The Ick Factor, Anticipated Regret, and Willingness to Become an Organ Donor

Transcription

1 Health Psychology 2011 American Psychological Association 2011, Vol. 30, No. 2, /11/$12.00 DOI: /a The Ick Factor, Anticipated Regret, and Willingness to Become an Organ Donor Ronan E. O Carroll, Catherine Foster, Grant McGeechan, and Kayleigh Sandford University of Stirling Eamonn Ferguson University of Nottingham Objective: This research tested the role of traditional rational-cognitive factors and emotional barriers to posthumous organ donation. An example of an emotional barrier is the ick factor, a basic disgust reaction to the idea of organ donation. We also tested the potential role of manipulating anticipated regret to increase intention to donate in people who are not yet registered organ donors. Design: In three experiments involving 621 members of the United Kingdom general public, participants were invited to complete questionnaire measures tapping potential emotional affective attitude barriers such as the ick factor, the desire to retain bodily integrity after death, and medical mistrust. Registered posthumous organ donors were compared with nondonors. In Experiments 2 and 3, nondonors were then allocated to a simple anticipated regret manipulation versus a control condition, and the impact on intention to donate was tested. Main Outcome Measures: Self-reported emotional barriers and intention to donate in the future. Results: Traditional rational-cognitive factors such as knowledge, attitude, and subjective norm failed to distinguish donors from nondonors. However, in all three experiments, nondonors scored significantly higher than donors on the emotional ick factor and bodily integrity scales. A simple anticipated regret manipulation led to a significant increase in intention to register as an organ donor in future. Conclusions: Negative affective attitudes are thus crucial barriers to people registering as organ donors. A simple anticipated regret manipulation has the potential to significantly increase organ donation rates. Keywords: organ, donor, donation, disgust, posthumous There is an insufficient supply of donor organs to meet the demand for organ transplantations worldwide. As of January 2010, over 100,000 Americans ( and 10,000 United Kingdom residents ( were on the waiting list for a solid organ transplant. The Health Belief Model (HBM) posits that the likelihood that a person will take a health related action depends upon core beliefs with regard to (a) perceived severity, (b) perceived susceptibility, (c) perceived benefits, (d) perceived barriers, (e) cues to action, and (f) self-efficacy. Several aspects of this model are pertinent to organ donation, in particular perceived benefits and barriers (see Brug, Van Vugt, Borne, Brouwers, & Van Hooff, 2000; Cacioppo & Gardner, 1993). For example, Horton and Horton (1990) tested the role of poor knowledge as a potential barrier to donation. They found that many members of Accepted under the editorial term of Robert M. Kaplan. Ronan E. O Carroll, Catherine Foster, Grant McGeechan, and Kayleigh Sandford, Department of Psychology, University of Stirling; Eamonn Ferguson, Department of Psychology, University of Nottingham. We thank Prof. Susan Morgan for kindly providing a copy of her organ donor questionnaire, and we thank all the participants for their involvement in this research. We would also like to thank Dr. Julie Chambers, Prof. Rory O Connor, and two anonymous reviewers for their helpful comments on a previous version of this paper. Correspondence concerning this article should be addressed to Ronan E. O Carroll, Centre for Health and Behavior Change, Psychology Department, University of Stirling, Stirling, FK9 4LA, United Kingdom. reo1@stir.ac.uk the U.S. general public demonstrated poor knowledge in four key areas: religious support for organ donation, the concept of brain death, separation of medical responsibility for donor and recipient, and erroneous beliefs regarding requirements for organ donor card registration. Horton and Horton (1990) speculate that improving knowledge with regard to these four barrier areas may lead to more positive attitudes to organ donation and perhaps a greater willingness to register as a posthumous organ donor. Traditional social cognitive theoretical models such as the HBM, Theory of Reasoned Action (TRA), and the Theory of Planned Behavior (TPB) view people as rational decision makers. However, Morgan, Stephenson, Harrison, Afifi, and Long (2008) recently came to the conclusion that a social scientific approach to the study for organ donation that presumes rational decision making has failed to help us fully understand the wide range of responses to the idea of donating one s organs. We have yet to identify and study a number of variables that may impact Americans responses to donations (p. 645). Evidence has accumulated indicating that negative outcome expectancies (such as medical mistrust) can act as important deterrents or barriers to people signing up as potential posthumous organ donors. Indeed, Cacioppo and Gardner (1993) argued that negative beliefs and fears constitute a particularly difficult barrier to inducing donor behaviors. They concluded that understanding and changing the negative as well as the positive substrates may be the key (p. 271). Brug et al. (2000) found the strongest associate of intention to donate was negative outcome expectancies measured using items such as: my death may be established too soon ; my organs may 236

