Health Psychology Copyright 2006 by the American Psychological Association

2006, Vol. 25, No. 3, 433– 437 0278-6133/06/$12.00 DOI: 10.1037/0278-6133.25.3.433

BRIEF REPORTS

The Effects of Applied Tension on Symptoms in French-Speaking Blood

Donors: A Randomized Trial

Blaine Ditto Christopher R. France

McGill University Ohio University
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

Blood-donation-related symptoms such as dizziness and weakness discourage people from participating
in this important health-related activity. Four hundred sixty-seven young adult, French-speaking blood
donors were randomly assigned to (a) a condition in which they learned a possible preventive technique
called applied tension and were asked to practice it from the time they got on the donation chair until they
were just about to get up, (b) a placebo condition in which they learned applied tension and were asked
to practice it from the time they got on the chair until the insertion of the donation needle, or (c) a
no-treatment control condition. Donors assigned to the treatment condition reported significantly fewer
blood-donation-related symptoms than did donors assigned to the other conditions and rated their
likelihood of returning to give blood again as greater than did those in the no treatment condition. Among
donors whose chairs were not reclined, participants in the treatment condition had significantly smaller
heart rate reactions to blood donation than did those in the other conditions.

Keywords: blood donation, vasovagal symptoms, fainting, prevention, applied tension

Blood collection systems based on voluntary, unpaid donations
have a number of advantages, especially in the area of blood
safety, and are promoted by agencies such as the World Health
Organization. Of interest from a health psychology perspective,
these systems highlight the importance of psychological and be-
havioral factors (Ferguson & Bibby, 2002; Piliavin, 1990). For
example, blood collection agencies are constantly looking for ways
to encourage this important health-related activity, particularly
among those who have given blood on previous occasions. The
importance of encouraging repeat donations has received increas-
ing attention in recent years not only because of the fact that most
blood comes from repeat donors but also because of the increasing
number of exclusionary criteria for giving blood (Thomson et al.,
1998). That is, to ensure the safety of the blood supply from AIDS,
hepatitis, and so forth, blood collection agencies have developed a
number of new criteria for giving blood in recent years, thereby
reducing the pool of prospective donors. One major advantage of
repeat donors is that, by definition, they were accepted as donors
on at least one prior occasion, which means that they are generally
Blaine Ditto, Department of Psychology, McGill University, Montreal,
Quebec, Canada; Christopher R. France, Department of Psychology, Ohio
University.
This research was supported by a grant from the Fonds de la Recherche
en Santé du Québec. We gratefully acknowledge the assistance of the staff
and organization of Héma-Québec.
Correspondence concerning this article should be addressed to Blaine Ditto,
Department of Psychology, McGill University, 1205 Dr. Penfield Avenue,
Montreal, Quebec H3A 1B1, Canada. E-mail: blaine.ditto@mcgill.ca
healthy and very likely to be accepted again if they volunteer to
give blood. Unfortunately, for various reasons, it has become
increasingly difficult to retain donors (Wu et al., 2001; Zuck et al.,
1995), and only about one half of first-time donors return to give
blood again (Ownby, Kong, Watanabe, Tu, & Ness, 1999; Thom-
son et al., 1998).
One of the strongest and best-documented reasons for donor
drop-out is the occurrence of unpleasant symptoms such as dizzi-
ness, weakness, nausea, and syncope. Although these occur in only
a minority of donors, these symptoms are not enjoyable and often
tip the balance toward nonparticipation. Several studies have found
that the experience of even mild symptoms is associated with a
decreased intention to donate again (Sauer & France, 1999; Thom-
son et al., 1998) as well as fewer actual repeat donations (France,
France, Roussos, & Ditto, 2004; Piliavin, 1990; Staallekker, Stam-
meijer, & Dudok de Wit, 1980). Further, although estimates of the
frequency of blood-donation-related symptoms based on objective
criteria such as fainting or the nurse reclining the donation chair to
treat a reaction have traditionally been low (e.g., 5%), recent
results suggest that many more donors experience unpleasant
symptoms, even if they are undetected by others or not sufficiently
severe to merit medical intervention. This has been aided by the
development of a questionnaire, the Blood Donation Reactions
Inventory (BDRI; Meade, France, & Peterson, 1996), to system-
atically record self-reported symptoms. In one study, 159 of 364
(44%) university-age blood donors reported at least a mild expe-
rience of at least one symptom (Meade et al., 1996). In sum,
although they are usually medically innocuous, donation-related
symptoms of varying severity occur in many donors and nega-
tively influence donor return.

