http://www.jhltonline.org

Level of awareness of personnel in hospital servicesrelated to the donation process: A Spanish and LatinAmerican multicenter studyAntonio Ríos Zambudio, PhD,a,b,c,d Ana López-Navas, PhD,a,b,e

Marcos Ayala-García, PhD,f,g María José Sebastián, PhD,h Anselmo Abdo-Cuza, PhD,i

Jeannina Alán, PhD,j Laura Martínez-Alarcón, PhD,a,b,c Ector Jaime Ramírez, PhD,k

Gerardo Muñoz, PhD,l Gerardo Palacios, PhD,h Juliette Suárez-López, MD,m

Roberto Castellanos, MD,i Beatriz González, PhD,f,k Miguel Angel Martínez, PhD,n

Ernesto Díaz, PhD,f,g Pablo Ramírez, PhD,a,b,c,d and Pascual Parrilla, PhDc,d

a“International Collaborative Donor Project,” Murcia, Spain; the bRegional Transplant Center, Consejería de Sanidad y Consumo de laRegión de Murcia, Spain; the cTransplant Unit, Surgery Service, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain; thedDepartment of Surgery, University of Murcia, Spain; the eDepartment of Psychology, Universidad Católica San Antonio, UCAM, Murcia,Spain; the fHospital Regional de Alta Especialidad del Bajío, León, Guanajuato, Mexico; the gHGSZ No. 10 del Instituto Mexicano delSeguro Social Delegación Guanajuato, Mexico; the hTransplant Coordination Center, UMAE Hospital de Especialidades N° 25 IMSS,Monterrey, Mexico; the iSurgical Medical Research Center, Cuba; the jUniversity of Costa Rica. Costa Rica; the kUniversity of Guanajuato,Mexico; the l21st Century National Medical Center of the Mexican Institute of Social Security, Mexico; the mHermanos Ameijeiras Hospital,

Cuba; and the nState Public Health Institute of Guanajuato, Mexico

BACKGROUND: Services related to the donation and transplantation process are fundamental for devel-oping solid organ transplantation and procuring organs from deceased donors. This study was conducted toanalyze the attitude toward deceased organ donation among hospital personnel working in donation- andtransplantation-related services in hospitals in Spain and Latin America.METHODS: Nine hospital centers within the “International Donor Collaborative Project” were selected(Spain, Mexico, Cuba, and Costa Rica). A random employee sample was taken and stratified according tothe type of service and job category in transplant-related hospital services.RESULTS: Of the 925 employees surveyed, 78% were in favor of donation. By job category, attitude wasmore favorable among physicians (89%; p � 0.001). By type of service, attitude was more positive amongpersonnel in transplant patient follow-up units (87%; p � 0.018). By country, the Cubans were most in favor(91%), followed by the Mexicans (81%), the Costa Ricans (77%), and the Spanish (70%; p � 0.001). Otherfactors were age (p � 0.001), sex (p � 0.005), considering the possibility of needing a transplant (p �0.002), understanding the concept of brain death (p � 0.001), being in favor of living donation (p � 0.001),having discussed the subject of donation and transplantation within the family and the partner (p � 0.001),carrying out pro-social activities (p � 0.002), and concern about mutilation after donation (p � 0.002).CONCLUSIONS: Transplant-related personnel had a favorable attitude toward deceased donation, although itwas not as positive as we would expect, especially among non-physicians. This attitude needs to be improvedbecause of the negative effect that can result in organ donation. There were pronounced differences betweencountries, and the discordance between attitude and actual deceased donation rates in each country is notable.J Heart Lung Transplant 2012;31:850–7© 2012 International Society for Heart and Lung Transplantation. All rights reserved.

KEYWORDS:attitude;transplantation;organ donation;health care personnel

Reprint requests: Antonio Ríos Zambudio, PhD, Avenida de la Libertad No. 208, Casillas, 30007 Murcia, Spain. Telephone: 968-27-07-57. Fax:968-36-97-16.

