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Improving blood donor recruitment and retention: Integrating theoretical

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 BLOOD DONORS AND BLOOD COLLECTION
Improving blood donor recruitment and retention: integrating
theoretical advances from social and behavioral science
research agendas
Eamonn Ferguson,1 Christopher R. France,2 Charles Abraham,3 Blaine Ditto,4 and Paschal Sheeran5
BACKGROUND: Increasing blood donor recruitment
and retention is of key importance to transfusion ser-
vices. Research within the social and behavioral
science traditions has adopted separate but comple-
mentary approaches to addressing these issues. This
article aims to review both of these types of literature,
examine theoretical developments, identify commonali-
ties, and offer a means to integrate these within a
single intervention approach.
STUDY DESIGN AND METHODS: The social and
behavioral science literature on blood donor recruitment
and retention focusing on theory, interventions, and
integration is reviewed.
RESULTS: The role of emotional regulation (anticipated
anxiety and vasovagal reactions) is central to both the
behavioral and the social science approaches to
enhancing donor motivation, yet although intentions
are the best predictor of donor behavior, interventions
targeting enactment of intentions have not been used
to increase donation. Implementation intentions (that
is, if-then plans formed in advance of acting) provide
a useful technique to integrate findings from social
and behavioral sciences to increase donor recruitment
and retention.
CONCLUSION: After reviewing the literature, imple-
mentation intention formation is proposed as a tech-
nique to integrate the key findings and theories from the
behavioral and social science literature on blood donor
recruitment and retention.
U
nderstanding and facilitating the recruitment
and retention of blood donors is the major
contribution that the social and behavioral
sciences can make to transfusion medicine.
Facilitating retention and recruitment is important given
that the number of donors may not meet the need of the
health services due to either reduction in the number of
active donors in the United Kingdom1 and United States2
or increased demand relative to a stable donor profile.3
Whether or not a decline in donors or failure to meet
demands best represents underlying trends, there is a
clear need to enhance recruitment and retention of blood
donors. In general, the social science literature has
focused on recruitment, whereas the behavioral sciences
have focused on retention. Thus, although complemen-
tary, these agendas developed separately. It is argued here
that the goal of producing successful interventions will be
ABBREVIATIONS: AT = applied tension; FIDT = foot-in-the-
door; NSF = negative state relief; TPB = theory of planned
behavior.
From 1Risk Analysis, Social Processes and Health (RASPH)
Group, School of Psychology, University of Nottingham, Not-
tingham, UK; 2the Department of Psychology, Ohio University,
Athens, Ohio; 3the Department of Psychology, University of
Sussex, Falmer, Brighton, UK; 4the Department of Psychology,
McGill University, Montreal, Quebec, Canada; and the 5Depart-
ment of Psychology, University of Sheffield, Sheffield, UK.
Address reprint requests to: Eamonn Ferguson, Risk Analy-
sis, Social Processes and Health (RASPH) Group, School of Psy-
chology, University of Nottingham, Nottingham, UK; e-mail:
eamonn.ferguson@nottingham.ac.uk.
This review arose form a symposium organized by EF and
CRF at the 26th International Congress of Applied Psychology;
July 16-21, 2006; Athens, Greece.
Received for publication February 26, 2007; revision
received April 24, 2007, and accepted April 25, 2007.
doi: 10.1111/j.1537-2995.2007.01423.x
TRANSFUSION **;**:**-**.
Volume **, ** ** TRANSFUSION 1
FERGUSON ET AL.
greatly advanced by integrating recent theoretical
advances from both of these perspectives. This review
briefly describes the social and behavioral science
research agendas, key theoretical models from each, their
main findings, how they have informed interventions, and
how they can be integrated to produce more powerful
interventions. Specifically, it is argued that interventions
based on implementation intentions4 that focus on man-
aging emotional reactions that precede and accompany
donation could bridge this literature, enhance existing
recruitment techniques, and produce better specified and
more successful interventions to increase donor recruit-
ment and retention.
