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Distraction Reduces Self-Reported Physiological Reactions to Blood Donation in Novice Donors With a Blunting Coping Style

From the Department of Psychology, Ohio University, Athens, Ohio.

Address reprint requests to: Christopher France, PhD, Department of Psychology, Ohio University, Athens, Ohio, USA 45701-2979. Email: france{at}ohio.edu

	ABSTRACT

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OBJECTIVE: Vasovagal reactions experienced by some blood donors (eg, faintness, lightheadedness, and dizziness) have been shown to be related to a decreased likelihood of future blood donations. This study evaluated the efficacy of audiovisual distraction as a means of reducing self-reported physiological reactions in first-time blood donors. Because interventions that are consistent with an individual’s preferred coping style have been shown to be more effective at reducing physiological and psychological responses to stressful medical procedures, coping style (monitoring vs. blunting) was assessed as a possible moderating variable.

METHODS: First-time blood donors were randomly assigned to one of two conditions: audiovisual distraction or no-treatment control. Participants in the distraction group donated blood at an American Red Cross blood drive while watching a three-dimensional video presentation on a personal visor and headset. The control group donated blood according to standard American Red Cross procedures. Score on a self-reported measure of physiological reactions completed immediately after donation served as the dependent variable.

RESULTS: Individuals who typically use blunting coping strategies to cope with stress reported an attenuation of vasovagal reactions to blood donation in the distraction vs. the control condition (t(49) = 2.29, p < .05), whereas donors who prefer a monitoring coping style did not benefit from distraction.

CONCLUSIONS: Among first-time blood donors, audiovisual distraction may be an effective means of reducing vasovagal reactions in donors who prefer to cope with stress using such strategies as distraction, denial, and reinterpretation.

Key Words: audiovisual distraction • vasovagal reactions • blood donation.

Abbreviations: ANOVA = analysis of variance; BDRI = Blood Donation Reactions Inventory.

	INTRODUCTION

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Each year more than 11 million units of red blood cells are needed for transfusion in the United States alone (1). Because this blood supply relies primarily on volunteer blood donors, maintaining a steady stream of donors is a priority for blood collection agencies. One potential complicating factor in the attempt to recruit and retain new donors is the risk of unpleasant physical sensations during the blood donation process (2, 3). Up to 4% of all donors experience a loss of consciousness during donation (4–7). Milder vasovagal reactions, such as faintness, lightheadedness, and dizziness, are significantly more common (3, 4, 8–10) and have been shown to be related to a decreased likelihood of future blood donations (2, 3, 5). Although many of the factors that have been related to vasovagal reactions are beyond the control of blood collection agencies (eg, age, sex, and body weight; Refs. 7, 8, 11), recent evidence suggests that efforts to decrease donor anxiety and enhance donor coping may result in a significant reduction in negative reactions and increase the likelihood of repeat donations (5, 12).

Distraction has been shown to be a helpful intervention for individuals undergoing various stressful medical procedures. For example, patients undergoing dental restoration report less pain and discomfort when listening to music (13) and less distress when playing video games (14, 15). Video game play has also been shown to reduce levels of distress and unpleasant treatment side effects in adult and pediatric patients undergoing chemotherapy (16–18). Finally, watching videos has been shown to result in fewer pain behaviors for patients undergoing a gynecological procedure (19) and lower ratings of discomfort for patients undergoing a dental procedure (20). Although few studies have compared the effectiveness of various modes of distraction, there is some indication that interventions that are more distracting may lead to greater reductions in stress associated with some medical procedures (20). To date there have been no experimental investigations of the effects of distraction on vasovagal reactions in volunteer blood donors.

Whereas distraction has proven to be useful for a variety of stressful medical procedures, interventions consistent with a patient’s preferred method of coping may be most beneficial. Miller (21, 22) hypothesized that two distinct coping styles exist, monitoring and blunting. In stressful situations, monitors tend to seek relevant information and attend to the situation. Blunters, on the other hand, tend to use such strategies as distraction, denial, and reinterpretation (21–23). In a study of interventions for women undergoing colposcopy, Miller and Mangan (24) found that patients displayed significantly smaller stress reactions when they received interventions consistent with their coping style. That is, blunters in a low-information condition and monitors in a high-information condition displayed lower levels of physiological arousal. Self-reports of anxiety and tension were also significantly higher for blunters in the condition inconsistent with their coping style (ie, high information). Similar results have been observed for patients under gynecological procedures (21), cardiac catheterization (25, 26), and gastrointestinal endoscopy (27). Overall, monitors seem to benefit from additional information about a stressful medical procedure, whereas blunters cope better in the same situations when they are given limited procedural information (21, 24–26).

