The Mediating Role of Emotional Arousal and Donation Anxiety on Blood Donation Intentions: Expanding on the Theory of Planned Behavior

Abstract

Blood donation is essential in health-care systems worldwide, dealing with the demand for transfusions, and for the treatment of a variety of medical conditions. A major obstacle is raising the rate of blood donations by recruiting and retaining donors in an efficient manner. This paper presents a comprehensive analysis of blood donation, utilizing an enhanced framework based on the theory of planned behavior with an emphasis on emotional arousal (positive and negative), attitudes towards advertisements, and blood donation anxiety, revealing critical psychological and communicative determinants of blood donation intention. To achieve this, a quantitative non-experimental correlational technique was employed to collect data from 414 individuals using an online questionnaire circulated across Greek society. The data were analyzed using structural equation modelling, with a focus on the direct impacts on donation intentions and the role of emotional arousal as a mediator. The findings indicate that attitudes and anxiety have strong direct impacts on the behavioral intention to donate, underlining the important barriers generated by donation anxieties as well as the efficacy of positive attitudes and successful advertising. Furthermore, the study demonstrates emotional arousal as a partial mediator, implying that both cognitive assessments and emotional responses play a role in influencing donation intentions. This study takes on a new approach to give emphasis and provide evidence of the mediating effect of emotional arousal on donation intention, utilizing structural equation modeling. Despite the critical role of marketing as a primary source of blood donors, the implementation of emotional marketing techniques has been one aspect less addressed throughout marketing professionals and communication efforts. Our results demonstrate the significance of emotional arousal on blood donation intentions, thus suggesting a more emotionally resonant approach of attracting potential donors.

1. Introduction

According to the most recent empirical data, the worldwide demand for blood is steadily increasing, indicating an urgent need to reinforce and scientifically improve the processes for recruiting and retaining blood donors [1,2,3]. In the social sciences, research has generally concentrated on connecting with and recruiting new blood donors, whereas research efforts in the behavioral sciences have primarily focused on preserving the current blood donor base [4,5]. Despite their complementary nature, these two scientific methodologies have been used independently up to this point. However, the theoretical urge for thorough unification and synergy between these two paths grows stronger, with the goal of creating and implementing more effective blood donation methods [4,6,7].

The primary emphasis of behavioral sciences research has been to examine the implications that negative experiences during blood donation could have on future blood donations [2,3]. Furthermore, it studies how various behavioral intervention strategies could potentially be utilized to retain existing blood donors. Understanding the motives that underlie voluntary blood donation is critical for improving the success of donor recruiting and retention initiatives, according to a study conducted by Glynn et al. [8]. Much of the relevant literature has demonstrated that altruism and prosocial dispositions are the primary motivators for blood donation [7,8,9]. Aside from altruism, other important contributing factors in the blood donation process include the awareness of the urgent need for blood, the influence of social factors, the desire to provide for relatives or friends, and the boost to personal self-esteem accompanied by social recognition. Researchers researched and recorded these driving elements in academic studies [10,11,12,13].

Extrinsic motivational factors, such as influence from social relationships with friends or family, as well as incentive through monetary rewards and gifts, have, instead, been identified as significant motivators for initial participation in blood donation, according to research [14,15,16]. These external motivations eventually decrease in importance as volunteer blood donors solidify their blood donor identity and form a more stable and inwardly driven role. This process becomes visible after the third or fourth repeated blood donation, as evidenced by the research of [2,6,8].

The formation of particular behavioral characteristics and outcomes is a multifaceted phenomenon involving the intricate interaction of cognitive processes, learning mechanisms, prevalent attitudes, and a variety of motivating elements. To gain an exhaustive and detailed understanding of the behavior of volunteer blood donors, researchers have explored a wide range of factors. The theory of planned behavior (TPB) constitutes a reliable and robust framework of behavior that culminates in a definitive outcome. It was developed by Ajzen and Madden [17], Ajzen [18] as an extension of the theory of reasoned action [19,20], with the objective of overcoming the original model’s limits in processing behaviors where volition is insufficient for full control. The TPB has achieved recognition as an exceedingly valuable tool for defining, quantifying, and experimentally analyzing the aspects that impact both the behavioral and prospective dimensions. It is based on the premise that the intention to adopt a behavior is the primary path to its fulfilment, with the assumption that the stronger the intended motivation in question, the higher the prospects for the successful execution of the desired behavior. According to TPB, the primary factor preceding and mediating behavior intentions is the drive to engage in it (actual behavior), which is predicted by three major variables: (a) individual attitude towards the specific behavior (attitude), (b) internalized subjective social norms (subjective norms), and (c) perceived controllability of behavior (perceived behavioral control) [18,19,21].

