Blood Donation,
The effects of a financial incentive on current blood donors and students.

Bobby de Graaf
Student Nummer 300152
Masteropleiding Marketing
Masterthesis
Erasmus Universiteit
Dr. Isabel Verniers
08.07.2011

Content

Abstract										4

1. Introduction: A history of Bloedbank Sanquin						5
	1.1 Present									5

2. Theory										7
	2.1 Voluntary Care								7
	2.2 Pro-Social Behavior								10
	2.3 The Social Responsibility Standard						14
	2.4 Changing behaviour								17
	2.5 Charity giving behaviour							20
	2.6 Theory of planned behaviour						23

3. Present Study									25

4. Methods										27
	4.1 Participants and Procedure							27
	4.2 Measures									28
	4.3 Data Analyses								32
	
5. Results 										33

6. Conclusions										41

7. Discussion										42

8. Limitations 										44

References										45

Appendix										53

Abstract

The recruitment of blood donors seems to be important because, the blood supply needs to stay in balance with the demand for blood. Nowadays it is in balance, but with the older donors fading away, the need for younger donors is increasing. How can young donors be motivated to become a registered blood donor? In this study we will look at the effect of a financial incentive when offered to economy and business school  students who are blood donors, students who aren’t donors and blood donors registered at the Sanquin Bloodbank in Dordrecht, to see whether or not their willingness to donate blood would increase. With a questionnaire they were asked for their opinion on several items, divided over several scales, thought to be important for the initiation of behaviour. Results showed that students did respond with a higher willingness to donate to a financial incentive. But, current blood donors, were less willing to donate blood after being offered a financial reward. Future research must look at ways how to attract young blood donors, but at the same time, keep the current donors registered.

1. An introduction into the history of the Sanquin Bloedbank.

The first blood transfusion occurred between 1665 and 1670, especially in France and England people experimented a lot with blood transfusions. During this first transfusions, safety hardly played any role. The Englishman Richard Löwer was the first one who successfully did a blood transfusion directly from the artery of one animal to the vein of another animal. In the meanwhile, the French Physician Jean-Baptiste pioneered with blood transfusion in humans. In 1667 he tried to replace a so called ‘bad blood’ by ‘fresh blood’. For this first transfusion in an human being he used the blood of lambs. It was assumed that a transfusion of blood of these gentle animals would promote rejuvenation. Moreover, it was assumed that ‘new blood’ could change people’s behaviour and therefore could cure mental illness (Sanquin.nl). However, the repeated administration of animal blood led to many complications. The experiments by Denys ultimately resulted in the death of a patient. Denys was not prosecuted, but after this sad incident the urban governance of Paris  banned all forms of blood donations. In 1818 it was the British obstetrician James Blundell who started again, after extensive animal experiments, with blood transfusion on humans. Patient and donor were placed next to each other and the blood was directly transferred from donor to patient. After several successful transfusions, Blundell drew two basic conclusions, which are still valid and made him the ‘father of blood transfusion’. 
	People should only be transfused with human blood, Blood transfusion is  only effective when it serves to complete the loss of a patient his blood.

1.1 The present.

With the start of blood transfusions, many lives were saved, and until this day, every year, enormous amounts of lives are saved all over the world because of blood donations and so an sufficient amount of safe blood is important for the use of medical treatment. Given that the safest blood arrives from voluntary, uncompensated blood donors, selected from populations with a low risk, a lot of nations count on people’s willing heart to give blood on a free base (WHO,2005). This also applies for the Netherlands. 
	Currently, the demand and supply of blood for transfusions and medicines are in balance, but to ensure this balance for the long run, it’s crucial to recruit new blood donors. And because of the more stringent criteria and ageing population, it is expected that the pressure on the blood supply shortage will increase (Sanquin, 2009).  
	In the Netherlands, the national blood supply foundation is Sanquin, which promotes blood transfusion and medicine. If you want to register as a donor, you have to be a healthy person within the age of 18 and 65 years and weigh over fifty pounds. However, the safety of the blood is very important to Sanquin, and so every one who registers will be invited for a health check to see if the wannabe donors are free of possible diseases, and to see which type of blood they have. Sanquin will then invite the donors for a following donations. Not in all countries this is way they operate. In some countries donors can visit a bloodbank at anytime, without being asked for a donation by the bloodbank, in other countries, especially outside of Europe, people receive money for their donations.   The reason why Sanquin doesn’t operate this way, is because Sanquin wants to exclude people that donate blood for a commercial decision. Those who don’t donate their blood out of an altruistic intension, may have certain health problems, infection risk, or may conceal risky sexual contacts. Moreover, there is a fear that a monetary reward will attract especially poorer people, these people have on average a slightly poorer health than ‘richer’ people (Sanquin.nl). 
	In stead of rewarding donors in the Netherlands in terms of money or in other remunerations for donating blood, Sanquin uses milestones for giving a symbolic gesture of thanks after 5, 10, and 20 donations. Many blood donors in the Netherlands donate with a socially useful purpose as a form of reward in itself.  

2. Theory.

Sanquin exists as long as donors keep on donating blood. But with the current donors ageing, and the higher demands for the quality of blood, the recruitment of new and younger donors seems to be of great importance. In this thesis, we will look at the different kinds of voluntary care, with specific interest in donations to see what voluntary care is and where it comes from; the restrictions of voluntary care, and why voluntary care doesn’t always work; theories on the reasons for people to engage in different kinds of voluntary care, and what motivates them; and models of how behavior can be changed. When we have broad this into picture, we will look at how this theoretical part applies to the participants in this study. 

2.1 Voluntary Care. 

Voluntary care exists in many different variations, and taking care of each other on a voluntary basis is an essential feature of the primary social contexts in which people live; our families, our household  and of course the circle of friends and acquaintances we are surrounded by. This form of voluntary care is called informal care (Struijs, 2006). The strong social relationships, within these primary social relationships, are based on mutual service and support. This is largely due to the sense of belonging, because voluntary care is almost a daily task within this context (Struijs, 2006).  Besides these everyday forms of mutual caring, you can also think of a less frequent expressive way of providing care, like providing hospitality, giving gifts on birthdays, loaning or gifting money or even sending Happy New Year cards.
	 The more or less organized forms of voluntary care deserve more attention. In this form of voluntary care people often go outside their own familiar circle to serve their fellow citizens. In many cases volunteering is for a cause that people experience as being more or less public. We are referring here to financial donations for charities, forms of volunteering and being a (blood) donor. The most common form of donation is preparing a donor card for cadaveric organ donation. About 20 percent of the adult population has made a codicil (Komter & Schuyt 1993a). 
	Another known form of donation is to give blood. Annually approximately half million Dutch people donate blood to provide a better chance of survival for other people (Sanquin Annual Report, 2009). Research shows that blood donation is mainly based on altruism and duty. With repeated blood donations the strength of the initial motives, motives like moral obligation and responsibility for the society, increase (Piliavin et al., 1982). There is also talk of 'role-person merging': blood donors will gradually see giving blood regularly as part of their personal identity (Callero et al., 1987).  
	
	Voluntary care is partially the result of a mindset that should be taught in early childhood for it to grow and develop (Grusec 1991). Particular priority must be given to modeling: good example, especially provided by the parents, will be followed. In this context, the research of Clary and Miller (1986) is particularly interesting. These researchers go back to a study by Rosenhan (1970) in which a group of American ex-activists in the civil rights movement was investigated. The most dedicated activists had a positive relationship with their parents and their parents had previously also been active in various social movements. Clary and Miller mention a dozen other studies that indicate the importance of an education based on altruism in the transfer of participating in voluntary work. In their own investigation on volunteers who are helping with telephone contact based missions, the volunteers that were trained altruistic continued to work longer than the volunteers that were not. In relation to the voluntary donation of blood it has repeatedly been shown that impulses from one's social network often are decisive when deciding to participate.  Many volunteers are asked to do this work by family, friends, colleagues or (staff) members of an association where all members already participate (Clary and Miller, 1986). It can be noted that such calls are almost always concrete. People are not approached with a general call for voluntary work, let alone citizenship, but with a specific request for a specific matter. It goes further saying that continuing to make voluntary donations is influenced by the circumstances that we face as a volunteer within the organizational framework in which this donation takes place. It also stressed the importance of guidance, expertise and good arrangements (Penrod, 1991). The government can also make promotional voluntary contributions. This brings us to the question under which conditions the call for voluntary care by the government is effective. The answer is partially given above: such calls are especially useful when a concrete character is evident, and when they are credible.
	Voluntary care also has its shortcomings, which Salamon (1987) called the ‘voluntary failures’: the shortcomings of many voluntary initiatives, especially those of the organized voluntary care in the sense of volunteering and donating blood. Voluntary care as a selective character, which can be explained by the motives of voluntary care and donation. Voluntary care or donation always involves costs for the giver. Reasoned from a selfish perspective it speaks for itself that people work very selectively: Only when the benefits exceed the costs, people will show pro-social behavior (Bierhoff, 2002). The selective nature of voluntary care or donation is also implicated in pseudo-altruistic and altruistic explanations of pro-social behavior. Voluntary care requires a degree of compassion for the needs of others. However, there are many circumstances to mention that compassion is not activated or suppressed by. The main circumstances are preoccupation with someone’s own activities and problems, and the experience of great psychological distance from others. People identify with others, preferably with whom they have kinship based on biological descent, common interests and many other social characteristics. Altruism also works selectively. A second consideration related to voluntary care or donation is the need to maintain standards. Even norms of reciprocity, social responsibility and distributive justice are usually working within limited circles of solidarity. Lack of citizenship, meaning the lack of involvement in the commonwealth, can coexist with strong sense of solidarity within the circle (Salamon,1987).

