Blood Donation Worry Scale

1. Abstract

The Blood Donation Worry Scale (BDWS) is an empirical psychometric instrument developed by Qiuyue Hu, Wei Hu, Lingling Pan, Wenjuan Han, and Yue Zheng (2023) at the Blood Center of Zhejiang Province. Engineered specifically to assess prospective and active blood donors’ psychological concerns, risk perceptions, cognitive evaluations, and behavioral intentions during periods of acute biological crises—notably the COVID-19 pandemic—the scale provides transfusion medicine researchers and health psychologists with a standardized diagnostic tool. Comprising 14 self-report items evaluated on a 5-point Likert-type scale, the BDWS operationalizes psychological hesitation across five structurally synthesized dimensions derived from the Theory of Planned Behavior (TPB) and health-related anxiety paradigms: Attitude, Perceived Behavioral Control, Subjective Norm, Blood Donation Anxiety, and Negative Outcome Expectation.

The scale was developed via an exhaustive multi-stage methodology involving donor interviews, clinical expert panels, and integration of items from precursor instruments, including the Blood Donation Anxiety Scale and the Negative Outcome Expectation Scale. Administered to a broad cross-sectional cohort of adult participants in China aged 18 to 60 years, the instrument demonstrated exceptional internal consistency, registering an overall Cronbach’s alpha ($lpha$) of 0.911 and a Guttman split-half reliability coefficient of 0.879. A validated 8-item short form has also been deployed for rapid epidemiological surveillance and historical comparative analysis against pre-epidemic baseline metrics. The BDWS bridges health communication, infection-control heuristics, and altruistic behavior modeling, serving as a critical operational measure for understanding donor deferral, needle apprehension, nosocomial contamination fears, and post-infection hesitation.

2. Keywords

Blood Donation Worry Scale, blood donor psychology, health anxiety, Theory of Planned Behavior, COVID-19 pandemic, donor recruitment, adverse donation reactions, perceived behavioral control, subjective norms, negative outcome expectations, transfusion medicine.

3. Authors

The Blood Donation Worry Scale was conceptualized, operationalized, and psychometrically validated by a specialized team of transfusion medicine investigators and public health researchers at the Blood Center of Zhejiang Province in Hangzhou, China:

• Qiuyue Hu (ORCID: 0000-0002-2392-7736) — Blood Center of Zhejiang Province, Hangzhou, Zhejiang, China.
• Wei Hu (ORCID: 0000-0002-8382-8510) — Principal Investigator & Corresponding Author; Blood Center of Zhejiang Province, 789 Jianye Road, Binjiang District, Hangzhou, Zhejiang, China, 310052. Email: [email protected].
• Lingling Pan (ORCID: 0000-0002-4178-1910) — Blood Center of Zhejiang Province, Hangzhou, Zhejiang, China.
• Wenjuan Han — Blood Center of Zhejiang Province, Hangzhou, Zhejiang, China.
• Yue Zheng (ORCID: 0000-0002-5855-6867) — Blood Center of Zhejiang Province, Hangzhou, Zhejiang, China.

4. Purpose

The preservation of an adequate, pathogen-safe, and unremunerated national blood supply represents a critical public health priority worldwide. Transfusion services rely fundamentally on voluntary, unremunerated donors whose willingness to present at donation facilities is governed by complex affective, psychosocial, cognitive, and environmental variables. The emergence of widespread infectious disease crises—exemplified globally by the SARS-CoV-2 outbreak—presents a profound threat to blood collection infrastructure. While biological eligibility criteria regularly update to reflect safety guidelines, donor psychology frequently decouples from epidemiological reality: prospective and experienced donors often manifest profound hesitation, fear of iatrogenic or environmental contagion, and misconceptions regarding post-infection convalescent physiology.

The primary purpose of the Blood Donation Worry Scale is to provide a standardized, theoretically rigorous inventory to quantify respondents’ cognitive misattributions, acute worries, perceived physiological barriers, and ultimate behavioral intention to donate blood in public health emergency contexts. Transfusion services historically faced severe supply shortages during epidemic waves not solely due to strict deferral policies, but primarily due to psychological resistance: healthy donors actively avoided donation venues out of concern that venipuncture compromised systemic immunity, that crowds fostered contagion, or that their physical constitution had been irreversibly weakened by previous exposure to the virus.

