Attitudes toward organ donation and donor

behavior: a review of the international literature

Objective—To conduct a systematic review of published research that assessed Claire E. Wakefield, PhD,
the predictors of attitudes toward deceased organ donation, willingness to donate, Kaaren J. Watts, PhD,
and donor behavior.
Judi Homewood, PhD,
Data Sources—MEDLINE, PreMEDLINE, PsycInfo, and the Cumulative Index
to Nursing and Allied Health Literature were searched for the period from 1988 to Bettina Meiser, PhD,
2009. Laura A. Siminoff, PhD
Study Selection—Eligible studies included members of the general public (ie, not University of New South Wales, Sydney,
transplant recipients, donor families, or health professionals) and used multivariate and Prince of Wales Hospital, Randwick,
analyses for quantitative assessment of predictors.
Australia (CEW, KJW, BM), Macquarie
University, North Ryde, Australia (JH),
Data Extraction—The search identified 33 relevant studies. Owing to heterogeneity Virginia Commonwealth University,
in populations and measures, results were summarized rather than subjected to Richmond (LAS)
meta-analysis.
Data Synthesis—Research suggests that individuals who are younger, female, have Corresponding author: Dr Claire
higher education levels and socioeconomic status, hold fewer religious beliefs, have Wakefield, Psychosocial Research
high knowledge levels, know others with positive attitudes, are more altruistic, and Group, Dickinson 3, Department of
have fewer concerns about manipulation of the body of the deceased donor are more Medical Oncology, Prince of Wales
likely to have positive attitudes toward donation and are more willing to donate Hospital, Randwick, NSW 2031,
their organs. Sydney, Australia (e-mail:
Conclusions—The review revealed the complexity of individuals’ attitudes toward
c.wakefield@unsw.edu.au)
donation and the need for more sophisticated future studies of the interactions between To purchase electronic or print reprints,
the broader factors influencing donation (such as social norms and existing legislation contact:
in each country) and individual factors, such as attitudes and beliefs. (Progress in The InnoVision Group
Transplantation. 2010;20:380-391) 101 Columbia, Aliso Viejo, CA 92656
Phone (800) 809-2273 (ext 532) or
(949) 448-7370 (ext 532)
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O ne deceased organ and tissue donor can save, or

dramatically improve the quality of, up to 10 peo-
ple’s lives.1,2 Organ transplantation can treat a wide
range of end-stage, life-threatening illnesses, including
diseases of the heart, kidney, liver, lung, and pancreas.2
If enough organs were available, many thousands of
patients worldwide could benefit from transplantation
medicine. Unfortunately, even in countries with high
transplantation success rates, many patients in need
will not receive a transplant because of the low rates of
donation around the globe.2 Moreover, thousands more
could benefit from a transplant should enough organs
become available and the numerous restrictions
applied to current waiting lists be relaxed.2
Public campaigns to promote organ donation gen-
erally either encourage individuals to declare their
intention to donate organs or attempt to address
deficits in public knowledge about organ donation.
Under the opt-in model of organ donation operating
within the United States, the United Kingdom, and
Australia, where the intention to donate one’s organs
must be voluntarily registered, attitudes toward and
beliefs about organ donation are likely to be an impor-
tant component of an individual’s decision to register
or not. Previous research suggests that people’s atti-
tudes and beliefs toward organ donation contribute sig-
nificantly to willingness to donate. For example, Parisi
and Katz3 found that individuals who held strong pos-
itive attitudes and weak negative attitudes toward
organ donation were the most committed to signing a
donor card. In order to develop more effective public
health campaigns, it is critical to understand more

