Directory UMM :Data Elmu:jurnal:J-a:Journal Of Business Research:Vol50.Issue3.2000:
Words versus Actions about Organ Donation:
A Four-Year Tracking Study of Attitudes
and Self-Reported Behavior
Thomas J. Cossé
UNIVERSITY OF RICHMOND
Terry M. Weisenberger
UNIVERSITY OF RICHMOND
Historically, the proportion of the American public that expresses positive
views about organ donation exceeds the proportion that actually signs an
organ donor card (ODC). The public seems to say one thing but does
another. In July 1994, The Advertising Council, Inc., in conjunction with
the Coalition on Donation, launched a major promotional campaign to
educate the U.S. public about organ and tissue donation. This article
reports on a four-year study tracking attitude toward organ donation and
transplantation and its relationship with direct experience (knowing an
organ recipient) and intermediate behaviors. The intermediate behaviors
investigated are donating blood and signing an ODC. No significant
changes were noted in attitude toward donation, but the proportion of
individuals who had signed an ODC increased significantly. J BUSN RES
2000. 50.297–303. 2000 Elsevier Science Inc. All rights reserved.
indicate that they support organ donation and transplantation
(Gallup, 1993), the positive views toward donation expressed
by the public are not matched by action.
It is doubtful that the supply of cadaveric organs will ever
fully meet the demand. In fact, artificial organs (Basu-Dutt et
al., 1997; Kaufmann et al., 1997), xenotransplantation, that
is, organs from animals (Arundell and McKenzie, 1997), and
even cloned organs (currently banned) may be the ultimate
solution. In the meantime, however, the organ donation and
transplantation community is actively seeking to increase the
number of posthumous donations. One program seeking to
increase donations is the national advertising and promotion
effort undertaken by the Advertising Council, Inc. and the
Coalition on Donation.
A
National Campaign for
Organ Donation
ccording to the United Network for Organ Sharing
(UNOS), the “# 1” issue confronting the transplantation community is the critical shortage of transplantable organs (UNOS, 1998a). In fact, the Coalition on Donation
(1998) describes the shortage as a public health crisis. During
1988, 27,805 patients in the United States were on the organ
waiting list and there were 4,084 cadaveric donors. By 1996,
the number of patients on the waiting list during the year had
nearly tripled to 72,836, but the number of cadaveric donors
had increased to only 5,417 (UNOS, 1998b). Although 20,354
organ transplants (cadaveric and living) were performed in
the United States during 1996, 4,022 patients—about 11 per
day—died while on the waiting lists (UNOS, 1998b). It is
surprising that the number of cadaveric donors has not increased over the years, as there are over 2 million deaths
annually in the United States. While most Americans (85%)
Address correspondence to Thomas J. Cosse, The E. Claiborne Robins School
of Business, University of Richmond, Richmond, VA 23173.
Journal of Business Research 50, 297–303 (2000)
2000 Elsevier Science Inc. All rights reserved.
655 Avenue of the Americas, New York, NY 10010
In 1993, The Advertising Council, Inc., (henceforth the Ad
Council) and the Coalition for Donation (henceforth the Coalition) developed a multi-media national promotion campaign
to educate the public about organ and tissue donation. The
overriding objective of the campaign is to increase the number
of organ and tissue donors. The campaign was launched in
July 1994 with the theme “Organ and Tissue Donation: Share
your life. Share your decision.” It stresses the need to sign an
organ donor card and to inform family members of that decision. During the campaign’s first year, $33.3 million of media
had been donated. In the next year, over $47 million was
donated. (Nathan, 1997).
This article reports the findings of a four-year study tracking
community attitude and behavior in metropolitan Richmond,
Virginia, concurrent with the Ad Council/Coalition campaign.
As is the case of the advertising and promotion campaign, the
ISSN 0148-2963/00/$–see front matter
PII S0148-2963(99)00024-7
298
J Busn Res
2000:50:297–303
focus of the study is on posthumous (or cadaveric) donation
rather than donation from living donors. Most donations,
especially between unknown or unrelated persons, are cadaveric. (See the Appendix for an overview of the cadaveric organ
procurement and allocation system in the United States.)
T. J. Cossé et al.
introducing significant bias when the telephone directory is
an appropriate sampling frame for a study (Landon and Banks,
1977). Usable responses were obtained from 161 persons in
1994, 126 in 1995, 142 in 1996, and 141 in 1997.
Measures
Study Objectives
It is believed that prior direct experience is a powerful contributor to attitude formation and reinforcement (Marks and Kamins, 1988; Smith and Swinyard, 1983). In the case of organ
donation and transplantation, knowing an organ recipient,
therefore, should have a positive influence on attitude toward
organ donation and transplantation.
Also, there are several intermediate behaviors between having a positive attitude toward organ donation and transplantation and the ultimate behavior of organ donation. These include such actions as donating blood and signing an organ
donor care (ODC). This last behavior indicates the intention
of performing the ultimate behavior of becoming an organ
donor. It is commonly held that such a demonstrated behavioral intention is a more accurate predictor of actual future
behavior than is attitude (Granbois and Summers, 1975;
Reibstein, 1978; Warshaw, 1980).
Therefore, the objectives of this study are to measure concurrent with the Ad Council/Coalition campaign:
1. the changes in attitude toward organ donation and
transplantation;
2. the relationship to the prior direct experience of knowing an organ recipient; and
3. the more proximate, intermediate behaviors of donating
blood and signing an ODC.
Research Methods
The study consists of four cross-sectional surveys conducted
approximately one year apart in Richmond, Virginia. The first
survey was conducted in June 1994, just prior to the July
launch of the Ad Council/Coalition campaign, and was repeated in 1995, 1996, and 1997.
