Enhancing Behavioral Intentions Toward Body Donation Through a Theory of Planned Behavior-Based, Culturally Tailored Educational Intervention: A Quasi-Experimental Study

Enhancing Behavioral Intentions Toward Body Donation Through a Theory of Planned Behavior-Based, Culturally Tailored Educational Intervention: A Quasi-Experimental Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Enhancing Behavioral Intentions Toward Body Donation Through a Theory of Planned Behavior-Based, Culturally Tailored Educational Intervention: A Quasi-Experimental Study K Vijayakumar, Mandar Ambike, Sulakshana Sawant, Shreya Singh This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7408051/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 02 Dec, 2025 Read the published version in BMC Public Health → Version 1 posted 13 You are reading this latest preprint version Abstract Background: Body donation remains crucial for medical education and research, yet donor shortages persist worldwide, often due to limited awareness and cultural barriers. The Theory of Planned Behavior (TPB) offers a robust framework to understand and influence donation intentions. This study evaluates the efficacy of a culturally sensitive, TPB-based educational intervention aimed at enhancing behavioral determinants related to body donation among adults in India. Methods: A quasi-experimental pre-post design was employed with 163 adult participants. The multi-component intervention included multimedia educational materials, peer discussions, motivational media, and practical guidance on registration. Participants completed a validated, bilingual TPB questionnaire assessing knowledge, attitudes, subjective norms, perceived behavioral control, and behavioral intentions immediately before and after the intervention. Statistical analyses involved paired-sample t-tests to compare pre- and post-intervention scores, multiple linear regression to identify predictors of behavioral intention, and subgroup analyses examining sociodemographic influences. Results: Post-intervention assessments revealed statistically significant improvements across all TPB constructs (all p < 0.001). Knowledge increased markedly from a mean score of 2.7 to 3.8 (on a 0–4 scale), corresponding to a large effect size (Cohen’s d = 1.68). Attitude, subjective norms, and perceived behavioral control all showed medium effect sizes (d = 0.65–0.70). Multiple regression indicated that attitude (β = 0.40, p < 0.001), subjective norms (β = 0.32, p < 0.01), and perceived behavioral control (β = 0.26, p < 0.01) were independent predictors of post-intervention intention, jointly explaining 52% of the variance (R² = 0.52). Notably, willingness or intention to donate increased to 66% post-intervention, with higher readiness observed among participants with prior knowledge, urban residence, male gender, higher education, and older age. Conclusion: The TPB-based, culturally tailored educational intervention effectively enhanced knowledge and psychosocial determinants of body donation intention among Indian adults. These findings underscore the potential of theory-driven, culturally adapted programs to increase readiness for body donation, offering scalable strategies to address donor shortages in diverse cultural contexts globally. Body donation Theory of Planned Behavior Behavioral intention Educational intervention culturally tailored intervention Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 1. Introduction Globally, awareness and rates of body donation remain low, with less than 20% of people having heard of the concept and actual donor participation being under 1% in many regions [ 1 ]. However, anatomical education for medical students, surgeons, and researchers relies heavily on these donations, as hands-on dissection provides essential clinical training that cannot be replicated through technological substitutes [ 2 , 3 ]. Persistent shortages of donor cadavers limit the effectiveness of medical curricula and impede research and surgical innovations [ 4 ]. Although body donation programs support education and medical advances, their success varies widely across countries [ 5 , 6 ]. The United States and parts of Europe have experienced growth in body donor registries; however, significant psychosocial and cultural barriers persist in Asia, Africa, and South America [ 7 , 8 ]. Taboos, religious beliefs, and misinformation continue to deter individuals from donating their bodies, contributing to ongoing shortages [ 9 – 11 ]. Psychological models, notably the Theory of Planned Behaviour (TPB), have provided insights into health-related decisions such as organ and body donation [ 12 ]. According to the TPB, behavioural intentions are shaped by attitudes, subjective norms, and perceived behavioural control [ 13 , 14 ]. TPB-based interventions have effectively predicted organ donation behaviours; however, comprehensive, multi-component applications specifically addressing body donation and tailored to distinct cultural contexts are rare [ 15 , 16 ]. Addressing the persistent challenges in body donation requires a comprehensive understanding of the psychological determinants guiding donation behaviours within diverse sociocultural contexts [ 17 ]. While the TPB provides a robust framework to examine attitudes, subjective norms, and perceived behavioural control, its application to body donation, primarily through multi-component, culturally tailored interventions, remains limited. Therefore, this study aimed to assess the effectiveness of a culturally tailored, TP-based educational intervention in enhancing knowledge, attitudes, subjective norms, perceived behavioural control, and behavioural intentions toward body donation among adults. By evaluating this TPB-informed intervention, the study seeks to fill the existing research gap and offer evidence-based insights to inform future educational strategies and policy initiatives that could ultimately improve donor rates and support the critical needs of medical education and research. 2. Objectives 2.1 To assess baseline knowledge, attitudes, subjective norms, perceived behavioural control, and behavioural intentions regarding body donation among adults. 2.2 To develop and implement a multi-component educational intervention guided by the Theory of Planned Behaviour, specifically tailored for the study population's cultural context. 2.3 To explore the influence of key sociodemographic factors (such as age, sex, education, religion, residence, and prior knowledge) on post-intervention outcomes related to body donation. 3. Methods 3.1 Study Design This quasi-experimental pre-post interventional study evaluated the effectiveness of a TPB-based educational intervention aimed at improving knowledge, attitudes, subjective norms, perceived behavioural control, and behavioural intentions related to body donation among adults. 3.2 Participants and setting The study was conducted in and around Pune, across tertiary healthcare centres, old age homes, and community centres. Participants aged ≥ 18 years without prior formal education or intervention on body donation and who were available for both pre- and post-intervention assessments were included. 3.3 Exclusion Criteria Participants with cognitive impairment, prior body donation education, residency outside service areas, and withdrawal or failure to complete study procedures were excluded. 3.4 Sampling method A non-probability convenience sampling technique was used to recruit adult participants for this quasi-experimental study that assessed behavioural intentions toward body donation. Recruitment was conducted through community outreach, local networks, and informational sessions within the target geographic area. To enhance the sample's representativeness within the constraints of convenience sampling, efforts were made to include participants from diverse sociodemographic backgrounds, including variations in age, sex, education, religion, and urban or rural residence. 3.5 Sample Size The sample size required for this quasi-experimental study was calculated using the standard formula for detecting a standardised effect size. n = ((Z₁–α ⁄ 2 + Z₁–β) / d) ². where Z 1 − α/2 = 1.96 corresponds to the 95% confidence level, Z 1 − β = 0.84 reflects 80% power, and d = 0.5 represents the expected moderate effect size based on prior behavioural intervention studies (Cohen, 1988) [ 18 , 19 ]. Substituting these values yielded a minimum sample size of 64 participants per group to reliably detect meaningful changes in the psychological constructs targeted by the intervention. Considering the quasi-experimental design, potential attrition, and planned subgroup analyses, 163 participants were enrolled to ensure sufficient statistical power for all primary and secondary analyses. 3.6 Ethical Considerations The study was approved and conducted with the Ethical Standards of Symbiosis International Deemed University, Ref. SIU/IEC/966. Written informed consent was obtained from all participants after providing them with clear information regarding the study's purpose, procedures, and rights. Participation was voluntary, and confidentiality and data privacy were rigorously maintained throughout the research process. The study was conducted in accordance with the Indian Council of Medical Research (ICMR), Declaration of Helsinki and its amendments and the National Ethical Guidelines for Biomedical and Health Research for involving Human Participants (2017). 3.7 Theoretical Framework The evaluation and intervention were grounded in Ajzen's TPB [12,20], focusing on four key constructs: Attitude: Participants' evaluation of body donation (positive or negative). Subjective Norms: Perceived social pressures or support for donation. Perceived Behavioural Control (PBC): Confidence and perceived ease of performing donation behaviours. Behavioural Intention: Readiness and plan to donate. 