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Table of Contents
Year : 2022  |  Volume : 16  |  Issue : 3  |  Page : 274-281

The empathy factor: The role of empathy in knowledge, attitude, and practice of organ donation in India - A crossectional, observational study

1 Department of Liberal Arts, Indian Institute of Technology, Hyderabad, Telangana, India
2 Department of Science and Humanities, Indian Institute of Information Technology, Tiruchirappalli, Tamil Nadu, India
3 Department of Biomedical Engineering, Indian Institute of Technology, Hyderabad, Telangana, India
4 Indian Council of Medical Research, Regional Medical Research Centre, Bhubaneshwar, Odisha, India
5 Department of Nephrology, Star Hospitals, Hyderabad, Telangana, India

Date of Submission21-Jun-2021
Date of Acceptance17-Oct-2021
Date of Web Publication30-Sep-2022

Correspondence Address:
Dr. Mahati Chittem
Department of Liberal Arts, Indian Institute of Technology, Hyderabad, Telangana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijot.ijot_64_21

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Background: Due to the scarcity of organs available for transplantation, several patients lose their lives each year. Increased awareness and positive attitudes alone may be insufficient to increase an individual's willingness to donate (i.e., the basic tenets of the knowledge-attitude-practice/KAP model). Therefore, it is pertinent to examine other psychological determinants that are associated with engaging in the altruistic/prosocial act of organ donation. Objective: To understand the association between empathy and KAP of organ donation in an Indian population. This pilot is the precursor to a larger project which aims to develop and test an empathy intervention to promote organ donation. Methods: Using a cross-sectional design, Indians (N = 419; female = 261; mean age = 28.48 years) aged 18 years and above were recruited using convenience sampling through an online survey. Questionnaires included the Awareness, Attitudes, and Practice of Organ Donation (Chakradhar et al., 2016) and Empathy Quotient-8 (Loewen et al., 2010). Multiple regression analyses were carried out to analyze the data. Results: Results showed that empathy was related to: (i) Total KAP (β = 0.123, P = 0.014), and (ii) attitudes (β = 0.195, P < 0.001) towards organ donation. Conclusion: These pilot study findings indicate that public health messages focused on evoking empathy can use the technique of patient/donor narratives, and training clinicians on empathic communication skills can help increase individuals' KAP of organ donation. Further, this pilot elucidated the need to conduct mixed-method studies with a donor and nondonor population and clinicians prior to developing and testing a larger empathy-centered intervention aimed at promoting the KAP of organ donation.

Keywords: Empathy, India, knowledge-attitude-practice, organ donation, pilot, transplantation

How to cite this article:
George P, Chittem M, Dwivedi R, Pal C, Guntupalli Y, Pati S, Chakravarthi R. The empathy factor: The role of empathy in knowledge, attitude, and practice of organ donation in India - A crossectional, observational study. Indian J Transplant 2022;16:274-81

How to cite this URL:
George P, Chittem M, Dwivedi R, Pal C, Guntupalli Y, Pati S, Chakravarthi R. The empathy factor: The role of empathy in knowledge, attitude, and practice of organ donation in India - A crossectional, observational study. Indian J Transplant [serial online] 2022 [cited 2023 Feb 8];16:274-81. Available from: https://www.ijtonline.in/text.asp?2022/16/3/274/357611

  Introduction Top

Worldwide, and Indian, research predominantly uses the knowledge (refers to an assessment of factual information that individuals have about organs that can be donated and about concepts such as brain death, legislations facilitating donation and information on attaining donor cards), attitude (refers to perceptions and misconceptions pertaining to organ donation such as religious beliefs hindering or favoring donation, notions of possible disfigurement and fear surrounding organ donation), and practice (refers to concrete actions taken towards the decision to donate one's organs such as whether an individual has already donated their organs or made their decision known by registering or obtaining a donor card) (KAP) model of organ donation to understand the predictors of organ donation.[1],[2] For example, Edmund et al. found that religion, birth order, and personality were predictors of organ donation among Malaysian medical students.[3] Given the predominance of the KAP approach to organ donation research, it is not surprising that the KAP-model continues to inform public policy and interventions as well.[4] Yet, research consistently shows that the KAP-model by itself may not be able to predict organ donation behavior. For instance, Sachdeva (2017) reported that although 53.1% of Indians were aware of and 58% had a positive attitude toward organ donation, 26.4% were willing to sign a pledge card to donate their organs.[5] Similarly, Annadurai et al. found that despite a favorable attitude towards organ donation, only few Indian college students were registered organ donors.[1] Indeed, recent research argues that organ donation decisions may not always be rational and cognitive factors, such as knowledge, are less influential in organ donation decisions compared to affective factors such as altruism/empathy.[6]

