The Role of a Theory-Based Educational Intervention Among Youth in Encouraging to Register Organ Donation Cards

Document Type : Original Research

Authors
H. Rezaei 1
R. Jorvand 1
N. Ghiasi 2
H. Sayadi 3
M.S. Abedzadeh Zavareh 1
1 Department of Public Health, School of Health, Ilam University of Medical Sciences, Ilam, Iran
2 Department of Midwifery, School of Nursing and Midwifery, Ilam University of Medical Sciences, Ilam, Iran
3 Non-Communicable Diseases Research Center, Ilam University of Medical Sciences, Ilam, Iran
10.58209/hehp.11.3.455
Abstract
Aims: Since important organs of brain-dead patients can be transplanted to patients in need, this study aimed to determine the effect of educational intervention based on the theory of planned behavior (TPB) on the youth of Ivan to receive an organ donation card.

Materials & Methods: This randomized clinical trial was performed on 80 people (40 people in each of the intervention and control groups). Samples were selected by two-stage random cluster sampling. A researcher-made questionnaire was used for data collection and data were analyzed by SPSS version 26 at a significance level of 0.05.

Findings: The mean age in the intervention and control groups was respectively 24.90±2.56 and 24.03±2.55 years. In both groups, 50% of the people were women. There was no significant difference between the two groups in terms of education level. The mean scores of the structures of the planned behavior theory (attitude, mental norm, perceived behavioral control, and behavioral intention) before the educational intervention in the intervention and control groups were not significantly different. After the educational intervention, the mean score of the structures of the planned behavior theory, including attitude (47.02±2.18 vs. 38.05±6.28), mental norm (17.47±2.03 vs. 13.42±2.38), perceived behavioral control (19.20±1.45 vs. 15.17±3.78), and behavioral intention (9.62±0.74 vs. 6.97±2.05) increased significantly in the intervention group (p<0.001) but in the control group, none of the structures had a significant improvement (p>0.05).

Conclusion: Training based on the theory of planned behavior led to a significant increase in its structures to receive an organ donation card in young people.

Keywords

Subjects

Introduction
Brain death refers to a state, in which the patient has lost his cortical and brainstem activities, is unable to breathe and respond to internal and external stimuli, and is in a state of complete coma [1]. Once brain dead is declared, the organs and tissues may be transplanted into patients suffering from insufficiency [2]. Organ donation is one of the most effective ways to improve the quality of life of people. It is estimated that 5 to 7% of patients die before receiving a suitable organ [3]. Specialists and organ transplant surgeons are well aware of the prevalence of chronic organ failure and the importance of organ transplantation, and they try to investigate brain death and support organ donation on time [4]. Organ transplantation in Iran has a history of more than 40 years [5] and the concept of organ transplantation was proposed many years ago with the approval of the law on organ donation. Many efforts have been made to develop humanitarian action with ethical considerations, but the organ donation rate is very low compared to the number of brain-dead people. According to the report of the Iranian Organ Donation Association, about 5,000 people in Iran die due to brain death annually year, while of 3,000 people died of brain death in 2017 who were eligible for organ donation, only 926 people had organ donation [6]. Statistics in Iran show that a small percentage of people with brain death are candidates for organ donation, which is not an answer to people in need [7].
The lack of organs for transplantation is an unsolved global problem; thus, the number of patients who die due to the lack of a transplanted organ is always increasing, and to reach the desired state, it is necessary to recognize and remove the obstacles to organ transplantation [8].
According to the report of the Iranian Organ Donation Association, about 5 million Iranians have organ donation cards. While in the past, 200 to 300 donation cards were requested daily, after holding various cultural and educational courses, this amount has increased significantly [6]. Theory-based educational programs are the most effective educational interventions rooted in behavior change patterns [9, 11].
One of the important theories for designing evidence-based interventions is the theory of planned behavior (TPB) [11]. TPB predicts the occurrence of a specific behavior, provided that the person intends to do it. According to the theory, the intention to perform a behavior is predicted by three factors: attitude, mental norms, and perceived behavioral control [12].
To properly affect the intention to get an organ donation card, the TPB can be considered an important theory. The theory assumes a person is a rational operator so that a person processes information before performing a behavior. During the process, a person's fundamental beliefs and as a result, his behavior may change. According to the theory, people's intention to perform a behavior is the most important factor in predicting that behavior [13]. Regarding the importance of organ donation, using TPB to create motivation, strengthening intention and behavior, and considering no similar study in this regard in Eyvan, this study was conducted to assess the role of TPB in encouraging the youth of Eyvan to receive an organ donation card.