3.8 Evaluation A. Assessment Tools and Procedure The questionnaire used in this study was designed and constructed in accordance with the pertinency of validated TPB models to establish the item structure, as recommended by Ajzen (1991) [12], and other similar adaptation studies in organ donation contexts [15, 21]. This structured TPB-based questionnaire was used to assess the participants' knowledge, attitudes, subjective norms, perceived behavioural control, and behavioural intentions associated with body donation. The tool was applied twice, immediately before (pre-test) and within one hour after (post-test) the educational intervention. Demographic and Sociodemographic Variables: Age, gender, education, occupation, religion, marital status, residence, and household income were used to examine moderating factors. Knowledge: Four multiple-choice questions about body donation eligibility, legal procedures, and myths were scored dichotomously (correct = 1, incorrect = 0). Attitude, Subjective Norms, Perceived Behavioural Control, and Behavioural Intention: Items rated on 5-point Likert scales (1 = strongly disagree to 5 = strongly agree), with negatively worded items reverse scored. The domain scores were computed by averaging the scores. B. Translation and Reliability of the Questionnaire The questionnaire was translated into Marathi using a forward–backward translation method to ensure accuracy. Cultural adaptation was performed to ensure that the questions were appropriate and easily understood by the Marathi-speaking participants. A pilot test was conducted with a small group to check for clarity and consistency. The internal consistency of the Marathi version was good, with a Cronbach's alpha value above 0.80 [22,23]. This suggests that the questionnaire items reliably measured the intended concept. Further validation studies are recommended to assess other aspects, such as construct and criterion validity. Trained facilitators supervised the data collection to ensure standardised administration. The immediate post-intervention assessment captured the direct impact on the knowledge and psychological determinants of body donation. 3.9 Intervention The multi-component intervention included: 1. Educational Sessions (30–45 minutes): Interactive multimedia presentations on body donation processes, timelines, ethical safeguards, benefits, myth dispelling, and legal consent to improve attitudes. 2. Peer Discussion Groups: Facilitated sharing of beliefs, cultural norms, and social expectations with testimonials from donors' families and community leaders to strengthen supportive subjective norms. 3. Motivational Media: Emotionally engaging videos and case studies highlighting altruism and societal benefits to reinforce attitudes and norms. 4. Skill-Building and Practical Guidance: Stepwise demonstrations of paper and online registration processes addressing barriers to enhance perceived behavioural control. 5. Resource Materials Distribution: Brochures, FAQs, contact details, and sample consent forms to encourage reflection and follow-up. 4. Statistical Analysis and Table/Figure Mapping Flow of participants through the quasi-experimental study, showing recruitment, intervention, and analysis, with all 163 participants completing the study (Fig. 1). Participant demographics were summarised using descriptive statistics (frequencies, percentages, means, standard deviations) and presented (Table.1). Baseline psychosocial status, including knowledge and Theory of Planned Behaviour (TPB) constructs, was summarised as means ± SD (Table.2). The effectiveness of the intervention was evaluated using paired‑samples t‑tests for pre‑ and post‑intervention comparisons of knowledge and TPB constructs. Effect sizes (Cohen’s d) and 95% confidence intervals (CIs) were calculated [24], and the changes are visualised (Fig. 2) (grouped bar chart). Multiple linear regression was used to examine the independent contributions of post‑intervention attitude, subjective norms, and perceived behavioural control to behavioural intention. Standardised beta coefficients (β), p‑values, and model fit statistics (R²) are summarised (Fig. 3). Post‑intervention behavioural intention distribution was displayed as a pie chart (Fig. 4). Subgroup analyses of post‑intervention outcomes used independent‑samples t‑tests (binary variables), one‑way ANOVA with Tukey post‑hoc tests (categorical variables), and Pearson correlations (continuous variables). Sociodemographic group differences in mean TPB construct scores are visualised (Fig. 5) (heatmap and clustered heatmap). Statistical significance was set at p < 0.05 for all tests. 5. Results 5.1 Overall Outcomes The culturally tailored, TPB–based educational intervention produced significant and meaningful improvements across all targeted psychosocial constructs. Post-intervention, mean knowledge scores increased by 1.1 points (p < 0.001, Cohen's d = 1.25), while attitudes, subjective norms, perceived behavioural control, and behavioural intention each improved by approximately 0.5 points (all p < 0.001) (Fig. 2 ). Multiple regression analysis identified attitude (β = 0.40, p < 0.001), subjective norms (β = 0.32, p < 0.01), and perceived behavioural control (β = 0.26, p < 0.01) as independent predictors of behavioural intention, collectively explaining 52% of its variance (R² = 0.52) (Fig. 3 ). Practically, 66% of participants reported willingness or intention to donate their bodies after the intervention, with one-third remaining undecided or unwilling (Fig. 4 ). Subgroup patterns showed that men, urban residents, older participants, those with higher educational attainment, and individuals with prior awareness of body donation consistently achieved higher post-intervention TPB scores (Fig. 5 ). 5.2 Sample Characteristics Participant demographics are detailed in (Table. 1), showing balanced representation across gender, age, education, religion, marital status, and residence. Nineteen percent (19%) reported prior knowledge of body donation. 5.3 Baseline Psychosocial Constructs Baseline knowledge and TPB construct scores, shown in (Table. 2), were moderate on average (knowledge M = 2.7, SD = 1.0), indicating scope for meaningful change through intervention. 5.4 Changes in TPB Constructs Significant increases in knowledge, attitude, subjective norms, perceived behavioural control, and behavioural intention were observed post-intervention, as depicted in (Fig. 2 ). The grouped bar chart illustrates improved mean scores and reduced variability, suggesting consistent gains across participants. 5.5 Predictors of Behavioural Intention Multiple linear regression results presented in (Fig. 3 ) show that attitude was the strongest predictor (standardized β = 0.40, p < 0.001), followed by subjective norms (β = 0.32, p < 0.01) and perceived behavioural control (β = 0.26, p < 0.01). The model explained 52% of variance in behavioural intention, reinforcing TPB’s applicability. 5.6 Behavioural Intention Distribution Post-intervention willingness or intention to donate was reported by 66% of participants, as shown in the pie chart (Fig. 4 ), while 34% remained undecided or unwilling. 5.7 Sociodemographic Differences Heatmap and clustered heatmap analyses in (Fig. 5 ) reveal that male participants, urban residents, older individuals, those with higher education, and participants with prior knowledge exhibited higher post-intervention psychosocial scores, highlighting demographic groups that may benefit from tailored approaches. Table 1: Participant Demographics (N=163) Demographic Variable Category n % Gender Male 86 53% Female 77 47% Age (years) Mean (SD) 37.8 -10.2 Religion Hindu 90 55.20% Muslim 35 21.50% Christian 25 15.30% Sikh 8 4.90% Other 5 3.10% Education Level No formal education 10 6.10% Primary 25 15.30% Secondary 40 24.50% Graduate 70 42.90% Postgraduate 18 11.00% Marital Status Single 55 33.70% Married 90 55.20% Widowed/Widower 10 6.10% Divorced 8 4.90% Residence Urban 95 58.30% Rural 68 41.70% Prior Knowledge of Body Donation Yes 31 19.00% No 132 81.00% Table. 1 Participant Demographic Characteristics – Distribution of study participants (n = 163) by gender, age group, religion, education level, marital status, residence, and prior knowledge of body donation. Percentages show the relative representation of each category, reflecting a demographically diverse and balanced sample that supports the generalisability of findings. Table. 2 Baseline Knowledge and TPB Construct Scores – Mean ± SD baseline scores for knowledge, attitude, subjective norms, perceived behavioural control (PBC), and behavioural intention prior to the intervention, indicating moderate knowledge and mid‑range psychosocial readiness at study entry. Construct Mean (SD) Knowledge (0–4 scale) 2.7 (1.0) Attitude (1–5 Likert scale) 3.7 (0.8) Subjective Norms (1–5) 3.5 (0.9) Perceived Behavioural Control (1–5) 3.6 (0.8) Behavioural Intention (1–5) 3.5 (0.9) 6. Discussion 6.1 Intervention Effectiveness On Psychosocial Determinants This study evaluated the efficacy of a culturally sensitive, TPB-based educational intervention in enhancing knowledge, attitudes, subjective norms, perceived behavioral control, and behavioral intentions related to body donation among 163 participants. The findings demonstrated statistically significant improvements across all measured constructs from pre- to post-intervention assessments, directly addressing the study objectives and promoting the positive behavioural determinants of body donation. The interplay of these psychosocial determinants was further evidenced by the regression findings, underscoring the theoretical and practical relevance of targeting these constructs to promote body donation intention. The pronounced effect among specific subgroups highlights the opportunities for more targeted, context-sensitive outreach in future initiatives. Specifically, knowledge scores increased markedly from a mean (SD) of 2.7 (1.0) to 3.8 (0.5) on a 0–4 scale, yielding a large effect size (Cohen's d = 1.68, p < 0.001). This substantial gain (Fig. 2 ) indicates that the educational content effectively addressed the informational gaps central to informed decision-making (baseline knowledge levels detailed in Table. 