Transplant Immunology 73 (2022) 101634

Contents lists available at ScienceDirect

Transplant Immunology
journal homepage: www.elsevier.com/locate/trim

Medical students' knowledge, attitudes and awareness toward

organ donation
Sami Akbulut a, f, *, Khaled Demyati b, Irem Toman c, Zeynep Gaygili c, Semih Kaya c,
Vildan Rana Akpolat c, Ayla Cing c, Taha Yasin Keles c, Hasan Saritas d, Selver Unsal e, Ali Ozer f
a
Department of Surgery and Liver Transplant Institute, Inonu University Faculty of Medicine, 44280 Malatya, Turkey
b
Department of Surgery, An-Najah National University Hospital, An-Najah National University, Nablus, Palestine
c
Medical Students, Inonu University, Faculty of Medicine, 44280 Malatya, Turkey
d
Department of Surgical Nursing, Inonu University Faculty of Nursing, 44280 Malatya, Turkey
e
Department of Nursing Service, Inonu University Faculty of Medicine, 44280 Malatya, Turkey
f
Department of Public Health, Inonu University, Faculty of Medicine, 44280 Malatya, Turkey

A R T I C L E I N F O A B S T R A C T

Keywords: Objective: This survey study aimed to evaluate medical students' attitudes, knowledge, and awareness toward
Organ donation organ donation.
Medical students Methods: For this questionnaire-based cross-sectional study, 1000 medical students were interviewed, out of
Attitudes
which 950 students agreed to participate in the study and were enrolled. A questionnaire form consisting of 29
Knowledge levels
Awareness
questions was used to determine the students' socio-demographic characteristics and rate their knowledge, at­
Barriers to the organ donation titudes, and behaviors about organ donation.
Results: While 95.5% (n = 907) of the students stated that they had not donated organs, 41.1% stated that they
had not yet decided to donate organs, and 59.7% stated that they had no specific reason for them not donating
organs. Out of the participants, 68.1% stated that organ donation complies with the Islamic rules; 40.7% stated
that the Directorate of Religious Affairs issued a fatwa on organ donation, and 39.4% stated that there are legal
regulations on organ donation in the country. While 22.1% of the students stated that a person with brain death
could come back to life, 19.7% stated that they did not know about this issue. The students who had donated
organs and who did not show significant differences regarding the answers given to the questions about whether
organ donation complies with religious rules (p < 0.001), where one must apply to donate organs (p = 0.032),
the will to donate the organs of a relative with brain death (p = 0.004), and whether preaching in mosques and
foundations is needed to increase organ donation rates (p = 0.042). Although there was a correlation between the
students' grade and their attitude and knowledge about organ donation, this correlation was weak and showed no
parallelism with increasing grades.
Conclusion: This study indicates that medical students have inadequate knowledge, attitudes, and behaviors
about organ donation. In our opinion, it is of paramount importance to provide physician candidates, who should
set an example for society, with periodic training on organ donation throughout their academic life in shaping
the national organ donation policy in the future.

1. Introduction number of individuals awaiting organ transplantation increasing daily

Organ transplantation is the best therapy for terminal and irrevers­
ible organ failure [1]. However, it is estimated that solid organ trans­
plants performed worldwide represent less than 10% of the global need
[2]. There is a worldwide critical shortage of organ donors, with the
[2,3]. The cadaveric organ donation rate in Turkey is low. The gap be­
tween the number of patients on the waiting list for an organ donation
and donors and available organs for transplantation continues to grow
each year [4,5]. One of the significant barriers to donation is community
misunderstanding of donation after cardiac death [6]. Studies have

* Corresponding author at: Department of Surgery and Liver Transplant Institute, Inonu University, Faculty of Medicine, Elazig Yolu 10. Km, Malatya 44280,
Turkey.
E-mail address: akbulutsami@gmail.com (S. Akbulut).