Empathy denotes the ability to relate to another individual's emotional state and take the individual's perspectives in a given situation.[7],[8] More recently, empathy was expanded to include cognitive (e.g., perspective-taking) and affective (e.g., empathic concern) components and is considered a multidimensional construct.[7] In organ donation research, Cohen and Hoffner argue that the willingness to become an organ donor relies more on empathy and the altruistic intention to help another than on increased knowledge regarding organ donation.[9] Since the individual does not gain anything by donating their organs, organ donation is considered a selfless and altruistic act based on empathic concern for an individual in need.[9]

Despite several studies demonstrating a link between empathy and prosocial behaviors,[9],[10] and the need to take into account psychological factors within the oft-utilized KAP-model of organ donation, research on empathy and the KAP-model is sparse and sporadic.[9] One of the earliest empathy interventions was carried out by Skumanich and Kintsfather (1996), who found that undergraduate students in the USA exposed to empathy arousing, persuasive organ donation messages had a higher behavioral intention to sign a donor card.[11] More recently, Milaniak et al. (2018) found that nursing and paramedical students in Poland who scored higher on dispositional empathy (empathic tendencies such as perspective-taking and empathic concern) had more favorable attitudes towards organ donation.[10] Similarly, individuals high in dispositional empathy were also more likely to agree to donate the organs of their deceased family members.[10] These studies suggest that individuals who are disposed to act empathetically tend to have more positive attitudes and behavioral intentions towards organ donation. However, no research has examined the link between empathy and knowledge of organ donation, a critical construct within the KAP-model of organ donation. In order to improve the relevance and utilization of the KAP-model for promoting organ donation, it is important to understand the role of empathy in relation to the total and individual constructs of the KAP.

To the best of our knowledge, no study in India examined the relationship between empathy and KAP regarding organ donation. The current study is a part of a larger project which aims to: (i) Develop an empathy intervention specifically for organ donation using the KAP framework, and (ii) test the effectiveness of this empathy intervention in the overall and individual KAP aspects of organ donation. The objectives of the present pilot study are to (i) examine the association between empathy and KAP of organ donation among the general public of India, and (ii) assess the relevance of the empathy approach to the KAP model.

  Methods Top

Participants and procedure

The study design was cross-sectional, with participants recruited using convenience sampling via social networking sites and messaging apps (e.g., Facebook, Instagram). A total of 419 participants who met the inclusion criteria (i.e., 18 years and above, currently residing in India, with the ability to read and comprehend English) were recruited. Participants' sociodemographic details are provided in [Table 1].
Table 1: Sociodemographic profile of the participants

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Awareness, attitudes, and practice of organ donation (knowledge-attitude-practice)

This 14-item scale was adapted from the awareness, attitudes, and practice of organ donation questionnaire by Chakradhar et al. (2016).[12] [Supplementary Table 1] provides the list of questions adapted from this scale. Responses were binary (i.e., yes/no). Cronbach's alpha for the scale was found to be 0.47 in this study.

Empathy Quotient-8

This 8-item scale[13] was used to assess empathy with items scored 2, 1 or 0, indicating high, medium, and low empathy levels. Cronbach's alpha was found to be 0.60 in this study.

Statistical analysis

The statistical analysis for this pilot was carried out in four stages. First, descriptive statistics was used to present the socio-economic and demographic characteristics of the sampled population. Second, to understand the relationship between KAP and demographic variables and empathy, student t and analysis of variance with post hoc analysis was used for multiple comparisons. Third, a histogram comparing age to KAP was also depicted. Finally, multiple logistic regression (MLR) analysis was employed to identify the major determinants of KAP and empathy.

