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Abstract

The scarcity of human transplant organs in China underscores the need for improved public engagement in organ donation. In this study, we examined a cognitive-noncognitive dual pathway model of organ donation registration (ODR). Based on this model, we explored the efficacy and underlying mechanism of priority incentives, a strategy that gives priority to receive an organ to those who register to donate, in promoting ODR. Two online studies involving 1,632 non-donor Chinese adults were conducted. Study 1 used the dual pathway model to measure the effect of cognitive factors (CF) (i.e., attitude and subjective norm) and noncognitive affective factors (NF) (i.e., ick and jink) on ODR intention and related behavior. Study 2 manipulated priority incentives to examine its effect on ODR intention and related behavior and the cognitive-noncognitive pathways underpinning how it works. Both studies provided support for the structural validity of the dual pathway model. Study 1 found that ODR intention can be predicted by both CF and NF, while ODR-related behavior was solely predicted by NF. Study 2 showed that offering priority incentives can enhance ODR intention. Its indirect effect on ODR-related behavior was mediated through the path from CF to ODR intention. These results bridge a gap in understanding mechanisms of incentives toward ODR and have practical implications for improving ODR rates.

Keywords

organ donation registration priority incentives cognitive-Noncognitive dual pathway model intention behavior

Introduction

The global shortage of human transplant organs poses a significant challenge. In 2022, the rate of global organ transplants failed to meet 10% of the demand for organs (Global Observatory on Donation and Transplantation [GODT], 2023). Due to its vast population, this disparity is particularly severe in China. Between 2015 and 2021, less than 2% of the overall demand for transplants (34,606 cases) was met with organs successfully transplanted from Chinese organ donors (China Organ Transplant Development Foundation [COTDF], 2021). This issue is driven primarily by the low rate of organ donation registration (ODR) in China. As of August 2025, the total number of citizens registered as voluntary organ donors in China was about 5.30 million, representing a mere 0.38% of the national adult population. The significant imbalance between donor supply and increasing demands in China highlights the pressing need to improve public engagement around the topic of organ donation.

The central prerequisite to promoting organ donation in China is to identify the psychological determinants that underlie individuals’ decisions to register as donors. As the dual-process model of decision-making suggests, the reflective system (cognitive, conscious) and the affective system (impulsive, intuitive, and automatic) precursors of behavior synergistically influence decision-making. (Evans, 2008; Michaelsen & Esch, 2022). In line with the dual-process model, recent studies suggest that ODR is influenced not only by rational or cognitive-based factors but also by noncognitive affective factors (Morgan et al., 2008; Rocheleau, 2013). Cognitive factors represent cognitive beliefs about organ donation, such as general attitudes towards organ donation and ODR, as well as perceived subjective norms of others’ opinions on organ donation decisions. Noncognitive affective factors represent affective beliefs associated with organ donation, such as fears or disgust related to the donation process (Morgan et al., 2008; O’Carroll et al., 2011). However, this model has not yet been systematically validated, especially in China.

Various studies of promotion strategies have been conducted to promote organ donor registration, such as educational programs, financial incentives (Levy, 2018), and non-financial incentives (Li et al., 2013; Sperling & Gurman, 2012). However, most of those strategies have demonstrated limited effectiveness (Li et al., 2021), been confined to intentions rather than actual behavior (Murakami et al., 2020), or even been criticized for being unethical or illegal (Falomir-Pichastor et al., 2013).

One of the possible interventions to resolve such challenges is a priority incentive, whereby individuals who register as an organ donor are given priority to receive an organ over those who have not registered (Meng & Clarke, 2020). This strategy has been implemented in various countries, including China (Burkell et al., 2013; National Health Commission of the People's Republic of China [NHCPRC], 2018). Despite its adoption, empirical research on priority incentives remains scarce, particularly in the Chinese context. Existing studies have primarily focused Therefore, further investigation into both the effectiveness and mechanisms of priority incentives is warranted.

According to behavioral scientists’ perspectives on the field of behavior change (Atkins et al., 2017; Cane et al., 2012; Carey et al., 2019; Michaelsen & Esch, 2022), an effective organ donation promotion strategy requires identifying the links between this strategy and its psychological pathways through which the strategy exerts its influence. Promotion strategies of ODR would be effective if they contribute to facilitating the determinants of ODR (Falomir-Pichastor et al., 2013). In this sense, these psychological determinants can serve as a litmus test for assessing the efficacy of ODR promotion strategies and can help to understand promotion processes (Atkins et al., 2017).

Thus, in this study, we aimed to identify the cognitive and noncognitive affective factors underlying ODR among Chinese residents and to explore the effect of priority incentives on ODR promotion and its psychological pathways through which it operates.

Cognitive Factors Underlying ODR

Classical social cognitive models, such as the Theory of Planned Behavior (TPB), represent the primary framework for understanding the cognitive factors underlying ODR (Ajzen & Madden, 1986). The TPB assumes that individuals are rational decision-makers and proposes that their intention to engage in donation-related behavior is a predictor of ODR behavior. ODR intentions, in turn, are influenced by three cognitive factors, namely attitudes, perceived subjective norms, and the individual's perception of control.

