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Emigration from the British Isles to Southeastern Spain: A Study of Attitudes Toward Organ Donation

  1. A. Ríos1,2,*,
  2. P. Cascales1,2,
  3. L. Martínez1,2,
  4. J. Sánchez3,
  5. N. Jarvis1,
  6. P. Parrilla1,
  7. P. Ramírez1,2

Article first published online: 5 JUL 2007

DOI: 10.1111/j.1600-6143.2007.01879.x

Issue

American Journal of Transplantation

American Journal of Transplantation

Volume 7, Issue 8, pages 2020–2030, August 2007

Additional Information

How to Cite

Ríos, A., Cascales, P., Martínez, L., Sánchez, J., Jarvis, N., Parrilla, P. and Ramírez, P. (2007), Emigration from the British Isles to Southeastern Spain: A Study of Attitudes Toward Organ Donation. American Journal of Transplantation, 7: 2020–2030. doi: 10.1111/j.1600-6143.2007.01879.x

Author Information

  1. 1

    Departamento de Cirugía. Hospital Universitario Virgen de la Arrixaca, El Palmar, Servicio Murciano de Salud, Murcia

  2. 2

    Coordinación Regional de Trasplantes de la Comunidad Autónoma de Murcia, Consejería de Sanidad, Murcia

  3. 3

    Asociación de Ayuda al Enfermo Renal (ADAER), Murcia

* * Corresponding author: Antonio Ríos, ZambudioARZRIOS@teleline.es

Publication History

  1. Issue published online: 5 JUL 2007
  2. Article first published online: 5 JUL 2007
  3. Received 25 December 2006, revised 21 April 2007 and accepted for publication 26 April 2007

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Keywords:

  • Attitude;
  • British;
  • cadaver;
  • family;
  • general population;
  • Irish;
  • organ donation;
  • Spain;
  • psychosocial factors

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and Methods
  5. Results
  6. Discussion
  7. References
  8. Appendix

Southeastern Spain is a cosmopolitan area where there is a growing British and Irish population. The objective is to analyze the attitude toward organ donation among British and Irish citizens living in southeastern Spain. A sample was taken stratified according to a respondent's country of origin (n = 1700) between November 2005 and April 2006. Attitude was evaluated using a validated questionnaire, which was self-administered and completed anonymously. A sample of 2000 Spanish citizens was used as a control group. The survey completion rate was 95% (n = 1611). Attitude toward donation is favorable in 72% (n = 1155) of respondents with 8% (n = 122) against and 20% (n = 334) undecided. Attitude is more favorable than in the control group (72% vs. 63%; p < 0.0001). The following factors influence this attitude: (1) attitude toward the donation of a family member's organs (OR = 4.891); (2) having discussed the matter of organ donation within the family (OR = 2.513); (3) a willingness to accept an autopsy if it were necessary (OR = 1.706); (4) having no concern about the mutilation of the deceased donor (OR = 3.294); (5) having a partner who is in favor of donation (OR = 2.786) and (6) a respondent's belief that he or she might need a transplant in the future (OR = 2.243). The attitude of this population is more positive than in the native Spanish population and is determined by many psychosocial factors.

Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and Methods
  5. Results
  6. Discussion
  7. References
  8. Appendix

Organ transplantation has become more efficient and offers increasingly more favorable life conditions (1). It is only limited by the shortage of organs available for carrying out this technique (2). In order to increase the number of transplant organs it is necessary to take action in different areas, both within organizations (3) and on the social conscience (4–6).

Currently, immigration is a frequent and growing phenomenon in Western European society given its great economic development. This fact is having an effect on the world of transplantation, because there is an increasing number of patients who are foreign nationals on the transplant waiting list (7), and requests for organs from nonnative families is also occurring (8).

In Spain, this notable increase in the foreign population is creating a new social and demographic reality in the whole country. Moreover, there is not just a nonnative population from poor countries but given its climate and the services on offer; in certain areas the number of residents from developed countries has increased, especially from the British Isles and Germany, places where the deceased organ donation rates are much lower than in Spain. This development, together with the new political and social European reality, involving the implementation of new European Union freedom of movement laws, makes the population flows between member countries easier and simpler. This has changed southeastern Spain into a cosmopolitan area in which the population originating from the British Isles is increasing and is perfectly integrated into the social structure. What is more, airline companies have created a network of flights in all the local airports that connect this area with the whole of the British Isles every day, with different flights and at a low cost.