Samples
A separate probability sample was selected for each survey.
The samples consisted of individuals at least 18 years of age
residing in the metro telephone calling area. Only persons
residing in households in which no one was employed in the
healthcare industry are included in this study. Telephone
numbers were randomly selected from the telephone directory
(current at the time of each study). The 11 sampling technique was employed so that new listings and unlisted numbers
could be accessed (Churchill, 1991). It has been shown to be
more efficient than random digit dialing designs while not
Attitude was measured using an 8-item, 5-point Likert type
scale named the DONATT scale (see Table 1). The scale was
developed following traditional scale development procedures
(Churchill, 1979). The range of possible scale scores is 8–40,
with higher scores indicating more positive attitudes. Coefficient a for the scale across all four sample years is 0.83. Testretest reliability was measured on three convenience samples
and ranges from 0.83 to 0.89.
Action was measured by asking participants if they had
executed an ODC. In addition, traditional demographic data
were collected. Finally, data on the prior direct experience
factor of knowing a transplant recipient and the intermediate
behavior factor of having donated blood were obtained.
Analyses and Findings
The four years of data were examined for variations in response
to the DONATT scale using one-way ANOVA. The DONATT
scores did not differ significantly over the course of the study
(p 5 0.773) (see Table 2). That is, there is no evidence of
any change in attitude toward donation over the years. Given
the millions of dollars in media expenditures, one might have
expected a positive change in attitude. While some might
suggest that the campaign was a failure, the absence of a
control group in this study makes measuring success or failure
impossible. It is possible that without the campaign, attitude
toward donation might have actually declined. It is also possible that an already high positive response would reduce the
chances of obtaining a significant gain in attitude.
A different perspective is gained from an examination of
the trend in the proportion of individuals reporting that they
had signed an ODC. The proportion reporting that they had
signed an ODC has increased significantly over the period of
the campaign (p , 0.01) (see Table 3). While there has been
no change in the community’s attitude toward donation, there
has been a significant increase in the percentage of respondents
who say that they have executed an ODC.
Are actions matching words? It appears that they are. The
proportion of each sample who had both agreed and strongly
agreed with one statement in the DONATT scale: I would
donate my organs after my death and who had signed an
ODC has shown a strong increase from 39% in 1994 to 63%
in 1997 (see Table 4).
To determine if these findings are the result only of sample
differences, the samples were compared along demographic
and experience characteristics. Wheeler and Cheung (1996)
and Prottas (1992) reported that younger, better-educated,
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2000:50:297–303
299
Table 1. DONATT Scale Itemsa
I would donate my organs after my death.b
I find the idea of organ donation repulsive.
I would not allow the organs of a loved one to be donated.
Organ transplantation is morally justified.b
Organ donation is against my religious beliefs.
If a family member signed a donor card, then I would approve the donation.b
I am worried that a loved one’s body would be disfigured if their organs were donated.
People who receive organ transplants cannot live normal lives.
Cronbach’s coefficient a: all four sample years 5 0.83; 1994, 0.83; 1995, 0.75; 1996, 0.88; 1997, 0.80.
Test-retest reliability was determined using the separate convenience samples of students: 18 undergraduates with 2-week measurement
interval 5 0.88; 61 undergraduates with 4-week measurement interval 5 0.83; and 15 MBA students with 4-week measurement interval 5 0.89.
a
b
Statement sequence rotated to control for order bias.
Strongly agree 5 5.
higher income persons are more likely to be organ donors.
The Gallup survey (1993) found the likelihood to donate
increases significantly with education and nonwhites are less
likely than whites to want their organs donated. Non-Hispanic
whites tend to have both higher donation rates and more
favorable attitudes toward organ donation than do Blacks
and Hispanics. This exacerbates the general organ shortage
problem as some specific groups with a higher need for transplants also have a lower donation rate (Farrell and Greiner,
1993). Wheeler and Cheung (1996) also found that single
Blacks and lower income Blacks are less willing to be donors
after death.
In some instances, notwithstanding how they feel about
donation, some people simply believe they are too old or
cannot donate their organs due to medical reasons (Gallup,
1993). Having donated blood (Pessemier et al., 1977; Sanner,
1994a, 1994b) and knowing an organ transplant recipient are
also thought to be related to willingness to donate (Horton
and Horton, 1991).
The results of the analyses are mixed. While the groups
do not differ by sex (p 5 0.90), by race (p 5 0.30), or by
education (p 5 0.31), they do differ significantly by age (p ,
0.01) and by income (p , 0.001). The samples do not differ
in the proportion of respondents who have donated blood
(p 5 0.70) or who personally know a transplant recipient
(p 5 0.50) (see Table 5).
Because the samples differ by age and income, DONATT
was tested against the same demographic and experiential
characteristics as were the sample groups (see Table 6). Recall
Table 2. Mean DONATT Scores by Year and ANOVA Results
Year
Number
Mean
F
Significance
1994
1995
1996
1997
161
126
142
141
31.24
31.45
31.01
31.52
0.372
0.773
that a higher DONATT score indicates a more favorable attitude toward organ donation. There is no difference in DONATT by sex (p 5 0.58); but there is by age (p , 0.001),
education (p , 0.001), income (p , 0.001, and race (p ,
0.001). The age groups split right at age 60, with those 60
and over having a lower score than those under 60. Higher
educational levels are associated with higher DONATT scores.
Persons with high school/vo-tech or less education have lower
scores than those with some college or a degree while those
who have some graduate school or a graduate degree have
higher scores than those with some college or an undergraduate degree. The income split occurs at $35,000. Those at or
above $35,000 are more positive than those under $35,000.
