An empirical investigation on the impact of attitudes towards organ donation in India

Background: Organ shortage is a global issue and it is imperative to take steps to bridge this gap. In the Indian context, despite its demographic dividend, the rate of organ donation has been abysmally low. This emphasizes a need to demystify the antecedents of organ donation intention among the Indian population. Methods: Using a cross-sectional research design and adopting a post-positivism research philosophy, this study identified 259 respondents by adopting a purposive sampling approach and data on knowledge of organ donation was collected using a structured, pretested questionnaire. Results: Awareness of organ donation law in India is low on specific issues and respondents from the health science & medicine discipline scored better on knowledge about organ donation. The findings show that most participants had heard about organ donation and had a favourable attitude toward it. The primary sources of information on organ donation were television and newspapers, and healthcare service providers. A complementary partial median is established (β = .217, t = 5.889, p < .001) which implies that willingness to discuss with family significantly mediates the association between attitude towards organ & tissue donation and willingness to sign the donor card. Conclusion: This study revealed that there is a general awareness of organ and tissue donation among the Indian population, but they lack clarity on certain specific issues. Mass media has to be effectively used to build awareness campaigns revolving around enhancing knowledge on a specific issue and building acceptance of the concept of organ and tissue donation.


Introduction
Organ donation is a significant milestone in the process of evolution of modern medicine. The act of donating an organ or a portion of an organ for transplantation to another person is known as organ donation. The Transplantation of Human Organs Act (Section 2), 1994, defines "transplantation as the grafting of any human organ from any living person or deceased person to some other living person for therapeutic purposes". This is the only way to prolong life and enhance the quality of life for people with terminal organ failures (Bedi et al., 2015). When Joseph E Murray and his colleagues performed the very first successful kidney transplant in Boston in 1954, the concept of organ donation gained traction (Watts, 2011). In the seven decades since organ transplantation has emerged to be a successful practice worldwide with kidneys, liver, and heart being the most transplanted solid organs (WHO, 2020) and musculoskeletal grafts & cornea being the most transplanted tissues. The International report on Organ Donation and Transplantation Activities (WHO, 2022) reported 129681 solid organ transplants globally in 2020. Despite this number of reported donations, there is still a supply-demand imbalance in the organ and tissue donation (OTD) space. The report further cites 17 deaths occurring every day due to the non-availability of organ donors and the existing donations are only catering to less than 10 percent of the global need. There is a significant difference between nations in the availability of appropriate transplantation procedures as well as in the level of safety, effectiveness, and quality of human cells and, OTD & transplantation. These systemic factors contribute to broadening the need-availability gap.

Literature review
In the Indian context, despite its demographic dividend, the rate of organ donation has been abysmally low. There is a significant mismatch between the demand and supply status in India. Despite the fact that approximately 180,000 people are estimated to suffer from renal failure each year, only 6,000 kidney transplants are performed (Chang et al., 2020). A timely liver transplant could save approximately 15% of the two lakh individuals who succumb in India every year from liver cancer or liver failure. As a result, India requires between 25,000 to 30,000 liver transplants per year, but only about 1,500 are carried out. Similarly, over 50,000 people die from heart failure each year in India, but only 10% to 15% of heart transplants are performed (Tamuli et al., 2019). Despite a 100,000 need, only approximately 25,000 Cornea transplants are performed each year (Mohan et al., 2020). These figures are not encouraging, regardless of the efforts of the government and voluntary organizations. The government has attempted to bring in a systemic change to ensure a transparent system of OTD and to stop human organ trafficking. The Government legalized organ donation under the "Transplantation of Human Organs Act" (THOA, 1994), and the Act has undergone various amendments since then The National Organ Transplant Program was initiated in the 12 th five-year plan of the Government of India to promote organ transplantation (THOA, 1994). The National Organ and Tissue Transplantation Organization (NOTTO) has been established as a nodal agency for this program, and it serves as a national-level registry for organ donation and transplantation.
Organ shortage is a global issue, and it is imperative to take steps to bridge this gap. The Government and Non-Governmental organizations have in tandem taken various steps to encourage people to register for organ donation. Several initiatives that spread fundamental knowledge, and enhance familiarity with and develop positive attitudes toward organ donation have been adopted. For instance, legalising organ donation and organ donation awareness campaigns on various media platforms are examples of initiatives that have been implemented by private and public organizations (Meena et al., 2023).