One particular aspect that could interfere with the logical decision-making process and TPB does not include, is that of emotional reactions and blood donation anxiety [21,22,23]. In behavioral contexts such as blood donation, where there is substantial variation between extensive cognitive assessments and emotional responses, the decision to donate blood could involve a number of deeply emotionally charged beliefs and implications that are not covered by the aforementioned theory. Such emotional reactions, especially in situations where the consequences of a behavior could have counterproductive and life-changing consequences, emotions can act as critical influencing factors in sha** individual attitudes and intentions [20,24,25].

The objective of this study is to implement a theoretical framework based on TPB to identify the psychosocial aspects that influence an individual’s intentions to donate blood. For this purpose, we designed ads that encourage and invite citizens to donate blood. Each advertisement comprises a core picture element intended to provoke an identifiable emotional response, as well as a textual narrative that highlights a reason for participating in blood donation. We aimed to investigate the mediating role of emotional arousal from the ads on future behavioral intention to donate blood and its influence on the participants’ motives, acknowledging the significance of advertising messages in volunteering behavior in the context of blood donation. Additionally, we expand our theoretical model beyond the standard TPB constructs with the inclusion of blood donation anxiety, attitude towards advertisements, and emotional arousal (positive/negative) to provide a comprehensive overview of both attitudinal and behavioral influences that could potentially affect blood donation behavior.

Health professionals have always been at the forefront of recruitment strategies that meet the urgent need for blood and organ donors. Nevertheless, this tactic often neglects the possibility of emotional arousal in marketing implementations, which is normally the preserve of marketers. Utilizing structural equation modeling as a source of understanding donor behavior, this study aims to bridge this gap and shed light on this issue, by investigating the mediating role imposed by emotional arousal and blood donation anxiety on intentions to donate. Thus, our research contributes to a reorientation in recruitment campaigns that are more compassionate, empathetic, and centered on donors by examining emotional behavior and knowledge among potential donors.

The article is structured as follows: Section 2 provides the relevant literature review on the current topics and determinants that influence blood donation behavior. In addition, we place particular emphasis on the factors of donation anxiety, attitude towards advertisements, and the impact of the theory of planned behavior in the context of blood donation. Moreover, we place particular emphasis on the role of emotional arousal with regard to future intentions to donate blood. In Section 3, we provide a detailed description of the model we constructed and evaluated in our research, followed by the analysis and presentation of our findings in Section 4. Section 5 discusses and interprets the results of our study and identifies related limitations. Finally, we conclude and provide suggestions for future research.

2. Literature Review

2.1. Determinants of Blood Donation Intentions

Smith’s altruistic approach recognizes humanitarianism as an essential incentive for voluntary blood donation. However, Rapport and Maggs [26] pointed out that altruism is not the sole justification for performing unpaid blood donations. He underlined the difficulties of describing any type of blood donor as absolutely selfless and entirely spontaneously altruistic. The need for a deeper sense of responsibility, gratitude, and self-interest, as well as a more conscious awareness about the significance and intended use of given blood, were emphasized. In the context of the research on the subject of voluntary blood donation, empirical studies indicate that the relevant behavior can be influenced by both altruistic and egocentric motivations [27,28,29]. Additionally, as human interactions and collaboration have been associated with the activation of reward mechanisms [2], blood donation appears to be influenced in part by the expectation of personal satisfaction combined with the desire to provide and assist others [2,4,5]. Parash, Suki, Shimmi, Hossain and Murthy [24] investigate the behavioral intention of students in Malaysia to voluntarily donate blood, utilizing the theory of planned behavior (TPB) as a guiding framework. The results indicate that knowledge plays a crucial role in influencing students’ intention to make voluntary blood donations. Specifically, a strong correlation was found between students’ knowledge about the impact of blood donation on saving lives and their inclination to donate blood. Another approach is that of Allah Pitchay et al. [30], who investigate the factors influencing individuals’ intentions to participate in donation crowdfunding, utilizing the self-determination theory. Specifically, a sense of self-worth, perceived donor effectiveness, and moral obligation were identified as significant drivers of DI. Also, there is an effort in the academic community to provide recommendations for social marketing designers to enhance the retention of blood donors. Van Steenburg and Spears [31] investigate how individuals respond to donation messages in broadcast advertising, considering both preexisting attitudes and beliefs related to donating and message processing.