The MLR can be used to predict a categorical dependent variable on the basis of independents, and to determine the percent of the variance in the dependent variable explained by the independents; to rank the relative importance of independents, and to understand the impact of covariates. Maximum likelihood estimation after transforming the dependent into a logit variable (the natural log of the odds of the dependent occurring or not). Hence, MLR estimates the probability of certain events, whether occurring or not. The MLR can be noted as:

Where P is the probability of possibility of high empathy p(y=1); b1b2,b3.......bi refer to the beta coefficients; x1x2x3.......xi refer to the independent variables and e is the error term. Weighting has been applied to the current survey data for adjusting variations in the composition of population, to make the estimates nationally more representative. Data underwent consistency, logical, and range checks prior to analysis in STATA/SE version 14.0 STATACorp., College Station, Texas, USA.

Participant consent

The participant consent has been taken for participation in the study and for publication of clinical details and images. Participants understand that the names and initials would not be published, and all standard protocols will be followed to conceal their identity.

Ethics statement

Institutional Ethics Committee (IEC) of the Indian Institute of Technology Hyderabad (IITH) IEC Protocol No. IITH/IEC/2018/03/18. The study was performed according to the guidelines in Declaration of Helsinki. All protocols of Declaration of Helsinki were followed.

  Results Top

The sociodemographic profile of the participants (mean age = 28.48 years, standard deviation = 10.53) and the associations with KAP and empathy are depicted in [Table 1] and [Table 2], respectively. The descriptive statistics for the KAP and empathy items is provided in [Supplementary Table 2]. A histogram depicting the relationship between age and KAP is provided in [Supplementary Figure 1]. Four hundred and nineteen respondents were included for the present study, out of which, 261 (67.3%) were female and 158 (37.7%) were male. Majority of the participants were female (2/3rd) and about 94% respondents reported their education status to be up to graduation or postgraduation and above. Majority of the participants composed of students (66%), with the relationship status as single (63%), having religious affiliation with Hinduism (64%), and belonged to the Southern zone (77%).
Table 2: Comparisons of sociodemographic characteristics between knowledge, attitude, and practice and empathy

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[Table 2] indicates that there was no significant difference (P = 0.31 and P = 0.11) as per the gender of respondents with KAP (male = 9.29 ± 1.89 and female = 9.45 ± 1.44) and empathy (male = 10.01 ± 2.66 and female = 10.36 ± 2.63). Similar results were observed for participants' occupation with KAP and empathy (P = 0.73 and P = 0.12). The relationship status and educational attainment have no association with KAP (P = 0.37 and P = 0.35). However, it was observed that the relationship status and educational attainment has a significant association with the level of empathy (P = 0.00). In addition, [Supplementary Figure 1] shows the age distribution and correlation with KAP scores. Age was classified into three groups, i.e., 18–24 years (49%), 25–39 years (36%), and 40 and above (15%). The Pearson correlation coefficient value indicates a significant association between KAP score and age distribution (R = 0.139; P < 0.01).

An MLR was employed to examine the relationship between KAP and demographic variables and empathy [Table 3],[Table 4],[Table 5],[Table 6]. Age was significantly related to KAP (β = 0.261, P = 0.003), with older individuals scoring significantly higher on KAP. Occupation was associated with KAP, with students scoring significantly higher than employed (β = −0.178, P = 0.005) and retired individuals (β = −0.143, P = 0.026). Empathy was also found to be associated with KAP (β = 0.123, P = 0.014), with individuals with higher empathy scoring higher on KAP.
Table 3: Multiple logistic regression analyses for variables predicting combined knowledge, attitude, and practice score

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Table 4: Multiple logistic regression analyses for variables predicting knowledge of organ donation

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Table 5: Multiple logistic regression analyses for variables predicting attitudes towards organ donation

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Table 6: Multiple logistic regression analyses for variables predicting practice of organ donation

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Students had more positive attitudes towards organ donation compared to employed individuals (β = −0.218, P = 0.001). Empathy was also found to be linked to attitudes (β = 0.195, P < 0.001). Age was significantly associated with organ donation practice (β = 0.322, P < 0.001), with older adults scoring higher on practice behaviors. Males scored significantly higher on practice than females (β = −0.095, P = 0.049). The occupation was associated with practice, with students scoring higher than retired individuals (β = −0.145, P = 0.020).

