There is an insufficient supply of donor organs to meet the demand for organ transplantations worldwide. Over 10,000 UK residents are currently on the waiting list for a solid organ transplant, and 3 patients die per day before they receive a transplant [1
]. A recent survey found that 90% of the UK general public approve of organ donation [2
]. Despite this, only 30% of people in the UK (38% in Scotland) have registered as posthumous organ donors. This discrepancy suggests that there are important barriers that deter people from registering as an organ donor. The UK Government has set aspirational targets for increasing numbers on the Organ Donor Register from the current level of 17 million to 25 million by 2013, and to increase the number of organs donated by 73% [2
]. There is therefore an urgent need to identify factors that promote and overcome the barriers that deter people from registering as an organ donor [3
Traditional social-cognitive models postulate that actions are determined by rational-cognitive factors. For example, the theory of planned behaviour (TPB) [4
] suggests that actions are determined by rational cognitive attitudes, subjective norms and perceived control. According to this theoretical model, people are likely to register as posthumous organ donors when they have a positive attitude towards donation ('organ donation is a benefit to humanity'), think that significant others support registration ('my family and friends think that I should register as an organ donor'), and believe that they have the ability to register ('it is easy for me to register as an organ donor'). Indeed, most behaviour change interventions adopt such social cognitive approaches. Information is given that is designed to change people's thoughts and perceptions of a specific health behaviour. For example, in 2009 the Gift of Life campaign used the slogan "Be a hero, put the kettle on", which aimed to increase organ donation by emphasising that registration was quick and easy, thus trying to alter people's perceived control over this action. Moreover, this slogan also associated organ donation with positive perceptions ('being a hero'), thereby increasing people's positive attitude towards this action. According to the TPB, such campaigns are likely to be effective. However, without rigorous scientific evaluation, it is difficult to determine their effectiveness.
Although the TPB has been found to predict a variety of actions [5
], including organ donation [7
], it has been criticised for not accounting for the affective/emotional factors that guide decision making [9
]. Indeed, recent research in the US [10
] and the UK [11
] has found that TPB variables are weaker predictors of organ donor registration in comparison to people's emotions and non-cognitive affective attitudes towards registration, suggesting that the key to increasing organ donor registration is to target these emotions and affective attitudes, rather than traditional social-cognitive factors. These emotions and affective attitudes can include feeling disgust towards the idea of organ donation (the "ick factor"), the superstitious belief that registration will in some way lead to harm or death for the registrant (the "jinx factor"), the desire to keep the body whole after death (bodily integrity), the fear that doctors may hasten the death of seriously ill patients in order to harvest their organs (medical mistrust), and the positive consequences of organ donation (perceived benefits). Non-donors are more likely than donors to feel these emotions and hold these negative affective attitudes, and are less likely to endorse the perceived benefits associated with organ donation [10
]. It should be noted, however, that due to the cross-sectional design of the latter studies a causal relationship cannot be established between the affective attitudes and organ donor registration. In the present study we will address this issue by using a prospective RCT design. We also aim to extend this line of work by investigating other emotions that may affect the decision to register as an organ donor or not. Our specific focus is on the emotion of regret.
Regret is an aversive counterfactual emotion that is experienced when people believe that their current situation could have been better if they had acted differently [13
]. It is also possible to anticipate
the amount of regret that one would feel for undertaking or failing to perform an action, thereby giving people a pre-emptive strategy for avoiding this aversive emotion [15
]. The desire to avoid this emotion motivates people to undertake (or avoid) actions when they anticipate feeling regret for inaction (or action). Anticipated regret, therefore, binds people to an action by signaling the aversive emotional consequences of inaction. Indeed, research from a variety of disciplines, ranging from psychology to economics, has found that anticipated regret influences decision making and the likelihood of an action being undertaken [15
]. Anticipated regret has also been found to predict people's intentions to perform an action and actual behavior over and above the traditional TPB components [22
]. For example, this has been found for driving behavior [20
], condom use [26
], exercising [31
], and weight loss [33
A growing body of research has assessed the effectiveness of using anticipated regret in behavior change interventions. Richard and colleagues [34
] found that asking students to rate how they would feel after undertaking unsafe sex increased self-reported condom use 5 months later. Although this finding is promising, it could be criticised for focusing on self-reported measures. A stronger test of the effectiveness of anticipated regret in behavior change interventions was conducted by Sandberg and Conner [18
]. They invited three groups of women for cervical screening: a control group, a group sent a TPB questionnaire and a group who were sent a TPB questionnaire plus anticipated regret questions. For those that completed and returned the questionnaire attendance rates were 21%, 44% and 65% respectively. This is a quite remarkable "mere measurement" effect, given the simplicity of the intervention. Simply asking people to think about and rate the amount of regret that they anticipated for not attending a cervical screening dramatically increased screening attendance.