REVISED Amendments from Version 1
The reviewers' comments have been incorporated, and the changes, wherever necessary, can be observed in the following areas of the manuscript: Any further responses from the reviewers can be found at the end of the article Intention to donate organs is shaped by an individual's knowledge of organ donation, attitude, and behaviour, and is further influenced by cultural and religious orientations (Chung et al., 2008;Rithalia et al., 2009;Mekahli et al., 2009;Ramadurg & Gupta, 2014;Manish et al., 2015;Vijayalakshmi et al., 2016, Vincent et al., 2022. Age, gender and socioeconomic status, and education have been reported to have a significant influence on attitudes toward organ donation (Bilgel et al., 2004;Spigner et al., 2002;Saleem et al., 2009;Balwani et al., 2015). A study undertaken by Gorczyca and Hartman (2017) emphasized the importance of including millennials in a larger conversation about organ donation and transplantation as they could contribute to future campaign tactics at local and national governmental levels. As India has a 34.8 percent representation of millennials in the population, or people aged 17 to 34 (according to the data furnished by the Social Statistics Division of the Central Statistics Office, Ministry of Statistics and Programme Implementation, Government of India, as of 2011), they could contribute to accelerating reach of the campaigns. In a similar study, to this evidence, undertaken by the United States Department of Health and Human Services (2013), it was identified that people above the age of 65 were less likely to sign up for organ donation compared to those of the age group 18-34 years. Loughery et al. (2018) have also cited the age and education status of the donor as significant barriers to organ donation. Additionally, a study undertaken by Alex et al. (2017) provided evidence of an inadequate level of knowledge on organ donation among medical students served as a barrier to OTD. Hence it is imperative to assess the current knowledge level, attitude, and willingness to register for organ donation among various age groups and whether it varies across the population with the discipline of education.
There exists sufficient research evidence to conclude a positive significant association between willingness to discuss OTD with family and attitudes toward OTD (Knox et al., 2017;Kopfman, 2002;Thompson et al., 2004;Wu & Tang, 2009). Although this association has been established, the details of the discussion are still an enigma. Most of the research evidence indicates a similar influence on the intention of organ donation, although there is a lack of empirical evidence proving this hypothesis. Knowledge of organ donation also has a positive association with discussion intention (Guadagnoli et al., 1999). Among gender, women were more likely to discuss organ donation intention than men (Thompson et al., 2004). Even though there is a direct effect of willingness to discuss with family on intention to enroll as an organ donor, the mediating role of this construct has not been explored. There is a paucity of research evidence that documents awareness and attitude with respect to organ donation in the Indian community. Hence this study intends to explore this further. This study will also explore the mediating role of willingness to discuss organ donation between the attitude toward OTD and the intention to enroll as an organ donor. The conceptual framework that has been proposed is shown below (Figure 1).

Ethics
This study was reviewed and approved by the Scientific Committee Manipal Academy of Higher Education, Manipal, India on 16 th March 2022. While administering the questionnaire, written informed consent was taken from the participants. Participants were ensured that the collected data would be used for research purposes and that the data would be sufficiently de-identified.

Study design
This proposed research endeavour is cross-sectional by research design and is quantitative by nature. The "postpositivism" research philosophy that is being considered in this study concerns the development of empirical methods for comprehending and investigating human behaviour. The philosophical assumptions in the backdrop of Post positivism approach is that consent from the participants has been taken to uphold the nature of research ethics and it is primarily quantitative nature of the inquiry. The conceptual framework for this study proposes a relationship between the independent, dependent, and mediating factors. Demographic factor like education is considered moderating variables.

