Design and Evaluation of a Workplace Intervention to Promote Organ Donation

Identifying behaviour change techniques within randomized trials of interventions promoting deceased organ donation registration

OBJECTIVE

Increasing deceased organ donation registration may increase the number of available organs for transplant to help save lives. This study aimed to identify which behaviour change techniques (BCTs; or 'active ingredients') are reported within randomized trials of interventions promoting deceased organ donation registration and of those, which are associated with a larger intervention effect.

METHODS

We conducted a secondary analysis of 45 trials included in a Cochrane systematic review of deceased organ donation registration interventions. Two researchers used the BCT Taxonomy v1 to independently code intervention content in all trial groups. Outcome data were pooled and we used meta-regression to explore associations between individual and combinations of recurring BCTs and effect on registration intention and/or registration behaviour.

RESULTS

A total of 27 different BCTs (mean = 3.7, range = 1-9) were identified in intervention groups across the 45 trials. The five most common BCTs were: 'Information about health consequences' (71%); 'Instruction on how to perform the behaviour' (47%); 'Salience of consequences' (40%); 'Adding objects to the environment' (28%); and 'Credible source' (27%). Comparator groups in 20/45 trials also included identifiable BCTs (n = 12, mean = 3.1, range = 1-7). Meta-regression revealed that a combination of the three most common BCTs was associated with a larger intervention effect size for registration behaviour (k = 8, β = .19, p = .02).

CONCLUSIONS

Trials of deceased organ donation registration interventions focus predominantly on providing information, instruction, and a means to register. While potentially effective, a much wider set of possible BCTs could be leveraged to address known barriers to registration.

Development and Psychometric Testing of the Signed Donor Card (SDC) Scale in an Islamic Society

The signed donor card is an important method to overcome the shortage of organs for transplantation. A valid and reliable scale is necessary to have with the development of interventions to increase the signed donor card. This study aimed to develop and psychometric testing of the Signed Donor Card (SDC) in an Islamic society. This methodological study was conducted in Hamadan city, Iran in 2018 on 600 employees of offices. A 46-item scale was developed. It was assessed by face, content, and construct validities. Reliability was examined using the calculation of the Cronbach's α and test-retest method. The SPSS software version 22 and Mplus version 7.4 were used for data analysis. Our scale demonstrated acceptable internal consistency (α = 0.58-0.93) and good test-retest reliability (ICC = 0.76). The fitness indices for the confirmatory factor analysis (CFA) indicated that the model fit was good. CFA revealed nine standalone components including attitude, subjective norms, intention, anticipated regret, descriptive norms, perceived control, knowledge, non-cognitive beliefs, and religious beliefs. Convergent validity and discriminant validity were established. This study provided evidence concerning the validity and reliability of SDC scale. It can be used for the development and implementation of effective interventions for increasing signed donor card with the consideration of contextual and cultural situations.

Interventions for increasing solid organ donor registration

BACKGROUND

A solution for increasing the number of available organs for transplantation is to encourage more individuals to register a commitment for deceased organ donation. However, the percentage of the population registered for organ donation remains low in many countries.

OBJECTIVES

To evaluate the benefits and harms of various interventions used to increase deceased organ donor registration.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 11 August 2020 through contact with an Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs), cluster RCTs and quasi-RCTs of interventions to promote deceased organ donor registration. We included studies if they measured self-reported or verified donor registration, intention to donate, intention to register a decision or number of individuals signing donor cards as outcomes.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed retrieved studies and extracted data from included studies. We assessed studies for risk of bias. We obtained summary estimates of effect using a random-effects model and expressed results as risk ratios (RR) (95% confidence intervals; CI) for dichotomous outcomes and mean difference (MD; 95% CI) or standardised mean difference (SMD; 95% CI) for continuous outcomes. In multi-arm trials, data were pooled to create single pair-wise comparisons. Analyses were stratified by specific intervention setting where available.