https://doi.org/10.1016/j.trim.2022.101634
Received 6 April 2022; Received in revised form 5 May 2022; Accepted 20 May 2022
Available online 25 May 2022
0966-3274/© 2022 Elsevier B.V. All rights reserved.
S. Akbulut et al. Transplant Immunology 73 (2022) 101634

shown that educational, socioeconomic, cultural, and religious factors Table 1

and knowledge of and attitudes toward organ donation contribute to the Sociodemographic characteristics of Medical Students.
decision to donate organs in life and after death [6–10]. The students of No %
the faculty of medicine could be strong supporters of organ donation and
Age (years) (median [IQR]) 22 (4)
transplantation and may play an essential role in increasing organ 24.1
BMI (median [IQR])
donation. (4.8)
Gender
2. Objective Male 482 50.7
Female 468 49.3
Grades
The present study aimed to determine the attitudes, knowledge First-year grade 191 20.1
levels, and awareness of medical students about organ donation at a Second-year grade 140 14.7
University located in the eastern Anatolia region of Turkey. Third-year grade 224 23.6
Fourth-year grade 141 14.8
Fifth-year grade 102 10.7
3. Material and methods Sixth-year grade 152 16.0
Where do you live?
3.1. Design and participants Student Dormitory 254 26.7
Student house 224 23.6
With family 472 49.7
This questionnaire-based cross-sectional study was designed to Choosing the Faculty of Medicine
evaluate medical faculty students' knowledge, attitudes, and behaviors Totally my own choice 355 37.4
about organ donation. To achieve this goal, nearly 1300 students My family's request and suggestion 138 14.5
studying at Inonu University Faculty of Medicine between January 2020 Desire of both me and my family 457 48.1
Residence of your family
and March 2020 were determined as the study's universe. In order to
City center 758 79.8
calculate an adequate sample size, appropriate values were entered into District center 139 14.6
the confidence level (99%), confidence interval (2.5), and population (n Village 53 5.6
= 1300) tabs at the https://www.surveysystem.com/sscalc.htm web­ In which part of Turkey do you live?
site, and the minimum number of participants required was calculated Eastern Anatolia region 574 60.4
Southeast Anatolia region 161 16.9
as 874. The researchers named in the study title used the face-to-face Central Anatolia region 93 9.8
interview method to conduct this questionnaire-based study. Nearly Black Sea region 15 1.6
1000 medical students were interviewed face-to-face for this study; Aegean region 16 1.7
however, 950 students who agreed to fill the questionnaire were The Mediterranean region 73 7.7
Marmara region 18 1.9
enrolled. All questions asked to the Medical Faculty students were
Socioeconomic status of your family (monthly income/
shown in Tables 1 and 2. Turkish liras)
Low (〈3000) 172 18.1
3.2. Ethics committee approval Moderate (3000–5000) 436 45.9
High (>5000) 342 36.0
Smoking
First, the required official administrative permissions from the Yes 176 18.5
Dean's Office of the Inonu University Faculty of Medicine were granted No 774 81.5
(Approval date: 19.12.2019). Then, Ethical approval was obtained from Smoking (median [IQR]) 12 (14)
the Inonu University Institutional Review Board (IRB) for non- Alcohol Use
Yes 135 14.2
interventional studies (Approval date: and number: 21.01.2020 and
No 815 85.8
208). The socio-demographic characteristics of the students and a 29-
item questionnaire form aimed to rate their knowledge, attitudes, and
behaviors about organ donation were used. The study was carried out in
accordance with the Helsinki Declaration “Ethical Principles for Medical
Research Involving Human Subjects “. Each participant gave verbal men was 22 years (IQR: 4), and the median age of women was 22 years
consent before the questionnaire was distributed. (IQR: 3) (p = 0.105). The median BMI of men was 23.7 kg/m2 (IQR:4)
and the BMI of women was 21.2 kg/m2 (IQR:3.7) (p < 0.001). Of the
3.3. Statistical analysis students participating in the study, 20.1% were in first-year grade,
14.7% in second-year grade, 23.6% in third-year grade, 14.8% in fourth-
The statistical analyses were performed using IBM SPSS Statistics year grade, 10.7% in fifth-year grade, and 16% in sixth-year grade. Two
v25.0 (Statistical Package for the Social Sciences, Inc., Chicago, IL, hundred fifty-four (26.7%) of the medical students lived in the student
USA). The quantitative variables were expressed as Median and Inter­ dormitory, 23.6% lived in the student housing, and the remaining 49.7%
quartile Range (IQR). The qualitative variables were reported as lived with their families. Four hundred thirty-six (45.9%) of the medical
numbers and percent (%).Kolmogorov–Smirnov were used to assess the student's families had a middle-income level, 36.0% had a high-income
normality of quantitative variables' distribution. A Nonparametric Mann status, and the remaining 18.1% had a low-income group. One hundred
Whitney-U test was used to compare quantitative variables. Pearson's seventy-six (18.5%) of participants were smokers and stated that they
chi-square test was used to compare qualitative variables. P ≤ 0.05 was used a median of 10 cigarettes per day (IQR: 14), and 14.2% of them
considered a statistically significant value. used alcohol. It has been shown that the use of both cigarettes (26.8% vs.
10%; OR:3.3; p < 0.001) and alcohol (10.2% vs. 4.0%; OR:2.8; p <
4. Results 0.001) is significantly higher in males. The demographic and socio-
cultural characteristics of the medical students are summarized in
4.1. Demographic and socio-cultural characteristics Table 1.

