Willingness of Patients With End-Stage Renal Disease to Accept a Kidney Transplant and Related Factors

ABSTRACT Background The prevalence of end-stage renal disease (ESRD) in Taiwan is among the highest in the world. Although kidney transplant is the most effective treatment for ESRD, the willingness of patients with ESRD to undergo kidney transplantation is low in Taiwan. The factors associated with willingness to accept kidney transplantation remain unclear, and studies on kidney transplant willingness and associated factors among Taiwanese patients with ESRD are scarce. Purpose The aim of this study was to assess willingness to undergo a kidney transplant and related factors among patients with ESRD in Taiwan. Methods A cross-sectional design was employed. Two hundred fourteen participants from a single medical center in Taiwan were recruited, and 209 valid questionnaires were collected (valid response rate: 97.7%). The study instruments included a kidney transplant knowledge scale, a kidney transplant attitude scale, and a kidney transplant willingness scale. Data were analyzed using Pearson's product–moment correlations, t tests, one-way analyses of variance, and multiple regressions. Results The mean kidney transplant willingness in the sample was 13.23 (out of 20). Being male, younger, married, or employed; having a college education or above; and having a shorter dialysis duration were all associated with higher kidney transplant willingness. Sociodemographics, dialysis duration, knowledge, and attitudes explained 45.4% of the variance in kidney transplant willingness, with two of these, kidney transplant attitudes (β = .61, p < .001) and dialysis duration (β = −.11, p = .041), identified as significant. Conclusions/Implications for Practice The findings support the important role of cultivating positive attitudes in patients with ESRD to increasing willingness to undergo kidney transplantation interventions.


Introduction
The incidence and prevalence of end-stage renal disease (ESRD) in Taiwan are among the highest in the world (United States Renal Data System, 2022).The main reasons for the high prevalence of ESRD in Taiwan include societal aging, the growth in the number of patients with chronic diseases such as diabetes and hypertension (Wang et al., 2021), the use of inappropriate kidney-related medications (Rasool et al., 2020), and the low rate of kidney transplantation (KT; Tsai et al., 2022).ESRD impacts negatively on patients, their families, and society and consumes significant medical resources (Hashmi et al., 2023).Alongside improving patient quality of life, KT is considered the optimal treatment for ESRD and is cost-effective in comparison to other related treatments (Abramyan & Hanlon, 2023).
KT involves the transplantation of a healthy kidney from a donor to a recipient.Depending on the source of the kidney, KTs are classified as either living-donor KTs or deceaseddonor KTs (Mayo Clinic, 2023).KTs can improve the survival rate of patients with ESRD, and patients receiving a KT often experience fewer symptoms of kidney disease (Dembowska et al., 2022).The 5-year patient survival rates for livingdonor and deceased-donor KTs have been reported as 97.6% and 95.7%, respectively, for recipients aged 18-34 years, and 84.4% and 72.5%, respectively, for recipients aged ≥ 65 years Purpose: The aim of this study was to assess willingness to undergo a kidney transplant and related factors among patients with ESRD in Taiwan.
Methods: A cross-sectional design was employed.Two hundred fourteen participants from a single medical center in Taiwan were recruited, and 209 valid questionnaires were collected (valid response rate: 97.7%).The study instruments included a kidney transplant knowledge scale, a kidney transplant attitude scale, and a kidney transplant willingness scale.Data were analyzed using Pearson's product-moment correlations, t tests, one-way analyses of variance, and multiple regressions.
Results: The mean kidney transplant willingness in the sample was 13.23 (out of 20).Being male, younger, married, or employed; having a college education or above; and having a shorter dialysis duration were all associated with higher kidney transplant willingness.Sociodemographics, dialysis duration, knowledge, and attitudes explained 45.4% of the variance in kidney transplant willingness, with two of these, kidney transplant attitudes (β = .61,p < .001)and dialysis duration (β = −.11,p = .041),identified as significant.
Conclusions/Implications for Practice: The findings support the important role of cultivating positive attitudes in patients with ESRD to increasing willingness to undergo kidney transplantation interventions.