Whites and non-Black minorities have higher DONATT scores
than Blacks. These findings conform with prior research
(Wheeler and Cheung, 1996; Prottas, 1992).
Those who personally know a transplant recipient are more
favorable than those who do not (p 5 0.026). Those who have
donated blood also have a more favorable attitude toward organ
donation and transplantation than do those who have not
(p , 0.001). This also is confirmatory of prior research (Pessemier, 1977; Sanner, 1994a, 1994b; Horton and Horton, 1991).
The two characteristics that are significantly different both
by sample year and by DONATT scores are age and income.
Those over 60 years of age were progressively less represented
in the samples. The level of income also shows a slight decline
over the years of the study. These changes in income and in
age distribution would likely mitigate against each other in
Table 3. Proportion of Participants Reporting That They Have/Have
Not Signed an ODC by Year
Signed an
ODC?
Yes
No
1994
(n 5 161)
1995
(n 5 126)
1996
(n 5 142)
1997
(n 5 141)
28%
72%
37%
63%
50%
50%
44%
56%
x2 significant at ,0.01.
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T. J. Cossé et al.
Table 4. Proportion of Participants Who Strongly Agree or Agree
with the Statement “I would donate my organs after my death” and
Who Report That They Have/Have Not Signed an ODC by Year
Signed an
ODC?
Yes
No
1994
(n 5 109)
1995
(n 5 86)
1996
(n 5 99)
1997
(n 5 91)
39%
61%
54%
46%
67%
33%
63%
37%
x2 significant at ,0.01.
both attitude (DONATT scores) and behavior (a signed ODC).
The change in age distribution should provide an upward
bias and the change in income distribution should provide a
downward bias.
The results of this study are mixed. DONATT scores are
unchanged over the course of the four-year study but the
proportion of respondents who had signed an ODC had actually risen significantly over the years. Something had to be
at work to counteract the lack of enthusiasm for donation
manifested by some members of the public. That “something”
may have been the Ad Council/Coalition campaign. While
there are differences among various demographic segments
in their attitudes toward donation, the reality is that there are
large numbers in all camps who have favorable attitudes. The
need is to capitalize on those favorable attitudes.
While this gratifying upturn in signed ODCs has been
contemporaneous with the Ad Council/Coalition campaign,
it cannot be totally ascribed to it. Also contemporaneous with
the campaign (perhaps due to the campaign) was news media
attention concerning organ donation and transplantation. Such
famous recipients as Larry Hagman, Mickey Mantle, and David
Crosby, and such previously unknown donors as Nicholas
Green (the young American boy whose parents donated his
organs after he was killed by bandits in Italy) were in the
news. This news should have helped galvanize public attention
to the issue of organ recovery and donation. Parsing these
effects is obviously difficult, but there can be little doubt the
campaign was a major factor.
Management Implications
This study indicates that the organ procurement and transplantation community must continue in its quest to understand what motivates individuals to become—or not to become—organ donors and to employ sophisticated marketing
techniques to encourage donation. Special emphasis must be
placed on the Black community in particular. While Blacks
continue to demonstrate disproportionate need, they generally
exhibit a less positive attitude toward donation and transplantation than do whites.
One approach to gaining insights about motivations may
be to study blood donors. They are a readily identifiable
group that is more positively disposed to the concept of organ
Table 5. Results of Tests Comparing Samples on Demographic and
Experience Characteristics
Characteristic
Age
Education
Income
Race
Sex
Blood Donor
Know Recipient
Test
Significance
ANOVA
Kruskal-Wallis
ANOVA (K-W)
Kruskal-Wallis
ANOVA (K-W)
x2
x2
x2
x2
,0.01
0.31
,0.001
0.30
0.90
0.70
0.50
donation and transplantation than persons who have never
given blood. They have also displayed an intermediate behavior—more than a positive attitude, less than a signed ODC.
The older segment of the population is also less inclined
than the younger to favor organ donation. A cynical response
may be “So what?” because they are very poor potential donors.
The fact is that the best cadaveric donors are young accidental
death victims. That response is, however, far too facile. The
older relative may be the one who has to make the decision
to allow the recovery and transplantation of organs from a
deceased loved one. If not the parent of the deceased, the
older relative may be at least a strong personal influence on
the relative who has to make the decision. Perhaps the Ad
Council/Coalition might want to focus part of the campaign
on the scenario of offering sage advice in a trying moment.
While the attitude toward organ donation has remained
very stable over the course of the study (as shown by DONATT
scores), the action of signing an ODC has become more prevalent. The lesson in this may be that the Ad Council/Coalition
is correct when they emphasize: “Share your life; Share your
decision.” In other words, it is not enough to think positive,
one must act positive. This is definitely an example of shaping
behavior in a market for a high-involvement decision.
Limitations
Although probability samples were employed in every phase
of the study, the study was limited to the metro area of Richmond, Virginia. This is the headquarters of UNOS, so there
might have been an initial higher awareness of donation and
transplantation. There is, however, no direct evidence of this.
Projecting the findings beyond this area may be inappropriate.
Also, although the upturn in signed ODCs has been contemporaneous with the Ad Council/Coalition campaign, it
should not be totally ascribed to it. As noted, several newsworthy events transpired which may have had an impact on the
public’s perception of donation and transplantation. These
events must also be allowed as having had an impact—
whether positive or negative.