2 THE ICK FACTOR, ANTICIPATED REGRET, AND ORGAN DONATION 237 be traded ; my body may be mutilated after my death. Negative outcome expectancies correlated.44 with intention to donate, whereas positive outcome expectancies correlated.21. Brug et al. (2000) concluded that, to persuade individuals to register as an organ donor, refutational messages would have to be developed to counterargue negative outcome expectations. Reubsaet et al. (2005) also found that negative outcome beliefs had the strongest association with organ donation registration. The evidence briefly reviewed above is in accord with the more recent findings of Morgan et al. (2008), who investigated the potential deterrent roles of variables they termed noncognitive, that is, emotional beliefs associated with a potential future negative outcome. The first of these, the ick factor, was defined as a basic disgust response to the idea of organ procurement or transplantation. Disgust, characterized by revulsion, has been described as the forgotten emotion (Philips et al., 1998). However, there has been a resurgence of interest in the scientific study of disgust in recent years. For example, in 2002, McNally published a paper entitled Disgust has arrived, in which he raised the important question, is disgust noncognitive? 1 The answer clearly depends on one s definition of cognitive, but if cognitive is defined as conscious beliefs, potentially changeable by rational discourse, then disgust may be impervious to such arguments (McNally, 2002). There is also a growing literature on individual differences in disgust sensitivity (Deacon et al., 2007). In the anxiety disorders, fear has traditionally been considered to be the dominant emotional state. However, disgust can also be a crucial determinant of avoidance behavior (Cisler et al., 2009), and in the present context, this may be particularly important if it leads to avoiding, or delaying, registering as an organ donor. Consistent with this view, Sherman et al. reported that the higher the disgust sensitivity, the more negative the attitude toward organ donation, and the lower the intention to donate organs (Sherman et al., 2001). As well as the ick factor, Morgan et al. (2008) explored the role of three other noncognitive variables that is, jinx factors, medical mistrust, and bodily integrity. Jinx factors are those that are related to fears, anxieties, and superstitions about the misfortune that would result if a person registered as an organ donor or actually donated his or her own organs (Morgan et al., 2008). Medical mistrust is viewed as the common fear that doctors may hasten the death of seriously ill patients to harvest their organs. Bodily integrity represents the belief in the need to maintain bodily integrity after death, or face serious afterlife consequences. Such fears persist despite the fact that all major religions have either issued statements of outright support of organ donation or that organ donation is a matter of individual conscience and is not precluded by scripture. Morgan et al. (2008) also tested the role of the perceived benefits of donation (e.g., the donor as hero and/or continuing survival after death through the recipient(s) of one s organs). This is similar to the idea of benevolence in blood donation with both the donor and recipient gaining from the transaction (Ferguson, Farrell & Lawrence, 2008). In their study of over 4,000 American adults, Morgan et al. (2008) found that the best predictors of having signed an organ donor card or not were the noncognitive barrier beliefs (i.e., ick factor, jinx factor, etc.). In contrast, traditional, rational-cognitive factors such as knowledge, attitude, and subjective norm were only weak predictors of organ donor registration. Morgan et al. (2008) concluded that the main barriers to becoming an organ donor are therefore not rational or cognitive in nature. The implications are clear, that in attempting to increase the number of organ donors world-wide, more emphasis should be placed on manipulating emotional and visceral factors rather than focusing exclusively on theories of reasoned action. Anticipated Regret Regret is a negative cognitive-based emotion that is experienced when we imagine that the present situation could have been better had we acted differently. It is also possible to anticipate regret and thus avoid actually experiencing this unpleasant emotion. It has been shown that over and above the traditional components of the TPB and TRA, anticipated regret adds significantly to the prediction of intentions to use condoms, engage in casual sex, eat junk food, use soft drinks, drink alcohol, commit driving violations, protect one s health, exercise, and predicts smoking initiation (Sandberg & Conner, 2008). Anticipated regret also has a direct impact on prospective behavior for example, future exercise (Abraham & Sheeran, 2003). In their recent meta-analysis, Sandberg and Conner (2008) reported a large effect size correlation between anticipated regret and intention (r.47), and found that anticipated regret significantly and independently added to the prediction of intentions over and above the standard TPB variables. A moderate relationship between anticipated regret and behavior was observed (r.28). However, only eight studies in the review measured actual behavior. In their multivariate analysis predicting intentions, the addition of anticipated regret increased the amount of variance explained by 7%. The addition of anticipated regret was highly significant after all the TPB variables were accounted for, increasing the amount of variance explained in prospective behavior from 17 to 18% (Sandberg & Conner, 2008). Sandberg and Conner (2009) conducted an experimental test of manipulating anticipated regret when inviting women for cervical screening. They invited three groups of women for cervical screening: a control group, a group also sent a TPB questionnaire and a group who were sent a TPB questionnaire plus anticipated regret questions. Of those who did not return the questionnaire, screening attendance was 21, 26, and 26%, respectively (i.e., simply sending out a questionnaire increased attendance by 5%). For those that completed and returned the questionnaire (i.e., were definitely exposed to the intervention) attendance rates were 21, 44, and 65%, respectively. This is a quite remarkable mere measurement effect. Of more direct relevance to organ donation, Godin, Sheeran, Conner, and Germain (2008) attempted to identify factors predictive of signing consent for posthumous organ donation in Canada. Six hundred adults completed a questionnaire at baseline. At 15 month follow-up, approximately two-thirds had signed their organ donor consent. Intention, perceived behavioral control, moral norm, and past behavior were predictive of consent for posthumous organ donation. Attitude and perceived barriers were also predictive of intention. The perceived barriers included items such 1 We have reservations regarding the term noncognitive. Clearly information (cognitive) processing is occurring when one has an emotional reaction. We prefer the term affective attitude or belief (Lawton et al., 2009).

