Othman NIE, Lim CY, Razak L, Yusuf M, Ahmed D, Idris F, Joshi N, Khalil MAM, Duong MC, Tan J. Informing national policy: Healthcare workers’ readiness for a deceased donor kidney transplant program in Brunei Darussalam. World J Transplant 2026; 16(2): 117585 [DOI: 10.5500/wjt.v16.i2.117585]
Corresponding Author of This Article
Jackson Tan, Department of Renal Services, Raja Isteri Pengiran Anak Saleha Hospital, Jalan Putera Al-Muhtadee Billah, Bandar Seri Begawan BA1712, Brunei Darussalam. drjacksontan74@gmail.com
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Transplantation
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Othman NIE, Lim CY, Razak L, Yusuf M, Ahmed D, Idris F, Joshi N, Khalil MAM, Duong MC, Tan J. Informing national policy: Healthcare workers’ readiness for a deceased donor kidney transplant program in Brunei Darussalam. World J Transplant 2026; 16(2): 117585 [DOI: 10.5500/wjt.v16.i2.117585]
Nor Islya Emma Othman, Chiao Yuen Lim, Musuriani Yusuf, Dalinatul Ahmed, Jackson Tan, Department of Renal Services, Raja Isteri Pengiran Anak Saleha Hospital, Bandar Seri Begawan BA1712, Brunei Darussalam
Lubna Razak, Department of Policy Planning, Ministry of Health, Bandar Seri Begawan BB3910, Brunei Darussalam
Fazean Idris, UBD PAPRSB Institute of Health Sciences, Universiti Brunei Darussalam, Bandar Seri Begawan BE1410, Brunei Darussalam
Nayan Joshi, Department of Ophthalmology, Raja Isteri Pengiran Anak Saleha Hospital, Bandar Seri Begawan BA1710, Brunei Darussalam
Muhammad Abdul Mabood Khalil, Center of Renal Diseases and Transplantation, King Fahad Armed Forces Hospital, Jeddah 23311, Makkah Al Mukarramah, Saudi Arabia
Minh Cuong Duong, School of Population Health, University of New South Wales, Sydney 2033, New South Wales, Australia
Author contributions: Othman NIE, Lim CY, Razak L, Yusuf M, Ahmed D, Idris F, Joshi N, Khalil MAM, Duong MC, and Tan J conceptualized the study; Authors Othman NIE, Lim CY, Razak L, Yusuf M, Ahmed D, Idris F, and Joshi N were involved in data collection; Tan J performed the statistical analysis and wrote the initial manuscript. All authors confirmed the final edition.
AI contribution statement: ChatGPT was used for language polishing and to improve readability.
Institutional review board statement: This study was approved by the Medical and Health Research Ethic Committee of Raja Isteri Pengiran Anak Saleha Hospital (Approval No. MHREC/MOH/2025/28).
Informed consent statement: Informed consent was obtained from all participants prior to enrolment in the study. Participants were provided with written information outlining the study purpose, procedures, potential risks, and their rights, including the voluntary nature of participation and the ability to withdraw at any time without penalty. All responses were anonymized to ensure confidentiality.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Data sharing statement: All data pertaining to this research can be shared through the corresponding author, if required.
Corresponding author: Jackson Tan, Department of Renal Services, Raja Isteri Pengiran Anak Saleha Hospital, Jalan Putera Al-Muhtadee Billah, Bandar Seri Begawan BA1712, Brunei Darussalam. drjacksontan74@gmail.com
Received: December 11, 2025 Revised: February 10, 2026 Accepted: March 13, 2026 Published online: June 18, 2026 Processing time: 170 Days and 0.9 Hours
Abstract
BACKGROUND
Brunei Darussalam currently lacks a deceased donor kidney transplant (DDKT) program, and its establishment in a small population poses challenges related to limited expertise and community misconceptions. Healthcare workers (HCWs), as the operational backbone of any transplant service, are central to translating policy into practice and guiding patient understanding. Assessing their perceptions is essential for gauging system readiness and informing strategies for future program development.