These three cognitive factors have been demonstrated to be important predictors of ODR intention (Britt et al., 2017; Hyde & White, 2009). Findings have been consistent across countries, including the United States (Britt et al., 2017; Morgan et al., 2008) and those in Europe (McGlade et al., 2012) and East Asia (Aksoy et al., 2021). They were also found to be consistent across populations, including the medical professionals (McGlade et al., 2012), students (Aksoy et al., 2021), and general public (Bae, 2008). However, although predictive of ODR intention, these cognitive factors have generally failed to predict real donation-related behavior or registration status. No differences in attitudes, subjective norms, or perceived control have been observed between organ donation registrants and non-registrants (Doherty et al., 2017). These findings are suggestive of a gap between the influence of cognitive factors on ODR intention and behavior.

Studies have also highlighted the influence of additional cognitive factors on ODR, such as altruism, knowledge, moral norms, and self-identity (D’Alessandro et al., 2012; Hyde & White, 2009). For example, altruistic motives have been found to have a relatively large impact on ODR intention, while actual knowledge about ODR was the most influential predictor of donor registration status (D’Alessandro et al., 2012). An extended model incorporating moral norms and self-identity accounts for a higher variance in ODR intention than the standard TPB model (Hyde & White, 2009).

Noncognitive Affective Factors Underlying ODR

On the other hand, studies on the Organ Donation Model (Morgan et al., 2008) have emphasized the impact of noncognitive affective factors on ODR. These factors can be defined as noncognitive beliefs that are related to reasoning, which have been formed without direct experience, and affective beliefs related to ODR (Morgan et al., 2008; O’Carroll et al., 2011). These factors include (1) bodily integrity, the belief that the body should remain intact after death or face serious afterlife consequences; (2) medical mistrust, fear that doctors may hasten the death of seriously ill patients to harvest their organs; (3) ick, discomfort or disgust associated with organ donation; (4) jinx, 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; and (5) perceived benefits, perceived benefits of becoming an organ donor after death, such as the sense of being a hero (Morgan et al., 2008).

The role of noncognitive affective factors on ODR has become increasingly evident. Cross-sectional studies have shown that noncognitive affective factors predict ODR intention (Chan, 2019; Miller et al., 2019; Rocheleau, 2013) and donation-related behavior. For example, in the USA (Morgan et al., 2008) and the UK (O’Carroll et al., 2011; Shepherd et al., 2024), non-registered organ donors are more likely to hold negative noncognitive affective beliefs associated with donation than registered donors, a as a result, are less likely to register as organ donors. Nevertheless, the only noncognitive affective factor found to predict a specific ODR behavior, i.e., clicking on a hyperlink to register as an organ donor, was body integrity (Shepherd & O’Carroll, 2014).

Other noncognitive affective factors of ODR, including anticipated regret, sympathy, humor, and frustration, have been more directly linked to emotion by researchers. Specifically, when individuals were experimentally induced to experience anticipated regret (O’Carroll et al., 2011, 2012, 2016), sympathy (Bae, 2008), or humorous emotions (Baumeister & Fischer, 2021), their intention and behavior regarding organ donors registration increased, whereas, in real donation scenarios, recalling a frustrating experience at the Department of Motor Vehicles (where most donor registrations occur) resulted in significantly lower intentions to register as an organ donor (Siegel et al., 2016).

A Cognitive-Noncognitive Dual Pathway Model of ODR

Dual-process models of decision-making (Evans, 2008; Michaelsen & Esch, 2022) suggest that two regulatory systems of reflective (cognitive, conscious) and affective (impulsive, intuitive, automatic) precursors of behavior act synergistically to influence decision-making. In parallel with this model, previous research in the ODR field had shown that ODR decision is influenced by rational / cognitive-based factors (Rocheleau, 2013) or by the noncognitive affective factors (Morgan et al., 2008). The social cognitive model, particularly the TPB (Ajzen & Madden, 1986), serves as a classic and widely adopted framework for examining cognitive determinants of organ donation. Complementing this perspective, the Organ Donation Model (Morgan et al., 2008) systematically addresses emotional factors and represents the most empirically supported framework for noncognitive determinants.

However, as revealed by a meta-analysis (Nijkamp et al., 2008), although cognitive or noncognitive affective factors can independently predict ODR, their predictive power remains relatively weak to moderate. This poor predictive power has two possible reasons.

First, there is currently no unified model integrating cognitive and noncognitive affective factors, which could enhance the overall predictability of ODR. For example, while incorporating noncognitive affective factors into the TPB framework, the total explanatory power of ODR intention can be increased by 7% (Rocheleau, 2013). However, this study and similar studies suffer from two limitations. They either focused exclusively on predicting the ODR intention (Rocheleau, 2013) or the ODR behavior (Morgan et al., 2008; O’Carroll et al., 2011). And their predictors only involved one of the cognitive or noncognitive affective factors. Consequently, such studies can hardly offer evidence on how to bridge the gap between ODR intention and behaviors, as well as on the combined predictive power of cognitive and noncognitive factors in explaining ODR.

Second, earlier studies may have overlooked the potential impact of confounding factors, especially the national or cultural context of ODR. Currently, most evidence regarding psychological factors related to ODR comes from the USA and countries in Europe (Doherty et al., 2017; O’Carroll et al., 2011). The primary determinants of ODR from these nations may differ significantly from those of East Asian nations due to their vast cultural differences. For instance, compared to Chinese respondents, American respondents had a higher attitude and social norm towards ODR and more intent to become organ donors (Bresnahan et al., 2008).