380 Progress in Transplantation, Vol 20, No. 4, December 2010


about the attitudes and beliefs that either increase or
decrease people’s willingness to donate and their com-
mitment to register their intentions.
Objective
This review aimed to identify any study published
in a peer-reviewed journal that assessed predictors of
attitudes toward deceased organ donation and donor
behaviors.
Methods
The inclusion criteria for studies were as follows:
(1) Quantitative research methods were used and pre-
dictors were assessed by using multivariate statistical
analyses and (2) Study participants were members of
the general public (ie, not transplant recipients, donor
families, or health professionals).
Core Variables
Studies measuring any of the following core vari-
ables were included in the review: respondent’s attitude
toward deceased organ donation (assessed by using a
validated or purposely designed quantitative attitudes
survey), self-reported willingness to donate (assessed by
using a validated or purposely designed survey), and
donor behavior (defined as having joined an organ
donor registry, having signed and/or carrying an organ
donor card, or having indicated their willingness to
become an organ donor on their driver’s license).
Data Sources
The databases MEDLINE, PreMEDLINE, PsycInfo,
and the Cumulative Index to Nursing and Allied
Health Literature were searched from 1988 to 2009,
limited to studies published in English and involving
human subjects.
Study Selection
The free-text search term “organ don$” was entered
individually. Next, the terms “psych$,” “attitude,” and
“belief” were entered individually and grouped to form
a stem group. This stem was combined with the initial
search and deduplicated. The remaining abstracts were
screened, and studies not fitting the inclusion criteria
were discarded. Table 1 provides a summary of the
excluded studies. The included articles were checked
by a second reviewer to determine whether they met
inclusion criteria. We used the techniques described by
Oxman4 to guide analysis of the findings.
Each included study was assessed for quality by
2 authors (C.W., K.W.) who used the criteria outlined
in Table 2 (based on the validated GRADE system37).
The 4 key elements that were considered when judging
the quality of evidence were: study design, study qual-
ity, consistency of estimates of effect across studies,
and directness (ie, the extent to which the people and
Progress in Transplantation, Vol 20, No. 4, December 2010
Attitudes toward organ donation and donor behavior
outcome measures were similar to those of interest).37
In the current context, observational studies that use
sound methods provide the best available evidence.
Randomized controlled trials are not relevant here
because this article is not intended to review interven-
tions designed to influence donor attitudes or behav-
iors. Observational studies that used sound methods,
including random sampling, were classified as “high”
quality. A study’s grade was decreased to “moderate”
if it used a convenience sample or if it provided insuf-
ficient information about the study measures or the
data analyses. Note, however, that the “convenience
sample” criterion is strict and that potential confound-
ing variables were usually controlled for in the multi-
variate analyses. The assessing authors completed the
assessment separately and the interrater agreement was
95.2%, with only 11 discrepancies across 231 assess-
ment criteria. Discrepancies were discussed with the
larger team before a consensus was reached for each
criterion. Studies were not excluded from the review
on the basis of quality; however, methodological qual-
ity of the studies is discussed later.
Results
In total, 788 articles were initially identified, with
33 meeting all inclusion criteria (Table 3). Nineteen
articles originated from the United States, 4 from
Spain, 3 from The Netherlands, and the remainder from
Hong Kong (n = 2), China (n = 2), Pakistan (n = 1), and
Switzerland (n=1). One article described a collaborative
study involving the United States, Japan, and Korea.
Quality Assessment
The GRADE approach37 was used to guide assess-
ment of the quality of the evidence presented in the
included studies. The quality of the observational
studies was generally high (Table 4). More than 50%
(17/33 = 52%) of the studies were classified as provid-
ing direct evidence because of their use of random
population samples rather than convenience samples.
Most studies used at least 1 valid and reliable assess-
ment tool, although many also used purposely created
unvalidated tools as well. However, only 30% explic-
itly reported using a theoretical framework to guide
their research.37
Predictors of Attitudes Toward Deceased
Organ Donation
Sociodemographic Predictors. Younger per-
sons11,16,18 and those with higher levels of education and
socioeconomic status11,13,26 are more likely to have pos-
itive attitudes toward organ donation. In one study,10
researchers reported a significant influence of sex on
attitudes, with female students in a Chinese university
being more likely to hold positive attitudes toward
donation than their male counterparts. In only 2
381
Wakefield et al

Table 1 Exclusion criteriaa

No. of studies
Exclusion criterion rejected
Live donation 79
Xenotransplantation 6
Qualitative study 40
Correlates of knowledge and attitudes about organ donation and donor behaviors 61
Attitudes and beliefs of health professionals and medical or allied health students 156
Studies of transplant recipients or organ donors 14
Process of practice of organ donation, or organ donation law (including financial incentives) 48
Bereaved families and predictors of their decision to donate (or not to donate) a loved one’s organs; 49
personality correlates of willingness to donate; family discussion about organ donation
Attitudes toward brain death, or the concept of death, and attitudes toward non-heart-beating donors 26
Care of bereaved families and the grieving process 24
Organ donation for research purposes 5
Other medical conditions 11
Review 33
Editorial comment, letter, or opinion piece 73
Public education about organ donation, or interventions designed to change attitudes toward organ donation 45
Donation of specific organs including kidneys, bone marrow, tissue, blood, and face transplantation 19
Case study 12
Unpublished dissertation 16
Pediatric donation 8
Abstract unavailable 5
Other, including duplication of previous data or a topic unrelated to organ donation 20
No. of studies 788
No. of studies excluded 755
No. of studies included 33

a When a study met 2 or more exclusion criteria, each excluded study was coded by its first, or main, exclusion reason so that each study was only included in the

table once.