	The knowledge of motives for donation is mostly coming from socio-psychological laboratory experiments in which, for the duration of the experiment, was tried to call for behavior as altruism, selfishness, and the complying to social norms artificially, if possible, to call for this behavior separately, and then to examine the determinants and effects (Alessandrini, 2007). In research to the motives for doing voluntary donations, this is not a viable option. Donating is an activity with a longer breath than artificially called behavior in the laboratory. This is evident from the way that voluntary donations in social psychology are identified: a 'continued commitment’ and ‘sustained helpfulness' (Clary and Snyder, 1996). Who wants to know why people voluntarily donate will have to ask them, with all the limitations this entails. The researcher will evaluate the responses to their internal consistencies, and if there is an ad hoc or from a theoretical point of view, if there is a certain application and a certain degree of unfairness of the respondents that the researcher will have to take for granted (Clary and Snyder, 1996). 
	We could also wonder how motivation changes over time. As previously stated there are motivational changes that occur with blood donors. Over time donors will view donating blood as naturally. In other words, different initial motives gradually converge to a common motivation to serve the community. Furthermore, we could ask ourselves why one keeps donating blood voluntarily while the other one drops out. In a few studies the relationship between initial motivation and the duration of volunteering has been examined. Rubin and Thorelli (1984) investigated such a volunteering project for maladjusted youth. This is often ungrateful work because of the small chances of prospect, and the lack of appreciation from the pupils. Volunteers who were counting on appreciation for their work by these young people dropped out first. It shows that the release of initial expectations has effect on the continuation of a particular activity. For the healthcare sector a declining participation in volunteering is found in more traditional forms (Van Daal et al., 1992).

2.2 Pro-Social Behavior.

Characteristic for the civil society is the prominent role of organizational connections that operate autonomously next to the state and private sector. With these connections civilians look after their private interests and give form to their civil duties and rights. In the citizenship debate as currently going on in our country, citizenship is described as: maintaining the social norms, behaving accordingly when socially interacting, protecting the public domain, comply to social rules and take others into consideration (Valentine, 2005). Lack of citizenship is expressed by: political disinterest, insufficient consideration of the law, calculated behavior, and the terrorization of other citizens (WRR, 1992).
	Tax evasion, running a red light, and the disposal of chemical products are signs of a lack of citizenship and not only have consequences for ourselves, but also for the community. In these particular cases especially negative consequences come to light, but when someone is donating blood or giving money to charity, the consequences are positive and these contribute to a better citizenship. We could call this the externalities of behaviour.  In many cases these externalities form a social dilemma, because the general interest is that everyone behaves socially, while everyone separately hasn’t got the tendency to behave according to the general interest. At least, that's the prevailing theory (Batson, 2003). When in a social dilemma, everyone wants to "ride along" on the social behavior of others. The consequence of this is,  is that no one is behaving socially and this will result in a situation that is bad for everyone. For example, you think it’s unnecessary for you to donate blood, because there are plenty of other people who can donate blood. When everyone has this state of mind, no one will donate blood, which leads to a shortcoming of the blood supply.
	The classical solution for social dilemmas is to encourage people to behave accordingly by setting up rules and by creating financial stimulants. A speeding camera keeps people from driving too fast, a train conductor makes sure you pay for your train ticket, and a subsidy on environment friendly cars stimulate people to buy them. This reasoning sounds so obvious, that it is hardly ever been put up for debate. However, the assumption that everyone is always and only driven by self-interest is too limited (Miller et al, 1998). Daily interaction shows many examples of this: People tip the waiter when at a restaurant, people don’t leave their trash in a public park even when nobody is around, or when people help others with car trouble. Adam Smith (1759) already pointed to this: “How selfish so ever man may supposed, there is evidently some principles in his nature, which interest him in the fortune of others” .
	Until recently the most common thought amongst economics was that pro-social behavior was driven by altruism: the idea that people derive a positive effect to the wellbeing of others (Becker, 1974). Pro-social behavior is discounted in rational choice theory: it is in someone’s own best interest to help others. The behavioral economic empire does however suggest that this hypothesis is too simplistic. Whoever assumes from altruism as an explanatory model, would for example predict that people will give less to charity if other people or the government would give more. An altruist makes a tradeoff between their own income and the income of others. If the income of others increases, the tradeoff will be in favor of the own income. The facts show however that donations increase when others donate more (Frey & Meier, 2004). In contradiction with what altruistic theories suggest, people are more willing to contribute to society if others contribute as well. Altruism in the economy is a very straightforward model: an altruist, according to the theory, would always derive a positive nut to more wellbeing for others, no matter the materialistic position of the other (Batson, 2003). This also contradicts the facts. People mostly are more envious when others have a higher economic status then their own and find it a comforting thought if they also have a downfall so now and then. The behavioral economics tries to explain these emotions from the idea of the inequality aversion (Fehr & Schmidt 1999; Bolton & Ockenfels 2000). People derive positive nut to the wellbeing of persons that are in worse economic status then their own, but negative nut to the wellbeing of those with a higher economic status. Dependent on the relative income position people will sometimes behave altruistic and sometimes envious of others. The behavioral economic additions to altruism show that pro-social behavior must be understood from a social environment: whether people will behave altruistic depends strongly on the actions of others. Cooperative behavior has generally a strong conditional character. A large sum of the people is willing to act pro-socially, but only if others do so too. Hardly anyone is willing to sacrifice themselves for common interest, when others behave as profiteers. Social behavior is conditional cooperative: a person will adjust his or her social behavior to the social behaviors of others in the same group. This means that information and expectations of the behavior of others plays a crucial role. If a conditional cooperative person expects that little people will act cooperative, this person will not act cooperative. However, if the expectation is that many people will act pro-socially, they will act according to their expectation. 
	If taxpaying citizens are asked about their own behavior and the expectations they have of the behavior of other people, there seems to be a very strong positive connection. If many think that many are evading tax, the chance of evading tax themselves is a lot higher (Torgler, 2002). This shows that expectations regarding to the pro-social behavior of others have a direct effect on our own behavior. This also applies to giving to charity and with voluntarily donating blood, conditional cooperation seems to play an important role. If people are asked to donate, they are more willing to donate if they know many have done so before them (Frey & Meier 2004). The value of their contribution is correlated with the contribution of others when provided with this information (Shang & Croson, 2005).
	Another relative factor for pro-social behavior is the relation between intrinsic and extrinsic motivation. Pro-social behavior like volunteering and donating blood are in a sense driven by intrinsic motivations as a positive self-image and the need to be a good person. From a purely economic point of view, financial benefits and rules and regulations can be used to enhance the emotional motives. This can positively influence the ‘relative price’ of pro-social behavior. The behavioral economy shows however that there might be a catch to this. If people strive to a positive self-image, the pro-social behavior becomes less important if extrinsic signals are involved (Benhabou & Tirole 2004). The pro-social behavior then no longer necessarily has to indicate a good character, but now can also be explained as well understood self interest. The consequence might be that the intrinsic motives will partially be driven by extrinsic motives. The exact effect of a financial stimulant, for example to donate blood, will be less strong and could possibly turn out negative. The problem is that external motivations are not always the motivations preferred getting. This is also called motivational crowding out (Seabright, 2002). This matter has been the subject of multiple researches. As part of an experiment at a daycare center in Israel, a fine was introduced to the parents to encourage the parents to pick the children up from daycare in time (Genesee & Rustichini 2000a). The effect was however that parents still arrived late. A possible explanation is that the parents viewed the fine as the price to pay for their bad behavior, while the fine was intended as an intrinsic stimulance to pick the children up from daycare on time. The implicit value that the parents attached to this pro-social behavior were evidently higher than the explicit price (the fine) that the daycare attached to this situation. Similar effects are attached to doing voluntary work, for example with collecting money (Frey & Goette, 1999) and with blood donors (Mellstrom & Johannesson, 2009). For the policy it’s important to recognize crowding out effects.  A simple but useful advice is to either reward accordingly or to not reward at all. When the budget at hand is limited, a pat on the shoulder or a symbolic gesture of appreciation is more effective than a financial reward.              
	The explanation provided earlier does however need to be put into perspective. In many cases a self-centered side is attached to the pro-social behavior of people. Many claim to be driven by motives as equality, honesty, and justice, but they explain these terms in an egocentric way. People often find themselves a more moral person then the average person. This could explain why a public or private call for morality and citizenship is usually not effective. People already find themselves pro-social (Babcock et al., 1995). The call for morality therefore not applies to them and is only relevant to others.  

