Reactance to
the promotion of
Donor Registration
The Role of Psychological Reactance
in Organ Donation Campaigns
Master’s programme Communication Science
Master Thesis
Name:
Stefan Wisselink
Studentnr:
10633790
Supervisor:
Sandra Zwier
Date:
31/01/2019
1
Abstract
Despite multiple campaigns and legislative changes by the Dutch government, there is a continued shortage of donor organs. In order to combat this shortage, this study is aimed at finding the effect of different campaign messages on attitudes toward organ donation and the willingness to register in the Donor Register among the public. One campaign message emphasizing the range of options and the freedom of choice when it comes to organ donation. Another campaign message encouraging individuals to register as an organ donor. Through an online experiment, respondents were exposed to one of the two messages that were
designed to invoke respectively low and high psychological reactance. Respondents reported more positive attitudes toward organ donation when exposed to the message invoking less reactance. This did however not lead to an increased willingness to register in the Donor Register. Overall, respondents reported fairly low levels of reactance and mostly positive attitudes toward organ donation. Consequently, evidence of psychological reactance
influencing the effect the messages had on the attitude toward organ donation was not found.
Introduction
In the field of post-mortem organ donation, the issue that organ demand is larger than the supply, remains a persistent reality. Advancements in the medical world have generated ever growing possibilities for organ transplantations and with that, a growing demand for organs. In The Netherlands, despite multiple campaigns and legislative changes, the growth in the
2 number of organ donors is still insufficient. Both the number of organ transplantations and the number of patients on a waiting list for a transplantation have remained virtually the same over the last five years (“Donatie en transplantatie,” 2018). Like most other countries, The Netherlands has a Donor Register in which citizens are asked to register their wish to be an organ donor after death or not. The number of individuals that have registered their choice in the Donor Register grew from 5.4 million in 2008 to 6.4 million in 2018 (“Donorregister – Cijfers,” 2018), which is less than half of the adult Dutch population. In order to increase the number of organ donors multiple countries have introduced – or are considering introducing – a so-called ‘opt-out’ system of donor registration. In such an opt-out system every adult is automatically registered as an organ donor, unless one actively deregisters if one does not wish to be a donor.
Twenty-four European countries have already introduced some form of an opt-out system for donor registration. In 2018, both the governments of England and The Netherlands decided to introduce the out system for organ registration in 2020. Switching from an opt-in system to an opt-out system has widely been presented as a solution to the shortage of organ donors. However, recent studies have cast doubt on this assumption (Lin, Osman, Harris & Read, 2018; Sharif, 2018), as next of kin are more likely to oppose a donation if their deceased relative has not given explicit consent. As a result, the introduction of an opt-out system would only artificially inflate the numbers on the register, while the actual number of organs donated would not significantly rise as a direct result. Spain is considered the world leader in organ donations, with 46.9 people per million in the population becoming posthumus organ donors in 2017 (Baraniuk, 2018), which is more than in any other country. Although Spain did introduce the opt-out system in 1979, the nation’s success in organ donation
however is often attributed to the introduction of a much wider set of policies, focusing on the process of organ donation itself (Miranda, Naya, Cuende, & Matesanz, 1999).
3 So far, introducing new laws and registration systems have not proved to be the
solution to the shortage of organ donors. Persuading individuals to actively register as a donor therefore remains a key method to fight this shortage, and research on communicating this message continues to be needed. The risk with this kind of persuasive strategies are that they may cause an aversive reaction within individuals, in the sense that they may feel threatened in their right to self-determination. Earlier research has shown that this so-called
‘psychological reactance’ is an important factor in the effect of persuasive messages concerning organ donation (Reinhart, Marshall, Feeley, & Tutzauer, 2007).