Materials and Methods
Study design
The statistical population of this experimental study was 18-29-year-old youth of Eyvan selected by a two-stage cluster sampling method. First, two health centers were randomly selected from the four urban health centers using the random allocation software RAS version 1.0.0. Next, among the neighborhood health centers covered by each base, one neighborhood health center for the intervention group and one for the control group were selected randomly. The total number of health centers in Eyvan was 22. Then, those aged 18-29 years from each center were considered, and using G*power software with a power of 80% and effect size of 60% for the independent t-test with an alpha of 5.0%, the sample size was calculated and 10% was added to the sample size to control the fallout. The resulting sample size was 40 people for each group (Figure 1). Inclusion criteria included being between 18 and 29 years old, informed consent, physical health, and no history of organ donation for oneself and his/her family, and the exclusion criteria included not attending training sessions and not completing the questionnaire.


Figure 1) CONSORT flow diagram of study design.

Data collection tool
The used tool was a researcher-made questionnaire with two parts, including demographic information and questions about the TPB on organ donation. The demographic information part included age, gender, marital status, and education level. For the constructs of attitude (ten questions), mental norm (four questions) self-efficacy (three questions), and behavioral intention (three questions), a total of 20 questions were designed. For example, for the attitude construct, the item "organ donation is a divine thing", for the mental norm construct, the item "If I receive an organ donation card, my family will approve it", for the perceived behavioral control construct, the item "organ donation is impossible for me after death" and the item "I will try to get an organ donation card" were designed to construct the behavioral intention. To determine the validity of the constructs of TPB, the content validity (CV) method, including the content validity ratio (CVR) and the content validity index (CVI) was used using a panel of ten health education and health promotion experts. To ensure the reliability of the questionnaire, a pilot study was conducted on 30 people. The validity and reliability results of the tool are presented in Table 1.

Table 1) Validity and reliability of the questionnaire


Intervention
The self-report questionnaire was completed by the participants before and two months after the intervention. After collecting the pre-test data, the training program was implemented in line with the constructs of TPB for the intervention group. The training was held in one month (five sessions) and each session took one hour (20:00 to 21:00) using WhatsApp. Educational topics included the definition of organ donation and the comparison of organ donation in Iran and worldwide, the difference between coma and brain death, common beliefs and correction of negative beliefs, persuasion, and presenting organ donation videos. During the training course, the participants were allowed to ask questions and answers. Audios, videos, and images were used in the training sessions. Two months after the intervention, the questionnaire was completed again by both groups. The control group did not receive any educational intervention.
Ethical issues
The approval was obtained from the Ethics Committee of Ilam University of Medical Sciences (ID IR.MEDILAM.REC.1400.042) and the research was registered at the Iranian Registration of Clinical Trials (IRCT20211210053347N1). Written informed consent was obtained from all participants in the study after explaining the aims of the study.
Statistical analysis
SPSS version 26 was used to analyze the collected data, and the significance level in all tests was considered less than 5%. The t-test was used to compare the quantitative variables between the groups, and the Chi-square test was used for the qualitative variables.

Findings
The average age of the intervention and control groups was 24.90±2.56 and 24.03±2.55 years, respectively, which showed no statistically significant difference based on the independent t-test (p>0.05). In both groups, half of the cases were women (20 people in both groups). There were no significant differences between the two groups in terms of marital status and education level (p>0.05; Table 2).

Table 2) Comparison of demographic characteristics of the intervention and control groups


Based on the results of the paired t-test, there was a significant difference between the average score of attitude, mental norms, perceived behavioral control, and the intention to receive a donation card in the intervention group, before and after the training (p<0.05), but no significant difference was found in the control group (Table 3).