By understanding the interplay between motivational factors and established behavioral theories, the study of M’Sallem [25] offers insights that can guide strategies to address the issue of unsustainable blood donations and contribute to more effective blood donation campaigns. The significance of the quality of the donation process in sha** donor satisfaction and strengthening both donor trust and loyalty is discussed by Alzola-Melian et al., 2020.

Chell and Mortimer [32] links the dimensions of donor value (altruistic, emotional, and social) and conspicuous donation behavior. The findings contribute valuable insights into the usage of conspicuous donation tokens of recognition on social media and enhance our understanding of the under-researched areas of donor value and conspicuous donation behavior. Williams et al. [33] aimed to test a model that integrates self-determination theory (SDT) and the theory of planned behavior (TPB) to predict the intention to donate blood. This research demonstrates that integrating SDT and TPB is a useful approach in blood donor research, providing evidence of plausible pathways through which motivational orientations impact the intention to donate blood. In another attempt, Torrent-Sellens et al. [34] identified three main prediction paths. The first two originate from feelings of trust in the digital community and a positive mood associated with a modern lifestyle. These paths are linked to attitudes and behavioral control, contributing to the explanation of both the intention to donate and the actual act of blood donation. The third path originates from modern lifestyles and is connected to the subjective norm, predicting both intention and actual donation.

Griffin, Grace and O’Cass [16] aim to enhance the understanding of donors and non-donors by exploring factors such as social responsibility, susceptibility to interpersonal influence, involvement in and attitude towards blood donation, and aroused feelings. In a similar matter, Bartsch and Kloß [35] investigate the impact of personalized charity advertising on promoting empathy, attitude change, and intentions to help stigmatized social groups. The study highlights the dual nature of personalized charity advertising: while it enhances involvement, empathy, and prosocial outcomes, it also triggers reactance. Pentecost et al. [36] suggest that emphasizing positive emotional feelings and the sense of control in the act of donating blood may be a more effective strategy than using external regulation, which implies a sense of obligation and may limit blood donation numbers. Another suggestion are the charity gift cards (CGCs), allowing recipients to allocate their gift across various charitable projects, that Mulder and Joireman [37] propose in their paper. Another significant finding is that from the survey of Chen et al. [38], which indicates that the negative association between blood donation anxiety and intention is mediated by moral disengagement. Furthermore, mindfulness was identified as a buffering factor, playing a role in mitigating the relationship between blood donation anxiety and moral disengagement, as well as the indirect relationship between blood donation anxiety and intention through moral disengagement.

2.2. Theory of Planed Behavior and Blood Donation

Numerous theoretical models have been developed to provide practical guidance and solutions to better understand and address the issue and lack of enough blood supplies. Among these, the theory of planned behavior, as described by Hardeman et al. [39], appears to be a potential approach for addressing this issue. This theory has been widely applied in empirical research to predict a variety of health-related behaviors. Particular emphasis has been placed on adopting healthy habits, performing preventative medical exams, and adhering to treatment plans [23,24,33,40,41,42,43]. Finally, it has been demonstrated that the theory helps to the prevention of cancer and the promotion of voluntary blood donation [24,25,42,44].

In our study, we primarily employ the theory of planned behavior (TPB) as the foundation to better understand the factors that influence blood donation intentions. Based on TPB, we further expand our conceptual framework by introducing elements of the attitude towards advertisements (AAD), blood donation anxiety (BDA), and further extended by studying the impact of emotional arousal. This broadened methodology provides an enhanced comprehension of the processes that govern the decision of providing blood willingly. This research process and strategy enable us to investigate a wider range of factors that influence and affect blood donation intentions. Personal views have an important role in determining individual attitudes towards various types of behavior in the field of behavioral science, with impacts ranging from positive to negative [4,17,21,45]. These attitudes are developed by attentively experiencing the predicted outcomes of engaging in a given behavior, as well as the evaluations that follow from those results. Thus, people’s behaviors could vary depending on the dominant attitudes they have developed.