O R I G I N A L A R T I C L E
The Journal of Nursing Research ▪ VOL. 32,NO. 3, JUNE 2024  ( Lentine et al., 2023).Between 2000 and2009, 81.3% of patients in Taiwan who survived KT did not return for longterm dialysis within 5 years of their KT surgery (National Health Research Institutes & Taiwan Society of Nephrology, 2022).However, the 5-year survival rate of patients receiving dialysis alone has been reported to be 44% (United States Renal Data System, 2022).Thus, KT is the preferred and goldstandard treatment modality for ESRD (Lang et al., 2022).
KT willingness refers to the willingness and behavioral intention of patients with ESRD to undergo a KT.The willingness of patients to undergo a KT is fundamental to KT referral and treatment processes.Willingness is the quality or state of being prepared to do something, and positive willingness is a good predictor of behavior actualization.Strong willingness becomes more stable over time and makes an individual less susceptible to external efforts to change related behaviors (Conner & Norman, 2022).
Rates of chronic kidney disease, hemodialysis, and willingness to undergo a KT among patients with ESRD vary significantly by country.For patients with chronic kidney disease, rates of KT willingness were found to be 54% in the United States (Ilori et al., 2015), 69% in India (Kaur et al., 2019), and 67% in Ghana (Boima et al., 2021).For hemodialysis patients, rates of KT willingness were found to be 69% in Saudi Arabia (Alansari et al., 2017), 63% in Turkey (Kalender et al., 2015), 63% in Tanzania (Mzee et al., 2020), 60% in Pakistan (Ali et al., 2023), 73.3% in Morocco (Kabbali et al., 2014), and 35%-46% in China (Qiao et al., 2016;Tan et al., 2017).For patients with ESRD, rates of KT willingness were found to be 66.7% in Nigeria (Takure et al., 2016) and 16% in Taiwan (Chang, 2013).The willingness of patients in countries in East Asia to undergo a KT is relatively low compared to other regions and countries.Although Taiwan is home to numerous patients with ESRD, the proportion of those willing to undergo a KT is low.Moreover, although Taiwanese dependent on dialysis in 2019 numbered 86,840, only 9.0% were registered on a KT wait list (National Health Research Institutes & Taiwan Society of Nephrology, 2022).Therefore, factors affecting patients' KT willingness merit further investigation.
Researchers have explored relationships between sociodemographics and willingness to undergo a KT.Previous studies have revealed that patients who are male (Calvo-Calvo et al., 2018;Kim et al., 2023), younger (Alansari et al., 2017;Tan et al., 2017), more highly educated (Alansari et al., 2017;Hamilton et al., 2017), single (Alansari et al., 2017;Hamilton et al., 2017), employed (Tan et al., 2017), and financially well-off (Ilori et al., 2015;Qiao et al., 2016) as well as those who have been on dialysis for shorter periods (Alansari et al., 2017;Qiao et al., 2016) tend to be more willing to undergo a KT.However, some studies have reported unemployed people as being more likely to receive a KT (Calvo-Calvo et al., 2018;Hamilton et al., 2017).However, other potential factors of influence on KT willingness such as patient sources of information on KT (Ilori et al., 2015) and KT-related religious beliefs (Doerry et al., 2022;UT Southwestern Medical Center, 2022) have yet to be clarified.Therefore, the relationship between sociodemographics and KT willingness requires further exploration to help healthcare professionals provide services that are person centered and culturally appropriate.
Although several studies have explored knowledge of and attitudes toward KT among patients with kidney disease, the relationships among knowledge, attitudes, and willingness have not been examined.In Ilori et al. (2015), the vast majority (79.8%) of the patients with kidney disease self-reported their knowledge of KT as "below" average.Also, Alansari et al. (2017) found 61% of the hemodialysis patient participants had "poor" or "very poor" knowledge of KT.Similarly, Boima et al. (2021) reported that approximately 90% of participants rated their knowledge of KT as "below average" or "average," and Mzee et al. (2020) found only 62.8% of participants had any awareness of KT.The above studies demonstrate a general lack of knowledge regarding KT among patients receiving dialysis.Conversely, one study found 77% of patients had knowledge of KT (Kalender et al., 2015), whereas other studies have revealed positive attitudes toward KT among a majority of participants (Boima et al., 2021;Mzee et al., 2020).However, a systematic literature review by Navaneethan and Singh (2006) identified generally negative attitudes toward KT among African American patients.Another study pointed out that attitudes were more negative and KT willingness was lower among patients aged ≥ 60 years (Alansari et al., 2017).These conflicting findings highlight the need for further investigation of the KT knowledge and attitudes of patients with ESRD and of the influence of these two factors on KT willingness.
Uncertainty persists regarding the significant factors associated with KT willingness, and studies on KT willingness and associated factors among Taiwanese patients with ESRD are scarce.Therefore, this study was designed to examine the KT willingness of patients receiving dialysis and associated influencing factors.

