Source and Message Framing Considerations for Recruiting Mature Adults as Organ Donors Through Direct Mail Campaigns

Abstract

Context:

Mature adults represent an important audience segment for organ donation practitioners. Despite their potential impact as organ donors, compared to other age demographics, their registration rates are much lower.

Objective:

The objective of the current campaign was to determine the most effective source and message strategy to promote organ and tissue donation among mature adults.

Methods:

A 2 (states: Illinois and Iowa) by 2 (sources: government agency and organ procurement organization [OPO]) by 3 (taglines: Any age is the right age to share the gift of life, Don’t rule yourself out, and Don’t rule yourself out: Any age is the right age to share the gift of life) between-subjects design was used to test the effectiveness of direct mailings promoting organ donation to mature adults.

Results:

Across both Illinois and Iowa, the results revealed that greater organ donation registration rates emerged following exposure to direct mail authored by a state official such as the Illinois Secretary of State or the Iowa Department of Public Health compared to local OPOs.

Conclusions:

Overall, the findings speak to the effectiveness of direct mail marketing campaign’s ability to register potential organ donors. Moreover, the results reveal that it is more important who sends the message as opposed to what the message states.

Keywords

direct mail campaign message framing organ donation registration mature adults message source

Each year, the number of individuals in the United States on the national waiting list for organ transplant grows. Currently, over 120 000 candidates are awaiting a lifesaving or life-extending organ transplant, and 1 donor can save or extend the lives of up to 25 people.¹ Despite a well-documented need for organ donors and strong public support for organ donation, less than half of American adults are registered organ donors.² Among the demographic groups with low registration rates, none may be more critical than mature adults between the ages of 50 and 64. The current study evaluates a direct mail campaign to promote organ donation among mature adults in Illinois and Iowa.

Mature adults represent a critical demographic in need of targeted efforts to increase their enrollment in state organ donor registries. Mature adults are disproportionately affected by the shortage of transplantable organs in the United States. According to the Organ Procurement and Transplant Network,³ 45% of national transplant waiting list candidates are between the ages of 50 and 64, despite this demographic accounting for only 20% of the US population.⁴ Mature adults are less likely than younger individuals to register as organ donors.² In fact, in 2014, 28% of donors were between the ages of 50 and 64, whereas the same age demographic made up 43% of recipients.³

Mature adults’ lower donor registration rates directly translate to fewer eligible organs available for transplant. As Goldberg et al estimate, if individuals age 50 to 64 gave authorization for organ donation at the same rate as the 18- to 39-year-old age demographic, an additional 409 potential donors—or 850 lifesaving or life-extending organs would be available for transplant each year.⁵ Furthermore, as mortality rates begin to increase around age 50,⁶ mature adults hold promise as one of the largest groups of potential donors. Despite the clearly documented need to increase registration rates among mature adults, limited research has examined strategies for promoting organ donation registration among this age demographic.⁷

One feasible strategy for encouraging donor registration among mature adults may be the use of direct mail campaigns. Direct mail campaigns to promote donor registration are effective at generating new registrants and can be operated on a limited budget. Recent findings by Quick et al demonstrated the utility of direct mailings to promote donor registration to young adults living in Illinois.⁸ Their efforts resulted in nearly 7000 newly registered donors at an average cost per registrant of only US$8.21. In addition, research points to printed materials as an ideal communication mode for targeting individuals of age 50 and above.⁷ Consider Tartaglia et al,⁹ who found that among mature adults who considered themselves to be computer savvy, print sources were identified as their preferred medium for obtaining information regarding organ donation.