  Discussion Top

The present pilot study examined the relationship between empathy and KAP of organ donation in an Indian population. It was found that: (i) Age, occupation, and empathy were related to KAP, (ii) occupation and empathy predicted attitudes, and (iii) age, gender, and occupation were related to practice. For the purposes of this article, the link between empathy and KAP will only be discussed.

In the current pilot study, increased empathy was associated with increased levels of total KAP. This finding is in line with previous studies, which suggested that empathic concern predicted positive attitudes and a willingness to donate.[9],[10],[11] Particularly with living donation, the motivation to donate must override the immediate discomforts that individuals may undergo,[14] and this may be due to the empathic concern that the donor feels for the patient awaiting a transplantation. However, these results must be interpreted with caution, as KAP in the present study is an aggregate measure of the individual components of knowledge, attitude, and practice.

The association of empathy with positive attitudes towards organ donation is consistent with previous research suggesting that individuals higher in dispositional empathy were more likely to perceive organ donation positively.[10] In addition, research showed that empathic individuals held a more positive attitude towards organ donation due to their lack of perceived risk.[9] Since the present study consisted of primarily a student sample who were younger and less prone to health risks, they may have held more positive attitudes due to their lack of perceived risks associated with donation. Although empathy was shown to be linked to attitudes in this study, it is uncertain whether this relationship was mediated or moderated by other closely related psychological constructs such as personality, anticipated guilt, or personal values.

Despite evidence suggesting that empathy predicted organ donation intentions and willingness,[9],[10],[11] the present study could not find any association between empathy and practice. This may be because of the nature of the items used to measure practice in the current study. The items pertaining to practice assessed whether individuals had already donated an organ or signed a donor card and not whether they would be willing to do so in the future. Hence, the measure of practice used in this study (i.e., actual practice behaviors) may not be an accurate comparison to existing worldwide research (i.e., behavioral intentions and willingness) on donation. As positive attitudes are a precursor to behavioral intentions and actual behavior,[9] it is possible that practice behaviors of the current sample may change over time, especially since the current study's sample was mainly students.

Empathy was not related to knowledge in the present study. Studies examining the relationship between empathy and organ donation have only explored its influence on attitudes and behavioral intentions[9],[10],[11] and have not investigated its relationship with knowledge. One possible reason may be because KAP surveys which assess awareness (i.e., the knowledge component) require individuals to recall previously learned information on a health-related behavior such as organ donation. Retrieving previously encoded information in KAP surveys may activate a different cognitive pathway as opposed to the retention of new information. As patient perspectives have been successful in enhancing empathy and retention of new information among medical students,[15],[16] organ donation campaigns can apply the same techniques to improve donation rates (i.e., empathy evoking personal narratives).


Since higher levels of empathy were observed to be linked to increased overall KAP and positive attitudes in the current pilot study, public health efforts which speak to the empathic aspects of human life may be more effective in increasing the number of living and deceased organ donations. For example, empathy interventions including videos or pamphlets containing patient and donor narratives can help induce compassion which can, in turn, increase knowledge retention, improve attitudes, and facilitate better practice outcomes such as increased behavioral intentions to donate and the actual signing of donor cards. Similarly, clinicians can be introduced to communication skills which focus on: (i) Identifying and harnessing an individual's empathic concern to strengthen their attitudes and overall KAP regarding organ donation, and (ii) displaying/expressing compassion which might help individuals/eligible donors to model similar behaviors, thus offering more opportunities for them to consider organ donation favorably.

Insights obtained from the pilot will facilitate the researchers in structuring a larger study aimed at (i) developing an empathy intervention specifically for organ donation using the KAP model and (ii) testing the impact of this empathy intervention in overall and individual KAP aspects of organ donation. Based on the findings of this pilot, it is proposed to first develop an empathy-centered intervention focused on personal accounts of patients in need of organs and benefitted from organ donation, individuals who donated organs, clinicians who facilitated transplantation, and policymakers or non-governmental organizations who share factual knowledge regarding organ donation. The content of these accounts will target the overall KAP, with special emphasis on promoting and strengthening positive attitudes towards organ donation. In parallel, KAP and empathy questionnaires targeting a general population in India will be developed and tested for validity and reliability. Following this, it is proposed to use a longitudinal, mixed-method study (as opposed to a randomized control trial) so as to examine the impact of the empathy intervention on the overall and individual aspects of KAP of organ donation overtime.