TWO RESEARCH AGENDAS
The social and behavioral science agendas can be distin-
guished in terms of the questions they address and the
measures they apply. The social sciences agenda examines
cognitive (e.g., perceived control), motivational (e.g.,
moral norms), and emotional (e.g., anticipated affect: that
is, emotion expected to be experienced in the future such
as anxiety or pleasure) factors with respect to predicting
donor behavior and intentions (see Ferguson,5 Piliavin
and Callero,6 and Piliavin,7 for reviews). This work has
examined both recruitment of new donors (e.g., Lemmens
et al.8) and retention of regular donors.6,9 By contrast, the
behavioral science agenda focuses on experimental inter-
ventions, with a particular emphasis on exploring the
impact of direct interventions (e.g., water or caffeine
preload, applied muscle tension) on the management of
emotional and physiologic responses (e.g., symptoms of
vasovagal syncope) during the donation experience and
how changes in these responses affect donor retention.10-13
These two research agendas have over the past three
decades followed separate lines of enquiry. The issues
relating to recruitment and retention, however, are inevi-
tably interlinked5,6,14,15 so that making more explicit theo-
retical links between this literature should enhance the
potential for intervention.
THE SOCIAL SCIENCE RESEARCH
AGENDA
This work has been primarily correlational, examining
how variables from theoretical models of motivation and
self-regulation predict donor intentions or attendance.
Three main models have been used: 1) the theory of
planned behavior (TPB), 2) stage models, and 3) motiva-
tion (altruism).
Theory of Planned Behavior
The TPB16 is the most widely applied model of cognitive
antecedents of action.17 It proposes that intention is a key
2 TRANSFUSION Volume **, ** **
determinant of action and that, intention is, in turn, deter-
mined by attitude, subjective norm, and perceived behav-
ioral control. Attitude refers to the person’s anticipation of
consequences following from action and evaluation of
these consequences (i.e., what will happen if I go to
donate blood and how will I feel about those outcomes).
Subjective norm represents perceived social approval of
an action or nonaction (i.e., how much will people who are
important to me approve of my becoming a blood donor),
and perceived behavioral control refers to the perception
that the action is feasible and under the person’s own
control (i.e., it is entirely up to me whether or not I become
a blood donor). Tests of the TPB indicate that it typically
accounts for between 39 and 42 percent of the variance in
intention and between 27 and 34 percent of the variance
in measures of behavior16,18-20 with intentions the stron-
gest predictor of blood donor returns.5
Applications of the TPB to blood donation motiva-
tion have suggested that it provides a good core model
in this context. Table 1 provides a basic description of
the main TPB variables (intentions, subjective norms,
attitudes, and perceived behavioral control) with respect
to the prediction of either donor intentions or actual
behavior.6,8,9,20-26
It has been argued that different variables are impor-
tant for novice and experienced donors.9 To examine this,
Table 1 is further divided into novice and experienced
donors as defined within each study.6,8,9,20-26 The main
problem with this distinction is that there is no consensus
about what constitutes novice and experienced donors.
Some researchers defined novices as four or fewer dona-
tions, experienced as five or more,9 and other as those who
have never donated versus those who have donated at
some time in the past.22 As such, novices have been
defined as a mixture of those who have never donated,8,22
TABLE 1. TPB measures as predictors of
intentions and behavior as a function of levels of
donor prior history*
Donation level Intentions Behavior
Novice PBC22 Norms23
Attitudes6,8,22,23 Intentions6,9,23,26
Self-efficacy8 PBC26
Subjective norms8
Experienced PBC22 Intentions9,23,26
Attitudes22-24 Past behavior9,23
Self-efficacy24 PBC26
Subjective norms24
Whole sample Attitudes20,21,23,25 Intentions20,21,23,25
Subjective norm20,21,25 Attitudes20,25
PBC21,25 Self-efficacy20,21
Self-efficacy20,21 Subjective norm20
* Novice is a mixture of never donated, 8,22 one to two previous
donations,23 first-time donors,26 and up to four donations.9
Experienced is a mixture of ever donated,22,24,26 three or more
donations,23 and five or more donations.9
PBC = perceived behavioral control.