Study Design and Participants
In this cross-sectional study, patients from the dialysis department of one medical center in Taiwan were recruited as participants.An estimated minimum sample size of 157 was calculated using G*Power Version 3.1.9.2 with the following conditions: effect size f 2 (medium) of 0.15, alpha level of .05,power of .9, and 12 predictors (Cohen, 2013).All of the participants were recruited in the Department of Nephrology and Dialysis at the study hospital using convenience sampling.Two hundred fourteen questionnaires were distributed, and 209 valid questionnaires were collected (valid response: 97.7%).
The inclusion criteria were as follows: (a) diagnosed with ESRD by a physician and having received hemodialysis on a regular basis for more than 3 months, (b) aged 20-65 years (Taiwan law stipulates kidney recipients must be younger than 66 years; Jih Sun Health Foundation, ROC, 2022), and (c) clear cognition and the ability to communicate in written or spoken Mandarin or Taiwanese.The exclusion criteria were as follows: (a) patients diagnosed with contraindications to KT (e.g., malignancy, severe cardiovascular disease, coagulation disorders, chronic respiratory failure, heart failure, psychiatric disease, severe congenital malformations of the urinary tract, AIDS) and (b) the presence of a speech impairment or refusal to complete the questionnaire.

Instruments
The questionnaire, including three scales (as described below), sociodemographics, and disease history, was developed based on related studies (Alansari et al., 2017;Ilori et al., 2015;Qiao et al., 2016).Five clinical experts and academics specializing in kidney disease were invited to review the content validity of the questionnaire items using a 4-point scale (1 = inappropriate to 4 = very appropriate; Gray & Grove, 2020).The content validity index values of the KT knowledge scale, KT attitude scale, and KT willingness scale were .89,.90, and 1.0, respectively.Next, a pilot test of the questionnaire was administered to 15 patients.

Kidney transplantation knowledge scale
The KT knowledge scale consists of 12 true/false items in the domains of KT evaluation (five items), registration criteria (one item), surgical procedures and sequelae (four items), and regulations (two items: "After receiving KT, a patient may still encounter problems such as infections, rejection, and malignant tumors" and "Renal transplant registries should be performed in multiple hospitals to ensure that registry data are valid").Correct and incorrect answers are respectively scored 1 and 0, with the total possible score ranging from 0 to 12 and higher scores indicating better KT knowledge.Difficulty levels for the items were .13-.87, and the item discrimination indices were .31-.92 (all > .3),indicating satisfactory discrimination power for the scale (Kumar et al., 2021).The Kuder-Richardson Formula 20 reliability coefficient of the scale was .87.

Kidney transplantation attitude scale
The KT attitude scale consists of 11 items.A principal component analysis was used to conduct an exploratory factor analysis of construct validity.Two major constructs were identified: attitudes toward transplant surgery (six items; e.g., adequate knowledge of KT, ability to discuss with family members, family support, attending surgical education courses) and attitudes toward negative transplant effects (five items; e.g., concerns about being too old, the cost, unsuccessful surgery, rejection).The total variance was 54.74%, and the Kaiser-Meyer-Olkin value was .802.Each item was rated on a bipolar 5-point Likert scale (−2 = strongly disagree to 2 = strongly agree), with the total possible score ranging from −22 to 22 and higher scores indicating more-positive attitudes toward KT.The Cronbach's α coefficient of the scale in this study was .80.