Overall, further research is required to establish systematic and direct evidence relating to ODR intentions and behaviors. To this end, and drawing on the dual-process models (Evans, 2008; Michaelsen & Esch, 2022), we propose a dual cognitive-noncognitive pathway model of ODR, integrating a total of 8 factors reported related to organ donation. Septically, the three cognitive factors (attitudes, perceived subjective norms, and perceived behavioral control) were selected based on the TPB model (Ajzen & Madden, 1986). The five non-cognitive factors (ick factor, jinx factor, bodily integrity, medical mistrust, and perceived benefits) were selected based on the Organ Donation Model (Morgan et al., 2008). We further hypothesized that the cognitive and non-cognitive can both jointly impact the intention and behavior of ODR.

Priority Incentive Strategies to Enhance ODR

Various qualitative studies of promotion strategies have been conducted to promote organ donor registration, such as educational programs, financial incentives (Levy, 2018), and non-financial incentives (Li et al., 2013; Sperling & Gurman, 2012). However, a recent meta-analysis reported that the above-mentioned approaches were not sufficiently effective to promote ODR (Li et al., 2021). Some strategies, such as financial incentive, are considered either ineffective, unethical, or even illegal (Falomir-Pichastor et al., 2013). Even when certain promotion strategies had a positive impact, the effects are typically limited to intentions rather than actual registration behavior. For instance, knowledge about organ donation and transplantation has been associated with willingness to register as an organ donor, but was not associated with ODR (Murakami et al., 2020).

Among these, priority incentives are one of the more prominently utilized strategies and have become a valuable technique for encouraging rates of ODR beyond those achieved as a function of altruism and social duty (Falomir-Pichastor et al., Priority incentives, based on social reciprocity, are designed to introduce fairness into the allocation process and provide moral justification for differential access to organ transplantation (Burkell et al., 2013). This system has already been implemented in countries with diverse cultural and developmental backgrounds, including Singapore in 1987, Israel in 2010 (Burkell et al., 2013), and China in 2018 (NHCPRC, 2018). In particular, a few countries, such as Japan, have adopted selective priority incentives. In Japan, relatives of deceased organ donors are granted priority for receiving deceased donor organ transplantation only if the donors have explicitly consented to organ donation for their family members on the waiting list.

Findings regarding the role of priority incentives in ODR are generally consistent. Several decision-game experiments have shown that shorter waiting times for registered donors lead to increased registration rates (Herr & Normann, 2016, 2019; Kessler & Roth, 2012; Li et al., 2013; Li & Riyanto, 2025). A recent scenario-based study revealed that priority incentives were effective at increasing the ODR intention among those with lower levels of altruistic motivation, and without reducing registration rates among those with higher altruistic motivation (Meng & Clarke, 2020). Real-world evidence from Israel has further demonstrated the beneficial function of priority incentives. In 2010, Israel enacted the Organ Transplant Act, granting citizens who registered as organ donor priority on the organ waiting list. In the first year of the priority program, the donor registration rate increased from 7.8 to 11.4 per million population (Lavee et al., 2013).

The Psychological Mechanism Underlying the Effect of Priority Incentives

Given its widespread application in the real world, understanding the psychological mechanisms underlying priority incentives work on ODR is crucial for at least two reasons. First, this understanding would serve as a litmus test for assessing the efficacy of ODR priority incentives, for any potential promotion strategies encouraging ODR, including priority incentives, would be more effective only if they contribute to the psychological factors impacting donation and transplantation (Falomir-Pichastor et al., 2013). Second, this understanding would also help to interpret the promotion processes of priority incentives (Atkins et al., 2017), thereby facilitating the identification of individuals who are most sensitive to such incentives.

Existing research has focused primarily on identifying the role of priority incentives in ODR while largely overlooking the psychological mechanisms underlying their effectiveness. To the best of our knowledge, only one recent study has explored this question (Meng & Clarke, 2020), suggesting that anticipated regret may play an important role in the decision to register as an organ donor under a priority incentive system. However, thus far, no study has systematically explored the influence of psychological factors motivating individuals to register under a priority incentive system.

Researches on the behavior change field may offer valuable insights on the psychological determinants underlying priority incentives (Atkins et al., 2017; Cane et al., 2012; Carey et al., 2019; Michaelsen & Esch, 2022). They propose that behavior can be changed through two types of internal psychological determinants. On the one hand, interventions could work by building up or strengthening internal cognitive factors, such as beliefs about capabilities, beliefs about consequences, and behavioral regulation. This type of intervention is typically nonregulatory and non-monetary (Hertwig & Grüne-Yanoff, 2017), such as self-monitoring of behavior and outcomes of behavior through nutritional counseling to increase beliefs about consequences (Ball et al., 2013). On the other hand, interventions could work by strategically engaging automatic processes, such as activating affective, experience-based automatic, or non-conscious factors. Examples of such interventions include lotteries and point systems (gamification) that increase reward expectations (Priesterroth et al., 2019).

