WHOLE BODY BEQUEATHMENT: PERCEPTION OF HEALTHCARE WORKERS IN SOUTHWESTERN NIGERIA

Journey of anatomy as a discipline began from crude ancient civilizations with credit to cadavers at the centre up to this modern computerized creativity with reference to magnanimity of cadavers and donors. The study investigated various limitations in acquiring cadavers amongst healthcare givers in southwestern Nigeria: awareness of bequest program, religious beliefs, socio-cultural heritage and family influences. Questionnaire-based proforma was adopted with three sections: facility, socio-demographics and donation characteristics containing 20 item self-administered Likertstyle: ‘yes’, ‘no’ and ‘not sure’. Facilities visited and formal permission sought to engage the middle-aged healthcare workers for one month’s period. Data subjected to statistical package for social scientists with statistical significance taking as p<0.05. One hundred and thirty six middle-aged healthcare workers and above participated. Highest participants recorded in: tertiary institution; age group 50 to 54 years; gender male; Ekiti indigenes; tertiary educational degrees; married workers; Christianity; and doctors by profession. Cronbach’s alpha reliability value of 0.801 established the study to be second to excellence. Issues on bequest program, sources of cadaver and affection independently explained poor awareness and alienation to bequeathment affairs. Influential factors on bequeathment synonymously judged unquestion-able religious beliefs, veritable sociocultural traditions and family dominancy as militating factors. Typically, awareness on bequeathment was still pitiful as the criteria were only known in papers rather than the hearts of healthcare workers who were meant to propagate the crusade of bequeathment. The need to establish a global policy for bequeathment affairs including social, moral, political and financial needs for broadcast was conclusively accented, most especially, in Nigeria and the likes.