433
 434 BRIEF REPORTS
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Figure 1. Sample breakdown.
In an attempt to address this problem, we adapted the behavior
therapy technique of applied tension (AT) for use in a blood
collection clinic and evaluated its effects in two studies (Ditto,
France, Lavoie, Roussos, & Adler, 2003, Ditto, Wilkins, France,
Lavoie, & Adler, 2003). AT is often used to facilitate behavior
therapy of individuals with blood and injury phobias. It involves
the repeated contraction of the major muscle groups of the arms
and legs and has been found to reduce vasovagal reactions during
presentation of feared stimuli, allowing treatment of these highly
anxious individuals to proceed (Hellstrom, Fellenius, & Ost, 1996;
Kozak & Montgomery, 1981; Ost & Sterner, 1987). As well,
Foulds, Wiedmann, Patterson, and Brooks (1990) found that AT
taught in an abbreviated, 5-min session can significantly increase
cerebral blood flow, another characteristic that suggested it might
be of value in the blood donation context. We developed a 2-min
instructional video that was presented to English-speaking donors
in Montreal, Quebec, Canada. Donors watched the video on a
notebook computer before their donation and were asked to prac-
tice AT while they were giving blood. In general, the results of
these studies were encouraging, indicating fewer symptoms in
some treated groups.
The second, larger study (Ditto, France, et al., 2003) also in-
cluded a large number of French-speaking individuals. However,
we decided not to include these data in that report for several
reasons, primarily because there was a significant difference be-
tween the English- and French-speaking samples in the frequency
of the main medical intervention for the treatment of reactions,
reclining the donor’s chair (11% vs. 17%, respectively).1 As a
result, in the present article, we describe the effects of AT on
blood-donation-related symptoms in a group of young adult,
French-speaking blood donors. It was predicted that donors in the
AT condition would report fewer donation-related symptoms and,
in general, a more positive experience.
Method
Participants
Donors were tested at mobile clinics operated by the provincial blood
collection agency held in various Montreal-area educational institutions.
All individuals who were sufficiently healthy to be accepted as blood
donors were invited to participate in the study. There were 1,254 donors
participating in the larger study (see Figure 1), completing pre- and
postdonation questionnaires, and participating in one of the treatment
conditions. Information from the nurses who collected the blood was
obtained for 1,072 of these individuals. The 605 donors who were tested at
English-speaking institutions were the focus of our previous report (Ditto,
France, et al., 2003), whereas the 467 who were tested in French-speaking
institutions are the focus of the present article. Participants were randomly
assigned to either a no-treatment condition, an AT condition, or a placebo
control condition in groups of 15–20 consecutive donors. That is, using a
table of random numbers, a research assistant would determine the condi-
tion to be used for 15–20 donors, set up the instructional video (discussed
below) for that purpose, and test a group of donors, after which the
procedure would be repeated. This procedure yielded 155 donors assigned
1
The most likely explanation for this was that French-speaking students
were tested primarily in Colleges d’Enseignement Général et Professionel.
These institutions serve as post– high school technical schools and com-
pulsory university preparatory schools for those bound for university. As a
result, they generally serve younger individuals, many who have just
become eligible to give blood. This probably increased the likelihood of
observing reactions in these environments, and nurses were also probably
more likely to intervene in ambiguous cases in this high risk setting.
 BRIEF REPORTS 435

to the no treatment condition, 172 to the AT treatment condition, and 140
to the placebo condition. There were no significant differences in gender,
age, body mass index, or previous blood donation experience among
participants assigned to the three conditions (see Table 1).
Measures
Participants completed two questionnaires. A brief predonation ques-
tionnaire including an abbreviated, five-item version of the State Anxiety
Inventory (Spielberger, Gorsuch, & Lushene, 1970) was completed just
after they were recruited and assigned to condition. The postdonation
questionnaire had another abbreviated State Anxiety Inventory. More im-
portant, it included a translated version of the BDRI, the primary measure
of donation-related symptoms. The BDRI requests ratings of 11 common
donation-related symptoms such as faintness, dizziness, weakness, nausea,
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video on a notebook computer and listened to the French-language sound-
track, using padded headphones. Donors were told to tense the major
muscle groups in their arms and legs at 5-s intervals while breathing
steadily and were given some hints, such as trying to imagine the tension
produced by squeezing a tennis ball. Emphasis was placed on repeated
tensing, as opposed to tensing and relaxing the muscles.
After watching the video, participants in the AT condition were asked to
practice the technique from the time they sat down on the donation chair
until they were just about to get up. In contrast, placebo participants were
asked to practice AT from the time they sat down on the donation chair
until the insertion of the donation needle. This was viewed as an inactive
treatment on the basis of its brief duration and of the fact that blood
donation–related fainting occurs almost always toward the end of blood
collection (Newman & Graves, 2001). On the other hand, placebo partic-
ipants viewed the same video as the AT participants, practiced the same