Due to the public debate that centers around two conflicting issues, being the availability of organs for donation and the individual’s right to self-determination, it is of relevance to focus on communication around these two issues and the role of psychological reactance in this process. Therefore, the present study aims to examine the moderating role of psychological reactance in the effect of messages highlighting freedom of choice in organ donation (related to the opt-in system) versus messages highlighting the importance of increasing the number of donors (related to the opt-out system) in shaping attitudes and behavioural intention toward donor registration. More specifically, the main research question will be:
To what extent does a message highlighting freedom of choice influence the attitude towards organ donation and the willingness to actively register as an organ donor, compared to a message mainly highlighting the importance of increasing the number of donors, and to what extent is this effect moderated by psychological reactance?
4
Theoretical framework
Psychological reactance
Psychological reactance is generally defined as a combination of negative cognition and anger in response to a threat, in cases that the freedom of an individual to exercise certain behaviour is challenged (Reinhart et al., 2007). In an attempt to explain why people are motivated to resist decisions that are forced upon them, Psychological Reactance Theory (PRT) was first introduced by Jack W. Brehm (1966). The theory consists of four elements, namely: (1) an individual has a specific freedom, (2) there is a certain threat to that freedom, (3) the individual experiences reactance, and (4) the individual performs an action to maintain the freedom (Reinhart & Anker, 2012).
A behaviour resulting from psychological reactance, is commonly a behaviour that is either undesired (e.g. wasting food) or prohibited (e.g. downloading movies), in order to deliberately taunt the authority who considers it undesired or prohibited, regardless of whether the behaviour serves the individual performing it. The extent of psychological reactance is affected by the individual's freedom to determine when and how to conduct a specific
behaviour, the level to which an individual is aware of the relevant freedom, and whether the individual is able to determine behaviors necessary to satisfy that freedom. It is assumed that if the behavioural freedom of an individual is threatened or reduced, that individual can become motivationally aroused. The fear of loss of further freedoms can stimulate this arousal and motivate the individual to regain the threatened freedom. Because this motivational state is a result of the perceived reduction of freedom, it is considered a counterforce, wherefore it is referred to as psychological reactance.
A current example of psychological reactance can be found in public service announcements trying to stop people from using smartphones while driving. Texting and
5 using apps behind the wheel is a behaviour that people have grown accustomed to. When they are asked to stop doing it, this can therefore be perceived as a threat to their freedom. The freedom in this case being the liberty of using a smartphone at any time or place. Due to this threat individuals will be motivated to battle the threat and to retain their freedom, for
example by dismissing the relevance or importance of the message, or by justifying their own behaviour. The experience of reactance may thus result in more negative attitudes toward the campaign and consequently a lower impact on the undesired behaviour of using a smartphone while driving. This is why it is of key importance to limit reactance to a minimal and the present study is designed to study to what extent the contents of a message play a role in this process.
Dillard and Shen (2005) have provided evidence that psychological reactance can be measured, in contrast to the opinion of Brehm, who originally developed the theory (1966). In their work they measured the impact of psychological reactance with two parallel studies: one encouraging teeth flossing and the other urging students to reduce their alcohol intake. The authors formed several conclusions about reactance. First, that reactance is mainly cognitive, which allows reactance to be measurable by self-report techniques, such as polls,
questionnaires and interviews. Also, they concluded that reactance is in part related to an anger response. This is in line with Brehm's (1966) assumption that while experiencing reactance, one tends to have antagonistic feelings, that are often aimed more at the source of a threatening message than at the message itself. Finally, according to Dillard and Shen,
both cognition and affect are intertwined to such an extent within reactance, that their effects on persuasion can not be distinguished from each other.
In the case of health communication, reactance can be associated with both the feeling of judgement whether a specific behaviour is good or bad, or the freedom to perform a behaviour that is considered bad. Individuals can feel that their free will to exercise these
6 behaviours is threatened as a result of persuasive messages included in public service
announcements attempting to socially influence individuals (Dillard & Shen, 2005).
