Using a Brief In-Person Interview to Enhance Donation Intention among Non-Donors. A thesis presented to. the faculty of

Transcription

1 Using a Brief In-Person Interview to Enhance Donation Intention among Non-Donors A thesis presented to the faculty of the College of Arts and Sciences of Ohio University In partial fulfillment of the requirements for the degree Master of Science Irina E. Livitz April Irina E. Livitz. All Rights Reserved.

2 This thesis titled 2 Using a Brief In-Person Interview to Enhance Donation Intention among Non-Donors by IRINA E. LIVITZ has been approved for the Department of Psychology and the College of Arts and Sciences by Christopher R. France Distinguished Professor of Psychology Robert Frank Dean, College of Arts and Sciences

3 Abstract 3 LIVITZ, IRINA, E., M.S., April 2016, Clinical Psychology Using a Brief In-Person Interview to Enhance Donation Intention among Non-Donors Director of Thesis: Christopher France Blood donation is an important and necessary voluntary activity. Individuals who have never donated blood often have fear and anxiety about negative adverse reactions, lack knowledge about the importance of donation and may have conflicting thoughts about donating. Most existing interventions to enhance blood donation are primarily aimed at donor retention and may not be appropriate to increase motivation among nondonors. A potential strategy to increase non-donor intent to give blood is motivational interviewing, a clinical approach that addresses ambivalence in an effort to promote an individual s autonomy in making a behavioral decision. By increasing intrinsic motivation, motivational interviewing may also contribute to the development of donor identity. The present study investigated whether a brief in-person interview based on principles of motivational interviewing (MI-based interview) could change intent to donate blood among current non-donors (n = 174). The study also examined whether an MI-based interview could increase autonomous motivation among non-donors. Participants were randomized into one of three interventions: a motivational interview (n = 60), a knowledge interview (n = 59), or an informational video about blood donation (n = 55). The primary analyses indicated that, contrary to hypothesized findings, participants who viewed the video had a greater increase in donation intention as compared to those who took part in either the MI-based interview or the knowledge interview (p <.001). Those who took part in either the MI-based interview or watched the video had a greater

4 positive change in autonomous motivation than those in the knowledge interview (p < 4.001). By prompting non-donors to reconsider their thoughts and feelings about donation, the MI-based interview and video may have been able to increase intrinsic motivation, and thereby shifted non-donors toward more autonomous motivation. The relative success of the video intervention may be explained by its ability to address multiple barriers that non-donors face, including lack of information. Further research should examine whether combining an MI-based intervention with additional materials, such as an educational video or action planning strategies, may be more effective at increasing intention and autonomous motivation among non-donors.

5 Acknowledgements 5 I would like to thank my advisor, Dr. Christopher France, for his continued mentorship and support throughout the thesis process. This thesis would also not have been possible without the contributions of my committee members, Dr. Christine Gydicz and Dr. Peggy Zoccola. Most importantly, I must thank my family and friends; without whose constant encouragement and guidance this would not have been possible.

6 Table of Contents 6 Page Abstract 3 Acknowledgements..5 List of Tables...7 List of Figures..8 Introduction..9 Materials and Methods...17 Procedure Statistical Analyses 27 Results 28 Discussion References..47 Appendix A: Instruments and Study Forms Appendix B: Baseline Sample Characteristics...70 Appendix C: Non-Parametric Analyses Appendix D: Follow-Up Analyses

7 List of Tables 7 Page Table 1. Sample characteristics at baseline Table 2. Means (±SEM) and group differences for each of the dependent measures at preintervention, post-intervention, and change from pre- to post-intervention.. 30 Table 3. Mean (±SEM) and group differences for measures of blood donor identity at pre-intervention, post-intervention, and change from pre- to post-intervention Table 4. Sample characteristics at baseline for participants who completed follow-up during versus after the semester Table 5. Measures of skewness and kurtosis for each of the dependent measures at preintervention, post-intervention, and change from pre- to post-intervention..71 Table 6. Mean ranks and Kruskal Wallis test statistics for each of the dependent measures at pre-intervention, post-intervention, and change from pre- to post-intervention Table 7. Mean ranks and Kruskal Wallis test statistics for measures of blood donor identity at pre-intervention, post-intervention, and change from pre- to postintervention Table 8: Pearson correlation coefficients between time points by group Table 9. One-way ANOVAs for group differences by time point Table 10. Mean (SD) Theory of Planned Behavior and blood donor identity scores at preintervention, post-intervention, and follow-up..79

8 List of Figures 8 Page Figure 1. Study protocol flowchart...22 Figure 2. Mean (±SEM) pre- to post- intervention change in donation intention, attitude, perceived behavioral control, and subjective norm Figure 3. Mean (±SEM) pre- to post- intervention change in measures of blood donor identity Figure 4. Standardized regression coefficients for the relationship between Video vs. Knowledge Interview intervention and intention change, as mediated by attitude....38

9 Introduction 9 Blood donation is an important and necessary activity. Indeed, in the United States over 41,000 donations are needed every day. Although 38% of the U.S. population is eligible to donate, only 6% does. Research indicates that for non-donors key barriers to donation include a lack of awareness of the importance and need for blood donation (Mathew et al., 2007), negative affective evaluations of donation (Breckler & Wiggins, 1989), and lack of intrinsic motivation to donate for the first time (Glynn et al., 2006). It is essential to preserve a steady rate of first-time blood donations in order to maintain a healthy blood supply. Thus, interventions must address barriers to donation and increase motivation to donate blood for the first time. Among non-donors, there is a general lack of information about the donation process (McVittie, Harris, & Tiliopoulos, 2006). Indeed, many individuals are simply unaware of the logistics of donating, such as finding a place and time (McVittie, Harris, & Tiliopoulos, 2006). Others have erroneous beliefs about donation (Shakeri, et al., 2012), such as beliefs that certain blood types or blood in general is not needed, and inaccurate information about exclusion criteria (i.e., medications, high blood pressure, etc.) (American Red Cross, 2012). Some non-donors do not donate because they believe they cannot give enough blood or that too much blood would be taken (Bendall & Bove, 2011). Stories from friends about poor donation experiences and cynicism towards blood collection agencies are additional deterrents (Bendall & Bove, 2011). Negative affective evaluations, including fear and anxiety, also often deter nondonors from donating (Hupfer, Taylor & Letwin, 2005). Over half of potential donors express concerns about experiencing physical reactions or being disqualified on the basis

10 10 of medical conditions (Oswalt & Hoff, 1975; Oswalt & Napoliello, 1974). Non-donors, in particular, have a greater fear of needles, pain, and the unknown (Gillespie & Hillyer, 2002). However, only one third of donors actually experience adverse effects and the frequency of these reactions declines with repeated donation (Newman, Pichette, Pichette, & Dzaka, 2003). Fears about contracting an infectious disease (i.e., AIDS or hepatitis) or finding out about an illness through the screening tests are also common (Piliavin, 1990; Mathew et al., 2007). Addressing specific non-donor fears and anxiety may aid in motivating them to donate for the first time (Vavić et al., 2012). Finally, non-donors may lack intrinsic motivation to donate (Glynn et al., 2006), which is internal, natural, spontaneous, and not due to any external influences (Reeve, 2009). Altruism, or the desire to help in the absence of obvious, external rewards (Batson & Powell, 2003) is often seen as the primary intrinsic motivator for blood donation (Gillespie & Hillyer, 2002; Glynn et al., 2002; Oswalt, 1977; Piliavin, 1990). However, blood donation is not a purely altruistic activity and results on whether altruism is a key motivator are mixed (Condie, Warner, & Gillman, 1976). Motivation to Donate for the First Time Two prominent motivational theories have been applied to health-related behaviors, and blood donation in particular, including the theory of planned behavior (TPB; Ajzen, 1985) and self-determination theory (SDT; Deci & Ryan, 1985, 2000). The TPB posits that intention is the strongest and most proximal predictor of behavior, and that intention is, in turn, predicted by attitudes, subjective norms, and perceived behavioral control (Ajzen, 1991). Attitude is the individual s positive or negative evaluation of performing a behavior, perceived behavioral control is an individual s

