Overcoming the impact of situationally induced
anxiety on would-be donors
Final Report
September, 2013
Authors:
Associate Professor Barbara Masser, The University of Queensland, Australia
Ms Faye Nitschke, The University of Queensland, Australia
Dr. Nicole Doherty, The University of Queensland, Australia
On behalf of:
Associate Professor Barbara Masser, The University of Queensland, Australia
Dr. Melissa Hyde, Griffith University, Australia
Professor Chris France, Ohio University, U.S.A
Dr. Geoff Smith, the Australian Red Cross Blood Service.
TABLE OF CONTENTS
Page Number
ABSTRACT
4
EXECUTIVE SUMMARY
6
Aims and Objectives
6
Principal Findings and
Conclusions
7
APPLICATIONS AND RECOMMENDATIONS
8
BACKGROUND AND OBJECTIVES
10
Current Study
15
Aims and Objectives
16
Hypotheses
16
METHODS AND MATERIALS
18
Participants
18
Study Design, Treatment and
Materials
19
Spielberger State-Trait Anxiety Inventory
20
Attitude
20
Subjective Norm
20
Blood Donation Self-efficacy
21
Intention to Donate
21
Donation Behaviour
21
RESULTS
26
Descriptive and Reliability
Statistics
26
Statistical Analyses
27
State Anxiety
28
Attitude
28
Subjective Norms
29
Blood Donation Self-efficacy
29
Intention to Donate in the Next 30 Days
30
1
Exploratory Analyses
31
Donation Behaviour
33
Correlation between Donation Intention and
Behaviour
34
Summary of Results
34
DISCUSSION
36
Utilising the Modified Brochure
40
Benefits to the Blood Service
40
Methodological Limitations
41
Future Research Directions
41
Conclusion
42
REFERENCES
44
ACKNOWLEDGEMENTS
49
APPENDICES
50
Appendix A
Standard Blood Donation Brochure
50
Appendix B
Modified Blood Donation Brochure
(intervention)
54
Appendix C
Survey Items
61
2
LIST OF FIGURES
Page
Figure 1.
Location and photographs of
MCU (UQ St Lucia)
24
Figure 2.
Procedure flow chart
25
Influence of MCU on anxiety
28
Figure 4.
Influence of brochure type on
donation self-efficacy
30
Figure 5.
Interaction of participant gender
and MCU presence on selfefficacy
30
Figure 6.
Interaction of brochure and MCU
presence on intention to donate
31
Figure 7.
Moderated mediated relationship
between brochure type, blood
donation self-efficacy, intention
to donate and affective state.
32
Figure 8.
Influence of brochure type on
presentation to donate
33
Figure 3.
LIST OF TABLES
Page
Table 1.
Distribution of participants in
experimental conditions
18
Table 2.
Descriptive and reliability
statistics for dependant
variables
26
3
ABSTRACT
BACKGROUND: Understanding how to convert non-donors to donors is a continuing challenge for
blood collection agencies (BCAs) worldwide. Anxiety about donation has been identified as a key
deterrent for non-donors who otherwise are positive towards blood donation (e.g. Clowes & Masser,
2012). As such, there is a clear need for BCAs to explore ways of helping non-donors overcome their
anxiety in order to expand the current donor panel and stabilise the blood supply. Building on past
work, the current research sought to explore the relationship between blood collection related
environmental stimuli (e.g. a mobile collection unit) and donation anxiety in non-donors. Further,
the effectiveness of a modified recruitment brochure in helping these non-donors build their
confidence to attempt to donate and was also assessed.
STUDY DESIGN AND METHODS: A field study comprising a 2 (affective state: hot, cold) x 2
(recruitment brochure: standard, modified) between-subjects design was conducted. Participants
were 922 donation eligible non-donors who were recruited in two waves of data collection.
Participation occurred either in the presence (hot affective state) or absence (cold affective state) of
a mobile collection unit (MCU). Participants read either a modified recruitment brochure or a
standard Blood Service recruitment brochure and completed self-report measures of their
orientation towards donation (attitude, subjective norm and self-efficacy), anxiety and donation
intentions. Data on blood donation behaviour by participants was provided by the Blood Service
(wave 1 of data collection) or via email self-report from the donor (wave 2 of data collection). The
self-report data collected in wave 2 of data collection was then corroborated by behavioural data
from the Blood Service donor records.
RESULTS: Non-donors recruited in the presence of the MCU were significantly more anxious than
non-donors recruited in the absence of the MCU. The modified brochure increased non-donors’
donation self-efficacy and, in turn, their intentions to donate blood. Critically, for those non-donors
recruited in the presence of the MCU, under conditions which provoked high donation anxiety, those
who read the modified brochure reported significantly stronger donation intentions than those who
4
read the standard Blood Service brochure. Further, those non-donors who read the modified
brochure were 3.56 times more likely to attempt to donate blood within the subsequent 30 days
than those who read the standard Blood Service brochure.
CONCLUSION: The presence of the MCU provokes anxiety in donors. However, non-donors selfefficacy, intention, and blood donation behaviour can be bolstered by the use of a modified
recruitment brochure.
5
EXECUTIVE SUMMARY
Aims and Objectives
Donor recruitment is critical to ensuring a stable and sufficient donor panel for blood
collection agencies (BCAs). While non-donors generally have a positive orientation towards blood
donation, they are prevented from donating by a range of psychological barriers including anxiety
(Clowes & Masser, 2012; McMahon & Byrne, 2008). However, despite the need to help non-donors
to overcome psychological barriers to expand the donor panel, relatively little is known about
precisely when in the blood donation recruitment process anxiety may be experienced and how this
impacts on non-donors donation decision-making. While prior analyses have attributed anxiety and
fear to the presence of needles or the sight of blood (Ditto & France, 2006; France, Montalva, France
& Trost, 2008; Piliavin, 1990), Clowes and Masser (2012) found that the mere presence of blood
donation paraphernalia, in the absence of needles and/or blood, was sufficient to increase nondonors anxiety about donating. Further, ways to overcome this anxiety to improve the recruitment
of non-donors have not been systematically evaluated in the Australian context. Building on a
substantial body of research conducted in the U.S. by France and colleagues (e.g. France, France,
Kowalsky & Cornett, 2010; France et al., 2008), the findings of Masser and France (2010) suggest that
modifying recruitment brochures may be a cost-effective way for BCAs to boost non-donors’ selfefficacy, donation intentions and donation behaviour.
The current research sought to quantify the impact of environmental cues to blood donation,
in the form of mobile collection units (MCUs), on non-donors anxiety about blood donation as well as
assessing the effectiveness of a modified recruitment brochure in bolstering non-donors self-efficacy
to cope with this anxiety. Therefore, the first aim of this study was to assess the impact of a MCU on
non-donors anxiety and general orientation towards blood donation (assessed by measures of
attitudes, subjective norms and donation self-efficacy). The second aim was to assess whether a
6
modified donor recruitment brochure could bolster non-donors’ self-efficacy and intention to donate
as well as increasing donation behaviour, even in the presence of a donation anxiety inducing
environmental cue.
Principal Findings and Conclusions
In line with the hypothesis, the MCU significantly increased non-donors’ anxiety in relation to
blood donation. The presence of the MCU also decreased women’s confidence in their ability to
donate blood. However, the modified brochure boosted non-donors’ confidence about donating
blood and in turn, this brochure also had a positive impact on non-donors’ intentions to donate.
Specifically, when the MCU was present the intention to donate was stronger for those exposed to
the modified brochure in comparison to those exposed to the standard Blood Service brochure.