A total of 950 medical students, 482 (50.7%) male, and 468 (49.3%) 4.2. Characteristics related to organ donation awareness
female, aged between 17 and 40 years (median: 22; IQR: 4), were
included in this survey-based cross-sectional study. The median age of Concerning previous donation experience, 32.3% of the included

2
S. Akbulut et al. Transplant Immunology 73 (2022) 101634

Table 2
Characteristics of Medical Students regarding organ donation.
No %

Have you ever donated blood?

Yes 307 32.3
No 643 67.7
Have you donated your organs?
Yes 43 4.5
No 907 95.5
Are you willing to donate your organs in the future? (n ¼ 907)
Yes 413 45.6
No 121 13.3
I am undecided 373 41.1
What are your reasons for refusing organ donation? (n ¼ 907)
Religious beliefs 97 10.7
Body integrity can deteriorate after death 62 6.8
Distrust against health institutions 32 3.5
My organs might use for commercial purposes 37 4.1
My organs might be harvested before brain death 43 4.7
No specific reason 542 59.7
No response 137 15.1
What are the most important reasons for you to donate organs? (n ¼ 43)
To save other people's lives 28 65.1
My relatives may need an organ transplant one day 13 30.2
Organ donation is a social responsibility that everyone should do 18 41.9
Having my organs live in someone else after I passed away 8 18.6
Awareness programs on social media organs 3 7.0
Because it is in line with my religious beliefs and worldview 11 25.6
Do religion or opinion leaders' views affect your decision to donate organs?
Yes 159 16.7
Partially 295 31.1
No 496 52.2
Do you think there is a legal regulation in our country regarding organ donation?
Yes 374 39.4
No 114 12.0
No idea 462 48.6
Do you think the Presidency of Religious Affairs has a fatwa on organ donation?
Yes 387 40.7
No 78 8.2
No idea 485 51.1
Do you think organ donation is appropriate for religious rules/beliefs?
Yes 647 68.1
No 38 4.0
No idea 265 27.9
Which is the ideal type of organ transplantation?
Living donor 389 40.9
Deceased donor 329 34.6
No idea 232 24.4

n %

Do you know where to apply for organ donation?

Yes 291 30.6
No 659 69.4
Do you believe that a patient with brain death might come back to life?
Yes 210 22.1
No 553 58.2
No idea 187 19.7
Do you have a relative waiting for organ transplantation?
Yes 28 2.9
No 922 97.1

Would you donate the organs of your relative who had brain death?
Yes 513 54.0
No 96 10.1
I'm not sure 341 35.9
Are you willing to donate your organs to close relatives when necessary?
Yes 704 74.1
No 46 4.8
I'm not sure 200 21.1
Would you accept one of your relatives to be a living donor candidate for you if it is necessary?
Yes 574 60.4
No 62 6.5
(continued on next page)