INTRODUCTION
In reasoning about the past event as a way to understand the present status of the mortalbody, the journey of anatomy as a naturalistic discipline might have started by the cave dwellers from anthropological documentation on remains of Homo sapiens loquens in the stone age but typically credit on origin is consecrated to the crude ancient civilizations of Egypt, Babylonia, Syria, Chinese and Hinduaccording to Wilcox (2016). Albeit in these civilizations, there was really no in-depth study of anatomy other than negotiation on spiritual and supernatural facts in the repose of spirit and soul of the dead through embalmment until the instance of Edwin Smith Surgical Papyrus in 1600 BC as illustrated by Lindermann (2010). The initiation of systematic study of anatomy was attributed to the Greeksin his study (Singer, 1957). Alcmaeon (500 BC), while in Italy was the first person to perform dissection on humans for research and identified the brain as the centre of intelligence. Empedocles (490-430 BC) while in Sicily described the heart as 'the life-giving heat' to the body; and delicate substance 'pneuma' which is air flowing with blood. Hippocrates (460-377 BC), the ordained father of medicine made impact in anatomy (without dissection) and treatment of diseases which were believed to be punishment from the godsin the study by Elizondo-Omaña et al (2005). Aristotle (384-322 BC), a philosopher had influence on healthcare givers who began dissection of animals to extrapolate the findings to treat humans according to most of authors (Siraisi, 1990;Nutton, 2004;Klestinec, 2004). Claudius Galenus (Galen) made his own contributions in anatomy with errata that lasted till 16 th century. Andreas Vesalius (1514-1564) was credited as father of anatomy and challenged Galen's ideas to expose some inaccuracies through his extensive dissection on humans and animals; and publication De Humani Corporis Fabricain his study by Klestinec (2004). Nevertheless, dissection of human as an integral appraise in anatomy was initially on sacrificial or legally executed criminals. At about 17 th century, human dissection with explanatory diagrams coupled with constitution of anatomic theatre adopted to further reinforce anatomic educationin the study by Howse (2009). The need for human body in dissection, prosection and researches escalated with resultant illegal acquisition of cadavers through robbery of the graves and criminal killing of innocent persons for financial aggrandizement. Burke and Hare saga (1827-1829) ensued in public execution, dissection and exhibition of Burke while equally London Burkering in 1831 were of note that finally led to the various pronouncements of anatomic acts thereby steering the modern innovative practice of anatomy in terms of body donation, advancement in tissue handling, tissue preservation and embalmmentby the authors (Rosner, 2010;Martinez, 2013;Tward and Patterson, 2002;London Anatomy Office, 2015. The historical perspective of Gangata alluded to five cardinal categories in the possession of cadavers for anatomic education: grave robbing, unwilled claimed body, purchased body, unknown body and body bequeathmentby the authors (Roach, 2003;Gangata, 2015). To this list, the use of legally executed humans was added. The category of people who were enshrined with the rapture and resurrection of the dead was neither in support of grave robbing nor unwilled body as earlier documented by Magee (2001). Nevertheless, so many security measures were being put in place to prevent grave robbing according to an historical corroboration on grave robbing era in his study by Hulkower (2011). Purchasing of body appeared similar to Burke and Hare heroic tale as well as London Burkering and had been banned in many countries culminated in propagation of laws to take charge of how cadavers be sourced for medical utilization by Martinez (2013). In those days, in some countries financial transaction of dead ones were made popular for quite some years, most especially, amongst the less privileged and marginalized tribes due to substandard legal proceedings as authenticated by Halperin (2007).In a nutshell, the idea of taking charge of unknown bodies and legally executed criminals for anatomic education is still very popular in Nigeria and some other developing countriesby most of the authors (Popoolaet al., 2018;Ewonubari, 2012). Whole body bequeathment can be defined as a will of leaving or giving a whole body after death for dissection, prosection, research and or therapeutic purposes in hospital and medical/teaching institutions. To this explanation, the donation for exhibition in Body World of Gunther von Hagens is added (Moore and Brown, 2004).Nevertheless, the origin of body donation (bequeathment) was credited to Punamas at about 1 st to 11 th century CE according to the Hindu's documentation on a troublesome evil supernatural being called Vrutrasoorof whom the gods and man wanted to eliminate as evidenced by Rokade and Bahetee (2013).A great sage called Dadhichi donated his body on the request from LordIndra and his bones harvested as a weapon to kill Vrutrasoor. In these days an age, whole body donation is basically for anatomic volitions. Body donation www.anatclinar.com.ar brings about provision of different kinds of cadaver necessary for dissection, prosection, research and therapeutics to appreciate the forms of structure as against the use of unclaimed bodies and legally executed criminals which are not reliable sources in ideal sovereignties. Of note is the authorization in donation of a body for anatomical examination by London Anatomy Office (2015). Stepwise process of whole body donation is elucidated by the authority engaging the donor (testator/testatrix) to carefully read through the booklet containing the information on body donation before signing the consent forms. The office coordinates the operation for medical institutions in need of cadavers. The receiving institution is made responsible for preservation and burial disposal if necessary thereafter. There is incorporation of Human Tissue Authority (HTA) responsible for regulating the use of bodies donated for anatomical examination within the legal framework set out in the HTA (2004). A body donation form is made available in the booklet of which a consent form is included for the donor to digest with the nearest relatives and or executor/executrix. Duration of body donation has two options for how long the body may be retained by the institution: indefinite or maximum of 3years and thereafter. The imaging of a donated body may be for education or training relating to human health; and research in connection with disorders or functioning of the human body. However, images including photographs, films and electronic images are outside the scope of the HTA withcode of practice encourages good principles set out in guidance issued by relevant professional and regulatory bodies. Total body bequeathment has a guide to reasons for non-acceptance including: post-mortem examination; some infectious diseases like viral hepatitis, HIV/AIDS, tuberculosis; if organs, other than corneas, have been donated for transplantation or medical research; obesity; some forms of dementia; severe bedsores or varicose ulcers, or recent surgery when the wound has not healed; gross peripheral edema; and severe deformity of the spine. If the donation cannot be accepted, the relatives or executor/executrix will be informed as soon as possible and on the other hand if a donation is accepted; an undertaker employed by the office will be instructed to transfer the body to the receiving institution. On expenses about funeral disposal, the office arranges the venue and meets the costs, even though, the next of kin or executor/executrix may assist. In addition, for final disposal in which cremation is preferred, further options are given to the relations or executor/executrix: to be notified of the date and time of cremation; to attend the service at cremation; and to take possession of the ashes. Thanksgiving services are organized annually by the office in collaboration with interested relatives for remembrance of the donors. It is vital that the death is registered with the local registrar of deaths as a matter of urgency and certificate will be issued as appropriate for the donation process. If a donation is not accepted the next of kin or executor/executrix must proceed with normal arrangements for disposal, either burial or cremation. The witness can be a person of choice, including spouse, next of kin, executor/executrix, legal professional, health professional, friend, neighbour and so on. Consent can be withdrawn at any time by simply notifying the office, in writing, and thereafter the details will be removed from the system and the consent form be destroyed. At this juncture, allusion should be made to individuals having interest in both organ and wholebody donation. Organ donation will go for life-saving transplantation in case of end organ failure while whole body donation will upgrade teaching, dissection, prosection, exhibition, research and therapeutic purposes. In that wise, the individual in question will be properly registered as an organ and wholebody donor by appropriate authorities who will have to work together just in case they are independent. In view of the fact that whole body donation program is practically not existing in Nigeria, perhaps, due to so many limitations including: validated socio-cultural heritage and spiritual beliefs, this study was then curiouslydesigned to demonstrating the challenges militating against whole body bequeathment as a reality in Nigeria and other countries alike amongst a crosssection of healthcare givers. Specific objectives included; investigationof awareness on whole body bequeathment program across a section of healthcare workers; inquiry into religious and socio-cultural influences on body bequeathment; and demonstration of influencesconcerning family members about whole body bequeathment.