Public Service Announcements
Public Service Announcements (PSA’s) are mostly messages and advertisements regarding social issues, to inform individuals or persuade them to perform a specific action, and are generally an important part of communication campaigns. Although there are many possible means of persuasion, PSA’s are generally trying to achieve this by evoking an emotional response among the audience (Dillard & Peck, 2000).
Earlier research on PSA’s concerning organ donation has indicated that psychological reactance negatively impacts the way in which someone experiences messages regarding organ donation, and the way someone reacts to it. Reinhart and Anker (2012) conducted a study on the effects of PSA’s concerning organ donation, using the theory of transportation, stating that when people become absorbed by a message, their attitudes and intentions change to reflect that message. They found psychological reactance to be a partial mediator between message transportation and message reactions. Specifically those individuals who felt a threat to their freedom of choice in becoming a donor were less likely to be transported by the message and less likely to experience positive message reactions toward organ donation.
Although PSA’s are in most cases threatening certain freedoms, it should be noted that individuals only possess freedoms to the extent that they have knowledge of them and
perceive that they are capable of enacting the relevant behavior (Dillard & Shen, 2005). In the case of organ donation, this means that a person needs to be aware of the process and
implications of being an organ donor, and needs to be knowledgeable about the possible options. This means that PSA’s regarding organ donation have a two sided role, on the one hand, informing individuals about possible options, while on the other hand, persuading them to choose the desirable option.
7 The present study will build on the existing research into the way different types of PSA messages regarding donor registration affect the extent to which individuals experience psychological reactance, and the way this influences their reaction to the PSA. It is to be expected that a message encouraging individuals to choose a desirable option will generate higher levels of psychological reactance, compared to a message solely making individuals aware of the range of possible choices. This leads to the following hypothesis:
H1: A PSA message emphasizing freedom of choice will generate lower levels of psychological reactance, compared to a PSA message encouraging to register as an organ donor.
Attitude toward organ donation
The concept of ‘attitude’ includes the beliefs values and opinions a person has towards a specific subject. A person can have both favorable and unfavorable feelings and beliefs about organ donation, which are influenced by a range of factors. Opposed to early research, over time evidence has been mounting that attitudes are not stable, but can be influenced by multiple factors (Erber, Hodges, & Wilson, 1995).
Research conducted by Morgan, Miller and Arasaratnam (2002) indicated that when individuals are exposed to factual information concerning organ donation, those who hold positive attitudes toward organ donation are more likely to indicate that they have consented to organ donation. Since studies have shown that the majority of people hold positive attitudes toward organ donation (Weber, Martin, Members of COMM 401, & Corrigan, 2006),
reaching the public without negatively influencing attitudes, should therefore result in an increase in the number of individuals registered in the Donor Register.
The present study uses psychological reactance theory to explain the effect of message content on the attitude toward organ donation. It is expected messages that imply higher levels
8 of choice will evoke lower levels of psychological reactance and therefore generate a more positive attitude toward organ donation.
H2: A PSA message emphasizing the freedom of choice concerning organ donation will lead to a more positive attitude toward organ donation, compared to a PSA message encouraging to register as an organ donor.
H3: The positive effect of the message type on attitude toward organ donation is moderated by psychological reactance: a PSA message emphasizing the freedom of choice concerning organ donation will lead to a more positive attitude toward organ donation, but more for those participants experiencing higher psychological reactance than for participants experiencing lower psychological reactance.
Willingness to register
The willingness to register as an organ donor is a form of a behavioural intention, which is defined as a course of action that an individual aims to follow (Fishbein & Ajzen, 1975). Extant research has repeatedly shown that attitudes are a main predictor of behavioural intentions. Although the likelihood that an attitude will be transformed into an intention will increase with the occurrence of opportunity, time, importance, urgency, and means
(Heckhausen & Kuhl, 1985), in general it can be assumed that attitudes are meaningful predictors of intentions (Shen & Dillard, 2007). From this, one can conclude that a positive attitude towards organ donation will correlate with a positive willingness to register in the Donor Register.
