|Year : 2020 | Volume
| Issue : 1 | Page : 30-37
Current knowledge status and attitude on heart transplantation among undergraduate medical students of a tertiary care medical institute in India
Anshuman Darbari1, Manisha Naithani2, Suresh Kumar Sharma3, Anish Gupta1, Ajay Kumar4, Deepak Kumar Satsangi1
1 Department of CTVS, AIIMS, Rishikesh, Uttarakhand, India
2 Department of Biochemistry, AIIMS, Rishikesh, Uttarakhand, India
3 Nursing College, AIIMS, Rishikesh, Uttarakhand, India
4 Department of Anaesthesia, AIIMS, Rishikesh, Uttarakhand, India
|Date of Submission||10-Sep-2019|
|Date of Acceptance||06-Jan-2020|
|Date of Web Publication||31-Mar-2020|
Dr. Anshuman Darbari
Department of CTVS, AIIMS, Rishikesh - 249 203, Uttarakhand
Source of Support: None, Conflict of Interest: None
Context: Organ transplantation can save thousands of lives as it is one of the greatest advancements of modern medical science but the process of organ donation and transplantation is very complex and multi-factorial, interplaying with- medical, legal, ethical, organizational and above all social factors. The future doctors can take up the role of promoting organ donation activity, especially the heart. Settings and Design: This cross-sectional questionnaire based survey study was conducted amongst the undergraduate medical students of our Institute, to ascertain their knowledge and ethical perception regarding orthotropic heart transplantation. Methods and Material: Students were approached in lecture halls and were asked to fill the questionnaire after explaining them the importance of this study in brief. Written consent for participation was taken from all of them. A total of 197 undergraduate students gave consent and filled the questionnaire. Statistical Analysis Used: All the quantitative variables were analyzed using mean and standard deviation and all the qualitative variables were described as numbers and percentages. Results: Nearly all the students knew the term organ donation and heart transplantation but in-depth knowledge of medical students on this topic was not good enough. Most participants (75%) considered “Internet“ as their major source of information, while only 01% regarded academic books as their source of information. This strongly highlights the point that the undergraduate medical books with curriculum is largely lacking in basic aspects of organ donation and heart transplantation. Very few medical students (4.5%) knew about the Non-Governmental Organization (NGOs) working for transplant activity and also majority (82.2%) are unaware of legal aspects related to organ donation. Conclusions: Currently heart transplantation is a totally neglected topic in undergraduate medical curriculum. Inclusion of this complex but interesting topic by a short lecture or interactive seminar for undergraduate medical students may be the most cost-effective and durable innovation for the future.
Keywords: Heart transplant, medical education, medical students, organ donation
|How to cite this article:|
Darbari A, Naithani M, Sharma SK, Gupta A, Kumar A, Satsangi DK. Current knowledge status and attitude on heart transplantation among undergraduate medical students of a tertiary care medical institute in India. Indian J Transplant 2020;14:30-7
|How to cite this URL:|
Darbari A, Naithani M, Sharma SK, Gupta A, Kumar A, Satsangi DK. Current knowledge status and attitude on heart transplantation among undergraduate medical students of a tertiary care medical institute in India. Indian J Transplant [serial online] 2020 [cited 2021 May 16];14:30-7. Available from: https://www.ijtonline.in/text.asp?2020/14/1/30/281767
| Introduction|| |
Organ transplantation can save thousands of lives as it is one of the greatest advancements of modern medical science, but the process of organ donation and transplantation is very complex and multifactorial, interplaying with medical, legal, ethical, organizational, and above all social factors. The organ donation rate and transplantation in India is far behind that in the other countries. Currently, in solid-organ transplant category, heart and lung transplant are the least common organs transplanted. Although heart transplantation is the gold standard treatment for the end-stage heart failure, available information on official website of National Organ and Tissue Transplant Organization (NOTTO) showed that only 51 heart transplants were done all over India, and out of these, 41 were done in Tamil Nadu state alone in 2018.