Based on the previous success of distraction as a means of reducing distress during medical procedures, the present study was designed to assess the effect of visual distraction on vasovagal reactions in novice blood donors. Because distraction is consistent with the preferred coping style of blunters, it was predicted that visual distraction would produce a significant reduction in vasovagal reactions in blunters but not monitors. Novice donors were selected for this study because they have a significantly greater risk of experiencing vasovagal reactions (5–7, 11, 12) and are a vital part of the ongoing effort to recruit and retain lifelong blood donors.

	MATERIALS AND METHODS

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Participants
One hundred fifty-three young adult men and women were recruited from introductory psychology classes for participation in a study of first-time blood donors. Participants received course credit for their participation in the study. Participants had to be at least 18 years old and, consistent with American Red Cross blood donor requirements, weigh at least 105 pounds and be in good general health. As illustrated in Figure 1, 41 participants failed to complete the study because of failure to show on the day of donation, medical deferral (eg, due to donor sickness, low iron levels, or fever), or technical problems during blood collection (eg, inability to locate a vein). Thus, a total of 112 donors (61 men and 51 women) completed the study. Donors who completed the study were predominantly white (93.8%) and averaged 19 years of age (SD = 1.8).

View larger version (33K): [in this window] [in a new window]   Fig. 1. Process of selection of the final sample of 112 blood donors in the study.

Questionnaires
The Miller Behavioral Style Scale (22) assesses information-seeking and response to stress. Based on respondent answers to four case scenarios of stressful situations, separate monitoring and blunting scores are computed. The total score for both scales is then calculated for all participants, and participants are divided into monitors and blunters on the basis of their score in relation to the mean of the sample; monitors score above the mean, and blunters score below the mean. This scale has acceptable test-retest reliability, satisfactory internal consistency, and demonstrated predictive validity (22).

The BDRI (12, 28) assesses subjective physiological reactions associated with blood donation. Eleven reactions are rated: faintness, dizziness, weakness, facial flushing, visual disturbance, difficulty hearing, lightheadedness, rapid or pounding heartbeat, sweating, rapid or difficulty breathing, and nausea or upset stomach. Responses are given on a six-point rating scale ranging from 0 to 5, with 0 meaning "not at all" and 5 meaning "to an extreme degree." Individual ratings are summed to create a total score; hence, possible total scores range from 0 to 55. Previous findings in this laboratory indicate that the scale has high internal consistency, and total scores have been shown to correlate significantly with phlebotomist ratings of donor reactions (12, 28).

A brief demographic and personal information questionnaire was created to record characteristics that might be associated with blood donation reactions. This questionnaire requests information about age, race, weight, and height. In addition, information on familial and personal history of fainting in response to blood or injury-related stimuli is recorded.

Procedure
Participants were randomly assigned to attend one of two intervention sessions 1 to 2 weeks before blood donation. Each intervention session included 8 to 16 participants and lasted 45 to 50 minutes. All interventions began by giving participants an informed consent form tailored to their group assignment. Once the participants completed the informed consent form, they were given the demographic questionnaire and the Miller Behavioral Style Scale. After participants finished the questionnaires, the group-specific interventions began. To standardize the presentations and to reduce the potential for experimenter bias, all interventions were presented to the participants using an audiotaped script with a corresponding slide presentation. Scripts for each group were similar in length and contained similar information.

Distraction.
The presentation for the distraction group began with a brief description of vasovagal reactions to blood donation. Then the rationale for using audiovisual distraction as an intervention during blood donation was explained. Several studies using distraction as an intervention during stressful medical procedures were briefly described. Use of the Virtual I-Glasses was then explained to the participants, and each participant had an opportunity to view a 1-minute clip of the Escape video using the Virtual I-Glasses. Participants were then given an overview of the blood donation procedure. After completion of the instructional session, participants signed up for a time to donate blood.