9 H4: A more positive attitude toward organ donation will lead to
an increased willingness to register as an organ donor.
H5: A PSA message emphasizing the freedom of choice concerning organ donation will lead to an increased willingness to register in the Donor Register, compared to a PSA message encouraging to register as an organ donor.
Method
Participants
Participants in this study were recruited through email and social media, and were presented with a link to the online questionnaire, which was distributed in both a Dutch and an English version. A total of 67 individuals participated in the study, 41 females (61.2%) and 26 males (38.8%). 53 participants (79.1%) completed the Dutch questionnaire and 14 (20.9%)
completed the English version. An overview of the age groups in the sample can be found in Table 1 below.
Table 1
Composition of the sample population
Under 25 26 - 45 46 - 65 Over 65 Total
Female 3 26 11 1 41
Male 3 12 9 2 26
10 The percentages of registrations in the Donor Register within the sample of the present study are shown in Figure 1. These numbers are partly in accordance with the registration figures of the Donor Register in The Netherlands, apart from the number of registered individuals not giving permission for organ donation, which is considerably higher in the Donor Register (about 30% of registrations) than in this study (“Donorregister – Cijfers,” 2018).
Figure 1. Donor registration status of respondents
Experimental design & stimulus materials
This study was conducted using an online experiment, using a one-factor experimental design in which participants were exposed to either of two different messages, after which they were asked to fill in a questionnaire. The independent variable, and the factor of manipulation, in this study was the message that the participants were exposed to. Two PSA messages were created, and respondents were randomly assigned to seeing one of the messages. The
messages were presented in the form of informative campaign material and consisted of short texts of about 150 words, accompanied by visual elements highlighting the key message of the texts. 52% 2% 4% 42%
Registration status
Registered organ donor Registered no permission Let relatives decide Not registered
11 The complete messages can be found in the appendix. The first message, emphasizing the range of possible choices regarding organ donation, listed both the options for wishing to become an organ donor and not wishing to become an organ donor, without providing any arguments to make a specific choice. However, it did highlight the importance of thinking about the options and making a decision. The second message, encouraging to become an organ donor, did not list the options for not wishing to become an organ donor, but instead emphasized the benefits for society of becoming an organ donor, suggesting the reader to register as an organ donor.
Earlier research regarding organ donation has shown that recipients react more positively to messages containing a gain-frame, compared to messages containing a loss frame (Reinhart et al, 2007). Since psychological reactance can be partly responsible for this, the messages used during this present study, all used a gain-frame. The first message by stating the benefits of free choice and the second message by stating the benefits of organ donation.
Dependent variables
After exposure to one of the messages, respondents were asked to assess a number of statements, in order to determine the extent to which they experienced psychological reactance, their attitude concerning organ donation and their willingness to register as an organ donor if they had not registered yet.
Psychological reactance
In order to measure psychological reactance, respondents were asked to assess seven
statements on a 7-point Likert scale, ranging from ‘strongly disagree’ (1) to ‘strongly agree’ (7). The list of statements used was based on the Hong Psychological Reactance Scale
12 (HPRS) (Hong & Faedda, 1996), and was slightly adapted to be applicable and relevant to the PSA messages. The list of statements can be found below in Table 2.
Table 2
Statements to measure psychological reactance based on HPRS
1 The campaign material pushes me to make a decision 2 The campaign material triggers a sense of resistance in me 3 The tone of the message prompts me to do the opposite 4 The message attempts to limit my freedom of choice
5 The message wants me to submit to social norms and constraints 6 The tone of the message makes me sceptical
7 The message points out things that are obvious to me
When checking the Cronbach’s alpha for the reliability of the scale, it appeared that the final two statements had a negative effect on the reliability. That is why it was decided to remove the items from the analysis. Removing the final two items from the list increased the
reliability of the original scale consisting of 7 items (α = .63), compared to the adapted scale using 5 items (α = .69). Although not perfect, this reliability is acceptable considering the relatively low sample size. By averaging the scores for these items a general reactance score (M = 2.76, SD = 0.82) was calculated.