Given the promise of direct mail, those responsible for campaign development are further charged with designing optimal message framing strategies appealing to their target audience. One major consideration is message source selection, particularly as individuals in the United States are confronted with a continually growing volume of direct mail, leading to increased competition for limited attention.¹⁰ In situations where individuals are not able or motivated to carefully scrutinize messages,^11,12 they likely rely on a limited number of heuristics to simplify the decision-making process.¹³ Cialdini noted authority as a core cognitive shortcut likely to influence individuals’ behavioral decisions in situations where they are not motivated or do not carefully scrutinize a message.¹⁴ In short, Cialdini argues that authority functions as a heuristic cue, whereby individuals rely on the belief that those with a high social status or position of power demonstrate correct social conduct. Reliance on this heuristic often results in social pressure to comply with requests made by those in positions of authority. To the authors’ knowledge, the current study is the first effort to test the effectiveness of source authority in the context of a direct mail campaign promoting donor registration to mature adults.

The current campaign targeted mature adults in Illinois and Iowa. Within each state, the message source was manipulated by sending campaign mailers addressed from a government office (ie, high authority) or a local organ procurement organization (OPO) (ie, low authority). For instance, in Illinois, mailers were addressed either from the office of the Illinois Secretary of State (SOS) or Gift of Hope (GOH) Organ and Tissue Donor Network. In Iowa, mailers were addressed from the Iowa Department of Public Health (IDPH) or the Iowa Donor Network (IDN). Based on Cialdini’s reasoning, mailers from the SOS and the IDPH were expected to result in increased organ donor registration rates, as compared to mailers from the GOH Organ and Tissue Donor Network and the IDN.¹⁴ The SOS and IDPH are more recognizable authority figures from which individuals have likely received mail in the past (eg, driver registration, voter registration). In contrast, OPOs are likely less well-known nonprofit organizations. Therefore, if mature adults rely on heuristic processing of direct mail messages, higher rates of donor registration should be obtained using an authoritative government official, rather than an OPO, as a message source. In addition to testing source effectiveness, the present study also tests the effectiveness of 3 message taglines used in earlier Health Resources & Services Administration’s (HRSA) Division of Transplantation promotional materials targeting the 50+ age demographic.¹⁵

Method

A 2 (states: Illinois and Iowa) × 2 (sources: government agency and OPO) × 3 (taglines: Any age is the right age to share the gift of life, Don’t rule yourself out, and Don’t rule yourself out: Any age is the right age to share the gift of life) between-subjects design was used to test the effectiveness of direct mailings to promote donation to mature adults. In March 2014, 80 000 mailers were randomly disseminated to 50 to 64-year-old residents living in Cook County (Illinois) and Polk County (Iowa) with a state driver’s license or identification card (ie, Illinois [n = 40 000] and Iowa [n = 40 000]). Mailing lists from both counties were obtained, and residents between the ages of 50 to 64 were randomly assigned to receive 1 of 6 messages. The targeted recipients were reached by using a proportionate random data record selection process, where a fixed number of records were chosen at random out of the entire population. Within Cook County, zip codes with higher percentages of African American and Latino residents were oversampled to receive the mailers. The mail was considered successfully delivered if it was not returned to the OPO as undeliverable. Below, the contents featured in the letters and brochures are presented.

Mailer

Letter

A total of 12 one-page letters were created and randomly disseminated to message recipients. Letters were printed on the official letterhead of the given message source and were addressed to intended recipients by their first name (eg, Dear Shirley). After the greeting, individuals were asked to consider joining their state’s organ and tissue donor registry. The letter then stated that a single donor can extend or improve the lives of up to 25 others and provided information about the number of candidates awaiting transplantation at the state and national levels. Specific information about the magnitude of need for donation among individuals in the 50 to 64 demographic was also presented. Message content noted the number of 50 to 64-year-old individuals who were awaiting transplant at the time of mailing, the number who receive organ transplants each year, and the total registration rate of the demographic within a message recipient’s given state. The letter concluded with 1 of 3 manipulated taglines and asked message recipients to please consider joining their state’s donor registry today. In addition to the letter, each recipient received 1 of 12 brochures that matched the message source and tagline condition to which they had been randomly assigned. Specifically, brochures complemented the tandem letter with respect to the state, source, and tagline. Each of the 12 message conditions was assigned a 4-digit code that was recorded upon entry of returned/completed registration forms.