3
S. Akbulut et al.
Table 2 (continued )
I'm not sure
Which of the following factors can increase the number of organ donations?
Providing financial support to organ donors by the state
Providing some social opportunities to organ donors
Organizing campaigns in public institutions related to organ donation
Giving a sermon about organ donation in mosques and foundations
Organizing educational seminars in schools in annual periods
Reduction of prison sentences for some prisoners who donate organs
Granting citizenship to relatives of foreign nationals who donate organs
students donated blood a median of 2 (IQR:2) times. Concerning the
organ donation rate, only 4.5% donated their organs. Among the med­
ical students who did not donate their organs, only 45.6% stated that
they are willing to consider organ donation in the future, and 13.3%
rejected organ donation in any condition. The remaining 41.1% were
not decided about organ donation yet. Among the medical students who
refused organ donation, 59.7% had no specific reason, and 15.1%
preferred not to answer this question. About 10.7% of the students de­
nied organ donation for religious beliefs, 6.8% were concerned about
body integrity, and 4.7% were worried that their organs might be taken
without proper diagnosis of brain death.
On the other hand, the remaining students who donated their organs
stated to be their motives were saving lives (65.1%), an act of social
responsibility that is expected from every individual (41.9%), and the
possible need for a relative for organ transplantation in the future
(30.2%). According to the survey, the opinions of religious leaders and
conviction leaders about organ donation do not influence 52.2% of the
medical students, whereas it only partially influences 31.1% of them.
The responses showed that nearly half of the students stated that they
did not know whether there was any legal regulation on organ donation
in the country, and 12% thought there was no such legal regulation. Out
of the students, 69.4% stated that they did not know where to apply to
donate their organs. Of the participants, 51.1% indicated they were not
informed about the religious statement of the Religious Affairs Associ­
ation about organ donation. 68.1% think organ donation is compatible
with Islamic rules, whereas 27.9% do not know about this issue. While
24.4% of the students indicated that they did not have any idea of the
ideal method for organ donation, 40.9% stated that living donor organ
donation is the ideal method. While 22.1% of the students stated that
brain death is reversible, 19.7% stated they are unsure about this issue.
Among the respondents, 2.7% said that a relative was placed on the
organ waiting list Following a possible diagnosis of brain death of a
relative, 54% of the students said they would consent to organ donation
from him, whereas 35.9% were not sure about this issue. Among the
medical students, 74.1% agreed on a possible living-related organ donor
for a close relative, and 60.4% accepted receiving an organ from a close
relative when required. Opinions of the medical students for increasing
the organ donation pool are as follows: organizing campaigns in public
institutions related to organ donation (56.7%), giving a sermon about
organ donation in mosques and foundations (54.4%), providing some
social opportunities and benefits to organ donors (52.4%), organizing
educational seminars in schools in annual periods (56.7%), organizing
campaigns in public institutions related to organ donation (51.8%),
providing financial support to organ donors by the state (49.7%),
reduction of prison sentences for some prisoners who donate organs