Based on the above insights, we propose that the cognitive or noncognitive affective pathways may serve as the mediators of priority incentives impact on ODR. The priority incentives may improve cognitive beliefs associated with ODR by altering the nature of organ donation from an altruistic behavior to a reciprocal altruistic behavior. This alternation of cognitive beliefs enables people to donate organs to those who need transplants by increasing the likelihood of receiving a transplant while they need it. Here, priority incentives could strengthen these beliefs about ODR consequences by providing a useful and rewarding act to oneself. It thereby produces an atmosphere towards ODR that encourages people to register as donor: those people around a person may prefer and encourage this person to sign in. On the other hand, priority incentives may also reshape the noncognitive affective factors associated with ODR by facilitating the alleviation of negative emotions that accompany the behavior (Yokoyama et al., 2015). Priority incentive emphasizes ODR benefits that one gets priority when needed. It would increase heightened awareness of the possibility of receiving an organ donation and alleviate the emotional barriers to organ donation, such as beliefs that misfortune will arise following ODR, that the body should remain intact, and disgust with the donation process.

Present Study

To examine above hypothesis, we performed two online studies in a Chinese adult non-donors sample. In Study 1 (preregistered, N = 964), we used an online survey to examine the structural validity of the cognitive-noncognitive pathway dual model and its predicting effect on ODR intention and behavior. In Study 2 (N = 668), using a randomized controlled trial, we examined the efficiency of priority incentives on ODR promotion and its underlying cognitive and noncognitive affective psychological pathways.

Study 1

To ensure stability and replicability, we registered Study 1 at AsPredicted (http://aspredicted.org/32zs7.pdf). All data and code for studies 1 and 2 have been made publicly available (https://www.scidb.cn/en/anonymous/NmZtcWFt).).

Method

Participants

Using G*Power and a medium to small effect size (OR = 1.30), we calculated that a minimum of 826 participants was required to achieve 95% statistical power in a logistic regression analysis. We recruited a total of 1030 participants via the WJX platform (http://www.wjx.cn), one of the largest online survey platforms in China. To ensure a representative sample, we implemented the following recruitment criteria: (1) Not registered organ donors; (2) Gender distribution was maintained between 40 and 60% for each gender; (3) Age distribution covered groups starting from 18 years old; (4) Educational level distribution was maintained between 40 and 60% for individuals with a senior high school education or below. Four attention check questions were embedded throughout the questionnaire. Participants who failed to answer these four questions were excluded from the subsequent data collection. The final valid sample size for Study 1 was 964 participants (93.60% of the recursion sample). Those who completed the questionnaire successfully received a small payment (approximately 10 RMB) via the WJX platform. Demographic characteristics are presented in Supplementary Table 1.

All participants in the two studies signed a written informed consent prior to the survey or experiment. The two studies were approved by the Institutional Review Board (IRB, No. H22133) committees at the Chinese Academy of Sciences.

Procedure and Measures

The online survey consisted of three sections which assessed ODR intention and related behavior, cognitive and noncognitive affective factors for ODR, and demographic information. The questionnaire took 10 to 15 min to complete.

ODR intention and related behavior. The ODR intention scale was adapted from the scale of Siegel et al. (2014) by 3 items on a 7-point Likert scale (1 = strongly disagree; 7 = strongly agree). The sample item included “I intend on registering to be an organ donor.” The scale's Cronbach's α in Study 1 is .90.

To assess ODR-related behavior, one dichotomous question was included. Prior research Substantial previous evidence has used the information-seeking behavior in donor registration as a valid proxy that meaningfully predicts eventual registration actions (Shepherd & O’Carroll, 2014), although it does not directly measure actual registration behavior. Following on this research, we asked participants if they would like to visit the Chinese Organ Donation Volunteer Services website (http://www.savelife.org.cn) to learn more about organ donation. Those who selected “yes” will be redirected to the website after submitting their answers.

Cognitive and Noncognitive Affective Factors for Organ Donation. Cognitive Factors Scale for Organ Donation (CFSOD) has three subscales adapted from previous studies: attitudes (Godin et al., 2008), subjective norms (Wong & Chow, 2018), and perceptual control (Britt et al., 2017). The attitudes subscale measures general attitudes toward organ donation. The subjective social norms subscale measures the perceptions of individuals of what other people do, motivations to comply, and perceptions of referent groups’ opinions on organ donation decisions. The perceived control subscale measures the perceived capacity to become an organ donor. Each subscale contains 4 to 6 items rated on a 7-point Likert scale (1 = strongly disagree; 7 = strongly agree). The Cronbach's alpha coefficient of CFSOD in Study 1 is .81, ranging from .64 to .87 in subscales.

Noncognitive Affective Factors Scale for Organ Donation (NFSOD) was adapted from a previous scale (Morgan et al., 2008) comprising five subscales: ick factor, jinx factor, bodily integrity, medical mistrust, and perceived benefits. The ick factor subscale measures an aversion to the concept of organ donation and a concern regarding bodily mutilation during the donation process. The jinx factor subscale measures fears and superstitions that misfortune will arise following ODR. The bodily integrity subscale measures the belief that the body should remain whole after death. The medical mistrust subscale measures fears regarding the medical profession in relation to organ donation. Finally, the perceived benefits subscale measures the perceived benefits of becoming an organ donor after death and was reverse scored to align with other subscales. Each subscale consisted of 2 to 4 items rated on a 7-point Likert scale (1 = strongly disagree; 7 = strongly agree). The Cronbach's alpha coefficient of NFSOD in Study 1 is .88, with the subscales ranging from .70 to.78.

Demographics. We also collected demographic information, including gender, age, education level, profession, ethnicity, religion, personal income, and donation needs. Six binary items were used to assess the organ donation-related experience and need. The sample item included “Do you have experiences or needs to receive organ donations?”

