1 Department for Kidney Disease and High Blood Pressure in the Centre for Internal Disease and 2 Department for General Surgery and Transplantation, University Clinic (GHS) Essen, Essen, Germany
Correspondence and offprint requests to: PD Dr. F. Weber, Transplantation Center, OPZ II, University Clinic Essen, Hufelandstr. 55, 45122 Essen, Germany.
Abstract
Background. The stagnation or decrease in organ donation rates since 1992 in Germany has partly been attributed to the negative impact of reports about organ donation periodically presented by German television between 1992 and 1997. This study was performed to elucidate the impact of the media on the public's attitudes towards organ donation.
Methods. A questionnaire concerning different aspects of organ donation was sent to the parents of pupils of a high school in a German city in 1994 and 1998.
Results. In 1994, 940 adults could be identified who had (TV+, n=546) or had not (TV-, n=394) followed at least one television discussion about the topic. In 1998, the group consisted of 756 (TV+, n=443 and TV-, n=313) adults. The discriminating question was of sufficient strength to reveal significant differences between TV(+) and TV(-) respondents. Contrary to an assumed negative impact of TV, differences between the groups were detectable mainly in questions regarding information, but not in those which dealt with personal fears and concerns. The main results obtained in both surveys were identical. Furthermore, from 1994 to 1998 there was a trend in favour of information and organ donation for TV(+) but not for TV(-) respondents.
Conclusion. The assumption that TV has had a negative impact on donation rates must be rejected. Therefore, the stagnation/decline in donation rates must be attributed to other factors.
Keywords: attitudes towards organ donation; Germany; media; questionnaire; survey; television
Introduction
After a long and critical public debate, a transplant act came into force in Germany on December 1, 1997, which regulated important issues on organ donation and transplantation. This heavy debate was accompanied by innumerable reports on organ donation and brain death in all media. Not least, was a spectacular case of a brain dead pregnant women who was kept on a respirator in order to save the life of her fetus. The role of the media as the conduit in shaping public opinion is well known and appreciated [1]. Although the majority of the transplant community in Germany was gratified by the efforts to bring brain death and organ donation to public attention, they [24], as well as physicians in other countries [5], felt uneasy about the way this topic was presented on television. They all suspected a negative impact on attitudes towards organ donation since a negative view seemed to predominate on television. On the other hand, broadcasters confronted with this objection argued that their role was not to motivate, but rather to report [6] and, furthermore, stressed their duty of well-balanced information [7].
To estimate the factual impact of television reports and discussions on attitudes towards organ donation, we investigated a group picked from the total population of a German city in 1994 and re-investigated a similar group in 1998 by comparing those who had at least followed one television discussion on this subject with those who had not.
Method
The first study was performed during summer 1994, about 2 years after television had started to present the topic of organ donation on nearly a weekly basis. In these reports, advocates and opponents of organ donation could express their opinion. The group in this study consisted of 940 parents of pupils of a high school in Essen (Nordrhein-Westfalen, Germany) who participated in an opinion poll about the main issues of organ donation and transplantation. The sample was drawn out of a larger survey conducted in the general population of the city of Essen [8].
With its 24 items, the questionnaire covered many different aspects of organ donation (Table 1). The answers could be given on a scale ranging from 1 to 6, with 1 denoting `definitely yes' or `good' and 6 denoting `definitely no' or `bad'. This pattern was chosen because of its similarity to school marks, which are familiar to parents of pupils, and as it provides the opportunity to express a well-differentiated opinion. In summer 1998, 756 parents with children in the same school responded to the questionnaire again. Some of the participants in this re-evaluation were probably the same as in 1994, but the groups are not identical, as nearly half of the pupils had left school between 1994 and 1998, rendering their parents unavailable. Other individuals probably returned one, but not the other questionnaire. Due to the data protection law we were not allowed to identify individual persons on the questionnaire, thus the rate of participants of both studies could not be calculated.
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All participants performed on a voluntary basis. The high return rate of 4045% in both investigations was achieved by the active support of the school headmaster.
Data analysis
For all answers to a single question the mean value±standard deviation (mean±SD) was calculated. The percentages of respondents who ticked 1 or 2 were combined in the category `yes', those who ticked 3 or 4 in the category `don't know' and those with answers 5 or 6 in the category `no'. The MannWhitney test was used to test significance for comparisons between the groups. Due to multiple group comparisons, the significance level was set at P<0.005. In accordance with this more conservative strategy of data analysis, P-values between <0.05 and >0.005 were judged as probable trends, but not as proven differences. Calculations were performed by the programs `Excel 5.0' and `StatView 4.5' for the Apple Macintosh Computer.
Results
The basic characteristics of the subjects in each sample group are shown in Table 2. There was no significant difference between the groups with respect to age, gender or education. This was valid for comparison between TV groups as well as for comparison between both polls.
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For those results revealing significant differences between the groups, the education of the respondents did not influence the answers with the exception that significantly more TV(+) respondents with a university degree claimed to be adequately informed than those with an elementary school education (P<0.0001).
In 1994, 94% of the TV(+) respondents answered `yes' and 0% `no' to question 1; the corresponding data for TV(-) respondents were 85% and 2% (P<0.002), respectively. In 1998 the percentage distribution was identical to 1994 for TV(+) and 76% and 2% for TV(-), respectively (P<0.0001).
The groups did not differ with regard to their acquaintance with patients on dialysis or with kidney diseases, neither within, nor between the polls.
The noticeable difference in the answers of TV(+) and TV(-) respondents to question 5 in the 1998 poll did not reach the significance level, however, there was a trend towards more owners of donor cards in the TV(+) group. Fifteen per cent claimed to have a donor card compared to 8% of TV(-) (P=0.049). In 1994, 10% of TV(+) and 8% of TV(-) answered `yes' to this same question. The results were not significantly different and did not even fulfill the criteria for a trend between 1994 and 1998.