AIM
To explore HCWs’ views on initiating a DDKT program, with specific focus on knowledge of kidney disease and attitudes toward deceased organ donation, opt-in donor card policy and transplant commercialization.
METHODS
This was a questionnaire-based knowledge, attitude and practice study conducted at the main tertiary hospital in Brunei Darussalam. Statistical analyses included bivariate tests for categorical variables and multivariable logistic regression to identify factors associated with supportive or non-supportive attitudes towards DDKT.
RESULTS
A total of 370 HCWs participated in the study, with a female predominance (76%), comprising 58 doctors, 271 nurses, and 41 allied health professionals. Overall, 61% of respondents demonstrated high knowledge, while 39% had low knowledge. Regarding attitudes toward DDKT, 44% agreed, 12% disagreed, and 45% remained neutral. An opt-in donor card system was favored by 54%, while 35% were neutral and 11% disagreed. Attitudes towards transplant commercialization showed little variation, with 21% expressing acceptance, 45% neutrality, and 33% disagreement. Islamic religion, Malay ethnicity, nursing profession, lower knowledge level, female sex, and unawareness of fatwa were significantly associated with disagreement towards both DDKT and the donor card system (all P < 0.05). In multivariable logistic regression analysis, profession [adjusted odds ratio (aOR) = 4.54], religion (aOR = 7.34), education level (aOR = 4.11) and knowledge status (aOR = 1.88) remained independently associated with disapproval of DDKT.
CONCLUSION
Among HCWs in Brunei Darussalam, support for a DDKT program outweighs opposition, although a sizeable proportion remain undecided. Notably, some view commercialized transplantation as a potential means to address donor shortages, signaling ethical and policy concerns. These findings underscore the need to address knowledge gaps, enhance educational exposure, and clarify contextual issues to inform the development of a national DDKT program.
Core Tip: This study explored the views of 370 healthcare workers in Brunei Darussalam on establishing a deceased donor kidney transplant (DDKT) program. Most were female (76%) and included doctors, nurses and allied health staff. Overall, 61% showed high knowledge. Support for DDKT (44%) exceeded opposition (12%), though 45% were undecided. An opt-in donor card system was favored by 54%, while attitudes toward transplant commercialization were mixed, with 21% accepting it. Disapproval of DDKT and donor cards was associated with Islamic religion, Malay ethnicity, nursing profession, lower knowledge, female sex, and unawareness of fatwa. Multivariable analysis confirmed profession, religion, education and knowledge as independent predictors of disapproval.
Citation: Othman NIE, Lim CY, Razak L, Yusuf M, Ahmed D, Idris F, Joshi N, Khalil MAM, Duong MC, Tan J. Informing national policy: Healthcare workers’ readiness for a deceased donor kidney transplant program in Brunei Darussalam. World J Transplant 2026; 16(2): 117585
Brunei Darussalam, a Muslim-majority country with the smallest population in Asia, inaugurated a living-related kidney transplant (LRKT) program in 2013[1]. The local-led program was pioneered with the guiding principles of equity, quality, sustainability and morality; and has expanded steadily over the past decade. At the end of 2024, the overall kidney transplant output has exceeded 20 per million population, comparable with that reported in many developed Asian countries[2]. Despite this progress, and notwithstanding the existence of a national religious decree (fatwa) permitting deceased organ donation, Brunei Darussalam has yet to implement a deceased donor kidney transplant (DDKT) program.