E-mail address: arzrios@teleline.es

1053-2498/$ -see front matter © 2012 International Society for Heart and Lung Transplantation. All rights reserved.http://dx.doi.org/10.1016/j.healun.2012.03.011

851Zambudio et al. Personnel Awareness of Donation Process

Current organ donation rates for transplantation are insuf-ficient to cover the minimal needs for transplantation.1 It isimportant for all of the personnel from health care centers to beinvolved in promoting this treatment, where donation plays anessential role. Along these lines, health care workers areobliged to promote health according to the deontologic code.2

In this sense, the health care group with the most cred-ibility in these matters consists of personnel from donation-and transplantation-related units. However, there are datathat have led us to suspect that not all of the workers from

Table 1 Variables Affecting Attitudein Transplant-Related Services in Spain

Variablea

RespondentsDemographics

CountrySpainMexicoCubaCosta Rica

Social-personalAge, years

SexMaleFemaleNo answer

Marital statusSingleMarriedWidowed, separated, divorcedDoes not know/no answer

Job variablesService where the respondent

worksSurgicalMedical

Type of hospital centerTransplant hospitalProcurement hospital

Service according to relationship withtransplantation

Donor procurement unitTransplant unitTransplant follow-up unit

Type of personnelHealth careNon-health care

Job categoryPhysicianNurseNursing assistantNon-health care personnel

Job situationPermanent positionTemporary, contractedDoes not know/no answeraCategoric data are presented as numb

deviation.

bStatistically significant (p � 0.05).

these units are in favor of donation and transplantation.3,4 Ifthis is the case, this is an important aspect because if theemployees who work in the donation and transplantationprocess are not in favor themselves, this could create agroup capable of generating very negative opinions. What ismore, the unfavorable attitude of personnel in these units isnot only going to affect the detection of donors but also theattitude of families who could donate.1–7

In the Spanish-speaking geographic area, few data areavailable on this matter, although we must highlight those

d Deceased Donation Among Personnelatin America

In favor Not in favor p-value

722 (78) 203 (22)

249 (70) 105 (30) �0.001b

311 (81) 75 (19)126 (91) 12 (9)36 (77) 11 (23)

10 36 � 10 40 � 10 �0.001b

299 (83) 60 (17) 0.005b

421 (75) 137 (25)2 6

0.089254 (81) 58 (19)406 (78) 115 (22)57 (70) 24 (30)5 6

310 (76) 96 (24) 0.269412 (79) 107 (21)617 (79) 166 (21) 0.198105 (74) 37 (26)

293 (76) 94 (24) 0.018b

308 (77) 91 (23)121 (87) 18 (13)

639 (79) 168 (21) 0.03b

83 (70) 35 (30)

290 (89) 37 (11) �0.001b

283 (75) 92 (25)66 (63) 39 (37)83 (70) 35 (30)

301 (74) 104 (26) 0.037b

385 (80) 95 (20)36 4

and continuous data as mean � standard

Towarand L

Total

925

35438613847

37 �

359558

8

3125218111

406519

783142

387399139

807118

327375105118

40548040

er (%)

852 The Journal of Heart and Lung Transplantation, Vol 31, No 8, August 2012

presented in a Spanish transplant hospital by our owngroup.3 A notable finding in this study is that the favorableattitude toward donation among hospital personnel in dona-tion- and transplant-related services is no greater than 70%and is determined by many psychosocial factors, the fol-lowing of which are very important: job category, the ser-vice in which the job activity is done, and understanding ofthe concept of brain death.3 The need to carry out donationpromotion activities in these services had already been con-sidered at the time of that study given the important influ-ence that the negative attitude of this group might have onthe attitude of the population.

In this sense, it has become necessary to find out if this factis generalized, or whether it only happens locally in the hos-pital where the study was conducted. Therefore, the objectiveof this study was to analyze the attitude toward deceaseddonation among hospital personnel in donation- and transplant-related services in hospitals in Spain and Latin America and toanalyze the variables affecting this attitude.

Material and methods

Study population

Nine hospitals in the “International Donor Collaborative Project”were selected, 3 in Spain, 3 in Mexico, 2 in Cuba, and 1 in CostaRica. In these hospitals, a random sample was taken and stratifiedby type of service and job category (physicians, nurses, health careassistants and non-health care personnel) among transplant-relatedservices (n � 1,039). These services were grouped into 3 catego-ries: (1) donor procurement units, (2) transplant units, and (3)transplant patient follow-up units.