2). Concurrently, key TPB constructs—attitudes, subjective norms, perceived behavioural control, and behavioural intention—improved significantly with medium effect sizes (d = 0.65 to 0.70), shifting from moderate baseline levels (Table 2 ) to enhanced post-intervention scores (Fig. 3 ). These consistent improvements across the TPB domains suggest holistic shifts in participants' psychological readiness to engage in body donation. 6.2 Theoretical Consistency and Regression Findings Multiple regression analysis further emphasized the theoretical consistency of the TPB framework, wherein post-intervention behavioral intention was significantly predicted by attitudes (β = 0.40, p < 0.001), subjective norms (β = 0.32, p < 0.001), and perceived behavioral control (β = 0.26, p < 0.001), collectively explaining 52% of the variance (R² = 0.52;) (Fig. 3 ). This strengthens the conceptual model by quantitatively endorsing the TPB’s proposition that these psychosocial constructs jointly drive behavioral intentions, underlining the intervention’s capacity to modify these determinants effectively. 6.3 Practical Relevance and Behavioral Intentions Approximately two-thirds (66.3%) of participants expressed willingness to donate bodies post-intervention, illustrating the practical relevance of these psychosocial gains (Fig. 4 ). The study also examined how sociodemographic factors influenced these outcomes, with subgroup comparisons and correlations revealing that prior knowledge, urban residence, male sex, higher education, and older age were associated with higher post-intervention scores (Fig. 5 ). Interestingly, religion was not a significant moderator, supporting the intervention’s broad cultural relevance. Our results are congruent with the prior literature, where knowledge enhancement is a fundamental precursor to attitude and behavior changes related to donation [ 12 , 25 ]. McEachan et al., (2011) stated that the medium effect sizes for attitudes and subjective norms parallel meta-analytic studies that emphasize the importance of these constructs [ 26 ]. Furthermore, the relatively elevated effect sizes observed may reflect the intervention’s bilingual and culturally tailored nature, aligning with recommendations that context-specific adaptation fosters greater engagement and efficacy [ 27 ]. Sniehotta et al. (2014) found that TPB works well across different cultures, and that improving knowledge, attitudes, social norms, and perceived control at the same time can clearly boost people’s intentions to change their behaviour [ 28 ]. Similarly, in the present study, we found that the TPB-based intervention significantly improved attitudes and behaviors toward body donation, supporting the findings of Sniehotta et al. From an applied perspective, the results suggest scalable strategies for mitigating global shortages in body donation, which are essential for medical education and research progress [ 29 ]. Policymakers and educators should consider integrating theory-based, culturally sensitive interventions into outreach and recruitment programs, potentially harnessing digital platforms to broaden their impact. 6.4 Strength, limitation and future directions The theory-driven, culturally adapted design based on TPB is one of the strengths of this study, as is the use of a validated bilingual questionnaire and inclusion of a socio-demographically diverse community sample, which improved the relevance of being situated in context and the possibility of performing subgroup analyses. The use of robust statistical methods, such as effect size estimation and multivariate regression, also increased the validity and interpretability of the results. Convenience sampling and quasi-experimental design were used in the present study as they allowed for the timely recruitment of a varied sample typical of the target community. The absence of a control arm does not allow for the definite attribution of any change observed exclusively to the intervention implemented. Although self-report measures are suitable for evaluating psychosocial constructs, they may be influenced by a social desirability bias. Further research using randomised controlled designs with a longer follow-up period is needed to obtain less subjective and more objective data on actual donor registrations and sustained behaviour change. With the increase in culturally tailored interventions using Internet-based approaches, greater scalability can be achieved by expanding through a digital platform to reach diverse populations. 7. Conclusion This quasi-experimental study demonstrates that a culturally sensitive educational intervention based on the Theory of Planned Behavior considerably improves the psychosocial determinants of knowledge, attitudes, subjective norms, perceived behavioral control, and consequently has a positive impact on the behavioral intentions of body donation among Indian adults. The intervention explained more than half of the variance in intention, emphasizing the relevance of these constructs for donation promotion. Subgroup analysis indicated a stronger effect among males, urban populations, older individuals, and those with higher education or awareness, indicating the need for customization. These findings have implications for public health and medical education and support an evidence-based, culturally adapted model for overcoming the chronic cadaver shortage that stifles clinical training and research. Operationally, the study recommends implementing such multi-component educational interventions as a health policy and societal intervention to enhance body donation rates sustainably. Declarations Ethics approval and consent to participate: The study was approved and conducted with the Ethical Standards of Symbiosis International Deemed University, Ref. SIU/IEC/966. Written informed consent was obtained from all participants after providing them with clear information regarding the study's purpose, procedures, and rights. Participation was voluntary, and confidentiality and data privacy were rigorously maintained throughout the research process. The study was conducted in accordance with the Indian Council of Medical Research (ICMR), Declaration of Helsinki and its amendments and the National Ethical Guidelines for Biomedical and Health Research for involving Human Participants (2017). Consent for publication : All authors have given their consent for publication of this manuscript. Availability of data and materials : The datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request. Competing interests : The authors declare that they have no competing interests. Funding : Nil Authors' contributions: VK conceived and designed the study, conducted data collection, and drafted the manuscript. MA performed data analysis and contributed to manuscript revision. SS3 assisted with data collection and study design and supervised the project. SS4 assisted with drafting the manuscript and revision. All authors read and approved the final manuscript. 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Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7408051","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":509321999,"identity":"76c312d2-51a9-4901-aab4-1c3f84b82949","order_by":0,"name":"K Vijayakumar","email":"data:image/png;base64,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","orcid":"","institution":"Symbiosis International (Deemed University","correspondingAuthor":true,"prefix":"","firstName":"K","middleName":"","lastName":"Vijayakumar","suffix":""},{"id":509322000,"identity":"9ebc4664-32d6-42af-b95b-158b5105a3b7","order_by":1,"name":"Mandar Ambike","email":"","orcid":"","institution":"Symbiosis International (Deemed University","correspondingAuthor":false,"prefix":"","firstName":"Mandar","middleName":"","lastName":"Ambike","suffix":""},{"id":509322001,"identity":"232d4682-ed3c-4c5f-b601-50a9890a8238","order_by":2,"name":"Sulakshana Sawant","email":"","orcid":"","institution":"Symbiosis International (Deemed University","correspondingAuthor":false,"prefix":"","firstName":"Sulakshana","middleName":"","lastName":"Sawant","suffix":""},{"id":509322002,"identity":"419f7da7-d8f1-4b2f-af6c-e942bac7212e","order_by":3,"name":"Shreya Singh","email":"","orcid":"","institution":"Symbiosis International (Deemed University","correspondingAuthor":false,"prefix":"","firstName":"Shreya","middleName":"","lastName":"Singh","suffix":""}],"badges":[],"createdAt":"2025-08-19 11:24:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7408051/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7408051/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12889-025-25544-5","type":"published","date":"2025-12-02T15:58:14+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":90805142,"identity":"2c5ff0e5-2cd1-4a92-a031-6dbf044cb107","added_by":"auto","created_at":"2025-09-08 10:43:46","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":11725,"visible":true,"origin":"","legend":"\u003cp\u003eParticipant Flow Diagram – Flow of participants through the quasi-experimental study, showing recruitment, intervention, and analysis, with all 163 participants completing the study and included in the final analysis.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7408051/v1/543653c6293bcccf383f4dc4.png"},{"id":90803535,"identity":"fe97e446-6c1d-434d-945a-448cfb74f724","added_by":"auto","created_at":"2025-09-08 10:35:46","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":26552,"visible":true,"origin":"","legend":"\u003cp\u003eChanges in Knowledge and Psychosocial Constructs Pre- and Post-Intervention : Grouped bar chart of mean ± SD scores for knowledge, attitude, subjective norms, PBC, and behavioural intention before and after the intervention; all post‑intervention increases were statistically significant (p \u0026lt; 0.001), with the largest improvement in knowledge.