2.3 The Social Responsibility Standard.

The social responsibility standard focuses on asymmetric relationships. This standard requires that we help others when if we feel that the person is designated to our help, whether he is capable of returning help or not. Schwartz and Howard (1981) have developed a model that mainly applies to doing volunteer work and in which social responsibility norm plays an important role. The decision to behave pro-socially or not is, according to this model, dependent not only on standards, but also depends on estimates of costs and benefits for the volunteering, and the estimated inevitability and reasonableness of the request for help. Complying with the social responsibility standard can give satisfaction and not complying with the standard can provide feelings of guilt, but again: this does not eliminate that maintaining the standard is the ultimate motive. Closely related to the social responsibility standard is the norm of distributive justice (fair sharing). In a recent discussion, between Batson and Shaw (Batson & Shaw, 1991) on the one side and Eisenberg and Krebs (Eisenberg & Krebs, 1982 ) on the other side, was discussed whether altruism and the enforcement of this standard is done for several different reasons or not. Batson and Shaw share the view that it is quite possible, where Krebs and Eisenberg emphasize that these motives are conceptual and that the individual assessments of pro-social behavior are indistinguishable (Wakefield 1993).
	With the statement above, that acting pro-socially isn’t dependent only on standards, but also depends on estimates of costs and benefits for the volunteering, and the estimated inevitability and reasonableness of the request for help (Schwartz & Howard, 1981), there are a few comments that can be made. First, our western culture seems to be afflicted with the prejudice that all human behavior is motivated by self-interest, even if many examples call to the contrary. Only in recent years there has been attempts to put this prejudice into perspective through scientific research. The socio-psychological research of Batson and his colleagues (1991) shows room for the notion that altruism under certain conditions is possible. One of the most important assumptions within the economic theory is the assumption that people, when making a decision, in most cases they first look at their personal interests (Miller et al., 1996). The question is how strict this assumption should be interpreted. Some say this assumption should be taken as strict as possible and that people will only be led by their own personal interests and not by the interests of others. So if you want to influence the behavior and decision making of people, you need to address the personal interests of that person. Meaning, you need to find out where people invest their money in (Miller et al., 1996).
	Rewarding someone for their effort, will increase their motivation, and punishing someone for their wrongdoing will keep them from doing wrong again. So when people are successful at their job, you need to reward them. When someone runs a red light, you fine him or her. But isn’t this statement exaggerated? Is it really true that people are always driven by self-interest? Research shows that people in some cases do take other people’s interests into account. Policy creators do not always acknowledge this and overestimate the weight of self-interest. Some call this the ‘Myth of self interest’ (Van den Bos, 2007). The reality is that people, to a certain degree, are willing to put their own interests aside for general interests. Like improving the environment. Even when the expense are higher than the financial benefits gained by saving on energy costs, like buying solar panels, but also when they make a decision about money spend on charity or when people donate blood voluntarily. Naturally people would like to see the contributions to the environment and blood donations to be higher than they are now. However this does not prove that people will always put the general interests above their personal interests. It seems right to say that people, when making decisions, take both their own personal interest and the general interest into consideration. The simple insight is also called the ‘social utility model’ (Loewenstein et al., 1989). This model suggests that people base their decisions on two things: The self-interest and the interest of others. People do not base their decision on one of the two interests, but always take into account both interests. 
	Another factor is the relative weight that is attached to either motive. This weight can be places differently from one individual to another. Some will most likely put more weight onto personal interest and others may put more weight onto the general interest. Differences like these are the main focus in research on social values (Van Lange et al. 2007). The weight that is attached to different interests is based on the current situation. In business environments the self-interest will be taken into consideration more so, then when someone is in a social environment. When speaking of the general interest, words like ‘honesty’ or ‘fairness’ are used. It seems that taking into account the interest of others are done in terms of distributive justness. 
	As a second comment, we could wonder ourselves whether people are as rationally calculated as in the altruism-egoism debate is assumed. The debate is conducted with a strong focus on individual calculations, without taking into account the possibility that people often act according to culturally embedded scripts. Why would people not follow cultural prescriptions without ever having to tire themselves with creating surveys of the cost-benefit balance of their actions? Quite a few people seem to accept social norms, social-responsibility norms and the norm of distributive justice naturally and are thereby encouraged to behave accordingly.
	The main question in the altruism-egoism debate on the motivations of voluntary care would probably be whether people are capable of acting on behalf of the general interest as their main focus, or does their personal interest always take the main role? This issue has been a well-loved theme for centuries in theology and philosophy, but now with the rise of modern science, biologists and social scientists also debate about this issue. 
	During the renaissance the universal egoism was mostly preached (Hobbes, 1651). The universal egoism has also been the dominant point of view in psychology; in fact, the point of view was so strongly focused on egoism that altruism was hardly ever used in psychological literature from 1930 till 1970. From 1970 on we see an upcoming interest for all sorts of ‘pro-social behavior’ in social psychology, voluntary behavior that usually results in positive consequences for others like performing voluntary work (Poppe, 1988). Altruism is usually formed in a way so it will fit in the egocentric society. In experimental research, on pro-social behavior, researchers observed that distress evokes empathy and feelings like sympathy, pity and sadness and often encourages to help. Helping is then interpreted as serving the personal-interest. Three pseudo-altruistic explanations are;
An aversive-arousal reduction:  We feel uncomfortable when we see others in distress and we help to get rid of this negative feeling. Empathy-specific punishment: We have learned that by helping, feelings like guilt and shame are prevented. And an empathy-specific reward :We have learned that helping builds up our self-esteem and social status (Cast & Burke, 2002).
	Some psychologists are opposed to this universal egoism as an explanation for pro-social behavior. A prominent advocate of altruism as a possible explanation for helping behavior is Batson (1991). When their empathic feelings are strong, people, according to Batson, are sometimes motivated to help with the intention of helping the person in need regardless of the costs and benefits for themselves. In a long series of experiments, Batson and his colleagues found support for this hypothesis. 

2.4 Changing Behavior.

Much of the most pressing social problems such as traffic accidents, the financial crisis and climate change are a result of the specific behavior of individuals (Alcott & Mullainathan, 2010, Lehman & Geller, 2004; Mayer & Frantz, 2009). As an example, instead of taking public transportation to save energy and money, people keep spending more than they can afford: they are still driving too fast and keep using air conditioners and continue purchasing other energy consuming equipment. To tackle such social problems, many researchers have searched for ways to persuade people to act in a 'better' way (Alcott & Mullainathan, 2010, Lehman & Geller, 2004; Mayer & Frantz, 2009). Many researchers concluded that money could be seen as one of the most powerful sources in order to motivate people. People change their behavior and have the tendency to hold on to this behavior if they find that they benefit financially. You could say that money acts as a stimulant and as an amplifier for the calling and maintaining of the behavior that is sought (Lea & Webley, 2006). It is therefore assumed that people by making undesired behavior more expensive (through sanctions) and desired behavior more attractive  (through rewards), people can be persuaded to change their behavior (Geller et al., 1982). Change the incentives and changes in behaviour will follow.
	But is it really that easy? If the taxes on cigarettes would be increased, will people start smoking less? Or, will there be less congestion once road pricing is introduced? After learning the financial benefits will people actually be more careful with their energy use? In other words, it is possible to buy the behavior you want to see from someone else?
	According to traditional perspectives money has several functions (Kiyotaki & Wright 1989).  First and most important is it being a medium of exchange; money makes it is easier to trade in goods and services. Second, it is a store of value: money is a mean to save, store and retrieve value. Third and final, money is an unit. Money can be used for a product or service to express a certain value. Money itself has no intrinsic value, but people only want money to buy the goods or services they like to have. So in other words, money derives its persuasiveness from its instrumental value (Lea & Webley, 2006).
	What can you achieve when you use money as a tool to influence behavioral change? If you provide people with a fee when they separate garbage, in order for a better recycling to be possible, will they do so? Probably so, because this way, people will have more money at their disposal and can therefore buy more goods that they desire. It could therefore be assumed that rewards should lead to the desired behaviour (Tracey & Meares, 1995). This prediction is also reflected in a number of prevailing assumptions in the economic literature. People in the neo-classical economics are described as rational agents who mainly focus on the pursuit of personal wealth and self-interest (Thaler, 2000). According to them rewards will lead to an increase in behavior and sanctions will lead  to a decrease in behavior that is sought. The personal wealth is enhanced by a reward and people do not want to see their wealth decline due to a sanction. An example of a reward that being used in order to reinforce the behavior of car drivers, is a subsidy for buying a hybrid car. An example of a penalty you could think of are the energy charges to ensure that people do not consume too much energy. There is a monotonic relationship between a financial consequence and the behavior of a person (Gneezy & Rustichini, 2000). However, empirical research suggests that financial rewards do not necessarily lead to an increase in the desired behavior, but it can also lead to a reduction in the desired behavior (Bonner et al., 2000). An introduction to a fine does not always lead to an increase in the desired behavior. Think back to the experiment as previously described for the nursery in Israel where a small financial penalty had been introduced to parents to encourage them to pick up their children on time. Paying the penalty resulted in an alleviation of the guilt of the parents and the effect was that parents were late more often. They were actually given the opportunity to be late without having to feel guilty. In the case of a reward, it also does not always result in an increase in desired behavior. As with people who do volunteer work, the performance of these people will decrease if they get a financial reward for this work (Gneezy & Rustichini, 2000). This is because they act out of their intrinsic motivation rather than to earn money. If they would  get a fee for their work, they fear that those around them might not view them as social, as someone who acts out of the good of his heart, but as someone who wants to earn some extra money. With this knowledge, the effects of money on behavior can’t be fully explained by the instrumental function of money.
	A reward makes the desired behavior financially attractive, but the behavior of people does not only come from personal goals to maximize profits, it also comes from normative and hedonic goals (Lindenberg & Steg, 2007). Hedonic goals ensure that people feel good and normative goals ensure that people act appropriately, for example by performing a voluntary donation. There is only one problem, which is that these two different stimuli can lead to a "clash" in the manifestation of your behavior. The purpose of acting properly may conflict with the aim to maximize the money available (Lindenberg & Steg, 2007). This doesn’t  mean that if someone has the goal to make a profit out of something, which is in violation with a conflict of purpose, that he or she will always choose to act according to his or her financial interest. This may be related to the reputational risk (Bateson, 2006). Picture a night out where you have spent too much money on drinks for yourself and your friends. It is financially very attractive to walk away and not pay the bill, but for your reputation in relation to your friends, it is not wise to do so. In this case, people are more likely to choose the hedonic/normative behavior than for the financial purpose of your behavior (Lindenberg & Steg, 2007). 
	The ability of money to change behavior is less evident if a competitive motive is present. A specific competitive motivation that can prevent behavior from changing even when money is offered, will be discussed next. As explained earlier, the assumption is that people are motivated to behave differently because of the prospect of an improvement in their personal income through a financial reward (Kiyotaki & Wright 1989). Money can be seen as an instrument for change to occur in a person's behavior. But people only concerned with their personal outcomes such as obtaining money, can be regarded as inappropriate and scabby. It may even go so far that the relentless pursuit of obtaining money results in social exclusion. People who only behave pro-socially when they they will receive a financial compensation for their behavior, are regarded as morally unworthy (Kretzmaan, 1992). So although people tend to generate maximum revenue for their personal wealth, they will always have to try to keep people in their environment to view them as a social person. This indicates a condition of the instrumental value of money, that people will not act in their own financial interests if it puts their moral self-image at risk in the  eyes of others (Kretzmaan, 1992). 
	Keeping the influence of money on behaviour in mind we assume that current donors will be less willing to donate blood after they have received a financial incentive.

