Transplantation is an effective treatment for individuals in the end stages of life and often represents the only option for patients with diseases such as liver and heart failure [1]. However, despite the increasing demand for organ transplants, the supply of available organs has remained relatively unchanged in recent years, resulting in thousands of patients dying before they can receive the transplants they need [2]. The shortage of donated organs for transplantation is a significant global issue in the 21st century [3].

Several studies have demonstrated a correlation between potential donors’ knowledge of organ donation and transplantation and their likelihood of agreeing to donate [4–7]. The attitudes of nurses and healthcare staff are also critical in influencing families’ decisions about organ donation from brain-dead patients [8]. Conversely, negative family attitudes toward organ donation significantly hinder the consent process [9]. Research in Iran has shown that family members often have the final decision-making power regarding the donation of their children’s organs, with the healthcare system playing an essential role in encouraging individuals to register for and carry donor cards [10].

The current study aimed to investigate the effectiveness of an intervention based on the theory of planned behavior (TPB) that employed a health campaign approach. The primary focus was to assess the impact of this intervention on individuals’ intentions to engage in organ donation. According to the TPB, an individual’s intention to participate in a specific behavior, such as organ donation, is primarily influenced by their attitude toward the behavior, subjective norms, and perceived behavioral control [11,12]. Therefore, this study utilized the principles of the TPB and health campaigns to promote the registration of organ donation cards among students.

Ethical approval was obtained through the Ethics Committee of Shahid Beheshti University of Medical Sciences (SBMU; approval No. IR.SBMU.PHNS.1395.92). All the recruited students provided informed consent before participating in the study.

Study Design

This study was an intervention that employed a health campaign strategy targeting programs at SBMU. Three schools—Medicine, Nursing and Midwifery, and Public Health—were randomly selected for participation. Using multistage sampling techniques, students were randomly chosen from each class cluster. In total, 260 students were recruited to participate.

Inclusion Criteria

Participants were required to meet the following conditions: (1) enrollment in the medical, midwifery-nursing, or health schools, (2) attendance at in-person classes during the specified 12-week data collection period, and (3) no prior experience carrying an organ donor card.

Measures

The questionnaire comprised 44 items based on TPB constructs: (1) attitudes toward donation, (2) subjective norms, (3) perceived behavioral control, (4) intentions, and (5) behavior. Additionally, it included 25 sociodemographic items to gather information on age, gender, and other relevant factors.

Attitudes were assessed using 14 questions, such as “Organ donation reduces mortality in the community.” Subjective norms were evaluated through 16 questions, including “My family thinks that I must register for the organ donor card.” Perceived behavioral control was measured with 10 questions, for example, “It is difficult to decide to receive a donor card at a young age.” Intentions were gauged by two questions, one of which was “I am planning to get a donor card next month.” Behavior was assessed using two dichotomous, forced-choice questions, such as “Do you have a donor card?” with the response options being yes or no. Each construct was measured on a 5-point Likert-type scale. The questionnaire is included in Supplementary Material 1. The validity of the questionnaire was evaluated by 10 experts, yielding results that demonstrated sufficient validity, with an average content validity index of 0.091. The reliability was assessed through internal consistency and test-retest methods, revealing a high degree of reliability as indicated by a Cronbach’s alpha of 0.89 and an intraclass correlation coefficient of 0.93.

Design of the Health Campaign

Data were collected, and each participant was assigned a code number for data entry and analysis. A total of 260 questionnaires were distributed to eligible students during in-class teaching sessions at the targeted schools to establish pretest scores. Based on the analysis of the pretest assessment, the health campaign was designed (Fig. 1).

Figure 1. Flow diagram of the study design.

Designing an effective campaign requires nine steps: (1) situation analysis, (2) goal identification, (3) identification of the target audience, (4) strategy development, (5) establishing tactics, (6) identifying the appropriate choice of media, (7) establishing a timetable, (8) budget planning, and (9) program evaluation (Supplementary Figs. 1–4) [13].

Situation analysis

Based on research, it was determined that the rate of organ donation falls short of the demand for transplantation, resulting in many individuals on the waiting list dying before they can receive organs. Furthermore, interventions targeting medical students are crucial, as they are likely to be the first point of contact for the relatives of brain-dead patients in their future roles at hospitals.

Determine the goals of the health campaign

The goals were set at two levels, including the personal and network levels. A SWOT (strengths, weaknesses, opportunities, and threats) analysis is a commonly used tool for analyzing the situation. In this study, SWOT included: (A) strengths: obtaining organ donation cards at SBMU and involvement of professors, religious leaders, students, and the Iranian Society of Organ Donation (ISOD). (B) Weaknesses: some programs’ inadequate cooperation with the researchers before the health campaign was implemented. (C) Opportunities: collaboration between SBMU and ISOD. (D) Threats: opposition from some stakeholders to the topic of organ donation.