Further, the odds of non-donors’ engaging in blood donation behaviour after reading the modified
brochure was 3.56 times higher than after reading the standard Blood Service brochure. Overall,
environmental cues to blood donation (e.g., the presence of MCU) induce anxiety in non-donors.
However, confidence in the ability to donate blood, intentions to donate blood and actual blood
donation behaviour can be bolstered by exposure to specially designed brochures that contain easily
implemented coping strategies for common fears associated with blood donation.
7
APPLICATIONS AND RECOMMENDATIONS
Applications
In combination with work by Clowes and Masser (2012), our research show that
environmental cues to blood donation, such as MCUs, and Blood Service promotional materials
induce anxiety in non-donors. Potentially, this presents a problem for BCAs as recruiting outside
MCUs and collection centres for walk-in appointments are a valuable opportunity to recruit new
donors using a personalised approach and the use of promotional materials are integral parts of the
Blood Service’s recruitment strategy. The results of the current evaluation demonstrate that these
potential problems can be overcome by the use of a modified recruitment brochure. In comparison
to standard Blood Service recruitment materials (see Appendix A), the modified brochure (see
Appendix B) improves blood donation self-efficacy, strengthens intentions to donate and increases
blood donation behaviour. As such, the modified brochure will both allow the Blood Service to
successfully recruit non-donors to walk-in appointments, capitalising on the prominent visual
reminders of blood donation present at MCUs and at collection centres as well as impacting
positively on those donors recruited in affectively cold contexts (such as via the National Call Centre).
Recommendations
On the basis of this research, it is recommended that the modified brochure be implemented
by the Blood Service as a BAU communication tool with current non-donors. This will allow for the
effective recruitment of non-donors:
1. In the presence of strong visual reminders of blood donation, which may induce anxiety,
including MCUs and large-scale promotional Blood Service promotional materials (e.g. stalls
or billboards).
2. In low anxiety contexts (e.g. those non-donors recruited through calls from the National Call
Centre)
8
In making this recommendation it is acknowledged that the modified brochure is longer than the
standard Blood Service recruitment one. As analyses were conducted on an intention-to-treat basis,
it appears that reading and comprehension of the modified material is not an issue for participants.
However, the relative cost of production of the modified brochures may be higher for the Blood
Service than the cost of producing the standard brochures. With this in mind a final
recommendation is that:
3. Additional research is undertaken to determine the specific elements of the modified
brochure that result in non-donors experiencing heightened self-efficacy, stronger intentions
and engaging in greater donation behaviour.
9
BACKGROUND & OBJECTIVES
Donor recruitment is an ongoing challenge to blood collection agencies (BCAs) (McVitte,
Harris & Tiliopoulos, 2006; Stephen, 2001). While a number of theories have been applied to
understand what motivates an individual to initially become and then remain a donor (Ferguson,
1996; Piliavin & Callero, 1991), one of the most enduring psychosocial theories applied in this area
has been the Theory of Planned Behaviour (TPB; Azjen, 1991). In the context of blood donation, the
TPB views individual intention to donate as the most proximal determinant of donation behaviour.
In turn, intention is derived from would-be donors’ attitudes towards donation (i.e., positive or
negative evaluation of donating blood) and their perceived control or self-efficacy over donating (i.e.,
confidence in their ability to be able to donate; Masser, White, Hyde, Terry & Robinson, 2009). The
third theoretical predictor of intention, subjective norm (i.e., the perception of important others’
support or not for the behaviour) has been less reliably linked to intention among non-donors and
experienced donors in past research (e.g., France, France & Himawan, 2007; Masser, White, Terry &
Hyde, 2008) but may still inform the decision to donate blood.
While the TPB is a good ‘base’ model in the context of blood donation, a number of issues
arise when applying it to account for the conversion of non-donors to donors. In a number of
analyses, non-donors’ attitudes, subjective norm, perceived control and intentions to donate are, on
average, neutral to positive in orientation (McMahon & Byrne, 2008; Robinson, Masser, White, Hyde
& Terry, 2008). This positivity towards donation contrasts sharply with this groups’ non-donation
behaviour. In one of the few analyses to use the TPB to examine non-donors behaviour, McMahon
and Byrne (2008) found that, in a sample comprising a majority of non-donors, although 57 out of
172 participants expressed a strong intention to donate, only 3 subsequently visited the blood
collection site.
In attempts to improve the predictive ability of the TPB, the basic model has been extended
to account for other influences on behaviour (France et al., 2007; Lemmens et al., 2009; Masser et al.,
10
2008; Robinson et al., 2008) . One such extension has involved a consideration of the influence of
affective reactions on blood donation intentions and behaviour (Ferguson, France, Abraham, Ditto &
Sheeran, 2010). In relation to blood donation, it has been suggested that would-be donors may
experience fear (France et al., 2008; Piliavin, 1991) or anxiety surrounding the paraphernalia
associated with blood donation (e.g., needles, exposure to blood; Bartel, Stelner & Higgins, 1975;
Ditto, Gilchrist & Holly, 2012; Sojka & Sojka, 2008) or the potential for pain (Ditto & France, 2006).
For some non-donors this anxiety results in them avoiding opportunities to donate blood. Our own
pilot research (Masser, 2012) attests to this – using a qualitative methodology, 80 Australians who
were eligible to donate blood were asked to indicate in their own words why they didn’t donate. The
most common theme in their responses centred on the anxiety that the thought of phlebotomy
elicited in them (e.g., “I’ve often seen the blood van and shuddered at the thought of what’s actually
going on inside…”). For those non-donors who are able to overcome their anxiety and attend a blood
collection site the experience may still be less than optimal. Pre-donation anxiety has been
consistently linked to a greater chance of experiencing a vasovagal reaction when donating (France
et al., 2012; Labus, France & Taylor, 2000; Meade, France & Peterson, 1996). Experiencing a
vasovagal reaction in turn results in those donors being less likely to return to donate again (Ditto &
France, 2006).
Within the TPB, affective reactions have traditionally been subsumed within the cognitions
comprising an individual’s attitude towards a behaviour (c.f. Fraley & Stasson, 2003; Godin et
al.,2005; Veldhuizen, Ferguson, de Kort, Donders & Astma, 2011). However, previous blood donation
research has found respondents’ anticipated affect – in the form of both regret (Godin et al., 2005;
Godin, Connor, Sheeran, Belanger-Gravel & Germain, 2007; Masser et al., 2009; Robinson et al., 2008)
and anxiety to account for additional variance in respondents’ intentions to donate (Lemmens et al.,
2009; Masser et al., 2009; Robinson et al., 2008). Specifically, (would-be) donors’ anxiety about
donating has been found to be either a direct predictor of intention (Masser et al., 2009) or an
indirect predictor with its influence mediated through attitudes (Robinson et al., 2008) or attitudes
and self-efficacy (Lemmens et al., 2009). The extant research has typically only focused on
11
anticipated emotions – that is, emotions that are rationally expected to be experienced if the
respondent were to present to engage (or not) in blood donation (Baumgartner, Pieters, & Bagozzi,
2008). In contrast to this rational perspective on the impact of emotion, Clowes and Masser (2012)
drawing on Loewenstein and Lerner (2003) argue that emotions may impact on blood donor
decision-making in a more immediate way (Ferguson et al., 2007). Specifically, noting that for some
the presence of paraphernalia associated with blood donation is anxiety provoking (Ditto & France,
2006), Clowes and Masser (2012) proposed that blood donation may be an affectively ‘hot’
behaviour (Loewenstein & Lerner, 2003).
Within the broad decision-making literature (Loewenstein, 1996; Van der Plight, Zeelenberg,
van Dijk, de Vries & Richard, 1998) the critical importance of arousal experienced as a function of the
immediacy of the decision-making context is well established. This research suggests that people
have a ‘hot’ self ruled by intense affect and a ‘cold’ non-emotional self (Nordgren, Van der Plight &
Van Harreveld, 2008). In considering these selves, a so-called empathy gap has been documented.
