaptation of Self-Competence in Death Work Scale. All the questions were dichotomous except for self-competence in death work using five-point Likert scale where possible responses ranged from ‘completely incompatible’ to ‘completely compatible’.27

Patient and public involvement

Patients and the public were not involved in the design, or conduct, or reporting, or dissemination plans of the research.

Statistical analysis

Demographic data were analysed by descriptive statistics. To explore the effect of clinical exposure on participant’s knowledge, attitudes and action of organ donation, participants were divided into two groups for analysis: preclinical and clinical. Participants in the first, second and third academic year mainly took courses about anatomy, physiology and biochemistry and thus they were categorised in ‘preclinical’ group. While for ‘clinical’ group, students in their fourth, fifth and final year had more clinical exposure as they mainly received the teaching in the hospital and had patient contact. Linear regression analyses were conducted to analyse the effect of year of study on knowledge of organ donation. Logistic regression analysis was performed to analyse the effect of year of study on attitudes and action of organ donation, and perceived confidence and competence on discussing organ donation.

The effects of the proposed factors on knowledge of organ donation were first analysed by univariate linear regression, and subsequently by multivariable linear regression to include all the significant factors in univariate analysis and control for the effects of demographic variables, including age, gender and university. Similarly, the effects of the proposed factors on action of organ donation were first analysed by univariate logistic regression, and subsequently, by multivariable logistic regression to include all the significant factors in univariate analysis and control for the effects of demographic variables.

All statistical analyses were performed using the JAMOVI software (V.1.6.15). All statistical tests were two sided and p values at the 5% level were considered statistically significant in the study. Our reporting follows the Checklist for Reporting Of Survey Studies reporting guideline.28

Results

A total of 377 medical students participated in the study. The mean age was 21.0 (SD=2.47 years). 51.5% of the study participants were female and 65.0% of them were preclinical students. Almost all of the respondents (99.5%) had a positive attitude towards organ donation, and the majority (89.9%) have considered to be a donor. However, only about one-fourth of the participants (28.1%) have signed up as a donor, showing a gap between respondents’ attitudes and practice. Mean knowledge score was 67.7% (SD=1.2%) and the self-competence in death work score was 3.22 out of 5 (SD=0.60). The demographic characteristics of the participants are reported in table 1.

Table 1

Descriptive statistics of main variables and sociodemographic characteristics of participants

Table 2 shows the variations of knowledge, attitudes, action and other factors along with year of study. Knowledge of organ donation differed significantly along with the year of study (p<0.001). Post hoc analysis showed that students in clinical years scored significantly higher than those in preclinical years (p<0.001). Among the five aspects of knowledge, medical knowledge of organ transplantation, knowledge about supply and demand of cadaveric organ, and medicolegal issues differed significantly with year of study (all p<0.05), although comparisons showed that students in clinical years scored significantly higher than in preclinical years only for medical knowledge (p<0.001). Respondents’ action of becoming an organ donor also depended on their year of study (p<0.001).

Table 2

Variation of knowledge, attitudes, action and other factors along with year of study

Table 3 demonstrates the effect of the proposed factors on knowledge of organ donation using linear regression. Two factors (believing the preservation of an intact body after death as important, and approaching family members of potential donors) remained significant associated with higher knowledge scores after adjustment for demographic variables (age, gender and university).

Table 3

Linear regression analysis predicting knowledge of organ donation with the proposed factors

Table 4 demonstrates the effect of the proposed factors on the registration status as organ donor using logistic regression. Four factors (belief of finding it convenient to register, two items of commitment to organ donation were also associated with higher action in the model, specifically, having discussed organ donation with their family, and having regular blood donation, and knowledge of organ donation) remained significant associated with higher registration status as organ donor after adjustment for demographic variables (age, gender and university). Please refer to online supplemental table S1 for the p values.

Table 4

Logistic regression analysis predicting action of organ donation with the proposed factors

Discussion

In our study, almost all medical students held a positive attitude towards organ donation, but only about a quarter of them have signed up as organ donors. Determinants of knowledge of organ donation included belief in preservation of intact body after death and perceived confidence and competence of organ donation discussion. Predictors of registration for being an organ donor included knowledge of organ donation, perceived convenience of organ donation registration, commitment to organ donation and exposure to organ donation.

Comparing our study with one conducted among medical students in 2008,17 both showed very high percentage of medical students, 99.5% in our study and 99% in 2008 study respectively, supported organ donation. Percentage of medical students having the thought of registering organ donation increased from 85% to 89.9% and signing up as organ donors also raised from 23% to 28.1% from 2008 to 2021. There are rising trends of their attitudes and actions towards organ donation over the decade, which may be related to the information promotion and convenience of registration. However, there was no substantial improvement and the gap in between knowledge and actions in organ donation needs to be addressed. Discrepancy between knowledge and action among medical students were also observed in China,18 Poland,19 Greece20 and India.21 Previous observational and interventional studies suggested that exposure and understanding about organ transplantation process and more organ donation dialogue can increase the rate of willingness to donate.20 29

Regarding the relationship between knowledge and action, our finding that higher knowledge is associated with higher likelihood of registering as organ donor in medical students is consistent with the findings from the literature in general.17 25 30 A Germany study of 1136 medical students showed a significant association between organ donation knowledge and likelihood of holding an organ donor card regardless of age and gender in multivariate analyses while a US study also demonstrated people with higher educational level usually had a more positive attitude as an organ donor.31 Our results adjusted with several demographic factors add more reliable evidence in the literature.