Several local studies have sought to support, strengthen and justify the national transplant program. A population-based study conducted in 2010 surveyed approximately 300 participants to assess knowledge of LRKT and willingness to donate kidneys. Notably, 78.7% of respondents expressed willingness to donate a kidney to a loved one[3]. Subsequently, another local study explored barriers preventing dialysis patients from pursuing kidney transplant. Key impediments identified included a lack of donors (71%), limited awareness (21.2%), and perceived unwillingness to accept procedural risks (26.5%)[4]. The high proportion of respondents reporting no available donors further underscores the persistent shortage of living kidney donors within this population. Alarmingly, 42.5% of respondents reported willingness to consider commercial kidney transplant overseas because of donor scarcity within the country[4].
Brunei Darussalam has expressed aspirations to establish a national DDKT program to strengthen kidney transplant rates. However, the feasibility of implementing such a service within a low-volume setting, particularly in the absence of established technical expertise, may present challenges. These challenges may be further compounded by prevailing community misconceptions and preconceived concerns surrounding deceased organ donation. Consequently, a comprehensive understanding of community knowledge, attitude and practice is important in evaluating the feasibility and acceptability of introducing a DDKT program. In particular, perceptions relating to deceased organ donation, opt-in system, and the ethical implications of organ commercialization are recognized as important factors influencing public acceptance and policy preparedness[5]. Accordingly, the primary objective of this national study is to assess healthcare workers (HCWs) knowledge, attitude and perceived future practice regarding DDKT using a purpose-designed questionnaire. Secondary objectives include assessment of relevant kidney-related and transplant-related information and evaluation of demographic factors that may be associated with variations in knowledge, attitude and perceived practice towards DDKT.
MATERIALS AND METHODS
Study design, context and participants
A cross-sectional survey was conducted at Raja Isteri Pengiran Anak Saleha Hospital, which is the main tertiary hospital in Brunei between August 1, 2025 and November 1, 2025. All HCWs including physicians, nurses, and allied health professionals (AHPs) were invited to participate in the study through direct invitation by the research team to complete a questionnaire, either electronically or in paper format. The online version was administered using Google Forms, integrating participant information, consent, and questionnaire content to facilitate participation (Supplementary material).
Inclusion criteria included those who were actively involved in clinical care, aged 18 years or older, and able to communicate clearly and coherently. Both citizens and foreign residents were eligible for participation. Exclusion criteria included incomplete questionnaire responses or inability to comprehend the study objectives. HCWs employed within renal services and non-clinical administrative staff were excluded to minimize professional and awareness bias.
Questionnaire development and conceptualization
A novel questionnaire assessing knowledge, attitude and perceived practice regarding DDKT was developed using a combination of evidence-based literature review and expert input from experienced clinicians. Particular emphasis was placed on local sociocultural and religious contexts to ensure content validity. An initial pool of 12 relevant questions and statements was generated, reviewed and pre-tested by the research team prior to final selection.
The participant information sheet, consent form, and questionnaire were originally developed in English and subsequently translated into Brunei Malay. Validation was ensured through a back-translation process performed by the research team to maintain semantic and conceptual equivalence.
The questionnaire commenced with an introductory section outlining the study purpose, objectives, and rationale. Demographic data collected included age, gender, race, religion, education level, and occupation. The knowledge domain assessed participants’ understanding of chronic kidney disease (CKD), end-stage kidney disease (ESKD) and kidney transplant. Knowledge scores were derived from five items assessing: (1) Awareness that CKD affects approximately one in ten individuals; (2) Understanding kidney transplant offers superior quality of life; (3) Recognition of improved life expectancy with transplantation; (4) Awareness that kidney transplant is the most cost-effective treatment for ESKD; and (5) Awareness of both living and deceased organ donation options. Each correct response was awarded one point, producing a total score ranging from 0 to 5. For the purposes of this study, scores of ≥ 3 were classified as high knowledge, while scores of ≤ 2 were classified as low knowledge. The questionnaire additionally assessed participants’ awareness of an existing national religious decree (fatwa) issued by the local religious jurisprudence, which permits deceased organ donation[1].