3 238 O CARROLL ET AL. as Could the fear of your body being mutilated prevent you from signing? and Could the fear of not having everything done to save your life prevent you from signing? These items are clearly very similar to the bodily integrity and medical mistrust scales used by Morgan et al. (2008). Importantly, Godin et al. (2008) also found that anticipated regret and knowing someone who donated one or more organs were independent significant moderators of the intention-behavior relationship. In this paper we aimed to (a) test of the role that noncognitive emotional factors play in relation to organ donation to U.K. samples, and (b) attempt, for the first time, to manipulate the emotion of anticipated regret to test whether this increases the intention of nondonors to register as posthumous solid-organ donors. General Method We conducted three experiments to further test the role of perceived emotional barriers and anticipated regret in influencing willingness to become a posthumous organ donor. Experiment 1 compares registered donors and nondonors on emotional barriers to donation. Experiment 2 again compares donors and nondonors on emotional barriers plus rationale-cognitive factors, and also tests a simple anticipated regret manipulation on future intention to donate in nondonors. Experiment 3 provides a larger scale replication of Experiment 2, and also tests the contribution of general superstitious beliefs to organ donation. Ethics All three experiments were approved by the ethics committee of the Psychology Department, University of Stirling, U.K. Power Analysis We conducted a preliminary power analysis for the betweengroups comparison (i.e., an ANOVA for donors vs. nondonors) using G-Power (Faul et al., 2007). To detect a directional medium effect size (.5) with alpha set at.05 and a power of.80, a minimum sample size of 102 participants was required. Experiment 1 In this first experiment, we tested whether U.K. registered organ donors would score significantly differently from nondonors on the emotional barrier domains reported as being discriminating by Morgan et al. (2008) in their U.S. study. Method Study population and data collection. There were 151 adults who participated in this study. All participants were members of the U.K. public. The participants were recruited opportunistically from adult students and staff at three Colleges/ Universities in Scotland and the North of England. Participants were approached directly by the researcher. Student participants from the University of Stirling (n 69) received a course credit for participation. All participants gave signed informed consent before completing the brief questionnaire and returning it to the researcher. The sample was divided into two groups (donors and nondonors) based on their answer (Yes or No) to the following question: I have registered as an organ donor. Of these, 141 participants answered this question and their demographic details are provided in Table 1. Dependent variables. All participants completed a modified version of the attitudes toward organ donation questionnaire devised by Morgan et al. (2008). Minor changes of wording were also made to make the questionnaire appropriate for a U.K. sample (e.g., replacing the word casket for coffin). All items were scored on a 7-point scale from 1 strongly disagree to 7 strongly agree. In their paper, Morgan et al. (2008) identified five components of beliefs associated with organ donation (i.e., jinx, ick, bodily Table 1 Demographic Characteristics of Donors and Nondonors in All Three Studies Experiment 1 Donors (n 56) Nondonors (n 85) Age (SD) 32.0 (13.1) 28.7 (12.5) t(139) 1.52, p.130, ns Sex 23M, 33F 44M, 41F 2 (1) 1.55, p.213, ns Experiment 2 Donors (n 47) Nondonors (n 91) Age group (1 5) 3.7 (1.7) 3.7 (1.8) 2 (4) 6.46, p.167, ns Sex 20M, 27F 39M, 52F 2 (1) 0.001, p.973, ns Social Department Index (3) 3.22, p.358, ns Experiment 3 Donors (n 149) Nondonors (n 193) Age group (1 5) 3.76 (1.6) 3.62 (1.8) 2 (4) 8.57, p.073, ns Sex 61M, 88F 95M, 98F 2 (1) 2.326, p.127, ns Social Department Index (3) 4.06, p.399, ns

4 THE ICK FACTOR, ANTICIPATED REGRET, AND ORGAN DONATION 239 integrity, medical mistrust, and perceived benefits). In this study we test this 5-factor solution using a confirmatory factor analysis. The questionnaire domains were measured as follows: Jinx factor: The jinx factor was measured by three items. Higher scores suggest a greater feeling that it is bad luck to talk about death or becoming an organ donor. Ick factor: This was measured by three items. Higher scores indicate greater feelings of disgust at the idea of organ donation. Medical mistrust: This was measured by four Items. Higher scores indicate greater feelings of medical mistrust. Bodily integrity: We used two items to calculate an overall score for bodily integrity. Higher scores indicate a greater belief in the need to maintain bodily integrity. Perceived benefit: This was measured by four items. Higher scores indicate a greater perceived benefit of being an organ donor. Data analysis. In their paper, Morgan et al. (2008) suggest that the first four factors (jinx, ick, bodily integrity, and medical mistrust) represent a single noncognitive factor but also treat these as separate factors (see their Table 3, p. 653). They did not test competing factor models. Based on Morgan et al. (2008), the following confirmatory factor analysis (CFA) models were examined: (a) a 2-factor model with items relating to jinx, ick, bodily integrity, and medical mistrust loading a single latent factor (noncognitive beliefs) and perceived benefit items as a second single latent factor, and (b) a 5-factor model with the items for jinx, ick, bodily integrity, medical mistrust, and perceived benefits all loading on separate factors. As we did not know whether the factors would be correlated, we tested both the 2- and 5-factor models as oblique and orthogonal solutions. The CFA models are specified at the item level and