made one to two previous donations,23 first-time donors,26
and up to four donations.9 Experienced donors have been
defined as a mixture of those who have ever donated,22,24,26
made three or more donations,23 or five or more dona-
tions.9 Research needs to empirically resolve how novice
and experienced are defined. Within this context, one
study27 showed that donors’ self-categorization indicated
a split into nondonors, first-time donors, occasional
donors (median of four donations), and experienced
donors (median of five donations; see also Ferguson and
Bibby9). Table 1 also contains studies that reported on
a whole sample without dividing donors into different
categories.
Examining Table 1 shows that the main difference in
predictors is between intention and behavior. (The lack of
difference between novice and experienced donors may
be due to confounding in relation to the manner that dif-
ferent studies define experienced and novice donors.)
Attitudes, perceived behavioral control, and subjective
norms predict intentions across experience, and intention
is the most consistent predictor of behavior. It has been
shown, however, that past behavior and not intention is
a better predictor of future donations in experienced
donors (five or more donations), with intention and not
past behavior the best predictor in novice donors (four or
less donations).9
Ajzen16 noted that the TPB could be extended if
further constructs were found to enhance the prediction
of intention or behavior. Research supports three key
modifications in the context of donor motivation. First,
the construct of perceived behavioral control is closely
related to Bandura’s28 self-efficacy construct, which refers
to one’s confidence in being able to successfully under-
take a proposed action or sequence of action. Conner and
Sparks29 suggest that both perceived behavioral control
and self-efficacy should be measured when applying the
TPB and, interestingly, when the two constructs have been
compared in the context of blood donation motivation
(see Table 1), self-efficacy has been found to be a stronger
correlate of intention.21 Certainly, self-efficacy should be
included in models of the antecedents of blood donation.
Second, personal moral norms (i.e., feeling that one is
morally obliged to undertake a behavior) are important to
donation motivation. Both Armitage and Conner20 and
Lemmens and coworkers8 found that measures of per-
sonal moral norm predicted donation intentions. Third,
the extent to which one identifies with donation or sees
donation as a compatible component of one’s identity
predicts donation.6,20,21 Thus an extended TPB for use in
blood donation contexts should include measures of self-
efficacy, moral norms, and blood donation identity.
Research into beliefs underlying attitudes toward
donation is an important first step toward designing
appropriately targeted motivational interventions. For
example, in a study on nondonors, Lemmens and col-
DONOR RECRUITMENT AND RETENTION
leagues8 found that attitude was a strong correlate of
donation intentions explaining 24 percent of the variance
in intention scores and, moreover, that 45 percent of the
variance in donation attitudes could be explained by two
beliefs, namely, the extent to which respondents believed
that blood and needles were frightening and the extent to
which they expected to feel nervous and tense before
donation. These findings also highlight the importance of
anticipated emotional responses to our understanding of
donation motivation and suggest that campaigns should
probably not highlight the role of needles and blood in
donation. For example, images of blood bags on red back-
grounds, which have featured in some recruitment cam-
paigns, could be counterproductive because they prompt
anticipated feelings found to undermine donation moti-
vation. Although reference to blood and the procedures is
difficult to avoid when developing recruitment cam-
paigns, it is suggested that such campaigns could focus
less on the paraphernalia of blood process and more on
donors themselves, for example, by reassuring potential
donors that current donors do not feel nervous and tense
before or after donation. Further experimental work is
required to confirm the efficacy of focusing on these key
beliefs, but work of this type identifies potential cognitive
targets for future recruitment campaigns.
Stage models
Stage models of self-regulation propose that people pass
through a number of decision making stages as they
attempt to change their behavior and that the transition
from one stage to the next is facilitated by different stage-
specific cognitive or behavioral processes.30 There is evi-
dence that there may be qualitative differences not only
between nondonors and donors, but also among donors
with varying degrees of experience,6,9 and this has inspired
initial work on stages models of blood donation.27 A reli-
able distinction has been drawn between occasional (one
to four donations) and regular (five or more donations)
donors.5,9 This work has particular relevance to issues of
retention but is still very much in its infancy, and no inter-
ventions based on these distinctions have been con-
ducted. These findings, however, indicate that donors
should not be treated as a homogeneous group and that
donor experience should be taken into account both in
research and the evaluation of interventions.
Motivation and/or altruism
Cross-sectional surveys of donor motivation indicate that
donors are motivated by altruistic motives and/or beliefs
(i.e., that donating will benefit society31-36), and many