MAIN RESULTS

Our search strategy identified 46 studies (47 primary articles, including one abstract) comprising 24 parallel RCTs, 19 cluster RCTs and 3 quasi-RCTs. Sample sizes ranged from 138 to 1,085,292 (median = 514). A total of 16 studies measured registration behaviour, 27 measured intention to register/donate and three studies measured both registration behaviour and intention to register. Interventions were delivered in a variety of different settings: schools (14 studies), driver's motor vehicle (DMV) centres (5), mail-outs (4), primary care centres (3), workplaces (1), community settings (7) and general public (12). Interventions were highly varied in terms of their content and included strategies such as educational sessions and videos, leveraging peer leaders, staff training, message framing, and priming. Most studies were rated as having high or unclear risk of bias for random sequence generation and allocation concealment and low risk for the remainder of the domains. Data from 34/46 studies (74%) were available for meta-analysis. Low certainty evidence showed organ donation registration interventions had a small overall effect on improving registration behaviour (16 studies, 1,294,065 participants: RR 1.30, 95% CI 1.19 to 1.43, I2 = 84%), intention to register/donate (dichotomous) (10 studies, 10,838 participants: RR 1.21, 95% CI 1.03 to 1.42, I2 = 91%) and intention to register/donate (continuous) (9 studies, 3572 participants: SMD 0.23, 95% CI 0.11 to 0.36, I2 = 67%). Classroom-based interventions delivered in a lecture format by individuals from the transplant community may be effective at increasing intention to register/donate (3 studies, 675 participants: RR 1.33, 95% CI 1.15 to 1.55, I² = 0%). Community interventions targeting specific ethnic groups were generally effective at increasing registration rates (k = 5, n = 4186; RR 2.14, 95% CI 1.35 to 3.40, I² = 85%), although heterogeneity was high. In particular, interventions delivered in the community by trained peer-leaders appear to be effective (3 studies, 3819 participant: RR 2.09, 95% CI 1.08 to 4.06, I² = 87%), although again, the data lacked robustness. There was some evidence that framing messages (e.g. anticipated regret) and priming individuals (e.g. reciprocity) in a certain way may increase intention to register/donate, however, few studies measured this effect on actual registration. Overall, the studies varied significantly in terms of design, setting, content and delivery. Selection bias was evident and a quarter of the studies could not be included in the meta-analysis due to incomplete outcome data reporting. No adverse events were reported.

AUTHORS' CONCLUSIONS

In our review, we identified a variety of approaches used to increase organ donor registration including school-based educational sessions and videos, leveraging peer leaders in the community, DMV staff training, targeted messaging and priming. The variability in outcome measures used and incompleteness in reporting meant that most data could not be combined for analysis. When data were combined, overall effect sizes were small in favour of intervention groups over controls, however, there was significant variability in the data. There was some evidence that leveraging peer-leaders in the community to deliver organ donation education may improve registration rates and classroom-based education from credible individuals (i.e. members of the transplant community) may improve intention to register/donate, however, there is no clear evidence favouring any particular approach. There was mixed evidence for simple, low-intensity interventions utilising message framing and priming. However, it is likely that interest in these strategies will persist due to their reach and scalability. Further research is therefore required to adequately address the question of the most effective interventions for increasing deceased organ donor registration.

Guiding Strategies for the Future of Vascularized Composite Allotransplantation: A Systematic Review of Organ Donation Campaigns

BACKGROUND

Since the 1990s, the field of vascularized composite allotransplantation has gained momentum, offering unprecedented solutions for patients with defects not amenable to autologous reconstruction. As with solid organ donation, the vascularized composite allotransplant donor pool remains limited. This systematic review identifies past successes and failures in organ donation campaigns to guide future strategies for expanding vascularized composite allotransplant donation.

METHODS

A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Three databases (PubMed/MEDLINE, PsycINFO, and Embase) were searched through July 31, 2019. The study compiled solid organ and vascularized composite allotransplant campaigns that aimed to increase donor registration. Articles depicting the current state of vascularized composite allotransplant donation were also assessed.

RESULTS

Of an initial 3318 articles identified, 40 were included. Six articles described direct mail or print interventions, 10 depicted Web-based interventions, 13 dealt with interpersonal interventions, and seven used multimodal interventions. Four articles described the current state of vascularized composite allotransplant donation. A qualitative synthesis was conducted. The authors found that social media campaigns can have a robust but fleeting effect on registration trends and that interpersonal interventions are effective at increasing registration rates. In addition, the opportunity for participants to immediately register as organ donors, by means of either return mail, in-person, or online, is vital to campaign success.

CONCLUSIONS

Public organ donation campaigns have had success in increasing organ donor registration rates, particularly through the use of social media and interpersonal interventions that allow for immediate registration. Synthesizing this information, we propose a multimodal campaign to expand the vascularized composite allotransplant donor pool.

