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Predicting blood donations among college students as a strategy to design voluntary blood donation campaigns in China

Dissertation
Author: Jia Lu
Abstract:
The current study investigated the voluntary, safe blood donation in China using an extended version of the Theory of Planned Behavior (TPB) (including attitudes, subjective norms, descriptive norms, moral norms, self-identity, and perceived behavioral control), the Health Belief Model (HBM) (including perceived susceptibility, perceived severity, and cues to action), and the Social Amplification of Risk Theory (SART) (including the concept of trust). Attitudes focus on individuals' evaluations of the behaviors. Subjective norms (i.e., perceived social pressure to engage in the behavior), descriptive norms (i.e., individuals' perceptions of what most people do), moral norms (i.e., personal feelings of social responsibility), and self-identity (i.e., individuals' perceptions of their social roles) were expected to form a multidimensional higher-order concept called norms. Perceived behavioral control was hypothesized to be a second-order multidimensional construct with two components: perceived controllability (i.e., individuals' perception that they have control over the behavior) and perceived self-efficacy (i.e., one's confidence in his/her ability to perform the behavior). Perceived susceptibility (i.e., beliefs that a certain negative outcome will occur) and perceived severity (i.e., the evaluation about how serious the outcome could be) were proposed to converge on a higher-order construct called perceived threats. Cues to action were operationalized as the requests for blood donations from various resources (i.e., blood banks, schools, family and friends, and social groups). The concept of trust emphasized the trust in blood banks. The current study hypothesized that blood donation intentions were a positive function of attitudes toward blood donations, norms, perceived behavioral control, threats, and cues to action. Trust in blood banks was hypothesized to be positively related to attitudes toward blood donations. A panel (two-wave) survey was conducted. A convenience sample of 248 undergraduate students was recruited from a large regional university in China. The results supported the extended TPB with additional components, including descriptive norms, self-standard (moral norms and self-identity), and self-efficacy. Subjective norms, descriptive norms, and self-standard converged to create a higher order construct: Norms. The convergence in the perceived behavioral control domain (self-efficacy and controllability) and the threats domain (perceived susceptibility and severity) were not obtained. Norms and self-efficacy appeared to be two primary predictors of intentions to donate blood. The direct effects of trust in blood banks on attitudes were confirmed. The results also revealed the indirect effects of trust in blood banks on blood donations intentions. Self-efficacy and controllability predicted past blood donation frequency directly. In addition, self-efficacy mediated the effects of norms on past blood donation frequency. The HBM components (i.e., perceived susceptibility, perceived severity, and cues to action) appeared to be non-significant predictors of blood donation intentions and past behaviors. This study provided a theoretic basis for designing voluntary blood donation campaigns and identified the beliefs and factors that should be targeted in the future campaigns. The current study results reinforce arguments for blood donation campaigns to appeal to social responsibility. One possible method is to frame blood donation as a socially admirable behavior. In addition, the study findings indicate that future blood donation campaigns should take advantage of the effects of perceived behavioral control on both blood donation intentions and blood donation behaviors. Study results indicate the potential utility of campaign messages that include specific coping strategies such as how to reduce barriers to blood donations. In particular, the current study revealed that several control related beliefs involving personal health issues (e.g. sickness, including colds, flu, anemia, etc), time constraints, the locations and schedules of facilities, including blood mobiles, and lack of awareness of blood donation opportunities should be featured in future campaigns. Donor recruitment materials should also emphasize the safety resulting from clean, well-equipped facilities, strict screening processes, and professional staffs. Moreover, the findings of the current study suggest the importance of beliefs about positive consequences (i.e., health benefits, blood tests results, adequate blood supplies for donors themselves, their family, and their friends, and saving lives) and negative consequences of blood donation (i.e., low resistance to colds, influenza, or infection, and the risk of contracting transfusion-transmitted infections). Beliefs about these consequences were the driving forces behind general attitudes toward blood donations in this study. In particular, these beliefs could serve as the themes of future blood donation campaigns. Finally, the study results indicate that various mass media (i.e., TV, radio, and newspaper) tend to be useful channels that reach a wide range of potential blood donors.

iv     TABLE OF CONTENTS

LIST OF TABLES ................................................................................................................ .......... v LIST OF FIGURES ............................................................................................................... ....... vii ABSTRACT ...................................................................................................................... ........... viii

