Promoting the Michigan Organ Donor Registry: Evaluating the Impact of a Multifaceted Intervention Utilizing Media Priming and Communication Design

Transcription

1 Health Communication, 25: , 2010 Copyright Taylor & Francis Group, LLC ISSN: print / online DOI: / Promoting the Michigan Organ Donor Registry: Evaluating the Impact of a Multifaceted Intervention Utilizing Media Priming and Communication Design Tyler R. Harrison, Susan E. Morgan, and Andy J. King Department of Communication Purdue University Mark J. Di Corcia School of Medicine Indiana University Elizabeth A. Williams, Rebecca K. Ivic, and Paula Hopeck Department of Communication Purdue University There are currently more than 100,000 individuals waiting for an organ transplant. Organ donor registries represent the easiest and most concrete way for people to declare their intent to donate, but organ donor registries are vastly underutilized. This study reports a campaign intervention designed to increase the rate of joining the Michigan Organ Donor Registry. Grounding intervention development in the theoretical principles of media priming and communication design, the intervention took place in two waves in three counties in Michigan. Each intervention consisted of a media component, point-of-decision materials, and an interpersonal component. Increases in registration rates of 200 to 300% in each intervention county, compared to stable statewide trends in registry rates, provide evidence of highly successful intervention efforts. The rate of registry increase in intervention counties was approximately 1,900% higher than statewide on a per capita basis. Even though almost 28,000 organ transplants were performed in each of the last five years, there are more than 100,000 people currently waiting for a transplant in the United States (United Network for Organ Sharing [UNOS], 2009). In 2008, 5,609 people died waiting for an organ transplant, bringing the total number of deaths since 1995 to more than 89,000 (Organ Procurement and Transplantation Network [OPTN], 2009). Increasing the number of individuals on organ donor registries is one way to lower the mortality rate of those waiting for a transplant. However, only 35% of the United States population has joined a registry even though Americans overwhelmingly (95%) have Correspondence should be addressed to Tyler R. Harrison, Department of Communication, Purdue University, Beering Hall, Room 2114, 100 N. University St., West Lafayette, IN tharrison@purdue.edu favorable views toward organ donation (Fleming, 2008; Gallup Organization, 2005). The discrepancy between those with favorable views and those on the registry results in the loss of thousands of lives every year. Research has identified lack of accurate knowledge (Morgan & Miller, 2002; Morgan, Miller, & Arasaratnam, 2002; Weber, Martin, Comm, & Corrigan, 2006) and other noncognitive factors such as the ick factor (Morgan, Stephenson, Harrison, Afifi, & Long, 2008) as potential causes for the discrepancy. Thus, many organ donation campaigns focus on overcoming barriers and objections to organ donation to persuade the 60% of the generally favorable public who have not yet put their name on an organ donor registry. Department of Motor Vehicles (DMV)-based registries are believed to be the most efficient way of increasing the number of registered individuals (Lewin Group, 2002).