Specifically, individuals in one affective state are unable to predict their preferences, decisions, and
behaviour in their other affective state. Evidence of this affective error has been found in a broad
range of health domains (Christensen-Szalanski, 1984; Loewenstein, Nagin & Paternoster, 1997;
Norris et al., 2009), but has not yet been systematically explored in relation to blood donation.
In an initial consideration of the empathy gap in the context of blood donation, Clowes and
Masser (2012) proposed that a cold-to-hot empathy gap may operate. That is, affectively ‘cold’
respondents who think about blood donation while not in a situation where blood donation
paraphernalia is present may systematically underestimate the impact of anxiety (induced by the
presence of blood donation paraphernalia) on their donation decision-making (Nordgren et al., 2008;
Loewenstein, 1996). Consistent with this assertion, Clowes and Masser (2012) found that
participants tested in an standard University laboratory (an affectively cold state) reported
significantly lower anxiety, along with more positive attitudes, subjective norms, self-efficacy and a
12
stronger intention to donate blood than participants who completed the same measures in a room
containing blood donation paraphernalia (an affectively hot state).
While Clowes and Masser (2012) provide important initial evidence for the existence of a
cold-to-hot empathy gap in relation to blood donation, their analysis is limited. First, due to practical
constraints they only explored intention to donate rather than donation behaviour. However, both
theoretically and practically a focus on actual donation behaviour is critical (Ferguson et al., 2007;
Masser et al., 2008). Theoretically, a cold-to-hot empathy gap may explain the poor correspondence
between (cold) intention and (hot) behaviour observed in previous blood donor TPB research
(McMahon & Byrne, 2008). Practically, the cold-to-hot empathy gap may also, at least partially,
explain the failure of those recruited in cold contexts (such as via the National Call Centre or in the
absence of the blood mobile) to attend their scheduled appointments to donate blood (Bosnes,
Aldrin, & Heier, 2005). However, to date, these assertions remain untested.
A second limitation of the Clowes and Masser (2012) study was that it was undertaken in a
University laboratory setting. While this context was sufficient to elicit the hypothesised cold-to-hot
empathy gap, Clowes and Masser (2012) note that their ‘hot’ condition comprising blood donation
paraphernalia (such as promotional posters, gloves, blood collection tubes, band aids, and
tourniquets) may only represent a ‘warm’ cognition condition in comparison to the affective heat
that a real donation context may elicit. Drawing on Goette, Stutzer, Yavuzcan, and Frey (2009) there
remains a need to establish the impact of hot cognition on donation behaviour in a field setting.
The impact of the presence of blood donation paraphernalia and its subsequent effects in
terms of anxiety and lowered intention to donate demonstrated by Clowes and Masser (2012)
suggests a potential recruitment problem for BCAs. Specifically, those who feel positively towards
blood donation may be deterred from actually donating by the presence of the paraphernalia
associated with phlebotomy. Arguably this may suggest that the paraphernalia or imagery associated
with blood donation should be minimised in early stage recruitment strategies. Alternatively, and
given that the paraphernalia associated with blood donation is typically an essential part of the
13
phlebotomy process, a more effective process may be to intervene directly at the point where the
good intentions of would-be donors waver. While how to do this is not immediately clear from the
hot/cold cognition literature, some suggestion is given by a secondary analysis of the data collected
by Clowes and Masser (2012) undertaken by CI Masser. Specifically, these results suggest that
intervening to bolster would-be donors’ self-efficacy may yield positive effects; for donors in Clowes
and Masser’s (2012) affectively hot condition, the relationship between anxiety and intention was
mediated by self-efficacy (i.e., confidence in their own ability to donate). That is, the significant
relationship between anxiety and intention was reduced to non-significance when self-efficacy was
introduced into the regression equation.
One mechanism, which has been demonstrated to be effective in bolstering would-be donors’
self-efficacy, is through the use of specially designed recruitment brochures. In a series of studies,
France and colleagues (France et al., 2008; France et al., 2010; Masser & France, 2010) have
demonstrated that brochures comprising educational information, responses to common donor
concerns about fear, pain and the potential for adverse reactions, and information on validated
coping strategies for use before, during and after donation bolster the positivity and attendance of
donors in comparison to control brochures. Specifically, France et al. (2008) established that
participants who read a modified brochure reported significantly lower anxiety, more positive
attitudes, greater self-efficacy and a stronger intention to donate in comparison to those participants
exposed to control brochures. A partial replication and extension of this in an Australian context
with non-donors by Masser and France (2010) also demonstrated that the modified brochure
resulted in heightened self-efficacy, greater intention and fewer anticipated vasovagal reactions than
exposure to a standard Blood Service recruitment brochure. France et al. (2010) extended this
analysis to consider participant’s willingness to sign up to volunteer for blood donation. They found
that those exposed to the modified brochure were more willing to sign up to donate blood than
those exposed to either a blood centre brochure or a non blood donation brochure. Further, this
greater willingness to volunteer by those in the modified brochure condition was found to be driven
by the heightened self-efficacy provided by exposure to the modified brochure.
14
In sum, the recent body of research on the impact of modified educational brochures
strongly suggests that these brochures bolster would-be donors’ self-efficacy, with resultant positive
effects both in terms of intention to donate (France et al., 2008; Masser & France, 2010) and
willingness to volunteer to donate blood (France et al., 2010). Given the key role of self-efficacy in
mediating the relationship between situationally induced anxiety and intention to donate
demonstrated by CI Masser in the secondary analysis of Clowes and Masser’s (2012) data, this
suggests that intervening with specially designed brochures may be sufficient to overcome the
hypothesised impact of situationally induced anxiety on donor behaviour. The aim of the proposed
research is, therefore, to test this hypothesis using a 2 (affective state: hot, cold) x 2 (recruitment
brochure: standard, modified) between-subjects design in a field setting.
The Current Study
This study is the first to examine the impact of a strong affective environmental cue in the
field, a MCU, on would-be donor’s orientation towards donation (measured by attitudes, subjective
norms and self-efficacy) and donation anxiety and then to examine whether a modified recruitment
brochure can improve donation self-efficacy, intention and behaviour. Understanding the impact of
environmental cues which induce anxiety in would-be donors and developing cost effective means of
intervening to improve donation self-efficacy may assist the Blood Service to improve the success of
current recruitment practices.
15
Aims and Objectives
The aims and objectives of the current study were as follows:
1.
To assess whether, consistent with Clowes and Masser (2012), the presence of blood
donation paraphernalia in a field setting induces anxiety in non-donors which results in a
decrease in their self-efficacy, intention to donate, and blood donation behaviour.
2.
To determine whether, consistent with France et al. (2008), France et al., (2010) and Masser
and France (2010) this decrease in self-efficacy, intention to donate and blood donation
behaviour can be ‘corrected’ by the use of specially designed blood donation recruitment
brochures.
Hypotheses
1.
Non-donors recruited in the affectively cold condition (in the absence of the MCU) will report
lower anxiety and a more positive orientation to blood donation (evidenced by more positive
attitudes, subjective norms and self-efficacy) and a stronger intention to donate blood than
non-donors recruited in the affectively hot condition (presence of the MCU).
2.
Because of the hypothesized cold-to-hot empathy gap, the association between non-donors’
donation intentions and actual donation behaviour will be stronger in the affectively hot
condition than in the cold condition.
3.
Non-donors who receive the modified brochure will generally have a more positive
orientation to blood donation (evidenced by more positive attitudes, subjective norms and
self-efficacy), a stronger intention to donate blood and greater donation behaviour than nondonors who receive the standard Blood Service recruitment brochure.