In both polls there was a striking difference in the answers of TV(+) and TV(-) to question 6 (P<0.0001 for both). In 1994, 47% of TV(+) knew where to obtain a donor card compared to only 32% in the TV(-) group. In 1998 the corresponding results were 59% and 35%, respectively. Between 1994 and 1998 (P=0.009), there was a positive trend only for TV(+) groups to know where to obtain a donor card.
Thirty per cent of the TV(+) respondents in 1994 considered themselves as not being adequately informed about organ donation compared to 55% of the TV(-) ones, the corresponding figures for 1998 were 23% and 48% (P<0.0001 for both), respectively. There was only a trend (P=0.016) toward a better informed public on this topic in 1998 in the TV(+) group. The answers of the TV(-) group in both polls did not differ (P=0.088). In both studies TV(+) respondents (1994, 57%; 1998, 63%) were more likely to speak with their family or friends about this topic than TV(-) respondents (1994, 28%; 1998, 26%) (P<0.0001).
In 1994, subjects of the TV(+) group were more inclined to believe that organ trade was possible in Germany (73% vs 63%, P=0.004); similar results were achieved in 1998 (58% vs 47%, P<0.0001). In 1998 significantly fewer people answered this question with `yes' (P<0.0001 for both TV groups).
Although there were no significant differences between TV groups in 1994 and 1998 with regard to question 12, there was a trend (P=0.0347) for more respondents of the TV(+) group willing to agree to organ donation in 1998 (61% vs 52%). The TV(-) group did not show this trend (54% vs 53%).
The answers to all other questions, in particular those which dealt with confidence in modern medicine, concerns regarding the behaviour of physicians or fairness in organ allocation did not differ, neither between the groups nor between the polls.
Discussion
We are aware that the question used to distinguish the groups in both polls does not cover the whole spectrum of TV influence and may have discriminated the groups only approximately. Nevertheless, we presumed that the discriminating strength of this question was sufficient enough to describe, at least in part, the impact of television on the attitudes of those who classified themselves as TV(+), while it was reasonable to suppose that subjects classifying themselves as TV(-) were not decisively influenced by television. Evidence supporting this view is provided by the fact that trends of changes between 1994 and 1998 were detectable in the TV(+) group only.
A possible objection might be that the results of this study may not reflect the impact of television on attitudes and their changes in the general population since (i) the response rates of 4045% were too low to allow generalization and (ii) the groups under investigation include too many respondents with a high school degree. Response rates of more than 40% are extraordinarily high for questionnaires performed on a voluntary basis, although they are not regarded as sufficient for epidemiologic studies. This study was not performed to provide a representative picture about people's attitudes towards organ donation. It was performed to elaborate differences in attitudes and their changes over time between TV(+) and TV(-) groups. It is not likely that those who did and those who did not respond to the questionnaire were influenced by TV in a different way. The nearly identical results in both polls allows a cautious generalization to be made. The level of education significantly influenced the answers of only one question.
We are not aware of any other study attempting to describe the impact of television on the public's attitudes towards organ donation over a longer period, thus we were not able to compare the results of our study with those of other studies. A study about a regional and short-lasting media campaign presented by Slapak et al. [9] describes only changes in rates of donor registration, organ donations and transplantations, but not in the public's attitudes.
This study demonstrates that the assumption of a negative impact of television reports on people's attitudes towards organ donation is not justified for the groups investigated. First, significant differences between the TV groups in both polls existed almost exclusively for questions regarding information, but not for those concerning personal fears, concerns or objections. More respondents of the TV(+) group had heard of organ donation, knew where to obtain a donor card, considered themselves adequately informed and had discussed this topic with their families or friends. It is of particular importance that more than twice as many respondents in 1998 had discussed this topic with their families. This is a key issue for the purpose of facilitating the organ donation process. The decision for donation is nearly always requested from the family at a traumatic time and it is critical, therefore, that families are aware of each other's attitudes towards donation beforehand [10]. For questions dealing with fears such as donors not being cared for correctly in the event of illness or accident or the accuracy of death certification the answers did not differ between both groups in both polls. Additionally, the decision to carry a donor card, the willingness to donate after death or to be a transplant recipient were independent of TV exposure on this topic in 1994 and 1998.
Secondly, trends of changes between 1994 and 1998 document the influence of television on attitudes towards organ donation over the years. They again were only detectable for informational questions, but not for questions dealing with fears or concerns. Furthermore, as an indication for a positive, rather than negative impact of television, there was a tendency for more respondents to agree to donate organs after death in 1998 than in 1994 in the TV(+) group only. Similar results have been obtained in the USA after an extensive media campaign which started in 1994 to promote organ donation. After 2 years, the percentage of respondents to a telephone survey who expressed a positive attitude towards donation and who had signed a donor card increased by 60% [11]. It may be supposed that these results are due to a better informed population in both countries.
In summary, the results of this study provide evidence to refute the widespread supposition of the German transplant community that TV reports had a negative impact on people's attitudes towards organ donation over the last 5 years. Furthermore, an encouraging result of this study is the fact that the respondents used TV reports as a source of improving their knowledge about this topic and not to consolidate concerns or provoke new fears.
Television cannot be charged with the responsibility for the stagnation/decrease in donation rates. This conclusion inevitably obliges the transplant community to search for other factors explaining this unfortunate development. Otherwise the widening gap between need and supply of transplantable organs will not be bridged in the future.
Acknowledgments
The study was supported by Deutsche Stiftung Organtransplantation and Novartis Pharma.
References