Opinion survey and study variables

Attitude toward the donation of one’s own organs after one’s deathwas evaluated using a survey about the psychosocial aspects of organdonation and transplantation validated in our geographic area.3,4,8 Thefollowing representatives in each service were contacted to distributethe questionnaires: the head of service for the physicians’ question-naires, the nursing coordinator for the nursing personnel, and anadministrator for non-health care personnel, who were each given anexplanation of the study and were made responsible for distributingthe survey in selected shifts. The questionnaire was completed anon-ymously and was self-administered in 3 to 5 minutes.

The dependent variable analyzed was attitude toward the do-nation of one’s own organs after death. The independent variableswere grouped into:

1. Demographic: country;2. Social-personal: age, sex, and marital status;3. Job: type of clinical service, type of hospital, service according

to its relationship with transplantation, type of personnel, jobcategory, and job situation;

4. Knowledge and attitude toward organ donation and transplan-tation: personal experience of organ donation and transplanta-tion, a belief in the possibility of needing a transplant foroneself in the future, knowledge of the concept of brain death,attitude toward living kidney donation, attitude toward living

liver donation;

5. Social interaction and pro-social behavior: attitude toward do-nating a family member’s organs, a discussion within the fam-ily about donation and transplantation, a partner’s opiniontoward donation and transplantation, and participating in pro-social type activities;

6. Religious: a respondent’s religion and a respondent’s knowl-edge of the attitude of his or her religion toward donation andtransplantation; and

7. Attitude toward the body: concern about possible mutilationafter donation, acceptance of cremation, burial, and autopsy ifnecessary.

Statistical analysis

The data were stored on a database and analyzed using SPSS 15.0software (SPSS Inc, Chicago, IL). Descriptive statistical analysiswas done on each of the variables, and for the comparison of thedifferent variables, Student’s t-test and the chi-square test werecomplemented with an analysis of the remainders. For the deter-mination and evaluation of multiple risks, a logistical regressionanalysis was done using the variables in the bivariate analysis thathad a statistically significant association. Values of p � 0.05 wereconsidered significant.

Results

Attitude toward the donation of one’s own solidorgans

Questionnaires were completed by 925 of 1,039 (89%), ofwhich 354 were from Spain, 386 from Mexico, 138 fromCuba, and 47 from Costa Rica. Of these respondents, 722(78%) were in favor of deceased donation. Some of the mostfrequent reasons for being in favor of donation includedreciprocity (55%) and solidarity (48%). Of the remaining203 (22%), 8% were against and 14% undecided. The 2most frequent reasons for not being in favor were a negativeassertion (40%) and the fear of apparent death (16%).

0

10

20

30

40

50

60

70

80

90

Per

cent

age

Rep

lies

Procurement Units Transplantation Services Transplant Patient Follow-upServices

Type of Service (p=0.018)

In favor Not in favor

Figure 1 Attitude toward organ donation and transplantation

according to where the job activity was done.

853Zambudio et al. Personnel Awareness of Donation Process

Factors affecting attitude toward donation

Demographic variableThe most favorable attitude we found was among LatinAmerican respondents: 91% of Cubans surveyed, 81% ofMexicans, and 77% of Cost Ricans were in favor, comparedwith 70% of the Spanish respondents (p � 0.001; Table 1).

Social-personal variablesThe most favorable attitude toward donation was foundamong younger respondents (36 vs 40-year-olds, p � 0.001)and in men (83% vs 75%; p � 0.005; Table 1). No signif-icant differences were found according to marital status(p � 0.05).

Job variablesThe type of clinical service and the type of hospital did nothave a statistically significant relationship with attitude

0

10

20

30

40

50

60

70

80

90Pe

rcen

tag

e R

eplie

s

Physicians Nurses Nursing Assistant Non-healthcarepersonnel

Job Category (p<0.0001)

In favor Not in favor

Figure 2 Attitude toward organ donation and transplantationaccording to the job category of personnel from transplant-relatedservices in Spain and Latin America.

Table 2 Knowledge and Attitude TowAffecting Attitude Toward Deceased DoServices in Spain and Latin America

Variable

RespondentsPersonal experience of donation and

transplantationYesNoDoes not know/no answer

Possibility of needing a transplantYesNoDoubts

Knowledge of the concept of brain deaThe concept is knownThe concept is not knownWrong concept of brain death (no

death of person)Does not know/no answer

aStatistically significant (p � 0.05).