Other than knowledge, family plays an important factor in action of organ donation of medical students. Medical students with greater exposure to organ donation, for example, students who have family members registered as an organ donor or who have discussed with their family about organ donation are more likely to sign the organ donation card compared with those who have no registered family members registered as donor or have not discussed with family. This findings are consistent with previous studies.32 33 The importance of family in relation to organ donation may be attributed to several reasons. First, it may be related to a subjective norm, in which students think that by donating their organs, their family who did the same will give them approval. Second, it may be due to the role of family in providing information about organ donation, facilitating their signing of organ donation.33 Moreover, there is a negative association between anticipated family objection and the action of signing organ donation cards, which is consistent with the study in 2008.17 Family influence has consistently been an important factor towards organ donation throughout the years34 and that family support plays a great part in students’ action of signing the organ donation card.

In addition, being a regular blood donor is associated with higher rate of being an organ donor. It is likely that this is because students who are regular blood donors feel more obliged to help people in need. Another possible reason is that students who have prior experience of blood donation may have a higher chance to be targeted for organ donation promotion. Our result is consistent with previous studies,18 which showed that Chinese university students who had previously donated blood demonstrated better knowledge about transplantation and also much more willing to donate their organs with an OR of 1.91.

It is important to note that respondents with higher self-perceived confidence and competence had better knowledge and higher rate of action of organ donation. Knowledge may affect people’s confidence and competence, or vice versa. Confidence and competence may determine people’s learning attitude, and these two factors reflect underlying qualities of students and further affect their knowledge and action.

In regard of beliefs about organ donation, our study found the belief of preservation of intact body remained important in determining knowledge of organ donation, which showed no change compared with the Hong Kong study in 2008.17 Participants holding such belief is associated with lower knowledge score, but not associated with the rate of action. In addition, the perceived convenience of organ donation registration determined likelihood of registering as organ donors. Providing students more information about the procedures and criteria of organ donation may enhance students’ motivation of organ donation registration. Therefore, these beliefs are particularly important if we were to promote organ donation to medical students.

Suggestions

Social contact-based interventions are effective to produce attitudinal and knowledge gains,35 consistent with our finding that contact with people with organ transplant as a predictor of action. In-person activities that facilitate interaction between students, organ recipients and family member of organ donors can deepen students’ understanding of the importance of organ donation. Knowledge of organ donation can be introduced before or after such activities to link knowledge to real-life implications.

Formal training in organ donation counselling is another effective strategy to promote organ donation. Communication skills training36 and other formal educational activities in organ donation37 can equip medical students with skills and prepare them to initiate discussion and answer potential questions from family. This provides an opportunity for them to learn about the ways to register and other logistic matters of organ donation, which is shown to be related to high action of organ donation in our study.

Different educational interventions, such as role play, small group teaching or lectures, were proven to be effective in increasing medical students’ knowledge, attitude and self-efficacy.37–39 Innovative educational programmes, for example, Transplant Organ Retrieval programme in the University of Oxford, also showed to successfully enhance related knowledge among medical students and increase their confidence in organ donation discussion with patients and relatives.40 We suggest organ donation education, regardless training methods, should be incorporated into the formal medical curriculum, for example, during clerkship41 or junior doctor training42 and this shall be supported by government organ donation policy.23

Strengths and limitations of the study

The strengths of this study include the additional variables tested and the statistical methods that controlled for covariates. This study tested the effects of new variables, including prosocial activities and exposure to organ donation, on knowledge and action of organ donation among medical students. Second, this study used logistic regression analysis that controlled for confounds that could affect the results, which is superior to the bivariate correlation in most previous studies. Therefore, the results from the present findings are more reliable than previous studies.

The questionnaire could have been improved by performing a pilot study for validation. There may be social desirability bias in our study which led to more students giving answers supporting organ transplantation, therefore, our study may have overestimated the actual number of students who support organ transplantation.

Conclusions and recommendations

Our study showed significant positive association between knowledge and action of organ donation, suggesting that enhancing students’ knowledge can improve the percentage of organ donation registration. Since the determinants of knowledge are beliefs about organ donation, perceived confidence and competence of organ donation, medical curriculum in the universities may target on enhancing medical students’ confidence and competence on organ donation discussion, and improving their knowledge on organ transplantation. Further studies may evaluate the effectiveness of different education and promotion programmes in improving medical students’ knowledge and action.

Data availability statement

Data are available on reasonable request.

Ethics statements

Patient consent for publication

Ethics approval

Ethics approval was granted by the Institutional Review Board (IRB) of The University of Hong Kong/Hospital Authority Hong Kong West Cluster (IRB: UW 20-748). Participants gave informed consent to participate in the study before taking part.

References

Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

Footnotes

  • Contributors ST-WC is responsible for the overall content as the guarantor. ST-WC and PPWC contributed to the conception of the work. LLS, HWL and NYY prepared the questionnaire. ST-WC, HWL, HCC analysed and interpreted the data. ST-WC, PPWC and YLH are major contributors in writing the manuscript. EYFW supervised the project. All authors read and approved the final manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.