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Organ and tissue donation (OTD) is vital to our health service for the opportunity that it provides recipients to regain health and function. In New Zealand, each year from 2008 and 2014, between 31 to 46 deceased persons (6.7 to 10 per million people) per year donated organs.1 When compared to international donor rates, New Zealands OTD rate lags behind that of many countries with similar socioeconomic status and health indicators, including Spain, Portugal, and Australia.1 There are many reasons why OTD rates may differ between countries, including (but not restricted to) legal and ethical considerations,2 medical resources (eg, availability of intensive care beds),3 and sociocultural factors such as knowledge and attitudes towards OTD.4-7 Factors influencing knowledge and attitudes towards OTD continually require exploration to guide the delivery of OTD practice in an informed, community-consultative and culturally appropriate manner, and determine how regulations and guidelines can best protect the beliefs and values of individuals and communities.4,8,10 Despite recent media interest regarding OTD in New Zealand,11-14 little critical analysis exists exploring what New Zealanders actually know about OTD. Young adults, for example, are consistently identified as central to OTD community engagement strategy as tomorrows donors,4,8 yet there is a paucity of research on their knowledge and attitudes to OTD. Harbour et al examined Auckland University medical students knowledge and attitudes to organ donation,15 finding support for this concept, but a lack of knowledge about it. However, no studies have examined OTD knowledge or attitudes in a non-medical, young adult population in New Zealand. This exploratory study utilised a knowledge and attitude survey in a university student population with the aim of providing information relevant to future educational or engagement campaigns.MethodsA random, stratified sample of students enrolled at the University of Otago (Dunedin, New Zealand) was surveyed in November 2014. The survey was not a replication of any pre-existing, published surveys, however some questions were modelled on previous OTD surveys and adapted for the New Zealand context and student population; other questions were developed by an intensivist involved in organ donation programmes (author RD).8,9 Inclusion criteria included participants being under 25 years of age,16 and having a permanent address in New Zealand. The study was approved by the University of Otago Ethics Committee (14/154).Survey questions were presented in four sections: demographic status (6 questions), knowledge relating to OTD in New Zealand (3 questions), knowledge and attitude relating to OTD and donation of own tissues (8 questions), and attitude to OTD of a loved ones organs/tissues (5 questions). The survey was pre-tested and finalised with input from university students and academics (six individuals). Questions included 5-point Likert-type responses (ranging from strongly agree to strongly disagree), yes-no answers, and multiple-choice options.Participants were randomly recruited (every tenth student invited to participate) by one of the authors (NL) from selected locations around the University of Otago over a two-day period. Locations were estimated to provide a representative sample of students with demographic data comparable to student demographics at this university (2013).17 Each potential participant was verbally informed of the project aims and provided written informed consent before completing the 10-minute paper questionnaire. An online version was available and completed by 6 participants who preferred this option.Statistical analysisData were analysed to determine whether participant responses for individual questions differed by sex, selected demographics of the known profile of enrolled University of Otago students, or supportive (vs. unsupportive) attitudes to OTD. Survey data were entered into an Excel (Microsoft Corp, Palo Alto, CA) spreadsheet, cleaned and imported into SAS (SAS Institute Inc., Cary, NC) statistical software for analysis. Between-group comparisons were undertaken using Chi-square or Fishers exact test as appropriate. For all analyses, significance was p<0.05.Post hoc analysis for support attitude for organ and tissue donationA supportive attitude to OTD was determined by combining agree/strongly agree responses to two questions in the section on knowledge and attitude relating to OTD and donation of own tissues; non-supportive status was determined by combining disagree, strongly disagree, and neutral responses. The questions used to indicate positive support were i) if medically possible I would donate organs/tissues, and ii) OTD benefits society. Positive support for OTD was compared to selected questions to determine whether this factor influenced (was correlated to) response outcomes. These questions included knowledge and attitude relating to OTD, and attitude towards OTD of a loved ones organs/tissues.ResultsDemographic dataIn total, 180 (n=120, 67% female, n=60, 33% male) students participated and had complete data for OTD questions; two female participants had missing data for age. The mean age of participants was 20.1 years (range 18-24, SD 1.8). The mean female age was 19.9 years (range 18-24, SD 1.6) and male age 20.5 (range 18-24, SD 1.9) (Table 1) with no significant age difference between sexes. Responses did not differ significantly by sex in regards to knowledge relating to OTD donation in New Zealand, attitude to OTD of own organs/tissues, or attitude to OTD donation of a loved ones organs/tissues.Table 1: Knowledge relating to organ/tissue donation in New Zealand. Correct responses are indicated. Questions and possible responses Females n=120 Males n=60 Total n=180 n % n % n % Percentage of deaths where organ donation is medically feasible Less than 5% (correct) 11 9.2 11 18.3 22 12.2 6 to 10% 26 21.7 9 15 35 19.4 11 to 20% 21 17.5 13 21.7 34 18.8 21 to 50% 19 15.8 11 18.3 30 16.7 More than 50% 10 8.3 5 8.3 15 8.3 Dont know 32 26.7 11 18.3 43 23.9 Age limit for someone to be an organ/tissue donor Age limit varies depending on clinical circumstances (correct) 74 61.7 38 63.3 112 62.2 55 years 4 3.3 8 13.3 12 6.7 60 years 10 8.3 9 15 19 10.6 65 years 5 4.2 0 0 5 2.7 70 years 3 2.5 1 1.7 4 2.2 Dont know 24 20 4 6.7 28 15.5 Circumstances in which organ/tissue donation is possible in NZ The family consent to organ/tissue donation irrespective of what is stated on the drivers license (correct) 33 27.5 9 15 42 23.3 A person has a valid registration on their drivers license 23 19.2 11 18.3 34 18.9 A person has a valid registration on their drivers license and family consent 51 42.5 37 61.7 88 48.9 Dont know 13 10.8 3 5 16 8.9 Students identified as New Zealand European (68%), M\u0101ori (6%), Pacific (2%), Asian (21%) or other (9%). Participants listed their permanent residence as Dunedin (50%), other South Island (20%), or North Island (30%). First-year students were the most well represented year-of-study category (40%), with fewer participants from second-year students (15%), third-year (21%), fourth-year (10%) and fifth or more (15%). Compared to 2013 data (University of Otago), ethnicity was proportionately representative of the 2013 University of Otago student profile, but under-representative of males (33% vs. 42% in 2013), over-representative of first-year students (40% vs. 20%), and permanent address in Dunedin (50% vs. 20%).Knowledge and attitudes relating to organ/tissue donation in New ZealandFor the question relating to the percentage of deaths where donation is medically feasible, only 12% of respondents identified the correct answer (Less than 5%; based on Australian data from the DonateLife website, http://www.donatelife.gov.au/) (Table 1). The question \u201cAge limit for someone to be an organ/tissue donor\u201d was correctly identified by 62%, while 23% correctly identified that \u201cthe family consent to organ/tissue donation irrespective of what is stated on the drivers license\u201d to the question on \u201cCircumstances in which organ/tissue donation is possible in NZ\u201d.Knowledge and attitude relating to organ/tissue donation and donation of own tissuesNearly all (93%) participants agreed that OTD benefits society, with 72% of participants indicating they would like to donate organs or tissues after death. Around one fifth of participants know or knew someone who had donated (21%) or received (18%) organs or tissues (Table 2). Just under half (42%) agreed with the statement that \u201cThere are many more potential organ donors than there are potential recipients in NZ\u201d, while only 5% indicated OTD was against their religion. Most (73%) favoured OTD being \u201copt-in\u201d in New Zealand, while under half (42%) indicated support for OTD being \u201copt-out\u201d.Table 2: Knowledge and attitude relating to organ/tissue donation, and donation of own tissues. Positive responses (agree, strongly agree) from a 5-point Likert scale and yes/no answers*. Questions Females n = 120 Males n = 60 Total n = 180 n % n % n % Organ/tissue donation benefits society 110 91.7 56 93.3 166 92.2 If this was medically possible I would like to donate my organs/tissues after death 80 66.7 48 80 128 71.1 There are many more potential organ donors than there are potential recipients in NZ 45 37.5 30 50 75 41.7 Organ/tissue donation is against my religion 7 5.8 2 3.3 9 5 Organ/tissue donation in NZ should be opt-in 89 74.2 41 68.3 130 72.2 Organ/tissue donation in NZ should be opt-out 47 39.2 29 48.3 76 42.2 Know/knew someone who donated organs/tissues* 21 17.5 17 28.3 38 21.1 Know/knew someone who received organs/tissues* 19 15.8 13 21.7 32 17.8 Attitude to organ/tissue donation of a loved ones organs/tissuesParticipants demonstrated supportive attitudes to four of the five questions on donation of a loved ones organs or tissues (Table 3). These questions related to being asked for consent (78%), the most important consideration being the expression of previous wishes (91%), whether other lives could be helped by the donation (75%), and the importance of the information about the specific benefits of donation being available at the time of deciding whether to consent (76%). The only question that received less than half of the participants support was related to providing consent when loved ones had not made their wishes clear about donating (43%).Table 3: Attitude to organ/tissue donation of a loved ones organs/tissues. Positive responses (agree, strongly agree) from a 5-point Likert scale. Questions Females n = 120 Males n = 60 Total n = 180 n % n % n % If donation of organs/tissues from a loved one was possible I would expect to be asked for consent 90 75 50 83.3 140 77.8 The most important consideration in whether I would consent to donating organs/tissues of a loved one would be their previous wishes 110 91.7 52 86.7 162 90 If my loved one had NOT made their wishes about donation known to me I would not consent to donating their organs/tissues 47 39.2 30 50 77 42.8 The most important consideration in whether I would consent to donating organs/tissues of a loved one would be whether others lives could be helped 89 74.2 45 75 134 74.4 Information about the specific benefits of donation would be important to me at the time of deciding whether to consent to organ/tissue donation of a loved one 93 77.5 43 71.7 136 75.6 Correlates of supportive attitudes to organ/tissue donation against selected survey questionsSupportive attitudes were reported by 78 (65%) females and 46 (77%) males; there was no significant difference between proportions of supportive attitude by sex. The supportive attitudes group was compared with not supportive on selected questions on OTD (policy for opt-in, opt-out questions), and all questions relating to donation of loved ones organs/tissues (Table 4). There were significant differences in responses between the supportive and not supportive groups when disagree (including strongly disagree), vs neutral, vs agree (including strongly agree), agree responses for three of the seven questions.Table 4: Comparison of supportive and not supportive attitudes to donation with positive responses to selected survey questions. *Indicates significant difference between supportive and not supportive groups (Chi square); percentages have been rounded to one decimal place. Male and female responses have been combined. DoF = degrees of freedom. Questions Response Supportive (%) Not supportive (%) Chi square (DoF) Organ/tissue donation in NZ should be opt-in Agree 72.6 72.7 8.4* (2) Neutral 13.7 25.5 Disagree 13.7 1.8 Organ/tissue donation in NZ should be opt-out Agree 46 34.6 2 (2) Neutral 18.6 21.8 Disagree 35.5 43.6 If donation of organs/tissues from a loved one was possible I would expect to be asked for consent Agree 75.8 83.6 1.5 (2) Neutral 17 12.7 Disagree 7.3 3.6 The most important consideration in whether I would consent to donating organs/tissues of a loved one would be their previous wishes Agree 94.3 83.6 7.7* (2) Neutral 2.4 12.7 Disagree 3.3 3.6 If my loved one had NOT made their wishes about donation known to me I would not consent to donating their organs/tissues Agree 36.3 58.2 13.7* (2) Neutral 29 32.7 Disagree 34.7 9.1 The most important consideration in whether I would consent to donating organs/tissues of a loved one would be whether others lives could be helped Agree 79 65.5 3.9 (2) Neutral 14.5 25.5 Disagree 6.5 9.1 Information about the specific benefits of donation would be important to me at the time of deciding whether to consent to organ/tissue donation of a loved one Agree 78.2 70.9 1.2 (2) Neutral 17 21.8 Disagree 4.8 7.3 DiscussionThis study examined attitudes and knowledge in a New Zealand young adult population at one university, providing unique information on OTD in this demographic. Findings suggest that OTD is generally supported, with results providing some insight into how young adults approach and engage with the decision making process in relation to donation of a loved ones organs/tissues.Demographic dataResults indicate that these data are not representative of the actual profile of University of Otago students, with sex, year of study, and home address different to the 2013 university student profile. Therefore, results from this exploratory study cannot necessarily be generalised to the University of Otago student population. However, they do provide an indication of the variety of attitudes and knowledge of OTD in young, university-attending adults in New Zealand. While the ethnic profile of participants was representative of University of Otago students, the low number of M\u0101ori and Pacific Island participants indicates that responses may not be representative of OTD attitudes and knowledge for these communities.18,19Knowledge relating to organ/tissue donation in New ZealandFindings indicate that young New Zealand adults do not realise that donation is a rare possibility when death occurs; in Australia organ donation is feasible in around 1% of hospital deaths.20 Furthermore, there is a lack of understanding that donor age limits depend on clinical circumstances, and an incorrect assumption that both drivers licence indication of intent and family consent are required for OTD to proceed (49% responses). Results also indicated that participants were not really aware of the rarity of OTD opportunities, or the fact that there is significant need for organs, with current demand far exceeding supply, suggesting that the circumstances in which OTD can occur in New Zealand after persons die are not well understood. This is important because such information is relevant to the expectations of potential donor families, and to clinicians who may assume a baseline knowledge of individuals and families. Improving community knowledge in this area may be important in order to assist communication and interaction between clinicians and families faced with a donation decision;21,22 therefore these findings provide an insight into potential OTD education requirements and establishing a benchmark for future investigations. Religious beliefs do not appear to be a barrier for OTD in New Zealand, based on our findings. This is perhaps not surprising given New Zealands secular population, confirming strategies to improve donation rates should not overemphasise religion as a potential barrier.Knowledge and attitude relating to organ/tissue donation, and donation of own tissuesOur findings indicate a high level of support for OTD at a conceptual (good for society) and personal level, similar to those from Auckland University medical students.15 Around 20% of respondents had knowledge of either an organ/tissue donor or recipient, an interesting finding given New Zealands low donor rate of between 31 and 46 people per year (2008-2014) with 919 total recipients (live and deceased donors) between 2010 and 2014.23 The figure for knowing a donor was similar to that for young adults in the UK and USA,8,22 with the percentage on knowing someone who has received higher than the UK (18% vs. 9.2%).22 This personal exposure to organ donation suggests many New Zealand young adults at the University of Otago are personally connected to donation, and provides a useful platform for engaging with them, given their demonstrated a priori knowledge of donation practice in this country.Various models exist internationally with respect to donor registries and the opt-in and opt-out systems of OTD. This study found support for both concepts, perhaps highlighting that they are not mutually exclusive. Some respondents may have ticked yes for both questions (ie, both are a good idea); both examine whether individual autonomy, or family consensus, or community need is the prevailing concept, however it is hard to compare the two concepts and draw any meaningful conclusions. Overall, opt-in received more positive responses (73% vs. 42%) which provides more support for the concept of donor registries as opposed to having an opt-out policy. Currently, there is no OTD register in New Zealand; previous reports have shown a low level of support in countries that implemented these programmes, indicating they may perform poorly.24 Recent data from the UK reported 38% of the adult population are registered organ donors,22 suggesting the establishment of opt-in OTD registers may be popular and potentially beneficial in some countries.Attitudes to organ/tissue donation of loved ones organs/tissuesThe consent for OTD following brain death in New Zealand is approximately 50%;25 in Australia it is around 60% and increasing the family consent rate is a key target of the Australian Organ and Tissue Authority.26 This indicates that understanding local factors that contribute to family consent decisions is important in regards to being able to improve the chances of family consent being granted in situations where donation is possible. In this study, most participants indicated they would expect information about the specific benefits of donation to other