(Table 1). However, depending on the relationship of theservice with transplantation, hospital personnel in transplantfollow-up units were more in favor of deceased donationthan those from procurement and transplant units (87% vs76%–77%; p � 0.018; Figure 1). Job category affectedattitude toward donation. Physicians (89%) had a morepositive attitude than those in other job categories, includingnursing (75%), non-health care personnel (70%), and healthcare assistants (63%; p � 0.001; Figure 2).

Variables about knowledge of and attitude towardorgan donation and transplantationNo differences were found in terms of having had perviouspersonal experience of organ donation and transplantation(p � 0.05; Table 2). The remaining variables analyzedaffected the respondents’ attitudes toward deceased organdonation. Those who believed they might need a transplantwere more in favor of donation than those who did notbelieve this (82% vs 53%; p � 0.002). Attitude among thosewho knew the concept of brain death was also more favor-able compared with those who did not know the concept(83% vs 63%; p � 0.001; Figure 3).

Variables of social interaction and pro-social behaviorAll of the social interaction and pro-social behavior vari-ables analyzed were associated with attitude toward organdonation (Table 3). Having discussed and spoken about thesubject of donation in the family nucleus led respondents tohave a more favorable attitude (82% vs 65%; p � 0.001).Furthermore, knowing that a partner had a favorable attitudetoward donation generated a more favorable attitude thanwhen the partner had an attitude against donation (89% vs50%; p � 0.001).

gan Donation and TransplantationAmong Personnel in Transplant-Related

talo.

In favorNo. (%)

Not in favorNo. (%) p-value

25 722 (78) 203 (22)

12 254 (81) 58 (19) 0.08612 468 (77) 144 (23)1 . . . 1

62 379 (82) 83 (18) 0.002a

15 8 (53) 7 (47)48 335 (75) 113 (25)

77 560 (83) 117 (17) �0.001a

99 125 (63) 74 (37)48 36 (75) 12 (25)

1 1 . . .

ard Ornation

ToN

9

36

4

4th

61

854 The Journal of Heart and Lung Transplantation, Vol 31, No 8, August 2012

Religious variablesThose respondents who did not have a religion (atheists/agnostics) were more in favor of deceased donation thanthose who believed in a religion (88% vs 77%; p �0.007; Table 4). Moreover, when a respondent believedthat his or her religion was in favor of donation andtransplantation, this encouraged acceptance of this kindof donation especially compared with those who believedthat their religious doctrine was against donation (83% vs46%; p � 0.001).

0

10

20

30

40

50

60

70

80

90Pe

rcen

tage

Rep

lies

Physician Nurse Healthcare Assistant Non-healthcare

Job Category (p<0.0001)

Wrong Concept (No death of person) Correct Concept Does not know

Figure 3 Knowledge of the concept of brain death according tojob category.

Table 3 Variables of Social InteractioToward Deceased Donation Among Persand Latin America

Variable

TotalAttitude toward donation of a family

member’s organsYes, I would donate themI would not donate themI would respect their wishesDoes not know/no answer

Family discussion about donationand transplantation

YesNoDoes not know/no answer

Partner’s opinion toward donationand transplantation

Yes, in favorI do not know itYes, againstI do not have a partnerDoes not know/no answer

Carrying out pro-social activitiesYesNoNo, but I would like toDoes not know/no answer

aStatistically significant (p � 0.05).

Variables of attitude toward the bodyA more favorable attitude toward donation was foundamong those who were not concerned about possible muti-lation of the body after donation (82% vs 70%; p � 0.002),those who would prefer an option other than burial (82% vs70%; p � 0.001), and those who would accept an autopsybeing performed if one were needed (88% vs 73%; p �0.001; Table 4).

Multivariate analysis

After applying a multivariate analysis to assess the variableswith most weight affecting attitude toward the donation ofone’s own solid organs, statistical significance persisted inthe following instances (Table 5):

1. the youngest had a more favorable attitude toward organdonation (odds ratio [OR], 1.033; p � 0.005);

2. hospital personnel in transplant follow-up units (OR,2.481; p � 0.025);

3. being a physician (OR, 2.976; p � 0.004);4. having discussed the subject of donation and transplan-

tation with one’s family (OR, 2.087; p � 0.004);5. a partner’s favorable attitude toward donation and trans-

plantation (OR, 5.208; p � 0.001);6. the preference for other options apart from burial for

treating the body after death (OR, 2.398; p � 0.001); and

Pro-social Behavior Affecting AttitudeIn Transplant-Related Services in Spain

In favorNo. (%)

Not in favorNo. (%) p-value

722 (78) 203 (22)

382 (94) 24 (6) �0.001a

24 (31) 53 (69)310 (73) 115 (27)6 11

576 (82) 123 (18) �0.001a

145 (65) 79 (35)1 1

415 (89) 53 (11) �0.001a

131 (65) 70 (35)22 (50) 22 (50)

109 (73) 40 (27)45 18

202 (82) 43 (18) 0.002a

37 (62) 23 (38)455 (78) 127 (22)28 10

n andonnel

TotalNo.