2 PROMOTING ORGAN DONATION IN MICHIGAN 701 DMV-based registries have the potential to sign up thousands of people, every day, across the country. Traditional media campaigns, interventions, and educational programs promoting organ donation would be lucky to have a fraction of that reach over the course of any initiative. One complication of promoting organ donation in DMV offices is the role of the clerks, as they are central to interactions with DMV customers. Training clerks to engage in conversations significantly increases registry signups (Harrison, Morgan, & Di Corcia, 2008), but such trainings are not always feasible because the state does not encourage clerks to ask customers about their wishes to donate. Not encouraging clerks to ask customers about joining the registry presents a potential structural barrier that warrants consideration when campaigning in DMV offices. Kent County has a population of almost 600,000 people, 9% African American (U.S. Census Bureau, 2009a), and five SOS branch offices. Saginaw (population 206,300; U.S. Census Bureau, 2009b) and Genesee (population 441,966; U.S. Census Bureau, 2009c) Counties are smaller, and were selected to receive the intervention in tandem. The first phase of the intervention took place in Kent County, and the second phase took place in Saginaw and Genesee counties. For each county, the intervention included multiple components, combining a mass media campaign, on-site events, point-of-decision (POD) materials, and community outreach events. Components were theoretically grounded in the principles of media priming (e.g., Cappella, Fishbein, Hornik, Ahern, & Sayeed, 2000) and communication design (e.g., Aakhus, 2007; Harrison & Morrill, 2004). ORGAN DONATION IN THE STATE OF MICHIGAN The Michigan Secretary of State policy to not require clerks to ask customers about joining the registry could be one explanation for why Michigan had the fifth lowest rate of joining the registry in 2006, despite being the eighth most populous state in the country (Michigan Office of the Secretary of State, 2007). Only about 11% of the population has joined the registry in Michigan compared to the national average of 35% (Fleming, 2008; Michigan Office of the Secretary of State, 2007). Given Michigan s large transplant waiting list and long wait times for those transplants, there is an urgent need to put forth efficacious strategies to address structural barriers that prevent growth of the number of registered potential donors statewide. The discrepancy between Michigan s signup rates and the national average represents a population that might be classified as passive positives. These individuals should be easily persuaded to become registered donors, but thus far have not because organ donation is not something they consider when conducting business at the DMV, or because they are unaware they need to be proactive in telling the clerk they wish to join the registry. Passive positives are the easiest population to persuade to join the registry, but the current study aimed to also persuade individuals who may avoid joining the registry because of one or two inaccurate beliefs about organ donation. BACKGROUND ON THE CURRENT PROJECT The intervention focused on Secretary of State (SOS) branch offices, the DMV equivalent in Michigan, in three counties in 2008: Kent, Saginaw, and Genesee. While the counties are not the most populous in the state, they were selected because of their similarity in demographics, size, average reach of SOS branch offices, and rates of registration, providing control and matching for analysis purposes. THEORETICAL BACKGROUND The campaign is described in greater detail in the methods section, but a brief summation assists in explicating the theoretical foundations of the study. The campaign consisted of a mass media component (billboards and radio), POD materials (found in branch offices of the SOS), and an interpersonal component (volunteers staffing SOS branch offices and interacting with customers). To reach the primary target audience of passive positives, concepts of media priming and communication design were used in the development and placement of mass media and POD campaign materials. Media Priming Media priming is the process of making a belief salient and accessible in individuals minds through some message, so the association between the belief and the desired behavioral outcome is stronger (Cappella et al., 2000; Domke, Shah, & Wackman, 1998; Fishbein & Yzer, 2003; Mendelsohn, 1996). Media priming does not aim to change a belief or attitude, but rather to stimulate and increase the positive (or negative) association between a belief and a behavior. In the case of organ donation, priming functions to activate cognitions about organ donation and the importance of signing up on a registry. While the effects of priming can have both undesired and unintentional outcomes (Fishbein & Yzer, 2003; Yzer, Cappella, Fishbein, Hornik, & Ahern, 2003), this should not pose problems to the current study as a strong majority of the general population holds favorable attitudes. Communication Design Communication design is a theoretical perspective not often used in health campaigns, but theorists have suggested its utility (Aakhus, 2007). Communication design is mostly concerned with changing the nature of communicative interactions and creating opportunities for communication