Summary

Abstract

Aim

Organ and tissue donation (OTD) rates in New Zealand are low compared to many countries. Young adults are tomorrows donors, yet the attitudes and knowledge of this group to OTD have not been examined locally. Such information is relevant to ODT education and clinical engagement.

Method

A random sample of University of Otago students (

Results

180 responses were gathered (mean age 20.1 years, 67% female, 68% New Zealand European); there were no age or response differences between sexes, participants were generally not representative of the University of Otago student profile. Outcomes indicated limited OTD knowledge, positive support for OTD, and willingness to engage in donation the decision-making process for loved ones. Differences between supportive and non-supportive OTD attitudes was seen for some questions.

Conclusion

Findings highlight areas for strategic OTD public engagement and provide details relevant to guiding appropriate clinical interaction in facilitating decisions about OTD.

Author Information

Jon Cornwall, Senior Research Fellow, Faculty of Law and Department of Physiology, University of Otago, Dunedin, and Centre for Health Professions, Zurich University of Applied Sciences, Zurich, Switzerland; Cyril Schafer, Senior Lecturer, Department of Anthropology and Archaeology, University of Otago, Dunedin; Navneet Lal, Assistant Research Fellow, University of Otago, Dunedin; Rohit DCosta, Intensive Care Specialist, Melbourne Hospital, and Deputy Medical Director DonateLife Victoria; Shyamala Nada-Raja, Senior Research Fellow, Department of Preventive and Social Medicine, University of Otago, Dunedin.

Acknowledgements

This article is dedicated to the memory of our fellow author and colleague Dr Cyril Schafer, who sadly passed away in June 2015. The authors would like to thank the Humanities Division of the University of Otago for the provision of a research grant to assist the completion of this study.

Correspondence

Jon Cornwall, Faculty of Law and Department of Physiology, University of Otago

Correspondence Email

jon.cornwall@otago.ac.nz

Competing Interests

Nil

- - Australia and New Zealand Organ Donation Registry. 2013 ANZOD annual report 2013. Ngahooro J, Gillett G. Over my dead body: the ethics of organ donation in New Zealand. NZ Med J. 2004;117(1201):U1051. McCall J. Organ donation and legislation. NZ Med J. 2006;119:5-7. Feeley TH. College students knowledge, attitudes, and behaviors regarding organ donation: An integrated review of the literature. J Appl Soc Psychol. 2007;37:243-71. Shaw R. Perceptions of the gift relationship in organ and tissue donation: Views of intensivists and donor and recipient coordinators. Soc Sci Med. 2010;70:609-15. Tam WWS, Suen LKP, Chan HYL. Knowledge, attitudes and commitment toward orga donation among nursing students in Hong Kong. Transplant P. 2012;44:1196-1200. Marck CH, Neate SL, Skinner MR, et al. Factors relating to consent for organ donation: prospective data on potential organ donors. Intern Med J. 2015;45(1):40- DAlessandro AM, Peltier JW, Dahl AJ. The impact of social, cognitive, and attitudinal dimensions on college students support for organ donation. Am J Transplant. 2012;12:152-61. Coad L, Carter N, Ling J. Attitudes of young adults from the UK towards organ donation and transplantation. Transplant Res. 2013;2:9 Shaw R. The ethical risks of curtailing emotion in social science research: The case of organ transfer. Health Sociol Rev. 2011;20(1):58-69. New Zealand Herald website. Accessed 6 April 2015. http://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=11420789 New Zealand Herald website. Accessed 6 April 2015. http://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=11407294 Yahoo news New Zealand website. Accessed 6 April 2015. https://nz.news.yahoo.com/a/-/top-stories/26411035/organ-transplants-hit-record-high/ New Zealand Herald website. Accessed 6 April 2015. http://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=11296853 Harbour L, Ingham C, Streat S, Bagg W. Attitudes to organ donation and knowledge of donation and transplantation among University of Auckland Medical students. Journal of Medical Education and Curricular Development. 2015:2 Whatman J, Schagen S, Vaughn K, Lander J. Engaging young people/young adults in literacy, language and numeracy skill development: A Literature Review. New Zealand Government 2010. University of Otago website. Accessed 20 February 2015. http://www.otago.ac.nz/about/quickstats.html Lewis G, Pickering N. Mori spiritual beliefs and attitudes towards organ donation. NZ Bioeth J 2003;4(1):31-5. Shaw R. Organ Donation in Aotearoa/New Zealand: Cultural phenomenology and moral humility. Body Soc 2010:16(3):127-47. Australian Organ and Tissue Authority, 2014 performance report. http://www.donatelife.gov.au/sites/default/files/OTA%202014%20Performance%20Report%20Jan%202015%20FINAL.pdf Siminoff LA, Lawrence RH. Knowing patients preferences about organ donation: does it make a difference? J Trauma. 2002;53:754-60. Siminoff L, Mercer MB, Graham G, Burant C. The reasons families donate organs for transplantation: implications for policy and practice. J Trauma. 2007;62:969-78. Organ Donation New Zealand Annual Report 2013. Accessed 20 January 2015. http://www.donor.co.nz/files/Annual_Report_FINAL_2013_online.pdf Childress JF, Liverman CT (eds). Organ Donation: Opportunities for Action. Committee for increasing rates of organ donation. Washington DC: Board on Health Sciences Policy, Institute of Medicine of the National Academies, National Academies Press; 2006. Organ Donation New Zealand website. Accessed 2 April 2015. http://www.donor.co.nz/statistics/number-of-transplant-operations-in-new-zealand Neate SL, Marck CH, Skinner M, et al. Understanding Australian families organ donation decisions. Anaesth Intens Care. 2015;43(1):42-50. Rodrigue JR, Cornell DL, Krouse J, Howard RJ. Family initiated discussions about organ donation at the time of death. Clin Transplant. 2010;24:493-9. Wakefield CE, Reid J, Homewood J. Religious and ethnic influences of willingness to donate organs and donor behaviour: an Australian perspective. Prog Transplant. 2011;21:161-8. Marck CH, Weiland TJ, Neate SL, et al. Personal attitudes and beliefs regarding organ and tissue donation: a cross-sectional survey of Australian emergency department clinicians. Prog Transplant. 2012;2(3):317-22- -