studies8,26 did researchers report a significant influence
of ethnicity or religious beliefs in attitudes toward
organ donation. The larger of these studies8 (involving
426 students from 3 countries) reported that stronger
religious beliefs or spiritual concerns were predictive
of less favorable attitudes toward donation. Interest-
ingly, researchers in that study also reported that the
perception that a spiritual connection exists between
the donor and the recipient was predictive of more
positive attitudes.8
Knowledge. In 8 studies,11-13,16,19,26,31 researchers
assessed knowledge about organ donation, and all
reported that increased knowledge about organ dona-
tion was predictive of more positive attitudes. Not sur-
prisingly, having a previous personal experience with
organ donation, or knowing a donor or recipient, also
is predictive of more favorable attitudes.26
Familial Influences. Two studies11,23 showed a sig-
nificant influence of family and significant others on
individuals’ attitudes about donation. For example,
Rios et al23 recently surveyed 3155 adults in Spain and
reported that having a partner who is in favor of organ
donation is predictive of more positive attitudes. These
authors also found that those who had discussed dona-
tion with their family had more positive attitudes.23
Other Predictors. In 2 studies, researchers reported
that individuals with altruistic tendencies19 and those
who trusted the attending physician had more positive
attitudes toward donation.5 Also, 3 studies11-13 showed
that individuals who have previously undertaken other
prosocial activities, such as blood donation, are more
likely to have a favorable attitude toward donation.
Finally, 4 studies investigated the influence of atti-
tudes toward the human body on attitudes toward

382 Progress in Transplantation, Vol 20, No. 4, December 2010

 Attitudes toward organ donation and donor behavior

Table 2 Quality assessment of studies included in review (N = 33)

Reference Other modifying Overall

and year Study design Study quality Consistency Directness factors quality
Alden and Observational SSQ plus 1 No important Direct High
Cheung,5 (survey, cross-sectional) validated measure inconsistencies
2000 No theoretical frame-
work specified
Alvaro et al,6 Observational SSTS No important Direct High
2005 (survey, cross-sectional) No theoretical frame- inconsistencies
work specified
Boulware et Observational SSTS No important Direct High
al,7 (survey, cross-sectional) No theoretical frame- inconsistencies
2002 work specified
Bresnahan et Observational SSQ plus 2 No important Indirect (CS) Mod
al,8 (survey, cross-sectional) validated inconsistencies
2007 measures
Theoretical frame-
work specified
Brug et al,9 Observational SSQ Negative expec- Indirect (CS) Mod
2000 (survey, cross-sectional) Theoretical frame- tations stronger
work specified predictor of
willingness to
donate than
positive
Chen et al,10 Observational No theoretical frame- No important Indirect (CS) Limited information Mod
2006 (survey, cross-sectional) work specified inconsistencies on study measures
Conesa et al,11 Observational SSQ No important Direct Limited detail Mod
2003 (survey, cross-sectional) No theoretical frame- inconsistencies on multivariate
work specified analyses variables
Conesa et al,12 Observational SSQ No important Direct Limited detail on Mod
2004 (survey, cross-sectional) No theoretical frame- inconsistencies multivariate analy-
work specified ses variables
Conesa et al,13 Observational SSQ No important Direct Limited detail Mod
2006 (survey, cross-sectional) No theoretical frame- inconsistencies on multivariate
work specified analyses variables
Feeley and Observational SSQ plus 2 No important Indirect (CS) Multicollinearity was Mod
Servoss,14 (survey, cross-sectional) validated measures inconsistencies controlled for
2005 No theoretical frame-
work specified
Horton and Observational SSQ plus 1 validated No important Direct High
Horton,15 (survey, cross-sectional) measure inconsistencies (community)
1990 Theoretical frame- Indirect
work specified (CS, students)

Horton and Observational SSQ plus 3 validated No important Indirect (CS) Mod
Horton,16 (survey, cross-sectional) measures inconsistencies
1991 Theoretical frame-
work specified
Li et al,17 Observational SSTS No important Direct High
2001 (survey, cross-sectional) No theoretical frame- inconsistencies
work specified
Miles and Observational SSTS No important Direct Limited measure of Mod
Frauman,18 (survey, cross-sectional) No theoretical frame- inconsistencies attitudes
1988 work specified