MATERIALS AND METHODS
The study was conducted across a section of healthcare workers (45 years and above) in Ekiti, Southwestern Nigeria with an anonymous proforma formulated from available indexed journals and literature. There were three sections: facility, socio-demographics and donation characteristics which contained 20 item self-administered questionnaire with Likert-style option of: 'yes', 'no' and 'not sure'. Facility www.anatclinar.com.ar represented the various healthcare centres: tertiary, secondary and primary in both public and private sectors. Socio-demographics contained: age, gender, marital status, state of origin, tribe/ethnicity and occupation. The questionnaire was structured to address: awareness on wholebody donation; sources of cadaver; willingness to whole body donation; influences from family, religion and diverse cultures; mode of burial disposal; predilection to continuing utility of legally executed criminals and unidentified bodies; and human cadaver substitutes. The authors visited the facilities, sought formal permission from managements and engaged the middle-aged healthcare workers for period of a month going from one section/department to another in distributing the questionnaire. Some workers filled the questionnaire immediately while others sent theirs to the authors later. A very few groups of middle-aged workers did not participate on the reasons best known to them. Data collated and subjected to statistical analysis using IBM statistical package for social scientists (version 21) to determine Cronbach's alpha value for reliability/internal consistency of the study, Kendall Coefficient of Concordance (KCC) along with analysis of frequency were estimated while statistical-significance was taken as p< 0.05. Results were represented in words, tables and figures.

Cronbach's Alpha
Number of items   (table 8). Nevertheless, there were very few professional embalmers in Ekiti as majority of this category of healthcare workers managing the mortuaries in Nigeria broadly speaking had no formal degree qualifications in mortuary services and tissue preservation. Thereby, ascertainingthe opinions of the very few professional embalmers in this study might be perceived as an exercise in futility. The Cronbach's alpha reliability score of 0.801 (tables 6 and 7) proved this study to be second to excellence and to be a reference point amongst its kinds in this sovereignty and the like as earlier illustrated by Gliem and Gliem (2013). Issues related directly to program on whole body donation were governed by three items: Q1, Q11 www.anatclinar.com.ar and Q12 and were considered independent interrogations going by p-value (0.001) in Kendall's test (table 1). Even though majority 70(51.4%) claimed to have been aware of the whole body bequest's program, equally majority 92 (67.6%) had no clue on the criteria for body donation and perhaps nobody seemed to have donated self for anatomic and or medical education. Whole body donation could then be rightly demonstrated to be alien to this locality and Nigeria at largeaccording to the study by Popoola and Sakpa (2018  Influence of training as ratified by items in Q5 and Q19 showed a p-value greater than 0.05 (table 2) thereby proving the items were either dependent or synonymous in which a very few 18 (13.3%) who wished to donate self might have valued the importance of generating ideas from the dead to integrate the living in healthcare training. All that was needed to increase this number of those willing to donate self might be for the teachers, students and researchers to strictly obey the rules guiding the utility of cadavers in order to attract many more people to value the same line of thought in donating self. Besides, there is a need for a feasible whole body bequeathment program in Nigeria and other sovereignties alike.

