Assessment of the Desire and Readiness of Taif Residents for Heart Donation After Death

Background/aim Heart transplantation is often the only preferable treatment for end-stage heart failure (HF); however, there are insufficient organ donors in Saudi Arabia. In this study, we aimed to understand the desire and readiness of Taif populations for heart donation after death. Methods We carried out a descriptive cross-sectional study among Taif residents in November 2022. A questionnaire designed from a previous survey was distributed among the participants. The questionnaire included sociodemographic data and questions assessing their desire for heart donation. Results The study included 405 subjects who have accepted to participate in the study. About half of the participants were aged 18 to 32 years (43.5%), most were females, were non-employed, and had a university degree. Of them, 86.2% accepted the concept of organ transplantation, 81% accepted the concept of heart transplantation, and one-third of the participants desired to donate their hearts. The participants with a university degree reported significantly less acceptance of the concept of heart transplantation (p-value=0.026), and those employed showed a significantly stronger desire for organ donation to a relative after death (p-value=0.049). In addition, younger participants showed a significantly higher willingness for organ donation to a relative or non-relative after death (p-value=0.017 and 0.009, respectively). Employed participants were significantly more willing to undergo heart transplantation surgery if needed (p-value=0.044). Conclusion Awareness campaigns could be established in the community and popularized during contact with the health system to build trust in the organ donation system, stress the importance of heart donation in saving the lives of more patients, and reduce the shortage of organ transplantation.


Introduction
The prevalence of heart failure (HF) highly increases worldwide, especially among the aging population. In addition, the high prevalence of risk factors, such as ischemic heart disorder, diabetes, and obesity, correlated with growing HF incidence [1]. It was estimated that HF had affected about 26 million individuals worldwide, about 5% of whom, at the end stage, reported an extremely poor quality of life (QOL) [2]. The prevalence of HF in developed countries ranges from 1% to 2% and rises to 10% or more among those over 70 years [3].
Advanced HF therapies, such as durable mechanical circulatory support (MCS) and heart transplantation, could provide hope for improved survival rates and QOL [4]. Heart transplantation is preferable, as it significantly increases survival, exercise capacity, and return to work compared with conventional treatment [5]. In the last century, an increase in median survival post-transplantation from 11-18 days to 11 years has been achieved with the enhancement of antibiotics and immunotherapy [6].
Despite medical and technological improvements and high awareness of organ donation and transplantation importance, the gap between supply and demand continues to broaden, and the lack of organ donation has become a significant public health problem [7,8].
Heart transplantation has been considered the final treatment choice for patients suffering from end-stage HF in the last decade; however, it has stagnated due to the high demand and lack of donors [3,9]. Therefore, the shortage of heart donors is a significant cause of extended waitlist times and mortality [9].
The annual number of cardiac transplants has reached 5000 worldwide. In Saudi Arabia, there are only two cardiac centers that conduct a total of approximately 30 heart transplantations per year [10,11].
Recently, multiple attempts have been made to counter organ transplantation shortages such as reducing demand by improving preventive measures and increasing supply by increasing organ donation. One of the attempts to increase organ donation had been achieved by controlled donation after circulatory death (DCD) and brain death (DBD) cardiac allografts obtained from DCD donors have been encouraging compared to those obtained from DBD donors [9].
In Saudi Arabia, large efforts are provided to increase the donation process by enhancing awareness among different population classes [12]. Hence, we aimed to discuss the desire and readiness of the Taif population for heart donation after death to identify gaps between the demand for and availability of heart donors.

Study design and setting
This cross-sectional study was conducted among the population residing in Taif city, Saudi Arabia, in November 2022.

Study population
The study included subjects who lived in Taif city, Saudi Arabia and were willing to participate in the study. People who were working in the medical field were excluded. Verbal consent was taken from the participants, and the study proposal was approved by the ethical committee of Taif University with No. HAO-02-T-105.

Sample size
The sample size was calculated with a Roasoft sample size calculator (Raosoft, Inc., Seattle, WA), considering a 50% population proportion, a 95% confidence interval, and a 5% margin of error, and the minimum representative sample was 385 participants.

Data collection tool
The data collection tool was a questionnaire from a previous study in Saudi Arabia [3]. It consisted of two sections; a demographic section and a section of questions that assessed the participants' desire and readiness toward heart donation after their death. The questionnaire was translated into Arabic to be easily understood by the participants.

Statistical analysis
After data extraction, they were revised and coded. The statistical calculations were done using the computer program IBM SPSS (version 26.0, Armonk, NY). Data were statistically described frequencies (number of cases), and valid percentages were used for categorical variables.
The chi-square test was used to determine the association between study questions and demographic variables. P-values less than 0.05 were considered statistically significant.

Results
The study included 405 subjects who have accepted to participate in the study. Most of the participants were with a university degree (75.1%), were females (60%), and were non-employed (64%). Approximately half of the participants were aged 18 to 32 years and married (43.5% and 54.8%, respectively). Details pertaining to the respondent demographics are summarized in Table 1.