and visual disturbance on a scale from 0 (not at all) to 5 (to an extreme technique, and presumably had the same expectations of positive benefit.
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degree). Donors also reported when, if at all, they practiced AT and rated
(a) how useful muscle tensing was in helping them to prevent negative
reactions, (b) how likely they would be to recommend AT to a friend who
was going to donate blood, and (c) how useful they thought AT would be
in general to prevent reactions, on a scale from 0 (not at all) to 4
(extremely). At the end of the questionnaire, they rated their overall
likelihood of returning to give blood again on a 167-mm visual analogue
scale with endpoints of definitely yes and definitely no.
Two measurements of blood pressure and heart rate were obtained
before and after donation with a portable digital monitor (Becton Dickin-
son Model A10, Franklin Lakes, NJ) with the donor seated and arm
supported at heart level. The nurses who collected the blood rated the
difficulty of needle insertion on a scale from 1 to 5 and provided infor-
mation about the procedure, such as whether they reclined the donor’s chair
to treat symptoms.
Procedure
Donors were approached either just before or just after they registered as
the clinic. Those agreeing to participate were assigned to the conditions in
groups of 15–20 consecutive donors. No-treatment control participants
simply completed the assessment procedures of the study and underwent
the typical blood collection process including a screening interview, a
finger prick to collect a small blood sample for testing, the venipuncture,
and blood donation. In contrast, those assigned to the placebo control and
AT conditions completed the predonation questionnaire and then viewed a
2-min video describing and demonstrating AT. Participants watched the
No participant questioned the placebo procedure (which was referred to as
applied tension), perhaps because it implicitly linked fainting with inser-
tion of the donation needle, which many people believe to be the key event
in blood donation.
Data Analysis
The primary analyses were Treatment Condition (3: AT, placebo, no
treatment) ⫻ Gender (2) analyses of covariance (ANCOVAs). A partici-
pant’s condition was determined on an intent-to-treat basis. The variable of
whether a donor’s chair was reclined to treat a reaction was used as a
covariate in the analyses. This intervention, administered at the discretion
of the nurses, was not under experimental control yet had the potential to
influence outcome. For example, chair reclining almost certainly reduces
symptom reports in some donors because its purpose is to reduce symp-
toms by increasing blood flow to the brain. To eliminate the effects of this
variable entirely, we also conducted a separate set of analyses using only
those whose chairs were not reclined. The distributions of the variables
were examined before statistical analysis. To reduce skewness, we log-
transformed the raw BDRI scores.
Results
There were no differences between those assigned to the no
treatment, placebo, and AT conditions in the medical characteris-
tics of their blood donations. There were no differences in nurse

Table 1
Demographic and Blood Donation Characteristics

No treatment Placebo Applied tension

(n ⫽ 155)a (n ⫽ 140)b (n ⫽ 172)c

Variable M SE M SE M SE

Age (years) 24.3 0.8a 22.8 0.9a 24.6 0.9a

Body mass index (kg/m2) 24.1 0.3a 24.0 0.3a 23.5 0.3a
Donation experience (previous
donations) 3.9 0.7a 3.2 0.8a 3.6 0.7a
Predonation anxiety (units) 3.8 0.2a 3.0 0.2b 2.7 0.2b
Postdonation anxiety (units) 2.0 0.2a 2.3 0.2a 2.0 0.2a
Blood Donation Reaction Inventory
(log units) 0.45 0.03a 0.43 0.03a 0.35 0.03b
Likelihood of future donation (mm) 152 1.6a 157 1.6a,b 158 1.4b

