Blackwell Publishing IncMalden, USATRFTransfusion0041-11322006 American Association of Blood BanksJune 200646610061010Original ArticleANXIETY, SYMPTOMS, AND DONOR RETURNDITTO AND

FRANCE

BLOOD DONORS AND BLOOD COLLECTION

Vasovagal symptoms mediate the relationship between

predonation anxiety and subsequent blood donation in
female volunteers

Blaine Ditto and Christopher R. France

F
rom the perspective of the inexperienced donor,
BACKGROUND: Although not universal, a certain the blood donation procedure involves a number
amount of predonation anxiety is common and not of potentially anxiety-eliciting features. In addi-
surprising among inexperienced blood donors. Variations tion to the possibility of physical “injury” in the
in predonation anxiety, however, may influence the form of a fingerprick, venipuncture, blood loss, and symp-
donor’s experience in several respects and might be toms such as dizziness and nausea, there is a risk of social
related to the likelihood of subsequent donation even stress or embarrassment. Reasonable or not, some people
among those who do not report particularly high levels of feel awkward about the possibility of displaying physical
anxiety. symptoms or answering personal screening interview
STUDY DESIGN AND METHODS: A total of 671 questions.1 All of these issues are probably accentuated
inexperienced blood donors (zero or one prior donation) by the uncertainty inexperienced donors have about the
enrolled in a treatment study and completed exact nature of the procedure. Fortunately, such concerns
questionnaires assessing anxiety before and after giving are outweighed (or else the person would not be in the
blood. Ratings of pain and blood donation–related clinic at all) by various altruistic motives, and most donors
symptoms were obtained after giving blood, as well as discover that the procedure is typically uneventful and not
information from the nurses about the blood donation unpleasant. Nonetheless, it may be premature to dismiss
procedure. Follow-up information on number of additional the issue and to assume that anxiety will largely habituate
visits to a blood collection clinic during the subsequent with experience, except for those who are extremely anx-
year was also obtained for most participants. ious and probably not well-suited to be blood donors any-
RESULTS: Predonation anxiety was positively related to way. While a certain degree of donor loss related to anxiety
ratings of blood donation–related symptoms and chair and donation-related symptoms is almost inevitable,
reclining by the nurses and negatively related to the there is reason to believe that there is not a clear “cutoff”
donor’s rating, obtained at the end of the procedure, of beyond which these issues do not affect donor return. For
the likelihood that he or she would give blood again.
Women, but not men, with higher predonation anxiety
were significantly less likely to return to a blood clinic in
the following year. The results of mediation analyses ABBREVIATION: BDRI = Blood Donation Reactions Inventory.
suggest that this was due to the association between From the Department of Psychology, McGill University, Montreal,
anxiety and donation-related symptoms. Quebec, Canada; and the Department of Psychology, Ohio
CONCLUSION: The results do not indicate whether or University, Athens, Ohio.
not it is feasible or useful to modify predonation anxiety, Address reprint requests to: Blaine Ditto, PhD, Department
but highlight the relationships between the emotional of Psychology, McGill University, 1205 Dr Penfield Avenue,
state of inexperienced donors and several aspects of the Montreal, Quebec H3A 1B1, Canada; e-mail: blaine.ditto@
donation experience, including subsequent donor return. mcgill.ca.
Further study of the psychosocial aspects of blood This research was supported by grants from the Canadian
donation and examination of related research (e.g., Blood Services/Canadian Institutes of Health Research
treatment of dental anxieties) may be worthwhile. Partnership in Transfusion Science and the Fonds de la
Recherche en Santé du Québec.
Received for publication August 4, 2005; revision received
October 12, 2005, and accepted November 1, 2005.
doi: 10.1111/j.1537-2995.2006.00835.x
TRANSFUSION 2006;46:1006-1010.