The “future doctors“ mean the current undergraduate medical students and they can take up the role of promoting organ donation activity, especially the heart. They can be the torchbearers and the most critical link who can create a positive thinking among the public by educating and motivating them to pledge their organs for donation. We did not find any study among the undergraduate medical students on heart transplant awareness in India. With this background, we planned and designed this study to assess the present knowledge about heart transplantation among the undergraduate medical students of our institute.
| Materials and Methods|| |
- Structured questionnaire
- Search and evaluation of previous similar studies and literature available on this subject.
This cross-sectional questionnaire-based survey study was conducted among the undergraduate medical students of All India Institute of Medical Sciences (AIIMS), Rishikesh, Uttarakhand, India, to ascertain their knowledge and ethical perception regarding heart transplantation. Prior approval was taken from the Institutional Ethical Review Committee (No.-ECR/736/Ins/UK/2015), and a questionnaire-based survey was conducted at AIIMS, Rishikesh, during 2017–2018. The total number of medical undergraduate students at AIIMS, Rishikesh, was around 450 at that time. Students were approached in lecture halls after the scheduled lectures and were asked to fill the questionnaire after explaining the importance of this study in brief. Written consent for participation was taken from all of them. Out of 450, a total of 197 undergraduate students gave the proper consent and filled the questionnaire. The students participated voluntarily in the study. Inclusion criteria were students enrolled in the 2nd, 3rd, and 4th year of undergraduate medical studies, whereas the exclusion criteria were those who were absent on that day and those who did not give the consent for participation.
A prevalidated questionnaire was used to collect the data. This survey questionnaire adapted to the study requirements was designed to capture the knowledge status toward organ donation and specifically the heart transplantation. The questionnaires were pretested on a sample of five postgraduates and ten undergraduate students and were finalized. The questionnaire included two main categories to ascertain the knowledge of students. A short introductory lecture was scheduled after which the questionnaires were distributed among these students. There were a total of 34 survey questions with options, including yes, no, and don't know. There were some multiple response questions, such as medium of awareness about organ donation, which organs can be donated, inclination, donor card, and family discussions. In the second category, 26 questions were exclusively on the topic related to heart transplantation history, indications, contraindications, basics of surgical technique, and laws. No prior information about this lecture or announcements was done, before distributing the questionnaires to the students, to minimize response bias, and the answers were collected back immediately after anonymous completion. General remarks and suggestions on the study and survey were also asked and collected.
All quantitative variables were analyzed using mean and standard deviation and all qualitative variables were described as numbers and percentages. Some of the questions were not answered by participants; hence, for data analysis purposes, those unreplied questions were not taken into account during percentage derivation. Chi-square test was applied, and P < 0.05 was considered statistically significant.
The participants consent has been taken for participation in the study and for publication of clinical details and images, if any. Participants understand that the names, initials would not be published, and all standard protocols will be followed to conceal their identity. The study has been approved by Institutional ethics committee of AIIMS, Rishikesh with IRB no.-AIIMS/IEC/16/18, Date-01.02.2016.
| Results|| |
A total of 197 participants, undergraduate medical students, filled the complete questionnaire after consent. Out of the 197 completely filled valid questionnaires, 61 were filled by the 2nd year medical students, 62 by 3rd year, and 74 by 4th year. 81 (41.1%) were female respondents and 116 (58.9%) were male respondents.
All participants (100%) were aware and had heard about the term organ donation and transplantation, but only 183 (92.9%) participants strongly approved ethically and found it morally correct to donate an organ and 12 (6.1%) participants were somewhat approving this. Two (1%) participants disapproved the concept of organ transplantation without any specific reasons.
On further exploration, 196 (99.5%), 195 (98.9%), and 194 (98.4%) participants stated that eye, heart, and kidney can be donated, respectively. 122 (61.9%) and 66 (33.6%) students answered that liver and lung can be donated, respectively, whereas 21 (10.7%) participants considered that all organs can be donated.
On the assessment of the responses to question about information source for organ donation and transplantation, we found that 138 (70.2%) participants mentioned internet/e-media as their source of information, whereas 40 (20.3%) participants considered newspaper/publication as their source of information, 6 (3%) answered movies, but only 3 (1.5%) answered academic books as their source of information.