11 11 perception of control over performing a behavior, and subjective norm refers to perceived social approval or disapproval of a behavior (Lemmens et al., 2009). Across studies, the TPB constructs have been shown to collectively account for 39 to 50% of the variance in intention to donate blood and between 27 and 36% of the variance in actual behavior (Ferguson, France, Abraham, Ditto, & Sheeran, 2007; Masser, White, Hyde, & Terry, 2008). Among non-donors, attitude is a strong predictor of intent to donate (Godin et al., 2005; Lemmens et al., 2005), accounting for 10.8% of the variance in intention to donate (Reid & Wood, 2008). Attitude can be broken down further in cognitive (knowing) and affective (feeling) components (Trafimow et al., 2004). Both cognitive and affective attitude are predictors of intention to donate blood (Conner, Godin, Sheeran & Germain, 2013). However, for non-donors affective attitude may be a more significant predictor of motivation than cognitive attitude (Lemmens et al., 2009). This may be due to nondonors more negative attitudes towards donating, which may be shaped by fear or anxiety about donating for the first time (Farley & Stasson, 2003). Perceived behavioral control can be broken down into self-efficacy (confidence in performing a behavior) and controllability (perception of whether a behavior is under one s control) (Ajzen, 2002). Reid and Wood (2008) found that in the presence of attitude and subjective norm, perceived behavioral control accounts for an additional 4.5% of the variance in intent to donate, indicating that individuals who believe they have more control over the donation, have higher intent to donate. This finding is consistent with previous research that has demonstrated perceived behavioral control to be a strong predictor of intent among nondonors (Godin et al., 2005; Lemmens et al., 2005). Others have suggested that self-

12 efficacy, in particular, is the strongest predictor of donation intention among all of the 12 TPB constructs (Giles, McClenahan, Cairns, & Mallet, 2004), with one study reporting that self-efficacy accounted for 12% of the variance in donation intention among nondonors, (Lemmens, et al., 2005). Studies on subjective norms have been mixed, with some finding subjective norm to be a significant predictor of blood donation intent among both donors and non-donors (Lee, Piliavin, & Call, 1999; Lemmens et al, 2005; France, France, & Himawan, 2007; Reid & Wood, 2008), and explaining approximately 5% of the variance in intention to donate blood, in the presence of attitude, among both donors and non-donors (Reid & Wood, 2008; Lemmens et al., 2005; Lemmens et al., 2009). However, others have found no significant effects (Godin et al., 2007; Godin et al., 2005; Armitage & Conner, 2001; Giles, McClenahan, Cairns, & Mallet, 2004). Combined, research on the TPB among non-donors demonstrates that both attitude and perceived behavior control (and particularly self-efficacy) are strong predictors of donation intention, while subjective norm is a weak predictor (Ferguson, 1996; Ferguson, France, Abraham, Ditto & Sheeran, 2007; Godin et al., 2005; Masser, White, Hyde & Terry, 2008). Multiple studies have expanded on the original Theory of Planned Behavior constructs, and have extended the model to include such variables as anticipated regret, personal moral norm, and anxiety. Among both existing and non-donors, anticipated regret, or negative feelings towards not donating, has been shown to be a significant predictor of both intention (Godin et al., 2005) and behavior (Godin et al., 2007), accounting for an additional 7% in intention after taking into account the original TPB constructs (Rivis, Sheeran & Armitage, 2009; Sandberg & Conner, 2008). Anticipated

13 13 regret is especially important for donors early in their donor career (Masser, White, Hyde, & Terry, 2008), particularly because it is a stronger predictor of donation intention for less experienced donors compared to more experienced donors (Godin et al., 2007). Moral norm, or the perceived moral correctness of a behavior, explains an additional 3% of the variance in intention across studies, after controlling for the TPB predictors (Rivis, Sheeran & Armitage, 2009). Moral norm can be distinguished from subjective norm in that it is the individual donor s perception of whether donation behavior is the right thing to do, as opposed to their perception of how important others view the behavior. Finally, anxiety about donating blood, perhaps due to concerns about adverse reactions, has been shown to be both a direct (Robinson, Masser, White, Hyde, & Terry, 2008) and an indirect predictor of intention to donate, via attitude (Masser, White, Hyde, & Terry, & Robinson, 2009). Across studies, anxiety has a small negative association with both donation intention and behavior (Bednall, Bove, Cheetham, & Murray, 2013). Unlike the Theory of Planned Behavior, Self Determination Theory incorporates the quality of an individual s motivation and posits that individuals are more likely to continue behaviors that are internally rather than externally motivated (Ryan & Deci, 2000). SDT proposes a continuum of motivation, which ranges from amotivation (lack of motivation due to failure to see value in an activity) to intrinsic motivation (doing an activity because it is satisfying). In between these two extremes, there are four distinct types of extrinsic motivations: external regulation (performing behavior based on external demand or a reward), introjected regulation (performing a behavior, sometimes to avoid guilt, but not fully identifying with it), identified regulation (performing a behavior because it is personally important) and integrated regulation (personally identifying with

14 14 a behavior and viewing it as consistent with one s values). France et al. (2014) found that, compared to donors, non-donors report more amotivation and less external regulation, introjected regulation, identified regulation, integrated regulation and intrinsic motivation. As individuals gain additional donation experience, they become more intrinsically motivated and develop an identity as a blood donor, or the role and expectations of being a blood donor (Charng, Piliavin, & Callero, 1988; Piliavin & Callero, 1991; Callero & Piliavin, 1983). Development of blood donor identity is thought to occur after three to five donations (Ringwald, Zimmerman, & Eckstein, 2010) and has been shown to shape future donation behavior, whereby more intrinsically motivated donors are more likely to donate on a repeated basis (Gillespie & Hillyer, 2002). Thus, interventions that directly address intrinsic motivations may be influential in increasing intent to donate blood for the first time. However, directly modifying psychosocial cognitions can be challenging. For non-donors, in particular, the decision to donate is influenced by a variety of motivating and deterring factors. These include a lack of information, fear and anxiety, attitude towards blood donation, perceived behavioral control, subjective norms, and the stage of donor identity development. Although few interventions have sought to influence these motivating and deterring factors, one intervention has been developed on the basis of motivational interviewing (MI) principles and has shown promise among experienced blood donors (Sinclair et al., 2010). Applying principles of MI to the blood donation context may be particularly effective because MI has been shown to increase motivation and intent to make a variety of health behavior changes (Dornelas, Sampson, Gray, & Waters, 2000; Martins & McNeil, 2009; Vitousek, Watson, & Wilson, 1998).

15 15 MI is a collaborative, person-centered form of guiding to elicit and strengthen motivation for change (Miller & Rollnick, 2009). MI is not used as a standalone treatment, but rather is an effective clinical tool that can be integrated with other evidence-based treatments (Miller & Rose, 2009). MI is used to strengthen a client s own motivation for change by eliciting and exploring the client s own reasons for the change (Miller & Rollnick, 2009). MI is effective at changing attitudes, increasing self-efficacy, and reducing barriers (Bennett, Young, Nail, Winters-Stone & Hanson, 2008; Viner, Christie, Taylor & Hey, 2003; Schmaling, Blume & Afari, 2001; Miller, Benefield & Tonigan, 1993; Miller & Rollnick, 1991). It has been used in an effort to promote a variety of health behavior changes, including smoking cessation, alcohol abuse, diet and exercise habits and overall healthy behaviors (Burke, Arkowitz & Menchola, 2003; Hettema, Steele & Miller, 2005; Lundahl, Kunz Brownell, Tollefson & Burke, 2010). It is expected that many of the same MI principles that have been used to promote health behavior change may also be pertinent to blood donation and may help to increase motivation among non-donors. Specifically, within the context of blood donation, MI may change non-donor attitudes, increase self-efficacy, and reduce barriers (i.e., donation anxiety, lack of information) by addressing concerns about donation, empowering the donor and increasing their confidence to avoid adverse reactions, helping them identify a convenient place and time to donate, and reframing donation within the context of each donor s personal values and goals. This, in turn, may increase non-donor motivation and intent to donate. As noted above, a previous application of an MI-based intervention with existing blood donors proved effective (Sinclair et al., 2010). Sinclair and colleagues (2010)

16 16 found that, relative to no-interview controls, donors who received a telephone-based MI interview within a few weeks of their last donation reported a greater intention to donate in the future, as well as more positive attitudes and increased confidence to avoid adverse reactions. Furthermore, donors in the MI group had significantly higher rates of attempted donation at 12-month follow-up. Given the initial success of this approach in motivating experienced blood donors, the present study was designed to explore whether a similar intervention would help motivate non-donors to consider blood donation. It was hypothesized that the MI-based interview would increase intention to donate blood for the first time. Specifically, it was also hypothesized that the MI-based interview would increase non-donors intrinsic motivation, and thereby aid in blood donor identity development. Furthermore, based on the TPB, it was hypothesized that non-donors in the MI-based interview group would report greater changes in attitude, subjective norm, perceived behavioral control, as well as greater changes in the extended TPB constructs of personal moral norm, anticipated regret, and donation anxiety, relative to non-donors in the knowledge interview and video groups. Finally, it was hypothesized that the changes in intention would be mediated by increases in positive attitudes and perceived behavioral control.