Analysis of the target audience

The target audience for the study was students in three programs—medical, midwifery-nursing, and health. This audience was selected based on characteristics such as age, gender, education level, and income.

Strategy

The strategy of this study involved a campaign complemented by peer education. The campaign aimed to enhance community awareness of organ donation among students and encourage them to obtain donor cards. Initial steps included meetings with the head of ISOD, and the deployment of peer educators. Previous research has demonstrated that peer educators are highly effective in disseminating information on a variety of topics [14].

After selecting peer educator candidates for each program, they were asked to read information on organ donation available at www.ehdacenter.ir. Upon completing the reading, they took an online exam covering the material. Candidates who scored at least 85 out of 100 were chosen as peer educators and tasked with educating other students. Twelve peer educators were ultimately accepted and served as organ donation volunteers, all of whom were SBMU students. These individuals underwent further training at the ISOD, which included topics such as brain death, distinguishing between brain death and coma, and strategies for assisting families in coping with brain death.

Tactics and media of choice

The objective was to produce high-quality materials while adhering to the allocated budget and specified timeframe. To ensure effectiveness, all materials were pilot-tested with a sample representative of the target audience. A variety of tactics were used to encourage students to obtain a donor card. These included developing a website, leveraging social media platforms like Telegram and Instagram, distributing pamphlets, displaying banners, disseminating leaflets, featuring images of a prominent soccer star, and hosting talk shows. Before launching the campaign, several meetings with program leaders and members were held to actively engage them and provide information about organ donation. The slogan for the health campaign was “Organ Donation=Life Donation.”

The primary goal was to enhance attitudes and knowledge regarding organ donation. The focus was on facilitating online registration at https://www.ehdacenter.ir. To streamline the registration process, volunteers assisted students with their registrations.

Choice of media

Some of the media outlets that we used in the campaign are shown in Table 1.

Table 1. Campaign strategies

Action	Mass media	Place
Organ donation advertisement	Posters, banners, website	University, faculty buses, dining room, and dormitories
Awareness	Pamphlets	Classes
Using images of famous soccer star	Images and banners	University, faculty buses, dining rooms
Related messages	70 Messages	Social media (Telegram, Instagram) Website (ehdacenter.ir)
Desktop images including the campaign logo	Computers	Computer sites and classes
Mail group	E-mail	Medicalstudent1395campaign@yahoo.com
Question-answer meetings	Face-to-face education	Campaign place
Enrollment for organ donation	-	Campaign place
Obtaining a donor card	-	Campaign place

Budget and funding

After an estimate of what resources are available, a budget is created to ensure appropriate spending. Some of the campaign costs included: (A) operational costs: all banner printing expenses and items used to implement this project were provided by the ISOD. (B) Staff costs: use of volunteers from SBMU’s students. (C) The cost of equipment: card printing machine, laptops, and organ donation cards.

Preparation of the action plan and timetable for the program

The primary target audience was students of the three above-listed programs at SBMU. The main goal was to improve the behavior of obtaining a donation card among the targeted students. The participants were assessed through a posttest questionnaire 2 months after the health campaign.

Statistical Analysis

Data were tabulated using SPSS ver. 16 software (SPSS Inc.). The normality of the data was assessed using the Kolmogorov-Smirnov test. Descriptive and analytical statistics, including frequency distribution tables, mean, and standard deviation, were employed for data analysis. A t-test was utilized to examine the relationship between the variables of the two groups and the outcome variables. Questionnaire items that were incomplete or unclear were reported as missing values. The significance level was set at 0.05.

Descriptive statistics are provided in Table 2. Participants had an average age of 22.12 years (standard deviation, 5.04; range, 17–49 years). Before the intervention, 44.2% of students reported that they had never discussed organ donation with their families. According to Table 3, the primary sources of information about organ donation were TV and social media. In addition, students identified their families and friends as the most and second-most influential groups, respectively, in their decision to obtain an organ donor card. The health campaign led to significant improvements across all TPB constructs (Table 4).

Table 2. Demographic characteristics of students

Variable	Value (n=260)	P-value
Age (yr)	22.12±5.04	0.309
Sex		0.405
Female	180 (69.2)
Male	80 (30.8)
Level of education		0.391
BS	132 (50.8)
Master’s	32 (12.3)
PhD	22 (8.5)
MD	74 (28.4)
Marital status		0.535
Single	235 (90.4)
Married	24 (9.2)
Other	1 (0.4)
Father’s education		0.274
	78 (30.0)
Diploma	91 (35.0)
Academic	91 (35.0)
Mother’s education		0.243
	57 (21.9)
Diploma	91 (35.0)
Academic	112 (43.1)

Values are presented as mean±standard deviation (range) or number (%).

Table 3. Frequency of students’ answers about resources for obtaining information about organ donation

Resource	No. of students (%)
TV	179 (68.85)
Social mediaa)	85 (32.69)
Webpages	87 (33.46)
Friends	65 (25.00)
Family	51 (19.62)
Physicians and medical staff	15 (5.77)

^a)Telegram, Instagram, WhatsApp.