CHAPTER 1: INTRODUCTION ................................................................................................... 1 Problem Statement ............................................................................................................. ......... 1 Summary Background .......... ................ ................ ............. .............. ............. ............. ............. ..... 2 Objectives .................................................................................................................... ................ 6 Chapter Organization .......................................................................................................... ........ 7

CHAPTER 2: LITERATURE REVIEW ........................................................................................ 8 Donor Demographics ............................................................................................................ ...... 8 Predictors of Blood Donation .................................................................................................. .... 9 Theoretical Base .............................................................................................................. .......... 16 Hypotheses and Research Questions ......................................................................................... 28

CHAPTER 3: METHODOLOGY ................................................................................................ 29 Procedures .................................................................................................................... ............. 29 Variables ..................................................................................................................... ............... 30 General Measures .............................................................................................................. ........ 30 Statistical Procedures ........................................................................................................ ........ 33

CHAPTER 4: RESULTS ............................................................................................................ .. 35 Demographic Characteristics ................................................................................................... . 35 Reliability and Validity ...................................................................................................... ....... 35 Main Analysis ................................................................................................................. .......... 49

CHAPTER 5: DISCUSSION ........................................................................................................ 62 Summary of Results ............................................................................................................ ...... 62 Implementation for Blood Donation Campaigns ...................................................................... 69 Future Research ............................................................................................................... .......... 72 Conclusions ................................................................................................................... ............ 74

APPENDIX A: HUMAN SUBJECTS APPROVAL ........... ........................................................ 75 APPENDIX B: INFORMED CONSENT FORM ........................................................................ 78 APPENDIX C: COMPLETE SURVEY ITEMS ................ .......................................................... 80 APPENDIX D: COMPLETE SURVEY QUESTIONNAIRES ................................................... 84 APPENDIX E: DEMOGRAPHIC INFORMATION ................................................................... 93 APPENDIX F: BEHAVIORAL BELIEFS ................................................................................... 95 APPENDIX G: ETA CORRELATIONS ..................................................................................... 97

REFERENCES .................................................................................................................... ......... 99 BIOGRAPHICAL SKETCH ...................................................................................................... 117

v     LIST OF TABLES

Table 1a. Principal components anal ysis of “attitudes” construct (n = 248) ................ .............. .. 37

Table 1b. Principal components analysis of measures of “trust” construct (n = 246) .................. 37

Table 1c. Principal components analysis of “norms” constructs (i.e., subjective norm, descriptive norm, and moral norm) (n = 241) ....................................................................................... 38

Table 1d. Principal components analysis of “perceived behavioral control” constructs (i.e., controllability and self-efficacy) (n = 244) ........................................................................ 39

Table 1e. Principal components anal ysis of “perceived threats” (i .e., perceived su sceptibility and perceived severity) (n = 247) ............................................................................................. 40

Table 1f. Principal components analysis of “intentions” (n = 245) .............................................. 41

Table 2. CFA fit indices for three domain constructs: norms, perceived behavioral control (PBC) and threats.................................................................................................................... ....... 42

Table 3a.Confirmatory factor analysis of three “norms” constructs (n = 244) ............................. 43

Table 3b.Confirmatory factor analysis of two “perceived behavioral control” constructs (i.e., controllability and self-efficacy) (n = 242) ........................................................................ 44

Table 3c. Confirmatory factor analysis of two “perceived threats” constructs (i.e., perceived susceptibility and perceived severity) (n = 244) ...... ............. ............. .............. ............. ..... 45

Table 4. Reliability and item-total correlations for the measures of first-order constructs .......... 46

Table 5. Pearson product-moment correlations for hypothesized predictor and predicted variables (n = 244 – 248) ............................................................................................................... .... 48

Table 6. Goodness-of-fit indices for “intention” models (n = 244) .................... ............. ............. 50

Table 7. Standardized factor loadings for the higher order norms construct in “intention” models (n = 244) ..................................................................................................................... ........ 50

Table 8. Standardized direct, indirect, and total effects for Model 3 predicting “intentions” to donate blood: Revised structural model (model 3) (n= 244) ............................................ 55

Table 9. Goodness-of-fit indices for “actual past beha vior” models (n = 244) .. ............. ............. 57