following recommendations they are treated as ordinal (Wirth & Edwards, 2007). As such, the data were analyzed using diagonally weighted least squares (DWLS). This method was chosen as this procedure works well with smaller sample sizes (Wirth & Edwards, 2007). However, DWLS can lead to biased estimates of standard errors and fit indices, as such the Satorra-Bentler Correction (Satorra & Bentler, 1994) was applied as recommended (Wirth & Edwards, 2007) leading to a Robust-DWLS. The models were specified in LISREL 8.8. Models were specified with error variance free and factor variances set to 1. To assess the fit of the competing models the recommendations of Hu and Bentler (1999) were adopted. They proposed a series of 2-index combination rules to assess model fit. These authors propose that a model has good fit when both the Comparative Fit Index (CFI) approach a minimum of.95 and a Standardized Root Mean Square Residual (SRMR) approaches a maximum of.08. We then compared donors and nondonors on the scales using independent t tests. Following Cleveland (1975) and Besser, Amir, and Barkan, (2004), in all analyses we also compared donors and nondonors on age and sex. Results The results for the CFA (N 151) indicated that the 5-factor oblique model was the best fit to these data (SRMR.08, CFI.99, SB ). The orthogonal 5-factor model had poorer fit (SRMR.31, CFI.90, SB ). The 2-factor oblique (SRMR.11, CFI.93, SB ) and orthogonal (SRMR.17, CFI.92, SB ) models were also poorer fits to the data. The factor loadings (standardized and unstandardized) and their standard errors for the 5-factor oblique model are shown in Table 2. 2 Internal reliability, as measured by Cronbach s alpha (shown in Table 2), was moderate to good for all five factors (0.67 to 0.85). The correlations between the 5 factors, derived from the oblique CFA, are shown in Table 3. This pattern of correlations is the same as those reported by Morgan et al. (2008) and replicated across Studies 2 and 3 (reported later). For Study 2 correlations ranged from.33 to.59 (mean r regardless of sign.27, SD.19) and for Study 3 the range was.24 to.43 (mean r regardless of sign.26, SD.14). This is comparable with data from Morgan et al. (2008) where the correlations ranged from.18 to.69 (mean r regardless of sign.38, SD.24). There were 141 participants who had also completed the necessary demographic data were included in the analyses of donors versus nondonors. Donors and nondonors were not significantly different with regard to age and sex (see Table 1). However, the two groups differed significantly on all the noncognitive factors (see Figure 1): perceived benefit, t(139) 2.74, p.007: r.23; ick (t(139) 5.87, p.0001: r.44); jinx (t(139) 3.83, p.0001; r.31); medical mistrust (t (139) 3.70, p : r.30); bodily integrity (t(139) 4.72, p.0001: r.37). Discussion We hypothesized that the noncognitive factors would distinguish posthumous organ donors from nondonors and found significant effects for all the noncognitive factors, that is, in order of effect size, for ick, bodily integrity, jinx, medical mistrust, and perceived benefit, respectively. We have thus replicated the Morgan et al. (2008) U.S. findings in a U.K. sample. Experiment 2: The Ick Factor and Anticipated Regret In this second experiment we attempted to further test whether emotional and visceral variables clearly distinguish between adults who have registered as organ donors versus those who have not. First, we extended this study to a more representative sample of the U.K. general population. Second, we compared these same participants on the traditional rational-cognitive TPB variables of 2 For the 5-factor oblique model one item (15) had a negative error variance (a possible HEYWOOD case). This was corrected by fixing the negative error variance to zero as recommend by Dillon, Kumar, and Mulani (1987). Dillon et al. (1987) showed this procedure to perform better then alternative fixes when the negative error variance is attributable to sample fluctuations. The procedures suggested by Dillon et al. (1989, see also Jones, Cauffman, Miller, & Mulvey, 2006) indicated that the HEYWOOD case was because of sampling fluctuation. Together these findings indicate that the Heywood case is likely because of sample fluctuations and the solution reported is tenable.

5 240 O CARROLL ET AL. Table 2 Confirmatory Factor Structure for the Oblique 5-Factor Model With Both Unstandardized (US) and Standardized (ST) Coefficients and Standard Errors in Parentheses Bodily integrity Medical mistrust Ick Jinx Perceived benefit Item US ST US ST US ST US ST US ST 1. Removing organs from the body just isn t right 1.33 (0.04) The body should be kept whole for burial 1.43 (0.07) Hospitals sometimes prescribe medication as a way of experimenting on people without their knowledge or consent 0.82 (0.15) If I sign an organ donor card, doctors might take my organs before I m actually dead 2.25 (0.11) Sometimes, medical procedures are done on people without their consent 1.12 (0.13) If I sign an organ donor card, doctors might not try so hard to save my life 1.65 (0.08) The idea of organ donation is somewhat disgusting 1.37 (0.08) I wouldn t like the idea of having another person s organs inside of me, even if I needed an organ transplant 1.43 (0.10) The thought of organ donation makes me uncomfortable 1.76 (0.07) People who donate their organs risk displeasing God or nature 1.37 (0.11) The surest way to bring about my own death is to make plans for it like signing an organ donor card 2.42 (0.31) Organ donors may not be resurrected because they don t have all of their parts 1.79 (0.11) Organ donors are heroic because they save lives 0.58 (0.28) Donating organs would allow part of me to live after I die 1.12 (0.33) Organ donation allows something positive to come out of a person s death 5.75 (0.30) Organ donation helps to bring meaning to the death of a loved one 2.15 (0.23).64 Cronbach s Note. Solution derived using Robust-DWLS. p.05. p.01.