925

40677

42517

699224

2

46820144

14963

24560

58238

855Zambudio et al. Personnel Awareness of Donation Process

7. the acceptance of performing an autopsy if one wereneeded (OR, 2.277; p � 0.003).

Discussion

Hospital personnel who work in services related to donationand transplantation are in direct contact with the processesof giving (donating) as well as receiving (transplantation).The awareness and participation of this sub-set of workers isessential for the process to develop appropriately and toachieve its objectives.9,10 It is important to note that whenpersonnel are selected, there is no assessment of attitudetoward a specific service, and some workers, especiallynon-medical staff, may even be working in an area they donot want to work in. However, achieving a whole multidis-ciplinary team that believes in these programs would be themost advisable and necessary course of action for achieving

Table 4 Religious Variables and VariabRelated Services Toward the Body Affect

Variable

TotalReligious

Respondent’s religion:CatholicOther religionsAtheist or agnosticDoes not know/no answer

Knowing the attitude of one’sreligion toward donation andtransplantation

Yes, in favorYes, againstI do not know his or her opinionDoes not know/no answer

Attitude toward the bodyConcern about mutilation after

donationI am concerned about thisI am not concerned about thisDoes not know/no answer

Acceptance of cremationYesNoDoes not know/no answer

Acceptance of burialYesNoDoes not know/no answer

Acceptance of autopsy if one wereneeded

YesNoDoes not know/no answeraStatistically significant (p � 0.05).

high donation rates.1

These data are a confirmation that employees working inunits related with the donation and transplant process do nothave such a favorable attitude as we would expect.3 In thissense, a favorable attitude toward organ donation has beenfound in more than 75% of respondents and it is similar tothat described in some population groups that are not relatedto donation and transplantation.11–14 These data are notuniversal and cannot be generalized in all areas, and impor-tant variations exist from one country to the next. Of par-ticular note is that in Spain, one of the countries included inthe study and which has one of the highest deceased dona-tion rates in the world, the attitudes of health care workersare among least favorable. This negative attitude needs to beimproved because of the negative effect that can result inorgan donation.

Perhaps the considerable experience achieved in thisfield due to the large amount of organ donation carried outhas made it possible for staff from all departments to be in

Attitude in Personnel in Transplant-titude in Spain and Latin America

In favorNo. (%)

Not in favorNo. (%) p-value

722 (78) 203 (22)

534 (77) 162 (23) 0.007a

25 (78) 7 (22)130 (88) 17 (12)33 17

335 (83) 70 (17) �0.001a

6 (46) 7 (54)210 (70) 90 (30)8 2

80 (70) 35 (30) 0.002a

604 (82) 135 (18)38 33

319 (77) 93 (23) 0.673400 (79) 109 (21)3 1

222 (70) 95 (30) �0.001a

496 (82) 107 (18)4 1

261 (88) 36 (12) �0.001a

458 (73) 166 (27)3 1

les ofing At

Total

925

69632

14750

40513

30010

11573971

412509

4

317603

5

297624

4

closer contact with patients diagnosed with brain death and

856 The Journal of Heart and Lung Transplantation, Vol 31, No 8, August 2012

everything involved in the donation process. This dailyactivity, far from facilitating matters, could lead to thegeneration of fear on some occasions. It is not the same togive an opinion about donation and brain death when theevent is very unlikely and largely seen as a “curiosity,” thanwhen it becomes a part of reality. This situation may leadthose respondents with a favorable attitude, but which is notwell grounded, to modify their attitude.