Table 10. Standardized factor loadings for the higher order norms construct in “past behavior models” (n = 244) ............................................................................................................. .. 57

vi    Table 11. Standardized direct, indirect, and total effects for actual past blood donation behaviors (Model 5, n = 244) .............................................................................................................. 59

Table 12. Control-related factors influencing blood donation decisions at the university in the next two months (Time1) (n = 133) ................................................................................... 60

Table 13. Factors kept participants from donating blood at the University in the past two months (Time 2) (n = 73) ................................................................................................................ 61

vii     LIST OF FIGURES

Figure 1. Standard Theory of Planned Behavior m odel (Ajzen, 1991) ........................................ 16 Figure 2. Standard Health Belief Model (Rosenstoc k, Strecher, & Becker, 1994) ...................... 22 Figure 3. Final Model ......................................................................................................... .......... 27 Figure 4. Model 2: Proposed Structural (Path) Model (n = 244) .................................................. 51 Figure 5. Model 3: Revised Structural (Path) Model (n = 244) .................................................... 53 Figure 6. Model 5: Structural model for past behavior s (n = 244) ............................................... 58

viii     ABSTRACT

The current study investigated the voluntary, safe blood donation in China using an extended version of the Theory of Planned Be havior (TPB) (including attitudes, subjective norms, descriptive norms, moral norms, self-identity, and perceived behavioral control), the Health Belief Model (HBM) (including perceived susceptibility, perceived severity, and cues to action), and the Social Amplification of Risk Theory (SART) (including the concept of trust). Attitudes focus on individuals’ evaluations of the behaviors. Subjective norms (i.e., perceived social pressure to engage in the behavior), descriptive norms (i.e., individuals’ perceptions of what most people do), moral norms (i .e., personal feelings of social responsibility), and self-identity (i.e., individual s’ perceptions of their social ro les) were expected to form a multidimensional higher-order concept called norms. Perceived behavioral control was hypothesized to be a second-order multidimensi onal construct with two components: perceived controllability (i.e., individuals’ perception that they have control over the behavior) and perceived self-efficacy (i.e., one’s confidence in his/her ability to perform the behavior). Perceived susceptibility (i.e., beliefs that a certain negative outcome will occur) and perceived severity (i.e., the evaluation about how serious the outcome could be) were proposed to converge on a higher-order construct called perceived threats. Cues to action were operationalized as the requests for blood donations from various resources (i.e., blood banks, schools, family and friends, and social groups). The concept of trust emphasized the trust in blood banks. The current study hypothesized that blood donation intentions were a positive function of attitudes toward blood donations, norms, perceived behavioral control, threats, and cues to action. Trust in blood banks was hypothesized to be positively re lated to attitudes toward blood donations. A panel (two-wave) survey was conducted. A convenience sample of 248 undergraduate students was recruited from a large regional university in China. The results supported the extended TPB with additional components, including descriptive norms, self-standard (moral norms and self-identity), and self-efficacy. Subjective norms, descriptive norms, and self- standard converged to create a higher order construct: Norms. The convergence in the perceived behavioral control domain (self-efficacy and controllability) and the threats domain (perceived susceptibility and severi ty) were not obtained.

ix    Norms and self-efficacy appeared to be two primary predictors of intentions to donate blood. The direct effects of trust in blood banks on attitudes were confirmed. The results also revealed the indirect effects of trust in blood banks on blood donations intentions. Self-efficacy and controllability predicted past blood donation frequency directly. In addition, self-efficacy mediated the effects of norms on past blood donation frequency. The HBM components (i.e., perceived susceptibility, perceived severity, and cues to action) appeared to be non-significant predictors of blood donation intentions and past behaviors. This study provided a theoretic basis for designing voluntary blood donation campaigns and identified the beliefs and factors that should be targeted in the future campaigns. The current study results reinforce arguments for blood donation campaigns to appeal to social responsibility. One possible method is to frame blood donation as a socially admirable behavior. In addition, the study findings indicate that future blood donation campaigns should take advantage of the effects of perceived behavioral control on both blood donation intentions and blood donation behaviors. Study results indicate the potential utility of campaign messages that include specific coping strategies such as how to reduce barriers to blood donations. In particular, the current study revealed that several control related beliefs involving personal health issues (e.g. sickness, including colds, flu, anemia, etc), time constraints, the locations and schedules of facilities, including blood mobiles, and lack of awareness of blood donation opportunities should be featured in future campaigns. Donor recruitment materials should also emphasize the safety resulting from clean, well-equipped facilities, strict screening processes, and professional staffs. Moreover, the findings of the current study suggest the importance of beliefs about positive consequences (i.e., health benefits, blood tests results, adequate blood supplies for donors themselves, their family, and their friends, and saving lives) and negative consequences of blood donation (i.e., low resistance to colds, influenza, or infection, and the risk of contracting transfusion-transmitted infections). Beliefs about these consequences were the driving forces behind general attitudes toward blood donations in this study. In particular, these beliefs could serve as the themes of future blood donation campaigns. Finally, the study results indicate that various mass media (i.e., TV, radio, and newspaper) tend to be useful channels that reach a wide range of potential blood donors.