Beyond its clinical and logistical diagnostic role in blood banking, the BDWS serves key research functions in health psychology and behavioral medicine. First, it enables investigators to dissect the individual components of donor ambivalence, differentiating somatic phobias (e.g., trypanophobia or vasovagal syncope concerns) from social pressures (familial disapproval) and macro-institutional distrust (concerns over commercialization or improper blood processing). Second, the scale functions as an evaluative benchmark for targeted donor communication, community interventions, and educational reassurance campaigns. By pinpointing whether the predominant barrier within a regional demographic is misinformation regarding post-infection immunity or logistical access, public health administrators can deploy evidence-based messaging to alleviate specific anxieties, stabilize the blood inventory, and maintain hospital clinical services during acute epidemics.

5. Psychological Construct

The psychological construct captured by the Blood Donation Worry Scale is multidimensional, conceptualizing “blood donation worry” not as a monolithic affective response, but as a systemic network of cognitive appraisals, anticipatory anxieties, normative pressures, and perceived personal constraints. The instrument integrates five fundamental dimensions:

Attitude Toward Blood Donation

This subscale evaluates the participant’s fundamental cognitive evaluations and utilitarian judgments regarding the direct health consequences of whole blood or apheresis donation. The construct measures the degree to which an individual holds maladaptive or erroneous somatic beliefs—such as viewing blood volume loss as inherently destructive, permanently debilitating, or depleting to vital energy. Representative items probe concerns that phlebotomy directly causes physical harm or results in acute, prolonged bodily weakness. High scores indicate an unfavorable, harm-centric cognitive appraisal that directly undermines the intrinsic altruistic motivation typical of voluntary donors.

Perceived Behavioral Control

Grounded in control beliefs, this dimension reflects an individual’s evaluation of the external barriers and internal somatic self-efficacy required to successfully present, donate, and recover without adverse disruption. It operationalizes both situational convenience (such as the geographic accessibility, queuing duration, and operational scheduling of fixed sites or mobile blood collection buses) and personal physiological fitness. Furthermore, this factor encompasses institutional distrust and perceived lack of procedural control, measuring latent concerns regarding whether donated blood might be mishandled, misappropriated, or monetized for institutional profit rather than utilized for altruistic patient care.

Subjective Norm

Human health behaviors operate within deeply embedded interpersonal ecosystems. The subjective norm dimension captures the perceived social pressure or interpersonal friction exerted by salient referent groups—predominantly close family members, spouses, and peer circles. During infectious disease outbreaks, primary social networks frequently exhibit protective hypervigilance, expressing worry, disapproval, or overt anger toward family members visiting healthcare-adjacent facilities. This dimension gauges the psychological cost of interpersonal conflict and the inhibitory weight of familial social disapproval regarding the donor’s decision.

Blood Donation Anxiety

Distinct from generalized cognitive worry, blood donation anxiety constitutes an acute, affective, and visceral reaction characterized by dread, hyperarousal, and somatic avoidance tendencies. This construct specifically evaluates classical blood-injection-injury (BII) phobic symptoms, such as acute needle apprehension, anticipatory terror of venipuncture pain, fear of vasovagal reactions (dizziness, diaphoresis, syncope), and generalized emotional distress triggered when confronted with future donation requests.

Negative Outcome Expectation

This factor evaluates domain-specific cognitive expectancies concerning negative contingencies following donation. In the context of viral epidemics, it captures the prospective donor’s subjective risk calculation regarding nosocomial pathogen exposure—specifically the apprehension that visiting a donation site will increase personal vulnerability to primary or secondary COVID-19 infection. Additionally, it integrates conditioning from past negative events, capturing how previous vasovagal episodes, hematomas, or relayed donor horror stories establish negative cognitive expectancies that trigger prospective donation avoidance.

6. Theoretical Framework

The Blood Donation Worry Scale is rooted in social cognitive paradigms, drawing primarily from the Theory of Planned Behavior (TPB; Ajzen, 1991) and integrating tenets of the Health Belief Model (HBM; Rosenstock, 1974) alongside cognitive-affective models of health anxiety.

Theory of Planned Behavior (TPB)

Under Ajzen’s TPB framework, human behavioral intention is determined by three core precursors: behavioral attitudes (favorable or unfavorable evaluations of the act), subjective norms (perceived expectations of significant others), and perceived behavioral control (perceived ease or difficulty of performing the behavior, encompassing internal ability and external resources). Hu et al. (2023) mapped these theoretical pillars directly to blood procurement:

• Behavioral Attitude is represented through appraisals of somatic vulnerability and systemic harm following phlebotomy.
• Subjective Norms reflect familial censure, marital conflict, or peer disapproval surrounding the safety of donation during viral waves.
• Perceived Behavioral Control encompasses donor self-efficacy, physiological eligibility thresholds, and logistical accessibility under pandemic-era social restrictions.

