Awareness Level Regarding Brain Death and the Acceptance of Organ Donation in Eastern Province, Saudi Arabia

Background There is a worldwide shortage of organ donations. In the United States, 20% of people on transplant waiting lists pass away annually due to the lack of accessible organs. Patients with brain death can donate organs, which may save other patients’ lives. The Saudi Ministry of Health endorses brain death as equivocal to whole-body death. A study conducted in Saudi Arabia showed that there was a mild to moderate level of awareness regarding brain death. This study aimed to investigate the awareness and knowledge level regarding brain death and the acceptance of organ donation among the general population in Eastern Province, Saudi Arabia. Methodology An observational, cross-sectional study was conducted among 1,740 adults using an online questionnaire created and published in February 2023 to collect data from Saudi males and females aged 18 or older who were willing to participate in the study. The data were analyzed using SPSS version 23.0 (IBM Corp., Armonk, NY, USA) after collecting and entering them using the Windows version of Microsoft Office Excel 2016. Results Overall, 85.6% of the study participants had heard about organ donation. Of them, about 42.4% were aware of brain death. Further, 40% of participants were in agreement with organ donation. According to the findings, the majority of participants (60.9%) believed that a person could donate his or her organs during their life, while only 42.6% were unaware that they could donate their organs during death. Only 10.8% of participants knew that blood can be donated. There was no significant association between factors associated with organ donation and gender, education level, or monthly income. Conclusions This study concluded that study participants had a low level of awareness about brain death. Understanding brain death is essential for persuading people to donate their organs. Thus, more has to be done to inform and educate people about brain death and how it affects organ donation.


Introduction
According to the American Academy of Neurology (AAN) and the British National Health Service, any patient who has had an irreversible loss of all brain functions, including brainstem function loss, by showing loss of respiratory function (apnea), absence of brainstem reflexes, and total loss of consciousness (coma), is considered to have brain death [1,2]. The Saudi Ministry of Health has settled the issue of brain death and judged that it is equivocal to body death. This was done based on medical and religious Islamic backgrounds. Moreover, the components of brain death are the same as in the British and American definitions, except that the Islamic Sharia insists on treating reversible brain insults such as metabolic diseases or drug intoxication due to the significance of soul preservation. Furthermore, it is mandatory to have two consultant examiners to diagnose brain death [3]. There are a variety of causes leading to brain death that include stroke, subarachnoid hemorrhage, intracerebral hemorrhage, and cardiopulmonary arrest with adequate resuscitation [4]. In the United States, brain death accounts for 2% of all adults and 5% of all pediatric mortality in hospitals [5]. Unfortunately, brain death is an irreversible condition. However, patients with brain death can donate organs, which may save other patients' lives [6]. The main indication of organ transplantation is end-stage organ dysfunction [7]. There is a worldwide shortage of organ donations. 1 1 2 1 1 Annually, the paucity of available organs results in the death of about 20% of individuals on transplant waiting lists [8,9]. In 2021, patients who were on the nation's transplant waiting list accounted for 105,800. Moreover, 90% of adults in the United States support organ donation, and 169 million people have signed up to be donors [10]. According to data from the Saudi Center for Organ Transplantation, there have been 11,866 incidents of brain death since the inception of organ donation in 1986 until 2016 [11]. The main concern with organ donation is obtaining the patient's and family's consent before the transplant. A study conducted in India found that although people were generally unaware of the concept of brain death, they were aware of organ donation [12]. Another study conducted in Saudi Arabia showed that there was a mildto-moderate level of awareness regarding brain death [13]. This study aimed to investigate the awareness and knowledge level regarding brain death and the acceptance of organ donation among the general population in Eastern Province, Saudi Arabia.

Study design and selection criteria
This study was designed as a community-based, cross-sectional study to assess the general population's awareness and knowledge of brain death and acceptance of organ donation among Saudi citizens older than 18 years, willing to participate, and who completed the entire questionnaire by utilizing an online tool. On the other hand, participants who were non-Saudi citizens, those who declined to participate, and those who did not finish the entire questionnaire were excluded.