Attitude toward organ donation
In order to measure attitude toward organ donation, respondents were asked to assess seven statements, again on a 7-point Likert scale ranging from ‘strongly disagree’ (1) to ‘strongly agree’ (7). The statements presented were based on the Organ Donation Attitude Scale (ODAS), first used by Parisi and Katz (1986), and can be found in Table 3 below.
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Table 3
Statements to measure attitude toward organ donation based on ODAS
1 Donating an organ after your death is something to be proud of 2 Organ donation benefits the whole of humanity
3 Organ donation should be considered a social duty 4 Organ donation interferes with the laws of nature
5 Organ donation would enable me to help someone who is suffering
6 Donating a body part would enable that part of myself to stay alive after my death 7 Organ donation leaves the body mutilated and disfigured
Scores for items 4 and 7 were reversed first to correct for their negative framing. A reliability check on the attitude scale resulted in a poor result (α = -.25) on the list of 7 items. Therefore, a Principal Component Analysis (PCA) was conducted, which showed that the items loaded on two factors, as can be seen in Table 4. The items loading on Factor 1, explaining 32% of variance, seemed to mainly have the theme of individual pride, i.e. organ donation as a way of personally having an impact. Factor 2, explaining 23% of variance, seemed based more on the fact that organ donation is important for society. Factor 1 proved to have the highest loadings and reliability score (α = .59), which was still on the low side, but could be further improved by removing item 4, resulting in a an acceptable Cronbach’s alpha of .67. The average score across the three remaining items was calculated to a score for attitude toward organ donation (M = 4.92, SD = 0.88).
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Table 4
Factor analysis of scale items measuring attitude toward organ donation
Factor loading
Item 1 2
Factor 1: Individual pride
1 Donating an organ after your death is something to be proud of .81 -.26
4 Organ donation interferes with the laws of nature .12 -.84
5 Organ donation would enable me to help someone who is suffering .54 -.11 6 Donating a body part would enable that part of myself to stay alive .82 -.24
Factor 2: Societal effects
2 Organ donation benefits the whole of humanity -0.50 .22
3 Organ donation should be considered a social duty .35 .83
7 Organ donation leaves the body mutilated and disfigured -.48 .04
Willingness to register in the Donor Register
Finally, respondents who indicated they had not registered in the Donor Register previously, were asked whether they were willing to register in the future, and whether the campaign message they were exposed to influenced their willingness to do so. Participants were asked to answer ‘Yes’, ‘No’ or ‘I don’t know’, on the question whether they would register now or in the future. Of the 28 participants (42%) that were not registered, 12 (43%) reported they would register, 2 (7%) reported they would not, while 14 participants (50%) reported not knowing whether they would or would not register. In addition participants were asked to reply to two statements, asking whether the message had either positively or negatively influenced their willingness to register. The replies were measured on a 7-point Likert scale ranging from ‘strongly disagree’ (1) to ‘strongly agree’ (7). The statements ‘The campaign message has positively influenced my willingness to register’ (M = 5.36, SD = 0.49) and ‘The campaign message has negatively influenced my willingness to register’ (M = 1.81, SD = 0.32) , had a significant, negative correlation r = -0.40, p = 0.044. The two scores were
15 combined into one score ranging from completely negative (-6) to completely positive (8), resulting in a total willingness score (M = 3.53, SD = 0.70).
Manipulation check
In order to measure the successfulness of the manipulation, participants were asked if they were aware of the type of message they were exposed to. To perform this manipulation check, participants were asked if they had been shown message 1 stating the range in choices or message 2 encouraging to register as an organ donor. Participants could either answer with the title ‘Organ donor? Please decide!’ or ‘Register as an organ donor!’, or the option ‘I’m not sure’, in case they could not remember.
