Awareness and attitude to deceased kidney donation among health-care workers in Sokoto, Nigeria.

BACKGROUND: Access to renal replacement therapy by the increasing population of patients with end-stage kidney disease across Sub-Saharan Africa, including Nigeria, has become a major public health challenge. Although deceased kidney donation constitutes a viable source, its uptake by patients is contingent on its acceptance by health-care workers.
OBJECTIVES: The aim of this study is to assess the awareness and attitude to deceased kidney donation among health-care workers in Sokoto, Nigeria.
MATERIALS AND METHODS: : A cross-sectional study was conducted among 470 staff of Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria (attending a 1-week seminar), selected by universal sampling. Data were collected with a set of pretested, self-administered, and semi-structured questionnaire.
RESULTS: The mean age of the respondents was 34.1 ± 7.8 years, and most of them (77.7%) were aged <40 years. Majority of respondents were males (60.6%), married (76.5%), and Moslems (73.5%). While almost all the respondents (98.1%) were aware of deceased kidney donation, only about half (51.9%) were willing to accept deceased kidney donation. Furthermore, 43.4% were willing to give consent to donate deceased relative's kidney, and 26.1% were willing to carry an organ donation card. Predictors of willingness to accept deceased kidney donation were male sex, being a medical doctor or laboratory scientist and being a Moslem (Odds ratio >2, P < 0.05). The major disincentives reported were fear that it may not work (42%) and fear of disease transmission (37.0%).
CONCLUSION: Periodic education of health-care workers on effectiveness and safety of deceased kidney donation is crucial to promoting its acceptance among them.

INTRODUCTION

Chronic kidney disease (CKD) has become a major public health challenge globally, especially in developing countries, with a marked burden in Sub-Saharan Africa.[12] A peculiar feature of the epidemiology of CKD in Sub-Saharan Africa is that it affects mainly young adults aged 20–50 years and is primarily due to hypertension and glomerular diseases, unlike developed countries where it presents in middle-aged and elderly patients and is predominantly due to diabetes mellitus and hypertension.[3] In addition to the very high prevalence of CKD reported in studies conducted among at risk populations in Sub-Saharan Africa, majority of those affected were largely unaware of the disease, as it is usually asymptomatic in its early stages. Most patients therefore present late to the hospital in end-stage renal disease (ESRD) when the required treatments such as dialysis and renal replacement therapy are either unavailable or unaffordable.[456] In Nigeria, studies conducted in Sagamu[7] and Port Harcourt[8] also reported high burden of ESRD with dismal outcome in the face of poor health-care services, inadequate infrastructure, poverty, ignorance, and poor access to specialist care.

For patients presenting with ESRD death is imminent without renal replacement therapies which include hemodialysis, peritoneal dialysis, and kidney transplantation. While accessibility to dialysis is increasing globally, the reverse is true of kidney transplantation particularly in the developing countries in Sub-Saharan Africa where only a few kidney transplantation centers are available. Although dialysis helps in prolonging life, ameliorate the symptoms of the disease and reduce its complications, the disease process and the adjunctive medications for the risk factors of the disease such as diabetes mellitus and hypertension negatively impact on the quality of life in these patients as manifested by adverse reactions to medication and sexual dysfunction.[910]

The superiority of kidney transplantation over hemodialysis and peritoneal dialysis in improving life expectancy, physical functioning, and mental health of patients has been documented in several studies, thus making it the gold standard treatment for patients with ESRD, and a potentially viable and effective lifesaving option in resource-poor countries including Nigeria.[1112]

With the establishment of a dialysis unit at the Usmanu Danfodiyo University Teaching Hospital (UDUTH), Sokoto, Nigeria, and the commencement of hemodialysis, there has been a tremendous increase in the number of patients being maintained on hemodialysis. If there is no provision for definitive treatment by kidney transplantation, the demand for hemodialysis services would outstrip the available resources over a short period of time. There is therefore an urgent need to commence kidney transplantation in UDUTH to address this emerging challenge.