Study population and sample size
The population consisted of participants who fulfilled the inclusion and exclusion criteria and were involved in this study. A total of 1,701 respondents constituted the sample size, which was calculated using the Richard Geiger equation with a 95% confidence level and a 5% margin of error.

Questionnaire
A Google Forms questionnaire was translated into Arabic, which is the native language of Saudi Arabia, and distributed randomly on social media platforms such as WhatsApp, Telegram, Twitter, Facebook, and Instagram. The questionnaire consisted of three domains. The first domain was socioeconomic, which included four questions regarding gender, age, educational level, and monthly income. The second domain was a brain death knowledge assessment, which included 12 questions, of which eight questions assessed the knowledge level regarding the definition, causes, and prognosis of brain death, and four questions assessed the knowledge level regarding the source of information and the interest to learn more about brain death. The knowledge level was calculated by giving the correct answer a score of 1 and the wrong answer a score of 0. The mean for each question was then calculated, with scores ranging between 0 and 8. The third domain was about awareness and acceptance of organ donation and included nine questions.

Data management and statistical analysis
The data were analyzed using SPSS version 23.0 (IBM Corp., Armonk, NY, USA) after collecting and entering data using the Windows version of Microsoft Office Excel 2016. With a significance level of 0.05, the data from the questionnaire were analyzed using descriptive analysis and the chi-square test.

Ethical consideration
The approval was obtained from the Ethics Committee at King Faisal University of Medical Sciences. The purpose of the study was explained to all participants, and only those who provided informed consent were included in the study. All participants were guaranteed that their confidentiality would be maintained, and no personal information was requested on the questionnaire.

Results
The

SR: Saudi Riyal
The results showed that the knowledge level of participants was 42.4%, with a mean of 3.69. The percentage of correct answers for each question was as follows: "Are you familiar with the term brain death?" (85.6%); "Is brain death different from a coma?" (75.8%); "Brain death is..." (72.6%); "Can brain death be cured?" (54.6%), "Do you think brain death is real death?" (37.4%); "What are the signs of brain death?" (25%); "Can brain-dead patients donate all their organs?" (17.4%); and "What do you think causes brain death?" (0.4%) (see Table 2).

Questions Frequency (correct answer) %
Are you familiar with the term brain death?  The results showed that the most informative source on brain death for participants was friends and family (25.5%), followed, in descending order, by healthcare providers (23.6%), non-governmental web searches and other social media platforms (23%), publicly available educational programs (15.4%), official government platforms (7%), personal experience (3.2%), drama (1.5%), and, finally, universities (0.8%) (see Table 3).  The results showed that 67.7% of the participants thought that they did not have enough information to understand and know about brain death, while 32.3% did. A total of 76% of the participants wanted more information about brain death, while 24% did not (see Table 4).

Questions Yes No
Do you think you have enough information to understand and know about brain death?  The results showed that the information people wanted to learn about the most was how to prevent brain death (64.3%), followed by, in descending order, the fate of patients with brain death (62.1%), how to diagnose patients with brain death (58%), how brain death happens (53.9%), what is brain death (48.8%), causes of brain death (48.1%), treatment of brain death, all of the above (0.2%), whether it is permissible to donate organs, the difference between brain death and coma, and how to deal with a person with brain death (0.1%) (see Table 5).  The results showed that there was a significant difference between males and females (t = −2.208, p = 0.027), between different ages (F = 15.212, p < 0.001), between education levels (F = 11.342, p < 0.001), and between monthly income (F = 3.919, p = 0.008) in the knowledge level of brain death (see Table 6).  during their lifetime, 56.7% could donate after death, and 42.6% could donate after being announced brain dead (see Table 7).