4.
The main effect of the modified brochure will be accentuated in the affectively hot condition.
Specifically, non-donors who receive the modified brochure will report lowered anxiety,
along with a more positive orientation to blood donation (evidenced by more positive
16
attitudes, subjective norms and self-efficacy), a stronger intention to donate blood and
greater donation behaviour than those receiving the standard Blood Service recruitment
brochure.
17
METHOD AND MATERIALS
Participants
A total of 1197 participants were recruited from the University of Queensland, St Lucia
campus in the periods 14 August – 7 September 2012 and 28 February – 15 March 2013. During each
data collection period, participants were recruited one week prior to the arrival of the mobile
collection unit (MCU), during the two weeks of the MCU presence, and in the week after the MCU
had departed. During this time, participants were randomly allocated to one of the two brochure
conditions (standard Blood Service recruitment brochure or modified recruitment brochure).
Although 1197 participants were recruited, in order to be eligible to participate, participants needed
to believe they were eligible to donate blood at the outset of the study and to not have previously
attempted to donate blood. From the original sample, 922 participants met these criteria as
indicated by screening questions included on the questionnaire. Data was subsequently retained and
analysed for these participants only. The mean age of the final sample was 22.22 years (Median = 20
years; SD=6.53) with a range from 16-66 years. Of these 362 (39.3%) were men and 727 (60.4%)
were women. Three participants (0.3%) failed to indicate their gender. Table 1 shows the
distribution of participants across conditions.
Table 1. Distribution of participants across conditions
Brochure
Presence of
Total
Modified
Control
Hot (yes)
272
252
524
Cold (no)
192
206
398
464
458
922
mobile collection
unit (MCU)
Total
Note. Modified is the brochure designed for this study; Control is the standard blood service
brochure
18
Study Design, Materials and Procedure
The design of the study was a 2 (affective state: hot, cold) x 2 (recruitment brochure:
standard, modified) between-subjects design that was conducted in a field setting.
All participants were recruited at the St. Lucia campus of the University of Queensland in the
vicinity of where the MCU is located when present (see Figure 1). The St. Lucia campus is the
largest of the University of Queensland sites with approximately 32,000 students in attendance. In
the week prior to the MCU visiting and the week after it had visited, participants were recruited for
the affectively cold condition. In the two weeks while the MCU was present, participants were
recruited for the affectively hot condition. Specifically, individuals in the vicinity of where the MCU
was going to be located were approached by a research assistant and asked whether they had
donated blood. Those participants who said ‘no’ to this screening question were invited to
participate in the current study and were provided with an information sheet that provided sufficient
detail about the current study to enable participants to provide informed consent.
Those non-donors who agreed to participate were then provided with an envelope
containing a recruitment brochure, a post brochure questionnaire, an additional unsealed envelope
containing consent for the behaviour follow-up, and a post questionnaire eligibility assessment sheet
(see Figure 2 for a procedure flow chart). Participants were asked to a) read the brochure, b)
complete the post brochure questionnaire and then -- if they wished -- c) complete the consent for
the behaviour follow-up. In addition, they were also asked to complete the post-questionnaire
eligibility assessment sheet. This assessment sheet asked participants to indicate their current
eligibility to donate blood by the use of the current Blood Service screening questions
(http://www.donateblood.com.au/ become-a-donor/am-i-eligible-to-give-blood). The two
recruitment brochures were distributed equally between the envelopes and the envelopes were
randomly allocated to participants. The research assistant was thus blind to the brochure condition
until after the instructions to participate had been provided. Participants either received a standard
Blood Service recruitment brochure (see Appendix A) or an updated version of the modified
19
brochure assessed in Masser and France (2010; see Appendix B) In line with France et al. (2008;
2010), this brochure included information derived from previous analyses of Australian non-donors
(Robinson et al., 2008) along with a coping strategy narrative from a first-time donor (France et al.,
2008).
The post-brochure questionnaire included a number of standardised scales to assess a
variety of constructs, including anxiety, attitude, subjective norm, self-efficacy and intention to
donate:
Six-item short form state scale of the Spielberger State-Trait Anxiety Inventory
The six item short form state scale of the Spielberger State-Trait Anxiety Inventory (Marteau
& Bekker, 1992) measures transient subjective feelings of apprehension, tension, nervousness and
worry (Spielberger et al., 1970). Example items are: “I feel calm” and “I am relaxed” and participants
respond on 1 (not at all) to 4 (very much so) scales (for all items see Appendix C). Total scores range
from 6 to 24, with higher scores after recoding of the relevant items indicating greater anxiety.
Based on Theory of Planned Behaviour research (e.g. Masser et al., 2009), standard measures
of attitudes, subjective norms, self-efficacy and intention were used.
Attitude Towards Donation
Attitudes towards blood donation were assessed using six semantic differential items.
Participants were asked “For you donating blood in the next month would be” and responded on a 7
point scale with the following bipolar anchors: Unpleasant-Pleasant, bad-good, unsatisfyingsatisfying, pointless-worthwhile, unrewarding-rewarding, stressful-relaxing. Scores on each item
were summed to form a total score for each participant and a maximum score of 42 was possible.
Subjective Norm about Donation
Subjective norms were measured using 2 items from based on past research (e.g. Robinson
et al., 2008). Responding on a 7 point scale, from strongly disagree to strongly agree, participants
indicated their agreement with the following statement: “People who are important to me would
20
recommend that I donate blood in the next month” and “People who are important to me would
think that I should donate blood in the next month”. These items were summed to form a composite
with a possible maximum score of 14.
Blood Donation Self-efficacy
Blood donation self-efficacy, indicating participants’ sense of competence to deal with a
negative donation reaction, was measured using 6 items from France et al. (2008). Participants
indicated their agreement with each statement on a 7-point scale ranging from strongly disagree to
strongly agree with a midpoint of neither agree nor disagree. Example statements are: “I feel
confident that there are things I can do to keep from having a bad blood donation experience” and “I
am able to reduce the intensity of a negative reaction such as faintness, dizziness, weakness,
lightheadedness or nausea” (for all items see Appendix C). The score on these items was summed to
form a composite, with a maximum possible score of 42. Higher scores on this composite were
indicative of participants feeling they were more capable of coping with a possible negative reaction
to donating blood.
Intention to Donate
Intention to donate, representing participants’ intentions to donate in the next month, was
measured using 4 items. Participants indicated their agreement on a 7 point scale ranging from
strongly disagree to strongly agree. Sample items included: “I intend to donate blood in the next
month” and “I intend to visit a blood collection centre in the next month to attempt to donate blood”
(for all items see Appendix C). A summed composite score was formed with a maximum possible
score of 28. Higher scores on this measure indicate stronger intentions to donate within the next
month.
After completion of these measures, participants indicated their consent to participate in the
behavioural follow up. Across both waves of data collection, consent was provided by 659
21
participants for follow up with the Blood Service. In addition, in wave 2, consent was provided by 302
participants for follow up via email.
Donation Behaviour
In wave 1 data collection, behaviour was measured through data extraction from Blood
Service donor records. Participants were asked to indicate their age and gender and to generate a
code identifier. The code identifier was used in the consent for the behaviour follow-up. Specifically,
on a separate consent form, participants were asked to provide their code identifier, along with their
name and date of birth to allow the tracking of any donation behaviour that participants engaged in
over a specified 1 month period. This consent form was sealed in a separate envelope by
participants and returned to the research assistant. These envelopes were then sent to the Blood
Service who, after a designated period, extracted data to determine whether any of the participants
in the current study had donated blood in the intervening period. The resultant behavioural data
was provided to CI Masser using only the code identifiers generated by participants. For wave 1,
behaviour was operationally defined as presenting to donate and successfully donating blood.