In addition to the enabling laws, infrastructure and trained personnel, kidney transplantation principally depends on the availability of the most essential and scarce commodities-kidneys. Worldwide, the kidneys are not yet available for off-shelf purchase like other surgical consumables, but should be obtained from willing living donors or cadaveric (CAD) sources.

Reports from studies across the world show wide variations in attitude to kidney transplantation despite high level of awareness among patients, members of the public and health-care workers, and this could have adverse effects on availability of donor kidneys. While only about a third (34.9%) of patients on hemodialysis would like to undergo transplantation in a study in China,[13] majority (73.3%) of patients on hemodialysis in another study in Morocco were willing to undergo transplantation.[14] In a community-based study in the United States, 38% of African-American stated that they would not donate organs compared to 10% of Whites; and whereas African-Americans cited personal reasons. Whites cited fear of organs being removed before their death as reason for not wanting to donate.[15] A study among health-care professionals in Qatar reported that, although majority (83%) of respondents were in support of organ donation, more than half of physicians (51.3%), nurses (61.6%), and technicians (54.1%) would like to be buried with all their organs intact.[16]

In a study among health workers in Nigeria, whereas 76% were willing to receive kidney transplant, only 50.7% were willing to donate their kidneys.[17] If the current trend continues, getting living kidney donors would increasingly become more difficult and the only viable option would be CAD donor kidneys.

The effectiveness of CAD donor kidneys as a viable alternative to living donor kidneys has been confirmed in several studies. A study that compared 136 living donor transplantation performed during the period of 1990–2003 with a control group of 4304 CAD donor transplantation found no differences regarding patient or graft survival during a 10-year follow-ups.[18] Another study that compared growth in children after kidney transplantation with living related donor (LRD) or CAD graft, reported that, whereas LRD recipients were taller at all ages and had greater growth velocity in infancy and during puberty, glomerular filtration rate was only higher immediately after transplantation in the LRD than CAD, but it did not differ between the groups during follow-up.[19] While the findings from these studies support the use of LRD kidneys as the preferred option in children, they provide evidence for the use of CAD donor kidney as a suitable and effective alternative to living donor kidney in adults, more so that living donor kidney is increasingly becoming scarce.

Health-care workers form a very important part of the community, in addition to providing health-care services, they are seen as role models with regard to health-related issues, and as such substantially influence the attitude and behavior of both their patients and members of the public by virtue of the information they pass across to them. Attitude of health-care workers to deceased donor kidney would influence their participation in promoting its uptake by patients.

While the awareness, knowledge, and attitude toward deceased kidney donation have been examined in studies conducted in different populations across the world,[202122] little is known about it in Sub-Saharan Africa, and particularly in Nigeria.[17232425] This study was therefore conducted to provide an insight into the situation on the ground, in addition to providing information for designing strategies for promoting acceptance of deceased kidney donation.

MATERIALS AND METHODS

The study was conducted at the UDUTH, Sokoto, Nigeria, in March 2015. The hospital serves the inhabitants of Sokoto state, neighboring Kebbi and Zamfara states, as well as people from neighboring Niger Republic. It has a bed capacity of 650 and consists of 42 departments of which 24 offer clinical services in the form of preventive, curative, and rehabilitative services apart from the laboratory units that only carry out investigations. Special units in the hospital include the dialysis and radiotherapy units, whereas the kidney transplant unit is about to take off.

The study population included all caders of staff of the hospital, attending a 1-week seminar on “Plan for retirement/contributory pension scheme” organized by the management of the hospital. The respective departments in the hospital were arranged into groups and members of staff were scheduled to attend the seminar on the day scheduled for their respective departments. The sample size was estimated at 470 using the Fisher's formula for estimating the minimum sample size for descriptive studies,[26] 42.9% prevalence of willingness to sign an organ donation card among health-care workers from a previous study,[17] precision level of 5% and an anticipated response rate of 80%. All the health-care workers in attendance at the workshop who gave their consent to participate were considered as eligible and enrolled into the study.