large-scale recruitment campaigns focus on altruism.
Unfortunately, such findings may reflect a shared stereo-
type of the blood donation as socially desirable rather
Volume **, ** ** TRANSFUSION 3
FERGUSON ET AL.
than an underlying motivational explanation. The lack of
prospective studies relating altruistic beliefs and motives
to blood donation is of concern given the prominence
afforded to altruistic motives in national recruitment cam-
paigns. For example, in the United Kingdom, the national
television and radio campaigns focus on celebrities who
relate how they or one of their relatives were helped by
donated blood. The accompanied by-line is “Do some-
thing amazing. Give blood.” In the United States, the most
recent campaign is based on a cartoon superhero—The
Red Defender—who states that he cannot save all lives by
himself and he needs our help in terms of donating blood.
These campaigns are predicated on the motivating power
of altruism.
Without denying the possibility of “pure” altruism,
evidence indicates that helping behavior may be driven by
egoistic and/or selfish concerns.37-40 Because human
cooperation is associated with activation of neurologic
reward centers,41 it is entirely plausible that blood dona-
tion is driven by a sense of personal reward combined with
the desire to help—the so-called benevolent response42
—rather than pure altruism.
Summary
The brief review above is consistent with other reviews of
the social science approaches to understanding donation
(e.g., Ferguson,5 Piliavin and Callero,6 and Piliavin7), indi-
cating that models based on the TPB are useful in predict-
ing donor intentions and that donor intentions predict
donation (see Table 1). The review adds to the literature by
summarizing current advances with respect to extensions
to the TPB within the context of blood donation and high-
lighting the potential for stage models. This research also
emphasizes that anticipated emotions (especially antici-
pated anxiety about donation) are also important to
donors’ decision making. How has this basic research
been translated into clinical practice and interventions?
INTERVENTIONS BASED ON SOCIAL
SCIENCE
Interventions derived from the social science research
agenda can be grouped into four types (altruism, remind-
ers, motivational, and intention-based).
Altruism-egoism
A number of studies have examined altruism with respect
to blood donation.43-46 Two of these are of particular inter-
est as they compare manipulations of altruism and ego-
ism.43,44 This distinction is important because it has been
suggested that blood donor behavior is driven by altruism
rather than egoism. Other studies have compared altru-
ism to incentives45 or altruism to fear appeals.46
4 TRANSFUSION Volume **, ** **
Paulhus and colleagues43 manipulated messages
given to donors at a donor drive, that either focused on the
societal duty (altruism) or personal benefits (blood
typing). They showed that those exposed to the altruistic
message were more likely to intend to donate in the future.
Reich and associates44 exposed participants (first-time
donors) to either patient-focused (altruistic) or donor-
focused (egoistic) messages and found that the patient-
focused message increased the number of donations.
Although these studies seem to support the utility of altru-
istic messages, their design or interpretation did not seem
to take full account of theories of altruism. The altruism
message of Paulhus and coworkers43 concerns social
duty—not sacrificing oneself to help others—whereas the
egoism message focuses on one aspect of egoism—
hedonism (personal gain only). Theories of altruism and
egoism would see these as polar extremes40 with other
aspects of egoism characterized as combinations of these
extremes (benevolence and kinship). Indeed, there is evi-
dence that hedonism does not predict blood donor behav-
ior.47 Moreover, “social duty” is closer to the concept of
moral norm than altruism, and evidence suggests that
moral norms predict donor intentions.8 Thus, the findings
of Paulhus and colleagues43 could be interpreted as
support for the role of moral norms, and indirectly the
TPB, rather than the motivating capacity of altruism.
Reich and coworkers44 manipulated patient focus
(altruism) with a story about a transplant patient in need
of a blood transfusion. The donor-focused manipulation
emphasized donor self-esteem and the fact that the donor
will be given their blood type—a manipulation of hedo-
nism. The altruism manipulation was designed to create
empathy and emotional involvement within the recipient.
The effect for altruism can be explained via the negative
state relief (NSR) model of altruism.37,38 That is, people
develop negative emotional reactions when considering
someone in need and help others to reduce this negative
affect and make themselves feel better. Thus, these results
can be interpreted as support for the role of egoism
because the mechanism underlying helping behavior
described in the NSF implies that one’s own mood and/or
affect regulation drives helping.
Reminders and commitments
There is considerable and consistent evidence that
reminders have a positive effect on attendance and com-
pliance across a number of clinical settings.48 The same is
true of blood donation where reminders have been shown
to be successful with respect to increasing donor
recruitment.49-51 The mechanism by which reminders
work remains unclear, however. One possible mechanism
might be that reminders heighten negative emotion and,
consistent with NSR model of altruism, this emotion
could motivate helping behavior.32 Another possibility is