17 Materials and Methods 17 Participants A sample of 178 non-donors (130 women and 48 men) was recruited from the Psychology Subject Pool at Ohio University. As shown in Table 1, the final sample consisted of 174 participants (129 women and 45 men) between 18 and 23 years of age (Mean = 19.1; SD = 0.98), and was primarily Caucasian (89.7%). Measures Demographic questionnaire. (Appendix A.1): This questionnaire gathered basic demographic information (i.e., age, gender, race/ethnicity), whether the participant has donated blood previously, self-reported English proficiency, and contact information. Participants perceived eligibility was assessed using the following question, To the best of your knowledge, are you eligible to donate blood? If no, please describe why not. Intention scale. (Appendix A.2): This scale included three statements regarding intention to donate blood within the next 8 weeks, which participants rated on a 7-point Likert-type scale (France et al., 2014). Previous research has demonstrated that this scale has strong internal consistency reliability (α =.99) and construct validity has been supported by confirmatory factor analysis (France et al., 2014). In the present study, the intention scale demonstrated internal consistency reliability of α =.93 for the initial preintervention administration and.97 for post intervention administration. Attitude scale. (Appendix A.3): This scale was comprised of six statements that assessed both cognitive (evaluative judgments) and affective (emotional reactions) attitudes toward blood donation, which participants rated on a 7-point Likert-type scale (France et al., 2014). The scale has strong internal consistency reliability (α = 0.80

18 (cognitive α = 0.82, affective α = 0.90)) and construct validity was supported by 18 confirmatory factor analysis (France et al., 2014). In the present study, the attitude scale had an internal consistency reliability of α =.79 for the pre-intervention administration and.81 for post-intervention administration. Perceived behavioral control. (Appendix A.4): This scale was comprised of six items that assessed an individual s perception of control over their ability to donate blood (France et al., 2014). The scale assessed two components of perceived behavioral control: self-efficacy (three items) and controllability (three items). The scale has strong internal consistency reliability [α = 0.83 (self- efficacy α = 0.91, controllability α = 0.93)] and construct validity was supported by confirmatory factor analysis (France et al., 2014). In the present study, the perceived behavioral control scale had an internal consistency reliability of α =.73 for the pre-intervention administration and.79 for the postintervention administration. Subjective norms. (Appendix A.5): This scale was comprised of six items that were rated on a 7-point Likert-types scale, which assessed both descriptive norms (perceived behavior of others) and injunctive norms (what an individual believes others want from him/her). The subjective norms scale has demonstrated good internal consistency for both descriptive (α = 0.87) and injunctive (α = 0.86) norms as well as the composite scale (α = 0.86) (France et al., 2014). The scale s construct validity was supported by confirmatory factor analysis. In the present study, the subjective norms scale had an internal consistency reliability of α =.88 for the pre-intervention administration and.91 for the post-intervention administration.

19 19 Blood donor identity survey. (Appendix A.6): This scale included 18 items that assessed an individual s motivation to donate, which is comprised of six motivational factors (amotivation, external regulation, introjected regulation, identified regulation, integrated regulation, and intrinsic regulation). A composite score for the total scale is derived by combining the six subscale scores using the weighting of -3, -2, -1, +1, +2, +3 for the amotivation, external regulation, introjected regulation, identified regulation, integrated regulation, and intrinsic regulation subscales, respectively. The scale has shown acceptable internal consistency reliability (amotivation, α = 0.75; external regulation, α = 0.85; introjected regulation, α = 0.90; identified regulation, α = 0.68; integrated regulation, α = 0.89; and intrinsic regulation, α = 0.89). The scale s construct validity was supported by confirmatory factor analysis (France et al., 2014). In the present study, the Blood Donor Identity Survey had an internal consistency reliability of α = 0.79 for the pre-intervention administration and α =.83 for the post-intervention administration. Internal consistency reliability for the subscales ranged from α =.58 (identified regulation) to α =.87 (interjected regulation) for pre-intervention and α =.60 (identified regulation) to α =.90 (integrated regulation) for post-intervention administration. Personal moral norm. (Appendix A.7): This scale included 3 items that assessed an individual s perception of the moral correctness associated with the act of donating blood. Personal moral norm has been demonstrated to be an indirect predictor of intent to donate blood (Masser, White, Hyde, Terry, & Robinson, 2009). In the present study, the personal moral norm scale had an internal consistency reliability of α = 0.84 for the preintervention administration and α = 0.89 for the post-intervention administration.

20 Anticipated regret. (Appendix A.8): Anticipated regret refers to the negative 20 feelings that one may feel if they fail to act in accordance with an intention to donate blood. It has been shown to be a direct predictor of donation intention (Masser, White, Hyde, Terry, & Robinson, 2009). Anticipated regret was assessed using 3 items. In the present study, the anticipated regret scale had an internal consistency reliability of α = 0.93for pre- and α = 0.95 for post-intervention administration. Donation anxiety. (Appendix A.9): This scale included three statements regarding anxiety specific to blood donation, which participants rated on a 7-point Likerttype scale. In a previous study, the scale showed good internal consistency reliability (α = 0.74) (Sinclair et al., 2010). Anxiety has also been shown to be an indirect predictor of donation intention (Masser, White, Hyde, Terry, & Robinson, 2009). In the present study, the anxiety scale showed excellent internal consistency reliability (α s = 0.98 for both the pre- and post-intervention administrations). Marlowe-Crowne Social Desirability Scale Short Form. (Appendix A.10): This scale consisted of 13 items that assessed for the potential effects of social desirability that may be associated with over-reporting of good behavior (i.e., intent to give blood). The scale has demonstrated acceptable internal consistency reliability (α = 0.76) and validity as supported by confirmatory factor analysis (Reynolds, 1982).

21 Procedure 21 Recruitment and Assignment A flowchart of the study protocol is provided in Figure 1. Potential participants were recruited through the Ohio University Psychology Subject Pool. Participants were screened for age, self-reported English proficiency, and whether they had donated blood previously. Those individuals who were 18 years of age or older, reported speaking and reading English fluently, and who indicated that they had never donated blood were given a brief description of the study and invited to participate via the Psychology Subject Pool website. Interested participants signed up for a study appointment. Once participants arrived at the study appointment, informed consent was obtained (Appendix A) and then participants were randomly assigned to the MI-based interview, the knowledge interview, or the video group based on a computer-generated list of random numbers. Next, participants completed the pre-intervention questionnaires, followed by participation in their assigned group.

22 22 Figure 1. Study protocol flowchart. MI-based interview group. The MI-based interviews were conducted in person by the principal investigator, who received training in motivational interviewing as a clinical psychology graduate student. The average completion time for the MI-based interviews was 5 minutes and 41 seconds. The interview followed a pre-prepared script that was adapted from a previous study on motivational interviewing for blood donors (Sinclair et al., 2010) (Appendix A.11). During the interview participants were asked

23 23 open-ended questions and the interventionist provided reflective responses, affirmations, and summaries in order to identify the specific motivation for donating, ambivalence about donation, as well as potential barriers or concerns about donating. All sessions were audio recorded and the interventionist completed end-of-session progress notes. For a randomly selected 50% of the interviews, trained graduate students assessed intervention fidelity using the Revised Global Scales: Motivational Interviewing Treatment Integrity (MITI) (Moyers et al., 2010). The MITI is a behavioral coding system used to assess MI competencies. Specifically, the sessions were given global rating scores for empathy, evocation, collaboration, autonomy, and direction. Counts were also tallied for specific MI behaviors (i.e., giving information, reflections). Coders were trained on the use of the MITI manual and practiced coding multiple times until they reached an inter-rater reliability of at least In the present study, inter-rater reliability was assessed using two-way mixed, consistency, average measures ICC. Results demonstrated that coders had good to excellent agreement ( ). This suggests a minimal amount of error introduced by the independent coders. Furthermore, all constructs were rated highly by both raters, with mean ratings falling in the 4.3 to 4.6 range. This reflects a strong adherence to the spirit of MI. Knowledge interview group. Participants in the knowledge interview group were asked a series of 13 open and close-ended questions that assessed their general and specific knowledge of blood donation (Appendix A.12). Questions were posed in a straight-forward, conversational manner and participants were not given any feedback on their responses. With the participant s permission, each interview was audio recorded. A randomly-selected 50% of the recordings were subsequently reviewed by the principal