It should also be pointed out that the measure of action—
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2000:50:297–303
301
Table 6. Results of Tests Comparing DONATT Scores by Demographic and Other Characteristics
Characteristic
Test
Significance
Description of Results
Age
Education
ANOVA
ANOVA
,0.001
,0.001
Income
ANOVA
,0.001
Race
Sex
Blood Donor
Know Recipient
ANOVA
t
t
t
,0.001
0.580
,0.001
0.026
Persons under 60 have higher scores than those 60 and older
Persons with high school/vo-tech or less education have lower scores than
those with some college or a degree, who have lower scores than those with
some graduate school or a graduate degree
Persons with household income less than $35,000 have lower scores than those
with higher income
Blacks have lower scores than other minorities and whites
Males and females do not differ
Persons who have donated blood have higher scores than non-donors
Persons who know a transplant recipient have higher scores than those who
do not know a recipient.
Groupings used for analysis: Age ,30, 30–39, 40–49, 50–59, .59; Education: high school/vo-tech or less, some college, college degree, some graduate school or graduate degree;
Income: ,$35K, $35K–$64.9K, $65K–$95K, .$95K; Race: Black, other minority, white; Blood Donor: have donated, have not donated; Know Recipient: know an organ transplant
recipient, do not know an organ transplant recipient.
Note: Duncan’s multiple range test (a 5 0.05) was used in conjunction with ANOVA to test for differences between groups.
whether a respondent had signed an ODC—was a self-report
and cannot be verified. Further, no attempt was made to
determine if social desirability, or “yea-saying,” was at play in
participants’ responses.
Appendix
Cadaveric Organ Procurement and
Allocation in the United States
The National Organ Transplant Act (NOTA) of 1984 (as
amended in 1988 and in 1990), the Uniform Anatomical
Gift Act (UAGA), and the Sixth Omnibus Budget Reconciliation Act (SOBRA) provide the legal framework for organ
donation in the United States. NOTA specifically outlawed
the buying or selling of human organs and tissue and established the National Organ Procurement and Transplantation
Network (OPTN) (Prottas, 1993; UNOS, 1997). Note that
the use of financial incentives has been suggested by some
as a means of increasing donations. For further information,
see Altshuler and Evanisko (1992), Barnett et al. (1992),
Cossé and Weisenberger (1997), and Kittur et al.(1991).
The UAGA explicitly authorized the voluntary gifting of
body parts upon death and delineates a hierarchy of rules
governing how the gift may be stipulated and who may
commit the gift. The U.S. organ donation process is based on
explicit consent. Under explicit consent, individuals (adults)
decide if they wish to become organ donors. Typically commitment to be a donor is made by signing an organ donor
card (ODC)—which may be one’s state driver’s permit. By
law an individual’s wish to be a donor, as demonstrated by
an executed ODC, is a binding authorization to remove the
person’s organs after death regardless of the wishes of the
individual’s family. In the absence of an ODC, the UAGA
specifies which family members have a right to authorize a
donation—generally, the spouse of an adult or the parents
of a minor. SOBRA states that when there is no ODC, physicians and hospitals are required to present organ donation as
an option to the families of patients judged to be dying or
who have just died. This is referred to as required request
(Farrell and Greiner, 1993).
The actual recovery and distribution is conducted by notfor-profit organ procurement organizations (OPOs) (Alexander et al., 1992). All OPOs and transplant hospitals are required by law to be OPTN members. Currently there are 54
independent and 12 transplant-center-affiliated OPOs in the
United States. Upon notification by a hospital of a potential
donor, OPO staff contact the families of potential donors to
discuss the donation option, and if permission to recover
organs is granted, they enter necessary donor data into the
United Network for Organ Sharing (UNOS) computer system.
UNOS is a private, non-profit organization that holds federal
contracts to operate the OPTN and to maintain the U.S. Scientific Registry of Transplant Recipients. UNOS has specific
policies regarding standards of membership, organ allocation,
and data management. At this time the policies and standards
are not enforceable by law and are considered voluntary guidance to OPTN members (UNOS, 1997).
UNOS provides the OPO with a priority listing of potential
recipients. The first list generated is usually limited to patients
in the OPO’s service area. If a suitable recipient is not found
on that list, a regional list is generated, and finally a nationwide
list is obtained. The OPO then contacts the OPOs in the
areas where potential recipients are located. The donor’s OPO
maintains the donor and coordinates organ recovery, preservation, and transportation. The recipients’ OPOs (one donor’s
organs may go to a number of different recipients) arrange
the transplant activities—line up the transplant teams and
prepare the recipients for surgery. UNOS assists the recovery
and transplantation teams with organ matching and transportation (Benenson, 1991) and oversees the process to ensure
conformance with allocation rules, policies, and procedures.
302
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In April 1998, the Department of Health and Human Services published the OPTN Rule requiring standardized criteria
for listing patients on the waiting lists and for determining
medical status (HHS 1998a). In addition, the rule eliminates
the current practice of first searching for recipients within the
recovering OPO’s service area. Further, it requires a nationwide search to find the person most in need of an organ(s).
The rule was set go into effect in July 1998 (see HHS, 1998b).
However, considerable opposition was expressed by members
of the procurement and transplantation community. In October 1998, the 1999 Omnibus Appropriations Act was passed.
The act places a one-year moratorium on the OPTN Rule.
During that year the act requires review of the OPTN policies
and a number of studies dealing with the impact of the OPTN
Rule on procurement and transplantation. Refer to the UNOS
homepage at www.unos.org and the Health Resources and
Services Administration homepage at www.hrsa.dhhs.gov for
regular updates on this issue (UNOS, 1998b).
For this article, the authors received the 1998 Steven J. Shaw Award for the
Best Conference Paper at the Annual Conference of the Society for Marketing
Advances.
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UNOS: http://www.unos.org/Newsroom/archive regs update 102199.htm(1998b).
UNOS: 1997 Annual Report: The U.S. Scientific Registry of Transplant
303
Recipients and The Organ Procurement Transplantation Network.
UNOS and Health Resources & Services Administration. U.S.