The objectives of this study are to: (1) find out the nature of attitude toward the donation of one's own organs in the population aged over 15 years in our Regional Community born anywhere in the British Isles and (2) to analyze the psychosocial variables that influence this attitude.

Materials and Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and Methods
  5. Results
  6. Discussion
  7. References
  8. Appendix

Study population

A random sample was taken of the population aged ≥15 years who reside in the Autonomous Regional Community of Murcia in southeastern Spain and who were born anywhere in the British Isles. This sample was stratified by the respondents' nationality (n = 1700). The sample was stratified by age and sex for each nationality and according to the available data. In order to find out about the population with these characteristics, we studied the most recent census of inhabitants in our Regional Community in which there is a record of the legal population born in the British Isles. This municipal census corresponds to the year 2003 (total population: 1,269,230 inhabitants) and the British/Irish population living here permanently comprises of 3,464 people (http://www.ine.es/inebase/cgi/axi). In addition, in housing estates created in the last 10 years in different areas of the coast, there is normally a population of 15,000 inhabitants from the British Isles according to the private companies that manage these housing estates. Such a population in each municipality tends to be located in specific areas or housing estates, making it easy to locate this population. The margin of error at a confidence level of 95.5% (2 sigmas), K = 2, was estimated to be e ± 1.91 for the whole sample, p = q = 0.5.

Data collection procedure

The instrument used to measure attitude was a questionnaire validated in our geographical area (4–6) (see Annex 1). A pilot study was carried out between May and August of 2005 involving a random sample, in order to confirm and validate the questionnaire in this population sub-group. The only problem encountered was the language in certain sub-groups so that one questionnaire was used in Spanish and another in English.

This questionnaire was self-administered and completed anonymously (3–5 min were necessary for it to be completed in person), and the whole process was supervised by collaborators from the Regional transplant Center (five professionals who were previously trained and they carried out the study between November 2005 and April 2006). To carry out the study the collaborators went to the areas where the British and Irish tend to reside.

Variables analyzed

The attitude toward the donation of one's own organs was studied as a dependent variable. The following were analyzed as independent variables: (1) social-personal factors [age, sex, marital status, having descendents, level of education and a respondent's place of origin in the British Isles where the respondent is native]; (2) knowledge about organ donation and transplantation [previous experience of organ donation and transplantation; knowledge of the concept of brain death; a respondent's belief that he or she might need a transplant in the future]; (3) social interaction variables [a partner's attitude toward organ donation and transplantation; family discussion about organ donation and transplantation; and attitude toward the donation of the organs of a family member if it had to be decided]; (4) pro-social behavior [attitude toward participation in voluntary type pro-social activities]; (5) factors related to religion [a respondent's religion; and knowledge of the attitude of a respondents religion toward organ donation and transplantation] and (6) variables about attitude toward the body [attitude toward corpse cremation, corpse burial and carrying out an autopsy if it were necessary and concern about the mutilation of the body after donation].

Control group

A random sample of 2000 citizens aged >15 years of the native population of our regional Community was taken as a control group. This group was stratified by age, sex and geographical location (7). In such a group, attitude toward the donation of a respondent's own solid organs was evaluated using the same questionnaire: attitude was favorable in 63% of cases (n = 1274), unfavorable in 31% (n = 620) and 6% (n = 106) were undecided. In Tables 1 and 2 there is a summary of the bivariate and multivariate statistical analysis of the control group.

Table 1.  Summary of the influence of different variables on the opinion toward the donation of one's own organs in the control group
VariableFavorable attitudeUnfavorable attitudep

  1. *This question is only included in the control group questionnaire.

  2. ODT = Organ donation and transplantation.

Socio-personal variables
 Mean age: 45 ± 13 years<35 years>50 years<0.001
 Sex––N.S.
 Marital statusSingleMarried, widowed<0.001
 Municipality20–50,000> = 250,000<0.001
100–250,000 
 Level of EducationSecondaryLiterate or less<0.001
 Profession––N.S.
 DescendentsNoYes<0.001
Variables of knowledge about ODT
 Previous experience of ODTYesNo<0.001
 Knowledge about needs––N.S.
 Knowledge about brain deathYesNo<0.01
Variables of social interaction
 Knowledge of a partner's attitudeYesNo<0.001
 Family discussion about ODTYes, favorableNot known<0.001
Against 
Variables of pro-social behavior
 *Attitude toward blood donationYes, usually willing to donateRefusal<0.001
 Attitude toward pro-social activitiesYes, usually willing to participateRefusal<0.001
Religious variables
 Religious attitudeAgnosticPracticing Catholic<0.001
 Knowledge of the opinion of the Church––N.S.
Variables of opinion about the body
 CremationYesNo<0.001
 Burial––N.S.
 Autopsy––N.S.
 Concern about mutilation after donationNoYes<0.01 
Table 2.  Variables associated with the donation of one's own solid organs in the control group (Multivariate study)
VariableRegression coefficient (β)Standard errorOdds ratio (CI)p