According to the results, one of the groups in which amore unfavorable attitude has been more prevalent is amongnon-physicians. However, these groups should be taken intoaccount as much as possible because of the close contactthey have with patients and their families, even more thanthe physicians themselves. All of their opinions are going toaffect their social surroundings and the community in gen-eral.4,8,15 It is not uncommon to hear a negative or inoppor-tune comment from a hospital worker that counteracts all ofthe hard work spent on previously convincing people toallow donation and becomes an important factor leading tofamily refusal.

Without a doubt, knowledge and acceptance of braindeath is of vital importance in these processes.16,17 In thisway, as shown in Figure 3, although most physicians un-derstand the concept, this proportion decreases in the re-

Table 5 Variables Affecting Attitude Toward Deceased DonatiSpain and Latin America

Variable Total

AgeService according to its relationship with

transplantationDonor procurement unit 387Transplant unit 399Transplant follow-up unit 139

Job categoryNursing assistant 105Physician 327Nursing 375Non-health care personnel 118

Family discussion about donation andtransplantation

No 224Yes 699

A partner’s attitude toward donation andtransplantation:

Against 44In favor 468I do not know his or her opinion 201I do not have a partner 149

Acceptance of burialYes 317No 603

Acceptance of autopsy:No 624Yes 297

CI, confidence interval, OR, odds ratio; SE, standard error.aRegression coefficient.bStatistically significant (p � 0.05).

maining job categories to the point where it is only known

by slightly more than 50% of non-health care personnel.These data suggest that non-physicians are frequently over-looked and are not provided with the necessary informationto allow them to understand the organ donation and trans-plantation process.4,8,18,19

The present study has shown that the most favorableattitude is found among workers in transplant follow-upunits. This situation is logical because they can see thepositive results of transplantation reflected in patients whorecover their health and attend programmed consultations.3

They can appreciate the situation “before” and “after,” andthis becomes a strong motivational element for the person-nel involved. However, procurement units are facing a harshreality in which patients die of brain death despite all of theefforts made by the medical team to save the patient’s life,and the families of donors suffer as a result. They represent2 very different points of view of the donation and thetransplantation process.

An analysis of the factors affecting attitude toward de-ceased donation has shown that many are similar to thosereported in the population,11,12 and social-personal factorsdeserve a special mention. In this way, the opinion of arespondent’s partner and having considered the subjectwithin the family are factors that significantly affect every-

ong Hospital Personnel From Transplant-Related Services in

SE OR (95% CI) p-value

0.012 1.033 (1.010–1.057) 0.005b

10.24 1.167 (0.729–1.870) 0.5190.405 2.481 (5.494–1.122) 0.025b

10.374 2.976 (6.172–1.428) 0.004b

0.327 1.277 (2.421–0.673) 0.4530.392 1.210 (2.610–0.562) 0.624

10.255 2.087 (3.436–1.265) 0.004b

10.42 5.208 (11.764–2.283) �0.001b

0.439 1.996 (4.716–0.843) 0.1150.451 2.493 (6.024–1.029) 0.043b

10.242 2.398 (3.846–1.490) �0.001b

10.279 2.277 (3.937–1.319) 0.003b

on Am

�a

0.033

0.1550.909

1.090.2450.192

0.735

1.6480.6920.913

0.874

0.824

one, whatever their profession and activity. Therefore, it is

857Zambudio et al. Personnel Awareness of Donation Process

particularly important to encourage dialogue about donationand transplantation in all areas of the family and in socialcircles.4,20,21

Finally, we highlight that a large proportion of the pop-ulation surveyed were concerned about the appearance ofthe body after organ extraction,2 and there was a low ac-ceptance rate of the eventual need for an autopsy afterdeath.22 If we take into account that the extraction of do-nated organs requires manipulation of the body and thatcultural factors related to the integrity of the body aredeeply rooted in the Latin population, especially in LatinAmerica, this could explain the situation.3,4,17,23–25 Thenotion of dignity and respect toward the body, which is afeature of each transplant, should be emphasized in allgroups of workers to slowly modify these concepts.

To conclude, the attitude toward deceased donationamong personnel who work in transplant-related services isnot as favorable as we would expect from someone in thisjob category, especially among non-physicians. There aremany pronounced differences between countries, highlight-ing the discrepancy between attitude and the actual de-ceased donation rates in each country. The factors affectingthis attitude are similar to those described in the population.

Disclosure statementNone of the authors has a financial relationship with a commercialentity that has an interest in the subject of the presented manuscriptor other conflicts of interest to disclose.

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