Kidney transplantation willingness scale
The KT willingness scale consists of four items related, respectively, to KT registration, deceased-donor KT, livedonor KT, and KT.Responses to each item range from strongly disagree (1) to strongly agree (5), with the total possible score for the scale ranging from 4 to 20 and higher scores indicating greater KT willingness.The Cronbach's α coefficient of the scale in this study was .95.

Sociodemographics and Disease History
The sociodemographic variables considered in this study included gender, age, educational level, marital status, employment status, financial status, religious beliefs, and sources of KT information.Disease history information included the type and duration of dialysis.

Data Collection
The study period ran from November 25, 2019, to January 31, 2020.The researchers obtained consent to conduct this study from the Director of the Department of Nephrology and Dialysis at the study hospital.Eligible participants were screened for inclusion and invited to participate by one researcher on the study team.After obtaining participants' verbal consent, the purpose of the study, data collection methods, anonymity, and participant rights were explained.The participants were asked to complete the questionnaire at home and return it to the dialysis center nurse at their next visit.

Ethical Considerations
This study was approved by the ethics review committee of Far Eastern Memorial Hospital (No. 108146-E).Participation was voluntary, and the participants had the right to interrupt, stop, or withdraw from the study without affecting their quality of care.Data were kept strictly confidential and were used for this study only.

Data Analysis
Data were analyzed using IBM SPSS Statistics 25.0 (IBM Inc., Armonk, NY, USA).The descriptive statistics in this study are presented in terms of counts, percentages, means, and SDs.Pearson's product-moment correlation, independent-samples t test, and one-way analysis of variance were used to examine the relationships between independent variables and dependent variables of interest.In addition, a multiple regression analysis with the enter method was used to examine the predictive power on KT willingness of sociodemographics, disease history, knowledge, and attitudes.In the regression analysis, assumptions of normality, linearity, independence of residuals, and multicollinearity were all met.For all of the analyses, the significance criterion was set to p < .05.

Sociodemographics and Disease History
Most (61.2%) of the participants were male, with ages ranging from 24 to 65 (mean = 53.80,SD = 8.65) years.The largest educational level category was high school (29.2%); most of the participants were married (71.8%) and unemployed (65.1%) and had religious beliefs (72.7%).Most perceived their financial status as adequate (57.9%).Most (79.4%) reported receiving information about KT from healthcare workers, and the average number of sources from which they had obtained information about kidney transplants was 1.68 (SD = 1.14), indicating participants' KT information sources were limited.Most (69.9%) had received hemodialysis, with dialysis durations ranging from 4 to 345 (mean = 63.02,SD = 60.04)months (Table 1).Thus, the average duration of dialysis of participants exceeded 5 years.

Kidney Transplantation Knowledge, Attitudes, and Willingness
Mean KT knowledge, attitude, and willingness scores were 6.14 ± 3.17, 0.39 ± 6.01, and 13.23 ± 4.89, respectively (Table 1), indicating participants had about 50% knowledge of KT, held neutral or slightly positive attitudes toward KT, and had 66% willingness to undergo a KT.In terms of KT willingness, 51.7%, 41.6%, 49.3%, and 50.2% agreed or strongly agreed that they would be willing to, respectively, register on a KT wait list, undergo deceased-donor KT, undergo live-donor KT, and undergo a KT.

Relationships Between Kidney Transplantation Willingness and Sociodemographics, Disease History, Knowledge, and Attitudes
Gender (t = 2.04, p = .043),age (r = −.26,p < .001),educational level [F(3, 205) = 4.38, p = .005],marital status (t = 2.49, p = .014),employment status (t = −3.65,p < .001),and dialysis duration (r = −.15,p = .036)were found to relate significantly to KT willingness.Specifically, being male, younger, single, and employed; having an education level of college or above; and having a shorter dialysis duration were associated with higher mean KT willingness scores.By contrast, self-perceived financial status, religious beliefs, information sources, and dialysis methods were not associated with KT willingness.Furthermore, KT knowledge and attitude scores correlated positively with KT willingness scores (r = .51and r = .40,respectively; both ps < .001;Table 2).This indicates better knowledge of KT and more-positive attitudes are associated with greater willingness to undergo a KT.