Study setting
As per the report submitted by the Health and Family Welfare, Ministry of Karnataka, Karnataka state has been one of the forerunners in terms of organ donation in India (Kute et al., 2020). As per the current statistics, 143 organ donations have been recorded in 2022 which has given a fresh lease of life to 397 people. Hence, this study was undertaken in Karnataka state. Footfalls are a metric that indicates the popularity of the mall and also reflects homogeneity in tenant mix and visitors to the mall (Mohan & Tandon, 2015). Hence 4 malls in each of the districts having the highest footfalls were identified to undertake the survey. Further, a simple random technique was employed to identify the malls in Dakshina Kannada and Udupi districts for data collection. The target population for this study was the general population residing in the above districts who were free of organ failure and who knew English. No other inclusion criteria were adopted. A purposive sampling technique was adopted to identify participants at four shopping malls; two located in each district. Participants were approached at the malls and after applying the inclusion criteria, were briefed on the objective of the research. On obtaining consent, the participants were requested to fill out the questionnaire. Data collection was undertaken from November 2022 to January 2023.

Sampling
This investigation used a purposive sampling approach (non-probability by nature), which was adopted due to the absence of a sampling frame. Data was collected from 259 respondents. The study comprises of respondents from three age groups (18-26, 27-42, and 42 and above). Respondents who know English were requested to fill the questionnaire.
The sample size was calculated based on the number of items on the rating scale multiplied by 10 as proposed by Hair et al. (2017b). Hence, The sample size was determined by multiplying the number of rating scale elements by ten [15] i.e. 15*10 = 150. Considering 10% of the unanswered sample (i.e.15) gives rise to 165 (150 + 15 = 165). Finally, 259 participant data were collected.

Data gathering
Data was collected using a structured questionnaire. A copy of the questionnaire is also placed the Extended data (Nayak & Nayak, 2023). The questionnaire was divided into five parts. Part 1 captured the demographic details of the participants, like age, income, education, and gender. In addition, two questions on participants' awareness of OTD and sources of information on OTD were also incorporated. Part 2 assessed the knowledge of participants on OTD Jacob Arriola et al. (2008). This section included eight items with true or false response options, which were further subdivided into four sub-scales: general donation-related statistics (two items), understanding of what signing a donor card entails (three items), medical fitness for donation (two items), and knowledge of religious institutions' approach to donation (one item). The maximum score in this component was 8, with one mark for each correct response. The third part of the questionnaire consisted of seven items to measure attitudes toward OTD (Morgan & Miller, 2001). The next section of the questionnaire inquired about the participant's willingness to talk about OTD with family and friends (Morgan & Miller, 2002). The final part of the questionnaire captured the participant's willingness to sign the organ donor card adopted from Horton and Horton (1991). All responses were coded using a 5-point Likert scale, with 1 representing strong disagreement and 5 representing strong agreement.

Data collection
Prior to the final data collection, the research instrument was subject to a pilot test to assess construct validity. Data were collected from 25 respondents through a purposive sampling technique. Cronbach Alpha was estimated to establish construct validity using IBM SPSS Statistics 27 (RRID: SCR_016479; Armonk, NY: IBM Corp). Cronbach alpha of the endogenous construct (willingness to sign the organ donor card = 0.875) and exogenous constructs (attitudes towards OTD=0.724& willingness to discuss OTD=0.867) were well above 0.7, indicating acceptable levels of internal consistency. Loadings of all factors and communalities were significantly greater than 0.5, and the Kaiser-Meyer-Olkin and Bartletts Test was significant (>0.8).

Data analysis
The negatively worded items were reverse-coded and considered for final data analysis. IBM SPSS Statistics 27 (RRID: SCR_016479; Armonk, NY: IBM Corp) RRID: SCR_016479; Armonk, NY: IBM Corp) was used to undertake a descriptive analysis of the demographic variables and is presented in the results section. To test the hypotheses and perform the mediation analysis, the statistical package SmartPLS4 (RRID: SCR 022040) was used. PLS-SEM is becoming more popular as a statistical package due to its versatility and dependability in analyzing composite and empirical studies. Structural Equation Modelling performed in this study can also be undertaken by using jamovi (RRID: SCR_016142), which is a free source software.