However, the existing academic literature reveals a relative lack of empirical studies investigating the relationship between elements of TPB and various dimensions of anxiety in the field of voluntary blood donation, such as the degree and frequency of anxiety levels, panic episodes, and the effect of anxiety on the final decision to donate blood [20,21,24,25,39]. Thus, applying and expanding this theory with different behavioral and attitudinal constructs can be an essential procedural tool for decision-makers in the field of strategy and health policy development. In current research incorporating TPB into blood donation, pooled samples of individuals, including active and non-donors, are utilized with the aim of analyzing blood donation decision-making depending on the donors’ blood donation phase. This approach focuses on the development of the “temporal trajectories” of donors, examining how novice donors become regulars [2,3,4]. Ferguson [15] points out the existing inconsistency regarding the classification and definition of blood donors at different stages of their journey, while recognizing the importance of how the theoretical approach should adjust for newcomers and experienced blood donors. According to Masser et al. [46], the integration of various constructs into the research process includes the analysis of moral norm, anticipated regret, past behavior or habit, self-identity, and emotional reactions in order to explore the transition from casual to regular blood donors and their influence in the decision-making process.

2.3. Emotional Appeals and Anxiety in the Context of Blood Donation

A common and significant critique levelled against TPB is the apparent absence of emotional components from the process of understanding and forecasting behavior [19,21,23,24,25,47]. Proponents of the theory argue that while emotive attributes could not be expressed explicitly, they are implicitly assimilated through subjective norms and perceived behavioral control. At the same time, as Ajzen and Fishbein [19], Ajzen [22] point out, the addition of the aspect of emotional implications from executing a behavior does not appear to have a significant effect on the predictability associated with that behavior. However, it has been shown that people in a positive affective state perceive positive events (such as the consequences of a given behavior) as those that they are more likely to adopt, and vice versa, which suggests a strong influence in sha** both the intention and eventual adoption of a behavior [40,41,45,48]. Telle and Pfister [49] focus on the relationship between empathy, particularly for positive emotions, and prosocial behavior. While existing research has extensively studied empathy in conjunction with negative emotions, there is a gap in understanding the connection between positive empathy and demonstrated prosocial behavior. The article proposes that individuals’ motivation to maintain a positive emotional state serves as a key mechanism linking positive empathy to prosocial behavior. One very important view on the subject of donation and charity is the recent one of Bae [50]. Their study examines the impact of message order on recipients’ responses to charity advertisements using the expectancy-contrast and negative-state relief models. The results show that a negative–positive message order evokes positive emotion, while a positive–negative order generates negative emotions. Both positive and negative emotions induced by charity advertisements affect hel** intention through positive and negative empathy. This study enhances the current understanding of the roles of emotion and empathy in charity intention formation. On the same topic, Homer [51] examined the effectiveness of emotional appeals, proposing a sympathy and inspiration-hel** hypothesis. The results suggest that combining hope and sadness in appeals generates both sympathy and inspiration, leading to increased donations for human-suffering causes. Additionally, improving emotion appeals that shift from sad to hopeful is found to result in higher donations compared to declining emotion appeals that shift from hopeful to sad. Similarly, Bennett [52] showed that mixed emotions play a significant role in sha** both the attitude towards the advertisement and participants’ intentions of future donations. Nabi [53] examines the persuasive influence of emotions in health messages, emphasizing a shift from focusing on individual emotions to exploring the flow or evolution of emotional experiences during exposure to a message. Morelli et al. [54] address the three limitations of empathy, affective congruence, perspective-taking, and prosocial motivation, by assessing empathic responses to individuals experiencing various emotions with variations in valence and social context. Functional magnetic resonance imaging reveals that empathy for positive and negative emotions selectively activates regions associated with the corresponding affective states.