\u003c/p\u003e","description":"","filename":"image1.png","url":"https://assets-eu.researchsquare.com/files/rs-7408051/v1/47450fa402f289f78e06cfd2.png"},{"id":90803536,"identity":"90685b57-3b64-459c-a9d7-156ee14e4a05","added_by":"auto","created_at":"2025-09-08 10:35:46","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":19585,"visible":true,"origin":"","legend":"\u003cp\u003ePredictors of Post‑Intervention Behavioural Intention – Horizontal bar chart of standardised beta coefficients (β) from regression analysis showing attitude (β = 0.40), subjective norms (β = 0.32), and PBC (β = 0.26) as significant predictors (p \u0026lt; 0.01) of behavioural intention, collectively explaining 52% of its variance (R² = 0.52).\u003c/p\u003e","description":"","filename":"image2.png","url":"https://assets-eu.researchsquare.com/files/rs-7408051/v1/882e0f21a103e57ef870b839.png"},{"id":90803546,"identity":"fc6a2fce-c380-444a-a5cf-66a55a6cd73d","added_by":"auto","created_at":"2025-09-08 10:35:46","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":26038,"visible":true,"origin":"","legend":"\u003cp\u003ePost‑Intervention Behavioural Intention Distribution – Pie chart depicting the proportion of participants willing/intending to donate (66%) versus undecided/unwilling (34%) after the intervention, demonstrating a substantial increase in donation readiness.\u003c/p\u003e","description":"","filename":"image3.png","url":"https://assets-eu.researchsquare.com/files/rs-7408051/v1/18224d07cb288dd2f1b15aad.png"},{"id":90803542,"identity":"ef7b8ad0-198c-45cd-adfe-090e4cc18d8d","added_by":"auto","created_at":"2025-09-08 10:35:46","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":81265,"visible":true,"origin":"","legend":"\u003cp\u003ePost‑Intervention TPB Scores by Sociodemographic Group – Heatmap and clustered heatmap showing mean post‑intervention construct scores by subgroup; higher scores are evident among males, urban residents, older adults, higher‑educated participants, and those with prior knowledge of body donation.\u003c/p\u003e","description":"","filename":"image4.png","url":"https://assets-eu.researchsquare.com/files/rs-7408051/v1/b8d49754c27d0245d4fa672f.png"},{"id":97723944,"identity":"5383f3cc-76fb-4565-b332-2d347248d4e1","added_by":"auto","created_at":"2025-12-08 16:10:00","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1084222,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7408051/v1/8df20edf-307a-4068-820e-c2685d452770.pdf"},{"id":90803533,"identity":"09b3f6bc-bbeb-4632-b35a-7db69371392f","added_by":"auto","created_at":"2025-09-08 10:35:45","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":26818,"visible":true,"origin":"","legend":"","description":"","filename":"Questionaire.docx","url":"https://assets-eu.researchsquare.com/files/rs-7408051/v1/d980e154c4c5a2cab5ef50b4.docx"},{"id":90805144,"identity":"64a27402-b3b6-4157-9e77-03507336c1df","added_by":"auto","created_at":"2025-09-08 10:43:46","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":20440,"visible":true,"origin":"","legend":"","description":"","filename":"Questionaire25.8.25.docx","url":"https://assets-eu.researchsquare.com/files/rs-7408051/v1/65965eff0770ad54e771ebbf.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Enhancing Behavioral Intentions Toward Body Donation Through a Theory of Planned Behavior-Based, Culturally Tailored Educational Intervention: A Quasi-Experimental Study","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eGlobally, awareness and rates of body donation remain low, with less than 20% of people having heard of the concept and actual donor participation being under 1% in many regions [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. However, anatomical education for medical students, surgeons, and researchers relies heavily on these donations, as hands-on dissection provides essential clinical training that cannot be replicated through technological substitutes [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Persistent shortages of donor cadavers limit the effectiveness of medical curricula and impede research and surgical innovations [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAlthough body donation programs support education and medical advances, their success varies widely across countries [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The United States and parts of Europe have experienced growth in body donor registries; however, significant psychosocial and cultural barriers persist in Asia, Africa, and South America [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Taboos, religious beliefs, and misinformation continue to deter individuals from donating their bodies, contributing to ongoing shortages [\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Psychological models, notably the Theory of Planned Behaviour (TPB), have provided insights into health-related decisions such as organ and body donation [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. According to the TPB, behavioural intentions are shaped by attitudes, subjective norms, and perceived behavioural control [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. TPB-based interventions have effectively predicted organ donation behaviours; however, comprehensive, multi-component applications specifically addressing body donation and tailored to distinct cultural contexts are rare [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAddressing the persistent challenges in body donation requires a comprehensive understanding of the psychological determinants guiding donation behaviours within diverse sociocultural contexts [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. While the TPB provides a robust framework to examine attitudes, subjective norms, and perceived behavioural control, its application to body donation, primarily through multi-component, culturally tailored interventions, remains limited. Therefore, this study aimed to assess the effectiveness of a culturally tailored, TP-based educational intervention in enhancing knowledge, attitudes, subjective norms, perceived behavioural control, and behavioural intentions toward body donation among adults. By evaluating this TPB-informed intervention, the study seeks to fill the existing research gap and offer evidence-based insights to inform future educational strategies and policy initiatives that could ultimately improve donor rates and support the critical needs of medical education and research.\u003c/p\u003e"},{"header":"2. Objectives","content":"\u003cp\u003e2.1 To assess baseline knowledge, attitudes, subjective norms, perceived behavioural control, and behavioural intentions regarding body donation among adults.\u003c/p\u003e\n\u003cp\u003e2.2 To develop and implement a multi-component educational intervention guided by the Theory of Planned Behaviour, specifically tailored for the study population\u0026apos;s cultural context.\u003c/p\u003e\n\u003cp\u003e2.3 To explore the influence of key sociodemographic factors (such as age, sex, education, religion, residence, and prior knowledge) on post-intervention outcomes related to body donation.\u003c/p\u003e"},{"header":"3. Methods","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Study Design\u003c/h2\u003e\u003cp\u003eThis quasi-experimental pre-post interventional study evaluated the effectiveness of a TPB-based educational intervention aimed at improving knowledge, attitudes, subjective norms, perceived behavioural control, and behavioural intentions related to body donation among adults.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e3.2 Participants and setting\u003c/h2\u003e\u003cp\u003eThe study was conducted in and around Pune, across tertiary healthcare centres, old age homes, and community centres. Participants aged\u0026thinsp;\u0026ge;\u0026thinsp;18 years without prior formal education or intervention on body donation and who were available for both pre- and post-intervention assessments were included.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e3.3 Exclusion Criteria\u003c/h2\u003e\u003cp\u003eParticipants with cognitive impairment, prior body donation education, residency outside service areas, and withdrawal or failure to complete study procedures were excluded.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003e3.4 Sampling method\u003c/h2\u003e\u003cp\u003eA non-probability convenience sampling technique was used to recruit adult participants for this quasi-experimental study that assessed behavioural intentions toward body donation. Recruitment was conducted through community outreach, local networks, and informational sessions within the target geographic area. To enhance the sample's representativeness within the constraints of convenience sampling, efforts were made to include participants from diverse sociodemographic backgrounds, including variations in age, sex, education, religion, and urban or rural residence.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e3.5 Sample Size\u003c/h2\u003e\u003cp\u003eThe sample size required for this quasi-experimental study was calculated using the standard formula for detecting a standardised effect size.\u003c/p\u003e\u003cp\u003en = ((Z₁\u0026ndash;α \u0026frasl; 2\u0026thinsp;+\u0026thinsp;Z₁\u0026ndash;β) / d) \u0026sup2;.\u003c/p\u003e\u003cp\u003ewhere Z\u003csub\u003e1\u003c/sub\u003e\u0026thinsp;\u0026minus;\u0026thinsp;α/2\u0026thinsp;=\u0026thinsp;1.96 corresponds to the 95% confidence level, Z\u003csub\u003e1\u003c/sub\u003e\u0026thinsp;\u0026minus;\u0026thinsp;β\u0026thinsp;=\u0026thinsp;0.84 reflects 80% power, and d\u0026thinsp;=\u0026thinsp;0.5 represents the expected moderate effect size based on prior behavioural intervention studies (Cohen, 1988) [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Substituting these values yielded a minimum sample size of 64 participants per group to reliably detect meaningful changes in the psychological constructs targeted by the intervention. Considering the quasi-experimental design, potential attrition, and planned subgroup analyses, 163 participants were enrolled to ensure sufficient statistical power for all primary and secondary analyses.