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action and then the person is subsequently influenced by the first few experiences. In the opponent process theory, the stronger the negative feelings before the action, the stronger are the positive feelings after successfully completing the action. Thus, despite initial fears or negative feelings, a good experience with donation could lead to a strongly positive attitude about continued donation. This theory attempts to account for the continuation of activities that were initially associated with negative feelings. The attribution theory postulates that if an individual believes that there is an external reason for the action, the action is attributed to that external force. In the identity theory, the sense of self is developed from the variety of social roles in which the individual engages. In the theory of reasoned action, the critical factor leading to an act is the development of an intention to carry out the act.

      Integrated model

Piliavin and Callero [4] believe that all five of the theories outlined earlier have some relevance to blood donation. The identity theory is thought to be “overarching,” and that the “sense of self as donor is clearly the central factor among the personal determinants of donation” [4]. Becker’s model applies to making the commitment to donate, the opponent process and attribution theories relate to the development of a sense of the individual as a blood donor, and the theory of reasoned action is involved in translating the person’s idea of himself or herself as a blood donor into action to donate. In integrating these theories, Piliavin and Callero [4] believe that the decision to donate is based on “childhood experience factors” negatively influenced by “pain and inconvenience” and positively influenced by “social pressures.”

      Experienced donors increasingly internalize the expectations and the role of being a blood donor. Donor identity correlates with the donation intention. Self‐determination theory indicates that people persist with behaviors that are internally versus externally motivated. This theory of self‐determination has been at the basis of thinking about blood donor recruitment [22].

      Theory of planned behavior

      This model is based on attitude, subjective norm, and perceived behavioral control [23]. These influence the intention to carry out behaviors. Although this model has a different name than those of Piliavin and Callero [4], theory of planned behavior really involves attitudes about the behavior, social pressure about the behavior, and control over performing the behavior. Thus, it is not surprising that several studies (reviewed by Masser et al. [23]) indicate that theory of planned behavior predicts a substantial portion of blood donation intention and behavior [24].

      Giving and not giving

      The reasons for donating are summarized generally [4] as: (a) extrinsic rewards and incentives, (b) intrinsic rewards and incentives, (c) perceived community needs, (d) perceived community support, (e) social pressure, and (f) addiction to donation. The reasons for not donating include: (a) medical ineligibility, (b) fear, (c) reactions and deferral (poor experiences), and (d) inconvenience and time requirements. Oswalt [6], in reviewing 60 English‐language reports regarding motivation for blood donation, concluded that the following factors were motivations to donate: (a) altruism and humanitarianism, (b) personal or family credit, (c) social pressure, (d) replacement, and (e) reward. Reasons for not donating included: (a) fear, (b) medical excuses, (c) reactions, (d) apathy, and (e) inconvenience. Rados [24] also found that fear, inconvenience, and never being asked were the most common reasons given for not donating. In general, the issues described earlier have seemed to appear rather consistently in these and other studies [25] of donor motivation or nondonation. Because they have been consistent over time, most recruitment strategies attempt to take these factors into consideration. Most blood donors have a rationale way of thinking about blood donation, but some think and make decisions about blood donation based on emotional, personal, or stereotype manner in continuing to donate blood, and the convenience of donation is a stronger factor than helping others [26]. In general, donors give blood out of altruism and in response to a general appeal or a specific request.

3.3 The donation experience and factors that influence continued donation

About 28% of blood is collected from first‐time donors, about half of whom return within the first year [27]. Those who return tend to be white, US born, and college educated [28]. Experience with the first donation has a major effect on their willingness to return for subsequent donations [4, 14, 16]. Although the first blood donation is anxiety producing, it is usually accompanied by good interactions with the donor staff and good feelings about the donation and oneself [28]. Thus, most donors realize that they are reasonably able to give and plan to do so again. With continued donation, the experience becomes easier and the reasons for continuing to donate become more “internal” [3]. Ferguson et al. [29] propose that the “warm glow” associated with donating supports a general benevolence hypothesis.

      About 70–80% of donors are repeat donors, although this percentage is decreasing [16, 30]. Repeat donors tend to be 16 and 17 years or older than 50 years, male, Rh negative, type O, without a reaction during donation, and have a college degree [16, 31]. A shorter interval between the first two donations also predicts more continued donations [28]. Over time a “blood donor role” develops in repeat donors, and this strengthens self‐commitment to blood donation, including “friendships contingent on donating, a self‐description as a regular donor, an increase in the ranking of the blood donor role, greater expectations from others, and even more donations” [4].

      Donors who are deferred are less likely to return to donate after the reason for the temporary deferral has passed [4, 16]. This is not surprising because deferral breaks the good feelings that might have developed about donation and makes future donation more difficult. Experiencing a reaction also reduces the likelihood of a donor returning [4, 14, 15]. This is because the donor begins to see himself or herself as someone who has trouble donating, and the reaction experience modifies any previous positive feelings about donation. Surprisingly, most multigallon donors report that they do not receive recognition for their donation, and the knowledge that a friend or relative was a blood donor did not make them more likely to donate [9]. These observations are consistent with the general view that the initial donation is motivated primarily by external factors and continued donation primarily by internal factors [32].

      A disconnect exists between blood supply shortages and demographic reports that there are actually more eligible blood donors in the United States [33]. Simply put, it should be easier to meet the blood unit demands of the US medical system. However, experiences have shown that 12 million units in 2017 were donated by 9 million donors, representing 4.8% of the of the population eligible to donate. For many reasons, from demographics to logistics, many potential donors do not present to donate [33].

      Donors are also more time conscious and desire a shorter (or more efficient) donor experience. Long wait times and screening may deter some from many blood drives. Blood collectors are looking at more self‐directed donor screening and additional software changes to decrease donor wait times.

      Perhaps the most contentious area affecting continued donation may be iron depletion of blood donors. This is a widely debated area, with some medical directors arguing for more stringent monitoring of donor iron loss and others suggesting that we maintain the status quo. A review by Zalpuri et al. [34] addresses existing literature from 12 studies, regarding whole blood donors and health consequences from iron deficiency. The authors did note a high prevalence of iron deficiency among whole blood donors. The studies were much more conflicting as to what symptoms or conclusions could be drawn.

      One confounding factor was that there is a lack of universally representative iron parameters for iron deficiency. Another confounding issue is that replenishment of hemoglobin and ferritin levels across the population of whole blood donors is widely varied, making comparisons between studies difficult. Ultimately, the effect of blood donation and subsequent iron deficiency (or transient deficiency) on overall quality of life could not be found [34].

      Social influences on blood donation and social media

Because

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