The second (attitude) and third (perceived practice) domains of the questionnaire employed a five-point Likert scale (strongly disagree, disagree, neutral, agree, strongly agree). The attitude domain explored perceptions relating to LRKT, organ commercialization and an opt-in donor card system; whereas the perceived practice domain assessed willingness towards future deceased donation decisions for oneself and family members. For statistical analyses of individual questionnaire domains “strongly disagree” and “disagree” were collated into a single disagree category, while “strongly agree” and “agree” were grouped as agree, to enhance analytic power. For multivariable logistic regression analysis, neutral responses were excluded to allow for dichotomous outcome categorization.
Sampling and sample size calculation
A purposive sampling strategy was employed to recruit participants from three HCWs groups: Doctors, nurses, and AHPs. The sample size was calculated to estimate a prevalence (approval rate for DDKT) of 40% with a 95% confidence level and a precision of ± 5%. The prevalence rate was obtained from previous similar studies conducted in Malaysia with similar ethno-religious participant groups[6,7]. Using the formula[8], the minimum required sample size was 369 participants.
Pilot testing and psychometric evaluation
A pilot study was conducted to assess the validity and reliability of the questionnaire. Exploratory factor analysis was used to evaluate construct validity, including both discriminant and convergent validity. Principal component analysis with varimax rotation was performed. Exploratory factor analysis demonstrated clear factor loading across three distinct domains, confirming appropriate domain segregation and absence of item overlap. No questionnaire items exhibited factor loadings below 0.40, allowing retention of all 12 items in the questionnaire. Internal consistency was strong across all three domains, with Cronbach’s alpha values exceeding 0.70, indicating satisfactory reliability.
Statistical analysis
Statistical analyses were conducted using R software (version 2.6.2; R Foundation for Statistical Computing, Vienna, Austria). Continuous variables were summarized using means or medians with corresponding standard deviations or interquartile ranges, as appropriate. Categorical variables were presented as n (%). Bivariate associations between categorical variables were assessed using Pearson’s χ2 test or Fisher’s exact test where appropriate. A P < 0.05 was considered statistically significant.
Crude odds ratios (ORs) and adjusted ORs (aORs) with 95% confidence intervals were estimated using univariable and multivariable logistic regression analyses respectively. Variables included in the multivariable model were selected using a combination of forward and backward stepwise selection. Multicollinearity and interaction effects were assessed prior to final model construction. Model fitness was evaluated using the Hosmer-Lemeshow goodness-of-fit test to confirm conformity with binary logistic regression assumptions.
RESULTS
Baseline characteristics of patients and knowledge level related to CKD and kidney transplant
A total of 370 HCWs participated in the study, comprising 58 doctors, 271 nurses, and 41 AHPs. The cohort demonstrated a marked female predominance (76%), particularly among nurses, of whom 85% were female. The majority of respondents identified as Muslim (80%) and ethnically Malay (75%); all Malay respondents self-reported as Muslims. Most participants had attained tertiary education (88%); while 12% had completed secondary education- primarily among nursing and laboratory assistants and healthcare helpers. Detailed demographic characteristics are presented in Table 1.
Table 1 Demographics and responses of participants.
Based on questionnaire-derived scoring, 61% of respondents were categorized as having high knowledge, while 39% were classified as having low knowledge. Detailed demographic characteristics and knowledge levels are presented in Tables 1 and 2.
Study participants’ attitude towards DDKT, LRKT, opt-in system and commercialization
Overall, 44% of participants expressed agreement with DKT (12% strongly agree; 32% agree), while 12% disagreed (4% strongly disagree; 8% disagree). A substantial proportion (45%) remained neutral. Regarding perceived future practice, 45% of respondents agreed with deceased donation for themselves, and 40% agreed with deceased donation for family members, with corresponding disagreement rates of 17% and 16% respectively. Support for LRKT was higher, with 62% in agreement, 29% neutral, and 9% in disagreement.