Predictive factors of kidney transplantation willingness
Significant variables found in the univariate analysis (e.g., gender, age, dialysis duration, and KT knowledge and attitude scores) were incorporated into a multiple regression analysis to examine their power in terms of predicting KT willingness.The aforementioned variables together explained 45.4% of the variance in participants' KT willingness, F(10, 198) = 18.33, p < .001.Moreover, KT attitudes (β = .61,p < .001)and dialysis duration (β = −.11,p = .041)were identified as significant variables in the multiple regression analysis (Table 3).

Discussion
The mean KT willingness score in this study was 13.23 (out of 20), indicating a KT willingness of 66%, which is similar

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to the rates (50%-70%) previously reported in Western countries (Boima et al., 2021;Ilori et al., 2015;Kabbali et al., 2014).There are some reasons for this finding.First, KTs in Taiwan have become increasingly advanced and successful.Moreover, the Taiwan government has strongly advocated for KTs, and the cost of the procedure is covered under the National Health Insurance program.In addition, half (49.3%) of the participants either agreed or strongly agreed they would be willing to receive a live-donor KT.This is higher than the findings of previous research, in which only 16% of patients with ESRD in Taiwan were identified as willing to receive a live-donor KT (Chang, 2013).One reason for this discrepancy may be that Chang's study included participants over the age of 66 years.Older adults are generally less inclined to receive a KT (Alansari et al., 2017;Tan et al., 2017).Notably, 51.7% of the participants in this study either agreed or strongly agreed that they would like to register for a KT wait list.Healthcare professionals should educate KT candidates about KT preparations, preoperative evaluations, and KT procedures and prognosis to reduce patient anxiety.Moreover, shared decision-making may be useful in informing patients with chronic kidney disease about the impact of different decisions on renal replacement therapy as well as in improving decision-making self-efficacy and reducing decision-making conflicts (Ho et al., 2020).Furthermore, special attention should be focused on those who disagree or strongly disagree with registering for and accepting a KT to understand their problems and concerns and provide timely services.This study found sociodemographics (e.g., gender, age, educational level, marital status, and employment) and disease history (e.g., dialysis duration) to be related to KT willingness.The average KT willingness score of male participants was higher than that of female participants, which is consistent with previous results (Calvo-Calvo et al., 2018;Kim et al., 2023).This disparity may relate to differences in the way men and women utilize healthcare services.Although women visit the doctor more often than men (You et al., 2019), men often utilize healthcare services in a business-like manner, are more likely to want active treatment, and may be more willing to undergo a major surgery (Reid et al., 2023).This study found younger participants to be relatively more willing to receive a KT, which is consistent with the findings of previous studies (Alansari et al., 2017;Tan et al., 2017).Possible reasons why older participants are less willing to undergo a KT are feeling comfortable with the status quo, lacking motivation to seek a transplant, and unwillingness to accept the related risks.The participants with an educational level of college or above were more willing to undergo a KT, which is also consistent with findings of previous studies (Alansari et al., 2017;Hamilton et al., 2017).It is possible that more highly educated individuals also have higher KT knowledge and more-positive attitudes toward KTs (Barth et al., 2021).
Notably, higher educational level and greater knowledge of KT were found in this study to be associated with morepositive attitudes toward KTs.Also, single participants were more willing to receive a KT than married participants, which is consistent with findings of previous relevant studies (Alansari et al., 2017;Hamilton et al., 2017).The reason for this may be that unmarried people do not have family responsibilities and are thus able to make decisions for themselves.Employed participants in this study were found to be more willing to receive a transplant than their unemployed peers, possibly because employed individuals are required to make time in their busy schedules to receive regular dialysis treatments.This finding is consistent with that of Tan et al. (2017) but is inconsistent with other studies (e.g., Calvo-Calvo et al., 2018;Hamilton et al., 2017).
Having a shorter dialysis duration was associated with greater KT willingness, which is consistent with the findings of previous studies (Alansari et al., 2017;Qiao et al., 2016).A possible reason for this trend is that individuals who have recently begun dialysis may wish to avoid related lifestyle changes and dialysis-related restrictions by receiving KT.Healthcare professionals should be concerned with impacts of sociodemographics and disease history on KT willingness to provide better, more appropriate care and services.
In this study, no statistically significant relationship was found between KT willingness and either financial status or religious beliefs.The former is inconsistent with the findings of a study conducted in China by Qiao et al. (2016) and a study conducted in the United States by Ilori et al. (2015) and may be attributed to the accessibility of universal health insurance under the National Health Insurance program in Taiwan (which covers KT).The lack of significant relationship found between religious beliefs and KT willingness is consistent with the results of Ilori et al.'s study but inconsistent with the findings of a study conducted in Saudi Arabia (Alansari et al., 2017).A possible reason for this is that Islam does not approve of accepting deceased-or live-donor KTs, whereas Taiwanese Buddhism and Taoism encourage organ donation and transplantation.The aforementioned variables in this study that show no effect on KT willingness should be further investigated.
The mean KT knowledge score in this study of 6.14 (out of 12) indicates that participants had about 50% knowledge of KT, which is similar to the findings of previous studies (Alansari et al., 2017;Ilori et al., 2015;Mzee et al., 2020).In addition, participants' KT knowledge and willingness scores were significantly and positively correlated, supporting that KT knowledge relates positively to KT willingness.Kalender et al. (2015) argued that patients may have extensive knowledge of KT because medical personnel voluntarily inform each patient receiving dialysis that they have the opportunity to register with an organ transplant center.Therefore, educational efforts are necessary to enhance willingness to receive a KT.
The mean KT attitude score in this study was 0.39 (mean score range: −2 to 2), indicating the participants generally held neutral or slightly positive attitudes toward KTs.This finding is similar to those of several previous studies (Ilori et al., 2015;Mzee et al., 2020).In this study, KT attitude scores were positively correlated with KT willingness scores, and attitudes were identified as the most important factor for predicting KT willingness.This study also showed that attitudes had a greater impact on KT willingness than knowledge.Previous studies have highlighted that attitudes involve emotions, values, and self-concepts, which are the main drivers of behavior, whereas knowledge is only an influencing factor (Bechler et al., 2021).Sometimes, achieving behavioral change requires deeper attitudinal changes, and simply providing knowledge may be insufficient (Verplanken & Orbell, 2022).The attitudes of participants toward KT in this study were more