Note. Means that share the same subscript are not significantly different. Means with different subscripts are
significantly different ( p ⬍ .05).
a
63% women, 37% men. b 55% women, 45% men. c 52% women, 48% men.
 436 BRIEF REPORTS
rating of the ease of needle insertion, M ⫽ 1.9, 2.0, 2.0, respec-
tively, F(2, 461) ⫽ 0.05, p ⫽ .95; whether a needle adjustment was
required, M ⫽ 10%, 14%, 16%, F(2, 461) ⫽ 1.33, p ⫽ .26; the
need for chair reclining, M ⫽ 14%, 19%, 18%, F(2, 461) ⫽ 1.13,
p ⫽ .32; or the percentage of full units of blood obtained, M ⫽
90%, 92%, 90%, F(2, 461) ⫽ .44, p ⫽ .65.
Effects of AT on Vasovagal Symptoms
The Treatment Group (3) ⫻ Gender (2) ANCOVA of BDRI
scores produced a significant main effect of treatment condition,
F(2, 457) ⫽ 3.43, p ⫽ .033. Symptom scores of donors assigned
to the AT condition were significantly lower than were those
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assigned to both the no treatment, t(323) ⫽ 2.39, p ⫽ .009, effect
This document is copyrighted by the American Psychological Association or one of its allied publishers.
size (ES) ⫽ .26, and placebo control, t(308) ⫽ 2.06, p ⫽ .021,
ES ⫽ .24, conditions. In contrast, the scores of those assigned to
the placebo condition did not differ from those in the typical blood
collection procedure (see Table 1). A comparable main effect of
treatment condition was observed in the analysis of variance of
BDRI scores of donors whose chairs were not reclined, F(2,
379) ⫽ 4.00, p ⫽ .019. Donors in the AT condition reported
significantly fewer symptoms, M ⫽ .19 ⫾ .03 log units, compared
with those in both the no treatment, M ⫽ .29 ⫾ .03, t(270) ⫽ 2.34,
p ⫽ .01, ES ⫽ .28, and placebo control, M ⫽ .29 ⫾ .03, t(248) ⫽
2.42, p ⫽ .008, ES ⫽ .31, conditions.
Effects of AT on Other Self-Reported Symptoms
In addition to participants in the AT condition reporting fewer
donation-related symptoms whereas those in the placebo condition
did not, several other findings suggest that this was not the result
of a placebo effect. Donors in the AT condition did not report
lower pain from the blood screening finger prick, the donation
venipuncture, or postvenipuncture arm pain. Despite the lower
anxiety scores observed in the predonation questionnaires of those
in the AT and placebo conditions, there were no group differences
in anxiety scores obtained from the postdonation questionnaire
(see Table 1). The predonation anxiety results suggest that the
placebo condition was an effective manipulation, giving donors
hope of a more positive outcome, but this was not sufficient to
reduce donation-related symptoms. The only difference in postdo-
nation symptom ratings among those in the AT condition was in
donation-related symptoms. An identical pattern of results was
observed among donors whose chairs were not reclined.
Heart Rate and Blood Pressure
The physiological data were analyzed using Treatment Condi-
tion (3) ⫻ Gender (2) ANCOVAs of pre- to postdonation change
scores, corrected for chair reclining and baseline (predonation)
values. There were no significant effects involving treatment con-
dition in the ANCOVAs of all participants. However, the
ANCOVA of heart rate change scores of donors whose chairs were
not reclined produced a significant main effect of AT treatment
condition on heart rate change, F(2, 378) ⫽ 4.01, p ⫽ .019. Donors
in the AT condition had significantly smaller increases in heart rate
from before to after donation, M ⫽ 2.2 ⫾ 0.8 bpm, compared with
those in the no treatment, M ⫽ 4.5 ⫾ 0.8 bpm, t(270) ⫽ 2.07, p ⫽
.021, ES ⫽ .27, and placebo control, M ⫽ 5.3 ⫾ 0.9 bpm, t(248) ⫽
2.67, p ⫽ .003, ES ⫽ .33, conditions.
Results From Treatment Evaluation Ratings and Intention
to Give Blood Again
Despite the lower reports of donation-related symptoms, there
were no significant effects involving treatment condition in Treat-
ment Condition (2) ⫻ Gender (2) ANCOVAs of responses to the
three questions about perceived treatment effectiveness (such as
“Would you recommend muscle tensing to a friend?”). There were
only two levels of the treatment condition factor in these analyses
because those in the no-treatment condition could not answer these
questions. These results provide additional evidence that the pla-
cebo condition was perceived as an equally plausible intervention
compared with the AT condition. That said, the apparent impact of
AT on donation-related symptoms may have had an effect on
participants’ willingness to give blood again. The analysis of their
ratings of the likelihood that they would give blood again yielded
a significant effect of treatment condition, F(2, 451) ⫽ 3.66, p ⫽
.026. Participants in the AT condition thought that they were more
likely to give blood again compared with donors in the no treat-
ment condition, t(319) ⫽ 2.64, p ⫽ .004, ES ⫽ .29. In contrast,
although there was a trend in that direction, the ratings of those in
the placebo condition did not differ from those who underwent the
typical blood collection procedure (see Table 1).
Discussion
Similar to our English-speaking donors (Ditto, France, et al.,
2003; Ditto, Wilkins, et al., 2003), blood donors assigned to the