Continued

Progress in Transplantation, Vol 20, No. 4, December 2010 383

Wakefield et al

Table 2 Continued

Reference Other modifying Overall

and year Study design Study quality Consistency Directness factors quality
Morgan et al,19 Observational SSQ plus 1 validated No important Indirect (CS) Mod
2003 (survey, cross-sectional) measure inconsistencies
Theoretical frame-
work specified
Morgan,20 Observational SSQ plus 1 validated No important Indirect (CS) Mod
2006 (survey, cross-sectional) measure inconsistencies
Theoretical frame-
work specified
Park and Observational SSQ No important Indirect (CS) Mod
Smith,21 (survey, cross-sectional) Theoretical frame- inconsistencies
2006 work specified
Reubsaet et Observational SSQ Negative out- Direct High
al,22 (survey, cross-sectional) Theoretical frame- come beliefs
2001 work specified were strongest
predictors of
willingness
to donate
Rios et al,23 Observational SSQ, validated in No important Direct Limited detail on Mod
2007 (survey, cross-sectional) previous studies in inconsistencies actual data col-
same geographical lection process
area
No theoretical frame-
work specified
Romero et al,24 Observational SSQ plus 1 validated No important Direct (Hispanic Limited measure Mod
2001 (survey, cross-sectional) measure inconsistencies and non-Hispanic of willingness
No theoretical frame- elderly) to donate
work specified
Rubens et al,25 Observational SSQ (some items No important Indirect (CS) Mod
1998 (survey, cross-sectional) adapted from inconsistencies
Gallup poll, and pilot
tested before use)
No theoretical frame-
work specified
Rumsey et al,26 Observational ODAS validated as No important Indirect (CS) Mod
2003 (survey, cross-sectional) part of this study inconsistencies
No theoretical frame-
work specified
Saleem et al,27 Observational SSQ No important Indirect (CS) Mod
2009 (survey, cross-sectional) No theoretical frame- inconsistencies
work specified
Saub et al, 28 Observational SSQ No important Direct Limited informa- Mod
1998 (survey, cross-sectional) No theoretical frame- inconsistencies tion about
work specified measures
Schulz et al,29 Observational SSTS No important Direct Good level of High
2006 (survey, cross-sectional) No theoretical frame- inconsistencies detail on scale
work specified attributes
provided
Siminoff et al,30 Observational SSQ, items based on No important Direct High
2006 (survey, cross-sectional) focus group results inconsistencies
No theoretical frame-
work specified
Sirois et al,31 Observational SSQ plus 2 validated No important Indirect (CS) Mod
2005 (survey, cross-sectional) measures inconsistencies
No theoretical frame-
work specified
Continued
 Attitudes toward organ donation and donor behavior

Table 2 Continued

Reference Other modifying Overall

and year Study design Study quality Consistency Directness factors quality
Skowronski,32 Observational SSQ plus 2 validated Negative beliefs Indirect (CS) Mod
1997 (survey, cross-sectional) measures discriminated
No theoretical frame- more clearly
work specified between
donors than
positive beliefs
Van den Berg Observational SSQ No important Indirect (CS) Mod
et al,33 2005 (survey, prospective, No theoretical frame- inconsistencies
6 month follow-up) work specified
Weber et al,34 Observational SSQ plus 1 validated No important Indirect (CS) Included meas- Mod
2007 (survey, cross-sectional) measure inconsistencies ure of actual
Theoretical frame- organ donor
work card signing
behavior
Yeung et al,35 Observational SSTS. No theoretical No important Direct High
2000 (survey, cross-sectional) framework specified inconsistencies
Wu and Tang,36 Observational SSQ, 1 validated No important Indirect (CS) Mod
2009 (survey, cross-sectional) measure, and inconsistencies
adaptations of
existing measures
Theoretical frame-
work
a Study design refers to the basic study design (observational studies or randomized trials); Study quality refers to the detailed study methods and execution;

Consistency refers to the similarity of estimates of outcomes across studies; Directness refers to the sample and outcome measures are similar to those of interest;
Other modifying factors include additional factors that may lower (or enhance) the quality of evidence, including imprecise or sparse data and a very strong effect or
association, respectively; and Overall quality ranks the quality of the evidence. The grades range from “very low” (any estimate of effect is very uncertain) to “high”
(further research is unlikely to change confidence in the estimate of the effect or outcome). These definitions are sourced from the GRADE system.4

Abbreviations: CS, convenience sample; Mod, moderate; ODAS, organ donation attitude scale; SSQ, study-specific questionnaire; SSTS, study-specific telephone survey.

organ donation. Two studies12,23 showed that individu-
als who were less concerned about the manipulation
of the body of the deceased donor (eg, autopsy) were
more likely to have a favorable attitude toward dona-
tion. Conversely, believing that the integrity of the body
should be maintained after death appears to be predic-
tive of negative attitudes toward organ donation.5,11,13
Predictors of Willingness to Donate and/or
Donor Behaviors
Sociodemographic Predictors. Six studies7,13,16,29,30,35
showed that younger persons are more willing to
donate their organs, and 3 of those studies16,29,30 were
assessments of actual donor behavior (ie, having
signed or carrying a donor card) (Table 5). Six stud-
ies7,13,24,27,30,35 showed that persons with higher socioeco-
nomic status and education are more willing to donate,
and 4 studies6,10,22,42 showed that women may be more
willing to donate than are men. In 3 studies,
researchers reported that African American7,18 and His-
panic American ethnicity24 were predictive of lower
willingness to donate. Strong religious beliefs also
appear to be predictive of lower willingness to donate,7,32
particularly among African Americans. 2 0 In one
study27 conducted in Pakistan, consisting of predomi-
nantly Muslim participants, the perception that reli-
gion allowed organ donation was a positive predictor
of motivation to donate (Table 5).
Knowledge. Twelve studies14-16,19,20,25,27-31,43 involved
assessment of knowledge about, or awareness of,
organ donation, and all reported that individuals with
greater knowledge were more willing to donate. Six
studies6,13,14,25,28,29 showed that knowing an organ donor,
transplant recipient, someone waiting for an organ, or
someone willing to donate was predictive of willing-
ness to donate and donor behaviors (Table 5).
Familial Influences. Perceived favorable atti-
tudes of a significant other toward organ donation, or
believing that a significant other would advocate or
influence one’s decision about becoming an organ
donor, was predictive of willingness or intention to
donate,19,21,22,28 willingness to communicate about
organ donation with others,19,21,42 and donor behavior
(Table 5).19,20,31