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003e3.6 Ethical Considerations\u003c/h2\u003e\u003cp\u003eThe study was approved and conducted with the Ethical Standards of Symbiosis International Deemed University, Ref. SIU/IEC/966. Written informed consent was obtained from all participants after providing them with clear information regarding the study's purpose, procedures, and rights. Participation was voluntary, and confidentiality and data privacy were rigorously maintained throughout the research process. The study was conducted in accordance with the Indian Council of Medical Research (ICMR), Declaration of Helsinki and its amendments and the National Ethical Guidelines for Biomedical and Health Research for involving Human Participants (2017).\u003c/p\u003e\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003e3.7 Theoretical Framework\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe evaluation and intervention were grounded in Ajzen\u0026apos;s TPB [12,20], focusing on four key constructs:\u003c/p\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003eAttitude: Participants\u0026apos; evaluation of body donation (positive or negative).\u003c/li\u003e\n \u003cli\u003eSubjective Norms: Perceived social pressures or support for donation.\u003c/li\u003e\n \u003cli\u003ePerceived Behavioural Control (PBC): Confidence and perceived ease of performing donation behaviours.\u003c/li\u003e\n \u003cli\u003eBehavioural Intention: Readiness and plan to donate.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003e3.8 Evaluation\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eA. Assessment Tools and Procedure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe questionnaire used in this study was designed and constructed in accordance with the pertinency of validated TPB models\u0026nbsp;to establish the item structure, as recommended by Ajzen (1991) [12], and other similar adaptation studies in organ donation contexts [15, 21]. This structured TPB-based questionnaire was used to assess the participants\u0026apos; knowledge, attitudes, subjective norms, perceived behavioural control, and behavioural intentions associated with body donation. The tool was applied twice, immediately before (pre-test) and within one hour after (post-test) the educational intervention.\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eDemographic and Sociodemographic Variables: Age, gender, education, occupation, religion, marital status, residence, and household income were used to examine moderating factors.\u003c/li\u003e\n \u003cli\u003eKnowledge: Four multiple-choice questions about body donation eligibility, legal procedures, and myths were scored dichotomously (correct = 1, incorrect = 0).\u003c/li\u003e\n \u003cli\u003eAttitude, Subjective Norms, Perceived Behavioural Control, and Behavioural Intention: Items rated on 5-point Likert scales (1 = strongly disagree to 5 = strongly agree), with negatively worded items reverse scored. The domain scores were computed by averaging the scores.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003eB. Translation and Reliability of the Questionnaire\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe questionnaire was translated into Marathi using a forward\u0026ndash;backward translation method to ensure accuracy. Cultural adaptation was performed to ensure that the questions were appropriate and easily understood by the Marathi-speaking participants. A pilot test was conducted with a small group to check for clarity and consistency. The internal consistency of the Marathi version was good, with a Cronbach\u0026apos;s alpha value above 0.80 [22,23]. This suggests that the questionnaire items reliably measured the intended concept. Further validation studies are recommended to assess other aspects, such as construct and criterion validity. Trained facilitators supervised the data collection to ensure standardised administration. The immediate post-intervention assessment captured the direct impact on the knowledge and psychological determinants of body donation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.9 Intervention\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe multi-component intervention included:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1.\u0026nbsp;Educational Sessions (30\u0026ndash;45 minutes): Interactive multimedia presentations on body donation processes, timelines, ethical safeguards, benefits, myth dispelling, and legal consent to improve attitudes.\u003c/p\u003e\n\u003cp\u003e2.\u0026nbsp;Peer Discussion Groups: Facilitated sharing of beliefs, cultural norms, and social expectations with testimonials from donors\u0026apos; families and community leaders to strengthen supportive subjective norms.\u003c/p\u003e\n\u003cp\u003e3.\u0026nbsp;Motivational Media: Emotionally engaging videos and case studies highlighting altruism and societal benefits to reinforce attitudes and norms.\u003c/p\u003e\n\u003cp\u003e4.\u0026nbsp;Skill-Building and Practical Guidance: Stepwise demonstrations of paper and online registration processes addressing barriers to enhance perceived behavioural control.\u003c/p\u003e\n\u003cp\u003e5. Resource Materials Distribution: Brochures, FAQs, contact details, and sample consent forms to encourage reflection and follow-up.\u003c/p\u003e"},{"header":"4. Statistical Analysis and Table/Figure Mapping","content":"\u003cp\u003eFlow of participants through the quasi-experimental study, showing recruitment, intervention, and analysis, with all 163 participants completing the study (Fig. 1). Participant demographics were summarised using descriptive statistics (frequencies, percentages, means, standard deviations) and presented (Table.1). Baseline psychosocial status, including knowledge and Theory of Planned Behaviour (TPB) constructs, was summarised as means \u0026plusmn; SD (Table.2). The effectiveness of the intervention was evaluated using paired‑samples t‑tests for pre‑ and post‑intervention comparisons of knowledge and TPB constructs. Effect sizes (Cohen\u0026rsquo;s d) and 95% confidence intervals (CIs) were calculated [24], and the changes are visualised \u0026nbsp;(Fig. 2) (grouped bar chart). Multiple linear regression was used to examine the independent contributions of post‑intervention attitude, subjective norms, and perceived behavioural control to behavioural intention. Standardised beta coefficients (\u0026beta;), p‑values, and model fit statistics (R\u0026sup2;) are summarised \u0026nbsp; (Fig. 3). Post‑intervention behavioural intention distribution was displayed as a pie chart (Fig. 4). Subgroup analyses of post‑intervention outcomes used independent‑samples t‑tests (binary variables), one‑way ANOVA with Tukey post‑hoc tests (categorical variables), and Pearson correlations (continuous variables). Sociodemographic group differences in mean TPB construct scores are visualised (Fig. 5) (heatmap and clustered heatmap). Statistical significance was set at p \u0026lt; 0.05 for all tests.\u0026nbsp;\u003c/p\u003e"},{"header":"5. Results","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003e5.1 Overall Outcomes\u003c/h2\u003e\u003cp\u003eThe culturally tailored, TPB\u0026ndash;based educational intervention produced significant and meaningful improvements across all targeted psychosocial constructs. Post-intervention, mean knowledge scores increased by 1.1 points (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, Cohen's d\u0026thinsp;=\u0026thinsp;1.25), while attitudes, subjective norms, perceived behavioural control, and behavioural intention each improved by approximately 0.5 points (all p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Multiple regression analysis identified attitude (β\u0026thinsp;=\u0026thinsp;0.40, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), subjective norms (β\u0026thinsp;=\u0026thinsp;0.32, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), and perceived behavioural control (β\u0026thinsp;=\u0026thinsp;0.26, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) as independent predictors of behavioural intention, collectively explaining 52% of its variance (R\u0026sup2; = 0.52) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Practically, 66% of participants reported willingness or intention to donate their bodies after the intervention, with one-third remaining undecided or unwilling (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Subgroup patterns showed that men, urban residents, older participants, those with higher educational attainment, and individuals with prior awareness of body donation consistently achieved higher post-intervention TPB scores (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003e5.2 Sample Characteristics\u003c/h2\u003e\u003cp\u003eParticipant demographics are detailed in (Table. 1), showing balanced representation across gender, age, education, religion, marital status, and residence. Nineteen percent (19%) reported prior knowledge of body donation.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003e5.3 Baseline Psychosocial Constructs\u003c/h2\u003e\u003cp\u003eBaseline knowledge and TPB construct scores, shown in (Table. 2), were moderate on average (knowledge M\u0026thinsp;=\u0026thinsp;2.7, SD\u0026thinsp;=\u0026thinsp;1.0), indicating scope for meaningful change through intervention.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003e5.4 Changes in TPB Constructs\u003c/h2\u003e\u003cp\u003eSignificant increases in knowledge, attitude, subjective norms, perceived behavioural control, and behavioural intention were observed post-intervention, as depicted in (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The grouped bar chart illustrates improved mean scores and reduced variability, suggesting consistent gains across participants.