Due to the low number of participants for whom blood donation behaviour could be
identified using this method and problems in the identification of participants in the Blood Service
records the methods for tracking behaviour was altered for wave 2 of data collection. Following
approval by UQ and Blood Service ethics, in wave 2 data collection, in addition to being asked to
consent to the behavioural follow up through the Blood Service donor records, participants were also
asked to consent to a self-report email behavioural follow up. To measure self-report behavioural
data, participants were asked to consent, on a separate form, to be contacted by email by the
researchers in 30 days time to respond to a single follow up question. Thirty days after completing
the survey, participants were contacted by the research team via email and asked to respond yes or
no to the question “Within the last if 30 days did you attend a mobile blood unit or collection centre
with the intention to donating blood?”. Self-report data was corroborated by behavioural data
extracted from the Blood Service donor records. In wave 2, behaviour was operationally defined as
22
presenting to donate blood and donating successfully or presenting to donate but being unable to
donate due to circumstances outside their control. This operational definition was employed so that
the behaviour of non-donors who were temporarily ineligible or prevented from donating for
practical reasons (e.g. due to taking antibiotics for a recent illness or there not being donation
appointments available) could be measured. Participants were coded positively for behaviour if they
reported performing behaviour (according to the operational definition) via email follow up or if
presented or donated blood according to the Blood Service donor records.
In wave 2 behavioural data, a mismatch was found between the number of donors who
reported that they had donated blood in response to the email follow up and data extracted from
Blood Service donor records. In response to the email follow up, 22 participants reported they had
presented at a MCU or collection centre to donate blood, however, donor records for 10 of these
participants were extracted from Blood Service donor records.
At the end of the study (or when participants decided to terminate participation),
participants were provided with a) the chance to enter a prize draw (as by way of a thank you for
their participation) and b) an email address through which they could request further information
about the study and relevant references.
23
Figure 1. Location of MCU at UQ St Lucia, photographs of MCU present (affectively hot condition)
and absent (affectively cold condition)
MCU located here
24
Figure 2. Procedure flow chart
MCU
Present/Modified
Brochure (n=272)
Did not
consent
(n=263)
MCU
Present/Standard
Brochure (n=252)
Eligible to
donate
(n=922)
Blood donor
records follow
up (wave 1 & 2)
Consented
(n=659)
Behavioural
follow up
MCU
Absent/Modified
Brochure (n=192)
Email self-report
follow up (wave
2 only)
Consented
(n=302)
Recruited
(N=1197)
Not eligible to
donate
(n=275)
Did not
consent
(n=101)
MCU
Absent/Standard
Brochure (n=206)
25
Did not reply
(n=103)
Replied
(n=179)
Email
undeliverable
(n=20)
RESULTS
Descriptives and Reliability Statistics
The descriptive and reliability statistics for the composites of key variables are presented in
Table 2.
Table 2. Mean scores, standard deviations, reliability coefficients and correlations for Anxiety,
Attitude, Subjective Norm, Self-efficacy and Intention.
Constructs
Reliability
coefficient
Mean
Scores
Anxiety
(STAI)
Attitude
Subjective
Norm
Donor
Selfefficacy
Donor
Intention
-
-.304**
-.151**
-.444**
-.324**
-
.254**
.326**
.381**
-
.207**
.365**
-
.347**
Anxiety (STAI)
(n=898)
.87
12.12
(4.43)
Attitude
(n=885)
.82
28.49
(8.00)
Subjective Norm
(n=917)
Blood Donor SelfEfficacy
(n=911)
Donation Intention
(n=908)
.89
r=.80***
.91
.95
8.82
(3.18)
30.49
(7.57)
10.92
(5.05)
-
Several one-sample t-tests were conducted to assess whether the mean (for the whole
sample) was significantly different to the scale midpoint for each variable, to assess the orientation,
anxiety and intentions towards blood donation in the participants of the current sample. For state
anxiety, the sample mean (M = 12.12) was significantly below the midpoint of the scale (15.00),
indicating that the participants were not generally anxious, t(914) = 19.63, p <.001. Overall,
participants had a positive orientation towards blood donation (as measured by attitude, subjective
norms and self-efficacy about blood donation). Participants’ attitude scores (M = 28.49) were
26
significantly higher than the scale midpoint (21.00), t(917) = 28.37, p <.001, indicating that overall
participants had a positive attitude towards blood donation. Similarly, participants’ subjective norm
scores (M = 8.81) were significantly higher than the scale midpoint (7.00), t(918) = 17.35, p<.001, and
participants’ self-efficacy about blood donation scores (M = 30.48) were also significantly higher than
the scale midpoint (21.00), t(916) = 37.98, p <.001. In contrast, participants’ intention to donate
blood scores (M = 10.92) were significantly below the scale midpoint (14.00), t(910) = 18.42, p<.001,
suggesting that as a whole participants in the sample did not intend to donate blood within the next
30 days.
Statistical Analyses
As participant gender effects have been found in a variety of prior analyses focusing on
anxiety in relation to blood donation (e.g., Ditto & France, 2006) an initial series of exploratory
analyses of covariance (ANCOVAs) were run. These examined the impact of condition on the main
dependent variables (anxiety, attitude, subjective norm, self-efficacy, intention, behaviour) with
affective state (hot, cold) and brochure (standard, modified) as the predictors and gender as the
covariate. In multiple instances, gender was found to be a significant covariate and so the analyses
were re-run as analyses of variance (ANOVAs) with participant gender as an additional predictor. An
intention-to-treat approach was taken to data analysis; that is the responses of all participants
allocated to conditions were retained for analysis. A series of 2 affective state (hot/MCU present,
cold/MCU absent) x 2 brochure (standard, modified) x 2 gender (male, female) ANOVAs were
conducted on the measures of anxiety, attitude, subjective norm, self-efficacy and intention to
donate. Mediation and moderation analyses were undertaken to explore the relationship between
the predictors, self-efficacy and intention. Finally loglinear analyses were conducted to examine the
impact of condition of the behaviour of participants. Due to low cell sizes, this analysis was followed
up with chi-square analyses. Differences were considered significant for probability values (p) less
than or equal to 0.05.
27
State Anxiety
A 2 affective state (hot/MCU present, cold/MCU absent) x 2 brochure (standard, modified) x
2 gender (male, female) ANOVA was conducted on the summed state anxiety scale from the shortform STAI. This showed a significant main effect of gender, F (1,904) = 40.61, p<.001, 2 = .04, with
women reporting significantly more anxiety (M = 12.84, SE = 0.19) than men (M = 10.94, SE = 0.23).
In addition, there was a significant main effect of affective state, F (1,904) = 4.23, p<.05, 2 = .01,
with those participating with the MCU present (hot condition) reporting significantly more anxiety (M
= 12.20, SE = 0.19) than those participating in the absence of the MCU (cold condition; M = 11.58, SE
= 0.23, see Figure 3). These results show that the presence of the MCU significantly increased nondonors’ anxiety in relation to blood donation. The main effect of brochure and all higher order
interactions were non significant (all F s < 1.07; all ps > .05).
13
12.5
12
11.5
Summed State
Anxiety
11
10.5
10
MCU present
MCU absent
Figure 3. State anxiety by presence (affectively hot condition) or absence (affectively cold condition)
of the mobile collection unit (MCU).
Attitude
A 2 affective state (hot/MCU present, cold/MCU absent) x 2 brochure (standard, modified) x
2 gender (male, female) ANOVA was conducted on the summed attitude scale. This analysis
revealed no significant effects (all Fs < 1.59, all ps > .21).