Progress in Transplantation, Vol 20, No. 4, December 2010 385

Wakefield et al

Table 3 List of studies included in review (N = 33)

Reference,
date, origin Outcome measures Sample characteristics Measures Findings
Alden and Possession of donor 425 adults, aged 16-60 (mean, SSQ Positive predictor: trust in doctors;
Cheung,5 card 41.0) y; random sampling negative predictor: belief in main-
2000, USA taining integrity of body after death
Alvaro et al,6 Family discussion 1203 Hispanic Americans, SSTS Positive predictors: female sex, fam-
2005, USA and donor status aged 18-90 (mean, 41.0) y; ily discussion, knowing an organ
random sampling donor, positive beliefs about
organ donation
Boulware et al,7 Willingness to 385 adults, aged 18-75 (mean, SSTS Negative predictors: older age,
2002, USA donate, donor card NR); random sampling African American ethnicity, being
unemployed, religion, mistrust in
hospitals
Bresnahan et al,8 Intention to register Convenience sample of students; SSQ plus Positive predictors: family commu-
2007, US, as a donor mean age NR knowledge nication, positive attitude; negative
Japan, Korea and attitudes3,15 predictor: spiritual concerns
Brug et al,9 Willingness to 145 high school students, SSQ Positive predictors: past donor
2000, The register as a donor aged 15-21 (mean, 16.2) y; behavior, perceiving that significant
Netherlandsa convenience sample others would want the respondent
to donate; negative predictor: neg-
ative beliefs about organ donation
Chen et al,10 Willingness to donate 922 Chinese undergraduates, SSQ Positive predictors: female sex,
2006, China aged 16-37 (mean, 20.8) y being a blood donor; reasons for
organ donation: altruism; reasons
against: concerns about integrity
of body and organ misuse
Conesa et al,11 Attitudes toward 2000 adults, >15 years (mean, 30-item PADQ3,15 Positive predictors: Younger age,
2003, Spain organ donation 41.2 y); random sampling higher education, previous experi-
and transplantation ence with organ donation, knowl-
edge, partner attitude; reasons for
donation: solidarity, reciprocity;
reasons against: fear of apparent
death, against corpse manipulation
Conesa et al,12 Attitudes toward 210 adolescents, aged 15-19 SSQ Positive predictors: being a student,
2004, Spaina organ donation (mean NR); random stratified positive attitude toward blood
and transplantation sample donation or body manipulation,
knowledge; reasons for donation:
solidarity, reciprocity; reasons
against donation: fear of apparent
death
Conesa et al,13 Attitudes toward 181 adults, mean age 41.1 y; SSQ Positive predictors: higher education,
2006, Spain organ donation random sampling previous experience with organ
donation, blood donation, agreeing
with corpse manipulation; reasons
for donation: solidarity, reciprocity;
reasons against: against manipu-
lation of the deceased’s body, fear
of apparent death
Feeley and Donor status 502 university students; Mean SSQ, plus Positive predictors: knowing a
Servoss,14 age, NR; convenience sample knowledge,38 donor, recipient, or someone on a
2005, USA attitudes16 waiting list
Horton and Donor behaviorb 481 students, aged 17 to 43 SSQ plus atti- Positive predictor: Knowledge.
Horton,15 (mean, 20) y; 465 members tudes scale39 Potential barriers: misconceptions
1990, USA of public, aged 15 to 85 y about Western religious support
for organ donation, death criteria,
process of signing up as a donor.
Horton and Donor behavior 295 students, mean age SSQ plus values, Positive predictors: Helpful values,
Horton,16 19.9 y; convenience sample knowledge, knowledge. Favourable attitudes
1991, USA attitudes15,39 predicted willingness to donate,
which predicted carrying of donor
card.
Continued
 Attitudes toward organ donation and donor behavior

