Talking about death to save lives: psychosocial antecedents of organ donation discussion intentions

Purpose Family refusal after brain death remains the primary barrier to increasing organ and tissue donation in Brazil, despite the country hosting the world’s largest public transplant program. This study aims to examine psychosocial factors influencing intention to discuss organ donation with family, a key predictor of consent. Using the theory of planned behavior (TPB) and integrating anticipated guilt, collectivism and media exposure, it explores culturally embedded drivers and barriers to family dialogue, with implications for social marketing and Sustainable Development Goal 3 (SDG 3). Design/methodology/approach A nationwide online survey (n = 414) measured TPB constructs, such as value-expressive attitude, ego-defensive attitude, subjective norms, self-efficacy, anticipated guilt, collectivism and media exposure. Data were analyzed using structural equation modeling to test the direct, indirect and moderating effects of gender, knowledge and sociodemographic variables. Findings Self-efficacy and anticipated guilt were strongly associated with discussion intention, whereas ego-defensive attitudes were negatively associated with it. Collectivism and media exposure were indirectly associated with discussion intention through higher self-efficacy, lower ego-defensive attitudes and stronger supportive beliefs. Value-expressive attitudes and subjective norms did not have a direct effect. Gender and knowledge moderated several relationships. Practical implications Social marketing campaigns should prioritize boosting self-efficacy, reducing emotional resistance and building trust in the health-care system. Family-centered appeals leveraging collectivist values can enhance cooperation. Targeted media use can address misinformation and strengthen supportive beliefs by tailoring messages to gender and knowledge level. Social implications By fostering family dialogue, interventions may help reduce Brazil’s high refusal rate, improve equity in transplantation and advance SDG 3. Clear, culturally sensitive communication may promote solidarity, informed decision-making and public trust. Originality/value To the best of the authors’ knowledge, this is the first Brazilian study to use an extended TPB to analyze discussion intentions, distinguishing between value-expressive and ego-defensive attitudes and revealing indirect pathways linking collectivism, media and anticipated guilt to discussion intention. Findings offer novel insights for targeted, culturally aligned social marketing strategies.