The waiting list for donor organs recently surpassed 100 000 individuals [Organ Procurement and Transplantation Network (OPTN), Organ by Ethnicity, www.optn.org/latestData/rptData.asp. Accessed 28 October 2008]. This figure includes a disproportionate number of candidates of Hispanic origin. Specifically, individuals who are Hispanic or Latino comprise 12.5% of the United States population , yet they comprise 16.9% of the candidates on the United States waiting list (OPTN data as of 24 October 2008). Projections suggest that the Hispanic-origin population will be the largest growing group in the United States, and contributes 39% of the Nation's population growth between 2000 and 2010, which comprises 22.5% of the United States population by the year 2050 (United States Census Bureau, Population Profile of the United States, www.census.gov/population. Accessed 28 October 2008). In conjunction with this growth, an increasing demand for donor organs among Hispanics is imminent, as certain diseases and conditions that can lead to a greater need for transplantation are more prevalent among Hispanics. For instance, Hispanics have the highest estimated lifetime risk for diabetes mellitus  and a greater incidence of end-stage renal disease (ESRD), relative to non-Hispanic individuals .
Hispanic-Americans are less likely to donate their organs; across a 20-year span, only 10.6% of deceased donors recovered were Hispanic, relative to 73.9% white and 12.4% black (OPTN, 1 January 1988–31 July 2008). Ultimately, Hispanic individuals are less likely than whites to be placed on the waiting list or receive a transplant , wait longer on the list for donor organs, and, relative to whites, exhibit a lower percentage of individuals transplanted 1 year after listing for a single organ with the exception of the heart (OPTN, 2003–2004 data). Data from a retrospective cohort study  of deceased donor recipients (1996–2002) show that, prior to the expanded donor criteria policy, Hispanics had 19% greater odds (relative to non-Hispanic whites) of receiving a lower grade kidney; however, when using the expanded donor criteria designation, Hispanics and whites numbers did not differ. Given access to renal transplantation, outcomes, such as graft failure, do not differ between Hispanics and whites . The goal of this study is to review what is known about the attitudes, beliefs, and behaviors that surround organ donation among Hispanic individuals, and to examine the potentially important role of women in organ donation decision-making.
The importance of understanding attitudes derives from a rich body of empirical, theory-based literature that substantiates a positive relationship between attitude toward a voluntary behavior and behavioral performance. Unlike other voluntary health behaviors, translating favorable attitudes toward organ donation directly into acts of donation is not acutely possible in cases other than living donation. Thus, approaches that influence a favorable attitude toward donation have measured key intermediate behaviors such as family discussion about organ donation and donor registration.
The most recent nationally representative household survey to address the American public's attitudes toward organ donation and transplantation was conducted over one decade ago . Data from this survey administration revealed general favorability toward organ donation; Hispanic respondents were more likely than white or black respondents to believe that economic status does not interfere with a person's chances of getting an organ transplant . Hispanic and black individuals expressed greater concern over body disfigurement and greater doubt that doctors do all they can to preserve life before pursuing organ donation than did whites . Other studies  at this time depicted less favorable attitudes among Hispanic groups, implicating language barriers, myth, and superstition.
More recent accounts indicate that efforts to increase positive attitudes toward living and posthumous organ donation have been successful among Hispanic individuals. For instance, a Spanish language mass media (television and radio) campaign that targeted organ donation in two Arizona counties resulted in an increase in prodonation attitudes and family discussion 1 month after exposure to the campaign. The theme for the television advertisements was the effort to save the life of potential donors, while demonstrating the gift of life that organ donation can bring. The radio advertisements primarily addressed the position of the Catholic Church on organ donation . This campaign can be compared with the results of a 4-year campaign by the Ad Council/Coalition Campaign with the theme ‘Organ and Tissue Donation: Share your life. Share your decision’. This campaign, which did not specifically target a particular ethnic group, resulted in a higher proportion of individuals who reported that they had signed an organ donor card, yet no measurable change in overall attitude toward donation was found .