28
Subjective Norm
A 2 affective state (hot/MCU present, cold/MCU absent) x 2 brochure (standard, modified) x
2 gender (male, female) ANOVA was conducted on the summed subjective norm measure. This
analysis revealed no significant effects (all Fs < 1.50, all ps > .22).
Blood Donation Self-efficacy
A 2 affective state (hot/MCU present, cold/MCU absent) x 2 brochure (standard, modified) x
2 gender (male, female) ANOVA was conducted on the summed blood donor self-efficacy scale. This
showed a significant main effect of brochure condition, F (1,913) = 11.10, p<.002, 2 = .01, with those
receiving the modified brochure reporting greater self-efficacy (M = 31.43, SE = 0.37) than those
receiving the standard brochure (M = 29.72, SE = 0.36; see Figure 4). These results show that those
who were exposed to the modified brochure reported greater confidence in their ability to donate
blood compared to those who read the standard Blood Service brochure.
In addition, there was a significant interaction between affective state and participant
gender, F (1,913) = 4.11, p<.05, 2 = .01. Follow up analyses indicated that women reported
significantly less self-efficacy in the presence of the MCU (hot condition; M = 29.41, SE = 0.43) than
women in the absence of the MCU (cold condition; M = 30.79, SE = 0.47; F (1, 906) = 4.68, p < .04) or
men in the presence of the MCU (hot condition; M = 31.40, SE = 0.51; F (1, 906) = 8.91, p < .004), see
Figure 5). These results show that the presence of the MCU had a negative impact on women’s
confidence to donate blood. All other main effects and higher order interactions were non
significant (all F s < 3.36; all ps > .05).
29
32
31.5
31
30.5
30
29.5
29
28.5
Control
Modified
Figure 4. Blood donor self-efficacy exposure to either the standard Blood Service recruitment
brochure (control) or the modified recruitment brochure (modified).
32
31.5
31
30.5
Men
30
Women
29.5
29
28.5
28
MCU present
MCU absent
Figure 5. Blood donor self-efficacy by participant gender and presence (affectively hot condition) or
absence (affectively cold condition) of the MCU.
Intention to donate in the next 30 days
A 2 affective state (hot/MCU present, cold/MCU absent) x 2 brochure (standard, modified) x
2 gender (male, female) ANOVA was conducted on the summed intention to donate blood in the
next month scale. There was no significant main effect of affective state, F (1, 900) = 0.01, p = .98 or
brochure, F (1, 900) = 0.03, p = .86. However, this analysis revealed a significant interaction between
affective state and brochure condition, F (1,900) = 7.09, p<.009, 2 = .01; see Figure 6. Follow up
analyses indicated that those receiving the modified brochure in the presence of the MCU (hot
30
condition, M = 11.36, SE = 0.31) were significantly more likely to intend to donate blood than those
receiving the standard Blood Service brochure in the presence of the MCU (M = 10.37, SE = 0.33; F (1,
900) = 4.82, p <.03). Intention by brochure did not differ significantly in the absence of the MCU
(cold condition; F (1, 900) = 2.66, p =.10).
11.5
11
Modified
10.5
Control
10
9.5
MCU present
MCU absent
Figure 6. Intention to donate blood in the next month by brochure condition and presence (hot) or
absence (cold) condition.
Exploratory analyses – mediation and moderation
To explore the relationship between brochure type, self-efficacy, intention to donate and
affective state, an exploratory mediated moderation analysis was conducted (see Figure 7 below). In
order to undertake this analysis, the PROCESS macro developed by Hayes (2013) was used. This
macro employs a bootstrapping procedure which produces more reliable results as it provides a
population estimate, thus eliminating idiosyncrasies that may be present in any given sample. This
resulting model was significant, F (1, 907) = 15.16, p < .001, with blood donation self-efficacy
mediating the relationship between brochure type and blood donation intentions such that the
modified brochure was associated with greater self-efficacy about blood donation (LLCI = -1.45, ULCI
= -0.48) and greater blood donation self-efficacy associated with greater intention to donate (LLCI =
0.19, ULCI = 0.28). Brochure type did not directly influence blood donation intention (LLCI = -0.13,
ULCI = 0.50). However, the direct relationship between brochure type and blood donation intention
31
was moderated by affective state (LLCI = 0.06, ULCI = 0.68). When participants were recruited in an
affectively hot context (MCU present), the relationship between brochure type and intention to
donate was not significant (LLCI = -0.60, ULCI = 0.22). However, when participants were recruited in
an affectively cold context (MCU absent) there was a significant relationship between brochure type
and intention to donate (LLCI = 0.08, ULCI = 1.) such that the control brochure was associated with
intention to donate. Although under this single condition, the control brochure was associated with
stronger intentions, the resulting improvement in self-efficacy about blood donation and the
consequent effect on intention to donate from the modified brochure was greater regardless of
affect, suggesting that the modified brochure is better suited to recruiting donors in a wider range of
contexts.
Figure 7. Moderated mediated relationship between brochure type, blood donation self-efficacy,
intention to donate and affective state.
Note: *p <.05. Figures presented are unstandardized weights.
32
Donation Behaviour
Donation behaviour was tracked for those donors who self-assessed at the end of the survey
to be eligible to donate blood using the Blood Service criteria (n = 638). Behaviour was tracked via
Blood Service donation records (for data collected in the first wave of data collection) and via selfreport (second wave of data collection) for those participants who provided permission (N=302).
Donation behaviour was coded as occurring if the donor presented to donate blood and successfully
donated (wave 1 & 2) or presented to donate blood but was unable to due to circumstances outside
of their control (e.g. no appointments being available at the MCU; wave 2).
This data was initially analysed using loglinear analyses. While this analysis indicated a main
effect of brochure condition, the presence of a number of low cell sizes (< 5) reduced the robustness
of this analysis. As such, this initial analysis was followed up with a chi-square analysis. This analysis
revealed a significant effect of brochure condition, 2 (1) = 4.53, p < .04, with the odds of engaging in
donation behaviour being 3.56 times higher after receiving the modified brochure than after
receiving the standard Blood Service brochure (see Figure 8).
5
4
3
% engaging
in
behaviour
2
1
0
Control brochure
Modified brochure
Figure 8. Percentage of participants engaging in behaviour after exposure to either the standard
Blood Service brochure (control) or the modified brochure.
33
Correlation between Donation Intention and Behaviour
Fishers’ test revealed no significant difference between the correlation between donation
intention and behaviour of participants recruited in the presence of the MCU (r = .23) and
participants recruited in the absence of the MCU (r = .16), z = 1.14, p =.252.
Summary of Results
The results provide partial support for hypotheses 1, 3 and 4. For the first hypothesis, that
non-donors recruited in the affectively cold condition (MCU absent) would report lower anxiety and
more positive attitudes, subjective norms, self-efficacy and stronger donation intentions compared
to the affectively hot condition (MCU present), partial support was found. While there was no impact
of affective state on attitudes, subjective norms or donation intentions, critically anxiety reported by
participants in the affectively cold condition was significantly lower than anxiety reported in the
affectively hot condition, suggesting that the presence of a MCU induces anxiety about donating
blood in non-donors. In addition, female non-donors reported significantly lower donation selfefficacy when the MCU was present compared to when the MCU was absent.
Hypothesis 2, that the association between intention and behaviour would be stronger in an
affectively hot context (MCU present) compared to an affectively cold context (MCU absent), was not
supported as the association between intention and behaviour in each affective state condition did
not significantly differ.