Another subject in the context of blood donation is how anxiety acts as a disincentive and influences donors’ behavioral intentions. Overall, in many cases, anxiety plays a key role in the psychological situation of the patient [55,56]. The study of Chen, Zhou, Zhang and ** approach was employed to examine path coefficients and their statistical significance, following the guidelines outlined by Sarstedt, Ringle and Hair [79]. This study also included the mediation analysis methodologies proposed by Preacher and Hayes [83], and, in accordance with Streukens and Leroi-Werelds [84], applied a bootstrap sample size of 10,000.

Table 6. Hypothesis testing.

Hypothesis	Path	Coefficient (β)	SD	t-Value	p-Value	Results
H1	ATT -> BI	0.084	0.039	2.173	0.030	Supported
H2	BDA -> BI	0.261	0.053	4.959	0.000	Partially Supported
H3a	BDA -> DESNEG	0.287	0.061	4.705	0.000	Supported
H3b	BDA -> DESPOS	0.234	0.051	4.586	0.000	Supported
H4a	DESPOS -> BI	0.226	0.047	4.766	0.000	Supported
H4b	DESNEG -> BI	0.303	0.046	6.515	0.000	Partially Supported
H5a	AAD -> DESNEG	0.227	0.056	4.060	0.000	Supported
H5b	AAD -> DESPOS	0.413	0.050	8.308	0.000	Supported

presents the empirical data from these investigations.

The results indicated a significant impact of attitudes (ATT) on behavioral intention to donate (BI) (β = 0.084, t = 2.173, p < 0.05), thereby supporting H1. Furthermore, blood donation anxiety (BDA) was found to influence behavioral intention to donate (BI) significantly and positively (β = 0.261, t = 4.959, p < 0.001), which partially supports H2. The analysis also revealed that BDA has a significant effect on DESNegative (DESNeg) (β = 0.287, t = 4.705, p < 0.001), supporting H3a, and a significant effect on DESPositive (DESPos) (β = 0.234, t = 4.586, p < 0.001), supporting H3b. Additionally, the DESNegative (DESNeg) was shown to significantly and positively affect behavioral intention to donate (BI) (β = 0.303, t = 6.515, p < 0.001), partially confirming H4b, while DESPositive (DESPos) also significantly influenced behavioral intention to donate (BI) (β = 0.226, t = 4.766, p < 0.001), hence H4a was supported. Attitudes towards the advertisement (AAD) had a significant impact on DESNegative (DESNeg) (β = 0.227, t = 4.060, p < 0.001), supporting H5a. Moreover, AAD was significantly related to DESPositive (DESPos) (β = 0.413, t = 8.308, p < 0.001), which supports H5b. The empirical evidence from these tests is consolidated in

Table 5. Fornell and Larcker criterion.

	AAD	ATT	BDA	BI	DESNEG	DESPOS
AAD	0.801
ATT	0.084	0.911
BDA	0.587	0.062	0.882
BI	0.590	0.141	0.501	0.846
DESNEG	0.395	0.112	0.420	0.496	0.903
DESPOS	0.550	0.032	0.476	0.452	0.329	0.738

.

Mediation Analysis

Mediation analysis was conducted to assess the mediating effects of emotional responses on the relationships between attitudes and behavioral intentions. The results revealed that the direct effect of blood donation anxiety (BDA) on behavioral intention to donate (BI) was significant (β = 0.261, t = 4.959, p < 0.001). Similarly, the direct effect of attitudes towards the advertisement (ADD) on behavioral intention to donate (BI) was significant (β = 0.344, t = 7.163, p < 0.001). The total effect of attitudes towards the advertisement (AAD) on behavioral intention to donate (BI) was significant (β = 0.162, t = 5.234, p < 0.001), and the total effect of blood donation anxiety (BDA) on behavioral intention to donate (BI) was also significant (β = 0.401, t = 8.878, p < 0.001). Regarding specific indirect effects, the indirect effect of AAD on BI through DESPositive (DESPos) was significant (β = 0.093, t = 3.630, p < 0.001), supporting H6a. The indirect effect of AAD on BI through DESNegative (DESNeg) was also significant (β = 0.069, t = 3.094, p = 0.002), partially supporting H6b, as we hypothesized a negative relationship. Additionally, the indirect effect of BDA on BI through DESPositive (DESPos) was significant (β = 0.053, t = 3.496, p < 0.001), supporting H7a, and the indirect effect of BDA on BI through DESNegative (DESNeg) was also significant (β = 0.087, t = 4.093, p < 0.001), thus H7b was partially supported. These findings indicate the presence of significant mediating effects of emotional responses in the relationship between attitudes, anxiety, and the intention to donate blood.