1006 TRANSFUSION Volume 46, June 2006


example, France and coworkers2 recently examined the
relationship between blood donation–related symptoms
assessed with the Blood Donation Reactions Inventory
(BDRI)3 and subsequent trips to a blood collection clinic.
The relationship was found to be continuous, with each
point increase on this 0 to 55 scale (11 symptoms, each
rated 0-5) related to a 4 percent reduction in the donor’s
likelihood of returning to give blood within 1 year. In large
part, such findings are responsible for recent interest in
various techniques aimed at reducing blood donation–
related symptoms.4-7 Similarly, it is possible that lower lev-
els of blood donation–related anxiety may be somewhat
more problematic than widely appreciated. This study
examined the relations between predonation anxiety and
various aspects of the blood donation procedure, symp-
toms, and donor return in inexperienced donors. It was
predicted that predonation anxiety in inexperienced
donors would be negatively related to the likelihood of
returning to give blood again and that this association
would be mediated primarily by the impact of anxiety on
risk for blood donation–related symptoms.
MATERIALS AND METHODS
Participants
Participants were part of a trial of the effects of a behav-
ioral technique called applied tension on blood donation–
related symptoms.7,8 Although applied tension is primarily
a physical, muscle tensing technique, the predonation
and postdonation questionnaires included an abbreviated
version of the widely used, well-validated Spielberger
State Anxiety Questionnaire.9 A total of 1254 donors at
mobile clinics held in colleges and universities partici-
pated in the trial, which included 671 individuals who
have given blood on no more than one previous occasion
(the median value). The sample was composed of 245
men, 426 women (461 first-time donors and 210 second-
time donors) and had a mean age of 20.1 (SD 3.9) years.
Measures
To minimize the impact of the study on the blood collec-
tion procedure, the predonation questionnaire included
an abbreviated version of the Spielberger State Anxiety
Scale.9 With data from a pilot study for this project,10 factor
analysis was used to identify the five highest loading items
from the full 20-item scale on the principal factor. Each of
these five items is rated on a 0 to 3 scale, creating a maxi-
mum possible score of 15 on the abbreviated version. Par-
ticipants completed the anxiety scale a second time, on
the postdonation questionnaire. The postdonation ques-
tionnaire also included the BDRI3 and several 167-mm
visual analog scales. Ratings of pain produced by the pre-
donation fingerprick and venipuncture were requested
and an overall judgment of the likelihood that they would
ANXIETY, SYMPTOMS, AND DONOR RETURN
return to give blood in the future. The nurses who col-
lected the blood reported whether any needle adjust-
ments were required, a full unit of blood was obtained,
and the donor’s chair had to be reclined to treat symptoms
and rated the difficulty of needle insertion. Finally, the
number of subsequent trips to a blood collection clinic
was obtained, with the donor’s written permission, from
the provincial blood collection agency, Héma-Québec.
The analyses of donor return focused on whether or not
the donor returned to a blood clinic in the following year.
This research was approved by the Research Ethics Boards
of McGill University and Héma-Québec.
Statistical analysis
Initial analyses revealed that none of the effects of anxiety
was mediated by treatment group. This is not surprising
because applied tension is a physical muscle tensing
intervention aimed at stabilizing blood pressure and facil-
itating blood return to the heart. Nevertheless, treatment
group was entered as a covariate in the analyses along
with age, body mass index, donation experience (first vs.
second time giving blood), and mother tongue (English vs.
French). Predonation anxiety score and sex were the inde-
pendent variables. Analyses were conducted with the gen-
eral linear model because this can accommodate both
continuous (anxiety) and categorical (sex) independent
variables.
Baron and Kenny11 described a procedure to test the
possible role of a psychosocial variable as a mediator of
the effects of another variable. That is, if a researcher
believes that Variable B mediates the relationship between
Variables A and C, then A should predict B and C, B should
predict C, and the regression coefficient reflecting the
relationship between A and C should become nonsignifi-
cant if B is entered in the same equation. The possibility
that the predicted relationship between predonation anx-
iety and the return of inexperienced donors is mediated
by blood donation–related symptoms was evaluated in
this manner.
The distributions of the variables were examined
before analysis. To reduce skewness, BDRI scores were
log-transformed. The criterion for statistical significance
was p < 0.05.
RESULTS
Predonation anxiety
The blood donation procedure began similarly for anxious
and nonanxious donors. Predonation anxiety was not
associated with the nurse’s rating of the ease of needle
insertion or the need for a needle adjustment. Predonation
anxiety, however, was significantly associated with blood
donation–related symptoms assessed by the BDRI
(F1,629 = 22.12, p < 0.001; (Fig. 1)). This does not seem to
Volume 46, June 2006 TRANSFUSION 1007
DITTO AND FRANCE