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Organ and tissue donation (OTD) is vital to our health service for the opportunity that it provides recipients to regain health and function. In New Zealand, each year from 2008 and 2014, between 31 to 46 deceased persons (6.7 to 10 per million people) per year donated organs.1 When compared to international donor rates, New Zealands OTD rate lags behind that of many countries with similar socioeconomic status and health indicators, including Spain, Portugal, and Australia.1 There are many reasons why OTD rates may differ between countries, including (but not restricted to) legal and ethical considerations,2 medical resources (eg, availability of intensive care beds),3 and sociocultural factors such as knowledge and attitudes towards OTD.4-7 Factors influencing knowledge and attitudes towards OTD continually require exploration to guide the delivery of OTD practice in an informed, community-consultative and culturally appropriate manner, and determine how regulations and guidelines can best protect the beliefs and values of individuals and communities.4,8,10 Despite recent media interest regarding OTD in New Zealand,11-14 little critical analysis exists exploring what New Zealanders actually know about OTD. Young adults, for example, are consistently identified as central to OTD community engagement strategy as tomorrows donors,4,8 yet there is a paucity of research on their knowledge and attitudes to OTD. Harbour et al examined Auckland University medical students knowledge and attitudes to organ donation,15 finding support for this concept, but a lack of knowledge about it. However, no studies have examined OTD knowledge or attitudes in a non-medical, young adult population in New Zealand. This exploratory study utilised a knowledge and attitude survey in a university student population with the aim of providing information relevant to future educational or engagement campaigns.MethodsA random, stratified sample of students enrolled at the University of Otago (Dunedin, New Zealand) was surveyed in November 2014. The survey was not a replication of any pre-existing, published surveys, however some questions were modelled on previous OTD surveys and adapted for the New Zealand context and student population; other questions were developed by an intensivist involved in organ donation programmes (author RD).8,9 Inclusion criteria included participants being under 25 years of age,16 and having a permanent address in New Zealand. The study was approved by the University of Otago Ethics Committee (14/154).Survey questions were presented in four sections: demographic status (6 questions), knowledge relating to OTD in New Zealand (3 questions), knowledge and attitude relating to OTD and donation of own tissues (8 questions), and attitude to OTD of a loved ones organs/tissues (5 questions). The survey was pre-tested and finalised with input from university students and academics (six individuals). Questions included 5-point Likert-type responses (ranging from strongly agree to strongly disagree), yes-no answers, and multiple-choice options.Participants were randomly recruited (every tenth student invited to participate) by one of the authors (NL) from selected locations around the University of Otago over a two-day period. Locations were estimated to provide a representative sample of students with demographic data comparable to student demographics at this university (2013).17 Each potential participant was verbally informed of the project aims and provided written informed consent before completing the 10-minute paper questionnaire. An online version was available and completed by 6 participants who preferred this option.Statistical analysisData were analysed to determine whether participant responses for individual questions differed by sex, selected demographics of the known profile of enrolled University of Otago students, or supportive (vs. unsupportive) attitudes to OTD. Survey data were entered into an Excel (Microsoft Corp, Palo Alto, CA) spreadsheet, cleaned and imported into SAS (SAS Institute Inc., Cary, NC) statistical software for analysis. Between-group comparisons were undertaken using Chi-square or Fishers exact test as appropriate. For all analyses, significance was p<0.05.Post hoc analysis for support attitude for organ and tissue donationA supportive attitude to OTD was determined by combining agree/strongly agree responses to two questions in the section on knowledge and attitude relating to OTD and donation of own tissues; non-supportive status was determined by combining disagree, strongly disagree, and neutral responses. The questions used to indicate positive support were i) if medically possible I would donate organs/tissues, and ii) OTD benefits society. Positive support for OTD was compared to selected questions to determine whether this factor influenced (was correlated to) response outcomes. These questions included knowledge and attitude relating to OTD, and attitude towards OTD of a loved ones organs/tissues.ResultsDemographic dataIn total, 180 (n=120, 67% female, n=60, 33% male) students participated and had complete data for OTD questions; two female participants had missing data for age. The mean age of participants was 20.1 years (range 18-24, SD 1.8). The mean female age was 19.9 years (range 18-24, SD 1.6) and male age 20.5 (range 18-24, SD 1.9) (Table 1) with no significant age difference between sexes. Responses did not differ significantly by sex in regards to knowledge relating to OTD donation in New Zealand, attitude to OTD of own organs/tissues, or attitude to OTD donation of a loved ones organs/tissues.Table 1: Knowledge relating to organ/tissue donation in New Zealand. Correct responses are indicated. Questions and possible responses Females n=120 Males n=60 Total n=180 n % n % n % Percentage of deaths where organ donation is medically feasible Less than 5% (correct) 11 9.2 11 18.3 22 12.2 6 to 10% 26 21.7 9 15 35 19.4 11 to 20% 21 17.5 13 21.7 34 18.8 21 to 50% 19 15.8 11 18.3 30 16.7 More than 50% 10 8.3 5 8.3 15 8.3 Dont know 32 26.7 11 18.3 43 23.9 Age limit for someone to be an organ/tissue donor Age limit varies depending on clinical circumstances (correct) 74 61.7 38 63.3 112 62.2 55 years 4 3.3 8 13.3 12 6.7 60 years 10 8.3 9 15 19 10.6 65 years 5 4.2 0 0 5 2.7 70 years 3 2.5 1 1.7 4 2.2 Dont know 24 20 4 6.7 28 15.5 Circumstances in which organ/tissue donation is possible in NZ The family consent to organ/tissue donation irrespective of what is stated on the drivers license (correct) 33 27.5 9 15 42 23.3 A person has a valid registration on their drivers license 23 19.2 11 18.3 34 18.9 A person has a valid registration on their drivers license and family consent 51 42.5 37 61.7 88 48.9 Dont know 13 10.8 3 5 16 8.9 Students identified as New Zealand European (68%), M\u0101ori (6%), Pacific (2%), Asian (21%) or other (9%). Participants listed their permanent residence as Dunedin (50%), other South Island (20%), or North Island (30%). First-year students were the most well represented year-of-study category (40%), with fewer participants from second-year students (15%), third-year (21%), fourth-year (10%) and fifth or more (15%). Compared to 2013 data (University of Otago), ethnicity was proportionately representative of the 2013 University of Otago student profile, but under-representative of males (33% vs. 42% in 2013), over-representative of first-year students (40% vs. 20%), and permanent address in Dunedin (50% vs. 20%).Knowledge and attitudes relating to organ/tissue donation in New ZealandFor the question relating to the percentage of deaths where donation is medically feasible, only 12% of respondents identified the correct answer (Less than 5%; based on Australian data from the DonateLife website, http://www.donatelife.gov.au/) (Table 1). The question \u201cAge limit for someone to be an organ/tissue donor\u201d was correctly identified by 62%, while 23% correctly identified that \u201cthe family consent to organ/tissue donation irrespective of what is stated on the drivers license\u201d to the question on \u201cCircumstances in which organ/tissue donation is possible in NZ\u201d.Knowledge and attitude relating to organ/tissue donation and donation of own tissuesNearly all (93%) participants agreed that OTD benefits society, with 72% of participants indicating they would like to donate organs or tissues after death. Around one fifth of participants know or knew someone who had donated (21%) or received (18%) organs or tissues (Table 2). Just under half (42%) agreed with the statement that \u201cThere are many more potential organ donors than there are potential recipients in NZ\u201d, while only 5% indicated OTD was against their religion. Most (73%) favoured OTD being \u201copt-in\u201d in New Zealand, while under half (42%) indicated support for OTD being \u201copt-out\u201d.Table 2: Knowledge and attitude relating to organ/tissue donation, and donation of own tissues. Positive responses (agree, strongly agree) from a 5-point Likert scale and yes/no answers*. Questions Females n = 120 Males n = 60 Total n = 180 n % n % n % Organ/tissue donation benefits society 110 91.7 56 93.3 166 92.2 If this was medically possible I would like to donate my organs/tissues after death 80 66.7 48 80 128 71.1 There are many more potential organ donors than there are potential recipients in NZ 45 37.5 30 50 75 41.7 Organ/tissue donation is against my religion 7 5.8 2 3.3 9 5 Organ/tissue donation in NZ should be opt-in 89 74.2 41 68.3 