A paid media advertising campaign that targeted Spanish language-dominant Hispanic adults who resided in southern California resulted in more favorable attitudes toward organ donation during the first 2 years following the campaign; moreover, the Hispanic consent rate for organ donation exceeded the project goals . The theory-based, culturally sensitive campaign presented three scenarios that highlighted children or young adults, in recognition of the importance of family to most Hispanic groups. The campaign did reveal continued distrust of the medical system; however, this finding was contemporaneous with media accounts of the death of heart transplant patient Jessica Santillan due to medical errors. Thus, attitudes are influenced by both positive and negative media accounts, particularly among Hispanic populations whom market researchers indicate may watch more television than the general United States population.
Interviews with Spanish-speaking people in Chicago, Houston, Los Angeles, Miami, and New York City revealed that Hispanics who intended to be organ donors were uninformed about organ donation, whereas those who were against or undecided about organ donation were misinformed . Thus, in a targeted effort to reach the Hispanic-American community, the Coalition on Donation launched a campaign that focused not on increasing the number of donors, but on disseminating correct information about organ donation .
The changing United States demographics, and the growing overall need for donor organs among Hispanic individuals in particular, suggest that a national survey that focuses on Hispanic-American populations may be timely and critical. Survey development should recognize that Hispanic-Americans are a heterogeneous group, and differences in attitudes and beliefs about donation may vary greatly depending upon one's national background . Furthermore, language preference (Spanish versus English) may contribute to diversity among Hispanic populations, as recognized by Siegal et al.. National campaigns that reach multiple Hispanic-American groups are necessary to ultimately increase expressed commitment to organ donation and instil trust in the medical establishment. Additionally, approaches directed to increase attitudes toward organ donation among Hispanics may vary depending upon whether living or posthumous donation is considered. Specifically, a number of barriers to posthumous donation within many Hispanic groups would be overcome by living donation, such as limited time for decision-making, involvement of all family members, concerns about surveillance or not making every effort to save the life of the donor, and equity in organ distribution [14••]. Finally, the promotion of favorable attitudes toward organ donation among Hispanic–American families who face donation decisions necessitate culturally sensitive approaches by healthcare providers .
Beliefs that surround organ donation among Spanish language-dominant Hispanics were examined in a qualitative interview study  conducted in southern California among five families (all of Mexican origin) who consented to the donation of a loved one's organs in the past year, and seven families (five from Mexico, one from El Salvador, and one from Guatemala) identified from the community who were ambivalent or opposed to organ donation. The interviews revealed that many did not realize that donation takes place after death, and that brain death is death. Opposing families expressed the belief that known organ donors may be under surveillance or pursued by organ retrieval organizations and doubted that organ donation is handled honestly and not for profit. Both opposing and consenting families expressed suspicion that there is a black market for organ sales, particularly in Mexico, and an overall reluctance to ‘plan for death’. Consenting families were motivated to donate by the belief that their loved one would go on living and that, by agreeing to donate their loved one's organs, someone else would be able to live .
Hispanic families are often not sure that their group is getting equal treatment, and that organs are distributed equitably across ethnic groups [7,16]. In fact, the Hispanic media campaign that was successful in increasing favorable attitudes toward donation and family discussion was not effective in changing perceptions of discrimination regarding the distribution of donated organs between Hispanic versus Anglo-Americans .