Control.
The presentation for the control group was designed to ensure that contact time with the experimenter was similar in length to the contact time of the distraction group. Participants were given verbal instructions on the completion of an irrelevant questionnaire. Questions asked participants for detailed information about their physical activity levels both during the week and on weekends. After answering these questions, participants were given an overview of the blood donation procedure.

Blood donation.
The participants donated blood at a local American Red Cross blood drive. Given the possible influences of caffeine on donation reactions (28), participants were asked to abstain from caffeine for 4 hours before their scheduled time to donate. On arrival at the donation site, participants registered and completed preliminary forms. All participants received the standard information sheet provided by the American Red Cross. Participants in the distraction group were given a sheet reminding them how to use the Virtual I-Glasses. Participants in the control group were not given additional information. Each participant then proceeded to the health screening station, where an American Red Cross technician measured blood pressure, heart rate, and body temperature. In addition, a drop of blood was drawn from the participant’s earlobe, and the participant was asked questions about her or his health and health-related behaviors. If the participant was approved to donate, he or she proceeded to the blood donation chair. Participants in the distraction group were fitted with the Virtual I-Glasses and the video began. Participants in the control group did not receive additional instruction. In addition, care was taken to ensure that control subjects did not participate in distraction tasks, which are sometimes provided by the Red Cross (eg, watching television or listening to music over headphones), while they donated. A technician then cleaned the participant’s donation arm with iodine and inserted a catheter. Approximately 450 ml of blood was drawn in 8 to 10 minutes. If the participant felt faint during the procedure, the technician reclined the participant’s chair. Once the blood had been drawn, the participant proceeded to the donor canteen, where all donors must recover and drink at least one cup of water or other beverage. Other refreshments were also available for the donors at the canteen. While resting, all participants completed the BDRI. After completion of the questionnaire, each participant received a debriefing form and received credit for his or her participation in the experiment. The procedure for this study was reviewed and approved by the Ohio University Institutional Review Board and the American Red Cross.

	RESULTS

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Data Reduction
BDRI scores ranged from 0 to 45 with an overall mean of 7.8 (SD = 10.84). The modal response for this sample was 0. In line with results from previous donor samples (12, 28), the distribution of raw BDRI scores was positively skewed (Figure 2, top). Therefore, the raw scores were submitted to a logarithmic transformation, log₁₀(BDRI + 1), and the resulting transformed values were then used in subsequent analyses. Coping styles (monitoring vs. blunting) were determined on the basis of a mean split of donor scores on the Miller Behavioral Style Scale. Monitors were identified as individuals who scored 6 or above, whereas blunters were identified as those who scored less than 6.

View larger version (16K): [in this window] [in a new window]   Fig. 2. (Top) Distribution of BDRI scores for donors in the distraction and control conditions. (Bottom) Mean and SEM of log-transformed BDRI scores for donors with monitoring and blunting coping styles in the control and distraction conditions.

Reactivity at Donation
Subjective ratings of vasovagal reactions to blood donation were examined using a 2 x 2 x 2 ANOVA of BDRI scores (treatment group [distraction, control] by coping style [monitor, blunter] by sex [female, male]). As can be seen in Figure 2, bottom, results of this analysis revealed a significant interaction of treatment group by coping style (F(1,104) = 4.21, p < .05), but no significant main effects for treatment group (F(1,104) = 0.54), coping style (F(1,104) = 1.86), or sex (F(1,104) = 1.09). To examine the treatment group-by-coping style interaction, separate t tests were conducted to assess treatment group effects within each coping style. Results of these analyses revealed significantly lower BDRI scores in the distraction group compared with the control group for donors with a blunting coping style (t(49) = 2.29, p < .05) but no significant group differences for participants with a monitoring coping style. Similar analyses conducted within treatment groups revealed significantly lower BDRI scores for monitors than for blunters in the control condition (t(58) = 2.69, p < .01) but no significant group differences in the distraction condition.