Table 3 Continued

Reference,
date, origin Outcome measures Sample characteristics Measures Findings
17
Li et al, 2001, Willingness to donate 1018 public (mean age, 32.6 y), SSTS Positive predictor: being a blood
Hong Kong and donor status 1227 blood donors (mean age, donor; for blood donors and
28.9 y); random sampling members of the public, main con-
cern about organ donation was
mutilation of the body after death
Miles and Attitudes toward 585 adults, aged 19-91 (mean, SSTS Positive predictors: younger age,
Frauman,18 organ donation 45) y; random sample. being white, rather than African
1988, USA American
Morgan,19 Donor status 310 African Americans, mean SSQ Positive predictors: knowledge,
2006, USA age 45 y favorable attitudes, and lower lev-
els of religiosity
Morgan et al,20 Donor behaviors 798 adults; mean age, NR; SSQ plus Positive predictors: knowledge,
2003, USA convenience sample attitudes16 altruism, perceived positive atti-
tudes of significant others
Park and Intention to register 261 university students, mean SSQ Positive predictors: positive atti-
Smith,21 and to talk with age, 20.5 y tudes toward organ donation and
2006, USA family perceived positive opinion of sig-
nificant others
Reubsaet et al,22 Intention to register 1836 adolescents, aged 16 to SSQ Positive predictors: positive beliefs,
2001, The 18 y (mean, NR) female sex, knowledge, having
Netherlandsa previously thought about or dis-
cussed organ donation, positive
opinions of significant others
Rios et al,23 Attitudes toward 1155 British and Irish adults SSQ Positive predictors: having discussed
2007, Spain organ donation living in Spain; 2000 native the issue with family, being uncon-
Spaniards (mean age, 45 y) cerned about corpse mutilation,
positive attitude of partner, belief
that respondent might need a
transplant in the future
Romero et al,24 Willingness to donate 883 adults (mean age, 74 y) SSQ, Iowa Self- Positive predictors: higher education
2001, USA organs Assessment and interpersonal trust; negative
Inventory predictors: Hispanic background,
poorer English skills
Rubens et al,25 Donor status 742 students; mean age, NR; SSQ Positive predictors: having knowl-
1998, USA convenience sample edge about organ donation system,
knowing someone with organ
donor card
Rumsey et al,26 Attitudes toward 197 students, aged 17-48 y Organ Donation Positive predictors: better education
2003, USA organ donation (male mean, 20.5 y; female Attitude Scale about organ donation, knowing an
mean, 20 y) organ donor or recipient; negative
predictor: strong religious beliefs
Saleem et al,27 Attitudes toward organ 408 adults, aged 18-60 y SSQ adminis- Positive predictors: higher socioe-
2009, Pakistan donation (motiva- (mean age, male: 32 y, female: tered conomic status, knowledge, and
tion to donate) 33.5 y); convenience sample in a face-to- perceived allowance of organ dona-
face interview tion in religion; reasons for organ
donation: to save life, compassion
/sympathy, monetary benefits,
responsibility; reasons against
organ donation: religious beliefs,
fear that organs will be wasted/
mistreated
Saub et al,28 Willingness to donate 378 adults; mean age, 44 y; Positive predictors: knowing how to
1998, USA convenience sample SSQ arrange organ donation, being
willing to accept an organ, belief
body appears normal after organ
removal, knowing an organ donor;
reasons against: wants body to
remain intact, not wanting body
used for science, fears life may
not be saved
Continued
Wakefield et al

Table 3 Continued

Reference,
date, origin Outcome measures Sample characteristics Measures Findings
29
Schulz et al, Willingness to donate, 1509 adults; mean age, NR; SSTS Positive predictors: positive affect,
2006, signing donor card stratified random sample knowing another donor card
Switzerland holder, knowledge about organ
donation; negative predictors:
negative affect, older age
Siminoff et al,30 Willingness to donate 1283 adults, mean age, SSQ Positive predictors: younger age,
2006, USA (signed donor card) 43.8 y; random sample higher education, agrees with pre-
sumed consent, belief that hospi-
tals need not ask family
permission for organ donation;
higher trust in medical system
was predictive of donor status for
whites, but not African Americans
Sirois et al,31 Donor status (donor 137 parent-adolescent dyads, SSQ, attitudes, Adolescent and parental positive
2005, USa or nondonor) mean age adolescents: 15.5, knowledge3,16 (and negative) attitudes toward
parents: 43.6). Convenience and knowledge about organ dona-
sample. tion, and frequency of communi-
cation about organ donation
distinguished between adolescent
donors and nondonors.
Skowronski,32 Willingness to donate Study 1: 1247 students SSQ Negative beliefs about organ dona-
11997, USA (median age: 19 y) tion discriminated more clearly
Study 2: 2491 students between donors than positive
(median age, NR) beliefs; negative beliefs included:
desire not to think about death,
concern about needing organs
after death, disfigurement and
death being declared prematurely
Van den Berg et Attitude, willingness 464 students; mean age, NR; SSQ More positive evaluation of organ
al,33 2005, The to receive info 85 in 6 month follow-up; donation 6 months earlier was
Netherlands convenience sample predictive of potential donors
agreeing to receive more informa-
tion about organ donation
Weber et al,34 Intention to donate 370 students; mean age, NR SSQ plus atti- Positive predictors: positive atti-
2007, USA and donor behavior tudes scale40 tudes toward organ donation,
belief that friends and family
would endorse organ donation;
intention to donate was strongest
predictor of signing a donor card
Yeung et al,35 Willingness to donate 284 adults, aged 15-64 y (mean, SSTS Positive predictors: younger age,
2000, Hong NR); probability sampling having a professional occupation,
Kong altruism, understanding about
organ donation, confidence in
doctors, and an absence of strong
beliefs about being buried whole
Wu and Tang,36 Attitudes toward organ 290 adults, aged 25-87 y (mean, SSQ plus death Negative predictor: death anxiety
2009, China donation and donor 46.56); convenience sample anxiety scale41 indirectly reduced the likelihood of
behavior signing a donor card through low-
ered perceived self-efficacy toward
signing a donor card
a Studies on adolescent samples.
b Donor behavior reported as either having signed or carrying an organ donor card.