Results

Structural Validity of the Cognitive-Noncognitive Dual Pathway Model of ODR

To assess the structural validity of cognitive and noncognitive affective dimensions of ODR with three cognitive and five noncognitive affective factors (the validity of the three cognitive and five noncognitive affective factors of ODR see supplementary material), we conducted a two-factor confirmatory factor analysis (CFA) using the standardized average scores for each factor. The results of the CFA (Table 1) indicated that the eight factors may be categorized into two correlated (r = –.51, p < .001) dimensions: cognitive factor (CF) and noncognitive factor (NF), χ²/df = 6.70, CFI = 0.95, SRMR = 0.08, RMSEA = 0.04. Thus, the standardized aggregate scores of three CF subdimensions and five NF subdimensions were used as the indicators of CF and NF for the subsequent analysis (descriptive statistics see Table 2; correlation see Supplementary Table 2).

Table 1.

Standardized Factor Loadings in CFA of CF and NF in Study 1 & 2.

Dimensions	Study1 (N = 964)		Study2 (N = 668)
Dimensions	Factor 1	Factor 2	Factor 1	Factor 2
Factor 1 (CF)
Attitude	0.65		0.61
Subjective norm	0.63		0.54
Perceived control	0.65		0.58
Factor 2 (NF)
Bodily integrity		0.63		0.74
Medical mistrust		0.65		0.72
Ick		0.80		0.83
Jink		0.78		0.81
Not perceived benefit		0.48		0.53

Note: The extraction method was maximum likelihood with an oblique (Promin) rotation.

Table 2.

Descriptive Statistics of Main Variables in Study 1 & 2.

Variable	Study 1(N = 964)		Study 2(N = 668)
	/		Control (N = 341)		Priority incentives (N = 327)
	M/%	SD	M/%	SD	Mean/%	SD
ODR intention	5.29	1.24	5.14	1.36	5.36	1.22
ODR-related behavior	49.4%	/	56.0%	/	54.1%	/
CF	0	2.34	–.31	2.18	.32	2.25
Attitude	4.33	1.45	4.11	1.43	4.57	1.52
Subjective norm	3.70	1.05	3.68	1.08	3.86	1.07
Perceived control	5.33	0.90	5.27	0.88	5.40	0.94
NF	0	3.72	.34	4.10	–.36	3.71
Bodily integrity	3.02	1.24	3.13	1.35	2.92	1.33
Medical mistrust	2.58	1.16	2.76	1.31	2.64	1.30
Ick	2.31	1.04	2.52	1.28	2.32	1.13
Jink	2.09	1.02	2.26	1.16	2.11	1.10
Not perceived benefit	2.03	0.82	2.18	0.90	2.05	0.78

The Effect of Cognitive-Noncognitive Dual Factors on ODR Intention and Related Behavior

Two hierarchical multiple linear regression models (Models 1-2) were conducted to examine the predictive effect of CF and NF factors on ODR intention. Five control variables (gender, age, religion, income, and organ donation) were entered into Model 1, and CF and NF were entered into Model 2 as predictors. The results (Table 3) showed that both CF and NF significantly predicted ODR intention (Model 2, △R² = .31, F (2, 956) = 274.08, p < .001), but their effects were in opposite directions. Specifically, CF was a positive predictor (β = .37, p < .001), whereas NF was a negative predictor (β = – .32, p < .001). Moreover, all CF and NF subdimensions were significant predictors of ODR intention (p < .001), except for two NF subdimensions: medical mistrust and jinx (Supplementary Table 3).

Table 3.

The Predictors of ODR Intention and Related Behavior in Study1 (N = 964).

Variables	ODR intention				ODR-related behavior
	Model 1		Model 2		Model 3		Model 4		Model 5
	β	95% CI	β	95% CI	OR	95% CI	OR	95% CI	OR	95% CI
ODR intention									1.54***	[1.32, .82]
Psychological factors
CF			.37***	[.31, .43]			1.06	[.99, 1.13]	.97	[.90, 1.05]
NF			–.32***	[–.38, –.27]			.90***	[.86, .94]	.94**	[.90, .98]
Control
Gender^a	.08*	[.02, .13]	.04	[–.00, .09]	.88	[.68, 1.14]	.82	[.63, 1.07]	.79	[.60, 1.04]
Age	.07*	[.01, .13]	.05	[–.00, .10]	.99	[.97, 1.01]	.99	[.97, 1.00]	.99	[.97, 1.00]
Religion^b	–.11***	[–.17, –.05]	–.06**	[–.11, –.02]	.72	[.47, 1.07]	.79	[.52, 1.20]	.86	[.56, 1.32]
Income^c	.10***	[.04, .16]	.03	[–.02, .08]	1.31	[.96, 1.80]	1.15	[.83, 1.59]	1.12	[.81, 1.55]
Organ donation need	.33***	[.27, .38]	.13***	[.08, .18]	10.75***	[5.06, 22.90]	5.91***	[2.67, 13.29]	4.21***	[1.87, 9.60]
Model fitting
R²/Nagelkerke's R²	.14***		.45***		.07		.12***		.16***
△ R²			.31***					.05***		.04***

Note: ^a Female = 1, ^b Religious = 1, ^c Over 10000 yuan per month = 1. *p < .05. **p < .01. ***p < .001

Two hierarchical multiple logistic regression models (Model 3-4) were used to test the predictive effect of CF and NF factors on ODR-related behavior. The results (Table 3) showed that, similar to ODR intention, NF negatively predicted ODR-related behavior (b = – .10, OR = .90, p < .001). However, the predictive effect of CF did not reach statistical significance (b = .06, OR = 1.06, p = .110), although CF and NF accounted for a significant level of changing variance (Model 4, △R² = .05, χ²(2) = 40.84, p < .001). Specifically, among NF subdimensions, only the ick factor was a significant negative predictor (b = –.35, OR = .77, p < .001) (Supplementary Table 3).

