INTRODUCTION

In medical education, cadaver [(k-dav’r) (L., from cadere to fall, to perish) a dead body; generally applied to a human body (^{Dorland, 2011}) is an indispensable material of medical education. Education on the human body is a "sine qua non" of anatomy. Scientific studies have been conducted on cadavers for centuries. Newly developed technological training materials do not appear to replace dissection and cadaver work. For a qualified anatomical and medical education, the students must work on a cadaver. The number of cadavers used in medical school education in Turkey is far below the desired level (^{Gürses et al., 2018}). Unfortunately, in some medical faculties, anatomy education is performed without cadavers. In developed countries, cadavers are provided by public donations. Thousands of people donate their bodies to medical schools for educational and scientific purposes. This is an important indicator of societies' belief and support in science.

Devoting the body to the development of humanity and science is the most valuable gift that a dead person can give to the living, which cannot be measured by any material value. At this point, voluntary body donors, who want to support scientific studies have a big duty. Within the framework of the law, as in other developed countries, in Turkey, after death, people can donate their body for educational and scientific purposes. In addition, the body of the person known to have willing can be donated for the same purpose with the approval of all heirs. The work on the donated bodies is carried out with the utmost respect within the ethical rules, and then the funeral procedures are performed according to the request of the donor. Despite the above, it is remarkable that the number of body donations is not at the desired level in Turkey.

While the number of donors in Europe and North America is quite high, unfortunately this number is very low in our country. Accordingly, the number of cadavers obtained from voluntary donors in medical education is extremely low (Gürses et al.). Undoubtedly, these difficulties in medical education on cadavers can be overcome by increasing the number of body donors. It is very important to investigate the reasons for not increasing the number of cadaver donors in the society and to propose solutions in this regard (^{Wight et al., 2000}; ^{Dinsmore et al., 2001}; Gürses et al.). This study aimed to assess the awareness, knowledge and attitudes about the importance of cadaver in medical education and cadaver donation.

MATERIAL AND METHOD

A cross-sectional study was conducted in 2015 and 2016. The data of the study was collected with a questionnaire form prepared by the researchers in accordance with the purpose of the study and the literature (^{Emson, 1987}; ^{Kleinman & Lowy, 1989}; Wight et al.; Dinsmore et al.; ^{Bøgh & Madsen, 2005}; ^{Mekahli et al., 2009}; ^{da Rocha et al., 2013}; ^{Caplan, 2014}; ^{Gatica-Araneda & Alfaro-Toloza, 2014}; ^{Dalal, 2015}; ^{Saha et al., 2015}; ^{Subasinghe & Jones, 2015}; ^{Abbasi Asl et al., 2017}; ^{Bamaç et al., 2018}; ^{Ciliberti et al., 2018}; ^{Gürses et al.; Wingfield, 2018}) [see additional file 1 (English translation of the questionnaire form)]. The questionnaire consists of three sections (Tabla I). The first section includes five questions (Q1-Q5) that question about some sociodemographic characteristics (gender, age, educational status, marital status, occupation). Education status categories are formed by grouping the levels reported at ISCED 2011 (UNESCO, 2012). Awareness and level of knowledge were questioned with ten items (Q6-Q15) in the second part. To determine the awareness and knowledge level, the answers are scored by giving 1 point for the "yes", and 0 point for the "no". Thus, the average level of awareness and knowledge (AWKL-Score) was calculated between 0 and 1. In the third part, the attitudes towards cadaver donation was questioned with a total of five questions (Q16-Q20). In the second and third part of the survey, thoughts about the cadaver, body donation, body donation campaigns and news were investigated as well as the thoughts for requirement of cadaver in medical faculties in our country and cadaver imports. In addition, it was investigated whether the participants knew the procedures related to cadaver donation, cadaver use and post-donation. Participants were asked to answer questions about their knowledge and behavior about body donation, both religiously and sociologically.

Tabla I Questionnarie on awareness, knowledge and attitude about the importance of cadaver and cadaver donation. 

The survey population were adults living in Izmir/ Turkey who had no impairment answering the questions.