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003e5.5 Predictors of Behavioural Intention\u003c/h2\u003e\u003cp\u003eMultiple linear regression results presented in (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) show that attitude was the strongest predictor (standardized β\u0026thinsp;=\u0026thinsp;0.40, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), followed by subjective norms (β\u0026thinsp;=\u0026thinsp;0.32, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and perceived behavioural control (β\u0026thinsp;=\u0026thinsp;0.26, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). The model explained 52% of variance in behavioural intention, reinforcing TPB\u0026rsquo;s applicability.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003e5.6 Behavioural Intention Distribution\u003c/h2\u003e\u003cp\u003ePost-intervention willingness or intention to donate was reported by 66% of participants, as shown in the pie chart (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e), while 34% remained undecided or unwilling.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003e5.7 Sociodemographic Differences\u003c/h2\u003e\u003cp\u003eHeatmap and clustered heatmap analyses in (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e) reveal that male participants, urban residents, older individuals, those with higher education, and participants with prior knowledge exhibited higher post-intervention psychosocial scores, highlighting demographic groups that may benefit from tailored approaches.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1:\u0026nbsp;\u003c/strong\u003eParticipant Demographics (N=163)\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"516\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003eDemographic Variable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 206px;\"\u003e\n \u003cp\u003eCategory\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 147px;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 206px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e53%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 206px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e47%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 206px;\"\u003e\n \u003cp\u003eMean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e37.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e-10.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" style=\"width: 147px;\"\u003e\n \u003cp\u003eReligion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 206px;\"\u003e\n \u003cp\u003eHindu\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e55.20%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 206px;\"\u003e\n \u003cp\u003eMuslim\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e21.50%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 206px;\"\u003e\n \u003cp\u003eChristian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e15.30%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 206px;\"\u003e\n \u003cp\u003eSikh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e4.90%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 206px;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e3.10%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" style=\"width: 147px;\"\u003e\n \u003cp\u003eEducation Level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 206px;\"\u003e\n \u003cp\u003eNo formal education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e6.10%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 206px;\"\u003e\n \u003cp\u003ePrimary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e15.30%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 206px;\"\u003e\n \u003cp\u003eSecondary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e24.50%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 206px;\"\u003e\n \u003cp\u003eGraduate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e42.90%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 206px;\"\u003e\n \u003cp\u003ePostgraduate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e11.00%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" style=\"width: 147px;\"\u003e\n \u003cp\u003eMarital Status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 206px;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e33.70%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 206px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e55.20%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 206px;\"\u003e\n \u003cp\u003eWidowed/Widower\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e6.10%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 206px;\"\u003e\n \u003cp\u003eDivorced\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e4.90%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 147px;\"\u003e\n \u003cp\u003eResidence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 206px;\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e58.30%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 206px;\"\u003e\n \u003cp\u003eRural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e41.70%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 147px;\"\u003e\n \u003cp\u003ePrior Knowledge of Body Donation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 206px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e19.00%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 206px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e132\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e81.00%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable. 1\u003c/strong\u003e Participant Demographic Characteristics \u0026ndash; Distribution of study participants (n = 163) by gender, age group, religion, education level, marital status, residence, and prior knowledge of body donation. Percentages show the relative representation of each category, reflecting a demographically diverse and balanced sample that supports the generalisability of findings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable. 2\u003c/strong\u003e Baseline Knowledge and TPB Construct Scores \u0026ndash; Mean \u0026plusmn; SD baseline scores for knowledge, attitude, subjective norms, perceived behavioural control (PBC), and behavioural intention prior to the intervention, indicating moderate knowledge and mid‑range psychosocial readiness at study entry.\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"418\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 269px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eConstruct\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 149px;\"\u003e\n \u003cp\u003eMean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 269px;\"\u003e\n \u003cp\u003eKnowledge (0\u0026ndash;4 scale)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 149px;\"\u003e\n \u003cp\u003e2.7 (1.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 269px;\"\u003e\n \u003cp\u003eAttitude (1\u0026ndash;5 Likert scale)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 149px;\"\u003e\n \u003cp\u003e3.7 (0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 269px;\"\u003e\n \u003cp\u003eSubjective Norms (1\u0026ndash;5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 149px;\"\u003e\n \u003cp\u003e3.5 (0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 269px;\"\u003e\n \u003cp\u003ePerceived Behavioural Control (1\u0026ndash;5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 149px;\"\u003e\n \u003cp\u003e3.6 (0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 269px;\"\u003e\n \u003cp\u003eBehavioural Intention (1\u0026ndash;5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 149px;\"\u003e\n \u003cp\u003e3.5 (0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e"},{"header":"6. Discussion","content":"\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003e6.1 Intervention Effectiveness On Psychosocial Determinants\u003c/h2\u003e\u003cp\u003eThis study evaluated the efficacy of a culturally sensitive, TPB-based educational intervention in enhancing knowledge, attitudes, subjective norms, perceived behavioral control, and behavioral intentions related to body donation among 163 participants. The findings demonstrated statistically significant improvements across all measured constructs from pre- to post-intervention assessments, directly addressing the study objectives and promoting the positive behavioural determinants of body donation. The interplay of these psychosocial determinants was further evidenced by the regression findings, underscoring the theoretical and practical relevance of targeting these constructs to promote body donation intention. The pronounced effect among specific subgroups highlights the opportunities for more targeted, context-sensitive outreach in future initiatives.\u003c/p\u003e\u003cp\u003eSpecifically, knowledge scores increased markedly from a mean (SD) of 2.7 (1.0) to 3.8 (0.5) on a 0\u0026ndash;4 scale, yielding a large effect size (Cohen's d\u0026thinsp;=\u0026thinsp;1.68, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). This substantial gain (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) indicates that the educational content effectively addressed the informational gaps central to informed decision-making (baseline knowledge levels detailed in Table. 2). Concurrently, key TPB constructs\u0026mdash;attitudes, subjective norms, perceived behavioural control, and behavioural intention\u0026mdash;improved significantly with medium effect sizes (d\u0026thinsp;=\u0026thinsp;0.65 to 0.70), shifting from moderate baseline levels (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2\u003c/span\u003e) to enhanced post-intervention scores (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). These consistent improvements across the TPB domains suggest holistic shifts in participants' psychological readiness to engage in body donation.