2.5 Charity giving behaviour.

In the recent 30 years, there has been a steady decline in charity giving, with the most worrying aspect of this trend the sharp decline in giving among people in their mid twenties and thirties. This decline suggest that charities are getting more dependent on their older donors (Pharoah & Tanner, 1998). It is therefore important that charities learn more about the giving behaviour of people so that they can alter their approach to reach a widest possible audience. But the issue of how and why individuals choose to offer their help to others, has been an puzzle for philosophers and economist since history (Sargeant, 1999). Only since recently have investigators tried to make a marketing contribution in this field (Sargeant 1999). With the first studies of Burnett and Wood (1988) representing a first real attempt to develop models of giving behaviour. According to these models, several factors seem to influence peoples decision whether they should start giving to a certain charity or not. 
	With the rise of charities, it seems like donors are becoming more discriminating with their donations and thus less willing to donate (Schmittlein and Peterson, 1996). And thus, to reach the donors, charities engage in a variety of different fundraising techniques. These techniques centre around media, such as, direct mail, door-to-door distribution, press advertising and radio advertising (Sargeant, 1999). The profiles of the donors recruited by these different techniques vary in their demographic, lifestyle and behavioural characteristics (Sargeant & McKenzie, 1998). Patterns of support that was exhibited by the different techniques were found by Weyant and Smith (1987), who found that the lowering of the requested donations, led to the increase of the donor compliance rate when requested in direct mail. Weyant (1984) also found that the manner in which a request for donation was asked, could make a big difference in the compliance with some techniques, like with face- to- face forms of solicitations, but not in other techniques. Strong evidence also suggests that to enhance compliance, before asking for a donation, we should ask people how they feel and then acknowledge their response (Sargeant, 1999). Roberts Wray (1994) and Saxton (1995) were first in suggesting that charities should be promoted as a brand, which both draws on, and projects the beliefs and values of, its various stakeholders. "Charities do not describe much of what they do as 'branding', organizations have long been concerned with maintaining a consistent style and tone of voice and conducting periodic reviews of both policies and actions to ensure that a consistent personality is projected (Grounds and Harkness, 1998)." This ‘personality’ will impact the organization’s ability to fundraise (Sargeant, 1999). 	 
	Individuals are more likely to help those that are perceived as being similar to themselves, which is stated as ‘fit with the desired self’. And so they will filter those messages from charities existing to support other segments op society (Sargeant, 1999).  Donors will donate to those charities that are most relevant to their segment of society, or with which they can identify, or want others to identify them with. Findings suggest that to donors, a generous, loving self image is more important than for non donors (Yavas et al., 1980). In ads, donors should be shown as generous and kind to help them to reflect the self-image that they wish, that others will accept. This way a more positive self image will be held by the donors, which could lead to more donations (Sargeant, 1999). 
	Two main variables that play a key in the decision whether or not to donate, are the past experience of donors with a charity and the demands that they have to evaluate a possible organisation for their support (Sargeant, 1999). Donors will support charities when they have benefited from the charity in the past, or when they think that they might benefit from it in the future. This benefit could come in either an emotional or a material way, it could do them political good, or enhance their career.   If donors then decide to donate to a charity, they are more likely to make several donations in the future. This is because donors are more selective with choosing a charity, and have made more of a commitment to it than they previously did, with all of the charities existing nowadays (Sargeant, 1999). 
	This decision making process is influenced by both intrinsic and extrinsic variables. The main extrinsic variable is the demographic profile of the (possible) donor. The age of an individual is directly related to engagement in charity giving and at what level that giving will take place (the amounts donated).  In general it seems that the younger generations are less giving than the older generations. They spend more money on their selves now, than they have ever done (Sargeant, 1999). Closely related to age is the life stage people are in. With different life stages, different kind of charities become interesting. This is especially the case with medically related charities. When someone is related to a sufferer, or suffers from a complaint their selves, the likelihood of them getting involved with a certain charity is bigger (Bruce, 1998). Gender also plays a key role in giving behaviour. Women would like to know how their donations will be used, and if they have the opportunity, they would like to choose how their donation will be spend. This is the case when donating money, but also with other kinds of donations, like donating blood or time (Braus, 1994). When the donations come in forms of money, women do tend to donate smaller amounts of money than men, and when we’re looking at percentages of income that donors donate, it seems like the extremely wealthy and the poor donate a much bigger percentage of their income, than the middle-class does (Sargeant, 1999).
	Intrinsic variables that influence the decision whether or not to donate to a certain charity are the amount of empathy that the potential donor feels with the recipient, the amount of sympathy, guilt and pity. These are all found motives that seem to impact both the compliance and the extent thereof (Feldman et al., 1985). Donating can also enhance feelings of self-worth, with some researchers indentifying that blood donations can often give the donor feelings of heroism (Piliavin et al., 1975). With both these intrinsic variables and the extrinsic variables that both seem to have an influence on the motivates to donate to charity, the question remains if  altruistic motives truly exists. 
	Knowing that both intrinsic and extrinsic variables influence the decision of donation behaviour, we assume that there will be a difference in the way males and females respond to a financial incentive. And that the main reasons for students not to be involved in donation behaviour will concern financial factors, both with the amount of situations they have been enrolled in. 