3 702 HARRISON ET AL. that might not otherwise exist. In the case of the current intervention, the goal was to create materials that afforded SOS branch office customers an opportunity to express their desire to join the organ donor registry. This follows the general goal of communication design, which is to allow communication where it was once difficult (Aakhus, 2007). This perspective takes into consideration both the physical structure (Harrison et al., in press) and the protocol structure (Harrison & Morrill, 2004; Jackson, 1998) of the SOS offices, informing the placement and type of POD materials used for the intervention. Communication design necessitates consideration of how to create, en masse, a period of time within the existing clerk customer interaction that could facilitate individuals indicating their desire to join the registry. Given these theoretical principles, and extant research on interventions promoting organ donation, three phases constitute each intervention wave. This phased structure allows for the evaluation of incremental contributions of various campaign elements. The first phase combines mass media with POD materials: H1: Over two months, the mass media campaign and POD materials will result in an increased number of individuals signing up on the organ donor registry compared with baseline data from the previous year and compared to control sites. While campaign messages are designed to prime cognitions for action, it is still relatively easy to ignore mediabased appeals. Phase two adds an interpersonal component to the intervention: H2: The addition of an on-site component featuring interpersonal interaction with persons touched by organ donation will result in an increase in registration rates greater than mass media and point-of-decision materials alone. Finally, the third phase involves the cessation of the mass media campaign and the interpersonal intervention. POD materials are left in SOS offices on an ongoing basis: H3: The ongoing use of POD materials will result in a gradual decrease in rates of registration to a level that is higher than baseline rates, but lower than when the media and interpersonal campaign components were included in the intervention. DESCRIPTION OF THE INTERVENTION AND METHODS The study timeline consisted of a mass media campaign and POD materials for the first two months; continued media campaign, POD materials, and volunteer-staffed on-site events for the third and fourth months; and then POD materials only for the following months. Community outreach events occurred at normal levels throughout the state, which provided no noticeable changes overall at the state level. Passive positives were the targeted audience for media and POD materials, and the on-site events attempted to persuade both passive positives and individuals favorable to organ donation but still reluctant to join the registry. Mass Media Campaign Component Media channels were selected independently in each county, and media buys focused on maximizing frequency and reach. The target audience for the media messages focused prominently on outlets most popular with females, as women are central to family discussions about organ donation (Dodd-McCue, Tartaglia, & Cowherd, 2007), and some evidence suggests women are more influential to organ donation decision making (Thompson, Robinson, & Kenny, 2003). The media buys took place so that the mass media had reach to approximately 70% of women in each intervention county, with an estimated 16 exposures per individual. All counties received radio ads, as well as billboards on local freeways and roads approaching the branch office. Billboards were selected within one-half mile of branches and placed for motorists to see them as they approached the branch offices from the most heavily trafficked roads. Radio ads were stock public service announcements, used necessarily as a condition of the project funding. Ads did have campaign-specific taglines, read by the Michigan Secretary of State, including the phrases Show Us Your Heart, and Tell Us Now, the two messages of the campaign that appeared individually or together on all materials and advertisements. 1 Show Us Your Heart is the phrasing used in previous campaigns by Gift of Life Michigan, the study s community partner, and was used because of the familiarity to the public. Tell Us Now emphasizes that those individuals who want to be donors need to ask to be added to the registry because the clerks would not ask customers. Billboards were created specifically for each intervention county. To emphasize a sense of shared community, as well as the idea that organ donation is something affecting people in Michigan, billboards featured pictures of individuals from the intervention counties, named their hometown, and explained how they had been touched by organ donation. Campaign materials featured stories of individuals on the waiting list, transplant recipients, and donor family members. Messages included statements such as Someone like you saved Charlie s life. Tell us now. Be an organ donor, or 1 The campaign also promoted the website which referred site visitors to the Michigan Secretary of State online organ donor registry sign up webpage. Michigan residents can sign up to join the registry online, but these findings are not discussed separately from the total number of registries in this paper as there were only minimal increases in web registrations between 2007 (baseline) and 2008 (intervention year).