Brochure

Organ donor brochure

The front cover of each brochure featured 3 photos: (1) an African American woman giving a teddy bear to a young girl, (2) a Caucasian man teaching a young boy how to ride a bicycle, and (3) a Latino family surrounding a soldier. Above this collage of photos, a caption read, “You give to your family, your community, your country.” Underneath the photos, the brochure read, “Now give the gift of life. Register to be an organ & tissue donor.” On the inside of the brochure, facts about organ donation pertaining to the lives saved due to organ donation, the organ shortage, ease of registration, and the lack of costs incurred by a donor and his/her family in association with donation were presented. As prior research supports the effectiveness of promoting organ donation by presenting various aspects of organ donation, each brochure included narratives featuring mature adult donors, recipients, and transplant candidates.^8,16 In addition, as current research documents health concerns as a particularly salient barrier that prevents mature adults from registering,^7,17,18 a quote from Dr. Juan Carlos Caicedo addressing this barrier was presented underneath the campaign tagline. Dr. Caicedo’s quote read, “Organ donors come from all walks of life. People of any age, religion, race—even with a variety of health conditions—can provide the gift of life through organ and tissue donation.”

On the back cover, individuals were given instructions on how to register by filling out the tear-off registration form and sending it back in the enclosed postage-paid envelope. Moreover, each brochure directed message recipients to the corresponding website of the message source to which they had been assigned such that they could obtain additional information about organ and tissue donation. Each brochure also contained the corresponding state agency or OPO logo. In short, brochures contained the same photographs, were visually identical in color and layout, and used approximately the same word count; brochures differed only by the message source, state, and campaign tagline.

Results

With variation in the number of mailers successfully delivered to mature adults per condition, z-tests for 2 proportions were computed to detect registration differences across experimental conditions. Overall, the campaign yielded 1817 organ donor registrations. In Illinois, the SOS mailer (n = 529, 2.65%) resulted in significantly more registrations than the GOH Organ and Tissue Donor Network mailer (n = 148, 0.74%, z = 14.80, P < .001, 95% confidence interval [CI]: 0.0161-0.0221). In fact, across each of the 3 taglines, the Illinois SOS mailer yielded a higher registration rate than the GOH Organ and Tissue Donor Network mailer: (i) Any age is the right age to share the gift of life (GOH Organ and Tissue Donor Network = 0.92%, SOS = 2.44%, z = 6.80, P < .001, 95% CI: 0.010-0.020), (ii) Don’t rule yourself out (GOH Organ and Tissue Donor Network = 0.60%, SOS = 2.78%, z = 9.80, P < .001, 95% CI: 0.016-0.028), and (iii) Don’t rule yourself out: Any age is the right age to share the gift of life (GOH Organ and Tissue Donor Network = 0.71%, SOS = 2.74%, z = 9.0, P < .001, 95% CI: 0.015-0.025). With respect to tagline differences, among GOH Organ and Tissue Donor Network mailers, the tagline, Any age is the right age to share the gift of life (0.92%) resulted in a higher registration rate than Don’t rule yourself out (0.60%), z = 2.70, P < .01, 95% CI: 0.000 to 0.006. No other tagline differences emerged.

Similarly, in Iowa, the IDPH mailer (n = 642, 3.22%) was more effective than the IDN mailer (n = 498, 2.50%), z = 4.30, P < .0001, 95% CI: 0.003 to 0.012. Across two-thirds of the taglines, the IDPH mailer yielded a higher registration rate than the IDN mailer: (i) Any age is the right age to share the gift of life (IDN = 2.44%, IDPH = 3.29%, z = 2.90, P < .05, 95% CI: 0.001-0.016) and (ii) Don’t rule yourself out (IDN = 2.42%, IDPH = 3.34%, z = 3.20, P < .01, 95% CI: 0.002-0.017). No source differences were observed for the tagline, Don’t rule yourself out: Any age is the right age to share the gift of life (IDN = 2.63%, IDPH = 3.02%, z = 1.40, P = not significant). No other tagline differences emerged.