Regarding the transplant or organ donation history in family or close relatives, only 1 (0.5%) participant's family member or closely known had undergone a transplant procedure. 73 (38.6%) participants had discussed the topic of organ donation procedure with close family members. Only 27 (13.8%) participants have signed or pledged for organ donation and all of them did this for the cornea/eye only. Although 124 (62.9%) participants responded positively to pledge their heart and other organs for donation after death, still 71 (37.1%) were not sure about their stand [Table 1].
|Table 1: Answers given by various participants for general set of questions|
Click here to view
Regarding the assessment of knowledge on heart transplant, majority of participants, 195 (99.5%), were aware and had heard about the heart transplantation. From the further assessment of the responses to this question, 144 (73%) participants mentioned internet/e-media as their source of information, whereas 31 (15.7%) participants regarded publication/newspaper as their source of information, but only 1 (0.5%) answered academic books as their source of information. Eight (4%) participants answered movies and 11 (5.6%) answered general information from colleagues as their source of information on this topic. On questioning about the source for gaining further information on this topic, 147 (76.3%) participants answered internet as the method of choice, 37 (19.1%) by general books, 7 (3.6%) by health-care colleagues/doctors, and only 2 (1%) by academic books or teachers.
On exploring the knowledge about history of heart transplantation, only 5 (2.5%) participants have the correct information about the first heart transplant surgeon's name, but only 1 (0.5%) answered correctly about operative place/country. No participant has correct information about the exact date, year, and recipient's name.
Regarding the transplant facility in Indian medical institutes, 136 (69%) participants answered AIIMS, Delhi, followed by PGIMER, Chandigarh; 75 (38.1%) and few other hospitals in lower proportions were mentioned. Information sought about heart transplant facility in the state of Uttarakhand was wrongly answered “Yes“ by 118 (67.4%) and significant participants (22/197) were unaware.
About the heart donor status, 180 (91.3%) participants rightly answered that donor can be human only and 17 (8.7%) answered that other animals can also be the donors. 158 (82.3%) respondents mentioned that there should be the same age group for donating heart, but for recipient's age, 145 (80.1%) mentioned that it should be of the same age as of donor. 143 (74.5%) participants mentioned male sex predilection for donors, but for recipient's sex predilection, 148 (76.7%) mentioned about no preference.
The correct knowledge about various indications of heart transplant (at least one correct indications) was mentioned by 105 (57.1%) and 40 (23.8%) participants in adult and pediatric recipients, respectively. The correct knowledge about various contraindications of heart transplant for recipients and donors was found in 29 (16.7%) and 36 (21.3%) only, respectively. Regarding whether only brain-dead patients can be considered as potential donors for heart donation, 150 (89.3%) stated it as true statement.
For gross surgical technical details, i.e., number of surgical teams, duration of heart preservation, hospital site, and transportation, knowledge level was very poor and only 3 (1.5%) participants were able to give all right answers of theses 7 questions. Regarding follow-up of transplanted patients, 45 (28%) participants mentioned lifelong surveillance. Majority (170; 91.9%) of the participants were aware of infectious disease as a major cause of failure and threat for transplant and contraindication for organ donation.
One hundred and sixty-seven (86.9%) participants were unaware of national law or legal formalities regarding the process of heart and other organ donation/transplantation, and only 9 (6.5%) participants mentioned about the nongovernmental organizations (NGOs) working for heart donation/transplantation at national or international level, but no participant was able to yield any name [Table 2].
|Table 2: Answers given by various participants for specific set of questions|
Click here to view
On questioning about the further willingness to know the details of this procedure, 183 (94.8%) give affirmation but for source of gaining further information on this topic, 147 (76.3%) answered internet as the method of choice, 37 (19.1%) by general books, 7 (3.6%) by health-care colleagues/doctors, and only 2 (1%) by academic books or teachers.