The population of Izmir in 2015 is 4,168,415 and Izmir's population aged 18 and over is estimated approximately 3,334,732. As considering unknown prevalence in general population, 50 % prevalence, 95 % confidence interval and 6 % margin of error were accepted for sample size calculating. Thus, the sample size was calculated as 196. For the research, people living in the center of Izmir were randomly reached in crowded bazaars and shopping centers. A sample group was formed with 245 people who agreed to participate in the study with verbal consent. The questionnaire was applied to the participants by face to face interview technique. Each interview lasted approximately 15-20 minutes.

The data were analyzed using IBM SPSS Statistics v25 (SPSS Inc, Chicago, IL) software package. Descriptive statistics (frequencies and percentages) were used to describe the obtained results. When comparing mean scores for groups two-tailed paired-sample t-test (when comparing two groups’ means) was used. One-way Analysis of Variance (ANOVA) test was used to compare the means for more than two groups and post hoc analysis was performed in paired comparisons. Statistical significance was set at p<0.05. and a p-value<0.001 as highly significant.

RESULTS

The majority of participants (n: 245) were aged between 45-59 years (n: 80, 32.7 %), male (n: 123, 50.2 %), held a Bachelor's or equivalent degree (Level 6) (n: 96, 39.2 %), married (n: 178, 72.7 %), and public employee (n: 49, 20 %). The participants' some sociodemographic characteristics are shown in Table II.

Table II Sociodemographic characteristics of participants. 

75.5 % of the participants knew what the word cadaver means. The percentage of those who knew they could donate their body (as cadaver) was 66.9 %. With regards to the question “Are you aware of the cadaver donation campaigns?”, 20.4 % (n:50) of the participants responded yes. With regards to the question “Do you know that Turkish Universities import donated cadavers from abroad and pay transfer fees?”, 17.6 % (n:43) of the participants responded yes. With regards to the question “Are you aware of the fatwa of the Presidency of Religious Affairs regarding the body donation is permissible in Sharia (Islamic law)?”, 29.8 % (n:73) of the participants responded yes. Table III shows the distribution of the answers of the participants to the questions measuring the level of awareness and knowledge about importance of cadaver and cadaver donation.

Table III The distribution of the answers given by the participants to the questions measuring the level of awareness and knowledge about the importance of cadaver and cadaver donation. 

The AWKL-Score of the all participants was 0.41±0.24 (min:0.00, max:0.90). The AWKL-Scores for the youngest (18y-29 y) and the oldest (60 y and older) age groups were 0.49±0.22 and 0.48±0.26, respectively, and were significantly higher (F:4.115; p:0.007) than the other age groups. The AWKL-Score was 0.39±0.25 in males and 0.44±0.23 in females, and no statistically significant difference was found between the genders (t:1.451; p:0.184). The highest AWKL-Score was at the group of master's degree or doctorate (Level 78) (F:22.997; p<0.001). It was observed that the higher the education level, the higher the AWKL-Score. The AWKLScore was 0.40±0.25 in married and 0.46±0.21 in single/widowed/divorced, and no statistically significant difference was found between the groups (t:1.934; p:0.055). AWKL-Score was significantly higher in public employees (0.55±0.21) and students (0.48±0.20) than in other occupational groups (F:5.930; p<0.001). Table IV shows AWKL-Scores of the participants about the importance of cadaver and cadaver donation according to some sociodemographic factors.

Table IV Awareness and Knowledge Level Scores (AWKL-Score) of the participants about the importance of cadaver and cadaver donation according to some sociodemographic factors. 

When asked where they would apply, if they decided to donate their body, 42.4 % (n: 104) of the participants gave the answer "state hospital". With regards to the question “Do you think cadaver donation is permissible in Sharia (Islamic law)?”, 40.0 % (n: 98) of the participants responded "I agree with the fatwa of the Presidency of Religious Affairs of Turkey, it is permissible". When asked what their reaction would be if a member of their family donates his/her body as a cadaver, 53.1 % (n: 104) of the participants gave the answer "I do not interfere. This is his/her free decision." 33.4 % (n: 82) of the participants answered "no" the question "Would you consider donating your body as a cadaver after death?". When asked their reason for not donating their body, almost half of the participants (45.7 %) left the question unanswered. Table V shows the distribution of the responses of the participants to the questions showing their attitudes about cadaver donation.

Table V Distribution of the answers given by the participants to the questions showing their attitudes towards cadaver donation. 