Acceptance of an opt-in donor card system was reported by 54% of participants, while 35% were neutral and 11% disagreed. Conversely, attitudes towards transplant commercialization showed little variation across categories, with acceptance 21%, neutrality (45%) and disagreement (33%). A summary of participant responses across attitude and perceived practice domains is provided in Table 2.
Associations between baseline characteristics and attitude towards donor kidney transplants
Bivariate analyses examining attitudes towards DDKT demonstrated that religion (Islam), race (Malay) ethnicity, nursing profession, lower knowledge level, female sex, and lack of awareness of the national fatwa were all significantly associated with disagreement towards DDKT, LRKT, and the donor card system (all P < 0.05). Conversely, male respondents and those in non-doctor professional roles (nurses and AHPs) were significantly more likely to have neutral views on commercialization. Results are shown Tables 3, 4, 5 and 6.
Table 3 Demographic breakdown of attitude towards deceased donor kidney transplantation, n (%).
Model for the prediction of negative attitude towards DDKTs
On univariable logistic regression analysis, religion (Islam), nursing profession, lower educational attainment, and lack of awareness of the fatwa were significantly associated with disapproval of DDKT. In multivariable logistic regression analysis, profession (aOR = 4.54), religion (aOR = 7.34), education level (aOR = 4.11), and knowledge status (aOR = 1.88) remained independently associated with DDKT disapproval. Race was excluded from the final multivariable model due to significant collinearity with religion. Results are shown in Table 7.
Table 7 Factors associated with disapproval of deceased donor kidney transplant.
This study is particularly relevant to Brunei Darussalam as it captures diverse perspectives from almost 0.1% of the national population, providing an initial scoping assessment of the feasibility of implementing a future DDKT program. In addition, it examines the views of HCWs, who form the clinical and operational foundation of any transplant initiative. By virtue of their professional roles and clinical exposure, HCWs are well positioned to translate policy into clinical practice, offer informed guidance to patients and families, and advocate for ethically sound transplantation services. Accordingly, understanding their perceptions offers an essential foundation for evaluating system readiness and informing strategic priorities for the phased implementation of DDKT services in Brunei, with potential relevance to other countries facing similar constraints.
Our findings demonstrate that acceptance of DDKT among HCWs remains divided: 43% expressed a favorable attitude towards deceased donation, 46% were undecided, and 11% were not supportive. This distribution is broadly consistent with findings from regional studies involving HCWs in Asia, particularly in Muslim-majority populations, including Malaysia (47%-68%)[6,7], Oman (35%)[9,10], Saudi Arabia (57%-65%)[11-14], Qatar (20%-44%), Pakistan (35%), Iran (47%-82%), and Bangladesh (25%)[15-19]. Collectively, these data suggest that ambivalence towards deceased donation among HCWs is a religio-cultural phenomenon rather than country-specific.
In this study, several interrelated factors were identified as negatively influencing HCWs’ intentions towards deceased organ donation, namely religious considerations, knowledge deficits, and educational attainment. Although these determinants are closely intertwined, they are potentially modifiable, thereby presenting opportunities for targeted educational strategies and policy-level interventions.
Influence of religion
Although the majority of Muslim respondents supported the development of DDKT services, a substantial minority remained unconvinced. This finding mirrors patterns observed in other multi-ethnic societies in the region, particularly Malaysia and Singapore, where Malay and Muslim respondents consistently demonstrate lower support for deceased organ donation[9,20-23] Such hesitancy is often attributed to religious and cultural concerns regarding bodily integrity after death, uncertainties surrounding the concept of brain death, and beliefs about the afterlife[5]. Concerns related to delays in burial - which some believe may interfere with the soul’s journey after death - have also been cited as important determinants of family refusal in deceased donation[24,25]. Additionally, theological debate persists among certain Islamic scholars regarding the adequacy and certainty of current medical criteria for brain death determination, further contributing to ambivalence[25,26].