Abbreviations: NR, not reported; PADQ, Psychosocial Aspects of Donation Questionnaire; SSQ, study-specific questionnaire; SSTS, study-specific telephone survey.

Altruism and Beliefs About Bodily Integrity. Indi- signed an organ donor card or to have enrolled in an
viduals who have altruistic beliefs about helping oth- organ donation registry.32 Positive attitudes toward
ers and about assisting science appear more willing to manipulation of the body of the deceased donor, or
discuss organ donation,6,20 to donate,32 and/or to have having low levels of concern about maintaining the

388 Progress in Transplantation, Vol 20, No. 4, December 2010

 Attitudes toward organ donation and donor behavior

Table 4 Summary of predictors of attitudes toward deceased organ donation

Variable
(No. of studies showing
significant association)
Sex (1/31)
Age (3/31)
Education/Socioeconomic
status (3/31)
Ethnicity/Religion (3/31)
Knowledge (8/31)
Attitudes of others (2/31)
Communication (1/31)
Altruism/Trust (2/31)
Attitude toward body
Prosocial activities (3/31)
Results
Female sex is predictive of more positive attitudes10
Younger age is predictive of positive attitudes11,16,18
Higher level of education and socioeconomic status are predictive of more favorable attitudes12,14,27,28
Stronger religious beliefs are predictive of less favorable attitudes8,26
Organ donation is predictive of more favorable attitudes27
Knowledge of organ donation is predictive of more favorable attitudes11-13,15,16,19,26,27,31
Knowing a donor or recipient is predictive of more favorable attitudes26
Favorable attitudes of significant others are predictive of an individual’s attitudes toward donation11,23
Discussing organ donation with a significant other is predictive of favorable attitudes toward donation23
Altruism and trust of the attending physician is predictive of positive attitudes14,19
Being unconcerned about manipulation of the deceased’s body is predictive of more favorable atti-
tudes12,23
Believing that the integrity of the body should be maintained is predictive of negative attitudes5,11,13
Belief that one might need an organ in the future is predictive of positive attitudes23
Experience with or having a positive attitude toward prosocial activities (eg, blood donation) is
predictive of favorable attitudes11-13

Table 5 Summary of predictors of willingness to donate and donor behaviors

Variable
(No. of studies showing
significant association)
Sex (4/31)
Age (6/31)
Education/Socioeconomic
status (6/31)
Ethnicity/Religion (5/31)
Knowledge (11/31) (6/31)
Attitudes of others (7/31)
Communication (2/31)
Altruism (4/31)
Attitude toward body
(3/31)
Prosocial activities (3/31)
a Willingness/intention
to donate.
b Willingnessto communicate about organ donation.
c Donor behavior (has signed and/or carries an organ donor card).
Results
Female sex is predictive of willingness to donate6a,10a,22a,42a
Younger age is predictive of willingness to donate7a,13,16c,29ac,30c,35a
Higher socioeconomic status7a,27,30c,35a and education13,24a,30c are predictive of willingness
African American7a,18a and Hispanic American24a ethnicity is predictive of lower willingness
Strong religious beliefs are predictive of lower willingness,7a,32ac particularly among African Americans20c
Perception that religion allows organ donation is predictive of willingness to donate27
Greater knowledge or awareness of organ donation is predictive of willingness14c,15c,16c,19a,20c,22a,25c,27,28a,29ac,30a,31c
Knowing someone needing or receiving an organ is predictive of willingness6bc,13a,14a,25c,28a,29a
Favorable attitudes of a significant other is predictive of willingness to donate19abc,20c,21ab,22a,28a,31c,42b
Communication about organ donation with significant others is predictive of willingness6a,14c
Altruism and higher levels of interpersonal trust are predictive of willingness to donate6a,20c,24a,32ac
Low levels of concern about maintaining integrity of the body after death are predictive of increase
willingness to donate19,20c
Concern about disfigurement of the body is a negative predictor of willingness to donate32ac
Prosocial activities are predictive of willingness to donate10a,17ac,30c (African Americans)