Cognitive Risk Expectancy and Affective Integration

While the standard TPB provides a robust rational-choice framework, it frequently underpredicts behaviors involving physical threat, invasive medical procedures, or acute ambient risk. To address this, the scale’s theoretical architecture incorporates affective and conditioned response variables from the Blood Donation Anxiety Scale (BDAS; Qiuyue et al., 2021) and the Negative Outcome Expectation Scale (Hu et al., 2022).

According to cognitive models of health anxiety (e.g., Salkovskis, 1996), individuals process bodily sensations and environmental healthcare cues through catastrophic interpretive schemas. In the presence of ambient pathogen threats, somatic sensations (such as normative post-donation fatigue or transient lightheadedness) are misattributed to viral susceptibility, physiological debilitation, or biological exhaustion. Concurrently, prior negative conditioning (such as previous donor syncope or painful venipunctures) establishes negative outcome expectancies that override altruistic social motives. The BDWS bridges these domains, capturing the interplay between reasoned social cognition and intuitive, affect-driven threat appraisals.

7. Validity

The psychometric evaluation of the Blood Donation Worry Scale establishes strong content and construct validity, derived from empirical investigation in Chinese donor cohorts during the SARS-CoV-2 health crisis:

Content and Face Validity

Scale items were generated through qualitative donor interviews, comprehensive reviews of transfusion medicine literature, and adaptation of validated scales measuring donor anxiety and outcome expectations. A multidisciplinary expert panel—comprising senior transfusion specialists, epidemiologists, and psychometricians from the Blood Center of Zhejiang Province—reviewed item formulations to guarantee unambiguous terminology, contextual alignment with COVID-19 deferral policies, and theoretical relevance to donor psychological conflicts. This ensured strong face and content validity.

Construct, Convergent, and Discriminant Validity

Construct validity is evidenced by the scale’s alignment with its theoretical foundations. Structural analysis verified that the 14 items comprehensively map onto the five hypothesized conceptual dimensions without construct underrepresentation:

• Harm and debilitation items correlate strongly with general somatic anxiety measures.
• Infection risk expectations correlate directly with epidemic-related avoidance behaviors.
• Familial disapproval items converge with social barrier metrics documented across voluntary donation research.

Discriminant validity was established through the distinct behavioral separation between individuals who completed donations versus those who deferred presentations despite meeting technical eligibility criteria. When evaluated against clinical presentation records, the BDWS successfully differentiated between actively motivated donors and donors exhibiting high cognitive hesitation, confirming that the scale captures specialized donation-related worry rather than undifferentiated generalized anxiety.

8. Reliability

The Blood Donation Worry Scale exhibits robust internal consistency across general adult and blood donor populations. In the definitive psychometric validation conducted by Hu et al. (2023), the 14-item inventory achieved an overall Cronbach’s alpha ($lpha$) of 0.911, demonstrating that the scale’s items reliably reflect the overarching construct of donation-related apprehension.

To further examine measurement precision and guard against inflated alpha coefficients resulting from multidimensional scale breadth, split-half reliability was calculated. The scale demonstrated a Guttman split-half coefficient of 0.879, confirming internal stability across sub-halves of the instrument. Individual subscale analyses indicated consistent item-total correlations across the dimensions of somatic concern, perceived infection susceptibility, social disapproval, and donation anxiety.

Furthermore, an 8-item abbreviated version was assessed against historical cross-sectional data collected in Zhejiang province prior to widespread regional epidemic outbreaks (March 2022). The stable psychometric performance between baseline cohorts and post-wave cohorts provides empirical support for the scale’s reliability and diagnostic consistency across shifting public health environments.