6 THE ICK FACTOR, ANTICIPATED REGRET, AND ORGAN DONATION 241 Table 3 Factor Inter-Correlations Form the Oblique CFA Solution knowledge, subjective norm, and attitude. Third, we focused on those who had not registered as organ donors, and randomly allocated them to an anticipated regret manipulation versus a control condition. We tested the hypothesis that simply asking participants to briefly reflect on the possible regret of not becoming an organ donor would act to increase the intention to become an organ donor in future. Method Bodily integrity Medical mistrust Ick Jinx Perceived benefit Bodily integrity 1 Medical mistrust.56 1 Ick Jinx Perceived benefit p 05. p.01. Study population and data collection. Participants were members of the adult general public in Scotland. There were 138 members of the general public who were opportunistically recruited from a busy shopping mall in Glasgow, in the West of Scotland. A shopping mall was selected in an attempt to recruit representative members of the Scottish general public. Shoppers in the mall were approached by the researcher and invited to participate. Participants gave informed consent and completed the brief questionnaire and returned them directly to the researcher. Participants were pseudorandomly allocated to either the control condition or an anticipated regret (AR) condition (equal numbers of the control and AR versions of the questionnaire were thoroughly mixed and shuffled before distribution). In an attempt to maximize response rate, a decision was made not to ask participants their exact age, but rather to mark one of seven response options that represented age bands (e.g., years). Participants were asked to record their postcode. In Scotland this can be used to give a rough estimate of social deprivation using the Carstairs Deprivation Index (McLoone, 2004), which is a 1 7 scale, with higher scores indicating greater social deprivation. The main independent variable in this study was organ donor status, defined as either self-reported registration as an organ donor or not. The second independent variable was allocation of nondonors to the anticipated regret versus the control condition. Those allocated to the anticipated regret condition completed two additional questions which were designed to measure anticipated regret. The first of these additional questions was placed as the very first question of the survey ( If I didn t register as an organ donor and someone I cared about died that could have been saved, I would feel regret ) and the second was placed immediately preceding the question measuring intention to donate ( If I don t register as an organ donor I will later wish that I had ). The anticipated regret questions were placed in these positions as previous studies have shown that placing an anticipated regret question as the first item on the scale increases its salience and that when regret items precede intention items, anticipated regret has a stronger impact on intentions (Sandberg & Conner, 2009). Dependent variables. All participants completed the modified version of the attitude toward organ donation questionnaire (Morgan et al., 2008) as described in Experiment 1. They also completed additional questions tapping cognitive-rational factors. Three key aspects of the theory of reasoned action (cognitive components) were included: Attitudes: Three questions were used to get an overall idea of the participants attitudes toward the general idea of organ donation. These questions were measured on a 7-point scale (from 1 strongly disagree to 7 strongly agree), with higher scores being associated with more positive attitudes toward the general idea of organ donation. An example item was I support the idea of organ donation for transplantation purposes. Knowledge: Five questions were used to assess knowledge, to which participants could answer yes or no. Example questions included It is possible for a brain-dead person to recover from his or her injuries?, It is possible to have an open-coffin funeral service following organ donation?, and Racial discrimination prevents minority patients from receiving the transplant they need. Correct answers were summed into a score ranging from zero to five with higher scores indicating greater knowledge. Subjective norm: Following Morgan et al. (2008), two questions were used to measure this variable. Participants were asked to think of the most important person in their life and whether or not they thought this person was in favor of organ donation. They were subsequently asked how much this person s opinion mattered to them. Both items were scored on a 7-point scale. In the current experiment, internal reliability of all scales (excluding knowledge as this was answered yes/no) was tested using Cronbach s alpha: attitude.85, subjective norm.61, perceived benefit.60, ick.86, jinx.81, medical mistrust.72, bodily integrity.89. Reliability for subjective norm and perceived benefit was relatively low. However, subjective norm was a 2-item scale with a between item correlation of.44, p.01. The benefit scale has four items, but deletion of any one item did not increase the reliability of the scale. Finally, for nondonors only, intention to become a donor at some point in the future was measured on a 1 7 scale, from 1 strongly disagree to 7 strongly agree. Overview of the analysis. Two main analyses were conducted. In the first, participants who had already signed up on a posthumous organ donor registry were compared with those who had not. In this analysis we compared donors versus nondonors on the rational-cognitive variables (knowledge, attitude, and subjective norm) and on the noncognitive variables (ick, jinx, medical mistrust, etc.). The second analysis was restricted to those participants who had not yet registered as organ donors. In this analysis we compared the nondonor control group (questionnaire alone, n 47) versus the nondonor anticipated regret group (questionnaire plus two additional questions measuring anticipated regret, n 44). The hypothesis

7 242 O CARROLL ET AL. MEAN SCORE (mean, s.e.) Experiment 1 - Affective Attitudes ** MEAN SCORE (mean, s.e.) Experiment 2 - Affective Attitudes 0 Ick Jinx Mistrust Body integ. Benefit 0 Ick Jinx Mistrust Body integ. Benefit Donors Non-Donors Donors Non-Donors Experiment 3 - Affective Attitudes 7 MEAN SCORE (mean, s.e.) ** 0 Ick Jinx Mistrust Body integ. Benefit Donors Non-Donors Figure 1. Affective attitudes of donors and nondonors over the 3 experiments. p.01, p.001. tested here was that this simple anticipated regret manipulation would result in an increased intention to become an organ donor at some point in the future. Results The demographic and background characteristics for the donors versus nondonors are presented in Table 1. Donors did not score significantly differently from nondonors on age, sex, social deprivation, or on any of the rational-cognitive variables that is, knowledge, donors (M 1.96, SE 0.20) versus nondonors (M 1.91, SE 0.15); attitude, donors (M 6.19, SE 0.17) versus nondonors (M 6.05, SE 0.13); and subjective norm, donors (M 3.39, SE 0.23) versus nondonors (M 3.22, SE 0.17). However, for the noncognitive variables, the donors scored significantly lower than the nondonors on the ick factor (t(135) 4.15, p.0001: r.34) and bodily integrity, (t(130) 5.22, p.0001: r.42) (see Figure 1). There were no significant differences in the other three noncognitive variables that is, benefit, jinx, and medical mistrust. Anticipated regret manipulation. We tested the hypothesis that intention scores would be significantly higher in the AR group versus the control group. There were no differences between the AR and control group with regard to age, sex, or social deprivation. However, the mean intention score for nondonors exposed to the two anticipated regret questions (M 5.5, SE.28) was