2.6 Theory of planned behaviour.

It seems clear that thru the years, a lot of research has been done on the behaviour on people. With one important question still remaining:  does true altruistic help still exists? Or are there always selfish motives to be found? 
	A theory that describes how people come to their performance of a behaviour, is the theory of planned behaviour. It includes variables about what others think, what the individual itself thinks and thus tries to combine the selfish motives with the altruistic motives to perform a certain behaviour. This theory started as an extension of the theory of reasoned action, which held that a person’s voluntary behaviour (intention, or motivation) could be predicted by his or her attitude toward that behaviour, and how he or she thinks other people would view them (subjective norm) if they performed the behaviour. Meaning, the subjective norms, combined with a person’s attitude, forms his or her behavioural intention (Azjen & Fishbein, 1977). The theory of planned behaviour was developed to make up for the original model’s limitations in dealing with behaviours, over which people have incomplete volitional control. Incomplete volitional control means that the person doesn’t have complete control over performing a behaviour. Some behaviours meet this requirement well, in whether or not the person can decide at will to perform or not perform the behaviour (Azjen, 1991), but most behaviours depend at least to some degree on factors as availability or requisite opportunities and resources like money or time. We could say that the theory of planned behaviour represents the actual control that people have over the behaviour (Azjen, 1991). 
	The individual’s intention to perform a behaviour is a central factor in the theory of planned behaviour, like it was in the theory of reasoned action (Azjen, 1991).  Behavioural intention is the primary motivation determinant of individual behaviour: the more someone intends to engage in a particular behaviour, the more like this person will undertake it (Hardeman, et al., 2002). The strength of intention is determined by three factors: attitude, subjective norm, and perceived behavioural control (self- efficacy) (Armitage & Conner, 1999). Perceived behavioural control is the most important addition to the theory of planned behaviour, and it “is  concerned  with judgments  of how well  one can execute  courses of action  required  to deal with  prospective  situations”  (Bandura, 1982) and moreover, research shows that the people’s performance of behaviour is strongly influenced by their perceived behavioural control (Bandura, 1991).
	Attitudes are created by behavioural beliefs that link a given behaviour to a certain outcome, such as the cost incurred in performing the behaviour. The attitude towards the behaviour is determent by the strength of these associations en by the beliefs that are most convincing at that time ( Armitage & Conner, 2001). Figure 1 shows how these different factors relate to one another. This figure was firstly used by Azjen, but was later used by many more investigators to depict how the theory of planned behaviour works. The attitude of someone towards the performance of a certain behaviour, reflect either a negative or a positive evaluation of that performance, and the more positive the attitudes are, the more stronger the behavioural intentions should be, and the more likely that person is to perform that behaviour (Armitage & Conner, 1999).
	The subjective norms are the ideas that people in your surrounding have about all kinds of behaviours. These norms are composed by the normative beliefs: those things that are thought to be normal in a society (Armitage & Conner, 1999; Azjen 1991). Whether or not to perform a behaviour is influenced by whether the specific individuals of or groups with whom the individual is motivated to comply with, will approve or disapprove of the behaviour (Armitage & Conner, 1999). 
	With this information in mind, we firstly think that when people have a lesser sense of control over their behaviour, they will develop less positive attitudes towards the behaviour, but we also believe that those with more positive attitudes will be less willing to donate blood after receiving a financial incentive and lastly we believe that the current donors will be the ones with the most positive attitudes.

Figure 1. Model of Theory of Planned behaviour by Azjen (1991).

3. Present Study.

Judging from the literature that is known about voluntary blood donation, this research will look at the current number of voluntary blood donors that will decline after an allowance is made towards blood donation. We think that the current number of blood donors will start donating less, or will even stop donating blood, for the simple reason that they are donating blood with the intrinsic motivation of wanting to be a good person. When they will receive a financial incentive for their good deeds, their intrinsic motivation will partly be replaced by extrinsic motivation (Deci, 2007). This is because they are afraid that other people will see them as people who donate blood just for the financial incentive, instead of out of their own good will. This same group is expected to have more positive attitudes towards blood donation (Azjen, 1991) and thus, participants with more positives attitudes towards blood donation, will be less willing to donate after receiving a financial incentive. Participants with a less perceived control of the behaviour of blood donation will have less positive attitudes towards blood donation (Azjen 1991).  We will also look at a group of students who, at the start of study, weren’t donating blood, but who are expected to start donating blood, after receiving a financial incentive (Fryer, 2010). We’ve chosen students because they overall have a good health and may have a long donor career (Lemmens et al., 2005). Besides, students do know about the importance of donating blood, but often don’t feel responsible for donating blood themselves, which has to do with the lifestage they are in (Sargeant, 1999). Most of the students haven’t come across a lot of situations in which they needed blood, or in which friends or family needed it. We expect the main reasons for students not to be a donor, to be reasons concerning the voluntary base of blood donation, and concerning the number of situations they have been in, in need of blood from the blood supply. Money is of big instrumental value for students, and so they’ll probably be quickly triggered by the financial compensation when this offered for their input (Fryer, 2010) .  Thus far not supported by literature, but expected by us to be found in this study, is a difference in response to a financial incentive by males and females. We expect males to be more sensitive to a financial reward. With the theory of planned behaviour as a base, we want to test these hypotheses. A few adjustments are made though, as seen in Figure 2. We added a factor called the financial incentive to the figure that was used by Azjen (1991). Within the theory of planned behaviour, the offering of a financial incentive will either increase of decrease the intention, or the motivation to perform the behaviour, which in this study in donating blood. What was called intention in the original theory of planned behaviour, is called motivation in this study, but as Azjen (1991) already explained, both are considered the same within this model. Because the studied behaviour in this study involves aspects that could lead to emotional responses with the participants which could lead them to behave in a certain way, we changed the behavioural beliefs into affective consequences (French et al., 2005). Affective consequences are at the base of the attitudes one holds towards an behaviour, and consist out of the emotional response someone has to the idea of a certain behaviour. The last change we made in the original figure, is the replacement of the normative beliefs with social influences. Social influences and normative beliefs show a large resemblance, but the term social influences places more emphasis on the fact that people are influenced by their social environment in the conduct of their behaviour.

Figure 2. Motivation-Behaviour Model, influenced by the different subscales.

4. Methods.

4.1 Participants and Procedure. 

The participants of this study are recruited  from voluntary blood donators registered at Sanquin Bloedbank in Dordrecht, and from first, second and third year students from Business administration and Economy studies from the Erasmus University in Rotterdam. Questionnaires with a short explanation of the study and the questionnaire were send thru email to the students who agreed to participate in the study, after already being approached and having received a detailed explanation of the study at the university. The blood donators were given questionnaires at the bloodbank and ask to hand them in after they had filled them in or to send them back to the researchers, after they had agreed to participate and after hearing the purposes of the study. Filling in the forms took them 5-10 minutes and had to be send back within two weeks.
	Of a total of 500 questionnaires, 187 got send back of which 123 complete.  From the total of 123 participants, 71 were females and 52 were males, of which 50 female students and 24 male students. The mean age of the total sample was 30.7 years old, with males having a average age of 33.6 years and females having an average age of 28.5 years.										
4.2 Measures.

Through the questionnaires, age, sex and whether or not they were already donating blood, got registered. In addition three different participant groups could be composed.
The factors, as mentioned in Figure 2, are listed together in the questionnaire, with each scale containing several items. These items are composed out of the literature that is described above, combining the theories and models on behaviour to set up a range of items, together with a survey that has been used by Lemmens and colleagues (2005) in a study on blood donation behaviour. In this study, the theory of planned behaviour was also used to analyse the behaviour of their participants, and thus the items they used for their different scales were greatly in line with the scales used in this study. 

 	Attitude was measured by 7 different items, of which 2 were only presented to the students who aren’t donating blood. On a 7 point scale, the participants could fill in to what extent the items applied to them. The items were all about how they felt about giving blood: ‘I think that I can have a important social contribution by donating blood’, ‘I feel responsible to give blood, because blood donors are needed’, ‘I have the impression that blood donors aren’t so vitally needed’, ‘The importance of a stock donor blood is exaggerated’, ‘Whether or not I give blood, makes little difference to the blood supply’ and for the students who weren’t donating blood ‘I don’t give blood, because my family, friends or acquaintances never needed any blood in the past’ and ‘I don’t give blood, because I myself, my family, partner or friends probably wont need blood in the future’. To make sure the interpretation of the scores on these items are done properly, some items had to be recode. These items were ‘I have the impression that blood donors aren’t so vitally needed’, ‘The importance of a stock donor blood is exaggerated’ and ‘Whether or not I give blood, makes little difference to the blood supply’. For these items, a higher score would indicate that they would have more negative attitudes towards blood donation, while with the other item that all the participants had to answer, a higher score indicates a more positive attitude held towards blood donation. The last item, only answered by the participants who aren’t donating, wasn’t recoded, even though higher scores on this item would suggest a more negative attitude. This was done because the separate analysis that was done on the questions that were only answered by the non donors.

	Subjective norm was measured by 2 items. Again on a 7 point scale, participants had to fill in how they thought significant would think about them donating blood: ‘Others will be proud of me, when I would donate blood’, and ‘Others will show respect for me when I would donate blood’. Higher scores on these items, and on this scale, indicate that the participants care about what significant others think about the behaviour. Lower scores indicate that they don’t matter that much what others think about how they behave.

	Self-efficacy was also measured by 2 items, to see if the participants felt like they were able to control the desired behaviour. Again on a 7 point scale, they had to answer the following items: ‘I’m capable to handle the physical tensions that often are associated with blood donation’, ‘If I would want to, I could donate blood’. Scores on this scales indicate a lower or higher sense of perceived control of their behaviour of blood donation. 