24 24 investigator to ensure that all of the questions in the script were asked as written, and this review confirmed that this was the case. The average completion time of the knowledge interview was 4 minutes and 16 seconds. Video group. In the video group participants were asked to view a 12 minute and 51 second American Red Cross website video, entitled Arm to Arm: Lifesaving Journey (American Red Cross, 2011). The video was produced by the American Red Cross and a news affiliate in Detroit, WDIV, for use in local broadcasts. This video details the donation process and explains why blood donation is important. The video does not make a personal appeal to the participant; rather, it provides detailed information about the blood collections process. During the video the experimenter remained in the room and recorded the percentage of time each participant spent attending to the video using a scale with anchors of 0% (participant did not pay any attention), 25% (participant paid very little attention), 50% (participant paid attention about half the time), 75% (participant paid attention most of the time), and 100% (participant paid attention all of the time). On average, participants paid attention to the video 90.6% of the time (SD = 13.3). Finally, participants completed post-intervention questionnaires and were then debriefed and dismissed from the study after any questions had been answered. Four participants, all from the video group, were excluded from the analyses. One withdrew from the study due to an adverse reaction to the video and three were excluded from the analyses because they paid 50% attention to the video.

25 Follow-Up 25 Four weeks after the initial study visit, all participants were sent an with a link to complete follow-up questionnaires. Donation behavior was assessed using one question, In the past 4 weeks, did you give blood or attempt to give blood (i.e., present to a blood collection site with the intent to donate blood)? If participants indicated that they did attempt a donation, they were asked a follow-up question, Did you successfully complete your donation? Finally, if they were unable to complete their donation, they were asked an additional question, Why were you unable to successfully complete your donation? Participants who did not complete the follow-up within one week were sent an reminder. It should be noted that during the semester, participants (n = 74) were offered partial credit for initial study visit and remaining study credit was granted after completion of follow-up questionnaires. Participants whose follow-up date was scheduled after the end of the semester (n = 104) were granted full credit at the initial study visit. The completion rate was 92% for those who completed follow-up during the semester and fell to 34% after the semester. The sample that completed follow-up after the end of the semester was slightly older (Mean = 19.2, SD = 1.0) and contained a higher proportion of male participants (32.2%). See Appendix B for full baseline characteristic comparisons between groups. Participants who completed follow-up during the semester also reported a significantly greater change in autonomous motivation compared to those who completed follow-up after the semester. No other significant differences on psychological measures were observed between these two groups. It should also be noted that participants in the post-semester follow-up group may have had fewer opportunities for donation off-campus. Complete one-month follow up data was collected from 110

26 26 participants (110/178 = 62% rate of return). Of these, only five participants attempted to donate (2 in the MI-based interview, 1 in the knowledge interview, and 2 in the video conditions) and two successfully donated blood; hence, it was not possible to analyze group differences in subsequent donation attempts.

27 Statistical Analyses 27 Examination of histograms and Q-Q plots revealed that the assumption of normality was violated on multiple measures. In particular, at baseline, the data was positively skewed on measures of intention, anticipated regret, anxiety, external regulation, introjected regulation, integrated regulation, and intrinsic regulation and was negatively skewed on measures of anxiety and identified regulation. Skewness and kurtosis of all dependent measures, pre-intervention, post-intervention and pre-post intervention can be found in Appendix C.1. Because the distribution of change scores met requirements for parametric analyses for some measures but not others, all analyses were conducted using both parametric and non-parametric procedures. These approaches yielded similar results in terms of significant effects, and therefore the results of parametric analyses are presented here while the equivalent non-parametric analyses are provided in Appendix C.2. Specifically, a series of one-way ANOVAs was conducted to examine the effects of intervention group on the primary Theory of Planned Behavior constructs (attitude, self-efficacy, subjective norm, intention), the extended Theory of Planned Behavior constructs (personal moral norm, anticipated regret, donation anxiety), and blood donor identity and its subscales. When significant main effects of intervention group were observed, follow-up analyses were conducted using Tukey HSD tests. In addition, path analysis was used to examine perceived behavioral control and attitude as potential mediators of change in donation intention. All analyses were conducted using IBM SPSS Statistics Version Path analyses were conducted using the PROCESS macro for SPSS (Hayes, 2013).

28 Results 28 Between-Group Baseline Comparisons Analyses were conducted to compare the groups on baseline characteristics. As shown in Table 1, no significant group differences were observed on measures of sex, race, perceived eligibility, social desirability, and age. Similarly, as shown in Table 2, analyses of baseline measures of intention, attitude, perceived behavioral control and subjective norm revealed no significant differences between the groups. Furthermore, no differences were observed between groups on additional measures of personal moral norm, anticipated regret, or donation anxiety (all p s >.10) (see Table 2). Hence, the primary analyses were conducted on pre- to post-intervention change scores without controlling for baseline levels.

29 29 Table 1. Sample characteristics at baseline. All MI-Based Interview Knowledge Interview Video Group Comparison (n=174) (n=60) (n=59) (n=55) (p) Sex 0.98 Female 73.6% 73.3% 74.6% 72.7% Male 26.4% 26.7% 25.4% 27.3% Race 0.09* White or Caucasian 89.7% 95.0% 89.8% 83.6% Black or African American 8.0% 3.3% 6.8% 14.5% Asian American 2.3% 1.7% 5.1% 0.0% American Indian/Alaska Native 2.3% 3.3% 169.5% 1.8% Other 1.7% 0.0% 0.0% 5.5% Perceived Eligibility 0.33 Eligible 86.2% 86.7% 81.4% 90.9% Ineligible 13.8% 13.3% 18.6% 9.1% Social Desirability, Mean (±SEM) 18.9 (0.2) 18.7 (0.3) 18.9 (0.2) 19.4 (0.3) 0.65 Age, Mean (±SEM) 19.1 (0.1) 19.0 (0.1) 19.2 (0.1) 19.0 (0.1) 0.38 *p-value based on White/Non-White group differences due to small sample sizes in Non-White race groups.

30 30 Table 2. Means (±SEM) and group differences for each of the dependent measures at pre-intervention, post-intervention, and change from pre- to post-intervention. Pre-Intervention Post-Intervention Post-Pre Intervention Measure (Range) Group Mean (SEM) p Mean (SEM) p Mean (SEM) p Intention (3-21) MI-based Interview 4.3 (0.4) 7.0 (0.6) 2.7 (0.4) Knowledge Interview 4.3 (0.3) 5.6 (0.5) 1.3 (0.3) Video 5.5 (0.5) 9.4 (0.7) 4.1 (0.6) Attitude (6-42) MI-based Interview 22.5 (1.1) 25.9 (1.1) 3.3 (0.8) Knowledge Interview 23.8 (0.9) 24.9 (0.9) 1.2 (0.6) Video 24.5 (1.1) 29.4 (1.1) 4.8 (0.5) Perceived Behavioral Control (6-42) MI-based Interview 25.2 (1.1) 25.8 (1.2) 0.6 (0.8) Knowledge Interview 25.5 (1.0) 25.8 (1.0) 0.3 (0.8) Video 28.1 (1.1) 29.2 (1.2) 0.7 (0.7) Subjective Norm (6-42) MI-based Interview 16.8 (1.1) 18.3 (1.2) 1.5 (0.5) Knowledge Interview 18.6 (1.1) 19.3 (1.1) 0.6 (0.4) Video 17.4 (1.1) 19.5 (1.2) 2.1 (0.6) Personal Moral Norm (3-21) MI-based Interview 13.9 (0.6) 12.4 (0.7) -1.5 (0.6) Knowledge Interview 12.9 (0.6) 13.4 (0.7) 0.5 (0.5) Video 13.9 (0.7) 10.3 (0.7) -3.6 (0.8) Anticipated Regret (3-21) MI-based Interview 5.6 (0.5) 7.1 (0.6) 1.4 (0.5) Knowledge Interview 5.9 (0.5) 6.8 (0.6) 0.9 (0.4) Video 6.7 (0.6) 9.7 (0.8) 3.0 (0.5)