  1. DK/NA = Does not know/ No answer; ODT = Organ donation and transplantation; BD = brain death.

Age
 15–34 years (n = 840) 1 
 35–49 years (n = 460)–0.403450.34980.83 (1.67–0.41) 
 ≥50 years (n = 700)–0.79490.19870.45 (0.67–0.3) 0.002
Level of education
 <Secondary (n = 1114) 1 
 ≥Secondary (n = 884)0.64320.21961.78 (2.76–1.15)0.006
Previous experience
 No (n = 1388) 1 
 Yes (n = 611)0.29890.06522.02 (2.30–1.77)0.001
Knowledge of the concept of BD
 No (n = 972) 1 
 Yes (n = 1028)0.91210.1012 1.4 (1.71–1.14)0.013
Knowledge of partner's attitude
 Not known (n = 556) 1 
 Yes, against (n = 129)–0.91100.5185 0.9 (2.53–0.32) 
 Yes, favorable (n = 853)0.62840.0281 2.6 (2.75–2.45) 
 No partner (n = 412)0.30070.62191.8 (6.2–0.52)0.002
Blood donation
 No (n = 727) 1 
 Yes (n = 1244)0.64910.2811 3 (5.26–1.7)<0.001
Pro-social attitude
 No (n = 529) 1 
 Yes (n = 1450)0.61000.1002 1.6 (1.95–1.31)0.017
In favor of cremation
 No (n = 1342) 1 
 Yes (n = 658)0.59190.0744 1.8 (2.11–1.55)<0.001

Statistical analysis

The data were stored on a database and analyzed using the SPSS 11.0 statistical package. Student's t-test and the χ2 test were used for the analysis of data. Fischer's exact test was applied when the contingency tables had cells with an expected frequency of <5. In order to determine and evaluate the multiple risks, a logistic regression analysis was applied using the variables that were statistically significant in the bivariate analysis. Values of p < 0.05 were considered to be statistically significant.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and Methods
  5. Results
  6. Discussion
  7. References
  8. Appendix

Attitude toward organ donation

The questionnaire completion rate was 95% (n = 1611). The 89 cases, which did not complete the questionnaire, comprised 57 respondents who directly refused to respond alleging a lack of time; 15 who refused to complete the survey because ‘it was about organ donation and transplantation’ and the remaining 17 were nonvalid questionnaires.

Attitude toward the donation of one's own solid organs is favorable in 72% of respondents (n = 1155). The main reasons given for this favorable attitude are: (1) to avoid the useless destruction of organs (49%; n = 571); (2) reciprocity, in other words doing for others what we would like to be done for ourselves (38%; n = 442) and (3) considering it to be a moral duty (33%; n = 386).

Of the rest, attitude is against in 8% (n = 122) and 20% (n = 334) are undecided. Most do not given any reason for such an attitude (n = 257; 56%), and among those who give a reason, the most common is fear of mutilation of the corpse 15% (n = 68), wanting to leave the dead in peace 12% (n = 56), and fear of apparent death when organ donation takes place 11% (n = 48).

In comparison with the Spanish control group we find that attitude toward organ donation is more favorable among residents of British and Irish origin (72% vs. 63%; p < 0.0001). What is more, among those who are not in favor, it is noteworthy that the percentage of the population that is undecided is much higher than in the control group (20% vs. 6%), as seen in Figure 1.

Figure 1. Attitude toward the donation of one's own organs in the study group and the control group.

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image

Socio-personal variables

There is a similar mean age among those who are in favor and not in favor of donation (45 vs. 43 years; p = 0.141). However when we analyze the sample according to age group, there is a less favorable attitude among the youngest respondents (between 15 and 34 years 66% are in favor; 35–49 years 72% are in favor and >50 years 75% are in favor). With respect to sex, attitude is more favorable among British and Irish women than among men (74% vs. 69%; p = 0.012). There is also an association between the respondent's attitude and his or her marital status (p = 0.012) and having descendents (p = 0.006) (Table 1).