Results
The demographic characteristics of the participants were analysed using IBM SPSS Statistics 27 software (Table 1). For the complete dataset, see Underlying data (Nayak & Nayak, 2023). Of the 259 respondents, 173 (67%) were female and 171 were between 18 to 26 years of age. 113 respondents had enrolled or completed their Bachelor's education in the healthcare domain like medicine, life science, nursing, health science, and allied health (Table 1). All the participants reported that they are aware of organ and tissue donation but only 125 (41%) stated that they were aware of OTD (Table 2). A "chi-square test of independence" displayed that there was a significant association between education and awareness of the OTD act in India Χ2 (1, N = 259 = 6.980, p ≤ 0.05).
Participants' knowledge of OTD was assessed by posing eight questions (Table 3). A majority (96.5%) of the participants were aware of the demand for transplants exceeding availability. They were also aware of the fact that many people were losing their lives due to the non-availability of organs to be transplanted (91.15%). Three questions were posed to the respondents to assess their knowledge of the implications of signing a donor card. The majority (95.8%) were aware they could specify the organs and tissues they want to donate on the donor card but only 33% of them knew that they could change their mind after signing the donor card. Two-thirds of the participants thought that the next of kin (family) must permit donation to occur even if the donor had signed the donor card. Participants were also assessed on their knowledge of how medical viability for donation is determined. More than half of the participants (51.7%) were not aware that the age or medical condition of the donor is important antecedent of becoming an organ donor. Whereas 82% of the participants knew that signing up for organ donation would not change the line of treatment they would receive in the future. Around 68% of the respondents believed that religious people would not oppose OTD. However, the standard deviation and mean of the knowledge score were estimated to be 1.116 and 5.25. The mean of the knowledge score of samples from the healthcare domain (7) was higher than the mean of both medical and non-medical participants put together.

Reliability and validity analysis
The measurement model was evaluated to determine the constructs' reliability and validity (Table 4) and the Structural Model evaluation is presented in Figure 2. First, the factor loadings of all items in the model were checked to ensure that they were greater than the minimum acceptable value of 0.5 (Hair et al., 2017a). Vinzi et al. (2010) opine a minimum acceptable factor loading of 0.7 but in social science studies, researchers frequently obtain lower outer loadings. Instead of automatically eliminating the indicators, it would be better to assess the impact of their elimination on the improvement in the reliability and validity of the constructs. Cronbach's alpha, rho a, and composite reliability were used to assess reliability; statistical values were higher than the recommended threshold value of 0.7 (Wasko & Faraj, 2005). The value of rho_a was found to be in between composite  reliability (Hair et al., 2017a) and Cronbach's alpha, and was also above 0.7 indicating excellent reliability (Henseler et al., 2016). "Average Variance Extracted" (AVE) was higher than 0.5 hence establishing convergent validity. Fornell & Larcker method was employed to establish discriminant validity (Table 5).

Structural model
The structural model reflects the hypothesised path of the research framework. R 2 , Q (Ahlawat et al., 2013), and the significance of the paths are used to evaluate the structural model. The R 2 value, which indicates the strength of each structural path in the model, can be used to assess a model's goodness. Falk and Miller claim (1992), the R 2 value should be equal to or above 0.1. This establishes the predictive capacity of the model. Q 2 value is used to establish the predictive relevance of the endogenous construct. Q 2 value above 0 indicates the predictive relevance of the construct. In the current study, both R 2 and Q 2 values are above this threshold value (Table 6) hence indicating the goodness of the model.   Furthermore, the "model fit" was evaluated using the Standard Root Mean Square Residual (SRMR). The value of the SRMR residual was 0.084 which was well within an acceptable range (Hair et al., 2017a).
In addition, the hypothesis was tested to explore the significance of the relationship. H1 evaluates if the attitude towards OTD has a significant impact on the intention to sign the donor card. Results revealed that attitude towards OTD has a significant impact on intention to sign the donor card (β = .258, t = 5.220, p < .001). Hence H1 was supported. H2 proposed an association between attitude towards OTD and willingness to discuss with family and was also supported (β = .407, t = 6.535, p < .001). Results also revealed that willingness to discuss with family had a significant positive association with intention to sign the donor card (β = .534, t = 9.851, p < .001). Table 6 shows the 95% confidence interval generated by the study of 5000 resamples. A confidence interval that is not zero indicates that there is a significant relationship.