130 72.2 Organ/tissue donation in NZ should be opt-out 47 39.2 29 48.3 76 42.2 Know/knew someone who donated organs/tissues* 21 17.5 17 28.3 38 21.1 Know/knew someone who received organs/tissues* 19 15.8 13 21.7 32 17.8 Attitude to organ/tissue donation of a loved ones organs/tissuesParticipants demonstrated supportive attitudes to four of the five questions on donation of a loved ones organs or tissues (Table 3). These questions related to being asked for consent (78%), the most important consideration being the expression of previous wishes (91%), whether other lives could be helped by the donation (75%), and the importance of the information about the specific benefits of donation being available at the time of deciding whether to consent (76%). The only question that received less than half of the participants support was related to providing consent when loved ones had not made their wishes clear about donating (43%).Table 3: Attitude to organ/tissue donation of a loved ones organs/tissues. Positive responses (agree, strongly agree) from a 5-point Likert scale. Questions Females n = 120 Males n = 60 Total n = 180 n % n % n % If donation of organs/tissues from a loved one was possible I would expect to be asked for consent 90 75 50 83.3 140 77.8 The most important consideration in whether I would consent to donating organs/tissues of a loved one would be their previous wishes 110 91.7 52 86.7 162 90 If my loved one had NOT made their wishes about donation known to me I would not consent to donating their organs/tissues 47 39.2 30 50 77 42.8 The most important consideration in whether I would consent to donating organs/tissues of a loved one would be whether others lives could be helped 89 74.2 45 75 134 74.4 Information about the specific benefits of donation would be important to me at the time of deciding whether to consent to organ/tissue donation of a loved one 93 77.5 43 71.7 136 75.6 Correlates of supportive attitudes to organ/tissue donation against selected survey questionsSupportive attitudes were reported by 78 (65%) females and 46 (77%) males; there was no significant difference between proportions of supportive attitude by sex. The supportive attitudes group was compared with not supportive on selected questions on OTD (policy for opt-in, opt-out questions), and all questions relating to donation of loved ones organs/tissues (Table 4). There were significant differences in responses between the supportive and not supportive groups when disagree (including strongly disagree), vs neutral, vs agree (including strongly agree), agree responses for three of the seven questions.Table 4: Comparison of supportive and not supportive attitudes to donation with positive responses to selected survey questions. *Indicates significant difference between supportive and not supportive groups (Chi square); percentages have been rounded to one decimal place. Male and female responses have been combined. DoF = degrees of freedom. Questions Response Supportive (%) Not supportive (%) Chi square (DoF) Organ/tissue donation in NZ should be opt-in Agree 72.6 72.7 8.4* (2) Neutral 13.7 25.5 Disagree 13.7 1.8 Organ/tissue donation in NZ should be opt-out Agree 46 34.6 2 (2) Neutral 18.6 21.8 Disagree 35.5 43.6 If donation of organs/tissues from a loved one was possible I would expect to be asked for consent Agree 75.8 83.6 1.5 (2) Neutral 17 12.7 Disagree 7.3 3.6 The most important consideration in whether I would consent to donating organs/tissues of a loved one would be their previous wishes Agree 94.3 83.6 7.7* (2) Neutral 2.4 12.7 Disagree 3.3 3.6 If my loved one had NOT made their wishes about donation known to me I would not consent to donating their organs/tissues Agree 36.3 58.2 13.7* (2) Neutral 29 32.7 Disagree 34.7 9.1 The most important consideration in whether I would consent to donating organs/tissues of a loved one would be whether others lives could be helped Agree 79 65.5 3.9 (2) Neutral 14.5 25.5 Disagree 6.5 9.1 Information about the specific benefits of donation would be important to me at the time of deciding whether to consent to organ/tissue donation of a loved one Agree 78.2 70.9 1.2 (2) Neutral 17 21.8 Disagree 4.8 7.3 DiscussionThis study examined attitudes and knowledge in a New Zealand young adult population at one university, providing unique information on OTD in this demographic. Findings suggest that OTD is generally supported, with results providing some insight into how young adults approach and engage with the decision making process in relation to donation of a loved ones organs/tissues.Demographic dataResults indicate that these data are not representative of the actual profile of University of Otago students, with sex, year of study, and home address different to the 2013 university student profile. Therefore, results from this exploratory study cannot necessarily be generalised to the University of Otago student population. However, they do provide an indication of the variety of attitudes and knowledge of OTD in young, university-attending adults in New Zealand. While the ethnic profile of participants was representative of University of Otago students, the low number of M\u0101ori and Pacific Island participants indicates that responses may not be representative of OTD attitudes and knowledge for these communities.18,19Knowledge relating to organ/tissue donation in New ZealandFindings indicate that young New Zealand adults do not realise that donation is a rare possibility when death occurs; in Australia organ donation is feasible in around 1% of hospital deaths.20 Furthermore, there is a lack of understanding that donor age limits depend on clinical circumstances, and an incorrect assumption that both drivers licence indication of intent and family consent are required for OTD to proceed (49% responses). Results also indicated that participants were not really aware of the rarity of OTD opportunities, or the fact that there is significant need for organs, with current demand far exceeding supply, suggesting that the circumstances in which OTD can occur in New Zealand after persons die are not well understood. This is important because such information is relevant to the expectations of potential donor families, and to clinicians who may assume a baseline knowledge of individuals and families. Improving community knowledge in this area may be important in order to assist communication and interaction between clinicians and families faced with a donation decision;21,22 therefore these findings provide an insight into potential OTD education requirements and establishing a benchmark for future investigations. Religious beliefs do not appear to be a barrier for OTD in New Zealand, based on our findings. This is perhaps not surprising given New Zealands secular population, confirming strategies to improve donation rates should not overemphasise religion as a potential barrier.Knowledge and attitude relating to organ/tissue donation, and donation of own tissuesOur findings indicate a high level of support for OTD at a conceptual (good for society) and personal level, similar to those from Auckland University medical students.15 Around 20% of respondents had knowledge of either an organ/tissue donor or recipient, an interesting finding given New Zealands low donor rate of between 31 and 46 people per year (2008-2014) with 919 total recipients (live and deceased donors) between 2010 and 2014.23 The figure for knowing a donor was similar to that for young adults in the UK and USA,8,22 with the percentage on knowing someone who has received higher than the UK (18% vs. 9.2%).22 This personal exposure to organ donation suggests many New Zealand young adults at the University of Otago are personally connected to donation, and provides a useful platform for engaging with them, given their demonstrated a priori knowledge of donation practice in this country.Various models exist internationally with respect to donor registries and the opt-in and opt-out systems of OTD. This study found support for both concepts, perhaps highlighting that they are not mutually exclusive. Some respondents may have ticked yes for both questions (ie, both are a good idea); both examine whether individual autonomy, or family consensus, or community need is the prevailing concept, however it is hard to compare the two concepts and draw any meaningful conclusions. Overall, opt-in received more positive responses (73% vs. 42%) which provides more support for the concept of donor registries as opposed to having an opt-out policy. Currently, there is no OTD register in New Zealand; previous reports have shown a low level of support in countries that implemented these programmes, indicating they may perform poorly.24 Recent data from the UK reported 38% of the adult population are registered organ donors,22 suggesting the establishment of opt-in OTD registers may be popular and potentially beneficial in some countries.Attitudes to organ/tissue donation of loved ones organs/tissuesThe consent for OTD following brain death in New Zealand is approximately 50%;25 in Australia it is around 60% and increasing the family consent rate is a key target of the Australian Organ and Tissue Authority.26 This indicates that understanding local factors that contribute to family consent decisions is important in regards to being able to improve the chances of family consent being granted in situations where donation is possible. In this study, most participants indicated they would expect information about the specific benefits of donation to other