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003e6.2 Theoretical Consistency and Regression Findings\u003c/h2\u003e\u003cp\u003eMultiple regression analysis further emphasized the theoretical consistency of the TPB framework, wherein post-intervention behavioral intention was significantly predicted by attitudes (β\u0026thinsp;=\u0026thinsp;0.40, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), subjective norms (β\u0026thinsp;=\u0026thinsp;0.32, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and perceived behavioral control (β\u0026thinsp;=\u0026thinsp;0.26, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), collectively explaining 52% of the variance (R\u0026sup2; = 0.52;) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). This strengthens the conceptual model by quantitatively endorsing the TPB\u0026rsquo;s proposition that these psychosocial constructs jointly drive behavioral intentions, underlining the intervention\u0026rsquo;s capacity to modify these determinants effectively.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec23\" class=\"Section2\"\u003e\u003ch2\u003e6.3 Practical Relevance and Behavioral Intentions\u003c/h2\u003e\u003cp\u003eApproximately two-thirds (66.3%) of participants expressed willingness to donate bodies post-intervention, illustrating the practical relevance of these psychosocial gains (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The study also examined how sociodemographic factors influenced these outcomes, with subgroup comparisons and correlations revealing that prior knowledge, urban residence, male sex, higher education, and older age were associated with higher post-intervention scores (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Interestingly, religion was not a significant moderator, supporting the intervention\u0026rsquo;s broad cultural relevance.\u003c/p\u003e\u003cp\u003eOur results are congruent with the prior literature, where knowledge enhancement is a fundamental precursor to attitude and behavior changes related to donation [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. McEachan et al., (2011) stated that the medium effect sizes for attitudes and subjective norms parallel meta-analytic studies that emphasize the importance of these constructs [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Furthermore, the relatively elevated effect sizes observed may reflect the intervention\u0026rsquo;s bilingual and culturally tailored nature, aligning with recommendations that context-specific adaptation fosters greater engagement and efficacy [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSniehotta et al. (2014) found that TPB works well across different cultures, and that improving knowledge, attitudes, social norms, and perceived control at the same time can clearly boost people\u0026rsquo;s intentions to change their behaviour [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Similarly, in the present study, we found that the TPB-based intervention significantly improved attitudes and behaviors toward body donation, supporting the findings of Sniehotta et al. From an applied perspective, the results suggest scalable strategies for mitigating global shortages in body donation, which are essential for medical education and research progress [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Policymakers and educators should consider integrating theory-based, culturally sensitive interventions into outreach and recruitment programs, potentially harnessing digital platforms to broaden their impact.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\u003ch2\u003e6.4 Strength, limitation and future directions\u003c/h2\u003e\u003cp\u003eThe theory-driven, culturally adapted design based on TPB is one of the strengths of this study, as is the use of a validated bilingual questionnaire and inclusion of a socio-demographically diverse community sample, which improved the relevance of being situated in context and the possibility of performing subgroup analyses. The use of robust statistical methods, such as effect size estimation and multivariate regression, also increased the validity and interpretability of the results.\u003c/p\u003e\u003cp\u003eConvenience sampling and quasi-experimental design were used in the present study as they allowed for the timely recruitment of a varied sample typical of the target community. The absence of a control arm does not allow for the definite attribution of any change observed exclusively to the intervention implemented. Although self-report measures are suitable for evaluating psychosocial constructs, they may be influenced by a social desirability bias. Further research using randomised controlled designs with a longer follow-up period is needed to obtain less subjective and more objective data on actual donor registrations and sustained behaviour change. With the increase in culturally tailored interventions using Internet-based approaches, greater scalability can be achieved by expanding through a digital platform to reach diverse populations.\u003c/p\u003e\u003c/div\u003e"},{"header":"7. Conclusion","content":"\u003cp\u003eThis quasi-experimental study demonstrates that a culturally sensitive educational intervention based on the Theory of Planned Behavior considerably improves the psychosocial determinants of knowledge, attitudes, subjective norms, perceived behavioral control, and consequently has a positive impact on the behavioral intentions of body donation among Indian adults. The intervention explained more than half of the variance in intention, emphasizing the relevance of these constructs for donation promotion. Subgroup analysis indicated a stronger effect among males, urban populations, older individuals, and those with higher education or awareness, indicating the need for customization. These findings have implications for public health and medical education and support an evidence-based, culturally adapted model for overcoming the chronic cadaver shortage that stifles clinical training and research. Operationally, the study recommends implementing such multi-component educational interventions as a health policy and societal intervention to enhance body donation rates sustainably.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eThe study was approved and conducted with the Ethical Standards of Symbiosis International Deemed University, Ref. SIU/IEC/966. Written informed consent was obtained from all participants after providing them with clear information regarding the study\u0026apos;s purpose, procedures, and rights. Participation was voluntary, and confidentiality and data privacy were rigorously maintained throughout the research process. The study was conducted in accordance with the Indian Council of Medical Research (ICMR), Declaration of Helsinki and its amendments and the National Ethical Guidelines for Biomedical and Health Research for involving Human Participants (2017).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication :\u0026nbsp;\u003c/strong\u003eAll authors have given their consent for publication of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials :\u0026nbsp;\u003c/strong\u003eThe datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests :\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding :\u0026nbsp;\u003c/strong\u003eNil\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions:\u0026nbsp;\u003c/strong\u003eVK conceived and designed the study, conducted data collection, and drafted the manuscript. MA performed data analysis and contributed to manuscript revision. SS3 assisted with data collection and study design and supervised the project. SS4 assisted with drafting the manuscript and revision. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement :\u0026nbsp;\u003c/strong\u003eI sincerely thank my first Anatomy teacher Dr. Saradha Kathiresan for being a source of inspiration to do research.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGiwa S, Lewis JK, Alvarez L, Langer R, Roth AE, Church GM et al. The promise of organ and tissue preservation to transform medicine. Nat Biotechnol 2017 June 7;35(6):530\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBehera S, Chowdhury RK, Sar M, Mishra SK. Awareness, Knowledge, and Attitude towards Body Donation among Medical and Paramedical Students. Natl J Clin Anat. 2023;12(1):20.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBourguet CC, Whittier WL, Taslitz N. Survey of the educational roles of the faculty of anatomy departments. Clin Anat. 1997;10(4):264\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAgrawal NL, Setiya M, Gour KK. Trends and Applications of Body Donation Program in Mahakaushal Region. Natl J Clin Anat. 2020;9(4):169.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSadhu DA, Meyur DR, Kundu DB, Biswas DS, Chakraborty DS. Trends in body donation for medical education: 10 year retrospective study. Applied Medical Research. 2(8).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAgthong S, Wiwanitkit V. Cadaver donation: a retrospective review at the King Chulalongkorn Memorial Hospital, Bangkok. Southeast Asian J Trop Med Public Health. 2002;33(Suppl 3):166\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMcLaughlin L, Williams L, Noyes J, Al-Haboubi M, Boadu P, Bostock J, et al. Evaluation of the Organ Donation (Deemed Consent) Act, 2019 in England [Internet]. Policy Innovation and Evaluation Research Unit, London School of Hygiene \u0026amp; Tropical Medicine; 2024.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMeiring KO, Gibbon VE, Alblas A. Anatomical human body donation in South Africa: Inconsistencies of informed consent. Annals Anat - Anatomischer Anzeiger. 2024;255:152292.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEhtuish EFA, Baker A. Understanding the Hesitancy: A Study on Reluctance Towards Organ Donation. Arab Board Med J. 2024;25(2):53.