Finally, there are no differences according to the respondent's level of education (p = 0.575), nor according to the respondent's original country (p = 0.176). For example, 77% of those respondents from the Republic of Ireland are in favor compared to 71% in favor in the UK. Moreover, within the UK, attitude toward donation is similar regardless of the country of origin. In this respect, there is a favorable attitude among 73% of the northern Irish, among 73% of the Scottish, among 76% of the Welsh and among 70% of the English (p = 0.416). The most numerous group of respondents is from England, and there are no differences according to the part of England from which they come, so that the attitude among those from the North is 72%, among those from the Midlands 72% and among those from the south it is 73% (p = 0.957). As shown in Figures 2 and 3, the percentages in favor of donation are similar between the different nations and also according to the different counties from which they come.

Figure 2. Favorable attitude toward the donation of one's own organs in the different countries of the British Isles.

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Figure 3. Favorable attitude toward the donation of one's own organs in the different countries of the British Isles and in different English counties.

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image

Variables of knowledge about organ donation

The respondents who have had previous experience of the matter, through family members and friends, have a more favorable attitude than those who have not (82% vs. 69%; p < 0.001). There is also an association between attitude and knowledge of the concept of brain death (p = 0.191) (Table 3). Thus, those who know of this concept and who accept it are more in favor than those who do not equate brain death with actual death or those who do not understand the concept (77% vs. 68% and 67% respectively; p < 0.001).

Table 3.  Socio-personal, knowledge about donation and transplantation and social interaction variables that influence attitude toward donation
VariableFavorable attitude (n = 1155; 72%)Unfavorable attitude(n = 456; 28%)p

  1. * Only 1497 respondents are from the UK.

  2. ** Only with the 864 respondents from England.

  3. DK/NA = Does not know/ No answer; ODT = Organ donation and transplantation.

Socio-personal variables
 Mean age: 45 ± 13 years45 ± 1343 ± 150.141
Age (groups)
 15–34 years (n = 365)241 (21%)124 (28%)0.009
 35–49 years (n = 556)398 (35%)158 (36%) 
 ≥50 years (n = 654)491 (44%)163 (37%) 
 DK/NA (n = 36)2511 
Sex
 Male (n = 718)492 (43%)226 (50%)0.012
 Female (n = 881)654 (57%)227 (50%) 
 DK/NA (n = 12)93 
Marital status
 Single (n = 234)234 (20%)126 (28%)0.012
 Separated/divorced (n = 161)119 (10%)42 (9%) 
 Married (n = 1048)773 (68%)275 (61%) 
 Widowed (n = 30)20 (2%)10 (2%) 
 DK/NA (n = 12)93 
Descendents
 Yes (n = 1117)823 (72%)294 (65%)0.006
 No (n = 487)326 (28%)161 (35%) 
 DK/NA (n = 7)61 
Level of education
 No education (n = 120)90 (12%) 30 (11%)0.575
 Primary (n = 30)24 (3%) 6 (2%) 
 Secondary (n = 469)337 (45%)132 (50%) 
 University (n = 387)291 (39%) 96 (36%) 
 DK/NA (n = 605)413192 
Country of origin
 United Kingdom (n = 1497)1067 (92%)430 (94%)0.176
 Republic of Ireland (n = 114)88 (8%)26 (6%) 
Country of United Kingdom*
 Northern Ireland (n = 180)131 (12%) 49 (11%)0.416
 Scotland (n = 327)237 (22%) 90 (21%) 
 Wales (n = 126)96 (9%)30 (7%) 
 England (n = 864)603 (57%)261 (61%) 
Area of England where native**
 North (n = 301)217 (40%) 84 (41%)0.957
 Midlands (n = 161)116 (21%) 45 (22%) 
 South (n = 286)209 (39%) 77 (37%) 
 DK/NA (n = 116)6155 
Variables of knowledge about ODT
Previous experience of ODT
 No (n = 1283)890 (78%)393 (87%)<0.001
 Yes (n = 310)254 (22%) 56 (13%) 
 DK/NA (n = 18)117 
Knowledge of the concept of brain death
 Wrong concept (n = 240)162 (15%) 78 (18%)<0.001
 Concept known (n = 692)538 (49%)158 (36%) 
 Concept not known (n = 605)405 (37%)200 (46%) 
 DK/NA (n = 74)5420 
A respondent's belief that he or she might need a transplant
   Yes (n = 126)110 (10%)16 (4%)<0.001
   No (n = 216)146 (13%) 70 (16%) 
   Not sure (n = 1209)859 (77%)350 (80%) 
   DK/NA (n = 60)4020 

It is worth noting that only 8% of respondents (n = 126) consider that they might need a transplant for themselves in the future. However, this factor is significantly associated with attitude toward donation, in such a way that those who believe that they would need one are in favor in 87% of cases, those who do not are in favor in 68%, and those who are undecided in 71% (p < 0.001).