Mediation analysis
Mediation analysis was performed to check if the willingness to discuss with family mediates the association between attitude towards OTD and willingness to sign the donor card. A complementary partial median is established (H4: (β = .217, t = 5.889, p < .001) which implies that willingness to discuss with family significantly mediates the association between attitude towards OTD and willingness to sign the donor card.
To explore if the attitude towards OTD varied across participants from the health science domain and engineering, management, and humanities, the Mann-Whitney U Test was utilized. The test revealed a significant difference in OTD among participants from the health science domain (Media = 30, n = 113) and engineering, management, and humanities (Media = 29, n = 146), U = 6838, z = 2.367, p = 0.018, r = 0.14). Hence, we can conclude that the discipline of education has a significant influence on attitude towards OTD. Even though education is determined to increase knowledge on OTD, it is suggested by Meier et al. (2000) that most donors do not explore organ donation before pledging to donate the organ.

Importance Performance Matrix Analysis
The Important-Performance Matrix Analysis (IPMA) elucidates the relative importance and performance of exogenous (attitude towards OTD & willingness to discuss with family) and endogenous constructs (intention to sign the OTD card) in relation to one another. Total effects and index values represent their significance and performance. Importance reveals the overall effect on the endogenous variable. The performance demonstrates the potential of latent variable scores. The X and Y axes are used to quantify importance and performance. The total effect is represented by the X-axis, while performance is represented by the Y-axis. A construct performs better when it has a higher mean value ( Table 7). The results of IPMA analysis reveal that willingness to discuss with family displays a high performance of 69.581 and a high total effect of 0.534 in comparison with the other exogenous (attitude towards OTD) displaying a performance of 83.028 and a total effect of 0.475. Hence a unit of increase in performance of attitude towards OTD enhances intention to sign donor card from 66.087 to 66.562. Similarly, an increase in one unit of construct, willingness to discuss with family would increase the performance of construct intention to sign OTD card by 0.534 points to 66.621 points. Figure 4 represents the IPMA map.

Discussion
This study intended to explore the knowledge of OTD across age groups in the Indian population. The goal was to assess the general public's knowledge and attitude toward organ donation. The findings show that most participants had heard about organ donation and had a favourable attitude toward it. These research findings are similar to results obtained by previous studies by Vijayalakshmi et al. In line with previous studies, we observed that the primary sources of information on organ donation were television and newspapers, healthcare service providers, and followed by social media and the internet. In line with the previous studies, healthcare service providers played an integral role in creating awareness of OTD (Vijayalakshmi et al., 2016; Narendran et al., 2022). They could be the primary motivators in raising awareness among their family, friends, relatives, and neighbours. A recent 5-year retrospective case record analysis revealed that only 10 (5%) of 205 patients diagnosed as brain dead had their organs donated (Sawhney et al., 2013). This study again highlights the lack of awareness of the concept of organ donation and the need for the relevant stakeholders to collectively work together to strengthen awareness of OTD. As a result, both governmental and non-governmental organizations should play an active role in raising public awareness about brain death. THOA was enacted in 1995, but only 42% of participants were aware of organ donation legislation. These findings were comparable to previous studies that found 5 ., 2015). The stakeholders could adopt television and digital campaigns to enhance awareness of OTD, the process involved, and THOA. According to the Global Overview report 2022, 35% of the Indian population resides in the urban landscapes of the country and most of this population has access to television, the internet, and social media (Digital 2022Global Overview Report, 2022. Hence, emphasis on television and digital campaigns could contribute strongly to creating awareness and registering for OTD as most of the participants (96%) are aware that people are dying  due to lack of availability of organs. In general, the donor will be given the organ donation card after signing it, and if the donor changes their mind about donating organs could tear up the organ donation card (Gungormüs & Dayapoglu, 2014). The majority of our study's participants (66%) believed that once they signed the organ donation card, they couldn't change their minds. As a result, these issues must be addressed when creating public awareness programs. Issues concerning the signing of organ donation cards should be clarified by the government and non-governmental organizations. 68% of all those surveyed believed that various religions oppose OTD. These findings were consistent with the documented literature, which indicated that religious beliefs were the most significant barrier to organ donation (Patthi et al., 2015;Vijayalakshmi et al., 2016). In India, the family traditionally looks after its members, even when they are sick. As a result, the consent of the next of kin is required for organ donation from a deceased donor (Ahlawat et al., 2013). Moreover, 61% of respondents agreed that knowing their family's wishes after their death was important. As a result, family members must have a positive attitude toward organ donation. Around one-third of the respondents thought that various religions opposed OTD. These findings echo the findings of the research endeavours of Vijayalakshmi et al.  (2022) present evidence for the fact that the nature of education was significantly associated with attitude towards OTD. It was observed that health science professionals had a more positive attitude towards OTD in comparison to their colleagues from other professional disciplines. Our study echoes this evidence as it is observed that respondents from a medical and health science domain had a more positive attitude towards OTD. Hence there is a need to create awareness and build a positive attitude toward OTD among the non-health/medical science population as attitude defines the intention to be an organ donor.
Willingness to discuss with family is reported to have a positive mediation between attitude towards OTD and intention to be an organ donor. Hence there is a need for government and non-governmental stakeholders to normalize the discussion on OTD in society. There appears to be a lack of consideration for the topic which creates a communication barrier (Feeley & Servoss, 2005). An OTD-friendly environment and family can increase the willingness to donate organs. Seeing family approval and willingness may help individuals make positive decisions about the subject (Sengul & Sahin, 2022) As a consequence, it is essential to explain the issue to all family members through community educational activities using plans and brochures for all family members. It may be beneficial to plan mass communication campaigns to strengthen acceptance of the topic among the population at large.