Indirect Effects of Cognitive-Noncognitive Dual Factors on ODR-Related Behavior

Next, we tested whether ODR intention mediates the relationship between cognitive-noncognitive dual factors and ODR-related behavior. A multiple mediator model with 10,00 bootstrapping resamples was conducted. Results (Figure 1a) showed that ODR intention fully and positively mediated the relationship between CF and ODR-related behavior (b = .05, SE = .01, 95% CI [.03, .07]), while partially and negatively mediating the relationship between NF and ODR-related behavior (b = –.03, SE = .01, 95% CI [–.04, –.02]). Specifically, the partially indirect effect of NF was primarily driven by the dimension of ick (Supplementary Figure 1).

Figure 1.

Mediation Models of ODR-Related Behavior in Study 1 & 2. a) In Study 1, ODR intention as mediators between CF & NF to ODR-related behavior. b) In Study 2, CF & NF as parallel mediators and ODR intention as serial mediators between priority incentives and ODR-related behavior. Path values represent the unstandardized regression coefficients with demographics controlled. IE = Indirect Effect; DE = Direct Effect. *p < .05. **p < .01. ***p < .001.

Discussion

Overall, Study 1 provided support for a cognitive-noncognitive dual pathway model of ODR in a sample of Chinese adults and reveals an asymmetrical predictive effect on ODR intention and related behavior. That is, ODR intention can be predicted by both CF and NF, while ODR-related behavior can be predicted solely by NF. These findings highlight distinct mediation pathways for CF and NF in influencing ODR-related behavior via ODR intention. CF was only able to predict ODR-related behavior through intentions, whereas NF could directly predict ODR-related behavior. These results suggest that an individual's irrational affective barriers toward organ donation may prevent individuals from registering to become an organ donor, even if they recognize on a rational level that they should. This partially elucidates the well-established intention-behavior gap in ODR.

Study 1 confirmed a cognitive-noncognitive dual pathway psychological model of ODR, which, according to previous research (Falomir-Pichastor et al., 2013), could be the psychological pathway that facilitates the promotion strategy to work. Hence, in Study 2, we aimed to utilize the dual pathway model to investigate the effects and psychological mechanisms of priority incentives, a popular ODR promotion strategy, to understand the relationship between the effective promotion strategy and the psychological factor influencing individuals’ decisions.

Study 2

Method

Participants

Using G*Power, we estimated a sample size of 574 participants to reach a medium to small effect (OR = 1.30) with a power of .85 for logistic regression. A total of 771 participants were recruited from two sources: the sample service of the WJX platform and a snowballing sample initiated through social networks on WeChat. The entry criteria and attention check questions were identical to those in Study 1. Additionally, participants could not have participated in Study 1. The final valid sample size for Study 2was 668 participants (86.64% of the recruited sample: N_WJX = 535, N_snowballing = 133). For information on demographic characteristics, see Supplementary Table 1. Given that the two sample sources showed no differences in all dependent variables, they were merged into one sample for further analysis.

Design and Materials

In Study 2, we manipulated the incentive type (priority incentive vs. control) for ODR using hypothetical scenarios. All participants read a paragraph briefly describing the current Chinese organ donation system and then were randomly assigned to one of two incentive conditions. In the priority incentive condition, participants read an extra paragraph describing the current priority incentive system in China: “Both the individual and their family members will be given a priority on the transplant waiting list” (see supplementary material for details). A binary-choice manipulation check question (priority incentive /no incentive) was asked after these paragraphs: “According to the above description, what form of incentive would be offered?” A total of 61 participants were excluded due to incorrect answers to their assigned incentive type conditions.

Subsequently, all participants completed the same questionnaire as in Study 1. The Cronbach α of each measure were: Intention Scale, .91; CFSOD, .78 (range for subscales: .59∼.88), and NFSOD for Organ Donation, .91 (range for subscales: .73∼.85).

Results

CFAs replicated the results of Study 1 and consistently revealed the stable structural validity of the cognitive-noncognitive dual pathway model of ODR with eight factors (Supplementary material).

The Effect of Priority Incentives on ODR Intention and Related Behavior

A between-subjects analysis of covariance (ANCOVA) suggested that participants in the priority incentive condition significantly increased their ODR intention (M = 5.36, SD = 1.36) compared to those in the control condition (M = 5.14, SD = 1.22), F (1,661) = 5.30, p = .02, $η_{p}^{2}$ = .01. However, hierarchical multiple logistic regression suggested that the incentive type could not significantly predict ODR-related behavior (b = –.09, OR = .91, p = .57) or account for a significant amount of additional variance (△R² = .00, χ²(1) = .325, p = .57) in ODR-related behavior.

The Effect of Priority Incentive on Cognitive-Noncognitive Dual Factors

The result of ANCOVA indicates that reading priority incentive information significantly increased participants’ positive cognitive beliefs toward ODR (M = .32, SD =2.25) than those in the control condition (M = –.31, SD =2.18), F (1,661) = 15.24, p < .001, $η_{p}^{2}$ = .02. This effect of priority incentive is significant across all three subdimensions of CF (Supplementary Table 5).