	DISCUSSION

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Consistent with our hypothesis, individuals with a blunting coping style reported significantly lower scores on the BDRI when blood donation was paired with audiovisual distraction compared with no intervention. In contrast, self-reported vasovagal reactions did not differ significantly in the distraction vs. the control condition among donors with a monitoring coping style. These findings are in agreement with existing evidence that distraction can serve to attenuate physiological and psychological responses to a wide variety of stressful medical procedures (13–20). They are also consistent with a growing body of literature that suggests that interventions for stressful medical procedures are most effective when they conform to an individual’s preferred manner of coping under stress (21, 24–27, 29, 30). Because individuals with a blunting coping style use strategies such as distraction and denial when under stress (21, 22), in the present study blunters may have benefited from audiovisual distraction because it allowed them to avoid watching or thinking about blood donation procedures such as preparation of the donation arm, catheter insertion, and blood drawing. Individuals classified as monitors typically seek relevant information and prefer to have more control in stressful situations (21, 22). Because distraction is inconsistent with this coping style, the distraction procedure used in this study might be expected to interfere with successful coping of monitors by decreasing their ability to be vigilant to the procedures of blood donation. However, our findings do not support the notion of a significant exacerbation of vasovagal reactions among monitors assigned to the distraction intervention.

An important aspect of our findings that must be addressed is the fact that, among our control subjects, blunters had significantly higher BDRI scores than monitors. This difference may be due in part to the information provided to all participants by the American Red Cross. Because previous studies indicate that the provision of detailed information before a stressful medical procedure is helpful to monitors (21, 24–26), it is possible that the American Red Cross’ standard procedure of providing careful and thorough information before donation is effective at alleviating anxiety and minimizing vasovagal reactions in this subgroup. Alternatively, the provision of thorough information before donation may actually heighten anxiety and vasovagal reactions among blunters if they are not subsequently provided with an effective means of distraction during the donation process. Finally, the observed differences may reflect a differential risk of vasovagal reactions among monitors vs. blunters that is independent of the informed consent procedure. Because monitors and blunters are likely to engage in different types of cognitive and behavioral coping strategies, differential efficacy of these spontaneous coping strategies in a blood donation context may lead to different rates of vasovagal reactions.

One potential limitation to the study may have resulted from the study design. Although all participants received detailed information about negative reactions during blood donation from the Red Cross before donation, only the distraction group received an overview of these reactions in the session 1 to 2 weeks before donation. This explanation was given to the distraction group as a means to introduce the distraction task. This explanation was not given to the control group because it was important to keep the contact with the control group as similar to standard Red Cross procedures as possible. Because there was no main effect of treatment, it is likely that this preparation did not affect the outcome of the study. However, further studies are needed to assess the necessity of this explanation for this particular intervention and its impact on the group differences. Another limitation of the current study is that our sample was restricted to college-aged, first-time blood donors. Although first-time donors were specifically selected for this study because they are at greater risk for vasovagal reactions, being unfamiliar with the donation process may have led novice donors to pay more attention to the donation procedures than to the distraction task. Thus, the distraction task may prove to be more helpful to individuals who are already familiar with blood donation. Future studies are also needed to assess the effectiveness of distraction on a more diverse population because the audiovisual distracter that we used may have different effects on donors of a different age, socioeconomic status, etc. Whereas participants in our study were typically enthusiastic about the three-dimensional visual display and stereo sound provided by our visor, this form of distraction may not be as enticing to all donors. Simpler, more familiar forms of distraction, such as listening to music with headphones or watching a film on a video screen, may actually increase the efficacy of distraction for some donors.

In summary, the results of this study suggest that, for first-time blood donors, interventions that are consistent with an individual’s coping style may be helpful in offsetting negative physiological reactions to blood donation. Individuals who typically use a blunting coping strategy reported less negative reactions in response to blood donation when they were in the distraction condition, whereas donors who prefer to use a monitoring coping strategy did not seem to benefit from this intervention. These findings highlight the importance of tailoring interventions to the specific demands of individual blood donors. Greater attention to individual differences in donor preference may prove to be the most effective way to increase overall donor satisfaction and enhance current rates of retention among novice donors.

Received for publication February 11, 2000.

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