8 THE ICK FACTOR, ANTICIPATED REGRET, AND ORGAN DONATION 243 significantly higher than in the control condition (M 4.4, SE.27), (t(89) 2.73 p.008: r.28). Mediation analyses. Nondonors exposed to the AR manipulation had higher perceived benefit scores (M 5.65; SE 0.19) than the controls (M 4.94; SE 0.19), (F(1, 89) 7.01, p.01, r.27). Similarly those in the AR condition scored higher on attitude (M 6.33; SE 0.18) compared to those in the control condition (M 5.76; SE 0.18) (F(1, 89) 5.04, p.027, r.23). This raises the possibility that benefit or attitude mediate the AR-Intentions link. Consistent with this, both perceived benefit (r.32, p.05) and attitude (r.42, p.05) were positively associated with intentions. Tests of mediation were implemented in ZUMASTAT (Jaccard, 2006) using the joint product of coefficients test as specified in MacKinnon, Lockwood, Hoffman, West, and Sheets (2002). This tests if the product of the regression coefficient between Y and the mediator and the mediator and X is different from zero. If it is, mediation is present. MacKinnon et al. (2002) showed this test to be superior to traditional tests of mediation. For perceived benefit the joint product was significantly different from zero (95% CI [.16,.83]). In addition, when the mediator was included in the regression the relationship between AR intervention and intention became nonsignificant, t 1.86, p.066: r.19. Thus, benefit fully mediates the ARintention link. For attitude the joint product was significantly different from zero (95% CI [.09,.78]). The association between AR and intentions was, however, still significant when attitude was controlled, t 2.19, p.03: r.23. Thus, attitude is a partial mediator of the AR-intention link. Discussion The results of this experiment have partially replicated those of Experiment 1, in that noncognitive variables clearly distinguished donors from nondonors in the general adult U.K. sample. However, this effect was not observed over all the noncognitive variables but was rather restricted to the ick factor and bodily integrity, the two factors that showed the greatest effect sizes in Experiment 1. This suggests that those domains, which tap disgust and bodily integrity, may be the strongest and most robust variables in distinguishing donors from nondonors. We also replicated Morgan et al. (2008) by finding that there were no differences between donors and nondonors on the standard TRA rationale-cognitive variables of attitude, knowledge, and subjective norm. Thus, traditional rational-cognitive variables have limited explanatory power when trying to understand organ donor behavior. Finally, we tested an anticipated regret manipulation on the nondonor participants. Simply adding two questions to the questionnaire that encouraged the participant to reflect briefly on the emotion of regret if they did not at some point become an organ donor resulted in a highly significant increase in intention to become a donor. To our knowledge this is the first controlled experimental test of an anticipated regret manipulation in posthumous solid organ donation research. If this is a robust and replicable finding, it could be potentially important as a means of increasing organ donor rates. Experiment 3: The Ick Factor and Anticipated Regret Extension and Replication The purpose of this final experiment was to carry out a further test of the ability of the noncognitive factors (ick, jinx, bodily integrity, etc.) to distinguish donors from nondonors in a larger sample of the U.K. general public. We also took this opportunity to test the hypothesis that nondonors hold more general superstitious beliefs than nondonors. Finally, we conducted a larger confirmatory test of the anticipated regret manipulation in a new, larger U.K. adult sample. Method Study population and data collection. There were 342 adult participants from the Scottish general population took part in this study. Questionnaires were completed by participants, who were directly approached in local shopping malls, bus stations and leisure centers in Central Scotland by the researcher. As in Experiment 2, these areas were selected so as to try and recruit as representative a sample of the general public as possible. The purpose of the study was explained and the surveys were given to participants who provided informed consent, and then took 5 to 10 min to complete and return them. Nondonors were pseudorandomly allocated to the control questionnaire or the anticipated regret manipulation questionnaire (via the procedure described in Experiment 2). Dependent variables. Experiment 3 used the same questionnaire as Experiment 1 for the noncognitive variables. Internal reliability was assessed via Cronbach s alpha as follows: benefit.59, ick.78, jinx.68, medical mistrust.59, and bodily integrity.77. For those scales with.70, omitting any one item did not significantly increase reliability. In addition, all participants completed six additional questions tapping general superstitious beliefs, three assessing positive and three negative beliefs, after Wiseman and Watt (2004). An example of a positive item is I sometimes carry a lucky charm or object and a negative item, I would be anxious if I broke a mirror as it is thought to bring bad luck, all scored on a 1 7 (strongly disagree to strongly agree) scale. Cronbach s alpha for superstitious beliefs was: positive.76, negative.87. Data analysis. As in Experiment 2, independent t tests were conducted comparing people registered as organ donors versus those that were not on the noncognitive variables and for the positive and negative general superstition scales. For the nondonors only, intention to donate in future was compared between those assigned to the control (n 90) versus the anticipated regret condition (n 103). Results The background demographics of the donors and nondonors are presented in Table 1, and there were no significant differences between donors and nondonors with regard to age, sex, or social deprivation. Donors versus nondonors. As in Experiment 1, all the noncognitive variables clearly differentiated donors from nondonors (see Figure 1) that is, perceived benefit (t(330) 4.44, p.0001: r.24); ick, (t(332) 5.88, p.0001: r.31); jinx (t(332) 5.56, p.0001: r.29); medical mistrust (t(333) 3.50, p.001: r.19); bodily integrity (t(322) 7.72, p.0001: r.39). There were no significant differences between donors and nondonors on general positive superstitious beliefs (M 3.18, SE 0.15) versus (M 3.25, SE 0.13) or negative