0.7 30
BDRI score (log units)

Chair reclined (%)

0.6
20

0.5

10
0.4

0.3 0
0,1 2,3 4,5 >5 0,1 2,3 4,5 >5

Predonation anxiety score Predonation anxiety score

Fig. 1. Anxiety quartiles and self-reported donation-related Fig. 2. Anxiety quartiles and chair reclining by nurses.
symptoms.

have been related simply to a general 70

tendency to complain because predona- 60
tion anxiety was also positively related
Returned (%)

50
to the frequency of chair reclining by the
nurses (F1,533 = 5.38, p = 0.021; (Fig. 2)). 40

Consistent with the literature indicating 30

a positive association between pain and 20
“relevant” anxiety (anxiety related to the
10
pain-producing procedure or environ-
12
ment), anxiety was associated with 0
0 3
ratings of both fingerprick (F1,626 = 4.93,
p = 0.027) and venipuncture (F1,624 =
5.99, p = 0.015) pain.
Fig. 3. Female blood donor return in relation to predonation anxiety score.
At the end of their donation experi-
ence, there was a significant main effect
of anxiety on the donors’ rating of the likelihood they
would give blood again (F1,619 = 14.78, p < 0.001). Those
with higher predonation anxiety rated their chances of
returning as significantly lower than those who were more
at ease. These judgments appear to have been relatively
accurate, at least for women. Follow-up data revealed a
significant interaction between predonation anxiety and
sex in whether or not the individual volunteered to give
blood again during the year (F1,482 = 4.22, p = 0.040). Sepa-
rate analyses of data from men and women indicated that
predonation anxiety was not related to whether or not the
donor returned among men. A separate GLM of data from
women, however, revealed a significant effect of predona-
tion anxiety (F1,310 = 4.06, p = 0.045; (Fig. 3)). When ana-
lyzed with logistic regression, the odds ratio (OR) was 0.93
(p = 0.045).
Mediation analyses
When BDRI score replaced predonation anxiety in this
regression equation predicting donor return in women,
BDRI score was significantly associated with a decreased
6 9 12 15
Predonation anxiety score
likelihood of return (OR, 0.51; p = 0.005). That is, inexperi-
enced female donors reporting more dizziness, etc., were
less likely to return, independent of age, body mass index,
and treatment group. When both predonation anxiety and
BDRI scores were included in the equation, the effect of
predonation anxiety on return was not significant (OR,
0.95; p = 0.203), whereas the effect of BDRI score on return
remained significant (OR, 0.53; p = 0.011). Following
Baron and Kenny,11 this suggests that the impact of predo-
nation anxiety on the return of inexperienced female
donors is mediated by increased likelihood of blood dona-
tion–related symptoms.
Postdonation anxiety
Similar and generally stronger relations were observed
between these measures and ratings of postdonation anx-
iety. For example, postdonation anxiety was strongly with
associated with BDRI score (F1,631 = 62.82, p < 0.001). A sig-
nificant negative association between postdonation anxi-
ety and whether or not a full unit of blood was obtained
was also observed (F1,538 = 22.01, p < 0.001; in contrast to a