Social interaction variables

Regarding social interaction variables, it has been found that those respondents who had previously discussed the matter of organ donation and transplantation within the family have a more positive attitude (85% vs. 53%; p < 0.001). Within the family, the opinion of a respondent's partner toward donation is very important. Thus, when the partner is in favor, 86% of respondents are in favor, whilst when they are against this percentage decreases to 56% (p < 0.001) (Table 4).

Table 4.  Variables of social interaction and pro-social activity variables that influence attitude toward donation
VariableFavorable attitude (n = 1155; 72%)Unfavorable attitude (n = 456; 28%)p

  1. DK/NA = Does not know/ No answer; ODT = Organ donation and transplantation.

Social interaction variables
Knowledge of a partner's attitude
 Yes, favorable (n = 804)693 (62%)111 (26%)<0.001
 Not known (n = 448)245 (22%)203 (47%) 
 Yes, against (n = 100)56 (5%) 44 (10%) 
 I do not have a partner (n = 194)120 (11%) 74 (17%) 
 DK/NA (n = 65)4124 
Family discussion about ODT:
 No (n = 657) 310 (69%)<0.001
 Yes (n = 935) 138 (31%) 
 DK/NA (n = 19) 8 
Donation of a family member's organs:
 Yes (n = 1165)980 (85%)185 (41%)<0.001
 No (n = 122)35 (3%) 87 (19%) 
 Not sure (n = 316)138 (12%)178 (40%) 
 DK/NA (n = 8)260 
Variables of Pro-social activity
Participation in pro-social activity (Voluntary):
 Yes (n = 459)348 (32%)111 (26%)<0.001
 No, nor will I (n = 400)252 (23%)148 (34%) 
 No, but I would like to (n = 664)490 (45%)174 (40%) 
 DK/NA (n = 88)6523 

It has been seen that those who are in favor of the donation of a deceased family member's organs are more in favor of the donation of their own organs (84%), than those who are not (29%) and those who are undecided (44%) (p < 0.001).

Variables of pro-social activity

The respondents who usually participate in pro-social voluntary type or social help activities, or who are willing to participate in them, have a more favorable attitude than those who do not [76% and 74% vs. 63% respectively; p < 0.001] (Table 4).

Variables of religion

Regarding religious activity there are some differences: those who believe in a religion that is other than Catholic or Anglican-Protestant have a less favorable attitude (59% vs. 70% and 72%, respectively). Moreover, those who state that they are atheist-agnostic are more in favor (77%) than those with a religion (p = 0.010). It must be emphasized that among those who state that they are religious, only 30% know that their religion is in favor of donation, and knowing that their religion is in favor is clearly associated to an attitude in favor of donation compared to those who believe that their religion is against or who do not know the opinion of their religion (80% vs. 25% and 67%, respectively) (Table 5).

Table 5.  Variables of religion and attitude toward the body that influence attitude toward donation
VariableFavorable attitude (n = 1155; 72%)Unfavorable attitude (n = 456; 28%)P

  1. *For this cross atheists and agnostics have been excluded because they do not have a Church.

  2. DK/NA = Does not know/ No answer.

Variables of religion
Religion
 Catholic (n = 540)380 (33%)160 (36%) 0.010
 Anglican-Protestant (n = 611)438 (35%)173 (39%) 
 Other religion (n = 70)41 (4%)29 (7%) 
 Atheist – Agnostic (n = 364)280 (25%) 84 (19%) 
 DK/NA (n = 26)1610 
Knowledge of the Church's attitude*:
 Yes, in favor (n = 365)293 (34%)72 (20%)<0.001
 Yes, against (n = 12) 3 (1%)9 (3%) 
 Does not know (n = 833)556 (65%)277 (77%)  
 DK/NA (n = 11)74 
Variables of attitude toward the body
In favor of cremation:
 No (n = 526)344 (30%)182 (40%)<0.001
 Yes (n = 1072)802 (70%)270 (60%) 
 DK/NA (n = 13)94 
In favor of burial:
 No (n = 917)674 (59%)243 (54%)> 0.066
 Yes (n = 681)472 (41%)209 (46%) 
 DK/NA (n = 13)94 
Acceptance of autopsy:
 No (n = 1040)694 (61%)346 (77%)<0.001
 Yes (n = 558)452 (39%)106 (24%) 
 DK/NA (n = 13)94 
Concern about mutilation after donation
 Concern (n = 229)111 (10%)118 (27%)<0.001
 No Concern (n = 1044)876 (77%)168 (38%) 
 Doubts (n = 312)156 (14%)156 (35%) 
 DK/NA (n = 26)1214 