Department of Health & Human Services, 1998b.
Warshaw, Paul R.: Predicting Purchase and Other Behaviors from
General and Contextually Specific Intentions. Journal of Marketing
Research 17 (February 1980): 26–33.
Wheeler, Mary S., and Cheung, Alan H. S.: Minority Attitudes Toward
Organ Donation. Critical Care Nurse 16 (February 1996): 30–33.
A Four-Year Tracking Study of Attitudes
and Self-Reported Behavior
Thomas J. Cossé
UNIVERSITY OF RICHMOND
Terry M. Weisenberger
UNIVERSITY OF RICHMOND
Historically, the proportion of the American public that expresses positive
views about organ donation exceeds the proportion that actually signs an
organ donor card (ODC). The public seems to say one thing but does
another. In July 1994, The Advertising Council, Inc., in conjunction with
the Coalition on Donation, launched a major promotional campaign to
educate the U.S. public about organ and tissue donation. This article
reports on a four-year study tracking attitude toward organ donation and
transplantation and its relationship with direct experience (knowing an
organ recipient) and intermediate behaviors. The intermediate behaviors
investigated are donating blood and signing an ODC. No significant
changes were noted in attitude toward donation, but the proportion of
individuals who had signed an ODC increased significantly. J BUSN RES
2000. 50.297–303. 2000 Elsevier Science Inc. All rights reserved.
indicate that they support organ donation and transplantation
(Gallup, 1993), the positive views toward donation expressed
by the public are not matched by action.
It is doubtful that the supply of cadaveric organs will ever
fully meet the demand. In fact, artificial organs (Basu-Dutt et
al., 1997; Kaufmann et al., 1997), xenotransplantation, that
is, organs from animals (Arundell and McKenzie, 1997), and
even cloned organs (currently banned) may be the ultimate
solution. In the meantime, however, the organ donation and
transplantation community is actively seeking to increase the
number of posthumous donations. One program seeking to
increase donations is the national advertising and promotion
effort undertaken by the Advertising Council, Inc. and the
Coalition on Donation.
A
National Campaign for
Organ Donation
ccording to the United Network for Organ Sharing
(UNOS), the “# 1” issue confronting the transplantation community is the critical shortage of transplantable organs (UNOS, 1998a). In fact, the Coalition on Donation
(1998) describes the shortage as a public health crisis. During
1988, 27,805 patients in the United States were on the organ
waiting list and there were 4,084 cadaveric donors. By 1996,
the number of patients on the waiting list during the year had
nearly tripled to 72,836, but the number of cadaveric donors
had increased to only 5,417 (UNOS, 1998b). Although 20,354
organ transplants (cadaveric and living) were performed in
the United States during 1996, 4,022 patients—about 11 per
day—died while on the waiting lists (UNOS, 1998b). It is
surprising that the number of cadaveric donors has not increased over the years, as there are over 2 million deaths
annually in the United States. While most Americans (85%)
Address correspondence to Thomas J. Cosse, The E. Claiborne Robins School
of Business, University of Richmond, Richmond, VA 23173.
Journal of Business Research 50, 297–303 (2000)
2000 Elsevier Science Inc. All rights reserved.
655 Avenue of the Americas, New York, NY 10010
In 1993, The Advertising Council, Inc., (henceforth the Ad
Council) and the Coalition for Donation (henceforth the Coalition) developed a multi-media national promotion campaign
to educate the public about organ and tissue donation. The
overriding objective of the campaign is to increase the number
of organ and tissue donors. The campaign was launched in
July 1994 with the theme “Organ and Tissue Donation: Share
your life. Share your decision.” It stresses the need to sign an
organ donor card and to inform family members of that decision. During the campaign’s first year, $33.3 million of media
had been donated. In the next year, over $47 million was
donated. (Nathan, 1997).
This article reports the findings of a four-year study tracking
community attitude and behavior in metropolitan Richmond,
Virginia, concurrent with the Ad Council/Coalition campaign.
As is the case of the advertising and promotion campaign, the
ISSN 0148-2963/00/$–see front matter
PII S0148-2963(99)00024-7
298
J Busn Res
2000:50:297–303
focus of the study is on posthumous (or cadaveric) donation
rather than donation from living donors. Most donations,
especially between unknown or unrelated persons, are cadaveric. (See the Appendix for an overview of the cadaveric organ
procurement and allocation system in the United States.)
T. J. Cossé et al.
introducing significant bias when the telephone directory is
an appropriate sampling frame for a study (Landon and Banks,
1977). Usable responses were obtained from 161 persons in
1994, 126 in 1995, 142 in 1996, and 141 in 1997.
Measures
Study Objectives
It is believed that prior direct experience is a powerful contributor to attitude formation and reinforcement (Marks and Kamins, 1988; Smith and Swinyard, 1983). In the case of organ
donation and transplantation, knowing an organ recipient,
therefore, should have a positive influence on attitude toward
organ donation and transplantation.
Also, there are several intermediate behaviors between having a positive attitude toward organ donation and transplantation and the ultimate behavior of organ donation. These include such actions as donating blood and signing an organ
donor care (ODC). This last behavior indicates the intention
of performing the ultimate behavior of becoming an organ
donor. It is commonly held that such a demonstrated behavioral intention is a more accurate predictor of actual future
behavior than is attitude (Granbois and Summers, 1975;
Reibstein, 1978; Warshaw, 1980).
Therefore, the objectives of this study are to measure concurrent with the Ad Council/Coalition campaign:
1. the changes in attitude toward organ donation and
transplantation;
2. the relationship to the prior direct experience of knowing an organ recipient; and
3. the more proximate, intermediate behaviors of donating
blood and signing an ODC.