Summary

Abstract

Aim

Organ and tissue donation (OTD) rates in New Zealand are low compared to many countries. Young adults are tomorrows donors, yet the attitudes and knowledge of this group to OTD have not been examined locally. Such information is relevant to ODT education and clinical engagement.

Method

A random sample of University of Otago students (

Results

180 responses were gathered (mean age 20.1 years, 67% female, 68% New Zealand European); there were no age or response differences between sexes, participants were generally not representative of the University of Otago student profile. Outcomes indicated limited OTD knowledge, positive support for OTD, and willingness to engage in donation the decision-making process for loved ones. Differences between supportive and non-supportive OTD attitudes was seen for some questions.

Conclusion

Findings highlight areas for strategic OTD public engagement and provide details relevant to guiding appropriate clinical interaction in facilitating decisions about OTD.

Author Information

Jon Cornwall, Senior Research Fellow, Faculty of Law and Department of Physiology, University of Otago, Dunedin, and Centre for Health Professions, Zurich University of Applied Sciences, Zurich, Switzerland; Cyril Schafer, Senior Lecturer, Department of Anthropology and Archaeology, University of Otago, Dunedin; Navneet Lal, Assistant Research Fellow, University of Otago, Dunedin; Rohit DCosta, Intensive Care Specialist, Melbourne Hospital, and Deputy Medical Director DonateLife Victoria; Shyamala Nada-Raja, Senior Research Fellow, Department of Preventive and Social Medicine, University of Otago, Dunedin.

Acknowledgements

This article is dedicated to the memory of our fellow author and colleague Dr Cyril Schafer, who sadly passed away in June 2015. The authors would like to thank the Humanities Division of the University of Otago for the provision of a research grant to assist the completion of this study.

Correspondence

Jon Cornwall, Faculty of Law and Department of Physiology, University of Otago

Correspondence Email

jon.cornwall@otago.ac.nz

Competing Interests

Nil

- - Australia and New Zealand Organ Donation Registry. 2013 ANZOD annual report 2013. Ngahooro J, Gillett G. Over my dead body: the ethics of organ donation in New Zealand. NZ Med J. 2004;117(1201):U1051. McCall J. Organ donation and legislation. NZ Med J. 2006;119:5-7. Feeley TH. College students knowledge, attitudes, and behaviors regarding organ donation: An integrated review of the literature. J Appl Soc Psychol. 2007;37:243-71. Shaw R. Perceptions of the gift relationship in organ and tissue donation: Views of intensivists and donor and recipient coordinators. Soc Sci Med. 2010;70:609-15. Tam WWS, Suen LKP, Chan HYL. Knowledge, attitudes and commitment toward orga donation among nursing students in Hong Kong. Transplant P. 2012;44:1196-1200. Marck CH, Neate SL, Skinner MR, et al. Factors relating to consent for organ donation: prospective data on potential organ donors. Intern Med J. 2015;45(1):40- DAlessandro AM, Peltier JW, Dahl AJ. The impact of social, cognitive, and attitudinal dimensions on college students support for organ donation. Am J Transplant. 2012;12:152-61. Coad L, Carter N, Ling J. Attitudes of young adults from the UK towards organ donation and transplantation. Transplant Res. 2013;2:9 Shaw R. The ethical risks of curtailing emotion in social science research: The case of organ transfer. Health Sociol Rev. 2011;20(1):58-69. New Zealand Herald website. Accessed 6 April 2015. http://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=11420789 New Zealand Herald website. Accessed 6 April 2015. http://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=11407294 Yahoo news New Zealand website. Accessed 6 April 2015. https://nz.news.yahoo.com/a/-/top-stories/26411035/organ-transplants-hit-record-high/ New Zealand Herald website. Accessed 6 April 2015. http://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=11296853 Harbour L, Ingham C, Streat S, Bagg W. Attitudes to organ donation and knowledge of donation and transplantation among University of Auckland Medical students. Journal of Medical Education and Curricular Development. 2015:2 Whatman J, Schagen S, Vaughn K, Lander J. Engaging young people/young adults in literacy, language and numeracy skill development: A Literature Review. New Zealand Government 2010. University of Otago website. Accessed 20 February 2015. http://www.otago.ac.nz/about/quickstats.html Lewis G, Pickering N. Mori spiritual beliefs and attitudes towards organ donation. NZ Bioeth J 2003;4(1):31-5. Shaw R. Organ Donation in Aotearoa/New Zealand: Cultural phenomenology and moral humility. Body Soc 2010:16(3):127-47. Australian Organ and Tissue Authority, 2014 performance report. http://www.donatelife.gov.au/sites/default/files/OTA%202014%20Performance%20Report%20Jan%202015%20FINAL.pdf Siminoff LA, Lawrence RH. Knowing patients preferences about organ donation: does it make a difference? J Trauma. 2002;53:754-60. Siminoff L, Mercer MB, Graham G, Burant C. The reasons families donate organs for transplantation: implications for policy and practice. J Trauma. 2007;62:969-78. Organ Donation New Zealand Annual Report 2013. Accessed 20 January 2015. http://www.donor.co.nz/files/Annual_Report_FINAL_2013_online.pdf Childress JF, Liverman CT (eds). Organ Donation: Opportunities for Action. Committee for increasing rates of organ donation. Washington DC: Board on Health Sciences Policy, Institute of Medicine of the National Academies, National Academies Press; 2006. Organ Donation New Zealand website. Accessed 2 April 2015. http://www.donor.co.nz/statistics/number-of-transplant-operations-in-new-zealand Neate SL, Marck CH, Skinner M, et al. Understanding Australian families organ donation decisions. Anaesth Intens Care. 2015;43(1):42-50. Rodrigue JR, Cornell DL, Krouse J, Howard RJ. Family initiated discussions about organ donation at the time of death. Clin Transplant. 2010;24:493-9. Wakefield CE, Reid J, Homewood J. Religious and ethnic influences of willingness to donate organs and donor behaviour: an Australian perspective. Prog Transplant. 2011;21:161-8. Marck CH, Weiland TJ, Neate SL, et al. Personal attitudes and beliefs regarding organ and tissue donation: a cross-sectional survey of Australian emergency department clinicians. Prog Transplant. 2012;2(3):317-22- -