	Motivation was measured at two different moments, with the first measurement before they knew a financial incentive would become available, and a second measurement after they were presented with the financial incentive. On a 7 point scale they had to indicate whether or not they would be willing to donate blood: ‘Would you be willing to donate blood?’, ‘Is there a possibility you will donate blood after receiving a financial incentive?’. On the first measurement, an higher score, would suggest that the participant is already a donor, since they answered that they were willing to donate blood. On the second measurement, an higher score would indicate that the participant is sensitive to a financial incentive, and willing to donate blood after they had received the financial incentive. Then, participants were asked for what amount they were willing to donate with two items one for those who were already donating and one for those who weren’t donating. With these items they had to choose an amount of money they wanted to receive in order to keep donating money, or in order to start donating money. When receiving money wasn’t an option for participants in order to keep donating, they had to fill in 0: ‘ I would keep donating blood, if I would receive an allowance of … € ‘, ‘I would start donating blood if I would receive an amount of … €’. A third item measuring whether or not they were sensitive to a financial incentive, was a second item presented to the students who were not donating: ‘I don’t give blood, because I don’t get paid for it and I won’t donate blood voluntary’. The scores on these items arranged from 1 to 7, with 1 meaning that the participants refused to receive money for their donation, and 7 meaning that they would like to receive an amount of 30 euro’s or more. 

	Affective consequences were measured with 3 items concerning the participants wellbeing.  Two items were presented to all of them, and the third one only to the students who weren’t donating: ‘I feel like a number when I go donate blood’, ‘Blood or/and needles scare me’, ‘I don’t give blood, because I will feel worse physically’. Two items of this scale had to be recode to make the interpretation of the results easier, ‘I feel like a number when I go donate blood’ and ‘Blood or/and needles scare me’. Higher scores on this scale would indicate more negative affective consequences, by recoding these items, higher scores now indicate more positive affective consequences. The item ‘I don’t give blood because I will feel worse physically’ isn’t recoded, because this item is analysed apart from the other items. This item was only asked to the non donors, and those questions answered only by the non donors, aren’t recoded because this wasn’t necessary for the results and conclusions drawn from these questions.

	Social influences are measured with 2 items, one presented to only the students who weren’t donating blood. Social influences are influences that come from the participants social surroundings. These surroundings include school, church, work, clubs or even the internet. Again, on a 7 point scale, the participants had to rate to what extent they related to the items: ‘My parents think its important that I register as a blood donor’, ‘I don’t give blood, because this is against my religious beliefs’. Higher scores on these items indicate a stronger influence on the participants behaviour by their social surroundings.  
	
	The questions that were asked only to the non donors, weren’t recoded, even though higher scores on these items related to a more negative outcome. The reason for not recoding these items, was because of the fact this was thought to be unnecessary for the results and conclusions that were drawn from these items. In table 1 all items are shown together with the construct they represent and the participant group that had to answer the items. The items that are used in the analyses to draw general conclusions, are the items that are answered by all participants. The items that were answered only by the non donors were taken separately in the analyses.

Table 1. All items, constructs and participant groups.
Item	Construct	Participant Group	
1. Ik denk dat ik een belangrijke maatschappelijke bijdrage kan leveren door bloed te geven.
	Attitude	All participants	
2. Anderen zouden trots op mij zijn als ik bloed doneer.
	Subjective Norm	All participants	
3. Ik voel mij verantwoordelijk om bloed te geven, omdat er altijd bloeddonoren nodig zijn. 
	Attitude	All participants	
4. Ik heb wel eens de indruk dat donoren niet zo hard nodig zijn.
	Attitude	All participants	
5. Het belang van een voorraad donorbloed wordt overdreven.
	Attitude	All participants	
6. Ik voel mij een nummer wanneer ik bloed ga doneren.
	Affective Consequences	All participants	
7. Ik ben in staat om met de lichamelijke spanningen, die vaak gepaard gaan met bloeddonatie, om te gaan.
	Self-Efficacy	All participants	
8. Mijn ouders vinden het belangrijk dat ik mij registreer als bloeddonor.                                  
	Social Influences	All participants	
9. Of ik wel of geen bloed geef maakt weinig uit voor de bloedvoorraad.
	Attitude	All participants	
10. Als ik zou willen zou ik bloed kunnen doneren.	
	Self-Efficacy	All participants	
11. Bloed en/of injectienaalden vind ik  eng	
	Affective Consequences	All participants	
12. Zou je bereid zijn bloed te doneren?
	Motivation	All participants	
13. Andere zullen respect voor mij opbrengen wanneer ik bloed doneer.
	Subjective Norm	All participants	
14. Ik blijf bloed geven als er een financiële beloning van maximaal .. euro  tegenover zou staan. Wanneer je weigert een financiële vergoeding te ontvangen, kies dan voor 0. 
	Financial Incentive	Donors	
15. Ik geef geen bloed omdat, Ikzelf, mijn familie, partner of vrienden in de toekomst waarschijnlijk zelf nooit bloed nodig hebben.
	Attitude	Non Donors 	
16. Ik geef geen bloed omdat, Ik er niet voor betaald krijg en ik niet vrijwillig bloed donor word.
	Financial Incentive	Non Donors	
17. Ik geef geen bloed omdat, Ik dit niet past binnen mijn geloofsovertuiging.
	Social Influences	Non Donors	
18. Ik geef geen bloed omdat, mijn familie, vrienden of kennissen in het verleden nooit bloed nodig hebben gehad.
	Attitude	Non Donors	
19. Ik geef geen bloed omdat, ik mij er fysiek slechter door ga voelen 
	Affective Consequences	Non Donors	
20. Ik zou bloed gaan geven als er een financiële beloning van .. euro tegenover zou staan.
	Financial Incentive	Non Donors	
21. Zou je bereid zijn na een financiële vergoeding bloed te doneren?
	Motivation	All Participants	

4.3 Data analyse.

To analyse the results we used the programme Statistical Package for Social Sciences (SPSS version 13.0). First of all the for items that had to be recode, where recode by computing them in SPSS. Then the participants were divided into three groups; de voluntary blood donors , de students who were already donating blood, and the students who weren’t donating blood .

5. Results.

To measure if the items on the different scales measured what we ought them to measure, we used a reliability test. With this test the correlations between the different items per scale are measured. The  Cronbach’s α for the attitude scale was .732. For the subjective norm the Cronbach’s α was .415 ,  and for the self efficacy scale the Cronbach’s α was .689. And final, the Cronbach’s α for the affective consequences was .589. For the social influence, the Cronbach’s α couldn’t me analysed, since there was only one item measuring this scale. The Cronbach’s α from the attitude and the self-efficacy scale are considered to represent a strong reliability within the scales. The affective consequences scale has a moderate reliability, and the reliability of the subjective norm scale is quiet weak.  1

Table 2. Correlations between the subscales.

** Correlation is significant at the 0.01 level (2-tailed).

 Factoranalyses show that the subjective norm scale has a high percentage of explained variance of 9.25%, social influences show the highest percentage of explained variance of 14.49%,but this scale only held one item.  The self-efficacy scale shows a very low reliability and so does the affective consequence scale.
	We analysed the correlations (Table 2) between the subscales with an  α = 0.01 to look for relationships between the scales, and to look for an answer on our hypothesis saying that a lower score on self-efficacy would be related to a lower score on attitudes, having less positive attitudes about blood donation.  The results showed a significant positive correlation between Attitude and Subjective Norm (r = .318, p < 0.01), and Attitude and Self Efficacy (r = .775, p < 0.01). Suggesting that indeed a lower score on self efficacy, is positively related to a lower score on attitude. And thus, when participants have a lesser perceived control over their behaviour, they will have more negative attitudes about blood donation. Another positive correlation was found by Attitude and Affective Consequences (r = .736, p < 0.01). Subjective Norm is positively related to Self Efficacy (r = .239, p < 0.01), Self Efficacy is positively correlated to Affective Consequences (r = .594, p < 0.01), and Social Influences isn’t correlated with any of the other scales. The relatively low correlations between some of the scales, even those who are significant, suggest that when doing a factor analysis, the internal consistencies might not be analysed precisely enough. If we would like to validate the survey, if that would be the main purpose of this study, then we could do a factor analysis to improve further research. 

Table 3. Mean scores and Std. Deviations per scale per participant group. 

	To test our first hypothesis, that current donors would have more positive attitudes towards blood donation, we had to compare the means of the three participant groups on the attitude scale. To make sure we wouldn’t miss any other interesting results, all scales were included in the analyses. The maximum score on all scales was 7. The significance of the differences between the three groups on the scales was analyzed by a Kruskal Wallis test. This test was chosen above a normal ANOVA, because of the more specific significance that this test shows, and because it is likely that this isn’t a normally distributed distribution. The blood donating volunteers score highest on the Attitude scale as seen in Table 3, with a mean of 6,19. This mean score is significant higher than both the mean score of the students who are donor (M= 5,92), and the students who aren’t donating(M=4.43), suggesting that they have the most positive beliefs about donating blood (p < 0.01). The mean score of the donating students were also significant higher than the mean score of the students who aren’t donating (p < 0.01) These results are like what we expected, with those who aren’t donating holding the most negative attitudes towards blood donating. On the Subjective Norm scale, both the blood donating volunteers and the students who are donating score 5.29. Indicating that they do care what other significant others think of them, but its not the main reason for them donating blood. The students who aren’t donating blood have a mean score of 4.55, suggesting that they care less about what significant others think about blood donating, or that perhaps they haven’t given  it much of a thought. Interesting to see is that the score of volunteers is significantly higher than the score of the students who aren’t donating (p < 0.01), but that the students who are donor, and have the same score, don’t score significantly higher than the students who aren’t donating (p < 0.01). This might be because of the small sample size of 7, with students who are donors. On the Self Efficacy scale, the mean score of the Students who are donors (M= 6.00),  and the mean score of the volunteers (M=6.15) are both significantly higher than the mean score from the students who aren’t donating (M= 4.13, P < 0.00). Indicating that the current donors have a greater perceived control over blood donation. The relatively low score of the students who aren’t donating blood (Mean = 4.13) shows that they might be afraid of the behaviour it self, donating blood. Not being able to control the situation.
	On the Social Influence scale, the blood donating volunteers have a score of 3.90 showing that this group isn’t really driven by their surroundings in their behaviour of donating blood, whereas students who are donating score higher on the scale with 5.14, probably because they are more influenced by what is believed to be important at their school and by their friends. Students who aren’t donating are much less influenced by their social environment ( M = 3.67). None of the differences in scores were found to be significant (p < 0.01). The higher scores ( Volunteers M = 4.34, and students M  = 4.00)  of the blood donating participants on the Affective Consequences scale, are a bit surprising, indicating that they scored higher on the items containing questions about how they scary they thought donating blood was. When running a ANOVA after the results were shown to be significant for some of the relationships, comparable results were found.