1     CHAPTER 1

INTRODUCTION

Blood safety is a critical issue worldwide. Unsafe blood transfusions can lead to several transfusion-transmissible infections (TTIs), such as human immunodeficiency virus (HIV)/ Acquired Immune Deficiency Syndrome (AIDS), hepatitis B virus (HBV) and hepatitis C virus (HCV) (Busche, Kleinman, & Nemo, 2003). A ccording to World Health Organization (WHO) fact sheets, approximately 10% of all HIV infections in the early 1990s were caused by unsafe transfusion (WHO, 2005). Although improvements have been made worldwide to prevent transfusion transmitted diseases, the safety of blood supplies is still an issue for a large number of developing countries (WHO, 2005). For exampl e, approximately 5% of HIV infections are attributed to unsafe blood in Africa today (WHO, 2005). The prevalence of HBV and HCV infections among donor population in Pakistan has ranged from 2% to 9% across different regional studies (Liu, Chen, & Chen, 2006; Mujeeb & Pearce, 2008). Voluntary blood donors are generally one source for blood safety. Previous research has shown that voluntary blood donors are less likely to carry diseases compared with paid donors (Beal & van Aken, 1992). Also, voluntary donors are not as worried about being disqualified as paid donors, therefore are more likely to be honest about their health status (WHO, 2008). In many countries, however, safe blood supplies ar e scarce, and the recruitment and retention of voluntary blood donors are challenging tasks. Consequently, people die prematurely because of insufficient, safe blood suppliers (WHO, 2005). Ther efore, it is crucial to identify factors that motivate people to donate blood voluntarily and that can be used to help design effective communication campaigns to promote blood safety and blood donation. Problem Statement A limited number of previous studies have identified several main motivations for voluntary blood donation, including altruism, social pressure, self-identity, awareness of needs, and personal benefits (Gillespie & Hillyer, 2002; P iliavin, 1990). A few studies have shown the utility of the Theory of Planned Behavior as a predictor of voluntary blood donation behaviors (Armitage & Conner, 2001; Giles and Cairns, 1995 ; Giles, McClenahan, Cairns & Mallet, 2004).

2     These previous studies, however, have limitations for current blood safety and blood donation campaigns. The first limitation is that most of the studi es were conducted ten to twenty years ago. Second, most were conducted in developed, western countries, particularly in the United States. Third, most studies asked current donors to report the most important factors that motivate them to donate blood, and few have applied social psychological theories of behavior and behavior change to help explain blood donation behaviors. Up-to-date blood safety and blood donation studies are needed that take into consideration recent changes in demographics, cultural values, public health and financial conditions. Studies in particular need to be conducted in non-western cultures. Finally, these studies need to identify the underlying cognitive structures associated with voluntary, safe blood donations (Cappella, Fishbein, Hornik, Ahern, & Sayeed, 2002). The current study investigates the voluntary, safe blood donation in the People’s Republic of China using an extended version of the Theory of Planned Behavior (TPB), the Health Belief Model (HBM) and the Social Amplification of Risk Theory (SART). Conceptual and empirical issues associated with these theories are addr essed. Alternative strategies for blood donation campaigns are identified and discussed. Summary Background Fishbein and Ajzen (1975) proposed the Theory of Reasoned Action (TRA) to predict and explain volitional behaviors. This theory proposes that behavioral intention, the best predictor of actual behavior, is the result of two determinan ts: attitudes and subjective norms. Ajzen (1991) developed the Theory of Planned Behavior (TPB) by adding the concept of perceived behavioral control to the TRA. More recently, several researchers have questioned the sufficiency of the TPB to predict behaviors, and have extended the theory by adding new predictor variables, such as descriptive norms, self-efficacy, self-identity, past behaviors, and moral obligations (Armitage & Conner, 2001; Giles, McClenah an, Cairns, & Mallet, 2004; Smith & McSweeney, 2007; Terry, Hogg & White, 1999). However, there are conceptual questions and inconsistent findings regarding the extended TPB. For example, there is a debate on whether self-efficacy and perceived behavior control are two distinctive predictors of beha vior intention (Armitage & Conner, 2001; Giles, McClenahan, Cairns, & Mallet, 2004). In addition, the TPB alone does not account for some key, documented predictors of blood donation behavior such as awareness and perceptions of blood