The mediation analysis revealed partial mediation in the relationships examined. Although the direct effects of blood donation anxiety (BDA) on behavioral intention to donate (BI) (β = 0.261, t = 4.959, p < 0.001) and attitudes towards the advertisement (ADD) on BI (β = 0.344, t = 7.163, p < 0.001) were significant, the presence of significant indirect effects through both DESPositive (DESPos) and DESNegative (DESNeg) demonstrates the mediating role of these emotional responses. Specifically, the indirect effects of AAD on BI through DESPos (β = 0.093, t = 3.630, p < 0.001) and DESNeg (β = 0.069, t = 3.094, p = 0.002), as well as the indirect effects of BDA on BI through DESPos (β = 0.053, t = 3.496, p < 0.001) and DESNeg (β = 0.087, t = 4.093, p < 0.001), were found to be statistically significant, confirming the partial mediating effect. Therefore, while the emotional responses mediated the relationship between the independent variables and the intention to donate blood, they did not fully account for the observed effects, indicating that other factors directly influenced the behavioral intention too. The detailed results are displayed in

Table 7. Mediation analysis.

Hypotheses	Direct Effects	Coefficient (β)	t-Value	p-Value	Results
	BDA -> BI	0.261	4.959	0.000
	ADD -> BI	0.344	7.163	0.000
	Total Effects	Coefficient (β)	t-value	p-value
	AAD -> BI	0.162	5.234	0.000
	BDA -> BI	0.401	8.878	0.000
	Specific Indirect Effects	Coefficient (β)	t-value	p-value
H6a	AAD -> DESPOS -> BI	0.093	3.630	0.000	Supported
H6b	AAD -> DESNEG -> BI	0.069	3.094	0.002	Partially Supported
H7a	BDA -> DESPOS -> BI	0.053	3.496	0.000	Supported
H7b	BDA -> DESNEG -> BI	0.087	4.093	0.000	Partially Supported

.

5. Discussion

In our study we employed a quantitative non-experimental correlation design and a SEM analysis approach to investigate the varying factors that impact blood donation intentions. Considering both behavioral and attitudinal influences, we included in our research the key elements of behavioral intentions, blood donation anxiety, attitudes, emotional arousal, and attitudes towards advertisements supporting blood donation campaigns. Our investigation revealed intriguing relationships between the variables in question.

The analysis of direct effects within the study highlights critical insights into the factors influencing the intention to donate blood. The significant direct effect of blood donation anxiety (BDA) on behavioral intention to donate (BI) highlights the influence of personal anxiety in the decision to donate blood, supporting hypothesis H2. Attitudes towards the advertisement (ADD) also have a direct and significant impact on BI, confirming H5b and underscoring the effectiveness of advertisement content in influencing donation intentions. The confirmed significant relationship between general attitudes (ATT) and BI, as indicated by H1, suggests that intrinsic beliefs and perceptions about blood donation are closely linked with the actual decision to engage in donation behavior. These direct relationships emphasize the need for strategies that mitigate donation-related anxieties and leverage the persuasive impact of advertisements to boost blood donation rates. Findings concerning the direct effects of blood donation-related stress (BDA) on negative (DESNeg) and positive (DESPos) emotional arousal, as captured in hypotheses H3a and H3b, demonstrate the privileged position of stress as an important affective influencer in blood donation. Subsequently, the analysis revealed that both emotional states, negative (DESNeg) and positive (DESPos), play a critical role in behavioral intentions, as supported by hypotheses H4a and H4b, highlighting the influence of emotional states on the sha** of behavior. Additionally, the direct correlation of a positive attitude toward advertising (ADD) with a positive emotional state (DESPos), as stated in hypothesis H5a, suggests the decisive contribution of positive emotional stimuli resulting from advertising efforts. Overall, the study findings draw attention to the need for targeted interventions that address stress and enhance positive emotional experiences, with the goal of improving voluntary participation in blood donation. Placing particular emphasis on the effect of emotional arousal and attitudes toward advertising on behavioral intentions, the need for more sophisticated communication strategies aimed at combating negative emotions and promoting positive emotional motivation becomes apparent. In particular, positive emotional activation plays a central role as a catalyst, encouraging willingness to donate blood, minimizing the adverse effects of stress, and exploiting the positive effects of promotional efforts. Correspondingly, negative affective activation points to the risk that adverse affective reactions can divert the intention to donate, despite the existence of favorable attitudes or persuasive advertising content. The dual nature of emotional mediation reveals the complexity in the decision-making process regarding blood donation, pointing out the necessity of effective management of emotional responses to enhance efforts to attract and retain blood donors.