Partial support was also found for hypothesis three, that non-donors who received the
modified intervention brochure would generally have a more positive attitudes, subjective norm,
self-efficacy and stronger intentions to donate blood than those who received a standard Blood
Service brochure. While no effect was found for attitudes, subjective norms, or donation intention,
self-efficacy was higher for those non-donors who received a modified intervention brochure
compared to those who received a standard Blood Service brochure. In addition, those who received
a modified blood donation brochure were 3.56 more times likely to present to donate blood than
those who received a standard Blood Service brochure.
34
Partial support was also found for hypothesis four, that non-donors recruited in the
affectively hot condition (MCU present) would report reduced anxiety along with more positive
attitudes, subjective norms, self-efficacy and a stronger intention to donate blood when they
received a modified brochure compared to the standard brochure. Again, although there was no
effect on anxiety, attitudes, subjective norms, or self-efficacy, participants in the affectively hot
condition who received the modified brochure reported significantly stronger intentions to donate
blood than those who received a standard blood service brochure.
In summary, the presence of the MCU arouses anxiety in non-donors and decreases women’s
self-efficacy or confidence with regard to donating. In comparison to the standard Blood Service
brochure the modified brochure boosts participants’ self-efficacy or confidence with regard to
donating. This, in turn impacts on intentions to donate. Specifically, in comparison to the standard
brochure, the modified brochure strengthens non-donors intentions to donate blood in the presence
of the MCU. A significantly higher proportion of those participants exposed to the modified brochure
present to donate than those exposed to the standard Blood Service recruitment brochure.
35
DISCUSSION
The process of transitioning non-donors with a positive orientation towards blood donation
into blood donors is an ongoing challenge for BCAs worldwide. While anxiety about donating blood
has been identified as a key deterrent to donation for non-donors (e.g. Clowes & Masser, 2012) there
is a gap in knowledge as to the nature and extent of the effect that anxiety has on deterring nondonors from becoming blood donors. This research responds to this gap by exploring the impact of
environmental cues (i.e. the presence or absence of a MCU) on non-donors anxiety about donation
and then testing the efficiency of a modified recruitment brochure to improve non-donors selfefficacy, donation intentions and the likelihood that they will engage in blood donation.
The first aim of this research was to explore whether blood donation paraphernalia in a field
setting (the presence of a MCU when participants were recruited for the study) would induce anxiety
about donation, a less positive orientation towards donating (measured by attitudes, subjective
norm and self-efficacy) and lower intentions to donate compared to non-donors recruited in an
affectively cold field setting (MCU absent). This hypothesis was partially supported. While there was
no effect of affective state on non-donors attitudes, subjective norms or donation intentions,
affective state did significantly impact non-donors donation anxiety and self-efficacy. When the MCU
was present, non-donors reported higher anxiety compared to when the MCU was absent. Female
non-donors also reported lower self-efficacy, or confidence in their ability to donate blood, when the
MCU was present compared to when the MCU was absent.
These results differ from those reported by Clowes and Masser (2012) who found that in the
presence of blood donation paraphernalia (e.g. Blood Service promotional material, latex gloves and
tubing) non-donors reported less positive attitudes, subjective norms, self-efficacy and donation
intentions as well as higher anxiety about donation. One explanation for the divergent results of the
current study may be the nature and salience of the environmental cue to donation (the MCU). The
blood donation paraphernalia and setting used by Clowes and Masser (2012) to create an affectively
36
hot state included gloves, blood collection tubing, band-aids and tourniquets in close proximity to
participants with the study conducted in a small University laboratory. Within this context, the
salience of the blood donation paraphernalia to participants was most likely very high. Further, given
the context of a University laboratory, participants in Clowes and Masser (2012) may have believed
that blood could, or would, be collected on the spot thus inducing a high level of anxiety. This anxiety
may have temporarily changed non-donors perception of their attitudes and existing subjective
norms. In contrast, the MCU used to induce an affectively hot state in the current study was more
physically distant to non-donors and was, given the field setting, less salient as an environmental
stimuli. Further, there were no indicators in the immediate vicinity in terms of phlebotomy
paraphernalia that indicated actual blood collection could take place (short of participants being
manhandled into the MCU). These differences in context may have induced a lower level of anxiety
in participants in the current study which did not impact the comparatively stable, and less malleable,
donation attitudes and subjective norms of non-donors (Masser & France, 2010). Ironically, given
our aim to create a ‘hotter’ environment than the lab, in the field the salience of blood donation may
have been lower and thus the context cooler than in Clowes and Masser (2012). Consistent with this
reasoning, a re-analysis of data obtained by Clowes and Masser (2012) indicates that the mean level
of anxiety reported for participants in their affectively hot condition (M = 13.80) was higher than the
mean level reported by participants in the affectively hot condition in the current analysis (M =
12.20).
It was also hypothesised that the association between non-donors’ donation intentions and
behaviour would be stronger in the affectively hot condition (MCU present) compared to the
affectively cold condition (MCU absent). This hypothesis was not supported, as results revealed that
while the association was stronger in the affectively hot condition than in the cold condition, the
difference did not reach statistical significance. The current research is the first study to examine the
strength of the association between and intentions and behaviour under different affective states in
relation to blood donation. While the results of the current analysis did not support the hypothesis,
this outcome may have been caused by the (relative) loss of power due to the comparatively smaller
37
sample retained for the behavioural analysis. Alternatively, the affectively ‘cooler’ context created by
the field (vs. the lab) setting may have impacted on the strength of the association observed
between intention and behaviour in this context.
In exploring the first aim of this research, the results show that the presence of an
environmental cue to blood donation, such as the presence of a MCU, creates an affectively hot state
in which anxiety is induced in non-donors. Importantly, female non-donors self-efficacy about blood
donation, their confidence to engage in blood donation, was also reduced in the presence of the
MCU. In combination with the results reported by Clowes and Masser (2012) the results of this study
show that some of the conditions under which BCAs recruit non-donors (outside MCUs and collection
centres) and the promotional material used (e.g. promotional posters) induces anxiety in non-donors
and reduce the self-efficacy of female non-donors. Potentially, this presents a problem for BCAs as in
person recruiting outside MCUs and collection centres for walk-in appointments is an opportunity
to use a personalised approach to recruit new donors as suggested in the Blood Service Strategic Plan
(ARCBS, 2009). Further potential problems arise from using promotional materials, an integral part of
the Blood Service’s recruitment strategy (ARCBS, 2013).
With this in mind, the second research aim of the current research was to test the
effectiveness of a modified recruitment brochure to increase non-donors donation self-efficacy,
intention to donate and donation behaviour. It was expected that non-donors who received the
modified brochure would have a more positive orientation to blood donation (evidenced by more
positive attitudes, subjective norms and self-efficacy), a stronger intention to donate blood and
greater donation behaviour than non-donors who receive the standard Blood Service recruitment
brochure. Although the results of the current study revealed no effect of brochure type on nondonors attitudes, subjective norms or main effect on donation intention, there was an effect on nondonors’ donation self-efficacy and donation behaviour.
Non-donors who received the modified brochure reported higher levels of self-efficacy about
donation compared to non-donors who received the standard brochure. This is consistent with work
38
by Masser and France (2010) which showed that a donor coping brochure including a personal
narrative, similar to the modified brochure in this study, increased non-donors’ donation self-efficacy
and intentions. The improvement seen in non-donors’ donation self-efficacy is particularly
encouraging as donation self-efficacy has been consistently shown to be a strong predictor of blood
donation intentions and behaviour (e.g. Masser et al., 2009). In line with this, exploratory mediated
moderation analysis conducted on the data from the current study showed a mediated effect of the
brochure on intention through self-efficacy. That is, participants who received the modified
brochure reported higher self-efficacy and this in turn resulted in stronger intentions to donate.