Limitations of the study
There were limitations regarding our questionnaire. Of the 34 questions, 26 questions were totally focused on heart transplantation history, indications, contraindications, basics of technique, and laws. For these 26 questions, highly variable, inconsistent knowledge and vague guesswork was shown by the participants. The questionnaire could have been improved by performing a pilot study before validation. As the questionnaires were distributed in the lecture theater, it is also possible that some answers were copied or collectively decided after discussion. As the study purpose and topic were mentioned just before questionnaire distribution, there could be a social bias, inducing students to give “pro-transplantation“ answers; thus, our study may have overestimated the number of participants with positive attitudes toward heart transplantation or organ donation.
| Discussion|| |
During the last few decades, organ transplant has emerged as the main modality of treatment for many end-stage organ diseases. The demand for transplantation of organs has increased many folds than their supply, which is very limited especially in a conservative country like India, causing a major hindrance to this most noble sacrifice. India is the second most populous country in the world. India has a total population of 1,210,193,422, but very limited donor and transplant activity.
The main solid-organ transplant carried out in India is kidney transplant with their numbers gradually rising each year. India's first organ transplant was conducted in the 1970s, which was a kidney transplant. Currently, around 5000 kidneys, 1000 livers, and around 40 hearts are transplanted annually. India shows a poor organ donation rate of 0.26 per million, compared to the other countries such as America, Spain, and Croatia having organ donation rate of 26, 35.5, and 36.5 per million, respectively. With a 1/million donation rate, India would have 1100 organ donors or 2200 kidneys, 1000 hearts, 1100 livers, 1100 pancreas, and 2200 eyes. There is a need of roughly 200,000 kidneys, 50,000 hearts, 100,000 corneas, and 50,000 livers for transplantation each year.,
“The Transplantation of Human Organs Act, 1994“ (THOA) was passed in 1994 in India. This act was a histrionic event, which accepted brain death as a form of death and transplantation of other solid organs such as liver, heart, and lung transplants became possible. The THOA curtailed illegal organ trade and the exploitation of impoverished and vulnerable. There was an increase of about 1200 additional organs transplanted in the last 10 years – around 1050 kidneys and over 150 livers, hearts, lungs, and pancreas after this deceased donor program.
The Indian Society of Organ Transplantation has established an “Indian Transplant Registry“ over the past 3 years. The Indian solid-organ transplant program was started in the early 1970s and is at present practiced in over 100 hospitals in all the major cities of the country. Some of the transplant registries, for example, on pancreas and bone marrow, have established successful international registries.,
The demand for human organs for transplantation is far more than the availability of organs. The factors which contribute to bringing down the number of actual organ retrieval from potential cadaver donors are public unawareness, inability to convince the near relatives to donate organs, religious sentiments, superstitious beliefs, and family pressures. During surveys done among general public, it was also found that there are multiple factors such as poor infrastructure for quick and safe transportation of accident victims, lack of ventilator facilities, and limited medical resources. There is also a big challenge for the organ procurement agencies and health professionals to motivate and make as many people aware about the patients needing organ transplants.
Similar types of studies on medical students but on the topic of organ donation have been done in Hong Kong, Pakistan, Turkey, and South India. These types of studies on health-care personnel and college students have already established the fact that myths and misconceptions are commonly prevailing for organ donation and transplantation.
Worldwide, cardiac transplant has developed from a highly experimental technique to now a recognized mode of treatment of many end-stage cardiac diseases. The advances in various areas such as surgical techniques, donor management, organ preservation, prevention and treatment of rejection, and complication management after transplantation has improved overall survival of cardiac transplantation cases.
Heart transplantation is generally reserved for patients with end-stage congestive heart failure who are estimated to have <1 year to live without transplantation and who have not been helped by conventional medical therapy because of the poor condition of the heart. In India, the first heart transplant was done by Dr. Profulla Kumar Sen at KEM Hospital in Mumbai. This was the world's 6th heart transplant, but his work was hampered due to absence of a law on brain death during those days. August 3, 1994, emerged as the next era of the heart transplant in India with the enactment of laws for brain-dead donors, which followed the first official and legally successful heart transplant in India done at AIIMS, Delhi, by Venugopal.
There are about 50,000 patients dying of heart ailments every year because of organ shortage. Heart transplant can only be done after brain death. As per available information, in AIIMS, New Delhi, at any point of time, there are 30–40 patients waiting for heart transplant. Even in the USA, there are 20,000 potential donors, 40,000 people die of heart failure every year, and only 2100 heart transplants are carried every year. As per available information by NOTTO from 1994 till date, India has done only 145 heart transplants. The numbers are very less due to the costs involved as well as the lack of awareness among donors. Of late, there had been an increase in both the number of centers and the number of donors involved in heart transplant programs following an active interest by various NGOs (MOHAN foundation) also.