Tabel 4.  Correlation between scores on 1st and 2nd measurement, Participant Group and Scores on Attitude Scale.  

** Correlation is significant at the 0.01 level (2-tailed).

	Testing our hypothesis that participants with more positive attitudes towards blood donation, will be less willing to donate blood after they had received a financial incentive, and that current donors held a more positive attitude, we analysed the relationships between attitude, participant group and the two measurement moments by analysing the correlations (table 4). First of all a negative correlation exists between the scores on the Attitude and the participant group (r = -.917, p < 0.01), with higher scores for the volunteers assigned to group 1 , and lower scores for the students who aren’t donating blood. A positive correlation was found between the attitudes and the willingness to donate blood at the first measurement ( r = .757, p < 0.01), indicating that participants who held a more positive attitude, were more willing to donate at their initial measurement. Other results shown in this table are discussed in table 5 and 6. Also in support of our hypothesis, we found that a negative correlation exists between the attitudes someone holds and the willingness to donate blood after receiving a financial incentive (r = -.435,p < 0.01), meaning that someone who holds more positive attitudes, will be less willing to donate blood, and those who hold less positive attitudes, will show a higher willingness to donate blood after receiving a financial incentive. 

Table 5. Correlations 1st and 2nd measurement, Participant Group and Sex of Participant.	

** Correlation is significant at the 0.01 level (2-tailed).
	
	In order to support our hypothesis that there is a difference in response to the financial incentive by males and females, and that current donors will be less willing to donate after they received a financial incentive,  the relationships between these variables were analysed. There is a negative correlation (table 5) between the first measurement and the second measurement of the participants motivation to be willing to donate blood (r = -.362, p < 0.01). Meaning that the participants in the lower groups, both the donor participant groups, are less willing to donate after they have received a financial incentive. There is also a negative correlation between the first measurement and the participant groups (r = -.774, p < 0,01), and a positive relation between the second measurement and the participant groups (r = .434, p < 0.01). We will see in table 6 what the differences are between males and females in their ratings on the first and second measure. Here we see that these differences are indeed significant, with a negative correlation between the sex of the participant and the first measurement (r = -.335, p < .000) and a positive correlation between the sex of the participant and the second measurement (r = .284, p < .001).

Table 6. Scores on 1st and 2nd measurement of willingness to donate blood.

	To further support the hypothesis that current donors would be less willing to donate blood after receiving a financial incentive, and to see what the difference in response to a financial incentive between males and females was, means scores were analysed and differences in scores were tested for their significance.  At the first measurement (table 6), asking if the participants were willing to donate blood, students who were donating showed the highest degree of willingness of all three participant groups (M = 6.57). Their score was significantly higher than the score of the students who aren’t donating, who showed the least willingness (M = 3.54, p < 0.01), which is in line with the fact that they aren’t donating blood yet. The student donors, also scored significantly higher than the students who weren’t donating at the first measurement (p < 0.01). When we look at the second measurement, where they were asked again if they were willing to donate blood, but only after a financial incentive, the students who weren’t donating had the highest score (M = 5.00), showing once again their sensitivity for a financial incentive. This results was found to be significantly higher than the voluntary blood donors (P < 0.01). When we looked for significance between the two measurements, we found that the scores on the second measurement were significantly lower for the current donors, and for the males. The scores for the students who aren’t donating on the second measurement were significant higher than on the first measurement.  Comparing males to females, male participants were significantly more willing to donate blood at the first measurement (M = 5.52), but after a financial incentive, female participants seemed significantly more willing to donate blood than males (M = 4.63, p < 0.01). 

Table 7. Scores on the Financial Incentive Items, and scores converted into  €’s. 

	To test our hypothesis that students were willing to receive more money for their donation, and  this way were more sensitive to a financial incentive, we compared the mean scores of the three participant groups and looked for the significance of these differences. When it comes to receiving a financial incentive for donating blood, the volunteers were willing to receive some money in order to keep donating (see table 7), but compared to the other participants, it was only a small amount (M = 2.59,) compared to the other two groups. The students who were donating already, would like to receive a much higher amount (M = 4,28), but the highest amount of money was chosen by the students who weren’t donating (M = 5.29). The differences in score between the voluntary blood donors and the student donors, and the students who aren’t donating are both significant differences ( p < 0.01).To make sense of these scores, they have to be converted to euro’s, in order to see how large the amounts of money were, that the participants asked for. Converted into euro’s, the volunteers wanted 7,95 € on average, the donating students 16,40 € and the students who weren’t donating 21,45 €. Indicating that this last group are more sensitive to an higher financial incentive than the other two participant groups and asked for larger amounts of money than the other two participant groups did.

Table 8. Scores on the five extra items with reasons for not donating.

	Our hypothesis concerning the main reasons for students not to donate, is partly confirmed by the results in table 8. The students who weren’t donating, were given five extra items, on which they had to rate on a 7 point scale, how much every item was a reason for them not to donate blood. In Table  8, the results are shown for how important they thought the reason were for them. We hypothesed that the main reasons for not donating were concerned with money, and the amount of situations they got involved in, when needing blood from the blood supply. They rated a 4,78, for not receiving any money for it, and not being willing to do it voluntary. The least important reason seemed to be that they weren’t donating because of their religious beliefs (M = 1.48), showing a small religious interest in this particular participant group. The idea that they self, nor their family and friends would need blood in the future, also was a wide held believe among the students who were not donating in this study (M = 3,25). Feeling less physically fit, after donating blood, was found less important (M = 3.09) and whether or not they had past encounters with friends or family who needed blood, was only of a small relevance (M = 2,52).

6. Conclusion.

Great part of the results were in line with our hypothesis, finding support for our hypothesis saying that those with the most positive attitudes, will be most willing to donate at the initial measurement in this study,  that those who have the most positive attitudes, will be less willing to donate blood after having received a financial incentive and that the current donors have the most positive attitudes towards blood donation. Thus, those with the most positive attitudes are those who are donors, and thus, current donors will be less willing to donate after receiving a financial incentive. A greater sense of perceived control of the behaviour will lead to more positive attitudes, whereas a lesser sense of perceived control of the behaviour will lead to less positive attitudes. The students in general were willing to receive quiet some money in return for their donation, but those who weren’t donating blood at the beginning of this study first of all showed the most willingness to donate blood after they received a financial incentive, but they also were willing to receive the highest amount of money for it by far. With the current donors, both the volunteers and the students, a large decline was found in their willingness to donate after having received the financial incentive, although, like said before, the student donors were willing to receive quiet some money, compared to the volunteers. When comparing women to men, we found that initially men were more willing to donate, but women responded more strongly to the financial incentive. And although this response was only a little increase on their initial willingness, males showed a large decline in willingness. When checking for the influences of age  on the different scales or for correlations between age and the scales, no significant differences were found for older or younger participants. 

Table 9. Hypotheses accepted or rejected.