1008 TRANSFUSION Volume 46, June 2006


more modest association with predonation anxiety, which
only approached significance [F1,535 = 2.82, p = 0.094]).
Although noteworthy, these ratings of anxiety are more
difficult to interpret because they could reflect distress
that was the result of an unpleasant experience produced
by some factor other than predonation anxiety.
DISCUSSION
This study provides several important pieces of informa-
tion. Most important, the results tie together several dis-
tinct findings and point to the possible importance of
searching for ways to reduce anxiety in inexperienced vol-
unteers. Donor anxiety has been related to risk for vasova-
gal symptoms in a number of studies,3,13-16 and blood
donation–related symptoms have been linked to reduced
donor return.2,17-19 The results of this study indicate that
apprehensive inexperienced female blood donors are
more likely to have unpleasant symptoms and, as a result,
less likely to return to give blood again. The chain of rea-
soning is unsurprising, but evidence for this belief has
been largely anecdotal to date.
The relationship between predonation anxiety and an
objective characteristic of the blood donation procedure,
that is, whether the donor’s chair is reclined by the nurse,
suggests that the effects of anxiety on reports of symptoms
such as dizziness and nausea on the BDRI were not simply
the product of reporting bias or hypochondriasis. The
nurses did not view donor questionnaires and presumably
decided whether or not to recline the chair based on their
objective judgment of the donor’s need for this interven-
tion. Although it is possible that some nurses may have
been influenced by anxious donors who did not really
need their chairs to be reclined but who expressed distress
verbally or nonverbally, this seems unlikely for at least two
reasons. First, most of the nurses working in these clinics
had considerable experience in blood collection and the
recognition of blood donation–related symptoms. Second,
we recently observed no relationship between chair reclin-
ing and a personality characteristic (alexithymia) strongly
related to emotional expressivity.20 In sum, it appears that
anxious donors were more likely to experience real blood
donation–related symptoms. As a result, anxious female
donors were less likely to return to give blood again.
Another useful aspect of this study is the observation
of a linear relationship between predonation anxiety and
blood donation–related symptoms (Fig. 1). The relation-
ship between predonation anxiety and syncope has been
appreciated for many years.13,14 The relationship between
anxiety and less dramatic symptoms, however, has
received much less attention and concern, although sev-
eral studies have examined personality correlates of dona-
tion anxiety.3,16,21,22 Zillmer and colleagues23 suggested that
the reduction of anxiety after blood donation and feeling
that one has done a good thing might even lead to a cer-
ANXIETY, SYMPTOMS, AND DONOR RETURN
tain euphoria, which increases the likelihood of subse-
quent donation. Although it is clear that people often feel
good about themselves after giving blood,24 these results
indicate little positive benefit to predonation anxiety and
suggest that only mild elevations may have negative
effects on the experience of inexperienced donors. For
example, the second quartile of predonation anxiety in
Figs. 1 and 2 corresponds to a predonation anxiety score
of 2 or 3. Because the anxiety questions were rated on a 0
to 3 scale, this would require only two symptoms rated as
mild. Yet these individuals reported significantly more
blood donation–related symptoms and had their chairs
reclined significantly more than donors who were more at
ease when entering the clinic.
That said, there were several limitations of the study.
Despite the prospective nature of the associations, the
present results do not demonstrate causal effects of pre-
donation anxiety on symptoms and donor return. For
example, it is possible that people who anticipate symp-
toms based on previous experiences with injections,
blood draws, etc., enter the blood donation clinic with
somewhat greater anxiety, but the relationship between
anxiety and subsequent symptoms is an artifact of the
donor’s accurate assessment of their susceptibility to
symptoms. Related to this idea, the results do not neces-
sarily imply that strategies aimed at reducing predonation
anxiety (e.g., distraction with movies) will lead to fewer
symptoms and improved donor retention. On the other
hand, this neglects extensive literature on anxiety about
medical procedures, much of which is relevant to the topic
of blood donation. For example, behavioral interventions
for dental anxieties have been found to affect both self-
report anxiety and dental attendance25 even with auto-
mated interventions.26 One particularly interesting feature
about the literature on dental anxieties is the fact that