A set of pretested, semi-structured, self-administered questionnaire was used to obtain information on respondent's socio-demographic characteristics, awareness, and attitude to deceased kidney donation. The questionnaire was adapted from the instrument used in previous studies.[1723] It was pretested on 20 health-care workers in another tertiary health-care facility in Sokoto, Nigeria. Some of the questions were rephrased for clarity based on the observations made during the pretest. Five resident doctors assisted in questionnaire administration after pretraining on conduct of survey research, the objectives of the study, selection of study subjects and questionnaire administration. Institutional ethical clearance was obtained from the Ethical committee of UDUTH, Sokoto, Nigeria. Permission to conduct the study was obtained from the management of the hospital, and informed consent was also obtained from the participants before data collection.

Data were analyzed using IBM Statistical Package for the Social Sciences (SPSS) version 20 software (SPSS, IBM Corp, Armonk, NY, USA) computer statistical software package. Quantitative variables were summarized using appropriate measures of central tendency and dispersion. Categorical variables were presented as frequencies and percentages; the Chi-square test was used for bivariate analysis involving categorical variables. Logistic regression analysis was used to determine the variables that predict willingness to accept deceased donor kidney. All levels of significance were set at P < 0.05.

RESULTS

Of the 479 questionnaires distributed, 472 (95.5%) were returned with complete information and were analyzed. The mean age of the respondents was 34.1 ± 7.8 years, and most of them (77.7%) were aged <40 years. Majority of respondents were males (60.6%), married (76.5%), and Moslems (73.5%). A larger proportion of respondents were nurses (48.7%), followed by doctors (29.5%) as shown in Table 1.

Table 1

Sociodemographic profile of respondents (n=472)

Variables	Frequency (%)
Age groups (years)
20-29	145 (30.7)
30-39	222 (47.0)
40-49	80 (16.9)
50-59	21 (4.4)
60-69	4 (0.8)
Sex
Male	286 (60.6)
Female	186 (39.4)
Marital status
Single	104 (22.0)
Married	361 (76.5)
Separated	4 (0.8)
Widowed	3 (0.6)
Religion
Islam	347 (73.5)
Christianity	125 (26.5)
Cader
Doctor	139 (29.4)
Nurse	230 (48.7)
Laboratory scientist/tech	32 (6.8)
Admin staff	14 (3.0)
Others	57 (12.2)

Awareness of deceased kidney donation by respondents

Almost all, 463 (98.1%) of the 472 respondents have heard of deceased kidney donation, and a larger proportion of respondents (48.1%) obtained information about it through the print media (books, journals, magazines, and newspapers). Medical personnel were the second most common source of information (41.4%), whereas only a few respondents (13.6%) obtained information about it through the electronic media (radio and television) as shown in Table 2.

Table 2

Awareness of deceased kidney donation by respondents (n=472)

Variables	Frequency (%)
Ever heard of deceased kidney donation
Yes	463 (98.1)
No	9 (1.9)
Sources of information*
Books/journals/magazines/newspapers	242 (51.3)
Radio/television	64 (13.6)
Medical personnel	194 (41.1)

*Multiple responses allowed

Willingness to accept deceased donor kidney among respondents

A little about half, 238 (51.9%) of the 459 respondents that responded to the question said they would accept deceased donor kidney, 59 (12.9%) would accept it reluctantly if it becomes inevitable, about a quarter of respondents 112 (24.4%) were unsure whether they would accept it or not, whereas 50 (10.9%) said they would never accept it [Figure 1]. The main reasons given for not willing to accept deceased donor kidney were fear that it may not work (42.0%) and fear of disease transmission (37.0%) as shown in Figure 2.