Variables of attitude about the body

With respect to variables about attitude toward manipulation of the corpse various associations have been found. In this respect, those respondents who are willing to accept cremation of the body after death are more in favor of organ donation than those who are not (75% vs. 65%; p < 0.001). Similarly, attitude is more favorable among those who would be willing to have an autopsy carried out upon death if it were necessary (81% vs. 67%; p < 0.001). Regarding attitude according to whether burial of the body is preferred or not, attitude is more favorable toward organ donation among those who prefer options other than burial, although this is not a statistically significant relationship (p = 0.066). As shown in Table 5, fear of mutilation after donation or uncertainty when faced with this situation make attitude toward donation less favorable than it is among those who do not report any fear about such possible mutilation (49% and 50% vs. 84%; p<0.001).

Multivariate analysis

The following variables persist as independent variables affecting attitude toward the donation of one's own organs: (1) attitude toward the donation of a family member's organs (Odds Ratio = 4.891 if it is favorable and OR = 0.432 if it is not favorable); (2) having discussed the matter of organ donation and transplantation within the family (OR = 2.513); (3) a willingness to have an autopsy carried out if it were necessary (OR = 1.706); (4) having no concern about mutilation of the deceased donor after death (OR = 3.294); (5) having a partner who is in favor of organ donation and transplantation (OR = 2.786) and (6) a respondent's belief that he or she might need a transplant in the future (OR = 2.243) (Table 6).

Table 6.  Variables that influence attitude toward deceased donor organ donation (Logistic regression multivariate analysis)
VariableRegression coefficient (β)Standard errorOdds Ratio (CI)p
Donation of a family member's organs:
 Doubts (n = 316)1.5870.1841 
 Yes (n = 1165)–0.8400.3254.891 (3.411–7.014)<0.001
 No (n = 122) 0.432 (0.228–0.816)  0.010
Family discussion about ODT:
 No (n = 657)0.9210.1761 
 Yes (n = 935) 2.513 (1.779–3.546)<0.001
Acceptance of autopsy:
 No (n = 1040)0.5350.1841 
 Yes (n = 558) 1.706 (1.190–2.445)  0.004
Concern about mutilation after donation
 Not sure (n = 312)0.1660.2401 
 Concern (n = 229)1.1920.1931.181 (0.737–1.891)  0.414
 No concern (n = 1044) 3.294 (2.255–4.812)<0.001
Knowledge of partner's attitude:
 No partner (n = 194)1.0250.2961 
 Yes, favorable (n = 804)0.1530.2852.786 (1.560–4.975)0.001
 Not known (n = 448)0.0790.3881.165 (0.666–2.038)  0.591
 Yes, against (n = 100) 1.082 (0.505–2.318)  0.839
Belief that one might need a transplant:
 Not sure (n = 1209)0.8080.3621 
 Yes (n = 126)–0.3200.2302.243 (1.104–4.560)0.026
 No (n = 216) 0.726 (0.462–1.140)  0.164

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and Methods
  5. Results
  6. Discussion
  7. References
  8. Appendix

There are fully developed transplant programs in the vast majority of European countries. However, it has been seen that donation rates in these countries are very disparate (12). These differences have been attributed, among other factors, mainly to cultural differences (9). However, although populational studies about attitude toward organ donation (10–11) provide disparate acceptance rates according to the country, there are generally favorable attitudes in different European countries, with rates ranging from between 65% and 90%.