3    needs, public announcements and reminders from blood banks (Piliavin, 1990; Gillespie & Hillyer, 2002). The Health Belief Model (HBM) was first developed in the area of health prevention (Rosenstock, Strecher, & Becker, 1994). The model was widely used to understand why individuals participate in preventive health actions such as exercise, cancer screening, and vaccination programs. The original HBM proposed that the health related behavior is a function of perceived threats and outcome expectancies (Janz & Becker, 1984; Rosenstock, 1990; Rosenstock & Kirscht, 1974). The concept of self-efficacy (i.e., one’s confidence in his/her ability to perform the behavior) and cues to action (i.e., “how-to” information that increases the awareness of certain issues) have subsequently been added to the model (Rosenstock, 1990; Rosenstock, Strecher, & Becker, 1994). Although the HBM has not been applied in the context of blood donation, recent studies have applied the model to several pro-social behaviors such as recycling and energy conservation, and revealed that the HBM explained a large proportion of the variances in voluntary behaviors. In addition, the model potentially can contribute to the understanding of blood donation because it addresses a few factors that are not included in the TPB, such as the perceived risks of certain situations (e.g., perceived susceptibility to a shortage of blood and perceived severity of blood shortage) and the effects of reminder messages (e.g., media appeals from local blood banks). Therefore, by combining the key components from the extended TPB and the HBM, the overall model could have better predictive power. The issues associated with safe blood donations are complex and the integrated TPB and HBM are still likely insufficient. Previous research, for example, has found a discrepancy between the actual risks and perceived risks of blood donation. For example, prior studies have revealed that although the chances of contracting transfusion-transmitted infections through blood donation are now very low in China, most potential donors still report the fear of contracting diseases as their number one barrier to donation (Liu, Tang, Liu, & Guo, 2003; Wang, Fu, Liang, Chen, & Wan, 2006). The constructs in the integrated TPB and HBM do not account for the differences in the actual risks and perceived risks. The Social Amplification of Risk Theory (SART), however, considers risk perceptions in the social context and offers a useful theoretical framework (Kasperson et al., 1988). In particular, the theory connects the perceived risks with trust and proposes that trust in institutions in charge might attenuate perceived risks (Breakwell, Barnett, Lofstedt, Kemp, & Glaser, 2001). Previous research has shown that Chinese

4     people have relatively low trust in the blood banks and the health care system in general (Reynold & McKee, 2009). It is reasonable to predict that low trust in blood banks actually amplifies individuals’ perceived risks of blood donation which prevent them from donating blood. Prior blood donation studies have not examined this issue. The TPB, the HBM, and the SART were all developed and mainly tested in Western cultures. Whether the model based on the above mentioned theory can be applied to Chinese cultures (recognized as collectivist cultures) is unknown. Therefore, a key contribution of the current study is to examine whether the proposed combined model predicts behavioral intentions and behaviors associated with safe blood donations in Chinese cultures. Blood Donation in China China has made great progress recently in building a safe voluntary blood donation system. In the 1980s, blood from paid donors and family members still accounted for 80% of the blood supplies in China (WHO, 2008). Based on UNAI DS (2008) estimates, China has 650,000 HIV- infected residents, and unsafe transfusions promote the spread of HIV infections. The HBV and HCV infections have been more serious. A nati onwide serosurvey on he patitis B surface antigen (HBsAg) reported a prevalent rate of roughly 7% (Liang et al., 2009). The prevalence of HCV was approximately 1% based on a re gional sample (Liu, et al., 2009). Recruitment of voluntary blood donors and building modern transfusion system are of great importance for China to ensure blood safety and reduce transfusion-transmissible infections. In 1998, the Blood Donation Law of the People’s Republic of China took effect and prohibited paid blood donations (Standing Committee of NPC, 1998). The law encouraged various incentives to voluntary blood donors, such as free blood transfusion at hospitals and discounted blood transfusion for their spouse and linear relatives (Standing Committee of NPC, 1998). By the end of 2001, local regulations had passed to guarantee the implementation of the blood donation law (Beijing Time, 2001). Additionally, China banned unregulated blood collection. Blood is now only collected at authorized blood centers. Strict criteria are currently applied to screen out ineligible donors and all donated blood is tested for infections before being processed into components and distributed to hospitals (WHO, 2006). Additionally , the Chinese government has now devoted a large amount of money to develop blood centers: building facilities, improving services, and offering traini ng programs to staff (Beijing Time, 2001).