The Value of Being Discrete: The Differential and Causal Effects of Positive Affect and Discrete Positive Emotions on Organ Donor Registration Outcomes

BACKGROUND

The current studies examined how positive affect (i.e. the blend of several positive feelings over time) and discrete positive emotions (i.e. a specific set of momentary thoughts and feelings) influence organ donor registration outcomes.

METHODS

In Study 1, participants were randomly assigned to a writing task intended to elicit positive or negative affect. In Study 2, participants received a discrete positively valenced emotion induction (i.e. elevation, humor, hubristic pride), or were in a control condition.

RESULTS

Study 1 (N = 503) indicated a causal relationship between general positive affect and registration attitudes. An indirect effect beginning with general positive affect, going through attitudes, and then intentions, to influence behavior was also indicated. Study 2a (N = 394) demonstrated that elevation, humor, and hubristic pride can be influenced using an online platform. Study 2b (N = 1,046) indicated a causal relationship between elevation and increased registration intentions and behavior. The humor recall task caused marginally significant greater registration intentions, but no significant behavioral differences. The hubristic pride task did not influence registration outcomes.

CONCLUSION

Organ donor practitioners and scholars could benefit from increased focus on the emotional states likely to be experienced at different venues when considering intervention contexts.

A Systematic Narrative Review of Effects of Community-Based Intervention on Rates of Organ Donor Registration

Background:

The demand for organ donation is increasing worldwide. One possible way of increasing the pool of potential posthumous donors is to encourage more members of the general public to join an organ donor registry.

Objective:

A systematic review was conducted to investigate the effectiveness of psychological interventions designed to increase the number of individuals in the community who register as organ donors.

Methods:

PsycINFO and PubMed databases were searched. No date limits were set. Randomized and nonrandomized controlled trials exploring the effects of community-based interventions on organ donor registration rates were included. Methodological quality was assessed using the “Quality Assessment Tool for Quantitative Studies.”

Results:

Twenty-four studies met the inclusion criteria; 19 studies found a positive intervention effect on registration. Only 8 studies were assessed as having reasonable methodological robustness. A narrative synthesis was conducted. Factors influencing registration rates include providing an immediate registration opportunity and using brief interventions to challenge misconceptions and concerns about organ donation.

Discussion:

Community-based interventions can be effective at increasing organ donor registrations among the general public. Factors that may increase effectiveness include brief interventions to address concerns and providing an immediate registration opportunity. Particular consideration should be paid to the fidelity of intervention delivery. Protocol registration number: CRD42014012975.

A Systematic Literature Review and Research Agenda for Organ Donation Decision Communication

Background:

This study systematically located and appraised peer-reviewed evidence for the efficacy of strategies to increase organ donation decision communication among adults including an assessment of study quality to guide future research in this field. There is little room to move in strengthening unanimously positive public attitudes toward organ donation. Consequently, researchers have called for a focus on organ donation decision communication to understand modifiable factors to increase organ donation rates.

Methods:

Multiple databases were searched during September 2015, and 44 studies were selected for inclusion. Data concerning participants, design, and outcomes were extracted. Studies were rated for quality and levels of evidence.

Findings:

Although not amenable to meta-analysis, the literature indicates that approximately 50% of adults who are willing to become an organ donor have discussed this decision with family. The majority of research was conducted in a Western context with an overrepresentation of students. Strategies to increase communication include education, motivation, input from lived experience, efforts to address salient audience beliefs, and scheduled reminders or prompts. Intentions and willingness to discuss organ donation were consistently positively related to discussion behavior; however, formative research and experimental studies testing theoretically driven interventions were scarce.

Conclusions:

There is mixed evidence for the role of demographic and attitudinal characteristics in the success of organ donation communication interventions. Additional theoretically based research is recommended to establish boundary conditions and validate strategies to increase organ donation decision communication among adults.