4 Stephanie is one of over 3,100 people in Michigan waiting for an organ. Tell us now. Be an organ donor. It is important to note that the waiting list messages were directed at promoting donation in general, and were not specific to one particular person touched by organ donation. Priming was the goal of all mass media materials. The media campaign functioned to enhance the POD and interpersonal elements of the campaign. While this does not allow specific claims about how the larger media campaign works in and of itself, it does allow data to demonstrate the additive effect of media campaigns along with other components. Point-of-Decision (POD) Materials Component Communication design helped us assess the physical layout of each Secretary of State (SOS) branch office and the protocol individuals engage in during transactions at those branch offices and influenced the creation of campaign POD materials. These materials included footprint stickers placed on the floors of every branch office, beginning at the entry and leading all the way up to the front of the line. These stickers, which featured statistics about organ donation in Michigan and the Tell Us Now cue to action, served as another source of priming. Posters were a second type of POD materials used in the campaign. Posters, like the billboards, featured stories of individuals touched by organ donation, and were placed in all intervention county branch offices. These posters intended to promote the importance of Michigan residents signing up to be donors, and to demonstrate that Michigan residents were the likely benefactors of the decision to donate. Posters in Kent County featured engaging narratives telling the story of each individual featured in intervention materials, while posters in Saginaw and Genesee had less narrative content but still focused on implying the community need for people to join the organ donor registry. 2 Utilizing the narratives of people touched by organ donation has been successful in other interventions (Harrison, Morgan, & Di Corcia, 2008; Morgan, Harrison, Chewning, Di Corcia, & Davis, 2010), and a key component to previous success of said narratives is featuring local individuals. As mentioned, Michigan residents and their connection to organ donation were used explicitly on all intervention materials. A third strategy used was clerk cards. Clerk cards were oversized postcards that were available at the check-in counter and at kiosks where customers regularly fill out forms and pick up other information. Priming messages were presented on the cards with explicit action instructions to give the card to the clerk if they wanted to add their name to the organ donor registry. Each card also included a community-based appeal, which featured a picture of an 2 Campaign materials are too numerous to include in this article. These materials are available from the first author. PROMOTING ORGAN DONATION IN MICHIGAN 703 individual from the posters who had been touched by organ donation, along with a brief caption about their story and background. Those cards were intended to offer a more passive outlet for customers wanting to put their name on the registry. Branch managers informed clerks that anyone handing a card over the counter should confirm that that individual wanted to be on the registry, and then follow protocol as required to add their name. The use of the clerk cards evolved from the intervention s use of communication design. As there was no way to engage with every DMV customer throughout the intervention period to encourage them to become an organ donor, providing a card that created the nonverbal opportunity to engage in a brief interaction about joining the registry allowed for an otherwise difficult interaction to become possible. Finally, counter cards that were adhered to the station of each clerk contained a simple message of Tell me now that you want to be an organ donor, as well as an image of a driver s license with a donor heart sticker highlighted. These cards were placed on counter tops at every clerk station, so that all individuals engaging in transactions with the clerk were exposed to the message. Similar to the clerk cards, these counter cards provided individuals an opportunity to interact with the clerks about organ donation, and were influenced by communication design. The counter card provided another easy solution that created an opportunity for customers to engage in an interaction about clerks about joining the registry. On-Site Events On-site events took place in the third and fourth months of the intervention cycle. For Kent County, on-site events took place in May and June 2008, and in Saginaw/Genesee the events took place in August and September Volunteers were recruited to staff these events by the community partner and trained during a weekend session by members of the research team. Similar trainings had been successfully utilized by the research team on several other projects (Harrison, Morgan, & Di Corcia, 2008; Morgan et al., 2010). Volunteers were trained to maximize the likelihood of constructive interactions with individuals, focus on correction of false information or beliefs about organ donation, work toward changing attitudes of those not in favor of signing up for the registry when on-site at a branch office, and remember to be respectful to individuals not wanting to discuss the topic or sign up on the registry. By training volunteers with a program grounded in theory and utilized in previous interventions, the on-site events were standardized with the goal of maximizing intervention fidelity. Interpersonal interactions with volunteers work to establish and reinforce the idea that organ donation is a topic affecting the local population, putting a face on a cause for customers who might otherwise distance themselves from the topic of organ donation. Helping establish that organ donation touches many lives and making the issue salient to