Meanwhile, the priority incentive showed the inverse effect to NF: it decreased participants’ negative noncognitive belief to ODR (M = –.36, SD = 3.72) than those in the control condition (M = .34, SD = 4.10), F (1,661) = 5.84, p = < .02, $η_{p}^{2}$ = .01. Specifically, this effect of priority incentive was only significant in the bodily integrity, ick, and perceived benefits subdimensions of NF (Supplementary Table 5).

The Indirect Effect of Priority Incentives on ODR-Related Behavior: CF and NF as Mediators

To assess the indirect effect of cognitive-noncognitive dual factors on the relationship between priority incentive and related behavior of ODR, a parallel-serial mediation model was used with 10,00 bootstrapping resamples, including both CF and NF as parallel mediators and ODR intention as a serial mediator. Results (Figure 1b) revealed that, mediated by ODR intention, priority incentives exerted a significant indirect effect on ODR-related behavior. This serial indirect effect may function through two paths: significantly mediated by the path from CF to ODR intention (b = .05, SE = .03, 95% CI [.02 .10]), or marginally significantly mediated by the path from NF to ODR intention (b = .03, SE = .02, 95% CI [.00, .07]). These serial indirect effects may be brought about by a combination of CF and NF, rather than separated CF or NF subdimensions (Supplementary Table 6).

Discussion

Study 2 re-verified the structure of the cognitive-noncognitive dual pathway model of ODR among Chinese participants. Study 2 revealed a gap in the effect of priority incentives on ODR intention and related behavior. Specifically, priority incentives can enhance ODR intention but has no direct effect on ODR-related behavior. This gap can possibly be attributed to the longstanding inconsistency between individuals’ attitudes toward organ donation and their actual registration behavior (Siegel et al., 2014). We found that priority incentives primarily influence ODR-related behavior through the pathway from CF via ODR intention.

General Discussion

Across two online studies of 1632 Chinese adults, we examined and confirmed the structural validity of the cognitive-noncognitive dual pathway model of ODR. Based on this model, we observed the effect of priority incentives on ODR and the asymmetrical psychological pathways by which it works. That is, offering priority incentives can enhance ODR intention, and can also exert an indirect effect on ODR-related behavior mediated via CF to ODR intention.

The Effect of the Cognitive-Noncognitive Dual Pathway Model of ODR

Our research is the first to directly provide evidence for the structure of the cognitive-noncognitive dual pathway model of ODR within a Chinese sample. Here, we found that the model comprises two negatively correlated factors: a cognitive factor (CF) with three subdimensions and a noncognitive factor (NF) with 5 subdimensions. Prior studies from the United States and Europe have postulated that these eight subdimensions reflect two distinct dimensions associated with cognitive or noncognitive affective factors (Morgan et al., 2008; O’Carroll et al., 2011). However, those studies only verified the structure of the NF. Our findings provide empirical evidence for the structure of the two integrated factors of both CF and NF and demonstrate the cross-national consistency of the psychological pathway model of ODR.

Based on this dual pathway model, we observed a distinct prediction pathway to ODR intention and related behavior, which we may contribute to a deeper understanding of the widely recognized intention-behavior gap in ODR. ODR intention was predicted by both CF and NF, while ODR-related behavior was solely predicted by NF. Previous research has reported that predictors of ODR intention included CF subdimensions such as attitudes and subjective norms (Britt et al., 2017), as well as NF subdimensions (Rocheleau, 2013), but CF subdimensions were not able to predict actual ODR behavior (Doherty et al., 2017). Our findings align with these results and provide evidence to compare the integrated impact of CF and NF. We also found some CF and NF subdimensions that previously identified as predictive were not significant predictors of ODR in the present study. For example, the jinx factor, which had previously been found to serve as a barrier to organ donation (Chan, 2019), had no such effect on ODR intention in our Chinese sample. This inconsistency may be attributed to lower levels of religiosity and spirituality in our Chinese sample compared with American and European samples.

We also observed distinct mediation pathways for CF and NF influencing ODR-related behavior via ODR intention. Specifically, CF could only predict ODR-related behavior through intention, whereas NF could directly predict ODR-related behavior. This finding adds some nuance to the notion that CF subdimensions have less or even no impact on the decision to donate compared to NF subdimensions, as suggested by a study of American participants (Morgan et al., 2008). Here, these cognitive factors may not be completely absent during the decision to donate but may rather exert an indirect impact.

The Effect of Priority Incentives on ODR and its Underlying Mechanisms

To the best of our knowledge, we were the first to provide evidence that priority incentives can increase the intention to donate among Chinese adults who are not currently donors. Previous research has provided only fragmented evidence regarding the effectiveness of priority incentives in promoting ODR. Only a recent study by Meng and Clarke (2020) reported a relatively small effect of priority incentives on ODR intention (OR = 1.91), which is consistent with the relatively small effect in our finding ( $η_{p}^{2} = .01$ ).

Our study shows that offering priority incentives indirectly enhances ODR-related behavior in China. This result was consistent with previous evidence focused on the direct role of priority on actual ODR behavior by experimental studies and real-world data. For instance, in decision-game experiments, allocating priority to those on a waiting list increased registration behavior (Herr & Normann, 2016, 2019; Kessler & Roth, 2012; Li et al., 2013). Similarly, in real data from Israel, priority incentives increased the organ donation rates from 7.8 to 11.4 donors per million population in the first year of the priority program (Lavee et al., 2013; Stoler et al., 2016, 2017).