Thus, we further explored the potential impact of emotional arousal as a mediating factor. The mediation analysis revealed that emotional arousal, specifically positive (DESPos) and negative (DESNeg), is identified as a mediating factor in the effect of attitudes toward advertisements (ADD) on behavioral donation intention (BI), validating hypotheses H6a and H6b. This partial mediation through affective reactions indicates that although emotions evoked by advertisements have a role in determining donation intentions, they are not the only factor sha** the overall influence of individuals’ attitudes toward the due to advertisements. Additionally, the indirect effect of blood donation stress (BDA) on BI through emotional reactions, as evidenced by hypotheses H7a and H7b, demonstrates the multidimensional contribution of stress, both directly and indirectly, through the activation of emotional reactions that affect the decision-making process of donating blood. The observed partial mediation points to the need for the implementation of holistic promotional strategies, which will consider both emotional and rational factors that shape individuals’ intentions towards voluntary blood donation. This approach enhances the understanding of the complex nature of the decision-making process to donate blood and highlights the importance of providing multidimensional information and awareness campaigns in the context of blood donation. Furthermore, incorporating the findings into action planning can optimize the effectiveness of blood donation promotion initiatives, increasing the attraction of new donors and enhancing repeat donation from existing ones.

To conclude, our research provides an in-depth analysis of blood donation intentions whilst aligning with and extending the current literature. By including emotional arousal, both positive and negative, within the framework of the theory of planned behavior (TPB), this study notably contributes to an improved understanding of the effect of emotional aspects on blood donor intentions. This addition provides a more thorough model of analysis that represents the donor’s broader behavioral dynamics, bridging a theoretical gap in the current literature that previously disregarded the emotional side [20,21,23,25]. Additional insights into how anxiety acts as a preventing factor to blood donation are revealed by this study’s singular analysis of anxiety related to blood donation, which examines both the direct and mediating impacts of anxiety on behavioral intentions [38,62,85]. This approach enhances TPB by emphasizing the importance of emotional states and broadening the set of criteria used for predicting and interpreting blood donation behavior. Furthermore, by empirically validating the influence of advertising on blood donation intentions, the study indicates the essential nature of focused communication strategies in the further development of the TPB model. The findings indicate the power of persuasive messages to change behavioral intentions, which contributes substantially to the larger discussion concerning the effectiveness of health communication efforts [50,86,87]. This study’s findings emphasize the crucial relevance of improving donor attitudes, attitudes, and self-efficacy, as well as shedding light on the effects of blood donation anxiety and emotional arousal. The necessity to employ more advanced and sophisticated methods and instruments for analyzing the behavior of blood donors is essential for obtaining an in-depth understanding of their psychology. Intervention strategies should be tailored to the different categories of blood donors, such as newcomers, occasional donors, and regular donors, with a focus on enhancing emotional incentive, such as promoting social interest and charitable giving, promoting cognitive empowerment through information about blood donation procedures, and negating false assumptions and fears associated with it [44,46,62,88].

Overall, our findings highlight the significance of addressing psychological factors such as blood donation anxiety and fostering positive attitudes towards both blood donation itself and related promotional materials. By targeting these variables, healthcare organizations and blood donation agencies can develop more impactful strategies to encourage and sustain blood donation behavior among the population.