5 704 HARRISON ET AL. customers assists in lessening potential barriers to individuals declaring their intent to be an organ donor. Volunteers staffed on-site events on the two busiest days every week of the specified intervention period. These efforts required 30 to 40 volunteers per intervention area, and volunteers staffed approximately 70% of the scheduled events. Generally, the events consisted of two or more volunteers per branch office standing by a table with promotional and intervention materials. Volunteers attempted to engage willing SOS customers in conversation about organ donation, and to encourage them to put their name on the Michigan registry if they had not already done so. Data As noted earlier, data for this evaluation come from the office of the Michigan Secretary of State, representing census data for all individuals who join the organ donor registry. Data are presented as number of new registries per branch office, county, or as a statewide count. While it would be ideal to obtain data on the number of registrations per number of transactions, individuals may engage in multiple transactions per visit (license, vehicle registration, voter registration, etc.), so that number lacks analytic meaning. Data are available from January 2007, when Michigan s new registry was implemented. This provides baseline data as well as statewide data for comparison to the intervention time frame and counties. RESULTS Overall, the campaign was successful and accounted for an increase of over 14,672 new registrants on the organ donor registry, compared to baseline data from the previous year. Over the same time period, the rest of the state combined experienced an increase of only 6,600 new registrants. When taking into account the population base of the intervention counties versus the rest of the state, the increase in new organ donor registries in intervention counties was approximately 1,900% higher than increases per capita statewide. 3 Hypothesis one predicted that a mass media campaign coupled with point-of-decision materials would result in an increase in the number of individuals signed up on the organ donor registry. Hypothesis one was supported. While Kent County represents only one of Michigan s 83 counties and accounts for only 6% of the state population, the increase in the number of people who joined the organ donor registry accounted for approximately 55% of the increase in the entire state (see Figure 1 for percentage of total registry increases accounted for by the intervention county). 3 This was calculated by taking the total number of registrations by the average population base of intervention and statewide counties, and by dividing the number of registrations per capita for intervention counties by the number of registrations per capita statewide. Additionally, the registrations in Kent County increased approximately 200% compared to the prior year s baseline data (see Figure 2 for registration rates for intervention counties). A similar pattern is present in Saginaw and Genesee counties, which also account for about 6.5% of the state population. For the months of June and July, when media and point-of-decision only materials were implemented, the average rates of registration increased more than 200% (see Figure 2) compared to baseline data. When these figures are compared to the numbers of registrations statewide, the state clearly experienced stable and similar trends from 2007 to 2008 (see Figure 3 for statewide data not including the intervention counties), while the intervention counties demonstrate significant changes from the previous year s baseline data (see Figure 2). 4 Hypothesis two predicted that adding on-site events staffed by volunteers who have been touched by organ donation to the media and point-of-decision campaign would result in even greater rates of joining the organ donor registry than predicted in the first hypothesis. Hypothesis two was fully supported. While the month of April demonstrates higher numbers of registrations overall compared to the month of June, the percentage increase from baseline data is lower. Kent County saw an increase of about 300% in May and June when volunteers were on-site (see Figure 2). The increased registration rates in Kent County during these months accounted for over 70% of all increases in registration rates statewide. Additionally, Genesee and Saginaw counties saw an increase of more than 380% for the months (August and September) when on-site volunteers were added to the campaign (see Figure 2). Hypothesis three predicted that the cessation of the media campaign and on-site events, with the ongoing use of POD materials, would result in a gradual decrease in rates of registration to a level higher than baseline, but lower than either the full intervention or the media/pod combination. Hypothesis three was supported (see Figure 2). Kent County saw decreases in registrations that slowly tapered off compared to both the media/pod combination and full intervention. While the more intensive campaign interventions ended in June for Kent County, registration rates did not drop below the levels of the first month of the media and point-of-decision intervention (March) until five months after the media component of the intervention ended (November). The rates of registration from July through December all represent rates much higher than baseline data, with the lowest month still representing approximately a 200% increase over baseline. The pattern for Saginaw and 4 The spike occurring statewide for the month of April is due to April being Donate Life Month, during which Michigan has an ongoing event where they place volunteers in every branch office in the state for one day. That event, along with additional media coverage about organ donation during the month, accounts for the spike in registration rates. Still, the rate of increase in Kent County where the intervention was occurring simultaneously was much higher than statewide increases.