Conclusion
This study provides several insights into the OTD scenario in India. This study revealed that there is a general awareness of OTD among the Indian population but they lack clarity on certain specific issues. The majority of participants were unaware of the legislation or the donation process & clarity on the role of family when the donor had signed the donor card was ambiguous. It was established that the willingness of the donor to discuss with family played an instrumental role in strengthening the intention to donate an organ. Attitudes toward organ donation was significantly different among people with health science or medical backgrounds and from engineering, management, and humanities domains. This situation highlights the need for governmental and non-governmental institutions to take up the mandate of creating awareness that could lead to bridging the demand-supply gap of organs in India.
The cross-sectional research design serves as a limitation of this research endeavour. Further studies could adopt qualitative or experimental approaches to explore the rationale of OTD. Future studies could investigate if the knowledge, attitude towards OTD, and organ donation intention varied across Generation Z (born between 1996-2000) and Millennials (born between 1981 to 1995) (Thangavel et al., 2021). Further, this research endeavour has been undertaken in the urban setting, which might limit the generalizability to the rural population. This will enable stakeholders to design appropriate campaigns and adopt the most appropriate media to create awareness of OTD thereby bridging the demandsupply gap. This project contains the following extended data:

Data availability
• Questionnaire with codes.docx  I agree with the changes you have made to the introduction section, including the incorporation of the research objective derived from the research questions. This addition helps to clarify the aims and objectives of your study.
Regarding the sampling technique, I appreciate the clarification provided on the selection of the four malls. The explanation of using footfalls as a metric to identify popular malls and reflect homogeneity in tenant mix and visitors to the mall is appropriate. Additionally, the mention of employing a simple random technique to identify the malls in Dakshina Kannada and Udupi districts for data collection further enhances the transparency and rigour of your methods.
I am also satisfied with the explanation you provided for the sample size calculation. The use of the proposed approach by Hair, Sarstedt, Ringle, and Gudergan (2017) to determine the sample size based on the number of items on the rating scale multiplied by 10 is appropriate. Your justification for considering 10% of the unanswered sample and resulting in a final sample size of 259 participants is sound.
I appreciate your efforts in providing additional details on the questionnaire used for data collection. The inclusion of construct-wise details in the Data Gathering section is helpful. Moreover, the fact that the detailed questionnaire is publicly available through Figshare, with the DOI mentioned in the manuscript, ensures transparency and allows for future replication and validation of the instrument. The mention of the reliability and validity of the scales being assessed through the pilot study, with the results presented in the "Data Collection" section, further strengthens the robustness of your methods.
Regarding the choice of statistical analysis methods, I understand and support your decision to use SmartPLS4 for PLS-SEM analysis, considering the blend of probability and nonprobability sampling techniques and the presence of a mediator in your conceptual framework. The mention of jamovi as an alternative free-source software for structural equation modelling provides valuable information for researchers who may want to replicate or build upon your study using different analytical tools.
I am glad to see that you have addressed the biases by presenting them as limitations of your research work in the Results section. By acknowledging these limitations, you demonstrate a clear understanding of the potential impact on the generalizability and interpretation of your findings.
Lastly, I appreciate the improvements made in the discussion section, particularly the mention of cross-sectional research design and the suggestions for future research directions, including experimental and qualitative research. The clarification on the generalizability of the results within the defined scope and research setting, as well as the suggestion for future research from a geographical perspective, adds value to your study.
In summary, I believe the manuscript has significantly improved based on your responses. You have adequately addressed the concerns raised, providing additional information, clarification, and justifications where needed. Given the changes made, I am pleased to approve the manuscript for indexing.
Once again, I commend you on your diligent revisions, and I look forward to seeing your research contribute to the field of organ donation in India.