Strong beliefs related to the Catholic faith are found among many Hispanic populations, including the belief in a miracle that delays death. Until a final declaration of death is made, Hispanic families may not be receptive to a discussion about organ donation . In fact, many Hispanics do not like to talk about death and hold an aversion to planning for events surrounding death; some believe by talking about death one may cause it to occur . Statements arising from the Vatican indicate that transplants are morally and ethically acceptable, and organ donation is encouraged as a genuine act of love and charity. Many Hispanics, however, do not realize that the Catholic Church supports organ donation . For Hispanics who are not Catholic, position statements from a majority of religions indicate support for organ donation and transplantation . How individuals conceptualize death and integrate the concepts of death, donation, and religious beliefs may, however, be new complications. A recent article that appeared in the New England Journal of Medicine[18•] refers to ‘flawed definitions of death’ and argues that informed consent from patients or surrogates should be the ethically relevant precondition for donation, and not the dead donor rule. Following publication of this article, a Vatican Conference was held on organ donation during which the Pope cautioned that, in the question of determination of death, ‘there must not be the slightest suspicion of arbitrariness. Where certainty cannot be achieved, the principle of precaution must prevail’ . Future directives from the Vatican will be necessary to guide Catholics in their decision-making and to discern whether singularly occurring, life-saving organs can continue to be removed for transplantation under conditions of informed consent and declaration of brain death in Catholic hospitals.
Hispanic individuals are less likely than non-Hispanic whites to agree to donate the organs of a deceased family member [15,20], including pediatric organ donation . Very often, failure to allow donation reflects doubt regarding the wishes or intentions of the decedent. Thus, expressing one's wishes to be an organ donor, particularly to one's family, remains a critical step in increasing the availability of donor organs. In one study , more than half of Hispanics surveyed did not know how to sign up to be an organ donor in the event of death, whereas between 36 and 41% of individuals in this same study indicated they would sign up if asked. Signing up at the doctor's office, by way of the driver's license, or at one's place of worship/church were the preferred methods of registration . These methods may facilitate discussion about the topic, which is an important part of decision-making among many Hispanic families. Discussions often include extended family , with Hispanics of native American descent that include the matriarch, whereas in families in which Spanish culture is strong, the patriarch will be an important participant . Data collected among 1200 Hispanic-Americans in Pima and Maricopa counties in Arizona using computer-assisted telephone interviewing revealed that knowing a potential organ donor and disagreeing that carrying a donor card results in inadequate medical care, were two key factors associated with family discussion about organ donation .
Effective communication within families regarding donation intentions and between medical staff and potential donor families is of critical importance. Latin Americans favor high-context communication, that is, communication that is rich in detail in which both physical and personal factors are brought into the context of the topic under consideration. Factors such as social status, relationship, history, setting, voice, gesture, and posture all are important in the overall interpretation of the situation . North Americans and men, in general, favor low-context communication, which focuses on the primary issue and gets straight to the point. The critical care context in which a donation request takes place may pose a crucial mismatch between the practical setting in which donation is discussed and the preferred context of communication for Hispanic families.
Examination of family refusal for organ donation in Puerto Rico revealed several mitigating factors that included fear of mutilation and suffering (often accompanied by an inability to accept the argument that the dead relative was not suffering because she/he was dead), denial of death (particularly for relatives on mechanical ventilation), and family dynamics and communication regarding decision-making and death. With regard to family dynamics and communication, ‘the extended family’ became a critical factor in the refusal to agree for donation. Specifically, although the opportunity to donate may be presented by medical staff to the next-of-kin, these individuals often preferred to wait for other senior or more prominent relatives to arrive to make the decision. As a consequence, critical time passes, and different perspectives must be incorporated into decision-making; greater time pressure and family dissent often leads to the next-of-kin deciding against donation. With regard to the family dynamics that surround death in this culture, Fernández et al. describe ‘collective hysteria’ in which the grieving process can be characterized by a contagious form of hysteria in which arriving family members shout, scream, cry uncontrollably, and sometimes succumb to fainting spells and convulsions. Collective hysteria can result in a trance-like state or the injury of key family members – two outcomes that render communication impossible . To address these factors effectively, Fernández et al.  suggest that staff share in the grieving process of the family. The factors of becoming more involved in the process and knowing who is in the room, their relationship to the deceased and who the family intends to involve in the decision-making regarding organ donation renders it less likely that medical staff will interrupt or intrude upon the grief process, thereby shutting down communication.