(Good) 20
Contrarily, majority 103 (75.7%) who declined the wish of donating self might be the group of healthcare workers clinching on some other reasons including different complex inviolable socio-cultural heritages, unfalteringly aged-long traditions, extended family dominancy and steadfast religious beliefs. The items in table 3 independently defined scope and structural institution of sourcing for cadavers in this locality. Majority preferred sourcing for cadavers from unknown/unidentified and deceased family members while at these assertions, relatively-significant percentages could be acclaimed to have been on the fence: Q3 and Q4. Nevertheless, the same majority www.anatclinar.com.ar seemed to have preferred sacrificial/executed and unclaimed bodies as alternatives to sources of cadaver: Q17 and Q18. One could then infer from all these affirmations that armed-robbery and other vices with resultant legal execution seemed to be advanced by the healthcare workers in this locality for the benefit of anatomic and medical education. The reason being that executed bodies are generally disowned and not reckoned in the community equalizing them to unknown/unidentified deceased bodies. The corollary encouraging anatomist to embark on aggressive enlightenment campaign for informed bequeathment should be extended to every healthcare worker as a crusade for the best source of cadavers as in the study by Osuagwuet al (2014).To buttress this point, majority 76 (55.9%) of Q20 declined to the utilization of artificial cadavers as substitutes and the minority of 22 (16.2%) who were not sure could be inspired to join the crusade of whole body bequeathmentso as to have a re-think since the human cadavers give the real feeling and texture of tissue in hands-on experience dissection. Accepting null hypothesis (p>0.05) meaning that the interrogative assertions in table 4 synonymously explained the reasons for nonacceptability of whole body bequeathment among healthcare workers in this locality. The influence of unquestionable religious beliefs, inarguable socio-cultural heritage and unfalteringly agedlong traditions, extended family dominancy and egocentric nature of individuals were portrayed in items Q6, Q7, Q8, and Q9. These developments were similarly affirmed to African and Asian sovereignties in a debate with eminent professors of anatomic sciences as participants across continents of the globe in Argentine Republic where Nigeria was potently representedas decently addressed by Biasutto et al (2014). Unequivocally, items in table 5 separately explained assertions on whole body bequeathment by rejecting null hypothesis. The process of whole body bequeathment was neither here nor there for self-donation as the 'yes' and 'no' options scored equal value in Q13. A close value of this kind was registered for 'Not sure' assertion yielding ratio of 9:9:7. This then called for an umpire either the next-of-kin or close family member to ascertain the submission of the deceased on whole body bequeathment thereby further proven the unparalleled influences of extended family dominancy in decision making in Nigeria and the likes. Majority supporting direct burial disposal and rejecting cremation Q14 and Q15 respectively further stressed the fact that people in this locality and Nigeria at large preferred established aged-long accepted funeral rites. These rites were gleefully being performed with premium as demonstrated in Q16 where majority rejected preservation of parts of the tissue in anatomy museum after dissection. The stepwise process of whole body bequeathment as enshrined for anatomical examination by London Anatomy Office (2015) in terms of returning the muddled dissected body to the relations (as if it had passed through investigative operation before disposal or funeral rites with the body in absentia) was alien to Nigeria. There were many factors militating against procurement of cadavers for their generosity in offering themselves one way or the other for anatomic and medical sciences. More often than not the awareness was still pitiful as the criteria were only known in papers rather than the hearts of healthcare workers who were meant to propagate the crusade of whole body bequeathment. Religious beliefs, cultural and traditional limitations were remarkable factors militating whole body bequeathment programs. Influence of family members with extended family dominancy in decision-making was still a factor that called for attention. The need for Anatomical Society of Nigeria (ASN) in collaboration with International Federation of Associations of Anatomists (IFAA) to establish a policy on strategies for getting bodies for medical education in this part of the globe is hereby further emphasized. The policy should include the social, moral, political and financial needs of whole body bequeathment affairs.

Conflict of interests
None.

Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Ethical Approval
Duly approved by ethical and clearance committee of the institution.

Informed Consent
Consent was verbal and not written.

Contributions
SOP initiated and designed the research work based on my observations and difficulties in getting the rightful cadavers for medical education in Nigeria. Educated people about relevance of Anatomy through historical perspective before some agreed to endorse the questionnaire. .AEO contributed in the collection and analysis of data. ODO contributed in collection of data. WOO reviewed the final manuscript before submission.