With respect to differences among Illinois and Iowa residents’ organ donation registration rates, the IDN-authored mailers resulted in significantly higher registration rates than the GOH Organ and Tissue Donor Network mailers (z = 13.90, P < .001, 95% CI: 0.015-0.02). Similarly, across state agencies, mailers from the IDPH garnered more registrations than the mail from the Illinois SOS (z = 3.40, P < .01, 95% CI: 0.002-0.009). In all, Iowa residents were more receptive to this direct mail campaign than Illinois residents across mail authored by OPOs and state agencies.

Discussion

As the need for more registered organ donors continues to escalate in the United States, identifying important audience segments to target with strategic promotional messages is paramount. Mature adults present an important target audience for organ donation practitioners due to their demand for organ transplantation paired with their comparatively low rates of donor registration.¹ Recognizing the need for easy-to-implement, effective, low-cost, empirically-based campaigns to educate mature adults about donation, the current study aimed to distill effective strategies for campaigning by identifying the message source and content selection that could be adopted by donation practitioners seeking to work with this audience segment in the future.

The current study highlights the importance of source selection in developing direct mail campaigns to promote donor registration. Specifically, in both Illinois and Iowa, mature adults receiving a mailer from a state government organization (eg, SOS, IDPH) registered as organ donors at higher rates than those receiving a mailer from a local OPO. One explanation for this pattern of findings is that individuals are simply more likely to open mailers addressed from the Illinois SOS and the IDPH than mail addressed from a state’s respective OPO. Receiving mail from a state government organization likely led individuals to perceive the contents as important, perhaps activating the authority heuristic.¹⁴ That is, it is likely that message recipients may have perceived mail addressed from a government source as a bill or an important notification regarding their ability to operate a motor vehicle, as both the Illinois SOS and IDPH address these issues in Illinois and Iowa, respectively. For this reason, it is possible that mailers addressed from the Illinois SOS and IDPH piqued message recipients’ attention, resulting in a greater likelihood of opening and reading the mailer, and subsequently enhanced donor registration rates.

In this vein, message recipients’ reliance on the authority heuristic may have alternatively served to directly influence their willingness to comply with the direct mailing request. Specifically, individuals may be accustomed to complying with mailed requests from government agencies (eg, returning motor vehicle registration forms). As heuristic cues are mostly influential under conditions with low levels of message processing such as deciding which envelope to open daily,^11,12 the use of an authoritative message source may have activated participants’ semi-habitual response of complying to government mailings, thus enhancing likelihood of returning the donor registration form.

A second explanation for study findings may be the source of the mailer actually enhanced individuals’ message processing. Research has shown that when a message uses a credible source in conjunction with strong arguments, having individuals think more carefully about such arguments can engender greater persuasion.¹⁹ Given that public opinion polls show strong support for organ donation,² it is possible that many individuals found the arguments presented in the mailing to be persuasive. Specifically, the source of the message may have interacted with the arguments presented, and thus, mailers were scrutinized more carefully and subsequently deemed more persuasive when addressed from the Illinois SOS and IDPH than from the OPOs. These explanations for study findings may not be mutually exclusive, and some combination may have led to results presented herein.

Although the specific manner message recipients use to process donor education materials could not be conclusively identified through the current project, the study does point to the promise of using heuristic cues in donor education materials. Future research should test to see whether specific heuristics are more influential than others in garnering organ donation registrations. For example, practitioners interested in this approach might rely on consistency, reciprocity, and social proof appeals in their promotional efforts. For instance, a social proof appeal could read, “More than 90% of residents support organ donation. Join others by registering today to become an organ donor.” An appeal to reciprocity may ask recipients, “If you would be willing to receive an organ from an organ donor, then why not register as a donor today?” Determining the effectiveness of these heuristic appeals could offer additional guidance to shape organ donation promotional efforts.