5    More recently, China have conducted several national and local campaigns to recruit voluntary blood donors (WHO, 2008). Current research has showed that the majority of the Chinese respondents mentioned mass media campaigns as their primary sources of blood donation information (Wang, Fu, Liang, Chen, & Wan, 2006). As a result, in the last ten years China has obtained significant improvement in blood safety and achieved almost 100 percent unpaid (voluntary and employer-organized) blood donations. Previous studies, however, have showed that a large proportion of the sample respondents have never donated blood (Gao et al., 2006; Liu, Tang, Liu, & Guo, 2003; Zhuang, Fu, Zhang, Zhu, & Lin, 2008). Liu, Tang, Liu, and Guo (2003) collected data from 437 college students in Nanjing, a city in the southern part of China and found that 36% of respondents had donated blood once. Among them 57% were school-organized donors. Gao and her colleagues (2006) surveyed 3,077 Beijing residents selected through a cluster sampling procedure and found that only 25% of the respondents had ever donated blood. Similarly, a more recent study conducted in Ningbo, a city located in southern China, found that blood donors only accounted for 25% of the sample (Zhuang, Fu, Zhang, Zhu, & Lin, 2008). In order to recruit enough volunteer donors and meet the demand of blood, one of the methods China has applied is to require state-run organizations to encourage their staff to donate blood and assign quotas to each organization (Shan et. al, 2002). Donors in the organization might receive small incentives such as paid leave and small subsidies for donation. The quotas in Beijing were originally at least two donors per every 100 employees per organization every year (Liu, 2006). With more and more people increasingly being aware of the needs and benefits of voluntary donation and becoming true volunteers, Beijing abolished quotas for blood donation in 2006 (Liu, 2006). However, similar regulations still exist in a few areas to guarantee sufficient blood supplies. Few studies examining the proportions of blood donors in the samples have distinguished voluntary blood donors from employer-organized blood donors. It is unclear that the blood supply based solely on voluntary blood donations can meet the demand. Therefore, effective campaigns are needed to educate people and motivate them to donate blood voluntarily. Currently, blood is at times in short supply, especially during summer time. College students are one of the main sources of voluntary donors in China. As a result, during summer break, blood donation decreases dramatically. Moreover, several major cities such as Beijing,

6     Tianjing, Wuhua have reported blood shortages and have urged people to donate blood (Xinhua News, 2006; Xinhua News, 2007; Zou, 2004). To date, a paucity of studies have addressed the factors associated with voluntary blood donation behaviors in China. Consistent with the findings from western countries, in China social pressure, altruism and wishing to know screening results have been identified as positive motivators for blood donation (Liu, Tang, Liu, & Guo, 2003; Wang, Fu, Liang, Chen, & Wan, 2006). Blood credits sometimes have been considered as an important motivator too (Wang, Fu, Liang, Chen, & Wan, 2006). On the other hand, fear of contracting transfusion-transmitted disease and fear of detrimental effect of blood loss on health have been identified as negative factors (Zaller, Nelson, Ness, Wen, Bai, & Shan , 2005). However, little is known about whether the factors mentioned above really predict blood donation behaviors. Other potential factors, such as awareness of needs and trust in blood banks have not been tested. Therefore, a systematic study is required to understand the social-psychological and behavior patterns of Chinese donors. Objectives The current study has three objectives. The first goal of the current study is to explore whether new predictors such as self-identity and moral norms can improve predictions using the TPB. The second goal is to propose a more co mplete model to predict blood donation behaviors by integrating the extended TPB, the HBM, and the concept of trust. The application of the proposed model in China is investigated. Finall y, this study provides a theoretic basis for designing voluntary blood donation campaigns. Alternative strategies for selecting effective messages are discussed. The current study contributes to the TPB research by not only incorporating additional components into the original model, but also examining the applicability of the overall model in China. In addition, the current st udy contributes to the blood donation literature by investigating the associations of various social psychological factors with blood donation intentions. This is especially important in China where the blood donation research literature is seriously underdeveloped. The current study is one of the first attempts to develop a psychological model explaining blood donation behaviors in China. Moreover, the current study contributes to blood donation campaigns by identifying the beliefs and fa ctors that should be targeted in the future campaigns.