Results
Manipulation check
Of the 67 respondents, 50 reported correctly which message they had seen, 6 reported
incorrectly, while 11 reported to not be sure about which message they had seen. To compare the difference in reported answers between conditions, the message promoting choice was coded as 1, the message encouraging to register as 2, and the option ‘I’m not sure’ as 1.5. An independent samples t-test showed that the respondents exposed to the message promoting choice scored significantly lower (M=1.16, SD=0.27) than the respondents exposed to the message encouraging to register (M=1.82, SD=0.37); t (65)=-1.61, p < 0.001. Since a lower score corresponds with having seen the message promoting choice, this indicated that the manipulation was successful.
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Psychological reactance
Hypothesis H1 stated that a PSA message emphasizing freedom of choice would generate lower levels of psychological reactance, compared to a PSA message encouraging to register as an organ donor. An independent samples t-test showed that the participants exposed to the message encouraging to register as an organ donor reported to experience significantly more reactance (M = 3.31, SD = 0.63) than the participants exposed to the message emphasizing the freedom of choice (M = 2.22, SD = 0.61); t (65)=-7.18, p < 0.001. This confirms the
hypothesis H1 that was put forward based on earlier studies.
Attitude
Hypothesis H2 stated that a message emphasizing the freedom of choice would lead to a more positive attitude regarding organ donation, compared to a message encouraging to make a specific decision. An independent samples t-test showed that the respondents exposed to the message emphasizing the freedom of choice reported a significantly more positive attitude toward organ donation (M = 5.18, SD = 0.88) than the respondents exposed to the message encouraging to register as an organ donor (M = 4.65, SD = 0.81); t (65)=1.44, p = 0.013. Therefore, hypothesis H2 can be confirmed.
Hypothesis H3 stated that the effect of the message type on attitude toward organ donation is moderated by psychological reactance. In order to perform the analysis to test this hypothesis, the participants were divided in two groups; one with low levels of reactance and one with high levels of reactance. Participants scoring below the median score on the scale of psychological reactance (Mdn = 2.80) were placed in the first category of lower reactance (N = 33), while the participants scoring above the median score were placed in the second category of higher reactance (N = 24). The 10 participants that scored the median score, were excluded from the groups.
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Table 5
Average Attitude scores toward organ donation as a function of different message types and for low and high reactance groups
Message promoting free choice Message encouraging to register Total Low reactance 5.35 (SD = 0.88) 4.94 (SD = 0.61) 5.27 (SD = 0.85) High reactance 4.50 (SD = 1.19) 4.70 (SD = 0.84) 4.68 (SD = 0.84) Total 5.29 (SD = 0.91) 4.75 (SD = 0.79) 5.02 (SD = 0.89)
Means for the groups are shown in Table 5. A two-way ANOVA was performed to examine the interaction effect of message type and reactance level on attitude toward organ donation. The analysis of variance did not show a significant interaction effect F(57) = 1.48, p = 0.421 between message type and reactance level. This result indicates that the effect of the message type on attitude toward organ donation did not differ for those people who experienced higher reactance compared to those people who experienced lower reactance toward the message. As a result, hypothesis H3 was not confirmed by this study.
Willingness to register
Of all respondents, 42 percent (N = 28) were not yet registered in the Donor Register. In Table 6 below, their attitude toward organ donation is shown in relation with their willingness to register in the Donor Register.
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Table 6
Attitude scores toward organ donation as a function of willingness to register
Willingness to
register N Attitude Std. Dev.
Yes 12 5.14 0.52
Not sure 14 4.90 0.81
No 2 5.33 0.47
The numbers in Table 6 do not suggest that a more positive attitude toward organ donation correlated with an increased willingness to register as an organ donor. After the answers were recoded for analysis (‘No’ = 0, ‘Not sure’ = 0.5, ‘Yes’ = 1), a Pearson correlation test
confirmed that there was no significant correlation between attitude toward organ donation and willingness to register in the Donor Register r = 0.06, p = 0.774. This indicates that an increased attitude toward organ donation does not necessarily increase the willingness of someone registering as an organ donor H4 claiming this correlation could not be confirmed.