9 244 O CARROLL ET AL. superstitious beliefs (M 2.41, SE 0.15) versus (M 2.80, SE 0.13). Negative and positive superstitious beliefs were highly correlated (r.66, p.0001). Negative superstitious beliefs were correlated with jinx (r.22, p.001) and bodily integrity (r.13, p.001). Positive beliefs correlated with jinx only (r 0.13, p.0002). Anticipated regret manipulation. There were no significant differences between nondonors allocated to the control or AR condition for age, sex, or social deprivation (see Table 1). The AR intervention resulted in a significantly higher intention to become a posthumous organ donor (M 4.6, SE 0.18) versus the control condition (M 4.1, SE 0.19), t(191) 2.12, p.036: r.15. There were no significant differences between those in the intervention and control conditions on any of the 5 noncognitive factors (all ps.15). Thus, one of the key criteria for mediation by the noncognitive factors is absent (the X-mediator link is nonsignificant). As such the mediation effects reported in Experiment 2 for perceived benefit did not replicate in Experiment 3. Discussion In this experiment, using a larger, new sample of the general adult public, we have again replicated the findings that emotional factors clearly differentiate donors from nondonors and are thus plausibly acting as barriers to registering as organ donors. General negative and positive superstitious beliefs did not differentiate donors from nondonors, and not surprisingly, both correlated with scores on the jinx factor. We also replicated the anticipated regret manipulation finding (but not the mediation by benefit), in that simply asking participants to briefly ponder on the emotion of regret should they not become an organ donor resulted in a significant increase in intention to become an organ donor in future. General Discussion In this paper we have reported the results of three separate but related experiments and have shown that people who have signed up as posthumous organ donors scored significantly differently from those who have not on emotionally valenced factors relating to disgust (ick factor) and bodily integrity. These findings from the U.K. replicate those of Morgan et al. (2008) from the U.S., and thus provide compelling evidence that these visceral, affective attitudes may be playing a crucial role as barriers, acting to prevent people registering as organ donors. These emotional variables are important targets for future interventions to try and increase the organ donor supply. Further work is required to test how modifiable these emotional gut feelings regarding organ donation are. Traditional cognitive variables such as attitude, knowledge, and subjective norm did not distinguish donors from nondonors, and thus targeting these domains is unlikely to be helpful in increasing the organ donor supply. Furthermore, general positive and negative superstitious beliefs did not differentiate donors from nondonors. We have also, in two separate experiments, demonstrated that a very simple anticipated regret manipulation led to significantly stronger intention to donate in the future for nondonors. To our knowledge this is the first time a simple anticipated regret manipulation has been tested in solid organ posthumous organ donation research. The effect sizes are relatively small (7.8% in Experiment 2 and 2.2% in Experiment 3), but are in accord with the range observed in previous anticipated regret intervention findings (Sandberg & Conner, 2008). Further research is clearly required to determine the robustness and replicability of these anticipated regret findings. However, if these small effect sizes can be replicated, we should not minimize their importance. Prentice and Miller (1992) set out clear guidelines when small effect sizes should be considered impressive. This occurs under two conditions: (a) when the intervention is minimal or (b) when the outcome is difficult to influence. The manipulation of anticipated regret in potential organ donors most certainly conforms to both criteria. This is why, within medicine, a minimal intervention (e.g., aspirin) that has a small but significant effect in reducing a difficult to influence outcome (e.g., risk of future cardiovascular events) has important public health implications (Steering, 1988). This was a small, but given the vast numbers being treated, a very important effect, resulting in many lives being saved. The mechanisms by which the AR effect operates need to be further explored. There are some very tentative possibilities suggested in these studies. One possibility is mediation via either perceived benefits or attitudes (Experiment 2). However, while the AR effect on intentions replicates, the mediation effect for perceived benefit did not. As we did not predict potential mediation effects a priori, and the effect did not replicate, we only offer this as a potential direction for future research. Limitations We acknowledge a number of limitations in these experiments. We have relied exclusively on self-report. While we have no reason to doubt participants endorsing whether they have signed up as organ donors, future work should strive for independent verification of this fact. Second, the reliability of some of our noncognitive scales was low, and further work is required to refine more reliable measures of these constructs. In particular, we assessed bodily integrity using only two items and reliability may be improved with the inclusion of additional items. Third, a selection bias in our samples is possible in that our participants demonstrated a slightly higher rate of organ donor registration compared with the U.K. national average of 28%, and the Scottish average of 32%. Registered organ donors may have been more motivated to participate in our research. The HEYWOOD case noted in the CFA may reflect this sample fluctuation (Dillon et al., 1987). Fourth, the sample size for the CFA was on the small size. However, the DWLS estimation used is known to work well with smaller sample sizes, and the Satorra-Bentler Correction was applied to correct for biases in standard error and fit indices (Wirth & Edwards, 2007). Fifth, our anticipated regret manipulation utilized intention as the dependent variable. There is a clear intentionbehavior gap between those who support the idea of organ donation versus those who have registered as posthumous organ donors. The next step in our research program is to test whether anticipated regret interventions lead to a significant increase in actual organ donor registrations. If such interventions do lead to this behavioral outcome, this would represent a rare example of a theoretically driven, relatively simple health psychology intervention that could result in thousands of lives being saved worldwide.