Madhur Verma
of expertise to confirm that it is of an acceptable scientific standard, however we have significant reservations, as outlined above.
clearer explanation of how the questionnaire was developed and validated would help to establish its reliability and validity.
The authors should provide more detail on the data analysis methods used. While it is stated that SmartPLS4 and jamovi were used for data analysis, the statistical tests used, and their justification should be described in more detail.

Results:
This section is well-written and provides a comprehensive analysis of the research study findings. The authors use appropriate statistical methods to analyze the data and report their results in a clear and concise manner. However, it is essential to note that the manuscript section does not provide information on the sampling strategy used to select the participants, which can impact the generalizability of the results. Additionally, the authors do not mention any potential biases that may have affected the results, such as response bias or social desirability bias.

Discussion:
There are also some limitations to the study that need to be considered. The cross-sectional research design can limit the ability to establish causal relationships or determine changes over time. Moreover, the study participants were only from urban areas, so the findings may not be generalizable to the entire population. Lastly, the manuscript did not provide detailed information on the sample size or the sampling procedure, which makes it difficult to evaluate the representativeness of the sample or the potential for bias.

In General:
The manuscript has several strengths, including a clear and concise writing style, a comprehensive literature review, and a well-organized presentation of the study results. The authors also make some important recommendations for future research, including exploring the knowledge, attitudes, and intentions of organ donation across different generations and investigating the reasons for the low donation rates in India.
Overall, the manuscript is well-written and provides valuable insights into the knowledge, attitudes, and intentions of organ donation in India. However, the limitations of the study should be considered, and future research should address these limitations to build on the findings presented in this manuscript.

If applicable, is the statistical analysis and its interpretation appropriate? Yes
Are all the source data underlying the results available to ensure full reproducibility?
of the manuscript. The items of each construct ( detailed questionnaire) is uploaded in Figshare, hence publicly available. The DOI of the same has been mentioned in the manuscript.
The reliability and validity of the scales was done through the pilot study, the results of which are presented in the "Data Collection" section of the manuscript.
4 PLS: as we have opted for a blend of probability and nonprobability sampling techniques, and the presence of a mediator in the conceptual framework, PLS-SEM was the tool chosen against Jamovi or AMOS.
"To test the hypotheses and perform the mediation analysis, the statistical package SmartPLS4 (RRID: SCR 022040) was used. PLS-SEM is becoming more popular as a statistical package due to its versatility and dependability in analyzing composite and empirical studies. Structural Equation Modelling performed in this study can also be undertaken by using jamovi (RRID:SCR_016142), which is a free source software." 5. Results: The biases are presented as limitations of the research work undertaken.
6. Discussion: Cross section research design: has been employed in the study. Experimental and Qualitative research has been suggested as a direction for future research. The results are generalizable as the scope and research setting are justified in the manuscript. Future research is suggested from a geographical perspective of the study.

Competing Interests:
No competing interests were disclosed.
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