Figure 1

Willingness to accept deceased donor kidney among respondents

Figure 2

Reasons against accepting deceased donor kidney

While there was significant association (P < 0.05) between willingness to accept deceased donor kidney and being aged <40 years, male, single, Moslem, and doctor or laboratory scientist/technician [Table 3], in logistic regression analysis, the predictors of willingness to accept deceased donor kidney were being male, Moslem and doctor or laboratory scientist/technician [Table 4]. Males were seven times more likely to be willing to receive deceased donor kidney compared to females (odds ratio [OR] = 7.467, 95% confidence interval [CI]: 4.883–11.418, P = 0.001). Similarly, Moslem were twice more likely to be willing to receive deceased donor kidney compared to Christians (OR = 2.127, 95% CI: 1.397–3.240, P = 0.001); whereas doctors and laboratory scientists/technicians were twice more likely to be willing to accept deceased donor kidney compared to nurses and other caders of health-care workers (OR = 2.296, 95% CI: 1.524–3.458, P = 0.001) as shown in Table 4.

Table 3

Willingness to accept deceased donor kidney by sociodemographic profile of respondents

Variables	Would accept deceased donor kidney				Test of significance
	Willingly, frequency (%)	Reluctantly, frequency (%)	Unsure, frequency (%)	Never, frequency (%)
Age groups (years)
20-29	65 (44.8)	18 (12.4)	38 (26.2)	24 (16.6)	χ2=29.833, P=0.003
30-39	128 (57.7)	23 (10.4)	51 (23.0)	20 (9.0)
40-49	37 (46.2)	15 (18.8)	18 (22.5)	10 (12.5)
50-59	7 (33.3)	3 (14.3)	5 (23.8)	6 (28.6)
60-69	1 (25.0)	0	0	3 (75.0)
Sex
Male	196 (68.5)	24 (8.4)	43 (15.0)	23 (8.0)	χ2=95.417, P<0.001
Female	42 (22.6)	35 (18.8)	69 (37.1)	40 (21.5)
Marital status
Single	58 (55.8)	6 (5.8)	27 (26.0)	13 (12.5)	χ2=19.014, P=0.004
Married	177 (49.0)	49 (13.6)	85 (23.5)	50 (13.9)
Separated/widowed	3 (42.9)	4 (57.1)	0	0
Religion
Islam	192 (55.3)	39 (11.2)	76 (21.9)	40 (11.5)	χ2=13.020, P=0.005
Christianity	46 (36.8)	20 (16.0)	36 (28.8)	23 (18.4)
Cader
Doctor	90 (60.7)	19 (13.7)	23 (16.5)	7 (5.0)	χ2=68.936, P<0.001
Nurse	85 (37.0)	27 (11.7)	71 (30.9)	47 (20.4)
Laboratory scientist/tech	21 (65.6)	2 (6.3)	7 (21.7)	2 (6.3)
Admin staff	8 (57.1)	1 (7.1)	2 (14.5)	3 (21.4)
Others	15 (55.6)	6 (22.2)	4 (14.8)	2 (7.4)

Table 4

Predictors of willingness to accept deceased donor kidney among respondents

Variables	OR	95% CI		P
		Lower	Upper
Age (below 40 vs. 40 years and above)	0.980	0.957	1.003	0.088
Sex (males vs. females)	7.467	4.883	11.418	0.001
Marital status (single vs. married, separated or divorced)	1.317	0.850	2.040	0.218
Religion (Moslems vs. Christians)	2.127	1.397	3.240	0.001
Cader (doctors and laboratory scientists/technologists vs. nurses and other caders)	2.296	1.524	3.458	0.001

OR=Odds ratio, CI=Confidence interval

Respondents’ willingness to donate deceased relative's kidney

Less than half of respondents (43.4%) would give consent to donate their deceased relative's kidney, 19.1% were against it, 15.2% were not sure, whereas 15.2% would prefer to leave the decision to other family members. The main reasons given for not willing to donate deceased relative's kidney were their religion being against it (35.2%), the need not to disturb or mutilate the dead (28.9%), and that it could delay burial rites (10.9%) as shown in Table 5.