10 THE ICK FACTOR, ANTICIPATED REGRET, AND ORGAN DONATION 245 References Abraham, C., & Sheeran, P. (2003). Acting on intentions: The role of anticipated regret. British Journal of Social Psychology, 42, Besser, A., Amir, M., & Barkan, S. (2004). Who signs an organ transplant donor card? A study of personality and individual differences in a sample of Israeli university students. Personality and Individual Differences, 36, Brug, J., Van Vugt, M., Borne, B. v. D., Brouwers, A., & Van Hooff, H. (2000). Predictors of willingness to register as an organ donor among Dutch adolescents. Psychology & Health, 15, Cacioppo, J. T., & Gardner, W. L. (1993). What underlies medical donor attitudes and behavior? Health Psychology, 12, Cisler, J. M., Olatunji, B. O., & Lohr, J. M. (2009). Disgust, fear, and the anxiety disorders: A critical review. Clinical Psychology Review, 29, Cleveland, S. E. (1975). Personality characteristics, body image and social attitudes of organ transplant donors versus nondonors. Psychosomatic Medicine, 37, Deacon, B., & Olatunji, B. O. (2007). Specificity of disgust sensitivity in the prediction of behavioral avoidance in contamination fear. Behaviour Research and Therapy, 45, Dillon, W. R., Kumar, A., & Mulani, N. (1987). Offending estimates in covariance structure analysis: Comments on the causes and solutions to Heywood cases. Psychological Bulletin, 101, Faul, F., Erdfelder, E., Lang, A. G., & Buchner, A. (2007). G*Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behavior Research and Methods, 39, Ferguson, E., Farrell, K., & Lawrence, C. (2008). Blood donation is an act of benevolence rather than altruism. Health Psychology, 27, Godin, G., Sheeran, P., Conner, M., & Germain, M. (2008). Asking questions changes behavior: Mere measurement effects on frequency of blood donation. Health Psychology, 27, Horton, R. L., & Horton, P. J. (1990). Knowledge regarding organ donation: Identifying and overcoming barriers to organ donation. Social Science & Medicine, 31, Hu, L. T., & Bentler, P. (1999). Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus alternatives. Structural Equation Modeling, 6, Jaccard, J. (2006). ZumaStat statistical methods. Miami, FL: Applied Scientific Analysis. Jones, S., Cauffman, E., Miller, J. D., & Mulvey, E. (2006). Investigating different factor structures of the Psychopathy Checklist: Youth Version: Confirmatory factor analytic findings. Psychological Assessment, 18, Lawton, R., Conner, M., & McEachan, R. (2009). Desire or reason: Predicting health behaviours from affective and cognitive attitudes. Health Psychology, 28, MacKinnon, D. P., Lockwood, C. M., Hoffman, J. M., West, S. G., & Sheets, V. (2002). A comparison of methods to test mediation and other intervening variable effects. Psychological Methods, 7, McLoone, P. (2004). Carstairs scores for Scottish postcode sectors from the 2001 census. Glasgow: MRC Social & Public Health Sciences Unit. McNally, R. J. (2002). Disgust has arrived. Journal of Anxiety Disorders, 16, Morgan, S. E., Stephenson, M. T., Harrison, T. R., Afifi, W. A., & Long, S. D. (2008). Facts versus feelings : How rational is the decision to become an organ donor? Journal of Health Psychology, 13, Phillips, M. L., Senior, C., Fahy, T., & David, A. S. (1998). Disgust: The forgotten emotion of psychiatry. British Journal of Psychiatry, 172, Prentice, D. A., & Miller, D. T. (1992). When small effects are impressive. Psychological Bulletin, 112, Reubsaet, A., Brug, J., Nijkamp, M. D., Candel, M. J. J. M., Hooff, J. P. v., & Borne, H. W. v. d. (2005). The impact of an organ donation registration information program for high school students in the Netherlands. Social Science & Medicine, 60, Sandberg, T., & Conner, M. (2008). Anticipated regret as an additional predictor in the theory of planned behaviour: A meta-analysis. British Journal of Social Psychology, 47, Sandberg, T., & Conner, M. (2009). A mere measurement effect for anticipated regret: Impacts on cervical screening attendance. British Journal of Social Psychology, 48, Satorra, A., & Bentler, P. M. (1994). Corrections to test statistics and standard errors in covariance structure analysis. In A. von Eye & C. C. Clogg (Eds.), Latent variable analysis: Application to developmental research (pp ). Thousand Oaks, CA: Sage. Sherman, N. C., Sherman, M. F., Smith, R. J., & Rickert-Wilbur, P. (2001). Disgust sensitivity and attitudes toward organ donation among African- American college students. Psychological Reports, 89, Steering, C. (1988). Findings from the aspirin component of the ongoing Physicians Health Study. New England Journal of Medicine, 318, Wirth, R. J., & Edwards, M. C. (2007). Item factor analysis: Current approaches and future directions. Psychological Methods, 12, Wiseman, R., & Watt, C. (2004). Measuring superstitious belief: Why lucky charms matter. Personality and Individual Differences, 37,