Motives N %
Religious motives 1,014 66.7 The desire to help others 1,072 70.5 The health status of the recipient 621 40.9 Social motives 573 37.7 Financial motives 69 4.5 Age of the recipient 259 17 There was no significant association with other factors (see Table 11).

Discussion
This study was conducted to investigate the awareness and knowledge of brain death and the acceptance of organ donation among the general population in the Eastern Province of Saudi Arabia. We observed a moderate level of knowledge on brain death of almost 42%, which corresponds with the results of a previous study conducted in Saudi Arabia in which a moderate level of knowledge regarding brain death was found [13]. This could be explained by the limited background of health information, especially brain death-related information, among the Saudi population. In this study, the most common source of information (25%) on brain death was family and friends, followed by social media (23%). Another study conducted in Saudi Arabia reported that the main source of information regarding brain death was social media [14]. This finding partially agrees with ours because the general population usually depends on social media as the main source of information; however, due to our small sample size, this finding might be slightly underestimated.
The public in the Kingdom of Saudi Arabia lacks an understanding of brain death, which can negatively impact organ donation. This study aimed to evaluate the current level of knowledge regarding brain death among the population. Previous studies have not concentrated on awareness of brain death but have instead focused on knowledge, attitudes, and practices related to organ donation. In addition, no validated Arabic questionnaire on brain death was available for use in this study. Hence, we developed a questionnaire based on validated evaluations, which was later translated from English to Arabic.
Our findings suggest similar means of knowledge levels for both males and females (3.6 and 3.75, respectively). The results indicate that the general population in the Kingdom of Saudi Arabia possesses limited-to-moderate knowledge of brain death. This is consistent with previous findings, where less than half of the participants surveyed demonstrated an adequate understanding of brain death and organ donation [15]. However, this finding differs from the results of two studies conducted in Turkey and Iran that indicated inadequate awareness and a necessity to enhance the understanding of brain death and organ donation [16,17]. Furthermore, numerous studies have investigated the awareness of organ donation and brain death among various groups in the Kingdom of Saudi Arabia, including university and secondary school students in the southern and Al-Ahsa regions [18][19][20]. These studies have revealed an insufficient understanding of brain death and underscored the significance of raising awareness on the topic to enhance knowledge among the Saudi population.
Our findings revealed that 48.8% of participants were familiar with the notion of brain death, surpassing the results of Febrero et al., whose study indicated that only 38% comprehended the concept of brain death. However, this is lower than the values reported in the Al-Ahsa study at 84.6% [18], and in the study by Al-Qahtani et al. at 76.9% [13]. We observed that the mean knowledge score on brain death increased significantly with the level of education, where those with a postgraduate degree had a score of 3.79 compared with those with primary education at just 2.53. Individuals with a higher level of education are more likely to have encountered or studied the concept of brain death and thus may not require additional information on the subject. No significant correlations were found between knowledge scores and other sociodemographic factors, such as gender. The limitations of this study are its small sample size and its single geographic location.

Recommendation
Future studies should aim to enroll participants from various regions of the country in equal numbers to obtain more precise results that can be generalized across the entire population. In summary, our findings indicate that the general population of the Kingdom of Saudi Arabia possesses limited-to-moderate knowledge about brain death. To enhance awareness of this topic, we recommend using various mass media platforms. Additionally, education and awareness programs on brain death are necessary, especially concerning prevention and causes, in both schools and workplaces.

Conclusions
This study showed that the overall awareness level regarding brain death was suboptimal. There was a significant association between age and organ donation, but there was no such association with gender, education level, or monthly income. Most participants wanted more information on brain death, and most participants agreed with organ donation; however, the majority were unaware that they can donate an organ while they are brain dead. Few participants were aware that hearts can be transplanted. The authors suggest launching additional awareness campaigns about brain death and organ donation. More studies are needed to determine the causes of people's reluctance to donate their organs.

Additional Information Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. King Faisal University issued approval KFU-REC-2022-SEP-ETHICS660. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.