31 Table 2: continued Pre-Intervention Post-Intervention Post-Pre Intervention Measure (Range) Group Mean (SEM) p Mean (SEM) p Mean (SEM) p Anxiety (3-21) MI-based Interview 14.9 (0.8) 14.5 (0.9) -0.4 (0.5) Knowledge Interview 16.2 (0.8) 15.8 (0.8) -0.4 (0.2) Video 15.6 (0.8) 14.1 (0.8) -1.5 (0.5) 31

32 Figure 2. Mean (±SEM) pre- to post- intervention change in donation intention, attitude, perceived behavioral control, and subjective norm. *p <

33 Theory of Planned Behavior Constructs 33 Results of the one-way ANOVAs of intervention group revealed significant 2 differences on measures of donation intention, F(2, 172) = 10.44, p < 0.001, η p = 0.11, 2 attitude, F(2, 172) = 8.31, p < 0.001, η p = 0.09, and subjective norm, F(2, 172) = 3.40, p 2 < 0.05, η p = 0.04, but not perceived behavioral control, F(2, 172) = 0.12, p =.88. As shown in Figure 2. As shown in Figure 2, post-hoc analyses of the observed significant effects revealed that 1) participants in the video group had a greater increase in donation intention than those in the MI-based interview or knowledge interview groups, 2) participants in both the MI-based interview and video groups had a more positive change in attitude as compared to those in the knowledge interview group, and 3) participants in the video group had a more positive change in subjective norm compared to those in the knowledge interview group. No other significant group differences were observed. Extended Theory of Planned Behavior Constructs Additional analyses were conducted to test the constructs of personal moral norm, anticipated regret, and donation anxiety, which are part of the extended Theory of Planned Behavior. Results of the one-way ANOVAs of intervention group revealed significant differences on measures of personal moral norm, F(2, 172) = 10.94, p <.001, 2 2 η p = 0.11 and anticipated regret, F(2, 172) = 5.96, p <.05, η p = As shown in Table 2, post-hoc analyses of the observed significant effects revealed that 1) participants in both the MI-based interview and the video groups had a more negative change in personal moral norm than those in the knowledge interview group, which represents an increase in feelings of obligation to donate, and 2) participants in the video group had a greater increase in anticipated regret compared to those in the MI-based and knowledge

34 interview groups. There was no significant group main effect observed for change in 34 2 donation anxiety, F(2, 172) = 2.29, p =.10, η p = Blood Donor Identity Development Results of the one-way ANOVA of donor identity revealed a significant main 2 effect of group, F (2, 171) = 18.24, p <.001, η p = Post-hoc analyses revealed that participants in both the MI-based interview and video groups reported a greater positive change in donor identity, a reflection of autonomous motivation, than those in the knowledge interview group. As shown in Table 3 and Figure 3, further examination of individual motivational factors revealed that the overall main effect of group on the full donor identity scale score was accompanied by significant group differences in 2 amotivation, F(2, 171) = 4.00, p <.05, η p = 0.05, introjected regulation, F(2, 171) = , p <.001, η p = 0.17, identified regulation, F(2, 171) = 5.92, p <.05, η p = 0.06, 2 integrated regulation, F(2, 171) = 17.05, p <.001, η p = 0.15, and intrinsic regulation, 2 F(2, 171) = 17.63, p <.001, η p = 0.17, but not external regulation, F(2, 171) = 0.10, p = 2.902, η p = Post-hoc analyses of these significant group main effects revealed that participants in the video group reported a greater change in amotivation compared to the knowledge interview group (p <.05) and marginally greater than the MI-based interview group (p =.06). Participants in both the MI-based interview and video groups reported greater changes in introjected regulation, identified regulation, integrated regulation, and intrinsic regulation, compared to participants in the knowledge interview group.

35 Table 3. Means (±SEM) and group differences for relative autonomy and the regulatory styles subscales of the Blood Donor Identity Survey at pre-intervention, post-intervention, and change from pre- to post-intervention. Measure (Range) Pre-Intervention Post-Intervention Post-Pre Intervention Group Mean (SEM) p Mean (SEM) p Mean (SEM) p Relative Autonomy Index (-20-20) MI-based Interview -0.8 (1.2) 5.5 (1.3) 6.2 (0.8) Knowledge Interview 0.4 (1.2) 1.6 (1.3) 1.5 (0.5) Video 2.8 (1.3) 9.8 (1.2) 7.1 (0.7) Amotivation (3-21) MI-based Interview 13.4 (0.6) 11.5 (0.6) -1.9 (0.4) Knowledge Interview 13.3 (0.6) 12.8 (0.6) -0.6 (0.4) Video 11.8 (0.7) 9.9 (0.6) -1.9 (0.4) External Regulation (3-21) MI-based Interview 3.8 (0.2) 4.0 (0.3) 0.1 (0.2) Knowledge Interview 3.5 (0.2) 3.5 (0.2) 0.0 (0.1) Video 3.7 (0.2) 3.8 (0.3) 0.1 (0.2) Introjected Regulation (3-21) MI-based Interview 8.0 (0.7) 10.0 (0.7) 2.0 (0.4) Knowledge Interview 7.7 (0.6) 8.3 (0.7) 0.6 (0.4) Video 8.1 (0.6) 12.2 (0.8) 4.0 (0.5) Identified Regulation (3-21) MI-based Interview 15.5 (0.4) 16.8 (0.5) 1.3 (0.4) Knowledge Interview 15.5 (0.4) 15.6 (0.5) 0.1 (0.3) Video 16.2 (0.4) 17.9 (0.4) 1.7 (0.4) Integrated Regulation (3-21) MI-based Interview 9.2 (0.7) 12.4 (0.7) 3.2 (0.5) Knowledge Interview 9.4 (0.7) 9.9 (0.7) 0.5 (0.3) Video 10.2 (0.7) 13.4 (0.7) 3.2 (0.3) 35

36 Table 3: continued Measure (Range) Pre-Intervention Post-Intervention Post-Pre Intervention Group Mean (SEM) p Mean (SEM) p Mean (SEM) p Intrinsic Regulation (3-21) MI-based Interview 6.8 (0.4) 9.3 (0.5) 2.5 (0.3) Knowledge Interview 7.1 (0.4) 7.8 (0.5) 0.8 (0.3) Video 7.7 (0.5) 11.1 (0.6) 3.4 (0.4) 36

37 37 5 MI-based Interview Knowledge Interview Video * 4 * * * Change in scale units (pre- to post-intervention) * * * * -2-3 * Amotivation External Regulation Introjected Regulation Identified Regulation Integrated Regulation Intrinsic Regulation Figure 3. Mean (±SEM) pre- to post- intervention change in measures of autonomous motivation. *p < 0.05

38 38 Mediating Role of Attitude on Intention Change Given the significant effect of the video versus knowledge group on changes in both intention and attitude, a mediation analysis was conducted to test whether attitude could serve as a potential mediator of the observed group-related changes in intention. The mediation analysis, illustrated in Figure 4, compared the effects of video versus knowledge groups and revealed a significant indirect effect, indicating that the effects of video versus knowledge group on change in intention were partially mediated through attitude, 0.19, 95% CI [0.02, 0.46], with attitude accounting for 20% of the change in intention, P M = Attitude Change Video vs. Knowledge Interview 0.76* (0.95*) Intention Change Figure 4. Standardized regression coefficients for the relationship between Video vs. Knowledge Interview intervention and intention change, as mediated by attitude. The standardized regression coefficient between Video vs. Knowledge Interview intervention and intention change is provided in parentheses. *p <.05

39 39 Discussion It was expected that an interview based on the principles of motivational interviewing would be more effective at enhancing intention to donate among nondonors, compared to either a standard donor recruitment video or a control interview. However, the present study demonstrated that an intervention based on the principles of MI was not effective at increasing intention to donate blood for the first time, and, in fact, that the video was more successful at changing non-donor intentions. Additionally, it was anticipated that, compared to the video and knowledge interview groups, participants in the MI-based interview group would have a greater change in attitude and perceived behavioral control, and that these changes would mediate increases in donation intention. Both the video and MI-based interview were effective at changing non-donor attitudes, but no changes were observed in perceived behavioral control between groups. Furthermore, the observed significant change in intention between the video versus the knowledge interview was mediated by the change in attitude. The current findings demonstrate that an American Red Cross video was effective at changing donation intention, attitude, subjective norm, personal moral norm, anticipated regret and donor identity among non-donors. The video provided information on the blood donation process as well as personal stories of past donors. Thus, it addressed both barriers and motivational factors for non-donors. This is consistent with other studies in medical contexts that have demonstrated the effectiveness of audiovisual materials in addressing barriers and offering coping strategies (Albert, Buschbaum, & Li, 2007; Luck, Pearson, Maddern, & Hewett, 1999; Pearson, Maddern, & Hewett, 2005).