TABLE 1: Demographic characteristics of participants
According to questions that assessed the participants' desire and readiness for organ and heart transplantations, 86.2% accepted the concept of organ transplantation and 13.8% of those refused it for religious reasons. In addition, most participants agreed with the humanity of organ transplantation and the concept of heart transplantation (95.3%, and 81%, respectively). Only one-third of the participants desired to donate their hearts, 67.9% agreed to donate their hearts to a relative after death, and 59.8% would donate their hearts to a non-relative after death.
Furthermore, when the respondents were asked if they prefer heart transplantation, 77.3% preferred heart transplantation for themselves. The details are described in Table 2  Unfortunately, 53.3% of the total participants who accepted the heart transplantation concept refused to donate a heart, whereas one-third (27.6%) of them accepted the heart concept and to donate a heart. In addition, 16.8% did not accept the concept of heart transplantation and donation.
It was found that more than half of the participants (54.5%) who did not accept the heart transplantation concept accepted to undergo heart transplantation surgery if needed, and 17.4% accepted the heart transplantation concept and refused to undergo the surgery.
The independent factors were compared with the participant's acceptance of the organ transplantation concept, and there was no significant impact of these factors on the acceptance of the organ transplantation concept (  Moreover, in comparing the demographic characteristics with the acceptance of the heart transplantation concept, the participants with a university degree reported significantly less acceptance of the concept of heart transplantation (78.8%, and 89.4%, respectively) (p-value=0.026). All details are illustrated in Table 4.

TABLE 5: Perspectives on organ donation among the different subgroups
The factors were also compared with the participants' desire for organ donation to a relative person after his/her death. The age and employment status significantly affected their willingness to organ donation to a relative after death. Employed participants had a significantly stronger desire for organ donation to a relative after death (74%) than unemployed participants (64.5%) (p-value= 0.049). In addition, those aged 33 years or less showed a significantly stronger desire toward organ donation to a relative after death (74%) than older participants (62.9%) (p-value=0.017). All information is described in Table 6  Regarding willingness to donate a heart to a non-relative person, individuals who are 33 years or older were less likely to donate their organs to a non-relative person after death (54%) than younger participants (66.9%) (p-value=0.009) ( Table 7).

Factors
Would you donate an organ to a non-relative whilst alive?

Discussion
Heart transplantation has been globally accepted as the best treatment option for patients suffering from end-stage HF [13]. On the other hand, there is an increase in wait lists at rates higher than transplant rates; thus, there is an urgent need to encourage organ transplantation to limit the organ supply shortage and save more patients' lives [9]. In this study, we aimed to assess the desire and readiness of Taif city, Saudi Arabia's population for heart donation after death.
Literature reviews reported that organ donation is not common in Saudi Arabia, and some studies have suggested that this is caused by social stigma and lack of information [14]. However, in the present study, a high number of the participants accepted organ and heart transplant concepts. According to a previous study in Saudi Arabia, results were consistent with ours in accepting the organ and heart transplant concept. [3]. Another study in Hong Kong reported that 85.2% of the respondents supported organ transplants [15]. Additionally, in an Indian study, the organ donation concept became familiar and acceptable among the general population [16].
There is variability in the impact of educational level on the acceptance of organ and heart donation concepts. In the present study, it was surprising that participants with lower education had significantly higher acceptance of the organ donation concept. The education level did not impact the acceptance of the heart donation concept. Our results were inconsistent with the fact that education could increase the public's awareness of the importance of organ donation [17]. In addition, previous studies in Saudi Arabia indicated that education level did not impact the acceptance of organ or heart transplantation concepts [3,12].
Several beliefs, including knowledge and religious beliefs, could play a role in determining a person's view of organ donation [18]. It was found that about half of the participants refused the heart and organ concepts due to religious barriers. These results are similar to a study conducted in Jazan, Saudi Arabia, which reported that 39% of participants considered religion a barrier to organ donation [12]. Another study in Saudi Arabia reported a close percentage of 42.4% of heart transplantation rejection for religious reasons [3].
Most participants thought organ donation saves lives; however, many were unwilling to donate a heart. Furthermore, it was found that a relatively high percentage (65.9%) of respondents who have accepted the heart transplantation concept refused to donate their hearts. Their refusal of heart donation might have resulted from the fact that approximately half of them did not trust that doctors would make an effort to save their life if they registered as organ donors. Additionally, the National Health Services Blood and Transplant reported that the most common issue regarding organ donation was a fear that medical staff may not do their best to save lives if the patient is a registered donor [19]. Therefore, it is possible that establishing regulations that guarantee the donors better medical care and easy access to health facilities would encourage people to donate organs during their lifetimes [17].
According to a study in Belgium, the acceptance of organ donation reduced with increasing age from 85.7% in young adults to 63.6% among grandparents [20]. In addition, a previous Saudi study reported that the younger generation was more accepting of the change and willing to donate an organ [3]. In the same concept, younger participants in our study showed a higher willingness to donate an organ to relatives and non-relative persons. These results may focus on younger generations being more open-minded about new concepts.
One-third of the participants in this study had not heard of artificial hearts; thus, when they were given a choice between heart transplantation and artificial hearts for themselves, they preferred heart transplantation. Hence, the role of physicians and healthcare providers is essential to provide more information about all treatment aspects of HF.
In this study, about half of the participants who refused the concept of heart transplantation would undergo heart transplantation surgery if needed. This conflict may arise from the lack of empathy toward others and could indicate that people may change their thoughts according to the disorder's severity and save their lives. It also may give a key to encouraging stakeholders to introduce sufficient information about the importance of heart transplantation for the survival of patients.

Limitations
This study assessed the participants' desire for heart and organ donation without identifying the gaps in their knowledge about the donation concepts. Further studies should determine the knowledge level of the participants and its reflection on their desires.