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Organ and tissue donation (OTD) is vital to our health service for the opportunity that it provides recipients to regain health and function. In New Zealand, each year from 2008 and 2014, between 31 to 46 deceased persons (6.7 to 10 per million people) per year donated organs.1 When compared to international donor rates, New Zealands OTD rate lags behind that of many countries with similar socioeconomic status and health indicators, including Spain, Portugal, and Australia.1 There are many reasons why OTD rates may differ between countries, including (but not restricted to) legal and ethical considerations,2 medical resources (eg, availability of intensive care beds),3 and sociocultural factors such as knowledge and attitudes towards OTD.4-7 Factors influencing knowledge and attitudes towards OTD continually require exploration to guide the delivery of OTD practice in an informed, community-consultative and culturally appropriate manner, and determine how regulations and guidelines can best protect the beliefs and values of individuals and communities.4,8,10 Despite recent media interest regarding OTD in New Zealand,11-14 little critical analysis exists exploring what New Zealanders actually know about OTD. Young adults, for example, are consistently identified as central to OTD community engagement strategy as tomorrows donors,4,8 yet there is a paucity of research on their knowledge and attitudes to OTD. Harbour et al examined Auckland University medical students knowledge and attitudes to organ donation,15 finding support for this concept, but a lack of knowledge about it. However, no studies have examined OTD knowledge or attitudes in a non-medical, young adult population in New Zealand. This exploratory study utilised a knowledge and attitude survey in a university student population with the aim of providing information relevant to future educational or engagement campaigns.MethodsA random, stratified sample of students enrolled at the University of Otago (Dunedin, New Zealand) was surveyed in November 2014. The survey was not a replication of any pre-existing, published surveys, however some questions were modelled on previous OTD surveys and adapted for the New Zealand context and student population; other questions were developed by an intensivist involved in organ donation programmes (author RD).8,9 Inclusion criteria included participants being under 25 years of age,16 and having a permanent address in New Zealand. The study was approved by the University of Otago Ethics Committee (14/154).Survey questions were presented in four sections: demographic status (6 questions), knowledge relating to OTD in New Zealand (3 questions), knowledge and attitude relating to OTD and donation of own tissues (8 questions), and attitude to OTD of a loved ones organs/tissues (5 questions). The survey was pre-tested and finalised with input from university students and academics (six individuals). Questions included 5-point Likert-type responses (ranging from strongly agree to strongly disagree), yes-no answers, and multiple-choice options.Participants were randomly recruited (every tenth student invited to participate) by one of the authors (NL) from selected locations around the University of Otago over a two-day period. Locations were estimated to provide a representative sample of students with demographic data comparable to student demographics at this university (2013).17 Each potential participant was verbally informed of the project aims and provided written informed consent before completing the 10-minute paper questionnaire. An online version was available and completed by 6 participants who preferred this option.Statistical analysisData were analysed to determine whether participant responses for individual questions differed by sex, selected demographics of the known profile of enrolled University of Otago students, or supportive (vs. unsupportive) attitudes to OTD. Survey data were entered into an Excel (Microsoft Corp, Palo Alto, CA) spreadsheet, cleaned and imported into SAS (SAS Institute Inc., Cary, NC) statistical software for analysis. Between-group comparisons were undertaken using Chi-square or Fishers exact test as appropriate. For all analyses, significance was p<0.05.Post hoc analysis for support attitude for organ and tissue donationA supportive attitude to OTD was determined by combining agree/strongly agree responses to two questions in the section on knowledge and attitude relating to OTD and donation of own tissues; non-supportive status was determined by combining disagree, strongly disagree, and neutral responses. The questions used to indicate positive support were i) if medically possible I would donate organs/tissues, and ii) OTD benefits society. Positive support for OTD was compared to selected questions to determine whether this factor influenced (was correlated to) response outcomes. These questions included knowledge and attitude relating to OTD, and attitude towards OTD of a loved ones organs/tissues.ResultsDemographic dataIn total, 180 (n=120, 67% female, n=60, 33% male) students participated and had complete data for OTD questions; two female participants had missing data for age. The mean age of participants was 20.1 years (range 18-24, SD 1.8). The mean female age was 19.9 years (range 18-24, SD 1.6) and male age 20.5 (range 18-24, SD 1.9) (Table 1) with no significant age difference between sexes. Responses did not differ significantly by sex in regards to knowledge relating to OTD donation in New Zealand, attitude to OTD of own organs/tissues, or attitude to OTD donation of a loved ones organs/tissues.Table 1: Knowledge relating to organ/tissue donation in New Zealand. Correct responses are indicated. Questions and possible responses Females n=120 Males n=60 Total n=180 n % n % n % Percentage of deaths where organ donation is medically feasible Less than 5% (correct) 11 9.2 11 18.3 22 12.2 6 to 10% 26 21.7 9 15 35 19.4 11 to 20% 21 17.5 13 21.7 34 18.8 21 to 50% 19 15.8 11 18.3 30 16.7 More than 50% 10 8.3 5 8.3 15 8.3 Dont know 32 26.7 11 18.3 43 23.9 Age limit for someone to be an organ/tissue donor Age limit varies depending on clinical circumstances (correct) 74 61.7 38 63.3 112 62.2 55 years 4 3.3 8 13.3 12 6.7 60 years 10 8.3 9 15 19 10.6 65 years 5 4.2 0 0 5 2.7 70 years 3 2.5 1 1.7 4 2.2 Dont know 24 20 4 6.7 28 15.5 Circumstances in which organ/tissue donation is possible in NZ The family consent to organ/tissue donation irrespective of what is stated on the drivers license (correct) 33 27.5 9 15 42 23.3 A person has a valid registration on their drivers license 23 19.2 11 18.3 34 18.9 A person has a valid registration on their drivers license and family consent 51 42.5 37 61.7 88 48.9 Dont know 13 10.8 3 5 16 8.9 Students identified as New Zealand European (68%), M\u0101ori (6%), Pacific (2%), Asian (21%) or other (9%). Participants listed their permanent residence as Dunedin (50%), other South Island (20%), or North Island (30%). First-year students were the most well represented year-of-study category (40%), with fewer participants from second-year students (15%), third-year (21%), fourth-year (10%) and fifth or more (15%). Compared to 2013 data (University of Otago), ethnicity was proportionately representative of the 2013 University of Otago student profile, but under-representative of males (33% vs. 42% in 2013), over-representative of first-year students (40% vs. 20%), and permanent address in Dunedin (50% vs. 20%).Knowledge and attitudes relating to organ/tissue donation in New ZealandFor the question relating to the percentage of deaths where donation is medically feasible, only 12% of respondents identified the correct answer (Less than 5%; based on Australian data from the DonateLife website, http://www.donatelife.gov.au/) (Table 1). The question \u201cAge limit for someone to be an organ/tissue donor\u201d was correctly identified by 62%, while 23% correctly identified that \u201cthe family consent to organ/tissue donation irrespective of what is stated on the drivers license\u201d to the question on \u201cCircumstances in which organ/tissue donation is possible in NZ\u201d.Knowledge and attitude relating to organ/tissue donation and donation of own tissuesNearly all (93%) participants agreed that OTD benefits society, with 72% of participants indicating they would like to donate organs or tissues after death. Around one fifth of participants know or knew someone who had donated (21%) or received (18%) organs or tissues (Table 2). Just under half (42%) agreed with the statement that \u201cThere are many more potential organ donors than there are potential recipients in NZ\u201d, while only 5% indicated OTD was against their religion. Most (73%) favoured OTD being \u201copt-in\u201d in New Zealand, while under half (42%) indicated support for OTD being \u201copt-out\u201d.Table 2: Knowledge and attitude relating to organ/tissue donation, and donation of own tissues. Positive responses (agree, strongly agree) from a 5-point Likert scale and yes/no answers*. Questions Females n = 120 Males n = 60 Total n = 180 n % n % n % Organ/tissue donation benefits society 110 91.7 56 93.3 166 92.2 If this was medically possible I would like to donate my organs/tissues after death 80 66.7 48 80 128 71.1 There are many more potential organ donors than there are potential recipients in NZ 45 37.5 30 50 75 41.7 Organ/tissue donation is against my religion 7 5.8 2 3.3 9 5 Organ/tissue donation in NZ should be opt-in 89 74.2 41 68.3 