Table 5

Respondents’ willingness to donate deceased relative's kidney

Variables	Frequency (%)
Willing to give consent to donate deceased relative's kidney (n=440)
Yes	191 (43.4)
No	84 (19.1)
Not sure	67 (15.2)
Would leave decision to other family members	61 (13.9)
Would encourage other family members	32 (7.3)
Would discourage other family members	5 (1.1)
Reason against donating deceased relative's kidney (n=128)
Against religion	45 (35.2)
Don’t disturb or mutilate the dead	37 (28.9)
Delay burial rites	14 (10.9)
May re-incarnate deformed	7 (5.5)
No reason	25 (19.5)

Respondents’ willingness to carry an organ donation card

Only about a quarter, 123 (26.1%) of the 472 respondents were willing to carry an organ donation card as evidence that they have given consent to donate their kidney after death. A larger proportion of respondents (35.81%) were against donating their kidney after death, 15.47% were not sure for now, and 9.75% said they may consider doing so in future [Table 6].

Table 6

Respondents’ willingness to carry an organ donation card (n=472)

Willing to carry an organ donation card	Frequency (%)
Yes	123 (26.1)
No	169 (35.8)
Not sure for now	73 (15.5)
Never thought of it	24 (5.1)
May consider it in future	46 (9.8)
Will never consider it	18 (3.8)
No response	19 (4.0)

DISCUSSION

The high level of awareness of deceased kidney donation (98.1%) among the respondents in this study compares well with the 93.3% awareness level obtained among health workers in two health-care facilities in South-western Nigeria,[23] and another study in Kano, northern Nigeria,[25] though with a slightly lower awareness level of 79.6%. The worrisome aspect is the fact that while the print media were the most common source of information on deceased kidney donation among the respondents in this study, the electronic media were the most common source of information among the respondents in the other studies, with medical personnel lagging far behind (particularly in the other studies) in creating awareness about this crucial issue. The role of health-care workers in disseminating accurate information on deceased kidney donation to their colleagues and members of the public cannot be overemphasized, and the effectiveness of education interventions conducted in different population groups in increasing perceived need for organ donation, shifting negative spiritual/religious beliefs about organ donation, and increasing willingness to donate organs, has been demonstrated in several studies.[2728] Similar interventions among college, health sciences, and nursing students and their families were found to be effective in improving knowledge on organ donation, correct misinformation, effect opinion change on organ donation, and also promote consent to organ donation by families.[293031] It is therefore imperative for management of health institutions to give prominence to education of their students and trainees on organ donation in their curriculum. This would enable them to appreciate its importance and promote it among their colleagues, patients and members of the public when they qualify as health-care professionals.

The low level of willingness to accept deceased donor kidneys (51.9%) among the respondents in this study, whereas it is in concordance with the 53.3% willingness to accept kidney transplant in a study by Ilori et al.,[32] it appears to be substantially higher than the 46.4% willingness to accept kidney transplant in another study by Tan et al.[33] On the contrary, in a study among health-care workers by Okpere and Anochie,[17] 76% were willing to receive kidney transplant and 71.0% were specifically in support of CAD donor kidneys. Another study in rural India also reported that most of the participants (70%) were willing to donate their organ after their death.[34] The main reasons given for unwillingness to accept deceased donor kidney by the respondents in this study were fear that it may not work (42%) and fear of disease transmission (37%). Although these reasons appear plausible enough, the low level of willingness to accept deceased donor kidney among the respondents in this study could be related to the absence of kidney transplantation services in the study setting (UDUTH), the fact that hemodialysis services have just begun, and the low participation by health-care workers in creating awareness about it both among their colleagues and members of the public. These findings underscore the need for health-care workers (particularly the professionals in the renal unit) to periodically educate their colleagues and members of the public on the effectiveness and safety of CAD kidney transplantation.