40 40 Although knowledge about blood donation was not quantified, during both the knowledge and MI-based interviews it was observed that the majority of non-donors either lacked general knowledge or had erroneous beliefs about blood donation, including eligibility criteria and the donation process. Thus, the educational component of the video may have been a particular strength in motivating non-donors and changing attitudes about donation. The video also produced more feelings of anticipated regret, or negative feelings at the thought of not donating. A reason for this may be that the video showed personal stories of transfusion recipients and in so doing may have created a sense of obligation to give or perhaps feelings of shame or guilt at not having donated in the past. Contrary to previous findings of increased intent to donate blood among donors who completed an adapted motivational interview (Sinclair et al., 2010; K. Sinclair- Miracle, personal communication, December 13, 2015), in the present study the MIbased interview was not successful at changing intention to donate for the first time. This could be potentially attributed to difference in sample characteristics. Particularly, the Sinclair et al. (2010) sample was older (Mean Age = 31.1, SD = 13.5), more diverse (71.0 % Whites, 24.3 % Blacks, 0.5 % American Indian, 0.5 % Asian, and 3.7 % other races), and had a mean of 7 (SD = 14) previous donations. The Sinclair et al. (2010) MI-based interview also included donation planning, which aided donors in picking a time and place for their next donation. This additional component of the intervention may have increased donor intent by addressing additional barriers and increasing confidence in their ability to donate. Although the MI-based interview did not enhance donation intent, it was effective at changing non-donor attitudes, personal moral norm and increasing

41 41 autonomous motivation, as measured by the blood donor identity survey. The changes in attitude were likely due to the ability of the MI-based interview to offer personalized coping strategies for barriers that are specific to non-donors, thereby increasing intrinsic motivation and improving attitudes towards donation. The observed changes in attitudes are also consistent with previous research among existing donors (Sinclair et al., 2010; K. Sinclair-Miracle, personal communication, December 13, 2015). Both the video and MI-based interview were effective at increasing feelings of personal moral norm, or the perceived moral correctness of a behavior (Ajzen, 1991). Past research has found that moral norm is the result of repeated experiences. However, the present study findings suggest that personal moral norm may be affected in individuals who have never donated blood. Perhaps non-donors tied the act of blood donation in with prior altruistic acts or it is possible that the concept of blood donation was salient enough that prior experience was not necessary to engage feelings of perceived moral correctness. Another potential explanation may be the overlap between the constructs of anticipated regret and personal norm. Newton, Newton, Ewing, Burney and Hay (2013) found that there is evidence of overlap between moral norms and anticipated regret for behaviors with moral implications, and consistent with this notion in the present sample there was a significant negative correlation between anticipated regret and personal moral norm at both pre- (r = -.51, p <.05) and post-intervention (r = -.49, p <.05). Thus, non-donors may have contemplated how blood donation was consistent with their moral norms and anticipated that they may experience feelings of regret towards not having donated. Alternatively, given the design of the present study, it

42 42 is also possible that the observed changes in personal moral norm may be short-lived and may not reflect an enduring change that can affect donation behavior outside of the laboratory. Another interesting finding was the observed changes on the Blood Donor Identity Scale. The scale assesses six different regulatory styles, which are thought to be shaped by past experience and environmental factors (France et al., 2014). Notably, introjected regulation, identified regulation and intrinsic regulation are associated with number of lifetime donations (France et al., 2014). In the present study, non-donors in both the video and MI-based interview conditions reported increases in autonomous motivation, as indicated by changes in introjected regulation, identified regulation, and intrinsic regulation. Although all groups reported a decline in amotivation, or nonregulation, those in the knowledge interview condition reported a greater drop compared to the other groups. Non-donors in all groups did not report high levels of external regulation and there were no significant changes pre and post intervention, indicating that external incentives, such as gifts, may not play a role in the decision to donate blood for the first time. Taken together, these findings indicate that it is possible to increase self-determination, and more importantly, internal motivation for giving even among non-donors. The MI-based interview and video may have also prompted participants to think about and reconsider their own thoughts and feelings about donation, as evidenced by additional changes in attitude and personal moral norm.

43 43 It should be noted that 13.5% of the present sample reported that they did not believe they were eligible to donate, which may have affected reported donation intention both during the study visit and at follow-up. Furthermore, twice as many participants in the video group reported that they were eligible to donate as compared to the knowledge interview group. Although this difference was non-significant, it may have contributed to the success of the video intervention. Additional analyses revealed that removal of individuals based on perceived eligibility resulted in significantly more positive changes in attitude in the video group, compared to the MI-based and knowledge interview groups. However, no other significant changes were observed as a result of perceived eligibility. The most common reported reason for ineligibility was being underweight, with participants reporting various weight cut-offs. Because participant weight was not measured in the current study, it is unclear whether these participants were actually ineligible to donate. Other reasons for ineligibility included having an autoimmune disease, low iron levels and travel outside the country. A particular strength or the MIbased interview was the ability to address some of the erroneous beliefs about eligibility criteria. Additionally, the video may have provided supplementary information that changed non-donors beliefs about eligibility. Accordingly, future studies should assess and control for perceived donation eligibility before and after intervention exposure. The generalizability of the study findings are strengthened by the use of a college sample, but may be limited by the use of a single experimenter. The current study utilized a college sample, which is a strength given that over a fifth of all blood donors, and more than a quarter of first-time donors, in the United States are between 16 and 25

44 44 years of age (Zou, Musavi, Notari & Fang, 2008; World Health Organization, 2008). In addition, the number of young first-time donors has increased in recent years (Zou, Musavi, Notari & Fang, 2008). Moreover, new donors are constantly needed and collegeaged non-donors are a key target for increasing first time donations in order to ensure maintenance of a stable blood supply. On the other hand, a limitation of the study is that the author conducted all motivational interviews, and thus it is not possible to separate the observed findings from the potential interviewer effects. Future studies should utilize additional interviewers in order to generalize findings. Although the current study findings provide evidence of the effectiveness of an MI-based intervention for changing attitudes, increasing autonomous motivation and personal moral norm, the strength of the video condition suggests a need for a fourth comparison group: one that receives both the MI-based interview and video interventions. Previous research has shown that combining an educational video with a brochure that addresses donor concerns is more effective at increasing donor intention, attitudes, and confidence compared to using either of these interventions alone (France, et al., 2011). This may be due to the ability of audiovisual materials to aid in knowledge acquisition and better coping, as shown in a variety of medical contexts (Albert, Buschbaum, & Li, 2007; Luck, Pearson, Maddern, & Hewett, 1999; Pearson, Maddern, & Hewett, 2005). Thus, combining MI with an educational video may produce greater changes in intent to donate for the first time than either of these interventions alone. Although follow-up data was compromised by low response rates (i.e., 62%), the available data suggest that none of the conditions was effective at influencing actual

45 45 donation behavior. For non-donors in particular, the lack of information about the logistics of donating (i.e., finding a time and place) is a key barrier to attempting and successfully completing a donation. Therefore, an additional avenue for intervention may be developing an action plan for completing a first donation. Action planning and the use of implementation intentions (i.e., developing an if-then plan) have been shown to be effective in behavior modification in a variety of health contexts (Hagger & Luszczynska, 2014). The MI-based interview in the current study utilized if-then planning to address non-donor concerns, but did not have the additional component of planning for an actual donation. Action planning may be effective at increasing intrinsic motivation, as well as bridging the gap between a change in donation intention and actual donation behavior. Future studies should also focus on developing a more streamlined and cost-effective methods of administration so that they may be tested in larger samples, and ultimately adapted for use in the general population. One promising avenue for this may be delivering an online intervention. France et al. (2013) used a web-based intervention to address concerns and offer coping strategies, similar to some of the goals of the MI-based interview, and were successful at increasing intent to donate among non-donors. Indeed, the use of a web-based or a video intervention may be particularly effective among young non-donors, who may be more receptive to technological recruitment approaches. The success of the video condition further supports the use of a less personalized, easily administered intervention in order to influence non-donor intent. Thus, an online intervention that combines elements of MI and the Red Cross video should be tested.