Research Methods
The study consists of four cross-sectional surveys conducted
approximately one year apart in Richmond, Virginia. The first
survey was conducted in June 1994, just prior to the July
launch of the Ad Council/Coalition campaign, and was repeated in 1995, 1996, and 1997.
Samples
A separate probability sample was selected for each survey.
The samples consisted of individuals at least 18 years of age
residing in the metro telephone calling area. Only persons
residing in households in which no one was employed in the
healthcare industry are included in this study. Telephone
numbers were randomly selected from the telephone directory
(current at the time of each study). The 11 sampling technique was employed so that new listings and unlisted numbers
could be accessed (Churchill, 1991). It has been shown to be
more efficient than random digit dialing designs while not
Attitude was measured using an 8-item, 5-point Likert type
scale named the DONATT scale (see Table 1). The scale was
developed following traditional scale development procedures
(Churchill, 1979). The range of possible scale scores is 8–40,
with higher scores indicating more positive attitudes. Coefficient a for the scale across all four sample years is 0.83. Testretest reliability was measured on three convenience samples
and ranges from 0.83 to 0.89.
Action was measured by asking participants if they had
executed an ODC. In addition, traditional demographic data
were collected. Finally, data on the prior direct experience
factor of knowing a transplant recipient and the intermediate
behavior factor of having donated blood were obtained.
Analyses and Findings
The four years of data were examined for variations in response
to the DONATT scale using one-way ANOVA. The DONATT
scores did not differ significantly over the course of the study
(p 5 0.773) (see Table 2). That is, there is no evidence of
any change in attitude toward donation over the years. Given
the millions of dollars in media expenditures, one might have
expected a positive change in attitude. While some might
suggest that the campaign was a failure, the absence of a
control group in this study makes measuring success or failure
impossible. It is possible that without the campaign, attitude
toward donation might have actually declined. It is also possible that an already high positive response would reduce the
chances of obtaining a significant gain in attitude.
A different perspective is gained from an examination of
the trend in the proportion of individuals reporting that they
had signed an ODC. The proportion reporting that they had
signed an ODC has increased significantly over the period of
the campaign (p , 0.01) (see Table 3). While there has been
no change in the community’s attitude toward donation, there
has been a significant increase in the percentage of respondents
who say that they have executed an ODC.
Are actions matching words? It appears that they are. The
proportion of each sample who had both agreed and strongly
agreed with one statement in the DONATT scale: I would
donate my organs after my death and who had signed an
ODC has shown a strong increase from 39% in 1994 to 63%
in 1997 (see Table 4).
To determine if these findings are the result only of sample
differences, the samples were compared along demographic
and experience characteristics. Wheeler and Cheung (1996)
and Prottas (1992) reported that younger, better-educated,
J Busn Res
2000:50:297–303
299
Table 1. DONATT Scale Itemsa
I would donate my organs after my death.b
I find the idea of organ donation repulsive.
I would not allow the organs of a loved one to be donated.
Organ transplantation is morally justified.b
Organ donation is against my religious beliefs.
If a family member signed a donor card, then I would approve the donation.b
I am worried that a loved one’s body would be disfigured if their organs were donated.
People who receive organ transplants cannot live normal lives.
Cronbach’s coefficient a: all four sample years 5 0.83; 1994, 0.83; 1995, 0.75; 1996, 0.88; 1997, 0.80.
Test-retest reliability was determined using the separate convenience samples of students: 18 undergraduates with 2-week measurement
interval 5 0.88; 61 undergraduates with 4-week measurement interval 5 0.83; and 15 MBA students with 4-week measurement interval 5 0.89.
a
b
Statement sequence rotated to control for order bias.
Strongly agree 5 5.
higher income persons are more likely to be organ donors.
The Gallup survey (1993) found the likelihood to donate
increases significantly with education and nonwhites are less
likely than whites to want their organs donated. Non-Hispanic
whites tend to have both higher donation rates and more
favorable attitudes toward organ donation than do Blacks
and Hispanics. This exacerbates the general organ shortage
problem as some specific groups with a higher need for transplants also have a lower donation rate (Farrell and Greiner,
1993). Wheeler and Cheung (1996) also found that single
Blacks and lower income Blacks are less willing to be donors
after death.
In some instances, notwithstanding how they feel about
donation, some people simply believe they are too old or
cannot donate their organs due to medical reasons (Gallup,
1993). Having donated blood (Pessemier et al., 1977; Sanner,
1994a, 1994b) and knowing an organ transplant recipient are
also thought to be related to willingness to donate (Horton
and Horton, 1991).
The results of the analyses are mixed. While the groups
do not differ by sex (p 5 0.90), by race (p 5 0.30), or by
education (p 5 0.31), they do differ significantly by age (p ,
0.01) and by income (p , 0.001). The samples do not differ
in the proportion of respondents who have donated blood
(p 5 0.70) or who personally know a transplant recipient
(p 5 0.50) (see Table 5).
Because the samples differ by age and income, DONATT
was tested against the same demographic and experiential
characteristics as were the sample groups (see Table 6). Recall
Table 2. Mean DONATT Scores by Year and ANOVA Results
Year
Number
Mean
F
Significance
1994
1995
1996
1997
161
126
142
141
31.24
31.45
31.01
31.52
0.372
0.773
that a higher DONATT score indicates a more favorable attitude toward organ donation. There is no difference in DONATT by sex (p 5 0.58); but there is by age (p , 0.001),
education (p , 0.001), income (p , 0.001, and race (p ,
0.001). The age groups split right at age 60, with those 60
and over having a lower score than those under 60. Higher
educational levels are associated with higher DONATT scores.