A government organization by the name of NOTTO has come into existence, which not only records, regulates, and facilitates organ transplantation but also creates awareness by its various outreach programs and activities. For organ and tissue donation purposes, NOTTO is publishing informative leaflets in Hindi and English for common people to encourage and clear doubts about this. For heart transplant information, the British Heart Foundation has also published informative booklets for common people, recipient family friends, and also story booklet to encourage and clear doubts about this.
As of now, India has a 4½-year medical undergraduate medical program of allopathic system consisting of first two preclinical years and subsequent three clinical years. In India, currently, there is no formal undergraduate or postgraduate degree or diploma course related to the teaching of organ transplantation. In undergraduate medical curriculum, very little information is provided about organ donation, transplantation techniques, and indications. Furthermore, as of now, cardiothoracic surgery is subspecialty section under general surgery curriculum for undergraduate teaching, so no formal information is provided on heart transplantation.
Overall, medical students do know about the term “organ donation,“ but there is substantial lack of adequate or informative knowledge on this topic. The obvious reasons for this are that there is no formal education or curriculum component with very lower rate of heart transplantations done in India compared to the other developed countries. Introducing this topic as a part of the medical curriculum may have a significant impact on the improvement of medical students' knowledge. There is overall a positive attitude of medical students toward heart transplantation. Furthermore, there is a high level of motivation and desire among the students to learn more on this fascinating topic.
Radunz et al. in a study in Germany 2012 concluded that well-directed interventions are needed to sensitize young adults on the topic of organ donation. Better understanding of medical students and future physicians in the field of organ donation will help them to become disseminators for this important topic in society.
Further, a study by Radunz et al. in 2015 in Germany found that only one brief intervention can significantly increase perceived knowledge of organ donation and positively influence attitude to organ donation among 4th year medical students. Intensive international effort in structured education on organ donation and further evaluation of the effectiveness of content delivery is imperative. This effort could increase the rate of organ donation and transplantation if measures are implemented in every medical school accessible for all medical students.
Overall, to conclude, it can be said that medical students are quite keen on learning about organ donation and heart transplantation, but there is a lack of sufficient knowledge on the topic. In general, there is a positive attitude of medical students toward organ donation. Creating a sufficient knowledge base by promoting organ donation and transplantation, through inclusion in medical curriculum toward this noble task, can increase the rate of heart transplant procedure.
It was inspiring that nearly all the students knew the term organ donation and heart transplantation. This can be due to keenness of medical students toward new medical conditions and innovations. However, apart from knowing the term, in-depth knowledge of medical students on this topic was not good enough. This can be attributed to many factors. Obviously one of them is the lack of inclusion of organ donation and transplantation as a part of the medical curriculum and perception of this topic as very complicated and highly specialized subject.
Very few medical students (4.5%) knew about the NGOs working for this task of organ donation and transplant activity and majority (82.2%) are unaware of legal aspects and current laws related to organ donation.
It is very disappointing to note that despite being medical students and in constant interaction with the medical literature and health professionals, mostly (75%) answered internet as their major source of information regarding this topic, whereas only 1% regarded academic books as their source of information. This strongly highlights the point that undergraduate medical books with curriculum is totally lacking on basic aspects related to organ donation and heart transplantation.
| Conclusion|| |
Currently, heart transplantation is a totally neglected topic in the undergraduate medical curriculum and source of knowledge is only from the internet or e-media literature. Our future doctors, in any capacity or at any work place, should be well equipped with basic knowledge and concepts of heart transplantation to promote and enhance transplant activity and to clear all doubts and myths of donor relatives and public. Early and clear information to our medical students will help in positive concept building of heart transplantation in them and ultimately promote this activity in future. Inclusion of this complex but interesting topic whether by a short lecture or interactive seminar of undergraduate medical students may be the most cost-effective and durable innovation for future.
Financial support and sponsorship
This study is approved as an intramural project and cleared from the Institutional Ethical Committee without any financial support from AIIMS, Rishikesh.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]