46 46 Such an intervention can be easily administered to large numbers of young non-donors and applied outside of the research setting. Overall, the study findings suggest that although an MI-based interview is effective at changing attitudes, autonomous motivation and perceived moral norm among non-donors, it does not appear to enhance donation intent in this group. Combined with existing evidence, this suggests that a standalone MI-based intervention may be more effective for motivating donation behavior among existing blood donors while alternative methods should be explored for those who have not previously given blood. Specifically, the greater success of the video intervention in changing intention implies that nondonors may benefit from receiving additional education about the donation process. Further research is needed to test whether combining an MI-based intervention with additional materials, such as an educational video or action planning strategies, may be more effective at increasing intrinsic motivation, intention and actual donation behavior among individuals who have never donated blood.

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58 58 Appendix A: Instruments and Study Forms Appendix A.1: Donor Characteristics and Demographic Questionnaire Directions: Please answer each question below Participant ID Date Age (you must be at least 18 to participate in this study) Gender Race: (check all those that apply to you) African American or Black American Indian or Alaska Native Asian American European American or White or Caucasian Native Hawaiian or Other Pacific Islander Other Ethnicity: (check one) Hispanic/Latino(a) Nonhispanic Have you donated blood before? Yes No If yes, how many times have you donated blood? If yes, when was the last time you donate blood? (If you cannot remember, please give your best guess.) / / Have you donated plasma before? Yes No Can you read, write and speak the English language? Yes No To the best of your knowledge, are you eligible to donate blood? Yes No If no, please describe why not:

59 59 Appendix A.2: Intention Scale I plan to donate blood in the next 8 weeks. Disagre e Agree 7 How likely is it that you will donate blood in the next 8 weeks? Unlikely Likely 7 I will donate blood in the next 8 weeks. Unlikely Likely 7

60 60 Appendix A.3: Attitude Scale For me, donating blood within the next 8 weeks would be For me, donating blood within the next 8 weeks would be (pointless/worthwhile) For me, donating blood within the next 8 weeks would be For me, donating blood within the next 8 weeks would be For me, donating blood within the next 8 weeks would be For me, donating blood within the next 8 weeks would be Useless Pointless 1 The Wrong Thing to Do Unpleasant Unenjoyabl e Frightening Useful 7 Worthw hile 7 The Right Thing to Do 7 Pleasant 7 Enjoyab le 7 Not Frighten ing 7

61 61 Appendix A.4: Perceived Behavioral Control Scale How confident are you that you will be able to donate blood within the next 8 weeks? For me, donating blood in the next 8 weeks would be Not Very Confident 1 Difficult Very Confident 7 Easy 7 If it were entirely up to me, I am confident that I would be able to donate blood in the next 8 weeks How much control do you have over whether you donate blood or not in the next 8 weeks? Disagree No Control Agree 7 Complete Control 7 I have complete control over whether I donate blood or not in the next 8 weeks It is entirely up to me to donate blood within the next 8 weeks Disagree Disagree Agree 7 Agree 7

62 62 Appendix A.5: Subjective Norm Scale Most people who are important to me would recommend I give blood in the next 8 weeks. My family thinks I should give blood in the next 8 weeks. The people who are most important to me think I should give blood in the next 8 weeks. A lot of people I know plan to give blood in the next 8 weeks. Disagree Disagree Disagree Disagree Agree 7 Agree 7 Agree 7 Agree 7 My friends will give blood in the next 8 weeks. Most people who are important to me will give blood in the next 8 weeks. Unlikely Unlikely Likely 7 Likely 7

63 63 Appendix A.6: Blood Donor Identity Survey Directions: For each of the following statements, choose a number from 1 ( Not at all true ) to 7 ( Very true ) to indicate how you feel about donating blood. Not at all true Somewhat true Very true 1. I really do not think about donating blood I donate blood for thank-you gifts, such as T shirts or water bottles. 3. I would feel guilty or ashamed of myself if I did not donate blood. 4. Donating blood is an important choice I really want to make. 5. I have carefully thought about it and believe donating blood is very important for many aspects of my life. 6. I enjoy donating blood Blood donation is something I rarely even think about. 8. I donate blood for the refreshments, such as drinks or snacks. 9. I would feel bad about myself if I did not donate blood. 10. Donating blood is very important for the health of others. 11. Donating blood is consistent with my life goals. 12. For me, being a blood donor means more than just donating blood. 13. I really do not have any clear feelings about blood donation. 14. I donate blood to get a donor sticker I would regret it if I did not donate blood Blood donation is an important thing to do Donating blood is very important to me Blood donation is an important part of who I am

64 64 Appendix A.7: Personal Moral Norm Scale I feel a moral obligation to give blood. Strongly Agree Strongly Disagree 7 I feel a personal responsibility to give blood. Strongly Agree Strongly Disagree 7 It is a social obligation to give blood. Strongly Agree Strongly Disagree 7

65 65 Appendix A.8: Anticipated Regret Scale If I do not donate blood within the next 8 weeks, I will regret it. Very Unlikely Very Likely 7 If I do not donate blood within the next 8 weeks, it will bother me. Very Unlikely Very Likely 7 If I do not donate blood within the next 8 weeks, I will be disappointed. Very Unlikely Very Likely 7

66 66 Appendix A.9: Donation Anxiety Scale DIRECTIONS: Please think about yourself donating blood. Read the statements below and circle the number that corresponds with how you feel right now about donating blood. If I donate blood I will feel nervous. Not at All Very Much 7 If I donate blood I will feel tense. Not at All Very Much 7 If I donate blood I will feel anxious. Not at All Very Much

67 67 Appendix A.10: Marlowe-Crowne Social Desirability Scale Listed below are thirteen statements concerning personal attitudes and traits. Read each item and decide whether the statement is true or false as it pertains to you personally. 1) It is sometimes hard for me to go on with my work if I am not encouraged true false 2) I sometimes feel resentful when I don't get my way true false 3) On a few occasions, I have given up doing something because I thought too little of my ability true false 4) There have been times when I felt like rebelling against people in authority even though I knew they were right true false 5) No matter who I'm talking to, I'm always a good listener true false 6) There have been occasions when I took advantage of someone true false 7) I'm always willing to admit it when I make a mistake true false 8) I sometimes try to get even rather than forgive and forget true false 9) I am always courteous, even to people who are disagreeable true false 10) I have never been irked when people expressed ideas very different from my own true false 11) There have been times when I was quite jealous of the good fortune of others true false 12) I am sometimes irritated by people who ask favors of me true false 13) I have never deliberately said something that hurt someone's feelings true false

68 68 Appendix A.11: Motivational Interviewing Script Overview Topic #1: Introduction and Permission to Interview Topic #2: Perceived Importance of Donation Topic #3: Donation Intention Topic #4: Individualized Coping Strategies Topic #5: Donation Confidence Topic #6: Personal Goals and Values Relating to Donation Topic #7: Summarizing the Session

69 69 Appendix A.12: Knowledge Interview 1. Please tell me what you know about blood donation. 2. Please tell me what you know about the blood donation process. 3. Have you ever known anyone who has donated blood? If yes, who? 4. What are some thoughts that come to your mind when talking about blood donation? 5. If you were interested in donating blood, how would you go about it? (finding a collection site, etc.) 6. What are some reasons someone might need blood? 7. There are several types of blood donation. What types are you familiar with? 8. What are the eligibility criteria for donating blood? 9. What are the exclusionary criteria for donating blood? 10. How often can an individual donate blood? 11. What types of recruitment efforts for blood donation have you seen in your community? 12. What are the different blood types? 13. Do you know which blood types are compatible with each other for donation?