Globally, Muslim-majority countries tend to report lower rates of DDKT compared with neighboring non-Muslim countries, with only 13 of 50 Muslim-majority countries reporting DDKT activity in 2023 and an overall transplant rate of approximately 0.9 per million population only[25]. While Brunei Darussalam has expressed intentions to establish a national DDKT program and a national fatwa permitting deceased organ donation is in place, awareness and acceptance of this ruling appear to remain limited, which may contribute to challenges in program development. In addition, regional variation in Islamic jurisprudence may generate uncertainty regarding the authority or applicability of specific fatwas[27]. As a result, individual interpretations of perceived religious ambiguity - particularly in relation to brain death - may exert a greater influence on personal attitudes than formal religious endorsements alone[28]. Collectively, these observations suggest that religious approval, while important, may not be sufficient in isolation without effective dissemination, education, and culturally sensitive engagement.
Role of knowledge and education
Our study acknowledges the strong association between knowledge levels, educational attainment, and attitudes towards DDKT. Notably, nurses were four times less likely to support DDKT compared with doctors and AHPs, but this finding may be partially confounded by knowledge and education levels. Subgroup analyses revealed that nurses - particularly nursing assistants and attendants with secondary-level education - had lower knowledge scores contrasting markedly with doctors and AHPs, most of whom had tertiary education and higher baseline knowledge.
Regional literature on knowledge, attitude and practice have also consistently reported the association of positive donation attitudes and good knowledge and awareness. A Chinese study involving 502 nurses (88% female) reported a similarly high proportion of neutral attitudes (49.6%), with higher knowledge scores independently predicting positive donation attitudes and family discussions about organ donation[29]. Likewise, a large Taiwanese study involving over 2000 nurses found that better knowledge was strongly associated with donor registration[30]. In Malaysia, knowledge was also identified as an independent predictor of donation willingness among predominantly Muslim and female HCWs[9]. Beyond Asia, a quantitative study exploring attitudes towards organ donation among Western Muslim populations identified several potentially modifiable pedagogical factors - including younger age, perceived religiosity, educational attainment, and greater awareness of organ shortage and CKD - as being associated with more positive donation attitudes[28].
Amongst studies comparing Asian and Western populations, the former group would typically have lower donation knowledge and more negative attitudes compared with the latter, contributing to disparities in donation and transplant rates[31,32]. These differences are commonly attributed to limited exposure, mistrust of healthcare systems, and misconceptions about clinical decision-making. In some Asian contexts, beliefs that financial incentives may influence end-of-life care or that life-saving efforts could be compromised for transplantation purposes further undermine trust[33]. Such findings reinforce the need for sustained, profession-specific education targeting ethical frameworks, clinical safeguards, and transplant governance.
Threats of commercialized transplantations
Of particular concern, this study identified a degree of acceptance towards kidney transplant commercialization, indicating limited understanding of ethical transplantation principles and the absence of strong deterrent narratives. Unlike other domains, there is no clear consensus opinion on kidney transplant commercialization, and attitudes appear relatively independent of religion, education level, or knowledge status. This finding is consistent with a previous local study involving ESKD patients where 42% would consider partaking in such practice[4]. A survey amongst past commercialized kidney transplant recipients in the Middle East found that 71% partake in commercialization because of the unavailability of organs[34]. Numerous other studies have shown that there is a high level of support for commercialization, even amongst tertiary educated participants and developed countries[35,36]. 23% of 708 patients surveyed in Canada reported a willingness to travel for commercialized kidney transplant[35] while another study from India showed that 23% of 150 doctors believed that legalization of kidney selling can save lives[37]. A possible explanation is the persistence of misconceived beliefs - particularly among relatively affluent or educated individuals - that commercialization represents a mutually beneficial arrangement enabling poor donors to escape poverty while addressing organ shortages[5]. Such permissive views risk normalizing exploitative practices, especially in wealthy countries with long kidney transplant waiting times and limited local donor availability[38].