A multidisciplinary organ donor council and performance improvement initiative can improve donation outcomes

The shortage of organs available for transplantation has become a national crisis. The Department of Health and Human Services established performance benchmarks for timely notification, donation after cardiac death (DCD), and conversion rates (total donors/eligible deaths) to guide organ procurement organizations and donor hospitals in their attempts to increase the number of transplantable organs. In January 2007, an organ donor council (ODC) with an ongoing performance improvement case review process was created at a Level I trauma center. A critical care devastating brain injury protocol and a DCD policy were instituted. Best performance benchmarks were evaluated before and after establishment of the ODC. At our center, the total number of referrals increased from 96 in 2006 to 139 in 2007 and 143 in 2008. Timely notification rate increased from 64 per cent in 2006 to 83 per cent in 2007 and 2008 (P < 0.01). DCD rate increased from 0 per cent in 2006 to 13 per cent in 2007 (P = 0.06) and 10 per cent in 2008 (P = 0.09). Conversion rate increased from 53 per cent in 2007 to 78 per cent in 2008 (P = 0.05) and 73 per cent in 2009 (P = 0.16). Organs transplanted per eligible death trended upward from 1.80 in 2007 to 2.54 in 2009 (P = 0.20). As a consequence, the establishment of a multidisciplinary ODC and performance improvement initiative demonstrated improved donation outcomes.

Incremental Increases in Organ Retrieval after Protocol Driven Change in an Organ Procurement Organization: A 15-Year Assessment

The need for transplantable organs exceeds the available supply. Organ procurement organizations (OPOs) have undergone both voluntary and mandated changes to optimize available organs. The data from a single statewide OPO was reviewed from 1993 to 2008 and tracked with implementation of new protocols. During the study, 5548 organs were recovered with 4875 transplanted from 1441 donors (3.38 organs transplanted/donor (OTPD)). The conversion rate (CR) for consent rose from 42 to 72 per cent whereas the average age of donors increased from 33 to 45 years. After implementation of a family support liaison program, a higher performing hospital in the OPO realized an increase in CR from 57 to 97 per cent over 8 years. Implementation of an intensivist program improved OTPD. The number of standard criteria donors and extended criteria donors (ECD) increased. The increase in standard criteria donors yielded a large number of thoracic organs. ECD increased as did the organ discard rate from 8 to 16 per cent. Increases in organ retrieval were noted after incremental changes in OPO protocol. Family support and intensivist programs enhanced CR and OTPD. Increases in the number of ECD were noted with increasing age after the introduction of the intensivist program and an increase in transplant center use of these organs.

Relationship of Exposure to Organ Donation Information to Attitudes, Beliefs, and Donation Decisions of Next of Kin

Context

Public education campaigns about organ donation are common, but their association to actual attitudes, beliefs, and decisions about organ donation among family members of donation-eligible individuals is unknown.

Objective

To examine the sources of organ donation information identified by donor and nondonor families who participated in a large-scale study to examine factors that influence organ donation decisions.

Design

Semistructured telephone survey conducted after a passive recruitment strategy.

Setting and Participants

Participants were 285 next of kin of donor-eligible individuals (147 donors, 138 nondonors) from one organ procurement organization.

Results

Most (85.6%) of next of kin were exposed to at least 1 source of donation information that was important to them, although the types of donation information they were exposed to varied widely. White and educated adults were more likely to have been exposed to more donation information than had minorities and persons with less education. Favorable attitudes and beliefs about organ donation, donor designation, and sharing donation intentions with others were all associated with more exposure to different types of donation information. Donation consent was more likely when next of kin had been exposed to more donation information in the months preceding the family member's death.

Conclusions

When examined in the context of other recent research, these findings argue for continued development and implementation of public education campaigns for organ donation, with an emphasis on repeated exposure over time.

Factors Predictive of Signed Consent for Posthumous Organ Donation

Context

The shortage of organs for transplantation has led public health authorities to invest significant efforts in the promotion of organ donation.

Objective

To identify factors predictive of signed consent for posthumous organ donation by using the theory of planned behavior.

Participants and Design

A random sample of 602 adults completed a questionnaire at baseline, and behavior was self-reported 15 months later.

Results

Logistic regression indicated that intention, perceived behavioral control, moral norm, and past behavior were factors predictive of consent for posthumous organ donation. Participants' perceived behavioral control, past behavior, and moral norm were also predictive of intention to sign, but attitude and perceived barriers were 2 additional determinants. Finally, anticipated regret and knowledge of persons who had made an organ donation were 2 moderators of the intention-behavior relationship.

Conclusion

Overall, the results showed that intention is an important determinant of signing the organ donor's consent sticker and also highlighted that moral consideration and perceived difficulties could be 2 potential avenues for designing interventions.