Despite a clear advantage of governmental sources as opposed to OPOs, no campaign tagline was consistently more effective than the others in the current study. Current campaign taglines were adopted from HRSA’s Division of Transplantation’s recently launched campaign to reach mature adults with information about donation.¹⁵ Current findings showed no advantage among these taglines. Rather, results suggest that it is more important who sends the message as opposed to what the message states. The mailers disseminated in the current campaign were packed with information, and thus, it is entirely possible that tagline differences went unnoticed.

The differences in campaign effectiveness obtained between Illinois and Iowa also warrant further comment. Specifically, mailers authored by Iowa’s government source outperformed those authored by Illinois’ government source, with mailers from state OPOs following the same pattern of findings. The researchers purposefully disseminated mailers to neighborhoods with a higher concentration of African American and Latino residents due to lower registration rates among these demographic groups. Despite such efforts, overall demographics of Illinois and Iowa differ. The US Census data indicate that 77% of Illinois residents report their racial background as white/Caucasian, with a corresponding figure of 92.1% in Iowa.⁴ In addition, 55% of Illinois residents have already registered as organ donors, whereas 72% of Iowa residents have signed their state’s donor registry.²⁰ Thus, both demographics of population served and social norms pertaining to donor registration may have enhanced campaign effectiveness in Iowa.

Although government sources were found to be more effective than OPO-authored mailings in both states, it is interesting to note this effect was larger in Illinois. Specifically, a larger effect size (d = 0.71) characterizes the difference in donor registrations obtained from government- versus OPO-authored mailings in Illinois, as opposed to Iowa (d = 0.15). While any donation practitioner may do well to partner with a government source in crafting donor education messages, it may particularly behoove OPOs working in more difficult-to-reach communities to do so. Future replications of direct mail campaigns in varied communities may help to demonstrate when investment in a partnership with a government (or other authoritative source) may be most impactful.

This study has several limitations. First, the study design limits the ability to ascertain the causal mechanisms underlying the effectiveness of state agencies in facilitating mature adults’ decision to register as organ donors. Research using a laboratory setting should examine cognitive and affective responses to mailers to uncover why mail authored by authoritative sources resulted in more registrations among this age demographic. Second, the current study is unable to report on the mailers’ effectiveness in registering mature adults from various racial backgrounds. Organ donation registration data in Illinois and Iowa do not indicate registrants’ racial demographics. As a result, the campaign’s effectiveness in registering African American and Latino mature adults is uncertain. With this limitation in mind, Cook County, Illinois, which boasts a large African American and Latino population, was blanketed with mailers in the current project, which suggests that the campaign was successful in reaching these underserved populations.

Third, the generalizability of findings of the current study is limited given its sample size. Replication studies using similar marketing strategies (eg, source and message manipulation) would add confidence to campaign findings reported herein. Finally, the current study is limited by its reliance on print messages containing both words and photographs. Given that message design was consistent across mailer conditions, the persuasiveness of words vis-à-vis photographs could not be deciphered. Although each of these limitations hinders ability to discover the underlying processes that facilitated direct mail campaign effectiveness, future research ideas to address these shortcomings abound.

To treat the growing number of individuals awaiting organ transplant in the United States, it is imperative to successfully reach mature adults with promotional messages about donation. Currently, mature adults represent nearly half of all recipients and those on a waiting list, yet they account for approximately one-quarter of all organ donors.¹⁵ The present study represents a promotional strategy requiring a limited budget. Consistent with previous studies relying on the use of direct mail with a much younger target audience,⁸ the current project supports the use of this campaign tactic with a more mature age demographic.

Footnotes

Declaration of Conflicting Interests

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

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by grant) (D71HS24203) from the Health Resources and Services Administration’s Division of Transplantation (HRSA/DoT), U.S. Department of Health and Human Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the views of HRSA/DoT.

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U.S. and world population clock. U.S. Census Bureau. Web site. http://www.census.gov/popclock/. Accessed November 11, 2015.

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