7     Chapter Organization Chapter two begins with the discussion of th e positive and negative determinants of blood donation identified in previous studies. The chapter is continued with a description of Chinese culture characteristics. In par ticular, the features of collectivist cultures are discussed. The studies that examined the components of the TPB and the HBM under collectivist cultures are also discussed briefly. This is followed by a literature review of the HBM, the TPB, and the SART. The review of the TPB not only discusses the original model proposed by Ajzen (1991) but also addresses additional variables that extend the model. Based on the review of the blood donation literature, the HBM literature, the TPB literature, and the SART literature, a model of blood donation is presented. Based on the literatu re review, six hypotheses are tested to examine the integrative model of the extended TPB and the HBM with trust. The predictive power of each predictor for intentions is investigated. Chapter three outlines the research methodology of the current proposed study. Sampling procedures are discussed. A sample is drawn from a large university in the southern area of China. Criteria used to select research sample are detailed. The measures for the independent and dependent variables are presented. Chapter four focuses on the analysis of th e survey results. Tests initially examine the differences between donor samples and non-donor samples in terms of social demographic characteristics. A structural equation modeling is then employed to test the model. Chapter five provides a discussion of the study results and features the contributions of the current study. Theoretic and practical implementations for blood donation campaigns are addressed. Limitations and recommendations for future research are then discussed.

8     CHAPTER 2

LITERATURE REVIEW

Donor Demographics Donor Demographics in the U.S. While this study is conducted in China, insights into potential issues can be found in research conducted in the United States. Previous research in the U.S. has revealed that demographic characteristics of blood donors have changed in the past decades. In the 1970s, the donor population was predominantly male, representing from 66% to 91% of the donor population (Oswalt, 1977). The same pattern cont inued in the 1980s (Callero & Piliavin, 1983). Recently, however, the proportions of female donors have increased dramatically. Wu et al. (2001) showed that for a period of 1991 to 1996, females accounted for almost half of the first- time donor samples. As regards race, almost 90% of blood donors were Caucasian in the 1960s (London & Hemphill, 1965); in th e 1991-1996 period, White non- Hispanics accounted for 74 % of the first time donor sample (Wu et al., 2001). In 1975, the average age of blood donors was approximately 35 (Bettinghaus & Milkovich, 1975). A more recent study showed that in the early 1990s, 64% of donor samples were less than 35 years old (Wu et al., 2001). However, Putnam (2001) subsequently found that people in their late thirties and early forties were most likely to donate blood. Zou et al. (2008) similarly documented that mean ages of blood donors increased dramatically in the past decade. In 2005, mean ages for female and male repeat donors increased to 42 and 45, respectively. They also found that from 1996 to 2005 the number of repeat donors aged 25 to 39 years declined more than 40% after adjusting for demographic trends in the general population. The number of first- time male donors of age 25 to 49 years decreased by more than 10%. With respect to social-demographic characteristics, an early study found that frequent donors, compared to nondonors, had higher income s and were better educated (Needham Harper Worldwide, 1986). Most d onors were married (Piliavin, 1990). More recent studies revealed that first time donors in particular tended to hold a college degree or higher (Wu et al., 2001). People who were employed are more likely than people who were unemployed to donate blood (Putnam,