We further found that priority incentives exert an indirect effect on ODR-related behavior through cognitive pathways. That is, priority incentives mainly affect CF but not NF, and CF subsequently affects ODR intention and related behavior. This suggests that priority incentives function more as cognitively driven rather than emotionally driven motivators. To our knowledge, only one qualitative study using an open-ended question has addressed the psychological mechanisms of priority incentives as driven by emotional factors, namely anticipated regret (Meng & Clarke, 2020). This discrepancy may be attributed to two factors. First, our study is based on the dual cognitive-noncognitive pathway model of ODR and quantitative research methods, which may represent a more robust interpretation of underlying mechanisms than those derived from qualitative approaches. Alternatively, our study did not include anticipated regret as an NF and may not fully capture the role of emotions.

Implications

Our study offers several theoretical and practical contributions to the field of ODR. Theoretically, it systematically examines the psychological mechanisms underlying priority incentives, thereby offering valuable insights and suggestions on the future directions for research on other types ODR incentives. Determining the mechanisms through which various incentive types exert their effects can help delineate their scope of applicability and effectiveness, thereby informing their strategic use in promoting ODR. For example, being an effective approach, the spiritual incentives, such as honorary certificates (Bedendo & Siming, 2019) might stimulate the intrinsic motivation by promoting individual's noncognitive emotions.

Practically, our finding that priority incentives work on ODR mainly through cognitive pathways may help identify individuals who are most responsive to such incentives. That is, if an individual's decision to register for organ donation is driven more by cognitive beliefs, then priority incentives are more likely to work for him/her. For example, priority incentives might be more suitable to individuals from low socioeconomic statuses or with low-level educational backgrounds, who tend to display insufficient knowledge and negative attitudes towards organ donation (Sarveswaran et al., 2018). Priority incentives could also apply to countries at an earlier development stage of organ donation systems or public awareness, such as China.

In addition, our findings regarding noncognitive affective factors highlight their role in influencing ODR-related behavior. Future organ donation advocates should focus on dispelling negative affective beliefs associated with organ donations, such as discomfort or disgust.

Limitations

There are several limitations to our study. Firstly, our correlational findings on the role of CF and NF in ODR should be cautious in inferring causality. Further research should further investigate ODR using controlled experimental techniques to infer causality. Some factors in CF and NF also could have overlaps in their original definitions, which might had a confounding effect to ODR. For example, attitude in CF may be influenced by medical distrust in NF. Future studies should develop more precise tools to measure these potentially overlapped variables. Second, there is room for improvement in measuring ODR-related variables. For example, self-reported intentions may be subject to social desirability bias. Furthermore, our behavioral measure did not directly capture actual registration behavior due to privacy protection protocols within China's organ donation system. Our participants may not immediately register as donor after visiting the Organ Donation Volunteer Services website but may do so later or when the opportunity to donate arises. Future studies should consider incorporating more direct behavioral indicators, such as those from online organ donation registries. At last, our study might be subject to sample selection bias, which may limit the generalizability of our findings. The samples in WJX platform may underrepresent populations without internet access or those with low survey engagement. Future studies could utilize broader online and offline samples to enhance representativeness.

Conclusion

Our findings provide evidence for a dual cognitive-noncognitive pathway model of ODR in a sample of Chinese adults. ODR intention is driven by both cognitive and noncognitive pathways, while ODR-related behavior is driven solely by noncognitive affective beliefs. The priority incentives could increase the intention to engage in ODR and indirectly influence ODR-related behavior through the path from CF to intention.

Supplemental Material

sj-doc-1-pac-10.1177_18344909251393768 - Supplemental material for How Priority Incentives Impact Organ Donation Registration Intention and Related Behavior in China

Supplemental material, sj-doc-1-pac-10.1177_18344909251393768 for How Priority Incentives Impact Organ Donation Registration Intention and Related Behavior in China by Xiao-Ju Wu, Jia-Hui Fu, Ya Li, Yu-han Gong and Zhu-Yuan Liang in Journal of Pacific Rim Psychology

Footnotes

Author Note

Correspondence: Zhu-Yuan Liang, CAS Key Laboratory of Behavioral Science, Institute of Psychology, Chinese Academy of Sciences, Beijing, China, 100101. Email: liangzy@psych.ac.cn.

The first author, Xiao-Ju Wu was affiliated with the Chinese Academy of Sciences when the research was conducted and is now with Chongqing University of Education.

ORCID iDs

Xiao-Ju Wu

Jia-Hui Fu

Ya Li

Yu-han Gong

Zhu-Yuan Liang

Ethical Approval

The study was approved by the Ethic Review Board of Institution of Psychology, Chinese Academy of Sciences (H22133). All participants signed the informed consent before the online survey.

Data files and data analysis code have been made publicly available online: .

Funding

This work was supported by the National Natural Science Foundation of China (72271230)，National Social Science Foundation of China (19ZDA358), Scientific Foundation of Institute of Psychology, Chinese Academy of Sciences (Y9CX303008), and CAS Engineering Laboratory for Psychological Service (KFJ-PTXM-29).

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Supplemental Material

Supplemental material for this article is available online.

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