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.

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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

2

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

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LIST OF FIGURES

Page

Figure 1. Location and photographs of

MCU (UQ St Lucia) 24

Figure 2. Procedure flow chart 25

Figure 3.

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 self-

efficacy

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

LIST OF TABLES

Page

Table 1. Distribution of participants in

experimental conditions 18

Table 2.

Descriptive and reliability

statistics for dependant

variables

26

4

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

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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 self-

efficacy, intention, and blood donation behaviour can be bolstered by the use of a modified

recruitment brochure.

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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 non-

donors 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’ self-

efficacy, 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

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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.

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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)

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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.

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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.,

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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

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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

13

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

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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.

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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.

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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 non-

donors 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

17

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.

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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 Total

Modified Control

Presence of

mobile collection

unit (MCU)

Hot (yes) 272 252 524

Cold (no) 192 206 398

Total 464 458 922

Note. Modified is the brochure designed for this study; Control is the standard blood service

brochure

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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

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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, unsatisfying-

satisfying, 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

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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

22

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

23

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.

24

Figure 1. Location of MCU at UQ St Lucia, photographs of MCU present (affectively hot condition)

and absent (affectively cold condition)

MCUlocatedhere

25

Figure 2. Procedure flow chart

Recruited (N=1197)

Not eligible to

donate

(n=275)

MCU

Present/Modified

Brochure (n=272)

MCU

Present/Standard

Brochure (n=252)

MCU

Absent/Modified

Brochure (n=192)

MCU

Absent/Standard

Brochure (n=206)

Eligible to

donate

(n=922)

Behavioural follow up

Blood donor records follow

up (wave 1 & 2)

Email self-report follow up (wave

2 only)

Consented (n=659)

Did not consent (n=263)

Consented (n=302)

Did not consent (n=101)

Replied (n=179)

Did not reply (n=103)

Email undeliverable

(n=20)

26

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 Self-

efficacy

Donor Intention

Anxiety (STAI) (n=898)

.87

12.12 (4.43)

- -.304** -.151** -.444** -.324**

Attitude (n=885)

.82

28.49 (8.00)

- .254** .326** .381**

Subjective Norm (n=917)

.89 r=.80***

8.82 (3.18)

- .207** .365**

Blood Donor Self-Efficacy (n=911)

.91 30.49 (7.57)

- .347**

Donation Intention (n=908) .95

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

27

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.

28

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 short-

form 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 non-

donors’ 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).

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).

10

10.5

11

11.5

12

12.5

13

MCU present MCU absent

Summed StateAnxiety

29

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).

30

Figure 4. Blood donor self-efficacy exposure to either the standard Blood Service recruitment

brochure (control) or the modified recruitment brochure (modified).

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

28.5

29

29.5

30

30.5

31

31.5

32

Control Modified

28

28.5

29

29.5

30

30.5

31

31.5

32

MCU present MCU absent

Men

Women

31

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).

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

9.5

10

10.5

11

11.5

MCU present MCU absent

Modified

Control

32

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.

33

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 self-

report (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).

Figure 8. Percentage of participants engaging in behaviour after exposure to either the standard

Blood Service brochure (control) or the modified brochure.

0

1

2

3

4

5

Control brochure Modified brochure

% engaginginbehaviour

34

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 self-

efficacy 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.

35

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.

36

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 non-

donors 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 self-

efficacy, 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

37

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

38

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 non-

donors attitudes, subjective norms or main effect on donation intention, there was an effect on non-

donors’ 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

39

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.

40

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

41

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.

42

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 pre-

contemplation 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

43

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.

44

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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