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found to be important than KT knowledge.Therefore, healthcare professionals should conduct KT campaigns focusing on the importance of KT, sharing successful KT cases, and illuminating the benefits of KT in improving quality of life (Yunanto et al., 2022).Further, healthcare professionals may implement strategies to provide psychological support to dispel patient fears about KT and promote positive KT attitudes.

Limitations
This study is affected by several limitations.First, all of the participants were patients receiving dialysis at a single medical center in Taiwan.Thus, the generalizability of the results is limited.Second, some of the participants completed the questionnaires at home and returned them during their next visit.However, we did not compare the difference between on-site and home-completed questionnaires due to participant anonymity.Third, those patients with ESRD who elect dialysis versus transplantation are eligible for healthcare coverage that includes medications.This may be an important factor in determining patient decision-making, which should be further explored in future research.

Conclusions
Participants with ESRD who participated in this study had a medium-to-high level of KT willingness.However, the participants had limited knowledge regarding KTs, and their attitudes toward KTs were generally neutral to slightly positive.KT knowledge and attitudes were shown to positively correlate with KT willingness.This highlights the importance of improving KT knowledge and attitudes in patients with ESRD.Patient sociodemographics, dialysis duration, knowledge, and attitudes may predict KT willingness, with attitudes toward KT exhibiting the greatest predictive value.Educational efforts are necessary to promote positive attitudes to increase KT willingness.

Table 1
Characteristics of Participants (N = 209) a More than one item could be marked.

Table 2
Correlations Between Characteristics and Kidney Transplant Willingness (N = 209) a Scheffe's method.