that reminders activate (increase the accessibility of) rel-
evant attitudes and intentions. Most reminders focus on
retention and are often sent out close to the time of the
blood drive. Unfortunately, although interventions to
improve compliance with medical appointment keeping
have been systematically reviewed,48 there are no data on:
1) how sustainable these effects are and 2) the type of
commitment (e.g., time, place, duration) is most effective.
Foot-in-the-door
Related work has compared foot-in-the-door (FIDT, that
is, ask for a small commitment first and, if agreed, then ask
for a larger one) to the door-in-the-face (that is, ask for a
big commitment, and when it is refused, then ask for a
smaller one) techniques. Evidence suggests that the FIDT
approach is more effective.52-54 The FIDT may work by
engendering positive mood—people continue to donate
to maintain this mood and avoid negative moods.55-57 The
central role for affect and/or mood suggested here is
wholly consistent with the NSR model of helping.38
Intentions and response format
Although intention to donate blood is the strongest pre-
dictor of donor behavior, only one study has manipulated
intentions.58 This study explored how the response
options to intentions questions affected behavior. Find-
ings showed that participants who were invited to report
their negative intention (not to donate blood) were more
likely to make a subsequent donation compared to par-
ticipants invited to report their positive intention (to
donate), positive or negative intention, and various
control conditions. These findings come about because
negative intention participants were liable to suspend
their donation decision (not respond to the question-
naire) but subsequently came around to the idea and
actually gave blood.
Summary of the social science agenda
Although intentions are the best predictor of blood donor
behavior, the focus of social science–based interventions
has been on altruism, reminders, or FIDT. Across these
interventions the role of emotions and emotional regula-
tion appears to be a key mechanism and one that should
be considered in intervention development.
BEHAVIORAL SCIENCE AGENDA
This work has primarily examined how the experience
of negative reactions during the donation process may
dissuade future donation and how different behavioral
strategies can be applied to enhance donor retention.
Although a number of factors can dissuade donors from
DONOR RECRUITMENT AND RETENTION
providing a repeat donation, the experience of vasovagal
reactions (e.g., dizziness, weakness, lightheadedness)
during the donation process is a particularly important
impediment to retention of whole-blood donors.7,13,59-63
For example, in a retrospective survey of more than 30,000
blood donors,62 donors’ perception of physical well-being
during or after donation was the single strongest predictor
of intention to donate again in the future. Donors who
rated their physical well-being as “fair to poor” reported
an anticipated attrition rate that was six times higher than
those who rated their well-being as “good to excellent.”
Direct evidence of the importance of vasovagal reactions
has also been obtained by comparing phlebotomist
records of donor reactions to actual donor return behav-
ior. For example, France and colleagues64 conducted a
large-scale, retrospective assessment of repeat donations
for approximately 90,000 allogeneic blood donors and
demonstrated that phlebotomist ratings of reactions was a
significant predictor of donor return. These findings are
consistent with similar results obtained in other regions of
the United States.65,66 Because donor perceptions may be
as important, if not more important, than phlebotomist
ratings of vasovagal experiences, France and colleagues67
examined the relationship between subjective reports of
vasovagal reactions to blood donation in a sample of 1,052
Canadian blood donors. Consistent with the findings
obtained from phlebotomist ratings, higher self-reports of
reactions were associated with a significantly lower likeli-
hood of repeat donation. Interestingly, studies of both
phlebotomist and donor ratings indicate that vasovagal
reactions have a deleterious influence on retention for
both novice and experienced blood donors.64,67 These
findings indicate that distress while donating in terms of
feeling faint has deleterious effects on donor retention.
Interestingly, recent work shows that vasovagal reactions
also reduce return rates in donors who elect to undergo
automated double red blood cell collections,68 suggesting
that new collection technology does not eliminate the
deterrent effect of negative reactions. In sum, interven-
tions that can reduce vasovagal reactions are a key focus
for behavioral scientists working on blood donation.
BEHAVIORAL SCIENCE INTERVENTIONS
During blood donation, a variety of physiologic and psy-
chological challenges can operate in isolation or in com-
bination to produce acute decreases in blood pressure.
Given a sufficient reduction in cerebral blood flow, the
donor will be susceptible to reactions that can range from
mild dizziness to unconsciousness. In principle, strategies
that prevent acute decreases in blood pressure should
decrease the likelihood of unpleasant physical reactions
and intervention studies suggest that there are several
simple and cost-effective methods that can be used to
reduce donor distress.
Volume **, ** ** TRANSFUSION 5
FERGUSON ET AL.
Distraction
For many years, patients have been encouraged to divert
their attention from stressful medical procedures as a
means of reducing pain and distress. Empirical evidence