130 72.2 Organ/tissue donation in NZ should be opt-out 47 39.2 29 48.3 76 42.2 Know/knew someone who donated organs/tissues* 21 17.5 17 28.3 38 21.1 Know/knew someone who received organs/tissues* 19 15.8 13 21.7 32 17.8 Attitude to organ/tissue donation of a loved ones organs/tissuesParticipants demonstrated supportive attitudes to four of the five questions on donation of a loved ones organs or tissues (Table 3). These questions related to being asked for consent (78%), the most important consideration being the expression of previous wishes (91%), whether other lives could be helped by the donation (75%), and the importance of the information about the specific benefits of donation being available at the time of deciding whether to consent (76%). The only question that received less than half of the participants support was related to providing consent when loved ones had not made their wishes clear about donating (43%).Table 3: Attitude to organ/tissue donation of a loved ones organs/tissues. Positive responses (agree, strongly agree) from a 5-point Likert scale. Questions Females n = 120 Males n = 60 Total n = 180 n % n % n % If donation of organs/tissues from a loved one was possible I would expect to be asked for consent 90 75 50 83.3 140 77.8 The most important consideration in whether I would consent to donating organs/tissues of a loved one would be their previous wishes 110 91.7 52 86.7 162 90 If my loved one had NOT made their wishes about donation known to me I would not consent to donating their organs/tissues 47 39.2 30 50 77 42.8 The most important consideration in whether I would consent to donating organs/tissues of a loved one would be whether others lives could be helped 89 74.2 45 75 134 74.4 Information about the specific benefits of donation would be important to me at the time of deciding whether to consent to organ/tissue donation of a loved one 93 77.5 43 71.7 136 75.6 Correlates of supportive attitudes to organ/tissue donation against selected survey questionsSupportive attitudes were reported by 78 (65%) females and 46 (77%) males; there was no significant difference between proportions of supportive attitude by sex. The supportive attitudes group was compared with not supportive on selected questions on OTD (policy for opt-in, opt-out questions), and all questions relating to donation of loved ones organs/tissues (Table 4). There were significant differences in responses between the supportive and not supportive groups when disagree (including strongly disagree), vs neutral, vs agree (including strongly agree), agree responses for three of the seven questions.Table 4: Comparison of supportive and not supportive attitudes to donation with positive responses to selected survey questions. *Indicates significant difference between supportive and not supportive groups (Chi square); percentages have been rounded to one decimal place. Male and female responses have been combined. DoF = degrees of freedom. Questions Response Supportive (%) Not supportive (%) Chi square (DoF) Organ/tissue donation in NZ should be opt-in Agree 72.6 72.7 8.4* (2) Neutral 13.7 25.5 Disagree 13.7 1.8 Organ/tissue donation in NZ should be opt-out Agree 46 34.6 2 (2) Neutral 18.6 21.8 Disagree 35.5 43.6 If donation of organs/tissues from a loved one was possible I would expect to be asked for consent Agree 75.8 83.6 1.5 (2) Neutral 17 12.7 Disagree 7.3 3.6 The most important consideration in whether I would consent to donating organs/tissues of a loved one would be their previous wishes Agree 94.3 83.6 7.7* (2) Neutral 2.4 12.7 Disagree 3.3 3.6 If my loved one had NOT made their wishes about donation known to me I would not consent to donating their organs/tissues Agree 36.3 58.2 13.7* (2) Neutral 29 32.7 Disagree 34.7 9.1 The most important consideration in whether I would consent to donating organs/tissues of a loved one would be whether others lives could be helped Agree 79 65.5 3.9 (2) Neutral 14.5 25.5 Disagree 6.5 9.1 Information about the specific benefits of donation would be important to me at the time of deciding whether to consent to organ/tissue donation of a loved one Agree 78.2 70.9 1.2 (2) Neutral 17 21.8 Disagree 4.8 7.3 DiscussionThis study examined attitudes and knowledge in a New Zealand young adult population at one university, providing unique information on OTD in this demographic. Findings suggest that OTD is generally supported, with results providing some insight into how young adults approach and engage with the decision making process in relation to donation of a loved ones organs/tissues.Demographic dataResults indicate that these data are not representative of the actual profile of University of Otago students, with sex, year of study, and home address different to the 2013 university student profile. Therefore, results from this exploratory study cannot necessarily be generalised to the University of Otago student population. However, they do provide an indication of the variety of attitudes and knowledge of OTD in young, university-attending adults in New Zealand. While the ethnic profile of participants was representative of University of Otago students, the low number of M\u0101ori and Pacific Island participants indicates that responses may not be representative of OTD attitudes and knowledge for these communities.18,19Knowledge relating to organ/tissue donation in New ZealandFindings indicate that young New Zealand adults do not realise that donation is a rare possibility when death occurs; in Australia organ donation is feasible in around 1% of hospital deaths.20 Furthermore, there is a lack of understanding that donor age limits depend on clinical circumstances, and an incorrect assumption that both drivers licence indication of intent and family consent are required for OTD to proceed (49% responses). Results also indicated that participants were not really aware of the rarity of OTD opportunities, or the fact that there is significant need for organs, with current demand far exceeding supply, suggesting that the circumstances in which OTD can occur in New Zealand after persons die are not well understood. This is important because such information is relevant to the expectations of potential donor families, and to clinicians who may assume a baseline knowledge of individuals and families. Improving community knowledge in this area may be important in order to assist communication and interaction between clinicians and families faced with a donation decision;21,22 therefore these findings provide an insight into potential OTD education requirements and establishing a benchmark for future investigations. Religious beliefs do not appear to be a barrier for OTD in New Zealand, based on our findings. This is perhaps not surprising given New Zealands secular population, confirming strategies to improve donation rates should not overemphasise religion as a potential barrier.Knowledge and attitude relating to organ/tissue donation, and donation of own tissuesOur findings indicate a high level of support for OTD at a conceptual (good for society) and personal level, similar to those from Auckland University medical students.15 Around 20% of respondents had knowledge of either an organ/tissue donor or recipient, an interesting finding given New Zealands low donor rate of between 31 and 46 people per year (2008-2014) with 919 total recipients (live and deceased donors) between 2010 and 2014.23 The figure for knowing a donor was similar to that for young adults in the UK and USA,8,22 with the percentage on knowing someone who has received higher than the UK (18% vs. 9.2%).22 This personal exposure to organ donation suggests many New Zealand young adults at the University of Otago are personally connected to donation, and provides a useful platform for engaging with them, given their demonstrated a priori knowledge of donation practice in this country.Various models exist internationally with respect to donor registries and the opt-in and opt-out systems of OTD. This study found support for both concepts, perhaps highlighting that they are not mutually exclusive. Some respondents may have ticked yes for both questions (ie, both are a good idea); both examine whether individual autonomy, or family consensus, or community need is the prevailing concept, however it is hard to compare the two concepts and draw any meaningful conclusions. Overall, opt-in received more positive responses (73% vs. 42%) which provides more support for the concept of donor registries as opposed to having an opt-out policy. Currently, there is no OTD register in New Zealand; previous reports have shown a low level of support in countries that implemented these programmes, indicating they may perform poorly.24 Recent data from the UK reported 38% of the adult population are registered organ donors,22 suggesting the establishment of opt-in OTD registers may be popular and potentially beneficial in some countries.Attitudes to organ/tissue donation of loved ones organs/tissuesThe consent for OTD following brain death in New Zealand is approximately 50%;25 in Australia it is around 60% and increasing the family consent rate is a key target of the Australian Organ and Tissue Authority.26 This indicates that understanding local factors that contribute to family consent decisions is important in regards to being able to improve the chances of family consent being granted in situations where donation is possible. In this study, most participants indicated they would expect information about the specific benefits of donation to other