The significant association (P < 0.05) between willingness to accept deceased donor kidney and being aged <40 years among the respondents in this study agrees with the finding in a study by Tan et al.,[33] that reported a significant association between younger age and willingness to accept kidney transplant. However while younger age was not a predictor of willingness to accept deceased donor kidney in this study, respondents aged 60 years and less were 13 times more likely to favor kidney transplantation than those aged above 60 years (OR = 12.99, 95% CI: 3.75–45.45) in the other study. The significant association between willingness to accept deceased donor kidney and other sociodemographic variables that were also found to be predictors of willingness to accept deceased donor kidney in this study such as being a doctor or laboratory scientist could indirectly be due to other factors, particularly awareness of the benefits of transplantation that was consistently identified as a predictor of acceptance of renal transplant in the other studies.[3233]

The low level of willingness (43.3%) to give consent to donate deceased relative's kidney, and the much lower willingness to carry an organ donation card (26%) as evidence that they have given consent to donate their own kidneys after death by the respondents in this study are in agreement with the findings in a similar study among health-care workers by Oluyombo et al.,[23] that reported that while 29.5% of respondents said they were willing to donate their kidneys, a much lower proportion (22.2%) would be ready to sign an organ donation card if asked to do so. Notably, the reasons given against retrieval of either deceased relative's kidneys or respondents own kidneys after death such as religious factors (35.2%), and the need not to disturb or mutilate the dead (28.9%) were also the most commonly cited reasons against both living and deceased kidney donation in previous studies, in addition to other reasons such as fear of body part being removed before death, desire to be buried with all their organs intact, and refusal by family members.[151634] Other studies across Nigeria show wide variations in the attitude of health-care workers to kidney donation despite high level of awareness and knowledge of kidney transplantation. While about a third and below of healthcare workers were willing to donate kidneys in studies carried out in Ibadan (29.5%) and Lagos (30%) in southern Nigeria, majority of respondents (79.1%) were willing to donate an organ in a community based survey in northern Nigeria by Iliyasu et al.[232425]

Kidney donation was hitherto considered to be very safe for the living donor with documented evidence of very low perioperative risk, preserved renal function, absence of any negative impact on long-term survival, and an excellent quality of life,[3536] but contrary findings have been reported in recent studies. In a study by Mjøen et al.,[37] living kidney donors were found to have 11.4 times increased risk of ESRD, and 1.4 times increased risk of cardiovascular death compared to controls after adjusting for potential confounders. Another study by Muzaale et al.,[38] found that the estimated risk of ESRD at 15 years after donation was 30.8/10,000 in kidney donors and 3.9/10,000 in their matched healthy nondonor counterparts. In response to these alarming findings, Cozzi et al.,[39] explained that the adverse outcomes reported in the two studies could be due to the inability of some patients to compensate the reduction in renal function loss following 50% renal mass ablation due to a reduced nephron number endowment. They concluded that in vivo measurements of nephron number may aid selection of ideal living donor in the near future. This is important, as an improvement in the selection process would help re-assure prospective living kidney donors of their safety.

A cause for concern is the fact that emergence of additional reports of adverse health effects following kidney donations could compound the existing fears (such as body mutilation, and organ being removed before death) that have been identified as barriers to living kidney donation in previous studies,[1540] in addition to creating the misconception that it is safer to be a recipient of kidney transplant (more so when it becomes inevitable), than to be a donor. These findings bring to the fore the need for the management of the hospital to organize health education interventions for the hospital staff (so as to remove misconceptions and effect favorable attitudinal change to organ donation and transplantation) as a vital component of the preparations for the take-off of the kidney transplantation unit of the hospital.

CONCLUSION

This study showed high awareness but generally low willingness to accept deceased kidney donation, give consent to donate deceased relative's kidneys or carry a donor card as evidence of acceptance to donate one's own kidneys after death among the respondents. Periodic education of health-care workers on the effectiveness and safety of deceased kidney donation is crucial to promoting its acceptance among them.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.