Table 3) The average scores of the theory of planned behavior structures before and after training in groups


Before the educational intervention, the independent t-test results showed no significant difference between the average score of attitude, mental norms, perceived behavioral control, and the intention to receive an organ donation card between the intervention and control groups (p>0.05). However, after the educational intervention, a statistically significant difference was observed in the average score of attitude, mental norms, perceived behavioral control, and the intention to receive an organ donation card between the intervention and control groups (p<0.05).

Discussion
The results of the present study showed that the educational intervention based on the TPB significantly increased the average score of all TPB constructs in the intervention group compared to before the intervention and led to a significant improvement in attitude, mental norms, perceived behavioral control, and behavioral intention of young people toward receiving an organ donation card.
In line with the results of the present study, Holzer et al. (2020) reported that training based on the TPB can significantly increase the average score of attitude, mental norms, perceived behavioral control, and behavioral intention to donate stem cells in studied people after the intervention and on the other hand, an increase in the attitude, mental norm, and perceived behavioral control can determine the increase in intention, and these results show the importance of education more than before [14].
In line with the results of the present study, Lin et al. (2014) stated that a TPB-based educational program increased the attitude and behavioral intention of intensive care unit (ICU) nurses in support of organ donation and recommended repetitive training to increase the participation of nurses in supporting organ donation [15].
In this regard, Bae et al. (2008) reported that a TPB-based educational program led to an improvement in all TPB structures regarding cornea donation in the intervention group [16].
Mohebi et al. (2016) also showed a significant difference between the average intention score of two groups of members and non-members in the organ donation bank in terms of behavioral intention [17]. Therefore, those who participate in receiving an organ donation card have a higher behavioral intention and show the need to strengthen the intention through training for more action.
According to the results of the present study, Kukulj (2014) reported an increase in positive intention for organ donation among students after providing organ donation education [18]. In a study by Hyde and White(2009), attitude, mental norms, and perceived behavioral control were effective in predicting the intention of organ donation in participants [19]. The results of Rocheleau also support the use of the theory of extensively planned behavior to predict the intention and behaviors related to organ donation [20]. Therefore, according to the mentioned contents, training, especially training based on the TPB, can lead to the improvement of behavioral intention to get an organ donation card in young people.
Azmandian et al. (2013) in line with the results of the present study concluded that after training, the knowledge and attitude average scores of the investigated nurses toward the process of brain death and organ donation increased significantly [21]. In this regard, Nikbakht et al. (2013) reported that the attitude score of people who want to receive an organ donation card is higher than people who do not want to receive an organ donation card, and increasing people's awareness is important to change beliefs [22]. Arjomand et al. also showed that the level of knowledge and attitude of organ donation card volunteers was significantly higher than non-volunteers; this study showed that the main reason for unwillingness to donate organs and tissues is insufficient knowledge, negative attitudes, and incorrect information in the field of donation and transplantation.  Therefore, it is possible to increase the number of donations and, as a result, the level of connection with public education at the community level and create a positive attitude [23].
By increasing the knowledge about organ donation, the attitude toward organ donation can be strengthened [24] and the importance of the issue becomes apparent when the results of the studies indicate the relationship between attitude and behavioral intention throughout the donation process [11, 13]. The prediction of people who have a better attitude toward organ donation is that people in their social network also support their decision to donate organs [11, 13, 25].
Regarding the importance of training and promoting mental norms to encourage people to receive an organ donation card, Khoshravesh et al. (2019) concluded that mental norms have a significant direct effect on receiving an organ donation card and these results show that regarding the design and implementation of interventions to increase receiving organ donation cards, it is necessary to pay attention to the variables based on the cultural and religious context of the studied population [26].
Emdadi et al. (2013) also reported that those who had an organ donation card had a significantly higher score of abstract norms than those without a card [27].
El-Menyar et al. (2020) reported that behavioral and normative beliefs play a very important role in contributing to a person's intention to donate an organ [28]. Stephenson et al. (2008) also concluded that people's abstract norms have a positive role in people's satisfaction with receiving an organ donation card [29].
The role of mental norms regarding receiving an organ donation card is such that if a person finds out that a close friend or a member of his/her family supports organ donation, he/she will feel a lot of pressure to receive an organ donation card and most likely will follow receiving the organ donation card behavior [27]. Therefore, the attitude and performance of the family members and the community have a great influence on the mental norms to take action to receive the organ donation card and to achieve significant results, education should be provided to different types of society.
Ghaffari et al.'s study (2018) evaluated the relationship between the TPB constructs and behavioral intention and showed that the perceived behavioral control was more related to the student’s intention to receive an organ donation card than other constructs. Therefore, perceived behavioral control affects participants' donation decisions. We also need to prepare families with knowledge of organ donation due to their influence on the approval or disapproval of the individual's organ donation and perception of the decision-making process. Our results have important implications for a more community-oriented education program and to encourage students to register as organ donors [13]. In general, based on the TPB, a favorable attitude and a supportive mental norm motivate one to participate in the behavior, but the specific intention to do it will be formed only when the perceived control over the behavior is strong enough [5].
Regarding carrying an organ donation card, a person's behavior indicates the extent to which he/she feels able to receive and regularly carry an organ donation card. The perceived behavioral control affects the individual's intention to engage in the behavior and indicates the individual's willingness to expend effort to complete the behavior [25].
According to the TPB, all effects on behavior act through behavioral intention or perceived behavioral control [30]; therefore, one of the most important structures along with intention and behavior of organ donation and action to receive an organ donation card is perceived behavioral control structure and considering that in the present study, education based on the TPB had a positive and significant effect on the promotion of the structure in young people, it is suggested to use this educational method for different groups of society.
Contrary to the reported results on the relationship between perceived behavioral control and behavioral intention to donate, Park et al. (2009) showed that attitudes and mental norms are significantly related to the intention to register for organ donation, while perceived behavior control did not have a significant relationship. To justify this result, the authors stated that when the target behavior is completely voluntary, perceived behavioral control has no power to predict the behavior. The results may indicate that the participants consider donation registration behavior as a purely voluntary behavior and therefore, as far as perceived control is concerned, rather than actual control, people may consider registration as a behavior that they can perform whenever they want. If so, there may be barriers that people are not aware of, but still influence enrollment behavior. People do not perceive these barriers as deterrents, but these barriers may still act against people's registration behaviors [31].
The use of a theory-based study and the implementation of the study among the members of health centers in Eyvan are the strengths of the study and the small sample size, completion of the questionnaires by self-administered method and the lack of samples from the rural community are some of the limitations of the present study. It is suggested to perform studies in the future to investigate the impact of theory-based training on organ donation behaviors in larger samples and rural youths.