Further, non-donors who received the modified brochure engaged in blood donation behaviour at a
higher rate than those receiving the standard brochure. While this result is consistent with the
greater tendency of participants in France et al. (2010) to register to donate blood when they
received the modified brochure in comparison to the standard brochure, the current analysis is the
first study to demonstrate an effect of the modified brochure on actual donation behaviour.
It was also expected that when the MCU was present, non-donors who received the modified
brochure would report lower anxiety, along with a more positive orientation to blood donation
(evidenced by more positive attitudes, subjective norms and self-efficacy), stronger donation
intentions and greater donation behaviour than those receiving the standard Blood Service brochure.
Within the affectively hot context, there was no simple effect of brochure on anxiety, attitudes,
subjective norms, self-efficacy or behaviour, however, there was an effect on donation intention. In
the presence of the MCU, non-donors who received the modified brochure reported stronger
donation intentions in comparison to those non-donors who received the standard brochure.
The modified brochure strengthened non-donors’ donation self-efficacy which in turn
strengthened participants’ intentions to donate blood. Those who received the modified brochure
donated at a rate 3.56x than of those who received the control brochure. Critically, these results
show that the modified recruitment brochure could be used by the Blood Service to successfully
recruit non-donors in both affectively hot and cold contexts.
39
Utilising the Modified Brochure
The modified brochure could be disseminated to non-donors in several different contexts to
successfully recruit these would-be donors. Firstly, the modified brochure could be used to recruit
donors in affectively hot contexts, including in the presence of MCUs. MCUs are a prominent visual
reminder to donors and non-donors of blood donation. However, as shown by the results of this
study, MCUs can also induce anxiety in non-donors about blood donation thus deterring them from
donating. Distributing the modified brochure to recruit non-donors would allow the Blood Service to
successfully recruit non-donors to walk in appointments thus improving current recruitment rates in
this context.
Secondly, the modified brochure may assist in supporting non-donors initially recruited in
affectively cold contexts (e.g. such as through the National Call Centre) to present at their
appointment to donate for the first time. Although the modified recruitment brochure did not
strengthen donation intention compared to the standard brochure in the affectively cold context,
non-donors recruited in these contexts may enter a hot affective state as their appointment date
approaches and donation becomes more proximal. Providing the modified recruitment brochure to
non-donors at this point, prior to their first appointment, may boost their self-efficacy sufficiently to
encourage them to attend their donation appointment. In this way utilising the modified brochure
may help the Blood Service improve the rate of absenteeism at appointments arranged through
National Call Centre recruitment efforts.
Benefits to the Blood Service
Implementing the modified brochure to recruit non-donors will provide the Blood Service
with a cost-effective method of increasing their recruitment rates while achieving several of the core
Blood Service objectives. Implementing the modified brochure will be relatively cost-effective as the
modified brochures could simply replace recruitment brochures already produced. While additional
costs may be incurred due to the greater length of the modified brochure, further research could be
conducted to identify the ‘core’ or key elements of the brochure in producing the desired changes in
40
self-efficacy, intentions and donation behaviour. Further, implementing the modified recruitment
brochure will assist the Blood Service in achieving their objectives to provide service excellence for
donors. The modified brochure may reduce the likelihood of donors having a negative reaction at
first donation by improving self-efficacy, confidence in dealing with donation and possible negative
reactions, thus providing a better donation experience for new donors. Implementing the modified
brochure, and possible increases in recruitment rates, will also assist Donor and Community Research
achieve their aim of providing research outcomes that contribute to marketing campaigns and
organisational policies to help promote an increase in donations.
Methodological Limitations
Despite the significant difference in those engaging in blood donation behaviour in response
to exposure to the modified brochure in comparison to the control brochure, the absolute number of
those engaging in donation behaviour remains small. This is perhaps not surprising given the ‘cold
call’ nature of recruitment for this study which is traditionally not a form of recruitment engaged in
by the Blood Service. Future studies should aim to replicate the behavioural effects observed in the
current analysis to verify their robustness.
Future Research Directions
The results of the current study and those reported by Clowes and Masser (2012), suggest
that external and environmental cues to donation can induce donation anxiety in non-donors.
However, as of yet, little is known about internal psychological antecedents to donation anxiety (e.g.
imagining the donation process) which may act as deterrents to non-donors’ engaging in donation.
Future research could focus on identifying and understanding these internal antecedents causing
higher levels of self-driven, rather than externally driven, donation anxiety as well as determining
how to intervene effectively on different levels (and forms) of donation anxiety. Research could also
explore the relationship between internally driven and externally driven anxiety on donation
intentions and behaviour.
41
Stage models of blood donor motivation (e.g. the Transtheoretical Model; Prochaska &
DiClemente, 1982; Ferguson & Chandler, 2005) suggest that non-donors vary in their willingness to
contemplate engaging in blood donation. Anxiety may influence non-donors progressing through the
pre-contemplation, contemplation and planning stages of the decision-making prior to engaging in
blood donation. Higher levels of internally driven anxiety may keep non-donors in the precontemplation stage of change, avoiding blood donation in order to cope with their anxiety about
blood donation. Non-donors who experience lower levels of anxiety about donation may be more
prepared to contemplate blood donation so interventions focusing on bolstering self-efficacy, such as
a modified recruitment brochure, may be most effective in encouraging them to donate. Future
research should explore ways of identifying non-donors in different stages of contemplation to
administer appropriate interventions to assist donors to manage their donation anxiety and engage
in blood donation.
Further, recent research on donation anxiety, negative reactions to donation and return
donation in new and novice donors (e.g. Ditto & France, 2006; France et al., 2013) suggests that
understanding, an intervening, on pre-donation anxiety is critical to ensuring that new donors do not
experience negative reactions to donation and thus are more likely to return to donate. Future
research should explore ways to intervene with non-donors experiencing anxiety in the affectively
hot context experienced by waiting outside the MCU or collection centre for their appointment
immediately prior to donation in order to reduce anxiety the likelihood of experiencing a negative
reaction to donation. Not only is this research important to improving the donors’ donation
experience but is critical to increasing and maintaining the size and stability of the donor panel by
converting first time donors into regular donors.
Conclusion
This research advances our understanding of the factors that elicit, and the impact of,
anxiety on non-donors’ donation decision-making. Critically, in conjunction with work by Clowes and
Masser (2012), the current research demonstrates that materials and circumstances utilised by the
42
Blood Service for recruitment of non-donors induces anxiety, which deters donation, and reduces
self-efficacy in female non-donors, which increases the likelihood of donation behaviour occurring.
However, the modified brochure, by increasing self-efficacy, donation intentions and behaviour, even
in the presence of the anxiety inducing MCU, can be used to improve Blood Service recruitment of
non-donors in both high anxiety (such as walk-in recruitment opportunities outside MCUs and
collection centres) and low anxiety contexts. It is recommended that the Blood Service adopt the
modified brochure in place of the standard brochure to increase the success rate of recruitment
attempts, ultimately to increase the size of the donor panel and stabilise blood supply for Australia.
43
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ACKNOWLEDGEMENTS
The authors gratefully acknowledge the assistance of all those who participated in this research.
Further, the tireless work of Sara Berndt, Tamara Butler, Kyle Jensen and Kathy Phillis in recruiting
participants is also acknowledged. Finally we would like to acknowledge the Australian Red Cross
Blood Service who provided funding for this research and particularly Jane Haymen of the Blood
Service who provided support for this research.
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APPENDICES
Appendix A – Standard Blood Donation brochure (4 pages)
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Appendix B – Modified brochure (intervention) (8 Pages)
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Appendix C – Survey Items
Six-item short form state scale of the Spielberger State-Trait Anxiety Inventory
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Self-efficacy Items
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Intention Items
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