Persons with high school/vo-tech or less education have lower
scores than those with some college or a degree while those
who have some graduate school or a graduate degree have
higher scores than those with some college or an undergraduate degree. The income split occurs at $35,000. Those at or
above $35,000 are more positive than those under $35,000.
Whites and non-Black minorities have higher DONATT scores
than Blacks. These findings conform with prior research
(Wheeler and Cheung, 1996; Prottas, 1992).
Those who personally know a transplant recipient are more
favorable than those who do not (p 5 0.026). Those who have
donated blood also have a more favorable attitude toward organ
donation and transplantation than do those who have not
(p , 0.001). This also is confirmatory of prior research (Pessemier, 1977; Sanner, 1994a, 1994b; Horton and Horton, 1991).
The two characteristics that are significantly different both
by sample year and by DONATT scores are age and income.
Those over 60 years of age were progressively less represented
in the samples. The level of income also shows a slight decline
over the years of the study. These changes in income and in
age distribution would likely mitigate against each other in
Table 3. Proportion of Participants Reporting That They Have/Have
Not Signed an ODC by Year
Signed an
ODC?
Yes
No
1994
(n 5 161)
1995
(n 5 126)
1996
(n 5 142)
1997
(n 5 141)
28%
72%
37%
63%
50%
50%
44%
56%
x2 significant at ,0.01.
300
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T. J. Cossé et al.
Table 4. Proportion of Participants Who Strongly Agree or Agree
with the Statement “I would donate my organs after my death” and
Who Report That They Have/Have Not Signed an ODC by Year
Signed an
ODC?
Yes
No
1994
(n 5 109)
1995
(n 5 86)
1996
(n 5 99)
1997
(n 5 91)
39%
61%
54%
46%
67%
33%
63%
37%
x2 significant at ,0.01.
both attitude (DONATT scores) and behavior (a signed ODC).
The change in age distribution should provide an upward
bias and the change in income distribution should provide a
downward bias.
The results of this study are mixed. DONATT scores are
unchanged over the course of the four-year study but the
proportion of respondents who had signed an ODC had actually risen significantly over the years. Something had to be
at work to counteract the lack of enthusiasm for donation
manifested by some members of the public. That “something”
may have been the Ad Council/Coalition campaign. While
there are differences among various demographic segments
in their attitudes toward donation, the reality is that there are
large numbers in all camps who have favorable attitudes. The
need is to capitalize on those favorable attitudes.
While this gratifying upturn in signed ODCs has been
contemporaneous with the Ad Council/Coalition campaign,
it cannot be totally ascribed to it. Also contemporaneous with
the campaign (perhaps due to the campaign) was news media
attention concerning organ donation and transplantation. Such
famous recipients as Larry Hagman, Mickey Mantle, and David
Crosby, and such previously unknown donors as Nicholas
Green (the young American boy whose parents donated his
organs after he was killed by bandits in Italy) were in the
news. This news should have helped galvanize public attention
to the issue of organ recovery and donation. Parsing these
effects is obviously difficult, but there can be little doubt the
campaign was a major factor.
Management Implications
This study indicates that the organ procurement and transplantation community must continue in its quest to understand what motivates individuals to become—or not to become—organ donors and to employ sophisticated marketing
techniques to encourage donation. Special emphasis must be
placed on the Black community in particular. While Blacks
continue to demonstrate disproportionate need, they generally
exhibit a less positive attitude toward donation and transplantation than do whites.
One approach to gaining insights about motivations may
be to study blood donors. They are a readily identifiable
group that is more positively disposed to the concept of organ
Table 5. Results of Tests Comparing Samples on Demographic and
Experience Characteristics
Characteristic
Age
Education
Income
Race
Sex
Blood Donor
Know Recipient
Test
Significance
ANOVA
Kruskal-Wallis
ANOVA (K-W)
Kruskal-Wallis
ANOVA (K-W)
x2
x2
x2
x2
,0.01
0.31
,0.001
0.30
0.90
0.70
0.50
donation and transplantation than persons who have never
given blood. They have also displayed an intermediate behavior—more than a positive attitude, less than a signed ODC.
The older segment of the population is also less inclined
than the younger to favor organ donation. A cynical response
may be “So what?” because they are very poor potential donors.
The fact is that the best cadaveric donors are young accidental
death victims. That response is, however, far too facile. The
older relative may be the one who has to make the decision
to allow the recovery and transplantation of organs from a
deceased loved one. If not the parent of the deceased, the
older relative may be at least a strong personal influence on
the relative who has to make the decision. Perhaps the Ad
Council/Coalition might want to focus part of the campaign
on the scenario of offering sage advice in a trying moment.
While the attitude toward organ donation has remained
very stable over the course of the study (as shown by DONATT
scores), the action of signing an ODC has become more prevalent. The lesson in this may be that the Ad Council/Coalition
is correct when they emphasize: “Share your life; Share your
decision.” In other words, it is not enough to think positive,
one must act positive. This is definitely an example of shaping
behavior in a market for a high-involvement decision.
Limitations
Although probability samples were employed in every phase
of the study, the study was limited to the metro area of Richmond, Virginia. This is the headquarters of UNOS, so there
might have been an initial higher awareness of donation and
transplantation. There is, however, no direct evidence of this.
Projecting the findings beyond this area may be inappropriate.
Also, although the upturn in signed ODCs has been contemporaneous with the Ad Council/Coalition campaign, it
should not be totally ascribed to it. As noted, several newsworthy events transpired which may have had an impact on the
public’s perception of donation and transplantation. These
events must also be allowed as having had an impact—
whether positive or negative.