6 PROMOTING ORGAN DONATION IN MICHIGAN % 90% 80% Percentage of Total Registry Increase 70% 60% 50% 40% 30% 20% 10% Positive Statewide Change Not Accounted for by Intervention Positive Change in Kent, Saginaw, and Genesee Counties (during intervention period) 0% March April May June July August September October November December ,980 1, ,071 1,725 1,592 1,579 2,294 2,144 1, FIGURE 1 Percentage of total registry increases. The intervention ran in Kent County from March through June, and in Saginaw and Genesee Counties from June through September, with POD materials remaining in each county through December. The black part of the bar is the percentage of positive change for Kent County only from March through June, and then a combination of the positive change in both counties through December. In November and December there was a drop in registry statewide, but the intervention counties produced almost 1,000 new names for the registry Genesee follows a similar trend, but drops off slightly more quickly than it did in Kent County. The media component of the campaign in these counties ended in September. The registration rates drop to the level of the first month of the media and POD campaign by November, only two months after the media portion ended. As of December, however, the rates were still at the level of the first month of the intervention and are approximately 200% higher than baseline data. To further support the effectiveness of the POD materials, the months of October, November, and December represent months where only POD materials remained in the three intervention counties. For October, those counties accounted for approximately 58% of increased registrations statewide, and for November and December, they accounted for more than 100% of the increase statewide, as nonintervention county registrations actually decreased statewide (see Figure 1). DISCUSSION The results of this study offer three main contributions to the existing body of knowledge on organ donation campaigns: (a) It reinforces the conclusion that campaign efforts are more successful when adding an interpersonal component, and this combination provides an extremely effective strategy for getting individuals to join the organ donor registry; (b) it demonstrates the effectiveness of campaign messages in influencing individuals (at least the passive positives ) to join an organ donor registry; and (c) it reinforces the claim that DMV offices are advantageous locations for campaigns to persuade people to join the organ donor registry. This campaign demonstrates that media and point-ofdecision campaigns can be effective in changing behavior. The magnitude of effects demonstrated by this campaign for the media and POD materials are much greater than typically reported in the literature. This is likely due to the extremely low rate of registration that existed prior to the campaign, such that even small actual increases represent very large percentages of increase. Additionally, this campaign targeted the easy target population (passive positives). This approach seems very effective for the conditions under which the campaign occurred, but is likely to have much smaller effects in states where rates of registration approach or exceed the national average. Considering the process individuals go through in obtaining or renewing their licenses and vehicle registrations and adopting a communication design approach resulted in the effective design and placement of messages and materials that maximize opportunities for positive yet minimal

7 706 HARRISON ET AL. 3,000 2,500 2,000 1,500 1, Kent Saginaw/Genesee 2007 Kent 2008 Saginaw/Genesee 2008 January March Media campaign rolled out and point-ofdecision materials placed in Kent County branch offices. April Buddy Day, an annual registry push by Gift of Life Michigan, takes place on the 2 nd. May On-site events, with volunteers promoting signing up on the registry in branch offices, take place in Kent County. FIGURE , , , , interactions to join the registry. This mitigated the structural barrier posed by the SOS branch offices of not requiring clerks to ask customers if they would like to join the registry. The successful implementation of the campaign, and of POD components such as the clerk cards, provides support for the use of communication design in creating DMV-based interventions for organ donation. Additionally, the pattern observed in both waves of the intervention suggests that the effects of POD materials were immediate and enhanced by the supports of an ongoing media campaign. While the media campaign and POD materials were effective in their own right, the addition of on-site volunteers added dramatically to the number of registrations, supporting the claims from previous campaigns that report media plus interpersonal campaigns produce the greatest effect (e.g., Morgan et al., 2010). No data were collected regarding knowledge, attitude, or intent to behave, but the increase demonstrated by having the interpersonal component suggests that the campaign reached both passive February March April May June July August September October November December , ,762 1,131 June Continued on-site events in Kent