Summary

Abstract

Aim

Organ and tissue donation (OTD) rates in New Zealand are low compared to many countries. Young adults are tomorrows donors, yet the attitudes and knowledge of this group to OTD have not been examined locally. Such information is relevant to ODT education and clinical engagement.

Method

A random sample of University of Otago students (

Results

180 responses were gathered (mean age 20.1 years, 67% female, 68% New Zealand European); there were no age or response differences between sexes, participants were generally not representative of the University of Otago student profile. Outcomes indicated limited OTD knowledge, positive support for OTD, and willingness to engage in donation the decision-making process for loved ones. Differences between supportive and non-supportive OTD attitudes was seen for some questions.

Conclusion

Findings highlight areas for strategic OTD public engagement and provide details relevant to guiding appropriate clinical interaction in facilitating decisions about OTD.

Author Information

Jon Cornwall, Senior Research Fellow, Faculty of Law and Department of Physiology, University of Otago, Dunedin, and Centre for Health Professions, Zurich University of Applied Sciences, Zurich, Switzerland; Cyril Schafer, Senior Lecturer, Department of Anthropology and Archaeology, University of Otago, Dunedin; Navneet Lal, Assistant Research Fellow, University of Otago, Dunedin; Rohit DCosta, Intensive Care Specialist, Melbourne Hospital, and Deputy Medical Director DonateLife Victoria; Shyamala Nada-Raja, Senior Research Fellow, Department of Preventive and Social Medicine, University of Otago, Dunedin.

Acknowledgements

This article is dedicated to the memory of our fellow author and colleague Dr Cyril Schafer, who sadly passed away in June 2015. The authors would like to thank the Humanities Division of the University of Otago for the provision of a research grant to assist the completion of this study.

Correspondence

Jon Cornwall, Faculty of Law and Department of Physiology, University of Otago

Correspondence Email

jon.cornwall@otago.ac.nz

Competing Interests

Nil

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