Progress in Transplantation, Vol 20, No. 4, December 2010 389

Wakefield et al
integrity of the body after death,20 and believing that
the body appears normal after organ removal also
appear to be predictive of willingness to donate.19
Concern about disfigurement of the body is a negative
predictor of willingness to donate (Table 5).32
Donate, and Donor Behavior. Researchers in numer-
Relationship Between Attitudes, Willingness to
ous studies have reported that individuals who have a
positive attitude toward donation are more likely to be
willing to donate6,8,19,29,33,36 and/or to sign a donor card
or enroll in an organ donation registry.5,15,16,19,21,22,31,34
Interestingly, researchers in 3 studies9,21,32 found that
negative attitudes and/or beliefs were a stronger pre-
dictor of willingness to donate than were positive
attitudes and/or beliefs. Finally, researchers in 4 stud-
ies8,22,31,42 have investigated the relationship between
reported willingness to donate and actual donor
behavior, all of which showed that reported willing-
ness to donate was a good predictor of actually sign-
ing a donor card (Table 5).
Conclusions
Before addressing the implications of the findings
of this review, the factors that compromised its ability
to provide a comprehensive assessment of predictors
of attitudes toward organ donation should be men-
tioned. These limitations include the heterogeneity of
the study populations in the published literature, the
heterogeneity of study measures and outcome vari-
ables adopted by the included articles (which severely
limited our ability to compare results directly), the
small sample sizes of many studies, the use of unvali-
dated measures in many studies, and the low quality of
the majority of studies. Also, the majority of studies in
the review originated in the United States, and this
may limit the generalizability of findings from these
studies to countries with different health systems and
cultural contexts.
In this review of studies on predictors of individ-
uals’ attitudes toward organ donation, willingness to
donate, and donor behaviors published between 1988
and 2009, we found 32 relevant articles from 9 coun-
tries. The review demonstrated that individuals who
are younger, are female, have higher educational lev-
els and/or socioeconomic status, hold fewer religious
beliefs, have higher knowledge levels, know others
with positive attitudes, are more altruistic and trusting,
and have fewer concerns about manipulation of the
body of the deceased donor are more likely to have
positive attitudes toward donation and are more will-
ing to donate. Thus this review shows that the predic-
tors of organ donation attitudes and behavior are
multifaceted and wide-ranging.
The complexity of the actual donation procedures
that govern organ donation within different countries
390
and the multiplicity of influences on these acts could
not be fully captured by using the systematic review
methods adopted for this study. Broader factors such
as prevailing social and cultural norms and existing
organ donation policies in different countries also sig-
nificantly influence organ donation decisions. Impor-
tantly, the actions of staff of emergency departments
and intensive care units,44,45 and the attitudes of family
members of the deceased46 also have a strong impact
on organ donation rates, and the contribution of these
factors was not assessed in the studies identified in
this review. The relative contribution of each of these
factors is unknown, but given the substantial differ-
ences between countries with regards to organ dona-
tion rates, it is likely that attitudinal differences are
only one of many factors that influence donation rates.
Future Directions
Future research would benefit from more sophis-
ticated analysis of the reasons for the low numbers of
organ donations worldwide. The older, more conven-
tional, public health assumptions that generalized edu-
cation will correct “ignorance” and therefore “improve
behavior” may be significantly flawed. It is possible,
for example, that previous education campaigns have
successfully altered community attitudes but did not
increase actual donor numbers because previous cam-
paigns have polarized donation, that is, they permitted
and endorsed community acceptance of making a firm
decision against donation, rather than increasing the
number of individuals making a firm positive deci-
sion.47 It is also important for future research to begin
to separate out the more modifiable individual atti-
tudes that could reasonably be addressed by commu-
nity educational intervention and those attitudes that
are based in more fundamental belief systems, such as
cultural and religious beliefs.
Acknowledgments
The authors acknowledge the contributions of David
Cairns (Department of Psychology, Macquarie University),
Tim Mathew (Kidney Health Australia), Alison Barn-
well (Bereavement Services, Red Cross Organ Donation
Network), and Elizabeth Lobb (Calvary Health Care and
Cunningham Centre for Palliative Care).
Financial Disclosures
Claire E. Wakefield is supported by a postdoctoral
training fellowship from the National Health and Medical
Research Council of Australia (NHMRC) (ID 510421). Bet-
tina Meiser is supported by a career development award
from the NHMRC (ID 350989).
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