Conclusion
Training based on the TPB leads to significant increases in attitudes, subjective norms, perceived behavioral control, and intention to volunteer for an organ donation card among youth. Unfortunately, most accidents, injuries, and cases of brain death occur among young people, making it crucial to increase knowledge and awareness in this age group. We should encourage them to discuss these issues in family conversations, which serve as the foundation for strengthening mental norms. Additionally, society needs to establish organ donation card registration centers in every organization and institution, enabling individuals to act as organ donor volunteers through perceived behavioral control.

Acknowledgements: The authors thank the Ilam University of Medical Sciences for its cooperation in conducting the study.
Ethical Permission: The approval was obtained from the Ethics Committee of Ilam University of Medical Sciences (IDIR.MEDILAM.REC.1400.042) and the research was registered at the Iranian Registration of Clinical Trials (IRCT20211210053347N1). Written informed consent was obtained from all participants in the study after explaining the aims of the study.
Conflict of Interests: The authors declared no conflicts of interests regarding the publication of this paper.
Authors’ Contribution: Rezaei H (First Author), Introduction Writer/Methodologist/Original Researcher/Discussion Writer (50%); Jorvand R (Second Author), Methodologist/ Assistant Researcher (15%); Ghiasi N (Third Author), Methodologist/ Assistant Researcher (10%); Sayadi H (Fourth Author), Assistant Researcher/Statistical Analyst (10%); Abedzadeh Zavareh MS (Fifth Author), Assistant Researcher/Statistical Analyst (15%);
Funding/Support: This study was partially funded by the Ilam University of Medical Sciences.
 
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Health Education and Health Promotion
Volume 11, Issue 3
Autumn 2023
Pages 455-460