Hypothesis H5 stated that a PSA message emphasizing the freedom of choice concerning organ donation would lead to an increased willingness to register in the Donor Register, compared to a PSA message encouraging to make a specific decision regarding organ donation. The counts of the participants’ willingness to register dependent on the message shown is shown in Table 7. The results of a Chi-square test showed an insignificant relation between the two variables, χ²(1) = 2.97, p = .227 , indicating that the participants exposed to the message promoting choice did not report more willingness to register in the Donor Register compared to the participants exposed to the message encouraging to register. Therefore hypothesis H5 could not be confirmed.
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Table 7
Counts of willingness to register as a function of message type
Message promoting choice Message encouraging to register Total Yes 5 7 12 Not sure 5 9 14 No 2 0 2 Total 12 16 28
Finally, participants reported the influence of the message in increasing their willingness to register as higher when they were exposed to the message emphasizing the freedom of choice (M = 3.70, SD = 0.82) compared to the participants that were exposed to the message
encouraging to register as an organ donor (M = 3.33, SD = 0.50); t (17) = 1.16, p = 0.264. However, the result of this independent samples t-test was not statistically significant.
Discussion and conclusion
Although the analyses provided mixed results, several conclusions can be drawn from the results of this study. First, the hypothesis that a message emphasizing the freedom of choice in organ donation would generate less psychological reactance than a message encouraging to register for organ donation was confirmed. In addition, the hypothesis stating the effect of the PSA messages on shaping attitudes was confirmed as well, as participants exposed to the message emphasizing choice reported a significantly more positive attitude toward organ donation than the participants exposed to the message encouraging to register. However, the results indicate that the effect of the message type on attitude toward organ donation did not differ significantly for those people who experienced higher reactance versus those people who experienced lower reactance toward the message. This dismisses the hypothesis stating
20 that level of reactance moderates the effect between message type and attitude toward organ donation. Furthermore, results indicate that individuals who hold more positive attitudes toward organ donation did not differ from individuals who hold less positive attitudes toward organ donation in their willingness to register in the Donor Register.
Limitations
What is notable in the results of the present study is that the registration status, attitude toward organ donation and willingness to register as an organ donor, seem to be more positive in the present sample than what is known about the general public (“Donorregister – Cijfers,” 2018). Although it cannot be completely ruled out that this is due to biased sampling (i.e., people with a more positive attitude toward organ donation were overrepresented in the sample), it is not unlikely that social desirability was also at play here. Studies have repeatedly shown that research involving self-reporting by respondents can often lead to socially desirable answers (Van de Mortel, 2008). This could have resulted in participants overstating their positive attitude and their willingness to register. Although the impact of social desirability must of course not be discarded, it should also be noted that it does not affect most results of the present study, since this effect will have impacted the respondents in both experimental conditions to the same extent. In addition, the concept of psychological reactance is a concept that is considered to be resisting social desirability (Dillard & Peck, 2000), wherefore it could actually be useful to study it in an environment where social desirability is at play. However, the possible effect of social desirability that negatively influenced the present study was that the scores for ‘willingness to register’ were concentrated on the positive side of the scale and therefore produced insignificant results.
A further issue was that although the participants exposed to the message encouraging to register reported a higher level of reactance than the participants exposed to the message promoting choice, reactance levels were actually quite low for both conditions. This could be
21 the cause of the non-significant moderation effect of psychological reactance.
Because of the limited sample size, precaution must be taken when generalizing the outcomes of the present study, as individuals under 25 and over 65 were under-represented, while females were over-represented in the sample. Also, this study was presented in a Dutch context, and although the current status of organ donor registration and the public discourse surrounding it are comparable for many countries, cultural differences should be noted. The factor analysis on the original attitude scale revealed two factors; individual pride over organ donation and organ donation as important for society. These two aspects are likely to differ for individualistic and collectivistic societies. Additionally, psychological reactance could play a larger role in individualistic cultures, while in collectivistic cultures individuals are more prepared to adhere to social norms.