9     2001). In addition, individuals with good physical health were more likely to donate blood (Alessandrini, 2006). Donor Demographics in China A paucity of studies have investigated the demographic characteristics of Chinese blood donors. It appears that no existing findings ha ve been based on national samples. Regional and local sample studies indicate that, compared with the older generation, fewer young people have donated blood (Gao, Gao, Liang, Dai, Zhang, & Dai, 2006). Gao and her colleagues (2006) surveyed 3077 Beijing residences selected through a cluster samp ling procedure and found that only 8% of the respondents in the 18 and 20 age range and 19% of the respondents

Full document contains 127 pages
Abstract: The current study investigated the voluntary, safe blood donation in China using an extended version of the Theory of Planned Behavior (TPB) (including attitudes, subjective norms, descriptive norms, moral norms, self-identity, and perceived behavioral control), the Health Belief Model (HBM) (including perceived susceptibility, perceived severity, and cues to action), and the Social Amplification of Risk Theory (SART) (including the concept of trust). Attitudes focus on individuals' evaluations of the behaviors. Subjective norms (i.e., perceived social pressure to engage in the behavior), descriptive norms (i.e., individuals' perceptions of what most people do), moral norms (i.e., personal feelings of social responsibility), and self-identity (i.e., individuals' perceptions of their social roles) were expected to form a multidimensional higher-order concept called norms. Perceived behavioral control was hypothesized to be a second-order multidimensional construct with two components: perceived controllability (i.e., individuals' perception that they have control over the behavior) and perceived self-efficacy (i.e., one's confidence in his/her ability to perform the behavior). Perceived susceptibility (i.e., beliefs that a certain negative outcome will occur) and perceived severity (i.e., the evaluation about how serious the outcome could be) were proposed to converge on a higher-order construct called perceived threats. Cues to action were operationalized as the requests for blood donations from various resources (i.e., blood banks, schools, family and friends, and social groups). The concept of trust emphasized the trust in blood banks. The current study hypothesized that blood donation intentions were a positive function of attitudes toward blood donations, norms, perceived behavioral control, threats, and cues to action. Trust in blood banks was hypothesized to be positively related to attitudes toward blood donations. A panel (two-wave) survey was conducted. A convenience sample of 248 undergraduate students was recruited from a large regional university in China. The results supported the extended TPB with additional components, including descriptive norms, self-standard (moral norms and self-identity), and self-efficacy. Subjective norms, descriptive norms, and self-standard converged to create a higher order construct: Norms. The convergence in the perceived behavioral control domain (self-efficacy and controllability) and the threats domain (perceived susceptibility and severity) were not obtained. Norms and self-efficacy appeared to be two primary predictors of intentions to donate blood. The direct effects of trust in blood banks on attitudes were confirmed. The results also revealed the indirect effects of trust in blood banks on blood donations intentions. Self-efficacy and controllability predicted past blood donation frequency directly. In addition, self-efficacy mediated the effects of norms on past blood donation frequency. The HBM components (i.e., perceived susceptibility, perceived severity, and cues to action) appeared to be non-significant predictors of blood donation intentions and past behaviors. This study provided a theoretic basis for designing voluntary blood donation campaigns and identified the beliefs and factors that should be targeted in the future campaigns. The current study results reinforce arguments for blood donation campaigns to appeal to social responsibility. One possible method is to frame blood donation as a socially admirable behavior. In addition, the study findings indicate that future blood donation campaigns should take advantage of the effects of perceived behavioral control on both blood donation intentions and blood donation behaviors. Study results indicate the potential utility of campaign messages that include specific coping strategies such as how to reduce barriers to blood donations. In particular, the current study revealed that several control related beliefs involving personal health issues (e.g. sickness, including colds, flu, anemia, etc), time constraints, the locations and schedules of facilities, including blood mobiles, and lack of awareness of blood donation opportunities should be featured in future campaigns. Donor recruitment materials should also emphasize the safety resulting from clean, well-equipped facilities, strict screening processes, and professional staffs. Moreover, the findings of the current study suggest the importance of beliefs about positive consequences (i.e., health benefits, blood tests results, adequate blood supplies for donors themselves, their family, and their friends, and saving lives) and negative consequences of blood donation (i.e., low resistance to colds, influenza, or infection, and the risk of contracting transfusion-transmitted infections). Beliefs about these consequences were the driving forces behind general attitudes toward blood donations in this study. In particular, these beliefs could serve as the themes of future blood donation campaigns. Finally, the study results indicate that various mass media (i.e., TV, radio, and newspaper) tend to be useful channels that reach a wide range of potential blood donors.