Our study challenges this theory where the differences are justified by cultural factors, at least in Spain and the British Isles. In this way we can see that the attitude toward organ donation among British and Irish citizens who come to reside in southeastern Spain is more favorable than that previously described in our native population. Moreover, various respondents have only been living in our Community for a short time, which makes it difficult to think of a change in mentality just because of living in Spain. All of this means that in the same country, with the same organ procurement system, the donation rates among Spanish citizens and British or Irish residents in Spain are very similar, as shown by the data of the National Transplant Organization (13). With this same attitude, the real donation rates in the British Isles are lower than Spanish rates (11,14–16). Therefore, the differences between donation rates in Spain and the British Isles, assuming that the British/Irish and Spanish populations are equally generous, must be found mainly at a structural and institutional level. In this respect, the Spanish model is currently the one that has proven to be most efficient (16) and because of this it is being copied by many countries. However, other factors should be considered (legislation, institutional and political support, etc) (17). In the UK professionals related to transplantation are in favor of a change in the donation system in order to increase the donation rate (18,19). In this respect, some studies in English-speaking communities suggest that the problem is the system and that when changes were made (similar to those of the Spanish model) there was an increase in the donation rate.

In Spain a coordination system has been achieved that has obtained high rates of donation and if we want to reduce donation refusals action should be taken at the level of the general public (3,12). The situation of awareness of the general public is the same, or better, among citizens from the British Isles; therefore, the donation rates of British and Irish citizens when they reside in Spain are similar to those of Spanish citizens and much higher than in their original countries (12,13). In our country, when donation is considered among British and Irish citizens, the thinking is the same as with the Spanish, and no special treatment is required. Perhaps one of the most important points is the language, because when a request is made for donation, at such a critical time for the family, it is essential to have a perfect level of communication if we want to achieve good results. In our study it was fundamental to have the questionnaire translated into English in order for it to be completed, which shows the importance of the language factor. However, because English is a language frequently used among health care professionals from around the world this problem is less important.

Perhaps there is a nuance in our study: that the population that travels to Spain from the British Isles is a ‘wealthy’ population group, so that it is possible that this is a more select group that might be more in favor. However, it is unlikely that by coincidence these respondents who travel to Spain have a more favorable attitude toward donation, whilst in other countries where there are many British and Irish citizens this is not the case. Moreover, as shown in Tables 3–5 the respondents are elderly people, with a low level of education, etc. that are classic factors in people who are against organ donation.

Finally, an analysis of the psychosocial profile shows that most factors described in western populational studies occur in our study group. It is worth noting that there is uniformity in the attitude toward donation independently of the country of origin or even the county, as seen in Figures 1 and 2. On the other hand, there are differences according to sex, with a greater predisposition to donate among women than men. This is important, especially if we take into account that British and Irish society is not so patriarchal as Spanish society.

Factors such as previous experience of donation and/or transplantation, that is, the fact of knowing a neighbor, family member or friend who has had a transplant (21,23), and participation in pro-social activities or being in favor of participating in them favor positive attitudes toward donation. It is clear that donation is part of an altruistic concept of life, like collaboration in pro-social activities (6,22); therefore, solidarity and moral duty are often indicated as reasons for being in favor of donation.

Knowledge of the concept of brain death, a classic factor related to attitude toward donation (4–6) is a significant factor in this subgroup. However, contrary to other studies (6) this does not persist as an independent factor. In this respect it should be emphasized that nearly half of the respondents accept that this is the death of an individual, which might explain why fear of apparent death does not figure as one of the main reasons for not being in favor of donation, whilst in other studies it is the main reason (4–6).

The most important factors detected in this population of British and Irish origin that persist in the multivariate analysis are mainly related to two aspects: the family and handling of the corpse. At the level of the family it has been found that discussing the matter in family circles increases the probability of being in favor by nearly three times (OR = 2.5). In this context, a partner's attitude toward donation is fundamental, so that if a partner is in favor and the respondent knows his or her attitude then attitude is clearly more favorable toward the matter (OR = 2.8). It should also be highlighted that there is a more favorable attitude among those respondents who are married with a family and who have descendents. Therefore, it would seem to be beneficial to encourage dialogue about matters of donation and transplantation within family circles and partners (6,11,24). However, this elementary mechanism for obtaining information and making decisions is in conflict with ancestral taboos that make conversations about death impossible or difficult.

The other group of independent variables is related to handling of the corpse (24). In general, those who have an unfavorable attitude toward donation, are more afraid of manipulation and disfiguration of the body, and they have a preference for a complete and intact body after death (24). Thus, those who prefer cremation after death would accept an autopsy if it were necessary and are not concerned about mutilation of the body after death, have a significantly more favorable attitude toward organ donation.