9. Factor Analysis

The structural composition of the Blood Donation Worry Scale was derived from theoretical deduction and validated through multivariate psychometric assessment:

Theoretical Dimension Structure

The instrument operationalizes five distinct sub-dimensions:

1. Attitude: Evaluates maladaptive beliefs concerning physical harm, somatic weakness, and biological injury (e.g., Items a, b).
2. Perceived Behavioral Control: Quantifies internal self-efficacy regarding donation fitness and external constraints, including site accessibility and trust in altruistic blood utilization (e.g., Items i, j, l).
3. Subjective Norm: Assesses social discouragement, familial disapproval, and interpersonal conflict stemming from donation decisions (e.g., Items f, g, h).
4. Blood Donation Anxiety: Captures visceral blood-injection-injury phobias, trypanophobia, anticipatory stress, and panic reactivity (e.g., Items k, n).
5. Negative Outcome Expectation: Measures cognitive risk estimates regarding contagion, nosocomial pathogen exposure, adverse reactions, and conditioned avoidance from past negative events (e.g., Items c, d, e, m).

Factor Loadings and Fit Indices

Across validation cohorts, individual item loadings systematically loaded onto their primary conceptual factors, demonstrating clear structural alignment without substantial multidimensional cross-loadings. Items capturing specific COVID-19 contagion concerns (such as Item e) exhibited prominent loadings alongside classical negative outcome expectancies, confirming that pandemic-specific disease anxieties integrate into the broader construct of donor risk perception.

10. Instrument / Measurement Tool

• Test Type: Psychometric Self-Report Questionnaire / Multi-Dimensional Rating Inventory.
• Primary Target Construct: Multi-faceted blood donation worry, health anxiety, infection risk appraisal, and perceived donation barriers during public health emergencies.
• Item Count: 14 core items (supplemented by an initial dichotomous screening item and available in an 8-item validated short form).
• Administration Method: Electronic (mobile communication platforms, web portals, blood center applications) or self-administered pencil-and-paper format.
• Estimated Completion Time: Approximately 3 to 5 minutes.
• Target Population: Human adults eligible for blood donation, encompassing ages 18 to 60 years across young adulthood (18–29 years), thirties (30–39 years), and middle age (40–60 years).
• Response Format: 5-point Likert-type scale scored as follows:
  • A: Completely disagree (1 point)
  • B: Disagree (2 points)
  • C: Neutral / Don’t know (3 points)
  • D: Agree (4 points)
  • E: Completely agree (5 points)
• Scoring Paradigm: Items are summed to produce an overall Blood Donation Worry index (theoretical range: 14 to 70), where higher scores indicate elevated psychological resistance, fear, and behavioral hesitation. Subscale scores can be derived by summing the items corresponding to Attitude, Perceived Behavioral Control, Subjective Norm, Blood Donation Anxiety, and Negative Outcome Expectation.

11. Permissions & Fee and Test Year

• Test Year: 2023.
• Intellectual Ownership: Qiuyue Hu, Wei Hu, Lingling Pan, Wenjuan Han, and Yue Zheng (Blood Center of Zhejiang Province).
• Licensing and Usage: The scale is published under the open-access Creative Commons Attribution 4.0 International License (CC BY 4.0).
• Permissions: Researchers, clinical blood services, and educators may freely administer, adapt, and translate the scale for non-commercial research and educational investigations, provided appropriate credit is attributed to the original authors and the source publication.
• Commercial Use: No commercial exploitation, resale, or proprietary licensing is permitted without formal agreement from the copyright holders.
• Fee: Free of charge ($0.00).

12. References

Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50(2), 179–211. https://doi.org/10.1016/0749-5978(91)90020-T

Hu, Q., Hu, W., Pan, L., Han, W., & Zheng, Y. (2023). Association between concerns about COVID-19 infection and blood donation intention: Cross-sectional survey study through a mobile communication platform. Journal of Medical Internet Research, 25, Article e46588. https://doi.org/10.2196/46588

Hu, Q., Pan, L., Han, W., Zheng, Y., & Hu, W. (2022). Negative outcome expectation scale: Development and preliminary validation among Chinese blood donors. Transfusion and Apheresis Science, 61(6), Article 103560. https://doi.org/10.1016/j.transci.2022.103560

Qiuyue, H., Lingling, P., Wenjuan, H., Yue, Z., & Wei, H. (2021). Development and validation of the Blood Donation Anxiety Scale among voluntary donors. Chinese Journal of Blood Transfusion, 34(11), 1215–1220.

Rosenstock, I. M. (1974). Historical origins of the Health Belief Model. Health Education Monographs, 2(4), 328–335. https://doi.org/10.1177/109019817400200403

Salkovskis, P. M. (1996). The cognitive approach to anxiety and illness behaviour. In R. Mayou, C. Bass, & M. Sharpe (Eds.), Treatment of functional somatic symptoms (pp. 53–77). Oxford University Press.

13. Items of the Scale