DISCUSSION

Awareness and knowledge level of the individuals are important factors for developing positive attitudes towards body donation. Therefore, encouraging works will have a positive effect on the cadaver donation and increase the donation rate (Bamaç et al.). "Yes" answers with a rate of 75.5 % to the question "Do you know what the word cadaver means?" does not mean that the participants have a high level of knowledge. Because “yes” answer to the other questions in the questionnaire measuring the knowledge level of the participants varies just between 17.6 % and 66.9 %. These results show that the participants have accurate information about cadaver donation at a maximum level of two thirds, which should be interpreted as an insufficient level.

The proportion of the participants considering applying to the state hospital and family physician (42.40 % and 13.98 %, respectively) for body donation shows that the personnel working in these institutions should be informed about body donation and related procedures.

The percentage (39.2 %) of the answer “no idea” to the question "Do you think body donation is permissible in Sharia (Islamic law)?" provides evidence that the activities of the Presidency of Religious Affairs of Turkey have not yet achieved the desired level.

When the educational level of the participants was evaluated, it was observed that the level of knowledge of the group of literate and primary school degree was inadequate. When the education level group was evaluated in terms of awareness and knowledge level score (AWKL-Score), it was determined that as the level of education increases, knowledge level score increases. In addition, it was determined that the knowledge level of the self-employed group was quite low in the occupational groups. Therefore, it was concluded that these groups should be informed about body donation.

Low body donation rates determined in this study shows that, in Turkey, making significant progress is needed.

The participants' awareness and knowledge level (AWKL-Scores) about cadaver and cadaver donation was evaluated as quite low (0.41±0.24). From this, it was concluded that the community should be informed about body donation. When the relationship between AWKL-Scores and age was evaluated, it was observed that the middle age group should be informed more than the younger (18-29 y) and 60 and older age group.

In parallel with the advancement of medicine, the need for cadavers is increasing in the fields of anatomy and medical research. Various methods are used in cadaver procurement in different countries and medical schools (Kleinman & Lowy, Mekahli et al.; Subasinghe & Jones). In the literature, from an ethical and broad perspective, it is suggested that cadavers obtained from donations will be more appropriate (Emson; Caplan). Throughout the history of anatomy and medicine, obtaining cadavers for education has been an important problem. As a result of ethical discussions, the most accurate method for cadaver procurement was considered to be voluntary donation of the human body or part of it (Bøgh & Madsen; Dalal). Today, cadavers used in medical schools in almost all developed countries are the corpses of people who voluntarily donated their bodies to science. The number of donations has increased in these countries in recent years and has exceeded the storage and/or usage capacity of laboratories. Therefore, there are medical schools that suspend their donation programs for a certain period. In addition, in the USA, the donation programs of scientific institutions for the procurement of cadavers to medical studies or the provision of services from private supply companies are being discussed (Wingfield). It is reported that strong body donation programs are needed in countries where there the body donations are not at desired level (Gatica-Araneda & Alfaro-Toloza).

There is inadequate published information about body donation programs. There are studies showing that donation rates have increased five times in four years through successful programs, mass media, distribution of posters and brochures, seminars and incentive visits to the anatomy museums (da Rocha et al.). It is reported that there is a gap between knowledge and motivation for organ and body donation, which should be filled with an appropriate guidance program and education (Saha et al.). The results of previous surveys show that ignorance is the main reason for the reluctance of body donation (Abbasi Asl et al.; Bamaç et al.; Ciliberti et al.).

Limitations. This study has some limitations. First, this is a cross-sectional study. The questionnaire form was developed by the researchers and no validity-reliability tests were performed. The study population consisted of 245 people and may not be considered as representative of Izmir province. However, results of the study offers evidence will provide insight on the subject in Izmir and Turkey.

CONCLUSIONS

The importance of cadaver in medical education and the awareness and knowledge level of the individuals in the society about cadaver donation are very important. The results in our survey was interpreted as indicators of the lack of knowledge of individuals about body donation. As high awareness and knowledge level will positively affect individuals' attitudes towards body donation, encouraging studies and programs on body donation will have a positive effect on cadaver donation and increase the donation rate.

The data obtained in our study provides important details about which part of the society has low level of knowledge about body donation. The results will also guide anatomists in Turkey about the informative and promotional activities on body donation should be focused on which parts of the society.

In particular, it will be useful to carry out body donation programs supported by public institutions through visual and written press. With the encouragement of these donation programs, we hope that body donation rates in our country can be increased to the required level.