Strengths and limitations

The study has several strengths. To the best of our knowledge, this is the first pan-India study to examine the association between empathy and KAP of organ donation. As the study was carried out via an online survey, it was possible to recruit participants from geographically diverse parts of the country. Second, the large sample size obtained for this pilot warrants that the insights and conclusions drawn can meaningfully aid in the development of the upcoming intervention study. Third, as most research on organ donation is limited to particular samples (e.g., students, patients, health professionals), the inclusion of the wider general public who are potential organ donors is seen as an advantage of this research. Finally, and most importantly, this is the first study in India which examined the role of empathy in the KAP-model of organ donation, thus offering critical insights into developing a unique empathy-focused intervention to promote organ donation in India.

These strengths notwithstanding, there are some limitations of this pilot study. First, owing to the cross-sectional nature of the study design, it is difficult to assess the impact of empathy on KAP or if this relationship is likely to change over time. Future research should adopt a randomized control trial, vignette, or longitudinal design to ascertain this impact or any subsequent changes. Second, the study sample has a large student cohort which may have influenced the reliability estimates of the KAP measure, thus making interpretations of some of the findings difficult. Third, the study examined donation in relation to any organ, i.e., it did not focus on a specific organ. Fourth, the study did not make any distinction between deceased and living donation. Fifth, the quantitative nature of the study makes it challenging to unpack the lived experiences, personal narratives and cultural underpinnings linked to organ donation. Sixth, this pilot study included only a general population which had not engaged in the practice of organ donation, thus not providing insight into the empathy-KAP relationship among those who either donated or possessed an organ donor card. Similarly, this pilot did not take into account the perspectives of clinicians who may have to engage in medical discussions on organ donation (e.g., nephrologists). Finally, the reliability scores for the KAP questionnaire is poor, suggesting that this scale is a poor discriminant and the findings of this pilot study need to be interpreted with care. Importantly, this brings to light the need to develop reliable scales to measure KAP for a range of Indian populations as well as for the larger intervention study for which the current study was a pilot. Taking into consideration these limitations, and before engaging in the larger intervention study, the authors will conduct mixed-methods studies using a vignette and qualitative design to better understand the role of empathy in relation to KAP among a representative sample Indian donors, nondonors, and clinicians.

  Conclusion Top

The present pilot study was the first to examine the association between empathy and KAP of organ donation among the general public of India. Results revealed that empathy was associated with total KAP and attitudes toward organ donation. In order to promote overall and individual KAP of organ donation, clinicians need to be trained in empathic communication skills, and public health messages aimed to persuade individuals to donate should focus on using patient narratives as a technique to evoke empathy. Finally, this pilot study sheds light on the next steps of the larger study, including conducting a mixed-method study to examine the role of empathy in the KAP-framework, which will, in turn, aid in designing and testing an empathy intervention to promote organ donation.


We thank Ms. Shweta Chawak for the initial support with the study development and data analysis.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest

  References Top

Annadurai K, Mani K, Ramasamy J. A study on knowledge, attitude and practices about organ donation among college students in Chennai, Tamil Nadu-2012. Prog Health Sci 2013;3:59-65.  Back to cited text no. 1
Balwani MR, Gumber MR, Shah PR, Kute VB, Patel HV, Engineer DP, et al. Attitude and awareness towards organ donation in western India. Ren Fail 2015;37:582-8.  Back to cited text no. 2
Edmund LW, Shazlyiana HN, Nursyahirah NF, Fam JC, Chua J. Factors affecting attitude and behaviour towards organ donation among medical students in Malaysia: A cross-sectional study. J Adv Med Med Res 2018;10:1-3.  Back to cited text no. 3
Jain M, Yadav NR, Sharma A, Singh S, Jain V, Khanna B, et al. Fostering cognizance of organ donation: An education-based approach. J Family Med Prim Care 2019;8:4021-6.  Back to cited text no. 4
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Loewen PJ, Lyle G, Nachshen JS. An Eight-Item Form of the Empathy Quotient (EQ) and an Application to Charitable Giving; 2010. Available from: http://individual.utoronto.ca/loewen/Research_files/Eight%20Question%20ES_final.pdf. [Last accessed on 2020 Feb 12].  Back to cited text no. 13
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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