AT condition reported significantly fewer unpleasant blood-
donation-related symptoms such as dizziness and weakness than
did those in the no treatment condition. Several features of the
pattern of results increase confidence in the validity of this key
finding. First, donors in the placebo condition did not report fewer
symptoms. Individuals in the placebo condition were told that they
were going to learn the technique of AT, watched the same video,
and actually practiced AT while in the donation chair, albeit for a
limited period of time. Several findings suggest that the placebo
condition was viewed as a plausible intervention. Second, donors
in the AT condition did not report a general reduction in all
physical and psychological symptoms. It seems to have been
limited to blood-donation-related symptoms. Third, although the
BDRI is a self-report instrument that requests ratings of subjective
symptoms, this should not be interpreted to mean that these symp-
toms are imaginary or purely psychological. The basic physiolog-
ical process (though perhaps not the causes) of blood donation–
related symptoms is fairly well described. The final common
pathway is a reduction in cerebral oxygenation as a result of a
reduction in cardiac output that is usually due, in turn, to a
vasovagal reaction, hypovolemia, or a combination of the two
processes. If sufficiently severe, the subjective symptoms of diz-
ziness and so forth can be manifest in very observable weakness
and fainting. Previous studies using the original English version of
the BDRI have observed significant correlations between scores
and observer ratings of symptoms (Meade et al., 1996; Sauer &
France, 1999). Finally, the heart rate results provide some intrigu-
ing, albeit tentative, objective evidence of a positive impact of AT
 BRIEF REPORTS
on cardiovascular activity during blood donation. Even though
donation blood loss is modest, homeostatic increases in sympa-
thetic nervous system are often observed to offset the effects of
hypovolemia (Haberthur, Schachinger, Seeberger, & Stebler Gysi,
2003; Kosowsky, Han, Collins, McAfee, & Storrow, 2002). That
donors in the AT condition exhibited significantly less heart rate
change from the very beginning to the very end of the blood
donation procedure compared with both the no treatment and
placebo control donors, who did not practice AT during the blood
draw, suggests that some feature of AT may have buffered the
impact of hypovolemia. Similarly, Vogele, Coles, Wardle, and
Steptoe (2003) found that blood and injury phobics who practiced
AT while they watched a video depicting open heart surgery
had more stable blood pressure than did phobics who did not
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practice AT.
The donors in the AT condition appear to have had a more
positive experience giving blood, which may have led to their
higher ratings of their chances of giving blood again than those in
the no-treatment control condition. This and other findings of the
study are encouraging, though subject to a number of qualifica-
tions. For example, in regard to return ratings, the difference
between the AT and placebo conditions was not significant. Al-
though the difference between the placebo and no-treatment con-
trol conditions was also not significant, it is possible that the higher
return ratings of those in the AT condition were due as much to the
belief they had learned a useful technique to use while giving
blood, as opposed to the immediate effects of AT on vasovagal
symptoms. This is an area for future research.
Another caution is the modest effect sizes. In general, the results
are interesting and statistically significant, but their potential clin-
ical importance is uncertain. One issue that may be related to this
is treatment compliance. On the basis of current standards that
maintain the random character of the groups, the analyses in the
present study were conducted on an intent-to-treat basis, not on
whether the person actually practiced AT. Unfortunately, self-
report data from the postdonation questionnaire suggest that only
about 57% of those assigned to the AT condition actually practiced
it as requested, for the entire time they were in the donation chair.
Although 84% said that they practiced the technique at least some
of the time they were in the donation chair, the fact that almost half
of those in the AT condition did not do it for the full time probably
reduced treatment effects. For example, those assigned to the
placebo condition, who practiced AT for a limited period of time,
clearly did not benefit from the technique. Compliance may have
been limited by the nature of the explanation of the study and
emphasis on the experimental nature of the treatment, which may
have led some donors to believe that it was not worth the effort.
This is another topic requiring additional research. The study of
blood donation reactions and blood donor behavior could have a
significant effect on donor retention and is an area in which
researchers in health psychology could contribute significantly to
public health.
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