Recommendations
Despite the fact that the present study has not been able to further define the role of psychological reactance in shaping attitudes toward and willingness to register for organ donation, it does confirm the importance of reactance, stated in earlier studies. The present study confirms that an increase in psychological reactance occurs in individuals if they feel that freedoms are taken away from them through information encouraging them to make certain decisions. Additionally, the study confirmed that public service announcements are able to shape attitudes toward organ donation.
Earlier studies have shown that providing clear factual information surrounding organ donation is a favorable method of communication when aiming for a positive attitude toward organ donation (Morgan et al., 2002). An example of how not to approach this was the
campaign that was launched in The Netherlands in 2018 titled ‘(Niet) kiezen is ook een keuze’ (‘(Not) making a choice is a choice as well’). The slogan was met with confusion by the public and was criticized by multiple organisations and the Dutch parliament, after which the
22 campaign was dropped (Kieskamp, 2018). This case demonstrates that factual information is preferred over ambiguous messages.
The present study underlines that it remains important to reduce the possibility of psychological reactance within individuals when aiming for more registered organ donors. Several approaches to achieve this goal have already been studied in the past. In research concerning the combating of psychological reactance, it was found that a successful way to limit the experience of threats to freedom and negative reactions was to include a way to restore the freedom directly in the promotional persuasive health message through a message feature placed at the end. (Miller et al, 2007). A practical method to achieve this is by
suggesting several different options for a person to take, or by emphasizing the fact that a person should make up his or her own mind about what actions to take.
Conclusion and future research
The present study reiterates that positively influencing attitudes and limiting psychological reactance are key aspects in persuading individuals to register in the Donor Register. Also, it provides unanswered questions suitable for future research. Since the present study did not differentiate between long-ingrained versus context-specific attitudes, it was not able to determine the direct influence of the messages on an individual’s attitude. This applies to psychological reactance as well, as the origin of reactance can be lie in the specific context, but it can also originate from personal traits. In the present study this was controlled for by random allocation to conditions, though future research into these different forms of attitude and psychological reactance could prove valuable.
Due to advancements in medical science, organ transplantations become ever more common, wherefore the demand for donor organs steadily increases. To keep up with the demand, it is of great importance to inform the public about donor registration and to persuade them to register as an organ donor.
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26
Appendix
Message promoting choice
Organ Donor?
Please decide!
In the Donor Register, you register your choice to donate your organs and tissues. Deciding on whether to donate or not and to register that choice remains important. Registering in the Donor Register provides clarity for everyone. For people who have not registered their decision yet, registration is highly encouraged.
Multiple options of organ donation.
You have several options when registering: Yes, I wish to donate all of my organs and tissues Yes, I wish to donate some specific organs and tissues No, I do not wish to donate my organs
I would like my relatives to decide if my organs are donated after I die
Take a couple of minutes to consider these options. After that, you may decide further on whether you wish to become a donor or not. Decide for yourself, so your relatives do not have to make this decision in an emotional moment in time.
27
Message encouraging to register
Register as an organ donor!
1 Donor can save up to 8 lives with multiple organs. Every year over 100.000 of lives are saved world wide, by about 35.000 deceased organ donors. Registering does only take a couple of minutes of your time, and in this way your relatives do not have to make this decision in an emotional moment.
Several options to save lives.
There are several options to register as an organ donor:
give permission to donate all your organs and tissues give permission to donate specific organs and tissues
In the Donor Register, you register your choice to donate your organs and tissues. Deciding on whether to donate or not and to register that choice remains important. Registering in the Donor Register provides clarity for everyone. For people who have not registered yet, registration is highly encouraged.