(27.8%), and granting citizenship to relatives of foreign nationals who
donate organs (16.9%). Perspectives of the medical students' on organ
donation and their knowledge, attitude, and behavior are summarized in
Table 2.
4
Transplant Immunology 73 (2022) 101634
n %
314 33.1
472 49.7
498 52.4
490 51.8
517 54.4
539 56.7
264 27.8
161 16.9
4.3. Comparison of medical students who donated and those who did not
donate
Participants included in this study were divided into two groups, The
medical students who donated their organs as Group A (n = 43) and the
medical students who didn't donate their organs as Group B (n = 907).
According to the survey responses, medical students who donated their
organs (Group A) were more informed about the compliance of organ
donation with religion (p < 0.001). They were also more knowledgeable
about where to apply for organ donation (p = 0.032) and more willing to
donate the organs of a relative who had brain death (p = 0.004). They
believed that reciting sermons in mosques effectively increases organ
donation (p = 0.042). On the other hand, no statistical significance was
found between groups in terms of age (p = 0.134), BMI (p = 0.254),
gender (p = 0.097), grades (p = 0.194), socioeconomic status (p =
0.642), smoking (p = 0.414), alcohol use (p = 1.000), history of blood
donation (p = 1.000), caring about the opinions of religious and opinion
leaders (p = 0.894), awareness of the legal regulation on organ donation
in our country (p = 0.062), information about whether there is a reli­
gious fatwa about donation (p = 0.093), information about the ideal
type of organ transplantation (p = 0.059), knowledge about whether
there is a patient with brain death might come back to life (p = 0.415),
whether to donate your organs to their relatives if necessary (p = 0.065),
and the desire to have organ transplantation from a relative when
necessary (p = 0.333). The data related to the comparison of these
groups are summarized in Table 3.
4.4. Comparison of medical students by grades
The students were divided into six groups according to their grades
in the faculty of medicine: first-year grade (n = 191), second-year grade
(n = 140), third-year grade (n = 224), fourth-year grade (n = 141), fifth-
year grade (n = 102) and sixth-year grade (n = 152). Significant sta­
tistical differences were found between groups in terms desire to donate
organs in the future (p < 0.001), whether beliefs have an impact on the
decision to refuse organ donation (p = 0.005), whether the religion or
opinion leaders' views were influenced by their views on organ donation
(p = 0.035), information on whether there is a legal regulation on organ
donation in the our country (p < 0.001), information on whether there is
a religious fatwa on organ donation in the our country (p < 0.001),
knowledge about the compliance of organ donation with religious rules
(p < 0.001), knowledge about which is the most ideal type of organ
transplantation (p < 0.001), information on where to apply for organ
donation (p < 0.001), knowledge about whether there is a patient with
brain death might come back to life (p < 0.001), whether there is a
desire to donate the organs of a relative who had brain death (p <
0.001), whether to donate organs to their relatives if necessary (p <
0.001), the necessity of public campaigns to increase organ donation (p
= 0.023), the necessity of reciting a sermon in mosques to increase organ
donation (p < 0.001), necessity of organizing annual training seminars
in schools to increase organ donation (p < 0.001), the necessity of a
S. Akbulut et al. Transplant Immunology 73 (2022) 101634