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMatshipi MN, De Gama BZ. Influence of religio-cultural beliefs on whole-body donation: A quantitative analysis of a predominantly South African Pedi Community. Annals Anat - Anatomischer Anzeiger. 2024;256:152315.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKoreaMed. Synapse [Internet]. [cited 2025 Aug 14]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://synapse.koreamed.org/articles/1148603\u003c/span\u003e\u003cspan address=\"https://synapse.koreamed.org/articles/1148603\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAjzen I. The theory of planned behavior. Organ Behav Hum Decis Process. 1991;50(2):179\u0026ndash;211.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLatifi M, Pauli J, Dehghani S, Nejad MS. Application of theory of planned behavior on organ donation behavior: A systematic review. Saudi J Kidney Dis Transpl. 2021;32(5):1201\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGhaffari M, Latifi M, Rakhshanderou S, Najafizadeh K, Courtney R, Ramezankhani A. Using the Theory of Planned Behavior Framework for Designing Interventions Related to Organ Donation. Transplantation. 2017;101:S57.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLatifi M, Rakhshanderou S, Najafizadeh K, Rocheleau CA, Ghaffari M. A theory-driven organ donation campaign: a field intervention among university students in Iran. Clin Transpl Res 2024 June 30;38(2):90\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSchirmer J, de Roza B. A. Family, patients, and organ and tissue donation: who decides? Transplant Proc. 2008;40(4):1037\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eStevens LM, Lynm C, Glass RM. JAMA patient page. Organ donation. JAMA. 2008;299(2):244.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLakens D. Calculating and reporting effect sizes to facilitate cumulative science: a practical primer for t-tests and ANOVAs. Front Psychol. 2013;4:863.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCohen J. (1988). Statistical Power Analysis for the Behavioral Sciences (2nd ed.). Hillsdale, NJ Lawrence Erlbaum Associates, Publishers. - References - Scientific Research Publishing [Internet]. [cited 2025 Aug 10]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.scirp.org/reference/ReferencesPapers?ReferenceID=2041144\u003c/span\u003e\u003cspan address=\"https://www.scirp.org/reference/ReferencesPapers?ReferenceID=2041144\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTesema B, Bogale EK, Wasihun Y, Anagaw TF. Intention to Donate Kidney and Associated Factors Among Students in Bahir Dar University: Application of Theory of Planned Behavior. Int J Gen Med. 2023;16:5363\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLiu PL, Li Q, Zhao X. Organ donation information scanning, seeking, and discussing: Impacts on knowledge, attitudes, and donation intentions. Soc Sci Med. 2025;365:117543.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTaber KS. The Use of Cronbach\u0026rsquo;s Alpha When Developing and Reporting Research Instruments in Science Education. Res Sci Educ. 2018;48(6):1273\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTavakol M, Dennick R. Making sense of Cronbach\u0026rsquo;s alpha. Int J Med Educ. 2011 June;27:2:53\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMcGough JJ, Faraone SV. Estimating the Size of Treatment Effects. Psychiatry (Edgmont). 2009;6(10):21\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eO\u0026rsquo;Carroll RE, Ferguson E, Hayes PC, Shepherd L. Increasing organ donation via anticipated regret (INORDAR): protocol for a randomised controlled trial. BMC Public Health. 2012;12:169.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMcEachan RRC, Conner M, Taylor NJ, Lawton RJ. Prospective prediction of health-related behaviours with the Theory of Planned Behaviour: a meta-analysis. Health Psychology Review. 2011 Sept 1;5(2):97\u0026ndash;144.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBarrera M, Castro FG, Strycker LA, Toobert DJ. Cultural Adaptations of Behavioral Health Interventions: A Progress Report. J Consult Clin Psychol. 2013;81(2):196\u0026ndash;205.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSniehotta FF, Presseau J, Ara\u0026uacute;jo-Soares V. Time to retire the theory of planned behaviour. Health Psychol Rev. 2014;8(1):1\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZdilla MJ, Balta JY. Human body donation and surgical training: a narrative review with global perspectives. Anat Sci Int. 2023;98(1):1\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Body donation, Theory of Planned Behavior, Behavioral intention, Educational intervention, culturally tailored intervention","lastPublishedDoi":"10.21203/rs.3.rs-7408051/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7408051/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e\u003cp\u003eBody donation remains crucial for medical education and research, yet donor shortages persist worldwide, often due to limited awareness and cultural barriers. The Theory of Planned Behavior (TPB) offers a robust framework to understand and influence donation intentions. This study evaluates the efficacy of a culturally sensitive, TPB-based educational intervention aimed at enhancing behavioral determinants related to body donation among adults in India.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e\u003cp\u003eA quasi-experimental pre-post design was employed with 163 adult participants. The multi-component intervention included multimedia educational materials, peer discussions, motivational media, and practical guidance on registration. Participants completed a validated, bilingual TPB questionnaire assessing knowledge, attitudes, subjective norms, perceived behavioral control, and behavioral intentions immediately before and after the intervention. Statistical analyses involved paired-sample t-tests to compare pre- and post-intervention scores, multiple linear regression to identify predictors of behavioral intention, and subgroup analyses examining sociodemographic influences.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e\u003cp\u003ePost-intervention assessments revealed statistically significant improvements across all TPB constructs (all p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Knowledge increased markedly from a mean score of 2.7 to 3.8 (on a 0\u0026ndash;4 scale), corresponding to a large effect size (Cohen\u0026rsquo;s d\u0026thinsp;=\u0026thinsp;1.68). Attitude, subjective norms, and perceived behavioral control all showed medium effect sizes (d\u0026thinsp;=\u0026thinsp;0.65\u0026ndash;0.70). Multiple regression indicated that attitude (β\u0026thinsp;=\u0026thinsp;0.40, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), subjective norms (β\u0026thinsp;=\u0026thinsp;0.32, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), and perceived behavioral control (β\u0026thinsp;=\u0026thinsp;0.26, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) were independent predictors of post-intervention intention, jointly explaining 52% of the variance (R\u0026sup2; = 0.52). Notably, willingness or intention to donate increased to 66% post-intervention, with higher readiness observed among participants with prior knowledge, urban residence, male gender, higher education, and older age.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e\u003cp\u003eThe TPB-based, culturally tailored educational intervention effectively enhanced knowledge and psychosocial determinants of body donation intention among Indian adults. These findings underscore the potential of theory-driven, culturally adapted programs to increase readiness for body donation, offering scalable strategies to address donor shortages in diverse cultural contexts globally.\u003c/p\u003e","manuscriptTitle":"Enhancing Behavioral Intentions Toward Body Donation Through a Theory of Planned Behavior-Based, Culturally Tailored Educational Intervention: A Quasi-Experimental Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-08 10:35:41","doi":"10.21203/rs.3.rs-7408051/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-07T08:40:06+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-26T06:13:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"168482161937985884796397330811226345588","date":"2025-09-20T17:01:11+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-19T12:53:01+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-12T17:50:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"210999711416936088034093248997101181195","date":"2025-09-12T09:49:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"17536231871440784279970379914448849104","date":"2025-09-12T05:44:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"173285636973652662395383545420990845205","date":"2025-08-30T14:22:39+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-28T11:08:13+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-28T11:02:32+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-26T07:57:59+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-25T17:58:23+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-08-25T17:55:32+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3cb5d392-6d34-47db-8963-16cba4aa0ba0","owner":[],"postedDate":"September 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-08T16:03:25+00:00","versionOfRecord":{"articleIdentity":"rs-7408051","link":"https://doi.org/10.1186/s12889-025-25544-5","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2025-12-02 15:58:14","publishedOnDateReadable":"December 2nd, 2025"},"versionCreatedAt":"2025-09-08 10:35:41","video":"","vorDoi":"10.1186/s12889-025-25544-5","vorDoiUrl":"https://doi.org/10.1186/s12889-025-25544-5","workflowStages":[]},"version":"v1","identity":"rs-7408051","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7408051","identity":"rs-7408051","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}