County. Media campaign rolled out and point-of-decision materials placed in Saginaw/Genesee branch offices. July Media campaign and on-site events end in Kent County. Point-of-decision materials still in Kent County branch offices. No new components added in Saginaw/Genesee Counties. August On-site events in Saginaw/Genesee branch offices ,675 1, ,549 1, ,532 1,092 Percentage of total registry increases accounted for by the intervention counties , , September Continued on-site events in Saginaw/Genesee Counties. October Media campaign and on-site events end in Saginaw/Genesee. Point-of-decision materials still in branch offices. November and December Only intervention component remaining in place are point-of-decision materials. positives and individuals not registering because of other superficial reasons (e.g., one or two mistaken beliefs about donation). Ultimately, the findings of this study warrant the recommendation that any campaign focusing on organ donation utilize a combination of media plus interpersonal interventions to maximize desired results. The trends in the data also suggest that the effects of POD materials had lasting value. When the rate of drop off in registrations after the media and on-site events ended is examined, this reveals that it took several months before rates dropped to the level demonstrated in the first month of the intervention when the media campaign was in its infancy. Given budgetary constraints facing many state governments, the efficacy of volunteers and low-cost POD materials present economically sound means to increase the number of individuals on organ donor registries nationwide. Finally, this intervention supports the claim that DMV offices represent advantageous sites to promote organ donation. The primary intervention in each county lasted

8 PROMOTING ORGAN DONATION IN MICHIGAN ,000 20,000 15,000 10,000 5,000 January State Minus Intervention ,908 State Minus Intervention ,310 February March April May June July August September October November December 11,274 11,126 9,946 10,933 16,136 16,782 11,147 11,841 10,731 11,238 11,105 11,758 11,718 11,901 10,379 12,359 9,910 11,056 FIGURE 3 Comparison of statewide registry rates (minus intervention counties in both years) in Michigan (2007 and 2008). only four months, with POD materials continuing to be displayed, and resulted in over 14,000 new registrations. It is hard to imagine traditional lunch-and-learns or other such standard types of interventions resulting in a fraction of this many new registrations. This intervention and evaluation are not without limitations. While most models of behavior change toward organ donation examine knowledge, attitude, intent to behave, and behavior at the individual level, this campaign only measured concrete behavior at the census level. Thus, there are no data available to determine whether changes in knowledge, attitudes, or behavioral intentions were experienced by the population in the intervention counties. However, given low rates of registration in the state of Michigan, the primary intent was to target those already favorable and consciously prime them into action. The dramatic increases in the intervention counties do indeed demonstrate actual behavior change, which many campaigns have difficulty achieving or measuring beyond self-report data. Additionally, there were limitations in the implementation of the intervention that may have affected the results, but only to the extent that the results may have been even stronger had the implementation occurred flawlessly. While the majority of POD materials were displayed on time and 9,661 8,838 7,966 7,864 in the appropriate locations for all counties, posters were hung in places inaccessible to people waiting in line in Kent County. Because of that placement, the likelihood of individuals reading the narratives on the posters was probably quite low, although they would still be able to see the community appeal (e.g., hometown of pictured resident) and priming call to action ( Tell Us Now ). Had individuals been able to read the narratives, the posters depending on the placement at each branch might have had a stronger impact as the featured narratives could have been more persuasive than other POD materials. Posters in Saginaw/Genesee counties were modified to include extremely brief narratives that were visible from greater distances. CONCLUSION Utilization of media priming and communication design principles motivated an action-oriented response and dramatically increased the rates of joining the Michigan Organ Donor Registry. DMV offices represent a reliable, cost-effective, and efficient location for organ procurement organizations to increase the number of individuals declaring their intention to be an organ donor. Even with the