Despite international efforts guided by the Declaration of Istanbul[39], transplant commercialism continues to undermine public trust in parts of the developing world[34]. The 2018 revision of the declaration explicitly broadened definitions to include organ trafficking and reinforced the obligation of healthcare professionals to uphold financial neutrality and combat unethical practices[39]. Nonetheless, several Muslim-majority countries continue to report high levels of transplant commercialization, driven by weak regulation and strong financial incentives amid limited domestic transplant activity[40,41]. These findings underscore the urgency of establishing a clear national stance against transplant commercialization and promoting ethical self-sufficiency through legitimate kidney transplant services.
Support for an opt-in donation framework
Encouragingly, respondents were generally supportive of an opt-in donor card system, suggesting that an expressed consent model would be the most culturally acceptable policy approach in Brunei Darussalam. Across much of Asia, ‘soft’ opt-in systems predominate, whereby family consent is still sought irrespective of the deceased’s prior wishes[42]. This approach aligns well with Bruneian cultural norms that emphasize family involvement in decisions relating to posthumous dignity and bodily integrity. Evidence from Malaysia further supports this approach; a study reported that 46% of HCWs would outright reject an opt-out or presumed consent system[13]. This suggests that hardline opt-out policy frameworks are unlikely to be acceptable or effective in transplant-naïve societies and may risk public backlash if introduced prematurely.
Recommendations
Interventional studies consistently demonstrate that education is a powerful modulator of donation attitudes. In Malaysia, a web-based educational program among HCWs significantly improved knowledge and donation intent[43]. Similarly, a systematic review by Araujo et al[44], encompassing 21 studies, confirmed that educational interventions effectively enhance knowledge and attitudes towards organ donation among healthcare professionals. Incorporating structured teaching on brain death, organ procurement processes, transplant ethics, and national donation policies into undergraduate and postgraduate medical and nursing curricula may help foster more informed perspectives among future clinical decision-makers[45]. Engagement with respected religious authorities may further support public understanding through sermons, lectures, and community dialogues in mosques[46]. In addition, collaboration with social media influencers and journalists could facilitate dissemination of accurate information to younger audiences and help address prevalent misconceptions[11]. Greater investment and institutional support for collaborative research with higher education institutions may also be beneficial in systematically identifying barriers and disseminating context-specific knowledge relevant to DDKT.
Limitations
This study did not collect information on age, years of professional experience, marital status, or specific clinical work areas. These variables were deliberately omitted to protect participant anonymity and maximize response rates, particularly in a small healthcare system where disclosure of such characteristics could increase identifiability. This decision aligned with recommendations from the local ethics committee given the sensitivity of the study topic. Although these demographic and professional attributes may influence donation attitudes, they represent an important avenue for future enquiry. Ongoing follow-up work aims to explore these dimensions more comprehensively, including detailed assessments of brain death knowledge and intent to donate. While awareness of brain death is fundamental to the effective implementation of a deceased DDKT programmed, the present study was designed as an initial exploration of HCWs’ readiness, deliberately “testing the waters” by introducing the concept of deceased donation in a measured and non-threatening manner.
Despite the anonymized approach, the study remains susceptible to volunteer bias. Recruitment strategies - primarily relying on social media dissemination and invitation during live educational events - may have preferentially attracted individuals with existing interest or favorable views on transplantation. The total number of individuals who declined participation is unknown, which limits estimation of response bias and may affect the generalizability of findings.
CONCLUSION
This study shows that while most HCWs in Brunei support a DDKT program, a notable proportion remain undecided, and acceptance of transplant commercialization persists. Targeted education is urgently needed to address misconceptions about brain death, donation ethics, and organ pledging. Clear regulatory policies must reinforce legitimate DDKT pathways and deter commercialized practices to safeguard ethical standards and build national organ self-sufficiency.
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