6. Conclusions

Blood donation and strategies for donor recruitment represent critical concerns within a nation’s healthcare infrastructure. This study has unveiled the multidisciplinary nature of this issue, with insights from fields including psychology and marketing. The involvement of these disciplines underscores the profound trust donors and potential donors place in the blood donation process. The intersection of marketing with blood donation initiatives reveals insights into effective communication strategies and branding techniques. Through targeted messaging and branding efforts, organizations can enhance the public perception of blood donation, making it a more appealing and accessible option for potential donors. Moreover, it highlights their perception of donation as the pinnacle of altruism and societal contribution, devoid of any apprehension or anxiety. By harnessing the collective expertise of these fields, policymakers and healthcare professionals can develop more comprehensive and impactful strategies to address the ongoing need for blood donations in society.

In terms of broad ramifications and practical implications, this study sets the groundwork for policy development and program design to improve blood donation efficiency. Our findings about the direct and mediating functions of emotional activation provide important scientific perspectives for designing tactics that seek to increase donation activity. Establishing the effect of positive and negative emotional activations can lead to the development of more specialized advertising initiatives, aimed at attracting new donors and strengthening the commitment of existing ones. Furthermore, the emergence of anxiety about blood donation as a primary barrier to voluntary participation highlights the imperative to implement interventions focused on reducing donor anxiety. Building an environment that provides support to donors, as well as implementing communication strategies that dispel the most common misunderstandings and concerns associated with blood donation, can significantly increase the willingness to donate. Moreover, deepening the understanding of donation behavior allows for the development of cohesive strategies to overcome psychological, emotional, and informational barriers to voluntary contribution. In addition, combining elements of psychology and communication methods in the context of health behavior creates opportunities for interdisciplinary research. It encourages additional research into how various behavioral theories and communication frameworks could be utilized to understand and influence health-related behaviors. As a result, this study significantly contributes to the scientific discussion on blood donation by providing a reinforced theoretical framework and practical insights that could potentially be used to enhance donation performance and public health prospects. Finally, confirming the influence of advertising attitudes on blood donation intentions provides the foundation for the development of evidence-based marketing approaches within the field of blood donation. Organizations can take advantage of this information to create communications that resonate with the values and emotions of potential donors, thereby improving the effectiveness of their advertising campaigns.

This research is not without limitations. The findings of this research, which are based on the Greek context, may not be universally applicable due to differences in cultural and socioeconomic dynamics between regions. Future attempts could delve deeper into the effects of moderating factors and control variables of age, gender, and past blood donation experiences and their impact on the observed outcomes. Though offering valuable insights into strategies for improving blood donation intentions, our findings may be limited in terms of their generalizability by the high level of education attained by the sample. The educational distribution of adult Greeks might not be fully represented since less than 40% of our sample were undergraduate students while a significant proportion had Master’s and doctoral degrees. This tendency toward higher education levels might be due to the recruitment channels used like academic, professional networks, and social media platforms. As there can exist differences in donation behavior among various educational backgrounds, further investigations are needed on how well these strategies work within a more diversified demographic profile. To ensure that representativeness can be improved upon, future investigations could seek a broader stratification of participants. One of the shortcomings of TPB is that it relies exclusively on individual reports to anticipate behavioral patterns. According to Armitage and Conner [21,47], these responses may contain stereotyped biases or fail to accurately convey people’s true intentions or perspectives. When implementing TPB, the primary focus is on conscious aspects of behavioral dispositions rather than cognitive processes, which can have a greater effect on behavior but be limited in their measurement and evaluation. Time is highlighted as an essential aspect which could confound the relationship between intentions and actual behavior. Future research could focus on examining the changes over time in individuals’ intentions and perceived control regarding blood donation, to gain a greater overview of how these interactions influence the actual manifestation of the blood donation behavior over specific periods of time [22]. Additionally, integrating variables from well-known models of altruistic dispositions, prosocial behavior, or psychological factors could potentially alter the current model and provide interesting directions for future research. As our research approach was based on an online survey with advertisements serving different purposes, from eliciting positive or negative emotions to conveying diverse textual messages, it would be intriguing to investigate how different scenarios impact donor behavior. Diverse blood donation policies and regulations have a considerable influence on donors’ attitudes and behaviors. The effectiveness of distinct motivating incentives, recruiting strategies, and public health initiatives could be evaluated via different communication methods, including experimental techniques, providing diverse results in regard to blood donation intentions.