Table 4. Changes in theory of planned behavior constructs about organ donation after the campaign

Variable	Before campaign	After campaign	Differences	P-value
Attitudes	155.01±32.587	195.402±40.741	39.82±51.96	0.001
Subjective norms	62.13±19.71	109.84±51.55	46.71±54.16	0.001
Perceived behavioral control	110.83±34.733	117.362±36.049	6.53±49.32	0.038

Values are presented as mean±standard deviation.

After the health campaign, 90.38% of students enrolled to obtain a donor card. Among those who did not receive a donor card after the intervention, 56% were opposed to receiving one, while 20% expressed their willingness to receive a donor card in the coming months. Approximately 24% of the students were undecided about whether to receive a card.

The results of this study indicated that students primarily obtained information about organ donation from television and social media platforms, including Telegram and Instagram. These findings align with those reported in the study by Zhang et al. [15]. Additionally, Khalil and Rintamaki [16] have shown that television dramas are effectively used to promote organ donation, generating interest among researchers.

Mass media is the optimal choice for conveying a message to a large population and informing people about organ donation. TV can be an effective source of information, bridging the gap between patients and doctors to foster a positive attitude towards organ donation [17–20]. Guadagnoli et al. [21] discovered that mass media was an important resource for measuring the effectiveness of family discussions about organ donation.

The results of this study demonstrated a significant shift in attitudes following a health campaign. This aligns with findings from various other researchers [22,23]. Similar to the current study, the results of Symvoulakis et al. [24] showed that health campaigns can boost awareness and, in turn, increase individuals’ willingness to obtain donor cards.

A TPB-based intervention can significantly impact students’ attitudes. Effective methods for promoting the adoption of donor cards include showing videos or movies about organ donation and facilitating discussions on topics such as brain death and donation. Additionally, research indicates a positive correlation between attitudes and behavioral intentions regarding organ donation [25].

Different forms of media, such as featuring a famous soccer star’s photo on a poster, daily posts on the Telegram channel and Instagram, and displaying the soccer star’s donor card picture, targeted subjective norms. Additionally, making printed donor cards readily available at the campaign site played a crucial role in enhancing the adoption of donor cards among participants. Further findings from this research indicated statistically significant increases in scores of subjective norms and perceived behavioral control compared to those recorded before the campaign.

Hyde and White [26] demonstrated that perceived behavioral control had the strongest association with behavioral intentions, followed by subjective norms. From this, it can be inferred that subjective norms and perceived behavioral control are critical areas for interventions in organ donation. These conclusions are further supported by Park et al. [27]. Educational programs that utilize the TPB can effectively predict behavioral intentions, and there is a positive relationship between attitude and behavioral intention in organ donation.

The findings of this research suggest a significant increase in the number of students who signed a donor card following the health campaign. Initially, no students had signed a donor card; however, by the campaign’s conclusion, this number had surged to over 90%. Similarly, Lin et al. [25] found that after training in the TPB, nurses exhibited significant changes in their attitudes and behavioral intentions toward promoting organ donation.

This suggests that a lack of educational programs may be one of the main reasons behind the low intentions and behaviors related to organ donation among this population [28]. Previous studies have also indicated that educational programs can enhance organ donation rates, and activities such as informing families about their children’s decision to carry a donor card can positively influence their willingness to donate their children’s organs postmortem [29].

Healthcare professionals, including physicians and nurses, can contribute to cultivating a donation culture by undergoing training in this area. As they often interact with the families of brain-dead patients, enhancing their awareness and skills in managing these situations can lead to an increase in donation rates [15].

Interventions that focus on attitudes, subjective norms, and perceived behavioral control are essential for enhancing organ donation behavior. To effectively address this, it is crucial to tackle knowledge gaps, cultural barriers, misconceptions about brain death, trust issues, and moral values. The effectiveness of these interventions can be amplified by leveraging social media and online education, as evidenced by the results of the study. Additionally, incorporating educational videos and television programs about organ donation can positively influence individuals’ willingness to donate organs. Families play a pivotal role in the decision to obtain a donor card, making it vital to educate and involve them in promoting donation behavior. Furthermore, providing adequate facilities, such as access to a printing machine, can significantly boost the acquisition of donor cards among participants.

The use of a self-report questionnaire represents one of the limitations of this study. Additionally, the absence of a control group, due to the potential for participants to reside in the same dormitory and interact during the intervention period, is another limitation.

Conflict of Interest

No potential conflict of interest relevant to this article was reported.

Author Contributions

Conceptualization: ML. Data curation: SR. Formal analysis: KN. Investigation: MG, SR. Supervision: ML. Writing–original draft: MG. Writing–review & editing: all authors. All authors read and approved the final manuscript.

Supplementary Materials

Supplementary materials can be found via https://doi.org/10.4285/ctr.24.0022.