Similar results have been found for research with more direct relevance to organ donation. Godin and colleagues [35
] randomly assigned 4,672 participants to an experimental condition that received a postal questionnaire measuring cognitions about blood donation (including anticipated regret items) or a control group that did not receive a questionnaire. Compared to control participants, the mean frequency of number of registrations at blood drives among participants in the experimental group was 8.6% greater at 6 months, and was 6.4% greater at 12 months. Significant effects were also observed for successful blood donations at 6 months and 12 months. Recently, Godin and colleagues [36
] conducted a further randomised controlled trial which attempted to increase blood donation in 4,391 novice donors. They found that; (a) questionnaire completion led to a significant increase in donations, and (b) simple "if-then" planning, specifying how, where and when donation would occur (implementation intentions) led to a 12% increase in donations. Manipulating anticipated regret in this study did not augment the intervention effect. However, this study (unlike others) measured anticipated regret with isolated questions, and the authors speculated that this may have been too blatant and that participants may have interpreted the obvious anticipated regret questions as an unsubtle emotional appeal. Godin and colleagues [36
] also suggest that the level of anticipated regret may need to be substantial for it to change intentions and behaviour, and failing to donate blood may not engender sufficient feelings of regret. Godin and colleagues [36
] conclude "Further research is needed concerning the blatancy of the induction of anticipated regret and the role of underlying levels of anticipated regret in explaining the behavioural impact of this type of intervention" (p. 643).
The research cited above suggests that subtle anticipated regret interventions increase the likelihood of an action being undertaken. Subtly increasing the prominence of anticipated regret in the decision making process emphasises the aversive emotional consequences of inaction. The desire to avoid the aversive feeling of regret motivates people to undertake the behaviour. Essentially, anticipated regret strengthens behavioural intentions and binds the person to action, because failing to act is associated with aversive emotions. However, this is only likely to occur when the anticipated regret intervention is subtle. Blatant anticipated regret interventions are likely to be interpreted as emotional appeals, decreasing the effectiveness of the intervention. Taken together, these studies therefore suggest that people are more likely to undertake an action when they anticipate regret for inaction, and that simply asking people whether they would later regret inaction can significantly increase the likelihood of an action occurring.
The aim of the present study is to determine whether simply asking people whether they would later regret not registering as an organ donor increases verified registration. In preparation, we have conducted 3 pilot studies [for full details, see 11,12]. We found that simply asking people whether they would later regret not registering as an organ donor increased their intentions to register [12, Study 2]. Moreover, we replicated this finding with a more representative sample of the adult Scottish general public [12, Study 3]. Although these findings are promising, people do not always act upon their intentions, the well recognised intention-behaviour gap. In a third pilot study we found that asking people whether they would later regret not registering as an organ donor increased self-reported organ donor registration [11
]. This latter finding suggests that anticipated regret promotes organ donor registration. However, this research can be criticised for using self-reported measures of registration. The acid test is clearly whether this intervention leads to a significant increase in verified
registrations on the UK NHS Blood and Transplant (NHSBT) posthumous Organ Donor Register. The aim of the present study is to test whether a large scale, simple anticipated regret intervention leads to a significant increase in NHSBT verified organ donor registrations.
(a) Does a brief, theory-based anticipated regret intervention lead to a significant increase in organ donor registrations?
(b) If we do observe an anticipated regret effect, what is the mechanism, e.g. is it fully mediated via intentions and/or non-cognitive affective attitudes?
(c) What effect size is observed, to inform the power calculation for the next stage, a UK-wide translational study?
(d) What is the feasibility, response rate etc. to inform such a study?