suggests that many such diversions can have significant
benefits. For example, patients undergoing dental restora-
tion report less pain and discomfort when listening to
music69 or watching videos70 and less distress when
playing video games.71,72 Video game play can also reduce
levels of distress and unpleasant treatment side effects in
patients undergoing chemotherapy.73-75 In the context of
blood donation, Kaloupek and colleagues59,76,77 reported
that donors who engage in coping strategies that involve
either thinking about being elsewhere or explicitly trying
to divert attention away from the donation procedures
experience less distress. Conversely, those who fail to
engage in avoidant coping behavior report a decreased
likelihood of making future donations.77 Based on these
findings, a recent study examined audiovisual distraction
as a potential method of reducing negative reactions in
first-time blood donors.10 Because different people may
prefer different coping styles when confronting stressors,
this study also compared donors who indicated that they
typically cope with stress through avoidance strategies
(e.g., turning away, preventing sight or sound of stressors,
preferring not to discuss the stressor) with donors who
typically prefer more vigilant coping styles (e.g., attending
to the stressor, seeking out additional information).
Results indicated that donors who prefer avoidant coping
strategies were less likely to experience negative reactions
when they watched a three-dimensional movie while
giving blood. Those who preferred vigilant coping were
neither helped nor harmed by watching the movie.10
Individual differences in coping have also been shown
to moderate the effect of background music on donor
experience.78 Ferguson and colleagues78 observed that the
presence of “easy listening” background music at the
donation site is associated with a complex mix of detri-
mental and beneficial effects upon donor mood and
appraisals, depending on donation experience and vigi-
lance coping. In sum, additional research is required to
further explore how distraction may combine with various
donor characteristics to maximize satisfaction with the
donation experience and likelihood of repeat donation.
Muscle tension
Repeated, rhythmic contraction of major muscle groups
of the arms and legs has been used for decades to treat
fainting reactions in individuals with blood and injury
phobia.79-82 Phobic individuals learn to make voluntary
muscular contractions when faced with feared stimuli,
and these actions can increase blood flow to the brain83
and effectively prevent faintness.80,81 Because the muscle
tension technique is simple to learn and safe to use in the
6 TRANSFUSION Volume **, ** **
context of blood donation, recent studies have assessed
the ability of this technique to prevent negative reactions
in blood donors. Ditto and colleagues84 showed inexperi-
enced blood donors an instructional video on muscle
tension immediately before their donation. Compared
with a control group of inexperienced blood donors who
did not watch the video, donors who learned the muscle
tensing technique reported significantly lower levels of
subjective physiologic reactions to blood donation and
manifested reactions similar to those of more experienced
donors. A subsequent, larger study of more than 1000
blood donors demonstrated that those who used muscle
tension during donation 1) reported a significantly lower
levels of negative reactions, 2) were more likely to provide
a full unit of blood, and 3) expressed greater confidence
that they would donate blood again in the future.85 From a
physiologic perspective, the success of muscle tension
may be due to the ability of rhythmic contractions to
increase the return of venous blood toward the heart by
“milking” the large veins of the arms and legs. Thus, this
procedure may offset the postural effects that can lead to
decreased blood pressure and blood flow to the brain.86
Benefits of muscle tension may, for some donors,
however, derive from the opportunity to engage in an
activity that helps distract the donor from the ongoing
blood collection procedures. Thus, this technique may
have both physiologic benefits (prevention of blood
pooling) and psychological benefits (reduction of anxiety
through distraction) that combine to reduce the risk of
negative reactions.
Caffeine and water loading
It has been suggested that donors at increased risk for
reactions should drink beverages, possibly containing caf-
feine, shortly before they donate.87 The suggestion to
increase fluid intake is based on evidence that healthy
men and women show significant cardiovascular changes,
including increases in vascular constriction and blood
pressure and arterial constriction, that peak approxi-
mately 30 minutes after consuming water.88-90 These
changes have been shown to increase orthostatic toler-
ance,89 suggesting that this effect may help compensate
for the reduction in blood volume that occurs when
healthy individuals move from a seated to upright posture.
To examine the effect of predonation hydration on the
experience of vasovagal reactions, Hanson and France91
asked healthy young blood donors to drink either 500 mL
of bottled water or no water approximately 30 minutes
before donation.91 Results revealed that acute hydration
was associated with significantly fewer adverse reactions
in both male and female donors. Further, there was no
relationship between baseline total body water levels and
reported reactions, suggesting that the benefit of water
loading arises from acute rather than chronic physiologic