It should also be pointed out that the measure of action—
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2000:50:297–303
301
Table 6. Results of Tests Comparing DONATT Scores by Demographic and Other Characteristics
Characteristic
Test
Significance
Description of Results
Age
Education
ANOVA
ANOVA
,0.001
,0.001
Income
ANOVA
,0.001
Race
Sex
Blood Donor
Know Recipient
ANOVA
t
t
t
,0.001
0.580
,0.001
0.026
Persons under 60 have higher scores than those 60 and older
Persons with high school/vo-tech or less education have lower scores than
those with some college or a degree, who have lower scores than those with
some graduate school or a graduate degree
Persons with household income less than $35,000 have lower scores than those
with higher income
Blacks have lower scores than other minorities and whites
Males and females do not differ
Persons who have donated blood have higher scores than non-donors
Persons who know a transplant recipient have higher scores than those who
do not know a recipient.
Groupings used for analysis: Age ,30, 30–39, 40–49, 50–59, .59; Education: high school/vo-tech or less, some college, college degree, some graduate school or graduate degree;
Income: ,$35K, $35K–$64.9K, $65K–$95K, .$95K; Race: Black, other minority, white; Blood Donor: have donated, have not donated; Know Recipient: know an organ transplant
recipient, do not know an organ transplant recipient.
Note: Duncan’s multiple range test (a 5 0.05) was used in conjunction with ANOVA to test for differences between groups.
whether a respondent had signed an ODC—was a self-report
and cannot be verified. Further, no attempt was made to
determine if social desirability, or “yea-saying,” was at play in
participants’ responses.
Appendix
Cadaveric Organ Procurement and
Allocation in the United States
The National Organ Transplant Act (NOTA) of 1984 (as
amended in 1988 and in 1990), the Uniform Anatomical
Gift Act (UAGA), and the Sixth Omnibus Budget Reconciliation Act (SOBRA) provide the legal framework for organ
donation in the United States. NOTA specifically outlawed
the buying or selling of human organs and tissue and established the National Organ Procurement and Transplantation
Network (OPTN) (Prottas, 1993; UNOS, 1997). Note that
the use of financial incentives has been suggested by some
as a means of increasing donations. For further information,
see Altshuler and Evanisko (1992), Barnett et al. (1992),
Cossé and Weisenberger (1997), and Kittur et al.(1991).
The UAGA explicitly authorized the voluntary gifting of
body parts upon death and delineates a hierarchy of rules
governing how the gift may be stipulated and who may
commit the gift. The U.S. organ donation process is based on
explicit consent. Under explicit consent, individuals (adults)
decide if they wish to become organ donors. Typically commitment to be a donor is made by signing an organ donor
card (ODC)—which may be one’s state driver’s permit. By
law an individual’s wish to be a donor, as demonstrated by
an executed ODC, is a binding authorization to remove the
person’s organs after death regardless of the wishes of the
individual’s family. In the absence of an ODC, the UAGA
specifies which family members have a right to authorize a
donation—generally, the spouse of an adult or the parents
of a minor. SOBRA states that when there is no ODC, physicians and hospitals are required to present organ donation as
an option to the families of patients judged to be dying or
who have just died. This is referred to as required request
(Farrell and Greiner, 1993).
The actual recovery and distribution is conducted by notfor-profit organ procurement organizations (OPOs) (Alexander et al., 1992). All OPOs and transplant hospitals are required by law to be OPTN members. Currently there are 54
independent and 12 transplant-center-affiliated OPOs in the
United States. Upon notification by a hospital of a potential
donor, OPO staff contact the families of potential donors to
discuss the donation option, and if permission to recover
organs is granted, they enter necessary donor data into the
United Network for Organ Sharing (UNOS) computer system.
UNOS is a private, non-profit organization that holds federal
contracts to operate the OPTN and to maintain the U.S. Scientific Registry of Transplant Recipients. UNOS has specific
policies regarding standards of membership, organ allocation,
and data management. At this time the policies and standards
are not enforceable by law and are considered voluntary guidance to OPTN members (UNOS, 1997).
UNOS provides the OPO with a priority listing of potential
recipients. The first list generated is usually limited to patients
in the OPO’s service area. If a suitable recipient is not found
on that list, a regional list is generated, and finally a nationwide
list is obtained. The OPO then contacts the OPOs in the
areas where potential recipients are located. The donor’s OPO
maintains the donor and coordinates organ recovery, preservation, and transportation. The recipients’ OPOs (one donor’s
organs may go to a number of different recipients) arrange
the transplant activities—line up the transplant teams and
prepare the recipients for surgery. UNOS assists the recovery
and transplantation teams with organ matching and transportation (Benenson, 1991) and oversees the process to ensure
conformance with allocation rules, policies, and procedures.
302
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2000:50:297–303
In April 1998, the Department of Health and Human Services published the OPTN Rule requiring standardized criteria
for listing patients on the waiting lists and for determining
medical status (HHS 1998a). In addition, the rule eliminates
the current practice of first searching for recipients within the
recovering OPO’s service area. Further, it requires a nationwide search to find the person most in need of an organ(s).
The rule was set go into effect in July 1998 (see HHS, 1998b).
However, considerable opposition was expressed by members
of the procurement and transplantation community. In October 1998, the 1999 Omnibus Appropriations Act was passed.
The act places a one-year moratorium on the OPTN Rule.
During that year the act requires review of the OPTN policies
and a number of studies dealing with the impact of the OPTN
Rule on procurement and transplantation. Refer to the UNOS
homepage at www.unos.org and the Health Resources and
Services Administration homepage at www.hrsa.dhhs.gov for
regular updates on this issue (UNOS, 1998b).
For this article, the authors received the 1998 Steven J. Shaw Award for the
Best Conference Paper at the Annual Conference of the Society for Marketing
Advances.
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