dental attendance has been increased among individuals
with dental phobias, that is, people who avoid dental
exams, as well as those with less pronounced fears. This
raises the idea of possible programs for those who might
otherwise be interested in giving blood but who have
never done so before, in part out of fear about the proce-
dure.27,28 Whether the focus is on retaining or recruiting
new donors, the study of psychosocial aspects of blood
donation is a useful area that may contribute to increased
blood donor satisfaction and, perhaps, blood supplies.
ACKNOWLEDGMENTS
The assistance of the staff and organization of Héma-Québec is
acknowledged.
REFERENCES
1. Mair M, Barrett SP, Campbell T, Ditto B. Prevalence,
disclosure and interpretations of sexual activities in a
Volume 46, June 2006 TRANSFUSION 1009
DITTO AND FRANCE
sample of Canadian college-aged blood donors. Int J STD
AIDS 2003;14:399-403.
2. France CR, France JL, Roussos M, Ditto B. Mild reactions to
blood donation predict a decreased likelihood of donor
return. Transfus Apheresis Sci 2004;30:17-22.
3. Meade MA, France CR, Peterson LM. Predicting vasovagal
reactions in volunteer blood donors. J Psychosom Res
1996;40:495-501.
4. Hanson SA, France CR. Predonation water ingestion
attenuates negative reactions to blood donation.
Transfusion 2004;44:924-8.
5. Bonk VA, France CR, Taylor BK. Distraction reduces self-
reported physiological reactions to blood donation in novice
donors with a blunting coping style. Psychosom Med
2001;63:447-52.
6. Sauer LA, France CR. Caffeine attenuates vasovagal
reactions in female first-time blood donors. Health Psychol
1999;18:403-9.
7. Ditto B, France CR, Lavoie P, et al. Reducing reactions to
blood donation with applied muscle tension: a randomized
controlled trial. Transfusion 2003;43:1269-75.
8. Ditto B, France CR. The effects of applied tension on
symptoms in French-speaking blood donors: a randomized
trial. Health Psychol 2006;in press.
9. Spielberger C, Gorsuch R, Lushene R. State-trait anxiety
inventory manual. Palo Alto (CA): Consulting Psychologists
Press; 1970.
10. Ditto B, Wilkins JA, France CR, et al. On-site training in
applied muscle tension to reduce vasovagal reactions to
blood donation. J Behav Med 2003;26:53-65.
11. Baron R, Kenny DA. The moderator-mediator variable
distinction in social psychological research: Conceptual,
strategic, and statistical considerations. J Personality Social
Psychol 1986;51:1173-82.
12. Janssen SA, Arntz A. Anxiety and pain: attentional and
endorphinergic influences. Pain 1996;66:145-50.
13. Callahan R, Edelman EB, Smith MS, Smith JJ. Study of the
incidence and characteristics of blood donor “reactors.”
Transfusion 1963;3:76-82.
14. Graham DT. Prediction of fainting in blood donors.
Circulation 1961;23:901-6.
15. Kleinknecht RA, Thorndike RM. The Mutilation
1010 TRANSFUSION Volume 46, June 2006
Questionnaire as a predictor of blood/injury fear and
fainting. Behav Res Ther 1990;28:429-37.
16. Labus J, France CR, Taylor BK. Vasovagal reactions in
volunteer blood donors: analyzing the predictive power of
the Medical Fears Survey. Int J Behav Med 2000;7:62-72.
17. Thomson RA, Bethel J, Lo AY, et al. Retention of “safe” blood
donors. The Retrovirus Epidemiology Donor Study.
Transfusion 1998;38:359-67.
18. Staallekker LA, Stammeijer RN, Dudok de Wit C. A Dutch
blood bank and its donors. Transfusion 1980;20:66-70.
19. Piliavin JA. Why do they give the gift of life? A review of
research on blood donors since 1977. Transfusion 1990;
30:444-59.
20. Byrne N, Ditto B. Alexithymia, cardiovascular reactivity, and
symptom reporting during blood donation. Psychosom Med
2005;67:471-5.
21. Kaloupek DG, Scott JR, Khatami V. Assessment of coping
strategies associated with syncope in blood donors.
J Psychosom Res 1985;29:207-14.
22. Kaloupek DG, White H, Wong M. Multiple assessment
of coping strategies used by volunteer blood donors:
implications for preparatory training. J Behav Med
1984;7:35-60.
23. Zillmer EA, Glidden RA, Honaker LM, Meyer JD. Mood states
in the volunteer blood donor. Transfusion 1989;29:27-30.
24. Sojka B, Sojka P. The blood-donation experience: perceived
physical, psychological and social impact of blood donation
on the donor. Vox Sang 2003;84:120-8.
25. Kvale G, Berggren U, Milgrom P. Dental fear in adults: a
meta-analysis of behavioral interventions. Community Dent
Oral Epidemiol 2004;32:250-64.
26. Coldwell SE, Getz T, Milgrom P, et al. CARL: a LabVIEW 3
computer program for conducting exposure therapy for the
treatment of dental injection fear. Behav Res Ther 1998;
36:429-41.
27. Hupfer ME, Taylor DW, Letwin JA. Understanding Canadian
student motivations and beliefs about giving blood.
Transfusion 2005;45:149-61.
28. Boulware LE, Ratner LE, Ness PM, et al. The contribution of
sociodemographic, medical, and attitudinal factors to blood
donation among the general public. Transfusion 2002;42:
669-78.