effects of hydration. These findings have since been repli-
cated in a much larger sample of approximately 9000 high
school donors.92 Predonation consumption of caffeine has
also been shown to be effective at reducing risk of reac-
tions. With a randomized, double-blind design, Sauer and
France13 had first-time blood donors drink 280 mL of
water and consume a pill that contained 0, 125, or 250 mg
of caffeine shortly before they donated for the first time.
Results indicated that predonation caffeine consumption
was associated with fewer severe reactions, fewer inter-
ventions by phlebotomists for reactions, and a greater
willingness on the part of these first-time donors to give
blood again in the future. Further, these effects showed a
dose–response relationship, with the highest dose leading
to the greatest benefit relative to placebo, and the 125-mg
dose showing an intermediate effect. Another encourag-
ing result was that even at the highest dose, equivalent to
approximately two to three cups of coffee, donors did not
report significantly higher levels of anxiety; this result is
important because too much caffeine could increase
anxiety and hence the likelihood of reactions. Although
this study provided a direct test of caffeine’s ability to
decrease vasovagal reactions, presumably via a pharma-
cologically mediated increase in resting blood pressure
levels, it is also possible that additional beneficial effects
were obtained as a result of the small amount of water
consumed by all donors.
Summary
The above evidence clearly shows that simple behavioral
techniques can reduce distress and fainting in donors and
in so doing increase the likelihood of return donations.
INTEGRATING THE AGENDAS: MANAGING
EMOTIONAL REACTIONS WITH
IMPLEMENTATION INTENTION FORMATION
Emotions and intentions
Two constructs, 1) emotional responding (anticipated
anxieties, vasovagal reactions) and 2) intentions to
donate, emerge from the above brief review as key to
improving donor recruitment and retention.
Throughout this review we have referred to antici-
pated emotions and experienced vasovagal reactions.
Loewenstein and associates93 have highlighted how the
distinction between anticipatory emotions (immediate
visceral reactions, in this case vasovagal reactions) and the
anticipated emotions (those not experienced in the imme-
diate environment but expected to be experienced in the
future, in this case, anxiety) is centrally important to deci-
sion making. As such, both need to be considered. The
behavioral sciences have examined anticipatory emotions
and the social sciences anticipated emotions. While one-
DONOR RECRUITMENT AND RETENTION
off interventions such as applied tension (AT) are known
to be effective with respect to anticipatory emotions,
donors may not use this technique every time. If donors
do not use AT each time they donate, they may experience
distress and may not return. Thus an important question
for the behavioral sciences is: How do you get donors to
use AT every time they donate? Similarly, social science
research indicates that intentions to donate predict dona-
tion but that such intentions may become derailed by
anticipated anxiety about donation. How can we increase
behaviors such as AT and also to help to manage antici-
pated emotions associated with donation? One theoretical
development from the social sciences that meets these
requirements is the formation of implementation inten-
tions. Implementation intention formation is an effective
technique for increasing compliance.4
Implementation intentions
Implementation intentions are if-then plans (“If it is situ-
ation X, then I will do Y to reach goal Z”) that facilitate the
translation of goal intentions into action (e.g., help to
ensure that one’s intention to donate blood results in
blood donation behavior). To form an implementation
intention, the person should specify a good opportunity to
act in the if-part of the plan, and specify a response that
moves one toward the goal in the then-part of the plan.
Thus, the goal intention of getting screened for cervical
cancer (“I intend to obtain screening”) could be furnished
by an implementation intention that specifies when,
where, and how to make an appointment with one’s
medical practitioner (e.g., “If I have finished coffee on
Monday at 11:10 am then I will phone the surgery.”94). By
forming an if-then plan, the person delegates control of
behavior from the self to the situational cues specified in
the plan; when the person subsequently encounters these
cues, the behavior is elicited automatically. Considerable
evidence attests to the idea that forming implementation
intentions increases attendance for medical screening
and promotes performance of health behaviors compared
to merely forming relevant goal intentions.4 Techniques
for forming implementation intention are fairly straight-
forward. Participants state their goal intention (i.e., to
donate blood) and then prompting them to state where
and when the will undertake particular subgoals associ-
ated behavior (such as drinking water before donation).
Gollwitzer and Sheeran4 argue that goal attainment (in
this case, donating blood) can be blocked by three key
self-regulatory problems: 1) failing to get started, 2)
getting derailed (behaviors and feelings that hinder an
ongoing behavioral goal), and 3) not calling a halt (trying
to continue in the face of disappointing feedback).
Forming appropriate implementation intentions to help
to resolve Problems 1 to 3 should facilitate positive dona-
tion experiences.
Volume **, ** ** TRANSFUSION 7
FERGUSON ET AL.