Another factor is religion. The respondents are mainly Christian (Catholic or Anglican-Protestant) or agnostic—atheist, and among these groups there are no clear differences. However, it has been found that among other religions that are currently emerging in the whole of Europe, attitude is significantly less favorable. What is more, it must be emphasized that the percentage of population who are religious and practice their religion to some extent is high and we should take advantage of this factor for promotion. Therefore, when these respondents know that their ‘Church’ is in favor of donation their attitude is more favorable. Currently, most religions are in favor, we should make religious authorities aware of the importance of informing their followers about the importance of organ donation so that they do not oppose such health care activity (25).

Finally, the type of study we have presented here represents the attitude of a populational group at a specific time. Any changes, especially in information, can influence changes in this attitude. What is more, although attitude and opinion are not quite the same, this study determines attitude using an opinion questionnaire (21). These studies are carried out in this way because attitude is understood to mean the willingness to respond in an evaluative way (emotional, cognitive or behavioral) when presented with a certain object and that this can expressed through language as a certain opinion toward a matter. Consequently, we believe as other authors (21) that opinions and attitudes are variables that interact with each other. Therefore, one of the most important elements in a change of attitude, in this case social, is the prior change of opinion.

To conclude, the attitude toward organ donation of British and Irish citizens who usually reside in southeastern Spain is more positive than in the native Spanish population and is determined by many psychosocial factors, mainly related to the family and to attitude toward the manipulation of the body.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and Methods
  5. Results
  6. Discussion
  7. References
  8. Appendix
  • 1
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    Conesa C, Ríos A, Ramírez P et al. Psychosocial profile in favor of organ donation. Transplant Proc 2003; 35: 1276–1281.
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    Conesa C, Ríos A, Ramírez P, Canteras M, Rodríguez MM, Parrilla P. Estudio multivariante de los factores psicosociales que influyen en la actitud poblacional hacia la donación de órganos. Nefrología 2005; 25: 684–697.
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Appendix

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and Methods
  5. Results
  6. Discussion
  7. References
  8. Appendix
Table ANNEX 1: .  Questionnaire about organ donation and transplantation
NoQuestionOptions
1Age 
2Sex1. Man; 2. Woman
3Marital Status1. Single; 2. Married; 3. Separated; 4. Divorced; 5. Widowed
4Original country and location 
5Qualifications/ Education 
6Profession 
7Do you have any children?1. Yes; 2. No
8Would you donate you organs upon death?1. Yes; 2. No; 3. Not sure
9If you are in favor of donation, what are your reasons? (Choose as many responses as you wish)1. For solidarity; 2. For cultural reasons; 3. In order to survive after my own death; 4. To avoid the useless destruction of my organs; 5. Because you think that you may also need organs from other donors; 6. Because you believe it is a moral duty; 7. Others:
10If you are not in favor of donation, what are your reasons? (Choose as many responses as you wish)1. Because the dead should be left in peace; 2. Because of religious reasons; 3. Because the idea of mutilating the body is displeasing; 4. Because of fear of a death that is only apparent; 5. Others:
11If you had to decide, would you donate the organs of a family member?1. Yes; 2. No; 3. Not sure
12Do you collaborate in any voluntary or social help activity?1. Yes; 2. No, nor will I ever collaborate; 3. No, but I would like to
13Have you discussed the matter of organ donation and transplantation with your family?1. Yes; 2. No
14Is there any possibility that a person with brain death might recover and live?1. Yes; 2. No; 3. I don't know
15When you die, would you accept cremation of your body?1. Yes; 2. No
16When you die, would you accept burial of your body?1. Yes; 2. No
17When you die, would you accept that an autopsy be carried out on your body if it were necessary?1. Yes; 2. No
18Do you know of anyone among your family members and friends who has needed or received an organ transplant?1. Yes; 2. No
19If you donated your organs, would you be concerned that your body might be left with scars or might be mutilated after organ extraction?1. Yes, it concerns me; 2. I do not mind; 3. I am not sure
20What is your religion?1. Catholic; 2. Protestant; 3. Church of England; 4. Muslim; 5. I do not have a religion; 6. Others:
21Do you know the attitude of your religion toward organ donation?1. Yes, it is in favor of donation; 2. Yes, it is against donation; 3. I do not know it
22Do you know the opinion of your partner toward organ donation?1. Yes, he or she is in favor; 2. I do not know his or her opinion; 3. Yes, he or she is against; 4. I do not have a partner
23Do you believe that you might ever need an organ transplant?1. Yes; 2. No; 3. Not sure
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