Table 3 5. Discussion
Comparison of Medical students who Donated and Those who did not Donate.
Donated (n No-donated p Organ transplantation is a life-saving treatment for end-stage organ
= 43) (n = 907) failure. However, organ shortage remains a problem in Turkey and
Do religion or opinion leaders' views worldwide. In Turkey, less than 30% of candidates waiting for liver
affect your decision to donate transplantation received an organ in 2017 [5]. In 2015, 935 patients per
organs?
0.894
million population had kidney failure; only 17.4% underwent organ
Yes 8 (18.6) 151 (16.6) transplantation [11]. In 2019, out of 31,764 patients registered for
Partially 14 (32.6) 281 (31.0)
No 21 (48.8) 475 (52.4)
organ transplantation in Turkey Organ and Tissue Donation System,
Do you think there is a legal only 10,720 organ transplantations were performed on the kidney, liver,
regulation in our country heart, lung, pancreas, small intestine, cornea, and bone marrow [2].
regarding organ donation?
0.062 Donation after cardiac death has been a topic of interest over the past
Yes 16 (37.2) 358 (39.5)
years to help address the disparity between available organs and the
No 10 (23.3) 104 (11.5)
No idea 17 (39.5) 445 (49.1) number of patients awaiting transplantation. The large gap between
Do you think the Presidency of organ donor availability and organ demand has resulted in many ini­
Religious Affairs has a fatwa on tiatives worldwide to increase the number of organ donors [12–14].
organ donation? Organ shortage is a social, psychological, ethical, moral, and political
0.093
Yes 23 (53.5) 364 (40.1)
No 5 (11.6) 73 (8.0)
problem, causing unjustifiable damage to public health.
No idea 15 (34.9) 470 (51.8) Studies have been performed to understand the factors that affect
Do you think organ donation is people's decisions on organ donation. Educational, socioeconomic, cul­
appropriate for religious rules/ tural, and religious factors and knowledge of and attitudes toward organ
beliefs?
<0.001 donation contribute to the decision to donate organs in life and after
Yes 42 (97.7) 605 (66.7)
No 0 (0.0) 38 (4.2) death [6–10]. In addition, community misunderstanding of the donation
No idea 1 (2.3) 264 (29.1) process after cardiac death, variable clinical and legal definitions of
Do you know where to apply for brain death, and the inconsistent legal upholding of brain death criteria
organ donation? all contribute as significant barriers to organ donation [2]. It is essential
0.032
Yes 20 (46.5) 271 (29.9)
to continue to promote organ donation to avoid mortality on the waiting
No 23 (53.5) 636 (70.1)
Do you believe that a patient with list. Society needs to be informed to increase organ donation and
brain death might come back to transplantation. Research indicates that knowledge about organ pro­
life?
0.415 curement is positively correlated with signing an organ-donor card
Yes 6 (14.0) 204 (22.5)
[15,16]. In this context, previous studies showed that Turkey's adult and
No 28 (65.1) 525 (57.9)
No idea 9 (20.9) 178 (19.6) youth population have inadequate organ donation knowledge
Would you donate the organs of your [10,17,18]. Those studies advocate for public education programs to
relative who had brain death? increase awareness among the general population about legislation
Yes 33 (76.7) 480 (52.9) 0.004 related to organ donation.
No 0 (0.0) 96 (10.6)
In this context, doctors are regarded as key players in organ dona­
I'm not sure 10 (23.3) 331 (36.5)
Are you willing to donate your tion. The medical profession could be role models to society by
organs to close relatives when demonstrating their willingness to donate their organs for trans­
necessary?
0.065 plantation and to carry organ donor cards. They should be expected to
Yes 38 (88.4) 666 (73.4)
clearly and precisely inform patients and their family members about
No 2 (4.7) 44 (4.9)
I'm not sure 3 (7.0) 197 (21.7)
organ donation. Furthermore, doctors care for a wide range of patients,
Would you accept one of your including brain death patients. They have a vital role in identifying
relatives to be a living donor potential donors, communicating with organ donor coordinators,
candidate for you if it is necessary? obtaining consent from the families of the potential donors, and
0.333
Yes 23 (53.5) 551 (60.7)
approaching the issue as role models. Knowledge and perceptions about
No 5 (11.6) 57 (6.3)
I'm not sure 15 (34.9) 299 (33.0) organ donation are positively associated with attitudes to donation,
Giving a sermon about organ willingness to donate, and donor registration [10,17]. Doctors and
donation in mosques and medical students as future doctors can play a significant role in maxi­
foundations 0.042
mizing the pool of potential donors by participating in educational
Yes 30 (69.8) 487 (53.7)
No 13 (30.2) 420 (46.3)
campaigns designed to promote national knowledge and attitude toward
organ donation. Utilizing the total capacity of medical students to pro­
mote organ donation in the country will largely depend on preparing
certain reduction in sentence for prisoners to increase organ donation (p them with adequate knowledge and an enhanced attitude toward organ
= 0.013), the necessity of granting citizenship to foreign nationals to donation.
increase organ donation (p = 0.037). These parameters were positively In this study, medical students showed a relatively positive attitude
correlated and higher with the higher grades in medical school. The data toward organ donation. While only 4.5% of them already donated their
related to the comparison of the groups are summarized in Table 4. In organs, 45.6% stated that they are willing to consider organ donation in
our country, medical students start clinical practice after the 3rd grade. the future. Only 13.3% of the medical students rejected organ donation
As Table 4 examined in detail, it showed that students' knowledge, at­ in any condition and only. Of the respondents, 74.1% agreed on a
titudes, and behaviors about organ donation are positively affected after possible living-related organ donor for a close relative, and 60.4%
the 3rd grade. However, one of the most important results of this study: accepted receiving an organ from a close relative when required.
is that regardless of their grades, a significant number of the students The students' knowledge status regarding organ donation and
(20%) do not know about the irreversibility of brain death. transplantation attitude and behavior are summarized in Table 2. The
study showed that most medical students have inadequate knowledge
regarding organ donation. Nearly half of the students did not know
whether there was any legal regulation on organ donation in the