70 70 Appendix B: Baseline Sample Characteristics Table 4. Sample characteristics at baseline for participants who completed follow-up during versus after the semester. During Semester After Semester During vs. After MI- MI- Group All Based Interview Knowledge Interview Video All Based Interview Knowledge Interview Video Comparis on (n=73) (n=27) (n=22) (n=24) (n=99) (n=33) (n=36) (n=30) (p) Sex 0.03 Female 82.4% 88.9% 73.9% 83.3% 67.7% 60.6% 75.0% 66.7% Male 17.6% 11.1% 26.1% 16.7% 32.3% 39.4% 25.0% 33.3% Race 0.79 White or Caucasian 90.5% 96.3% 91.3% 83.3% 88.9% 93.9% 88.9% 83.3% Black or African American 6.8% 3.7% 0.0% 16.7% 9.1% 3.0% 11.1% 13.3% Asian American 4.1% 3.7% 8.7% 0.0% 1.0% 0.0% 2.8% 0.0% American Indian/Alaska Native 2.7% 3.7% 0.0% 4.2% 2.0% 3.0% 2.8% 0.0% Other 1.4% 0.0% 0.0% 4.2% 2.0% 0.0% 0.0% 6.7% Perceived Eligibility 0.75 Eligible 85.1% 81.5% 78.3% 95.8% 86.9% 90.0% 83.3% 86.7% Ineligible 14.9% 18.5% 21.7% 4.2% 13.1% 9.1% 16.7% 13.3% Mean Social Desirability (SD) Mean Age (SD) 19.0 (2.2) 18.7 (2.2) 18.8 (1.8) 18.9 (0.9) 18.7 (0.8) 19.1 (0.9) 19.5 (2.4) 18.8 (0.8) 19.0 (2.0) 18.6 (2.0) 18.9 (2.0) 19.2 (1.0) 19.0 (1.0) 19.2 (0.9) *p-value based on White/Non-White group differences due to small sample sizes in Non-White race groups (2.0) (1.3) 0.04

71 71 Appendix C.1: Measures of Skewness and Kurtosis Appendix C: Non-Parametric Analyses Table 5. Measures of skewness and kurtosis for each of the dependent measures at pre-intervention, post-intervention, and change from pre- to post-intervention. Measure Pre-Intervention Post-Intervention Post-Pre Intervention Group Skewness Kurtosis Skewness Kurtosis Skewness Kurtosis Intention MI-based Interview Knowledge Interview Video Attitude MI-based Interview Knowledge Interview Video Perceived Behavioral Control MI-based Interview Knowledge Interview Video Subjective Norm MI-based Interview Knowledge Interview Video Personal Moral Norm MI-based Interview Knowledge Interview Video Anticipated Regret MI-based Interview Knowledge Interview Video

72 Table 5: continued Measure Pre-Intervention Post-Intervention Post-Pre Intervention Group Skewness Kurtosis Skewness Kurtosis Skewness Kurtosis Anxiety MI-based Interview Knowledge Interview Video Relative Autonomy Index MI-based Interview Knowledge Interview Video Amotivation MI-based Interview Knowledge Interview Video External Regulation MI-based Interview Knowledge Interview Video Introjected Regulation MI-based Interview Knowledge Interview Video Identified Regulation MI-based Interview Knowledge Interview Video Integrated Regulation MI-based Interview Knowledge Interview Video

73 Table 5: continued Measure Pre-Intervention Post-Intervention Post-Pre Intervention Group Skewness Kurtosis Skewness Kurtosis Skewness Kurtosis Intrinsic Regulation MI-based Interview Knowledge Interview Video

74 Appendix C.2: Non-Parametric Analyses Table 6. Mean ranks and Kruskal Wallis test statistics for each of the dependent measures at pre-intervention, post-intervention, and change from pre- to post-intervention. Pre-Intervention Post-Intervention Post-Pre Intervention Measure Mean Mean Mean Group Rank X 2 p Rank X 2 p Rank X 2 p Intention MI-based Interview Knowledge Interview Video Attitude MI-based Interview Knowledge Interview Video Perceived Behavioral Control MI-based Interview Knowledge Interview Video Subjective Norm MI-based Interview Knowledge Interview Video Personal Moral Norm MI-based Interview Knowledge Interview Video Anticipated Regret MI-based Interview Knowledge Interview Video Anxiety MI-based Interview Knowledge Interview Video

75 Table 7. Mean ranks and Kruskal Wallis test statistics for measures of blood donor identity at pre-intervention, post-intervention, and change from pre- to post-intervention. Measure Pre-Intervention Post-Intervention Post-Pre Intervention Group Mean X 2 p Mean X 2 p Mean X 2 p Rank Rank Rank Relative Autonomy Index MI-based Interview Knowledge Interview Video Amotivation MI-based Interview Knowledge Interview Video External Regulation MI-based Interview Knowledge Interview Video Introjected Regulation MI-based Interview Knowledge Interview Video Identified Regulation MI-based Interview Knowledge Interview Video Integrated Regulation MI-based Interview Knowledge Interview Video Intrinsic Regulation MI-based Interview Knowledge Interview Video

76 76 Appendix D: Follow-Up Analyses Appendix D.1: Additional Analyses Across Timepoints Table 8: Pearson correlation coefficients between time points by group. Time 1 month 8 weeks 3 months 6 months 12 months 1 month 1.774**.714**.582**.420** 8 weeks 1.670**.628**.503** 3 months 1.882**.734** 6 months 1.830** 12 months 1 Total Sample MI-based Interview Knowledge Interview Video *p <.05 **p <.01 1 month 1.761**.667**.512**.300* 8 weeks 1.599**.501**.319* 3 months 1.866**.675** 6 months 1.841** 12 months 1 1 month 1.767**.563**.547**.278* 8 weeks 1.628**.700**.487** 3 months 1.891**.747** 6 months 1.787** 12 months 1 1 month 1.806**.846**.672**.670** 8 weeks 1.763**.671**.694** 3 months 1.891**.797** 6 months 1.869** 12 months 1

77 77 A repeated measures ANOVA was conducted to compare the effect of time on change in intention. Mauchly s test indicated that the assumption of sphericity had been violated, χ 2 (9) = , p =.000, therefore degrees of freedom were corrected using Greenhouse-Geisser estimates of sphericity (ε =.57). The results show that there was no significant effect of time on change in intention, F(2.28, ) = 2.62, p =.07. Table 9. One-way ANOVAs for group differences at time of study visit on measures of intention by time point. Time F df Sig. 1 month , weeks , months , months , months ,

78 78 Appendix D.2: Repeated Measures ANOVA for Attitude Change Over Time A series of 3 Group (MI-based interview, knowledge interview, video) X 3 Time (pre-intervention, post-intervention, follow-up) ANOVAs was conducted for the Theory of Planned Behavior and blood donor identity constructs (Table 10). When the assumption of sphericity was violated, degrees of freedom were corrected using Greenhouse-Geisser estimates of sphericity (ε =.03). When the effect of time and condition on a variable was significant, post hoc tests were conducted. There was a significant effect of group and time on attitude, F(4, 3.849) = 5.24, p <.001. Post-hoc analysis of this significant time by group difference revealed that participants in the video group had a greater change in attitude over time, compared to the MI-based interview and knowledge interview conditions. Significant group and time effects were also observed on measures of introjected regulation, F(4, 3.220) = 4.42, p <.001, integrated regulation, F(4, 3.121) = 4.03, p <.05, and intrinsic regulation, F(4, 3.275) = 4.95, p <.001. However, post-hoc analyses of these significant main effects revealed no significant pairwise comparisons.

79 Table 10. Mean (SD) Theory of Planned Behavior and blood donor identity scores at pre-intervention, post-intervention, and followup. Mean (SD) Pre Post Follow -Up Attitude (1.3) (1.4) (1.3) Subjective Norm (1.4) (1.3) (1.5) Perceived Behavioral Control (1.3) (1.3) (1.7) Amotivation (5.0) (4.9) (4.3) External Regulation (1.6) (2.2) (3.7) Introjected Regulation (5.9) (6.4) (5.3) Identified Regulation (3.0) (3.8) (3.8) Integrated Regulation (5.5) (5.9) (5.9) Intrinsic Regulation (4.0) (4.4) (4.9) MI-based Interview Knowledge Interview Video n = 31 n = 41 n = 32 Pre Post Follow -Up (1.1) (1.2) (1.3) (1.2) (1.2) (1.4) (1.2) (1.2) (1.5) (4.4) (4.8) (4.4) (1.4) (1.6) (3.5) (3.7) (4.7) (4.6) (3.1) (3.5) (3.9) (5.0) (5.2) (5.3) (3.3) (3.9) (4.3) Pre Post Follo w-up (1.1) (1.2) (1.2) (1.2) (1.4) (1.3) (1.3) (1.4) (1.5) (4.9) (4.3) (4.8) (1.6) (2.3) (2.9) (3.7) (5.9) (5.0) (3.2) (3.1) (4.2) (5.0) (5.4) (4.8) (3.3) (4.0) (3.8) F p η

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