9 708 HARRISON ET AL. constraints imposed on this project to limit interaction with DMV clerks, both absolute increases and proportional increases are much larger than demonstrated in the majority of public education campaigns promoting organ donation (Feeley & Moon, 2009). This study represents one of the first attempts at evaluating the impact of communication design principles in the context of a health communication campaign. Given the tiered success shown by campaign efforts, perhaps Census-level data should be considered when evaluating the effects of communication design applications. However, there are no quality measures to determine whether the ease of the interaction about organ donation created by design principles affected individual decision making. Future research should consider exploring this relationship in a laboratory setting. Additionally, the inclusion of an interpersonal component seems to further increase the effectiveness of organ donation campaigns in general, supporting findings of previous research (Feeley & Moon, 2009; Morgan et al., 2010). While this campaign was highly successful, it should be replicated in other contexts and with more diverse populations who may demonstrate greater reluctance toward donation. ACKNOWLEDGMENTS This study was supported by grant D71HS 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. The authors thank Tammie Havermahl, Gift of Life Michigan staff and volunteers, and the office of the Michigan Secretary of State for their help in implementing this campaign. REFERENCES Aakhus, M. (2007). Communication as design. Communication Monographs, 74, Cappella, J. N., Fishbein, M., Hornik, R., Ahern, R. K., & Sayeed, S. (2000). Using theory to select messages in antidrug media campaigns: Reasoned action and media priming. In R. Rice & C. K. Atkin (Eds.), Public communication campaigns (pp ). Thousand Oaks, CA: Sage. Dodd-McCue, D., Tartaglia, A., & Cowherd, R. (2007). The role of women in the donation consent decision: Building on previous research. Progress in Transplantation, 17, Domke, D., Shah, D. V., & Wackman, D. B. (1998). Media priming effects: Accessibility, association, and activation. International Journal of Public Opinion Research, 10, Feeley, T. H., & Moon, S. (2009). A meta-analytic review of communication campaigns to promote organ donation. Communication Reports, 22, Fishbein, M., & Yzer, M. C. (2003). Using theory to design effective health behavior interventions. Communication Theory, 13, Fleming, D. (2008, April 14). National donor designation report card reveals a 10% increase in registered organ, eye, and tissue donors since 2006 [Press release]. Richmond, VA: Donate Life America. Retrieved from Release pdf Gallup Organization. (2005). National survey of organ and tissue donation attitudes and behaviors. Retrieved from survey2005/index.shtm Harrison, T. R., Morgan, S. E., Chewning, L. V., Williams, E., Barbour, J., Di Corcia, M. & Davis, L. (in press). Revisiting the worksite in worksite health campaigns: Evidence from a multi-site organ donation campaign. Journal of Communication. Harrison, T. R., Morgan, S. E., & Di Corcia, M. J. (2008). Effects of information, education, and communication training about organ donation for gatekeepers: Clerks at the Department of Motor Vehicles and organ donor registries. Progress in Transplantation, 18, Harrison, T. R., & Morrill, C. (2004). Ombuds processes and disputant reconciliation. Journal of Applied Communication Research, 32, Jackson, S. (1998). Disputation by design. Argumentation, 12, Lewin Group. (2002). Guidelines for donor registry development conference final report. August, 2002, second revision. Retrieved from Mendelsohn, M. (1996). The media and interpersonal communications: The priming of issues, leaders, and party identification. Journal of Politics, 58, Michigan Office of the Secretary of State. (2007). Unpublished data. Morgan, S. E., Harrison, T. R., Chewning, L. V., DiCorica, M. J., & Davis, L. A. (2010). The effectiveness of high- and low-intensity worksite campaigns to promote organ donation: The Workplace Partnership for Life. Communication Monographs, 77, Morgan, S. E., & Miller, J. (2002) Communicating about gifts of life: The effect of knowledge, attitudes, and altruism on behavior and behavioral intentions regarding organ donation. Journal of Applied Communication Research, 30, Morgan, S. E., Miller, J., and Arasaratnam, L. A. (2002). Signing cards, saving lives: An evaluation of the Worksite Organ Donation Promotion Project. Communication Monographs, 69, Morgan, S. E., Stephenson, M., Harrison, T. R., Afifi, W. A., & Long, S. D. (2008). Facts versus feelings : How rational is the decision to become an organ donor. Journal of Health Psychology, 13, Organ Procurement and Transplantation Network. (2009). Retrieved from Thompson, T. L., Robinson, J. D., & Kenny, R. W. (2003). Gender differences in family communication about organ donation. Sex Roles, 49, United Network for Organ Sharing. (2009). Waiting list candidates. Retrieved from U.S. Census Bureau (2009a). Kent County, Michigan QuickFacts. Retrieved from U.S. Census Bureau (2009b). Saginaw County, Michigan QuickFacts. Retrieved from U.S. Census Bureau (2009c). Genesee County, Michigan QuickFacts. Retrieved from Weber, K., Martin, M. M., Comm, M., & Corrigan, M. (2006). Creating persuasive messages advocating organ donation. Communication Quarterly, 54, Yzer, M. C., Cappella, J. N., Fishbein, M., Hornik, R., & Ahern, R. K. (2003). The effectiveness of gateway communications in anti-marijuana campaigns. Journal of Health Communication, 8,