5
S. Akbulut et al. Transplant Immunology 73 (2022) 101634

Table 4
Comparison of medical students' knowledge regarding organ donation by grading.
I (n = II (n = III (n = IV (n = V (n = VI (n = p
191) 140) 224) 141) 102) 152)

Smoking
Yes (%) 12.6 27.1 18.8 21.3 14.7 17.8 0.022
No (%) 87.4 72.9 81.3 78.7 85.3 82.2
Have you ever donated blood
Yes 23.0 37.1 32.6 39.0 33.3 32.2 0.035
No 77.0 62.9 67.4 61.0 66.7 67.8
Are you willing to donate your organs in the future (n ¼ 907)
Yes 35.1 44.9 38.6 51.5 61.7 53.9
<0.001
No 14.1 16.2 17.2 15.4 8.5 5.0
I am undecided 50.8 39.0 44.2 33.1 29.8 41.1
What are your reasons for refusing organ donation (Religious beliefs)
Yes 6.5 11.0 13.0 16.2 2.1 12.8 0.005
No 93.5 89.0 87.0 83.8 97.9 87.2
Do religion or opinion leaders' views affect your decision to donate
organs
Yes 9.9 11.4 19.2 23.4 17.6 19.7 0.035
Partially 28.8 32.9 30.8 31.9 34.3 29.6
No 61.3 55.7 50.0 44.7 48.0 50.7
Do you think there is a legal regulation in our country regarding organ
donation
Yes 30.9 38.6 27.7 50.4 52.0 49.3 <0.001
No 5.8 8.6 10.7 13.5 21.6 17.1
No idea 63.4 52.9 61.6 36.2 26.5 33.6
Do you think the Presidency of Religious Affairs has a fatwa on organ
donation
Yes 21.5 34.3 31.3 53.2 63.7 57.9 <0.001
No 9.9 4.3 8.9 4.3 9.8 11.2
No idea 68.6 61.4 59.8 42.6 26.5 30.9
Do you think organ donation is appropriate in terms of religious rules/
beliefs
Yes 53.9 72.1 59.4 73.0 85.3 78.9 <0.001
No 5.2 3.6 4.0 3.5 4.9 2.6
No idea 40.8 24.3 36.6 23.4 9.8 18.4
Which is the ideal type of organ transplantation
Living donor 38.2 46.4 42.0 42.6 40.2 36.8
<0.001
Deceased donor 20.4 23.6 27.2 41.1 55.9 53.3
No idea 41.4 30.0 30.8 16.3 3.9 9.9
Do you know where to apply for organ donation
Yes 19.4 24.3 28.6 39.7 44.1 36.2 <0.001
No 80.6 75.7 71.4 60.3 55.9 63.8
Do you believe that a patient with brain death might come back to life
Yes 23.0 34.3 33.5 13.5 8.8 9.9
<0.001
No 48.2 40.7 42.0 76.6 79.4 79.6
No idea 28.8 25.0 24.6 9.9 11.8 10.5
Would you donate the organs of your relative who had brain death
Yes 47.6 51.4 42.9 63.8 69.6 61.2
<0.001
No 11.0 9.3 12.9 9.9 5.9 8.6
I'm not sure 41.4 39.3 44.2 26.2 24.5 30.3
Are you willing to donate your organs to close relatives when it is
necessary
Yes 66.0 70.7 67.9 82.3 86.3 80.9 <0.001
No 6.8 3.6 8.0 2.1 1.0 3.9
I'm not sure 27.2 25.7 24.1 15.6 12.7 15.1
Which of the following factors can increase the number of organ
donations
Organizing campaigns in public institutions related to organ donation 45.5 47.9 48.2 52.5 59.8 61.2 0.023
Giving a sermon about organ donation in mosques and foundations 38.2 55.0 50.4 54.6 70.6 69.1 <0.001
Organizing educational seminars in schools in annual periods 50.3 56.4 49.1 53.2 70.6 70.4 <0.001
Reduction of prison sentences for some prisoners who donate organs 19.4 37.9 29.0 29.1 25.5 27.6 0.013
Granting citizenship to relatives of foreign nationals who donate organs 10.5 18.6 17.9 19.1 12.7 23.0 0.037

country, and 12% thought there was no such regulation. Most of them
did not learn where to apply for Organ donation, and most are not
informed about the religious statement of the Religious Affairs Associ­
ation about organ donation. Regarding knowledge and perception about
brain death, 22.1% of the participants stated that brain death is
reversible, whereas another sub-group of 19.7% was not sure about this
issue. One of the significant obstacles to organ donation in Muslim-
majority countries, such as Turkey, is a widely perceived notion that
organ transplantation is not suitable for the Islamic religion, which is not
true [7]. Organ transplantation and donation are permissible in Islam.
An Egyptian head mufti issued the first modern fatwa related to organ
donation was issued in 1966 by an Egyptian head mufti. This fatwa was
followed by the fatwas issued by muftis of Malaysia (1969), Algeria
(1972), Jordan (1977), Kuwait (1979), Turkey (1980), and Saudi Arabia
(1982) [7]. The High Board of Religious Affairs of Turkey declared a
decree stating that organ donation is allowed in Islam [7]. In this study,
medical students who donated their organs were more informed about
the compliance of organ donation with religion. They were also more
knowledgeable about where to apply for organ donation.
There have been contradicting results reported in the literature