In Puerto Rico, a ‘culture of donation’ was achieved by first decoupling the organ procurement efforts from the transplant program and implementing an aggressive administrative and educational plan to identify problems in the steps leading to donation and transplantation in hospitals. Subsequent to these efforts, public education campaigns and training for hospital administration and staff were carried out. The recognition that all Hispanics are not the same led to an appreciation of the importance of cultural sensitivity among coordinators, including language, accent, and cultural background. Together, these efforts resulted in a 16-fold increase in organ donation from 1984 to 1995 compared with 2001 to 2006 among Hispanics living in Puerto Rico [25••].
Importance of women
Sex is related to organ donation and transplantation in important ways. For instance, between the years 1988 and 2008, only 39% of the transplants performed were on women. Furthermore, women with ESRD have reduced access to the transplant waiting list relative to men and are less likely than men to receive a transplant, even after accounting for comorbid medical conditions, social class, and health status [26–28]. Importantly, women are often the decision makers of the family when it comes to health-related issues, and, on average, women live longer than their spouses. Women also tend to have more contact with the medical community than do men, be it for their own health and well-being or that of their children. For these reasons and others, women of Hispanic and non-Hispanic ethnicity represent an important group to target in efforts to increase organ donations.
The survey of Hispanic-Americans in Arizona revealed that women were more likely than men to have told someone of their desire to be an organ donor and to have discussed organ donation with their family , which is consistent with earlier data that showed that women who were likely to donate their own organs were significantly more likely than men to have shared this wish with their family .
Between June 2006 and November 2007, organ donation beliefs and intentions were surveyed among 2583 women (74% Hispanic) who attended a women's health clinic in southeast Texas. Sixty-eight percent of the Hispanic women surveyed were immigrants, of these the majority (86%) were born in Mexico and 34% moved to the United States at 19 years of age or older. Our data revealed that 16% of Hispanic women were unaware that individuals could be organ donors when they die relative to 4% of whites and 8% of blacks (P < 0.0001). With regard to key intermediate behaviors, 33% of women reported talking about organ donation with a family member; however, minority women were less likely to have done so (31% of Hispanics, 26% of blacks, and 46% of whites, P < 0.0001). Similarly, fewer Hispanic and black women reported having signed a donor card or driver's license relative to white women (11% of Hispanics, 12% of blacks, and 26% of whites, P < 0.0001). Over half (51%) of the women surveyed indicated they would like to become organ donors; however, fewer (42%) Hispanics indicated this fact relative to blacks (64%) and whites (79%) (P < 0.0001).
Considering only the Hispanic subsample (n = 1898), relative to United States-born Hispanics, immigrant Hispanics were less likely to be aware of organ donation, discuss donation with their family, intend to be a donor, or sign a donor card/driver's license (all P < 0.05). Immigrant (versus United States-born) Hispanics indicated greater agreement that a poor person has as good a chance as a rich person of getting an organ (P < 0.0001), and that racial discrimination prevents minorities from receiving organ transplants (P < 0.05).
Hispanic-Americans and women represent two segments of the United States population that hold great importance with regard to the future availability of donor organs. Recognizing the diversity within the Hispanic culture and the important role of women in taking care of the health of the family are likely to be instrumental in increasing family discussion and commitment regarding organ donation. Addressing living donation and posthumous donation separately within the Hispanic community is justified by existing data and may result in increased donations. Creating a ‘culture of donation’ among Hispanic-Americans (as was accomplished in Puerto Rico) represents a tremendous challenge, with potentially rich rewards for families of donors and recipients.
The original data presented within this review were collected as part of a larger study funded by the National Institutes of Health, National Cancer Institute (R01 CA107015-01A1).
References and recommended reading
Papers of particular interest, published within the annual period of review, have been highlighted as:
• of special interest
•• of outstanding interest
Additional references related to this topic can also be found in the Current World Literature section in this issue (p. 215).
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