The successful application of this technique depends

If I feel faint after donation, then I will tell myself this

I will not worry about this and see it as something

I will not worry about this and see it as something

then I will change my diet, in preparation to make

then I will change my diet, in preparation to make

crucially on identifying critical subgoals that will facilitate

If I am unable to donate after the anemia test, then

If I am unable to donate after the anemia test, then

If I feel faint after donation, then I will tell myself
that happens from time to time! If I am anemic

that happens from time to time! If I am anemic

performance.4 For example, careful pilot work needs to be
conducted with representative subsamples of donors at
different stages of the donor career cycle5 or who have
experienced different types of donation experience

Not calling a halt

(feeling faint, deferred). Appropriate specification and
phrasing of the implementation intentions can be under-
taken on the basis of this work. If this stage of intervention

a donation in the future!

a donation in the future!

development is not conducted properly, the resultant
intervention will be unlikely to succeed. Examples of some

this is normal!
types of implementation that might be considered are
described in the next section. It needs to be emphasized,

is normal.
however, that these are only examples; identifying the
most effective for implementation requires pilot work
focusing on the real opportunities and impediments
facing donors.

drink a cup or coffee or a large glass of water and

If I am donating blood then I will use muscle tension

use breathing and imagery exercises to stay calm
If I am going to give blood, then before I go I will
Implementation intentions and donor recruitment

TABLE 2. Example implementation intentions

and retention
Donor recruitment. The social science literature
shows that goal intentions are the strongest predictor of

Getting derailed
attendance5 but also that fear of negative emotional con-

and relaxation techniques!

sequence acts as an inhibitor. Both the social and the
behavioral science data demonstrate that negative
emotion experience reduces the likelihood of donor
returns and that this is especially the case for first time
donors.65,68 The behavioral science data also show that and relaxed!

drinking coffee before donation reduces the chances of

feeling faint and having a negative emotional experi-
ence.13 There is also evidence that convenience and time
management are important predictors of donor behav-
ior.5 Thus, to aid recruitment and manage the donation
then I will ensure that I have enough time to do so

then I will ensure that I have enough time to do so

experience, three implementation intentions should be

If it is the day I have decided to go and give blood,

If it is the day I have decided to go and give blood,

and arranged any necessary child care or cover

and arranged any necessary child care or cover

formed: 1) one that focuses on scheduling (getting

started), 2) one that focuses on coffee intake (getting
derailed), and 3) one that focuses on managing any
negative emotional experiences or consequence of tem-
porary deferral (not calling a halt). Table 2 provides
Getting started

some examples of the types of implementation inten-

tions that could be formed by donors to achieve each of
these.
These donors are likely to be first-time donors and
could also be taught applied muscle tension techniques.
National advertising campaigns could not just ask people
needed!

needed!

to donate but ask them to think about how, where, and

when to donate to get them to form an if-then plan.
Potential donors could also be asked to form an imple-
mentation intention around preparing for their donation
by drinking sufficient fluid such as coffee and using
Recruitment
Donor cycle

relaxation if they feel anxious. Donors should also be told

Retention

not merely to consider donation as an act that helps

others, but to consider also what they might get out of it
themselves in terms of a sense of personal achievement.

8 TRANSFUSION Volume **, ** **

 DONOR RECRUITMENT AND RETENTION

Implementation intentions,
specific to deferral reason

BEHAVIORAL AND SOCIAL Deferral

SOCIAL COGNITION SOLUTIONS
BARRIERS
SOLUTIONS
TRADITIONAL
Hydration
- Fear of fainting Donation without reactions
- Fear of fainting + implementation intentions
Reminders - Scheduling
- Scheduling
- Motivation
- Motivation Applied Tension
+ implementation intentions Vasovagal reaction

Implementation intentions,
specific to contributors to
vasovagal reactions

RECRUITMENT PERIOD ARRIVAL AT DONATION SITE DONATION

Fig. 1. Donor cycle and the integration of traditional and new social science and behavioral science interventions.

Donor retention. The work from the behavioral sci- SUMMARY AND AGENDA FOR FUTURE
ences shows that techniques such as AT can reduce symp- RESEARCH
toms of feeling faint and increase goal intentions to make
This review highlights the utility of integrating social
future donations,85 as can preloading with water91 and caf-
science and behavioral science research agendas within
feine.13 Implementation intentions offer a technique that
transfusion medicine to increase the recruitment and
enables continual use of techniques like AT. Once AT has
retention of blood donors. Although this literature has
been demonstrated and used, the donor can be requested
developed separately, their integration is timely and
to form an implementation intentions about the use of AT
worthwhile. Most important, this review points to several
along with an implementation intention to donate next
possibilities for integrative interventions that can, and
time. The donation implementation plan would focus on
should, be tested in future studies. In particular, experi-
when and where they would next donate whereas the
mental tests of the application of implementation inten-
focus of the AT plan would be on when and where to
tion prompts to promote scheduling and instruction in AT
perform AT (e.g., from registration through to recovery in
and predonation hydration in donor recruitment and
the donation location). These if-then plans could be made
retention materials are warranted.
at the end of a donor session as well as being part of the
reminder letters that are sent out. In this way, the power of
a simple behavioral technique can be strengthened with a
social science technique that ensures that the behavioral
technique is used every time, and at the right time, that
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