6
S. Akbulut et al.
concerning this issue. In a similar and recent study from Turkey, stu­
dents at the Fırat University Medical School showed comparable results
to our data [2]. Anwar and colleagues [19] reported that the willingness
of medical students to donate their organs was found to be 28% of
medical students in Bangladesh. A recent Canadian survey reported that
most medical students (n = 613/750; 82%) had legally given consent to
organ donation after death. However, despite this favorable attitude,
medical students in that survey have limited knowledge of organ
donation [20]. From Spain, Rios and colleagues [21] reported that only
22% of the medical students in Spanish universities consider themselves
good information about organ donation. Interestingly, the study said
that a high percentage of these students had received negative infor­
mation on the subject. In a study from Italy, while 97.8% of medical
students reported being in favor of organ donation, only 24.9% were
registered as donors [22]. In general, most of these studies indicated that
the knowledge level correlated positively with organ donation. Our
study also showed that as medical students progress through the grade
levels, their perceptions and knowledge of organ donation and trans­
plantation also increase positively. These data were consistent with
other studies [2]. These data suggest that with sufficient information
and appropriate training, the motivation of these medical students could
become more positive.
In this study, the most important motivation for medical students for
organ donation was saving lives, the social responsibility expected from
every individual, and the possible need for a relative for organ trans­
plantation in the future. The opinions of religious leaders and conviction
leaders about organ donation do not influence 52.2 of the respondents,
whereas it only partially influences 31.1% of them. In a study conducted
among university students in Turkey, 50.4% stated that their religious
beliefs did not prevent organ transplantation, 19.5% said it was an
obstacle, and 30.1% indicated that they did not know about this subject
[2]. In the literature, some studies indicated that religious views and
beliefs affect the view of organ transplantation among medical school
students; other studies did not show this effect [21–23].
Cadaveric organ donation should be promoted to address organ
shortage and prevent the risks involved in organ donation. Immuno­
logical outcomes from cadaveric organ donations are encouraging. For
example, while liver grafts from brain dead donors appear to have a
higher inflammatory cell infiltrate and cytokine concentration at
retrieval than donation after circulatory death (DCD) or living donor
grafts, however clinical differences in rejection, as a result, are not
evident. Clinical solid evidence that procurement of a deceased in­
dividual's organs can occur following brain death, cardiac death, or
Living donor liver transplantation is associated with a lower rate of
acute T-cell–mediated rejection (TCMR) is not apparent. Further edu­
cation and training of medical students and medical staff with these facts
would be instrumental in promoting organ donation, increasing organ
availability, and reducing death rates on the waiting lists [24].
6. Conclusion
This study indicates that medical students have inadequate knowl­
edge, attitudes, and behaviors about organ donation. The study showed
that the knowledge level correlated with donation rate and suggests that
educational programs about organ donation and transplantation are
needed before the full potential of medical students in organ donation
campaigns, and the whole transplant process can be utilized efficiently.
Institutional review board statement
This study was reviewed and approved by the Inonu University
institutional review board (IRB) for non-interventional studies
(Approval No: 2021/ 208).
7
Transplant Immunology 73 (2022) 101634
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Informed consent statement
Verbal consents were obtained from all participants.
Data availability statement
The datasets analyzed during the current study are available from the
corresponding author on reasonable request.
Author contributions
Akbulut S, Toman I, Gaygili Z, Kaya S, Akpolat VR, Cing A, Keles TY
and Saritas H contributed to the study's concept, design, data collection,
data analysis, interpretation, and manuscript writing. Akbulut S, Saritas
H, and Unsal S, contributed to the data collection and approved the
manuscript's final version. Akbulut S, Ozer A and Demyati K contributed
to the statistical analysis and writing. All authors have approved the
manuscript's final version.
Declaration of Competing Interest
The authors declare no conflicts of interest regarding this
manuscript.
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