7. Discussion.

The reason for focusing on students as participants for this study, is for the mere reason that they have a long donor life ahead of them, once they register as blood donor. Besides that, research shows that students have a good health (Lemmens et al., 2005). With the knowledge of students always being in need of money, it made them an easy group to study in this research with financial incentives. Also, we knew that not a lot of students would be registered as blood donors, so we could actually see if there behaviour would change (Sanquin Bloedbank, 2010). By comparing their scores to blood donors, we could make assumptions about their changing behaviour.
	Almost as an assumption, we said that those participants who held more positive attitudes towards donating blood would be more willing to donate blood at the initial measurement moment. In line with that thought, we though that current donors would have more positive attitudes towards blood donations, than non-donors. Then we said, that those with more positive attitudes, would be less willing to donate blood after receiving a financial incentive.  When asking the participants whether they were willing to donate or not before they were presented with a possible financial incentive, the students who weren’t donating were the least willing participant group, the group with the least positive attitudes towards blood donation. This is in line with the expectations of this study, suggesting that the students don’t feel responsible for donating blood themselves (Sargeant, 1999). If they would feel responsible, and would be willing, they probably already would be donating blood. But when these participants were offered a financial incentive, it seemed like they were more willing to donate than either one of the two groups that were already donating (the students and the volunteers). And not alone were they more willing, they also asked for an higher amount of money in return for their donation. The main reason they gave for not donating blood, was that they weren’t receiving any money for it, and weren’t planning on being a donor voluntary, which was in line with our hypothesis. Looking at this reason, it makes sense that after they have been offered a financial reward, they would be more willing to donate, much more willing than either one of the two other participant groups. Another factor we thought to be an important reason for students not be donating, was the amount of situations they had been in which involved the need of blood supply. Results show that this is indeed an important factor, but especially the future situations in which they thought to be getting involved with the need of blood from the blood supply, seems to influence the students (Sargeant, 1999).
	The results of the group of participants with the students who were already donating, showed that they initially had the highest willingness to donate blood, and after being offered a financial incentive their willingness was almost as high as that of the non donating students. Also the amount of money that they asked in turn for their donation was much higher than the amount of money the volunteers asked. These findings might be explained by the fact that for younger people, donating blood or doing other sorts of voluntary work, is less common. So when younger people, or students in this case, make a choice for participating in voluntary work, or donating blood, it can be expected that their willingness to do so, is very high. The still rather  high rates of willingness after being offered a allowance can be explained by the high value that students in general place on money (Fryer, 2010). Even if they were already donating blood, the offer of a financial incentive makes it interesting for them to donate blood. 
	When the voluntary blood donors, who had the most positive attitudes,  got offered an financial reward, we see a larger decline in the rates of their willingness to donate blood when compared to their initial willingness to donate. This is in line with previous empirical research suggesting that financial rewards do not necessarily lead to an increase in the desired behavior, but it can also lead to a reduction in the desired behavior, because these people act out of their intrinsic motivation rather than to earn money (Bonner et al, 2000; Gneezy & Rustichini, 2000). This is also support for our hypothesis, saying first of all that current donors would have the most positive attitudes towards blood donation, and second of all suggesting that those with the most positive attitudes, would be least willing to donate blood after receiving a financial incentive. 
	Thus, in both groups, the students who were donating and the volunteers, there was a decline in willingness after being offered a financial reward, but the decline was less strong with the students. However the biggest difference between these two groups was the amount of money they were willing to ask in favor for their donation. The volunteers asked much smaller amounts of money when we asked them, than did the students do, and a larger number of participants in the volunteers group stated that they would stop donating blood if they would receive a financial incentive in return. 
	Not knowing what to expect we did some analysis on females and males and their response to a financial incentive, because we thought to find some differences. The results showed that at the initial measurement, the males we more willing to donate blood. But when a financial incentive got offered, the females showed a slight increase in their willingness to donate blood whereas males showed a significant decrease in willingness. This could be an interesting finding, and might be worth studying further. What also seems to be an interesting finding is the support we found for our hypothesis that having less of a perceived control of the behaviour, would lead to less positive attitudes about blood donation (Azjen, 1991). When people feel that aren’t able to control the behaviour their selves, they might get scared, and this way develop  less positive attitudes about it. 

8. Limitations

The willingness of blood donating participants in this study declined after they were offered a financial incentive, so in further research, we must look at ways to make blood donation more attractive for those who aren’t donating blood yet, but at the same time we have to make sure that we don’t lose the current blood donators. But although the results show that the participants who at the start of this study weren’t donating, were more willing to donate after they had been offered a financial incentive, we think that at least part of these participants would also help by donating blood if they wouldn’t receive a financial incentive. To be active in any kind of voluntary work, you need to know that it exists and that you can participate in it. In this study we used a group of students, who most likely are busy with their studies, friends and sports. Voluntary work, or becoming a blood donor isn’t their main priority at this time in their lives. So to see if it really is the financial incentive that these students are responding to, or just the mere fact that they are being introduced to something that they could do to help, you would have to set up a programme in which you teach them about voluntary work and blood donation first. If their willingness to donate blood or participate in voluntary work increases, it might have been that they just didn’t know that they could get involved in these activities. If their willingness doesn’t increase, then you could do what we did in this study:  offer them a financial incentive to see if their willingness increases then.  
	Limitations for this study were further found in the short questionnaire. While performing a factor analysis, different factors were found, that couldn’t be integrated into this study anymore. Also, for the different scales we used in this study, the number of items we unequally divided, with most scales consisting out of a minimum number of items. Surprisingly, the Cronbach’s alpha was relatively high for most scales, but for the Social Influence scale, it couldn’t even be measured, since it had only one item. For future research, the study should make used of a validated questionnaire, or should validate its own survey before entering this research. Because of the very small sample of 7 students who were already blood donors, almost non of their scores were found to be significantly different from any of the other two groups. The importance of equally divided groups within the total sample, must be stressed in the future. 

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 Op welke datum vult u deze vragenlijst in?                 		 . . - . . - 2011

 Wat is uw geboortedatum?					 . . - . . - . . . .

 Wat is uw geslacht?						Man   Vrouw 

Bent u een bloed donor?					Ja / Nee

Bent u student? 						Ja / Nee

Hoe vaak heeft u de afgelopen 2 jaar gedoneerd?		. . keer

Wat is uw mening over het geven van bloed?

De volgende stellingen gaan over het geven van bloed. Wilt u aangeven in hoeverre u het eens of
oneens bent met de volgende stellingen?

1=helemaal mee oneens; 2=mee oneens; 3=een beetje mee oneens; 4=neutraal; 5=een beetje mee eens; 6=mee eens; 7=helemaal mee eens

			                     			 Helemaal 		          Helemaal
							 mee				     mee
						               oneens			                   eens

							    1        2       3       4       5       6       7
 
Ik denk dat ik een belangrijke maatschappelijke                                   
	bijdrage kan leveren door bloed te geven.

Anderen zouden trots op mij zijn als ik bloed	                                 
doneer.

Ik voel mij verantwoordelijk om bloed te geven,	                                 
	omdat er altijd bloeddonoren nodig zijn. 

Ik heb wel eens de indruk dat donoren niet zo	                                  
hard nodig zijn.

Het belang van een voorraad donorbloed wordt	                                 
overdreven.

Ik voel mij een nummer wanneer ik bloed ga	                                 
doneren.

Ik ben in staat om met de lichamelijke 		                                 
	spanningen, die vaak gepaard gaan met 
	bloeddonatie, om te gaan.

Mijn ouders vinden het belangrijk dat ik mij	                                 
	registreer als bloeddonor.

Of ik wel of geen bloed geef maakt weinig uit	                                  
voor de bloedvoorraad

Als ik zou willen zou ik bloed kunnen doneren.	                                

Bloed en/of injectienaalden vind ik eng	 	                                

Zou je bereid zijn bloed te doneren?	                               	  

Andere zullen respect voor mij opbrengen	                               	  
	wanneer ik bloed doneer.

De volgende vraag hoeft u alleen in te vullen u al een donor bent. 
U heeft 7 antwoord mogelijkheden, 7 bedragen waartussen u kunt kiezen. Kies het bedrag waarbij u denkt dat u bloed zou blijven doneren. 

Ik blijf bloed geven als er een 	   	   	  0       5       10      15     20     25     30+
financiële beloning van maximaal.. euro  	                                 	
	tegenover zou staan. Wanneer je weigert 
 	een financiële vergoeding te ontvangen, kies
	dan voor 0. 

Bent u al een trouwe bloed donor? Dan kunt u doorgaan naar Vraag 21
Bent u (nog) geen bloed donor ga dan verder met Vraag 15.

			                     			 Helemaal 		          Helemaal
 							 mee				     mee
							 oneens			                   eens

							    1        2       3       4       5       6       7
Ik geef geen bloed omdat,
Ikzelf, mijn familie, partner of vrienden in de	                                 
toekomst waarschijnlijk zelf nooit bloed
nodig hebben.

Ik er niet voor betaald krijg en ik niet 		                                 
vrijwillig bloed donor word.

Dit niet past binnen mijn geloofsovertuiging.	                                 

Mijn familie, vrienden of kennissen in het 	                                 
verleden nooit bloed nodig hebben gehad.

Ik mij er fysiek slechter door ga voelen		                                 

Voor de volgende vraag heeft u 7 antwoord mogelijkheden, 7 bedragen waartussen u kunt kiezen. Kies het bedrag waarvan u denkt dat u bloed zou blijven doneren. Kies voor 0 als u vind dat u geen financiële beloning moet krijgen voor het geven van bloed 

Ik zou bloed gaan geven als er een 	   	   0        5      10     15     20     25     30+
financiële beloning van .. euro  		 	                                	
	tegenover zou staan

			                     			 Helemaal 		          Helemaal
 		 					 mee				     mee
							 oneens			                   eens

							    1        2       3       4       5       6       7

Zou je bereid zijn na een financiële 		                                 
vergoeding bloed te doneren?	

De enquête is klaar! Bedankt dat u de tijd heeft genomen om de enquête in te vullen!